I.

Patient’s Data

I. General Data

Patient’s. Name: Mrs Kliyente

Sex: female
Age: 53 y/o
Date of Birth: May 20, 1955
Civil status: Married
Citizenship: Filipino
Current Address: Magsaysay Area, Brgy. Sto. Cristo Tala Caloocan City
Religion: Catholic
Occupation: Employer (Carinderia owner)
Room and Bed number:
Hospital number: 52-56-34
Chief Complaint: Abdominal pain
Admitting Diagnosis: t/c Periappendical Abscess
Admission Date and Time: January 27, 2009- 5: 00 pm
Final Diagnosis: Periappendical abscess s/p Exploratory Laparotomy

II Chief Complaint: Abdominal pain

III History of Present illness:

4 weeks prior to admission patient experienced abdominal pain at RLQ of the

abdomen with a pain scale of “10” accompanied by recurrent fever at night and resolved
by paracetamol affording temporary relief of fever. Patient also experienced nausea,
anorexia. Constipation was managed by taking suppository 3x a week. Pt. also took two
tablets of Buscupan in the morning and afternoon for abdominal pain once but didn’t take
effect. Persistence of the condition pt. consulted St. Peter hospital but no diagnosis and
medication given.

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 3 weeks prior to admission patient experienced consistent Right Lower Quadrant
abdominal pain, recurrent fever, nausea constipation, and anorexia. With continuous pain
pt seek consultation at FEU Fairview but no clear diagnosis has been given but given
Cefuroxime and Metronidazole for UTI. Still with persistent abdominal pain pt still used
suppository for temporary relief.
2 weeks prior to admission persistence of above condition, as advised by
personnel’s from FEU Fairview, patient undergone CT scan and Health scan. Still patient
used suppository for temporary relief of constipation and abdominal pain.
A week prior to admission with unfailing occurrence of above condition, patient
prompted to seek consultation of EAMC OPD with the CT scan result. No diagnosis and
medication has been given. Patient still used suppository and stopped using UTI
medications.
Few hours prior to admission patient came back at EAMC still with the CT scan
result and above condition; patient is diagnosed with a leaked abcess from the appendix
T/C “periappendecal abscess” based on the CT scan result. Patient was given Cefuroxime
for abdominal pain w/c took effect and subsequently admitted. CBC laboratory procedure
done and no other exams was done.

IV Past Medical History

Patient has no previous hospitalization, no history of HPN, DM, BA, no known

allergies.

V Family Medical History

(+) DM – brother
(+) Appendicitis – daughter

VI Personal and Social Data

Non smoker nor alcoholic drinker

No specific sleeping pattern. The Client prefers vegetables and Fluid Intake one
glass per meal approximately 3-4 times a day.
Own a Carinderia

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VII Review of System

General/Constitutional

• (-)Weight loss or gain

• (-)Fatigue
• (-)Headache
• (+)Weakness
• (+)Restlessness
• (-)Trouble sleeping
• (+) Activity Intolerance

Skin
• (-)Rash,
• (-)Itching,
• (-)Pigmentation
• (+)Dryness
• (-)Nail changes

Eyes/Ears/Nose/Mouth/Throat
• (+) Headaches
• (-) Vertigo
• (-) Lightheadedness
• (-) Injury
• (-) Double vision
• (-) Tearing
• (-) Pain
• (-) Nose bleeding
• (-) Colds
• (-) Obstruction
• (-) Discharge
• (+)Dental difficulties
• (-) Gingival bleeding
• (-) Dentures
• (+) Difficulty chewing
• (-) Neck stiffness
• (-) Tenderness

Cardiovascular
• (-)Chest pain
• (-) Substernal distress
• (-) Palpitations
• (-) Syncope
Respiratory
• (-) Pain

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• (-) Cough
• (-) Hemoptysis
• (-) Dyspnea on exertion,
• (-) Orthopnea
• (+) Tachynea

Gastrointestinal
• (+)Anorexia
• (-) Dysphagia,
• (-) Food idiosyncrasy
• (-) Abdominal pain
• (-) Heartburn
• (-) Eructation
• (-) Nausea
• (-) Vomiting
• (-) Hematemesis,
• (+) Constipation
• (-) Flatulence
• (-) Hemorrhoids

Genitourinary
• (-) Urgency
• (-) Frequency
• (-) Dysuria
• (-) Nocturia
• (-) Polyuria
• (-) Oliguria

Musculoskeletal
• (-) Pain
• (-) Swelling
• (-) Redness or heat of muscles and joints
• (+) Muscular weakness
• (-) Cramps

Neurologic:

• (-) Dizziness
• (-) Lightheadedness
• (-) Numbness
• (-) Tremor

Psychiatric:
• (+) Nervousness
• (+) Stress
• (+) Restlessness

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VIII Physical Examination

Date of Assessment: January 29, 2009

Vital Signs:
Blood Pressure: 110/80 mmHg
Pulse Rate: 110 bpm
Respiratory Rate: 24 bpm
Temperature: 37.7 degrees Celsius (Febrile)
Stool: once a week
General Appearance:
Medium frame built, stooped posture, smooth rhythmic gait, appropriate
dressed, no body and breath odor and obvious physical deformity.
Mental Status/ Neurologic:
Conscious, oriented, anxious, uses simple words for communication.
Integument:
Flushed, warm and dry skin, no edema in extremities,
no lesions, decreased skin turgor, concave nail plate shape,
smooth pink nail bed color and capillary refill within 3 seconds.
Head and Face:
Skull is proportionate to body size, white scalp; partly black to gray shinny
evenly distributed hair. Face is symmetrically and easy facial movement.

Eyes:
Thin eyebrows, effective closure of eyelids and lashes,
bilateral blink response, eyeballs are symmetrical, pinkish bulbar
conjunctiva, white sclera, equal pupils and moist lacrimal apparatus.
Ears:
Auricle color is normal racial, symmetrical and elastic, pinna recoils when
folded, some cerumen in external canal, no aural discharge & responds to
normal voice.

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Nose:
Normal external racial tone, midline septum, pink mucosa, moist nasal
cavity, with non tender sinuses.
Mouth:
Pallor in the lips & mucosa, midline tongue, smooth and movable,
teeth incomplete.
Pharynx:
Pallor in mucosa, none inflamed tonsil, gag reflex present.
Neck:
ROM neck muscle; palpable non tender lymph nodes, midline trachea,
palpable thyroid gland.
Breast and Axilla:
Sagging, smooth & palpable non tender lymph nodes.
Chest and Lungs:
Symmetrical fremitus, shallow breathing, resonant percussion, heart rate at
110 cpm, pulmonic, aortic, tricuspid and apical heart sounds present.
Abdomen:
Normal racial tone of the skin, flat contour and symmetry, symmetrical
movement, hypoactive bowel sounds, negative in rovsing’s sign and Mc
Burney’s sign.(direct maneuver)

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X Course in the Ward

January 29, 2009 Received patient lying in bed, very anxious looking, waiting
for the impending surgery. On DAT diet and will progress to
NPO diet post midnight, with no contraptions attached. Vital
Signs taken and recorded. Patient was febrile (37.7 C)

January 30, 2009 The patient was scheduled for surgery (Exploratory
laprotomy), very anxious yet conscious and coherent
However the surgery was cancelled because she has no CP
clearance so the surgery was rescheduled on Tuesday (Feb.
02). V/S has been taken & recorded. Patient was febrile
(37.8 C)

February 05, 2009

Received patient. on bed on its second day post-OP,
conscious and coherent. Tense and weak in appearance,
facial grimacing when surgery incision border is palpated,
and verbally reported pain at both sides of abdominal area
with the score of 6. With on going IVF of D5LR at 300cc
level infusing at KVO rate and heplock at the right arm kept
intact. With abdominal elastic bandage dressing then
changed to abdominal sterile gauze dressing kept dry and
clean. On NPO diet and progressed to sips of water.

