I. INTRODUCTION

Appendicitis is an inflammation of the vermiform appendix that develops most

commonly in adolescents and young adults. It can occur at any age but is rare in clients younger

than 2 years and reaches a peak incidence in clients between 20 and 30 years. It is not common

in older adults; however, when it does occur in such clients, rupture of the appendix is most

common(Medical – Surgical Nursing: Clinical Management for Positive Outcome 8 th by Joyce

Black and Jane Hokanson Hawks, page 683). It is classified as a medical emergency and many

cases require removal of the inflamed appendix, either by laparoscopy or laparotomy. If left

untreated, mortality is high, mainly because of peritonitis (inflammation of the peritoneum) and

shock. (http://www.wikipedia.org/wiki/Appendicitis?wasRedirected=true)

There is no specific test for appendicitis, but blood tests such as a white blood cell count

and x – rays may help a physician make a diagnosis. Abdominal ultrasound has proven to be

useful in differentiating causes of abdominal pain.

(http://www.healthscout.com/ency/68/658/main.html) The most specific physical finding is

rebound tenderness, pain on percussion, Rovsing’s sign (Right Lower Quadrant pain with

palpation of the Left Lower Quadrant), Psoas sign (Right Lower Quadrant pain is felt with

hyperextension of the right hip) are present in the patients with acute appendicitis.

(http://www.ufs.ph/tinig/mayjun02/05060225.html)

Anecdotal reports describe the success of intravenous antibiotics in treating acute

appendicitis in patients without access to surgical interventions

(http://www.ufs.ph/tinig/mayjun02/05060225.html). But in most cases, a surgical removal of the

appendix is more advisable to relieve the recurrence of pain and to prevent bursting of the

appendix. The surgery that corrects the appendicitis, called an appendectomy, is a procedure with

relatively little risk. Many surgeons are performing laparoscopic appendectomy in which the

appendix is removed through three small incisions less than an inch long using special

instrument and a special camera. With laparoscopic appendectomy, most patients can go home

within 24 hours of the operation. (http://www.healthscout.com/ency/68/658/main.html) Appendix

can also be removed through laparotomy. The surgeon makes a small incision at the Mcburney’s

point (Mcburney’s incision) to remove the appendix. Appendectomy is done under a general or

1

regional anesthesia, which means the patient will not feel any pain during the procedure.

(http://www.nlm.nih.gov/medlineplus/ency/arcticle/002921.html)

The incidence rate of appendicitis in the United States is approximately 680, 000 per year

or 56, 000 per month (http://www.diagnosis.com/a/acute_appendicitis/prevalence.html). In the

Philippines, there are approximately 215, 604 cases recorded annually (in the estimated

population of 88, 241, 697).

(http://wiki.answers.com/Q/What_is_the_appendicitis_rate_in_the_Philippines)

To gather more information about appendicitis and appendectomy, the group chose this case

for presentation; and to help future patients in improving their lives, and also this case study may

be used as reference for future researchers.

2

OBJECTIVES

Student – Nurse Centered

General Objectives

To gather additional knowledge from the patient’s condition and give proper nursing care

on her post – operative state to prevent complications through the use of the nursing process.

Specific Objectives

At the end of the study the student nurse will:

Understand and be knowledgeable about the patient’s condition.

Assess the needs for care of the patient.

Plan appropriate interventions related to the patient’s needs.

Implement the planned nursing interventions.

Evaluate whether the goals are met or not.

Reassess if the care of plan was effective.

Patient – Centered

General Objectives

The patient will be knowledgeable about the proper care needed on her post – operative

state, to attain maximum level of care, and to prevent complications.

Specific Objectives

At the end of the study, the patient will:

Be knowledgeable about her condition.

Understand the extent of restrictions of food and activities.

3

Achieve the needed nursing care appropriate for her age and condition.

Decrease the anxiety she is experiencing after the surgery and possible complications.

Respond to the prescribed treatments or managements.

Become better and will live normally like with other people.

4

I. NURSING PROCESS

A. ASSESSMENT

1. Personal Data

a. Demographic Data

Name : Adding J

Age : 12 years old

Sex : Male

Birthday :

Address : baldios, Sta. Ignacia Tarlac

Religion : Roman Catholic

Nationality : Filipino

Civil Status : Single

Occupation : N/A

Height :

Weight :

Chief Complaint : Abdominal pain – Right Lower Quadrant

Date of Admission : January 4, 2011

Admitting Diagnosis : t/c Appendicitis

Final Diagnosis : Acute Appendicitis

5

b. Environmental Status

Ading J resides at Baldios,Sta. Ignacia, Tarlac. Their house was a bungalow type which is

made up of bamboo where there are mango trees around it. There are two rooms in their house

which they use for sleeping. They are five living in their house. There is available sari – sari

stores available in their place. The available means of transportation in their area are thru

jeepney, tricycle and mini bus. They also have a forced pump located at their backyard which

they also use for their drinking water. They have 2 cats and a dog which they allow to stay inside

their house. They said that they have a good relationship with their neighborhood.

c. Lifestyle

Ading J is a grade six student. He usually sleeps at 8 or 9 in the evening and wakes up at

around 6 in the morning to prepare his self to school. Every day, he plays basketball as his

exercise and past time. According to his sister, their mother usually cooks meat or pork dishes,

and sometimes vegetables. He usually drinks 8 - 10 glasses of water a day. Right after he eats, he

goes back to his friends to play basketball. He takes a bath every day, usually every morning

before he goes to school. His sister also stated that adding J started eating junk foods and soft

drinks every afternoon.

6

2. FAMILY HISTORY OF HEALTH AND ILLNESS

7

87

81

74

5477

48

69

63

78

CA

ASTHMA

76

71 60 6967

64

LEGEND

BOY

GIRL

X DECEASED

PATIENT

APPENDICITIS

CA Cancer

V/A Vehicular Accident

43

49

47

MATERNALPATERNAL

41

v/a

3. History of Past Illness

According to Ading J this is his second time of hospitalization. He was 5 years old when

he was first hospitalized, that was when some of his body part (specifically his armpit) burned

because of the explosion of the gasoline when his parents was cooking. He already had Chicken

Pox and measles. Ading J did not know if he was fully immunized, he does not have any

allergies to any foods, medication and pets. Cough and Colds, Diarrhea and fever are the usual

condition that he acquired and his mother buys over the counter drugs like paracetamol, neozep

and loperamide.

4. History of Present Illness

Two weeks prior to admission, the patient felt an abdominal pain at the right lower

quadrant. Though Ading J experienced pain, he can still tolerate it and continued to play

basketball.

One week prior to admission, abdominal pain was still present and his mother decided to

seek consultation to Gilberto O. Teodoro Memorial Hospital Emergency Room. He was

diagnosed with Appendicitis and his physician prescribed cefalexin as the first course of

treatment.

After one week, she went to another clinic which is the Iglesia Clinic in Camiling, Tarlac.

The findings were also Appendicitis, and the physician prescribed diclofenac. She was referred

to Tarlac Provincial Hospital for further laboratory examination. Urinalysis was ordered, after

reading the result the physician decided to admit her for more evaluation. After certain

laboratory tests, the physician subjected the patient for appendectomy.

5. 13 AREAS OF ASSESSMENT

I. SOCIAL STATUS

8

Ading J is the third of the six siblings. The family resides at Baldios, Sta Ignacia Tarlac.

Ading J belongs to a nuclear family. He is a Roman Catholic and a grade six student. His mother

is a house wife and his father works in Tuguegarao as an auto technician earning P1,200 a week,

which they spend for their foods and groceries, electric bill, cellular phone load, and daily school

allowance of their children. Ading J’s medical expenses are supported by his family, relatives

and health insurance (philhealth). He usually goes to talk with their neighbors and play

basketball with his playmates. He has a good relationship with their neighbors.

NORMS

Social status included family relationship that serves as his support system especially at

times of need and stress related conditions. It meets a fundamental human need for social ties

making life less anxious. Also social support system buffers the negative effect of stress as

means of achievement of a good health. (Friedman and Smith 1988)

ANALYSIS

Ading J has a normal social status because he is able to mingle with the other people and

do the usual things a typical child does. They are also able to provide their basic needs.

II. MENTAL STATUS

Adding J is conscious and coherent. Oriented to time and date, he is able to read and

write and follow instructions, able to maintain eye to eye contact. He is open to any questions,

approachable and is able to converse but slowly with the student nurses. During the assessment,

Ading J talks about his past memories showing that his long term memories are still active.

9

NORMSTo consider a person’s mental status is normal, he should be oriented. He should be able

to evaluate and act appropriately in situations regarding judgment. (Health Assessment and

Physical Examination 3rd Edition by Mary Ellen Zator Ester)

ANALYSIS

Ading J’s mental status is normal, it is usual that a patient in pain has a hard time when

talking.

III. EMOTIONAL STATUS

Prior to hospitalization according to his sister, he is very cheerful; he loves to make

conversations with his playmates, and siblings. His sister also stated that they have financial

problems but since their family and relatives are very supportive not just financially but also

emotionally along with the health insurance they are able to lessen their burden regarding their

expenses in the hospital. This shows that they have a good relationship status with her family.

Ading J’s after the procedure was still asleep due to the anesthesia. When Ading J’s was awake,

he stated that she can feel the pain on the incision site, which is a normal response several hours

after the operation.

NORMS

Integrity manifests with wisdom and feelings of satisfaction with one’s life while despair

arises from remorse about what could have been. The presence of despair causes life to be

viewed as meaningless. (Source: Nursing CEU.com: The process of human development)

Carrying out emotional feelings through words and facial expressions are normal signs that client

was aware of his physical conditions. (Nursing Fundamentals, Rick Daniels) Expression of self

control and self perception is just normal (Fundamentals of Nursing, Kozier, Erb, Berman, and

Synder).

10

ANALYSIS

Ading J’s emotional status is considered normal, due to his condition it is normal to feel

pain and become unresponsive in some instances.

IV. SENSORY PERCEPTION

VISION

In assessing the vision, Ading J is instructed to look straight to observe the general

appearance of her eyes. His eyes are almond in shape, irises are black in color and scleras are

whitish in color, eyebrows and eye lashes are equally distributed. His conjunctiva is pale and

moist. Ading J was also instructed to follow the direction of a finger with his eyes following six

cardinal positions. And his eyes were able to move in full ranges of motion and in all directions.

With the use of penlight pupils are assessed, pupils are equally round and reactive to light

accommodation. Ading J does not use eyeglasses or contact lenses.

Visual acuity was assessed by asking Ading J to read the word written on a piece of paper

with a font size of approximately 12 at about 3 feet away from his using the right eye first then

the left eye and then both eyes. Mrs. F read all the samples correctly during the test.

NORMS

For the test of the Cardinal Fields of Gaze, the extra ocular muscle movements are being

assessed. Normally, both eyes of the patient should move smoothly and symmetrically in each of

the six fields. Light and accommodation reading is possible in the distance of 14 inches for the

assessment of near vision. (Health Assessment and Physical Examination 3rd edition by Estes)

Analysis

The patient’s visual capacity or status is normal, extra ocular muscle movements and

papillary response and visual acuity are normal.

