Student name: Princess Joyce A. Palma BSN 4-D Residency Clinical Instructor: Sir.

Jaymar Rogado

PATIENT PROFILE

Name: Delos Santos Joy Misa Area: Surgical Ward

Address: Nagcarlan, Laguna Admitting Physician: June R.Mendoza
Age: 19 years old Date & time of Admission: 8-19-22 01:42 AM
Birthday: August 24, 2002 Admission Diagnosis: T/C AP
Case number: 210052
Hospital number: 000000000300901
Operation Records:

Pre-operative diagnosis: Acute Appendicitis Time operation began: 07:23 am

Post-operative diagnosis: PED/Pelvic Abdominal Time operation ended: 08:33 am
Surgeon: Dr. Mendoza Surgical Nurse: Marlene Paraiso
Anesthesiologist: Dr. Espiritu
Anesthetic: Bupivacaine heavy SAB
Title of operation performed: Appendectomy

Laboratories:

Ultrasound Report

findings: Minimal fluid seen in the hepatorenal and pelvic region

Impression: Ascites, consider reactive cholecystitis; No gross pathology seen in the scan of the liver, pancreas, spleen, kidneys and urinary
bladder
Nursing Care Plan
Assessments Diagnosis Planning Implementation Evaluation

Subjective: : “Masakit Acute pain at the location
yung catheter ko, lalo
kapag umiihi napaka
hapdi”. as verbalized by
the patient, moderate pain
with pain scale of 6
Objective:
● Facial Grimace
● Discomfort
● Guarding behavior
● Positioning to
alleviate pain
Vital signs
BP: 100/70
P:92
T: 36. 5
R: 19
After the intervention pt.
of the foley catheter as will be able to:
evidence by guarding
behavior.
After the intervention pt.
● Established a was able to:
connection
● Assess the site between the nurse ● Demonstrated use
and position of and the patient of relaxation skills
foley catheter ● Monitored and and ways of
tube. recorded the vital avoiding.
● Encourage client signs ● Pain is reduced to
to limit physical ● Assessed and a manageable
activity and get documented level.
adequate rest. presence of ● Appears relaxed
● Identify ways of possible causes of and reported pain
avoiding and or pain. is relieved and
pain management. ● Acknowledged the controlled.
● Report physical & pain experienced ● Reported pain
psychological and convey scale of 1
● Maintain pain level acceptance of
at 4 or less client’s response
to pain.
● Administered
tramadol and
ketorolac drugs as
ordered by the
physician to
relieve pain.
● Administered
cefuroxime &
metronidazole per
doctor’s order to
treat bacterial
infections.
● Hooked 1L of
 D5LR as ordered
by the physician to
avoid dehydration.

