ANGELES UNIVERSITY FOUNDATION

College of Nursing

Appendectomy
(A Case Study)

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

Submitted to:
Ms. Jazper Herrera, RN
Clinical Instructor

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TABLE OF CONTENTS:
I. INTRODUCTION……………………………………………………………………….3
a. Current trends about the disease condition………………………………..4
b. Reasons for choosing such case for presentation………………………..5
II. NURSING ASSESSMENT……………………………………………………..…….6
a. Personal History…………………………………………………………...…6
b. Pertinent Family Health-Illness History………………………………….…7
c. History of Past Illness…………………………………………………….….8
d. History of Present Illness………………………………………………..…..8
e. Physical Examination……………………………………………… ………..9
f. Diagnostic and Laboratory Procedures……………………………..……12
III. ANATOMY and PHYSIOLOGY(with visual aids)…………………………….…...14
IV. THE PATIENT’S ILLNESS…………………………………………………….…….18
a. Synthesis of the disease……………………………………………...….…..18
a1. Definition of the disease……………...……………………….……18
b2. Predisposing / Precipitating factors…………………………...….18
c3. Signs and symptoms with rationale………………………… ……19
d4. Health promotion and preventive Aspects of the Disease ..…..20
V. THE PATIENT AND HIS CARE………………………………………………………21
a. Medical Management……………………………………….……… …21
a. IVF’s, BT, NGT feeding, Nebulization, TPN, Oxygen therapy, ...21
b. Drugs……………………………………………………………....….23
c. Diet……………………………………………………………….……25
d. Activity / Exercise………………………………………….….……..26
b. Surgical Management (actual SOPIERs)…………………………….……27
c. Nursing Mangement…………………………………………………….….…28
a. Nursing Care Plan……………………………………………….……28
b. Actual SOAPIES …………………………………………………..…29
VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL…………………………...…..31
a. Client’s daily Progress Chart………………………….………………….….31
b. Discharge Planning……………………………………………………….….31
a. General Condition of Client upon Discharge…….……………...31
b. METHOD…………………………………………...……………….31
VII. CONCLUSION and RECOMMENDATIONS…………………………….….……32

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I. Introduction

The appendix is a closed-ended, narrow tube that attaches to the cecum (the first
part of the colon) like a worm. (The anatomical name for the appendix, vermiform
appendix, means worm-like appendage.) The inner lining of the appendix produces a
small amount of mucus that flows through the appendix and into the cecum. The wall of
the appendix contains lymphatic tissue that is part of the immune system for making
antibodies. Like the rest of the colon, the wall of the appendix also contains a layer of
muscle.

Appendicitis is inflammation of the appendix. It is thought that appendicitis begins

when the opening from the appendix into the cecum becomes blocked. The blockage
may be due to a build-up of thick mucus within the appendix or to stool that enters the
appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks
the opening. This rock is called a fecalith (literally, a rock of stool). At other times, the
lymphatic tissue in the appendix may swell and block the appendix. Bacteria which
normally are found within the appendix then begin to invade (infect) the wall of the
appendix. The body responds to the invasion by mounting an attack on the bacteria, an
attack called inflammation. (An alternative theory for the cause of appendicitis is an initial
rupture of the appendix followed by spread of bacteria outside the appendix.. The cause
of such a rupture is unclear, but it may relate to changes that occur in the lymphatic
tissue that line the wall of the appendix.)

If the inflammation and infection spread through the wall of the appendix, the
appendix can rupture. After rupture, infection can spread throughout the abdomen;
however, it usually is confined to a small area surrounding the appendix (forming a peri-
appendiceal abscess). The treatment for appendicitis is antibiotics and surgical removal of the
appendix (appendectomy). Appendectomy is the removal by surgery of the appendix, the small
worm-like appendage of the colon (the large bowel). An appendectomy is performed because of
probable appendicitis.

