Transcript PowerPoint - NC-NET

Beth Downing, MSN, RN-BC, ONC
Anna Gordon, MSN, RN
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Utilize the nursing process to plan culturally
competent developmentally appropriate care for
a client diagnosed with appendicitis.
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Outline perioperative nursing concepts related to
an appendectomy.
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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?
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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
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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.
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Lungs clear, HRR w/o murmur
Pain with guarding of the RLQ
VS - 101.4 (ax) – 125 – 35 – 119/79 – 98%
Labs:
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WBC – 17,500
HgB HcT UA - negative
CT Abdomen – acute appendicitis
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Does this clinical picture coincide with a
diagnosis of appendicitis?
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Are vital signs normal for a child this age? Why
the changes?
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Jose’s pain suddenly stops what is your
priority?
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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
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SBAR report from the ED nurse to the pediatric
nurse to prepare Jose for surgery.
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How do you get the consent signed? By whom?
In what language?
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Discuss issues/concerns regarding the use of
translators – what is appropriate & what is
not?
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The OR has called and it is time for Jose to go to
surgery. His parents escorted to the holding
room with him.
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What should be sent with Jose or
communicated to the OR/holding room nurse?
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What is the role of the holding room/OR nurse?
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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.
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What type of anesthesia is used for this
procedure?
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How should the anesthesia be administered to
Jose?
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Why would other types be inappropriate?
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As the circulating nurse what would your
duties include during this procedure?
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As the scrub nurse what would your duties
include during this procedure? Review sterile
technique
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What are the principles of surgical asepsis?
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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
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What are the priority assessments that should
be completed in PACU?
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What patient/family teaching should occur at
this time?
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VS – 99.1 – 114 – 24 - 106/68 – 98% O2 2L
Jose’s Aldrete Score is 8
Oucher Pain Rating is 3
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Based on this information is Jose ready to
leave PACU?
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What information should be passed on in
report from the PACU RN to the Pediatric RN?
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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.
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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
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What other assessment & laboratory data
should the nurse monitor? Why?
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Priority nursing diagnoses
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Potential complications? How do you assess
for them?
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If Jose’s appendix had ruptured how would his
care be different – what additional assessment
findings should be seen?
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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
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How is this postoperative teaching completed?
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Anything else that needs to be taught??
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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).
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What teaching needs to be included at
discharge?

Ricci, S. and Kyle, T. (2008). Maternity and Pediatric Nursing.
Lippincott, Williams & Wilkins.
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Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2010). Brunner
and Suddarth’s Medical Surgical Nursing. 12th ed.
Lippincott, Williams & Wilkins.