I.

Introduction

Appendicitis is an urgent surgical illness with different manifestation, generous overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay. No single sign, symptoms, or diagnostic test accurately makes the diagnosis of appendiceal inflammation in all cases. Right Lower Quadrant tenderness is present in 96% of patients but is a very nonspecific finding. Incidence of appendicitis is lower in culture with a higher intake of dietary fiber. Dietary fiber is to decrease bowel-transmit time and discourage formation of fecaliths, which pre-dispose individuals to obstruction of the appendiceal lumen. Migration of pain from the periumbilical area to the RLQ is the most discriminating historical feature, with sensitivity and specificity of approximately 80%. There are three different kinds of appendicitis: acute, chronic, and gangrenous. Acute appendicitis is more common. The symptoms of this type of appendicitis are easily recognized because they are more intense. However, many of the symptoms of appendicitis are similar to other types of illnesses. This makes appendicitis difficult to diagnose. Symptoms are often compared to a bad case of influenza. The symptoms of chronic appendicitis are more problematic. While some of the symptoms of chronic appendicitis are similar to those of acute appendicitis, their intensity is much weaker. This can cause serious problems because the cause of appendicitis (infection), if left untreated, can spread. The gangrenous type of appendicitis is an acute appendicitis with necrosis of the wall of the appendix, most commonly developing in obstructive appendicitis and frequently causing perforation and acute peritonitis.

Surgery is indicated if appendicitis is diagnosed. An appendectomy (surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation. Appendectomy can be performed as open surgery using one abdominal incision that's about 2 to 4 inches (5 to 10 centimeters) long. Or appendicitis surgery can be done as a laparoscopic operation, which involves several small abdominal incisions. During a laparoscopic appendectomy, the surgeon inserts special surgical tools and a video camera into your abdomen to remove your appendix.
Currently, about 7% of the world 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. In the Philippines studies done show that about 215,604 people experience appendicitis per year. Only 70% of these people choose or were able to have an appendectomy.

This case was chosen because its relevance to Nursing education gives way to better understanding of appendicitis; its symptoms, probable causes, effects, and plausible treatments. Also about post-operative patients, especially those who undergone appendectomy. Thorough nursing health history, physical assessment and the like were obtained to render appropriate nursing intervention and management to the client.
Page | 1

OBJECTIVES GENERAL OBJECTIVE: This study aims to supply additional knowledge to our colleagues and post-operative client, apply appropriate nursing interventions and help the client cope with the changes and complications caused by Appendicitis and its treatment.

STUDENTS SPECIFIC OBJECTIVES: Knowledge To know the definition of Appendicitis. To know manifestations of Appendicitis. To recall the ideal interventions to be done before and after Appendectomy. To apply the steps in performing the proper post operative care for an Appendectomy patient. To perform the specific skills necessary before, during and after entering the operating room. To apply the skills learned while in the actual field of duty. To understand the proper behavior while in the field of duty, considering the case of a patient with Appendicitis. To establish rapport appropriate to a client having anxiety due to surgery. To understand how to manage own emotions while in the actual field of duty.

Skills

Attitude

Page | 2

CLIENTS SPECIFIC OBJECTIVES: Knowledge To explain to the client the different body changes before, and after the surgery. To inform the client the causative factors of Appendicitis. To elaborate to the client the reasons behind the interventions done to improve the clients health. To be able to teach the client proper exercises possible to regain physical strength. To be able to teach the client ways of maintaining proper diet. To teach the client proper health management after the surgery. To help client express feelings about Appendicitis and its treatment. To be able to adjust the client to the different changes especially when it comes to post operative blues. To discuss proper belief regarding self-perception and management as a recovering patient.

Skills

Attitude

Page | 3

II.

NURSING ASSESSMENT

A. Personal History Name: Ms. M.D. Permanent Address: Batia, Bocaue, Bulacan Birthdate: January 8, 1995 Birthplace: Sorsogon Age: 16 years old Sex: Female Nationality : Filipino Race: Asian Civil Status: Single Religious Orientation: Roman Catholic Educational Attainment: High School Undergraduate Source of health care financing: Family support Healthcare insurance: None Date of Admission: July 14, 2011 at 2:42 p.m. Date Handled: July 15 & 21, 2011 Date Interviewed: July 21, 2011 Date of Discharge: July 21, 2011 at 6 p.m. Initial Diagnosis: Acute Appendicitis Final Diagnosis: Gangrenous Appendicitis B. Chief Complaint and Reason for Visit Sobrang sakit na kasi nung tiyan ko, kaya nagpasugod na ako sa ospital, as verbalized by the client while pointing her right lower abdomen. C. History of Present Illness The client was admitted to Bulacan Medical Center because of the severe pain she felt on the Right Lower Quadrant of her abdomen. According to her, she felt stabbing pain on that area in the middle of January 2011. The said pain started recurring since then. Going to the nearest Barangay Health Clinic, she was given paracetamol and pain relievers. Disregarding the thought that her case might be anything worse, she continued doing chores and expecting the pain to be relieved by the medication. Consequently, she was not able to carry heavy materials since then.

Page | 4

While doing laundry on July 14, she felt unbearable abdominal pain and claimed that she cant take it anymore (pain scale: 8/10). Family members took her to the hospital via tricycle and public utility jeepney to seek immediate medical intervention. Her initial diagnosis was acute appendicitis. Prior to admission, the patient had episodes of vomiting 3 times of almost clear fluid. Fever was also noted, with the temperature of 37.9*C after the day of admission so the doctor ordered Paracetamol 300 mg., TIV as needed. According to her medical records, the physician also ordered laboratory tests which included CBC and Urinalysis. Vital signs were monitored every four hours. Patient M.D then underwent appendectomy on the next day, July 15, 2011 at 4 oclock in the afternoon.

D. History of Past Illness

The client told us that she didnt undergo any operation, whether major or minor in the past. She only went to the health center for consultations regarding mild influenza. Aside from that, patient denies allergies to any medications, foods or animals. The patient claims that she only suffered from two common childhood illnesses, like Chicken pox when she was 6 yrs old and German measles when she was 8 years old. According to her she was completely immunized when she was a child as evidenced by an immunization card. She also told us that no accidents happened to her in her younger years that would have lead to major injuries.

Page | 5

E. Family Health History (Genogram)

Patient MD was not able to give information about the generations before her, so the mother was asked to help with the obtaining of proper information. But even Mrs. PD was not sure about the names and whereabouts of some of her in-laws. The only thing she was sure of is that they do not have any hereditary diseases passed from older generations to their children. Aside from occasional drinking, the men in their family was said to
Page | 6

be smokers, each having at least 4 sticks of cigarette per day. She still claims that their family is healthy and according to her, the case of Patient MD doesnt have any connection with their familial background.

Page | 7

A. Gordons Functional Health Pattern

PATTERN PRIOR TO HOSPITALIZATION DURING HOSPITALIZATION

1. Health Perception and Health Management Pattern

Patient MD verbalized, importante naman po yung kalusugan sakin kaso lang hindi ko lang po alam na sa mga kinakain ko pala at mga ginagawa magkakaroon ako ng sakit. When we asked her to rate her health before the surgery using the scale of 1-10 (1 being the lowest and 10 being the highest) is 5 and she verbalized nung hindi pa po kasi ako naooperahan wala talaga akong nagagawa kundi tiisin lang yung sakit sa bandang tiyan ko. She also perceives herself as a healthy person during the time that she doesnt experiencing pain. The client does not smoke and drink alcoholic drinks. She seldom goes to the barangay clinic if she doesnt feel well like if she has cough, colds and fever. According to the client, her mother let her take herbal medicines like boiled oregano leaves if she has cough and fever and if it doesnt work that is the time that she takes over the counter drugs like paracetamol tablet.

