Name of Student: Kathleen Joyce Dimacali Date : Feb 4, 2021

Clinical Area: Medical ward

CLINICAL ANALYSIS
I. Patient’s Profile
Name: Patient B
Age:18 years old
Date of birth: August 8,2002
Gender:Female
Religion:Catholic
Nationality:Filipino
Address: Cabanatuan city,Nueva Ecija
Date admitted: Feb 4, 2021
Admitting Diagnosis: Appendicitis
Attending Physician: Dr. Dela cruz

II. Medical History

a. Present
A 18 years old female was admitted to Immaculate Conception Medical center on
Feb 4, 2021 with chief complaint of pain at the Right Lower Quadrant of abdomen
2 days prior to admission. In her diagnostic test her chest x-ray is normal but CBC
revealed elevated white blood cell count and PT and PTT are in normal
range.Diagnosis to consider Appendicitis.

b. Past
The patient has experienced episode of constipation that can be relieved by the
over the counter drugs and never been hospitalized
c. Socio-economic
The patients lives in concrete house with 3 bedrooms,with her parents and two
siblings. She is first year college. She likes to eat meat rather than vegatables and
eat minimal fruits.
 III. Anatomy and Physiology

The appendix (or vermiform appendix; also cecal [or caecal] appendix; vermix; or
vermiform process) is a finger-like, blind-ended tube connected to the cecum,
from which it develops in the embryo. The cecum is a pouch-like structure of the
colon, located at the junction of the small and the large intestines. The term
"vermiform" comes from Latin and means "worm-shaped." The appendix used to
be considered a vestigial organ, but this view has changed over the past decades.
Recent research suggests that the appendix may serve an important purpose. In
particular, it may serve as a reservoir for beneficial gut bacteria.

Structure
The human appendix averages 9 cm (3.5 in) in length but can range from 5 to 35
cm (2.0 to 13.8 in). The diameter of the appendix is 6 mm (0.24 in), and more than
6 mm (0.24 in) is considered a thickened or inflamed appendix. The longest
appendix ever removed was 26 cm (10 in) long.The appendix is usually located in
the lower right quadrant of the abdomen, near the right hip bone. The base of the
appendix is located 2 cm (0.79 in) beneath the ileocecal valve that separates the
large intestine from the small intestine. Its position within the abdomen
corresponds to a point on the surface known as McBurney's point.

The appendix is connected to the mesentery in the lower region of the ileum, by a
short region of the mesocolon known as the mesoappendix
Function
The function of the appendix is unknown. One theory is that the appendix acts as
a storehouse for good bacteria, “rebooting” the digestive system after diarrheal
illnesses. Other experts believe the appendix is just a useless remnant from our
evolutionary past. Surgical removal of the appendix causes no observable health
problems.

Heather F. Smith, Ph.D., Associate Professor, Midwestern University Arizona

College of Osteopathic Medicine, is currently studying the evolution of the
appendix across mammals. Dr. Smith's international research team gathered data
on the presence or absence of the appendix and other gastrointestinal and
environmental traits for 533 mammal species. They mapped the data onto a
phylogeny (genetic tree) to track how the appendix has evolved through
mammalian evolution, and to try to determine why some species have an
appendix while others don't.

They discovered that the appendix has evolved independently in several mammal
lineages, over 30 separate times, and almost never disappears from a lineage
once it has appeared. This suggests that the appendix likely serves an adaptive
purpose. Looking at ecological factors, such as diet, climate, how social a species
is, and where it lives, they were able to reject several previously proposed
hypotheses that have attempted to link the appendix to dietary or environmental
factors. Instead, they found that species with an appendix have higher average
concentrations of lymphoid (immune) tissue in the cecum. This finding suggests
that the appendix may play an important role as a secondary immune organ.
Lymphatic tissue can also stimulate growth of some types of beneficial gut
bacteria, providing further evidence that the appendix may serve as a "safe
house" for helpful gut bacteria.
 IV. Pathophysiology (in flow chart form)

