A 4-year-old girl comes into the emergency room for nausea, vomiting, fever and abdominal pain. The mother reports that the child has been saying their tummy hurts for the past 3 days and not wanting to eat very much but that today she started to throw up.
Critical Thinking Check
Bloom's Taxonomy: Application
What nursing assessment data and history questions would you obtain at this time?
How many times the child has vomited, what the vomit looks like?
Does she have any known medical conditions or allergies?
Full set of vitals
Full abdominal assessment
Assess the child’s countenance and behavior for signs of guarding or discomfort
The emesis is yellow and the child has thrown up 4 times. Upon assessment of the child, the girl cries anytime she sees a nurse or doctor and hugs her blanket and mother. The nurse notes tears, pink dry skin and a patent airway. The nurse stays in the room and plays with the child until the nurse is finally able to get a set of vitals:
HR 122
RR 28
BP 91/52
Temp 101°F axillary
The child still will not let anyone auscultate or palpate her abdomen. The doctor orders blood work, Tylenol and an X-Ray of the abdomen. The nurse draws the blood work and sends the child to X-Ray with her mother.
Critical Thinking Check
Bloom's Taxonomy: Analysis
Which labs do you expect will be abnormal for the child?
Tylenol is weight-based medication so the nurse should make sure the child was properly weighed and that the medication was properly dosed.
The nurse should also check that the child doesn’t have any allergies to Acetaminophen.
The child has returned from X-Ray and is cuddled up with her mother and blanket. The child still will not let the nurse listen with her stethoscope but isn’t crying anymore. The X-Ray has resulted and shows the child has appendicitis. The nurse knows she needs to prepare the parents and the child for being admitted to the hospital and surgery. A re-check in vital signs shows the following:
HR 110
BP 95/53
RR 22
Temp 101.2°F axillary
Critical Thinking Check
Bloom's Taxonomy: Application
Which non-pharmacological interventions should the nurse implement at this time to address the child's fever
The mother needs to try to transfer less warmth to the child. If the child will allow it, having the child on the stretcher and not in mother’s arms will help bring the temp down.
The blanket needs to be taken away when the child isn’t looking and make sure the child is in a gown, not her home clothes to help address the child’s temperature.
What would be the most concerning behavior that the nurse should be watching out for in the child?
Critical Thinking Check
Bloom's Taxonomy: Analysis
What would be the most concerning behavior that the nurse should be watching out for in the child?
The nurse should be concerned if the child stops fussing and if the child allows the nurse to touch her abdomen. This would indicate that the pain has suddenly disappeared.
This would be concerning for perforated appendicitis, which is a true emergency and needs to be sent to OR immediately.
The OR schedules the child’s surgery for tomorrow at 6 AM and the hospital room is ready for the child to be admitted to overnight.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What is the most important thing for the nurse to educate the mother on before sending them to the room?
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 