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College of Nursing
City of Malolos, Bulacan
A Case Presentation of an 11- year old client with Acute Appendicitis
Submitted by:
Reyes, Jenefer L.
Reyes, Phoebegail Shayne E.
Roque, Sarah Mae V.
Sacdalan, Hazel Joy C.
Salvador, Mary Grace S.D.
Santos, DanpaulH.
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Bulacan State University
Taganas, Mary Lyann M.
Tamayo, Camille F.
Tan, Elaine Joy D.
Usi,George Anthony P.
BSN III-B, Group 4
Submitted to:
3nd level Clinical Instructors
I.Introduction
Patient CMG is 11 year old who was admitted at the surgery Department last August 20, 2012due to severe pain at her right lower quadrant, the patient was
diagnosed with acute appendicitis and underwent appendectomy last August 22, 2012.
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed
appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to peritonitis and shock.
Appendectomy, removal of the appendix, is the standard treatment for acute appendicitis, it is important to immediately remove the appendix after the diagnoses to
prevent the occurrence of the life-threatening complication of appendix. The most frequent complication of appendicitis is perforation. Perforation of the appendix can lead
to periappendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection of the entire lining of the abdomen and the pelvis) the major reason for appediceal
perforation is delay in diagnosis and treatment is general the longer the delay between diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours
after the onset of symptoms is at least 15% therefore, once appendicitis is diagnosed, surgery should be done without unnecessary delay.
Objective
General Objective
 To be able to acquire knowledge and skills on how to deal with patient who has diagnosis of acute appendicitis
Specific Objectives
 Client based:
- To obtain necessary information regarding the patient and her condition
- To assess the patients overall health status
- To identify patient health care needs through analysis of all the data gathered.
- To assist the patient throughout rehabilitation, recovery and discharge
- To impart necessary health teachings to the patient
- To perform appropriate nursing care in conjunction w/ the condition of the patient
 Student based:
- To widen and enhance the student nurse’s knowledge and skills through additional research about the nature of the disease, its pathophysiology and
treatment.
- To discuss and interpret the diagnostic results and compared to the normal values and relate them to the disease process.
II. Nursing Assessment
A. Personal History
Demographic Data of the Patient
 Name: CMG
 Age: 11 years old
 Gender: Female
 Address: Lawa, Meycauyan, Bulacan
 Birthday: May 15, 2001
 Religion: Roman Catholic
 Nationality: Filipino
 Dialect Spoken: Tagalog
 Attending Physician: Dra. Maria Glenda D. Zilmar
 Surgeon: Dr. Teoxon
 Assistant surgeon: Dr. Lustre
 Date and time of admission: August 20, 2012 at 4:24 pm
 Date of surgery: August 22, 2012
B. CHIEF COMPLAINT
Pain at the right lower quadrant
C. History of Present Illness
She was admitted in the hospital last August 20, 2012 at 4:24 pm at Bulacan Medical Center due to pain at the right lower quadrant.
D. HISTORY OF THE PAST ILLNESS
According to the client’s mother, the client was hospitalized for 10 days when she was 5 years old because of Kawasaki disease.
E. Family Health History
Her mother has a history of UTI (Urinary Tract Infection), her grandmother has diabetes and her grandfather died because of heart attack or cardiac arrest.
Genogram
RM PM
FG
AG VG
68 70 71 67
40
RLMM
4247
DG NG
45 384O47
AG SG
F. Functional Health Pattern
Health Perception/Health Management Pattern
PRIOR DURING
When the client was asked to describe her previous health the client verbalized,
“Okay lang naman po yung health ko dati, pero nung sumakit yung tyan ko, minsan
nagsuka ko saka nilagnat din.” She experienced colds thrice last year. She eats fruits
everyday to make her strong and healthy. She takes her vitamins every day.
“Madalas nga siya kumain ng mga junkfood kaya nung sumakit na yung tiyan nya
saka lang namin nalaman na may sakit na siya”, as verbalized by her grandmother.
When I asked the client what she feels during the interview, she verbalized
“Nanghihina pa po ako pero po tinutulungan ako ni lola at hindi naman po
ako nilalagnat ngayon.”about her surgical incision hygiene, the client
verbalized” Yung nurse ang nag-linis ng sugat ko, tinitignan nga ni lolakasi
hindi din nga alam kung paano linisin pagnasa bahay na kami.”
Nutritional and Metabolic Pattern
11
LEGEND:
Female Patient Male
Deceased Cardiac Arrest Diabetes
CMG
PRIOR DURING
When it comes to her daily food intake, the client verbalized, “Halos po lahat naman
kinakain ko.” When we ask her to rank her appetite with 10 as the highest score, she
answered 10. According to our client she has vegetable in her daily meal. According
to our client, sometimes she eats junk foods and soft drinks as her snacks. Her
wound heals well and doesn’t have dental problems and eating discomfort.
Frequency
Meat 2-3 times a week
Fish 4 times a week
Frozen food 6-7 times a week
She doesn’t eat any food since she was admitted to the hospital and after the
surgery she took general liquid diet. The client has poor appetite as verbalized
by her grandmother, “Medyo wala siyang gana kumain”.
(We don’t have the chance to weight the patient because of the decrease
mobility of the patient.)
Elimination Pattern
PRIOR DURING
“Hindi naman ako hirap sa pag ihi at pagtae dati, pero nung nagsimula na sumakit
tyan ko, nahirapan na ako.” as verbalized by the client. She doesn’t perspire
excessively and she doesn’t have odor problems.
Output Frequency
( per day)
Amount Characteristics
Urine
Stool
5-6
irregular
500mL
-----
Light yellow
Brownish in color;
without blood
She experience difficulties upon urination because she felt the pain in her
lower abdomen and she hasn’t been defecating since after the surgery. Her
mother changes her diaper 3 times a day.
Output Frequency Amount Characteristics
Urine
Stool
3
-----
500mL
-----
Light yellow color
-----
Sleep-Rest Pattern
PRIOR DURING
The client verbalized “mga 9 hours ako nakakatulog sa gabi, matutulog ako ng 8 ng
gabi tapos gigising ako ng 5 ng umaga. She has no problem in sleeping.She takes a
nap every afternoon and watching T.V is her form of leisure and relaxation.
During hospitalization, she has no definite time of sleeping. “Minsan,
paidlip idlip lang po ng mga 30mins,” as verbalized by the client.
Activity Exercise Pattern
PRIOR DURING
The patient does some ofthe household chores. It also serves asher exercise. Her leisure time would
include watching television, computer gaming and sleeping.
_0_feeding _0_dressing
_0_bathing _0_grooming
_0_toileting _0_bed mobility
_0_cooking _0_home
_0_shopping
_0_general mobility maintenance
Level 0- full self-care
Level I- requires use of equipment/device
Level II- requires assistance or supervision from another person
“Hindi kopokayangumupo at tumayo, lalo na kung akolang mag’isa”, as verbalized bythe
client. The client experience 7out of10pain scales.
_0_feeding _II_dressing
_II_bathing _II_ grooming
_II_toileting
_II_bed mobility
_II_general mobility
Level 0- full self-care
Level I- requires use of equipment/device
Level II- requires assistance or supervision from another person
Sexuality-Reproductive Pattern
PRIOR DURING
The client is only 11 years old and doesn’t have menstruation yet. The client is only 11 years old and doesn’t have menstruation yet.
Cognitive Pattern
PRIOR DURING
According to our client she doesn’t have vision and hearing problems. Madali
naman po ako makasaulo lalo na po sa school”, as verbalized by the client.
While doing the interview, we observed that our client has a little problem in
hearing because sometimes we need to repeat the question to her but she can
still understand and answer appropriately.
Self-Perception-Self-Concept Pattern
PRIOR
DURING
“Ok lang naman po ako bago ako magkasakit”, as verbalized by the client when she
described herself prior to hospitalization. She was able to get along with her sibling
and attend her class to school.
According to her she thinks she lostsome weight. “Masakit po dito sa baba,
hindi pa rin po kasi masyadong magaling ang sugat ko at sakamasakitsiya”,
as verbalized by the client while pointing at the right lower quadrant of her
abdomen.
Role-Relationship Pattern
PRIOR DURING
The patient is living with her grandmother.According to her, she always tells her
problem to her grandmother. She is a choir member in their church. She didn’t feel
being outcast with the other family member and in their barangay. “Palakaibigan
siya at malalahanin sa akin.” as verbalized by her grandmother as we asked how is
CMG as a grandchild.
Her grandmother is the one who takes care of her during her hospitalization.
Coping Stress Tolerance Pattern
PRIOR DURING
According to our client whenever she is stressed, she watch movies, plays computer
gamesand sleep as well.
During hospitalization, the most stressful situation for her is her illness and
the pain she feels.
Value-Belief Pattern
PRIOR DURING
According to the client, her family is the most important people to her because it
gives her strength and makes her happy.She always attends the mass once a week to
increase her faith with God.
During hospitalization as verbalized by the client, “Ang lola ko po ang nag-
papalakas sa akin ngayon”. She is always praying to improve her health.
III. A. Growth and Development
THEORY PSYCHOSOCIAL COGNITIVE PSYCHOSEXUAL MORAL
STAGE Industry vs. Inferiority
(Erik Erikson)
Concrete Operation
(Jean Piaget)
Latency Stage
(Sigmund Freud)
Conventional Morality
(Social Conformity
Orientation)
(Lawrence Kohlberg)
DEFINITION  Children need to cope with new
social and academic demands.
Success leads to a sense of
competence, while failure
results in feelings of inferiority.
 During the concrete
operation stage, children can
perform a number of logical-
mental operations.
 These mental operations
include the ability to classify
objects according to some
dimensions, such as height or
length, and the ability to
figure out relationships
between objects such as
larger or smaller.
 When the child represses
sexual thoughts and engages
in non-sexual activities, such
as developing social and
intellectual skills.
 By adolescence, most
individuals have
developed to this stage.
There is a sense of what
"good boys" and "nice
girls" do and the
emphasis is on living up
to social expectations
and norms because of
how they impact day-to-
day relationships.
THEORY THEORIST DESCRIPTION
APPLICATION OF NURSING PRACTICE IN
THE CARE OF CLIENT
Nightingale's
Environmental Theory
Florence Nightingale (1820-
1910)
 Major Concepts and Definitions
Environment - concepts of ventilation, warmth,
light, diet, cleanliness and noise. She focus o
the physical aspect of environment.
 She believed that "Healthy surroundings were
necessary for proper nursing care."
 5 essential components of healthy environment:
1. pure air
2. pure water
3. efficient drainage
4. cleanliness
5. Light
 Providing a non –stimulating environment is
essential especially for our patient in a way that
it promotes faster recovery on her through
minimizing external and stressful stimuli such
as providing proper ventilation and clean
environment. It is not only for promoting fast
recovery but also a preventive for possible
complications such as infection.
B. Theoretical Application
Twenty –one nursing
problem
Faye –Glenn Abdellah  Nursing is broadly grouped into 21 problem areas
to guide care and promote the use of nursing
judgement.
 We must know the 21 nursing problem to provide
a rationale for collecting reliable and valid data
about the health status of clients, which are
essential for effective decision making and
implementation. We should facilitate the
maintenance of a supply of oxygen to all
body cells, nutrition of all body cells, fluid
and electrolyte balance, elimination, maintain
good body mechanics and prevent and
correct deformities, good hygiene and
physical comfort, promote optimal activity:
exercise, rest and sleep and to facilitate the
maintenance of regulatory mechanisms and
functions.
Maslow's hierarchy of
needs
Abraham H. Maslow (1908-
1970)
 Maslow's hierarchy explains human behavior
in terms of basic requirements for survival and
growth. These requirements, or needs, are
arranged according to their importance for
survival and their power to motivate the
individual. The most basic physical
requirements, such as food, water, or oxygen,
constitute the lowest level of the need
hierarchy. These needs must be satisfied before
other, higher needs become important to
individuals. Needs at the higher levels of the
hierarchy are less oriented towards physical
survival and more toward psychological well-
being and growth. These needs have less power
to motivate persons, and they are more
influenced by formal education and life
experiences. The resulting hierarchy of needs is
often depicted as a pyramid, with physical
survival needs located at the base of the
pyramid and needs for self-actualization
located at the top.
 Maslow theory provides a guide lines in the
prioritization of patient care needs in our case
study.
.
IV. ANATOMY AND PHYSIOLOGY of DIGESTIVE SYSTEM
The human digestive system is a complex series of organs and glands that processes food. In order to use
the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to
excrete waste.
Most of the digestive organs (like the stomach and intestines) are tube-like and contain the food as it makes
its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the
anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals.
The Digestive Process:
The start of the process - the mouth:
The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by
the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down
starches into smaller molecules).
On the way to the stomach: the esophagus:
After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-
like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're
upside-down.
In the stomach
The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed
with stomach acids is called chyme.
In the small intestine
After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small
intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of
the small intestine help in the breakdown of food.
In the large intestine
After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are
removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in the digestion
process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels
across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon.
The end of the process
Solid waste is then stored in the rectum until it is excreted via the anus.
