REFERENCE CARE PLAN: Appendectomy, Non-Ruptured

REFERENCE CARE PLAN: Appendectomy, Non-Ruptured PATIENT POPULATION This care plan is intended for pediatric patients who have received an appendectomy for non-ruptured appendicitis. Hospital stay for these patients is usually 24-36 post-surgery.

DEFINITIONS Appendix - A small, finger-shaped pouch. The appendix is located at the base of the cecum, near the ileocecal valve where the taenia coli converge on the cecum. The appendix is a true diverticulum of the cecum. The attachment of the appendix to the base of the cecum is constant1. Appendicitis - Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts. Despite diagnostic and therapeutic advancement in medicine, appendicitis remains a clinical emergency and is one of the more common causes of acute abdominal pain. An appendectomy may be required for patients who have non-ruptured appendix. Appendectomies may be completed through laparoscopic or open approach6; Non-ruptured appendix surgeries are typically performed laparoscopically. Most patients leave the hospital within 24–36 hours after surgery2. Appendectomy - The surgical removal of the appendix, a small finger-shaped pouch extending from the inferior large intestine. An appendectomy is performed to treat appendicitis3. Laparoscopic Approach - Laparoscopic appendectomy may be performed using a three port (three incisions) or single incision technique. The three incision technique involves incisions in the left lower quadrant, the umbilicus, and above the symphysis pubis3. Laparotomy (Open) Approach - In an open appendectomy, a small incision is made in the right lower quadrant (RLQ) of the abdomen, the abdominal muscles are separated, and the appendix is removed while the patient is under general anesthesia; and in the supine position1. Antibiotic Therapy – In some cases, patients can be treated with intravenous (IV) antibiotics alone, without surgical removal of the appendix.

Established: Mar-07-2016 Reviewed/Revised: Mar-08-2017

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REFERENCE CARE PLAN: Appendectomy, Non-Ruptured Problem/Potential Problem

Alteration in comfort related to surgical procedure

Objectives Patient will remain comfortable post-op

Anticipatory/Therapeutic Nursing Interventions ● ● ● ●

Alteration in fluid balance related to surgery: Pre-op, nausea, NPO, vomiting.

Maintain optimal fluid balance

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Potential for bleeding or infection

Patient will remain free of infection

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Assess and document pain q4h and PRN using an age and developmentally appropriate pain scale. Administer analgesic as ordered PRN. Consider providing patient with around-the-clock analgesia for the first 2448hours post-operatively. Assess effectiveness of analgesic 30-45 minutes post administration. If ordered analgesic is ineffective, contact appropriate services.

Evidence-base/Rationale - Establishing a painmanagement plan based on the findings from the assessment and incorporating the person’s beliefs and goals is important for 10 minimizing pain and distress . - Unrelieved acute pain can cause long-term pain problems 10 that affect body functioning .

Maintain IV as orders. Check site q1h and PRN. Advance diet as ordered/tolerated. Asses and document accurate intake and output q1-4h and PRN. Administer anti-emetics as ordered PRN. Replace NG losses as ordered. Assess lab values including: ○ CBC ○ Electrolytes; etc. Monitor for signs and symptoms of dehydration including: level of consciousness, and respiratory and mental health 1 status .

- Optimal fluid balance is important to facilitate regulation of body function and wound 11 healing .

Check vital signs post-op as per BCCH policy. ○ Assess incision with vital signs ○ Assess abdomen and bowel sounds with vital signs then every shift once bowl sounds present. Check surgical site with dressing change and PRN. Frequently assess the wound, dressings, and drains, if 1 present . Change surgical incision dressing as per BCCH policy

- Frequent assessments are useful for early detection of wound infection, which leads to quicker treatment and decreases the risk of 11 septicemia .


- Dehydration can cause headaches, tiredness and loss of concentration and slow 1 healing . - Fluid imbalances lead to imbalance of electrolyte and decrease the body’s ability to 11 function properly .

- Frequent assessments also can detect any potential 11 impairment of wound healing .


