Table of contents

....................................................................1 Introduction……………………………………………………………………………….2 Objectives………………………………………………………………………………….3 Patient Profile…………………………………………………………………………….4 Physical Assessment…………………………………………………………..………56 Anatomy and Physiology…………………………………………………………….7 Pathophysiology………………………………………………………………………….8 -9 Laboratory…………………………………………………………………………………. 9 Medical Surgical Intervention……………………………………………………….10-11 Gordon’s Pattern of functioning………………………………………………….1213 Drug study……………………………………………………………………………………14 Nursing Care Plan………………………………………………………………………… 15-16 Discharge Planning…………………………………………………………………………17 Reference…………………………………………………………………………………… 18

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Introduction:

About Appendicitis The appendix is a small finger-like organ that's attached to the large intestine in the lower right side of the abdomen. The inside of the appendix forms a cul-de-sac that usually opens into the large intestine. When that opening gets blocked, the appendix swells and can easily get infected by bacteria. Appendicitis is a condition characterized by inflammation of the appendix. It is a medical emergency. All cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of peritonitis and shock. Reginald Fitz first described acute and chronic appendicitis in 1886, and it has been recognized as one of the most common causes of severe acute abdominal pain worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis".

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Objectives:
General After four weeks of Related Learning Experience, I will be able to acquire the knowledge, skills and attitude regarding appendicitis.    This study will help us to learn more about appendicitis To learn how to give quality nursing care to patients who are suffering from the disease itself. It will also give us knowledge on what we can teach to the patients and their relatives on how to prevent in acquiring the disease.

Specific      Within the days of case study, I will be able to construct a pathophysiology connecting the conditions of Dengue Fever. To be able to make two (2) appropriate NCP’s for my patient. To be able to deeply understand what is appendicitis. To be able to know the signs and symptoms of the complication. To be able to render quality nursing care to the patient with appendicitis.

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PATIENTS PROFILE NAME : MB Age : 10/yrs Sex: Male Physician : Dr. Arcellana/zaen Room : 533d Chief complaint: abdominal pain Diagnosis : Acute appendicitis

Past Medical History (+)skin asthma History f present illness: A few hours prior to admission, the patient experienced severe amount of epigastric pain Associated with 3x vomiting,(+) low grade fever. At around 4pm ,increased pain in RLQ, patient was brought to the nearest hospital, then transferred to the institution

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Physical Assessment
Assessment Technique Findings Normal Findings Analysis

General Appearance and Mental Status Built Inspection Thin Bent Posture No distress noted Healthy appearance Cooperative Appropriate to situation Understandable Proportionate to height Erect Posture No distress noted Healthy appearance Cooperative Appropriate to situation Understandable Normal normal Normal Normal

Posture Inspection Signs of distress Inspection Signs of health Inspection

Attitude Affect Speech

Inspection Inspection Inspection

Normal Normal Normal

Evenness Thickness Texture Presence of infection or infestation

Inspection Inspection, Inspection, Inspection,

Hair Evenly Evenly distributed distributed Thick hair Thick hair Silky, resilient Silky, resilient hair hair No infection or No infection or infestation infestation Few Variable Nails Convex curvature Smooth texture Intact epidermis

Normal Normal Normal Normal

Amount of body Inspection hair Fingernail plate Inspection shape Fingernail and Palpation toenail texture Tissues Inspection surrounding nail Nail Hygiene Inspection

Normal

Convex curvature Smooth texture Intact epidermis Dirty, long nails

Normal Normal Normal

Clean, trimmed nails

Poor nail hygiene 5

Skin abdomen Inspection No laceration, With suture in equal skin color the right lower quadrant; dry and intact There is deviation on normal skin contour because of the laceration made for the operation

Arms

Inspection

Extremities No ecchymosis Right metacarpal noted. Full and connected to the IV equal pulses. line.

