A CASE STUDY OF CLIENT WITH ACUTE APPENDICITISTHAT UNDERGONE APPENDECTOMY

Submitted by:BSN 3A-Group 1Aguilar, Divine Grace P.Angeles, Sharmaine I.Arojo, Dhianne Joye C.Azul, Kizsia MaeBagay, Maria Fatima C.Batac, Joice M.Bernardo, Jamaica EzzaBonifacio, Ann Rio S.Bulanadi, Krisna Jane D.Carlos, Jenikka Mhae

Submitted to Clinical Instructor:

Narcisa Cruz RN, MANMylene Fajardo RN, MANJesusa Capispisan RNAbigail Ramos RN, MANMaribel Valencia RN, MANJose Florante C. Nabong RN, MANMarlon Robles RN

October 03, 2013

I. INTRODUCTION

Our client is Mr.N.C, a 12-year old client from Tigbe, Norzagaray, Bulacan, admitted at Bulacan Medical Center on August 25, 2013 with an initial diagnosis of Acute Appendicitis with chief complain of an abdominal pain.According to US National Library of Medicine, Appendicitis is considered to be a serious illness and the most efficient treatment at the time being involves medical surgery. Appendicitis is therefore a surgical emergency and it can be efficiently overcome only by removing the diseased appendix from the body. The vermiform appendix is a tubular extension of the large intestine (colon) and it is considered to have a role in the process of digestion. The actual function of the appendix is not exactly known, but its absence doesn't cause any changes inside the organism. Appendicitis occurs due to strangulation or obstruction of the vermiform appendix. The appendix can either be blocked by feces or it can be pressed against by swollen lymph nodes. The appendix gradually stops receiving blood and it eventually dies. Bacteria accumulate inside the appendix and cause inflammation and swelling. Acute appendicitis may lead to complications such as perforation of the appendix and sepsis (severe bacterial infection). In rare cases, abdominal traumatic injuries can also lead to the development of appendicitis. In some people, genetic predispositions to appendicitis can also facilitate the occurrence of the illness.Appendicitis can be either acute or chronic. Acute appendicitis develops faster and the presence of the illness is easier to detect. Chronic appendicitis is slower to evolve and it is more difficult to diagnose. The most common symptoms of appendicitis are intense, continuous abdominal pain, nausea, vomiting, constipation or diarrhea and fever. The pain usually begins in the umbilical region of the abdomen and later shifts to the right lower side. The abdominal pain characteristic to acute appendicitis intensifies with physical effort.An interesting aspect of appendicitis is that it can be very difficult to detect and diagnose correctly, due to the unspecific character of its symptoms. In some cases, the patients might not have any symptoms at all (elderly people, people that have previously suffered surgical interventions, people with HIV, people with diabetes and overweight people). The form of appendicitis that generates no specific symptoms is called a typical appendicitis. The rate of mortality among patients with atypical appendicitis is very high.Anyone can develop appendicitis, regardless of age and sex. However, the illness has a higher incidence in men. Also, children with ages between 3-15 are exposed the most to developing acute appendicitis. Elderly people and patients with special conditions usually develop atypical acute appendicitis. If appendicitis is discovered in time and treated appropriately; the patients fully recover within weeks. However, if the illness is discovered late, it may lead to serious complications (perforation, gangrene, sepsis).Although appendicitis can't be effectively prevented, it is thought that a diet rich in fibers may reduce the chances of developing the illness.Incidence extrapolations for USA for Acute Appendicitis: 680,000 per year, 56,666 per month, 13,076 per week, 1,863 per day, 77 per hour, 1 per minute, 0 per second. Note: this extrapolation calculation uses the incidence statistic: 25 per 10,000 (age 10-17), 1-2 per 10,000 (under 4) Death rate extrapolations for USA for Acute Appendicitis:389 per year, 32 per month, 7 per week, 1 per day, 0 per hour, 0 per minute, 0 per second.Note:this extrapolation calculation uses the deaths statistic: 390 deaths reported in USA 2010 for appendix conditions (NVSR Sep 2010). According to Department of Health, as of September 2012, statistics in the Philippines shows that about 215,604 of the 86,241,697 Filipinos had an incident of appendicitis. Incidence (annual) of Acute Appendicitis: 25 per 10,000 (age 10-17), 1-2 per 10,000 (under 4). Lifetime risk for Acute Appendicitis:8.6% risk for males, 6.7% for females.OBJECTIVES

GENERAL OBJECTIVE:After 3-4 hours of Case Presentation, we nursing students will be able to gain knowledge about Appendicitis.

STUDENT-CENTERED:1. KnowledgeDefine what Appendicitis isEnumerate signs and symptoms of Appendicitis.Identify nursing interventions to be done when handling patient with Appendicitis.1. SkillsProperly assess the patient.Perform proper nursing care to patient.Present a liable case study to clinical instructors about the patient handled at the hospital.

1. AttitudeObserve discipline while in the field of duty.Manage own emotions while in the field of duty.Establish self-confidence when giving nursing care into the client.

CLIENT-CENTERED:

I. KnowledgeEnumerate some causes of AppendicitisEnumerate signs and symptoms.Identify some foods to eat and to avoid when suffering from Appendicitis.II. SkillsPractice and enhance improvement a good communication skills through interviews.Conduct a comprehensive assessment of patient who had appendicitis and undergone appendectomy.Develop a critical thinking and analytical skills through frequent brainstorming sessions.III. Attitude Establish rapport with patient Develop a warm environment between the student and the patient fora better working relationship towards improvement of health. Provide health teachings with the client

II. NURSING ASSESSMENT

1. PERSONAL HISTORYName: N.C.Permanent Address: Tigbe, Norzagaray, Bulacan Birthday: September 23, 2000Age: 12 years old Gender: Male Occupation: None Race: AsianMarital Status: Single Religious Orientation: Roman CatholicEducational Attainment: Elementary level

Source of Healthcare Financing: Fathers IncomeHealthcare Insurance: Phil Health

Date of Admission: August 25, 2013 at 12:39 pmDate of discharge: September 03, 2013

Initial diagnosis: Acute appendicitis

Final diagnosis: supperative appendicitis

1. CHIEF COMPLAINT

Abdominal Pain

1. HISTORY OF THE PRESENT CONDITION

According to the father of our client, his son having an abdominal pain for 3 days on August 21, 2013. On August 17, 2013 they go in the center in Norzagaray, and they gave 1 capsule of 10 mg of Buscopan when the abdominal cramps. Then, August 23, 2013 he admitted at Norzagaray Hospital. The diagnosis of the doctor in Norzagaray Hospital is appendix and the appendix might blow. He was transferred at Bulacan Medical Center at 12:39 pm of August 25, 2013 and the operations do. N.C. is a 12 years old.According to the father of our client, his son feels the symptoms of having abdominal pain and vomiting. And he never goes in the hospital or having a checkup. According to N.C., he is having an acute appendicitis, because when he done eating he is playing immediately. He ignores the pain on that day and sleep but on the second day morning he suffers again the pain and he tell to his father about his feeling. His father brought him to the Health center near there barangay and was checked up by the rural health doctor prescribed medication such as Buscopan 10 mg 1tablet a day when his abdomen cramps.In this 7 days onset of severe pain and symptoms his father brought him in the Norzagaray Hospital at August 23, 2013 and confined him.Then the doctor diagnosed that the client had Acute Appendicitis with positive anorexia and vomiting in which referral for another hospital admitted in Bulacan Medical Center, August 25, 2013 time of 12:39:19 pm for surgery.

