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A Care Study



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Submitted by:

I. Introduction
Overview of the case

II. Health History
Profile of patient

III. Developmental Data

IV. Anatomy and Physiology

V. Pathophysiology

VI. Medical Management

VII. Laboratory Results

VIII. Drug Study

IX. Ideal Nursing Management

X. Actual Nursing Management

XI. Health Teachings

XII. Referrals and Follow up

XIII. Bibliography

a. Overview of the Case

Any part of the lower gastro-intestinal tract is susceptible to acute
inflammation caused by bacterial, viral or fungal infection. Two such situations
are appendicitis and diverticulitis. Appendicitis is inflammation of the appendix. It
is thought that appendicitis begins when the opening from the appendix into the
cecum becomes blocked. The blockage may be due to a build-up of thick mucus
within the appendix or to stool that enters the appendix from the cecum. The
mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is
called a fecalith (literally, a rock of stool). At other times, the lymphatic tissue in
the appendix may swell and block the appendix. Bacteria which normally are
found within the appendix then begin to invade (infect) the wall of the appendix.
The body responds to the invasion by mounting an attack on the bacteria, an
attack called inflammation. (An alternative theory for the cause of appendicitis is
an initial rupture of the appendix followed by spread of bacteria outside the
appendix.. The cause of such a rupture is unclear, but it may relate to changes
that occur in the lymphatic tissue that line the wall of the appendix.)

If the inflammation and infection spread through the wall of the appendix, the
appendix can rupture. After rupture, infection can spread throughout the
abdomen; however, it usually is confined to a small area surrounding the
appendix (forming a peri-appendiceal abscess).

Sometimes, the body is successful in containing ("healing") the appendicitis
without surgical treatment if the infection and accompanying inflammation do not
spread throughout the abdomen. The inflammation, pain and symptoms may
disappear. This is particularly true in elderly patients and when antibiotics are
used. The patients then may come to the doctor long after the episode of
appendicitis with a lump or a mass in the right lower abdomen that is due to the
scarring that occurs during healing. This lump might raise the suspicion of
cancer. The main symptom of appendicitis is abdominal pain. The pain is at first
diffuse and poorly localized, that is, not confined to one spot. (Poorly localized
pain is typical whenever a problem is confined to the small intestine or colon,
including the appendix.) The pain is so difficult to pinpoint that when asked to
point to the area of the pain, most people indicate the location of the pain with a
circular motion of their hand around the central part of their abdomen.

As appendiceal inflammation increases, it extends through the appendix to its
outer covering and then to the lining of the abdomen, a thin membrane called the
peritoneum. Once the peritoneum becomes inflamed, the pain changes and then
can be localized clearly to one small area. Generally, this area is between the
front of the right hip bone and the belly button. The exact point is named after Dr.
Charles McBurney--McBurney's point. If the appendix ruptures and infection
spreads throughout the abdomen, the pain becomes diffuse again as the entire
lining of the abdomen becomes inflamed. Nausea and vomiting also occur in
appendicitis and may be due to intestinal obstruction.

a. Profile of Patient

Patient’s Name: X
Birth Date: X
Birthplace: X
Age: X
Sex: Female
Status: Single (child)
Religion: Roman Catholic
Nationality: Filipino
Father’s Name: X
Mother’s Name: X
Address: BX
Allergy: None
Date of Admission: May 5, 2007
Time of Admission: 11:30 am
Chief Complaints: Epigastric pain, vomiting and fever
Admitting Diagnosis: Acute Appendicitis


Grade School:
Stage 4 - Industry vs. Inferiority

• To bring a productive situation to completion is an aim which gradually
supersedes the whims and wishes of play.

