appendectomy
TRANSCRIPT
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
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TABLE OF CONTENTS:
I. INTRODUCTION……………………………………………………………………….3
a. Current trends about the disease condition………………………………..4
b. Reasons for choosing such case for presentation………………………..5
II. NURSING ASSESSMENT……………………………………………………..…….6
a. Personal History…………………………………………………………...…6
b. Pertinent Family Health-Illness History………………………………….…7
c. History of Past Illness…………………………………………………….….8
d. History of Present Illness………………………………………………..…..8
e. Physical Examination……………………………………………… ………..9
f. Diagnostic and Laboratory Procedures……………………………..……12
III. ANATOMY and PHYSIOLOGY(with visual aids)…………………………….…...14
IV. THE PATIENT’S ILLNESS…………………………………………………….…….18
a. Synthesis of the disease……………………………………………...….…..18
a1. Definition of the disease……………...……………………….……18
b2. Predisposing / Precipitating factors…………………………...….18
c3. Signs and symptoms with rationale………………………… ……19
d4. Health promotion and preventive Aspects of the Disease ..…..20
V. THE PATIENT AND HIS CARE………………………………………………………21
a. Medical Management……………………………………….……… …21
a. IVF’s, BT, NGT feeding, Nebulization, TPN, Oxygen therapy, ...21
b. Drugs……………………………………………………………....….23
c. Diet……………………………………………………………….……25
d. Activity / Exercise………………………………………….….……..26
b. Surgical Management (actual SOPIERs)…………………………….……27
c. Nursing Mangement…………………………………………………….….…28
a. Nursing Care Plan……………………………………………….……28
b. Actual SOAPIES …………………………………………………..…29
VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL…………………………...…..31
a. Client’s daily Progress Chart………………………….………………….….31
b. Discharge Planning……………………………………………………….….31
a. General Condition of Client upon Discharge…….……………...31
b. METHOD…………………………………………...……………….31
VII. CONCLUSION and RECOMMENDATIONS…………………………….….……32
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I. Introduction
The appendix is a closed-ended, narrow tube that attaches to the cecum (the first
part of the colon) like a worm. (The anatomical name for the appendix, vermiform
appendix, means worm-like appendage.) The inner lining of the appendix produces a
small amount of mucus that flows through the appendix and into the cecum. The wall of
the appendix contains lymphatic tissue that is part of the immune system for making
antibodies. Like the rest of the colon, the wall of the appendix also contains a layer of
muscle.
Appendicitis is inflammation of the appendix. It is thought that appendicitis begins
when the opening from the appendix into the cecum becomes blocked. The blockage
may be due to a build-up of thick mucus within the appendix or to stool that enters the
appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks
the opening. This rock is called a fecalith (literally, a rock of stool). At other times, the
lymphatic tissue in the appendix may swell and block the appendix. Bacteria which
normally are found within the appendix then begin to invade (infect) the wall of the
appendix. The body responds to the invasion by mounting an attack on the bacteria, an
attack called inflammation. (An alternative theory for the cause of appendicitis is an initial
rupture of the appendix followed by spread of bacteria outside the appendix.. The cause
of such a rupture is unclear, but it may relate to changes that occur in the lymphatic
tissue that line the wall of the appendix.)
If the inflammation and infection spread through the wall of the appendix, the
appendix can rupture. After rupture, infection can spread throughout the abdomen;
however, it usually is confined to a small area surrounding the appendix (forming a peri-
appendiceal abscess). The treatment for appendicitis is antibiotics and surgical removal of the
appendix (appendectomy). Appendectomy is the removal by surgery of the appendix, the small
worm-like appendage of the colon (the large bowel). An appendectomy is performed because of
probable appendicitis.
Acute appendicitis is the most common cause in the USA of an attack of severe,
acute abdominal pain that requires abdominal operation.
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The incidence of acute appendicitis is around 7% of the population in the United
States and in European countries. In Asian and African countries, the incidence is
probably lower because of the dietary habits of the inhabitants of these geographic
areas. Appendicitis can effect any at any age, with highest incidence occurring during
the second and third decades of life. Rare cases of neonatal and prenatal appendicitis
havebeenreported. Appendicitis occurs more frequently in men than in women, with a
male-to-female ratio of 1.7:1.
