COLLEGE OF NURSING

Foundation University
Dr. Miciano Road, Taclobo, Dumaguete City 6200

CASE STUDY ON RUPTURED APPENDICITIS

In Partial Fulfillment of the Requirements for the

Degree of Bachelor of Science in Nursing
NUR205 B

Submitted by:
Ian Kevin M. Molijon

December 2, 2023

TABLE OF CONTENTS

1
 I. FOUNDATION UNIVERSITY VISION, MISSION AND SPECIFIC
OBJECTIVES…………………………..................................................................................................3
II. CENTRAL OBJCTIVES AND SPECIFIC OBJECTIVES……………………………………………………………………………………………………………………….4
III. ACKNOWLEDGEMENT………………………………………………………………………………………………………………………………………………………...5
IV. INTRODUCTION………………………………………………………………………………………………………………...........................................................................6
V. DEMOGRAPHIC PROFILE……………………………………………………………………………………………………………………………………………………...7
A. IDENTIFICATON DATA…………………………………………………………………………………………………………………………………………………….7
VI. DEVELOPMENTAL TASK……………………………………………………………………………………………………………………………………………………...8
VII. ANATOMY AND PHYSIOLOGY……………………………………………………………………………………………………………………………………………9-12
VIII. REVIEW OF RELATED LITERATURE…………………………………………………………………………………………………………………...……………….12-13
IX. MEDICAL MANAGEMENT……………………………………………………………………………………………………………………………………………………
13
A. LABORATORY EXAMS AND CORRELATION………………………………………………………………………………………………………………......13-
15
B. TREATMENT MODALITIES
C. DRUG STUDY……………………………………………………………………………………………………………………………………………………….15-32
D. CONCEPT MAP……………………………………………………………………………………………………………………………………………………...32-
33
X. NURSING MANAGEMENT……………………………………………………………………………………………………………………………………………………34
A. NURSING HISTORY………………………………………………………………………………………………………………………………………………………34
1. FAMILY HISTORY AND GENOGRAM.………………………………………………………………………………………………………………………………
34
2. PSYCHOSOCIALHISTORY…………………………………………………………………………………………………………………………………………....34
3. ENVIRONMENTAL HISTORY………………………………………………………………………………………………………………………………......…….34
4. SPIRITUAL HISTORY………………………………………………………………………………………………………………………………………………….34
B. PHYSICAL ASSESSMENT…………………………………………………………………………………………………………………………………………………
35
C. NURSING THEORY………………………………………………………………………………………………………………………………………………………...36

2
 D. GORDON’S FUNCTIONAL HEALTH PATTERN…………………………………………………………………………………………………………………......36-
39
E. SUMMARY OF NURSING
DIAGNOSIS………………………………………………………………………………………………………………………………......39
F. NURSING CARE PLAN…………………………………………………………………………………………………………………………………………………40-
42
XI. ANNOTATED READINGS………………………………………………………………………………………………………………………………………………......…43
XII. CONCLUSION…………………………………………………………………………………………………………………………………………………………….…….44
XIII. REFERENCES…………………………………………………………………………………………………………………………………………………………….…44-45

Foundation University
COLLEGE OF NURSING

I. FOUNDATION UNIVERSITY VISION, MISSION AND SPECIFIC OBJECTIVES

Mission:
To enhance and promote a climate of excellence relevant to the challenges of the time, where individuals are committed to pursue new knowledge and life.

Vision:
Foundation University envisions itself as a dynamic, progressive environment that cultivates effective learning, generates creative ideas, response to societal needs and
offers equal opportunity for all.

3
Life Purpose:
To educate and develop individuals to become productive, creative, useful, and responsible citizens of the society.

Core Values:
Excellence
Commitment
Integrity
Service

II. CENTRAL OBJECTIVES:

At the end of this study, the presenter will be able to acquire adequate knowledge and develop appropriate attitude and skills in caring for a patient being diagnosed
with Ruptured Appendicitis

Specific Objectives:

At the end of our presentation, the learners will be able:

a. Accurately present thorough general assessment of the client which includes physical assessment
b. Understand the pathophysiology and etiology of the case being presented
c. Know the role of drug therapy in managing the client related to patient’s diagnosis
d. Recognize the contributing factors associated in the development of the diagnosis
e. Systematically present the data pertinent to the case being gathered
f. Efficiently provide appropriate and proper nursing diagnosis in line with the client’s medical condition and skillfully formulate nursing care plans for the problems
identified
g. Appropriately apply nursing interventions necessary for the patient’s condition in reference with the learned theories and concepts of the disease.

