ELIMINATION

1. Appendicitis: obstruction of appendiceal lumen and subsequent bacterial invasion of appendiceal wall; acute emergency.
   1. Pathophysiology: when obstruction is partial or mild, inflammation begins in mucosa with slight appendiceal swelling, accompanied by periumbilical pain. As the inflammatory process escalates and/or obstruction becomes more complete, the appendix becomes more swollen, the lumen fills with pus, and mucosal ulceration begins. When inflammation extends to the peritoneal surface, pain is referred to the right lower abdominal quadrant. Danger: rigidity over the entire abdomen is usually indicative of ruptured appendix; the patient is then prone to peritonitis.
   2. Risk factors:
      1. Men more than women.
      2. Most frequently seen between age 10 and 30 yr.
   3. Assessment:
      1. Subjective data:
         1. Pain: generalized, then right lower quadrant at McBurney’s point, with rebound tenderness.
         2. Anorexia, nausea.
      2. Objective data:
         1. Vital signs: elevated temperature, shallow respirations.
         2. Either diarrhea or constipation.
         3. Vomiting, fetid breath odor.
         4. Splinting of abdominal muscles, flexion of knees onto abdomen.
         5. Lab data:
            1. WBC elevated (>10,000).
            2. Neutrophil count elevated (>75%).
         6. Diagnostic studies:
            1. Ultrasound.
            2. CT scan.
   4. Analysis/nursing diagnosis:
      1. Pain related to inflammation of appendix.
      2. Risk for trauma related to ruptured appendix.
      3. Knowledge deficit related to possible surgery.
   5. Nursing care plan/implementation:
      1. Goal: promote comfort.
         1. Preoperative:
            1. Explain procedures.
            2. Assist with diagnostic workup.
         2. Postoperative:
            1. Relieve pain related to surgical incision.
            2. Prevent infection: wound care, dressing technique.
            3. Prevent dehydration: IVs, I&O, fluids to solids by mouth as tolerated.
            4. Promote ambulation to prevent postoperative complications.
   6. Evaluation/outcome criteria:
      1. No infection.
      2. Tolerates fluid; bowel sounds return.
      3. Heals with no complications.
      
      
2. Hernia: protrusion of the intestine through a weak portion of the abdominal wall.
   1. Types:
      1. Reducible: visceral contents return to their normal position, either spontaneously or by manipulation.
      2. Irreducible, or incarcerated: contents cannot be returned to normal position.
      3. Strangulated: blood supply to the structure within the hernia sac becomes occluded (usually a loop of bowel).
      4. Most common hernias: umbilical, femoral, inguinal, incisional, and hiatal.
   2. Pathophysiology: weakness in the wall may be either congenital or acquired. Herniation occurs when there is an increase in intraabdominal pressure from coughing, lifting, crying, straining, obesity, or pregnancy.
   3. Assessment:
      1. Subjective data:
         1. Pain, discomfort.
         2. History of feeling a lump.
      2. Objective data:
         1. Soft lump, especially when straining or coughing.
         2. Sometimes alteration in normal bowel pattern.
         3. Swelling.
   4. Analysis/nursing diagnosis:
      1. Activity intolerance related to pain and discomfort.
      2. Risk for trauma related to lack of circulation to affected area of bowel.
      3. Pain related to protrusion of intestine into hernia sac.
   5. Nursing care plan/implementation:
      1. Goal: prevent postoperative complications.
         1. Monitor bowel sounds.
         2. Prevent postoperative scrotal swelling with inguinal hernia by applying ice and support to scrotum.
      2. Goal: health teaching.
         1. Prevent recurrence with correct body mechanics.
         2. Gradual increase in exercise.
   6. Evaluation/outcome criteria: healing occurs with no further hernia recurrence.