A.

CASE DESCRIPTION

Appendicitis

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.

a. Risk Factors

 Obstruction by fecalith or foreign bodies, bacteria or toxins.

 Low-fiber diet
 High intake of refined carbohydrates

b. Complications

 Sudden pain that begins on the right side of the lower abdomen
 Sudden pain that begins around your navel and often shifts to your lower right
abdomen
 Pain that worsens if you cough, walk or make other jarring movements
 Nausea and vomiting
 Loss of appetite
 Low-grade fever that may worsen as the illness progresses
 Constipation or diarrhea
 Abdominal bloating
 Flatulence
c. Signs and Symptoms

 Pain in the periumbilical area that descends to the right lower quadrant.
 Abdominal pain that is most intense at McBurney’s point
 Rebound tenderness and abdominal rigidity
 Low-grade fever
 Elevated white blood cell count
 Anorexia, nausea, and vomiting
 Client in side-lying position, with abdominal guarding and legs flexed
 Constipation or diarrhea

d. How does Appendicitis diagnosed?

 Physical Exam
 Rovsing’s sign- palpating in the left lower quadrant causes pain in right
lower quadrant
 Obturator’s sign- internal rotation of the hip causes pain, suggesting the
possibility of an inflamed appendix located in the pelvis
 Dunphy’s sign- increases pain in the right lower quadrant with coughing
 Iliopsoas sign- extending the right hip causes pain along posterolateral
back and hip.
 Sitkovskiy sign- increased pain in the right iliac region as the person is
being examined lies on his/her left side
 Laboratory tests
 Blood Tests
 Urinalysis
 Imaging
 Abdominal CT scan

e. Management
 Appendectomy
 Analgesics
 Antibiotics
 Intravenous fluids are administered until surgery is performed to prevent fluid and
electrolyte imbalance and dehydration
Appendectomy
Appendectomy is an operation to remove the appendix, which is a small, tube-like part of
the bowel. It often needs to be performed urgently when someone has an infected and
inflamed appendix (appendicitis).
Pre-operative
 NPO, Administration of IV fluids, and medications including antibiotics
 General Anesthesia
 Surgery typical lasts around 1 hour
Intra-operative
 The surgeon makes a small cut in the lower right side of your belly area and
remove the appendix
 The appendix can also be removed using small surgical cuts and a camera, a
procedure called laparoscopic appendectomy.
 If the appendix broke open or abscess is formed, a small tube may be left in the
belly area to help drain out fluid or pus.

Post-operative
 NPO
 Administration of IVF
 Antibiotics

Gastrointestinal System

The primary function of the gastrointestinal system is to achieve proper nutrition by the
digestion and absorption of ingested nutrients; normal function includes the production of
enzymes and hormones as well as the maintenance of proper motility, including
excretion of wastes.  GIS is responsible for the breakdown, digestion of foods, the
absorption of nutrients, and the removal of waste.
 B. ANATOMY AND PHYSIOLOGY

a. Stomach
The stomach is a J-shaped organ that digests food. It produces enzymes
(substances that create chemical reactions) and acids (digestive juices).
b. Colon
The longest part of the large intestine (a tube-like organ connected to the
small intestine at one end and the anus at the other).
c. Cecum
A pouch that forms the first part of the large intestine.
d. Small Intestine
The small intestine has three parts: the duodenum, jejunum, and ileum. It
helps to further digest food coming from the stomach.
e. Appendix
The appendix is a small, thin pouch about 5 to 10cm (2 to 4 inches) long. It’s
connected to the large intestine, where poo forms.
f. Anus
The anus is the opening where the gastrointestinal tract ends and exits the
body.
 C. NURSING HISTORY

1. Demographic Data
Patient’s Name: Mr. T
Age: 28
Sex: Male
Birthdate: May 31, 1994
Address: Purok 1, Minanga Proper, Angadanan, Isabela 3307
Education: College Undergraduate
Occupation: Worker at Sr. Pedro’s Lechon Manok
Nationality: Filipino
Marital Status: Married
Religion: Roman Catholic
Date of Admission: October 24, 2022
Diagnosis: T/C Acute Appendicitis
Room: Surgery Ward
Admitting physician: Ceyshell Angelica D. Tan, MD (Internal Medicine)
Jaime L. Jimenez, MD (General Surgeon)

Name of Hospital: Adventist Hospital Santiago City, Inc.

