I.

Patient Profile

Name: Bernardo Matobato
Age: 26 years old
Gender: male
Occupation: construction worker
Educational Attainment: grade 4
Civil Status: single
Nationality: filipino
Address: brgy. Dapdap Alang-alang Leyte
Religion: catholic
C/C: abdominal pain
Date Admitted: july 22, 2010 @ 9:00pm
Admitting Diagnosis: ruptured appendicitis
Attending Physician: Dr. Baez
Source of Information: patient and mother
Reliability: 90%

II. Present Illness:

14 hours prior to admission, the patient experienced mild pain on his right lower quadrant abdomen
while eating in the morning, followed by a severe pain. The client tried to eliminate the pain using herbal oil
but were not eradicated.
Persistence of the noticed pain, prompted his mother to bring him to EVRMC, hence this admission.

III. Past Health History:

The patient did not receive any vaccination as claimed by the mother, has experienced acute
respiratory infection such as cough, cold and mild fever and took biogesic (250mg) every 4 hours for fever and
some herbal plants (decoction of lagundi) for cough relief. Pain in the right lower abdomen 1
st
felt when the
client was 25 years old but were ignored no history of hospitalization.

IV. Family History:

The mother claimed that her mother is asthma positive, and noted hypertension history on the
paternal side.

V. Birth History:

The patient is 3
rd
on eight siblings of Mr. and Mrs. Matobato. Born via normal vaginal delivery on their
house.

VI.Psychosocial history:

The patient sorrounding is good and there were no lakes, swamp or river nearby. They used a deep
well for drinking and taking a bath. He smokes 5 sticks of cigar. Per day, and play basketball in freetime.







PATTERNS OF FUNCTIONING CLINICAL INSPECTION OTHER SOURCES
1. RESPIRATORY
- (+) Hx of Asthma
- Consumed 5 sticks of
cigar/day
- Started smoking since
17 y.o


2. CIRCULATORY
- (+)Hx of HPN






3. FOODS AND FLUIDS INTAKE
- Usual food taken: leafy
vegetables, fish, rice,
root crops
- (-)food allergies
- (-)food preferences &
dislikes
- Drink 4 glasses of water
each day
- Drink 10 glasses of tuba
occasionally

4. ELIMINATION
- Void more than 5x/day
- Defecate 1x/day or
sometimes 1 time every
2 days
- Fun of retaining stools if
at work







5. REGULATORY MECHANISM
- (+) mild fever during
childhood


6. HYGIENE
- Take a bath 1-2x/day
- Seldom use shampoo
- Change cloth everyday
- No allergies to soap &
shampoo
- Combs hair



7. EXERCISE & LOCOMOTION
- Take the daily activities
as exercise




- RR = 26cpm
- No accessory
muscle used
- No respiratory aids
used
- No cough and cold

- BP = 110/70 mmHg
- PR = 53 bpm
- No presence of
discoloured or
swollen parts
- Good capillary refill


- Good skin turgor
- Dry lips
- With an IVF of D5LR
@ 30gtts/min
- No NGT








- Not constipated
- Presence of
indwelling catheter
- (-) nausea









- T = 36.6
- Afebrile
- (-) chills



- Untidy to look at
- (-)skin lesions
- Hair is equally
distributed
- (+)Halitosis
- Poor dental care
- Presence of plaque


- Impaired mobility
due to pain












Hematology:
WBC: 18.30x10^9/L
Neutrophil: .90
Lymphocyte: .10
Hematocrit: .46















URINALYSIS
Color : Dark yellow
Transparency: Turbid
Specific gravity: 1.025
PH: 6.0
Glucose: negative
Albumin: trace
WBC: 2-3/hpf
Bacteria: moderate
Mucus threads: many
Costs: coarse granular: 0-1/lpf
Uric acid: moderate











































8. REST & SLEEP
- Retire @ 9pm, rises @
5am
- Side lying position
- Uses 2 pillow


9. COMMUNICATION &
SPECIAL SENSES
- Right handed
- No visual/auditory
disturbances
- Speaks waray
- (-)ear, eye gadgets

10. SENSORY
- (-) Hx of convulsions, Hx
of epilepsy




11. PAIN & DISCOMFORT
- Pain experienced in the
RLQ of the abdomen &
used herbal oil &
kerosene for relief

12. RECREATION/DIVERSION
- Playing basketball for
fun


13. RELIGIOUS LIFE
- Roman Catholic

14. COPING MECHANISM
- Self keeping of problem

15. SOCIAL OCCUPATION
- Heavy type of work





- Interrupted sleep
due to pain





- Eyelashes are
equally
Distributed
- Whitish sclera
- Pinkish conjunctiva



- (-) convulsions nor
epilepsy





- Pain scale of 8
- Impaired mobility
due to pain



- Throw jokes while
interview process


- No medals worn



- Friendly

LABORATORY RESULTS
Hematology:
















