1. NURSING GRAND ROUNDS Kelly Wiggins 3/5/15 N421

2. INTRODUCTION TO PATIENT S.G. is a 9 (almost 10) year old male admitted to CHKD with RLQ abdominal pain He c/o nausea and vomiting for 4 days prior to admission, lethargic 7 days prior, and anorexia for 2 days prior Diagnoses with ruptured appendix admitted to CHKD on 1/24/15 and scheduled to undergo emergent appendectomy surgery Other medical history-asthma

3. HOSPITALIZATION COMPLICATIONS-TIME TABLE Appendectomy 1/24/15 Abcess develops Drain placed 1/30/15 Purulent drainage from appendectomy site 2/4/15 Incision an drainage performed 2/5/15

4. RUPTURED APPENDIX A ruptured appendix often results from Appendicitis Appendicitis -acute inflammation of the appendix Occurs when the lumen of appendix is obstructed Infection results as bacteria invade the appendix wall Mucosa secretes fluid, causing increase in internal pressure and a blood flow restriction Symptoms-abdominal pain, nausea, vomiting, and anorexia CT scan for diagnosis Appendectomy as treatment

5. APPENDECTOMY AND FURTHER COMPLICATIONS An appendectomy, or a removal of his appendix, was done on 1/24/15. One incision in RLQ Abcess formed after appendectomy (RLQ) Drainage tube placed 1/30/15

6. INCISION AND DRAINAGE On 2/4/15, incision site draining large amounts of purulent fluid Incision and drainage scheduled and performed on 2/5/15 Throughout the day, the wound dressing remained dry and intact, with minimal drainage S.G. developed post-op fever (39.3) that was gone by the end of the day

7. CULTURE/CONCERNS THAT IMPACTED CARE Hospitalized for 12 days 3 surgeries in that time Not in usual setting Regression Not normal behavior according to mom

8. DEVELOPMENTAL STAGE Piaget-Concrete Operational Stage (7- 12 year olds) - The child should be able to reason logically with concrete things and be able to add and subtract. He should understand conversation. Patient met theoretical developmental stage norms

9. DEVELOPMENTAL NORMS OF A 10 YEAR OLD Likes mother and wants to please her Demonstrates affection Is successful in looking after own needs Can use factitive words (think, know, believe) Forms grammatically correct sentences Can use telephone for practical purposes Responds to advertising/television Enjoys conversation Slow height increase, rapid weight increase

10. ASSESSMENT DATA Pain 3/10-4/10 throughout day Respiratory wheezing bilaterally dyspnea on exertion Pt on O2 sat monitor GastroIntestinal incision site RLQ covered with dressing pain at incision site 3/10 Integumentary incision RLQ dressing clean, dry, intact Musculoskeletal needs assistance with ambulation & when being transferred strength x1 in lower extremities pt unable to stand up on own Psychosocial mom only at bedside for 1 hour in 2 days pt calls mom by her name and not “mom” regression

11. NURSING DIAGNOSIS 1 INFECTION Infection related to appendectomy as evidenced by WBC count 15.5 (2/3/15) Purulent drainage from appendectomy incision site Abscess formation RLQ Culture positive for E. coli and S. Pneumoniae bacteria Medications-piperacillin-tazobactam (Zosyn) Abscess developed in RLQ (Drained 2/5/5 via I&D Post op day 12 for appendectomy, post op day 6 for drainage tube insertion of abscess, PICC line

12. INTERVENTIONS Assess WBC count, temperature daily Administer Antibiotics as prescribed, on time Promote increased fluid and nutrient intake Assess incision site for drainage color, amount, odor Teach patient about hand washing and proper hygeine

13. EXPECTED OUTCOMES AND EVALUATION Expected Outcomes W ithin one week the WBC count will reach normal limits, pt will learn ways to prevent infection spread, and incision site will be free of drainage. Evaluation pt. WBC count down to 12.2 on 2/5 (down from 20.4 on 1/29/15, pt verbalized the importance of washing hands

14. NURSING DIAGNOSIS 2 IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Hx of nausea/vomiting 4 days prior to admission Hx of anorexia for 2 days prior to admission Weight drop from admission weight (admission weight 28.7 kg and weight on 2/5/15 25.9 kg) Pt fatigued and weak (strength in extremities x1) Decreased caloric consumption Pt wouldn’t eat after TPN was discontinued 5 th percentile on the growth chart for weight on 2/5/15

15. INTERVENTIONS Teach patient why he needs increased fluid and caloric consumption Offer small frequent meals instead of large meals 3 times Control pain prior to meal times Monitor weight daily Teach family to encourage him to eat Find out food preferences

16. EXPECTED OUTCOME AND EVALUATION Expected outcomes-patient will eat ¾ of meals throughout the day and drink 1 full pediasure, progressing to eating full meal in 5 days. Evaluation On 2/5/15 pt. ate two full meals, but didn’t drink any pediasure