11

SMELL

Ading J’s nose has no deviations in terms of shape and size. Nose is pointed and no

discharges were seen during the assessment. According to the patient he doesn’t have any history

of sinus infection or epistaxis (nose bleeding). Before the next procedure, permission was asked

to Ading J to do another test. Using a perfume and an orange peel without the patient’s

knowledge we ask him to identify the 2 samples by smelling. After smelling he correctly

identifies the perfume and orange peel. Test shows that there are no abnormalities or obstructions

were identified in his sense of smell.

Norms

Nose must be symmetrical and along of the face. Each nostril must be patent and

recognize the smell of an object. (Health assessment and physical examination, Mary Ellen

Zator Estes)

Analysis

Client was able to recognize the odor. He has normal sense of smell but he has difficulty

of breathing that leads to the need of oxygen therapy.

HEARING

General appearance of Ading J’s ears was parallel, symmetrically proportional to the size

of the head, bean shape, has a firm cartilage and with the presence of cerumen. In assessing the

hearing acuity of the patient, Ading J is instructed to repeat the words that will be whisper at a

distance of 2 feet away on the left ear first, and then the right after the test he was able to repeat

the whispered words. Another test by the use of the beeping sound of the digital thermometer at

the distance of 4 feet away and still he was able to hear the sound. He verbalized that he has no

known auditory deficits nor ear infection history and unusual sensations like ringing or buzzing.

12

Norms

For the auditory acuity, the patient should be able to repeat the whispered words from a

distance of two feet. (Health assessment and physical examination, Mary Ellen Zator Estes)

Analysis

Based on the given data, patient’s auditory acuity is normal.

TASTE

Ading J’s lips are dry and symmetrical in shape, tongue is pale in color, no presence of

tooth decay, but there is a presence of tooth cavities, no false dentures and no teeth loss, no sign

of gingivitis, buccal area are pale. The patient was asked to open his mouth widely to assess the

entire mouth. To assess his sense of taste, patient was asked to do some taste test. He was ask to

taste a cotton ball soak with orange juice and cotton ball soaked in water with salt without

knowing what the two samples are. After patting the cotton balls on the lips of the patient, Ading

J identified the 2 samples correctly.

Norms

Taste is intact in the posterior one third of the tongue. (Health Assessment and Physical

Examination, Mary Ellen Zator Estes)

Analysis

Client’s sense of taste is normal.

TOUCH

In assessing’s sense Ading J’s of touch, he was asked to close his eyes a cotton ball was

stroke to the back of his neck. Then using another cotton ball we poured alcohol on it and rub it

on the same area. He stated that he felt a sensation of wet and cold on his skin.

13

Norms

The skin contains receptors for pain, touch, pressure and temperature. Sensory signals are

transmitted along rapid sensory pathways, and less distinct signals such as pressure of localized

touch are sent via slower sensory pathways. (Health Assessment and Physical Examination,

Mary Ellen Zator Estes)

Analysis

Ading J’s sensory transmission functions well as manifested by the data presented, it is

considered normal.

V. MOTOR STABILITY

Several hours after the surgery, the patient was asked to perform ROM exercise on the

upper and lower extremities. He was asked to raise both of his arms. He performed it with ease

and freely moved without any difficulty. He can bend and straightened his elbows and extend

and spread his fingers. He performed it with ease. According to the patient he felt pain in the

right lower quadrant of his abdomen when raising his right leg and cannot move it freely. There

is no presence of deformity. There are also proper symmetry between left and right on each

extremity. Early ambulation was encouraged. Patient can bend his legs with limited range of

motion and needs assistance when standing and going to the comfort room.

NORMS

Fine motor skills involve the small muscle of the body that enables such functions as

writing, grasping objects and fastening of clothes. Fine motor skill involves strength, fine motor

controls and dexterity. Gross motor skills involve the large muscles of the body that enable such

functions as walking, kicking, sitting upright, lifting and throwing a ball. A person’s gross motor

skills depend on both muscle tone and strength.

Low muscle tone is characteristics disabling conditions such as Down syndrome, genetics

or muscle disorders, or central nervous system disorders.

ANALYSIS

14

Ading J’s motor ability is not in good condition due to the presence of pain in the right

lower quadrant of the abdomen when raising the right legs.

VI. BODY TEMPERATURE

The table below shows the temperature of Mrs. F during the shift

DATE TIME TEMPERATURE ANALYSISJanuary 4, 2011

January 5, 2011

January 6, 2011

8:00 am

9:00 am2:00 pm

3:00 pm

8:00 pm

36.7C

36.9C36.8C

38.5C

37C

Normal

NormalNormal

Above normal

Normal

INTERPRETATION

Ading J’s temperature at January 4 was normal, on January 5, he was febrile. On January

6, his temperature returned to normal.

NORMS

Normal temperature for axilla is within 35.4-37.4c (Fundamentals of Nursing by Kozier

and Erbs 7th edition)

ANALYSIS

According to the data gathered on September 30, 2010 at 6:00 pm Ading J’s body

temperature is on normal range. The patient had altered body temperature on October 1, 2010 at

3:00 pm up to 6:00 pm, and became normal at 10:00 pm.

VII. Respiratory Rate

15

DATE T IMERESPIRATORY RATE

ANALYSIS

January 4, 2010

8:00 am

9:00 am

2:00 pm

20cpm

18cpm

19cpm

Normal

January 5, 2010 9:30 pm 20 cpm Normal

January 6, 2010 8:00 am 19 cmp Normal

Norms

Respiration in the resting adult, the normal respiratory rate is 12 to 20 breaths per minute.

