LAURENCE R.
ZERNA
NCM 116 CASES
RHEUMATOID ARTHRITIS
ASSESSMENT
 Presence of Rheumatoid nodules
 Joint inflammation during
palpation
 Classical symptoms may include:
Joint pain, swelling, warmth,
erythema, and lack of function in
affected areas
 Other symptoms may include:
Sunrise stiffness (most severe
pain), soft feeling in joints, and
that it is bilateral or symmetrical
DIAGNOSIS
The tests typically ordered for
diagnosis may include:
 Rheumatoid factor (positive)
 Erythrocyte sedimentation rate
(increased)
 CBC (moderate anemia; inc.
WBC)
 C-reactive protein
 X-ray of involved joints (soft-
tissue swelling, erosion of joints,
etc.)
MEDICAL-SURGICAL MGT
Early RA:
 Salicylates or NSAIDs. COX-2
medications block the enzyme
involved in inflammation
 Analgesics. Additional analgesia
may be prescribed for periods of
extreme pain.
 Methotrexate. Methotrexate is
currently the standard treatment
of RA because of its success in
preventing both joint destruction
and long-term disability.
Moderate, erosive RA:
 Formal program of occupational
and physical therapy; an
immunosuppressant such as
cyclosporine may be added.
Persistent, erosive RA:
 Reconstructive surgery and
corticosteroids.
Advanced unremitting RA:
 Immunosuppressants.
Immunosuppressive agents are
prescribed because of their
ability to affect the production of
antibodies at the cellular level.
 Antidepressants. For most
patients with RA, depression and
sleep deprivation may require
the short-term use of low-dose
antidepressants such as
amitriptyline, paroxetine, or
sertraline, to reestablish an
adequate sleep pattern and to
manage chronic pain.
NURSING INTERVENTION
The most common issues for the
patient with RA include pain, fatigue,
limited mobility, and many more. To
address these issues, some
interventions may include:
 Provide a variety of comfort
measures
 Administer anti-inflammatory,
analgesic, and slow-acting
antirheumatic medications as
prescribed.
 Encourage verbalization of
feelings about pain
 Assess for subjective changes in
pain
 Explain how to use energy
conservation techniques
 Facilitate development of
appropriate activity/rest
schedule
 Encourage adequate nutrition
 Assist patient and teach them
about the use of assistive devices
for mobility.
CEREBROVASCULAR ACCIDENT
ASSESSMENT
Stroke can have a variety of
symptoms depending on many
factors. But general signs and
symtoms include:
 Numbness or weakness of the
face.
 Change in mental status.
 Trouble speaking or
understanding speech.
 Visual disturbances.
 Homonymous hemianopsia.
 Loss of peripheral vision.
 Hemiparesis.
 Hemiplegia.
 Ataxia.
 Dysarthria.
 Dysphagia.
 Paresthesia.
 Expressive aphasia.
 Receptive aphasia.
 Global aphasia.
DIAGNOSIS
Tests ordered to diagnose CVA
includes:
 Non-contrast CT scan
 PET scan
 MRI
 12-lead ECG and carotid
ultrasound
 CT angiography or MRI and
angiography
 Lumbar puncture
 Transcranial Doppler flow studies
 Transthoracic or transesophageal
echocardiography
 Xenon-enhanced CT scan
 Single photon emission CT
(SPECT) scan
 Other Lab studies to rule out:
CBC, platelet and clotting studies,
VDRL/RPR, erythrocyte
sedimentation rate (ESR),
chemistries (glucose, sodium,
etc.)
MEDICAL-SURGICAL MGT
 Recombinant tissue plasminogen
activator would be prescribed
unless contraindicated, and there
should be monitoring for
bleeding.
 Increased ICP. Management of
increased ICP includes osmotic
diuretics, maintenance of PaCO2
at 30-35 mmHg, and positioning
to avoid hypoxia through
elevation of the head of the bed.
