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Introduction

Our subject case was in relation to a man with an initial of JLP,33 years old, a resident in NHV Friendship Village Resour,
Norzagaray, Bulacan, recently admitted in Bulacan Medical Center Hospital on September 0 4,2010 at around 10:36 am due to
generalized abdominal pain and loss of appetite.

Appendicitis is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity. It has
been found that identification of risk factors of more common between the ages of 11 and 20,cystic fibrosis or the scarring and
cyst formation within the pancreas, People whose diet, predisposes it to infection, runs in certain families. Having a family history
of appendicitis, gastrointestinal infections such as Amebiasis, Bacterial Gastroenteritis, Mumps, Coxsackievirus B and Adenovirus
can be a risk factor of Rupture Appendicitis. Thus the early recognition is very important and beneficial for which this study was
done.

Appendicitis has the manifestations of lower quadrant pain accompanied by a low grade fever, nausea, vomiting and loss of
appetite. Also it can be identified through blood test in able to check for signs of infections such as elevated WBC count, urine test
to rule out Urinary tract Infection, Imaging procedures including CT scan, ultrasound and x-ray to determine whether the appendix
is inflamed, also a treatment of appendectomy should be done after the positive results for appendicitis cause the inflammation
can result to further complication if not treated such as progression to abscess, perforation, peritonitis, and death. After the
surgical procedure the patient can live a normal life without his appendix and specific changes in diet, exercise, or other lifestyle
factors may not be necessary.

Objective:
 To be able to attain and extend our knowledge, skills and attitude to provide quality nursing care to our patient with
ruptured appendicitis

Specific objectives
Student Centered:

 Discover how the patient acquired the disease through the nursing health history, physical examinations, and
some other some other factors that may contribute in relation to Chronic Kidney Disease and be able to assess,
organize and validate those data efficiently.

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 To understand the disease process, its etiology, signs and symptoms, pathophysiology and diagnostic
procedures.
 Design a plan of care for patient with chronic kidney disease (CKD).
 To be able to formulate those data into nursing diagnoses that may aid in the patient’s current health condition.
 To be able to set priorities and goal outcomes in collaboration with the patient.

Client Centered:

 To be able to establish rapport with the patient and folks.


 To be able to develop respect and trust.
 To discuss and describe interventions for health promotion, prevention and treatment of patients with
appendicitis
 To assist patients in overcoming the anxiety and depression brought about by the condition.

Nursing Assessment
A. Personal History
1. Demographic Data.
 Name: J.L.P.
 Age: 33 years old
 Religion: EMELIF
 Sex: Male
 Civil Status: Married
 Position in the Family: Father
 Address: NHV Friendship Village Resour Norzagaray, Bulacan
 Place of birth: Norzagaray, Bulacan
 Date of birth: December 20, 1976

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 Nationality: Filipino
 Educational Attainment: College
 Health Care Financing /Usual source of medical care: own business.
 Date of Admission: September 4, 2010
 Admission Diagnosis: Acute Appendicitis probably Ruptured
 Principal Diagnosis: Ruptured Appendicitis
B. Reasons for Visit/Chief Complain.cry

Patient experienced abdominal pain at the Epigastric area particularly at the Right Lower Quadrant. Other Signs and
Symptoms are cold, fever, and anorexia.

C. History of Past Illness


The patient verbalized that he had experienced having chicken pox when he was 13 years old. He also had a Typhoid fever
when he was 20 years old. He have completed his vaccination when he was young (BCG, DPT, OPV, Hepa B, measles). He has also
encountered having the usual cold, cough and fever.
D. History of Present Illnesses
Prior to hospitalization, patient experienced a sudden pain in his right lower abdomen. The pain was so intense that he
screamed and cried. He could not move because of the pain so his family decided to bring him to the hospital.

E. Family Health Illness History


According to J.L.P. his grandfather, from the mother side, died due to Pneumonia. His grandmother, Aunt P.N. and Aunt
M.D.C., also from the mother side, died due to cancer of the neck, ovaries, and breast respectively. While his grandfather on the

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father side died as a result of Skin cancer, his grandmother passed away due to Heart attack. His father recently died because of
Heat stroke.

Family Health Illness History

SP 95 FP 60
CL 93 VL 69

MP BP
NL75 PL 70 ET AP TN RQ SS PP GP
CF JL 68 KL ST VL 74 SP 71 57
54 51 77 69 65 61 56
27 19 59 49

JP
56 DP 59

LEGEND

Appendicitis Breast Cancer

Death Heat Stroke


JP 35 J.L.P. 33 DP 32 JP 30 JP 19
Ovarian Cancer Female

Neck tumour Male


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Heart Attack Pneumonia

Skin Cancer Flu


F. Functional Health Pattern

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Prior to Hospitalization During Hospitalization
1. HEALTH According to Mr J.L.P. eventhough their business is The patient always follows the medical regimen
PERCEPTION/ piggery his usual foods are vegetables and fish. ordered by his doctor. He also used some health
HEALTH Every time that he is sick he takes medicines in promotion activities like ambulating and deep
MANAGEMENT accordance to his illness. He does not believe in breathing exercise. His eats according to the
PATTERN Albularyos but he believes that herbal medicines recommended diet. “Malakas naman noon, bago ko
are effective though he hasn’t tried one. He does magkasakit ng ganito” as verbalized by the patient.
not smoke but he is an alcohol drinker.
2. NUTRITION His usual foods are fish and vegetables. He only During his stay at the hospital the doctor ordered him
METABOLIC PATTERN eats pork once in a week. He also drinks 6-8 to take nothing by mouth because he was to undergo
glasses of water everyday and drinks alcoholic an operation. Afterwards he was ordered again
beverages occasionally. nothing by mouth then after a positive flatus his diet
Date Breakfast Lunch Dinner shift to general liquid.
Sept 1 2 cups of 2 cups of 2 cups of
rice, rice, 2 rice, 2 Date Breakfast Lunch Dinner
1 pc saucers of saucers of Sept 4 1 cup of Admitted to NPO
Galunggon chopseuy, chopseuy, 3 rice, 2 tuyo the hospital.
g, 3 glasses glasses of and 1 NPO
2 glasses of water water tomato, 2
of water glasses of
Sept 2 3 cups of 2 cups of 2 cups of water
rice, 3 pcs rice, 2 rice, 1 Sept 5 NPO NPO NPO
pangat, saucers of saucer of Sept 6 NPO 1 bowl of 2 glasses of
3 glasses pakbet, 3 pakbet, 2 soup, 1 glass water
of water glasses of glasses of of water
water water
Sept 3 2 cups of 2 cups of 3 cups of
fried rice, 1 rice water, 1
slice fried 1 bowl of bowl
bangus sinigang sinigang na
with 1 pc nab angus, bangus, 3
tomato, 3 3 glasses glasses of
glasses of of water water
water

3. ELIMINATION “pakiramdam ko naman ayos lang ung pagdumi at “Tatlong araw na akong hindi dumudumi simula ng
pag ihi ko” as verbalized by the patient. operahan ako” as verbalized by the patient.
PATTERN
Urine Urine
Date Frequen Color Odor Amount Date Frequen Color Odor Amount
cy 6 cy
Sept 1 5 Light Aromati 650 mL Sept 4 Foley yellow Aromati 450 mL
yellow c Cathete c
Sept 2 4 Light Aromati 500 mL r
E.GROWTH AND DEVELOPMENT

THEORY STAGE Reason/s


J.R.R. falls under this stage
Erickson’s Stage of Intimacy VS. Isolation. because he already has a family of
Psychosocial Development. his own. He had already formed an
intimate relationship with his wife
and his family.

The patient is in Genital stage


Freud’s Stage of Genital stage since he has a good sexual
Psychosexual Development. relationship with his wife. He is
sexually gratified and has no
problem during intercourse.

The client thinks rationally and


Jean Piaget’s Stage of Formal Operations stage logically.
Cognitive Development. He can think more extensive and
more general especially when
faced with problems.

He falls under this stage because


Kohlberg’s Stage of Moral Post-conventional (level III) he already knows and understands
Development. Stage 5 Social Contract the principle of human rights. He
Orientation has a background knowledge
regarding the law and the
consequences when it is not
followed.

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Anatomy and Physiology

Urinary System

Your body takes nutrients from food and uses them to maintain all bodily functions including energy and self-repair. After your
body has taken what it needs from the food, waste products are left behind in the blood and in the bowel. The urinary system
works with the lungs, skin, and intestines—all of which also excrete wastes—to keep the chemicals and water in your body
balanced. Adults eliminate about a quart and a half of urine each day. The amount depends on many factors, especially the

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amounts of fluid and food a person consumes and how much fluid is lost through sweat and breathing. Certain types of
medications can also affect the amount of urine eliminated.

The urinary system removes a type of waste called urea from your blood. Urea is produced when foods containing protein, such as
meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys.

The kidneys are bean-shaped organs about the size of your fists. They are near the middle of the back, just below the rib cage.
The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of
small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste
substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.

From the kidneys, urine travels down two thin tubes called ureters to the bladder. The ureters are about 8 to 10 inches long.
Muscles in the ureter walls constantly tighten and relax to force urine downward away from the kidneys. If urine is allowed to
stand still, or back up, a kidney infection can develop. Small amounts of urine are emptied into the bladder from the ureters about
every 10 to 15 seconds.

The bladder is a hollow muscular organ shaped like a balloon. It sits in your pelvis and is held in place by ligaments attached to
other organs and the pelvic bones. The bladder stores urine until you are ready to go to the bathroom to empty it. It swells into a
round shape when it is full and gets smaller when empty. If the urinary system is healthy, the bladder can hold up to 16 ounces (2
cups) of urine comfortably for 2 to 5 hours.

Circular muscles called sphincters help keep urine from leaking. The sphincter muscles close tightly like a rubber band around the
opening of the bladder into the urethra, the tube that allows urine to pass outside the body.

Nerves in the bladder tell you when it is time to urinate, or empty your bladder. As the bladder first fills with urine, you may notice
a feeling that you need to urinate. The sensation to urinate becomes stronger as the bladder continues to fill and reaches its limit.
At that point, nerves from the bladder send a message to the brain that the bladder is full, and your urge to empty your bladder
intensifies.

When you urinate, the brain signals the bladder muscles to tighten, squeezing urine out of the bladder. At the same time, the
brain signals the sphincter muscles to relax. As these muscles relax, urine exits the bladder through the urethra. When all the
signals occur in the correct order, normal urination occurs.

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Gastrointestinal System

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth,
continuing through the pharynx, oesophagus, stomach and intestines to the rectum and anus, where food is expelled. There are
various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. Thus
the salivary glands, liver, pancreas and gall bladder have important functions in the digestive system. Food is propelled along
the length of the GIT by peristaltic movements of the muscular walls. The gastrointestinal tract (GIT) consists of a hollow
muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, esophagus, stomach
and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by

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secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder
have important functions in the digestive system. Food is propelled along the length of the GIT by peristaltic movements of the
muscular walls. Anatomy and Physiology

Respiratory System

The primary function of the respiratory system is to supply the blood with oxygen in order for the blood to deliver oxygen to all
parts of the body. The respiratory system does this through breathing. When we breathe, we inhale oxygen and exhale carbon
dioxide. This exchange of gases is the respiratory system's means of getting oxygen to the blood.
Respiration is achieved through the mouth, nose, trachea, lungs, and diaphragm. Oxygen enters the respiratory system through
the mouth and the nose. The oxygen then passes through the larynx (where speech sounds are produced) and the trachea which
is a tube that enters the chest cavity. In the chest cavity, the trachea splits into two smaller tubes called the bronchi. Each
bronchus then divides again forming the bronchial tubes. The bronchial tubes lead directly into the lungs where they divide into

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many smaller tubes which connect to tiny sacs called alveoli. The average adult's lungs contain about 600 million of these spongy,
air-filled sacs that are surrounded by capillaries. The inhaled oxygen passes into the alveoli and then diffuses through the
capillaries into the arterial blood. Meanwhile, the waste-rich blood from the veins releases its carbon dioxide into the alveoli. The
carbon dioxide follows the same path out of the lungs when you exhale.
The diaphragm's job is to help pump the carbon dioxide out of the lungs and pull the oxygen into the lungs. The diaphragm is a
sheet of muscles that lies across the bottom of the chest cavity. As the diaphragm contracts and relaxes, breathing takes place.
When the diaphragm contracts, oxygen is pulled into the lungs. When the diaphragm relaxes, carbon dioxide is pumped out of the
lungs.

Renal System

The kidneys are essentially regulatory organs which maintain the volume and composition of body fluid by filtration of the blood
and selective reabsorption or secretion of filtered solutes.

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the kidneys are retroperitoneal organs (ie located behind the peritoneum) situated on the posterior wall of the abdomen on each
side of the vertebral column, at about the level of the twelfth rib. The left kidney is lightly higher in the abdomen than the right,
due to the presence of the liver pushing the right kidney down.

The kidneys take their blood supply directly from the aorta via the renal arteries; blood is returned to the inferior vena cava via the
renal veins. Urine (the filtered product containing waste materials and water) excreted from the kidneys passes down the
fibromuscular ureters and collects in the bladder. The bladder muscle (the detrusor muscle) is capable of distending to accept
urine without increasing the pressure inside; this means that large volumes can be collected (700-1000ml) without high-pressure
damage to the renal system occuring.
When urine is passed, the urethral sphincter at the base of the bladder relaxes, the detrusor contracts, and urine is voided via the
urethra.

PATHOPHYSIOLOGY

Non-modifiable Modifiable
Age: 10-30 yrs old *Diet- people whose diet is low in
Gender: male fiber and rich in refined
(male – female = 2:1) carbohydrates
Hereditary tumor formation the *infections- gastrointestinal
opening of the appendix infection such as amoebiasis,
bacterial gastroenteritis mumps

Obstruction of the appendix by fecal


(hardened stool), lymph node, tumor,
foreign objects

Increase in pressure inside the


appendix lumen that result to
distention of the appendix
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Impaired venous return causing
hyperthermia (improper oxygen, and
nutrient supply) normal bacteria found
in appendix begin to invade (infect)
the lining
Inflammatory of the body
response- wall
response to the bacterial invasion in
the wall of appendix
Increase immune complex (disease
plus antibody) cause swelling of
tissue resulting to inflammation of
appendix
S/Sx : abdominal pain, fever and
increase swelling of appendix ,
vomiting and loss of appetite

Appendectomy,
pain medication

Inflammation and infection


Pain- located at RLQ, spread through the wall of
causing Guarding, vomiting the appendix causing
and loss of appetite rupture due to the increase
pressure
(Perforation)

Appendectomy with
explore Laparotomy
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Perforation (formation of
hole in an organ), fecal
material exist to peritoneal
cavity causing formation of
abscesses (periappendical
abscess), infection can
spread throughout the
abdomen
(Peritoneal cavity)
Acterial invasion of peritoneal cavity causing
inflammation of the membrane that lies the abdomen
peritoneum (Peritonitis)
S/Sx : swelling of the abdomen ,severe pain , and
weight loss

Sespsis (the condition or


syndrome caused by the presence
of microorganism or their toxins
in the tissue or the bloodstream)
septicemia

If not TREATED If TREATED


Septic shock
S/Sx: increase blood
pressure
Increase blood volume Strong antibiotic
medication

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COMA Fluid Volume
DEATH Replacement
therapy
RECOVERY
Definition of terms
• The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the cecum just below the ileocecal valve.
No definite functions can be assigned to it in humans. The appendix fills with food and empties as regularly as does the
cecum, of which it is small, so that it is prone to become obstructed and is particularly vulnerable to infection (appendicitis).

• Appendicitis is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity. About 7%
of the population will have appendicitis at some time in their lives, males are affected more than females, and teenagers
more than adults. It occurs most frequently between the age of 10 and 30.
• The disease is more prevalent in countries in which people consume a diet low in fiber and high in refined carbohydrates.
• The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting. Loss of appetite is
common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burney’s point applied located at halfway
between the umbilicus and the anterior spineof the Ilium.
• Constipation can also occur with an acute process such as Appendicitis. Laxative administered in the instance may result in
perforation of the in flared appendix. In general a laxative should never be given when a person’s has fever, nausea or pain.

Predisposing Factors

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 Medication include IV antibiotics ,analgesic for pain ,and antipyretics for fever

 Comfort measures until a diagnosis is confirmed: surgery if the diagnosis is confirmed; in the absence of the rebound
tenderness, IV fluids are given to confirmed possible GI virus (pain improves after fluid are given with a virus)

 Avoid enemas ,carthartics , heating pad or abdominal palpation with a confirmed diagnosis to prevent rupture

 Monitor vital signs , especially temperature

 Administer standard postoperative care: turn, cough ,deep breathing :early ambulation ,assess bowel sounds, monitor
urinary output, and provide wound care
Review of System

Systems Findings
Cardiovascular No significant sign such as palpitation, lower limb edema, orthopnea , dizziness,
syncope etc.

Endocrine No significant findings such as moon face, exophthalmos, tremors, acromegaly eyc.

Gastrointestinal As stated
Genitourinary No significant findings such as dysuria, olyuria, hematoria, incontinence, nocturia etc.

Hematopoieteic No significant findings such as pallor, jaundice or bleeding tendency etc.

Musculoskeletal No significant findings such as myalgia, arthragia , or arthritis etc.

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Neurologic No significant findings such as recurrent headache, fits, blurring of vision, or drowsiness etc.

Respiratory No finger clubbing , no accessory muscle use during respiration, no shortness of breath, no noisy breathing ,no
hemoptysis, no night sweat
Skin , Hair ,nails No significant findings, the skin color is normal according to his race, hair is evenly distributed , nail is
normal no clubbing, koilonichia, leukonichia etc.