A. Current Trends about Appendicitis
Care protocols reduce appendectomy complications - Tips from Other
Journals
Appendectomy is the fourth most common abdominal surgery performed in the United
States. Up to 18 percent of patients have postoperative infectious complications ranging
in significance from wound infection to intra-abdominal abscess. The rate of infections
depends on the degree of contamination during surgery and reaches nearly one third of
cases when the appendix is perforated or gangrenous. Helmer and colleagues studied
the effect of an evidence-based clinical practice guideline in reducing infectious
complications of appendectomy.
The clinical practice protocol that was developed from a critical review of the literature
(see accompanying figure) was applied to 206 patients with a presumptive diagnosis of
appendicitis who presented to a Texas county hospital during 1999. Outcomes in this
cohort of patients were compared with those in 232 patients treated for the same
condition at the hospital during the previous year. No patients were excluded from the
study. Data were gathered on demographic and surgical features, comorbidities, use of
antibiotics, evidence of infection, and other complications during the hospital stay.
Eight patients (4 percent) who were treated according to the protocol had postoperative
surgical infections, compared with 20 patients (9 percent) in the comparison group. The
number of patients with intra-abdominal abscesses dropped from 12 to five after
introduction of the protocol, and the number of wound infections dropped from 14 to four.
The improvement was particularly significant in patients presenting with a perforated or
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gangrenous appendix. In these patients, the total number of infections dropped from 16
(33 percent) to five (13 percent).
The authors conclude that use of an evidence-based clinical practice guideline can
significantly reduce surgically related infections following appendectomy and is
particularly effective in patients with perforation or gangrene of the appendix.
B. Reasons for choosing such case
One of the formidable part in doing a case study is choosing what case is to
present. We had this unanimous decision of choosing Girl Agnes’ case, first and
foremost because with our initial contact we already established hormonious relationship
with the patient and her significant others. We had established the “trust” we yearn from
them and that makes it easy for us to ask certain questions we need for our case and
interact with them properly. Another thing is because we find them kind and humorous
that is why our previous interaction with them is smooth and conventional. Most
importantly, the term Appendicitis is not accustomed to us that much. With that thought
alone, we want to further enhance our knowledge about the disease such as to ensure
appropriate evaluation of the etiology, reassess and address the course the illness takes
in its progression. Also, to have an experience in handling and providing humanitarian
health services to a patient who has it and provide any intervention or treatment
indicated based on the specific etiology and the course it follows in that specific patient.
With that scenario, it is not only the knowledge that was enhanced but also our skills as
health care practitioners.
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II. Nursing Assessment
A. Personal History
Princess Lulu M. Ba 65 years old, female, currently residing at 176
Dolores, Magalang Papanga. A typical Filipina and presently a part of the Roman
Catholic. She was born on January 3, 1939. She is married with eight children, where
some are married. Currently, she is just staying at home and she is dependent to his
children for support. Sometimes she takes care of her grandchildren at home. She also
cooks food for them and clean the house. Since he has this kind of lifestyle, and
because of his age, last February 28, 2006 she manifested symptoms of appendicitis
which was the reason why she was rushed to ONA.
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B. Pertinent Family Health-Illness History
7
Ba Family
Palaceo Father o Alcoholico Died of a ruptured
appendicitis
Jewelo Mothero Alcoholico Died of
Tuberculosis
Prince Stepheno husband
Princess Luluo Patiento Dignosed
with appendicitis
Bu
-37-Married -working
La-32-single-Construction worker
Ba-28-married-housewife
Jel-27-marriedconstruction worker
Tah-15-single-not going to school
Mah-17-single-college student
Ad-22-single-vendor
Bon-24-married-vendor
Living Condition
House:
They live in a bungalow type of house, concrete and some of the married
members of the family resides
Food:
Their food is always a usual Filipino dish consisting of rice, fish, meat and
vegetables. Their source of water is the pump.
Economic Status:
Princess Lulu is not working; she is dependent on his children for support. Her
daughter, told us that 150-200 pesos a day is enough for them to satisfy the day.
Beliefs:
The BA Family believes in “herbolarios” and “hilots” and directly seek
advices from them if any sickness occurred. They seldom bring members of the family to
doctors or to the hospital for consultation or treatment of any disease.
C. History of Past Illness
She has always been healthy ever since he was a kid and he was never been
brought to the hospital. She had normal Blood pressure, with no signs of hypertension,
Diabetes Mellitus or even Tuberculosis. Aside from fever, colds and cough, nothing
hinders him from doing his daily activities.
