St.

Paul University Dumaguete

Dumaguete City, Negros Oriental
COLLEGE OF NURSING
(PAASCU Level III)
Academic Year 2023 - 2024

A Case Study on

Acute Appendicits with localize peritonitis

Submitted by:

Franz Anthony Q. Go

Allied Care Experts (ACE) Dumaguete Doctors, Inc. – Ward

May 2024
 St. Paul University Dumaguete
Dumaguete City, Negros Oriental
COLLEGE OF NURSING
(PAASCU Level III)
Academic Year 2023 - 2024

ACKNOWLEDGEMENTS

First and foremost, the student nurse would like to give praises
and thanks to the Almighty Father for His guidance and for His showers
of blessings throughout the clinical duty in the Allied Care Experts
(ACE) Dumaguete Doctors, Inc. – Ward and the process of completing the
clinical paper successfully.

The student nurse would also like to extend their gratitude to

the nurses, staff, and Allied Care Experts (ACE) Dumaguete Doctors,
Inc. – Ward for enabling the student nurse to participate in a
valuable clinical rotation that was very beneficial to them, and for
their patience, acceptance, and trust to all student nurses for them
to continue and finish their clinical case paper.

The student nurse would like to express his deep and sincere
gratitude to their clinical instructor, Miss Maria Rowena Masicampo,
RN, MAN for her knowledge, skills and the time invested in instructing
and imparting her knowledge for the improvement of the case and the
clinical paper. Her help, understanding, and support inspired them to
do their best. She also gave them the chance to apply what they
learned and their patient-handling abilities throughout the clinical
rotation.

To the patient and his significant others who took part and
provided them with information that will allow them to talk more in-
depth about his disease

To the families of the student nurse, for their unwavering love,

support, prayers, and sacrifices in helping them attend school and get
ready for the future. They are very appreciative of their teammates'
companionship, support, assistance, solace, and affection for one
another throughout the clinical rotation. Without their assistance and
encouragement, their endeavor would not have been possible.
 St. Paul University Dumaguete
Dumaguete City, Negros Oriental
COLLEGE OF NURSING
(PAASCU Level III)
Academic Year 2023 - 2024

CHAPTER II CASE DATA AND INFORMATION

Patient’s Biographical Data

Patient’s Name: D.R.

Age: 24 years old

Date of Birth: November 9, 1999

Address: Maloh, Siation,

Sex: Male

Blood Type: B+

Occupation: Student

Source of Income: none

Citizenship: Filipino

Ethnicity: Asian

Religion: Christian-Roman Catholic

Marital Status: Single

Educational Attainment: College Level (Bachelor of Science in

business administration)

Medical (Admitting) Diagnosis: Appendicitis

Operation Performed: Open Appendectomy, Exploratory laparotomy

Date and Time of Operation: April 29 2024 4:45 pm

Post-op Diagnosis: Acute appendicitis with localize peritonitis

Date of Admission: April 28 2024, 6:20 pm

Physicians: Dr. S.T.,Dr. MCV, Dr.

Source of Referral: Lamberto Macias memorial hospital

Source of Information:

Client = 80%
 St. Paul University Dumaguete
Dumaguete City, Negros Oriental
COLLEGE OF NURSING
(PAASCU Level III)
Academic Year 2023 - 2024

Patient’s Chart = 20%

Total = 100%

Health History

Chief Complaint

“Nag sakit ako tiyan sa tunga padung sa ako kilid”

“He was experiencing pain on the middle of the abdomen radiating to

the side”

History of Present Illness

Patient was having bicol express for his lunch then after 2 pm patient
experience Epigastric pain then after 30 mins it radiates to
hypogastric area and increases the intensity of the pain. As he stated
that he can barely breathe due to the pain.

Past Health History

Childhood/Serious Illnesses

Patient has history of experiencing common colds, cough and

fever.

Hospitalizations

Patient was admitted to negros oriental provincial hospital when

he was still at kinder(2006) due to dengue fever.

Surgeries/Serious Injuries

No history of previous surgeries or any serious injuries.

Serious/Chronic Illnesses

No history of serious/chronic illnesses

Immunizations

The patient received full immunization and vaccinations as a

child. And has also received AstraZeneca COVID-19 vaccine.

