I.

Introduction
Appendicitis is a common and urgent surgical illness with variable
manifestations, generous overlap with other clinical syndromes, and significant
morbidity, which increases with diagnostic delay. No single sign, symptom, or
diagnostic test accurately confirms the diagnosis of appendiceal inflammation in
all cases.
The chosen case would enable the student nurse to understand the
disease more clearly in a pragmatic and practical setting. By knowing its cause,
precipitating and predisposing factors, and other important facts with regards to
the disease, the student nurse would be able to relate it with the patients
condition and therefore be able to come up with a good plan as to how to give
the utmost and best care.
Expectations from this case study would include the development of the
student nurses skills needed in performing holistic care with clients having their
corresponding conditions, especially clients with acute appendicitis. This will
also develop the student nurses ability to make appropriate decisions with
regards to the care of such patients. Moreover by knowing the disease more
thoroughly, the student nurse can assist the client in coping with the present
condition by imparting knowledge as to the definition of the disease, and on how
to manage it both independently and dependently.

Self-care activities,

medication regimen, diet modification are only some of the things that are to be
considered.
Acute appendicitis commonly presents with periumbilical pain, nausea,
and vomiting. Within days, the pain localizes to the right lower quadrant and is
accompanied by peritoneal signs on physical examination. A clinical diagnosis is
often difficult to make, as a variety of other disorders can have a similar clinical
presentation.

An inflamed appendix is identified as a blind-ended, aperistaltic and

noncompressible tube arising from the cecum and exceeding 6 mm in AP
diameter. An appendicolith (or fecalith) may be visible within its lumen. The
presence of an appendicolith, even without visualization of an inflamed appendix,
suggests acute appendicitis. The finding of an echogenic periappendiceal mass,
representing inflammation of the surrounding fat, suggests perforation of the
appendix. Compression sonography can expedite diagnosis and surgical
intervention, thereby decreasing the morbidity of the condition.

II. Objectives
Student-nurse
General Objectives:
After 2 days of giving holistic nursing care to the patient, the student-nurse
will be able to acquire knowledge attitude and skills about the care for patients
with Acute appendicitis and its management which include Appendectomy
Specific Objectives:
After 2 days of giving holistic nursing care to the patient, the student-nurse
will be able to:
1. establish rapport with client and significant others
2. perform thorough nursing assessment
3. review the anatomy and physiology of the organ system affected in
acute appendicitis
4. perform appropriate nursing intervention based on the needs and
problems identified
5. impart health teaching to the patient and significant others
Patient and the family
General Objectives:
After 2 days of giving holistic nursing care or student nurse-patientsignificant others interaction, the patient as well as the significant others will be
able to acquire knowledge, attitude, and skills in the management of Acute
appendicitis and the care of the patient especially after Appendectomy
Specific Objectives:
After 2 days of student-nurse client interaction, the client will be able to:
1. participate in a trusting relationship with the student nurse
2. identify needs/problems with regards to his condition.
3. discuss with the student nurse set activities for health management.

4. demonstrate positive attitude in performing set activities.

5. verbalize evaluation of the interaction.
6. terminate interaction

III. Nursing Assessment

1. Personal History
1.1 Patients Profile
Name: Mr. Romulo Nadela
Age: 54 years old
Sex: Male
Civil Status: Married
Religion: Roman Catholic
Date of Admission: February 20,2007
Room: Male Surgical Ward 10
Chief complaints: Fever and Vomiting, Loose Bowel Movement
Impression/ Diagnosis: Acute Appendicitis
Physician: Dr. Stanley Uy

1.2 Family and Individual Information, Social and Health History

A case of Mister Romulo Nadela, married, 54 years old, Filipino. He is
non-asthmatic and non-diabetic. He smokes and drinks occassionaly. He has no
history of surgery. He has no known allergies to food and drugs. Patient
complaints of fever and vomiting and loose bowel movement. He is now admitted
for the first time at Cebu Doctors Hospital for having acute appendicitis and had
undergone Appendectomy last February 20,2007.

1.3 Level of Growth and development

1.3.1 Normal Development at a particular stage (Kozier,2004)
Middle Aged Adults (40 to 65 years old)
The middle years from 40 to 65 have been called the years of stability and
consolidation. For most people, it is a time when children have grown and moved
away or are moving away from home. There partners generally have more time
for and with each other and time to pursue interests they may have deferred for
years.
Physical Development
Both men and women experience decreasing hormonal production during
the middle years. The menopause refers to the so-called change of life in
women, when menstruation ceases. It is said to have occurred when a woman
has not had a menstrual period within a year. This usually occurs anywhere
between ages 40 and 55. The average is about 47 years. At this time, ovarian
activity declines until ovulation ceases. Common symptoms are hot flashes,
chilliness, a tendency of the breasts to become smaller and flabby, and a
tendency to gain weight. Insomnia and headaches also occur with relative
frequency. Psychologically, the menopause can be an anxiety-producing time,
especially if the ability to bear children is an integral part of the womans selfconcept.
Appearance:
Hair begins to thin, and gray hair appears. Skin turgor and moisture
decrease. Subcutaneous fat decreases and wrinkling occurs. Fatty tissue is
redistributed, resulting in fat deposits in the abdominal area.
Musculoskeletal system:
Skeletal muscle bulk decreases at about age 60. Thinning of the
intervertebral discs causes a decrease in height of about 1 inch. Calcium loss
from bone tissue is more common among postmenopausal women. Muscle
growth continues in proportion to use.