February 06, 2009

At 8:00 am the pt. was febrile (37.6*c) done TSB. The pt.
was on IVF of D5LR at 800cc level infusing at KVO rate
and instructed on moderate high back rest. Still on sips of
water diet, vital signs taken & recorded.

XI Final Diagnosis: Periappendical abscess s/p Explore Laparotomy

II Review of Related Literature

7
What is Appendicitis?

The appendix is a closed-ended, narrow tube up to several inches in length 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 open center of 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, but the muscle is poorly developed.

What is appendicitis and what causes appendicitis?

Appendicitis means inflammation of the appendix. 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. This rock is called a fecalith (literally, a rock of stool). At other times, the
lymphatic tissue in the appendix may swell and block the appendix. After the blockage
occurs, bacteria which normally are found within the appendix begin to invade (infect)
the wall of the appendix. The body responds to the invasion by mounting an attack on the
bacteria, an attack called inflammation. An alternative theory for the cause of appendicitis
is an initial rupture of the appendix followed by spread of bacteria outside the appendix..
The cause of such a rupture is unclear, but it may relate to changes that occur in the
lymphatic tissue, for example, inflammation, that line the wall of the appendix.)
If the inflammation and infection spread through the wall of the appendix, the appendix
can rupture. After rupture, infection can spread throughout the abdomen; however, it
usually is confined to a small area surrounding the appendix (forming a peri-appendiceal
abscess).

Sometimes, the body is successful in containing ("healing") the appendicitis without

surgical treatment if the infection and accompanying inflammation do not spread

8
throughout the abdomen. The inflammation, pain and symptoms may disappear. This is
particularly true in elderly patients and when antibiotics are used. The patients then may
come to the doctor long after the episode of appendicitis with a lump or a mass in the
right lower abdomen that is due to the scarring that occurs during healing. This lump
might raise the suspicion of cancer.

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What are the complications of appendicitis?

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

appendix can lead to a Periappendiceal 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.

A less common complication of appendicitis is blockage 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.

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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.

What are the symptoms of appendicitis?

The main symptom of appendicitis is abdominal pain. The pain is at first diffuse and
poorly localized, that is, not confined to one spot. (Poorly localized pain is typical
whenever a problem is confined to the small intestine or colon, including the appendix.)
The pain is so difficult to pinpoint that when asked to point to the area of the pain, most
people indicate the location of the pain with a circular motion of their hand around the
central part of their abdomen. A second, common, early symptom of appendicitis is loss
of appetite which may progress to nausea and even vomiting. Nausea and vomiting also
may occur later due to intestinal obstruction.

As appendiceal inflammation increases, it extends through the appendix to its outer

covering and then to the lining of the abdomen, a thin membrane called the peritoneum.
Once the peritoneum becomes inflamed, the pain changes and then can be localized
clearly to one small area. Generally, this area is between the front of the right hip bone
and the belly button. The exact point is named after Dr. Charles McBurney--McBurney's
point. If the appendix ruptures and infection spreads throughout the abdomen, the pain
becomes diffuse again as the entire lining of the abdomen becomes inflamed.

Rovsing's sign

Deep palpation of the left iliac fossa may cause pain in the right iliac fossa. This is the
Rovsing's sign, also known as the Rovsing's symptom. It is used in the diagnosis of acute
appendicitis. Pressure over the descending colon causes pain in the right lower quadrant
of the abdomen.

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McBurney’s Sign

McBurney's sign, is a sign of acute appendicitis.[2] The clinical sign of rebound pain
when pressure is applied is also known as Aaron's sign.

Specific localization of tenderness to McBurney's point indicates that inflammation is no

longer limited to the lumen of the bowel (which localizes pain poorly), and is irritating
the lining of the peritoneum at the place where the peritoneum comes into contact with
the appendix. Tenderness at McBurney's point suggests the evolution of acute
appendicitis to a later stage, and thus, the increased likelihood of rupture. Because the
location of the appendix is often different in different people, and can migrate within the
abdomen, many cases of appendicitis do not cause point tenderness at McBurney's point.
Other abdominal processes can also sometimes cause tenderness at McBurney's point.
Thus, this sign is highly useful but neither necessary nor sufficient to make a diagnosis of
acute appendicitis. Also, the anatomical position of the appendix is highly variable (for
example in retrocaecal appendix, an appendix behind the caecum), which also limits the
use of this sign.

Psoas sign

Occasionally, an inflamed appendix lies on the psoas muscle and the patient will lie with
the right hip flexed for pain relief.

Obturator sign

If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can
be demonstrated by flexing and internally rotating the hip. This maneuver will cause pain
in the hypogastrium.

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If the appendix curls around behind the cecum, pain and tenderness may be felt in the
lumbar region. If its tip is in the pelvis, these signs may be elicited only on rectal
examination. Pain on defecation suggests that the tip of the appendix is resting against the
rectum; pain on urination suggests that the tip is near the bladder or impinges on the
ureter.

How is appendicitis diagnosed?

The diagnosis of appendicitis begins with a thorough history and physical examination.
Patients often have an elevated temperature, and there usually will be moderate to severe
tenderness in the right lower abdomen when the doctor pushes there. If inflammation has
spread to the peritoneum, there is frequently rebound tenderness. Rebound tenderness is
pain that is worse when the doctor quickly releases his hand after gently pressing on the
abdomen over the area of tenderness.

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White Blood Cell Count

The white blood cell count in the blood usually becomes elevated with infection. In early
appendicitis, before infection sets in, it can be normal, but most often there is at least a
mild elevation even early. Unfortunately, appendicitis is not the only condition that
causes elevated white blood cell counts. Almost any infection or inflammation can cause
this count to be abnormally high. Therefore, an elevated white blood cell count alone
cannot be used as a sign of appendicitis.

Urinalysis

Urinalysis is a microscopic examination of the urine that detects red blood cells, white
blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is
inflammation or stones in the kidneys or bladder. The urinalysis also may be abnormal
with appendicitis because the appendix lies near the ureter and bladder. If the
inflammation of appendicitis is great enough, it can spread to the ureter and bladder
leading to an abnormal urinalysis. Most patients with appendicitis, however, have a
normal urinalysis. Therefore, a normal urinalysis suggests appendicitis more than a
urinary tract problem.

Abdominal X-Ray

An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece
of stool that blocks the appendiceal opening) that may be the cause of appendicitis. This
is especially true in children.

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Ultrasound

An ultrasound is a painless procedure that uses sound waves to identify organs within the
body. Ultrasound can identify an enlarged appendix or an abscess. Nevertheless, during
appendicitis, the appendix can be seen in only 50% of patients. Therefore, not seeing the
appendix during an ultrasound does not exclude appendicitis. Ultrasound also is helpful
in women because it can exclude the presence of conditions involving the ovaries,
fallopian tubes and uterus that can mimic appendicitis.

Barium Enema

A barium enema is an x-ray test where liquid barium is inserted into the colon from the
anus to fill the colon. This test can, at times, show an impression on the colon in the area
of the appendix where the inflammation from the adjacent inflammation impinges on the
colon. Barium enema also can exclude other intestinal problems that mimic appendicitis,
for example Crohn's disease.

Computerized tomography (CT) Scan

In patients who are not pregnant, a CT Scan of the area of the appendix is useful in
diagnosing appendicitis and peri-appendiceal abscesses as well as in excluding other
diseases inside the abdomen and pelvis that can mimic appendicitis.