Allergies
 St. Paul University Dumaguete
Dumaguete City, Negros Oriental
COLLEGE OF NURSING
(PAASCU Level III)
Academic Year 2023 - 2024

It was discover back in 2023 when they had muscles as for their
dinner. After he taken a bite, he suddenly feel “g kabuhi”
(heartburn” then decided to stop eating.

Medications

Doesn’t have any maintenance medication.

Family History

Functional Health Pattern

Functional
Prior to During
Health Justification
Admission Hospitalization
Patterns
Health According to the Day 1-4 on April
Perception/ patient, he 29,30, May 2 and
Health suffered 3 2024
Management childhood The patient is
diseases, he had lying on bed
common cold, resting. Patient
cough and fever. realize that he
He also said that needs to stop
he was physically drinking alcohol
active and and pay more
excessive drinks attention about
alcohol and do his health.
not smoke. He
drinks alcohol
about two- three
times a week. The
patient received
a full
vaccination when
he was still a
child, as well as
the COVID-19
vaccine. The
patient doesn’t
seek any medical
advice from
medical
 St. Paul University Dumaguete
Dumaguete City, Negros Oriental
COLLEGE OF NURSING
(PAASCU Level III)
Academic Year 2023 - 2024

prfessionals when
feeling sick and
only asks for
advice from his
mother. According
to the patient
that he takes
medicol whenever
he experiencing
severe headache.
Back when he was
in kinder (2006)
he was admitted
to the Negros
oriental
provincial
hospital due to
dengue fever.
Nutrition During the
According to the
and admission,
patient, he
Metabolism patient is
doesn’t usually
currently NPO
eat for breakfast
from March 27-
he only have
coffee for the
morning. Then for
lunch he eats at
school and buy
bicol express
with 1-2 cups of
rice. lastly for
dinner, his usual
meal is either
meat,fish or
vegetables with
1-2 cups of rice.
Patient also
stated that he
drinks about 10-
 St. Paul University Dumaguete
Dumaguete City, Negros Oriental
COLLEGE OF NURSING
(PAASCU Level III)
Academic Year 2023 - 2024

14 glassess a day

Elimination Before admission, Day 1- naka

the patient libang
stated that he
usually defecated
a well-formed
brownish stool
once or twice a
day without any
difficulty and
usually urinated
clear to light
yellow 3-5 times
daily,
approximately 200
ml to 250 ml per
urination without
any pain
Activity According to the Bed rest
and patient he
Exercise doesn’t have any
impairments and
usually do
exercise like
jogging 2 times a
week and he plays
either basketball
or mobile games
during his free
time.
Sleep and
According to the
Rest
patient he
doesn’t have any
sleeping problems
and usually
sleeps about 7-8
hours he sleeps
 St. Paul University Dumaguete
Dumaguete City, Negros Oriental
COLLEGE OF NURSING
(PAASCU Level III)
Academic Year 2023 - 2024

at 10pm then
wakes up at 6-
7am.

Cognitive- According to the Day 1 February The patient's

Perceptual significant 21, 2024, unable cognitive-
others, the to assess perceptual
patient is cognitive function
wearing glasses perceptual of the significantly
with 20/250 patient. deteriorated
vision, patient Day 2 February during
doesn’t have any 22, patient hospitalization,
hearing problem makes despite having
nor cognitive incomprehensive 20/250 vision
problem speech, groans, before admission.
and sometimes The patient
moves his feet struggled to
attempting to speak clearly and
answer the assessed his
questions. cognitive state
on the first day,
Day 3-5 February indicating
23,24 and 25 potential
No significant neurological or
changes were cognitive issues.
noted.
Self- According to the Day 1 February The patient's
perception significant 21, 2024, Unable self-perception
and Self- others, the to assess and self-concept
concept patient was fit patient’s self- significantly
before when he perception and changed before
was at high self-concept. and during
school then hospitalization.
became overweight Day 2 February 22 The patient was
after getting No significant described as fit
into college. The changes were in high school
patient was very noted. but overweight in
friendly, other college. Despite
 St. Paul University Dumaguete
Dumaguete City, Negros Oriental
COLLEGE OF NURSING
(PAASCU Level III)
Academic Year 2023 - 2024

than that can’t Day 3 February this, the patient

further assess 23, 2024, was friendly,
the patient’s according to the indicating a
self-perception significant positive self-
and self-concept. others the image and social
patient was confidence.
embarrassed During
attempting to hospitalization,
pull up his the patient's
diaper after his self-perception
friends arrived and self-concept
to visit him. were assessed,
the patient was
Day 4-5 February embarrassed on
24 and 25 Day 3 indicating
No significant an impact on
changes were self-image and
noted. self-esteem.

