INTRODUCTION

The appendix is a small finger-like structure appendage about

10cm (4 inches) long that is attached to the cecum just below the ileocecal valve. The appendix fills with food and empties regularly into the cecum. Because it empties inefficiently and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable to infection (i.e. appendicitis). Appendicitis is the most common reason for emergency abdominal surgery. Although it can occur at any age, it more commonly occurs between the ages of 10 and 30 years.

OBJECTIVES:
To obtain necessary information regarding the patient and

her condition To assess the patients overall health status To identify patients health care needs through analysis of all the data gathered To impart necessary health teachings to the patient To widen and enhance the student nurses knowledge and skills through the additional research about the nature of the disease, its signs and symptoms, pathophysiology, and its diagnosis and treatment.

CLIENT PROFILE
Name of patient: Mr. NVM Address: 204 Adiola St. Caloocan City Age: 27 years old Sex: Male Civil Status: Single Religion: Roman Catholic Birth day: May 28, 1985 Birth place: Valderama Lying-In clinic Educational attainment: College Graduate (2 year course in IT)

NURSING ADMISSION DATA BASE

Date Admitted: August 22, 2012 Arrival time: 8am Under the service of: Faith D. Agbanlog, MD Admitted from: ER Mode of arrival: Wheelchair Reason for hospitalization: Severe abdominal pain and vomiting Brought by: Brother

HISTORY OF PRESENT ILLNESS

Mr. NVM is a full time security guard in one agency at Caloocan City. Last august 21, 2012 one of their boss had celebrated her birthday in their office and everyone was encourage to eat. He admitted that he had consumed a lot (3 cups of rice, 2medium slice of grilled chicken, 1 grilled tilapia, half cup of menudo and 1 bowl of macaroni salad as a dessert). After taking his lunch he went back to his duty, an hour after he felt sudden pain located at the RLQ of his abdomen and vomited twice. He thought that it was just an abdominal spasm because of too much eating. As management he took 1 tab of Kremil S, but the pain is still not relieved after another hour, and so he took 1 tab of Diatabs.

Even if the pain is aggravating he still finished his duty hours. When he went home, he wasnt able to take his dinner because of exhaustion and too much felt pain, he then went to bed. When he wakes up and still felt the pain, he decided to call the office and inform them that he wont be able to come to work that day, instead he will go to the hospital for consultation.

PAST MEDICAL HISTORY

A. Childhood Illnesses Mr.NVM had chickenpox at the age of 9. He did not experienced mumps and measles. Sometimes he gets minor coughs for a few days and uses over-the-counter drugs like Solmux until his cough subsides. And he also uses Neozep for colds and Paracetamol for fever. B. Childhood Immunization Since the patient is 27 years old and lives with his other brothers, he is not sure about the completeness of his immunization because their mother is living in their province.

MEDICATIONS Prescription/Overthe-Counter Drugs

Paracetamol

DOSAGE

LAST DOSE

FREQUENCY

500 mg TIV

Q 4, PRN for fever above 37.8C

Tramadol

50 mg, slow IV

August 22, 2012 4 PM

Q 8, PRN for severe pain

Ketorolac

30 mg TIV

August 22, 2012 6 PM

Q 6, for 6 doses ANST (-)

Cefuroxime

750 mg TIV

August 22, 2012 6 PM

Q 6, for 6 doses ANST (-)

GORDONS FUNCTIONAL HEALTH PATTERNS

HEALTH-MAINTENANCE PERCEPTION PATTERN
Patient is non-alcoholic drinker and non-smoker. Denies illicit drug use. No known allergies. The patient perceives that being sick is unavoidable and he believes that he can get well by following treatment regimen.

SELF-CARE ABILITY:
0- Independent 1- Assistive Device 2- Assistance from others 3- Assistance from person and equipment 4- Dependent/ Unable

ACTIVITY EXERCISE PATTERN

Before Admission
0 Eating/Drinking Bathing Dressing/grooming Toileting Bed Mobility 1 2 3 4

Transferring
Ambulating Stair Climbing Shopping Cooking Home Management

ACTIVITY EXERCISE PATTERN

During Admission
0 Eating/Drinking Bathing Dressing/grooming Toileting Bed Mobility 1 2 3 4

Transferring
Ambulating Stair Climbing Shopping Cooking Home Management

NUTRITION METABOLIC PATTERN

BEFORE

DURING

DAT diet NPO for 6 hours (post op) Can consume full meal without excess Clear liquid diet to soft diet Normal taste sensation Regular diet when normal bowel No difficulty in swallowing sounds return No history of wound healing problem No dentures Prefer to eat meat and processed foods than vegetables

ELIMINATION PATTERN
BEFORE
Defecates at least every other day or once in 3 days No difficulty in defecating and in urinating Urinates 3-5 times a day, amount depends on fluid intake Claims that when he is at work he wasn't able to drink a lot of water because he hates going back to comfortroom

DURING
Inability to pass stool Decrease bowel sounds With indwelling catheter Decrease urine output (concentrated urine), 300 ml the whole day NPO for 6hrs post operatively

SLEEP-REST PATTERN
BEFORE
Sleeps at least 6 to 7 hours at night No afternoon nap Feel rested after sleep

DURING
Interrupted sleeping pattern ( 3 to 4 hours) Easily disturbed by noise

COGNITIVE-PERCEPTUAL PATTERN
BEFORE
Mental status: oriented to person, place, time and event Able to speak, comprehend, communicate in Filipino and English language Verbalize no visual and hearing impairment

DURING
Lassitude (post-op) Mental Status: alert, drowsy, oriented to person, place ,time and event Behaves appropriately Able to speak, comprehend, communicate in Filipino and English language Verbalize no visual and hearing impairment Complaints of RLQ abdominal pain (management : Tramadol 50mg q8 slow IV, PRN for sever pain)

COPING-STRESS TOLERANCE/SELFCONCEPT PATTERN

BEFORE
Major stressors are schedules of payment of their monthly bills and unannounced change s on his duty Copes by saving money, sleeping, and socialization with friends

DURING
Financial insufficiency ( hospital bills, expenses on medications) Ask for help from other relatives

SEXUAL-REPRODUCTIVE PATTERN
Had his circumcision at the age of 11 Denies problem on his penile part

ROLE RELATIONSHIP PATTERN

Single; 2nd eldest With 2 other brothers Lives with brothers and nephews Currently employed as a full time security guard Major support systems is family and friends

VALUE-BELIEF PATTERN
All of them are Roman Catholic
His grandparents still believe in some superstitions They dont have any religious belief/restrictions that can

greatly affect his treatment.

PHYSICAL ASSESSMENT
NEUROLOGICAL
LOC: Alert, Drowsy, Oriented to person, place, time, event, Appropriate behaviour Speech pattern: fluent Grips: Strong, weak, equal Dorsiflexion against resistance: Strong, weak, equal Pupils: Equal, round, reactive to light and accommodation, pupil size: 2cm Gait/balance: remains on bed for 6-8 hours post operatively

RESPIRATORY
Respiration rate: 20bpm, quite, regular, symmetrical Work of breathing: effortless Sounds: (anterior and posterior) clear, coarse, diminished, crackles, wheeze CRT: < 3 secs Cough: non-productive, productive Sputum color: Nail bed color: pale Mucous membranes: pale, moist, dry Oxygen: mask, cannula, 2-3 L/min

CARDIOVASCULAR
Auscultation: (aortic, pulmonic, tricuspid, mitral) regular s1 and s2, irregular Peripheral pulses: palpable, regular strength and quality, calf tenderness Neck vein flat at 45 degrees, distension Edema: pitting, non-pitting Hair growth: evenly distributed Skin color: brown complexion Temp: 37.8 c, moist, dry IV site: right arm, basilic vein, redness, swelling, induration, infiltration