Parts of digestive system and its functions
 digestive system - (also called the gastrointestinal tract or GI tract) the system of the body that processes food and gets rid of waste.
 abdomen - the part of the body that contains the digestive organs. In human beings, this is between the diaphragm and the pelvis
 alimentary canal - the passage through which food passes, including the mouth, esophagus, stomach, intestines, and anus.
 anus - the opening at the end of the digestive system from which feces (waste) exits the body.
 appendix - a small sac located on the cecum.
 ascending colon - the part of the large intestine that run upwards; it is located after the cecum.
 cecum - the first part of the large intestine; the appendix is connected to the cecum.
 descending colon - the part of the large intestine that run downwards after the transverse colon and before the sigmoid colon.
 duodenum - the first part of the small intestine; it is C-shaped and runs from the stomach to the jejunum.
 epiglottis - the flap at the back of the tongue that keeps chewed food from going down the windpipe to the lungs. When you swallow, the epiglottis automatically
closes. When you breathe, the epiglottis opens so that air can go in and out of the windpipe.
 esophagus - the long tube between the mouth and the stomach. It uses rhythmic muscle movements (called peristalsis) to force food from the throat into the
stomach.
 gall bladder - a small, sac-like organ located by the duodenum. It stores and releases bile (a digestive chemical which is produced in the liver) into the small
intestine.
 gastrointestinal tract - (also called the GI tract or digestive system) the system of the body that processes food and gets rid of waste.
 ileum - the last part of the small intestine before the large intestine begins.
 intestines - the part of the alimentary canal located between the stomach and the anus.
 jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum and the ileum.
 liver - a large organ located above and in front of the stomach. It filters toxins from the blood, and makes bile (which breaks down fats) and some blood proteins.
 mouth - the first part of the digestive system, where food enters the body. Chewing and salivary enzymes in the mouth are the beginning of the digestive process
(breaking down the food).
 pancreas - an enzyme-producing gland located below the stomach and above the intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats
and proteins in the small intestine.
 rectum - the lower part of the large intestine, where feces are stored before they are excreted.
 salivary glands - glands located in the mouth that produce saliva. Saliva contains enzymes that break down carbohydrates (starch) into smaller molecules.
 sigmoid colon - the part of the large intestine between the descending colon and the rectum.
 stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical and mechanical digestion takes place in the stomach. When food enters the
stomach, it is churned in a bath of acids and enzymes.
 transverse colon - the part of the large intestine that runs horizontally across the abdomen
 peristalsis - rhythmic muscle movements that force food in the esophagus from the throat into the stomach. Peristalsis is involuntary - you cannot control it. It is
also what allows you to eat and drink while upside-down.
 bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and secreted into the small intestine.
 chyme - food in the stomach that is partly digested and mixed with stomach acids. Chyme goes on to the small intestine for further digestion.
Risk Factors
(modifiable)
 Diet
 Daily
lifestyle
 Low fiber
diet
Risk Factors
(Non
modifiable)
 Age
THE PATIENT AND HER ILLNESS
A. PATHOPHYSIOLOGY
1. Schematic Diagram
Low fiber diet and Episodes of
constipation
Occlusion of Appendix by Fecalith
Decreased flow/drainage of mucosal
secretions
Increased ILP in the appendix
Vasocongestion
Decreased blood supply in the appendix
Decreased O2 supply in the appendix
Appendix starts to be necrotic; Bacteria invade the appendix
Appendix starts to be necrotic; Bacteria invade the appendix
Appendix starts to be necrotic; Bacteria invade the appendix
Disruption of Cell Membrane of Appendix
Start of Inflammatory Process
Neutrophils to area
Leukotrienes, Bradykinin
Histamine, Prostaglandin
Swelling of Appendix
Prostaglandin, Bradykinin
Pain in the RLQ of
Abdomen
Acute Pain
Interleukin-1
Release of Chemical
Mediators Activation of the Vomiting
Stimulation
of Vagus Nerve
Suppression of
sympathetic GI
functions
Anorexia
Risk for Deficient of
fluid volume
Nausea and Vomiting
Risk for Imbalanced
Nutrition
Neutrophils to area
Pus Formation
phagocytized bacteria
and dead cells
Risk for Infection
(if appendix ruptures)
Increased WBC
Inflammation of Appendix (Appendicitis)
Open wound
Inflammation of Appendix (Appendicitis)
Disruption of Cell
Membrane
Nociceptors on the dermis
Impaired
Tissue
Integrity
Tissue trauma
Appendectomy
Send impulses to CNS
Pain on surgical site
Release of Prostaglandin
Bradykinin
Start of Inflammatory
process
Activity intolerance
Risk for
infection
2. Definition of the disease
APPENDICITIS
Appendicitis is an irritation, inflammation, and infection of the appendix (a narrow, hollow tube that branches off the large intestine). The appendix functions as a
part of the immune system during the first few years of life. After this time period, the appendix stops functioning and other organs continue helping fight infection.
Although the appendix does not seem to serve any purpose, it can become infected and, if untreated, can burst, causing more infection and even death.
3. Predisposing factors
 Ages of 10 and 30 years.
 Having a family history of appendicitis may
 Gender, especially in males, and
 Having cystic fibrosis also seems to put a child at higher risk.
4. Signs and symptoms
The following are the most common symptoms of appendicitis. However, each individual may experience symptoms differently. Symptoms may include:
>Pain in the abdomen which:
o May start in the area around the belly button, and move over to the lower right-hand side of the abdomen, but may also start in the lower right-hand
side of the abdomen.
o Usually increases in severity as time passes.
o May be worse with moving, taking deep breaths, being touched, and coughing or sneezing.
o May spread throughout the abdomen if the appendix ruptures.
>Nausea and vomitingDiarrhea >Inability to pass gas
>Abdominal swelling >Loss of appetite
>Fever and chills >Constipation
AREA OF ASSESSMENT ASSESSMENT
TECHNIQUES
NORMAL FINDINGS ACTUAL FINDINGS REMARKS
General Survey
Describe body built Inspection Arm span equals to height, crown
to pubis equal to length from
pubis to sole
Height and weight are
proportional.
Normal
Observe height and weight in
relation to client’s age
Inspection Proportionate, varies with lifestyle The client loss some weight due
to her poor appetite.
Deviation from normal
Posture and gait Observation Relaxed, erect posture;
coordinated movement
Unable to assess the clients
posture and gait due to her
decrease mobility
Not examined
Describe over all hygiene and
grooming in relation to the
person’s activities prior to the
assessment.
Inspection Clean, neat Hair properly done; with clean
clothes
Normal
Note for body and breathe
odor in relation to the person’s
activities prior to the
assessment.
Inspection No body odor or minor body odor
relative to work or exercise; no
breath odor
No body odor and no breath
odor
Normal
Mental state
Identify signs of distress Observation No distress noted Client is bending over because
of abdominal pain.
Deviation from normal
Note obvious sign of health or
illness
Observation Healthy appearance Sometimes she is frowning
maybe because of incisional
pain.
Deviation from Normal
Assess clients attitude Observation Cooperative, able to follow
instructions
Answers in our questions are
appropriate; cooperative
Normal
Describe clients affect or
mood
Observation Appropriate to situation Client’s mood and affect is
appropriate to situation.
Normal
Assess appropriateness of
clients responses
Observation Appropriate to situation Answers of our client in our
questions are appropriate.
Normal
Describe quantity of speech
(amount and pace), quality
Observation Understandable, moderate pace;
clear tone and inflection; exhibits
Speech is loud with a clear
diction.
Normal
V. Physical Examination
(loudness, clarity, inflection)
and organization (coherence of
thought, over generalization,
thought association
Listen for the relevance and
organization of thoughts.
Observation Logical sequence; makes sense;
has sense of reality
Client’s answer has sense of
reality.
Normal
Hair
Inspect the evenness of growth
over the scalp
Inspection Evenly distributed hair No presence of alopecia Normal
Inspect hair thickness or
thinness
Inspection Thick hair With thick hair. Normal
Inspect hair texture and
oiliness
Inspection Silky, resilient hair Slightly dull hair because client
hasn’ttaken a bath since
admitted to hospital.
Deviation from Normal
Note presence of infections or
infestations
Inspection No infection or infestation No observable signs of infection
or any infestations.
Normal
Inspect amount of body hair Inspection Variable Variable; hair is evenly
distributed all over the client’s
body.
Normal
Skull
Inspect the skull for size,
shaped and symmetry
Inspection Rounded, smooth skull contour Normocephalic and symmetric Normal
Palpate the skull for nodules
or masses and depressions
Palpation Smooth, uniform consistency;
absence of nodules or masses
No palpable nodules, lumps and
masses.
Normal
Face
Facial features Inspection Symmetric or slightly asymmetric
facial features; palpebral fissures
equal in size; symmetric
nasolabial folds
Facial features are symmetric. Normal
Symmetry of the facial
movements
Inspection Symmetric facial movements Eyebrows elevate at the same
time; eyes blink and closed at
the same time
Normal
Eyebrows and eyelashes
Evenness of distribution,
direction of curl and
movement
Inspection Evenly distributed, eyebrows
symmetrically aligned; curled
slightly upward
Eyebrows raise and lower at the
same time; symmetrically
aligned; both eyebrows curled
slightly upward
Normal
Eyelids
Surface characteristics and
ability to blink
Inspection Skin intact, no discharge, no
discoloration;
Lids closed symmetrically
Eyelids skin are intact; no
discharge and discoloration;
eyelids blink symmetrically
Normal
Conjunctiva
Inspect the bulbar conjunctiva
for color, texture and the
presence of lesions
Inspection Transparent Bulbar conjunctiva are
transparent; no presence of
lesions; with evident capillaries
Normal
Inspect the palpebral
conjunctiva for color, texture
and the presence of lesions
Inspection Shiny, smooth and pink or red Palpebral conjunctiva is shiny;
pinkish in color
Normal
Sclera
Color and clarity Inspection Sclera appears white Sclera is white and clear Normal
Cornea
Color and clarity Inspection Transparent, shiny and smooth Cornea’s surface is smooth
transparent and shiny
Normal
Iris
Shape and color Inspection Round Round, black in color Normal
Pupils
Color, shaped and symmetry
of size
Inspection Black in color, equal in size Pupil is round black in color and
equal
Normal
Pupil light reaction and
accommodation
Inspection
Asking the client to look
first at a distant object and
then at a distant object
behind the penlight
Pupils constricts when looking at
near objects; pupils dilate when
looking at far object; pupil
converge when near object is
moved towards nose
Pupils are equally rounded. Normal
Pupils direct and consensual
reaction to light
Inspection
Asking the client to look
straight ahead, by using the
penlight and approaching
from the side, shining a
light on the pupil
Illuminated pupil constricts
(direct response)
Non illuminated pupil constricts
(consensual response)
Pupil constricts Normal
Visual acuity
Test near vision Asking the client to read
the newspaper held at a
distance of 36 cm
Able to read newsprint No difficulty reading newsprint Normal
Test distance vision Inspection 20/20 vision on Snellen–type
chart
Not examined Not examined
Lacrimal gland, lacrimal sac
and nasolacrimal duct
Presence of edema Inspection and palpation No edema or tenderness There are no presence of
tenderness and edema.
Normal
Extraocular muscles
Test each eye for alignment
and coordination
Inspection Both eyes coordinated, move in
unison with parallel alignment
Both eyes are coordinated with
parallel alignment
Normal
Visual fields
Test for peripheral visual
fields
Inspection
noted
When looking straight ahead,
client can see objects in periphery
Client can see object using
peripheral vision
Normal
Ear auricle
Color and symmetry of size
and position
Inspection Color same as facial skin,
symmetrical, auricle aligned with
outer canthus of the eye, about
10° from vertical.
Both ear auricle has the same
color with the skin
Normal
Texture, elasticity and areas of
tenderness
Palpation Mobile, firm, and not tender;
pinna recoils after it is folded
There are no areas of
tenderness; no nodules or lump
Normal
External ear canal
Cerumen, skin lesions, pus
and blood
Inspection Dry cerumen, grayish-tan color;
or sticky, wet cerumen in various
shades of brown
Dry cerumen; no skin lesions,
pus and blood
Normal
Hearing acuity test
Clients response to normal
voice tones
Inspection Normal voices tones audible Has difficulty in hearing Deviation from Normal
Perform watch tick test Inspection Able to hear ticking in both ears Not examined Not examined
Nose
Shape, size or color and
flaring or discharge from the
nares
Inspection Symmetric and straight, uniform
color, no discharge or flaring
Symmetric uniform in skin
color; no presence of discharge
or flaring.
Normal
Presence of redness, swelling,
growths and discharge of
nares, using the flashlight
Inspection Mucosa pink, clear, watery
discharge, no lesions
Mucosa is pinkish; no lesions Normal
Position of nasal septum Inspection Nasal septum intact and in
midline
Nasal septum in midline Normal
Test patency of both nasal
spectrum
Inspection Air moves freely as the client
breath through the nares
Client can breath freely using
nasal nares.
Normal
Tenderness, masses and
displacement of bone and
cartilage
Palpation No tenderness, masses and
displacement of bone and
cartilage
No presence of tenderness,
masses and displacement of
bone and cartilage
Normal
Sinuses
Presence of tenderness Palpation Not tender Sinuses are not tender. Normal
Lips
Symmetry of contour, color
and texture
Inspection Uniform pink color, soft moist,
smooth texture, symmetry of
contour, ability to purse lips
Pinkish color of lips; symmetry
in contour
Normal
Buccal mucosa
Color, moisture, texture and
the presence of lesions
Inspection and palpation Moist, firm texture, glistening and
elastic texture
Buccal mucosa is moist Normal
Teeth `
Inspect for color, number and
condition and presence of
dentures
Inspection 32 adult teeth, smooth, shiny,
white tooth enamel
No presence of dental problems Normal
Gums
Color and condition Inspection No presence of lesions, no
retraction of gums, pink gums
No observable presence of
lesions; without retracted gums;
without bleeding gums
Normal
Tongue /floor of the mouth
Color and texture of the mouth
floor and frenulum
Inspection Pink color, slightly rough, thin
whitish coating, smooth lateral
margins, no lesions
Pinkish in color Normal
Position, color and texture,
movement and base of the
tongue
Inspection Central position, moves freely, no
tenderness
Tongue is in center; can moved
freely and without tenderness
Normal
Palates and uvula
Color, shape, texture and the
presence of bony prominences
Inspection Light pink, smooth, soft palate,
lighter pink hard palate, more
irregular texture
Palates are pink Normal
Position of the uvula and
mobility
Inspection Positioned in midline of soft
palate
In midline of soft palate Normal
Oropharynx and tonsils
Color and texture Inspection Pink and smooth posterior wall Pink posterior wall Normal
Size of the tonsils, color and
discharge
Inspection Pink and smooth, no discharge, of
normal size or not visible
No discharge; pink and smooth;
has normal size
Normal
Gag reflex Inspection Present Not examined Not examined
Neck and lymph nodes
Symmetry and visible mass of
the thyroid gland
Inspection Gland ascends during swallowing
but is not visible
No visible masses Normal
Presence of tenderness or
nodules in the lymph nodes
Palpation Not palpable No nodules or tenderness Normal
Placement of the trachea Palpation Central placement in midline of
neck; spaces are equal on both
sides
In midline of neck Normal
Smoothness and areas of
enlargement, masses or
nodules in the thyroid gland
Palpation
Asking the client to lower
the chin slightly
Lobes may not be palpable No areas of enlargement,
masses or nodules.
