Appendectomy An appendectomy (sometimes called appendisectomy or appendicectomy) is thesurgical removal of the vermiform appendix.

This procedure is normally performed as anemergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset ofsepsis; it is now recognized that many cases will resolve when treated perioperatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix, causing transruptural flotation. This is a relativecontraindication to surgery. Appendectomy may be performed laparoscopically (this is called minimally invasive surgery) or as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or if it is desirable to hide the scars in the umbilicus or in the pubic hair line. Recovery may be a little quicker with laparoscopic surgery; the procedure is more expensive and resource-intensive than open surgery and generally takes a little longer, with the (low in most patients) additional risks associated with pneumoperitoneum (inflating the abdomen with gas). Advanced pelvic sepsis occasionally requires a lower midline laparotomy. An appendectomy is an emergency surgical procedure to remove an inflamed or infected appendix, a condition known as appendicitis. Without surgery, the appendix can rupture, spilling infectious material into the bloodstream and abdomen, which can be life-threatening. There is no alternative treatment; surgery is considered the only way to treat appendicitis. During the traditional, or open, appendectomy procedure, an incision two to three inches long is made in the right lower abdomen several inches above the hip bone. The incision opens both the skin and divides the abdominal muscle tissue, allowing the surgeon to see the appendix and pull it closer to the surface for better access. Once the appendix is identified, it is cut away from the surrounding tissue, including the intestine, and infected tissue is removed. The opening that is left after the appendix is removed is closed by surgical staples or by sewing the area closed. The appendix and surrounding tissues are then closely inspected to make sure the infection is isolated to the tissue that has been removed. If necessary, the surgeon can use sterile fluid to wash the area and then suction out any evidence of pus. If the surrounding tissues are healthy, the surgeon can begin to close the incision by first sewing the layers of muscle together, then closing the skin with stitches or staples. The incision will be covered with a sterile bandage to protect the skin and prevent infection. The procedure, from the initiation of anesthesia to bandaging, takes less than an hour if there are no complications.

Once the incision is covered, the anesthesia will be stopped, allowing the patient to slowly begin to wake and the breathing tube to be removed. The patient will be transferred to the Post-Anesthesia Care Unit to be monitored by nursing staff. The patient will be groggy at first, and will then slowly become more alert as the anesthesia wears off completely. During the post-anesthesia phase, vital signs will be monitored closely for any possible complications and pain medication given when necessary. Once the patient is completely awake, they will be transferred to a hospital

room to begin healing. Most patients have a notable decrease in pain after surgery, even with the pain of the incision. The next day, the patient may begin taking small sips of clear fluids and then progress to a regular diet if the fluid is tolerated. Sitting up on the edge of the bed, then walking short distances will be encouraged several times a day. Medication will be available to make movement less painful. Most patients are discharged within 24 hours of surgery to continue recovering from surgery . The incision is usually held closed with small strips of adhesive that will slowly fall off as the patient showers and goes about their normal activities. Internal sutures will slowly dissolve and do not need to be removed. Some patients may need a mild pain medication during this part of recovery, and most will continue to take antibiotics for up to a week after surgery. Most patients are able to return to normal activities within a few weeks; more strenuous activities may take a week or two longer. Acute appendicitis is an inflammation of the appendix due to infection (Bruce and Finlay, 1997). It is known to be one of the most common surgical conditions, and affects about seven per cent of the population (Hardin, 1999). The disease can affect people of all ages but is most common in young adults from developed countries (Bruce and Finlay, 1997). About 150 people die each year in England and Wales from acute appendicitis (Duncan and Stoddard, 1992), with the majority of deaths seen in the older age group. The primary cause of death is a delay in diagnosis (Duncan and Stoddard, 1992) leading to perforation of the appendix followed by peritonitis. The treatment is surgical removal of the appendix (Dunlop, 2002). Prompt diagnosis and surgical referral reduces the risk of perforation and prevents complications (Hardin, 1999). Pathology The appendix is situated in the right iliac region of the abdomen. It is attached to the caecum, which is the area where the small and large bowel join (Fig 1). The full term for the appendix is the vermiform appendix. The appendix is described by Tortora and Grabowski (1993) as a twisted, coiled tube that is about 8cm long. A normal appendix measures 6mm or less in diameter (Hardin, 1999). If it is larger than this, it is likely the patient has appendicitis. In most people the appendix is located in the intraperitoneal region but studies have shown that 30 per cent may lie in a pelvic position, hidden from the anterior peritoneum. This can change the clinical manifestations of the disease (Hardin, 1999). The appendix is not a vital organ and has no particular function within the body, but it can become diseased. If untreated it may burst and cause peritonitis, infecting other organs and sometimes leading to death (National Digestive Disease Information Clearinghouse, 2004). Causes

