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COLLEGE OF NURSING
CASE STUDY:
ACUTE APPENDICITIS
SUBMITTED BY:
BUNGAY , MARIA PAULA
FABUNAN , ROMAN
GAMBOA, LYZEL M.
BSNIII-3
SUBMITTED TO:
SERRANO , THERESA, RN, MAN
OCTOBER 02, 2013
INTRODUCTION
So long as you have courage and a sense of humor, it is never too late to start
life afresh.
Freeman Dyson
lumen. Left untreated, appendicitis has the potential for severe complications,
including perforation or sepsis, and may even cause death. However, the
differential diagnosis of appendicitis is often a clinical challenge because
appendicitis can mimic several abdominal conditions.
According to Sleisenger and Fordtran, the crude incidence rate of
appendicitis in the US for all age groups is 11/10,000 persons/year, and similar
rates are noted in other developed countries. Inexplicably, the rates of
appendicitis are as much as ten times lower in many less-developed African
countries. The incidence rate of disease peaks between 15 and 19 of age at
48.1/10,000 population per years and falls to about 5/10,000 population per year
by age 45 years, after which it remains constant. Men are at a greater risk than
women, with a case ratio in most series of 1:4:1. The lifetime risk of appendicitis
has been estimated at 8.6% in men and 6.7% in women.
Appendectomy remains the only curative treatment of appendicitis. The
surgeon's goals are to evaluate a relatively small population of patients referred
for suspected appendicitis and to minimize the negative appendectomy rate
without increasing the incidence of perforation. The emergency department (ED)
clinician must evaluate the larger group of patients who present to the ED with
abdominal pain of all etiologies with the goal of approaching 100% sensitivity for
the diagnosis in a time-, cost-, and consultation-efficient manner.
Objectives:
STUDENT-CENTERED:
Short term:
During the course of the study the student nurse will be able to:
Establish therapeutic relationship
Explain the purposes in conducting the interview
Collect information about the demographic data of the patient
Collect information about socio-economic & cultural beliefs of the patient;
Collect information about environmental factors of the patient
Collect data about the patients family health illness history, post &present
illness
List the diagnostic procedure done & explain
Identify the different medical, surgical,& nursing management
Highlight the importance of health teaching
Long term:
After the completion of the study the student nurse will be able to:
Assess the patient thoroughly
Classify manifestation of Appendicits.
Relate abnormal diagnostic findings with his disease condition
Demonstrate nursing interventions for procedure done
Identify nursing diagnoses & prioritize them
Formulate recommendations to be imparted for the patients same condition
Provide information regarding Appendicits.
Explain the indication, time route and dosage of medications upon discharge
PATIENT-CENTERED
Short term:
During the course of the study the patient will be able to:
Develop trust with the student nurse
Comprehend the purpose in conducting such interview
Give information regarding his demographic data
Give information regarding his socio-economic & cultural beliefs
Describe the environment he lives in
Provide data regarding the clients family-illness history, past & present illness
Demonstrate compliance to medical regimen
Identify risk factors
Long term:
After the completion of the study the patient will be able to:
Continue his cooperation with physical assessment
Express feelings regarding his condition
Will be able to accept his situation & have sense of control
Understand the manifestation related to his condition
Gain the basic information concerning Appendicits.
Eradicate activities that may worsen his condition
Obey with the treatment regimen given upon discharge.
his parents owns a small business were they sell cooked food in a small branch
in Angeles City. His parents only make at least 800 pesos per day. As for his
siblings, two of them works and shares a total of six thousand pesos per month.
The money is spent for their electricity bill of two thousand pesos per month, food
and school allowance for Ace and his youngest brother.
Ace is currently studying as a fourth year high school student, in a public
school in Bamban. He gets at least fifty pesos per day for school allowance. Ace
usual agenda during school days, is he wakes up at five thirty (5:30) in morning;
takes a shower, eats breakfast, which is generally rice since he cant go on a day
without having a heavy meal. By six thirty (6:30) he leaves their home and gets
to school by seven oclock (7:00) in the morning. At eleven thirty (11:30) in the
morning he comes home to have lunch. Then, comes back to school at one
oclock (1:00) in the afternoon until four thirty (4:30) in the afternoon. He also
mentioned that, he usually plays basketball after school as one of his recreational
activity.
As for his diet, Ace is a fan of eating vegetables; especially bitter melon
and he also loves to eat fish such as tilapia. As mentioned, he does not eat meat
due to religious purposes. However, he prefers white meat instead such as
chicken.
