Answer:

1.      Pathophysiology: The patient is having chronic pain in the lower right quadrant of the abdomen. The potential complication may include appendicitis

2.    Abnormal laboratory results include hemoglobin, hematocrit, neutrophils, sodium, and glucose.

3.      Pre-operative laboratory tests, such as CBC (complete blood count), helps in detecting the major requirements during operation.

4.      Consent refers to granting permission. Assent refers to agree or disagree about taking part in clinical research.

5.      Nursing interventions :

·      Note and assess the severity and location of the pain.

·      Provide honest and accurate information to the patient.

·      Rest in semi-Fowler's position.

·      Early ambulation.

·      Give diversional activities

·      Administer medicines as indicated

·      The icing of the abdominal area regularly during the initial 48 hours

·      Note vital signs regularly

6.      The parents must assure the child comfort before leaving. I will prefer to talk to Malcolm about his surgery

7.      Post-operative orders include analgesics and medicines that will help the patient in recovery and reducing pain.

8.      Acetaminophen is an analgesic, which can treat moderate to severe pain and fever in combination with other drugs.

Gentamicin is an antibiotic that helps to treat various viral infections, such as pneumonia and pelvic infection.

Ampicillin is also a broad-spectrum antibiotic that can treat or prevent bacterial infections, such as salmonellosis, endocarditis, a streptococcal, and respiratory infection.

Morphine sulfate is an opiate drug. It one of the most effective drugs used to treat pain.

Step-by-step explanation

Stomach pain can occur due to a variety of complications, such as organ damage, indigestion, gallstones, allergic reaction, appendicitis. It occurs between the chest and pelvic regions. It can be acute or chronic and diffuse or localized.

1.    Pathophysiology: The patient is having chronic pain in the lower right quadrant of the abdomen (localized). The onset of pain is sudden and accompanies fever.

The potential complication may include appendicitis (swelling of the appendix), cecal diverticulitis (swelling in cecum), Meckel diverticulum (swelling in the last bulge of the small intestine), and mesenteric adenitis (swelling in lymph nodes).

2.    Review of laboratory reports: The neutrophil count is 2100 cells/mm³ (cubic millimeter), which is slightly less than the normal range of 2500 to 6000 cells/mm³.

Hemoglobin represents the part of red blood cells (RBCs), which contains hematocrit or iron. The value of Hemoglobin (9.2 g/dL) and hematocrit (27.6%) are lower than the normal range of 9.5 to 15.5 g/dL (gram per deciliter) and 32 to 44%, respectively. The low values indicate anemia.

Na⁺ (sodium) is an important ion that maintains electrolyte balance in the body. Its value (130 mEq/L) is slightly less than the normal range of 135 - 147 mEq/L (milliequivalent per liter).

Glucose level excepted after 12-hour fasting is 60-110 mg/dL (milligram per deciliter). However, the concentration of glucose increases after the meal and decrease slowly. The glucose concentration of 68 mg/dL at around 3:00 AM (anti-meridian) indicates hypoglycemia.

Height and weight of Malcolm are in an average range of high school going children (14 to 15 years).

Review of vital signs: The temperature is higher (101.3°Fahrenheit) than the normal body temperature. Respiratory rate and heart rate of the patient is also higher than normal. It must be in response to abdominal pain.

3.    The rationale of pre-operative orders: Preoperative laboratory tests, such as CBC (complete blood count), helps in detecting the major requirements during operation. For instance, the patient has slight hypoglycemia and anemia. Therefore, the doctor will give him a shot of insulin to normalize his serum glucose concentration. The patient may require extra units of blood due to anemia. The orders also help to determine the presence of any systemic disease, hematological, and bleeding disorder.

4.    In the preoperative stage, guardians have to sign the consent letter. Consent refers to granting permission for something to happen. For instance, if death happens during surgery, guardians of the patient cannot blame doctors for that due to a consent letter. The consent letter contains all potential complications, side effects, and dangers associated with surgery.

Assent refers to agree or disagree about taking part in clinical research. For children, assent is given by parents. For instance, Children taking part in research on the effects of anesthesia requires assent from parents to become part of the research. The assent letter includes the benefits, risks of research, and the freedom to withdraw from research.

Nurse responsibilities in research: He/she should verify and assure that the patient's representative (guardian) is real and of legal age (above 18 years). The nurse should make sure that the guardian signs the consent in their presence.