It is not always known how the appendix becomes inflamed but obstruction is a main cause. In about 40 per cent of cases this is due to faecolith - hardened faeces (NDDIC, 2004). The appendix's location between the join of the small and large bowel mean it can become blocked with faecolith. If faecolith blocks the lumen of the appendix, mucus and pus cannot drain into the caecum. This can result in dilation and perforation of the appendix, letting faecal matter enter the peritoneal cavity causing peritonitis. Obstruction may also occur due to carcinoma of the caecum. The appendix is the most common site for carcinoid tumours. The vast majority are benign but if they are larger than 2cm they can infiltrate the wall of the appendix and spread (Dunlop, 2002). Signs and symptoms The signs and symptoms of appendicitis differ among patients (Irving and Jones, 1998). Abdominal pain is the most common symptom. Specific characteristics of abdominal pain and other associated symptoms have proved to be reliable indicators of acute appendicitis (Hardin, 1999). Some studies also show that sudden onset of epigastric pain or periumbilical pain may occur in less than 50 per cent of patients with appendicitis (Irving and Jones, 1998). The remaining patients present with a variety of pain patterns (Bruce and Finlay, 1997). Loss of appetite, nausea and vomiting are commonly associated with appendicitis (Hardin, 1999), as is a change in bowel habit with a tendency to constipation (Bruce and Findlay, 1997). The patient's temperature may be normal or slightly raised. The pulse may show an increase and the tongue is usually furred and moist (Colmer, 1986). The white blood cell (leukocyte) count may be raised above 10,000/m3 (Irving and Jones, 1998). Referred pain When the appendix is hidden from the anterior peritoneum the usual signs and symptoms may not be present. Pain and tenderness can occur in places other than the right lower quadrant area (Hardin, 1999). Pain may not be localised, particularly in children. Tenderness may be diffuse or noted only on rectal or pelvic examination (Irving and Jones, 1998). A patient with a pelvic appendix may show no abdominal signs, but the rectal examination may elicit tenderness (Hardin, 1999). Appendicitis with peritonitis Perforation of the appendix is the main source of risk that leads to complications. Perforation occurs when the tube from the appendix becomes blocked. Research shows 20 per cent of patients undergoing surgery for appendicitis have a ruptured appendix (Peterson, 2002). If perforation occurs in acute appendicitis, faecal matter can enter the peritoneal cavity causing peritonitis. Peritonitis is the inflammation of the peritoneum, which is caused by bacteria migrating through the damaged wall to infect the peritoneal cavity (Dunlop, 2002). Hardin (1999) explains that diagnosis of a perforated appendix is usually easier than that of a non-perforated one. This is due to the more specific symptoms (Box 1). As a result a brief period of hospital observation in some cases will not increase the risk of perforation but may increase and improve diagnostic accuracy.

