Appendectomynursing care plan

Appendectomy is the surgical removal of the vermiform appendix. Appendicitis remains one of the more common surgical emergencies, though it has markedly decreased in recent years. Appendectomy remains the most common treatment for non-complicated appendicitis. The number of people who die and get sick has been going down, especially in the last few decades, thanks to antibiotics, early detection, and better anesthesia and surgical techniques..

As recently as 2014, more than 95% of U.S. clients with appendicitis underwent appendectomy. Although there have been several randomized trials of antibiotics for appendicitis in adults, the exclusion of important subgroups, small sample sizes, and questions about applicability to the general population have limited the use of this treatment.

Clients with appendicitis always need an urgent referral and prompt treatment. An appendectomy should be considered for clients with a history of persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis, especially if leukocytosis is present. If the clinical picture isn’t clear, a CT scan and a short period of “watchful waiting” (4-6 hours) may help improve diagnostic accuracy and speed up the process of finding out what’s wrong.

For reasons of time and cost, open appendectomy was long the most common approach. However, an increasing number of surgeons have come to prefer laparoscopic appendectomy, especially in female clients, because of its diagnostic ability. Laparoscopic appendectomy has now been improved and standardized. It has some advantages over open appendectomy, including decreased postoperative pain, better aesthetic results, a shorter time to return to usual activities, and a lower incidence of wound infections or dehiscence.

Appendectomy

To understand the outcomes of appendectomy, it is warranted to review the pathophysiology of appendicitis. The appendix becomes blocked by feces, a foreign object, or a tumor. Obstruction, along with the continued secretion of mucus, causes the wall of the appendix to become distended, thereby reducing the blood supply to the wall. This results in ischemia and the accumulation of toxins. The wall of the appendix starts to break down, and normal bacteria are found in the gut attacking the decaying appendix. If left untreated, this may lead to necrosis and perforation of the appendix.

There are no known contraindications for appendectomy in clients with suspected appendicitis, except in the case of a client with a long history of symptoms and signs of a large phlegmon. Certain contraindications exist for laparoscopic appendectomy, including extensive adhesions, radiation or immunosuppressive therapy, severe portal hypertension, and coagulopathies. It is also contraindicated in the first trimester of pregnancy.

Nursing care planning for clients who underwent appendectomy requires the nurse’s knowledge of the procedure and its possible outcomes and complications. The following are nursing diagnoses associated with appendectomy.

  • Risk for Infection
  • Acute Pain
  • Risk for Deficient Fluid Volume

Appendectomy Nursing Care Plan 

Below are sample nursing care plans for the problems identified above.

Risk for Infection

Regardless of the surgical technique (laparoscopic or open surgery), appendectomy remains a skeptical surgical intervention associated with a substantial risk of surgical site infections (SSIs). SSIs after appendectomy are postoperative nosocomial infections affecting the incision site, deep tissues, and organs at the operative site within 30 days after the surgical procedure. Healthcare-associated infections are acquired by clients when receiving care and are the most frequent adverse event affecting client safety worldwide.

Nursing Diagnosis

  • Risk for Infection

Risk Factors

  • Inadequate primary defenses
  • Perforation or rupture of the appendix, peritonitis, abscess formation
  • Invasive procedures, surgical incision

Evidenced by

  • Not applicable on risk diagnosis; the presence of signs and symptoms establishes an actual diagnosis

Desired Outcomes

After implementation of nursing interventions, the client is expected to:

  • Achieve timely wound healing.
  • Be free of signs of infection and inflammation, purulent drainage, erythema, and fever.

Nursing Interventions

Assessment Rationale
Assess the client’s vital signs, especially the temperature. Monitor the client’s pulse rate and temperature for signs of infection. An elevated temperature and pulse rate are suggestive of the presence of infection, developing sepsis, abscess, and peritonitis.
Note onset of chills, diaphoresis, changes in mentation, and reports of increasing abdominal pain. Severe infection may result in a dynamic ileus. Clients in these conditions present with wound tenderness or soreness, drainage of fluid from the incision, or swelling and redness at the incision site. The client also presents with abdominal pain, disorders of bowel transit, persistent nausea and vomiting, difficulty with micturition, and persistent pain in the lower limbs.
Inspect incision and dressings. Note the characteristics of drainage from the wound or drains (if inserted) and the presence of erythema. This provides for early detection of developing infectious processes and monitors the resolution of preexisting peritonitis.
Independent
Practice and instruct in good hand hygiene and aseptic wound care, Healthcare worker (HCW) hand hygiene at appropriate times during client care is an effective means of reducing the risk of nosocomial infections. Providing hand sanitizers on bedside tables, with meal trays, or with commodes is likely to result in a significant increase in client hand hygiene. If HCWs are also involved in facilitating client hand hygiene, there may be an added benefit of improved HCWs’ hand hygiene.
Obtain drainage specimens, as indicated. Gram stain, culture, and sensitivity testing are useful in identifying causative organisms and choice of therapy.
Review the client’s laboratory results. WBCs are often elevated above 12,000/mm³ and the neutrophil count is often elevated to greater than 75% in the presence of infection.
Dependent
Administer antibiotics, as appropriate. Antibiotics given before appendectomy are primarily for prophylaxis of wound infection and are not usually continued postoperatively. Therapeutic antibiotics are administered if the appendix is ruptured or abscessed, or peritonitis has developed.
Assist with placing a surgical drain, as indicated. Surgical drains are used to remove blood, pus, and other body fluids from wounds. the primary reasons for placing an abdominal drain after an appendectomy are: drainage of established intra-peritoneal collection, prevention of further fluid accumulation, and identification of fecal fistula. The use of abdominal drainage can avoid the accumulation of intra-peritoneal dirty collections, thereby reducing bacterial contamination of the surgical site.
Assist with incision and drainage (I&D) if indicated. I&D may be necessary to drain the contents of a localized abscess.

