Appendicitis Output
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Transcript of Appendicitis Output
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PERSONAL PROFILE
Patients Name: MS
Address: Purok 2, Ibung Villaberde, Nueva Vizcaya
Sex: Female
Age: 13 years old
Civil status: Single
Birth Date: December 5, 1997
Birth Place: Ibung Villaberde, Nueva Vizcaya
Citizenship: Filipino
Primary Language: Tagalog
Educational Attainment: 2nd High School at present
Religion: Roman Catholic
Fathers Name: Mr. S
Mothers Name: Mrs. S
Admission Date: September 20, 2011
Admitting Physician: Welbert Reyes M.D.
Consulting Physician: Rodolfo Hidalgo M.D.
Admission Diagnosis: Acute Appendicitis
Principal Diagnosis: Acute Gangrenous Appendicitis
Principal Operation/Procedure: s/p E appendectomy
Date of Operation: September 21, 2011
Ward: Surgery
Name of Hospital: Veterans Regional Hospital
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PRESENT HEALTH PROBLEM
The complaint of the patient started 2 days prior to her hospitalization. As stated by her, last
Sunday afternoon, she felt pain suddenly at her abdomen located at her right lower quadrant. Initially,
she disregarded the pain thinking that it will subside after some time. But Monday came and the pain
was still present, and so she started to take pain reliever such as Buscopan given to her by her aunt. OnTuesday, she felt that the pain worsens and so she was encouraged by her Lola to take Herbaca which is
a herbal medicine. Still, the pain did not ease up. The medication and the herbal medicine she took up
did not help to alleviate the pain. She cannot remember any food she had eaten that might cause the
pain on her abdomen, she stated that it happened suddenly. The patient also tried to see a
manghihilot. She stated that the pain still felt the same. She cannot even eat well already. Thats the
time they decided to bring her to the hospital for a check up.
She came to the hospital because of the following reason: Pain at her right lower abdomen. She
was advised to be admitted for further treatment of her current illness. She was confined at Veterans
Regional Hospital (VRH). She was seen and examined by Dr. Welbert Reyes, forwarded to the surgery
ward via wheelchair accompanied by her father with the admission diagnosis of Acute Appendicitis. She
was given medications such as Cefoxitin, Ranitidine, Tramadol, Ketorolac, Metronidazole, Paracetamol
and Amino acid + Multivitamins.
Upon admission, she had the following vital signs: BP: 80/60 mmHg, Temp: 36.00C, RR: 16 cpm,
and PR: 82 bpm
PAST HEALTH PROBLEM
According to her significant other, the patient was born without any complication. But during
her childhood years, she has been hospitalized once due to her fever. Other than that, she did not have
or suffered from any serious illness aside from common colds and cough. She completed her
immunizations as a child which is very important especially nowadays.
The patient has no known allergy to any medication, food and to her environment. Neither did
she encounter any accidents before nor had any injuries.
Whenever she suffers from common colds or anybody from their family, they manage to treat it
by taking over the counter medications like Paracetamol and Solmux. They also use herbal medicines
such as Oregano and Dahong Maria, insisted by their lola. Another is that they also go to manghihilot,and also to some herbalist whenever the situation calls for it.
FAMILY HISTORY
The patient lives with her parents together with her younger brother. No history of any disease
was identified in their family. Both her parents are in good health. Her brother is also confined at the
same hospital due to his cough. Her brother also has completed his immunizations already.
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BRIEF DESCRIPTION OF THE DISEASE
The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the cecum just
below the ileocecal valve. No definite functions can be assigned to it in humans. 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. 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. It occurs most frequently
between the age of 10 and 30.
The disease is more prevalent in countries in which people consume a diet low in fiber and high
in refined carbohydrates.
The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting. Loss
of appetite is common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burneys
point applied located at halfway between the umbilicus and the anterior spine of the Ilium.
Rebound tenderness (ex. Production or intensification of pain when pressure is released) may
be present. The extent of tenderness and muscle spasm and the existence of the constipation or
diarrhea depend not so much on the severity of the appendiceal infection as on the location of the
appendix.
