Possible appendicitis

[RNCourt]

Hello everyone,

I graduated from nursing school in May 2012. By August I got a job as a School Nurse. I was more than thrilled but very nervous. Since day 1 I doubted my clinical skills. I had not experienced a lot of things so most of the time I spent researching on the internet and using some manuals that were left behind by the previous school nurse.

Since August I have become more confident in my practice. I have suspected strep throat which was indeed strep. I have sent students to ERs for possible concussions in which they had concussions. I have performed the annual screenings in which I have caught on to a couple cases of scoliosis which had otherwise gone unnoticed.

Today a student came in c/o RLQ stomach pains. After some more assessing I thought it would be best to notify the parents. The parents said that they were going to call her doctor and set up an appointment for tomorrow. They also stated that they had no transportation and therefore could not bring her this day. Long story short, our school director came in an hour later demanding I call 911. He stated that it was in the best interest of the student to be seen. While waiting for the ambulance the student stated they wished the ambulance had not been called and that they could see her doctor tomorrow as I had previously reccommended.

I feel completely underminded. While I know she should have been seen, was it necessary to call for an ambulance?

[rdsxfnrn]

I would have stressed to the parents that if she is not picked up and brought to doctor appt that I was going to call 911. I understand that sometimes folks do not have a way of getting somewhere, but everytime I have told this to a parent, somehow they magically get a ride. However, I do not use this tactic unless I do indeed plan on calling 911. The goal is to get the student some medical attention, not call the parents out. Think about it this way, if you had not gotten in touch with the parents, what would you have done?

[RNCourt]

I guess what I am wondering is...was this an emergency situation? I know that an appendicitis can be ugly if it ruptures and its best to be seen before it does, but I just wasn't seeing the signs that scream emergency. To answer your question: if I was unable to get ahold of the parents I would have monitored her throughout the day but I still would not have called an ambulance. It may be more helpful to know the student is 20years old, no temp, no guarding, no rebound tenderness. Personally I have never had appendicitis nor have I seen someone with it in a hospital setting so it was difficult to differentiate this from gas pains or any other GI problem. What would be the signs I should look or for that would tell me this is an emergency?

[Flare, ASN, BSN]

This is a definite had to be there type scenario. Basically if i were in the same scanario, a student having the same pain would be shown to the bathroom followed by a temp. f there were nausea, vomiting or rebound tenderness accompanied with any fever, then i'd be pushing the issue and possibly considering an ER visit if the parents were blowing me off, but that'd only be if the student seemed really uncomfortable.

One thing you should be aware of is that an ovarian cyst can cause pain very similar to an appendicitis and while painful, is not necessarily an emergency.

Just curious, is this a special needs student? or a college student?? if special needs, what are her limitations.

[rdsxfnrn]

Sorry, I should have been more clear. I would have done what I wrote IF there were positive signs of appendicitis. IF NOT, I would have done what you and Flare have suggested, moniter throughout the day. What was the outcome?

[RNCourt]

Flare: The student has MD. So it may very well be that she manages pain well and I just wasn't believing how bad it was. I didn't think of an ovarian cyst! Does the pain usually occur just right side or left or is it both?

rdsxfnrn: The student was absent from school today as to be expected. I called to check up and see how things went. Turns out she was at the ER until 9pm all alone and still had not been seen by a doctor. She left the ER and will be seen by her primary care doctor today (the appointment that I had her parents set up for her originally). Hopefully the poor kid gets some answers soon.

[NutmeggeRN, BSN]

How did the director get involved? Did a teacher call? I love when kid leaves my office under the same scenario ( and I would have done what you did-continuing to check in and monitor fever) and magically appears somehwere else looking like 911 should be called.....

Especialy with girls the possibilities are:

Appendix, Ovarian cyst, constipation, UTI, STI, ectopic pregnancy, gastritis, IBS....Is the director gunshy? p[rev hx with family or a similar sitatuation? Maybe sit down and talk about why you did what you did and what would they suggest in the future? Can never really tell with some folks

Hopefully she made out ok...they did not rush her to the OR (where she was triaged again) so it sounds like you used good judgment!

[strytellerchayka]

i had a child who came in with a stomachache no fever, no pain nothing he said his stomachached. I called to send the child home but no one picked him up he sat with me all day it was so bizarre cause i didnt even expect anything more than a stomachache but the kid went to the er and had appendicitis..