Week 8: Appendicitis, Alcohol Withdrawal Flashcards
What are the 2 main causes of appendicitis?
occlusion of the appendiceal lumen by a fecalith (accumulated feces) or intramural thickening caused by hypergrowth of lymphoid tissue
What are the clinical manifestations of appendicitis?
How is it diagnosed?
-Periumbilical pain (RLQ/ McBurney point), anorexia, N&V
Localized tenderness, rebound tenderness and muscle guarding
Low grade fever
-CT scan or ultrasound
What is the Rovsing sign?
Palpation of the LLQ causing pain to be felt in the RLQ
What is the blumberg sign?
Pain upon removal of pressure rather than application of pressure to the abdomen (rebound tenderness)
What are possible complications of appendicitis?
Perforation, perionitis, abscess
What is the treatment of appendicitis?
Appendectomy
-if the appendix has ruptured, and there is evidence of peritonitis or an abscess, antibiotics and parenteral fluids may be used to prevent sepsis and dehydration for 6-8 hours before an appendectomy
When do S&S of alcohol withdrawal appear and for how long do they last?
S&S of withdrawal generally begin 6-12 hours after the last drink, and may last for 3-5 days
What are S&S of alcohol withdrawal?
tremors, N&V, anxiety, sweating, hyper reflexia, agitation, insomnia, increased HR and BP
What are possible complications of alcohol withdrawal?
Alcohol-withdrawal delirium
Death may be caused by hyperthermia, peripheral vascular collapse or cardiac failure
What is Wernick’s Encephalopathy?
inflammatory, hemorrhagic, degenerative condition of the brain caused by a thiamine deficiency resulting from poor diet and alcohol-induced suppression of thiamine absorption.
If untreated, can lead to irreversible amnesia
What benzodiazepine antagonist can be used in the case of overdose?
What other interventions can be initiated?
-Flumazenil
-gastric lavage, activated charcoal
What are the S&S of benzodiazepine overdose?
Agitation, confusion, lethargy, stupor, slurred speech, nystagmus, slow or rapid shallow respirations, hypotension
What are the S&S of opioid withdrawal?
craving, abdominal cramps, diarrhea, N&V, flu-like symptoms
peaks 2 to 3 days after last use, resolves by days 5 to 7
What are the S&S of opioid overdose?
pinpoint pupils, clammy skin, depressed respirations, and decreased LOC that may lead to coma and death
What drugs can be used in management of opioid withdrawal?
Methadone or Buprenorphine
What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?
A. Risk for injury R/T central nervous system stimulation
B. Disturbed thought processes R/T tactile hallucinations
C. Ineffective coping R/T powerlessness over alcohol use
D. Ineffective denial R/T continued alcohol use despite negative consequences
ANS: A
The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.
A nurse evaluates a client’s patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance dependence?
A. Narcotic pain medication is contraindicated for all clients with active substance-abuse problems.
B. Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control.
C. There is no need to assess the client for substance dependence. There is an obvious PCA malfunction.
D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.
ANS: B
The nurse should assess the client for substance dependence because clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics, and require increased doses to achieve effective pain control. Cross-tolerance occurs when one drug lessened the client’s response to another drug.
On the first day of a client’s alcohol detoxification, which nursing intervention should take priority?
A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days.
B. Educate the client about the biopsychosocial consequences of alcohol abuse.
C. Administer ordered lorazepam in a dosage according to protocol.
D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.
ANS: C
A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediate report to the ED physician?
A. Tactile hallucinations
B. Blood pressure of 180/100 mm Hg
C. Mood rating of 2/10 on numeric scale
D. Dehydration
ANS: B
The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption.
Upon admission for symptoms of alcohol withdrawal a client states, “I haven’t eaten in 3 days.” Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis?
A. Knowledge deficit
B. Fluid volume excess
C. Imbalanced nutrition: less than body requirements
D. Ineffective individual coping
ANS: C
The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.
A client telephones the health clinic with complaints of generalized abdominal pain which is aggravated by moving or walking. The client has not been able to eat for a day and is nauseated. Which advice should the nurse provide to this client?
A. “Take a warm shower and apply a heating pad to the abdomen.”
B. “Rest in bed and drink warm fluids.”
C. “Seek immediate medical attention.”
D. “Take an over-the-counter laxative.”
ANS: C
Which clinical manifestation does the nurse expect with acute appendicitis?
A. High fever
B. Nausea and vomiting
C. Rebound tenderness
D. Pain relieved with ambulation
ANS: C
Which condition may occur if the client does not seek medication attention for acute appendicitis within 24-36 hours? (Select all that apply.)
A. Seizure
B. Constipation
C. Nausea
D. Peritonitis
E. Perforation
Answer: D, E
Rationale: If treatment is not initiated, tissue necrosis and gangrene result within 24-36 hours, leading to perforation (rupture). Perforation allows the contents of the gastrointestinal (GI) tract to flow into the peritoneal space of the abdomen, resulting in peritonitis. Appendicitis does not cause seizures, nausea, or constipation.
A teenage boy presents with suspected appendicitis. The caregiver asks, “Why did my son get this?” Which response by the nurse is the most appropriate?
