NRS - MEDICAL SURGICAL NURSING II (LEC)

UNIT #: UNIT TITLE (PLM-CN BATCH 2020) NRS 3217-9

OUTLINE concentration of sodium chloride), retention enema using your

GI DISORDERS 7. Hemorrhoids oil
CONTINUATION A. Assessment o The saline solution, tap water, hypertonic we do not retain
1. Colorectal Cancer B. Management inside but rather, we retain is the oil and that is a composition
A. Nursing Interventions C. Hemorrhoidectomy of your mineral oil such or other lubricating oil such as the
2. Appendicitis D. Nursing Interventions castor oil
A. Causes E. Additional Notes o The oil will penetrate and primarily use to lubricate and soften
B. Stages (Posted in Teams) the stool
C. Assessment 8. Appendicitis o The retention enema is usually used for cases of fecal
D. Management A. Example lang to impaction.
3. Peritonitis a. Disorders of o We used saline solution in cleansing enema (tap water or
A. Causes Automaticity sterilled) DO NO RETAIN ( MECHANICAL CLEANSING)
B. Assessment b. Disorders of o RETENTION ENEMA is usually bibigay ng oil, hahayaan lang
C. Management Conduction doon para mapalambot.
4. Colorectal Cancer c. Re-entry of
A. Nursing Interventions Impulse MEDICATION ENEM
5. Colonic Surgery B. General Clinical - DUPHALAC (for the exchange of ammonia)
A. Preop and Postop Care Manifestations o Pharmacologic suspension neomycin
6. Stoma Care and Skin Care sulfate
A. Colostomy Irrigation o - tablet na dinudurog tapos hahaluhin sa
B. Managing Odor in enema, habang enema yung pateint, just to
Colostomy reduce bacterial flora
C. Nursing Interventions o The neomycin is enhanced by excretions of
bacteria of colonic bacteria normal form,
GI DISORDERS CONTINUATION kaya hindi siya iniinom orally
o Vitamin C – very necessary for immunity, to
COLONIC SURGERY prevent being susceptible
o Vitamin K – necessary for clotting factor,
o Medicine evolves due to evidence-based that is
What is the common pre-op care in colonic surgery? why we are not purely theoretical; we use theory
o Bowel preparation – the most important and evidence based. That is why educations are
o Thorough bowel cleansing is done also outcome-based.
o Depends on what specific portion of colon that o Remember that Vit C and K are lost during
we are going to manipulate enema especially the repeated administration of
o Objective: to have a clean bowel to lessen the enema.
chances of infection during the operation. AS o That is why prior to do that, we must have
much as possible we reduce the bacteria, SUPPLEMENTS to replace that.
including the normal flora in the intestine o Informed Consent must be obtained.
o Usually, we start at Diet Modifications, most o Patient is put in NPO
esp with in-house and OPD patients
o Clear instructions are given to them that they POSTOP CARE
need to do bowel preparations 3-5 days prior to o Management of the perineal wound or APR
the operation by consuming a LOW RESIDUE o Manage the anterior posterior line of the wound.
DIET to prevent bulky stools o Supplement information about APR:
o We put patients on a CLEAR LIQUID DIET 24- o APR stands for Abdominoperineal Resection. It
36 hours prior to operation is a surgical procedure performed to remove the
o Then, we do Mechanical Cleansing lower part of the rectum, the anal canal, and the
o Laxative is given (usually during midnight) as surrounding tissues in the treatment of certain
cleansing enema conditions, most commonly rectal cancer.
o Enema o APR is a complex surgical procedure that
requires expertise and careful postoperative
management. The decision to perform an APR
PREOP CARE is made by a multidisciplinary team of healthcare
→ 1.Soapsud enema professionals, including surgeons, oncologists,
o Being term as hypertonic enema and gastroenterologists, based on the individual
o Usually mixed with mild soap (castile) and it is usually mixed patient's condition and needs
with warm water o Patient requires minimum of 6 months for the
o The purpose is for bowel evacuation to stimulate the movement complete healing of wound.
of colon, this enema will irritate the rectal lining leading to
o Colonic irrigations – used only NORMAL
increase of bowel contraction which will urge to defecate.
