ANGELES UNIVERSITY FOUNDATION

College of Nursing

Appendectomy(A Case Study)

Submitted by:

Mistal, Mona Liza

David, Audrey

Cordero, Jelica Joy

Torres , Robinson

BSN 3-II Group 42

Submitted to:

Ms. Jazper Herrera, RN

Clinical Instructor

1

TABLE OF CONTENTS:

I. INTRODUCTION……………………………………………………………………….3

a. Current trends about the disease condition………………………………..4

b. Reasons for choosing such case for presentation………………………..5

II. NURSING ASSESSMENT……………………………………………………..…….6

a. Personal History…………………………………………………………...…6

b. Pertinent Family Health-Illness History………………………………….…7

c. History of Past Illness…………………………………………………….….8

d. History of Present Illness………………………………………………..…..8

e. Physical Examination……………………………………………… ………..9

f. Diagnostic and Laboratory Procedures……………………………..……12

III. ANATOMY and PHYSIOLOGY(with visual aids)…………………………….…...14

IV. THE PATIENT’S ILLNESS…………………………………………………….…….18

a. Synthesis of the disease……………………………………………...….…..18

a1. Definition of the disease……………...……………………….……18

b2. Predisposing / Precipitating factors…………………………...….18

c3. Signs and symptoms with rationale………………………… ……19

d4. Health promotion and preventive Aspects of the Disease ..…..20

V. THE PATIENT AND HIS CARE………………………………………………………21

a. Medical Management……………………………………….……… …21

a. IVF’s, BT, NGT feeding, Nebulization, TPN, Oxygen therapy, ...21

b. Drugs……………………………………………………………....….23

c. Diet……………………………………………………………….……25

d. Activity / Exercise………………………………………….….……..26

b. Surgical Management (actual SOPIERs)…………………………….……27

c. Nursing Mangement…………………………………………………….….…28

a. Nursing Care Plan……………………………………………….……28

b. Actual SOAPIES …………………………………………………..…29

VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL…………………………...…..31

a. Client’s daily Progress Chart………………………….………………….….31

b. Discharge Planning……………………………………………………….….31

a. General Condition of Client upon Discharge…….……………...31

b. METHOD…………………………………………...……………….31

VII. CONCLUSION and RECOMMENDATIONS…………………………….….……32

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I. Introduction

The appendix is a closed-ended, narrow tube that attaches to the cecum (the first

part of the colon) like a worm. (The anatomical name for the appendix, vermiform

appendix, means worm-like appendage.) The inner lining of the appendix produces a

small amount of mucus that flows through the appendix and into the cecum. The wall of

the appendix contains lymphatic tissue that is part of the immune system for making

antibodies. Like the rest of the colon, the wall of the appendix also contains a layer of

muscle.

Appendicitis is inflammation of the appendix. It is thought that appendicitis begins

when the opening from the appendix into the cecum becomes blocked. The blockage

may be due to a build-up of thick mucus within the appendix or to stool that enters the

appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks

the opening. This rock is called a fecalith (literally, a rock of stool). At other times, the

lymphatic tissue in the appendix may swell and block the appendix. Bacteria which

normally are found within the appendix then begin to invade (infect) the wall of the

appendix. The body responds to the invasion by mounting an attack on the bacteria, an

attack called inflammation. (An alternative theory for the cause of appendicitis is an initial

rupture of the appendix followed by spread of bacteria outside the appendix.. The cause

of such a rupture is unclear, but it may relate to changes that occur in the lymphatic

tissue that line the wall of the appendix.)

If the inflammation and infection spread through the wall of the appendix, the

appendix can rupture. After rupture, infection can spread throughout the abdomen;

however, it usually is confined to a small area surrounding the appendix (forming a peri-

appendiceal abscess). The treatment for appendicitis is antibiotics and surgical removal of the

appendix (appendectomy). Appendectomy is the removal by surgery of the appendix, the small

worm-like appendage of the colon (the large bowel). An appendectomy is performed because of

probable appendicitis.

Acute appendicitis is the most common cause in the USA of an attack of severe,

acute abdominal pain that requires abdominal operation.

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The incidence of acute appendicitis is around 7% of the population in the United

States and in European countries. In Asian and African countries, the incidence is

probably lower because of the dietary habits of the inhabitants of these geographic

areas. Appendicitis can effect any at any age, with highest incidence occurring during

the second and third decades of life. Rare cases of neonatal and prenatal appendicitis

havebeenreported. Appendicitis occurs more frequently in men than in women, with a

male-to-female ratio of 1.7:1.

