What is the appropriate post-operative care for a young to middle-aged adult immediately after laparoscopic appendectomy?

Nursing SOAP Note: Immediate Post-Laparoscopic Appendectomy

SUBJECTIVE

• Pain Assessment: Document pain level using 0-10 numeric scale at surgical sites (trocar insertion points) and referred shoulder pain from residual CO2 1
• Nausea/Vomiting: Ask about presence and severity, as this affects oral intake timeline 1
• Urinary Function: Inquire about ability to void if Foley catheter removed 1
• Mobility Tolerance: Ask about dizziness or lightheadedness with position changes 1

OBJECTIVE

Vital Signs Monitoring

• Respiratory rate, heart rate, blood pressure, oxygen saturation - monitor every 15 minutes initially, then per protocol 1
• Core temperature - maintain normothermia and monitor for fever indicating potential intra-abdominal abscess 1
• Level of consciousness and neurological status - assess orientation and alertness 1
• Red flags: Persistent tachycardia, hypotension, or signs of shock require immediate intervention 1

Surgical Site Assessment

• Trocar site inspection: Examine all laparoscopic port sites for bleeding, hematoma formation, or early signs of infection 1
• Abdominal examination: Assess for distension, bowel sounds, and tenderness beyond expected post-operative discomfort 1
• Note: Wound infection rates are significantly lower with laparoscopic approach compared to open surgery 1

Cardiovascular/Respiratory

• Cardiac monitoring: Watch for atypical presentations of serious complications in first 24 hours 1
• Respiratory effort: Ensure adequate oxygenation and incentive spirometry use 1

Genitourinary

• Foley catheter: Remove within 24 hours in majority of cases, individualize only for high-risk urinary retention patients 1
• Urine output: Monitor adequacy if catheter in place 1

Activity Level

• Mobilization status: Patient should achieve 30 minutes of mobilization on day of surgery 1
• Ambulation tolerance: Document distance walked and any assistance required 1

ASSESSMENT

Uncomplicated Appendicitis (if applicable)

• Expected course: Patient should tolerate regular diet quickly and have minimal complications 1
• Antibiotic status: Single preoperative dose is standard; no postoperative antibiotics required 2
• Oral intake: Offer oral fluids as soon as patient is lucid; advance to solid foods within 4 hours postoperatively 1

Complicated Appendicitis (if applicable - perforation/abscess)

• Extended monitoring needed: Recovery extends to 4-6 weeks with longer hospitalization required 1
• Antibiotic continuation: Continue for maximum 3-5 days postoperatively with adequate source control 1
• NPO considerations: Maintain NPO status longer if signs of ileus develop, typically 24-72 hours depending on severity 2
• Higher complication risk: Monitor closely for intra-abdominal abscess (1-3% incidence) and prolonged ileus 1

Complication Surveillance

• Intra-abdominal abscess indicators: Fever with abdominal pain beyond 48 hours, inability to tolerate oral intake beyond expected timeframe 1
• Ileus signs: Abdominal distension, absent bowel sounds, nausea/vomiting 2

PLAN

Pain Management

• First-line: Combination of oral paracetamol and NSAIDs 1
• Second-line: Add non-opioid adjuncts as needed 1
• Last resort: Opioid-containing medications in low doses only 1
• Rationale: Multimodal opioid-sparing analgesia reduces opioid consumption without increasing pain scores 3

Nutrition Protocol

• Uncomplicated cases: Offer oral fluids immediately when lucid, advance to solid foods within 4 hours 1
• Complicated cases: Begin clear liquids cautiously once ileus resolves (24-72 hours postoperatively depending on severity) 2

Mobilization Requirements

• Day of surgery: 30 minutes of mobilization mandatory 1
• Subsequent days: 6 hours per day mobilization to reduce complications and accelerate recovery 1

Catheter Management

• Remove Foley within 24 hours unless patient at high risk for urinary retention 1

VTE Prophylaxis

• Mechanical: Compression stockings and/or intermittent pneumatic compression 1
• Pharmacologic: Low molecular weight heparin or unfractionated heparin 1

Antibiotic Management

• Uncomplicated: No postoperative antibiotics needed 2
• Complicated: Continue for 3-5 days maximum with adequate source control 1

Monitoring Schedule

• First 24 hours: Intensive monitoring for cardiac complications and vital sign instability 1
• Beyond 48 hours: If fever persists with abdominal pain, suspect intra-abdominal abscess 1
• Oral intake tolerance: Inability to tolerate beyond 24-48 hours requires prompt attention 1

Discharge Planning Considerations

• Uncomplicated cases: May be candidates for same-day discharge if clinically stable 4
• Complicated cases: Require longer hospitalization with closer monitoring 1