SALINE.
o Saline solution, tap water composition (sterile or filtered water),
hypertonic solution (soapsud enema, saline solution with high

TRANSCRIBED BY: GROUP 3 AND 4

 o Absorbent dressing is used in dressing the
stoma until there is a wound closure.
o Drainage is expected during the initial period.
o Papules and serosanguineous – this are the
expected drainage on a regular basis.
o This is done to prevent infections.
o If there is an abscess formation, we need to
drain it.
o That is why every time that we have surgery,
whether you have colostomy, APR, or wala,
dapat lahat ng abscess sa wound ay pinipiga.
o Put pressure when you are doing wound care,
hindi dapat bine-baby.
o Wound Care:
o Remove the dressing
o Put betadine
o Then, pipigain
o This is done especially in sutures because
suture abscess may happen.
o Once na nag-undermine or nag sit in hanggang
sa loob, this would cause infection.
o That is why abscess should be removed habang
superficial pa lang.
o This prevents infections or surgical site infection
(SSI).
o Binder is used to secure perineal dressing, hindi
bumuka yung tahi, prevents eviscerations and
dehiscence.
o Hot Sitz Bath is necessary especially for
ambulatory patient
o Side lying position during sleep
STOMA CARE AND SKIN CARE
1. Gently encourage the client to look at the stoma.
o For the patient to see the characteristics of the
stoma so that they may be able to recognize if
there is something wrong with the stoma.
o It’s important for patients to recognize
abnormal findings in the stoma (e.g.,
retractions and necrosis of the stoma) to prevent
complications.
o There are times na yung mga blood vessels sa
stoma ay aksidenteng nasasamang matahi [sa
abdomen] ng doctor. This leads to the necrosis
of the stoma. This is why patients need to know
what a normal stoma looks like, so that they can
report any changes that happen to their
stoma.
o Because of depression, most of the patients
don’t want to look at their stoma. However, it is
our nursing responsibility to teach our client
stoma care and skin care.
2. Inform that stoma has no touch or pain sensation.
o Patients may have a misconception that
touching their stoma will hurt. This may be a
reason why they don’t want to touch their stoma.
o We need to inform them that their stoma
doesn’t have any sensation and will not hurt
even if they touch the area.
3. Instruct to report immediately any purple or black discoloration of the
stoma
o Inform the patient of the expected findings when
they are looking at their stoma (e.g., pinkish in
color).
o Nurses must also assess the length of the stoma
to see if the stoma is retracting or protruding.
This will inform the patient of the status of their
stoma. Surgery may be required to correct the
stoma if it is retracting or protruding.
→ 4. Cleanse the stoma initially with antiseptic.
SKIN CARE
1. Wash the skin with warm water, pat dry.
o Do not apply friction, just pat the area dry.
2. Assess skin for signs or irritation or infection.
o Irritation can lead to infections.
3. When pouch seal leaks, change pouch immediately.
o There are times when the pouch is leaking due
to manufacturing defect.
o Leaking pouch must be changed immediately as
it can cause irritation to the skin. And irritation
can lead to infections.
o Liquid stool commonly causes skin
problems around the peristomal skin area. This
is why we use skin barrier to protect the
peristomal skin area (e.g., karaya powder)
o If the patient has a fungal type of infection, we
use mycostatin powder to manage the infection.
o Common microbial flora of the intestine has
fungi, if the fungi spreads to other parts of the
body, it is no longer normal and it becomes
pathologic.
4. Use skin barrier to protect the peristomal skin from liquid stool.
COLOSTOMY IRRIGATION
1. Initial colostomy irrigation is done to stimulate peristalsis;
subsequent irrigations are done to promote evacuation of feces at a
regular and convenient time.
o You do not only wait for the effluent to be
released from the stoma, you also irrigate it
especially if out patient.
o Colostomy is a common hindrance for the pt.
leading to isolation d/t odor, thus it is important
to teach pt about irrigation.
o We have different types of colonic surgery
requiring irrigations, and use of irrigating sleeves
2. Recommended with sigmoid colostomy
3. Initiated 5 to 7 days postop
4. Done in semi-fowler’s position; then sitting on a toilet bowl once
ambulatory.
