INTRODUCTION

Our body has composed of twelve (12) different body systems; one of this is the digestive
system. Digestive system breaks down food into absorbable units that enter the blood for
distribution to body cells; indigestible foodstuffs are eliminated as feces. Digestion takes place
almost continuously in a watery, slush environment. The large intestine absorbs the water from
its inner contents and stores the rest until it is convenient to dispose of it. Attached to the first
portion of the large intestine is a pouch called the vermiform appendix. According to our
ancestors and even on the present time, appendix has no function in the human body but it is part
of the large intestine. However, many theories, that human appendix have a function; it carries
good bacteria. With function or without, appendix can be fatal when it gets infected and not
treated right away.

The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the
cecum just below the ileocecal valve. The appendix fills with food and empties as regularly as
does the cecum, of which it is small, so that it is prone to become obstructed and is particularly
vulnerable to infection (appendicitis). Appendicitis is the most common cause of acute
inflammation in the right lower quadrant of the abdominal cavity. It is thought that appendicitis
begins when the opening from the appendix into the cecum becomes blocked. The blockage may
be due to build-up thick mucus within the appendix or stool that enters the appendix from the
cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is
called Fecalith.

Patient M is 23 years old, resides at Brgy. Poblacion Dapa Surigao Del Norte. Patient M
experienced Right Lower Quadrant pain associated with anorexia and fever. He was admitted at
Surigao Dapa Hospital eventually Patient M is referred to Caraga Regional Hospital for further
management. He admitted on August 28, 2018 with the impression of Acute Appendicitis and his
final diagnosis is Periappendical Abscess.

According to oxfordjurnals.org, the author’s analyzed National Hospital discharge survey

data for the years 1979-1984. Approximately 250,000 cases of appendicitis occurred annually in
the United States during this period. The highest incidence of primary positive appendectomy
(appendicitis) was found in persons aged 10-19 years old; males had higher rates of appendicitis
than females for all age groups. Furthermore, the incident rate of appendicitis in the Philippines
is approximately 215,604 persons, out of estimated population of 86, 241, and 6972.

Appendicitis is an inflammation of the appendix, a 3 1/2-inch-long tube of tissue that

extends from the large intestine. If the inflammation and infection spread through the wall of the
appendix, the appendix can rupture, causing infection of the peritoneal cavity called peritonitis.

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The pain become more diffuse, abdominal distention develops as a result of paralytic ileus, and
the patient’s condition become worsens.

I choose the case of Patient M to know the nature of the disease the risk factors, its
complications and preventable measures; because, the complications of the disease cause many
devastating health problem if left untreated.

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 REVIEW OF RELATED LITERATURE

Appendicitis, the most common cause of acute inflammation in the right lower quadrant
of the abdomen, is the most common reason for emergency abdominal surgery especially when
ruptured occurs. According to Brunner & Suddarth, “about 7% of the population will have
appendicitis at some time in their lives; males are affected more than females and teenagers more
than adults. Although it can occur at any age, it occurs most frequently between the ages of 10
and 30 years old”.

It is thought that appendicitis begins when the opening from the appendix into the cecum
becomes blocked. The blockage may be due to a build-up of thick mucus within the appendix or
to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like,
and blocks the opening

Appendicitis usually happens after an infection in the digestive tract, or when the tube
connecting the large intestine and appendix is blocked by trapped feces or food. Both situations
cause inflammation, which can lead to infection or rupture of the appendix. Untreated, mortality
is high, mainly because of the risk of rupture leading to peritonitis and shock. Also, if the
abdomen on palpation is also involuntary guarded (rigid) there should be a strong suspicion of
peritonitis.

Signs and Symptoms:

 Pain starting around the navel, then moving down and to the right side of the
abdomen. The pain gets worse when moving, taking deep breaths, coughing
sneezing or being touched (McBurney’s point).
 Loss of appetite
 Nausea, and Vomiting

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 Change in bowel movements, including diarrhea or constipation or unable to pass
gas.
 Fever
 Rovsing’s sign: continuous deep palpation starting from the left iliac fossa
upwards (counterclockwise along the colon) may cause pain in the right iliac
fossa, by pushing bowel contents towards the ileocaecal valve and thus increasing
pressure around the appendix.
 Psoas sign: is the right lower-quadrant pain that is produced with either the
passive extension of the patients right hip (pt. lying on the left side, with knee in
flexion) or the patient’s active flexion of the right hip while supine. Straightening
out the legs causes pain because it stretches these muscles, while flexing the hip
activated the iliopsoas and therefore causes pain.
 Obturator sign: if an inflamed appendix is in contact with the obturator
internus, spasm of the muscle can be demonstrated by flexing and internal
rotation of the hip. This maneuver will cause pain in the hypogastrium.
 Dunphy’s sign: increased pain in the right lower quadrant with coughing.
 Kocher’s Sign: the appearance of pain in the epigastric region or around the
stomach at the beginning of disease with a subsequent shift to the right iliac
region.
 Stikovskiy (resenstein’s) sign: increased pain on palpation at the right iliac
region as patient lies on his/her left side.
 Blumberg sign: also referred as rebound tenderness. Deep palpation of the
viscera over the suspected inflamed appendix followed by sudden release of the
pessue causes the severe pain on the site indicating positing Blumberg’s sign and
peritonitis.

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Risk Factors

Risk factors for Appendicitis are factors that do not seem to be a direct cause of the
disease, but seem to be associated in some way. Having a risk factor for Acute Appendicitis
makes the chances of getting the condition higher but does not always lead to Acute
Appendicitis.

Age: Appendicitis can occur in all age groups but it is more common between the ages of
11 and 20.

Gender: A male preponderance exists, with a male to female ratio (1.4: 1) and the
overall lifetime risk is 8.6% for males and 6.7% for females. A male child suffering from cystic
fibrosis is at a higher risk for developing appendicitis.

Diet: People whose diet is low in fiber and rich in refined carbohydrates have an
increased risk getting appendicitis.

Hereditary: A particular position of the appendix, which predisposes it to infection, runs

in certain families. Having a family history of appendicitis may increase a child's risk for the
illness.

Seasonal variation: Most cases of appendicitis occur in the winter months - between the
months of October and May.

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 Infections: Gastrointestinal infections such as Amebiasis, Bacterial Gastroenteritis,
Mumps, Coxsackievirus B and Adenovirus can predispose an individual to Appendicitis.

Causes

On the basis of experimental evidence, acute appendicitis seems to be the end result of a
primary obstruction of the appendix lumen (the inside space of a tubular structure). Once this
obstruction occurs the appendix subsequently becomes filled with mucus and swells, increasing
pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion
of the small vessels, and stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this
point. As the former progresses, the appendix becomes ischemic and then necrotic. As bacteria
begin to leak out through the dying walls, pus forms within and around the appendix
(suppuration). The end result of this cascade is appendiceal rupture (a 'burst appendix') causing
peritonitis, which may lead to septicemia and eventually death.

The causative agents include foreign bodies, trauma, intestinal worms, lymphadenitis,
and most commonly calcified fecal deposits known as appendicoliths or fecalith. The occurrence
of an obstructing fecalith has attracted attention since their presence in patients with appendicitis
is significantly higher in developed than in developing countries, and an appendiceal fecalith is
commonly associated with complicated appendicitis. Also, fecal stasis and arrest may play a role,
as demonstrated by a significantly lower number of bowel movements per week in patients with
acute appendicitis compared with healthy controls. The occurrence of a fecalith in the appendix
seems to be attributed to a right side fecal retention reservoir in the colon and a prolonged transit
time. From epidemiological data it has been stated that diverticular disease and adenomatous
polyps were unknown and colon cancer exceedingly rare in communities exempt for
appendicitis. Also, acute appendicitis shown to occur antecedent to cancer in the colon and
rectum. Several studies offer evidence that a low fiber intake is involved in the pathogenesis of
appendicitis. This is in accordance with the occurrence of a right sided fecal reservoir and the
fact that dietary fiber reduces transit time.