• The fundamentals of technology are developed
• To lose the hope of such "industrious" association may pull the child back
to the more isolated, less conscious familial rivalry of the Oedipal time
• The child can become a conformist and thoughtless slave whom others


Piaget's Cognitive Development:

• Concrete operations (ages 7-11)--As physical experience accumulates,
the child starts to conceptualize, creating logical structures that explain his
or her physical experiences. Abstract problem solving is also possible at
this stage. For example, arithmetic equations can be solved with numbers,
not just with objects.
• Formal operations (beginning at ages 11-15)--By this point, the child's
cognitive structures are like those of an adult and include conceptual
May 6, 2007
> Temperature every 4 hours > During this period of time, potentially fatal

Name of drug Date Classification
may develop
Mechanism of Specific Contraindications Side Effects Nursing
Ordered Frequency Action Indication Implication
Paracetamol May6,2007 Antipyretic, 1 tab, P.O. Chemical Effect: Reduces fever - Contraindicated Hematologic: - Assess
> Diet As Tolerated > Serves as transition to the regular diet; is a patient’s pain
(Biogesec) analgesic (prn) May produce in patients hemolytic
nutritionally adequate diet;
analgesic effectis a modification of
hypersensitive to anemia,leucopenia temperature
before and
normal diet in consistency and texture
by blocking pain drug. Hepatic: liver
dring therapy.
impulses, by - Use cautiously damage, jaundice. - Assess
patient’s drug
inhibiting in patients with Metabolic:
prostaglandin. history of chronic hypoglycemia - Be alert for
> Labs: CBC stat., U/A, S/E > CBC- leukocytosis usually present, although adverse
Therapeutic alcohol abuse. Skin: rash, urticaria
reactions and
a low WBC counts may present in viral
Effect:: Relieves drug
infection. pain and reduces

Cefuroxime May6,2007 Antibiotic 400 g every Chemical effect: Hinders or - Contraindicated CNS: headache, - Assess
Paracetamol 10mL every 4 > Paracetamol is for fever reduction. patient’s
(Zinacef) 8 hours. Inhibits cell-wall kills in patients malaise, dizziness.
hours PRN synthesis, susceptible hypersensitive to GI: nausea, before
promoting bacteria. drug or other anorexia, vomiting,
- Ask patient
> Intake and Output every shift osmotic
> To know if the patient has a normal fluidcephalosporins. diarrhea, glossitis, about
instability. - Use cautiously abdominal cramps.
intake and output. To know for normal kidney reactions to
Therapeutic in patients with Respiratory: dyspnea cephalosporin
functioning and for laboratory purposes. - Be alert for
effect: Kills history of Skin: rashes,
susceptible sensitivity to urticaria. reactions and
> IVF follow up D5LR I L > Fluids are required
bacteria to replace losses, to
prevent patient dehydration. It aids also for
mobilization of secretion.

May 7, 2007

Name of Date Classification Dosage/ Mechanism of Specific Contraindications Side Effects Nursing Implication
drug Ordered Frequency Action Indication
Tramadol May6,2007 Pharmacologic 300 g IVTT Chemical Relieves - Contraindicated in CNS: - Assess patient’s pain
class: opioid every 8 effect: pain. patients dizziness, before starting the
agonist hours. Centrally acting hypersensitive to drug vertigo, therapy.
Therapeutic synthetic or any of its headache - Monitor CV and
class: analgesic component. CV: respiratory status.
analgesic compound - Use cautiously in vasodilation - Monitor patient for
thought to bind patients at risk for EENT: visual drug dependence.
opioid seizures or respiratory disturbances. Be alert for adverse
receptorsand depression. GI: nausea, reaction.
inhibit reuptake constipation,
of vomiting,
norepinephrine diarrhea
and serotonin.
effect: Relieves
Name of Date Classification Dosage/ Mechanism of Specific Contraindications Side Effects Nursing Implication
drug Ordered Frequency Action Indication
Ketorolac May7,2007 Pharmacologic 30 mg IV Chemical Relieves - Contraindicated in CNS: - Assess patient’s
infection before
(Toradol) class: NSAID every 6 effect: May pain and patients drowsiness,
Therapeutic: hours. inhibit inflammation. hypersensitive to insomnia, - Ask patient about
previous reactions to
analgesic, prostaglandins drug or any of its dizziness,
anti- synthesis. components. headache. - Be alert for adverse
reactions and drug
inflammatory. Therapeutic - Not recommend for CV: edema,
effect: intrathecal or epidural hypertension,
Relieves pain administration palpitations.
and because of its alcohol GI: nausea,
inflammation. content. GI pain,
- Use cautiously in diarrhea.
patients in the Skin:
perioperative period. sweating.

