SURIGAO EDUCATION CENTER

Km. 2, 8400 Surigao City, Philippines

RUPTURED APPENDICITIS WITH LOCALIZE PERITONITIS

A CASE PRESENTATION
Presented to:

THE FACULTY OF THE COLLEGE OF ALLIED MEDICAL SCIENCES NURSING DEPARTMENT SURIGAO EDUCATION CENTER

In Fulfillment Of the Requirements for the Degree BACHELOR OF SCIENCE IN NURSING LEVEL 3
Presented by: ARGUILLAS, Grace za T. CHUA, Emily L. COSTINIANO, Daryll Richmond J. ENARIO, Cheryl C. EVIOTA, Lanie Ann A. GIER, Rosemarie M. PADILLA, Ruth D. PAQUEO, Michael M. RAMOS, Honna Bina N. REPUTANA, Jane A.

OCTOBER 2011

DEDICATION This case presentation is indeed the fruit of our endeavor. A sweet success from the sweat of our hard work that worth every single moment and time that we share in making this, precious art of learning. Of all the sacrifices, we would heartily dedicate our case presentation to the following people: To our parents, who undyingly showed their moral and financial support to us, as we take every fruitful steps of our endeavor. To our clinical instructors, for imparting us their knowledge on how are we going to perform all different procedures of the nursing process, to make us fully equipped as we embark towards the realization of our chosen profession. And most especially to our Heavenly Father, who showered us all the guidance and the abundance of grace.

THE PRESENTORS

ACKNOWLEDGEMENT As the presenters of this group case presentation, with deep appreciation and heartfelt gratitude, we would like to acknowledge the following people who have supported us and made this study a successful one: To our parents who morally and financially supported us. For their encouragement and understanding why were always late in coming home. To our instructors who undoubtedly impart their knowledge and showed their support to us. To all staff of Caraga Regional Hospital, who gave us the permit to copy all the information necessary for this educational output to be completed from the patients chart. To the patient and patients family who never ceased to answer whatever questions we have raised. And most especially, to our Heavenly Father for giving us all the blessings, strength, wisdom and enlightenment that we are able to complete all the information needed. Indeed, this case study has definitely enhanced and advanced our knowledge in our chosen career.

THE PRESENTORS

CASE CONTENTS

TITLE

PAGE

DEDICATION ACKNOWLEDGMENT INTRODUCTION REVIEW OF RELATED LITERATURE PATIENT HEALTH HISTORY PHYSICAL ASSESSMENT 12 CRANIAL NERVE ASSESSMENT REVIEW OF SYSTEM LABORATORY EXAM ANATOMY AND PHYSIOLOGY PATHOPHYSIOLOGY DRUG STUDY NURSING CARE PLAN DISCHARGE PLAN APPENDICES A. B. C. BIBLIOGRAPHY INTRAVENOUS FLUID FAMILY GENOGRAM DEFINITION OF TERMS

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.

Mr. P., 16 years old, College student resides at Vasquez St. Surigao City while attending school at SSCT. He grew up at Brgy. Villa Flor, Gigaguit, Surigao Del Norte. Admitted at Caraga Regional Hospital last September 01, 2011 and diagnosed with ruptured appendicitis with localized peritonitis. His chief complaint was severe abdominal pain scale of 10/10 and vomiting 5-7 times in one day.

According to oxfordjurnals.org, the authors 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. The pain become more diffuse, abdominal distention develops as a result of paralytic ileus, and the patients condition become worsens. In Mr. Ps case, he has ruptured appendicitis with localized peritonitis. We choose the case of Mr. P, 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.

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 (McBurneys point). Loss of appetite Nausea, and Vomiting Change in bowel movements, including diarrhea or constipation or unable to pass gas. Fever Rovsings 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 patients 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. Dunphys sign: increased pain in the right lower quadrant with coughing. Kochers 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 (resensteins) 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 Blumbergs sign and peritonitis.

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. 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. 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 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.

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. 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 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.

