case study of ruptured appendicitis with localize peritonitis (final)
TRANSCRIPT
RUPTURED APPENDICITIS WITH LOCALIZE PERITONITIS
A CASE PRESENTATION
Presented to:
THE FACULTY OF THE COLLEGE OF ALLIED MEDICAL SCIENCESNURSING DEPARTMENT
SURIGAO EDUCATION CENTER
In FulfillmentOf the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSINGLEVEL – 3
Presented by:
ARGUILLAS, Grace za T.CHUA, Emily L.
COSTINIANO, Daryll Richmond J.ENARIO, Cheryl C.
EVIOTA, Lanie Ann A.GIER, Rosemarie M.PADILLA, Ruth D.
PAQUEO, Michael M.RAMOS, Honna Bina N.
REPUTANA, Jane A.
OCTOBER 2011DEDICATION
SURIGAO EDUCATION CENTERKm. 2, 8400 Surigao City, Philippines
This case presentation is indeed the fruit of our endeavor. A sweet success from the sweat
of our hard work that worth every single moment and time that we share in making this, precious
art of learning. Of all the sacrifices, we would heartily dedicate our case presentation to the
following people:
To our parents, who undyingly showed their moral and financial support to us, as we take
every fruitful steps of our endeavor.
To our clinical instructors, for imparting us their knowledge on how are we going to
perform all different procedures of the nursing process, to make us fully equipped as we embark
towards the realization of our chosen profession.
And most especially to our Heavenly Father, who showered us all the guidance and the
abundance of grace.
THE PRESENTORS
ACKNOWLEDGEMENT
As the presenters of this group case presentation, with deep appreciation and heartfelt
gratitude, we would like to acknowledge the following people who have supported us and made
this study a successful one:
To our parents who morally and financially supported us. For their encouragement and
understanding why were always late in coming home.
To our instructors who undoubtedly impart their knowledge and showed their support to
us.
To all staff of Caraga Regional Hospital, who gave us the permit to copy all the
information necessary for this educational output to be completed from the patients chart.
To the patient and patient’s family who never ceased to answer whatever questions we
have raised.
And most especially, to our Heavenly Father for giving us all the blessings, strength,
wisdom and enlightenment that we are able to complete all the information needed.
Indeed, this case study has definitely enhanced and advanced our knowledge in our
chosen career.
THE PRESENTORS
CASE CONTENTS
TITLE PAGE
DEDICATION
ACKNOWLEDGMENT
INTRODUCTION
REVIEW OF RELATED LITERATURE
PATIENT HEALTH HISTORY
PHYSICAL ASSESSMENT
12 CRANIAL NERVE ASSESSMENT
REVIEW OF SYSTEM
LABORATORY EXAM
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
DRUG STUDY
NURSING CARE PLAN
DISCHARGE PLAN
APPENDICES
A. INTRAVENOUS FLUID
B. FAMILY GENOGRAM
C. DEFINITION OF TERMS
BIBLIOGRAPHY
INTRODUCTION
Our body has composed of twelve (12) different body systems; one of this is the digestive
system. Digestive system breaks down food into absorbable units that enter the blood for
distribution to body cells; indigestible foodstuffs are eliminated as feces. Digestion takes place
almost continuously in a watery, slush environment. The large intestine absorbs the water from
its inner contents and stores the rest until it is convenient to dispose of it. Attached to the first
portion of the large intestine is a pouch called the vermiform appendix. According to our
ancestors and even on the present time, appendix has no function in the human body but it is part
of the large intestine. However, many theories, that human appendix have a function; it carries
good bacteria. With function or without, appendix can be fatal when it gets infected and not
treated right away.
The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the
cecum just below the ileocecal valve. The appendix fills with food and empties as regularly as
does the cecum, of which it is small, so that it is prone to become obstructed and is particularly
vulnerable to infection (appendicitis). Appendicitis is the most common cause of acute
inflammation in the right lower quadrant of the abdominal cavity. It is thought that appendicitis
begins when the opening from the appendix into the cecum becomes blocked. The blockage may
be due to build-up thick mucus within the appendix or stool that enters the appendix from the
cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is
called Fecalith.
Mr. P., 16 years old, College student resides at Vasquez St. Surigao City while attending
school at SSCT. He grew up at Brgy. Villa Flor, Gigaguit, Surigao Del Norte. Admitted at
Caraga Regional Hospital last September 01, 2011 and diagnosed with ruptured appendicitis
with localized peritonitis. His chief complaint was severe abdominal pain scale of “10/10” and
vomiting 5-7 times in one day.
According to oxfordjurnals.org, the author’s analyzed National Hospital discharge survey
data for the years 1979-1984. Approximately 250,000 cases of appendicitis occurred annually in
the United States during this period. The highest incidence of primary positive appendectomy
(appendicitis) was found in persons aged 10-19 years old; males had higher rates of appendicitis
than females for all age groups. Furthermore, the incident rate of appendicitis in the Philippines
is approximately 215,604 persons, out of estimated population of 86, 241, and 6972.
Appendicitis is an inflammation of the appendix, a 3 1/2-inch-long tube of tissue that
extends from the large intestine. If the inflammation and infection spread through the wall of the
appendix, the appendix can rupture, causing infection of the peritoneal cavity called peritonitis.
The pain become more diffuse, abdominal distention develops as a result of paralytic ileus, and
the patient’s condition become worsens.
In Mr. P’s case, he has ruptured appendicitis with localized peritonitis. We choose the
case of Mr. P, to know the nature of the disease the risk factors, its complications and
preventable measures; because, the complications of the disease cause many devastating health
problem if left untreated.
REVIEW OF RELATED LITERATURE
Appendicitis, the most common cause of acute inflammation in the right lower quadrant
of the abdomen, is the most common reason for emergency abdominal surgery especially when
ruptured occurs. According to Brunner & Suddarth, “about 7% of the population will have
appendicitis at some time in their lives; males are affected more than females and teenagers more
than adults. Although it can occur at any age, it occurs most frequently between the ages of 10
and 30 years old”.
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
Appendicitis usually happens after an infection in the digestive tract, or when the tube
connecting the large intestine and appendix is blocked by trapped feces or food. Both situations
cause inflammation, which can lead to infection or rupture of the appendix. Untreated, mortality
is high, mainly because of the risk of rupture leading to peritonitis and shock. Also, if the
abdomen on palpation is also involuntary guarded (rigid) there should be a strong suspicion of
peritonitis.
Signs and Symptoms:
Pain starting around the navel, then moving down and to the right side of the
abdomen. The pain gets worse when moving, taking deep breaths, coughing
sneezing or being touched (McBurney’s point).
Loss of appetite
Nausea, and Vomiting
Change in bowel movements, including diarrhea or constipation or unable to pass
gas.
Fever
Rovsing’s sign: continuous deep palpation starting from the left iliac fossa
upwards (counterclockwise along the colon) may cause pain in the right iliac
fossa, by pushing bowel contents towards the ileocaecal valve and thus increasing
pressure around the appendix.
Psoas sign: is the right lower-quadrant pain that is produced with either the
passive extension of the patients right hip (pt. lying on the left side, with knee in
flexion) or the patient’s active flexion of the right hip while supine. Straightening
out the legs causes pain because it stretches these muscles, while flexing the hip
activated the iliopsoas and therefore causes pain.
Obturator sign: if an inflamed appendix is in contact with the obturator
internus, spasm of the muscle can be demonstrated by flexing and internal
rotation of the hip. This maneuver will cause pain in the hypogastrium.
Dunphy’s sign: increased pain in the right lower quadrant with coughing.
Kocher’s Sign: the appearance of pain in the epigastric region or around the
stomach at the beginning of disease with a subsequent shift to the right iliac
region.
Stikovskiy (resenstein’s) sign: increased pain on palpation at the right iliac
region as patient lies on his/her left side.
Blumberg sign: also referred as rebound tenderness. Deep palpation of the
viscera over the suspected inflamed appendix followed by sudden release of the
pessue causes the severe pain on the site indicating positing Blumberg’s sign and
peritonitis.
Risk Factors
Risk factors for Appendicitis are factors that do not seem to be a direct cause of the
disease, but seem to be associated in some way. Having a risk factor for Acute Appendicitis
makes the chances of getting the condition higher but does not always lead to Acute
Appendicitis.
Age: Appendicitis can occur in all age groups but it is more common between the ages of
11 and 20.
Gender: A male preponderance exists, with a male to female ratio (1.4: 1) and the
overall lifetime risk is 8.6% for males and 6.7% for females. A male child suffering from cystic
fibrosis is at a higher risk for developing appendicitis.
Diet: People whose diet is low in fiber and rich in refined carbohydrates have an
increased risk getting appendicitis.
Hereditary: A particular position of the appendix, which predisposes it to infection, runs
in certain families. Having a family history of appendicitis may increase a child's risk for the
illness.
Seasonal variation: Most cases of appendicitis occur in the winter months - between the
months of October and May.
Infections: Gastrointestinal infections such as Amebiasis, Bacterial Gastroenteritis,
Mumps, Coxsackievirus B and Adenovirus can predispose an individual to Appendicitis.
Causes
On the basis of experimental evidence, acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen (the inside space of a tubular structure). Once this
obstruction occurs the appendix subsequently becomes filled with mucus and swells, increasing
pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion
of the small vessels, and stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this
point. As the former progresses, the appendix becomes ischemic and then necrotic. As bacteria
begin to leak out through the dying walls, pus forms within and around the appendix
(suppuration). The end result of this cascade is appendiceal rupture (a 'burst appendix') causing
peritonitis, which may lead to septicemia and eventually death.
The causative agents include foreign bodies, trauma, intestinal worms, lymphadenitis,
and most commonly calcified fecal deposits known as appendicoliths or fecalith. The occurrence
of an obstructing fecalith has attracted attention since their presence in patients with appendicitis
is significantly higher in developed than in developing countries, and an appendiceal fecalith is
commonly associated with complicated appendicitis. Also, fecal stasis and arrest may play a role,
as demonstrated by a significantly lower number of bowel movements per week in patients with
acute appendicitis compared with healthy controls. The occurrence of a fecalith in the appendix
seems to be attributed to a right side fecal retention reservoir in the colon and a prolonged transit
time. From epidemiological data it has been stated that diverticular disease and adenomatous
polyps were unknown and colon cancer exceedingly rare in communities exempt for
appendicitis. Also, acute appendicitis shown to occur antecedent to cancer in the colon and
rectum. Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis. This is in accordance with the occurrence of a right sided fecal reservoir and the
fact that dietary fiber reduces transit time.
Complications of Appendicitis
Rupture of the Appendix
The most frequent complication of appendicitis is perforation. Perforation of the
appendix can lead to a peri-appendiceal 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 36 hours
after the onset of symptoms is at least 15%. Therefore, once appendicitis is diagnosed, surgery
should be done without unnecessary delay.
Peritonitis or Abscess
Peritonitis is a dangerous infection. This complication can occur when bacteria and other
contents of the torn appendix leak into the abdomen (stomach). A ruptured appendix can lead to
peritonitis and abscess. An abscess usually takes the form of a swollen mass filled with fluid and
bacteria.