Complications of Appendicitis

Rupture of the Appendix

The most frequent complication of appendicitis is perforation. Perforation of the

appendix can lead to a peri-appendiceal abscess (a collection of infected pus) or diffuse
peritonitis (infection of the entire lining of the abdomen and the pelvis). The major reason for
appendiceal perforation is delay in diagnosis and treatment. In general, the longer the delay
between diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours
after the onset of symptoms is at least 15%. Therefore, once appendicitis is diagnosed, surgery
should be done without unnecessary delay.

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Peritonitis or Abscess
Peritonitis is a dangerous infection. This complication can occur when bacteria and other
contents of the torn appendix leak into the abdomen (stomach). A ruptured appendix can lead to
peritonitis and abscess. An abscess usually takes the form of a swollen mass filled with fluid and
bacteria.

Blockage or Obstruction of the intestine

A less common complication of appendicitis is blockage or obstruction of the intestine.
Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to
stop working, and this prevents the intestinal contents from passing. If the intestine above the
blockage begins to fill with liquid and gas, the abdomen distends and nausea and vomiting may
occur. It then may be necessary to drain the contents of the intestine through a tube passed
through the nose and esophagus and into the stomach and intestine.

Sepsis

A feared complication of appendicitis is sepsis, a condition in which infecting bacteria

enter the blood and travel to other parts of the body. This is a very serious, even life-threatening
complication. Fortunately, it occurs infrequently.

Diagnosis

Diagnosis is based on patient history (symptoms) and physical examination backed by an

elevation of neutrophilic white blood cells. Histories fall into two categories, typical and
atypical. Typical appendicitis usually includes abdominal pain beginning in the region of the
umbilicus for several hours, associated with anorexia, nausea or vomiting. The pain then "settles"
into the right lower quadrant, where tenderness develops. Atypical histories lack this typical
progression and may include pain in the right lower quadrant as an initial symptom. Atypical
histories often require imaging with ultrasound and/or CT scanning.[23] A pregnancy test is vital
in all women of child bearing age, as ectopic pregnancies and appendicitis present with similar
symptoms. The consequences of missing an ectopic pregnancy are serious, and potentially life
threatening. Furthermore the general principles of approaching abdominal pain in women (in so
much that it is different from the approach in men) should be appreciated.

Blood Test

Most patients suspected of having appendicitis would be asked to do a blood test. 50% of
the time, the blood test may be normal, so it is not foolproof in diagnosing appendicitis. Two
forms of blood tests are commonly done: FBC (Full blood count) or CBC (Complete blood
count) is an inexpensive and commonly requested blood test. It involves measuring the blood for
its richness in red blood cells as well as the number of the various white blood cell constituents

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in it. The number of white cells in the blood is a usually less than 10,000 cells per cubic
millimeter. An abnormal rise in the number of white blood cells in the blood is a crude indicator
of infection or inflammation going on in the body. Such rise is not specific to appendicitis alone.
If it is abnormally elevated, with a good history and examination findings pointing towards
appendicitis, the likelihood of having the disease is higher. In pregnancy, there may be a normal
elevation of white blood cells, without any infection present.

CRP

CRP is an acronym for C-reactive protein. It is an acute phase response protein produced
by the liver in response to any infection or inflammatory process in the body. Again, like the
FBC, it is not a specific test. It is another crude marker of infection or inflammation.
Inflammation at ANY site can lead to the CRP to rise. A significant rise in CRP with
corresponding signs and symptoms of appendicitis is a useful indicator in the diagnosis of
appendicitis. It is said that if CRP continues to be normal after 72 hours of the onset of pain, it is
likely that the appendicitis will resolve on its own without intervention. A worsening CRP with
good history is a sure signal of impending perforation or ruptures and abscess formation.

Urine Test

Urine test in appendicitis is usually normal. It may however show blood if the appendix is
rubbing on the bladder, causing irritation a urine test or urinalysis is compulsory in women, to
rule out pregnancy in appendicitis, as well to help ensure that the abdominal pain felt and
thought to be acute appendicitis is not in fact, due to ectopic pregnancy.

X – Ray

In 10% of patients with appendicitis, plain abdominal x-ray may demonstrate hard
formed feces in the lumen of the appendix (Fecolith). It is agreed that the finding of Fecolith in
the appendix on X – ray alone is a reason to operate to remove the appendix, because of the
potential to cause worsening symptoms. In this respect, a plain abdominal X-ray may be useful
in the diagnosis of appendicitis, though plain abdominal x- ray is no longer requested routinely in
suspected cases of appendicitis. An abdominal X – ray may be done with a barium enema
contrast to diagnose appendicitis. Barium enema is whitish toothpaste like material that is passed
up into the rectum to act as a contrast. It will usually fill the whole of the large bowel. In normal
appendix, the lumen will be present and the barium fills it up and is seen when the x-ray film is
shot. In appendicitis, the lumen of the appendix will not be visible on the barium film.

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 Ultrasound

Ultrasonography and Doppler sonography provide useful means to detect appendicitis,

especially in children and shows free fluid collection in right iliac fossa along with a visible
appendix without blood flow in color Doppler. In some cases (15% approximately), however,
ultrasonography of the iliac fossa does not reveal any abnormalities despite the presence of
appendicitis. This is especially true of early appendicitis before the appendix has become
significantly distended and in adults where larger amounts of fat and bowel gas make actually
seeing the appendix technically difficult. Despite these limitations, in experienced hands
sonographic imaging can often distinguish between appendicitis and other diseases with very
similar symptoms such as inflammation of lymph nodes near the appendix or pain originating
from other pelvic organs such as the ovaries or fallopian tubes.

Computed tomography

A cat scans demonstrating acute appendicitis (note the appendix has a diameter of
17.1mm and there is surrounding fat stranding.) In places where it is readily available, CT scan
has become frequently used, especially in adults whose diagnosis is not obvious on history and
physical. Concerns about radiation, however, tend to limit use of CT in pregnant women and
children. A properly performed CT scan with modern equipment has a detection rate (sensitivity)
of over 95% and a similar specificity. Signs of appendicitis on CT scan include lack of oral
contrast (oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than
6 mm in cross sectional diameter), and appendiceal wall enhancement with IV contrast (IV dye).
The inflammation caused by appendicitis in the surrounding peritoneal fat (so called "fat
stranding") can also be observed on CT, providing a mechanism to detect early appendicitis and
a clue that appendicitis may be present even when the appendix is not well seen. Thus, diagnosis
of appendicitis by CT is made more difficult in very thin patients and in children, both of whom
tend to lack significant fat within the abdomen.

Management

Before surgery

The treatment begins by keeping the patient from eating or drinking in preparation for
surgery. An intravenous drip is used to hydrate the patient. Antibiotics given intravenously such
as cefuroxime and metronidazole may be administered early to help kill bacteria and thus reduce
the spread of infection in the abdomen and postoperative complications in the abdomen or
wound. Equivocal cases may become more difficult to assess with antibiotic treatment and
benefit from serial examinations. If the stomach is empty (no food in the past six hours) general
anaesthesia is usually used. Otherwise, spinal anaesthesia may be used.

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 Once the decision to perform an appendectomy has been made, the preparation procedure
takes more or less one to two hours. Meanwhile, the surgeon will explain the surgery procedure
and will present the risks that must be considered when performing an appendectomy. With all
surgeries there are certain risks that must be evaluated before performing the procedures.
However, the risks are different depending on the state of the appendix. If the appendix has not
ruptured, the complication rate is only about 3% but if the appendix has ruptured, the
complication rate rises to almost 59%. The most usual complications that can occur are
pneumonia, hernia of the incision, thrombophlebitis, bleeding or adhesions. Recent evidence
indicates that a delay in obtaining surgery after admission results in no measurable difference in
patient outcomes.

The surgeon will also explain how long the recovery process should take. Abdomen hair
is usually removed in order to avoid complications that may appear regarding the incision. In
most of the cases patients experience nausea or vomiting which requires specific medication
before surgery. Antibiotics along with pain medication may also be administrated prior to
appendectomies.