If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar
region. Rovsings sign maybe elicited by palpating the left lower quadrant. If the appendix has ruptured,
the pain become more diffuse, abdominal distention develops as a result of paralytic ileus, and the
patient condition become worsens.
Constipation can also occur with an acute process such as appendicitis. Laxative administered in
the instance may result in perforation of the in flared appendix. In general a laxative should never be
given
Clinical Manifestations
1. Generalized or localized abdominal pain in the epigastric or periumbilical areas and upper rightabdomen. Within 2 to 12 hours, the pain localizes in the right lower quadrant and intensity increases.
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2. Anorexia, moderate malaise, mild fever, nausea and vomiting.3. Usually constipation occurs ; occasionally diarrhea.4. Rebound tenderness, involuntary guarding, generalized abdominal rigidity.Diagnostic Evaluation
1. Physical examination consistent with clinical manifestations.2. WBC count reveal moderate leukocytosis (10,000 to 16,000/mm3) with shift to the left (increased
immature neutrophils).
3. Urinalysis rule out urinary disorders.4. Abdominal x-ray may visualize shadow consistent with fecalith in appendix; perforation will reveal
free air.
5. Abdominal ultrasound or CT scan can visualize appendix and rule out other conditions, such asdiverticulitis and crohns disease. Focused appendiceal CT can quickly evaluate for appendicitis.
6. Barium Enema is an x-ray test where liquid barium is inserted into the colon from the anus to fill thecolon. This test can, at times, show an impression on the colon in the area of the appendix where the
inflammation from the adjacent inflammation impinges on the colon. Barium enema also can exclude
other intestinal problems that mimic appendicitis, for example Crohn's disease
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Medications
Analgesics Intravenous fluids replacements AnalgesicsTreatment
Appendectomyis the effective treatment if peritonitis develops treatment involves.
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GI Intubation Parenteral replacement of IV fluids and electrolytes Administration of AntibioticsSurgery is indicated if appendicitis is diagnosed. Antibiotics and IV fluids are administered until surgery is
performed analgesics can be administered after the diagnosed is made.
An appendectomy (surgical removal of the appendix) is performed as soon as possible to decrease the
risk of perforation. T he appendectomy may be performed under a (general or spinal anesthetics) with a
low abdominal incisions or by (laparoscopy) which is recently highly effective method.
Complications
The major complication of appendicitis is perforation of the appendix, which can lead to peritonitis,
abscess formation (collection of purulent material), or portal pylephlebitis, which is septic thrombosis of
the portal vein caused by vegetative emboli that arise from septic intestines.
Perforation generally occurs 24 hours after the onset of pain symptoms include a fever of 37.7 degree
Celsius or 100 degree Fahrenheit or greater, a toxic appearance and continued abdominal pain or
tenderness.
Nursing Interventions
1. Monitor frequently for signs and symptoms of worsening condition, indicating perforation, abscess,or peritonitis (increasing severity of pain, tenderness, rigidity, distention, absent bowel sounds,
fever, malaise, and tachycardia).
2. Notify health care provider immediately if pain suddenly ceases, this indicates perforation, which is amedical emergency.
3. Assist patient to position of comfort such as semi-fowlers with knees are flexed.4. Restrict activity that may aggravate pain, such as coughing and ambulation.5. Apply ice bag to abdomen for comfort.6. Avoid indiscriminate palpation of the abdomen to avoid increasing the patients discomfort.7. Promptly prepare patient for surgery once diagnosis is established.8. Explain signs and symptoms of postoperative complications to report-elevated temperature, nausea
and vomiting, or abdominal distention; these may indicate infection.9. Instruct patient on turning, coughing, or deep breathing, use of incentive spirometer, and
ambulation. Discuss purpose and continued importance of these maneuvers during recovery period.
10.Teach incisional care and avoidance of heavy lifting or driving until advised by the surgeon.11.Advise avoidance of enemas or harsh laxatives; increased fluids and stool softeners may be used for
postoperative constipation.