1. HISTORY OF THE PAST CONDITION/ ILLNESS

The father of our client told us that his son didnt undergo any operations, aside from he is under go before in the appendectomy cause by acute appendicitis. His childhood or previous diseases are fever, cough, colds, diarrhea, measles, sore eyes, and mumps. According to his father, during his childhood he has the complete immunization like BCG, DPT, OPV, HEPA A, B, and C. He has no allergies, accidents, injuries this past years, and hospitalization aside from the present.

F. FUNCTIONAL HEALTH PATTERNPRIOR TO HOSPITALIZATIONDURING HOSPITALIZATION

A. Health Perception and Health Management PatternThe client perceives himself unhealthy. He suffers abdominal pain around the epigastric area, which may have an sudden onset and become increasingly severe pain, started August 16, 2013. He also suffers vomiting, diarrhea and body malaise. He rate his pain for about 8/10 in pain scale. Kasi kung minsan hindi siya palakain inuuna pa ang laro kesa sa kain yan siguro dahilan ng pagkakasakit ng tiyan niya as verbalized by his father.After Surgery the client feels calm and quiet with IVF which is 0.9 NaCL 500cc @ 450 cc level regulated at 16 gtts/min. He has incision on right lower quadrant for about 2 inches transverse and sutures. Masakit yung tahi ko as verbalized by the client. He rates the pain scale 5. He also add Kumakati ang tahi ko as he stated

B. Nutritional Metabolic Pattern -72 HOURS DIET RECALLAugust 24, 2013August 25, 2013August26,2013

BreakfastLunchDinnerNPONPONPO

The client usually drink 2-3 glasses of soft drink a day, 3fruit guava and eat flavored snack. He doesnt want to consume his full meal as stated by his father. He would go with his friend and play with them. His weight was 23 kilograms and a height of 3 feet and 9 inches with a Body Mass Index of 17.6 which is classified as underweight. There's no difficulty in swallowing and no known allergy to foods His wounds dont heal easily as stated by his father. In fact there are many scars in his legs caused by stumbling and lack of balance in playing like basketball and hide n' seek. He has twenty six permanent teeth with no third molars yet.-72 HOURS DIET RECALL

August 27, 2013August 28, 2013August 29, 2013

Breakfast1 glass of water (250ml)1 piece of bread1 glass of water (250 ml)2 piece of bread1 glass of water (250 ml)

Lunch20 grams of noodles soup1 glass of water (250 ml)1 glass of water (250 ml)40 grams of Nissan cup noodles1 serving of kare-kare1 half rice1 glass of water (250 ml)

DinnerNone1 bottled mineral waterNone

On august 27, 2013 the doctor ordered General liquid diet And August 28-29, 2013 the doctor ordered Diet As Tolerated. "Pipilitin ko na talaga siya kumain ngayon sa ayaw at sa gusto niya" as verbalized by his father.

C. Elimination PatternColor FrequencyAmount CharacterDiscomfort

Urine yellowish4x a day480 mlhazyNone

Stoolbrownish0-1x a dayNot applicablefloatingSlightly

Theres no excessive perspiration but he sweat immediately while playing basketball with his friend as stated by his father. Minsan amoy pagpapawis niya na parang mgangasim asim lalo na ka kili-kili as verbalized by his father.Color FrequencyAmount CharacterDiscomfort

Urine yellowish6x a day720 mlhazynone

Stoolbrownish1-2x a dayNot applicableloosenone

Post op the client doesnt feel any discomfort in urinating and defecating.

D. Activity Exercise Pattern(Code Level)Level 0 - Full Self careLevel 1 - Requires use of equipment or deviceLevel 2- Requires assistance or supervision from another person Level 3- Requires assistance or supervision from another person or deviceLevel 4- Is dependent and does not participateMeron siyang sapat na enerhiya para maglaro pero pag uutusan sa bahay walang nagagawa as verbalized by the father. The client tells that he exercise everyday by walking to school. The school which he entered grade 6 was just walking distance as the client states. He does some recreation like basketball, hide n seek, playing some activities with his friends either morning or in the afternoon. If he has free time he just sleeps or watches television every morning especially his favorite shows like Dragon Ball Z and Doraemon Perceive ability for (code level):0 Feeding0 Dressing0 Bathing0 Grooming0 Toileting0 General Mobility0 Bed MobilityOn August 27, 2013, 8 am, the doctor orders the father of my client for ambulation. And for not carrying any heavy materials or objects. Being hospitalized interfered with Activities of daily living especially in his school attendance. Perceive ability for (code level):

(Code Level)Level 0 - Full Self careLevel 1 - Requires use of equipment or deviceLevel 2- Requires assistance or supervision from another person Level 3- Requires assistance or supervision from another person or deviceLevel 4- Is dependent and does not participate0Feeding0 Dressing0 Bathing0 Grooming0 Toileting0 General Mobility0 Bed Mobility

E. Sleep- Rest PatternStart of Sleep8: 00 pm

End of Sleep 9: 00 am

Nap timenone

Total no. of Hours10 hours

The sleeping hours of my client starts from 8pm to 9am in the morning for a total of 10 hours in week days. But in school days it is 8pm to 6am for a total of 7hours. He has no nap time because he spent this time for recreational activities. He doesn't have any sleeping problems and no sleeping medications. He has continuous sleep but interrupts when he felt pain on the abdomen. He only rest when he feel exhausted from playing sport.Start of Sleep10: 30 pm

End of Sleep 7: 00 am

Nap time15 mins

Total no. of Hours

The hours of sleep during are intermittent sleep for about 10:30 pm to 7 am. Then he sleeps at the afternoon for nap time of 15 mins. Nahihirapan akong akong matulog dito as verbalized by the client.

F. Cognitive- Perceptual PatternHe doesnt have any hearing difficulties and not using hearing aid. No blurred vision and also not using eye glasses. No consultation of doctor about vision. Doesnt have any changes in the memory lately. His easiest way to learn things is to have time by his mother to teach him. The client only suffers a bit of achiness and ichiness in his incision. No changes in the 5 senses.

G. Self- Perception Pattern and Self- Concept PatternHe said hes healthy before his condition as my client stated. As he grows up in the age of 12 years old there so many thing changes specifically his physical appearance. He grows more having an Adams apple and his voice gets deeper. He starts to clean by himself in hygienic purposes. Kapag pinapagalitan ako ni papa dun ako naiinis o kaya nalulungkot kaya dinadaan ko na lang sa laro ito as verbalized by the client.He stated that his healthy now though he can still feel a little pain. He also state that he has impaired skin integrity due to surgical incision.