With regards to their cultural practices that affect the familys overall
health, they certainly believe in albularios, manghihilot and mananawas. They
also make use of herbal medicines like guava decoction for cleaning wounds and
toothache, oregano for cough and colds. However, they still prefer medical
treatment for serious complications. For instance, ruptured appendicitis; his
family is aware of the signs and symptoms since his father was diagnosed with
similar condition years ago.
C.ENVIRONMENTALS FACTORS
FAMILY HEALTH-ILLNESS HISTORY
GENOGRAM
PATERNAL
72 y/o
Heart problem
MATERNAL
74 y/o
Unknown cause
76 y/o
Heart problem
55 y/o
76 y/o
45 y/o
20 y/o
LEGENDS:
23 y/o
MALE
FEMALE
22 y/o
19 y/o
Ace
16 y/o
12 y/o
DECEASED MALE
DECEASED FEMALE
8
upon palpation, with 10 being the highest. He appears pale, irritated and
lethargic; due to the current condition he was experiencing.
The next day on the 18th of September it was Ace birthday, he turned 19
on the day of his surgery. It was twelve two (12:02) in the afternoon, when he
was admitted in the operating room for appendectomy, known as the removal of
the appendix.
10
ABDOMEN
Slightly muscular tone with gauze present on the right lower
quadrant of the abdomen.
Pain scale is 7/10.
GENITOURINARY
No gross deformities
EXTREMITIES
No bipedal edema
2. Physical Assessment (September 19, 2013)
General Appearance
On the 2nd visit, the patient was seen lying on bed. Unlike the previous day,
he was in less pain with a scale of 4/10. His nails are clean, appears relaxed and
comfortable. Throughout the assessment, the patient is cooperative. Vital Signs
taken as follows:
T= 36.6
PR= 68 bpm
RR= 20 bpm
BP= 100/70 mmHg
Skin Assessment
Appears to have a fair brown skin complexion.
It has normal skin turgor.
No body hair present on the patient.
HEAD
11
Abdomen
EXTREMITIES
Full and equal peripheral pulses
3. Physical Assessment (Sept 20, 2013)
General Appearance
On the last day of nurse patient interaction, the patient appears very
relaxed. He is conscious, coherent and happy before getting discharged from the
hospital. During the physical assessment, there is note that the patient is
sweating excessively. Throughout the final assessment, the patient is
cooperative.
Vital signs taken as follows:
T= 36.1 C
PR= 79 bpm
RR= 20 bpm
BP= 110/80 mmHg
GENERAL PHYSICAL SURVEY
The patient was seen in an appropriate shirt and pajamas.
The patient has a cooperative behavior and attitude.
He is not experiencing any signs of weakness.
The Integumentary
Upon the assessment of his skin, it appears to have a fair brown
skin complexion.
It has normal skin turgor.
He is sweating while lying down on bed.
There is no sign of edema present.
12
Appears to have very smooth and clean nails and toe nails.
Nail and toe nail bed are pinkish in color.
Fast capillary refill of less than 1 sec.
Has a pinkish nail bed color
Hair
Nails
Musculoskeletal System
He is able to move hands freely without difficulty.
Pain is felt on right lower quadrant when walking.
There is also pain manifested by the patient when sitting or
lying down on bed due to pressure being exerted in the lower
abdomen.
Musculoskeletal System
Patient is able to move and flex them voluntarily.
14
Neurologic System
Patient is very cooperative throughout the assessment.
He replies in a polite manner throughout.
Legs and Feet
There is presence of spot like scars on right feet.
Slight pain is felt when walking.
Presence of hair on the legs.
Glasgow Coma Scale
Eye Response
Given a score of 4.
Eyes are able to open spontaneously.
Verbal Response
Given a score of 5.
Patient replies and complies.
Motor Response
Given a score of 6.
The patient does simple things asked.
REVIEW OF SYSTEM
15
Diagnostic
Laboratory
Procedures
Date
Ordered
Result
Indication or Purpose
Normal
Values
Date
Perform
ed
Date
Change
1. Hematology
D.O
09-17-13
D.R.
09-17-13
Hemoglobin
0 Hemoglobin
screening test is a part
of CBC in a general
physical
examination,
specifically
upon
admission to a health
care facility to assess an
existing health condition.
The purpose of the test
is to measure the
oxygen carrying capacity
of the blood, and to
measure the severity of
anemia.
147
16
D.O
09-17-13
D.R.
09-17-13
D.O
09-17-13
D.R.
09-17-13
Hematocrit
It is indicated to
measure the volume
of RBC in the whole
blood or the total
percentage of the
RBC in the whole
blood. It aids in
diagnosis of abnormal
states of hydration,
polycythemia and
anemia.