Normal
Skin
Inspect for color and
uniformity
Inspection Varies from light to deep brown,
ruddy pink to light pink, yellow
overtones to olive; generally
uniform except in areas exposed
to the sun, areas of lighter
pigmentation in dark-skinned
people
Brown in color Normal
Inspect for the presence of
edema.
Inspection and palpation No edema No presence of edema Normal
Inspect and palpate for skin
lesions according to location,
distribution, color,
configuration, size, shape,
type or structure.
Inspection and palpation Freckles, some birthmarks, some
flat and raised nevi; no abrasions
or other lesions
No observable lesions, freckles
and birthmarks
Normal
Observe and palpate skin
moisture.
Inspection and palpation Moisture in the skin folds and
axillae
Moist skin Normal
Palpate skin temperature. Palpation Uniform, within normal range Skin temperature is within
normal range
Normal
Note for skin turgor of the
client.
Inspection Skin springs back to previous
state; may be slower in elders
Skin turgor is good. Normal
Nails
Inspect fingernail shape to
determine its curvature and
angle
Inspection Convex curvature, angle of nail
plate about 1600
No signs of early clubbing. Normal
Inspect fingernail and toenail
texture
Inspection Smooth texture Skin is smooth Normal
Inspect fingernail and toenail
bed color
Inspection Highly vascular and pink in light
skinned clients; dark skinned
Pink in color Normal
clients may have brown or black
pigmentation in longitudinal
streaks
Inspect tissues surrounding
nails
Inspection Intact epidermis No presence of lesions Normal
Perform blanch test of
capillary refill
Inspection Prompt return of pink or usual
color
Skin return to its normal color Normal
Posterior Thorax
Shape, symmetry, and
compare the diameter of the
antero posterior thorax to
tranverse diameter.
Inspection Anteroposterior to transverse
diameter in ratio of 1:2, chest
symmetric
Symmetrically aligned Normal
Spinal alignment Observation Spine vertically aligned No observable signs of
osteoporosis and kyphosis
Normal
Breathing pattern Inspection Proper breathing pattern Can breathe properly Normal
Respiratory excursion Inspection Full and symmetric chest
expansion
Chest expands at the same time. Normal
Temperature, tenderness,
masses
Palpation Uniform temperature, no
tenderness, no masses
With uniform temperature; no
signs of tenderness or masses
Normal
Vocal fremitus Palpation Bilateral symmetry of vocal
fremitus, heard most clearly at the
apex of the lungs
Has good vocal fremitus Normal
Percuss the posterior thorax Percussion Percussion notes resonate, except
over scapula, lowest point of
resonance is at the diaphragm
Not examined Not examined
Auscultate the posterior thorax Auscultation Vesicular and bronchovesicular
breath sounds
Breath sounds are clear Normal
Anterior thorax
Breathing pattern Inspection Quiet, rhythmic, and effortless
respirations
No problems with regards to
respiration of the client.
Normal
Temperature, tenderness,
masses
Palpation Uniform temperature, no presence
of masses and tenderness
No observable presence of
masses
Normal
Respiratory excursion Inspection Full symmetric excursion; thumbs Has good respiratory excursion Normal
normally separate 3 to 5 cm
Vocal fremitus Inspection Same as posterior vocal fremitus;
Fremitus is normally decreased
over heart and breast tissue
Has good vocal fremitus Normal
Percuss the anterior thorax Percussion Percussion notes resonate down to
the sixth rib at the level of the
diaphragm but are flat over areas
of heavy muscle and bone, dull on
areas over the heart and the liver,
tympanic over the underlying
stomach
Not examined Not examined
Auscultation of the trachea Auscultation Bronchial and tubular breath
sounds
Breath sounds are clear Normal
Auscultate the anterior thorax Auscultation Bronchial and vesicular breath
sounds
Breath sounds are clear Normal
Abdomen Normal
Skin integrity Inspection Unblemished skin, uniform color,
stretch marks
Has an incision in the RLQ Deviation from Normal
Abdominal contour Inspection Flat, rounded(convex) or scaphoid
(concave)
Symmetrical Normal
Enlarges liver or spleen Palpation Liver and spleen must not be
palpated.
Without enlarge liver and spleen Normal
Symmetry of contour Inspection Symmetric contour Symmetrical Normal
Abdominal movements Inspection Symmetric movements caused by
respiration
Symmetrical movements Normal
Vascular pattern Inspection No visible vascular pattern Not visible Normal
Bowel sounds, vascular
sounds and peritoneal friction
rubs
Auscultation Audible bowel sounds, absence of
bruits, absence of friction rub
Not examined Not examined
Percuss abdominal quadrants Percussion Tympany over the stomach and
gas-filled bowels; dullness,
especially over the liver and
Not examined Not examined
spleen, or a full bladder
Light palpation of abdominal
quadrants
Palpation No tenderness; relaxed abdomen
with smooth, consistent tension
Felt pain during palpation Deviation from Normal
Musculoskeletal system Normal
Muscle size, compare the
muscles on one side of the
body (arm, thigh, calf) to the
same muscle on the other side
Inspection Equal on both sides of body Muscle size are equal all
throughout the body.
Normal
Muscle tonicity Inspection Has good muscle tonicity. Normal
Muscle strength Inspection Equal strength on each body side Has equal muscle strength. Normal
Bones
Normal
structure
Inspection No deformities No observable bone deformities Normal
Edema or
tenderness
Palpation No tenderness or swelling No observable presence of
tenderness or swelling
Normal
Diagnostic Procedures
TEST Actual Values Normal Values Analysis Interpretation Nursing Responsibility
HEMATOLOGY
DATE: 8-17-12 8-18-12
Hgb 122 g/L 141 g/L 120-151 g/L NORMAL  Monitor Vital Signs, intake and output.
 Observe standard precautions, and follow the
general guidelines. Positively identify the patient,
and label the appropriate tubes with the
corresponding patient demographics, date, and time
of collection.
 The specimen should be analyzed within 24 hr
when stored at room temperature or within 48 hr if
stored at refrigerated temperature.
 Remove the needle and apply direct pressure with
dry gauze to stop bleeding. Observe/assess
venipuncture site for bleeding or hematoma
formation and secure gauze with adhesive bandage.
 Promptly transport the specimen to the laboratory
for processing and analysis.
Hct 0.36 % 0.41 % 0.36-0.41 % NORMAL
Neutrophils 0.81 0.57 0.45-0.65 Within normal range on second test
Lymphocyte 0.19 0.43 17-48 NORMAL
Pus cells 3-5 hpf 0-2 hpf None Indication of inflammation or
infection
RBC 0-2 hpf 8-12 hpf Negative Indication of inflammation or
infection
Epithelial cells few rare Occasional / lpf Indication of inflammation or
infection
Amorphous
urates
few rare None Amorphous urates may cause urine
to appear more cloudy or hazy
Bacteria plenty rare None Indication of inflammation or
infection
URINALYSIS
Color yellow yellow Amber NORMAL  Instruct the patient to void directly into a clean, dry
container. Sterile, disposable containers are
recommended. Women should always have a clean-
catch specimen if a microscopic examination is ordered.
Feces,discharges, vaginal secretions and menstrual
blood will contaminate the urine specimen.
 Cover all specimens tightly, label properly and send
immediately to the laboratory.
 Observe standard precautions when handling urine
specimens.
Transparency turbid hazy Clear Purulent matter will make cloudy
{infection is present )
Reaction 6.0 5.0 4.6- 8.0 NORMAL
Specific Gravity 1.030 1.015 1.002-1.030 NORMAL
Sugar negative negative Negative NORMAL
Protein negative trace Negative Indication of inflammation or
infection
VI. PATIENT AND HIS CARE
A. IVF (Intravenous Fluid Therapy)
Medical
management
Date ordered/
Date
performed/
Date
changed/ DC
General Description Indication/ Purposes Client’s Response to the
Treatment
Nursing Responsibilities
D5O.3 NaCl
500cc x 60
ugtts/min
Date ordered:
August 20,
2012
 D5 0.3NaCl is a
hypertonic solution
owing to the higher than
normal amount of Na
and Cl ions. It pulls
fluid and electrolytes
from the intracellular
and interstitial
compartments into the
intravascular
compartments.
 To compensate
cellular
dehydration and
corrects
moderate fluid
loss, prevents
alkalosis,
provides calorie
and NaCl.
 The patient could
not verbalized
and distinguish
the possible side
effects of drugs
and manifestation
to her condition.
Before:
 Verify the doctor’s order indicating the
type of solution, the amount to be
administered, the rate of flow of the
infusion and any allergies.
 Explain the procedure and prepare the
client.
 Prepare the equipments needed.
 Wash hands thoroughly.
 Obtain IV solution and check for the
sediments and any crack or leak from
the container.
 Check also the expiration date.
 Check fluid discoloration or defect. If
noted, dispose the defected tubing and
get another.
 Assess client’s vital signs for baseline
data, skin turgor, bleeding tendencies,
disease, or injury to the extremities,
status of vein to determine the
appropriate puncture site.
During:
 Explain the importance and purpose
of IVF.
 Place the patient in a comfortable
position to facilitate easy insertion of
the IV line.
 Use the smallest gauge needle if
possible.
 Maintain aseptic technique
throughout the procedure.
 Follow proper procedures in infusing
IV solution.
 Watch out for fluid overload.
 Secure the needle properly after
insertions. Always check the needle
of the Iv, if it is in the vein:
 Bring the IV bottle lower
than the patient arm.
 Pinch the IV tubing.
 Observe the backflow of
the blood in the distal
portion
B. Drugs
Name of
Drug
Date Route of
Administration
dosage,frequen
cy
General activities,
Classification,
Mechanism of
actions
Purpose/
Indication
Client’s response/
Side effect
Nursing responsibilities
Cefuroxime August
20,
2012
Oral  Bind to the
bacterial cell
wall
membrane
causing cell
death.
 Bactericidal
action.
 Treatment
of serious
life
threatening
infection
due to
susceptible
organisms.
 The patient could
not verbalized
and distinguish
the possible side
effects of drugs
and manifestation
to her condition.
ASSESSMENT:
 Assess the infection, (vital signs, and appearance
of wood, sputum, urine, and stool, WBC at the
beginning and during the therapy.
 Observe patient signs and symptoms of
anaphylaxis (rash, pruritus, wheezing, edema)
 Assess the patient renal dysfunction.
IMPLEMENTATION
 IF it is tablets don not swallow whole not
crushed, because of bitter taste.
EVALUATION
 Resolution of signs and symptoms of infection
 Decreased in the incidence of infection
Tramadol August
20,
2012
IM  Binds to mu-
opioid receptors
and inhibits the
reuptake of
norepinephrine,
and serotonin,
that has
analgesics
effects,
Acetaminophen
blocks the
activity of
cyclooxygenase
, an enzyme
necessary for
prostaglandin
synthesis. And
prostaglandins
are important
mediators of
inflammatory
response that
causes local
vasodilation,
swelling and
pain.
 Relief of
moderate to
moderately
severe pain.
 The patient could
not verbalized
and distinguish
the possible side
effects of drugs
and manifestation
to her condition.
 Know the 10 Rights in drug administration.
 Get patient’s history of allergy to tramadol or
opioids.
 Inform the patrient about the side effects if
sweating or CNS effects.
 Watch for some allergic reactions especially after
receiving the medication including
bronchospasm
 Assess the respiratory status of the client
Ketorolac August
20,
2012
IV  Anti-
inflammatory
and analgesic
activity;
inhibits
prostaglandins
and leukotriene
synthesis
 Short-term
management
of pain
 The patient
could not
verbalized and
distinguish the
possible side
effects of drugs
and
manifestation to
her condition
 Know the 10 Rights in drug administration.
 Do not mix with morphine, sulfate, mepiridine
 Instruct patient about the side effects.
 History: renal impairment, impaired hearing,
allergies, hepatic, lactation, pregnancy
 Physical: skin color and lesions, orientation,
reflexes, peripheral sensation, clotting times,
CBC, adventitious sounds
 Be aware that patient may be at risk for CV
events, GI bleeding, renal toxicity, monitor
accordingly.
 Do not use during labor, delivery, or while
nursing.
 Keep emergency equipment readily available at
time of initial dose, in case of severe
hypersensitivity reaction.
 Protect drug vials from light.
Metronidazole August
20,
2012
IV  Disrupts DNA
and protein
synthesis in
susceptible
organisms.
 Bactericidal, or
amebicidal
action
 Amebicide in
the
management
of amebic
dysentery
 The patient could
not verbalized
and distinguish
the possible side
effects of drugs
and manifestation
to her condition
 Administer with food or milk to minimize GI
irritation.
 Tablets may be crushed for patients with
difficulty swallowing.
 Instruct patient to take medication exactly as
directed evenly spaced times between dose, even
if feeling better. Do not skip doses or double up
on missed doses. If a dose is missed, take as soon
as remembered if not almost time for next dose.