 Possible hemicraniectomy. For
increased ICP from brain edema
in a very large stroke.
 Carotid endarterectomy. This is
the removal of atherosclerotic
plaque or thrombus from the
carotid artery to prevent stroke
in patients with occlusive disease
of the extracranial cerebral
arteries.
 Endotracheal Tube. There is a
possibility of intubation to
establish patent airway if
necessary.
 Hemodynamic monitoring.
Continuous hemodynamic
monitoring should be
implemented to avoid an
increase in blood pressure.
 Neurologic assessment to
determine if the stroke is
evolving and if other acute
complications are developing
NURSING INTERVENTION
Nursing care has a significant impact
on the patient’s recovery. In
summary, here are some nursing
interventions for patients with
stroke:
 Position to prevent contractures,
relieve pressure, attain good
body alignment, and prevent
compressive neuropathies.
 Prevent flexion. Apply splint at
night to prevent flexion of the
affected extremity.
 Prevent adduction. Prevent
adduction of the affected
shoulder with a pillow placed in
the axilla.
 Prevent edema. Elevate affected
arm to prevent edema and
fibrosis.
 Full range of motion
 Prevent venous stasis by letting
patient exercise
 Teach patient to maintain
balance in a sitting position, then
to balance while standing and
begin walking as soon as standing
balance is achieved.
 Encourage personal hygiene
activities as soon as the patient
can sit up.
 Manage sensory difficulties.
 Visit a speech therapist
 Voiding pattern
 Be consistent in patient’s
activities. Be consistent in the
schedule, routines, and
repetitions; a written schedule,

MENINGITIS
ASSESSMENT
Meningitis is usually presented by a
triad of signs and symptoms: Fever,
Headache, and Neck Stiffness. But
other data may be assessed such as:
 Fever. The patient presents with
fever at first, which ultimately
grow worse.
 Seizures. As bacterial meningitis
progresses, patients of any age
may have seizures.
 Neurologic symptoms. Patients
with subacute bacterial
meningitis and most patients
with viral meningitis present with
neurologic symptoms developing
over 1-7 days.
 Photalgia (photophobia).
Discomfort when the patient
looks into bright lights.
 You can also verify that the
patient has stiff neck by testing
for positive Kernig’s sign and a
positive Brudzinski’s sign.
DIAGNOSIS
The diagnostic tests in patients with
clinical findings of meningitis are as
follows:
 Lumbar puncture. In general,
whenever the diagnosis of
meningitis is strongly considered,
a lumbar puncture should be
promptly performed;
examination of the cerebrospinal
fluid (CSF) is the cornerstone of
the diagnosis.
 CT scan. A screening computed
tomography (CT) scan of the
head may be performed before
LP to determine the risk of
herniation.
 Blood studies. CBC may have
leukocytosis as a result.
 Cultures and bacterial antigen
testing. The utility of cultures is
most evident when LP is delayed
until head imaging can rule out
the risk of brain herniation.
MEDICAL-SURGICAL MGT
Medical Management of the patient
includes:
 Crystalloid infusion when patient
experiences shock
 Seizure precautions
 IVT and O2 administration
 Begin empiric antibiotic coverage
according to age and presence of
overriding physical conditions.
Administer other drugs such as:
 Corticosteroids.
 Diuretics (osmotic and loop).
Osmotic diuretics may reduce
subarachnoid-space pressure
while loop diuretics increases the
excretion of water.
 Anticonvulsants. Anticonvulsants
are used to help aggressively
control seizures (if present).
checklists, and audiotapes may
help with memory and
concentration, and a
communication board may be
used.
 Assess skin. Frequently assess
skin for signs of breakdown, with
emphasis on bony areas and
dependent body parts.
NURSING INTERVENTION
Nursing interventions include:
 Assessing neurologic status and
v/s constantly.