DRUG STUDY

Drug name Dose, Drug class & Indication Side effects Nursing Responsibility
(brand name) Route & Mechanism of
Frequenc action
y
1. Tramadol 50mg IV Centrally acting Indicated to relieve Agitation, ● Assess for decrease
(Ultram) q8 analgesic with a moderate to hallucinations (seeing in pain 30 minutes
unique, dual moderately severe things or hearing after IV administration
mechanism of action pain. Tramadol voices that do not and 60 minutes after
– it exerts agonistic extended-release exist), fever, oral medication.
properties at opioid tablets and capsules sweating, confusion, ● Be alert for excessive
receptors and are only used by fast heartbeat, sedation or
interferes with people who are shivering, severe somnolence.
neurotransmitter expected to need muscle stiffness or ● Notify physician or
reuptake. medication to relieve twitching, loss of nurse immediately if
pain around-the- coordination, nausea, patient is unconscious
clock. Tramadol is in vomiting, or diarrhea. or extremely difficult to
a class of nausea, vomiting, loss arouse.
medications called of appetite, ● Monitor other changes
opiate (narcotic) weakness, or in mood and behavior,
analgesics. dizziness. changes in including euphoria,
heartbeat. confusion, malaise,
nervousness, and
anxiety.
● Notify physician if
these changes
become problematic.
2. Keterolac 30 mg IV nonsteroidal anti- It is indicated for Ketorolac may cause ● Blood pressure
(Toradol, and q8 inflammatory drug short term side effects. Tell your (BP) should be
Biorolac) (NSAID) that exhibits management of doctor if any of these monitored closely
analgesic activity in acute pain that symptoms are severe during the initiation of
animal models. The requires the calibre or do not go away: NSAID treatment and
mechanism of action of pain management Headache, dizziness throughout the course
of ketorolac, like that offered by opioids. Drowsiness, diarrhea of therapy. Fluid
of other NSAIDs, is Constipation, gas retention, edema,
not completely sores in the mouth, retention of NaCl,
understood but may sweating Some side oliguria, elevations of
be related to effects can be serum urea nitrogen
prostaglandin serious. Such as and creatinine have
synthetase inhibition. blisters unexplained been reported in
weight gain, clinical trials with
shortness of breath or Toradol.
difficulty breathing,
swelling in the
abdomen, ankles,
feet, or legs, yellowing
of the skin or eyes,
excessive tiredness,
unusual bleeding or
bruising, lack of
energy, nausea, loss
of appetite pain in the
upper right part of the
stomach, flu-like
symptoms, pale skin
fast heartbeat, cloudy,
discolored, or bloody
urine, back pain
difficult or painful
urination
 3. Cefuroxime 1750 mg Cephalosporin Indicated for variety Nausea, vomiting, ● Watch for seizures;
(Ceftin) IV q8 Antibiotic - binds to of infections diarrhea, stomach notify physician
specific penicillin- including acute pain, bloating, bluish immediately.
binding proteins wall, bacterial otitis color, diarrhea, ● Monitor signs of
it inhibits the third and media, several difficulty in breathing allergic reaction and
last stage of bacterial upper respiratory or swallowing anaphylaxis (tightness
cell wall synthesis tract infections, in throat & chest,
gonorrhea, early cough, dyspnea)
Lyme disease and ● Monitor signs of blood
impetigo dyscrasia.
● Monitor injection site
for pain, swelling and
irritation.
4. Metronidazole 500 mg IV Nitroimidazole - treat trichomoniasis, stomach pain, hot ● Report balance
(Flagyl) q8 enters cells by amebiasis, flushes, difficulty problems &
passive diffusion, inflammatory lesions breathing, functional/limitations
ferredoxin or of rosacea, bacterial palpitations, ● Be alert for confusion,
flavodoxin reduce its infections and headaches agitation, headache,
nitro group to nitro prevent post- or other alterations in
radicals leading to operative infections mental status
production of ● Monitor IV injection
metabolites which site for pain, swelling,
may damage DNA of and irritation
replicating organisms
CASE STUDY: RECTAL CANCER

Overview
Appendicitis is an inflammation of the appendix, a finger-shaped pouch that projects from your colon on the lower right side of your
abdomen. Appendicitis causes pain in your lower right abdomen. However, in most people, pain begins around the navel and then
moves. As inflammation worsens, appendicitis pain typically increases and eventually becomes severe. Although anyone can
develop appendicitis, most often it occurs in people between the ages of 10 and 30. Standard treatment is surgical removal of the
appendix. In 1880 Robert Lawson Tait made the first diagnosis of appendicitis and surgically removed the appendix. In 1886
Reginald Heber Fitz published a study on appendicitis and named the procedure an appendectomy. In 1889, Tait split open and
drained an inflamed appendix without removing it.

Background

The word appendicitis stems from Latin, combining appendix and -itis, and it means the inflammation of the appendix. The term
appendix was coined in the 1540s to describe an elongated outgrowth of an internal organ. Appendicitis was first described in 1759
by Metiever, but it was believed at the time that the appendix was not the origin of the disease process and it was termed
perityphlitis, typhlitis, paratyphlitis, or extra-peritoneal abscess of the right iliac fossa. From the early 20th century onwards,
appendicitis originated from obstruction leading to the secretion of fluids by the appendix. An early study demonstrated, by inserting
a manometric recording device (Figure (Figure1),1), that higher pressures resulted in histologically evident hypercellularity and
exudate pattern correlating with appendicitis. Early mortality secondary to appendicitis was reported to be 26%. The anatomy of the
appendix has been described as narrow and long, passing upward behind the cecum, to the left behind the ileum and mesentery,
or downward and inward into the pelvis. The average size is 1-9 inches. It is held by the mesentery and comprises three layers:
organ sera, submucosa, and mucous.

From the early days onwards, the timeliness of diagnosis was considered to be critical to reducing mortality rates related to
appendicitis. The clinical diagnosis was developed to determine if appendicitis is present. Charles McBurney labeled the precise
spot to be 1.5-2 inches from the right anterior superior spinous process of the ilium on a line drawn to the umbilicus. We now call
this clinical sign the McBurney’s point.
Patient history

The patient is a 19-year-old female who came to the hospital complaining of abdominal pain for the whole day and even night and
the pain is not tolerable before being admitted to the hospital. She has signs and symptoms of nausea and vomiting yellow fluid.
Upon physical examination, minimal fluid was seen in the hepatorenal and pelvic regions. The result confirmed that the patient has
appendicitis. He had an appendectomy scheduled for August 19, 2022, and is now recovering in the surgery ward. 

Pathophysiology: Appendicitis