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Donald is currently un-employed since the Covid-19 pandemic in April 2020

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Donald is currently un-employed since the Covid-19 pandemic in April 2020. Malcom has been going to high school remotely since April and done mid-June along with his siblings. The family has met only a few of their neighbors and tends to keep to themselves. Money has been tight, and the mother is struggling with schooling from home. 

History:

    Malcolm woke up at 2:00 AM screaming, telling his mother that his "stomach is killing him". He has an elevated temperature 37.9° C (100.2°F) and begins vomiting. His parents administered 500 mg of acetaminophen orally, however, Malcolm has an emesis within 5 minutes of receiving it. The parents continue to monitor him for an hour and then Mr. Donald decides that they should take Malcolm to the local hospital emergency room. Mr. Malcolm wakes the other two children to bring them along. The family all go to the hospital. Malcolm s is admitted through the emergency department. On admission Malcolm's vital signs are tympanic temperature 38.5° C (101.3°F); pulse 118 beats/minute; respirations 24 breaths/minute; blood pressure 119/79; weight 50 kg (110 lb.); height 165 cm (65 in). Malcolm guards the lower right quadrant of his abdomen and is cussing. An intravenous access is established, and a CBC with differential & Chemistry 7 panel for Na+, K+, Cl-, CO2, BUN, Cr, glucose is sent to lab, and morphine sulfate 8 mg is administered for pain control. An abdominal ultrasound is prescribed to confirm the suspected diagnosis.  Malcolm's lab results are:

CBC w/differential:

·      RBC 4.49 M/uL,Hgb 9.2, Hct 27.6%, Plt 160,000 g/dL

·      Leukocyte count is 21,000 cells/mm? (neutrophils 72%, Lymphocytes 21%, Monocytes- 5%, Eosinophils 1%; Basophils 1% )

Chemistry panel

·      N + is 130 mEq/L; Cl- 98 mEq/L; K+ 4.0 mg/L; CO2 22 mEq/L; BUN 19mg/dL; Cr 1.0 mg/dL; Glucose 68 mg/dL

STUDENT MUST COMPLETE PRIOR TO SIMULATION 

Critical Thinking Questions

 

1.      What is your impressions of this case including pathophysiology and potential complications?

2.      Review Malcolm's vital signs, labs, height and weight and potential rationale for abnormal values.

·      VS

·      Height & weight

·      Abnormal labs:

Additional Critical Thinking.... MUST COMPLETE PRIOR TO SIMULATION DAY

3.      What is the rationale for pre-op orders?

4.      The preoperative instructions are given to the family. Mr. and Mrs. Donald give consent and Malcolm

 assents to the surgery. What is the difference between consent and assent? 

What is the nurse's responsibility in the consent?

5.      Malcolm undergoes an exploratory laparotomy and appendectomy. 

What are the priority nursing interventions in the recovery room?

6.      After being admitted to his room, Mr. Donald says they must now leave with the other 2 children

and he return to work. They will return after dinner. Thoughts on what to say before they leave.

How will you communicate with Malcolm after they leave?

7.      Discuss the rationale for post-op orders.

PRE-OP

Patient name: Malcolm Donald

DOB: 009/25/20XX        MR#: 397852

Age: 15-year-old               Gender: Male

Weight: 110 pounds

Diagnosis: Acute Appendicitis

Allergies & Sensitivities: NKDA

Date

Time

PHYSICIAN ORDER AND SIGNATURE

Admit to Pediatric Surgery

Diet: NPO

Activity: Bed rest

Place NG to gravity - will X-Ray in OR

IV fluids RL @ 100 ml/hr

Gentamicin 90 mg IV on call to operating room

Morphine sulfate 5 mg IV every 1-2 hours PRN Pain

K-pad to abdomen

Prepare for OR for laparoscopic appendectomy

PHYSICIAN SIGNATURE

William Saunders, MD

POST-OP ORDERS

Patient name: Malcolm Donald

DOB: 009/25/20XX        MR#: 397852

Age: 15-year-old               Gender: Male

Weight: 110 pounds

Diagnosis: Acute Appendicitis

Allergies & Sensitivities: NKDA

Date

Time

PHYSICIAN ORDER AND SIGNATURE

Admit to Pediatrics- Routine Post-operative vital signs

 

Diet: NPO except medications

Activity: Bed rest

IV fluids RL @ 88 ml/hr can saline-lock once urine output adequate and taking PO

Gentamicin 125 mg IV q 8 hrs

Ampicillin 2 g IV q 12 hrs

Morphine sulfate 5 mg IV every 1-2 hours PRN Pain

Acetaminophen 500 mg PO q 4-6 hrs for temperature > 38° C (100.4° F)

Incentive spirometry 10 times each hour while awake

Notify House officer if temperature > 38° C (100.4° F)

Begin Discharge Teaching:

  Advance diet from liquid to soft then regular as tolerated

   Return immediately if temp >100.5 F and/or Pain not relieved with analgesics

   Return to surgery clinic or primary provider in 5 days

   Return to school/work in 1 week

PHYSICIAN SIGNATURE

Dr. William Saunders, MD

Complete the Columns below classification; calculate therapeutic range; & nursing considerations/potential side effects

Medication/Dose:

Medication Classification/

Mechanism of Action:

Is this Prescribed dose

Within therapeutic range? (Calculate with Greg's weight where appropriate to determine if safe)

Nursing Considerations/

Potential Side Effect

Hint: What do you monitor for? What are contraindications or warnings? 

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

Gentamicin 125 mg IV q 8 hrs

Ampicillin 2 g IV q  12 hrs

Morphine sulfate 5 mg IV every 1-2 hours PRN Pain

Therapeutic Range of Acetaminophen is 10-15 mg/kg/dose every 4-6 hr

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Therapeutic Dose: 1-1.7 mg/kg/dose IV q 8h; 

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Recommended dosage of Ampicillin

is 1.5-3 g IM/IV q6h

Max: 12 g/day;

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Therapeutic Range of Morphine is Dose: 2.5-10 mg SC/IM/IV q2-6h prn; Alt: 0.05-0.1 mg/kg/dose IV x1, then 0.8-10 mg/h IV prn

 

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