Risk for Infection - Nursing Care Plan for Appendicitis

Appendicitis is an inflammation of the appendix, the incident is more likely to occur in men than women affected by appendicitis.
Appendicitis is more often attack at the age of 10 to 30 years.

Appendicitis perforation is a major complication of the appendix, where the appendix has ruptured appendix so that the contents out into the perineal cavity can cause peritonitis or abscess.

There are 4 factors that influence the occurrence of appendices:

1. The presence of lysis lumen.
2. Continuous degrees of blockage.
3. Continuous mucus secretion.
4. Properties in elastic / no bending of the mucosa of the appendix.

Clinical manifestations

1. Lower quadrant pain feels and is usually accompanied by mild fever, nausea, vomiting and loss of appetite.
2. Local tenderness at McBurney's point pressure when it's done.
3. Tenderness off.
4. There constipation or diarrhea.
5. Lumbar pain, when the circular appendix behind the cecum.
6. Painful defecation, when the appendix is located near the rectum.
7. Urinary pain, if the tip of the appendix is near the bladder or ureter.
8. Rectal examination was positive if the tip of the appendix at the end of the pelvis.
9. Signs Rovsing by palpating the lower left quadrant is paradoxical that causes right upper quadrant pain.
10. If the appendix had ruptured, pain becomes diffuse, with paralytic ileus caused by abdomen.
11. In elderly patients for signs and symptoms vary widely appendix. The patient may not experience symptoms until rupture of the appendix.

Nursing Diagnosis for Appendicitis

Risk for infection r / t invasive measures, post-surgical incisions, decreased endurance primary

Goal:

• Infection control and detected

Outcomes:

• There are no signs of infection.
• Vital signs within normal limits (Temperature: 36 - 37.5 c)

Nursing Interventions

Infection control :

• Clean up the environment after use for other patients .
• Limit visitors when necessary .
• Instruct family to wash their hands when contact and thereafter .
• Use anti- microbe soap for hand washing .
• Perform hand washing before and after nursing actions .
• Use clothing , masks and gloves as protective equipment ( Universal Precaution / UP ) .
• Maintain aseptic environment during the installation of equipment .
• Perform wound care , drainage and intravenous dressings , catheter care every day .
• Increase intake of nutrients and fluids
• Give antibiotics as ordered.

Protection of infection :

• Monitor for signs and symptoms of systemic and local infections .
• Monitor granulocytes and WBC count .
• Monitor susceptibility to infection .
• Maintain aseptic technique for each action .
• Maintain isolation techniques when necessary .
• Inspection of the skin and mucous mebran redness , heat , drainage .
• Inspection of the condition of the wound , surgical incision .
• Take culture if necessary .
• Encourage and explain the importance of adequate rest .
• Explain the importance of increased mobility and exercise , and teach .
• Instruct patient to take antibiotics as ordered.
• Teach family / client about the signs and symptoms of infection .
• Report suspicion of infection .
• Report related to the health care team if a positive culture .

Share :

Facebook Twitter Google+