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Patient Profile
14 hours prior to admission, the patient experienced mild pain on his right lower
quadrant abdomen while eating in the morning, followed by a severe pain. The client
tried to eliminate the pain using herbal oil but were not eradicated.
Persistence of the noticed pain, prompted his mother to bring him to EVRMC,
hence this admission.
The patient did not receive any vaccination as claimed by the mother, has
experienced acute respiratory infection such as cough, cold and mild fever and took
biogesic (250mg) every 4 hours for fever and some herbal plants (decoction of lagundi)
for cough relief. Pain in the right lower abdomen 1st felt when the client was 25 years old
but were ignored no history of hospitalization.
The mother claimed that her mother is asthma positive, and noted hypertension
history on the paternal side.
V. Birth History:
The patient is 3rd on eight siblings of Mr. and Mrs. Matobato. Born via normal
vaginal delivery on their house.
VI.Psychosocial history:
The patient sorrounding is good and there were no lakes, swamp or river nearby.
They used a deep well for drinking and taking a bath. He smokes 5 sticks of cigar. Per
day, and play basketball in freetime.
PATTERNS OF FUNCTIONING CLINICAL INSPECTION OTHER SOURCES
1. RESPIRATORY
– (+) Hx of Asthma – RR = 26cpm
– Consumed 5 sticks – No accessory
of cigar/day muscle used
– Started smoking – No respiratory
since 17 y.o aids used
– No cough and
cold
1. CIRCULATORY Hematology:
– (+)Hx of HPN – BP = 110/70 WBC: 18.30x10^9/L
mmHg Neutrophil: .90
– PR = 53 bpm Lymphocyte: .10
– No presence of Hematocrit: .46
discoloured or
swollen parts
– Good capillary
1. FOODS AND FLUIDS refill
INTAKE
– Usual food taken:
leafy vegetables, – Good skin
fish, rice, root crops turgor
– (-)food allergies – Dry lips
– (-)food preferences – With an IVF of
& dislikes D5LR @
– Drink 4 glasses of 30gtts/min
water each day – No NGT
– Drink 10 glasses of
tuba occasionally
URINALYSIS
1. ELIMINATION Color : Dark yellow
– Void more than Transparency: Turbid
5x/day Specific gravity: 1.025
– Defecate 1x/day or PH: 6.0
sometimes 1 time Glucose: negative
every 2 days – Not constipated Albumin: trace
– Fun of retaining – Presence of WBC: 2-3/hpf
stools if at work indwelling Bacteria: moderate
catheter Mucus threads: many
– (-) nausea Costs: coarse granular:
0-1/lpf
Uric acid: moderate
1. REGULATORY
MECHANISM
– (+) mild fever
during childhood
– T = 36.6
– Afebrile
1. HYGIENE – (-) chills
– Take a bath 1-
2x/day
– Seldom use
shampoo – Untidy to look
– Change cloth at
everyday – (-)skin lesions
– No allergies to soap – Hair is equally
& shampoo distributed
– Combs hair – (+)Halitosis
– Poor dental care
– Presence of
plaque
1. EXERCISE &
LOCOMOTION
– Take the daily – Impaired
activities as mobility due to
Components Normal values Results Interpretation Clinical Significance
LABORATORY RESULTS
Hematology:
Urinalysis:
Components Normal Results Interpretation Clinical Significance
1. Color Pale yellow to amber Dark Yellow Not normal Not enough water
intake, presence of
bilirubin
2. Transparency Clear to slightly hazy Turbid Not normal
Cystisis, presence of
3. Specific gravity 1.015-1.025 1.025 Normal bacteria
Absence of calculi
ANATOMY AND PHYSIOLOGY
Vermiform appendix
In human anatomy, the appendix (or vermiform appendix; also cecal (or caecal)
appendix; also vermix) is a blind-ended tube connected to the cecum (or caecum),
from which it develops embryologically. The cecum is a pouchlike structure of the
colon. The appendix is near the junction of the small intestine and the large intestine.
The appendix averages 10 cm in length, but can range from 2 to 20 cm. The
diameter of the appendix is usually between 7 and 8 mm. The appendix is located in
the lower right quadrant of the abdomen, or more specifically, the right iliac fossa the
position within the abdomen corresponds to a point on the surface known as
McBurney's point. While the base of the appendix is at a fairly constant location, 2 cm
below the ileocaecal valve, the location of the tip of the appendix can vary from being
retrocaecal to being in the pelvis to being extraperitoneal. In rare individuals with situs
inversus, the appendix may be located in the lower left side.
Maintaining gut flora: major function
Although it was long accepted that the immune tissue, called gut associated lymphoid
tissue, surrounding the appendix and elsewhere in the gut carries out a number of
important functions
The digestive tract's immune system is often referred to as gut-associated lymphoid
tissue (GALT) and works to protect the body from invasion. GALT is an example of
mucosa-associated lymphoid tissue.
The mucosa-associated lymphoid tissue (MALT) (also called mucosa-associated
lymphatic tissue) is the diffuse system of small concentrations of lymphoid tissue found
in various sites of the body such as the gastrointestinal tract, thyroid, breast, lung,
salivary glands, eye, and skin.
1242 movement.
5. To maintain
“acceptable” level in
pain. Notify physician if
regimen is inadequate
to meet pain control
goal.
Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation
Impaired skin integrity Surgical intervention involves After 8 hours of nursing DEPENDENT: 1. Post-operative After 8 hours of nursing
related to surgical incision removal of appendix within 24 intervention the patient hemorrhage is likely interventions the patient’s
to 28 hours in which surgery will Achieve timely 1) Observe wound, to occur during first 2 wound appears to be dry and
SUBJECTIVE: can be performed through a wound healing and be note characteristics days, whereas freed from drainage or
“katapus ko la ka operahe” small incision that causes a free of infection, of drainage. infection may purulent substances therefore
as verbalize by the patient disruption or damage to the demonstrate how to develop anytime. goal was met.
skin tissues. Which will leads keep wound dry and
OBJECTIVE: to impairment of the first promote healing. 2. Reduce skin irritation
- open wound protective layer from 2) Change dressing as and potential
- visible surgical incision infections or foreign object. needed using infection, also to
- post-operative patient aseptic technique. prevent soaking the
dressing by any
Reference: discharges.
Temp - 36.6 oC
Medical surgical nursing by 3) Encourage side lying 3. May decrease
PR - 53 bpm brunner and suddarth, 11th position (on the left- pressure to operated
RR - 26 cpm edition volume 2 @ page: side) or a semi- site, thus relieving
1242 fowlers position. abdominal distention.
BP - 110/70mmhg
4. Promote protection to
4) Encourage guarding the incision site.
behavior.
5. Hasten the healing of
DEPENDENT the wound.
5) Administer
antibiotics as
doctor’s order
Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation