Americaa Case Study

8/10/2019 Americaa Case Study

1/27

ACUTE APPENDICITIS

A Case Study

Presented to the College of Nursing

In Partial Fulfillment of

The requirements for

Related Learning ExperienceIn Surgery Ward of QMC

Mr. Felipe Merano RN,MSNClinical Instructor

Klent Nikko G. Melencion

BSN-IV


2/27

i

FOREWORD/PREFACE

In creating this study, the authors share to life the experiences and differences

theyve made within these pages, by describing what they have studied and learned

during their clinical exposure in the Surgery Ward of Quezon Medical Center

And thus, not only did they become improved nursing students but also they

become more aware, open minded, found responsibility, help others and have move

forward together, ready to face whats coming next for them.

Their knowledge was enhanced as they encountered different cases and

procedures in the Surgery Ward. These form important learning experiences, creating

much new light for them from pre-conferences and post-conferences, computations and

medications, patients and significant others, assessments and laboratories, nasogastric

tubes and a whole lot more vital to their nursing careers.


3/27

ii

DEDICATION

This study is dedicated to our loved ones who serves as our inspiration and never

failed in giving us support financially, spiritually and morally, for guiding us through and

for showing us that even a big task can be accomplished as long as there is teamwork and

dedication. We also dedicate this to ourselves because of the hard work and dedication

we have showed in making this study and to Mr. Felipe Merano for guiding us and

believing in us.

Lastly, we dedicate this to the healthcare team of Quezon Medical Center because

without them, there will be no basis for this study. They have opened up their doors for

us to attain and broaden our knowledge in the health care industry.


4/27

iii


5/27

iv

OBJECTIVES

This study is conducted to provide information regarding Chronic Hypertension. Our

objective is to help and provide adequate knowledge to fellow nursing students as well.

This study has the answers for the following:

1) What is Acute appendicitis?

2) What are the risk factors of Acute appendicitis?

3) What are the diagnostic tests needed to determine Acute appendicitis?

4) What is the nursing care plan for Acute appendicitis?


6/27

1

CASE INTRODUCTION

A 18 year old female client admitted with chief complaint of RLQ pain and with

Diagnosis of Acute Appendicitis with pain at the Right Lower Quadrant for 1 night.

Appendicitisis a condition characterized by inflammation of the appendix. It is

classified as a medical emergency and many cases requires removal of the inflame

appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly

because of the risk of rupture leading to infection and inflammation of the intestinal

lining (peritoneum) and eventual sepsis, clinically known as peritonitis which can lead to

circulatory shock.


7/27

2

NAME: X

GENDER: Male

BIRTHDAY: July 03, 1995

Address: Balungay, Alabat Quezon

Chief Complain: RLQ pain since last night

Diagnosis: Acute Appendicitis

Admitting Physician: Dr. Combalicer


8/27

3

PHYSICAL ASSESSMENT

A. HEAD: symmetric, proportionate to body size, free from masses and lesions

B. HAIR: Black in color, thin and fine, uncombed and slightly clean.

C. EYES: White sclera, dark brown pupil, Pupil Equally Round Reactive to Light

Accommodation (PERRLA)

D.NOSE: no nasal flaring noted, nose is located at the midline of the face, without

lesions or masses noted,

E. NECK: neck is symmetrical with the head in central position

F. FACE: normal lining of the nose, eyes and ears; pinkish lips and not dry

G. EARS: patient ears are working normally and can hear clearly, minimal ear wax

noted

H. CHEST/THORAX: chest is symmetrical upon breathing, not in respiratory

distress, breast are engorged with minimal stretch marks with good milk lactation

I. ABDOMEN: : Non-tender abdomen, pain noted upon palpation, no signs of

abnormal sounds upon auscultation, not bloated

J. LOWER EXTREMITIES: with Homans Sign on both lower extremities

K. SKIN: skin is warm to touch, no rashes or dryness noted, no edema

L. NAILS: Good capillary refill of 2-3 sec, slightly long nails, no dead nails noted


9/27

4

LABORATORY WORK-UPS

COMPLETE BLOODCOUNT

Test Result Reference

Hemoglobin 15.20 g/dL 12.0-16.0 g/dL

Hematocrit 0.45 0.37-0.43

RBC count 5.15 x10^12/L 4.0-5.4

WBC 17.60 x10^9/L 4.0-10.0

Neutrophils 0.81 0.55-o.65

Lymphocytes .19 0.25-0.35

Platelet Count 349 150-400

Color Yellow RBC 3-4/hpf

Transparency Blurred WBC 15-20/hpf

Spec. Quantity 1.030 Epithelial Cells Moderate

Ph Reaction 6.5

Bacteria Few

Chemical Test

Sugar (-) A. Urates Many

Albumin (+) A. Phosphate Many


10/27

5

NORMAL ANATOMY AND PHYSIOLOGY

Small intestineThe small intestine is composed of the duodenum, jejunum, and

ileum. It averages approximately 6m in length, extending from the

pyloric sphincter of the stomach to the ileo-caecal valve separating

the ileum from the caecum. The small intestine is compressed into

numerous folds and occupies a large proportion of the abdominal

cavity.

The duodenum is the proximal C-shaped section that curves aroundthe head of the pancreas. The duodenum serves a mixing function as

it combines digestive secretions from the pancreas and liver with the

contents expelled from the stomach. The start of the jejunum is

marked by a sharp bend, the duodenojejunal flexure. It is in the


11/27

6

jejunum where the majority of digestion and absorption occurs. The

final portion, the ileum, is the longest segment and empties into the

caecum at the ileocaecal junction.

The small intestine performs the majority of digestion and absorption

of nutrients. Partly digested food from the stomach is further broken

down by enzymes from the pancreas and bile salts from the liver and

gallbladder. These secretions enter the duodenum at the Ampulla of

Vater. After further digestion, food constituents such as proteins, fats,

and carbohydrates are broken down to small building blocks and

absorbed into the body's blood stream.The lining of the small intestine is made up of numerous permanent

folds called plicae circulares. Each plica has numerous villi (folds of

mucosa) and each villus is covered by epithelium with projecting

microvilli (brush border). This increases the surface area for

absorption by a factor of several hundred. The mucosa of the small

intestine contains several specialised cells. Some are responsible for

absorption, whilst others secrete digestive enzymes and mucous to

protect the intestinal lining from digestive actions.

Large intestine

The large intestine is horse-shoe shaped and extends around the

small intestine like a frame. It consists of the appendix, caecum,

ascending, transverse, descending and sigmoid colon, and the

rectum. It has a length of approximately 1.5m and a width of 7.5cm.

The caecum is the expanded pouch that receives material from the

ileum and starts to compress food products into faecal material. Food

then travels along the colon. The wall of the colon is made up of


12/27

7

several pouches (haustra) that are held under tension by three thick

bands of muscle (taenia coli).

The rectum is the final 15cm of the large intestine. It expands to hold

faecal matter before it passes through the anorectal canal to theanus. Thick bands of muscle, known as sphincters, control the

passage of faeces.


13/27

8

Pathophysiology


14/27


15/27

10

IVF D5LR 1L x 8*

Cefuroxime 750 mg

q8* ANST (-)

Metronidazole 500

mg

For Appendectomy

Notify on ROD

Refer

9:24 PM

NPO

Pre Op meds

>is useful for dailymaintenance of body fluidsand nutrition, and forrehydration.

>Anti bacterial drug

>Anti bacterial drug

>Removal of the appendix

>To notify the ROD.

>Nothing per orem No food

intake until bowel

movement returns

>Check physicians

order and start IV

>administer initial

doze and note in

medication sheet

>Check the clearance

and instruments

needed prior to the

operation

> to inform the ROD

prior to the operation

>Inform the client for

NPO

other


16/27

11

09/26/14

POST

ANESTHESIA

ORDERED

SLP

APPENDECTOMY

To PACU

O2 inhalation via

Nasal Cannula @

2-3 lpm

NPO

Monitor VS q15

Pls. regulate

present IVF to 31-

32 gtts/mins.

> Post Anesthesia care

prior to post operative client

>Removal of appendix

>for fast recovery from

anesthesia

>to promote oxygenation

>nothing per orem No foodintake until the Bowel

Movement presents

>Monitors clients VS every

15 minutes

>Regulate IVF as desired

>Check the

physicians order and

counter signed

>Render pre

operative care

>check the


start oxygenation

>Instruct the clientabout NPO

>get the client VS

every 15 minutes and

refer any

abnormalities

>Regulate IVF as

desired


17/27

12

IVF to follow

D5LR 1Lx8*

D5LR 1Lx8*

D5LR 1Lx8*

D5LR 1Lx8*

Meds

TDL 50 IV q8*

Paracetamol (IV)

1gm q8* for 15-

20mins. Duration x

3 dose

Continue present

antibiotics as

ordered

09/27/14

Ambulate

09/28/14

Ambulate

Cefuroxime IV

Refer

>It is useful for dailymaintenance of body fluidsand nutrition, and forrehydration.

>Non steroidal anti

inflammatory drugs

>Anti inflammatory and anti

pyretic drug.

>Continue the Cefuroxime

and metronidazole

>Ambulate to promote

Bowel movement

>anti bacterial drug.

>Check the


start the IV.

>Administer initial

doze and note at the

medication sheet

>Administer the drug

and note at the

medication sheet.

>Instruct the client

and assist to

ambulate.

Administer initial doze

and note at the

medication sheet


18/27

13

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONSubjective:

Nanghihina ako at

di masyadomakatindig as

verbalized by theclient.

Objective:>With facialgrimace.>Pale and weak inappearance.>Always lying onbed>with goodcapillary refill>BP 100/80mmHg

Activityintolerance relatedto the operation

After 8 hours ofnursingintervention,Thepatient will be ableto:

>demonstrate andperform theexercise (ROM)>The patient willincrease his activitytoleranceX

> Assessedpatients ability toperformtasks/noting reportsof weakness,

fatigue anddifficultyaccomplishing task

>Recommendedquiet atmosphere;bed rest if indicatedstress-need tomonitor and limitvisitors, phone callsand repeatedunplannedinterruptions.

>Elevated head of

bed as tolerated.

>Provided/recommendedassistance withactivities

/ambulation asnecessary, allowing

>Influence of choice

of interventions

assistance.

>Enhances rest tolower bodys oxygen

requirements, and

reduces strain on the

heart and lungs.

>Enhances lung

expansion to

maximize

oxygenation

for cellular uptake.

>Although help

maybe necessary,

self esteem is

enhanced when

patients does things

for self.

>Promotes adequate

rest energy level, and

alleviates strain on

After eight hoursnursinginterventions, thepatient was able tocope with fatigue

and verbalization offeelings of comfortand increaseactivity participation

After eight hoursnursing interventionthe clientdemonstrate anincrease activitytolerance.


19/27

14

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

nananakit

ang tiyan ko

sa may

bandang

kanan

ibabang

parte as

verbalized

by the

Acute pain

related to

Acute

Appendicitis

After 8 hours of

non-stop caring

to the patient.

The patient will

be able to:

>lessen the

pain

>demonstrate

diverticulative

techniques to

divert pain

> Assessed the

general condition of

the client

>Recommended

quiet atmosphere;

bed rest if indicated

stress-need to

monitor and limit

visitors, phone calls

and repeated

>To provide baseline data

To lessen the

consumption of

oxygen and promote

rest and to avoid

stress.

After eight hours

nursing interventions,

the patient was able

to demonstrate

diverticular activities.

Pain lessen from

8/10 to 3/10.

doing as much aspossible.

>Assisted patient toprioritize

ADLs/desiredactivities.

the cardiac and

respiratory systems


20/27

15

patient.

Objective:

>With facial

grimace.

>pain scale

of 8/10

>Pale and

weak in

appearance.

unplanned

interruptions.

>Demonstrate

diverticular

activities.

>Administer

medications such

as pain killer and

pain reliever to

relieve pain.

To divert and relieve

the pain

To relieve or lessen

the pain


21/27

16

DRUG STUDY

Therapeutic

Classification

Action Contraindicaiton Toxicity/ Side Effects Intervention Safe Doze

Tramadol

- narcotic like pain

reliever

NSAIDS

Anti-inflammatory.

The

overall analgesic profile of

tramadol supports use in

the treatment of

intermediate pain,especially chronic pain. It

is slightly less effective for

acute pain

than hydrocodone, but

more effective

than codeine. It has a

dosage ceiling similar

to codeine, a risk of

seizures when overdosed,

and a relatively long half-

life making its potential

for misuse relatively low

amongst intermediate

strength analgesics.

Tramadol

hydrochloride

should not be

administered to

patients who havepreviously

demonstrated

hypersensitivity to

tramadol, any other

component of this

product or opioids.

Tramadol

hydrochloride is

contraindicated in

any situation where

opioids are

contraindicated,

including acute

intoxication with any

of the following:alcohol, hypnotics,

and narcotics,

centrally acting

analgesics, opioids

or psychotropic

drugs. Tramadol

may worsen central

Tramadol is generally well tolerated,

and side effects are usually transient.