A. Current Trends about Appendicitis

Care protocols reduce appendectomy complications - Tips from Other

Journals

Appendectomy is the fourth most common abdominal surgery performed in the United

States. Up to 18 percent of patients have postoperative infectious complications ranging

in significance from wound infection to intra-abdominal abscess. The rate of infections

depends on the degree of contamination during surgery and reaches nearly one third of

cases when the appendix is perforated or gangrenous. Helmer and colleagues studied

the effect of an evidence-based clinical practice guideline in reducing infectious

complications of appendectomy.

The clinical practice protocol that was developed from a critical review of the literature

(see accompanying figure) was applied to 206 patients with a presumptive diagnosis of

appendicitis who presented to a Texas county hospital during 1999. Outcomes in this

cohort of patients were compared with those in 232 patients treated for the same

condition at the hospital during the previous year. No patients were excluded from the

study. Data were gathered on demographic and surgical features, comorbidities, use of

antibiotics, evidence of infection, and other complications during the hospital stay.

Eight patients (4 percent) who were treated according to the protocol had postoperative

surgical infections, compared with 20 patients (9 percent) in the comparison group. The

number of patients with intra-abdominal abscesses dropped from 12 to five after

introduction of the protocol, and the number of wound infections dropped from 14 to four.

The improvement was particularly significant in patients presenting with a perforated or

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gangrenous appendix. In these patients, the total number of infections dropped from 16

(33 percent) to five (13 percent).

The authors conclude that use of an evidence-based clinical practice guideline can

significantly reduce surgically related infections following appendectomy and is

particularly effective in patients with perforation or gangrene of the appendix.

B. Reasons for choosing such case

One of the formidable part in doing a case study is choosing what case is to

present. We had this unanimous decision of choosing Girl Agnes’ case, first and

foremost because with our initial contact we already established hormonious relationship

with the patient and her significant others. We had established the “trust” we yearn from

them and that makes it easy for us to ask certain questions we need for our case and

interact with them properly. Another thing is because we find them kind and humorous

that is why our previous interaction with them is smooth and conventional. Most

importantly, the term Appendicitis is not accustomed to us that much. With that thought

alone, we want to further enhance our knowledge about the disease such as to ensure

appropriate evaluation of the etiology, reassess and address the course the illness takes

in its progression. Also, to have an experience in handling and providing humanitarian

health services to a patient who has it and provide any intervention or treatment

indicated based on the specific etiology and the course it follows in that specific patient.

With that scenario, it is not only the knowledge that was enhanced but also our skills as

health care practitioners.

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II. Nursing Assessment

A. Personal History

Princess Lulu M. Ba 65 years old, female, currently residing at 176

Dolores, Magalang Papanga. A typical Filipina and presently a part of the Roman

Catholic. She was born on January 3, 1939. She is married with eight children, where

some are married. Currently, she is just staying at home and she is dependent to his

children for support. Sometimes she takes care of her grandchildren at home. She also

cooks food for them and clean the house. Since he has this kind of lifestyle, and

because of his age, last February 28, 2006 she manifested symptoms of appendicitis

which was the reason why she was rushed to ONA.

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B. Pertinent Family Health-Illness History

7

Ba Family

Palaceo Father o Alcoholico Died of a ruptured

appendicitis

Jewelo Mothero Alcoholico Died of

Tuberculosis

Prince Stepheno husband

Princess Luluo Patiento Dignosed

with appendicitis

Bu

-37-Married -working

La-32-single-Construction worker

Ba-28-married-housewife

Jel-27-marriedconstruction worker

Tah-15-single-not going to school

Mah-17-single-college student

Ad-22-single-vendor

Bon-24-married-vendor

Living Condition

House:

They live in a bungalow type of house, concrete and some of the married

members of the family resides

Food:

Their food is always a usual Filipino dish consisting of rice, fish, meat and

vegetables. Their source of water is the pump.

Economic Status:

Princess Lulu is not working; she is dependent on his children for support. Her

daughter, told us that 150-200 pesos a day is enough for them to satisfy the day.

Beliefs:

The BA Family believes in “herbolarios” and “hilots” and directly seek

advices from them if any sickness occurred. They seldom bring members of the family to

doctors or to the hospital for consultation or treatment of any disease.

C. History of Past Illness

She has always been healthy ever since he was a kid and he was never been

brought to the hospital. She had normal Blood pressure, with no signs of hypertension,

Diabetes Mellitus or even Tuberculosis. Aside from fever, colds and cough, nothing

hinders him from doing his daily activities.

