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1 Acute Pain related to Distension of intestinal Possibly evidenced by Reports of pain Facial grimacing, muscle guarding; distraction behaviors Expressive behavior (restlessness, moaning, crying, vigilance, irritability, sighing) tissues by inflammation • Assess pain, noting location, characteristics, severity (0–10 scale). Investigate and report changes in pain as appropriate. • Rationale: Useful in monitoring effectiveness of medication, progression of healing. Changes in characteristics of pain may indicate developing abscess or peritonitis, requiring prompt medical evaluation and intervention. • Provide accurate, honest information to patient and SO. • Rationale: Being informed about progress of situation provides emotional support, helping to decrease anxiety • Keep at rest in semi-Fowler’s position. • Rationale: To lessen the pain. Gravity localizes inflammatory exudate into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position. • Encourage early ambulation. • Rationale: Promotes normalization of organ function (stimulates peristalsis and passing of flatus, reducing abdominal discomfort).
cont • Provide diversional activities • Rationale: Refocuses attention, promotes relaxation, and may enhance coping abilities. • Keep NPO and maintain NG suction initially. • Rationale: Decreases discomfort of early intestinal peristalsis, gastric irritation and vomiting. • Administer analgesics as indicated. • Rationale: Relief of pain facilitates cooperation with other therapeutic interventions (ambulation, pulmonary toilet). • Place ice bag on abdomen periodically during initial 24–48 hr, as appropriate. • Rationale: Soothes and relieves pain through desensitization of nerve endings. Note: Do not use heat, because it may cause tissue congestion. • Never apply heat to the right lower abdomen. • Rationale: This may cause the appendix to rupture. • Watch closely for possible surgical complications. • Rationale: Continuing pain and fever may signal an abscess
2.Risk for Fluid Volume Deficit Risk factors may includePreoperative vomiting, postoperative restrictions (e.g., NPO) • Monitor BP and pulse. • Rationale: Variations help identify fluctuating intravascular volumes • Inspect mucous membranes; assess skin turgor and capillary refill. • Rationale:Indicators of adequacy of peripheral circulation and cellular hydration. • Monitor I&O; note urine color and concentration, specific gravity. • Rationale: Decreasing output of concentrated urine with increasing specific gravity suggests dehydration and need for increased fluids. • Auscultate and document bowel sounds. Note passing of flatus, bowel movement. • Rationale: Indicators of return of peristalsis, readiness to begin oral intake. Note: This may not occur in the hospital if patient has had a laparoscopic procedure and been discharged in less than 24 hr. • Provide clear liquids in small amounts when oral intake is resumed, and progress diet as tolerated.
cont • Rationale: Dehydration results in drying and painful cracking of the lips and mouth. • Maintain gastric and intestinal suction, as indicated. • Rationale: An NG tube may be inserted preoperatively and maintained in immediate postoperative phase to decompress the bowel, promote intestinal rest, prevent vomiting. • Administer IV fluids and electrolytes. • Rationale: 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 electrolyte imbalances. • Never administer cathartics or enemas. • Rationale: Cathartics and enemas may rupture the appendix. • Give the patient nothing by mouth, and administer analgesics judiciously. • Rationale: This may mask symptoms.
3. Risk for Infection Related Inadequate primary defenses; perforation/rupture of the appendix; peritonitis; abscess formation • Practice and instruct in good handwashing and aseptic wound care. Encourage and provide perineal care. • Rationale: Reduces risk of spread of bacteria. • Inspect incision and dressings. Note characteristics of drainage from wound (if inserted), presence of erythema. • Rationale: Provides for early detection of developing infectious process and monitors resolution of preexisting peritonitis. • Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in mentation, reports of increasing abdominal pain. • Rationale: Suggestive of presence of infection or developing sepsis, abscess, peritonitis. • Obtain drainage specimens if indicated. • Rationale: Gram’s stain, culture, and sensitivity testing is useful in identifying causative organism and choice of therapy.
cont • Administer antibiotics as appropriate. • Rationale: Antibiotics given before appendectomy are primarily for prophylaxis of wound infection and are not continued postoperatively. Therapeutic antibiotics are administered if the appendix is ruptured or abscessed or peritonitis has developed. • Prepare and assist with incision and drainage (I&D) if indicated. • Rationale: May be necessary to drain contents of localized abscess. • Watch closely for possible surgical complications. • Rationale: Continuing pain and fever may signal an abscess.
4. Deficient Knowledge May be related to Lack of exposure/recall; information misinterpretationInaccurate follow-through of instruction • Identify symptoms requiring medical evaluation (increasing pain; edema or erythema of wound; presence of drainage, fever). • Rationale: Prompt intervention reduces risk of serious complications (delayed wound healing, peritonitis). • Review postoperative activity restrictions (heavy lifting, exercise, sex, sports, driving). • Rationale: Provides information for patient to plan for return to usual routines without untoward incidents. • Encourage progressive activities as tolerated with periodic rest periods. • Rationale: Prevents fatigue, promotes healing and feeling of well-being, and facilitates resumption of normal activities. • Recommend use of mild laxative or stool softeners as necessary and avoidance of enemas. • Rationale: Assists with return to usual bowel function; prevents undue straining for defecation.
4. Deficient Knowledge May be related to Lack of exposure/recall; information misinterpretationInaccurate follow-through of instruction Discuss care of incision, including dressing changes, bathing restrictions, and return to physician for suture and staple removal. • Rationale: Understanding promotes cooperation with therapeutic regimen, enhancing healing and recovery process. • Encourage the patient to cough, breathe deeply, and and turn frequently. • Rationale: To prevent pulmonary complication
