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Appendicits Case Study LATEST CHANGES
Appendicits Case Study LATEST CHANGES
TITLE PAGE
Submitted to:
Submitted by:
Date
DECEMBER 1, 2009
II. TABLE ON CONTENTS
I. Introduction ---------------------------------------------------------------------
X. Pathophysiology ---------------------------------------------------------------
A. GENERAL
B. SPECIFIC
To identify patient’s health care needs through analysis of all the data
gathered
The large intestine is the second to last part of the digestive system—the
final stage of the alimentary canal is the anus —in vertebrate animals. Its function
is to absorb water from the remaining indigestible food matter, and then to pass
useless waste material from the body. This article is primarily about the human
gut, though the information about its processes are directly applicable to most
mammals.
The large intestine consists of the cecum and colon. It starts in the right iliac
region of the pelvis, just at or below the right waist, where it is joined to the
bottom end of the small intestine. From here it continues up the abdomen, then
across the width of the abdominal cavity, and then it turns down, continuing to its
endpoint at the anus.
The large intestine is about 1.5 metres (4.9 ft) long, which is about one-fifth of the
whole length of the intestinal canal.
The cecum or caecum (from the Latin caecus meaning blind) is a pouch,
connecting the ileum with the ascending colon of the large intestine. It is separated
from the ileum by the ileocecal valve (ICV) or Bauhin's valve, and is considered to
be the beginning of the large intestine. It is also separated from the colon by the
cecocolic junction.
ABDOMEN - the part of the body of a vertebrate that contains the stomach,
intestines, and other organs
ANUS - the opening at the lower end of the alimentary canal through which feces
are released
CECUM - the pouch in which the large intestine begins, which is open at one end
LARGE INTESTINE - last section of the intestinal tract: the end section of the
alimentary canal reaching from ileum to anus, and consisting of the cecum, colon,
and rectum. Its function is to extract water and form feces
ROVSIGN SIGN - exist when the lower left abdomen is palpated by the doctor,
but causes pain in the right
PSOAS SIGN - If the hip is moved and stretched, this can cause pain to be felt at
the spot where the appendix lies
Name: R. C.
Age: 17
No. of Dependents:
Gender: Male
Nationality: Filipino
Occupation: none
> The client consults his doctor whenever he experiences some changes regarding his
health; this includes stomach pain, high fever, and any other health problems. He never
believed in “hilots” or any natural remedies. He takes medicines such as biogesic for
fever, solmux for occasional cough and some antibiotics. He also takes clusivol and
enervon once a day as his daily supplement.
> Patient eats 3 times a day and drinks water at same time. Has good appetite and has no
significant dietary restrictions. He said that he is heavier before than the present. He likes
to eat different kinds of foods, especially chicken adobo. He doesn’t like his food dry, it
always comes with a soup.
3. ELIMINATION PATTERN
> Patient approximately voids 5 times a day and defecates everyday. This is his
elimination pattern before his hospitalization. Under normal conditions, client has normal
elimination pattern, but due to his operation, his elimination pattern is also altered.
> Client does his own self exercise, he jogging and crutches during weekends
> Client has no problem when it comes to rest or sleep periods. He sleeps 8 hours a day,
from 9pm till 7 in the morning, he sometimes takes a nap in the afternoon.
6. COGNITIVE PERCEPTION
> Patient has complete level of visual, auditory, olfactory and gustatory functioning and
can speak or pronounce words clearly.
7. SELF-PERCEPTION SELF-CONCEPT PATTERN
> Client is on appropriate age, he has high level of self-esteem. And very confident in
facing different kinds of personalities.
> Client is the second child from the five children. He has his own responsibilities in
doing chores inside the house, and responsible for the safety of his younger sisters and
brothers.
> Client has no experienced of having a companion of his opposite sex. And is not
experiencing any problems with regards to his reproductive organs and sexual response.
> When the client experience some difficulties and problems he shares it to his friends
and ask them for opinions and solutions. He plays computer as his problem management.
> Client has no beliefs in other religions. He is a roman catholic and he doesn’t believe in
any other Gods. He has its own values in life that has been taught by their churh.
VI. HEALTH HISTORY
Patient was in usual state of good health until November 24, 2009,
after having his dinner he experienced a severe pain at his abdomen which
started at the area around his periumbilical area shifted to right lower
quadrant region. He was immediately rushed to the hospital and was
admitted at CLMMRH at 9:55 PM, He was diagnosed with acute
appendicitis. He underwent an emergency appendectomy a few hours prior
to admission, November 23, 2009. Her operation begun at 12:08 AM and
ended at 12:40 AM, her surgeon was Dr. Taroja
According to the patient, He had been experiencing mild pain at her
abdominal region since he was 14 years old, He even consulted it to the
doctor but they did not pay much attention to it thinking that it was just a
manifestation of his kidney problem and that it was nothing serious.