D. History of present Illness
It was February 28, 2006, 7 in the evening when she started to feel some pain in
the abdominal area, accompanied by fever; she was chilling and felt nauseated and
vomited several times. At 11 pm of the same night, she was still experiencing the same
but the pain is worsen. Early in the Morning, they rushed him to the ONA. Dr. Dizon
assessed her and diagnosed it as acute appendicitis because of (+) muscle guarding,
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(+)direct and rebound tenderness on the right lower quadrant. The patient was also
assessed for Psoas sign and Obturator sign and was found out that the patient was in
pain during the assessment hence he was admitted right away and had an emergency
appendectomy.
E. Physical Examination
March 01, 2006
BP=110 / 90 RR= 20 bmp
T= 37.2º C PR=84 bpm
SKIN
a .General: dark brown in color; dry skin; absence of edema; when pinched skin
springs back to previous state, poor turgor
NAILS
a. General: converse curvature; smooth texture; long with dirt; promp return of pink
or usual color
HAIR
a. evenly distributed; thick hair; dry; black in color
HEAD AND FACE
a. scalp: no evidence of flaking or dandruff
b. skull: rounded; smooth skull contour; absence of nodules or masses
c. face: palpabral fissures equal size
EYES
a. general: symmetrically aligned
b. eyebrows: symmetrically aligned equal movement; hair evenly distributed
c. eyelashes: equally distributed curled slightly outward
d. eyelids: skin intact; no discharge; no discoloration; involuntary blinks
e. sclera: whitish with capillaries
f. conjunctiva: shiny; smooth
g. pupils: black in color; equal size; + PERRLA; round, smooth border
h. vision: able to read newsprint; sensitivity to light
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EARS
a. general: mobile;firm; no tenderness; pinna recoils after it is folded; no infection
b. external ear canal: presence of hair follicles; presence discharge
NOSE
a. external: symmetric and straight; not tender; air moves freely as the client
breaths
b. internal: presence of hair
MOUTH AND OROPHARYNX
a. lips: uniform pink color; dry; ability to pursue lips
b. teeth: missing teeth due to cavities; discoloration of enamel
c. tongue: no lesions; with thin whitish coating; able to roll the tongue upward and
side to side
d. palates and uvula: light pink; positioned in the middle of soft palate
e. tonsils: pink; no swelling
NECK
a. muscles: equal in size; head centered; equal strength
b. movement: coordinated smooth movements without discomfort
c .lymph nodes: not palpable
d.thyroid gland: not visible
CHEST
a. external: symmetric; spinal column is straight; skin intact; chest wall intact; no
tenderness; full symmetrical chest expansion
b. lungs: normal breath sounds; absence of DOB
CARDIOVASCULAR
a. heart: absence of heart sounds; normal beating pattern
ABDOMINAL
a. general: with direct and rebound tenderness on the right lower quadrant; with
indirect tenderness;
MUSCULOSKELETAL
a. general: equal size on both sides of the body; no contractures; no tremors;
normally firm; no deformities
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Cranial Nerves
I. Olfactory– have the sense of smell
II. Optic – normal visual acuity
III. Oculomotor– positive papillary reflex and eye convergence test
IV Trochlear– positive papillary reflex and eye convergence test
V. Trigeminal – can sense the sensation of pain, touch, temperature and normal muscle
strength.
VI. Abducens– positive papillary reflex and eye convergence test
VII.Facial – normal muscle strength of facial expressions
VIII. Vestibulocochlear– normal voice tones audible; able to hear ticking on the both
ears.
IX. Glossopharyngeal– (+) gag reflex; can swallow
X. Vagus– (+) gag reflex
XI. Accessory– normal muscle strength
XII. Hypoglossal – normal tongue movements
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F. Diagnostic and Laboratory Procedures
Diagnosis/ Lab procedure
Date orderedDate result
Indication or purpose
result normal value
Analysis & interpretation of result
Urinalysis
O: 03-01-06
R: 03-01-06
- to determine urine composition such as blood, glucose, protein
Yellow, clearSugar: ( - )Ph: acidicSp. Gravity: 1.030Pus cells: 0-1 HPFRBC: 1-2 HPF
Yellow, clearSugar: ( - )Ph: acidicSp. Gravity: 1.003-1.030Pus cells: +10 HPFRBC: 0-3 HPF
The microscopic analysis shows normal levels.
Nursing Responsibilities:
Explain the procedure and the purpose to the client. Explain to the client the importance of the procedure Explain to the client that urine sample is needed Ask the client if he/she had eaten, it can alter the result Ask the client what are the medication that he/she had taken. If there is infection, tell the patient that the test will be repeated to monitor any
development.