GASTROINTESTINAL
Abdomen: soft, firm, tender, non-tender Bowel sounds: active, hypoactive, hypertactive, absent, flatus Diet ordered: clear liquid to soft then shift to regular diet when normal bowel sounds returns, nausea, vomiting, NGT Last BM: august 19/ 8am, color: brown consistency: soft, normal for patient

GENITOURINARY
Urine: clear, cloudy, color: concentrated amount: 300cc for the 1st 24 hours post op Dysuria, distention, void, steam of urine Catheter: indwelling Perineal area: clean, redness, swelling, discharge, odor, itching > Urine output is lesser than normal because patient is on NPO pre op and 6hrs. Post op

MUSCULOSKELETAL
Active/passive ROM all extremities, symmetrical strength, paresthesia, ambulate Assistance device: wheel chair, special bed, restraints Muscle: weakness, stiffness, tenderness, joint swelling > pt. Feels tired and avoids bed mobility to lessen the pain

INTEGUMENTARY
Skin: brown complexion Temperature: 37.8c , moist Turgor: good skin turgor Rash, ecchymosis, petechiae, tattoo, body piercing Wound/pressure ulcer/location: transverse cut located at the RLQ of the abdomen Size: 2-3 inches, odor, dressing: surgical Type: transverse cut (appendectomy) Date : August 22, 2012, old incision/scar location

PSYCHOSOCIAL
Mood and affect: still lethargic but answers questions appropriately when asked Fears, anxieties: worries about hospital bills and medication expenses Support person: parents, relatives and friends Lives with: brothers and nephews occupation: a full time security guard

PAIN
Location: RLQ of the abdomen Description: dull aching pain Treatment: medications prescribed by the physician Tramadol 50mg slow IV q8 PRN for severe pain

DIAGNOSTIC EXAMS AND LABORATORY RESULTS

RESULT WBC Neutrophils Lymphocytes Monocytes Eosinophils Basophils Fibrinogen HGB RBC HCT PLT

REFERENCE VALUE 5-10 x 10 /L 2.5 7.5 40-60 30-34 0-3 0-1 < 320 120-160 4.04-5.48 37.0-47.0 150-400

12.5 10 65 62 10 5
443 131 4.99 36.0 238

Significance :
Elevation on the level of WBC indicates an existing infection, this and the other findings during physical assessment will support the medical diagnosis of appendicitis. The inflammation of the appendix of the patient will trigger the inflammatory action of the macrophages and the neutrophils to perform phagocytosis , thus increasing their amont during inflammatory process to fight the invading microorganisms.

PATHOPHYSIOLOGY

LIST OF MODIFIABLE AND NON-MODIFIABLE FACTORS

MODIFIABLE Over eating Improper food preparation and food handling NON-MODIFIABLE Ingestion of food toxins Age

Over eating; ingestion of food toxins

Appendix start to be necrotic

Inflammation of the appendix (appendicitis)

Occlusion of the appendix by fecalith

Decrease blood supply in the appendix, thus decreasing the oxygen supply

Bacteria's invades the appendix

Start of the inflammatory process by the WBC and macrophages

FAYE GLENN ABDELLAH: TYPOLOGY OF 21 NURSING PROBLEMS

1. To promote good hygiene and physical comfort 2. To promote optimal activity, exercise, rest, and sleep 3. To promote safety through prevention of accidents, injury, or other trauma and through the prevention of the spread of infection 4. To maintain good body mechanics and prevent and correct deformities 5. To facilitate the maintenance of a supply of oxygen to all body cells 6. To facilitate the maintenance of nutrition of all body cells 7. To facilitate the maintenance of elimination 8. To facilitate the maintenance of fluid and electrolyte balance 9. To recognize the physiologic responses of the body to disease conditions 10. To facilitate the maintenance of regulatory mechanisms and functions