Blockage or Obstruction of the intestine
A less common complication of appendicitis is blockage or obstruction of the intestine.
Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to
stop working, and this prevents the intestinal contents from passing. If the intestine above the
blockage begins to fill with liquid and gas, the abdomen distends and nausea and vomiting may
occur. It then may be necessary to drain the contents of the intestine through a tube passed
through the nose and esophagus and into the stomach and intestine.
Sepsis
A feared complication of appendicitis is sepsis, a condition in which infecting bacteria
enter the blood and travel to other parts of the body. This is a very serious, even life-threatening
complication. Fortunately, it occurs infrequently.
Diagnosis
Diagnosis is based on patient history (symptoms) and physical examination backed by an
elevation of neutrophilic white blood cells. Histories fall into two categories, typical and
atypical. Typical appendicitis usually includes abdominal pain beginning in the region of the
umbilicus for several hours, associated with anorexia, nausea or vomiting. The pain then "settles"
into the right lower quadrant, where tenderness develops. Atypical histories lack this typical
progression and may include pain in the right lower quadrant as an initial symptom. Atypical
histories often require imaging with ultrasound and/or CT scanning.[23] A pregnancy test is vital
in all women of child bearing age, as ectopic pregnancies and appendicitis present with similar
symptoms. The consequences of missing an ectopic pregnancy are serious, and potentially life
threatening. Furthermore the general principles of approaching abdominal pain in women (in so
much that it is different from the approach in men) should be appreciated.
Blood Test
Most patients suspected of having appendicitis would be asked to do a blood test. 50% of
the time, the blood test may be normal, so it is not foolproof in diagnosing appendicitis. Two
forms of blood tests are commonly done: FBC (Full blood count) or CBC (Complete blood
count) is an inexpensive and commonly requested blood test. It involves measuring the blood for
its richness in red blood cells as well as the number of the various white blood cell constituents
in it. The number of white cells in the blood is a usually less than 10,000 cells per cubic
millimeter. An abnormal rise in the number of white blood cells in the blood is a crude indicator
of infection or inflammation going on in the body. Such rise is not specific to appendicitis alone.
If it is abnormally elevated, with a good history and examination findings pointing towards
appendicitis, the likelihood of having the disease is higher. In pregnancy, there may be a normal
elevation of white blood cells, without any infection present.
CRP
CRP is an acronym for C-reactive protein. It is an acute phase response protein produced
by the liver in response to any infection or inflammatory process in the body. Again, like the
FBC, it is not a specific test. It is another crude marker of infection or inflammation.
Inflammation at ANY site can lead to the CRP to rise. A significant rise in CRP with
corresponding signs and symptoms of appendicitis is a useful indicator in the diagnosis of
appendicitis. It is said that if CRP continues to be normal after 72 hours of the onset of pain, it is
likely that the appendicitis will resolve on its own without intervention. A worsening CRP with
good history is a sure signal of impending perforation or ruptures and abscess formation.
Urine Test
Urine test in appendicitis is usually normal. It may however show blood if the appendix is
rubbing on the bladder, causing irritation a urine test or urinalysis is compulsory in women, to
rule out pregnancy in appendicitis, as well to help ensure that the abdominal pain felt and
thought to be acute appendicitis is not in fact, due to ectopic pregnancy.
X – Ray
In 10% of patients with appendicitis, plain abdominal x-ray may demonstrate hard
formed feces in the lumen of the appendix (Fecolith). It is agreed that the finding of Fecolith in
the appendix on X – ray alone is a reason to operate to remove the appendix, because of the
potential to cause worsening symptoms. In this respect, a plain abdominal X-ray may be useful
in the diagnosis of appendicitis, though plain abdominal x- ray is no longer requested routinely in
suspected cases of appendicitis. An abdominal X – ray may be done with a barium enema
contrast to diagnose appendicitis. Barium enema is whitish toothpaste like material that is passed
up into the rectum to act as a contrast. It will usually fill the whole of the large bowel. In normal
appendix, the lumen will be present and the barium fills it up and is seen when the x-ray film is
shot. In appendicitis, the lumen of the appendix will not be visible on the barium film.
Ultrasound
Ultrasonography and Doppler sonography provide useful means to detect appendicitis,
especially in children and shows free fluid collection in right iliac fossa along with a visible
appendix without blood flow in color Doppler. In some cases (15% approximately), however,
ultrasonography of the iliac fossa does not reveal any abnormalities despite the presence of
appendicitis. This is especially true of early appendicitis before the appendix has become
significantly distended and in adults where larger amounts of fat and bowel gas make actually
seeing the appendix technically difficult. Despite these limitations, in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with very
similar symptoms such as inflammation of lymph nodes near the appendix or pain originating
from other pelvic organs such as the ovaries or fallopian tubes.
Computed tomography
A cat scans demonstrating acute appendicitis (note the appendix has a diameter of
17.1mm and there is surrounding fat stranding.) In places where it is readily available, CT scan
has become frequently used, especially in adults whose diagnosis is not obvious on history and
physical. Concerns about radiation, however, tend to limit use of CT in pregnant women and
children. A properly performed CT scan with modern equipment has a detection rate (sensitivity)
of over 95% and a similar specificity. Signs of appendicitis on CT scan include lack of oral
contrast (oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than
6 mm in cross sectional diameter), and appendiceal wall enhancement with IV contrast (IV dye).
The inflammation caused by appendicitis in the surrounding peritoneal fat (so called "fat
stranding") can also be observed on CT, providing a mechanism to detect early appendicitis and
a clue that appendicitis may be present even when the appendix is not well seen. Thus, diagnosis
of appendicitis by CT is made more difficult in very thin patients and in children, both of whom
tend to lack significant fat within the abdomen.
Management
Before surgery
The treatment begins by keeping the patient from eating or drinking in preparation for
surgery. An intravenous drip is used to hydrate the patient. Antibiotics given intravenously such
as cefuroxime and metronidazole may be administered early to help kill bacteria and thus reduce
the spread of infection in the abdomen and postoperative complications in the abdomen or
wound. Equivocal cases may become more difficult to assess with antibiotic treatment and
benefit from serial examinations. If the stomach is empty (no food in the past six hours) general
anaesthesia is usually used. Otherwise, spinal anaesthesia may be used.
Once the decision to perform an appendectomy has been made, the preparation procedure
takes more or less one to two hours. Meanwhile, the surgeon will explain the surgery procedure
and will present the risks that must be considered when performing an appendectomy. With all
surgeries there are certain risks that must be evaluated before performing the procedures.
However, the risks are different depending on the state of the appendix. If the appendix has not
ruptured, the complication rate is only about 3% but if the appendix has ruptured, the
complication rate rises to almost 59%. The most usual complications that can occur are
pneumonia, hernia of the incision, thrombophlebitis, bleeding or adhesions. Recent evidence
indicates that a delay in obtaining surgery after admission results in no measurable difference in
patient outcomes.
The surgeon will also explain how long the recovery process should take. Abdomen hair
is usually removed in order to avoid complications that may appear regarding the incision. In
most of the cases patients experience nausea or vomiting which requires specific medication
before surgery. Antibiotics along with pain medication may also be administrated prior to
appendectomies.
Pain management
Pain from appendicitis can be severe. Strong pain medications (i.e., narcotic pain
medications) are recommended for pain management prior to surgery. Morphine is generally the
standard of care in adults and children in the treatment of pain from appendicitis prior to surgery.
In the past (and in some medical textbooks that are still published today), it was commonly
accepted among the majority of academic sources that pain medication not be given until the
surgeon has the chance to evaluate the patient, so as to not "corrupt" the findings of the physical
examination. This line of practice, combined with the fact that surgeons may sometimes take
hours to come to evaluate the patient, especially if he or she is in the middle of surgery or has to
drive in from home, often leads to a situation that is ethically questionable at best. More recently,
due to better understanding of the importance of pain control in patients, it has been shown that
the physical examination is actually not that dramatically disturbed when pain medication is
given prior to medical evaluation. Individual hospitals and clinics have adapted to this new
approach of pain management of appendicitis by developing a compromise of allowing the
surgeon a maximum time to arrive for evaluation, such as 20 to 30 minutes, before active pain
management is initiated. Many surgeons also advocate this new approach of providing pain
management immediately rather than only after surgical evaluation.
Surgery
The surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy). Often now the operation can be performed via a laparoscopic
approach, or via three small incisions with a camera to visualize the area of interest in the
abdomen. If the findings reveal supportive appendicitis with complications such as rupture,
abscess, adhesions, etc., conversion to open laparotomy may be necessary. An open laparotomy
incision if required most often centers on the area of maximum tenderness, McBurney's point, in
the right lower quadrant. A transverse or a gridiron diagonal incision is used most commonly.
According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic
and open procedures, laparoscopic procedures seem to have various advantages over the open
procedure. Wound infections were less likely after laparoscopic appendicectomy than after open
appendicectomy (odds ratio (OR) 0.45; confidence interval (CI) 0.35 to 0.58), but the incidence
of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21). The duration of surgery
was 12 minutes (CI 7 to 16) longer for laparoscopic procedures. Pain on day 1 after surgery was
reduced after laparoscopic procedures by 9 mm (CI 5 to 13 mm) on a 100 millimeter visual
analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity,
work, and sport occurred earlier after laparoscopic procedures than after open procedures. While
the operation costs of laparoscopic procedures were significantly higher, the costs outside
hospital were reduced. Young female, obese, and employed patients seem to benefit from the
laparoscopic procedure more than other groups.
There is debate whether emergency appendicectomy (within 6 hours of admission)
reduces the risk of perforation or complication versus urgent appendicectomy (greater than 6
hours after admission). According to a retrospective case review study no significant differences
in perforation rate among the two groups were noted (P=.397). Various complications (abscess
formation, re-admission) showed no significant differences (P=0.667, 0.999). According to this
study, beginning antibiotic therapy and delaying appendicectomy from the middle of the night to
the next day does not significantly increase the risk of perforation or other complications. This
finding is important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during the
night, when people may be more tired and there is fewer staff available, have higher rates of
surgical complications.
Findings at the time of surgery are less severe in typical appendicitis. With atypical
histories, perforation is more common and findings suggest perforation occurs at the beginning
of symptoms. These observations may fit a theory that acute (typical) appendicitis and
suppurative (atypical) appendicitis are two distinct disease processes.
Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours
in complicated cases.
Complications of Appendectomy
The most common complication of appendectomy is infection of the wound, that is, of
the surgical incision. Such infections vary in severity from mild, with only redness and perhaps
some tenderness over the incision, to moderate, requiring only antibiotics, to severe, requiring
antibiotics and surgical treatment. Occasionally, the inflammation and infection of appendicitis
are so severe that the surgeon will not close the incision at the end of the surgery because of
concern that the wound is already infected. Instead, the surgical closing is postponed for several
days to allow the infection to subside with antibiotic therapy and make it less likely for infection
to occur within the incision.
Another complication of appendectomy is an abscess, a collection of pus in the area of
the appendix. Although abscesses can be drained of their pus surgically, there are also non-
surgical techniques.