Cardiovascular system:
Blood vessels lose elasticity and become thicker.
Sensory perception:
Visual acuity declines, often by the late 40s, especially for near vision
(presbyopia). Auditory acuity for high-frequency sounds also decreases
(presbycusis), particularly in men. Taste sensations also diminish.
Metabolism:
Metabolism slows, resulting in weight gain.
Gastrointestinal system:
Gradual decrease in tone of large intestine may predispose the individual
to constipation.
Urinary system:
Nephron units are lost during this time, and glomerular filtration rate
decreases.
Sexuality:
Hormonal changes take place in both men and women.
Psychosocial Development
Havighurst outlines seven tasks for this age group: achieving adult civic
and social responsibility, establishing and maintaining an economic standard of
living, assisting teenage children to become responsible and happy adults,
developing adult leisure-time activities, relating oneself to ones spouse as a
person, accepting and adjusting to the physiologic changes of middle age and
adjusting to aging parents.
Erikson views the developmental choice of the middle-aged adults as
generativity verses stagnation. Generativity is defined as the concern for
establishing and guiding the next generation. In other words, the concern about
providing for the welfare of humankind is equal to the concern of providing for
self. In middle age, the self seems more altruistic, and concepts of service to
others and love and compassion gain prominence. These concepts motivate
charitable and altruistic actions such as church work, social work, political work,

community fundraising drives and cultural endeavors. Erikson believes that

people who are unable to expand their interests at this time and who do not
assume the responsibility of middle age suffer a sense of boredom and
impoverishment, that is, stagnation. These people have difficulty accepting their
aging bodies and become withdrawn and isolated. They are preoccupied with
self and unable to give to others. Some may regress to younger partners of
behavior, for example adolescent behavior.
Pecks tasks of Middle Age

Valuing wisdom versus physical power and attractiveness.

As

individuals approach middle age, physical strength and attractiveness

decline.

It then becomes necessary to gain satisfaction and ego

strength through mental and intellectual abilities. Middle-aged persons

must learn to rely more on their physical powers.

Socializing versus sexualizing. In middle age, people should begin

to redefine their interpersonal relationships. It is no longer appropriate
t relate to the opposite sex in terms of physical attractiveness; other
criteria such as friendship, warmth, and understanding should be
adopted.

Emotional flexibility versus emotional rigidity. This task concerns

the ability to become flexible, such as being able to shift emotional
investment from one person to another and from one task to another.
During this phase of life, the children often leave home, and parents
may die.

Middle-aged adults must be able to develop new roles;

socially and emotionally, or they may find themselves isolated.

Mental flexibility versus mental rigidity. Individuals often become

set in their ways as they approach middle age. They may not seek new
ideas or accept the novel solutions of others. To cope most effectively,
however, middle-aged adults should strive to remain flexible in their
thinking. The solutions of the past may not solve todays problems.
New ideas and perspectives should be considered.
8

Cognitive Development
The middle-aged adults cognitive and intellectual abilities change very
little. Cognitive processes include reaction time, memory perception, learning,
problem solving, and creativity. Reaction time during the middle years stays
much the same or diminishes during the later part of the middle years. Memory
and problem solving are maintained through the middle adulthood. Learning
continues and can be enhanced by increased motivation a this time.
Middle-aged adults are able to carry out all the strategies described in
Piagets phase of formal operations. Some may use postformal operations
strategies to assist them in understanding the contradictions that exist in both
personal and physical aspects of reality. The experiences of the professional,
social, and personal life of middle-aged persons will be reflected in their cognitive
performance. Thus approaches to problem solving and completion will vary
considerably in a middle-aged group. The middle-aged adult can reflect on the
past and current experience and can imagine, anticipate, plan and hope.
Moral Development
According to Kohlberg, the adult can move beyond the conventional level
to the post conventional level. Kohlberg believes that extensive experience of
post moral choice and responsibility is required before people can reach the post
conventional level. Kohlberg found that few of his subjects achieved the highest
level of moral reasoning. To move from stage 4, a law and order orientation, to
stage 5, a social contract orientation, requires that the individual move to a stage
in which rights of others take precedence. People in stage 5 take steps to
support anothers rights.
Spiritual Development
Not all adults progress through Fowlers stages to the fifth, called the
paradoxical-consolidative stage. At this stage, the individual can view truth from
a number of viewpoints. Fowlers fifth stage corresponds to Kohlbergs fifth stage

of moral development. Fowler believes that only some individuals after the age of
30 years reach this stage.
In middle adult, people tend to be less dogmatic about religious beliefs,
and religion often offers more comfort to the middle-aged person than it did
previously. People in this age group often rely on spiritual beliefs to help them
deal with illness, death and tragedy.

10

1.3.2 The ill person at particular stage of patient (Kozier,2004)

Many middle-aged adults remain healthy; however, the risk of developing
a health problem is greater than that of the young adult. Leading causes of death
in this age group include motor vehicle and occupational accidents, chronic
disease such as cancer and cardiovascular disease. Lifestyle patterns in
combination with aging, family history, and developmental stressors (e.g.
menopause, climacteric) and situational stressors (e.g. divorce) are often related
to health problems that do arise. For example smoking and excessive alcohol
consumption places an individual at greater risk of developing chronic respiratory
problems, lung cancer, and liver disease. Overeating can result in obesity,
diabetes mellitus, atherosclerosis, and its associated risk for hypertension and
coronary artery disease.
Accidents
Changing physiologic factors, as well as concern over personal and workrelated responsibilities, may contribute to the accident rate of middle-aged
people. Motor vehicle accidents are the most common cause of accidental death
in this age group. Decreased reaction times and visual acuity may make the
middle-aged adult prone to accidents. Other accidental causes of death for
middle-aged adults include falls, fires, burns, poisonings and drownings.
Occupational accidents continue to be a significant safety hazard during the
middle years.
Cancer
Cancer accounts for considerable mortality and morbidity in both men and
women. The patterns of cancer types and incidences for men and women have
changed during the past several decades. Men have a high incidence of cancer
of the lung and bladder. In women, breast cancer is highest in incidence, followed
by cancer of the colon, rectum, uterus and lung. The incidence of lung cancer is
increasing in women.
Female clients may need to be reminded to perform monthly breast selfexaminations and male clients to perform monthly testicular self-examinations in

11

order to detect growths. Postmenopausal women should report any vaginal

bleeding.
Cardiovascular disease
Coronary heart disease (CHD) is the leading cause of death nowadays.
Several factors contribute to risk of CHD. These include smoking, obesity,
hypertension, hyperlipidemia, diabetes mellitus, sedentary lifestyle, a family
history of myocardial infarction or sudden death in a father less than 55 years old
or in a mother less than 65 years old, and the individuals age. Men over 45
years of age and women over 55 years of age are at greater risk of developing
CHD than younger adults. Physical inactivity places individuals at greater risk of
developing CHD than any other factor.
Obesity
Middle-aged adults who gain weight may not be aware of some common
factors abou this age period. Decreased metabolic activity and decreased
physical activity mean a decrease in caloric need. The nurses role in nutritional
health promotion is to counsel clients to prevent obesity by reducing caloric
intake and participating in regular exercise. Clients should also be warned that
being overweight is a risk factor for many chronic diseases such as diabetes and
hypertension and for problems of mobility such as arthritis. Clients should seek
medical advice before considering any major changes in their diets.
Alcoholism
The excessive use of alcohol can result in unemployment, disrupted
homes, accidents and diseases. Nurses can help clients by providing information
about the dangers of excessive alcohol use, by helping the individual clarify
values about health, and by referring the client to special groups.
Mental Health Alterations
Developmental stressors, such as the menopause, the climacteric, aging,
and impending retirement, and situational stressors, such as divorce,
unemployment, and death of a spouse, can precipitate increased anxiety and
depression in middle-aged adults. Clients may benefit from support groups or
individual therapy to help them cope with specific crises.

12

2. Diagnostic Results
February 21,2007
DIAGNOSTIC
TEST
HISTOPATH

X-RAY

NORMAL
VALUES

PATIENTS
RESULTS

SIGNIFICANCE

Chest PA-Lateral
CHEST-PAL
These are patchy infiltrates at the
Bronchopneumonic at the
medial aspect of both lungs. The
both lungs is entertained.
trachea is in the midline. The cardiac
shadow is not enlarged. The pulmonary
vasculature and mediastinal structure
are unremarkable. The hemidiaphragm
and costophrenic sulci are intact. The
soft tissues and visualized osseous
structure are unremarkable.
Abdomen AP (supine upright)
There is a well defined radio-opaque
Impression:
density measuring 1.4cm at the right
Abdomen supine and upright
lower hemi abdomen, anterolateral to 1. Well defined calcified
L4 and L5 level. There is no evidence nodular density at the right
of hepatic or spleenic enlargement.
hemi-abdomen anterolateral
Both renal shadows are fairly distinct. to L4 and L5 level. This is non
Both psoas shadows are symmetrical. specific and likely a fecalith.
Both properitoneal fat lines are intact. Ultrasound correlation
The soft tissues and visualized osseous suggested if clinically
structure are unremarkable.
warranted.
Diagnosis:
Specimen:
Vermiform Appendix
Vermiform appendix
Acute suppurative
Gross Examination:
appendicitis
Received is a vermiform appendix
measuring 10x5 mm. the serosa is
covered with fibrino purulent exudates.
The lumen is dilated filled with fecalith
Representive tissue is processed.
Microscopic Examination:
Microscopic examination of processed
specimen shows section of the
appendix. The mucosa of which is
largely denuded and replaced by
purulent exudant. The muscular wall
and serosa shows moderate infiltration
of polymorphonuclear leikocytes.

February 21,2007
DIAGNOSTIC

NORMAL

PATIENTS

SIGNIFICANCE

13

TEST

VALUES

RESULTS

Hemoglobin

14.0-17.5g/dl

12.5

severe hemorrhage

Hematocrit

41.5-50.4%

36.71

acute/massive blood loss

4.4-11.0x10^9/ul

15.45

acute infectious disease

Neutrophil

40-70%

79

acute infectious disease

Lymphocytes

20-40%

14

in aplastic anemia,
agranulocytosis

0-8%

02

normal

4.5-5.9 10^12/ul

3.92

acute presence of anemia

MCV

80-96 fl

91.3

normal

McH

27.5-33.2pg

25.97

acute presence of anemia

McHc

33.4-35.5%

30.89

acute presence of anemia

150-450 10^9/L

582

malignancy of disease and

postoperatively

White Blood Cell

Monocytes
Red Blood Cells

Platelets

(Medical Surgical Nursing by

Smeltzer and Bare Ed.9 Vol.II
pages1953-1954)

3. Functional Health Patterns

14

3.1 Health Perception-Health Management Pattern

Patient appears tired as he has slow guarded movements and could
only speak minimally. Discomforts of postoperative surgery were evident as the
patient felt pain, constipation and feeling of weakness. However, he verbalizes
that h is happy for a successful operation, and describes hisealth better, now that
he is slowly recovering.
3.2 Nutritional Metabolic Pattern
His meals usually consist of rice and fish, and often pork during lunch
and dinner time and usually eat bread with coffee or milk during breakfast. For
snacks he eats banana or bread. His fluid intake is about 5 glasses a day and
says that he drinks carbonated drinks often. He does not have any problems with
his appetite. He doesnt have any problems with ability to eat such as swallowing
or chewing liquids and solids.
3.3 Elimination Pattern
The client has a good elimination pattern before his admission. But
now due to his present condition the client has difficulty in performing his usual
waste elimination. He doesnt use any assistive devices in voiding. The client
has good bowel elimination before his admission. He eliminate his waste daily.
But during his admission he has difficulty eliminating his waste. He hasnt
defecated for 3 days already. His skin turgor is warm and dry.
3.4 Activity/Exercise
Patient is found lying in bed and still asks assistance from significant
others for help. He cant change positions, as he complains. He looks tired.
Before admission he exercises by walking and working.
3.5 Cognitive/ Perceptual Pattern
He used to have glasses. He can read and write. However, as of now, se is
tired and rests in bed most of the time. He doesnt have any complaints of
vertigo. He usually complains on the pain he felt on his abdomen where he was
operated
3.6 Rest / Sleep

