You are on page 1of 79

ANGELES UNIVERSITY FOUNDATION

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

Everyone 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 18 th 2013 he had
his operation done known as Appendectomy, the removal of appendix. However,
Ace was expected to be discharge on September 20 th 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

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

HISTORY OF PAST ILLNESS


During 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 18 th 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.

10

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 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

Pink and non-tender palpebral conjunctiva


Anicteric sclera

11

CHEST and LUNGS


No rales and wheezes noted.
HEART

Abdomen

Adynamic precordium with regular rate and rhythm

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.
12

His skin temperature is slightly cool.


No body hair present on the patient.

When inspecting the hair, it is evenly distributed.


Its very thin and not oily.
No presence of infections or infestations noted.

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

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.
13

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.

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

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.

15

Diagnostic and Laboratory Procedures

Diagnostic
Laboratory
Procedures

Date
Ordered

Result
Indication or Purpose

Normal
Values

Analysis and Interpretation


of Result

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

140-180 The patient has a normal


gm/L
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.

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

0.40-0.54 The patients hematocrit level


L/L
is within the normal limits,
which indicates absence of
blood
volume
depletion,
erythrocytosis or problem in
the hydration of the patient.

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

The patient WBC count is


above the normal range which
indicates a possible infection.

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

The 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.

18

Lymphocytes
D.O
09-17-13
D.R.
09-17-13

0.09

0.20-0.35

The test is indicated


to determine
lymphocytes blood
count and to
determine presence of
viral infection in the
body.

count is low which indicates


the patients vulnerable to lifethreatening infection.

Platelet Count
D.O
09-17-13
D.R.
09-17-13

The patients lymphocytes

432

150-400
x10^9/L

The 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.

19

Blood and
RH Type

D.O

Blood Type and Rh test is

The patients blood type is B,

09-17-13 carried our before a patient


gets a blood transfusion. It is
D.R.
also done to check the
09-17-13 antigens of the patient, to

which means that he can only

identify

compatibility

blood.

However,

Result varies receive blood type B and O


to every
person

of

different

antigens in the blood will be


incompatible

blood

and

antibodies in the patients


blood will destroy the donor
blood

cells.

reaction

caused

Transfusion
by ABO

blood group incompatibility


can cause illness and in
some cases, even death.

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

Analysis and interpretation of

values

results (Client- Centered)

e Results
A. Urinalysis
1. Color

D.O

The color of urine is use

09-17-13

for indication of disease

D.R.
09-17-13
2. Transparency

the

color

may

be

Clear,
strawcolored to
dark yellow

urine. Which indicate normal


bilirubin in the body.

manifestation of one or
more illness.
It is indicated to detect

09-17-13

kidney problem such as

09-17-13

Yellow

conditions. Changes in

D.O

D.R.

The patient has yellow color of

crystal formation, tissue


damage

leading

bleeding

and

to

The urine of Ace is clear which


Clear

Clear and

indicates good health and well

transparent

hydrated.

tissue

damage caused by the


presence of bacteria.

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

Ace urine is slightly acidic but


near to normal range. Which

(basic).

indicates that patient does not


manifest any discomfort or pain
during urination.

4. Specific
gravity

D.O

The Specific gravity is

09-17-13

indicated to check the

D.R.
09-17-13

amount of substances in

The specific gravity of the urine


1.010

1.010-1.030 is under normal limits. Which

the urine. It also shows

indicates that the patient is well

how

hydrated

well

the

kidneys

balance the amount of


water

in

higher

urine.
the

and

no

signs

of

Diabetes insipidus.

The

specific

gravity, the more solid


material is in the urine.
5. Albumin

D.O
09-17-13
D.R.
09-17-13

Albumin

urine

test

is

used

+1

Absent

The patients kidney was unable

to detect the ability of

to filter albumin, the proteins in

the

the blood.

kidney

to

filter

efficiently. To identify if
24

the kidneys filters the


one

needed

to

be

excreted and needed to


remain in the body.
6. Glucose

D.O
09-17-13
D.R.
09-17-13

Glucose

urine

test

measures the amount of


sugar

(glucose)

urine

sample,

in

Negative

Negative

The patients urine has negative


result.