Appendicitis
Precipitating factors:

Precipitating Factors:
Patient broke her right leg
due to falling on the stairs
Predisposing Factors: Diet: Low Fiber

Age: 18 years old Stress

Episodes of constipation

Occlusion of Appendix Fecalith

Decrease flow/Drainage of mucosal secretions

Increase Intaraluminal Pressure in the Appendix

Vasocongestion

Decrease blood supply and oxygen in the appendix

Appendix starts to be necrotic:Bacteria invade the appendix

Disruption of cell membrane of process

Start inlammatory process

Release of chemical
mediators Activation of the vomiting Neutrophils to area
Center in the Medulla

Histamine,prostaglandin Pus formation

,leukotrines,bradykinin
Stimulation of the vagus Suppression of (Phagocyttized bacteria
nerve sympathetic GI function and dead cells)
Swelling of appendix
Nausea & Vomiting
Anorexia
Prostaglandin,bradykinin

Abdominal
Pain in RLQ of abdomen Bloating,Flatulence

Constipation or
Acute Pain Rebound pain Diarrhea
 Interleukin-1

Increased WBC

Inflammation of the Appendix

(Appendicitis)
 V. Physical Assessment
Abdominal
INSPECTION Shape- flat.
No scar of prior surgery
Umbilicus inverted.
Flank not full
All quadrants moving symmetry with breathing
AUSCULTATION Bowel sound present but hypoactive
No renal bruit
PERCUSSION Resonance in all quadrants
No rebound Tenderness
PALPATION Guarding, Tenderness at RLQ
 VI. Diagnostic Tests
a. Laboratory
Laboratory Test Results Clinical Significance
Complete Blood Elevated White blood If the white blood cell
Count Cell count is higher than
normal, It may indicate an
infection or inflammation.

PT and PTT Normal limits The PTT and PT tests

each evaluate coagulation
factors that are part of
different groups of
chemical reaction
pathways in the cascade,
called the intrinsic,
extrinsic, and common
pathways.

 The PTT is used to

evaluate the
coagulation factors XII,
XI, IX, VIII, X, V, II
(prothrombin), and I
(fibrinogen) as well as
prekallikrein (PK) and
high molecular weight
kininogen (HK).
 A PT test evaluates
the coagulation factors
VII, X, V, II, and I
(fibrinogen)

b. Radiologic tests

Chest X-ray

Chest X-rays produce images of your heart, lungs, blood vessels, airways, and the
bones of your chest and spine. Chest X-rays can also reveal fluid in or around your
lungs or air surrounding a lungs.
VI.Medical management
DRUG STUDY
Name of Drug Dosage and Action Side Effects Nursing Considerations
Route

Generic name: Dosage: 30mg -Inhibits prostaglandin -Drowsiness, -Provide rest after administration
Ketorolac synthesis, producing headache, and
Brand name: Route:IV peripherally mediated fatigue
Toradol analgesia
- Also has antipyretic -GI pain ,nausea -Before administering medication
and anti-inflammatory instruct to take meals to decrease GI
properties. upset
-Therapeutic effect:
Decreased pain -Monitor BP upon administration. <
90/80never administer. Refer to doctor.

-Asthma and -Patients who have asthma, aspirin-

Dyspnea induced allergy, andnasal polyps are at
increased risk for developing
hypersensitivityreactions. Assess for
rhinitis, asthma, andurticaria.

- Assess pain (note type, location,

andintensity) prior to and1-2 hr following
administration.

- Ketorolac therapy should always be

given initially by the IM or IV route. Oral
therapyshould be used only asa
continuation of parenteral therapy.
- Caution patient to avoid concurrent use
of alcohol, aspirin, NSAIDs,
Name of Drug Dosage and Route Action Side Effects Nursing Considerations

Generic name: Dosage: 750 mg antimicrobials -Avoid rapid or bolus I.V.

