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NURS 1102 Fundamentals of Nursing-SaraLin Clinical Worksheets Deep Patel

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vSim for Nursing | Fundamentals CONCEPT MAP WORKSHEET: Sara Lin – Pain Management CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) D... IAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) Ultrasonography may show appendiceal inflammation. CT scan demonstratessuspected perforation or abscess. WBCs to see elevation = signs of infection PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS - Low-grade fever, diaphoresis, chills - Anorexia - Tachycardia - Fetal position to decrease pain - Guarding, voluntary and involuntary - Rightlower quadrant tenderness - Rovsing sign - Psoas sign - Obturatorsign ANTICIPATED NURSING INTERVENTIONS - pain assessment - transition Sara to oral medications - educate on incision care - educate on pain medication and antibiotics - educate on signs of infection - educate on activity restrictions - educate on surgical follow-up - Encourage the patient to ambulate - Encourage the patient to cough while splinting the abdomen, to breathe deeply, and to change positions frequently. - Auscultate for bowelsounds in all four quadrants. - Inspect the abdomen for distention - Perform surgicalsite dressing changes, as ordered. Also inspect surgicalsite dressing Appendecitis: - Inflammation of the vermiform appendix, a bulge from the apex of the cecum - Mucosal ulceration triggersinflammation, which temporarily obstructs the appendix. - Obstruction with stool, tumors, or foreign bodies causes mucus outflow, increasing pressure in the distended appendix; the appendix then contracts. Fluids and mucus continue to be secreted and stagnate. - Bacteria multiply and inflammation and pressure increase, restricting blood flow and causing thrombus, abdominal pain, and ischemia to the wall of the appendix Patient is postoperative from her appendectomy*** [Show More]

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