Nursing Children and Young People Assessment Answer

Introduction

The case study is about Siena who is 9 years old and has been partially immunized from Wagin in Western Australia. She was presented to the emergency department on account of one week’s history of abdominal pain and fever. At the emergency department, her ultrasound confirmed a perforated appendix. Appendicitis is an acute inflammation affecting the appendix (Xu, Adams, Liu, & Karpelowsky, 2017). In the US the condition affects 70000 cases per year for children aged 4-12 years. This translates to 1-2 cases per every 10,000 children per year (Fisher, et al., 2021). Meanwhile, the condition may be caused by other infections leading to abdominal pains.

Pathophysiology

Incidences of blockage and obstruction of the appendiceal orifice are the major reason for appendicitis. Depending on the different age groups the aetiology of obstruction may be different (Vaos, Dimopoulou, Gkioka, & Zavras, 2019). Inflammation of the appendix may also stem from lymphoid hyperplasia. Other scenarios may also include perforation and the development of a contained abscess. Candidly, the inflammation may also be caused by peritonitis. Obstructions are the major causes of appendicitis and it is the reason behind the increased fecaliths and benign and malignant tumours. Increased inflammation also leads to intraluminal and intramural pressure which will always lead to the tiny vessel’s occlusion (Gignoux, et al., 2018). The inflammations are also the causes of lymphatic stasis. The process of inflammation begins with obstruction and the filling of the appendix by the mucus. The appendix then appears distended and the lymphatic and vascular fluids then move and prevent fluid advancement to the other parts of the body. This is the reason Siena was having a nasogastric tube and indwelling catheter in situ to help in draining the fluids. The appendix walls consequently develop ischemic and necrotic conditions. Due to the exposure to intracellular fluids, the bacteria take advantage and begin their growth process which consequently obstructs the appendix (Eng, et al., 2019). The obstruction is also providing a favourable environment for aerobic and anaerobic reactions which lead to abdominal pains. Common bacterial infections may include E. coli, Pseudomonas, and Peptostreptococcus . If the inflammation persists then necrosis occurs leading to appendix perforation and causing abscessing and may sometimes also cause frank peritonitis (Khan, et al., 2018). The appendix, in this case, will assume the retrocausal position while the anatomical position in this case can vary from a tail position to or anatomical positioning of the root.

Nursing Assessment and Management

Nurses are supposed to help in the management of children such as Siena and prepare them adequately for surgery. Considering that Siena has a phobia for drugs the nurse should ensure that she is addressing this concern by encouraging and enlightening the patient on the consequences of not taking the drugs while also educating them on the advantages of taking drugs (Stringer, 2017). For a 9-year-old an unexpected surgery can be tragic especially if the patient is coming from a diverse cultural background. For this reason, Sienna's mother is supposed to be in charge and provide consent concerning her daughter's intervention procedures (Bhangu, Søreide, Di Saverio, Assarsson, & Drake, 2015). As a nurse, I have the duty of performing pre-operative assessment in an environment that is quiet, and enticing to the patient considering that she is very naive and has never been through surgery (Addiss, Shaffer, Fowler, & Tauxe, 2020). This will also require that I put the patient in a private room and assist her in remaining calm and positive while engaging in healthcare interventions to prevent further abdominal pains. I also have the duty of administering pharmacological and non-pharmacological management. In this case, I will administer pain-relieving drugs while non-pharmacological methods aimed at pain relief such as weight management, exercise and acupuncture.

Through the use of the pediatric assessment triangle, the primary assessment framework and also the pediatric acute recognition and response observation tools a nurse can be able to assess pediatric deterioration and therefore prioritize the kind of intervention and care that is to be given (Hamilton, Kamm, & Morrison, 2018). Through the initial assessment of the patient using the PAT model assessing the patient’s abdominal pain through palpation in a circular manner is to be done to detect the site of inflammation (Redden & Ghadiri, 2022). This assessment is going to help the patient in reducing abdominal pains. Appearance and looks together with interactiveness, sociability and the tone used with the patient are also very important during the observation process (Snyder, Guthrie, & Cagle, 2018). Examining other forms of inflammation and causes of appendicitis may also be very important.

The physical assessment of the pain may also begin with the doctor applying gentle pressure on the abdominal region that is affected by the pain. Releasing of the pressure suddenly may result in pain from appendicitis which is likely to signal the adjusted peritoneum that is inflamed (Awayshih, Nofal, & Yousef, 2019). The doctor is also supposed to look for abdominal rigidity while also looking at the tendency for the patient to still feel abdominal muscles while responding to pressure that is coming from the inflamed appendix. This process is known as guarding (Yang, et al., 2016). Using a lubricated glove, the doctor may also examine the lower rectum region for any form of appendicitis.