This type of breathing is termed eupnea, or normal breathing.

(Health Assessment and Physical Examination, 3rd edition by Estes, page 455)

(Analysis is presented on the table above)

VIII. Circulatory Rate

DATE TIME B.P ANALYSISSeptember 30, 2010

October 01, 2010

September 30, 2010

October 01, 2010

3:35 pm

9:30 pm

3:35 pm

9:30 pm

90/70

100/80P.R

64

70

Normal

Normal

Normal

Normal

Norms

Pulse

Normal pulse rate vary with age. The table below shows the normal range of pulse rate

according to age:

16

AGE RESTING PULSE RATE AVERAGE

10 years 70 – 110 bpm 90

14 years 60 – 110 bpm 85 – 90

Adult 60 – 100 bpm 72

Source: Health Assessment and Physical Examination, 3rd edition by Estes, page 253

Normal blood pressure varies with age. As a person ages, blood pressure generally

increases. The table below shows the general ranges of normal blood pressure at different ages

and gender:

BLOOD PRESSURE: Normal Range According to Age and Gender

Female

AGE SYSTOLIC (mm Hg) DIASTOLIC (mm Hg)5

1015

≥18

103 – 109

112 – 118120 – 127

<120

66 – 70

73 – 7678 – 81

<80

Male

AGE SYSTOLIC (mm Hg) DIASTOLIC (mm Hg)5

1015

≥18

104 – 102

111 – 119122 – 131

<120

65 – 70

73 – 7876 – 81

<80

17

Source: Health Assessment and Physical Examination, 3rd edition by Estes, page 260

IX. Nutritional Status

Before he was confined to the hospital, adding J eats 3 to 4 times per day and drinks 8 to

10 glasses of fluids. He also eats fruits like banana and mango. When the patient was admitted in

the hospital, he was on a nothing by mouth state. His BMI is in normal range.

BMI COMPUTATION:

Weight: 48kg

Height: 5”1’

BMI = WEIGHT IN KILOGRAMS

HEIGHT IN METER SQUARED

= 48kg

2.4006 m

BMI =19.99 - NORMAL

Norms

According to the Health Asian Diet Pyramid, there should be a daily intake of rice,

grains, bread, fruit and vegetables; optional daily for fish, shellfish, and dairy products; weekly

for sweets, eggs and poultry, and monthly for meat.

There should be an increase intake of a wide variety of fruits and vegetables. Include in

the diet foods higher in vitamins C and E, and omega-3 fatty acid rich foods. (www.webmd.com)

Analysis

Mrs. F nutritional status was affected because of the surgical procedure done to her

(appendectomy). Her BMI is in the normal range.

18

X. Elimination Status

Mrs. F usually defecates once every day with hard stools bur not painful and urinates 4 to 5

times per day with an approximately 30 to 40 cc of urine per urination. When she was admitted

she voids 4 times and defecates once.

Norms

The frequency of defecation is highly individual, varying from several times per day to

two or three times per week. The amount defecated also varies from person to person.

(Fundamentals of Nursing 7th edition by Kozier, et. Al., page 1126)

Average Daily Urine Output by Age

AGE AMOUNT(mL)5 to 8 years

8 to 14 years14 years through adulthood

Older adulthood

700 – 1000

800 – 14001500

1500 or less

Source: Fundamentals of Nursing 7th edition by Kozier, ET. Al., page 1261

ANALYSIS

Mrs. F elimination status is affected. Because she was on nothing by mouth state after the

operation, she has nothing to defecate.

XI. Reproductive Status

Ading J had his circumcision at the age of 10. He does not had any sexual experience.

Norms:

(Maternal and Child health Nursing 4th Edition by Pilliteri)

19

ANALYSIS

Based on the statement above Ading J has a normal reproductive status. He doesn’t have

sexually transmitted disease.

XII. Sleep – Rest Pattern

He usually sleeps at 8 to 9 in the evening and wakes up at 6 in the morning. He watches

television during his rest hours or play basketball with friends. He also spends time to be with his

family and playmates. But when he was confined his sleep pattern was always interrupted.

Norms

CATEGORY

NORMAL HOURS OF

SLEEP PER DAYNewborns

InfantsToddlers

PreschoolersSchool – age children

Young adultsMiddle – aged adults

Elders

16 to 18

12 to 1410 to 1211 to 128 to 127 to 86 to 8

About 6 hours

Source: Fundamentals of Nursing 7th edition by Kozier, ET. Al., page 1116

ANALYSISBecause of his condition, Ading J's sleep pattern was affected.

XIII. State of Skin and Appendages

20

Ading J’s skin is brown in color. His skin in the foot is dry, some calluses are observed. He

complains of some itchiness on his lower extremities. His conjunctiva is pale. He has some scar

on his lower extremities. His nails are pale, short and clean. His nail beds are slightly pale. His

capillary refill time is 2 seconds.

NORMS

The palpebral conjunctiva should appear pink and moist. Normally the skin is a uniform

whitish pink or brown color depending on the patient's race. Normally, the nails have pink cast

light skinned individuals and are brown in dark-skinned individuals. (Health assessment and

Physical Examination, 3rd edition by Mary Ellen Zator Estes).

AnalysisAding J’s skin appendages are affected due to decreased oxygen supply. The patient’s dry

skin was due to restriction in fluid and any food. The Patient’s capillary refill is normal.

6. Laboratory and Diagnostic Procedures

DATE ORDERED: September 29, 2010

Urinalysis

INDICATION RESULT NORMAL RANGE ANALYSIS

21

>to detect renal and metabolic diseases.

