MED-SURG EXAM 3 - N'S PART
QUESTIONS WITH CORRECT ANSWERS
Diagnosing appendicitis - Answer-- Ultrasound will show an enlarged appendix -
confirms
- CT scan is most commonly used diagnostic test
- perform a pregnancy test in women of childbearing age to rule out ectopic pregnancy
(this is done before any radiologic test are performed)
- urinalysis to rule out UTI or renal calculi
- diagnostic laparoscopy- acute appendicitis (allows direct visualization of contents of
abdomen or pelvis)
Gangrene can occur in ________ hours of appendicitis - Answer-24-36
Perforation can occur in as little as ____ hours of appendicitis- risk increases after
_____ hours - Answer-24 hours; 48 hours
6-24 hours after onset of pain
WBC in acute appendicitis - Answer-10,000-20,000 with shift to the left
Normal CRP levels - Answer-<10mg/L
>10= serious infection, trauma, chroric disease
- marker for inflammation
How to know if a patient has rebound tenderness - Answer-Palpate deeply and then
quickly release pressure. If it hurts more when you release, the patient has rebound
tenderness
What NOT to give a patient with appendicitis - Answer-NO laxatives or enemas- leads
to perforation
NO heat - can cause rupture, which leads to peritonitis
NO analgesics until cause of pain is determined
NO driving while taking opioids due to dizziness
What does it mean if pain suddenly stops in a patient with appendicitis? - Answer-The
appendix just ruptured
N/V before pain means - Answer-Gastroenteritis
N/V after pain means - Answer-Appendicitis
Nursing management for appendicitis - Answer-No heating pads, edemas, or laxatives
Maintain NPO until blood count reports received
No analgesics until cause of pain is determined
,Ice bag
Watch for peritonitis
Sudden absence of pain can indicate that the appendix is ruptured
Referred pain indicates peritoneal irritation
Pain can initially be anywhere in abdomen or flank, but always progresses to RLQ
Surgical Management for appendicitis - Answer-appendectomy: 2 types
- laparoscopy: if uncomplicated (minimally invasive surgery)
- laparotomy: if rupture or peritonitis is suspected
Surgery may be delayed if patient has abscess, perforation, or peritonitis because that
has to be dealt with first
Pre-op nursing interventions for an appendectomy - Answer-Maintain NPO
Administer prescribed fluids to prevent dehydration
Monitor for changes in level of pain
Monitor for s/s of ruptured appendix and peritonitis
Position patient in right side-lying or low semi Fowler's position for comfort
Monitor bowel sounds
Apply Ice packs for 20-30 mins every hour
Administer abx
Post-op appendectomy - Answer-- NPO until return of bowel sounds/bowel function
returns
- advance diet gradually as tolerated/prescribed when bowel sound returns
- adequate pain management prior to and after surgery
- if rupture of appendix had occurred- expect a drain to be inserted/incision may be left
open to heal from inside to outside (secondary intention)
- drainage may be profuse for the first 12 hours
- place patient in right side lying or low semi Fowler's position with legs flexed to
facilitate drainage
- perform wound irrigation as prescribed
- maintain NG suction and patency of the NG tube is present
- administer abx and analgesics
-most patients returns to normal ADL 1-2 weeks
- incentive spirometry used 10 times/hr while awake- encourage use every 2 hours
- abx prophylaxis <24 hours if non-perforated and <5 days if perforated
- patient is placed in high Fowler's position- reduces tension on the incision and
abdominal organs = decreased pain= promotes thoracic= diminishes work of breathing/
decreases risk of atelectasis
- parenteral opioid (morphine) for pain = switched to PO analgesics when patient can
tolerate fluids/food
- IV fluids if patient was dehydrated before surgery will continue
- follow up with surgeon in 1-2 weeks
- avoid heavy lifting/ normal activities for 2-4 weeks
, Complications of appendicitis - Answer-gangrene, abscess, perforation, peritonitis,
portal pylephlebitis
portal pylephlebitis - Answer-(Rare complication of intra-abdominal infection)
- portal vein thrombosis
- often missed due to non-specific clinical presentation
- high rate of morbidity & mortality
What can we do to prevent abdominal distention - Answer-Nasogastric - stomach
decompression
How to prevent atelectasis post-op - Answer-Get patient up and moving the same day
Patients with complicated appendicitis - Answer-- Gangrenous/perforated appendix:
greater risk for infection/ peritonitis
- secondary abscesses may form under diaphragm of liver (elevated temp & elevated
pulse)
- elevated WBC
Primary spontaneous peritonitis - Answer-Rare- peritoneum infected by bloodstream
Secondary peritonitis - Answer-Injury or infection in the abdominal cavity
- perforation of abdominal organs with spillage that infects the serous peritoneum
- pancreatitis
- ruptured appendix is main cause
- perforated peptic ulcers- stomach ulcers
- diverticulitis- resulting in perforated colon
- surgery/trauma
Tertiary peritonitis - Answer-Superinfection in a patient who is immunocompromised
- Tuberculosis peritonitis in a patient with AIDS (rare cause)
Peritonitis happens often after - Answer-Surgery
Main bactria responsible for peritonitis - Answer-E. Coli
Chemical peritonitis - Answer-Leakage of bile/ pancreatic enzymes/ gastric acids
Patho of peritonitis - Answer-Transudate (50mL of fluid in peritoneal cavity)
Contaminated peritoneal cavity- inflammatory response fails
Main cause- bacteria or chemicals
Bacteria gains access to peritoneal cavity due to perforation/external penetrating wound
- perforation from appendix, diverticulitis, PUD
- external penetrating wound, gangrenous gallbladder, bowel obstruction, tumors
- fluid in peritoneal cavity becomes turbid with increased WBC's, cellular debris, and
