CASE PRESENTATIONAcute Appendicitis

CHAPTER I

Introduction

The appendix is a closed-ended narrow tube up to several inches in length approximately about 10 cm. (4in) long. The anatomical name of appendix is Vemiform appendix which is a finger-like appendage that is attached to the cecum (the first part of the large intestine) just below the ileocecal valve. The wall of this organ contains lymphatic tissue that is part of the immune system for making antibodies.

Appendicitis literally means – the inflammation of appendix. One of the common acute inflammatory disorders in lower gastrointestinal tract. It is said to be that 7% of the population were affected and it affects males more than female. It occurs more in teenagers than adults and most commonly between the ages of 10-30 years

Once this kind of inflammatory disorder develops, it is usually requires immediate medical attention and surgery is a must to remove the organ to prevent bursting a perforating can cause death. Unfortunately, there is no alternative treatment for this.

Appendicitis is mainly manifested by abdominal pain; specifically the aching pain begins around the navel and often shifts to lower right abdomen. This symptom is usually accompanied by nausea and vomiting, loss of appetite, low grade fever and sometimes constipation and diarrhea is associated.

If the pain becomes sharper over several hours, sharp pain RLQ of abdomen occurs if it will press and then quickly released ( rebound tenderness test ) and if coughing, walking, laughing on other jarring movements is accompanied by pain, it is in need to site medical attention to diagnosed and conclude acute appendicitis is present and appendectomy

( surgical removal of vermiform appendix ) is requires immediately.

Normally, people believed that you can have appendicitis if you walk, jump or do jarring things after eating. But it is not actually the main reason or cause of appendicitis. It is said to be that blockage or obstruction in their proximal lumen can cause acute appendicitis.

The opening from appendix into the cecum becomes blocked due to the built up of thick mucus within the appendix or stool that enters the appendix coming from cecum. The mucus or stool hardens and becomes rock, like and blocks the opening ( fecalith- a rock of stool). After the blockage, bacteria in the appendix begin to invade its wall to inflame the appendix. That’s why, it is necessary to undergo appendectomy to prevent bursting or rupture of appendix. Ruptured appendix followed by spread of bacteria outside the appendix resulting to different complications or even death. The cause of such a rupture is unclear, but it may relate to changes that occur in the lymphatic tissue, for example, inflammation, that line the wall of the appendix.

Appendicitis may diagnosed through physical examination such as rebound tenderness, pain test which is done by processing the RLQ of abdomen and quickly releases it, testing the McBurneys point ( pain elicited in the RLQ when firm pressure is applied) and the Rovsing's sign done by pressing, on the LLQ deeply and evenly for 5 sec were frequently used.

Laboratory test, done to diagnose Appendicitis are CBC, Urinalysis, Abdominal X-ray, Ultrasound or even Ct-scan.

We have chosen this case because we want to obtain further information for us to know the real causes and reasons why someone acquire this kind of disorder.

CHAPTER II

Objectives

GENERAL OBJECTIVES

We aim to acquire knowledge, skills, and attitude for us to be able to use the nursing process as a framework of care of our patient. In acquiring the role of health care providers, we aim to render proper therapeutic management to our client’s faster and full recovery.

SPECIFIC OBJECTIVES1. Skills

To conduct a comprehensive assessment of patient who had appendicitis and undergone appendectomy.

To practice and enhance improvement a good communication skills through interviews.

To develop a critical thinking and analytical skills through frequent brainstorming sessions.

2. Knowledge  To gain adequate knowledge regarding

the patient status. To develop awareness on the existing

needs of a person with appendicitis and understand the significance of each and to know its impact to the overall health status of the individuals.

To broaden the scope, of knowledge regarding the nursing process.

3. Attitude

To establish rapport with each team members.

To strengthen cooperation and unity among members of the group.

To develop a warm environment between the student and the patient for a better working relationship towards improvement of health.

CHAPTER III

Theoretical framework

LYDIA HALL

Introduced the model on nursing, focusing on the nations that centers around three components of care, core, cure. Care represents nurturance and is exclusive to nursing care is essential human need, necessary for the health and survival of all individuals. Core involves the therapeutic use of it self and emphasizes the use of reflection. And cure focuses on nursing related to the physicians order.