Potential for respiratory complications and/or infection

Objectives Patient will remain free of respiratory infection

Anticipatory/Therapeutic Nursing Interventions ● ● ●

● ● ●

Anxiety and disturbance of selfconcept due to diagnosis and illness

Patient/family will demonstrate positive coping skills in response to their condition and hospitalization prior to discharge

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Assess chest by auscultation with vitals. Access RT or PT to assist with suctioning PRN. Mobilization: ○ Sit at the edge of bed for a few minutes after surgery if possible. ○ Up to sit in chair post-op day 1 ○ Refer to physiotherapy PRN Assist in repositioning q2h and PRN Encourage deep breathing and coughing q1-2h. Educate client and family on how to split operative site with pillow. Encourage early use of incentive spirometry if age and developmentally appropriate.

Orient patient and caregiver(s) to hospital unit and routines. ○ Provide direction to hospital resources, Family Resource Library, and Education Services. Involve patient and caregiver(s) in establishing the nursing care plan on admission; review changes as they occur. Promote autonomy and control by structuring the plan of care with the patient and family at the beginning of the shift. Determine effectiveness of present coping skills; guide patient and caregiver(s) to new ones as needed. Observe patient/caregiver(s) demonstrating home care routines including: bathing, feeding, and activity.

Update care plan PRN with patient-specific needs: __________________________________________________ __________________________________________________ __________________________________________________



Evidence-base/Rationale - Deep breathing and coughing decreases the risk of atelectasis and/or depression of the central respiratory drive, and decreases 11 retained thick secretions . - The use of incentive spirometry decreases the risk of 11 atelectasis . - Early introductive of incentive spirometry significantly reduces the incidence of chest infection, however, the benefit is lost if introduction of spirometry is 12 delayed . - Having open, reliable and timely information available regarding the plan of care for family members and caregivers increases families’ satisfaction 8 with the hospital experience . - Collaboration with Childlife specialists address the emotion needs of pediatric surgical patients and their families, and improve the surgical 15 experience .


Objectives

Anticipatory/Therapeutic Nursing Interventions

Evidence-base/Rationale

Comfort measures for the patient are: __________________________________________________ __________________________________________________ __________________________________________________ While in the hospital, the caregiver(s) would like to be involved with: __________________________________________________ __________________________________________________ __________________________________________________

Patient/family education and discharge planning


Patient and family will state understanding of the diagnosis, treatments and medications and express realistic plans for home care prior to discharge

The patient and family would like referrals to: Social Work Physiotherapy Occupational Therapy Community Nurse Child Life Specialist Psychology Pastoral Care Patient/Caregiver Education: ● Have patient and caregiver(s) explain in their own words basic facts about: nature of condition, symptoms, and treatment ○ Provide a review handouts on condition and medications: “A Handbook for Families” ● Discuss prescribed medications: ○ Purpose, action, side effects, dose and administration and clarify misconceptions. ● Prepare patient and family prior to all tests and procedures; utilize teaching pamphlets and videos as applicable; give rationale.


- Implementing age-appropriate teaching strategies reduces 13 anxiety in pediatric patients . - Children benefit from ageappropriate teaching in a variety of forms, parental involvement in teaching, and ample time to 13 process information . - Families that are discharged without appropriate postoperative teaching experience high levels of worry 14 and higher instances of pain .


Objectives

Anticipatory/Therapeutic Nursing Interventions Discharge/Follow-Up: Begin discharge Post-Op Day 1 – Checklist Ensure appropriate follow-up information is given. Review and give caregiver(s) discharge instruction sheet. Review medications: Teach patient and family/caregiver(s) what to expect post-operatively, including how the postoperative pain will be managed. Advise the patient of possible shoulder pain after laparoscopic surgery caused by the gas used to 1 distend the abdomen Wound care: Teach caregiver(s)/family wound 1 sterilization and dressing care, as appropriate . Indicate clinic/physician follow-up appointment. Review community support services. Review activity restrictions, as indicated by physician. Advise patient that full recovery takes 4–6 weeks, and to avoid strenuous activity and lifting anything over 5 pounds before full recovery. Advise family/caregiver(s) to contact the physician in the event of: • Redness, swelling, increased pain, excessive bleeding, 1 or discharge from the incision site . • Signs of infection (such as fever and chills, cough, shortness of breath, chest pain, severe nausea and vomiting, increased abdominal pain, fainting, or if there 1 is blood in the stool) . • Seek immediate medical attention for new or worsening 1 symptoms .



