Postoperative appendectomy after ruptured appendix

Diagnosis: Postoperative appendectomy after ruptured appendix Sara Lin is an 18-year-old Asian female who had an emergency appendectomy 2 days ago for a ruptured appendix. She is scheduled for discharge this afternoon with an order for oral antibiotics and oral pain medications.

The students are expected to make a focused pain assessment, decide the most appropriate pain intervention at this time, and administer the medication using safe medication administration techniques. They are also expected to provide education for managing pain at home after discharge.

Learning Objectives

General:

□ Assess patients to recognize normal versus abnormal findings

□ Respond to changes in patient status

□ Assume accountability for the plan of care by order of priority, implementation, and evaluation

□ Use standard precautions when caring for the patient

□ Ensure patient and healthcare provider safety

□ Collaborate appropriately with the healthcare team in a timely, organized, and patient-specific manner

□ Use critical thinking when making clinical judgments and decisions

□ Establish a therapeutic environment for the patients and their families

□ Use therapeutic communication techniques in a manner that illustrates caring for the patient’s overall well-being

Patient Case Introduction

Location: Surgical Unit 0800

Report from night shift charge nurse:

Situation: Sara Lin is an 18-year-old female patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today.

Background: Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive.

Assessment: Sara is alert and oriented, appropriate for age. She needs to be reminded to use her incentive spirometer. Abdomen is soft, tender to touch. Bowel sounds active. She has progressed to regular diet, and she’s eating small amounts. No nausea reported since postoperative day 1. The abdominal dressing was changed by the surgery team early this a.m. The incision is closed with staples; the edges are well-approximate and only slightly reddened with minimal serosanguinous drainage. Her sequential compression devices were discontinued, and her Jackson-Pratt drain was pulled this morning. A small amount of bleeding was present; no further bleeding is noted. This morning, she had her first small soft brown stool since surgery.

Recommendation: You will have to transition Sara to oral antibiotics and pain medication. She last had pain medication 4 hours ago. You will need to provide discharge patient education on incision care, pain medication and antibiotics, signs of postoperative infection, activity restrictions, and surgical follow-up.

Patient Details

Patient Data: Female, Asian, 18 years. Weight: 56 kg (124 lb), Height: 165 cm (65 in.)

DOB: 1/4/XX

Allergies: No known allergies

Immunizations: Up to date through tdap (tetanus, diphtheria, and pertussis booster) at age 15 years

Past Medical History: No previous hospitalizations or surgeries

 

 

Provider’s Orders

Day of surgery:

· Oxygen per nasal cannula to keep SpO2 greater than or equal to 95%

· Vital signs every 4 hours

· Incentive spirometry every 1-2 hours

· Diet: Clear liquids, advance as tolerated

· Foley to gravity

· Sequential compression devices

· Medication:

o IV 5% dextrose with 0.9% sodium chloride at 125 mL/hr

o Ceftriaxone 1 g IV every 12 hours

o Morphine sulphate 5 mg IV every 6 hours prn pain

o Ondansetron 4 mg IV every 8 hours prn for nausea or vomiting

o Docusate sodium 100 mg orally twice daily

· Call orders:

o HR less than 60/min, greater than 100/min

o RR less than 12/min, greater than 20/min

o SpO2 less than 92%

o Systolic BP less than 90 mm Hg, greater than 180 mm Hg

o Diastolic BP less than 50 mm Hg, greater than 100 mm Hg

o Temperature greater than 38.6 °C (101.5 °F)

Post-op day #1 orders:

· Activity: Bed rest, may be up with assistance to bathroom

· Discontinue Foley catheter

· IV to saline lock

· Discontinue sequential compression devices

· Medication:

o Discontinue IV morphine sulfate

o Discontinue IV ondansetron

o Oxycodone 5 mg orally every 4 hour

o Acetaminophen 325 mg orally every 4 hours

o Oxycodone 2.5 mg orally every 6 hours prn for breakthrough pain

Day of discharge:

· Discontinue IV ceftriaxone

· Discontinue saline lock upon discharge

· Medication:

o Oxycodone 5 mg orally every 4 hours prn for pain

o Acetaminophen 325 mg orally every 4 hours prn for pain

o Levofloxacin 500 mg orally daily for 7 days

· Activity: Up as tolerated at home

o No heavy lifting, no driving

o May shower, cover incision with dry dressing

· Discharge after 1500

· Schedule follow-up in Dr. Patel’s office in 1 week

Case Considerations

This case presents a female who had an emergency appendectomy 2 days ago for a ruptured appendix. She is scheduled for discharge this afternoon with an order for oral antibiotics and oral pain medications. The students are expected to make a focused pain assessment and decide, in collaboration with the patient, the most appropriate pain intervention at this time. Students are expected to

administer medications using safe medication administration techniques. They are also expected to provide patient education for managing pain at home after discharge. Pain management is an important aspect of postoperative care. Considered the fifth vital sign, pain is defined as the sensory and emotional experience associated with actual or potential tissue damage. Pain, therefore, includes not only the perception of an uncomfortable stimulus but also the response to that perception. Explain to the patient how pain medications work together with other pain management therapies to provide relief.