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, BP 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 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 appendicitis. chloride infusing at 125 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

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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 and 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 RLQ to aid in pain relief - avoid using heat as it may cause the appendix to rupture

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