- Name - Age - Gender - Date of Birth - Etc.. 2. Medical History - Recent Health History The main complaint the client will get around epigastric pain radiating to the lower right abdomen. Embossed lower right abdominal pain complaints may be a few hours later after the pain in the center or in the epigastrium felt in some time ago. The nature of pain is felt constantly, can be lost or there is pain in a long time. Complaints that accompany the client usually complain of nausea and vomiting, fever. - Past Health History Patient will have related complain with the recent history. 3. Physical Assessment o Rovsing sign (palpation of LLQ worsens RLQ pain) o Psoas sign (extension of R leg at hip while pt lies on L side elicits abd pain) o Obturator sign (internal and external rotation of thigh at hip elicits pain o Peritonitis suggested by: a. Right heel strike elicits pain b. Guarding Name of Examination Sign and Symptoms Rovsing’s sign Positive if palpation with pressure on the lower left quadrant and there is pain on the right side. Psoas sign or Obraztsova’s The patient was placed on the left side, then sign do the extension of the right pelvis. Positive if there is pain in the lower right. Obturator sign The patients were performed hip flexion and internal rotation of the hip. Positive if there is pain in hipogastrium or vagina. Dunphy’s sign Added pain in the lower right tertis with cough Ten Horn sign Pain that arises when done gentle traction on the right spermatic cord Kocher (Kosher)’s sign Pain at first in the epigastric region or around the center, then move to the right lower quadrant. Sitkovskiy (Rosenstein)’s sign Growing pains in the lower right quadrant of the abdomen while the patient was placed on the left side Aure-Rozanova’s sign Increased pain with petit triangle finger on the right (positive will Shchetkin-Bloomberg's sign) Blumberg sign Also called rebound tenderness. Palpation in the right lower quadrant and then released suddenly. 4. Diagnostic Studies :
WBC: Leukocytosis above 12,000/mm3, neutrophil count often elevated to greater
than 75%. Abdominal x-rays: May reveal hardened bit of fecal material in appendix (fecalith), localized ileus. Ultrasound or CT scan: May be done for differentiation of appendicitis from other causes of abdominal pain (e.g., perforating ulcer, cholecystitis, reproductive organ infections) or to localize drainable abscesses. DIAGNOSES 1. Dx : Acute Pain related to distension of intestinal tissues by inflammation or presence of surgical incision. Desired Outcomes : Pain Control, Pain Level Report pain is relieved/controlled. Appear relaxed, able to sleep/rest appropriately. Demonstrate use of relaxation skills and diversional activities, as indicates, for individual situation. Intervention : Pain Management Nursing Interventions Rationale Assess pain, noting location, Useful in monitoring effectiveness of Nursing Interventions Rationale medication, progression of healing. Changes in characteristics, severity (0–10 scale). characteristics of pain may indicate developing Investigate and report changes in pain as abscess or peritonitis, requiring prompt appropriate. medical evaluation and intervention. Being informed about progress of situation Provide accurate, honest information to provides emotional support, helping to patient and SO. decrease anxiety To lessen the pain. Gravity localizes inflammatory exudate into lower abdomen or Keep at rest in semi-Fowler’s position. pelvis, relieving abdominal tension, which is accentuated by supine position. Promotes normalization of organ Encourage early ambulation. function (stimulates peristalsis and passing of flatus, reducing abdominal discomfort). Refocuses attention, promotes relaxation, and Provide diversional activities may enhance coping abilities. Keep NPO and maintain NG suction Decreases discomfort of early intestinal initially. peristalsis, gastric irritation and vomiting. Relief of pain facilitates cooperation with other Administer analgesics as indicated. therapeutic interventions (ambulation, pulmonary toilet). Soothes and relieves pain through Place ice bag on abdomen periodically desensitization of nerve endings. Note: Do not during initial 24–48 hr, as appropriate. use heat, because it may cause tissue congestion. Never apply heat to the right lower This may cause the appendix to rupture. abdomen. Watch closely for possible surgical Continuing pain and fever may signal an complications. abscess. Evaluation : Is patient report pain is relieved/controlled? Is patient appear relaxed, able to sleep/rest appropriately? Is patient demonstrate use of relaxation skills and diversional activities, as indicates, for individual situation? 2. Dx : Risk for Deficient Fluid Volume related to nausea and vomit. Desired Outcomes : Fluid Balance, Hydration Hydration (NOC) Maintain adequate fluid balance as evidenced by moist mucous membranes, good skin turgor, stable vital signs, and individually adequate urinary output. Intervention : Fluid Management, Fluid Monitoring Nursing Interventions Rationale Variations help identify fluctuating Monitor BP and pulse. intravascular volumes Inspect mucous membranes; assess skin Indicators of adequacy of peripheral turgor and capillary refill. circulation and cellular hydration. Decreasing output of concentrated urine Monitor I&O; note urine color and with increasing specific gravity suggests concentration, specific gravity. dehydration and need for increased fluids. Indicators of return of peristalsis, readiness to begin oral intake. Note: This Auscultate and document bowel sounds. may not occur in the hospital if patient has Note passing of flatus, bowel movement. had a laparoscopic procedure and been discharged in less than 24 hr. Provide clear liquids in small amounts Reduces risk of gastric irritation and when oral intake is resumed, and progress vomiting to minimize fluid loss. diet as tolerated. Give frequent mouth care with special Dehydration results in drying and painful attention to protection of the lips. cracking of the lips and mouth. An NG tube may be inserted preoperatively and maintained in Maintain gastric and intestinal suction, as immediate postoperative phase to indicated. decompress the bowel, promote intestinal rest, prevent vomiting. Administer IV fluids and electrolytes. The peritoneum reacts to irritation and infection by producing large amounts of intestinal fluid, possibly reducing the circulating blood volume, resulting in dehydration and relative Nursing Interventions Rationale electrolyte imbalances. Cathartics and enemas may rupture the Never administer cathartics or enemas. appendix. Give the patient nothing by mouth, and This may mask symptoms. administer analgesics judiciously. Evaluation : - Is patient maintain adequate fluid balance as evidenced by moist mucous membranes, good skin turgor, stable vital signs, and individually adequate urinary output? 3. Dx : Risk for Infection related to invasive procedures, surgical incision Desired Outcomes : Infection Severity Achieve timely wound healing; free of signs of infection/inflammation, purulent drainage, erythema, and fever. Intervention : Infection Control Nursing Interventions Rationale Practice and instruct in good handwashing and aseptic wound care. Encourage and Reduces risk of spread of bacteria. provide perineal care. Inspect incision and dressings. Note Provides for early detection of developing characteristics of drainage from wound (if infectious process and monitors resolution inserted), presence of erythema. of preexisting peritonitis. Monitor vital signs. Note onset of fever, Suggestive of presence of infection or chills, diaphoresis, changes in mentation, developing sepsis, abscess, peritonitis. reports of increasing abdominal pain. Gram’s stain, culture, and sensitivity testing Obtain drainage specimens if indicated. is useful in identifying causative organism and choice of therapy. Antibiotics given before appendectomy are primarily for prophylaxis of wound infection and are not continued Administer antibiotics as appropriate. postoperatively. Therapeutic antibiotics are administered if the appendix is ruptured or abscessed or peritonitis has developed. Prepare and assist with incision and May be necessary to drain contents of Nursing Interventions Rationale drainage (I&D) if indicated. localized abscess. Watch closely for possible surgical Continuing pain and fever may signal an complications. abscess. Evaluation : - Is patient free sign of infection ?