College of Nursing

Telephone No. (043) 723-0706 loc. 109/110

Lyceum of the Philippines University – Batangas

College of Nursing

Surgical Ward Clinical Duty at

Batangas Medical Center

Case Analysis

of

RUPTURED APPENDICITIS

By:

Espiritu, Leslee Amor

BSN IV-2 D

November 9, 2023

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TABLE OF CONTENTS

I. Patient’s Profile 3

II. Clinical History 4

III. Review of Systems 5

IV. Physical Assessment 6

V. Anatomy and Physiology 8

VI. Pathophysiology 10

VII. Laboratory and Diagnostic Examinations 11

VIII. Drug Study 13

IX. Nursing Care Plan (FDAR) 28

X. References 20

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I. Patient’s Profile

PATIENT’S PORTFOLIO

Name R.V.
Address Looc, Mindoro

Age 29 Gender Phone Number: -

Religion R/C Status Birth date: 04/06/1994
Ethnic Place of birth: Looc, Mindoro
Background
Educational Occupation: Rice Farmer Primary or Secondary Language:
Level: High Tagalog and English
School
Support Provider of history: Patient and Relative (Mother)
Person
Hospital No. -
Diagnosis Admitting Ruptured Appendicitis
Diagnosis
Final Diagnosis -

Physician: Dr. Nikko Valentino M. Magalona

Reason for Admission / Seeking Health Care:
4 days prior to admission, the patient felt epigastric pain with pain scale of 10/10. Consult was
done at Lubang District Hospital ER, and was given Omeprazole with some relief of pain. In
the afternoon, epigastric pain shifted to infraumbilical area with radiation to back with right
lower quadrant pain with pain scale of 10/10. The patient was advised to be admitted to
hospital of choice to tertiary hospital.

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II. Clinical History

Name Patient RV Age 29

Diagnosis Ruptured Appendicitis Hospital No.
Ward/RM Surgical/RM8A

CLINICAL APPRAISAL

History of • Four days prior to admission, the patient felt epigastric pain of 10/10.
Present Health
Concern Consult was done at Lubang District Hospital ER and was given
Omeprazole with some relief of pain. In the afternoon, epigastric pain
shifted to infraumbilical area with radiation to back with right lower
quadrant pain with pain scale of 10/10. The patient was advised to be
admitted to hospital of choice to tertiary hospital.
Past Health Past Medical & Surgical History
History • No known allergies to food, medication, or vaccination.

• The patient has no history of other diseases.

• No maintenance medication.

• No other history of surgery.

Family History
• The patient has no family history of hypertension, diabetes, cancer, or
other diseases.
Lifestyle and • Has good relationship with his family.
Health
Practices • Diet includes vegetables, fruits, and meat on occasional times.

• Consumes alcohol on an occasional basis.

• Does not take illicit drugs.

• Does not smoke cigarette.

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III. Review of Systems

Name Patient RV Age 29

Diagnosis Ruptured Appendicitis Hospital No.
Ward/RM Surgical/RM8A

CLINICAL APPRAISAL
Review of General condition
Systems for • Patient is sitting on bed, and was conscious, alert, cooperative, oriented to
Current Health time, place, and person, and not in distress.
Problem • There was no puffiness in his face. His palm was warm, no clubbing, no
fungal infection between the fingers.
• No edema noted.
• No fungal infection in the toes.
Head & Neck
Inspection
• Palpebral conjunctiva is pink with white sclera, no sign of jaundice.
• Lips is dry and has cracks.
• Thyroid gland are not enlarged.
Cardiovascular System
Palpation
• The peripheral pulse was present and appreciated.
Auscultation
• Heart sounds are at a regular rate and rhythm, no murmur.
Respiratory System
Inspection
• The chest moved symmetrically with respiration with no deformity seen.
Auscultation
• Breath sounds are clear.
Abdominal Examination
Inspection
• On examination, the abdomen was flat
• The umbilicus was centrally located.
Auscultation
• With normal active bowel sound.
Palpation
• Upon palpation, there tenderness in the hypogastric area and right lower
quadrant.
Extremities
Inspection and Palpation
• Skin is warm to touch on upper and lower limbs.
• Both upper extremities look weak.
Central Nervous System
• Mental status: He was alert and conscious, orientated to time, place and
person. His memory function was intact. He was not in a state of confusion.
Developmental Stage 6: Intimacy vs. Isolation
Level
The objective for 20- to 30-year-olds is to form an intense, lasting relationship or a
commitment to another person, a cause, an institution, or a creative effort (Murray,
Zentner, & Yakimo, 2009).

