Acute Appendicitis

OBJECTIVES

General Objectives:
At the end of the case presentation, the presenters together with students and panels
will be able to enhance understanding on the Acute Appendicitis, its nursing management and
paves a way to us student-nurses appreciate our roles of being health care providers and in
promoting health and in preventing illness.

Specific Objectives:
In order to meet the general objective, the group aims to:

Interpret the pertinent data gathered from the patient .

Determine the etiology factors (precipitating and predisposing) of the disease.
Discuss thoroughly the Anatomy and Physiology of the involved organs and organ systems
in accord to the final diagnosis.
Discuss thoroughly the drugs of the said disorder.
Formulate effective, specific, measurable, attainable, realistic and time-bounded nursing
care plans base on identified actual and potential nursing problems.

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Acute Appendicitis

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
flows 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, a 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
year2011. 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 100,000populations. 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 approximately1.4 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 is6-10 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
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Acute Appendicitis

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.

NURSING HISTORY
Biographic Profile

Name: JL
Address: Laguna
Age: 18 years old
Date of Birth: July 29, 1997
Religion: Catholic
Date of Admission: July 13, 2016
Chief Complaint: Right Lower Quadrant Pain
Admitting Diagnosis: Acute Appendicitis

History of Present Illness

This is a case study of a 18 years old, male who works at the furniture shop as a helper
in Tondo. 1 day prior to admission, patient JL complains right lower quadrant pain with nausea
and vomiting.

Family History

(-) allergies, asthma, diabetes mellitus and cancer

(-) hypertension both side of parents
Social History
(+) cigarette smoking 8 sticks/day
(+) alcohol

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Acute Appendicitis

ANATOMY AND PHYSIOLOGY

The pathophysiology of appendicitis

development of acute appendicitis from
the development of acute appendicitis
supply due to obstruction of its lumen
found in gut normally.

is the constellation of process that leads to the

a normal appendix. The man thrust of events leading to
lies in the appendix developing a compromised blood
and becoming very vulnerable to invasion by bacteria

Obstruction of the appendix lumen by fecalth, enlarge lymph node, worms tumor, or
indeed foreign objects, brings about a raised intra-luminal pressure, which cause the wall of the
appendix to become distended. Normal mucus secretions con-within the lumen of the appendix,
thus causing further build up of intralumenal pressures. This in turn leads to the occlusion of the
lymphatic channels, then the various return, and finally the arterial supply become undermined.
Reduce blood supply to wall of appendix gets little or nonutrion and O2. H also mean a little or
no supply and other natural fighters of infection found in the blood being mode available to the
appendix within 36 hours from the point of luminal obstruction, worsening the process of a
appendictis. This leads to necrosis and perforation of the appendix pus formation occurs when
nearby wbc are requited to fight the bacterial invation. A combination of deal wbc bacterial, and
dead tissue makes up pus. The content of the appendix (fecalith, pus and macus see) are then
released into the gen. abdominal cavity, bringing causing peritonitis. In acute appendicitis,
bacterial colonization focus only when the process have commended.
These events occur so rapidly, that the complete pathoof appendicitis takes about one to three
days. This is why delay can be deadly. Pain in appendicitis is thus caused, initially by the
distension of the wall of the appendix and later when the grossly inflamed.

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Acute Appendicitis

PATHOPHYSIOLOGY
Obstruction of appendix
lumen by fecalith

Mucosa of appendix
secretes

Distention of the appendix

Increase intra-luminal pressure

Impaired blood supply

Infection

Inflammation

Ulceration

Pain at right lower

quadrant

Vomiting

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GORDONS FUNCTIONAL HEALTH ASSESSMENT
ADMISSION ASSESSMENT

DEMOGRAPHIC DATA

Date: ______________ Time: ______________

Name: _______________________________________________________
Date of Birth: _________________________ Age: ________ Sex: ________
Primary significant other: ____________________ Telephone: ___________
Name of primary information source: _______________________________
Admitting medical diagnosis:______________________________________

VITAL SIGNS:
Temperature: ____F ____C ; oral__ rectal __ axillary __ tympanic __
Pulse Rate: ____bpm; radial __ apical ___; regular ___ irregular __
Respiratory Rate: ___cpm; abdominal ___ diaphragmatic ___
Blood Pressure: left arm ___ right arm___;
standing__ sitting__ lying down ___
Weight: __ pounds; ___kg
Height: ___feet ___inches; ___meters

Do you have any allergies? No__ Yes__ What?! ________________

(Check reactions to medications, foods, cosmetics, insect bites, etc.)