The patient’s vital signs during the shift were as follow:
Temperature: 36.2 °C
Pulse Rate: 86 bpm
Respiratory Rate: 20 cpm
Blood Pressure: 120/80 mmHg
a. Childhood illness
> The client has only experienced stomach pain and minor health
problems such as occasional cough, colds, and mild fever.
b. Past Hospitalization
> Patient has no previous hospitalization, no history of Hypertension,
Diabetes, Cancer, no known allergies.
d. Previous Surgery
> No previous history of surgical operation.
Systems Review
Cephalo Caudal
a. General appearance
> Neat Appearance with dark complexion and short curly hair
> Wearing T-shirt with matching long pants
b. Vital signs
> Blood Pressure: 120/80 mmHg
> Temperature: 36.2°C
> Pulse Rate: 86 bpm
> Respiratory Rate: 20 cpm
c. Integumentary
> Warm to touch; Afebrile, T: 36.2°C
> With good skin turgor
d. Cardiovascular
> With IVF #1 PLR 1L x 100cc/hr, infusing well at right cephalic vein
> Blood pressure of 120/80 mmHg, Pulse rate of 80 bpm
> With good capillary refill at less than 2 seconds
e. Respiratory
> Breathes spontaneously to room air at 34 cpm
> With symmetrical rise and fall of chest upon respiration
f. Abdomen
> Flat abdomen with thumblike protrusion of his right lower quadrant
g. Gastrointestinal Tract
> On NPO as ordered
> Has not defecated upon assessment
> Able to pass out flatus upon assessment
> With normoactive bowel sounds at 13 cpm
h. Gastrourinary Tract
> Able to void freely to a light yellow colored urine
i. EENT
> Pupils Equally Round and Reactive to Light Accommodation
> With pinkish conjunctiva
j. Musculoskeletal
> Moderately active, moving freely; ambulatory
IX. LABORATORY AND RADIOLOGY
HEMATOLOGY REPORT
The white blood cell count in the blood usually becomes elevated with
infection. In early appendicitis, before infection sets in, it can be normal, but most often
there is at least a mild elevation even early. Unfortunately, appendicitis is not the only
condition that causes elevated white blood cell counts. Almost any infection or
inflammation can cause this count to be abnormally high. Therefore, an elevated white
blood cell count alone cannot be used as a sign of appendicitis.
2. ABDOMINAL X-RAY
An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized
piece of stool that blocks the appendiceal opening) that may be the cause of appendicitis.
This is especially true in children.
3. ULTRASOUND
4. LAPAROSCOPY
↓
Inflammation
↓
Increase intraluminal pressure
↓
Distention of the Appendix → causes pain
↓
Decrease venous drainage
↓
Blood flow and oxygen restriction to the appendix
↓
Bacterial Invasion of the Blood wall →causes fever
↓
Necrosis of the appendix
↓
Acute pain on RLQ
So, in acute appendicitis, bacterial colonization follows only when the process
have commenced.
These events occur so rapidly, that the complete pathophysiology of appendicitis takes
about one to three days. This is why delay can be deadly.
Pain in appendicitis is thus caused, initially by the distension of the wall of the
appendix, and later when the grossly inflamed appendix rubs on the overlying inner wall
of the abdomen (parietal peritoneum) and then with the spillage of the content of the
appendix into the general abdominal cavity (peritonitis). Fever is brought about by the
release of toxic materials (endogenous pyrogens) following the necrosis of appendicael
wall, and later by pus formation. Loss of appetite and nausea follows slowing and
irritation of the bowel by the inflammatory process.
Early symptoms of appendicitis are those symptoms that most people with this
condition may recognize and complain of.
They include lower right sided abdominal pain of gradual onset, feeling sick (or
nausea), and loss of appetite.
Any one with these three symptoms can be assumed to have appendicitis until proven
otherwise.
Abdominal pain
This pain typically starts from around the belly button (peri-umbilical
region), or the upper central abdomen (epigastrium) and then move downwards
and to the lower right abdomen (right iliac fossa). When the pain occurs in this
pattern, it is the most dependable of all symptoms of appendicitis, as over 8 out 10
(80%) cases that present this way is definitely due to the appendix. In some other
individuals, the pain starts right way from the right iliac fossa. Depending on
where the tip of the appendix is, the pain could even be on the right flank (retro-
caecal appendix). If the appendix is quite long, and in the pelvic cavity, it could as
well cause lower left abdominal pain, with frequent passage of urine if the
inflamed appendix irritates the bladder.