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

PATIENT HEALTH HISTORY Biographic Data: Name of patient: Address: Age: Sex: Civil Status: Date of birth: Religion: Source of information: Mr. P. G Prk 2, Brgy. Villa Flor, Gigaguit. 16 years old Male Single November 20, 1995 Catholic Primary source- patient Secondary source- chart and mother Admission Data: Hospital: Room #: Date admitted: Time admitted: Arrived via: Vital Signs upon admission: Caraga Regional Hospital Surgical Ward, S-2 September 1, 2011 10:12 AM Via Wheelchair Temperature: 37.8 C Heart rate: 96 bpm

Respiratory rate: 28 cpm Blood Pressure: 100/70 Weight: Height: Admitting Physician: Attending Physician: Surgeon: Anesthesiologist: Chief Complaints: Impression: Final Diagnoses: Date of Discharge: 47kg. 56 Dr. Glenn Alfred Baban Dr. Glenn Alfred Baban Dr. Relliquette Dr. C. Dumas Severe abdominal pain and vomiting 7-10x in a day Intussisuption Ruptured Appendicitis with localize Peritonitis September 8, 2011

BODY MASS INDEX

Reference: Underweight = <18.5 Normal weight = 18.524.9 Overweight = 2529.9 Obesity = BMI of 30 or greater

Given: Weight: 47 kg. Height: 5 ft. 6 inches

Formula: BMI = ____mass (lb.) x 703____ [height (inches)] squared Conversion: 703 = (constant value in BMI) 47 kg. = (2.20 lb./ 1 kg) = 103.4 lb. 5 ft. = (12 inches/ 1 ft.) = 60 inches 6 inches = (no need to convert) Solution: BMI= _______103.4 lb. x 703_______ (60 inches + 6 inches) squared = ____72690.2 lb.___ (66 inches) squared = _72690.2 lb. 4356 inches = 16.69 BMI Patient is Underweight.

History of Present Illness: Last August 30, 2011, two days prior to admission. Mr. P experienced on and off fever (37.80C-38.70C), abdominal pain (scale of 10/10), and vomiting 7x (clear and viscous). As a management Mr. P took Biogesic one tab for fever and pain, he says it helped subside the fever after few hours. However, after lunch time of August 31, his temperature spiked up again to 38.70C, that is when Mr. Ps mother decided to take him to see Dr Ycong the same day. On September 1, 2011 Mr. P was admitted at Caraga Regional Hospital with the advice of Dr. Ycong. Past Health History A. Childhood Illness Mr. P. had chicken pox at age of 11 years old. He did not experience mumps and measles. Sometimes he gets minor coughs for few days and uses over the counter drugs like Solmux 500 mg once a day until his cough subsides. Also, he uses Neozep for colds or paracetamol for fever occasionally. B. Childhood Immunization Since the patient is 16, and the EPI (Expanded Program on Immunization) was launched on 1970s. Mr. Ps mother claimed that his son is complete of his childhood immunization. She takes him to Barangay Clinic for his immunization shots. The following Immunization given to the patient during his mother visits in a certain clinic are: BCG, 1 dose and Hep B, 3 doses at birth; Measles 9 months; DPT week 6, 3 doses; and OPV week 7, 3 doses. C. History of Hospitalization Mr. P claimed that as far as he can remember he is been admitted in the hospital twice prior to the present hospitalization. First, last 2009 at Caraga Regional Hospital due to appendicitis. Dr. Amoncio was his attending physician and he was discharge after 1 week receiving of series of antibiotics, and take home medications no surgical intervention was done. Second hospitalization, was August 27, 2009 due to motorcycle accident, and admitted at Municipal Hospital