D. History of present Illness

It was February 28, 2006, 7 in the evening when she started to feel some pain in

the abdominal area, accompanied by fever; she was chilling and felt nauseated and

vomited several times. At 11 pm of the same night, she was still experiencing the same

but the pain is worsen. Early in the Morning, they rushed him to the ONA. Dr. Dizon

assessed her and diagnosed it as acute appendicitis because of (+) muscle guarding,

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(+)direct and rebound tenderness on the right lower quadrant. The patient was also

assessed for Psoas sign and Obturator sign and was found out that the patient was in

pain during the assessment hence he was admitted right away and had an emergency

appendectomy.

E. Physical Examination

March 01, 2006

BP=110 / 90 RR= 20 bmp

T= 37.2º C PR=84 bpm

SKIN

a .General: dark brown in color; dry skin; absence of edema; when pinched skin

springs back to previous state, poor turgor

NAILS

a. General: converse curvature; smooth texture; long with dirt; promp return of pink

or usual color

HAIR

a. evenly distributed; thick hair; dry; black in color

HEAD AND FACE

a. scalp: no evidence of flaking or dandruff

b. skull: rounded; smooth skull contour; absence of nodules or masses

c. face: palpabral fissures equal size

EYES

a. general: symmetrically aligned

b. eyebrows: symmetrically aligned equal movement; hair evenly distributed

c. eyelashes: equally distributed curled slightly outward

d. eyelids: skin intact; no discharge; no discoloration; involuntary blinks

e. sclera: whitish with capillaries

f. conjunctiva: shiny; smooth

g. pupils: black in color; equal size; + PERRLA; round, smooth border

h. vision: able to read newsprint; sensitivity to light

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EARS

a. general: mobile;firm; no tenderness; pinna recoils after it is folded; no infection

b. external ear canal: presence of hair follicles; presence discharge

NOSE

a. external: symmetric and straight; not tender; air moves freely as the client

breaths

b. internal: presence of hair

MOUTH AND OROPHARYNX

a. lips: uniform pink color; dry; ability to pursue lips

b. teeth: missing teeth due to cavities; discoloration of enamel

c. tongue: no lesions; with thin whitish coating; able to roll the tongue upward and

side to side

d. palates and uvula: light pink; positioned in the middle of soft palate

e. tonsils: pink; no swelling

NECK

a. muscles: equal in size; head centered; equal strength

b. movement: coordinated smooth movements without discomfort

c .lymph nodes: not palpable

d.thyroid gland: not visible

CHEST

a. external: symmetric; spinal column is straight; skin intact; chest wall intact; no

tenderness; full symmetrical chest expansion

b. lungs: normal breath sounds; absence of DOB

CARDIOVASCULAR

a. heart: absence of heart sounds; normal beating pattern

ABDOMINAL

a. general: with direct and rebound tenderness on the right lower quadrant; with

indirect tenderness;

MUSCULOSKELETAL

a. general: equal size on both sides of the body; no contractures; no tremors;

normally firm; no deformities

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Cranial Nerves

I. Olfactory– have the sense of smell

II. Optic – normal visual acuity

III. Oculomotor– positive papillary reflex and eye convergence test

IV Trochlear– positive papillary reflex and eye convergence test

V. Trigeminal – can sense the sensation of pain, touch, temperature and normal muscle

strength.

VI. Abducens– positive papillary reflex and eye convergence test

VII.Facial – normal muscle strength of facial expressions

VIII. Vestibulocochlear– normal voice tones audible; able to hear ticking on the both

ears.

IX. Glossopharyngeal– (+) gag reflex; can swallow

X. Vagus– (+) gag reflex

XI. Accessory– normal muscle strength

XII. Hypoglossal – normal tongue movements

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F. Diagnostic and Laboratory Procedures

Diagnosis/ Lab procedure

Date orderedDate result

Indication or purpose

result normal value

Analysis & interpretation of result

Urinalysis

O: 03-01-06

R: 03-01-06

- to determine urine composition such as blood, glucose, protein

Yellow, clearSugar: ( - )Ph: acidicSp. Gravity: 1.030Pus cells: 0-1 HPFRBC: 1-2 HPF

Yellow, clearSugar: ( - )Ph: acidicSp. Gravity: 1.003-1.030Pus cells: +10 HPFRBC: 0-3 HPF

The microscopic analysis shows normal levels.