 May cause dizziness or light-headedness. Caution
patient or other activities requiring alertness until
response to medication is known.
 Inform patient that medication may cause an
unpleasant metallic taste.
 Inform patient that medication may cause urine to
turn dark.
 Advise patient to consult health care professional
if no improvement in a few days or if signs and
symptoms of superinfection (black furry
overgrowth on tongue; loose or foul-smelling
stools develop).
C. Diet
TYPE OF
DIET
DATE STATED,
DATE CHANGED
GENERAL
DESCRIPTION
INDICATIONS, PURPOSES SPECIFIC FOOD TAKEN CLIENT’S RESPONSE
TO THE DIET
NPO August 20, 2012 Restriction of solid nor
liquid foods by mouth
This is done to avoid paralytic
ileum that occurs from bowel
handling during surgery.
The patient complied with
the prescribed diet..
Clear Liquid
Diet
August 22, 2012 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. Patient with acute illness
and infections, to relieve thirst, to
reduce colonic fecal matter. It is
done between 1-2 feeding intervals.
Water She seemed to have loss of
appetite with the ordered diet
Soft Diet August 23-24, 2012 A diet that is soft in
texture, low in residue,
easily digested, and well
tolerated.
This is given for the patient who is
recovering from a surgery as the
bowel is waking up.
Porridge and water The patient still not have
good appetite with the
prescribed diet. , but then
gradually took in the foods
that were ordered by the
physician.
Type of exercise General description Indication/ purpose Client’s response to
activity or exercise
Nursing responsibilities
Post surgery Bed Exercises  Starting off with basic leg pumps
and lifts of the lower and upper
extremities
 Help improve blood flow
and circulation in the
lower portions of your
body. In addition,
performing bed exercises
can also help reduce the
risk of blood clots
forming in your lower
extremities.
 The clients has no
response
 Assess the client on how to
perform the proper way of
this type of exercise.
Short Walks
 You should begin your post-
appendicitis exercise regimen
with short walks. During these
walks, be aware of your walking
form and posture,
 Trying to keep additional
weight off of your
abdominal muscles. Stop
walking as soon as you
feel fatigued and do not
push yourself to exercise
for extended periods of
time.
 The clients has no
response
 Assess the client on how to
perform the proper way of
this type of exercise.
Passive Abdominal Exercise  Start by sitting down on the edge
of a bed with your feet hanging
off of the edge of the bed. With
your back straight and core
tightened, slowly lift up your legs
until they are parallel with the
floor. Hold this position for
several seconds before slowly
lowering your legs back to their
original position.
 Performing basic
abdominal exercise will
help return your
midsection to a stronger
place.
 The clients has no
response
 Assess the client on how to
perform the proper way of
this type of exercise.
D. Activity Exercise
VII. SURGICAL MANAGEMENT
BRIEF DESCRIPTION INDICATION/ PURPOSES CLIENT’S RESPONSE NURSING RESPONSIBILITIES
 Appendectomy is one of the most
commonly performed operations
with about 7% of the population
having that operation. It should be
an operation where every detail
has been examined in prospective
clinical trials but it is not. Of an
overwhelming number of scientific
reports on appendicitis (more than
5500 entries in the Medline) only a
few are about randomized trials.
We should have firm knowledge
about such things as antibiotic
treatment (initiation, route and
duration), wound management
(incision and closure) and excision
of the appendix (stump closure and
drains). It seems that much of the
surgical technique evolved from
- The main purpose of
appendectomy is to
remove the infected
appendix in order to
protect the patient‘s life.
When appendix got
infection, either it get pus
or sometimes it get
rupture before this
condition surgeon, after
diagnosing the patient
and reviewing his
medical reports, makes a
small surgery and they
will remove the
appendix. The main
symptom of this
appendix is severe pain
cause in lower abdomen
 The patient was asleep after the
operation.
 The patient was lying on bed 6-
8 hours after the surgery.
 The patient had chills few hours
after the operation.
 The patient had fever one day
after the operation.
Prior:
 Check vital signs.
 Instruct the patient to be on nothing per
Orem 8 hours prior to surgery
 Educate the patient about coughing,
deep breathing exercises and turn side to
side after the surgery.
 Let the patient to voice out what she
feels to decrease anxiety.
 Listen to the patient to what he says.
During:
 Promote sterility in the sterile field.
 Monitor the vital signs.
After:
 Keep the patient on NPO for 8 hours
after peristalsis occurs.
 Keep the patient lie flat on bed without
pillow for 6-8 hours.
 Monitor for bleeding and signs of
traditions and later knowledge has
been engaged in simplification.
For example, multiple drains with
or without continuous irrigation
are not used for perforated
appendicitis any longer but it must
have made sense at the time. Even
the single passive drain for a
periappendiceal abscess is thought
inappropriate by most surgeons
today. So, when speaking about
evidence here it must be viewed
against strong traditions that are
continuously changing regardless
of real scientific evidence. When
such evidence is available its
penetration is often slow. Further,
it must be accepted that the
underlying conditions have
changed so what seemed
reasonable at one time is no longer
appropriate. For instance, wounds
and patient feel vomiting
and last symptom is
fever which will continue
over a period of time.
shock.
 Monitor of signs for signs of infection.
used to be infected in the range of
30–50% in perforating
appendicitis. Infection is much less
frequent now for reasons that
patient care and surgical technique
are different.
VIII. Nursing Prioritization
DATE IDENTIFIED SUBJECTIVE CUES PROBLEM/NURSING
DIAGNOSIS
JUSTIFICATION
August 24, 2012 “Masakit dito sa baba”, while
pointing at RLQ of abdomen.
Acute pain related to presence of
surgical incision in RLQ
According to Maslow of hierarchy of needs physiological needs
must prioritize first. Acute pain is a physical health problem thus
belongs to physiological stage. Absence of pain may indicate that
the client’s health status is getting better.
August 24, 2012 “Hindi pa masyado magaling
ang sugat ko at saka masakit
siya.”
As verbalized by the client.
Impaired Skin Integrity related
to tissue trauma manifested by
appendectomy incision
The skin is considered as the primary defense of our body. Integrity
of our skin is vital to our physical and psychological health. Intact
and well healing wound has low risk of getting infection; because of
that impaired skin is the 2nd priority nursing diagnosis.
August 24, 2012 ”Yung nurse ang nag-linis ng
sugat, tinitignan nga ni lola.
Kasi hindi niya alam kung
paano linisin pag-nasa bahay
na kami.” As verbalized by
the client.
Risk for infection related to
insufficient knowledge regarding
proper wound care to avoid
exposure to pathogens.
To prevent complication for fast recovery we consider risk for
infection as 3rd priority problem.
August 24, 2012 “Medyo wala siyang gana
kumain” as verbalized by the
mother
Impaired nutrition less than body
requirements related to loss of
appetite.
Impaired nutrition was the 4th priority nursing problem. Because the
patient will not be able to commence food and fluids for a few days;
this is to enable the bowel to regain normal function. The pain feel
by the client added to reduce her appetite.
August 24, 2012 “Hindi ko po kayang umupo at
tumayo” asverbalized bythe client
Activity intolerance associated
with the limitation of motion
secondary to pain
The patient should be encouraged to get up and out of bed as soon as
possible to prevent the formation of emboli. We make it 5th because
by resolving the 1st problem it will also resolve or manage
IX. . Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective cues :
“Masakit dito sa
baba”, while pointing
at RLQ of abdomen.
Objective cues:
Vital sign taken as
follow:
BP: 120/80mmHg
RR: 20cpm
PR: 105 bpm
T: 36.5 C
S/P Appendectomy
 With dry intact
dressing on the
surgical site.
 facial grimacing
 Acute pain related
to presence of
surgical incision in
RLQ
Within 1 hour of nursing
intervention, the client will be
able to manifest ability to cope
within pain as evidenced by:
a.) verbalization of decrease
pain form 7/10 to 2/10
b.) engagement in diversion
of activities such as,
watching TV, and
listening mellow music
c.) Verbalize method that
provide pain reliving
 Taking pain
relieve medicines
 Avoiding
movement that
provide pressure
in the abdomen
 provided splinting
 Assess pain
characteristics
including
location,
intensity, and
frequency.
 Assess surgical
site for swelling,
redness or loose
sutures.


 Promote
adequate rest
periods by
temporarily
limiting activity
 Encourage client
to verbalize pain
perception.
 Elevation in
intensity and
frequency may
indicate worsening
condition.
 Swelling, redness
, and loose
sutures may
contribute to the
pain felt by client
and are indicative
of further
management
 To lessen pain
felt.
 To allow
continuous
monitoring and
assessment
of client’s
condition.
Within 1 hour of nursing
intervention, the client will be
able to manifest ability to cope
within completely relieved pain
as evidenced by
a.) verbalization of decrease
pain form 5/10 to 2/10
b.) engagement in
diversional activities
such as watching TV,
and listening mellow
music
c.) Verbalize method that
provide pain reliving
 Taking pain
relieve medicines
 Avoiding
movement that
provide pressure
in the abdomen
 provided splinting
 Provide client
with diversional
activities such as
socialization,
watching TV,
and listening
mellow music.
 Encourage SO’s
to continue
provision
of diversional
activities and a
quiet
environment.
 Administer
analgesics as
indicated.
 To help client
divert his
attention to other
matters than pain
felt.
 Refocuses
attention,
promotes
relaxation, and
may enhance
coping abilities.
 Relief of pain
facilitates
cooperation with
other therapeutic
interventions,
e.g., ambulation,
pulmonary toilet
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective cues :
“ Hindi pa masyado
magaling ang sugat ko at
masakit pa ”
As verbalized by the
client.
Objective cues :
S/P: Appendectomy
 With surgical
incision at right
lower abdominal
area
 With dry intact
dressing on the
surgical site
Impaired Skin Integrity
related to tissue trauma
manifested by
appendectomy incision
After 30 minutes of
nursing intervention the
patient will be able to
gain knowledge on how
to improve skin integrity
in ways such as:
a) keeping the
incision area
clean.
b) maintain optimal
nutrition that
deals in proper
wound healing.
c) Exercises to
provide good
blood circulation.
 Assess operative site
for redness, swelling,
loose sutures, or
soaked dressing.
 Encourage the client
on keeping the
incision clean
 Discuss with the
client proper wound
healing such as
 Food rich in
vit. E 
 Food rich in
protein.
 Assist in passive
movements (while
7hrs. flat on bed) such
as bed turning and
passive ROM exercise
and active exercise
there after movements
such as bed position,
sitting, standing, and
walking.
 To check skin
integrity, monitor
progress of healing
and identify need for
further
 To prevent infection.
 For fast recovery
 To promote
circulation to the
surgical site for
timely healing. For
early ambulation also

After 30 minutes of
nursing intervention the
patient is able to gain
knowledge on how to
improve skin integrity in
ways such as:
d) keeping the
incision area
clean.
e) maintain optimal
nutrition that
deals in proper
wound healing.
f) Exercises to
provide good
blood circulation.
Nursing Care Plan
 Support incision as in
splinting when
coughing and during
movement.
 Encourage pt to
verbalize his for any
untoward feelings
especially pain,
discomfort as well as
changes noted on
operative site.
 Instruct pt and SO’s to
immediately report
when dressing are
soaked.
 Instruct pt and SO’s to
refrain from
touching/scratching
operative site.
 To reduce pressure
on the operative site.
 To allow continuous
monitoring and
assessment of pt.
Condition.
.

 For immediate
replacement to
prevent skin break
down and
contamination
of operative site.
 To prevent or
reduced the risk of
cross contamination
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective cues:
Yung nurse ang nag-linis
ng sugat, tinitignan nga ni
lola. Kasi hindi niya alam
kung paano linisin pag-
nasa bahay na kami.” As
verbalized by the client.

Objective cues:
Vital sign taken as
follow:
BP: 120/80mmHg
RR: 20cpm
PR: 105 bpm
T: 36.5 C
S/P Appendectomy
 With dry intact
dressing on the
surgical site
Risk for infection
related to insufficient
knowledge regarding
proper wound care to
avoid exposure to
pathogens.
After 1 hour of nursing
intervention the
significant others will be
able to:
a) Provide the client
proper wound
care at home.
b) Determine signs
that indicate
infection and
complication.
Demonstrate and enumerate
to the significant other the
proper ways of wound care
such as
 Assess operative site for
signs of infection.
 Provide regular dressing
care.
 Instruct pt and SO’s to
refrain from
touching/scratching
operative site.
 Encourage pt to
verbalized any changes
noted on operative site such
as redness, swelling and
unusual/odorous drainage.
 Stress proper hand
washing techniques by
 Identify need for further
management.
 To prevent unnecessary
exposure and
contamination of
operative site which
may delay wound
healing.
 To prevent bacteria
harbor in operative site.
 to allow continuous
monitoring and
assessment of pt.
condition
 A first-liner defense
against nosocomial
After 1 hour of nursing
intervention the significant
others will be able to:
a.) Provide the client
proper wound care
at home.
b.) Determine signs
that indicate
infection and
complication.
all caregivers between
therapies/ clients.
 Clean the incisions site
daily
withpovidoneiodine or
other appropriate
solution.
 Instruct client/ SO(s) in
techniques to protect
the integrity of the skin,
care for lesions, and
prevention of spread of
infection.
infection/cross-
contamination.
 To prevent
contamination.
 To promote wellness
X. Discharge Planning
Medication
Advice the patient to continue the prescribed medication to obtain her total recovery such as antibiotics and analgesics.
Exercise
Within 12 hours of surgery the client may get up and move around. The client can usually return to normal activities in 2-3 weeks after laparoscopic surgery
Environment
Provide client a well-ventilated and relaxing environment to provide comfortable environment while recovering.
Treatment
Pretreatment of foods with lactase preparations (e.g. lactacid drops) before ingestion can reduce symptoms. Ingestion of lactase enzyme tablets with the first bite of
food can reduce symptoms.
Health Teaching
To care wound perform dressing changes and irrigations as prescribe avoid taking laxative or applying heat to abdomen when abdominal pain of unknown cause is
experienced. Reinforce need for follow-up appointment with the surgeon. Call your physician for increased pain at the incision site
Out Patient
Document bowel sounds and the passing of flatus or bowel movements (these are signs of the return of peristalsis) Watch for surgical complications such as
continuing pain or fever, which indicate an abscess or wound dehiscence .Stitches removed between fifth and seventh day (usually in physicians office)
Diet
Liquid or soft diet until the infection subsides. Soft diet is low in fiber and easily breaks down in the gastrointestinal tract
XI. Conclusion
In this study, the clinical and nursing procedures performed at the Bulacan Medical Center on August 24 ,2012 were described in detail. Case studies were also
presented to exemplify these procedures and see how every case is unique in this way, appendicitis and appendectomy were fully explored by using methods of participant
observation, informal interviews, research of the nature of disease and other information about the patient health condition. Although, this is a thorough examination of
appendectomy and appendicitis, this study could not possibly capture our experiences in the surgical ward. The most significant lesson we learned throughout the study was
the ambiguity of diagnosis and nursing care. The results of our study with interpretations made with secondary sources reveals that a better and assessment action in the
hospital.
Can take to better diagnosis of appendicitis patients, construct an effective procedure for assessment, diagnosis, and nursing intervention, and health teaching before and
after the surgery, however these things may aid in improving the rate of negative appendectomies and improving post surgical care.
This only leaves one very important lesson nurses and patients must realize, that each case must be taken as its own. An assembly line approach to diagnosing and treating
appendicitis is not the solution: no appendicitis presents itself in the same way.
Bibliography:
Books:
 Sparks and Taylor’s Nursing Diagnosis, Reference Manual 6th edition, 2005
 Tomey,AnnMarriner ,Nursing Theorists and their Work: 6th Edition, 2002
 Kozier&Erb’s, Fundamentals of Nursing., 8th edition.
 Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 10th Edition
Internet:
 www.medicinenet.com/appendicitis/article.htm
 digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/
 http://nurseslabs.com/4-appendectomy-nursing-care-plans/

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143921866 case-study-bmc-surgical-ward

  • 1. College of Nursing City of Malolos, Bulacan A Case Presentation of an 11- year old client with Acute Appendicitis Submitted by: Reyes, Jenefer L. Reyes, Phoebegail Shayne E. Roque, Sarah Mae V. Sacdalan, Hazel Joy C. Salvador, Mary Grace S.D. Santos, DanpaulH. Homework Help https://www.homeworkping.com/ Research Paper help https://www.homeworkping.com/ Online Tutoring https://www.homeworkping.com/ click here for freelancing tutoring sites Bulacan State University
  • 2. Taganas, Mary Lyann M. Tamayo, Camille F. Tan, Elaine Joy D. Usi,George Anthony P. BSN III-B, Group 4 Submitted to: 3nd level Clinical Instructors I.Introduction Patient CMG is 11 year old who was admitted at the surgery Department last August 20, 2012due to severe pain at her right lower quadrant, the patient was diagnosed with acute appendicitis and underwent appendectomy last August 22, 2012. Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to peritonitis and shock. Appendectomy, removal of the appendix, is the standard treatment for acute appendicitis, it is important to immediately remove the appendix after the diagnoses to prevent the occurrence of the life-threatening complication of appendix. The most frequent complication of appendicitis is perforation. Perforation of the appendix can lead to periappendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection of the entire lining of the abdomen and the pelvis) the major reason for appediceal perforation is delay in diagnosis and treatment is general the longer the delay between diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours after the onset of symptoms is at least 15% therefore, once appendicitis is diagnosed, surgery should be done without unnecessary delay.
  • 3. Objective General Objective  To be able to acquire knowledge and skills on how to deal with patient who has diagnosis of acute appendicitis Specific Objectives  Client based: - To obtain necessary information regarding the patient and her condition - To assess the patients overall health status - To identify patient health care needs through analysis of all the data gathered.
  • 4. - To assist the patient throughout rehabilitation, recovery and discharge - To impart necessary health teachings to the patient - To perform appropriate nursing care in conjunction w/ the condition of the patient  Student based: - To widen and enhance the student nurse’s knowledge and skills through additional research about the nature of the disease, its pathophysiology and treatment. - To discuss and interpret the diagnostic results and compared to the normal values and relate them to the disease process. II. Nursing Assessment A. Personal History Demographic Data of the Patient  Name: CMG  Age: 11 years old  Gender: Female  Address: Lawa, Meycauyan, Bulacan  Birthday: May 15, 2001  Religion: Roman Catholic  Nationality: Filipino  Dialect Spoken: Tagalog
  • 5.  Attending Physician: Dra. Maria Glenda D. Zilmar  Surgeon: Dr. Teoxon  Assistant surgeon: Dr. Lustre  Date and time of admission: August 20, 2012 at 4:24 pm  Date of surgery: August 22, 2012 B. CHIEF COMPLAINT Pain at the right lower quadrant C. History of Present Illness She was admitted in the hospital last August 20, 2012 at 4:24 pm at Bulacan Medical Center due to pain at the right lower quadrant. D. HISTORY OF THE PAST ILLNESS According to the client’s mother, the client was hospitalized for 10 days when she was 5 years old because of Kawasaki disease. E. Family Health History Her mother has a history of UTI (Urinary Tract Infection), her grandmother has diabetes and her grandfather died because of heart attack or cardiac arrest.
  • 6. Genogram RM PM FG AG VG 68 70 71 67 40 RLMM 4247 DG NG 45 384O47 AG SG
  • 7. F. Functional Health Pattern Health Perception/Health Management Pattern PRIOR DURING When the client was asked to describe her previous health the client verbalized, “Okay lang naman po yung health ko dati, pero nung sumakit yung tyan ko, minsan nagsuka ko saka nilagnat din.” She experienced colds thrice last year. She eats fruits everyday to make her strong and healthy. She takes her vitamins every day. “Madalas nga siya kumain ng mga junkfood kaya nung sumakit na yung tiyan nya saka lang namin nalaman na may sakit na siya”, as verbalized by her grandmother. When I asked the client what she feels during the interview, she verbalized “Nanghihina pa po ako pero po tinutulungan ako ni lola at hindi naman po ako nilalagnat ngayon.”about her surgical incision hygiene, the client verbalized” Yung nurse ang nag-linis ng sugat ko, tinitignan nga ni lolakasi hindi din nga alam kung paano linisin pagnasa bahay na kami.” Nutritional and Metabolic Pattern 11 LEGEND: Female Patient Male Deceased Cardiac Arrest Diabetes CMG
  • 8. PRIOR DURING When it comes to her daily food intake, the client verbalized, “Halos po lahat naman kinakain ko.” When we ask her to rank her appetite with 10 as the highest score, she answered 10. According to our client she has vegetable in her daily meal. According to our client, sometimes she eats junk foods and soft drinks as her snacks. Her wound heals well and doesn’t have dental problems and eating discomfort. Frequency Meat 2-3 times a week Fish 4 times a week Frozen food 6-7 times a week She doesn’t eat any food since she was admitted to the hospital and after the surgery she took general liquid diet. The client has poor appetite as verbalized by her grandmother, “Medyo wala siyang gana kumain”. (We don’t have the chance to weight the patient because of the decrease mobility of the patient.) Elimination Pattern PRIOR DURING “Hindi naman ako hirap sa pag ihi at pagtae dati, pero nung nagsimula na sumakit tyan ko, nahirapan na ako.” as verbalized by the client. She doesn’t perspire excessively and she doesn’t have odor problems. Output Frequency ( per day) Amount Characteristics Urine Stool 5-6 irregular 500mL ----- Light yellow Brownish in color; without blood She experience difficulties upon urination because she felt the pain in her lower abdomen and she hasn’t been defecating since after the surgery. Her mother changes her diaper 3 times a day. Output Frequency Amount Characteristics Urine Stool 3 ----- 500mL ----- Light yellow color -----
  • 9. Sleep-Rest Pattern PRIOR DURING The client verbalized “mga 9 hours ako nakakatulog sa gabi, matutulog ako ng 8 ng gabi tapos gigising ako ng 5 ng umaga. She has no problem in sleeping.She takes a nap every afternoon and watching T.V is her form of leisure and relaxation. During hospitalization, she has no definite time of sleeping. “Minsan, paidlip idlip lang po ng mga 30mins,” as verbalized by the client. Activity Exercise Pattern PRIOR DURING
  • 10. The patient does some ofthe household chores. It also serves asher exercise. Her leisure time would include watching television, computer gaming and sleeping. _0_feeding _0_dressing _0_bathing _0_grooming _0_toileting _0_bed mobility _0_cooking _0_home _0_shopping _0_general mobility maintenance Level 0- full self-care Level I- requires use of equipment/device Level II- requires assistance or supervision from another person “Hindi kopokayangumupo at tumayo, lalo na kung akolang mag’isa”, as verbalized bythe client. The client experience 7out of10pain scales. _0_feeding _II_dressing _II_bathing _II_ grooming _II_toileting _II_bed mobility _II_general mobility Level 0- full self-care Level I- requires use of equipment/device Level II- requires assistance or supervision from another person Sexuality-Reproductive Pattern PRIOR DURING The client is only 11 years old and doesn’t have menstruation yet. The client is only 11 years old and doesn’t have menstruation yet. Cognitive Pattern
  • 11. PRIOR DURING According to our client she doesn’t have vision and hearing problems. Madali naman po ako makasaulo lalo na po sa school”, as verbalized by the client. While doing the interview, we observed that our client has a little problem in hearing because sometimes we need to repeat the question to her but she can still understand and answer appropriately. Self-Perception-Self-Concept Pattern PRIOR DURING “Ok lang naman po ako bago ako magkasakit”, as verbalized by the client when she described herself prior to hospitalization. She was able to get along with her sibling and attend her class to school. According to her she thinks she lostsome weight. “Masakit po dito sa baba, hindi pa rin po kasi masyadong magaling ang sugat ko at sakamasakitsiya”, as verbalized by the client while pointing at the right lower quadrant of her abdomen. Role-Relationship Pattern PRIOR DURING The patient is living with her grandmother.According to her, she always tells her problem to her grandmother. She is a choir member in their church. She didn’t feel being outcast with the other family member and in their barangay. “Palakaibigan siya at malalahanin sa akin.” as verbalized by her grandmother as we asked how is CMG as a grandchild. Her grandmother is the one who takes care of her during her hospitalization. Coping Stress Tolerance Pattern
  • 12. PRIOR DURING According to our client whenever she is stressed, she watch movies, plays computer gamesand sleep as well. During hospitalization, the most stressful situation for her is her illness and the pain she feels. Value-Belief Pattern PRIOR DURING According to the client, her family is the most important people to her because it gives her strength and makes her happy.She always attends the mass once a week to increase her faith with God. During hospitalization as verbalized by the client, “Ang lola ko po ang nag- papalakas sa akin ngayon”. She is always praying to improve her health. III. A. Growth and Development
  • 13. THEORY PSYCHOSOCIAL COGNITIVE PSYCHOSEXUAL MORAL STAGE Industry vs. Inferiority (Erik Erikson) Concrete Operation (Jean Piaget) Latency Stage (Sigmund Freud) Conventional Morality (Social Conformity Orientation) (Lawrence Kohlberg) DEFINITION  Children need to cope with new social and academic demands. Success leads to a sense of competence, while failure results in feelings of inferiority.  During the concrete operation stage, children can perform a number of logical- mental operations.  These mental operations include the ability to classify objects according to some dimensions, such as height or length, and the ability to figure out relationships between objects such as larger or smaller.  When the child represses sexual thoughts and engages in non-sexual activities, such as developing social and intellectual skills.  By adolescence, most individuals have developed to this stage. There is a sense of what "good boys" and "nice girls" do and the emphasis is on living up to social expectations and norms because of how they impact day-to- day relationships.
  • 14. THEORY THEORIST DESCRIPTION APPLICATION OF NURSING PRACTICE IN THE CARE OF CLIENT Nightingale's Environmental Theory Florence Nightingale (1820- 1910)  Major Concepts and Definitions Environment - concepts of ventilation, warmth, light, diet, cleanliness and noise. She focus o the physical aspect of environment.  She believed that "Healthy surroundings were necessary for proper nursing care."  5 essential components of healthy environment: 1. pure air 2. pure water 3. efficient drainage 4. cleanliness 5. Light  Providing a non –stimulating environment is essential especially for our patient in a way that it promotes faster recovery on her through minimizing external and stressful stimuli such as providing proper ventilation and clean environment. It is not only for promoting fast recovery but also a preventive for possible complications such as infection. B. Theoretical Application
  • 15. Twenty –one nursing problem Faye –Glenn Abdellah  Nursing is broadly grouped into 21 problem areas to guide care and promote the use of nursing judgement.  We must know the 21 nursing problem to provide a rationale for collecting reliable and valid data about the health status of clients, which are essential for effective decision making and implementation. We should facilitate the maintenance of a supply of oxygen to all body cells, nutrition of all body cells, fluid and electrolyte balance, elimination, maintain good body mechanics and prevent and correct deformities, good hygiene and physical comfort, promote optimal activity: exercise, rest and sleep and to facilitate the maintenance of regulatory mechanisms and functions.
