Question

PN 105 Fundamentals of Nursing I Concept Map- Infection Mr. Jeb Jones, a 26-year-old male, has been admitted to your unit with right sided lower quadrant pain. His WBC is 24,000; erythrocyte sedimentation rate is 27; Basophil 1%; Neutrophils 80%; Lymphocytes 45%. He has had nausea and vomiting for the past 24 hours and has no food and little to drink. Vital signs are T.102.2, P 98 rapid and strong, R. 24 and shallow, B/P 156/88. He denies any health problems; usual childhood diseases such as measles, chicken pox, etc. There is an IV in his left hand with 1000 mL of 0.9 % sodium chloride infusing at 125 m/L per hour and is NPO. Sates his pain is on a level of 5 on a scale of 0-10. He has pain only when he moves. He has not had any pain medication because of the suspected diagnosis of citis. Now please go to the Concept Map Suspected diagnosis is a good medical assumption, but it should not be used as a diagnosis Reviewed 3/19

Answer 1

NURSING CARE PLAN Nursing Nursing Nursing Intervention Diagnosis Goal aluation Plan Due to the Acute pain thin Estabish rapport. presence rlated to our 8 nflammation nfiammation hour Togan trust and Goal partialy met span of VStaken and recorded.Serves as baselne and mass on of the the RLQ of appendx. care, the abdomen, t causes wil beEnoourage verbalizationTo assess the level aleviatedof feelings about pain of pain. obs tructon in the lumen of the appendx ▶ have diversonal activities such as moble internet and watching TV Encourage patent to To aleviate pain. pan. n turn causes s sharp acute pain in the Right Lower Quadrart part of the Encourage patent to use Distract attention relaxation techniqueS such as deep breathing and reduce tension. Provide camfort measuresTo promote non- such as touch, repos tioning, quiet enviranment and calm pharmacologic pain Encourage adequate rest To promote welness and prevent fatigue. Observe and document Togeta baseline severity (1-10 scale) an data of pain scale. character of pain (steady, ntermittent, olicky)

Nursing Interventions and Rationales: Place in semi-Fowler's position This position allows gravity to assist by reducing abdominal stress and relieves discomfort Monitor Labs Abnormal labs are indications of illness progression Monitor for: CRP >1 mg/dL - indicates inflammation. Very high levels may indicate gangrene WBC >10,500 indicates infection Neutrophils-75% Monitor vital signs Fever, chills and diaphoresis are signs of infection, developing sepsis, abscess or peritonitis Hypotension with tachycardia may indicate dehydration if vomiting or diarrhea is severe Prep for surgery to remove appendix (appendectomy)

Initiate IV access Informed Consent obtained Provide Post-Op care after appendectomy Maintain NPO status to empty gastric contents an remain NPO post surgery until gag reflex has returned to reduce the risk of aspiration Clear liquids, advance diet as tolerated Assess and manage pain Note location, severity and quality of pain and any changes in characteristics which may signify abscess or peritonitis Administer analgesics as ordered for pain management Place ice pack on RLO to aid in pain relief - avoid using heat as it may cause the appendix to ruptur Encourage abdominal splinting

Education the patient on ways to protect abdomen before and after surgery by splinting with a pillow this will aid in pain management and prevent dehiscence of incision