ASSESSMENT
1. Assess patient identity
- Name
- Age
- Gender
- Date of Birth
- Etc..
2. Medical History
- Recent Health History
The main complaint the client will get around epigastric pain radiating to the
lower right abdomen. Embossed lower right abdominal pain complaints may
be a few hours later after the pain in the center or in the epigastrium felt in
some time ago. The nature of pain is felt constantly, can be lost or there is pain
in a long time. Complaints that accompany the client usually complain of
nausea and vomiting, fever.
- Past Health History
Patient will have related complain with the recent history.
3. Physical Assessment
o Rovsing sign (palpation of LLQ worsens RLQ pain)
o Psoas sign (extension of R leg at hip while pt lies on L side elicits abd
pain)
o Obturator sign (internal and external rotation of thigh at hip elicits pain
o Peritonitis suggested by:
a. Right heel strike elicits pain
b. Guarding
Name of Examination Sign and Symptoms
Rovsings sign Positive if palpation with pressure on the
lower left quadrant and there is pain on the
right side.
Psoas sign or Obraztsovas The patient was placed on the left side, then
sign do the extension of the right pelvis. Positive if
there is pain in the lower right.
Obturator sign The patients were performed hip flexion and
internal rotation of the hip. Positive if there is
pain in hipogastrium or vagina.
Dunphys sign Added pain in the lower right tertis with cough
Ten Horn sign Pain that arises when done gentle traction on
the right spermatic cord
Kocher (Kosher)s sign Pain at first in the epigastric region or around
the center, then move to the right lower
quadrant.
Sitkovskiy (Rosenstein)s sign Growing pains in the lower right quadrant of
the abdomen while the patient was placed on
the left side
Aure-Rozanovas sign Increased pain with petit triangle finger on the
right (positive will Shchetkin-Bloomberg's
sign)
Blumberg sign Also called rebound tenderness. Palpation in
the right lower quadrant and then released
suddenly.
4. Diagnostic Studies :
WBC: Leukocytosis above 12,000/mm3, neutrophil count often elevated to greater
than 75%.
Abdominal x-rays: May reveal hardened bit of fecal material in appendix (fecalith),
localized ileus.
Ultrasound or CT scan: May be done for differentiation of appendicitis from other
causes of abdominal pain (e.g., perforating ulcer, cholecystitis, reproductive organ
infections) or to localize drainable abscesses.
DIAGNOSES
1. Dx : Acute Pain related to distension of intestinal tissues by inflammation or
presence of surgical incision.
Desired Outcomes : Pain Control, Pain Level
Report pain is relieved/controlled.
Appear relaxed, able to sleep/rest appropriately.
Demonstrate use of relaxation skills and diversional activities, as indicates, for
individual situation.
Intervention : Pain Management
Nursing Interventions Rationale
Nursing Interventions Rationale
Useful in monitoring effectiveness of
Assess pain, noting location,
medication, progression of healing. Changes in
characteristics, severity (010 scale).
characteristics of pain may indicate developing
Investigate and report changes in pain as
abscess or peritonitis, requiring prompt
appropriate.
medical evaluation and intervention.
Being informed about progress of situation
Provide accurate, honest information to
provides emotional support, helping to
patient and SO.
decrease anxiety
To lessen the pain. Gravity localizes
inflammatory exudate into lower abdomen or
Keep at rest in semi-Fowlers position.
pelvis, relieving abdominal tension, which is
accentuated by supine position.
Promotes normalization of organ
Encourage early ambulation. function (stimulates peristalsis and passing of
flatus, reducing abdominal discomfort).
Refocuses attention, promotes relaxation, and
Provide diversional activities
may enhance coping abilities.
Keep NPO and maintain NG suction Decreases discomfort of early intestinal
initially. peristalsis, gastric irritation and vomiting.
Relief of pain facilitates cooperation with other
Administer analgesics as indicated. therapeutic interventions (ambulation,
pulmonary toilet).
Soothes and relieves pain through
Place ice bag on abdomen periodically desensitization of nerve endings. Note: Do not
during initial 2448 hr, as appropriate. use heat, because it may cause tissue
congestion.
