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I.

Patient Profile

Name: Bernardo Matobato


Age: 26 years old
Gender: male
Occupation: construction worker
Educational Attainment: grade 4
Civil Status: single
Nationality: filipino
Address: brgy. Dapdap Alang-alang Leyte
Religion: catholic
C/C: abdominal pain
Date Admitted: july 22, 2010 @ 9:00pm
Admitting Diagnosis: ruptured appendicitis
Attending Physician: Dr. Bañez
Source of Information: patient and mother
Reliability: 90%

II. Present Illness:

14 hours prior to admission, the patient experienced mild pain on his right lower
quadrant abdomen while eating in the morning, followed by a severe pain. The client
tried to eliminate the pain using herbal oil but were not eradicated.
Persistence of the noticed pain, prompted his mother to bring him to EVRMC,
hence this admission.

III. Past Health History:

The patient did not receive any vaccination as claimed by the mother, has
experienced acute respiratory infection such as cough, cold and mild fever and took
biogesic (250mg) every 4 hours for fever and some herbal plants (decoction of lagundi)
for cough relief. Pain in the right lower abdomen 1st felt when the client was 25 years old
but were ignored no history of hospitalization.

IV. Family History:

The mother claimed that her mother is asthma positive, and noted hypertension
history on the paternal side.

V. Birth History:
The patient is 3rd on eight siblings of Mr. and Mrs. Matobato. Born via normal
vaginal delivery on their house.

VI.Psychosocial history:
The patient sorrounding is good and there were no lakes, swamp or river nearby.
They used a deep well for drinking and taking a bath. He smokes 5 sticks of cigar. Per
day, and play basketball in freetime.
PATTERNS OF FUNCTIONING CLINICAL INSPECTION OTHER SOURCES
1. RESPIRATORY
– (+) Hx of Asthma – RR = 26cpm
– Consumed 5 sticks – No accessory
of cigar/day muscle used
– Started smoking – No respiratory
since 17 y.o aids used
– No cough and
cold
1. CIRCULATORY Hematology:
– (+)Hx of HPN – BP = 110/70 WBC: 18.30x10^9/L
mmHg Neutrophil: .90
– PR = 53 bpm Lymphocyte: .10
– No presence of Hematocrit: .46
discoloured or
swollen parts
– Good capillary
1. FOODS AND FLUIDS refill
INTAKE
– Usual food taken:
leafy vegetables, – Good skin
fish, rice, root crops turgor
– (-)food allergies – Dry lips
– (-)food preferences – With an IVF of
& dislikes D5LR @
– Drink 4 glasses of 30gtts/min
water each day – No NGT
– Drink 10 glasses of
tuba occasionally
URINALYSIS
1. ELIMINATION Color : Dark yellow
– Void more than Transparency: Turbid
5x/day Specific gravity: 1.025
– Defecate 1x/day or PH: 6.0
sometimes 1 time Glucose: negative
every 2 days – Not constipated Albumin: trace
– Fun of retaining – Presence of WBC: 2-3/hpf
stools if at work indwelling Bacteria: moderate
catheter Mucus threads: many
– (-) nausea Costs: coarse granular:
0-1/lpf
Uric acid: moderate

1. REGULATORY
MECHANISM
– (+) mild fever
during childhood
– T = 36.6
– Afebrile
1. HYGIENE – (-) chills
– Take a bath 1-
2x/day
– Seldom use
shampoo – Untidy to look
– Change cloth at
everyday – (-)skin lesions
– No allergies to soap – Hair is equally
& shampoo distributed
– Combs hair – (+)Halitosis
– Poor dental care
– Presence of
plaque
1. EXERCISE &
LOCOMOTION
– Take the daily – Impaired
activities as mobility due to
Components Normal values Results Interpretation Clinical Significance