Components Normal values Results Interpretation Clinical Significance

1. WBC


2. Neutrophils



3. Lymphocyte




4. Hematocrit

4.5 11x10
9
/L


0.45 0.73



0.2 0.4




Males: 42 52 %
Females: 35 47 %

18.30 x 10
9
/L


0.90



0.10




46 %

Increased


Increased



Decreased




Normal

Presence of inflammation


Acute infection, trauma or
surgery


Aplastic anemia, SLE,
immunodeficiency including
AIDS


Balance proportion of blood
volume that is occupied by
RBC

Urinalysis:
Components Normal Results Interpretation Clinical Significance

1. Color


2. Transparency

3. Specific gravity

4. PH


5. Glucose

6. Albumin

7. WBC

8. Bacteria

9. Casts


10. Uric Acid

Pale yellow to amber


Clear to slightly hazy

1.015-1.025

4.5-8.0


Negative

Negative

Negative or rare

Negative

Occasionally hyaline casts


1.58-4.43 mmol/24 h

Dark Yellow


Turbid

1.025

6.0


Negative

Negative

2-3/hpf

Moderate

Coarse granular: 0-1/hpf


3.13 mmol/24 h

Not normal


Not normal

Normal

Normal


Normal

Normal

Not normal

Not normal, bacteremia

Not normal


Normal

Not enough water intake,
presence of bilirubin

Cystisis, presence of bacteria

Properly diluted urine

Not risk for calcification, and
infection

Absence of DM

Proper filtration of glumerolus

Cystisis, nephritis,

Urinary tract infection

Presence of renal infection or
disease

Absence of calculi




ANATOMY AND PHYSIOLOGY
Vermiform appendix
In human anatomy, the appendix (or vermiform appendix; also cecal (or caecal)
appendix; also vermix) is a blind-ended tube connected to the cecum (or caecum),
from which it develops embryologically. The cecum is a pouchlike structure of the
colon. The appendix is near the junction of the small intestine and the large intestine.
The appendix averages 10 cm in length, but can range from 2 to 20 cm. The
diameter of the appendix is usually between 7 and 8 mm. The appendix is located in
the lower right quadrant of the abdomen, or more specifically, the right iliac fossa the
position within the abdomen corresponds to a point on the surface known as
McBurney's point. While the base of the appendix is at a fairly constant location, 2 cm
below the ileocaecal valve, the location of the tip of the appendix can vary from being
retrocaecal to being in the pelvis to being extraperitoneal. In rare individuals with situs
inversus, the appendix may be located in the lower left side.
Maintaining gut flora: major function
Although it was long accepted that the immune tissue, called gut associated lymphoid
tissue, surrounding the appendix and elsewhere in the gut carries out a number of
important functions
The digestive tract's immune system is often referred to as gut-associated lymphoid
tissue (GALT) and works to protect the body from invasion. GALT is an example of
mucosa-associated lymphoid tissue.
The mucosa-associated lymphoid tissue (MALT) (also called mucosa-associated
lymphatic tissue) is the diffuse system of small concentrations of lymphoid tissue found
in various sites of the body such as the gastrointestinal tract, thyroid, breast, lung,
salivary glands, eye, and skin.



FOR the PATHOPYSIOLOGY just go to this site :
http://www.scribd.com/doc/46437230/Pathophysiology-of-Appendicitis







Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation

Limited movement related to
pain as manifested by:
Subjective:
Anay, hinay hinay la ke ma
ol-ol tak samad as
verbalized by the patient.

Objective:
Temp - 36.6
o
C
PR - 53 bpm
RR - 26 cpm
BP - 110/70mmhg

weakness
facial grimace
guarding behavior
incision on RLQ




Having an Appendectomy is
a procedure that has the
need to cause the tissue to
be traumatized, which leads
to the inflammatory process
characterized by pain,
redness, swelling and loss of
function of some part, it is
effective in the treatment of
appendicitis with perforation,
surgery leaves tissue
damage that causes the
release of chemical
mediators, and WBCs which
causes to form exudates then
this exudates causes the
nerve endings to be
compressed thus making
pain and this pain makes a
person to have limited
movement.

Reference:
Medical Surgical nursing by
Brunner and Suddarth 11
th

edition; Vol.2 pages 1240-
1242



After 8 hours of nursing
interventions, the patient will
be able to Regain / maintain
mobility at the higher
possible level, Demonstrate
techniques that enable
resumption of activities, and
Increase strength/ function
of affected and
compensatory body parts.