0.44
WBC
It is indicated for the
count of the number
of WBCs (leukocytes)
in a liter of peripheral
venous blood as well
as the percentage of
each type of
leukocyte. In which
could indicate
presence of infection
and
immunosuppressed.
21.0
5-10 x
10^9/L
17
RBC
The test is indicated
D.O
for the count of
circulating red blood
09-17-13
cells (RBCs) in a liter
of peripheral blood. It
D.R.
is performed as part
of a CBC. In which,
09-17-13
Red blood cells carry
oxygen from the lungs
to the rest of the body;
it also carry carbon
dioxide back to lungs
so it can be exhaled.
Low RBC (anemia)
count indicates low
oxygen in the body.
However, if the count
is too high
(polycythemia), there
is a chance of blood
clotting that may
result into thrombosis.
5.14
4.5-6.3 L/L
18
Lymphocytes
D.O
09-17-13
D.R.
09-17-13
0.09
0.20-0.35
Platelet Count
D.O
09-17-13
D.R.
09-17-13
432
150-400
x10^9/L
19
Blood and
RH Type
D.O
identify
compatibility
blood.
However,
of
different
blood
and
cells.
reaction
caused
Transfusion
by ABO
20
NURSING RESPONSIBILITIES
CBC AND HEMATOLOGY TEST:
1. Explain test procedure. Explain that slight discomfort may be felt when the skin is
punctured.
2. Encourage to avoid stress if possible because altered physiologic status
influences and changes normal hematologic values.
3. Explain that fasting is not necessary. However, fatty meals may alter some test
results as a result of lipidemia.
4. Apply manual pressure and dressings over puncture site on removal of dinner.
5. Monitor the puncture site for oozing or hematoma formation.
6. Instruct to resume normal activities and diet.
BLOOD CHEMISTRY TEST:
1. Inform the patient this test can assist in evaluating the amount of hemoglobin in
the blood to assist in diagnosis and monitor therapy.
2. Obtain a history of the patient's complaints, including a list of known allergens,
especially allergies or sensitivities to latex.
3. Obtain a history of the patient's cardiovascular, gastrointestinal, hematopoietic,
hepatobiliary, immune, and respiratory systems; symptoms; and results of
previously performed laboratory tests and diagnostic and surgical procedures.
4. Note any recent procedures that can interfere with test results.
5. Obtain a list of the patient's current medications, including herbs, nutritional
supplements, and nutraceuticals.
6. Review the procedure with the patient. Inform the patient that specimen
collection takes approximately 5 to 10 min. Address concerns about pain and
explain that there may be some discomfort during the venipuncture.
7. Sensitivity to social and cultural issues, as well as concern for modesty, is
important in providing psychological support before, during, and after the
procedure.
8. There are no food, fluid, or medication restrictions unless by medical direction.
21
9. If the patient has a history of allergic reaction to latex, avoid the use of equipment
containing latex.
10. Instruct the patient to cooperate fully and to follow directions. Direct the patient to
breathe normally and to avoid unnecessary movement.
11. Observe standard precautions, and follow the general guidelines. Positively
identify the patient, and label the appropriate tubes with the corresponding
patient demographics, date, and time of collection. Perform a venipuncture;
collect the specimen in a 5-mL lavender-top (EDTA) tube. An EDTA Microtainer
sample may be obtained from infants, children, and adults for whom
venipuncture may not be feasible. The specimen should be mixed gently by
inverting the tube 10 times. The specimen should be analyzed within 24 hr when
stored at room temperature or within 48 hr if stored at refrigerated temperature. If
it is anticipated the specimen will not be analyzed within 24 hr, two blood smears
should be made immediately after the venipuncture and submitted with the blood
sample. Smears made from specimens older than 24 hr may contain an
unacceptable number of misleading artifactual abnormalities of the RBCs, such
as echinocytes and spherocytes, as well as necrobiotic white blood cells.
12. Remove the needle and apply direct pressure with dry gauze to stop bleeding.
Observe/assess venipuncture site for bleeding or hematoma formation and
secure gauze with adhesive bandage.
13. Promptly transport the specimen to the laboratory for processing and analysis.
14. A report of the results will be sent to the requesting HCP, who will discuss the
results with the patient.
22
Diagnostic/Lab
Date
Procedures
Ordered/Dat
Indications or purposes
Results
Normal
values
e Results
A. Urinalysis
1. Color
D.O
09-17-13
D.R.
09-17-13
2. Transparency
the
color
may
be
Clear,
strawcolored to
dark yellow
manifestation of one or
more illness.