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

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

A. Current Trends about Appendicitis

Care protocols reduce appendectomy complications - Tips from Other
Journals

Appendectomy is the fourth most common abdominal surgery performed in the United
States. Up to 18 percent of patients have postoperative infectious complications ranging
in significance from wound infection to intra-abdominal abscess. The rate of infections
depends on the degree of contamination during surgery and reaches nearly one third of
cases when the appendix is perforated or gangrenous. Helmer and colleagues studied
the effect of an evidence-based clinical practice guideline in reducing infectious
complications of appendectomy.

The clinical practice protocol that was developed from a critical review of the literature
(see accompanying figure) was applied to 206 patients with a presumptive diagnosis of
appendicitis who presented to a Texas county hospital during 1999. Outcomes in this
cohort of patients were compared with those in 232 patients treated for the same
condition at the hospital during the previous year. No patients were excluded from the
study. Data were gathered on demographic and surgical features, comorbidities, use of
antibiotics, evidence of infection, and other complications during the hospital stay.

Eight patients (4 percent) who were treated according to the protocol had postoperative
surgical infections, compared with 20 patients (9 percent) in the comparison group. The
number of patients with intra-abdominal abscesses dropped from 12 to five after
introduction of the protocol, and the number of wound infections dropped from 14 to four.
The improvement was particularly significant in patients presenting with a perforated or

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gangrenous appendix. In these patients, the total number of infections dropped from 16
(33 percent) to five (13 percent).

The authors conclude that use of an evidence-based clinical practice guideline can
significantly reduce surgically related infections following appendectomy and is
particularly effective in patients with perforation or gangrene of the appendix.

B. Reasons for choosing such case

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

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II. Nursing Assessment

A. Personal History

Princess Lulu M. Ba 65 years old, female, currently residing at 176

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

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 B. Pertinent Family Health-Illness History

Ba Family

Jewel Palace
o Mother o Father
o Alcoholic o Alcoholic
o Died of o Died of a ruptured
Tuberculosis appendicitis

Prince Stephen Princess Lulu

o husband o Patient
o Dignosed
with
appendicitis

Bu Ba Jel
La
-28 -27
-37 -32 -married -married
-Married -single
-housewife construction
-working -Construction
worker
worker

Tah Mah Ad Bon

-15 -17 -22 -24
-single -single -single -married
-not going to -college -vendor -vendor
school student

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Living Condition

House:
They live in a bungalow type of house, concrete and some of the married
members of the family resides

Food:
Their food is always a usual Filipino dish consisting of rice, fish, meat and
vegetables. Their source of water is the pump.

Economic Status:
Princess Lulu is not working; she is dependent on his children for support. Her
daughter, told us that 150-200 pesos a day is enough for them to satisfy the day.

Beliefs:
The BA Family believes in “herbolarios” and “hilots” and directly seek
advices from them if any sickness occurred. They seldom bring members of the family to
doctors or to the hospital for consultation or treatment of any disease.

C. History of Past Illness

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

D. History of present Illness

It was February 28, 2006, 7 in the evening when she started to feel some pain in
the abdominal area, accompanied by fever; she was chilling and felt nauseated and
vomited several times. At 11 pm of the same night, she was still experiencing the same
but the pain is worsen. Early in the Morning, they rushed him to the ONA. Dr. Dizon
assessed her and diagnosed it as acute appendicitis because of (+) muscle guarding,

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(+)direct and rebound tenderness on the right lower quadrant. The patient was also
assessed for Psoas sign and Obturator sign and was found out that the patient was in
pain during the assessment hence he was admitted right away and had an emergency
appendectomy.