Ranitidine May7,2007 Antiulcerative 300g IVTT Chem. Effect: Relieves GI - Contraindicated in CNS: vertigo, -Assess patient’s GI
(Zantac) every 8 Competitively discomfort. malaise. condition before
hypersensitive to
hours. inhibits action drug or any of its EENT: starting therapy.
of H2 at blurred vision - Be alert for adverse
Use cautiously in
receptor site. patients with Hepatic: reactions of drug
impaired kidney
-Relieves GI Jaundice. interactions.

May 6, 2007

Specimen: Random Sample
Color: Yellow
Appearance: Clear
Glucose: negative
Protein: negative
Reaction: 6.0 pH
Specific gravity: 1.030

WBC: 0-2
RBC: 0-1
Epithelial Cells: 4-5
Pus Cells: 2-4 hpf
Mucus Threads: none seen
Urates: none seen
Bacteria: none seen

Sodium 141.00 mmol/L
Potassium 4.0 mmol/L
Glucose-RBS L 2.6
Creatinine L 44.70mmol/L
May 6, 2007

Total WBC *11.76
Total RBC 4.69
Hemoglobin 134
Hematocrit 0.40
MCV 81.4
MCH 26.8
MCHC 32.9
Platelet Count 227

Differential Count

Lymphocytes 91
Monocytes 7
Eosinophils 2
Basophils 13.5

The appendix is a small finger-like projection that comes off the
cecum of the large intestine and has no apparent function in the human.
When the opening in the sac is blocked, it leads to an inflammation of
the appendix called appendicitis. This condition occurs most commonly
in the young, between childhood and young adulthood.

Appendicitis is an emergency condition and requires urgent surgical
removal of the appendix. The appendix is a narrow, muscular tube. One
end is attached to the first part of the large intestine, while the other end is
closed. The position of the appendix in the body can vary from person to
person. An average adult appendix is about 4 inches (10cm) long. However, it
can vary in length from as less as an inch to 8 inches. Its diameter is usually
about about 6 to 7 mm.
The function of the appendix is unknown. Foods that have not been digested
tends to move into the appendix and are forced out again by the contractions
of appendix. In herbivorous animals like cow and goat, the appendix can
function. In man, this has become what is called as a vestigial organ (an
organ that is no more required). The vermifom appendix or appendix in short,
is a small part of the bowel or intestine. It is situated on the right side of the
abdomen at the junction of the small and large intestines. It is a small narrow
sac approximately 10 cm long and 1 cm wide. The appendix is a vestigial
organ, that is, it serves no useful purpose.

The appendix is a small projection that develops from a portion of
the large intestine called the cecum. As the appendix develops it
lengthens and the tip can be found in almost any position about the
- The appendix is a finger-like projection from the beginning
of the large bowel called the cecum. The blood supply for the
appendix lies in a fatty tissue, the mesoappendix.
a. Ideal Nursing Management (NCP)

NURSING DIAGNOSIS: Nutrition: imbalanced, risk for less than body
Risk factors may include
Inability to ingest or digest food or absorb nutrients because of biological,
psychological, or economic factors
Increased metabolic demands
Possibly evidenced by
[Not applicable, presence of signs and symptoms establishes an actual

Nutritional Status (NOC)
Ingest nutritionally adequate diet for age, activity level, and metabolic
Demonstrate stable weight/progressive weight gain toward goal.


Nutrition Management (NIC)

Identify children at risk for malnutrition (e.g.,
Provides opportunity for early
intestinal surgery, hypermetabolic states,
restricted intake, prior nutritional

Determine ability to chew, swallow, taste;
presence of mechanical barriers; or These factors can affect ingestion
conditions such as lactose intolerance, and/or digestion of nutrients, and
cystic fibrosis, diabetes, inflammatory bowel specific dietary choices.

Determine child’s current nutritional status
using age-appropriate measurements, Identifies individual nutritional
including weight and body build, strength, needs and provides comparative
activity level, sleep/rest cycles. baseline.

