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: P.A,B AGE: 16 years old CIVIL STATUS: Single ADDRESS: Salang, Balasan, Iloilo RACE: Brown RELIGION: Seventh Day Adventist OCCUPATION: Student DATE OF ADMISSION: February 15, 2011 TIME OF ADMISSION: 5 am ROOM: Surgical Ward Department PHYSICIAN’S: Dr. N. O II – CLIENT HEALTH HISTORY: A. Chief Complaint: * Right Lower Quadrant Pain B. Admitting Impression: * T/C Ruptured Appendicitis C. History of Present Illness: * 2 days before the client was admitted he had fever and experiencing pain at Right Lower Quadrant Pain. D. Post Health History: * Patient had a complete immunization when he was a child, but he had experienced mumps and measles when he was a child. E. Family History: Heredofamilial Disease Asthma Diabetes Mellitus Hypertension Cancer Others (specify) Paternal Maternal
F. Socio – Cultural History: * The patient interacted to others with a good attitude. He is also friendly and had his own group friends at their school. He socializes with their neighbors at their place.
G. Environmental History: * Patient P,A.B lived at Salang, Balasan, Ilo-ilo. Their house was near the road, and made up of concrete materials and they are maintaining their surroundings clean. H. Medical Substance Use: * Eteroxib (Arcoxia) 120 mg OD I. Assessment: Vital Signs: T- 36.9, P- 78, R- 20, BP- 110/70 mmHg Weight: 53 kg Height: 5’2’’ Speech: Clear Mental Status: Responsive Emotional Status: Sometimes happy, sometimes silent III – PATTERN AND FUNCTIONING: HOME Eat 3x a day, sometimes with snacks. Drinks water 8-10 glasses a day. He slept at around 10:30 pm and wakes up at 5:30 am. Normally eliminates his bowel about 2x a day and urinates normally. Sometimes he plays basketball every afternoon after his class. Takes a bath every morning and also after playing basketball and half bath in the evening. HOSPITAL DAT Patient slept at around 9 pm and wakes up at 6 am and had a nap frequently. Eliminates bowel once a day and urinates a lot. Walking in the hospital’s corridor from surgical ward to O.R. Sponge bath by his mother in the morning.
A. FLUID AND NUTRITION B. REST AND SLEEP C. ELIMINATION D. ACTIVITY AND EXERCISE E. PERSONAL HYGIENE IV – TYPE OF EXAMINATION: Date: 2-15-11 Laboratory Test Sodium Potassium URINALYSIS Color Reaction Specific Gravity Protein Sugar
Result 139 mmol/L 3.7 mmol/L Results Straw Hazy pH 7.0 1.015 Albumin Negative Negative
Normal Values 135-148 mmol/L 3.7-5.3 mmol/L
HEMATOLOGY Hemoglobin Mass Concentration Erythrocyte Volume Fraction Erythrocyte Number Concentration Leukocyte Number Concentration V – PHYSICAL ASSESSMENT: CEPHALOCAUDAL SKIN HAIR HEAD FACE & LYMPHATICS EYES NOSE MOUTH & THROAT NECK INSPECTION Brown in color, slightly dry skin Short, black, curly hair Round in shape, no lesions found, no birth marks Round face, brown in color, no lesions Long lashes, pupils equally round No lesions, short nose Lips symmetrical, light red in color No lesions, no nodules noted, mandible and clavicle easily seen Movement of chest easily seen every time he inhale and exhale
Result 149 gms/L 0.44 4.7 6.3
Normal Values Male: 130-170 gms/L Male: .40-.50 Male: 4.5-5.5 5.0-10.10
PALPATION Slightly rough, warm to touch Dry to touch Skull can easily palpated and also mandible Soft cheek, short nose Round eyes and easily palpated Not easy to pinch, warm to touch Trachea easily palpated Warm to touch
PERCUSSION N/A N/A N/A N/A N/A N/A N/A N/A
AUSCULTATION N/A N/A N/A N/A N/A N/A N/A N/A
Rib cage easily palpated but no palpable masses
Pathophysiology of Appendicitis
Appendicitis is inflammation of the vermiform appendix caused by an obstruction attributable to infection, structure, fecal mass, foreign body, or tumor. Appendicitis can affect either gender at any age, but is most common in males 10 to 30. Appendicitis is the most common disease requiring surgery. If left untreated, appendicitis may progress to abscess, perforation, subsequent peritonitis, and death.
Text Book Discussion: Appendicitis
Introduction 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 spine of the Ilium.