During hospitalization when we asked client to describe her health she answered Mas okay na po ako ngayon kaso kumikirot pa yung tinahi sa akin. She managed the pain by taking rest and moving in minimal range. And her rate for her health after the surgery using the scale of 1-10 (1 being the lowest and 10 being the highest) is 8. She also agreed that it is important for her to follow doctors order that is why she try her very best to obey it all. Patient MD admits that she is not aware that Appendicitis is the term for her condition because according to her its not the term that she usually hears, she thought that that the pain she experienced is just a sign of stomach ache and it was the first time she heard of it. The patient also understands that her poor nutrition and activities may have had lead her to acquire it. July 14 & 15 2011 breakfast NPO July 16, 2011
2 glasses of water (480ml)

2. Nutritional Metabolic Pattern

July 11, July 12, July 13, 2011(Tuesday) 2011(Wednesday) 2011(Thursday) Breakfast -1 cup of plain rice - pc. fried egg -1 glass of water (240 ml) -1 cup of rice -adobong manok (1pc. sliced) -1 glass of water (240 ml) -none

July 17, 2011

-1 cup of porridge, -1 glass of water (240ml)

July 18, 2011 - cup of porridge -1 glass of water (240 ml) -Sinigang

Lunch

1 cup soup of sinigang

-1 cup of porridge, na baboy 2 -1 glass Page | 8

Snack am Lunch

None -1 cup of rice -1 small pc. fried tilapia -1 glass of water (240 ml)

-none - 1cup of rice -1 sliced fried tilapia -1 glass of water (240ml)

none -1 glass of water (240 ml) (during taking of medicine for stomach pain) (cant recall the name of medicine) none Dinner NPO

na baboy (200 ml) - 1 glass of water (240 ml)

of water (240ml)

sliced , -1 cup plain rice -1glass of water (240ml)

Snack pm

Snack pm

Dinner

-1 biscuit rebisco -1 glass of water (240 ml) - I cup rice -adobong manok (2 pcs. sliced) -1 glass of water (240 ml)

-none

- 1 cup porridge -1 glass of water (240 ml)

none

-1 cup soup of sinigang na baboy (200 ml) - 1 glass of water (240 ml)

-9 pcs biscuit (fita) -C2 1 glass (240 ml) -1 cup of --Sinigang

porridge, -1 glass na bangus of water sliced, (240ml)

- 1 cup of plain rice

-1 glass water(240ml)

The patient stated that she often eats junk foods and she seldom eats fruits and vegetables that good for her health. She only consumes 4-5 glasses of water per day and she doesnt take any vitamins for food supplement.

Page | 9

3. Elimination Pattern

URINE Frequency Color Odor

July 11, 2011 3 times (600ml) Amber Aromatic

July 12, 2011

July 13, 2011 2times(400ml) none Amber Aromatic

URINE

July 16, 2011 Frequency 3-4 (600800ml) diapers Consistency Amber Amber Color Aromatic Aromatic

July 14, 2011 once

July 17, 2011 3times (600ml)

July 18, 2011 3times (600ml)

Amber Amber Aromatic Aromatic

July 11, 2011 Frequency once Consistency firm Characteristics Dark brown, formed and foul odor

STOOL

July 12, 2011 none

July 13, 2011 none

STOOL

July 14, 2011

July 16, 2011 none

July 17, 2011 once firm Dark brown, formed and foul odor

The client experienced constipation but doesnt experience any voiding difficulties. She admits that when she feels the urge to defecate thats the only time for her to defecate. The client also stated that she perspires enough, not little and not too much.

Frequency once Consistency firm Characteristics Dark brown, formed and foul odor

July 18, 2011 once firm

Dark brown, formed and foul odor

After the operation the client urinates like she does before but with the used of diaper because she was prohibited to walk too much because of her incision. But after a day she already void in the comfort room with the help of her mother. The client doesnt experience any defecation difficulties. The client was not allowed to carry heavy objects. She cant ambulate well without the help of her mother, but she said Kaya ko na pong tumayo at maglakad lakad, medyo kumikirot nga lang yung tinahi sakin kaya nagpapatulong
Page | 10

4. Activity and Exercise Pattern

Patient M.Ds daily activities are: waking up usually 6am in the morning, eat her breakfast at usually 7am and take a rest for a while and taking the responsibility to wash the laundry and household chores of her neighbours in order to help her family in the matter of financial. She said

that sometimes she also help in their household chores like washing dishes and sweeping the floor. She enjoys watching TV and reading pocket books for her leisure time. When we asked if what exercise she usually does and how often, she verbalized Siguro po 2 beses sa isang lingo naglalakad lakad lang ako sa labas ng bahay namin, at pag naglalaro kami ng mga kaibigan ko katulad ng habulan. a. b. c. d. e. f. g. Feeding- 0 Bathing- 0 Toileting- 0 Bed mobility- 0 Dressing- 0 Grooming- 0 General Mobility- 0

po ako sa nanay ko. She also wants to go home because she gets bored in the hospital and according to her, sometimes she is experiencing difficulty in sleeping due to the environment. a. b. c. d. e. f. g. Feeding- II Bathing- II Toileting- II Bed mobility- 0 Dressing- II Grooming- 0 General Mobility- II

0-Full self care I-requires use of equipment or device II-requires assistance or supervision from person III- requires assistance or supervision from a person or device IV- Dependent and doesnt participate

0-Full self care I-requires use of equipment or device II-requires assistance or supervision from person III- requires assistance or supervision from a person or device IV- Dependent and doesnt participate

Page | 11

5. Sleep-Rest Pattern

July 11, 2011 Time of Sleep 10 pm

July 12, 2011 10pm 6am 8hours

July 13, 2011 7 pm 7 am 12 hours Time of Sleep Time of Awakening Total No. of Sleep

July 2011

16, July 2011

17, July 2011

18,

9pm / 1am 11pm / 5am 6 hours

Time of 6 am Awakening Total No. of 8 hours Sleep

10pm / 8pm / 1am 1am 11 pm / 11pm/ 4am 6am 6 hours 7hours

Patient MD sleeps for about 8hrs per day continuously, from 10 pm and wakes up at 6am. She said that she doesnt experience any sleeping difficulties.

During admission, client MD experienced sleep disturbances because of strange environment. Also, because of the nurses that monitor her Vital Signs. She said that if nurse comes in and take her V/S it would take a couple of hours like 2-3 hours for her to be able to sleep again. After the operation the client doesnt experience any alterations in her senses. During interview process, the client responded well despite of being shy and answered well all the questions that were asked to her. She also listens and understands our health teachings. When asked to describe herself, the client replied that she feels better than before. Mas mabuti na po ang pakiramdam ko kaso magkakaroon na ako ng peklat sa tiyan ko. As verbalized by the client. During hospitalization, her parents and her youngest sibling
Page | 12

6. Cognitive Perceptual Pattern

7. Self Perception/ Self Concept Pattern

8. Role- Relationship

Patient MD has no hearing difficulty. She doesnt wear eyeglasses and has a 20/20 vision. She has no difficulty in learning or absorbing information despite of being not in school for almost 2 years. The client has no problem in communicating with others and remembering recent activities. With regards to decision making the client ask her parents opinion for her to decide. When asked what makes her angry the client replied, nagagalit ako kapag inaasar ako ng bunso naming kapatid. And shes irritated if they have no food. She also said that if theres nothing to eat, she will buy whatever she wants like junk foods. The patient has7 siblings. She is the 2nd to the youngest. She lives with

Pattern

her parents and with her youngest sibling. She stated that her parents decide about some issues on their lives. She said that sometimes her parents have a misunderstanding especially about money or financial problems. She works as a maid to help her parents. She has close friends in their barrios. She does not belong to a social organization. She had her first menstruation when she was 15 years old. According to client her menstruation cycle is irregular, and she verbalized noong May at June hindi ako nadatnan. Every time that she has menstruation, she doesnt experienced dysmenorrhea. She consumed whole pack of sanitary napkin or 8pcs on her entire menstrual period. Her menstrual period is 5 days. The patient stated that whenever she has a problem, sometimes she only kept it in herself. But if she has problems about school, she shares it with her father. She also said that sometimes, she watches television or doing household chores for her to relax and to forget her problem. The client is a Roman Catholic, she attends every Sunday Mass. During times of difficulties, she believes that only God can provide them comfort. And she said that God help them in their lives. Whenever she has a problem, she goes to Church and pray for guidance.

are present to give support to her, took care of her and gives whatever she needs. Her other 6 siblings cant visit her because they lives in Bicol.

9. Sexuality Reproductive Pattern

When asked about her monthly menstrual cycle, the patient said that she doesnt have menstruation on the days that shes in the hospital.

10. Coping Stress Tolerance

During hospitalization, she is worrying if how her parents settled her hospital bills. She always prays to God to help her to overcome her problems.

11. Value Belief Pattern

She always believed that God is always there for her and for her family.

Page | 13

III. Theory

Growth and Development Sigmund Freuds Psychosexual Theory Erik Ericksons Psychosocial Theory (Developmental Task) Young Adulthood 18-25 y/o Intimacy vs. isolation Jean Piagets cognitive Theory (Development of thought/Intellectual Development) Formal Operational (11 years to adulthood) Lawrence Kohlbergs Moral Development Theory Fowlers Stages of Spiritual Development

Stage

Genital (12 years to adulthood)

Post-conventional (12 years to adulthood)

Paradoxical-Consolidative (After 30 years)

Definition

Matured sexuality is achieved as physical growth is completed and development of skills to cope with the environment

(+) Intimate relationship with another person. Commitment to work and relationships. (-) Impersonal relationships. Avoidance of relationship, career or lifestyle commitments. Negative, because sometimes she has an immature and childish attitude, and she doesnt have an intimate relationship with another person.

Fully matured intellectual thought, reality, abstract thought.

