NUR3503 ASSESSMENT 2: CASE STUDY ANALYSIS

Answer

• NUR3503 Assessment 2: Case Study Analysis

  This case study essay will focus on Sienna, a 9-year old girl diagnosed with -perforated appendicitis, a life-threatening condition affecting the appendix. Sienna lives with her family in Wagin, West Australia. Admitted after a week’s history of continued abdominal pain and fever, an ultrasound was conducted, detecting Sienna had a perforated appendix. Perforated appendicitis required an emergency laparoscopic appendectomy. After surgery, Sienna was placed in a post-surgical ward for recovery and monitoring. During her recovery and monitoring, Sienna shows signs of having a phobia of intravenous medication. However, after intravenous antibiotics and PRN analgesia, Sienna's pain went down, and she is alert as her wound heals. In addition, the application of a nasogastric tube to help with her feedings and indwelling catheter were insitu and connected to a drainage bag while she recovered before her discharge from the hospital five days post-surgery. The information surrounding Sienna's diagnosis of having perforated appendicitis will help explain the condition's pathophysiology, assessments on the management of Sienna's condition, and an in-depth discussion of health promotion and discharge education surrounding Sienna's care at home.

  Pathophysiology

  Perforated appendicitis is a life-threatening condition occurring in an individual's appendix emanating from the obstruction of the appendiceal orifice (Jones et al., 2019). Acute perforated appendicitis occurs from bacterial infections in the appendix. The presence of bacterial infections in the appendix prompts the excess production of lymphocytes, known as lymphoid hyperplasia, and mucus that blocks the appendix (Jones et al., 2019). Increased lymphoid hyperplasia increases the irritation of the epithelial wall of the appendix, causing irritation and resultant inflammation of the appendix. 

  Jones et al. (2019) reiterate that the increased inflammation of the appendix escalates localized ischemia, which is the restriction of blood flow and oxygen to the appendix. Resultantly, peritonitis, which is the reddening and swelling of the abdomen, occurs around the appendix. Furthermore, the obstructed appendix caused by the inflammation and peritonitis around the appendix gives rise to a proper condition of the replication of the bacteria, shooting up the infection in the appendix, causing acute perforated appendicitis (Jones et al., 2019).

  Sivit et al. (2001) add that physically, the manifestation of acute perforated appendicitis in patients consists of symptoms including increasingly progressive abdominal pain, nausea and vomiting, loss of appetite, and a low-grade fever. In addition, an ultrasound in the patient's abdomen shows the swollen area of the abdomen around the appendix. Therefore, interventions to rid the patient of acute perforated appendicitis include non-operative management and operative management. While non-operative management of appendicitis is successful, Howell et al. (2018) explain that the patients will be at risk of readmission, abscess occurring, and an overall high cost of care for the patient. Therefore, the hospital’s surgical team conducting a laparoscopic appendectomy on the patient, reducing patient complications, prefers operative management for appendicitis.  Through operative management of appendicitis, Howell et al. (2018) add that there is lowered cost of care, fewer complications, and fewer hospital readmissions.

  Nursing Assessment and Management

  Nurses and healthcare professionals should ensure that a patient recuperates properly under optimal conditions and a thorough assessment. According to the Royal Children's Hospital Melbourne (2017), the assessment of the patient encompasses a physical, shifted, and focused assessment. To understand the kind of care administered to Sienna, a physical assessment involving vitals is recorded. Past the physical assessment, the focused assessment should be on the post-operative wound on the abdomen, ensuring that there are no stitches broken or an abscess coming out; hence, proper healing of the wound (The Royal Children's Hospital Melbourne, 2017). Gadiparthi and Waseem (2019) explain that a team, including a surgeon, radiologist, emergency department physician, pediatrician, and nurse, should work together to properly assess and manage perforated appendicitis increasing optimal outcomes for Sienna's condition. Also, nurses in charge of the patient should include pediatric assessment tools like the Children's Early Warning Tool (CEWT) to help with the identification of patient deterioration or patient recovery, post-surgical care, and management of the wound at home after discharge.

  The Children’s Early Warning Tool

  Lambert et al. (2017) and Slater et al. (2021) explain that the Children’s Early Warning Tool (CEWT) helps nurses and caregivers interpret vitals and the condition of a patient determining whether the patient is deteriorating or recovering towards desired health outcomes. Using the CEWT scale depending on the age of the pediatric patient, the vitals of the patient are compared to normal levels on the CEWT chart towards deterioration or recuperation (Lambert et al., 2017). Observations of Sienna’s condition show a temperature of 38.6, a heart rate (HR) of 130 beats per minute, and oxygen saturation of 90% on room air, a respiration rate (RR) of 28 beats per minute with mild distress, and a blood pressure (BP) of 100/70mm/Hg. Calibrated on the CEWT chart scale, Sienna scores an overall score of 4. According to Slater et al. (2021) and Tantivitayatan (2019), an overall score of 4 on the CEWT implicates a need to review Sienna's recovery by her physician. In addition, Tantivitayatan (2019) clarifies that the nurse will take the lead on the medical assessment while offering support to the doctor and emergency team in case of any presented complications. Looking into these, nurses in charge of Siena’s recovery should apply patient management tools.