 Insert cuffed endotracheal tube
(or tracheostomy), and position
patient on mechanical ventilation
as prescribed.
 Rapid IV fluid replacement may
be prescribed, but take care not
to overhydrate patient
 Reduce high fever to decrease
load on heart and brain from
oxygen demands
 Protect the patient from injury
 Monitor daily body weight
 Prevent complications associated
with immobility, such as pressure
and pneumonia.
 Institute infection control
precautions until 24 hours after
initiation of antibiotic therapy
CHOLECYSTITIS
ASSESSMENT
 Nausea/Vomiting
 Pain in abdomen (epigastric) that
tends to radiate to the right
shoulder pain, especially after
consuming a greasy meal
 Positive Murphy’s Sign: Lay
patient in supine position and
palpate under the ribs on the
right side at the midclavicular
line. Then have the patient
breathe out and then take a deep
breath in. While the patient is
breathing in, palpate on this area
under the ribs. If the patient
stops breathing in during
palpation it is considered a
positive Murphy’s Sign.
 Fever
 Bloating
 Steatorrhea, jaundice, dark
brown urine, light colored stools
(chronic cholecystitis)
DIAGNOSIS
Diagnostic tests include:
 Biliary ultrasonography (i.e.
cholecystosonography) can
detect gallstones in most cases.
 White blood cell count reveals
leukocytosis
 Serum alkaline phosphatase is
elevated
 Ultrasonography detects
gallstone
 Endoscopic retrograde
cholangiopancreatography may
reveal inflamed common bile
ducts, gallbladder, and
gallstones.
 Percutaneous transheptic
cholangiography can identify
gallstones within the bile ducts.
 Hepatobiliary (HIDA, PIPIDA)
scan: May be done to confirm
diagnosis of cholecystitis,
especially when barium studies
are contraindicated.
MEDICAL-SURGICAL MGT
Management may involve controlling
the signs and symptoms and the
inflammation of the gallbladder.
 NPO. The patient may not be
allowed to drink or eat at first in
order to take the stress off the
inflamed gallbladder. Patient may
recieve nutrients via TPN/IV.
 Daily stimulation of gallbladder
contraction with IV
cholecystokinin may help prevent
the formation of gallbladder
sludge in patients receiving TPN.
Medications:
 Antibiotic therapy such as
Levofloxacin and Metronidazole.
 Promethazine or
Prochlorperazine
 Oxycodone or Acetaminophen
Surgery:
 Cholecystectomy.
Cholecystectomy is most
commonly performed by using a
laparoscope and removing the
gallbladder.
 Endoscopic retrograde
cholangiopancreatography
(ERCP). ERCP visualizes the biliary
tree by cannulation of the
common bile duct through the
duodenum.
NURSING INTERVENTION
Treatment of cholecystitis depends
on the severity of the condition and
the presence or absence of
complications.
 Pain assessment. Observe and
document location, severity (0-10
scale), and character of pain.
 Activity. Promote bedrest,
allowing the patient to assume a
position of comfort.
 Diversion. Encourage use of
relaxation techniques, and
provide diversional activities.
 Communication. Make time to
listen and to maintain frequent
contact with the patient.
 Calories. Calculate caloric intake
to identify nutritional deficiencies
or needs.
 Food planning. Consult the
patient about likes and dislikes,
foods that cause distress, and
preferred meal schedules.
 Promote appetite. Provide a
pleasant atmosphere at mealtime
and remove noxious stimuli.
 Laboratory studies. Monitor
laboratory studies: BUN, pre-
albumin, albumin, total protein,
transferrin levels.
CROHN’s DISEASE (IBD)
ASSESSMENT DIAGNOSIS MEDICAL-SURGICAL MGT NURSING INTERVENTION
The signs and symptoms of Crohn’s Diagnostic tests include: Medications:  Help patient understand that
disease may vary from mild to  Blood test to check for anemia  Anti-inflammatory drugs, there is no cure for the disease;
severe. If the condition is active, it and infection including corticosteroids and oral that surgery is only done to
can develop symptoms such as:  Stool studies to check for blood, 5-aminosalicylates – initially used correct strictures, fistula, etc.