4
 III. ACKNOWLEDGEMENT

I would like to extend my sincere thanks and gratitude to the following persons who have contributed and supported in the fulfillment of this case study.

To Mr. Jethri Ken Carlo M. Catalan, RN, MSN COLLEGE DEAN, for allowing me to have this Related Learning Experience and for all out support of Mr. Jed Keoni U.
Jolo, RN my clinical instructor in Surgery Ward for the patience and time, for sharing suggestions and for guiding me during the exposure.

Thank you also to my patient and her family, for their unwavering support. That meant so much for the completion of this study, to Family A, respondents of this study,
thank for being approachable, cooperative and for spending their time in answering all the questions being asked. I would like to extend wholeheartedly the gratitude and praise to
ever loving and merciful God for letting me through despite all the challenges that I have faced.

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IV. INTRODUCTION

6
 V. DEMOGRAPHIC PROFILE

A. IDENTIFICATION DATA
Patient name: N.B
Age: 26 yrs old
Sex: Male
Date of birth: August 5, 1997
Address: Gomentoc, Ayungon Negros Oriental
Civil Status: Single
Religion: Roman Catholic
Height: 164 cm
Weight: 53.8 kg
Date of Admission: 10/22/223
Time: 2:12 A:M

7
 Admitting Diagnosis: Acute Uncomplicated Appendicitis
Admitting Physician: Dr. Victor Giorgio M. Villegas, M.D.
Chief Complaint: 2 days prior to admission onset of RLQ pain, (-) BM changes, (-) Fever, 1× vomiting
General Survey: Received patient on bed lying awake and oriented to time and date. Ongoing PLR 1L infusing well at left metacarpal vein at 30 gtts/min.

VI. DEVELOPMENTAL TASK

DEVELOPMENTAL TASK DEFINITION CORRELATION

PSYCHOSOCIAL DEVELOPMENT Stage 6: Intimacy and Isolation

According to Erik Erikson’s theory, the sixth stage of Client is 26 years old and claims the he is happy with his
psychosocial development is that young adults need to life. He lived with his family and four siblings. He goes
form intimate, loving relationships with other people. to church often.
Success leads to strong relationships, while failure results
in loneliness and isolation. This stage covers the period
of early adulthood when people are exploring personal
relationships. Erikson believed it was vital that people
develop close, committed relationships with other
people. Those who are successful at this step will form
relationships that are enduring and secure.

Genital Stage:

The genital stage, which Freud believed to be the last

stage of psychosexual development, starts at puberty. In Client wasn’t able to share some information regarding

8
PSYCOSEXUAL DEVELOPMENT this stage, the adolescent has overcome latency, formed his sex life, but he did say that his desire for pleasure is
associations with one gender or the other, and is now active.
looking for pleasure in other people's company. The
focus
of the desired sexual encounter has changed from the
opposite sex parent in the phallic stage to opposite sex
individuals in a comparable age range. They now derive
their enjoyment from the opposite sex's genuine physical
stimulation of their genitalia.
COGNITIVE DEVELOPMENT Formal Operational Stage: Client is capable, oriented to time and place, and was
able to understand the situation surrounding him. He
As per Jean Piaget's theory of cognitive development, the feels good about herself and accepts the way she is.
fourth and final stage starts around the age of 12 and lasts
until adulthood. As adolescents enter this stage, they gain
the ability to think in an abstract manner by manipulating
ideas in their head, without any dependence on concrete
manipulation. Skills such as logical thought, deductive
reasoning, and systematic planning are developed during
this time.
MORAL DEVELOPMENT Postconventional (Level III) Stage 6 Client can act and make his own decisions in life and at
the same time he stands firm upholding moral principles
The person transcends their own society's perspective for and sticking to social mores. He claims he does not harm
Kohlberg's postconventional level. Morality is described
someone’s feelings.
in terms of universally applicable abstract values and
concepts. The person makes an effort to view things from
everyone else's perspective. The standards by which
people receive justice are described in Stage 6.
According to Kohlberg's Morality Theory, this is the
pinnacle of moral development. When people get to this
point, they have a well-rounded perspective on society,
where their sense of fairness leads them to regard
everyone equally.

