Angeles University Foundation
College Of NursingCase 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 DysonEveryone make mistakes,
nobody is perfect. If you made a mistake, it is fine, but if you
made another mistake, then that is the time where you need to look
back and reflect. If a time of hardship has come at us due to those
flaws of ours, do not lose hope and turn back. Instead, face it
with courage and take it as a lesson. When the hurdle has ended,
reflect is what we need to fix those flaws that caused us crisis
and start life afresh. Just like our patient who experienced
Appendicitis due to his mistake, but he didnt lose courage as he
faced his situation with determination and carried it until he was
operated. And because of this new experienced, he made it as a
valuable lesson to change his mistake and live a better life.
Appendicitis is defined as an inflammation of the inner lining
of the vermiform 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. In
fact, despite diagnostic and therapeutic advancement in medicine,
appendicitis remains a clinical emergency and is one of the more
common causes of acute abdominal pain.
No single sign, symptom, or diagnostic test accurately confirms
the diagnosis of appendiceal inflammation in all cases, and the
classic history of anorexia and periumbilical pain followed by
nausea, right lower quadrant (RLQ) pain, and vomiting occurs in
only 50% of cases.
Appendicitis may occur for several reasons, such as an infection
of the appendix, but the most important factor is the obstruction
of the appendiceal 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.
II. Nursing Process
ASSESSMENT
Personal History
Demographic Data
Ace is 19 years old, male, single, and was born as a natural
Filipino citizen on the 18th of September 1994 in Mabalacat,
Pampanga. Ace is the fourth child among the six children in the
family. He is associated to the INC Religion; also known as Iglesia
ni Cristo. Ace currently lives in Bamban, San Roque, Tarlac
together with his siblings.
Ace was admitted in the Surgical Ward in the Secondary Hospital
in Angeles City, Pampanga last 17th of September 2013 at around
four thirty (4:30) in the afternoon with a chief complaint of pain
in the right lower quadrant; and was diagnosed of T/C Acute
Appendicitis. The next day September 18th 2013 he had his operation
done known as Appendectomy, the removal of appendix. However, Ace
was expected to be discharge on September 20th 2013.
Socio-Economic and Cultural Factors
Ace lives with his parents and his five siblings. Overall he has
six siblings, but one of them is married and no longer lives with
them. There are four boys and two girls; and Ace is the fourth
child among them. They own a house and lot, which is made in a
single-story house and built in a cement walls.
As stated by Ace, their way of living is very simple and not run
by modern lifestyles. Their house is built with two bedrooms, one
for his parents and the other one for his sister. The rest of the
siblings sleeps in the living room, which all of them were boys.
Their house is built with one bathroom only and a small kitchen. As
Ace described their house, there was not much appliances except for
a television, radio and electric fan. For their monthly income and
daily expenses, 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
HISTORY OF PAST ILLNESSDuring the interview, Ace stated that he
has never been hospitalized for severe illness in the past.
However, as for his past illness when he was a child, the least
that he could recall was when he had measles and sprained ankle. He
mentioned that he sprained his ankle from jumping and missed a
step. For the remedies for measles, his mother applied a blue paste
on the affected part of the face and neck; and this paste is known
as a tina. As for his sprained ankle, Ace went to a manghihilot to
get his sprained ankle massage and within a week he was well.
Ace does self-medicate when he has a fever, coughs and colds. He
believes that the signs and symptoms for fever were body ache,
headache, feeling cold and skin is warm to touch. For remedies, he
uses over the counter drugs usually paracetamol, robitusin and
neosep for coughs and colds. He also manages to take adequate fluid
intake and adequate rest.
HISTORY OF PRESENT ILLNESS
According to Ace, a month ago he experienced pain on the lower
abdomen for two days and then it disappeared. It was September 14,
2013 as Ace was working at his sister in laws canteen; he consumed
soda and carried kitchen pots right after having his lunch, without
resting first. Then, Ace started experiencing pain on the abdomen.
The next day he felt epigastric pain for the whole day. Then the
following day, September 17, 2013 the pain radiated on the Right
Lower Quadrant and he vomited. He thought it was a kidney
problem.
The next day September 17th 2013 Ace rushed to the Emergency
Room in the Secondary Hospital in Angeles City and was diagnosed of
T/C Appendicitis. During his stay in the Hospital, the group
handled Ace in the Surgery Ward while waiting for his scheduled
Surgery on the 18th of September. Based on our initial assessment,
Ace was experiencing pain with a scale of 7 out 10 and 9 over 10
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.
PHYSICAL EXAMINATION (CEPHALOCAUDAL APPROACH)PHYSICAL
ASSESSMENT
Date of Physical Assessment: GENERAL SURVEY
1. Physical Examination (September 18, 2013)
(First NPI)
General Appearance:
Patient is awake, oriented and responds appropriately. His
conjunctiva is pale, anicteric scelera and non-tender lymph nodes.
His skin has a fair color. The patient is with a symmetric chest
expansion, LBS, no retractions with clear breath sounds, adynamic
precordium. He stated that there is pain on the right lower
quadrant of his abdomen with a scale of 7/10, no bipedal edema
noted.