>diagnosis of diseases or disorders of the kidney or urinary tract.

Color: Yellow

Transparency: TurbidLeukocytes/Nitrates: NegativeUrobilirogen: NormalProtein: TracepH: 6.0Blood cells: negativeSpecific gravity: 1.010Ketone: NegativeBilirubin: NegativeGlucose: NegativeMucus threads: ModeratePus cells: 3 - 4

RBC: 0 - 1Epitheleal Cells: ModerateBacteria: Rare

Urates/Phosphates: Moderate

Straw yellow – amber

Transparent – turbidAbsent0.2 – 1. 0 mg/dlAbsent - Trace5.0 – 8.5Absent1.010 – 1.015AbsentAbsentAbsentNegative or fewFew

0 – 3/ HPFFewNegative or Few

Few

Normal

NormalNormalNormalNormalNormalNormalNormalNormalNormalNormalNormalHigh. An indicator that there is an infection present in the urinary tract.NormalNormalNormal

Normal

NURSING RESPONSIBILITIES

Prior to procedure:

Explain the procedure to the patient and family/relatives.

Provide for patient’s privacy.

Instruct the patient to go to the laboratory with the request form.

Instruct the patient to dispose the first urine and catch the midstream urine.

Educate the patient not to contaminate the inside part of the container.

Instruct the patient to send the specimen to the laboratory immediately

During the procedure:

Maintain the sterility of the specimen container by not touching the inside part.

22

Maintain the freshness and sterility of the urine specimen.

After the procedure:

Interpret the result

Refer to the physician if abnormalities are noted.

DATE ORDERED: September 29, 2010

Complete Blood Count

INDICATION RESULT NORMAL RANGE ANALYSIS

>to detect/diagnose blood disorders.

>to detect presence of infection.

BLOOD TYPE: A+

WBC: 13.9 G/L

LYM: 1.8 R2 12.9%L*MID: 0.8 5.5%MGRAN:7.0 81.6%GRBC: 4.17 T/LHGB: 113 g/LHCT: .373 L/L

4.1 – 10.9 G/L

0.6 – 4.1 10.0– 58.5%L0.0 – 1.8 0.1 – 24 %M2.0 – 7.8 37.0–92.0 %G4.20 – 6.30 T/L120 – 180 g/L.370 - .510 L/L

WBC is high because of the presence of infection. WBC defends our body against infection.

NormalNormalNormalNormal

23

>to screen for fluid and electrolyte problem.

MCV: 82.6 fLMCH: 27.1 pgMCHC: 328 g/L

PLT: 379 G/L

80.0 – 97.0 fL26.0 – 32.0 pg310 – 360 g/L11.5 – 14.5 %

140 – 440 G/L

NormalNormalNormalNormalNormalNormal

Normal

NURSING RESPONSIBILITIES

Prior to procedure:

Explain the procedure to the patient and family/relatives. Educate the patient about what to expect during the procedure.

During the procedure:

Advise the patient to relax during the procedure.

After the procedure:

Interpret the result Refer to the physician if abnormalities are noted.

24

7. Anatomy and Physiology

The Appendix

The appendix averages 10 cm in length, but can range from 2 to 20 cm. The diameter of

the appendix is usually between 7 and 8 mm. The appendix is located in the lower quadrant of

the abdomen, or, more specifically, the right iliac fossa. Its position within the abdomen

corresponds to a point on the surface known as McBurney's point (see below). While the base of

the appendix is at a fairly constant location, 2 cm below the ileocecal valve, the location of the

tip of the appendix can vary from being retrocecal (74%) to being in the pelvis to being

25

extraperitoneal. In rare individuals with situs inversus, the appendix may be located in the lower

left side.

New studies propose that the appendix may harbor and protect bacteria that are beneficial

in the function of the human colon. Some researchers argue that the appendix has a function in

fetuses and adults.[7] Endocrine cells have been found in the appendix of 11-week-old fetuses that

contribute to "biological control (homeostatic) mechanisms." In adults, Martin argues that the

appendix acts as a lymphatic organ. The appendix is experimentally verified as being rich in

infection-fighting lymphoid cells, suggesting that it might play a role in the immune system.

Although it was long accepted that the immune tissue, called gut associated lymphoid tissue,

surrounding the appendix and elsewhere in the gut carries out a number of important functions,

explanations were lacking for the distinctive shape of the appendix and its apparent lack of

importance as judged by an absence of side-effects following appendectomy.

8. PATHOPHYSIOLOGY

Book based

26

Non modifiable risk factors:

>age

>gender

Modifiable risk factors:

>constipation

>activity

>low fiber dietSeverity of symptoms is related to

the degree of inflammation

present.

The inflammatory process ranges

from mild to severe appendiceal

swelling and obstruction.

Concurrent infection can cause mucosal

ulceration and subsequent development of

abscess, necrosis or rupture.

Abdominal pain is present, usually

described as being in the right lower

quadrant, localized at Mcburney’s point.

Appendectomy is often

suggested by the

physician.

Other common

symptoms include

anorexia, nausea and

vomiting, low grade

fever, elevated WBC

Patient – based

27

Modifiable Factors

Constipation Low Fiber – Diet

Nausea and loss of appetite

Acute abdominal pain at the Mcburney’s point.

Start of the inflammatory process

Increased intra luminal pressure in the appendix

Occlusion of appendix by fecalith

Non Modifiable Factors

AgeGender

Appendectomy Inflammation of appendix (appendicitis)

Low grade fever

B. PLANNING

NURSING CARE PLAN

Acute Pain

Assessment Planning Intervention Expected outcome

Subjective: “Masakit ang sugat ko” P/S is 6/10.Objectives:

facial grimace increase ability to perspire

irritable at times

guarding behavior

limited movements and range of motion.

assisted with the significant others when turning in other position.