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VII. ANATOMY AND PHYSIOLOGY

10
VIII. REVIEW OF RELATED LITERATURE

11
 IX. MEDICAL MANAGEMENT

A. LABORATORY AND CORRELATIONS

Laboratory and Diagnostic Results Normal Values Correlation
Exams
WBC 22.40 4.5-11 T/cumm
RBC 4.32 4.6-60 T/cumm Normal RBC count indicates there is no anemia.
Hemoglobin 14.70 13.5-18g/dl
Hematocrit 44.40 40-54% Normal hemoglobin indicates there is enough red blood cells in the body.
Neutrophil 76.90 55 – 70% When your neutrophil count is too high it indicates bacterial infection.
Lymphocyte 12.20 20 – 35% Low lymphocyte count indicates risk for infection.
Monocyte 8.40 2-8%
Eosinophil 1.10 1-4% Normal eosinophil count indicates body have enough white blood cells to support the immune system.
Basophil 1.40 0.5-1%
Platelet 350 150-400 T/cumm Normal platelet count indicates no sign of bleeding.
MCV 91 76 - 96 um^3 Normal MCV count indicates the size and volume of red blood cells are normal.
MCH 30 27 - 32 pg
MCHC 33.10 30 - 35 g/dL Normal MCHC count indicates hemoglobin is in normal volume.
RDW 13.20 11 - 16 % Normal RDW indicates red blood cells are in same size.
MPV 7.60 7-9 fL
PDW 8 8.3% to 56.6%

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Sodium 138.00 136-145 mEq/L
Potassium 3.90 3.6-5.0 mEq/L
Creatinine 0.5 0.65-0.7 g/dL

B. TREATMENT MODALITIES

PHYSICIAN’S ORDER RATIONALE

POST-OP ORDER
 To PACU
 02 inhalation at 2-3 LPM via NC
 Monitor V/S q15min x 1hour, qhourly until stable, then q4H
 MIO q4H
 NPO
 IVF: PLR 1L at 30 gtts/min
 IVF: PLR 1L at 30 gtts/min x 3 cycles
 Meds:
1. Paracetamol 600 mg IV q6H x 8 doses
2. Tramadol 50 mg IV q6H x 8 doses
3. Ketorolac 30 mg IV q8H x 6 doses
4. Celecoxib 20 mg 1 cap, 1 cap BID x days
5. Omeprazole 40 mg IV OD
6. Continue antibiotics

 Refer for pain

 To ward once stable
 Continue meds

13
 C. DRUG STUDY
Generic name: Celecoxib
Brand name: CeleBREX

14
Classification: NSAID
Indication: Relief of signs/symptoms of osteoarthritis, rheumatoid arthritis (RA) in adults. Treatment of acute pain, primary dysmenorrhea. Relief of signs/symptoms associated
with ankylosing spondylitis. Treatment of juvenile rheumatoid arthritis (JRA) in pts 2 yrs and older and weighing 10 kg or more.
Contraindication: Hypersensitivity to celecoxib, sulfonamides, aspirin, other NSAIDs. Active GI bleeding. Pts experiencing asthma, urticaria, or allergic reactions to aspirin,
other NSAIDs. Treatment of perioperative pain in coronary artery bypass graft (CABG) surgery.
Side effects: Frequent: Diarrhea, dyspepsia, headache, upper respiratory tract infection. Occasional: Abdominal pain, flatulence, nausea, back pain, peripheral edema,
dizziness, insomnia, rash.
Nursing Responsibilities:
• Assess onset, type, location, duration of pain/inflammation. Inspect appearance of affected joints for immobility, deformity, skin condition.
• Assess for allergy to sulfa, aspirin, or NSAIDs (contraindicated).
• Assess for therapeutic response: pain relief; decreased stiffness, swelling; increased joint mobility; reduced joint tenderness; improved grip strength.
• Observe for bleeding, bruising, weight gain.
PATIENT/FAMILY TEACHING
• If GI upset occurs, take with food.
• Avoid aspirin, alcohol (increases risk of GI bleeding).
• Immediately report chest pain, jaw pain, sweating, confusion, difficulty speaking, one-sided weakness (may indicate heart attack or stroke).