Pain management

Pain from appendicitis can be severe. Strong pain medications (i.e., narcotic pain
medications) are recommended for pain management prior to surgery. Morphine is generally the
standard of care in adults and children in the treatment of pain from appendicitis prior to surgery.
In the past (and in some medical textbooks that are still published today), it was commonly
accepted among the majority of academic sources that pain medication not be given until the
surgeon has the chance to evaluate the patient, so as to not "corrupt" the findings of the physical
examination. This line of practice, combined with the fact that surgeons may sometimes take
hours to come to evaluate the patient, especially if he or she is in the middle of surgery or has to
drive in from home, often leads to a situation that is ethically questionable at best. More recently,
due to better understanding of the importance of pain control in patients, it has been shown that
the physical examination is actually not that dramatically disturbed when pain medication is
given prior to medical evaluation. Individual hospitals and clinics have adapted to this new
approach of pain management of appendicitis by developing a compromise of allowing the
surgeon a maximum time to arrive for evaluation, such as 20 to 30 minutes, before active pain
management is initiated. Many surgeons also advocate this new approach of providing pain
management immediately rather than only after surgical evaluation.

Surgery

The surgical procedure for the removal of the appendix is called an appendicectomy (also
known as an appendectomy). Often now the operation can be performed via a laparoscopic
approach, or via three small incisions with a camera to visualize the area of interest in the

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abdomen. If the findings reveal supportive appendicitis with complications such as rupture,
abscess, adhesions, etc., conversion to open laparotomy may be necessary. An open laparotomy
incision if required most often centers on the area of maximum tenderness, McBurney's point, in
the right lower quadrant. A transverse or a gridiron diagonal incision is used most commonly.

According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic

and open procedures, laparoscopic procedures seem to have various advantages over the open
procedure. Wound infections were less likely after laparoscopic appendicectomy than after open
appendicectomy (odds ratio (OR) 0.45; confidence interval (CI) 0.35 to 0.58), but the incidence
of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21). The duration of surgery
was 12 minutes (CI 7 to 16) longer for laparoscopic procedures. Pain on day 1 after surgery was
reduced after laparoscopic procedures by 9 mm (CI 5 to 13 mm) on a 100 millimeter visual
analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity,
work, and sport occurred earlier after laparoscopic procedures than after open procedures. While
the operation costs of laparoscopic procedures were significantly higher, the costs outside
hospital were reduced. Young female, obese, and employed patients seem to benefit from the
laparoscopic procedure more than other groups.

There is debate whether emergency appendicectomy (within 6 hours of admission)

reduces the risk of perforation or complication versus urgent appendicectomy (greater than 6
hours after admission). According to a retrospective case review study no significant differences
in perforation rate among the two groups were noted (P=.397). Various complications (abscess
formation, re-admission) showed no significant differences (P=0.667, 0.999). According to this
study, beginning antibiotic therapy and delaying appendicectomy from the middle of the night to
the next day does not significantly increase the risk of perforation or other complications. This
finding is important not simply for the convenience of the surgeons and staff involved but for the
fact that there have been other studies that have shown that surgeries taking place during the
night, when people may be more tired and there is fewer staff available, have higher rates of
surgical complications.

Findings at the time of surgery are less severe in typical appendicitis. With atypical
histories, perforation is more common and findings suggest perforation occurs at the beginning
of symptoms. These observations may fit a theory that acute (typical) appendicitis and
suppurative (atypical) appendicitis are two distinct disease processes.

Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours
in complicated cases.

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Complications of Appendectomy

The most common complication of appendectomy is infection of the wound, that is, of
the surgical incision. Such infections vary in severity from mild, with only redness and perhaps
some tenderness over the incision, to moderate, requiring only antibiotics, to severe, requiring
antibiotics and surgical treatment. Occasionally, the inflammation and infection of appendicitis
are so severe that the surgeon will not close the incision at the end of the surgery because of
concern that the wound is already infected. Instead, the surgical closing is postponed for several
days to allow the infection to subside with antibiotic therapy and make it less likely for infection
to occur within the incision.

Another complication of appendectomy is an abscess, a collection of pus in the area of

the appendix. Although abscesses can be drained of their pus surgically, there are also non-
surgical techniques.

Laparotomy

Laparotomy is the traditional type of surgery used for treating appendicitis. This
procedure consists in the removal of the infected appendix through a single larger incision in the
lower right area of the abdomen. The incision in a laparotomy is usually 2-3 inches long. This
type of surgery is used also for visualizing and examining structures inside the abdominal cavity
and it is called exploratory laparotomy.

During a traditional appendectomy procedure, the patient is placed under general

anesthesia in order to keep his/her muscles completely relaxed and to keep the patient
unconscious. The incision is two to three inches (76 mm) long and it is made in the right lower
abdomen, several inches above the hip bone. Once the incision opens the abdomen cavity and the
appendix is identified, the surgeon removes the infected tissue and cuts the appendix from the
surrounding tissue. After the surgeon inspects carefully and closely the infected area and there
are no signs that surrounding tissues are damaged or infected, he will start closing the incision.
This means sewing the muscles and using surgical staples or stitches to close the skin up. In
order to prevent infections the incision is covered with a sterile bandage. The entire procedure
does not last longer than an hour if complications do not occur.

Laparoscopic surgery

The newer method to treat appendicitis is the laparoscopic surgery. This surgical
procedure consists of making three to four incisions in the abdomen, each 0.25 to 0.5 inch (6.3 to
13 mm) long. This type of appendectomy is made by inserting a special surgical tool called
laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the
patient's body and it is designed to help the surgeon to inspect the infected area in the abdomen.

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The other two incisions are made for the specific removal of the appendix by using surgical
instruments. Laparoscopic surgery also requires general anesthesia and it can last up to two
hours. The latest methods are NOTES appendectomy pioneered in Coimbatore, India where there
is no incision on the external skin and SILS (Single incision laparoscopic Surgery) where a
single 2.5 cm incision is made to perform the surgery.

After surgery

Hospital lengths of stay typically range from a few hours to a few days, but can be a few
weeks if complications occur. The recovery process may vary depending on the severity of the
condition, if the appendix had ruptured or not before surgery. Appendix surgery recovery is
generally a lot faster if the appendix did not rupture. It is important that patients respect their
doctor's advice and limit their physical activity so the tissues can heal faster. Recovery after an
appendectomy may not require diet changes or a lifestyle change.

After surgery occurs, the patient will be transferred to a Post-anesthesia care unit so his or
her vital signs can be closely monitored in order to detect anesthesia and/or surgery related
complications. Pain medication may also be administrated if necessary. After patients are
completely awake, they are moved into a hospital room to recover. Most individuals will be
offered clear liquids the day after the surgery and then progress to a regular diet when the
intestines start to function properly. It is highly recommended that patients sit up on the edge of
the bed and walk short distances for several times a day. Moving is mandatory and pain
medication may be given if necessary. Full recovery from appendectomies takes about 4 to 6
weeks but it can prolong to up to 8 weeks if the appendix had ruptured.

Prognosis

Most appendicitis patients recover easily with surgical treatment, but complications can
occur if treatment is delayed or if peritonitis occurs. Recovery time depends on age, condition,
complications, and other circumstances, including the amount of alcohol consumption, but
usually is between 10 and 28 days. For young children (around 10 years old), the recovery takes
three weeks.

The real possibility of life-threatening peritonitis is the reason why acute appendicitis
warrants speedy evaluation and treatment. The patient may have to undergo a medical
evacuation. Appendectomies have occasionally been performed in emergency conditions (i.e.,
outside of a proper hospital), when a timely medical evaluation was impossible.

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Prevention

Appendicitis is probably not preventable, although there is some indication that a diet
high in green vegetables and tomatoes may help prevent appendicitis.

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NURSING HEALTH HISTORY

Biographic Data:

Hospital : CARAGA REGIONAL HOSPITAL

Case No. : 17114
Ward : Surgical Ward
Name of Patient : Patient M
Age : 23
Sex : Male
Civil Status : Single
Address : Brgy. 10 Poblacion Dapa, SDN
Date of Birth : 10/11/1994
Religion : ROMAN CATHOLIC
Height : 5’6
Weight : 71.9kg

Admission Data:

Mode of admission : Wheelchair

Date and Time of Admission : 08/28/18 10:33PM
Vital Signs upon admission
 Heart Rate : 80 bmp
 Respiratory Rate : 22 cpm
 Blood Pressure : 110/70 mmHg
 Body Temperature : 38.9 Degree Celsius

Admitting Physician : Roey C. Yee MD.

