Appendicitis is inflammation of the appendix, usually from a blockage. Pain often starts near the belly button and moves to the right lower quadrant. Your priorities are pain control, preventing rupture and infection, and preparing the client for surgery.
A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation
Each care plan below follows the nursing process (ADPIE).
CARE PLAN 1 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Acute Pain
Related to
- Inflammation and swelling of the appendix
As evidenced by
- Right lower quadrant pain at McBurney's point
- Rebound tenderness
- Guarding and lying still with knees bent
- Nausea and loss of appetite
Short-term goals
- Client rates pain at 3 out of 10 or less within 1 hour of pain medicine
Long-term goals
- Client has controlled pain after surgery and returns to normal activity
- Pain location, intensity, and any sudden change
- Abdominal tenderness and rigidity
- Vital signs
| INTERVENTION | RATIONALE |
|---|---|
| Give pain medicine as ordered once the diagnosis is made | Pain control is safe and does not hide the diagnosis once it is known. |
| Keep the client NPO before surgery | An empty stomach lowers aspiration risk during anesthesia. |
| Never apply heat to the abdomen | Heat increases blood flow and can lead to rupture. |
| Avoid laxatives and enemas | They increase bowel movement and pressure, which can rupture the appendix. |
EVALUATION
- Client rates pain at 3 or lower
- Client rests comfortably
CARE PLAN 2 · NURSING DIAGNOSIS
ASSESSMENT
Risk for Infection
Risk factors
PLANNING · EXPECTED OUTCOMES- Possible rupture of the appendix
- Surgical incision
Short-term goals
- Temperature stays below 38.3 °C (101 °F) after surgery
- Incision stays clean and dry
Long-term goals
- Client is free of peritonitis and wound infection at follow-up
- Sudden pain relief followed by worse diffuse pain, a sign of rupture
- Temperature, heart rate, and WBC
- Incision for redness, drainage, and swelling
| INTERVENTION | RATIONALE |
|---|---|
| Report sudden relief of pain followed by a rigid abdomen and fever right away | This pattern suggests rupture and peritonitis, which is an emergency. |
| Give antibiotics as ordered before and after surgery | Antibiotics prevent and treat infection. |
| Use clean technique for dressing changes and teach hand hygiene | This keeps germs out of the incision. |
| Encourage early walking and incentive spirometer use after surgery | Moving and deep breathing prevent pneumonia and blood clots. |
EVALUATION
- Client is afebrile
- Incision is healing without signs of infection
- Client demonstrates wound care
Practice this in This vs That
Sort appendicitis from other causes of abdominal pain.
Play This vs ThatQuick answers
A client with appendicitis suddenly says the pain is gone. What should the nurse do?
Assess right away and notify the provider. Sudden relief can mean the appendix ruptured, and peritonitis can follow.
Why is a heating pad unsafe in suspected appendicitis?
Heat increases blood flow to the area, which can speed up rupture.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.