APPENDICITIS CASE.doc

7/27/2019 APPENDICITIS CASE.doc

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TABLE OF CONTENTS

I. IntroductionII. Objectives

General Objectives Specific Objectives

III. Patients DataA) Vital InformationB) Family BackgroundC) History of Past illnessD) History of Present illnessE) Effects and Expectation

F) GenogramG) Developmental Data

IV. Review of SystemsPhysical Assessment

V. Textbook DiscussionsA) Complete DiagnosisB) Anatomy and PhysiologyC) Definition of terms

D) Etiology and SymptomatologyE) Pathophysiology

VI. Laboratory ExaminationVII. Complete Doctor's OrderVIII.List of Drugs

Drug StudyIX. List of Nursing Case PlanX. PrognosisXI. Bibliography


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INTRODUCTION

This is a case of Mrs. Rose, female patient, was admitted at provincial hospital Last April 26, 2010 at

around 2:10 pm and was diagnosed of having acute appendicitis and was scheduled for operation forceasarian operation

The appendix is a finger-like appendage about 10 cm (4m) long that is attached to the ceccum just belowthe ileocecal valve. The appendix fills with food and empties regularly into the cecum, because it emptiesinefficiently and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable toinfection.

Appendicitis is an inflammation of the vermiform appendix that develop most commonly in

adolescents and young adults. It can occur at any age but is rare in clients younger than 2 years andreaches a peak incidence in clients between 20 and 30 years. It is not common in older adult however,when it does occur in such clients, rupture of the appendix is more common.

According to the statistics appendicitis affects 7% to 12% of the population. It is the most commonreason for emergency abdominal surgery in the United States.

The classic manifestations of appendicitis begin with acute acute abdominal pain that comes inwaves. At first, the pain may be perceived merely as discomfort that makes the client feel that passingflatus or having a bowel movement will bring relief.

Assessment may reveal vomiting that begins after the pain starts, loss of appetite, low-grade fever,coated-tongue and bad breath. Mild leukocytosis is usually present, with the white blood cell (WBC) countbetween 10,000 and 15,000/mm. Pain at Mcburney's point, which lies midway between the right anteriorsuperior iliac crest and the umbilicus, confirms the diagnosis.

This is what happened to Ms. Gev, a 21 years old patient, she was admitted because of the painperceived at right lower quadrant. Surgical management was done during his hospitalization.

This case was made to create awareness to the listener about appendicitis thereby impartingknowledge.


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OBJECTIVE OF THE STUDY

General Objectives:

At the end of 2 hours presentation, the reader will be able to have adequate knowledge about

appendicitis.

Specific Objectives:

After the case presentation, the listener will be able to:

1. Know the important information regarding my patient.

2. Appreciate the result of physical assessment.

3. Know and understand the real meaning of appendicitis.

4. Understand the anatomy and physiology of the system affected with appendicitis.

5. Trace the pathophysiology of the disease.

6. Know the predisposing, factors and precipitation factors of the disease occurrence.

7. Interpret the laboratory result and know the nursing responsibility.

8. Know the signs and symptoms of the disease.

9. Identify the drugs that the physician ordered for the wellness of the patient

10. Identify the possible nursing diagnosis of the clients with appendicitis.


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PATIENT'S VITAL INFORMATION

Patient's Name : Mrs. RoseAge : 21 years old

Sex : FemaleAddress : Purok Rosas, Barangay Dajay, Surallah, South CotabatoBirth Date : August 03, 1977Civil Status : SingleCitizenship : FilipinoReligion : Roman CatholicOccupation : NoneEducational Attainment : High School Graduate

Date Admitted : April 26, 2010Time Admitted : 2:00 amAdmitting Diagnosis : Acute AppendicitisAttending Physician : Jose June Tabanda, MDName of t he Institution : South Cotabato Provincial HospitalPost-operative Diagnosis : Acute appendicitis Procedure :Chief complaintName of Partner : Mr. JM

Age : 21 years old

Name of Father : Mr. DVOccupation : FarmerName of Mother : Mrs. MLOccupation : Housekeeper

SOURCE OF INFORMATIONPatient


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FAMILY BACKGROUND

Ms. ROSE is the 4th daughter of Mr. D and Mrs. M. she is 33 years old at this age she already haveher first baby. Her grandparents are already dead but she doesn't know the reason behind it.