Attending Physician : Ruth Lus Almeda, MD
Chief Compliant : Right Lower Quadrant Pain
Impression : Acute appendicitis
Final Diagnosis : Periappendical Abscess

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History of Present Illness (HPI):

Two days prior to admission onset of RLQ pain was experienced by the patient
associated with anorexia and fever admitted at Surigao Dapa Hospital with the impression of
Bowel Obstruction. One day prior to admission at CRH for further management he was given
bisacodyl tablet, bisacodyl suppository, hyoscine butylbromide and ampicillin as initial
management.

Past Health History:

Childhood Illness:

- Patient had experienced chicken pox when he was still a child and can’t recall other
illnesses he experienced as stated.

Childhood Immunization:

- The patient stated he had received immunizations such as BCG and OPV as he
remembered.

History of Hospitalization

Medical and Surgical History:

- Patient had experienced minor surgery incision of his right upper anterior leg 2 years
ago when he was 21 years old.

Accidents and Injuries:

- Patient had experienced Accident/Injury when his co worker accidentally hit his right
leg using long knife when they had cleaning at farm. It was happened 2 years ago
when he was 21 years old.

Allergies:

- Patient had an allergy in seafood’s such as shrimp and crabs. He experienced redness
and itching of his extremities when he eats shrimps and crabs.

Medication:

- The patient cannot recall the name of his previous medication he only remembered
he was given an antibiotic and pain reliever.

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Sexual History

Patient had no comment about patient’s sexual history.

Family History

Patient stated that there was a history of hypertension in both mother and father side.

Personal and Social History

Personal Habits:

- Patient smoked about half of pack (12 sticks of Malboro ) of cigarettes per day when
he was 20 years old.
- Patient drinks alcohol beverages one case of beer ( Red horse ) occasionally only.

Diet:

Patient eats three meals in a day. His usual meal are vegetables, meat and consists
of 2 cups of rice and his favorite is chicken feet which he eat almost every day and also
include the bones of the chicken. His snacks usually consist of bread, biscuits and soft
drinks such as coke and Pepsi. He has allergy on seafood such as shrimp and crabs.

During Hospitalization:

At the hospital, his usual meal consists of 2 cups of rice, fish and meat, with
vegetables and also drinks 2 glasses of water(300ml/glass) during hospital stay.

Body Mass Index

- His admitting weight is 71.9 kilos and his height is 5’6” or 1.6764 meters. His
body mass index (BMI) is shown below.

BMI = 71.9 kg = 25.6 kg/m2

2.810317 meter

- Based on the BMI category; Below 18.5 is underweight, Normal is between 18.5-
24.9, overweight is between 25-29.9, obese is above 30. Patient M, present BMI
is 25.6 that belong to overweight category.

Sleep and rest pattern:

- Patient usual sleeping time was around 8pm and wakes up at 5:00 am.

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 During Hospitalization:

- When patient was hospitalized, he usually sleeps 9 pm and wakes up at 5 am

Elimination Pattern:

- The Patient has no difficulty in urination and defecation. Patient urinates 5 times a
day and defecates 2 times per day.

During Hospitalization:

- Patient urinates 4 times per day and defecates once a day without difficulty.

Activities of Daily Living:

- Patient can perform activities of daily living such as bathing, grooming, elimination
and dressing.

During hospitalization

- Patient needs assistance in performing activities of daily living such as bathing,

grooming, elimination and dressing.

Recreation and Hobbies:

- Patient likes playing basketball and driving a tricycle as a source of his income as
claimed.

SOCIAL DATA

Family Relationship/ Friendship:

- Patient’s family supported him when it comes to stress and problems.

Ethnic affiliation:

- Patient consults at Dapa Health Center whenever he is not feeling well.

Educational History:

- Patient stated that he was a high school graduate.

Occupational History:

18
 - Patient’s work as a tricycle driver as claimed.

Economic status:

- Patient’s financial need is covered by the Philhealth program as claimed.

Psychological Data:

- The major stressors that can trigger the patient is financial problems.

Patterns of Health Care:

- Patient’s financial need is covered by the Philhealth program as claimed.

19
 REVIEW OF SYSTEM

Integumentary System
Patient claimed he did not experience any rashes or lesions in his skin. He also claimed
that sometimes he experienced skin itchiness and dry skin.

Head, Eyes, Ears, Nose, Throat (HEENT)

Patient experienced common colds occasionally. Also stated he had an eye irritation once
or twice when he was in high school.

Neck
He did not experience any lump, tenderness, distention in jugular veins or stiffness.

Breast and Axillae

Patient said that he has no previous experience of any abnormalities on his breasts and
axilla.

Thorax and Lungs

Client doesn’t have any thorax and lung abnormalities.

Cardiovascular System
Client denies of any problems pertains to his cardiovascular system. However, he states
that his father has hypertension.

Gastrointestinal System
Client claims that occasionally he experiences constipation (Color: dark-brown;
Frequency: once in 3 days; Appearance: dry; Consistency: hard stool) .

Musculoskeletal System
No musculoskeletal abnormalities and or deformities experienced by the patient.
Neurologic System
The client is alert, attentive, and follows commands. He claimed that he can comprehend
well at school. He is an average student. No history of hallucinations and seizures as
verbalized by the patient.

Urinary System
Client claimed that he did not experience any difficulty and or problems urinating. Prior
to hospitalization he urinates 3x at day time and twice at night time.

Reproductive System

20
 Client reported that he did not experience any penile discharges or tenderness.

Endocrine
Client did not experience of any thyroid abnormalities.

21
 Physical Examination (PE)

(September 3, 2018)

General Survey

- Patient lies on bed conscious, interactive and cooperative during my interview and
assessment. With an IVF of D5LR 1L infusing well at the right cephalic vein at a
level of 900cc running with a flow rate of 20gtt/min.

T – 36 C

RR – 22 cpm

PR – 80 bpm

BP – 120/ 80 mmHg

INTEGUMENTARY:
Skin
Inspection:
 Generally light-brown uniform in color.
 Old scars are noted at the right leg.
 Skin is intact.
Palpation:
 Both lower and upper extremities has moist and warm skin to touch.
 Good skin turgor when pinched it goes back to previous state after 1 second.
 Body temperature 37 °C

Hair
Inspection:
 Short and slightly silky black hair.
 Evenly distributed hair on the scalp and all over the body.
 Dandruff noted at the scalp.
 No signs of infestations.
Palpation:
 Smooth hair noted

Nails
Inspection:
 Nail color – slightly pale.
 Convex curvature of nail plate.
 Intact epidermis on both fingernails and toe nails.

22
 Palpation:
 Smooth texture noted.
 The nails returned at its original color – slightly pale <2 seconds upon performing the
capillary refill test.

Head, Eyes, Ears, Nose and Throat (HEENT)

Skull and Face
Inspection:
 Rounded and normocephalic skull contour.
 Symmetric facial features.
Palpation:
 Smooth, uniform consistency of the skull.
 No inflammation, and lumps or masses noted at the skull.

Eyes and Vision

Inspection:
 External structure, eyebrows, eyelashes, eyelids are evenly distributed
 No abnormal discharges of the eyes noted.
 Pupils are black, equal in sizes (about 2 mm) and responsive to light.
Palpation:
 Upon palpating the lacrimal gland, no edema noted and tenderness reported.

Ear and Hearing

Inspection:
 Color same as facial noted.
 Symmetric ear positions that lines with outer canthus of the eye
 Able to hear at both ears upon performing the watch tick and follows simple words
commanded.
Palpation:
 Auricles are mobile and firm.
 No tenderness noted.