in Gigaquit for observations and pain management. Only minor scrapes and small open wound on the right and left knee. a. Surgical History Mr. P. claimed that he did not undergo any surgery in the past. b. Accidents and Injuries Mr. P. was involved in a motorcycle accident last August 27, 2009. He was admitted at municipal Hospital in Gigaquit for minor open wound on the right and left knee and minor scrapes on the right and left elbow. c. Medications. Mr. P. claimed that he uses over the counter drugs for occasionally cough, fever, and or head ache. D. Family Health History Client is the 2nd child among 5 siblings. 3 boys, and 2 girls. His grandmother on paternal side and grandfather on maternal side are deceased due to hypertension. Also his father ha hypertension as well and taking medicine for maintenance. (He forgot what the medications name) E. Personal Health History a. Life Style Personal Habits: Mr. P claimed that he started drinking alcohol and smoke cigarette at the age of 14years old. He can consume 73 cigarette packs a year. Sometimes twice a month he consumed 3-5 glasses of hard liquor (tanduay). But he claimed that by the age of 15and years old he stop smoocking cigarette. But still drink alcohol occasionally. b. Diet Before hospitalization, Mr. P. eats at least 1-2cups of plain rice, 1-2small fish (could be fried sometimes grilled, paksiw.), and vegetables. He also claimed that he loves to eat kinilaw sometimes 3x a week. He drinks 2-3 glasses ( small cup, 240cc) of water a day, and 12oz of carbonated drinks 3-4x a day. During Hospitalization Mr. P was on NPO ( nothing per orem).

c. Sleep and Rest Pattern Before Hospitalization, he usually sleeps between 11 pm to 12 midnight, and wakes up around 6:30 am. During hospitalization, he claimed that he has problem sleeping because he is not comfortable with the bed and it is noisy in the ward. He also claimed it is hard to sleep for more than 4 hours because nurses wakes him up for medications and vital signs. d. Elimination Pattern Before hospitalization, Mr. P. urinates 3 times a day and defecates at least once every other day and sometimes once every 3 days. During Hospitalization, he urinated 3-4 times a day. However, no bowel movement noted during our 2 days of assessment. e. Activities with Daily living. Before hospitalization, Patient claimed that he does not have problems with his daily activities, such as; bathing, dressing, eating, and or any difficulty with his locomotion. During Hospitalization, Patient still able to perform daily activities but slow and with assistance when dressing and setting up, due to abdominal pain on the right lower quadrant. f. Recreational Activities and Hobbies. Mr. P. claimed that he loves to play basketball. He plays at least twice a week. He hangs out with his friends on the weekend and sometimes drinks alcohol, like tanduay. He listens to music and watch television when he is at home. F. Social Data a. Family Relationships/friendship. With regards to their family relationship, Mr. P. has a strong family ties, and has a very supportive siblings and parents. Clients friends visited him in the hospital and showed empathy to the client and clients family. He has also an open communication with his family and girlfriend. b. Ethnic Affiliation. Mr. P is a native Filipino. He assimilated the values, beliefs, and culture of Filipinos. Filipinos are known to be loving, hardworking, religious, and

hospitable. He stated that he uses herbal medicines. He verbalized also that if some health problems will arise, they prefer to go to health care professionals. c. Educational History When Mr. P was on 6th grade he was on top 6 out of 10. He awarded Boy Scout of the year. During High School he claimed, he did not received any special award because he was a working student. Mr. P. is currently attending as a fulltime college student at SSCT. Here in Surigao City. d. Occupational History Before attending College, he was working as a tricycle driver and put himself through high school. e. Economic Status Mr. P. claimed that his family is able to afford the necessities at the household and can support him going to college. G. Environmental Data According to Mr. P. he lives in a simple two story house. 1st floor is made of concrete and 2nd floor made of wood materials in Gigaquit. His parents are farmers and owned chickens and 4 pigs. They have 3 rooms that are separated only by curtains. The toilet is flushed type and located inside. As a method of garbage disposal they separate the recyclable from biodegradable and nonbiodegradable waste and collected by the garbage truck. H. Psychological Data Mr. P. claimed that he gets stress when time for major examination at school and when his parents scolded him. I. Patterns of Health Care Clients family initially seeks the quack doctor in times of health problems and would try to use herbal medicinal plants as remedy; for instance, sambong for panohot and karabo for cough. However, if condition persist, they visits health center for check-up.

