NORTHERN CHRISTIAN COLLEGE

“The Institution for Better Life”

Laoag City

ACUTE APPENDICITIS

Submitted to:

Mr. Benny De la Cruz

Clinical Instructor

Submitted by:

Alejandro, Lhovelie

Baltazar, Joyce

Cabie, Franz Micko

Columbano, Elaine S.

Fernandez, Ferdinand R.

Lumbo, Hidiewin B.

Oriendo, Jessamae U.

Sagsagat, Jennifer B.

Tinaza, Gemmy L.

September 28, 2010

INTRODUCTION
 Patient Michael, is a 29 year old married man, who was admitted at the surgery
department last September 23, 2010 due to severe pain at his right lower quadrant. The patient
was diagnosed with Acute Appendicitis. The patient underwent emergency appendectomy the
following day, September 24, 2010.

Appendicitis is the inflammation of the vermiform appendix and was first described as a
pathologic condition by Reginald Fitz in 1886, it is caused by an obstruction attributed to an
infection, stricture, fecal mass, foreign body or tumor. Appendicitis can affect either gender at
any age, but is most common in male ages 10-30 years old. Appendicitis is the most common
disease requiring surgery and one of the most commonly misdiagnosed diseases.

Appendectomy, removal of the appendix, is the standard treatment for acute appendicitis,
it is important to immediately remove the appendix after the diagnosis to prevent the occurrence
of the life-threatening complications of appendix. The most frequent complication of
appendicitis is perforation. Perforation of the appendix can lead to periappendiceal abcess (a
collection of infectious pus) or diffuse peritonitis (infection of the entire lining of the abdomen
and the pelvis). The major reason for appendiceal peforation is delay in diagnosis and treatment.
In general, the longer the delay between diagnosis and surgery, the more likely perforation
occurs. The risk of perforation 36 hours after the onset of symptoms is at least 15%. Therefore,
once appendicitis is diagnosed, surgery should be done without unnecessary delay.

NURSING OBJECTIVES

 To obtain necessary information regarding the patient and his condition;

 To assess the patient’s overall health status;
 To identify patient’s health care needs through analysis of all the data gathered;
 To assist the patient throughout rehabilitation, recovery and discharge;
 To impart necessary health teachings to the patient
 To perform appropriate nursing care in conjunction with the condition of the patient;
 To widen and enhance the student nurses’ knowledge and skills through additional
research about the nature of the disease, its signs and symptoms, its pathophysiology, its
diagnosis aand treatment.

I. PERSONAL DATA

Name: MICHAEL SORIANO LAGUNDINO

Age: 29
Sex: MALE

Civil Status: MARIED

Date of Birth: 11/23/80

Address: BRGY 34 BACCARA ILOCOS NORTE

Religion: ROMAN CATHOLIC

Nationality: FILIPINO

Place of Admission: GRAMH

Date admitted: SEPTEMBER 23 2010

Time Admitted: 6:50PM

Chief Complaint: PAIN AT THE RIGHT LOWER QUADRANT

Attending Physician: DR. PICHAY

Admitting Diagnosis: ACUTE APPENDICITIS

Final Diagnosis: SUPPURATIVE APPENDICITIS

 I.FAMILY BACKGROUND

TABLE I. DEMOGRAPHIC PROFILE

MEMBER GENDER AGE CIVIL RELATIONS EDUCATION OCCUPATI PLACE OF

STATU HIP TO THE AL ON RESIDENCE
S PATIENT ATTAINME
NT
ML MALE 29 M HS GRAD. FARMER CABAROAN
BACARRA
EDELYN F 28 M HUSBUND COL.GRAD HOSEWIFE CABARAON,B.
PRINCESS F 7 N/A FATHER ELEM. CABAROAN B.
EUGENYO M 56 M SON-IN- HS GRAD. FARMER CABAROAN B.
LAW
LETICIA F 52 M SON-IN- HS GRAD HOUSEWIF CABAROAN B.
YANOS LAW E

Mr. truness is the eldest son of mr. and mrs. Tsuba 29 years old, high school graduate,
currently residing at brgy. Caruan, Bacarra Ilocos Norte and married to Mrs. truness 28 years
old, a college graduate. Mr. eklabu 56 years old, high school graduat, father in law of mr truness
and mrs. Eklabu 52 years old, elementary graduate mother in law of mr tsuba. Where in they are
currently residing at the house of mr. and mrs eklabum. Mr tsuba and mr ekklabu are both
farmer.

Mr and mrs tsuba is blessed with 1 child, female named tseness, their child is an
elementary pupil at Cabaruan Elem School a grade 1 pupil.

Mr. tsuba belongs to an extended type of family. When it comes to decision-making

including health care, the couple and her parent in law talks about it and come up with a
consensus decision; this means that decisions are vested upon both of them.

