ANGELES UNIVERSITY FOUNDATION College of Nursing

Appendectomy (A Case Study)

Submitted by: Mistal, Mona Liza David, Audrey Cordero, Jelica Joy Torres , Robinson BSN 3-II Group 42

Submitted to: Ms. Jazper Herrera, RN Clinical Instructor

TABLE OF CONTENTS: I. INTRODUCTION.3 a. Current trends about the disease condition..4 b. Reasons for choosing such case for presentation..5 II. NURSING ASSESSMENT...6 a. Personal History...6 b. Pertinent Family Health-Illness History.7 c. History of Past Illness..8 d. History of Present Illness....8 e. Physical Examination ..9

f. Diagnostic and Laboratory Procedures..12

III. ANATOMY and PHYSIOLOGY(with visual aids)....14 IV. THE PATIENTS ILLNESS..18 a. Synthesis of the disease......18 a1. Definition of the disease....18 b2. Predisposing / Precipitating factors....18 c3. Signs and symptoms with rationale 19 d4. Health promotion and preventive Aspects of the Disease ....20 V. THE PATIENT AND HIS CARE21

a. Medical Management.

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a. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen therapy, ...21 b. Drugs.....23 c. Diet.25 d. Activity / Exercise....26 b. Surgical Management (actual SOPIERs).27
c. Nursing Mangement..28 a. Nursing Care Plan.28 b. Actual SOAPIES ..29 VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL.....31 a. Clients daily Progress Chart...31 b. Discharge Planning..31

a. General Condition of Client upon Discharge....31 b. METHOD....31

VII. CONCLUSION and RECOMMENDATIONS..32

I. Introduction
The appendix is a closed-ended, narrow tube that attaches to the cecum (the first part of the colon) like a worm. (The anatomical name for the appendix, vermiform appendix, means worm-like appendage.) The inner lining of the appendix produces a small amount of mucus that flows through the appendix and into the cecum. The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies. Like the rest of the colon, the wall of the appendix also contains a layer of muscle. Appendicitis is inflammation of the appendix. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is called a fecalith (literally, a rock of stool). At other times, the lymphatic tissue in the appendix may swell and block the appendix. Bacteria which normally are found within the appendix then begin to invade (infect) the wall of the appendix. The body responds to the invasion by mounting an attack on the bacteria, an attack called inflammation. (An alternative theory for the cause of appendicitis is an initial rupture of the appendix followed by spread of bacteria outside the appendix.. The cause of such a rupture is unclear, but it may relate to changes that occur in the lymphatic tissue that line the wall of the appendix.) If the inflammation and infection spread through the wall of the appendix, the appendix can rupture. After rupture, infection can spread throughout the abdomen; however, it usually is confined to a small area surrounding the appendix (forming a periappendiceal abscess). The treatment for appendicitis is antibiotics and surgical removal of the
appendix (appendectomy). Appendectomy is the removal by surgery of the appendix, the small worm-like appendage of the colon (the large bowel). An appendectomy is performed because of probable appendicitis.

Acute appendicitis is the most common cause in the USA of an attack of severe, acute abdominal pain that requires abdominal operation.

The incidence of acute appendicitis is around 7% of the population in the United States and in European countries. In Asian and African countries, the incidence is probably lower because of the dietary habits of the inhabitants of these geographic areas. Appendicitis can effect any at any age, with highest incidence occurring during the second and third decades of life. Rare cases of neonatal and prenatal appendicitis havebeenreported. Appendicitis occurs more frequently in men than in women, with a male-to-female ratio of 1.7:1.