Head and Neck Normal head size ,shape, and symmetry , no skull enlargement, bossing etc. no significant findings in neck
such us webbing and goiter

Diagnostic Laboratory Procedure


Diagnostic Date Ordered Indication and Normal Values Result Analysis and Nursing
Laboratory and Date Purposes (units used in Interpretation Responsibilitie
Procedure Result In the hospital) of the results s
Complete Blood September 4,2010 The hemoglobin test 125-175 g/L 123 g/L Normal Range Prior:
Count September 4,2010 is normally ordered Gather the materials
Hemoglobin as a part of Normal level of needed; syringe,
the complete blood hemoglobin tourniquet, vial
count (CBC), which During:
is ordered for many Cubital vein is
different reasons, commonly used
including for a After:
general health Direct pressure and
screen. assess for bleeding

To screen for
disease associated
with anemia,

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determine severity
of anemia, and
follow the response
to treatment for
anemia

Hematocrit September 4,2010 The hematocrit is 0.40-0.52 l/l 0.360 l/l Normal Range Prior:
September 4,2010 normally ordered as Gather the materials
a part of Normal hematocrit needed; syringe,
the complete blood tourniquet, vial
count (CBC). During:
Indicators are Cubital vein is
dehydration and commonly used
anemia. After:
Direct pressure and
To evaluate anemia, assess for bleeding
dehydration and for
blood transfusion
decision if severe
anemia is seen
White Blood Cell September 4,2010 Conditions or 5-10x10 /L 11.8 x10 /L Increase Normal Prior:
September 4,2010 medications that Range Gather the materials
weaken the immune needed; syringe,
system. The WBC Increase WBC tourniquet, vial
count detects indicates infection During:
dangerously low Cubital vein is
numbers of these commonly used
cells. After:
Direct pressure and
To determine the assess for bleeding
presence of an
infection

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% Lymphocytes September 4,2010 Responsible for 20.0-0-45.0% 8.6% Decrease Normal Prior:
September 4,2010 initiating and Range Gather the materials
regulating the needed; syringe,
immune response Percentage of tourniquet, vial
by the production of Lymphocytes at During:
antibodies and decrease normal Cubital vein is
cytokines. range indicates viral commonly used
infection After:
Direct pressure and
assess for bleeding

# Lymphocytes September 4,2010 Responsible for 1.2-3.2 1.0 Decrease Normal Prior:
September 4,2010 initiating and Range Gather the materials
regulating the needed; syringe,
immune response Lymphocytes at tourniquet, vial
by the production of decrease normal During:
antibodies and range indicates viral Cubital vein is
cytokines. infection commonly used
After:
Direct pressure and
assess for bleeding
% Monocytes September 4,2010 Process and present 4-10% 4.2% Within Normal Prior:
September 4,2010 antigens to Range Gather the materials
lymphocytes, as an needed; syringe,
event required for tourniquet, vial
lymphocyte Normal Monocyte During:
activation count indicates no Cubital vein is
chronic bacterial commonly used
infection. After:
Direct pressure and
assess for bleeding
# Monocytes September 4,2010 Process and present 0.3-0.8 0.4 Within Normal Prior:
September 4,2010 antigens to Range Gather the materials
lymphocytes, as an needed; syringe,
event required for tourniquet, vial
lymphocyte Normal Monocyte During:
activation count indicates no Cubital vein is
chronic bacterial commonly used
infection. After:

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Direct pressure and
assess for bleeding
% Granulocytes September 4,2010 Help protect the 40.0-75.0 87.2% Increase Normal Prior:
September 4,2010 body against Range Gather the materials
needed; syringe,
bacterial and Elevated tourniquet, vial
fungal infections Granulocytes is an During:
and ingest indicative of Cubital vein is
foreign debris. underlying bacterial commonly used
infection. After:
Direct pressure and
assess for bleeding
# Granulocytes September 4,2010 Help protect the 2.5-7.5 10.4 Increase Normal Prior:
September 4,2010 body against Range Gather the materials
needed; syringe,
bacterial and Elevated tourniquet, vial
fungal infections Granulocytes is an During:
and ingest indicative of Cubital vein is
foreign debris. underlying bacterial commonly used
infection. After:
Direct pressure and
assess for bleeding
Platelet Count September 4,2010 A platelet count is 150-400x10 214x10 g/L Within Normal Prior:
September 4,2010 often ordered as a g/L Range Gather the materials
part of a complete needed; syringe,
blood count, which Indicates normal tourniquet, vial
may be done at an blood clotting During:
annual physical Cubital vein is
examination commonly used
After:
Bleeding disorders , Direct pressure and
such as leukemia, assess for bleeding
require the
determination of the
number of platelets
present and/or their
ability to function
correctly.

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Mean corpuscular September 4,2010 Mean corpuscular 27-33 pg 21.7 Decrease Normal Prior:
hemoglobin (MCH) September 4,2010 hemoglobin (MCH) Range Gather the
is a calculation of materials needed;
the average amount Low MCH indicates syringe, tourniquet,
of oxygen-carrying iron deficiency vial
hemoglobin inside a During:
red blood cell. Cubital vein is
Macrocytic RBCs are commonly used
large so tend to After:
have a higher MCH, Direct pressure and
while microcytic red assess for bleeding
cells would have a
lower value.

Mean corpuscular September 4,2010 Mean corpuscular 82-92 fl 63.0 fl Low level Range Prior:
volume (MCV) September 4,2010 volume (MCV) is a Gather the materials
measurement of the Low MCV means needed; syringe,
average size of your cells are smaller tourniquet, vial
RBCs. The MCV is to than usual and During:
determine when indicates iron Cubital vein is
your RBCs are deficiency commonly used
larger than normal After:
(macrocytic), for Direct pressure and
example in anemia assess for bleeding
Mean corpuscular September 4,2010 Mean corpuscular 31-36 g/dL 34.1g/dl Normal Range Prior:
hemoglobin September 4,2010 hemoglobin Gather the materials
concentration concentration Normal MCHC needed; syringe,
(MCHC) (MCHC) is a indicates normal tourniquet, vial
calculation of the amount of Hgb that During:
average will fit inside a RBC Cubital vein is
concentration of commonly used
hemoglobin inside a After:
red cell Direct pressure and
assess for bleeding

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Red Cell Distribution September 4,2010 It tells how 10.2-14.5% 15.2% Increase Normal Prior:
Width (RDW) September 4,2010 consistent are Range Gather the materials
needed; syringe,
the size of the tourniquet, vial
red blood cells. The high RDW During:
helps determine Cubital vein is
if there is only a commonly used
B12 and/or folic After:
Direct pressure and
acid deficiency assess for bleeding
(with normal
RDW showing
the red cells are
mostly the same
size) or with
concomitant iron
deficiency (a
high RDW due to
small and large
red blood cells).
Mean Platelet September 4,2010 Bleeding 9.0-13.0 7.6 fl Decrease Normal Prior:
Volume September 4,2010 tendency, and is Range Gather the materials
needed; syringe,
used to tourniquet, vial
Low MPV indicates
determine Iron deficiency During:
changes in bone Cubital vein is
marrow function, commonly used
as well as After:
Direct pressure and
diagnosis and assess for bleeding
treatment of
certain
diseases..

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Platelet Distribution September 4,2010 An indication of 10.0-18.0 13.7 % Normal Range Prior:
Width (PDW) September 4,2010 variation in Gather the materials
PDW within the needed; syringe,
platelet size tourniquet, vial
which can be a normal range During:
sign of active showed high Cubital vein is
platelet release. platelet volume commonly used
uniformity After:
Direct pressure and
assess for bleeding

Serum Electrolytes September 4,2010 This test is a part of 136-145 mmol/L 138.5 mmol/L Normal Range Prior:
September 4,2010 the routine lab Gather the materials
evaluation of most Normal blood level needed; syringe,
Sodium patients. And when of sodium tourniquet, vial
patient has During:
symptoms of Cubital vein is
hypoantremia and commonly used
hypernatremia such After:
as confusion, Direct pressure and
weakness nad assess for bleeding
decrease urine
output.

To detect
hyponatremia or
hypernatremia
associated with
dehydration
Potassium September 4,2010 Tests for potassium 3.5-5.0 mmol/L 4.15 mmol/L Normal Range Prior:
September 4,2010 levels are routinely Gather the materials
performed in most blood level of needed; syringe,
patients when they potassium tourniquet, vial
are investigated for During:
any type of serious Cubital vein is
illness. commonly used
After:
To detect Direct pressure and
assess for bleeding

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concentrations that
are too high
(hyperaemia) or too
low (hypokalemia).

