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An inflamed appendix may be removed using a laparoscopic approach with laser. However, the presence of multiple adhesions, retroperitoneal positioning of the appendix, or the likelihood of rupture necessitates an open (traditional) procedure. Studies indicate that laparoscopic appendectomy results in significantly less postoperative pain, earlier resumption of solid foods, a shorter hospital stay, lower wound infection rate, and a faster return to normal activities than open appendectomy.
Although many of the interventions included here are appropriate for the short-stay patient, this plan of care addresses the traditional appendectomy care provided on a surgical unit.
Peritonitis Psychosocial aspects of care Surgical intervention
Patient Assessment Database (Preoperative)
May report: Malaise
May exhibit: Tachycardia
May report: May exhibit: Constipation of recent onset Diarrhea (occasional) Abdominal distension, tenderness/rebound tenderness, rigidity Decreased or absent bowel sounds
May report: Anorexia Nausea/vomiting
May report: Abdominal pain around the epigastrium and umbilicus, which may have an insidious onset and become increasingly severe; pain may localize at McBurney’s point (halfway between umbilicus and crest of right ileum) and be aggravated by walking, sneezing, coughing, or deep respiration. Increasingly severe, generalized pain or the sudden cessation of severe pain (suggests perforation or infarction of the appendix). Varied reports of pain/vague symptoms (due to location of appendix [e.g., retrocecally or next to ureter] or due to onset of peritonitis) Guarding behavior; lying on side or back with knees flexed; increased right lower quadrant (RLQ) pain with extension of right leg/upright position Rebound tenderness on left side (suggests peritoneal inflammation)
May exhibit: Tachypnea; shallow respirations
May exhibit: Fever (usually low-grade)
DISCHARGE GOALS 1. . regional ileitis May occur at any age DRG projected mean length of inpatient stay: 4. surgical incision Possibly evidenced by [Not applicable. erythema.. perforation/rupture of the appendix. Provide information about surgical procedure/prognosis. presence of erythema.TEACHING/LEARNING May report: History of other conditions associated with abdominal pain. Ultrasound or CT scan: May be done for differentiation of appendicitis from other causes of abdominal pain (e. neutrophil count often elevated to greater than 75%. Inspect incision and dressings. Discharge plan considerations: DIAGNOSTIC STUDIES WBC: Leukocytosis above 12. acute salpingitis. localized ileus. e. risk for Risk factors may include Inadequate primary defenses.000/mm3. 3. presence of signs and symptoms establishes an actual diagnosis. perforating ulcer. NURSING DIAGNOSIS: Infection. free of signs of infection/inflammation. peritonitis. Encourage/provide perineal care. cholecystitis. reproductive organ infections) or to localize drainable abscesses. Plan in place to meet needs after discharge. and potential complications.. Abdominal x-rays: May reveal hardened bit of fecal material in appendix (fecalith). Reduces risk of spread of bacteria. acute pyelitis. 2. Pain alleviated/controlled.2 days/short stay: 24 hours May need brief assistance with transportation. treatment needs. abscess formation Invasive procedures.g. therapeutic regimen. Surgical procedure/prognosis. and fever.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Wound Healing: Primary Intention (NOC) Achieve timely wound healing. Promote comfort. 2. Provides for early detection of developing infectious process.g. ureteral stone. 3. homemaker tasks Refer to section at end of plan for postdischarge considerations. and possible complications understood. NURSING PRIORITIES 1. and/or monitors resolution of preexisting peritonitis. purulent drainage. Complications prevented/minimized. 4. Note characteristics of drainage from wound/drains (if inserted). ACTIONS/INTERVENTIONS Infection Control (NIC) RATIONALE Independent Practice/instruct in good handwashing and aseptic wound care. Prevent complications.
NURSING DIAGNOSIS: Fluid Volume. assess skin turgor and capillary refill. May be necessary to drain contents of localized abscess. Note onset of fever. and individually adequate urinary output. abscess. ACTIONS/INTERVENTIONS Fluid Monitoring (NIC) RATIONALE Independent Monitor BP and pulse. Therapeutic antibiotics are administered if the appendix is ruptured/abscessed or peritonitis has developed. diaphoresis. specific gravity. Gram’s stain. changes in mentation.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Hydration (NOC) Maintain adequate fluid balance as evidenced by moist mucous membranes. presence of signs and symptoms establishes an actual diagnosis. postoperative restrictions (e. Decreasing output of concentrated urine with increasing specific gravity suggests dehydration/need for increased fluids. reports of increasing abdominal pain.. culture. Collaborative Administer antibiotics as appropriate. note urine color/concentration. stable vital signs. Monitor I&O. Inspect mucous membranes.g. . NPO) Hypermetabolic state (e. fever. and sensitivity testing isuseful in identifying causative organism and choice of therapy. Antibiotics given before appendectomy are primarily for prophylaxis of wound infection and are not continued postoperatively. chills. Indicators of adequacy of peripheral circulation and cellular hydration. Prepare for/assist with incision and drainage (I&D) if indicated. Variations help identify fluctuating intravascular volumes..g. Obtain drainage specimens if indicated. risk for deficient Risk factors may include Preoperative vomiting.ACTIONS/INTERVENTIONS Infection Control (NIC) RATIONALE Independent Monitor vital signs. peritonitis. Suggestive of presence of infection/developing sepsis. healing process) Inflammation of peritoneum with sequestration of fluid Possibly evidenced by [Not applicable. good skin turgor.