A. Current Trends about Appendicitis

Care protocols reduce appendectomy complications - Tips from Other Journals
Appendectomy is the fourth most common abdominal surgery performed in the United States. Up to 18 percent of patients have postoperative infectious complications ranging in significance from wound infection to intra-abdominal abscess. The rate of infections depends on the degree of contamination during surgery and reaches nearly one third of cases when the appendix is perforated or gangrenous. Helmer and colleagues studied the effect of an evidence-based clinical practice guideline in reducing infectious complications of appendectomy. The clinical practice protocol that was developed from a critical review of the literature (see accompanying figure) was applied to 206 patients with a presumptive diagnosis of appendicitis who presented to a Texas county hospital during 1999. Outcomes in this cohort of patients were compared with those in 232 patients treated for the same condition at the hospital during the previous year. No patients were excluded from the study. Data were gathered on demographic and surgical features, comorbidities, use of antibiotics, evidence of infection, and other complications during the hospital stay. Eight patients (4 percent) who were treated according to the protocol had postoperative surgical infections, compared with 20 patients (9 percent) in the comparison group. The number of patients with intra-abdominal abscesses dropped from 12 to five after introduction of the protocol, and the number of wound infections dropped from 14 to four. The improvement was particularly significant in patients presenting with a perforated or

gangrenous appendix. In these patients, the total number of infections dropped from 16 (33 percent) to five (13 percent). The authors conclude that use of an evidence-based clinical practice guideline can significantly reduce surgically related infections following appendectomy and is particularly effective in patients with perforation or gangrene of the appendix.

B. Reasons for choosing such case

One of the formidable part in doing a case study is choosing what case is to present. We had this unanimous decision of choosing Girl Agnes case, first and foremost because with our initial contact we already established hormonious relationship with the patient and her significant others. We had established the trust we yearn from them and that makes it easy for us to ask certain questions we need for our case and interact with them properly. Another thing is because we find them kind and humorous that is why our previous interaction with them is smooth and conventional. Most importantly, the term Appendicitis is not accustomed to us that much. With that thought alone, we want to further enhance our knowledge about the disease such as to ensure appropriate evaluation of the etiology, reassess and address the course the illness takes in its progression. Also, to have an experience in handling and providing humanitarian health services to a patient who has it and provide any intervention or treatment indicated based on the specific etiology and the course it follows in that specific patient. With that scenario, it is not only the knowledge that was enhanced but also our skills as health care practitioners.

II. Nursing Assessment

A. Personal History
Princess Lulu M. Ba 65 years old, female, currently residing at 176 Dolores, Magalang Papanga. A typical Filipina and presently a part of the Roman Catholic. She was born on January 3, 1939. She is married with eight children, where some are married. Currently, she is just staying at home and she is dependent to his children for support. Sometimes she takes care of her grandchildren at home. She also cooks food for them and clean the house. Since he has this kind of lifestyle, and because of his age, last February 28, 2006 she manifested symptoms of appendicitis which was the reason why she was rushed to ONA.

B. Pertinent Family Health-Illness History

Ba Family 6

Jewel
o o o Mother Alcoholic Died of Tuberculosis o o o

Palace
Father Alcoholic Died of a ruptured appendicitis

Prince Stephen o husband

Princess Lulu
o o Patient Dignosed with appendicitis

Bu
-37 -Married -working

La -32
-single -Construction worker

Ba
-28 -married -housewife

Jel
-27 -married construction worker

Tah
-15 -single -not going to school

Mah
-17 -single -college student

Ad -22
-single -vendor

Bon -24
-married -vendor

Living Condition House:

They live in a bungalow type of house, concrete and some of the married members of the family resides Food: Their food is always a usual Filipino dish consisting of rice, fish, meat and vegetables. Their source of water is the pump. Economic Status: Princess Lulu is not working; she is dependent on his children for support. Her daughter, told us that 150-200 pesos a day is enough for them to satisfy the day. Beliefs: The BA Family believes in herbolarios and hilots and directly seek advices from them if any sickness occurred. They seldom bring members of the family to doctors or to the hospital for consultation or treatment of any disease.

C. History of Past Illness

She has always been healthy ever since he was a kid and he was never been brought to the hospital. She had normal Blood pressure, with no signs of hypertension, Diabetes Mellitus or even Tuberculosis. Aside from fever, colds and cough, nothing hinders him from doing his daily activities.

