Case study:

The child with acute appendicitis

Tilisha Brezeale 8 yr old Jeremy has been admitted for possible appendicitis. He can to the ED with acute abdominal pain, nausea, and low grade fever. He holds himself in a stiff posture with his right leg flexed. He says that he is not in pain, but his parents believe that he is. He has an IV running, is NPO, and has had blood drawn for a CBC. 1.What in this situation is indicative of appendicitis? location of abd pain, nausea, low grade fever.

2. What other behaviors should the nurse assess for? Jeremy is in denial (pain). Possibly fearful of what they may do to him.(surgery, needles, etc.)., he's holding himself(rt leg flexed), stiff posture. 3. If Jeremy has appendicitis what are the assessments likely to show? tenderness in the RLQ, He may have decreased or absent bowel sounds, Tachcardia, raid shallow breathing, pallor, lethargy, irritability, stooped posture. Most intense pain @ MrBurney's point/referred pain. Labs: UA to r/o UTI. Elevated Bands to show inflammatory porcess. CT showing enlarged appendiceal diameter. 4.Identify areas of preoperative teaching that are necessary if an appendectomy is scheduled. In calm and reassuring manner explain what he needs to get better is having the hurt removed. That he will have to have an IV site to give him fluids when he is unable to breathe. He will have an opening that will be sore for a while but will be stapled shut while he is asleep when getting the hurt removed. He will have to tcdb after getting the hurt removed so his lungs gets some exercise. TEll him he may have a drain coming from the closed spot to take out more of the hurt, and that a small tube may be down in his nose going to his stomach to keep him from throwing up after surgery.If there is time let him explore needles, tubing, syringes, etc. During the night, Jeremys appendix ruptured and he had to have an emergency appendectomy. The next morning he continues to be NPO and has an IV. He keeps asking for something to drink. How should this situation be handled? Calmly let him know that he will be able to drink when the doctor says he can. This is to keep him from becoming sick after getting the hurt removed, and as long as he can see through the liquid he can have any he would like to have. Jeremy denies pain. He does not have a PCA but he does have an order for IM Demerol. How should the nurse respond? Ask him again if he is hurting. Let him know there is medicine out there that can help him ease the soreness of getting the hurt out. In what position should Jeremy be placed and why? semifowler, to help aid in drainage Jeremy progresses well and one day later he is eating. He is no longer receiving IV fluids and has an INT in place for IV antibiotics. He is ambulating when told to do so but he has a stooped posture. Is there any response the nurse should make? He's going to be sore after surgery. Helping him learn how to splint his abd will be helpful.

His teacher visits and brings a large envelope of cards made by his classmates. Jeremy wants them hung on his wall even though he anticipates discharge soon. Of what significance is this? that he still is able to manage some things in his life. What discharge teaching is necessary for Jeremy and his parents. Instructions for Your Child after an Appendectomy Dressing: Your child will have: A white gauze dressing(s) covered by a clear plastic (Tegaderm) Remove this dressing 3 days after surgery. Beneath the gauze dressing(s) are small white bandages (Steri-strips) - These will usually fall off in 1-3 weeks. Stitches: Stitches hold the incision together. They are under the skin; they do not need to be removed, the body will absorb them. They are on the skin and will be removed at the follow up visit. Bath: Remove the dressing(s) 3 days after surgery. Sponge bathing is okay while the dressing is in place. After the dressing(s) are removed, the child should have tub baths in warm water. Activity: Open Appendectomy: No strenuous activity such as bike riding, gymnastics, contact sports, martial arts, school gym, or weight lifting until you check with the surgeon at the follow-up appointment. Laparoscopic Appendectomy: The child may resume normal activities without restriction as tolerated. Diet: Your child may eat or drink as usual. If vomiting occurs, do not give your child anything to eat or drink for 2 hours. Then offer small amounts of clear liquids or half strength juice until your child does not vomit any more. Then slowly start on their normal diet. If your child continues to vomit please call the office. Pain: Your child may have a prescription for pain medication such as Tylenol with Codeine or Percocet. If the incision(s) remain uncomfortable use the prescription medication according to instructions. Your child may take Tylenol (acetaminophen) or Motrin (ibuprofen) for discomfort if the pain is mild. Take antibiotics as prescribed for amount of time prescribed even if he is feeling better. Call the MD for any worrisome signs Please call the office if you child develops any of the following: Fever > 100.5 Redness, swelling, or drainage from the incision site Pain despite the prescription medication (http://www.mgh.harvard.edu/children/specialtiesandservices/general_min_invasive_thoracic_surgery/ post_op_appendectomy_eng.aspx) Take antibiotics as prescribed for amount of time prescribed even if he is feeling better. Call the MD for any worrisome signs. Meds: Rocephin 150 mg q12hr-Patient/Family Teaching

Instruct patient to take medication around the clock and to finish the medication completely, even if feeling better. Take missed doses as soon as possible unless almost time for next dose; do not double doses. Advise patient that sharing of this medication may be dangerous. Pedi: Instruct parents or caregivers to use calibrated measuring device with liquid preparations. Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy. Caution patients that concurrent use of alcohol with cefoperazone may cause a disulfiram-like reaction (abdominal cramps, nausea, vomiting, headache, hypotension, palpitations, dyspnea, tachycardia, sweating, flushing). Alcohol and alcohol-containing medications should be avoided during and for several days after therapy. Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional. (Davis Drug Guide for nurses 11th ed.)