A CASE STUDY OF CLIENT WITH ACUTE APPENDICITIS

THAT UNDERGONE APPENDECTOMY

Submitted by:
BSN 3A-Group 1
Aguilar, Divine Grace P.
Angeles, Sharmaine I.
Arojo, Dhianne Joye C.
Azul, Kizsia Mae
Bagay, Maria Fatima C.
Batac, Joice M.
Bernardo, Jamaica Ezza
Bonifacio, Ann Rio S.
Bulanadi, Krisna Jane D.
Carlos, Jenikka Mhae
Submitted to Clinical Instructor:
Narcisa Cruz RN, MAN
Mylene Fajardo RN, MAN
Jesusa Capispisan RN
Abigail Ramos RN, MAN
Maribel Valencia RN, MAN
Jose Florante C. Nabong RN, MAN
Marlon Robles RN
October 03, 2013

I.

INTRODUCTION

Our client is Mr.N.C, a 12-year old client from Tigbe, Norzagaray, Bulacan, admitted at Bulacan Medical Center on August 25, 2013 with an initial diagnosis
of Acute Appendicitis with chief complain of an abdominal pain.
According to US National Library of Medicine, Appendicitis is considered to be a serious illness and the most efficient treatment at the time being involves
medical surgery. Appendicitis is therefore a surgical emergency and it can be efficiently overcome only by removing the diseased appendix from the body. The
vermiform appendix is a tubular extension of the large intestine (colon) and it is considered to have a role in the process of digestion. The actual function of the
appendix is not exactly known, but its absence doesn't cause any changes inside the organism. Appendicitis occurs due to strangulation or obstruction of the
vermiform appendix.
The appendix can either be blocked by feces or it can be pressed against by swollen lymph nodes. The appendix gradually stops receiving blood and it
eventually dies. Bacteria accumulate inside the appendix and cause inflammation and swelling. Acute appendicitis may lead to complications such as perforation of
the appendix and sepsis (severe bacterial infection). In rare cases, abdominal traumatic injuries can also lead to the development of appendicitis. In some people,
genetic predispositions to appendicitis can also facilitate the occurrence of the illness.
Appendicitis can be either acute or chronic. Acute appendicitis develops faster and the presence of the illness is easier to detect. Chronic appendicitis is
slower to evolve and it is more difficult to diagnose. The most common symptoms of appendicitis are intense, continuous abdominal pain, nausea, vomiting,
constipation or diarrhea and fever. The pain usually begins in the umbilical region of the abdomen and later shifts to the right lower side. The abdominal pain
characteristic to acute appendicitis intensifies with physical effort.
An interesting aspect of appendicitis is that it can be very difficult to detect and diagnose correctly, due to the unspecific character of its symptoms. In some
cases, the patients might not have any symptoms at all (elderly people, people that have previously suffered surgical interventions, people with HIV, people with
diabetes and overweight people). The form of appendicitis that generates no specific symptoms is called a typical appendicitis. The rate of mortality among patients
with atypical appendicitis is very high.
Anyone can develop appendicitis, regardless of age and sex. However, the illness has a higher incidence in men. Also, children with ages between 3-15 are
exposed the most to developing acute appendicitis. Elderly people and patients with special conditions usually develop atypical acute appendicitis. If appendicitis is
discovered in time and treated appropriately; the patients fully recover within weeks.

However, if the illness is discovered late, it may lead to serious complications (perforation, gangrene, sepsis).Although appendicitis can't be effectively
prevented, it is thought that a diet rich in fibers may reduce the chances of developing the illness.
Incidence extrapolations for USA for Acute Appendicitis: 680,000 per year, 56,666 per month, 13,076 per week, 1,863 per day, 77 per hour, 1 per minute, 0
per second. Note: this extrapolation calculation uses the incidence statistic: 25 per 10,000 (age 10-17), 1-2 per 10,000 (under 4) Death rate extrapolations for USA
for Acute Appendicitis: 389 per year, 32 per month, 7 per week, 1 per day, 0 per hour, 0 per minute, 0 per second. Note: this extrapolation calculation uses the deaths
statistic: 390 deaths reported in USA 2010 for appendix conditions (NVSR Sep 2010). According to Department of Health, as of September 2012, statistics in the
Philippines shows that about 215,604 of the 86,241,697 Filipinos had an incident of appendicitis. Incidence (annual) of Acute Appendicitis: 25 per 10,000 (age 1017), 1-2 per 10,000 (under 4). Lifetime risk for Acute Appendicitis: 8.6% risk for males, 6.7% for females.
OBJECTIVES
GENERAL OBJECTIVE:
After 3-4 hours of Case Presentation, we nursing students will be able to gain knowledge about Appendicitis.
STUDENT-CENTERED:
I
Knowledge

Define what Appendicitis is

Enumerate signs and symptoms of Appendicitis.

Identify nursing interventions to be done when handling patient with Appendicitis.

II
Skills

Properly assess the patient.

Perform proper nursing care to patient.

Present a liable case study to clinical instructors about the patient handled at the hospital.
III

Attitude
Observe discipline while in the field of duty.
Manage own emotions while in the field of duty.
Establish self-confidence when giving nursing care into the client.

CLIENT-CENTERED:
I.

II.

III.

Knowledge
Enumerate some causes of Appendicitis
Enumerate signs and symptoms.
Identify some foods to eat and to avoid when suffering from Appendicitis.
Skills
Practice and enhance improvement a good communication skills through interviews.
Conduct a comprehensive assessment of patient who had appendicitis and undergone appendectomy.
Develop a critical thinking and analytical skills through frequent brainstorming sessions.
Attitude
Establish rapport with patient
Develop a warm environment between the student and the patient fora better working relationship towards improvement of health.
Provide health teachings with the client

II. NURSING ASSESSMENT

A PERSONAL HISTORY
Name: N.C.
Permanent Address: Tigbe, Norzagaray, Bulacan
Birthday: September 23, 2000
Age: 12 years old
Gender: Male
Occupation: None
Race: Asian
Marital Status: Single
Religious Orientation: Roman Catholic
Educational Attainment: Elementary level
Source of Healthcare Financing: Fathers Income
Healthcare Insurance: Phil Health
Date of Admission: August 25, 2013 at 12:39 pm
Date of discharge: September 03, 2013
Initial diagnosis: Acute appendicitis
Final diagnosis: supperative appendicitis

B CHIEF COMPLAINT
Abdominal Pain

C HISTORY OF THE PRESENT CONDITION

According to the father of our client, his son having an abdominal pain for 3 days on August 21, 2013. On August 17, 2013 they go in the center in
Norzagaray, and they gave 1 capsule of 10 mg of Buscopan when the abdominal cramps. Then, August 23, 2013 he admitted at Norzagaray Hospital. The
diagnosis of the doctor in Norzagaray Hospital is appendix and the appendix might blow. He was transferred at Bulacan Medical Center at 12:39 pm of
August 25, 2013 and the operations do. N.C. is a 12 years old.
According to the father of our client, his son feels the symptoms of having abdominal pain and vomiting. And he never goes in the hospital or having
a checkup. According to N.C., he is having an acute appendicitis, because when he done eating he is playing immediately.
He ignores the pain on that day and sleep but on the second day morning he suffers again the pain and he tell to his father about his feeling. His father
brought him to the Health center near there barangay and was checked up by the rural health doctor prescribed medication such as Buscopan 10 mg 1tablet a
day when his abdomen cramps.
In this 7 days onset of severe pain and symptoms his father brought him in the Norzagaray Hospital at August 23, 2013 and confined him.
Then the doctor diagnosed that the client had Acute Appendicitis with positive anorexia and vomiting in which referral for another hospital admitted
in Bulacan Medical Center, August 25, 2013 time of 12:39:19 pm for surgery.