The individual has internalized ethical standards on which to base decisions. Social responsibilities are recognized. The value in each of two differing moral approaches can be considered and a decision made. Positive, because shes the one who asked for her parents to admit her in the hospital. Dahil po hindi kaya ang sobrang sakit ako na po nagsabi sa mga magulang ko na dalhin ako sa hospital.

Awareness of truth in a variety of viewpoints.

Outcome

Positive, because she achieved matured sexuality and completed physical growth and relationship with others.

Positive, because she answered all our questions in logical manner.

Negative, because she is unaware and she doesnt understands her condition well. Kung hindi pa po sinabi sa akin na dahil sa mga kinakain ko hindi ko malalaman kung paano ako nagkaroon ng ganitong sakit
Page | 14

IV.

Anatomy & Physiology

The human gastrointestinal tract refers to the stomach and intestine, and sometimes to all the structures from the mouth to the anus. (The "digestive system" is a broader term that includes other structures, including the accessory organs of digestion.) In an adult male human, the gastrointestinal (GI) tract is 5 metres (20 ft) long in a live subject, or up to 9 metres (30 ft) without the effect of muscle tone, and consists of the upper and lower GI tracts. The tract may also be divided into foregut, midgut, and hindgut, reflecting the embryological origin of each segment of the tract. The GI tract releases hormones to help regulate the digestion process. These hormones include gastrin, secretin, cholecystokinin, and grehlin, are mediated through either intracrine or autocrine mechanisms, indicating that the cells releasing these hormones are conserved structures throughout evolution Upper gastrointestinal tract The upper gastrointestinal tract consists of the esophagus, stomach, and duodenum. The exact demarcation between "upper" and "lower" can vary. Upon gross dissection,
Page | 15

the duodenum may appear to be a unified organ, but it is often divided into two parts based upon function, arterial supply, or embryology.

Lower gastrointestinal tract The lower gastrointestinal tract includes most of the small intestine and all of the large intestine. According to some sources, it also includes the anus.

Bowel or intestine
o

Small intestine, which has three parts:

Duodenum - Here the digestive juices from pancreas (digestive enzymes) and gallbladder (bile) mix together. The digestive enzymes break down proteins and bile emulsifies fats into micelles. Duodenum contains Brunner's glands which produce bicarbonate and pancreatic juice contains bicarbonate to neutralize hydrochloric acid of stomach

Jejunum - It is the midsection of the intestine, connecting duodenum to ileum. Contain plicae circulares, and villi to increase surface area.

Ileum - It has villi, where all soluble molecules are absorbed into the blood (capillaries and lacteals).

Large intestine, which has three parts:

Cecum (the vermiform appendix is attached to the cecum). Colon (ascending colon, transverse colon, descending colon and sigmoid flexure). The main function of colon is to absorb water, but it also contains bacteria that produce beneficial vitamins like Vitamin K.
Page | 16

Appendix

The appendix is a closed-ended, narrow tube up to several inches in length that attaches to the cecum , the first part of the colon, like a worm. The anatomical name for the appendix is vermiform appendix which means worm-like appendage. It's pencil-thin and normally about 4 inches (7 cm) long. The appendix is usually located in the right iliac region, just below the ileocecal valve (designated McBurney's point) and can be found at the midpoint of a straight line drawn from the umbilicus to the right anterior iliac crest. The inner lining of the appendix produces a small amount of mucus that flows through the open center of the appendix and into the cecum. The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies. During the first few years of life, the appendix functions as a part of the immune system, it helps make immunogobulins. But after this time period, the appendix stops functioning. However, immunoglobulins are made in many parts of the body, thus, removing the appendix does not seem to result in problems with the immune system. Like the rest of the colon, the wall of the appendix also contains a layer of muscle, but the muscle is poorly developed.

Page | 17

V.

Physical Assessment

Weight: 40 kg Height: 50 BMI: 17.78

BP: 110/70 PR: 96 bpm RR: 22 cpm

Temp: 36.8 C

PARTS TO BE ASSESSED
GENERAL APPEARANCE 1. Body built, height and weight in relation to clients age, lifestyle and health

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

Inspection

Proportionate, varies with lifestyle

2. Clients posture and gait, standing, sitting and walking 3. Clients overall hygiene and grooming 4. Body and breath odor 5. Signs of distress in posture of facial expression

Inspection

Erect posture and coordinated movement

Not proportional body weight and height to the clients age Clients BMI: BMI: 17.78 Weight: 40 kg Height: 50 Cant walk, stand, and sit easily, Not erect posture

Deviation from Normal -Not proportional body weight and height to the clients age

Deviation from Normal - Cant walk, stand, and sit easily, Not erect posture Normal Normal Deviation from Normal - Grimace observed during change in posture; with presence of eye bags and appeared weak Deviation from Normal Page | 18

Inspection Inspection and smelling Inspection

Clean and neat No body odor or minor body odor; no breath odor No distress noted

Clean and neat No body odor or minor body odor; no breath odor Grimace observed during change in posture; with presence of eye bags and appeared weak

6. Obvious signs of health or illness

Inspection

Healthy appearance

Appeared uncomfortable and in pain with guarding over incision

site 7. Clients attitude

Inspection

Cooperative

Cooperative but with times of irritability

- Appeared uncomfortable and in pain with guarding over incision site Deviation from Normal - Cooperative but with times of irritability Deviation from Normal - yawning is observed from the client Normal

8. Clients affect/ mood appropriateness of the clients response 9. Quantity of speech, quality and organization 10. Relevance and organization of thoughts SKIN 1. Skin color and uniformity

Inspection

Appropriate to situation

Appropriate to situation; yawning is observed from the client Understandable

Inspection

Understandable, moderate face, exhibit thoughts association Logical sequence, make sense, has sense of reality

Inspection

Make sense

Normal

Inspection

2. Presence of edema 3. Skin lesions

Palpation Palpation

Varies from light to deep brown, generally uniform except in areas expose to the sun No edema Freckles, birthmarks, no abrasion or other lesions

Color brown and uniform

Normal

4. Skin moisture

Palpation

5. Skin temperature

Palpation

Moisture in skin folds and axillae (varies with the environment temp. & humidity; body temp. and activity) Normal temperature within normal range

No edema noted Normal With dry and intact wound with 5 Deviation from Normal Blanket continuous stitches in her right lower quadrant (RLQ); - With dry and intact wound with With small scar on her both left 5 Blanket continuous stitches in and right deltoid. her right lower quadrant (RLQ) - With small scar on her both left and right deltoid Normal skin moisture Normal

Uniform along all body areas except the incision site

Deviation from Normal Page | 19

6. Skin turgor

Palpation

When pinched, skin springs back to previous state

Skin springs back when pinched (performed at patients mid portion of inner arm) Convex curvature; 160 degrees Pink in color Intact epidermis Pink in color Normal capillary refill less than 4 seconds Even and normally distributed Thick hair No infections or infestations Silky, resilient hair

-the incision site has hotter temperature. Normal

NAILS 1. Determine fingernails plate shape and its angle and curvature 2. Fingernail and toenail bed color 3. Tissues surrounding nails 4. Fingernail and toenail color 5. Blanch test of capillary refill HAIR AND SCALP 1. Evenness and growth of hair over the scalp 2. Hair thickness and thinness 3. Presence of infections or infestations 4. Texture and oiliness over the scalp SKULL 1. Size shape and symmetry Inspection Inspection Inspection Inspection Palpation Convex curvature; angle of nail about 160 degrees Highly vascular and pink Intact epidermis Highly vascular and pink Capillary refill is less than 4 seconds Evenly distributed over the scalp Thick hair No infections or infestations Silky, resilient hair Normal Normal Normal Normal Normal

Inspection Inspection Inspection Palpation

Normal Normal Normal Normal

Inspection

2. Nodules or masses and depressions FACE 1. Facial features

Palpation

Rounded (normocephalic and symmetrical ; smooth skull contour Smooth, uniform consistency absence of nodules or masses

Normocephalic and symmetrical

Normal

No nodules, masses and depression

Normal

Inspection

Symmetric or slightly facial features

Symmetric facial features; grimace noted during change in posture

Deviation from Normal - grimace noted during change in posture Page | 20

2. Symmetry of the facial movements EYEBROWS AND EYELASHES 1. Evenness of distribution and direction of curl EYELIDS 1. Surface characteristics and ability to blink CONJUCNTIVA 1. Bulbar conjunctiva, color, texture and presence of lesions 2. Palpebral conjunctiva, texture and presence of lesions SCLERA 1. Color and clarity

Inspection

Symmetric, palpebral fissures equal in size

Symmetric

Normal

Inspection

Hair evenly distributed; slightly curved outward

Evenly distributed; slightly outward

Normal

Inspection

Skin intact; no discharge; no discoloration; lids closely symmetrical

No discharge; bilateral blinking; symmetrical

Normal

Inspection Inspection

Transparent; capillaries sometimes evident Shiny smooth, pink or red

Transparent; no lesions Light pink; no lesions

Normal Normal

Inspection

Appears white (yellowish in dark- skinned persons)