Diagnosis/Lab
Date orderedDate result in
Indication or purpose result Normal value
Analysis & interpretati
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procedure on of the result
Hematologic test
O: 03-01-06
R: 03-01-06
-to indicate anemia and polycythemia
Hgb: 1.50
WBC: 14.6Hct: 0.45
RBC: 5.25
Hgb:M: 140-180 gm/LF: 120-160 gm/LWBC:5.10 x 10/LHct:M: 0.40-0.54 L/LF: 0.37-0.47 L/LRBC:M: 4.5-6.3 x 10/LF: 4.2-5.4 x 10/L
White blood cell is above the normal range, there is systemic infection. Leukocytosis indicates appendicitis.
Diagnosis/Lab procedure
Date orderedDate result in
Indication or purpose result Normal value
Analysis & interpretation of the result
Hematologic test
O: 03-01-06
R: 03-01-06
-to indicate anemia and polycythemia
Hgb: 139
WBC: 12.4Hct: 0.41
RBC: 5.25
Hgb:M: 140-180 gm/LF: 120-160 gm/LWBC:5.10 x 10/LHct:M: 0.40-0.54 L/LF: 0.37-0.47 L/LRBC:M: 4.5-6.3 x 10/LF: 4.2-5.4 x 10/L
A decrease in hemoglobin indicates anemia.White blood cell is above the normal range, there is systemic infection. Leukocytosis indicates appendicitis.
Nursing Responsibilities:
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Explain the procedure and the purpose to the patient. Explain to the patient that it requires blood sample and it can cause pain and
discomfort due to the needle puncture. Ask the patient if he/she had eaten food because it can alter the result. Ask the patient if he/she had taken some drugs because it can alter the result. Ask for the religion and culture of the patient.
III. Anatomy and Physiology
In a normal human female, the GI tract is approximately 25 feet or 7 and a half meters
long and consists of the following components
Mouth (Oral cavity/ Bucal Cavity, includes tongue, teeth, salivary glands and
mucosa)
The mouth is the first of the digestive tract. It is the opening through
which takes in food. It is lined by stratified squamous non-cornified
epithelium, except the hard palate, gingival and filiform papillae of tongue which
are cornified.
It is bound infront by the lips, above by the hard and soft palate, below by
the floor of the mouth including the tongue and behind by the faucial isthmus.
Pharynx
The pharynx is the part of the digestive system which connects the mouth
with esophagus. It is where the digestive tract and the respiratory tract cross,
commonly called the throat. The human pharynx is bent at a sharper angle.
Esophagus (Gullet/ Oesophagus)
The esophagus is a muscular tube, lined with moist stratified squamous
epithelium that extends from the pharynx to the stomach. It is about 25 cms.
Long and lies anterior to the vertebrae and posterior to the trachea within the
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mediastinum. It passes through the diaphragm and ends at the stomach. It
transports food from the pharynx to the stomach.
Stomach
The stomach is an enlarged segment of the digestive tract in the left
superior part of the abdomen. It is an alimentary canal used to strore and digest
food. It’s primary function is as a storage and mixing chamber for ingested food.
It is lined with simple columnar epithelium. Latin names for the stomach include
Ventriculus and Gasti, many medical terms related to the stomach part in “gastro”
or “gastric”.
In humans the stomach is a highly acidic environment (maintained by the
hydrochloric acid secretion) wit peptidase digestive enzymes.
In ruminants, the stomach is a large multichambered organ that hosts
symbiotic bacteria which produced enzymes required for the digestion of
cellulose from plant matter. The partially digestive plant matter passes through
each of the stomach’s chambers in sequence, being regurgitated and rechewed
at least once in the process.
Bowel/Intestine
Small Intestine
Small intestine is the portion of the alimentary tract between the stomach
and the large intestines whose main function is for absorption. It is about 6
meters long and consists of 3 parts: duodenum; jejunum and ileum.
Duodenum
Duodenum is a hollow jointed tube that connects the stomach to the
jejunum, it is the shortest, the widest and most fixed part of the small intestine
and is largely retro-peritoneal closely attached to the dorsal wall.
Jejunum
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Jejunum is about 2.5 meters long and makes up 2/5 of the total length of
the small intestine.
Ileum
The ileum joins with the cecum at ileocal junction. It is about 3.5 meters
long and it makes up 3/5 of the small intestine.