This

means

that

the

The

kidneys of the patient were able

presence of glucose in

to retain the glucose needed for

the

the body to use and no signs of

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

Pus cell in urine test is


used

to

detect

the

1-2/HPF

5HPF

The patients urine has 1-2/HPF,

presence of any harmful

which indicates no presence of

chemical

any harmful chemical or signs of

of

other

unexpected substance in
the

urine.

glucose

infection in the body.

Specifically,
(diabetics),

blood (kidney problems),


25

crystals (kidney stones)


and also pus cells that
indicate some kind of
infection in the body.
8. Epithelial
Cells

D.O
09-17-13
D.R.
09-17-13

This 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.

few

0-5/HPF

The 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.

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

ANATOMY AND PHISIOLOGY OF APPENDIX


Also 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.

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:

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)

29

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): Retrocecal
Second most common position of appendix (20% of cases): Subcecal
If 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.
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:

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 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

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

32

8. THE PATIENT AND HIS ILLNESS


A. PATHOPHYSIOLOGY
(Book-centered)

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

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

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 modifiable
Adolescent and young adults
Fibrous condition of the Bowel.

Justification
They tend to have a detrimental lifestyle.
Fecalith may become occluded in this kind

Kinking of the Appendix


External occlusion of the bowel by

of surface.
A fecalith may also be occlusion.
Severe pathway and cause occlusion.

adhesion.
Yersinia Infection

May cause inflammation of the small

Men

intestine and eventually cause occlusion.


Have more detrimental lifestyle than
women.

Moidifiable
Fecalith
Swelling of the abdomen

a.3.

Justification
Can occlude the lumen of the appendix.
Can eventually cause occlusion.

Signs and symptoms

Signs and symptoms


Pain

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

Due to fear in vomiting


Bodys mechanism to alert the body for

Halitosis

infection
Due to occluded fecalith and/or infection.

36

a. PATHOPHYSIOLOGY
(Client-centered)
Non-modifiable

Modifiable

Adolescent and young adults:


18 y/o
Men

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

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 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

Swelling of the abdomen

appendix.
Can eventually cause occlusion.

b.3.

Signs and symptoms

Signs and symptoms


Pain (RLQ)

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

intestine due to occlusion


Due to fear in vomiting

39

Low grade fever

Bodys mechanism to alert the body for


infection

40

B. PLANNING NURSING CARE


#1 Acute pain r/t inflammation of tissues secondary to Appendicitis
Assessment
S=
O= patient
manifested
the following:
>Facial
grimace
>Guarding
behavior
>Rebound
tenderness
>Limited
ROM
Patient may
manifest the
following:
>Irritability

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

> To gain patients


trust & cooperation

>Assess general
condition

> To gain baseline


data

>Observe
patients non
verbal cues such
as facial
expression

> Indicates need


for further
evaluation

>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

>Maintain semifowlers position

>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

> To detect any


abnormalities

>Provide comfort
measures such
as back rubs
providing
diversional
activities, and
massages

>To provide nonpharmacologic


pain management
>To assess
contributing factors
to pain

>Perform
comprehensive
assessment to
pain.
>Perform pain
assessment each
time pain occurs,
note changes
from previous
reports

>To rule out


worsening of
condition.

>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 distract the


patient & reduce
pain

>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:

Pain upon moving


Limited mobility

>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

>To gain patients


trust & cooperation

> Monitor & record


VS.

>To gain baseline


data

>Assess general
condition.

>To detect any


abnormalities

>Provide adequate
rest.

>To prevent fatigue


and conserve energy

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.