D. History of present Illness

It was February 28, 2006, 7 in the evening when she started to feel some pain in the abdominal area, accompanied by fever; she was chilling and felt nauseated and vomited several times. At 11 pm of the same night, she was still experiencing the same but the pain is worsen. Early in the Morning, they rushed him to the ONA. Dr. Dizon assessed her and diagnosed it as acute appendicitis because of (+) muscle guarding, (+)direct and rebound tenderness on the right lower quadrant. The patient was also assessed for Psoas sign and Obturator sign and was found out that the patient was in

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

E. Physical Examination
March 01, 2006 BP=110 / 90 T= 37.2 C SKIN a .General: dark brown in color; dry skin; absence of edema; when pinched skin springs back to previous state, poor turgor NAILS a. General: converse curvature; smooth texture; long with dirt; promp return of pink or usual color HAIR a. evenly distributed; thick hair; dry; black in color HEAD AND FACE a. scalp: no evidence of flaking or dandruff b. skull: rounded; smooth skull contour; absence of nodules or masses c. face: palpabral fissures equal size EYES a. general: symmetrically aligned b. eyebrows: symmetrically aligned equal movement; hair evenly distributed c. eyelashes: equally distributed curled slightly outward d. eyelids: skin intact; no discharge; no discoloration; involuntary blinks e. sclera: whitish with capillaries f. conjunctiva: shiny; smooth g. pupils: black in color; equal size; + PERRLA; round, smooth border h. vision: able to read newsprint; sensitivity to light EARS a. general: mobile;firm; no tenderness; pinna recoils after it is folded; no infection RR= 20 bmp PR=84 bpm

b. external ear canal: presence of hair follicles; presence discharge NOSE a. external: symmetric and straight; not tender; air moves freely as the client breaths b. internal: presence of hair MOUTH AND OROPHARYNX a. lips: uniform pink color; dry; ability to pursue lips b. teeth: missing teeth due to cavities; discoloration of enamel c. tongue: no lesions; with thin whitish coating; able to roll the tongue upward and side to side d. palates and uvula: light pink; positioned in the middle of soft palate e. tonsils: pink; no swelling NECK a. muscles: equal in size; head centered; equal strength b. movement: coordinated smooth movements without discomfort c .lymph nodes: not palpable d.thyroid gland: not visible CHEST a. external: symmetric; spinal column is straight; skin intact; chest wall intact; no tenderness; full symmetrical chest expansion b. lungs: normal breath sounds; absence of DOB CARDIOVASCULAR a. heart: absence of heart sounds; normal beating pattern

ABDOMINAL a. general: with direct and rebound tenderness on the right lower quadrant; with indirect tenderness; MUSCULOSKELETAL a. general: equal size on both sides of the body; no contractures; no tremors; normally firm; no deformities Cranial Nerves I. Olfactory have the sense of smell

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II. Optic normal visual acuity III. Oculomotor positive papillary reflex and eye convergence test IV Trochlear positive papillary reflex and eye convergence test V. Trigeminal can sense the sensation of pain, touch, temperature and normal muscle strength. VI. Abducens positive papillary reflex and eye convergence test VII.Facial normal muscle strength of facial expressions VIII. Vestibulocochlear normal voice tones audible; able to hear ticking on the both ears. IX. Glossopharyngeal (+) gag reflex; can swallow X. Vagus (+) gag reflex XI. Accessory normal muscle strength XII. Hypoglossal normal tongue movements

F. Diagnostic and Laboratory Procedures

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Diagnosis/ Lab procedure

Date ordered Date result

Indication or purpose - to determine urine composition such as blood, glucose, protein

result Yellow, clear Sugar: ( - ) Ph: acidic Sp. Gravity: 1.030 Pus cells: 0-1 HPF RBC: 1-2 HPF

normal value Yellow, clear Sugar: ( - ) Ph: acidic Sp. Gravity: 1.003-1.030 Pus cells: +10 HPF RBC: 0-3 HPF

O: 03-01-06 Urinalysis R: 03-01-06

Analysis & interpretati on of result The microscopic analysis shows normal levels.