Review admission CBC, urinalyses and chest-xray. Note any abnormalitites here:
________________________________________________________
_____________________________________________________________

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

OBJECTIVE
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1. Mental Status (indicate assessment with a )

a. Oriented__ Disoriented__
Time: Yes__ No__; Place: Yes__ No__; Person: Yes__ No__;
b. Sensorium
Alert__ Drowsy__ Lethargic__ Stuporous__ Comatose__
Cooperative__ Combative__ Delusional__
c.Memory
Recent: Yes__ No__; Remote: Yes__ No__

2. Vision
a. Visual acuity: Both eyes 20/___; Right 20/___; Left 20/___; Not assessed___
b. Pupil size: Right: Normal__ Abnormal__;
Left: Normal__ Abnormal__
c. Pupil reaction: Right: Normal__ Abnormal__;
Left: Normal__ Abnormal__

3. Hearing
a. Not assessed__
b. Right ear: WNL__ Impaired__ Deaf__; Left ear: WNL__ Impaired__ Deaf__
c. Hearing aid: Yes__ No__
4. Taste
a. Sweet: Normal__ Abnormal__ Describe:______________________
b. Sour: Normal__ Abnormal__ Describe:_______________________
c. Tongue movement: Normal__ Abnormal__ Describe:____________
d. Tongue appearance: Normal__ Abnormal__ Describe:___________
5. Touch
a. Blunt: Normal__ Abnormal__ Describe:_______________________
b. Sharp: Normal__ Abnormal__ Describe:______________________
c. Light touch sensation: Normal__ Abnormal__ Describe:__________
d. Proprioception: Normal__ Abnormal__ Describe:________________
e. Heat: Normal__ Abnormal__ Describe:_______________________
f. Cold: Normal__ Abnormal__ Describe:________________________
g. Any numbness? No__ Yes__ Describe:_______________________
h. Any tingling? No__ Yes__ Describe:__________________________
6. Smell
a. Right nostril: Normal__ Abnormal__ Describe:__________________
b. Left nostril: Normal__ Abnormal__ Describe:___________________

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Acute Appendicitis

7. Cranial Nerves: Normal__ Abnormal__ Describe deviations:_________

_________________________________________________________

8. Cerebellar Exam (Romberg, balance, gait, coordination, etc.)

Normal__ Abnormal__ Describe:______________________________
_________________________________________________________

9. Reflexes: Normal__ Abnormal__ Describe: ______________________

_________________________________________________________

10. Any enlarged lymph nodes in the neck? No__ Yes__ Location and size:
_________________________________________________________
_________________________________________________________

11. General appearance:

a. Hair: __________________________________________________
b. Skin: __________________________________________________
c. Nails: _________________________________________________
d. Body odor: _____________________________________________
SUBJECTIVE
1. How would you describe your usual health status?
Good__ Fair__ Poor__
2. Are you satisfied with your usual health status?
Yes__ No__ Source of dissatisfaction: ____________________________
3.
4.
5.
6.

Tobacco use? No__ Yes__ Number of packs per day? _______________

Alcohol use? No__ Yes__ How much and what kind? ________________
Street drug use? No__ Yes__ What and how much? _________________
Any history of chronic disease? No__ Yes__ Describe: _______________
___________________________________________________________

7. Immunization history: Tetanus__ Pneumonia__ Influenza__ MMR__ Polio__ Hepatitis B__

8. Have you sough any health care assistance in the past year? No__ Yes__ If yes, why?
_________________________________________________
9. Are you currently working? No__ Yes__ How would you rate your working conditions? (e.g.
safety, noise, space, heating, cooling, water, ventilation)? Excellent__ Good__ Fair__ Poor__
Describe any problem
areas:______________________________________________________
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10. How would you rate living conditions at home? Excellent__ Good__ Fair__ Poor__ Describe
any problem areas: ________________
__________________________________________________________
11. Do you have any difficulty securing any of the following services?
Grocery store: Yes:__ No:__; Pharmacy: Yes__ No__; Health Care Facility: Yes:__ No:__;
Transporation: Yes:__ No:__; Telephone (for police, fire, ambulance): Yes:__ No:__; If any
difficulties, note referral here:
______________________________________________________
__________________________________________________________