Using the PARROT procedure, it is possible to find out if the patient’s condition is deteriorating and therefore escalate the level of care. On arrival, Siena was alert, and her observations were: Temperature 38.6-degree, HR= 130 beats per minute, Oxygen saturation 90% on room air, RR= 28 breaths per minute with mild distress, BP = 100/70mmHg. The “family concern” scored "1" on the PARROT. It is estimated that Siena and her family will be on admission for at least 5 days

The score requires immediate and urgent medical review. Within the next 30 minutes, a blood test should be conducted to check the level of white blood cell counts which may also be an indication of infection (Withers, Grieve, & Loveland, 2019). Within the next 2 hours, blood and kidney test should also be conducted through urinalysis to ensure that the urinary tract infection is not because of the pain and hence the kidneys are safe (Pooler, Repplinger, Reeder, & Pickhardt, 2018). Before undertaking surgery, the patient may also be taken for imaging tests using MRI scans and CT scans to help in detecting abdominal inflammation. The use of technology comes in handy as this will help in confirming appendicitis and directly point at the cause of the pain.

Using the pediatric assessment triangle, it will be as necessary to assess the breathing if there is any compromise in the area. Using the results of the test it is also important to check on respirations on whether they are absent, decreased or moderate (Swenson, Ayyala, Sams, & Lee, 2019). From the case study, the temperatures are very high above normal indicating 38.6° c. This should be stabilized back. The heart rate of 130 beats per minute is also very high for 9 years old. Interventions should be made to reduce the pressure back to normal. The oxygen saturation is only 90% which is not normal and can lead to severe deterioration of the patient. This means that an intervention should be carried on to elevate the oxygen levels to 95% or 100% room air (Kim, et al., 2018). The patient is suffering from low blood pressure which should also be corrected from the case study. The tests are indicating that Sienna is continuously deteriorating and therefore should be closely monitored.

Further assessment should be done on the intravenous cannulas that are having a nasogastric tube and building catheter connected to a drainage bag. The aim of assessing these areas is to prevent pain and escalate the patient’s fear, pain and anxiety before she undergoes surgery (Hwang, 2018). Test on disability assessment is also done to determine the neurological state before the patient is taken to the theatre. This is because respiratory compromise has a way of affecting and leading to the inadequate profession of the brain and therefore, I affect the consciousness level of the patient. Due to the low oxygen levels in the blood, the patient should also be provided with enough oxygen before undergoing surgery. This will help in determining the amount of pain even though pain-relieving drugs have been administered (Kumar, Jalan, Patowary, & Shrestha, 2016). Since the surgical reports are showing three steri strips at the incisional sites it is also necessary to ensure that this pain is managed properly. The final component that must be assessed is the family assessment school which is 1. This is a poor score considering that the patient’s mother is undergoing some form of emotional distress. Counselling can be offered to elevate her self-esteem.

Health Promotion

Since Sienna is just about to undergo surgery, her mother is undergoing stress and anxiety. There is a need to provide counselling to her to reduce the risk of post-operative stress (Thambidorai & Aman, 2008). There is also a need to use the ABCDE assessment to ensure a proper post-operative baseline is determined so that the patient will be comfortable and recover very fast (Khashab & Kalloo, 2012). The patient’s weight is needed to help in calculating medication quantities while also ensuring that the fluids antibiotics and other pain relief medications are provided in the right doses (Van de Moortele, De Hertogh, Sagaert, & Van Cutsem, 2020). Involving Sienna's mother in observing any form of behavioural changes and assisting them being obtaining consent will help to contribute positively to Siena’s recovery.

Conclusion

Siena’s post-operative care and management will require collaboration between the healthcare address and the family. This is to ensure and overall well-being of the patient. The post-operative assessments will also ensure optimal health outcomes and positive experiences between the patient under the mother. This partnership is likely to ensure that the assessment frameworks have been adopted leading to the recovery of the patient’s health.

References

Addiss, D., Shaffer, N., Fowler, B., & Tauxe, R. (2020). The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. , 132(5):910-25.  DOI: 10.1093/oxfordjournals.aje.a115734

Awayshih, M., Nofal, M., & Yousef, A. (2019). Evaluation of Alvarado score in diagnosing acute appendicitis. Pan Afr Med J , 34:15. doi: 10.11604/pamj.2019.34.15.17803

Bhangu, A., Søreide, K., Di Saverio, S., Assarsson, J., & Drake, F. (2015). Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet , 386(10000):1278-1287. doi: 10.1016/S0140-6736(15)00275-5

Eng, K., Abadeh, A., Ligocki, C., Lee, Y., Moineddin, R., Adams-Webber, T., . . . Doria, A. (2019). Acute Appendicitis: A Meta-Analysis of the Diagnostic Accuracy of US, CT, and MRI as Second-Line Imaging Tests after an Initial US. Radiology , Sep;288(3):717-727. doi: 10.1148/radiol.2018180318

Fisher, J., Tomita, S., Ginsburg, H., Gordon, A., Walker, D., & Kuenzler, K. (2021). Increase in pediatric perforated appendicitis in the new York City metropolitan region at the epicenter of the COVID‐19 outbreak. Ann. Surg , 273: 410. doi: 10.1097/SLA.0000000000004426.

