Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?
A.
Fluid volume excess.
B.
Risk for infection.
C.
Ineffective thermoregulation.
D.
Pain.
The Correct Answer and Explanation is:
Correct Answer: A. Fluid volume excess
Explanation:
When assessing and planning care for a patient with appendicitis, certain nursing diagnoses are more pertinent due to the nature of the condition. Appendicitis is an inflammation of the appendix, which can lead to infection, perforation, and severe abdominal pain. The key nursing diagnoses typically include those related to pain, infection, and potential complications associated with these issues.
- Pain: Pain is a primary symptom of appendicitis, often characterized by sharp, localized pain in the lower right quadrant of the abdomen (McBurney’s point). The pain is due to the inflammation of the appendix and irritation of the surrounding peritoneum. Managing this pain is a priority in caring for the patient, making “Pain” a highly relevant nursing diagnosis.
- Risk for infection: Infection is a significant concern with appendicitis, especially if the appendix ruptures. A ruptured appendix can lead to peritonitis, a life-threatening infection of the abdominal cavity. Therefore, monitoring and preventing infection are crucial, making “Risk for infection” another critical nursing diagnosis.
- Ineffective thermoregulation: Patients with appendicitis may develop fever due to the inflammatory response and infection, indicating that the body’s ability to regulate temperature is compromised. This makes “Ineffective thermoregulation” a relevant nursing diagnosis as well, especially if the patient’s temperature is unstable.
- Fluid volume excess: This diagnosis refers to an excessive accumulation of fluid in the body, often related to conditions like heart failure, kidney dysfunction, or excessive fluid intake. In the context of appendicitis, this is the least likely diagnosis because appendicitis typically does not involve fluid overload. Instead, patients might experience fluid volume deficit due to nausea, vomiting, and potential dehydration.
Thus, the nurse would be least likely to choose “Fluid volume excess” as a nursing diagnosis for a patient with appendicitis. The focus would more appropriately be on managing pain, preventing infection, and monitoring for signs of systemic infection or complications.