E. Physical Examination
March 01, 2006

BP=110 / 90 RR= 20 bmp

T= 37.2º C PR=84 bpm

SKIN
a .General: dark brown in color; dry skin; absence of edema; when pinched skin
springs back to previous state, poor turgor
NAILS
a. General: converse curvature; smooth texture; long with dirt; promp return of pink
or usual color
HAIR
a. evenly distributed; thick hair; dry; black in color
HEAD AND FACE
a. scalp: no evidence of flaking or dandruff
b. skull: rounded; smooth skull contour; absence of nodules or masses
c. face: palpabral fissures equal size
EYES
a. general: symmetrically aligned
b. eyebrows: symmetrically aligned equal movement; hair evenly distributed
c. eyelashes: equally distributed curled slightly outward
d. eyelids: skin intact; no discharge; no discoloration; involuntary blinks
e. sclera: whitish with capillaries
f. conjunctiva: shiny; smooth
g. pupils: black in color; equal size; + PERRLA; round, smooth border
h. vision: able to read newsprint; sensitivity to light

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EARS
a. general: mobile;firm; no tenderness; pinna recoils after it is folded; no infection
b. external ear canal: presence of hair follicles; presence discharge

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

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

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

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F. Diagnostic and Laboratory Procedures

Diagnosis/ Date ordered Indication or Analysis &

Lab Date result purpose result normal value interpretati
procedure on of result
- to determine Yellow, clear Yellow, clear The
urine Sugar: ( - ) Sugar: ( - ) microscopic
O: 03-01-06 composition Ph: acidic Ph: acidic analysis
Urinalysis such as Sp. Gravity: Sp. Gravity: shows
R: 03-01-06 blood, 1.030 1.003-1.030 normal
glucose, Pus cells: Pus cells: levels.
protein 0-1 HPF +10 HPF
RBC: RBC:
1-2 HPF 0-3 HPF

Nursing Responsibilities:

 Explain the procedure and the purpose to the client.

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

Diagnosis/ Date ordered Indication Analysis &

Lab Date result in or purpose result Normal value interpretati

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procedure on of the
result

O: 03-01-06 -to indicate Hgb: Hgb: White blood

Hematologic anemia and 1.50 M: 140-180 cell is above
test R: 03-01-06 polycythemi gm/L the normal
a F: 120-160 range, there
gm/L is systemic
WBC: WBC: infection.
14.6 5.10 x 10/L Leukocytosi
Hct: Hct: s indicates
0.45 M: 0.40-0.54 appendicitis.
L/L
F: 0.37-0.47
L/L
RBC: RBC:
5.25 M: 4.5-6.3 x
10/L
F: 4.2-5.4 x
10/L

Diagnosis/ Date ordered Indication Analysis &

Lab Date result in or purpose result Normal value interpretati
procedure on of the
result

O: 03-01-06 -to indicate Hgb: Hgb: A decrease

Hematologic anemia and 139 M: 140-180 in
test R: 03-01-06 polycythemi gm/L hemoglobin
a F: 120-160 indicates
gm/L anemia.
WBC: WBC: White blood
12.4 5.10 x 10/L cell is above
Hct: Hct: the normal
0.41 M: 0.40-0.54 range, there
L/L is systemic
F: 0.37-0.47 infection.
L/L Leukocytosi
RBC: RBC: s indicates
5.25 M: 4.5-6.3 x appendicitis.
10/L
F: 4.2-5.4 x
10/L

Nursing Responsibilities:

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

III. Anatomy and Physiology

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

 Mouth (Oral cavity/ Bucal Cavity, includes tongue, teeth, salivary glands and
mucosa)

The mouth is the first of the digestive tract. It is the opening through
which takes in food. It is lined by stratified squamous non-cornified
epithelium, except the hard palate, gingival and filiform papillae of tongue which
are cornified.

It is bound infront by the lips, above by the hard and soft palate, below by
the floor of the mouth including the tongue and behind by the faucial isthmus.

 Pharynx

The pharynx is the part of the digestive system which connects the mouth
with esophagus. It is where the digestive tract and the respiratory tract cross,
commonly called the throat. The human pharynx is bent at a sharper angle.