Achievement of the task results in the capacity for mutual love and respect between
two people and the ability of an individual to pledge a total commitment to another.

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The intimacy goes far beyond the sexual contact between two people. It describes a
commitment in which personal sacrifices are made for another, whether it be another
person or, if one chooses a career or other type of cause or endeavor to which an
individual elects to devote his or her life.

Intimacy is achieved when an individual has developed the capacity for giving of
oneself to another. This is learned when one has been the recipient of this type of
giving within the family unit.

IV. PHYSICAL ASSESSMENT

Name Patient RV Age 29

Diagnosis Ruptured Appendicitis Hospital No.
Ward/RM Surgical/RM8A

General Survey
• Patient is sitting on bed, and was conscious, alert, cooperative, oriented to time, place, and
person, and not in distress.
• There was no puffiness in his face. His palm was warm, no clubbing, no fungal infection between
the fingers.
• No edema noted.
• No fungal infection in the toes.

PHYSICAL ASSESSMENT
Date November 6, 2023
Vital Signs BP – 120/80
HR – 69
RR – 20
Temp – 37.7
O2 sat – 96%
Body Parts Methods Findings Analysis
Head & Neck Inspection • Palpebral Normal – indicates
conjunctiva is pink normal blood flow and
• Conjunctiva with white sclera, no liver problem
no sign of jaundice.

• Mouth • Lips is dry and has Abnormal – may indicate

cracks dehydration

Normal – Landmarks are

• Thyroid • Thyroid gland are
positioned midline
not enlarged.
Cardiovascular System

• Peripheral • The peripheral Normal – the rate should

pulses Palpation pulse was present be 60-100 bpm.
and appreciated.

• Heart Auscultation • Heart sounds are Normal - the rate should

at a regular rate be 60-100 bpm.

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and rhythm, no
murmur.

Respiratory System
• Chest Inspection • The chest moved Normal – chest is
symmetrically with midline at lateral line
respiration with no
deformity seen.
• Breath sounds Auscultation • Breath sounds are Normal – Breath sounds
clear. should be clear and no
adventitious sounds

Abdominal Inspection • Abdomen was not

Examination distended. Normal – abdominal
• Abdomen • umbilicus was should not be distended
centrally located.

Auscultation • With normal active Nomal – borborygmi

bowel sound. sound is normal with 5–
30 bowel sounds per
minute
Palpation • Upon palpation, Abnormal -tenderness
there tenderness in may indicate underlying
the hypogastric condition
area and right
lower quadrant.
Extremities Inspection and Normal - Increased
Palpation • Skin is warm to blood flow to an area of
touch on upper and the body can make it
lower limbs feel warm

• Both upper limbs Not Normal – weakness

look weak. may indicate underlying
condition
Central Nervous Inspection • Mental status: He Normal – normal state
System was alert and of consciousness;
conscious, comprises state of
orientated to time, wakefulness,
place and person. awareness, and
• His memory alertness
function was intact.
He was not in a
state of confusion

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V. ANATOMY AND PHYSIOLOGY

The appendix
originates from the
posteromedial aspect of
the cecum. It is supported
by the mesoappendix, a
fold of mesentery which
suspends the appendix
from the terminal ileum.

The position of the free-end of the

appendix is highly variable and can
be categorized into seven main
locations depending on its
relationship to the ileum, caecum or
pelvis. The most common position is
retrocecal. They may also be
remembered by their relationship to a clock face:
• Pre-ileal – anterior to the terminal ileum – 1 or 2 o’clock.
• Post-ileal – posterior to the terminal ileum – 1 or 2 o’clock.
• Sub-ileal – parallel with the terminal ileum – 3 o’clock.
• Pelvic – descending over the pelvic brim – 5 o’clock.
• Subcecal – below the cecum – 6 o’clock.
• Paracecal – alongside the lateral border of the cecum – 10 o’clock.
• Retrocecal – behind the cecum – 11 o’clock.