Nose and Sinuses

Inspection:
 Nose is symmetrical.
 No discharges or flaring noted.
 Air moves freely as the client breaths through the nares.
 Nasal septum is intact and in middle.
 No presence of discharges noted.
Palpation:

23
  No tenderness and lesions on both nose and sinuses observed.

Oropharynx (mouth and throat)

Inspection:
 Lips have symmetric contour, slightly pale in color. Soft and slightly dry.
 Able to perform pursed lip breathing.
 Tongue is positioned centrally.
 Tongue moves freely.
Palpation:
 No presence of lesions and tenderness.
 Positive gag reflex upon touching the posterior part of the tongue with the use of
tongue depressor.

Neck
Inspection:
 Neck muscles are equal with head positioned at the center.
 Able to flex, extend and hyperextend his head when asked to do so.
Palpation:
 No tenderness reported and lesions observed upon palpation

Thorax and Lungs

Inspection:
 Respiratory rate is 19 cpm
 Spine vertically aligned
 Chest is symmetric
 No respiratory distress observed
 Chest wall is intact
Palpation:
 No tenderness noted upon palpation
Percussion:
 Resonant sound at the posterior part of the shoulder
Auscultation:
 Normal breath sounds heard upon auscultation.

Cardiovascular System and Peripheral Vascular System

Inspection:
 Blood pressure of 110/70 mmHg
 Pulse rate of 80 bpm
 No edema noted
 No palpitations observed all over the body

24
  No jugular vein distention noted upon inspection
Palpation:
 Capillary refill test-less than 2 seconds

Breast and Axillae

Inspection:
 Same color as the skin of the abdomen and back
 He had dark brown areola with nipple
 No discharges on nipple noted
 Presence of hair at the axilla
Palpation:
 No masses, nodules or tenderness noted.

Abdomen
Inspection:
 Uniform in color
 Abdominal incision at hypogastric region
 Abdominal guarding noted
Auscultation:
 Bowel sounds heard in 4 quadrants (10 bowel sounds per minute)
Percussion:
 Dull sounds heard at the liver and pancreas region
 Tympanic sounds heard at the spleen region
Palpation:
 Nontender, no masses noted

Musculoskeletal
Inspection:
 Muscle are equal on both upper and lower extremities of the body
 No contractures and deformities noted
Palpation:
 Smooth coordinated movements when asked to perform the ROM in upper
extremities.
 ROM on lower extremities performed with slight difficulty due to felt pain.

Genitals
 Patient refused to perform physical examination on genital area.

25
MENTAL STATUS

Language

 Client is able to speak clearly and had no difficulty speaking. He displays verbal and
non-verbal communication (ex. Gestures, facial expression).

Orientation

 Client is oriented to self, time, and place. Able to identify the present location and can
easily recognize significant others.

Memory

 Able to recall the nurse on duty who had just given him his medication.
 Able to recall his closest friends in elementary years.

Attention Span

 Client has approximately 30 minutes of conversation.

26
Cranial Nerve Assessment

Cranial Nerve Name Result

I Olfactory -Patient can smell and can identify what the object is.

II Optic -Patient has a blurred vision.

III Occulomotor -Patient is reactive to light accommodation.

IV Trochlear -Patient both eyes are coordinated and moves in unison

without tenderness felt when left and right eyes moves. Patient’s lids close symmetrically.

V Trigeminal -Patient has no difficulty in moving his mouth.

VI Abducens -Patient can move both eyeballs in a moderate manner.

VII Facial -Patient raises her left eyebrows whenever you say
something to her. Can close her eyes together.

VIII Acoustic -Patient can hear in a normal toned voice.

IX Glossopharyngeal -Positive gag reflex.

X Vagus -Positive swallowing reflex.

XI Spinal Accessory -Patient can move her neck

XII Hypoglossal -Can protrude tongue.

27
 CLINICAL LABORATORIES

COMPLETE BLOOD COUNT

August 28, 2018

TEST RESULT NORMAL VALUES SIGNIFICANCE

WHITE BOOLD 21.40 4.00-10.00 Infection

CELLS

Neutrophil 83.5 50.0-70.0 Neutrophilia

Lymphocyte 6.4 20.0-40.0 Lymphocytopenia

Monocyte 8.0 3.0-12.0 Normal

Eosinophil 0.9 0.5-5.0 Normal

Basophil 1.2 0.0-0.1 Basophilia

RED BLOOD CELL 4.91 4.00-5.50 Normal

HEMOGLOBIN 15.8 12.0-16.0 Normal

HEMATOCRIT 45.6 40.0-54.0 Normal

MCV 93.0 80.0-100.0 Normal

MCH 32.3 27.0-34.0 Normal

MCHC 34.7 31.0-37.0 Normal

PLATELETE 282.00 150-400 Normal

COUNT

RDW 10.5 11.0-16.0 Normal

28
 URINALYSIS

August 28, 2018

ITEM NAME MARK RESULT REFERENCE SIGNIFICANCE

RANGE

UROBILINOGEN Normal 17.0 3.4-17.0 Normal

BILIRUBIN 1+ 17.00 0-16 Bilirubinuria

KETONE Negative 0-0.4 Negative

BLOOD Negative Negative

PROTEIN 3+ >=3.0 0-0.1 Proteinuria

MICROALBUMIN 150.0 10-20 Microalbuminuria

NITRATE Positive Negative UTI

LEUKOCYTES Negative <Ca15 Negative

GLUCOSE Negative 0-5.6 Negative

PH 5.5 5.9 Acidic

Specific Gravity 1.043 1.015-1.025 Hypersthenuria

COLOR Orange UTI

Turbidity Clear Normal

MUCUS 119 0-28 UTI

29
 BLOOD CHEMISTRY

August 29, 2018

EXAMINATION RESULT REFEREANCE SIGNIFICANCE

Sodium 132.2 135-145 mmol/L Normal

Potassium 3.12 3.5-5.5 mmol/L Normal

Chloride 99.60 98-108 mmol/L Normal

30
 ANATOMY AND PHYSIOLOGY
(DIGESTIVE SYSTEM)

The digestive tract, also called the alimentary canal or gastrointestinal (GI) tract, consists
of a long continuous tube that extends from the mouth to the anus. It includes the mouth,
pharynx, esophagus, stomach, small intestine, and large intestine. The tongue and teeth are
accessory structures located in the mouth. The salivary glands, liver, gallbladder, and pancreas
are major accessory organs that have a role in digestion.

Food undergoes three types of processes in the body:

 Digestion
 Absorption
 Elimination

Digestion and absorption occur in the digestive tract. After the nutrients are absorbed,
they are available to all cells in the body and are utilized by the body cells in metabolism.

The digestive system prepares nutrients for utilization by body cells through six activities, or
functions.

1. Ingestion. The first activity of the digestive system is to take in food through the mouth. This
process, called ingestion, has to take place before anything else can happen.
2. Mechanical Digestion. The large pieces of food that are ingested have to be broken into
smaller particles that can be acted upon by various enzymes.
3. Chemical Digestion. Through a process called hydrolysis, uses water and digestive enzymes
to break down the complex molecules. Digestive enzymes speed up the hydrolysis process,
which is otherwise very slow.
4. Movements. After ingestion and mastication, the food particles move from the mouth into
the pharynx, then into the esophagus. This movement is deglutition, or swallowing. Mixing
movements occur in the stomach as a result of smooth muscle contraction.
5. Absorption. The simple molecules that result from chemical digestion pass through cell
membranes of the lining in the small intestine into the blood or lymph capillaries. This
process is called absorption.
6. Elimination. The food molecules that cannot be digested or absorbed need to be eliminated
from the body. The removal of indigestible wastes through the anus, in the form of feces, is
defecation or elimination.

31
Digestive Organs

The digestive system is a group of organs (Buccal cavity (mouth), pharynx, oesophagus,
stomach, liver, gall bladder, jejunum, ileum and colon) that breakdown the chemical components
of food, with digestive juices, into tiny nutrients which can be absorbed to generate energy for
the body.

The Buccal Cavity

Food enters the mouth and is chewed by the teeth, turned over and mixed with saliva by the
tongue. The sensations of smell and taste from the food sets up reflexes which stimulate the
salivary glands.

The Salivary glands

Saliva lubricates the food enabling it to be swallowed and contains the enzyme ptyalin which
serves to begin to break down starch.

32
The Pharynx

Situated at the back of the nose and oral cavity receives the softened food mass or bolus by the
tongue pushing it against the palate which initiates the swallowing action.