15

The client usually sleeps for about 7 hours per day. He can sleep well
and has energy of doing his usual activities in the home. He usually sleeps at 10
oclock in the evening and wakes up at 6 oclock in the morning. But during his
admission and after his operation the client becomes irritable due to pain. He
sleeps for about 5-7 hours and sometimes woke up due to pain felt in his
operation. He doesnt have any problems in falling asleep except that if he feels
the pain he needs medication to tolerate it. He also doesnt have any problems in
remaining asleep or feeling of not rested after sleep.
3.7 Self Perception
The client is concerned of his present condition since it hinders him
from doing the things. Being ill made the client feel differently since it makes him
very irritable.
3.8 Role Relationship
The client speaks Cebuano and English. He express his feelings
verbally also through facial expressions and gestures. He lives with his family.
He asks for help in time of need usually to his wife and family. They have good
communication to his family. And the family open up to the problems they
encounter and solve problems together.
3.9 Sexuality - Productive Pattern
Client is aware of his sexual functioning.
3.10 Coping Stress Tolerance Pattern
The client makes decision with his family. He hasnt loss anyone or
something in his life. The thing that he likes about himself is that he close with
his family. Due to his present condition the things he likes to do was hindered.
The client rest, sleep and be with his family when he is tense, irritable, or under
stress. The significant others as well as the client expect the nurse to provide
them more comfort and security during their hospitalization by rendering them
exceptional care and provide them appropriate in formations they need to help
the condition of the client.
3.11 Value-Belief System

16

He strongly believes Gods existence in our lives. The family as well as

the client find source of strength or meaning to God. They pray to God to help
them in their problems in life as well as thanking God for the blessings they have
receive. They usually go to church every Sunday but due to the clients present
condition the family has lesser time to go to church. But they never forgot to pray
to God even if they are too busy for their daily activities.

4. Anatomy and Physiology

17

4.1 Explain the normal anatomy and physiology of organ/system

affected
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.
The appendix averages 10 cm in length, but can range from 2-20 cm. The
diameter of the appendix is usually less than 7-8 mm. While the base of the
appendix is at a fairly constant location, the location of the tip of the appendix can
vary from being retrocaecal to being in the pelvis to being extraperitoneal. In
most people, the appendix is located at the lower right quadrant of the abdomen.
In people with situs inversus, the appendix may be located in the lower left side.
The appendix is longest in childhood and gradually shrinks throughout
adult life. The wall of the appendix is composed of all layers typical of the
intestine, but it is thickened and contains a concentration of lymphoid tissue.
Similar to the tonsils, the lymphatic tissue in the appendix is typically in a
constant state of chronic inflammation, and it is generally difficult to tell the
difference between pathological disease and the "normal" condition (Fawcett and
Raviola 1994, p. 636). The internal diameter of the appendix, when open, has
been compared to the size of a matchstick. The small opening to the appendix
eventually closes in most people by middle age. A vermiform appendix is not
unique to humans.
Medical literature shows that the appendix is not generally credited with
significant function. The appendix is rich in infection-fighting lymphoid cells,
suggesting that it might play a role in the immune system. Whether the appendix
has a function or not, it can be removed without any ill effects.

18

The appendix helps support the immune system in two ways. It helps tell
lymphocytes where they need to go to fight an infection and it boosts the large
intestine's immunity to a variety of foods and drugs. The latter helps keep your
gastrointestinal tract from getting inflamed in response to certain food and
medications you ingest.
The appendix to the human anatomy is by its active participation in the
lymphatic system. The lymphatic system consists of fluid called lymph (95
percent water) which flows through specific lymphatic vessels thus performing a
number of important functions within the human anatomy: First, it drains tissue
spaces within the body of excess interstitial fluid thus ensuring their proper
function. In addition to this, it also operates as a transport system for lipids (that
is absorbed by the gastrointestinal tract) and eventually moving them into the
blood stream. Lastly, it also carries out immune responses which targets specific
invaders and irregular cells thus eliminating these unwanted abnormalities. The
appendix has a direct relationship with this system due to its richness in lymphoid
tissue. Because of this, it therefore functions as a sift or filter thus removing
bacteria and other harmful entities from the intestines. Without this, the colon
(and other structures in the vicinity) may undergo infection and might even trigger
septic shock. Thus, through the presence of lymphatic vessels in the appendix, it
therefore ensures the proper health of the intestines hence proving its
importance to the human anatomy. In addition to these reasons, another
contribution of the appendix to the body is its possible production of antibodies
that help combat a variety of serious diseases.

