Subjective Skin integrity Comments: Sakit pa gamay ako tinahian as verbalized by the patient.

Dry ACTIVITY/SAFETY Comments: kapoy Pa ako a Lawas ug di pako makabarog as verbalized by the patient. With limitation in ability, ambulate COMMUNICATION Comments: ok ra ako Pandungog as verbalized by the patient. OXYGENATION Comments: wala man na lipongas verbalized by the patient. COMFORT/ SLEEP/ AWAKE Comments: dili lang ko makatulog ug sakto kay saba man as verbalized by the Patient. ko

Objective Incision is 3 inches and patients incision is dry and with intact dressing. With facial grimace and a pain scale of 4/10 Dry

LOC and orientation: patient is oriented to time, place and person. Sensory and motor losses in face or extremities: Needs assistance in defecating, sitting and TSB done by the significant others. Pupil size: R 3cm L 3cm

Reaction: Pupils Equally Round Reactive to Light Accomodation. Respiration is regular Describe: Patient RR 17 cpm. There is no chest pain noted and with clear respiratory sound

With Guarding movements Other signs of pain: PS: 4/10 incision site Patient is pale and sleepy looking.

CIRCULATION Comment: ok raman ako pamati as verbalized by the patient. no chest pain, leg pain and numbness on extremities Heart Rhythm is regular Pulse Car Rad R 88 L 87 DP Fem

COPING Occupation: student Members of household: parents and younger sister makasabot raman akoa mama ani as verbalized by the patient Most supportive person: NUTRITION comment: di pako kakaon kay bago pako operahan as verbalized by the patient ELIMINATION Date of last BM 6/29/11 mother

Post operative appendectomy, NPO, oral mucosa is dry, dry lips noted, no nausea but vomiting is present. Observed non-verbal behavior: NONE

The patient is under NPO before and after the operation.

Bowel Sounds: 4 cycle/minutes Urine (color, consistency, odor) Yellow, cloudy, faint aromatic Comments: normal volume, odor and color of urine. With 400-600cc per shift of urine output MGT. OF HEALTH & ILLNESS Briefly describe patients ability to follow treatments (diet, medication etc.) for chronic health problems, if present: Patient is takes her medication as prescribed. Adherence of surgical incision. Presence of both parents

Diagnostic result and its significance Cbc result result reference Indication

WBC Hemoglobin Hematocrit MCV MCH RBC Count MCHC

24.60 10^9/L 166 g/L 0.51 L/L 92.00 fl 29.60 pg 5.59 10^12/L 322 g/L

4.8-10.8 140-180 0.42-0.52 80-94 27-31 4.70-6.10 330-370

Indicates infection, systemic illness, inflammation, allergy, and leukemia and tissue injury. Within normal range Within normal range Within normal range Within normal range Within normal range Decreased MCHC values (hypochromia) are seen in conditions where the hemoglobin is abnormally diluted inside the red cells, such as in iron deficiency anemia and in thalassemia. Within normal range Within normal range Within normal range

RDW MPV Platelet count Differential count Neutrophil Lymphocyte Monocyte Eosinophil Basophil

11.90 fl 9.00 fl 163.00 10^9/L

11-16 7.2-11.1 150-400

85.30 % 8.00 % 5.20 % 1.10 % 0.40 %

40-74 19-48 3-9 0.7 0.2

High may indicate physical or emotional stress and trauma. Low may indicate sepsis Within normal range High may indicate infections from parasites or due to some inflammations occurring in the body. Low may indicate acute infection.

Blood typing and cross matching- is done to make certain that a person who needs a transfusion will receive blood that is compatible with his blood. BLOOD TYPING: O+

Sign and symptoms

Explanation

Abdominal pain

Obstruction of the appendicle lumen, the building-up of intra luminal pressure in the appendix. Typically it begins around the belly button and then after several hours (or 1-2 days) the pain moves to the right, lower part of the abdomen. The pain is constant and hurts worse with movement or when the belly is pressed.

Loss of appetite

Anorexia occurs when there is inflammation in the bowels or gut, such as occurs with appendicitis. It is said that loss of appetite is the most constant symptom of appendicitis. Intense pain.

Nausea and vomiting Increase swelling of the appendix Fever Constipation

Inflammatory response of the body to the bacterial invasion in the wall of the appendix. Bacterial infection. Constipation usually is caused by the slow movement of stool through the colon this may be because of poor bowel habits or low fiber diets.

Name of drug

Dosage classification frequency preparation IV 750 mg , q 8h Antibiotic

Mechanism of action

Specific indication

Adverse effect

Nursing consideration

cefuroxime

Bactericidal: Inhibits the synthesis of bacterial cell wall, causing cell death.

-Lower respiratory infection caused by S. pneumoniae, S. aureus, E. coli, klebsiella pneumoniae. H. influenza, S. pyogenes. -perioperative prophylaxis - Treatment of acute bacterial maxillary sinusitis.

CNS- headache, dizziness, lethargy, paresthesis. GI- nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence GUnephrotoxicity HematologicBone marrow depression( decr eased in WBC, PLATELETS, HCT.) HypersensitivityRanging from rush to fever to anaphylaxis, serum sickness reaction.

Give oral drug with food to decrease GI upset and enhance absorption. Parenteral drug Avoid alcohol when taking this drug and for 3 days after because severe reaction often occur. -you may experience these side effects: stomach upset or diarrhea. Report severe diarrhea, difficulty of breathing, unusual tiredness or fatigue, pain at injection site.

Name of drug

Dose Frequency preparation IV

classification

Mechanism of action

Specific indication

Adverse effect

Nursing consideration Administer oral with food. Take full course of

Metronidazole

Antebacterial Bactericidal: inhibits DNA synthesis in specific

Acute infection with susceptible anaerobic bacteria.

CNSheadache, dizziness, ataxia, vertigo, in