The Oesophagus

The oesophagus travels through the neck and thorax, behind the trachea and in front of
the aorta. The food is moved by rhythmical muscular contractions known as peristalsis (wave-
like motions) caused by contractions in longitudinal and circular bands of muscle.

The Stomach

The stomach lies below the diaphragm and to the left of the liver. It is the widest part of
the alimentary canal and acts as a reservoir for the food where it may remain for between 2 and 6
hours. Here the food is churned over and mixed with various hormones, enzymes including
pepsinogen which begins the digestion of protein, hydrochloric acid, and other chemicals; all of
which are also secreted further down the digestive tract.

Small Intestine

The small intestine measures about 7m in an average adult and consists of the duodenum,
jejunum, and ileum. Both the bile and pancreatic ducts open into the duodenum together. The
small intestine, because of its structure, provides a vast lining through which further absorption
takes place.

The Pancreas

The Pancreas is connected to the duodenum via two ducts and has two main functions:

1. To produce enzymes to aid the process of digestion

2. To release insulin directly into the blood stream for the purpose of controlling blood
sugar levels

The Liver

The liver, which acts as a large reservoir and filter for blood, occupies the upper right portion
of abdomen and has several important functions:

1. Secretion of bile to the gall bladder

2. Carbohydrate, protein and fat metabolism
3. The storage of glycogen ready for conversion into glucose when energy is required.

33
 4. Storage of vitamins
5. Phagocytosis - ingestion of worn out red and white blood cells, and some bacteria

The Gall Bladder

The gall bladder stores and concentrates bile which emulsifies fats making them easier to
break down by the pancreatic juices.

The Large Intestine

The large intestine averages about 1.5m long and comprises the caecum, appendix, colon,
and rectum. After food is passed into the caecum a reflex action in response to the pressure
causes the contraction of the ileo-colic valve preventing any food returning to the ileum. Here
most of the water is absorbed, much of which was not ingested, but secreted by digestive glands
further up the digestive tract.

34
 ANATOMY AND PHYSIOLOGY
(APPENDIX)

Appendix is a tube-shaped
organ with a length of approximately
10 cm and the stem on the cecum. It
sits at the junction of the small
intestine and large intestine.
Sometimes the position of the
appendix in the abdomen may vary.
Most of the time the appendix is in
the right lower abdomen, but the
appendix, like other parts of the
intestine has a mesentery. This
mesentery is a sheet-like membrane that attaches the appendix to other structures within the
abdomen. If the mesentery is large it allows the appendix to move around.

In addition, the appendix may be

longer than normal. The combination of a
large mesentery and a long appendix
allows the appendix to dip down into the
pelvis (among the pelvic organs in
women) it also may allow the appendix to
move behind the colon (a retrocolic
appendix).

35
 PATHOPHYSIOLOGYOF APPENDICITIS
(SCHEMATIC DIAGRAM)

PRECIPITATING FACTORS
 Diet (chicken feet)
PREDISPOSING FACTORS  Smoker
 Age (23 y.o.)  Constipation (Fecalithe
 Sex (Male) matter)

Obstruction of the appendix by

fecalithe (hardened stool), lymph
nodes, tumor, and foreign objects

Right Lower Increased intraluminar pressure inside Pale, facial grimace, and
Quadrant Pain the appendix that result to distention of abdominal guarding
appendix

Normal bacteria found in appendix

begin to invade (infect) the lining of the
wall

↑ WBC result Inflammatory response – body

(21.40) Ref. 4.00- response to the bacterial invasion in the s/sx: abdominal pain
10.00 wall of appendix. ,guarding, fever, and
Increased immune complex (disease increased swelling of
appendix
plus antibody) causes swelling of tissue
vomiting, and loss of
resulting to inflammation of appendix.
appetite

Exploratory laparotomy,
Appendectomy
(site: lower part distal from naval
area; 8 inches longitudinal incision
with 9 transverse stitches

Inflammation and infection spread

through the wall of the appendix
causing death of tissue. The appendix
36
ruptures due to increased pressure
 Perforation (formation of a hole in an
organ), fecal materials exits to
peritoneal cavity causing formation of
abscess (periappendiceal abscess).
Infection spreads throughout the
abdomen (peritoneal cavity)

s/sx: swelling of the

abdomen, acute pain,
Bacteria invasion of peritoneal cavity and weight loss
causing inflammation of the membrane
that lines the abdomen peritoneum
(peritonitis)

If not treated If treated

Septic shock Exploratory laparotomy,

s/sx: 1. Decrease blood Appendectomy
pressure
2. decrease blood volume
Prescribed antibiotic
(Cefoxitin,Metronidazole)

Coma

Fluid volume replacement

therapy (D5NSS 50 gtts/min)
DEATH

LEGENDS: RECOVERY

Risk Factor Management Pathology

Manifestation Diagnostic/
Lab Tests

37
 DRUG STUDY # 1

Generic Name: Metronidazole

Brand Name: Zolnid
Classification: Antibiotic
Dosage ordered: 500 mg IV drip q 8 hours
Mechanism of action: May cause bactericidal effect by interacting with DNA.
Indication: Treatment for infection of the colon caused by C. difficile and infections caused
by H. pylori.
Contraindication: Contraindicated in patients hypersensitive to drug or its ingredients, such
as parabens, and other nitroimidazole derivatives. Use cautiously in patients with
history or evidence of blood dyscrasia and in those with hepatic impairment.
Adverse action: CNS: headache, numbness, seizures
GI: nausea, loss of appetite, metallic taste,
Nursing Implications:
 Discontinue therapy immediately if symptoms of CNS toxicity develop.
Monitor especially for seizures and peripheral neuropathy.
 Lab tests: Obtain total and differential WBC counts before, during, and after
therapy, especially if a second course is necessary.
 Monitor for S&S of sodium retention, especially in patients on corticosteroid
therapy or with a history of CHF.
 Monitor patients on lithium for elevated lithium levels.
 Caution to patient to avoid alcohol while in therapy.

38
 DRUG STUDY # 2

Generic Name: Tramadol hydrochloride

Brand Name: Ultram
Classification: Synthetic, centrally active analgesic
Dosage Ordered: 50 mg IVTT PRN for pain
Mechanism of action: Unknown. Thought to bind to opioid receptors and inhibit reuptake of
norepinephrine and serotonin.
Indication: To relieve from moderate to moderately severe pain.
Contraindication: Contraindicated in patients hypersensitive to drug or other opioids, and in
those with intoxication from alcohol, hypnotics, centrally acting analgesic, opioids
or psychotropic drugs. Serious hypersensitive reactions can occur, usually after the
first dose. Patients with history of anaphylactic reaction to codeine and other
opioids may be at increased risk. Use cautiously in patients at risk for seizures or
respiratory depression; in patients with increased intracranial pressure or head
injury, acute abdominal conditions, or renal or hepatic impairment; or in patients
with physical dependence on opioids.
Adverse Reaction: CNS: dizziness, headache, somnolence, vertigo, seizure
GI: constipation, nausea, vomiting
Respiratory: respiratory depression
Nursing Responsibilities:
 Reassess patient’s level of pain at least 30 minutes after administration.
 Monitor CV and respiratory status. Withhold dose and notify prescriber if
respirations are shallow or rate is below 12 breaths/minute
 Monitor bowel and bladder function. Anticipate for stimulant laxative.
 Monitor patients at risk for seizures. Drug may reduce seizure threshold.
 Withdrawal symptoms may occur if stopped abruptly. Reduce dosage gradually.
 Tell patient to take drug as prescribed and not to increase dose or dosage interval
unless ordered by prescriber.
 Caution ambulatory patient to be careful when rising and walking. Warn outpatient
to avoid driving and other potentially hazardous activities that require mental
alertness until drug’s CNS effects are known.

39
 DRUG STUDY # 3

Generic Name: Omeprazole

Brand Name: Prilosec
Classifications: Proton pump inhibitor
Dosage: 40 mg, IV, OD

Actions: An antisecretory compound that is a gastric acid pump inhibitor. Suppresses gastric
acid secretion by inhibiting the H+, K+-ATPase enzyme system [the acid (proton H+) pump] in
the parietal cells.