Her parents are still alive but she doesn't know any disease that they possess. Her father is afarmer while her mother is a housekeeper. Their farm is the only source of their family's income They are10 in the family including her parents and seven siblings.

Her parents decide for them due to the fact that they are still young to make such decisions.

HISTORY OF PAST ILLNESS

Ms. Rose verbalized that this is her second time to be hospitalized, previously because of denguefever but she can't remember the date.

She also said that whenever she experienced diseases like cough, fever and flu. She just but over-the-counter drugs like paracetamol and biogesic. She said that she is not consulting quack doctorswhenever she is sick. They are not also taking herbal medicine except those drugs in a capsule and tabletform already.

She added that she has no allergies to any kind of food and medicine. She confessed that this isher first time to undergo a surgical operation. She haven't experienced any accidents and injuries.

She delivered her baby on the 31st day of October at home. She said that she had no complicationsduring her delivery.

HISTORY OF PRESENT ILLNESS

Two hours prior to admission, the patient experienced pain localized at right lower quadrant withvomiting within that span of time she also tried to take medicine but the pain did not disappeared So her


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EXPECTATIONS TO SELF

The patient expects to recover very soon. She is also expecting, that they can settle her account sothat she can go home. Due to the fact, that she really wants to see her baby.

EXPECTATION FROM THE FAMILY

The family expects that the patients will recover soon and that they can settle the accountimmediately. They are also expecting that she will not be hospitalize again.


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REVIEW OF SYSTEMS

GENERAL:

The patient said that she never experienced fever prior to April 26, 2010. She denies ofexperiencing weight loss. she also verbalize body weakness and due to pain.

SKIN:

The patient states that she experienced having skin darkening on her neck during her pregnancy..

She also said that she has no rashes/allergies to any food.

HEAD:

The patient verbalized that nagasakit ang ulo ko kis-a She also said that she doesn't experiencedany head injury and she never observed tenderness.

EYES:

The patient said that wala man problema sa mata ko, makakita man ko maayo. She denies ofexperiencing temporary loss of vision.

NOSE:

The patient said that she also has no allergies to any odor. She denies of having sinus problem andshe has no problem in term of her sense of smell.


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hypertensive.

GASTROINTESTINAL:The patient said that she experienced vomiting on the day she was admitted to the hospital. She

also said that she experienced constipation.

GENITOURMARY:

She said that she has no problems in urination. And she voids 5-6 times a day. She also said thatthese are no presence of blood in her urine.

MUSCULOSKELETAL:

She denies of having problems in moving. One said that she doesn't have arthritis. She states thatshe is a little bit weak because of pain.

PSYCHIATRIC:

She admits that she is anxious and worried because of her baby.


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PHYSICAL ASSESSMENT REPORT

November 13, 20073:00 PM

GENERAL:

A mesomorphic individual with an in IV fluid infusion of DSLR 30 gtts/min attached at leftmetacarpal vein. She is not distress looking individual, oriented to time and place but can't remember someinformation. Can speak well with audible voice and can understand my question.

SKIN, HAIR AND NAILS

She possesses brown color of the skin. Skin rashes are out present, no abrasions and lesionsnoted. She is wet with her sweat.

The nails are cut and clean. Clubbing are not observed-capillary refill within 3 second.

HEAD

The skull is rounded (normocephalic) and possesses symmetrical facial movement. No lesions andtenderness noted. Hair is evenly distributed which is straight and black in color. She has a poor memory.

EYES AND VISION

Eyes are bilateral to each other. No discharges noted. The eyeballs can move normally and round.Can see far objects. Eyeballs are distributed normally, eye brows are black and can elevate it, present in anormal condition. Conjunctiva is a little bit pinkish in color.

No deformities noted eyes are moist normally No discharge noted Pupils are equally round


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MOUTH AND NECK

Outer lips are slightly dry, able to pursed lip. She can move her head without discomfort. Lymphnodes are not palpable. Uvula is found in the middle upper of the mouth. Gums is slightly pink in color.