  • 16. Maslow's hierarchy of needs Abraham H. Maslow (1908- 1970)  Maslow's hierarchy explains human behavior in terms of basic requirements for survival and growth. These requirements, or needs, are arranged according to their importance for survival and their power to motivate the individual. The most basic physical requirements, such as food, water, or oxygen, constitute the lowest level of the need hierarchy. These needs must be satisfied before other, higher needs become important to individuals. Needs at the higher levels of the hierarchy are less oriented towards physical survival and more toward psychological well- being and growth. These needs have less power to motivate persons, and they are more influenced by formal education and life experiences. The resulting hierarchy of needs is often depicted as a pyramid, with physical survival needs located at the base of the pyramid and needs for self-actualization located at the top.  Maslow theory provides a guide lines in the prioritization of patient care needs in our case study. .
  • 17. IV. ANATOMY AND PHYSIOLOGY of DIGESTIVE SYSTEM The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to excrete waste. Most of the digestive organs (like the stomach and intestines) are tube-like and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals. The Digestive Process: The start of the process - the mouth: The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches into smaller molecules). On the way to the stomach: the esophagus: After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave- like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're upside-down.
  • 18. In the stomach The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme. In the small intestine After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food. In the large intestine After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in the digestion process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon. The end of the process Solid waste is then stored in the rectum until it is excreted via the anus. Parts of digestive system and its functions  digestive system - (also called the gastrointestinal tract or GI tract) the system of the body that processes food and gets rid of waste.  abdomen - the part of the body that contains the digestive organs. In human beings, this is between the diaphragm and the pelvis
  • 19.  alimentary canal - the passage through which food passes, including the mouth, esophagus, stomach, intestines, and anus.  anus - the opening at the end of the digestive system from which feces (waste) exits the body.  appendix - a small sac located on the cecum.  ascending colon - the part of the large intestine that run upwards; it is located after the cecum.  cecum - the first part of the large intestine; the appendix is connected to the cecum.  descending colon - the part of the large intestine that run downwards after the transverse colon and before the sigmoid colon.  duodenum - the first part of the small intestine; it is C-shaped and runs from the stomach to the jejunum.  epiglottis - the flap at the back of the tongue that keeps chewed food from going down the windpipe to the lungs. When you swallow, the epiglottis automatically closes. When you breathe, the epiglottis opens so that air can go in and out of the windpipe.  esophagus - the long tube between the mouth and the stomach. It uses rhythmic muscle movements (called peristalsis) to force food from the throat into the stomach.  gall bladder - a small, sac-like organ located by the duodenum. It stores and releases bile (a digestive chemical which is produced in the liver) into the small intestine.  gastrointestinal tract - (also called the GI tract or digestive system) the system of the body that processes food and gets rid of waste.  ileum - the last part of the small intestine before the large intestine begins.  intestines - the part of the alimentary canal located between the stomach and the anus.  jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum and the ileum.  liver - a large organ located above and in front of the stomach. It filters toxins from the blood, and makes bile (which breaks down fats) and some blood proteins.  mouth - the first part of the digestive system, where food enters the body. Chewing and salivary enzymes in the mouth are the beginning of the digestive process (breaking down the food).  pancreas - an enzyme-producing gland located below the stomach and above the intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats and proteins in the small intestine.
  • 20.  rectum - the lower part of the large intestine, where feces are stored before they are excreted.  salivary glands - glands located in the mouth that produce saliva. Saliva contains enzymes that break down carbohydrates (starch) into smaller molecules.  sigmoid colon - the part of the large intestine between the descending colon and the rectum.  stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical and mechanical digestion takes place in the stomach. When food enters the stomach, it is churned in a bath of acids and enzymes.  transverse colon - the part of the large intestine that runs horizontally across the abdomen  peristalsis - rhythmic muscle movements that force food in the esophagus from the throat into the stomach. Peristalsis is involuntary - you cannot control it. It is also what allows you to eat and drink while upside-down.  bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and secreted into the small intestine.  chyme - food in the stomach that is partly digested and mixed with stomach acids. Chyme goes on to the small intestine for further digestion.
  • 21. Risk Factors (modifiable)  Diet  Daily lifestyle  Low fiber diet Risk Factors (Non modifiable)  Age THE PATIENT AND HER ILLNESS A. PATHOPHYSIOLOGY 1. Schematic Diagram Low fiber diet and Episodes of constipation Occlusion of Appendix by Fecalith Decreased flow/drainage of mucosal secretions Increased ILP in the appendix Vasocongestion Decreased blood supply in the appendix Decreased O2 supply in the appendix Appendix starts to be necrotic; Bacteria invade the appendix Appendix starts to be necrotic; Bacteria invade the appendix Appendix starts to be necrotic; Bacteria invade the appendix Disruption of Cell Membrane of Appendix
  • 22. Start of Inflammatory Process Neutrophils to area Leukotrienes, Bradykinin Histamine, Prostaglandin Swelling of Appendix Prostaglandin, Bradykinin Pain in the RLQ of Abdomen Acute Pain Interleukin-1 Release of Chemical Mediators Activation of the Vomiting Stimulation of Vagus Nerve Suppression of sympathetic GI functions Anorexia Risk for Deficient of fluid volume Nausea and Vomiting Risk for Imbalanced Nutrition Neutrophils to area Pus Formation phagocytized bacteria and dead cells Risk for Infection (if appendix ruptures) Increased WBC Inflammation of Appendix (Appendicitis)
  • 23. Open wound Inflammation of Appendix (Appendicitis) Disruption of Cell Membrane Nociceptors on the dermis Impaired Tissue Integrity Tissue trauma Appendectomy Send impulses to CNS Pain on surgical site Release of Prostaglandin Bradykinin Start of Inflammatory process Activity intolerance Risk for infection
  • 24. 2. Definition of the disease APPENDICITIS Appendicitis is an irritation, inflammation, and infection of the appendix (a narrow, hollow tube that branches off the large intestine). The appendix functions as a part of the immune system during the first few years of life. After this time period, the appendix stops functioning and other organs continue helping fight infection. Although the appendix does not seem to serve any purpose, it can become infected and, if untreated, can burst, causing more infection and even death. 3. Predisposing factors  Ages of 10 and 30 years.  Having a family history of appendicitis may  Gender, especially in males, and  Having cystic fibrosis also seems to put a child at higher risk. 4. Signs and symptoms The following are the most common symptoms of appendicitis. However, each individual may experience symptoms differently. Symptoms may include: >Pain in the abdomen which: o May start in the area around the belly button, and move over to the lower right-hand side of the abdomen, but may also start in the lower right-hand side of the abdomen. o Usually increases in severity as time passes. o May be worse with moving, taking deep breaths, being touched, and coughing or sneezing. o May spread throughout the abdomen if the appendix ruptures. >Nausea and vomitingDiarrhea >Inability to pass gas >Abdominal swelling >Loss of appetite >Fever and chills >Constipation
  • 25. AREA OF ASSESSMENT ASSESSMENT TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS REMARKS General Survey Describe body built Inspection Arm span equals to height, crown to pubis equal to length from pubis to sole Height and weight are proportional. Normal Observe height and weight in relation to client’s age Inspection Proportionate, varies with lifestyle The client loss some weight due to her poor appetite. Deviation from normal Posture and gait Observation Relaxed, erect posture; coordinated movement Unable to assess the clients posture and gait due to her decrease mobility Not examined Describe over all hygiene and grooming in relation to the person’s activities prior to the assessment. Inspection Clean, neat Hair properly done; with clean clothes Normal Note for body and breathe odor in relation to the person’s activities prior to the assessment. Inspection No body odor or minor body odor relative to work or exercise; no breath odor No body odor and no breath odor Normal Mental state Identify signs of distress Observation No distress noted Client is bending over because of abdominal pain. Deviation from normal Note obvious sign of health or illness Observation Healthy appearance Sometimes she is frowning maybe because of incisional pain. Deviation from Normal Assess clients attitude Observation Cooperative, able to follow instructions Answers in our questions are appropriate; cooperative Normal Describe clients affect or mood Observation Appropriate to situation Client’s mood and affect is appropriate to situation. Normal Assess appropriateness of clients responses Observation Appropriate to situation Answers of our client in our questions are appropriate. Normal Describe quantity of speech (amount and pace), quality Observation Understandable, moderate pace; clear tone and inflection; exhibits Speech is loud with a clear diction. Normal V. Physical Examination
  • 26. (loudness, clarity, inflection) and organization (coherence of thought, over generalization, thought association Listen for the relevance and organization of thoughts. Observation Logical sequence; makes sense; has sense of reality Client’s answer has sense of reality. Normal Hair Inspect the evenness of growth over the scalp Inspection Evenly distributed hair No presence of alopecia Normal Inspect hair thickness or thinness Inspection Thick hair With thick hair. Normal Inspect hair texture and oiliness Inspection Silky, resilient hair Slightly dull hair because client hasn’ttaken a bath since admitted to hospital. Deviation from Normal Note presence of infections or infestations Inspection No infection or infestation No observable signs of infection or any infestations. Normal Inspect amount of body hair Inspection Variable Variable; hair is evenly distributed all over the client’s body. Normal Skull Inspect the skull for size, shaped and symmetry Inspection Rounded, smooth skull contour Normocephalic and symmetric Normal Palpate the skull for nodules or masses and depressions Palpation Smooth, uniform consistency; absence of nodules or masses No palpable nodules, lumps and masses. Normal Face Facial features Inspection Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds Facial features are symmetric. Normal Symmetry of the facial movements Inspection Symmetric facial movements Eyebrows elevate at the same time; eyes blink and closed at the same time Normal
  • 27. Eyebrows and eyelashes Evenness of distribution, direction of curl and movement Inspection Evenly distributed, eyebrows symmetrically aligned; curled slightly upward Eyebrows raise and lower at the same time; symmetrically aligned; both eyebrows curled slightly upward Normal Eyelids Surface characteristics and ability to blink Inspection Skin intact, no discharge, no discoloration; Lids closed symmetrically Eyelids skin are intact; no discharge and discoloration; eyelids blink symmetrically Normal Conjunctiva Inspect the bulbar conjunctiva for color, texture and the presence of lesions Inspection Transparent Bulbar conjunctiva are transparent; no presence of lesions; with evident capillaries Normal Inspect the palpebral conjunctiva for color, texture and the presence of lesions Inspection Shiny, smooth and pink or red Palpebral conjunctiva is shiny; pinkish in color Normal Sclera Color and clarity Inspection Sclera appears white Sclera is white and clear Normal Cornea Color and clarity Inspection Transparent, shiny and smooth Cornea’s surface is smooth transparent and shiny Normal Iris Shape and color Inspection Round Round, black in color Normal Pupils Color, shaped and symmetry of size Inspection Black in color, equal in size Pupil is round black in color and equal Normal Pupil light reaction and accommodation Inspection Asking the client to look first at a distant object and then at a distant object behind the penlight Pupils constricts when looking at near objects; pupils dilate when looking at far object; pupil converge when near object is moved towards nose Pupils are equally rounded. Normal
  • 28. Pupils direct and consensual reaction to light Inspection Asking the client to look straight ahead, by using the penlight and approaching from the side, shining a light on the pupil Illuminated pupil constricts (direct response) Non illuminated pupil constricts (consensual response) Pupil constricts Normal Visual acuity Test near vision Asking the client to read the newspaper held at a distance of 36 cm Able to read newsprint No difficulty reading newsprint Normal Test distance vision Inspection 20/20 vision on Snellen–type chart Not examined Not examined Lacrimal gland, lacrimal sac and nasolacrimal duct Presence of edema Inspection and palpation No edema or tenderness There are no presence of tenderness and edema. Normal Extraocular muscles Test each eye for alignment and coordination Inspection Both eyes coordinated, move in unison with parallel alignment Both eyes are coordinated with parallel alignment Normal Visual fields Test for peripheral visual fields Inspection noted When looking straight ahead, client can see objects in periphery Client can see object using peripheral vision Normal Ear auricle Color and symmetry of size and position Inspection Color same as facial skin, symmetrical, auricle aligned with outer canthus of the eye, about 10° from vertical. Both ear auricle has the same color with the skin Normal Texture, elasticity and areas of tenderness Palpation Mobile, firm, and not tender; pinna recoils after it is folded There are no areas of tenderness; no nodules or lump Normal External ear canal Cerumen, skin lesions, pus and blood Inspection Dry cerumen, grayish-tan color; or sticky, wet cerumen in various shades of brown Dry cerumen; no skin lesions, pus and blood Normal
  • 29. Hearing acuity test Clients response to normal voice tones Inspection Normal voices tones audible Has difficulty in hearing Deviation from Normal Perform watch tick test Inspection Able to hear ticking in both ears Not examined Not examined Nose Shape, size or color and flaring or discharge from the nares Inspection Symmetric and straight, uniform color, no discharge or flaring Symmetric uniform in skin color; no presence of discharge or flaring. Normal Presence of redness, swelling, growths and discharge of nares, using the flashlight Inspection Mucosa pink, clear, watery discharge, no lesions Mucosa is pinkish; no lesions Normal Position of nasal septum Inspection Nasal septum intact and in midline Nasal septum in midline Normal Test patency of both nasal spectrum Inspection Air moves freely as the client breath through the nares Client can breath freely using nasal nares. Normal Tenderness, masses and displacement of bone and cartilage Palpation No tenderness, masses and displacement of bone and cartilage No presence of tenderness, masses and displacement of bone and cartilage Normal Sinuses Presence of tenderness Palpation Not tender Sinuses are not tender. Normal Lips Symmetry of contour, color and texture Inspection Uniform pink color, soft moist, smooth texture, symmetry of contour, ability to purse lips Pinkish color of lips; symmetry in contour Normal Buccal mucosa Color, moisture, texture and the presence of lesions Inspection and palpation Moist, firm texture, glistening and elastic texture Buccal mucosa is moist Normal Teeth ` Inspect for color, number and condition and presence of dentures Inspection 32 adult teeth, smooth, shiny, white tooth enamel No presence of dental problems Normal