PHYSICAL ASSESSMENT

Date of Assessment: September 1, 2, and 3, 2011 (7am-1pm shift)

GENERAL SURVEY Assessed lying on bed ( in supine position), conscious, responsive, coherent, not in respiratory distress, complained of abdominal pain on his right lower quadrant , facial grimacing noted, with an IVF of D5LR 1L (@550 ml receiving level) regulated @ 20 gtts/min infusing well @ left metacarpal vein and with the following vital signs: T: 38.10C PR: 73bpm RR: 19cpm B/P 110/70mmHg

INTEGUMENTARY: Skin Inspection: Generally light-brown uniform in color. Old scars are noted at the right knee (4 inches wide, upper) and at the back (lower quadrant (2 inches wide) 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. Elevated body temperature 38.1C

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. 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, (PERRLA). 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: 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 73 bpm No edema noted No palpitations observed all over the body 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 distention is noted (28 inches in circumference) Abdominal guarding noted Auscultation: Bowel sounds heard in 4 quadrants (10 bowel sounds per minute) Percussion: Dull sounds heard at the liver region Tympanic sounds heard at the spleen region Palpation: Positive on rebound tenderness when palpate on the left lower quadrant. sakit ako tiyan sa kilid scale of 7/10 he pointed on the right lower quadrant.

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.

Neurologic System Language Client is able to speak clearly and had no difficulty speaking. He displays verbal and non-verbal communication (ex. Gestures, facial expression). Client is able to understand Visayan dialect. Orientation Client is oriented to self, time, and place. Able to identify the present location and can easily recognize significant others jadto si mama Memory Able to recall the nurse on duty who had just given him his medication. ( Immediate memory). Able to recall one of his relatives from Brgy. Villaflor, Gigaquit who called him 4 days ago asking about his condition (Recent memory). Able to recall his closest friends in elementary years (Remote memory) Attention Span Client has approximately 30 minutes to 1 hour of conversation.

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 doesnt 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) and minor abdominal cramps and able to control it with over the counter medicine.

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 2-3x at day time and once at night time.

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

Endocrine Client experience of any problems related to the endocrine system.

LABORATORY EXAMS SEPTEMBER 1, 2011 TEST RESULT 13.1 x 103 mm

3

NORMAL VALUES 3.5-10 x 103 mm

3

SIGNIFICANCE

RATIONALES

WBC(white blood count)

WBC fights infection. Increase in WBC signifies bacterial infection..

Indicates presence of infection

RBC(red blood cells) HGT(hemoglobin)

5.44 x 103 cellmm

3

3.80-5.80 x 103 mm
3

RBC transports oxygen in the blood Iron containing Oxygen transport in the blood

Within Normal Range Within Normal Range

14.5 g/dl

11.0-16.5 g/dl

HCT(hematocrit)

43.7% 255 x 103 mm3 0.161%

35 -50% 150-390 x 103 mm3 0.100-0.500%

Percentage of RBC in the blood.

Within Normal Range Within Normal Range Within Normal Range

PLT(platelet count) PCT

Important factor for blood to clot Procalcitonin. To determine from bacterial to nonbacterial

MCV(mean cell volume)

80 fl

70-97 fl

The average size of erythrocytes or RBC

Within Normal Range

MCH(mean cell hemoglobin)