Teeth are in normal condition, no dentures and have a complete set of teeth.

There is no visible mass on the thyroid gland during inspection. The gland moves down whenswallowing but is not visible. No abnormalities noted.

CHEST AND LUNGSHas a respiratory rate of 25 breaths per minute. Can breath normally without using the accessory muscle.

No harsh sound noted during auscultation.

ABDOMEN

Abdomen is soft and flat. Presence of pain in the incision site is observed. Striae are still present.No lesions noted.

EXTREMITIES

UPPER: No deformities and swelling observed. Able to flex, extend and rotate..Rashes are not noted in both arms and hands.

LOWER: Normal range of motion is observed. There is no lesions present. Thenails are dirty in this extremities. There is no amputated parts of the body.

GENITALS

No deformities noted during the operation. The patient denies to show this part during assessment.


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ANATOMY AND PHYSIOLOGY

The Large Intestine

Cecum is the proxional end of the large intestine and is where the large and small intestine meet atthe ileocecal junction. The cecum is located in the right lower quadrant of the abdomen near the iliac fossa.The cecum is a sac that extends inferiorly about 6 cm past the ileocecal junction. Attached to the cecum isa tube about 9 cm long called the appendix.

The colon is about 1.5-1.8 m long and consist of four parts: ascending colon, transverse colon,descending colon and the sigmoid colon.

RECTUM is a straight, muscular tube that begins at the termination of the sigmoid colon and endsat the anal canal. The muscular tunic is smooth muscle and it is relatively thick in the rectum compared with

the rest of the digestive tract.ANAL CANAL is the last 2-3 cm of the digestive tracts. It begins at the inferior end of the rectum

and ends at the anus. The smooth muscle layer of the anal canal is even thicker than that of the rectumand forms the internal and sphinotes.

In humans, the vermiform appendix is a small, finger-sized structure, found at the end of our smallcaecum and located near the beginning of the large intestine .The adjective "vermiform" literally means

"worm-like" and reflects the narrow, elongated shape of this intestinal appendage. The appendix is typicallybetween two and eight inches long, but its length can vary from less than an inch (when present) to over afoot. The appendix is longest in childhood and gradually shrinks throughout adult life. The wall of theappendix is composed of all layers typical of the intestine, but it is thickened and contains a concentrationof lymphoid tissue. Similar to the tonsils, the lymphatic tissue in the appendix is typically in a constant stateof chronic inflammation, and it is generally difficult to tell the difference between pathological disease andthe "normal" condition .The internal diameter of the appendix, when open, has been compared to the sizeof a matchstick. The small opening to the appendix eventually closes in most people by middle age. A

vermiform appendix is not unique to humans. It is found in all the hominoid apes, including humans,chimpanzees, gorillas, orangutans, and gibbons, and it exists to varying degrees in several species of NewWorld and Old World monkeys.


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Throughout medical history many possible functions for the appendix have been offered, examined, andrefuted, including exocrine, endocrine, and neuromuscular functions (Williams and Myers 1994, pp. 28-29).

Today, a growing consensus of medical specialists holds that the most likely candidate for the function ofthe human appendix is as a part of the gastrointestinal immune system. Several reasonable argumentsexist for suspecting that the appendix may have a function in immunity. Like the rest of the caecum inhumans and other primates, the appendix is highly vascular, is lymphoid-rich, and produces immune
http://www.talkorigins.org/faqs/vestiges/appendix.html#WilliamsMyers1994http://www.talkorigins.org/faqs/vestiges/appendix.html#WilliamsMyers1994http://www.talkorigins.org/faqs/vestiges/appendix.html#WilliamsMyers1994


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ETIOLOGY

PREDISPOSING

FACTORS

RATIONALE REMARKS

Age Appendicitis commonly occurs in personaging from 10-30 years. It reaches a peakincidence in clients between 20 and 30years. May patient is 21 years old.

Present

Sex In the United States 7% of the populationwill have appendicitis at one time in theirlives, males are affected more thanfemales.