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The appendix is derived from

the embryologic midgut.
Therefore, the vascular supply is
via branches of the superior
mesenteric vessels.
Arterial supply is from the
appendicular artery (derived
from the ileocolic artery, a
branch of the superior
mesenteric artery) and venous
drainage is via the corresponding appendicular vein. Both are contained within the
mesoappendix.
Sympathetic and parasympathetic branches of the autonomic nervous system
innervate the appendix. This is achieved by the ileocolic branch of the superior mesenteric
plexus. It accompanies the ileocolic artery to reach the appendix.

Lymphatic fluid from the appendix drains

into lymph nodes within the mesoappendix
and into the ileocolic lymph nodes (which
surround the ileocolic artery).

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VI. PATHOPHYSIOLOGY

A blockage in the lining of the appendix is the likely cause of appendicitis. This
blockage can cause an infection. The bacteria then multiply quickly, causing the
appendix to become inflamed, swollen and filled with pus. If not treated right away,
the appendix can break rupture. In established appendicitis, the abdomen is most
tender at McBurney’s point – situated one third of the distance from the right
anterior superior iliac spine to the umbilicus. This corresponds to the location of the
base of the appendix when it lies in a retrocecal position.
The etiology of appendicitis depends on age. In the young, it is mostly due to
an increase in lymphoid tissue size, which occludes the lumen. From 30 years old
onwards, it is more likely to be blocked due a fecalith.
Initially, pain from the appendix and its visceral peritoneum is referred to the
umbilical region. As the appendix becomes increasingly inflamed, it irritates the
parietal peritoneum, causing the pain to localize to the right lower quadrant.
If the appendix is not removed, it can become necrotic and rupture, resulting
in peritonitis (inflammation of the peritoneum).

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VII. LABORATORY AND DIAGNOSTIC EXAMINATIONS

Name Patient RV Age 29

Diagnosis Ruptured Appendicitis Hospital
No.
Ward/RM Surgical/RM8A

LABORATORY EXAMINATION
Date November 5, 2023
HEMATOLOGY

Laboratory Exam Normal Values Result Significance

Complete Blood Count

Erythrocyte 4.6 – 6.2 x 10^12/l 4.57 Within Normal Range

Hgb 140 - 180 gms/l 98 Below Normal Range –

low amount of iron-rich
protein in RBC
Hct 0.40 – 0.54 vol % 0.295 Below Normal Range –
insufficient measure of portion
in blood
Leukocyte 4.5 – 11.0 x 10^9/L 19.22 Above Normal Range –
indicates that the patient is
fighting an infection
Neutrophil 0.37-0.72% 0.848 Above Normal Range –
indicating that the body is
fighting a bacteria, fungi, or
foreign debris
Lymphocyte 0.20-0.50% 0.071 Below Normal Range –
indicating that the patient is at
risk for viral infection
Monocyte 0.0-0.014% 0.072 Above Normal Range –
indicating possible enhanced
mobilization from the bone
marrow or increased
monopoiesis
Eosinophil 0.0-0.6% 0.004 Within Normal Range

Basophils 0.0-0.01% 0.005 Within Normal Range

Thrombocyte 150-400 x 10^9/L 412 Above Normal Range –

indicates that the patient has
risk for blood clot
MCH 27.0-31.0 pg 21.4 Below Normal Range –
indicates the body has low
hemoglobin
MCV 80.0-96.0 fL 64.6 Below Normal Range –
indicates smaller size of RBC
MCHC 0.32-036 0.33 Within Normal Range

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RDW 11.5-14.5% 15.9 Above Normal Range –

indicates nutria t or iron
deficiency
MPV RNF 9.4 ---

ABO Type “B”