D HISTORY OF THE PAST CONDITION/ ILLNESS

The father of our client told us that his son didnt undergo any operations, aside from he is under go before in the appendectomy cause by acute
appendicitis. His childhood or previous diseases are fever, cough, colds, diarrhea, measles, sore eyes, and mumps. According to his father, during his
childhood he has the complete immunization like BCG, DPT, OPV, HEPA A, B, and C. He has no allergies, accidents, injuries this past years, and
hospitalization aside from the present.

F. FUNCTIONAL HEALTH PATTERN

PRIOR TO HOSPITALIZATION
DURING HOSPITALIZATION
A. Health Perception and Health Management Pattern
The client perceives himself unhealthy. He suffers abdominal pain around the epigastric area, which may have an sudden onset and become increasingly severe pain,
started August 16, 2013. He also suffers vomiting, diarrhea and body malaise. He rate his pain for about 8/10 in pain scale. Kasi kung minsan hindi siya palakain
inuuna pa ang laro kesa sa kain yan siguro dahilan ng pagkakasakit ng tiyan niya as verbalized by his father.

After Surgery the client feels calm and quiet with IVF which is 0.9 NaCL 500cc @ 450 cc level regulated at 16 gtts/min. He has incision on right lower quadrant for
about 2 inches transverse and sutures. Masakit yung tahi ko as verbalized by the client. He rates the pain scale 5. He also add Kumakati ang tahi ko as he stated

B. Nutritional Metabolic Pattern

-72 HOURS DIET RECALL
August 24,
2013

August 25,
2013

August26,201
3

The client usually drink 2-3 glasses of soft drink a day, 3fruit guava and eat flavored snack. He
doesnt want to consume his full meal as stated by his father. He would go with his friend and
Breakfast
play with them. His weight was 23 kilograms and a height of 3 feet and 9 inches with a Body
Lunch
NPO
NPO
NPO
Mass Index of 17.6 which is classified as underweight. There's no difficulty in swallowing and
Dinner
no known allergy to foods His wounds dont heal easily as stated by his father. In fact there
are many scars in his legs caused by stumbling and lack of balance in playing like basketball and hide n' seek. He has twenty six permanent teeth with no third
molars yet.

-72 HOURS DIET RECALL

August 27,
2013
Breakfast 1 glass of
water
(250ml)

August 28, 2013

1 piece of bread
1 glass of water
(250 ml)

20 grams of
noodles soup
1 glass of
water (250 ml)

Lunch

August 29,
2013
2 piece of
bread
1 glass of
water (250 ml)
1 serving of
kare-kare
1 half rice
1 glass of
water (250 ml)
None

1 glass of water
(250 ml)
40 grams of
Nissan cup
noodles
Dinner
None
1 bottled mineral
water
On august 27, 2013 the doctor ordered General liquid diet And August 28-29, 2013 the doctor ordered Diet As Tolerated. "Pipilitin ko na talaga siya kumain ngayon
sa ayaw at sa gusto niya" as verbalized by his father.

C. Elimination Pattern
Urine
Stool

Color
yellowis
h
brownish

Frequency
4x a day

Amount
480 ml

Character
hazy

Discomfort
None

0-1x a day

Not
applicable

floating

Slightly

Theres no excessive perspiration but he sweat immediately while playing basketball with his friend as stated by his father. Minsan amoy pagpapawis niya na
parang mgangasim asim lalo na ka kili-kili as verbalized by his father.
Color

Frequency

Amount

Character

Discomfort

Urine
Stool

yellowis
h
brownish

6x a day

720 ml

hazy

none

1-2x a day

Not
applicable

loose

none

Post op the client doesnt feel any discomfort in urinating and defecating.
D. Activity Exercise Pattern
Meron siyang sapat na enerhiya para maglaro pero pag uutusan sa bahay walang nagagawa as verbalized by the father. The client tells that he exercise everyday
by walking to school. The school which he entered grade 6 was just walking distance as the client states. He does some recreation like basketball, hide n seek,
playing some activities with his friends either morning or in the afternoon. If he has free time he just sleeps or watches television every morning especially his
favorite shows like Dragon Ball Z and Doraemon
Perceive ability for (code level):
1
1
1
1
1
1
1

Feeding
Dressing
Bathing
Grooming
Toileting
General Mobility
Bed Mobility

(Code Level)
Level 0 - Full Self care
Level 1 - Requires use of equipment or
device
Level 2- Requires assistance or supervision
from another person
Level 3- Requires assistance or supervision
from another person or device
Level 4- Is dependent and does not
participate

On August 27, 2013, 8 am, the doctor orders the father of my client for ambulation. And for not carrying any heavy materials or objects. Being hospitalized
interfered with Activities of daily living especially in his school attendance.
Perceive ability for (code level):
0Feeding
0 Dressing
0 Bathing
0 Grooming

(Code Level)
Level 0 - Full Self care
Level 1 - Requires use of equipment or
device
Level 2- Requires assistance or supervision
from another person
Level 3- Requires assistance or supervision
from another person or device
Level 4- Is dependent and does not
participate

Start of Sleep
End of Sleep
Nap time
Total no. of Hours

10: 30 pm 8: 00 pm
7: 00 am
9: 00 am
15 minsnone
10 hours

0 Toileting
0 General Mobility
0 Bed Mobility
E. Sleep- Rest Pattern

The sleeping hours of my client starts from 8pm to 9am in the morning for a total of 10 hours in week days. But in school days it is 8pm to 6am for a total of
7hours. He has no nap time because he spent this time for recreational activities. He doesn't have any sleeping problems and no sleeping medications. He has
continuous sleep but interrupts when he felt pain on the abdomen. He only rest when he feel exhausted from playing sport.

The hours of sleep during are intermittent sleep for about 10:30 pm to 7 am. Then he sleeps at the afternoon for nap time of 15 mins. Nahihirapan akong akong
matulog dito as verbalized by the client.
F. Cognitive- Perceptual Pattern
He doesnt have any hearing difficulties and not using hearing aid. No blurred vision and also not using eye glasses. No consultation of doctor about vision. Doesnt
have any changes in the memory lately. His easiest way to learn things is to have time by his mother to teach him.
The client only suffers a bit of achiness and ichiness in his incision. No changes in the 5 senses.
G. Self- Perception Pattern and Self- Concept Pattern

He said hes healthy before his condition as my client stated. As he grows up in the age of 12 years old there so many thing changes specifically his physical
appearance. He grows more having an Adams apple and his voice gets deeper. He starts to clean by himself in hygienic purposes. Kapag pinapagalitan ako ni papa
dun ako naiinis o kaya nalulungkot kaya dinadaan ko na lang sa laro ito as verbalized by the client.

He stated that his healthy now though he can still feel a little pain. He also state that he has impaired skin integrity due to surgical incision.
H. Role- Relationship Pattern
He has parents and with 3 siblings not living alone. He lives in Tigbe, Norzagaray, Bulacan and has a nuclear family as stated by his father. He thinks that his father
was worrying about his status. He also has friends that join also in playing basketball. Opo, minsan kulang ang aking baon sa pang araw-araw kong
pangngangailangan as verbalized by the client. He said that his neighbor was kind and frequently going outside the house to talk with my neighbor.
The client was able to listen and follow on his fathers instruction. He felt uneasy with other patient. Maayos ang mga nurse at doctor dito as verbalized by the
father.
I. Sexuality Reproductive Pattern
He was circumcised last April 13, 2010. This Elective surgery was done in their barangay where in they have free circumcision on that day.
He grows physically as hes father stated. He had an Adams apple and with deep voice and underarm hair.
J. Coping Stress Tolerance Pattern
He doesnt take any drugs to cope stress neither drinks alcoholic beverages. He usually goes to the computer shop to refresh his mind. He doesnt change any in the
past 1-2 years ago with the problems.
Theres stress now as the client stated. He was uncomfortable when sleeping. He was disturbed by his surroundings like noise at night. The client also shared that he
is easily bored at bed so he usually wonder around the hospital ward.
K. Value- Belief Pattern
He doesnt like being yelled by his father. For him, family is very important and he values his studies. He's a roman catholic and religion is very important to him
especially when he has problems. Hindi nakakahadlang sa relihiyon ko ang kalagayan ko ngaun as verbalized by the client.

