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Nursing Diagnosis: Infection, risk for
Risk factors may include
- Inadequate primary defenses; perforation/rupture of the appendix; peritonitis; abscess formation
- Invasive procedures, surgical incision
Desired Outcomes
- Achieve timely wound healing; free of signs of infection/inflammation, purulent drainage, erythema, and fever.
Nursing Priorities
- Prevent complications.
- Promote comfort.
- Provide information about surgical procedure/prognosis, treatment needs, and potential complications.
Discharge Goals
- Complications prevented/minimized.
- Pain alleviated/controlled.
- Surgical procedure/prognosis, therapeutic regimen, and possible complications understood.
- Plan in place to meet needs after discharge.
4 Appendectomy Nursing Care Plan (NCP)
- Acute Pain — Appendectomy Nursing Care Plan (NCP)
- Risk for Deficient Fluid Volume — Appendectomy Nursing Care Plan (NCP)
- Risk for Infection — Appendectomy Nursing Care Plan (NCP)
- Knowledge Deficit — Appendectomy Nursing Care Plan (NCP)
Risk for Infection — Appendectomy Nursing Care Plan (NCP)
| Nursing Interventions | Rationale |
| Practice/instruct in good handwashing and aseptic wound care. Encourage/provide perineal care. | Reduces risk of spread of bacteria. |
| Inspect incision and dressings. Note characteristics of drainage from wound/drains (if inserted), presence of erythema. | Provides for early detection of developing infectious process, and/or monitors resolution of preexisting peritonitis. |
| Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in mentation, reports of increasing abdominal pain. | Suggestive of presence of infection/developing sepsis, abscess, peritonitis. |
| Obtain drainage specimens if indicated. | Gram’s stain, culture, and sensitivity testing isuseful in identifying causative organism and choice of therapy. |
| Administer antibiotics as appropriate. | Antibiotics given before appendectomy are primarily for prophylaxis of wound infection and are not continued postoperatively. Therapeutic antibiotics are administered if the appendix is ruptured/abscessed or peritonitis has developed. |
| Prepare for/assist with incision and drainage (I&D) if indicated. | May be necessary to drain contents of localized abscess. |
Found through:
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