  • 30. Gums Color and condition Inspection No presence of lesions, no retraction of gums, pink gums No observable presence of lesions; without retracted gums; without bleeding gums Normal Tongue /floor of the mouth Color and texture of the mouth floor and frenulum Inspection Pink color, slightly rough, thin whitish coating, smooth lateral margins, no lesions Pinkish in color Normal Position, color and texture, movement and base of the tongue Inspection Central position, moves freely, no tenderness Tongue is in center; can moved freely and without tenderness Normal Palates and uvula Color, shape, texture and the presence of bony prominences Inspection Light pink, smooth, soft palate, lighter pink hard palate, more irregular texture Palates are pink Normal Position of the uvula and mobility Inspection Positioned in midline of soft palate In midline of soft palate Normal Oropharynx and tonsils Color and texture Inspection Pink and smooth posterior wall Pink posterior wall Normal Size of the tonsils, color and discharge Inspection Pink and smooth, no discharge, of normal size or not visible No discharge; pink and smooth; has normal size Normal Gag reflex Inspection Present Not examined Not examined Neck and lymph nodes Symmetry and visible mass of the thyroid gland Inspection Gland ascends during swallowing but is not visible No visible masses Normal Presence of tenderness or nodules in the lymph nodes Palpation Not palpable No nodules or tenderness Normal Placement of the trachea Palpation Central placement in midline of neck; spaces are equal on both sides In midline of neck Normal
  • 31. Smoothness and areas of enlargement, masses or nodules in the thyroid gland Palpation Asking the client to lower the chin slightly Lobes may not be palpable No areas of enlargement, masses or nodules. Normal Skin Inspect for color and uniformity Inspection Varies from light to deep brown, ruddy pink to light pink, yellow overtones to olive; generally uniform except in areas exposed to the sun, areas of lighter pigmentation in dark-skinned people Brown in color Normal Inspect for the presence of edema. Inspection and palpation No edema No presence of edema Normal Inspect and palpate for skin lesions according to location, distribution, color, configuration, size, shape, type or structure. Inspection and palpation Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions No observable lesions, freckles and birthmarks Normal Observe and palpate skin moisture. Inspection and palpation Moisture in the skin folds and axillae Moist skin Normal Palpate skin temperature. Palpation Uniform, within normal range Skin temperature is within normal range Normal Note for skin turgor of the client. Inspection Skin springs back to previous state; may be slower in elders Skin turgor is good. Normal Nails Inspect fingernail shape to determine its curvature and angle Inspection Convex curvature, angle of nail plate about 1600 No signs of early clubbing. Normal Inspect fingernail and toenail texture Inspection Smooth texture Skin is smooth Normal Inspect fingernail and toenail bed color Inspection Highly vascular and pink in light skinned clients; dark skinned Pink in color Normal
  • 32. clients may have brown or black pigmentation in longitudinal streaks Inspect tissues surrounding nails Inspection Intact epidermis No presence of lesions Normal Perform blanch test of capillary refill Inspection Prompt return of pink or usual color Skin return to its normal color Normal Posterior Thorax Shape, symmetry, and compare the diameter of the antero posterior thorax to tranverse diameter. Inspection Anteroposterior to transverse diameter in ratio of 1:2, chest symmetric Symmetrically aligned Normal Spinal alignment Observation Spine vertically aligned No observable signs of osteoporosis and kyphosis Normal Breathing pattern Inspection Proper breathing pattern Can breathe properly Normal Respiratory excursion Inspection Full and symmetric chest expansion Chest expands at the same time. Normal Temperature, tenderness, masses Palpation Uniform temperature, no tenderness, no masses With uniform temperature; no signs of tenderness or masses Normal Vocal fremitus Palpation Bilateral symmetry of vocal fremitus, heard most clearly at the apex of the lungs Has good vocal fremitus Normal Percuss the posterior thorax Percussion Percussion notes resonate, except over scapula, lowest point of resonance is at the diaphragm Not examined Not examined Auscultate the posterior thorax Auscultation Vesicular and bronchovesicular breath sounds Breath sounds are clear Normal Anterior thorax Breathing pattern Inspection Quiet, rhythmic, and effortless respirations No problems with regards to respiration of the client. Normal Temperature, tenderness, masses Palpation Uniform temperature, no presence of masses and tenderness No observable presence of masses Normal Respiratory excursion Inspection Full symmetric excursion; thumbs Has good respiratory excursion Normal
  • 33. normally separate 3 to 5 cm Vocal fremitus Inspection Same as posterior vocal fremitus; Fremitus is normally decreased over heart and breast tissue Has good vocal fremitus Normal Percuss the anterior thorax Percussion Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, tympanic over the underlying stomach Not examined Not examined Auscultation of the trachea Auscultation Bronchial and tubular breath sounds Breath sounds are clear Normal Auscultate the anterior thorax Auscultation Bronchial and vesicular breath sounds Breath sounds are clear Normal Abdomen Normal Skin integrity Inspection Unblemished skin, uniform color, stretch marks Has an incision in the RLQ Deviation from Normal Abdominal contour Inspection Flat, rounded(convex) or scaphoid (concave) Symmetrical Normal Enlarges liver or spleen Palpation Liver and spleen must not be palpated. Without enlarge liver and spleen Normal Symmetry of contour Inspection Symmetric contour Symmetrical Normal Abdominal movements Inspection Symmetric movements caused by respiration Symmetrical movements Normal Vascular pattern Inspection No visible vascular pattern Not visible Normal Bowel sounds, vascular sounds and peritoneal friction rubs Auscultation Audible bowel sounds, absence of bruits, absence of friction rub Not examined Not examined Percuss abdominal quadrants Percussion Tympany over the stomach and gas-filled bowels; dullness, especially over the liver and Not examined Not examined
  • 34. spleen, or a full bladder Light palpation of abdominal quadrants Palpation No tenderness; relaxed abdomen with smooth, consistent tension Felt pain during palpation Deviation from Normal Musculoskeletal system Normal Muscle size, compare the muscles on one side of the body (arm, thigh, calf) to the same muscle on the other side Inspection Equal on both sides of body Muscle size are equal all throughout the body. Normal Muscle tonicity Inspection Has good muscle tonicity. Normal Muscle strength Inspection Equal strength on each body side Has equal muscle strength. Normal Bones Normal structure Inspection No deformities No observable bone deformities Normal Edema or tenderness Palpation No tenderness or swelling No observable presence of tenderness or swelling Normal
  • 35. Diagnostic Procedures TEST Actual Values Normal Values Analysis Interpretation Nursing Responsibility HEMATOLOGY DATE: 8-17-12 8-18-12 Hgb 122 g/L 141 g/L 120-151 g/L NORMAL  Monitor Vital Signs, intake and output.  Observe standard precautions, and follow the general guidelines. Positively identify the patient, and label the appropriate tubes with the corresponding patient demographics, date, and time of collection.  The specimen should be analyzed within 24 hr when stored at room temperature or within 48 hr if stored at refrigerated temperature.  Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage.  Promptly transport the specimen to the laboratory for processing and analysis. Hct 0.36 % 0.41 % 0.36-0.41 % NORMAL Neutrophils 0.81 0.57 0.45-0.65 Within normal range on second test Lymphocyte 0.19 0.43 17-48 NORMAL Pus cells 3-5 hpf 0-2 hpf None Indication of inflammation or infection RBC 0-2 hpf 8-12 hpf Negative Indication of inflammation or infection Epithelial cells few rare Occasional / lpf Indication of inflammation or infection Amorphous urates few rare None Amorphous urates may cause urine to appear more cloudy or hazy Bacteria plenty rare None Indication of inflammation or infection URINALYSIS Color yellow yellow Amber NORMAL  Instruct the patient to void directly into a clean, dry container. Sterile, disposable containers are recommended. Women should always have a clean- catch specimen if a microscopic examination is ordered. Feces,discharges, vaginal secretions and menstrual blood will contaminate the urine specimen.  Cover all specimens tightly, label properly and send immediately to the laboratory.  Observe standard precautions when handling urine specimens. Transparency turbid hazy Clear Purulent matter will make cloudy {infection is present ) Reaction 6.0 5.0 4.6- 8.0 NORMAL Specific Gravity 1.030 1.015 1.002-1.030 NORMAL Sugar negative negative Negative NORMAL Protein negative trace Negative Indication of inflammation or infection
  • 36. VI. PATIENT AND HIS CARE A. IVF (Intravenous Fluid Therapy) Medical management Date ordered/ Date performed/ Date changed/ DC General Description Indication/ Purposes Client’s Response to the Treatment Nursing Responsibilities D5O.3 NaCl 500cc x 60 ugtts/min Date ordered: August 20, 2012  D5 0.3NaCl is a hypertonic solution owing to the higher than normal amount of Na and Cl ions. It pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartments.  To compensate cellular dehydration and corrects moderate fluid loss, prevents alkalosis, provides calorie and NaCl.  The patient could not verbalized and distinguish the possible side effects of drugs and manifestation to her condition. Before:  Verify the doctor’s order indicating the type of solution, the amount to be administered, the rate of flow of the infusion and any allergies.  Explain the procedure and prepare the client.  Prepare the equipments needed.  Wash hands thoroughly.  Obtain IV solution and check for the sediments and any crack or leak from the container.  Check also the expiration date.  Check fluid discoloration or defect. If noted, dispose the defected tubing and get another.  Assess client’s vital signs for baseline data, skin turgor, bleeding tendencies, disease, or injury to the extremities, status of vein to determine the appropriate puncture site.
  • 37. During:  Explain the importance and purpose of IVF.  Place the patient in a comfortable position to facilitate easy insertion of the IV line.  Use the smallest gauge needle if possible.  Maintain aseptic technique throughout the procedure.  Follow proper procedures in infusing IV solution.  Watch out for fluid overload.  Secure the needle properly after insertions. Always check the needle of the Iv, if it is in the vein:  Bring the IV bottle lower than the patient arm.  Pinch the IV tubing.  Observe the backflow of the blood in the distal portion
  • 38. B. Drugs Name of Drug Date Route of Administration dosage,frequen cy General activities, Classification, Mechanism of actions Purpose/ Indication Client’s response/ Side effect Nursing responsibilities Cefuroxime August 20, 2012 Oral  Bind to the bacterial cell wall membrane causing cell death.  Bactericidal action.  Treatment of serious life threatening infection due to susceptible organisms.  The patient could not verbalized and distinguish the possible side effects of drugs and manifestation to her condition. ASSESSMENT:  Assess the infection, (vital signs, and appearance of wood, sputum, urine, and stool, WBC at the beginning and during the therapy.  Observe patient signs and symptoms of anaphylaxis (rash, pruritus, wheezing, edema)  Assess the patient renal dysfunction. IMPLEMENTATION  IF it is tablets don not swallow whole not crushed, because of bitter taste. EVALUATION  Resolution of signs and symptoms of infection  Decreased in the incidence of infection
  • 39. Tramadol August 20, 2012 IM  Binds to mu- opioid receptors and inhibits the reuptake of norepinephrine, and serotonin, that has analgesics effects, Acetaminophen blocks the activity of cyclooxygenase , an enzyme necessary for prostaglandin synthesis. And prostaglandins are important mediators of inflammatory response that causes local vasodilation, swelling and pain.  Relief of moderate to moderately severe pain.  The patient could not verbalized and distinguish the possible side effects of drugs and manifestation to her condition.  Know the 10 Rights in drug administration.  Get patient’s history of allergy to tramadol or opioids.  Inform the patrient about the side effects if sweating or CNS effects.  Watch for some allergic reactions especially after receiving the medication including bronchospasm  Assess the respiratory status of the client
  • 40. Ketorolac August 20, 2012 IV  Anti- inflammatory and analgesic activity; inhibits prostaglandins and leukotriene synthesis  Short-term management of pain  The patient could not verbalized and distinguish the possible side effects of drugs and manifestation to her condition  Know the 10 Rights in drug administration.  Do not mix with morphine, sulfate, mepiridine  Instruct patient about the side effects.  History: renal impairment, impaired hearing, allergies, hepatic, lactation, pregnancy  Physical: skin color and lesions, orientation, reflexes, peripheral sensation, clotting times, CBC, adventitious sounds  Be aware that patient may be at risk for CV events, GI bleeding, renal toxicity, monitor accordingly.  Do not use during labor, delivery, or while nursing.  Keep emergency equipment readily available at time of initial dose, in case of severe hypersensitivity reaction.  Protect drug vials from light.
  • 41. Metronidazole August 20, 2012 IV  Disrupts DNA and protein synthesis in susceptible organisms.  Bactericidal, or amebicidal action  Amebicide in the management of amebic dysentery  The patient could not verbalized and distinguish the possible side effects of drugs and manifestation to her condition  Administer with food or milk to minimize GI irritation.  Tablets may be crushed for patients with difficulty swallowing.  Instruct patient to take medication exactly as directed evenly spaced times between dose, even if feeling better. Do not skip doses or double up on missed doses. If a dose is missed, take as soon as remembered if not almost time for next dose.  May cause dizziness or light-headedness. Caution patient or other activities requiring alertness until response to medication is known.  Inform patient that medication may cause an unpleasant metallic taste.  Inform patient that medication may cause urine to turn dark.  Advise patient to consult health care professional if no improvement in a few days or if signs and symptoms of superinfection (black furry overgrowth on tongue; loose or foul-smelling stools develop).
  • 42. C. Diet TYPE OF DIET DATE STATED, DATE CHANGED GENERAL DESCRIPTION INDICATIONS, PURPOSES SPECIFIC FOOD TAKEN CLIENT’S RESPONSE TO THE DIET NPO August 20, 2012 Restriction of solid nor liquid foods by mouth This is done to avoid paralytic ileum that occurs from bowel handling during surgery. The patient complied with the prescribed diet.. Clear Liquid Diet August 22, 2012 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. Patient with acute illness and infections, to relieve thirst, to reduce colonic fecal matter. It is done between 1-2 feeding intervals. Water She seemed to have loss of appetite with the ordered diet Soft Diet August 23-24, 2012 A diet that is soft in texture, low in residue, easily digested, and well tolerated. This is given for the patient who is recovering from a surgery as the bowel is waking up. Porridge and water The patient still not have good appetite with the prescribed diet. , but then gradually took in the foods that were ordered by the physician.
