Cagayan de Oro College PHINMA Education Network

College of Allied Health Sciences

Nursing Department
BSN-3 Medical Surgical Nursing Activity Sheet
2nd Semester, Periodical 1, S.Y. 2020-2021

NAMES:__________MAMBUAY, IRIS JUNE F.__________________________________________ DATE:_02/16/2021______

SECTION:__C1-01___________ C.I:_MS. PHOEBE JAENN TAN, RN_________

APPENDICITIS CONCEPT MAP

APPENDICITIS
NURSING INTERVENTIONS
RISK FACTORS Inflammation of the appendix as a result of CLINICAL MANIFESTATIONS
 Monitor bowel sounds periodically COMPLICATIONS
 Monitor for changes in level of  Male becoming kinked or occluded by a fecalith  Vague periumbilical pain that progresses to right
pain  Familial predisposition lymphoid hyperplasia or rarely foreign bodies  Perforation/gangrene lower quadrant
 Monitor for signs of ruptured  More prevalent in teenagers or tumors  Peritonitis  Low-grade fever
appendix and peritonitis. Refer  Ages 10-30 years old  Nausea
immediately.  Kinked or occluded  Rebound tenderness
 Position right side-lying or semi-  Having tumors ASSESS/DX  Local tenderness at McBurney’s point when
Fowler’s to promote comfort.  Foreign bodies pressure is applied
 Complete patient history
 Maintain NPO status  Rovsing’s sign elicited by palpating at the left
 Physical examination
lower quadrant
 CBC
 Abdominal distension
 CT scan
 Constipation may occur
 Pregnancy test to rule out ectopic pregnancy to women of childbearing age
 Transvaginal ultrasound
 Urinalysis
 Diagnostic laparoscopy

NURSING DIAGNOSES
 Acute pain related to inflammation
 Risk for infection related to surgical incision
 Imbalanced nutrition: less than body requirements
related to altered nutrient absorption
 Risk for deficient fluid volume secondary to
appendicitis
 Risk for injury secondary to appendectomy
MANAGEMENT
MEDICAL/SURGICAL NURSING
 IV fluids to replace fluid loss and promote adequate renal function.  Monitor IV infusion pre-op and post-op.
 Antibiotics to prevent or treat sepsis.  Administer antibiotics as prescribed and morphine for pain.
 Analgesics administered after diagnosis.  Place patient on high Fowler’s after surgery
 Laxatives should never be given while patient has fever, nausea or pain.  Offer oral fluids when tolerated.
 Immediate surgery – appendectomy by laparotomy/laparoscopy.  Provide food as desired/tolerated when normal bowel sounds are present
already.
 Discuss incision care and perform dressing changes