Elicit information from child/parent of
younger child regarding typical daily food Baseline information to determine
intake, determining foods and beverages adequacy of intake. Knowledge of
normally consumed. Note types of snacks. child’s specific likes/dislikes may
Discuss eating habits and food preferences be helpful in meeting child’s
(likes and dislikes). nutritional needs during a time
when appetite is suppressed or
child has no interest in food.
Determine psychological factors, cultural or
religious desires/influences on dietary Dietary beliefs, such as
choices. vegetarianism, can affect
nutritional intake. Ethnic food
choices can improve a child’s
intake when appetite is poor.
Determine whether infant is breastfed or
formula-fed and typical pattern of feedings Providing usual and typical
during a 24-hr period. Note type and feedings is important to infant well-
amounts of solid foods an infant/young being and early growth.
toddler eats.

Auscultate bowel sounds. Note
characteristics of stool (color, amount, Provides information about
frequency, and so on). digestion/bowel function and may
affect choice/timing of feeding.
Discuss with parent what types of candy,
other sweets, snacks, and sodas child Identifies what child eats in a
eats/drinks. typical day. Provides opportunity
for identifying and providing
healthy snacks.
Emphasize importance of well-balanced,
nutritious intake. Provide information Although nutritious intake is
regarding individual nutritional needs and important, arguing over food is
ways to meet these needs within financial counterproductive. Providing age-
constraints. Avoid arguing over food intake. appropriate guidelines to children
Provide food without comment. as well as to parents/care provider
may help them in making healthy
Review drug regimen, side effects, and
potential interactions with other Timing of medication doses,
medications/over-the-counter drugs. interaction with certain foods can
alter effect of medication or
digestion/absorption of nutrients.
Clarify family/caregiver access to/use of
resources such as food stamps, budget May be necessary to improve
counseling, WIC, community food bank, child’s intake and/or availability of
and/or other appropriate assistance food to meet nutritional needs.

Establish a nutritional plan that meets
individual needs incorporating specific food Corrects/controls underlying
restrictions, special dietary needs. causative factors (e.g., diabetes,
cancer, malabsorption syndrome,
and anorexia).
Consult dietitian/nutritional team as
indicated. Useful in determining individual
nutritional needs and therapeutic
Review indicated laboratory data (e.g.,
serum albumin/prealbumin, transferring, Indicators of nutritional health and
amino acid profile, iron, blood urea nitrogen effects of nutrients in organ
[BUN], nitrogen balance studies, glucose, function.
liver function, electrolytes, total lymphocyte
count, indirect calorimetry).

NURSING DIAGNOSIS: Fluid volume, risk for imbalance
Risk factors may include
Lack of adequate intake, increase in fluid needs, e.g. fever
Rapid/sustained loss, e.g., hemorrhage, burns, vomiting, diarrhea, fistulas
Rapid/excessive fluid replacement
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual

Hydration (NOC)
Demonstrate adequate fluid balance as evidenced by stable vital signs,
palpable pulses/good quality, normal skin turgor, moist mucous
membranes; individual appropriate urinary output; lack of excessive
weight fluctuation (loss/gain), and absence of edema.
Verbalize understanding of child’s fluid needs.
Promote adequate age-appropriate fluid intake.


Fluid Management (NIC) RATIONALE

Independent Causative/contributing factors for
Note potential sources of fluid loss/intake, fluid imbalances.
presence of conditions such as diabetes,
burns, use of total parenteral nutrition
(TPN), etc.

Note child’s age, size, weight, and Affects ability to tolerate fluctuations
cognitive abilities. in fluid level and ability to respond to
fluid needs.

Monitor vital signs, mucous membranes, Indicators of hydration status. Note:
weight, skin turgor, breath sounds, urinary Hypotension indicative of developing
and gastric output, amount of blood shock may not be readily observed
draws, hemodynamic measurements. in pediatric patients until very late in
the clinical course.

Review child’s intake of fluids. Children often do not take in enough
oral fluids to meet hydration needs.