Initial Vital signs
Temperature: 36.6 degree celcius
Respiration: 22 breaths/min
Pulse Rate: 80 beats/min
Blood Pressure: 110/70
O2 Saturation: 96%
Height: 157 cm
Weight: 53 kg
Chief Complaint:
 (RLQ) Abdominal Pain
2. History of Present Illness
2 days PTC, Patient complained of abdominal pain on the right lower quadrant,
Took diatabs w/c provided no relief of symptoms. No fever and no complains of
vomiting and diarrhea. Last October 24, 2022, patient still complained of pain on
the lower quadrant, hence decided to seek consultation. On October 25, the
patient is under post op and has fever.

3. History of Past Illness

The patient only experienced common illnesses such as cough, fever, colds, and
diarrhea. The patient verbalized that this was his first time being admitted to the
hospital and having surgery.

4. Family History
The patient stated that his mother has hypertension, diabetes, and
arthritis.

5. Gordon’s Functional Pattern

Health Perception/ Health Management

Before During
Patient stated that he is conscious about Using the pain scale, 10 out of 10, the
health. Already vaccinated with patient has reported complaints of pain
Astrazenica for Covid. No allergies to on incision site in RLQ
food and medicines and takes pain
reliever and biogesic when in pain.
Nutritional- Metabolic

Before During
Patient eats 3 times a day. Patient stated Patient is on full diet and increased fluid
that he likes to eat meat than vegetables intake
Drinks 5-6 glasses of water a day

Elimination
Before During
Patient voids 9-10 times a day with Patient was in urinary catheter post op
amber colored urine, approximately with amber colored urine. No complaint
170ml per voiding. Stated no discharge, in defecating and no vomiting noted
and no experience of urinary problems. during hospitalization
Does not use laxatives and stated no
problem during passing defecation.

Activity- Exercise
Before During
Patient works at Sr. Pedro’s Lechonan Patient rests on bed, has decreased
and verbalize that he views his work as mobility due to hospitalization, surgery
his exercise and used to rest at home. and presence of urinary catheter.

Cognitive- Perceptual
Before During
Oriented about time and place, no Patient is still oriented to time, place and
difficulty in sentence making. Responds person. Can follow instructions,
to stimuli verbally and physically. comprehend and can answer questions
being asked.

Sleep- Rest
Before During
Patient sleeps 7-8 hours. His time going Patient sleeps at 11:00 pm and uses
to bed is 11:00 pm and wakes up at 6:00 phone for him to fall asleep such us
AM. Doesn’t use any medications for playing online games and browsing
sleeping, takes naps in the afternoon for social media. Patient stated that he has
at least 30 minutes to 1 hour no difficulty in sleeping.
Self-Perception/ Self-Concept
Before During
Patient is confident about his image, Patient stated that he is thankful for his
verbalized being thankful to God and recovery.
likes grooming.

Role-Relationship
Before During
Patient has a good relationship with his Patient stated that his elder sibling took
family, friends and relatives. He plays a care of his daughter during
role being a father in his family and as hospitalization and all family members
budget controller and his wife as the are cooperative.
decision maker.
 Sexual Reproduction
Before During
Patient reported no sexual problem. No changes noted.

Coping- Stress Tolerance

Before During
Coping mechanism of the patient is being He spends his time with his wife during
alone for him to think, drinks alcohol but hospitalization, spending time with their
not as a habit. phones while resting.

Value- Belief
Before During
Patient is a Roman Catholic, verbalized Patient’s faith and prayer still continued.
not going to church anymore but still
prays before going to bed.
 D. NURSING ASSESSMENT

1. Head to toe Assessment

General Appearance
Pt. Is receive on lying on bed in a High-Fowler's position, yellow hep-lock is
inserted, positive facial grimace, positive guarding behavior complaining in a pain scale
of 10/10 in the RLQ of the abdomen, but is alert and attentive.
Pt. Is w/o difficulty in breathing, hearing, and vision.
VS: BP-110/80mmHg
Temp - 37.4 Degree Celsius
RR - 22cycles/mins
PR - 68Beats/mins
O2 SAT - 98%
Conclusion: Normal Vital Signs
AREAS METHOD FINDINGS INTERPRETATION
1. SKIN Color Inspection Light Brown Normal
Texture Palpation Thin And Dry Normal
Inspection
Presence Of Palpation None Normal
Edema Inspection
Temperature Palpation Warm To Normal
Touch
Skin Turgor Pinching Less Than 1 Normal
Second
2. HAIR Distribution Inspection Normal Normal
Distribution
Palpation
Color Inspection Black Normal
 Lesions Inspection None Normal
Palpation
3. NAILS Color Inspection Pinkish Normal
Capillary Pinching Color goes Normal
Refill Back Within
less than 2
Seconds
4. HEAD Shape Inspection Round and Normal
Palpation symmetrical
Deformities, Palpation None Normal
Lumps,
Swelling Inspection