 Esophagus (Gullet/ Oesophagus)

The esophagus is a muscular tube, lined with moist stratified squamous

epithelium that extends from the pharynx to the stomach. It is about 25 cms.
Long and lies anterior to the vertebrae and posterior to the trachea within the

14
 mediastinum. It passes through the diaphragm and ends at the stomach. It
transports food from the pharynx to the stomach.

 Stomach

The stomach is an enlarged segment of the digestive tract in the left

superior part of the abdomen. It is an alimentary canal used to strore and digest
food. It’s primary function is as a storage and mixing chamber for ingested food.
It is lined with simple columnar epithelium. Latin names for the stomach include
Ventriculus and Gasti, many medical terms related to the stomach part in “gastro”
or “gastric”.

In humans the stomach is a highly acidic environment (maintained by the

hydrochloric acid secretion) wit peptidase digestive enzymes.

In ruminants, the stomach is a large multichambered organ that hosts

symbiotic bacteria which produced enzymes required for the digestion of
cellulose from plant matter. The partially digestive plant matter passes through
each of the stomach’s chambers in sequence, being regurgitated and rechewed
at least once in the process.

 Bowel/Intestine

 Small Intestine
Small intestine is the portion of the alimentary tract between the stomach
and the large intestines whose main function is for absorption. It is about 6
meters long and consists of 3 parts: duodenum; jejunum and ileum.

 Duodenum
Duodenum is a hollow jointed tube that connects the stomach to the
jejunum, it is the shortest, the widest and most fixed part of the small intestine
and is largely retro-peritoneal closely attached to the dorsal wall.

 Jejunum

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 Jejunum is about 2.5 meters long and makes up 2/5 of the total length of
the small intestine.

 Ileum
The ileum joins with the cecum at ileocal junction. It is about 3.5 meters
long and it makes up 3/5 of the small intestine.

 Large Intestine
The large intestine extends from the ileocal junction up to the anal
opening in the peritoneum. It is about 5-6 feet long. It is subdivided into: cecum
and appendix, colon, rectum and anal canal.

 Cecum and Appendix

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

 Colon
The colon is about 1.5-1.8 meters long and consists of four parts:

 Ascending colon
 Transverse colon
 Descending colon and sigmoid colon

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

 Descending Colon and Sigmoid Colon

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 The descending colon extends from the left colic flexure to the pelvis,
where it becomes the SIGMOID COLON. The sigmoid colon forms an S-shaped
tube that extends medically and the inferiorly into the pelvic cavity and ends at
the rectum.

 Rectum
The rectum is a straight muscular tube that begins at the termination of
the sigmoid colon and ends at the anal canal.

 Anal Canal
The anal canal represents the terminal portion of the large intestines and
it is about 2-3 cms. long

IV. The Patient’s Illnesses

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A. Synthesis of the Disease
a1. Definition of the Disease
Appendicitis is the inflammation of the vermiform appendix, which is
attached to the cecum and lies in the right lower quadrant, the appendix can lie
medial, lateral, anterior or posterior to the cecum, it is behind the bowel or
mesentery or in the pelvis.
The average adult appendix is 9-10 cm in length with a diameter of 0.5 to
1 cm. Its blood supply, the appendiceal artery, is a terminal branch of the
ileocolic artery which transverses the length of the appendix.
This small finger shaped tube branches of the large intestine. There is no
specific cause of appendicitis, although inflammation can occur spontaneously
from an infection or from fecal waste that have been trapped in the lumen of the
appendix. The appendix can also become kinked, obstructing the circulation.
Abscess formation generally occurs and danger of rupture is omnipresent.
Appendicitis is characterized by a sharp abdominal pain that may be
localized at McBurney’s point (half way between the umbilicus and right iliac
crest). Palpation of the abdomen causes pain in the right quadrant.
Pressing the abdomen at McBurney's point causes tenderness in a
patient with appendicitis. When the abdomen is pressed, held momentarily, and
then rapidly released, the patient may experience a momentary increase in pain.
This "rebound tenderness" suggests inflammation has spread to the peritoneum.
If the appendix ruptures, the pain may disappear for a short period and
the patient may feel suddenly better. However, once peritonitis sets in, the pain
returns and the patient becomes progressively more ill. At this time the abdomen
may become rigid and extremely tender.
Appendix occurs most commonly on children, adolescents and young
adults but individuals of any age may have appendicitis.