H. Role- Relationship PatternHe has parents and with 3 siblings not living alone. He lives in Tigbe, Norzagaray, Bulacan and has a nuclear family as stated by his father. He thinks that his father was worrying about his status. He also has friends that join also in playing basketball. Opo, minsan kulang ang aking baon sa pang araw-araw kong pangngangailangan as verbalized by the client. He said that his neighbor was kind and frequently going outside the house to talk with my neighbor.The client was able to listen and follow on his fathers instruction. He felt uneasy with other patient. Maayos ang mga nurse at doctor dito as verbalized by the father.

I. Sexuality Reproductive PatternHe was circumcised last April 13, 2010. This Elective surgery was done in their barangay where in they have free circumcision on that day.He grows physically as hes father stated. He had an Adams apple and with deep voice and underarm hair.

J. Coping Stress Tolerance PatternHe doesnt take any drugs to cope stress neither drinks alcoholic beverages. He usually goes to the computer shop to refresh his mind. He doesnt change any in the past 1-2 years ago with the problems.Theres stress now as the client stated. He was uncomfortable when sleeping. He was disturbed by his surroundings like noise at night. The client also shared that he is easily bored at bed so he usually wonder around the hospital ward.

K. Value- Belief PatternHe doesnt like being yelled by his father. For him, family is very important and he values his studies. He's a roman catholic and religion is very important to him especially when he has problems. Hindi nakakahadlang sa relihiyon ko ang kalagayan ko ngaun as verbalized by the client. He prayed to God for successful surgery and for better recovery.

G. GROWTH AND DEVELOPMENTTHEORYERICKSONs PSYCHOSOCIAL DEVELOPMENT THEORYPIAGETs COGNITIVE DEVELOPMENT THEORYFREUDs PSYCOSEXUAL DEVELOPMENT THEORYKOHLBERGs MORAL THEORYFOWLERS STAGES OF FAITH

STAGEIndustry vs. InferiorityFormal Operational Stage Latency StageConventional MoralitySynthetic-Conventional Faith and the Interpersonal Self

DEFINITIONChildren are at the stage where they will be learning to read and write, to do sums, to make things on their own. Teachers begin to take an important role in the childs life as they teach the child specific skills.It is at this stage that the childs peer group will gain greater significance and will become a major source of the childs self esteem. The child now feels the need to win approval by demonstrating specific competencies that are valued by society, and begin to develop a sense of pride in their accomplishments.If children are encouraged and reinforced for their initiative, they begin to feel industrious and feel confident in their ability to achieve goals. If this initiative is not encouraged, if it is restricted by parents or teacher, then the child begins to feel inferior, doubting his own abilities and therefore may not reach his or her potential.If the child cannot develop the specific skill they feel society is demanding (e.g. being athletic) then they may develop a sense of inferiority. Some failure may be necessary so that the child can develop some modesty. Yet again, a balance between competence and modesty is necessary. Success in this stage will lead to the virtue ofcompetence.As adolescents enter this stage, they gain the ability to think in an abstract manner, the ability to combine and classify items in a more sophisticated way, and the capacity for higher-order reasoning.At about age 11+ years, the child begins to manipulate ideas in its head, without any dependence on concrete manipulation; it has entered the formal operational stage. It can do mathematical calculations, think creatively, use abstract reasoning, and imagine the outcome of particular actions.No further psychosexual development takes place during this stage (latent means hidden). The libido is dormant. Freud thought that most sexual impulses are repressed during the latent stage and sexual energy can be sublimated (re: defense mechanism) towards school work, hobbies and friendships. Much of the child's energies are channeled into developing new skills and acquiring new knowledge and play becomes largely confined to other children of the same gender.Conventional morality as defined in Kohlberg's stages of morality is the concept of acceptable behavior that mirror's the values of certain political or social context. Stage 3 - Interpersonal RelationshipsOften referred to as the "good boy-good girl" orientation, this stage of moral development is focused on living up to social expectations and roles. There is an emphasis on conformity, being "nice," and consideration of how choices influence relationships. Stage 4 - Maintaining Social OrderAt this stage of moral development, people begin to consider society as a whole when making judgments. The focus is on maintaining law and order by following the rules, doing ones duty and respecting authority.This was a watershed in faith development for Fowler: young person uses logic and hypothetical thinking to construct and evaluate ideas. New cognitive abilities make mutual perspective-taking possible and enable one to integrate diverse self-images into a coherent identity. A persona and largely unreflective synthesis of beliefs and values evolves to support identity and to unite one in emotional solidarity with others.

FINDING/ANALYSISThe client has the ability to read and write which is primarily needed by a child develop his full potential.The client speaks accordingly with appropriate thoughts. The client has a social life for he plays with his childhood friends.The client obeyed his father when we asked for a permission to see the site of operation.The patient grimaced when we palpated the side of the incision site.

REMARKSPositivePositivePositivePositivePositive

III. ANATOMY AND PHYSIOLOGYSmall intestine- completes digestion. Mucus protects gut wall. It absorbs nutrients, mostly water. Peptidase digests proteins. Sucrases digest sugars. Amylase digests polysaccharides.Large intestine- reabsorbs some water and ions. It also forms and stores feces.Appendix- is a tube-shaped organ with a length of approximately 10 cm and the stem on the cecum. It sits at the junction of the small intestine and large intestine. Sometimes the position of the appendix in the abdomen may vary. Most of the time the appendix is in the right lower abdomen, but the appendix, like other parts of the intestine has a mesentery. This mesentery is a sheet-like membrane that attaches the appendix to other structures within the abdomen. If the mesentery is large it allows the appendix to move around. In addition, the appendix may be longer than normal. The combination of a large mesentery and a long appendix allows the appendix to dip down into the pelvis (among the pelvic organs in women) it also may allow the appendix to move behind the colon (a retrocolic appendix). In infants, the appendix is a conical diverticulum at the apex of the cecum, but with differential growth and distention of the cecum, the appendix ultimately arises on the left and dorsally approximately 2.5 cm below the ileocecal valve. The taeniae of the colon converge at the base of the appendix, an arrangement that helps in locating this structure at operation. The appendix in youth is characterized by a large concentration of lymphoid follicles that appear 2 weeks after birth and number about 200 or more at age 15. Thereafter, progressive atrophy of lymphoid tissue proceeds concomitantly with fibrosis of the wall and partial or total obliteration of the lumen. Appendix is blooded by apendicular artery which is a branch of the artery ileocolica. Arterial appendix is end arteries. Appendix has more than 6 mesoapendiks obstruct lymph channels leading to lymph nodes ileocaecal. Although the appendix has less functionality, but the appendix can function like any other organ. Appendix produces mucus 1-2ml per day. The mucus poured into the caecum. If there is resistance there will be a pathogenesis of acute appendicitis. GALT (Gut Associated Lymphoid Tissue) in the appendix produce Ig-A. However, if the appendix removed, none affect the immune body system.Ascending colon- watery stoolTransverse colon- mushy stoolDescending colon- semi-formed stoolSigmoid colon- feces are formedRectum- stores and expels feces.

