106 Case Pres Appendicitis
-
Upload
kevinjancelestino -
Category
Documents
-
view
233 -
download
2
description
Transcript of 106 Case Pres Appendicitis
I. INTRODUCTIONAppendicitisis a condition in which the appendix becomes swollen, inflamed, and filled withpus. The appendix is a small pouch shaped like a small finger. It is on the right side of the abdomen, connected to the colon.
Experts are not sure what the appendix is for. Charles Darwin wondered whether it might have been an organ our ancestors used to digest plants. Recent studies indicate thatthe appendix may be a dedicated environment for friendly bacteria which facilitate digestion and fight infection.
Appendicitis generally affects people aged between 10 and 30, but it can strike at any age.II. SIGNIFICANCE OF THE STUDY
General Objective
This study aims to explore assessment of the digestive tract, identify disorder or diseases process which is Appendicitis and discuss medical treatment and nursing management.
Specific Objectives:
1. Assess client with Appendicitis.
2. Describe the pathophysiology and its clinical manifestations.
3. Discuss the medical and nursing care of client with Appendicitis.
4. Develop nursing diagnoses, client outcomes and plan of interventions.III. NURSING HEALTH HISTORYA. Biographical Data
Name:
Patient X
Age:
10 y/o
Gender:
MaleAddress: Blk 13 Lot 16 Phase 1 city homes Resort Ville Dasma Cavite Height:
43Weight:
36 kgCivil Status:
SingleReligion:
Roman Catholic
Diagnosis:
Acute AppendicitisB. Chief Complaint
Persistent vomiting, fever, rebound tenderness, pain at right iliac fossa region.C. History of Present Illness
One day prior to admission, the patient experienced abdominal pain associated with vomiting and was also febrile. The consultation was done at Divine Grace Medical Center and was diagnosed to have acute appendicitis. Appendectomy was immediately done.D. Past Health HistoryThe patient had childhood illnesses like cough and colds, mumps and chicken pox. He has no allergy in food and medications. Based on his grandmother, his grandson is a fully immunized child.E. Family History of IllnessHis family has no known history of diabetes mellitus, hypertension, cancer, tuberculosis, asthma, kidney disease, anemia, mental disorder and other cardiovascular diseases.F. Social DataThe parents of the patient are working abroad. His grandmother is the one who takes care of him. He is a grade five student and in school he gets to play with his classmates.G. Lifestyle HabitsPatient X is fond of eating salty and fatty foods like potato chips, barbecue, and foods from fast food chains. He only drinks 5 glasses of water a day. He usually consumes 3 bottles of soft drinks every day.H. ProsthesisPatient X does not have any prosthesis.
I. Activities of daily livingPatient X has a routinely daily living. He wakes up at 5am in the morning to prepare for school and travel at 6am and attend his class from 7am to 3pm. By the time he reached their house, he eat snacks and watch television programs, do assignments, eat dinner and sleep at around 10 pm.J. Patterns of Health CareThe client just usually takes medications such as Paracetamol during fever and Tuseran forte for cough and colds without any prescription of the doctor. He also takes his vitamins daily.IV. PHYSICAL ASSESSMENTA. VITAL SIGNS
Actual Finding
Normal ValuesAnalysis
Body Temperature37.0C36.5-37.5CNormal
Pulse Rate90bpm (80) 60-100 bpmNormal
Respiration18 cpm (16) 12-20 cpmNormal
Blood Pressure90/60 mmHg120/80 mmHgNormal
B. HEAD TO TOE ASSESSMENT
BODY PARTTechnique usedNORMAL FINDINGSACTUAL FINDINGSANALYSIS
SkinInspectionUniform in color; no abrasions or any lesions
Well moistened skin.Normal color, turgor and temperature. No ulcerations or rashes noted.Normal
HEAD
SKULL &FACEInspection PalpationRound or normocephalic; smooth, absence of nodules or masses; symmetric facial movement.Head is normocephalic and atraumatic. Extraocular muscles are intact.Normal
HAIRInspectionEven distribution of hair, resilient thick hair with no signs of infections or infestations.Normal hair distribution. No evidence of infestations.Normal
Eyebrow
Eyes
Eyelashes
Eyelids
Pupils (color ,shape andsymmetry of size)
Inspection
Inspection
Inspection
Inspection
InspectionEvenly distributed hair ;eyebrows symmetrically aligned;
Lids close symmetrically, shiny smooth, pinkish conjunctiva; no edema or tenderness
Equally distributed
,Curled slightly outward
No discoloration,
Lids close symmetrically.Black in color, equal in
size normally
3-7 mm in
diameter
,round smooth border , iris
flat and roundEvenly distributed hair ;eyebrows symmetrically aligned;Conjunctivae pink with no scleral jaundice
Equally distributed
,Curled slightly outward
No discoloration,
Lids close symmetrically.