o Can be done in bedside if pt is not yet
ambulatory, but doing in toilet bowl is preferred
especially if pt is already ambulatory
5. Use warm normal saline solution
6. Initially, introduce 200 mls of NSS then 500 to 1000 mls
subsequently
o ‘wag bibiglain, usually, you start in ample
amount (200, then 500, up until 1000) as the pt
tolerate it
7. Dilate stoma with lubracted gloved finger before insertion of catheter
o Prior to inserting catheter for irrigations, dilate
the stoma
o Use a lubricated gloved finger > insert it into the
stoma > dilate it since it is tight at first > insert
catheter
o Use a water-soluble lubricant (KY jelly)
o Finger is used to be able to feel if there is
resistance which may be d/t tumor, because you
won’t know that there is resistance if you insert
tube immediately
o If there is resistance, you cannot proceed with
colostomy irrigations. Refer it back to the
attending physician and further assessment is
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 necessary (maybe there is an inflammation or
tumor that grows up faster)
o Eto yung dinrawing ni sir na catheter na pang-
irrigate
8. Lubracte catheter before insertion
o Use a water-based lubricant as well
o DO NOT USE oil-based lubricant as it somehow
irritates the intestine
9. Insert 2 to 4 inches of the catheter into the stoma
10. Height of solution is 1.8 inches above the stoma.
o Height of solution = at the shoulder level of the
pt (should not be lower or higher than the
shoulder)
o ‘wag din mabilis or mabagal yung pag-irrigate
11. If abdominal cramps occur during introduction of solution,
temporarily stop the flow of solution until peristalsis relaxes.
o Temporarily stop > open it until movement of the
intestine relaxes
12. Allow the catheter to remain in place for 5 to 10 minutes for better
cleansing effect, then remove catheter to drain for 15 to 20 minutes.
o Do not let the pt stand while draining the bag to
have proper evacuation of the output/effluent
13. Clean the stoma, apply new pouch.
o Do the colostomy care after irrigations
MANAGING ODOR IN COLOSTOMY
1. Avoid gas – forming and foul odor foods
o Manage the odor by avoiding gas forming or foul
odor food especially dairy products
o Ex. Cabbage and cauliflower
2. Rinse pouch with tepid water or weak vinegar solution.
o In rinsing the pouch, we use tepid water or weak
vinegar solutions para di mabaho
3. Place deodorant tablet or small amount of mouthwash or a piece
of charcoal into the pouch.
o In rinsing the pouch, we use tepid water or weak
vinegar solutions para di mabaho
4. Do not pulverize ASA
o Never pulverize Aspirin (it is done before but
today not) since it can cause irritation in stoma
or sometimes cause damage in stoma bag
(causes leakage)
NURSING INTERVENTIONS
1. Supporting a Positive Self-Concept
o Encourage pt to look at the stoma so they could
see the characteristics and be able to recognize
if there is something wrong with the stoma
o Binabantayan even the length of stoma to
identify if there are retractions or necrosis
o Encourage the patient to participate in
colostomy care and verbalize feelings. To
determine if they have concerns/questions
regarding stoma care
o Encourage patient to assume normal activities of
daily living. Help them return to previous
activities because they can’t be dependent on
their caregivers forever. This also promotes
positive self-concept of the patient.
2. Avoid tight belts or waistbands over the stoma
o Patients usually use this to prevent leaking but
this is not advised. If leakage occurs,
recommend bringing extra supplies especially
during travels. If the belt (goma) is too tight, it
can harm the stoma.
3. Preventing Sexual Dysfunction
o Although there is no direct link on the client’s
sexual functions, patients still develop sexual
dysfunction due to being shy about their
colosomy.
o Sex is one of basic human needs so advise
exploration of alternative ways to resume sexual
activity.
o Advise positions that minimize stress to the
patient and pressure to the pouch (patient lying
down, partner is the one above).
o Prior to sexual activity, clean and empty the
colostomy pouch to prevent leaks.
o Use smaller pouch size during sexual activity to
prevent dangling and distracting the patient.
o Refer to the doctor if the patient needs more
advice.
o Part of basic needs that’s why allow them to
explore
HEMORRHOIDS
→ Dilated blood vessesls beneath the lining of the skin in the anal
canal
Two Types of Hemorrhoids
→ External Hemorrhoids
o Below the anal sphincter
→ Internal Hemorrhoids
o Above the anal sphincter
Causes
→ Chronic constipation
→ Pregnancy
→ Obesity
→ Prolonged sitting or standing
→ Wearing constricting clothings
o Sinisikipan ang belt will obstruct the circulation
→ Disease conditions like liver cirrhosis, RSCHF
o Hindi kaagad nakakabalik ang blood sa heart so
nagkakaroon ng pooling of blood and by the law
of gravity sa center napupunta → hemorrhoids
o Blood vessels rupture
o Daflon 500 mg – common medication given to
px with hemorrhoid
o If you have dilated blood vessels
o For px with venous insufficiency
o Help reduce the pain, bleeding, inflammation
o Improve microcirculations tone to the venous
area to relieve the pressure because if there is
high pressure → puputok especially when you
do straining
o Dosage varies on the indication of the px
o OTC drug
o 500 mg per day and usually in the moring and in
the evening (BID)
o 6 am and 6 pm
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 o Given as maintenance
o If nasa exacerbation stage, we give this
medication as 6 tablets per day for 4 days. 6
tablets divided into 24 hours, every 6 hours ang
inom. Then followed as maintenance dose 2
tablets for the succeeding days.