5. FACE Color Inspection Light Brown Normal

Texture Palpation Smooth Normal
Deformities, Palpation None Normal
Lumps,
Swelling Inspection

6. EYES Color Inspection Black Normal

Consensual Penlight Normal Normal
Light Reflex
Vision w/o difficulty Normal
7. EARS Ear canal Inspection Clean and Normal
Clear
Hearing w/o difficulty Normal
Lesion And Palpation None Normal
Tenderness
Inspection
8. NOSE Inflammation Inspection None Normal
Patency Inspection Clear Normal
9. MOUTH Lips Inspection Brownish Normal
Color, Moist
Teeth And Inspection Presence of
Gums dental carries
Palate Inspection Pinkish Normal
No Lesions
Tongue Inspection Pinkish With Normal
 Nodules
10. ABDOMEN Color Inspection Light Brown Normal
Lesions, Palpation none Normal
lumps and
Inspection

2. Diagnostic and Lab Results

October 24, 2022 (10:17AM)

URINANALYSIS
MACROSCOPIC RESULTS INTERPRETATION
Color STRAW YELLOW NORMAL
Tramsparency CLEAR NORMAL
Volume (mL) 9 NORMAL
MICROSCOPIC
white Blood Cells/ hpf 0-2 NORMAL
Red Blood Cell/ hpf 0 NORMAL
Epithelial Cells Round - Squamous NONE NORMAL
Epithelial Cells Round - Round NONE NORMAL
Amorphous Sediments NONE NORMAL

PARAMETERS RESULTS NORMAL RANGE INTERPRETATION

Specific gravity 1.005 1.005 - 1.030 NORMAL

pH 6.0 4.6 - 8.0mmHg/L NORMAL
Protein NEGATIVE NORMAL
Glucose NEGATIVE NORMAL
Ketone NEGATIVE NORMAL
Erythrocytes NEGATIVE NORMAL
Nitrite NEGATIVE NORMAL
Urobilinogen NORMAL NORMAL
Bilirubin NEGATIVE NORMAL
Leukocytes NEGATIVE NORMAL

October 24, 2022 (08:12AM)

HEMATOLOGY
PARAMETERS RESULTS NORMAL RANGE INTERPRETAION
RBC 5.1x10^12/L 4.0 - 6.0 NORMAL
Hematocrit 0.42% 0.40 - 0.54% NORMAL
Hemoglobin 143 g/dL 130 - 180 NORMAL
WBC 16.8x10^9/L(H) 5.0 - 10.0 INDICATES INFECTION
or INFLAMMATION
Lymphocytes 0.09%(L) 0.25 - 0.35% INDICATES VIRAL
INFECTION
Monocytes 0.09 0.03 - 0.14 NORMAL
Eosinophils 0.0%(L) 0.01 - 0.06% INDICATES INFECTION
Basophils 0.00 0.00 - 0.01 NORMAL
Segmenters 0.82(H) 0.50 - 0.65 INDICATES SEVERE
INFECTION
MCV 83 fL(L) 86 - 110 Microcytic anemia
MCH 28 pg 26 - 38 NORMAL
MCHC 34 g/dL 31 - 37 NORMAL
RVW-CB 12.3% 11.0 - 16.0 NORMAL
Platelet count 337x10^9/L 150 - 450 NORMAL
MVP 8.8 6.5 - 12.0 NORMAL

October 24, 2022 (08:48AM)

CHEMISTRY
PARAMETERS RESULTS NORMAL RANGE INTERPRETATION
Creatinine 63 umol/L 58.00 - 110.00 umol/L NORMAL
Sodium 139.4 mmol/L 136.00 - 145.00 mmol/L NORMAL
Potassium 3.33(L) mmol/L 3.50 - 5.10 mmol/L HYPOKALEMIA
Rationale:
WBC - An increased in WBC indicates increased production of white blood cells due to
an infection or inflammation because of Appendicitis as an admitting diagnosis.
Lymphocytes - a decreased in lymphocytes
MCV - decreased MCV shows that RBC are smaller size than normal which indicates
microcytic anemia
Potassium - a decreased in potassium is due to diarrhea 2 days prior to admission.

