Open access peer-reviewed chapter
Abstract
Acute appendicitis is a common emergency in general surgery and globally appendectomy is at the top of emergency surgical procedures. Evidence suggests appendectomy is the first-line treatment for acute appendicitis. About 9% of patients develop complications after appendectomy, leading to a long hospital stay and recurrent surgery among others. Surgical site infection (SSI) is a common complication of appendectomy. Many factors may contribute to the occurrence of SSI either during preoperative, intraoperative, or postoperative periods. The important role nurses play in the management of appendicitis from admission to discharge cannot be underestimated. This chapter describes nursing assessment, diagnoses and the care plan for a patient with appendicitis on admission. Also, the role of the nurse play during preoperative, intraoperative and postoperative periods, and at Discharge are presented. This information could improve the quality of care and reduce complications.
Keywords
- appendicitis
- appendectomy
- preoperative
- postoperative
- nursing assessment
- nursing diagnoses
- nursing care plan
1. Introduction
The vermiform appendix is a thin, tube-like organ attached to the cecum and has lymphatic tissues that control infection. Appendicitis, also called epityphlitis, is the inflammation of the appendix, a small finger-like appendage attached to the cecum found just below the ileocecal valve. In other words, appendicitis is an acute inflammation of the vermiform appendix. Acute appendicitis is the most common abdominal surgical emergency, with an incidence of almost 100 per 100,000 people in Australia, Europe, and North America [1]. Appendicitis is common among the age group between 10 and 30 years [2].
An individual with appendicitis complains of vague epigastric or periumbilical pain, which progresses to the right lower quadrant generally accompanied by low-grade fever, anorexia, nausea, and sometimes vomiting. In 50% of patients, local tenderness is elicited at McBurney’s point, when pressure is applied [3]. Also, there is rebound tenderness or the production or intensification of pain when pressure is released. In addition, Rovsing’s sign may be elicited by palpating the left lower quadrant; this unexpectedly causes pain to be felt in the right lower quadrant. Furthermore, there is elevated white blood cell count, client taking the side-lying position, as well as constipation or diarrhea. These symptoms may indicate uncomplicated appendicitis.
For complicated appendicitis the patient experiences severe abdominal pain, which prevents movement, the patient holds his/her abdomen very still and avoids deep breaths. Also, the abdomen feels very firm to touch due to abdominal guarding, legs are flexed, and the patient presents with fever (37.7°C [100° F] or greater) and toxic appearance. These symptoms could indicate a ruptured appendix, which might result in peritonitis or appendicular abscess. Some of the predisposing factors are obstruction by fecalith or foreign bodies, bacteria or toxins, low-fiber diet, and high intake of refined carbohydrates [4].
Usually, diagnosis of appendicitis is based on a comprehensive physical examination, laboratory and radiologic tests, and the treatment is by appendectomy. Appendectomy is the surgical removal of the vermiform appendix and evidence suggests it is the first-line treatment for acute appendicitis globally [5]. Nonetheless, antibiotic therapy may be effective for a selected group of patients with uncomplicated acute appendicitis. It is important to state that appendectomy is a relatively safe surgical intervention with a case fatality rate of 2.1–2.4 per 1000 patients, as reported in studies conducted in Europe [2, 3, 6]. However, about 9% of patients develop complications after appendectomy leading to a long hospital stay and recurrent surgery among others. Surgical site infection (SSI) is a common complication of appendectomy [7]. Many factors may contribute to the occurrence of SSI either during preoperative, intraoperative, or postoperative periods. The important role nurses play in the management of appendicitis from admission to discharge cannot be underestimated.
This chapter describes nursing assessment, diagnoses, and the care plan for a patient with appendicitis on admission. Also, the role of the nurse play during preoperative, intraoperative and postoperative periods, and at discharge are presented. This information could improve the quality of care and reduce complications among patients.
2. Nursing assessment, nursing diagnoses, and the care plan on admission
Adequate nursing assessment and diagnoses are necessary on admission for proper planning and implementing a patient-centered quality nursing care. The following subsection presents guidelines for conducting nursing assessments and formulating diagnoses for patients with appendicitis.
