Name: Kirstin Ansley Class/Group: NSG123 Med/Surg Date: 12/16/2024
Scenario
R.O. is a 12-year-old girl who lives with her family on a farm in a rural community. R.O. has four
siblings who have recently been ill with stomach pains, vomiting, diarrhea, and fever. They were seen
by their primary care provider (PCP) and diagnosed with viral gastroenteritis. A week later, R.O. woke
up at 0200 crying and telling her mother that her stomach “hurts really bad!” She had a temperature
of 37.9° C (100.2° F). R.O. began to vomit over the next few hours, so her parents took her to the
local emergency department (ED). R.O.’s vital signs, complete blood count, and complete metabolic
panel were normal, so she was hydrated with IV fluids and discharged to home with instructions for
her parents to call their PCP or to return to the ED if her condition did not improve or if it worsened.
Over the next 2 days, R.O.’s abdominal pain localized to the right lower quadrant. She refused to eat
and had slight diarrhea. On the third day, she began to have more severe abdominal pain, increased
vomiting, and fever that did not respond to acetaminophen. R.O. has returned to the ED. Her VS are
128/78, 130, 28, 39.5° C (103.1° F). R.O. is guarding her lower abdomen, prefers to lie on her side
with her legs flexed, and is crying. IV access is established, and morphine sulfate 2 mg IV is
administered for pain. R.O.’s white blood count is 12,000 mm 3 (12 x 109/L).
1. Which findings are common clinical manifestations of appendicitis? Select 4 options.
a. Fever
b. Diarrhea
c. Vomiting
d. Arthralgia
e. Constipation
f. Diffuse rash
g. Left lower quadrant abdominal pain
2. Underline the assessment findings that are consistent with appendicitis.
- Fever of 103.1 F and not responding to Tylenol
- Guarding her lower abdomen
-Localized right lower quadrant pain
-Increased WBC count at 12,000mm3
-Vomiting
-Diarrhea
3. Discuss why R.O.’s presenting clinical manifestations make diagnosis more difficult. Identify 2
other possible diagnoses.
, Her description to her PCP was very vague and since her family had a stomach bug recently, it was
easy to pin it on the viral gastroenteritis considering she was showing symptoms like vomiting,
generalized stomach pain, diarrhea, and a fever. Other diagnoses that could have been used for this
set of symptoms could be:
-Crohn’s Disease
-Inflammatory Bowel disease (IBD)
-Peritonitis
CASE STUDY PROGRESS
An abdominal CT scan confirms that R.O. has appendicitis. The ED physician has written orders.
Emergency Department Orders
1. Make patient NPO
2. Place a peripheral IV and begin D5 {1/2} NS at 80 mL/hr
3. Administer Fleet Enema now to rule out impaction
4. Administer morphine sulfate 2 mg IV q2h for pain
5. Obtain surgical consent from patient
6. Administer cefotaxime (Claforan) IVPB, at 50 mg/kg STAT
4. Note whether the orders are appropriate or inappropriate and give a rationale for each response.
- NPO: Appropriate – because she was confirmed by CT that she has appendicitis and surgery Is
the treatment option for this illness and requires the patient to be NPO to avoid aspiration of
vomit during the surgery.
- Placing PIV with D5 ½ NS: Appropriate – All patients surgical or not should have an IV placed
for emergent situations. In R.O.’s case she is going to be having surgery and she has lost fluids
due to vomiting and diarrhea so administering D5 ½ NS would also be appropriate because this
fluid maintains body fluids, nutrition and rehydration and she has no known history of diabetes
so this fluid would not place her at risk for hyperglycemia since it has dextrose in this fluid.
- Fleet Enema: Inappropriate – This would not be needed since the patient already has a
confirmed diagnosis of appendicitis via CT scan and if the patient was severely constipated it
would have shown on the abdominal CT scan.
Scenario
R.O. is a 12-year-old girl who lives with her family on a farm in a rural community. R.O. has four
siblings who have recently been ill with stomach pains, vomiting, diarrhea, and fever. They were seen
by their primary care provider (PCP) and diagnosed with viral gastroenteritis. A week later, R.O. woke
up at 0200 crying and telling her mother that her stomach “hurts really bad!” She had a temperature
of 37.9° C (100.2° F). R.O. began to vomit over the next few hours, so her parents took her to the
local emergency department (ED). R.O.’s vital signs, complete blood count, and complete metabolic
panel were normal, so she was hydrated with IV fluids and discharged to home with instructions for
her parents to call their PCP or to return to the ED if her condition did not improve or if it worsened.
Over the next 2 days, R.O.’s abdominal pain localized to the right lower quadrant. She refused to eat
and had slight diarrhea. On the third day, she began to have more severe abdominal pain, increased
vomiting, and fever that did not respond to acetaminophen. R.O. has returned to the ED. Her VS are
128/78, 130, 28, 39.5° C (103.1° F). R.O. is guarding her lower abdomen, prefers to lie on her side
with her legs flexed, and is crying. IV access is established, and morphine sulfate 2 mg IV is
administered for pain. R.O.’s white blood count is 12,000 mm 3 (12 x 109/L).
1. Which findings are common clinical manifestations of appendicitis? Select 4 options.
a. Fever
b. Diarrhea
c. Vomiting
d. Arthralgia
e. Constipation
f. Diffuse rash
g. Left lower quadrant abdominal pain
2. Underline the assessment findings that are consistent with appendicitis.
- Fever of 103.1 F and not responding to Tylenol
- Guarding her lower abdomen
-Localized right lower quadrant pain
-Increased WBC count at 12,000mm3
-Vomiting
-Diarrhea
3. Discuss why R.O.’s presenting clinical manifestations make diagnosis more difficult. Identify 2
other possible diagnoses.
, Her description to her PCP was very vague and since her family had a stomach bug recently, it was
easy to pin it on the viral gastroenteritis considering she was showing symptoms like vomiting,
generalized stomach pain, diarrhea, and a fever. Other diagnoses that could have been used for this
set of symptoms could be:
-Crohn’s Disease
-Inflammatory Bowel disease (IBD)
-Peritonitis
CASE STUDY PROGRESS
An abdominal CT scan confirms that R.O. has appendicitis. The ED physician has written orders.
Emergency Department Orders
1. Make patient NPO
2. Place a peripheral IV and begin D5 {1/2} NS at 80 mL/hr
3. Administer Fleet Enema now to rule out impaction
4. Administer morphine sulfate 2 mg IV q2h for pain
5. Obtain surgical consent from patient
6. Administer cefotaxime (Claforan) IVPB, at 50 mg/kg STAT
4. Note whether the orders are appropriate or inappropriate and give a rationale for each response.
- NPO: Appropriate – because she was confirmed by CT that she has appendicitis and surgery Is
the treatment option for this illness and requires the patient to be NPO to avoid aspiration of
vomit during the surgery.
- Placing PIV with D5 ½ NS: Appropriate – All patients surgical or not should have an IV placed
for emergent situations. In R.O.’s case she is going to be having surgery and she has lost fluids
due to vomiting and diarrhea so administering D5 ½ NS would also be appropriate because this
fluid maintains body fluids, nutrition and rehydration and she has no known history of diabetes
so this fluid would not place her at risk for hyperglycemia since it has dextrose in this fluid.
- Fleet Enema: Inappropriate – This would not be needed since the patient already has a
confirmed diagnosis of appendicitis via CT scan and if the patient was severely constipated it
would have shown on the abdominal CT scan.
