Nursing care

1. Assessment

According to Potter & Perry (2010), assessment of client nursing with post appendectomy,
namely:

a. The respiratory system

Assess airway patency, breath rate, rhythm into ventilation, chest wall motion simulations,
breath sounds, and mucosal color.

b. Circulation

Patients are at risk for cardiovascular complications due to loss of blood from the surgery
site, a side effect of anesthesia. Examined assessments of heart rate and rhythm, along with
blood pressure, reveal the patient's cardiovascular status. Assess capillary circulation by
noting capillary refill, pulse, nail color and skin temperature. A common problem with early
circulation is bleeding. Blood loss can occur externally through an internal duct or incision.

c. Nervous System

Assess pupil and vomiting reflexes, hand grip, and leg movements. If the patient has
undergone surgery involving part of the nervous system, do a more thorough neurological
assessment.

d. Urinary System

Epidural or spinal anesthesia often prevents the sufferer from sensing a full bladder. Feel the
lower abdomen over the symphysis pubis to assess for bladder distension. If the patient has a
urine catheter inserted, there should be a continuous flow of urine of 30-50 ml / hour in
adults. Observe the color and smell of urine, surgery involving the urinary tract will usually
cause the urine to bleed for at least 12 to 24 hours, depending on the type of surgery.

e. Digestive system

Inspection of the abdomen to check for flatulence due to gas accumulation. Nurses need to
monitor the initial oral intake of patients who are at risk of causing aspiration or the presence
of nausea and vomiting. Also assess for return of peristalsis every 4 to 8 hours. Regular
auscultation of the stomach to detect bowel sounds returned to normal, 5-30 loud sounds per
minute in each quadrant indicates returned peristalsis. A high tinkling sound accompanied by
abdominal distension indicates that the intestines are not functioning properly. Ask if the
patient is passing gas (flatus), this is an important sign indicating normal bowel function.

2. Nursing Diagnosis

Nursing diagnoses that may appear in post appendectomy surgery patients based on NANDA
(2010) are as follows:
a. Impaired gas exchange associated with residual effects of anesthetics.

b. Ineffective airway hygiene is associated with increased mucosal secretions.

c. Pain associated with post-surgical incision wounds and position during surgery.

d. Damage to the integrity of the skin associated with post-surgical wounds, drainage or
surgical wound infection.

e. Fluid volume deficit is related to fluid loss during surgery.

f. Change in elimination pattern: decrease in relation to anesthetic agents and immobilization.

g. Activity intolerance related to surgery and length of bed rest.

h. Selfcare deficit associated with surgical wounds, pain and therapeutic regimens.

i. Lack of knowledge is associated with less information about the therapeutic regimen.

3. Nursing Planning

Nursing plans in post appendicitis surgery patients according to Wilkinson and Ahern (2013):

a. Acute Pain

1) Criteria for results:

Shows pain control as evidenced by the following indicators:

a) Recognizing the onset of pain

b) Using precautions

c) Report pain can be controlled

2) Nursing Interventions

a) Observe nonverbal cues of discomfort, especially in those who are unable to communicate
effectively

b) Ask the patient to rate pain or discomfort on a scale of 0 to 10 (0 = no pain or discomfort,

10= severe pain).

c) Perform a comprehensive pain assessment including location, characteristics, onset and

duration, frequency, quality, intensity or severity of pain, and precipitating factors.

d) Inform the patient about procedures that can increase pain

e) Provide information about pain such as the cause of pain, how long the pain will last and
anticipate discomfort due to the procedure.
f) Teach the use of non-pharmacological techniques such as deep breath relaxation
techniques.

g) Help sufferers to focus more on activities, not pain and discomfort by doing distractions
through television, radio, tapes, and interactions with visitors

h) Control environmental factors that can affect the patient's response to discomfort (for
example, room temperature, lighting, and noise)

i) Ensure administration of therapeutic analgesics or nonpharmacological strategies before

undertaking any painful procedure.

4. Nursing Implementation

Nursing implementation is a series of activities carried out by nurses to help clients with
better health status problems that describe the expected outcome criteria (Potter & Perry,
2010).

5. Evaluation

According to (Craven & Hirnle, 2007), evaluation is defined as a decision on the

effectiveness of nursing care between the client's basic nursing goals that have been set and
the behavioral response shown by the client.