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Patient’s Data
I. General Data Patient’s. Name: Mrs Kliyente Sex: female Age: 53 y/o Date of Birth: May 20, 1955 Civil status: Married Citizenship: Filipino Current Address: Magsaysay Area, Brgy. Sto. Cristo Tala Caloocan City Religion: Catholic Occupation: Employer (Carinderia owner) Room and Bed number: Hospital number: 52-56-34 Chief Complaint: Abdominal pain Admitting Diagnosis: t/c Periappendical Abscess Admission Date and Time: January 27, 2009- 5: 00 pm Final Diagnosis: Periappendical abscess s/p Exploratory Laparotomy II Chief Complaint: Abdominal pain III History of Present illness: 4 weeks prior to admission patient experienced abdominal pain at RLQ of the abdomen with a pain scale of “10” accompanied by recurrent fever at night and resolved by paracetamol affording temporary relief of fever. Patient also experienced nausea, anorexia. Constipation was managed by taking suppository 3x a week. Pt. also took two tablets of Buscupan in the morning and afternoon for abdominal pain once but didn’t take effect. Persistence of the condition pt. consulted St. Peter hospital but no diagnosis and medication given.

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3 weeks prior to admission patient experienced consistent Right Lower Quadrant abdominal pain, recurrent fever, nausea constipation, and anorexia. With continuous pain pt seek consultation at FEU Fairview but no clear diagnosis has been given but given Cefuroxime and Metronidazole for UTI. Still with persistent abdominal pain pt still used suppository for temporary relief. 2 weeks prior to admission persistence of above condition, as advised by personnel’s from FEU Fairview, patient undergone CT scan and Health scan. Still patient used suppository for temporary relief of constipation and abdominal pain. A week prior to admission with unfailing occurrence of above condition, patient prompted to seek consultation of EAMC OPD with the CT scan result. No diagnosis and medication has been given. Patient still used suppository and stopped using UTI medications. Few hours prior to admission patient came back at EAMC still with the CT scan result and above condition; patient is diagnosed with a leaked abcess from the appendix T/C “periappendecal abscess” based on the CT scan result. Patient was given Cefuroxime for abdominal pain w/c took effect and subsequently admitted. CBC laboratory procedure done and no other exams was done. IV Past Medical History Patient has no previous hospitalization, no history of HPN, DM, BA, no known allergies. V Family Medical History (+) DM – brother (+) Appendicitis – daughter VI Personal and Social Data Non smoker nor alcoholic drinker No specific sleeping pattern. The Client prefers vegetables and Fluid Intake one glass per meal approximately 3-4 times a day. Own a Carinderia

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VII Review of System General/Constitutional • • • • • • • Skin • • • • • (-)Weight loss or gain (-)Fatigue (-)Headache (+)Weakness (+)Restlessness (-)Trouble sleeping (+) Activity Intolerance (-)Rash, (-)Itching, (-)Pigmentation (+)Dryness (-)Nail changes

Eyes/Ears/Nose/Mouth/Throat • (+) Headaches • (-) Vertigo • (-) Lightheadedness • (-) Injury • (-) Double vision • (-) Tearing • (-) Pain • (-) Nose bleeding • (-) Colds • (-) Obstruction • (-) Discharge • (+)Dental difficulties • (-) Gingival bleeding • (-) Dentures • (+) Difficulty chewing • (-) Neck stiffness • (-) Tenderness Cardiovascular • (-)Chest pain • (-) Substernal distress • (-) Palpitations • (-) Syncope Respiratory • (-) Pain 3

• • • • •

(-) Cough (-) Hemoptysis (-) Dyspnea on exertion, (-) Orthopnea (+) Tachynea

Gastrointestinal • (+)Anorexia • (-) Dysphagia, • (-) Food idiosyncrasy • (-) Abdominal pain • (-) Heartburn • (-) Eructation • (-) Nausea • (-) Vomiting • (-) Hematemesis, • (+) Constipation • (-) Flatulence • (-) Hemorrhoids Genitourinary • (-) Urgency • (-) Frequency • (-) Dysuria • (-) Nocturia • (-) Polyuria • (-) Oliguria Musculoskeletal • (-) Pain • (-) Swelling • (-) Redness or heat of muscles and joints • (+) Muscular weakness • (-) Cramps Neurologic: • • • • (-) Dizziness (-) Lightheadedness (-) Numbness (-) Tremor

Psychiatric: • (+) Nervousness • (+) Stress • (+) Restlessness

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VIII Physical Examination Date of Assessment: January 29, 2009 Vital Signs: Blood Pressure: 110/80 mmHg Pulse Rate: 110 bpm Respiratory Rate: 24 bpm Temperature: 37.7 degrees Celsius (Febrile) Stool: once a week General Appearance: Medium frame built, stooped posture, smooth rhythmic gait, appropriate dressed, no body and breath odor and obvious physical deformity. Mental Status/ Neurologic: Conscious, oriented, anxious, uses simple words for communication. Integument: Flushed, warm and dry skin, no edema in extremities, no lesions, decreased skin turgor, concave nail plate shape, smooth pink nail bed color and capillary refill within 3 seconds. Head and Face: Skull is proportionate to body size, white scalp; partly black to gray shinny evenly distributed hair. Face is symmetrically and easy facial movement.

Eyes: Thin eyebrows, effective closure of eyelids and lashes, bilateral blink response, eyeballs are symmetrical, pinkish bulbar conjunctiva, white sclera, equal pupils and moist lacrimal apparatus. Ears: Auricle color is normal racial, symmetrical and elastic, pinna recoils when folded, some cerumen in external canal, no aural discharge & responds to normal voice.

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Nose: Normal external racial tone, midline septum, pink mucosa, moist nasal cavity, with non tender sinuses. Mouth: Pallor in the lips & mucosa, midline tongue, smooth and movable, teeth incomplete. Pharynx: Pallor in mucosa, none inflamed tonsil, gag reflex present. Neck: ROM neck muscle; palpable non tender lymph nodes, midline trachea, palpable thyroid gland. Breast and Axilla: Sagging, smooth & palpable non tender lymph nodes. Chest and Lungs: Symmetrical fremitus, shallow breathing, resonant percussion, heart rate at 110 cpm, pulmonic, aortic, tricuspid and apical heart sounds present. Abdomen: Normal racial tone of the skin, flat contour and symmetry, symmetrical movement, hypoactive bowel sounds, negative in rovsing’s sign and Mc Burney’s sign.(direct maneuver)

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X Course in the Ward January 29, 2009 Received patient lying in bed, very anxious looking, waiting for the impending surgery. On DAT diet and will progress to NPO diet post midnight, with no contraptions attached. Vital Signs taken and recorded. Patient was febrile (37.7 C) January 30, 2009 The patient was scheduled for surgery (Exploratory laprotomy), very anxious yet conscious and coherent However the surgery was cancelled because she has no CP clearance so the surgery was rescheduled on Tuesday (Feb. 02). V/S has been taken & recorded. Patient was febrile (37.8 C) February 05, 2009 Received patient. on bed on its second day post-OP, conscious and coherent. Tense and weak in appearance, facial grimacing when surgery incision border is palpated, and verbally reported pain at both sides of abdominal area with the score of 6. With on going IVF of D5LR at 300cc level infusing at KVO rate and heplock at the right arm kept intact. With abdominal elastic bandage dressing then changed to abdominal sterile gauze dressing kept dry and clean. On NPO diet and progressed to sips of water. February 06, 2009 At 8:00 am the pt. was febrile (37.6*c) done TSB. The pt. was on IVF of D5LR at 800cc level infusing at KVO rate and instructed on moderate high back rest. Still on sips of water diet, vital signs taken & recorded. XI Final Diagnosis: Periappendical abscess s/p Explore Laparotomy

