About
Surgery to remove the appendix.
Assess
Incision, bleeding, bruising, circulation; Vital signs, pulse oximetry, pain level.
Complications
Infection; post-operative complications ( pneumonia, DVT, constipation, paralytic ileus, pain, PE)
Diagnosis
- Acute pain related to surgical procedure
- Risk for infection related to surgical procedure
- Deficient knowledge related to post surgical treatment regimen
Goals
- The client will understand pre-, intra-, and post-operative instructions.
- The client will remain free from post-operative complications.
Interventions
- Monitor vital signs every 15 minutes X 2, 30 minutes X2, one hour X2, than every 4 hours ( may have different guidelines for each clinical agency).
- Monitor for signs and symptoms of infection.
- Assess lung sounds, pulse oximetry, bowel sounds, circulation frequently.
- Implement incentive spirometry pre-operatively.
- Encourage to do IS post-operatively at least ten times an hour.
- Teach abdominal splinting.
- Apply elastic compression stockings and/or sequential compression device as ordered.
- Maintain NPO prior to surgery and start with clear liquids after surgery.
- Encourage early ambulation to avoid complications.
- Teach client signs and symptoms requiring immediate follow-up by a health care provider.
- If ruptured appendix, monitor for sepsis, and administer antibiotics as ordered.
- Monitor for signs/ symptoms of complications.
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