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LaGuardia Community College
City University of New York
Practical Nursing Program
SCL 116 Pediatric Nursing
Case Study
Presentation
by
Marie Jimenez, SPN
Client’s Initials: A.H.
Client’s Age: 7
Primary Diagnosis: Appendicitis, Peritonitis
Image courtesy of: radiologyassistant.nl
CLIENT INFORMATION
Data Collected:
A.H. is a 7-year-old female who was admitted on 11/04/07 for appendicitis with
peritonitis. A.H. was received in bed in the supine position watching cartoons and states of
feeling no pain. Pt. was cooperative and talkative. A.H. is alert and oriented times three.
Pt. weighs 37.1kg. IV site on the client’s right hand showed no redness or swelling. Pt. was
given Flagyl (275mg IVPB) & Gentamicin (275mg IVPB). Pt. was put on a soft diet. Vitals
were T – 99.1, P – 82, R – 15, BP – 100/61.
Etiology of Appendicitis
Appendicitis occurs when there is an inflammation or obstruction of the appendix.
The appendix is located on the lower right side of the abdomen. As food passes along the gastrointestinal tract through the stomach and intestines, food also passes through the appendix.
Therefore, when an obstruction or inflammation of the appendix occurs, the pain “localizes in the
right lower quadrant (RLQ) of the abdomen”(Leifer, 2007, p. 651).
According to Sommers & Johnson, some of the causes of appendicitis occur when there
is “a fecalith (hard mass of feces), a foreign body in the lumen of the appendix, fibrous disease of
the bowel wall, infestation of parasites or twisting of the appendix by adhesions”(Sommers &
Johnson, 200, p 105). These possible causes of appendicitis may cause localized pain however,
when the pain becomes systemic, the disease spreads to other parts of the body as evidenced by
peritonitis(Leifer, 2007).
Etiology of Peritonitis
Peritonitis occurs when the peritoneum becomes inflamed. The peritoneum consists of
two sac-like layers that cushions and protects the abdominal organs from other organs within the
body and other foreign particles. According to Sommers & Johnson, “although the peritoneum
walls of contamination to prevent the spread of infection, if the contamination is massive or
continuous, the defense mechanism may fail, resulting in peritonitis”(Sommers & Johnson,
2002, p. 755).
The causes of peritonitis can occur both from internal and external sources. These
sources may originate from infections such as E. coli, streptococci, staphylococci, inflammation
within the bloodstream, and external sources such as a gun shot wound(Sommers & Johnson,
2002, p. 755).
GROWTH AND DEVELOPMENTAL TASKS
The developmental growth ascribed to the age level of my client, according to Santrock,
occurs during “6 to 11 years of age, approximately corresponding to the elementary school
years”(Santrock , 2000, p. 321). At this level of development, children become more involved
with reading and writing skills and tend to think more logically than being imaginative. The
following chart gives a comparison of my client’s responses and the major developmental
theroists that examines the stage at which school-age children think, behave, and act.
COMPARISON OF MAJOR DEVELOPMENTAL THEORISTS
Age
Erikson
Freud
Piaget
Actual Client
Results
6 years of age
until puberty
6 years of age
and puberty
7 to 11 years
of age
A.H. is 7 years old
Industry vs.
Inferiority
Latency Stage
Concrete operational
Occurs when the
child represses all
interest in sexuality
and develops social
and intellectual skills
Involves using
operations, and
logical reasoning
replaces intuitive
reasoning, but only in
concrete situations
A.H. was very
inquisitive and
seemed more
interested in learning
about her medical
condition when I
interacted with her.
She stated, “I want to
become a doctor one
day so that I can help
people”.
This activity
channels much of the
child’s energy into
emotionally safe
areas and aids the
child in forgetting
the highly stressful
conflicts of the
phallic stage
Characterized by a
lack of abstract
thinking but
classification skills
are present.
Reasoning is logical
but limited to own
experience,
understands cause and
effect
Stage
Industry is achieved
by mastering
knowledge and
intellectual skills,
when children don’t
achieve this mastery,
they feel inferior
Task
Put their energy into
learning academic
skills, if they don’t
they feel inadequate
and incompetent
Upon socially
interacting with the
client, A.H. talked
about her favorite
subjects in school
and was curious
about my stethoscope
asking what is the
purpose of using a
stethoscope.
PHYSICAL CHARACTERISTICS
According to Leifer, during the stage of physical development in the school-age group is
that “the average weight gain in weight per year is about 2.5 to 3.2kg (5.5 to 7 pounds)”(Leifer,
2007, p. 430). My client’s weight is 37.1kg (81.1lbs).
In reference to vital signs, according to Leifer, “the vital signs of the child of school age
are near those of the adult. The temperature is 37ºC (98.6ºF), pulse is 85 to 100 beats/min,
respirations are18 to 20 breaths/min. The systolic blood pressure ranges from 90 to 108 mmHg;
the diastolic blood pressure ranges from 60 to 68 mmHg”(Leifer, 2007, p. 430).
My client’s temperature was 99.1ºF. My client’s pulse was 82, respiration was 15, and
blood pressure was 100/61 which shows that A.H. was within normal limits of the vital sign
range.