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

Diagnosis/ Lab procedure

Date ordered Date result in

Indication or purpose

result

Normal value

Analysis & interpretati on of the result

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O: 03-01-06 Hematologic test R: 03-01-06

-to indicate anemia and polycythemi a

Hgb: 1.50

WBC: 14.6 Hct: 0.45

RBC: 5.25

Hgb: M: 140-180 gm/L F: 120-160 gm/L WBC: 5.10 x 10/L Hct: M: 0.40-0.54 L/L F: 0.37-0.47 L/L RBC: M: 4.5-6.3 x 10/L F: 4.2-5.4 x 10/L

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

Diagnosis/ Lab procedure

Date ordered Date result in

Indication or purpose

result

Normal value

Analysis & interpretati on of the result A decrease in hemoglobin indicates anemia. White blood cell is above the normal range, there is systemic infection. Leukocytosi s indicates appendicitis.

O: 03-01-06 Hematologic test R: 03-01-06

-to indicate anemia and polycythemi a

Hgb: 139

WBC: 12.4 Hct: 0.41

RBC: 5.25

Hgb: M: 140-180 gm/L F: 120-160 gm/L WBC: 5.10 x 10/L Hct: M: 0.40-0.54 L/L F: 0.37-0.47 L/L RBC: M: 4.5-6.3 x 10/L F: 4.2-5.4 x 10/L

Nursing Responsibilities: Explain the procedure and the purpose to the patient.

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

III. Anatomy and Physiology

In a normal human female, the GI tract is approximately 25 feet or 7 and a half meters long and consists of the following components

Mouth (Oral cavity/ Bucal Cavity, includes tongue, teeth, salivary glands and
mucosa) The mouth is the first of the digestive tract. It is the opening through which takes in food. It is lined by stratified squamous non-cornified epithelium, except the hard palate, gingival and filiform papillae of tongue which are cornified. It is bound infront by the lips, above by the hard and soft palate, below by the floor of the mouth including the tongue and behind by the faucial isthmus. Pharynx The pharynx is the part of the digestive system which connects the mouth with esophagus. It is where the digestive tract and the respiratory tract cross, commonly called the throat. The human pharynx is bent at a sharper angle. Esophagus (Gullet/ Oesophagus) The esophagus is a muscular tube, lined with moist stratified squamous epithelium that extends from the pharynx to the stomach. It is about 25 cms. Long and lies anterior to the vertebrae and posterior to the trachea within the

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mediastinum. It passes through the diaphragm and ends at the stomach. It transports food from the pharynx to the stomach. Stomach The stomach is an enlarged segment of the digestive tract in the left superior part of the abdomen. It is an alimentary canal used to strore and digest food. Its primary function is as a storage and mixing chamber for ingested food. It is lined with simple columnar epithelium. Latin names for the stomach include Ventriculus and Gasti, many medical terms related to the stomach part in gastro or gastric. In humans the stomach is a highly acidic environment (maintained by the hydrochloric acid secretion) wit peptidase digestive enzymes. In ruminants, the stomach is a large multichambered organ that hosts symbiotic bacteria which produced enzymes required for the digestion of cellulose from plant matter. The partially digestive plant matter passes through each of the stomachs chambers in sequence, being regurgitated and rechewed at least once in the process. Bowel/Intestine Small Intestine Small intestine is the portion of the alimentary tract between the stomach and the large intestines whose main function is for absorption. It is about 6 meters long and consists of 3 parts: duodenum; jejunum and ileum. Duodenum Duodenum is a hollow jointed tube that connects the stomach to the jejunum, it is the shortest, the widest and most fixed part of the small intestine and is largely retro-peritoneal closely attached to the dorsal wall. Jejunum

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Jejunum is about 2.5 meters long and makes up 2/5 of the total length of the small intestine. Ileum The ileum joins with the cecum at ileocal junction. It is about 3.5 meters long and it makes up 3/5 of the small intestine. Large Intestine The large intestine extends from the ileocal junction up to the anal opening in the peritoneum. It is about 5-6 feet long. It is subdivided into: cecum and appendix, colon, rectum and anal canal. Cecum and Appendix

Cecum is the proximal end of the large intestine and is where the large and the small intestine meet at the ileocal junction. It is located in the right lower quadrant of the abdomen near the iliac fossa. It is a sac that extends inferiorly about 6 cms. past ileocal junction. Attached to the cecum is a tube about 9 cms. long called the APPENDIX. Colon

The colon is about 1.5-1.8 meters long and consists of four parts: Ascending colon Transverse colon Descending colon and sigmoid colon Ascending Colon

The ascending colon extends superiorly from the cecum to the right colic flexure near the liver, where it turns left Transverse Colon The transverse colon extends from the right colic flexure to the left colic flexure near the spleen, where the colon turns inferiorly.

