Complaints that often arise in post appendectomy is the verbal communication of pain that is felt, behavior too cautious, behavioral aberrations, (moaning, crying, restlessness), the face shows pain (eyes gloomy, sullen, restricting movement).
Nursing Assessment for Appendicitis
Assessment is the process whereby data relating to clients systematically collected. This process is dynamic and organized process that involves three basic activities, ie systematically collect, sort and organize the collected data and document data in a format that can be opened again. Assessment is used to recognize and identify health problems and needs of the client and the client's nursing physical, mental, social and environmental.
This Assessment contains:
1) Identity.
The identity of the client Appendicitis Post Operative on which to base the assessment, include: name, age, gender, education, occupation, religion, address, medical diagnosis, medical treatment, medical record number, date of entry, date of surgery and the date of assessment.
The identity of the person in charge, include: name, age, gender, education, occupation, religion, address, relationship with the client and resource costs.
2) The scope of health problems containing the main complaint when assessed client, the client post appendectomy usually complain of pain in the surgical wound and activity limitations.
History of Disease.
1) History of present illness.
History of present illness found during the assessment, which is described from start to enter care facilities to do the assessment. Complaints are now assessed using PQRST (palliative and provocative, quality and quantity, region and radiation, the severity scale and timing). Clients who have undergone appendectomy surgery generally complain of pain at the surgical site will increase when moved or pressed and generally decreases after being given the drug and rested. The pain is felt just as tingling with pain scale of more than five (0-10). The pain will be localized in the area of operation can also be spread throughout the abdomen and right thigh and generally persists throughout the day. Pain may be able to interfere with the activity of the corresponding tolerance range of each client.
2) Formerly medical history.
Contains previous illness experience, whether it impinges on the illness now and if ever experienced before surgery.
3) Family health history.
Keep in mind if there are other family members who suffer from the same illness as clients, also examined the presence of infectious disease in the offspring or family.
4) Psychological History.
In general, clients with post appendectomy, do not undergo psychological aberration function. Nevertheless, you still need to be done on the fifth concept of client self (body image, self-identity, role function, ideal self and self-esteem.
5) Social History.
Clients with post appendectomy is not impaired in social relationships with other people, but still have to compare the social relationship between the client before and after surgery.
6) Spiritual History.
In general, clients who underwent treatment will experience limitations in activities as well as in religious activities. Need to be assessed against sickness client confidence and motivation for recovery.
7) Daily Habit.
Clients who underwent surgical removal of the appendix is generally experienced difficulties in the move, because of acute pain and weakness. Clients may experience a disruption in self-care (bathing, brushing teeth, shampoo and nail clippers), as activity intolerance, impaired.
Clients will experience a restriction digestion oral input to the function back into the normal range. Possible clients will experience nausea, vomiting and constipation in the early postoperative period due to the influence of anesthesia. Oral intake can be started after the digestive functions back into the normal range. Clients can also experience decreased urine output because of the restriction of oral input. Urine output would gradually to normal after an increase in oral input. The pattern can be disturbed ataupu break client is not compromised, depending on client's tolerance to pain is felt.
Physical Examination
Physical examination includes:
General state
Post-appendectomy clients achieve full consciousness after a few hours back from the operating table, the appearance suggests a state of mild pain to severe depending on the period of acute pain. Generally stable vital signs but will experience instability in clients who experienced perforation of the appendix.
Respiratory System
Clients will post appendectomy decreased or increased respiratory rate (tachypnea) and shallow breathing, according to the range tolerated by the client.
Cardiovascular system
Generally clients experience tachycardia (as a response to stress and hypovolemia), had hypertension (as a response to pain), hypotension (weakness and bed rest). Usually normal capillary refill, also examined the state of the conjunctiva, and the presence of cyanosis, auscultation of heart sounds.
Digestive system
The presence of pain at the surgical site in the lower right abdomen when palpated. Clients post appendectomy usually complain of nausea and vomiting, constipation in early postoperative and decreased bowel sounds. Will appear the surgical wound in the lower right abdominal incision surgery.
urinary system
Early postoperative client will experience a decrease in the amount of urine output, this happens because of the restriction of oral intact during the initial period of post-appendectomy. Normal urine output would gradually with increasing oral intake.
Musculoskeletal system
In general, the client may experience weakness due to postoperative bed rest and stiffness. Muscle strength gradually improved with increasing activity tolerance.
Integumentary system
Will appear the surgical wound in the lower right abdomen for surgical incision with redness (usually in early onset). Skin turgor will improve with an increase in oral intake.
Nerve system
Generally clients with post appendectomy is not experiencing irregularities in neural function. Assessment persafan functions include: level of consciousness, cranial nerves and reflexes.
Hearing system
Assessment conducted include: ear shape and symmetry, presence or absence of inflammation and auditory function.
Endocrine system
Generally clients post appendectomy, no abnormal endocrine function. But still need to be assessed adequacy endocrine function (thyroid, etc.).