Pinky Assessment Part2

II.
Assessment
PHYSICAL ASSESSMENT
General Survey
Received lying on bed conscious, responsive and coherent. Fairly groomed. With
clean and intact top dressing at right lower quadrant. With IVF #4 PNSS 1L infusing
well at the right dorsal metacarpal vein regulated at 30 gtts/min. On NPO. Capillary
refill of 2 sec.
Vital Signs
Date
06-26-13
Shift
7-3
Time
8:00am
12:00p
CR
89
90
PR
88
92
RR
18
19
BP
129/83
130/80
Temp.
37.4
37.0
m
Skin
Brown skin generally uniform in color in areas except in areas exposed in the sun
No jaundice
Normal capillary refill time 2sec.
Head
No head and scalp lessions
Symmetric facial features and movements
Symmetric nasolabial folds
Evenly distributed black hair
No infestations
Eyes
Eyebrows symmetrical with equal movement
Eyelashes equally distributed and curled slightly outward
Skin of eyelids intact with no discoloration
Eyelids close symmetrically
Bilateral blinking exhibited
No discharges
Slightly in pale palpebral conjunctiva
Iris black in color
Pupils equals in size with smooth borders
Illuminated pupils constricts
Pupils converge when near object is moved toward the nose
When looking straight ahead, the client can see objects in the periphery
Both eyes coordinated, move in unison with parallel alignment
Ears
Color same as facial skin
Symmetrically aligned
Pinna immediately recoils after it is folded
Pinna is not tender
No lesions or discoloration
Normal voice tones audible
Able to hear ticking of a watch in both ears
Nose
Symmetric and straight
Nasal septum intact and in the midline
Mouth and throat
Outer lips uniform slightly pale in color with symmetric contour
Buccal mucosa is of uniform slightly pale in color
Gums are slightly pale
Tongue slightly pinkish, not so moist, at central position
Neck
No tenderness
Symmetrical neck
Chest
Firm
No tenderness
Generally symmetric in size
Cardiovascular
BP 129/83
PR 88
Symmetric pulse strength
Respiratory/Chest
Chest symmetric
Chest wall intact, no tenderness, no masses
Symmetric chest expansion and excursion
Endothelin-converting Enzyme ECE, (+) crackles, (+) wheezes
Respiratory rate 18
Gastrointestinal/Abdomen
Globular
Normoactive bowel sounds
No splenomegaly
No hepatomegaly
Soft
Tympanic
No tenderness
GenitoUrinary
No tenderness when urinating
Musculoskeletal/Extremities
Muscle equal size on both sides of the body
No tenderness
Smooth coordinated movements
Neurologic
Can respond to verbal commands
Oriented
Conscious
Coherent
G. COURSE IN THE WARD

Nurses
Date/Shift
06-25,26-2013
Assessment
Risk for fluid
Nurses
Intervention
Regulate IVF @
deficiency
desired rate
Risk for infections Monitor body
Medical
management
IVF therapy
Antibiotic Therapy
Activity
temperature
Promote early
Pain reliever
intolerance due
ambulation
Therapy
incision
Self-care deficit:
Providing oral care
Hygiene and
hygiene
and proper hygiene
grooming as
Knowledge deficit
and grooming
Reinforcing NPO diet
doctors ordered
NPO diet as ordered
regarding on diet
Crumpled bed
Tucked bed linens
to surgical
linens
F. Laboratory Findings
Laboratory exam
Hemoglobin
Hematocrit
Lymphocytes
Normal
Value (Hospital
Based)
140-170g/L
0.40-0.50
0.35-0.55
Result
140
0.40
0.18
Interpretation/Implication
Normal
Normal
When the
count
is
lymphocyte
lowered,
the
body's ability to resist and

fight
off
infections
is
severely compromised and

its susceptibility to cancer
is increased. In addition,
low
lymphocyte
counts
may also lead to damage

to various organs.
http://www.md-health.com/Low-Lymphocytes.html
AutoCrea
Result
m/dL
Normal Values
Interpretations/Implications
Na
75.4
133.4
135-145 mEq/L
Decreased levels
(hyponatremia) may be
caused by: vomiting,
diarrhea, gastric suction,
excessive perspiration,
continuous IV 5%
Dextrose/water; lowsodium diet, burns,
inflammatory reactions,
tissue injury, others.