Patient and his care


A. Medical Management

Medical Date ordered/Date General Indications/Purposes Client’s Nursing


Management performed/Date Description Response to Responsibilities
Treatment changed the

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treatment
Intravenous Fluid Date started: D5LR is actually Used to provide free -maintains PRIOR:
September 4,2010 5% dextrose in water and treat cellular balance in the -Check for doctor’s
D5LR
lactated ringer's dehydration. These patient’s body order
solution. It is a solutions promote waste fluid -Check for 10 R’s in
hypertonic solution elimination by the -replaces administering IVF D5 LR
which means it kidneys. patient’s fluid -Explain to the client
pulls fluid out of loss what you are going to
the cells into the do, why it is necessary,
intravascular and how she can
space (veins). cooperate.
-Confirm the route is
correct
-Assess vital signs
DURING:
-Use aseptic techniques
-regulate to prescribed
flow
AFTER:
-Make sure that the
tubing is not kinked and
there should be no air
bubbles to be sure that
the fluid is delivered
directly to the
bloodstream.
-Monitor the
consumption of the IVF.
-Observe for signs of
adverse reaction.
-Assess vital signs

26
Medical Date ordered/Date General Indications/Purposes Client’s Nursing
Management performed/Date Description Response to Responsibilities
Treatment changed the treatment
Oxygen inhalation Date started: Oxygen therapy is Oxygen is used as a - Easy PRIOR:
September 4,2010 the administration medical treatment in breathing -Check for doctor’s
of oxygen at both chronic and acute order
concentrations cases, and can be used -Check for 10 R’s in
greater than that in hospital, pre-hospital administering
in room air to treat or entirely out of oxygen therapy
or prevent hospital, dependant on -Explain to the client
hypoxemia (not the needs of the patient what you are going
enough oxygen in and the views of the to do, why it is
the blood). medical professional necessary, and how
advising. she can cooperate.
-check proper mask
to be used and
proper delivery
performed
-Assess vital signs
DURING:
-Use aseptic
techniques
AFTER:
-Make sure that the
tubing is not kinked.
-Observe for signs of
adverse reaction.
-Assess vital signs

27
B. Drugs

Generic Date Route of General Indications/Pur Client’s Nursing


Name/ Brand ordered/Date administratio Action, poses Response to the Responsibilities
Name taken/ Date n, dosage, Classification medication
Changed frequency , Mechanism
of action
Diphenhyrami Date ordered: Intravenous Diphenhydrami Diphenhydramin Relives patient -Check for doctor’s
ne September 50mg 30 mins. ne is an e is used for the nasal allergy. order
3,2010 Prior to BT antihistamine relief of nasal -Explain to the client
used for and non-nasal the action of
treating symptoms of Diphenhyramine
allergic various allergic -Check for the 10R’s
reactions. conditions such in administering
Diphenhydrami as seasonal Diphenhyramine
ne also blocks allergic rhinitis. It -Assess vital signs
the action of is also used to DURING:
acetylcholine alleviate cold -Use aseptic
(anticholinergic symptoms and technique
effect) and is chronic urticaria -Assess vital signs
used as a (hives). AFTER:
sedative -Monitor client the
because it effect to the client
causes -assess vital signs
drowsiness.

28
Paracetamol Date ordered: Intravenous Decreased -Relieves pain Patient’s pain was PRIOR:
September 300mg fever by and anti-pyretic relieved -Check for doctor’s
4,2010 inhibiting the - Paracetamol is order
effects of used to treat -Explain to the client
pyrogens on many conditions the action of
the such as paracetamol
hypothalamic headache, -Check for the 10R’s
heat regulating muscle aches, in administering
centers and by arthritis, paracetamol.
a hypothalamic backache, -Assess vital signs
action leading toothaches, DURING:
to sweating colds, and -Use aseptic
and fevers. technique
vasodilation. -Assess vital signs
AFTER:
-Monitor client the
effect to the client
-assess vital signs
- Warn patient that
high doses or
unsupervised long
term use can
Cause liver damage.

29
Ranitidine Date ordered: Intravenous Inhibits Ranitidine blocks -Check for doctor’s
September 150mg histamine at the action of order
3,2010 H2 receptor histamine on -Explain to the client
site in the stomach cells, the action of
gastric parietal and reduces ranitidine
cells, which stomach acid -Check for the 10R’s
inhibits gastric production. in administering
acid secretion Ranitidine is ranitidine
useful in -Assess vital signs
promoting DURING:
healing of -Use aseptic
stomach and technique
duodenal ulcers, -Assess vital signs
and in reducing AFTER:
ulcer pain. -Monitor client the
Ranitidine has effect to the client
been effective in -assess vital signs
preventing ulcer
recurrence when
given in low
doses for
prolonged
periods of time.

30
Bupivacaine Date started: Since pain Bupivacaine is PRIOR:
September 4, Intravenous transmitting indicated for -Check for doctor’s
2010 175mg nerve fibres local anaesthesia order
tend to be including -Explain to the client
thinner and infiltration, nerve the action of
either block, epidural, bupivacaine
unmyelinated and intrathecal -Check for the 10R’s
or lightly anaesthesia. in administering
myelinated, Bupivacaine bupivacaine.
the agent can often is -Assess vital signs
diffuse more administered by DURING:
readily into epidural injection -Use aseptic
them than into before total hip technique
thicker and arthroplasty -Assess vital signs
more heavily . It also is AFTER:
myelinated commonly -Monitor client the
nerve fibres injected to effect to the client
like touch, surgical wound -assess vital signs
proprioception sites to reduce - Warn patient that
pain for up to 20 high doses or
hours after the unsupervised long
surgery. term use can
Cause liver damage.

31
Nalbuphine Date started: Intravenous Binds with The usual -relieves patient’s PRIOR:
September 4, 10mg opiate recommended pain -Check for doctor’s
2010 receptors in adult dose is 10 order
the CNS: mg for a 70 kg -Explain to the client
ascending pain individual, the action of
pathways in administered nalbuphine
limbic system, subcutaneously, -Check for the 10R’s
thalamus, intramuscularly in administering
midbrain, or intravenously; nalbuphine.
hypothalamus, this dose may be -Assess vital signs
altering repeated every 3 DURING:
perception of to 6 hours as -Use aseptic
and emotional necessary. technique
response to Dosage should -Assess vital signs
pain. be adjusted AFTER:
according to the -Monitor client the
-relieves pain severity of the effect to the client
pain, physical -assess vital signs
status of the - Warn patient that
patient, and high doses or
other unsupervised long
medications term use can
which the patient Cause liver
may be receiving

32
Ketorolac Date started: Intravenous Ketorolac is Ketorolac is PRIOR:
September 4, used short- indicatedfor -Check for doctor’s
2010 term (5 days or short-term order
less) to treat management of -Explain to the client
moderate to moderate to the action of
severe pain. severe ketorolac.Check for
postoperative the 10R’s in
- Ketorolac pain. Concerns administering
works by about the high ketorolac.
reducing incidence of -Assess vital signs
hormones that reported side DURING:
cause effects led to -Use aseptic
inflammation restriction in its technique
and pain in the dosage and -Assess vital signs
body. maximum AFTER:
duration of use. -Monitor client the
effect to the client
-assess vital signs
- Warn patient that
high doses or
unsupervised long
term use can
Cause liver
Midazolam Date started: Intravenous Depresses the Intravenous PRIOR:
September 4, 5mg limbic system midazolam is -Check for doctor’s
2010 and reticular indicated for order
formation by procedural -Explain to the client
increasing or sedation (often the action of
facilitating the in combination midazolam
inhibitory with an opioid, -Check for the 10R’s
neurotransmitt such as in administering
er activity of fentanyl), for midazolam.

33
GABA. preoperative -Assess vital signs
sedation, for the DURING:
induction of -Use aseptic
general technique
anaesthesia, and -Assess vital signs
for sedation of AFTER:
ventilated -Monitor client the
patients in effect to the client
critical care units -assess vital signs
- Warn patient that
high doses or
unsupervised long
term use can
Cause liver

34
Tramadol Date started: Intravenous centrally acting Tramadol is used PRIOR:
September 4, analgesic not similarly to -Check for doctor’s
2010 chemically codeine, to treat order
related to moderate to -Explain to the client
opioids but moderately the action of x
binds to mu- severe pain and tramadol
opioid most types of -Check for the 10R’s
receptors and neuralgia, in administering
inhibits including tramadol.
reuptake of trigeminal -Assess vital signs
norepinephrine neuralgia DURING:
and serotonin -Use aseptic
technique
-Assess vital signs
AFTER:
-Monitor client the
effect to the client
-assess vital signs
- Warn patient that
high doses or
unsupervised long
term use can
Cause liver

35
Ephedrine Date started: Intravenous Releases Ephedrine has PRIOR:
sulfate September 4, norepinephrine been used in the -Check for doctor’s
order
2010 from synaptic treatment of -Explain to the client
storage sites. asthma and the action of
bronchitis for ephedrine sulphate
-other effects centuries. -Check for the 10R’s
are in administering
ephedrine sulphate.
bronchodilatatio Both ephedrine -Assess vital signs
n, relaxation of and DURING:
smooth muscles pseudoephedrin -Use aseptic
of GIT, nasal e act as a technique
decongestion bronchodilator, -Assess vital signs
AFTER:
and increase but -Monitor client the
tone of bladder pseudoephedrin effect to the client
trigone and e has -assess vital signs
vesicle sphincter considerably less - Warn patient that
effect. Both also high doses or
unsupervised long
increase blood term use can
pressure, with Cause liver
again
pseudoephedrin
e being
considerably less
effective.
Metronidazole Date started: IVF 500mg Metronidazole, Systemic PRIOR:
September taken up by metronidazole is -Check for doctor’s
order
5,2010 diffusion, is indicated for the -Explain to the client
selectively treatment of the action of
absorbed by bacteria. metronidazole
anaerobic -Check for the 10R’s
bacteria and in administering
metrnidazole.
sensitive -Assess vital signs