4.2 Schematic diagram of organ affected

Susceptible Person

19

(Predisposing and precipitating factor)

Obstruction of the appendiceal lumen

(inspissated feces and fecalith, hyperplasia of lymphoid tissue,
mucous, foreign body, parasites, bacterial gastroenteritis)

Continued production of mucous

Distension and increased pressure of the appendix

due to accumulated intraluminal fluid

Venous congestion and ischemia, necrosis, and ulceration

(Bacterial infection may also occur)

Subsequent epigastric and periumbilical pain

Necrosis of appendiceal wall, there is peritoneal irritation

and adherence to the parietal peritoneum

Causes a shift of the pain to the right lower quadrant

of the abdomen

And involve other clinical manifestation like fever, nausea and vomiting,
diarrhea and loss of appetite

Perforation

Inflamed appendix fills with pus

or spread to the entire peritoneal cavity

Leading to progressive appendicitis

4.3 Disease process and its effects on different organ/system

20

Acute Appendicitis
Acute appendicitis, inflammation of the appendix, is the most common
surgical disease of the abdomen. Appendiceal inflammation is associated with
obstruction in 50 to 80% of cases, usually in the form of a fecalith and, less
commonly, a gallstone, tumor, or ball of worms. It is mainly a disease of
adolescents and young adults, but it may occur in any age group and affects
males slightly more than females.
Etiology and Pathophysiology
Appendicitis is thought to result from obstruction of the appendiceal
lumen, typically by lymphoid hyperplasia, but occasionally by a fecalith, foreign
body, or even worms. The obstruction leads to distention, bacterial overgrowth,
ischemia, and inflammation. If untreated, necrosis, gangrene, and perforation
occur. If the perforation is contained by the omentum, an appendiceal abscess
results.
Other conditions affecting the appendix include carcinoids, cancer, villous
adenomas, and diverticula. The appendix may also be affected by Crohn's
disease or ulcerative colitis with pancolitis.
Symptoms and Signs
The classic symptoms of acute appendicitis are epigastric or periumbilical
pain followed by brief nausea, vomiting, and anorexia; after a few hours, the pain
shifts to the right lower quadrant. Pain increases with cough and motion. Classic
signs are right lower quadrant direct and rebound tenderness located at
McBurney's point (junction of the middle and outer thirds of the line joining the
umbilicus to the anterior superior spine). Additional signs are pain felt in the right
lower quadrant with palpation of the left lower quadrant (Rovsing's sign), an
increase in pain from passive extension of the right hip joint that stretches the
iliopsoas muscle (psoas sign), or pain produced by passive internal rotation of
21

the flexed thigh (obturator sign). Low-grade fever (rectal temperature 37.7 to
38.3 C is common.
Unfortunately, these classic findings appear in < 50% of patients. Many
variations in symptoms and signs occur. Pain may not be localized, particularly in
infants and children. Tenderness may be diffuse or, in rare instances, absent.
Bowel movements are usually less frequent or absent; if diarrhea is a sign, a
retrocecal appendix should be suspected. RBCs or WBCs may be present in the
urine. Atypical symptoms are common in elderly patients and pregnant women; in
particular, pain is less severe and local tenderness is less marked.

4.4 Classical and Clinical Signs and symptoms

22

CLASSICALSYPTOMS

CLINICAL SYMPTOMS

RATIONALE

right lower quadrant

abdominal pain

Manifested

It is manifested due to an increase in

intraluminal pressure initiating a
progressively sever generalized or upper
abdominal pain.

fever
Manifested

Not manifested

This may be a symptom of an

underlying physical problem which
results to uneasy sensation in the upper
abdomen, sometimes preceding the act
of vomiting.

Manifested

Occurs because the vomiting center

has been excited by impulses stimulated
by stomach-turning sights or odors, by
particular drugs and anesthesia. Also
due to the occurrence of abdominal
pressure.

nausea

vomiting

loss of appetite
Manifested
diarrhea before
surgery

constipation after
surgery

anorexia

It occurs due to presence of appendiceal

infection.

Manifested

It is common since it is associated with

nausea and vomiting.
Occurs due to the presence of infection
which invades the surface mucosa and
the presence of abdominal tenderness
and muscle spasm

Manifested

It occurs due to restriction of food and

liquid intake after pts. surgery which
leads to pts. abdominal distention.

Not manifested

It is usually manifested in gastric and

abdominal problems to individuals.
Hence, it is associated with low grade
fever, nausea and vomiting.

IV. Nursing Intervention

23

1. Care guide of patient with disease condition

Medical Management
Treatment of acute appendicitis is appendectomy; because treatment delay
increases mortality. The surgeon can usually remove the appendix even if
perforated. Occasionally, the appendix is difficult to locate: In these cases, it
usually lies behind the cecum or the ileum and mesentery of the right colon. A
contraindication to appendectomy is inflammatory bowel disease involving the
cecum. However, in cases of terminal ileitis and a normal cecum, the appendix
should be removed.
Appendectomy should be preceded by IV antibiotics. Third-generation
cephalosporins are preferred. For nonperforated appendicitis, no further
antibiotics are required. If the appendix is perforated, antibiotics should be
continued until the patient's temperature and WBC count have normalized.
Surgical Management

Appendectomycurative

Laparoscopic appendectomycurative, faster recovery

Interval appendectomywith abscess first treated with antibiotics,

intravenous fluids, possibly surgical drainage; elective appendectomy six
weeks to three months later.

Nursing Management of the Surgical Client

ASSESSMENT
Perform the usual postoperative assessments. Evaluation of psychological
manifestations is also important. Assess GI function by listening for bowel
sounds, noting distention and seeing whether the abdomen is soft or firm.
Passing of flatus (bowel gas) indicates the return of GI function.

24

PAIN RELIEF.
Pain and abdominal discomfort are not uncommon. Analgesics are
administered as prescribed to relieve pain and promote daily ambulation.
PROMOTE PERISTALSIS.
Pain and discomfort after abdominal hysterectomy usually center on the
on the incision and postoperative gas pains. After abdominal hysterectomy, GI
functioning returns slowly. Uncomfortable gas pains are often experienced during
the early postoperative period. Early, frequent ambulation helps to improve GI
function. If gas pains persist, a small enema may be prescribed to facilitate
peristalsis and to prevent constipation. Continue to encourage frequent
ambulation to facilitate the return of normal GI functioning. Drinking warm fluids
may encourage return of peristalsis.

