GEORGE DEWEY MEDICAL COLLEGE

BSN – IV Ena Cecilia Evangelista Charmaine Kaye Gayacao Alexander von O. Schoppenthau

October 12, 2011 1 GEORGE DEWEY MEDICAL COLLEGE BSN – IV CASE PRESENTATION

Rebound tenderness may be present. the pain become more diffuse. nausea. In general a laxative should never be given when a person has fever. nausea or pain. Appendicitis is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity. Laxative administered in the instance may result in perforation of the inflamed appendix. it is therefore prone to become obstructed and is particularly vulnerable to infection (appendicitis). The appendix is a small fingerlike appendage about 10 cm (4 in) long. and teenagers more than adults. The appendix fills with food and empties as regularly as does the cecum. No definite functions can be assigned to it in humans. The disease is more prevalent in countries in which people consume a diet low in fiber and high in refined carbohydrates. attached to the cecum just below the ileocecal valve. It occurs most frequently between the age of 10 and 30. 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. The lower quadrant pain is usually accompanied by a low-grade fever. If the appendix curls around behind the cecum. pain and tenderness may be felt in the lumbar region. a 15 year old female was diagnosed of an acute appendicitis. About 7% of the population will have appendicitis at some time in their lives. If the appendix has ruptured. Constipation can also occur with an acute process such as appendicitis. abdominal distention develops as a result of paralytic ileus. Our patient manifested these signs and symptoms:  Rebound tenderness on the Right lower quadrant of the abdomen  Continuous pain  Anorexia  Low grade fever – 38 ºC  Nausea and vomiting  Slightly Weak  Facial grimace and guarding position Complications that could manifest:  Possible rupture of appendix therefore leaking the contents to the peritoneal cavity causing peritonitis  Abscess  Constipation  Septicemia 2 GEORGE DEWEY MEDICAL COLLEGE BSN – IV CASE PRESENTATION . local tenderness is elicited at Mc Burney’s point applied located at halfway between the umbilicus and the anterior spine of the Ilium. and often vomiting. males are affected more than females. Rovsing’s sign maybe elicited by palpating the left lower quadrant. In up to 50% of presenting cases.Introduction Patient A. According to (Brunner and Suddarth’s 2010) Appendicitis is the inflammation of the vermiform appendix. and the patient condition worsens. because it is small. Loss of appetite is common.

23 cpm Patient’s History Clients Name: Patient X Age: 15y/o Sex: Female Referring Physician: Dr. Alangan Limay Bataan Birthday: December 08.Alcantara Chief Complaint: Pain at the Right lower quadrant History of Present Illness: 12 hours prior to admission patient is complaining of on and off abdominal pain Past Medical History: None Social History: the patient is a 3 year high school in Alangan Limay Bataan. and she mostly drinks carbonated beverages and always drink coffee every morning. 1995 Nationality: Filipino Religion: Roman Catholic Date of Admission: September 19.Alcantara Vital Signs: BP-100/70 mmHg T-38 ºC PR-105 bpm RR. Lopez Attending Physician: Dr. rd 3 GEORGE DEWEY MEDICAL COLLEGE BSN – IV CASE PRESENTATION . The patient said that she loves to eat meat rather than vegetables. drank alcohol or use drugs. She never smoked. She lives with her parents and sister.Demographic Data Clients Name: Patient X Age: 15y/o Gender: Female Civil Status: Single Address: Camia St. 2011 Chief Complaint: Pain at the Right lower quadrant Attending Physician: Dr. The patient’s hobby is to read pocket books and watch television.