INDEPENDENT:
1. Instruct the client to
minimize activities
that will put pressure
on his abdomen.
2. Reposition
periodically and
slowly and
encourage deep
breathing exercises.
3. Encourage rest.
4. Move patient
slowly and
deliberately.
5. Administer
analgesics as
ordered





1. Activity that require
holding the breath and
bearing down can result
in pain to surgical site in
RLQ, bradycardia and
rebound tachycardia
with elevated BP.
2. Prevent / reduces
incidence of skin and
respiratory
complications.
3. Reduces myocardial
workload / oxygen
consumption, reducing
risk of complication.
4. Reduces muscle
tension or guarding,
which may help
minimize pain of
movement.
5. To maintain
acceptable level in
pain. Notify physician if
regimen is inadequate
to meet pain control
goal.


After 8 hours of nursing
interventions the patient
is able to Rest quietly Sit
in a high-fowlers position
from lying in bed, and
know the proper way in
seating from a supine
position. therefore:
GOAL MET



















Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation

Impaired skin integrity
related to surgical incision

SUBJECTIVE:
katapus ko la ka operahe
as verbalize by the patient

OBJECTIVE:
- open wound
- visible surgical incision
- post-operative patient

Temp - 36.6
o
C
PR - 53 bpm
RR - 26 cpm
BP - 110/70mmhg


Surgical intervention involves
removal of appendix within 24
to 28 hours in which surgery
can be performed through a
small incision that causes a
disruption or damage to the
skin tissues. Which will leads
to impairment of the first
protective layer from
infections or foreign object.

Reference:
Medical surgical nursing by
brunner and suddarth, 11
th

edition volume 2 @ page:
1242


After 8 hours of nursing
intervention the patient
will Achieve timely
wound healing and be
free of infection,
demonstrate how to
keep wound dry and
promote healing.

DEPENDENT:

1) Observe wound,
note characteristics
of drainage.



2) Change dressing as
needed using
aseptic technique.



3) Encourage side lying
position (on the left-
side) or a semi-
fowlers position.


4) Encourage guarding
behavior.

DEPENDENT
5) Administer
antibiotics as
doctors order

1. Post-operative
hemorrhage is likely
to occur during first 2
days, whereas
infection may
develop anytime.

2. Reduce skin irritation
and potential
infection, also to
prevent soaking the
dressing by any
discharges.

3. May decrease
pressure to operated
site, thus relieving
abdominal distention.

4. Promote protection to
the incision site.

5. Hasten the healing of
the wound.

After 8 hours of nursing
interventions the patients
wound appears to be dry and
freed from drainage or
purulent substances therefore
goal was met.
Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation

Risk for infection related to
surgical incision at right lower
quadrant of the body.
Objective:
incised skin @ right
lower quadrant
RR 26 cpm
PR 53 bpm
Temp 36.6
o
C
Incision pain




The creation of surgical
incision during appendectomy
disrupts the skin integrity of
the skin and its protective
function. Exposure of deep
body tissues to the pathogens
in the environment places the
patient at risk for infection of
the surgical site, a potentially
threatening complication.
Factors related to the surgical
procedure include the method
of preoperative skin
preparation, surgical attire of
the team, method of sterile
draping, duration of surgery
and length of procedure.



After 8 hours of
nursing intervention,
the patient will be able
to Verbalize and
understand the
causative/risk factor for
the infection.
Demonstrate
techniques in
minimizing infection.
Remove all possible
factors that may
contribute to the
infection process.
Achieve timely wound
healing; be free of
purulent drainage or
erythema.



INDEPENDENT:
1. Monitor vital signs,
onset of fever with
chills, and pain.
2. Practice/ instruct good
hand washing and
aseptic wound care.
3. Inspect incision site.
Note characteristics of
drainage from wound.
4. Change wound
dressing as indicated,
using proper
technique for
changing/ disposing of
contaminated
materials.
5. Encourage intake of
fluid and food that is
rich in Vitamin C.



1. Fever and pain indicate
inflammatory
responses, which
contribute to infection.
2. Reduces the risk for
infection or cross
contamination of
bacteria.
3. Provides early detection
of infection process, and
presence of discharges
may help to identify
whether there is an
infection.
4. To reduce/ correct
existing risk factors.
5. Promotes healing and
prevents dehydration.



After 8 hours of nursing
education and interventions,
the patient was More
conscious about his
environment and the patient
seems to be hesitated and
confused or failed to
express some of the
information imparted by the
nursing students therefore:
GOAL WAS PARTIALLY
MET.