 Diarrhea parasites and other organisms to reduce the inflammation  Ostomy care if patient has
 Fever  Colonoscopy – used for  Immunosuppressant and biologic ileostomy or colostomy
 Fatigue visualization of the drugs – decrease inflammation  Encourage the patient to stop
 Abdominal pain gastrointestinal tract and its by targeting the immune system smoking if applicable
 Abdominal cramps affected areas  Antibiotics – used to fight off  Administering TPN order
 Blood in stool  Computerized tomography (CT) harmful bacteria found in the  Monitoring weight
 Mouth sores Scan intestines and to decrease pus  Monitoring I/O
 Loss of appetite  Magnetic resonance imaging formation and drainage from  Monitoring GI system: bowel
 Weight loss (MRI) fistula and abscess movements, pain/bloating,
 Rectal Bleeding  Capsule endoscopy  Anti-diarrhea medications frequency of bowel movement
 Pain or drainage near or around  Balloon-assisted enteroscopy  Analgesics  Educate patient with what to eat
the anus  Vitamins and supplements and what to avoid eating
Nutrition therapy
Severe cases of Crohn's disease may  A special diet may be prescribed
develop: to treat malnutrition and reduce
 Inflammation of skin, eyes, joints, inflammation by allowing the
liver, or bile ducts bowel to rest. A low fiber and low
 Kidney stones residue diet may also be
 Iron deficiency (anemia) recommended to reduce
 Delayed growth or sexual blockage of the intestines and
development, in children the quantity of stools.
Surgery:
 This is usually recommended
when the medication, nutrition
therapy, and lifestyle
modification fail to alleviate or
improve symptoms.
NOTE: SURGERY DOES NOT CURE but
only save unaffected portions of the
intestines.
ULCERATIVE COLITIS (IBD)
ASSESSMENT
 Severe diarrhea containing pus,
blood and mucosa
 Abdominal cramping and
tenderness
 Anorexia and weight loss
 Usually occurs in the descending
colon and rectum
 Rectal bleeding and or rectal pain
 Inability to defecate
 Fever
 Fatigue
Has similar signs and symptoms with
Crohn’s disease, the main difference
being that ulcerative colitis usually
occurs in the descending colon and
rectum while Crohn's disease occurs
in the ileum and ascending colon.
DIAGNOSIS
Diagnostic tests include:
 Colonoscopy: small camera used
to examine the whole colon
 Barium enema: x-ray used to
assess the colon. An enema of
contrast is given through the
rectum to help line the colon and
rectum for x-ray pictures. Then
the anatomy of the colon can be
assessed by the physician.
 Stool analysis is positive for
blood. Entemoeba histolytica,
which causes dysentery, must be
ruled out.
MEDICAL-SURGICAL MGT NURSING INTERVENTION
Medications:  Monitor VS, patient’s bowel
 Anti-inflammatory drugs. These movements, keep hydrated,
are the first line of treatment for monitor daily weights, focus on
people with ulcerative colitis. GI assessment (bowel sounds:
 5-Aminosalicylates can be given hyperactive, hypoactive, or
by mouth or as suppository absent, tenderness).
depending on the affected part of  Signs and symptoms of toxic
the colon. megacolon: abdominal
 On the other hand, distention, fever, diarrhea,
corticosteroids are commonly abdominal pain, dehydration,
prescribed if other treatments tachycardia, hypoactive or absent
cause no response. bowel sounds
 Immune system suppressors.  Signs and Symptoms of
These drugs work by prohibiting peritonitis: distention or
inflammatory response through abnormal bloating, increased
suppressing the immune system. heart rate, tachypnea, pain
 Biologics. Also called monoclonal  Educate patient with what to eat
antibodies, these drugs are and what to avoid eating
usually prescribed to people with
ulcerative colitis who cannot
tolerate other treatments.