a.2.Predisposing / Precipitating Factors

Predisposing Factors:
 Classic history of appendicitis

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  Sex: Appendicitis is 1.3 to 1.6 times more common in males than in
females
 Age: the peak incidence is in the second and third decades with 80 %
of cases occurring in persons younger than 45 years of age but
individuals of any age may have appendicitis.
 Anatomical Variations in the position of the appendix.
Precipitating Factors:
 Lymphoid Follicular Hyperplasia
 Infections by viruses, parasites or bacteria
 Diet deficient in fiber

a.3. Sign and Symptoms

Appendicitis often starts with mild pain near the navel. The pain gradually
moves to the right lower part of the abdomen. It worsens with time, and is more
intense when the person moves. Other symptoms of appendicitis may include:

· Nausea or vomiting.

· Elevated temperature.

· Increased pulse rate.

· Loss of appetite.

· Constipation.

· Abdominal swelling.

If the infection continues, the appendix may rupture. When this occurs,
there is often relief of the pain for a short while. This improvement is followed by
more intense but similar pain.

Chronic appendicitis is rare. It causes a milder pain in the right lower

abdomen that may come and go.

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

A-void too much activity(eating then working or playing right away)

P-eople of any age are susceptible, male are more prone

P-revent obstruction of the lumen

E-xercise

N-otify physician if any signs and symptoms occur

D-iet should be high in fiber; so to..

I-increase peristalsis to prevent constipation

X-ray, ultrasound and other lab test should be take into consideration to

avoid rupture of the appendix

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V. THE PATIENT AND HIS CARE

1. Medical management
A. IVF’s
Indication/s Client’s Client’s
Medical Date General Initial response to
Or
Manageme ordered; Description Reaction to the
nt/ performed; Purpose/s the Treatment
Treatment changed Treatment

Slightly Client has a

Used to >Check IV
D5LRS 1L hypertonic guarding
x 8 @ 30- solution, this replace behavior but Tubing for
31 gtts./min solution was
deficits in the the
exerts higher cooperative
#1 O: 03-01-06 osmotic extracellular with the presence of
C: 03-01-06 pressure than treatment
compartment air
of the blood procedure.
plasma. in patients He >Check
#2 O:03-02-06 D5LRS will responded
that are Integrity of
C:03-02-06 increase the well to the
solute dehydrated treatment. the Infusion
concentration
and volume >Monitor IV
#3 O:03-02-06 of plasma,
C:03-03-06 draining water depleted. flow rate
out of the
>Adjust rate
cells into the
of flow of
#4 O:03-03-06 extracellular D5LRS is
fluids
C:03-04-06 compartment administered
appropriate
to restore and given to
to need of
osmotic patient to
patient as
#5 O:03-04-06 equilibrium. give the
prescribed
C:03-05-06 D5LRS necessary
contains 130 nutrients to
mEq/L replace any
#6 O:03-05-06 Sodium, 4 lost fluids
C:03-05-06 mEq/L of since the
Potassium. patient is in
109 mEq/L NPO. It is
Chloride, 3.0 also used as
mEq/L of a main line
Calcium. It to administer
has 120 Antibiotics

21
 calories. and
medications
IV.