Generic name: Ketorolac

Brand name: Toradol
Classification: NSAID

15
Indication: Short-term (5 days or less) relief of mild to moderate pain.
Contraindication: Hypersensitivity to ketorolac, aspirin, or other NSAIDs. Intracranial bleeding, hemorrhagic diathesis, incomplete hemostasis, high risk of bleeding
Side effects: Frequent: Headache, nausea, abdominal cramps/pain, dyspepsia. Occasional: Diarrhea. Nasal: Nasal discomfort, rhinalgia, increased lacrimation, throat irritation,
rhinitis. Ophthalmic: Transient stinging, burning. Rare: Constipation, vomiting, flatulence, stomatitis. Ophthalmic: Ocular irritation, allergic reactions (manifested by pruritus,
stinging), superficial ocular infection, keratitis.
Nursing Responsibilities:
• Assess onset, type, location, duration of pain.
• Obtain baseline renal/hepatic function tests.
• Monitor renal function, LFT, urinary output.
• Monitor daily pattern of bowel activity, stool consistency.
• Observe for occult blood loss.
• Assess for therapeutic response: relief of pain, stiffness, swelling; increased joint mobility; reduced joint tenderness; improved grip strength.
• Monitor for bleeding (may also occur with ophthalmic route due to systemic absorption).
PATIENT/ FAMILY TEACHING
• Avoid aspirin, alcohol.
• Report abdominal pain, bloody stools, or vomiting blood.
• If GI upset occurs, take with food, milk.
• Ophthalmic: Transient stinging, burning may occur upon instillation.
• Do not administer while wearing soft contact lenses.

Generic name: Omeprazole

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Brand name: Losec
Classification: Proton pump inhibitor
Indication: Short-term treatment (4–8 wks) of erosive esophagitis (diagnosed by endoscopy) symptomatic gastroesophageal reflux disease (GERD) poorly responsive to other
treatment. H. pylori–associated duodenal ulcer (with amoxicillin and clarithromycin). Long-term treatment of pathologic hypersecretory conditions, treatment of active duodenal
ulcer or active benign gastric ulcer.
Contraindication: Hypersensitivity to omeprazole, other proton pump inhibitors. Concomitant use with products containing rilpivirine.
Side effects: Frequent: Headache. Occasional: Diarrhea, abdominal pain, nausea. Rare: Dizziness, asthenia, vomiting, constipation, upper respiratory tract infection, back pain,
rash, cough.
Nursing Responsibilities:

• Evaluate for therapeutic response (relief of GI symptoms). Question if GI discomfort, nausea, diarrhea occurs.

PATIENT/FAMILY TEACHING

• Report headache, onset of black, tarry stools, diarrhea, abdominal pain.

• Avoid alcohol.

• Swallow capsules whole; do not chew, crush, dissolve, or divide.

• Take before eating.

Generic name: Tramadol

Brand name: ConZip

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Classification: Analgesic

Indication: Management of moderate to moderately severe pain.

Contraindication: Hypersensitivity to tramadol, opioids. Pediatric pts under 12 yrs of age; post-op management in pts under 18 yrs following tonsillectomy and/or
adenoidectomy; severe respiratory depression; acute bronchial asthma in absence of appropriate monitoring; GI obstruction (paralytic ileus [known or suspected]).

Side effects: Frequent: Dizziness, vertigo, nausea, constipation, headache, drowsiness. Occasional: Vomiting, pruritus, CNS stimulation (e.g., nervousness, anxiety, agitation,
tremor, euphoria, mood swings, hallucinations), asthenia, diaphoresis, dyspepsia, dry mouth, diarrhea. Rare: Malaise, vasodilation, anorexia, flatulence, rash, blurred vision,
urinary retention/frequency, menopausal symptoms.

Nursing Responsibilities:

• Assess onset, type, location, duration of pain.

• Assess drug history, esp. carBAMazepine, analgesics, CNS depressants, MAOIs.

• Review past medical history, esp. epilepsy, seizures.

• Assess renal function, LFT.

• Monitor pulse, B/P, renal/hepatic function.

• Assist with ambulation if dizziness, vertigo occurs.

• Dry crackers, cola may relieve nausea.

• Palpate bladder for urinary retention.

• Monitor daily pattern of bowel activity, stool consistency.

18
• Sips of water may relieve dry mouth.

• Assess for clinical improvement, record onset of relief of pain. Monitor closely for misuse or abuse.

PATIENT/FAMILY TEACHING

• May cause physical dependence.

• Pts with history of drug abuse are at increased risk for misuse or abuse. Take medication only as prescribed.

• Avoid alcohol, other narcotics, sedatives. May cause drowsiness, dizziness, blurred vision.

• Avoid tasks requiring alertness, motor skills until response to drug is established.

• Report severe constipation, difficulty breathing, excessive sedation, seizures, muscle weakness, tremors, chest pain, palpitations.

Generic name: Paracetamol

Brand name: Abenol

Classification: Non-opioid Analgesic

Indication: Fever reduction. Temporary relief of mild to moderate pain.

