Appendix
illeo cecal junction, where small intestine meets large intestine
Where is the appendix?
Inspect, Auscultate, Percuss, and Palpate
How do you assess the abdomen?
Assessment, Diagnosis, Planning, Implementation, and Evaluation
What is ADPIE?
assess the client, analyze information from the assessment, and then write a 3 part nursing diagnostic statement (problem nursing diagnosis label), etiology (related to phase), symptoms (defining characteristics)
What is a nursing diagnosis?
It aims to reduce risks, errors and harm that occur to patients during provision of health care
What is patient safety?
Persistent, continuous, periumbilical pain. Followed by anorexia, n/v, pain can shift to rt lower quad, localized tenderness
What are the signs and symptoms of appendicitis?
the cecum, appendix, right ureter, right ovary and fallopian tube (in women), and the right spermatic cord (in men)
What organs are in the RLQ?
The nurse collects subjective and objective data. This includes physical assessments as well as obtaining and documenting past histories in the patient's medical record
What is assessment?
Risk for _____________ as evidenced by __________________________ (Risk Factors).
How do you write a nursing diagnosis?
Place the hospital bed in a low position when a patient is resting in bed; keep the hospital bed brakes locked; keep nonslip, comfortable, well-fitting footwear on the patient
How to prevent falls in the hospital?
What is appendicitis?
wait 5 minutes
What to do when the nurse does not hear any sounds while auscultating the abdomen?
Formed after completion of a comprehensive nursing assessment. Developed by NANDA and should be prioritized based on Maslow's Hierarchy of Needs
What is a nursing diagnosis?
1. Set priorities for nursing diagnosis according to Maslow's
2. Identify and write patient outcomes
3. Select evidence based nursing interventions
4. communicate the plan of care
What are the four steps in Planning and Outcome Identification?
Make sure all hallways, stairs, and paths are well lit and clear of objects such as books or shoes. Use rails and banisters when going up and down the stairs. Never place scatter rugs at the bottom or top of stairs. Clear pathway of any extension cords.
What is home safety?
with right leg flexed to a 90 degree angle
How does a patient with appendicitis lay?
What assessment findings are expected for patients with appendicitis?
Includes developing an individualized care plan, setting goals, and identifying expected outcomes. This is tailored to the patient, setting short and long term goals, and using the SMART system
What is planning?
North American Nursing Diagnosis Association
What does NANDA stand for?
Right Patient, Right Medication, Right Time, Right Dose, Right Route
What are the 5 checks to medication administration?
urine specimen (rule out UTI), WBC test sequencial (it goes up after time), abdominal ultrasound (rule out etopic or cysts), CT scan
How is appendicitis diagnosed?
What is the treatment for appendicitis? What happens when the appendix is removed? What are the side effects of an appendectomy? Can the appendix heal itself?
What questions should I ask about appendicitis?
Where the nurse determines if the patient has met the goals in the patient's plan of care
What is evaluation?
Specific to the nursing diagnosis, patient centered (the patient will), mutual (if possible) the patient and nurse should agree on the goal, Measurable, specify a time frame
What are patient goals or nursing outcomes?
When the medication is taken out of the drawer. When the medication is being poured. When the medication is being put away/or at bedside.
What are the 3 checks to medication administration?