DIET
Upon my observation with the client, I noticed that A.H. had no appetite and no desire to
eat her dinner. The diet of my client consisted of a soft diet which included the following:
-1/2 cup of soup
-3 oz. of chopped meat
-1/2 cup of starch
-1/2 cup of chopped vegetables
-soft dessert
-1 slice of bread with margarine
-8 oz. tea
-8 oz. milk
MEDICATIONS
Medication Name
Medication
Dosage
Medication Route
Time of
Administration
1.Genericmetronidazole
Trade-Flagyl
275 mg
IVPB
(Intravenous
Piggyback)
q6h
(every six hours)
2. Generic –
gentamicin
Trade Garamycin
275 mg
IVPB
(Intravenous
Piggyback)
q.d.
(every day)
Purpose of Drug
 Perioperative
prophylactic agent
in colorectal
surgery
 Is used to treat
gram negative
bacillary infections
and infections
caused by
staphylococci
when penicillins or
other less toxic
drugs are
contraindicated
DIAGNOSTIC LABORATORY TESTS
Serum Laboratory Test
1. WBC (white blood cell
count)
2. RBC (red blood cell
count)
Purpose of Lab Test
 is used to determine
infection or
inflammation,
determine need for
further tests. An
elevated WBC count
commonly signals
infection, such as an
abscess, meningitis,
appendicitis
 is used to provide data
for calculating MCV
and MCH, which
reveal RBC size and
Hb content and support
other hematologic tests
for diagnosing anemia
or polycythemia
Normal Values
Infant:
6.0 – 7.5
k/uL
Preschooler: 5.5 – 15.5
k/uL
School-aged: 4.5 – 13.5
k/uL
Adolescent: 4.5 – 11
k/uL
Infant:
2.7 – 5.4
million/uL
Preschooler: 4.27
million/uL
School-age: 4.31
million/uL
Adolescent: 4.60
million/uL
Actual Client Results
29.6 k/uL
(School aged: Abnormally
high)
5.06 million/uL
(School-age)
3. Hemoglobin (Hb)
4. Hematocrit (Hct)
 is used to measure the
severity of anemia or
polycythemia and to
monitor response to
therapy
Age 1 to 3 days: 14.5 –
22.5 g/dL
Age 2 months:
9.0 –
14.0 g/dL
Age 6 to 12 years: 11.5 –
15.5 g/dL
Age 12 to 18 years:12.0 –
16.0 g/dL
 low hematocrit levels
suggest anemia,
hemodilution or
Newborn:44 – 75%
Infant: 28 – 42%
Age 6 to 12: 35 – 45%
15.0 g/dL
(School-age)
43.2%
(School-age)
Serum Laboratory Test
1. Prothrombin Time (PT)
massive blood loss
Purpose of Lab Test
 is used to evaluate the
extrinsic coagulation
system and to monitor
response to oral
anticoagulant therapy
Adolescent: 36 – 49%
Normal Values
Newborn:
12 – 21
seconds
All other ages: 11 – 15
seconds
Actual Client Results
15.6 seconds
(Abnormally high)
6. Red Cell Indices
 is used to aid in the
diagnosis of anemias
7. Red Cell Distribution
Width (RDW)
8. Mean Platelet Volume
(MPV)
9. White Blood Cell
Differential
 increased RDW
indicates mixed
population of RBCs;
immature RBCs tend
to be larger
 measures the average
volume (size) of your
platelets. Higher-thannormal MPV is
associated with an
increased risk of heart
attacks and stroke
 is used to evaluate the
body’s capacity to
resist and overcome
infection and
determine stage and
severity of an
infection, also used to
detect types of
leukemia
MCV: 84 – 99 um³
MCH: 26 – 32 pg/cell
MCHC: 30 – 36 g/dL
MCV: 85.4 um³
MCH: 29.6 pg/cell
MCHC: 34.7 g/dL
11.0 – 15.0
12.8
7.5 – 11.5
8.8
Segmented Neutrophils:
50 – 65%
Lymphocytes:
Monocytes: 4-9%
Eosinophils: 1-¹%
Segmented Neutrophils:
88.1%
Lymphocytes: 6.8%
Monocytes: 5.0%
Eosinophils: 1.0%
Chemistry Laboratory
Test
1. Sodium
2. Potassium
3. Chlorine
4. Carbon Dioxide
5. Blood Urea Nitrogen
(BUN)
6. Glucose
7. Creatine
8. Calcium
Purpose of Lab Test
 is used to evaluate
fluid/electro-lyte and
acid-base balance and
related neuromuscular,
renal, and adrenal
functions
 is used to evaluate
clinical signs of
hyperkalemia or
hypokalemia
 is used to detect
acidosis or alkalosis
and to aid evaluation of
fluid status and
extracellular cationanion balance
 is used to detect
changes in CO2 levels
because these levels can
indicate the loss or
retaining of fluids
which causes an
electrolyte imbalance
 is used to evaluate
kidney function and aid
in the diagnosis of renal
disease
 is used to screen for