Computed Tomography Report October 24, 2022

Clinical Hx: Abdominal pain
CT scan of the whole abdomen
Multiple axial tomography images of the whole abdomen were obtained w/o
contrast.
Within a small, fluid-filled, tubular structure with a mildly thickened wall arising
from the cecum measuring 3.92x1.87cm. are at least two radiopaque calculi, the larger
one in the isthmus measuring 1.50cm in diameter and the smaller one in the fundus
measuring 0.72cm in diameter. Few short stranding densities are seen in the adjacent
paricecal fat. No loculated fluid collection is seen.
There are not other focal masses seen in the rest of the abdomen. The liver,
spleen, pancreas and kidneys are unremarkable. No radiopaque calculi are seen in the
gallbladder and kidneys.
The abdominal aorta is normal in course and caliber. The stomachand bowel
loops are not unusual No ascites or pleural effusion is present. The loony structure are
unremarkable.

Conclusion: 1. Acute appendicitis w/ two fecaliths, as describe.

2. Mild pericecal fat standing.

X-ray Report October 24, 2022

The lungs fields are clear, the heart is not enlarge, the costophrenic sulci and
diaphragm are intact, the bony thorax is unremarkable.
Conclusion: Normal chest finding
E. COURSE IN THE WARD
Date/Time Ordered Doctor's Order Interpretation
Physician's notes

10/24/2022 Please admit to. ROC - For proper care and

under the service of Dr. treatment
Jaime Jimenez (General
Surgeon)

Secure consent for - To ask permission to

BP- 110/70 admission and perform invasive
management procedure/s
PR-80
RR-22
T-36.6
Monitor I and O
O2sat-96% - For baseline data

NPO temporarily.
Ht- 157cm - To avoid nauseous once
Wgt- 53kg contrast or sedation is
administered

IVF: D5LRS 1L X 8hrs.

- For maintenance of body
fluids, nutrition and for
rehydration

Dx:
- For further assessment

and treatment
CBC
-To review overall health
Na
-To help find and monitor
conditions that affect the
balance of fluids,
electrolyte and acidity in
the body
K
- To measure the amount
of potassium in the blood
 Creatinine -To measure the total
amount of the substance
creatinine in the blood or
the urine.
Whole abdominal CT Scan -To help detect diseases of
without contrast
the small bowel, large
bowel, and other internal
organs.

Urinalysis -To detect and manage

wide range of disorders
such as urinary tract
infections.

Refer accordingly
10/24/22 RE: Pain scale-10/10 -For baseline data

9:55 am Buscopan 1 amp now -To relieve pain by helping

your digestive system and
bladder relax.
10/25/22
12:20 hrs Secure consent -To ask permission to
perform invasive
procedure/s

-To check for lung

Chest x-ray problems
ECG -To detect heart problems
CardioPulmonary -To see if the patient is in
Evaluation low risk, moderate risk or
high risk before undergo to
surgical procedure.

Care of Dra. Sabrina

- For further assessment
Rodriguez. Cardio
and treatment

Date/Time Ordered Doctor's Order Interpretation

Physician's notes
10/24/2022 Stratified as - This indicates that the
contraindicated risk to physician can continue
develop cardio pulmonary doing the pending
complication peri - procedure
operatively
-To carry out plan of care to
the patient.
May go ahead w/ planned
Procedure
- To replace potassium loss

Start potassium chloride

drops as follows 40 meq of
KCl in 250mL of PNSS to
run at 5 ugtts/min

10-24-2022 POST OPERATIVE

ORDERS

To recovery room status

post appendectomy -For strict monitoring

Vital signs every 15

minutes for two hours then -For baseline data and strict
every 30 minutes in 2 monitoring postoperatively
hours

O2 inhalation at 2LPM via - To help facilitate proper

NC breathing and oxygenation/
ventilation

NPO - To avoid aspiration

IV fluid to run 45 drops per - For rehydration

minute to follow
D5NSS 1L X 8h
D5LR 1L X 8h
D5NSS 1L X 8h
-To improve the patient
 conditions
Medications
-Indicated for the treatment
of a variety of infections
-For antibiotic
Cefuroxime 750 mg -For pain management
-Treatment of pain mild to
moderate intensity
Metronidazole 500mg. -Treat patient with severe
pain especially after surgery
Keterolac 30mg - To avoid spinal headache