Vital Signs taken as follows: T= 36.5 C
PR= 76 bpm
RR= 20 bpm
BP= 110/70 mmHg
HEAD Pink and non-tender palpebral conjunctiva Anicteric sclera
Non-tender lymph nodes.THORAX and LUNGS
Symmetric chest expansion, LBS.
HEART
Adynamic precordium, NRRA, 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 edema2. 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 Pink and non-tender palpebral conjunctiva
Anicteric sclera
CHEST and LUNGS
No rales and wheezes noted.HEART
Adynamic precordium with regular rate and rhythm
Abdomen Clean surgical dressing is intact on the right lower
quadrant of the 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.
His skin temperature is slightly cool. No body hair present on
the patient.
Hair When inspecting the hair, it is evenly distributed.
Its very thin and not oily.
No presence of infections or infestations noted.
Nails 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
Skull and Face Skull is symmetrical in shape and size.
There are no nodules seen or noted upon assessment.
Facial expressions are symmetrical and even.
Eyes are evenly hollowed.
Eyes and Visual Activity Eyebrows are symmetrical and evenly
distributed with similar movement to one another.
Eyelashes are even with the lashes curling out.
Pale conjunctiva noted.
No signs of edema on the lacrimal gland.
Cornea constricts upon sight of light
Ears and Hearing Auricles are similar color.
Symmetrical in size and position.
Both auricles are elastic.
There are no signs of crumen present in both ears.
Both ears can hear the watch during the clock test..
Nose and Sinuses
Symmetrical in shape.
No masses or tenderness noted upon assessment.
Air is expelled freely on both nares.
No discharges present.
Mouth and Oropharynx Lips are symmetrical in contour and
shape.
They are not dry.
Appears blackish in color.
Small scar is present on upper lip.
No lesions found upon assessment.
Teeth and Gums
Teeth appear yellowish with presence of tartar.
No dentures found.
Neck The clients neck has coordinated.
Smooth movement with no discomfort.
Muscle strength and muscles are equal in strength.
No lymph nodes palpable at the back of the ears.
No pain felt upon moving or rotating.
Lymph nodes are not palpable.
Jugular vein not visible.
Cardiovascular and Peripheral System
Skin color of the palm of the hand and feet is pale. Pale nail
beds upon inspection. Systemic pulse volumes and full pulsations of
peripheral pulses.Respiratory System Chest is symmetric and the
chest wall is intact plus it has uniform temperature.
No rales or adventitious breath sounds heard upon
auscultation.
Full and symmetric chest wall expansion.
Abdomen
Abdominal skin is intact. Audible bowel sound upon auscultation.
Presence of 1 inch scar noted on right lower quadrant of the
abdomen.
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.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
Head - The patient had no history of any form of head
injuries.
Eyes - Patient had no history of any eye problems. Ears and
Hearing - Patient had no history of smelly discharges on both ears,
and no complaints of hearing impairment.
Respiratory System - The patient experienced slow irregular
breathing patterns.
Cardiovascular System - The patient has a history of
hypertension.
Gastrointestinal System - The patient had no history of
difficulty in defecation.
Musculoskeletal System - Patient has no history of joint
pain.
Neurologic System - Patient had no history of any major mental
problems but had episodes of mental absences.
Diagnostic and Laboratory Procedures
Diagnostic Laboratory ProceduresDate Ordered
Date Performed
Date ChangeIndication or PurposeResultNormal ValuesAnalysis and
Interpretation of Result
1. HematologyD.O
09-17-13
D.R.
09-17-13 Hemoglobin
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. 147 140-180 gm/LThe patient has a
normal hemoglobin level, which indicates increase in bilirubin
level and the red bone marrow is able to compensate with the loss.
It also reflects the absence of anemia nor erythrocytosis or
changes in plasma concentration.
D.O
09-17-13
D.R.
09-17-13Hematocrit
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 0.40-0.54 L/LThe patients hematocrit level is within the
normal limits, which indicates absence of blood volume depletion,
erythrocytosis or problem in the hydration of the patient.
D.O
09-17-13
D.R.
09-17-13WBC
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. 21.05-10 x 10^9/LThe patient WBC
count is above the normal range which indicates a possible
infection.
D.O
09-17-13
D.R.
09-17-13RBC
The test is indicated for the count of circulating red blood
cells (RBCs) in a liter of peripheral blood. It is performed as
part of a CBC. In which, 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.5.144.5-6.3 L/LThe patients RBC count is within the
normal range which indicates that there is oxygen carrying capacity
of the blood, therefore, absence of anemia. He has an adequate
number of correctly sized red blood cells containing enough Hgb to
carry sufficient oxygen at the bodys tissues.
D.O
09-17-13
D.R.
09-17-13Lymphocytes
The test is indicated to determine lymphocytes blood count and
to determine presence of viral infection in the body.
0.090.20-0.35The patients lymphocytes count is low which
indicates the patients vulnerable to life-threatening
infection.
D.O
09-17-13
D.R.