12. Medications (over-the-counter and prescription)

Nam
e

Dosag
e

Times/D
ay

Reaso
n

Taken as
Ordered
Yes_
_

No__

13. Have you followed the routine prescribed for you?

Yes__ No__ Why not? ______________________________________
14. Did you think this prescribed routine was best for you?
Yes__ No__ What would be better? ____________________________
15. Have you had any accidents/injuries/falls in the past year?
No__ Yes__ Describe: ______________________________________
16. Have you had any problems with cuts healing?
No__ Yes__ Describe: ______________________________________
17. Do you exercise on a regular basis?
No__ Yes__ Type & Frequency: ______________________________
18. Have you experienced any ringing in the ears: Right ear: Yes__ No___
Left ear: Yes__ No__
19. Have you experienced any vertigo: Yes__ No__ How often and when?
_________________________________________________________
20. Do you regularly use seat belts? Yes__ No__
21. For infants and children: Are car seats used regularly? Yes__ No__
22. Do you have any suggestions or requests for improving your health?
Yes__ No__ Describe: ______________________________________
_________________________________________________________
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23. Do you do (breast/testicular) self-examination? No__ Yes__

How often? _______________________________________________
NUTRITIONAL-METABOLIC PATTERN

OBJECTIVE
1. Skin examination
a. Warm__ Cool__ Moist__ Dry__
b. Lesions: No__ Yes__ Describe: _______________________________
c. Rash: No__ Yes__ Describe: _________________________________
d. Turgor: Firm__ Supple__ Dehydrated__ Fragile__
e. Color: Pale__ Pink__ Dusky__ Cyanotic__ Jaundiced__ Mottled__
Other____________________________________________________
2. Mucous Membranes
a. Mouth
i.
Moist__ Dry__
ii.
Lesions: No__ Yes__ Describe: __________________________
iii.
Color: Pale__ Pink__
iv.
Teeth: Normal__ Abnormal__ Describe:____________________
v.
Dentures: No__ Yes__ Upper__ Lower__ Partial__
vi.
Gums: Normal__ Abnormal__ Describe:____________________
vii.
Tongue: Normal__ Abnormal__ Describe:___________________
b. Eyes
i.
Moist__ Dry__
ii.
Color of conjunctiva: Pale__ Pink__ Jaundiced__
iii.
Lesions: No__ Yes__ Describe:___________________________
3. Edema
a.
General: No__ Yes__ Describe:_______________________________
Abdominal girth: ___inches
b.
Periorbital: No__ Yes__ Describe:_____________________________
c.Dependent: No__ Yes__ Describe:_____________________________
Ankle girth: Right:__ inches; Left__inches

4.
5.
6.
7.

Thyroid: Normal__ Abnormal__ Describe: _________________________

Jugular vein distention: No__ Yes__
Gag reflex: Present__ Absent__
Can patient move easily (turning, walking)? Yes__ No__
Describe limitations: __________________________________________
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8. Upon admission, was patient dressed appropriately for the weather?

Yes__ No__ Describe: ________________________________________

For breastfeeding mothers only:

9. Breast exam: Normal__ Abnormal__ Describe:______________________

___________________________________________________________
10. If mother is breastfeeding, have infant weighed. Is infants weight within normal limits? Yes__
No__
SUBJECTIVE:
1.
2.
3.
4.
5.

Any weight gain in the last 6 months? No__ Yes__ Amount: ___________
Any weight loss in the last 6 months? No__ Yes__ Amount:____________
How would you describe your appetite? Good__ Fair__ Poor__
Do you have any food intolerance? No__ Yes__ Describe: ____________
Do you have any dietary restrictions? (Check for those that are a part of a prescribed regimen
as well as those that patient restricts voluntarily, for example, to prevent flatus) No__ Yes__
Describe: ___________________
___________________________________________________________

6. Describe an average days food intake for you (meals and snacks): _____
___________________________________________________________
___________________________________________________________
7. Describe an average days fluid intake for you. _____________________
___________________________________________________________
8. Describe food likes and dislikes. _________________________________
___________________________________________________________
9. Would you like to: Gain weight?__ Lose weight?__ Niether__
10. Any problems with:
a. Nausea: No__ Yes__ Describe: _______________________________
b. Vomiting: No__ Yes__ Describe: ______________________________
c. Swallowing: No__ Yes__ Describe: ____________________________
d. Chewing: No__ Yes__ Describe: ______________________________
e. Indigestion: No__ Yes__ Describe: ____________________________
11. Would you describe your usual lifestyle as: Active__ Sedate__
For breastfeeding mothers only:
12. Do you have any concerns about breast feeding? No__ Yes__ Describe:
___________________________________________________
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Acute Appendicitis
13. Are you having any problems with breastfeeding? No__ Yes__ Describe:
___________________________________________________
ELIMINATION PATTERN