IV. PATIENT AND HIS CONDITION / ILLNESSA. PHYSICAL ASSESSMENTNAME: NARCAGE: 12 years old DATE: August 26, 2013 8 AM12 PMVITAL SIGNS: PR= 90 bpm PR= 84 bpm TEMPERATURE= 35.3 C TEMPERATURE= 36.3 C RR= 26 cpm RR= 26 cpmBP=100/80mmHgBP=100/80mmHg

PARTS TO BE ASSESSEDTECHNIQUENORMAL FINDINGSACTUAL FINDINGSREMARKS

GENERAL SURVEY

1. Body built, height & weight in relation to clients age, lifestyle & healthInspectionProportionate and varies with lifestyle.Height: 23 kgWeight : 39 inchesBMI: 17.6Deviation from normal due to malnourishment

3. Clients overall hygiene & groomingInspectionClean, neatClient is clean and neat.NORMAL

4. Body & breath odorInspectionNo body odor or minor body odor relative to work or exercise, no breath odor.Neither body odor nor breath odor was observed.NORMAL

5. Signs of distress in posture or facial expressionInspectionNo distress noted.No distress noted.NORMAL

6. Obvious signs of health or illnessInspectionHealthy appearance.Obvious sign of illness such as pallorNORMAL

SKIN

1. Skin color & uniformityInspection and PalpationColor- varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive.Uniformity- generally uniform except in areas exposed to sunlight; areas of lighter pigmentation (palms, lips, nail beds) in dark skinned people.The client has a light brown complexion, uniformity in color except those with clothes,and have scars in the both legs and feet.Deviation from normal due to insect bites.

2. Presence of edemaInspectionNo edema.No edema noted.NORMAL

3. Skin lesionsInspectionFreckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions.Skin lesion located at the left hand due to IV insertionDeviation from normal due to IV insertion.

4. Skin moisturePalpationMoisture in skin folds and axillae (varies with environmental temperature and humidity, body temperature and activity.)Moistened skin especially in the skin folds. NORMAL

5. Skin temperaturePalpationUniform; within normal rangeUniform in temperature. NORMAL

6. Skin turgorPalpationWhen pinched, skin springs back to previous state.

\Skin returns back to previous state in less than 2 seconds.NORMAL

NAILS

1. Fingernails plate shape to determine its curvature & angleInspectionConvex curvature, angle of nail plate about 160 degrees.Nails are in convex curvature; NORMAL

2. Fingernail & toenail bed colorInspectionHighly vascular and pink in light skinned clients; dark- skinned clients may have brown or black pigmentation in longitudinal streaks.Fingernails and toe nails color are pinkish.NORMAL

3. Tissues surroundings nailsInspectionIntact epidermis.Intact epidermis, pale in colorNORMAL

4. Fingernail & toenail texturePalpationSmooth texture.Clients nails are smooth in textureNORMAL

5. Blanch test of capillary refillPalpationPrompt return of pink or usual color (generally less than 4 seconds.)Prompt return of pink or usual color (generally less than 4 seconds.)NORMAL

HAIR & SCALP

1. Evenness of growth over the scalpInspectionEvenly distributed hair.Hairs are evenly distributed.NORMAL

2. Hair thickness & thinnessPalpationThick/thin hair.The client has thick hair on head.NORMAL

3. Presence of infections or infestationsInspectionNot present.No infestations notedNORMAL

4. Texture & oiliness over the scalpPalpationSilky, resilient hair.Oily, thick, resilient hairNORMAL

SKULL

1. Size, shape & symmetryPalpationRounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); smooth skull contour.Head is symmetrically round.NORMAL

2. Nodules or masses & depressionsPalpationSmooth, uniform consistency; absence of nodules or masses.No mass or nodules notedNORMAL

FACE

1. Facial featuresInspectionSymmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds.Symmetrical facial features; palpebral fissures equal in size; nasolabial folds are symmetrical NORMAL

2. Symmetry of the facial movementsInspectionSymmetrical facial movements.Facial movements are all symmetricalNORMAL

EYEBROWS & EYELASHES

1. Evenness of distribution & direction of curlInspectionHair evenly distributed; skin intact. Eyebrows asymmetrically aligned equal movement. Eyelashes curl slightly outward.Eyebrows and eyelashes are both evenly distributed, symmetrical aligned. Eyelashes curl slightly outward. NORMAL

EYELIDS

1. Surface characteristics & ability to blinkInspection and PalpationSkin intact, no discharge, no discoloration. Lids close symmetrically approximately 15-20 involuntary blinks per minute; bilateral blinking. When lids open, no open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered.Eyelids skin are intact, no noted discharge, and no noted discoloration. Lids close symmetrically. Client exhibited 15 involuntary blinks per minute.NORMAL

CONJUNCTIVA

1. Bulbar conjunctivas color, texture & presence of lesionsInspectionTransparent; capillaries sometimes evident.Transparent, capillaries evident, no discharge was noted.NORMAL

2. Palpebral conjunctivas color, texture & presence of lesionsInspectionShiny, smooth, pink or red in color.Shiny, smooth and pale in colorNORMAL

SCLERA

1. Color & clarityInspectionSclera appears white (yellowish in dark- skinned clients).Sclera appears whiteNORMAL

CORNEA

1.Clarity & colorInspectionTransparent, shiny and smooth; details of the iris are visible. In older people, a thin grayish white ring around the margin, called arcus senilis, may be evident.Details of iris are visible. Transparent, shiny and smooth.

NORMAL

IRIS

1. Shape & colorInspectionFlat and roundFlat and round and uniform in color.NORMAL

PUPILS

1. Color, shape & symmetry of sizeInspectionBlack in color; equal in size; normally 3-7 mm in diameter; round, smooth border.Black, equal in size, about 3 mm in diameter; round, smooth & symmetrical.NORMAL

2. Pupil light reaction & accommodationInspectionIlluminate pupil constricts (direct response)Illuminated pupil constrictsNORMAL

3. Pupils direct & consensual reaction to lightInspectionNonillluminated pupil constricts (consensual response)Pupils constrict when looking at near object; pupil dilates when looking at far object; pupils converge when object is moved towards the nose.Non-illuminated pupil constricts too. Pupils dilated when ask to look on distant objects, constricts when pen was placed near eyes; when pen is moved towards the noseNORMAL

LACRIMAL GLAND, LACRIMAL SAC & NASOLACRIMAL DUCT

1. Presence of edemaInspectionNo edema or tenderness over lacrimal gland.No edema notedNORMAL

VISUAL FIELDS

1. Test for peripheral visual fieldsInspectionWhen looking straight ahead, the client can see objects in the periphery.Client can see objects in the periphery.NORMAL

EARS AURICLE

1. Color & symmetry of size & positionInspectionColor same as facial skin, symmetrical, auricle aligned with outer canthus of eye, about 10cm from vertical.Color is same with facial skin, symmetrical with each other, auricle aligned with outer canthus of eye, NORMAL