1. WBC 4.5 – 11x109/L 18.30 x 109/L Increased Presence of


inflammation

2. Neutrophils 0.45 – 0.73 0.90 Increased


Acute infection, trauma
or surgery

3. Lymphocyte 0.2 – 0.4 0.10 Decreased


Aplastic anemia, SLE,
immunodeficiency
including AIDS

4. Hematocrit Males: 42 – 52 % 46 % Normal


Females: 35 – 47 % Balance proportion of
blood volume that is
occupied by RBC

LABORATORY RESULTS

Hematology:
Urinalysis:
Components Normal Results Interpretation Clinical Significance
1. Color Pale yellow to amber Dark Yellow Not normal Not enough water
intake, presence of
bilirubin
2. Transparency Clear to slightly hazy Turbid Not normal
Cystisis, presence of
3. Specific gravity 1.015-1.025 1.025 Normal bacteria

4. PH 4.5-8.0 6.0 Normal Properly diluted urine

Not risk for calcification,


5. Glucose Negative Negative Normal and infection

6. Albumin Negative Negative Normal Absence of DM

7. WBC Negative or rare 2-3/hpf Not normal Proper filtration of


glumerolus
8. Bacteria Negative Moderate Not normal, bacteremia
Cystisis, nephritis,
9. Casts Occasionally hyaline Coarse granular: 0-1/hpf Not normal
casts Urinary tract infection

10.Uric Acid 3.13 mmol/24 h Normal Presence of renal


1.58-4.43 mmol/24 h infection or disease

Absence of calculi
ANATOMY AND PHYSIOLOGY

Vermiform appendix
In human anatomy, the appendix (or vermiform appendix; also cecal (or caecal)
appendix; also vermix) is a blind-ended tube connected to the cecum (or caecum),
from which it develops embryologically. The cecum is a pouchlike structure of the
colon. The appendix is 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. The appendix is located in
the lower right quadrant of the abdomen, or more specifically, the right iliac fossa the
position within the abdomen corresponds to a point on the surface known as
McBurney's point. While the base of the appendix is at a fairly constant location, 2 cm
below the ileocaecal valve, the location of the tip of the appendix can vary from being
retrocaecal to being in the pelvis to being extraperitoneal. In rare individuals with situs
inversus, the appendix may be located in the lower left side.
Maintaining gut flora: major function
Although it was long accepted that the immune tissue, called gut associated lymphoid
tissue, surrounding the appendix and elsewhere in the gut carries out a number of
important functions
The digestive tract's immune system is often referred to as gut-associated lymphoid
tissue (GALT) and works to protect the body from invasion. GALT is an example of
mucosa-associated lymphoid tissue.
The mucosa-associated lymphoid tissue (MALT) (also called mucosa-associated
lymphatic tissue) is the diffuse system of small concentrations of lymphoid tissue found
in various sites of the body such as the gastrointestinal tract, thyroid, breast, lung,
salivary glands, eye, and skin.

FOR the PATHOPYSIOLOGY just go to this site :


http://www.scribd.com/doc/46437230/Pathophysiology-of-Appendicitis
Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation

Limited movement related to INDEPENDENT:


pain as manifested by: Having an Appendectomy is After 8 hours of nursing
After 8 hours of nursing
a procedure that has the interventions the patient
1. Instruct the client to 1. Activity that require
Subjective: need to cause the tissue to interventions, the patient will
is able to Rest quietly Sit
be traumatized, which leads minimize activities holding the breath and
“Anay, hinay hinay la ke ma be able to Regain / maintain in a high-fowlers position
to the inflammatory process
ol-ol tak samad” as that will put pressure bearing down can result from lying in bed, and
characterized by pain, mobility at the higher
verbalized by the patient. redness, swelling and loss of on his abdomen. in pain to surgical site in know the proper way in
possible level, Demonstrate
function of some part, it is seating from a supine
2. Reposition RLQ, bradycardia and
effective in the treatment of techniques that enable position. therefore:
Objective: appendicitis with perforation, periodically and rebound tachycardia GOAL MET
resumption of activities, and
surgery leaves tissue
slowly and with elevated BP.
Temp - 36.6 oC damage that causes the Increase strength/ function
release of chemical encourage deep 2. Prevent / reduces
of affected and
PR - 53 bpm mediators, and WBC’s which
breathing exercises. incidence of skin and
causes to form exudates then compensatory body parts.
RR - 26 cpm this exudates causes the 3. Encourage rest. respiratory
nerve endings to be
BP - 110/70mmhg 4. Move patient complications.
compressed thus making
pain and this pain makes a slowly and 3. Reduces myocardial
person to have limited deliberately.
workload / oxygen
• weakness movement. 5. Administer
consumption, reducing
analgesics as
• facial grimace risk of complication.
ordered
• guarding behavior Reference: 4. Reduces muscle
• incision on RLQ Medical Surgical nursing by tension or guarding,