White

Normal

CORNEA 1. Clarity and color IRIS 1. Shape and color PUPILS 1. Color , shape and symmetry Inspection Symmetrical; brown or black in color Black, round and equal in size Normal Page | 21 Inspection Usually color brown of black; flat and round Black and round Normal Inspection Transparent, shiny and smooth, details of iris are visible Transparent and shiny Normal

2. Pupil light reaction and accomodation 3. Pupils direct and consensual reaction to light VISUAL ACUITY 1. Test near vision 2. Test distant vision LACRIMAL GLAND 1. Presence of edema or tenderness LACRIMAL SAC 1. Presence of edema or tenderness NASOLACRIMAL DUCT 1. Presence of edema or tenderness

Inspection Inspection

Illuminated pupil constrict (direct response) Not illuminated pupil constrict (consensual response) Able to read news print at 14 inches away 20/20 vision on Snellens chart

Not illuminated Not illuminated constrict

Normal Normal

Inspection Inspection

Able to read news print at 14 inches away 20/20 vision

Normal Normal

Palpation

No edema or tenderness over lacrimal gland

No edema or tenderness over lacrimal gland

Normal

Palpation

No edema or tearing

No edema or tearing

Normal

Palpation

No edema or tearing

No edema or tearing

Normal

EXTRAOCULAR MUSCLE 1. Test each eye for alignment and coordination VISUAL FIELDS 1. Test peripheral visual field EARS AURICLE 1. Color , symmetry, size and position of ears auricle

Inspection

Both eyes (coordinated), move in unison with parallel alignment

Both eyes are coordinated

Normal

Inspection

When looking straight ahead, clients can see objects periphery

Can see objects periphery

Normal

Inspection

Uniform color that varies with the normal clients skin color, symmetrical, lined on the outer

Uniform and symmetrical properly aligned; with 1 pair of puncture on both auricles for her

Normal

Page | 22

2. Texture, elasticity and areas of tenderness EXTERNAL EAR CANAL 1. Cerumen, skin lesion, pus and blood HEARING ACUITY TEST 1. Clients response to normal voice tones 2. Perform watch tick test

Palpation

eye canthus Mobile, firm and not tender; pinna recoils after it is folded

earrings Mobile, firm and not tender

Normal

Inspection

Presence of cerumen, no skin lesions, pus and blood

No lesions, pus and blood

Normal

Inspection Inspection

Normal voice tone audible Able to hear the ticking of watch in both ears at 1 to 2 inches away

Can hear normal voice tones Able to hear the ticking of watch in both ears at 1 to 2 inches away

Normal Normal

NOSE 1. Shape, size or color and flaring or discharge 2. Presence of redness, swelling, growths and discharge of nares using the flashlight 3. Position of nasal septum 4. Test patency of both nasal septum 5. Note for tenderness, masses and displacement of bone and cartilage SINUSES 1. Presence of tenderness LIPS 1.Symmetry of contour, color and

Inspection Inspection

Symmetry, aligned to the center, color brown and no discharge No redness, swelling, no discharge or flaring Intact and in the midline Air moves freely Not tender, no masses and no displacement of bone and cartilage

Symmetric, aligned, color brown and no discharge No redness, swelling, no discharge or flaring Midline positioned Air moves freely Not tender, no masses and no displacement of bone and cartilage

Normal Normal

Inspection Inspection and Sensing Palpation

Normal Normal Normal

Palpation Inspection

Not tender Symmetrical contour,

Not tender smooth Moist, symmetry, color light

Normal Normal Page | 23

texture BUCCAL MUCOSA 1. Inspect for color, moisture, texture and presence of lesions TEETH 1. Inspect for color, condition and presence of dentures Inspection

texture, moist and color pink or brown brown in dark people

Moist, smooth, color pink and no lesions

Moist color pink and no lesions

Normal

Inspection

Smooth, shiny, color white

Color white and shiny but with the cavity in her both upper premolar teeth

Deviation from Normal - with the cavity in her both upper pre-molar teeth

GUMS 1. Color and condition TONGUE/ FLOOR OF THE MOUTH 1. Color and texture of the mouth floor and frenulum 2. Position, texture, color, movement and base of the tongue PALATES AND UVULA 1. Color, shape, texture, and the presence of bony prominences of palates 2. Position of the uvula and mobility OROPHARYNX AND TONSILS 1. Color and texture 2. Size of the tonsils, color and discharge Inspection Palpation Pink tongue, smooth with no palpable nodules Central position, smooth tongue base with prominent veins Color pink with no palpable nodules Central position, smooth tongue Normal Normal Inspection Pink gums and no nodules and lesions Color pink and no nodules Normal

Inspection

Light pink, smooth soft palate, Light pink and smooth light pink hard palate Position in the midline of soft palate In the midline

Normal

Inspection

Normal

Inspection Inspection

Pink and smooth posterior wall Normal size, pink and no discharge

Pink and smooth posterior wall Normal, pink, and no discharge

Normal Normal Page | 24

3. Elicit Gag reflex NECK AND LYMPH NODES 1. Symmetry and visible mass in the thyroid gland 2. Presence of tenderness or nodules in the lymph nodes 3. Placement of the trachea Palpation Palpation Palpation

Present of Gag reflex

React in Gag reflex

Normal

Symmetry, no visible mass in the thyroid gland Not tender and no nodules in the lymph nodes Central placement in the midline of neck, space are equal on both sides Smooth, n o areas of enlargement, no masses or nodules in the thyroid gland Symmetric, anteroposterior thorax to transverse diameter is in ratio of 1:2 Vertically aligned No alteration Full symmetric excursion; thumbs normally separate 3-5 cm during deep breathing Normal body temperature, no tenderness or masses Fremitus palpated more on the apex of the lungs bilateral symmetry Resonate except the scapula Vesicular and bronchovesicular sounds

No visible mass in thyroid gland and symmetrical Not tender and no nodules Equal and midline in both sides

Normal Normal Normal

4. Smoothness and areas of enlargement, masses or nodules in the thyroid gland POSTERIOR THORAX 1. Shape symmetry and comparison of diameter of posterior thorax 2. Spinal alignment 3. Breathing pattern 4. Respiratory excursion

Palpation

Smooth, no areas of enlargement, no nodules

Normal

Inspection

Palpation Inspection Palpation

5. Temperature, Tenderness and masses 6. Vocal fremitus

Palpation Palpation

Symmetric, anteroposterior and transverse are proportional in diameter ratio of 1:2 Vertically aligned No alteration Full symmetric excursion; thumbs normally separate 3-5 cm during deep breathing No tenderness and masses Fremitus is palpated more on the apex of the lungs Resonance Vesicular and broncho-vesicular sounds

Normal

Normal Normal Normal

Normal Normal

7. Percussion of the posterior thorax 8. Auscultate the posterior thorax ANTERIOR THORAX

Palpation Auscultation

Normal Normal

Page | 25

1. Breathing pattern 2. Temperature, tenderness and masses 3. Respiratory excursion

Auscultation Palpation Palpation

Quiet, rhythmic, effortless respirations Normal temperature, no tenderness and masses Full symmetric excursion; thumbs normally separate 3-5 cm Same as the posterior thorax where the upper portion has more vibration than the lower Resonate down to the 6th rib level of the diaphragm Bronchal and tubular breaths sounds over the trachea Bronchovesicular and vesicular breath sounds Uniform skin color, symmetrical and rounded No tenderness, masses, nodules, and nipple discharge

Quiet, rhythmic, effortless respirations Normal temperature, no tenderness and masses Full symmetric excursion; thumbs normally separate 3-5 cm Upper anterior thorax has more vibration Resonance Breath sounds over the trachea Bronchovesicular and vesicular breath sounds Uniform skin color, symmetrical and rounded No tenderness, masses, nodules, and nipple discharge

Normal Normal Normal

4. Vocal fremitus

Palpation

Normal

5.Percuss the anterior thorax 6. Auscultation of the trachea 7. Auscultation of the anterior thorax BREAST 1. Inspect the skin color, size symmetry and shape 2. Palpate breast, areola and nipples. CAROTID ARETERIES 1. Pulsation of the carotid arteries 2. Auscultation of the Carotid arteries JUGULAR VEINS 1. Visibility of jugular veins ABDOMEN 1. Skin integrity

Percussion Auscultation Auscultation

Normal Normal

Inspection Palpation

Normal Normal

Palpation Auscultation

Palpable No rushing sounds

Palpable No rushing sounds

Normal Normal

Inspection

Not visible

Not visible

Normal

Inspection

Uniform at all areas of the abdomen

With dry and intact wound with 5 Deviation from Normal Blanket continuous stitches in her right lower quadrant (RLQ) - With dry and intact wound with Page | 26

2. Abdominal contour

Inspection

Flat

Flat but the incision site is slightly swelling Palpation in the liver area not performed but the palpation in the spleen area is performed and normal Symmetric contour except on the incision site

5 Blanket continuous stitches in her right lower quadrant (RLQ) Deviation from Normal - incision site is slightly swelling Normal

3. Enlarged liver or spleen

Palpation

No enlargement of liver and spleen

4. Symmetry of contour

Inspection

Symmetric contour

Deviation from Normal -incision site is not symmetry from the abdominal area Normal Deviation from Normal -with Minimum vascular patterns noted in the incision site

5. Abdominal movements 6. Vascular movements

Inspection Inspection

Symmetric movements caused by respiration No visible vascular pattern

Symmetric movements Minimum vascular patterns noted in the incision site

7. Bowel sounds, vascular sounds and peritoneal friction rubs

Auscultation

Audible bowel sounds

Not performed

Refused -due to pain experiencing by the client Refused --due to pain experiencing by the client Refused --due to pain experiencing by the client

8. Percuss abdominal quadrants

Percussion

Tympanic over the stomach and gas-filled bowel; dullness

Not performed

9. Light palpation of abdominal quadrant

Palpation

No tenderness; relaxed abdomen with smooth, consistent tension.

