- Acute Pain related to Bloating/gas and Ruptured appendix as evidenced by Complaints of sudden abdominal pain and Guarding of the abdominal area
- Ineffective Tissue Perfusion related to Appendix obstruction and Abdominal compartment syndrome as evidenced by Nausea and vomiting, Abdominal discomfort
and Abdominal distention - Risk For Deficient Fluid Volume related to Vomiting and Diarrhoea as evidenced by NPO status
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Verbal reports from the patient expressions of pain, such as crying -Unpleasant feeling Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns -Guarding or protective behaviors | Acute Pain related to Bloating/gas and Ruptured appendix as evidenced by Complaints of sudden abdominal pain and Guarding of the abdominal area | Patient will report a pain score of 0/10 by discharge. Patient will display signs of comfort as evidenced by resting with eyes closed and vital signs within normal limits. Patient will verbalize an understanding of their prescribed pharmacologic regimen to control pain. | 1. Administer analgesics. Appendicitis is very painful, and patients should be given opioids, Acetaminophen, and NSAIDs to control inflammation. 2. Offer distraction. Until pain relief occurs, or surgery takes place the patient may need distractive measures to refocus their attention and promote relaxation. 3. Keep NPO. Instruct the patient that not eating or drinking is important to prevent further gastric irritation and vomiting and as a safety measure in preparation for potential surgery. 4. Instruct on medications at discharge. Some cases of uncomplicated appendicitis may not require surgery. Patients may continue a course of antibiotics and pain relief at discharge. Ensure the patient understands to complete the entire course of antibiotics and to contact their provider if symptoms worsen or do not improve. | Patient reported a pain score of 0/10 by discharge. Patient displayed signs of comfort as evidenced by resting with eyes closed and vital signs within normal limits. Patient verbalized an understanding of their prescribed pharmacologic regimen to control pain. |
| Subjective data: Chest Pain Dyspnea Sense of impending doom Objective data: -Arrhythmias -Capillary refill >3 seconds -Altered respiratory rate -Use of accessory muscles to breathe -Abnormal arterial blood gases -Unstable blood pressure -Tachycardia or bradycardia -Cyanosis | Ineffective Tissue Perfusion related to Appendix obstruction and Abdominal compartment syndrome as evidenced by Nausea and vomiting, Abdominal discomfort and Abdominal distention | Patient will remain free from gastrointestinal complications from appendicitis like peritonitis, abscess formation, and sepsis. Patient will maintain active bowel sounds in all quadrants | 1. Administer prophylactic antibiotics. When appendicitis is diagnosed, antibiotics are started to prevent bacterial growth and complications before and after surgery. 2. Prepare the patient and assist in appendectomy. Surgical intervention through appendectomy is indicated to help remove the appendix and prevent further complications with ineffective gastrointestinal tissue perfusion. 3. Administer oxygen as needed. Supplemental oxygenation helps ensure adequate oxygenation to the gastrointestinal tract and other parts of the body. 4. Manage surgical drains. Surgical drains may be necessary if an abscess or perforation is present before surgery can be safely completed. The nurse is responsible for monitoring drain output and alerting the provider to abnormalities. 5. Ensure that the patient will not receive laxatives or enemas. Administration of enemas and laxatives can cause perforation of the appendix, disrupting gastrointestinal tissue perfusion. | Patient remained free from gastrointestinal complications from appendicitis like peritonitis, abscess formation, and sepsis. Patient maintained active bowel sounds in all quadrants |
| Subjective Data: Verbalizes increased Thirst and feels like nausea and vomiting Objective Data: -Vomiting -Diarrhoea -Loss of appetite -NPO status | Risk For Deficient Fluid Volume related to Vomiting and Diarrhoea as evidenced by NPO status | Patient will maintain an adequate fluid balance as evidenced by stable vital signs and adequate urine output. Patient will report an absence of vomiting or diarrhoea by discharge. | 1. Administer IV fluids. Replacing fluids lost through vomiting or diarrhoea will be an initial intervention. The patient may also be prescribed NPO status and will not be able to take in oral fluids. 2. Administer antiemetics. Nausea and vomiting are common symptoms of appendicitis and also contribute to pain and discomfort along with fluid loss. An antiemetic can prevent further nausea and vomiting. 3. Progress diet as prescribed. After surgery or once symptoms are controlled, the patient will likely start on a liquid diet and then advance as tolerated to bland foods and then a normal diet. Once cleared to consume liquids, the patient should drink plenty of fluids. | Patient maintained an adequate fluid balance as evidenced by stable vital signs and adequate urine output. Patient reported absence of vomiting or diarrhoea by discharge. |