Laparotomy
Laparotomy is the traditional type of surgery used for treating appendicitis. This
procedure consists in the removal of the infected appendix through a single larger incision in the
lower right area of the abdomen. The incision in a laparotomy is usually 2-3 inches long. This
type of surgery is used also for visualizing and examining structures inside the abdominal cavity
and it is called exploratory laparotomy.
During a traditional appendectomy procedure, the patient is placed under general
anesthesia in order to keep his/her muscles completely relaxed and to keep the patient
unconscious. The incision is two to three inches (76 mm) long and it is made in the right lower
abdomen, several inches above the hip bone. Once the incision opens the abdomen cavity and the
appendix is identified, the surgeon removes the infected tissue and cuts the appendix from the
surrounding tissue. After the surgeon inspects carefully and closely the infected area and there
are no signs that surrounding tissues are damaged or infected, he will start closing the incision.
This means sewing the muscles and using surgical staples or stitches to close the skin up. In
order to prevent infections the incision is covered with a sterile bandage. The entire procedure
does not last longer than an hour if complications do not occur.
Laparoscopic surgery
The newer method to treat appendicitis is the laparoscopic surgery. This surgical
procedure consists of making three to four incisions in the abdomen, each 0.25 to 0.5 inch (6.3 to
13 mm) long. This type of appendectomy is made by inserting a special surgical tool called
laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the
patient's body and it is designed to help the surgeon to inspect the infected area in the abdomen.
The other two incisions are made for the specific removal of the appendix by using surgical
instruments. Laparoscopic surgery also requires general anesthesia and it can last up to two
hours. The latest methods are NOTES appendectomy pioneered in Coimbatore, India where there
is no incision on the external skin and SILS (Single incision laparoscopic Surgery) where a
single 2.5 cm incision is made to perform the surgery.
After surgery
Hospital lengths of stay typically range from a few hours to a few days, but can be a few
weeks if complications occur. The recovery process may vary depending on the severity of the
condition, if the appendix had ruptured or not before surgery. Appendix surgery recovery is
generally a lot faster if the appendix did not rupture. It is important that patients respect their
doctor's advice and limit their physical activity so the tissues can heal faster. Recovery after an
appendectomy may not require diet changes or a lifestyle change.
After surgery occurs, the patient will be transferred to a Post-anesthesia care unit so his or
her vital signs can be closely monitored in order to detect anesthesia and/or surgery related
complications. Pain medication may also be administrated if necessary. After patients are
completely awake, they are moved into a hospital room to recover. Most individuals will be
offered clear liquids the day after the surgery and then progress to a regular diet when the
intestines start to function properly. It is highly recommended that patients sit up on the edge of
the bed and walk short distances for several times a day. Moving is mandatory and pain
medication may be given if necessary. Full recovery from appendectomies takes about 4 to 6
weeks but it can prolong to up to 8 weeks if the appendix had ruptured.
Prognosis
Most appendicitis patients recover easily with surgical treatment, but complications can
occur if treatment is delayed or if peritonitis occurs. Recovery time depends on age, condition,
complications, and other circumstances, including the amount of alcohol consumption, but
usually is between 10 and 28 days. For young children (around 10 years old), the recovery takes
three weeks.
The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment. The patient may have to undergo a medical
evacuation. Appendectomies have occasionally been performed in emergency conditions (i.e.,
outside of a proper hospital), when a timely medical evaluation was impossible.
Prevention
Appendicitis is probably not preventable, although there is some indication that a diet
high in green vegetables and tomatoes may help prevent appendicitis.
PATIENT HEALTH HISTORY
Biographic Data:
Name of patient: Mr. P. G
Address: Prk 2, Brgy. Villa Flor, Gigaguit.
Age: 16 years old
Sex: Male
Civil Status: Single
Date of birth: November 20, 1995
Religion: Catholic
Source of information: Primary source- patient
Secondary source- chart and mother
Admission Data:
Hospital: Caraga Regional Hospital
Room #: Surgical Ward, S-2
Date admitted: September 1, 2011
Time admitted: 10:12 AM
Arrived via: Via Wheelchair
Vital Signs upon admission: Temperature: 37.8 C
Heart rate: 96 bpm
Respiratory rate: 28 cpm
Blood Pressure: 100/70
Weight: 47kg.
Height: 5’6
Admitting Physician: Dr. Glenn Alfred Baban
Attending Physician: Dr. Glenn Alfred Baban
Surgeon: Dr. Relliquette
Anesthesiologist: Dr. C. Dumas
Chief Complaints: Severe abdominal pain and vomiting 7-10x in a day
Impression: Intussisuption
Final Diagnoses: Ruptured Appendicitis with localize Peritonitis
Date of Discharge: September 8, 2011
BODY MASS INDEX
Reference:
Underweight = <18.5Normal weight = 18.5–24.9 Overweight = 25–29.9 Obesity = BMI of 30 or greater
Given:
Weight: 47 kg. Height: 5 ft. 6 inches
Formula:
BMI = ____mass (lb.) x 703____[height (inches)] squared
Conversion:
703 = (constant value in BMI)47 kg. = (2.20 lb./ 1 kg) = 103.4 lb.5 ft. = (12 inches/ 1 ft.) = 60 inches6 inches = (no need to convert)
Solution:
BMI= _______103.4 lb. x 703_______(60 inches + 6 inches) squared
= ____72690.2 lb.___(66 inches) squared
= _72690.2 lb.4356 inches
= 16.69 BMI
Patient is Underweight.
History of Present Illness:
Last August 30, 2011, two days prior to admission. Mr. P experienced on and off fever
(37.80C-38.70C), abdominal pain (scale of “10/10”), and vomiting 7x (clear and viscous). As a
management Mr. P took Biogesic one tab for fever and pain, he says it helped subside the fever
after few hours. However, after lunch time of August 31, his temperature spiked up again to
38.70C, that is when Mr. P’s mother decided to take him to see Dr Ycong the same day. On
September 1, 2011 Mr. P was admitted at Caraga Regional Hospital with the advice of Dr.
Ycong.
Past Health History
A. Childhood Illness
Mr. P. had chicken pox at age of 11 years old. He did not experience
mumps and measles. Sometimes he gets minor coughs for few days and uses over
the counter drugs like Solmux 500 mg once a day until his cough subsides. Also,
he uses Neozep for colds or paracetamol for fever occasionally.
B. Childhood Immunization
Since the patient is 16, and the EPI (Expanded Program on Immunization)
was launched on 1970’s. Mr. P’s mother claimed that his son is complete of his
childhood immunization. She takes him to Barangay Clinic for his immunization
shots. The following Immunization given to the patient during his mother visits in
a certain clinic are: BCG, 1 dose and Hep B, 3 doses – at birth; Measles – 9
months; DPT – week 6, 3 doses; and OPV – week 7, 3 doses.
C. History of Hospitalization
Mr. P claimed that as far as he can remember he is been admitted in the
hospital twice prior to the present hospitalization. First, last 2009 at Caraga
Regional Hospital due to appendicitis. Dr. Amoncio was his attending physician
and he was discharge after 1 week receiving of series of antibiotics, and take
home medications no surgical intervention was done. Second hospitalization, was
August 27, 2009 due to motorcycle accident, and admitted at Municipal Hospital
in Gigaquit for observations and pain management. Only minor scrapes and small
open wound on the right and left knee.
a. Surgical History
Mr. P. claimed that he did not undergo any surgery in the past.
b. Accidents and Injuries
Mr. P. was involved in a motorcycle accident last August 27, 2009. He
was admitted at municipal Hospital in Gigaquit for minor open wound on the
right and left knee and minor scrapes on the right and left elbow.
c. Medications.
Mr. P. claimed that he uses over the counter drugs for occasionally cough,
fever, and or head ache.
D. Family Health History
Client is the 2nd child among 5 siblings. 3 boys, and 2 girls. His
grandmother on paternal side and grandfather on maternal side are deceased due
to hypertension. Also his father ha hypertension as well and taking medicine for
maintenance. (He forgot what the medications name)
E. Personal Health History
a. Life Style
Personal Habits: Mr. P claimed that he started drinking alcohol and smoke
cigarette at the age of 14years old. He can consume 73 cigarette packs a year.
Sometimes twice a month he consumed 3-5 glasses of hard liquor (tanduay). But
he claimed that by the age of 15and ½ years old he stop smoocking cigarette. But
still drink alcohol occasionally.
b. Diet
Before hospitalization, Mr. P. eats at least 1-2cups of plain rice, 1-2small fish
(could be fried sometimes grilled, paksiw.), and vegetables. He also claimed that
he loves to eat “kinilaw” sometimes 3x a week. He drinks 2-3 glasses ( small cup,
240cc) of water a day, and 12oz of carbonated drinks 3-4x a day.
During Hospitalization Mr. P was on NPO ( nothing per orem).
c. Sleep and Rest Pattern
Before Hospitalization, he usually sleeps between 11 pm to 12 midnight, and
wakes up around 6:30 am. During hospitalization, he claimed that he has problem
sleeping because he is not comfortable with the bed and it is noisy in the ward. He
also claimed it is hard to sleep for more than 4 hours because nurse’s wakes him
up for medications and vital signs.
d. Elimination Pattern
Before hospitalization, Mr. P. urinates 3 times a day and defecates at least once
every other day and sometimes once every 3 days.
During Hospitalization, he urinated 3-4 times a day. However, no bowel
movement noted during our 2 days of assessment.
e. Activities with Daily living.
Before hospitalization, Patient claimed that he does not have problems with his
daily activities, such as; bathing, dressing, eating, and or any difficulty with his
locomotion.
During Hospitalization, Patient still able to perform daily activities but slow and
with assistance when dressing and setting up, due to abdominal pain on the right
lower quadrant.
f. Recreational Activities and Hobbies.
Mr. P. claimed that he loves to play basketball. He plays at least twice a week. He
hangs out with his friends on the weekend and sometimes drinks alcohol, like
tanduay. He listens to music and watch television when he is at home.
F. Social Data
a. Family Relationships/friendship.
With regards to their family relationship, Mr. P. has a strong family ties, and has a
very supportive siblings and parents. Client’s friends visited him in the hospital
and showed empathy to the client and client’s family. He has also an open
communication with his family and girlfriend.
b. Ethnic Affiliation.
Mr. P is a native Filipino. He assimilated the values, beliefs, and culture of
Filipinos. Filipinos are known to be loving, hardworking, religious, and
hospitable. He stated that he uses herbal medicines. He verbalized also that if
some health problems will arise, they prefer to go to health care professionals.
c. Educational History
When Mr. P was on 6th grade he was on top 6 out of 10. He awarded Boy Scout of
the year. During High School he claimed, he did not received any special award
because he was a working student. Mr. P. is currently attending as a fulltime
college student at SSCT. Here in Surigao City.
d. Occupational History
Before attending College, he was working as a tricycle driver and put himself
through high school.
e. Economic Status
Mr. P. claimed that his family is able to afford the necessities at the household
and can support him going to college.
G. Environmental Data
According to Mr. P. he lives in a simple two story house. 1st floor is made of
concrete and 2nd floor made of wood materials in Gigaquit. His parents are
farmers and owned chickens and 4 pigs. They have 3 rooms that are separated
only by curtains. The toilet is flushed type and located inside. As a method of
garbage disposal they separate the recyclable from biodegradable and non-
biodegradable waste and collected by the garbage truck.