Indications: Duodenal and gastric ulcer. Gastroesophageal reflux disease including severe
erosive esophagitis (4 to 8 wk treatment). Long-term treatment of pathologic hypersecretory
conditions such as Zollinger-Ellison syndrome, multiple endocrine adenomas, and systemic
mastocytosis. In combination with clarithromycin to treat duodenal ulcers associated with
Helicobacter pylori.

Contraindications: Long-term use for gastroesophageal reflux disease, duodenal ulcers;

lactation.

Adverse effects:
CNS: Headache, dizziness, fatigue.
GI: Diarrhea, abdominal pain, nausea, mild transient increases in liver function tests.
Urogenital: Hematuria, proteinuria.
Skin: Rash

Nursing implications:

• Report any changes in urinary elimination such as pain or discomfort associated with
urination, or blood in urine.

• Report severe diarrhea; drug may need to be discontinued.

• Do not breast feed while taking this drug.

40
 DRUG STUDY # 4

Generic Name: Ketorolac

Brand Name: Acuvil
Classifications: NSAID, Nonopoid Analgesic
Dosage: 30 mg, IVTT, Q 6 hrs.

Actions: Anti-inflammatory and analgesic activity; inhibits prostaglandin and leukotriene

synthesis.

Indications: short term management for pain.

Contraindications: contraindicated with significant renal impairment, during labor and delivery,
lactation, patient wearing contact lenses, aspirin allergy.

Adverse effects:
CNS: Headache, dizziness, fatigue.
GI: Diarrhea, abdominal pain, nausea, mild transient increases in liver function tests.
Urogenital: Hematuria, proteinuria.
Skin: Rash,pruritus

Nursing implications:

• Report any changes in urinary elimination such as pain or discomfort associated with
urination, or

blood in urine.

• Reassess patient’s level of pain at least 30 minutes after administration.

• Report severe diarrhea; drug may need to be discontinued.

• Do not breast feed while taking this drug.

41
 DRUG STUDY # 5

Generic Name: Cefoxitin

Classification: Antibiotic
Dosage ordered: 1g IV drip q 8 hours
Mechanism of action: Bactericidal inhibits the synthesis of bacterial cell wall, causing cell
death.
Indication: Treatment for infection of the colon caused by C. difficile and infections caused
by H. pylori.
Contraindication: Contraindicated in patients hypersensitive to drug or its ingredients, such
as parabens, and other nitroimidazole derivatives. Use cautiously in patients with
history or evidence of blood dyscrasia and in those with hepatic impairment.
Adverse action: CNS: headache, numbness, seizures
GI: nausea, loss of appetite, metallic taste,
Nursing Implications:
 Discontinue therapy immediately if symptoms of CNS toxicity develop.
Monitor especially for seizures and peripheral neuropathy.
 Lab tests: Obtain total and differential WBC counts before, during, and after
therapy, especially if a second course is necessary.
 Monitor for S&S of sodium retention, especially in patients on corticosteroid
therapy or with a history of CHF.
 Monitor patients on lithium for elevated lithium levels.
 Caution to patient to avoid alcohol while in therapy.

42
 POST APPENDECTOMY

NCP 1

ASSESSMENT

Subjective:

“Sakit pa ag tinahian sir” As verbalized by the patient

Objective:

 Facial grimace
 Irritable
 Guarding behavior
 Dry and intact surgical incision in the hypogastric abdominal region
 Pain scale 6 out of 10

DIAGNOSIS

Acute pain r/t surgery (appendectomy)

PLANNNG

After 30 minutes of nursing intervention the patient will be able to verbalized reduction
of pain scale from 6 to 4.

INTERVENTION

 Encourage patient to verbalize about pain.

R: Promotes cooperation from the client.
 Provide comfort measures such as deep breathing exercise.
R: This calms and soothes the patient.
 Encourage diversional activities such as watching TV, listening to the music etc.
R: To divert the attention from pain.
 Provide therapeutic touch.
R: To promote feeling of comfort.
 Increase intake of vitamin C.
R: To promotes healing of wound.
 Monitor Vital Signs.
R: An information baseline comparison from previous data.

Collaborative:

 Administer ketorolac 30mg Q6hrs as ordered.

43
 R: To comply with the physician ordered.

EVALUATION

Goal met, After 30 minutes of nursing intervention the patient was able to verbalized
reduction of pain scale from 6 to 4.

44
 NCP 2

ASSESSMENT

Objective:

 Surgical incision in the hypogastric abdominal region

 Dry dressing at surgical site

DIAGNOSIS

Risk for infection r/t post surgical dressing at hypogastric abdominal region

PLANNING

After 1 hr of nursing interventions the patient will be able to verbalize understanding of

and willingness to follow up the prescribed regimen and will be free from localized signs and
symptoms of infection.

INTERVENTIONS

Independent:

 Note risk factors for occurrence of infection.

R: To evaluate presence or character of infection
 Assess and document skin conditions, noting inflammation and drainage.
R: To check skin integrity, monitor progress of healing and identify need for
further.
 Cleanse the incision site with appropriate solution.
R: To prevent infection in the area.
 Administer and instruct precautions regarding medication regimen and note client
response.
R: To determine the effectiveness of therapy and if there is a presence of side
effects.
 Emphasize necessity of taking antibiotics as ordered.
R: To inform the client the risk of discontinuation of treatment.
 Review environmental factors.
R: To assess if there’s a need of avoidance or modification of environment to
reduce incidence of infection.

Collaborative:

 Administer antibacterial ( Cefoxitin ) 1g Q8hrs as prescribed by physician.

45
 R: To prevent intra abdominal infections.

EVALUATION

Goal met, After 1 hr of nursing interventions the patient will be able to verbalize
understanding of and willingness to follow up the prescribed regimen and will be free from
localized signs and symptoms of infection.

46
 NCP 3

ASSESSMENT

Objective:

 Surgical incision in the hypogastric abdominal region

 Redness on the skin surrounding the incision site
 Injury on the skin layers

DIAGNOSIS

Impaired skin integrity r/t skin tissue trauma in the hypogastric abdominal region

PLANNING

After 3-4 days of nursing interventions the patient will be able to maintain normal skin
integrity and intact wound, shows sign of wound healing and no redness on the surrounding area.

INTERVENTIONS

Independent:

 Assess operation site for redness, swelling, loose sutures or soaked dressing.
R: To check skin integrity, monitor progress of healing and identify need for
further.
 Keep the area clean and dry.
R: Moistures harbors bacteria and pathogens.
 Provide splinting pillow.
R: Splinting provide support to the area.
 Carefully dress wound.
R: To prevent infection.
 Increase protein and vitamin C.
R: To promote wound healing.
 Support incision as in splinting when coughing and during movements.
R: To reduce pressure on the operation site.
 Encourage patient to verbalized his any untoward feelings especially pain and
discomfort.
R: To allow continues monitoring and assessment of the patient condition.

47
EVALUATION

Goal met, after 3-4 days of nursing interventions the patient was able to maintain normal
skin integrity and intact wound , shows sign of wound healing and no redness on the surrounding
area.

48
 NCP 4

ASSESSMENT

Subjective:

“Dili pa ako maka lingas-lingas pag ajo” As verbalized by the patient.

Objective:

 Restlessness
 Surgical incision in the hypogastric abdominal region
 Irritable

DIAGNOSIS

Activity intolerance r/t presence of surgical incision as manifested by limited mobility

PLANNING

After 8 hours of nursing interventions the patient will be able to exhibit tolerance during
physical activity and ability to performed required activity of daily living.

INTERVENTIONS

 Note the presence of medical diagnosis regimen.

R: This may have potential for interfering with client’s ability to perform at a desire level
of activity.
 Determined current activity/physical condition with observation, exercise and tolerance
testing.
R: Provides baseline for comparisons and opportunity to track changes.
 Implement physical therapy exercise with client and team members.
R: Coordination of program enhances likelihood of success.
 Instruct client in unfamiliar activities and alternative ways of doing familiar activities.
R: To conserve energy and promote safety.
 Have the patient perform the activity more slowly, in a longer time with more rest or
pauses, or with assistance if necessary.
R: Helps in increasing the tolerance for the activity.
 Gradually increase activity with active range-of-motion exercises in bed, increasing to
sitting and then standing.