Ketesse IV
-For fluid and electrolyte
monitoring
Fentanyl IV

- Evaluate underlying
Flat on bed X 6hrs.
changes associated with the
condition and for further
assessment/treatment
Monitor I and O hourly and
record

Refer accordingly

Date/Time Ordered Doctor's Order Interpretation

Physician's notes

10/25/2022 Stable Cardio pulmonary -To go home and be

status no objection if for discharged
home management cardio
wise

Clear liquids then -Soft diet first to avoid

gastrointestinal problems
General liquids
 may have soft diet tonight -To avoid gastrointestinal
complications

Update bill tomorrow

possible discharge on -So that the patient can be
Thursday discharged

10/25/2022 Paracetamol lamp IV every 6hrs - To reduce fever

slow IV push for fever 38 and
Temperature- 38. 1 above

Remove catheter, for bladder -To have proper bladder

training (3 urges)
function

Update bill possible

-To be ready for discharge
discharge
Kindly dress wound
-For optimum wound
healing
Full diet tomorrow

-For nutritional
IVF to KVO replacement

Shift IV (Cefuroxime to -For fluid replacement

oral)
- Used to treat bacterial
Furoxen 500 mg) BID infections

Shift Metronidazole
to oral 500mg TID. -Antibiotic that is used to
treat bacterial infection

-Dolo Jaga Temp BID

-Used to relieve pain and
fever
-celecoxib 200mg BID

-To treat pain or

inflammation
 F. PATHOPHYSIOLOGY

PREDISPOSING FACTORS PRECIPITATING FACTORS

- Age (10-30 years old) - Diet (low fiber, raw foods)
- Gender (male-female=2:1) -Prolonged constipation (fecalith matter)
- Hereditary - GI infections (amoebiasis. Bacterial
Gastroenteritis)

Obstruction of the lumen in

appendix by fecalith (hardened
stool), tumor, and foreign objects

Increased intraluminal pressure

inside the appendix that result to
distention of the appendix

Bacterial invasion
(resident bacteria from the intestine)

Inflammatory response/body
response to the bacterial invasion in
the wall of the appendix

Appendicitis

Right Lower
 [Link] CARE PLANS
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute abdominal After 30 minutes of Independent: After 8 hours of

pain related to nursing intervention,
“sobrang sakit ng nursing intervention
swelling and the patient will be
tiyan ko lalo na
inflammation of able to: 1. Assess - Provides information the patient was able
kapag
the appendix. pain, noting location, to aid
gumagalaw.” as to:
intensity (scale of 0–
the patient in determining choice
- reports a relief from 10), duration.
verbalized with a or
pain and reduced
pain scale of 10 - Report pain is
pain with a scale of 3 effectiveness of
out of 10.
and below. interventions. relieved
or
Objective:
2. Monitor the vital - to identify the extent controlled
 CT scan signs and pain score of pain.
result regularly. as
reveals the
presence of evidenced
inflammed 3. Advice the client not - to prevent rupture of
appendix. to massage the appendix leading to by
abdomen in an complications like decreased pain
attempt to relieve pain. peritonitis.
 VS as Dependent: sensation
follows:
- to relieve from pain.
T- 38.3 4. Adminster analgesic
RR- 24 as ordered.
PR- 95 - to reduce
BP- 100/80
5. Inform the client the fear/anxiety and
need for surgical remove the inflammed
intervention and appendix.
prepare the client for
surgery.

6. Maintain NPO
- to reduce the risk of
before the surgery.
aspiration during
anesthesia.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Activity intolerance After 8 hours of Independent:

related to the nursing
- Client is imposed Client was able to
surgical intervention intervention, the
to bed immediately performed activities
“Masakit ang sugat (appendectomy) patient will: 1. Assess the
after surgery and of daily living as
ko kapag causing pain in the client’s ability to
needs assistance evidenced by
gumagalaw ako.” abdomen during perform activity.
in activities. wound healing and
as the patient movement. - gain tolerance to
increased activity
verbalized with pain activity by the
tolerance.
scale of 10 out of ability to perform
10. activities of daily
living. - To progress
2. Provide surgical
dressing to the wound healing and
incision. improve client’s
tolerance to
Objective:
activity.

3. Provide
 Presence of
reassurance that - To gain
surgical wound
once the wound is confidence and to
on RLQ.
healed, the client provide comfort.
will be able to
 VS as follows: perform activities of
normal daily living.