II Review of Related Literature
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What is Appendicitis? The appendix is a closed-ended, narrow tube up to several inches in length that attaches to the cecum (the first part of the colon) like a worm. (The anatomical name for the appendix, vermiform appendix, means worm-like appendage.) The inner lining of the appendix produces a small amount of mucus that flows through the open center of the appendix and into the cecum. The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies. Like the rest of the colon, the wall of the appendix also contains a layer of muscle, but the muscle is poorly developed. What is appendicitis and what causes appendicitis? Appendicitis means inflammation of the appendix. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is called a fecalith (literally, a rock of stool). At other times, the lymphatic tissue in the appendix may swell and block the appendix. After the blockage occurs, bacteria which normally are found within the appendix begin to invade (infect) the wall of the appendix. The body responds to the invasion by mounting an attack on the bacteria, an attack called inflammation. An alternative theory for the cause of appendicitis is an initial rupture of the appendix followed by spread of bacteria outside the appendix.. The cause of such a rupture is unclear, but it may relate to changes that occur in the lymphatic tissue, for example, inflammation, that line the wall of the appendix.) If the inflammation and infection spread through the wall of the appendix, the appendix can rupture. After rupture, infection can spread throughout the abdomen; however, it usually is confined to a small area surrounding the appendix (forming a peri-appendiceal abscess). Sometimes, the body is successful in containing ("healing") the appendicitis without surgical treatment if the infection and accompanying inflammation do not spread

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throughout the abdomen. The inflammation, pain and symptoms may disappear. This is particularly true in elderly patients and when antibiotics are used. The patients then may come to the doctor long after the episode of appendicitis with a lump or a mass in the right lower abdomen that is due to the scarring that occurs during healing. This lump might raise the suspicion of cancer.

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What are the complications of appendicitis? The most frequent complication of appendicitis is perforation. Perforation of the appendix can lead to a Periappendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection of the entire lining of the abdomen and the pelvis). The major reason for appendiceal perforation is delay in diagnosis and treatment. In general, the longer the delay between diagnosis and surgery, the more likely is perforation. 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. A less common complication of appendicitis is blockage of the intestine. Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop working, and this prevents the intestinal contents from passing. If the intestine above the blockage begins to fill with liquid and gas, the abdomen distends and nausea and vomiting may occur. It then may be necessary to drain the contents of the intestine through a tube passed through the nose and esophagus and into the stomach and intestine.

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A feared complication of appendicitis is sepsis, a condition in which infecting bacteria enter the blood and travel to other parts of the body. This is a very serious, even lifethreatening complication. Fortunately, it occurs infrequently. What are the symptoms of appendicitis? The main symptom of appendicitis is abdominal pain. The pain is at first diffuse and poorly localized, that is, not confined to one spot. (Poorly localized pain is typical whenever a problem is confined to the small intestine or colon, including the appendix.) The pain is so difficult to pinpoint that when asked to point to the area of the pain, most people indicate the location of the pain with a circular motion of their hand around the central part of their abdomen. A second, common, early symptom of appendicitis is loss of appetite which may progress to nausea and even vomiting. Nausea and vomiting also may occur later due to intestinal obstruction. As appendiceal inflammation increases, it extends through the appendix to its outer covering and then to the lining of the abdomen, a thin membrane called the peritoneum. Once the peritoneum becomes inflamed, the pain changes and then can be localized clearly to one small area. Generally, this area is between the front of the right hip bone and the belly button. The exact point is named after Dr. Charles McBurney--McBurney's point. If the appendix ruptures and infection spreads throughout the abdomen, the pain becomes diffuse again as the entire lining of the abdomen becomes inflamed. Rovsing's sign Deep palpation of the left iliac fossa may cause pain in the right iliac fossa. This is the Rovsing's sign, also known as the Rovsing's symptom. It is used in the diagnosis of acute appendicitis. Pressure over the descending colon causes pain in the right lower quadrant of the abdomen.

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McBurney’s Sign McBurney's sign, is a sign of acute appendicitis.[2] The clinical sign of rebound pain when pressure is applied is also known as Aaron's sign. Specific localization of tenderness to McBurney's point indicates that inflammation is no longer limited to the lumen of the bowel (which localizes pain poorly), and is irritating the lining of the peritoneum at the place where the peritoneum comes into contact with the appendix. Tenderness at McBurney's point suggests the evolution of acute appendicitis to a later stage, and thus, the increased likelihood of rupture. Because the location of the appendix is often different in different people, and can migrate within the abdomen, many cases of appendicitis do not cause point tenderness at McBurney's point. Other abdominal processes can also sometimes cause tenderness at McBurney's point. Thus, this sign is highly useful but neither necessary nor sufficient to make a diagnosis of acute appendicitis. Also, the anatomical position of the appendix is highly variable (for example in retrocaecal appendix, an appendix behind the caecum), which also limits the use of this sign. Psoas sign Occasionally, an inflamed appendix lies on the psoas muscle and the patient will lie with the right hip flexed for pain relief. Obturator sign If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and internally rotating the hip. This maneuver will cause pain in the hypogastrium.

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If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar region. If its tip is in the pelvis, these signs may be elicited only on rectal examination. Pain on defecation suggests that the tip of the appendix is resting against the rectum; pain on urination suggests that the tip is near the bladder or impinges on the ureter.

How is appendicitis diagnosed? The diagnosis of appendicitis begins with a thorough history and physical examination. Patients often have an elevated temperature, and there usually will be moderate to severe tenderness in the right lower abdomen when the doctor pushes there. If inflammation has spread to the peritoneum, there is frequently rebound tenderness. Rebound tenderness is pain that is worse when the doctor quickly releases his hand after gently pressing on the abdomen over the area of tenderness.

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White Blood Cell Count The white blood cell count in the blood usually becomes elevated with infection. In early appendicitis, before infection sets in, it can be normal, but most often there is at least a mild elevation even early. Unfortunately, appendicitis is not the only condition that causes elevated white blood cell counts. Almost any infection or inflammation can cause this count to be abnormally high. Therefore, an elevated white blood cell count alone cannot be used as a sign of appendicitis. Urinalysis Urinalysis is a microscopic examination of the urine that detects red blood cells, white blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or stones in the kidneys or bladder. The urinalysis also may be abnormal with appendicitis because the appendix lies near the ureter and bladder. If the inflammation of appendicitis is great enough, it can spread to the ureter and bladder leading to an abnormal urinalysis. Most patients with appendicitis, however, have a normal urinalysis. Therefore, a normal urinalysis suggests appendicitis more than a urinary tract problem. Abdominal X-Ray An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece of stool that blocks the appendiceal opening) that may be the cause of appendicitis. This is especially true in children.