Easiest way to learn things is by visual learning or watching. Speaks tagalong only. Walks around with friends or reads books during spare time. rarely once/3days. Sleep Rest Has 6-10 hours of sleep at school days. Attention span is satisfactory. Eats 3 times a day. Nutritional Metabolic Daily food intake is mostly meat. Exercise every morning in school for 10 mins everyday. Pain COLDSPA (Weber. Has difficulty in logical aspects. Takes a bath everyday with grooming. Her sister mostly makes her angry and annoyed. Does house chores everyday when going home if available. sometimes 4 times. the actions made it worse as claimed. eats vegetables and fruits rarely (once every 2 weeks as estimated by the client). rice and bread (“pandesal”) in the morning. 4 GEORGE DEWEY MEDICAL COLLEGE BSN – IV CASE PRESENTATION . A – Associated factors: fever and rebound tenderness. Has dry skin. With a straight body posture and normal walking gait. No supplementary intake nor vitamins. Eye contact is inconsistent due to pain. The client has many friends. 2011 afternoon. Self perception/Self concept She describes herself as a source of happiness to her family. Appetite was always good and sometimes with diet restrictions. Elimination Defecates 1-2 times/2days. D – duration: nonstop.. Snacks include mostly junk foods and carbonated drinks in school. Cognitive-perceptual Has ease on decision making for important things. Voice and speech pattern is slightly slurred and weak due to pain.7/10 on September 18. Does exercise in school every morning. 2003): C – character: Continuous. The loss of her parents makes her fearful and depressed. O – Onset: September 17. P – pattern: from umbilical to mcburney’s point. Client is unrelaxed.and 10/10 upon admission. Attention span is satisfactory due to that she is distracted by pain. When first of the symptoms occurred she went to the quack doctor and did a massage on her abdomen. S – severity: pain scale of 5/10 on September 17. rarely are the sandwiches or any bread. Wakes up as early as 6am in the morning during school days. mostly in school. Family feels very worried about the client’s condition and more when we cited the complications that could happen. Activity Exercise Not easily fatigable.Gordon’s Functional Health Patterns Health Perception and Management Non-smoker. Role Relationship Has a nuclear type of family. Urinates 4-6 times per day. Daily fluid intake is 5-7 glasses every day. Wakes up but conditions body first before doing activities during school days. non-alcoholic and was not indulged into any drug addiction. Having problems in her academics makes her anxious like reporting and exams. L – location: Right lower quadrant of the abdomen. Prefers any kind of meat rather than fruits and vegetables. Feels good most of the times due to her mom. and 10-12 at weekends.

2011. Her hair color is black. Her body temperature is 38⁰C taken through axilla. Skin Patient has a brownish skin color. quantity is thick and textures brittle and evenly distributed. PR 105bpm. her mother’s appearance will help a lot. Eyes Patient eyes are straight normal. When tensed. Eyebrows are thin. Physical Assessment General Appearance Patient has small body built. place and person. To finish her studying is very important. 5 GEORGE DEWEY MEDICAL COLLEGE BSN – IV CASE PRESENTATION . sore and lice. This is an effective closure and the blink response is bilateral. Her eyeballs are symmetrical. has a pink nail bed and capillary refill is within 3 seconds Head and Face The patient skull shape is proportionate to body size. She is cooperative and uses simple words in communicating. It is smooth and pink. Value-Belief Pattern Does not get the most things that she wants from life. Nails Patient nail plate is convex. Has dysmenorrhea sometimes. Pupils are equal round reactive to light and accommodation. Her face and facial movements are symmetrical. She has no obvious physical deformities. No presence of flaking. LMP was on September 3. She is oriented to time. Very religious (Roman Catholic) as taught by her mother and father. Problems are solved through decision making and most of them succeed with the help of her mom and sister. Has dry skin. Mental Status Patient is conscious and coherent.Sexuality Reproductive Had no relationship to males up to now. She also has a pink palpebral conjunctiva. RR 23cpm. Sometimes religion helps when problem arises according to her. Coping Stress Tolerance Her mom is her sole problem solver and emotional supporter.

Breast and Axilla Patient’s breast is symmetrical. Lymph nodes are not palpable. Gag reflex is present Neck Patient has a supple neck. Neck muscles are equal in size. 6 GEORGE DEWEY MEDICAL COLLEGE BSN – IV CASE PRESENTATION . Upper extremities Patient is able to move her upper extremities and has a normal muscle tone. Chest and Lungs Both anterior and posterior lung expansion was symmetrical Abdomen Her abdomen is normal racial tone. Septum is located midline. and thyroid gland is not palpable. Peripheral pulses are normal. Nasal cavity was moist and no discharges. Lymph nodes are not palpable. Pharynx Uvula is located midline and mucosa is pink. Lower extremities Patient is able to move and her lower extremities and has a normal muscle tone. There is no deformity no edema and cyanosis. Pinna recoils when folded. Lymph nodes are not palpable. Bowel sounds – growl due to hunger. She is responsive to normal voice. Mucosa is pink and both are patent. Lymph nodes are not palpable. Nose Patient’s nose has a normal racial tone. Peripheral pulse is normal. Sinuses are non-tender. Her teeth were complete and gums were pink. Bladder is not distended and liver is not palpable. Mouth Patient’s lips and mucosa is pink. trachea is located midline.Ears Patient’s auricle has a normal racial tone and is elastic and symmetric. Tonsils and posterior pharynx are not inflamed.