He prayed to God for successful surgery and for better recovery.

G. GROWTH AND DEVELOPMENT

THEORY

ERICKSONs
PSYCHOSOCIAL
DEVELOPMENT
THEORY

PIAGETs
COGNITIVE
DEVELOPMENT
THEORY

FREUDs
PSYCOSEXUAL
DEVELOPMENT
THEORY

KOHLBERGs
MORAL THEORY

FOWLERS STAGES
OF FAITH

STAGE

Industry vs. Inferiority

Formal Operational
Stage

Latency Stage

Conventional Morality

Synthetic-Conventional
Faith and the
Interpersonal Self

DEFINITION

Children are at the stage

where they will be
learning to read and
write, to do sums, to
make things on their
own. Teachers begin to
take an important role in
the childs life as they
teach the child specific
skills.
It is at this stage that the
childs peer group will
gain greater significance
and will become a major
source of the childs self

As adolescents enter this

stage, they gain the
ability to think in an
abstract manner, the
ability to combine and
classify items in a more
sophisticated way, and
the capacity for higherorder reasoning.
At about age 11+ years,
the child begins to
manipulate ideas in its
head, without any
dependence on concrete
manipulation; it has

No further psychosexual
development takes place
during this stage (latent
means hidden). The
libido is dormant. Freud
thought that most sexual
impulses are repressed
during the latent stage
and sexual energy can be
sublimated (re: defense
mechanism) towards
school work, hobbies
and friendships. Much
of the child's energies
are channeled into

Conventional morality
as defined in Kohlberg's
stages of morality is the
concept of acceptable
behavior that mirror's
the values of certain
political or social
context.

This was a watershed in

faith development for
Fowler: young person
uses logic and
hypothetical thinking to
construct and evaluate
ideas. New cognitive
abilities make mutual
perspective-taking
possible and enable one
to integrate diverse selfimages into a coherent
identity. A persona and
largely unreflective
synthesis of beliefs and

Stage 3 Interpersonal
Relationships
Often referred to as
the "good boy-good
girl" orientation, this

esteem. The child now

feels the need to win
approval by
demonstrating specific
competencies that are
valued by society, and
begin to develop a sense
of pride in their
accomplishments.
If children are
encouraged and
reinforced for their
initiative, they begin to
feel industrious and feel
confident in their ability
to achieve goals. If this
initiative is not
encouraged, if it is
restricted by parents or
teacher, then the child
begins to feel inferior,
doubting his own
abilities and therefore
may not reach his or her
potential.
If the child cannot
develop the specific skill
they feel society is
demanding (e.g. being

entered the formal

operational stage. It can
do mathematical
calculations, think
creatively, use abstract
reasoning, and imagine
the outcome of
particular actions.

developing new skills

and acquiring new
knowledge and play
becomes largely
confined to other
children of the same
gender.

stage of moral
development is
focused on living up
to social
expectations and
roles. There is an
emphasis on
conformity, being
"nice," and
consideration of how
choices influence
relationships.

Stage 4 Maintaining Social

Order
At this stage of
moral development,
people begin to
consider society as a
whole when making
judgments. The
focus is on
maintaining law and
order by following
the rules, doing
ones duty and
respecting authority.

values evolves to
support identity and to
unite one in emotional
solidarity with others.

FINDING/
ANALYSIS

REMARKS

athletic) then they may

develop a sense of
inferiority. Some failure
may be necessary so that
the child can develop
some modesty. Yet
again, a balance between
competence and
modesty is necessary.
Success in this stage will
lead to the virtue
of competence.
The client has the ability
to read and write which
is primarily needed by a
child develop his full
potential.
Positive

The client speaks

accordingly with
appropriate thoughts.

The client has a social

life for he plays with his
childhood friends.

The client obeyed his

father when we asked
for a permission to see
the site of operation.

The patient grimaced

when we palpated the
side of the incision site.

Positive

Positive

Positive

Positive

III.

ANATOMY AND PHYSIOLOGY

Small intestine- completes digestion. Mucus protects gut wall. It absorbs nutrients, mostly water. Peptidase digests proteins. Sucrases digest sugars. Amylase
digests polysaccharides.
Large intestine- reabsorbs some water and ions. It also forms and stores feces.
Appendix- is a tube-shaped organ with a length of approximately 10 cm and the stem on the cecum. It sits at the junction of the small intestine and large intestine.
Sometimes 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 (a retrocolic appendix).

In infants, the appendix is a conical diverticulum at the apex of the cecum, but with differential growth and distention of the cecum, the appendix ultimately arises
on the left and dorsally approximately 2.5 cm below the ileocecal valve. The taeniae of the colon converge at the base of the appendix, an arrangement that helps in
locating this structure at operation.
The appendix in youth is characterized by a large concentration of lymphoid follicles that appear 2 weeks after birth and number about 200 or more at age 15.
Thereafter, progressive atrophy of lymphoid tissue proceeds concomitantly with fibrosis of the wall and partial or total obliteration of the lumen.
Appendix is blooded by apendicular artery which is a branch of the artery ileocolica. Arterial appendix is end arteries. Appendix has more than 6 mesoapendiks
obstruct lymph channels leading to lymph nodes ileocaecal. Although the appendix has less functionality, but the appendix can function like any other organ.
Appendix produces mucus 1-2ml per day. The mucus poured into the caecum. If there is resistance there will be a pathogenesis of acute appendicitis. GALT (Gut
Associated Lymphoid Tissue) in the appendix produce Ig-A. However, if the appendix removed, none affect the immune body system.
Ascending colon- watery stool
Transverse colon- mushy stool
Descending colon- semi-formed stool
Sigmoid colon- feces are formed
Rectum- stores and expels feces.

IV.
PATIENT AND HIS CONDITION / ILLNESS
A. PHYSICAL ASSESSMENT
NAME: NARC
AGE: 12 years old
DATE: August 26, 2013
8 AM

12 PM

VITAL SIGNS: PR= 90 bpm

PR= 84 bpm

TEMPERATURE= 35.3 C

TEMPERATURE= 36.3 C

RR= 26 cpm

RR= 26 cpm

BP=100/80mmHg

PARTS TO BE ASSESSED

TECHNIQUE

BP=100/80mmHg

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

GENERAL SURVEY
1. Body built, height & weight Inspection
in relation to clients age,

Proportionate and varies with Height: 23 kg

lifestyle.
Weight : 39 inches
BMI: 17.6

Deviation from normal due to

malnourishment

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

3. Clients overall hygiene &

Inspection
grooming

Clean, neat

Client is clean and neat.

NORMAL

4. Body & breath odor

No body odor or minor body

Neither body odor nor breath
odor relative to work or
NORMAL
odor was observed.
exercise, no breath odor.

lifestyle & health

Inspection

5. Signs of distress in posture

Inspection
or facial expression

No distress noted.

No distress noted.

6. Obvious signs of health or

Inspection
illness

Healthy appearance.