Client’s Client’s
Medical Indication/s
Date General Initial response to
Managem ordered; Description Or Reaction to the
ent/ performed;
Purpose/s
the Treatment
Treatmen changed Treatment
t

D5NM 1Lx Hypotonic Provides Client has a

No signs of
35 gtts/min solution it principal ions guarding
abnormalities
maybe iso- of normal behavior but
observed or
#4 O: osmolar since plasma is was
felt by the
01-31-06 dextrose is almost the cooperative
C: 01-31-06 rapidly same with the patient.
metabolized. proportions as treatment
Normosol M with normal procedure.
contains plasma. He
dextrose 50g, Replacement responded
dehydrated of acute well to the
alcohol 40ml, looses of treatment.
potassium extraxcellular
acetate 1.28g, fluid volume in
fructose surgery, it
150g,NaCl was given to
2.34g, Mg the patient to
acetate 0.1g prevent
dehydration
and contains
plasma
volume.

Nursing Responsibilities

 Before administering the IV, identify first the pationt

 Explain the procedure
 Prepare the equipment
 Wash hands
 Check the fluid to be infused
 Use the smallest gauge needle possible
 Drip the tubing before connecting to the needle once being infused
 Adjust the IVF as indicated

22
  Report any pain, infufusion or dislocation felt by the patient
B. Drugs

Name of the Date Route and Indication/ Specifi Client’s

Drugs Ordered Frequency of Purposes Foods response to
Generic Date administration taken medication
Name Taken
Brand Name Date
Changed
NPO The patient
03-01-06 1 amp. IV q 4° ,non narcotic took the drugs
Paracetamol 03-01-06 analgesics properly,
03-06-06 decreases fever infection
reduced, no
side effects
observed

Cefuroxime 03-02-06 750mg IV q 8° -Antiinfective NPO The patient

03-02-06 -2nd generation took the drugs
03-04-06 cephalospor properly,
ins infection
-inhibits bacterial reduced, no
cell wall side effects
synthesis observed
rendering cell
wall osmotically
unstable, leading
to cell death by
binding to cell
wall membrane

Metronidazole 03-02-06 500mg IV >Ambecide NPO Patient had no

03-03-06 q8° ANST(-) >Anti-infective manifestations
03-06-06 >kills susceptible of any side
amoeba, effects
trichomonas and
bacteria

Tramadol 03-02-06 100mg IV q 6º >Analgesic, NPO- Patient had no

03-03-06 RTC centrally acting Clear manifestations
03-06-06 > liquid of any side
effects

Plasil 03-02-06 5mg/ml q 8° x >anti-emetic NPO Patient had no

03-02-06 4 doses manifestation
regarding any

23
 03-03-06 side effects

Famotidine 03-02-06 20 mg IV q 12º Histamine H2 NPO Patient had no

03-02-06 x 3 doses antagonist manifestation
03-03-06 regarding any
side effects

Kortezor 03-02-06 30 mg IV q 8º x Pain reliever NPO Patient had no

03-02-06 4 doses manifestation
03-03-06 regarding any
side effects

Captopril 03-03-06 25mg SL NPO-

03-03-06 Clear
03-03-06 liquid
03-05-06 Supp 2 suppl -laxative, Patient had no
Dulcolax 03-05-06 rectum stimulant Soft manifestation
03-05-06 - diet regarding any
diphenylmethane side effects
-acts directly on
the intestine by
increasing motor
activity; thought
o irritate colonic
intramural
plexus;
increases ater in
the colon

Nursing Responsibilities:

 Assess patient from allergic reaction (ANST)

 Assess the patient for any sign and symptoms
 Identify Urine output, if decreasing, notify the physician
 Caution patient to report bleeding, bruising or fatigue
 Monitor patient bowel and consistency of stool
 Evaluate for therapeutic response: release of pain, stiffness, swelling
 Document indications for therapy.location, onset, and charcteristic of symptoms
 Assess for history of drug addiction, allergy to any medicine