A. “Your son has been eating too much fiber.”
B. “Your son is eating too many fruits and vegetables.”
C. “Your son has not been getting enough exercise.”
D. “Your adolescent son is in an at risk group.”
Answer: D
Rationale: Adolescent boys are at greatest risk for appendicitis. Appendicitis cannot be prevented, but certain dietary habits may reduce the risk of developing this condition. Eating foods that contain high fiber content, such as fresh fruits and vegetables, decreases the incidence of appendicitis.
Appendicitis almost always results from an obstruction in the appendiceal lumen. Which problem should the nurse identify as the cause of this obstruction?
A. Monolith
B. Fecalith
C. Tonsillolith
D. Ptyalith
Answer: B
Rationale: The obstruction is often caused by a hard mass of feces (fecalith). Ptyalith is a calculus in the salivary gland. Tonsillolith is a calculus in the tonsil. A monolith is a large stone used in sculpture.
A teenage girl is being assessed for the possibility of appendicitis. Which other condition should the nurse consider? (Select all that apply.)
A. Pelvic inflammatory disease
B. Ovulation
C. Menstruation
D. Urinary tract infection
E. Ruptured ectopic pregnancy
Answer: A, B, E
Rationale: In adolescent and young women, symptoms must be differentiated from those associated with ovulation, ruptured ectopic pregnancy and pelvic inflammatory disease. Although a urinary tract infection may cause abdominal pain, it typically does not present in the same way as appendicitis. Menstruation does not have the same symptoms as appendicitis.
For which collaborative therapy for peritonitis following a ruptured appendix should the nurse prepare the client? (Select all that apply.)
A. Antibiotics
B. A low-fat, high-calorie diet
C. Passive range of motion
D. Fluid resuscitation
E. Surgery
Answer: A, D, E
Rationale: Clinical therapies for the treatment of peritonitis include removal of the ruptured appendix, antibiotics, and fluid resuscitation. A low-fat, high-calorie diet and passive range of motion are not therapies used to treat peritonitis after a ruptured appendix.
The nurse is caring for a client admitted for a ruptured appendix. Which information should the nurse expect to provide to this client? (Select all that apply.)
A. A laparotomy will be performed.
B. Intravenous fluids will be provided.
C. Antibiotic medication will be provided before and after the surgery.
D. Pain medication will be provided after the surgery.
E. A laparoscopic appendectomy will be performed.
Answer: A, B, C, D
Rationale: For a ruptured appendix, a laparotomy will be performed. The client will receive antibiotics before and after the surgery to prevent the development of infection from fecal contents, which have spilled into the abdominal cavity. Intravenous fluids will be provided to maintain fluid and electrolyte balance. Pain medication will be provided after the surgery. A laparoscopic appendectomy is performed for clients whose appendix has not ruptured.
A client with acute appendicitis asks the nurse, “Why don’t you give me a heating pad? I think that will help me with my pain.” The nurse’s response should be based on which reason?
A. It increases the need for fluids.
B. It increases the spread of infection.
C. It reduces white blood cell count.
D. It encourages perforation.
ANS: D
The nurse is evaluating a client recovering at home after an emergency appendectomy. Which observation indicates that self-care has been effective? (Select all that apply.)
A. The client snacks on pretzels and club soda during the visit.
B. The client plans to recover at home until cleared by the surgeon.
C. The client uses a pillow to splint the incision before coughing.
D. The client performs abdominal wound care appropriately.
E. The client requests a prescription for more pain medication.
Answer: B, C, D
Rationale: Observations that indicate that the client is appropriately providing self-care after an appendectomy include using a pillow to splint the incision before coughing, performing wound care appropriately, and planning to recover at home until cleared by the surgeon. Observations that indicate that self-care could improve include the need for more pain medication and ingesting a less-than-nutritious snack.
The nurse is preparing to conduct a physical examination on a client diagnosed with appendicitis. Which intervention should the nurse include in this assessment? (Select all that apply.)
A. Characteristics of bowel sounds
B. Presence of abdominal pain on palpation
C. Presence of blood in the stool
D. Contour of the abdomen
E. Current body temperature
Answers: A, B, D, E
Rationale: When conducting the physical assessment on a client with appendicitis, the nurse should include abdominal contour, current body temperature, characteristics of bowel sounds, and whether the client is experiencing tenderness to light palpation. Blood in the stool is not an area to assess in the client with appendicitis.
Where is the appendix?
RLQ, below the cecum
What are the S&S that an appendix has ruptured?
Pain is more diffuse, and distention develops as result of paralytic ileus
Define Appendicitis
Inflammation of appendix, commonly caused by occlusion of the appendiceal
What are S&S of periostitis?
abdominal tenderness, rigidity; fever, vomiting & tachycardia
What interventions are initiated post-appendectomy?
What teaching should the nurse provide
Position in high Fowler’s to reduce tension on incision
Manage pain- opiates
Fluids, food as tolerated when bowel sounds return on day of surgery
Teaching
Follow-up appointment 5- 7 days for suture removal
Incision care guidelines reviewed
No heavy lifting but can resume usually activities within 2- 4 weeks