09-17-13Platelet Count432150-400 x10^9/LThe patients platelet
count is within higher limits, which indicates no bleeding
tendencies. This also means that the body has increase chance of
surviving the operation. Platelet count can help in any wounds. It
also means that the patient have more increased clotting factors,
intra-operatively and also on post-operative. However, it could
possibly lead to thrombosis.Platelet Count93150-400 x10^9/L
Blood and RH TypeD.O
09-17-13
D.R.
09-17-13Blood Type and Rh test is carried our before a patient
gets a blood transfusion. It is also done to check the antigens of
the patient, to identify compatibility of blood. However, different
antigens in the blood will be incompatible blood and antibodies in
the patients blood will destroy the donor blood cells. Transfusion
reaction caused by ABO blood group incompatibility can cause
illness and in some cases, even death.B
Result varies to every personThe patients blood type is B, which
means that he can only receive blood type B and O
NURSING RESPONSIBILITIESCBC 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.
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. Diagnostic/Lab
ProceduresDate Ordered/Date ResultsIndications or
purposesResultsNormal valuesAnalysis and interpretation of results
(Client- Centered)
A. Urinalysis
1. ColorD.O
09-17-13
D.R. 09-17-13The color of urine is use for indication of disease
conditions. Changes in the color may be a manifestation of one or
more illness. YellowClear, straw-colored to dark yellow
The patient has yellow color of urine. Which indicate normal
bilirubin in the body.
2. TransparencyD.O
09-17-13
D.R. 09-17-13It is indicated to detect kidney problem such as
crystal formation, tissue damage leading to bleeding and tissue
damage caused by the presence of bacteria.ClearClear and
transparent
The urine of Ace is clear which indicates good health and well
hydrated.
3. pHD.O
09-17-13
D.R. 09-17-13The pH is indicated to measure the urine acidity or
alkalinity (basic).6.54.50-8.00
Ace urine is slightly acidic but near to normal range. Which
indicates that patient does not manifest any discomfort or pain
during urination.
4. Specific gravityD.O
09-17-13
D.R. 09-17-13The Specific gravity is indicated to check the
amount of substances in the urine. It also shows how well the
kidneys balance the amount of water in urine. The higher the
specific gravity, the more solid material is in the urine.
1.0101.010-1.030The specific gravity of the urine is under normal
limits. Which indicates that the patient is well hydrated and no
signs of Diabetes insipidus.
5. AlbuminD.O
09-17-13
D.R. 09-17-13
Albumin urine test is usedto detect the ability of the kidney to
filter efficiently. To identify if the kidneys filters the one
needed to be excreted and needed to remain in the body.+ 1AbsentThe
patients kidney was unable to filter albumin, the proteins in the
blood.
6. GlucoseD.O
09-17-13
D.R. 09-17-13Glucose urine test measures the amount of sugar
(glucose) in a urine sample, The presence of glucose in the urine
is called glycosuria or glucosuria. It is commonly used to test for
diabetes.NegativeNegativeThe patients urine has negative result.
This means that the kidneys of the patient were able to retain the
glucose needed for the body to use and no signs of diabetes.
7. Pus cellsD.O
09-17-13
D.R. 09-17-13Pus cell in urine test is used to detect the
presence of any harmful chemical of other unexpected substance in
the urine. Specifically, glucose (diabetics), blood (kidney
problems), crystals (kidney stones) and also pus cells that
indicate some kind of infection in the body.
1-2/HPF5HPFThe patients urine has 1-2/HPF, which indicates no
presence of any harmful chemical or signs of infection in the
body.
8. Epithelial CellsD.O
09-17-13
D.R. 09-17-13This test is performed by examining urine to
analyze the content and chemical characteristics. While it is
typically done prior to surgery to identify any kidney issues that
may be present, a urinalysis may be performed in your doctor's
office if a kidney infection, urinary tract infection, or some
other issue is suspected.
few0-5/HPFThe patients urine has few epithelial cells. Which
indicates presence of pus in urine and infection.
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.
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.ANATOMY AND PHISIOLOGY OF
APPENDIXAlso called as the vermix, vermiform appendix is a narrow
vermin (worm shaped) tube arising from the posteromedial aspect of
the cecum (a large blind sac forming the commencement of the large
intestine) about 1 inch below the iliocecal valve. Small lumen of
appendix opens into the cecum and the orifice is guarded by a fold
of mucous membrane known as valve of Gerlach. The 3 taenia coli
(taenia libera, taenia mesocoli and taenia omental) of the
ascending colon and caecum converge on the base of the
appendix.
Although the appendix serves no digestive function, it is
thought to be a vestigial remnant of an organ that was functional
in human ancestors.
The length varies from 2 to 20 cm with an average of 9 cm with
diameter of about 5mm. It is longer in children compared to adults.
In the fetus it is a direct outpouching of the caecum, but
differential overgrowth of the lateral caecal wall results in its
medial displacement.
The appendix is suspended by a small traignular fold of
peritoneum, called the mesoappendix.