o Common adverse reaction is transient
o Common side effects: GI disturbance,
abdominal pain, dyspepsia, diarrhea
o Very rare to develop allergic reaction and
hypersensitivity
o If may hypersensitivity sa daflon, immediately
consult the attending physician or bring to the
nearest hospital.
o Almoranas – filipino term ng hemorrhoids
ASSESSMENT
→ Constipation
● In an effort to prevent pain or bleeding associated with
defecation
→ Anal pain
→ Rectal bleeding
→ Anal itchiness
o Itchy, almond-like
→ Mucous secretion from the anus
→ Sensation of incomplete evacuation of the rectum
→ Internal hemorrhoids may prolapse
o If may prolapse, surgery is needed →
hemorrhoidectomy
MANAGEMENT
1. High fiber diet, liberal fluid intake
2. Bulk laxatives
3. Hot Sitz bath, warm compress
o Most especially after the surgery, it is advised to
do hot sitz bath dahil may anal pack and hindi ito
pwedeng matanggal.
4. Local anesthetic application
5. Surgery
o hemorrhoidectomy
HEMORRHOIDECTOMY
PREOP CARE
o OPD basis
POSTOP CARE
o Promotions of comfort of the px after the surgery
o Pain – analgesic as prescribed by the doctor
o Usually ayaw dumumi ng px dahil masakit, we
can give analgesic before the initial defecation
after surgery. Hindi pwedeng every time na
magdedefecate analgesic.
o Positions of the bed – side-lying position
o Hot sitz bath – 12 to 24 hours postop
o Dahil may anal pack pa at masyado pang
masakit kapag tinanggal ng mano-mano
o Promotes proper elimination
o If there is occurrences of constipation, give stool
softener as prescribed by attending physicians
o Only encourage px to defecate ONLY if there is
an urge.
o Impeded ang circulation kapag nakadiin sa bowl
and masyadong matagal dumumi
o Enema if hindi talaga makadumi as prescribed
using a small-bore rectal tubing.
NURSING INTERVENTIONS
→ Clean rectal area thoroughly after each defecation
o If px is able allow them to perform it.
o In other countries, talagang nagpapahugas sila.
o In the Philippines, may nursing aid who can
assist and do the dirty works.
→ Sitz bath at home especially after defecation
→ Avoid constipation:
● High-fiber diet
● High fluid intake
● Regular exervise
● Regular time for defecation
● Use stool softener until healing is complete
o Hindi pwedeng laging magbigay ng stool
softener.
o Stool softener can cause weakening of colonic
muscles → diverticulitis (sila yung matagal na
umiinom ng stool softeners)
o Educate px and avoid dependence on the
medications.
● Notify physication for the untoward complication
o Rectal bleeding, pain, drainage (suppurative),
continuous constipation
o Refer only after necessary interventions: high
fiber diet, increased oral fluid 2 to 3 L per day
o If sinabi ng px na hindi makakain ng gulay, you
should still encourage the px.
ADDITIONAL POSTED IN TEAMS
ENEMA
→ Drug guidelines: In the treatment of hemorrhoidal disease, the initial
dosage may involve taking 6 tablets of 500 mg each per day for 4
days, followed by a maintenance dose of 4 tablets per day for the
following 3 days.
→ Enema using lactulose can be utilized as a treatment option for
patients with hepatic encephalopathy or for individuals who are
unable to take lactulose orally. Lactulose enemas work in a similar
manner to oral lactulose, aiming to reduce ammonia levels in the
blood and alleviate hepatic encephalopathy symptoms. Here's
some information on lactulose enemas:
→ Enema using lactulose can be utilized as a treatment option for
patients with hepatic encephalopathy or for individuals who are
unable to take lactulose orally. Lactulose enemas work in a similar
manner to oral lactulose, aiming to reduce ammonia levels in the
blood and alleviate hepatic encephalopathy symptoms. Here's
some information on lactulose enemas:
PREPARATION:
o Lactulose Solution: Obtain lactulose solution, typically in a
concentrated form.