Commonly reported side effects

include nausea,

constipation, dizziness, headache,drowsiness, and vomiting. Less

commonly reported side effects include

itching, sweating, dry mouth,

diarrhea, rash, visual disturbances,

and vertigo. Some patients who

received tramadol have reported

seizures. Abrupt withdrawal of tramadol

may result in anxiety,

sweating, insomnia, rigors, pain,

nausea, diarrhea, tremors, and

hallucinations.

Monitor V/S 50-100mg


22/27

17

nervous system and

respiratory

depression in these

patients.

Therapeutic

Classification


Paracetamol

Anti Pyretic, Pain

reliever

Paracetamol reduces the

synthesis of

prostaglandins which are

responsible for the

mediation of pain and

fever.

Paracetamol is

contraindicated in

hypersensitivity,

analgesic

nephropathy, renal

and hepatic

impairment.

is caused by excessive use or overdose

of the analgesic drugparacetamol (called

acetaminophen in North America).

Mainly causing liver injury, paracetamol

toxicity is one of the most common

causes of poisoning worldwide. In the

United States and the United Kingdom it

is the most common cause of acute liver

failure.

Monitor V/S 500mg

Therapeutic

Classification


Cefuroxime

Antibiotic/

Antibacterial

Cefuroxime is a

semisynthetic

cephalosporin antibiotic,

chemically similar to

penicillin. Cephalosporins

stop or slow the growth of

bacterial cells bypreventing bacteria from

forming the cell wall that

surrounds each cell. The

cell wall protects bacteria

from the external

environment and keeps

the contents of the cell

Hypersensitivity to

cephalosporins.

Swelling, redness, pain, or soreness at

the injection site may occur. This

medication may also infrequently cause

loss of appetite,nausea,

vomiting,diarrhea,irritability,

orheadache.

monitor V/S - Powder

for

Injection

750 mg

(2.4 mEq

sodium/g)

- Powderfor

Injection

1.5 g

(2.4 mEq

sodium/g)

- Powder

for
http://www.webmd.com/digestive-disorders/digestive-diseases-nausea-vomitinghttp://www.webmd.com/digestive-disorders/digestive-diseases-nausea-vomitinghttp://www.webmd.com/digestive-disorders/digestive-diseases-nausea-vomitinghttp://www.webmd.com/digestive-disorders/digestive-diseases-diarrheahttp://www.webmd.com/digestive-disorders/digestive-diseases-diarrheahttp://www.webmd.com/digestive-disorders/digestive-diseases-diarrheahttp://www.webmd.com/migraines-headaches/default.htmhttp://www.webmd.com/migraines-headaches/default.htmhttp://www.webmd.com/migraines-headaches/default.htmhttp://www.webmd.com/migraines-headaches/default.htmhttp://www.webmd.com/digestive-disorders/digestive-diseases-diarrheahttp://www.webmd.com/digestive-disorders/digestive-diseases-nausea-vomiting


23/27

18

together. Without a cell

wall, bacteria are not able

to survive.

Injection

7.5 g (2.4

mEq

sodium/g)

- Injection

750 mg

(2.4 mEq

sodium/g)

- Injection

1.5 g (2.4mEq

sodium/g)


24/27


25/27

20

Discharge Planning

M Medication -Mefenamic Acidthrice a day for pain in one week

-Cephalexin Thrice a day in one week

-Ferrous Sulfate Once a day in one month

E Environment -Ensure safety precautions outside and inside the house

-Keep patient away from materials or equipments that

may harm him

-Make sure that the patients bed is near the restroom

-Remove floor mats or anything that may cause injury

T Treatment -Follow up check up after 2 weeks for repeat FBS

H Health Teaching -Provide adequate knowledge regarding postpartum

prescribed by the dietician

-Encourage SO to give medications at home on the right

time and right dose

-Explain the importance of eating foods that prevents

constipation

O Observation -No further complaints noted. Patient started to show

good signs of recovery.

D Diet -Refer to dietician for diet


26/27

21

Prognosis

After the patient had undergone the surgery, and have removed her

appendix by surgical procedure called appendectomy the patient is now at

state of wellness. It takes 3-4 days to be totally recovered after the

procedure. The client is now well and discharged from the QMC Surgery

Ward. The patient is now free from appendicitis and has no further chance

to occur again.


27/27

22

IMPLICATION OF THE STUDY

The implication of this study in the practice of nursing serves as a

guide or a tool for the fellow nursing students and staff nurses. It provides a

detailed background, management, interpretations and documentations for

patients who have Acute Appendicitis. It will help broaden the knowledge

and skills of the healthcare team.

Americaa Case Study

Documents

Transcript of Americaa Case Study