Investigations Investigations needed for suspected appendicitis are (Hardin, 1999; Irving and Jones, 1998): - A careful systemic examination of the abdomen is essential. This is the most accurate way to diagnose appendicitis and will be carried out by a member of the surgical team; - The white blood cell count should be checked. In 80 per cent of cases the level will be elevated; - Ultrasound and computerised tomography scans are rarely used. Diagnosis The signs and symptoms of acute appendicitis vary among individuals, which can make diagnosis difficult. The number of conditions that can be diagnosed from acute right iliac fossa pain is enormous (Duncan and Stoddard, 1992). As the appendix has no apparent function within the body, removal of the organ would be safer if any of symptoms suggest appendicitis rather than waiting for further signs to confirm diagnosis. Pelvic examination should be performed on all women with abdominal pains, as gynaecological conditions can mimic appendicitis. Treatments Appendectomy is the best and most common treatment performed for appendicitis. This is usually carried out by laparoscopic surgery. An oblique incision is made in the right iliac fossa region splitting, not cutting, the muscles to gain access to the peritoneum (Colmer, 1986). Antibiotics should be given to patients as either therapeutic or prophylactic therapy depending on the severity of the case (Colmer, 1986). About 20 per cent of patients who present with symptoms of appendicitis and have an appendectomy are found to have had a normal appendix (Hardin, 1999). Despite this statistic it is accepted that prompt treatment is important to prevent morbidity and mortality. Nursing implications - Preoperative care It is important to prepare a patient several hours pre-surgery. The patient may be dehydrated due to symptoms such as vomiting. It may be necessary to administer IV fluids. The patient's vital signs should be recorded every 2-4 hours. The nurse should not apply any heat over the area of pain while the patient is awaiting diagnosis as this could cause the appendix to rupture (Box 2). Analgesia should not be administered before examination because this can lead to an inaccurate diagnosis as the pain may subside and the examination will be ineffective. Aperients should also be avoided as induced peristalsis may cause perforation. If appendicitis has been diagnosed regular analgesia, usually an opioid depending on pain severity, should be given to make the patient comfortable before treatment. They may feel anxious so the nurse or surgical team should fully explain the procedure to them and answer any questions. The operation site will be washed and shaved before surgery, depending on local procedures.

- Postoperative care The severity of the patient's pain needs to be assessed with the use of a pain scale. Appropriate pain relief can then be administered. Vital signs should be regularly monitored at half-hourly intervals for two hours postoperatively, hourly for two hours and, if stable, every four hours while the patient is recovering in hospital. If the patient has had a straightforward appendectomy the surgical team should review the patient on recovery and decide when they may eat and drink. A drain may have been inserted during surgery. If so, the output of the drain should be recorded every 24 hours. The drain can be removed when there is minimal drainage - usually 50ml or less. The wound should be managed aseptically. If the wound is covered with a dry dressing then it should be changed every 1-2 days. Clips/stitches should be removed 10 days postoperatively. The patient can go home with these in place and the district or practice nurse can remove them. If dissolvable stitches have been used this is unnecessary, although a visit to check the wound will reduce anxiety. Before discharge, the patient must be confident in how to manage their wound and have details of who they should contact in case of concern. The patient should be encouraged to get up and out of bed as soon as possible to prevent the formation of emboli. Anticoagulants are usually administered in the form of subcutaneous injections before surgery and postoperatively. Antiembolism stockings should be worn. If peritonitis has developed, the patient's postoperative management will be over a longer period but will follow the same principles. The patient will not be able to commence food and fluids for a few days, this is to enable the bowel to regain normal function. The convalescence period is almost invariably smooth and the patient recovers rapidly (Colmer, 1986). The hospital stay for patients who have undergone an uncomplicated appendectomy is usually 2-3 days. In most cases the patient will be discharged when their temperature is normal and their bowels have started to function again (Peterson, 2002). People can live a full life without their appendix. Changes in diet, exercise or other lifestyle factors are not necessary (NDDIC, 2004). Conclusion Appendicitis is a condition that is prevalent in the developed world and should have minimal complications. Surgical action should be taken without delay. If left untreated there is a risk of peritonitis, which is the main complication of this condition. Medical awareness of appendicitis has improved and complications are less common. With the use of laparoscopic surgery recovery time is rapid. - Identify where the appendix is situated - Recognise the signs and symptoms of appendicitis - Understand pre and postoperative nursing care for a patient with appendicitis - Know the possible complications for these patients

MEDICAL MANAGEMENT Surgery is indicated if appendicitis is diagnosed and should be performed as soon as possible to decrease risk of perforation. Administer antibiotics and intravenous fluids until surgery is performed. Analgesic agents can be given after diagnosis is made.

NURSING MANAGEMENT Nursing goals include relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating infection due to the potential or actual disruption of the gastrointestinal tract, maintaining skin integrity, and attaining optimum nutrition. Preoperatively, prepare patient for surgery, start intravenous line, administer antibiotic, and insert nasogastric tube (if evidence of paralytic ileus). Do not administer an enema or laxative (could cause perforation). Postoperatively, place patient in semi-Fowlers position, give narcotic analgesic as ordered, administer oral fluids when tolerated, give food as desired on day of surgery (if tolerated). If dehydrated before surgery, administer intravenous fluids. If a drain is left in place at the area of the incision, monitor carefully for signs of intestinal obstruction, secondary hemorrhage, or secondary abscesses (eg. fever, tachycardia, and increased leukocyte count).