Large Intestine
The large intestine extends from the ileocal junction up to the anal
opening in the peritoneum. It is about 5-6 feet long. It is subdivided into: cecum
and appendix, colon, rectum and anal canal.
Cecum and Appendix
Cecum is the proximal end of the large intestine and is where the large
and the small intestine meet at the ileocal junction. It is located in the right lower
quadrant of the abdomen near the iliac fossa. It is a sac that extends inferiorly
about 6 cms. past ileocal junction. Attached to the cecum is a tube about 9 cms.
long called the APPENDIX.
Colon
The colon is about 1.5-1.8 meters long and consists of four parts:
Ascending colon
Transverse colon
Descending colon and sigmoid colon
Ascending Colon
The ascending colon extends superiorly from the cecum to the right colic
flexure near the liver, where it turns left
Transverse Colon
The transverse colon extends from the right colic flexure to the left colic
flexure near the spleen, where the colon turns inferiorly.
Descending Colon and Sigmoid Colon
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The descending colon extends from the left colic flexure to the pelvis,
where it becomes the SIGMOID COLON. The sigmoid colon forms an S-shaped
tube that extends medically and the inferiorly into the pelvic cavity and ends at
the rectum.
Rectum
The rectum is a straight muscular tube that begins at the termination of
the sigmoid colon and ends at the anal canal.
Anal Canal
The anal canal represents the terminal portion of the large intestines and
it is about 2-3 cms. long
IV. The Patient’s Illnesses
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A. Synthesis of the Disease
a1. Definition of the Disease
Appendicitis is the inflammation of the vermiform appendix, which is
attached to the cecum and lies in the right lower quadrant, the appendix can lie
medial, lateral, anterior or posterior to the cecum, it is behind the bowel or
mesentery or in the pelvis.
The average adult appendix is 9-10 cm in length with a diameter of 0.5 to
1 cm. Its blood supply, the appendiceal artery, is a terminal branch of the
ileocolic artery which transverses the length of the appendix.
This small finger shaped tube branches of the large intestine. There is no
specific cause of appendicitis, although inflammation can occur spontaneously
from an infection or from fecal waste that have been trapped in the lumen of the
appendix. The appendix can also become kinked, obstructing the circulation.
Abscess formation generally occurs and danger of rupture is omnipresent.
Appendicitis is characterized by a sharp abdominal pain that may be
localized at McBurney’s point (half way between the umbilicus and right iliac
crest). Palpation of the abdomen causes pain in the right quadrant.
Pressing the abdomen at McBurney's point causes tenderness in a
patient with appendicitis. When the abdomen is pressed, held momentarily, and
then rapidly released, the patient may experience a momentary increase in pain.
This "rebound tenderness" suggests inflammation has spread to the peritoneum.
If the appendix ruptures, the pain may disappear for a short period and
the patient may feel suddenly better. However, once peritonitis sets in, the pain
returns and the patient becomes progressively more ill. At this time the abdomen
may become rigid and extremely tender.
Appendix occurs most commonly on children, adolescents and young
adults but individuals of any age may have appendicitis.
a.2.Predisposing / Precipitating Factors
Predisposing Factors:
Classic history of appendicitis
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Sex: Appendicitis is 1.3 to 1.6 times more common in males than in
females
Age: the peak incidence is in the second and third decades with 80 %
of cases occurring in persons younger than 45 years of age but
individuals of any age may have appendicitis.
Anatomical Variations in the position of the appendix.
Precipitating Factors:
Lymphoid Follicular Hyperplasia
Infections by viruses, parasites or bacteria
Diet deficient in fiber
a.3. Sign and Symptoms
Appendicitis often starts with mild pain near the navel. The pain gradually
moves to the right lower part of the abdomen. It worsens with time, and is more
intense when the person moves. Other symptoms of appendicitis may include:
· Nausea or vomiting.
· Elevated temperature.
· Increased pulse rate.
· Loss of appetite.
· Constipation.
· Abdominal swelling.
If the infection continues, the appendix may rupture. When this occurs,
there is often relief of the pain for a short while. This improvement is followed by
more intense but similar pain.
Chronic appendicitis is rare. It causes a milder pain in the right lower
abdomen that may come and go.
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d.3. Health promotion and Preventive Aspects of the Disease
A-void too much activity(eating then working or playing right away)
P-eople of any age are susceptible, male are more prone
P-revent obstruction of the lumen
E-xercise
N-otify physician if any signs and symptoms occur
D-iet should be high in fiber; so to..
