I.

INTRODUCTION

A. OVEVIEW OF THE CASE

The appendix is a closed-ended, narrow tube up to several inches in
length that attaches to the cecum the 1st 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 open center of the appendix and into the cecum.
The wall of the appendicitis 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 but the muscle is fully developed.
The appendicitis is the inflammation of the vermiform appendix and
st
was 1 described as a pathologic condition by Reginald Fitz in 1886; it was
caused by an obstruction attributed to infection, stricture, fecal mass, foreign
body or tumor. Appendicitis can affect either gender at any age, but most
common in male ages 10-30. Appendicitis is the most common disease
requiring surgery and one of the most commonly misdiagnosed diseases.
Appendectomy removal of the appendicitis, is the standard
treatment for acute appendicitis, it is important to immediately remove the
appendix after the diagnosis to prevent the occurrence of life threatening
complications of 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 appendiceal perforation is
delay in diagnosis and treatment. In general, the longer the delay between
diagnosis and surgery, the more likely is perforation. The risk of perforation is
36hour after the onset of symptoms at least 15 percent. Therefore once
appendicitis is diagnosed surgery should be done with out unnecessary delay

B. OBJECTIVE OF THE STUDY

The objectives of this study are as follows;
 Know how it is manifested and how it is diagnosed.
 Trace the disease process which is related to the actual condition of the
patient.
 Recognize the medical care of the client and know the significance of
the medical managements rendered.
 Recognize the significance of all diagnostic tests given to the client.
 Formulate and implement an effective nursing care plan especially
designed for client’s problems as identified in the nursing assessment.
 Encourage empathy and compassion to dealing with these patients
  To widen and enhance the students nurse’s knowledge and skill’s
through additional research about the nature of the disease, its sign and
symptoms, its phatophysiology, its diagnosis and treatment.
 Provide appropriate health teachings to patients with these disease
conditions

C. SCOPE AND LIMITATIONS OF THE STUDY

This case presentation involves patient Patricio Pardillo who was
diagnosed with acute appendicitis. The scope and limitation of this case study are
as follows:
- Patient’s history and background
- Predisposing and precipitating factors as manifested by the patient
- Anatomy, Physiology and Pathophysiology of appendicitis Nursing
and Medical management during the confinement period
- Discharge plan, referrals and evaluation of the study
- Assessment of patient is inclusive only from January 14-19, 2010
- Sources of information were limited only to the patient himself

II. HEALTH HISTORY

A. PATIENT'S PROFILE

Name: Pardillo, Patricio

Age: 38 years old
Address: District 8 upper Canitoan
Gender: Male
Civil Status: Married
Date of Birth: June 25, 1927
Place of Birth: Bukidnon City
Religion: Roman Catholic
Nationality: Filipino
Occupation: maintenance at Xavier state
Educational Attainment: High school level
Height: 5'4''
Weight: 64 kg
Date of Admission: January 14, 2010
Time Admitted: 09:00 pm
Chief Complaint: Abdominal Pain
Admitting Physician: Dr. Hudiries
Admitting Diagnosis: acute appendicitis
Father's Name: Mr. Teodoro Pardillo
Occupation: Decease
Mother's Name: Mrs. Luisa Pardillo
Occupation: Decease

B. FAMILY AND PERSONAL HEALTH HISTORY

The patient denies allergies to any medications, foods or
animals. The patient claims that he only suffered from two common childhood
illnesses, chicken pox and measles, when she was a kid. According to him he was
completely immunized when he was a child as evidence by scars on the patient’s
left and right deltoid. The patient admits a family history of hypertension,
according to the patient her father died of heart attack.

C. HISTORY OF PRESENT ILLNESS

 This is the case of Guillermo H. Jayme, age 82 years old, male, Filipino, Roman
Catholic who lives in Zone 5 Mantibugao Manolo Fortich Bukidnon and was admitted at
Northern Mindanao Medical Center on December 30, 2009 at 09:00 pm with chief
complaints of community acquired pneumonia with cough and fever episode. The patient
felt severe coughing and take Robitusin as a method to resolve the problem, but it was
still having an onset of severe coughing. Four Days prior to admission the patient had
already felt the severe coughing, he seeks medical consultation.

