Appendicitis - Assessment, Nursing Diagnosis and Interventions

Assessment
History:
Data collected by nurses from clients with possible appendicitis include: age, sey, surgical history, and other medical history, oral / rectal barium administration, history of diit especially fibrous foods.

a. Subjective Data
Before surgery
• Navel area pain radiates to the lower right abdomen
• Nausea, vomiting, bloating
• No appetite, fever
• The right leg cannot be straightened
• Diarrhea or constipation
After surgery
• Pain in the surgery area
• Weak
• Thirst
• Nausea, bloating
• Dizzy

b. Objective data
Before surgery
• Tenderness at McBurney point
• Muscle spasm
• Tachycardia, tachypnea
• Pale, nervous
• Bowel noise is reduced or absent
• Fever 38 - 38.5 degrees C
After surgery
• There are surgical wounds in the right lower quadrant of the abdomen
• Attached infusion
• There is a drain / gastric pipe
• Reduced bowel sounds
• Dry oral mucous membranes

Laboratory examination
• Leukocytes: 10,000 - 18,000 / mm3
• Netrophils increase by 75%
• Increased WBC up to 20,000 may be an indication of perforation (red blood cell count)

Diagnostic check
• Radiology: X-ray colon that allows fecalite in the valve.
• Barium enema: the appendix is only partially filled with barium.

Potential Complications
• Perforation
• Peritonitis
• Dehydration
• Sepsis
• Blood electrolytes are not balanced
• Pneumonia

Nursing Diagnosis and Interventions

1. Acute pain related to obstruction and inflammation of the appendix.
Subjective data:
• Navel area pain radiates in the lower right abdomen.
• The right leg cannot be straightened.
Objective:
• Tenderness at Mc Burney's point.
Goal:
Reduced pain / no pain

Outcomes:
The client said the pain was reduced.
The face and body position appear relaxed.

Interventions:
• Assess vital signs
• Assess pain complaints, determine the location, type and intensity of pain. Measure on a scale of 1-10.
• Explain the cause of pain and how to reduce it.
• Give a half-sitting position to reduce the spread of infection in the abdomen.
• Teach relaxation techniques.
• Compress ice on the affected area to reduce pain.
• Encourage the client to sleep in a comfortable position (tilted by bending the right knee).
• Create a calm environment.
• Carry out medical programs.
• Monitor the therapeutic and non-therapeutic effects of administration of analgesics.

2. Risk for fluid volume deficits related to nausea, vomiting, anorexia and diarrhea.
Goal:
Fluids and electrolytes are balanced.
Outcomes:
Good skin turgor.
Output and input fluids are balanced.

Interventions:
Observation of vital signs of temperature, pulse, blood pressure, respiration every 4 hours.
Observation of input and output fluids.
Keep food / odors that stimulate nausea or vomiting.
Collaboration of infusion and gastric pipes.

3. Impaired skin integrity related to surgical wounds.
Goal:
Incision wounds heal without signs of infection.
Interventions:
• Monitor surgical wounds from signs of inflammation: deformation, redness, swelling and discharge, color, amount and characteristics.
• Treat wounds sterile.
• Give quality food or client support to eat. Food is sufficient to speed up the healing process.