Nursing 213

N213: Health Differences Across the Lifespan 3 Study Guide

Rigid abdomen

Behavioral changes

• Nursing assessment for appendicitis: • Abdominal assessment: inspection, auscultation, percussion, and palpation; check for guarding and rebound tenderness • Vital signs: check for increased body temperature • Have patient cough gently, appendicitis pain gets worse withcough • Perform rectal or pelvic exam to check for flank tenderness • Review laboratory and radiology reports: o CBC: WBCs will be elevated from 10,000 to 18, 000 with a shift to the left; anything over 20,000 indicates peritonitis; look for elevated lymphocytes and neutrophils o Urinalysis: Rules out other causes of abdominal pain o CT scan o Ultrasound Nursing diagnosis for appendicitis: • Pain related to inflammation, infection, and tissue trauma or post-operative pain • Risk for infection related to bacterial invasion, rupture, or surgical site contamination • Risk for fluid volume deficit related to NPO status • Risk for altered respiratory function related to post-anesthesia, immobility, and pain • Knowledge deficit related to disease process, signs of complications, and treatment plan Nursing interventions for appendicitis: • Administer analgesics per MD order after physician makes diagnosis (pain medications may mask symptoms) • Monitor vital signs for fever and signs of infection or rupture • Keep patient NPO in preparation for surgery and to promote bowel rest • Monitor intake and output • Watch urine for cloudiness and purulent drainage, which are signs of infection • Give antibiotics per MD order to prevent or treat infection within 30 minutes of medication scheduled time • Never give laxatives due to possible rupture of appendix; never use a heating pad due to possible rupture risk • Place patient in high-fowler’s position prior to and after surgery for pain relief • Offer patient a warm bath, warm blanket, back rub, and teach pain diversion techniques • Practice aseptic technique to reduce risk of infection; teach patient and visitors to wash hands •

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