Nursing Assessment - Physical Examination for Appendicitis

Physical Examination for Appendicitis

Interview

• Get a thorough medical history, especially regarding:
• The main complaint: the client will get a pain around the epigastrium radiating to the lower right abdomen. Complaints arising under the right abdominal pain may be a few hours later after the pain in the center or in the epigastrium felt in some time ago. Pain is felt continuously, may be lost or attributable to, pain in a long time. Complaints which usually accompanies a client complaining of nausea and vomiting, the body heat.
• Past medical history of health problems usually associated with a client right now.
• Diet, eating foods low in fiber.
• Elimination habits.

Physical examination

• Physical examination of the general state of ill clients seem mild / moderate / severe.
• Circulation: tachycardia.
• Respiratory: Tachypnea, shallow breathing.
• Activity / rest: Malaise.
• Elimination: Constipation in early onset, sometimes diarrhea.
• Abdominal distension, tenderness / pain off, stiffness, decreased or absent bowel sounds.
• Pain / comfort, epigastric and abdominal pain around the umbilicus, the increased severe and localized to the point Mc. Burney, an increase of walking, sneezing, coughing or breathing deeply. Pain in the lower right quadrant because the position of the right leg extension / seated upright position.
• Fever over 38 ° c.
• Psychological data, appear restless.
• There are changes in pulse rate and breathing.
• On rectal toucher palpable lump and the patient will feel pain in the pro-lithotomy.
• Weight as an indicator to determine the drug.

Examination Support

• Signs of peritonitis, lower right quadrant. Line drawings of air fluid level in the cecum or ileum.
• Erythrocyte sedimentation rate (ESR) is increased in the state of appendicitis infiltrates.
• Routine urinalysis is important to see what there is infection in the kidney.
• The increase of leukocytes, Neutrophilia, without eosinophils.
• Appendix on barium enema is not filled.
• Ultrasound: fekalit non-calcified, non-perforated appendix, appendix abscess.

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Risk for Deficient Fluid Volume - Nursing Interventions for Appendicitis

Appendicitis

The main complaint in patients with appendicitis is pain around the epigastrium radiating to the lower right abdomen. Complaints arising under the right abdominal pain may be a few hours later after the pain in the center or in the epigastrium felt in some time ago. Nature of the complaints of persistent pain is felt, may be lost or there is pain in a long time. Complaints which usually accompanies a client complaining of nausea and vomiting, loss of heat.



Risk for Deficient Fluid Volume

Definition: The decrease intravascular fluid, interstitial, and / or intrasellular. This leads to dehydration, loss of fluids with sodium expenditure.

Characteristics :

• Weakness
• Thirst
• Decreased skin turgor / tongue
• Mucous membrane / dry skin
• Increased pulse rate, decreased blood pressure, decrease in volume / pulse pressure
• Completion of decreased venous
• Changes in the mental position
• The concentration of urine increased
• Increased body temperature
• Elevated hematocrit
• Weight loss immediately (except on third spacing)

Nursing Diagnosis Interventions for Appendicitis

Risk for deficient Fluid Volume related to a sense of nausea and vomiting,
characterized by:

• Sometimes diarrhea.
• Abdominal distension.
• Tense abdomen.
• Decreased appetite.
• There is a sense of nausea and vomiting.

Purpose: Maintaining the balance of fluid volume

Results Criteria:

• The client is not diarrhea.
• A good appetite.
• The client no nausea and vomiting.

Nursing Intervention for Appendicitis :

1) Monitor vital signs.
Rational: This is an early indicator of hypovolemia.

2) Monitor intake and urine output and concentration.
Rational: Decreased urine output and concentration will improve the sensitivity / sediment as one the impression of dehydration and require increased fluids.

3) Give fluid little by little but often.
Rationale: To minimize the loss of fluids.

Pediatric Nursing Care Plan – Fluid Volume Deficit related to Diarrhea

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