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Name: BM

Age : 15 years old

Weight : 61 Kg

Gender : Female

Reason for admission : Pt developed a sudden onset of abdominal pain which then shifted to her lower right quadrant. Symptoms include nausea with no vomitting. No fever and No chills.

History : No prior medical history. Healthy.

Medical Diagnosis: Acute Appendicitis

PEWS Score: 2+ (due to decreased blood pressure and increased HR)

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-Pipercillian and Tazobactam 3.375g IV Q6H

-Tylenol 650 mg PO Q4H PRN

-Morphine 2-4 mg IV Q2H PRN

-Gravol 25-50 mg IV/PO Q4H PRN

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On admission

WBC- 19.5 H

CRP 54 H

7/11/23  @08:52

WBC- 7.3

RBC-3.89 L

Hgb- 92 L

Hct- 0.31 L

MCV-79

RDW 17.5 H

Plt Count-143 L

Immature Gran- 0.1

Neutrophils- 6.8

Monocytes-0.2

Lymphocytes- 0.2 L

Eosinophils-0.1

Basophils -0.1

7/11/23 @08:52

Sodium- 137

Potassium- 3.0 L

Chloride- 109 H

Serum Bicarbonate- 16L

Anion Gap- 12

BUN- 3

Creatinine- 78

Lactic Acid-2.1

Imaging- Ultrasound to LRQ (inflamed appendix)

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-Resp rate of 20 breaths per minute (normal)

-Respirations are regular (normal)

-Expansion of chest is symmetrical (normal)

-No abdominal breathing (normal)

-No use of accessory muscles (normal)

-spO2 level 99% on Room Air (normal)

-Lungs sound clear bilaterally (normal)

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-state of consciousness is alert and oriented x3 (normal)

-Pt is easily rousable and reacts appropriately to stimuli (normal)

-Pt reports feeling dizzy at some times (Abnormal)

-Adequate ROM in all extremities (normal)

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-Heart rate tachycardic at 132 bpm (Abnormal)

-S1 and S2 heart sounds audible with no presence of murmur (normal)

-Peripheral capillary refill time of less than 2 seconds (normal)

-CWMS: pt is pale and clammy but warm to touch (Abnormal)

-Peripheral pulses are palpable and regular

-Dorsalis pedis pulses are palpable (Normal)

-Blood pressure 88/54 (69) (Abnormal)

-CWMS intact to laparoscopic incision on abdomen

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IV: NS w/KCl @125ml/hr. CWMS intact. Site is secure and has no redness.

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-Pain reported 6/10 using numeric scale (0 being no pain and 10 being a lot of pain) (Abnormal)

-Pain localized to the abdominal region. Not radiating. Present at rest. (Abnormal)

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-Family is of orthodox christian background as mother explains she is the only one practicing the faith

-Patient expresses that she is currently not active in her faith and does not practice at this time, but does keep in touch with her russian roots

-Patient expresses that she values family and respects the faith that her mother practices

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-Pt lives with her mother, father and brothers aged 15 and 17. She is the youngest of the family.

-Mother expresses that they have a lot of family members in Abbotsford that can provide support if needed

-Pt also expresses that she has friends from school that provide emotional support as well

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-Mother and 2 brothers currently at bedside

-Father will visit when he is off of work

-Mother expresses that they are a close family and live together (no strains in marriage)

-Grandparents live close by

-Family originates from Russia, as mom and dad immigrated to Canada but children are all born in canada

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Stressors : Pt expresses that being away from her family and friends makes her feel isolated and lonely. She is also worried about the perception of her condition and everything that she might be missing out on while she is not going to school

Coping:

- Pt relies on social media to keep her connected to her friends and family while she is in the hospital.

-pt also states that she listens to music to keep her mind off of her illness and surgery. This acts as a distraction for her

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Piaget: Formal Operational

-can think logically and form own opinions about treatment and medical conditions

-thinks about the future and ideological problems exhibited by expressing concern about surgery and how long her stay in the hospital may affect her life outside of the hospital

Erikson: Identity vs. Role confusion (Adolescent)

-Developing identity and role, as they are experiencing life and developing a strong sense of self. They value social circles and are learning how to navigate relationships

- Pt demonstrates that she she values her social circle and relationships because she is communicating with her friends constantly and wanting to go home as soon as possible to return to school

Gross & Fine Motor

-Reaching Maturity

Sensory

-Nothing Significant

Social/Cognition

Abstract Thinking : remains self centered, questioning moral values, understand duty and rights of others and gaining independence from family

-pt demonstrates this by being able to communicate her needs without her family being present at her bedside. Pt is taking responsibility for her medical condition and caring for herself.

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-Axillary temperature of 36.7

-4 incision sites to abdomen. CWMS Intact (significant)

-No bruises or rashes

-Skin turgor less than 1 second

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Gastrointestinal System

B.M presented with appendicitis which resulted in an appendectomy (GI), currently VS are HR: 132, BP: 88/54, T: 36.7, RR: 20, O2 sat is 99% on room air. Due to surgery B.M is at risk for hypovolemia due to blood and fluid loss (Shahi et al., 2021), as evidenced by increased HR (132) and decreased BP (88/54) (CV/GU). Bolus was given running @125ml/hr to counter the low blood pressure and increase fluid volume.Will continue to monitor vital signs Q1H to detect signs of deterioration.

HR changes can also be due to pain, anxiety and medications (Shahi et al., 2021). Pain can be due to cramps, abdominal gas build up and incision sites (Integ/GI). She rates her pain a 6/10 on numeric scale, PRN acetaminophen PO given. Will continue to monitor pain level and administrator acetaminophen to keep pain level at a baseline. Pt is also at risk for infection post surgery. At this time CWMS to incision sites intact and temperature is at 36.7, Pt had a past increased temperature so I will continue to monitor temperature and CWMS status to detect potential infection (Integ) Pt is receiving antibiotics.

Pt was NPO prior to surgery and Pt reports only urinating once post surgery, a very minimal amount and is not drinking adequately at this time (GU). Input at this time is 700ml and output is at 200ml. Will continue to monitor ins and outs and encourage oral liquids.

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-Mother at bed side and very supportive towards daughter

-2 brothers visiting providing support

-Pt is independent and able to care for self

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Priority Assessment Systems & Nursing Actions

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Priority Assessment Systems & Nursing Actions

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-Bowel sounds hyperactive in all 4 quadrants(abnormal)

-abdomen is round, distended, tender (abnormal)

-no masses palpated

-Passing flatus

-No BM after surgery

-Pt expresses feeling bloated, gassy and cramping in abdomen region this is due to the laparoscopic surgery (significant)

- Pt is not adequately drinking fluids at this time due to nausea and prior NPO status

-Pt ate only 20% of dinner and drank a quarter of a snack size booster juice smoothie

-Low potassium (given KCl) (abnormal)

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-No pain while voiding

-Pt expresses urine is clear, odourless and yellow in colour

-Pt expresses voiding once post surgery but very minimal amount

-Total urine output is 200ml post surgery