36
protozoa. Once DURING:
taken up by -Use aseptic
technique
anaerobes, it is -Assess vital signs
non- AFTER:
enzymatically -Monitor client the
reduced by effect to the client
reacting with -assess vital signs
- Warn patient that
reduced high doses or
ferredoxin, unsupervised long
which is term use can
generated by Cause liver
pyruvate oxido-
reductase. This
reduction causes
the production of
toxic products to
anaerobic cells,
and allows for
selective
accumulation in
anaerobes

37
Cefuroxime Date started: Intravenous To reduce the As for the other PRIOR:
September 50mg development of cephalosporins, -Check for doctor’s
order
5,2010 drug-resistant although as a -Explain to the client
bacteria and second- the action of
maintain the generation it is cefuroxime
effectiveness of less susceptible -Check for the 10R’s
Cefuroxime to Beta- in administering
cefuroxime.
Axetil tablets lactamase and -Assess vital signs
and other so may have DURING:
antibacterial greater activity -Use aseptic
drugs, against technique
Cefuroxime Haemophilu -Assess vital signs
AFTER:
Axetil tablets influenzae, -Monitor client the
should be used Neisseri effect to the client
only to treat or gonorrhoeae and -assess vital signs
prevent Lyme disease. - Warn patient that
infections that Unlike other high doses or
unsupervised long
are proven or second term use can
strongly generation Cause liver
suspected to be cephalosporins
caused by cefuroxime can
bacteria. cross the blood-
brain-barrier.

C. Diet

Type of Date General Indications/Pur Specific foods Client response Nursing


diet started/Date description poses taken to the diet Responsibilities
changed

38
Npo September 5, -it is usually Typical reasons none Loss of energy PRIOR:
2010 because the for NPO -explain to the client
-nothing per September 6, person has a instructions are what npo is.
orem 2010 procedure the prevention of -discuss to him the
coming that aspiration right nutrition he
requires them pneumonia, e.g. must acquire
to be sedated. in those who will DURING:
If you have a undergo general -monitor clients diet
full stomach, anaesthetic, or -monitor his tolerance
you could those with weak AFTER:
vomit while swallowing -Monitor client’s
you are musculature, or response to the diet
sedated and in case of
aspirate the gastrointestinal
vomit into your bleeding or
lungs. gastrointestinal
blockage.
-is a medical
instruction
meaning to
withhold oral
food and fluids
from a patient
for various
reasons like
undergoing an
operation.

39
Type of Date General Indication/ Specific food Client response Nursingresposibilities
diet started/date description purposes taken to diet
changed
GL September 6, -A liquid diet is -About to -water -gradual gain of PRIOR:
-General 2010 the one that undergo certain -soup energy -explain to the client what
liquid diet allows intake of medical tests, npo is.
liquid forms of
food only.
surgery or any -discuss to him the right
Generally a liquid other medical nutrition he must acquire
diet includes clear procedures that DURING:
liquids or opaque require your -monitor clients diet
fluids that are stomach or -monitor his tolerance
completely or
partially fluid in intestine to be AFTER:
consistency. In devoid of solid -Monitor client’s response to
general a liquid food particles the diet
diet can be
classified into two
basic categories –
the clear liquid
diet and the full
liquid diet.

D.Activity/ Exercise
Type of Date General Description Indications/Purposes Client’s Response Nursing
Exercise ordered/ to the exercise Responsibilities
Date
changed
Deep Diaphragmatic breathing, It is generally considered -Comfortable PRIOR:
Breathing abdominal breathing, a healthier and fuller way -easy breathing -Explaining to the client
belly breathing, deep to ingest oxygen, and is -pain relief the proper abdominal
breathing or costal breathing.
often used as a therapy
breathing is the act of DURING:
breathing deep into one's for hyperventilation, -Observe and assess
lungs by flexing one's anxiety disorders and client

40
diaphragm rather than stuttering. AFTER:
breathing shallowly by -Monitor condition
flexing one's rib cage. -For normal breathing
This deep breathing is pattern.
marked by expansion of -For lung expansion and
the stomach (abdomen) preventing the
rather than the chest accumulation of
when breathing secretions.

SURGICAL MANAGEMENT:
An appendectomy is the surgical removal of the vermiform appendix, a small, finger-shaped projection in the lower right abdomen
at the juncture of the large and small intestines. The appendix, which protrudes from a section of the large intestine (cecum),
generally has been considered an unessential organ that is removable without significant loss of body function., it is part of the
gut-associated lymphoid tissues (GALT), important tissue where immune responses are initiated. The appendix produces a small
amount of mucus that normally flows into the large intestine.

Symptoms such as severe abdominal pain accompanying an inflamed and infected and ruptured appendix tend to occur rapidly
(acute). For this reason, an appendectomy usually is an emergency procedure.
Appendectomy is done by a general surgeon as an inpatient surgery under general anesthesia. The surgery may be performed
using an open incision or via laparoscopy.

TRADITIONAL APPENDECTOMY:
During a traditional open appendectomy done to our patient, a small incision (McBurney incision) is made in the abdominal wall.
The incision is made in the lower right side of the abdomen, in the area over the appendix, and the muscles over the appendix are
split or cut. The surgeon then locates the appendix and inspects it. If there are no complications involving the surrounding tissues,
the surgeon separates the appendix from the abdomen and/or large intestine and then cuts its attachment to the cecum,
removing the appendix. The cecum is then closed with sutures. If a pocket of infection (abscess) has formed, it will be cleansed
and suctioned away by a special instrument (suction irrigator). A tube also may be inserted into the abdomen to promote drainage
from the infected site. The abdominal incision is then closed, and the procedure is complete.

LAPAROSCOPY:
In most cases in America, surgeons choose a laparoscopic procedure to remove the appendix in which a tiny video camera

41
(laparoscope) is inserted into the abdomen through a very small incision. During the laparoscopic procedure, the surgeon uses the
video camera to view the abdominal cavity and its contents. Because abdominal regions can be seen easily, this technique is
especially useful when the diagnosis of appendicitis is unclear. Specialized surgical tools that can be inserted through tiny incisions
are used to remove the appendix in the same manner as for the conventional open surgical procedure. Although the laparoscopic
approach can take longer to perform, the benefits of laparoscopic surgery include less postoperative discomfort and quicker
recovery time. In the case of a ruptured or perforated appendix, the open incision method may be preferred because it is
associated with fewer incidences of postoperative abdominal abscesses.

having ruptured (perforated appendix), the surgeon flushes the spilled material (pus) from the abdomen with sterile warm water,
and a drain is inserted and left in place to promote drainage of infected fluids.

PHYSICAL ASSESSMENT
Patient’s Name: J.L.P Sex: M Age: 33 y/o
Vital Signs: BP= 130/80mmHg PR=118 BPM RR=25CPM T=37.9C
BODY ASSESS TECHNIQU NORMAL FINDINGS ACTUAL FINDINGS REMARKS
E
1. GENERAL
SURVEY
a. BODY BUILT, Inspection Varies with lifestyle Normal weight Normal
HEIGHT & WEIGHT BMI of
(Normal BMI= 20-25)

b. POSTURE AND Inspection Relaxed, erect posture; Slightly flexed posture, difficulty Due to pain in
GAIT, STANDING coordinated movement of standing straight the RLQ of the
AND WALKING abdomen
c. OVERALL Inspection Clean, neat Clean and neat Normal
HYGIENE &
GROOMING
d. BODY & BREATH Inspection No body odor or minor body No body odor, no breath odor Normal
ODOR odor relative to work or
exercise; no breath odor
e. SIGNS OF Inspection No signs Facial grimace Due to

42
DISTRESS IN tenderness post-
POSTURE / FACIAL surgery.
EXPRESSION
f. OBVIOUS SIGNS Inspection Healthy appearance Weak in appearance, Obvious Patient is
OF HEALTH / illness showcasing facial
ILLNESS grimace with
elevated
temperature.
g. ATTITUDE Inspection Cooperative Patient barely cooperates Patient is in pain
and having a
fever
h. AFFECT/MOOD & Inspection Appropriate to situation Appropriate to situation Normal
APPROPRIATENESS
OF RESPONSES
i. QUANTITY & Inspection Understandable, moderate pace, Understandable, slow pace Normal
QUALITY OF exhibits thought association Exhibited thought association
SPEECH
j. RELEVANCE & Inspection Logical sequence, makes sense, Logical sequence, Deviation from
ORGANIZATION OF has sense of reality Flight of idea; confusion Normal.
THOUGHTS May be due to
pain.
2.
INTEGUMENTARY
(SKIN)
a. COLOR & Inspection Varies from light to deep brown; flushed appearance Due to elevated
UNIFORMITY OF from ruddy pink to light pink; temperature or
COLOR from yellow overtones to olive. high fever
Generally uniform in color
except in areas exposed to the
sun; areas of lighter
pigmentation in dark skinned
people
b. EDEMA Inspection Absent Absent Normal