K+
4.22
3.5-5.0 mEq/L
Normal
+
Ca
105
95-105 mEq/L
Normal
http://www.nurseslearning.com/courses/nrp/labtest/course/section4/
INTRODUCTION
The appendix is a closed-ended, narrow tube that attaches
to the cecum (the first part of the colon) like a worm. (The
anatomical name for the appendix, vermiform appendix,
means worm-like appendage.) The inner lining of the appendix
produces a small amount of mucus that fl ows through the
appendix and into the cecum. The wall of the appendix
contains lymphatic tissue that is part of the immune system
for making antibodies. Like the rest of the colon, the wall of
the appendix also contains a layer of muscle.
Acute appendicitis can occur when a piece of food, stool or
object becomes trapped in the appendix, causing irritation,
inflammation, and the rapid growth of bacteria and infection.
Acute appendicitis can also happen after a gastrointestinal
infection.
Rarely,
tumor
may
cause
acute
appendicitis.
Sometimes the cause of acute appendicitis is not known. The

inflammation is usually caused by a blockage, but may be caused
by an infection. Without treatment, an inflamed appendix can
rupture, causing infection of the peritoneal cavity (the lining
around the abdominal organs) and even death.
Appendicitis
is
one
of
the
most
common
causes
of
emergency abdominal surgery. Up to 75,000 appendectomies are

done each year in the U.S. The estimated population in the
Philippines is 86, 241, 6972 and the incident rate of acute

appendicitis is 215,604 as of year 2011. Appendicitis is one of the
more common surgical emergencies, and it is one of the most
common causes of abdominal pain. In the United States, 250,000
cases of appendicitis are reported annually, representing 1 million
patient-days of admission. The incidence of acute appendicitis has
been declining steadily since the late 1940s, and the current
annual
incidence
is
10
cases
per
100,000
populations.
Appendicitis occurs in 7% of the US population, with an incidence

of
1.1
cases
per
1000
people
per
year.
Some
familial
predisposition exists.
In Asian and African countries, the incidence of acute
appendicitis is probably lower because of the dietary habits of the
inhabitants
of
these
geographic
areas.
The
incidence
of
appendicitis is lower in cultures with a higher intake of dietary

fiber. Dietary fiber is thought to decrease the viscosity of feces,
decrease bowel transit time, and discourage formation of
fecaliths, which predispose individuals to obstructions of the
appendiceal lumen.
In the last few years, a decrease in frequency of appendicitis
in Western countries has been reported, which may be related to
changes in dietary fiber intake. In fact, the higher incidence of
appendicitis is believed to be related to poor fiber intake in such
countries.
There is a slight male preponderance of 3:2 in teenagers and

young
adults;
in
adults,
the
incidence
of
appendicitis
is
approximately 1.4 times greater in men than in women. The

incidence of primary appendectomy is approximately equal in
both sexes.
The incidence of appendicitis gradually rises from birth,
peaks in the late teen years, and gradually declines in the
geriatric years. The mean age when appendicitis occurs in the
pediatric population is 6-10 years. Lymphoid hyperplasia is
observed more often among infants and adults and is responsible
for the increased incidence of appendicitis in these age groups.
Younger children have a higher rate of perforation, with reported
rates of 50-85%. The median age at appendectomy is 22 years.
Although rare, neonatal and even prenatal appendicitis have been
reported. Clinicians must maintain a high index of suspicion in all
age groups.
Acute appendicitis can occur in any age group or population.
However, it most often occurs in teens and young adults. It is rare
in children younger than two years of age. Classic symptoms of
acute appendicitis include pain in the right lower abdomen, where
the appendix is located, that gets progressively sharp and more
intense. Pain increases when pressure is put on the area (called
the McBurneys point), and the area becomes even more painful
and tender when the pressure is released (rebound tenderness).
This is one exam a health care provider uses to diagnosis acute

appendicitis. The symptoms of acute appendicitis can vary, and
not all people with acute appendicitis will experience the typical
symptoms of abdominal pain. In early acute appendicitis,
the abdominal pain may be located around the navel or belly
button area, then move to McBurneys point as acute appendicitis
progresses.
Acute appendicitis that is not treated promptly leads to lifethreatening complications. Complications of acute appendicitis
include: Abdominal abscess, Peritonitis (infection of the lining that
surrounds the abdomen), Ruptured appendix, Sepsis, Shock.
As teen-agers living in a fast-phased world and governed by
schedules, they too are predisposed to lifestyle modification
especially diet and food preferences which can contribute to the
disease. With this study, the student nurses hope to apply their
learning in taking care not only of their patients but also of
themselves.
As nursing students and future nurses, we would want to
understand and appreciate more on what is happening to a
patient with acute appendicitis. Consequently, we are interested
on what will be the necessary management that will be given. All
in all, these will help us to become efficient nurses and better
persons later on.
OBJECTIVE OF THE STUDY