26.7 pg

26.5-33.5 pg

Measure of the mass of hemoglobin contained by a RBC

Within Normal Range

MCHC(mean cell hemoglobin concentration

33.2 g/dl

31.5-38.5 g/dl

The average hemoglobin concentration in

Within Normal Range

RBC RDW (red blood cell distribution width) 14.6 % 10.0-18.0 % Red Cell Distribution Widthstandard Direct measurement of RDW at a certain level. MPV (mean platelet volume) 6.3 fl 6.5-11.0 fl Mean Platelet Volume, typical size of platelet in blood PDW ( platelet distribution width) Lymphocytes % 8.6 % L 17.0-48.0 % 12.7 % 10.0-18.0 % Direct measurement of Platelet Lymphocytes B and T are the natural cell killers. Monocytes % 1.0 % L 4.0-10.0 % Monocytopenia- not enough cell to fight infection. Granulocytes % 90.4 % H 43.0-76.0 # Granulocytosis: abnormally high Lymphocytes # 1.1 (10^3/mm3) L Monocytes # 0.1 (10^3/mm3) L Granulocytes # 11.9 (10^3/mm3) H 1.2-6.8 (10^3/mm3 0.3-0.8 (10^3/mm3) 1.2-3.2 (10^3/mm3) Lymphocytes B and T are the natural cell killers. Monocytopenia- not enough cell to fight infection. Granulocytosis: abnormally high Indicates presence of bone marrow dysfunction Indicates presence of infection Indicates presence of infection. Indicates presence of viral infection Indicates presence of infection Indicates presence of bleeding. Below normal secondary to platelet lyses Within Normal Range Indicates presence of viral infection Within Normal Range

URINALYSIS September 1, 2011 TEST Urine Creatinine Specific gravity pH Glucose Protein Bacteria Crystals Urates RESULT Yellow/cloudy 1.1 mg/dl 1.030 6.0 Negative Trace Plenty Amorphous Few NORMAL VALUES Amber yellow 0.9-1.4 1.002-1.030 5-7 Negative Negative Infection Normal Normal Normal Normal SIGNIFICANCE

ULTRASOUND OF THE LOWER ABDOMEN Patient: Mr. P. G Date: September 1, 2011 Ordered by Dr. Ycong.

Findings: Both kidneys show a normal range in size with a mild to moderate inhomogeneous parenchymal echogenicity with non-uniform echo pattern. The Right Kidney measures 11.06 x 4.57 cm with a cortical thickness of 1.20cm. While the Left kidney measures 9.91x4.63 cm with a cortical thickness of 1.17cm. There are a few tiny high level echogenic structures exhibiting posterior acoustic shadowing appreciated at both collecting structures, namely at the Right Kidney ranging in measurement from 0.18cm to 0.31cm, while at the left kidney ranging in measurement from 0.16cm to 0.25cm. There are few tiny rounded medium to high level echoes seen at the calices with both kidneys without posterior acoustic shadowing. Bilateral prominence with the pelvocaliceal structures are seen with a splitting with the central echo complex. The urinary bladder is physiologically distensible and sub-optimally filled with a prevoiding urine volume with 85.83cc. There are few tiny rounded medium to high level in traluminal echogenic structures seen that settle at the dependent portion. No transducer

tenderness is elicited. The bladder wall is mildly thickened measuring 0.66cm. There are pockets with free fluid noted at the interserosal surfaces of the pelvic region. There is a an echowic tubular structure noted at the right lower quadrant that is compressible measuring 0.63cm at rest and 0.45cm with compression suspected with being the vermiform appendix. The lumen of the tubular structure contains fecal materials. The region adjacent the cecum shows another tubular structure with accompanying vascular pedicle that appears to enter the lumen with the cecum and is suggestive with intussusceptions (ilio-colic type). Correlation with laboratory findings is imperative. The rest of the right lower quadrant exhibits small bowel loops that are distended and fluid filled and showing sluggish peristalsis.

IMPRESSION: NORMAL SIZE KIDNEYS WITH BILATERAL MILD HYDRONEPHROSIS, GRAD 1, THAT MAY ONLY BE TRANSIENT IN NATURE; TINY ROUNDED MEDIUM TO