H. Psychological Data
Mr. P. claimed that he gets stress when time for major examination at school and
when his parents scolded him.
I. Patterns of Health Care
Client’s family initially seeks the “quack doctor” in times of health problems and
would try to use herbal medicinal plants as remedy; for instance, “sambong” for
“panohot” and “karabo” for cough. However, if condition persist, they visits
health center for check-up.
PHYSICAL ASSESSMENT
Date of Assessment: September 1, 2, and 3, 2011 (7am-1pm shift)
GENERAL SURVEY
Assessed lying on bed ( in supine position), conscious, responsive, coherent, not in
respiratory distress, complained of abdominal pain on his right lower quadrant , facial grimacing
noted, with an IVF of D5LR 1L (@550 ml receiving level) regulated @ 20 gtts/min infusing well
@ left metacarpal vein and with the following vital signs:
T: 38.10C PR: 73bpm RR: 19cpm B/P 110/70mmHg
INTEGUMENTARY:
Skin
Inspection:
Generally light-brown uniform in color.
Old scars are noted at the right knee (4 inches wide, upper) and at the back (lower
quadrant (2 inches wide)
Skin is intact.
Palpation:
Both lower and upper extremities has moist and warm skin to touch.
Good skin turgor when pinched it goes back to previous state after 1 second.
Elevated body temperature 38.1°C
Hair
Inspection:
Short and slightly silky black hair.
Evenly distributed hair on the scalp and all over the body.
Dandruff noted at the scalp.
No signs of infestations.
Palpation:
Smooth hair noted
Nails
Inspection:
Nail color – slightly pale.
Convex curvature of nail plate.
Intact epidermis on both fingernails and toe nails.
Palpation:
Smooth texture noted.
The nails returned at its original color – slightly pale <2 seconds upon performing the
capillary refill test.
Head, Eyes, Ears, Nose and Throat (HEENT)
Skull and Face
Inspection:
Rounded and normocephalic skull contour.
Symmetric facial features.
Palpation:
Smooth, uniform consistency of the skull.
No inflammation, and lumps or masses noted at the skull.
Eyes and Vision
Inspection:
External structure, eyebrows, eyelashes, eyelids are evenly distributed
No abnormal discharges of the eyes noted.
Pupils are black, equal in sizes (about 2 mm) and responsive to light, (PERRLA).
Palpation:
Upon palpating the lacrimal gland, no edema noted and tenderness reported.
Ear and Hearing
Inspection:
Color same as facial noted.
Symmetric ear positions that lines with outer canthus of the eye
Able to hear at both ears upon performing the watch tick and follows simple words
commanded.
Palpation:
Auricles are mobile and firm.
No tenderness noted.
Nose and Sinuses
Inspection:
Nose is symmetrical.
No discharges or flaring noted.
Air moves freely as the client breaths through the nares.
Nasal septum is intact and in middle.
No presence of discharges noted.
Palpation:
No tenderness and lesions on both nose and sinuses observed.
Oropharynx (mouth and throat)
Inspection:
Lips have symmetric contour, slightly pale in color. Soft and slightly dry.
Able to perform pursed lip breathing.
Tongue is positioned centrally.
Tongue moves freely.
Palpation:
No presence of lesions and tenderness.
Positive gag reflex upon touching the posterior part of the tongue with the use of
tongue depressor.
Neck
Inspection:
Neck muscles are equal with head positioned at the center.
Able to flex, extend and hyperextend his head when asked to do so.
Palpation:
No tenderness reported and lesions observed upon palpation
Thorax and Lungs
Inspection:
Respiratory rate is 19 cpm
Spine vertically aligned
Chest is symmetric
No respiratory distress observed
Chest wall is intact
Palpation:
No tenderness noted upon palpation
Percussion:
Resonant sound at the posterior part of the shoulder
Auscultation:
Normal breath sounds heard upon auscultation.
Cardiovascular System and Peripheral Vascular System
Inspection:
Blood pressure of 110/70 mmHg
Pulse rate of 73 bpm
No edema noted
No palpitations observed all over the body
No jugular vein distention noted upon inspection
Palpation:
Capillary refill test-less than 2 seconds
Breast and Axillae
Inspection:
Same color as the skin of the abdomen and back
He had dark brown areola with nipple
No discharges on nipple noted
Presence of hair at the axilla
Palpation:
No masses, nodules or tenderness noted.
Abdomen
Inspection:
Uniform in color
Abdominal distention is noted (28 inches in circumference)
Abdominal guarding noted
Auscultation:
Bowel sounds heard in 4 quadrants (10 bowel sounds per minute)
Percussion:
Dull sounds heard at the liver region
Tympanic sounds heard at the spleen region
Palpation:
Positive on rebound tenderness when palpate on the left lower quadrant. “sakit ako
tiyan sa kilid” scale of “7/10” he pointed on the right lower quadrant.
Musculoskeletal
Inspection:
Muscle are equal on both upper and lower extremities of the body
No contractures and deformities noted
Palpation:
Smooth coordinated movements when asked to perform the ROM in upper
extremities.
ROM on lower extremities performed with slight difficulty due to felt pain.
Genitals
Patient refused to perform physical examination on genital area.
Neurologic System
Language
Client is able to speak clearly and had no difficulty speaking. He displays verbal and
non-verbal communication (ex. Gestures, facial expression). Client is able to
understand Visayan dialect.
Orientation
Client is oriented to self, time, and place. Able to identify the present location and can
easily recognize significant others “ jadto si mama”
Memory
Able to recall the nurse on duty who had just given him his medication. ( Immediate
memory).
Able to recall one of his relatives from Brgy. Villaflor, Gigaquit who called him 4
days ago asking about his condition (Recent memory).
Able to recall his closest friends in elementary years (Remote memory)
Attention Span
Client has approximately 30 minutes to 1 hour of conversation.
REVIEW OF SYSTEM
Integumentary System
Patient claimed he did not experience any rashes or lesions in his skin. He also claimed
that sometimes he experienced skin itchiness and dry skin.
Head, Eyes, Ears, Nose, Throat (HEENT)
Patient experienced common colds occasionally. Also stated he had an eye irritation once
or twice when he was in high school.
Neck
He did not experience any lump, tenderness, distention in jugular veins or stiffness.
Breast and Axillae
Patient said that he has no previous experience of any abnormalities on his breasts and
axilla.
Thorax and Lungs
Client doesn’t have any thorax and lung abnormalities.
Cardiovascular System
Client denies of any problems pertains to his cardiovascular system. However, he states
that his father has hypertension.
Gastrointestinal System
Client claims that occasionally he experiences constipation (Color: dark-brown;
Frequency: once in 3 days; Appearance: dry; Consistency: hard stool) and minor
abdominal cramps and able to control it with over the counter medicine.
Musculoskeletal System
No musculoskeletal abnormalities and or deformities experienced by the patient.
Neurologic System
The client is alert, attentive, and follows commands. He claimed that he can comprehend
well at school. He is an average student. No history of hallucinations and seizures as
verbalized by the patient.
Urinary System
Client claimed that he did not experience any difficulty and or problems urinating. Prior
to hospitalization he urinates 2-3x at day time and once at night time.
Reproductive System
Client reported that he did not experience any penile discharges or tenderness.
Endocrine
Client experience of any problems related to the endocrine system.
LABORATORY EXAMS
SEPTEMBER 1, 2011
TEST RESULT NORMAL
VALUES
SIGNIFICANCE RATIONALES
WBC(white blood
count)
13.1 x 103
mm3
3.5-10 x 103
mm3
WBC fights
infection. Increase
in WBC signifies
bacterial infection..
Indicates presence
of infection
RBC(red blood
cells)
5.44 x 103
cellmm3
3.80-5.80 x 103
mm3
RBC transports
oxygen in the blood
Within Normal
Range
HGT(hemoglobin) 14.5 g/dl 11.0-16.5 g/dl Iron containing
Oxygen transport in
the blood
Within Normal
Range
HCT(hematocrit) 43.7% 35 -50% Percentage of RBC
in the blood.
Within Normal
Range
PLT(platelet
count)
255 x 103
mm3
150-390 x 103
mm3
Important factor for
blood to clot
Within Normal
Range
PCT 0.161% 0.100-0.500% Procalcitonin. To
determine from
bacterial to non-
bacterial
Within Normal
Range
MCV(mean cell
volume)
80 fl 70-97 fl The average size of
erythrocytes or
RBC
Within Normal
Range
MCH(mean cell
hemoglobin)
26.7 pg 26.5-33.5 pg Measure of the
mass of hemoglobin
contained by a RBC
Within Normal
Range
MCHC(mean cell
hemoglobin
concentration
33.2 g/dl 31.5-38.5 g/dl The average
hemoglobin
concentration in
Within Normal
Range
RBC
RDW (red blood
cell distribution
width)
14.6 % 10.0-18.0 % Red Cell
Distribution Width-
standard Direct
measurement of
RDW at a certain
level.
Within Normal
Range
MPV (mean
platelet volume)
6.3 fl 6.5-11.0 fl Mean Platelet
Volume, typical
size of platelet in
blood
Indicates presence
of bleeding. Below
normal secondary
to platelet lyses
PDW ( platelet
distribution width)
12.7 % 10.0-18.0 % Direct measurement
of Platelet
Within Normal
Range
Lymphocytes % 8.6 % L 17.0-48.0 % Lymphocytes B and
T are the natural
cell killers.
Indicates presence
of viral infection
Monocytes % 1.0 % L 4.0-10.0 % Monocytopenia- not
enough cell to fight
infection.
Indicates presence
of infection
Granulocytes % 90.4 % H 43.0-76.0 # Granulocytosis:
abnormally high
Indicates presence
of infection.
Lymphocytes # 1.1
(10^3/mm3)
L
1.2-3.2
(10^3/mm3)
Lymphocytes B and
T are the natural
cell killers.
Indicates presence
of viral infection
Monocytes # 0.1
(10^3/mm3)
L
0.3-0.8
(10^3/mm3)
Monocytopenia- not
enough cell to fight
infection.
Indicates presence
of bone marrow
dysfunction
Granulocytes # 11.9
(10^3/mm3)
H
1.2-6.8
(10^3/mm3
Granulocytosis:
abnormally high
Indicates presence
of infection
URINALYSIS
September 1, 2011
TEST RESULT NORMAL VALUES SIGNIFICANCE
Urine Yellow/cloudy Amber yellow
Creatinine 1.1 mg/dl 0.9-1.4 Normal
Specific gravity 1.030 1.002-1.030 Normal
pH 6.0 5-7 Normal
Glucose Negative Negative Normal
Protein Trace Negative
Bacteria Plenty Infection
Crystals Amorphous
Urates Few
ULTRASOUND OF THE LOWER ABDOMEN
Patient: Mr. P. G
Date: September 1, 2011 Ordered by Dr. Ycong.