Not Present

Race Asian and African less likely to developappendicitis as compared to Americans

Present

PRECIPITATINGFACTORS

RATIONALE REMARKS

Low-fiber dietPerson who has a low fiber diet is moreprone to appendicitis because they lackbulk which makes their stool to be refined,avoiding breakdown of small matters thatwill lodge into the lumen causing

Present ; The patient hasa low fiber diet.


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COMPLETE DOCTOR'S ORDER

DATE AND

TIME

DOCTOR'S ORDER RATIONALE REMARKS

April 23, 201010:00 am Pls admit to P500 This is done for further evaluation of

patients condition and managementas well. To ensure patients safety.

This is doneimmediately.

TPR 98o

Getting the vital sign of the patientsaids the physicians to properlydiagnose the client thereby planningfor the treatment is done.

This is followed /carried out by theNOD.

NPO NPO is ordered to the patient due tothe fact that she will undergoneoperation which will require propervisualization of the field as well as itwill promote the cleansing of theabdominal part thereby reducing therisk for infection.

Patient was instructedand followed.

Labs: CBC stat

Urinalysis-stat

This is done to determine anyabnormalities that will manifest in the

blood.Urinalysis is done to confirm that it isreally an appendicitis or it is aninfection in the genitourinary system

Lab exam done, Labresult attached to the

chart, abnormalfindings reported tothe physician.


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opioid to relief mild to severe pain.

Ranitidine 1 amp IVTT This decreases acid secretionthereby decreasing stomach pain toperson who are in NPO

Given to the patient

Ketorolac 30 mg IVTT nowthen q8 hr

This decreases feeling of pain frommild to moderate while having antiinflammatory and anti pyretics effects

Given to the patient

For Appendectomy This is ordered by the physician totreat underlying condition and to

prevent the occurrence ofcomplications

Done surgically inaseptic techniques

Appendectomyprep. Done

This is done to decrease the no. ofbacteria in that area therebydecreasing chance of infection.

Done carefully,avoiding to hurt/harmthe patient.

Inform OR /

anesthesiologist

This is done to inform the OR and

anesthesiologist and this is also doneto find out if there is an available slotfor this operation.

This is done prior

patient will go to OR.

Insert foleycatherer F 14

This is done to empty the patientsbladder as well as it will aids thenurse in monitoring the urine ouputperi-operatively.

This is doneaseptically

refer accordingly Referring the patient in a correctcondition will prevent the exhaustionof both,nurse & physician in givingth i t ti

Done


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9:20 am To RR, then towardonce stable

room aids the nurse in propermonitoring of the condition of thepatient because patient who arepost operative are high risk for the

occurrence of complications.

RR.

VS q15 till stablethen q40

Vital sign monitoring every 15minutes is a must to postanesthetize client becausehomeostasis of the patinet wasdisrupted due to ansthesiaadministration.

Carried out by theNOD strictly.

NPO The patient is NPO post surgerybecause all muscles in theabdomen is relaxed in whichintroducing food can causeaspiration pneumonia.

Patient wasinstructed andfollowed.

Cont. IVF patientDSLR

This will correct hydration of thepatient that was disrupted by thesurgery.

IVF infused atdesired drops

Meds:1. betorlacIVTT now the age 98o

This decreases feeling of pain frommild to moderate while having antiinflammatory & anti pyretics effect.

Given to the patientat desired dosage.

2. Tramadol 50mgIVTT now then 98o

A centrally acting syntheticanalgesic compound notchemically related to opioids torelief mild to severe pain.

Given to the patient atdesired dosage.

3. Ranitadine 50mgIVTT 98o next dose 2 pm

This decreases acid secretionthereby decreasing stomach pain

Given to the patient atdesired dosage.


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until awake supplemental oxygen to be able tosupport the intracellular &extracellular respiration therebymaintaining or regaining the

homeostasis Watch out for any

unusualityThis will aid the nurse indetermining any development ofcomplication.

Done

Refer This is done to avoid exhaustion ofenergy of the doctor .

Done


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Bibliography

1. Black JM, Hawks, JH, (2005), Med-Surg Nursing:Clinical Management for positive Outcome (7 th Ed.)

Singapore, Elsevier Inc.

