NCP for Appendicitis
According to Potter & Perry (2010), nursing assessments in patients with post appendectomy are:
a. Respiratory system
Assess airway patency, respiratory rate, rhythm, depth, chest wall symmetries, breath sounds, and mucosal color.
b. Circulation system
Patients are at risk for cardiovascular complications caused by blood loss from the surgical site, a side effect of anesthesia. Assessment of heart rate and rhythm, along with blood pressure, reveals the patient's cardiovascular status. Assess capillary circulation by noting capillary refill, pulse, and nail color and skin temperature. A common early circulation problem is bleeding. Blood loss can occur externally through an internal channel or incision.
c. Nervous system
Assess pupillary and gag reflex, hand grip, and leg movement. If the patient has undergone surgery, which involves part of the nervous system, perform a more thorough neurological assessment.
d. Urinary system
Epidural or spinal anesthesia often prevents the patient from feeling a full bladder. Feel the lower abdomen just above the pubic symphysis to assess bladder distention. If the patient has a urinary catheter in place, there should be a continuous urine flow of 30-50 ml/hour in adults. Observe the color and smell of urine, surgery involving the urinary tract will usually cause the urine to bleed for at least 12 to 24 hours, depending on the type of surgery.
e. Digestive system
Inspect the abdomen to check for flatulence due to gas accumulation. Nurses need to monitor the initial oral intake of patients who are at risk of causing aspiration or the presence of nausea and vomiting. Also assess return of peristalsis every 4 to 8 hours. Routine abdominal auscultation to detect bowel sounds returned to normal, 5-30 loud sounds per minute in each quadrant indicates peristalsis has returned. A high ringing sound accompanied by abdominal distension indicates that the intestines are not functioning properly. Ask if the patient passes gas (flatus), this is an important sign that indicates normal bowel function.
2. Nursing Diagnosis
Nursing diagnoses that may appear in patients with Appendectomy - Post Operative, based on NANDA (2010), are as follows:
a. Impaired gas exchange related to residual anesthetic effects.
b. Ineffective airway clearance related to increased mucosal secretions.
c. Acute pain related to postoperative incision and position during surgery.
d. Impaired skin integrity related to postoperative wound, drain or surgical wound infection.
e. Fluid volume deficit related to fluid loss during surgery.
f. Altered elimination pattern: decreased related to anesthetic agents and immobilization.
g. Activity intolerance related to surgery and length of bed rest.
h. Self-care deficit related to surgical wound, pain and treatment regimen.
i. Knowledge Deficit related to lack of information about the therapeutic regimen.
3. Nursing Planning
The nursing plan for Appendicectomy Postoperative patients according to Wilkinson and Ahern (2013):
a. Acute Pain
1) Outcomes:
Demonstrate pain control as evidenced by the following indicators:
a) Recognize the onset of pain.
b) Using precautionary measures.
c) Reporting pain can be controlled.
2) Nursing Interventions
a) Observation of nonverbal cues of discomfort, especially in those who are unable to communicate effectively.
b) Ask the patient to rate pain or discomfort on a scale of 0 to 10 (0 = no pain or discomfort, 10 = severe pain).
c) Perform a comprehensive pain assessment including location, characteristics, onset and duration, frequency, quality, intensity or severity of pain, and precipitating factors.
d) Inform the patient about procedures that can increase pain.
e) Provide information about pain such as the cause of the pain, how long the pain will last and anticipated discomfort due to the procedure.
f) Teach the use of non-pharmacological techniques, such as deep breathing relaxation techniques.
g) Help sufferers to focus more on activities, not on pain and discomfort by diverting through television, radio, tape, and interactions with other people.
h) Control environmental factors that may affect the patient's response to discomfort (eg, room temperature, lighting, and noise).
i) Ensure administration of therapeutic analgesics or non-pharmacological strategies prior to performing painful procedures.
4. Nursing Implementation
Nursing implementation is a series of activities carried out by nurses to assist clients in better health status problems that describe the expected outcome criteria (Potter & Perry, 2010).
5. Evaluation
According to (Craven & Hirnle, 2007), evaluation is defined as a decision on the effectiveness of nursing care between the basic client nursing goals that have been set and the behavioral response shown by the client.
0 Comment for "NCP for Appendicitis - Assessment, Nursing Diagnosis, Interventions"