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Descending Colon and Sigmoid Colon

The descending colon extends from the left colic flexure to the pelvis, where it becomes the SIGMOID COLON. The sigmoid colon forms an S-shaped tube that extends medically and the inferiorly into the pelvic cavity and ends at the rectum. Rectum The rectum is a straight muscular tube that begins at the termination of the sigmoid colon and ends at the anal canal. Anal Canal The anal canal represents the terminal portion of the large intestines and it is about 2-3 cms. long

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IV. The Patients Illnesses

A. Synthesis of the Disease

a1. Definition of the Disease

Appendicitis is the inflammation of the vermiform appendix, which is attached to the cecum and lies in the right lower quadrant, the appendix can lie medial, lateral, anterior or posterior to the cecum, it is behind the bowel or mesentery or in the pelvis. The average adult appendix is 9-10 cm in length with a diameter of 0.5 to 1 cm. Its blood supply, the appendiceal artery, is a terminal branch of the ileocolic artery which transverses the length of the appendix. This small finger shaped tube branches of the large intestine. There is no specific cause of appendicitis, although inflammation can occur spontaneously from an infection or from fecal waste that have been trapped in the lumen of the appendix. The appendix can also become kinked, obstructing the circulation. Abscess formation generally occurs and danger of rupture is omnipresent. Appendicitis is characterized by a sharp abdominal pain that may be localized at McBurneys point (half way between the umbilicus and right iliac crest). Palpation of the abdomen causes pain in the right quadrant. Pressing the abdomen at McBurney's point causes tenderness in a patient with appendicitis. When the abdomen is pressed, held momentarily, and then rapidly released, the patient may experience a momentary increase in pain. This "rebound tenderness" suggests inflammation has spread to the peritoneum. If the appendix ruptures, the pain may disappear for a short period and the patient may feel suddenly better. However, once peritonitis sets in, the pain returns and the patient becomes progressively more ill. At this time the abdomen may become rigid and extremely tender. Appendix occurs most commonly on children, adolescents and young adults but individuals of any age may have appendicitis.

a.2.Predisposing / Precipitating Factors

Predisposing Factors: Classic history of appendicitis

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Sex: Appendicitis is 1.3 to 1.6 times more common in males than in females Age: the peak incidence is in the second and third decades with 80 % of cases occurring in persons younger than 45 years of age but individuals of any age may have appendicitis.

Anatomical Variations in the position of the appendix. Lymphoid Follicular Hyperplasia Infections by viruses, parasites or bacteria Diet deficient in fiber

Precipitating Factors:

a.3. Sign and Symptoms

Appendicitis often starts with mild pain near the navel. The pain gradually moves to the right lower part of the abdomen. It worsens with time, and is more intense when the person moves. Other symptoms of appendicitis may include: Nausea or vomiting. Elevated temperature. Increased pulse rate. Loss of appetite. Constipation. Abdominal swelling. If the infection continues, the appendix may rupture. When this occurs, there is often relief of the pain for a short while. This improvement is followed by more intense but similar pain. Chronic appendicitis is rare. It causes a milder pain in the right lower abdomen that may come and go.

