Process Information:

• This would indicate an infection within the body.

• Nil Known Allergies

• 32-year-old male

Situation

• 0900 Joshua Nguyen is admitted to the Emergency Department with persistent, periumbilical pain, nausea and vomiting over the past 12 hours.

Background: Nil Medical/Surgical history

Assessment:

• GCS 15: alert and orientated, PEARL, normal ROM.

• Vitals signs completed - see Obs. chart

• A FBC count and CT scan have been performed, and a diagnosis of acute appendicitis has been made.

• Objective data:

  • Pain 7/10 with movement and 6/10 with rest

  • Nausea and vomiting over the past 12 hours

• Subjective data:

  • Pain: Joshua complains of persistent periumbilical pain, stating, "The pain in my lower stomach is really bad."

  • Anxiety: "Being in a hospital for the first time has made me anxious.

  • Other: "I feel so sick - something is wrong."

Social History: Lives with his partner, Brian, in an inner-city apartment

Psychosocial History: Joshua is very anxious about his upcoming surgery as he has never been in a hospital before.

Admission charting complete

Recommendations:

• He is scheduled to undergo a laparoscopic appendicectomy as soon as an Operating Theatre is available.

• The surgeon is coming to discuss surgical consent for the procedure.

• No medications

• Takes a herbal supplement - Ginseng 200 mg once a day

Emergency Dept. Meds

PRN Meds:

• IV Morphine 1-2mgs every 15mins max dose 20mg/24hrs - PRN for pain

• IV Metoclopramide 10mins 8hrly - PRN for nausea

Scheduled Meds:

• IV Ceftriaxone 1gram BD for Appendicitis

Vital Signs:

• Resp 22

• 02 Sats 98%

• BP 120/70 normal

• HR 98 and 102

• Temp: 38.2 and 38.4

• Pain: 7/10 with movement and 6/10 with rest

• Urinalysis: Nil findings

Process Information:

• Resp. 22 elevated due to pain

• HR 98: normal parameters, but heading towards abnormal.

• HR 102 is above normal. This could be due to pain, anxiety and infection

• Temp febrile

• Pain is moderate at rest and increases to severe with movement.

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• Falls Risk Screen: 0 = Low Risk (> or equal to 9 = high risk)

• Water Pressure Ulcer Screening Assessment: Score 6 (low risk) - charted as 8

• Malnutrition Screening Tool (MST): Score 8 (low risk)

• Admission checklist

• Valuables: phone and clothes

Process Information:

• Waterlow score identified he is smoker

• Falls Risk: 0 - not at risk and independent mobilising

• Waterlow score: 6 - Low risk of pressure injury, even though below-average BMI (17.9), healthy skin

• What do we already know about Joshua? 

• Where did we get this information from?  

Other Nursing Assessments to Complete:

• Complete a focused assessment.

  • Which one would you conduct based on Joshua's admission history?

• Assess the severity of the infection:

  • Review laboratory results and radiology results.

  • Why is this important?

  • Would this change how often you conduct the vital signs and the type of patient assessment, such as changing to a primary survey?

• Diabetic Patients: If the patient is diabetic, obtain their blood glucose level (BGL) and ketone levels.