A. INCOME

CASH

Source Amount

Mr. tseness --------------------------------------------------------------------Php 3,000.00/month

 1,580.00 quarterly

-395/month

Mr. tsuba -------------------------------------------------------------------- 3,000.00/month

TOTAL: Php 6,395.00/ month

RICE

Mr truness -------12 sacks every harvest season – 4 sacks=8 sacks x 2 harvest seasons = 16 sacks

(4 sacks is go to the land owner)

Mr tsuba----------15 sacks ever harvest season -5 sacks = 10 sacks x 2 harvest seasons = 20 sacks

TOTAL : 36 sacks of rice

1 sack = 40 kgs

36 sacks a year x 40 kgs a sacks ÷ 12 months a year = 120 kg. a month

B. EXPENSES

Electric bill ----------------------------------------------------------- Php 950.00

Foods/snacks ----------------------------------------------------------- 750.00

Groceries/Toilettries -------------------------------------------------- 1000.00

Fertilizer ------------------------------------------------------------------ 2,100.00

Gasul 1 tank/ month ---------------------------------------------------- 650.00

Medicines ---------------------------------------------------------------- 226.00

Clothes ------------------------------------------------------------------- 300.00

TOTAL: Php 5,976.00

Savings = income – expenses

Php 6,395.00 – 5,976.00

Savings = Php 419.00 a month

Budget allocation

300
2100
650 FERTILIZER
226 419 GROCERIES
ELECTRIC BILL
FOOD AND SNACK
GASUL
CLOTHES
MEDICINES
750 SAVINGS
950
1000

Most of the couple’s monthly budget is being spent for their farm supply which is
32.83% of their total budget. 15.63% is allotted for their groceries and toiletries and 14.85% for
their electric bill. 11.72% for their food and snack and 10.16% is allotted for their gasul and
4.69% for their clothes and 3.53% for their medicines.

Although they are living with their mother and father, the couple tries to save money as much as
they could for them to have their own house. When it comes to emergency cases wherein their
savings is not enough, they consult to their relatives to borrow money.

III.HEALTH HISTORY

A.Family Health History

 Mr. Lagundino stated that his grandfather at his paternal side died due to tuberculosis and
was diagnosed at Bangui district Hospital in 2002, his grandmother experienced hypertension
and died on year 2004.

Our patient both grandparents at maternal side died due to old age. His grandfather
smokes tobacco and drinks tuba. His mother often experienced leg cramping whenever she is
tired and she consumed 1 pack of lacampana for 3 days as her daily habit. She also seeks
traditional health practitioners when she experienced itchiness on the different parts of her body
which caused by witch craft according to her she managed it by using “tapal-tapal”. His father
was diagnosed of having ulcer and managed it by boiling leaves of guava and drinks it. He also
used 5 fingers marijuana on relieving his ulcer’s pain by boiling the leaves. According to his
mother her father was also diagnosed on having a hypertension. His father usually drinks a
bottle of gin at night on daily basis and smokes 1 pack of cigarette a day.

In the family if they had common illnesses like cough and colds they managed it thru
boiling of leaves of oregano or kutsay and drinks the decoction product to treat the said illnesses.
However when it worsen they but OTC drugs. They said that the old folks haven’t receive any
vaccines on their times.

B.Past Health history

Mr. Michael claimed that he had chicken pox when he was 8, his mother just gave him
black clothes to wear to “alleviate” the condition but he could not explain the connection of the
black clothing when we ask him about it. He also mention that he had mumps when he was 9
y/o, and her mother manage it by placing “acot-acot” on the affected site believing that the Acot-
acot” can alleviate the swelling of the affected area. There was no other medication aside from
that. He also mentioned that he was hospitalize last april 1 2010 at GRASMH with a chief
complaint of pain on the hypogastric region but can no longer remember the diagnosis when he
was asked him. He stays only just for a one night and went home the following day. Last july of
the same year he met on motor accident he claimed that he was drunk when it happened and was
brought to GRASMH with a chief complaint of headache

Like any other people he also takes paracetamol for fever ,neosep for couldsd, sulmox for
cough and diatabs for diarrhea . According to him he never receive any immunization during his
childhood as evidenced by absence of scar.

C. Present History
 According to our patient, before he was admitted, he had been experiencing episodes of
epigastric pain for a week @ Right Lower Quadrant every after he finishes his meals. In treating
this, he didn’t make excessive movements after meals and tried to rest until the foods taken in
were digested. After 1 week, he then had this excruciating pain that persisted for 3 days and he
tried to treat the pain by taking in over – the –counter drugs; disloverine and buscopan which
according to him, lessened the pain a bit but when he couldn’t bear it, he decided to go to the
hospital with his wife for a better treatment.

Our patient was admitted @ GRAMMH on the 23 rd of September 2010, Wednesday @

exactly 7:05 PM by Dr. Pitchay and ordered CBC, urinalysis, blood typing and “E”
appendectomy. D5LRS 1 L was inserted as venolysis. The operation was done last September
23, 2010 by Dr. Y. Post operative medications includes cefuroxime (750 mg IV q 6 hours),
Ketorolac Tromethamine (30 mg IV q 6 hours x 4 doses), Ranitidine (25 mg IV q 8 hours) and
last September 26, 2010, Dr Y ordered Diclofenac Na 1 amp (stat).

IV.Pathophysiology:

Obstruction of the appendix

 (by fecalith, lymphnode, tumor, foreign objects)

Inflammation

Increased intraluminal pressure

Distention of the appendix ---- can cause pain

Decreaed venous drainage

Blood flow and oxygen restriction of the appendix

Bacterial invasion of the blood wall--- causes fever

Necrosis of the appendix

The pathophysiology of the appendicitis is the constellation of processes that lead to the
development of acute appendicitis from a normal appendix. The main thrust of events leading to
the development of the acute appendicitis lies in the appendix developing a compromised blood
supply due to obstruction of its lumen and becoming very vulnerable to invasion by bacteria
found in the gut normally.