5.    Nursing interventions for laparotomy and appendectomy: The former refers to an incision into the cavity of the abdomen for surgery. The latter refers to the removal of the appendix through surgery.

i.              Note and assess the severity and location of pain: It helps in monitoring the effect of medicines, the development of abscess at point of surgery, and progression of recovery.

ii.             Provide honest and accurate information to the patient: It will help to reduce anxiety and provide emotional support.

iii.           Rest in semi-Fowler;s position: Supine position may accentuate the abdominal tension and cause inflammation of pelvis and abdomen.

iv.           Early ambulation: It will help in fast recovery and reduce discomfort.

v.             Give diversional activities: It will promote relaxation and increase fighting abilities.

vi.           Administer medicines as indicated: It will help to relieve pain and recover.

vii.          The icing of the abdominal area regularly during the initial 48 hours: It relieves and soothes pain.

viii.        Note vital signs regularly: Fever may indicate the presence of peritonitis or abscess.

6.    The parents must assure the child comfort before leaving. He must talk about his surgery, introduce him to the nurse, and tell him that soon things will go normal then he will also join them to home. The necessity of keeping the daily routine should be addressed to the child.

I will prefer to talk to Malcolm about his surgery. It will help to determine the behavior, such as reaction to anesthesia, pain, and discomfort after surgery. Surgery can have a great psychological impact. Therefore, the patient must know accurate information and happenings around him. It will help the patient feeling alone. The patient must also be aware of the expected discomfort and recovery period. It will prevent unnecessary fears.

7.    Post-operative orders include analgesics and medicines that will help the patient in recovery and reducing pain. If any symptom of an abscess is seen, CBC helps to determine the level of infection. Timely presentation of infection will help to cure it with few doses of medicine. However, if it grows and diffuses to other areas, it can lead to severe complications.

After some time, the patient is supposed to change from NPO (nothing by mouth) to a normal diet. Initially, provide soft and semi-thick food, then progress gradually towards normal. If pain or fever occurs, return to the previous stage. It will help to recover and get back to a normal routine.

Post-operative orders:

Acetaminophen: 500 mg PO every 4-6 hours for fever > 101

It is an analgesic, which can treat moderate to severe pain and fever in combination with other drugs.

Medication/Dose: 12.5 mg/kg (milligram per kilogram) IV (intravenous) every 4 hours.

Medication Classification: NSAID (Nonsteroidal anti-inflammatory drug)

Mechanism of Action: It inhibits the COX (cyclooxygenase) pathways, which elevates the symptom of pain. These pathways induce the synthesis of prostaglandin, which is responsible for the feeling of pain. The drug also causes vasodilation and radiation of heat from the body.

Is this Prescribed dose: No, the prescribed dose is less than the recommended dose.

Therapeutic range: Therapeutic range equals 10 to 15 mg/kg/dose. Malcolm's weight is 49.8 Kg. Thus, therapeutic range is 498 to 747 mg/dose. (49.8 × 10 = 498 and 49.8 × 15 = 747). It is calculated by multiplying body weight with values of therapeutic range.

Nursing Considerations: Overdose can lead to hepatotoxicity. Therefore, provide the dose very carefully to prevent toxic effects.

Potential Side Effect: Dizziness, nausea, dry mouth, rash, flushing, anxiety, and sweating.

Contraindications: It is contraindicated in hypersensitive patients and alcoholic patients.

 

Gentamicin 125 mg IV q 8 hrs

It is an antibiotic that helps to treat various viral infections, such as pneumonia and pelvic infection.

Medication/Dose: It depends on the type of infection. For example, the dose for surgical infection is 1.5 mg/kg/day IV.

Medication Classification: Aminoglycosides

Mechanism of Action: It is a narrow-spectrum drug, which inhibits the growth of only gram-negative bacteria. It inhibits the synthesis of protein in the cell. The cells cannot grow without proteins.

Is this Prescribed dose: The prescribed dose is higher than the recommended dose.

Within therapeutic range: Therapeutic range equals 5 to 10 mg/L. For Malcolm, the range is 249 to 498 mg/L. Yes. The prescribed dose is in the therapeutic range.

Nursing Considerations: Monitor the gentamicin level periodically is essential to prevent toxicity, such as ototoxicity and renal toxicity.

Potential Side Effect: Auditory dysfunction, nephrotoxicity, and nervous system blockade.

Contraindications: Hypersensitivity, dehydration, and myasthenia gravis.

 

Ampicillin 2 g IV every 12 hrs

It is also a broad-spectrum antibiotic that can treat or prevent bacterial infections, such as salmonellosis, endocarditis, a streptococcal, and respiratory infection.

Medication/Dose: 25 mg/kg IV or 1.25 g/kg (gram per kg) IV.