Nursing Responsibilities:

Explain the procedure and the purpose to the client. Explain to the client the importance of the procedure Explain to the client that urine sample is needed Ask the client if he/she had eaten, it can alter the result Ask the client what are the medication that he/she had taken. If there is infection, tell the patient that the test will be repeated to monitor any

development.

Diagnosis/Lab

Date orderedDate result in

Indication or purpose result Normal value

Analysis & interpretati

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procedure on of the result

Hematologic test

O: 03-01-06

R: 03-01-06

-to indicate anemia and polycythemia

Hgb: 1.50

WBC: 14.6Hct: 0.45

RBC: 5.25

Hgb:M: 140-180 gm/LF: 120-160 gm/LWBC:5.10 x 10/LHct:M: 0.40-0.54 L/LF: 0.37-0.47 L/LRBC:M: 4.5-6.3 x 10/LF: 4.2-5.4 x 10/L

White blood cell is above the normal range, there is systemic infection. Leukocytosis indicates appendicitis.

Diagnosis/Lab procedure

Date orderedDate result in

Indication or purpose result Normal value

Analysis & interpretation of the result

Hematologic test

O: 03-01-06

R: 03-01-06

-to indicate anemia and polycythemia

Hgb: 139

WBC: 12.4Hct: 0.41

RBC: 5.25

Hgb:M: 140-180 gm/LF: 120-160 gm/LWBC:5.10 x 10/LHct:M: 0.40-0.54 L/LF: 0.37-0.47 L/LRBC:M: 4.5-6.3 x 10/LF: 4.2-5.4 x 10/L

A decrease in hemoglobin indicates anemia.White blood cell is above the normal range, there is systemic infection. Leukocytosis indicates appendicitis.

Nursing Responsibilities:

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Explain the procedure and the purpose to the patient. Explain to the patient that it requires blood sample and it can cause pain and

discomfort due to the needle puncture. Ask the patient if he/she had eaten food because it can alter the result. Ask the patient if he/she had taken some drugs because it can alter the result. Ask for the religion and culture of the patient.

III. Anatomy and Physiology

In a normal human female, the GI tract is approximately 25 feet or 7 and a half meters

long and consists of the following components

Mouth (Oral cavity/ Bucal Cavity, includes tongue, teeth, salivary glands and

mucosa)

The mouth is the first of the digestive tract. It is the opening through

which takes in food. It is lined by stratified squamous non-cornified

epithelium, except the hard palate, gingival and filiform papillae of tongue which

are cornified.

It is bound infront by the lips, above by the hard and soft palate, below by

the floor of the mouth including the tongue and behind by the faucial isthmus.

Pharynx

The pharynx is the part of the digestive system which connects the mouth

with esophagus. It is where the digestive tract and the respiratory tract cross,

commonly called the throat. The human pharynx is bent at a sharper angle.

Esophagus (Gullet/ Oesophagus)

The esophagus is a muscular tube, lined with moist stratified squamous

epithelium that extends from the pharynx to the stomach. It is about 25 cms.

Long and lies anterior to the vertebrae and posterior to the trachea within the

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mediastinum. It passes through the diaphragm and ends at the stomach. It

transports food from the pharynx to the stomach.

Stomach

The stomach is an enlarged segment of the digestive tract in the left

superior part of the abdomen. It is an alimentary canal used to strore and digest

food. It’s primary function is as a storage and mixing chamber for ingested food.

It is lined with simple columnar epithelium. Latin names for the stomach include

Ventriculus and Gasti, many medical terms related to the stomach part in “gastro”

or “gastric”.

In humans the stomach is a highly acidic environment (maintained by the

hydrochloric acid secretion) wit peptidase digestive enzymes.

In ruminants, the stomach is a large multichambered organ that hosts

symbiotic bacteria which produced enzymes required for the digestion of

cellulose from plant matter. The partially digestive plant matter passes through

each of the stomach’s chambers in sequence, being regurgitated and rechewed

at least once in the process.

Bowel/Intestine

Small Intestine

Small intestine is the portion of the alimentary tract between the stomach

and the large intestines whose main function is for absorption. It is about 6

meters long and consists of 3 parts: duodenum; jejunum and ileum.

Duodenum

Duodenum is a hollow jointed tube that connects the stomach to the

jejunum, it is the shortest, the widest and most fixed part of the small intestine

and is largely retro-peritoneal closely attached to the dorsal wall.

Jejunum

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Jejunum is about 2.5 meters long and makes up 2/5 of the total length of

the small intestine.