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Discharge Planning
M Antibiotics for infection
Analgesic agent (morphine) can be given for pain after the surgery
E Within 12 hrs of surgery you may get up and move around.
You can usually return to normal activities in 2-3 weeks after laparoscopic surgery.
T Pretreatment of foods with lactase preparations (e.g. lactacid drops) before ingestion can reduce
symptoms.
Ingestion of lactase enzyme tablets with the first bite of food can reduce symptoms.
H To care wound perform dressing changes and irrigations as prescribe avoid taking laxative or
applying heat to abdomen when abdominal pain of unknown cause is experienced.
Reinforce need for follow-up appointment with the surgeon
Call your physician for increased pain at the incision site
O Document bowel sounds and the passing of flatus or bowel movements (these are signs of the
return of peristalsis)
Watch for surgical complications such as continuing pain or fever, which indicate an abscess or
wound dehiscence
Stitches removed between fifth and seventh day (usually in physicians office)D Liquid or soft diet until the infection subsides
Soft diet is low in fiber and easily breaks down in the gastrointestinal tract
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ANATOMY AND PHYSIOLOGY
The appendix is a closed-ended, narrow tube up to several inches in length 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 open center of 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, but the muscle is poorly developed.
The appendix is a worm-shaped appendage that sticks out from the top portion of the l
intestine. The main function of the appendix is unknown. The human appendix p0 attached to the large
intestine where it joins the small intestine does not directly assist digestion. Biologists believe it is a
vestigial organ left behind from a plan-eating ancestor. Interestingly, it been noted by palcontologistAlfred Sherwood Romer in his text The vertebrae Body that the major importance of the appendix
would appear to be a financial support of the surgical profession referring to, of course, the large
numbers of appendectomies performed annually. In 2000 in fact, there were nearly 300,000
appendectomies performed in the United States and 37.1 death from appendicitis. Any secondary
function that the appendix might perform certainly is not missed in who had removed before it might
have ruptured.
The clue to the appendixs function is its strategic position where the small bowel meets colon.
The colon is loaded with bacteria and is useful there. But which must be kept away other areas. The
appendixs main role is likely to be in early childhood. The organs highly concentrated lymphoid follicles,
which play an important role in the immune system, develops about two weeks after birth- at the same
time the colon begins to be colonized with the necessary bacteria.
The appendix is highly specialized organ with a rich blood support, not what you would expect
from a degenerate, useless structure. It has long been known that the appendix contains lymphatic
tissue and has a role in controlling bacteria entering the intestines.
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PERSON ASSESSMENT
September 23, 2011
PSYCHOSOCIAL
Assessment Significance
Significant Others
Caring father who is always
ready to comfort the patient in
times of difficulties
The presence of her significant
others helps her to cope and
recover from her
illness/condition
Coping Mechanism
She faces her problems and tries
to find for solutions to solve or
eliminate the problem
Religion Roman catholic
It helps us, as health care
providers to determine what
procedures or treatments mustbe implemented that are
accepted to their beliefs
Primary Language Tagalog
Knowing the primary language
will help us communicate with
the patient/significant other thus
gaining more information
Primary Source of Health Care Hospital
It is important in choosing what
kind of services are preferred
and usually utilized by the family
Financial Resources related toIllness
They are insured to Philhealth
To determine the extent of the
familys ability to confine a
member for treatment or to
support their expenses during
hospitalization
General Appearance
Appropriately dressed for her
age
Appears to be her stated age
With proper hygiene(nails are
properly cut)
Very weak in appearance
With minimal responses to
questions being asked
Objective cues are very
important to determine the need
for immediate interventions and
to identify improvement on the
condition
Affect Blunted affect
Due to her weakness the patientcannot fully express verbally and
nonverbally her mood and
emotions
Orientation
Oriented to time: Hapon na po
ngayon
Oriented to place: Nandito po
ako sa ospital nung Tuesday pa
ng gabi
Oriented to person: Si papa po