Pupils are equal, round, and reactive to light and accommodationNormal
EARInspectionColor same as facial skin
symmetrical; mobile ,firm and not tender;
No notable discharges normal voice tones
AudibleNo acute purulent dischargeNormal
NOSE AND
SINUSESInspection
Symmetric and straight;
No discharge or flaring; not tender, no lesions.
Uniform in color
Air moves freely as the patient breaths through the nares.
No tenderness in maxillary and frontal sinuses.Normal mucosa and septumNormal
MOUTH
TONGUE
Inspection
Inspection
Uniform in pink color; symmetrical lips
In central position; pink in color
moves freely with no tenderness.Smooth tongue base with prominent veins.Uvula positioned in midline of soft palate.gag reflex present
The lips were moist and teeth are incomplete. There was no swelling or lesions. The jaw is perfectly aligned. No foul odor noted.The oral mucosa, tongue, gums and uvula are pink, moist and without lesions. There were no inflammations in the tonsils.
Uvula in midline position.
Normal
NECK MUSCLES
Lymph nodesInspection
Palpation
PalpationCoordinated, smooth movement with no discomfort.
Has equal muscle strength.
Not palpable
The skin is uniform in color. Neck muscles are equal in size. No tenderness and masses upon palpation.Normal
Upper extremitiesInspection
PalpationMuscle:
Equal size on both sides of the body No contractures
Bones:
No skeletal deformities.
Joints:
No swelling, tenderness, crepitation or nodules.
Moves freely
Without any cyanosis, clubbing, rash, lesions or edema.Normal
Thorax and LungsInspection Auscultation PalpationPosterior thorax:
Symmetry: Spine vertically aligned; spinal column is straight, right and left shoulders are the same in height
Skin intact; uniform temperature
No tenderness and no presence of masses
Vesicular and broncho-Vesicular breath sounds
Anterior thorax: Quite, rhythmic, and effortless respirations
No tenderness and no presence of masses
Chest is symmetric. Spine is vertically aligned. Chest wall intact; no tenderness and masses. With normal breath sounds.Normal
AbdomenInspection
Auscultation
Unblemished skin
Uniform in color
Flat, rounded or scaphoid
Symmetric movement caused by respiration.Audible bowel soundThere is a wound dressing at RLQ, dry and intact.
Audible bowel sound
Not Normal
Lower extremitiesInspection PalpationMuscle: Equal in size on both sides of the body No contractures. No lesions, swelling and inflammation
Bones:
No skeletal deformities.
Joints:
No swelling, tenderness,
crepitation or nodules and moves freely No swelling or effusion in any of the joints of the hands or feet. No peripheral edemaNormal
V. LABORATORY AND DIAGNOSTIC EXAMINATIONS RESULTSA. BLOOD TYPING:
ABO: B
RH: Positive
B. ROUTINE HEMATOLOGY
CBCResultsNormal Values
Hb1414-17 gms %
Hct0.430.42-0.48 vol %
RBC4.84.6-5.0 x 10/L
WBC160005,000-10,000/L
Platelet count250,000150-450,000 cumm
C. URINALYSISINVESTIGATIONResultsNormal Values
Appearancecloudyclear
ColorYellowyellow
Specific Gravity1.0281.003-1.030
pH6.04.6-8.0
AlbuminnegativeNegative
GlucoseNegativeNegative
Ketones1.5Negative
RBC10u/L1-9
VI. DRUG STUDYName of Drugs and ClassificationActionIndicationContraindicationNursing Management
Generic Name:
Paracetamol
Classification:
Non-narcotic analgesic
Brand Name:
Acetaminophen, biogesic, tempra,
Dosage:
260 mg IVP Decreases fever by a hypothalamic effect leading to sweating and vasodilatation. Also inhibit the effects of pyrogens on the hypothalamic heat-regulating centers. May cause analgesia by inhibiting CNS prostaglandin synthesis, acetaminophen has no anti-inflammatory or uricosuric effect. Does not cause any anticoagulant effects or ulceration of the GI tract. Control of pain due to headache, earache, dysmenorrhea,arthralgia, myalgia, muscoskeletal pain, arthritis, immunizations, teething, tonsillectomy,
To reduce fever in bacterial or viral infections.
As substitute for aspirin in upper GI disease, aspirin allergy, bleeding disorder.
Renal insufficiency, anemia, Client w/ cardiac or pulmonary disease is more susceptible to acetaminophen toxicity.