diabetes mellitus and to
monitor drug or diet
therapy in the DM
patient
 is used to assess
glomerular filtration in
the kidneys and screen
for renal damage
 is used to evaluate
endocrine function,
calcium metabolism,
and acid-base blanace
Normal Values
Premature infant: 132140 mEq/L
Infant: 139 – 146 mEq/L
School aged : 138 – 145
mEq/L
Adolescent : 136 – 145
meq/L
Infant: 4.1 – 5.3 mEq/L
School age: 3.4 – 4.7
mEq/L
Adolescent: 3.5 – 5.1
mEq/L
98 – 106 mEq/L
Infant: 27 – 41 mmHg
Child (male): 35 – 48
mmHg
Child (female): 32 – 45
mmHg
Newborn: 8 – 18 mg/dL
Infant or child: 5 – 18
mg/dL
Adolescent: 8 – 17 mg/dL
40 – 100 mg/dL
Infant: 0.2 – 0.4 mg/dL
Child: 0.3 – 0.7 mg/dL
Adolescent: 0.5 – 1.0
mg/dL
Full-Term infant: 7.5 – 11
mg/dL
Child: 8.8 – 10.8 mg/dL
Adolescent: 8.4 – 10.2
mg/dL
Actual Client Results
134 mEq/L
(School age: Abnormally
low)
5.7 mEq/L
(School age: Abnormally
high)
100 mEq/L
21 mmHg
(Female Child:
Abnormally low)
9.0 mg/dL
126 mg/dL
(Abnormally high)
0.8 mg/dL
(child- abnormally high)
9.4 mg/dL
CLIENT’S
PROBLEM(S)
NEED(S) (Using
the Nursing
Diagnostic
language)
Problem: Pain
R/T
Etiology: clotting
formation of
surgical wound
AEB
Signs &
Symptoms:
 Discomfort,
facial
grimacing,
changing
positions
CLIENT’S SHORT
TERM
GOAL/OUTCOME
(PLANNING)
 Client will
demonstrate relief
of acute pain
post-operatively
until discharge
NURSING
INTERVENTIONS
(APPROACH)
(ACTION)
SCIENTIFIC
RATIONALE FOR
NURSING
INTERVENTION
1. Assess severity of
pain, generalized
abdominal pain
descending to
lower right
quadrant and
localized
McBurney’s point
with rebound
tenderness,
reduced bowel
sounds; behaviors
indicating pain
1. Provides
information
symptomatic of
appendicitis with
pain being the
most common
presenting
complain;
behaviors
manifested by
pain vary with
age with infant
responding with
crying, facial
expression
2. Assess severity of
post-operative pain
2. Provides
information
needed to
administer most
effective
analgesic therapy
3. Provide toys,
games for quiet
play
3. Promotes
diversionary
activity to
distract from pain
CLIENT’S
PROBLEM(S)
NEED(S) (Using
the Nursing
Diagnostic
language)
Problem: Anxiety
R/T
Etiology:
hospitalization of
child
AEB
Signs &
Symptoms:
 Apprehensive,
facial grimacing,
expressed
concern and
worry
CLIENT’S SHORT
TERM
GOAL/OUTCOME
(PLANNING)
 Reduced parental
and child anxiety
verbalized as
illness and
surgery resolved
 Verbalizes
understanding of
cause of fear and
anxiety and
positive effect of
surgical treatment
NURSING
INTERVENTIONS
(APPROACH)
(ACTION)
SCIENTIFIC
RATIONALE FOR
NURSING
INTERVENTION
1. Assess source
and level of anxiety
and how anxiety is
manifested; need for
information that will
relieve anxiety
1.Provides
information about
anxiety level and need
for interventions to
relieve it
2. Allow
expression of
concerns and ask
questions about
condition,
procedures,
recovery surgery
by parents and
child
2.Provides
opportunity to vent
feelings and fears and
secure information to
reduce anxiety
3. Communicate
with parents and
answer questions
calmly and
honestly; use
pictures,
drawings, and
models for
explanations to
child
3.Promotes calm and
supportive trusting
environment
REFERENCES
Nursing Care Plan Reference
Jaffe, M. (1998) (2nd ed). Pediatric Nursing Care Plans. Skidmore-Roth Publishing, Inc.
Etiology & Developmental References
Leifer, G. (2007). Introduction to Maternity & Pediatric Nursing (5th ed). St. Louis:
Mosby, 361, 430, 651
Santrock, W.J. (2006) (6th ed). Psychology. Boston: McGraw-Hill Companies, 321, 334, 338,
418
Sommers, S.M., & Johnson, A.S. (2002) (2nd ed.) Diseases and Disorders: A Nursing
Therapeutic Manual. Philadephia: F.A. Davis Company, 105, 755
Medication and Diagnostic Test References
Deglin, H. J., & Vallerand, H. A.(2005) (10th ed.) Davis’s Drug Guide for Nurses. Philadelphia:
F.A. Davis Company
Professional Guide to Diagnostic Tests (2005). Ambler: Lippincott Williams & Wilkins
Sowden, B. (2004) (5th ed.) Mosby’s Pediatric Nursing Reference. St. Louis: Mosby