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Ultrasound An ultrasound is a painless procedure that uses sound waves to identify organs within the body. Ultrasound can identify an enlarged appendix or an abscess. Nevertheless, during appendicitis, the appendix can be seen in only 50% of patients. Therefore, not seeing the appendix during an ultrasound does not exclude appendicitis. Ultrasound also is helpful in women because it can exclude the presence of conditions involving the ovaries, fallopian tubes and uterus that can mimic appendicitis. Barium Enema A barium enema is an x-ray test where liquid barium is inserted into the colon from the anus to fill the colon. This test can, at times, show an impression on the colon in the area of the appendix where the inflammation from the adjacent inflammation impinges on the colon. Barium enema also can exclude other intestinal problems that mimic appendicitis, for example Crohn's disease. Computerized tomography (CT) Scan In patients who are not pregnant, a CT Scan of the area of the appendix is useful in diagnosing appendicitis and peri-appendiceal abscesses as well as in excluding other diseases inside the abdomen and pelvis that can mimic appendicitis. Laparoscopy Laparoscopy is a surgical procedure in which a small fiberoptic tube with a camera is inserted into the abdomen through a small puncture made on the abdominal wall. Laparoscopy allows a direct view of the appendix as well as other abdominal and pelvic organs. If appendicitis is found, the inflamed appendix can be removed with the laparascope. The disadvantage of laparoscopy compared to ultrasound and CT is that it requires a general anesthetic.4

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There is no one test that will diagnose appendicitis with certainty. Therefore, the approach to suspected appendicitis may include a period of observation, tests as previously discussed, or surgery. Why can it be difficult to diagnose appendicitis? It can be difficult to diagnose appendicitis. The position of the appendix in the abdomen may vary. Most of the time the appendix is in the right lower abdomen, but the appendix, like other parts of the intestine, has a mesentery. This mesentery is a sheet-like membrane that attaches the appendix to other structures within the abdomen. If the mesentery is large, it allows the appendix to move around. In addition, the appendix may be longer than normal. The combination of a large mesentery and a long appendix allows the appendix to dip down into the pelvis (among the pelvic organs in women). It also may allow the appendix to move behind the colon (called a retro-colic appendix). In either case, inflammation of the appendix may act more like the inflammation of other organs, for example, a woman's pelvic organs. The diagnosis of appendicitis also can be difficult because other inflammatory problems may mimic appendicitis. Therefore, it is common to observe patients with suspected appendicitis for a p eriod of time to see if the problem will resolve on its own or develop characteristics that more strongly suggest appendicitis or, perhaps, another condition. What other conditions can mimic appendicitis? The surgeon faced with a patient suspected of having appendicitis always must consider and look for other conditions that can mimic appendicitis. Among the conditions that mimic appendicitis are:

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* Meckel's diverticulitis. A Meckel's diverticulum is a small outpouching of the small intestine which usually is located in the right lower abdomen near the appendix. The diverticulum may become inflamed or even perforate (break open or rupture). If inflamed and/or perforated, it usually is removed surgically. * Pelvic inflammatory disease. The right fallopian tube and ovary lie near the appendix. Sexually active women may contract infectious diseases that involve the tube and ovary. Usually, antibiotic therapy is sufficient treatment, and surgical removal of the tube and ovary are not necessary. * Inflammatory diseases of the right upper abdomen. Fluids from the right upper abdomen may drain into the lower abdomen where they stimulate inflammation and mimic appendicitis. Such fluids may come from a perforated duodenal ulcer, gallbladder disease, or inflammatory diseases of the liver, e.g., a liver abscess. * Right-sided diverticulitis. Although most diverticuli are located on the left side of the colon, they occasionally occur on the right side. When a right-sided diverticulum ruptures it can provoke inflammation they mimics appendicitis. * Kidney diseases. The right kidney is close enough to the appendix that inflammatory problems in the kidney-for example, an abscess-can mimic appendicitis How is appendicitis treated? Once a diagnosis of appendicitis is made, an appendectomy usually is performed. Antibiotics almost always are begun prior to surgery and as soon as appendicitis is suspected. There is a small group of patients in whom the inflammation and infection of appendicitis remain mild and localized to a small area. The body is able not only to contain the inflammation and infection but to resolve it as well. These patients usually are not very ill

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and improve during several days of observation. This type of appendicitis is referred to as "confined appendicitis" and may be treated with antibiotics alone. The appendix may or may not be removed at a later time. On occasion, a person may not see their doctor until appendicitis with rupture has been present for many days or even weeks. In this situation, an abscess usually has formed, and the appendiceal perforation may have closed over. If the abscess is small, it initially can be treated with antibiotics; however, the abscess usually requires drainage. A drain (a small plastic or rubber tube) usually is inserted through the skin and into the abscess with the aid of an ultrasound or CT scan that can determine the exact location of the abscess. The drain allows pus to flow from the abscess out of the body. The appendix may be removed several weeks or months after the abscess has resolved. This is called an interval appendectomy and is done to prevent a second attack of appendicitis. How is an appendectomy done? During an appendectomy, an incision two to three inches in length is made through the skin and the layers of the abdominal wall over the area of the appendix. The surgeon enters the abdomen and looks for the appendix which usually is in the right lower abdomen. After examining the area around the appendix to be certain that no additional problem is present, the appendix is removed. This is done by freeing the appendix from its mesenteric attachment to the abdomen and colon, cutting the appendix from the colon, and sewing over the hole in the colon. If an abscess is present, the pus can be drained with drains that pass from the abscess and out through the skin. The abdominal incision then is closed. Newer techniques for removing the appendix involve the use of the laparoscope. The laparoscope is a thin telescope attached to a video camera that allows the surgeon to inspect the inside of the abdomen through a small puncture wound (instead of a larger incision). If appendicitis is found, the appendix can be removed with special instruments that can be passed into the abdomen, just like the laparoscope, through small puncture wounds. The benefits of the laparoscopic technique include less post-operative pain

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(since much of the post-surgery pain comes from incisions) and a speedier return to normal activities. An additional advantage of laparoscopy is that it allows the surgeon to look inside the abdomen to make a clear diagnosis in cases in which the diagnosis of appendicitis is in doubt. For example, laparoscopy is especially helpful in menstruating women in whom a rupture of an ovarian cysts may mimic appendicitis. If the appendix is not ruptured (perforated) at the time of surgery, the patient generally is sent home from the hospital after surgery in one or two days. Patients whose appendix has perforated are sicker than patients without perforation, and their hospital stay often is prolonged (four to seven days), particularly if peritonitis has occurred. Intravenous antibiotics are given in the hospital to fight infection and assist in resolving any abscess. Occasionally, the surgeon may find a normal-appearing appendix and no other cause for the patient's problem. In this situation, the surgeon may remove the appendix. The reasoning in these cases is that it is better to remove a normal-appearing appendix than to miss and not treat appropriately an early or mild case of appendicitis.

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What are the complications of appendectomy? The most common complication of appendectomy is infection of the wound, that is, of the surgical incision. Such infections vary in severity from mild, with only redness and perhaps some tenderness over the incision, to moderate, requiring only antibiotics, to severe, requiring antibiotics and surgical treatment. Occasionally, the inflammation and infection of appendicitis are so severe that the surgeon will not close the incision at the end of the surgery because of concern that the wound is already infected. Instead, the surgical closing is postponed for several days to allow the infection to subside with antibiotic therapy and make it less likely for infection to occur within the incision. Wound infections are less common with laparoscopic surgery. Another complication of appendectomy is an abscess, a collection of pus in the area of the appendix. Although abscesses can be drained of their pus surgically, there are also non-surgical techniques, as previously discussed.

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Are there long-term consequences of appendectomy? It is not clear if the appendix has an important role in the body in older children and adults. There are no major, long-term health problems resulting from removing the appendix although a slight increase in some diseases has been noted, for example, Crohn's disease. Gerontologic Considerations Acute appendicitis does not occur frequently in the elderly population. Classic signs and symptoms are altered and may vary greatly. Pain may be absent or minimal. Symptoms may be vague, suggesting bowel obstruction or another process. Fever and leukocytosis may not be present. As a result, diagnosis and prompt treatment may be delayed, causing potential complications and mortality. The patient may have no symptoms until the appendix ruptures. The incidence of perforated appendix is higher in the elderly population because many of these patients do not seek health care as quickly as younger patients. PHARMACOLOGIC ASPECTS OF AGING Older people use more medications than does any other age group: although they comprise only 12.6% of the total population, they use 30% of all prescribed medications and 40% of all over-the-counter medications. Medications have improved the health and well-being of older people by alleviating symptoms of discomfort, treating chronic illnesses, and curing infectious processes. Problems commonly occur, however, because of medicationinteractions, multiple medication effects, multiple medication use (polypharmacy), and noncompliance. Combinations of prescription medications and some over-the-counter medications further complicate the problem. Any medication is capable of altering nutritional status, which, in the elderly, may already be compromised by a marginal diet or by chronic disease and its treatment.