D. CHIEF COMPLAINT
 Four days prior to admission because of cough and fever
III. DEVELOPMENT DATA
IV. MEDICAL MANAGEMENT
A. Medical Order and Rationale
B. Drug study
1. General Name of ordered drug: Acetylcysteine
Brand Name: Mucomyst
Date Order: January 4, 2010
Classification: Mucolytic
Dose/Frequency/Route: 600mg > Tab >70cc
Mechanism of Action: Decrease viscosity of secretions in respiratory
tract by breaking disulfide links of mucoproteins.
Specific Indication: Drug is given because patient had diagnosed of
pneumonia and relief of the symptoms of pneumonia.
Contraindication: Hypersensitivity
Side Effect/Toxic Effect: This medication can cause drowsiness,
headache, tooth damage, and constipation.
Nursing Precaution: Dilute oral doses with cola, fruit juice, or water
before administering.
2. Generic Name of Ordered Drug: Omeprazole
Brand Name: Omeprazole
Date Ordered: January 3, 2010
 Classification: Therapeutic – Antiulcer agent
Pharmacologic – Proton – Pump Inhibitors
Dose/Frequency/Route: 40mg ┬ cap BID
Mechanism of Action: Inhibits the activity of the acid (proton). This
blocks the formation gastric acid.
Specific Indication: Treatment of anemia secondary to upper gastric
intestinal bleeding.
Contraindication: Hypersensitivity
Side Effect/Toxic Effect: Dizziness, fatigue, and headache.
Nursing Precaution: Asses the patient routinely for epigastric or
abdominal pain and occult blood in the stool.
3. Generic Name of Ordered Drug: Dig

V. PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

A. Pathophysiology of Acute Appendicitis
Obstruction of the appendix
(By fecalith, lymph node, tumor, foreign objects)

Inflammation

Increased intraluminal pressure

Distention of the appendix – causes pain

Decreased venous drainage

 Blood flow and oxygen restriction to the appendix

Bacterial invasion of the blood wall- causes fever

Necrosis of the appendix

B. ANATOMY AND PHYSIOLOGY

The pathophysiology of appendicitis is the constellation of process that leads to the

Dev. Of acute appendicitis from a normal appendix. The man thrust of events
leading to the dev. Of acute appendicitis lies innthe appendix developing a
compromised blood supply due to obstruction of its lumen and becoming very
vulnerable to inasion by bacteria found in gut normally.
Obstruction of the appendix lumen by fecalth, enlarge lymph rode, worms
tumor, or indeed foreign objects, brings about a raised intra-luminal pressure, w/c
Cause the wall of the appendix to become distended. Normal mucus secrations con-
w/in the lumen of the appendix, thus causing further build up of intralumenal
pressures. This in turn leads to the ocelusion of the lymphatic channels, then the
various return, and finally the arterial supply become undermined. Reduce blood
supply to wall of appendix gets little or nonutrion and O2. H also means a lil or no
supply and other natural fighters of infection found in the blood being mode
available to the appendix within 36 hours from the point of luminal obstruction,
worsening the process of a appendiatis. This leads to necrosis and perforation of the
appendix pus formation occurs when nearby wbc are requited to fight the bacterial
invation. A combination of deal wbc bacterial . and dead tissue makes up pus. The
content of the appendix (fecalith,pus and macus see) are then released into the gen.
abdominal cavity, brining causing peritonitis. So in acute appendicitis, bacterial
colonization folous only when the process have commended.
These events occur so rapidly, that the complete pathoof appendicitis takes about
one to three days. This is why delay can be deadly. Pain in appendicitis is thus
caused, initially by the distention of the wall of the appendix and later when the
grossly inflamed

VI. NURSING MANAGEMENT

NURSING SYSTEM REVIEW CHART
Name: Jayme, Guillermo H. Date: January 4, 2009
Temp.:37°C Pulse Rate: 66 BPM Resp. Rate: 26CPM BP: 120/80 mmHg Height: 5’4’’ Weight: 70kg

INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the
location of the problem in the figure using [X].