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  Monitor vital signs
 Obtain CBC and necessary cultures before administering
 Encourage increased fluid intake
 Document
C. Diet
Types Date ordered General Indications or Specific Client’s
Of Diet Date started Description Purpose Foods taken response to the
Date treatment
changed
NPO 03-01-06 Restriction of solid Upon admission She exhibited
03-01-06 nor liquid foods by to provide more some loss of
03-03-06 mouth accurate appetite.
observation in the
condition of the
client and for pre
and post
operative patient
to prevent
aspiration of the
food taken in as
an effect of the
anesthesia.
Clear 03-03-06 Made up of clear It is mainly used she first seemed
Liquid 03-03-06 liquid foods which for post operative Water to have a loss of
Diet 03-03-06 leave no residue in patients, patients Pineapple appetite with the
the GIT. It is non- with acute illness juice ordered diet, but
stimulating, non- and infections, to Jelly ace then gradually
gas forming, and relieve thirst, to took in the foods
non-irritating. reduce colonic that were
fecal matter. It is ordered by the
done between 1-2 physician.
feeding intervals.
Soft 03-04-06 It is similar to the It is used for The patient
Diet 03-04-06 regular diet except patients with Soup manifested an
03-06-06 that the texture of acute infections, Lugaw improved
the foods has been some GIT Crackers appetite.
modified. It is a diet disturbances or Mammon
modified in chewing Pineapple
consistency to have problems and juice
new roughage, following surgery water
liquefied foods,
semi-solid foods
and those which
are easily digested.
This could offer an
entirely adequate,
liberal diet.

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Nursing Responsibilities:

 The benefits as well as the disadvantages should be explained well to the client.

 The nurse should make sure that the patient adheres to the ordered diet.

 The ordered diet should be monitored.

 Continuous monitoring of the client’s diet should be observed

d. Activity/Exercise

Type of Date General Indication or Client’s

exercise ordered, description purpose response to the
date activity or
started, exercise
date
changed

Date Pt. is restricted To decrease Pt. was able to

ordered from any stressful oxygen and avoid any
Bed rest 03- 01 -06 activities energy demand. stressful
Date started activities.
03-01-06
Date
changed
03-03-06

Ambulation Date Pt. performed To be able limit Pt. was able

(walking) ordered ADLs, maintain movements and performed her
03-04-06 good body strengthen the ADLs like walking
Date started alignment and muscles.
03-04-06 carry out active
ROM exercises.

Nursing responsibilities:

 Check for the doctors order

 Explain the purpose of the exercise to the client
 Instruct client to maintain the exercise ordered by the physician
 Assist the patient in moving and walking

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 Provide comfort measures to avoid injury of the patient

B. Surgical Management

a. Brief Description

A surgical procedure called an appendectomy is necessary before the appendix

ruptures. Attempts are made to remove the inflamed appendix before it ruptures and
preoperative care is directed toward resting the colon. No enemas, heating or laxatives
should be used before surgery because they could stimulate peristalsis and cause a
rupture of the appendix.

The appendix is removed through a small incision over McBurney’s point or

through a right paramedical incision. The incision usually heals with no drainage. Drains
are used when an abscess is discovered when the appendix has rupture and sometimes
when the appendix was edematous and ready to rupture and was surrounded by clear
fluid.

If no rupture has occurred, a laparoscopic appendectomy, in which the appendix

is removed through a scope maybe done. A laparoscopic appendectomy requires only
small incision and allows client to be discharged 24 hours after surgery.

Bowel function is usually normal soon after surgery and convalescence is short.