Within 30 minutes to 1 hour of giving proper nursing interventions, the patient will verbalize reduction of pain.

Monitor the pain scale. (to know if there is an improvement)

Position on a semi-fowlers position.(for the patient to feel comfortable)

Provide a clean bed. (to have a good relaxation.)

Encourage to have a bed rest.( to gain energy)

Encourage to continue limiting body movements. (to prevent pain)

Educate the importance of deep breathing exercises. (for the patient to feel calm and relax)

Within 30 minutes to 1 hour of giving proper nursing interventions, the patient will:

-verbalize a decrease of pain.-can move freely without assistance.-free from irritability.

-facial grimace will be absent.

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Nursing Diagnosis:Acute pain related to surgical incision on the abdomen.Scientific Explanation:

Unpleasant sensory and emotional experience arising fromactual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity frommild to severe with an anticipated or predictable end and a duration of less than 6 months. (Nurse’s Pocket Guide Edition 11 by F.A Davis, page 498)

Divert attention by instructing to read books.(to lessen and divert pain)

Instruct to increase fluid intake.(to prevent dehydration)

Instruct to guard the site when coughing. (to prevent from opening of the site)

Instruct to take medications that are prescribed by the physician. (for the patient safety to drugs)

Educate the patient to clean the site regularly. (to prevent any complications and infection)

Hyperthermia

Assessment Planning InterventionsExpected Outcomes

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Subjective:Ø

Objective:

warm to touch diaphoretic

weak in appearance

irritable at times

vital signs taken as follows:

BP-90/70 mmHgRR-20 cpmPR-64 bpmTemp- 38.5°c

Diagnosis:Altered body temperature related to inflammatory process.

Scientific Explanation:Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. It may also occur as assign of infection.

Within 1 hour of proper nursing interventions, the patient’s temperature will subside to 37.5 °c from 38.5 °c.

Monitor vital signs especially temperature. (To know if it has an improvement of the patient’s temperature.)

Perform Tepid Sponge bath. (To lower body temperature.)

Provide clean and comfortable bed. (for the patient to have a good rest and feel comfortable)

Provide clean and comfortable clothing. (for the patient not to feel irritable)

Instruct to increase fluid intake after NPO. (to prevent dehydration)

Instruct to eat nutritious foods like green leafy vegetables after NPO. (to gain more energy)

Instruct to take medications that are prescribed by the physician. (For safety purposes.)

Within 1 hour of proper nursing interventions, the patient’s temperature will subside to 37.5 °c from 38.5 °c.

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Risk for Infection

ASSESMENT PLANNING INTERVENTION AND RATIONALE

EXPECTED OUTCOME

S O

O

Irritable Poor hygiene Long fingernails Dirty surroundings Incision on the right

lower quadrant of the abdomen

DiagnosisRisk for infection related to surgical incision on the right lower quadrant of the abdomen

SCIENTIFIC EXPLANATION

There’s a risk for infection for a client who undergone a surgical incision because there is a break in the tissue or that would serve as an opening that can be

Within 2 hours of proper nursing intervention the client risk for infection will decrease to achieve timely wound healing

Instruct in good hand washing(Reduces risk of spread of bacteria)

Instruct good body hygiene(Reduces risk of spread of bacteria and promote relaxation)

Demonstrate aseptic wound care(Reduces risk of spread of bacteria)

Inspect incision and dressings(Provides for early detection of developing infections process)

Encourage to cut the fingernails(Reduce risk of spread of bacteria)

Encourage to keep the surroundings of the patient clean(To minimize the chance of getting infection through microorganisms around the ward)

After 2 hours of proper nursing intervention the client risk for infection is decrease to achieve timely wound healing as evidenced by:

a. Washing the hands using soap

b. Good body hygiene

c. Well kept surrounding

d. Short fingernails

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invaded by different kind of microorganisms.

Impaired Skin Integrity

ASSESSMENT PLANNING INTERVENTIONSEXPECTED OUTCOME

S

“nangangati ang sugat ko”O

with surgical incision at the mcburney’s point

with suture noted

with surgical dressing intact

poor skin turgor

limited movement

Within 1 hour of proper nursing interventions, the patient will regain integrity of the skin and demonstrate measures to protect care and heal the skin lesion.

Assess site of skin impairment (the cause of the wound must be determined before appropriate interventions can be implemented).

Monitor site of skin impairment for color change, redness, swelling, warmth, pain, or other signs of infections (systematic inspection can identify impending problem early).

Clean the site aseptically (to decrease the production of bacteria).

Select a topical treatment that will maintain a moist wound – healing environment and that is balanced with the need to absorb exudates ( keep peri wound skin dry and control

After 1 hour of rendering proper nursing interventions, the patient will regain integrity of the skin and demonstrate measures to protect care and heal the skin lesion.

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DiagnosisImpaired skin integrity related to tissue damage.Scientific explanation

Invasion of body structures, destruction of skin layers (dermis), disruption of skin surface (epidermis).

exudates and eliminate dead space) Avoid massaging around the site of

skin impairment and over bony prominences (massage may lead to tissue trauma).

Monitor nutritional intake (Altered nutrition can prevent wound healing and put at risk for further skin breakdown).

Fatigue

Assessment Planning Interventions Expected OutcomesSubjective: Nanghihina ako”

Objective:

with limited body movements

weak in appearance

slow and low voice noted

diaphoretic

vital signs taken as follows:

BP-80/70 mmHg

Within 1 hour of proper nursing interventions, the patient will verbalize increase body strength.