OBJECTIVE
1. Auscultate abdomen:
a. Bowel sounds: Normal__ Increased__ Decreased__ Absent__
2. Palpate abdomen:
a. Tender: No__ Yes__ Where?_________________________________
b. Soft: No__ Yes__; Firm: No__ Yes__
c. Masses: No__ Yes__ Describe: _______________________________
d. Distention (include distended bladder): No__ Yes__ Describe: _______
_________________________________________________________
e. Overflow urine when bladder palpated? Yes__ No__
3. Rectal Exam:
a. Sphincter tone: Describe: ____________________________________
b. Hemorrhoids: No__ Yes__ Describe: ___________________________
c. Stool in rectum: No__ Yes__ Describe: _________________________
d. Impaction: No_- Yes__ Describe:______________________________
e. Occult blood: No__ Yes__ Location: ___________________________
4. Ostomy present: No__ Yes__ Location: ___________________________
SUBJECTIVE
1. What is your usual frequency of bowel movements? _________________
a. Have to strain to have a bowel movement? No__ Yes__
b. Same time each day? No__ Yes__
2. Has the number of bowel movements changed in the past week?
No__ Yes__ Increased?__ Decreased?__

3. Character of stool
a. Consistency: Hard__ Soft__ Liquid__
b. Color: Brown__ Black__ Yellow__ Clay-colored__
c. Bleeding with bowel movements: No__ Yes__
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4. History of constipation: No__ Yes__ How often? ____________________

Do you use bowel movement aids (laxatives, suppositories, diet)?
No__ Yes__ Describe:_________________________________________

5. History of diarrhea: No__ Yes__ When?___________________________

6. History of incontinence: No__ Yes__ Related to increased abdominal pressure (coughing,
laughing, sneezing)? No__ Yes__
7. History of travel? No__ Yes__ Where?____________________________
8. Usual voiding pattern:
a. Frequency (times per day) ____ Decreased?__ Increased?__
b. Change in awareness of need to void: No__ Yes__ Increased?__ Decreased?__
c. Change in urge to void: No__ Yes__ Increased?__ Decreased?__
d. Any change in amount? No__ Yes__ Increased?__ Decreased?__
e. Color: Yellow__ Smokey__ Dark__
f. Incontinence: No__ Yes__ When? _____________________________
Difficulty holding voiding when urge to void develops? No__ Yes__
Have time to get to bathroom: Yes__ No__ How often does problem reaching bathroom
occur? ___________________________________
g. Retention: No__ Yes__ Describe: _____________________________
h. Pain/burning: No__ Yes__ Describe: ___________________________
i. Sensation of bladder spasms: No__ Yes__ When? ________________
ACTIVITY-EXERCISE PATTERN

OBJECTIVE
1. Cardiovascular
a. Cyanosis: No__ Yes__ Where? _______________________________
b. Pulses: Easily palpable?
Carotid: Yes__ No__; Jugular: Yes__ No__; Temporal: Yes__ No__
Radial: Yes__ No__; Femoral: Yes__ No__; Popliteal: Yes__ No__;
Postibial: Yes__ No__; Dorsalis Pedis: Yes__ No__

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Acute Appendicitis
c. Extremities:
i.
Temperature: Cold__ Cool__ Warm__ Hot__
ii.
Capillary refill: Normal__ Delayed__
iii.
Color: Pink__ Pale__ Cyanotic__ Other__ Describe: __________
____________________________________________________
iv.
v.
vi.

Homans sign: No__ Yes__

Nails: Normal__ Abnormal__ Describe: _____________________
Hair distribution: Normal__ Abnormal__ Describe: ____________
____________________________________________________

vii.

Claudication: No__ Yes__ Describe: _______________________

____________________________________________________

d. Heart: PMI location: ________

i.
Abnormal rhythm: No__ Yes__ Describe: ___________________
____________________________________________________
ii.