43
c. SKIN LESIONS Inspection Freckles, some birthmarks, Some birthmarks, some flat & Normal
some flat & raised nevi; no raised nevi; no abrasions or other
abrasions or other lesions lesions
d. MOISTURE Palpation Moisture in skin folds and the dry skin Accumulation of
axillae sweat on the
skin makes the
skin hot and
dry, and body
temperature
rises.
In dry climates
also sweat can
evaporate
rapidly and you
may loose
tremendous
amount of fluid.
d. TEMPERATURE Palpation Uniform; within normal range Temperature: 37.9⁰C Sign of infection
f. SKIN TURGOR Palpation When pinched, skin quickly When pinched, skin quickly sprung Normal
springs back to previous state back to previous state
(NAILS)
a. FINGERNAIL Inspection Convex curvature; angle Convex curvature; angle between Normal
PLATE SHAPE between nail & nail bed of about nail & nail bed of about 160
160 degrees degrees
b. FINGERNAIL & Inspection Highly vascular & pink in light- Highly vascular & pink Normal
TOENAIL BED skinned clients; dark-skinned
COLOR clients may have brown or black
pigmentation in longitudinal
streaks
c. FINGERNAIL & Palpation Smooth Smooth Normal
TOENAIL TEXTURE
d. TISSUES Inspection Intact epidermis Intact epidermis Normal
SURROUNDING

44
NAILS
e. BLANCH TEST Palpation Prompt return of pink or usual Prompt return Normal
color (within 3 seconds)
3. HEAD
(SKULL)
a. SIZE, SHAPE / Inspection Rounded; smooth skull contour Rounded; smooth skull contour Normal
SYMMETRY
b. NODULES, Palpation Smooth, uniform consistency, Smooth, uniform consistency, Normal
MASSES & absence of nodules/masses absence of nodules/masses
DEPRESSIONS
(SCALP)

a. COLOR & Inspection White / pinkish in color; no whitish & no presence of scales Normal
APPEARANCE scales; no lice

b. AREAS OF Palpation No tenderness no presence of tenderness Normal


TENDERNESS

(HAIR)

a. EVENNESS OF Inspection Thick hair Thin Normal


DISTRIBUTION,
THICKNESS /
THINNESS

b. TEXTURE & Palpation Silky, resilient hair Silky Normal


OILINESS OVER
THE SCALP

(FACE)
a. FACIAL Inspection Symmetric or slightly symmetric facial features; Normal
FEATURES, asymmetric facial features; palpebral fissures equal in size;
SYMMETRY OF palpebral fissures equal in size; symmetric nasolabial folds
FACIAL symmetric nasolabial folds
MOVEMENTS

45
(EYES)
1. EYEBROWS
a. HAIR Inspection Hair evenly distributed; skin hair evenly distributed; skin Normal
DISTRIBUTION, intact; eyebrows symmetrically intact; eyebrows symmetrically
ALIGNMENT, SKIN aligned; equal movement aligned; equal movement
QUALITY &
MOVEMENT
2. EYELASHES
a. EVENNESS OF Inspection Equally distributed; curled equally distributed; curled slightly Normal
DISTRIBUTION & slightly outward outward
DIRECTION OF
CURL
3. EYELIDS
a. SURFACE Inspection Skin intact; no discharge; no skin intact; no discharge / Normal
CHARACTERISTICS, discoloration; lids close discoloration; lids closed
POSITION IN symmetrically; approximately symmetrically; 16 involuntary
RELATION TO THE 15-20 involuntary blinks per blinks per minute; bilateral
CORNEA, ABILITY minute; bilateral blinking blinking; when lids opened, no
TO BLINK & visible sclera above
FREQUENCY OF When lids open, no visible
BLINKING sclera above corneas, & upper & Corneas & upper & lower borders
lower borders of cornea are of cornea were slightly covered
slightly covered

4. CONJUNCTIVA
a. COLOR, Inspection Transparent; capillaries Transparent; sclera appears white Normal
TEXTURE & sometimes evident, sclera
PRESENCE OF appears white
LESIONS IN THE
BULBAR
CONJUNCTIVA Palpation Shiny, smooth & pink Normal
Shiny, smooth & pink / red
b. COLOR,
TEXTURE &
LESIONS IN THE

46
PALPEBRAL
CONJUNCTIVA

5. SCLERA

a. COLOR & Inspection White, shiny white Normal


CLARITY
6.CORNEA
a. CLARITY Inspection Transparent, shiny & smooth; transparent, shiny & smooth; Normal
details of the iris are visible details of the iris were valuable /
visible
7. IRIS
a. SHAPE & COLOR Inspection Round; the color varies round; black Normal
8. PUPILS
a. COLOR, SHAPE & Inspection Black in color; equal in size; black in color; equal in size; round Normal
SYMMETRY OF SIZE normally 3-7mm in diameter;
round, smooth border
(VISUAL ACUITY)
a. NEAR VISION Inspection Able to read newsprint Able to read in normal distance Normal
b. DISTANCE Inspection 20/20 vision on snellen chart Able to read newsprint in normal Normal
VISION distance.
(PUPILS)
a. LIGHT REACTION Inspection Illuminated pupil constricts; non- Illuminated pupil constricted; non- Normal
& ACCOMODATION illuminated pupil constricts; illuminated pupil constricted
Pupils constrict when looking at Pupils constricted when looking at
near object; Pupils dilate when near objects; Pupils dilated when
looking at far objects; Pupils looking at far objects; Pupils
converge when near object is converged when near object was
moved toward nose moved toward nose.
(LACRIMAL
GLAND,
LACRIMAL SAC &

47
NASOLACRIMAL
DUCT)
1. LACRIMAL Inspection No edema / tenderness No edema or tenderness Normal
GLAND and
palpation
(EXTRAOCULAR
MUSCLES)d

a. ALIGNMENT & Inspection Both eyes coordinated, move in both eyes coordinated; moved in Normal
COORDINATION unison, with parallel alignment unison, with parallel alignment
(VISUAL FIELDS)

a. PERIPHERAL Inspection When looking straight ahead, can see objects in the periphery Normal
FIELDS OF VISION client can see object in the
periphery
(EARS)
1. AURICLES
a. COLOR, Inspection Color same as facial skin; Flushed appearance; symmetric Flushed auricles
SYMMETRY, SIZE & symmetric position. Line drawn position aligned with outer due to elevated
POSITION from lateral angle of eye to canthus of eye temperature.
point where top part of auricle
joins head is horizontal;
imaginary line drawn from the
top to the bottom of the ear
varies no more than 10 degrees
from the vertical
b. TEXTURE, palpation Mobile, firm & not tender; pinna mobile, firm & not tender; pinna Normal
ELATICITY & AREAS recoils after it is folded recoiled after it was folded
OF TENDERNESS
2. EXTERNAL EAR
CANAL
a. CERUMEN, SKIN Inspection Dry cerumen, grayish-tan color; Dry cerumen Normal
LESIONS, PUS & or sticky, wet cerumen in
BLOOD various shades of brown
(HEARING

48
ACUITY TESTS)
a. RESPONSE TO Inspection Whispered voice heard Able to repeat nonconsecutive Normal
WHISPERED VOICE numbers
b. WATCH TICK Inspection Able to hear tickling in both ears Able to hear tickling in both ears Normal
TEST
(NOSE)
a. DEVIATIONS IN Inspection Symmetric in shape & straight; symmetric & straight; flaring; with Normal
SHAPE, SIZE / no discharge / flaring; uniform no discharges in the nares;
COLOR & color; not tender; no lesions
FLARING /
DISCHARGE FROM
THE NARES
b. REDNESS, Inspection Not tender; no lesions & no not tender; no lesions; no Normal
SWELLING, discharge discharges
GROWTHS &
DISCHARGE
c. NASAL SEPTUM Inspection Intact & in midline intact & in midline Normal
BETWEEN THE
NASAL CHAMBERS
d. PATENCY OF Palpation Air moves freely as the client Air moves freely as the client Normal
BOTH NASAL breathes through the nares breathes through the nares
CAVITIES
e. TENDERNESS, Palpation Not tender; no lesions not tender & no lesions Normal
MASSES &
DISPLACEMENT OF
BONE &
CARTILAGE
(SINUSES)
a. TENDERNES Palpation Not tender No presence of tenderness Normal
S
(MOUTH)
1. LIPS
a. SYMMETRY OF Inspection Uniform pink color, darker in Uniform pink color; soft, slightly Due to decrease
CONTOUR, COLOR dark-skinned people; soft, moist, dry; symmetry of contour; able to hydration and
& TEXTURE smooth texture; symmetry of purse lips impaired

49
contour; able to purse lips perspiration due
to elevated
temperature
2. BUCCAL
MUCOSA
a. COLOR, Inspection Uniform pink color (freckled Slightly dry Due to decrease
MOISTURE, and brown in color in dark-skinned hydration and
TEXTURE & palpation clients); moist, smooth, soft, impaired
PRESENCE OF glistening & elastic texture perspiration due
LESIONS to elevated
temperature.