Laparoscopy

Laparoscopy is a surgical procedure in which a small fiberoptic tube with a camera is

inserted into the abdomen through a small puncture made on the abdominal wall.
Laparoscopy allows a direct view of the appendix as well as other abdominal and pelvic
organs. If appendicitis is found, the inflamed appendix can be removed with the
laparascope. The disadvantage of laparoscopy compared to ultrasound and CT is that it
requires a general anesthetic.4

15
There is no one test that will diagnose appendicitis with certainty. Therefore, the
approach to suspected appendicitis may include a period of observation, tests as
previously discussed, or surgery.

Why can it be difficult to diagnose appendicitis?

It can be difficult to diagnose appendicitis. 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 (called a retro-colic appendix). In either
case, inflammation of the appendix may act more like the inflammation of other organs,
for example, a woman's pelvic organs.

The diagnosis of appendicitis also can be difficult because other inflammatory problems
may mimic appendicitis. Therefore, it is common to observe patients with suspected
appendicitis for a p
eriod of time to see if the problem will resolve on its own or develop characteristics that
more strongly suggest appendicitis or, perhaps, another condition.

What other conditions can mimic appendicitis?

The surgeon faced with a patient suspected of having appendicitis always must consider
and look for other conditions that can mimic appendicitis. Among the conditions that
mimic appendicitis are:

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 * Meckel's diverticulitis. A Meckel's diverticulum is a small outpouching of the small
intestine which usually is located in the right lower abdomen near the appendix. The
diverticulum may become inflamed or even perforate (break open or rupture). If inflamed
and/or perforated, it usually is removed surgically.

* Pelvic inflammatory disease. The right fallopian tube and ovary lie near the
appendix. Sexually active women may contract infectious diseases that involve the tube
and ovary. Usually, antibiotic therapy is sufficient treatment, and surgical removal of the
tube and ovary are not necessary.

* Inflammatory diseases of the right upper abdomen. Fluids from the right upper
abdomen may drain into the lower abdomen where they stimulate inflammation and
mimic appendicitis. Such fluids may come from a perforated duodenal ulcer, gallbladder
disease, or inflammatory diseases of the liver, e.g., a liver abscess.

* Right-sided diverticulitis. Although most diverticuli are located on the left side of the
colon, they occasionally occur on the right side. When a right-sided diverticulum ruptures
it can provoke inflammation they mimics appendicitis.

* Kidney diseases. The right kidney is close enough to the appendix that inflammatory
problems in the kidney-for example, an abscess-can mimic appendicitis

How is appendicitis treated?

Once a diagnosis of appendicitis is made, an appendectomy usually is performed.

Antibiotics almost always are begun prior to surgery and as soon as appendicitis is
suspected.

There is a small group of patients in whom the inflammation and infection of appendicitis
remain mild and localized to a small area. The body is able not only to contain the
inflammation and infection but to resolve it as well. These patients usually are not very ill

17
and improve during several days of observation. This type of appendicitis is referred to as
"confined appendicitis" and may be treated with antibiotics alone. The appendix may or
may not be removed at a later time.

On occasion, a person may not see their doctor until appendicitis with rupture has been
present for many days or even weeks. In this situation, an abscess usually has formed,
and the appendiceal perforation may have closed over. If the abscess is small, it initially
can be treated with antibiotics; however, the abscess usually requires drainage. A drain (a
small plastic or rubber tube) usually is inserted through the skin and into the abscess with
the aid of an ultrasound or CT scan that can determine the exact location of the abscess.
The drain allows pus to flow from the abscess out of the body. The appendix may be
removed several weeks or months after the abscess has resolved. This is called an interval
appendectomy and is done to prevent a second attack of appendicitis.

How is an appendectomy done?

During an appendectomy, an incision two to three inches in length is made through the
skin and the layers of the abdominal wall over the area of the appendix. The surgeon
enters the abdomen and looks for the appendix which usually is in the right lower
abdomen. After examining the area around the appendix to be certain that no additional
problem is present, the appendix is removed. This is done by freeing the appendix from
its mesenteric attachment to the abdomen and colon, cutting the appendix from the colon,
and sewing over the hole in the colon. If an abscess is present, the pus can be drained
with drains that pass from the abscess and out through the skin. The abdominal incision
then is closed.

Newer techniques for removing the appendix involve the use of the laparoscope. The
laparoscope is a thin telescope attached to a video camera that allows the surgeon to
inspect the inside of the abdomen through a small puncture wound (instead of a larger
incision). If appendicitis is found, the appendix can be removed with special instruments
that can be passed into the abdomen, just like the laparoscope, through small puncture
wounds. The benefits of the laparoscopic technique include less post-operative pain

18
(since much of the post-surgery pain comes from incisions) and a speedier return to
normal activities. An additional advantage of laparoscopy is that it allows the surgeon to
look inside the abdomen to make a clear diagnosis in cases in which the diagnosis of
appendicitis is in doubt. For example, laparoscopy is especially helpful in menstruating
women in whom a rupture of an ovarian cysts may mimic appendicitis.

If the appendix is not ruptured (perforated) at the time of surgery, the patient generally is
sent home from the hospital after surgery in one or two days. Patients whose appendix
has perforated are sicker than patients without perforation, and their hospital stay often
is prolonged (four to seven days), particularly if peritonitis has occurred. Intravenous
antibiotics are given in the hospital to fight infection and assist in resolving any abscess.

Occasionally, the surgeon may find a normal-appearing appendix and no other cause for
the patient's problem. In this situation, the surgeon may remove the appendix. The
reasoning in these cases is that it is better to remove a normal-appearing appendix than to
miss and not treat appropriately an early or mild case of appendicitis.

19
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What are the 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. Wound
infections are less common with laparoscopic surgery.

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, as previously discussed.

24
Are there long-term consequences of appendectomy?

It is not clear if the appendix has an important role in the body in older children and
adults. There are no major, long-term health problems resulting from removing the
appendix although a slight increase in some diseases has been noted, for example,
Crohn's disease.

Gerontologic Considerations
Acute appendicitis does not occur frequently in the elderly population. Classic signs
and symptoms are altered and may vary greatly. Pain may be absent or minimal.
Symptoms may be vague, suggesting bowel obstruction or another process. Fever
and leukocytosis may not be present. As a result, diagnosis and prompt treatment
may be delayed, causing potential complications and mortality. The patient may
have no symptoms until the appendix ruptures. The incidence of perforated
appendix is higher in the elderly population because many of these patients do not
seek health care as quickly as younger patients.

PHARMACOLOGIC ASPECTS OF AGING

Older people use more medications than does any other age group: although they
comprise only 12.6% of the total population, they use 30% of all prescribed medications
and 40% of all over-the-counter medications. Medications have improved the
health and well-being of older people by alleviating symptoms of discomfort, treating
chronic illnesses, and curing infectious processes. Problems commonly occur, however,
because of medicationinteractions, multiple medication effects, multiple medication
use (polypharmacy), and noncompliance. Combinations of prescription medications and
some over-the-counter medications further complicate the problem.
Any medication is capable of altering nutritional status, which, in the elderly, may
already be compromised by a marginal diet or by chronic disease and its treatment.