17. NURSING DIAGNOSIS 3 FATIGUE Related to decreased caloric consumption History of lethargy, anorexia, and nausea/vomiting before admission Pt complaint of nausea when eating, not eating full meals or drinking pediasure as ordered RBC count 3.27 (2/3/15) Hgb 9.4 (2/3/15) Hct (28.7%) Anemia

18. INTERVENTIONS Encourage proper rest, no distractions, calm environment Encourage proper caloric intake and consumption of meals and pediasure Assess fatigue level before performing activities that are not critical Allow patient to take his time with ambulation, repositioning-don’t make him feel rushed

19. EXPECTED OUTCOME AND EVALUATION Patient will verbalize that he has more energy and is less fatigued after consuming 3 meals/pediasure and resting quietly in bed Evaluation Patient had 2 full meals, no physical activity throughout the day, is still very fatigued

20. NURSING DIAGNOSIS 4 ACUTE PAIN Related to abdominal surgery (appendectomy and incision & drainage) Reports pain 4/10 consistently throughout day at incision site Facial grimacing when anyone goes near dressing/incision site Acetaminophen/hydrocodone po q6h prn Morphine IV drip

21. INTERVENTIONS Assess pain q4h using pain scale Administer pain meds before pain becomes unbearable and assess for effectiveness (30 minutes after for Acetaminophen-hydrocodone) Determine any alleviating/worsening factors affecting his pain

22. EXPECTED OUTCOMES AND EVALUATION Patient will report pain 5/10 Evaluation Pain stayed around a 4/10 throughout day, pt verbalized when he was in pain and needed prn meds, but said 4/10 was tolerable for him

23. NURSING DIAGNOSIS 5 KNOWLEDGE DEFICIENT-PARENT Patient has hx of asthma, but mother continues to smoke around him Mother not at bedside for more than 2 hours She didn’t know what kind of surgery he had that morning (I&D) Mother didn’t know/understand why fluid and caloric intake was so important

24. INTERVENTIONS Teach mother about patients condition Allow her to ask questions and be receptive to them Do not judge mother for knowledge/lack of knowledge, she needs to feel comfortable when discussing the patient Carefully explain everything being done to the patient while its being done so she can see it

25. EXPECTED OUTCOME Mother will take active participation in care of patient and learn about his hospitalization, asking questions when need be Mother will be able to verbalize back to nurse the importance of her son intaking the proper amount of fluid/nutrients Evaluation Mother left bedside after brief interaction with patient-said she now understands the reason for increased caloric demand/necessity

26. TYING IT ALL TOGETHER InfectionInfection Imbalanced Nutrition FatigueFatigue Acute Pain Knowledge Deficit

27. CARE GIVEN Nutritional support- TPN post-op (DC’d), Pediasure Medications - Piperacillin-tazobactam, Acetaminophen-Hydrocodine, Morphine, Zofran Play therapy

28. TEACHING AND DISCHARGE PLANNING Patient teaching needs Dressing and incision site Fluid and caloric consumption Infection control Parent teaching needs Information about patient hospitalization Caring for patient at home Encouraging increased fluid and caloric intake Play therapy Discharge Planning Patient will need to complete antibiotics prior to discharge (IV) Mother should monitor for signs of worsening infection once discharged Monitor for further abscess formation Instruction of caring for incision site prior to discharge

29. NURSING RESEARCH The use of non-pharmacological methods for children’s postoperative pain relief Examined nurses use of non-pharmacological methods for school-aged children’s post op pain relief Surveyed 134 RN’s in Singapore using questionnaires Results showed that methods like relaxation techniques and breathing techniques were used most often, with massage and thermal regulation being used least often Only 58% reported frequently using preparatory information, or telling the patient what to expect before doing any procedure

30. SUMMARY AND CONCLUSION S.G. 9 year old patient with ruptured appendix Appendectomy -> abscess -> incision and drainage Developmental considerations Concept map discussion with expected outcomes and evaluation Teaching and discharge planning Research article

31. QUESTIONS?

32. REFERENCES Hockenberry, M. J., & Wilson, D. (2011). Wong's nursing care of infants and children (9th ed.). St. Louis, MO: Mosby/Elsevier. He, H., Lee, T., Sinnappan, R., Vehvilainen-Julkunen, K., Polkki, T., & Ang, E. (2011). Use of nonpharmacological methods in children's postoperative pain relief: Singapore nurses' perspectives. Journal for Specialists in Pediatric Nursing, 16(1), 27-38. Ignatavicius, D. D. (2011). Medical-surgical nursing: patient-centered collaborative care(7th ed.). St. Louis, Mo.: Saunders/Elsevier.