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b. Nursing Responsibilities

Preoperative

 Assess the location, severity, onset, duration, precipitating factors and

alleviating measures in relation to the pain
 Intravenous fluids as prescribed to maintain fluid and electrolyte balance
 Instruct nothing by mouth to the patient prior to surgery
 Record allergies and medications as well
 Place the patient in semi fowlers or side lying position to provide comfort
 Analgesics are withheld until physicians determines diagnosis

Post Operative

 Determine (+) flatus

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

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b. Actual SOPIE
S>Ø

O> the patient manifest the following

(+) guarded behavior

(+) facial grimaces

(+) restlessness

(+) pupillary dilatation

(+) narrowed focus

Onset of pain: often; Quality: Stabbing and throbbing; Region on RLQ;

severely: always; Level of pain of 10/10

A> Acute pain R/T stimulation of nerve endings

P> After 2-3° of Nursing Intervention and health teaching the pt will be

able to decrease pain from 10 to 6 using a scale of 10 as evidence by

using of relaxation technique and diversional activities.

I>

 Monitored and recorded vital signs

 Assessed patient condition

 Performed comprehensive assessment of pain

 Accepted patient perception of pain

 Observed non-verbal cues

 Encouraged verbalization of feeling about pain

 Provided quiet and calm environment

 Provided patient comfort measures

 Encouraged relaxation exercise such as deep breathing

 Encouraged diversional activities

 Encouraged adequate rest

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 Discussed with SO way on how to assist patient to reduce pain

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

30
 VI.CLIENT’S DAILY PROGRESS IN THE HOSPITAL

a.Client’s daily progress chart

Days Admission 03-02-06 03-03-06 03-04-06 03-05-06

Nursing Problems
Acute Pain / / / / /
Risk for deficient / /
fluid volume
Impaired skin / / / /
Integrity
Physical Immobility / / / / /
Risk for Infection / / / / /
Vital Signs 8am 8am 8am 8am 8am
Blood Pressure 110/80 100/70 110/60 110/80 90/60
Temperature 36.9 37 37 36.6 36.1
Respiratory Rate 20 21 21 21 20
Pulse Rate 82 84 89 66 70
Lab Procedures

Medical / / / / /
Managements
1. IVF’s
D5LRS
Drugs:
Paracetamol / /
Cefuroxime / /
Metronidazole / / / /
Tramadol / / / /
Plasil / / / /
Famotidine / / / /
Kortezor /
Captopril /
Dulcolax /
Diet
NPO /
Clear Diet /
Soft Diet / / /

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 B.Discharge Planning

a. General Condition Of client upon Discharge

Since we were not able to see the client when she was discharged

from the Hospital, with few days of nursing intervention, the client’s

general condition has improved:

1. She is slowly regaining his strength

2. She can ambulate with assistance

b. METHOD
M- take the medicines prescribed

E- exercise such as walking and proper breathing

T- daily wound cleaning

H- increase fluid intake, vitamin C, apply hot compress

O- be back at OPD as ordered by the doctor

D- Diet as tolerated with an increase intake of Vitamin C

VII. Conclusion and Recommendation

Every individual of any age are prone to appendicitis though its more common
with males, still everyone is susceptible, mild umbilical pain maybe vague at first, but it
increases intensity. Over a period of time, signs and symptoms occur rapidly, it cannot
be presented an experience of this shall be contented with proper prevention.

Faulty diet especially low in fiber is one cause of the observation therefore by
eating fiber- rich food will increase peristalsis. So there is regular bowel movement. So
there is no fecal material that will be formed.

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 Not everyone with appendicitis has all the symptoms. The pain may intensify and
worsens other may have a sensation called “down ward urge” pain medication and other
laxatives should not be taken in their situation. Anyone with these symptoms need to see
a qualified physician immediately.

Recommendation

One should always remember the health promotion and prevention of

appendicitis. Just remember the acronym APPENDIX, which is avoiding too much
activity, that people of any age and sex are susceptible. One should always play safe in
preventing obstruction of the lumen. Exercise is important. Notify physician if any signs
and symptoms occur. Diet should always be high in fiber to increase peristalsis and to
prevent constipation. Lastly x-ray, ultrasound and other laboratory test should be taken
into consideration to avoid response of the appendix.

33