I-increase peristalsis to prevent constipation
X-ray, ultrasound and other lab test should be take into consideration to
avoid rupture of the appendix
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V. THE PATIENT AND HIS CARE
1. Medical management
A. IVF’s
Medical Management/ Treatment
Date ordered; performed; changed
General Description
Indication/s
Or
Purpose/s
Client’s Initial Reaction to the Treatment
Client’s response to the Treatment
D5LRS 1L x 8 @ 30-31 gtts./min
# 1
# 2
# 3
# 4
# 5
# 6
O: 03-01-06C: 03-01-06
O:03-02-06C:03-02-06
O:03-02-06C:03-03-06
O:03-03-06C:03-04-06
O:03-04-06C:03-05-06
O:03-05-06C:03-05-06
Slightly hypertonic solution, this solution exerts higher osmotic pressure than of the blood plasma. D5LRS will increase the solute concentration of plasma, draining water out of the cells into the extracellular compartment to restore osmotic equilibrium. D5LRS contains 130 mEq/L Sodium, 4 mEq/L of Potassium. 109 mEq/L Chloride, 3.0 mEq/L of Calcium. It has 120
Used to
replace
deficits in the
extracellular
compartment
in patients
that are
dehydrated
and volume
depleted.
D5LRS is administered and given to patient to give the necessary nutrients to replace any lost fluids since the patient is in NPO. It is also used as a main line to administer Antibiotics
Client has a guarding behavior but was cooperative with the treatment procedure. He responded well to the treatment.
>Check IV
Tubing for
the
presence of
air
>Check
Integrity of
the Infusion
>Monitor IV
flow rate
>Adjust rate of flow of fluids appropriate to need of patient as prescribed
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calories. and medications IV.
Medical Management/ Treatment
Date ordered;
performed; changed
General Description
Indication/s
Or
Purpose/s
Client’s Initial
Reaction to the
Treatment
Client’s response
to the Treatment
D5NM 1Lx 35 gtts/min
#4 O: 01-31-06C: 01-31-06
Hypotonic solution it maybe iso-osmolar since dextrose is rapidly metabolized. Normosol M contains dextrose 50g, dehydrated alcohol 40ml, potassium acetate 1.28g, fructose 150g,NaCl 2.34g, Mg acetate 0.1g
Provides principal ions of normal plasma is almost the same proportions as with normal plasma. Replacement of acute looses of extraxcellular fluid volume in surgery, it was given to the patient to prevent dehydration and contains plasma volume.
Client has a guarding behavior but was cooperative with the treatment procedure. He responded well to the treatment.
No signs of abnormalities observed or felt by the patient.
Nursing Responsibilities
Before administering the IV, identify first the pationt
Explain the procedure
Prepare the equipment
Wash hands
Check the fluid to be infused
Use the smallest gauge needle possible
Drip the tubing before connecting to the needle once being infused
Adjust the IVF as indicated
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Report any pain, infufusion or dislocation felt by the patient
B. Drugs
Name of the DrugsGeneric NameBrand Name
Date OrderedDate TakenDate Changed
Route and Frequency of administration
Indication/ Purposes
Specifi Foods taken
Client’s response to medication
Paracetamol03-01-0603-01-0603-06-06
1 amp. IV q 4° ,non narcotic analgesicsdecreases fever
NPO The patient took the drugs properly, infection reduced, no side effects observed
Cefuroxime 03-02-0603-02-0603-04-06
750mg IV q 8° -Antiinfective-2nd generation cephalospor ins-inhibits bacterial cell wall synthesis rendering cell wall osmotically unstable, leading to cell death by binding to cell wall membrane
NPO The patient took the drugs properly, infection reduced, no side effects observed
Metronidazole 03-02-0603-03-0603-06-06
500mg IVq8 ANST(-)
>Ambecide >Anti-infective>kills susceptible amoeba, trichomonas and bacteria
NPO Patient had no manifestations of any side effects
Tramadol 03-02-0603-03-0603-06-06
100mg IV q 6º RTC
>Analgesic, centrally acting>
NPO-Clear liquid
Patient had no manifestations of any side effects
Plasil 03-02-0603-02-06
5mg/ml q 8° x 4 doses
>anti-emetic NPO Patient had no manifestation regarding any
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03-03-06 side effects
Famotidine 03-02-0603-02-0603-03-06
20 mg IV q 12º x 3 doses
Histamine H2 antagonist
NPO Patient had no manifestation regarding any side effects
Kortezor 03-02-0603-02-0603-03-06
30 mg IV q 8º x 4 doses
Pain reliever NPO Patient had no manifestation regarding any side effects
Captopril 03-03-0603-03-0603-03-06
25mg SL NPO-Clear liquid
Dulcolax03-05-0603-05-0603-05-06
Supp 2 suppl rectum