Ileum

The ileum joins with the cecum at ileocal junction. It is about 3.5 meters

long and it makes up 3/5 of the small intestine.

Large Intestine

The large intestine extends from the ileocal junction up to the anal

opening in the peritoneum. It is about 5-6 feet long. It is subdivided into: cecum

and appendix, colon, rectum and anal canal.

Cecum and Appendix

Cecum is the proximal end of the large intestine and is where the large

and the small intestine meet at the ileocal junction. It is located in the right lower

quadrant of the abdomen near the iliac fossa. It is a sac that extends inferiorly

about 6 cms. past ileocal junction. Attached to the cecum is a tube about 9 cms.

long called the APPENDIX.

Colon

The colon is about 1.5-1.8 meters long and consists of four parts:

Ascending colon

Transverse colon

Descending colon and sigmoid colon

Ascending Colon

The ascending colon extends superiorly from the cecum to the right colic

flexure near the liver, where it turns left

Transverse Colon

The transverse colon extends from the right colic flexure to the left colic

flexure near the spleen, where the colon turns inferiorly.

Descending Colon and Sigmoid Colon

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The descending colon extends from the left colic flexure to the pelvis,

where it becomes the SIGMOID COLON. The sigmoid colon forms an S-shaped

tube that extends medically and the inferiorly into the pelvic cavity and ends at

the rectum.

Rectum

The rectum is a straight muscular tube that begins at the termination of

the sigmoid colon and ends at the anal canal.

Anal Canal

The anal canal represents the terminal portion of the large intestines and

it is about 2-3 cms. long

IV. The Patient’s Illnesses

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A. Synthesis of the Disease

a1. Definition of the Disease

Appendicitis is the inflammation of the vermiform appendix, which is

attached to the cecum and lies in the right lower quadrant, the appendix can lie

medial, lateral, anterior or posterior to the cecum, it is behind the bowel or

mesentery or in the pelvis.

The average adult appendix is 9-10 cm in length with a diameter of 0.5 to

1 cm. Its blood supply, the appendiceal artery, is a terminal branch of the

ileocolic artery which transverses the length of the appendix.

This small finger shaped tube branches of the large intestine. There is no

specific cause of appendicitis, although inflammation can occur spontaneously

from an infection or from fecal waste that have been trapped in the lumen of the

appendix. The appendix can also become kinked, obstructing the circulation.

Abscess formation generally occurs and danger of rupture is omnipresent.

Appendicitis is characterized by a sharp abdominal pain that may be

localized at McBurney’s point (half way between the umbilicus and right iliac

crest). Palpation of the abdomen causes pain in the right quadrant.

Pressing the abdomen at McBurney's point causes tenderness in a

patient with appendicitis. When the abdomen is pressed, held momentarily, and

then rapidly released, the patient may experience a momentary increase in pain.

This "rebound tenderness" suggests inflammation has spread to the peritoneum.

If the appendix ruptures, the pain may disappear for a short period and

the patient may feel suddenly better. However, once peritonitis sets in, the pain

returns and the patient becomes progressively more ill. At this time the abdomen

may become rigid and extremely tender.

Appendix occurs most commonly on children, adolescents and young

adults but individuals of any age may have appendicitis.

a.2.Predisposing / Precipitating Factors

Predisposing Factors:

Classic history of appendicitis

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Sex: Appendicitis is 1.3 to 1.6 times more common in males than in

females

Age: the peak incidence is in the second and third decades with 80 %

of cases occurring in persons younger than 45 years of age but

individuals of any age may have appendicitis.

Anatomical Variations in the position of the appendix.

Precipitating Factors:

Lymphoid Follicular Hyperplasia

Infections by viruses, parasites or bacteria

Diet deficient in fiber

a.3. Sign and Symptoms

Appendicitis often starts with mild pain near the navel. The pain gradually

moves to the right lower part of the abdomen. It worsens with time, and is more

intense when the person moves. Other symptoms of appendicitis may include:

· Nausea or vomiting.

· Elevated temperature.

· Increased pulse rate.

· Loss of appetite.

· Constipation.

· Abdominal swelling.

If the infection continues, the appendix may rupture. When this occurs,

there is often relief of the pain for a short while. This improvement is followed by

more intense but similar pain.

Chronic appendicitis is rare. It causes a milder pain in the right lower

abdomen that may come and go.