2.1 Nursing assessment and diagnoses
On admission, the nurse is expected to assess the patient presenting with the signs and symptoms of appendicitis in order to formulate nursing diagnoses, plan, and implement quality care. A comprehensive and systematic health assessment that is completed within a reasonable time frame remains one of the most significant components of patient care and cannot be underestimated [8]. The comprehensive health assessment (also known as complete or initial health assessment) is made up of a thorough health history taking (interview with the patient) and physical examination, which is often done when the patient is stable. The initial health assessment is conducted to obtain the patient’s baseline information, which is very vital in monitoring the patient and evaluating interventions implemented [9].
This is done by questioning the patient about chief complaint, and past and current symptoms as well as reviewing the patient’s past medical and surgical records, including family history and lifestyle. A thorough physical examination is then conducted to determine if the Rovsing’s sign is positive [10]. The nurse palpates the left lower quadrant of the abdomen and asks the patient if this action increases the pain felt in the right lower quadrant. Also, (s)he applies pressure at McBurney’s point to ascertain if it is tender and then checks for rebound tenderness (if the pain is intensified when pressure is released) [11].
The severity of the pain is then determined and the patient’s vital signs are checked and recorded. Furthermore, relevant laboratory findings are reviewed (results may reveal an elevated white blood cell count of above 10,000 per cubic millimeter, while abdominal radiographs, ultrasound studies, and CT scans may reveal right lower quadrant density or localized distention of the bowel) [12]. It is important to note that the comprehensive health assessment may indicate a problem-focused assessment, which is often done when a potential health problem has been identified [13].
The information gathered from the complete health assessment is then synthesized, analyzed, and documented. Another type of assessment that may still be performed is the interval (abbreviated) health assessment, which should be conducted after obtaining baseline data from the comprehensive assessment [14]. The nurse usually performs an interval (abbreviated) assessment at change of shift, when the patient returns from tests, or upon transfer to another unit (i.e., from the theater to the surgical unit) as well as at subsequent visits on an outpatient basis (see Section 4.3.1).
It is worth stating that for the health assessment to be thorough, the nurse is expected to communicate appropriately with the patient and performs a culturally sensitive physical examination [15]. This helps to elicit the required information needed for proper planning and the provision of quality nursing care. The subsequent section presents some guidelines for conducting a thorough health assessment for all patients with appendicitis including those with disabilities.
2.1.1 Guidelines for performing nursing assessment and formulating diagnoses
The health assessment of a patient with appendicitis may gather both objective and subjective; hence, good interviewing and physical examination skills are mandatory. Thus, the following subsections provide guidelines for conducting health assessments and stating nursing diagnoses.
2.1.1.1 Principles guiding the conduct of health assessments
When conducting health assessments, the nurse should:
Be prepared to accommodate special needs persons and conduct a culturally sensitive assessment.
Take into consideration the psychosocial, physical, emotional, environmental, cultural, and spiritual factors that might influence the procedure.
Adapt the environment (examination room, table, etc.) accordingly to suit those with various disabilities; minimize noise, colors, smells, and bright lights as needed.
Get all necessary equipment handy to avoid wasting time and causing exhaustion.
Modify the physical exam techniques employed for the procedure accordingly for each individual, especially those with disabilities.
Demonstrate effective communication (verbal and nonverbal) and interviewing skills, which establish an atmosphere of trust and respect at the beginning and throughout the procedure. Adapt different modes of communication where necessary, keeping speech slow and alternating tone as required.
Introduce yourself and obtain consent from the patient before proceeding with the assessment.
Appropriately and adequately assist patients needing help with completing hospital forms, undressing, climbing, and going down from examination tables.
Avoid being judgmental and show respect for each patient’s culture.
Be patient and treat patient with courtesy, avoid harm or repeating harmful maneuvers.
Observe proper hygiene practices to control infection, ensures patient’s privacy, and use draping as required as well as maintain confidentiality.
Employ the recommended framework for history taking and physical examination while making modifications to accommodate patients with disabilities.
Exhibit skills to appropriately distinguish between normal, variations of normal, and abnormal findings in patient data recognizing while influential factors and their clinical significance.
Demonstrate skills in documenting and describing verbally the findings of the health assessment in a format appropriate for proper and accurate communication in the multidisciplinary health care setting.