Findings: Both kidneys show a normal range in size with a mild to moderate
inhomogeneous parenchymal echogenicity with non-uniform echo pattern. The Right Kidney
measures 11.06 x 4.57 cm with a cortical thickness of 1.20cm. While the Left kidney measures
9.91x4.63 cm with a cortical thickness of 1.17cm. There are a few tiny high level echogenic
structures exhibiting posterior acoustic shadowing appreciated at both collecting structures,
namely at the Right Kidney ranging in measurement from 0.18cm to 0.31cm, while at the left
kidney ranging in measurement from 0.16cm to 0.25cm. There are few tiny rounded medium to
high level echoes seen at the calices with both kidneys without posterior acoustic shadowing.
Bilateral prominence with the pelvocaliceal structures are seen with a splitting with the central
echo complex.
The urinary bladder is physiologically distensible and sub-optimally filled with a pre-
voiding urine volume with 85.83cc. There are few tiny rounded medium to high level in
traluminal echogenic structures seen that settle at the dependent portion. No transducer
tenderness is elicited. The bladder wall is mildly thickened measuring 0.66cm. There are
pockets with free fluid noted at the interserosal surfaces of the pelvic region. There is a an
echowic tubular structure noted at the right lower quadrant that is compressible measuring
0.63cm at rest and 0.45cm with compression suspected with being the vermiform appendix.
The lumen of the tubular structure contains fecal materials. The region adjacent the cecum
shows another tubular structure with accompanying vascular pedicle that appears to enter the
lumen with the cecum and is suggestive with intussusceptions (ilio-colic type). Correlation with
laboratory findings is imperative. The rest of the right lower quadrant exhibits small bowel loops
that are distended and fluid filled and showing sluggish peristalsis.
IMPRESSION:
NORMAL SIZE KIDNEYS WITH BILATERAL MILD HYDRONEPHROSIS, GRAD
1, THAT MAY ONLY BE TRANSIENT IN NATURE; TINY ROUNDED MEDIUM TO
HIGH LEVEL ECHOES WITHIN THE CALICES THAT MAY BE DUE TO SLOUGHED
OFF RENAL PAPILLAE, URINARY SEDIMENT, AND/OR FAT GLOBULES; AND, FEW
TINY LITHIASES AT BILATERAL COLLECTING STRUCTURES, AS DESCREBED.
NO SONOGRAPHIC EVIDENCE SUPPORTING ACUTE APPENDICITIS WITH A
DISTENDED AND COMPRESSIBLE TUBULAR STRUCTURE AT THE RIGHT LOWER
QUADRANT THAT IS PRESUMED TO BE THE VERMIFORM APPENDIX. THERE IS
HOWEVER SONOGRAPHIC EVIDENCE OF INTUSSUCEPTION (ILIO-COLIC TYPE).
KINDLY CORRELATE WITH CLINICAL AND LABORATORY FINDINGS.
MINIMAL NON-SPECIFIC ASCITES NOTED AT THE PELVIC REGION.
PHYSIOLOGICALLY DISTENSIBLE AND SUB-OPTIMALLY FILLED URINARY
BLADDER WITH MILD THICKENING OF THE ANTERIOR WALL MAY REPRESENT
EVIDENCE CURRENT/RECENT CYTITIS VERSUS SUB-OPTIMAL FILLING; AND,
MINIMAL TINY INTRALUMINAL ECHOES THAT MAY REPRESENT SLOUGHED OFF
CELLS URINARY SEDIMENT, AND /OR BLOOD PRODUCTS, KINDLY CORRELATE
WITH CLINICAL AND LABORATORY FINDINGS.
READ BY: ANGELO S. CO, M.D., D.P.B.R
RADIOLOGIST/SONOLOGIST
ANATOMY AND PHYSIOLOGY
(DIGESTIVE SYSTEM)
The digestive tract, also called the alimentary canal or gastrointestinal (GI) tract, consists
of a long continuous tube that extends from the mouth to the anus. It includes the mouth,
pharynx, esophagus, stomach, small intestine, and large intestine. The tongue and teeth are
accessory structures located in the mouth. The salivary glands, liver, gallbladder, and pancreas
are major accessory organs that have a role in digestion.
Food undergoes three types of processes in the body:
Digestion
Absorption
Elimination
Digestion and absorption occur in the digestive tract. After the nutrients are absorbed,
they are available to all cells in the body and are utilized by the body cells in metabolism.
The digestive system prepares nutrients for utilization by body cells through six activities, or
functions.
1. Ingestion. The first activity of the digestive system is to take in food through the mouth. This
process, called ingestion, has to take place before anything else can happen.
2. Mechanical Digestion. The large pieces of food that are ingested have to be broken into
smaller particles that can be acted upon by various enzymes.
3. Chemical Digestion. Through a process called hydrolysis, uses water and digestive enzymes
to break down the complex molecules. Digestive enzymes speed up the hydrolysis process,
which is otherwise very slow.
4. Movements. After ingestion and mastication, the food particles move from the mouth into
the pharynx, then into the esophagus. This movement is deglutition, or swallowing. Mixing
movements occur in the stomach as a result of smooth muscle contraction.
5. Absorption. The simple molecules that result from chemical digestion pass through cell
membranes of the lining in the small intestine into the blood or lymph capillaries. This
process is called absorption.
6. Elimination. The food molecules that cannot be digested or absorbed need to be eliminated
from the body. The removal of indigestible wastes through the anus, in the form of feces, is
defecation or elimination.
Digestive Organs
The digestive system is a group of organs (Buccal cavity (mouth), pharynx, oesophagus,
stomach, liver, gall bladder, jejunum, ileum and colon) that breakdown the chemical components
of food, with digestive juices, into tiny nutrients which can be absorbed to generate energy for
the body.
The Buccal Cavity
Food enters the mouth and is chewed by the teeth, turned over and mixed with saliva by the
tongue. The sensations of smell and taste from the food sets up reflexes which stimulate the
salivary glands.
The Salivary glands
Saliva lubricates the food enabling it to be swallowed and contains the enzyme ptyalin which
serves to begin to break down starch.
The Pharynx
Situated at the back of the nose and oral cavity receives the softened food mass or bolus by the
tongue pushing it against the palate which initiates the swallowing action.
The Oesophagus
The oesophagus travels through the neck and thorax, behind the trachea and in front of
the aorta. The food is moved by rhythmical muscular contractions known as peristalsis (wave-
like motions) caused by contractions in longitudinal and circular bands of muscle.
The Stomach
The stomach lies below the diaphragm and to the left of the liver. It is the widest part of
the alimentary canal and acts as a reservoir for the food where it may remain for between 2 and 6
hours. Here the food is churned over and mixed with various hormones, enzymes including
pepsinogen which begins the digestion of protein, hydrochloric acid, and other chemicals; all of
which are also secreted further down the digestive tract.
Small Intestine
The small intestine measures about 7m in an average adult and consists of the duodenum,
jejunum, and ileum. Both the bile and pancreatic ducts open into the duodenum together. The
small intestine, because of its structure, provides a vast lining through which further absorption
takes place.
The Pancreas
The Pancreas is connected to the duodenum via two ducts and has two main functions:
1. To produce enzymes to aid the process of digestion
2. To release insulin directly into the blood stream for the purpose of controlling blood
sugar levels
The Liver
The liver, which acts as a large reservoir and filter for blood, occupies the upper right portion
of abdomen and has several important functions:
1. Secretion of bile to the gall bladder
2. Carbohydrate, protein and fat metabolism
3. The storage of glycogen ready for conversion into glucose when energy is required.
4. Storage of vitamins
5. Phagocytosis - ingestion of worn out red and white blood cells, and some bacteria
The Gall Bladder
The gall bladder stores and concentrates bile which emulsifies fats making them easier to
break down by the pancreatic juices.
The Large Intestine
The large intestine averages about 1.5m long and comprises the caecum, appendix, colon,
and rectum. After food is passed into the caecum a reflex action in response to the pressure
causes the contraction of the ileo-colic valve preventing any food returning to the ileum. Here
most of the water is absorbed, much of which was not ingested, but secreted by digestive glands
further up the digestive tract.
ANATOMY AND PHYSIOLOGY
(APPENDIX)
Appendix is a tube-shaped
organ with a length of approximately
10 cm and the stem on the cecum. It
sits at the junction of the small intestine and large intestine. Sometimes the position of the
appendix in the abdomen may vary. Most of the time the appendix is in the right lower abdomen,
but the appendix, like other parts of the intestine has a mesentery. This mesentery is a sheet-like
membrane that attaches the appendix to other structures within the abdomen. If the mesentery is
large it allows the appendix to move around.
In addition, the appendix may be
longer than normal. The combination of a
large mesentery and a long appendix
allows the appendix to dip down into the
pelvis (among the pelvic organs in
women) it also may allow the appendix to
move behind the colon (a retrocolic
appendix).
In infants, the appendix is a conical diverticulum at the apex of the cecum, but with
differential growth and distention of the cecum, the appendix ultimately arises on the left and
dorsally approximately 2.5 cm below the ileocecal valve. The taeniae of the colon converge at
the base of the appendix, an arrangement that helps in locating this structure at operation.
The appendix in youth is characterized by a large concentration of lymphoid follicles that
appear 2 weeks after birth and number about 200 or more at age 15. Thereafter, progressive
atrophy of lymphoid tissue proceeds concomitantly with fibrosis of the wall and partial or total
obliteration of the lumen.
Appendix is blooded by apendicular artery which is a branch of the artery ileocolica.
Arterial appendix is end arteries. Appendix has more than 6 mesoapendiks obstruct lymph
channels leading to lymph nodes ileocaecal. Although the appendix has less functionality, but the
appendix can function like any other organ. Appendix produces mucus 1-2ml per day.
The mucus poured into the caecum. If there is resistance there will be a pathogenesis of acute
appendicitis. GALT (Gut Associated Lymphoid Tissue) in the appendix produce Ig-A.
However, if the appendix removed, none affect the immune body system.
PREDISPOSING FACTORS Age (11-20y.o.) Sex (Male)
PRECIPITATING FACTORS Diet (raw foods, guava) History of appendicitis Constipation (Fecalithe
matter)
Pale, facial grimace, and abdominal guarding
Abdominal Ultrasound
↑ WBC result (13.1 x 103
mm3)
s/sx: abdominal pain scale 7/10,guarding, fever, and
increased swelling of appendixvomiting, and loss of appetite
PATHOPHYSIOLOGY OF RUPTURED APPENDICITIS WITH LOCALIZE
PERITONITIS
(SCHEMATIC DIAGRAM)
Obstruction of the appendix by fecalithe (hardened stool), lymph nodes, tumor, and foreign objects
Increased intraluminar pressure inside the appendix that result to distention of
appendix
Normal bacteria found in appendix begin to invade (infect) the lining of the
wall
Inflammatory response – body response to the bacterial invasion in the wall of
appendix.Increased immune complex (disease
plus antibody) causes swelling of tissue resulting to inflammation of appendix.