There is also a sign referred to as the Rovsign sign. This is said to exist
when the lower left abdomen is palpated by the doctor, but causes pain in the
right. If the appendix is the pelvic type, examining the back passage (rectal
examination) would cause some pain too. If the hip is moved and stretched, this
can also cause pain to be felt at the spot where the appendix lies. This is referred
to as the psoas sign.
XI. Nursing Care Plan
1. Ketorolac 30mg, Possesses anti- > Management of > Hypersensitivity to CNS: drowsiness, sedation, > Use as part of a regular
tromethamine IVTT inflammatory, analgesics severe, acute pain in the drug or allergic dizziness, headache analgesic schedule rather than on
(Toradol) q8 and antipyretic effects adults that requires symptoms to aspirin or CV: edema, hypertension, as needed basis.> Give oral form
analgesia and the opiate other NSAID’s. palpitations, arrhythmias with meals
level, usually in a > Active peptic ulcer , GI: nausea, dyspepsia, GI > If pain returns within 3-5
CLASSIFICATION: postoperative setting recent GI bleeding or pain, diarrhea, peptic hours, the next dose can be
CNS drugs / NSAID’s perforation, history of ulceration, vomiting, increased by up to 50 %
peptic ulcer or GI constipation, flatulence, > Do not mix IV/IM ketorolac in
bleeding. stomatitis a small volume with morphine
> Advanced renal Hematologic: decreased sulfate, meperinide HCL,
impairment platelet adhesion, pupura, promethazine HCL, or
prolonged bleeding time hydroxyzine HCL, will
Skin: pruritus, rash, precipitate from solution.
diaphoresis
Other: pain at injection site
2. Ranitidine 50mg, Inhibits histamine at H2 > Used in the > Hypersensitivity to CNS: vertigo, malaise, > Assess patient for abdominal
IVTT receptor site in the gastric management of various drug or its components headache. pain. Note presence of blood in
CLASSIFICATION: q8 parietal cells, which inhibits gastrointestinal > Alcohol intolerance EENT: blurred vision emesis, stool, or gastric aspirate
GIT drugs / Antiulcer gastric acid secretion. disorders such as (with some oral Hepatic: jaundice > Ranitidine may be added to
drugs dyspepsia products) Other: burning and itching at total parenteral nutrition solution
gastrointestinal reflux > History of acute injection site, anaphylaxis, > Evaluate results of laboratory
disease [GERD], peptic porphyria. angioedema tests, therapeutic effectiveness
ulcer and zolunger- and adverse reactions
ellisou syndrome. (bradycardia, PVC’s,
Prophylaxis of GI tachycardia, CNS changes, rash,
hemorrhage from the gynecomasticia, GI disturbance
stress ulceration and in and hepatic failure.)
patients at risk of > Assess knowledge and teach
developing acid patient appropriate use, possible
aspiration during side effects or appropriate
general anesthesia interventions and adverse
prophylaxis of symptoms to report.
mendelson syndrome.
Name of Drug Dosage Mechanism of action Indication Contraindication Adverse reaction Nursing considerations
Frequency
Route
1. Cefuroxime 500mg, Second-generation > Perioperative > Contraindicated in CV: phlebitis, > Before administration, ask
1 tab cephalosporin that inhibits prevention patients thrombophlebitis patient if he is allergic to
CLASSIFICATION: TID cell-wall synthesis, hypersensitivity to drug GI: pseudomembranous penicillin or cephalosporins.
Anti-invectives/ promoting osmotic or other cephalosporins. colitis, nausea and vomiting, > Obtain specimen for culture
Cephalosporins instability; usually >Use cautiously in anorexia, diarrhea and sensitivity tests before
bactericidal. patients hypersensitive Hematologic: transient giving first dose.
to penicillin because of neutropenia, eosinophilia, > For I.M. administration, inject
possibility of cross- hemolytic anemia, deep into a large muscle, such as
sensitivity with other thrombocytopenia. the gluteus maximus or the
beta-lactam antibiotics. Skin: maculopapular and lateral aspect of the thigh
erythematous rashes, urticaria, > Absorption of cefuroxime is
pain, induration, sterile enhanced by food.
abscesses, temperature
elevation.
Other: hypersensitivity
reactions, serum sickness,
anaphylaxis.