Obvious sign of illness such as

NORMAL
pallor

NORMAL

SKIN

1. Skin color & uniformity

Inspection and Palpation

Color- varies from light to

deep brown; from ruddy pink
to light pink; from yellow The client has a light brown
overtones to olive.
complexion, uniformity in
Deviation from normal due to
Uniformity- generally uniform color except those with insect bites.
except in areas exposed to clothes,and have scars in the
sunlight; areas of lighter both legs and feet.
pigmentation (palms, lips, nail
beds) in dark skinned people.

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

2. Presence of edema

Inspection

No edema.

No edema noted.

NORMAL

Inspection

Freckles, some birthmarks,

Skin lesion located at the left Deviation from normal due to
some flat and raised nevi; no
hand due to IV insertion
IV insertion.
abrasions or other lesions.

4. Skin moisture

Palpation

Moisture in skin folds and

axillae
(varies
with
Moistened skin especially in
environmental
temperature
NORMAL
the skin folds.
and
humidity,
body
temperature and activity.)

5. Skin temperature

Palpation

Uniform; within normal range

3. Skin lesions

When pinched, skin springs

back to previous state.
6. Skin turgor

Palpation

Uniform in temperature.

NORMAL

Skin returns back to previous

NORMAL
state in less than 2 seconds.

\
NAILS
1. Fingernails plate shape to
determine its curvature & Inspection
angle
2. Fingernail & toenail bed Inspection
color

Convex curvature, angle of

Nails are in convex curvature;
nail plate about 160 degrees.

NORMAL

Highly vascular and pink in Fingernails and toe nails color NORMAL
light skinned clients; dark- are pinkish.
skinned clients may have

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

NORMAL

brown or black pigmentation

in longitudinal streaks.
3. Tissues surroundings nails

Inspection

Intact epidermis.

Intact epidermis, pale in color

4. Fingernail & toenail texture

Palpation

Smooth texture.

Clients nails are smooth in

NORMAL
texture

5. Blanch test of capillary

Palpation
refill
HAIR & SCALP
1. Evenness of growth over the
Inspection
scalp

Prompt return of pink or usual Prompt return of pink or usual NORMAL

color (generally less than 4 color (generally less than 4
seconds.)
seconds.)

Evenly distributed hair.

Hairs are evenly distributed.

Thick/thin hair.

The client has thick hair on

NORMAL
head.

3. Presence of infections or
Inspection
infestations

Not present.

No infestations noted

NORMAL

4. Texture & oiliness over the

Palpation
scalp

Silky, resilient hair.

Oily, thick, resilient hair

NORMAL

2. Hair thickness & thinness

SKULL
1. Size, shape & symmetry

Palpation

Palpation

Rounded (normocephalic and Head is symmetrically round.

symmetrical, with frontal,
parietal,
and
occipital
prominences); smooth skull

NORMAL

NORMAL

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

contour.
2. Nodules or masses &
Palpation
depressions

Smooth, uniform consistency;

No mass or nodules noted
absence of nodules or masses.

NORMAL

FACE
1. Facial features

Inspection

2. Symmetry of the facial

Inspection
movements

Symmetric
or
slightly
asymmetric facial features;
palpebral fissures equal in
size; symmetric nasolabial
folds.
Symmetrical
movements.

Symmetrical facial features;

palpebral fissures equal in
NORMAL
size; nasolabial folds are
symmetrical

facial Facial movements

symmetrical

are

all

NORMAL

EYEBROWS & EYELASHES

1. Evenness of distribution &
Inspection
direction of curl

EYELIDS
1. Surface characteristics & Inspection and Palpation
ability to blink

Hair evenly distributed; skin

intact.
Eyebrows
asymmetrically aligned equal
movement. Eyelashes curl
slightly outward.

Skin intact, no discharge, no

discoloration.
Lids
close
symmetrically approximately
15-20 involuntary blinks per
minute; bilateral blinking.
When lids open, no open, no
visible sclera above corneas,

Eyebrows and eyelashes are

both
evenly
distributed,
symmetrical
aligned. NORMAL
Eyelashes
curl
slightly
outward.
Eyelids skin are intact, no NORMAL
noted discharge, and no noted
discoloration.
Lids
close
symmetrically.
Client
exhibited
15
involuntary
blinks per minute.

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

and upper and lower borders

of cornea are slightly covered.
CONJUNCTIVA
1. Bulbar conjunctivas color,
Inspection
texture & presence of lesions

Transparent,
capillaries
Transparent;
capillaries
evident, no discharge was NORMAL
sometimes evident.
noted.

2. Palpebral conjunctivas
color, texture & presence of Inspection
lesions

Shiny, smooth, pink or red in Shiny, smooth and pale in

NORMAL
color.
color

SCLERA
1. Color & clarity

Inspection

Sclera
appears
white
(yellowish in dark- skinned Sclera appears white
clients).

Inspection

Transparent,
shiny
and
smooth; details of the iris are
Details of iris are visible.
visible. In older people, a thin
Transparent,
shiny
and
grayish white ring around the
NORMAL
smooth.
margin, called arcus senilis,
may be evident.

Inspection

Flat and round

NORMAL

CORNEA

1.Clarity & color

IRIS
1. Shape & color

PUPILS
1. Color, shape & symmetry of Inspection

Flat and round and uniform in

NORMAL
color.
NORMAL

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

size

Black in color; equal in size; Black, equal in size, about 3

normally 3-7 mm in diameter; mm in diameter; round,
round, smooth border.
smooth & symmetrical.

2. Pupil light reaction &

Inspection
accommodation

Illuminate pupil
(direct response)

constricts

Illuminated pupil constricts

REMARKS

NORMAL

Nonillluminated
constricts
response)
3. Pupils direct & consensual
Inspection
reaction to light

pupil
pupil
(consensual Non-illuminated
constricts too. Pupils dilated
when ask to look on distant
Pupils constrict when looking objects, constricts when pen NORMAL
at near object; pupil dilates was placed near eyes; when
when looking at far object; pen is moved towards the
pupils converge when object is nose
moved towards the nose.

LACRIMAL GLAND, LACRIMAL SAC & NASOLACRIMAL DUCT

No edema or tenderness over
1. Presence of edema
Inspection
No edema noted
lacrimal gland.

NORMAL

VISUAL FIELDS
1. Test for peripheral visual
Inspection
fields

When looking straight ahead,

Client can see objects in the
the client can see objects in the
NORMAL
periphery.
periphery.

EARS AURICLE
1. Color & symmetry of size
Inspection
& position

Color same as facial skin,

symmetrical, auricle aligned
with outer canthus of eye,
about 10cm from vertical.

Color is same with facial skin,

symmetrical with each other,
NORMAL
auricle aligned with outer
canthus of eye,

PARTS TO BE ASSESSED

TECHNIQUE

2. Texture & elasticity & areas

Palpation
of tenderness

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

Both pinna recoils after being

Mobile, firm and not tender,
folded. Mobile, firm and not NORMAL
pinna recoils after it is folded.
tender.

EXTERNAL EAR CANAL

1. Cerumen, skin lesions, pus
Inspection
& blood

Distal third contains hair

follicles and glands. Dry
NORMAL
cerumen in various shades of No noted pus, blood and odor.
Minimal cerumen noted.
brown

NOSE
1. Shape, size or color &
flaring or discharge from the Inspection
nares

2. Presence of redness,
swelling, growths & discharge Inspection
or nares using the flashlight

Symmetric and straight

No discharge or flaring
Uniform color
Mucosa pink
Clear, watery discharge
No lesions.

No discharge and/or flaring

noted. Symmetrical on both NORMAL
sides. Also uniform in color.

Mucosa is intact and pinkish;

minimal moist noted inside; no NORMAL
swelling or nodules found.