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Medications can depress the appetite, cause nausea and vomiting, irritate the stomach, cause constipation or diarrhea, and decrease absorption of nutrients. In addition, they can alter electrolyte balance and carbohydrate and fat metabolism. A few examples of medications capable of altering the nutritional status are antacids, which produce thiamine deficiency; cathartics, which diminish absorption; antibiotics and phenytoin, which reduce utilization of folic acid; and phenothiazines, estrogens, and corticosteroids, which increase food intake and cause weight gain. Age Age has long been the focus of research on pain perception and pain tolerance, and again the results have been inconsistent. For example, although some researchers have found that older adults require a higher intensity of noxious stimuli than do younger adults before they report pain (Washington, Gibson & Helme, 2000), others have found no differences in responses of younger and older adults (Edwards & Filligim, 2000). Other researchers have found that elderly patients (older than 50 years of age) reported significantly less pain than younger patients (Li, Greenwald, Gennis et al., 2001). Experts in the field of pain management have concluded that if pain perception is diminished in the elderly person, it is most likely secondary to a disease process (eg, diabetes) rather than to aging (American Geriatrics Society, 1998). More research is needed in the area of aging and its effects on pain perception to understand what the elderly are experiencing. Although many elderly people seek health care because of pain, others are reluctant to seek help even when in severe pain because they consider pain to be part of normal aging. Assessment of pain in older adults may be difficult because of the physiologic, psychosocial, and cognitive changes that often accompany aging. In one study, as many as 93% of nursing home residents reported being in pain daily for the past 6 months (Weiner, Peterson, Ladd et al., 1999). Unrelieved pain contributes to the problems of depression, sleep disturbances, delayed rehabilitation, malnutrition, and cognitive dysfunction (Miaskowski, 2000). The way an older person responds to pain may differ from the way a younger person responds.

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Because elderly people have a slower metabolism and a greater ratio of body fat to muscle mass than younger people, small doses of analgesic agents may be sufficient to relieve pain, and these doses may be effective longer (Buffum & Buffum, 2000). Elderly patients deal with pain according to their lifestyle, personality, and cultural background, as do younger adults. Many elderly people are fearful of addiction and, as a result, will not report that they are in pain or ask for pain medication. Others fail to seek care because they fear that the pain may indicate serious illness or they fear loss of independence. Elderly patients must receive adequate pain relief after surgery or trauma. When an elderly person becomes confused after surgery or trauma, the confusion is often attributed to medications, which are then discontinued. However, confusion in the elderly may be a result of untreated and unrelieved pain. In some cases postoperative confusion clears once the pain is relieved. Judgments about pain and the adequacy of treatment should be based on the patient’s report of pain and pain relief rather than on age.

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Peri-appendiceal abscess

(Appendix, cut section, showing that pus fills the appendix lumen and spills out into the fat, forming a peri-appendiceal abscess. This is a surgical emergency.) If the inflammation and infection spread through the wall of the appendix, the appendix can rupture. After rupture, infection can spread throughout the abdomen; however, it usually is confined to a small area surrounding the appendix (forming a periappendiceal abscess). Treatment A laparotomy is a large incision made into the abdomen. Exploratory laparotomy is used to visualize and examine the structures inside of the abdominal cavity. Purpose: Exploratory laparotomy is a method of abdominal exploration, a diagnostic tool that allows physicians to examine the abdominal organs. The procedure may be recommended for a patient who has abdominal pain of unknown origin or who has sustained an injury to the abdomen. Because of the nature of the abdominal organs, there is a high risk of

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infection if organs rupture or are perforated. In addition, bleeding into the abdominal cavity is considered a medical emergency. Exploratory laparotomy is used to determine the source of pain or the extent of injury and perform repairs if needed. Laparotomy may be performed to determine the cause of a patient's symptoms or to establish the extent of a disease. Some other conditions that may be discovered or investigated during exploratory laparotomy include:
• • • • • •

cancer of the abdominal organs peritonitis (inflammation of the peritoneum, the lining of the abdominal cavity) appendicitis (inflammation of the appendix) pancreatitis (inflammation of the pancreas) abscesses (a localized area of infection) adhesions (bands of scar tissue that form after trauma or surgery)

• • • • •

diverticulitis (inflammation of sac-like structures in the walls of the intestines) intestinal perforation ectopic pregnancy (pregnancy occurring outside of the uterus) foreign bodies (e.g., a bullet in a gunshot victim) internal bleeding

Demographics Because laparotomy may be performed under a number of circumstances to diagnose or treat numerous conditions, no data exists as to the overall incidence of the procedure. Description The patient is usually placed under general anesthesia for the duration of surgery. The advantages to general anesthesia are that the patient remains unconscious during the

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procedure, no pain will be experienced nor will the patient have any memory of the procedure, and the patient's muscles remain completely relaxed, allowing safer surgery. Incision Once an adequate level of anesthesia has been reached, the initial incision into the skin may be made. A scalpel is first used to cut into the superficial layers of the skin. The incision may be median (vertical down the patient's midline), paramedian (vertical elsewhere on the abdomen), transverse (horizontal), T-shaped, or curved, according to the needs of the surgery. The incision is then continued through the subcutaneous fat, the abdominal muscles, and finally, the peritoneum. Electrocautery is often used to cut through the subcutaneous tissue as it has the ability to stop bleeding as it cuts. Instruments called retractors may be used to hold the incision open once the abdominal cavity has been exposed. Abdominal Exploration The surgeon may then explore the abdominal cavity for disease or trauma. The abdominal organs in question will be examined for evidence of infection, inflammation, perforation, 26 abnormal growths, or other conditions. Any fluid surrounding the abdominal organs will be inspected; the presence of blood, bile, or other fluids may indicate specific diseases or injuries. In some cases, an abnormal smell encountered upon entering the abdominal cavity may be evidence of infection or a perforated gastrointestinal organ. If an abnormality is found, the surgeon has the option of treating the patient before closing the wound or initiating treatment after exploratory surgery. Alternatively, samples of various tissues and/or fluids may be removed for further analysis. For example, if cancer is suspected, biopsies may be obtained so that the tissues can be examined microscopically for evidence of abnormal cells. If no abnormality is found, or if immediate treatment is not needed, the incision may be closed without performing any further surgical procedures. During exploratory laparotomy for cancer, a pelvic washing may be performed; sterile fluid is instilled into the abdominal cavity and washed around the abdominal organs, then

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withdrawn and analyzed for the presence of abnormal cells. This may indicate that a cancer has begun to spread (metastasize). Closure Upon completion of any exploration or procedures, the organs and related structures are returned to their normal anatomical position. The incision may then be sutured (stitched closed). The layers of the abdominal wall are sutured in reverse order, and the skin incision closed with sutures or staples. Diagnosis/Preparation Various diagnostic tests may be performed to determine if exploratory laparotomy is necessary. Blood tests or imaging techniques such as x ray, computed tomography (CT) scan, and magnetic resonance imaging (MRI) are examples. The presence of intraperitoneal fluid (IF) may be an indication that exploratory laparotomy is necessary; one study indicated that IF was present in nearly three-quarters of patients with intraabdominal injuries. Directly preceding the surgical procedure, an intravenous (IV) line will be placed so that fluids and/or medications may be administered to the patient during and after surgery. A Foley catheter will be inserted into the bladder to drain urine. The patient will also meet with the anesthesiologist to go over details of the method of anesthesia to be used. Aftercare The patient will remain in the postoperative recovery room for several hours where his or her recovery can be closely monitored. Discharge from the hospital may occur in as little as one to two days after the procedure, but may be later if additional procedures were performed or complications were encountered. The patient will be instructed to watch for symptoms that may indicate infection, such as fever, redness or swelling around the incision, drainage, and worsening pain.