It is indicated to detect
09-17-13
09-17-13
Yellow
conditions. Changes in
D.O
D.R.
leading
bleeding
and
to
Clear and
transparent
hydrated.
tissue
23
3. pH
D.O
09-17-13
D.R.
09-17-13
The pH is indicated to
measure
acidity
the
or
urine
6.5
4.50-8.00
alkalinity
(basic).
4. Specific
gravity
D.O
09-17-13
D.R.
09-17-13
amount of substances in
how
hydrated
well
the
kidneys
in
higher
urine.
the
and
no
signs
of
Diabetes insipidus.
The
specific
D.O
09-17-13
D.R.
09-17-13
Albumin
urine
test
is
used
+1
Absent
the
the blood.
kidney
to
filter
efficiently. To identify if
24
needed
to
be
D.O
09-17-13
D.R.
09-17-13
Glucose
urine
test
(glucose)
urine
sample,
in
Negative
Negative
This
means
that
the
The
presence of glucose in
the
urine
is
called
glycosuria or glucosuria.
diabetes.
It is commonly used to
test for diabetes.
7. Pus cells
D.O
09-17-13
D.R.
09-17-13
to
detect
the
1-2/HPF
5HPF
chemical
of
other
unexpected substance in
the
urine.
glucose
Specifically,
(diabetics),
D.O
09-17-13
D.R.
09-17-13
few
0-5/HPF
The patients
urine
has
few
Nursing Responsibilities:
BEFORE PROCEDURE:
Confirm the patients identity using two patient identifiers according to facility policy.
Inform the patient that the test is used to assist in the diagnosis of renal disease, urinary tract infections,
and neoplasm of the urinary tract, and as an indication of systemic or inflammatory diseases.
26
Obtain a history of the patients complaints, including a list of known allergens and inform the HCP
accordingly.
Obtain a list of medications the patient is taking.
Review the procedure with the patient. If catheterized specimen is to be collected, explain this to the patient
and obtain a catheterization tray.
There are no food, fluid or medications restricted unless by medical direction.
DURING PROCEDURE:
If the patient has a history of severe allergic reaction to latex, care should be taken to avoid the use of
equipment containing latex.
Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to
avoid unnecessary movement.
Observe standard precautions.
For clean-catch specimen: Clean the head of the penis with a sterile wipe. If you are not circumcised, you
will need to pull back (retract) the foreskin first.
Urinate a small amount into the toilet bowl, and then stop the flow of urine.
Then collect a sample of urine into the clean or sterile cup, until it is half full.
You may finish urinating into the toilet bowl.
AFTER PROCEDURE:
Inform the patient that he may resume his usual diet and medications.
Instruct the patient to report symptoms such as pain related to tissue inflammation, pain or irritation during
void, bladder spasms, or alterations in urinary elimination.
Report anxiety related to test results.
27
28
Location of Appendix:
Right lower quadrant of abdomen and more specifically right iliac fossa.
McBurneys point lying at the junction of lateral one-third and the medial two-thirds of
the line joining the umbilicus to the right anterior superior iliac spine roughly
corresponds to the position of the base of the appendix.
McBurneys point is the site of maximum tenderness in appendicits.
Variations in Appendix position:
Although the base of the appendix is fixed, the tip can point in any direction.
Hence, the position of the appendix is extremely variable. The appendix is the only
organ in the body which is said to have no anatomy. When compared to the hour hand
of a clock, the positions would be:
29
Arterial Supply:
Appendicular artery: The mesoappendix, containing the appendicular branch of
the ileocolic artery (branch of superior mesenteric artery), descends behind the ileum.
Accessory appendicular artery: An accessory appendicular artery can branch
from the posterior cecal artery which is also a branch of ileocolic artery.
30
Venous drainage:
Appendicular vein > Ileocolic vein > Superior mesenteric vein > Portal vein
Lymphatic drainage:
From the body and apex of the appendix 8-15 vessels ascend in the mesoappendix
and are ocasionally interrupted by one or more nodes > unite to form 3 or 4 larger
vessels > inferior and superior ileocolic nodes
A few of them pass indirectly through the appendicular nodes situated in the
mesoappendix.
Nerve supply:
1. Sympathetic nerves: T9 and T10 spinal segments through the celiac plexus.
2. Parasympathetic nerves: Vagus
Histology: Inside to outside
1. Mucosa:
No villi
31
Epithelium invaginates to form crypts of Liberkuhn but the crypts do not occur as
frequently as in the colon
2. Submucosa:
3. Muscularis externa:
Comprises 2 layers: Inner circular muscle layer and Outer longitudinal muscle layer
Outer longitudinal smooth muscle layer does not aggregate into taenia coli
32
Non-modifiable
Modifiable
A fecalith.