2. Meloxicam 15mg, Unknown, may inhibit > Relief from pain > Contraindicated in CNS: dizziness, headache, > Rehydrate dehydrated patients
1 tab prostaglandin synthesis, to patients insomnia, fatigue before starting drug
CLASSIFICATION: OD prn for produce anti-inflammatory, hypersensitivity to CV: arrhythmias, palpitations, > Watch for signs and symptoms
NSAID, CNS drug pain analgesic and antipyretic drug. tachycardia, heart failure, of overt poor overall health
effects hypertension >NSAIDs can cause fluid
GI: abdominal pain, diarrhea, retention: closely monitor
dyspepsia, flatulence patients who have hypertension,
edema, or heart failure.
3. Ascorbic acid 250mg Vitamin C is essential in the > vitamin C > Contraindicated in CNS: paresthesia of limbs, > ascorbic acid aren’t
1 tab synthesis of collagen, a deficiency patients listlessness, confusion, flaccid interchangeable; verify
CLASSIFICATION: BID connective tissue protein of > Post operative hypersensitivity to paralysis. preparation before use.
Vitamin C the body incisions ascorbic acid CV: arrhythmias, heart block, > Make sure powders are
>Large doses of hypotension ECG changes. completely dissolved before
vitamin C should be GI: nausea, vomiting, diarrhea giving.
given with care to Metabolic: hyperkalemia >Enteric-coated tablets aren’t
patients with Respiratory: respiratory recommended because of
hyperoxaluria. paralysis. increased risk of GI bleeding and
small-bowel ulcerations.
XIII. HEALTH TEACHING
Medication Exercise Treatment Hygiene Outpatient Diet
` Ketorolac tromethamine
(Toradol) 30mg IVTT q8 for acute Medications Personal hygiene pertains to > Continue prescription
pain > LEG EXERCISES hygiene practices performed drugs if symptoms comes Practice of ingesting food in
> Ketorolac by an individual to care for back a regulated fashion to
- to promote blood - Management of one’s bodily health and well achieve or maintain a
` Ranitidine 50mg, IVTT q8 circulation. Moderate severe, acute pain in being through cleanliness. >Compliance to follow up controlled weight. In most
For inhibiting gastric acid secretion. exercise in the morning adults that requires Conditions and practices that check ups cases the goal is weight loss
within the patient’s limit and analgesia and the opiate serve to promote or preserve in those who are overweight
`Teach the patient & folks about the with rest. Inform client that level, usually in a health. > Continue ROM and leg or obese, but some athletes
indications of the drugs and let them the normal activity can be postoperative setting. exercises aspire to gain weight
know the effect & adverse effects of resumed after 3-4 weeks. Personal hygiene practices - to avoid further (usually in the form of
the medications. > Ranitidine include: seeing a doctor, seeing complications to health muscle) and diets can also
Client must understand the - inhibits gastric acid a dentist, regular washing be used to maintain a stable
importance of drugs to their body and secretion. Used in the (bathing or showering) of the > Adequate fluids body weight.
why they must acquire it. >ROM management of various body, regular hand washing, - for hydration
gastrointestinal disorders brushing and flossing of the > Balanced diet
Remind them to question and not to -for circulation such as dyspepsia and teeth, and healthy eating. > Prevention/Promotion of - Eat fresh fruits and
administer medication that have improvement. patients at risk of diseases must be vegetables for essential
been, improperly stored, look Exercises may not be developing acid aspiration >self-help bath/Bed bath implemented nutrients and minerals
discolored, or do not look like their important, but it can during general anesthesia - strengthen immunity
usual medication. minimize the chance of prophylaxis of mendelson >Tepid sponge bath
acquiring and spreading of syndrome. > Rest for comfort > Avoid junk
Advise the patient to always read the diseases. >Brushing and flossing the and street foods
label before taking a drug, to take it Laboratory test teeth > Careful handling of items - to avoid GIT infections
exactly as prescribed, and never to - to remove dental plaque in the environment, to - to prevent complications
share prescription drugs. >Regular monitoring of minimize viral such as amoeba and
CBC (platelets) >providing special oral care contamination. hepatitis.
Encourage them to ask further - To prevent lowering of -to maintain intactness of
questions about their drugs. platelets that may cause health of lips, tongue and > Regular bowel
After discussion make sure the client spontaneous bruising & mucus membranes of the elimination
understands and ask to repeat if bleeding mouth.
verification is needed. > Urinalysis -to prevent oral infections
- serves as indication for
infection.
XIV. BIBILIOGRAPHY