Categories
Health Care Plan

Nursing Diagnosis and Nursing Interventions for Appendicitis

Acute appendicitis is the most common cause of acute inflammation in the lower right quadrant of the abdominal cavity, the most common causes of emergency abdominal surgery (Smeltzer, 2001).

Appendicitis is a condition in which infection occurs in the appendix. In mild cases may recover without treatment, but many cases require laparotomy with removal of the infected appendix. If untreated, the mortality rate is quite high, due to peritonitis and shock when an infected appendix destroyed. (Anonymous, Appendicitis, 2007)

Nursing Diagnosis for Appendicitis

  1. Ineffective Breathing Pattern related to the act of anesthetics.
  2. Acute Pain related to the surgical incision.
  3. Risk for Fluid Volume Deficit associated with vomiting.
  4. Imbalanced Nutrition: Less than Body Requirements related to anorexia.
  5. Risk of Infection related to surgical incision.

Nursing Diagnosis for Appendicitis

Risk for infection related to an inadequate primary defenses, perforation, peritonitis secondary to inflammatory processes.

Nursing Interventions for Appendicitis

  • Assess and record the quality, location and duration of pain. Beware of the pain becomes severe.
  • Monitor and record vital signs of the increase in temperature, pulse, breathing fast and shallow existence.
  • Assess the abdomen against the rigidity and distention, decreased bowel sounds.
  • Perform wound care with aseptic technique.
  • See incision and bandage. Record the drainage characteristics of the wound / drain, erythema.
  • Collaboration: antibiotics

Nursing Diagnosis for Appendicitis

Acute Pain related to distention of intestinal tissue by inflammation, a surgical incision

Nursing Interventions for Appendicitis

  • Assess pain. Record the location, characteristics of pain.
  • Keep the rest in semi-Fowler position.
  • Suggest to early ambulation.
  • Teach diaphragmatic breathing techniques to slow to help release muscle tension.
  • Avoid pressure popliteal area.
  • Give antiemetic, analgesic according to the program.

Source : https://nursingdiagnosis-nursinginterventions.blogspot.com/2012/05/nursing-diagnosis-and-nursing.html

Popular Posts

Categories
Health Care Plan

Nursing Care Plan for Anaphylaxis

Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. It typically causes a number of symptoms including an itchy rash, throat swelling, and low blood pressure. Common causes include insect bites and stings, foods, and medications.

On a mechanistic level, anaphylaxis is caused by the release of mediators from certain types of white blood cells triggered by either immunologic or non-immunologic mechanisms. It is diagnosed on the basis of the presenting symptoms and signs. The primary treatment is injection of epinephrine, the administration of intravenous fluids, and positioning the person flat, with other measures being complementary.

Anaphylaxis typically presents many different symptoms over minutes or hours with an average onset of 5 to 30 minutes if exposure is intravenous and 2 hours for foods. The most common areas affected include: skin (80–90%), respiratory (70%), gastrointestinal (30–45%), heart and vasculature (10–45%), and central nervous system (10–15%)[5] with usually two or more being involved.

Nursing Diagnosis for Anaphylaxis

1. Impaired gas exchange related to ventilation perfusion imbalance.
characterized by: shortness of breath, tachycardia, flushing, hypotension, shock, and bronchospasm.

2. Altered tissue perfusion related to decreased blood flow secondary to vascular disorders due to anaphylactic reactions.
characterized by: palpitations, skin pale, cold acral, hypotension, angioedema, arrhythmias, ECG features horizontal and inverted T waves.

3. Ineffective breathing pattern related to the swelling of the nasal mucosa wall
characterized by: shortness of breath, breath with the lips, there rhinitis.

4. Acute pain related to gastric irritation
characterized by: abdominal pain, looked grimacing while holding stomach.

5. Impaired skin integrity related to changes in circulation
characterized by: swelling and itching of the skin and the nose, there are hives, urticaria, and runny nose.

Read More :

POPULAR POSTS