Swelling of the abdomen
Obstructed Appendix
Increase Intraluminal
Pressure
Decrease venous
drainage
Thrombosis, edema,
bacterial invasion
Inflammation
Abscess
formation
33
Mild
Leukocytosis
Pain (RLQ)
Guarding reflex
Vomiting,
anorexia, low
grade fever, and
halitosis
Gangrene and
perforation
34
Justification
They tend to have a detrimental lifestyle.
Fecalith may become occluded in this kind
of surface.
A fecalith may also be occlusion.
Severe pathway and cause occlusion.
adhesion.
Yersinia Infection
Men
Moidifiable
Fecalith
Swelling of the abdomen
a.3.
Justification
Can occlude the lumen of the appendix.
Can eventually cause occlusion.
Justification
Due to the inflammation of the Verniform
Mild leukocytosis
Appendix.
Due to the infection of the Verniform
Vomiting
appendix.
Food unable to pass through the intestine
due to occlusion
35
Anorexia
Low grade fever
Halitosis
infection
Due to occluded fecalith and/or infection.
36
a. PATHOPHYSIOLOGY
(Client-centered)
Non-modifiable
Modifiable
A fecalith.
Swelling of the abdomen
Alcohol
Acidic drinks
Obstructed Appendix
Increase Intraluminal
Pressure
Decrease venous
drainage
Thrombosis, edema,
bacterial invasion
Abscess
formation
Inflammation
37
Mild
Leukocytosis
September 18,
2013
Pain (RLQ)
September 1418, 2013
Vomiting,
anorexia, and
low grade fever
September 17,
2013
Gangrene
Appendecto
my
Sept. 18,
38
Definition of Disease
Non modifiable
Adolescent and young adults
Justification
They tend to have a detrimental
Men
lifestyle.
Have more detrimental lifestyle than
women.
Modifiable
Fecalith
Justification
Can occlude the lumen of the
appendix.
Can eventually cause occlusion.
b.3.
Justification
Due to the inflammation of the
Mild leukocytosis
Verniform Appendix.
Due to the infection of the Verniform
Vomiting
appendix.
Food unable to pass through the
Anorexia
39
40
Nursing
Diagnosis
Acute pain r/t
inflammation of
tissues
secondary to
Appendicitis
Scientific
Explanation
Appendicitis is the
inflammation of the
vermiform
appendix located
on the right lower
quadrant. It is
caused by an
obstruction
attributable to
infection, stricture,
fecal mass, foreign
body or tumor.
Appendicitis can
affect either
gender at any age,
but is most
common in males
ages 10 to 30.
Appendicitis is the
most common
disease requiring
surgery. If left
untreated,
appendicitis may
progress to
Planning
Short Term:
After 4 hours
of Nursing
Interventions,
the patient
pain scale will
be able to
decrease from
7/10 to 5/10
Long Term:
After 2 days of
Nursing
Intervention,
the patient will
be able to
demonstrate
actions of pain
relieved
Interventions
Rationale
>Establish
therapeutic
communication
>Assess general
condition
>Observe
patients non
verbal cues such
as facial
expression
>Investigate pain
reports noting
location, duration,
intensity (0-10
scale), and
characteristics
(dull,sharp,
constant)
>Changes in
location or
intensity are not
uncommon but
may be reflect
developing
complications
>To reduce
abdominal
distention, thereby
Expected
Outcome
Short term:
The patient shall
have decreased
pain scale from
7/10 to 5/10
Long Term:
The patient shall
have demonstrated
actions of pain
relieved.
41
>Weakness
>Restlessne
ss
abscess,
perforation,
subsequent
peritonitis, and
death
reduces tension
> Monitor &
record vital signs
>Provide comfort
measures such
as back rubs
providing
diversional
activities, and
massages
>Perform
comprehensive
assessment to
pain.
>Perform pain
assessment each
time pain occurs,
note changes
from previous
reports
>Help in alleviating
anxiety and relieve
pain.
>Make time to
listen and
maintain frequent
42
contact with
patient.
>To prevent
fatigue that will
worsen the pain
>Provide
adequate rest
periods.
>Encourage and
instruct to
increase fluid
intake.
>Suggest patient
to assume
position of
comfort while in
bed. Promote
bedrest as
indicated.
>Administer
analgesics as
ordered.
>To prevent
dehydration &
promote wound
healing
>To increase the
bodys resistance
against possible
complication.
>To reduce
metabolic rate and
aids in pain relief
and promotes
healing.