Levofloxacin involves inhibition -CNS: seizures administration,because this may cause
Brand name: Route:IV of bacterial severe hypotension.
Levaquin, Novo- topoisomerase IV -Check v/s, specially BP. Too-
Lefloxacin, and DNA gyrase rapidinfusion can cause hypotension
Oftaquiz,Quixin, (both of which are -Closely monitor patients with renalin
Tavani type II sufficiency
topoisomerases), -GI:
enzymes required pseudomembrano -Assess for severe diarrhea, which
for DNA replication, us colitis mayindicate pseudomembranous colitis.
transcription, repair -Hematologic: -Watch for hypersensitivity reaction. D/C
and recombination lymphocytopenia drug immediately of rash or other s/sx
occur.
-Nausea, -Provide rest after administration
headache,dizziness
, lightheadedness
VII.Surgical Management
Name/Type of Surgical Description
Procedure
Appendectomy An appendectomy is the surgical removal of the
appendix. It's a common emergency surgery that's
performed to treat appendicitis, an inflammatory
condition of the appendix.
Open appendectomy. A cut or incision about 2 to
4 inches long is made in the lower right- side of the
abdomen. The appendix is taken out through the
incision.
Laparoscopic appendectomy. This method is less
invasive. That means it’s done without a large
incision. Instead, from 1 to 3 tiny cuts are made. A
long, thin tube called a laparoscope is put into one
of the incisions. It has a tiny video camera and
surgical tools. The surgeon looks at a TV monitor to
see inside your abdomen and guide the tools. The
appendix is removed through one of the incisions.
Indication Complication
-Patients with a history of persistent abdominal Some possible complications of an appendectomy
pain, fever, and clinical signs of localized or diffuse include:
peritonitis, especially if leukocytosis is present.
-Acute appendicitis
1. Bleeding
-Recurrent appendicitis - As Interval appendectomy
2. Wound infection
after drainage of abcess or in appendicial mass
3. Infection and redness and swelling
-Carcinoid tumour : at the tip. <2cm
(inflammation) of the belly that can occur if the
-Mucocele of the appendix appendix bursts during surgery (peritonitis)
- Appendicular graft; ileal conduit 4. Blocked bowels
- On table colonic lavage 5. Injury to nearby organs
Pre-operative Post-operative

1. Maintain NPO status.
2. Administer fluids intravenously to prevent dehydration.
3. Monitor for changes in level of pain.
4. Monitor for signs of ruptured appendix and peritonitis
5. Position right-side lying or low to semi fowler position to promote comfort.
6. Monitor bowel sounds.
7. Apply ice packs to abdomen every hour for 20-30 minutes as prescribed.
8. Administer antibiotics as prescribed
9. Avoid the application of heat in the abdomen.
10.Avoid laxatives or enema.
1. Monitor vital signs for sign of infection and shock such as fever, hypotension and
tachycardia.
2. Monitor I and O for sign of imbalance, dehydration, and shock.
3. Assess abdomen for increased pain, distention, rigidity, and rebound tenderness because
these may indicate postoperative complications.
4. Evaluate dressing and incision.
Evaluate the passing of flatus or feces.
Monitor for nausea and vomiting.
5. Laboratory values are monitored and patient is evaluated for sign and symptoms of
electrolyte imbalances.
6. Wound drains, I.V, and all other catheter are monitored and evaluated for signs of
infections.
7. Turning , coughing, deep breathing, and incentive spirometry are performed every 2 hours.
8. Diet is advised as ordered.
9. Administration of medications as ordered
10. Patient Education and Health Maintenance
11. Instruct patient to avoid heavy lifting for 4 to 6 weeks after surgery.
12. Instruct patient to report symptoms of anorexia, nausea, vomiting, fever, abdominal pain,
incision area redness and drainage postoperatively.
VIII. Nursing Management
NCP
Assessment Background Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation
Knowledge