-laxative, stimulant-diphenylmethane-acts directly on the intestine by increasing motor activity; thought o irritate colonic intramural plexus; increases ater in the colon
Soft diet
Patient had no manifestation regarding any side effects
Nursing Responsibilities:
Assess patient from allergic reaction (ANST)
Assess the patient for any sign and symptoms
Identify Urine output, if decreasing, notify the physician
Caution patient to report bleeding, bruising or fatigue
Monitor patient bowel and consistency of stool
Evaluate for therapeutic response: release of pain, stiffness, swelling
Document indications for therapy.location, onset, and charcteristic of symptoms
Assess for history of drug addiction, allergy to any medicine
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Monitor vital signs
Obtain CBC and necessary cultures before administering
Encourage increased fluid intake
Document
C. Diet
Types Of Diet
Date orderedDate startedDate changed
General Description
Indications or Purpose
Specific Foods taken
Client’s response to the treatment
NPO 03-01-0603-01-0603-03-06
Restriction of solid nor liquid foods by mouth
Upon admission to provide more accurate observation in the condition of the client and for pre and post operative patient to prevent aspiration of the food taken in as an effect of the anesthesia.
She exhibited some loss of appetite.
Clear Liquid Diet
03-03-0603-03-0603-03-06
Made up of clear liquid foods which leave no residue in the GIT. It is non-stimulating, non-gas forming, and non-irritating.
It is mainly used for post operative patients, patients with acute illness and infections, to relieve thirst, to reduce colonic fecal matter. It is done between 1-2 feeding intervals.
WaterPineapple juiceJelly ace
she first seemed to have a loss of appetite with the ordered diet, but then gradually took in the foods that were ordered by the physician.
Soft Diet
03-04-0603-04-0603-06-06
It is similar to the regular diet except that the texture of the foods has been modified. It is a diet modified in consistency to have new roughage, liquefied foods, semi-solid foods and those which are easily digested. This could offer an entirely adequate, liberal diet.
It is used for patients with acute infections, some GIT disturbances or chewing problems and following surgery
SoupLugawCrackersMammonPineapple juicewater
The patient manifested an improved appetite.
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Nursing Responsibilities:
The benefits as well as the disadvantages should be explained well to the client.
The nurse should make sure that the patient adheres to the ordered diet.
The ordered diet should be monitored.
Continuous monitoring of the client’s diet should be observed
d. Activity/Exercise
Type of exercise
Date ordered, date started, date changed
General description
Indication or purpose
Client’s response to the activity or exercise
Bed rest
Ambulation(walking)
Date ordered03- 01 -06Date started03-01-06Date changed03-03-06
Date ordered03-04-06Date started03-04-06
Pt. is restricted from any stressful activities
Pt. performed ADLs, maintain good body alignment and carry out active ROM exercises.
To decrease oxygen and energy demand.
To be able limit movements and strengthen the muscles.
Pt. was able to avoid any stressful activities.
Pt. was able performed her ADLs like walking
Nursing responsibilities:
Check for the doctors order
Explain the purpose of the exercise to the client
Instruct client to maintain the exercise ordered by the physician
Assist the patient in moving and walking
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Provide comfort measures to avoid injury of the patient
B. Surgical Management
a. Brief Description
A surgical procedure called an appendectomy is necessary before the appendix
ruptures. Attempts are made to remove the inflamed appendix before it ruptures and
preoperative care is directed toward resting the colon. No enemas, heating or laxatives
should be used before surgery because they could stimulate peristalsis and cause a
rupture of the appendix.
The appendix is removed through a small incision over McBurney’s point or
through a right paramedical incision. The incision usually heals with no drainage. Drains
are used when an abscess is discovered when the appendix has rupture and sometimes
when the appendix was edematous and ready to rupture and was surrounded by clear
fluid.
If no rupture has occurred, a laparoscopic appendectomy, in which the appendix
is removed through a scope maybe done. A laparoscopic appendectomy requires only
small incision and allows client to be discharged 24 hours after surgery.