25
Medications can depress the appetite, cause nausea and vomiting, irritate the stomach,
cause constipation or diarrhea, and decrease absorption of nutrients. In addition, they can
alter electrolyte balance and carbohydrate and fat metabolism. A few examples of
medications capable of altering the nutritional status are antacids, which produce
thiamine
deficiency; cathartics, which diminish absorption; antibiotics and phenytoin, which
reduce utilization of folic acid; and phenothiazines, estrogens, and corticosteroids, which
increase food intake and cause weight gain.
Age
Age has long been the focus of research on pain perception and pain tolerance, and again
the results have been inconsistent. For example, although some researchers have found
that older adults require a higher intensity of noxious stimuli than do younger adults
before they report pain (Washington, Gibson & Helme, 2000), others have found no
differences in responses of younger and older adults (Edwards & Filligim, 2000). Other
researchers have found that elderly patients (older than 50 years of age) reported
significantly less pain than younger patients (Li, Greenwald, Gennis et al., 2001).
Experts in the field of pain management have concluded that if pain perception is
diminished in the elderly person, it is most likely secondary to a disease process (eg,
diabetes) rather than to aging (American Geriatrics Society, 1998). More research is
needed in the area of aging and its effects on pain perception to understand what the
elderly are experiencing. Although many elderly people seek health care because of pain,
others are reluctant to seek help even when in severe pain because they consider pain to
be part of normal aging. Assessment of pain in older adults may be difficult because
of the physiologic, psychosocial, and cognitive changes that often accompany aging.
In one study, as many as 93% of nursing home residents reported being in pain daily for
the past 6 months (Weiner, Peterson, Ladd et al., 1999). Unrelieved pain contributes to
the problems of depression, sleep disturbances, delayed rehabilitation, malnutrition, and
cognitive dysfunction (Miaskowski, 2000). The way an older person responds to pain
may differ from the way a younger person responds.

26
Because elderly people have a slower metabolism and a greater ratio of body fat to
muscle mass than younger people, small doses of analgesic agents may be sufficient
to relieve pain, and these doses may be effective longer (Buffum & Buffum, 2000).
Elderly patients deal with pain according to their lifestyle, personality, and cultural
background, as do younger adults. Many elderly people are fearful of addiction and,
as a result, will not report that they are in pain or ask for pain medication. Others
fail to seek care because they fear that the pain may indicate serious illness or they fear
loss of independence. Elderly patients must receive adequate pain relief after surgery or
trauma. When an elderly person becomes confused after surgery or trauma, the confusion
is often attributed to medications, which are then discontinued. However, confusion in the
elderly may be a result of untreated and unrelieved pain. In some cases postoperative
confusion clears once the pain is relieved. Judgments about pain and the adequacy of
treatment should be based on the patient’s report of pain and pain relief rather than on
age.

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 Peri-appendiceal abscess

(Appendix, cut section, showing that pus fills the appendix lumen and spills out into the
fat, forming a peri-appendiceal abscess. This is a surgical emergency.)

If the inflammation and infection spread through the wall of the appendix, the
appendix can rupture. After rupture, infection can spread throughout the abdomen;
however, it usually is confined to a small area surrounding the appendix (forming a peri-
appendiceal abscess).
Treatment

A laparotomy is a large incision made into the abdomen. Exploratory laparotomy is used
to visualize and examine the structures inside of the abdominal cavity.

Purpose:

Exploratory laparotomy is a method of abdominal exploration, a diagnostic tool that

allows physicians to examine the abdominal organs. The procedure may be recommended
for a patient who has abdominal pain of unknown origin or who has sustained an injury to
the abdomen. Because of the nature of the abdominal organs, there is a high risk of

28
infection if organs rupture or are perforated. In addition, bleeding into the abdominal
cavity is considered a medical emergency. Exploratory laparotomy is used to determine
the source of pain or the extent of injury and perform repairs if needed.

Laparotomy may be performed to determine the cause of a patient's symptoms or to

establish the extent of a disease.

Some other conditions that may be discovered or investigated during exploratory

laparotomy include:

• cancer of the abdominal organs

• peritonitis (inflammation of the peritoneum, the lining of the abdominal cavity)
• appendicitis (inflammation of the appendix)
• pancreatitis (inflammation of the pancreas)
• abscesses (a localized area of infection)
• adhesions (bands of scar tissue that form after trauma or surgery)

• diverticulitis (inflammation of sac-like structures in the walls of the intestines)

• intestinal perforation
• ectopic pregnancy (pregnancy occurring outside of the uterus)
• foreign bodies (e.g., a bullet in a gunshot victim)
• internal bleeding

Demographics
Because laparotomy may be performed under a number of circumstances to diagnose or
treat numerous conditions, no data exists as to the overall incidence of the procedure.

Description
The patient is usually placed under general anesthesia for the duration of surgery. The
advantages to general anesthesia are that the patient remains unconscious during the

29
procedure, no pain will be experienced nor will the patient have any memory of the
procedure, and the patient's muscles remain completely relaxed, allowing safer surgery.

Incision
Once an adequate level of anesthesia has been reached, the initial incision into the skin
may be made. A scalpel is first used to cut into the superficial layers of the skin. The
incision may be median (vertical down the patient's midline), paramedian (vertical
elsewhere on the abdomen), transverse (horizontal), T-shaped, or curved, according to the
needs of the surgery. The incision is then continued through the subcutaneous fat, the
abdominal muscles, and finally, the peritoneum. Electrocautery is often used to cut
through the subcutaneous tissue as it has the ability to stop bleeding as it cuts.
Instruments called retractors may be used to hold the incision open once the abdominal
cavity has been exposed.

Abdominal Exploration
The surgeon may then explore the abdominal cavity for disease or trauma. The abdominal
organs in question will be examined for evidence of infection, inflammation, perforation,
26
abnormal growths, or other conditions. Any fluid surrounding the abdominal organs will
be inspected; the presence of blood, bile, or other fluids may indicate specific diseases or
injuries. In some cases, an abnormal smell encountered upon entering the abdominal
cavity may be evidence of infection or a perforated gastrointestinal organ.
If an abnormality is found, the surgeon has the option of treating the patient before
closing the wound or initiating treatment after exploratory surgery. Alternatively, samples
of various tissues and/or fluids may be removed for further analysis. For example, if
cancer is suspected, biopsies may be obtained so that the tissues can be examined
microscopically for evidence of abnormal cells. If no abnormality is found, or if
immediate treatment is not needed, the incision may be closed without performing any
further surgical procedures.
During exploratory laparotomy for cancer, a pelvic washing may be performed; sterile
fluid is instilled into the abdominal cavity and washed around the abdominal organs, then

30
withdrawn and analyzed for the presence of abnormal cells. This may indicate that a
cancer has begun to spread (metastasize).

Closure
Upon completion of any exploration or procedures, the organs and related structures are
returned to their normal anatomical position. The incision may then be sutured (stitched
closed). The layers of the abdominal wall are sutured in reverse order, and the skin
incision closed with sutures or staples.

Diagnosis/Preparation
Various diagnostic tests may be performed to determine if exploratory laparotomy is
necessary. Blood tests or imaging techniques such as x ray, computed tomography (CT)
scan, and magnetic resonance imaging (MRI) are examples. The presence of
intraperitoneal fluid (IF) may be an indication that exploratory laparotomy is necessary;
one study indicated that IF was present in nearly three-quarters of patients with intra-
abdominal injuries.

Directly preceding the surgical procedure, an intravenous (IV) line will be placed so that
fluids and/or medications may be administered to the patient during and after surgery. A
Foley catheter will be inserted into the bladder to drain urine. The patient will also meet
with the anesthesiologist to go over details of the method of anesthesia to be used.

Aftercare

The patient will remain in the postoperative recovery room for several hours where his or
her recovery can be closely monitored. Discharge from the hospital may occur in as little
as one to two days after the procedure, but may be later if additional procedures were
performed or complications were encountered. The patient will be instructed to watch for
symptoms that may indicate infection, such as fever, redness or swelling around the
incision, drainage, and worsening pain.

31
Risks
Risks inherent to the use of general anesthesia include nausea, vomiting, sore throat,
fatigue, headache, and muscle soreness; more rarely, blood pressure problems, allergic
reaction, heart attack, or stroke may occur. Additional risks include bleeding, infection,
injury to the abdominal organs or structures, or formation of adhesions (bands of scar
tissue between organs).

