Manila Tytana Colleges

MANILA DOCTORS COLLEGE OF NURSING

Diosdado Macapagal Ave. Pasay City

Case Analysis No. 1

RLE / MEDICAL-SURGICAL NURSING

A. Case 2: A 25-year-old woman with no previous medical history reported to the emergency
department with abdominal pain, anorexia, nausea, and vomiting. Pain began 8 hours ago in the
periumbilical region and is now localized to the right lower quadrant. She denied hematemesis,
diarrhea, hematochezia, and melena

Specific Questions:

1. Discuss the anatomical region or quadrant of the abdomen

The abdomen is divided into four quadrants: right upper quadrant (RUQ), right lower
quadrant (RLQ), left upper quadrant (LUQ), and left lower quadrant (LLQ). The right upper
quadrant consists of the right lobe of the liver, gallbladder, pylorus of the stomach,
duodenum, pancreas, right kidney, right suprarenal gland, distal ascending colon, hepatic
flexure of the colon, and right half of the transverse colon. The right lower quadrant on the
other hand consists of the ileum, cecum, vermiform appendix, proximal ascending colon,
and proximal right upper ureter. The left upper quadrant consist of the left lobe of the liver,
spleen, stomach, jejunum, proximal ileum, body and tail of the pancreas, left kidney, left
suprarenal gland, left half of the transverse colon, superior part of the descending colon.
Lastly, the left lower quadrant contains ovary, uterine tube, ductus deferens, uterus and
urinary bladder. On the other hand, there are nine regions of the abdomen. The right and left
hypochondriac regions are found superiorly on either side of the abdomen, while the
epigastric region sits between them in a central, superior position. The right and left lumbar
regions surround the umbilical region, which is central and has the umbilicus as its center
point. Lastly, the right and left inguinal regions are found inferiorly on either side of the
hypogastric region, which is the most inferior of the central line of segments (Sieroslawska,
A., 2022).

2. What is the probable organ that is causing the symptoms of the patient
 Appendix - the periumbilical discomfort of the patient is a specific sort of abdominal pain
that occurs either around or behind the umbilicus. The pain is localized in the right lower
quadrant which could signify the appendix is the organ causing the pain. The appendix, right
ovary (in women), and fallopian tube (in women) are all located in the right lower quadrant
(RLQ). Indeed, diagnosing appendicitis in the right lower quadrant may be examined, and
this quadrant may be sensitive and painful.

3. What are the immediate nursing interventions that need to be done in this case

As a student nurse, it is important to:

a. Assess the patient’s pain using COLDSPA (characteristic, onset, location, duration,
severity, pattern, and associated factors)
Rationale: COLDSPA is used in order to have a baseline data on where to conduct the
physical assessment associated with pain

b. Conduct a physical assessment, especially on the abdomen

Rationale: To get more pertinent information that could indicate the periumbilical pain of
the patient and by using the region and quadrants of the abdomen we will be able to
determine what organs are more likely to be affected and a major source of the pain or
abnormality

c. Ensure patient comfort by placing them in a semi-fowler’s position

Rationale: Semi-fowler position lessen the pain as gravity localizes inflammatory
exudates into the abdomen, relieving abdominal tension which can occur if the patient is
lying in a supine position

d. Administer analgesic as ordered by the physician

Rationale: Analgesic reduces the pain caused by the appendix of the patient

e. Collaborate with the medical technologist and radiologist for diagnostic testing as
ordered by the physician
Rationale: To further evaluate and support information that causes the pain
B. Physical examination revealed a low-grade fever of 38.3 °C and pain and tenderness on
palpation of the right lower quadrant.

Specific Questions:
1. What are the pertinent data in the physical examination
● Temperature - 38.3°C (Normal: 36.5 to 37.5°C)
● Palpation of right lower quadrant - pain and tender
Indeed, the pertinent data show low-grade fever of 38.3 °C and pain and tenderness on
palpation of the right lower quadrant. These data may signify an inflammation which is the
compensatory mechanism of the body to infection. Signs of infection may include fever and
pain which are all present to the patient

C. The doctors ordered the following diagnostics, Complete blood count (CBC), C-reactive protein
(CRP), pregnancy test (beta human chorionic gonadotropin [β-hCG]), and computed
tomography (CT) scan of the abdomen.

The test results are as follows:

CT SCAN

An abdominal CT scan demonstrated concentric thickening of the appendiceal wall with

haziness of the surrounding fat consistent with an inflamed appendix. The appendiceal lumen
was distended with an appendicolith.
Specific Questions:
1. What are the indications for the test performed
● Complete blood count (CBC) - It provides fast results and can be used in the diagnosis
of appendicitis. Neutrophil, WBC, and NLR are helpful and useful parameters for
physical examination and other diagnostic methods in diagnosing acute appendicitis and
measuring severity (Peksöz, R., & Bayar, B, 2021).
● C-reactive protein (CRP) - CRP levels of greater than 3 mg/dL are commonly reported
in patients with appendicitis, but very high levels of CRP in patients with appendicitis
indicate gangrenous, perforation or suppurative evolution of the disease, especially if it is
associated with leukocytosis and neutrophilia (Ahmed, M., 2017).
● Pregnancy test (beta human chorionic gonadotropin [β-hCG]) - A negative β-hCG
rules out pregnancy complications (eg, ectopic pregnancy) as the cause of the patient’s
pain (Breeding, E. & Conran, R., 2020).
● CT Scan - Abdominal CT is a well-established technique in the study of acute abdominal
pain and has shown high sensitivity and specificity for diagnosing and differentiating
appendicitis, providing an accurate diagnosis in the early stages of disease (Cunha, P.,
2005). A CT scan is ordered to assist the physician in diagnosing, narrowing the
differential diagnosis, and confirming the doctor's assumption. The doctor orders a CT
Scan to help confirm appendicitis or find other causes of the patient’s pain. Additionally
 physicians are increasingly ordering CT scans to balance risk of a negative
appendectomy with the risk of delayed surgery and a perforated appendix.