Determine child’s normal pattern of Provides information for baseline
elimination, and whether child is toilet and comparison. If child is in
trained. diapers, output may be determined
by weighing diapers.
Determine whether child has problems Evaluation of these issues is
with urination, such as urine retention, important for determining cause and
bed-wetting, burning, holding. treatment of underlying problem.
Note uses of drainage devices such as May increase fluid and electrolyte
nasogastric tube, wound drain; use of losses.
laxatives, enemas, and suppositories.

Because smaller volumes are
Administer IV fluids via control
administered, close monitoring and
regulation is required to prevent fluid
overload while correcting fluid

Replace electrolytes as indicated by oral
Oral replacement solutions
route whenever possible.
formulated for children are often
safer and better tolerated when
given orally if time/condition allows.

Monitor laboratory results, e.g.,
Indicators of adequacy of
hemoglobin/hematocrit (Hb/Hct), BUN,
hydration/therapeutic interventions.
urine osmolality/specific gravity.

Arrange with laboratory to combine
Excessive/repetitive blood draws
common tests and draw smallest amount
may markedly reduce Hb/Hct levels
of blood that is necessary to perform
in pediatric patients.
required tests.

NURSING DIAGNOSIS: Infection, risk for (septicemia)
Risk factors may include
Inadequate primary defenses (broken skin, traumatized tissue, altered
Inadequate secondary defenses (immunosuppression)
Invasive procedures
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual
Infection Status (NOC)
Achieve timely healing; be free of purulent drainage or erythema; be afebrile.
Risk Control (NOC)
Verbalize understanding of the individual causative/risk factor(s).

Infection Control (NIC)
Independent RATIONALE

Assess vital signs frequently, noting Signs of impending septic shock.
unresolved or Circulating endotoxins eventually
progressing hypotension, decreased produce vasodilation, shift of fluid from
pulse pressure, circulation, and a low cardiac output
tachycardia, fever, tachypnea. state.

Note changes in mental status (e.g., Hypoxemia, hypotension, and acidosis
confusion, stupor). can cause
deteriorating mental status.

Note skin color, temperature, moisture. Warm, flushed, dry skin is early sign of
Monitor urine output. septicemia. Later manifestations
include cool, clammy, pale skin and
cyanosis as shock becomes refractory.

Perform/model good handwashing Reduces risk of cross-
technique. Monitor staff/patient contamination/spread of infection.

Monitor/restrict visitors and staff as Reduces risk of exposure to/acquisition
appropriate. Provide protective of secondary infection in
isolation if indicated. immunosuppressed patient.

Obtain specimens/monitor results of Identifies causative microorganisms
serial blood, urine, and helps in
wound cultures. assessing effectiveness of antimicrobial

Administer amoebecides e.g., Therapy is directed at anaerobic
Metronidazole. bacteria.

X. Actual Nursing Management (SOAPIE)
“ Sakit akong tiyan diri dapit sa akong kilid ” as verbalized by the

O - Facial grimace
- Guarding
- Restlessness

A Alteration in comfort pain related to
Distension of intestinal tissues by inflammation

P At the end of 30 minutes of rendering nursing intervention the patient
will be able to verbalize relief/ control of pain.

I Assess pain noting location, characteristics and intensity. (0-10 scale).
- Helps evaluate degree of discomfort.

Provide accurate, honest information to patient/SO. Keep at rest in
semi-Fowler’s position.
- Being informed about progress of situation provides emotional
support, helping to decrease anxiety. Gravity localizes inflammatory
exudate into lower abdomen or pelvis, relieving abdominal tension,
which is accentuated by supine position.

Apply hot or cold compress when indicated.
- Reduces pain

Provide comfort measures e.g. back rub, repositioning the patient.
- Promotes relaxation and may enhance coping abilities.


Administer medications as indicated e.g. narcotics, analgesics.
- Relieves pain enhances comfort and promotes rest.

E At the end of 30 minutes of rendering nursing intervention the patient
was able to verbalized relief/ control of pain.

