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PATIENT POPULATION
This care plan is intended for pediatric patients who have received an appendectomy for non-ruptured appendicitis. Hospital stay for these patients
is usually 24-36 post-surgery.
DEFINITIONS
Appendix - A small, finger-shaped pouch. The appendix is located at the base of the cecum, near the ileocecal valve where the taenia coli
converge on the cecum. The appendix is a true diverticulum of the cecum. The attachment of the appendix to the base of the cecum is constant
1
Appendicitis - Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts. Despite
diagnostic and therapeutic advancement in medicine, appendicitis remains a clinical emergency and is one of the more common causes of acute
abdominal pain. An appendectomy may be required for patients who have non-ruptured appendix. Appendectomies may be completed through
laparoscopic or open approach 6 ; Non-ruptured appendix surgeries are typically performed laparoscopically. Most patients leave the hospital within
24โ36 hours after surgery^2.
Appendectomy - The surgical removal of the appendix, a small finger-shaped pouch extending from the inferior large intestine. An appendectomy
is performed to treat appendicitis 3.
Laparoscopic Approach - Laparoscopic appendectomy may be performed using a three port (three incisions) or single incision technique. The
three incision technique involves incisions in the left lower quadrant, the umbilicus, and above the symphysis pubis^3.
Laparotomy (Open) Approach - In an open appendectomy, a small incision is made in the right lower quadrant (RLQ) of the abdomen, the
abdominal muscles are separated, and the appendix is removed while the patient is under general anesthesia; and in the supine position 1.
Antibiotic Therapy โ In some cases, patients can be treated with intravenous (IV) antibiotics alone, without surgical removal of the appendix.
Established: Mar-07- Reviewed/Revised: Mar-08- Refer to online version โ Print copy may not be current โ Discard after use
Problem/Potential
Problem
Objectives Anticipatory/Therapeutic Nursing Interventions Evidence-base/Rationale
Alteration in comfort related to surgical procedure
Patient will remain comfortable post-op
โ Assess and document pain q4h and PRN using an age and developmentally appropriate pain scale. โ Administer analgesic as ordered PRN. Consider providing patient with around-the-clock analgesia for the first 24- 48hours post-operatively. โ Assess effectiveness of analgesic 30-45 minutes post administration. โ If ordered analgesic is ineffective, contact appropriate services.
- Establishing a pain- management plan based on the findings from the assessment and incorporating the personโs beliefs and goals is important for minimizing pain and distress 10.
- Unrelieved acute pain can cause long-term pain problems that affect body functioning 10. Alteration in fluid balance related to surgery: Pre-op, nausea, NPO, vomiting.
Maintain optimal fluid balance โ Maintain IV as orders. Check site q1h and PRN. โ Advance diet as ordered/tolerated. โ Asses and document accurate intake and output q1-4h and PRN. โ Administer anti-emetics as ordered PRN. โ Replace NG losses as ordered. โ Assess lab values including: โ CBC โ Electrolytes; etc. โ Monitor for signs and symptoms of dehydration including: level of consciousness, and respiratory and mental health status 1.
- Optimal fluid balance is important to facilitate regulation of body function and wound healing^11.
- Dehydration can cause headaches, tiredness and loss of concentration and slow healing^1.
- Fluid imbalances lead to imbalance of electrolyte and decrease the bodyโs ability to function properly^11. Potential for bleeding or infection
Patient will remain free of infection
โ Check vital signs post-op as per BCCH policy. โ Assess incision with vital signs โ Assess abdomen and bowel sounds with vital signs then every shift once bowl sounds present. โ Check surgical site with dressing change and PRN. โ Frequently assess the wound, dressings, and drains, if present^1. โ Change surgical incision dressing as per BCCH policy
- Frequent assessments are useful for early detection of wound infection, which leads to quicker treatment and decreases the risk of septicemia^11.
- Frequent assessments also can detect any potential impairment of wound healing^11.
