Risk for infection related to the surgical incision
OUTCOMES. Immune status; Knowledge: Infection control; Risk control; Risk detection;
Tissue integrity: Skin; Nutritional status
INTERVENTIONS. Infection control; Infection protection; Medication prescribing; Surveil- lance; Wound care; Nutritional management; Fluid/electrolyte management
PLANNING AND IMPLEMENTATION Collaborative
SURGICAL. An appendectomy (surgical removal of the appendix) is the preferred method of management for acute appendicitis if the inflammation is localized. An open appendectomy is completed with a transverse right lower quadrant incision, usually at the McBurney point. A laparoscopic appendectomy may be used in females of childbearing age, those in whom the diagnosis is in question, and for obese patients. If the appendix has ruptured and there is evi- dence of peritonitis or an abscess, conservative treatment consisting of antibiotics and intra- venous (IV) fluids is given 6 to 8 hours prior to an appendectomy. Generally, an appendectomy is performed within 24 to 48 hours after the onset of symptoms under either general or spinal anesthesia. Preoperative management includes IV hydration, antipyretics, antibiotics, and, after definitive diagnosis, analgesics.
POSTOPERATIVE. Postoperatively, patient recovery from an appendectomy is usually uncomplicated, with hospital discharge in 24 to 48 hours (sometimes sooner depending on the 100 Appendicitis
General Comments:Note that the diagnosis of appendicitis is made by clinical evalua- tion with the diagnostic tests of secondary importance. Prior to radiography, complete a pregnancy test on women who might be pregnant.
Abnormality with
Test Normal Result Condition Explanation
Diagnostic Highlights
Complete blood
count Adult males and
females 4500–11,000/µL
Infection and inflammation may elevate the WBC count
Leukocytosis may range from 10,000 to 16,000/µL. Neutrophil count is frequently elevated above 75%. In 10% of cases, leukocyte and differential cell counts are normal.
Other Tests: Flat-plate abdominal x-ray to confirm the diagnosis; urinalysis in 25%–40%
of people with appendicitis indicates pyria, albumininuria, and hematuria; serum elec- trolytes, blood urea nitrogen, and serum creatinine identify dehydration; abdominal ultrasound (particularly useful in women to rule out gynecological causes); abdominal computed tomography (CT) scan; barium enema; diagnostic laparoscopy.
technique). The development of peritonitis complicates recovery, and hospitalization may extend 5 to 7 days. The physician generally orders oral fluids and diet as tolerated within 24 to 48 hours after surgery.
Prescribed pain medications are given by the intravenous or intramuscular routes until the patient can take them orally. Antibiotics may continue postoperatively as a prophylactic meas- ure. Ambulation is started the day of surgery or the first postoperative day.
Appendicitis 101
Medication or
Drug Class Dosage Description Rationale
Pharmacologic Highlights
Crystalloid intra- venous fluids
Antibiotics
100–500 mL/hr of IV, depending on volume state of the patient
Varies with drug
Isotonic solutions such as normal saline solu- tion or lactated Ringer’s solution
Broad-spectrum antibiotic coverage
Replaces fluids and elec- trolytes lost through fever and vomiting; replacement continues until urine output is 1 cc/kg of body weight and electrolytes are replaced
Controls local and systemic infection and reduces the incidence of postoperative wound infection Other Drugs: Analgesics.
Independent
PREOPERATIVE. Preoperatively, several nursing interventions focus on promoting patient comfort. Avoid applying heat to the abdominal area, which may cause appendiceal rupture. Per- mit the patient to assume the position of comfort while maintaining bedrest. Reduce the patient’s anxiety and fear by carefully explaining each test, what to expect, and the reasons for the tests.
Answer the patient’s questions concerning the impending surgery, and provide the patient with instructions regarding splinting the incision with pillows during coughing, deep breathing, and moving.
POSTOPERATIVE. Postoperatively, assess the surgical incision for adequate wound healing.