25

2.2 Nursing Care Plan

Name of Patient:Mr. Romulo Nadela
Age: 54 years old
Room No. Male Surgical Ward 10

Chief Complaints: LBM, Fever, Diarrhea

Diagnosis: Acute Appendicitis

26

Nursing Care Plan

NEEDS/
PROBLEMS/
CUES
I. Physiologic
Overload
1. Pain
Cues:
- post
operative
patient
(appendectomy)
- located in
the right
quadrant of
the abdomen
- 2-3 mins.
duration of
pain
- sharp
throbbing
pain
-aggrevated
by sudden
movements
- relieve by
rest and
proper
positioning
facial grimace
- 5 inches
length of
incision
- slow
movement
- irritability
- fatigue
- restlessness
- sakit pa
man gihapon
ang tahi

II. Physiologic
Overload
2.
Constipation

NURSING
DIAGNOS
IS
Alteration
in comfort:
pain
related to
tissue
trauma
sustained
after
surgical
procedure

Altered
bowel
elimination
:
Constipati

SCIENTIFIC
BASIS
The degree and
severity of postoperative pain on
the physiological
make-up of the
person, the
subsequent
tolerance level,
the incision site,
the nature of the
operation, the
extent of surgical
trauma, and the
type of anesthetic
agent and how it
was
administered.
(Medical Surgical
nursing,Smeltzer
p443)

Because of bowel
manipulation,
assessing for GI
function and
seeing whether

OBJECTIV
ES OF
CARE
After 8
hours of
giving
holistic
nursing
care, the
patient will
be able to:
1.
experience
alleviation
of pain as
evidenced
by:
a. reports
pain relief
or comfort
from a pain
scale of 7
to 5.
b. appears
relaxed.
c. ability to
relax or
sleep
appropriate
ly.

2. regain
normal
pattern of
bowel
functioning

NURSING
INTERVENTION

Measures to:
a. promote relief
from pain
1. assist patient
to change in
position

RATIONALE

1. to promote comfort
and improve ventilation
( Nurses Pocket Guide
Ed. 8 P.355)

2. teach deep
breathing
technique

2. helps hasten recovery

& decrease tendency to
hypoventilation
( Nurses Pocket Guide
Ed. 8 P.355)

3. provide
comfort
measures like
backrub, use of
heat & cold
application and
positioning

3. to provide
nonpharmaco-logical
pain management
( Nurses Pocket Guide
Ed. 8 P.350)

4. encourage
adequate rest
periods

4. helps decrease pain

& increase effectiveness
to pain management
( Nurses Pocket Guide
Ed. 8 P.355)

5.provide
diversional
activities by
listening to
radio,
socialization
and massage

5. to prevent
fatigue( Nurses Pocket
Guide Ed. 8 P.355)

6. administer
analgesics as
ordered

6. to help decrease pain

sensation
( Nurses Pocket Guide
Ed. 8 P.355)

b. promote
regular bowel
functioning
1. auscultate

1. reflecting bowel

27

cues:
- unable to
pass stool
- abdominal
pain
- nausea
- irritable
- weakness
- fatigue
- decrease
skin turgor
-wala pa ko
kalibang

III. Physiologic
Problem
High risk for
infection

on related
to bowel
manipulati
on during
surgery

Risk for
infection:
traumatize
d tissue
related to

the abdomen is
soft or firm,
passing of flatus
(bowel gas)
indicates the
return of GI
function; this
should be noted
after an
abdominal
hysterectomy.
(Medical Surgical
Nursing by Black
pg.993

Infection is often
due to lack of
blood supply, lack
of oxygen, autocontamination or

3. remain
the patient
free from
infection as
evidence

abdomen for
presence,
location, and
characteristics
of bowel sounds

activity (Nurses Pocket

Guide Ed.8 p.150)

2. encourage
the patient early,
frequent
ambulation

2. helps to improve GI
function and to relieve
abdominal
distention(Med Surg Ng
by Black pg.993)

3.provide
privacy and
routinely
schedule time
for defecation

3. to facilitate
concentration in bowel
elimination(Nurses
Pocket Guide Ed.8
p.151)

4. assist in
digitally remove
impacted stools

4. to facilitate bowel
elimination(Nurses
Pocket Guide Ed.8
p.151)

5. provide sitz
bath after stools

5. for soothing effect of

rectal area (Nurses
Pocket Guide Ed.8
p.151)

6.instruct patient
to maintain
elimination daily
as appropriate

6. to help monitor bowel

pattern(Nurses Pocket
Guide Ed.8 p.151)

7 administer
laxatives or stool
softeners per
order

-to facilitate peristalsis

and prevent
constipation(Med Surg
Ng by Black pg.993)
-may facilitate passage
of stool

c. prevent
occurence of
infection
1. adhere to

1. establish mechanisms

28

-undergone
surgical
procedure
-with surgical
wound at the
abdominal
area dressed
with betadine,
sterile OS
secured with
plaster
-surgical
incision of
about 5
inches located
in the right
quadrant of
the abdomen

surgical
operation

exposure to
environmental
pathogens.
Clinical
manifestations of
wound infection
includes
increased
drainage, odor
from the wound,
increasing pain
fever and general
malaise. The
infected wound is
slow to heal and
may open.
(Medical Surgical
Nursing by Black
p. 413)

by a
normal
body
temperatur
e

facility infection
control,
sterilization and
aseptic policies

designed to prevent
infection
NCP:6th ed. by
:Doenges p.770

2. wash hands
before contact
with posoperative patient

2. it remains the most

effective method of
infection control
NCP:6th ed. by
:Doenges p.291

3. examine
skin for break
or irritation,
signs of
infection

3. disruptions of skin
integrity of near the
operative site are sources
of contamination to the
incision
NCP:6th ed. by :
Doenges p.770

4. provide
appropriate
wound care
like use
dressing
materials that
maintain a
moist free
wound surface

4. proper wound are

facilitates wound healing
and reduces persistent
irritation of one
area
NCP by Ulrich p.48

5. apply sterile
dressing

5. prevents environmental
contamination of fresh
wound
NCP:6th ed. by :
Doenges p.770

6. encourage
early
ambulation,
deep breathing
and changing
positions

6. for mobilization of
respiratory secretions
Nurses Pocket Guide
by Doenges p. 294

7. administer
antibiotic as
indicated

7. May be given
prophylactically for
suspected infection for
contamination
Nurses Pocket Guide
by Doenges p. 294

2.3 SOAPIE
SOAPIE NO.1
February 23,2007
29

S- Sakit man gihapon akong tahi.

