Medical-surgical Nursing Demystified

(Sean Pound) #1

CHAPTER 7 Gastrointestinal System^287


INTERPRETING TEST RESULTS



  • Elevated white blood cell count (WBC).

  • CT scan shows enlarged appendix or fecalith.

  • Ultrasound may show enlarged appendix.


TREATMENT



  • Surgical removal of the appendix—appendectomy (may be done via laparo-
    scopy or open laparotomy).

  • NPO—nothing by mouth to avoid further irritation of the intestinal area, and
    prep for surgery.

  • Intravenous fluids until diet resumed.

  • Pain medications after surgery as needed; pain medication is used cautiously
    preoperatively to maintain awareness of increase in pain due to possible rup-
    ture of appendix.

  • Antibiotics postoperatively if needed.


NURSING DIAGNOSES



  • Acute pain

  • Hyperthermia

  • Nausea


NURSING INTERVENTION



  • Monitor vital signs for fever, increased heart rate, respiratory rate, and decrease
    in blood pressure.

  • Assess pain level for changes.

  • Monitor surgical site for appearance of wound, drainage.

  • Monitor abdomen for distention, presence of bowel sounds.

  • Monitor intake and output.

  • Monitor bowel function.

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