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Introduction to Specialty Practice: Paediatric Nursing

Case Study

The case study is about an 11-year-old girl Haley as she was administered in the community health centre with the issue of abdominal pain and blood glucose level of about 13mmols/L. Then she was transferred to the regional base hospital for further review after went she undergone for laparoscopic appendicectomy. The article is going to analyse the patient condition to provide her with the best assistance and reflecting upon the action.

The initial assessment of the patient revealed that she is having a higher respiration rate with an increased heart rate that directly indicates discomfort of the patient. The patient complains about abdominal pain that is about 9/10 that is the major issue of the patient. The temperature of the patient is also abnormal that is about 39.1 and the abdomen is the tenderness with palpation that indicate with Blumberg sign. After the assessment, it was evident that she was unable to have diet from the past 24 hours and now her blood glucose level is about 15.9mmols/l. Patient medical history reveals that she has type 1 diabetes mellitus which can lead to complication for the patient. Type1 diabetes is considered to be the autoimmune disorder that has led to the loss of insulin-producing beta cell and exogenous insulin that directly increase blood glucose level. The immune-mediated destruction of the insulin-producing beta cells in the pancreas leads to type 1 diabetes (Simmons & Michels, 2015).

She has recently undergone laparoscopic appendicectomy due to acute appendicitis. The acute appendicitis is the inflammation of the appendix that occurs because of the obstruction of the appendiceal orifice. Some symptoms associated with appendicitis include right quadrant abdominal pain, fever and tenderness in the stomach (Jones et al., 2019). After the surgery, she is maintaining her airways with a slightly high respiratory rate but has a normal respiratory effort. She has not passed urine after the operation and her bowels were last opened this morning with increase blood glucose level. Perioperative hyperglycemia management is very important to decrease the chances of complication that occur due to increase blood glucose level (Duggan et al., 2017).

Haley was able to manage her diabetes on her own with the help of the insulin pump that helps to self-manage the complication associated with diabetes. Self-management of diabetes is one of the best methods that utilize the patient skills to understand the disease and managing technique for associated complication (Zheng et al., 2019). Before administration to the hospital 3 days ago she has encountered with diarrhea, vomiting, decreased appetite and abdominal pain with fever some other issues that are raised after administration to the hospital include right-sided guarding with elevated lactate, WCC and CRP. The clinical feature associated with acute appendicitis includes abdominal pain, nausea, vomiting, bowel changes and diarrhea. Some other features that are associated with the disorder include abdominal tenderness; McBurney point tenderness and obturator sign (Hirsch & Colomb, 2017).

The ultrasound of the patient reveals that compressible appendix with increased wall thickness and free fluid in the abdominal cavity. The increased thickness of the appendix wall and fluid in the abdominal cavity directly indicate signs for the perforation. The increased complication leads to perforation and it increases the discomfort of the patient (Balogun et al., 2019). After surgery, she can maintain her airways with little increase in the respiratory rate but she is having normal respiratory effort. The postoperative pulmonary complication is a major issue that increases patient hospital stays thus nurses should continuously monitor the patient pulmonary function. The laparoscopic surgeries are associated with many respiratory complications that can increase individual complication thus proper assessment should be performed (Eikermann et al., 2019).

During the assessment, Haley appears to be pink with little warm and she was also well-perfused that indicate proper oxygen supply which leads to decrease chances of complication. Optimize organ perfusion assessment should be done after the surgery to analyse the oxygen supply rate. Inadequate organ perfusion can lead to decrease oxygen supply to the tissue which leads to the condition of the hypoxia (Parker et al., 2019). Harley assessment reveals that she is a little tachycardia that was settled by medication and she has normal blood pressure in recovery. Tachycardia is one of the important symptoms associated with postoperative that remain unexamined that can lead to complication of the patient thus nurses are expected to consider this during the post-operative assessment (Sigmund et al., 2017).