43
44
Assessment
Nursing
Diagnosis
Risk for
S>
Infection
related to post
O> Patient
surgical
manifested
incision site
the following: secondary to
appendectomy
>Afebrile
>Pale oral
mucosa
>Good skin
turgor
>Irritability
>With pain
when moving
Patient may
manifest the
following:
Scientific
Explanation
Skin is the
primary
defense
against foreign
bodies and
microbes.
Damage of the
skin allows
entry of
microorganism
s into the body.
Therefore, It
leads a
susceptibility of
infection.
Objectives
Short term:
After 4 hrs of
nursing
interventions,
the patient will
be able to
identify
interventions to
reduce/prevent
risk of
infections
Long Term:
After 3 days of
nursing
interventions,
the patient will
be free from
any kind of
infections
Nursing
Interventions
>Establish
therapeutic
communication
>Monitor and
record vital
signs
> Stress proper
hand washing
techniques by
all caregivers
Rationale
>To gain
patients trust
and
cooperation
>To obtain
baseline data
Expected
Outcome
Short term:
Patient shall
have identified
interventions to
reduce/prevent
risk of infections
>Cleanse
incision sites
daily
>First line
defense against
cross
contamination
Long Term:
Patient shall be
free from any
>To prevent
kind of
infection
infections
>Maintain
adequate
hydration
>To avoid
bladder
distention
>Change
dressings daily
>To prevent
soiling
>Encourage
early
ambulation
>To prevent
pressure ulcers
>fever
>To have
45
>Decrease
capillary refill
>Pale
palpebral
conjunctiva
>Increase
WBC
>Instruct client
in techniques to
protect the
integrity of the
skin, care for
lesions, and
prevention of
spread of
infection.
>Emphasize
necessity of
taking
antibiotics
knowledge of
the continuity of
care and for the
client to be
dependent from
care
>Premature
discontinuation
of treatment
when client
begins to feel
well may result
in return of
infection
46
Assessm
ent
S=
Nursing
Diagnosis
Activity
Intolerance R/T
O= Patient post surgical
manifested incision
the
following:
>Limited
ROM
Scientific
Explanation
Obstruction of the
Appendicitis
Pain in the RLQ of
the abdomen
Surgical Incision
APPENDECTOMY
>Facial
Grimace
PAIN
>Guarded
movement
Patient
may
manifest
the
following:
>Irritability
>Weaknes
s
>Sleepless
ACTIVITY
INTOLERANCE
Planning
Short Term:
After 4 hours of
Nursing
Interventions,
the patient will
be able to
verbalize
understanding
on improvement
of activity
tolerance within
patients
limitation.
Long Term:
After 1-2 days of
Nursing
Interventions,
the patient will
be able to
maintain activity
level within
capabilities.
Interventions
Rationale
>Establish
therapeutic
communication
>Assess general
condition.
>Provide adequate
rest.
Expected Out
Short Term:
Patient shall ha
verbalized
understanding
improvement o
activity toleranc
within patients
limitation
Long Term:
>Adjust activities to
enhance ability.
>Encourage patient
to maintain a
positive outcome
>To participate in
activities
>To enhance sense
of wellbeing
Patient shall ha
maintained acti
level within
capabilities.
>Teach ways on
how to conserve
47
night
energy such as
sitting when doing
activities
>Administer
medication prior to
activity as ordered
48
B. IMPLEMENTATION
1. MEDICAL MANAGEMENT (IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen therapy, etc..)
A. IVF: D5LRS 1L
Medical
management/
Treatment
D5LRS 1L
Date ordered
Date performed
Date changed
General Description
Indication(s) or Purposes
Nursing Responsibilities:
1. Check Doctors order for the amount and type of solution.
2. Identify clients name.
3. Advise to maintain cleanliness of site to avoid infection.
4. Keep record of drugs administered via IV.
5. Monitor when changing new IV
B. DRUGS
49
Date ordered,
Route of
General action,
Indications /
Clients
(Generic and
Date
administration,
classification,
Purposes
response to
Brand Name)
taken/given,
dosage and
mechanism of
the medication
Date changed
frequency
action
with actual
side effects.
The patient
types of bacterial
eventually got
bacterial
infections such as
better. Had a
multiplication.
UTI, meningitis,
slight burn
D.G
gonorrhea,
whenever drug
09-17-2013
pneumonia,
is administered.
09-18-2013
09-19-2013
Ampicillin
D.O
09-17-2013
tract infections.
Gentamycin
D.O
9-17-2013
80 mg/IV q8ANST
Antibiotic; thought to
Indicated for
The patient
(-)
inhibit protein
eventually got
systhesis; usually
diarrhea, Bacterial
better. Had a
50
bactericidal.
infections, Biliary
slight burn
tract infections,
whenever drug
09-17-2013
Endocarditis, Food
is administered.