Morbidity and Mortality Rates

The operative and postoperative complication rates associated with exploratory
laparotomy vary according to the patient's condition and any additional procedures
performed.
Alternatives
Laparoscopy is a relatively recent alternative to laparotomy that has many advantages.
Also called minimally invasive surgery, laparoscopy is a surgical procedure in which a
laparoscope (a thin, lighted tube) and other instruments are inserted into the abdomen
through small incisions.

The internal operating field may then be visualized on a video monitor that is connected
to the scope. In some patients, the technique may be used for abdominal exploration in
place of a laparotomy. Laparoscopy is associated with faster recovery times, shorter
hospital stays, and smaller surgical scars.

32
During a laparotomy, and an incision is made into the patient's abdomen (A). Skin and
connective tissue called fascia is divided (B). The lining of the abdominal cavity, the
peritoneum, is cut, and any exploratory procedures are undertaken (C). To close the
incision, the peritoneum, fascia, and skin are stitched (E). (Illustration by GGS Inc.)

33
 III Anatomy and Physiology

Large Intestine:
.
Its primary purpose is to extract water from feces. About 1.5 M (5 feet) long, it
extends from the ileocecal valve to the anus.
Major functions are to dry out the indigestible food residue by absorbing water &
to eliminate these residues from the body as feces.
It frames the small intestine on these sides & has the following subdivisions:
cecum, appendix, colon, rectum & anal canal.
Cecum
The cecum (also spelled caecum), the first portion of the large bowel, situated in
the lower right quadrant of the abdomen.
The cecum receives fecal material from the small bowel (ileum) which opens into
it. The appendix is attached to the cecum.
The bottom of the cecum is a blind pouch (a cul de sac) leading nowhere.A pouch
connected to the ascending colon of the large intestine and the ileum. It is separated from
the ileum by the ileocecal valve (ICV) or Bauhin's valve, and is considered to be the
beginning of the large

34
Appendix

The appendix is a branch of the cecum, like the appendix, the cecum was once
believed to have no function.
The appendix is a small, finger-like appendage about 10 cm (4 in) long that is
attached to the cecum just below the ileocecal valve. The appendix fills with food and
empties regularly into the cecum. Because it empties inefficiently and its lumen is small,
the appendix is prone to obstruction and is particularly vulnerable to infection.

Ascending colon

Smaller in caliber than the cecum, with which it is continuous.It passes upward,
from its commencement at the cecum, opposite the colic valve, to the under surface of the
right lobe of the liver, on the right of the gall-bladderyeo, where it is lodged in a shallow
depression, the colic impression; here it bends abruptly forward and to the left, forming
the right colic flexure (hepatic).

Transverse Colon
Longest and most movable part of the colon, passes with a downward convexity
from the right hypochondrium region across the abdomen, opposite the confines of the
epigastric and umbilical zones, into the left hypochondrium region, where it curves
sharply on itself beneath the lower end of the spleen, forming the splenic or left colic
flexure. The right colic flexure is adjacent to the liver.
.
Rectum
The last 6 to 8 inches of the large intestine. The rectum stores solid waste until it
leaves the body through the anus.
Anus
Termination of Rectum formed of spichnter which relaxes to allow fecal matter to
pass through.

35
 IV Pathophyisiology

A. Written Report:

The following case introduces a fifty three year old female patient who was

brought to the hospital because of the persistent conditions such as abdominal pain,

recurrent fever, nausea, anorexia. After further tests and surgery performed, the patient

was diagnosed with Periappendical abscess s/p Exploratomy Laparotomy.

This study focuses on one of the complications of Appendicitis which is the Peri-

appendicial abscess that is cause of untreated inflammation of appendix. The patient

obstruction of the lumen was believed to arise spontaneously on an obscure or unknown

cause. Impediment of the lumen causes the mucous secretion to increase and its

accumulation causes luminal pressure to increase. Condition appears to favor resident

bacterial growth. Inflammation develops resulting to mucosal damage. With continued

swelling, the appendix presses against the adjacent abdominal wall and its sensitive

parietal peritoneum causing to deteriorate and perforate. Contents of appendical abscess

leaked to the peritoneum surfaces. Contents are confined to a small area of appendix.

Spillage of the contents causes the inflammation of parietal peritoneum leading to the

manifestation of fever.

36
 Idiopathic
(Constipation/Fecalith)

Obstruction of the lumen

↑ mucosal secretion

↑ intraluminal pressure

Bacterial Invasion
( resident Bacteria from intestine)

Inflammation

Mucosal damage

Spillage of infected
appendical contents
outside appendix

Confined to a small area surrounding

appendix
( peri-appendiceal abscess)

Inflammation of parietal Anticipatory for

peritoneum Surgery (Exploratory
Laparotomy)

FEVER

anxiety Activity Acute

Hyperthermia Intolerance pain

B. Diagram

37
 V Problem List

Pre-operative:
1. Fever – Hyperthermia
2. Anxiety
Post-operative:
1. Acute Pain
2. Activity Intolerance
3. Anxiety

38
 VI Laboratory and Diagnostic Procedures
January 27. 2009

LABORATORY PROCEDURE: Complete Blood Count

Hemoglobin

Red pigments in red blood cell that carries oxygen all through out the body.

A. Test and Result

Test Result Reference Value

Hemoglobin (Hgb) 123 Male: 140-170/L

Female: 120-150/L

B. Interpretation
Hemoglobin count was within the normal range

C. Significance
Increase in normal range
• Polycythemia,
• Chronic Obstructive Pulmonary Disease
• Congestive Heart Failure
Decrease in normal range
• Anemia
• Hemorrhage

Hematocrit

The Percentage of Red Blood Cell of the total blood volume.

A, Test and Result

Test Result Reference Value

Hematocrit (Hct) 37% Male:42-51%

Female:37-47%

B. Interpretation

Hematocrit count was within the normal range

39
C. Significance

Increase in normal range

• Erythrocytosis
• Dehydration
Decrease in normal range
• Hemorrhage
• Anemia
• Pregnancy

RBC Count

It is the count of the actual number of red blood cells per volume of blood.

A. Test and Result

Test Result Reference Value

RBC count 4.3 Male:4.5-5.9 x 106g/L

Female:4.5-5.1 x 106g/L

B. Interpretation
RBC count was .2 lower that the normal range which may indicate dietary
deficiency because the client was anorexic.

C. Significance
Increase in normal range
• Dehydration
• Pulmonary Fibrosis
• Erythrocytosis
• Polycythemia
• Congenital Heart Disease
• Chronic Obstructive Pulmonary Disease
Decrease in normal range
• Hemorrhage
• Anemia
• Pregnancy
• Dietary Deficiency

40
WBC Count
It is the count of the actual number of white blood cells per volume of blood.

A. Test and Result

Test Result Reference Value

WBC Count 6.1 5.0-10.0x103/L

B. Interpretation
WBC count was within the normal range

C. Significance
Increase in normal range
• Infection
• Steroid use
Decrease in normal range
• Bone Marrow failure
• Iron Deficiency
•

Platelet Count

A. Test and Result

Test Result Reference Value

Platelet Count Adequate 150-400x106/L

B. Significance
Increase in normal range
• Rheumatoid arthritis
• Malignant Disorder
• Polycythemia
• Iron Deficiency Anemia
Decrease in normal range
• Thrombocytopenic
• Purpura,
• Acute leukemia,

41
 • Aplastic anemia,
• Cancer chemotherapy.

Differential Count

Neutrophils
Make up 50% to 60% of leukocytes in the blood and are responsible for
phagocytosis of bacteria and cellular debris.

Lymphocytes
Make up 20% to 30% of the total white blood cells and are responsible in
producing antibody

Monocytes
Are phagocytic cell.It can be produced rapidly and make up about 5% of the total
white blood cell count.

Eosinophils
Make up 1%-4% of the total leukocytes. Increases in number during allergic states
and infestation with worms.