Right Iliac Pain
Diagnostic Test:Abdominal Ultrasound
s/sx: swelling of the abdomen, acute pain, and
weight loss
Risk Factor ManifestationDiagnostic/ Lab
Tests
LEGENDS:
Inflammation and infection spread through the wall of the appendix
causing death of tissue. The appendix ruptures due to increased pressureAppendectomy explore laparotomy
(site: lower part distal from naval area; 8 inches longitudinal incision
with 9 transverse stitchesPerforation (formation of a hole in an
organ), fecal materials exits to peritoneal cavity causing formation of
abscess (periappendical abscess).Infection spreads throughout the
abdomen (peritoneal cavity)
Bacteria invasion of peritoneal cavity causing inflammation of the membrane
that lines the abdomen peritoneum (peritonitis)
If not treated If treated
Septic shocks/sx: 1. Decrease blood
pressure2. decrease blood volume
Coma
DEATH
Prescribed antibiotic (lomefloxacin HCL; Maxaquin)
Fluid volume replacement therapy (D5NSS 50 gtts/min)
RECOVERY
Management
Pathology
DRUG STUDY
ranitidine hydrochloride (Zantac)
Date Ordered: September 1, 2011 (During Hospitalization)
Classification: H2 receptor blocker
Dosage Ordered: 50 mg IVTT q 8 hours
Mechanism of Action: Competitively inhibits action of histamine on the H2 at the receptor sites
if the parietal cells, decreasing gastric acid secretion.
Indication: Treatment for active duodenal and gastric ulcer, GERD, erosive esophagitis, and
heartburn.
Contraindication: Contraindicated in patients hypersensitive to drug and those with acute
porphyria. Use cautiously in patients with hepatic dysfunction. Adjust dosage in
patients with impaired renal function.
Adverse Reaction: CNS: headache, malaise, vertigo
EENT: blurred vision
Hepatic: jaundice
Other: anaphylaxis, burning and itching at the injection site
Nursing Responsibilities:
Assess patient for abdominal pain. Note presence of blood in emesis, stool, or
gastric aspirate.
Remind patient to take once-daily prescription drug at bedtime for best results.
Instruct patient to take without regard to meals because absorption isn’t affected by
food.
Urge patient to avoid cigarette smoking because this may increase gastric acid
secretion and worsen disease.
Advise patient to report abdominal pain and blood in stool and emesis.
tramadol hydrochloride (Ultram)
Date ordered: September 1, 2011 (During Hospitalization)
Classification: Synthetic, centrally active analgesic
Dosage Ordered: 50 mg IVTT PRN for pain
Mechanism of action: Unknown. Thought to bind to opioid receptors and inhibit reuptake of
norepinephrine and serotonin.
Indication: To relieve from moderate to moderately severe pain.
Contraindication: Contraindicated in patients hypersensitive to drug or other opioids, and in
those with intoxication from alcohol, hypnotics, centrally acting analgesic, opioids
or psychotropic drugs. Serious hypersensitive reactions can occur, usually after the
first dose. Patients with history of anaphylactic reaction to codeine and other
opioids may be at increased risk. Use cautiously in patients at risk for seizures or
respiratory depression; in patients with increased intracranial pressure or head
injury, acute abdominal conditions, or renal or hepatic impairment; or in patients
with physical dependence on opioids.
Adverse Reaction: CNS: dizziness, headache, somnolence, vertigo, seizure
GI: constipation, nausea, vomiting
Respiratory: respiratory depression
Nursing Responsibilities:
Reassess patient’s level of pain at least 30 minutes after administration.
Monitor CV and respiratory status. Withhold dose and notify prescriber if
respirations are shallow or rate is below 12 breaths/minute
Monitor bowel and bladder function. Anticipate for stimulant laxative.
Monitor patients at risk for seizures. Drug may reduce seizure threshold.
Withdrawal symptoms may occur if stopped abruptly. Reduce dosage gradually.
Tell patient to take drug as prescribed and not to increase dose or dosage interval
unless ordered by prescriber.
Caution ambulatory patient to be careful when rising and walking. Warn outpatient
to avoid driving and other potentially hazardous activities that require mental
alertness until drug’s CNS effects are known.
metronidazole (Zolnid)
Date ordered: September 1, 2011 (During Hospitalization)
Classification: Nitroimidazole, antibiotic
Dosage ordered: 500 mg IV drip q 8 hours
Mechanism of action: Unknown. May cause bactericidal effect by interacting with DNA.
Indication: Treatment for infection of the colon caused by C. difficile and infections caused
by H. pylori.
Contraindication: Contraindicated in patients hypersensitive to drug or its ingredients, such
as parabens, and other nitroimidazole derivatives. Use cautiously in patients with
history or evidence of blood dyscrasia and in those with hepatic impairment.
Adverse action: CNS: headache, numbness, seizures
GI: nausea, loss of appetite, metallic taste,
Nursing Implications:
Discontinue therapy immediately if symptoms of CNS toxicity develop.
Monitor especially for seizures and peripheral neuropathy.
Lab tests: Obtain total and differential WBC counts before, during, and after
therapy, especially if a second course is necessary.
Monitor for S&S of sodium retention, especially in patients on corticosteroid
therapy or with a history of CHF.
Monitor patients on lithium for elevated lithium levels.
Caution to patient to avoid alcohol while in therapy.
ketorolac tromethamine (Acular)
Date ordered: September 1, 2011 (During Hospitalization)
Classification: NSAID
Dosage Ordered: 30 mg IVTT q 8 hours
Mechanism of action: May inhibit prostaglandin synthesis, to produce anti-inflammatory,
analgesic, and antipyretic effects.
Indication: For short-term management of moderately severe acute pain
Contraindication: Contraindicated in patients hypersensitive to drug and in those with active
peptic ulcer disease, recent GI bleeding or perforation, advanced renal impairment,
cerebrovascular bleeding, hemorrhagic diathesis, or incomplete hemostasis, and
those at risk for renal impairment from volume depletion or at risk for bleeding.
Contraindicated as prophylactic analgesic before major surgery or intraoperatively
when hemostasis is critical; and inpatients currently receiving aspirin, an NSAID, or
probenecid. Contraindicated for treatment of perioperative pain in patients requiring
coronary bypass graft surgery. Use cautiously in patients who are elderly or have
hepatic or renal impairment or cardiac decompensation.
Adverse Reaction: CNS: dizziness, headache, drowsiness
CV: arrhythmias, edema, hypertension
GI: dyspepsia, GI pain, nausea, diarrhea, vomiting
Skin: pruritus, rash
Other: pain at injection site
Nursing Responsibilities:
Correct hypovolemia before giving.
Don’t give drug epidurally or intrathecally because of alcohol content.
NSAIDs may mask signs and symptoms of infection because of their antipyretic and
anti-inflammatory actions.
Teach patient signs and symptoms of GI bleeding, including blood in vomit, urine,
or stool; coffee-ground vomit; and black, tarry stool. Tell him to notify prescriber
immediately if any of these occurs.
cefuroxime sodium
Date ordered: September 1, 2011 (During Hospitalization)
Classification: Second-class cephalosporin
Dosage Ordered: 750 mg IVTT q 8 hours ANST
Mechanism of action: Inhibits cell-wall synthesis, promoting osmotic instability; usually
bactericidal.
Indication: Perioperative prevention
Contraindication: Contraindicated to patients hypersensitive to drug and other form of
cephalosporins. Use cautiously in patients hypersensitive to penicillin because of
possibility of cross-sensitivity with other beta-lactam antibiotics.
Adverse Reaction: CV: phlebitis, thrombocytopenia
GI: diarrhea pseudomembraneous colitis, nausea, vomiting
Hematologic: hemolytic anemia, thrombocytopenia
Skin: maculopapular and erythematous rashes, urticaria, pain, induration, sterile
abscesses, temperature elevation
Other: anaphylaxis
Nursing Responsibilities:
Monitor signs and symptoms of superinfection.
Tell patient to take drug as prescribed, even after he feels better.
Instruct patient to notify prescriber about rash, loose stools, diarrhea or evidence of
superinfection.
Advise patient receiving drug I.V. to report discomfort at I.V. insertion site.
Generic name: ranitidine (Home Med)Brand name: RaxideClassification: Therapeutic: Anti-ulcer agents; Pharmacologic: Histamine H2 antagonistsDosage: 150 mg bid POMechanism of Action: Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion.• In addition, ranitidine bismuth citrate has some antibacterial action against H. pylori.Indication:•Treatment and prevention of heartburn, acid indigestion, and sour stomach.Contraindications•Hypersensitivity, Cross-sensitivity may occur; some oral liquids contain alcohol and should be avoided in patients with known intolerance.Use Cautiously in:• Renal impair- ment• Geriatric patients (moresusceptible to adverse CNS reactions)• Pregnancy or LactationSide Effects• CNS: Confusion, dizziness, drowsiness, hallucinations, headache• CV: Arrhythmias• GI: Altered taste, black tongue, constipation, dark stools, diarrhea, drug-induced hepatitis, nausea• GU: Decreased sperm count, impotence• ENDO: Gynecomastia• HEMAT: Agranulocytosis, Aplastic Anemia, neutropenia, thrombocytopenia• LOCAL: Pain at IM site• MISC: Hypersensitivity reactions, vasculitisNursing Implications/Responsibilities:• Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate.• Nurse should know that it may cause false-positive results for urine protein; test with sulfosalicylic acid.• Inform patient that it may cause drowsiness or dizziness.• Inform patient that increased fluid and fiber intake may minimize constipation.• Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health car professional promptly.• Inform patient that medication may temporarily cause stools and tongue to appear gray black.
Generic name: lomefloxacin hydrochloride and/or lomecin (Home Med)
Brand name: Maxaquin
Classification: Antibiotic, Flouroquinolone
Indication : Treatment of infectious in adults caused by susceptible organism: Lower
respiratory tract infections caused by Haemophilus influenzae, Moraxella catarrhalis.
Contraindications:
Contraindicated in:
Allergy to lomefloxacin, or any fluoroquinolone; lactation
Use cautiously with renal impairement and seizures, pregnancy.
Dosage: 400 mg tab 2x/day PO total of 16 tabs.
Mechanism of Action: Interferes with DNA replication by inhibiting DNA gyrase in susceptible
gram negative and gram positive bacteria, preventing cell reproduction and causing cell death.
Nursing Implication/Responsibilities:
Arrange for culture and sensitivity tests before beginning the therapy.
Continue therapy for full prescription, even if the signs and symptoms of infection have
disappeared.
Give oral drug without regard to meals
Drink plenty of fluids
Advised patient to report presence of rash, visual changes, severe GI problems,
weakness, tremors.
Generic name: mefenamic acid (Home Med)
Brand name: Ponstel
Classification: NSAID
Mechanism of action:
Anti inflammatory, analgesic, and antipyretic activities related to inhibition of
prostaglandin synthesis; exact mechanisms of action are not known.
Indication:
Relief of moderate pain when therapy will not exceed 1 week.
Contraindications:
Contraindicated in:
Hypersensitivity to mefenamic acid, aspirin allergy, and as treatment of perioperative
pain with coronary artery bypass grafting.
Use cautiously with asthma, renal or hepatic impairment, peptic ulcer disease, GI
bleeding, hypertension, heart failure, pregnancy, lactation.
Dosage: 500mg capsule once a day PO for 16 days total
Nursing Implication/Responsibilities
Patient may be at increased risk for CV events, GI bleeding; monitor accordingly.