Obstruction of the appendix lumen by fecalith, enlarged lymph node, worms, tumor or
indeed foreign objects, brings about a raised intraluminal pressure, which causes the wall of the
appendix to be distended. Normal mucus secretions continue with the lumen of the appendix,
thus causing further build-up of intraluminal pressure. This in turn leads to the occlusion of the
lymphatic channels, then the venous return and finally the arterial supply becomes undermined.
Reduced blood supply to the walls of the appendix means the appendix gets little or no nutrition
and oxygen. It also means a little or no supply of white blood cells and other natural fighters of
infections found in the blood being made available to the appendix. The wall of the appendix
will thus start to break up and rot. Normal bacteria found in the gut gets all the inducement
needed to multiply and attack the decaying appendix within 36 hours from the point of luminal
obstruction, worsening the process of appendicitis. This leads to necrosis and perforation of the
appendix. Pus formation occurs when nearby white blood cells are recruited to fight the bacterial
invasion. A combination of dead white blood cells, bacteria, and dead tissue makes up pus. The
content of the appendix (fecalith, pus and mucus secretions) are then released into the general
abdominal cavity, bringing/causing peritonitis.

So, in acute appendicitis, bacterial colonization follows only when the process has
commenced.

These events occur so rapidly, that the complete pathophysiology of appendicitis takes
about 1-3 days. This is why delay can be deadly.

Pain in appendicitis is thus caused, initially by the distention of the walls of the
appendix and later when the grossly inflamed appendix rubs on the overlying inner wall of the
abdomen (parietal peritoneum) and then with the spillage of the content of the appendix into the
general abdominal cavity (peritonitis). Fever is brought about by the release of toxic materials
(endogenous pyrogens) following the necrosis of appendiceal wall, and later by pus formation.
Loss of appetite and nausea follows slowing and irritation of the bowel by the inflammatory
process.

Early symptoms of appendicitis are those symptoms that most people with this condition
may recognize and complain of.

They include lower right sided abdominal pain of gradual onset, feeling sick (nausea),
and loss of appetite.

Anyone with these three symptoms can be assumed to have appendicitis until proven
otherwise.

 Abdominal pain.

This pain typically starts from around the belly button (peri-umbilical region), or the
upper central abdomen (epigastrium) and then move ownward and to the lower right
abdomen (right iliac fossa). When the pain occurs in this pattern, it is the most dependable of
all symptoms of appendicitis, as over 8 out of 10 (80%) cases that present this way is
definitely due to the appendix. In some other individuals, the pain starts right way from the
right iliac fossa. Depending on where the tip of the appendix is, the pain could even be on the
right flank (retrocaccal appendix). If the appendix is quite long, and in the pelvic, it could as
well cause lower left abdominal pain, with frequent passage of urine in the inflamed
appendix irritates the bladder.

When the appendix is severely inflamed, the pain can be localized to a spot on the outer
1/3 of a line drawn between the belly button and front of the tip of the waist bone called the
McBurneys point. The McBurneys point is also open to the point of maximum tenderness
when the abdomen is examined. The pain is even worse when the hand suddenly removed
from that spot because of the appendix rubbing on the covering of the abdomen (rebound
tenderness).

There is also a sign referred to as the Rovsign sign. This is said to exist when the lower
left abdomen is palpated by the doctor, but causes pain in the right. If the appendix is the
pelvic type, examining the back passage (rectal examination) would cause some pain too. If
the hip is moved and stretched, this can also cause pain to be felt at the spot where the
appendix lies. This is referred to as the psoas sign.

 Loss of appetite, nausea and vomiting

This is another very important set of symptoms of appendicitis. It is said that loss of appetite
is the most constant symptoms. They may actually vomit. It is important to note that
 vomiting in appendicitis usually follows the pain. If you vomit before the pain, it is not likely
that the appendix is to blame.

 Change in Bowel movement

There may be diarrhea or constipation, especially in young children. This could lead to a
wrong diagnosis of food poisoning or gastroenteritis on the part of the unwary dctor. Up to 1-
5 persons could have diarrhea or even constipation with appendicitis

 Fever

There is usually a low grade fever in most patients with this disease. Nevertheless, in up to 1-
5 persons, they have normal temperature, even with severe disease. Temperature above
38.5®C with rigors is suggestive of a ruptured appendicitis.

PATTERNS OF FUNCTIONING

A. EATING PATTERN

Before Illness During Illness at Home During Illness at Hospital

When it comes to food, Mr. Mr. Lagundino said that even Mrs. Lagundino is on soft diet.
Lagundino said that he is not though he has illness, he still According to him, he ate
choosy. But vegetables are the have appetite to eat. minimal food.
ones usually prepared and he
Breakfast: Breakfast:
loved to eat fried eggplant dip
with soy. He eats three times a He eats his breakfast at around Half serving of lugaw
day composed of breakfast, 7:00 am which consists of the
Zip of water
lunch and dinner. He takes his ff:
meal as follows: Lunch:
1 cup of rice or pandesal
Breakfast: 1 cup of noodles
Leftover food from dinner
Usually taken at 7:00 AM: Zip of water
1 cup of coffee
1 cup of rice or pandesal Dinner:
1 glass of water
Leftover food from dinner 1 cup of noodles
 1 cup of coffee Lunch: Zip of water

1 glass of water Usually taken between 12:00

NN – 1pm which consist of
Lunch: *1 bear brand sterilized milk
the ff: for a day.
He eats his lunch at around
2-2 ½ cup of rice
12:00NN or 1 pm usually
consists of: 1 serving of vegetable/
(meat/fish –sometimes only)
2-2 ½ cup of rice
2 glasses of water
1 serving of vegetable/
(meat/fish –sometimes only) Snack:

2 glasses of water He usually has snack like

chippy or any chitchiria.
Snack:
1 glass of coke
He usually has snack like
chippy or any chitchiria. Dinner:

1 glass of coke He eats his dinner at around 7

0r 8 pm. his dinner consists of:
Dinner:
1 cup of rice
He eats his dinner at around 7
0r 8 pm. his dinner consists of: 1 serving of vegetable/
(fish/meat-sometimes only)
1 cup of rice
2 glasses of water
1 serving of vegetable/
(fish/meat-sometimes only)

4 glasses of water

ANALYSIS:

There is a slight alteration in his eating pattern before illness and during illness at
hospital wherein there where a change on his diet due to his operation.
 B. DRINKING PATTERN

Before Illness During Illness at Home During Illness at Hospital

He stated that he consumes: He stated that even though his He can consume 1 glass of
illness occurs he can consume water a day (240ml). 1
1 cup of coffee/day during
same amount of fluid which is sterilized bear brand for a day
breakfast (200ml). A glass of
1 cup of coffee everyday (250ml). IVF of 1L in a two
coke in snack (240ml). And
during breakfast (200ml) And bottle tube a day. (2000ml)
also consumes 7-8 glasses
also consumes 8-9 glasses
(1680ml-1920ml) of water per
(1920ml-2160ml) of water per
day. 1 bottle of redhorse
day and a glass of coke at Total: 2590ml/day
before dinner (330ml)
snack (240ml).
(Approximately
1 glass at breakfast;
1 glass at breakfast;
2 glasses at lunch;
3 glasses at lunch;
4 glasses at dinner;
4 glasses at dinner;
1 glass when he feels thirsty
1 glass when he feels thirsty
Total: 2690 ml/day
Total: 2600ml/day
(Approximately)
(Approximately)

ANALYSIS:

There is a slight alteration in his drinking pattern before illness and during illness at
hospital wherein there where a change on his diet due to his operation and an IVF round
the clock.

C. BLADDER ELIMINATION

Before Illness During Illness at Home During Illness at Hospital

He urinates 5-6 times a day, He urinates 7-8 times a day in He urinates 9-10 times a day.
which is once upon waking a large amount before his According to him she wakes
 up, once before lunch, once
after lunch, twice after dinner
and once before going to bed.
Mr. Lagundino said that the
color of his urine was dark
yellow.
hospitalization. According to
him, he urinates a lot because
he induced large volume. He
said his urine’s color was dark
yellow.
up thrice every night just to
urinate. He feels like urinating
mostly in the morning and
before going to bed. He said
his urine’s color is yellow.

ANALYSIS:

There was a change as to the frequency of Mr. Lagundino’s bladder elimination

pattern during her illness at home due to increased volume of fluid intake and due to the
medications given.

D. BOWEL ELIMINATION

Before Illness During Illness at Home During Illness at Hospital

According to him he defecates
once a day and the urge to do
so is usually at morning. He
used to defecate a formed
stool which is dark brown in
color.
He defecates once a day
usually at morning. His stool
is formed and dark brown in
color.
His bowel movement was
every time he urinates he also
eliminates bowel. His stool
consistency was watery stool
with minimal in amount.

ANAYLSIS:

There was an alteration on the consistency and amount of stool during illness at
home and during illness at hospital.

E. SLEEPING PATTERN

Before Illness During Illness at Home During Illness at Hospital

Mr. Lagundino usually sleeps He sleeps at 9-10 PM to 5:30 He said that he can’t sleep
8 hours a day (9:30p.m.- – 6:00a.m. (7-8 hrs) and takes well at night because every
5:30a.m.). his afternoon nap for 30 now and then he wakes up. He
minutes which is usually after sleeps in between 10p.m. –
 eating his lunch. 11p.m. and wakes up at
around 12a.m due to nurse
All in all he usually sleeps 7
routine and sleeps again after
-8 hours a day.
it. (6-7 hours). He also takes
naps just about 30 minutes
usually 4 times a day. All in
all she usually sleeps 9 hours a
day.

ANALYSIS:

A slight alteration of sleep pattern during illness at home and during illness at
hospital due to less activity that his doing.

F. BATHING PATTERN

Before Illness During Illness at Home During Illness at Home

Mr. Lagundino takes a bath He takes a bath once a day just He only takes sponge bath
once a day usually in the after taking his breakfast. assisted by his wife.
morning after breakfast.

ANALYSIS:

There was an alteration of his bathing pattern as to frequency comparing before

and during hospitalization.

LEVELS OF COMPETENCIES

A. Physical

Before Illness During Illness at Home During Illness at Hospital

In the morning after he wakes When his illness occurred, he In the hospital, he spends most
 up. He helps his wife in doing still helps in the field but in of the time lying on bed, or
household chores like cleaning minimal work. Instead, he sitting on his bed, talking to
the backyard. He said that he spends his time listening to the his watcher and relatives who
also go to the field and to help radio or watching TV. He also come and visit his as well as
plant or harvest vegetables or said that oftentimes, he talks conversing with other patients.
palay. He finds time attending with their neighbors when he
sessions on their barangay and doesn’t have anything to do.
seldom attends to church.
Likewise, he also attends to
fiesta celebrations as well as
weddings when invited.

ANALYSIS:

His usual daily routine at home and work as farmer were greatly affected by the
presence of his illness. He could no longer go to places without any assistance.

B. EMOTIONAL

Before Illness During Illness at Home During Illness at Hospital

Mr. Lagundino gets along well He usually feels irritable and Whenever he feels abdominal
with other people easily. He is restless whenever he pain he finds a way to ease the
a jolly person and experienced tenderness at his pain by taking rest.
approachable. He usually stomach. But once pain is
smiles especially when talking relieve, he said that he calms
with his family and friends, immediately and goes back to
laughs at things that make him his usual mood after the onset
happy. of pain.