Subjective Cues: Surgical pain is an Acute pain related After 2- 4 hours of 1.Assess pain, noting 1.Useful in After 2- 4 hours of
unpleasant to post operative appropriate location, monitoring appropriate nursing
“Masakit yung
sensation that surgical incision as nursing characteristics, effectiveness of intervention the
opera ko ”as
results from a evidenced by intervention the severity (0–10 scale). medication, patient was able to
verbalized by the
surgical facial patient will be Investigate and progression of report relieved of
patient.
procedure. Pain is frimace,restlessne able to report report changes in healing. Changes in pain,appear relaxed,
caused by the ss,irritability and relief of pain as appropriate. characteristics of able to rest
damage done to pain scale of 8/10 pain,appear pain may indicate appropriately and P/s
Objective cues: tissue by the relaxed, able to developing abscess of 8/10 to 4/10.
-Facial grimace incision, the rest appropriately or peritonitis,
Goal met
procedure itself, and P/s of 8/10 to requiring prompt
-restlessness the closing of the 4/10. medical evaluation
-irritability wound and any and intervention.
force that is
2. Keep at rest in 2. To lessen the pain.
applied during the
semi-Fowler’s Gravity localizes
procedure.
VItal signs: position. inflammatory
exudate into lower
BP-110/70mmhg
abdomen or pelvis,
T-36 C relieving abdominal
tension, which is
PR-112bpm
accentuated by
RR-22cpm supine position.

O2sat- 99% 3.to reduce oxygen

3. maintain bed rest
consumption and
P/s- 8/10 during pain, with
demand, to reduce
position of
competing stimuli
comfort,maintain
and reduces
relaxing environment
anxiety.
to promote
calmness. 4.Helpful in
decreasing pain and
4. Instruct patient
promote relaxation.
to do relaxation
techniques: deep
and slow
breathing,.Assist as
needed. 5.Refocuses
5. Provide attention, promotes
diversional activities. relaxation, and may
NCP
Assessment Background Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation
Knowledge

Subjective cues: Wounds involving Risk of infection Within 24 hours of 1. Practice and 1. Reduces risk of Within hours of
injury to soft related to post appropriate instruct in good spread of bacteria. appropriate nursing
“Kahapon lang ako
tissue can vary surgical incision as nursing handwashing and intervention the
naoperahan,baka
from minor tears evidenced by intervention the aseptic wound care. patient was able to
maimpekyon yung
to severe crushing incision on right patient will be Encourage and achieve timely wound
sugat ko” As
injuries. The lower quadrant able to achieve provide perineal healing; free of signs of
verbalized by the
decision to suture timely wound care. infection/inflammation,
patient.
a wound depends healing; free of 2. Provides for early purulent drainage,
2. Inspect incision
Objective cues: on the nature of signs of detection of erythema, and fever.
and dressings. Note
the wound the infection/inflamm developing infectious
-Post operative characteristics of
time since the ation, purulent process and
incision drainage from
injury was drainage, monitors resolution Goal met
wound (if inserted),
-with wound sustained the erythema, and of preexisting
presence of
dressing dry and degree of fever. peritonitis.
erythema.
intact contamination.
3. Monitor vital 3. Suggestive of
-Weak in apperance signs. Note onset of presence of infection
fever, chills, or developing sepsis,
-irritability
diaphoresis, changes abscess, peritonitis.
in mentation, reports
VItal signs: of increasing
abdominal pain.
BP-120/70mmhg

T-36 C
4. Obtain drainage 4. Gram’s stain,
PR-98bpm specimens if culture, and
indicated. sensitivity testing is
RR-22cpm useful in identifying
O2sat- 99% causative organism
and choice of
therapy.

5. Antibiotics given
5. Administer before
antibiotics as appendectomy are
appropriate. primarily for
prophylaxis of
wound infection and
are not continued
postoperatively.
Comments and suggestions_____________________________________

Clinical Instructor_________________________________