Medication Classification: Beta-lactam antibiotics

Mechanism of Action: It inhibits the transpeptidase enzyme, which essential for the synthesis of the cell wall in bacteria. Thus, it inhibits the growth of bacteria.

Is this Prescribed dose: Yes, the recommended dose is within the range of prescribed dose.

Within therapeutic range: Therapeutic range equals 50 to 250 mg/kg/day. The therapeutic range for Malcolm is 2.5 to 12.45 g/day. However, the dose should not increase 12 g a day.

Nursing Considerations: Prevent overdose, in case of overdose, take help from the poison control center.

Potential Side Effect: Rash, nausea, anemia, renal inflammation, dark urine, bruising, thrush, and eosinophilia.

Contraindications: Infectious mononucleosis and hypersensitivity

 

Morphine sulfate 5 mg IV every 1-2 hours

It is an opiate drug. It one of the most effective drugs used to treat pain.

Medication/Dose: For continuous infusion of morphine, the initial dose is 1 to 2 mg per hour. The dose should not exceed 100 mg per day

Medication Classification: Narcotics or opioids

Mechanism of Action: It interacts with the opioid receptor (OP₃ or µ-receptor) and stimulates the synthesis of dopamine that helps to relieve the pain. It also increases the synthesis of histamine and causes hypovolaemia.

Is this Prescribed dose: No, the prescribed dose is higher than the recommended dose.

Within therapeutic range: Therapeutic range equals 0.05 to 0.1 mg/kg/dose IV. Thus, the therapeutic range for Malcolm is 2.49 to 4.98 mg/hour IV. Yes, the dose is within range.

Nursing Considerations: Closely monitor the symptoms of respiratory depression and hypovolaemia.

Potential Side Effect: Sedation and hallucinations.

Contraindications: The drug is contraindicated in alcoholism, renal failure, high intracranial pressure, corna, pancreatitis, ileus, myxoedema, and inflammatory bowel disease.

 

References: -

1.    Acute Abdominal Pain - Gastrointestinal Disorders - MSD Manual Professional Edition. (2020). Retrieved 27 July 2020, from https://www.msdmanuals.com/professional/gastrointestinal-disorders/acute-abdomen-and-surgical-gastroenterology/acute-abdominal-pain

2.    Abdominal Pain: Symptoms, Signs, Causes & Treatment. (2020). Retrieved 27 July 2020, from https://www.medicinenet.com/abdominal_pain/symptoms.htm

3.    Common Blood Analysis Data | The Medical Biochemistry Page. (2020). Retrieved 27 July 2020, from http://themedicalbiochemistrypage.org/common-blood-analysis-data/

4.    National Guideline Centre (UK). Preoperative Tests (Update): Routine Preoperative Tests for Elective Surgery. London: National Institute for Health and Care Excellence (UK); 2016 Apr. (NICE Guideline, No. 45.) 11, Full blood count test. Available from: https://www.ncbi.nlm.nih.gov/books/NBK367882/

5.    4 Appendectomy Nursing Care Plans - Nurseslabs. (2020). Retrieved 27 July 2020, from https://nurseslabs.com/4-appendectomy-nursing-care-plans/

6.    Acetaminophen. (2020). Retrieved 27 July 2020, from https://pubchem.ncbi.nlm.nih.gov/compound/acetaminophen

7.    Acetaminophen Dosage Guide with Precautions - Drugs.com. (2020). Retrieved 27 July 2020, from https://www.drugs.com/dosage/acetaminophen.html

8.    Morphine Sulfate 10 mg/ml solution for injection - Summary of Product Characteristics (SmPC) - (emc). (2020). Retrieved 27 July 2020, from https://www.medicines.org.uk/emc/product/6426/smpc

9.    Komissarov I. A. (1978). Farmakokinetika ampitsillina pri ostrom appenditsite u dete? [Pharmacokinetics of ampicillin in acute appendicitis in children]. Vestnik khirurgii imeni I. I. Grekova, 120(2), 97-100.

10. Ampicillin: Side Effects, Dosages, Treatment, Interactions, Warnings. (2020). Retrieved 27 July 2020, from https://www.rxlist.com/consumer_ampicillin_penicillin/drugs-condition.htm

11. Medicine, A., Pediatrics, D., Pediatrics, G., Diseases, I., Medicine, L., & Cardiology, P. et al. (2020). Gentamicin - Mechanism, Indication, Contraindications, Dosing, Adverse Effect, Interaction, Renal Dose, Hepatic Dose | Drug Index | Pediatric Oncall. Retrieved 27 July 2020, from https://www.pediatriconcall.com/drugs/gentamicin/612