→ Dilution: Dilute the lactulose solution with water according to the
instructions provided by the manufacturer or as directed by a
healthcare professional. The concentration may vary, but a typical
dilution is 300 mL of water mixed with 200 mL of lactulose solution.
ADMINISTRATION:
→ Positioning: Ensure the patient is lying on their left side with knees
bent, allowing for easy insertion of the enema tube.
→ Lubrication: Apply a water-soluble lubricant to the tip of the enema
tube to ease insertion.
→ Insertion: Gently insert the enema tube into the rectum, aiming
toward the navel. Take care to avoid any resistance or discomfort
during insertion.
→ Administration: Slowly squeeze the contents of the lactulose
solution into the rectum. The exact volume and rate of
administration will depend on the healthcare professional's
instructions and the specific patient's needs.
→ Retention: Instruct the patient to retain the lactulose solution in the
rectum for the recommended duration. The duration may vary, but
it is typically around 30 minutes to allow for sufficient absorption and
action.
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→ Evacuation: After the retention period, the patient can evacuate the
enema solution and waste material. It is important to provide access
to toilet facilities or a bedpan.
→ It's important to note that lactulose enemas should be administered
under the guidance of a healthcare professional, and the specific
instructions may vary depending on the patient's condition and the
healthcare provider's recommendations. Adherence to aseptic
techniques, maintaining patient privacy and comfort, and monitoring
for any adverse effects or complications are essential during the
administration of enemas.
APR
o APR stands for Abdominoperineal Resection. It is a surgical
procedure performed to remove the lower part of the rectum, the
anal canal, and the surrounding tissues in the treatment of certain
conditions, most commonly rectal cancer.
o APR is a complex surgical procedure that requires expertise and
careful postoperative management. The decision to perform an
APR is made by a multidisciplinary team of healthcare
professionals, including surgeons, oncologists, and
gastroenterologists, based on the individual patient's condition
and needs.
COLORECTAL CANCER
NURSING INTERVENTIONS
→ Clean rectal area thoroughly after each defecation
→ Sitz bath at home especially after defecation
→ Avoid constipation
o Refer back to the physician after you do necessary
interventions if the patient is still constipated
→ High-fiber diet
→ High fluid intake
o Increase 2-3 Liters per day
→ Regular exercise
→ Regular time for defecation
→ Use stool softener until healing is complete
o We cannot give unlimited stool softener since it
causes weakening of colonic muscles
o Weak colon muscles lead to diverticulitis
→ Notify physician for the unwanted complication
APPENDICITIS
→ Inflammation of the vermiform appendix
→ More common in males, 10 to 30 years of age
CAUSES
→ There is parasitic infection in toddlers
→ Obstruction by fecalith or foreign bodies infection
→ Low fiber diet
→ High intake or refined carbohydrates
4 STAGES OF APPENDICITS
1. Early/Suppurative – there is inflammation in the appendix.
2. Congestive – Really inflamed, more painful. The area is being
compromised to receive oxygenated blood.
3. Gangrenous – Due to no blood supply, the area loses its function and
dies as it becomes gangrenous.
4. Perforative – this is when rupture of appendix happens.
Note: Sometimes it’s hard to assess and determine the signs and
symptoms of appendicitis, which is why many patients were sent
home instead of treating undiagnosed appendicitis.
CONGESTIVE APPENDICITS
● When there is a severe inflammation, the area is being
compromised from receiving oxygenated blood
o From suppurative, congestive going to gangrenous
since there is no supply of blood (namamatay yung
area)
GANGRENOUS APPENDICITS
• It can rupture easily
ASSESSMENT
→ Acute abdominal pain
→ Pain gradually becomes localized RLQ
→ Pain is initially intermittent then becomes steady and serves over a
short period
→ Anorexia, nausea and vomiting
→ Rigid abdomen, guarding
→ Rebound tenderness
→ Fever
→ Elevated white blood cell
→ Psoas Sign
→ Decreased or absent bowel sounds
o Usually, a CBC, X-ray, and Urinalysis results in
a clearance or pediatric clearance for an
operation (appendectomy).
o Appendicitis: acute abdominal pain;
Helminthiasis/STH (bulate sa tiyan): on and
off abdominal pain
o Abdominal pain should be followed by an
assessment or triage by the pediatric (or
whichever assigned) department. The triage
result should then be given to the assigned
surgeon of the patient in order for the surgery
department to evaluate whether it is a surgical
abdomen or not.