2.1.1.2 Guidelines for formulating and stating nursing diagnoses
Clinical decision-making and diagnostic reasoning are approaches to support the identification of a patient’s problem. The nurse applies his/her clinical decision-making skills to synthesize health assessment information, use critical inquiry and clinical reasoning to diagnose health risks, and differentiate signs of health from ill health [16]. The information gathered is compared to norms and standards, organized according to a predetermined structure, and subsequently interpreted yielding individualized strengths and limitations from which a problem list is created. Identifying the problem enables the nurse to initiate the treatment plan [17]. Thus, after listing the problems, appropriate interventions are planned, implemented and continually evaluated, and revised to assist the patient to achieve and maintain optimal health.
2.2 The nursing care plan for the patient with appendicitis on admission
Usually, the nurse is expected to prioritize the patient’s problems and draw up a nursing care plan to focus on life-threatening symptoms. In drawing up the care plan, the following components are taken into account; the nursing diagnoses, goals to be achieved, interventions, the expected outcomes, and evaluation to determine if the interventions were effective [18]. Below are presented these different aspects.
2.2.1 Nursing diagnoses
Generally, based on the assessment data, the most appropriate diagnoses for a patient with appendicitis on admission and before appendectomy would probably be [19]:
Pain (acute) related to obstructed appendix /inflammation due to distension of intestinal tissues as evidenced by expressive behavior (e.g., restlessness, moaning, crying, vigilance, irritability, and sighing).
Risk for deficient fluid volume related to preoperative vomiting evidenced by poor skin turgor.
Risk for infection related to a ruptured appendix, peritonitis, and abscess formationevidenced by the disruption of the GI tract.
Risk for malnutrition related to anorexia and nausea evidenced by less-than-body requirements.
2.2.2 Planning interventions
This stage starts with stating the goals to be achieved for a patient with appendicitis, based on the problems identified [20], these include; to:
Relieve pain.
Prevent fluid volume deficit.
Reduce anxiety.
Eliminate infection due to the potential or actual disruption of the GI tract.
Maintain skin integrity.
Attain optimal nutrition.
The plan for care should be negotiated with patients and their caregivers to ensure clear expectations and compliance with the nursing interventions [21].
2.2.3 Implementing nursing interventions
2.2.3.1 Uncomplicated appendicitis
Based on the stated goals of the nurse:
Administers analgesics (Opioids) as prescribed respecting the route and frequency of administration.
Administers fluids as prescribed to replace fluid loss and promote adequate renal functioning while monitoring the patient for fluid overload. Oral fluids when tolerated, could be administered.
Administers antibiotics (e.g., ceftriaxone) as prescribed.
Educates the patient about his/her condition to reduce anxiety.
Ensures daily baths (body hygiene).
Serves well-balanced meals.
Monitors patient closely for signs of improvement.
Immediately reports abnormal findings.
2.2.3.2 Complicated appendicitis
For complicated cases, in addition to the above interventions the nurse:
Administers the required analgesics strictly respecting the route and frequency of administration as well as uses non-pharmacological measures to reduce severe pain or discomfort (see Section 3.1 for details).
Monitors the patient closely for signs of perforation and peritonitis such as if the abdomen appears to be very firm and tender to touch.
Should alert the physician immediately if signs of perforation and peritonitis are evident.
Should closely monitor vital signs to determine sudden changes, such as increased heart rate (tachycardia) or fever, as this could indicate infection or acute inflammation.
Should check and empty drain if put in place preoperatively, and provide appropriate and adequate care.
Reports signs of infection.
Prepares the patient for surgery as required.
2.2.4 Expected or desired outcomes
After implementing the intervention, the nurse:
Expects the patient to report a reduction in pain.
Documents adequate hydration.
Reports no signs of infection.
Documents reduced level of anxiety.
Reports intact skin.
Documents adequate nutrition.
2.2.5 Evaluation
The outcomes of the interventions are evaluated to ensure the goals are achieved as expected [22]. For instance:
The patient verbalized reduction in pain.
The nurse documented normal fluid volume.
The nurse noticed reduced level of anxiety.
The nurse reported no signs of infection.
The nurse reported intact skin.
The nurse recorded adequate nutrition.