Appear relaxed. progression of healing.ACTIONS/INTERVENTIONS Fluid Monitoring (NIC) RATIONALE Independent Auscultate bowel sounds. . Give frequent mouth care with special attention to protection of the lips. and progress diet as tolerated. Reduces risk of gastric irritation/vomiting to minimize fluid loss. Investigate and report changes in pain as appropriate. noting location. distraction behaviors Autonomic responses DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Pain Level (NOC) Report pain is relieved/controlled. characteristics. prevent vomiting. bowel movement. resulting in dehydration and relative electrolyte imbalances. Collaborative Maintain gastric/intestinal suction. acute May be related to Distension of intestinal tissues by inflammation Presence of surgical incision Possibly evidenced by Reports of pain Facial grimacing. Indicators of return of peristalsis. promote intestinal rest. Dehydration results in drying and painful cracking of the lips and mouth. Provide clear liquids in small amounts when oral intake is resumed. muscle guarding. able to sleep/rest appropriately. severity (0–10 scale). An NG tube may be inserted preoperatively and maintained in immediate postoperative phase to decompress the bowel. as indicated. Note: This may not occur in the hospital if patient has had a laparoscopic procedure and been discharged in less than 24 hr. readiness to begin oral intake. Useful in monitoring effectiveness of medication. ACTIONS/INTERVENTIONS Pain Management (NIC) RATIONALE Independent Assess pain. Administer IV fluids and electrolytes. Note passing of flatus. Changes in characteristics of pain may indicate developing abscess/peritonitis. The peritoneum reacts to irritation/infection by producing large amounts of intestinal fluid. possibly reducing the circulating blood volume. NURSING DIAGNOSIS: Pain. requiring prompt medical evaluation and intervention.
Collaborative Keep NPO/maintain NG suction initially. and may enhance coping abilities. as appropriate. which is accentuated by supine position. Encourage early ambulation. Verbalize understanding of therapeutic needs. request for information. e. Relief of pain facilitates cooperation with other therapeutic interventions. deficient [Learning Need] regarding condition. and discharge needs May be related to Lack of exposure/recall.g. NURSING DIAGNOSIS: Knowledge. Participate in treatment regimen. Soothes and relieves pain through desensitization of nerve endings. prognosis. honest information to patient/SO. Place ice bag on abdomen periodically during initial 24–48 hr. Decreases discomfort of early intestinal peristalsis and gastric irritation/vomiting.ACTIONS/INTERVENTIONS Pain Management (NIC) RATIONALE Independent Provide accurate. helping to decrease anxiety Gravity localizes inflammatory exudate into lower abdomen or pelvis. Note: Do not use heat.g. verbalization of problem/concerns Statement of misconception Inaccurate follow-through of instruction Development of preventable complications DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Knowledge: Illness Care (NOC) Verbalize understanding of disease process and potential complications. Being informed about progress of situation provides emotional support. Administer analgesics as indicated. e. information misinterpretation Unfamiliarity with information resources Possibly evidenced by Questions. reducing abdominal discomfort. treatment. Promotes normalization of organ function. ambulation. Provide diversional activities. promotes relaxation. because it may cause tissue congestion. ACTIONS/INTERVENTIONS RATIONALE . relieving abdominal tension.. stimulates peristalsis and passing of flatus. self-care. pulmonary toilet.. Refocuses attention. Keep at rest in semi-Fowler’s position.
g. POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patient’s age. Recommend use of mild laxative/stool softeners as necessary and avoidance of enemas. Encourage progressive activities as tolerated with periodic rest periods. Assists with return to usual bowel function. e.. physical condition/presence of complications. Discuss care of incision. demands made on individual (family. sex. and facilitates resumption of normal activities.g.Teaching: Disease Process (NIC) Independent Identify symptoms requiring medical evaluation. Review postoperative activity restrictions. Provides information for patient to plan for return to usual routines without untoward incidents. heavy lifting. and life responsibilities) Therapeutic Regimen: ineffective management—perceived seriousness/susceptibility.g. . presence of drainage. personal resources. delayed wound healing. Understanding promotes cooperation with therapeutic regimen. sports. perceived benefit.. exercise. including dressing changes. increasing pain. prevents undue straining for defecation. Prevents fatigue. and return to physician for suture/staple removal. promotes healing and feeling of wellbeing. driving.. e. peritonitis. edema/erythema of wound. fever. enhancing healing and recovery process. work). bathing restrictions. Prompt intervention reduces risk of serious complications. e.
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