Bowel function is usually normal soon after surgery and convalescence is short.
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b. Nursing Responsibilities
Preoperative
Assess the location, severity, onset, duration, precipitating factors and
alleviating measures in relation to the pain
Intravenous fluids as prescribed to maintain fluid and electrolyte balance
Instruct nothing by mouth to the patient prior to surgery
Record allergies and medications as well
Place the patient in semi fowlers or side lying position to provide comfort
Analgesics are withheld until physicians determines diagnosis
Post Operative
Determine (+) flatus
Clear Liquid after Flatus
Soft Diet after
Assist patient in turning, coughing and deep breathing to promote
expansion of the lungs
Assess abdominal wound for redness, swelling and foul discharge
Provide wound care
Promote early ambulation
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b. Actual SOPIE
S>Ø
O> the patient manifest the following
(+) guarded behavior
(+) facial grimaces
(+) restlessness
(+) pupillary dilatation
(+) narrowed focus
Onset of pain: often; Quality: Stabbing and throbbing; Region on RLQ;
severely: always; Level of pain of 10/10
A> Acute pain R/T stimulation of nerve endings
P> After 2-3° of Nursing Intervention and health teaching the pt will be
able to decrease pain from 10 to 6 using a scale of 10 as evidence by
using of relaxation technique and diversional activities.
I>
Monitored and recorded vital signs
Assessed patient condition
Performed comprehensive assessment of pain
Accepted patient perception of pain
Observed non-verbal cues
Encouraged verbalization of feeling about pain
Provided quiet and calm environment
Provided patient comfort measures
Encouraged relaxation exercise such as deep breathing
Encouraged diversional activities
Encouraged adequate rest
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Discussed with SO way on how to assist patient to reduce pain
E> Goal met AEB reducing of pain from 10 to 6 using a scale of 10
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VI.CLIENT’S DAILY PROGRESS IN THE HOSPITAL
a.Client’s daily progress chart
Days Admission 03-02-06 03-03-06 03-04-06 03-05-06Nursing Problems
Acute Pain / / / / /Risk for deficient
fluid volume/ /
Impaired skin Integrity
/ / / /
Physical Immobility / / / / /Risk for Infection / / / / /
Vital SignsBlood PressureTemperature
Respiratory RatePulse Rate
8am110/80
36.92082
8am100/70
372184
8am110/60
372189
8am110/80
36.62166
8am90/6036.12070
Lab Procedures
Medical Managements
1. IVF’sD5LRS
/ / / / /
Drugs:Paracetamol / /Cefuroxime / /
Metronidazole / / / /Tramadol / / / /
Plasil / / / /Famotidine / / / /
Kortezor /Captopril /Dulcolax /
DietNPO /
Clear Diet /Soft Diet / / /
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B.Discharge Planning
a. General Condition Of client upon Discharge
Since we were not able to see the client when she was discharged
from the Hospital, with few days of nursing intervention, the client’s
general condition has improved:
1. She is slowly regaining his strength
2. She can ambulate with assistance
b. METHODM- take the medicines prescribed
E- exercise such as walking and proper breathing
T- daily wound cleaning
H- increase fluid intake, vitamin C, apply hot compress
O- be back at OPD as ordered by the doctor
D- Diet as tolerated with an increase intake of Vitamin C
VII. Conclusion and Recommendation
Every individual of any age are prone to appendicitis though its more common
with males, still everyone is susceptible, mild umbilical pain maybe vague at first, but it
increases intensity. Over a period of time, signs and symptoms occur rapidly, it cannot
be presented an experience of this shall be contented with proper prevention.
Faulty diet especially low in fiber is one cause of the observation therefore by
eating fiber- rich food will increase peristalsis. So there is regular bowel movement. So
there is no fecal material that will be formed.
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Not everyone with appendicitis has all the symptoms. The pain may intensify and
worsens other may have a sensation called “down ward urge” pain medication and other
laxatives should not be taken in their situation. Anyone with these symptoms need to see
a qualified physician immediately.
Recommendation
One should always remember the health promotion and prevention of
appendicitis. Just remember the acronym APPENDIX, which is avoiding too much
activity, that people of any age and sex are susceptible. One should always play safe in
preventing obstruction of the lumen. Exercise is important. Notify physician if any signs
and symptoms occur. Diet should always be high in fiber to increase peristalsis and to
prevent constipation. Lastly x-ray, ultrasound and other laboratory test should be taken
into consideration to avoid response of the appendix.
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