EENT:
[x] impaired vision [ ] blind [ ] pain
[ ] reddened [ ] drainage [ ] gums
[x] hard of hearing [x] deaf [ ] burning IMPAIRED VISION
[ ] edema [ ] lesion [ ] teeth HARD OF HEARIHG
Assess eyes, ears, nose throat for abnormalities.
[ ] No problem

RESPIRATORY:
[ ] asymmetric [ ] tachypnea [ ] apnea
[ ] rales [x] cough [ ] barrel chest
[ ] bradypnea [ ] shallow [ ] rhonchi Pain scale (6-10)
[ ] sputum [ ] diminished [ ] dyspnea abnormal
[ ] orthopnea [ ] labored [ ] wheezing abdominal pain prior to
[ ] pain [ ] cyanotic surgery ongoing
Assess resp. rate, rhythm, pulse blood breath sounds, comfort nf of DSLR11
• [ ] No problem 8 40ts/min

W(L) hand infusing

CARDIOVASCULAR: well

[ ] arrhythmia [ ] tachypnea [ ] numbness

[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sound, rate, rhythm, pulse, blood pressure.
Circulation, fluid retention, comfort
[x] No problem

GASTROINTESTINAL TRACT:
[ ] obese [ ] distention [ ] mass
[ ] dysphagia [ ] rigidity [x] pain
Assess abdomen, bowel habits, swallowing bowel sounds, comfort.
[x] no problem

GENITO-URINARY AND GYNE:

[ ] pain [ ] urine color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] nocturia
Assess urine frequency, control, color, odor,
 Comfort, gyne bleeding, discharge
[x] No problem

NEURO:
[ ] paralysis [ ] stuporous [ ] unsteady
[ ] seizures [ ] lethargic [ ] comatose
[ ] vertigo [ ] tremors [ ] confused
[ ] vision [ ] grip
Assess motor, function, sensation, LOC, strength
Grip, gait, coordination, speech
[x] No problem

MUSCULOSKELETAL AND SKIN:

[ ] appliance [ ] stiffness [ ] itching
[ ] petechiae [ ] hot [ ] drainage
[ ] prosthesis [ ] swelling [ ] lesion
[ ] poor turgor [ ] cool [ ] deformity
[ ] wound [ ] rash [ ] skin color
[ ] flushed [ ] atrophy [ ] pain
[ ] ecchymosis [ ] diaphoretic [ ] moist
Assess mobility, motion, gait, alignment, joint function
Skin color, texture, turgor, integrity
[x] No problem

NURSING ASSESSMENT II

COMMUNICATION:
[x] Hearing loss
[ ] Visual changes
[ ] Denied
SUBJECTIVE OBJECTIVE
Comments: “Galisud na jud [ ] glasses [ ] languages
kog dungog kung naa koy [ ] contact lens [ ] hearing aide
kaistorya.” As verbalized by [ ] Speech difficulties
the pt. R L
Pupil size: 3mm
Reaction: PERRLA

OXYGENATION:
[ ] Dyspnea Comments: “ Wala man koy Respiration: [x] regular [ ] irregular
[ ] Smoking history problema sa akong pag- Describe: Pt. has normal cycle per min. of 26 cpm
[ ] Cough ginhawa.” As verbalized by the R: symmetric breathing sound to L - lung
[ ] Sputum pt. L: symmetric breathing sound to R - lung
[x] Denied

CIRCULATION:
[ ] Chest pain Comments: “Wala man koy Heart rhythm [x] regular [ ] irregular
gibati na sakit sa akong Ankle edema: none
[ ] Leg pain dughan ug sa akong tiil,
malihok man nako.” As Pulse Carotid Radial Dorsal Pedis Femoral
[ ] Numbness of verbalized by the patient. R + 66bpm + no opportunity
Extremities L + 66bpm + no opportunity
[x] Denied Comments: Pulse has low beat per min. of 66bpm
*If applicable
NUTRITION:
Diet: Lugaw Comments: “Lugaw ra [ ] dentures [x] none
[]N []V man akong gakaonon,
mao may sugo sa Full Partial With patient
Character doctor.” As verbalized
[ ] recent changes in by the pt. Comments:
Upper There is no [ ] [] []
Weight, appetite abdominal distension
[ ] swallowing during
Lower palpitation. For [ ] [] []
difficulty bowel sounds it has a
[x] Denied gurgling noise. The pt.
doesn’t have any
complaint regarding on
difficulty on maturation
symmetric contour also at
the abdomen.
ELIMINATION:
Usual bowel pattern
Two times a day
[ ] constipation
Remedy
Increase fluid intake
Date of Last BM
January 4, 2009
Diarrhea Character
Brown stool
Bowel sounds: Audio bowel
Urinary frequency sounds.
3-5 per day_____ Abdominal distention present [ ]
[] urgency yes [x] no
[] dysuria Urine* (color consistency, odor)
[] hematuria Yellowish in color and odorless,
[] incontinence aromatic odor.
[] polyuria *if Foley is in place?
[] Foley in place
[x] denied

MGT. OF HEALTH & ILLNESS:

[ ] alcohol [x] denied Briefly describe the patient's ability to follow treatments (diet,
( amount, frequency) medication, etc.) for chronic health problems (if present).
“Wala man ko gainom” The pt. follow the treatment specially in his diet because
[ ] SBE Last Pap Smear: NA that time when I observe he is taking his, he eats at the
LMP: NA right time for his right route of his medication.