Acute Pain

Postoperative pain is one of the most frequent complaints after surgery. Most people experience pain in postoperative periods, for various reasons. Inappropriate postoperative pain control is associated with client dissatisfaction, increased hospital stay and costs, increased morbidity, and risk of developing chronic pain. Inflammation has been proposed as one of the possible mechanisms of postoperative pain.

Nursing Diagnosis

  • Acute Pain

Related Factors

  • Distention of intestinal tissues
  • Inflammation
  • Presence of surgical incision

Evidenced by

  • Verbalizations of pain
  • Facial grimace
  • Muscle guarding and/or guarding behaviors
  • Autonomic responses

Desired Outcomes

After the implementation of nursing interventions, the client is expected to:

  • Verbalize pain is relieved or controlled.
  • Appear relaxed.
  • Resume a normal sleep and rest pattern.

Nursing Interventions

Assessment Rationale
Assess pain, noting location, characteristics, and severity (0 to 10 scale). Using a pain scale is useful in monitoring the effectiveness of medication and the progression of healing. Changes in characteristics of pain may indicate developing abscess or peritonitis, requiring prompt medical evaluation and intervention.
Assess the client’s vital signs. Monitor the client’s vital signs for changes in temperature or heart rate. Fever and tachycardia can both indicate infection or inflammation.
Assess the client’s bowel movements. Monitor for adequate bowel movements. Opioids can be necessary for pain control, but they often lead to constipation.
Monitor the client’s incision. Continuous monitoring of the incision is needed for any signs of infection such as redness, swelling, drainage, or increased pain and must be reported to the surgeon.
Independent
Provide accurate and honest information to the client and significant others. Being informed about the progress of the situation provides emotional support, helping to decrease anxiety.
Place the client in a semi-Fowler’s position. Gravity localizes inflammatory exudate into the lower abdomen or pelvis, relieving abdominal tension, which is accentuated by the supine position .
Encourage the client to ambulate early. Early ambulation promotes the normalization of organ function and stimulates peristalsis and passing of flatus, thereby reducing abdominal discomfort.
Provide diversional activities and relaxation techniques. Diversional activities refocus attention, promote relaxation, and may enhance coping abilities.
Educate the client to avoid strenuous activities for the first 4-6 weeks. Normal activity can usually resume within a few days to a week. However, the client should avoid any strenuous activity and heavy lifting for the first 4-6 weeks, unless otherwise noted by the provider. Frequent small walks may be encouraged.
Educate the client about the side effects of pain medications. If pain medications are prescribed such as opioids, ensure that the client knows not to drive or operate machinery while taking the drugs.
Place an ice bag on the abdomen periodically during the initial 24 to 48 hours, as appropriate. Cool application soothes and relieves pain through desensitization of nerve endings. Do not use heat because it may cause tissue congestion and increase edema formation.
Dependent
Keep the client on NPO. Suction NG tube initially. This decreases the discomfort of early intestinal peristalsis and gastric irritation or vomiting.
Administer analgesics as prescribed. Relief of pain facilitates cooperation with other therapeutic interventions, such as early ambulation.
Assist with anesthesia administration as appropriate. Bupivacaine liposome provides prolonged pain relief and reduces opioid requirement in the first 72 hours after surgery. When surgery exceeded 40 minutes, bupivacaine use had a greater association with less pain and fewer analgesics use.

Risk for Deficient Fluid Volume

During early acute appendicitis, clients frequently has not had sufficient oral intake and present with some degree of intravascular dehydration. Clients diagnosed with appendicitis usually require fluid boluses prior to operation in order to counteract dehydration. However, these clients need continued fluid resuscitation appropriate to their fluid status and severity of appendicitis.

Nursing Diagnosis

  •  Risk for Deficient Fluid Volume

Risk Factors

  • Preoperative vomiting
  • Postoperative restrictions (NPO)
  • Hyper-metabolic state (fever, healing process)
  • Inflammation of the peritoneum

Evidenced by

  • Not applicable on risk diagnosis; the presence of signs and symptoms establishes an actual diagnosis

Desired Outcomes

After the implementation of nursing interventions, the client is expected to:

  • Maintain adequate fluid volume.
  • Display moist mucous membranes, good skin turgor, and adequate urine output.
  • Maintain stable vital signs.

