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PEDS Concept
Map
Risk for deficient fluid volume
Risk factors: factors influencing fluid needs, loss of fluid through abnormal routes, deviations affecting intake of fluids
AEB NPO status, verbalization of N/V for 5 days, and increased urine concentration & straw-color
STO #1
Pt will maintain normal blood pressure and pulse throughout the shift
1. Goal partially met: pt blood pressure and pulse slightly elevated, but could be due to pain
STO #2
Pt will maintain urine output of >30mL/hour throughout the shift
Nursing
Diagnosis
2. Goal met: pt had 300mL output in 4.5 hours
1. Nurse will maintain IV fluid administration and frequent V.S. (every 4 hours at a minimum)
By Mariah McGriff
References
3. Unable to assess: did not see pt after shift
LTO #1
Pt will maintain urine output >30mL/hr, normal blood pressure & pulse, and moist mucous membranes throughout hospital stay
Norther Arizona University
Ackley, B. J., & Ladwig, G. B. (2010). Nursing diagnosis handbook: an evidence-based guide to planning care. Maryland Heights, MO: Mosby.
Deglin, J.H., Vallerand, A., & Sanoski, C. (2014). Davis's drug guide for nurses (14th Ed.). Philadelphia: F. A. Davis Company.
Kong, V., Aldous, C., Handley, J., & Clarke, D. (2013). The cost effectiveness of early managements of acute appendicitis underlies the importance of curative surgical services to a primary healthcare program. Annals of the Royal College of Surgeons of England, 95(4), 280-4.
London, M.L., Ladewig, P.W., Davidson, M.R., Ball, J., Bindler, R.M., & Cowen, K.J. (2017). Maternal & child nursing care. Boston: Pearson Education, Inc.
Porth, C.M. (2014). Essentials of pathophysiology: concepts of altered states. Philadelphia: Wolters Kluwer.
Thompson, Schuh, Gravel, Reid, Fitzpatrick, Turner, & Nettel-Aguirre. (2015). Variation in the diagnosis and management of appendicitis at canadian pediatric hospitals. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine, 22(7), 811-22.
Yu, Abbas, Smith, Carberry, Ren, Patel, & Lopez. (2017). Time-driven activity-based costing: a dynamic value assessment model in pediatric appendicitis. Journal of Pediatric Surgery, 52(6), 1045-1049.
2. Nurse will teach pt and mother the importance of urinating in the urinal and keeping it for the nurse to assess.
3. Nurse will assess for signs of hypovolemia (cold clammy skin, weak thready pulse, oliguria)
Acute pain r/t biological injury agents AEB pt. statement of 9 on pain scale, pt inability to ambulate, guarding of abdomen, and diaphoresis
Impaired verbal communication r/t language and cultural differences AEB "no habla ingles," and patient and patient shaking their head "no."
1. Nurse will ask pt to ID comfort pain level (from 0-10) to set a basis for pain management effectiveness at the beginning of shift.
1. Goal met: pt verbalized comfort pain level of 5/10 considering circumstances
STO #1
Pt will establish a comfort-functional goal by verbalizing pain tolerance # on pain scale by 0900
2. Goal partially met: pt pain level decreased, but not to comfort level by the time he left to surgery (pain can be difficult to decrease with his condition pre-op)
LTO #1
Pt will perform ambulation activities twice per day by discharge
2. Nurse will administer IV opioid analgesic every 3 hours when needed.
1. Nurse will use the Rosetta Stone system for communication with pt and mother
STO #2
Pt will report pain management by achieving manageable pain # on pain scale within the next 2 hours
3. Unable to assess: pt not discharged or able to ambulate at time
STO #1
Pt will use an alternative and effective method of communication (a translator).