ANALYSIS:

His discomforts are just but normal. Nevertheless, it is interesting to note that he can
get along well with other people easily and remains a jolly person despite her condition.
 A. SOCIAL

Before Illness During Illness at Home During Illness at Hospital

Mr. Lagundino said that he
has a good interpersonal
relationship with other people
around him. He also stated
that he is member of Brgy.
Official as “tanod”. He said
that he attends to birthday
parties, weddings whenever
invited.
During the course of illness,
he still able to interact with
other peoples especially his
friends who come and visit
him.
During his stay at the hospital,
he still socializes with other
people around him, especially
with the student nurses who
care for him and other health
care providers.

ANAYSIS:

There was no alteration in our client’s social competency. He remains friendly and
manages to talk well with other people. During hospitalization, despite his condition, he
was still able to establish a good rapport with other people.

D.MENTAL

Before Illness During Illness at Home During Illness at Hospital

Mr. Lagundino easily
understands or comprehends
what is being explained/
instructed to him. He is well
oriented about time, place,
persons, events, and what is
being happening around him.
He answers questions
coherently. He c
an also remember his past
significant experienced.
His illness didn’t cause any
alteration to his
comprehension and is still
oriented with events, time,
place, person and what’s
happening around him. He can
respond to questions being
asked appropriately.
In the hospital setting, he was
well oriented with time, place,
events or persons. He
understands all of the doctor’s
pieces of advice. He knows
how to answer properly when
asked.
 ANALYSIS:

There was no significant alteration to the client’s mental health and status. Our
client remained to mentally stable as evidenced by the fact that he was able to answer
questions appropriately.

E. SPIRITUAL

Before Illness During Illness at Home During Illness at Hospital

Our client claimed that he His faith and belief is not that He wasn’t able to go to church
believes in God and has faith strong but he seeks for God’s anymore because of his
in Him. But he only seldom help regarding his condition. confinement. He also claimed
attends mass. Nevertheless she According to him, and he that his faith in God never
never failed to pray to God didn’t blame God for the changed and he prays for his
and thank Him for the things that are happening to faster recovery.
blessings they received. him. Although he could
seldom attend mass already.

ANALYSIS:

Even though he couldn’t go to church because he was confined, hes faith in god
remained intact as manifested by his constant praying and worshiping to God.
ONGOING APPRAISAL

September 23, 2010

Mr. Miguel was admitted @ GRAMH due to pain on the lower quadrant 3 days PTA.
D5LRS started as venoclysis @ 7:05 pm. He was admitted by Dr. Pitchay different Diagnostic
procedure were ordered such as blood typing, CBC, Urinalysis and for surgical operation
(appendectomy). Consent for operation was secured vitals was follow:

BP- 110/80

PR- 81

BT- 36C

RR- 20

On the same day our patient undergoes “E” Appendectomy. The operation started at
10:40 p.m. and ended at 11:30 p.m.

September 24, 2010

On our second day of appraisal our patient is lying on bed awake with an IVF of D5NM
1L + 100 mg tramadol at 450cc level regulated at 30 gtts/min. He appears weak and pale and
complained of pain on operative site. He was on NPO. Vital signs were taken as follows:

BP- 110/70

PR- 96

BT- 37

RR- 22

September 25, 2010

On the 3rd day our patient was lying on bed on a supine position. Fair in appearance and
complaining of pain on the operative site with an IVF of D5LRS 1L @700 cc levels regulated @
30 gtts/ min. Mr. Michael was seen by Dr. Caday with ordered made and carried out. Clear
liquid and ketorolac to consume was ordered and follow up IVF was D5NM 1L to run for 12
hours + 1 amp of B complex and D5LRS 1L to run for 12 hours. Vital signs as follows:

BP- 120/80

RR- 20

PR- 80
 BT- 36.8

September 26, 2010

On our fourth day of our ongoing appraisal, we saw Mr. Michael sitting in bed side chair
conversing with his wife, with ongoing IVF of D5NM 1L @ 650cc level going on @ 20
gtts/min. Our patients still complaints of bearable pain on the operative site. He was on general
liquid diet. Vital signs were taken as follows:

BP- 110/80

BT- 36.7

RR- 23

PR- 81

September 27, 2010

On our fifth day, we saw our patient sitting on bed wearing black shirt and red short, with
an IVF of PNSS 1L @ 900cc level regulated @ 20 gtts/ min. He was fair in appearance and no
complaint of pain and with dry and intact dressing at the right lower quadrant. Our patient was @
soft diet. We instructed Mr. Michael to always keep the operative site dry and clean to prevent
infection. Vital signs were taken as follows:

BP- 110/80

BT- 36.9C

RR- 22

PR- 79
PHYSICAL ASSESTMENT

September 25, 2010

Our patient appear fairly well with no signs f uncoordinated movement or body
weakness. He speaks clearly and available with good eye contact. He appears well
nourished based from his body size. He is coherent and conversant as he answered
question being asked. He is wearing a black sando and gray short. He is about 5ft. and 2
inches in height and weight about 65lbs., vital signs were taken as follows:

BT: 36.9

PR: 79

RR: 22

BP: 110/80

Head

Normocephalic

In proportion with the size of the neck

Symmetrically round

Hair and scalp

Oily and thick texture of hair

With dandruff noted

No palpated mass on the scalp

With 2-3 inches scar noted at the left parietal area

Eyes

Symmetrical in line with each other

With pale conjunctiva

Pupils are equally round and reactive to light accommodation

No eye pain, no discharge noted

Ears

With serumen noted

 Equally symmetrical and in line with the other canthus of the eye

With good hearing acquity within our 2 feet distance

No lesion noted

Nose

Patent with no obstruction nor discharge noted

Mouth & throat

With yellow teeth

With dental carries noted

Moist brown lips

No inflamed tonsils

Pinkish to brownish gums

Neck

No inflamed lymph nodes

Neck vein is prominent

No neck vein distention (with bounding pulse)

Chest & lungs

Equal lung expansion

No wheezes, rales , crackles noted

Point of maximal impulse heard at 4th ICS

Abdomen

Round contour

Audible bowel sound

With dry and intact dressing at the right lower quadrant

Upper extremities

Movable at all ranges of motion

 With trimmed and clean fingernails

With good capillary refill at 1-2 seconds.