SUBJECTIVE OBJECTIVE
SKIN INTEGRITY:
[ ] Dry [ ] dry [ ] cold [ ] pale
Comments: “Wala man koy
[ ] flushed [ ] warm
[ ] Itching mga bunga singot.” As [ ] moist [ ] cyanotic
verbalized by the patient
[ ] Others *rashes, ulcers, decubitus (describe size, location, drainage,
color, and odor) There is no rashes ucer and decubitus…
[x] Denied

ACTIVITY/ SAFETY:
[ ] Convulsion
Comments: “kong naa ko [ ] LOC and orientation: The pt. was oriented in the place.
[ ] Dizziness gusto kwaon ipasugojud nako
Gait: [ ] walker [ ] cane [ ] other
[x] Limited motion kay gapanakit na akong
of joints bukogtungod sa tigulang na [ ] steady [ ] unsteady
Limitation in pud ko ug kong maligo, [ ] sensory and motor losses in face or extremities:
ability to kilangan jud naa uban” As The pt. is conscious, has good sensory
[ ] ambulate verbalized by the patient [ ] ROM limitations: The pt. has limitation in activity, when
[ ] bathe self he wants to out in the bed; he needs to have an assistant.
[ ] other
[ ] denied

COMFORT/ SLEEP/ AWAKE:

[ ] Pain Comments: “Magsige ju ko [x] facial grimace

(location , mata – mata inig gabie kay [ ] guarding
Frequency, sige ihi2x.” As verbalized by [ ] other signs of pain: There is no pain, when he is frowning his
Remedies) the patient face when he does not want to do that thing.
[ ] Nocturia [ ] side rail release form signed (60+years)
[ ] Sleep difficulties
[ ] Denied
COPING:

Occupation: Farmer(before) Observed non- verbal behavior: When he does not want to do that
Members of household: (7)seven members things, he just frown as his facial grimace, and also if there is
Most supported person: his child; arltufo jayme and relatives; signs of pain.
bobbie jones segualatan.
The person and his phone number that can be
reached any time: 0929269741

VII. NURSING MANAGEMENT

A. Ideal Nursing Management (NCP)
B. Actual Nursing Management (SOAPIE)

“Dili kaayo ko makatulog kay sige lang ko mata – mata.” As verbalized by

S
the patient.
- Body weakness
- Dark circle under eyes
O - Sleep pattern before from 11pm – 5-6am.
- Sleep pattern during hospitalization 2 – 3 hours in the evening.
- Reports difficulty in falling asleep.
A Sleep pattern disturbance r/t environmental changes psychological stress.
Long term: Physical Assessment
Short term:
P - Giving health teaching regarding with his changing in life style.
- Discuss the purpose for the pt.’s knowledge.
- Monitor vital signs.
 1. Foods and fluid that containing caffeine has been restricted.
2. Family members of the pt. have been instructed to continue guide
and support for the pt. usual bedtime rituals.
3. Family members have been instructed to always provide a quite
I environment and do comfort.
4. The pt. must participate to some exercise for his regular activity to
aid in stress control and to release of energy.
5. Has been recommended inclusion of bedtime shack for his paper
diet.
At the end of 3 days and 8 hours the pt. will be able to have been
E instructed to experience good sleep pattern as evidence of sleeping for
about 8 hours.

S “Maglisud ko og ginhawa.” As verbalized by the patient

- Weakness
- Drowsy
O
- Shallow breathing
- Diagnose with Pneumonia
Impaired gas exchange related to ventilation perfusion imbalance
A
secondary to accumulation of secretion in the lungs.
Long term: Monitor client’s behavior.
P
Short term: Monitor vital signs.
I 1. Instructed the pt. to make a position either semi fowlers’ position
or side lying position.
2. I was encouraging the pt. to cough as tolerated.
3. I monitored the pt. respiratory rate, depth, and effort. Including the
used of his accessory muscle, nasal flaring and thoracic or
abdominal breathing.
4. I monitored the behavior of the clients and his mental status for
onset of restlessness, agitation, confusion and in the late stages
extreme lethargy.
5. I was observing for cyanosis in the skin: note special color of
 tongue and oral mucous membrane.
At the end of 8 hours of giving effective nursing intervention and health
E teaching the pt. will demonstrate and improve ventilation as evidence by
blood gases within client’s normal parameters.