Side Effects:
Hematologic: Methemoglobinemia, hemolytic anemia, neutropenia, thrombocytopenia, pancytopenia, leucopenia.
Allergic: Uticarial and erythematous skin reactions, skin eruptions, fever.
Miscellaneous: CNs stimulation, hypoglycemic coma, jaundice,drowsiness, glossitis.
Do not exceed a dose of 4g/ 24 hr in adults and 75 mg/kg/day in children.
Do not take for more than 5 days for pain in children, 10 days for pain in adults, or more than 3 days for fever in adults or children w/out consulting provider.
Store suppositories below 27c.
Take extended relief product w/ water; do not crush, chew, or dissolve before swallowing.
Bubble gum flavored OTC pediatric products (Liquid and chewable tablet) are available for children to treat fever and/ or pain.
Generic Name:
Ranitidine hydrochloride
Classification:
Histamine H-2 receptor blocking drug
Brand Name:
Zantac
Dosage:20 mg TIV Competitively inhibits gastric acid secretion by blocking the effect of histamine H-2 receptors.
Both daytime and nocturnal basal gastric acid secretion, as well as food and pentagastrin- stimulated gastric acid are inhibited Short term (4-8 weeks) and maintenance treatment of duodenal ulcer
Short term treatment of active, benign gastric ulcers.
Maintenance of healing gastric ulcers.
Pathologic hypersecretomy conditions such as Zollinger- Ellison syndrome and systemic mastocytosis
Cirrhosis of the liver, impaired renal or hepatic function
Side Effects:
GI: Constipation, N&V, diarrhea, abdominal pain, pancreatitisCNS: Headache, dizziness, malaise, insomnia, vertigo, anxiety, agitation, fatigue.
CV:Bradycardia or tachycardia, premature
Cardiac arrest
Hematologic: Thrombocytopenia, granulocytopenia, leukopenia, pancytopenia
Hepatic: Hepatotoxicity, jaundice, hepatitisDermatologic: Erythema, multiforme, rash, alopeciaGive antacids concomitantly for gastric pain although they may interfere w/ ranitidine absorption.
Dissolve effect dose tablets and granules in 6-8 oz of water before talking.
About one-half of clients may heal completely w/in 2 weeks; thus, endoscopy may show no need for further treatment.
No dilution is required for IM use.
Store the syrup bet. 4-25C
Generic Name:
Cefuroxime sodiumClassification:
CephalosporinsBrand Name:
Zinacef
Dosage:750mg TIVSecond-generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal-Uncomplicated skin and skin structure infection-Perioperative prevention-hypersensitivity to drug-patients hypersentive to penicillin because of possibility of cross-sensitivity
Side-effects:
CV: phlebitis
GI: diarrhea, nausea, anorexia, vomiting
Hematologic: thrombocytopenia
Skin: maculopapular rash, pain, temperature elevation1.) Ask patient if he is allergic to penicillins or cephalosporins2.) Obtain specimen culture and sensitivity before administering drug.
3.) Tell patient to notify prescriber about rash, loose stools, diarrhea, or evidence of superinfection
Generic Name:
Metronidazole
Classification:
Antiprotozoans and amebicides
Brand Name:
Flagyl
Dosage: 500mg TIVEnter the cells of microorganisms that contain nitroreductase, forming unstable compounds that bind to DNA and inhibit synthesis, causing cell death.-Intestinal amoebiasis-To prevent postoperative infection in contaminated or potentially contaminated colorectal surgery-Patients hypersensitive to nitroimidazole derivatives and in women in first trimester of pregnancy.-Use cautiously in patients with history of blood dyscrasia, CNS disorder or retinal, visual changes
Side effects:
CNS: headache, fever, seizures, vertigo, dizziness
CV: flushing, edema, thrombophlebitis
GI: nausea, vomiting, abdominal pain, anorexia, diarrhea
Respi: upper respiratory tract infection1.) Tell patient he may experience a metallic taste and dark or red-brown urine2.) Tell patient to report prescriber immediately any neurologic symptoms.
Generic Name:Ketorolac tromethamine
Classifications:
Nonsteroidal anti-inflammatory drug
Brand Name:
Toradol
Dosage:
10 mg TIV 3 doses Possesses anti-inflammatory, analgesics and antipyretic effects. Indicated for short term (up to 5 days) management of moderately severe acute pain that requires analgesia at the opioid level.
Not to be used for minor or chronic painful conditions
Side-effects:
CV: Vasodilation, pallor
GI: GI pain, peptic ulcers, nausea, dyspepsia, flatulence, GI fullness, stomatitis, excessive, thirst, GI bleeding, perforationCNS: Headache, nervousness, abnormal thinking, depression, euphoria
Hypersensitivity:Bronchospasm, anaphylaxis Use as part of a regular analgesic schedule rather than on an as needed basis.