Inspection

Nasal septum intact and in Nasal septum is intact and in

NORMAL
midline, intact
midline

4. Test patency of both nasal

Inspection
septum

Air moves freely as the client Air moves freely as the client
NORMAL
breathes through the nares
breathes through each nares

5. Tenderness, masses
displacement of bone
cartilage

Not tender; no lesions

3. Position of nasal septum

&
& Palpation

No tenderness, no lesions
noted. No displacement of NORMAL
bone & cartilage.

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

Palpation

Not tender

ACTUAL FINDINGS

REMARKS

SINUSES
1. Presence of tenderness

Not tenderness noted.

NORMAL

LIPS

1. Symmetry of contour color

Inspection and Palpation
& texture

Uniform pink color (darker,

e.g.,
bluish
hue,
in
Mediterranean groups and
dark-skinned clients)
Uniform pink color, smooth,
soft and symmetrical. Client is NORMAL
Soft, moist, smooth texture
able to purse lips.
Symmetry of contour
Ability to purse lips

BUCCAL MUCOSA

1. Color, moisture, texture &

Inspection and Palpation
presence of lesions

Uniform pink color (freckled

brown pigmentation in darkskinned clients)Moist, smooth, Uniform pink color. Moist,
soft, glistening, and elastic smooth, glistening and elastic NORMAL
texture (drier oral mucosa in texture.
elderly due to decreased
salivation)

TEETH
1. Inspect for color, number &
condition & presence of Inspection
dentures

32 adult teeth

2Loss Molar tooth,

Smooth, white, shiny tooth

1Tooth Decay at the molar
enamel

Deviation from normal due to

improper mouth care.

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

GUMS
1. Color & condition

Inspection

Pink gums (bluish or dark

patches
in
dark-skinned Pink gums, moist, firm, no
NORMAL
clients)
noted lesions and nodules
Moist, firm texture to gums

TONGUE/FLOOR OF THE MOUTH

1. Color & texture of the
Inspection and Palpation
mouth floor & frenulum

Smooth tongue
prominent veins

base

with Smooth tongue

prominent veins

base

with

NORMAL

Central in position

2. Position, color & texture,

movement & base of the Inspection and Palpation
tongue

Pink in color (some brown

pigmentation
on
tongue
borders
in
dark-skinned Centered; slightly pink in
clients); moist; slightly rough; color, moist, slightly rough,
thin white coating
has thin white coating, NORMAL
smooth, no lesions; moves
Smooth, lateral margins, no
freely.
lesions
Raised papillae (taste buds)

Moves freely, no tenderness

PALATES & UVULA
1. Color & shape, texture & Inspection and Palpation
presence of bony prominences

Soft palate- light pink, smooth, Light pink, smooth and moist NORMAL

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

no lesions, moist.

soft palate.

REMARKS

Hard palate- lighter pink, more Light pink, irregular textured

irregular texture/ridges no and moist hard palate.
lesions
No noted nodules or masses
2. Position of the uvula &
Inspection
mobility

Positioned in midline of soft

Midline of soft palate
palate.

NORMAL

OROPHARYNX & TONSILS

1. Color & texture

Inspection and Palpation

Pink and smooth posterior Smooth and pinkish posterior

NORMAL
wall.
wall

2. Size of the tonsils, color &

Inspection
discharge

Tonsils are of normal size or Tonsils are normal size or not

not visible, pink in color and visible, smooth and pink in NORMAL
smooth. No discharge.
color. No discharge noted.

3. Gag reflex

Present

Present

Not visible on inspection

Symmetric and not visible

NORMAL
upon inspection.

2. Presence of tenderness or
Inspection and Palpation
nodules in the lymph nodes

Not palpable.

No nodules were palpated

3. Placement of the trachea

Inspection

Central placement in midline

Trachea is placed at the center.
of neck, spaces are equal on
NORMAL
Spaces are equal on both sides.
both sides.

4. Smoothness & areas of Inspection

enlargement,
masses
or

Lobes may not be palpitated. Lobes were not palpated. Rise NORMAL
If palpitated, lobes are small,

Inspection

NECK & LYMPH NODES

1. Symmetry & visible mass in
Inspection
the thyroid gland

NORMAL

NORMAL

PARTS TO BE ASSESSED

TECHNIQUE

ACTUAL FINDINGS

REMARKS

smooth, centrally located,

painless, and rise freely with freely when swallowing.
swallowing.

nodules in the thyroid gland

BREAST
1 Symmetry and visible
Inspection
mass in the breast.
1

NORMAL FINDINGS

Color,
moisture,
texture and presence of Inspection and Palpation
lesion

Symmetrical,
no
visible Symmetrical,
no
visible
NORMAL
masses upon inspection.
masses upon inspection.
Uniformity in color, moisture
Uniform in color,
and texture. No presence of
was noted
lesion.

no lesion NORMAL

POSTERIOR THORAX
1. Shape, symmetry &
compare the diameter of
Inspection
antero posterior thorax to
transverse diameter

Anteroposterior to transverse 1:2 ratio of the anteroposterior

diameter ratio of 1:2, chest is to transverse diameter is NORMAL
symmetric.
symmetric.

2. Spinal alignment

Inspection

Spine vertically aligned.

Spine is vertically aligned.

3. Breathing excursion

Inspection

No adventitious breath sounds.

NoAdventitious breathing was

NORMAL
inspected.

NORMAL

5. Temperature, tenderness,
Palpation
masses

Uniform skin temperature, no No mass were palpated and

NORMAL
masses or tenderness.
uniform skin temperature.

7. Percuss the posterior thorax

Percussion notes resonate, Resonant sound was heard at

except over scapula.
the upper portion and dull
NORMAL
Lowest point of resonance is sound was heard over the
scapula.
at the diaphragm.

Percussion

PARTS TO BE ASSESSED

TECHNIQUE

8. Auscultate the posterior

Auscultation
thorax

NORMAL FINDINGS
Vesicular
bronchovesicular
sounds.

ACTUAL FINDINGS

REMARKS

Bronchovesicular sound was

and heard at the upper portion and
breathe vesicular sound was heard at NORMAL
the lower portion of the
thorax.

ANTERIOR THORAX
1. Breathing pattern

Inspection

Quiet, rhythmic, and effortless

Wheezing sounds
respirations.

2. Temperature, tenderness,
Inspection and Palpation
masses

Uniform skin temperature,

Uniform skin temperature, no
neither masses nor tenderness NORMAL
masses or tenderness.
was palpated.

5. Percuss the anterior thorax

Percussion

Percussion notes resonate

down to the sixth rib at the
level of the diaphragm but are
flat over areas of heavy
muscle and bone, dull on areas
over the heart and the liver,
and tympanic over the
underlying stomach.

6. Auscultate the trachea

Auscultation

Bronchial and tubular breath Bronchial and tubular breath

NORMAL
sounds.
sounds were heard

7. Auscultate
thorax

Auscultation

Bronchovesicular
vesicular breath sounds.

Palpation

No pulsations, lifts or heaves.

the

anterior

CAROTID ARTERIES
1. Pulsation of carotid arteries

and

Resonant sound was heard

down to the sixth rib at the
level of the diaphragm. On the
other hand, flat sound was NORMAL
heard over heavy muscles, and
dull on the areas of the heart
and liver.

Bronchovesicular
and
vesicular breath sounds were NORMAL
heard.
No

pulsations

and

lifts NORMAL

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

observed.
2. Auscultation of the carotid
Auscultation
arteries

No
sound
auscultation.

heard

on No sound was heard upon

NORMAL
auscultation.

JUGULAR VEIN
1. Visibility of jugular vein

Veins were not visible upon

NORMAL
inspection.

Inspection

Veins not visible.