the appendix is a conical diverticulum at the apex of the cecum.Anatomy and Physiology Appendix is a blind-ended tube connected and located near the junction of the small intestine and the large intestine. 7 GEORGE DEWEY MEDICAL COLLEGE BSN – IV CASE PRESENTATION . but with differential growth and distention of the cecum. The diameter of the appendix is usually between 7 and 8 mm. but can range from 2 to 20 cm. the appendix ultimately arises on the left and dorsally approximately 2. The appendix averages 10 cm in length. The appendix is fixed retrocecally in 16% of adults and is freely mobile in the remainder. It is located in the right lower quadrant of the abdomen. Its position within the abdomen corresponds to a point on the surface known as McBurney's point In infants. an arrangement that helps in locating th is structure at operation. The taeniae of the colon converge at the base of the appendix.5 cm below the ileocecal valve.

 Small intestine.  Sigmoid colon.  Ascending colon. Cecum six centimeters (cm) long and 7. Some of the non-pathogenic bacteria are also thought to aid in the digestion or absorption of essential nutrients.stores and expels feces. Pepsin digests protein.  Transverse colon. The predominance of nonpathogenic bacteria under normal conditions is thought to help prevent disease. Forms and stores feces. Peptidase digests proteins.5 cm wide  Appendix.reabsorbs some water and ions.feces are formed. it blind extension of posteromedial cecum. Often called the intestinal flora. Amylase digest polysaccharides Pharynx.mushy stool. but some biologist believes that the appendix serve as a sort of breeding ground for intestinal bacteria.  Anus. kills germ. breaks up food.  Descending colon.  Large intestine. Mucus protects gut wall.stores and churns food.moisten and lubricate food.HCL activates enzymes.completes digestion. Limited absorption.breaks up food particles Salivary glands.  Rectum. a community of various bacterial populations normally inhibits the colon. Amylase digests polysaccharide. most water.     Mouth. Absorbs nutrients.swallows Esophagus. It contains many lymphoid nodules and serves as bacterial reservoir of sorts.semi-formed stool.its function is not certain.watery stool. Also.  Cecum-marks the beginning of the large intestine and is basically a big pouch that receives waste material from the small intestine.transports food Stomach. Sucrase digests sugar. Mucus protects stomach wall.opening for elimination of feces 8 GEORGE DEWEY MEDICAL COLLEGE BSN – IV CASE PRESENTATION .

80 0.19.25-0.20 437x109/L B-positive Normal 120-150 gm/L 0.5 1.33 21.010 Negative Negative Negative 0-1 hpf Few Moderate HEMATOLOGY Result 109. X-ray had shown a fecalith occlusion on the vermiform appendix. 2011       Received patient lying on bed with ongoing IVF of D5LR 1L Vital signs taken and recorded Febrile Scheduled for appendectomy on (Wednesday) September 21.35-0.35 150-350x109/L CBC hemoglobin Hematocrit WBC Segmenters Lymphocytes Platelet count Blood typing X-ray A visual device using Roentgen radiation to outlined the organs and bones or other kind of mass.37-0. 2011 Needs attended Endorsed 9 GEORGE DEWEY MEDICAL COLLEGE BSN – IV CASE PRESENTATION .0x109/L 0.4 x 109/L 0.Laboratory Results URINALYSIS Color Transparency Reaction Specific Gravity Protein Sugar RBC WBC Epithetlial cells Amorphous urates Light Yellow Clear 6.85 0. Course in the Ward Sept.47 5.09/L 0.

H . O . Within 12 hrs after surgery you may get up and move around. You can usually return to normal activities in 2-4 weeks after appendectomy surgery.  Stitches are removed between fifth and seventh day.Medications such as Antibiotics (Cefoxitin.Discharge Planning M . D . To care wound perform dressing changes with antiseptics 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 (Dr. Cefuroxime) for infection must be taken strictly as how the doctor prescribed it even if feeling well already.Oral intake of Liquids or soft diet until the infection subsides. T . E .Help wound healing for faster healing and to avoid complications. Soft diet is low in fiber and easily breaks down in the gastrointestinal tract.To inform the physician of any increase in the intensity and continuing pain or fever and other complications after surgery is a must.Document bowel sounds and the passing of flatus or bowel movements (these are signs of the return of peristalsis). Alcantara).Early ambulation. this may indicate an abscess or wound dehiscence. 10 GEORGE DEWEY MEDICAL COLLEGE BSN – IV CASE PRESENTATION .

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master Your Semester with a Special Offer from Scribd & The New York Times

Cancel anytime.