No lesion, no bruises

Lower extremities

Can move to its desired range of motion

With short but dirty toenails

With several scars on the both legs

No edema noted

Symmetrical to the body size

MEDICAL MANAGEMENT

A. INTRAVENOUS THERAPY

The choice of an IVF solution depends on the purpose of its administration. Generally IV
fluids are administered to achieve one or more of the following indicators.

 Establish or maintain a fluid/ electrolyte balance

 Maintain or correct patient’s nutritional status
 Administer bolus medication
 Administer fluid to KVO
 Administer blood/blood component
 Administer Intravenous anesthetics
 Administer diagnostic reagents
 Monitor hemodynamic functions

PNSS

Contents:

 154 meq/L of Na and Cl

Uses:

 Isotonic used in patients with ECF deficits with low serum of levels of NA or Cl
 and metabolic alkalosis
 Used before and after the infusion of blood products
Contraindication:

 Routine administration of IV fluids because it contains more sodium than ECF

D5NM

 Normosol Maintenance was given.

 Rationale: to provide calories, electrolytes and protein substance from being used
to provide energy
D5 NSS

Contents:

 50 g dextrose
 154 meq/L Na and Cl
Uses:

 ECF deficits in patients with low serum levels of NA or Cl in metabolic alkalosis

 Before and after the infusion of blood products and provides modest calories
 Rationale: to maintain fluid and electrolyte balance

Nursing Responsibilities:

1. Verify Doctor’s order

2. Explain to the patient why IV therapy should be administered because knowledge
increases both patient’s comfort and cooperation.
3. Determine the doctor’s order for the appropriate IVF and proper regulation to avoid
circulatory overload or may lead to hypovolemic shock
4. Always use aseptic technique when handling IV solution to prevent infection.
5. Always check for signs and symptoms of infiltration to prevent complication such as
swelling in the IV site, pain, and cold clammy skin. This may also indicate that the
needle is dislodged.
6. Check for bubbles in the tubing to prevent formation of air embolism.

DIET THERAPHY

Dietary management is usually prescribed to meet the specific needs of each person.
Integral to gastric ulceration is a prescribed plan for nutrition therapy. Therapy goals include
maintenance of nutrition while limiting the production of gastric acid to prevent irritations.
 1. Nothing Per Orem(NPO)
This was indicated for the purpose of decreasing the workload of the stomach
therefore preventing the stimulation of the vagal nerve which decreases the
hydrochloric secretion thus neutralizing or buffering hydrochloric acid, inhibiting
acid secretion, decreasing the cavity of pepsin, and to eradicate helicobacter
pylori.

Purpose:

This was done to our patient in preparation for surgical procedure which is
appendectomy.

LABORATORY PROCEDURES.

 Complete Blood Count( CBC)

This encompassed the study of bloods cells and coagulation. It consists of several tests
that allow for the evaluation of different cellular components of the blood on a broad spectrum of
clients. The findings give valuable diagnostic information about the hematologic and other body
system, prognosis, response to treatment and recovery.

Purposes of CBC:

1. To determine Hgb, Hct, RBC (like the bloods ability to carry oxygen), and WBC level
(which signals infection when elevated)
2. It determines if there is presence of infection or any health problems.

Name: Mr. Michael Date ordered: September 23, 2010

Age: 29 Date received: September 23, 2010

Sex: Male Date printed: September 23, 2010

Hematology Result Reference Range Significance

RBC 4.36 4.69- 6.13 x 10 / L Normal
WBC 9.8 5.0 – 10.0 x 10 /L Normal
 Hemoglobin 139 140-180 g/L Decreased
Hematocrit 0.43 0.40 – 0.54 L/L Normal

Differential Count Result Reference Range Significance

Neutrophils 0.75 0.30 – 70 Increased
Lymphocytes 0.20 0.20 – 40 Normal
Monocytes 0.06 0.00- 0.07 Normal
Eosinophils 0.00-0.01
Basophils 0.00 – 0.05
Bands
ANALYSIS :

There is slight decrease in hemoglobin level maybe due to renal damage. There is an
increased level in neutrophils wherein it is the primary phagocyte that arrives early at the
site of inflammation.

Nursing Responsibilities:

1. Check Doctor’s order to determine procedure to be done to the patient.

2. Inform and explain to the patient and significant other/s the reasons why specimen was
ordered and how it is to be collected and the stingy sensation that may be felt to gain
cooperation
3. Fill up laboratory request properly and forward it to the laboratory to notify the medical
technologies.
4. Upon the arrival of the result, refer it to the physician and attach it to the patient’s chart
for the physician to determine the appropriate management to be applied to the patient.

 URINALYSIS

Urinalysis is used as a screening and/or diagnostic tool because it can help detect
substances or cellular material in the urine associated with different metabolic and kidney
disorders.

Purpose:

This test if performed to our patient to assess the effects of the disease on the
renal function and the existence of concurrent renal or systemic disease.