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Risks Risks inherent to the use of general anesthesia include nausea, vomiting, sore throat, fatigue, headache, and muscle soreness; more rarely, blood pressure problems, allergic reaction, heart attack, or stroke may occur. Additional risks include bleeding, infection, injury to the abdominal organs or structures, or formation of adhesions (bands of scar tissue between organs). Morbidity and Mortality Rates The operative and postoperative complication rates associated with exploratory laparotomy vary according to the patient's condition and any additional procedures performed. Alternatives Laparoscopy is a relatively recent alternative to laparotomy that has many advantages. Also called minimally invasive surgery, laparoscopy is a surgical procedure in which a laparoscope (a thin, lighted tube) and other instruments are inserted into the abdomen through small incisions. The internal operating field may then be visualized on a video monitor that is connected to the scope. In some patients, the technique may be used for abdominal exploration in place of a laparotomy. Laparoscopy is associated with faster recovery times, shorter hospital stays, and smaller surgical scars.

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During a laparotomy, and an incision is made into the patient's abdomen (A). Skin and connective tissue called fascia is divided (B). The lining of the abdominal cavity, the peritoneum, is cut, and any exploratory procedures are undertaken (C). To close the incision, the peritoneum, fascia, and skin are stitched (E). (Illustration by GGS Inc.)

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III Anatomy and Physiology

Large Intestine: . Its primary purpose is to extract water from feces. About 1.5 M (5 feet) long, it extends from the ileocecal valve to the anus. Major functions are to dry out the indigestible food residue by absorbing water & to eliminate these residues from the body as feces. It frames the small intestine on these sides & has the following subdivisions: cecum, appendix, colon, rectum & anal canal. Cecum The cecum (also spelled caecum), the first portion of the large bowel, situated in the lower right quadrant of the abdomen. The cecum receives fecal material from the small bowel (ileum) which opens into it. The appendix is attached to the cecum. The bottom of the cecum is a blind pouch (a cul de sac) leading nowhere.A pouch connected to the ascending colon of the large intestine and the ileum. It is separated from the ileum by the ileocecal valve (ICV) or Bauhin's valve, and is considered to be the beginning of the large

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Appendix The appendix is a branch of the cecum, like the appendix, the cecum was once believed to have no function. The appendix is a small, finger-like appendage about 10 cm (4 in) long that is attached to the cecum just below the ileocecal valve. The appendix fills with food and empties regularly into the cecum. Because it empties inefficiently and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable to infection. Ascending colon Smaller in caliber than the cecum, with which it is continuous.It passes upward, from its commencement at the cecum, opposite the colic valve, to the under surface of the right lobe of the liver, on the right of the gall-bladderyeo, where it is lodged in a shallow depression, the colic impression; here it bends abruptly forward and to the left, forming the right colic flexure (hepatic). Transverse Colon Longest and most movable part of the colon, passes with a downward convexity from the right hypochondrium region across the abdomen, opposite the confines of the epigastric and umbilical zones, into the left hypochondrium region, where it curves sharply on itself beneath the lower end of the spleen, forming the splenic or left colic flexure. The right colic flexure is adjacent to the liver. . Rectum The last 6 to 8 inches of the large intestine. The rectum stores solid waste until it leaves the body through the anus. Anus Termination of Rectum formed of spichnter which relaxes to allow fecal matter to pass through.

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IV Pathophyisiology
A. Written Report: The following case introduces a fifty three year old female patient who was brought to the hospital because of the persistent conditions such as abdominal pain, recurrent fever, nausea, anorexia. After further tests and surgery performed, the patient was diagnosed with Periappendical abscess s/p Exploratomy Laparotomy. This study focuses on one of the complications of Appendicitis which is the Periappendicial abscess that is cause of untreated inflammation of appendix. The patient obstruction of the lumen was believed to arise spontaneously on an obscure or unknown cause. Impediment of the lumen causes the mucous secretion to increase and its

accumulation causes luminal pressure to increase. Condition appears to favor resident bacterial growth. Inflammation develops resulting to mucosal damage. With continued swelling, the appendix presses against the adjacent abdominal wall and its sensitive parietal peritoneum causing to deteriorate and perforate. Contents of appendical abscess leaked to the peritoneum surfaces. Contents are confined to a small area of appendix. Spillage of the contents causes the inflammation of parietal peritoneum leading to the manifestation of fever.

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Idiopathic (Constipation/Fecalith) Obstruction of the lumen

↑ mucosal secretion

↑ intraluminal pressure Bacterial Invasion ( resident Bacteria from intestine) Inflammation

Mucosal damage

Spillage of infected appendical contents outside appendix

Confined to a small area surrounding appendix ( peri-appendiceal abscess) Inflammation of parietal peritoneum FEVER anxiety Activity Intolerance Acute pain Anticipatory for Surgery (Exploratory Laparotomy)

Hyperthermia
B. Diagram

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V Problem List

Pre-operative: 1. Fever – Hyperthermia 2. Anxiety Post-operative: 1. Acute Pain 2. Activity Intolerance 3. Anxiety

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VI Laboratory and Diagnostic Procedures
January 27. 2009 LABORATORY PROCEDURE: Complete Blood Count Hemoglobin Red pigments in red blood cell that carries oxygen all through out the body. A. Test and Result Test Hemoglobin (Hgb) Result 123 Reference Value Male: 140-170/L Female: 120-150/L

B. Interpretation Hemoglobin count was within the normal range C. Significance Increase in normal range • Polycythemia, • Chronic Obstructive Pulmonary Disease • Congestive Heart Failure Decrease in normal range • Anemia • Hemorrhage Hematocrit The Percentage of Red Blood Cell of the total blood volume. A, Test and Result Test Hematocrit (Hct) B. Interpretation Hematocrit count was within the normal range Result 37% Reference Value Male:42-51% Female:37-47%

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C. Significance Increase in normal range • Erythrocytosis • Dehydration Decrease in normal range • Hemorrhage • Anemia • Pregnancy RBC Count It is the count of the actual number of red blood cells per volume of blood. A. Test and Result Test RBC count Result 4.3 Reference Value Male:4.5-5.9 x 106g/L Female:4.5-5.1 x 106g/L

B. Interpretation RBC count was .2 lower that the normal range which may indicate dietary deficiency because the client was anorexic. C. Significance Increase in normal range • Dehydration • Pulmonary Fibrosis • Erythrocytosis • Polycythemia • Congenital Heart Disease • Chronic Obstructive Pulmonary Disease Decrease in normal range • Hemorrhage • Anemia • Pregnancy • Dietary Deficiency

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WBC Count It is the count of the actual number of white blood cells per volume of blood. A. Test and Result Test WBC Count Result 6.1 Reference Value 5.0-10.0x103/L

B. Interpretation WBC count was within the normal range C. Significance Increase in normal range • Infection • Steroid use Decrease in normal range • Bone Marrow failure • Iron Deficiency • Platelet Count A. Test and Result Test Platelet Count B. Significance Increase in normal range • Rheumatoid arthritis • Malignant Disorder • Polycythemia • Iron Deficiency Anemia Decrease in normal range • Thrombocytopenic • Purpura, • Acute leukemia, Result Adequate Reference Value 150-400x106/L

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• •

Aplastic anemia, Cancer chemotherapy.