3. TEETH
a. COLOR, Inspection Smooth, white, shiny tooth Yellowish tooth enamel Due to poor oral
NUMBER, enamel hygiene
CONDITION &
PRESENCE OF
DENTURES
4. GUMS
a. COLOR & Inspection Pink gums; bluish / dark patches Pink gums; slightly dry firm Slight dryness
CONDITION in dark skinned people; moist, texture; no retractions due to decrease
firm texture; no retractions hydration and
impaired
perspiration due
to elevated
temperature.
5. TONGUE /
FLOOR OF THE
MOUTH
a. COLOR & Inspection Smooth tongue base with smooth tongue base with Slight dryness
TEXTURE OF THE and prominent veins; pink color; prominent veins; pale in color; due to decrease
MOUTH FLOOR & palpation moist, slightly rough; pink color slightly dry; slightly rough hydration and
FRENULUM impaired
perspiration due
to elevated

50
temperature.
b. POSITION, Inspection Central position; moves freely Central position, moved freely Normal
TEXTURE, and
MOVEMENT & BASE palpation
OF THE TONGUE
c. NODULES, palpation Smooth with no palpable No palpable nodules Normal
LUMPS / nodules
EXCORIATED
AREAS
(PALATES &
UVULA)
a. COLOR, SHAPE, Inspection Light pink, smooth, soft palate, Pale in color, smooth, soft palate, Normal
TEXTURE & THE and more irregular texture more irregular texture
PRESENCE OF palpation
BONY
b. POSITION & Inspection Position in midline of soft palate position in midline of soft palate Normal
MOBILITY WHILE
EXAMINING THE
PALATES
(OROPHARYNX &
TONSILS)
a. COLOR & Inspection Pink & smooth posterior wall Pink & smooth posterior wall pink Normal
TEXTURE and pink & smooth; no discharge; of & smooth; no discharge; of normal
palpation normal size size
b. SIZE OF Inspection Pink & smooth; no discharge; of Pink & smooth; no discharge; of Normal
TONSILS, COLOR & normal size normal size
DISCHARGE
c. GAG REFLEX Inspection present Present Normal
(NECK & LYMPH
NODES)
1. LYMPH NODES
a. TENDERNESS palpation Not palpable not palpable Normal
2. TRACHEA
a. PLACEMENT Inspection Central placement in midline of central placement in midline of Normal
neck; spaces are equal on both neck; spaces were equal on both

51
sides sides

3. THYROID
GLAND
a. SYMMETRY & Inspection Not visible on inspection not visible when inspected Normal
VISIBLE MASSES
b. SMOOTHNESS & palpation Lobes may not be palpated; if lobes were not palpable & rose Normal
AREAS OF palpated, lobes are small, freely with swallowing
ENLARGEMENT, smooth, centrally located,
MASSES / painless & rise freely with
NODULES swallowing
(THORAX &
LUNGS)
a. BREATHING Auscultatio Full and symmetric chest Full and symmetric chest Normal
PATTERNS n expansion, quiet, rhythmic expansion, quiet, rhythmic
and effortless breathing and effortless breathing
b. ADVENTITIOUS Auscultatio Absence of adventitious sounds Absence of adventitious sounds Normal
BREATH SOUNDS n
(CARDIOVASCUL
AR)
a. ABNORMAL Inspection No pulsation, lift and No pulsation, lift and Normal
PULSATIONS, LIFTS Palpation heaves; symmetric pulse heaves; symmetric pulse
& HEAVES volumes volumes
b. JUGULAR VEINS Palpation Jugular vein is not visible Jugular vein is not visible Normal

c.PERIPHERAL Inspection Skin color pink, Skin color pink, temperature is Due to presence
PERFUSION Palpation temperature not excessively warm of infection or
excessively warm or cold fever.

(BREAST &
AXILLLAE)
a. SIZE, SYMMETRY Inspection Rounded shape; slightly unequal Rounded shape; slightly unequal Normal
& CONTOUR / in size; generally symmetric in size; generally symmetric
SHAPE
b. LOCALIZED Inspection Skin uniform in color, intact Skin uniform in color, intact Normal

52
DISCOLORIZATION
S/
HYPERPIGMENTATI
ON, RETRACTION /
DIMPLING,
LOCALIZED
HYPERVASCULAR
AREA, SWELLING /
EDEMA
c. AREOLA Inspection Round / oval & bilaterally the round; brownish color Normal
same; color varies from light
pink to dark brown
d. NIPPLES Inspection Round, equal in size, similar in Round, equal in size, similar in Normal
color soft & smooth; both points color & both points in same
in same direction; no discharges direction; presence of discharges
except in pregnant or breast
feeding females
e. AXILLARY, palpation No tenderness, masses / no tenderness, masses, nodules Normal
SUBCLAVICULAR & nodules
SUPRACLAVICULAR
LYMPH NODES
(ABDOMEN)
a.SKIN INTEGRITY, Inspection Unblemished skin, uniform Incision at the RLQ dry and intact, Incision at the
COLOR, CONTOUR, Palpation in color, no evidence of uniform in color, RLQ post surgery
& SYMMETRY enlargement of liver or no evidence of
spleen, flat rounded or enlargement of liver or
scaphoid spleen, has rounded
abdomen
b.BLADDER Palpation Bladder not palpable Bladder is non-palpable at Normal
RETENTION time of assessment
(MUSCULOSKELE
TAL SYSTEM)
1. MUSCLES
a. SIZE Inspection Equal on both sides equal on both sides Normal
b. CONTRACTURES Inspection No contractures no contractures Normal

53
c. FASCICULATIONS Inspection No fasciculation & tremors no fasciculation & tremors Normal
& TREMORS
d. TONICITY Palpation Normally firm Firm Normal
e. STRENGTH Equal strength on both sides equal strength on both sides Normal
2. BONES
a. SKELETON FOR Inspection No swelling & deformities No swelling & deformities Normal
NORMAL
STRUCTURES &
DEFORMITIES
3. JOINTS
a. SWELLING Inspection No swelling no swelling Normal
b. TENDERNESS, Palpation No tenderness, swelling, no tenderness, swelling, nodules; Normal
SMOOTHNESS OF crepitation / nodules; joints joints move smoothly
MOVEMENT, move smoothly
SWELLING,
CREPITATION &
PRSENCE OF
NODULE
(JOINT RANGE OF
MOTION)
a. UPPER Inspection Varies to some degree in Difficulty in Circumduction of Due to post
EXTREMITIES accordance with a person’s abdominal area surgery incision
genetic make-up & degree of and pain at the
physical activity RLQ
b. LOWER Inspection Varies to some degree in Can move the joints smoothly but Normal
EXTREMITIES accordance with a person’s slowly
genetic make-up & degree of
physical activity

Prioritizing Nursing Care Plan


DATE PROBLEM CUES JUSTIFICATION

54
September 6, 2010 Acute Pain related to incision at S> “Masakit ang tahi ko sa A c u t e Pa i n i s ou r pr io r it y
the RLQ as manifested by tiyan” as verbalized by the b e c a u s e p a i n is t h e in it ia l
guarding behavior at right patient c om pl a i n t o f t h e pa t ie n t
lower abdomen t h e re fo re n e e ds
i m m e d ia t e m a n a g e m e n t .
O>
 Positioning to avoid pain
 Changes in appetite
(Anorexic)
 Moaning
 Facial grimace
 Guarding behavior at RLQ
 Pain scale of 8/10

BP – 130/80
P – 118
R – 25
T – 37.9
September 6, 2010 Hyperthermia related to S> Ø Hyperthermia is the next
disease process or infection. priority because this may
aggravate infection.
O> Hyperthermia when not treated
 Flushed skin appropriately may lead to
 Warm to touch seizure episodes or convulsion.

BP – 130/80
P – 118
R – 25
T – 37.9

55
September 6, 2010 Constipation related to S- “Tatlong araw na akong Constipation worsens
decrease peristalsis secondary hindi dumudumi simula ng abdominal pain so it should be
to anesthetic operahan ako” as verbalized by alleviated. It also indicates
the patient. decreased in hydration.

O-
 No defication
 Vomiting
 Abdominal dullness

BP – 130/80
P – 118
R – 25
T – 37.9
September 6, 2010 Risk for Fluid volume deficit S> Ø B e c a u s e of v o m i t i n g
related to loss of fluid at pa t i e n t is r is k f or
abnormal routes as manifested O- d e f ic ie n c y of f lu id s . I f n ot
by vomiting  Vomiting P ri o ri t iz e pa t i e n t m a y
 Decreased skin and tongue e x p e r ie n c e e x c e s s iv e
turgor t h i rs t a n d m a y a l t e rs
 weakness pa t i e n t ’ s m e n t a l s t a t u s

BP – 130/80
P – 118
R – 25
T – 37.9

Nursing Care Plan

56
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUANTION
S> “Masakit ang Acute Pain related Short Term Goal: INDEPENDENT: Short Term Goal:
tahi ko sa tiyan” as to incision at the After 1 hour of  Monitor vital  To obtain After 1 hour of
verbalized by the RLQ as manifested nursing intervention signs baseline data nursing intervention
patient by guarding the patient’s pain and to assess the patient’s pain
behavior at right scale will be for respiratory scale decreased
lower abdomen decrease from 8/10 insufficiency from 8/10 to 2/10
O> to 2/10
 Positioning to Long Term Goal:
avoid pain Long Term Goal:  Establish  To build trust After 3 hours of
 Changes in After 3 hours of rapport and promote nursing intervention
appetite nursing intervention cooperation the patient’s pain
(Anorexic) the patient’s pain was relieved
 Moaning will be relieved  Replacing
 Facial grimace  Provide wound dressings may
 Irritability care decrease
 Pain scale of irritability and
8/10 pain
 Offer position
BP – 130/80 changes, back  To provide
P – 118 rubs, and comfort
R – 25 relaxation.
T – 37.9
 Change bed
linens, if  To decrease
necessary irritability and
provide comfort