Gignoux, B., Blanchet, M., Lanz, T., Vulliez, A., Saffarini, M., Bothorel, H., . . . Frering, V. (2018). Should ambulatory appendectomy become the standard treatment for acute appendicitis. World J Emerg Surg , 13:28. doi: 10.1186/s13017-018-0191-4

Hamilton, A., Kamm, M., & Morrison, M. (2018). Proteus spp. as Putative Gastrointestinal Pathogens. Clin Microbiol Rev , 31(3). doi: 10.1128/CMR.00085-17

Hwang, M. (2018). Sonography and Computed Tomography in Diagnosing Acute Appendicitis. Radiol Technol , 89(3):224-237. doi: 10.2214/AJR.07.2955.

Khan, M., Chaudhry, M., Shahzad, N., Tariq, M., Memon, W., & Alvi, A. (2018). Risk of appendicitis in patients with incidentally discovered appendicoliths. J Surg Res. , 221:84-87. doi: 10.1016/j.jss.2017.08.021

Khashab, M., & Kalloo, A. (2012). NOTES: current status and new horizons. Gastroenterology , 142(4):704-710.e1. DOI: 10.1053/j.scrs.2012.10.008

Kim, D., Suh, C., Yoon, H., Kim, J., Jung, A., Lee, J., & Cho, Y. (2018). A Systematic Review and Meta-Analysis. . Visibility of Normal Appendix on CT, MRI, and Sonography: AJR Am J Roentgenol , 211(3):W140-W150. doi: 10.2214/AJR.17.19321

Kumar, S., Jalan, A., Patowary, B., & Shrestha, S. (2016). Laparoscopic Appendectomy Versus Open Appendectomy for Acute Appendicitis: A Prospective Comparative Study. Kathmandu Univ Med J (KUMJ) , 14(55):244-248. doi: 10.1097/SLE.0b013e3182754543

Pooler, B., Repplinger, M., Reeder, S., & Pickhardt, P. (2018). MRI of the Nontraumatic Acute Abdomen: Description of Findings and Multimodality Correlation. Gastroenterol Clin North Am , 47(3):667-690. doi: 10.1016/j.gtc.2018.04.010

Redden, M., & Ghadiri, M. (2022). Acute appendicitis with associated trichobezoar of feline hair. J Surg Case Rep , (3)133. doi: 10.1093/jscr/rjac133

Snyder, M., Guthrie, M., & Cagle, S. (2018). Acute Appendicitis: Efficient Diagnosis and Management. Am Fam Physician , 98(1):25-33. doi: 10.1001/jama.2021.20502

Stringer, M. (2017). Acute appendicitis. J Paediatr Child Health , 53(11):1071-1076. doi: 10.1111/jpc.13737

Swenson, D., Ayyala, R., Sams, C., & Lee, E. (2019). Practical Imaging Strategies for Acute Appendicitis in Children. AJR Am J Roentgeno , 211(4):901-909. doi: 10.2214/AJR.18.19778

Thambidorai, C., & Aman, F. Y. (2008). Laparoscopic appendicectomy for complicated appendicitis in children. Singapore Med J , 49(12):994-7. doi: 10.1016/j.jpedsurg.2009.03.037.

Van de Moortele, M., De Hertogh, G., Sagaert, X., & Van Cutsem, E. (2020). Appendiceal cancer : a review of the literature. Acta Gastroenterol Belg , 83(3):441-448. doi: 10.1055/s-0035-1564433.

Vaos, G., Dimopoulou, A., Gkioka, E., & Zavras, N. (2019). Immediate surgery or conservative treatment for complicated acute appendicitis in children? A meta-analysis. J Pediatr Surg , 54(7):1365-1371. doi: 10.1016/j.jpedsurg.2018.07.017.

Withers, A., Grieve, A., & Loveland, J. (2019). Correlation of white cell count and CRP in acute appendicitis in paediatric patients. S Afr J Surg , 57(4):40. doi: 10.1111/ans.13760

Xu, J., Adams, S., Liu, Y., & Karpelowsky, J. (2017). Nonoperative management in children with early acute appendicitis: a systematic review. J. Pediatr. Surg , 52: 1409–15. doi: 10.1016/j.jpedsurg.2017.05.003.

Yang, H., Wang, Y., Chung, P., Chen, W., Jeng, L., & Chen, R. (2016). Laboratory tests in patients with acute appendicitis. ANZ J Surg , 76(1-2):71-4. doi: 10.1111/j.1445-2197.2006.03645.x

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