1. Skin integrity

Inspection

Unblemished skin, uniform in Uniform in color.

color, silver white striae
Surgical Incision at the right
(stretch marks) or surgical
scars.
Lower quadrant(RLQ)

Deviation from normal due to

surgical incision.

2. Abdominal contour

Inspection

Flat, rounded (convex) or

Convex in shape.
scaphoid(concave)

NORMAL

3. Enlarge liver or spleen

Palpation

No evidence of enlargement of
No enlargement was observed.
liver or spleen.

NORMAL

4. Symmetry of contour

Inspection

Symmetric contour.

NORMAL

5. Abdominal movements

Inspection

Symmetric movements caused

by
respiration.
Visible Symmetric movement due to
peristalsis in very lean people. respiration. Peristalsis not NORMAL
Aortic pulsations in thin visible.
persons at epigastric area.

6. Vascular patterns

Inspection

No visible vascular pattern.

ABDOMEN

Symmetric contour.

NORMAL

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

No visible vascular pattern.

7. Bowel sounds, vascular
Auscultation
sound & peritoneal sounds

Audible
bowel
sounds,
No arterial bruit was heard.
absence of arterial bruit and
NORMAL
Audible bowel sound.
friction rubs.

8.
Percuss
quadrants

Percussion

Tympanic sound over the

stomach and gas-filled bowels;
dullness, especially over the
liver and spleen or in full
bladder.

Uncomfortable for the client

to percuss because of the
surgical incision in the
abdomen.

Palpation

Tenderness may be present

near xiphoid process, over
cecum, and over sigmoid
colon.

Uncomfortable for the client

to palpate because of the
surgical incision in the
abdomen

abdominal

9.
Light
palpation
abdominal quadrants

of

MUSCOLOSKELETAL SYSTEM
1. Muscle size compare the
muscles on one side of the
Inspection
body (arm, thigh, calf) to the
same muscle on the other side

Equal size on both sides of Equal on both sides of the

NORMAL
body.
body.

2. Constructures (shortening)
Inspection
of the muscles & tendons

No contractures.

No contractures.

NORMAL

3. Muscle fasciculations &

tremors. Presence of tremors
Inspection
of the hands & arms when
stretched in front of the body

No tremors.

No tremors.

NORMAL

4. Muscle tonicity

Normally firm.

Firm.

NORMAL

Inspection

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS

5. Muscle strength

Inspection

Equal strength on each body Equal strength on each body

NORMAL
side.
side.

BONES
1. Normal structure

Inspection

No deformities.

No deformities

NORMAL

2. Edema & tenderness

Inspection

No tenderness or swelling.

No tenderness.

NORMAL

JOINTS
1. Swelling

Inspection

No swelling.

No swelling.

NORMAL

2. Presence of tenderness,
smoothness of movement,
Inspection
swelling,
crepitation
&
presence of nodules

ACTUAL FINDINGS

REMARKS

No
tenderness,
swelling,
Joints move smoothly. No
crepitation or nodules. Joints
NORMAL
tenderness was observed.
move smoothly.

RANGE OF MOTION

1. Upper extremities

Inspection

Uniform in color, veins are

visible in face, neck and
dorsum of the hands, average
muscles size, fingers are
complete
No lesions, no edema.

2. Lower extremities

Inspection

Uniform in color, veins are

visible in face, neck and
dorsum of the hands, average
NORMAL
muscles size, fingers are
complete.Skin Lesions due to
IV insertion, no edema.

Uniform
in
color,
no Uniform
in
color,
no
deformities, complete fingers deformities, complete fingers NORMAL
in both feet.
in both feet.

B. DIAGNOSTIC PROCEDURE / LABORATORY

LABORATORY
PROCEDURE

URINALYSIS

DATE
ORDERED/DATE
RESULT
08/23/13

INDICATION/PURPOSES

NORMAL
VALUES

ACTUAL
VALUES

NURSING
RESPONSIBILITY

ANALYSIS /
INTERPRETATION

Performed to check for

urinary tract infection
occassionaly the urine screen
may pick up other
abnormalities of renal
functions such as excess
sugar or protein.

Color:yello
w
Ph: 7.0
SP Gravity:
1.005

Macroscopic
Color:yellow
Character:haz
y
Protein: (-)
Sugar: (-)
Ph: 7.0
SP Gravity:
1.020
Microscopic
Pus cells: 0-1
hpf
RBC:
Epithelial
cells:
Bacteria-(-)
Mucous
thread:
Casts:
Crystals:

All materials should

be clean for urine
analysis, gather only
midstream urine.

NORMAL

COMPLETE BLOOD
COUNT

CREATININE

08/23/13

08/23/13

It is used to check for

blood diseases and
disorders ,infections in
the blood ,oxygen
levels in the blood
,diabetes, kisner and
liver diseases and host
of ailments

It is used to find out if

the client has signs of
renal failure

WBC: 4.0-12.0
LYM: 0.8-7.0
MIDSIZED CELL: 0.11.5
GRAN: 2.0-8.0
LYM%:20.0-60.0
MIDSIZED CELL
%:3.0-15.0
GRAN%: 40.0-70.0
RBC: 4.00-6.00
HGB: 110-160
HCT:35.0-49.0
MCV:80.0-100.0
MCH:27.0-34.0
MCHC:310-370
RDW-CV:11.0-16.0
RDW-SD:35.0-56.0
PLATELET:150-400
44.2-150.3

WBC: 12.5
LYM: 1.4
MIDSIZED CELL: 0.7
GRAN: 9.6
LYM%:12.2
MIDSIZED CELL
%:5.9

Na: 135-148
K: 3.5-5.3
C: 1.1-1.3

133.5mmol/l
3.74

GRAN%: 81.9
RBC: 5.46
HGB: 141
HCT:43.9
MCV:80.5
MCH:25.8
MCHC:321
RDW-CV:13.5
RDW-SD:41.0
PLATELET:465
52.2 umo/l

Explain the procedure

to the client

WBC indicates the

presence of an infection
granulocytes indicates
a reaction to an
infection
lymphocytes count
indicates increased
rates of infection after
surgery or trauma
platelets indicates
inflammation

Explain the procedure

to the client

normal

Cl: 96-107

99.2

V.

THE PATIENT AND HIS CARE

A. MEDICAL MANAGEMENT
I. INTRAVENOUS FLUID
MEDICAL MANAGEMENT
D50.9 NaCl
21-22 gtts/min

DATE ORDERED/DATE
GIVEN/CHANGED/DISCONTINUED
08/23/13

GENERAL DESCRIPTION

NURSING RESPONSIBILITY

Dextrose and Sodium

Chloride Injection, is a sterile,
nonpyrogenic solution for
fluid
and electrolyte replenishment
and caloric supply in single
dose containers
for intravenous administration
.

Prior:
-Check the physicians order in thrice check
-Explain to the client the antibiotics and IV that the
patient will encounter
-Monitor the vital signs
-Determine the allergies to th antibiotics
-Prepare the client for the surgery
During:
-Check for the physicians order of doses
-Check for the gtts/min
-Check for the time management of the medicines
-Monitor the clients response
-Assess the vital signs

After:
-Monitor the vital signs and the clients
reaction/response
-Check for the physicians order
-Monitor the ugtts/min
-Time of the medication
-Report and document the procedure
D5 WATER

Dextrose provides a source of calories.