Take drug with food; take only the prescribed dosage; do not take the drug longer than 1
week.
Dizziness or drowsiness can occur.
Advised patient to report onset of black tarry stools, severe diarrhea, fever, rash, itching.
Generic Name: Multivitamins (Home Med)
Brand Name: Enervon - C
Classification: Vitamins & Minerals
Dosage: 1 tab OD
Mechanism of Action: Enhance immune function to increase resistance and maintain optimum
health.
Indication: helps ensure optimum energy and increases body resistance against infections and
stress conditions.
Contraindications: Allergies to medicine, foods, or other substances.
Side Effects: Rash, itching, tightness in the chest, and swelling in mouth and lips.
Adverse Reactions: Severe allergy reactions and DOB
Nursing Implications:
Assess if the patient is taking any prescription or herbal preparation because it may
interact with multivitamin
Assess patient if he/she has allergy of food, or any substances.
Educate the patient that multivitamin may counteract with other medicine intake.
Instruct the patient to check with health care provider before they start, stop, or change
the medicine.
If stomach upset occurs, take with food to reduce stomach irritation.
Inform the patient/SO not to take the medicine twice a day.
NURSING CARE PLAN # 1
(PRE-OP)
September 1, 2011 @ 9:00 am
Subjective cue:
“ Sakit ako tiyan” as verbalized by the patient.
Objective cue:
Facial grimacing noted
Pain scale of 7 out of 10
v/s taken: T: 36.9C
P: 64 bpm
R: 21 cpm
BP: 100/60 mmHg
Nursing Diagnosis: Acute pain related to inflammation of tissues
Planning: Within 40 mins. of nursing intervention, the patient will reduce the pain from 7 to 0.
Intervention:
Independent:
1. Establish rapport on the client.Rationale: To establish trust and cooperation on the client
2. Monitor the vital signsRationale: To obtain the baseline data
3. Perform a comprehensive assessment of pain to include location, characteristics, onset and duration, frequency, intensity or severity of pain and precipitating factor.Rationale: To have necessary information on the case of the client.
4. Help patient focus on activities rather than on pain and discomfort by providing diversion through radio and visitiors.Rationale: To focus more on activities rather than pain.
5. Provide comfort measure like back rubs and deep breathingRationale: Promotes relaxation and may enhance patient’s coping abilities.
Collaborative:
Administer analgesics as prescribed by the physician.
Rationale: Aids in pain relief
Evaluation: Goal partially met. Patient was able to reduce the pain from 7 to 3.
NURSING CARE PLAN # 2
(PRE-OP)
September 1, 2011 @ 10:12 am
Subjective Cue:
“init ang pamati naku sa akung lawas” as verbalized by the patient.
Objective cues:
Temperature: 38.8C Flushed skin General weakness noted Shivering Skin moist and warm to touch WBC above the normal range 13.1
Nursing Diagnosis:
Altered body temperature related to inflammatory response as evidence by body temperature higher than the normal range.
Planning:
Within 30 mins. of nursing intervention patient’s temperature will decrease to within normal range.
Intervention:
Independent: Rationales
Monitor V/S To have a baseline data Increase oral fluid intake
If not contraindicated w/ disease To prevent dehydration
Promote bed rest To reduce metabolic demand and O2 consumption
Provide TSB as needed Heat is lost by evaporation &conduction
Dependent: Rationales
Administer paracetamol as ordered By the M.D Antipyretic medication helps lowers temp.
Administer IVF as ordered to prevent dehydration
Evaluation: Goal met. After 30 mins. of nursing intervention patient’s body temperature decreased to 37.5C.
NURSING CARE PLAN # 3
(PRE-OP)
September 2, 2011 @ 8:45 am
Subjective cue:
“3 days nako ya makakalibang ma’am” as verbalized by the patient.
Objective cue: Distended abdomen and Percussed abdominal dullness
Nursing Diagnosis:
Constipation related to depressed gastrointestinal function accompanied by difficult or incomplete passage of stool.
Planning:
Within 6 hours of appropriate nursing intervention, patient will be able to defecate at least once before shift ends.
Intervention:
Independent
Promote adequate fluid intake, including highfiber fruit juices; suggest drinking warm, stimulating fluids (e.g., coffee, hot water, tea)Rationale: To promote passage of stool
Identify areas of stress (e.g., personal relationships, occupational factors, financial problems)Rationale: Individuals may fail to allow time for good bowel habits and/or suffer gastrointestinal effects from stress/tension.
Encourage activity/exercise within limits of individual ability.Rationale: To stimulate contractions of the intestines
Encourage increase mobility within patient exercise tolerance
Dependent
Administer laxatives prior to doctor’s orderRationale: To promote defecation
Collaborative
Discuss client’s current medication regimen with physician to determine if drugs contributing to constipation can be discontinued or changed.
Rationale: To determine if drugs contributing to constipation can be discontinue or changed.
Evaluation: Goal met. Patient defecates once a day
NURSING CARE PLAN # 4
(PRE-OP)
September 2, 2011 @ 9:12 am
ASSESSMENT
Subjective Cues:
“Kalain na sa ako gibati karon sa gilid sa akong tiyan,” as verbalized by the
patient prior to hospitalization.
Objective Cues:
The patient manifested:
Weakness
Irritability
Moist skin
Facial grimace
NURSING DIAGNOSIS
Infection related to released of pathogenic organisms in peritoneal cavity.
PLANNING
Within 2 days of nursing intervention, the client’s infection will ease.
INTERVENTION
INDEPENDENT
Established rapport
Monitored and recorded vital
signs.
Practiced and instructed in good
hand-washing.
Inspected incision and
dressings.
Monitored v/s
DEPENDENT
RATIONALE
To gain trust of the patient.
To obtain baseline data.
Reduces the risk of spreading infection
Provides for early detection of
developing infectious process and
monitors resolution of peritonitis.
Suggestive of presence of infection,
developing sepsis, abscess, and
peritonitis.
Administered antibiotic as
prescribed by doctor.
Primarily for prophylaxis of wound
infection.
EVALUATION
Goal partially met. Client’s infection eased a bit.
NURSING CARE PLAN # 5
(PRE-OP)
September 2, 2011 @ 11:12 am
ASSESSMENT
Subjective Cues:
“Ang ako ra nahibaw-an na na-appendicitis ako tungod sa pirmi ako magduwa ng
basketball human nako kaon,” as verbalized by the patient.
Objective Cues:
Always asking question regarding to his condition.
NURSING DIAGNOSIS
Knowledge deficient related to information misinterpretation
PLANNING
Within at least 50 mins. of nursing intervention, patient will know the disease process.
INTERVENTION
INDEPENDENT
Identified symptoms requiring
medical intervention.
Provided the client about the
information of disease process
Reviewed postoperative activity
restrictions.
Encouraged activities as
tolerated with periodic rest
periods.
Discussed care of incision,
including dressing changes.
RATIONALE
Prompt intervention reduces risk of
serious complication.
Patient will be aware the process of his
disease.
Provides information for client to plan
for return to usual routines without
untoward incidents.
Prevents fatigue, promotes healing and
feeling of well-being, and facilitates
resumption of normal activities.
Understanding promotes cooperation
with therapeutic regimen, enhancing
healing and recovery process.
EVALUATION: Goal met. Patient knew already the disease process of appendicitis.
NURSING CARE PLAN # 6
(POST-OP)
ASSESSMENT
Subjective Cues:
“Kasakit sa ako operasyon,” as verbalized by the patient after operation
(appendectomy). Pain scale: 5/10
Objective Cues:
The patient manifested:
Facial Grimace
Abdominal guarding
Sweating
v/s taken: T – 36.9 C
P – 68 bpm
R – 27 cpm
BP – 120/80 mmHg
NURSING DIAGNOSIS
Pain related to post-appendectomy.
PLANNING
Within 40 mins. of nursing intervention, pain will reduce from 5/10 to 0/10.
INTERVENTION
INDEPENDENT
Established rapport
Monitored and recorded vital
signs.
Assessed pain, location, and
severity.
Kept at rest in semi-fowler’s
position
RATIONALE
To gain trust of the patient.
To obtain baseline data.
Useful in monitoring effectiveness of
medication and progression of healing
Gravity localizes inflammatory exudate
into lower abdomen or relieving
abdominal tension which is accentuated
by supine position.
Encouraged early ambulation.
Provided diversional activities.
DEPENDENT
Administered prescribed
analgesic.
Promotes normalization of organ
function and reducing abdominal
discomfort.
Refocuses attention, promotes
relaxation, and enhance coping
abilities.
Relief pain.
EVALUATION
Goal met. Patient pain (pain scale) reduced from 5/10 – 0/10.
NURSING CARE PLAN # 7(POST-OP)
Subjective Cues: “sige ako nag mata mata kay init ug sakit ako tag operahan ug ngotngot”, as verbalized by the patient.
Objective Cues: RestlessnessIrritabilitySlowed Reaction
Nursing Diagnosis: Sleep deprivation related to prolonged discomfort.
Planning: The patient will report improvement in sleep pattern within the shift.
Interventions:1. Determined presence of physical or psychological stressors
Rationale: To know the reasons why the patient can’t sleep.2. Noted environmental factors that affect sleep.
Rationale: To help the client have a better rest and sleep.3. Determined patient’s usual sleep pattern.
Rationale: To provide comparative baseline.4. Observed physical signs of fatigue.
Rationale: To know if the client will not get stressed5. Recommended quiet activities such as, listening to soothing music.
Rationale: To help the client have a better rest and sleep.6. Provided calm, quiet environment and manage controllable sleep disrupting factors.
Evaluation: Goal met. After 6 hours of nursing intervention, the patient was able to report sleep that day and there is a decrease over all body malaise.
NURSING CARE PLAN # 8
(POST-OP)
ASSESSMENT
Subjective Cues:
“Waya pa karajaw nadajaw ang ako samad sukad na gi-operahan ako,” as
verbalized by the patient.
Objective Cues:
The patient manifested:
Epidermis (disruption of the skin surface)
Surgical incision at right lower abdominal area.
NURSING DIAGNOSIS
Impaired skin integrity related to skin/tissue trauma as evidenced by the surgical incision
at right lower abdominal area due to appendectomy.
PLANNING
Within 3 days of nursing intervention, the client will be able to manifest intact sutures,
dry and intact wound dressing, and active/passive participation in ROM exercise.
INTERVENTION
INDEPENDENT
Established rapport
Monitored and recorded vital
signs.
Assessed operative site for
redness, swelling, loose sutures
and soaked dressings.
Assisted passive/active ROM
exercise
Instructed the patient to refrain
from scratching/touching the
surgical site.
Provided regular dressing care.
RATIONALE
To gain trust of the patient.
To obtain baseline data.
To check skin integrity and monitor the
progress of healing.
To promote circulation to the surgical
site and healing.
To avoid accumulation of moisture at
the operative site which may led to skin
breakdown.
To prevent bacteria harbor in the
operative site.
DEPENDENT
Administered antibiotic therapy
as prescribed by the physician.
To promote wound healing.
EVALUATION
Goal was partially met. Client manifested intact sutures, dry and intact wound dressing,
and slightly followed passive/active ROM exercise.
