Care Plan

Student: Kamrie Godfrey Date: 08/03/19

Course: NSG-434CC Instructor: Jamie Sutton

Clincial Site: Banner Thunderbird Client Identifier: N.C. Age: 10 y.o.

Reason for Admission: Abdominal pain – admitted 7/26/19. N.C. compains of abdominal pain, vomiting, and a fever up to 101 F starting on
Tuesday, 7/23/19. His parents thought it was a stomach virus, but he continued to have vomiting episodes, a fever, and pain unrelieved by
ibuprofen and tylenol. He came into the E.D. on 7/26/19 with suspicion of appendicitis.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

Acute appendicitis with abscess: Appendicitis is inflammation of Expected: Sudden pain on the right lower quadrant of the
the appendix, which is a pouch on the colon. It is found on the abdomen, pain that worsens when walking, anorexia,
right lower side of the stomach. While the causes of acute nausea, vomiting, fever, constipation, diarrhea, abdominal
appendicitis are not clear, if the appendix continues to be bloating, gas.
inflamed, it can get worse, and eventually rupture. When an Presented: Sudden RLQ pain, pain that worsens when
appendix ruptures, it can spread infection in the stomach. It is
ambulating, anorexia, nausea, vomiting, fever, bloating.
important to have surgery right away to take out the appendix in
that case. It is possible to develop pockets of infection filled with
pus when the appendix ruptures. If this occurs, antibiotics are
given and drains are usually placed to drain the abscess.
Risk factors: Cystic fibrosis, current infection, family history of
appendicitis, being age 10-30, abdominal trauma.
(Mayo Clinic, 2019) (Mayo Clinic, 2019)

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

 Assessment Data
Subjective Data: Pain 6/10 when ambulating. “It mostly just hurts really bad when I move.”
VS @ 11:26 Labs: 7/26/19 @ 14:40 Diagnostics:
T : 36.7 C WBC: 18.2 k/mm3 (normal: 4-11 k/mm3): Echocardiogram 7/30 @ 00:01 – because murmur; showed
patient had a ruptured appendix which causes thick/dysplastic aortic valve leaflets, severe aortic valve
BP: 92/56
increased WBC’s. stenosis, moderate dilated ascending aorta
HR: 82
08/03/19 @ 04:23 Wound culture gram stain 8/2 @ 07:07 – because pelvic
RR: 20 abscess; showed many WBC’s, moderate RBC’s, no
Triglycerides: 199 mg/dL (normal: <150mg/dL):
O2 Sat: 98% RA organisms
This could be due to the medications he was put
VS @ 15:15 on after surgery. Wound culture gram stain 8/2 @ 14:15 – because RLQ
abscess; showed many WBC’s, moderate RBC’s, no
T: 36.3 C organisms
BP: 97/62 (Mayo Clinic, 2018).
CT abdomen/pelvis w/ contrast 7/26 @ 16:00 – because
HR: 86 abdominal pain; showed acute appendicitis

RR: 18 CT fluid Coll/Drn peritoneal by catheter 8/1 @ 15:06 –

because abscess drainage; showed successful PICC
O2 Sat: 99% RA
placement

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Assessment: Orders:
PMH: Congenital bicuspid aortic valve w/ insufficiency, anxiety, Maintain surgical drain – irrigate w/ sterile saline 5 ml qshift
ADHD, POP-2.
Vitals Q4h
Neuro: Patient is A&O x4 (person, place, time, situation). Pupils are
Emergency response order set
equal, round, and reactive to light and accomodation; approximately
3mm bilaterally. Patient responds to light and sound. He is cooperative. Notify provider when vitals – O2 <92% awake or <89% asleep
Respiratory: Patient is breathing at a regular rate and rhythm with Skin/wound education
equal chest expansion. No cough or sputum present. Lung sounds are
diminished x2 in the lower lobes but clear throughout, breathing at 18 Rapid response team order set (pediatric)
respirations/min. He is breathing on room air with an O2 saturation of Continuous RSP oximeter
98%.
IV continuous infusion parenteral nutrition pediatric 1680 mL
Cardiac: No edema is present on upper or lower extremities. He is
normal sinus rhythm with a cappilarry refill of <2 seconds bilaterally.
Radial and pedal pulses are strong, equal and approximately 2+
bilaterally. No JVD. Heart rate is 86 bpm and BP is 97/62. S1 and S2
heart tones were auscultated. A murmur was heard; the patient is having
a repair done next month for a congenital bicuspid aortic valve.
GI/GU: Patient had 2 loose stools today. His abdomen is soft and
round. He has normoactive bowel sounds. He is receiving TPN and
lipids through his PICC line to avoid nutrition deficits. He is on a
regular diet which will be advanced as tolerated, however the child has
expressed no interest in eating. He denies pain/burning during urination.
Last recorded glucose was
Musculoskeletal: Patient has equal ROM on upper and lower
extremities bilaterally. His upper and lower body strength, with and
without resistance is strong and equal bilaterally. Patient is on fall
precautions and is up with assist.