If given on PRN basis, base the size of a repeat dose in duration of pain relief from previous dose.
Shortening the dosing intervals recommended will lead to an increased frequency and duration of the side effects.
Correct hypovolemia prior to administering
VII. REVIEW OF SYSTEMSSYSTEMS OF THE BODYFindings
GENERAL No weight loss, fever, chills, weakness or fatigue.
EENT EYES
EARS, NOSE AND THROAT No visual loss, blurred vision, double vision or yellow sclerae.
No hearing loss, sneezing, congestion, runny nose or sore throat
SKIN No rash or itching.
CARDIOVASCULAR No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY No shortness of breath, cough or sputum.
GASTROINTESTINAL Positive for nausea and vomiting, complains of pain at RLQ.
GENITO-URINARY No dysuria, frequency or urgency.
HEMATOLOGIC No pallor, bruising or bleeding.
NEUROLOGIC No headache or loss of consciousness.
ALLERGIES With history of asthma. No eczema or rhinitis.
VIII. ANATOMY AND PHYSIOLOGY
IX. PATHOPHYSIOLOGY
X. NURSING CARE PLANASSESSMENTNURSING DIAGNOSISPLANNINGNURSING INTERVENTIONSEVALUATION
Subjective:
Sumasakit po ang tahi ko sa tiyanas verbalized by the patient.
Pain Scale:
>7/10
Objective:
>Temp. 37c
>RR: 18cpm
>PR: 90bpm
>BP: 90/60mmHg
>facial grimace
>irritable
>guarding behavior
>self-focusing
Acute pain discomfort related to surgical incision.> After 3hrs. of Nursing Intervention the pain will be lessen at the surgical wound site.
Pain scale
> 7/10 to 3/10
Independent
>Promote bedrest and position patient in low-fowlers or any position of his comfort. R: To lessen the pain of the patient, Bed rest in low-fowlers reduces intra-abdominal pressure.
> Provide non- pharmacological
Therapies ex.:
Radio, Books, Socialization w/ others. R: > To relax & provide comfort to the patient.
> Encourage relaxation techniques such as deep breathing. R: To provide comfort, and reduce risk of complication such as pneumonia.>Teach patient to use pillow splinting when coughing to reduce pain and prevent tension on suture lines.
Dependent
> Administer analgesic as ordered.> After 3hrs. of Nursing Intervention the pain was lessened from 7 to 3.
ASSESSMENTNURSING DIAGNOSISPLANNINGNURSING INTERVENTIONSEVALUATION
Objective:
>Temp. 37c
>RR: 18cpm
>PR: 90bpm
>BP: 90/60mmHg
-wound dressing at RLQRisk for infection related to post surgical incisionShort term goal:
Within the shift, patient will be able to identify factors to reduce risk for infection
Long term goal:
At the end of hospitalization, patient will not manifest any signs and symptoms of infection
Independent
>Assess signs and symptoms ofinfection especially temperature.
>Emphasize the importance of handwashing technique.
>Maintain aseptic technique when changing wound dressing.Dependent
> Emphasize necessity of taking antibiotics as ordered.> Patient was free from any signs and symptoms of infection as manifested by absence of redness, swelling, heat on surgical incision and absence of fever.
XI. DISCHARGE PLAN
M MEDICINE-Advice patient and guardian to continue to take medications as prescribed by the physician.E ENVIRONMENT AND EXERCISE
-Maintain a quiet, pleasant, environment to promote relaxation.
-Provide clean and comfortable environment.
-Encourage walking every day.
T TREATMENT
-Continue home medications.
-Teach patient and guardian about wound care.-Encourage patient to take multivitamins for immunity.H HEALTH TEACHING
-Provide written and oral instructions about wound care, activity, diet recommendations, medications, and follow-up visits.
-Instruct patient to limit his activity for 24 to 48 hrs after discharge.
O OUT PATIENT FOLLOW-UP
-Patient will be advised to go back in the hospital in a specific date to have a follow-up checkup after discharge.
-Consult doctor for any problems or complications encountered.
D DIET
-Encourage patient to increase protein intake for tissue repair
-Advice patient to eat foods that are rich in fiber like vegetables and fruits and an increase in fluid intake to avoid constipation.S SPIRITUALITY
-Encourage patient to communicate with God.
-Encourage patient to communicate with other people.
Peritonitis
Perforation (24 to 36 hours)
Gangrene
Abscess
-Lymphoid swelling
-Decreased venous drainage
-Thrombosis
-Bacterial Invasion
Intraluminal pressure
Inflammation
1