In the recovery, Harley was administered with three doses of IV morphine with the good effect as she was facing the pain of about 5/10. Post-operative pains are one of the major complications associated with increasing discomfort of the patient thus increase the need to provide accurate intervention to reduce pain. Morphine is considered to be one of bets analgesic that can be used to reduce post-operative pain but many side effects are associated with medicine so patient education and nursing monitoring are required (Nada & Alabdulkareem, 2018).

Harley reveals that she has passed urine preoperatively and her bowel was last opened in the morning that can increase complication. Her blood glucose level also increases that is managed by insulin infusion in-situ to decrease the blood glucose level up to normal range. The diabetic requires extra attention before during and after surgery as they are at higher to encounter a post-operative complication. The health care professionals are expected to continuously monitor and manage the blood glucose level of the patient to reduce the rate of the complication diabetic patient can encounter (Wang et al., 2018).

Haley has four lap sites with minimal ooze and there is nil drain in-situ with minimal blood loss. The surgical site infections are highly prevalent hospitals associated infection thus proper wound assessment should be performed to understand the current wound status. The nurses are expected to perform the accurate assessment and document it to reduce the chances of error that can occur during the next assessment (Ding et al., 2016).

One of the issues identified after the ABCDE assessment is the increase respiratory rate of the Haley that can increase pulmonary complication. Postoperative respiratory complications are more of the common issue that arises due to inadequate oxygen supply, increased respiratory rate or difficulty in breathing. The respiratory complication associated with many risk factors that include the duration of surgery, location of surgery and type of anaesthesia. The patient with an increased respiratory rate should provide accurate intervention to reduce the chances of further complication (Kelkar, 2015).

The surgical site is also one of the issues as improper management lead to an infection that can increase complication. The surgical site infection are most common hospital-associated infection that directly increases patient complication physically as well as economically as it increases hospital stay. Post-operative surgical site assessment and proper care is required to decrease the rate of the surgical site infection. The surgical site infection can occur after 30 or 90 days after the surgery so require extra care during this time to reduce chances of complication (Pogatzki-Zahn et al., 2017).

No urine output after the surgery is also one of the major issues that are related to the case study as it can increase the complication for the patient. The urological complications are not common as a postoperative complication of appendicectomy but children are considered to be at higher risk for the decrease urine output or urinary tract infection. The urological complication directly increases the discomfort of the patient by increasing toxic accumulation it the body (Hotonu & Milan Gopal, 2019). Post-operative pain is the complication that requires urgent attention as it directly increases the discomfort of the patient. The postoperative pain can be acute and chronic depending upon the intensity of the pain and pain scale score. The pain after the surgery can be initiated by the release of inflammatory mediators that lead to nociception. The untreated acute pain can be converted to the chronic pain that can increase the complication of the patient thus postoperative pain require urgent attention (Pogatzki-Zahn et al., 2016).

The three goals are established to improve the post-operative health status of the patient and reduce the chances of complication that can arise due to carelessness. These interventions will try to improve the current issue of the patient to improve the comfort of the patient.

The first goal that will be established to improve the health status of Haley will include improving her respiratory rate to increase the comfort of the patient. Normal respiratory rate will help to maintain the normal oxygen and carbon dioxide concentration in the body and the normal respiratory rate is of about 12-25 breath per min that changes with age (Chourpiliadis & Bhardwaj, 2020). The second goal will be to reduce the chances of surgical site infection by providing accurate wound management. The management help to improve the surgical site that directly reduces the chances of infection that can increase the patient.

Management process can include removal of the implant, retention of implant, antibiotic therapy and suppressive therapy (Kawakita & Landy, 2017). The third goal is to improve the urine output of the individual that will help to reduce the complication of the patient. The exercise can be utilized to improve the urine output of the individual that help to improve the muscle strength associated with urination. The decreased urine output of the individual can be corrected by performing an exercise that helps to improve the urine flow and reduce complication (Small, et al., 2017).

