GEORGE DEWEY MEDICAL COLLEGE

BSN IV Ena Cecilia Evangelista Charmaine Kaye Gayacao Alexander von O. Schoppenthau

October 12, 2011 1 GEORGE DEWEY MEDICAL COLLEGE BSN IV CASE PRESENTATION

Introduction
Patient A, a 15 year old female was diagnosed of an acute appendicitis. According to (Brunner and Suddarths 2010) Appendicitis is the inflammation of the vermiform appendix. The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the cecum just below the ileocecal valve. No definite functions can be assigned to it in humans. The appendix fills with food and empties as regularly as does the cecum, because it is small, it is therefore prone to become obstructed and is particularly vulnerable to infection (appendicitis). Appendicitis is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity. About 7% of the population will have appendicitis at some time in their lives, males are affected more than females, and teenagers more than adults. It occurs most frequently between the age of 10 and 30. The disease is more prevalent in countries in which people consume a diet low in fiber and high in refined carbohydrates. The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting. Loss of appetite is common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burneys point applied located at halfway between the umbilicus and the anterior spine of the Ilium. Rebound tenderness may be present. The extent of tenderness and muscle spasm and the existence of the constipation or diarrhea depend not so much on the severity of the appendiceal infection as on the location of the appendix. If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar region. Rovsings sign maybe elicited by palpating the left lower quadrant. If the appendix has ruptured, the pain become more diffuse, abdominal distention develops as a result of paralytic ileus, and the patient condition worsens. Constipation can also occur with an acute process such as appendicitis. Laxative administered in the instance may result in perforation of the inflamed appendix. In general a laxative should never be given when a person has fever, nausea or pain. Our patient manifested these signs and symptoms: Rebound tenderness on the Right lower quadrant of the abdomen Continuous pain Anorexia Low grade fever 38 C Nausea and vomiting Slightly Weak Facial grimace and guarding position Complications that could manifest: Possible rupture of appendix therefore leaking the contents to the peritoneal cavity causing peritonitis Abscess Constipation Septicemia

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Demographic Data
Clients Name: Patient X Age: 15y/o Gender: Female Civil Status: Single Address: Camia St. Alangan Limay Bataan Birthday: December 08, 1995 Nationality: Filipino Religion: Roman Catholic Date of Admission: September 19, 2011 Chief Complaint: Pain at the Right lower quadrant Attending Physician: Dr.Alcantara Vital Signs: BP-100/70 mmHg T-38 C PR-105 bpm RR- 23 cpm

Patients History
Clients Name: Patient X Age: 15y/o Sex: Female Referring Physician: Dr. Lopez Attending Physician: Dr.Alcantara Chief Complaint: Pain at the Right lower quadrant History of Present Illness: 12 hours prior to admission patient is complaining of on and off abdominal pain Past Medical History: None Social History: the patient is a 3 year high school in Alangan Limay Bataan. She lives with her parents and sister. She never smoked, drank alcohol or use drugs. The patients hobby is to read pocket books and watch television. The patient said that she loves to eat meat rather than vegetables, and she mostly drinks carbonated beverages and always drink coffee every morning.
rd

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Gordons Functional Health Patterns