2. Bullock, BL Henze, R.L (2000) Focus on PathophysiologyPhiladelphia, Lippincoot William and Wilkins

3. Doenges, ME, Moorhouse, MF, Geissler Burr, Ac. (2005)Nursing Diagnosis Manual, Planning, IndividualsDocumenting Client Care, USA F.A. Davis Company

4. Smeltzer, S.C Bare, B.S. Hinkle, JL et al, Brunner and Suddarthstextbook of head-surg Nursing (Hth Ed.)Philadelphia, Lippincott William and Wilkins

5. Wynsberghe, D.V; Noback C.R.; Carola, R. (1995)Human Anatomy and Physiology (3rd ed)United States of America, McGraw-Hill, Inc.


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Bibliography

2. Black JM, Hawks, JH, (2005), Med-Surg Nursing:Clinical Management for positive Outcome (7 th Ed.)Singapore, Elsevier Inc.

5. Bullock, BL Henze, R.L (2000) Focus on PathophysiologyPhiladelphia, Lippincoot William and Wilkins

6. Doenges, ME, Moorhouse, MF, Geissler Burr, Ac. (2005)Nursing Diagnosis Manual, Planning, IndividualsDocumenting Client Care, USA F.A. Davis Company

7. Smeltzer, S.C Bare, B.S. Hinkle, JL et al, Brunner and Suddarthstextbook of head-surg Nursing (Hth Ed.)Philadelphia, Lippincott William and Wilkins

6. Wynsberghe, D.V; Noback C.R.; Carola, R. (1995)Human Anatomy and Physiology (3rd ed)United States of America, McGraw-Hill, Inc.


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Problem List

1. Pain related to surgical incision as manifested by facial grimace.2. Risk for infection related to surgical wound3. Risk for injury related to effects of anesthesia4. Fear related to impending surgery and prognosis.


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Notre Dame of Tacurong College

City of Tacurong

Drug Study

Name of Patient: Mrs. Rose Prepared by: Group 4

Yr. &Sec: BSN-3

Age: 33 years old Checked by: Gina Cuenca, RN, MN

Diagnosis: acute appendecitis

Attending Physician: Dr. Tabanda M.D

NAME DRUGACTION

SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES

Generic:Ranitidine

Brand:Zantac

Classification:Anti-ulcerdrug

MODE OFADMINISTR

ATION

Route:IVTT

Dosage:50mg

Time:q 8

Mechanismsof Action:Potent anti-

ulcer drug thatcompetitivelyand reversiblyinhibitshistamineaction at H2receptor sitesparietal cellsdecreasinggastric acidsecretions.

Bibliography:Nursing DrugHandbook2005, Page712, 713

Indication;Duodenal andgastric ulcer

CNS: dizziness,headacheGI: Nausea,

vomiting,GIirritation,constipation.EENT: blurredvisionHepatic: JaundiceOthers: burning anditching at injectionsite.

ADVERSEEFFECT

Anaphylaxis, angioedema

Contraindicated in patienthypersensitivity to drugand those with acute

prophyria

SPECIALPRECAUTION

Use cautiously in patientwith hepatic dysfunctions

DRUG INTERACTION

Drug-DrugAntacids: May interferewith ramitidine absorptionstragger doses, if possible.Diazepam: may decreasedabsorption of diazepammonitor patient closely.

1. Before giving the drug, Practice Proper handwashing

R: proper hand washing will reduce presence of

microorganism in your hands, thus it willprevent another complication to your pt.2. Check the patency of the IV tube, before

giving the medicine.R: checking the patency of the IV tube will

facilitate easy administration of the drug thusreducing discomfort to the patient

3. Administer the medicine once it has beenprepared.R: Administering the drug after preparing will

reduce incidence of mistake and ensuring thesterility and effectiveness of the medication.

4. Offer pt. some ice ships and small amount ofcrackers to prevent occurrence of nausea andvomiting.

R: This will provide comfort to the pt sincenausea and vomiting are considered as sideeffect of the said drug.

5. Infuse the medication at slow rate about 10-15minutes.

R: this will prevent or lessen the burning anditching sensation at the injection site which isseen as the usual complains of the patient,


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therefore give it slowly to prevent it.6. Before giving the drug, educate first the

patient about the purpose of it.R: Giving information to the patient will

facilitate cooperation and relieve their

anxiety.7. Instruct patient to rest after administering thedrug.