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 pointis 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:
12 o clock: Retrocolic or retrocecal (behind the cecum or
colon)
2 o clock: Splenic (upwards and to the left Preileal and
Postileal)
3 o clock: Promonteric (horizontally to the left pointing the
sacral promontory)
4 o clock: Pelvic (descend into the pelvis)
6 o clock: Subcecal (below the cecum pointing towards inguinal
canal)
11 o clcok: Paracolic (upwards and to the right)
Most common position of appendix (75% of cases):RetrocecalSecond
most common position of appendix (20% of cases):SubcecalIf the
appendix is very long, it may actually extend behind the ascending
colon and abut against the right kidney or the duodenum; in these
cases its distal portion lies extraperitoneally.
Arterial Supply:
( Appendicular artery:The mesoappendix, containing the
appendicular branch of the ileocolic artery (branch of superior
mesenteric artery), descends behind the ileum.
( Accessoryappendicular artery:An accessory appendicular artery
can branch from the posterior cecal artery which is also a branch
of ileocolic artery.
Venous drainage:Appendicular vein > Ileocolic vein >
Superior mesenteric vein > Portal vein
Lymphatic drainage:
There is abundant lymphoid tissue in its walls.
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 outside1. Mucosa:
No villi
Epithelium invaginates to form crypts of Liberkuhn but the
crypts do not occur as frequently as in the colon
Muscularis mucosae is ill defined
2. Submucosa:
Large accumulations of lymphoid tissue in the lamina propria and
submucosa. Hence appendix is also called abdominal tonsil.
There is often fatty tissue in the submucosa.
3. Muscularis externa:
Thinner than in the remainder of the large intestine
Comprises 2 layers: Inner circular muscle layer and Outer
longitudinal muscle layer
Outer longitudinal smooth muscle layer does not aggregate into
taenia coli
4. Serosa and peritoneum
8. THE PATIENT AND HIS ILLNESS
A. PATHOPHYSIOLOGY
(Book-centered)
a. SYNTHESIS OF THE DISEASE
a.1.Definition of Disease
Appendicitis is defined as an inflammation of the inner lining
of the vermiform 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. It is
the most common acute abdominal emergency seen in developed
countries.
a.2.Predisposing and Precipitating factors
Non modifiableJustification
Adolescent and young adultsThey tend to have a detrimental
lifestyle.
Fibrous condition of the Bowel.Fecalith may become occluded in
this kind of surface.
Kinking of the AppendixA fecalith may also be occlusion.
External occlusion of the bowel by adhesion.Severe pathway and
cause occlusion.
Yersinia InfectionMay cause inflammation of the small intestine
and eventually cause occlusion.
MenHave more detrimental lifestyle than women.
MoidifiableJustification
FecalithCan occlude the lumen of the appendix.
Swelling of the abdomenCan eventually cause occlusion.
a.3.Signs and symptoms
Signs and symptomsJustification
Pain Due to the inflammation of the Verniform Appendix.
Mild leukocytosisDue to the infection of the Verniform
appendix.
VomitingFood unable to pass through the intestine due to
occlusion
AnorexiaDue to fear in vomiting
Low grade feverBodys mechanism to alert the body for
infection
Halitosis Due to occluded fecalith and/or infection.
a. PATHOPHYSIOLOGY
(Client-centered)
b. SYNTHESIS OF THE DISEASE
b.1.Definition of Disease
Appendicitis is defined as an inflammation of the inner lining
of the vermiform 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. It is
the most common acute abdominal emergency seen in developed
countries.
b.2.Predisposing and Precipitating factors
Non modifiableJustification
Adolescent and young adultsThey tend to have a detrimental
lifestyle.
MenHave more detrimental lifestyle than women.
ModifiableJustification
FecalithCan occlude the lumen of the appendix.
Swelling of the abdomenCan eventually cause occlusion.
b.3.Signs and symptoms
Signs and symptomsJustification
Pain (RLQ)Due to the inflammation of the Verniform Appendix.
Mild leukocytosisDue to the infection of the Verniform
appendix.
VomitingFood unable to pass through the intestine due to
occlusion
AnorexiaDue to fear in vomiting
Low grade feverBodys mechanism to alert the body for
infection
B. PLANNING NURSING CARE
#1 Acute pain r/t inflammation of tissues secondary to
AppendicitisAssessmentNursing DiagnosisScientific
ExplanationPlanningInterventionsRationaleExpected Outcome
S=
O= patient manifested the following:
>Facial
grimace
>Guarding behavior
>Rebound tenderness
>Limited ROM
Patient may manifest the following:
>Irritability
>Weakness
>RestlessnessAcute pain r/t inflammation of tissues secondary
to AppendicitisAppendicitis 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 abscess, perforation, subsequent
peritonitis, and deathShort 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>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)
>Maintain semi-fowlers position
> 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
>Make time to listen and maintain frequent contact with
patient.
>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 gain patients trust
& cooperation
> To gain baseline data
> Indicates need for further evaluation
>Changes in location or intensity are not uncommon but may be
reflect developing complications
>To reduce abdominal distention, thereby reduces tension
> To detect any abnormalities
>To provide non-pharmacologic pain management
>To assess contributing factors to pain>To rule out
worsening of condition.
>Help in alleviating anxiety and relieve pain.
>To prevent fatigue that will worsen the pain
>To prevent dehydration & promote wound healing
>To increase the bodys resistance against possible
complication.
>To distract the patient & reduce pain
>To reduce metabolic rate and aids in pain relief and
promotes healing.
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.
AssessmentNursing DiagnosisScientific
ExplanationObjectivesNursing InterventionsRationaleExpected
Outcome
S>
O> Patient manifested the following:
>Afebrile
>Pale oral mucosa
>Good skin turgor
>Irritability
>With pain when moving
Patient may manifest the following:
>fever
>Decrease capillary refill
>Pale palpebral conjunctiva
>Increase WBC
Risk for Infection related to post surgical incision site
secondary to appendectomySkin is the primary defense against
foreign bodies and microbes. Damage of the skin allows entry of
microorganisms into the body. Therefore, It leads a susceptibility
of infection. 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>Establish therapeutic
communication
>Monitor and record vital signs
> Stress proper hand washing techniques by all caregivers
>Cleanse incision sites daily
>Maintain adequate hydration
>Change dressings daily
>Encourage early ambulation
>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
>To gain patients trust and cooperation
>To obtain baseline data
>First line defense against cross contamination
>To prevent infection
>To avoid bladder distention
>To prevent soiling
>To prevent pressure ulcers
>To have 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 infectionShort term:
Patient shall have identified interventions to reduce/prevent
risk of infections
Long Term:
Patient shall be free from any kind of infections
AssessmentNursing DiagnosisScientific
ExplanationPlanningInterventionsRationaleExpected Outcome
S=
O= Patient manifested the following:
>Limited ROM
>Facial Grimace
>Guarded movement
Patient may manifest the following:
>Irritability
>Weakness
>Sleepless night
Activity Intolerance R/T post surgical incisionObstruction of
the Appendicitis
Pain in the RLQ of the abdomen
Surgical Incision
APPENDECTOMY
PAIN
Pain upon moving
Limited mobility
ACTIVITY INTOLERANCEShort Term:
After 4 hours of Nursing Interventions,
the patient will be able to verbalize understanding on
improvement ofactivity tolerance within patients limitation.
Long Term:
After 1-2 days of Nursing Interventions, the patient will be
able to maintain activity level within capabilities.>Establish
therapeutic communication
> Monitor & record VS.
>Assess general condition.
>Provide adequate rest.
>Adjust activities to enhance ability.
>Encourage patient to maintain a positive outcome
>Assist patient to lean and demonstrate safety measures
>Teach ways on how to conserve energy such as sitting when
doing activities
>Administer medication prior to activity as ordered>To
gain patients trust & cooperation
>To gain baseline data
>To detect any abnormalities
>To prevent fatigue and conserve energy
>To participate in activities
>To enhance sense of wellbeing
>To prevent injuries
>To limit fatigue &maximize use ofenergy
>For pain relief, to permit maximal effort and involvement in
activity needShort Term:
Patient shall have verbalized understanding on improvement of
activity tolerance within patients limitation
Long Term:
Patient shall have maintained activity level within
capabilities.
B. IMPLEMENTATION1. MEDICAL MANAGEMENT (IVFs, BT, NGT feeding,
Nebulization, TPN, Oxygen therapy, etc..)
A. IVF: D5LRS 1L
Medical management/ TreatmentDate ordered
Date performed
Date changedGeneral DescriptionIndication(s) or PurposesClients
response to the treatment
D5LRS 1LOrdered: 09/17/2013
Performed: 09/17-20/2013D5LRS is useful for daily maintenance of
body fluids and nutrition, and for rehydration.Substitution and
treatment to patient Ace for extra calories when he was on NPO.
Can also be a route for medicine administration in case of
emergency.The patient Ace had a slight sense of irritation but
eventually complied.
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. DRUGSName of the drugs (Generic and Brand Name)Date ordered,
Date taken/given,
Date changed
Route of administration, dosage and frequencyGeneral action,
classification, mechanism of actionIndications / PurposesClients
response to the medication with actual side effects.
AmpicillinD.O
09-17-2013
D.G
09-17-2013
09-18-2013
09-19-2013
I gm/IV q6 ANST (-)Antibiotic; inhibits cell wall synthesis
during bacterial multiplication.Indicated for certain types of
bacterial infections such as UTI, meningitis, gonorrhea, pneumonia,
bronchitis, ear, lung, skin and respiratory tract infections.
The patient eventually got better. Had a slight burn whenever
drug is administered.
Gentamycin D.O
9-17-2013
D.G
09-17-2013
09-18-2013
09-19-2013
80 mg/IV q8ANST (-)Antibiotic; thought to inhibit protein
systhesis; usually bactericidal.Indicated for conditions like Acute
diarrhea, Bacterial infections, Biliary tract infections,
Endocarditis, Food allergy, Muscle relaxation (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, Urinary tract
infection, and can also be given in adjunctive therapy as an
alternative drug of choice in Solid tumor.The patient eventually
got better. Had a slight burn whenever drug is administered.