NURSING CARE PLAN # 9
(POST-OP)
Subjective cue:
“tag operahan ako kahapon” as verbalized by patient.
Objective cue:
Abdominal dressing noted Incision on the abdomen area noted.
Nursing Diagnosis:
Risk for infection related to surgical incision.
Planning:
Within 6 hours of nursing intervention, Patient and SO will be able to identify signs and symptoms of infection.
Intervention:
Independent
Instruct Patient and SO how to identify signs and symptoms of infection (fever, chills, redness and burning sensation around, surgical site, and or drainage.)
o Rationale: so they will be able to notify Nurse and or MD and to prevent sepsis
Assess and document skin condition around surgical site. Note for any abnormalities.
o Rationale: to monitor and prevent potential post op complications. Keep dressing dry and intact and proper hand washing
o Rationale: to prevent infection
Dependent:
Give antibiotic per M.D’s ordero Rationale: to help prevent infection
Cleanse surgical site and dressing change per M.D ordero Rationale: to keep surgical site dry and intact.
Evaluation:
Patient and SO verbalized understanding by restating the given instructions.
NURSING CARE PLAN # 10
(POST-OP)
Subjective cue:
“luya ako lawas ma’am” as verbalized by the patient.
Objective cue:
Weakness noted Needs assistance in sitting down, standing and walking Prefers to stay on bed
Nursing diagnosis:
Activity intolerance related to post appendectomy.
Planning:
Within 3days of nursing interventions, patient will be able to use identified techniques to enhance activity tolerance.
Nursing intervention:
Independent:
Provide bed resto Rationales: Promotes periods of rest and relaxation. Available energy is
used for healing Provided environment conducive to relief fatigue.
o Rationales: fatigue affects both the clients actual and perceived ability to participate in activities.
Recommended changing position every 2 hours.o Rationales: to prevent bed sores and promotes optimal respiratory
function. Instructed energy conserving techniques such as sitting instead of standing
during shower and any activities.o Rationales: helps minimize fatigue allowing client to accomplish more
and feel better about self Increased activity as tolerated. Demonstrate active ROM exercise. Rationales: prolong bed rest can be debilitating and causes muscle atrophy Encourage use of stress management technique such as guided imagery.
o Rationales: promotes relaxation and conserves energy, redirect attention and may enhance coping.
Evaluation:
Goal partially met, as evidenced by patient understanding and following instructions and techniques that would enhance activity tolerance.
DISCHARGE PLAN
Upon discharge from Caraga Regional Hospital, the patient as well as the SO will be
given a home care instruction which contains the following:
MEDICATION:
Take home medicines
o lomefloxacin hydrochloride: 400mg one tab by mouth twice a day total of
16tablets only
o ranitidine:150mg one tab by mouth three times a day, total of 16 tablets only
o ponstel (mefinamic acid): 500mg 1 cap by mouth three times a day total of 16
caps only.
o Multivitamins (Enervon – C): 1 tab OD
ENVIRONMENTAL CONCERNS:
Instructed patient to provide a peaceful relaxing, comfortable and well ventilated room
Instructed patient to provide a stress free environment
Instructed patient to follow the prescribed meal plan
Instructed to provide clean environment to prevent lodging of infectious microorganisms.
Changes in his environment can aid in his recovery by making it easier for him to bathe,
dress and prepare meals while his muscles return to normal levels of strength
TREATMENTS:
Discussed on the importance of strict adherence to medication regime to ensure complete
healing.
Instructed patient to understand and follow discharge instruction religiously and
accurately.
Instructed patient to follow proper instruction on medication prescribed by the physician
Reinforced proper incision care.
HEALTH TEACHINGS:
Review information about medications to be taken at home, including name, dosage,
frequency and possible side effects, discussed the importance of continuing to take
Patient is counseled regarding importance of eating meals on time and in a relaxed
setting.
Instructed Patient to avoid any strenuous activities, until the incision completely healed.
Keep incision site dry and clean.
Notify MD if s/sx of infection noted. (ex: fever, chills, redness around the incision, and
any discharges.)
OUT PATIENT (FOLLOW UP CHECK-UP)
Patient is advised for follow up check up to his physician one (1) week after discharge
Instructed patient to notify physician of there is any undesired feeling about the disease
DIET
Advised patient to avoid raw foods, fruits and vegetables that contain seeds (e.g. guava,
tomatoes, )
Advised to eat foods rich in protein and Vitamin C for wound healing.
SPIRITUAL
Encourage patient to go church and pray regularly together with his whole family. Never
forget to thank god for all the blessings he and his family has been receiving.
Advised patient to find time with his family members and friends and share the good
news written in the bible.
Encouraged SO to pray for the health of the patient.
INTRAVENOUS FLUID
Date/time
started
Intravenous
fluid and
volume
Drop Rate /min Number of
hours to be
infused
Date /time
consumed
09-01-11 D5LR/1L 20 drops 16hrs &39mins 09/01/11
12:39pm
09-01-11 D5LR/1L 20 drops 16hrs&39mins 09/03/11
5:30am
09-03-11 D5LR/1L 50 drops 6hrs & 39 mins 09/03/11
12:09pm
09-03-11 D5NSS/1L 50drops 6hrs & 39 mins 09/03/11
6:48pm
09-03-11 D5LR/1L +
Multivitamins
50drops 6hrs & 39 mins 09/04/11
1:27 am
09-04-11 D5LR /1L 50drops 6hrs & 39 mins 09/04/11
8:08am
09-04-11 D5NSS /1L 50drops 6hrs & 39 mins 09/04/11
2:27pm
09-04-11 D5LR/1L 50drops 6hrs & 39 mins 09/04/11
9:26pm
Grandmother, 59Hypertension Grandmother
1st Sibling 2nd Sibling 5th Sibling 8th Sibling 1st Sibling, 32Eclampsia
Mother
1st Sibling 3rd Sibling
Female Female Deceased
FAMILY GENOGRAM
LEGENDS:
PATERNAL SIDE MATERNAL SIDE
Grandfather, 79Hypertension/Stroke
Grandfather
Father, has Hypertension 4th Sibling 6th Sibling 7th Sibling 3rd Sibling
Patient, 17 4th Sibling 5th Sibling
Male MaleDecease
Patient
DEFINITION OF TERMS
1. Appendectomy – surgical removal of the vermiform of appendix.
2. Appendicitis - inflammation of the vermiform appendix called also
epityphlitis.
3. Appendix – a bodily outgrowth or specifically processed.
4. Blumberg sign - also referred as rebound tenderness. Deep palpation of the viscera over
the suspected inflamed appendix followed by sudden release of the pessue causes the
severe pain on the site indicating positing Blumberg’s sign and peritonitis.
5. Dunphy’s sign - increased pain in the right lower quadrant with coughing.
6. Fecalithe - a concretion of dry compact feces formed in the intestine
or vermiform appendix.
7. Hematocrit (Ht or HCT) or packed cell volume (PCV) or erythrocyte volume
fraction (EVF) - is the proportion of blood volume that is occupied by red blood cells. It
is normally about 48% for men and 38% for women. It is considered an integral part of a
person'scomplete blood count results, along with hemoglobin concentration, white blood
cell count, and platelet count.
8. IgA - has two subclasses (IgA1 and IgA2) and can exist in a dimeric form called
secretory IgA (sIgA). In its secretory form, IgA is the main immunoglobulin found in
mucous secretions, including tears, saliva, colostrum and secretions from the
genitourinary tract, gastrointestinal tract, prostate and respiratory epithelium. It is also
found in small amounts in blood.
9. Kocher’s Sign - the appearance of pain in the epigastric region or around the stomach at
the beginning of disease with a subsequent shift to the right iliac region.
10. Laparotomy – surgical section of the abdominal wall.
11. Obturator sign - if an inflamed appendix is in contact with the obturator internus, spasm
of the muscle can be demonstrated by flexing and internal rotation of the hip. This
maneuver will cause pain in the hypogastrium.
12. Perforation - a rupture in a body part caused especially by accident or disease
and/or a natural opening in an organ or body part.
13. Peritoneum - the smooth transparent serous membrane that lines the
cavity of the abdomen of a mammal, is folded inward over the
abdominal and pelvic viscera, and consists of an outer layer closely
adherent to the walls of the abdomen and an inner layer that folds to
invest the viscera.
14. Peritonitis – inflammation of the peritoneum.
15. Psoas sign - is the right lower-quadrant pain that is produced with either the passive
extension of the patients right hip (pt. lying on the left side, with knee in flexion) or the
patient’s active flexion of the right hip while supine. Straightening out the legs causes
pain because it stretches these muscles, while flexing the hip activated the iliopsoas and
therefore causes pain.
16. Rovsing’s sign - continuous deep palpation starting from the left iliac fossa upwards
(counterclockwise along the colon) may cause pain in the right iliac fossa, by pushing
bowel contents towards the ileocaecal valve and thus increasing pressure around the
appendix.
17. Stikovskiy (resenstein’s) sign - increased pain on palpation at the right iliac region as
patient lies on his/her left side.
18. Ultrasound - is cyclic sound pressure with a frequency greater than the upper limit of
human hearing. Although this limit varies from person to person, it is approximately 20
kilohertz (20,000 hertz) in healthy, young adults and thus, 20 kHz serves as a useful
lower limit in describing ultrasound. The production of ultrasound is used in many
different fields, typically to penetrate a medium and measure the reflection signature or
supply focused energy. The most well known application of ultrasound is its use in
sonography to produce pictures of fetuses in the human womb. There are a vast number
of other applications as well.
19. Vermiform – a resembling worm in shape.
20. Vermiform Appendix - a narrow blind tube usually about three or
four inches (7.6 to 10.2 centimeters) long that extends from the cecum
in the lower right-hand part of the abdomen, has much lymphoid wall
tissue, normally communicates with the cavity of the cecum, and
represents an atrophied terminal part of the cecum.
BIBLIOGRAPHY
A. Textbook References/Primary References:
Assessment: Lippincott; 2007 Edition.
Taber’s Cyclopedic Medical Dictionary: 18th edition
Fundamentals of Nursing: Kozier and Erb; 8th Edition.
Medical-Surgical of Nursing: Bunner and Suddarth; 12th Edition.
NANDA: Doenges, Moorhouse and Murr; 12th Edition.
Nursing Care Plans: Doenges, Moorhouse and Murr; 8th Edition.
Nursing Drug Guide: Lippincott; 2010 Edition.
PDQ for RN:Mosby; 2nd Edition.
PPD for Registered Nurses: Mosby; 2nd Edition.
Principles of Internal Medicine: Harrison and Braunswald; 11th Edition.
Public Health Nursing: Nurses Contributors; 2007 Edition.
B. Electronic References/Secondary References:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001302/
http://www.webmd.com/digestive-disorders/digestive-diseases-appendicitis
http://kidshealth.org/parent/infections/stomach/appendicitis.html
http://en.wikipedia.org/wiki/Appendectomy
http://www.appendicitisreview.com/laparoscopic-appendectomy/
http://medical-dictionary.thefreedictionary.com/Ruptured+appendix
www.sciencedaily.com
www.healthycase.com