R: Having the patient to rest will promotecomfort and prevent injury since one of theside effect of the drug is dizziness.

8. Provide safety to the patient by raising the siderails and always stay at the bedside givingassistance during ambulation.

R: this will provide comfort to the pt. duringthe occurrence of

Temporary blurred vision as a side effect

of the drug.9. Instruct patient to report any unusualities.R: Instructing our patient to report unusualities

will help us to provide proper and prompttreatment.

10. Before giving the drug asses if the patient hastaken a meal.

R: Assessing if the patient has taken any food,because the drug works better when thestomach is empty.

11.encourage patient to include fibers in the

diet to preventconstipation.

R: Increase in fiber intake will prevent thept from experiencing constipation as a sideeffect of the drug.


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Notre Dame of Tacurong College

City of Tacurong

Drug Study

Name of Patient: Mrs. rose Prepared by: Group 4

Yr. &Sec: BSN-3

Age: 33 years old Checked by: Gina Cuenca, RN, MN

Diagnosis: acute appendecitis

Attending Physician: Dr. Tabanda M.D

NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIESGeneric:

Metoclopramide

Brand name:

Reglan

Classification:

Anti ulcer

drug

Mode of

Administration:

Route:IVTT

Dosage:

- 5mg/ml

Time:

-

Mechanism of

Action:

Stimulates motility

of upper GI tract,Increasesesophageal

sphincter tone,

andblocksdopamine

receptors at thechemoreceptor

trigger zone.

Bibliography:

Nursing 2007

drug handbook.

PPDs Nuring

drug Guide

Indication:

Restlessness,anxiety,

drowsiness, fatigue,

lassitude,dystonicreaction,sedation,

Adverse Effect:

Fever,

depression,akathisia,insomia,confusion,su

icide

ideation,seizures,neurolepti malignant

syndrome,hallucinations,headache,extra

pyramidalsymptoms,tardivedyskinesia.

CV: transienthypertension,suprave

ntricular tachycardia,bradycardia.

GI: nausea, bowel

Contraindicated in patients

with hypersensitivity to

drugand in those withpheochromocytoma or

seizure disorders.

Patients with presence of

GI hemorrhage.

Catraindicated to patients

who are lactating and pts

with breast cancerSpecial Precaution:

Use cautiously in pts with

history of depression,parkinsons disease,or

hypertension.

Drug Interaction:

Drug-drug:

anticholinergics, opiod

analgesics: may

antagonize GI motilityeffects of

Assess pt first for any GI

complaints such as nausea and

vomiting.

R: this drus is only given to pt.experiencing nausea and vomiting

and assessment is needed prior togiving it.

Assess pts Blood pressure prior to

administering the drug.

R: drug may cause transienthypertension and pt. must be

monitored closely.

Check for patency of the IV line before

administration and infuse the drug in

abou 1-2 minutes.

R: this may cause irritation of the


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Antiemetics disorders, diarrhea.GU: urinary frequency,

incontinence.Hematologic:

neutropenia,

agranulocytosis.Skin: rash, urticaria.

Other:prolactinsecretion, loss oflibido.

metoclopramide. Usetogether cautiously.

CNS depressant: may

cause additive.

CNS effects: avoidusing together.

Levodopa: Levodopa

and metoclopramide haveopposite effects on

dopamine receptors.Avoid using together.

MAO inhibitors: may

increase release ofcatecholamines in pts

with hypertension.Phenothiazines: may

increase risk oftrapyramidal effects,monitor pt closely.

vein if infused in fast rate.

Give appropriate dose ordered by the

physician.

R: Giving the drug in higher dose willproduce drug induced advesr reaction

such as hypertension.

Educate pt. and SO that drug may cause

temporarily neurological disorder such

as involuntarily twisting of limb.R: this will let the pt. know that it is just

temporary and pt. will feel at ease.

Encourage pt. to do energy savingtechniques that would help her not to

feel fatigue such as sit instead ofstanding.