HIGH LEVEL ECHOES WITHIN THE CALICES THAT MAY BE DUE TO SLOUGHED OFF RENAL PAPILLAE, URINARY SEDIMENT, AND/OR FAT GLOBULES; AND, FEW TINY LITHIASES AT BILATERAL COLLECTING STRUCTURES, AS DESCREBED. NO SONOGRAPHIC EVIDENCE SUPPORTING ACUTE APPENDICITIS WITH A DISTENDED AND COMPRESSIBLE TUBULAR STRUCTURE AT THE RIGHT LOWER QUADRANT THAT IS PRESUMED TO BE THE VERMIFORM APPENDIX. THERE IS HOWEVER SONOGRAPHIC EVIDENCE OF INTUSSUCEPTION (ILIO-COLIC TYPE). KINDLY CORRELATE WITH CLINICAL AND LABORATORY FINDINGS. MINIMAL NON-SPECIFIC ASCITES NOTED AT THE PELVIC REGION. PHYSIOLOGICALLY DISTENSIBLE AND SUB-OPTIMALLY FILLED URINARY BLADDER WITH MILD THICKENING OF THE ANTERIOR WALL MAY REPRESENT EVIDENCE CURRENT/RECENT CYTITIS VERSUS SUB-OPTIMAL FILLING; AND, MINIMAL TINY INTRALUMINAL ECHOES THAT MAY REPRESENT SLOUGHED OFF CELLS URINARY SEDIMENT, AND /OR BLOOD PRODUCTS, KINDLY CORRELATE WITH CLINICAL AND LABORATORY FINDINGS.

READ BY: ANGELO S. CO, M.D., D.P.B.R RADIOLOGIST/SONOLOGIST

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.

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. 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 (wavelike 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. 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.

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).

In infants, the appendix is a conical diverticulum at the apex of the cecum, but with differential growth and distention of the cecum, the appendix ultimately arises on the left and dorsally approximately 2.5 cm below the ileocecal valve. The taeniae of the colon converge at the base of the appendix, an arrangement that helps in locating this structure at operation. The appendix in youth is characterized by a large concentration of lymphoid follicles that appear 2 weeks after birth and number about 200 or more at age 15. Thereafter, progressive atrophy of lymphoid tissue proceeds concomitantly with fibrosis of the wall and partial or total obliteration of the lumen. Appendix is blooded by apendicular artery which is a branch of the artery ileocolica. Arterial appendix is end arteries. Appendix has more than 6 mesoapendiks obstruct lymph channels leading to lymph nodes ileocaecal. Although the appendix has less functionality, but the appendix can function like any other organ. Appendix produces mucus 1-2ml per day. The mucus poured into the caecum. If there is resistance there will be a pathogenesis of acute appendicitis. GALT (Gut Associated Lymphoid Tissue) in the appendix produce Ig-A. However, if the appendix removed, none affect the immune body system.

PATHOPHYSIOLOGY OF RUPTURED APPENDICITIS WITH LOCALIZE PERITONITIS (SCHEMATIC DIAGRAM)

PREDISPOSING FACTORS Age (11-20y.o.) Sex (Male)

PRECIPITATING FACTORS Diet (raw foods, guava) History of appendicitis Constipation (Fecalithe matter)

Obstruction of the appendix by fecalithe (hardened stool), lymph nodes, tumor, and foreign objects

Right Iliac Pain

Increased intraluminar pressure inside the appendix that result to distention of appendix

Pale, facial grimace, and abdominal guarding

Normal bacteria found in appendix begin to invade (infect) the lining of the wall

Abdominal Ultrasound

WBC result (13.1 x 103 mm3)

Inflammatory response body response to the bacterial invasion in the wall of appendix. Increased immune complex (disease plus antibody) causes swelling of tissue resulting to inflammation of appendix.

s/sx: abdominal pain scale 7/10,guarding, fever, and increased swelling of appendix vomiting, and loss of appetite

Appendectomy explore laparotomy (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 ruptures due to increased pressure

Perforation (formation of a hole in an organ), fecal materials exits to peritoneal cavity causing formation of abscess (periappendical abscess). Infection spreads throughout the abdomen (peritoneal cavity)

Diagnostic Test: Abdominal Ultrasound

Bacteria invasion of peritoneal cavity causing inflammation of the membrane that lines the abdomen peritoneum (peritonitis)

s/sx: swelling of the abdomen, acute pain, and weight loss

If not treated

If treated

Septic shock s/sx: 1. Decrease blood pressure 2. decrease blood volume

Prescribed antibiotic (lomefloxacin HCL; Maxaquin)