  Nurse –Patient Management

  According to the patient report, Sienna has a phobia of intravenous medication. However, post-surgery, Sienna's recovery includes introducing analgesics and antibiotics intravenously, which may be one reason for her elevated heart rate observed at 130 beats per minute compared to the normal heart rate that ranges between 70 and 110 beats per minute. Therefore, nurses in charge of her care should manage Sienna’s health-induced trauma and anxiety through effective communication, active listening, and medication.

  First, Lerwick (2016) explains that the nurse should communicate intravenous injections to the patient. However, Sienna has a phobia for intravenous medication, the nurse explaining to her that she cannot swallow medication at the time at the risk of rupturing the incision made during swallowing and digestion (Lerwick, 2016). Therefore, the nurse should ensure that Sienna is well-advised that intravenous medication will work better towards her recovery and reduce medical complications of sutures opening and incision surgical wound rupturing, which will keep her in hospital longer (Lerwick, 2016). Effective communication in a language that Sienna can understand builds a trust bond to accept treatment and intravenous medication.

  In addition, considering Sienna is nine years old, as a child, her development and fear of intravenous medication trigger her heart rate to rise. Therefore, Lerwick (2016) insists on the nurse's need to explain to Sienna the treatment and medication process, reiterating the purpose of each medication. Ali (2019) infers that while explaining the medication and need for intravenous medication, the nurse should employ language free from medical jargon, provide only information that is relevant to Sienna instead of overloading her with irrelevant information, and have a systematic approach that will accommodate Sienna's behavior while catering to increase her health outcomes and reduce complications. Informative nurses who educate their patients on medication help decrease the level of distress on the patient (Lerwick, 2016). Observed that Sienna shows mild distress, calming her through explaining the medication delivery process calms her and reducing her anxiety, improving her health outcomes.

  Last, active listening to the patient is a method of patient management. Sienna’s anxiety and trauma stem from the laparoscopic appendectomy and her needle-injection phobia. Therefore, Lerwick (2016) proposes that the nurse offer a listening ear to understand Sienna's pain. Understanding Sienna's pain levels will help the nurse advise Sienna on seating positions that lessen the pain, proper medication administration, and coping mechanisms on maintaining the wound's sutures from opening, causing wound rapture. Having delivered these assessment and management strategies, the nurse should prepare Sienna and the family for discharge information.

  Health Promotion

  Health promotion for a post- laparoscopic appendectomy pediatric patient like Sienna involves the process of caring for the child's incision and wound, managing her pain, feeding habits, lifestyle changes, attending follow-up doctor's appointments, and knowing when to alert the doctor in case of complications. During Sienna's discharge from the hospital, the nurse should advise the parents on cleaning and dressing the wound. Marks (2018) expounds on this, explaining that the nurse should advise the parents that Sienna's wound should be dry during showering. Optional sponge baths for the first three weeks are advisable. While cleaning and dressing the wound, the nurse should point out that the parents should look out for any swelling, reddening, bleeding, rapture, or excess abscess. On any of these, the parents should notify the doctor.

  Marks (2018) points that home pain management is essential for proper healing of the wound. Post-surgery, Sienna may have some discomfort as recorded with mild distress that may come from the pain of the healing surgical wound. Therefore, the physician should prescribe pain medication for Sienna that the parents should follow and avoid overdosing on her. Part of the pain medication may be intravenous (Marks, 2018). Hence, the nurse should show Sienna's parents how to administer the medication while finding ways to calm her anxiety and fear of intravenous medication.

  Marks (2018) advises that feeding should start with soft foods before moving to hard solid foods. Soft foods like yogurts, soups, rice, and mashed potatoes offer easy digestion and less discomfort during bowel movements. In addition, Sienna should drink many fluids to avoid constipation that may aggravate the healing wound from the laparoscopic appendectomy (Marks, 2018). Last, the nurse should advise against strenuous activities, lifting heavy things, sports, which strain the abdominal muscles; hence, increasing the risk of sutures rupturing and wound infection. While doing this, the nurse should write down the follow-up appointments a week after release, on which Sienna's parents will be notified of upcoming appointments depending on the wound healing progress.

  Conclusion

  Perforated appendicitis is a life-threatening condition in children if left untreated through a laparoscopic appendectomy. While conducting the surgical procedure, post-operative care should encompass a team of a surgeon, radiologist, emergency department physician, pediatrician, and nurse. The nurse will observe the patient, assess their recovery and manage pain. Also, the nurse should help the child's guardians on care processes that improve the health outcomes while reducing complications through proper wound and incision cleaning, pain management through prescription drugs, observing feeding and lifestyle changes, and visiting the doctor for follow-up appointments. Patient care goes beyond the hospital into the home by following care plans put out by the healthcare professionals.