11. To facilitate the maintenance of sensory function 12. To identify and accept positive and negative expressions, feelings, and reactions 13. To identify and accept the interrelatedness of emotions and organic illness 14. To facilitate the maintenance of effective verbal and nonverbal communication 15. To promote the development of productive interpersonal relationships 16. To facilitate progress toward achievement of personal spiritual goals 17. To create and maintain a therapeutic environment 18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs 19. To accept the optimum possible goals in light of physical and emotional limitations 20. To use community resources as an aid in resolving problems arising from illness 21. To understand the role of social problems as influencing factors in the cause of illness

UTILIZATION OF THE NURSING PROCESS

ASSESSMENT CUES
1. Abdominal Pain

NURSING DIAGNOSIS
Pain related to post-op Surgery (appendectomy)

GOAL OF MANAGEMENT
Administration of analgesic as prescribed by the physician. Positioning; fowler or semi-fowler position. Promotion of relaxation technique like deep breathing exercise, coughing technique and diversional activities. Administration of Prophylactic antibiotic as prescribed by the physician. Proper wound dressing using prescribed anti septic solution and observing

2. Surgical incision located at the RLQ, transverse cut approximately 2-3 inches

Risk for infection related to post-operative Incision

NURSING CARE PLAN

ASSESSMENT CUES

NURSING DIAGNOSIS/ THEORY

GOALS AND OBJECTIVES

NURSING INTERVENTION

NURSING OUTCOME

Subjective abdominal pain pain scale of 7/10 (moderate) Objectives Inspection: facial grimace limited bed mobility rapid, shallow breathing; RR: 26 cpm abdominal guarding, covering the abdomen when someone is moving at the bedside T: 37.8C Auscultation: diminished bowel sounds Palpation: (-) abdominal

Pain related to post operative surgery (appendectomy) Faye Glenn Abdellah Typology of 21 Nursing Problems

Goal: To alleviate pain and provide comfort . Objectives: 1.Administratio MEDICATION n of NIC: Administer pharmacologic analgesics treatment (Tramadol 50mg slow IV q8 PRN for severe pain) as prescribed. Rationale: To reduce metabolic rate and intestinal irritation from circulating/ local toxins, which aids in pain relief and promotes healing.

9. To recognize the physiologic responses of the body to disease conditions.

NOC: Pain is relieved/ controlled Indicators : Verbalization of relief of pain / controlled to tolerable level Pain scale of 3/10 (mild) from 7/10

ASSESSMENT CUES

NURSING DIAGNOSIS/ THEORY

GOALS AND OBJECTIVES

NURSING INTERVENTION

NURSING OUTCOME

2.Promotes comfort by reducing muscle tension

POSITIONING NIC: Instruct client to maintain in semifowlers position. Rationale: Facilities fluid/wound drainage by gravity, reducing diaphragmatic irritation/abdominal tension, and thereby reducing pain. NIC: Move patient slowly on bed. Rationale: Reduces muscle tension/guarding, which may help minimize pain during movement.

NOC: Maintained on the prescribed position Indicators : Always on semi fowlers position. Verbalization of comfort on the indicated position. NOC: Gentle on bed movements is observed. Indicators: doesnt complain of any discomfort during positioning.

ASSESSMENT CUES

NURSING DIAGNOSIS/ THEORY

GOALS AND OBJECTIVES

NURSING INTERVENTION

NURSING OUTCOME

RELAXATION TECHNIQUES 3. Provide NIC: Encourage deep NOC: Exhibits relaxation breathing and compliance to techniques coughing exercises. prescribed to help Provide diversional relaxation alleviate activities. techniques. pain and Rationale: Promotes Indicators: discomforts relaxation and may Demonstrates

enhance patients coping abilities by refocusing attention. Deep breathing and coughing exercises improves pulmonary gas exchange or to maintain respiratory function, especially after prolonged inactivity or general anesthesia.

deep breathing and coughing exercises as advised. Watching movies and interacts with other patients on the ward.