RH Type Positive

Prothrombin Time
Patient 11.5-16.0 sec 17.2 Above Normal Range –
indicates longer time to
make blood clot
Activity 70-100% 76.9 Within Normal Range
INR 0.80-1.95 1.16 Within Normal Range
Partial Thromboplastin
Patient 26-35 sec 34.7 Within Normal Range
CLINICAL CHEMISTRY
Blood Urea Nitrogen 2.1 – 7.1 mmol/L 6.5 Within Normal Range
Creatinine 58 – 110 umol/L 56 Below Normal Range –
indicates kidney problems
Sodium 135 – 148 mmol/L 138.5 Within Normal Range
Potassium 3.5 – 5.5 mmol/L 4.36 Within Normal Range

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VIII. Drug Study

Drug Name Classification and Indication Contraindication Side Nursing Monitoring
Mechanism of Effects/Adverse Responsibilities Parameters
Actions Reaction
Brand Ketorolac belongs to Ketorolac is >Contraindicated Side Effects >Assist patient >Blood pressure
Name: the class of non- indicated for in patients with >Drowsiness when mobilizing. >Serum creatinine
Ketorolex steroidal short-term known >Dizziness >Assist patient to >BUN
antiinflammatory management hypersensitivity to >Blurred vision comfortable >Urine output
agents (NSAID) with of moderate ASA or NSAIDs. >Headache position. >CBC and Platelet
Generic antipyretic and to severe >Current active >Nausea >Provide >Observe for signs
Name: analgesic properties. pain that bleeding inhibits >Stomach pain or medication as of gastrointestinal
Ketorolac It suppresses the requires platelet discomfort prescribed. bleeding.
synthesis of analgesia at aggregation and >Indigestion >Determine rights >Liver Function Tests
prostaglandins E the opioid platelet >Vomiting of medication >Weight
Dosage: and F, thus, level. thromboxane >Ringing of the ears administration >LOC
300mg producing production >Dyspnea before giving the
peripherally leading to >Edema medication.
mediated analgesia, prolonged >Inform physician
Route: IV and reducing the bleeding time. Adverse Effects of the signs and
sensitization of pain >History of severe >Rashes symptoms of
receptors after acute or fatal >Breathlessness hepatotoxicity and
Frequency: trauma. anaphylactic-like >Bloody or black kidney toxicity.
Q8 reactions to tarry stools
NSAIDs. >Chest pain
>For patients who >Slurred speech
used NSAID in >Dark colored urine
the last 6 hours. >Sudden weight
gain
>Hematuria
>Dematitis

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Drug Name Classification Indication Contraindication Side Nursing Monitoring

and Mechanism Effects/Adverse Responsibilities Parameters
of Actions Reaction
Brand Ciprofloxacin It is indicated for the Ciprofloxacin is Side Effects >Advise patient >Blood pressure
Name: Hydrochloride treatment of: contraindicated >Agitation to take drug with >Potassium
Ciproxin belongs to a class >Acute sinusitis for patients with >Headache or without food at >Blood glucose
of >Prostatitis hypersensitivity to >Restlessness the same time level
fluoroquinolones >Intra-abdominal drug or other >Orthostatic each day. >LOC
Generic and anti-infective. infections fluoroquinolones hypotension >Advise patient >Intake and
Name: It inhibits bacterial >Febrile neutropenic and concomitant >Nausea and not to take drug Output
Ciprofloxacin DNA synthesis by patients administration of vomiting with dairy >ROM
Hydrochloride inhibiting DNA >Gonorrhea tizanidine. >Diarrhea products or
gyrase in >Infectious diarrhea >Constipation calcium-fortified
susceptible gram- >Inhalation anthrax >Discomfort juices alone or
Dosage: negative and (post-exposure) >Blurred vision with caffeinated
400mg gram-positive >Infections of the lower >Hyperglycemia beverages.
organisms. respiratory system >Hyperkalemia >Monitor for
>Nosocomial signs of burning,
Route: IV pneumonia Adverse numbness, or
>Typhoid fever Reaction tingling in hands
>UTI >Delirium or feet, yellow
Frequency: >Acute otitis externa >Peripheral eyes or skin,
Q8 >Bacterial conjunctivitis Neuropathy unusual
cause by susceptible >Anaphylaxis tiredness,
organisms >Renal calculi persistent
>Corneal ulcers caused >Hepatic diarrhea, rash,
by susceptible necrosis tendon pain,
organisms >Myalgia swelling, or
>Rash inflammation,
>Toxic epidermal and report it to
necrolysis the physician.