Dextrose is readily metabolized, may
decrease losses of body protein and
nitrogen, promotes glycogen deposition
and decreases or prevents ketosis if
sufficient doses are provided

Prior:
-Check the physicians order in thrice check
-Explain to the client the antibiotics and IV
that the patient will encounter
-Monitor the vital signs
-Determine the allergies to th antibiotics
-Prepare the client for the surgery
During:
-Check for the physicians order of doses
-Check for the gtts/min
-Check for the time management of the
medicines
-Monitor the clients response
-Assess the vital signs
After:
-Monitor the vital signs and the clients

reaction/response
-Check for the physicians order
-Monitor the ugtts/min
-Time of the medication
-Report and document the procedure

II.
NAME

DRUGS
MECHANISM OF
ACTION

INDICATION

CONTRAINDICATION

SIDE EFFECTS

NURSING
RESPONSIBILITIES

Generic Name:
Cefuroxime
Frequency:
TID

Second-generation
cephalosporin that
inhibits cell wall
synthesis, promoting
osmotic instability,
usually bactericidal.

It is used for surgical

prophylaxis, reducing or
eliminating infection.

Hypersensitivity to
cephalosporin and related
antibiotics.

GI:
Diarrhea, nausea,
antibiotic-associated
colitis.

SKIN:
rashes, pruritus, urticaria

Dosage:
1tab 500mg q8
Route:
OP

NAME

MECHANISM OF

INDICATION

CONTRINDICATION

SIDE EFFECTS

Determine history
of
hypersensitivity
reactions to
cephalosporins,
penicillins, and
history of
allergies,
particularly to
drugs before
therapy is
initiated.
Inspect IM and IV
injection sites
frequency for
signs of phlebitis.
Report of loose
stools or diarrhea.
Monitor I&O
rates and pattern.

NURSING

Generic Name:
Cefuroxime
Frequency:
TID
Dosage:
750mg q8
Route:
IV

ACTION
Second-generation
cephalosporin that
inhibits cell wall
synthesis, promoting
osmotic instability,
usually bactericidal

It is used for surgical

prophylaxis, reducing or
eliminating infection.

Hypersensitivity to
cephalosporins and
related antibiotics

GI:
Diarrhea, nausea,
antibiotic-associated
colitis.
SKIN:
rashes, pruritus, urticaria

RESPONSIBILITIES
Determine history
of hypersensitivity
reactions to
cephalosporins,
penicillins, and
history of allergies,
particularly to
drugs before
therapy is initiated.
Inspect IM and IV
injection sites
frequency for signs
of phlebitis.
Report of loose
stools or diarrhea.
Monitor I&O rates
and pattern.

NAME
Generic Name:
Ketorolac
Frequency:
TIV
Dosage:
10mg q8 (-) anst
Route:
IV

MECHANISM OF
ACTION
Anti-inflammatory and
analgesics activity,
inhibits prostaglandins
and leukotriene
synthesis.

INDICATION
Short term management
of pain.

CONTRAINDICATION

SIDE EFFECTS

Contraindicated with
significant renal
impairment,
hypersensitivity to NonSteroidal Anti
Inflammatory Drugs.

rash
ringing in the
ears
headache
dizziness
drowsiness
abdominal pain
nausea
diarrhea
constipation
heartburn
fluid retention

NURSING
RESPONSIBILITIES
Pain as well as
inflammation and
its signs and
symptoms redness,
swelling, fever and
pain as reduced.
Instruct client to
report any adverse
reaction to the
physician or nurse.
Tell the patient that
adverse reaction
can occur with
overuse.

NAME
Generic Name:
Ranitidine
Frequency:
TID
Dosage:
25mg q8
Route:
IV

MECHANISM OF
ACTION
Inhibits the action of
histamine at the H2
receptor site located
primarily in gastric
parietal cell. resulting in
inhibition of gastric acid
secretion.

INDICATION
Used prevent ulcer while
patient is on NPO.

CONTRAINDICATION

SIDE EFFECTS

Hypersensitivity to
ranitidine or any
component of the
formulation.

constipation
diarrhea
fatigue
headache
insomnia
muscle pain
nausea
vomiting
agitation
depression
bleeding

NURSING
RESPONSIBILITIES
C- Gastrointestinal agent,
antisecretory (H2 receptor
antagonist)
H- Reduced amount of
acid in the stomach that
may result to prevented
ulcer incidence.
E- Every 8hrs while
patient is on NPO.
C- Instruct client to report
any adverse reaction to the
physician or nurse. Tell
patient antacids may
decrease the absorption of
ranitidine.
K- Ranitidine can interfere
with the metabolism of
alcohol.

NAME
Generic Name:
Mefenamic acid
Frequency:
TID
Dosage:
250mg 1cap
Route:
PO

MECHANISM OF
ACTION
Anti-inflammatory and
analgesic activity.

INDICATION

CONTRINDICATION

For relief of mild to

moderate pain in patients
12yrs 0ld and above.

Active ulceration or
chronic inflammation of
either the upper or lower
GI tract, preexisting renal
desease.

SIDE EFFECTS

rash
ringing of ears
nausea
heartburn

NURSING
RESPONSIBILITIES
It comes as a
capsule to be taken
by mouth.
It is usually taken
every 4 to 6 hours
on a schedule or as
needed for pain.

III.

DIET

Type of
Diet

Date Ordered,
Date Changed

General Description

NPO

August 23-25,
2013

NPO dietary state in which patient is

force to take nothing by mouth over a
given period of time.

Indication/Purposes

Specific Food
Taken

Clients
Response

Nursing Responsibilities
Prior

Cleanse the GI
tract from any
impurities and
maintains
immobility of the
Normally instructed to pre- op patient tract.
and patient that have to undergo a
certain laboratory examination.

During

After

Nothing Per
orem

Feeling
Check for
weak,
doctors
restlessnes order
s noted
Explain to
the client
what is
NPO and its
purpose

Make sure
that patient
followed
doctors
order

Document
date and
time. Noted
positive
gastric
motility.

40 gms
Nissan soup

Feeling
weak

Make sure
that patient
followed
doctors
order

Document
date and
time. Noted
positive
gastric
motility.

Ex. serum electrolyte.

During OR
procedure.
General
Liquid

August 27,
2013

Diet contains only liquids or foods

turn to liquid at body temperture

Liquid diets are

ordered after
surgery to reduce
the nausea and
vomiting that

3 glass of
water

Check for
doctors
order
Explain to

sometimes result
from the
anesthetic,
medications or the
surgery itself.
Liquids are
tolerated better
than solids and
allow the
gastrointestinal
tract to ease its
way back into
operation.
DAT
with
SAP
Diet as
tolerated
with
Strict
aspiratio
n
precauti
on

August 28, 13

Aspiration precautions are measures

taken to prevent a person from
aspirating, or choking. Aspiration can
occur in debilitated patients who have
a diminished swallowing reflex, and
the condition can even cause a type
of pneumonia called aspiration
pneumonia. Typically, when a person
swallows, the contents pass through
the esophagus and into the stomach.
Aspiration occurs when the
swallowed contents do not pass
through the esophagus, but go
directly into the lungs.

To prevent
aspiration.

the client
what is
General
Liquid and
its purpose

No signs
72 Diet Recall of
aspiration

Check
physicians
order
Monitor
vital signs

Monitor
intake
& output

Check Vital
signs

IV.
TYPE OF
EXERCISE

ACTIVITY EXERCISE
DATE
ORDERED,DATE
TAKEN/GIVEN,DATE
OF CHANGE,DATE
OF DISCONTINUE

GENERAL
DESCRIPTION

INDICATION/PURPOSES
CLIENTS
RESPONSE

NURSING RESPONSIBILITIES
(prior,during,after)

Ambulation

Started: August 27, 2013

The act of
traveling by
foot ; walking
is healthy for
exercise

It can help prepare and

condition the body for
the stress that the suture
will cause
Improves muscle tone in
legs
To stimulate the lower
extremities circulation
after the appendectomy
with the ambulation

The patient
can
facilitate to
walk with a
slow
movement

Prior :
- Assess the client if he can walk dependently
- Explain to the client the purpose of
ambulation
During :
- Encourage the patient to walk dependently
with minimal movement for atleast 30 mins.
After :
- Instruct the client to take a rest

V.
SURGICAL MANAGEMENT
Brief Description of the Procedure

An appendectomy is surgery to remove the appendix. An appendectomy is done using Spinal anesthesia. Medicine is put into your back to make you numb below
your waist. You will also get medicine to make you sleepy.
The surgeon makes a small cut in the lower right side of your belly area and removes the appendix.