Not performed

MUSCULOSKELETAL Page | 27

SYSTEM 1. Muscle size compare the muscle on the side of the body to the same muscle on the other side 2. Contractures of the muscles and tendons 3. Muscle fasciculations and tremors, presence of tremors of the hand and arms when stretched in front of the body 4. Muscle tonicity

Inspection

Equal size on both side of the body

Not equal in the left iliac region due slightly swell incision site

Deviation from Normal - Not equal in the left iliac region due slightly swell incision site Normal Deviation from Normal - Uncoordinated movements particularly at lower extremities; no tremors noted Deviation from Normal - Not normally firm in the incision site at RLQ Deviation from Normal - Not equal in both sides due to the incision at the RLQ

Inspection Inspection

No contractures of muscles and tendons Smooth coordinated movements, no tremors

No contractures of muscles and tendons Uncoordinated movements particularly at lower extremities; no tremors noted

Inspection

Normally firm

Not normally firm in the incision site at RLQ

5. Muscle strength

Inspection

Equal strength of each body side

Not equal in both sides due to the incision at the RLQ

BONES 1. Normal structure 2. Presence and tenderness Inspection Palpation No deformities No edema and tenderness No deformities No edema and tenderness; except from tenderness at the hip bone area Normal Deviation from Normal -with tenderness at the right hip bone area Normal

JOINTS 1. Swelling Palpation No swelling No swelling

2. Presence of tenderness, smoothness of movements, swelling, crepitating

Palpation

No tenderness, smoothness of movements; no nodules

No tenderness, smoothness of movements, no nodules; except from tenderness during flexion of

Deviation from Normal -with tenderness during flexion Page | 28

and presence of nodules RANGE OF MOTION 1. Upper extremities 2. Lower extremities Palpation/ inspection Palpation/ inspection Ability to perform certain actions or movements Ability to perform certain actions or movements

right hip Can perform certain actions Cant perform certain actions; the patient cant stand alone and with pain felt during flexion of right hip

of right hip Normal Deviation from Normal - Cant perform certain actions; the patient cant stand alone and with pain felt during flexion of right hip

SUMMARY: The client is at BMI of 17.78 which is a deviation from normal because the desirable range of BMI of a person is 22 for males and 20.8 to 21 for females. The clients is also experiencing pain with grimace noted when she change in position and also with the presence of eye beg and appeared uncomfortable and irritable during our past interview. The client has scar on her both right and left deltoid due to vaccination she had undergone when she was a baby and has cavity on her both upper prep- molar teeth. The incision site is dry and intact with 5 Blanket continuous stitches at her right lower quadrant and slightly elevated temperature compare to remaining body areas. It is slightly swelled and not symmetry contoured and firmed with minimum vascular patterns noted. Percussion and palpation on the abdominal areas were not performed due to the clients refusal for pain as well as auscultation on bowel sounds, vascular sounds and peritoneal friction rubs. The client cannot perform certain actions like flexion of her right leg due to tenderness she felt also result from difficulty in walking and cannot stand alone.

Page | 29

VI.

Patient and His Illness

Pathophysiology of Gangrenous Appendix

Non-Modifiable Factors Modifiable Factors Diet The severe gangrenous type of appendicitis is confined to meateating people, low fiber diet and increased in refined carbohydrate foods.

Page | 30

Low Fiber Diet

Obstruction by fecalith, parasites, toxins, Bacteria and foreign bodies

High intake of Refined Carbohydrate

Obstruction of the lumen of the appendix

Start of the inflammation process

Release of chemical mediators (Histamine,Prostaglandin, Leukotrines and Bradykinin)

Activation of vomiting center in the medulla oblongata

Presence of Neutrophils on affected sites

Distention of the appendix Stimulation of vagus nerve Suppression of sympathetic GI function WBC and Platelets

Page | 31

Pain in the Right lower quadrant

Nausea and vomiting

Anorexia

Pus formation

Temperature

Increased intra luminal pressure due to obstruction of the lumen of the appendix

Decreased venous blood flow due to obstruction of lumen of the appendix

Decreased oxygen due to decreased venous blood flow

Hypoxia due to low oxygen level

Page | 32

Ischemia of cells

Cell Death

Tissue Death

Necrosis of the appendix

Gangrene Accumulated 24 to 36 hours

Gangrenous Appendix

Page | 33

The Pathophysiology of appendicitis is the constellation of processes that leads to the development of acute appendicitis from a normal appendix. The main thrust of events leading to the development of acute appendicitis lies in the appendix developing a compromised blood supply due to obstruction of its lumen and becoming very vulnerable to invasion by bacteria found in the gut normally. Obstruction of the appendix lumen by fecalith, enlarged lymph node, worms, tumor, or indeed foreign objects, brings about a raised intra-luminal pressure, which causes the wall of the appendix to become distended. The inflammation process continue within the lumen of the appendix, thus causing further build up of intra-luminal pressures. Reduced blood supply to the wall of the appendix means that the appendix gets little or no nutrition and oxygen. It also means a little or no supply of white blood cells and other natural fighters of infection found in the blood being made available to the appendix. The wall of the appendix will thus start to break up and rot. Normal bacteria found in the gut gets all the inducement needed to multiply and attack the decaying appendix within 36 hours from the point of luminal obstruction, worsening the process of appendicitis. This leads to necrosis or gangrene and perforation of the appendix. Pus formation occurs when nearby white blood cells are recruited to fight the bacterial invasion. A combination of dead white blood cells, bacteria, and dead tissue makes up pus. The content of the appendix (fecalith, pus and mucus secretions) are then released into the general abdominal cavity, bringing causing peritonitis.

Page | 34

VII.

Patient and his Care A. Diet Date Ordered/ Date Changed/ Date Discontinued Date Ordered: July 14, 2011 Description Indication/ Purpose Specific food taken Clients Response Nursing Responsibilities (Prior, During, After) Prior: Verify physicians order Explain the diet prescribed to the patient Instruct patient to withhold oral fluids and foods During: Ensure that the patient strictly follow the diet After: Assess for patients condition; how he responds to the diet

Type of Diet

NPO

Nothing per Orem means nothing to eat

A pre- operative patient must be NPO before surgery to prevent risk of aspiration during induction of anesthesia

None

Since the patient was oriented and understand needed interventions, he followed with the doctors prescriptions.