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d.3. Health promotion and Preventive Aspects of the Disease

A-void too much activity(eating then working or playing right away)

P-eople of any age are susceptible, male are more prone

P-revent obstruction of the lumen

E-xercise

N-otify physician if any signs and symptoms occur

D-iet should be high in fiber; so to..

I-increase peristalsis to prevent constipation

X-ray, ultrasound and other lab test should be take into consideration to

avoid rupture of the appendix

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V. THE PATIENT AND HIS CARE

1. Medical management

A. IVF’s

Medical Management/ Treatment

Date ordered; performed; changed

General Description

Indication/s

Or

Purpose/s

Client’s Initial Reaction to the Treatment

Client’s response to the Treatment

D5LRS 1L x 8 @ 30-31 gtts./min

# 1

# 2

# 3

# 4

# 5

# 6

O: 03-01-06C: 03-01-06

O:03-02-06C:03-02-06

O:03-02-06C:03-03-06

O:03-03-06C:03-04-06

O:03-04-06C:03-05-06

O:03-05-06C:03-05-06

Slightly hypertonic solution, this solution exerts higher osmotic pressure than of the blood plasma. D5LRS will increase the solute concentration of plasma, draining water out of the cells into the extracellular compartment to restore osmotic equilibrium. D5LRS contains 130 mEq/L Sodium, 4 mEq/L of Potassium. 109 mEq/L Chloride, 3.0 mEq/L of Calcium. It has 120

Used to

replace

deficits in the

extracellular

compartment

in patients

that are

dehydrated

and volume

depleted.

D5LRS is administered and given to patient to give the necessary nutrients to replace any lost fluids since the patient is in NPO. It is also used as a main line to administer Antibiotics

Client has a guarding behavior but was cooperative with the treatment procedure. He responded well to the treatment.

>Check IV

Tubing for

the

presence of

air

>Check

Integrity of

the Infusion

>Monitor IV

flow rate

>Adjust rate of flow of fluids appropriate to need of patient as prescribed

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calories. and medications IV.

Medical Management/ Treatment

Date ordered;

performed; changed

General Description

Indication/s

Or

Purpose/s

Client’s Initial

Reaction to the

Treatment

Client’s response

to the Treatment

D5NM 1Lx 35 gtts/min

#4 O: 01-31-06C: 01-31-06

Hypotonic solution it maybe iso-osmolar since dextrose is rapidly metabolized. Normosol M contains dextrose 50g, dehydrated alcohol 40ml, potassium acetate 1.28g, fructose 150g,NaCl 2.34g, Mg acetate 0.1g

Provides principal ions of normal plasma is almost the same proportions as with normal plasma. Replacement of acute looses of extraxcellular fluid volume in surgery, it was given to the patient to prevent dehydration and contains plasma volume.

Client has a guarding behavior but was cooperative with the treatment procedure. He responded well to the treatment.

No signs of abnormalities observed or felt by the patient.

Nursing Responsibilities

Before administering the IV, identify first the pationt

Explain the procedure

Prepare the equipment

Wash hands

Check the fluid to be infused

Use the smallest gauge needle possible

Drip the tubing before connecting to the needle once being infused

Adjust the IVF as indicated

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Report any pain, infufusion or dislocation felt by the patient

B. Drugs

Name of the DrugsGeneric NameBrand Name

Date OrderedDate TakenDate Changed

Route and Frequency of administration

Indication/ Purposes

Specifi Foods taken

Client’s response to medication

Paracetamol03-01-0603-01-0603-06-06

1 amp. IV q 4° ,non narcotic analgesicsdecreases fever

NPO The patient took the drugs properly, infection reduced, no side effects observed

Cefuroxime 03-02-0603-02-0603-04-06

750mg IV q 8° -Antiinfective-2nd generation cephalospor ins-inhibits bacterial cell wall synthesis rendering cell wall osmotically unstable, leading to cell death by binding to cell wall membrane

NPO The patient took the drugs properly, infection reduced, no side effects observed

Metronidazole 03-02-0603-03-0603-06-06

500mg IVq8 ANST(-)