blood
QUESTIONS WITH CORRECT ANSWERS
Diagnosing appendicitis - Answer-- Ultrasound will show an enlarged appendix -
confirms
- CT scan is most commonly used diagnostic test
- perform a pregnancy test in women of childbearing age to rule out ectopic pregnancy
(this is done before any radiologic test are performed)
- urinalysis to rule out UTI or renal calculi
- diagnostic laparoscopy- acute appendicitis (allows direct visualization of contents of
abdomen or pelvis)
Gangrene can occur in ________ hours of appendicitis - Answer-24-36
Perforation can occur in as little as ____ hours of appendicitis- risk increases after
_____ hours - Answer-24 hours; 48 hours
6-24 hours after onset of pain
WBC in acute appendicitis - Answer-10,000-20,000 with shift to the left
Normal CRP levels - Answer-<10mg/L
>10= serious infection, trauma, chroric disease
- marker for inflammation
How to know if a patient has rebound tenderness - Answer-Palpate deeply and then
quickly release pressure. If it hurts more when you release, the patient has rebound
tenderness
What NOT to give a patient with appendicitis - Answer-NO laxatives or enemas- leads
to perforation
NO heat - can cause rupture, which leads to peritonitis
NO analgesics until cause of pain is determined
NO driving while taking opioids due to dizziness
What does it mean if pain suddenly stops in a patient with appendicitis? - Answer-The
appendix just ruptured
N/V before pain means - Answer-Gastroenteritis
N/V after pain means - Answer-Appendicitis
Nursing management for appendicitis - Answer-No heating pads, edemas, or laxatives
Maintain NPO until blood count reports received
No analgesics until cause of pain is determined
,Ice bag
Watch for peritonitis
Sudden absence of pain can indicate that the appendix is ruptured
Referred pain indicates peritoneal irritation
Pain can initially be anywhere in abdomen or flank, but always progresses to RLQ
Surgical Management for appendicitis - Answer-appendectomy: 2 types
- laparoscopy: if uncomplicated (minimally invasive surgery)
- laparotomy: if rupture or peritonitis is suspected
Surgery may be delayed if patient has abscess, perforation, or peritonitis because that
has to be dealt with first
Pre-op nursing interventions for an appendectomy - Answer-Maintain NPO
Administer prescribed fluids to prevent dehydration
Monitor for changes in level of pain
Monitor for s/s of ruptured appendix and peritonitis
Position patient in right side-lying or low semi Fowler's position for comfort
Monitor bowel sounds
Apply Ice packs for 20-30 mins every hour
Administer abx
Post-op appendectomy - Answer-- NPO until return of bowel sounds/bowel function
returns
- advance diet gradually as tolerated/prescribed when bowel sound returns
- adequate pain management prior to and after surgery
- if rupture of appendix had occurred- expect a drain to be inserted/incision may be left
open to heal from inside to outside (secondary intention)
- drainage may be profuse for the first 12 hours
- place patient in right side lying or low semi Fowler's position with legs flexed to
facilitate drainage
- perform wound irrigation as prescribed
- maintain NG suction and patency of the NG tube is present
- administer abx and analgesics
-most patients returns to normal ADL 1-2 weeks
- incentive spirometry used 10 times/hr while awake- encourage use every 2 hours
- abx prophylaxis <24 hours if non-perforated and <5 days if perforated
- patient is placed in high Fowler's position- reduces tension on the incision and
abdominal organs = decreased pain= promotes thoracic= diminishes work of breathing/
decreases risk of atelectasis
- parenteral opioid (morphine) for pain = switched to PO analgesics when patient can
tolerate fluids/food
- IV fluids if patient was dehydrated before surgery will continue
- follow up with surgeon in 1-2 weeks
- avoid heavy lifting/ normal activities for 2-4 weeks
, Complications of appendicitis - Answer-gangrene, abscess, perforation, peritonitis,
portal pylephlebitis
portal pylephlebitis - Answer-(Rare complication of intra-abdominal infection)
- portal vein thrombosis
- often missed due to non-specific clinical presentation
- high rate of morbidity & mortality
What can we do to prevent abdominal distention - Answer-Nasogastric - stomach
decompression
How to prevent atelectasis post-op - Answer-Get patient up and moving the same day
Patients with complicated appendicitis - Answer-- Gangrenous/perforated appendix:
greater risk for infection/ peritonitis
- secondary abscesses may form under diaphragm of liver (elevated temp & elevated
pulse)
- elevated WBC
Primary spontaneous peritonitis - Answer-Rare- peritoneum infected by bloodstream
Secondary peritonitis - Answer-Injury or infection in the abdominal cavity
- perforation of abdominal organs with spillage that infects the serous peritoneum
- pancreatitis
- ruptured appendix is main cause
- perforated peptic ulcers- stomach ulcers
- diverticulitis- resulting in perforated colon
- surgery/trauma
Tertiary peritonitis - Answer-Superinfection in a patient who is immunocompromised
- Tuberculosis peritonitis in a patient with AIDS (rare cause)
Peritonitis happens often after - Answer-Surgery
Main bactria responsible for peritonitis - Answer-E. Coli
Chemical peritonitis - Answer-Leakage of bile/ pancreatic enzymes/ gastric acids
Patho of peritonitis - Answer-Transudate (50mL of fluid in peritoneal cavity)
Contaminated peritoneal cavity- inflammatory response fails
Main cause- bacteria or chemicals
Bacteria gains access to peritoneal cavity due to perforation/external penetrating wound
- perforation from appendix, diverticulitis, PUD
- external penetrating wound, gangrenous gallbladder, bowel obstruction, tumors
- fluid in peritoneal cavity becomes turbid with increased WBC's, cellular debris, and
blood