o Equivocal – uncertain or questionable in nature;
unknown reason (if used in this case, not sure if
the cause of abdominal pain was appendicitis or
the cause is unknown)
o Remember: As long as the appendix is intact or
has not yet ruptured, there is pain. But the
moment it ruptured, and pressure is released,
the pain subsides. The latter is more dangerous
as there is a high chance that digestive waste
will fill in the abdominal cavity. We have to
differentiate the two because the kind of
operation for a ruptured appendix differs from a
simple appendectomy.
o Open Surgery – simple appendectomy is done
with a simple and downward slanted cut or
through laparoscopic surgery which is done by
making four small holes/incisions.
o Exploratory Laparoscopic Sugery – for a
ruptured appendix, this surgery is done by
making an incision starting from the top of the
umbilicus (navel) downward across the
abdomen while avoiding the umbilicus. This is
done to make way for abdominal washing which
can help avoid infections caused by displaced
waste in the abdominal cavity.
o Antibiotics given to patients who underwent
simple appendectomy due to a case of
unruptured appendix also differs from those with
ruptured cases.
Question: Is it true that jumping after meals and eating seeds can
cause appendicitis?
→ This is a fallacy since appendicitis is caused by fecalith
obstruction, not because of seeds or jumping after eating. High
intake of refined carbohydrates could cause constipation which
can lead to obstruction.
Acute abdominal pain
● Whenever you encounter equivocal abdominal pain, put
the patient on monitoring.
● No pain medication or antibiotics until we are certain what
the case is.
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 o Pain medications relieve pain, but it doesn’t
prevent the appendix from rupturing.
o Antibiotics resolves inflammation and pain but
doesn’t guarantee that the appendix will not
rupture.
Cefuroxime
● Given 1hr before the surgery for simple appendectomy.
● Cefuroxime 500mg (initial dose) before the surgery
● Cefuroxime 1,000mg (loading dose) before the surgery.
o Prophylaxis base medication to prevent risk of
infection during and after surgery.
● A skin test must be done before administering antibiotics.
● Monitor the patient for any adverse effects or allergic
reactions after administering antibiotics.
o Give emergency medications such as antihistamine
and epinephrine.
● Oral Cefuroxime 500 mg q8h after surgery once the
patient can consume.
Abdominal washing
● Done with patients with ruptured appendix who will
undergo exploratory laparotomy.
● Abdominal organs will be taken out to be washed.
● The ruptured appendix will be removed first, suture the
remaining appendix, abdominal washing, then antibiotics.
Different Types of Antibiotics used are usually Third Generation
Cephalosporin with Broad spectrum coverage such as Ceftriaxone plus
Metronidazole because they are effective in many types of bacteria found
in abdomen (intraabdominal infection, particularly ruptured appendicitis
• Ceftriaxone covers gram negative bacteria
• Metronidazole covers anaerobic agent and protozoa
sometimes
Other antibiotics:
• Piperacillin, Tazobactam,
• Cefoxitin - 2nd Generation Antibiotics but have broad
spectrum coverage for both gram-positive and gram-
negative bacteria including anaerobic bacteria. But
instead of using this, ceftriaxone plus metronidazole
combination is used, unless allergic reaction appears
→ Dictum: Do not let the appendicitis rupture because sepsis occurs
immediately (after 1 day)
Rebound tenderness
● Roving sign
Low grade fever
● 38-38.5 C
● More than 38.5 is indicative of sepsis due to rupture
Elevated WBC
● More than 20,000 wbc/mm
Psoas Sign
● Patient is in Lateral position with flexed hips
● The patient cannot kick because it feels like there is
stretching in lower abdominal area and there is increasing
pain
Decreased or absent bowel sounds
● Due to inflammation
● Paralytic ileus is expected so abdominal distension is
present. Distension is due to relaxed bowel that occupied
space. Recall that stomach muscles have rugae, which
means that they only take up small amount of space
during rhythmic contractions. Once it is relaxed, it will
occupy space, thus abdominal distension every time
paralytic ileus is experienced.