2. What are the nursing considerations before the test is conducted

CBC and CRP
a. Explain to the patient that there will be slight discomfort that will be felt because of the
needle that will puncture the skin
Rationale: Informing the patient about the sensation to be felt during needle insertion
helps the patient cope with experiences
b. Encourage the patient to avoid stress as physiologic status influences and alter normal
hematologic values
Rationale: Stress stimulates the sympathetic nervous system which will trigger the
adrenal gland and it will be the adrenal medulla who will the epinephrine causing
tachycardia and norepinephrine causing vasoconstriction leading to increase blood
pressure which alter the hematologic values
c. Instruct the patient that fasting is not necessary
Rationale: Fasting can cause dehydration of the cells which can also alter the
hematologic values

PREGNANCY TEST
a. Instruct the patient the fasting is not necessary
Rationale: Fasting can cause dehydration of the cells which can also alter the
hematologic values
b. Instruct the patient that the test requires a first-voided morning specimen
Rationale: The first void in the morning contains the highest amount of microorganisms
in the body and it should be taken at the midstream urination for accurate result

CT SCAN
a. Take off some or all of the clothing and wear a hospital gown as per instruction
b. Remove any metal objects, such as a belt or jewelry, which might interfere with image
results.
c. Do not eat a few hours before the scan because the injection especially if receiving a
contrast agent may cause stomach upset.
 d. To receive the contrast injection, inform that patient that an IV is inserted into the arm
just prior to the scan.
e. Prior to most CT scans of the abdomen and pelvis, it is important to drink an oral
contrast agent that contains dilute barium. This contrast agent helps the radiologist
identify the gastrointestinal tract (stomach, small and large bowel), detect abnormalities
of these organs, and to separate these structures from other structures within the
abdomen.
f. If the patient has a history of allergy to contrast material (such as iodine), the requesting
physician and radiology staff should be notified.
g. The patient will be asked to drink slightly less than a quart spread out over 1.5 to 2
hours.

3. What significant findings revealed in the test results

Based on the complete blood count (CBC), C-reactive protein (CRP), pregnancy test
(beta human chorionic gonadotropin [β-hCG]), and computed tomography (CT) scan of the
abdomen. It is indicated that in the CBC there is an increased WBC count (cell/mm³) of
12,700 considering the normal is 4,500 to 11,000. Under the WBC Differential the
segmented neutrophils (Result: 70 | Normal: 54-62) and band neutrophils (Result: 8 |
Normal: 3-5) is high. A high neutrophil result indicates that there is an infection or
inflammation. Neutrophilia can point to a number of underlying conditions and factors,
including: infection, most likely bacterial. The C-reactive protein is also increased with a
result of 34.0 and the normal is < 3. A high CRP test result is a sign of acute inflammation. It
may be due to serious infection, injury or chronic disease. Lastly, an abdominal CT scan
demonstrated concentric thickening of the appendiceal wall with haziness of the surrounding
fat consistent with an inflamed appendix. The appendiceal lumen was distended with an
appendicolith. Appendix normally is not inflamed unless there is an infection and
appendicolith may obstruct the appendix lumen, causing appendicitis

4. What do you think is the management of this patient

Appendectomy - it is a surgery to remove the appendix when it is infected. This

condition is called appendicitis. There are 2 types of surgery to remove the appendix. The
standard method is an open appendectomy. A newer, less invasive method is a laparoscopic
appendectomy. Open appendectomy which is a cut or incision about 2 to 4 inches long is
made in the lower right-hand side of your belly or 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 (John Hopkins Medicine, 2019).
REFERENCES:

Appendectomy. Johns Hopkins Medicine. (2019, August 14). Retrieved from

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/appendectomy

CT evaluation of appendicitis and its complications: Imaging techniques and key diagnostic
findings : American Journal of roentgenology : Vol. 185, no. 2 (AJR). American Journal of
Roentgenology. (n.d.). Retrieved from
https://www.ajronline.org/doi/full/10.2214/ajr.185.2.01850406

Peksöz, R., & Bayar, B. (2021). The role of complete blood count parameters in diagnosing
acute appendicitis and measuring the severity of inflammation. Akut apandisit tanısını
koymada ve ciddiyetini belirlemede hemogram parametre değerlerinin rolü. Ulusal travma
ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTES, 27(6),
654–661. https://doi.org/10.14744/tjtes.2020.69195

Sieroslawska, A. (2022, July 19). Regions of the abdomen. Kenhub. Retrieved from
https://www.kenhub.com/en/library/anatomy/regions-of-the-abdomen