Basophils
Increased in numbers in such pathological conditions and make up approximately
0.5%-1.0% of leukocytes.
A. Test and Result
Test Result Reference Value

Neutrophils 0.63 0.45-0.65

Lymphocytes 0.37 0.25-0.35

Monocytes -- 0.03-0.06

Stabs -- 0.02-0.04

Eosinophils -- 0.02-0.04

42
 Basophils
-- 00-0.05

Blasts
-- 0.0
ABO/RH Typing B+

B. Interpretations

The result for Neutrophils count was within the normal range. Lymphocytes count
was .0.02 more than the normal range which may indicate chronic bacterial infection or
viral infection. The patient blood type appeared to be B+.

C. Significance
Increase in normal range

Neutrophils
• Acute infections
• Trauma or surgery
• Leukemia,
• Malignant disease
• Necrosis
• Stress
Lymphocytes
• Chronic Infection
• Viral Infection
• Mononecleosis
Monocytes
• Chronic Inflammatory Disorder
• Tuberculosis
• Parasitic disease
Eosinophils
• Parasitic Infections
• Allergic reactions

43
 • Leukemia
Basophils
• Leukemia
Decrease in normal range
Neutrophils
• Aplastic Anemia
• Dietary Deficiency
• Radiation Therapy
• Bone marrow suppression
Lymphocytes
• Leukemia
• Sepsis
• Immunodeficiency disease
• SLE
• Immunodeficiency including AIDS
Monocytes
• Drug therapy: Prednisone

Eosinophils
• Stress
• Use of some medications (ACTH, epinephrine, thyroxine)
Basophils
• Allergic reactions
• Stress
Nursing Considerations

1. Make sure that the vital signs are stable.

2. Choose non-dominant hand for the site when getting the specimen
3. Clean the site
4. Apply tourniquet to the site but not more than two minutes

44
 5. Apply light pressure to make sure that the site is correct

6. If failed to the first attempt, change the site from distal to proximal
7. Release the tourniquet once there is blood in the hub
8. Transfer immediately the collected blood to the specimen container with purple
cap and deliver to the laboratory not more that 30 minutes.
9. To prevent coagulation turn the container upside down.

Diagnostic Procedures
A. Test and Result

CT Scan
Painless diagnostic procedure for examining soft tissue. It allows
visualization of grey matter, necrotic tissue, and tumors.

EXAM: CT SCAN of the whole abdomen

Date: January 15, 2009

CT SCAN Report

History: 1 Month. History of Intermittent right Quadrant pain. Multiple axial tomograpic
sections of the whole abdomen with oral contrast and intravenous contrast were obtained.
A peripherally enhancing complex predominantly cystic mass is seen in the Right Lower
abdomen, adjacent to the ileo-cecal junction, most likely extra-luminal. It measures 5 cm
x 7cm x 5 cm. Surrounding fat stranding is seen. The visualized small and large bowels
appear unremarkable. The liver, gall bladder, pancreas, adrenal glands and spleen show
no unusual findings. The kidney and its collecting structures including the urinary bladder
are intact. The uterus is normal in size with no focal lesions noted. No adrenal masses
seen. The abdominal aorta shows no dilatation. Minimal curvilinear are seen in the
included lung bases. The rest of the soft tissues, vascular and osseous structures are
unremarkable.

45
Impression:
Complex mass at the right lower abdomen; consider a Periappendiceal periceal
abscess
- Minimal fibrotic changes, bilateral lower lungs.

B. Nursing Considerations

1. Secure Consent of the client.

2. Inform client that the procedure will take 30 minutes to 1 hour.
3. Explain test purpose and procedure. Provide written instructions. Reinforce
knowledge regarding possible adverse effects such as radiation.
4. Inform the client that there will be clicking and whirring noise and that he/she
may use earplugs.
5. Provide medications as ordered.
6. Reassure the patient that scanning procedures no greater radiation than
conventional x-ray studies
7. Check for patient allergies such as nausea, vomiting, warmth, and flushing of the
face may signal possible allergy for iodine.
8. Check for signs of claustrophobia
9. Be aware that abdominal cramping and diarrhea may occur; therefore medication
may be given as ordered to decrease these side effects.
10. Inform the patient that solid foods are usually withheld on the day of examination.
Clear liquids may be taken up to 2 hours before examination.
11. For CT of the abdomen, the patient usually can take nothing by mouth.
12. Notify physician immediately if allergic reaction occurs.
13. Secure Consent of the client.
14. Inform client that the procedure will take 30 minutes to 1 hour.
15. Inform the client that there will be clicking and whirring noise and that he/she
may use earplug.

46
A. Test and Result

Roentegnographic

Roentenographic Report

Date: January 10, 2009

Abdomen:

Shows gas in the visualize bowel loops. Minimal feces are seen in the rectum. Gas
pattern is non obstructive. Osseous structures & soft tissue outline are intact.

Impression:

Unremarkable abdomen

B. Nursing Considerations

1. The patient should be given a brief explanation of the purpose of and procedure
for the test and assured that there will be no discomfort.
2. Remove all jewelry and other ornamentation in the abdomen area before the X-
ray
3. Remind the patient of need to remain motionless during the procedure.

47
48
 VII Drug Study
Name of Drug Action Indication Route and Availability Contraindications Adverse Nursing
Dosage Effects Indications

-Tell patient
Hyoscine N- Inhibits Used in the Tablet: Injection: 0.3 Myasthenia gravi, Xerostomia,
to avoid
Butykbromide acetycholine management of adult and mg/ml and 1 megacolon, tachycardia,
hazardous
at receptor various children >6 mg/ml in 1- hypersensitivity. urinary
activities
sites in gastrointestinal yrs: 10- ml vials, 0.4 retention..
requiring
autonomic disorders. 20mg 3-5 mg/ml in 0.5-
alertness;
nervous times daily. ml ampules
dizziness
system, which and 1-ml
may occur.
controls vials, 0.86
secretions, mg/ml in 0.5-
-Advice
free acids in ml ampules
patient to
stomach;
avoid use of
blocks central
alcohol or
muscarinic Tablets: 0.4
mg other CNS
receptors,
depressants
which
while taking
decreases
Transdermal
medication.

49
 involuntary
system
movements.. -Explain that
(Transderm-
rinsing the
Scop): 1.5
mouth, good
mg/patch
oral hygiene,
(releases 0.5
and sugarless
mg
gum or candy
scopolamine
will help to
over 3 days)
counteract
dryness.

 Started: December 28, 2008

 Discontinued: December 28, 2008

50
Name of Drug Action Indication Route Availability Contraindications Adverse Effects Nursing
and Indications
Dosage

Acetaminophen May cause Relief mild- 25 to 650 Caplets, Hypersensitivity: Stimulation, -Tell the
analgesia by to-moderate mg P.O. q capsules: 160 Intolerance to drowiness, patient to
inhibiting pain: 4 to 6 mg, 500 mg, tartrazine, alcohol, nausea,vomiting, read label on
CNS treatment of hours, or 650 mg table sugar, abdominal pain, the other
prostaglandin fever. 1,000 mg (Drops: 100 saccharin. heapatotoxicity, OTC.
synthesis. three or mg/ml hepatic seizure,
four times Elixir: 80 renal failure, -Advised the
daily. mg/2.5 ml, 80 thrombocytopenia, client to
mg/5 ml, 120 pancytopenia, avoid
mg/5 ml, 160 rash, uticaria and alcohol.
mg/5 ml hypersensitivity,
Gelcaps: 500 cyanosis, anemia, -Inform
mg neutropenia, patient to
Liquid: 160 jaundice, CNS recognized
mg/5 ml, 500 stimulation, signs of
mg/15 ml delirium followed chronic
Solution: 80 by vascular overdose,

51
mg/1.66 ml, collapse, bleeding,
100 mg/1 ml, convulsion, bruising,
120 mg/2.5 trauma, death. malaise,
ml, 160 mg/5 . fever.
ml, 167 mg/5
ml -Tell patient
Suppositories: to notify
80 mg, 120 physician for
mg, 125 mg, pain or fever
300 mg, 325 lasting for 3
mg, 650 mg days.
Suspension:
32 mg/ml, 160
mg/5 ml
Syrup: 160
mg/5 ml
Tablets
(chewable): 80
mg, 160 mg
Tablets
(extended-

52
 release): 160
mg, 325 mg,
500 mg, 650
mg
Tablets (film-
coated): 160
mg, 325 mg,
500 mg.