Evidence-base/Rationale

REFERENCE CARE PLAN: Appendectomy, Non-Ruptured CROSS-REFERENCES BCCH - Prescriber's Orders for: Appendicitis - Postoperative (Pediatric) BCCH – Pre- and Post-Operative Care BCCH - Post-Operative Care of Incisions: Dressing Change

REFERENCES

1. Buckley, L., & Schub, T. (2015). Appendectomy. CINAHL Nursing Guide 2. Craig, S. (2014). Appendicitis. Medscape reference. Retrieved February 20, 2016, from http://emedicine.medscape.com/article/773895-overview 3. UpToDate. (2016). Acute appendicitis in children: Management. Retrieved February 23rd, 2016, from http://www.uptodate.com/contents/acuteappendicitis-in-children-management 4. UpToDate. (2015). Evaluation and management of pain in children. Retrieved February 23rd, 2016, from http://www.uptodate.com/contents/evaluation-and-management-of-pain-inchildren?source=see_link§ionName=Assessment+of+pain+severity+and+cognition&anchor=H5#H5 5. Markar, S.R., Blackburn, S., Cobb, R., Karthikesalingam, A., Evans, J., Kinross, J., Faiz, O. (2012). Laparoscopic versus open appendectomy for complicated and uncomplicated appendicitis in children. Journal of Gastrointestinal Surgery, 16(10), 1993-2004. 6. St Peter S.D., Adibe O.O., Juang D., Sharp, S.W., Garey, C.L., Laituri, C.A., & Ostlie, D.J. (2011). Single incision versus standard 3-port laparoscopic appendectomy: A prospective randomized trial. Annals of Surgery, 254(4), 586-590. 7. Day Care Laparoscopic Appendectomy. (2015). Ambulatory Surgery, 21(4), 170-172. 8. Comp, D. (2011). Improving parent satisfaction by sharing the inpatient daily plan of care: An evidence review with implications for practice and research. Pediatric Nursing, 37(5), 237-242 6p. 9. Alder, A., & Minkes, R.K. (2015). Pediatric appendicitis workup. Retrieved March 1st, 2016, from http://emedicine.medscape.com/article/926795workup#c13 10. Registered Nurses’ Association of Ontario. (2007) Assessment and management of pain. Best Practice Guidelines. Retrieved March 8th, 2016 from: http://rnao.ca/bpg/guidelines/assessment-and-management-pain Established: Mar-07-2016 Reviewed/Revised: Mar-08-2017


REFERENCE CARE PLAN: Appendectomy, Non-Ruptured 11. Lewis, S.M., Dirksen, S.R., Heitkemper, M.M., & Bucher, L. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.). St. Louis: Mosby. 12. Rollins, K.E., Aggarwal, S., Fletcher, A., Knight, A., Rigg, K., Williams, A.R., Bhattacharjya, S. (2014). Impact of early incentive spirometry in an enhanced recovery program after laparoscopic donor nephrectomy. Transplantation Proceedings, 45(4), 1351-1353. doi: 10.1016/j.transproceed.2013.01.036 13. Perry, J.N., Hooper, V.D., & Masiongale, J. (2012). Reduction of preoperative anxiety in pediatric surgery patients using age-appropriate teaching interventions. Journal of PeriAnesthesia Nursing, 27(2), 69-81. doi: 10.1016/j.jopan.2012.01.003 14. Ford, K., Courtney-Pratt, H., & FitzGerald, M. (2012). Post-discharge experiences of children and their families following children’s surgery. Journal Of Child Health Care, 16(4), 320-330 11p. doi:10.1177/1367493512448129 15. Martin, J. A., Lee, T., & Newman, B. (2013). Child Life Specialists in a Pediatric Surgical Setting. Journal Of Perianesthesia Nursing, 28(3), e134 1p. doi:10.1016/j.jopan.2013.04.040



REFERENCE CARE PLAN: Appendectomy, Non-Ruptured

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