Established: Mar-07- Reviewed/Revised: Mar-08- Refer to online version โ Print copy may not be current โ Discard after use
Problem/Potential
Problem
Objectives Anticipatory/Therapeutic Nursing Interventions Evidence-base/Rationale
Comfort measures for the patient are:
While in the hospital, the caregiver(s) would like to be involved with:
The patient and family would like referrals to: Social Work Physiotherapy Occupational Therapy Community Nurse Child Life Specialist Psychology Pastoral Care Patient/family education and discharge planning
Patient and family will state understanding of the diagnosis, treatments and medications and express realistic plans for home care prior to discharge
Patient/Caregiver Education: โ Have patient and caregiver(s) explain in their own words basic facts about: nature of condition, symptoms, and treatment โ Provide a review handouts on condition and medications: โA Handbook for Familiesโ โ Discuss prescribed medications: โ Purpose, action, side effects, dose and administration and clarify misconceptions. โ Prepare patient and family prior to all tests and procedures; utilize teaching pamphlets and videos as applicable; give rationale.
- Implementing age-appropriate teaching strategies reduces anxiety in pediatric patients 13.
- Children benefit from age- appropriate teaching in a variety of forms, parental involvement in teaching, and ample time to process information^13.
- Families that are discharged without appropriate postoperative teaching experience high levels of worry and higher instances of pain 14.
Established: Mar-07- Reviewed/Revised: Mar-08- Refer to online version โ Print copy may not be current โ Discard after use
Problem/Potential
Problem
Objectives Anticipatory/Therapeutic Nursing Interventions Evidence-base/Rationale
Discharge/Follow-Up: Begin discharge Post-Op Day 1 โ Checklist Ensure appropriate follow-up information is given. Review and give caregiver(s) discharge instruction sheet. Review medications: Teach patient and family/caregiver(s) what to expect post-operatively, including how the postoperative pain will be managed. Advise the patient of possible shoulder pain after laparoscopic surgery caused by the gas used to distend the abdomen 1 Wound care: Teach caregiver(s)/family wound sterilization and dressing care, as appropriate 1. Indicate clinic/physician follow-up appointment. Review community support services. Review activity restrictions, as indicated by physician. Advise patient that full recovery takes 4โ6 weeks, and to avoid strenuous activity and lifting anything over 5 pounds before full recovery.
Advise family/caregiver(s) to contact the physician in the event of:
- Redness, swelling, increased pain, excessive bleeding, or discharge from the incision site 1.
- Signs of infection (such as fever and chills, cough, shortness of breath, chest pain, severe nausea and vomiting, increased abdominal pain, fainting, or if there is blood in the stool) 1.
- Seek immediate medical attention for new or worsening symptoms
1 .
Established: Mar-07- Reviewed/Revised: Mar-08- Refer to online version โ Print copy may not be current โ Discard after use
11. Lewis, S.M., Dirksen, S.R., Heitkemper, M.M., & Bucher, L. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical
Problems (9th ed.). St. Louis: Mosby.
12. Rollins, K.E., Aggarwal, S., Fletcher, A., Knight, A., Rigg, K., Williams, A.R., Bhattacharjya, S. (2014). Impact of early incentive spirometry in an
enhanced recovery program after laparoscopic donor nephrectomy. Transplantation Proceedings, 45(4), 1351-1353. doi:
10.1016/j.transproceed.2013.01.
13. Perry, J.N., Hooper, V.D., & Masiongale, J. (2012). Reduction of preoperative anxiety in pediatric surgery patients using age-appropriate
teaching interventions. Journal of PeriAnesthesia Nursing, 27(2), 69-81. doi: 10.1016/j.jopan.2012.01.
14. Ford, K., Courtney-Pratt, H., & FitzGerald, M. (2012). Post-discharge experiences of children and their families following childrenโs surgery.
Journal Of Child Health Care, 16(4), 320-330 11p. doi:10.1177/
15. Martin, J. A., Lee, T., & Newman, B. (2013). Child Life Specialists in a Pediatric Surgical Setting. Journal Of Perianesthesia Nursing, 28(3), e13-
4 1p. doi:10.1016/j.jopan.2013.04.
Established: Mar-07- Reviewed/Revised: Mar-08- Refer to online version โ Print copy may not be current โ Discard after use