Contraindication: Hypersensitivity to acetaminophen or phenacetin; use with alcohol.

Side effects: Anorexia, nausea, vomiting, dizziness, lethargy, diaphoresis, chills, epigastric or abdominal pain, diarrhea

Nursing Responsibilities:

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  Monitor for signs and symptoms hepatotoxicity.

PATIENT/FAMILY EDUCATION

 Do not take other medications (e.g., cold preparations) containing acetaminophen without medical advice.
 Do not self-medicate adults for pain more than 10 days (5 d in children) without consulting a physician.
 Do not use this medication without medical direction for: fever persisting longer than 3 days, fever over 39.5° C (103° F), or recurrent fever

D. CONCEPT MAP

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X. NURSING MANAGEMENT

A. FAMILY HISTORY

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 1. Nursing History:
a. Chief Complaints: 2 days prior to admission onset of RLQ pain, (-) BM changes, (-) Fever, 1× vomiting
b. Diagnosis: Acute Uncomplicated Appendicitis
c. History of Present Illness: 2 Days prior admission onset of RLQ pain. No bowel changes associated with 1x vomiting
d. Past Health History:
 Childhood Illness: As per said by client, he does not experienced colds, cough, and fever when he was still a child.
 Immunization: The client said she was immunized 2 doses of Moderna
 Medical: The client stated that he was never hospitalized, and this is his first time to be admitted in the hospital
 Allergies: (-)
 Habits and Lifestyle: He has a job and do exercise often and drink Tanduay once in a week. Client plays basketball after he finish his meals.

2. Psychosocial History
 The client loves to play basketball and use his cellphone when he is bored.

3. Environmental History
 The client lives at Gomentoc, Ayungon, Negros Oriental together with his family and 4 siblings.

4. Spiritual History
 He goes to church often

GENOGRAM

22
 J

56
T
B
53
59

S K N L M

35 30 26 20 18

LEGEND: FEMALE DECEASED

MALE DECEASED

B. PHYSICAL ASSESSMENT

GENERAL SUREY: Received patient on bed lying awake and oriented with ongoing D5 0.3 NaCl 500ml infusing well on the left metacarpal vein at 8 gtts/min. Oxygen
therapy with the use nasal cannula at 2 LPM.

23
 Vital signs:
T = 35.3 °C
P = 95 bpm
RR = 21 cpm
BP = 140/90 mmHg
O2 Sat = 95%

NORMAL FINDINGS STUDENT’S FINDINGS

SKIN AND NAILS  Color of the skin is light brown.
No wounds and scars seen. There
are moles seen in the lower portion
of the neck
 Nails are intact and well groom.
Shape is well rounded and convex.
Nails without clubbing and
without cyanosis.
 Pt’s skin is uniformly warm, with no abrasions, color is light
brown. No rashes and lesions noted. insertion seen in the left
metacarpal vein.
 Pt’s fingernails are clean, short and transparent. Well-rounded
and no clubbing upon inspection. Nail bed is intact and smooth.
CRT: less than 2 seconds

HEAD, HAIR AND EYES  Head is round and symmetrical.
No presence of nodules upon
palpation.
 Normal hair distribution, no actual
hair loss or any signs of alopecia.
No nodules upon palpation and no
areas of excess hair growth on the
body.
 No swelling, lesions on the eyelid.
The sclera appears white. The
cornea is transparent, and the
details of the iris are visible.
PERRLA must be present.
ABDOMEN  Abdomen is free from lesions or
rashes. Umbilical skin tones are
 Head is round and symmetrical and presence of mass and
nodules.
 Pt’s hair is in black in color and evenly distributed, shiny, and
straight. Scalp has no lesions, bumps, and dandruff.
 The pupils of the eyes are black and equal in size. PERRLA is
present. Pupils are constrict when looking at near objects and
dilate at far objects.
 Pt’s abdomen is flat, round and symmetrical. Umbilicus is at the
midline and has the same skin tone with the skin. Bowel sounds

24
 similar to surrounding abdominal are normal. Tenderness felt at the RLQ where incision cite is
skin tones or even pinkish. located.
Umbilicus is midline at lateral
line. Abdomen is flat, rounded, or
scaphoid and symmetrical Bowel
sounds should be hypoactive.
Abdomen is nontender and soft.