Date Discontinued: July 16, 2011

or drink

Type of Diet

Date Ordered/ Date Changed/ Date Discontinued

Description

Indication/ Purpose

Specific food taken

Clients Response

Nursing Responsibilities (Prior, During, After) Prior:

Page | 35

Clear Liquid

Date Ordered: July 16, 2011 Date Discontinued: July 17, 2011

A clear liquid diet consists of transparent liquid foods

It provides some Breakfast electrolyte as sodium and (480ml)

Since the patient

Check the physicians order Explain prescribed the to diet the

such 2 glasses of water was oriented and understand needed interventions, followed the he with doctors

potassium. It also Lunch 1 cup soup of gives some sinigang na baboy energy for (200 ml) - 1 glass of water patients when (240 ml) normal food intake must be Dinner

patient During: The nurse should

prescriptions.

make sure that the patient adheres to the ordered diet. The ordered diet

1 cup soup of This diet is sinigang na baboy (200 ml) indicated - 1 glass of water for the postoperative (240 ml) patient's first feeding when it is necessary to fully ascertain return of gastrointestinal function Type of Diet Date Ordered/ Date Changed/ Date Discontinued Description Indication/ Purpose Specific food taken Clients Response

interrupted.

should be monitored. After: Assess for patients condition; how he

responds to the diet

Nursing Responsibilities (Prior, During, After)

Page | 36

Breakfast Soft Diet Date Ordered: July 17, 2011 Date Discontinued: July 18, 2011 Soft diet is soft The soft diet serves in texture and as a transition from consists liquids semi-solid foods. indicated certain postoperative cases, for Dinner -1 cup of porridge, -1 glass of water (240ml) It of liquids to a regular and diet for individuals who are recovering is from surgery or a in long illness -1 cup of porridge, -1 glass of water (240ml) Lunch -1 cup of porridge, -1 glass of water (240ml) Since the patient was oriented and understand needed interventions, he followed with the doctors prescriptions

Prior: Verify the physicians order During: Encourage compliance After: Assess for patients condition diet

convalescents who tolerate cannot a

regular diet, in acute illnesses, and in some

gastrointestinal disorders. Clients Response

Type of Diet

Date Ordered/ Date Changed/ Date

Description

Indication/ Purpose

Specific food taken

Nursing Responsibilities (Prior, During, After)

Page | 37

Discontinued Breakfast: DAT Date Ordered: July 18, 2011 When patient can now eat any food she desires as much as it is nutritious Diet as tolerated is a term that indicates that the gastrointestinal tracts is tolerating food and is ready for advancement to the next stage. Therefore, this statement is most applicably in regard to the diet after abdominal or gastrointestinal surgery, signifying the patient's tolerance of his diet. cup porridge, 1 glass water (240ml) Since the patient was oriented and understand needed Lunch -Sinigang na baboy 2 sliced , -1 cup plain rice -1glass of water (240ml) Snacks: -9pcs of fita biscuits, -C2 1 glass (240ml) Dinner: -Sinigang na bangus sliced, - 1 cup of plain rice
Page | 38

Prior: Verify the physicians order Explain the type of diet prescribed to the patient During: Ensure patient that the

interventions, he followed with the doctors prescriptions.

strictly

follow the diet After: Assess for patients condition

-1 glass water(240ml)

B. Exercise Type of Exercise Date ordered Description Indication Clients Response Nursing Intervention

Prior Walking July 16, 2011 It is one of the main Ambulation has been The client have a gaits of locomotion and found to be beneficial slight is typically slower than in running and other gaits. the process difficulty in Check doctors order for any other considerations needed. Explain the purpose of exercise to the patient. Explain why it is important and how could improve his condition. During Assess condition. Reinforce appropriate. Assist the patient in moving and walking
Page | 39

of walking but still tries and to walk.

recovery improving

bowel

function and blood circulation

patients

present

information

as

After Note patients response to activity

Page | 40

VIII.

Medical/Surgical Management

A. Surgical Management

Type of Surgery Appendectomy

Description

Indication

Patients Response

Nursing Intervention

An appendectomy (sometimes called appendisectomy or appendicecto my) is the surgical removal of

Symptoms

of

acute While interviewing our PRIOR client she verbalized Client was place in supine position with contraptions and checked noted by that medyo natatakot

appendicitis include:

Pain: abdominal pain (located in the lower right side)

the vermiform appendix. This procedure is normally performed as an emergency

nga

din

ako kaya ay talaga

magpaopera, nung una

procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis; it is now recognized that many cases will resolve

anesthesiologist. Skin preparation of the induction site of anesthetic agents Induction anesthesia, of either

Fever temperature)

(elevated

kinakabahan

ako. Ito kasi ang unang appetite beses na maooperahan ako ng ganito e.

Reduced (anorexia)

Nausea; vomiting

when treated non-operatively. In some The doctor will: cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix. This is a Check your abdomen for tenderness and

spinal or epidural and sometimes anesthesia Abdominal skin

Page | 41

general

relative contraindication to surgery. Appendectomy may be

tightness Check your rectum for tenderness Check your blood for an increase in white blood cells (WBC) Perform a pelvic exam in women, to exclude pain caused by the

preparation done

to

be

performed laparoscopically (this is called minimally invasive surgery) or as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or if it is desirable to hide the scars in the umbilicus or in the pubic hair line. Recovery may be a little quicker with laparoscopic surgery; the procedure is more expensive and resourceintensive than open surgery and generally takes a little longer, with the (low in most patients) additional risks associated the pelvic lower If

Application of drapes, eye sheet,

laparotomy sheet DURING Sequential begins: the incision skin,

subcutaneous, penetrating to the

ovaries or uterus your doctors about they a are the can

abdominal wall Removal of the organ uncertain diagnosis, perform

AFTER: Sequential using closing

with pneumoperitoneum (inflating abdomen sepsis with gas). Advanced requires a

computed

tomography (CT) scan to see if the appendix is inflamed.

appropriate

occasionally

absorbable sutures Hemostasis secured, peritoneal wash done Initials instruments OS, and

midline laparotomy.

needles completed
Page | 42

B. Intravenous Fluid

Management

Date Ordered; Date Result In DO: 07-14-11 DP: 07-14-11 3:20pm

General Description

Indication/ Purpose IV Therapy is indicated to maintain hydration and/or correct hydration in patients unable to tolerate sufficient volumes of oral fluids by mouth, to provide salts needed to maintain electrolyte balance, to provide glucose (dextrose, and for administration of drugs.

Clients Response >maintain fluid and electrolyte. >no dehydration noted >fast effect of medication.

Nursing Responsibilities IV Therapy. Prior >Check physicians order >Wash hands >Gather all materials needed >Explain the procedure and provide *patient teaching. During >Check patency of IV Therapy >Monitor for signs of complications >Check regulation and flow rate. After >Dispose of all materials used in the right waste can. >document the procedure and clients response.

D5LR

IV infusion of D5LR 1L 32gtts/min Run for 8 hours

D5NM

DO: 07-15-11 DP: 07-15-11 7:00am

IV infusion of D5NM 1L 31gtts/min Run for 8 hours

D5LR

DO: 07-16 to18-11 DP: 07-16-11 6:20pm

IV infusion of D5LR 1L 25gtts/min Run for 10 h0urs

Page | 43

C. Drug Study Date ordered, taken/given Route of administration, dosage, frequency Generic Name: RANITIDINE Brand Name: ZANTAC Date ordered: July 15,2011 Date given: July 15,2011 6:00am 80 mg TIV Q8 General action, Classification, Mechanism of Action Classification: H2 RECEPTOR BLOCKER GENERAL ACTION >anti-ulcer MECHANISM OF ACTION >Competitively inhibits the action of histamine at the H2 receptors of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric Indications/Purpose Client response to the medication, actual side effects Nursing Responsibilities

NAME of DRUG

INDICATION >Short-term treatment of active duodenal ulcer > Maintenance therapy for duodenal ulcer at reduced dosage >Short-term treatment of active, benign gastric ulcer

Clients response >decreased abdominal pain Side effects >abdominal pain, constipation,

PRIOR Check for doctors order Assess patient for contraindication. Assess for baseline data. Tell patient that she may experience side effects brought about by the drug. DURING Administer the drug slowly. AFTER Instruct her to report intolerable side effects so as prompt intervention could be done. Instruct her to report adverse effects that she may experience.

acid secretion that is stimulated by food, insulin, histamine, cholinergic agonist, gastrin, and
Page | 44

NAME of DRUG

Date ordered,

Route of administration,

General action, Classification,

Indications/Pu rpose

Client response Nursing Responsibilities

pentagastrin.

Page | 45

taken/given

dosage, frequency

Mechanism of Action Short term management of pain (not to exceed 5 days total for all routes combined The client takes the medicine and the pain she feels from her incision is slowly declining. PRIOR Check for doctors order. Assess pain (note type, location, and intensity) prior to administration. DURING Give IV bolus dose over at least 15seconds give through a Y-Tube in a free flowing IV. AFTER Assess pain (note type, location, and intensity)after the administration. Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur.

Ketorolac (Toradol)

Date Ordered: July 14, 2011 Date Given: July 15,2011 (10:15 am)

Non-steroidal anti30mg/amp1 inflammatory drug incorporate to 90mg in (NSAID) 800ml D5W to run for - Inhibits 30ugtts/min prostaglandin synthesis, producing peripherally mediated analgesia - Also has antipyretic and anti-inflammatory properties. - Therapeutic effect: Decreased pain

Page | 46

Name of drug

Date ordered, taken/given

Route of administration , dosage, frequency 300mg, TIV now, q4, PRN for 38C

General action, Classification, Mechanism of Action

Indications/Pu rpose

Client response

Nursing Responsibilities

Generic name: PARACETAMOL Brand name: Acetaminophen

Date ordered: July 15, 2011 Date Given: July 15, 2011 11:30am

Classification Nonopoid analgesics and antipyretic GENERAL ACTIONS > decreases body temperature MECHANISM OF ACTION > Reduces fever by acting directly on the hypothalamic heatregulating center to cause vasodilation and sweating, which helps dissipate heat.