Date ordered: September 23,2010

Date received: September 23, 2010

Date printed: September 23,2010

Components Result Normal Value Significance

Color Dark yellow Colorless – deep Normal
yellow
Character/Clarity Turbid Clear Abnormal
Specific Gravity 1.020 1.005 – 1.035 Normal
Sugar Negative Negative Normal
Protein Positive Negative Abnormal
Amorphus Urates Few Negative Abnormal
Amorphus Phosphate
Mucus Thread Few Negative Abnormal
Epithelial Rare Negative Abonormal

ANALYSIS:

The clarity of the urine of our patient is turbid. This is due to a few amount of
mucus thread in the urine and also to the presence of protein in the urine. The presence of
protein may indicate glomerular damage allowing albumin to leak out in the filtrate.

NURSING RESPONSIBILITIES

1. Check Doctor’s order to determine the procedure to be done to the patient

2. Inform and explain to the patient and significant other/s the reason why the specimen
was ordered.
3. Provide specimen bottle with proper instructions so that the patient and the significant
other/s will know what to do and to be able to obtain a proper specimen for the
laboratory procedure
4. Fill up laboratory request properly and completely so that the medical technologies
will know the specimen test to be done to the specimen once forwarded
5. When the specimen is available, send it immediately to the laboratory to avoid delay
in transport that may alter the result
6. Refer the result to the physician once available and attach it to the patient’s chart
afterwards so that the physician will be able to determine the problem occurring to the
patient and determine the appropriate management to be applied.

DRUG STUDY

Generic Name: Cefuroxime

Brand Name: Zinacef

Classification: Antibiotic, Cephalosporin

Dosage/Route/Frequency: 750 mg IV q 6 hours

Mechanism of Action:

Bactericidal: Inhibits synthesis of bacterial cell wall causing cell death

Desired Effect:

This drug is given to our patient as a prophylaxis for infectio

Adverse Reaction:

GI bleeding, stomatitis, peripheral edema, tinnitus,

Side effects:

Headache, dizziness, sweating

Nursing Responsibilities:

 Verify doctor’s order to prevent errors

 Check culture and sensitivity before administering the first dose to determine if there is
sensitivity to the drug
 Do not mix with aminoglycosides with the same IV solution because they are not
compatible
 Inject slowly over 3-5 minutes for better absorption
 Since diarrhea is usually the side effect, increase oral intake to replace fluid loss
 In cases of dizziness, and headache, provide client restful and compatible environment to
decrease degree of headache
 Discontinue if hypersensitivity occurs to prevent further complication

Generic Name: Ketorolac Tromethamine

Brand Name: Toradol

Classification: Non opioid analgesic, NSAID, Antipyretic

Dosage/Route/Frequency: 30 mg IV q 6 hours x 4 doses

Mechanism of Action:
 Analgesic activity related to inhibition of prostaglandin synthesis

Desired effect:

This drug is given to our patient to relieve pain

Adverse Reaction:

Depression, nervousness, black tarry stool

Side Effects:

Dizziness, Drowsiness

Nursing Responsibility:

 Check Doctor’s order to prevent errors

 Observe ten golden rules in giving medications to prevent errors
 Give drug with meals for faster absorption
 Take the only prescribed dosage and do not take the drug longer than 1 week to prevent
overdosing
 Instruct to report sore throat, fever,changes of vision, severe diarrhea. Any of these
indicates adverse reaction and drug toxicity.
 Do not mix with morphine sulfate, meperidine, promethazine or hydroxyzine because it
may precipitate the condition of the patient.
 Administer every 6 hours to maintain serum level and to control pain.
 Monitor patient accordingly because it may increase risk CV events GI bleeding, and
renal toxicity.

Generic Name: Ranitidine

Brand Name: Zantac

Classification: H2 blocker

Dosage/Route/Frequency: 25 mg IV every 8 hours

Mechanism of Action:

Inhibits the action of histamine at the H2 receptor of the parietal cells of the stomach,
inhibit basal gastric acid secretion and gastric acid secretion that is stimulated by food, insulin,
histamine, cholinergic agonists, gastrin and pentagastrin.
Desired Effect:

This drug is given to our patient to decrease gastric secretion.

Adverse Effect:

Alopecia, bradycardia, Hepatitis, Thrombocytopenia.

Side Effects:

Headache, dizziness

Nursing Responsibilities:

 Take drug as directed with or immediately following meals for faster absorption
 Do not combine with antacids because it may interfere with ranitidine absorption
 Report any evidence of yellow discoloration of skin or eyes or diarrhea, confusion
or disorientation to prevent complication.
 The drug is stable for 48 hours at room temp. for preservation of the drug.

Generic Name: Diclofenac

Brand Name: Voltaren

Classification: Anti inflammatory, antipyretic, NSAID, non opioid analgesic

Dosage/Route/Frequency: 1 amp, IM stat (9-26-10)

Mechanism of Action:

Inhibits prostaglandin synthesis to cause antipyretic and anti inflammatory effect, the
exact mechanism is unknown.

Desired Effect:

This drug is given to our patient to reduce pain.

Adverse Effect:

Renal impairment, GI bleeding, peripheral edema

Side Effects:

Fatigue, sweating, dry mucus membrane

Nursing Responsibilities:
  Take drug with food or with meals if GI upset occurs to reduce esophageal
irritation and improve absorption
 Assess for redness, infection, pain or vision changes with eye therapy to provide
immediate intervention and avoid complications.
 Ensure that drug is administered in high enough doses for anti-inflammatory
effect when needed and in low doses for an analgesic effect to achieve to achieve
optimal healing.
 Limit sodium intake, monitor weight and report any evidence of swelling or
unusual weight gain to prevent complications
 Maintain fluid intake of 2 Liter /day for assumed fluid balance.