2. Texture & elasticity & areas of tendernessPalpationMobile, firm and not tender, pinna recoils after it is folded.Both pinna recoils after being folded. Mobile, firm and not tender.NORMAL

EXTERNAL EAR CANAL

1. Cerumen, skin lesions, pus & bloodInspectionDistal third contains hair follicles and glands. Dry cerumen in various shades of brownNo noted pus, blood and odor. Minimal cerumen noted. NORMAL

NOSE

1. Shape, size or color & flaring or discharge from the naresInspectionSymmetric and straightNo discharge or flaringUniform colorNo discharge and/or flaring noted. Symmetrical on both sides. Also uniform in color.NORMAL

2. Presence of redness, swelling, growths & discharge or nares using the flashlightInspectionMucosa pinkClear, watery dischargeNo lesions.Mucosa is intact and pinkish; minimal moist noted inside; no swelling or nodules found.NORMAL

3. Position of nasal septumInspectionNasal septum intact and in midline, intactNasal septum is intact and in midlineNORMAL

4. Test patency of both nasal septumInspectionAir moves freely as the client breathes through the naresAir moves freely as the client breathes through each naresNORMAL

5. Tenderness, masses & displacement of bone & cartilagePalpationNot tender; no lesionsNo tenderness, no lesions noted. No displacement of bone & cartilage.NORMAL

SINUSES

1. Presence of tendernessPalpationNot tenderNot tenderness noted.NORMAL

LIPS

1. Symmetry of contour color & textureInspection and PalpationUniform pink color (darker, e.g., bluish hue, in Mediterranean groups and dark-skinned clients)Soft, moist, smooth textureSymmetry of contourAbility to purse lipsUniform pink color, smooth, soft and symmetrical. Client is able to purse lips.NORMAL

BUCCAL MUCOSA

1. Color, moisture, texture & presence of lesionsInspection and PalpationUniform pink color (freckled brown pigmentation in dark-skinned clients)Moist, smooth, soft, glistening, and elastic texture (drier oral mucosa in elderly due to decreased salivation)Uniform pink color. Moist, smooth, glistening and elastic texture.NORMAL

TEETH

1. Inspect for color, number & condition & presence of denturesInspection32 adult teethSmooth, white, shiny tooth enamel2Loss Molar tooth,1Tooth Decay at the molarDeviation from normal due to improper mouth care.

GUMS

1. Color & conditionInspectionPink gums (bluish or dark patches in dark-skinned clients)Moist, firm texture to gumsPink gums, moist, firm, no noted lesions and nodulesNORMAL

TONGUE/FLOOR OF THE MOUTH

1. Color & texture of the mouth floor & frenulumInspection and PalpationSmooth tongue base with prominent veinsSmooth tongue base with prominent veinsNORMAL

2. Position, color & texture, movement & base of the tongueInspection and PalpationCentral in position

Pink in color (some brown pigmentation on tongue borders in dark-skinned clients); moist; slightly rough; thin white coatingSmooth, lateral margins, no lesionsRaised papillae (taste buds)

Moves freely, no tendernessCentered; slightly pink in color, moist, slightly rough, has thin white coating, smooth, no lesions; moves freely.NORMAL

PALATES & UVULA

1. Color & shape, texture & presence of bony prominencesInspection and PalpationSoft palate- light pink, smooth, no lesions, moist.Hard palate- lighter pink, more irregular texture/ridges no lesionsLight pink, smooth and moist soft palate.Light pink, irregular textured and moist hard palate.No noted nodules or massesNORMAL

2. Position of the uvula & mobilityInspectionPositioned in midline of soft palate.Midline of soft palateNORMAL

OROPHARYNX & TONSILS

1. Color & textureInspection and PalpationPink and smooth posterior wall.Smooth and pinkish posterior wallNORMAL

2. Size of the tonsils, color & dischargeInspectionTonsils are of normal size or not visible, pink in color and smooth. No discharge.Tonsils are normal size or not visible, smooth and pink in color. No discharge noted.NORMAL

3. Gag reflexInspectionPresentPresentNORMAL

NECK & LYMPH NODES

1. Symmetry & visible mass in the thyroid glandInspectionNot visible on inspectionSymmetric and not visible upon inspection.NORMAL

2. Presence of tenderness or nodules in the lymph nodesInspection and PalpationNot palpable.No nodules were palpatedNORMAL

3. Placement of the tracheaInspectionCentral placement in midline of neck, spaces are equal on both sides.Trachea is placed at the center. Spaces are equal on both sides.NORMAL

4. Smoothness & areas of enlargement, masses or nodules in the thyroid glandInspectionLobes may not be palpitated. If palpitated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing.Lobes were not palpated. Rise freely when swallowing.NORMAL

BREAST

1. Symmetry and visible mass in the breast.InspectionSymmetrical, no visible masses upon inspection.Symmetrical, no visible masses upon inspection.NORMAL

1. Color, moisture, texture and presence of lesionInspection and PalpationUniformity in color, moisture and texture. No presence of lesion.Uniform in color, no lesion was noted NORMAL

POSTERIOR THORAX

1. Shape, symmetry & compare the diameter of antero posterior thorax to transverse diameterInspectionAnteroposterior to transverse diameter ratio of 1:2, chest is symmetric.1:2 ratio of the anteroposterior to transverse diameter is symmetric.NORMAL

2. Spinal alignmentInspectionSpine vertically aligned.Spine is vertically aligned.NORMAL

3. Breathing excursionInspectionNo adventitious breath sounds.NoAdventitious breathing was inspected.NORMAL

5. Temperature, tenderness, massesPalpationUniform skin temperature, no masses or tenderness.No mass were palpated and uniform skin temperature.NORMAL

7. Percuss the posterior thoraxPercussionPercussion notes resonate, except over scapula.Lowest point of resonance is at the diaphragm.Resonant sound was heard at the upper portion and dull sound was heard over the scapula.NORMAL

8. Auscultate the posterior thoraxAuscultationVesicular and bronchovesicular breathe sounds.Bronchovesicular sound was heard at the upper portion and vesicular sound was heard at the lower portion of the thorax.NORMAL

ANTERIOR THORAX

1. Breathing patternInspectionQuiet, rhythmic, and effortless respirations.Wheezing sounds

2. Temperature, tenderness, massesInspection and PalpationUniform skin temperature, no masses or tenderness.Uniform skin temperature, neither masses nor tenderness was palpated.NORMAL

5. Percuss the anterior thoraxPercussionPercussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach.Resonant sound was heard down to the sixth rib at the level of the diaphragm. On the other hand, flat sound was heard over heavy muscles, and dull on the areas of the heart and liver.NORMAL

6. Auscultate the tracheaAuscultationBronchial and tubular breath sounds.Bronchial and tubular breath sounds were heardNORMAL

7. Auscultate the anterior thoraxAuscultationBronchovesicular and vesicular breath sounds.Bronchovesicular and vesicular breath sounds were heard.NORMAL

CAROTID ARTERIES

1. Pulsation of carotid arteriesPalpationNo pulsations, lifts or heaves.No pulsations and lifts observed.NORMAL

2. Auscultation of the carotid arteriesAuscultationNo sound heard on auscultation.No sound was heard upon auscultation.NORMAL

JUGULAR VEIN

1. Visibility of jugular veinInspectionVeins not visible.Veins were not visible upon inspection.NORMAL

ABDOMEN

1. Skin integrityInspectionUnblemished skin, uniform in color, silver white striae (stretch marks) or surgical scars.Uniform in color.Surgical Incision at the rightLower quadrant(RLQ)Deviation from normal due to surgical incision.