MANAGEMENT
o Bedrest is necessary to provide comfort to
patient
o Put patient in NPO because patient is expected
to be subjected to surgery (6-8 hrs prior to
surgery)
• Relieve pain
o by using cold applications (cold compress over
the abdomen)
• Avoid factors that will increase peristaltic movement that
prompts the rupture of the appendix
o e.g heat applications over the abdomen, giving
laxatives, and doing enema [Rationale: Giving
enema = giving pressure to the abdomen leads
to rupture of the appendix]
• IVF Therapy to maintain fluid-electrolytes balance
• Antibiotic Therapy
o Cefuroxime (any brand) IV and oral.
o For ruptured, combination of Ceftriaxone [q8] and
Metronidazole [q6] (Ofloxacin [q12] is replacement
for Metronidazole)
• Surgery
o Laparoscopic appendectomy
APPENDECTOMY
• Spinal Anesthesia
o Place patient flat on bed 6-8 hours
QUESTION:
WHY DO WE PUT PATIENT FLAT ON BED AFTER THE INDUCTION
OF THE SPINAL ANESTHESIA?
ANSWER:
Avoid spinal headache. Spinal headache happens when there is a
leakage of CSF.
Nursing Trend: Patient flat on bed are no longer practiced due to thin
needles [thinner than hair] used by anesthesiologists which dramatically
minimizes the chances of CSF leakage.
● Monitor for return of sensation in the lower extremities
● NPO until peristalsis returns
● Usually, we ask if the patient has already defecated or
"umutot”
● However, even though the patient hasn’t “utot” yet, still
look and monitor for the peristaltic movement by
auscultating the abdomen in the 4 quadrants including the
center, 1-minute each quadrant making the auscultation in
5 full minutes.
● Ambulation after 24 hours
● Why does the patient need to walk after 24 hours?
● Since ambulation promotes circulation and wound
healing. Also, a patient can develop postop adhesion due
to prolonged bed rest as well as MI, stroke or pulmonary
embolism which are the common causes of death among
patients who are confined in bed for a long period of time
and then suddenly stands up during discharge.
▪ It is the nurse's fault because they allowed
the patient to be confined in bed for a long
time, knowing that it is not a stroke patient
or disabled.
▪ Always encourage patients to do
ambulation post-surgery as long as there is
no contraindication to improve circulation
and limit the occurrence of stroke, MI, and
pulmonary embolism.
▪ If not necessary or there are no indications,
a bedside commode and insertion of a
urinary catheter are not advised.
▪ Encouraging ambulation in patients who
have undergone abdominal surgery is the
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 hardest because the area that needs to be
monitored is extensive (more prone to
dehiscence and evisceration).
• If appendicitis ruptured
o Management (E.g., for patient who have undergone
exploratory laparotomy due to ruptured appendicitis)
▪ An abdominal binder or use a pillow to
apply a little pressure for a patient who
fears dehiscence
▪ Break in suture is likely only if there is an
infection because bacteria secrete a
specific enzyme that makes the suture
fragile
▪ Gradual position changes to avoid
hypotension
▪ Lying --> sitting --> dangling the feet -->
standing at the bedside --> ambulation
▪ Ask the pt if they are feeling dizzy when you
elevate the head of the bed to a sitting
position. If not, check the vital signs. If bp is
normal, advise to sit on the bed and dangle
their feet.
▪ If there is no dizziness or blurring of vision,
advise to stand up with the support of the IV
pole; if it’s okay again, do ambulation
▪ Technique: Tell the pt about possible
adhesions that may cause them to undergo
another surgery to repair it (adhesiolysis)
because apart from circulation problems
(e.g., DVT), post-op adhesions are
common if there is abdominal manipulation
▪ If there are post-op adhesions, pt must
come back for adhesiolysis. Magdidikit dikit
yung intestines kapag may adhesions
causing obstruction. This happens when pt
is in a particular position for a prolonged
period of time. (For example, bedridden
patients. That’s why we encourage them to
AMBULATE)
• Peritonitis -> Penrose drains
o If pt develops peritonitis we are expecting an
output hence a penrose drain is used to collect
the fluids coming out of the peritoneum. It is very
important to document the I&O whenever there
is drainage (whether it is a penrose, jackson-
pratt, hemovac, etc)
o There are indications that need to be observed
when removing a drainage because it cannot
stay inside the pt’s body because it is considered
foreign, and the nurse’s assessment and
monitoring are important to the doctors to decide
whether the drainage must be removed or not. If
the I&O is less than 50cc x 3days that is the time
the doctors will decide to remove the drainage to
allow the incision to heal completely. If the
output is more than 50cc the body would have a
hard time absorbing, leading to an infection.