Note the color and odor of the drainage, any edema, the approximation of the wound edges, and the color of the incision. Encourage the patient to splint the incision during deep-breathing exer- cises. Assist the patient to maintain a healthy respiratory status by encouraging deep breathing and coughing 10 times every 1 to 2 hours for 72 hours. Turn the patient every 2 hours, and con- tinue to monitor the breath sounds. Encourage the patient to assume a semi-Fowler position while in bed to promote lung expansion.
DOCUMENTATION GUIDELINES
• Location, intensity, frequency, and duration of pain
• Response to pain medication, ice applications, and position changes
• Patient’s ability to ambulate and tolerate food
• Appearance of abdominal incision (color, temperature, intactness, drainage)
DISCHARGE AND HOME HEALTHCARE GUIDELINES
MEDICATIONS. Be sure the patient understands any pain medication prescribed, including doses, route, action, and side effects. Make certain the patient understands that he or she should avoid operating a motor vehicle or heavy machinery while taking such medication.
102 Arterial Occlusive Disease
DRG Category: 130 Mean LOS: 5.8 days
Description: MEDICAL: Peripheral Vascular Disorders with CC
DRG Category: 478 Mean LOS: 6.3 days
Description: SURGICAL: Other Vascular Procedures with CC
Arterial Occlusive Disease
A
rterial occlusive disease, and in particular peripheral arterial occlusive disease (PAOD), is characterized by reduced blood flow through the major blood vessels of the body because of an obstruction or narrowing of the lumen of the aorta and its major branches. Changes in the arte- rial wall include the accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue in the endothelial lining. Arterial occlusive disease, which may be chronic or acute, may affect the celiac, mesenteric, innominate, subclavian, carotid, and vertebral arteries.Arterial disorders that may lead to arterial obstruction include arteriosclerosis obliterans, throm- boangiitis obliterans, arterial embolism, and an aneurysm of the lower extremity. A sudden occlusion usually causes tissue ischemia and death, whereas a gradual blockage allows for the development of collateral vessels. Usually, arterial occlusive diseases are only part of a complex disease syndrome that affects the entire body. Complications include severe ischemia, skin ulceration, gangrene, leg amputation, and sepsis.
CAUSES
Arteries can become occluded by atherosclerotic plaque, thrombi, or emboli. The most common cause of acute arterial insufficiency is embolization, with cardiac sources accounting for more than 70% of emboli. Subsequent obstruction and damage to the vessels can follow chemical or mechan- ical trauma and infections or inflammatory processes. Arteriosclerosis obliterans is marked by plaque formation on the intimal wall of medium-sized arteries, causing partial occlusion. In addi- tion, there is calcification of the media and a loss of elasticity that predisposes the patient to dila- tion or thrombus formation. Thromboangiitis obliterans (Buerger disease), which is characterized by an inflammatory infiltration of vessel walls, develops in the small arteries and veins (hands and feet) and tends to be episodic. Risk factors include hyperlipidemia, hypertension, and smoking.
INCISION. Sutures are generally removed in the physician’s office in 5 to 7 days. Explain the need to keep the surgical wound clean and dry. Teach the patient to observe the wound and report to the physician any increased swelling, redness, drainage, odor, or separation of the wound edges. Also instruct the patient to notify the doctor if a fever develops. The patient needs to know these may be symptoms of wound infection. Explain that the patient should avoid heavy lifting and should question the physician about when lifting can be resumed.
COMPLICATIONS. Instruct the patient that a possible complication of appendicitis is peri- tonitis. Discuss with the patient symptoms that indicate peritonitis, including sharp abdominal pains, fever, nausea and vomiting, and increased pulse and respiration. The patient must know to seek medical attention immediately should these symptoms occur.
NUTRITION. Instruct the patient that diet can be advanced to her or his normal food pattern as long as no gastrointestinal distress is experienced.
GENETIC CONSIDERATIONS
Familial forms of arterial occlusive disease have been reported and genetic risk factors may con- tribute to the various subtypes of vascular disease. A locus strongly linked to the disease has been identified on chromosome 1.
GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS
Thromboangiitis obliterans, a causative factor for arterial occlusive disease, typically occurs in male smokers between the ages of 20 and 40. Arterial insufficiency usually occurs in individu- als over 50 years of age, and is more common in men than women. PAOD affects 20% of people over 70 years of age in the United States. Ethnicity and race have no known effect on the risk of most arterial occlusive diseases.
Buerger disease is less common in people of European descent, but people from India, Korea, and Japan, and Israeli Jews of Ashkenazi descent have the highest incidence of the disease. It is more common in men as contrasted with women, and most typically occurs between ages 20 to 45 years.
ASSESSMENT
HISTORY. Elicit a history of previous illnesses or surgeries that were vascular in nature; ask if the patient has been diagnosed with arterial occlusive disease in the past. Determine if a positive family history exists for hypertension or vascular disorders in first-order relatives. Ask if the patient smokes cigarettes; eats a diet high in fats; leads a sedentary lifestyle; or is subject to emo- tional stress, anxiety, or ulcers. Determine if the patient has experienced any pain, swelling, red- ness, or pallor. Establish a history of signs and symptoms that may point to the site of occlusion.
Determine if the patient has experienced any transient ischemic attacks (TIAs) because of reduced cerebral circulation. Elicit a history of such signs and symptoms as unilateral sensory or motor dysfunction, difficulty in speaking (aphasia), confusion, difficulty with concentration, or headaches, all of which are signs of possible carotid artery involvement. Ask if the patient has experienced signs of vertebrobasilar artery involvement, such as binocular visual disturbances, vertigo, dysarthria, or episodes of falling down. Determine if the patient has experienced lame- ness in the right arm (claudication), which is a sign of possible innominate artery involvement.
The specific finding in PAOD is intermittent claudication. The pain is insidious in onset, occurring with exercise and relieved by resting for 2 to 5 minutes; determining how much phys- ical activity is needed before the onset of pain is crucial. The onset of pain is often related to a particular walking distance in terms of street blocks, helps to quantify patients with some stan- dard measure of walking distance before and after therapy.
Determine if the patient’s mesenteric artery is involved by asking if he or she has experienced acute abdominal pain, nausea, vomiting, or diarrhea. Ask the patient if she or he has experienced numbness, tingling (paresthesia), paralysis, muscle weakness, or sudden pain in both legs, which are all signs of aortic bifurcation occlusion. Determine if the patient has experienced sporadic claudication of the lower back, buttocks, and thighs or impotence in male patients, all of which are indicators of iliac artery occlusion. Elicit a history of sporadic claudication of the patient’s calves after exertion; ask if the patient has experienced pain in the feet—these are signs of femoral and popliteal artery involvement.
PHYSICAL EXAMINATION. Observe both legs, noting alterations in color or temperature of the affected limb. Cold, pale legs may suggest aortic bifurcation occlusion. Inspect the patient’s legs for signs of cyanosis, ulcers, or gangrene. Limb perfusion may be inadequate, resulting in thickened and opaque nails, shiny and atrophic skin, decreased hair growth, dry or fissured heels, and loss of subcutaneous tissue in the digits. Check the patient’s skin on a daily basis.
The most important part of the examination is palpation of the peripheral pulses. Absence of a normally palpable pulse is the most reliable sign of occlusive disease. Comparison of pulses in both extremities is helpful. Ascertain, also, whether the arterial wall is palpable, Arterial Occlusive Disease 103
tortuous, or calcified. Auscultation over the main arteries is useful, as a bruit (sound produced by turbulent flow of blood through an irregular or stenotic lumen) often indicates an atheroma- tous plaque. A bruit over the right side of the neck is a possible indication of innominate artery involvement.
PSYCHOSOCIAL. Occlusive diseases are chronic or lead to chronic illness. They are usually slow in onset, and much irreversible vascular damage may have occurred before symptoms are severe enough to bring the patient for treatment. Treatment is often long and tedious and brings additional concerns regarding finances, curtailment of usual social outlets, and innumerable other problems. Assess the patient’s ability to cope with a chronic illness.
104 Arterial Occlusive Disease