>Ambecide >Anti-infective>kills susceptible amoeba, trichomonas and bacteria

NPO Patient had no manifestations of any side effects

Tramadol 03-02-0603-03-0603-06-06

100mg IV q 6º RTC

>Analgesic, centrally acting>

NPO-Clear liquid

Patient had no manifestations of any side effects

Plasil 03-02-0603-02-06

5mg/ml q 8° x 4 doses

>anti-emetic NPO Patient had no manifestation regarding any

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03-03-06 side effects

Famotidine 03-02-0603-02-0603-03-06

20 mg IV q 12º x 3 doses

Histamine H2 antagonist

NPO Patient had no manifestation regarding any side effects

Kortezor 03-02-0603-02-0603-03-06

30 mg IV q 8º x 4 doses

Pain reliever NPO Patient had no manifestation regarding any side effects

Captopril 03-03-0603-03-0603-03-06

25mg SL NPO-Clear liquid

Dulcolax03-05-0603-05-0603-05-06

Supp 2 suppl rectum

-laxative, stimulant-diphenylmethane-acts directly on the intestine by increasing motor activity; thought o irritate colonic intramural plexus; increases ater in the colon

Soft diet

Patient had no manifestation regarding any side effects

Nursing Responsibilities:

Assess patient from allergic reaction (ANST)

Assess the patient for any sign and symptoms

Identify Urine output, if decreasing, notify the physician

Caution patient to report bleeding, bruising or fatigue

Monitor patient bowel and consistency of stool

Evaluate for therapeutic response: release of pain, stiffness, swelling

Document indications for therapy.location, onset, and charcteristic of symptoms

Assess for history of drug addiction, allergy to any medicine

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Monitor vital signs

Obtain CBC and necessary cultures before administering

Encourage increased fluid intake

Document

C. Diet

Types Of Diet

Date orderedDate startedDate changed

General Description

Indications or Purpose

Specific Foods taken

Client’s response to the treatment

NPO 03-01-0603-01-0603-03-06

Restriction of solid nor liquid foods by mouth

Upon admission to provide more accurate observation in the condition of the client and for pre and post operative patient to prevent aspiration of the food taken in as an effect of the anesthesia.

She exhibited some loss of appetite.

Clear Liquid Diet

03-03-0603-03-0603-03-06

Made up of clear liquid foods which leave no residue in the GIT. It is non-stimulating, non-gas forming, and non-irritating.

It is mainly used for post operative patients, patients with acute illness and infections, to relieve thirst, to reduce colonic fecal matter. It is done between 1-2 feeding intervals.

WaterPineapple juiceJelly ace

she first seemed to have a loss of appetite with the ordered diet, but then gradually took in the foods that were ordered by the physician.

Soft Diet

03-04-0603-04-0603-06-06

It is similar to the regular diet except that the texture of the foods has been modified. It is a diet modified in consistency to have new roughage, liquefied foods, semi-solid foods and those which are easily digested. This could offer an entirely adequate, liberal diet.

It is used for patients with acute infections, some GIT disturbances or chewing problems and following surgery

SoupLugawCrackersMammonPineapple juicewater

The patient manifested an improved appetite.

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Nursing Responsibilities:

The benefits as well as the disadvantages should be explained well to the client.

The nurse should make sure that the patient adheres to the ordered diet.

The ordered diet should be monitored.

Continuous monitoring of the client’s diet should be observed

d. Activity/Exercise

Type of exercise

Date ordered, date started, date changed

General description

Indication or purpose

Client’s response to the activity or exercise

Bed rest

Ambulation(walking)

Date ordered03- 01 -06Date started03-01-06Date changed03-03-06

Date ordered03-04-06Date started03-04-06

Pt. is restricted from any stressful activities

Pt. performed ADLs, maintain good body alignment and carry out active ROM exercises.

To decrease oxygen and energy demand.

To be able limit movements and strengthen the muscles.

Pt. was able to avoid any stressful activities.

Pt. was able performed her ADLs like walking

Nursing responsibilities:

Check for the doctors order

Explain the purpose of the exercise to the client

Instruct client to maintain the exercise ordered by the physician

Assist the patient in moving and walking

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Provide comfort measures to avoid injury of the patient

B. Surgical Management

a. Brief Description

A surgical procedure called an appendectomy is necessary before the appendix

ruptures. Attempts are made to remove the inflamed appendix before it ruptures and

preoperative care is directed toward resting the colon. No enemas, heating or laxatives

should be used before surgery because they could stimulate peristalsis and cause a

rupture of the appendix.

The appendix is removed through a small incision over McBurney’s point or

through a right paramedical incision. The incision usually heals with no drainage. Drains

are used when an abscess is discovered when the appendix has rupture and sometimes

when the appendix was edematous and ready to rupture and was surrounded by clear

fluid.

If no rupture has occurred, a laparoscopic appendectomy, in which the appendix

is removed through a scope maybe done. A laparoscopic appendectomy requires only

small incision and allows client to be discharged 24 hours after surgery.