If the appendix broke open or a pocket of infection (abscess) formed, your abdomen will be washed out during surgery. A small tube may be left in the belly area to
help drain out fluids or pus.
II

Patients response to Procedure

After the appendectomy, the client stays in the hospital for about Eight days. According to the client he can feel discomfort and slight pain in surgical site because of
the suture. But when we interviewing the client, he is calm. And he is always asleep.
III

Nursing Responsibilities

Prior:
- Check the doctors order.
- Monitor the vital signs
- Medicines for fever.
- If fever, must be lowered before anesthesia.
During:
- Check for the doctors order
- Check for the time management of the medicines
- Monitor the clients response
- Assess the vital signs
After:
- Monitor the vital signs and the clients reaction/response
- Check for the doctors order
- One day after surgery patients are encouraged to sit up in bed for 2 30 minutes.
- On the second day the patient can stand and sit outside the room.
- Report and document the procedure
VI.
NURSING PROBLEM PRIORITIZATION
Date Identified

Cues

Problem/ Nursing Diagnosis

Justification

August 27, 2013

Due to surgical incision.

Acute Pain

Because he underwent appendectomy.

August 27, 2013

Due to surgical incision.

Impaired skin integrity.

August 27, 2013

Due to unfamiliar environment and Disturbed sleeping pattern.

August 27, 2013

frequent interruptions.
Due to his lack of interest in food Imbalanced

August 27, 2013

and poor muscle tone.

than body requirement
Due to inadequate primary defense. Risk for infection.

nutrition:

Because of the presence of incision site at the right

lower quadrant of the abdomen.
Because the client has been admitted for __ days at

the hospital.
Less Because he underwent appendectomy.
Because of the presence of incision site at the right
lower quadrant of the abdomen.

VII.
Assessment

NURSING CARE PLAN No. 1

Nursing
Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective:
Masakit yung
tahi ko ,as
verbalized
by the client.
Objective:
Facial Grimace
Pain scale of
5/10.
Guarding
behavior

Acute pain related Short term goal:

Independent
to distention of
After 30 minutes of
Encourage use of
intestinal
nursing
relaxation
tissues
by
intervention, the
techniques such
inflammation
client will be
as
focus,
as manifested
able to verbalize
breathing,
by
facial
alleviation
of
imaging, CDs or
grimace,
pain, from a pain
tapes
muscle
scale of 5/10 to
guarding and a
2/10.
Encourage
pain scale of
verbalization of
5/10.
Long term goal:
feelings
about
Within 2 hours, the
the pain.
client will be
able to report
Encourage
that
pain
is
adequate
rest
relieved/controll
period.
ed
Keep in rest in
Within 2 hours, the
Semi Fowlers
client will be
Position.
able to follow
prescribed
pharmacological
regimen.
Within 2 hours, the
client will be
able
to
demonstrate use
of
relaxation
skills
and
diversional

Dependent
Take medicines as
prescribed

Long term goal:

To distract attention and reduce
tension
GOAL MET

To serve as baseline data.

Short term goal:
GOAL MET
To prevent fatigue.

Gravity localize inflammatory

exudates into lower abdomen
or pelvis, relieving abdominal
pain, which is accentuated by
supine position.

To alleviate the pain that the

client is experiencing.

activities
indicated
individual
situation.

are
for

NURSING CARE PLAN No. 2

Assessment
Subjective:
Kumakati
yung
tahi
koas
verbalized
by the client.
Objective:
Facial Grimace
Surgical
incision at the RLQ
of the abdomen.

Nursing
Diagnosis

Planning

Intervention

Impaired
skin Short term goal:
Independent
integrity related
After 30 minutes of
Instruct
proper
to disruption of
nursing
handwashing.
skin surface as
intervention, the
manifested by
client
and
presence
of
significant others
Inspet
incision
surgical
will be able to
site/dressing.
incision.
gain knowledge
and information
about treatment
Note for fever,chills,
needs
and
diaphoresis, and
potential
increasing
complications.
abdominal pain.

Rationale

Evaluation
Long term goal:

Reduces risk
bacteria.

of

spread

of
GOAL MET

Provides early detection of

developing infectious process.
Suggestive of presence of
infection/developing sepsis,
abscess, peritonitis.
Short term goal:
GOAL MET

Long term goal:

Within 2 hours, the
client will be
able to achieve
timely
wound
healing and be
free of signs of
infection
and

Dependent
Take medicines as
prescribed

To alleviate the pain that the

client is experiencing.

inflammation,
purulent
drainage
and
fever.
NURSING CARE PLAN No. 3
Assessment
Subjective:
Nahihirapan
akong
makatulog
dito
,as
verbalized
by the client.
Objective:
Facial Grimace
# or more
times
nighttime
awakenings.

Nursing
Diagnosis

Planning

Disturbed
Short term goal:
sleeping pattern
After 30 minutes of
related
to
nursing
environmental
intervention, the
noise,
client will be
unfamiliar
able to verbalize
furnishings, and
plans
to
interruptions
implement
for
bedtime routines.
therapeutics,
monitoring and
lab tests.
Long term goal:
Within 2 hours, the
client will be
able to awaken
refreshed and not
fatigued during
the day.

Intervention
Independent
Assess client's sleep patterns
and usual bedtime rituals and
incorporate these into the plan
of care.

Rationale

Evaluation
Long term goal:

To provide baseline
information.

Observe client's medication,

diet, and caffeine intake. Look
for hidden sources of caffeine,
such as over-the-counter
medications.

Difficulty sleeping
can be a side effect of
medications such as
bronchodilators;
caffeine can also
interfere with sleep.

Provide pain relief shortly

before bedtime and position

Clients have reported

that uncomfortable

GOAL MET

Short term goal:

GOAL MET

client comfortably for sleep.

VI.
I

positions and pain are

common factors of
sleep disturbance

DISCHARGE PLANNING
M-MEDICATION TO TAKE

Instruct and explain to the patients mother that the medication is very important to continue depending on the duration that the doctor ordered for the total recovery
of the patient.
II

E-EXERCISE

Instruct the mother to let her child for early ambulation

III

T-TREATMENT

Client undergone Appendectomy

IV H-HEALTH TEACHING
Encourage and explain to the patients mother that it is important to maintain proper hygiene to prevent further infection. Instruct the patients mother to bath the
child every day.
V O-OUT PATIENT FOLLOW-UP
Hes follow up check will be on September 03, 2013 and regular consultation to the physician can be a factor for recovery and assess and monitor the patients
condition.
VI

D-DIET

Diet as tolerated
VII

S- Sex/ Spiritual

The client is a boy needs to focus on Gods wisdom with his parents.

VII.

CONCLUSION

We therefore conclude that after case presentation we nursing students will gain knowledge about Appendicitis, Enumerate signs and symptoms of
Appendicitis, Identify nursing interventions to be done when handling patient with Appendicitis, Perform proper nursing care to patient.

VIII. BIBLIOGRAPHY

http://www.webmd.com/digestive-disorders/digestive-diseases-appendicitis
http://www.medicinenet.com/appendicitis/article.htm
http://www.nlm.nih.gov/medlineplus/ency/article/000256.htm
Medical Surgical .. Brunner and Sudhhart