yung kasama ko
Oriented to event: Nagsimulapo nung Sunday nung sumakit
yung tyan ko bigla
Rules out any neurologic alterations
Memory
The patient has an intact
immediate, recent and remote
memory
Speech Slowly paced and in low tone but To identify the need for the
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shows associated with thoughts
and still understandable
significant other to supplement
the needed data
Nonverbal Behavior
Furrowed forehead
Poor eye contact
Restlessness
IrritabilityGrimacing when in pain
Distraction behaviors
Aids in verbal communication and
any suggest hidden problems which
cannot be expressed verbally
ELIMINATION
Assessment Significance
Stool
Pattern: 3x a week
Consistency and shape: soft
Amount: moderate
Odor: no unusual odor
Color: yellow to brown
Normal bowel movement for the
patient
Urine
Quantity per voiding: 200-220ml
Frequency: 5-6x/day
Color: yellow
Clarity: turbid
Specific gravity: 1.010
pH: 6.0
Normal for the patient
Abdomen
Shape: flat
Bowel sound: normoactive
Surgical incision noted due to
previous appendectomy (1 day
post)Wound has still drains
Due to appendectomy
Toileting ability Assisted when going to toilet
Due to her previous operation,
the patient is still dependent to
her significant other
REST AND ACTIVITY
Assessment Significance
Current Activity LevelOn bedrest
With limited activity
Because of her previous
operation, the patient is
expected to stay always in bed
ADLs
Scale (0-4)
0 completely independent
1 requires devices or
equipment
2 requires supervision,
direction or assistance
3 requires both devices andassistance
4 totally dependent
Activity
Bathing
Hygiene
Toileting
Dressing
Transferring
AmbulatingFeeding
Score
4
4
4
4
4
40
At her condition, the patient is
still dependent to her significant
other
Sleep
Usual bedtime: 9-10 pm
Usual waking time: 5-6 am
Preferred environment for
sleeping: at her bedroom with
her own pillows
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Duration:7-8 hors a night
Quality: easily awakened
Body Frame Endomorph
Posture
n/a due to hindrances like the
patient cannot stand alone due
to her weakness
Gait
n/a due to hindrances like the
patient cannot walk alone due to
her weakness
Coordination Good motor coordination
Balance
Patient can stand alone
With complaints of room/ceiling
spinning around
The patient still needs assistance
Muscle
5 100% of normal strength against
full gravity and resistance
4 75% normal full movement
against gravity and minimal
resistance
3 50% normal movement against
gravity
2 25% full muscle movement
against gravity with full support
1 10% no movement; contraction
of muscle
0 0% normal strength with
complete paralysis
3/5 3/5
3/5 3/5
There is perceived body
weakness that impedes muscle
movement on extremities
Motor Function
Gross: can flex and extend
extremities in a low level
Fine: n/a
Range of MotionLegs and arms: limited
movement (90 degrees)
Pain Relief Measures
Tries to sleep
Takes pain reliever medications
ordered by the doctor
SAFE ENVIRONMENT
Assessment Significance
Allergies/Reaction
Medications: none
Food: none
Environment: none
Eyes/Vision
PERRLA
Glasses: none
Visual acuity: can recognize
familiar facesSymmetry: symmetrical
Blinking reflex: present
No redness of the conjunctiva
and sclera
It indicates that the patient isalert to external stimuli
Hearing
Structure: no mass noted
Hearing acuity: responds to
normal voice
The patient is able to hear
normally
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Skin
Scars: none
Temperature: warm to touch
(37.8)
Temperature of the patient
indicates hyperthermia
Mucous Membranes Moist and intact
Temperature 37.8 celsius
OXYGENATION
Assessment Significance
Activity Tolerance
Easy fatigability after an activity
Totally dependent when
performing ADLs
Experiences sudden headache
when standing
It is due to her present condition
Airway Clearance
No presence of secretion, mass
No inflammationNo redness
Respiration
Rate: 14 cpm
Rhythm: regular
Position assumed: supine
position
Lung Sounds
Normal breath sounds
No presence of crackles or rales,
or wheezes
Color
(-) pale
(-) cyanosis
(-) jaundiceCapillary Refill 1-2 seconds
PulseRate:80 bpm
Rhythm: regular
Blood Pressure 90/60 mmHg
Edema None
Homans Sign Negative
NUTRITIONAssessment Significance
Hospital Diet/Restrictions Clear Liquids
As ordered by the physician for
nourishment and also
appropriate for her previous
surgery which is appendectomy
IVFs
Location: left hand
Solution: D5LRS
Rate: 21 gtts/min
Side drips: none
Height and Weight45 kg
54Tissue Turgor Well hydrated
Ability to
Swallow: positive
Gag reflex: positive
Can tolerate food: on clear liquid
diet
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LABORATORY RESULTS
HEMAT
OLOG
Y
Is a series of test used to evaluate the composition and concentration of the cellular components ofblood.