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

A-void too much activity(eating then working or playing right away) P-eople of any age are susceptible, male are more prone P-revent obstruction of the lumen E-xercise N-otify physician if any signs and symptoms occur D-iet should be high in fiber; so to.. I-increase peristalsis to prevent constipation X-ray, ultrasound and other lab test should be take into consideration to avoid rupture of the appendix

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V. THE PATIENT AND HIS CARE

1. Medical management
A. IVFs

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Indication/s Medical Manageme nt/ Treatment Date ordere d; perfor med; change d General Description Or Purpose/s

Clients Initial Reaction to the Treatment

Clients response to the Treatment

D5LRS 1L x 8 @ 3031 gtts./min #1 O: 03-01-06 C: 03-01-06 O:03-02-06 C:03-02-06 O:03-02-06 C:03-03-06 O:03-03-06 Date C:03-04-06 ordere d; perfor O:03-04-06 med; C:03-05-06 change d O:03-05-06 C:03-05-06

#2

#3

#4

Medical Managem ent/ Treatmen #5 t

#6
D5NM 1Lx 35 gtts/min #4

O: 01-31-06 C: 01-31-06

Slightly hypertonic solution, this solution exerts higher osmotic pressure than of the blood plasma. D5LRS will increase the solute concentration of plasma, draining water out of the cells into the extracellular General compartment Description to restore osmotic equilibrium. D5LRS contains 130 mEq/L Sodium, 4 mEq/L of Hypotonic Potassium. it solution 109 maybe mEq/L isoChloride, since 3.0 osmolar mEq/L of dextrose is Calcium. It rapidly metabolized. has 120 Normosol M calories.
contains dextrose dehydrated alcohol 40ml, potassium acetate 1.28g, fructose 150g,NaCl 2.34g, Mg acetate 0.1g

Client has a guarding replace behavior but was deficits in the cooperative extracellular with the treatment compartment procedure. in patients He responded that are well to the dehydrated treatment. Used to and volume depleted. Clients Initial Reaction to the Treatment

>Check Tubing the

IV for

presence of air >Check Integrity of the Infusion >Monitor IV flow rate >Adjust rate of Clients of flow fluids response to appropriate the to need of Treatment patient as prescribed

D5LRS is Indication/s administered Or and given to patient to Purpose/s give the necessary nutrients to replace any lost fluids since the Provides patient is in principal ions NPO. It is of normal also used as plasma is a main line almost the to administer same Antibiotics proportions as with normal and plasma. medications 50g, Replacement IV.
of acute looses of extraxcellular fluid volume in surgery, it was given to the patient to prevent dehydration and contains plasma volume.

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

No signs of abnormalities observed or felt by the patient.

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Nursing Responsibilities Before administering the IV, identify first the pationt Explain the procedure Prepare the equipment Wash hands Check the fluid to be infused Use the smallest gauge needle possible Drip the tubing before connecting to the needle once being infused Adjust the IVF as indicated Report any pain, infufusion or dislocation felt by the patient B. Drugs Name of the Drugs Generic Name Brand Name Date Ordered Date Taken Date Changed 03-01-06 03-01-06 03-06-06 Route and Indication/ Frequency of Purposes administration Specifi Foods taken Clients response to medication

NPO 1 amp. IV q 4 Paracetamol ,non narcotic analgesics decreases fever

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

Cefuroxime

03-02-06 03-02-06 03-04-06

750mg IV q 8

-Antiinfective -2nd generation cephalospor ins -inhibits bacterial cell wall synthesis rendering cell wall osmotically unstable, leading to cell death by binding to cell wall membrane

NPO

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Metronidazole

03-02-06 03-03-06 03-06-06

500mg IV q8 ANST(-)

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

Patient had no manifestations of any side effects

Tramadol

03-02-06 03-03-06 03-06-06

100mg IV q 6 >Analgesic, RTC centrally acting >

Patient had no manifestations of any side effects

Plasil

03-02-06 03-02-06 03-03-06

5mg/ml q 8 x >anti-emetic 4 doses

NPO

Patient had no manifestation regarding any side effects

Famotidine

03-02-06 03-02-06 03-03-06

20 mg IV q 12 Histamine H2 NPO x 3 doses antagonist

Patient had no manifestation regarding any side effects Patient had no manifestation regarding any side effects

Kortezor

03-02-06 03-02-06 03-03-06

30 mg IV q 8 x Pain reliever 4 doses

NPO

Captopril

Dulcolax

03-03-06 03-03-06 03-03-06 03-05-06 03-05-06 03-05-06

25mg SL Supp 2 suppl rectum

NPOClear liquid -laxative, stimulant Soft diet diphenylmethane -acts directly on the intestine by increasing motor activity; thought o irritate colonic intramural plexus; increases ater in the colon Patient had no manifestation regarding any side effects