RanitidineD.O
09-17-2013
D.G
09-17-2013
09-18-2013
09-19-2013
50 mg/IV q8Antiulcer; H2 receptor agonist. Competitively
inhibits action of histamine at H2-receptor sites of parietal
cells, decreasing gastric acid secretion.Indicated to treat and
prevent ulcers in the stomach and intestines. It also treats
conditions in which the stomach produces too much acid, such as
Zollinger-Ellison syndrome. Ranitidine also treats gastroesophageal
reflux disease (GERD) and other conditions in which acid backs up
from the stomach into the esophagus, causing heartburn.Patient Ace
complied and didnt complain of any problems.
KetorolacD.O
09-18-2013
D.G
09-18-2013
09-19-2013
30 mg IV q6 (-) ANST X 4 dosesAntipyretic; non-opioid analgesic;
NSAID; anti-inflammatory; inhibits prostaglandins and leukotrine
synthesis.Indicated for short term management of pain and relief of
post operative inflammation.The post- operative pain of patient Ace
eventually disappeared.
TramadolD.O
09-18-2013
D.G
09-18-2013
09-19-2013
100mg/IV q6 Analgesic; binds to mu-opioid receptors and inhibits
the reuptake of norepinephrine and serotonin; causes many effects
similar to the opioids but does not have the respiratory depressant
effects.Indicated for relief of moderate to moderately severe
pain.The post- operative pain of patient Ace eventually
disappeared.
MefenamicD.O
09-17-2013
D.G
09-17-2013
50mg/tab q4 x pain Mefenamic acid and other NSAIDs (nonsteroidal
anti-inflammatory drugs) are thought to work by inhibiting the
action of certain hormones, called prostaglandins, that cause
inflammation and pain in the body. By blocking the effects of
prostaglandins, mefenamic acid is useful at reducing pain related
to bone, muscle, or tendon injury or inflammation.Indicated for
relief of moderate to moderately severe pain.The post- operative
pain of patient Ace eventually disappeared.
Nursing Responsibilities: Ampicillin
1. Assess for history of allergies to penicillins,
cephaosporins, or other allergens; renal disorders; lactation
2. Culture infected area; skin color, lesion; R; adventitious
sounds; bowel sounds; CBC
3. Check IV site carefully for signs of thrombosis or drug
reaction.
4. Do not give IM injections in the same site; atrophy can
occur. Monitor injection sites.
5. Administer oral drug on an empty stomach, 1 hr before or 2 hr
after meals with a full glass of water; do not give with fruit
juice or soft drinks.
6. Monitor liver function, kidney function and complete blood
counts regularly while taking this medication.
Nursing Responsibilities: Gentamycin
1. Evaluate patients hearing before and during therapy.
2. Notify prescriber if patient complains of tinnitus, vertigo,
or hearing loss.
3. Weight patient and review renal function studies before
therapy begins.
4. Use preservative-free form when intrathecal route is used
adjunctively for serious CNS infections, such as meningitis and
ventriculitis.
Nursing Responsibilities: Ranitidine
1. Assess patient for abdominal pain.
2. Note presence of blood in emesis, stool, or gastric
aspirate.
3. Drug maybe added to total parenteral nutrition solution
Nursing Responsibilities: Ketorolac
1. Assess pain prior to and 1-2 hours following
administration.
2. Caution patient to avoid concurrent use of alcohol, aspirin,
NSAIDs, acetaminophen, or other OTC medications without consulting
a physician.
3. Administer IV injection over at least 15 seconds.
4. Instruct patient to notify physician immediately if he
experiences blood in urine, easy bruising, itching, rash, swelling,
yellow eyes or skin.
5. Explain that Ketorolac may increase the risk of serious
adverse cardiovascular and gastrointestinal reactions.
6. Caution patient to avoid hazardous activities.
7. Teach patient proper oral hygiene measures and encourage to
use soft-bristled toothbrush while taking Ketorolac.
Nursing Responsibilities: Tramadol
1. Control environment (temperature, lighting) if sweating or
CNS effects occur.
2. Limit use in patients with past or present history of
addiction to or dependence on opioids.
3. Report severe nausea, dizziness, and constipation.
Nursing Responsibilities: Mefenamic Acid
1. Assess patients who develop severe diarrhea and vomiting for
dehydration and electrolyte imbalance.
2. Lab tests: With long-term therapy (not recommended) obtain
periodic complete blood counts, Hct and Hgb, and kidney function
tests.
3. Discontinue drug promptly if diarrhea, dark stools,
hematemesis, ecchymoses, epistaxis, or rash occur and do not use
again. Contact physician.
4. Notify physician if persistent GI discomfort, sore throat,
fever, or malaise occur.
5. Do not drive or engage in potentially hazardous activities
until response to drug is known. It may cause dizziness and
drowsiness.
6. Monitor blood glucose for loss of glycemic control if
diabetic.
7. Do not breast feed while taking this drug without consulting
physician.