INDICATION >reduce body temperature

Clients response >fever decreases from 38C- 37C

PRIOR 1. Check for doctors order 2. Not to be given in patients hypersensitive to drugs 3. Inform the patient about the possible side effect of the drug DURING 1. Inject directly slowly AFTER 1. Tell patient that she may experience some side effects brought upon by the drug

Page | 47

Name of drug

Date ordered, taken/given

Metronidazole Infusion: Flagyl IV RTU

Date ordered: July 14,2011 July 15,2011 Date Given: July Date Ordered: July 19, 2011 No oral meds bought

Route of administration, dosage, frequency 750mg TIV now then q8 parenteral 300mg TIV q4 RTC Cont: 500mg TIV q8

General action, Classification, Mechanism of Action Anti-Protozoal, Antibacterial

Indications/Pu rpose

CLIENTS RESPONSE

NURSING RESPONSIBILITIES

Amebiasis Anaerobic Bacterial Infections

none

Oral: Stat 500mg/tab BID for 1week

PRIOR Check for doctors order Obtain C&S before beginning drug therapy to identify if correct treatment has been initiated. Obtain baseline information on patients infection: fever, wound characteristics, vaginal secretions, WBC count (>100,000/mm3) and regular assess during treatment. DURING Give IV solution slowly during administration Inform patient that it may cause dizziness or light-headedness. Caution patient or other activities requiring alertness until response to medication is known. AFTER Assess for allergic reactions: rash, urticaria, pruritus.

Page | 48

Name of drug

Date ordered, taken/given

Route of administratio n, dosage, frequency

General action, Classification, Mechanism of Action Antibiotic, Antibacterial Cephalosporin antibiotic Cefuroxime is an antibiotic used to treat a wide variety of bacterial infections. It may also be used before and during certain surgeries to help prevent infection. This medication is known as a cephalosporin antibiotic. It works by stopping the growth of bacteria.

Indications/Pu rpose

Clients Response

Nursing Responsibilities

Infusion: Cefuroxime sodium (Zinacef)

Date ordered: July 15,2011 Continue: July 16,17,18 2011 Date Given July 15,2011 (8:30pm) Date Ordered: July 19, 2011 No oral meds bought

Urinary Tract Infection Lower Respiratory Tract Infections, Skin Infections

750mg q 8hours IV

Capsule: Cefuroxime axetil (Ceftin)

500mg/cap BID

The client received this drug for severe/life threatening infections such as septicemia, or in poor-risk clients, especially in presence of shock.

PRIOR Check for doctors order Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated. Verify correct IV concentration and rate of infusion. DURING Give IV solution slowly during administration AFTER Monitor I&O rates and pattern. Report any significant changes Inspect IM and IV injection sites frequently for signs of phlebitis.

Page | 49

D. Laboratory Results

HEMATOLOGY: Date: 07/14/2011 COMPLETE BLOOD COUNT

DIAGNOSTIC WBC

ACTUAL RESULT
17.1
10 9/l

NORMAL RESULT
5.0-10.0

NURSING IMPLICATION
High-indicates infection

NURSING RESPONSIBILITIES
>Instruct patient to increase intake of Vitamin C and increase fluid intake >Administer antibiotic as ordered

RBC HGB HCT PLT PCT MCV

5.31 10 12/l 137 9/l .409 1/l 407 10 9/l .296 10 -2/l 77 l fl

3.80-5.80 110-165 .350-.500 150-390 .100-.500 80-97

Normal Normal Normal High-indicates infection Normal Low-indicates anemia >Instruct patient to increase intake of Vitamin C and increase fluid intake

MCH MCHC RDW PPV PDW

26.9 l pg 336 g/l 15.7 H% 7.3 fl 12.6 %

26.5-33.5 315-350 10.0-15.0 6.5-11.0 10.0-18.0

Normal Normal Normal Normal Normal

Page | 50

WBC FLAGS DIFF:

DIAGNOSTIC
%LYM %MON %GRA

ACTUAL RESULT 6.7 l % 4.5 l % 91.8 H%

NORMAL RESULT 17.0-48 4.0-10.0 43.0-76.0

NURSING IMPLICATION
Low-indicates exhausted immune system Normal High-indicates infection

NURSING RESPONSIBILITIES

>Monitor signs of infection such as elevated Body Temp. >Administer antibiotic as ordered

DIAGNOSTIC
%LYM %MON %GRA

ACTUAL RESULT 1.1 l % 4.2 l % 15.8 H%

NORMAL RESULT 17.0-48 4.0-10.0 43.0-76.0

NURSING IMPLICATION
Low-indicates exhausted immune system Normal High-indicates infection

NURSING RESPONSIBILITIES

>Monitor signs of infection such as elevated Body Temp. >Administer antibiotic as ordered

Page | 51

URINALYSIS
Date 7/14/2011
UROBILINOGEN Glucose Bilirubin Ketone S.P Gravity # + 1.030

Blood pH Protein Nitrile Leukocytes

5.0 -

Microscopic Examination (Urinalysis)

RBC Crystals Amorphous Urates Ephitelial cells Bacteria Remarks;

0-1/hpt few rare Many

WBC Casts Mucous Threads Others; Preganancy Test

6.8/hpt Negative

Amorphous urates (Na, K, Mg, or Ca salts) tend to form in acidic urine and may have a yellow or yellow-brown color. Bacteria in the urine are more likely to develop urinary tract (UTI) and kidney infections

Page | 52

IX.

Prioritization CUES S: Masakit pa din ung tahi ko As verbalized by the client. O: >guarding behavior >facial grimace >irritability >weak in appearance >pain scale of 6/10 1 RANK JUSTIFICATION This should be prioritized first because under Maslows hierarchy of needs, pain avoidance is under the physiologic needs which are the basic need of man. And also, if we correct this problem we may also correct impaired physical mobility, impaired walking, and self care deficit, because all of these problems are caused by the pain felt by the client. O: This should be given priority because the client has undergone a major surgery therefore his 3 immune system is altered so we should focus on the prevention of infection.

NURSING DIAGNOSES Acute pain related to surgical incision as manifested by pain scale of 6/10.

Risk for infection related to surgical incision on abdomen.

Vertical incision on midline of the abdomen due to recent Appendectomy

Page | 53

Disturbed sleeping patterns related to sleep interruptions for therapeutics, monitoring and other generate awakening and excessive environmental stimulation (like noise and lighting).

S: Paputol putol ung tulog ko kasi madaming lakad ng lakad sa paligid. As verbalized by the client. O: >presence of eye bags >irritability >weakness >sunken eyes >unfavorable environment 2

This should be 2nd because sleep and rest is under the physiologic needs of man, which are basic for us to survive. And enough rest is good for the clients recovery from operation.

Self care deficit (bathing and hygiene) related to muscle weakness secondary to recent surgical incision on abdomen as evidenced by slight body odor.

O: >slight body odor 4

This should be prioritized 4th because the client may resume daily self care activities if he has regained his strength by sleeping and absence of pain.

Page | 54

X.

Nursing Care Plan NURSING DIAGNOSIS

SCIENTIFIC BACKGROUND

ASSESSMENT

PLANNING

INTERVENTION

RATIONALE

EVALUATION

S: Masakit pa din ung tahi ko . As verbalized by the client.

Acute pain related to surgical incision as manifested by pain scale of 6/10. Surgical incision on the right lower quadrant of the abdomen

Short term Goal

Independent

Short term Goal

>After 30mins. of nursing intervention the client will be able to demonstrate use

>Provide comfortable environment

>Calm environment Goal met helps like anxiety decrease >After 30mins. of of the nursing intervention

changing bed linens patient and promote the client was able and tuning on the likelihood fan decreasing p.368 Pocket of to demonstrate use pain. of relaxation skills Nurses and diversional Guide 9th activities to

O: >guarding behavior >facial grimace > weak in appearance >irritability >pain scale of 6/10

Disruption of skin tissue and muscle integrity

of relaxation skills and diversional activities to alleviate pain.

edition(F.A company)

Davis alleviate pain.

>After 30mins. of nursing Stimulation of sensory nerve endings intervention the client will be able to verbalize

>Instruct binder abdomen.

to on

put >To

protect

the Goal met

the area of incision and >After 30mins. of to improve comfort. nursing intervention p.368 Pocket Nurses the client was able Guide 9th to verbalize
Page | 55

methods that Injurious noxious stimuli provides relief from pain Nociceptors Long term Goal

edition(F.A company) >Instruct patient to >For

Davis methods that provides relief from

pulmonary pain Goal met when

do deep breathing ventilation and exercise. coughing especially

exercising and to After 4 hrs. of relieve stress and nursing intervention promote relaxation. p.229 Fundamentals the patients pain scale was of decrease from 6/10

Spinal cord

After 4 hrs. of nursing

Brain stem

intervention the patients pain scale

Brain (somatic sensory cortex)

will decrease from 6/10 to 3/10. >Provide diversionary

Nursing (Kozier 7th to 3/10 edition) >To promote

Nociception

activities, ankle active

initiate circulation, prevent pumping, venous stasis and lower prevent pressure on p.368 Pocket Nurses Guide 9th

Release of endorphins

extremity ROM, and the operative site. walking.