Brunner and Suddarth 11th which may help

edition; Vol.2 pages 1240- minimize pain of

1242 movement.
5. To maintain
“acceptable” level in
pain. Notify physician if
regimen is inadequate
to meet pain control
goal.
Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation

Impaired skin integrity Surgical intervention involves After 8 hours of nursing DEPENDENT: 1. Post-operative After 8 hours of nursing
related to surgical incision removal of appendix within 24 intervention the patient hemorrhage is likely interventions the patient’s
to 28 hours in which surgery will Achieve timely 1) Observe wound, to occur during first 2 wound appears to be dry and
SUBJECTIVE: can be performed through a wound healing and be note characteristics days, whereas freed from drainage or
“katapus ko la ka operahe” small incision that causes a free of infection, of drainage. infection may purulent substances therefore
as verbalize by the patient disruption or damage to the demonstrate how to develop anytime. goal was met.
skin tissues. Which will leads keep wound dry and
OBJECTIVE: to impairment of the first promote healing. 2. Reduce skin irritation
- open wound protective layer from 2) Change dressing as and potential
- visible surgical incision infections or foreign object. needed using infection, also to
- post-operative patient aseptic technique. prevent soaking the
dressing by any
Reference: discharges.
Temp - 36.6 oC
Medical surgical nursing by 3) Encourage side lying 3. May decrease
PR - 53 bpm brunner and suddarth, 11th position (on the left- pressure to operated
RR - 26 cpm edition volume 2 @ page: side) or a semi- site, thus relieving
1242 fowlers position. abdominal distention.
BP - 110/70mmhg
4. Promote protection to
4) Encourage guarding the incision site.
behavior.
5. Hasten the healing of
DEPENDENT the wound.
5) Administer
antibiotics as
doctor’s order
Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation

Risk for infection related to After 8 hours of INDEPENDENT:


surgical incision at right lower The creation of surgical nursing intervention, 1. Fever and pain indicate After 8 hours of nursing
1. Monitor vital signs,
quadrant of the body. incision during appendectomy the patient will be able inflammatory education and interventions,
onset of fever with
disrupts the skin integrity of to Verbalize and responses, which the patient was More
Objective: chills, and pain.
the skin and its protective understand the contribute to infection. conscious about his
2. Practice/ instruct good
incised skin @ right function. Exposure of deep causative/risk factor for 2. Reduces the risk for environment and the patient
hand washing and
lower quadrant body tissues to the pathogens the infection. infection or cross seems to be hesitated and
aseptic wound care.
RR – 26 cpm in the environment places the Demonstrate contamination of confused or failed to
3. Inspect incision site.
PR – 53 bpm patient at risk for infection of techniques in bacteria. express some of the
Note characteristics of
Temp – 36.6 oC the surgical site, a potentially minimizing infection. 3. Provides early detection information imparted by the
drainage from wound.
Incision pain threatening complication. Remove all possible of infection process, and nursing students therefore:
4. Change wound
Factors related to the surgical factors that may presence of discharges GOAL WAS PARTIALLY
dressing as indicated,
procedure include the method contribute to the may help to identify MET.
using proper
of preoperative skin infection process. whether there is an
technique for
preparation, surgical attire of Achieve timely wound infection.
changing/ disposing of
the team, method of sterile healing; be free of 4. To reduce/ correct
contaminated
draping, duration of surgery purulent drainage or existing risk factors.
materials.
and length of procedure. erythema. 5. Promotes healing and
5. Encourage intake of
prevents dehydration.
fluid and food that is
rich in Vitamin C.