“luya kaayo akong lawas, dili ko ganahan maglihok – lihok.” As verbalized

S
by the patient.
- Weakness is noted
O - Inadequate chest expansion
- RR - 16
Ineffective breathing pattern related to decreased energy and fatigue
A
secondary to disease process.
Long term: Physical assessment
Short term:
P
- Monitor respiratory rate, and depth.
- Giving health teaching
1. I instructed the patient to provide small, frequent feedings.
2. I encourage the pt. to take a depth breath.
I 3. I was encourage the pt. avoid unnecessary movement or activity.
4. I monitored the respiratory rate, depth and ease of respiration..
5. I was noted the pattern of respiration of the pt.
At the end of 8 hour of giving nursing intervention and health teaching the
E
pt. will demonstrate proper breathing pattern with less energy consumed.
VIII. REFERRALS AND FOLLOW – UP

He must always take his medication which is omeprazole for his

upper gastric intestinal bleeding with the right dose, frequency
MEDICATION
and route of 40mg; ┬ cap BID so that he may not over those; and
let the pt. to b aware the side effect that he may possible
experience such as dizziness, drowsiness, fatigue, headache,
weakness, abdominal pain, nausea, and vomiting.
He must exercise daily to strengthen his body and to be healthy.
Exercise that is fit to him walking and then jagging in order for
EXERCISE
him not to feel lazy.
He must follow the doctor’s order regarding for his medication
for easily and continuously recover and take his daily exercise so
TREATMENT
that he can maintain his healthy body.
He must continue to take his medication as doctor’s
recommended and also continue his daily exercise. Encourage to
OUT PATIENT
increase fluid intake and vit. C, avoid in crowded places and
must continue check up once in a month.
He must need a proper diet in order for him to stay healthy so
that he can manage to take his daily medication and exercise.
DIET
X. EVALUATION AND IMPLICATIONS
Implementation which serves actual interventions were proven to
be successful in the patient course of care. The patient cooperated and
participated in the instruction given to him, by which I can proudly say that
our nursing intervention was good.
I also learned to humble myself even more. I also realized that I need to
thank God for giving me a healthy life and letting me care for those people in
need. Indeed, nurses are given a healing gift by God.

This care study has given me a lot of overview on the isolation setting. I
was also given the chance to care for a patient in two days. For those days
various nursing functions was rendered and it gave me the opportunity to
develop and enhance my nursing skills.

Also, with the diagnosis of my client, my knowledge regarding pneumonia

was broadened and it became more visual to us while taking care of my client.
I was able to expand the views regarding disease and widened the horizons to
various clinical manifestations.

My over all general ward exposure at Medical Ward, Northern Mindanao

Medical Center was a great one. It’s a well learned exposure for us.

VIII. DOCUMENTATION
A. Documentation of Evidence of Care for 1 week rotation
 B. Organization/Grammar/Bibliography

Kozier, Erb, Berman, Snyder, FUNDAMENTALS OF NURSING, 7th edition published

by Pearson Education Inc. Copyright 2004,

Wilson, Shannon, Stang, NURSES DRUG GUIDE 2004, Philippine edition published by
PEARSON EDUCATION SOUTH ASIA PTE LTD. Copyright @ 2004, volume 1 & 2,
pp.86- 89, 270- 271

Joyce Young Jonhson, R, PhD, Handbook for Brunner & Suddarth’s: TEXTBOOK OF
MEDICAL- SURGICAL NURSING, 19th edition copyright @ 2004 by Lippincott
Williams & Wilkins

Smeltzer, Bare, Brunner & Suddarth’s, TEXTBOOK OF MEDICAL –SURGICAL

NURSING, 10th edition, volume 1

Marilynn E. Doenges, RN, BSN, MA, CS, Mary Frances Moorhouse, RN, BSN, CRRN,
CLNC, NURSING CARE PLANS: Guidelines for Individualizing Patient Care, 6
edition, copyright @2002 by F.A. Davis Company, pp.304- 328