ASSESSMENT CUES

NURSING THEORY / DIAGNOSIS

GOALS AND OBJECTIVES

NURSING INTERVENTIONS

NURSING OUTCOME

Objective: Surgical incision located at the RLQ, transverse cut approximately 2-3 inches

Risk for infection related to post operative incision (appendectomy)

Faye Glenn Abdellah Typology of 21 Nursing Problems 9. To recognize the physiologic responses of the body to disease condition

Goals: To prevent the occurrence of infection and be free of purulent discharge and promote healing
Objectives : 1. Provision of pharmacologic treatment MEDICATION NIC: Administer antibiotic (Cefuroxime 750 mg TIV q6 for 6 doses, Ketorolac 30 mg TIV q6 for 6 doses) Rationale : To prevent development of infection and to provide prophylactic treatment after surgery.

NOC: Development of infection is prevented Indicators: free of purulent discharge no redness and swelling observe

ASSESSMENT CUES

NURSING THEORY / DIAGNOSIS

GOALS AND OBJECTIVES

NURSING INTERVENTIONS

NURSING OUTCOME

2. To Observe proper wound dressing

WOUND CARE NIC: Provide proper wound dressing using aseptic technique, proper disposal of contaminated materials and the use of prescribed antiseptic solution Rationale: To promote wound healing and to prevent contamination of wound.

NOC: proper wound dressing application is observed Indicators: use of aseptic technique during wound care use of prescribed antiseptic solution proper disposal of contaminated materials no purulent discharge, no redness, no swelling observe

ASSESSMENT CUES

NURSING THEORY / DIAGNOSIS

GOALS AND OBJECTIVES

NURSING INTERVENTIONS

NURSING OUTCOME

3. Promote personal hygiene

HYGIENE NIC: instruct client to observe proper hygiene practices by washing hands regularly and avoid touching sutured area Rationale: To promote personal hygiene and to prevent contamination of wound. This is also considered as a preventive measure to the spread of microorganisms.

NOC: Instructed client about proper hygiene practices Indicators: verbalized understanding and demonstrates compliance to proper hygiene practices (washes hands regularly)

DISCHARGE PLAN

Medication: Patient has to continue her medication: Paracetamol 500mg/tab, if fever is above 37.8c Cefuroxime -- 250mg/tab twice a day for 10 days Mefenamic Acid -- 500mg/tab, for pain

Exercise/Environment: Instruct patient to avoid heavy lifting and driving until incision heals Encourage patient to do deep breathing and coughing exercises Encourage patient to perform light exercises like walking in the morning Instruct patient to provide a hazard free and clean environment

Treatment: Instruct patient to observe proper hygiene practices especially on caring for his wounds Instruct and demonstrate proper application of wound dressing using the prescribed antiseptic solution and observing aseptic technique Discussed on the importance of compliance to medication regimen to ensure complete healing and to prevent development of complications.

Health Teaching Review information about medications to be taken at home, including name, dosage, frequency and possible side effects, discussed the importance of continuing to take Instructed patient to avoid any strenuous activities, until the incision completely healed Avoid taking laxative or applying heat to abdomen when abdominal pain of unknown cause is experienced. Notify physician if sign and symptoms of infection noted (purulent discharge on the incision site, fever and chills)

Out Patient Department Patient is advised for follow up check up to his physician one week after discharge and for removal of suture Instructed patient to notify physician any undesired feeling about the disease.

Diet Instruct patient to observed proper food selection, food handling and preparation Instruct patient to eat nutritious food especially high caloric and high protein containing foods Instruct to increase intake of dietary fiber like vegetables and fruits Avoid caffeinated beverages, alcohols and soft drinks Encourage patient to increase oral fluid intake at least10-12 glasses of water daily.

Socio-Economic/Sex Instruct family members to support patient and guide him during his recovery Instruct family members to remind patient in taking his medications and on his follow up check up Socializations with friends and other significant people is not prohibited as long as it doesn't affect his recovery Sexual intercourse is prohibited for at least 4-6 weeks after surgery or until the wound properly heals