Fluid volume replacement therapy (D5NSS 50 gtts/min) Coma

RECOVERY DEATH LEGENDS: Risk Factor

Manifestation Diagnostic/ Lab Tests

Pathology

Management

DRUG STUDY

ranitidine hydrochloride (Zantac)

Date Ordered: September 1, 2011 (During Hospitalization) Classification: H2 receptor blocker Dosage Ordered: 50 mg IVTT q 8 hours Mechanism of Action: Competitively inhibits action of histamine on the H2 at the receptor sites if the parietal cells, decreasing gastric acid secretion. Indication: Treatment for active duodenal and gastric ulcer, GERD, erosive esophagitis, and heartburn. Contraindication: Contraindicated in patients hypersensitive to drug and those with acute porphyria. Use cautiously in patients with hepatic dysfunction. Adjust dosage in patients with impaired renal function. Adverse Reaction: CNS: headache, malaise, vertigo EENT: blurred vision Hepatic: jaundice Other: anaphylaxis, burning and itching at the injection site Nursing Responsibilities: Assess patient for abdominal pain. Note presence of blood in emesis, stool, or gastric aspirate. Remind patient to take once-daily prescription drug at bedtime for best results. Instruct patient to take without regard to meals because absorption isnt affected by food. Urge patient to avoid cigarette smoking because this may increase gastric acid secretion and worsen disease. Advise patient to report abdominal pain and blood in stool and emesis.

tramadol hydrochloride (Ultram)

Date ordered: September 1, 2011 (During Hospitalization) 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 patients 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 drugs CNS effects are known.

metronidazole (Zolnid)

Date ordered: September 1, 2011 (During Hospitalization) Classification: Nitroimidazole, antibiotic Dosage ordered: 500 mg IV drip q 8 hours Mechanism of action: Unknown. 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.

ketorolac tromethamine (Acular)

Date ordered: September 1, 2011 (During Hospitalization) Classification: NSAID Dosage Ordered: 30 mg IVTT q 8 hours Mechanism of action: May inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic, and antipyretic effects. Indication: For short-term management of moderately severe acute pain Contraindication: Contraindicated in patients hypersensitive to drug and in those with active peptic ulcer disease, recent GI bleeding or perforation, advanced renal impairment, cerebrovascular bleeding, hemorrhagic diathesis, or incomplete hemostasis, and those at risk for renal impairment from volume depletion or at risk for bleeding. Contraindicated as prophylactic analgesic before major surgery or intraoperatively when hemostasis is critical; and inpatients currently receiving aspirin, an NSAID, or probenecid. Contraindicated for treatment of perioperative pain in patients requiring coronary bypass graft surgery. Use cautiously in patients who are elderly or have hepatic or renal impairment or cardiac decompensation. Adverse Reaction: CNS: dizziness, headache, drowsiness CV: arrhythmias, edema, hypertension GI: dyspepsia, GI pain, nausea, diarrhea, vomiting Skin: pruritus, rash Other: pain at injection site Nursing Responsibilities:

Correct hypovolemia before giving. Dont give drug epidurally or intrathecally because of alcohol content. NSAIDs may mask signs and symptoms of infection because of their antipyretic and anti-inflammatory actions.

Teach patient signs and symptoms of GI bleeding, including blood in vomit, urine, or stool; coffee-ground vomit; and black, tarry stool. Tell him to notify prescriber immediately if any of these occurs.

cefuroxime sodium

Date ordered: September 1, 2011 (During Hospitalization) Classification: Second-class cephalosporin Dosage Ordered: 750 mg IVTT q 8 hours ANST Mechanism of action: Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal. Indication: Perioperative prevention Contraindication: Contraindicated to patients hypersensitive to drug and other form of cephalosporins. Use cautiously in patients hypersensitive to penicillin because of possibility of cross-sensitivity with other beta-lactam antibiotics. Adverse Reaction: CV: phlebitis, thrombocytopenia GI: diarrhea pseudomembraneous colitis, nausea, vomiting Hematologic: hemolytic anemia, thrombocytopenia Skin: maculopapular and erythematous rashes, urticaria, pain, induration, sterile abscesses, temperature elevation Other: anaphylaxis Nursing Responsibilities: Monitor signs and symptoms of superinfection. Tell patient to take drug as prescribed, even after he feels better. Instruct patient to notify prescriber about rash, loose stools, diarrhea or evidence of superinfection. Advise patient receiving drug I.V. to report discomfort at I.V. insertion site.

