NUR 242 Unit 7 & 8 Test 2 Outline
Appendicitis: inflammation of appendix
Common causes: infection (most common), trauma/injury
S/S: pain originating
... [Show More] around “belly area”, then localizes in RLQ; Pain increases w/movement, coughing,
bending knees; constipation, N/V, WBC count elevated; low grade temp
Assessment: rebound tenderness is positive in RLQ
Treatment: surgery; pain management, NPO = no peristalsis r/t appendix rupture; begin antibiotics,
surgery prep
Nursing measures: pain management, IV hydration; if NG tube, then suction it/functioning & properly
secured; all post-op nursing care management is r/t whether they had a laparoscopic appendectomy or
an open appendectomy and whether it was ruptured; if ruptured, intensive post-op care of open,
infected wound with drains; pt & family teaching r/t wound & drain care
Complications: peritonitis = if abdominal pain is alleviated, then returns = “red flag for peritonitis”;
distended abdomen then becomes rigid/board-like; pain is relieved when pt pulls knees toward
abdomen/fetal position; progressing signs of shock: tachypnea, tachycardia, drop in BP and O2 sats
GERD: reflux of gastric content into esophagus *usually after a large meal; risk factors: overweight, or
hiatal hernia (anything that effects movement of food); pt positioning becomes “very very” important in
GERD management; looks like severe heartburn; may complain of lump in throat (especially w/hiatal
hernia); may have dry cough, hoarse voice; wakes up at night coughing w/acrid taste in mouth/throat;
higher risk for aspiration = assess for crackles!
Assessment: listen to lungs for crackles (aspiration during sleep)
Lifestyle modifications and diet changes = “bland diet”; restrict fatty spicy foods; sitting upright when
eating & remain for 30 minutes post meal; don’t eat late at night before bed; no restrictive clothing; lose
weight; avoid vigorous exercise/strain; medications
Nursing measures around teaching; prevent attacks of GERD
Complications: esophageal cancer r/t persistent irritation by gastric juices [Show Less]