Obtain vital signs. (for baseline purposes)

Maintain on a flat position as an order of the physician.

Encourage to have adequate rest. (to gain energy)

Encourage to ask some help to the nurse or significant others if she want to move or change in position. (for the patients safety)

Instruct to increase fluid intake after

Within 1 hour of proper nursing interventions, the patient will verbalize increase body strength.

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RR-20 cpmPR-64 bpmTemp- 35.8 °cDiagnosis:Fatigue related to post surgical procedure.Scientific Explanation:

An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.

NPO. (to prevent dehydration)

Instruct to eat nutritious foods like green leafy vegetables after NPO. (to gain more energy)

Educate about the significant others to assist the patient when moving. (for safety and for the patient to move easily)

Instruct to take medications that are prescribed by the physician. (To avoid any drug accident such as overdosing.)

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C. IMPLEMENTATION

1. DRUGSName of Drug Date

AdministeredRoute and

AdministrationGeneral Action Indication Client’s actual

response to medication

Cefoxitin October 1, 2010

6:00pm

IVP

1gq 8 hours

Bactericidal: Inhibits synthesis of bacterial cell

wall, causing cell death.

Perioperative prophylaxis.

Presence of pain was noted on the IV insertion site during the drug administration.

Nursing Responsibilities:

Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.

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Name of Drug Date Administered Route and Administration

General Action Indication Client’s actual response to medication

Ketorolac September 30, 2010

6:00pm

IVP

30mgq 6 hours

anti-inflammatory, antipyretic and analgesic effects is the inhibition of prostaglandin synthesis by competitive blocking of the enzyme cyclooxygenase (COX)

Short-term management of pain due to surgical procedure done

Pain scale of 8/10 decreases to 4/10 which is consider as bearable pain.

Nursing Responsibilities:

Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.

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Name of Drug Date Administered

Route and Administration

General Action Indication Client’s actual response to medication

Omeprazole September 30, 2010

6:00pm

IVP

40mgq 12 hours

Gastric acid-pump inhibitor. Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production.

Perioperative client who is NPO

Pain due to hypersecretion of hydrochloric acid in the stomach is lessen.

Nursing Responsibilities:

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Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.

Name of Drug Date Administered

Route and Administration

General Action Indication Client’s actual response to medication

Paracetamol October 1, 2010

6:00pm

IVP

30mgPRN

The main mechanism of action of paracetamol is considered to be the inhibition of cyclooxygenase (COX)

For client who has elevated temperature (hyperthermia)

Client’s temperature of 38.5oc decreases to 37.5oc

Nursing Responsibilities:

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Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.

2. MEDICAL MANAGEMENT

Medical Management

Date Ordered/ Performed/ Changed/ Discontinued

General Description Indication/s or purpose/s

Client’s reaction to treatment

Intravenous FluidD5LRS @

Changed: September 30, 2010 at 10:28 pm.

D5LR is actually 5% dextrose in lactated ringer's solution. It is a hypertonic solution which

This solution is indicated for use in adults and

The patient was hydrated. The fluid and electrolytes level

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20gtts/min means it pulls fluid out of the cells into the intravascular space (veins).

5% Dextrose in Lactated Ringer's Injection provides electrolytes and calories, and is a source of water for hydration. It is capable of inducing diuresis depending on the clinical condition of the patient. This solution also contains lactate which produces a metabolic alkalinizing effect.

pediatric patients as a source of electrolytes, calories and water for hydration.

of her body is maintained.

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Nursing Management

Prior

Before starting I.V therapy, consider duration of therapy, type of infusion condition

of veins and medical condition of the patient to assist in choosing in I.V site and type

of catheter.

Ensure that you are competent in initiating the type of I.V therapy decided on and

familiar with institutional policy and procedure before initiating therapy.

Explain the procedure to the client and why is it necessary.

During

Monitor the insertion site for signs of phlebitis or infiltration.

Monitor the flow rate of the IV fluid.

Maintain the cleanliness of the plaster.

After

After initiation of I.V therapy, monitor the patient frequently for:

1. Signs of infiltration of sluggish flow

2. Signs of phlebitis or infection

3. Correct solution, medication, volume and rate

4. Dwell time of catheter and need to be replace

5. Condition of catheter dressing and frequency of change

6. Fluid and electrolyte balance

7. Signs of fluid overload or dehydration

8. Patient satisfaction with mode therapy

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MedicalManagement

Date Ordered/Performed

Changed/discontinuedGeneral Description Indication/s or purpose/s

Client’s reaction to treatment

Oxygen Therapy 09-30-2010

08-30-2010

Oxygen may be classified as an element, a gas, and a drug. Oxygen therapy is the administration of oxygen at concentrations greater than that in room air to treat or prevent hypoxemia (not enough oxygen in the blood). Oxygen delivery systems are classified as stationary, portable, or ambulatory. Oxygen can be administered by nasal cannula, mask, and tent. Hyperbaric oxygen therapy involves placing the patient in an airtight chamber with oxygen under pressure.

The body is constantly taking in oxygen and releasing carbon dioxide. If this process is inadequate, oxygen levels in the blood decrease and the patient may need supplemental oxygen. Oxygen therapy is a key treatment in respiratory care. The purpose is to increase oxygen saturation in tissues where the saturation levels are too low due to illness or injury.

Breathing prescribed oxygen increases the amount of oxygen in the blood, reduces the extra work of the heart, and decreases shortness of breath. Oxygen therapy is frequently ordered in the home care setting, as well as in acute (urgent) care facilities.