R: the drug may cause fatigue as aside effect and this would help to

alleviate the pt. from feeling it.

Encourage patient not to engage in

activities that require alertness.

R: The drug may cause temporary

impairment of mental status.

Assist pt. during ambulation and

provide a period for rest.

R: this will prevent the occurrenceof unnecessary injury since the drug


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may cause drowsiness.

Instruct pts SO to report any unusual

feeling after receiving the medication.

R: this is to provide prompt care and

management to the patient.


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NOTRE DAME OF TACURONG COLLEGECity of Tacurong

DRUG STUDYName of the Patient: Mrs. Rose

Attending Physician: Dr. Tabanda M.D Diagnosis: Acute appendecitis Prepared by: Group 4 Year & Section: BSN 3Checked By: Gina Cuenca RN, MN

NAME DRUGACTION

SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES

Generic:

Tramadol

Brand:

Vitram

Classification:Opioid Analgesic

MODE OF

ADMINISTRAT

ION:

ROUTE:

IVTT

DOSAGE:300mg

Frequency:

24 hrs.

Mechanism of

Action:

Unknown that acentrally acting

synthetic analgesicchemically related

to opioids.

Thought to bind toopioids receptors

and inhibitreuptake and

norepinephrine andserotonin.

Bibliography:

Lippincott

Williams &Wilkins NursingDrug Handbook

2005, 25th edition,

pgs. 405-406

Indication:

Moderate to

moderately severe

Dizziness, headache,

malaise, diarrhea,

N&V, visualdisturbances,

constipation, drymouth, urine

retention, rash

ADVERSE

EFFECTIVE

CNS stimulation,asthenia,coordinationdisturbance,respiratorydepression,hypertonia, and

pruritus

If the drug was tolerated itcan cause diarrhea nausea,vomiting, headache, ormigraine, dizziness andabdominal pain.

SPECIAL PRECAUTION

Use cautiously in pts

hypersensitivity drug and otheropiods, in breast feeding women,

and patient intoxicated withalcohol. And also in pt with renal

and hepatic impairment.

DRUG INTERACTION

Diuretics: May risk of adverse

renal reactions.

DRUG-DRUG:

Carbomazepine may increaseTramadol metabolism, patient longterm carbomazepine therapy at upto 800mg daily may used to twice

to recommend those Tramadol

Stay at patients bedside and raised siderails.

Drug causes dizziness, thus puttingpatient high risk for injury.

Limit activities that requires excursion. To prevent headache and, and to lessenmalaise Encourage patient to control oral fluid

intake if diarrhea occurs. Fluid is restricted to pt. with urine retentionand fluid excess in tissue spaces. Small amountof fluid can prevent dehydration as caused bydiarrhea. Encourage patient to consume crackers and

ice chips if nauseated. To allay feeling of nausea, thus preventsvomiting Assess clients visual acuity by asking

patient if she can see object with in 5meters To check if patient manifest visualdisturbances. Encourage patient to include fiber in the

diet Drug causes constipation, fiber facilitatesvowel movement. Note for rashes on the skin after giving the

medicine.


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pain. This may be a sign of allergic reaction Always keep O2 at bedside. For immediate

management of respiratory depression.


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NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING

NURSING CARE PLANName of Patient: Mrs. Rose

Age: 33 yrs. oldDiagnosis: acute appendecitis

Attending Physician: Dr. Tabando M.D

ASSESSMENT NEEDS NURSING

DIAGNOSIS

GOALS/OBJECTIVES NURSING

INTERVENTION

RATIONALE EVALUATION

Date: APRIL 26,

2010

Subjective Data:

no verbal cues.

Objective Data:

Irritabilitynoted

Guardingbehavior

facial

grimacenoted.

C

O

G

NI

T

I

V

E

P

E

R

CE

P

T

U

A

L

Acute pain

related tosurgical

procedure as

evidenced byfacialgrimacing,

guarding

behavior andirritability

Rationale:

Unpleasant

sensation and

emotional

experiencefrom actualtissue damage.

> pt.experiences

piercing pain

on the surgicalwound due to

expose

General:

After rendering effectivenursing intervention the

pt. will be able to

verbalize reduce in painwith scale of 8 to 3 outof 10

Specific:

After 8hrs. of nsg.