Differential Count Neutrophils Make up 50% to 60% of leukocytes in the blood and are responsible for phagocytosis of bacteria and cellular debris. Lymphocytes Make up 20% to 30% of the total white blood cells and are responsible in producing antibody Monocytes Are phagocytic cell.It can be produced rapidly and make up about 5% of the total white blood cell count. Eosinophils Make up 1%-4% of the total leukocytes. Increases in number during allergic states and infestation with worms. Basophils Increased in numbers in such pathological conditions and make up approximately 0.5%-1.0% of leukocytes. A. Test and Result Test Result Reference Value Neutrophils Lymphocytes Monocytes Stabs Eosinophils 0.63 0.37 ---0.45-0.65 0.25-0.35 0.03-0.06 0.02-0.04 0.02-0.04

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Basophils -Blasts ABO/RH Typing B. Interpretations The result for Neutrophils count was within the normal range. Lymphocytes count was .0.02 more than the normal range which may indicate chronic bacterial infection or viral infection. The patient blood type appeared to be B+. C. Significance Increase in normal range Neutrophils • • • • • • • • • • • • • • Acute infections Trauma or surgery Leukemia, Malignant disease Necrosis Stress -B+ 0.0 00-0.05

Lymphocytes Chronic Infection Viral Infection Mononecleosis

Monocytes Chronic Inflammatory Disorder Tuberculosis Parasitic disease

Eosinophils Parasitic Infections Allergic reactions 43

• •

Leukemia

Basophils Leukemia

Decrease in normal range Neutrophils • • • • • • • • • • Aplastic Anemia Dietary Deficiency Radiation Therapy Bone marrow suppression

Lymphocytes Leukemia Sepsis Immunodeficiency disease SLE Immunodeficiency including AIDS

Monocytes Drug therapy: Prednisone

Eosinophils • • • • Stress Use of some medications (ACTH, epinephrine, thyroxine)

Basophils Allergic reactions Stress

Nursing Considerations 1. Make sure that the vital signs are stable. 2. Choose non-dominant hand for the site when getting the specimen 3. Clean the site 4. Apply tourniquet to the site but not more than two minutes 44

5. Apply light pressure to make sure that the site is correct

6. If failed to the first attempt, change the site from distal to proximal 7. Release the tourniquet once there is blood in the hub 8. Transfer immediately the collected blood to the specimen container with purple cap and deliver to the laboratory not more that 30 minutes. 9. To prevent coagulation turn the container upside down.

Diagnostic Procedures
A. Test and Result CT Scan Painless diagnostic procedure for examining soft tissue. It allows visualization of grey matter, necrotic tissue, and tumors. EXAM: CT SCAN of the whole abdomen Date: January 15, 2009 CT SCAN Report History: 1 Month. History of Intermittent right Quadrant pain. Multiple axial tomograpic sections of the whole abdomen with oral contrast and intravenous contrast were obtained. A peripherally enhancing complex predominantly cystic mass is seen in the Right Lower abdomen, adjacent to the ileo-cecal junction, most likely extra-luminal. It measures 5 cm x 7cm x 5 cm. Surrounding fat stranding is seen. The visualized small and large bowels appear unremarkable. The liver, gall bladder, pancreas, adrenal glands and spleen show no unusual findings. The kidney and its collecting structures including the urinary bladder are intact. The uterus is normal in size with no focal lesions noted. No adrenal masses seen. The abdominal aorta shows no dilatation. Minimal curvilinear are seen in the included lung bases. The rest of the soft tissues, vascular and osseous structures are unremarkable.

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Impression: Complex mass at the right lower abdomen; consider a Periappendiceal periceal abscess - Minimal fibrotic changes, bilateral lower lungs.

B. Nursing Considerations 1. Secure Consent of the client. 2. Inform client that the procedure will take 30 minutes to 1 hour. 3. Explain test purpose and procedure. Provide written instructions. Reinforce knowledge regarding possible adverse effects such as radiation. 4. Inform the client that there will be clicking and whirring noise and that he/she may use earplugs. 5. Provide medications as ordered. 6. Reassure the patient that scanning procedures no greater radiation than conventional x-ray studies 7. Check for patient allergies such as nausea, vomiting, warmth, and flushing of the face may signal possible allergy for iodine. 8. Check for signs of claustrophobia 9. Be aware that abdominal cramping and diarrhea may occur; therefore medication may be given as ordered to decrease these side effects. 10. Inform the patient that solid foods are usually withheld on the day of examination. Clear liquids may be taken up to 2 hours before examination. 11. For CT of the abdomen, the patient usually can take nothing by mouth. 12. Notify physician immediately if allergic reaction occurs. 13. Secure Consent of the client. 14. Inform client that the procedure will take 30 minutes to 1 hour. 15. Inform the client that there will be clicking and whirring noise and that he/she may use earplug.

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A. Test and Result Roentegnographic Roentenographic Report Date: January 10, 2009 Abdomen: Shows gas in the visualize bowel loops. Minimal feces are seen in the rectum. Gas pattern is non obstructive. Osseous structures & soft tissue outline are intact. Impression: Unremarkable abdomen B. Nursing Considerations 1. The patient should be given a brief explanation of the purpose of and procedure for the test and assured that there will be no discomfort. 2. Remove all jewelry and other ornamentation in the abdomen area before the Xray 3. Remind the patient of need to remain motionless during the procedure.

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48

VII Drug Study
Name of Drug Action Indication Route and Dosage Tablet: adult and children >6 yrs: 1020mg 3-5 times daily. Availability Contraindications Adverse Effects Xerostomia, tachycardia, urinary retention.. Nursing Indications -Tell patient to avoid hazardous activities requiring alertness; dizziness may occur. -Advice patient to avoid use of Tablets: 0.4 mg alcohol or other CNS depressants while taking Transdermal medication.

Hyoscine NButykbromide

Inhibits acetycholine at receptor sites in autonomic nervous system, which controls secretions, free acids in stomach; blocks central muscarinic receptors, which decreases

Used in the management of various gastrointestinal disorders.

Injection: 0.3 mg/ml and 1 mg/ml in 1ml vials, 0.4 mg/ml in 0.5ml ampules and 1-ml vials, 0.86 mg/ml in 0.5ml ampules

Myasthenia gravi, megacolon, hypersensitivity.

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involuntary movements.. system (TransdermScop): 1.5 mg/patch (releases 0.5 mg scopolamine over 3 days) -Explain that rinsing the mouth, good oral hygiene, and sugarless gum or candy will help to counteract dryness.

 Started: December 28, 2008  Discontinued: December 28, 2008

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Name of Drug

Action

Indication

Route and Dosage 25 to 650 mg P.O. q 4 to 6 hours, or 1,000 mg three or daily.

Availability

Contraindications

Adverse Effects

Nursing Indications

Acetaminophen May cause analgesia by inhibiting CNS prostaglandin synthesis.

Relief mildto-moderate pain: treatment of fever.

Caplets, capsules: 160 mg, 500 mg, 650 mg (Drops: 100 mg/ml mg/2.5 ml, 80 mg/5 ml, 120 mg/5 ml, 160 mg/5 ml Gelcaps: 500 mg Liquid: 160 mg/5 ml, 500 mg/15 ml Solution: 80

Hypersensitivity: Intolerance to tartrazine, alcohol, table sugar, saccharin.