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Drug Name Classification Indication Contraindication Side Nursing Monitoring

and Mechanism Effects/Adverse Responsibilities Parameters
of Actions Reaction
Brand Name: Ondansetron It is indicated for >Contraindicated >Rash >Encourage >Intake and
Emodan belongs to the management of for patients with >Pruritus patient to hydrate Output
class of serotonin nausea and hypersensitivity to >Headache adequately. >Blood pressure
Generic Name: (5HT3) vomiting in the drug. >Diarrhea >Assist patient >Heart rate
Ondansetron antagonists and cytotoxic >Constipation when mobilizing. > AST
antiemetics. chemotherapy, >Chest pain >Provide skin >ALT
Ondansetron is a and for prevention >Arrhythmia care to the >LDH
Dosage: 4mg potent, highly and treatment of >Hypotension & patient. >r-ALT
selective 5HT3 post-op nausea bradycardia >Inform the >Total bilirubin
receptor- and vomiting. >Transient patient of the side
Route: IV antagonist. Its increase in AST, effects and
precise mode of ALT, LDH, r-ALT adverse reaction
action in the & total bilirubin of the medication.
Frequency: STAT control of nausea >Visual >Advise patient to
and vomiting is disturbance rest.
not known. >Vertigo >Provide a rest
conducive
environment.

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Drug Name Classification Indication Contraindication Side Nursing Monitoring

and Effects/Adverse Responsibilities Parameters
Mechanism of Reaction
Actions
Brand Name: Omeprazole Omeprazole is >Omeprazole is >Headaches >Check the >Vital Signs
Prilosec belongs to a used to treat a contraindicated >Stomach pain patient's medical >GI
class of Proton number of for patients with >Diarrhea background, Symptoms
Generic Name: Pump Inhibitor stomach hypersensitivity >Flatulence including any >Vitamin B12
Omeprazole (PPI). problems that are to omeprazole or >Vitamin B12 allergies and levels
Omeprazole caused by acid, other PPIs. deficiency medications they >Magnesium
Dosage: works by such as: >Concomitant >Hypomagnesemia are currently taking. levels
40mg blocking the Gastroesophageal use with >Bone fractures >Assist patient >Kidney
hydrogen- Reflux Disease medications that >Kidney toxicity when moving. function
potassium (GERD) causes are sensitive to >Provide
Route: IV adenosine stomach acid to gastric pH (e.g., nonpharmacological
triphosphatase back up into the atazanavir, pain management.
Frequency: OD (H+/K+ food pipe. ketoconazole).
ATPase) pump >Severe damage
in the to the liver.
gastric parietal
cells. This
makes the
stomach make
less acid.
Gastric acid
production
drops by a lot
as a result of
this action.

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Drug Name Classification Indication Contraindication Side Nursing Monitoring

and Mechanism Effects/Adverse Responsibilities Parameters
of Actions Reaction
Brand Name: Paracetamol It is indicated for >Paracetamol is >Anemia >Observe the >Serum
Ifimol IV belongs to a class the relief of minor contraindicated to >Leukopenia rights in giving paracetamol
of Analgesics and aches & pains patients who have >Neutropenia medication. levels in patients
Generic Name: Antipyretics. It such as hypersensitivity to >Jaundice >Assess the with hepatic
Paracetamol produces headache, the drug. >Hypoglycemia patient is not disease during
analgesia by backache, >Use cautiously >Rash taking any other prolonged use.
Dosage: blocking pain menstrual in patients with >Urticaria medication >Blood glucose
600mg impulses by cramps, muscular long term alcohol containing level
inhibiting aches, minor use because paracetamol. >WBC
synthesis of arthritis pain, therapeutic doses >Evaluate >LFT
Route: IV prostaglandin in toothache & pain cause therapeutic
the CNS or of associated with hepatotoxicity. response.
Frequency: Q6 x other substances common cold and >Inform the
3 doses that sensitize pain flu. physician if
receptors to symptoms
stimulation. The persist for more
drug may relieve than 3 days.
fever through >Provide skin
central action in care to the
the hypothalamic patient.
heat regulating
center.