In addition, the nurse continues to monitor the patient and be alert to identify, intervene or report any new symptom(s) that may come up. Hence, other nursing responsibilities include vital signs monitoring, assisting the patient to do laboratory investigations as required, reviewing laboratory findings, and acting accordingly [23]. Above all, the nurse is expected to prepare the patient for surgery (see Section 5.1). Since abnormal laboratory findings are indications of illness progression, the nurse should:
Review laboratory results to identify abnormal values, such as:
CRP >1 mg/dL, which indicates inflammation, very high levels may indicate gangrene.
WBC >10,500, which indicates infection.
The nurse should closely monitor the patient with the following in mind:
That fever, chills, and diaphoresis are signs of infection, eminent sepsis, abscess, or peritonitis.
Hypotension with tachycardia may indicate dehydration if vomiting or diarrhea is severe.
It is important to note that pain, which is the main symptom of appendicitis, can be controlled by the use of pharmacological as well as non-pharmacological measures [24]. The next section presents these details.
2.3 Relieving pain through non-pharmacologic interventions
There are a variety of nursing actions that are undertaken to relieve a patient’s pain. These include distraction techniques, positioning, and application of ice bags among others [25]. The non-pharmacological methods for relieving pain in a patient with appendicitis are presented below.
Placing the patient in a semi-Fowler’s position: After the surgery, the nurse places the patient in a High-fowler’s position to reduce the tension on the incision and abdominal organs, thereby reducing pain. This position allows gravity to assist by reducing abdominal stress and relieving discomfort [4].
Applying ice bag on the abdomen periodically during the first 24- to 48-hour period as required. This intervention soothes and relieves pain through the desensitization of nerve endings [26].
Educating and assisting the patient to protect the abdomen before and after surgery by splinting with a pillow while coughing or engaging in any stressful activity. This will aid in pain reduction and prevent the dehiscence of an incision.
2.4 Dos and do nots during nursing interventions
It is worth mentioning that there are some nursing interventions that must not be performed on the patient with appendicitis because of their harmful consequences [27]. The dos and do nots at admission, pre- and postoperative periods regarding a patient with appendicitis are stated below.
2.4.1 Dos
The nurse should:
Administer analgesics judiciously before the diagnosis of appendicitis. This may mask the symptom of pain.
Administer regular analgesia after appendicitis has been diagnosed, usually, an opioid depending on pain severity is given to make the patient comfortable before health assessment.
Recommend the use of mild laxatives or stool softeners as necessary. This may assist with a return to usual bowel function and prevents undue straining for defecation.
Monitor the patient closely to identify signs of rupture.
Give the patient nothing by mouth several hours before surgery.
Place the ice bag on the abdomen periodically during the first 24- to 48-hour period as required. This intervention soothes and relieves pain through the desensitization of nerve endings.
Maintain NPO status after surgery until bowel function has returned.
Advance diet gradually as tolerated or as prescribed when bowel sounds return.
2.4.2 Do nots
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.
Use heat on the patient’s right lower abdomen, because it may cause tissue congestion.
Administer enemas as they may induce peristalsis, which may cause perforation.
Administer analgesia before examination because this can lead to an inaccurate diagnosis as the pain may subside and the examination will be ineffective.
3. Nursing assessment and interventions during preoperative and postoperative periods
These periods are crucial for the patient and the health care team as it determines the patient’s outcome [28]. The specific nursing activities during the preoperative and postoperative periods are discussed in the subsequent sections.
3.1 Nursing interventions during preoperative period
The nurse needs to prepare the patient several hours presurgery. Generally, during this period the main goal is to prepare the patient adequately for surgery (appendectomy) in order to ensure a successful surgery and a positive outcome post-surgery [29]. However, the abbreviated health assessment may be conducted on the patient if needed. This will help to identify symptoms that were not present at admission and those missed during routine care after admission so that necessary actions could be taken accordingly. For instance, the patient may be dehydrated due to continuous nausea and vomiting [30], and or might be anxious probably due to inadequate information regarding condition and surgery. Thus, the nurse is expected to intervene accordingly while observing the patient closely. Depending on local policies, the nurse:
Maintains patent IV hydration to continuously replace fluid loss as needed, and promote adequate renal functioning.
Thoroughly explains the procedure to the patient and obtain informed consent.
Educates the patient on pre- and postoperative care/activities.
Cleans and shaves the operation site before surgery.