Stimulation, drowiness, nausea,vomiting, abdominal pain, heapatotoxicity, hepatic seizure, renal failure, pancytopenia, rash, uticaria and hypersensitivity, cyanosis, anemia, neutropenia, jaundice, CNS stimulation, delirium followed by vascular

-Tell the patient to read label on the other OTC. -Advised the avoid alcohol. -Inform patient to recognized signs of chronic overdose,

four times Elixir: 80

thrombocytopenia, client to

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mg/1.66 ml, 100 mg/1 ml, 120 mg/2.5 ml, 160 mg/5 ml, 167 mg/5 ml Suppositories: 80 mg, 120 mg, 125 mg, 300 mg, 325 mg, 650 mg Suspension: 32 mg/ml, 160 mg/5 ml Syrup: 160 mg/5 ml Tablets (chewable): 80 mg, 160 mg Tablets (extended-

collapse, convulsion, trauma, death. .

bleeding, bruising, malaise, fever. -Tell patient to notify physician for pain or fever lasting for 3 days.

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release): 160 mg, 325 mg, 500 mg, 650 mg Tablets (filmcoated): 160 mg, 325 mg, 500 mg.

 Started: December 29, 2008  Discontinued: January 12, 2009

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Name of Drug

Action

Indication

Route and Dosage

Availability

Contraindications

Adverse Effects

Nursing Indications

Metronidazole Direct-acting amebicide or It binds to bacterial and protozoan DNA to cause loss of helical structurem strand breakage, inhibition if nucleic acid synthesis and cell death.

Infections in the intraskin and skin structure.

750 mg P.O. q Tabs: 8 hours for 5 to 10 days 250, 375 500mg Ext Rel tabs: 750mg Injection

Blood dyscrasias, active CNS diseases, hypersebsitivity to imidazole, tuberculosis if mucous membranes and

Convulsive seizures, peripheral neuropathy, rash, pruritus, GI comfort, anorexia, nausea,

-Obtain C&S before beginning drug therapy to identify if correct treatment has been initiated. -Assess for allergic reactions: rash, urticaria and pruritus. -Monitor for

trichomobacide. abdominal

500mg/100ml: certain viral Powder for Injection: 500mg single dose trimester if pregnancy.

conditions and first furred tongue, dry mouth and unpleasant metallic taste, headache,

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less frequently vomiting, diarrhea, weakness, dizziness and darkening of the urine.

possible drug induced adverse reactions. -Monitor renal function: urine output, input and output ratio.

 Started: January 13, 2008  Discontinued: January 20, 2008

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Name of Drug

Action

Indication

Route and Dosage

Availability

Contraindications

Adverse Effects

Nursing Indications

Cefuroxime

Inhibits bacterial cell wall synthesis, rendering cell wall unstable, leading to cell death by binding to cell wall membrane

Uncomplicated UTI due to E.coli or K. pneumoniae. Preoperative prophylaxis in undergoing surgical procedures classified as cleancontaminated or potentially contaminated. .

Tablets: 250 mg Standing Order: 750 mg IV q8 (ANST)

Oral suspension: 125 mg/5 ml Powder for injection: 750 mg, 1.5 g, 7.5 g Premixed containers: 750 mg/50 ml, 1.5 g/50 ml Tablets: 125 mg, 250 mg, 500 mg

Diarrhea/loose stool, nausea and vomiting, abdominal pain.

Adverse reactions CNS: headache, hyperactivity,

- Give in even doses around the clock; If GI upset with food;

hypertonia, seizures occurs, give GI: nausea, vomiting, diarrhea, abdominal pain, dyspepsia, colitis GU: hematuria, vaginal candidiasis, renal dysfunction, drug must be given for 1014 days to ensure death and prevent superinfection

osmotically clients

pseudomembranous organism

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acute renal failure Hematologic: hemolytic anemia, aplastic anemia, hemorrhage Hepatic: hepatic dysfunction Metabolic: hyperglycemia Skin: toxic epidermal necrolysis, erythema multiforme, Stevens-Johnson syndrome

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Other: allergic reaction, drug fever, superinfection, anaphylaxis Interactions Drug-drug. Antacids containing aluminum or magnesium, histamine2-receptor antagonists: increased cefuroxime absorption Probenecid: decreased excretion and increased blood

58

level of cefuroxime Drug-diagnostic tests. Blood glucose, Coombs' test, urine glucose tests using Benedict's solution: false-positive results Glucose, hematocrit: decreased levels White blood cells in urine: increased level Drug-food. Moderate- or high-

59

fat meal: increased drug bioavailability

Name of

Action

Indication

Route and

Availability

Contraindications

Adverse Effects

Nursing

60

Drug

Dosage

Indications

Ranitidine

Inhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits gastric acid secretion.

Used in the management of various gastrointestinal disorders such as dyspepsia gastrointestinal reflux disease [GERD], peptic ulcer and zolungerellisou syndrome. Prophylaxis of GI hemorrhage from the stress

Standing Order : 50 mg IV q8

Capsules (liquid-filled): 150 mg, 300 mg Solution for injection: 25 mg/ml in 2-, 6-, and 40-ml vials Solution for injection (premixed): 50 mg/50 ml in 0.45% sodium chloride Syrup: 15 mg/ml Tablets: 150

Hypersensitivity to drug or its components • Alcohol intolerance (with some oral products) • History of acute porphyria.

Cardiac arrythmias, bradycardia, headache, somnolence, hallucinations, depression, insomnia, alopecia, rash, erythema multiforme, nausea and vomiting, abdominal discomfort, diarrhea, constipation,

-Monitor ASL, ALT and serum creatinine when used to prevent stress-related bleeding. -Evaluate results of laboratory tests, therapeutic effectiveness and adverse reactions (bradycardia, PVC’s, tachycardia,

fatigue, dizziness, GI tract

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ulceration and in patients at risk of developing acid aspiration during general anesthesia prophylaxis of mendelson syndrome. .

mg, 300 mg Tablets (effervescent): 150 mg

pancreatitis, agranulocytosis, autoimmune hemolytic or aplastic anemia, thrombocytopeni a

CNS changes, rash, gynecomasticia, GI disturbance and hepatic failure.) - Assess

granulocytopenia, knowledge and cholestatic or hepatocellular effects, hypersensitivity reactions. teach patient appropriate use, possible side effects or appropriate interventions and adverse symptoms to report.

 Started: February 3, 2009

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 Standing Order : 50 mg IV q8

63

Name of Drug

Action

Indication

Route and Dosage

Availability

Contraindications

Adverse Effects

Nursing Indications

Keterolac
(tromethamine)

Possesses antiinflammatory, analgesics and antipyretic effects

Management of severe, acute pain in adults that requires analgesia and the opiate level, usually in a postoperative setting

Standing IV q6

Tablets: Each film-coated tablet, with one side printed in black ink with KET10 on one side, contains: ketorolac tromethamine 10 mg. Nonmedicinal ingredients: hydroxypropyllactose, magnesium

-Hypersensitivity to the drug or allergic symptoms to aspirin or other NSAID’s. -Active peptic ulcer , recent GI bleeding or of peptic ulcer or GI beeding. -Advanced renal

Systemic use: headache, dizziness, diarrhea, nausea, dyspepsia/

-Use as part of a regular analgesic schedule as needed basis.

Order: 30 mg white, round,

drowsiness, rather than on

indigestion, -If pain returns within next dose can be increased by up to 50 % -Do not mix IV/IM ketorolac in a GI pain and 3-5 hours, the edema, Purpura, asthma, abnormal visio, abnormal

perforation, history epigastric/

methylcellulose, impairement

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stearate, cellulose, polyethylene glycol and titanium dioxide. Bottles of 100 and 500. Store at room temperature with protection from light.