Rebound tenderness (ex. Production or intensification of pain when pressure is released) may be present. The extent of tenderness and muscle spasm and the existence of the constipation or diarrhea depend not so much on the severity of the appendiceal infection as on the location of the appendix. If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar region. Rovsing’s sign maybe elicited by palpating the left lower quadrant. If the appendix has ruptured, the pain become more diffuse, abdominal distention develops as a result of paralytic ileus, and the patient condition become worsens. 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. Clinical Manifestations 1. Generalized or localized abdominal pain in the epigastric or periumbilical areas and upper right abdomen. Within 2 to 12 hours, the pain localizes in the right lower quadrant and intensity increases. 2. Anorexia, moderate malaise, mild fever, nausea and vomiting. 3. Usually constipation occurs ; occasionally diarrhea. 4. Rebound tenderness, involuntary guarding, generalized abdominal rigidity. Diagnostic Evaluation 1. Physical examination consistent with clinical manifestations. 2. WBC count reveal moderate leukocytosis (10,000 to 16,000/mm3) with shift to the left (increased immature neutrophils). 3. Urinalysis rule out urinary disorders. 4. Abdominal x-ray may visualize shadow consistent with fecalith in appendix; perforation will reveal free air. 5. Abdominal ultrasound or CT scan can visualize appendix and rule out other conditions, such as diverticulitis and crohn’s disease. Focused appendiceal CT can quickly evaluate for appendicitis. Medications
• • •
Analgesics Intravenous fluids replacements Analgesics
Treatment Appendectomy is the effective treatment if peritonitis develops treatment involves.
• • •
GI Intubation Parenteral replacement of IV fluids and electrolytes Administration of Antibiotics
Surgery is indicated if appendicitis is diagnosed. Antibiotics and IV fluids are administered until surgery is performed analgesics can be administered after the diagnosed is made.
An appendectomy (surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation. T he appendectomy may be performed under a (general or spinal anesthetics) with a low abdominal incisions or by (laparoscopy) which is recently highly effective method. Complications The major complication of appendicitis is perforation of the appendix, which can lead to peritonitis, abscess formation (collection of purulent material), or portal pylephlebitis, which is septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines. Perforation generally occurs 24 hours after the onset of pain symptoms include a fever of 37.7 degree Celsius or 100 degree Fahrenheit or greater, a toxic appearance and continued abdominal pain or tenderness. Nursing Interventions 1. Monitor frequently for signs and symptoms of worsening condition, indicating perforation, abscess, or peritonitis (increasing severity of pain, tenderness, rigidity, distention, absent bowel sounds, fever, malaise, and tachycardia). 2. Notify health care provider immediately if pain suddenly ceases, this indicates perforation, which is a medical emergency. 3. Assist patient to position of comfort such as semi-fowlers with knees are flexed. 4. Restrict activity that may aggravate pain, such as coughing and ambulation. 5. Apply ice bag to abdomen for comfort. 6. Avoid indiscriminate palpation of the abdomen to avoid increasing the patients discomfort. 7. Promptly prepare patient for surgery once diagnosis is established. 8. Explain signs and symptoms of postoperative complications to report-elevated temperature, nausea and vomiting, or abdominal distention; these may indicate infection. 9. Instruct patient on turning, coughing, or deep breathing, use of incentive spirometer, and ambulation. Discuss purpose and continued importance of these maneuvers during recovery period. 10. Teach incisional care and avoidance of heavy lifting or driving until advised by the surgeon. 11. Advise avoidance of enemas or harsh laxatives; increased fluids and stool softeners may be used for postoperative constipation. Discharge Planning M E Antibiotics for infection Analgesic agent (morphine) can be given for pain after the surgery Within 12 hrs of surgery you may get up and move around. You can usually return to normal activities in 2-3 weeks after laparoscopic surgery.
T Pretreatment of foods with lactase preparations (e.g. lactacid drops) before ingestion can reduce symptoms. Ingestion of lactase enzyme tablets with the first bite of food can reduce symptoms. H To care wound perform dressing changes and irrigations as prescribe avoid taking laxative or applying heat to abdomen when abdominal pain of unknown cause is experienced. Reinforce need for follow-up appointment with the surgeon Call your physician for increased pain at the incision site
O Document bowel sounds and the passing of flatus or bowel movements (these are signs of the return of peristalsis) Watch for surgical complications such as continuing pain or fever, which indicate an abscess or wound dehiscence Stitches removed between fifth and seventh day (usually in physicians office) D Liquid or soft diet until the infection subsides Soft diet is low in fiber and easily breaks down in the gastrointestinal tract
References: Medical and Surgical Nursing by Brunner and Suddarth’s Medical Surgical Nursing by Josie Quiambao Udan Manuals of Nursing Practice by Lippincott Mosby’s Medical Surgical Nursing
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