C. NURSING THEORY

Nursing theory that can be use in this case study is the Self Care Theory by Dorothea Orem. In Self Care theory, Orem considers that self-care is an activity to
establish the independence of individuals who will improve their health. So, when a deficit, he needs help from the nurse to obtain independence again. This theory is a
dynamic approach, where nurses work to improve the client's ability to take care for themselves rather than put the client in a dependent position because Self Care is a
learned behavior. In the case of post-op appendicitis, the self-care theory can be applied because the patient was having post-op appendicitis which requires treatment, it
requires an independence so that when the patient is hospitalized and return home the patient is able and understand to control the pain that arises after the surgery and able
to run wound care independently. This is in accordance with what is described in Dorothea Orem's theory of patients being treated for the purpose of being self- sufficient
and able to take care of themselves in order to improve the health and patients’ welfare.

E. GORDON’S FUNTIONAL HEALTH PATTERNS

FUNCTIONAL HEALTH USUAL INITIAL (10/25/23) ONGOING
PATTERN (10/26/23)

25
Health Pattern/Health
Management Pattern
Nutritional-Metabolic Pattern
 Client stated that he has a
job.
 Client stated that he does
not experienced any cold
and coughs before the
admission.
 Client stated that he do not
use any alternative
medications.
 Client stated that he do not
do annual check-ups.
 Client claims that his diet
is composed mostly of
rice, vegetables dried fish,
fish, and sometimes meat.
 Client claims that he
drinks 6-7 glasses of water
regularly.
 Client do not have any
supplements and vitamins.
 Client has no problem
with her appetite.
 Client has no discomfort
Vital signs: Vital signs:
T = 36.2 °C T = 36.5 °C
P = 92 bpm P = 93 bpm
RR = 18 cpm RR = 18 cpm
BP = 110/80 mmHg BP = 120/80 mmHg
O2 Sat = 92% O2 Sat = 95%
FINAL DIAGNOSIS: RUPTURED APPENDICTIS MEDICATIONS:
1. Paracetamol 600 mg IV q6h ×
MEDICATIONS: 8 doses
1. Paracetamol 600 mg IV q6h × 8 doses 2. Tramadol 50 mg IV q6h × 8
2. Tramadol 50 mg IV q6h × 8 doses doses
3. Ketoroloc 30 mg IV q8h × 6 doses 3. Ketoroloc 30 mg IV q8h × 6
4. Celecoxib 20 mg 1 cap, 1 cap BID × 3 doses
days
4. Celecoxib 20 mg 1 cap, 1 cap
5. Omeprazole 40 mg IV OD
BID × 3 days
LAB EXAMS: 5. Omeprazole 40 mg IV OD
 CBC with blood typing
 Na, K+, Protine
 Admitted October 22, 2023  PLR 950 ml infusing well at left
 PLR 950 ml infusing well at left metacarpal vein metacarpal vein @ 30 gtts/min
@ 30 gtts/min  The client stated his diet consisted
 The client is in NPO mostly:
 The client consumed 150 ml of clear fluid. Breakfast:
 The patient has no problem with her appetite ➢ Fish
and claims to have been drinking water
regularly. ➢ 1 cup of rice
 Height: 165 cm ➢ 250 ml of water
 Weight: 53.8 kg Lunch:
 Upper and lower skin is warm ➢ 1 cup of rice
 Incision cite at RLQ
26
 and difficulties in ➢ Vegetables
swallowing. ➢ 250 ml of water
 The patient has no problem with her
appetite and claims to have been
drinking water regularly.
 Upper and lower skin is warm
 Incision cite at RLQ

ELIMINATION PATTERN  SO states that the client  Bowel  Bowel

urinates up to 4 times a
day with no discomfort
and is in clear yellow.
 SO states that the client
defecates 2 times a day
with no discomfort
Activity-Exercise Pattern  Client has a job.
 Play basketball after
finishing his meals.
 No problem with walking
and balance
 Takes a bath every day
and uses toilet without
assistance
Sleep-Rest Pattern  Client usually sleeps at 9
pm and wakes up at 8 am.
 No use sleeping and aids
 Frequency - 0
 Character – none
 Discomfort – none
 Problem with control – none
 Urinary
 Frequency – 2-3 times (7-12 pm)
 Character –
 Discomfort – none
 Problem with control - none
 Do standing often.
 Need an assistance when going to toilet.
 No problem with walking and balance
 Client sleep is fragmented.
 Takes a nap in afternoon
 No use sleeping and aids and did not experience
 Frequency – 1 (7-12 pm)
 Character – brown
 Discomfort – none
 Problem with control – none
 Urinary
 Frequency – -34 times (7-12
pm)
 Character – yellowish
 Discomfort – none
 Problem with control - none
 Do standing often.
 Need an assistance when going to
toilet.
 No problem with walking and balance
 Client sleep is fragmented.
 Takes a nap in afternoon
 No use sleeping and aids and did not

