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Pre-op diagnoses: - Altered Comfort: Acute Pain r/t obstruction on the lumen of the inflammed appendix secondary to appendicitis - Anxiety r/t impending surgery - Risk for fluid volume deficit r/t oral restriction and vomiting
Risk Factors: - Fecalith formation -kinking of the appendix -swelling of the bowel wall -external occlusion of bowel by adhesion
Pre-op Nursing Interventions -relieve anxiety and offer emotional support - provide knowledge and clarify patient's doubts about the procedure and condition - relieve pain through relaxation techniques and othe non-pharmacologic techniques - address body image issues before surgery - offer spiritual support - start IVF as ordered -insert FBC and monitor urine output - give anitbiotic therapies as ordered - put on CBR status - NPO - do skin preparation of the abdomen - make sure informed consent is obtained - transport patient to the Operating Room shifting of fluids
-RLQ abdominal pain -rebound tenderness - rise in Temp= >37.5 0C - nausea and vomiting - rigidity of the lower portion of t right rectus muscle
Obstruction on the lumen of the appendix
increase accumulation of mucus
increase intraluminal pressure
decrease blood flow / supply
Diagnostic Period Nursing Interventio - make patient comfortable and relieve an - relieve pain through relaxation technique non-pharmacologic techniques - address body image issues before surger - offer spiritual support - start IVF as ordered - NPO ! do not give laxatives ! withhold Analgesics ! Do not apply hot compress on abdom
venous congestion Thrombosis of the luminal blood vessels
ulceration of lume
edema ischemia Diagnostic Exams: 1. CBC= increase in WBC and Neutrophils ---infection 2. Urinalysis 3. X-ray/ CT scan of abdomen : imflammed appendix 4. Peritoneal Lavage: * increase in amylase level * presence of bacteria * presence of bile and fecal material * RBC= > 100, 000
purulent exudates form
tissue necrosis
further distention of the appendix
perforation/ rupture of the appendix
gangrene
gangrene
appendix
POST-OP Nursing Interventions For unruptured Appendicitis 1. Assess for: - Bowel sounds - bowel movement - passing of flatus - nausea - boardlike abdominal rigidity - vital signs (Temperature) - incision site 2. Give pain medications as ordered 3. Offer clear fluids in the morning after surgery 4. remove IVF if patient is able to eat and drink 5. monitor s/s of infection 6. do wound care 7. encourage mobility 1-2 days postop; 8. expect ambulation 4-5 days postop 9. monitor urine output
For ruptured Appendicitis 1. Assess for: - Bowel sounds - bowel movement - passing of flatus - nausea - boardlike abdominal rigidity - vital signs (Temperature) - incision site 2. Place in high- fowler's position 3. give morphine sulfate for pain 4. if bowel sounds is ok, provide food, as ordered 5. for NPO status patients, pat OS or tissue on lips to prevent crackings and dryness 6. Assess for infection and do wound care 7. for patients using diapers, encourage changing as often 8. watch out for complications 9. turn and position patient every 2 hours 10. teach patient how to support and splint site upon movement 11. teach deep breathing 12. encourage early mobility and ambulation 13. give ordered supplements
Legend: Pathology
Nursing Interventions
laboratory exams
Clinical manifestations
Medical interventions Nursing Diagnoses
Possible Post-op complications
release of exudates with E.coli, Klebsiella, Proteus, Pseudomonas bacteria to peritoneal cavity
localized inflammation of the peritoneum
Post-op diagnoses: - Altered Comfort: Pain of incision site on abdo - Altered Nutrition: Les requirement r/t NPO st - Risk for infection r/t b skin secondary to App
- Observe for abdominal tenderness, vomiting, abdominal rigidity and tac - Employ constant nasogastric suctio - Correct dehydration as prescribed - Administer antibiotic agent as pres - Assess incision site for undesirable pus formation - Assess for pain - Change dressing as frequently as n - Observe for fever and tachycardia - Administer antibiotic agent as pres - Assess for bowel sounds - Employ nasogastric intubation and - Replace fluids and electrolytes by I prescribed - Prepare for surgery, if diagnosis of ileus is established
Medical interventions Nursing Diagnoses
Possible Post-op complications
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necrosis
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gnoses: mfort: Pain r/t presence e on abdomen ition: Less than body r/t NPO status ction r/t break in the ry to Appendectomy
rventions
nderness, fever, y and tachycardia ric suction escribed t as prescribed