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Integumentary: Skin color is appropriate for ethnicity. Skin is warm,
pink and dry. He has bulb drains on the RUQ, RLQ, and L flank. He
also has 3 one-inch laparoscopic sites from the appendectomy with skin
adhesive gauze covering them. The mucous membranes are pink and
moist.
I/O: Intake: 710 mL. Output: 675 mL. Patient lost 2.5 mL of
serosanguinous fluid from the RLQ bulb drain. He lost 5 mL of
serosanguinous fluid from the other RLQ bulb drain. 10 mL
serosanguinous fluid was collected from the L flank bulb drain.
Lines: Patient has a 4 french double lumen PICC in his right upper arm.
It is patent, clean, dry and no irritation/redness/edema is present.
Hygiene: Patient was given a shower this morning by his parents.
Pain/Nausea: Patient reports pain 6/10 and nausea 8/10 with morphine
administration.
P: Ambulation
Q: Throbbing
R: Lap sites and drain sites
S: 6/10
T: Lasts 10 minutes or until back in bed

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 Medications
ALLERGIES: NKDA

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing Considerations

Effect
Acetaminophen 380 mg Rectal Q4h PRN Antipyretic; patient CNS: agitation, anxiety, headache, Assessment
(Tylenol) suppository fever has had a fever due to fatigue, insomnia • Assess IV site q1h to
Resp: atelectasis (↑ in children), check for infiltration or
Safe dose: appendicits irritation.
10-20 dyspnea
mg/kg/dose CV: hypertension, hypotension • Monitor patient’s vital
GI: HEPATOTOXICITY, signs q1h to monitor
Weight: 26.2 kg constipation, ↑ liver enzymes, temperature.
nausea, vomiting • Assess for rash during
Safe range: 262 F and E: hypokalemia therapy.
mg – 524 mg GU: renal failure Teaching
Hemat: neutropenia, pancytopenia • Advise parents to call the
Yes, this is a MS: muscle spasms, trismus nurse and HCP if hey
safe dose. Derm: ACUTE GENERALIZED notice a rash developing.
EXANTHEMATOUS • Teach the parents about
PUSTULOSIS, STEVENS- proper dosage and
JOHNSON SYNDROME, TOXIC calculations for
EPIDERMAL NECROLYSIS, rash, neonates.
urticaria • Educate parents about
the reason that their child
needs acetainophen
(Vallerand, et al 2017)
(Vallerand, et al 2017).