Nursing Interventions

Assessment Rationale
Assess the client’s vital signs, especially the BP and pulse rate. Variations in the client’s vital signs help identify fluctuating intravascular volumes or changes in vital signs associated with the immune response to inflammation.
Assess the client’s mucous membranes, skin turgor, and capillary refill. The mucous membranes, skin turgor, and capillary refill are indicators of adequacy of peripheral circulation and cellular hydration. A capillary refill time of more than 2 seconds or peripheries cold to touch are indicators that the client may need urgent fluid resuscitation, according to the National Institute for Health and Care Excellence (NICE) guidelines on intravenous fluid therapy in adults.
Monitor intake and output; note urine color and concentration and specific gravity. If the fluid status is unclear, urine output is the most common measure. Urine output should be no lower than 0.5 ml/kg/h. If dehydration is suspected, monitoring of the urine output and correct fluid replacement is indicated.
Auscultate bowel sounds. Note passing of flatus and bowel movement. These are indicators of return of peristalsis and readiness to begin oral intake. However, this may not occur in the hospital if the client has a laparoscopic procedure and has been discharged in less than 24 hours.
Independent
Provide the client with clear liquids in small amounts, as appropriate. If tolerated and the client is not NPO anymore, oral fluid intake should be encouraged. This reduces the risk of gastric irritation and vomiting to minimize fluid loss.
Provide frequent oral care with special attention to the protection of the lips. Dehydration results in drying and painful cracking of the lips and mouth.
Dependent
Maintain nasogastric (NG) and intestinal suction, as indicated. Although not frequently needed an NG tube may be inserted preoperatively and maintained in the immediate postoperative phase to decompress the bowel, promote intestinal rest, and prevent vomiting.
Administer intravenous fluids and electrolytes. The peritoneum reacts to irritation and infection by producing large amounts of intestinal fluid, pulling fluid from the vascular space, and possibly reducing the circulating blood volume, resulting in dehydration and relative electrolyte imbalances.

References

  1. Alder, A. C., & Cuffari, C. (2018, October 25). What is the role of fluid resuscitation in the treatment of pediatric appendicitis? Retrieved March 30, 2022, from https://www.medscape.com/answers/926795-186496/what-is-the-role-of-fluid-resuscitation-in-the-treatment-of-pediatric-appendicitis
  2. Castañeda, V., Steiner, M., Bustos, C., & Duarte, Z. (2021, September 9). Appendicitis (Nursing) – StatPearls. NCBI. Retrieved March 29, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK568712/
  3. The CODA Collaborative. (2020, November 12). A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. The New England Journal of Medicine, 383, 1907-1919. 10.1056/NEJMoa2014320
  4. Danwang, C., Bigna, J. J., Tochie, J. N., Mbonda, A., Mbanga, C. M., Nzalie, R. N. T., Guifo, M. L., & Essomba, A. (2020). Global incidence of surgical site infection after appendectomy: a systematic review and meta-analysis. BMJ Open Journals, 10(2). http://dx.doi. org/10.1136/bmjopen-2019- 034266
  5. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
  6. Ha, H.-K., Lee, K.-G., Choi, K. K., Kim, W. S., & Choi, H. R. (2020, January 31). Effect of bupivacaine on postoperative pain and analgesics use after single-incision laparoscopic appendectomy: double-blind randomized study. Annals of Surgical Treatment and Research, 98(2), 96-101. https://doi.org/10.4174/astr.2020.98.2.96
  7. Lacey, J., Corbett, J., Forni, L., Hooper, L., Hughes, F., Minto, G., Moss, C., Price, S., Whyte, G., Woodcock, T., Mythen, M., & Montgomery, H. (2019, June 17). Assessment Rationale Assess pain, noting location, characteristics, and severity (0 to 10 scale). Using a pain scale is useful in monitoring the effectiveness of medication and the progression of healing. Changes in characteristics of pain may indicate dev. Annals of Medicine, 51(3-4), 232-251. https://doi.org/10.1080/07853890.2019.1628352
  8. Li, Z., Zhao, L., Cheng, Y., Cheng, N., & Deng, Y. (2021). Abdominal drainage to prevent intra‐peritoneal abscess after appendectomy for complicated appendicitis. Cochrane Database of Systematic Reviews, (8). 10.1002/14651858.CD010168.pub4
  9. Moghadam, M. Y., Nemat-Shahi, M., Soroosh, D., Nehmat-Shahi, M., & Asadi, A. (2020, March 28). Effect of evening primrose oil on postoperative pain after appendectomy: A double-blind, randomized, clinical trial. Biomedicine (Taipei), 10(1), 28-32. 10.37796/2211-8039.1002
  10. Santacroce, L., & Geibel, J. (2021, May 3). Appendectomy: Background, Indications, Contraindications. Medscape Reference. Retrieved March 25, 2022, from https://emedicine.medscape.com/article/195778-overview#a1
  11. Srigley, J.A., Furness, C.D., & Gardam, M. (2016, April). Interventions to improve patient hand hygiene: a systematic review. Journal of Hospital Infection, 16.10.1016/j.jhin.2016.04.018
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