Appendicitis/Appendectomy SKINNY Reasoning

Appendicitis/Appendectomy SKINNY Reasoning John Washington, 14 years old Primary Concept Inflammation Interrelated Concepts (In order of emphasis) • Pain • Stress • Clinical Judgment • Patient Education NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment  Management of Care 17-23%   Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12%  Psychosocial Integrity 6-12%  Physiological Integrity  Basic Care and Comfort 6-12%   Pharmacological and Parenteral Therapies 12-18%   Reduction of Risk Potential 9-15%   Physiological Adaptation 11-17%  SKINNY Reasoning Part I: Recognizing RELEVANT Clinical Data History of Present Problem: John Washington is a healthy 14-year-old African American male who weighs 150 lbs. (68.2 kg). He came to the emergency department because he woke up this morning at about 2 am with "excruciating" generalized abdominal pain around his belly button that has been progressively getting worse over the past several hours. It is now 2 pm. He took ibuprofen 400 mg PO this morning, which decreased the pain some but is now more painful and uncomfortable. The pain is now localized to his RLQ. The pain increases with walking and movement but he feels better when he lies down in a fetal position. He vomited three times after he drank some orange juice for breakfast this morning and has had nothing to drink since. He continues to feel nauseated but has not had an emesis since this morning. Personal/Social History: John lives with his mother and three younger brothers. He is active in athletics and has a strong social network of friends and family in the inner-city neighborhood where he lives. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: Woke by Acute abd. pain, progressively worse. Localized RLQ. Treated with 400 mpg Motrin Vomits x 3 Pain was sudden, not attributed to an MOI, localized to the area of the appendicitis. He attempted to treat with an anti inflammatory but it continues to progress. He is in a fetal position and cant maintain oral hydration . RELEVANT Data from Social History: Clinical Significance: Lives in the inner city, with single mother and 3 siblings. Plays sports nformation he has a single mother and 3 siblings. Receiving care needed maybe difficult due to resources and time. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 100.5 F/38.1 C (oral) Provoking/Palliative: Movement, palpation P: 106 (regular) Quality: Sharp, cramping R: 20 (regular) Region/Radiation: Mid abdomen, RLQ BP: 142/76 Severity: 8/10 O2 sat: 99% RA Timing: Continuous What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: 100.5 Temp 106 H/R 20 R Pain assessment Raised temp: Potential infection Raised HR: tachycardia from pain, anxiety, infection Raised respiration: hyperventilating (watch SPO2), due to pain, anxiety Pain assessment details characteristics of his pain helping to identify underlying cause. Because his pain is sharp, continues, provokable, and located in the LQR it may be appendicitis Initial Assessment by Primary Nurse What body system(s) will the nurse most thoroughly assess based on the problem and the clinical data collected to this point? (Reduction of Risk Potential/Physiologic Adaptation) PRIORITY Body System(s): PRIORITY Nursing Assessments: GI/GU Look: for any lumps, bumps, pulsating masses, disention, symmetry and muscle guarding Listen: bowel sounds all 4 quadrants Palpate area looking tenderness, rebound tenderness, positive heal tap Current Assessment: GENERAL SURVEY: Alert, oriented, pleasant, appears tense, uncomfortable, dress appropriate for the season, hygiene and grooming normal for age and gender. NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4) HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. ABDOMEN: Abdomen round, rebound tenderness in RLQ to gentle palpation. Rebound tenderness present in RLQ, BS + in all four quadrants, bowel sounds diminished/hypoactive GU: Voiding without difficulty, urine clear/dark amber INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. Cap refill 3 seconds. Hair soft- distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: All data is relevant in r/o potential causes Appearance A&O x 4 ABD GU Appearance confirms he is in pain, but hasn’t progressed to the point of impacting neurological status. His abd. Exam confirms tenderness to palpating and rebound tenderness with possible distention. He is able to void but has dark urine since he cant orally hydrate. Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation) Ultrasound: Abdomen Results: Clinical Significance: Enlarged, non-compressible appendix It confirms inflammation from the appendix