Bowel function is usually normal soon after surgery and convalescence is short.

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b. Nursing Responsibilities

Preoperative

Assess the location, severity, onset, duration, precipitating factors and

alleviating measures in relation to the pain

Intravenous fluids as prescribed to maintain fluid and electrolyte balance

Instruct nothing by mouth to the patient prior to surgery

Record allergies and medications as well

Place the patient in semi fowlers or side lying position to provide comfort

Analgesics are withheld until physicians determines diagnosis

Post Operative

Determine (+) flatus

Clear Liquid after Flatus

Soft Diet after

Assist patient in turning, coughing and deep breathing to promote

expansion of the lungs

Assess abdominal wound for redness, swelling and foul discharge

Provide wound care

Promote early ambulation

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b. Actual SOPIE

S>Ø

O> the patient manifest the following

(+) guarded behavior

(+) facial grimaces

(+) restlessness

(+) pupillary dilatation

(+) narrowed focus

Onset of pain: often; Quality: Stabbing and throbbing; Region on RLQ;

severely: always; Level of pain of 10/10

A> Acute pain R/T stimulation of nerve endings

P> After 2-3° of Nursing Intervention and health teaching the pt will be

able to decrease pain from 10 to 6 using a scale of 10 as evidence by

using of relaxation technique and diversional activities.

I>

Monitored and recorded vital signs

Assessed patient condition

Performed comprehensive assessment of pain

Accepted patient perception of pain

Observed non-verbal cues

Encouraged verbalization of feeling about pain

Provided quiet and calm environment

Provided patient comfort measures

Encouraged relaxation exercise such as deep breathing

Encouraged diversional activities

Encouraged adequate rest

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Discussed with SO way on how to assist patient to reduce pain

E> Goal met AEB reducing of pain from 10 to 6 using a scale of 10

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VI.CLIENT’S DAILY PROGRESS IN THE HOSPITAL

a.Client’s daily progress chart

Days Admission 03-02-06 03-03-06 03-04-06 03-05-06Nursing Problems

Acute Pain / / / / /Risk for deficient

fluid volume/ /

Impaired skin Integrity

/ / / /

Physical Immobility / / / / /Risk for Infection / / / / /

Vital SignsBlood PressureTemperature

Respiratory RatePulse Rate

8am110/80

36.92082

8am100/70

372184

8am110/60

372189

8am110/80

36.62166

8am90/6036.12070

Lab Procedures

Medical Managements

1. IVF’sD5LRS

/ / / / /

Drugs:Paracetamol / /Cefuroxime / /

Metronidazole / / / /Tramadol / / / /

Plasil / / / /Famotidine / / / /

Kortezor /Captopril /Dulcolax /

DietNPO /

Clear Diet /Soft Diet / / /

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B.Discharge Planning

a. General Condition Of client upon Discharge

Since we were not able to see the client when she was discharged

from the Hospital, with few days of nursing intervention, the client’s

general condition has improved:

1. She is slowly regaining his strength

2. She can ambulate with assistance

b. METHODM- take the medicines prescribed

E- exercise such as walking and proper breathing

T- daily wound cleaning

H- increase fluid intake, vitamin C, apply hot compress

O- be back at OPD as ordered by the doctor

D- Diet as tolerated with an increase intake of Vitamin C

VII. Conclusion and Recommendation

Every individual of any age are prone to appendicitis though its more common

with males, still everyone is susceptible, mild umbilical pain maybe vague at first, but it

increases intensity. Over a period of time, signs and symptoms occur rapidly, it cannot

be presented an experience of this shall be contented with proper prevention.

Faulty diet especially low in fiber is one cause of the observation therefore by

eating fiber- rich food will increase peristalsis. So there is regular bowel movement. So

there is no fecal material that will be formed.

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Not everyone with appendicitis has all the symptoms. The pain may intensify and

worsens other may have a sensation called “down ward urge” pain medication and other

laxatives should not be taken in their situation. Anyone with these symptoms need to see

a qualified physician immediately.

Recommendation

One should always remember the health promotion and prevention of

appendicitis. Just remember the acronym APPENDIX, which is avoiding too much

activity, that people of any age and sex are susceptible. One should always play safe in

preventing obstruction of the lumen. Exercise is important. Notify physician if any signs

and symptoms occur. Diet should always be high in fiber to increase peristalsis and to

prevent constipation. Lastly x-ray, ultrasound and other laboratory test should be taken

into consideration to avoid response of the appendix.

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