As health provider it is our responsibility to perform certain nursing intervention as care, core, and cure health teaching to secure our client the optimum level of health we needed.

CHAPTER IV

Nursing history

PATIENT'S PROFILE

Name: Agent X44 Age: 15 y/o Birthday: February 3, 1994 Address: Quezon City Religion: Roman Catholic Status: Child Occupation: Student Admitting Diagnosis: Acute Appendicitis Final Diagnosis: Acute Appendicitis Attending Physician: Dr. Lim Time and date of admission: 10:35 AM;

September 14, 2009

Chief Complaint: Severe abdominal RLQ pain accompanied by nausea and vomiting.

HISTORY OF PRESENT ILLNESS

2 days PTA, patient was in usual state of good health but after having his dinner, he felt severe pain at his abdomen which started at the area around his peri-umbilical area shifted to the right lower quadrant region and accompanied by nausea and vomiting.

 1 day PTA, patient continuously had abdominal pain on the epigastric area and is concentrated on the RLQ. Still accompanied by nausea and vomiting.

Few hours PTA, patient still experienced severe abdominal pain. He was immediately rushed to the hospital and was admitted at the surgery ward at 11:35 PM, he was diagnose with acute appendicitis. He underwent an emergency appendectomy the next day, September 14 2009. His operation begun at 8:50 AM and ended at 9:25AM.

HISTORY OF PAST ILLNESS

According to Agent X44 he never had severe illnesses before other than a simple fever, cough and colds. He said that he got hospitalized for the first time. He declared to have complete primary vaccinations / immunizations taken in the past.

FAMILIAL HISTORY

Family has a history of hypertension and diabetes mellitus on the both mother and father side.

CHAPTER V

13 areas of Physical Assessment

1. SOCIAL STATUS Agent X44 is a 15 years old son of Mr. &Mrs.

X42 and X43. He is a high school student of TIP and lives at Quezon City. He was born in February 3, 1994 and a Roman Catholic. He is a happy & playful child. He likes to go everywhere with his friends to play basketball with them. He was said to be the eldest of his 2 brothers and sister.

Agent X44 is an adolescent which is according to Erickson’s Theory of Psychosocial Development. During this stage new interpersonal dimension emerges which is identity vs. role confusion. To achieve right identity adolescents must bring together everything they have learned about themselves because if not they will left them role confusion which gives them negative identity.

2. MENTAL STATUS

Agent X44 is currently a senior high school student.

During day 1 of Assessment the patient is very weak because of post operation (Appendectomy). Day 2, conscious and coherent, he was slightly shy to answers some of our question that’s why her mother helps him to answer questions. But he still remembered what happened before his hospitalization.

He speaks and understands English and Tagalog. Day 3, he is conscious and responsive. He is oriented to time, date and person.

3. EMOTIONAL STATUS

During day 1 and day 2, while assessing the pt. He was obviously not comfortable with his hospitalization aside from that he was complaining about his abdominal pain. Day 3 he answered the questions being asked to him by verbal and non-verbal language. He maintains eye contact while he was responding.

4. SENSORY PERCEPTION

4.a. VisionThere is no presence of discharges and

no lesions around his eyes. He can recognize different colors. Pupils are equally reacted to light and accommodations, test is done using penlight. He can recognize person in far distance space. He can read without difficulty in large letters and small letters.

4.b. GustatoryA day after operation patient has low

appetite. All he ate were tasted bitter according his mother. During assessment, 2 days after his operation patient’s diet is clear liquids only. Day 3, can now recognized different taste. It was done by giving patient food such as candy and soup. His buccal cavity and gums is clean, red in color and not swollen. His teeth are clean though there is some tooth decay noted

4.c. AuditoryThere is no discharge and odor around

his ears. Ears are symmetrically on each other. Patient shows no signs of difficulty in hearing and heard the tic sounds of wristwatch when placed close to his ears.

4.d. OlfactoryA day after operation, patient can’t

distinguish different smell according to his mother. Upon assessing his olfaction, he can now distinguish different smell. Assessment done by spraying cologne, lending patient some fruits to smell. No discharges and secretions noted.

4.e. TactilePatient is able to identify

smooth from rough, hard from soft. He is sensitive to cold and warmth and response to slightly painful stimuli. No signs of numbing.

5. MOTOR ABILITYThe patient still lying on his

bed. He can move but limited only because once he move he feels pain in the operated site.

