NR 328 Week 8 Pediatric Appendicitis Case Analysis Example

Case Study Analysis: A 5-Year-Old With Belly Pain Who Said It Stopped Hurting, Read in the Order the Findings Came

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College of Nursing, Chamberlain University

NR 328: Pediatric Nursing

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Case Study Analysis: A 5-Year-Old With Belly Pain Who Said It Stopped Hurting, Read in the Order the Findings Came

Findings in the Order They Arrived

The case follows Mateo, 5 years old and 19 kilograms, through a Sunday on a pediatric observation unit; details have been changed. It is read here in the order the findings arrived, with each value set against what a 5-year-old is expected to show. The unit's age chart gives a waking heart rate of roughly 80 to 120 and a breathing rate in the low to middle 20s for his age.

0900, on arrival from the emergency department. His mother says the pain started around his belly button last night and "moved to the right side" this morning. He vomited twice and refused breakfast, which she says he never does. Temperature 37.9 C. Heart rate 118, at the top of the range for his age but reasonable for a child in pain. He walks bent forward and will not hop. His right lower abdomen is tender. His white count is 14,800 with mostly neutrophils. Ultrasound did not see the appendix clearly. The surgical team plans to observe and re-examine at 1300.

Read against the Pediatric Appendicitis Score, which Samuel (2002) developed from 1,170 children aged 4 to 15, Mateo already has most of the features the score counts: pain that moved to the right lower abdomen, loss of appetite, vomiting, fever, tenderness at the right lower quadrant, pain with hopping, and a high white count with neutrophils. He is not a child with vague belly pain. He is a child in whom appendicitis is likely, being watched because the scan was not conclusive.

Holding

1100. Heart rate 112, temperature 38.0 C, breathing 24. He is lying on his side with his knees bent, watching a cartoon, and says his tummy "hurts a lot." He has had one dose of intravenous morphine and fluids at maintenance. He is still holding: his numbers have not moved much, his pain is where it was, and his behavior fits a child with a sore belly who has had some pain relief. The reserve question at this point is simple: he is uncomfortable but compensated.

One thing at 1100 deserves a note because it can mislead. The morphine dose makes him more comfortable and may soften what the abdomen reveals when it is examined, and it can blunt a rising heart rate. The surgical team is aware of this and has asked for the re-examination at 1300 to be done when the dose is wearing off. For the nurse, the practical point is that comfort after morphine is expected and says little about whether the appendix is getting worse. What would say more is a change that morphine does not explain: a rising fever, a heart rate that climbs rather than settles, or tenderness that spreads.

The Turn

1230. His mother calls the nurse, relieved: "He says it doesn't hurt anymore." Mateo is lying still on his back, pale, with his eyes half closed. Heart rate 138. Temperature 38.9 C. Breathing 30, shallow. His abdomen, which was tender only on the right, is now tender everywhere and firm, and he cries out when the bed is bumped.

This is the turn. A child with appendicitis whose pain suddenly eases, while his heart rate rises, his fever climbs and his whole abdomen becomes tender, has not improved. The easing is typical of the moment the appendix perforates, when the pressure inside it is released, and the tenderness spreading across the abdomen is the start of peritonitis. His heart rate of 138 is now well above the range for his age, and his fast, shallow breathing is how a child limits the movement of an inflamed abdomen. He is lying still because moving hurts, not because he is resting.

The entries before 1230 pointed the same way. The fever was edging up at every set, 37.9 then 38.0, and the heart rate never fell back into the middle of his range despite morphine. Those were not alarms on their own, and it would be unfair to say they should have been. But they were consistent with a process that was continuing rather than settling, and they were the reason the surgical re-examination had been planned for 1300.

What the Nurse Does, and Says

At 1232 the nurse calls the surgical resident directly rather than waiting for the 1300 review: "Mateo in bed 4, possible appendicitis, says the pain has stopped but his heart rate is 138, temp 38.9, and his whole belly is now tender and rigid. I think he may have perforated. Can you see him now?" The nurse stays with him, keeps him nil by mouth, checks that his intravenous line is running, and prepares for the antibiotics and fluid bolus the resident is likely to order. The resident arrives at 1240, and Mateo goes to the operating room at 1415, where a perforated appendix is found.

The Adult's Strand

His mother's account ran through the whole case, and it was accurate at every point. Her report that the pain had moved was the first clue in the case. Her comment that he never refuses breakfast told the team that his loss of appetite was real. And her words at 1230, "He says it doesn't hurt anymore," were an honest report of what her son told her. Her conclusion, that he was better, was the natural one for a parent to reach. The nurse's job at that moment was to take the report seriously and the conclusion carefully, and to explain gently why the team was worried when she was relieved. The nurse said: "I'm glad he's more comfortable, and I need the surgeon to see him now, because when this kind of pain suddenly stops, it can mean the appendix has burst."

An Ending in the Family's Words

On the second day after surgery, Mateo was walking to the playroom with his drain in place and antibiotics running. His mother told the nurse: "I would have taken him home at lunchtime if you'd let me. I thought the pain stopping was good news." That sentence is the most useful thing in the case for teaching. For this family, going home, the teaching focused on what she already knew how to watch, and on one change to her reading of it: if Mateo's belly pain comes back, or if he gets a fever again, or if the pain eases but he looks more unwell, she calls the surgical clinic that day. Pain stopping is only good news when he looks better too.

References

Samuel, M. (2002). Pediatric appendicitis score. Journal of Pediatric Surgery, 37(6), 877-881. https://doi.org/10.1053/jpsu.2002.32893