Inflammation: Appendicitis & The Perioperative Experience

1. Beth Downing, MSN, RN-BC, ONC Anna Gordon, MSN, RN Inflammation:Appendicitis & The Perioperative Experience

2. Objectives • 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.

3. Jose Rodriguez • 6 yr old male recently moved to the US from Mexico with his mother, 7 yr old sister Carle, & 14 yr old brother Juanto 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.

4. What is the priority concern based on this information?

5. History • 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

6. ER Visit • 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.

7. Assessment • 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

8. 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?

9. Admission Orders • Admit to Pediatrics • Bedrest • NPO • Consent for laparoscopic appendectomy • D5 ½ NS with 10 meQKCl @ 70 mL/hr • Gentamicin 45 mg IV on call to OR • Morphine Sulfate 2 mg IV q 1-2 hr prn pain

10. 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?

11. Perioperative Experience • The OR has called and it is time for Jose to go to surgery. His parents escorted to the holding room with him.

12. What should be sent with Jose or communicated to the OR/holding room nurse? • What is the role of the holding room/OR nurse?

13. Intraoperative • 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.

14. What type of anesthesia is used for this procedure? • How should the anesthesia be administered to Jose? • Why would other types be inappropriate?

15. 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?

16. Post Anesthesia Care Unit • 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

17. What are the priority assessments that should be completed in PACU? • What patient/family teaching should occur at this time?

18. Ready to leave PACU?? • VS – 99.1 – 114 – 24 - 106/68 – 98% O2 2L • Jose’s Aldrete Score is 8 • Oucher Pain Rating is 3

19. 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?

20. Postoperative Orders • Routine VS • D5 ½ NS w/ 20 mEqKCl @ 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.

21. 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 Postoperative Assessment

22. 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?

23. 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

24. How is this postoperative teaching completed? • Anything else that needs to be taught??

25. Discharge • 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 prnacetaminophen (Tylenol).

26. What teaching needs to be included at discharge?

27. References • 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.