 Started: December 29, 2008

 Discontinued: January 12, 2009

53
 Name of Action Indication Route and Availability Contraindications Adverse Nursing
Drug Dosage Effects Indications

Metronidazole Direct-acting Infections in 750 mg P.O. q Tabs: Blood dyscrasias, Convulsive -Obtain C&S
amebicide or the intra- 8 hours for 5 250, 375 active CNS seizures, before
trichomobacide. abdominal to 10 days 500mg diseases, peripheral beginning
It binds to skin and skin hypersebsitivity to neuropathy, drug therapy
bacterial and structure. Ext Rel tabs: imidazole, rash, to identify if
protozoan DNA 750mg tuberculosis if pruritus, GI correct
to cause loss of mucous comfort, treatment has
helical Injection membranes and anorexia, been initiated.
structurem 500mg/100ml: certain viral nausea,
strand conditions and first furred -Assess for
breakage, Powder for trimester if tongue, dry allergic
inhibition if Injection: pregnancy. mouth and reactions:
nucleic acid 500mg single unpleasant rash, urticaria
synthesis and dose metallic and pruritus.
cell death. taste,
headache, -Monitor for

54
 less possible drug
frequently induced
vomiting, adverse
diarrhea, reactions.
weakness,
dizziness -Monitor
and renal
darkening function:
of the urine output,
urine. input and
output ratio.

 Started: January 13, 2008

 Discontinued: January 20, 2008

55
 Name of Action Indication Route and Availability Contraindications Adverse Effects Nursing
Drug Dosage Indications

Cefuroxime Inhibits Uncomplicated Tablets: Oral Diarrhea/loose Adverse reactions - Give in even
bacterial UTI due to 250 mg suspension: stool, nausea and doses around
cell wall E.coli or K. 125 mg/5 ml vomiting, CNS: headache, the clock; If
synthesis, pneumoniae. Standing Powder for abdominal pain. hyperactivity, GI upset
rendering Preoperative Order: injection: hypertonia, seizures occurs, give
cell wall prophylaxis in 750 mg 750 mg, 1.5 with food;
osmotically clients IV q8 g, 7.5 g GI: nausea, drug must be
unstable, undergoing (ANST) Premixed vomiting, diarrhea, given for 10-
leading to surgical containers: abdominal pain, 14 days to
cell death procedures 750 mg/50 dyspepsia, ensure
by binding classified as ml, 1.5 g/50 pseudomembranous organism
to cell wall clean- ml colitis death and
membrane contaminated Tablets: 125 prevent
or potentially mg, 250 mg, GU: hematuria, superinfection
contaminated. 500 mg vaginal candidiasis,
. renal dysfunction,

56
acute renal failure

Hematologic:
hemolytic anemia,
aplastic anemia,
hemorrhage

Hepatic: hepatic
dysfunction

Metabolic:
hyperglycemia

Skin: toxic
epidermal
necrolysis,
erythema
multiforme,
Stevens-Johnson
syndrome

57
Other: allergic
reaction, drug
fever,
superinfection,
anaphylaxis
Interactions

Drug-drug.
Antacids
containing
aluminum or
magnesium,
histamine2-receptor
antagonists:
increased
cefuroxime
absorption

Probenecid:
decreased excretion
and increased blood

58
level of cefuroxime

Drug-diagnostic
tests. Blood
glucose, Coombs'
test, urine glucose
tests using
Benedict's solution:
false-positive
results

Glucose,
hematocrit:
decreased levels

White blood cells

in urine: increased
level

Drug-food.
Moderate- or high-

59
 fat meal: increased
drug

bioavailability

Name of Action Indication Route and Availability Contraindications Adverse Effects Nursing

60
 Drug Dosage Indications

Ranitidine Inhibits Used in the Standing Capsules Hypersensitivity to Cardiac -Monitor ASL,
histamine at management Order : 50 (liquid-filled): drug or its arrythmias, ALT and serum
H2 receptor of various mg IV q8 150 mg, 300 components bradycardia, creatinine when
site in the gastrointestinal mg • Alcohol headache, used to prevent
gastric disorders such Solution for intolerance (with somnolence, stress-related
parietal as dyspepsia injection: 25 some oral fatigue, dizziness, GI tract
cells, which gastrointestinal mg/ml in 2-, products) hallucinations, bleeding.
inhibits reflux disease 6-, and 40-ml • History of acute depression,
gastric acid [GERD], vials porphyria. insomnia, -Evaluate
secretion. peptic ulcer Solution for alopecia, rash, results of
and zolunger- injection (pre- erythema laboratory tests,
ellisou mixed): 50 multiforme, therapeutic
syndrome. mg/50 ml in nausea and effectiveness
Prophylaxis 0.45% sodium vomiting, and adverse
of GI chloride abdominal reactions
hemorrhage Syrup: 15 discomfort, (bradycardia,
from the mg/ml diarrhea, PVC’s,
stress Tablets: 150 constipation, tachycardia,

61
 ulceration mg, 300 mg pancreatitis, CNS changes,
and in Tablets agranulocytosis, rash,
patients at (effervescent): autoimmune gynecomasticia,
risk of 150 mg hemolytic or GI disturbance
developing aplastic anemia, and hepatic
acid thrombocytopeni failure.)
aspiration a
during - Assess
general granulocytopenia, knowledge and
anesthesia cholestatic or teach patient
prophylaxis hepatocellular appropriate use,
of mendelson effects, possible side
syndrome. hypersensitivity effects or
. reactions. appropriate
interventions
and adverse
symptoms to
report.

 Started: February 3, 2009

62
 Standing Order : 50 mg IV q8

63
 Name of Action Indication Route and Availability Contraindications Adverse Nursing
Drug Dosage Effects Indications

Keterolac Possesses anti- Management Standing Tablets: Each -Hypersensitivity Systemic -Use as part
(tromethamine) inflammatory, of severe, Order: 30 mg white, round, to the drug or use: of a regular
analgesics and acute pain in IV q6 film-coated allergic symptoms headache, analgesic
antipyretic adults that tablet, with one to aspirin or other dizziness, schedule
effects requires side printed in NSAID’s. drowsiness, rather than on
analgesia and black ink with diarrhea, as needed
the opiate KET10 on one -Active peptic nausea, basis.
level, usually side, contains: ulcer , recent GI dyspepsia/
in a ketorolac bleeding or indigestion, -If pain
postoperative tromethamine perforation, history epigastric/ returns within
setting 10 mg. of peptic ulcer or GI pain and 3-5 hours, the
Nonmedicinal GI beeding. edema, next dose can
ingredients: Purpura, be increased
hydroxypropyl- -Advanced renal asthma, by up to 50 %
methylcellulose, impairement abnormal -Do not mix
lactose, visio, IV/IM
magnesium abnormal ketorolac in a

64
stearate, -High risk of liver small volume
microcrystalline bleeding. function. with morpine
cellulose, . sulfate,
polyethylene meperinide
glycol and HCL,
titanium promethazine
dioxide. Bottles HCL, or
of 100 and 500. hydroxyzine
Store at room HCL, will
temperature precipitate
with protection from solution.
from light.
-the IV bolus
Parenteral: must be given
10 mg/mL: over no less
Each mL of than 15 sec.
clear, slightly give IM
yellow, sterile slowly and
solution deeply into
contains: the muscle.
ketorolac

65
tromethamine
10 mg.
Nonmedicinal
ingredients:
alcohol 10%
w/v and sodium
chloride in
sterile water.
The pH is
adjusted with
sodium
hydroxide or
hydrochloric
acid. Ampuls of
1 mL, trays of
5. Store at room
temperature
with protection
from light.