Right arm has limited movement due to the IV connection

Legs

Inspection

No deformities, good ROM, no edema and ecchymosis

Absence of deformities and good ROM. Absence of edema and ecchymosis

Normal

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ANATOMYAND PHYSIOLOGY OF APPENDIX 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.

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Pathophysiology
Non modifiable: *gender(male) *age(10-30) Episodes of Constipation ↓ Modifiable *lifestyle *food preferrence Low Fiber Diet ↓

↓ Occlusion of Appendix by Fecalith ↓ Decreased flow/drainage of mucosal secretions ↓ Increased ILP in the appendix ↓ Vasocongestion ↓ Decreased blood supply in the appendix ↓ Decreased O2 supply in the appendix ↓ Appendix starts to be necrotic; Bacteria invade the appendix ↓ Disruption of Cell Membrane of Appendix ↓ Start of Inflammatory Process ↓ ↓ ↓ ↓ Release of Chemical Mediators Activation of the Vomiting Neutrophils to area Center in the Medulla ↓ ↓ ---> Histamine, Prostaglandin, Stimulation of Vagus Suppression of Pus Formation Leukotrienes, Bradykinin Nerve Sympathetic (phagocytized bacteria ↓ GI Function and dead cells) Swelling of Appendix ---> Prostaglandin, Bradykinin ↓ Pain in the RLQ of Abdomen ↓ Acute Pain ---> Interleukin-1 ↓ Increased WBC Nausea & Vomiting Risk for Deficient Fluid Volume Anorexia Risk for Infection (if appendix ruptures) Risk for Imbalanced Nutrition less than body requirements

Inflammation of Appendix (Appendicitis) ↓ Appendectomy

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↓ Tissue Trauma Open Wound ↓ ↓ Impaired Tissue Risk for Integrity Infection Disruption of Cell Membrane ↓ Start of Inflammatory Process Release of Prostaglandin/ Bradykinin ↓ Norciceptors on the Dermis ↓ Send Impulse to CNS Pain on Surgical Site Activity Intolerance

Laboratory findings
INVESTIGATION RESULTS UNIT REFERENCE RANGE

Analysis

FULL BLOOD COUNT Red Cell Count Haemoglobin Hematocrit MCV MCH MCHC RDW Platelet count White cell count*

4.79 132 low 0.38low 79.5low 27.60 34.60 13.2high 235 21.2high

x10^12/L mg/dL % fL Pg g/dL % x10^9/L x10^9/L

( 4.5 - 6.0 ) (120-150 ) ( 0.40-0.48 ) ( 80-96 ) ( 27-33 ) ( 32 - 36 ) ( 4.0 - 11.0 ) ( 150 - 400 ) ( 5.0-10.0 )

normal a blood loss that is more acute, such as a hemorrhage Indicates a blood loss that is more acute, such as a hemorrhage normal normal

-normal Shows an infection

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Medical surgical management:
APPENDECTOMY During an appendectomy, an incision two to three inches in length is made through the skin and the layers of the abdominal wall over the area of the appendix. The surgeon enters the abdomen and looks for the appendix which usually is in the right lower abdomen. After examining the area around the appendix to be certain that no additional problem is present, the appendix is removed. This is done by freeing the appendix from its mesenteric attachment to the abdomen and colon, cutting the appendix from the colon, and sewing over the hole in the colon. If an abscess is present, the pus can be drained with drains that pass from the abscess and out through the skin. The abdominal incision then is closed.

Newer techniques for removing the appendix involve the use of the laparoscope. The laparoscope is a thin telescope attached to a video camera that allows the surgeon to inspect the inside of the abdomen through a small puncture wound (instead of a larger incision). If appendicitis is found, the appendix can be removed with special instruments that can be passed into the abdomen, just like the laparoscope, through small puncture wounds. The benefits of the laparoscopic technique include less post-operative pain (since much of the post-surgery pain comes from incisions) and a speedier return to normal activities. An additional advantage of laparoscopy is that it allows the surgeon to look inside the abdomen to make a clear diagnosis in cases in which the diagnosis of appendicitis is in doubt.