Health Perception and Management Non-smoker, non-alcoholic and was not indulged into any drug addiction. Prefers any kind of meat rather than fruits and vegetables. Does exercise in school every morning. When first of the symptoms occurred she went to the quack doctor and did a massage on her abdomen, the actions made it worse as claimed. Nutritional Metabolic Daily food intake is mostly meat, rice and bread (pandesal) in the morning, eats vegetables and fruits rarely (once every 2 weeks as estimated by the client). No supplementary intake nor vitamins. Snacks include mostly junk foods and carbonated drinks in school, rarely are the sandwiches or any bread. Daily fluid intake is 5-7 glasses every day. Appetite was always good and sometimes with diet restrictions. Has dry skin. Elimination Defecates 1-2 times/2days, rarely once/3days. Urinates 4-6 times per day. Activity Exercise Not easily fatigable. Exercise every morning in school for 10 mins everyday. Walks around with friends or reads books during spare time. Eats 3 times a day, sometimes 4 times. Takes a bath everyday with grooming. Does house chores everyday when going home if available. With a straight body posture and normal walking gait. Sleep Rest Has 6-10 hours of sleep at school days, and 10-12 at weekends. Wakes up but conditions body first before doing activities during school days. Wakes up as early as 6am in the morning during school days. Cognitive-perceptual Has ease on decision making for important things. Easiest way to learn things is by visual learning or watching. Has difficulty in logical aspects. Speaks tagalong only. Attention span is satisfactory. Pain COLDSPA (Weber, 2003): C character: Continuous, O Onset: September 17, 2011 afternoon, L location: Right lower quadrant of the abdomen, D duration: nonstop, S severity: pain scale of 5/10 on September 17- 7/10 on September 18- and 10/10 upon admission, P pattern: from umbilical to mcburneys point, A Associated factors: fever and rebound tenderness.. Self perception/Self concept She describes herself as a source of happiness to her family. Feels good most of the times due to her mom. Her sister mostly makes her angry and annoyed. The loss of her parents makes her fearful and depressed. Having problems in her academics makes her anxious like reporting and exams. Eye contact is inconsistent due to pain. Attention span is satisfactory due to that she is distracted by pain. Voice and speech pattern is slightly slurred and weak due to pain. Client is unrelaxed. Role Relationship Has a nuclear type of family. Family feels very worried about the clients condition and more when we cited the complications that could happen. The client has many friends, mostly in school.
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Sexuality Reproductive Had no relationship to males up to now. LMP was on September 3, 2011. Has dysmenorrhea sometimes. Coping Stress Tolerance Her mom is her sole problem solver and emotional supporter. When tensed, her mothers appearance will help a lot. Problems are solved through decision making and most of them succeed with the help of her mom and sister. Value-Belief Pattern Does not get the most things that she wants from life. To finish her studying is very important. Very religious (Roman Catholic) as taught by her mother and father. Sometimes religion helps when problem arises according to her.

Physical Assessment
General Appearance Patient has small body built. She has no obvious physical deformities. Her body temperature is 38C taken through axilla, RR 23cpm, PR 105bpm. Mental Status Patient is conscious and coherent. She is oriented to time, place and person. She is cooperative and uses simple words in communicating. Skin Patient has a brownish skin color. Has dry skin. Her hair color is black; quantity is thick and textures brittle and evenly distributed. No presence of flaking, sore and lice. Nails Patient nail plate is convex. It is smooth and pink, has a pink nail bed and capillary refill is within 3 seconds Head and Face The patient skull shape is proportionate to body size. Her face and facial movements are symmetrical. Eyes Patient eyes are straight normal. Eyebrows are thin. This is an effective closure and the blink response is bilateral. Her eyeballs are symmetrical. Pupils are equal round reactive to light and accommodation. She also has a pink palpebral conjunctiva.

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Ears Patients auricle has a normal racial tone and is elastic and symmetric. Pinna recoils when folded. She is responsive to normal voice. Nose Patients nose has a normal racial tone. Septum is located midline. Mucosa is pink and both are patent. Nasal cavity was moist and no discharges. Sinuses are non-tender. Mouth Patients lips and mucosa is pink. Her teeth were complete and gums were pink. Pharynx Uvula is located midline and mucosa is pink. Tonsils and posterior pharynx are not inflamed. Gag reflex is present Neck Patient has a supple neck. Neck muscles are equal in size. Lymph nodes are not palpable, trachea is located midline, and thyroid gland is not palpable. Breast and Axilla Patients breast is symmetrical. Lymph nodes are not palpable. Chest and Lungs Both anterior and posterior lung expansion was symmetrical Abdomen Her abdomen is normal racial tone. Bowel sounds growl due to hunger. Bladder is not distended and liver is not palpable. Upper extremities Patient is able to move her upper extremities and has a normal muscle tone. There is no deformity no edema and cyanosis. Peripheral pulse is normal. Lymph nodes are not palpable.

Lower extremities Patient is able to move and her lower extremities and has a normal muscle tone. Peripheral pulses are normal. Lymph nodes are not palpable.