Roles and According to a Day 1 February The patient was

Relationshi significant 21, 2024, obedient and
p other, the According to the loving towards
patient was very significant his parents, with
obedient as a other, Patient many friends in
son; the patient was visited by their hometown
usually did her friends and and Dumaguete
chores at their helped the City. During
house without patient in hospitalization,
being told, and financial needs their support
he was a very for hospital network expanded
loving son to bills; the one to include
both of his who is watching friends and ex-
parents. The over him is his romantic
patient also has former partners. By Day
lots of friends girlfriend, his 3, the patient
in their cousin and her continued
hometown as well mother. receiving visits
as in Dumaguete from friends,
City and because Day 2 February 22 highlighting the
 St. Paul University Dumaguete
Dumaguete City, Negros Oriental
COLLEGE OF NURSING
(PAASCU Level III)
Academic Year 2023 - 2024

of being No significant importance of

friendly he changes were these
gained noted. relationships in
supporters and their recovery
became SK and overall well-
chairman from Day 3 February being.
their hometown. 23, 2024, patient
The significant was visited by
others stated his friends to
that he don’t check the current
have a father status of the
due to an patient.
affair.
Day 4-5 February
24 and 25
No significant
changes were
noted.

Sexuality New NEW The patient's

and According to the On Day 1, history of past
Reproductio significant February 21, relationships and
n other, the 2024, the patient the presence of
patient had a 4- was seen lying in his former
year relationship bed in a semi- girlfriend during
that ended in Fowler's hospitalization
2020. position, asleep, offer important
and snoring contextual
loudly, with his information for
former girlfriend understanding the
beside him, who patient's
was acting as a sexuality and
watcher at the reproductive
time. concerns. These
aspects may
Day 2-5 February influence the
22,23,24 and 25 patient's
No significant emotional well-
changes were being, social
noted. support network,
 St. Paul University Dumaguete
Dumaguete City, Negros Oriental
COLLEGE OF NURSING
(PAASCU Level III)
Academic Year 2023 - 2024

and coping
mechanisms as
they navigate his
recovery from the
CVD bleed in the
left basal
ganglia.
Coping and New New The patient's
Stress Previously, On Day 1, coping and stress
Tolerance according to the February 21, tolerance appear
significant 2024, we were to be influenced
other, whenever unable to assess by significant
the patient felt the patient's life events, such
stressed or was coping and stress as the breakup in
having trouble tolerance since 2020, which led
with something, he was unable to to a maladaptive
he would go to communicate coping mechanism
his older brother properly as he involving alcohol
or his mother to was still consumption.
ask for advice. unconscious. However, the
However, there assessment of
was a significant Day 2-5 February coping and stress
change in the 22,23,24 and 25 tolerance during
year 2020 when he No significant hospitalization
broke up with his changes were was limited by
ex-girlfriend. noted. the patient's
His coping unconscious
mechanism became state.
drinking
alcoholic
beverages (e.g.,
Red Horse and
Tanduay Select)
to help him sleep
and forget his
problems.
According to his
mother, from 2020
up to the
 St. Paul University Dumaguete
Dumaguete City, Negros Oriental
COLLEGE OF NURSING
(PAASCU Level III)
Academic Year 2023 - 2024

present, the
patient's coping
mechanism hasn’t
changed.

Values and NEW NEW NEW

Beliefs As stated by the On February 21, The patient's
significant 2024 (Day 1), the values and
other, the patient’s beliefs,
patient’s significant other characterized by
religion was asked for their Roman
Roman Catholic. guidance from a Catholic faith
He goes to church higher power and and reliance on
every Sunday. was hoping for a spirituality for
Their religion is fast recovery. strength and
important as it guidance, are
helps them to Day 2-5 February integral
guide their 22,23,24 and 25 components of
decisions and No significant their coping
actions in their changes were mechanism and
everyday lives noted. approach to
and when illness both
challenging times before and during
arise. The hospitalization.
significant other These values and
also claimed that beliefs may
he did not continue to
practice any influence their
superstitious journey towards
beliefs. recovery and
well-being.