C. DIET
Type of DietDate ordered
Date performedGeneral DescriptionIndication(s) or
PurposesSpecific foods takenClients response and/or reaction to the
diet
NPO Ordered: 09/17/2013
Performed: 09/17-19/2013
Discontinued: 09/19/2013Patient Ace will not take anything via
mouth, but with an IVF hooked for sufficient nutrition.To not
aggravate the inflammation of the Verniform Appendix and also for
pre-operative care.NoneThe patient tolerated not eating anything
even though he could feel slight irritation at the epigastric
region.
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. Observe for any side effects.
Type of DietDate ordered
Date performedGeneral DescriptionIndication(s) or
PurposesSpecific foods takenClients response and/or reaction to the
diet
Diet as Tolerated Ordered: 09/20/2013
Performed: 09/20/2013Patient can take food orally as long as
patient Ace can tolerate or no complication seen.To bring the
patient to his normal diet and give enough nutrients to help his
body to cope after not eating for several days.Patient Ace consumed
bread and chocolate drink called Milo after his surgery called
Appendectomy.The patient eventually returned to his normal eating
pattern.
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 ExerciseDate ordered
Date performed
Date changedGeneral DescriptionIndication(s) or purposesSpecific
foods takenClients response
Bed RestOrdered: 09/17/2013
Performed:
09/17-18/2013
Refraining from activities or being carried only when
necessary.To provide enough rest that is needed by the
patientNPOThe patient complied with the said activity. The patients
curent state slightly improved.
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 ExerciseDate ordered
Date performed
Date changedGeneral DescriptionIndication(s) or purposesSpecific
foods takenClients response
Early ambulationOrdered: 09/19/2013
Performed:
09/19-20/2013
This is performed by the patient walking around the room if
tolerated but with enough rest between the activities.Improves
health and to provide proper healing of the incision site of
patient Ace.NPO at the first but when the doctor approved of a diet
as tolerated, he ate bread and chocolate drink called Milo.The
patient complied with the said activity. The patients current state
improved.
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
Surgical Management/Special Procedures (Client-centered)
Appendectomy is the removal of the appendix. This procedure is
performed only if the appendix gets inflamed and when it ruptures.
This kind of operation is considered an emergency case since the
rupture will cause the waste contents to spread and cause sepsis to
your body which is very fatal. It is required that this operation
must be performed with 24 48 hours before it gets worse.
As of today, there are no contraindications for appendectomy.
Before the operation begins, the patient will be instructed not to
eat anything for 8 hours. This is done to prevent bowel contents
from causing operation. After that, the anesthesiologist sedates
the patient making him/her lose consciousness. Once the patient is
sedated, the operation begins.
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
1st 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.
Instruments Used for Appendectomy
1. 01 Metzenbaum Scissors 20cm TC Straight
2. 01 Metzenbaum Scissors 20cm TC Curved
3. 01 Mayo Scissors 14cm Curved TC
4. 02 Scalpel Handle # 4
5. Allis Tissue Forceps 15cm
6. 04 Kochers Tissue Forceps 1:2
7. 01 Mcindoe Forceps 15cm
8. 02 Babcocks Tissue Forceps 16cm
9. 02 Mayo Hagar Needle Holder 16cm
10. 02 Sponge Holding Forceps
11. 04 Backhaus Towel Clamps 11cm
12. 08 Criles Forceps14cm curved
13. 06 Criles Forceps14cm Straight
14. 06 Spencer WellsStraight 18cm
15. 08 Spencer Wells Curved 18cm
16. 02 U S Army Retractor 21cm
17. 02 Adson Forceps 12cm
18. 02 Adson Forceps 1:2 12cm
19. 02 Lane Forceps 1:2 18cm
22. Kidney Basin
Nursing ResponsibilitiesPre - 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 - Operative1. 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. NURSING MANAGEMENT
(Actual SOAPIERS)
#1 SOAPIE (September 18, 2013)
S
Masakit ung right side ng tiyan ko. As verbalized by the
patient.
O
> Receive patient in a lying position with an ongoing IVF of
#2 D5LRS 1L x 30 gtts/min at 900 cc level.
> with a continuous throbbing mild to severe pain, localized
in the RLQ area with a pain scale of 7/10 and 9/10 when it is
provoked upon palpation, with 10 being the highest.
> Initial Vital signs of the ffg.
T= 36.5 C
PR= 76 bpm
RR= 20 bpm
BP= 110/70 mmHg
A
Pain related to incision made on Right Lower Quadrant of the
Abdomen
P
After 2-3 hours of nursing interventions, the patients pain
scale will decrease.
I
> Established therapeutic relationship.
> Vital signs taken and recorded.
> Assessed for referred pain.
> Obtained patients assessment of pain.
> Accepted clients description of pain.
> Enforced rest periods.
> Encouraged clean environment.
>Encouraged good personal hygiene.
> Encouraged to limit intake of liquor.
> Encouraged smoking cessation.
> Instructed in and encouraged use of relaxation technique
such as focused breathing.
> Instructed to have diversional activities such as listening
to music or conversing with others.