6. BODY TEMPERATUREDuring assessment he was

afebrile with 37° C. Temperature was taken at right axilla for 5 minutes using thermometer (normal range 36.5 ° C – 37.5 ° C). His temperature was stable until our last assessment.

7. RESPIRATORY STATUSDuring the assessment patients

RR is 18cpm. His breathing pattern is rhythmic & shallow. No presence of adventitious sounds. No difficulty of breathing noted. His respiration was clear when auscultation done to his back using stethoscope.

8. CIRCULATORY STATUSHis BP is 110/70 mm/Hg, taken

on right brachial artery. His pulse rate was 76 bpm taken on his right radial artery. Capillary refill time (CRT) was also assessed on his right thumb of 2 seconds.

9. NUTRITIONAL STATUSPatient infused with D5LR 1 liter

regulated at 31-32 gtts/min for 8 hrs. IV line is infusing well without any signs of redness on insertion site. Day 1,NPO; Day 2, clear liquids and day 3 soft diet. He weighs 58kgs and in 5’7 in tall. His BMI is 20.78 normal (20-25 normal weight).

10. ELIMINATION STATUS10.a. UrineUpon assessment the patient.

already voided but with assistance. Color of urine is golden yellow, urine output 35cc per hour in day 1 based on his record. Day 2, he was voided 270cc based on record 6am-2pm shifts.

10.b. Stool During assessment,

patient has already defecates once after operation. He defecates normal consistency and little amount only because on his diet.

11. REPRODUCTIVE STATUSThe patient had been

circumcised when he was 11 y/o (done by the surgeon).

12. STATE OF PHYSICAL REST & COMFORT

Before confinement patient sleeping hours is usually from 10pm to 6am. After operation, patient was not yet comfortable because of his complaint – pain in operated site. Difficulty of falling asleep noted especially in strong stimuli and in every nurses rotation.

13. STATES OF SKIN & APPENDAGES

During assessment the patient has soft and smooth skin. His lips are slightly dry. Fingernails are clean and cut short. Has short hair with some dandruff presence but no lesions sited.

Patient has some scars on his lower extremities because of his ADL such as playing etc. Has mole on his lower cheeks, no malignancy sign.

CHAPTER VIAnatomy and Physiology

GASTROINTESTINAL TRACT

The structures that make up the digestive system:

The digestive system consists of a long muscular tube beginning at the lips and mouth and ending at the anus and includes the pharynx, esophagus, stomach and the small and large intestines. Certain large accessory glands located outside the digestive tube, including salivary glands, liver, gallbladder, and pancreas. Each of which secretes its special digestive juice into the digestive tube.

The digestive function of the upper portion of the tract, food is received into the mouth, where the tongue functions is to mix it with saliva from the salivary glands to keep the mass pressed between the teeth for chewing. In the process of swallowing, the tongue pushes the food back into the throat, initiating a wave of muscular contraction that propels the mixture to the stomach. The pharynx and the esophagus are muscular tubes that convey the chewed food from the mouth to the stomach.

For us to know and understand better the process of this system. Let’s follow this course after eating hamburger…

After taking a bite of your hamburger and your teeth chew it up. The saliva (mucous membrane of the mouth) secreted by your salivary glands moistens the food and begin to digest the starch in the bread.  The soft mass of chewed food (bolus) in your mouth to be swallows and travels down your ESOPHAGUS. The ESOPHAGUS is a muscular tube about 22-30 cm long that passes through the middle of your chest, through your diaphragm, and attaches to your STOMACH.  Your PYLORIC SPHINCTER – a specialized ring of muscle that surrounds the orifice between the stomach and duodenum that relaxes, to let the food into your stomach, and then tightens to keep food from going back up the esophagus. 

Your stomach makes hydrochloric acid and enzymes which break down the protein - in this case, the beef patty. If the sphincter isn't working just right, one gets the acidic stomach contents refluxing back into the esophagus.  This is Gastro-Esophageal Reflux Disease, or GERD.  This is also known as heartburn. The stomach is very muscular and also acts to grind up the food by squeezing and relaxing.

The stomach is connected to the SMALL INTESTINE, and another sphincter opens to let the food through.  The small intestine is another hollow tube.  If fully stretched out, it would measure between 15 and 34 feet.  It's divided into three sections.  The three sections, in order, are: the DUODENUM, the JEJUNUM, and the ILEUM.

