Assessment
a. The identity of the client
b. History of Nursing
1. current medical history; complaints of pain in postoperative wound apendektomi, nausea, vomiting, increased body temperature, increased leukocytes.
2. Past medical history
3. physical examination
a. Cardiovascular System: To determine vital signs, presence or absence of jugular venous distention, pallor, edema, and abnormal heart sounds.
b. Hematologic System: To determine whether there is an increase in leukocytes is a sign of infection and bleeding, nosebleeds splenomegaly.
c. Urogenital System: Whether or not the bladder tension and back pain complaints.
d. Musculoskeletal System: To determine if there is difficulty in movement, pain in the bones, joints, and there is a fracture or not.
e. The immune system: To determine whether there is lymph node enlargement.
c. Investigations
1. Routine blood tests: to determine an increase in leukocytes is a sign of infection.
2. Examination of the abdomen photo: for the presence of post-surgical complications.
Appendicitis Nursing Diagnosis
a. Pre surgery
1. High risk of fluid volume deficits associated with less than body requirements related to operating pre vomiting.
2. Impaired sense of comfort pain associated with distention of the colon tissue inflammation.
3. Anxiety associated with changes in health status.
b. Post surgery
1. Impaired sense of comfort pain associated with the presence of postoperative wound apendektomi.
2. impaired nutrition less than body requirements related to anorexia decreased, nausea.
3. High risk of infection related to surgical incision. Lack of knowledge about the care and diseases related to lack of information.
Plan
1. Preparation of general surgery
It can be done by nurses when a client enters the nurse prior to surgery:
a. Introducing clients and close relatives of hospital facilities to reduce client anxiety and relatives (the orientation).
b. Measuring vital signs.
c. Measure weight and height.
d. Collaboration is important laboratory tests (hematocrit, serum glucose, Urinalisa).
e. Interview.
2. Preparation of client the night before surgery
Four points to consider in the night before surgery:
a. Skin Preparation
the skin is the first line of defense against the entry of germs. Due to damage the integrity of the skin, the operation would lead to the risk of ifeksi.
Some surgeons prefer to shave the hair because it can interfere with the surgical procedure.
b. Preparation of the gastrointestinal tract
case preparation is done in the gastrointestinal tract is useful for:
1. Reduce the possible forms and aspirations during anesthesia.
2. Reduce the possibility of intestinal obstruction.
3. Preventing infection at the operation stool.
To prevent these three things to do:
1. Fasting and restrictions on eating and drinking.
2. Giving enemas if necessary.
3. Installing the intestine or gastric tube if necessary.
4. If the client menerimaanastesi general should not eat or drink for 8-10 hours prior to surgery: prevention of gastric aspiration. Hose gastro intestinal provided the night before or the morning before the surgery to remove intestinal fluid or gester.
c. Preparation for anesthesia
Anesthetists always berkunjunng patients the night before surgery to indent a complete cardiovascular and neurological examination. This would indicate the type of anesthesia that will be used during the operation.
d. Increase rest and sleep
Clients pre operation will rest enough before surgery if there is no physical, mental power and given adequate sedation.
3. Preparation of the morning before the surgery clients
1. Noting the vital signs
2. Check the client's identity bracelet
3. Check skin preparation performed well
4. Check back special instructions such as infusion
5. Ensure that the client had not eaten in 8 hours
6. Encourage clients to urinate
7. Oral treatment if necessary
8. Help clients use RS clothes and headgear
9. Remove nail polish so easy to check for signs of hypoxia easier.
4. Interpesi pre surgery
1. Observation of vital signs
2. Assess fluid intake and output
3. Auscultation of bowel sounds
4. Assess the status of pain: the scale, location, characteristics
5. Teach relaxation techniques
6. Give fluids intervena
7. assess the level of anxiety
8. Give information about the disease process and actions
5. Postoperative Intervention
1. Observations of vital signs
2. Assess the scale of pain: characteristics, scale, location
3. Assess the state of the wound
4. Advise to change positions as tilted to the right, to the left and sit down.
5. Assess nutritional status
6. Auscultation of bowel sounds
7. Give wound care and disease information.
Evaluation
a. Impaired sense of comfort is resolved
b. No infection
c. Nutritional Disorders resolved
d. Clients understand about the treatment and the disease
e. No weight loss
f. Vital signs are within normal limits
a. The identity of the client
b. History of Nursing
1. current medical history; complaints of pain in postoperative wound apendektomi, nausea, vomiting, increased body temperature, increased leukocytes.