T - 38.4
RR - 25 Dependent:
PR - 95
BP - 110/80
 - To increase
energy to gain
activity tolerance
and for faster
wound healing.
4. Provide
appropriate
nutritional
supplements when
indicated. - Ensure patient
receives
appropriate pain
medication in
advance of activity.
5. Administer
analgesic as
oredered.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Deficient After 30 minutes of Independent: After 30 minutes
knowledge nursing of nursing
“Hindi ko nga alam regarding intervention, the 1. Discuss information - To provide intervention:
kung paano ko to condition related patient will: about condition using information for
nakuha”, as to unfamiliarity illustrations, simple patient to fully -the patient
verbalized by the with information -verbalize sentences and understand about verbalized
patient. reseources understanding of concept. condition. understanding of
condition, disease condition.
Objective: process and 2. Review - Provides
treatment. postoperative activity information for -verbalized
-Inability to restrictions (strenuous patient to plan for understanding of
understand history -Perform necessary activities, heavy lifting, return to usual procedure to
of present illness. procedures sports, sex, driving) routines without perform such as
correctly and untoward incidents. care of incision
explain reasons for 3. Encourage and dressing
action. progressive activities - Prevents fatigue, changes.
as tolerated with Promotes healing
-Participate in periodic rest periods. and feeling of well- -able to
treatment regimen being and facilitates understand and
resumption of normal to cooperate in
activities. treatment
4. Discuss care of regimen
incision, including - Understanding
dressing changes, Promotes
bathing restrictions, cooperation with
and return to therapeutic regimen,
physician for check up enhancing healing
and suture removal and recovery process
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for impaired After 8 hours of Independent Client’s skin

skin integrity related nursing integrity was
to surgical intervention, the improved as
“ Masakit ang sugat procedure client will be able 1. Provide surgical - To prevent wound evidenced by:
ko lalo na kapag (appendectomy) to: dressing twice a dayinfection and
gumagalaw.” as the by following strict thereby prevents
patient verbalized aseptic technique. further skin - early wound
with pain scale of - improve the skin breakdown. healing and intact
10 out of 10. integrity with no 2. Wash hands - To prevent cross- skin with a minimal
further signs of regularly while infection. scar mark at the
skin breakdown. providing care to surgical site.
client.

3. Teach the client

Objective: about hygienic - To follow wound
measures and care and promote
demonstrate wound early wound
 Presence of site care to be healing.
surgical followed at home.
incision.

 Presence of
4. Advice the client - To promote early
penrose drain.
to take balanced wound healing.
nutrition with foods
 Positive rich in protein and
guarding vitamin C.
behavior in the
incision site.
 VS as follows: Dependent:

T - 38.2
RR - 26 5. Apply emollients - To prevent further
like vaseline, oil to skin breakdown
PR - 98
the skin as and minimize
BP- 110/80
prescribed. surgical scar.

6. Apply anti-septic
ointments to the - To prevent wound
surgical wound. infection and
promote wound
healing.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Risk for infection After 8 hours of Independent: After 8 hours of

secondary to nursing nursing
presence of intervention, the
shift the nurse
 presence of surgical incision. patient will be 1. Practice and instruct - Reduces risk of spread
was able
surgical able to: in of bacteria.
incision good handwashing and to:
aseptic wound care. 
- meet the goals
 presence of - free of signs
with an evidence
penrose drain and symptoms 2. Inspect incision and
of infection. - Provides for early of the absence of
dressings. Note the signs and
characteristics of detection of developing
symptoms related
VS as follows: drainage from wound infectious process.
to infection.
(if inserted), presence
of erythema.
T - 37.9
RR - 27
PR - 97 3. Observed - To evaluate if the
for localized sign character, presenceand
BP - 100/80 of infection at condition of the present
insertionsites of infection.
invasive lines,surgical
incisions or wounds.
4. Make health - To help the client
teachings especially modify/change/avoidsome
inidentification of the environmental
of environmental factors present which
risk factors that could could reduce the
add up on infection. incidence of infection.

