Introducing 

Prezi AI.

Your new presentation assistant.

Refine, enhance, and tailor your content, source relevant images, and edit visuals quicker than ever before.

Loading content…
Loading…
Transcript

History and Physical: A.P is a 45 year old male

PMH: Diabetes type II, MRSA

Past surgical history: traumatic right hand injury

HPI: Abdominal pain, acute appendicitis, status post op day 3

Allergies: Penicillin

References:

Appendicitis. (2019, May 24). Retrieved November 12, 2020, from https://www.mayoclinic.org/diseases-conditions/appendicitis/symptoms-causes/syc-20369543

Pearson Nursing: Concept-Based Approach (pg. 682-687)

Medical Diagnosis: Acute appendicitis

Medical Diagnosis: Acute appendicitis

Definition: Appendicitis occurs when there is an obstruction to at the opening of the appendix that would lead to inflammation and build up of bacteria. This is a projection off the cecum of the large intestine.

Pathophysiology

Pathophysiology

  • The patient presented with abdominal pain, nausea, and vomiting that lasted for 3 days. He stated he had pain in his lower right quadrant of his abdomen. This is known as McBurney point.
  • The function of the appendix is unknown but one theory suggests it holds the "good" bacteria of the gut.
  • Obstruction of the appendix causes the bacteria to multiply, and become inflamed, filling with pus (Appendicitis 2019). Potentially leading to perforation.

McBurney point

Assessment and Labs

Assessment

Look for signs and symptoms:

  • Rebound tenderness during the abdominal assessment.
  • Pain that begins at the naval and moves to the lower right quadrant
  • Nausea and vomiting
  • Loss of appetite
  • Low-grade fever
  • Constipation/ diarrhea
  • Abdominal bloating

Because inflammation can go to perforation very quickly, time is key. Obtain vitals, abdominal assessment and any diagnostic tests and labs.

Labs

White Blood Cell (WBC) count:

Normal range: 4,000-10,000

Patient result: 16,000

This shows that the patient could have presence of inflammation or infection.

CT scan would be how to determine if the source of pain and confirm if it is appendicitis. An abnormal CT scan would show the appendix to be enlarged and inflamed.

Picture

Risk Factors

  • Adolescent boys, although can occur at any age/ or gender
  • Patients that have low fiber diet and high in carbohydrates
  • GI infections can also lead to appendicitis

Risk Factors

Complications

Complications

  • A ruptured appendix: spreads the infection into the abdomen.
  • Abscess can form this is a pocket filled of infection that happens when the appendix bursts. Surgeons would have to go and place a drain and make sure it's gone before surgery can happen to remove and clean the abdomen.

Nursing Diagnosis

  • Gas exchange, Impaired
  • Infection, risk for
  • Pain, Acute
  • Fluid volume, risk for deficient

Nursing Diagnosis

Nursing Interventions

Nursing Intervention

  • Assess pain noting location, severity, and characteristics (0-10 scale)
  • Assess abdomen and bowel function
  • Monitor vitals and have accurate I & O's
  • Encourage early ambulation
  • Keep patient on a clear liquid diet until bowel function returns
  • Use an ice pack as needed to LRQ
  • Monitor for post op complications
  • Administer medications as prescribed
  • Inspect incision and dressing
  • Continuing pain and fever can indicate abscess

Nutrition

  • Keep patient NPO until surgery, once patient is out of surgery, place patient on clear liquid diet until bowel sounds are present and is no longer nauseous. Advance diet as tolerated once patient is having bowel function and the HCP orders it (Pearson Vol. 1 pg. 685).

Medications

Pharmacology

Cephalexin: Written order:

Dose/Frequency: 1000 mg 3x Daily

Duration: 7

Route: Oral

2 tabs of 500 mg given three times a day for 7 days.

Often used when patients have allergies to penicillin, this is used to treat infection and prevent post op infection

Oxycodone Hydrochloride

Written order

Dose/Frequency: 5 mg Every 4 Hours PRN

Route: Oral

  • Give 1 tab (5 mg) every 4 hours as needed for pain
  • Used for moderate to severe pain due to post operative pain

Patient Education

  • Wound care/incision care
  • Explain the importance of hand hygiene, complete dressing change as indicated due to the open appendectomy
  • Report to HCP any indication of infection; fever, increased abdominal pain, swelling, redness, drainage/bleeding, and/or pain to the incision site.
  • No heavy lifting until approved by surgeon at follow up appointment
  • When they are able to return to work
Learn more about creating dynamic, engaging presentations with Prezi