Surgery:
 Proctocolectomy: Complete
removal of the colon and rectum.
Patient will have a permanent
ileostomy
 Ileoanal anastomosis (J-pouch):
Colon and rectum removed and a
pouch is created that is attached
to the ileum to allow stool to
pass from the small intestine to
the anus (so no outside ostomy
created)
DIABETES MELLITUS (DM)
ASSESSMENT
Clinical manifestations depend on the
level of the patient’s hyperglycemia.
 Polyuria or increased urination.
Polyuria occurs because the
kidneys remove excess sugar from
the blood, resulting in a higher
urine production.
 Polydipsia or increased thirst.
Polydipsia is present because the
body loses more water as polyuria
happens, triggering an increase in
the patient’s thirst.
 Polyphagia or increased appetite.
Although the patient may
consume a lot of food but glucose
could not enter the cells because
of insulin resistance or lack of
insulin production.
 Fatigue and weakness. The body
does not receive enough energy
from the food that the patient is
ingesting.
 Sudden vision changes.The body
pulls away fluid from the eye in an
attempt to compensate the loss of
fluid in the blood, resulting in
trouble in focusing the vision.
 Tingling or numbness in hands or
feet. Tingling and numbness occur
due to a decrease in glucose in the
cells.
 Dry skin. Because of polyuria, the
skin becomes dehydrated.
 Skin lesions or wounds that are
slow to heal. Instead of entering
the cells, glucose crowds inside
DIAGNOSIS
Several blood tests are used to
measure blood glucose levels, the
primary test for diagnosing diabetes.
Additional tests can determine the
type of diabetes and its severity.
 Random blood glucose test —
for a random blood glucose test,
blood can be drawn at any time
throughout the day, regardless
of when the person last ate. A
random blood glucose level of
200 mg/dL (11.1 mmol/L) or
higher in persons who have
symptoms of high blood glucose
suggests a diagnosis of diabetes.
 Fasting blood glucose test —
fasting blood glucose testing
involves measuring blood
glucose after not eating or
drinking for 8 to 12 hours
(usually overnight). A normal
fasting blood glucose level is less
than 100 mg/dL. A fasting blood
glucose of 126 mg/dL (7.0
mmol/L) or higher indicates
diabetes. The test is done by
taking a small sample of blood
from a vein or fingertip. It must
be repeated on another day to
confirm that it remains
abnormally high .
 Hemoglobin A1C test (A1C) —
The A1C blood test measures
the average blood glucose level
during the past two to three
months. It is used to monitor
MEDICAL-SURGICAL MGT
 There is no known cure for DM.
Management of the disease
focuses on control of the serum
glucose level to prevent or delay
the development of
complications.
 When diet, exercise and
maintaining a healthy weight
aren’t enough, you may need the
help of medication. Medications
used to treat diabetes include
insulin.
 Many people inject themselves
with insulin using a syringe or an
insulin pen injector,a device that
looks like a pen, except the
cartridge is filled with insulin.
A number of drug options exist for
treating type 2 diabetes, including:
 Sulfonylurea drugs
 Meglitinides
 Biguanides
 Alpha-glucosidase inhibitors
 Thiazolidinediones
 Drug combinations. By combining
drugs from different classes, you
may be able to control your
blood sugar in several different
ways.
NURSING INTERVENTION
 Advice patient about the
importance of an individualized
meal plan in meeting weekly
weight loss goals and assist with
compliance.
 Assess patients for cognitive or
sensory impairments, which may
interfere with the ability to
accurately administer insulin.
 Demonstrate and explain
thoroughly the procedure for
insulin self-injection. Help patient
to achieve mastery of technique
by taking step by step approach.