Our chewed-up hamburger now enters the DUODENUM.  The LIVER makes bile, which is green and helps the digestion of fats. Bile is stored in the GALL BLADDER, and conveniently squirted into the DUODENUM when food enters. PANCREATIC juice also enters the duodenum. The PANCREAS makes strong enzymes which help break down the fats, carbohydrates, and proteins in the mayonnaise, bread, and beef patty, respectively. The pancreatic juice also contains bicarbonate, which neutralizes the strong hydrochloric acid the stomach has contributed to the mixture.

The tail end of the DUODENUM, the JEJUNUM and the ILEUM absorb the nutrients from the broken down food. They also reabsorb water from the food mixture, and from all the saliva and other secretions that were used to break down the food.  The small intestine also contains helpful bacteria which aid the digestion of certain vitamins. It may take 2-4 hours for food to pass from one end of the small intestine to the LARGE INTESTINES.

The large intestine neither receives nor secretes digestive juices into its interior. By the time chyme reaches the large intestine, digestion is complete, and only some water, salts, and vitamins remain to be absorbed. A considerable amount of fluid moves into the intestinal contents as they pass through the stomach and small intestine. Much of water is reabsorbing through the walls of the large intestine. The remaining becomes solid waste, known as feces and moved along by peristaltic waves to the RECTUM, where it is eliminated from the body through the anal canal.

The major areas of the large intestine are:Cecum – wherein the appendix is

attached.Colon – distinguish into three areas:

Ascending colonTransverse colonDescending colon

Rectum – begin at the end of the descending colon and terminates in the narrow canal.

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 large intestine which is the storage tank for our human waste. During transit through the colon, the waste continues to have more liquid and vitamins removed. When this function does not occur regularly, or normally, waste can block the appendix, and become lodged so that it is not sent along for removal naturally. In these cases, an infection will result. The immune system will fight the infection causing the appendix to become swollen and inflamed. The resulting infection can cause the appendix to swell until bursting. A ruptured appendix can spread infection products throughout the body and with it solid waste from the colon. The combination of infection and waste inside the human body can cause death in otherwise healthy individuals. The occurrences of acute appendicitis in America can be regarded as common, though most cases are recognized and treated prior to a life-threatening result.

Physiology of appendix:

Some researcher says that appendix has no known physiologic function. The removal of it appears no changes in the digestive system. But recent study released that one of the function of the appendix is storing and protection (act as a safe house) of good bacteria that aids the digestion of food. The intestinal bacteria are harmless as long as they remain in the large intestine; in fact, they are useful in synthesizing vitamins K. Bacterial activity in the large intestine also contributes to the production of intestinal gas or flatus (blowing), which cause flatulence. The cells in the intestinal glands of the large intestine secrete large amount of alkaline mucus, which helps neutralize acids produced by intestinal bacteria and also lubricates the lumen for the easy passage of feces.  