Initiates NPO status to empty gastric contents if indicated.
Assesses (monitors for changes in the level of pain) and continues to manage pain.
Places an ice pack on RLQ to aid in pain relief every hour for 20–30 minutes as prescribed.
Encourages abdominal splinting to control pain.
Encourages bed rest.
Continues to administer antibiotic prophylaxis to prevent infection.
Monitors for signs of a ruptured appendix.
Administers medication if necessary to lower an elevated temperature.
Assesses relevant laboratory findings.
Assesses and records the patient’s vital signs in preparation for surgery.
Positions the patient in right-side lying or semi-fowler position to promote comfort.
Monitors bowel sounds.
3.2 The role of the nurse during surgery
The role nurses play during surgery cannot be overemphasized. The nurse acts as the scrub nurse, instrument nurse, or circulating nurse as well as assisting the surgeon directly during surgery [31]. The scrub nurse also known as the instrument nurse sets up the sterile field observing strict aseptic techniques. She/he assists the surgeon to scrub and dress into his/her theater wear, and hands surgical instruments to the surgeon during surgery. The instrument nurse is a member of the sterile team who scrubs, gowns, and gloves for the surgical procedure. She is responsible for setting up and handing sterile supplies and instruments to the surgeon [32].
The circulating nurse oversees nursing care during the procedure and ensures that the operating room remains sterile. Responsibilities include ensuring that surgical asepsis is adhered to during the surgical procedure, keeping track and conducting an inventory of supplies and equipment used during and after the surgical procedure, or calling for a time-out [33]. An operating nurse also acts as a liaison between the patient, the patient’s relatives, and the medical team. In addition, the nurse can also function as an anesthetics, she/he assesses the patient, administers anesthesia, and monitors the patient closely during surgery.
3.3 Postoperative nursing assessment, diagnoses, and interventions
3.3.1 Postoperative nursing assessment
Generally, after surgery, the nurse performs an abbreviated health assessment (and then a focused health assessment if indicated) in order to produce a list of the patient’s problems. The abbreviated health assessment is not as detailed as the complete assessment that occurs at admission. The advantage of an abbreviated assessment is that at this time it allows the nurse to thoroughly assess the surgical patient in a shorter period of time [34]. The problem-focused assessment may be conducted if a new symptom emerges, or the patient develops any distress.
The focused health assessment focuses on a specific injury or medical complaint and vital signs, which include pulse, respirations, skin signs, pupils, and blood pressure. In conducting the focused health assessment, the nurse focuses the physical examination on that specific injury or new complaint [35]. Generally, in a focused physical examination, only the requested body part or system is examined. After the assessment, the nursing priorities in the postoperative period mainly include:
Prevent complications.
Promote comfort.
Provide information about surgical procedure/prognosis, treatment needs, and potential complications.
The nurse uses the care plan to achieve all of the above in the postoperative period as shown below.
3.3.2 Postoperative nursing diagnoses and interventions
Note; the procedure for formulating the nursing diagnoses is as stated above (see Section 2.2).
3.3.2.1 Nursing diagnoses, goals, and desired (expected) outcomes
After the health assessment, the nursing diagnoses (ND) should be prioritized as follows:
ND-1: Acute pain related to surgical incision evidenced by [36]:
Complaints of pain.
Facial grimacing and muscle guarding.
Expressive behavior (restlessness, moaning, and crying).
Autonomic responses.
The goal is to reduce pain and increase comfort.
Desired outcomes; the patient should:
Report reduced pain.
Appear relaxed, able to sleep, and rest appropriately.
Demonstrate the use of relaxation techniques and diversional activities, as indicated for an individual situation.
ND-2: Risk for fluid volume deficit related possibly to [37]:
Preoperative vomiting and postoperative restrictions (e.g., NPO);
Hypermetabolic state (e.g., fever, healing process);
Inflammation of peritoneum with sequestration of fluid evidenced by:
The goal is to maintain adequate fluid intake and output.
Desired outcomes.
The nurse should document the following within a reasoning time frame [38]:
Adequate hydration (by IV fluids)/fluid balance as evidenced by moist mucous membranes, good skin turgor, stable vital signs, and normal urine input & output chart.