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Nursing Responsibilities: Assess patient from allergic reaction (ANST) Assess the patient for any sign and symptoms Identify Urine output, if decreasing, notify the physician Caution patient to report bleeding, bruising or fatigue Monitor patient bowel and consistency of stool Evaluate for therapeutic response: release of pain, stiffness, swelling Document indications for therapy.location, onset, and charcteristic of symptoms Assess for history of drug addiction, allergy to any medicine Monitor vital signs Obtain CBC and necessary cultures before administering Encourage increased fluid intake Document C. Diet Types Of Diet NPO Date ordered Date started Date changed 03-01-06 03-01-06 03-03-06 General Description Indications Purpose or Specific Foods taken Clients response to the treatment She exhibited some loss of appetite.

Clear Liquid Diet

03-03-06 03-03-06 03-03-06

Restriction of solid Upon admission nor liquid foods by to provide more mouth accurate observation in the condition of the client and for pre and post operative patient to prevent aspiration of the food taken in as an effect of the anesthesia. Made up of clear It is mainly used liquid foods which for post operative leave no residue in patients, patients the GIT. It is non- with acute illness stimulating, non- and infections, to

Water Pineapple juice Jelly ace

she first seemed to have a loss of appetite with the ordered diet, but then gradually

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gas forming, non-irritating.

Soft Diet

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

and relieve thirst, to reduce colonic fecal matter. It is done between 1-2 feeding intervals. It is similar to the It is used for regular diet except patients with that the texture of acute infections, the foods has been some GIT modified. It is a diet disturbances or modified in chewing consistency to have problems and new roughage, following surgery liquefied foods, semi-solid foods and those which are easily digested. This could offer an entirely adequate, liberal diet.

took in the foods that were ordered by the physician. Soup Lugaw Crackers Mammon Pineapple juice water The patient manifested an improved appetite.

Nursing Responsibilities: The benefits as well as the disadvantages should be explained well to the client. The nurse should make sure that the patient adheres to the ordered diet. The ordered diet should be monitored. Continuous monitoring of the clients diet should be observed d. Activity/Exercise Type of Date exercise ordered, date started, date changed Date ordered 03- 01 -06 Date started 03-01-06 Date General description Indication purpose or Clients response to the activity or exercise

Bed rest

Pt. is restricted from any stressful activities

To decrease Pt. was able to oxygen and avoid any energy demand. stressful activities.

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changed 03-03-06 Ambulation (walking) Date ordered 03-04-06 Date started 03-04-06 Pt. performed ADLs, maintain good body alignment and carry out active ROM exercises. To be able limit Pt. was able movements and performed her strengthen the ADLs like walking muscles.

Nursing responsibilities: Check for the doctors order Explain the purpose of the exercise to the client Instruct client to maintain the exercise ordered by the physician Assist the patient in moving and walking Provide comfort measures to avoid injury of the patient

B. Surgical Management a. Brief Description A surgical procedure called an appendectomy is necessary before the appendix ruptures. Attempts are made to remove the inflamed appendix before it ruptures and preoperative care is directed toward resting the colon. No enemas, heating or laxatives should be used before surgery because they could stimulate peristalsis and cause a rupture of the appendix. The appendix is removed through a small incision over McBurneys point or through a right paramedical incision. The incision usually heals with no drainage. Drains are used when an abscess is discovered when the appendix has rupture and sometimes when the appendix was edematous and ready to rupture and was surrounded by clear fluid.