Appendicitis facts The appendix is a small, worm-like appendage attached to the colon. Appendicitis occurs when bacteria invade and infect the wall of the appendix. The most common complications of appendicitis are abscess and peritonitis. The most common symptoms of appendicitis are abdominal pain, loss of appetite, nausea and vomiting, fever, and abdominal tenderness. Appendicitis usually is suspected on the basis of a patient's history and physical examination; however, a white blood cell count, urinalysis, abdominal X-ray, barium enema, ultrasonography, CT scan, andlaparoscopy also may be helpful in diagnosis. Due to the varying size and location of the appendix and the proximity of other organs to the appendix, it may be difficult to differentiate appendicitis from other abdominal and pelvic diseases. The treatment for appendicitis usually is antibiotics and appendectomy (appendectomy or surgery to remove the appendix). Complications of appendectomy include wound infection and abscess.

Other conditions that can mimic appendicitis include Meckel'sdiverticulitis, pelvic inflammatory disease (PID), inflammatory diseases of the right upper abdomen (gallbladder disease, liver disease, or perforated duodenal ulcer), right-sided diverticulitis, and kidney diseases.

What is the appendix? The appendix is a closed-ended, narrow tube up to several inches in length that attaches to the cecum (the first part of the colon) like a worm. (The anatomical name for the appendix, vermiform appendix, means worm-like appendage.) The open central core of the appendix drains into the cecum. The inner lining of the appendix produces a small amount of mucus that flows through the open central core of the appendix and into the cecum. The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies. Like the rest of the colon, the wall of the appendix also contains a layer of muscle, but the layer of muscle is poorly developed.

What is appendicitis and what causes appendicitis? Appendicitis means inflammation of the appendix. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is called a fecalith (literally, a rock of stool). At other times, it might be that the lymphatic tissue in the appendix swells and blocks the opening. After the blockage occurs, bacteria which normally are found within the appendix begin to invade (infect) the wall of the appendix. The body responds to the invasion by mounting an attack on the bacteria, an attack called inflammation. An alternative theory for the cause of appendicitis is an initial rupture of the appendix followed by spread of bacteria outside of the appendix. The cause of such a rupture is unclear, but it may relate to changes that occur in the lymphatic tissue, for example, inflammation, that lines the wall of the appendix.)

If the inflammation and infection spread through the wall of the appendix, the appendix can rupture. After rupture, infection can spread throughout the abdomen; however, it usually is confined to a small area surrounding the appendix (forming a peri-appendiceal abscess).

Sometimes, the body is successful in containing ("healing") the appendicitis without surgical treatment if the infection and accompanying inflammation do not spread throughout the abdomen. The inflammation, pain and symptoms may disappear. This is particularly true in elderly patients and when antibiotics are used. The patients then may come to the doctor long after the episode of appendicitis with a lump or a mass in the right lower abdomen that is due to the scarring that occurs during healing. This lump might raise the suspicion of cancer.

How is appendicitis diagnosed? The diagnosis of appendicitis begins with a thorough history and physical examination. Patients often have an elevated temperature, and there usually will be moderate to severe tenderness in the right lower abdomen when the doctor pushes there. If inflammation has spread to the peritoneum, there is frequently rebound tenderness. Rebound tenderness is pain that is worse when the doctor quickly releases his or her hand after gently pressing on the abdomen over the area of tenderness.

White Blood Cell Count The white blood cell count in the blood usually becomes elevated with infection. In early appendicitis, before infection sets in, it can be normal, but most often there is at least a mild elevation even early in the process. Unfortunately, appendicitis is not the only condition that causes elevated white blood cell counts. Almost any infection or inflammation can cause this count to be abnormally high. Therefore, an elevated white blood cell count alone cannot be used to confirm a diagnosis of appendicitis.

Urinalysis Urinalysis is a microscopic examination of the urine that detects red blood cells, white blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or stones in the kidneys or bladder. The urinalysis also may be abnormal with appendicitis because the appendix lies near the ureter and bladder. If the inflammation of appendicitis is great enough, it can spread to the ureter and bladder leading to an abnormal urinalysis. Most patients with appendicitis, however, have a normal urinalysis. Therefore, a normal urinalysis suggests appendicitis more than a urinary tract problem.

Abdominal X-Ray An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece of stool that blocks the appendiceal opening) that may be the cause of appendicitis. This is especially true in children.

Ultrasound An ultrasound is a painless procedure that uses sound waves to provide images of identify organs within the body. Ultrasound can identify an enlarged appendix or an abscess. Nevertheless, during appendicitis, the appendix can be seen in only 50% of patients. Therefore, not seeing the appendix during an ultrasound does not exclude appendicitis. Ultrasound also is helpful in women because it can exclude the presence of conditions involving the ovaries, Fallopian tubes and uterus that can mimic appendicitis.

Barium Enema A barium enema is an X-ray test in which liquid barium is inserted into the colon from the anus to fill the colon. This test can, at times, show an impression on the colon in the area of the appendix where the inflammation from the adjacent inflammation impinges on the colon. Barium enema also can exclude other intestinal problems that mimic appendicitis, for exampleCrohn's disease.

Computerized tomography (CT) Scan In patients who are not pregnant, a CT scan of the area of the appendix is useful in diagnosing appendicitis and peri-appendiceal abscesses as well as in excluding other diseases inside the abdomen and pelvis that can mimic appendicitis.

Laparoscopy Laparoscopy is a surgical procedure in which a small fiberoptic tube with a camera is inserted into the abdomen through a small puncture made on the abdominal wall. Laparoscopy allows a direct view of the appendix as well as other abdominal and pelvic organs. If appendicitis is found, the inflamed appendix can be removed with the laparoscope. The disadvantage of laparoscopy compared to ultrasound and CT is that it requires a general anesthetic.

There is no one test that will diagnose appendicitis with certainty. Therefore, the approach to suspected appendicitis may include a period of observation, tests as previously discussed, or surgery. Nursing Interventions: Appendicitis 1. 2. 3. Make sure the patient with suspected or unknown appendicitis receives nothing by mouth until surgery is performed. Administer I.V. fluids to prevent dehydration. Never administer cathartics or enemas because they may rupture theappendix.

4.

Dont administer analgesics until the diagnosis is confirmed because they mask symptoms. Once the diagnosis is confirmed, analgesics maybe given. 5. Place the patient in fowlers position to reduce pain. Never apply heat to the right lower abdomen; this may cause the appendix to rupture. 6. Once the diagnosis is confirmed, prepare the patient for surgery. 7. If peritonitis occurs, nasogastric drainage may be necessary to decompress the stomach and reduce nausea and vomiting. 8. Monitor the patients vital signs. 9. Assess intake and output for signs of hydration, such as hypotension or fluid imbalance. 10. Evaluate the severity and location of abdominal pain. Notify doctor immediately if pain suddenly ceases. 11. Observe the patient for complications, such as peritonitis, appendiceal abscess, and pyelophlebitis.

Appendicitis is an inflammation that often occurs in the appendix which is a serious case of abdominal surgery are the most common.

Appendectomy An appendectomy is the surgical removal of the vermiform appendix. This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenousantibiotics are used to delay or avoid the onset of sepsis; it is now recognized that many cases will resolve when treated perioperatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix, causing transruptural flotation. This is a relative contraindication to surgery.

Etiology of Appendicitis Appendicitis is a bacterial infection caused by obstruction or blockage due to:

1. 2. 3. 4. 5.

Hyperplasia of lymphoid follicles Fecalith presence in the lumen of the appendix Appendix tumor The presence of foreign objects such as ascariasis worm. Appendix mucosal erosion due to parasites such as: E. Histilitica.

According to research, epidemiology suggests eating foods low in fiber will cause constipation which can cause appendicitis. This will increase intra-caecal pressure, causing a functional obstruction appendix and increase the growth of germs in the colon flora. Pathophysiology of Appendicitis Signs and Symptoms of Appendicitis

Pain, felt in the lower abdominal quadrant and is usually accompanied by mild fever, nausea, vomiting and loss of appetite. Local tenderness at the point Mc. Burney, when done pressure. Tenderness may be found out. The degree of tenderness, muscle spasm, and whether there is constipation or diarrhea does not depend on the severity of infection and location of the appendix. If the appendix at the back of the cecum circular, pain and tenderness can be felt in the lumbar region; when one end was in the pelvis, these signs can only be known on rectal examination. Pain on defecation shows that the tip of theappendix is close to the bladder or ureter. The existence of muscle stiffness in the bottom right of the rectum may occur. Rovsing sign can arise with left lower quadrant palpation, which causes pain felt in the lower right quadrant. If the appendix has ruptured, the pain can be more spread out; abdominal distension due to paralytic ileus and the client's condition worsened. Complications of Appendicitis The main complication of appendicitis is perforation of the appendix, which can lead to peritonitis or abscess. The incidence of perforation is 105 to 32%. The incidence is higher in young children and the elderly. Perforation generally occurs 24 hours after the onset of pain. Symptoms include a fever with a temperature of 37.7 C or higher, continuous abdominal tenderness.

Management of Appendicitis In acute appendicitis, the best treatment is surgery the appendix. Within 48 hours must be performed. Patients in the observation, rest in Fowler's position, givenantibiotics and given food that does not stimulate peristalsis, if there is perforated drain given the lower right stomach.

1. 2. 3.

Preoperative Appendectomy, including patients in hospital, givenantibiotics and compress, to reduce the temperature of the patient, the patient is asked to bed rest and fasted. Operative action; Appendectomy Postoperative Appendectomy, one day post surgery clients are encouraged to sit upright in bed for 2 x 30 minutes, the next day soft food and stand upright outside the room, the seventh day stitches removed, the client's home. Nursing Care Plan Appendicitis

Nursing Assessment

1. 2.

The identity of the client History of Nursing o o Current medical history; complaints of pain in postoperative wound appendectomy, nausea, vomiting, increased body temperature, increased leukocytes. Past medical history

3.

Physical Examination o o o o o Cardiovascular System: To determine vital signs, presence or absence of jugular venous distension, pallor, edema, and abnormal heart sounds. Hematologic System: To determine whether there is an increase in leukocytes is a sign of infection and bleeding, nosebleeds splenomegaly. Urogenital System: Whether or not the tension of the bladder andlower back pain complaints. Musculoskeletal System: To determine whether there is difficulty in movement, pain in bones, joints and there is a fracture or not. The immune system: To determine whether there is lymph node enlargement. Routine blood tests: to determine an increase in leukocytes is a sign of infection. Abdominal examination photo: to know the existence of post-surgical complications.

4.

Investigations o o

Nursing Diagnosis Preoperative and Postoperative Appendectomy Preoperative Appendectomy 1. Risk for deficient fluid volume related to preoperative vomiting. 2. Acute pain related to distention of the intestinal tissue by inflammation. 3. Anxiety related to change in health status. Postoperative Appendectomy 1. Acute pain related to the presence of postoperative wound appendectomy. 2. Impaired nutrition less than body requirements related to reduced anorexia, nausea. 3. Risk for infection related to surgical incision. 4. Deficient knowledge: about the care and diseases related to lack of information.

Nursing Interventions

1. Preparation of general surgery This can be done by the nurse when the client entered the operating room nursebefore surgery:

Introducing the client and close relatives of hospital facilities to reduce the anxiety of clients and their relatives (the orientation of the environment). Measuring vital signs.

Measure weight and height. Collaboration is an important laboratory tests (hematocrit, serum glucose, Urinalisa). The interview.

2. Preoperative Interventions

Observation of vital signs Assess fluid intake and output Auscultation of bowel sounds Assess the status of pain: the scale, location, characteristics Teach relaxation techniques Give fluids intervena Examine the level of anxiety Give information about the disease process and actions

PostoperativeIinterventions

Observation of vital signs Assess the scale of pain: characteristics, scale, location Assess the state of the wound Advise to change position as tilted to the right, left and sat down. Assess nutritional status Auscultation of bowel sounds Give wound care information and disease.

Evaluation

1. 2. 3. 4. 5. 6.

Impaired sense of comfort: pain is resolved No infection Overcome nutritional deficiencies The client understands about care and illness Weight loss does not occur Vital signs within normal limits