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 R: Gradual progression of the body prevents overexertion.
 Dangle the legs from the bed side for 10-15 minutes.
R: Prevents orthostatic hypotension.
 Refrain from performing nonessential activities or procedures.
R: Patient with limited activity tolerance need to prioritize important tasks first.
 Assist with ADLs while avoiding patient dependency.
R: Assisting the patient with ADLs allows conservation of energy.

EVALUATION

Goal met, After 8 hours of nursing interventions the patient was able to exhibit tolerance
during physical activity and ability to performed required activity of daily living.

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 DISCHARGE PLAN

Upon discharge from Caraga Regional Hospital, the patient as well as the SO will be
given a home care instruction which contains the following:

MEDICATION:

 Advice patient to take his medications on time as per advice by the physician such as:
 Cefoxitin 1g BID
 Mefenamic Acid 500mg BID

ENVIRONMENTAL CONCERNS:

 Instructed patient to provide a peaceful relaxing, comfortable and well ventilated room
 Instructed patient to provide a stress free environment
 Instructed patient to follow the prescribed meal plan
 Instructed to provide clean environment to prevent lodging of infectious microorganisms.
 Changes in his environment can aid in his recovery by making it easier for him to bathe,
dress and prepare meals while his muscles return to normal levels of strength

TREATMENTS:

 Discussed on the importance of strict adherence to medication regimen to ensure

complete wound healing.
 Instructed patient to understand and follow discharge instruction religiously and
accurately.
 Instructed patient to follow proper instruction on medication prescribed by the physician
 Reinforced proper incision care.

HEALTH TEACHINGS:

 Review information about medications to be taken at home, including name, dosage,

frequency and possible side effects, discussed the importance of continuing to take
 Patient is counseled regarding importance of eating meals on time and in a relaxed
setting.
 Instructed Patient to avoid any strenuous activities, until the incision completely healed.
 Keep incision site dry and clean.
 Notify MD if s/sx of infection noted. (ex: fever, chills, redness around the incision, and
any discharges.)

OUT PATIENT (FOLLOW UP CHECK-UP)

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  Patient is advised for follow up check up to his physician one (1) week after discharge
 Instructed patient to notify physician of there is any undesired feeling about the disease

DIET

 Advised patient to avoid raw foods, fruits and vegetables that contain seeds (e.g. guava,
tomatoes, )
 Advised to eat foods rich in protein and Vitamin C for wound healing.

SPIRITUAL

 Encourage patient to go church and pray regularly together with his whole family. Never
forget to thank god for all the blessings he and his family has been receiving.
 Advised patient to find time with his family members and friends and share the good
news written in the bible.
 Encouraged SO to pray for the health of the patient.

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 INTRAVENOUS FLUID

BOTTLE DATE AUDITIVE SOLUTION DROP RATE

VOLUME

1 8-28-18 D5LR 1L 20 gtts/min

2 8-30-18 D5LR 1L 20 gtts/min

VITAL SIGNS

Time / Date Blood Pulse Rate Respiratory Temperature SpO2

Pressure Rate

9/3/18

8 am 110/80 82 20 37 -----

12nn 120/80 80 20 36.5 -----

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GENOGRAM

Mother
Father
Age: 55
Age: 60
Arthritis
Heart Attack

Patient
Eldest Sister Age: 23
Periappendiceal
Age: 35
Abcess

LEGEND:

Women

Men

Deceased

Alive

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 DEFINITION OF TERMS

1. Appendectomy – surgical removal of the vermiform of appendix.

2. Appendicitis - inflammation of the vermiform appendix called also epityphlitis.

3. Appendix – a bodily outgrowth or specifically processed.
4. Blumberg sign - also referred as rebound tenderness. Deep palpation of the viscera over
the suspected inflamed appendix followed by sudden release of the pessue causes the
severe pain on the site indicating positing Blumberg’s sign and peritonitis.
5. Dunphy’s sign - increased pain in the right lower quadrant with coughing.

6. Fecalithe - a concretion of dry compact feces formed in the intestine or vermiform

appendix.
7. Hematocrit (Ht or HCT) or packed cell volume (PCV) or erythrocyte volume
fraction (EVF) - is the proportion of blood volume that is occupied by red blood cells. It
is normally about 48% for men and 38% for women. It is considered an integral part of a
person'scomplete blood count results, along with hemoglobin concentration, white blood
cell count, and platelet count.
8. IgA - has two subclasses (IgA1 and IgA2) and can exist in a dimeric form called
secretory IgA (sIgA). In its secretory form, IgA is the main immunoglobulin found in
mucous secretions, including tears, saliva, colostrum and secretions from the
genitourinary tract, gastrointestinal tract, prostate and respiratory epithelium. It is also
found in small amounts in blood.
9. Kocher’s Sign - the appearance of pain in the epigastric region or around the stomach at
the beginning of disease with a subsequent shift to the right iliac region.
10. Laparotomy – surgical section of the abdominal wall.
11. Obturator sign - if an inflamed appendix is in contact with the obturator internus, spasm
of the muscle can be demonstrated by flexing and internal rotation of the hip. This
maneuver will cause pain in the hypogastrium.
12. Perforation - a rupture in a body part caused especially by accident or disease and/or a
natural opening in an organ or body part.

13. Peritoneum - the smooth transparent serous membrane that lines the cavity of the
abdomen of a mammal, is folded inward over the abdominal and pelvic viscera, and
consists of an outer layer closely adherent to the walls of the abdomen and an inner layer
that folds to invest the viscera.
14. Peritonitis – inflammation of the peritoneum.

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15. Psoas sign - is the right lower-quadrant pain that is produced with either the passive
extension of the patients right hip (pt. lying on the left side, with knee in flexion) or the
patient’s active flexion of the right hip while supine. Straightening out the legs causes
pain because it stretches these muscles, while flexing the hip activated the iliopsoas and
therefore causes pain.
16. Rovsing’s sign - continuous deep palpation starting from the left iliac fossa upwards
(counterclockwise along the colon) may cause pain in the right iliac fossa, by pushing
bowel contents towards the ileocaecal valve and thus increasing pressure around the
appendix.
17. Stikovskiy (resenstein’s) sign - increased pain on palpation at the right iliac region as
patient lies on his/her left side.
18. Ultrasound - is cyclic sound pressure with a frequency greater than the upper limit of
human hearing. Although this limit varies from person to person, it is approximately 20
kilohertz (20,000 hertz) in healthy, young adults and thus, 20 kHz serves as a useful
lower limit in describing ultrasound. The production of ultrasound is used in many
different fields, typically to penetrate a medium and measure the reflection signature or
supply focused energy. The most well known application of ultrasound is its use in
sonography to produce pictures of fetuses in the human womb. There are a vast number
of other applications as well.
19. Vermiform – a resembling worm in shape.
20. Vermiform Appendix - a narrow blind tube usually about three or four inches (7.6 to
10.2 centimeters) long that extends from the cecum in the lower right-hand part of the
abdomen, has much lymphoid wall tissue, normally communicates with the cavity of the
cecum, and represents an atrophied terminal part of the cecum.

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 BIBLIOGRAPHY

A. Textbook References

 Assessment: Lippincott; 2007 Edition.

 Fundamentals of Nursing: Kozier and Erb; 8th Edition.
 Medical-Surgical of Nursing: Bunner and Suddarth; 12th Edition.
 NANDA: Doenges, Moorhouse and Murr; 12th Edition.
 Nursing Drug Guide: Lippincott; 2010 Edition.

B. Online Sources

 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001302/
 http://www.webmd.com/digestive-disorders/digestive-diseases-appendicitis
 http://kidshealth.org/parent/infections/stomach/appendicitis.html
 http://en.wikipedia.org/wiki/Appendectomy
 http://www.appendicitisreview.com/laparoscopic-appendectomy/
 http://medical-dictionary.thefreedictionary.com/Ruptured+appendix

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