Aripiprazole 5 mg PO QD Mood stabilizer; the CNS: SUICIDAL Assessment

(Abilify) 1 tab child has a history of THOUGHTS, drowsiness, extrapyra • Assess mental status,
midal reactions, akathisia, confusion, mood, behavior before
anxiety. and during therapy.
depression, fatigue, hostility,
Safe dose: 2-5
impaired cognitive function, impulse • Monitor for suicidal
mg/day
control disorders (eating/binge tendencies.
Yes this eating, gambling, sexual, shopping), • Monitor BP, pulse, RR
medication is insomnia, lightheadedness, manic during therapy, Monitor
for neuroleptic malignant
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 wihtin the safe reactions, nervousness, restlessness, syndrome (diaphoresis,
range. sedation, seizures, tardive dyskinesia seizures, tachycardia,
Resp: dyspnea muscle rigidity)
CV: bradycardia, chest pain, edema, Teaching
hypertension, orthostatic • Teach family about
hypotension, tachycardia tardive dyskinesia and
EENT: blurred vision, when to call the provider
conjunctivitis, ear pain with concerns
GI: constipation, anorexia, ↑ • Teach the child and
salivation, nausea, vomiting, weight parents to notify the
gain, weight loss provider if thoughts of
GU: urinary incontinence suicide or worse
depression occur
Hemat: AGRANULOCYTOSIS,
anemia, leukopenia, neutropenia • Advise patient to avoid
temperature extremes
Derm: dry skin, ecchymosis, skin
ulcer, sweating
MS: muscle cramps, neck pain
(Vallerand, et al 2017).
Metabolic: dyslipidemia,
hyperglycemia
Neuro: tremor, abnormal gait
Misc: HYPERSENSITIVITY
REACTIONS, NEUROLEPTIC
MALIGNANT SYNDROME, ↓ heat
regulation, injection site reactions
(Vallerand, et al 2017).
Ceftriaxone 1270 mg IV PB QD over Anti-infective; patient CNS: SEIZURES (HIGH DOSES) Assessment
pediatric 25.4 mL 20 min had acute appendicitis GI: CLOSTRIDIUM DIFFICILE- • Observe for signs and
ASSOCIATED DIARRHEA, symptoms of
(Rocephin) with abscess, putting anaphylaxis (rash,
diarrhea, cholelithiasis, gallbladder
Safe dose: 50- him at risk for sludging, pancreatitis wheezing)
75 mg/kg/day infection. Derm: rash, urticaria • Monitor bowel function;
GU: acute renal failure, urolithiasis diarrhea, cramping,
Weight: 26.2kg
Hemat: bleeding, eosinophilia, blood stools could
hemolytic anemia, leukopenia, indicate C. difficile
Safe range:
1310-1965 mg thrombocytosis • Monitor vital signs and
Local: pain at IM site, phlebitis at wounds for signs of
This dose is IV site infection
below the Teaching

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 therapeutic safe Misc: ALLERGIC REACTIONS • Teach child and parents
range. INCLUDING ANAPHYLAXIS, about signs of a
superinfection superinfection and when
to call a professional
• Notify the provider if a
(Vallerand, et al 2017). fever or diarrhea develop
• Teach parents about
possible infection from
ruptured appendix

(Vallerand, et al 2017).
Metronidazole 762 mg IV PB QD over Anti-infective; patient CNS: SEIZURES, dizziness, headac Assessment
(Flagyl) 152.4mL 2hr had a ruptured he, aseptic meningitis • Observe for signs and
(IV), encephalopathy (IV), psychosis symptoms of
appendix anaphylaxis (rash,
Max safe dose: EENT: optic neuropathy, tearing
(topical only) wheezing)
30 mg/kg/day
GI: abdominal • Monitor bowel function;
pain, anorexia, nausea, diarrhea, dry diarrhea, cramping,
Weight: 26.2kg
mouth, furry tongue, glossitis, blood stools could
unpleasant taste, vomiting indicate C. difficile
Max safe dose:
786 mg Derm: STEVENS-JOHNSON • Monitor vital signs and
SYNDROME, rash, urticariatopical wounds for signs of
Yes, this order only: burning, mild dryness, skin infection
is below the irritation, transient redness Teaching
max dose. Hemat: leukopenia • Teach child and parents
Local: phlebitis at IV site about signs of a
superinfection and when
Neuro: peripheral neuropathy
to call a professional
Misc: superinfection
• Notify the provider if a
fever or diarrhea develop
(Vallerand, et al 2017).
• Teach parents about
possible infection from
ruptured appendix