Abnormal sounds: No__ Yes__ Describe: ___________________

____________________________________________________

2. Respiratory
a. Rate:__ Depth: Shallow__ Deep__ Abdominal__ Diaphragmatic__
b. Have patient cough. Any sputum? No__ Yes__ Describe: ___________
_________________________________________________________
c. Fremitus: No__ Yes__
d. Any chest excursion? No__ Yes__ Equal__ Unequal__
e. Auscultate chest:
i.
Any abnormal sounds (rales, rhonchi)? No__ Yes__ Describe: __
____________________________________________________
f.

Have patient walk in place for 3 minutes (if permissible):

i.
Any shortness of breath after activity? No__ Yes__
ii.
Any dypnea? No__ Yes__
iii.
BP after activity: ___/___ in (right/left) arm
iv.
Respiratory rate after activity: _______
v.
Pulse rate after activity: _______

3. Musculoskeletal
a. Range of motion: Normal__ Limited__ Describe: __________________
b. Gait: Normal__ Abnormal__ Describe: __________________________
c. Balance: Normal__ Abnormal__ Describe: ______________________
d. Muscle mass/strength: Normal__ Increased__ Decreased__
Describe: ________________________________________________
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e. Hand grasp: Right:: Normal__ Decreased__

Left: Normal__ Decreased__
f.

Toe wiggle: Right: Normal__ Decreased__

Left: Normal__ Decreased__

g.
h.
i.
j.

Postural: Normal__ Kyphosis__ Lordosis__

Deformities: No__ Yes__ Describe: ____________________________
Missing limbs: No__ Yes__ Where? ____________________________
Uses mobility aids (walker, crutches, etc)? No__ Yes__ Describe: ____
_________________________________________________________

k. Tremors: No__ Yes__ Describe: ______________________________

_________________________________________________________
4. Spinal cord injury: No__ Yes__ Level: ____________________________
5. Paralysis present: No__ Yes__ Where? ___________________________
6. Developmental Assessment: Normal__ Abnormal__ Describe: _________
___________________________________________________________

SUBJECTIVE

1. Have patient rate each area of self-care on a scale of 0 to 4. (Scale has been adapted by
NANDA from E. Jones, et. Al., Patient Classification for Long Term Care; Users Manual. HEW
Publication No. HRA-74-3107, November 1974.)
0 Completely independent
1 requires use of equipment or device
2 requires help from another person for assistance, supervision or teaching
3 requires help from another person and equipment device
4 dependent; does not participate in activity

Feeding__; Bathing/hygiene__; Dressing/grooming__; Toileting__; Ambulation__; Care of

home__; Shopping__; Meal preparation__; Laundry__; Transportation__

2. Oxygen use at home? No__ Yes__ Describe: ______________________

3. How many pillows do you use to sleep on?_____
4. Do you frequently experience fatigue? No__ Yes__ Describe: _________
___________________________________________________________
5. How many stairs can you climb without experiencing any difficulty (can be individual number
or number of flights)? ___________________________
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6. How far can you walk without experiencing any difficulty? _____________
7. Has assistance at home for self-care and maintenance of home:
No__ Yes__ Who? __________ If no, would you like to have or believes needs assistance:
No__ Yes__ With what activities? _________________
8. Occupation (if retired, former occupation): _________________________
9. Describe you usual leisure time activities/hobbies: ___________________
___________________________________________________________
10. Any complaints of weakness or lack of energy? No__ Yes__ Describe:
___________________________________________________
11. Any difficulties in maintaining activities of daily living? No__ Yes__ Describe:
_____________________________________________
12. Any problems with concentration? No__ Yes__ Describe: ______
_____________________________________________________________

SLEEP REST PATTERN

OBJECTIVE

SUBJECTIVE
1. Usual sleep habits: Hours per night ___; Naps: No__ Yes__ a.m.__ p.m.__ Feel rested?
Yes__ No__ Describe: ________________________
2. Any problems:
a. Difficulty going to sleep? No__ Yes__
b. Awakening during night? No__ Yes__
c. Early awakening? No__ Yes__
d. Insomnia? No__ Yes__ Describe: _____________________________
3. Methods used to promote sleep: Medication: No__ Yes__ Name: _______
Warm fluids: No__ Yes__ What? __________________; Relaxation techniques: No__ Yes__
Describe: _______________________________