30 mg/mL:

66
Each mL of
clear, slightly
yellow, sterile
solution
contains:
ketorolac
tromethamine
30 mg.
Nonmedicinal
ingredients:
alcohol 10%
w/v and sodium
chloride in
sterile water.
The pH is
adjusted with
sodium
hydroxide or
hydrochloric
acid. Ampuls of
1 mL, trays of

67
 5. Store at room
temperature
with protection
from light.

 Started: Feb 3, 2009

 Discontinued: Feb 4, 2009
 Standing Order: 30 mg IV q6

68
VIII NCP

69
  PRE-OPERATIVE NURSING CARE PLAN
Assessment Diagnosis Planning Nursing Rationale Evaluation
Interventions

Subjective: Hyperthermia Short term Diagnostic

“ Masakit ang ulo related to Planning: Underlying cause of >To assess Within one hour of
ko at mainit ang inflammatory excessive heat causative or nursing
pakiramdam ko” as response as Within one hour of production contributing factors interventions the
verbalized by the evidenced by nursing Identified patient’s body
patient. increased body interventions the temperature of 37.7
temperature ( 37. 7 patient will reduce Surface >To evaluate effects C reduced to 37. 4C
Objective: C) the body Temperature or degree of
> Increased in body Rationale: temperature from Monitored hyperthermia >Goal is met
surface temperature Fever is caused by 37.6 C to 37. 4 C
above normal range secretion of cytokines Therapeutic
of 36.5-37.4 C by cells that appear in Surface cooling by >To reduce heat
the inflammatory
(37.7 C) means of doing
reaction (e.g.
>warm to touch TSB, heat loss by
macrophages). Two
>Flushed skin evaporation and
common cytokines
conduction
are interleukin-1 (Il-1)

70
and tumor necrosis Promoted.
factor (TNF). Given
that these factors Educative
cause fever and are
Instructed to >This will help in
produced by
Maintain bed rest. reducing metabolic
inflammatory cells, it
demands and
follows that a large
oxygen
number of cells
produce large
Consumption.

amounts of cytokines
resulting in higher Advised to increase >Increase in oral
fever. There is, then, a Fluid intake. fluids will prevent
direct relationship dehydration.
between the severity
of the inflammatory .
response and fever.

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 Assessment Nursing Goal Nursing Rationale Evaluation
Diagnosis Interventions

Subjective: Short term Diagnostic: After 8 hours of

“Natatakot ako sa Anxiety related to Planning Vital Signs To identify physical rendering nursing
gagawing impending surgery After 8 hours of Monitored responses care and
operasyon sa akin” as evidenced by rendering nursing associated with interventions the
as verbalized by the restlessness care and both medical and client was able to
patient. interventions the emotional verbalize awareness
Rationale: client will be able conditions. of feelings of
Disturbed behavior to Verbalize anxiety.
Objective: is due to awareness of
> poor eye contact apprehension of the feelings of anxiety. Therapeutic Goal is met
outcome of the
>Extraneous surgery and Long Term Established a To gain client’s
movement (rocking imagined threat to Planning therapeutic trust.
movements) one’s health. The patient will relationship to the
appear relax and client.
>Restlessness will reduce anxiety
to a manageable

72
>Difficulty of level. Encouraged the client These are effective
concentrating for participation in non-chemical ways
relaxation exercise to reduce anxiety
>Confusion (Deep breathing and client’s ability
exercise, progressive to deal with
muscle excessive stimuli is
relaxation,meditation) impaired.
and provide comfort
V/S: measures.g
BP: 110/80 mmHg environmental
RR: 24 bpm factors).
PR: 110 cpm
Temp: 37.7 C Educative:

Encourage client to To determine her

acknowledge and to feelings towards the
express feelings procedure or
about the procedure/ conditions
operation that will be
done.

73
 Encourage client to To divert patients
have an exercise/ attention and reduce
activity program such level of anxiety
as reading books about the surgery

 POST-OPERATIVE NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

74
Subjective: Acute pain related Short Term Goal Diagnostic:
”Masakit ang tahi After 1 hour of Duration, frequency, >This is a base to
to tissue injury After 8 hours of
ko”as verbalized by Nursing Care, client intensity plan the intervention
secondary to Nursing Care, the
the client will be able to and precipitating
surgical intervention client verbalized
verbalize reduction factors Assessed.
as evidenced by reduction of pain
of pain from 6 to 4.
Objective: report of 6 pain from 6 to 4. and able
>Facial Grimace and will be able to
scale. Therapeutic: to ambulate
>Guarding behavior ambulate
The Client
>Cannot ambulate
Goal is Met
Rationale: positioned to Semi- >DBE can make the
>Pain score of 6
Acute Pain is Long Term Goal:
Fowler’s and Deep client feel relaxed; it
>Incision site in the The Client will be
common to the breathing exercise helps in coping up
abdomen (7 inches) able to demonstrate
client who Instructed with a with pain. In semi-
is erythematous. nonpharmacological
undergone pillow to support the fowlers position
technique for
surgery procedure relaxation. inscision wound pressure in the
abdomen is reduced.
because there is a
break in the skin.

Educative:

Advised the client to > It helps to reduce

75
apply pain by increasing
nonpharmacological the release of
technique such as endorphins
relaxation technique
before,during and
after pain occur

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 IX Discharge Plan

MEDICATION:
The Patient and the relatives are provided information about the time of
medication to be taken as ordered by her doctor.
ENVIRONMENT
Provide information to patient and significant others that the environment must be
clean and use clean materials because the surrounding may contribute to the client of risk
of infection.
EXERCISE:
Instruct the client to do leg exercise to promote blood circulation,Moderate
exercise in the morning within the patient’s limit and with rest.Inform client that the
normal activity can be resumed after 3-4 weeks.
HEALTH TEACHING:
Instruct the patient and significant others of proper way to clean the incision
wound,from incision site to the surrounding area of wound with cottons and betadine
or alcohol,one cotton each stroke and use sterile dressings.Inform client that the
Semi-fowler’s position may help to reduce tension to the incision site
Inform client and Instruct Deep Breathing Exercise and that she may use a pillow
to support abdomen because Deep Breathing Exercise promotes heeling.
DIET
Inform the patient to increased her intake of water a day(8-12glasses) and intake
of fiber must be increased too to treat her constipation.
OUT-PATIENT FOLLOW-UP:
Inform patient to make an appointment to have the surgeon remove the sutures
between 5th and 4th days.
SPIRITUAL
The Patient and the significant others are advised to have a deep Faith to Devine
God for Guidance.

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 X Bibliography
1. Brunner and Suddarth's Textbook of Medical-Surgical Nursing
i. by Suzanne C. Smeltzer and Brenda G. Brade
2. Fundamentals of Nursing by Kozier
3. Nurses’s Drug Handbook by George R. Spratto and Adrienne L. Woods
4. Essentials of Human Anatomy And Physiology by Elaine N. Marieb
5. Blackwell’s Nursing Dictionary
6. Nurse’s Pocket Guide by Marilyn E. Doenges
7. Pathophysiology by Thomas J. Nowak
8. (http://www.radiology.rsnajnls.org )http://radiology.rsnajnls.org/cgi/content-
nw/full/215/2/337/
9. http://www.aafp.org/afp/991101ap/2027.html
10. www.medicinenet.com

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