ND-3: Risk for infection related to surgery and surgical site, and inadequate primary defenses evidenced by fever, inflammation, and pus at the surgical site [39].
The goal is to prevent infection.
Desired outcomes; the nurse should document:
Timely wound healing with no signs of infection/inflammation, purulent drainage, erythema, and fever.
ND-4: Deficient knowledge probably related to:
Inability to recall information or information misinterpretation.
Unfamiliarity with information resources.
All evidenced possibly by:
Questions; request for information; and verbalization of problem/concerns.
Statement of misconception.
Inaccurate follow-through of instruction.
Development of preventable complications.
The goal is to provide adequate information on the condition and reduce anxiety. Desired outcomes, the patient should:
Verbalize understanding of disease process and potential complications.
Verbalize understanding of therapeutic needs.
Participate in the treatment regimen.
3.3.2.2 Nursing interventions
The nursing interventions (NI) for the stated problems are presented below accordingly NI-1; the nurse should do the following:
Assess pain, noting location, characteristics, and severity (on a scale of 0–10), then investigate and report changes in pain as appropriate. This is important in determining the effectiveness of medication and the progression of healing [40]. The nurse should:
Provide accurate, honest information to patients and families, this helps to decrease anxiety.
Use non-pharmacological measures to reduce pain.
Encourage early ambulation, this helps to normalize organ function (stimulates peristalsis and passing of flatus, reducing abdominal discomfort). For an immobile patient, serial compression devices (SCD) and TED hose should be used to avoid DVT clots.
Provide diversional activities; this refocuses the patient’s attention, promotes relaxation, and may enhance coping abilities.
Keep NPO and maintain NG suction initially(if inserted), this minimizes the discomfort of early intestinal peristalsis, gastric irritation, and vomiting.
Administer analgesics as prescribed, this helps to relieve pain and enhances cooperation with other therapeutic interventions (such as ambulation and pulmonary toilet).
Place the ice bag on the abdomen during the first 24–48-hour period as required. This intervention soothes and relieves pain through the desensitization of nerve endings.
Watch closely for possible signs of surgical complications; continuous pain, inflammation, and fever may signal surgical site infection
NI-2; the nurse should do the following:
Monitor BP and pulse; changes in these parameters help identify fluctuating intravascular volumes.
Inspect mucous membranes, and assess skin turgor and capillary refill; these indicate if peripheral circulation and cellular hydration are adequate.
Monitor input and output noting the color of urine and concentration, as well as specific gravity. It is worth stating that decreasing output of concentrated urine with increasing specific gravity indicates dehydration and the need for increased fluids [41].
Auscultate and document bowel sounds noting the passing of flatus and bowel movement. These are pointers of the return of peristalsis, and readiness to begin oral intake. Note for a patient who has had a laparoscopic procedure and been discharged in less than 24 hours, this may not happen in the hospital [42].
Provide clear liquids in small amounts when oral intake is indicated, and progress to liquid, then semi-liquid diet and solids as tolerated. This reduces the risk of gastric irritation and vomiting, which minimizes fluid loss.
Give frequent mouth care with special attention to the protection of the lips. This is because dehydration results in drying and painful cracking of the lips and mouth [43].
Continue administering IV fluids and electrolytes as needed. This is because the peritoneum reacts to irritation and infection by producing large amounts of intestinal fluid, possibly reducing the circulating blood volume, resulting in dehydration and relative electrolyte imbalances.
NI-3; the nurse should do the following:
Administer antibiotics (e.g., ceftriaxone and metronidazole IV as prescribed.
Dress the incision side using a strict aseptic technique.
Monitor temperature for signs of infection.
Assess the incision for signs of infection, such as redness, swelling, and pain.
NI-4; the nurse should:
Identify symptoms requiring medical evaluation (e.g., increasing pain; edema or erythema of wound; the presence of drainage, fever). The timely intervention will reduce the risk of serious complications, such as delayed wound healing and peritonitis [44].
Review postoperative activity restrictions that are, heavy lifting, exercise, sex, sports, and driving. This is in order to assist the patient to plan for a return to usual routines without untoward incidents.
Encourage the patient to return to normal activities progressively as tolerated with periodic rest periods. This will prevent fatigue, promote healing and feeling of well-being, and enable the patient to return to normal activities without complications.