 Divert patient  It helps patient


attention to focus on
through music activities rather
therapy and than pain and
visitors. discomfort

 Provide  To lessen
emotional discomfort
support

DEPENDENT:  To relieved
57
pain
 Administer
analgesic as
ordered by the
Nursing Care Plan

58
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUANTION
S> Ø Hyperthermia Short Term Goal: INDEPENDENT: Short Term Goal:
related to disease After 1 hour of  Monitor vital  To obtain After 1 hour of
process or infection. nursing intervention signs baseline data nursing intervention
O> the patient’s and to assess the patient’s
 Flushed skin temperature will for respiratory temperature
 Warm to touch decrease from insufficiency decreased from
37.9⁰C to 36.5⁰C 37.9⁰C to 36.5⁰C
BP – 130/80
P – 118 Long term Goal :  Establish  To build trust Long term Goal :
R – 25 After 3 hours of rapport and promote After 3 hours of
T – 37.9 nursing intervention cooperation nursing intervention
patient’s patient’s
temperature will  To decrease temperature
remain at normal  Tepid Sponge temperature remains at normal
range from 36.5⁰C- bath should be range (36.5⁰C).
37.5⁰C done  To provide
comfort and
 Provide cool relaxation
and quiet
environment
 To provide
comfort
 Emphasized
wearing of light
clothes
 For relaxation
 Provide purposes
adequate rest
 To remove
 Instruct Proper harmful
Hygeine by microorganism
taking a bath s
everyday and
washing hands
before and
after meals

59  Increase Fluid  For hydration


intake
DEPENDENT:

 Administer  To decrease
Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

60
S- “Tatlong araw na Constipation related Short Term: INDEPENDENT: Short Term:
akong hindi to decrease After 4 hours of  Monitor Vital  To know the After 4 hours of
dumudumi simula peristalsis nursing intervention signs. base line nursing intervention
ng operahan ako” secondary to the patient’s condition of the the patient’s
as verbalized by the anesthetic constipation will be patient constipation was
patient. alleviated as alleviated as
indicated by bowel  Establish  To build up trust indicated by bowel
elimination rapport and promote elimination
O- cooperation.
 No defication Long Term: Long Term:
 Vomiting After 1 day of  Positive flatus After 1 day of
 Abdominal nursing intervention  Assess after surgery nursing intervention
dullness the patient will be passage of flatus indicates a shift the patient was able
able to defecate of diet from NPO to defecate
BP – 130/80 normally. to General liquid normally.
P – 118
R – 25  Foods rich in
T – 37.9  Restriction of fibers makes
fiber in the diet. the stool dry
and hard to
eliminate

 Encouraged  To stimulate
ambulation bowel
eliminations
 Provide privacy
and safety  To alleviate
during bowel discomfort.
elimination

DEPENDENT:
 Administer IV  For hydration

61
medication as
ordered.

 Administer  To soften the


laxatives as stool for easier
ordered. bowel
elimination

 General liquid  To condition the


after positive Gastrointestinal
flatus as Tract
ordered

Nursing Care Plan

62
63
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUANTION
S> Ø Risk for Fluid Short Term Goal: INDEPENDENT: Short term Goal:
volume deficit After 1 hour of After 1 hour of
O- related to loss of nursing intervention  Establish rapport  To build trust nursing intervention
 Vomiting fluid at abnormal the patient will and promote the patient knew
 Decreased skin routes as exhibit good cooperation proper nutritional
and tongue manifested by hydration.  Monitor vital signs diet and foods rich
turgor vomiting  To obtain in nutrients,
 weakness baseline date vitamins and
Long term Goal :  Evaluate minerals needed by
BP – 130/80 After 1 day of nutritional  To assess weight our body
P – 118 nursing intervention status, noting loss or weight
R – 25 patient is in good current intake, gain.
T – 37.9 nutritional condition weight changes Long term Goal:
problem with After 3 hours of
oral intake use of nursing intervention
supplement the patient
feeding. Measure increased level of
subcutaneous fat potassium need and
able to normalize
 Observe urinary his condition as
output color and  To determine the manifested by
measure amount degree of absence of pallor
and specific electrolyte loss. and decrease
gravity. Measure epigastric pain
or estimate other
fluid loss.

 Encourage  For optimum


sufficient fluid hydration
intake
 Alcohol increases
 Encourage dehydration.
patient to quit, if
not, to limit
intake of alcohol
and caffeinated
beverages  To determine
weight loss or
64
 Maintain weight gain
accurate input
and output,
calculate 24
Health Teaching

LEARNING TARGET EXPECTED EVALUATIO


DATE/VENUE OBJECIVE STRATEGIES RESOURCES
CONTENT POPULATION OUTCOME N
Date:  After 20-30 This health Lecture and This health Manpower At the end of The client
September minutes of teaching will focus discussion. teaching will teaching the was able to
7,2010 health on the following focus on our client is know and
teaching the topics to be patient Mr. JLP expected to give
Venue: client would discussed on the and know: feedback to
Bulacan be able to: client: significant all health
Medical others.  Proper teachings.
Center  Practice/instr  Proper wound wound
(Surgery uct in good care and care and
Ward) hand wound wound
washing and dressing. dressing
aseptic
wound care.  Proper hand  Proper
washing hand
 Always prevent washing.
provide clear complications
liquids in or infections  Appropriat
small that may e
amounts interfere the measures
when oral wound. how to
intake is care
resumed,  Reduces risk of himself.
and progress gastric

65
diet as irritation/vomit  Time to
tolerated ing to rest and
minimize fluid sleep.
 Keep at rest loss. Avoiding
in semi- dehydration
Fowler’s results in
position drying and
painful
 Encourage cracking of the
early lips and
ambulation. mouth.

 Review  Gravity
postoperativ localizes
e activity inflammatory
restrictions, exudates into
e.g., heavy lower abdomen
lifting, or pelvis,
exercise, relieving
sex, sports, abdominal
driving. tension, which
is accentuated
 Encourage by supine
progressive position
activities as
tolerated  Promotes
with periodic normalization
rest period of organ
function, e.g.,
 Discuss care stimulates
of incision, peristalsis and
including passing of

66
dressing flatus,
changes, reducing
bathing abdominal
restrictions, discomfort.
and return to
physician for  Provides
suture/staple information for
removal. patient to plan
for return to
usual routines
without
untoward
incidents

 Prevents
fatigue,
promotes
healing and
feeling of well-
being, and
facilitates
resumption of
normal
activities.

 Understanding
promotes
cooperation
with
therapeutic
regimen,
enhancing

67
healing and
recovery
process

Discharge Planning

68
M-MEDICATION

Instruct the patient about the way of taking his medicines. Explain the proper measurement and time of intake. Instruct the
patient and relative to take the medications with food.

E-ENVIRONMENT/EXERCISE

Maintain clean environment at home. Provide a peaceful and quiet environment to reduce stress. Provide a right
temperature (not too hot) in a room. A too hot environment causes the blood pressure to rise. Encourage to do some exercise
every morning such as a simple walking.

T-TREATMENT

Position the client to where he is comfortable.

H-HYGIENE

Instruct the patient to take a bath daily and instruct the relatives to assist the patient when taking a bath. Sponge bath is
recommended if the patient still has a hard time independently doing activities, for this will reduce movement.

O-OUT PATIENT
Follow up check up should be done subsequent to discharge. Encourage patient to visit his doctor on a given time and
place.

D-DIET

Advice the patient to eat nutritious foods such as vegetables, meat, fish and fruits after patient’s bowel movement has been
conditioned through General liquid diet. Instruct to drink milk and drink enough fluids to maintain fluid and electrolyte balance in
the body.

69
Conclusion:
Upon the completion of this study our group was able to present information and knowledge regarding appendicitis.
Furthermore, we are able to provide the readers a comprehensive manifestation of our hospital experience, specifically in the
Surgical Ward.

We the student nurses of BSU: CON conclude that our patient was able to receive the best nursing care that fits to her
condition, an appendicitis patient. All of our nursing care plans have met its goals that aim to the wellness of our patient. The
provided health teachings for our patient was effective as manifested by our patient’s verbalization and demonstration of the
given health teachings, which then lead him in achieving self wellness.

And at the end of this paper we are all glad that we are all able to acquire knowledge that we can use in our future
patient cares. And with God’s grace and guidance we are all able to give the best of what we could offer for the fulfillment of
this paper.

Bibliography:
1. Fundamentals of Nursing: Concepts, Process and Practice, Eight Edition by Kozier & Erb’s 2008

2. Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales, Edition 11

3. Textbook of Medical-Surgical Nursing by Brunner & Suddarth eleventh edition.

4. Priscilla lemone medical surgical nursing

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