27

Cognitive-Perceptual Pattern
Self-Perception/Self Concept
Role-Relationship Pattern
Sexuality-Reproductive
Pattern
Coping-Stress Tolerance
Pattern
Value-Belief Pattern
F. SUMMARY OF NURSING DIAGNOSIS
and did not experience any
dreams and nightmares
 Client has no difficulty in
hearing and seeing
 Client does not wear any
hearing aid and glasses
 Client has no problem
with his self
 Client stated that he
usually use his
smartphone when is bored.
 Client is single and living
with his family together
with his 4 siblings.
 Client is shy to talk about
his sex life
 Client coping
mechanisms is by using
his smartphones and
playing basketball
 Client is a Roman
Catholic
 He goes to church often.
any dreams and nightmares
 Client has no difficulty in hearing and seeing
 Client does not wear any hearing aid and glasses
 Pain scale: 7
 He has no problem with his self after the surgery
 Client is visited with his mother and father
 Client is shy to talk about his sex life
 Client always use his smartphones
 His values and belief have become stronger
experience any dreams and nightmares
 Client has no difficulty in hearing and
seeing
 Client does not wear any hearing aid
and glasses
 Pain scale: 6
 He has no problem with his self after
the surgery
 Client is visited with his mother and
father
 Client is shy to talk about his sex life
 Client always use his smartphones
 His values and belief have become
stronger
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 NURSING DIAGNOSIS RATIONALE
Ineffective breathing pattern related to presence of bronchial Ineffective breathing pattern is when breathing is not productive. Client stated that she is having
secretions and inadequate oxygen distribution cough with phlegm.
Activity Intolerance related to inability to cope oxygen demand Activity Intolerance is the inability to perform activities of daily living. Client stated that some
her activities of daily living has stop because she is getting weaker.
Disturbed sleeping related inability to maintain sleep due to Disturbed sleeping pattern is the inability to maintain sleep. Client stated that her usual time of
dissatisfaction of with sleep sleep is not the same anymore

G. NURSING CARE PLAN

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Patient Name: A.A Dated Cared: September 14, 2023

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALAUTION

Subjective Data: Ineffective breathing At the end of my 8 Independent: At the end of my 8 hours of nursing interventions the
pattern related to hours of nursing patient was able to improve breathing pattern as
“Gi ubo siya nga naay presence of bronchial interventions the Elevate head of the bed evidenced by:
dalang plema dayon secretions and patient will be able to and encourage client to
galuya siya maong inadequate oxygen improve breathing change position every 2
among gipa admit” as distribution pattern as evidenced hours
verbalized by the by: Partially met:
patient’s SO Monitor respirations and
Vital signs within breath sounds Vital signs within normal range:
Objective Data: normal range:
V/S Encourage increase fluid RR = 11- 20 cpm
RR = 21 cpm RR = 11- 20 cpm intake within the client’s
O2 Sat = 95% tolerability O2 Saturation: 96-100%
O2 Saturation: 96-
O2 inhalation via nasal 100% Dependent: Demonstrate the absence of abnormal breath sounds
cannula at 2 LPM
Demonstrate the Administer Sultamicilin Demonstrate the absence of O2 inhalation
Progressive crackles absence of abnormal (Silgram) 750 mg 8h
heard breath sounds Capillary refill back to normal (2 seconds)
Administer Salbutamol
Poor capillary refill (5 Demonstrate the (Ventolin) neb, 1 neb TID
seconds) absence of O2 waking hours
inhalation
Administer N-
Capillary refill back to Acetylcysteine (Azemax)
normal (2 seconds) 500 mg/tab, 1 tab OD PC
x 5 days