Discuss care of the incision, including dressing changes, bathing restrictions, and removing sutures as indicated. This will enhance compliance with the therapeutic regimen, and promotes the healing and recovery process [45].
Encourage the patient to cough, breathe deeply, and turn frequently in order to prevent pulmonary complication
Other important nursing responsibilities during the postoperative period
The nurse ensures that during the postoperative period vital signs are regularly monitored that is, every 30 minutes for 2 hours, and every hour for 2 hours. If the patient is stable, vital signs monitoring should be done every 4 hours while the patient is recovering in the hospital.
The nurse makes sure for patients who have had a straightforward appendectomy the surgical team should review them on recovery and decides when they may eat and drink.
The nurse is expected to record input and output daily as well as the output of the drain if the drain was inserted during surgery. Consider removing the drain when minimal drainage is noticed; usually 50 ml or less.
The nurse uses aseptic techniques to care for the wound; if the wound is covered with a dry dressing, it should be changed every 1–2 days [46]. The clips or stitches should be removed after 10 days of surgery except if indicated otherwise. The patient may be discharged home with stitches in place; hence, the patient might be told to return for removal or referred to the nearest health facility. If dissolvable stitches were used, the patient is told when to come back for the wound to be accessed.
The nurse encourages the patient to get up and out of bed as soon as possible (
ambulation ) to prevent the formation of emboli. Anticoagulants are usually administered in the form of subcutaneous injections before surgery and postoperatively.The nurse encourages the patient to wear anti-embolism stockings and
deep breathing and coughing exercises. The nurse should be aware of the following:
The convalescence period is almost invariably smooth and the patient recovers rapidly.
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.
The nurse educates the patient and significant others during this period on how to continue care at home, for instance, proper wound care, nutrition (
proper high fiber, protein, and vitamin C diets) , hygiene, and exercise among others.
4. Discharge procedure and the role of the nurse
The nurse has the duty to ensure that before discharge, the patient is confident in how to continue care for the incision site at home and has details of who to contact in case of any concern [47]. Generally, before discharge, the patient is assessed and the incision site checked for signs of healing and the outcome will determine whether the patient is to be discharged or not.
4.1 Patient and family teaching on home care and prevention of complications
Discharge teaching for patient and family is mandatory; therefore, the nurse is expected to educate the patient on the following before discharge:
When the sutures will be removed: The nurse discusses with the patient to return for the removal of the sutures (if still in place).
Medications to be taken at home if any: The nurse explains to the patient how each medication is to be taken, dosage, frequency, and duration, and side effects to watch for and report as necessary.
How to return to normal activities: Heavy lifting is to be avoided postoperatively; however, normal activity can be resumed gradually within 2 to 4 weeks.
Proper hygiene practices: The nurse educates on good hand washing and perineal care.
Wound care: A home care nurse may be needed to assist with the care of the surgical site if available, and to monitor the patient for complications and wound healing (or signs of infection). If not the patient and family are educated on aseptic wound care to prevent infection.
Nutrition: Instruct the patient that diet can be advanced to her or his normal food pattern as long as no gastrointestinal distress is experienced. What class of food and proportion to take frequently to enhance healing and maintain good health is mentioned.
Preventing/minimizing complications: The nurse informs the patient that a possible complication of appendicitis is peritonitis, and discusses with the patient symptoms that indicate peritonitis, such as sharp abdominal pains, fever, nausea and vomiting, and increased pulse and respiration. The patient must seek medical attention immediately should these symptoms occur.
Meeting needs after discharge: The nurse plans with the patient on how to report new complaints.
5. Conclusion
Appendicitis is an acute inflammation of the vermiform appendix, which is the cause of the most common abdominal surgical emergency with minimal complications. However, surgical action should be taken without delay. If left untreated there is a risk of peritonitis, which is the main complication of this condition. Some signs and symptoms of appendicitis are a pain in the right lower quadrant of the abdomen. Nurses play a significant role in the management of appendicitis from admission to discharge. Understanding the nurse’s responsibilities at admission, pre- and post-surgery is very vital for proper nursing interventions and good outcomes. Nurses are expected to use good clinical decision and clinical reasoning skills to analyze and synthesize patient data in order to prioritize patient problems, set goals, and plan and implement patient-centered care.
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