09-18-2013
allergy, Muscle
09-19-2013
relaxation
D.G
(intermediate
duration) during
intensive care,
Muscle relaxation
(intermediate
duration) for surgery
or intubation, Muscle
relaxation (long
duration) during
intensive care,
Pneumonia in
hospital patients,
Septicaemia,
Ulcerative colitis and
crohn's disease,
51
Urinary tract
infection, and can
also be given in
adjunctive therapy
as an alternative
drug of choice in
Ranitidine
Antiulcer; H2
Solid tumor.
Indicated to treat
Patient Ace
receptor agonist.
complied and
Competitively inhibits
didnt complain
action of histamine at
intestines. It also
of any
H2-receptor sites of
treats conditions in
problems.
09-17-2013
parietal cells,
09-18-2013
decreasing gastric
09-19-2013
acid secretion.
acid, such as
D.O
09-17-2013
D.G
50 mg/IV q8
Zollinger-Ellison
syndrome.
Ranitidine also
treats
gastroesophageal
52
reflux disease
(GERD) and other
conditions in which
acid backs up from
the stomach into the
esophagus, causing
Ketorolac
D.O
30 mg IV q6 (-)
Antipyretic; non-
heartburn.
Indicated for short
09-18-2013
ANST X 4 doses
opioid analgesic;
NSAID; anti-
of patient Ace
inflammatory; inhibits
post operative
eventually
prostaglandins and
inflammation.
disappeared.
Analgesic; binds to
The post-
mu-opioid receptors
moderate to
operative pain
moderately severe
of patient Ace
reuptake of
pain.
eventually
D.G
09-18-2013
The post-
leukotrine synthesis.
09-19-2013
Tramadol
D.O
09-18-2013
D.G
100mg/IV q6
norepinephrine and
disappeared.
53
09-18-2013
serotonin; causes
09-19-2013
Mefenamic
D.O
09-17-2013
D.G
09-17-2013
50mg/tab q4 x pain
depressant effects.
Mefenamic acid and
The post-
other NSAIDs
moderate to
operative pain
(nonsteroidal anti-
moderately severe
of patient Ace
inflammatory drugs)
pain.
eventually
disappeared.
by inhibiting the
action of certain
hormones, called
prostaglandins, that
cause inflammation
and pain in the body.
By blocking the
effects of
prostaglandins,
54
mefenamic acid is
useful at reducing
pain related to bone,
muscle, or tendon
injury or
inflammation.
55
2.
3.
56
57
C. DIET
Type
Date ordered
of Diet
Date performed
NPO
General Description
Indication(s) or
Specific foods
Clients response
Purposes
taken
None
diet
The patient tolerated not
Ordered:
09/17/2013
inflammation of the
Verniform Appendix
Performed:
09/17-19/2013
operative care.
epigastric region.
Discontinued:
09/19/2013
58
Nursing Responsibilities:
1.
2.
3.
4.
5.
6.
Type of
Date ordered
Diet
Date
Diet as
General Description
Indication(s) or
Specific foods
Clients response
Purposes
taken
performed
Ordered:
09/20/2013
or no complication seen.
Tolerated
diet
The patient eventually
Performed:
drink called
09/20/2013
surgery called
eating pattern.
Appendectomy.
59
Nursing Responsibilities:
1. Check Doctors order for the
proper diet of the patient.
2. Assess patients identity.
3. Inform the SO about the
patients ordered diet.
4. Place the patient in proper
position.
5. Note any effects of the diet
to the patient.
6. Note the amount of intake.
7. Watch out for any signs of
aspiration.
8. Providing small frequent
feeding.
C. ACTIVITY/EXERCISE
Type of
Exercise
Date
ordered
Date
performed
Date
changed
Bed Rest Ordered:
09/17/2013
Performed:
General
Description
Refraining from
activities or
being carried
only when
necessary.
Indication(s) or purposes
Clients response
NPO
09/1718/2013
Nursing Responsibilities:
1. Check Doctors order for the proper diet of the patient.
2. Assess patients identity.
3. Inform the SO about the patients exercise.
4. Inform patient about the purpose of activity.
5. Demonstrate technique
6. Document any findings.
C. ACTIVITY/EXERCISE
Type of
Date
General
Indication(s) or purposes
Clients response
Exercise
Early
ambulation
ordered
Date
performed
Date
changed
Ordered:
09/19/2013
Performed:
09/1920/2013
Description
This is
performed by
the patient
walking around
the room if
tolerated but
with enough
rest between
the activities.
Nursing Responsibilities:
1.
2.