Intervention the pt. willbe able to:

1.) Report that pain

is controlled.

2.) Verbalizemethods thatprovide relief,

such asdiversional

activities.

3.) Demonstrate useof relaxation

skills as well as

O1

Administerpain.

medication as

ordered. Instruct pt. to

splintincision when

coughing.

O2

Providediversional

activities such

as readingarticles, &

talking topeople.

Have the pt.perform

breathing &coughing

exercise if pain

To relievepain.

To reducepain due to

muscle

contraction.

To preoccupy

pain

perception by

focus in otherareas.

To reduce the

pain she fails.

Date: a

Goal met asevidenced by

pts.

Verbalization ofa in such assplinting the

surgical wound

whenrepositioning,

and pt. have talkparticipative

during

therapeutic

communication.


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P

A

T

T

E

R

N

By:Gordons

FunctionalHealth

Patterns

nociceptorswhich detects

pain sensation.

Bibliography:

Nurses PocketGuide (Edition

11)by: Doenges,

Moorhouse,Murr

diversionalactivities.

occurs.

Encourage pt.

to keep self ina dim lighted

room.

Assess pts.Perception of

pain & howshe feels it.

Limit activities

that requires

exertion.

Healthteachings.

To reduce

stimuli andstress.

This mayreduce feeling

of anxiety thuspromotes

relaxation.This provides

adequate bed

rest.

To reinforce

pts. Skills indiverting pain.


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NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING

NURSING CARE PLANName of Patient: Mrs. Rose

Age: 33 yrs. oldDiagnosis: Acute appendecitis

Attending Physician: Dr. Tabando M.D

ASSESSMENT NEEDS NURSING

DIAGNOSIS

GOALS/OBJECTIVES NURSING

INTERVENTION

RATIONALE EVALUATION

Date: april 26,

2010Subjective Data:

sakit ang tinahian

ka ang sugatmismo asverbalized pt.

- pain scale of

(severe)

Objective Data:

FacialGrimace

noted

GuardingBehavior

noted

Level of

ADLs.

Exudates on

incisionnoted

Diaphoresis

N

U

T

RI

O

N

A

L

M

E

T

AB

O

L

I

C

Fluid volume

excess r/tvasospasm

secondary to

preeclampsia asevidenced byedema of the

lower

extremities, adecreased in

urine output &presence of

protein in

urine.

Rationale:Increaseisotonic fluid

retention.> pt.

experiences

increased BP of140/110 mmHg

and has a

General:

After rendering effectivenursing intervention the

pt. will be able to have a

stabilize fluid volume asevidenced by balancedI/O, v/s in the normal

range, and with signs of

edema. Specific:

After 8hrs. of nsg.Intervention the pt. will

be able to:

1.) verbalize

understanding ofindividualdieatary/ fluid

restrictions.2.) Demonstrate

behaviors to

monitor fluidstatus and

recurrence of

O1

Healthteachings on

balance diet.

Inform pt. that

she will berestricted on

fluids.

Restrict &

rationalizedlow fat and

low salt diet as

indicated.

O2

Instruct pt. to

keep urineoutput in

container for24 hours.

This provides pt.with cognizance

on healthy diet.

For awarenessand complianceto care.

For clients

understandingon dietary

plan.

A 24 hrs. urine

collection willdetermine pts.

Urine output.

For changes

Date:

Goal met asevidenced by

lessened pedal

edema.> pt. was able todemonstrate to

behaviors to

prevent of fluidexcess such as

compliance todietary protocol

[ low salt diet],

controlled fluid

intake. And pt.manifest stableBP of 110/80

mmHg


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noted

v/s: BP:

140/110mmHg

T: 36

P: 75 bpm

RR: 24 cpm

P

A

T

T

E

RN

By:Gordons

FunctionalHealth

Patterns

bipedal edema.

Bibliography:

Nurses Pocket

Guide (Edition

11)by: Doenges,

Moorhouse,Murr

fluid excess. Measure

abdominal

girth.

may indicateincreasing

fluid retention/edema.


37/38


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