The objectives of this study are as follows;
Know how it is manifested and how it is diagnosed.
Trace the disease process which is related to the actual condition of
the patient.
Recognize the medical care of the client and know the significance
of the medical managements rendered.
Recognize the significance of all diagnostic tests given
to the
client.
Formulate and implement an effective nursing care plan especially
designed
for clients
problems as
identified
in
the
nursing
assessment.
Encourage empathy and compassion to dealing with these patients
To widen and enhance the students nurses knowledge and skills
through additional research about the nature of the disease, its sign
and symptoms, its phatophysiology, its diagnosis and treatment.
Provide appropriate health teachings to patients with these disease
conditions
Signs and
Symptoms
Right Lower
Quadrant Pain
Presen
t
Absent
Rationale
Right lower-quadrant pain that is

produced with either the passive
extension of the patient's right hip
(patient lying on left side, with knee
in flexion) or by the patient's active
flexion of the right hip while supine.
The pain elicited is due to

inflammation of the peritoneum
overlying the iliopsoas muscles and
inflammation of the psoas muscles
themselves. Straightening out the
leg causes pain because it stretches
these muscles, while flexing the hip
activates the iliopsoas and
therefore also causes pain.
Source: (http://www.freeed.net/sweethaven/science/biology/
anatomyphysiol/Human01_LessonM
ain.asp?iNum=1008)
McBurney's
Sign
Deep tenderness at McBurney's

point, known as McBurney's sign, is
a sign of acute appendicitis.[2] The
clinical sign of referred pain in
the epigastrium when pressure is
applied is also known as Aaron's
sign. Specific localization of
tenderness to McBurney's point
indicates that inflammation is no
longer limited to the lumen of the
bowel (which localizes pain poorly),
and is irritating the lining of
the peritoneum at the place where
the peritoneum comes into contact
with the appendix. Tenderness at
McBurney's point suggests the
evolution of acute appendicitis to a

later stage, and thus, the increased
likelihood of rupture.
Source:
(http://en.wikipedia.org/wiki/McBurn
ey's_point)
Fever
/
Fever is a nonspecific response that is

mediated by endogenous pyrogens
released from host cells in response
to infectious or non-infections
disorders. It may be brought about by
prostaglandins released
during inflammation.
Source: Carol Mattson Porth (2005.

Pathophysiology, Seventh edition page
205)
Constipation
/
difficulty in defecation: a condition in which

or animal has difficulty in eliminating solid was
the body and the feces are hard and dry.
(Microsoft Encarta 2009. 1993-2008

Corporation. All rights reserved.)
Nausea
Nausea sometimes occurs with biliary

colic. The inflammation of the
appendix causes pain and spasms of
the abdominal muscles which may
make one feel nauseated.
Source: Understanding
Medical Surgical Nursing by Williams
and Hopper (page 742)

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II.

Normal capillary refill time 2sec.

No head and scalp lessions

Symmetric facial features and movements

Symmetric nasolabial folds

Evenly distributed black hair

Eyebrows symmetrical with equal movement

Eyelashes equally distributed and curled slightly outward

Skin of eyelids intact with no discoloration

Eyelids close symmetrically

Bilateral blinking exhibited

Slightly in pale palpebral conjunctiva

Iris black in color

Pupils equals in size with smooth borders

Illuminated pupils constricts

Pupils converge when near object is moved toward the nose

Both eyes coordinated, move in unison with parallel alignment

Color same as facial skin

Pinna immediately recoils after it is folded

Pinna is not tender

Normal voice tones audible

Able to hear ticking of a watch in both ears

Symmetric and straight

Nasal septum intact and in the midline

Mouth and throat

Outer lips uniform slightly pale in color with symmetric contour

Buccal mucosa is of uniform slightly pale in color

Gums are slightly pale

Tongue slightly pinkish, not so moist, at central position

Generally symmetric in size

Symmetric pulse strength

Chest wall intact, no tenderness, no masses

Symmetric chest expansion and excursion

Endothelin-converting Enzyme ECE, (+) crackles, (+) wheezes

Normoactive bowel sounds

No tenderness when urinating

Muscle equal size on both sides of the body

Smooth coordinated movements

Can respond to verbal commands

G. COURSE IN THE WARD

Providing oral care

and proper hygiene

Tucked bed linens

body's ability to resist and

severely compromised and

may also lead to damage

tissue injury, others.

Sometimes the cause of acute appendicitis is not known. The

emergency abdominal surgery. Up to 75,000 appendectomies are

Philippines is 86, 241, 6972 and the incident rate of acute

Appendicitis occurs in 7% of the US population, with an incidence

appendicitis is lower in cultures with a higher intake of dietary

There is a slight male preponderance of 3:2 in teenagers and

approximately 1.4 times greater in men than in women. The

This is one exam a health care provider uses to diagnosis acute

OBJECTIVE OF THE STUDY

Right lower-quadrant pain that is

The pain elicited is due to

Deep tenderness at McBurney's