2. Nurse will have Rosetta Stone system ready and available when the surgical team comes for information and consent
3. Nurse will teach pt about nonpharmacological methods (distraction, relaxation, splinting) when preparing for ambulation
1. Goal met: pt and mother used Rosetta Stone to communicate with nurse
Acute appendicitis is one of the most common ED admissions in the pediatric population. Even though the etiology is mostly unknown, dehydration and/or viral infections can be related to the submucosal lymphoid hyperplasia that obstructs the appendix. The obstruction then causes bacteria to be trapped within the appendix and leads to a multitude of additional problems. An inflammation response and/or distention is correlated to a decrease in venous drainage, congestion, and ischemia of the appendix. When the obstructed appendix is left untreated, necrosis can occur and perforation can ultimately result (usually over 72 hours). In addition, the appendix has innervation from T10 that causes periumbilical pain. The exudate released by the inflammation can also cause more intense pain if it comes in contact witht he parietal peritoneum. As perforation occurs, more inflammation and bacteria leads to peritonitis. (Porth, 2014)
STO #2
Pt and mother will demonstrate understanding of pre-operative procedures and sign the surgical consent.
2. Goal met: pt and mother demonstrated and verbalized understanding; mother signed consent
3. Nurse will communicate with the pt and mother that they should always ask for a translator and that the Rosetta Stone is available throughout the hospital
LTO #1
Pt and mother will understand all care throughout hospital stay by effective communication with translator.
3. Not able to assess: was not on shift or see pt and mother rest of hospital stay
Medications
Morphine 6mg/3mL IV push Q3hr PRN for pain >4
Class: Opioid analgesic
Indication: Severe pain
Action: Bind to opiate receptors to alter perception of pain stimuli
Side Effects: Confusion, sedation, respiratory depression, constipation, hypotension
Effectiveness: Partially effective- given 10/27 @ 0852 for pain of 9/10 and decreased to 7/10 @ 0926
Interventions/Teaching: Push over 5 min; assess pain, V.S., LOC
Assessment Findings
Ondansetron 4mg/2mL IV push Q6hr for N/V
Class: Antiemetic
Indication: Prevention of N/V
Action: Blocks serotonin receptors in vagal nerve
Side Effects: HA, constipation, diarrhea
Effectiveness: Partially effective- given 10/27 @ 0846 (patient holding bucket) and was able to set bucket down @0926; verbally said had decreased some
Interventions/Teaching: Assess V.S., N/V, bowel sounds, abdominal distention; push over 5 min before morphine since it can also cause N/V
Focused Assessment
Intake & Output
From 10/27 0700- 10/27 1130 (taken to surgery)
Acetaminophen 650mg PO PRN Q4hr for pain (1-3) or temperature (>38.3 C)
Class: Nonopioid analgesic & antipyretic
Indication: Mild-moderate pain or fever
Action: Inhibit prostaglandins that are mediators of pain and fever
Side Effects: Muscle spasms, constipation, atelectasis, agitation, HA
Effectiveness: Effective: given 10/27 0413 for temp of 39C; decreased to 38.1 @ 0700
Interventions/Teaching: Assess for rash, pain, and temperature change;
Intake 905 mL
Output 300mL
Zosyn 3.375g IV in 100 mL D5 with LR (given once at 0600 per surgeon request for possible adjustment after surgery)
Class: anti-infective extended spectrum penicillin
Indication: Prophylactic for appendicitis and suspected appendectomy w/rupture
Action: bind to bacterial cell wall to cause cell death and inhibit beta-lactamase to prevent destruction of penicillin component
Side Effects: Seizure, diarrhea, pain/plebitis @ IV site, Cdif, anaphylaxis
Effectiveness: Unable to assess- did not see the patient after surgery
Interventions/Teaching: Assess IV site, V.S., sign of anaphylaxis, skin rashes,
Continuous infusion of D5 in LR 200mL/hr
Class: Glucose/mineral/electrolyte supplement
Indication: Vascular and intracellular hydration maintenance pre-operative
Action: Maintain water distribution, acid-base balance, & osmotic pressure by stabilizing permeability of cell walls
Side Effects: Pulmonary edema, hyperglycemia
Effectiveness: Unable to assess- only one set of labs- nothing to compare (could be done post-op)
Interventions/Teaching: Daily wt, I&O's, edema, lung sounds, assess IV site