2. Past medical history
3. physical examination
a. Cardiovascular System: To determine vital signs, presence or absence of jugular venous distention, pallor, edema, and abnormal heart sounds.
b. Hematologic System: To determine whether there is an increase in leukocytes is a sign of infection and bleeding, nosebleeds splenomegaly.
c. Urogenital System: Whether or not the bladder tension and back pain complaints.
d. Musculoskeletal System: To determine if there is difficulty in movement, pain in the bones, joints, and there is a fracture or not.
e. The immune system: To determine whether there is lymph node enlargement.
c. Investigations
1. Routine blood tests: to determine an increase in leukocytes is a sign of infection.
2. Examination of the abdomen photo: for the presence of post-surgical complications.
Appendicitis Nursing Diagnosis
a. Pre surgery
1. High risk of fluid volume deficits associated with less than body requirements related to operating pre vomiting.
2. Impaired sense of comfort pain associated with distention of the colon tissue inflammation.
3. Anxiety associated with changes in health status.
b. Post surgery
1. Impaired sense of comfort pain associated with the presence of postoperative wound apendektomi.
2. impaired nutrition less than body requirements related to anorexia decreased, nausea.
3. High risk of infection related to surgical incision. Lack of knowledge about the care and diseases related to lack of information.
Plan
1. Preparation of general surgery
It can be done by nurses when a client enters the nurse prior to surgery:
a. Introducing clients and close relatives of hospital facilities to reduce client anxiety and relatives (the orientation).
b. Measuring vital signs.
c. Measure weight and height.
d. Collaboration is important laboratory tests (hematocrit, serum glucose, Urinalisa).
e. Interview.
2. Preparation of client the night before surgery
Four points to consider in the night before surgery:
a. Skin Preparation
the skin is the first line of defense against the entry of germs. Due to damage the integrity of the skin, the operation would lead to the risk of ifeksi.
Some surgeons prefer to shave the hair because it can interfere with the surgical procedure.
b. Preparation of the gastrointestinal tract
case preparation is done in the gastrointestinal tract is useful for:
1. Reduce the possible forms and aspirations during anesthesia.
2. Reduce the possibility of intestinal obstruction.
3. Preventing infection at the operation stool.
To prevent these three things to do:
1. Fasting and restrictions on eating and drinking.
2. Giving enemas if necessary.
3. Installing the intestine or gastric tube if necessary.
4. If the client menerimaanastesi general should not eat or drink for 8-10 hours prior to surgery: prevention of gastric aspiration. Hose gastro intestinal provided the night before or the morning before the surgery to remove intestinal fluid or gester.
c. Preparation for anesthesia
Anesthetists always berkunjunng patients the night before surgery to indent a complete cardiovascular and neurological examination. This would indicate the type of anesthesia that will be used during the operation.
d. Increase rest and sleep
Clients pre operation will rest enough before surgery if there is no physical, mental power and given adequate sedation.
3. Preparation of the morning before the surgery clients
1. Noting the vital signs
2. Check the client's identity bracelet
3. Check skin preparation performed well
4. Check back special instructions such as infusion
5. Ensure that the client had not eaten in 8 hours
6. Encourage clients to urinate
7. Oral treatment if necessary
8. Help clients use RS clothes and headgear
9. Remove nail polish so easy to check for signs of hypoxia easier.
4. Interpesi pre surgery
1. Observation of vital signs
2. Assess fluid intake and output
3. Auscultation of bowel sounds
4. Assess the status of pain: the scale, location, characteristics
5. Teach relaxation techniques
6. Give fluids intervena
7. assess the level of anxiety
8. Give information about the disease process and actions
5. Postoperative Intervention
1. Observations of vital signs
2. Assess the scale of pain: characteristics, scale, location
3. Assess the state of the wound
4. Advise to change positions as tilted to the right, to the left and sit down.
5. Assess nutritional status
6. Auscultation of bowel sounds
7. Give wound care and disease information.
Evaluation
a. Impaired sense of comfort is resolved
b. No infection
c. Nutritional Disorders resolved
d. Clients understand about the treatment and the disease
e. No weight loss
f. Vital signs are within normal limits
