Appendectomy is the surgical removal of the vermiform appendix, a small, finger-shaped projection in the lower right abdomen at the juncture of the large and small intestines. The appendix, which protrudes from a section of the large intestine(cecum), generally has been considered an unessential organ that is removable without significant loss of body function.
Surgical Removal of the appendix is the only treatment for appendicitis. Without it, the appendix can rupture, spilling infectious material into the bloodstream and abdomen, which can be life-threatening.
1. Prevent complications.
2. Promote comfort.
3. Provide information about surgical procedure/prognosis, treatment needs, and potential complications.
1. Complications prevented/minimized.
2. Pain alleviated/controlled.
3. Surgical procedure/prognosis, therapeutic regimen, and possible complications understood.
4.Plan in place to meet needs after discharge.
NURSING DIAGNOSIS: Acute pain
May be related to
- Distension of intestinal tissues by inflammation
- Presence of surgical incision
Possibly evidenced by
- Reports of pain
- Facial grimacing, muscle guarding; distraction behaviors
- Autonomic responses
- Report pain is relieved/controlled.
- Appear relaxed, able to sleep/rest appropriately.
Appendectomy Nursing Care Plan (NCP)-Acute Pain
|Provide accurate, honest information to patient/SO.
|Being informed about the progress of the situation provides emotional support, helping to decrease anxiety
|Keep at rest in semi-Fowler’s position.||Gravity localizes inflammatory exudate into the lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position.|
|Encourage early ambulation.||Promotes normalization of organ function, e.g., stimulates peristalsis and passing of flatus, reducing abdominal discomfort.|
|Provide diversional activities.||Refocuses attention, promotes relaxation, and may enhance coping abilities.
|Keep NPO/maintain NG suction initially.
|Decreases discomfort of early intestinal peristalsis and gastric irritation/vomiting.|
|Administer analgesics as indicated.||Relief of pain facilitates cooperation with other therapeutic interventions, e.g., ambulation, pulmonary toilet|
|Place the ice bag on the abdomen periodically during the initial 24–48 hr, as appropriate.||Soothes and relieves pain through the desensitization of nerve endings. Note: Do not use heat, because it may cause tissue congestion|