O- received a 54 y.o. male patient with wound dressing at right fundal area, dry and
intact, with IVF D5LR 1L @ 30gtts/min at the left hand, lying in bed, weak and
tired, complains of intermittent gnawing pain felt at surgical site lasting from 2-3
minutes, located in the right quadrant of the abdomen, sharp throbbing pain,
aggrevated by sudden movements, relieve by rest and proper positioning, facial
grimace noted
A- Alteration in comfort: pain related to tissue trauma from surgical procedure
P- To verbalize diminishing of pain
I- Performed proper handwashing before performing procedures to the patient,
assisted patient in changing position, assisted in his early ambulation,
encouraged adequate rest periods, monitored and regulated IVF, monitored and
recorded vital signs, monitored and recorded input and output, provided
diversional activities
E- Verbalize relief from pain after patient and experience comfort after interventions
are implemented.

SOAPIE NO.2
February 24,2007

30

S - Wala pa ko kalibang
O -received patient, lying in bed, afebrile, conscious, able to ambulate with
assisstance, with IVF D5LR 1L @ 30gtts/min at the left hand, lying in bed, noted
abdominal distention, fatigue, irritable, muscle weakness
A - Altered bowel elimination: Constipation related to bowel manipulation during
surgery
P - To regain normal pattern of bowel functioning
I - Performed proper handwashing, encouraged patient to ambulate, palpated
abdomen for improvement from abdominal distention, checked and secured
wound dressing, monitored and regulated IVF, monitored and recorded vital
signs, monitored and recorded input and output
E- Cige, salamat kau day ha.

2.4 Health Teaching Plan

Name of Patient: Mr. Romulo Nadela
Age: 54 years old

Chief Complaints: LBM, Fever, Diarrhea

Diagnosis: Acute Appendicitis

31

Room No. Male Surgical Ward 10

HEALTH TEACHING PLAN
OBJECTIVES
General
Objectives
After 1 day of
nurse-patient
interaction the
client will be
able to gain
knowledge,
attitude and
skills in the
care for
postoperative
patients of
appendectomy

CONTENTS

METHODOLOGY

EVALUATION

Specific
Objectives:
After 30
minutes of
student nurseclient and
significant
others
interaction, the
client and the
significant
others will be
able to:
1. define
wound
dressing

2. cite
importance of
wound
dressing

1. Definition of Wound dressing

Informal discussion
Wound dressing- it is a procedure
covering a wound with clean or
sterile materials for absorption of
secretions, protection from trauma,
administration of medication or to
stop the bleeding
Sharing
2. Importance of wound dressing
1. treatment for wounds, ulcers and
recalcitrant dermatitis
2.create an optimal environment for
healing

The patient listened

attentively and was
able to understand the
meaning of wound
dressing.

The patient was able

to share some
importance of
wound dressing.

3. wounds less painful when kept

moist and absorption of topical

32

medication is enhanced
4. prevent from any infection
Demonstration
3. demonstrate
on proper
wound
dressing

3. Skills in proper wound dressing

1. wash hands and establish sterile
field with all equipments and
supplies
2. cleanse all areas of wound from
inner to outer to wash away debris,
pus, blood and necrosis
3. apply topical medication as
prescribed
4. gently place and cover wound
with sterile gauze and secure
dressing edges to the patients skin
with nonhypoallergenic tape.
5. make sure patient is comfortable
and dispose soiled materials
properly

4. enumerate
measures for
pain relief

4. Measures to relieve pain

1. Bed rest for the first 24
hours.
2. Splint incision when moving
or coughing.
3. Ambulate as soon as
possible to decrease flatus
and abdominal distention.
4. Proper breathing techniques
could promote relaxation
and relief of pain
5. Pain medications as
prescribed

5. cite ways to
prevent
infection

6. state
general post-

5. Measures to prevent infection

1. Change of dressing by
urologist on the first postoperative day; after that
dressing changes may
become nurses
responsibilities
2. increase fluid intake at least
2 to 4 L of liquid daily
3. antibiotics as prescribed

The patient was able

to cooperate follow
the right procedure of
wound dressing.

Informal discussion The patient was able

to identify bed rest as
a comfort measure to
relieve pain.

The patient was able

to ask questions about
Informal discussion wound dressing.

Informal discussion
6. Measures of general postoperative care:
1. Advise patient against sitting
too long at one time, as in

33

operative care
measures

driving long distances,

because of the possibility of
blood pooling in the lower
extremities, causing
thromboembolism.
2. Instruct patient to report
fever higher than 37.8 C
(100 F), drainage, increased
pain or cramping and foul
odor of discharge
3. Emphasize the importance
of follow-up visits and
routine physical and
gynecologic examinations.