XV. NURSING CARE PLAN

A. NURSING DIAGNOSIS

Fluid volume deficit related to vascular loss as evidenced by delayed capillary

refill, restlessness, poor skin turgor, skin dryness, decreased urine output, increased rate
and depth of respiration.

NURSING INTERFERENCE

Due to excessive intake of NSAIDs, it increases hydrochloric secretion and causes

irritation of the gastric mucosa, that leads to inflammation of the gastric mucosa and
further results to ulceration which causes bleeding and vascular dehydration leading to
Fluid Volume Deficit.

NURSING GOAL

After 1-2 days of rendering nursing intervention, the patient will be able to regain
his normal fluid volume as will be evidenced by normal capillary refill, good skin turgor,
smooth and mist skin, good state of well being, normal urine output and normal
respiration.
 NURSING INTERVENTION
1. Monitor for the existence of factors
causing deficient fluid volume such
as vomiting, diarrhea, and fever.
2. Monitor I and O every 8 hours.
3. Monitor v/s
RATIONALE
To prevent further fluid loss
To determine the progress of the therapy
To determine the progress of the therapy

4. Encourage regular oral intake to To maximize intake and maintain fluid

evaluate degree of fluid deficit balance
5. Apply lotion or skin moisturizer To maintain skin integrity and prevent
excessive dryness

6. Administer IV fluid as ordered To correct/replace fluid loss

7. Administer BT as ordered To correct/replace fluid loss

NURSING EVALUATION

After 1-2 days of rendered nursing intervention, the patient was able to regain his
normal fluid volume as evidenced by normal capillary refill, good skin turgor, smooth
and moist skin, good state of well being, normal urine output and normal respiration.

B. NURSING DIAGNOSIS

Sleep Pattern Disturbance related to external environment (new environment) as

manifested by presence of eye bags, frequent yawning, restlessness, interrupted sleeping
pattern and verbalization of “Saanko maimas ti maturog no adda silaw ke no sabali ti
paggianak”.

NURSING INFERENCE

Due to hospitalization, there was a sudden change of her environment that

disturbed her sleeping pattern.

NURSING GOAL
 After 1-2 days of rendering nursing interventions, the patient’s sleeping patter will
be improved as will be manifested by not prominent eye bags, absence of yawning fain in
appearance, and verbalization of “makaturog nak met lang nga nasayaaten”.

NURSING INTERVENTIONS RATIONALE

1. Provide quiet and comfortable
environment
2. Provide rest and relaxation
3. Decrease external stimuli such as
light, noise and odorous smell.
To promote restful sleep
For better healthier disposition/ well –
being
This provides atmosphere conducive to
sleep

4. Provide good ventilation/well This provides relaxation thereby inducing

ventilated place. sleep and rest.

5. Provide measure to induce sleep like To provide a relaxing, soothing effect and
back rubbing, clean and straighten conducive effect thereby inducing sleep
sheets/linens and light clothing in
preparation for sleep
NURSING EVALUATION

After 1-2 days of rendering nursing interventions, the patient’s sleeping pattern
was improved as manifested by no prominent eye bags, absence of yawning, fain in
appearance and verbalization of “makaturog nak metlang nga nasayaaten”

NURSING DIAGNOSIS

Acute Pain related to injury agents (chemical – NSAIDs) secondary to presence of

surgical incision as manifested by grimacing face, guarding behavior on the abdominal
area, weakness, restlessness with a pain scale of 3/10 with 10 as the highest and a
verbalization of “nautot etuy naopera”.

NURSING INFERENCE

Due to the disruption of the abdomen causing the released of chemical mediator
leading to irritation of the nerve endings causing pain that react to the stimulation of the
receptor site

NURSING GOAL
 After 2-3 hours of rendering nursing intervention, the pain felt by the patient will
be diminished as will be manifested by relaxed appearance, absecnce of guarding
behavior n the abdominal area and verbalization of “haan nga nasakit ken naapges toy
rusok kon”.

NURSING INTERVENTION RATIONALE

1. Provide and encourage use of
relaxation techniques (deep
breathing exercises, back rub/touch)
2. Assist the patient to assume a
comfortable position and if possible
minimize too much movement
3. Provide diversional activities
4. Provide a restful, comfortable and
quiet environment.
5. Encourage small frequent feeding
6. Instruct the patient to adhere to the
prescribed diet (soft diet)
7. Encourage verbalization of feelings
about the pain
These are necessary to refocus attention,
promote relaxation and may enhance
coping abilities. These may also help in
diverting the attention of the patient so that
the pain perception will be lessened and/or
eradicated.
Infrequent changing of position may
decrease contraction and decrease spasm,
thus reducing pain
To divert attention from pain
This is necessary to promote relaxation,
thus reducing pain experienced by the
client.
Small meals prevent over secretion of
acids and avoid distention, thereby
reducing pain.
This will decrease irritation or prevent
further irritation of the mucosal lining, thus
reducing pain.
To be able to evaluate if the above
interventions are effective or not and this is
a way to obtain baseline data. It also helps
alleviate anxiety thus reduce pain
perception.

NURSING EVALUATION

After 2-4 days of rendering nursing intervention, the pain felt by our patient was
diminished as manifested by relaxed appearance, absence of guarding behavior on the abdominal
area and verbalization of “haan nga nasakit ken naapges toy buksit kun”