(Vallerand, et al 2017).
Pantoprazole 20 mg IV push QD Proton pump CNS: headache Assessment
(Protonix) 6.25 mL inhibitor; patient’s GI GI: CLOSTRIDIUM DIFFICILE- • Assess for abdominal
ASSOCIATED DIARRHEA pain/cramping
tract is sensitive due
(CDAD), abdominal pain, diarrhea,
to ruptured appendix, eructation, flatulence
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 Safe dose: 20 and this will help to Derm: cutaneous lupus • Monitor for vomiting,
mg decrease stomach acid erythematosus diarrhea and bloody
Endo: hyperglycemia stools
Yes, this is a F and E: hypomagnesemia • Monitor for
safe dose. (especially if treatment duration ≥3 hypomagnesemia
mo) Teaching
GU: acute interstitial nephritis • Teach patient to report
Hemat: vitamin B12 deficiency black, tarry stools to the
MS: bone fracture health care professional
Misc: systemic lupus erythematosus • Tell patient to notify the
provider of a new rash,
fever, cramping, or
(Vallerand, et al 2017). diarrhea
• Teach the patient about
why he is taking this PPI
(Vallerand, et al 2017).
Morphine 1.2 mg IV push Q2h PRN Opioid analgesic; the CNS: confusion, sedation, dizziness, Assessment
0.6 mL pain patient is in a lot of dysphoria, euphoria, floating feeling, • Assess for signs of
hallucinations, headache, unusual respiratory depression.
pain related to his
dreams • Assess level of
Safe dose: 0.05- appendectomy and EENT: blurred vision, diplopia, consciousness, BP, pulse
0.2 mg/kg q3h drains. miosis and respirations.
Weight: 26.2kg Resp: RESPIRATORY • Monitor pain type,
DEPRESSION location, and intensity
Safe range: CV: hypotension, bradycardia before, during, and after
1.31-5.24 mg Endo: adrenal insufficiency administration.
GI: constipation, nausea, vomiting Teaching
This is just GU: urinary retention • Teach the patient about
below the Derm: flushing, itching, sweating side effects of the drug
therapeutic Misc: physical dependence, (drowsiness, dizziness)
range. psychological dependence, tolerance • Encourage the patient to
turn, cough, deep breathe
and use his incentive
(Vallerand, et al 2017). spirometer.
• Change positions slowly
• Notify a professional
immediately if trouble
breathing occurs.

(Vallerand, et al 2017).
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 Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why intervention Was goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
Priority Nursing Diagnosis Acute pain related to abscess as evidenced by the child rating his pain 6/10. (Phelps, Ralph & Taylor, 2017)
This is my primary nursing diagnosis because pain can slow the healing process and impair coping abilities.
Patient will feel in less Patient will verbally 1. Administer ordered 1. Analgesics depress the 1. Goal met. Patient
pain. report his pain under a analgesics. central nervous system reported less pain
3/10 for the remainder of 2. Provide comfort and reduce the pain. after prescribed
the shift. measures like massage, 2. Nonpharmacologic analgesics were
repositioning, and techniques decrease the given.
relaxation. focus on pain and reduc 2. Goal not met. Mom
3. Provide diversional muscle tension. sat with the patient
activities, such as books, 3. This will help to and scratched his
toys, or Xbox. distract him from the head to relax him.
(Phelps, et al, 2017) pain. 3. Goal met. Patient
(Phelps, et al, 2017) enjoyed playing
Xbox and expressed
less pain during this
time.
Secondary Nursing Diagnosis: Risk for infection related to surgical wounds. (Phelps, et al, 2017)

Patient will remain free
from infection.
The patient’s vital signs
will remain within their
baseline range for the
remainder of the shift.
1. Good handwashing 1. Hand washing is the 1. Goal met. The nurses
before and after best way to avoid as well as the patient
providing care. spreading pathogens. demonstrated good
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 2. Monitor temperature 2. Sustained temperature handwashing
q4h. elevation can indicate technqiue.
3. Monitor WBC count, an infection. 2. Goal met. Patient’s
as ordered. 3. Elevated total WBC temperature remained
(Phelps, et al, 2017) count indicates within the normal
infection. range.
(Phelps, et al, 2017) 3. Goal not met. Patient
did not have labs
ordered.
Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence-based care for the achievement of
quality client outcomes.”

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 References

Mayo Clinic (2019). Appendicitis. Retrieved from https://www.mayoclinic.org/diseases-conditions/appendicitis/diagnosis-

treatment/drc-20369549

Mayo Clinic, 2018). Triglycerides: Why do they matter? Retrieved from https://www.mayoclinic.org/diseases-conditions/high-blood-

cholesterol/in-depth/triglycerides/art-20048186

Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylors nursing diagnosis reference manual (10th ed.). Philadelphia, PA: Wolters

Kluwer.

Vallerand, A. H., Sanoski, C. A., & Delgin, J. H. (2017). Davis's drug guide for nurses (15th ed.). Philadelphia, PA: F. A. Davis.

ISBN-13: 9780803657052

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