7. Deep breathing techniques:

1. Inhale slowly and through
the nose for a count of 2
2. Exhale slowly and evenly
against pursed lips. Avoid
exhaling forcefully.
Inhalation to exhalation rate Return
is 1:2
Demonstration
7. demonstrate
3. Breathe slowly in a rhythmic
proper deep
and relaxed manner.
breathing
techniques for
8. Evidence in active participation
lung hygiene
on health teaching
and pain relief
1. listen attentively
2. share knowledge or information
they know
3. asking relevant questions

The patient was able

to demonstrate proper
breathing techniques

Sharing
8. participate
actively in the
health teaching

2.5 Drug Therapeutic Record

Name of Patient: Mr. Romulo Nadela
Chief Complaints: LBM, Fever, Diarrhea
Age: 54 years old
Diagnosis: Acute Appendicitis
Room No. Male Surgical Ward 10
Drug Therapeutic Record
DRUG/ROUTE/

CLASSIFICATION/

INDICATIONS/

PRINCIPLES

TREATMENT

34

FREQUENCY/
DOSE
Ketorolac
(Toradol) 30mg
IVTT now

MECHANISM OF
ACTION
Opiod analgesic
-inhibits
prostaglandin
synthesis
producing
peripherally
mediated
analgesia
-also has antiinflammatory
properties

CONTRAINDICATIONS/
SIDE-EFFECTS
Indications:
-management of acute
pain following major
abdominal, orthopaedic,
dental or gynecological
surgery. Short-tern
management of
moderate severe acute
pain that requires
analgesia at the opiod
level
Contraindications:
-dehydration or
hypovolemia
-moderate or severe
renal impairment
-patients with operations
with a high risk of
hemorrhage
-hypersensitivity to
Ketorolac or NSAIDs
-history of asthma

OF CARE
1. use
cautiously in
patients with
history of GI
bleeding, renal
impairment,
cardiovascular
disease
2. use
cautiously in
elderly patients
3.avoid driving
and operating
machinery

1. monitor
vital signs
2. monitor
input and
output
3.assess for
lung sounds
or any
respiratory
disorders.
4.administer
medications
per doctors
order

1. use
cautiously in
patients with
renal
impairment
severe hepatic
dysfunction
2. also use
cautiously in
patients with
hypersensitivity
to
cephalosporins
and renal
leukemia.

1. monitor
vital signs
2. monitor
input and
output
3. perform
regular hand
washing
4.administer
medications

Side-effects
-drowsiness, asthma,
edema, vasodilation, GI
pain, diarrhea, bleeding,
urinary frequency
Amoxicillin
(Himox)
500mg IVTT
8h
(8am-4pm12pm)

Broad Spectrum
antibiotic
-binds to bacterial
cell wall causing
cell death

Indications:
-infections of URT, LRT,
GUT, skin, soft tissues,
bone and joint
-septic abortion
-peripheral and intraabdominal sepsis
-dental and genital
infection
-septicemia
-post-surgical infections
-prophylaxis against
infections associated
with major surgical
procedure
Contraindications:
-hypersensitivity to
penicillins
Side-effects:
-diarrhea
-pseudomembranous
colitis

35

-indigestion
-GI disturbance
-rarely urticaria and
rashes

V. Evaluation and Recommendation

The patient had undergone appendectomy. The patient is already two
days postoperative. He still complains of pain at the incision site, aggravated by
movement and coughing and relieved by medication (Ketorolac). The patient is
not yet able to pass out stool. His vital signs remained stable.

36

Proper compliance to medication, diet, and treatment prescribed by the

doctor is highly recommended. Straining should be avoided to prevent bleeding
or further trauma to the incision site. Hygiene measures should be properly
observed, dressing changes should be done regularly.
The patient should eat a well balanced diet, drink six to eight glasses of
water daily and get plenty of rest. He should avoid heavy lifting for about 6
weeks, to prevent straining on the abdominal muscles and surgical sites. The
patient should also report signs of complications to the physician and to seek for
regular check-ups until full recovery is achieved. The student nurse also
recommends to the next and future researchers to tackle more on the pathology
and physiology of the disease to better understand its etiology

VI. Evaluation and Implication of Case Study

Nursing Practice
This case study nurtures the student nurses ability to integrate
knowledge, attitude and skills taught in the classroom, into the actual clinical set-

37

up. It provides the student nurse a comprehensive view about the field of medical
diseases and broadens knowledge in giving holistic care to the patient. It benefits
not only the patient and significant others but the student nurse as well.
Nursing Education
This case study is as vital as classroom teaching a clinical exposure in
nursing education as it broadens the student nurses knowledge even more than
classroom teaching and clinical exposure. It is an additional force in promoting
nursing education as it better helps the nurse understand the disease condition
and updates ones knowledge.
Nursing Research
This case study enhances the student nurses research ability as one
strives to have a comprehensive and thorough investigation about the case. The
student nurse utilizes the maximum resources available and is able to use them
effectively in making good and comprehensive research. This case study can be
used as a source for further researches.

VII. Bibliography
Black, Joyce M., et.al. Medical Surgical Nursing. 6 th ed. Philadelphia: W.B.
Saunders Company. 2001, pg 991-994

38

Deonges, Marilynn E., Mary Frances Moorhouse, et al. Nursing Care

Plans:Guidelines for Individualizing Patient Care. 6th Ed. Philadelphia: F.A.
Davis Company. 1997
Kozier, Barbara, et.al. Fundamentals of Nursing: Concepts, Process, and
Practice. 7th ed. USA: Pearson Education, Inc. 2004, p.629-636
Smeltzer, Suzanne C., Bare, Brenda G.. Brunner and Suddarths textbook of
Medical Surgical Nursing. 7th ed. USA: J.B. Lippincot Company. 1992. p.
1275, 1989-2006
www.faqs.org/health/Sick-V1/Appendicitis.html
www.healthatoz.com/healthatoz/Atoz/ency/appendicitis.jsp
www.medscape.com/medline/abstract/11800278
www.merck.com/mmpe/sec02/ch011/ch011e.html
www.wrongdiagnosis.com/a/acute_appendicitis/intro.html

39