This lad study is also indicated to know any suspected anaemia and the response to treatment, blood lossand the response to blood replacement.
NURSING CONSIDERATIONS:
1. The nurse inserting the needle should clean the skin first. The tourniquet should be removed from the arm
as soon as the blood flows.2. If a finger stick is used to collect the blood, care must be taken to wipe away the first drop, and not to
squeeze the finger excessively as this causes the blood to be diluted by tissue fluid.
3. Discomfort or bruising may occur at the puncture site. Apply pressure to the puncture site until the bleeding
stops help to reduce bruising; warm packs relieve discomfort. Some people feel dizzy or faint blood has been
drawn and should be treated by resting awhile.
HEMATOLOGY
TEST RESULT RANGES REMARKS
Hemoglobin 133M: 135-180 g/l
F: 120-160g/lNormal
Hematocrit 40 M: 40-54F: 37-47
Normal
WBC count 13.0 5-10x109/L Increased
Neutrophils 0.81 0.40-0.70 Increased
Lymphocyte 0.19 0.20-0.40 Decreased
Platelet 282 150-400x109/L Normal
URINALYSIS
PHYSICAL EXAMINAT
IONColor Light Yellow
Transparency Slightly Turbid
Protein Negative
Sugar Negative
pH 6.0
Specific Gravity 1.010
MICROSCOPIC EXAMINATION
Epithelial Cells Moderate
Pus Cells 0.1/hpf
Mucus Threads III
Amorphous Urates IIII
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COURSE IN THE WARD
DATE ORDERS INTERVENTIONSSeptember 20, 2011
BP: 80/60
10:00 pm
yAdmit patient under surgeryySecure consent for admission
and management
yNPO temporarily, may wet lipsyIVF D5LRS 1Lx80yDiagnostics
-CBC typing
-Urinalysis
yTherapeutics-Cefoxitin 1gm IV q 8
0
(-) ANST
-Ranitidine 50g IV q 8
0
yPlan: E RLQ ExploratoryySecure consent for operation
and anesthesia
yNotify OR/NOD/AnesthesiologistyPrepare areayRefer accordingly
Focus: ADMISSION
10:00 pm
D: BP 80/60, wt. 45 kgs.,
conscious and coherent, vital
signs taken, with abdominal pain
2days PTA
A: Seen and examined by Dr.
Reyes with orders made and
carried out, consent for
hospitalization secured signed
by father, CBC typing done,
urinalysis done, result attached
to chart of patient, patient with
D5LRS 1L hooked
Focus: E RLQ EXPLORATION
A: OR notified, consent for said
procedure secured, signed by
father, NPO motivated,
preparation done
Focus: ADMISSION CARE
11:00 pmD: inform OR/wheelchair with
same IVF, conscious and
coherent
A: placed on bed comfortably, on
NPO maintained, on call to OR,
medications started
R: no other complaints made
September 21, 2011 6:25 am
yMaintain NPOyFor OR todayySpecimen received by father
7:45 am
yPost op ordersyTo PACUx4hrsyFlat on bed for 80yMonitor v/s every 15 minutesuntil stable then every 1
0
thereafter
yAdminister O2 inhalation @2LPM
yNPOyIVF of D5LRS 1Lx30gtts/minyMedications-Cefoxitin 1gm IV q 8
0
-Tramadol 50mg IV q 80
x 3 doses
-Ketorolac 30mg IV q 80
x 3 doses
(-) ANST
-Ranitidine 50mg IV q 80 x 3
Focus: E RLQ EXPLORATION
6:45 am
-in from OR/wheelchair with
ongoing IVF of D5LRS 1L @ fulllevel
-conscious and coherent, afebrile
-transferred to OR table safely
-positioned to supine BP- 100/60
-hooked to O2 inhalation @
3LPM
-pulse oximeter sensor to left
thumb reading to PR-82 O2-99%
-positioned to right lateral
decubitus
-skin preparation done in lumbar
area
7:00 am
-SAB inducted by Dr.