O - Facial grimace
- Guarding
- Restlessness

A Knowledge, deficient regarding condition,
prognosis, treatment, self-care, and discharge needs related to
Lack of exposure/recall; information misinterpretation

P At the end of 30 minutes of rendering nursing intervention the patient
will be able to verbalize understanding of disease process and potential

I Identify symptoms requiring medical evaluation, e.g.,
increasing pain; edema/erythema of wound; presence of
drainage, fever.
- Prompt intervention reduces risk of serious
complications, e.g., delayed wound healing, peritonitis.

Encourage progressive activities as tolerated with
periodic rest periods.
- Understanding promotes cooperation with therapeutic
regimen, enhancing healing and recovery process.

Discuss care of incision, including dressing changes,
bathing restrictions, and return to physician for
suture/staple removal.
- Understanding promotes cooperation with therapeutic
regimen, enhancing healing and recovery process.

E At the end of 30 minutes of rendering nursing intervention the patient
was able to verbalized understanding of disease process and potential


O Poor appetite when eating.
A Nutrition: Imbalances, less than body requirements related to poor

P At the end of 1 hour, patient will be able to demonstrate good appetite
and verbalized her feelings concerning resumption of diet.

I Encouraged bed rest and limited activity.

- Decreasing metabolic needs aids in preventing caloric depletion and
conserves energy.

Intake and output recorded.

- Useful in identifying specific deficiencies and determining GI response
to foods.

Recommended rest before meals.

-Quiets peristalsis and increase available energy or eating.

Encouraged patient to verbalize feelings concerning resumption of diet.

- Hesitation to eat may result of fear that food will cause exacerbation o

E At the end of 1 hour, patient was able to demonstrate good appetite and
already spoken about her feelings concerning resumption of diet

Name of Patient: Judy Ann Roque

MEDICATIONS  Advised and encouraged patient
or family to give the patient
paracetamol when she has
 Do not give patient more than 5
doses in 24 hours unless
prescribed by physician.

EXERCISE  Take some rest to prevent stress
and other complications.

TREATMENT  Maintain clear surroundings.

OUT-PATIENT  Advised the parents to visit the
(Check-up) nearest hospital for further
check-up for their child.
DIET  Diet as to age.
 Increase fluid intake.


To allow continuous monitoring of the patient’s healing progress, patient
was encouraged to consult her doctor 2 weeks after discharge for follow-up
check up of her general condition. This will ensure thorough follow up of her
condition and prevention of potential complications. Apart from this, patient was
advised to increase fluid intake, make sure that proper hand washing is practiced
before and after eating.


Black, Joyce M. 1993. Medical-Surgical Nursing- A Psychologic Approach. 4th ed.
W.B Saunders Company: Philadelphia, Pennsylvania,USA.
Smeltzer, Suzanne al.2004. Medical Surgical Nursing. - 10th ed.Lippincott
Williams and Wilkins: Philadelphia

Price, Sylvia A. 1997. Pathophysiology: Clinical Concepts of Disease Processes.
5th ed. Mosby Year Book, Inc: United States of America

Carpenito, Lynda Juall.2000. Nursing Diagnosis: Application to Clinical Practice.
8th ed. Lyndal Juall Carpenito: United States of America.

Pillitteri, Adele. 2003. Maternal and Child Health Nursing.4rth ed.Wolter Kluwer
Company: Hong Kong.

Doenges, Marilynn E.2006.Nurse’s Pocket Guide.F.ADavis Company:


Predisposing factors:

 Age
 Gender
 Lifestyle

Precipitating factors:

 Infections


obstruction of the narrow appendiceal lumen.

Obstruction has many sources, including fecaliths, lymphoid hyperplasia (related
to viral illnesses such as upper respiratory infections, mononucleosis, or

gastroenteritis gastrointestinal parasites, foreign bodies, and Crohn's disease

Continued secretion of mucus from within the obstructed appendix results in
elevated intraluminal pressure,

leading to tissue ischemia, over-growth of bacteria, transmural inflammation,
appendiceal infarction, and possible perforation.

Inflammation may then quickly extend into the parietal peritoneum and
adjacent structures.

s/s: epigastric pain, vomiting, anorexia, fever

Complications: wound infections, intra-abdominal abscess,
intestinal obstruction, and prolonged ileus