2. Abdominal contourInspectionFlat, rounded (convex) or scaphoid(concave)Convex in shape.NORMAL

3. Enlarge liver or spleenPalpationNo evidence of enlargement of liver or spleen.No enlargement was observed.NORMAL

4. Symmetry of contourInspectionSymmetric contour.Symmetric contour.NORMAL

5. Abdominal movementsInspectionSymmetric movements caused by respiration. Visible peristalsis in very lean people. Aortic pulsations in thin persons at epigastric area.Symmetric movement due to respiration. Peristalsis not visible.NORMAL

6. Vascular patternsInspectionNo visible vascular pattern.No visible vascular pattern.NORMAL

7. Bowel sounds, vascular sound & peritoneal soundsAuscultationAudible bowel sounds, absence of arterial bruit and friction rubs.No arterial bruit was heard. Audible bowel sound.NORMAL

8. Percuss abdominal quadrantsPercussionTympanic sound over the stomach and gas-filled bowels; dullness, especially over the liver and spleen or in full bladder.Uncomfortable for the client to percuss because of the surgical incision in the abdomen.

9. Light palpation of abdominal quadrantsPalpationTenderness may be present near xiphoid process, over cecum, and over sigmoid colon.Uncomfortable for the client to palpate because of the surgical incision in the abdomen

MUSCOLOSKELETAL SYSTEM

1. Muscle size compare the muscles on one side of the body (arm, thigh, calf) to the same muscle on the other sideInspectionEqual size on both sides of body.Equal on both sides of the body.NORMAL

2. Constructures (shortening) of the muscles & tendonsInspectionNo contractures.No contractures.NORMAL

3. Muscle fasciculations & tremors. Presence of tremors of the hands & arms when stretched in front of the bodyInspectionNo tremors.No tremors.NORMAL

4. Muscle tonicityInspectionNormally firm.Firm.NORMAL

5. Muscle strengthInspectionEqual strength on each body side.Equal strength on each body side.NORMAL

BONES

1. Normal structureInspectionNo deformities.No deformitiesNORMAL

2. Edema & tendernessInspectionNo tenderness or swelling.No tenderness.NORMAL

JOINTS

1. SwellingInspectionNo swelling.No swelling.NORMAL

2. Presence of tenderness, smoothness of movement, swelling, crepitation & presence of nodulesInspectionNo tenderness, swelling, crepitation or nodules. Joints move smoothly.Joints move smoothly. No tenderness was observed.NORMAL

RANGE OF MOTION

1. Upper extremitiesInspectionUniform in color, veins are visible in face, neck and dorsum of the hands, average muscles size, fingers are completeNo lesions, no edema.Uniform in color, veins are visible in face, neck and dorsum of the hands, average muscles size, fingers are complete.Skin Lesions due to IV insertion, no edema.NORMAL

2. Lower extremitiesInspectionUniform in color, no deformities, complete fingers in both feet.Uniform in color, no deformities, complete fingers in both feet.NORMAL

B. DIAGNOSTIC PROCEDURE / LABORATORYLABORATORY PROCEDUREDATE ORDERED/DATE RESULTINDICATION/PURPOSESNORMAL VALUESACTUAL VALUESNURSING RESPONSIBILITYANALYSIS /INTERPRETATION

URINALYSIS08/23/13Performed to check for urinary tract infection occassionaly the urine screen may pick up other abnormalities of renal functions such as excess sugar or protein.Color:yellowPh: 7.0SP Gravity: 1.005MacroscopicColor:yellowCharacter:hazyProtein: (-)Sugar: (-)Ph: 7.0SP Gravity: 1.020MicroscopicPus cells: 0-1 hpfRBC:Epithelial cells:Bacteria-(-)Mucous thread:Casts:Crystals:

All materials should be clean for urine analysis, gather only midstream urine.NORMAL

COMPLETE BLOOD COUNT 08/23/13It is used to check for blood diseases and disorders ,infections in the blood ,oxygen levels in the blood ,diabetes, kisner and liver diseases and host of ailmentsWBC: 4.0-12.0LYM: 0.8-7.0MIDSIZED CELL: 0.1-1.5GRAN: 2.0-8.0LYM%:20.0-60.0MIDSIZED CELL%:3.0-15.0GRAN%: 40.0-70.0RBC: 4.00-6.00HGB: 110-160HCT:35.0-49.0MCV:80.0-100.0MCH:27.0-34.0MCHC:310-370RDW-CV:11.0-16.0RDW-SD:35.0-56.0PLATELET:150-400WBC: 12.5LYM: 1.4MIDSIZED CELL: 0.7GRAN: 9.6LYM%:12.2MIDSIZED CELL%:5.9

GRAN%: 81.9RBC: 5.46HGB: 141HCT:43.9MCV:80.5MCH:25.8MCHC:321RDW-CV:13.5RDW-SD:41.0PLATELET:465Explain the procedure to the clientWBC indicates the presence of an infectiongranulocytes indicates a reaction to an infection lymphocytes count indicates increased rates of infection after surgery or traumaplatelets indicates inflammation

CREATININE08/23/13It is used to find out if the client has signs of renal failure44.2-150.3

Na: 135-148K: 3.5-5.3C: 1.1-1.3Cl: 96-10752.2 umo/l

133.5mmol/l3.74

99.2Explain the procedure to the clientnormal

V. THE PATIENT AND HIS CAREA. MEDICAL MANAGEMENTI. INTRAVENOUS FLUID MEDICAL MANAGEMENTDATE ORDERED/DATE GIVEN/CHANGED/DISCONTINUEDGENERAL DESCRIPTIONNURSING RESPONSIBILITY

D50.9 NaCl21-22 gtts/min

08/23/13Dextrose and Sodium Chloride Injection, is a sterile, nonpyrogenic solution for fluid andelectrolytereplenishment and caloric supply in single dose containers forintravenousadministration.Prior:-Check the physicians order in thrice check-Explain to the client the antibiotics and IV that the patient will encounter-Monitor the vital signs-Determine the allergies to th antibiotics-Prepare the client for the surgery

During:

-Check for the physicians order of doses-Check for the gtts/min-Check for the time management of the medicines-Monitor the clients response-Assess the vital signs

After:

-Monitor the vital signs and the clients reaction/response-Check for the physicians order -Monitor the ugtts/min-Time of the medication-Report and document the procedure

D5 WATERDextrose provides a source of calories. Dextrose is readily metabolized, may decrease losses of body protein and nitrogen, promotes glycogen deposition and decreases or prevents ketosis if sufficient doses are providedPrior:-Check the physicians order in thrice check-Explain to the client the antibiotics and IV that the patient will encounter-Monitor the vital signs-Determine the allergies to th antibiotics-Prepare the client for the surgery

During:

-Check for the physicians order of doses-Check for the gtts/min-Check for the time management of the medicines-Monitor the clients response-Assess the vital signs

After:

-Monitor the vital signs and the clients reaction/response-Check for the physicians order -Monitor the ugtts/min-Time of the medication-Report and document the procedure

II. DRUGSNAMEMECHANISM OF ACTIONINDICATIONCONTRAINDICATIONSIDE EFFECTSNURSING RESPONSIBILITIES

Generic Name:Cefuroxime

Frequency:TID

Dosage:1tab 500mg q8

Route:OPSecond-generation cephalosporin that inhibits cell wall synthesis, promoting osmotic instability, usually bactericidal.It is used for surgical prophylaxis, reducing or eliminating infection.Hypersensitivity to cephalosporin and related antibiotics. GI:Diarrhea, nausea, antibiotic-associated colitis.

SKIN:rashes, pruritus, urticaria Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs before therapy is initiated. Inspect IM and IV injection sites frequency for signs of phlebitis. Report of loose stools or diarrhea. Monitor I&O rates and pattern.

NAMEMECHANISM OF ACTIONINDICATIONCONTRINDICATIONSIDE EFFECTSNURSING RESPONSIBILITIES

Generic Name:Cefuroxime

Frequency:TID

Dosage:750mg q8

Route:IVSecond-generation cephalosporin that inhibits cell wall synthesis, promoting osmotic instability, usually bactericidalIt is used for surgical prophylaxis, reducing or eliminating infection.Hypersensitivity to cephalosporins and related antibioticsGI:Diarrhea, nausea, antibiotic-associated colitis.

SKIN:rashes, pruritus, urticaria Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs before therapy is initiated. Inspect IM and IV injection sites frequency for signs of phlebitis. Report of loose stools or diarrhea. Monitor I&O rates and pattern.

NAMEMECHANISM OF ACTIONINDICATIONCONTRAINDICATIONSIDE EFFECTSNURSING RESPONSIBILITIES

Generic Name:Ketorolac

Frequency:TIV

Dosage:10mg q8 (-) anst

Route:IVAnti-inflammatory and analgesics activity, inhibits prostaglandins and leukotriene synthesis.Short term management of pain.Contraindicated with significant renal impairment, hypersensitivity to Non-Steroidal Anti Inflammatory Drugs. rash ringing in the ears headache dizziness drowsiness abdominal pain nausea diarrhea constipation heartburn fluid retention Pain as well as inflammation and its signs and symptoms redness, swelling, fever and pain as reduced. Instruct client to report any adverse reaction to the physician or nurse. Tell the patient that adverse reaction can occur with overuse.

NAMEMECHANISM OF ACTIONINDICATIONCONTRAINDICATIONSIDE EFFECTSNURSING RESPONSIBILITIES

Generic Name:Ranitidine

Frequency:TID

Dosage:25mg q8

Route:IVInhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cell. resulting in inhibition of gastric acid secretion.Used prevent ulcer while patient is on NPO.Hypersensitivity to ranitidine or any component of the formulation. constipation diarrhea fatigue headache insomnia muscle pain nausea vomiting agitation depression bleedingC- Gastrointestinal agent, antisecretory (H2 receptor antagonist)

H- Reduced amount of acid in the stomach that may result to prevented ulcer incidence.

E- Every 8hrs while patient is on NPO.

C- Instruct client to report any adverse reaction to the physician or nurse. Tell patient antacids may decrease the absorption of ranitidine.

K- Ranitidine can interfere with the metabolism of alcohol.

NAMEMECHANISM OF ACTIONINDICATIONCONTRINDICATIONSIDE EFFECTSNURSING RESPONSIBILITIES

Generic Name:Mefenamic acid

Frequency:TID

Dosage:250mg 1cap

Route:POAnti-inflammatory and analgesic activity.For relief of mild to moderate pain in patients 12yrs 0ld and above.Active ulceration or chronic inflammation of either the upper or lower GI tract, preexisting renal desease. rash ringing of ears nausea heartburn It comes as a capsule to be taken by mouth. It is usually taken every 4 to 6 hours on a schedule or as needed for pain.

III. DIETType of DietDate Ordered,Date ChangedGeneral DescriptionIndication/PurposesSpecific Food TakenClients ResponseNursing Responsibilities

PriorDuringAfter

NPOAugust 23-25, 2013

NPO dietary state in which patient is force to take nothing by mouth over a given period of time.

Normally instructed to pre- op patient and patient that have to undergo a certain laboratory examination.Ex. serum electrolyte.Cleanse the GI tract from any impurities and maintains immobility of the tract.

During OR procedure.Nothing Per oremFeeling weak, restlessness notedCheck for doctors orderExplain to the client what is NPO and its purposeMake sure that patient followed doctors orderDocument date and time. Noted positive gastric motility.

General LiquidAugust 27, 2013

Diet contains only liquids or foods turn to liquid at body tempertureLiquid diets are ordered after surgery to reduce the nausea and vomiting that sometimes result from the anesthetic, medications or the surgery itself. Liquids are tolerated better than solids and allow the gastrointestinal tract to ease its way back into operation.40 gms Nissan soup 3 glass of water Feeling weakCheck for doctors order Explain to the client what is General Liquid and its purpose

Make sure that patient followed doctors order

Document date and time. Noted positive gastric motility.

DAT with SAPDiet as tolerated with Strict aspiration precaution

August 28, 13Aspirationprecautions are measures taken to prevent a person from aspirating, or choking. Aspiration can occur in debilitated patients who have a diminishedswallowingreflex, and the condition can even cause a type ofpneumoniacalledaspiration pneumonia. Typically, when a person swallows, the contents pass through theesophagusand into the stomach. Aspiration occurs when the swallowed contents do not pass through the esophagus, but go directly into the lungs.To prevent aspiration.72 Diet RecallNo signs of aspirationCheck physicians order

Monitor vital signsMonitor intake& outputCheck Vital signs

IV. ACTIVITY EXERCISETYPE OF EXERCISEDATE ORDERED,DATE TAKEN/GIVEN,DATE OF CHANGE,DATE OF DISCONTINUEGENERAL DESCRIPTIONINDICATION/PURPOSES

CLIENTS RESPONSENURSING RESPONSIBILITIES(prior,during,after)

AmbulationStarted: August 27, 2013

The act of traveling by foot ; walking is healthy for exercise It can help prepare and condition the body for the stress that the suture will cause Improves muscle tone in legs To stimulate the lower extremities circulation after the appendectomy with the ambulation The patient can facilitate to walk with a slow movementPrior : Assess the client if he can walk dependently Explain to the client the purpose of ambulationDuring : Encourage the patient to walk dependently with minimal movement for atleast 30 mins.After : Instruct the client to take a rest