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Anatomy and Physiology

Appendix is a blind-ended tube connected and located near the junction of the small intestine and the large intestine. The appendix averages 10 cm in length, but can range from 2 to 20 cm. The diameter of the appendix is usually between 7 and 8 mm. It is located in the right lower quadrant of the abdomen. Its position within the abdomen corresponds to a point on the surface known as McBurney's point In infants, the appendix is a conical diverticulum at the apex of the cecum, but with differential growth and distention of the cecum, the appendix ultimately arises on the left and dorsally approximately 2.5 cm below the ileocecal valve. The taeniae of the colon converge at the base of the appendix, an arrangement that helps in locating th is structure at operation. The appendix is fixed retrocecally in 16% of adults and is freely mobile in the remainder. 7 GEORGE DEWEY MEDICAL COLLEGE BSN IV CASE PRESENTATION

Mouth- breaks up food particles Salivary glands- moisten and lubricate food. Amylase digest polysaccharides Pharynx- swallows Esophagus- transports food Stomach- stores and churns food. Pepsin digests protein.HCL activates enzymes, breaks up food, kills germ. Mucus protects stomach wall. Limited absorption. Small intestine- completes digestion. Mucus protects gut wall. Absorbs nutrients, most water. Peptidase digests proteins. Sucrase digests sugar. Amylase digests polysaccharide. Large intestine- reabsorbs some water and ions. Forms and stores feces. Cecum-marks the beginning of the large intestine and is basically a big pouch that receives waste material from the small intestine. Cecum six centimeters (cm) long and 7.5 cm wide Appendix- its function is not certain, but some biologist believes that the appendix serve as a sort of breeding ground for intestinal bacteria. Often called the intestinal flora, a community of various bacterial populations normally inhibits the colon. The predominance of nonpathogenic bacteria under normal conditions is thought to help prevent disease. Some of the non-pathogenic bacteria are also thought to aid in the digestion or absorption of essential nutrients. Also, it blind extension of posteromedial cecum. It contains many lymphoid nodules and serves as bacterial reservoir of sorts. Ascending colon- watery stool. Transverse colon- mushy stool. Descending colon- semi-formed stool. Sigmoid colon- feces are formed. Rectum- stores and expels feces. Anus- opening for elimination of feces

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Laboratory Results
URINALYSIS
Color Transparency Reaction Specific Gravity Protein Sugar RBC WBC Epithetlial cells Amorphous urates Light Yellow Clear 6.5 1.010 Negative Negative Negative 0-1 hpf Few Moderate

HEMATOLOGY Result 109.09/L 0.33 21.4 x 109/L 0.80 0.20 437x109/L B-positive Normal 120-150 gm/L 0.37-0,47 5.0x109/L 0.35-0.85 0.25-0.35 150-350x109/L

CBC hemoglobin Hematocrit WBC Segmenters Lymphocytes Platelet count Blood typing X-ray

A visual device using Roentgen radiation to outlined the organs and bones or other kind of mass. X-ray had shown a fecalith occlusion on the vermiform appendix.

Course in the Ward

Sept.19, 2011 Received patient lying on bed with ongoing IVF of D5LR 1L Vital signs taken and recorded Febrile Scheduled for appendectomy on (Wednesday) September 21, 2011 Needs attended Endorsed

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Discharge Planning
M - Medications such as Antibiotics (Cefoxitin, Cefuroxime) for infection must be taken strictly as how the doctor prescribed it even if feeling well already. E - Early ambulation. Within 12 hrs after surgery you may get up and move around. You can usually return to normal activities in 2-4 weeks after appendectomy surgery. T - To inform the physician of any increase in the intensity and continuing pain or fever and other complications after surgery is a must, this may indicate an abscess or wound dehiscence. Stitches are removed between fifth and seventh day. H - Help wound healing for faster healing and to avoid complications. To care wound perform dressing changes with antiseptics and irrigations as prescribe avoid taking laxative or applying heat to abdomen when abdominal pain of unknown cause is experienced. Reinforce need for follow-up appointment with the surgeon (Dr. Alcantara). O - Oral intake of Liquids or soft diet until the infection subsides. Soft diet is low in fiber and easily breaks down in the gastrointestinal tract. D - Document bowel sounds and the passing of flatus or bowel movements (these are signs of the return of peristalsis).

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