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Subjective Data: Activity Intolerance At the end of my 8 Independent: At the end of my 8 hours of nursing interventions the
related to inability to hours of nursing patient was able to cope oxygen demand as evidenced by:
“Nagluya siya tungod cope oxygen demand interventions the Monitor vital signs
sa iayng ubo og lugos patient will be able to Partially met:
sa pagginhawa” as cope oxygen demand Elevate client’s head while
verbalized by the as evidenced by: resting Vital signs within normal range:
client’s SO
Vital signs within Encourage client to BP: 120/80 mmHg
normal range: perform activities
gradually RR: 12-20 cpm
Objective data: BP: 120/80 mmHg
O2 Sat: 96-100%
V/S: RR: 12-20 cpm
Dependent: Demonstrate absence of O2 inhalation
BP = 140/90 mmHg O2 Sat: 96-100%
RR = 21 cpm Administer Salbutamol
O2 Sat = 95% Demonstrate absence (Ventolin) neb, 1 neb TID
of O2 inhalation waking hours
O2 inhalation via nasal
cannula at 2 LPM

Subjective data: Disturbed sleeping At the end of my 8 Independent: At the end of my 8 hours of nursing interventions the
related inability to hours of nursing patient was able to maintain sleep pattern as evidenced
“Makamata siya kay maintain sleep due to interventions the Assess client’s usual sleep by:
iya ipa adjust and katre dissatisfaction of with patient will be able to patterns
og iyang unlan” as sleep maintain sleep pattern

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 as evidenced by:
verbalized by the Note environmental Partially met:
client’s SO Demonstrate sense of factors that affect sleeping
feeling rested pattern Demonstrate sense of feeling rested

Maintain usual sleep Determine client’s sleep Maintain usual sleep pattern: 7pm-8am
Objective data: pattern: 7pm-8am expectations

Usual sleeping pattern: Provide bedtime care

7pm-8am

Initial sleeping pattern:

12am-7am

Client is weak

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XI. ANNOTATED READINGS

Community-acquired pneumonia causes great mortality and morbidity and high costs worldwide. Suspected community-acquired pneumonia is defined by
acute symptoms and presence of signs of lower respiratory tract infection (LRTI) without other obvious cause, whereas new pulmonary infiltrate on chest
radiograph is needed for definite diagnosis. The most common signs and symptoms are dyspnea, cough, fever, and new focal chest signs. In subgroups of
patients (eg, elderly people), clinical presentation can have less evident symptoms (eg, an altered state of consciousness, gastrointestinal discomfort, and fever
can be absent) and diagnosis is frequently delayed. A prolonged time between the onset of symptoms and a medical visit has been described for less severe
pneumonia, individuals with alcoholism, and for patients receiving drugs such as corticosteroids, non-steroidal anti-inflammatory drugs, and antibiotics. For
some pathogens, unusual clinical presentations that involve the gradual onset of symptoms such as dry cough, the absence of fever, and extra pulmonary
manifestations are frequent.

Empirical selection of antibiotic treatment is the cornerstone of management of patients with pneumonia. To reduce the misuse of antibiotics, antibiotic
resistance, and side-effects, an empirical, effective, and individualized antibiotic treatment is needed. Follow-up after the start of antibiotic treatment is also
important, and management should include early shifts to oral antibiotics, stewardship according to the microbiological results, and short-duration antibiotic
treatment that accounts for the clinical stability criteria. New approaches for fast clinical (lung ultrasound) and microbiological (molecular biology) diagnoses
are promising. Community-acquired pneumonia is associated with early and late mortality and increased rates of cardiovascular events. Studies are needed that
focus on the long-term management of pneumonia.

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 XII. CONCLUSION

Community acquired pneumonia is a serious condition and if not treated can lead to death. Proper health education to others such as in the community will be a
great help in preventing this condition. Information regarding this disorder is vital to formulate actions that could lessen the risk of acquiring this condition and
to provide appropriate lifestyle modification for the prevention of developing pneumonia, which could cause serious complications if left untreated. Moreover,
prevention is vital as the medical management for this condition is expensive as this requires medical intervention if it cause obstruction and disturbances to the
daily life of the patient.

All in all, as a student I will do my best to spread awareness regarding community acquired pneumonia through health education in our community or sharing of
information regarding this condition in social media platform. I was able to deliver safe, effective care as a student nurse who was unfamiliar with this kind of
condition by according to the nursing process's steps. Additionally, I was able to investigate my patient's illness and offer nursing measures that were suitable for
it. Last but not least, I was able to provide my patient a health lesson that was pertinent to their recovery and illness prevention. My clinical experience will
undoubtedly be useful to me as I continue my nursing career.

XIII. REFERENCES

Kizior, R.J., & Hodgson, K.J. (2021). Saunders Nursing Drug Handbook 2021. Elsevier.
Monograph. (n.d.). http://www.robholland.com/Nursing/Drug_Guide/data/monographs/monoframe.html?vfile=A006.html. Retrieved on November 13, 2023.

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