Dependent:

- Antibiotics will help kill

5. Administer
and stop the proliferation
antibiotics, as
and growth of the bacteria
appropriate.
which could cause
infection
 H. DRUG STUDY

Name of of Drug Indication Mechanism of Contraindication Adverse/side Nursing

action effects Responsibilities

Generic name:  Relieves  Blocks the  Myasthenia  Blurred vision  Assess for eye
painful muscarinic gravis,  Dry mouth pain
Hyocine N- stomach receptors mechanical  Reduced  Assess for
Butylbromide cramps, found on the stenosis in the ability to urinary
including those smooth muscle gastrointestinal sweat. hesitancy.
linked with walls. tract , paralytical  Weakness
Brand name: irritable bowel or obstructive
syndrome ileus,
Buscopan (IBS) megacolon

Classification:
Antispasmodic

Dosage:
1 ampule IV now
Name of of Drug Indication Mechanism of Contraindication Adverse/side Nursing
action effects Responsibilities

Generic name:  Relieves  Blocks the  Myasthenia  Blurred vision  Assess for eye
painful muscarinic gravis,  Dry mouth pain
Hyocine N- stomach receptors mechanical  Reduced  Assess for
Butylbromide cramps, found on the stenosis in the ability to urinary
including those smooth muscle gastrointestinal sweat. hesitancy.
linked with walls. tract , paralytical  Weakness
Brand name: irritable bowel or obstructive
syndrome ileus,
Buscopan (IBS) megacolon

Classification:
Antispasmodic

Dosage:
1 ampule IV now
Name of of Drug Indication Mechanism of Contraindication Adverse/side Nursing
action effects Responsibilities

Generic name:  Treatment is  The  High levels of  Bleeding  Check serum

indicated for maintenance of potassium in  Indigestion potassium
KCl the treatment intracellular the blood  Rash levels
and prophylaxis tonicity;  Decreased  Continuous
of hypokalemia transmission of kidney function ECG monitoring
Classification: in patients for nerves; the  Severe burn and serial
whom dietary contraction of measurements
Electrolyte management cardiac, of plasma
supplements with potassium- skeletal, and potassium.
rich foods or smooth muscle
diuretic dose and the
Dosage: reduction are maintenance of
insufficient normal renal
kCl 40meq in function.
250ml of pnss to
run at 5micro
drops/min.
Name of Drug Indication Mechanism of contraindication Adverse/side Nursing
action effects Responsibilities

Generic name:  For short term  Activation of  Should used  Irregular heart  Monitoring of
treatment of descending with caution in beat temperature
Paracetamol moderate pain, serotonergic cases of of  Difficulty of every q4
especially pathways severe renal breathing
following insufficiency,  Muscle pain or
Brand name: surgery and hepatocellular cramps
for the short- insufficiency,  Loss of
Amcetam term treatment appetite
of fever.

Classification:
Analgesic and
antipyretic

Dosage
1 ampule q6 IV prn
for fever

Name of Drug Indication Mechanism of Contraindication Adverse/side effect Nursing

 action responsibilities

Generic name: To treat wide Diffuses into the  Prior history of  Agitation  Be alert for
variety of organism, inhibits Hypersensitivity  Back pain confusion,
Metronidazole
infection, it works protein synthesis   Headache agitation,
by stopping the by interacting with  Burning, headache or
growth of certain DNA. numbness or other alteration
Classification: bacteria. painful in mental
sensations in status
Antibiotic hands and feet.  Monitor IV
 Eye pain injection site for
 Mood or mental pain, swelling,
Dosage: changes and irritation.
Report
prolonged of
excessive
500mg IV q8 injection site
reactions to the
physician.

Name of the drug Indication Mechanism of Contraindication Adverse/ side effect Nursing
 action Responsibilities

Generic name : Short- term(<5 Anti-inflammatory, Moderate to severe  Headache  Monitor signs of
days) management atipyretic and renal impairment or  Stomach pain abdominal
Ketorolac  Dizziness pain,
of moderately analgesic effects is risk for renal failure
severe acute pain the inhibition of due to volume  Indigestion  Monitor signs of
that requires prostagladin depletion or allergic
Brand name: analgesia at the synthesis by dehydration . reactions and
anaphylaxis
Ketorolex opioid level, competitive
usually in a blocking of the
postoperative enzymes
setting. cyclooxygenase
Classification:
(COX)
NSAIDs
(Nonsteroidal anti-
inflammatory
drugs; primary
appendicitis.