 Review dosage and time of
injections in relation to meals,
activity, and bedtime based on
patients individualized insulin
regimen.
 Instruct patient in the
importance of accuracy of insulin
preparation and meal timing to
avoid hypoglycemia.
 Explain the importance of
exercise in maintaining or
reducing weight.
 Advise patient to assess blood
glucose level before strenuous
activity and to eat carbohydrate
snack before exercising to avoid
hypoglycemia.
 Assess feet and legs for skin
temperature, sensation, soft
tissues injuries, corns, calluses,
dryness, hair distribution, pulses
and deep tendon reflexes.
 blood vessels, hindering the
passage of white blood cells which
are needed for wound healing.
 Recurrent infections. Due to the
high concentration of glucose,
bacteria thrives easily.
 Oral glucose tolerance test —
blood glucose control in people  Maintain skin integrity by
with known diabetes, but is not protecting feet from breakdown.
normally used to diagnose  Advice patient who smokes to
diabetes. Normal values for A1C stop smoking or reduce if
are 4 to 6 percent . The test is possible, to reduce
done by taking a small sample of vasoconstriction and enhance
blood from a vein or fingertip. peripheral flow.
Oral glucose tolerance testing
(OGTT) is the most sensitive test
for diagnosing diabetes and pre-
diabetes. However, the OGTT is
not routinely recommended
because it is inconvenient
compared to a fasting blood
glucose test.
CASE: APPENDICITIS

Questions:

1. What is the equivalent of 101̊F in ̊

Celcius?
 38 ̊ Celcius
2. Assuming that the administration of D5 LR 1L @44gtts/min started at 3pm, how many hours does it take to finish it all and at what time do you need to
follow-up your IV fluid?
 It takes 5 hours and 42 mins to finish the IV fluids. Follow-up may be performed at approximately 8:42 pm.
3. What is the prophylaxis used in appendectomy?
 Antibiotic prophylaxis should be administered before every appendectomy. These prophylactic medications may include: Cefotetan and cefoxitin.
4. What assessment is done to indicate inflammed appendix while one leg is flexed?
 The assessment indicator is called the Psoas sign. It is elicited by having the patient lie on his or her left side while the right thigh is flexed backward.
Pain may indicate an inflamed appendix overlying the psoas muscle.
5. What are the perioperative nursing responsibilities for laparotomy and laparascopic appendectomy?
 Instruments used for amputation of the appendix are to be isolated in a basin.
 If ruptured, the case must be considered contaminated, and the surgeon may elect to use antibiotic irrigation prior to closure of the abdomen with an
insertion of a drain.
 There may be no skin closure of the wound if the appendix has rupture.
6. Give at least 2 NCPs for appendicitis.
 Acute pain related to inflammation as evidenced by reports of abdominal pain
 Risk for fluid volume deficit related to vomiting and anorexia
PRIORITY NURSING DIAGNOSIS #1: ACUTE PAIN

SUBJECTIVE OBJECTIVE NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOMES
 The patient  Nausea Acute pain related to Inside the appendix is After hours of nursing  Assess pain, noting  Useful in After hours of nursing
reports having  Vomiting inflammation as mucosal lining, which interventions, the location, monitoring interventions, the
abdominal pain.  Anorexia evidenced by reports is continuously patient will be able to: characteristics, effectiveness of patient reports of
 She says that her  Elevated WBC of abdominal pain secreting mucus and severity (0–10 medication, controlled or relieved
pain under the upon CBC – fluids. There are also  Report pain is scale). Investigate progression of pain; she appears to
pain scale is 8/10. 15,000µL Definition: bacteria that normally relieved/controlled. and report healing. Changes be relaxed and is able
 CT-scan shows Unpleasant sensory live in the appendix.  Appear relaxed, changes in pain as in characteristics to sleep; patient
presence of and emotional The blockage in the able to sleep/rest appropriate. of pain may demonstrates
inflammed experience associated lumen of the appropriately. indicate relaxation skills and
appendix with actual or appendix causes  Demonstrate use developing diversional activities.