Remegio/W. Laguerta, then to
supine position
-incision site prepared
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doses aseptically
-sterile draped applied
7:10 am
-procedure started by Dr. Reyes
with A. Torres and G. Domingo
as scrub nurses with R. Santiago
as instrument nurse
-needed sutures provided
Focus: SPECIMEN OUT
7:31 am
-specimen placed in a sterile
bottle and labeled properly
- specimen handed to relative
with instructions given
-suturing done
-counting of instruments,sponges and needles done
complete
-closing of incision done
-procedure ended
-sterile dressing applied near the
incision site
Focus: TO PACU
-v/s 100/60 O2-99% RR-16
-O2 inhalation weared off
-pulse oximeter sensor removed
7:55 am
-transferred/stretcher with same
IVF on still sedated
-endorsed to NOD
Focus: IN FROM OR S/P E
APPENDECTOMY VIA STRETCHER
8:05 am
D: sedated, with dry and intact
dressing
A: v/s monitored and recorded,
monitored for any untoward
signs, kept thermoregulated,
administered O2 inhalation @
3LPM via nasal cannula as
ordered, medications started
R: no untoward signs noted
Focus: ENDORSED TO SURGERY
WARD
2:00 pm
D: latest v/s BP 100/70, P 76,R 20, T - 36.8, with same IVF on
Focus: IN FROM PACU
2:10 pm
D: received awake, conscious
and coherent, s/p E
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appendectomy, with bearable
post op pain, with intact
dressing, on NPO
A: placed on bed comfortably,
due meds given, NPO
maintained, needs attended
7:00 pm
D: awake, with IVF on NPO, with
intact dressing, with post op pain
A: NPO maintained, kept
comfortable, needs attended
September 22, 2011 6:30 am
yAfebrileyMay wet lipsyContinue medications
D: on bed awake, sitting
A: wound care done, hygiene
emphasized
7:00 pm
D: swelling at incision site, withtenderness
A: deep breathing exercises,
encouraged ambulation
September 23, 2011 6:25 am
yMay have clear liquidy(+) febrileyMetronidazole 500mg IV q 60yParacetamol 300mg IV q 40-for temp 37.8
yAmino acid + multivitamins500ml to run for 6hours ODyChange dressing PRNyRefer accordingly
Focus: FEBRILE
5:00 am
D : warm to touch, flushing of
skin, temp -38.5
6:00 am
A: TSB done, loosen tight
clothing
7:00 am
D: on bed, awake with loose
dressing
A: encouraged to take a bath,
hand care done, may have clear
liquid diet, encouraged
ambulation
9:00 am
D: seen by Dr. Reyes with new
orders made and carried out
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Saint Marys University
School of Health and Sciences
Bayombong, Nueva Vizcaya
INDIVIDUAL
CASE STUDYAcute Gangrenous Appendicitis
In partial fulfillment of the requirements in NCM 103 RLE
Submitted by:
Alma Nympha G. Bertos
Student
Submitted to:
Mr. Joman Baliton RN MSN
Clinical instructor
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CONTENTS
I. PERSONAL PROFILE
II. PAST AND PRESENT HEALTH HISTORY
III. BRIEF DESCRIPTION OF THE DISEASE
IV. ANATOMY AND PHYSIOLOGY OF ORGANS INVOLVED
V. PATHOPHYSIOLOGYVI. LABORATORY ANALYSIS
VII. PERSON ASSESSMENT
VIII. COURSE IN THE WARD
IX. DRUG STUDY
X. NURSING CARE PLAN