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If the appendix is not ruptured (perforated) at the time of surgery, the patient generally is sent home from the hospital after surgery in one or two days. Patients whose appendix has perforated are sicker than patients without perforation, and their hospital stay often is prolonged (four to seven days), particularly if peritonitis has occurred. Intravenous antibiotics are given in the hospital to fight infection and assist in resolving any abscess.

Occasionally, the surgeon may find a normal-appearing appendix and no other cause for the patient's problem. In this situation, the surgeon may remove the appendix. The reasoning in these cases is that it is better to remove a normal-appearing appendix than to miss and not treat appropriately an early or mild case of appendicitis

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Gordon’s Pattern of functioning
Patterns of functioning Health perception Before hospitalization The patient did not undergo self medication, they immediately consult to the MD The patient eats a variety of foods a day 2-3 times a day The patient has no difficulty or pain in urinating or defecating using the bathroom The patient was able to play basketball with his friends inside the patient’s house The patient is conversant and cooperative, the patient is currently enrolled as a Grade 5 student The patient has no difficulty in sleeping and is able to sleep 8 hours a day with his family in a room. He wake up early for school Patient is active and is active with friends During hospitalization The patient abides with the doctor’s orders Analysis The patient’s family believe that consulting the doctor immediately can lessen the danger during illness There is change in the metabolic pattern since patient has restriction to diet The patient complained restlessness while on catheter The patient feel bored during hospitalization Even though the patient is hospitalized he still has a functional cognitive function which is not related to his condition The patient has more time to rest but interrupted due o treatments to be done

Metabolic Pattern

The patient is on general liquid diet The patient has no bathroom privileges after the surgery which made him urinate through folly catheter The patient is on bed and is not able to ambulate; until after the operation The patient is conversant and cooperative; he always state that he will miss much in their class The patient is subjected to bed rest and sleep pattern is interrupted due to treatment and medical procedures Patient is now shy because of his condition and he still needs to urinate in a

Elimination Pattern

Activity and Exercise

Cognitive and Perception

Sleep-rest pattern

Self-perception

The patient may have felt a lower self-worth because of his condition 12

Role-relationship pattern

bed pan The patient is the Though hospitalized eldest among the the patient was able to siblings and is maintain family obedient to his parents bonding through family visits The patient plays basketball with his friends with the same gender and watches “anime movies”

Sexuality

Stress and Coping

Vales and Beliefs

The patient tries to eat or play with friends when subjected to stress The patient is able to go to mass every Sunday with his family

No significant change is observed, even though hospitalized family members still strengthen bond through visits The patient does not The patient’s activities play with his friends was appropriate for anymore because of his gender before and hospitalization he during hospitalization only draws on his he uses his time to color book most of the draw so he will not time get bored in the hospital The patient sleep Patient had a different when in pain or approach in coping stressors are present with stress when he was hospitalized The patient and his During hospitalization family does not the patient did not perform any ritual or perform any religion religion bound related activity activity in he hospital because of the limitations brought by the illness

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Drugstudy
Generic Name >Ketorolac Brand Name Korteg or Classifi Dosage cations NSAID 15 mg s IV Indication Relief for mild pain to severe pain. Mechanism Adverse of action Reaction Inhibits Stimulat Coax-2 ion, drowsin ess, nausea, vomitin g, Contra Indication Nursing implication Assess pain after administrat ion.