Acute pain Dependent

edition(F.A company)

Davis

Page | 56

>Administer analgesics as doctors order.

>Relieves pain felt by p.369 Pocket the patient. Nurses Guide 9th

edition(F.A company)

Davis

ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC BACKGROUND
Environmental stimuli

PLANNING

INTERVENTION

RATIONALE

EVALUATION

S: Paputol putol ung tulog ko kasi madaming lakad ng lakad sa paligid As verbalized by the client.

Disturbed sleeping patterns related to sleep interruptions for therapeutics, monitoring and other generate awakening and excessive

Short term Goal Independent >After 2 hours of nursing intervention the >provide quiet environment and comfort measures such as back rub, washing hands and face and straightening of bed linens as preparations for >caffeine mental >to relaxation

. promote Long term Goal to the Goal met

client and to initiate After 4 hrs of sleep. p.1124 nursing intervention of the client was able

Disruption of sleep

client will be able to identify and demonstrate

Fundamentals

Nursing (Kozier 7th to report increase edition) sense of well being and feeling rested.

O: >presence of eyebags >irritability

environmental stimulation (like noise and lighting). As manifested by

Awakening of the patient

appropriate interventions to promote sleep.

causes Short term Goal alertness.

Page | 57

>weakness >frequent yawning > 5-6 hrs of sleep

frequent yawning

Inability to go back to seep

>After 1 hour of nursing intervention the client will be able

sleep. >recommend limiting of inducing caffeine containing foods especially before bed time.

p.1126 Fundamentals of Goal met Nursing (Kozier 7th After 2 hours of edition) nursing intervention the client was able >To avoid to identify and

Disturbed sleeping pattern

to verbalize understanding of sleep disturbance.

disturbances during demonstrate

>Do as much care as sleep, and also to appropriate possible without maximize the sleep interventions to waking up the client and rest of the promote sleep. and do as much care as possible while the client is still awake.

Long term Goal

After 4 hrs of nursing intervention the client will be able to report increase sense of well being and feeling rested.

client.

p.1125 of Goal met

Fundamentals

Nursing (Kozier 7th After 1 hour of edition) nursing intervention

>Explain necessity of disturbances for monitoring Vital Signs and care when hospitalized

>For the patient to the client was able have understanding an to verbalize of understanding of

the importance of sleep disturbance. care being done to her and to minimize the p.1125
Page | 58

complaint.

Fundamentals

of

Nursing (Kozier 7th edition)

ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC BACKGROUND

PLANNING

INTERVENTION

RATIONALE

EVALUATION

O: Vertical incision on midline of abdomen due to recent surgical procedure

Risk for infection related to surgical incision on abdomen. Traumatized tissue on Surgical Incision Short term Goal

>cleanse incision site daily with

>to ensure clean incision site, to prevent contamination. p860 Fundamentals of Nursing(Kozier 7th edition) >for mobilization of respiratory secretions. p.308 Nurses Pocket Guide 9th Short term Goal Goal met After 4 hours of nursing intervention the patient was

After 4 hours of appropriate nursing intervention the to solution/according to the hospital policy.

patient will be able understand factors, >encourage early signs of ambulation, deep and breathing and

able to understand causative identify infections factors, signs of and

injured site

causative identify infections

Invasion pathogenic

of report them to the position change. health care

report them to the health care

Page | 59

microorganisms

provider accordingly. >monitor white blood cell count

edition(F.A Davis company)

provider accordingly.

Increasing risk of infection

>rising WBC indicates bodys efforts to combat Long term goal After 2-3 days of nursing intervention the patient will achieve timely healing of wound and be free from infection. >monitor elevated temperature, redness, swelling, increased pain, or purulent drainage at incision. pathogens. Normal values: 4000 to 11000 mm3. p861 Fundamentals of Nursing(Kozier 7th edition) >these are signs of infection. p861 Fundamentals of Nursing(Kozier 7th edition) >wash hands before contact with patient before procedures >friction from running water effectively removes
Page | 60

Long term goal After 3 days of nursing intervention the patients wound was healed.

microorganisms from hands. Washing between procedures reduces risk of transmitting pathogens from one area to another. p644 Fundamentals Dependent >administer antibiotics >antibiotics combat pathogens. p.308 Nurses Pocket Guide 9th edition(F.A Davis company) of Nursing(Kozier 7th edition)

Page | 61

XI.

Discharge Planning

A. General condition of the patient upon discharge The patient can already ambulate, her vital signs is normal and she is not pale in color. Theres a minimal pain in her incision and no signs of inflammation and redness in the area. B. METHODS: MEDICATION: Metronidazole This medication is for Anti bacterial, the dosage is 500 mg tablet every 12 hours for 1 week This medication is taken after meal to prevent Gi upset. Celecoxib The medication is used to treat mild to moderate pain, dosage is 200 mg capsule, every 12 Hours as needed for pain take this medication after meal to avoid GI upset Cefuroxime Used to treat bacterial infection, the dosage is 500mg capsule, every 12 hours for 1 week. Take this medication after meal EXERCISE

Advised to walk frequently as possible at least 5-10 minutes, even if a few steps. Provide environment that is well ventilated, quiet, and gives comfort to her for easily recovery Walking is a particularly good choice, because you can set the pace to your energy level. It also has wonderful health benefits. It can improve circulation, decrease the risk of blood clots, reduce intestinal swelling, and promote healing .She can also do a house hold chores but avoid strenuous activity such as lifting heavier things. Advised deep breathing exercise to lessen the pain she felt.
Page | 62

TREATMENT:

Encourage patient to perform regular wound care to avoid infection, advised to use abdominal binder to protect wound and or surrounding tissue. Advise to continue to take the prescribed home medication until end of the regimen or unless specified by the physician. HYGIENE: Advised to take a bath daily and encouraged the patient to perform wound care to avoid infection and to promote healing. OUT PATIENT APPOINTMENT She should return after 1 week or July 26, 2011 for follow up checkups and consultation. DIET: Food rich in iron such as, avocado, oats, tofu, meat, fish, and eggs. Iron is good for blood needed to form hemoglobin. Prevents anemia (fatigue, irritability, pale colored skin) Food rich in protein such as meat, fish, milk, beans, and nuts. It helps for the growth and repair of the body's tissues; proteins provide energy. Food rich in vitamin C such as fruits like dalandan and orange. Vitamin C helps to fight bacterial growth and to increase immune response. Drink plenty of water. Drink to satisfy your thirst, but be sure to drink 8 to 10 glasses of water every day. To avoid constipation SPIRITUAL

Encourage significant other to strengthen her spiritual beliefs.

Page | 63

XII.

Conclusion

In this study, the diagnostic, clinical and surgical procedures done to treat appendicitis were described in detail. Research was also presented to exemplify these procedures and see how every case is unique. In this way, appendicitis and appendectomy were fully explored by using methods of participant observation, informal interviews, and personal accounts. As a team, appropriate nursing care plans were given and health teachings were imparted to the client. Although this is a thorough examination of appendicitis, this case study could not possibly capture student nurses experiences in the operating room. The most significant lesson we learned throughout the study was the ambiguity of diagnosis and medicine. We learned one very important lesson doctors, nurses, and patients must realize: each case must be taken as its own. An assembly line approach to diagnosing and treating appendicitis is not the solution: no appendicitis presents itself in the same way. Thus, having discussed and debated over this subject matter, we, as nursing students, have applied the necessary skills, showed the appropriate attitude, and learned many things as we took turns in handling the patient. We observed and cared for the post operative patient and gave the proper nursing implementations we can offer. It was a big relief to see that her recovery would not be only because of her medications, but also because of our nursing interventions.

Page | 64

XIII. Bibliography

http://www.medilexicon.com/medicaldictionary.php?t=5701 http://medical-dictionary.thefreedictionary.com/gangrenous+appendicitis http://heartburn.about.com/od/otherdigestivedisorder1/a/appendicitis.htm http://www.medicinenet.com/appendicitis/article.htm http://www.mayoclinic.com/health/appendicitis/DS00274 http://www.webmd.com/digestive-disorders/digestive-diseases-appendicitis http://www.symptomsofappendicitis.org/Appendicitis-Statistics.html http://www.medicinenet.com/gangrene/page2.html http://en.wikipedia.org/wiki/Gut_flora http://en.wikipedia.org/wiki/Human_microbiome http://www.ncbi.nlm.nih.gov/books/NBK7670/ http://www.textbookofbacteriology.net/normalflora.html

Page | 65