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Beth Downing, MSN, RN-BC, ONC
Anna Gordon, MSN, RN
Utilize the nursing process to plan culturally
competent developmentally appropriate care for
a client diagnosed with appendicitis.
Outline perioperative nursing concepts related to
an appendectomy.
6 yr old male recently moved to the US from Mexico
with his mother, 7 yr old sister Carle, & 14 yr old brother
Juan to join his father who works for a metal recycling
company.
Except for Juan no one speaks English.
Jose’s parents are excited to have their family together.
Jose & his siblings enjoy playing with neighborhood
children who mostly speak English.
The family attends the local Hispanic Catholic Church.
What is the priority concern based on
this information?
20.69 kg, 116.1 cm
No previous hospitalizations
No surgical history
Current with immunizations
Attends 1st grade
Lives with parents & siblings in a nonsmoking
household
Maternal grandmother – DM
Paternal grandfather - HTN
Jose presents with sharp abdominal pain, not
feeling well & woke up crying at 0100. The pain
went away for a while at school this a.m., but
came back. Now the pain is constant between his
umbilicus & right iliac crest. He is complaining of
feeling cold. Jose began vomiting after he
entered the ER and is now lying on left side with
his right leg flexed.
Lungs clear, HRR w/o murmur
Pain with guarding of the RLQ
VS - 101.4 (ax) – 125 – 35 – 119/79 – 98%
Labs:
WBC – 17,500
HgB HcT UA - negative
CT Abdomen – acute appendicitis
Does this clinical picture coincide with a
diagnosis of appendicitis?
Are vital signs normal for a child this age? Why
the changes?
Jose’s pain suddenly stops what is your
priority?
Admit to Pediatrics
Bedrest
NPO
Consent for laparoscopic appendectomy
D5 ½ NS with 10 meQ KCl @ 70 mL/hr
Gentamicin 45 mg IV on call to OR
Morphine Sulfate 2 mg IV q 1-2 hr prn pain
SBAR report from the ED nurse to the pediatric
nurse to prepare Jose for surgery.
How do you get the consent signed? By whom?
In what language?
Discuss issues/concerns regarding the use of
translators – what is appropriate & what is
not?
The OR has called and it is time for Jose to go to
surgery. His parents escorted to the holding
room with him.
What should be sent with Jose or
communicated to the OR/holding room nurse?
What is the role of the holding room/OR nurse?
Jose is brought into the operating room, after
receiving oral midazolam hydochloride (Versed)
in the holding room. A timeout is completed
prior to beginning the surgery.
What type of anesthesia is used for this
procedure?
How should the anesthesia be administered to
Jose?
Why would other types be inappropriate?
As the circulating nurse what would your
duties include during this procedure?
As the scrub nurse what would your duties
include during this procedure? Review sterile
technique
What are the principles of surgical asepsis?
Jose arrives in the PACU, extubated, arousable
when spoken to. His parents are notified and
brought in to comfort Jose.
His Aldrete score on admission is 6 (Activity – 2,
Respiration – 1, Circulation – 1, Consciousness –
1, O2 Saturation – 1).
Oucher Pain Rating is 8
VS – 99.0 – 120 – 30 – 114/70 – 96% on O2 2L
What are the priority assessments that should
be completed in PACU?
What patient/family teaching should occur at
this time?
VS – 99.1 – 114 – 24 - 106/68 – 98% O2 2L
Jose’s Aldrete Score is 8
Oucher Pain Rating is 3
Based on this information is Jose ready to
leave PACU?
What information should be passed on in
report from the PACU RN to the Pediatric RN?
Routine VS
D5 ½ NS w/ 20 mEq KCl @ 75 mL/hr
HL when taking fluids
Gentamicin 45 mg IV q8 hr
Unasyn 900 mg IV q 6 hr
Morphine 1 mg IV q 1 hr prn pain
Acetaminophen 240 mg q 4 hr for T > 99.5 F
Clear liquids, advance as tolerated if no nausea
IS 10 times/hr while awake
OOB to chair this p.m.
Notify MD T > 100.4
CBC, Chem 14 in a.m.
Alert & oriented
Lungs clear
HR – 110 Regular
Bowel sounds hypoactive
Oucher pain rating – 3
Abdominal drsg dry & intact
IVF infusing in RA at 75 mL/hr
Denies nausea
Due to void
What other assessment & laboratory data
should the nurse monitor? Why?
Priority nursing diagnoses
Potential complications? How do you assess
for them?
If Jose’s appendix had ruptured how would his
care be different – what additional assessment
findings should be seen?
Jose is recovering without complications. He has
been advanced to a full liquid diet and his parents
have questions about why he can not eat solid
foods yet
Encouragement is needed for Jose to ambulate &
use the IS
Surgical dressing remains in place
Antibiotics are being continued
How is this postoperative teaching completed?
Anything else that needs to be taught??
Jose is now being discharged home with his
parents. He is tolerating a regular diet without
nausea, had a bowel movement yesterday. His
incision is well approximated with the staples
intact, no drainage present. Pain is tolerable with
prn acetaminophen (Tylenol).
What teaching needs to be included at
discharge?
Ricci, S. and Kyle, T. (2008). Maternity and Pediatric Nursing.
Lippincott, Williams & Wilkins.
Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2010). Brunner
and Suddarth’s Medical Surgical Nursing. 12th ed.
Lippincott, Williams & Wilkins.