CHAPTER VII

Pathophysiology

Risk Factor

Luminal Obstruction

Increase Mucosal Secretion

Increase intraluminal pressure

Exceeds capillary perfusion pressure Epithelial mucosal secretions accumulate

Venous and lymphatic drainage are obstructed

Arterial stasis and tissue infarction

Appendical distentionIntraluminal hypertensionSTAGNATION exceeding the appendix

capacity of 0.1-0.3 ml

Venous out flow obstruction

Visceral afferent fibers are stimulated enters the 10th thoracic vertebral level

Referred Epigastric pain Periumbilical pain

Inflamation of serosa & adjacent structure

Radiating pain in the periumbilical area to the RLQ

Triggers somatic pain fibers innervating PERITONEA structures

APPENDICITIS

Loss of epithelial integrity

Ischemia

Vascular constriction and susceptibility to bowel flora invasion

Thrombosis of appendicular artery and vein

Luminal bacteria multiply

Perforation and spillage of infected appendical contents in PERITONEUM

Gangrene occur

Appendicitis is caused by obstruction of appendiceal lumen. The causes of obstruction include lymphoid hyperplasia, secondary to irritable bowel disease (IBD) or infection, fecal stasisand fecaliths (common to elderly patient), parasites, foreign bodies (rare). Lymphoid hyperplasia of the appendix may be related to crohns disease, mononucleosis, amoebiasis, GI and respiratory infections. Fecaliths are solid bodies within the appendix that form after the precipitation of calcium salts, undigested fiber in a matrix of dehydrated fecal materials. When the lumen is obstructed there will be an increase mucosal secretion that may cause increase in intraluminal pressure. When the intraluminal pressure increase either the pressure exceeds capillary perfusion or epithelial mucosal secretion will accumulates. If the pressure exceeds the venous and lymphatic drainage are obstructed. Stagnation occurs when the appendix reach its capacity (0.1-0.3ml). At the same time venous outflow is obstructed.

As a consequence, at the appendiceal wall Ischemia begins (inadequate flow of blood to a part of the body) resulting to loss of epithelial integrity allowing vascular constriction and susceptibility to bowel flora invasion. Thrombosis of appendicular artery and vein then luminal bacterial multiplies formation of pus. Within few hours this localized condition may worsen because leading to perforation & spillage of appendical contents in Peritoneum and gangrene occurs. While if the epithelial mucosal secretions accumulate arterial stasis and tissue infarction occurs that will result to Intraluminal hypertention and appendiceal distention. Visceral afferent fibers are stimulated and enter the 10th thoracic vertebral level. Pain is typically felt in the epigastric and periumbilical area it is generally vague and poorly localized. Inflamation of serosa & adjacent structures occurs which triggers somatic pain fibers innervating PERITONEAL structures which typically casing pain to the right lower quadrant (RLQ).

CHAPTER VII NURSING

MANAGEMENT

Diagnostic Tests

Impression:

The white blood cell count in the blood usually becomes elevated with infection. In early appendicitis, before infection sets in, it can be normal, but most often there is at least a mild elevation even early. Unfortunately, appendicitis is not the only condition that causes elevated white blood cell counts. Almost any infection or inflammation can cause this count to be abnormally high. Therefore, an elevated white blood cell count alone cannot be used as a sign of appendicitis.

COMPLETE BLOOD COUNT

RESULT NORMAL VALUES

POSSIBLE SIGNIFICANCE

Hemoglobin 121g/l M:140-180g/lF:120-160g/l

Anemia, Hemorrhage leukemia

Hematocrit 0.36 M:0.40-0.54F:0.37-47

Anemia, Hemorrhage leukemia

WBC 16-6x10g/l 5-10x10g/l Bacterial infection, Leukemia, severe

sepsis

Neutrophils 0.85 0.35-0.65 Bacterial infection, tumor inflammation, stress, drug reaction

lymphocytes 0.22 0.20-0.40 Normal

Monocytes 0.05 0.020.05 Normal

URINALYSIS

Test Result Normal values

Color Yellow Amber

Transparency Slightly turbid

pH 6.1 4.8-8.0

Specific Gravity

1.025 1.015-1.025

Protein negative negative

Glucose negative negative

MICROSCOPIC Results

WBC 0-1/hpf

RBC 0-1/hpf

Epithelial Cells Few

Mucus Threads Moderate

Bacteria few

Impression:Urinalysis is a microscopic examination of the urine that

detects red blood cells, white blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or stones in the kidneys or bladder. The urinalysis also may be abnormal with appendicitis because the appendix lies near the ureter and bladder. If the inflammation of appendicitis is great enough, it can spread to the ureter and bladder leading to an abnormal urinalysis. Most patients with appendicitis, however, have a normal urinalysis.

DRUG STUDY

Dug name: Diphenhydramine 1 ampule TIV PRN for pruritis

Brand name:Benadryl

Classification:Antihistamine

Indications: Symptomatic relief of allergic symptoms caused by histamine

release including nasal allergies and allergic dermatosis; adjunct to epinephrine in the treatment of anaphylaxis; night time sleep aid; prevention of treatment of motion sickness. Topically for relief of pain and itching.

Contraindications:Hypersensitivity to diphehydramine or any component of the

formulation; active asthma; neonates or premature infants. Adverse reaction:

Anorexia, constipation, dry mucous membrane, epigastric distress, vomiting, itchiness.

RouteIV

FrequencyPRN

Dosage1 amp

NURSING CONSIDERATION

Monitor effectiveness of therapy and adverse reaction.