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If no rupture has occurred, a laparoscopic appendectomy, in which the appendix is removed through a scope maybe done. A laparoscopic appendectomy requires only small incision and allows client to be discharged 24 hours after surgery. Bowel function is usually normal soon after surgery and convalescence is short.

b. Nursing Responsibilities Preoperative Assess the location, severity, onset, duration, precipitating factors and alleviating measures in relation to the pain Intravenous fluids as prescribed to maintain fluid and electrolyte balance Instruct nothing by mouth to the patient prior to surgery Record allergies and medications as well Place the patient in semi fowlers or side lying position to provide comfort Analgesics are withheld until physicians determines diagnosis

Post Operative Determine (+) flatus

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 Clear Liquid after Flatus Soft Diet after Assist patient in turning, coughing and deep breathing to promote expansion of the lungs Assess abdominal wound for redness, swelling and foul discharge Provide wound care Promote early ambulation

b. Actual SOPIE
S> O> the patient manifest the following (+) guarded behavior (+) facial grimaces (+) restlessness (+) pupillary dilatation (+) narrowed focus Onset of pain: often; Quality: Stabbing and throbbing; Region on RLQ; severely: always; Level of pain of 10/10 A> Acute pain R/T stimulation of nerve endings

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P> After 2-3 of Nursing Intervention and health teaching the pt will be able to decrease pain from 10 to 6 using a scale of 10 as evidence by using of relaxation technique and diversional activities. I> Monitored and recorded vital signs Assessed patient condition Performed comprehensive assessment of pain Accepted patient perception of pain Observed non-verbal cues Encouraged verbalization of feeling about pain Provided quiet and calm environment Provided patient comfort measures Encouraged relaxation exercise such as deep breathing Encouraged diversional activities Encouraged adequate rest Discussed with SO way on how to assist patient to reduce pain

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

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VI.CLIENTS DAILY PROGRESS IN THE HOSPITAL

a.Clients daily progress chart
Days Nursing Problems Acute Pain Risk for deficient fluid volume Impaired skin Integrity Physical Immobility Risk for Infection Vital Signs Blood Pressure Admission / / 03-02-06 / / / / / 8am 110/80 / / 8am 100/70 03-03-06 / / / / 8am 110/60 03-04-06 / / / / 8am 110/80 03-05-06 / / / / 8am 90/60

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Temperature Respiratory Rate Pulse Rate Lab Procedures Medical Managements 1. IVFs D5LRS Drugs: Paracetamol Cefuroxime Metronidazole Tramadol Plasil Famotidine Kortezor Captopril Dulcolax Diet NPO Clear Diet Soft Diet

36.9 20 82 /

37 21 84 /

37 21 89 /

36.6 21 66 /

36.1 20 70 /

/ /

/ / / / / / / /

/ / / /

/ / / /

/ / / / /

/ / / / /

B.Discharge Planning a. General Condition Of client upon Discharge

Since we were not able to see the client when she was discharged from the Hospital, with few days of nursing intervention, the clients general condition has improved: 1. She is slowly regaining his strength 2. She can ambulate with assistance

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b. METHOD
M- take the medicines prescribed E- exercise such as walking and proper breathing T- daily wound cleaning H- increase fluid intake, vitamin C, apply hot compress O- be back at OPD as ordered by the doctor D- Diet as tolerated with an increase intake of Vitamin C

VII. Conclusion and Recommendation

Every individual of any age are prone to appendicitis though its more common with males, still everyone is susceptible, mild umbilical pain maybe vague at first, but it increases intensity. Over a period of time, signs and symptoms occur rapidly, it cannot be presented an experience of this shall be contented with proper prevention. Faulty diet especially low in fiber is one cause of the observation therefore by eating fiber- rich food will increase peristalsis. So there is regular bowel movement. So there is no fecal material that will be formed. Not everyone with appendicitis has all the symptoms. The pain may intensify and worsens other may have a sensation called down ward urge pain medication and other laxatives should not be taken in their situation. Anyone with these symptoms need to see a qualified physician immediately. Recommendation One should always remember the health promotion and prevention of appendicitis. Just remember the acronym APPENDIX, which is avoiding too much activity, that people of any age and sex are susceptible. One should always play safe in preventing obstruction of the lumen. Exercise is important. Notify physician if any signs and symptoms occur. Diet should always be high in fiber to increase peristalsis and to

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prevent constipation. Lastly x-ray, ultrasound and other laboratory test should be taken into consideration to avoid response of the appendix.

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