Never apply heat to the right lower
This may cause the appendix to rupture.
abdomen.
Watch closely for possible surgical Continuing pain and fever may signal an
complications. abscess.
Evaluation :
Is patient report pain is relieved/controlled?
Is patient appear relaxed, able to sleep/rest appropriately?
Is patient demonstrate use of relaxation skills and diversional activities, as
indicates, for individual situation?
2. Dx : Risk for Deficient Fluid Volume related to nausea and vomit.
Desired Outcomes : Fluid Balance, Hydration
Hydration (NOC)
Maintain adequate fluid balance as evidenced by moist mucous membranes, good
skin turgor, stable vital signs, and individually adequate urinary output.
Intervention : Fluid Management, Fluid Monitoring
Nursing Interventions Rationale
Variations help identify fluctuating
Monitor BP and pulse.
intravascular volumes
Inspect mucous membranes; assess skin Indicators of adequacy of peripheral
turgor and capillary refill. circulation and cellular hydration.
Decreasing output of concentrated urine
Monitor I&O; note urine color and
with increasing specific gravity suggests
concentration, specific gravity.
dehydration and need for increased fluids.
Indicators of return of peristalsis,
readiness to begin oral intake. Note: This
Auscultate and document bowel sounds.
may not occur in the hospital if patient has
Note passing of flatus, bowel movement.
had a laparoscopic procedure and been
discharged in less than 24 hr.
Provide clear liquids in small amounts
Reduces risk of gastric irritation and
when oral intake is resumed, and progress
vomiting to minimize fluid loss.
diet as tolerated.
Give frequent mouth care with special Dehydration results in drying and painful
attention to protection of the lips. cracking of the lips and mouth.
An NG tube may be inserted
Maintain gastric and intestinal suction, as
preoperatively and maintained in
indicated.
immediate postoperative phase to
Nursing Interventions Rationale
decompress the bowel, promote intestinal
rest, prevent vomiting.
The peritoneum reacts to
irritation and infection by producing large
amounts of intestinal fluid, possibly
Administer IV fluids and electrolytes.
reducing the circulating blood volume,
resulting in dehydration and relative
electrolyte imbalances.
Cathartics and enemas may rupture the
Never administer cathartics or enemas.
appendix.
Give the patient nothing by mouth, and
This may mask symptoms.
administer analgesics judiciously.
Evaluation :
- Is patient maintain adequate fluid balance as evidenced by moist mucous
membranes, good skin turgor, stable vital signs, and individually adequate urinary
output?
3. Dx : Risk for Infection related to invasive procedures, surgical incision
Desired Outcomes : Infection Severity
Achieve timely wound healing; free of signs of infection/inflammation, purulent
drainage, erythema, and fever.
Intervention : Infection Control
Nursing Interventions Rationale
Practice and instruct in good handwashing
and aseptic wound care. Encourage and Reduces risk of spread of bacteria.
provide perineal care.
Inspect incision and dressings. Note Provides for early detection of developing
characteristics of drainage from wound (if infectious process and monitors resolution
inserted), presence of erythema. of preexisting peritonitis.
Monitor vital signs. Note onset of fever, Suggestive of presence of infection or
chills, diaphoresis, changes in mentation, developing sepsis, abscess, peritonitis.
Nursing Interventions Rationale
reports of increasing abdominal pain.
Grams stain, culture, and sensitivity testing
Obtain drainage specimens if indicated. is useful in identifying causative organism
and choice of therapy.
Antibiotics given before appendectomy are
primarily for prophylaxis of wound
infection and are not continued
Administer antibiotics as appropriate.
postoperatively. Therapeutic antibiotics are
administered if the appendix is ruptured or
abscessed or peritonitis has developed.
Prepare and assist with incision and May be necessary to drain contents of
drainage (I&D) if indicated. localized abscess.
Watch closely for possible surgical Continuing pain and fever may signal an
complications. abscess.
Evaluation : - Is patient free sign of infection ?