Dosage:
30mg
IV q8
Name of Drug Indication Mechanism of Contraindication Adverse/side Nursing
action effect responsibilities

Generic name: Analgesic action of Binds to oploid  Hypersensitivity  Difficulty of  Assess IV site
short duration during receptors the mu  Respiratory breathing closely for signs
Fentanyl depression  Unusual of extravasation
anesthetic oploid receptor
periods,premedication, which coupled to  Not aploid tiredness  Assess adverse
induction of g proteins tolerant  Irregular or reactions
Classification: maintenance and in  Intermittent pain slow  Continuous
heartbeat cardiorespiratory
Narcotic (opiate) the immediate
 Pale or blue and blood
analgesics postoperative period
lips, finger pressure
as the need arises nails or skin monitoring
 Sedation  Monitor Oxygen
Dosage:  Pain relief Saturation

25mg
IV prn for pain q6
Name of Drug Indication Mechanism of action Contraindication Adverse/side Nursing
effect responsibilities

Generic name:  Symptomatic  Non steroidal  Not given to  Nausea  Obtain

treatment for anti those who have  Constipation baselines for
Dexketoprofen acute pain inflammatory history of stroke,  Abdominal weight and
trometamol (NSAID) cerebrovascular pain height, B/P,
 Reduction of accident, heart  Dyspepsia serum glucose,
prostagladin attact,  Dizziness electrolytes.
Brand name: synthesis by the uncontrolled  Melaena  This drug may
inhabition of Hypertension . cause
Ketesse cyclooxygenase dizziness, or
pathway. visual
disturbances, if
Classification: affected, do not
drive or operate
Propionic acid machinery.
derivatives of  Monitor blood
non-steroidal counts and
anti-inflammatory hypersensitivity
and anti- reaction
 Do not change
rheumatic
dose or stop
products
taking drug.
Dosage:1tab
Frequency: TID
Name of Drug Indication Mechanism of Contraindication Adverse/side effect Nursing
action responsibilities

Generic name: Treatment of Binds to bacterial  Patient with  Mild abdominal  Administer
variety of cell membranes, cephalosporin cramps medication with
Cepuroxime hypersensitivity  Discomfort food to hasten
infections inhibit cell wall
including acute synthesis  Mild diarrhea absorption
bacterial otitis  Watch for
Brand name: media , several seizure
 Monitor signs
Zefuxime upper respiratory
of diarrhea,
tract infections,
abdominal
skin infection, pain, fever.
Classification:
Cephalosporin
antibiotic

Dosage:
500mg 1cap

Frequency:
BID
Name of Drug Indication Mechanism of action Contraindication Adverse/side Nursing
effect responsibilities

Generic name:  Relieve pain,  Due to selective  Sallicylate  Itching or rash  Assess range
tenderness, inhibition of hypersensitive  White colored motion, degree
Celecoxib swelling and cyclooxygenase- or NASAID stool of swelling,
stiffness. 2 which is hypersensitivity  Seizures pain in
responsible for  Sickness like affected joints
Brand name: prostagladin reaction before and
synthesis, an periodically
Celebrex integral part of therapy
the pain and  Assess skin
inflammation rash frequently
Classification: pathway. during therapy.

COX 2 inhibitors

Dosage:
200mg BID
Name of Drug Indication Mechanism of Contraindication Adverse/side effect Nursing
action responsibilities

Generic name:  Used to  Increases  Hypersensitivity  Feeling of  Inform the

relieve pain resistance  Allergic warmth doctor about
Paracetamol, and fever. stress and reactions  Weakness the current
Vitamin b complex meet nutritional  Hepatic  Sleepiness medication
needs vitamin impairment  Headache over the
B1, B6, and  Breathing counter, Dolo
Brand name: B12 problem jaga may
 Skin rashes increase risk
Dolo jaga side effect or
drug may not
work properly
Classification:  During
treatment
Anilide preparation should
regularly
monitor the
blood picture
Dosage:
and
1cap BID coagulation
 I. DISCHARGE PLANNING
Medication and Treatment
 Ensure adequate patient education to complete all the prescribed medicines,
strictly following the dosage, frequency, and other instructions before taking it.
 Monitor the incision site for any signs of infection such as redness, swelling,
drainage, or increased pain, and report these immediately to their surgeon.

Incision care
 Wear loose-fitting clothes. This will help you be more comfortable and cause less
irritation around the incision.
 Shower as usual.
 Gently wash around your incision with soap and water.
 Don’t bathe or soak in a tub or swim in a pool until your incisions are well healed.
 If your incision was closed with small, white strips of tape, leave them in place
for 10 days.

Diet 
 Drink 6 to 8 glasses of water a day.
 Take a fiber-based laxative if you are constipated.
 Eat a bland, low-fat diet, such as:
 Plain bread, crackers
 Soup
 Rice
 Low-fat milk
 Canned fruit (except pineapple)
 Very ripe bananas

Activity
 Resume light activities around your home once you feel able to do so.
 Bed rest
 No heavy exercise or lifting heavy objects
 Limit sports and strenuous activities for 1 or 2 weeks.