Medical Surgical Appendicitis #2

Question

Which nursing intervention being performed by the novice nurse should the charge nurse intervene in a client with severe pain and preparing for an appendectomy? Select all that apply.

Answers

  1. Administration of bisacodyl
    • Rationale:

      This answer is correct because clients with appendicitis do not need to be given laxatives due to the possibility of appendix rupture which can be life-threatening. Other interventions that should be avoided include giving an enema and placing a heating pad on the lower abdomen.

  2. Warm saline enema
    • Rationale:

      This answer is correct because clients with appendicitis do not need to be given a warm saline enema due to the possibility of appendix rupture which can be life-threatening. Other interventions that should be avoided include giving a laxative and placing a heating pad on the lower abdomen.

  3. Initiate lactated ringer IV therapy
    • Rationale:

      This answer is not correct because we want the client to be made NPO and started on IV fluids such as Lactated Ringers to help regulate BP/Pulse (especially if the client is in shock), to administer medications, and regulate fluid balance. However, the charge nurse should intervene if a novice nurse performs interventions such as administration of bisacodyl (a laxative), an enema, or application of a heating pad. These interventions are contraindicated in a client with appendicitis.

  4. Heating pad application
    • Rationale:

      This answer is correct because clients with appendicitis do not need to use a heating pad due to the possibility of appendix rupture which can be life-threatening. Other interventions that should be avoided include giving an enema or a laxative.

  5. Prepare prescribed antibiotics
    • Rationale:

      This answer is not correct because the client with appendicitis can be given antibiotics before/after surgery as prophylactic broad spectrum treatment of the bacteria. However, the charge nurse should intervene if a novice nurse performs interventions such as administration of bisacodyl (a laxative), an enema, or application of a heating pad. These interventions are contraindicated in a client with appendicitis.

Overview

The charge nurse should intervene if a novice nurse performs interventions such as administration of bisacodyl (a laxative), an enema, or application of a heating pad. These interventions are contraindicated in a client with appendicitis and could worsen the problem.

Explanation

Learning Outcomes

Appendicitis is inflammation of the appendix. It presents as pain in the lower right abdomen, nausea, vomiting, decreased appetite, fever, constipation/diarrhea and/or abdominal bloating. For diagnosis, a physical assessment of pain, blood test, and CT scan is used. Once confirmed by CT, an appendectomy is the next step. It is important to visually see the appendix before performing surgery. This will also confirm the appendix has not perforated or ruptured, requiring emergent surgery. An appendectomy is a surgical procedure to remove the appendix and will be performed soon after confirmation of appendicitis since there is a high risk of perforation or rupture in appendicitis. Administration of laxatives, enemas, and application of heat should be avoided since each will cause pressure which can potentially perforate the appendix. Perforation can cause peritonitis, sepsis, and death if immediate surgery does not occur.

Test Taking Tip

Read the question, decide what the question is asking for. When the question is pertaining to the client, choose the answer that would be in the best interest of the client and get them treatment as quickly as possible. While working as a nurse, when in doubt ask for help! Do your research.

Video Rationale