The breathing exercise intervention can be utilized to improve the respiratory rate of the patient as it helps to increase endurance and breathing capacity of the individual. The deep breathing exercise with the pursed-lip breathing technique will help to improve the breathing pattern and balance the respiratory rate. Deep breathing exercise will directly reduce the chances of respiratory complication and improve the breathing rate of the individual (Ünver et al., 2018). I will try to assist the patient during the exercise so that she can properly perform the exercise that can help her to improve the respiratory discomfort.

Patient and healthcare-associated engagement in the care is required to reduce the chances of surgical site infection. The patient education regarding the self-care of the wound can help to reduce the chances of infection. The health care associate working practises like hand hygiene and sterilized equipment use reduce the chances of complication (Tartari et al., 2017). I will try to help the patient to improve the understanding regarding the self-care technique and how avoiding the methods can increase chances of infection. I will also try to work according to the standard of practice to avoid chances of the infection.

Kegal exercise can help the individual to improve the urine output that is creating complication of the individual. The Kegal exercise will help to improve the strength of the muscle that directly helps to improve the urine output (Sayılan & Özbaş, 2018). I will try to help the patient with the therapist to understand and perform the exercise accurately. I will help the patient to understand the importance of exercise and accurate position that can be used for the exercise.

Haley will be assessed at a regular time interval to understand her condition and effect of the intervention over her health. I will perform the pain assessment to understand the intensity of the post-operative pain. I will evaluate the effect of the breathing exercise over the patient respiratory rate and if she still has any respiratory issue I will try to reframe the intervention as per the patient need. The surgical site assessment will be continuously performed to reduce the chances infection and I will utilize my clinical skills to manage the surgical site infection. The kegal exerciser performed by the patient will be continuously monitored to evaluate the effect of the exerciser over urine output. I will also try to continuously assess the urine output of the patient to understand the effect and there is requirement intervention can be changed to increase the comfort of the patient. I will help Haley to understand the current health condition and how she can utilize her self-management skill to maintain good health status. The blood glucose level of the patient will be continuously evaluated that helps to keep the record as the deviation in the BGL can affect the patient health status.

Next time I will try to improve the assessment process so that early assessment can be done to reduce the chances of complication that can increase complication. In future working, I will try to improve the time management that helps me to provide quality of care to the patient by managing all the related work. Clinical thinking is also one of the key aspects in the nursing profession that I will try to utilize in future practice which will help me to improve the assessment process of the patient that directly improve the treatment process. The importance of teamwork is also important in clinical practice and I will try to improve my rapport with the team members that will help in the patient care. This scenario helped to understand the different nursing skills that are required to improve the working practice and I will try to incorporate my learning from this scenario in future to improve the quality of care.

References

Balogun, O. S., Osinowo, A., Afolayan, M., Olajide, T., Lawal, A., & Adesanya, A. (2019). Acute perforated appendicitis in adults: Management and complications in Lagos, Nigeria. Annals of African Medicine, 18(1), 36–41. https://doi.org/10.4103/aam.aam_11_18

Chourpiliadis, C. & Bhardwaj, A. (2020). Physiology, Respiratory Rate. Treasure Island, United Kingdom: StatPearls Publishing.

Ding, S., Lin, F., Gillespie, B. M. (2016). Surgical wound assessment and documentation of nurses: an integrative review. Journal of Wound Care, 25(5), 232‐240. DOI:10.12968/jowc.2016.25.5.232

Duggan, E. W., Carlson, K., & Umpierrez, G. E. (2017). Perioperative hyperglycemia management: an update. Anesthesiology, 126(3), 547–560. https://doi.org/10.1097/ALN.0000000000001515

Eikermann, M., Santer, P., Ramachandran, S. K., & Pandit, J. (2019). Recent advances in understanding and managing postoperative respiratory problems. F1000Research, 8(197), 1-9. https://doi.org/10.12688/f1000research.16687.1

Hirsch, T. M. & Colomb, D. (2017). Acute appendicitis. Journal of the American Academy of Physician Assistants, 30(6), 46-47. DOI: 10.1097/01.JAA.0000516357.34621.aa

Hotonu, S. A. & Milan Gopal, M. (2019). Bladder injury in a child during laparoscopic surgery. Journal of Surgical Case Reports, 2019(2), 1-2. https://doi.org/10.1093/jscr/rjz043

Jones, M. W., Lopez, R. A. & Deppen, J. G. (2019). Appendicitis. Treasure Island, United Kingdom: StatPearls Publishing.