Take as prescribe; avoid excessive dosage

Monitor patient’s response and arrange for adjustment of dosage to lowest possible effective dose.

Drug name:Paracetamol 300mg TIV q 4hrs for fever 38C above

Brand name:Aeknil

Classification: Analgesic Indications:

Paracetamol has good analgesic and antipyretic properties. It is suitable for the treatment of pain of all kinds (such as postoperative pain post traumatic pain).

Contraindications:Paracetamol should not be used in hypersensitivity to the preparation and in

severe liver diseases. Adverse reaction:

In rare cases hypersensitivity reactions, predominantly skin allergy (itching and rash), may appear long-term treatment with high doses may cause a toxic hepatitis with following initial symptoms: nausea, vomiting, sweating, and discomfort.

Route IV

Dosage300mg

Frequency q4 for Temp. above 38ºC

Nursing consideration: Do not exceed recommended dose; do not take for longer than 10 days

Drug name: Nalbuphine 5 mg TIV PRN for severe pain

Brand name: Nubain

Indications: Moderate to severe pain

Contraindications:Contraindicated in patients hypersensitive to drug.

Adverse reaction: Biliary tract spasms, constipation, cramps, dyspnea,

nausea and vomiting. Route

IV Dosage

5mg Frequency

PRN for severe pain Nursing consideration:

Reassess patients level of pain at least 15 and 30 minutes after parenteral administration.

Constipation is often severe with maintenance therapy. Make sure stool softener or other laxative is ordered.

Drug name: Cefuroxime 750mg TIV q 8º

Brand name: Cefuroxine sodium (Zinacef)

Indications: Lower respiratory infections caused by bacteria Pneumonia,

Aureus, E-coli Contraindications:

Contraindicated with allergy to cephalosporins/penicillin. Adverse reaction: Headache, insomnia, fatigue, rashes, pruritus, dyspepsia Route

IV Dosage

750 mg Frequency

q 8º Nursing consideration:

Be aware that patient may be at increase risk for GI bleeding, monitor accordingly.

Establish safety measures if CNS/ visual disturbances occur.

NCP

Assessment Nursing Diagnoses Planning Intervention Rationale Evaluation

Subjective Cues:“ masakit yung parting inoperahan sa akin” as verbalized by the patient.Objective:~ A mild pain felt in the right lower quadrant of the abdomen.~ Pain scale of 7 (from pain scale of 0-10) is the highest.~ Facial mask of pain.~ Guarding behavior.~ Discomfort in movement.

Acute pain due to post operation (appendectomy)

Within 1 hour of nursing intervention the patient will able to verbalize decrease in pain from pain scale of 7 to level 2.

Independent:1.Assess location, character, onset/duration, frequency, quality, severity of pain. 2. Accept patient’s description of pain.3. Observe non-verbal cues. 4. Monitor vital signs.

5. Provide quiet environment.

1.Serves as baseline data.

2.Pain is subjective experience and cannot be felt by others. 3. Provide comparison of subjective data.4. Usually altered in acute pain; to monitor progress of condition.

5. Provide relaxation technique.

The goal was met after 1 hour of nursing intervention the patient pain level decrease from pain scale of 7 to pain scale of 2. The patient falls asleep after intervention done.

6.Provide comfort measures such as back rub, change in position and use of heat and cold.7.Encourage deep breathing exercise.

8. Encourage diversional activities such as watching tv, listening to music.9. Encourage adequate rests periods.

Dependent:1.Administer pain medication as prescribed.Generic name: Nalbuphine HCLBrand name:Nubain

6. Provide pharmacological management.

7. Aids in better tissue oxygenations thus reduce pain.8.Diverts perception of pain.

9. To prevent fatigue.

1.Control and relieves pain.Indication:Relief of moderate to severe pain. Pre-operative analgesia, as a supplement to balanced anesthesia

Assessment Nursing Diagnosis Planning Intervention

Rationale Evaluation

Subjective Cues:“Pagising-gising ako pagtulog gawa ng opera ko” as verbalized by the patient.Objective:~ Dark circles under eyes.~ irritable

Sleep pattern disturbance related to pain due to post operation.

