Nursing Care Plan for Appendicitis
Appendicitis
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of peritonitis and shock. Reginald Fitz first described acute and chronic appendicitis in 1886, and it has been recognized as one of the most common causes of severe acute abdominal pain worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis".
Signs & Symptoms
For the most part symptoms relate to disturbed function of bowels. Pain first, vomiting next and fever last has been described as classic presentation of acute appendicitis. Pain starts mid abdomen,and except in children below 3 years, tends to localize in right iliac fossa in a few hours. This pain can be elicited through various signs. Signs include localized findings in the right iliac fossa. The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there is severe pain on suddenly releasing a deep pressure in lower abdomen rebound tenderness. In case of a retrocecal appendix, however, even deep pressure in the right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the cecum, distended with gas, prevents the pressure exerted by the palpating hand from reaching the inflamed appendix. Similarly, if the appendix lies entirely within the pelvis, there is usually complete absence of the abdominal rigidity. In such cases, a digital rectal examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness in this area (McBurney's point) and this is the least painful way to localize the inflamed appendix. If the abdomen on palpation is also involuntarily guarded (rigid), there should be a strong suspicion of peritonitis requiring urgent surgical intervention.
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Assessment
- Patient Identity
The identity of the client's name, age, sex, marital status, religion, tribe / nation, education, occupation, income, address and registration number. - Nursing History
- Health history now : complaints of pain in post operative wounds, nausea, vomiting, increased body temperature, increased leukocytes.
- Health history of the past
- Physical examination
- Cardiovascular System: To check vital signs, presence or absence of jugular vein distension, pale, edema, and abnormal heart sounds.
- Hematological System: To determine whether there is increase in leukocytes is a sign of infection and bleeding, nosebleeds splenomegaly.
- Urogenital System: There are at least tension of the bladder and back pain complaints.
- Musculoskeletal System: To determine whether there is difficulty in movement, pain in bones, joints and there is a fracture or not.
- The immune system: To determine whether there is lymph node.
- Examination Support
- Routine Blood tests: to determine an increase in leukocytes is a sign of infection.
- Abdominal x-ray examination: to know the existence of post-surgical complications.
Nursing Diagnosis
Pain related to abdominal wound incision in the lower right quadrant of postoperative
Nursing Intervensi
Goal :
Pain is reduced / lost
Result Criteria :
Seemed relaxed and could sleep properly.
Intervention :
- Assess the scale of pain location, pain characteristics and report changes accordingly.
- Maintain a break with the semi powler.
- Encourage early ambulation.
- Give your entertainment activities.
- Collaborate with team doctors in the provision of analgesics.
Rational :
- Useful in the supervision and efficient medicine, healing progress, changes and characteristics of pain.
- Eliminating stress is increased by abdominal supine position.
- Improve kormolisasi organ function.
- Increase relaxation.
- Pain relief.