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IX. Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Acute pain Short-term Goals Independent Nursing After 8 hours of
Data related to After 8 hours of Action nursing
"Masakit dito sa operation of nursing interventions, >Respond immediately to >If the patient is interventions, the
pinag- the appendix the patient will be reports of pain. experiencing an altered patient:
operahan.” As as evidenced able to: passage of time due to pain, >Reported pain is
verbalized by by pain scale >Report pain is fear of delayed pain relief controlled with pain
the patient of 8/10, facial relieved or controlled can exacerbate the pain scale of 1/10
>Pain Scale- grimace, and with pain scale lower experience. Prompt >Followed
7/10 abdominal that 3/10. responses to reports of pain prescribed
guarding >Follow prescribed reduce anxiety and promote pharmacological
Objective Data pharmacological trust. regimen and
>Facial grimace regimen. complied to
>Abdominal >Verbalize >Promote periods of rest >Use relaxation and medications.
guarding nonpharmacological for the patient. breathing exercises and >Verbalized
methods that provide music therapy. These understanding of
relief. techniques help produce a nonpharmacological
sense of tranquility for the methods that
Long-term Goals patient. provide relief.
During the patient’s
hospital stay, the >Remove the stimuli. >Divert away the patient’s Short-term goals
patient will be able to: attention from the painful met.
>Demonstrate use of stimuli using effective
relaxation skills and distractors that can reduce Also, during the
diversional activities. the pain the patient patient’s hospital
>Verbalize sense of perceives. stay, the patient:
control of response to >Demonstrated use
acute situation and >Monitor for side effects of >Monitoring for side effects of relaxation skills
positive outlook for medications. is also essential to maintain and diversional
the future. the patient’s comfort and activities.
safety.

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>Apply a cold compress.
> Educate the patient
about pain management.
> Encourage feedback
from the patient.
Dependent Nursing
Interventions
>Administer Ketorolac
300mg IV Q8.
Collaborative Nursing
Intervention
>Refer to physical
therapists.
>A cold pack could be >Verbalized a
helpful as it promotes sense of control of
vasoconstriction, thus response to acute
reducing pain. situation and
positive outlook for
> Patients can help the future.
effectively manage their pain
with additional knowledge of Long-term goals
when to request pain met.
medication to maximize its
effectiveness and prevent
severe pain episodes.
> Feedback can assist the
care team in modifying and
improving pain control
strategies.
> Ketorolac is indicated for
short-term management of
moderate to severe pain that
requires analgesia at the
opioid level.
> Physical therapy could
ease the pain brought on by
illnesses, as well as injuries.
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XI. References
• Appendicitis: Causes, Symptoms, and Treatment. (2012, July 25).
Healthline. https://www.healthline.com/health/appendicitis#symptoms
• The Appendix - Retrocecal - Arterial supply - Appendicitis -
TeachMeAnatomy. (n.d.). Teachmeanatomy.info.
https://teachmeanatomy.info/abdomen/gi-
tract/appendix/#:~:text=The%20appendix%20is%20a%20narrow
• Appendicitis - Symptoms and causes. (n.d.). Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/appendicitis/symptoms-
causes/syc-20369543#:~:text=A%20blockage%20in%20the%20lining
• Kulvatunyou, N., Zimmerman, S. A., Joseph, B., Friese, R. S., Gries, L.,
O’Keeffe, T., Stroster, J. A., & Tang, A. L. (2019). Risk Factors for
Perforated Appendicitis in the Acute Care Surgery Era-Minimizing the
Patient’s Delayed Presentation Factor. The Journal of Surgical Research,
238, 113–118. https://doi.org/10.1016/j.jss.2019.01.031

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