QLexNursing

Effective coping with illness-related anxiety

📌 The client verbally reports anxiety, which is common in young adults presenting to the ED with sudden-onset abdominal pain and pending surgery.

📌 Providing emotional support and reassurance promotes psychological stability and reduces sympathetic overdrive.

📌 Anxiety may also exacerbate pain perception and impair cooperation with treatment or consent.

📌 Including a psychosocial goal supports a holistic care plan, in line with the nursing model of whole-person care.

📌 Effective coping enhances recovery and satisfaction with care, especially in unfamiliar, acute care settings.

Infection prevention related to illness

📌 The CT scan shows a dilated appendix with fat stranding, consistent with acute appendicitis—an inflammatory condition with high infection risk.

📌 If untreated or delayed, this may progress to perforation and peritonitis, which are life-threatening.

📌 Early interventions such as IV antibiotics and fluid resuscitation help reduce this risk preoperatively.

📌 Infection prevention also includes monitoring vital signs, white blood cell trends, and surgical prep.

📌 Preventing infection is a priority nursing goal during emergency stabilization of surgical abdominal pain.

Relief of acute pain

📌 The client reports a pain score of 9/10, located in the right lower quadrant, a hallmark of appendicitis.

📌 Morphine 4 mg IV was ordered STAT, and timely administration is critical to ensure comfort and physiologic stability.

📌 Severe pain can increase tachycardia, tachypnea, and emotional distress, interfering with assessment and procedures.

📌 Relieving pain supports better breathing, lowers stress response, and aids in diagnostic cooperation (e.g., imaging).

📌 Pain control is an essential nursing focus in the ED setting, particularly for surgical cases.

Fluid volume management

📌 The client is receiving a 1-liter bolus of Lactated Ringer’s, ordered to correct relative hypovolemia from vomiting, fever, and possible early sepsis.

📌 She is tachycardic (HR 121 bpm) and tachypneic (RR 28/min), both of which are signs of fluid volume deficit or early shock.

📌 Maintaining intravascular volume ensures adequate perfusion to vital organs, including during anesthesia and surgery.

📌 Monitoring for response (BP, HR, urine output) is essential to guide further fluid needs or resuscitation.

📌 Fluid management reduces risk of hypotension during OR transfer and promotes stabilization.

Client education about diagnosis and plan of care

📌 The nurse must educate the client on what has been found (appendicitis), what it means, and what to expect next (surgery).

📌 Providing clear, calm, age-appropriate explanations helps reduce anxiety and promote informed cooperation.

📌 Education supports consent, understanding of labs, imaging, and expectations for admission.

📌 It also prepares the client for perioperative care, fasting, and procedural prep.

📌 This communication improves patient satisfaction, trust, and outcomes, especially in young adults.