The patient’s oxygen need was sustained. Airway becomes easier. Breathing pattern becomes normal.

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3. Surgical Management

DATE PERFORMED: September 30, 2010 – 11:45 a.m

Name of Procedure Brief Description Indication/ PurposeClient’s Response to

Operation

Appendectomy Surgical removal of the Appendix

To remove the inflamed appendix to prevent rupture - this will eventually lead to peritonitis.

The patient was asleep after the operation.

The patient was lying flat on bed 6 – 8 hours after the surgery.

The patient had chills few hours after the operation.

The patient had fever 1 day after the operation.

Nursing Responsibilities

Prior to the Surgery

Check the vital signs for baseline data.

Instruct the patient to be on nothing per Orem 8 hours prior to surgery.

Educate the patient the patient about coughing, deep breathing exercises and turning side

– to – side after the surgery.

Let the patient voice out what she feels to relieve anxiety.

Listen to what the patient says.

During the surgery

Promote sterility on the sterile field.

Monitor the patient’s well being.

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Monitor patient’s vital signs

After the Surgery

Keep the patient on NPO for 6 to 8 hours or until peristalsis occurs.

Keep the patient lie flat on bed without pillow for 6 to 8 hours.

Monitor for bleeding and signs of shock.

Monitor for signs of infection.

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4. DIET

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5. ACTIVITY/EXERCISE

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D. EVALUATION

III. CONCLUSION

The group’s grand case study is about ruptured appendicitis. It was a good learning

experience for our group to handle such case.

The client manifest hyperthermia, fatigue, impaired physical mobility, and impaired skin

integrity, the group therefore concludes that nursing intervention should be done to alleviate

predicament on the client’s health. The highlight of our principle is to provide optimum nursing

care primarily to our client and the significant others as well. The group believes that the first

thing to consider for our client’s wellness to make them feel special and be sincere in rendering

quality services.

Susceptibility of the client to acquire complication is greatly at risk. Hence, client should

be monitor carefully and medications must be maintained ideally.

IV. RECOMMENDATION

The group recommends providing wound care aseptically as frequently as possible to

prevent infection and apply cold compress to the abdomen when abdominal pain is experience.

Advice regular consultation to the physician for it can be a factor for recovery and assess the

patient’s progress. Advised the client who has to religiously take his medication prescribed to

alleviate symptoms and prevent further complications. Instruct the patient normal activities can

be resumed within a few days, but it takes four to six weeks for full recovery. Heavy lifting and

strenuous activities should be avoided during recovery. Encourage continuous range of motion

exercises. Eat healthy foods from all of the five food groups; fruits, vegetables, breads, dairy

products, meats, fishes. Eating healthy foods may help the patient feel better and have more

energy and also help recover faster from sickness. Emphasize the importance of increase dietary

intake of fiber and vitamin C. Avoid foods that can cause constipation such as apple, guava and

star apple. Encourage to increase fluid intake to maintain hydration and electrolyte balance.

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V. REVIEW OF RELATED LITERATURE

Viral Infections Linked to Appendicitis

By Rajshri on January 19, 2010 at 6:55 PM

A new study by UT Southwestern Medical Center surgeons and physicians says that appendicitis may also be caused by a virus and that you can actually "catch" it.

The researchers evaluated data over a 36-year period from the National Hospital Discharge Survey and concluded in a paper appearing in the January issue of Archives of Surgery that appendicitis may be caused by undetermined viral infection or infections, said Dr. Edward Livingston, chief of GI/endocrine surgery at UT Southwestern and senior author of the report.

The review of hospital discharge data runs counter to traditional thought, suggesting that appendicitis doesn't necessarily lead to a burst appendix if the organ is not removed quickly, Dr. Livingston said.

"Just as the traditional appendix scar across the abdomen is fast becoming history, thanks to new single-incision surgery techniques that hide a tiny scar in the bellybutton, so too may the conventional wisdom that patients with appendicitis need to be operated on as soon as they enter the hospital," said Dr. Livingston. "Patients still need to be seen quickly by a physician, but emergency surgery is now in question."

Appendicitis is the most common reason for emergency general surgery, leading to some 280,000 appendectomies being performed annually.

Appendicitis was first identified in 1886. Since then, doctors

have presumed quick removal of the appendix was a necessity to avoid a subsequent bursting,

which can be an emergency. Because removing the appendix solves the problems and is

generally safe, removal became the standard medical practice in the early 20th century.

SOURCE: http://www.medindia.net/news/Viral-Infections-Linked-to-Appendicitis-63833-1.htm

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VI. BIBLIOGRAPHY

Published Materials

Medical – Surgical Nursing: Clinical Management for Positive Outcome 8th by Joyce Black and

Jane Hokanson Hawks,

Fundamentals of Nursing Practice 7th edition by Kozier and Erbs

Health Assessment and Physical Examination 3rd edition by Estes

Medical – Surgical Nursing 8th edition by Joyce Black

2010 Lippincotts Nursing Drug Guide by Amy Karch

Prentice Hall Nursing Diagnosis Handbook by Judith M. Wilkinson and Nancy R. Ahern

Unpublished Materials

http://www.wikipedia.org/wiki/Appendicitis?wasRedirected=true

http://www.healthscout.com/ency/68/658/main.html

http://www.ufs.ph/tinig/mayjun02/05060225.html

http://www.nlm.nih.gov/medlineplus/ency/arcticle/002921.html

http://www.diagnosis.com/a/acute_appendicitis/prevalence.html

http://wiki.answers.com/Q/What_is_the_appendicitis_rate_in_the_Philippines

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