XIII.

Pathophysiology: Non-modifiable factor: Age Female Modifiable factors: Lifestyle Diet

Obstruction of the appendix by fecalith (harden stool), lymph node, tumor, foreign object.

Increase in pressure inside the appendix lumen that result to distention of appendix

Impaired venous return causing hyperemia (improper O2, and nutrient supply) Normal bacteria found in appendix begin to invade (infect) the lining of the wall

Inflammatory Response body response to the bacterial invasion in the wall of appendix. Increased Immune complex (disease plus antibody) causes swelling of tissue resulting to inflammation of appendix S/S: Abdominal pain, fever, and increase swelling of appendix,nausea
Pain- located @ RLQ, causing Guarding, nausea

Appendectomy, pain medications

Inflammation and infection spread through the wall of the appendix causing death of tissue. The appendix ruptures due to increase pressure (Perforation) Appendectomy with explore laparotomy Perforation (formation of a hole in an organ), fecal materials exits to peritoneal cavity causing formation of abscesses (peri-appendiceal abscess).Infection can spread throughout the abdomen (peritoneal cavity)

Bacterial invasion of Peritoneal Cavity causing inflammation of the membrane that lines the abdomen peritoneum (Peritonitis) S/S: swelling of the abdomen, severe pain, and nausea

Sepsis (the condition or syndrome caused by the presence of microorganisms or their toxins in the tissue or the blood stream) Septicemia

LEGEND AAA- signs and symptoms AAA- medical interventions AAA- pathophysiology

IF NOT TREATED:

IF TREATED: Strong antibiotic Medication

Septic Shock S/S: decrease Blood pressure decrease blood volume

Fluid Volume Replacement therapy COMA RECOVERY DEATH

NURSING CARE PLAN Assessment Nursing Diagnosis Planning Nursing Interventions >Establish rapport >Monitor V.S. Rationale Evaluation

S> O

Risk for infection Short term: secondary to surgical O> the patient After 4 hours of incision manifested: nursing interventions, the patient shall -Weakness identify and demonstrate -Pallor intervention to prevent infection -with dry and intact dressing on the area. Long term: -Pain over the After 1 day incision of nursing interventions, the -Irritability patient will not have infection -Impaired physical mobility

>To gain trust

Short term:

>To obtain baseline The patient identified and data demonstrated interventions to prevent >Note signs and risk of infection symptoms of sepsis >To reduce complication and monitor for infection Long term: >Provide wound healing such as cleaning of wound >Provide care, change dressing as needed >Encourage increase intake of Vitamin C >Encourage deep breathing exercise >To reduce risk for The patient doesnt infection experience infection

>To promote healing to the incision >To prevent infection to increase immune resistance >To increase healing of wound

Assessment

Nursing Diagnosis

Planning

Nursing Interventions Establish rapport Monitor vital signs

Rationale

Evaluation

S> The patient may manifest: concerns due to change in life event fear nausea abdominal pain fatigue sleep disturbance urinary hesitancy

Anxiety related to situational crisis

Short term: After 3 hours of nursing interventions the patient will verbalized awareness of feelings of anxiety

To gain trust To obtain baseline data

Short term: The patient verbalized awareness of feelings of anxiety

Listen attentively; allow patient to express feelings verbally

To allow patient to identify anxious behaviors and discover source of anxiety

Long term: The patient appeared relaxed and reported that anxiety was reduced to a manageable level

Long term: After 1 day of nursing interventions the patient will appear relaxed and report anxiety is reduced to a manageable level

Identify and reduce as many Anxiety commonly environment results from lack of stressors trust in the environment

O> The patient may manifest: - poor eye contact - extraneous

Provide accurate information about the situation

Helps the patient what is reality based

movement - restlessness - irritability - impaired attention Trembling, hand tremors Refer patient to professional menta l health resources Provide comfort measures like back rub and soft music Use cognitive therapy To decrease autonomic response toanxiety To correct faulty catastrophic interpretations of physical symptoms To provide ongoing mental health assistance