The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes the abdomen is distended and bowel sounds are diminished.
Which is the most appropriate nursing intervention?
A.
Administer the prescribed medication.
B.
Reposition the client and apply a heating pad on the warm setting to the client’s abdomen.
C.
Call the healthcare provider.
D.
Call and ask the operating room team to perform surgery as soon as possible.
The Correct Answer and Explanation is :
The correct answer is C. Call the healthcare provider.
Explanation:
A client with a diagnosis of appendicitis who develops sudden increased abdominal pain, vomiting, a distended abdomen, and diminished bowel sounds may be experiencing a complication such as appendiceal rupture. This is a medical emergency that can lead to peritonitis, a life-threatening infection in the abdominal cavity.
Signs of Appendiceal Rupture:
- Increased pain: The client’s abdominal pain becoming worse is a red flag indicating the potential rupture of the appendix.
- Vomiting: The body’s response to severe abdominal distress often includes vomiting.
- Distended abdomen: This occurs when the abdomen becomes swollen, which may indicate that the appendix has ruptured, causing fluid or gas to accumulate in the abdominal cavity.
- Diminished bowel sounds: These suggest decreased peristalsis, possibly due to inflammation of the peritoneum or paralytic ileus secondary to peritonitis.
Appropriate Nursing Intervention:
- C. Call the healthcare provider: The nurse’s immediate priority is to notify the healthcare provider, as the client’s condition may require urgent surgical intervention. Delaying action could worsen the client’s outcome. If rupture and peritonitis are suspected, emergency surgery might be needed.
Incorrect Answers:
- A. Administer the prescribed medication: Administering medication (e.g., pain relief) may mask symptoms and delay the identification of the complication. Pain medications may also decrease bowel motility, which is dangerous in this scenario.
- B. Reposition the client and apply a heating pad on the warm setting to the client’s abdomen: Applying heat to the abdomen is contraindicated in suspected appendicitis or rupture. Heat can increase blood flow to the area, worsening inflammation and possibly causing the appendix to rupture.
- D. Call and ask the operating room team to perform surgery as soon as possible: Although surgery is likely required, contacting the healthcare provider for an assessment is the first step. The provider may want to assess the client or order further diagnostic tests before proceeding.
In conclusion, the nurse’s priority is to act quickly by notifying the healthcare provider to evaluate the client’s changing symptoms and prevent life-threatening complications.