V. SURGICAL MANAGEMENT1. Brief Description of the ProcedureAn appendectomy is surgery to remove the appendix. An appendectomy is done using Spinal anesthesia. Medicine is put into your back to make you numb below your waist. You will also get medicine to make you sleepy. The surgeon makes a small cut in the lower right side of your belly area and removes the appendix.If the appendix broke open or a pocket of infection (abscess) formed, your abdomen will be washed out during surgery. A small tube may be left in the belly area to help drain out fluids or pus.1. Patients response to ProcedureAfter the appendectomy, the client stays in the hospital for about Eight days. According to the client he can feel discomfort and slight pain in surgical site because of the suture. But when we interviewing the client, he is calm. And he is always asleep.1. Nursing ResponsibilitiesPrior: Check the doctors order. Monitor the vital signs Medicines for fever. If fever, must be lowered before anesthesia.During: Check for the doctors order Check for the time management of the medicines Monitor the clients response Assess the vital signsAfter: Monitor the vital signs and the clients reaction/response Check for the doctors order One day after surgery patients are encouraged to sit up in bed for 2 30 minutes. On the second day the patient can stand and sit outside the room. Report and document the procedureVI. NURSING PROBLEM PRIORITIZATION

Date IdentifiedCuesProblem/ Nursing DiagnosisJustification

August 27, 2013Due to surgical incision.Acute PainBecause he underwent appendectomy.

August 27, 2013 Due to surgical incision.Impaired skin integrity.Because of the presence of incision site at the right lower quadrant of the abdomen.

August 27, 2013Due to unfamiliar environment and frequent interruptions.Disturbed sleeping pattern.Because the client has been admitted for __ days at the hospital.

August 27, 2013Due to his lack of interest in food and poor muscle tone.Imbalanced nutrition: Less than body requirementBecause he underwent appendectomy.

August 27, 2013Due to inadequate primary defense.Risk for infection.Because of the presence of incision site at the right lower quadrant of the abdomen.

VII. NURSING CARE PLAN No. 1AssessmentNursingDiagnosisPlanningInterventionRationaleEvaluation

Subjective:Masakit yung tahi ko ,as verbalized by the client.Objective:Facial Grimace Pain scale of 5/10. Guarding behaviorAcute pain related to distention of intestinal tissues by inflammation as manifested by facial grimace, muscle guarding and a pain scale of 5/10.Short term goal:After 30 minutes of nursing intervention, the client will be able to verbalize alleviation of pain, from a pain scale of 5/10 to 2/10.Long term goal:Within 2 hours, the client will be able to report that pain is relieved/controlledWithin 2 hours, the client will be able to follow prescribed pharmacological regimen.Within 2 hours, the client will be able to demonstrate use of relaxation skills and diversional activities are indicated for individual situation.IndependentEncourage use of relaxation techniques such as focus, breathing, imaging, CDs or tapesEncourage verbalization of feelings about the pain.Encourage adequate rest period.

Keep in rest in Semi Fowlers Position.

DependentTake medicines as prescribedTo distract attention and reduce tension

To serve as baseline data.

To prevent fatigue.

Gravity localize inflammatory exudates into lower abdomen or pelvis, relieving abdominal pain, which is accentuated by supine position.

To alleviate the pain that the client is experiencing.Long term goal:GOAL MET

Short term goal:

GOAL MET

NURSING CARE PLAN No. 2AssessmentNursingDiagnosisPlanningInterventionRationaleEvaluation

Subjective:Kumakati yung tahi koas verbalized by the client.Objective:Facial Grimace Surgical incision at the RLQ of the abdomen.Impaired skin integrity related to disruption of skin surface as manifested by presence of surgical incision.Short term goal:After 30 minutes of nursing intervention, the client and significant others will be able to gain knowledge and information about treatment needs and potential complications. Long term goal:Within 2 hours, the client will be able to achieve timely wound healing and be free of signs of infection and inflammation, purulent drainage and fever.IndependentInstruct proper handwashing.

Inspet incision site/dressing.

Note for fever,chills, diaphoresis, and increasing abdominal pain.

DependentTake medicines as prescribedReduces risk of spread of bacteria.

Provides early detection of developing infectious process.Suggestive of presence of infection/developing sepsis, abscess, peritonitis.

To alleviate the pain that the client is experiencing.Long term goal:GOAL MET

Short term goal:

GOAL MET

NURSING CARE PLAN No. 3AssessmentNursingDiagnosisPlanningInterventionRationaleEvaluation

Subjective:Nahihirapan akong makatulog dito ,as verbalized by the client.Objective:Facial Grimace # or more times nighttime awakenings.Disturbed sleeping pattern related to environmental noise, unfamiliar furnishings, and interruptions for therapeutics, monitoring and lab tests.Short term goal:After 30 minutes of nursing intervention, the client will be able to verbalize plans to implement bedtime routines.

Long term goal:Within 2 hours, the client will be able to awaken refreshed and not fatigued during the day..Independent Assess client's sleep patterns and usual bedtime rituals and incorporate these into the plan of care.

Observe client's medication, diet, and caffeine intake. Look for hidden sources of caffeine, such as over-the-counter medications.

Provide pain relief shortly before bedtime and position client comfortably for sleep.

To provide baseline information.

Difficulty sleeping can be a side effect of medications such as bronchodilators; caffeine can also interfere with sleep.

Clients have reported that uncomfortable positions and pain are common factors of sleep disturbance

Long term goal:GOAL MET

Short term goal:

GOAL MET

VI. DISCHARGE PLANNING

1. M-MEDICATION TO TAKE

Instruct and explain to the patients mother that the medication is very important to continue depending on the duration that the doctor ordered for the total recovery of the patient.

1. E-EXERCISE

Instruct the mother to let her child for early ambulation

1. T-TREATMENT

Client undergone Appendectomy1. H-HEALTH TEACHING

Encourage and explain to the patients mother that it is important to maintain proper hygiene to prevent further infection. Instruct the patients mother to bath the child every day.1. O-OUT PATIENT FOLLOW-UPHes follow up check will be on September 03, 2013 and regular consultation to the physician can be a factor for recovery and assess and monitor the patients condition.

1. D-DIET

Diet as tolerated

1. S- Sex/ Spiritual

The client is a boy needs to focus on Gods wisdom with his parents.

VII. CONCLUSION

We therefore conclude that after case presentation we nursing students will gain knowledge about Appendicitis, Enumerate signs and symptoms of Appendicitis, Identify nursing interventions to be done when handling patient with Appendicitis, Perform proper nursing care to patient.

VIII. BIBLIOGRAPHY

http://www.webmd.com/digestive-disorders/digestive-diseases-appendicitishttp://www.medicinenet.com/appendicitis/article.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000256.htm Medical Surgical .. Brunner and Sudhhart