Which of the following nursing interventions should be implemented to manage a client with appendicitis?
A. Assessing pain.
B. Encouraging oral intake of clear fluids.
C. Providing discharge teaching.
D. Assessing for symptoms of peritonitis.
Correct Answer: D. Assessing for symptoms of peritonitis
The focus of care is to assess for peritonitis, or inflammation of the peritoneal cavity. Peritonitis is most commonly caused by appendix rupture and invasion of bacteria, which could be lethal. Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in mentation, reports of increasing abdominal pain. This can be suggestive of the presence of infection or developing sepsis, abscess, peritonitis.
Option A: The client with appendicitis will have pain that should be controlled with analgesia. Assess pain, noting location, characteristics, severity (0–10 scale). Investigate and report changes in pain as appropriate. Keep the client at rest in semi-Fowler’s position to lessen the pain. Gravity localizes inflammatory exudate into the lower abdomen or pelvis, relieving abdominal tension, which is accentuated by a supine position.
Option B: The nurse should discourage oral intake in preparation for surgery. Aperients should also be avoided as induced peristalsis may cause perforation. If appendicitis has been diagnosed regular analgesia, usually an opioid depending on the pain severity, should be given to make the patient comfortable before treatment.
Option C: Discharge teaching is important; however, in the acute phase, management should focus on minimizing preoperative complications and recognizing when such may be occurring.
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