 Positive Psoas sign potential tissue major INCREASE of relaxation skills abscess or
 Positive Rovsing’s damage or described PRESSURE inside the and diversional peritonitis,
sign in terms of such appendix as these activities, as requiring prompt
damage; sudden or contents continue to indicates, for medical evaluation
V/S: slow onset of any grow and it can NOT individual situation. and intervention.
Temperature: 38 ̊
C intensity and with a move anywhere due
duration of less than 3 to the blockage. This  Keep at rest in  To lessen the pain.
months leads to inflammation semi-Fowler’s Gravity localizes
and eventually pain in position inflammatory
Reference: the abdomen. exudate into lower
Doenges, M. E., abdomen or pelvis,
Moorhouse, M., & relieving
Murr, A. C. (2019). abdominal
Nurse's Pocket Guide tension, which is
Diagnoses, Prioritized accentuated by
Interventions, and supine position.
Rationales 15th Ed. In
Decreased Cardiac  Provide diversional  Refocuses
Output (p. 633). activities attention,
promotes
relaxation, and
may enhance
coping abilities.

 Keep NPO and  Decreases

maintain NG discomfort of early
suction as intestinal
 ordered. peristalsis, gastric
irritation and
vomiting.
 Place ice bag on
abdomen  Soothes and
periodically during relieves pain
initial 24–48 hr, as through
appropriate. desensitization of
nerve endings.
 Never apply heat
to the right lower  This may cause the
abdomen appendix to
rupture
 Watch closely for
possible surgical  Continuing pain
complications and fever may
signal an abscess
PRIORITY NURSING DIAGNOSIS #2: FLUID DEFICIT
SUBJECTIVE OBJECTIVE NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EXPECTED OUTCOMES
 The patient  Nausea Risk for fluid volume Appendicitis can After hours of nursing  Monitor BP and  Variations help After hours of nursing
reports having  Vomiting deficit related to cause nausea and interventions, the pulse. identify fluctuating interventions, the
abdominal pain.  Anorexia vomiting and anorexia vomiting. Patients patient will be able to: intravascular patient maintains
 She says that her  Elevated WBC who experience volumes adequate fluid balance
pain under the upon CBC – Definition: appendicitis lose the  Maintain adequate and adequate urinary
pain scale is 8/10. 15,000µL Susceptible to appetite to eat. Due fluid balance as  Inspect mucous  Indicators of output. Patient also
 CT-scan shows experiencing to constant vomiting evidenced by moist membranes; adequacy of demonstrates lifestyle
presence of decreased added with loss of mucous assess skin turgor peripheral changes that prevents
inflammed intravascular, appetite, eventually it membranes, good and capillary refill. circulation and fluid volume deficit.
appendix interstitial, and/or will lead to fluid skin turgor, stable cellular hydration.
 Positive Psoas sign intracellular fluid deficiency in your vital signs, and
 Positive Rovsing’s volumes, which may body or dehydration. individually  Monitor I&O and  Decreasing output
sign compromise health adequate urinary note urine color, of concentrated
output. concentration, and urine with
V/S: Reference:  Demonstrate specific gravity. increasing specific
Temperature: 38 ̊
C Doenges, M. E., lifestyle changes to gravity suggests
Moorhouse, M., & prevent dehydration and
Murr, A. C. (2019). development of need for increased
Nurse's Pocket Guide fluid volume deficit fluids.
Diagnoses, Prioritized
Interventions, and  Health teaching on  May help in
Rationales 15th Ed. In the importance of changing behavior
Decreased Cardiac hydration. lifestyle choices
Output (p. 361).
 Administer D5 LR  To rehydrate the
1L @44gtts/min patient

 Never administer  Cathartics and

cathartics or enemas may
enemas rupture the
appendix.