Kawakita, T., & Landy, H. J. (2017). Surgical site infections after cesarean delivery: epidemiology, prevention and treatment. Maternal health, neonatology and Perinatology, 3(12), 1-9. https://doi.org/10.1186/s40748-017-0051-3

Kelkar K. V. (2015). Post-operative pulmonary complications after non-cardiothoracic surgery. Indian journal of anaesthesia, 59(9), 599–605. https://doi.org/10.4103/0019-5049.165857

Nada, E. M., Alabdulkareem, A. (2018). Morphine versus fentanyl patient-controlled analgesia for postoperative pain control in major hepatic resection surgeries including living liver donors: A retrospective study. Saudi Journal of Anaesth, 12, 250-255.

Parker, T., Brealey, D., Dyson, A., & Singer, M. (2019). Optimising organ perfusion in the high-risk surgical and critical care patient: a narrative review. British journal of anaesthesia, 123(2), 170–176. https://doi.org/10.1016/j.bja.2019.03.027

Pogatzki-Zahn, E. M., Segelcke, D., & Schug, S. A. (2017). Postoperative pain-from mechanisms to treatment. Pain reports, 2(2), 1-16. https://doi.org/10.1097/PR9.0000000000000588

Pogatzki-Zahn, E. M., Segelcke, D., & Schug, S. A. (2017). Postoperative pain-from mechanisms to treatment. Pain reports, 2(2), 1-16 https://doi.org/10.1097/PR9.0000000000000588

Sayılan, A. A., & Özbaş, A. (2018). The effect of pelvic floor muscle training on incontinence problems after radical prostatectomy. American journal of men's health, 12(4), 1007–1015. https://doi.org/10.1177/1557988318757242

Sigmund, A. E., Fang, Y., Chin, M., Revnolds, H. R. (2017). Postoperative tachycardia: the clinically meaningful or benign consequence of orthopaedic surgery? Mayo Clin Proc, 92(1), 98‐105. DOI:10.1016/j.mayocp.2016.08.005

Simmons, K. M., & Michels, A. W. (2015). Type 1 diabetes: A predictable disease. World journal of diabetes, 6(3), 380–390. https://doi.org/10.4239/wjd.v6.i3.380

Small, D. M., Beetham, K. S., Howden, E. J., Briskey, D. R., Johnson, D. W., Isbel, N. M., Gobe, G. C. & Coombes, J. S. (2017). Effects of exercise and lifestyle intervention on oxidative stress in chronic kidney disease. Redox Report, 22(3), 127-136, DOI: 10.1080/13510002.2016.1276314

Tartari, E., Weterings, V., Gastmeier, P., Rodríguez Baño, J., Widmer, A., Kluytmans, J., & Voss, A. (2017). Patient engagement with surgical site infection prevention: an expert panel perspective. Antimicrobial resistance and infection control, 6(45), 1-9. https://doi.org/10.1186/s13756-017-0202-3

Ünver, S., Kıvanç, G., & Alptekin, H. M. (2018). Deep breathing exercise education receiving and performing status of patients undergoing abdominal surgery. International journal of health sciences, 12(4), 35–38.

Wang, Y., Hu, S., Ying, H., Chen, L., Li, H., Tian, F. & Zhou, Z. (2018). Postoperative tight glycemic control significantly reduces postoperative infection rates in patients undergoing surgery: a meta-analysis. BMC Endocrine Disorder 18(42), 1-12. https://doi.org/10.1186/s12902-018-0268-9

Zheng, F., Liu, S., Liu, Y., & Deng, L. (2019). Effects of an outpatient diabetes self-management education on patients with type 2 diabetes in China: a randomized controlled trial. Journal of diabetes research, 2019, 1-7. https://doi.org/10.1155/2019/1073131

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