• Semi-fowler's position
o After 6-8 hours, the patient must be positioned
into a semi-fowler's or high-fowler's position to
localize the inflammation within the pelvic area.
(kasi pag naka-flat lang sya sa bed, aakyat yung
inflammation sa upper organs)
• Resume all normal activities within 2 to 4 weeks
→ peritoneum usually drained with the insertion of a
QUESTION: Once the appendix is inflamed, is there an estimated
hour or day before it ruptures?
ANSWER: There’s none. It depends on the individual and the
bacteria present inside the appendix. (e.g., there are patients who
experienced pain in the morning and immediately ruptured in the
evening.). There’s no exact data that gives information about the
exact time of when the appendix will rupture from the early stage.
Be careful on the assessment of the history and clinical findings on
the abdominal manipulation together with the diagnostic
procedures.
QUESTION: Do we use CT scan?
ANSWER: Yes, but usually only in rich countries and hospitals
because it is more accurate. While in government hospitals,
ultrasound is typically used but it is not that certain. We still need
congruency of the data (from the history, clinical findings,
laboratory and diagnostic results)
PERITONITIS
• Inflammation of the peritoneum
o Not a disorder but a manifestation or
consequences of a certain pathologic conditions
CAUSES
● Ruptured appendix
● Perforated peptic ulcer
● Bacterial invasion
● Diverticulitis
● Pelvic inflammatory disease
● Urinary tract infection or trauma
● Bowel obstruction
● Liver disease
ASSESSMENT
1. Abdominal guarding and rigidity
2. Abdominal distention
3. Paralytic ileus
o To diagnose, get a stethoscope and listen to the
bowel sounds. If there is an absence of bowel
sounds within full 5 minutes, suspect that there
is paralysis ileus.
4. Fever
o As high as 40 or 41 degrees Celsius
5. Elevated WBC
o 20,000 or higher
6. Nausea and vomiting
7. WOF early s/sx of shock
o Tachycardia (increased heart rate)
o Tachypnea (increased respiratory rate)
o Oliguria (leak of fluid secondary to the conditions
because the body is trying to conserve the fluid
to have a proper circulation. That’s why the
kidneys are deprived to receive blood)
o Restlessness (deprived oxygen in the brain)
o Weakness
o Pallor
o Diaphoresis
NOTE: All kinds of shock will end up into septic shock
especially in this kind of condition
MANAGEMENT
• Monitor VS, I&O
• NGT
o If there is abdominal distention, in able for us to
relieve the abdominal compressions, NGT insertions
are done.
• Bed rest in Semi-Fowler’s position
• Encourage deep breathing exercises
• Peritoneal lavage with warm saline
o We do lavage, and removal of the fluids into the
drainage tube. Doctors do it with a blind approach,
but it should be guided by Ultrasound. It could be
done at the bedside. For example, 3000 mL of water
inside the pt, we can drain 500 mL initially as we
cannot drain it full 3000 mL, remember that our body
maintains its homeostasis. It is drained little by little
and does not disrupt homeostasis.
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 o Every time we do that, we must monitor fluid and
electrolytes and do colloid replacement as
necessary. If there is no need for you to do a
replacement of blood product. Remember, in
replacement or into the support of the intravascular
compartment, the content of blood is not all blood
components, and there is a fluid component. If it
empties because of the leak, possibly you will have
shock because the volume does not have the right
amount of fluid in your veins. So, we have to replace
what is necessary.
o If fluid, it can be replaced by necessary fluid. If blood,
we can actually do replacement of colloid or blood
product. But of course, colloid replacements have
implications. While the crystalloid drains out fast in
the body.
o Plain NSS OR Plain LR to support intravascular
compartment. You do not use Lactated Ringers
because every time that you develop decrease into
the intravascular volume, you also develop
hypovolemic shock from aerobic metabolism to
anaerobic metabolism, so you will have many lactic
acids inside the body. Lactated ringers are converted
to lactic acid later on therefore, the environment of
body will be highly acidotic. We do not want that, so
we do replacement of fluids.
o For blood replacement, we do blood transfusions to
the pt.
o Crystalloid - IV fluid
o Colloid - Histerine and Albumin (has big molecules
but once used 2-3 L of colloid, it can damage kidney,
that’s why after giving colloid, patient’s kidney should
be evaluated in the long run).
• Insertion of drainage tubes
• Fluid, electrolyte and colloid replacement
• Antibiotics
• TPN Solutions