Introduction
Complaining about right lower quadrant pain, nausea, vomiting, and fever for the last couple of days, S. M. visits the emergency department. He is a seven-year-old boy. His symptoms may require additional assessment and management. The pediatric unit admitted him, and a surgical consultation revealed that he urgently needed a laparoscopic appendectomy. Transport to the PACE is expected for him within an hour. Assessing S. and ensuring that sending him into surgery is secure are critical responsibilities for me as his primary nurse.
Assessment and Decision Making
The crucial factor in evaluating whether S. is fit for surgery depends on his assessment. The green Lippincott Advisor links to the Preoperative Care Pediatric Clinical Decision Support Tool, a comprehensive guide that provides the assessment and decision-making process for a pediatric patient undergoing surgery (Ricci et al., 2020). Healthcare professionals can utilize this tool to ensure the best care for their young patients. The CDS tool suggests monitoring the patient’s vital signs before surgery.
The patient’s vital signs, including temperature, heart rate, respiratory rate, and blood pressure, are carefully observed (Webster et al., 2019). It is necessary to assess any potential risk factors that could impact the patient’s capacity to handle surgery, like medical comorbidities or allergies, before proceeding with the procedure (Webster et al., 2019). Evaluating all psychosocial issues that could impact the patient’s recovery is necessary.
S. can safely undergo surgery, according to the CDS tool evaluation. With a temperature of 99.5°F, a higher-than-average pulse rate of 112 BPM was also observed, with twenty-four breaths taken in one minute and a blood pressure measurement reading of 112/78 mmHg. No known medical comorbidities, allergies, or psychosocial issues will affect his ability to tolerate the surgery. Besides, there are no present infections or other issues that would contradict the feasibility of surgery. S. can be sent for surgery safely based on this assessment. In addition, the Notes section of the chart contains all pertinent evidence to justify this decision.
Postoperative Care
According to the examination results, stable vital signs within the normal range indicate that S. recovers well after the surgery. Also, no signs of breathing problems were found, and his lungs seemed clear. He has some postoperative pain, anticipated after abdominal surgery, as his abdomen is tender in all quadrants and slightly firm. Due to the absence of bowel sounds, he is NPO, as expected after abdominal surgery.
Additionally, he receives 1/2 NS through a peripheral IV at a rate of 50 mL per hour, demonstrating that he is hydrated and getting the needed fluids. The determination made based on this assessment is that the nurse’s immediate response is not necessary for S.. Monitoring him closely for any changes in his condition is advisable, however. It is essential to prioritize S.’s comfort and pain management.
Medication Administration
The doctor has prescribed giving the patient 3.0/0.375 gm IV x 1 of piperacillin sodium and tazobactam sodium. Before administering this medication, evaluating the patient’s fitness for taking it is significant for ensuring safety. This order intends to address any possible infection caused by the surgery, such as appendicitis. Evaluating symptoms like fever, elevated WBC count, and deviant laboratory values is critical in detecting infections. The evaluation of the patient’s history for allergies or hypersensitivity is crucial before administering this medication.
Assessing the patient for drug interactions with other medications is also necessary. In addition, an evaluation is necessary to check if the patient is getting sufficient hydration. Taking the medication at a dose within the safe range of 2.0- 4.0 g given through IV is recommended. The examination concludes that administering this medicine to a patient with a suitable dose range would be secure.
All six essential components of medication administration are outlined in detail within this provider’s order to guarantee safe practice; these include selecting the proper drug for a specific patient at an accurate dosage via an optimal route during an ideal timeframe while recording information meticulously. These rights ensure safe and effective medication administration. Providing education to the patient and family regarding the medication is crucial.
Encompassed with this is information about common side effects, what symptoms one should be alert for, and when to contact their medical practitioner if they experience any apprehension. It has been established through an assessment that giving this medication is safe, and all of its corresponding orders are accurately recorded in the MAR. The Administration Notes also contain documentation of the reason for administering the medication.
Conclusion
Assessing and managing S. M. is crucial to his successful recovery from the surgery. During the assessment, it was noted that S.’s vital signs were stable and within normal limits, which implies recovery from surgery. Also, his hydration status was sufficient without any indications of an infection or contraindications for the medicine given. The assessment concluded that S. was a good fit for the surgery and was safe to proceed.
S.’s vital signs were stable and within normal limits during his recovery from the surgery. He was also getting sufficient fluids and had no indications of infection. A system for managing his discomfort was implemented to ensure S.’s comfort and control of his pain. Also, an evaluation for safety was done on the medication ordered before it was administered, and its orders were documented in the MAR. Overall, S.’s assessment and management were done securely and effectively to ensure he recovers successfully after his surgery.
References
Ricci, S., Kyle, T., & Carman, S. (2020). Maternity and pediatric nursing (4th ed.). Wolters Kluwer.
Webster, J., Sanders, C., Ricci, S., Kyle, T., & Carmen, S. (2019). Canadian Maternity and Pediatric Nursing. Lippincott Williams & Wilkins.