>nalbuphine

>

25mg IV

Relief for mild pain to severe pain. For acidic Inhibits gastric secretions environme of Hcl acid nt Urticaria Constipati and on pruritus

Assess pain after administrat ion. Taken before meals

>ranitidine

>zantac

>antaci d

25mg IV

>cefuroxim e

>zegen

cephalo sporins

500mg BID

Treatment for infection

Thromb Allergy to ophlebiti cephalosp s and orins pruritus

Taken on full stomach

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ASSESSMENT Subjective: “Sumasakit yung pinag operahan sa akin” As verbalized by the patient. Objective: > Facial grimace >guarding behavior >restlessness >pain scale of 6 out of 10;where 10 is the highest

DIAGNOSIS Acute pain related to post operative incision as observed in the objective

PLANNING Short-term Goal: After 30min.-1 hour of nursing interventions, the patient will be able to verbalize that the pain is relieved from pain scale of 6 out of 10 to 2 out of 10 Long-term Goal: After 2-3 nursing shift the patient will be able to state and practice diff. non pharmacolog ical techniques to reduce pain perception

INTERVENTIONS RATIONALE >identify the scale or intensity of pain >To have a baseline scale of pain to evaluate the effectiveness of therapy > to distract attention and reduce tension >to promote non pharmacologic al pain management.

EVALUATION Short-term goal: After 1 hour of nursing interventions the patient was able to verbalize that the pain is relieved from pain scale of 6 out of 10 to 2 out of 10 Long-term Goal: After 2-3 nursing shift the patient was able to state and practice diff. non pharmacological techniques to reduce pain perception

>encourage use of relaxation techniques such as focused breathing >provide comfort measures e.g. cold packs Dependent: >Administer analgesics as prescribed by MD

>to maintain acceptable level of pain

Nursing care plan

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ASSESSMENT DIAGNOSIS Risk for infection related to broken skin (surgical incision) secondary to appendectomy .

PLANNING Short term goal: After 2-3 hours of nursing interventions, patient will be able to verbalize understanding of individual causative risk factors. Long term goal: After 2-3 nursing shifts the patient will be able to achieve timely wound healing; be free of purulent drainage or erythema; be afebrile

INTERVENTIONS RATIONALE >stress proper hand hygiene especially all care givers

EVALUATION

>>first line Short term goal: defense against After 2-3 hours infection of nursing interventions, >instruct client to patient was able protect the integrity to verbalize of the skin >premature understanding of >emphasize discontinuation individual necessity of taking of treatment causative risk antibiotics as potentiate drug factors. directed resistant bacteria Long term goal: >recommend routine >to reduce After 2-3 nursing pre operative body bacterial shifts the patient shower/scrubs colonization was able to >maintain sterile achieve timely techniques for all wound healing; invasive procedure free of purulent drainage; afebrile

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DISCHARGE PLANNING M – edication Advise intake of appropriate vitamin supplement to increase protection mechanism of the immune system. Continuation of cefuroxime BID for 5 days+ vitamin -c E – xercise There are no activities or exercises that are contraindicated for the client when the wound heals. He may proceed with his regular activity and play. Immediately after discharge the patient should have more time to rest to regain the normal daily living pattern T – reatment Ensure clients compliance to treatment regimen and go back for further follow up in the institution H –ealth teachings Advise to follow proper body hygiene and cleanliness on surroundings. O – ut Patient/ Follow-up Encourage patient to go to scheduled follow up check up in Dr. Zaen’s office in the building of capitol medical center D – iet Instruct to eat foods that are rich in vitamins and minerals such as fruits, vegetables, meat and milk to help the client get the energy he needs for his daily activities and to boost his immune system. S - piritual belief Encourage the client to go to church and pray. It is essential for the client to have a strong faith in order to help him cope with the challenges he may encounter and to mold himself as a person.

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REFERENCE 1. Brunner and Suddarth’s Textbook of Medical Surgical Nursing. 2. Priscilla lemone medical surgical nursing . 3. Ross and Wilson Anatomy and Physiology in Health and Illness. Tenth Edition. 4. Medical Surgical Nursing Critical Thinking in client care Third Edition 5. MIMS and MIMS Annual 6. NANDA 7. Pictures www.wikipedia.com Eleventh Edition

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