COGNITIVE=PERCEPTUAL PATTERN

OBJECTIVE
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1. Review sensory and mental status completed in health perception-health management pattern
2. Any overt signs of pain? No__ Yes__ Describe: _____________________
SUBJECTIVE
1. Pain
a. Location (have patient point to area) : __________________________
b. Intensity (have patient rank on scale of 0 to 10): __________________
c. Radiation: No__ Yes__ To where? _____________________________
d. Timing (how often: related to any specific events): ________________
_________________________________________________________
e. Duration: _________________________________________________
f. What done relieve at home? __________________________________
g. When did pain begin? _______________________________________
2. Decision-making
a. Decision making is: Easy__ Moderately easy__ Moderately difficult__ Difficult__
b. Inclined to make decisions: Rapidly__ Slowly__ Delay__
3. Knowledge level
a. Can define what current problems is: Yes__ No__
b. Can restate current therapeutic regimen: Yes__ No__
SELF-PERCEPTION AND SELF-CONCEPT PATTERN

OBJECTIVE
1. During this assessment, does patient appear: Calm__ Anxious__ Irritable__ Withdrawn__
Restless__
2. Did any physiologic parameters change? Face reddened: No__ Yes__; Voice volume
changed: No__ Yes__ Louder__ Softer__; Voice quality changed: No__ Yes__ Quavering__
Hesitation__ Other: ______________
___________________________________________________________
3. Body language observed: ______________________________________
4. is current admission going to result in a body structure or function change for the patient?
No__ Yes__ Unsure at this time__
SUBJECTIVE
1. What is your major concern at the current time? ____________________
___________________________________________________________
2. Do you think this admission will cause any lifestyle changes for you?
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No__ Yes__ What? ___________________________________________

3. Do you think this admission will result in any body changes for you?
No__ Yes__ What? ___________________________________________
4. My usual view of myself is: Positive__ Neutral__ Somewhat negative__
5. Do you believe you will have any problems dealing with your current health situation? No__
Yes__ Describe: ___________________________
6. On a scale of 0 to 5 rank your perception of your level of control in this situation:
___________________________________________________
___________________________________________________________
7. On a scale of 0 to 5 rank your usual assertiveness level: ______________
ROLE-RELATIONSHIP PATTERN

OBJECTIVE
1. Speech Pattern
a. Is English the patients native language? Yes__ No__ Native language is:
__________________ Interpreter needed? No__ Yes__
b. During interview have you noted any speech problems? No__ Yes__ Describe:
________________________________________________
2. Family Interaction
a. During interview have you observed any dysfunctional family interactions? No__ Yes__
Describe: ___________________________
b. If patient is a child, is there any physical or emotional evidence of physical or psychosocial
abuse? No__ Yes__ Describe: ____________
_________________________________________________________

SUBJECTIVE
1. Does patient live alone? Yes__ No__ With whom? __________________
2. Is patient married? Yes__ No__ Children? No__ Yes__ Ages of Children:
___________________________________________________________
3. How would you rate your parenting skills? Not applicable__ No difficulty__ Average__ Some
difficulty__ Describe: ___________________________
___________________________________________________________
4. Any losses (physical, psychologic, social) in past year? No__ Yes__ Describe:
___________________________________________________
5. How is patient handling this loss at this time? ______________________
___________________________________________________________

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6. Do you believe this admission will result in any type of loss? No__ Yes__ Describe:
___________________________________________________
7. Ask both patient and family: Do you think this admission will cause any significant changes in
the patients usual family role? No__ Yes__ Describe:
___________________________________________________
8. How would you rate your usual social activities? Very active__ Active__ Limited__ None__
9. How would you rate your comfort in social situations? Comfortable__ Uncomfortable__
10. What activities or jobs do you like to do? Describe: ___________
___________________________________________________________
11. What activities or jobs do you dislike doing? Describe: _________
___________________________________________________________

SEXUALITY-REPRODUCTIVE PATTERN

OBJECTIVE
Review admission physical exam for results of pelvic and rectal exams. If results not
documented, nurse should perform exams. Check history to see if admission resulted from a
rape.