3.
4.
5.
6.
The doctor ordered the operation at patient Ace on September 18, 2013
and was performed at the same date, September 18, 2013. A small incision in the
RLQ of patient Ace is made. Then, the incision gets deeper until it reaches to the
appendix. Soon as it gets there, the surgeon leaves it hanging and cuts it. After
cutting the appendix, the surgeon sutures everything else.
After the operation, patient Ace is on a huge risk for acquiring infection
because of an open wound created to punctures the bodys 1 st line of defense. To
prevent this, it is wise to change wound dressings every day. Another problem
that patient Ace manifested is pain due to the operation sight made. To treats
this, It is important provide other comfort measures.
4. 02 Scalpel Handle # 4
Nursing Responsibilities
Pre - Operative
1. Ensure that the patients consent is signed.
2. Keep patient under NPO for the next 8 hrs before the surgery.
3. Provide the patient information about the surgery.
Intra - Operative
1. Keep the patient safe throughout the surgery.
Post Operative
1. Change wound dressing regularly.
2. Encourage patient to consume foods high in protein.
3. Provide other methods of pain relief.
2.
D.
EVALUATION
1. CLIENTS DAILY PROGRESS CHART (From admission to
discharge)
Nursing
Problems
Acute pain r/t
inflammation of
tissues
Risk for Infection
related to post
surgical incision
site secondary to
appendectomy
Activity
Intolerance R/T
post surgical
incision
Vital Signs
Temperature
Pulse rate
Respiratory rate
Blood Pressure
Admission
(09-18-13)
09-19-13
09-20-13
36.5
76
22
100/70
36.7C
72
20
110/70
36.1
79
22
110/80
Diagnostic
Procedure
Medical
Management
D5LRS 1L
Drugs
Ampicillin
1gm/IV q 6
Gentamycib
80mg/IV q 8
Ranitidine
50mg/IV q 8
Keterolac
30mg/IV q 6
Tramadol
100mg/IV q 6
Mefenamic 500
mg/tab q 4 x
Discharge
pain
Diet
NPO Pre-
NPO/DAT
DAT
OP
Activity
Bed rest
Ambulation
SURGICAL MANAGEMENT
Appendectomy
2. DISHARGE PLANNING
I.
appendix that spreads to its other parts. This condition is a common and urgent
surgical illness with protean manifestations, generous overlap with other clinical
syndromes, and significant morbidity, which increases with diagnostic delay.
Appendicitis is considered as the most common cause of acute abdominal pain,
and the management for it is antibiotic, but never pain reliever for it will mask the
manifestation of a ruptures appendix. Appendectomy is the only surgical
management for this complication.
With the problems of patient Ace, the doctor treated him with antibiotic and
drugs for anti-inflammation, especially for the inflamed appendix. Afterwards,
because the patient couldnt tolerate the pain anymore, they performed
Appendectomy on September 18, 2013. After the surgery, the patient was
eventually relieved of the condition except for the post-operative complications.
Afterwards, the patient was discharged on September 20, 2013.
RECOMMENDATION
For students:
This study is recommended for student nurses to use as a reference if
ever they will encounter the same case. This can also be used to widen their
knowledge or to sharpen their skills. This can help the future student nurses if
ever they will become interested as to what or how the case of Appendicitis really
performs.
For the other health care team:
This study is also recommended for the member of a health care
team to also sharpen their skills or use this case study as a reference if ever they
will encounter the same case as the researchers.
For the community:
This study is also recommended for those in the community who are at
risk and also for those who already had this disease. This can help those who
are at risk to avoid and prevent. And for those who were already experiencing the
same manifestation, this can help them to make a better decision-making or be
aware of their present health.
II.
LEARNING DERIVED
We, the researchers, were very glad to have this case, Acute
Appendicitis, for the first time. This research of ours honed our skills and
knowledge about this case but we know that we still have to practice
more, not just once, not twice, but infinite.
This case study made us aware that Veniform Appendix is not just
for show. Even though it is just an accessory organ of the body, it can still
harm us painfully or put our lives in agonizing danger.
This also gave us attention to protect our self and prevent the
things that may harm to us. We now appreciate the Veniform Appendix
and believe that we will value every part of our body.
Bibliography
Books
2059-2060
J. Black, J. Hawks.2009.Medical-Surgical Nursing 8th edition: clinical
management for positive outcomes. Management of Client with
Intestinal Disorders. Pp.683-685
Websites:
http://emedicine.medscape.com/article/773895-overview
http://medchrome.com/basic-science/anatomy/anatomy-appendix-
appendicitis/
http://emedicine.medscape.com/article/773895-overview