After 4 hours of nursing intervention the patient must able to learn some techniques of effective sleeping pattern, as evidenced by

1. Establish rapport with the patient.

2. Ask the patient what is the reason why he can’t sleep.

3. Health teaching to the patient.

Explain necessity of disturbances for monitoring vital signs and or other care

Provide quiet environment and comfort measures (eg. Back rub, washing hands/face, cleaning) in preparation for sleep.

1. For the patient to feel at ease and comfortable, thus facilitating client-nurse interaction.2. To have an idea on what and how to start the health teaching.3. For the patient to understand the purpose of viral signs that causes him to be awake and why vital signs have to be done.4. For the client to help him more comfortable/relax on his bed.

After doing the nursing interventions, the patient now understand all the techniques of sleeping pattern and can able to sleep comfortable.Day 3 the patient verbalized “sige, naiintindihan ko po, tatry ko po”

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: “bakit ako nagkaroon ng appendicitis?”As verbalized by the patient.

ObjectiveAlways asks questions.

Deficient knowledge related to lack of exposure and unfamiliarity of information resources.

Within 1 hour of nursing intervention, the patient will have sufficient knowledge about appendicitis.

Independent:1.Provide active role for client in learning process.

2.Provide an environment that in conducive to learn

3.Provide written information/guidelines and self learning modules for client to refer to us for recovery.

1.Promotes self of control over situation and is means for determining that, that client is assimilating / using new information.

2.Helps to retain information what has been discussed.

3.Reinforces learning process, allows client to proceed at over pace.

After 1 hour of nursing intervention the patient can now understand the nature of disorder.

Assessment Nursing Diagnosis

Planning Intervention Rationale Evaluation

4. Discuss information relevant only to the situation.

5. Provide information about additional learning resources

4.To prevent overload.

5.May assist with further learning/promote learning at own pace

Evaluation

Chapter IX

Medications

Patient was given a dose of antibiotic intravenously during the surgery and the antibiotic is continued until the day after surgery. Take home medicines are cefalexin 500 mg TID for 5 days and mefenamic acid 500 mg q6 for 3 days.

 Exercise

Patient should be encouraged to leave bed and increase ambulation gradually. Activity restrictions will depend on the severity of the appendicitis. Driving exercise and lifting heavy objects will be limited for a few weeks to allow for incisional healing. Light exercise is advisable such as walking but not too far.

 

TreatmentLight activity at home is encouraged

after surgery; patient is advised to avoid strenuous activity like lifting heavy objects and activity that requires energy.

Heath teaching>eat food rich in ascorbic acid to boost immune system of the body.>remind the family member to note for fever.>educate the client to maintain a clean environment.>instruct the patient to have rest and take the prescribed medicine and comply with it.

Out-patientPatient should be seen about one to two

weeks after discharge. The wound should be examined for evidence of inflammation and the patient should be checked for fever.

DietTo allow the digestive tract to rest after

surgery, patient will not be given anything to eat or drink for the first 24 hours after an appendectomy. After that, patient gradually be given small amounts of water, then clear liquids and then solid foods, until finally the patient is able to handle required diet.

PrognosisAppendicitis is usually treated

successfully by appendectomy. Unless there are complications, the patient should recover without further problems. The mortality rate in cases without complications is less than 0.1%. When an appendix has ruptured or a severe infection has developed, the likelihood is higher for complications with slower recovery or death from disease. After different interventions done by nurses and doctors to the client, the patient will spend few days in the hospital until the different symptoms of the said illness is cured.

AcknowledgementWe group A1 as a Nursing group would like to show our

deepest heartfelt gratitude for those people who help us to make this case study a successful one.

To God almighty who gave us enough strength, inspiration and empowerment for daily lives so we could perform properly and act accordingly.

To our beloved parents and family for whom we dedicate this case study and especially for their moral support understanding as well as for their financial support. To our beloved WCC faculty and staff especially to Mr. Ramilo “yogo” Paralejas Clinical Instructor in NCM 121 RLE who devoted his time in supervising us in our exposure in the Hospital and for his patience in correcting our work to make it better.

To our chosen patient agent X44 and her family who welcomed us whole hearted open and shared their stories and being cooperative to answer our queries. For allowing us to gather some information so that our case made possible. 

To our group for sharing laughers, the rapport that we had established and the understanding and helping arms and hands of everyone. We have learned lot of things that we will treasured it on journey and as we strive forward registered Nurses.