-High risk of .

liver function.

small volume with morpine sulfate, meperinide HCL, promethazine HCL, or hydroxyzine HCL, will precipitate from solution. -the IV bolus

microcrystalline bleeding.

Parenteral: 10 mg/mL: Each mL of clear, slightly yellow, sterile solution contains: ketorolac

must be given over no less than 15 sec. give IM slowly and deeply into the muscle.

65

tromethamine 10 mg. Nonmedicinal ingredients: alcohol 10% w/v and sodium chloride in sterile water. The pH is adjusted with sodium hydroxide or hydrochloric acid. Ampuls of 1 mL, trays of 5. Store at room temperature with protection from light. 30 mg/mL:

66

Each mL of clear, slightly yellow, sterile solution contains: ketorolac tromethamine 30 mg. Nonmedicinal ingredients: alcohol 10% w/v and sodium chloride in sterile water. The pH is adjusted with sodium hydroxide or hydrochloric acid. Ampuls of 1 mL, trays of

67

5. Store at room temperature with protection from light.

 Started: Feb 3, 2009  Discontinued: Feb 4, 2009  Standing Order: 30 mg IV q6

68

VIII NCP

69

 PRE-OPERATIVE NURSING CARE PLAN
Assessment Diagnosis Planning Nursing Interventions
Diagnostic Underlying cause of excessive heat Within one hour of nursing interventions the patient will reduce the body temperature from 37.6 C to 37. 4 C Therapeutic Surface cooling by means of doing TSB, heat loss by evaporation and conduction >To reduce heat Surface Temperature Monitored >To evaluate effects or degree of hyperthermia >Goal is met production Identified >To assess causative or contributing factors Within one hour of nursing interventions the patient’s body temperature of 37.7 C reduced to 37. 4C

Rationale

Evaluation

Subjective: “ Masakit ang ulo ko at mainit ang pakiramdam ko” as verbalized by the patient. Objective: > Increased in body surface temperature above normal range of 36.5-37.4 C (37.7 C) >warm to touch >Flushed skin

Hyperthermia related to inflammatory response as evidenced by increased body temperature ( 37. 7 C) Rationale:
Fever is caused by secretion of cytokines by cells that appear in the inflammatory reaction (e.g. macrophages). Two common cytokines are interleukin-1 (Il-1)

Short term Planning:

70

and tumor necrosis factor (TNF). Given that these factors cause fever and are produced by inflammatory cells, it follows that a large number of cells produce large amounts of cytokines resulting in higher fever. There is, then, a direct relationship between the severity of the inflammatory

Promoted. Educative Instructed to Maintain bed rest. >This will help in reducing metabolic demands and oxygen Consumption. Advised to increase Fluid intake. >Increase in oral fluids will prevent dehydration. .

response and fever.

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Assessment

Nursing Diagnosis

Goal

Nursing Interventions

Rationale

Evaluation

Subjective: “Natatakot ako sa gagawing operasyon sa akin” as verbalized by the patient. Rationale: Disturbed behavior Objective: > poor eye contact >Extraneous movement (rocking movements) >Restlessness is due to apprehension of the outcome of the surgery and imagined threat to one’s health. Anxiety related to impending surgery as evidenced by restlessness

Short term Planning After 8 hours of rendering nursing care and interventions the client will be able to Verbalize awareness of feelings of anxiety. Long Term Planning The patient will appear relax and will reduce anxiety to a manageable

Diagnostic: Vital Signs Monitored To identify physical responses associated with both medical and emotional conditions.

After 8 hours of rendering nursing care and interventions the client was able to verbalize awareness of feelings of anxiety.

Therapeutic Established a therapeutic relationship to the client. To gain client’s trust.

Goal is met

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>Difficulty of concentrating >Confusion

level.

Encouraged the client for participation in relaxation exercise (Deep breathing exercise, progressive muscle and provide comfort

These are effective non-chemical ways to reduce anxiety and client’s ability to deal with excessive stimuli is

relaxation,meditation) impaired. V/S: BP: 110/80 mmHg RR: 24 bpm PR: 110 cpm Temp: 37.7 C Educative: Encourage client to acknowledge and to express feelings about the procedure/ operation that will be done. To determine her feelings towards the procedure or conditions measures.g environmental factors).

73

Encourage client to have an exercise/ activity program such as reading books

To divert patients attention and reduce level of anxiety about the surgery

POST-OPERATIVE NURSING CARE PLAN
Diagnosis Planning Intervention Rationale Evaluation

Assessment

74

Subjective: ”Masakit ang tahi ko”as verbalized by the client

Acute pain related to tissue injury secondary to surgical intervention as evidenced by report of 6 pain scale.

Short Term Goal After 1 hour of Nursing Care, client will be able to verbalize reduction of pain from 6 to 4. and will be able to ambulate

Diagnostic: Duration, frequency, >This is a base to intensity and precipitating factors Assessed. plan the intervention

After 8 hours of Nursing Care, the client verbalized reduction of pain from 6 to 4. and able to ambulate Goal is Met

Objective: >Facial Grimace >Guarding behavior >Cannot ambulate >Pain score of 6 >Incision site in the abdomen (7 inches) is erythematous.

Therapeutic: The Client

Rationale:

positioned to SemiLong Term Goal: The Client will be able to demonstrate nonpharmacological technique for Fowler’s and Deep breathing exercise Instructed with a inscision wound

>DBE can make the client feel relaxed; it helps in coping up with pain. In semipressure in the abdomen is reduced.

Acute Pain is common to the client who undergone because there is a break in the skin.

pillow to support the fowlers position

surgery procedure relaxation.

Educative: Advised the client to > It helps to reduce

75

apply nonpharmacological technique such as relaxation technique before,during and after pain occur

pain by increasing the release of endorphins

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IX Discharge Plan
MEDICATION: The Patient and the relatives are provided information about the time of medication to be taken as ordered by her doctor. ENVIRONMENT Provide information to patient and significant others that the environment must be clean and use clean materials because the surrounding may contribute to the client of risk of infection. EXERCISE: Instruct the client to do leg exercise to promote blood circulation,Moderate exercise in the morning within the patient’s limit and with rest.Inform client that the normal activity can be resumed after 3-4 weeks. HEALTH TEACHING: Instruct the patient and significant others of proper way to clean the incision wound,from incision site to the surrounding area of wound with cottons and betadine or alcohol,one cotton each stroke and use sterile dressings.Inform client that the Semi-fowler’s position may help to reduce tension to the incision site Inform client and Instruct Deep Breathing Exercise and that she may use a pillow to support abdomen because Deep Breathing Exercise promotes heeling. DIET Inform the patient to increased her intake of water a day(8-12glasses) and intake of fiber must be increased too to treat her constipation. OUT-PATIENT FOLLOW-UP: Inform patient to make an appointment to have the surgeon remove the sutures between 5th and 4th days. SPIRITUAL The Patient and the significant others are advised to have a deep Faith to Devine God for Guidance.

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X Bibliography
1. Brunner and Suddarth's Textbook of Medical-Surgical Nursing i. by Suzanne C. Smeltzer and Brenda G. Brade 2. Fundamentals of Nursing by Kozier 3. Nurses’s Drug Handbook by George R. Spratto and Adrienne L. Woods 4. Essentials of Human Anatomy And Physiology by Elaine N. Marieb 5. Blackwell’s Nursing Dictionary 6. Nurse’s Pocket Guide by Marilyn E. Doenges 7. Pathophysiology by Thomas J. Nowak 8. (http://www.radiology.rsnajnls.org )http://radiology.rsnajnls.org/cgi/contentnw/full/215/2/337/ 9. http://www.aafp.org/afp/991101ap/2027.html 10. www.medicinenet.com

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