> Instructed patient to avoid hot compression in the RLQ.
> Administered medication as prescribed.
E= Goal Met as evidenced by patients pain scale has lowered from
7/10 to 5/10.
#2 SOAPIE (September 19, 2013)
S
Namamaga at masakit yung kamay ko dahil siguro dito sa IV as
verbalized by the patient.
O
> Received patient on bed in a lying position, with an
ongoing IVF of #54 D5LRS 1L x 30 gtts/min. at 950 cc level.
> Weak in appearance, with a presence if edema on the left
upper extremity.
> Initial Vital signs of the ffg.
T= 36.6
Pr= 68 bpm
RR= 20 bpm
BP= 100/70 mmHg
A
Impaired skin integrity related to edema on the left hand
secondary to IV infiltration.
P
After 2-3 hours of nursing interventions, the patient will
display timely healing of skin edema.
I
>Established therapeutic relationship.
> Vital signs taken and recorded.
> Assessed general condition.
> Kept back dry.
> Instructed patient to apply pressure on the skin.
> Alternated from hot and cold compress.
> Provided comfort and safety measures by assisting the
patient from going in and out of bed.
> Promoted early ambulated.
> Instructed patient to move from side to side.
> Instructed NPO as ordered.
> Inspected surrounding skin for erythema.
E
Goal met as evidenced by patient displayed timely healing of
skin edema.
#3 SOAPIE (September 20, 2013)
SHindi ako makagalaw kasi masakit yung sugat ko sa right side ng
tiyan ko as verbalized by the patient.
O
> Receive patient lying on bed conscious and awake, with an
ongoing IVF of #6 D5LRS 1L x 30 gtts/min. at 940 cc level.
> Patient appears relaxed and comfortable. But upon further
observation, patient appears to have difficulty ambulating as
slight pain is felt when performing small activities such as
walking to the comfort room.
Initial Vital signs of the ffg.
T= 36.1 C
PR= 79 bpm
RR= 20 bpm
BP= 110/80 mmHg
A
Activity Intolerance related to post- operative pain.
P
After 1-2 hours of nursing intervention, the patient will
understands the health teachings provided by the student nurse and
complies.
I
> Established therapeutic relationship with the patient.
> Vital signs taken and recorded.
> Assessed wound dressing color.
> Instructed ambulation when tolerated.
> Provided proper wound care.
> Changed wound dressing.
> Kept incision site clean.
>Instructed patient to avoid touching the incision.
> Instructed patient to increase intake of green leafy
vegetables and fresh fruits.
> Encouraged patient to increase oral fluid intake.
E
Goal met as evidenced by patient understands the health
teachings provided by the student nurse and complies.
D. EVALUATION
1. CLIENTS DAILY PROGRESS CHART (From admission to
discharge)Nursing ProblemsAdmission
(09-18-13)09-19-1309-20-13Discharge
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 Pressure36.5
76
22
100/7036.7C
72
20
110/7036.1
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 6Mefenamic 500 mg/tab q 4 x pain
Diet
NPO Pre-OPNPO/DAT
DAT
Activity
Bed rest
Ambulation
SURGICAL MANAGEMENT
Appendectomy
2. DISHARGE PLANNING
I. SUMMARY OF FINDINGS AND CONCLUSIONAppendicitis is defined as
an inflammation of the inner lining of the vermiform 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.RECOMMENDATIONFor
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
Sleisenger and Fordtran. (2010). Gastrointestinal and liver
disease, Vol. 2. pathophysiology/diagnosis/management.
Appendicitis. Pp. 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-overviewPATERNAL
GENOGRAM
MATERNAL
76 y/o
Heart problem
72 y/o
Heart problem
DECEASED FEMALE
DECEASED MALE
20 y/o
FEMALE
MALE
LEGENDS:
12 y/o
16 y/o
19 y/o Ace
23 y/o
22 y/o
45 y/o
55 y/o
76 y/o
74 y/o
Unknown cause
Inflammation
Non-modifiable
Adolescent and young adults.
Fibrous condition of the Bowel.
Kinking of the Appendix
External occlusion of the bowel by adhesion.
Yersinia Infection
Men
Modifiable
A fecalith.
Swelling of the abdomen
Obstructed Appendix
Thrombosis, edema, bacterial invasion
Increase Intraluminal Pressure
Decrease venous drainage
Abscess formation
Gangrene and perforation
Vomiting, anorexia, low grade fever, and halitosis
Mild Leukocytosis
Pain (RLQ)
Guarding reflex
Non-modifiable
Adolescent and young adults: 18 y/o
Men
Modifiable
A fecalith.
Swelling of the abdomen
Alcohol
Acidic drinks
Obstructed Appendix
Increase Intraluminal Pressure
Decrease venous drainage
Thrombosis, edema, bacterial invasion
Inflammation
Abscess formation
Pain (RLQ)
September 14-18, 2013
Vomiting, anorexia, and low grade fever
September 17, 2013
Mild Leukocytosis
September 18, 2013
Gangrene
Appendectomy
Sept. 18, 2013
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