>To prevent injuries


>Assist patient to
lean and
demonstrate safety
measures

>To limit fatigue


&maximize use
of energy

>Teach ways on
how to conserve

47

night

energy such as
sitting when doing
activities
>Administer
medication prior to
activity as ordered

>For pain relief, to


permit maximal effort
and involvement in
activity need

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

Ordered: 09/17/2013 D5LRS is useful for daily


maintenance of body fluids
and nutrition, and for
Performed: 09/17rehydration.
20/2013

Indication(s) or Purposes

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.

Clients response to the


treatment

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. DRUGS

49

Name of the drugs

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

Antibiotic; inhibits cell Indicated for certain

side effects.
The patient

wall synthesis during

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

bronchitis, ear, lung,

09-19-2013

skin and respiratory

Ampicillin

D.O

I gm/IV q6 ANST (-)

09-17-2013

tract infections.

Gentamycin

D.O
9-17-2013

80 mg/IV q8ANST

Antibiotic; thought to

Indicated for

The patient

(-)

inhibit protein

conditions like Acute

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.

and prevent ulcers

complied and

Competitively inhibits

in the stomach and

didnt complain

action of histamine at

intestines. It also

of any

H2-receptor sites of

treats conditions in

problems.

09-17-2013

parietal cells,

which the stomach

09-18-2013

decreasing gastric

produces too much

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;

term management of operative pain

NSAID; anti-

pain and relief of

of patient Ace

inflammatory; inhibits

post operative

eventually

prostaglandins and

inflammation.

disappeared.

Analgesic; binds to

Indicated for relief of

The post-

mu-opioid receptors

moderate to

operative pain

and inhibits the

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

many effects similar


to the opioids but
does not have the
respiratory

Mefenamic

D.O
09-17-2013

D.G
09-17-2013

50mg/tab q4 x pain

depressant effects.
Mefenamic acid and

Indicated for relief of

The post-

other NSAIDs

moderate to

operative pain

(nonsteroidal anti-

moderately severe

of patient Ace

inflammatory drugs)

pain.

eventually

are thought to work

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

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.

56

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.

57

C. DIET

Type

Date ordered

of Diet

Date performed

NPO

General Description

Indication(s) or

Specific foods

Clients response

Purposes

taken

and/or reaction to the

None

diet
The patient tolerated not

Ordered:

Patient Ace will not take anything

To not aggravate the

09/17/2013

via mouth, but with an IVF hooked

inflammation of the

eating anything even

for sufficient nutrition.

Verniform Appendix

though he could feel

Performed:

and also for pre-

slight irritation at the

09/17-19/2013

operative care.

epigastric region.

Discontinued:
09/19/2013

58

Nursing Responsibilities:
1.
2.
3.
4.
5.
6.

Check Doctors order for the proper diet of the patient.


Assess patients identity.
Inform the SO about the patients ordered diet.
Place the patient in proper position.
Note any effects of the diet to the patient.
Observe for any side effects.

Type of

Date ordered

Diet

Date

Diet as

General Description

Indication(s) or

Specific foods

Clients response

Purposes

taken

and/or reaction to the

performed
Ordered:

Patient can take food orally as

To bring the patient to Patient Ace

09/20/2013

long as patient Ace can tolerate

his normal diet and

or no complication seen.

give enough nutrients and chocolate

Tolerated

diet
The patient eventually

consumed bread returned to his normal

Performed:

to help his body to

drink called

09/20/2013

cope after not eating

Milo after his

for several days.

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

To provide enough rest that


is needed by the patient

Specific foods taken

Clients response

NPO

The patient complied


with the said activity.
The patients curent
state slightly improved.

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

Specific foods taken

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.

Improves health and to


provide proper healing of
the incision site of patient
Ace.

Nursing Responsibilities:
1.
2.
3.
4.
5.
6.

Check Doctors order for the proper diet of the patient.


Assess patients identity.
Inform the SO about the patients exercise.
Inform patient about the purpose of activity.
Demonstrate technique.
Document any findings

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.

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 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.

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 Wells Straight 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 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.

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)


S
Hindi 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
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.

SUMMARY OF FINDINGS AND CONCLUSION


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.
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

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-overview