  • 43. Type of exercise General description Indication/ purpose Client’s response to activity or exercise Nursing responsibilities Post surgery Bed Exercises  Starting off with basic leg pumps and lifts of the lower and upper extremities  Help improve blood flow and circulation in the lower portions of your body. In addition, performing bed exercises can also help reduce the risk of blood clots forming in your lower extremities.  The clients has no response  Assess the client on how to perform the proper way of this type of exercise. Short Walks  You should begin your post- appendicitis exercise regimen with short walks. During these walks, be aware of your walking form and posture,  Trying to keep additional weight off of your abdominal muscles. Stop walking as soon as you feel fatigued and do not push yourself to exercise for extended periods of time.  The clients has no response  Assess the client on how to perform the proper way of this type of exercise. Passive Abdominal Exercise  Start by sitting down on the edge of a bed with your feet hanging off of the edge of the bed. With your back straight and core tightened, slowly lift up your legs until they are parallel with the floor. Hold this position for several seconds before slowly lowering your legs back to their original position.  Performing basic abdominal exercise will help return your midsection to a stronger place.  The clients has no response  Assess the client on how to perform the proper way of this type of exercise. D. Activity Exercise
  • 44. VII. SURGICAL MANAGEMENT BRIEF DESCRIPTION INDICATION/ PURPOSES CLIENT’S RESPONSE NURSING RESPONSIBILITIES  Appendectomy is one of the most commonly performed operations with about 7% of the population having that operation. It should be an operation where every detail has been examined in prospective clinical trials but it is not. Of an overwhelming number of scientific reports on appendicitis (more than 5500 entries in the Medline) only a few are about randomized trials. We should have firm knowledge about such things as antibiotic treatment (initiation, route and duration), wound management (incision and closure) and excision of the appendix (stump closure and drains). It seems that much of the surgical technique evolved from - The main purpose of appendectomy is to remove the infected appendix in order to protect the patient‘s life. When appendix got infection, either it get pus or sometimes it get rupture before this condition surgeon, after diagnosing the patient and reviewing his medical reports, makes a small surgery and they will remove the appendix. The main symptom of this appendix is severe pain cause in lower abdomen  The patient was asleep after the operation.  The patient was lying on bed 6- 8 hours after the surgery.  The patient had chills few hours after the operation.  The patient had fever one day after the operation. Prior:  Check vital signs.  Instruct the patient to be on nothing per Orem 8 hours prior to surgery  Educate the patient about coughing, deep breathing exercises and turn side to side after the surgery.  Let the patient to voice out what she feels to decrease anxiety.  Listen to the patient to what he says. During:  Promote sterility in the sterile field.  Monitor the vital signs. After:  Keep the patient on NPO for 8 hours after peristalsis occurs.  Keep the patient lie flat on bed without pillow for 6-8 hours.  Monitor for bleeding and signs of
  • 45. traditions and later knowledge has been engaged in simplification. For example, multiple drains with or without continuous irrigation are not used for perforated appendicitis any longer but it must have made sense at the time. Even the single passive drain for a periappendiceal abscess is thought inappropriate by most surgeons today. So, when speaking about evidence here it must be viewed against strong traditions that are continuously changing regardless of real scientific evidence. When such evidence is available its penetration is often slow. Further, it must be accepted that the underlying conditions have changed so what seemed reasonable at one time is no longer appropriate. For instance, wounds and patient feel vomiting and last symptom is fever which will continue over a period of time. shock.  Monitor of signs for signs of infection.
  • 46. used to be infected in the range of 30–50% in perforating appendicitis. Infection is much less frequent now for reasons that patient care and surgical technique are different.
  • 47. VIII. Nursing Prioritization DATE IDENTIFIED SUBJECTIVE CUES PROBLEM/NURSING DIAGNOSIS JUSTIFICATION August 24, 2012 “Masakit dito sa baba”, while pointing at RLQ of abdomen. Acute pain related to presence of surgical incision in RLQ According to Maslow of hierarchy of needs physiological needs must prioritize first. Acute pain is a physical health problem thus belongs to physiological stage. Absence of pain may indicate that the client’s health status is getting better. August 24, 2012 “Hindi pa masyado magaling ang sugat ko at saka masakit siya.” As verbalized by the client. Impaired Skin Integrity related to tissue trauma manifested by appendectomy incision The skin is considered as the primary defense of our body. Integrity of our skin is vital to our physical and psychological health. Intact and well healing wound has low risk of getting infection; because of that impaired skin is the 2nd priority nursing diagnosis. August 24, 2012 ”Yung nurse ang nag-linis ng sugat, tinitignan nga ni lola. Kasi hindi niya alam kung paano linisin pag-nasa bahay na kami.” As verbalized by the client. Risk for infection related to insufficient knowledge regarding proper wound care to avoid exposure to pathogens. To prevent complication for fast recovery we consider risk for infection as 3rd priority problem. August 24, 2012 “Medyo wala siyang gana kumain” as verbalized by the mother Impaired nutrition less than body requirements related to loss of appetite. Impaired nutrition was the 4th priority nursing problem. Because the patient will not be able to commence food and fluids for a few days; this is to enable the bowel to regain normal function. The pain feel by the client added to reduce her appetite. August 24, 2012 “Hindi ko po kayang umupo at tumayo” asverbalized bythe client Activity intolerance associated with the limitation of motion secondary to pain The patient should be encouraged to get up and out of bed as soon as possible to prevent the formation of emboli. We make it 5th because by resolving the 1st problem it will also resolve or manage
  • 48. IX. . Nursing Care Plan ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION Subjective cues : “Masakit dito sa baba”, while pointing at RLQ of abdomen. Objective cues: Vital sign taken as follow: BP: 120/80mmHg RR: 20cpm PR: 105 bpm T: 36.5 C S/P Appendectomy  With dry intact dressing on the surgical site.  facial grimacing  Acute pain related to presence of surgical incision in RLQ Within 1 hour of nursing intervention, the client will be able to manifest ability to cope within pain as evidenced by: a.) verbalization of decrease pain form 7/10 to 2/10 b.) engagement in diversion of activities such as, watching TV, and listening mellow music c.) Verbalize method that provide pain reliving  Taking pain relieve medicines  Avoiding movement that provide pressure in the abdomen  provided splinting  Assess pain characteristics including location, intensity, and frequency.  Assess surgical site for swelling, redness or loose sutures.  Promote adequate rest periods by temporarily limiting activity  Encourage client to verbalize pain perception.  Elevation in intensity and frequency may indicate worsening condition.  Swelling, redness , and loose sutures may contribute to the pain felt by client and are indicative of further management  To lessen pain felt.  To allow continuous monitoring and assessment of client’s condition. Within 1 hour of nursing intervention, the client will be able to manifest ability to cope within completely relieved pain as evidenced by a.) verbalization of decrease pain form 5/10 to 2/10 b.) engagement in diversional activities such as watching TV, and listening mellow music c.) Verbalize method that provide pain reliving  Taking pain relieve medicines  Avoiding movement that provide pressure in the abdomen  provided splinting
  • 49.  Provide client with diversional activities such as socialization, watching TV, and listening mellow music.  Encourage SO’s to continue provision of diversional activities and a quiet environment.  Administer analgesics as indicated.  To help client divert his attention to other matters than pain felt.  Refocuses attention, promotes relaxation, and may enhance coping abilities.  Relief of pain facilitates cooperation with other therapeutic interventions, e.g., ambulation, pulmonary toilet
  • 50. ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION Subjective cues : “ Hindi pa masyado magaling ang sugat ko at masakit pa ” As verbalized by the client. Objective cues : S/P: Appendectomy  With surgical incision at right lower abdominal area  With dry intact dressing on the surgical site Impaired Skin Integrity related to tissue trauma manifested by appendectomy incision After 30 minutes of nursing intervention the patient will be able to gain knowledge on how to improve skin integrity in ways such as: a) keeping the incision area clean. b) maintain optimal nutrition that deals in proper wound healing. c) Exercises to provide good blood circulation.  Assess operative site for redness, swelling, loose sutures, or soaked dressing.  Encourage the client on keeping the incision clean  Discuss with the client proper wound healing such as  Food rich in vit. E  Food rich in protein.  Assist in passive movements (while 7hrs. flat on bed) such as bed turning and passive ROM exercise and active exercise there after movements such as bed position, sitting, standing, and walking.  To check skin integrity, monitor progress of healing and identify need for further  To prevent infection.  For fast recovery  To promote circulation to the surgical site for timely healing. For early ambulation also After 30 minutes of nursing intervention the patient is able to gain knowledge on how to improve skin integrity in ways such as: d) keeping the incision area clean. e) maintain optimal nutrition that deals in proper wound healing. f) Exercises to provide good blood circulation. Nursing Care Plan
  • 51.  Support incision as in splinting when coughing and during movement.  Encourage pt to verbalize his for any untoward feelings especially pain, discomfort as well as changes noted on operative site.  Instruct pt and SO’s to immediately report when dressing are soaked.  Instruct pt and SO’s to refrain from touching/scratching operative site.  To reduce pressure on the operative site.  To allow continuous monitoring and assessment of pt. Condition. .  For immediate replacement to prevent skin break down and contamination of operative site.  To prevent or reduced the risk of cross contamination
  • 52. ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION Subjective cues: Yung nurse ang nag-linis ng sugat, tinitignan nga ni lola. Kasi hindi niya alam kung paano linisin pag- nasa bahay na kami.” As verbalized by the client. Objective cues: Vital sign taken as follow: BP: 120/80mmHg RR: 20cpm PR: 105 bpm T: 36.5 C S/P Appendectomy  With dry intact dressing on the surgical site Risk for infection related to insufficient knowledge regarding proper wound care to avoid exposure to pathogens. After 1 hour of nursing intervention the significant others will be able to: a) Provide the client proper wound care at home. b) Determine signs that indicate infection and complication. Demonstrate and enumerate to the significant other the proper ways of wound care such as  Assess operative site for signs of infection.  Provide regular dressing care.  Instruct pt and SO’s to refrain from touching/scratching operative site.  Encourage pt to verbalized any changes noted on operative site such as redness, swelling and unusual/odorous drainage.  Stress proper hand washing techniques by  Identify need for further management.  To prevent unnecessary exposure and contamination of operative site which may delay wound healing.  To prevent bacteria harbor in operative site.  to allow continuous monitoring and assessment of pt. condition  A first-liner defense against nosocomial After 1 hour of nursing intervention the significant others will be able to: a.) Provide the client proper wound care at home. b.) Determine signs that indicate infection and complication.
  • 53. all caregivers between therapies/ clients.  Clean the incisions site daily withpovidoneiodine or other appropriate solution.  Instruct client/ SO(s) in techniques to protect the integrity of the skin, care for lesions, and prevention of spread of infection. infection/cross- contamination.  To prevent contamination.  To promote wellness
  • 54. X. Discharge Planning Medication Advice the patient to continue the prescribed medication to obtain her total recovery such as antibiotics and analgesics. Exercise Within 12 hours of surgery the client may get up and move around. The client can usually return to normal activities in 2-3 weeks after laparoscopic surgery Environment Provide client a well-ventilated and relaxing environment to provide comfortable environment while recovering. Treatment Pretreatment of foods with lactase preparations (e.g. lactacid drops) before ingestion can reduce symptoms. Ingestion of lactase enzyme tablets with the first bite of food can reduce symptoms. Health Teaching To care wound perform dressing changes and irrigations as prescribe avoid taking laxative or applying heat to abdomen when abdominal pain of unknown cause is experienced. Reinforce need for follow-up appointment with the surgeon. Call your physician for increased pain at the incision site Out Patient Document bowel sounds and the passing of flatus or bowel movements (these are signs of the return of peristalsis) Watch for surgical complications such as continuing pain or fever, which indicate an abscess or wound dehiscence .Stitches removed between fifth and seventh day (usually in physicians office) Diet Liquid or soft diet until the infection subsides. Soft diet is low in fiber and easily breaks down in the gastrointestinal tract
  • 55. XI. Conclusion In this study, the clinical and nursing procedures performed at the Bulacan Medical Center on August 24 ,2012 were described in detail. Case studies were also presented to exemplify these procedures and see how every case is unique in this way, appendicitis and appendectomy were fully explored by using methods of participant observation, informal interviews, research of the nature of disease and other information about the patient health condition. Although, this is a thorough examination of appendectomy and appendicitis, this study could not possibly capture our experiences in the surgical ward. The most significant lesson we learned throughout the study was the ambiguity of diagnosis and nursing care. The results of our study with interpretations made with secondary sources reveals that a better and assessment action in the hospital. Can take to better diagnosis of appendicitis patients, construct an effective procedure for assessment, diagnosis, and nursing intervention, and health teaching before and after the surgery, however these things may aid in improving the rate of negative appendectomies and improving post surgical care. This only leaves one very important lesson nurses and patients must realize, that each case must be taken as its own. An assembly line approach to diagnosing and treating appendicitis is not the solution: no appendicitis presents itself in the same way.
  • 56. Bibliography: Books:  Sparks and Taylor’s Nursing Diagnosis, Reference Manual 6th edition, 2005  Tomey,AnnMarriner ,Nursing Theorists and their Work: 6th Edition, 2002  Kozier&Erb’s, Fundamentals of Nursing., 8th edition.  Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 10th Edition Internet:  www.medicinenet.com/appendicitis/article.htm  digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/  http://nurseslabs.com/4-appendectomy-nursing-care-plans/