SUBJECTIVE
Female
1. Date of LMP:___ Any pregnancies? Para__ Gravida__ Menopause? No__ Yes__ Year__
2. Use of birth control measures? No__ N/A__ Yes__ Type: _____________
3. History of vaginal discharge, bleeding, lesions: No__ Yes__ Describe:
___________________________________________________________
4. Pap smear annually: Yes__ No__ Date of last pap smear: ____________
5. Date of last mammogram: ______________________________________
6. History of sexually transmitted disease: No__ Yes__ Describe: _________
___________________________________________________________

If admission is secondary to rape:

7. Is patient describing numerous physical symptoms? No__ Yes__ Describe:
___________________________________________________
8. Is patient exhibiting numerous emotional symptoms? No__ Yes__ Describe:
___________________________________________________
9. What has been your primary coping mechanism in handling this rape episode?
___________________________________________________
10. Have you talked to persons from the rape crisis center? Yes__ No__ If no, want you to contact
them for her? Yes__ No__ If yes, was this contact of assistance? No__ Yes__
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Male
1. History of prostate problems? No__ Yes__ Describe: ________________
2. History of penile discharge, bleeding, lesions: No__ Yes__
Describe:
___________________________________________________
3. Date of last prostate exam: _____________________________________
4. History of sexually transmitted diseases: No__ Yes__ Describe: ________
___________________________________________________________

Both
1. Are you experiencing any problems in sexual functioning? No__ Yes__
Describe:___________________________________________________
2. Are you satisfied with your sexual relationship? Yes__ No__
Describe:___________________________________________________
3. Do you believe this admission will have any impact on sexual functioning? No__ Yes__
Describe: ________________________________________
COPING-STRESS TOLERANCE PATTERN

OBJECTIVE
1. Observe behavior: Are there any overt signs of stress (crying, wringing of hands, clenched
fists, etc)? Describe: ____________________________
SUBJECTIVE
1. Have you experienced any stressful or traumatic events in the past year in addition to this
admission? No__ Yes__ Describe:___________________
___________________________________________________________
2. How would you rate your usual handling of stress? Good__ Average__ Poor__
3. What is the primary way you deal with stress or problems? ____________
___________________________________________________________
4. Have you or your family used any support or counseling groups in the past year? No__ Yes__
Group name: ________________________________
Was the support group helpful? Yes__ No__ Additional comments: _____
___________________________________________________________
5. What do you believe is the primary reason behind a need for this admission?
_________________________________________________
6. How soon, after first noting the symptoms, did you seek health care assistance?
_________________________________________________
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7. Are you satisfied with the care you have been receiving at home? No__ Yes __ Comments:
___________________________________________
8. Ask primary caregiver: What is your understanding of the care that will be needed when the
patient goes home? ____________________________
___________________________________________________________

VALUE-BELIEF PATTERN

OBJECTIVE
1. Observe behavior. Is the patient exhibiting any signs of alterations in mood (anger, crying,
withdrawal, etc.)? Describe: ___________________
___________________________________________________________

SUBJECTIVE
1. Satisfied with the way your life has been developing? Yes__ No__ Comments:
_________________________________________________
2. Will this admission interfere with your plans for the future? No__ Yes__ How?
______________________________________________________
3. Religion: Protestant__ Catholic__ Jewish__ Muslim__ Buddhist__ None__ Other:
_____________________________________________________
4. Will this admission interfere with your spiritual or religious practices? No__ Yes__ How?
________________________________________________
5. Any religious restrictions to care (diet, blood transfusions)? No__ Yes__ Describe:
___________________________________________________
6. Would you like to have your (pastor/priest/rabbi/hospital chaplain) contacted to visit you?
No__ Yes__ Who? _________________________
7. Have your religious beliefs helped you to deal with problems in the past?
No__ Yes__ How?____________________________________________

GENERAL
1. Is there any information we need to have that I have not covered in this interview? No__
Yes__ Comments? ______________________________
2. Do you have any questions you need to ask me concerning your health, plan of care or this
agency? No__ Yes__ Questions: _________________
___________________________________________________________
3. What is the first problem you would like to have help with? ____________
___________________________________________________________

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COURSE IN THE WARD

July 13, 2016 (Wednesday)

Received the patient awake with IVF of PLR 1L regulated 30 gtts/min infusing well at

his right arm with pain scale of 7/10 at right lower quadrant.
Monitored VS every 1 hour with initial VS of BP-110/70 RR-25 PR-75 T-37.1 oxygen

saturation-99%.
Provided comfort to the patient to alter his pain by talking with him therapeutically and

provided adequate rest and sleep.

Encouraged deep breathing exercise and provided safety by raising side rails.
Assisted on giving medications such as omeprazole 40mg IV and cefoxitin 1g IV.

JRRMMC | ER