Generic name: ranitidine (Home Med) Brand name: Raxide Classification: Therapeutic: Anti-ulcer agents; Pharmacologic: Histamine H2 antagonists Dosage: 150 mg bid PO Mechanism of Action: Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. In addition, ranitidine bismuth citrate has some antibacterial action against H. pylori. Indication: Treatment and prevention of heartburn, acid indigestion, and sour stomach. Contraindications Hypersensitivity, Cross-sensitivity may occur; some oral liquids contain alcohol and should be avoided in patients with known intolerance. Use Cautiously in: Renal impair- ment Geriatric patients (more susceptible to adverse CNS reactions) Pregnancy or Lactation Side Effects CNS: Confusion, dizziness, drowsiness, hallucinations, headache CV: Arrhythmias GI: Altered taste, black tongue, constipation, dark stools, diarrhea, drug-induced hepatitis, nausea GU: Decreased sperm count, impotence ENDO: Gynecomastia HEMAT: Agranulocytosis, Aplastic Anemia, neutropenia, thrombocytopenia LOCAL: Pain at IM site MISC: Hypersensitivity reactions, vasculitis Nursing Implications/Responsibilities: Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. Nurse should know that it may cause false-positive results for urine protein; test with sulfosalicylic acid. Inform patient that it may cause drowsiness or dizziness. Inform patient that increased fluid and fiber intake may minimize constipation. Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health car professional promptly. Inform patient that medication may temporarily cause stools and tongue to appear gray black.

Generic name: lomefloxacin hydrochloride and/or lomecin (Home Med) Brand name: Maxaquin Classification: Antibiotic, Flouroquinolone Indication : Treatment of infectious in adults caused by susceptible organism: Lower respiratory tract infections caused by Haemophilus influenzae, Moraxella catarrhalis. Contraindications: Contraindicated in: Allergy to lomefloxacin, or any fluoroquinolone; lactation Use cautiously with renal impairement and seizures, pregnancy.

Dosage: 400 mg tab 2x/day PO total of 16 tabs.

Mechanism of Action: Interferes with DNA replication by inhibiting DNA gyrase in susceptible gram negative and gram positive bacteria, preventing cell reproduction and causing cell death.

Nursing Implication/Responsibilities: Arrange for culture and sensitivity tests before beginning the therapy. Continue therapy for full prescription, even if the signs and symptoms of infection have disappeared. Give oral drug without regard to meals Drink plenty of fluids Advised patient to report presence of rash, visual changes, severe GI problems, weakness, tremors.

Generic name: mefenamic acid (Home Med) Brand name: Ponstel Classification: NSAID Mechanism of action: Anti inflammatory, analgesic, and antipyretic activities related to inhibition of prostaglandin synthesis; exact mechanisms of action are not known. Indication: Relief of moderate pain when therapy will not exceed 1 week.

Contraindications: Contraindicated in: Hypersensitivity to mefenamic acid, aspirin allergy, and as treatment of perioperative pain with coronary artery bypass grafting. Use cautiously with asthma, renal or hepatic impairment, peptic ulcer disease, GI bleeding, hypertension, heart failure, pregnancy, lactation. Dosage: 500mg capsule once a day PO for 16 days total Nursing Implication/Responsibilities Patient may be at increased risk for CV events, GI bleeding; monitor accordingly. Take drug with food; take only the prescribed dosage; do not take the drug longer than 1 week. Dizziness or drowsiness can occur. Advised patient to report onset of black tarry stools, severe diarrhea, fever, rash, itching.

Generic Name: Multivitamins (Home Med) Brand Name: Enervon - C Classification: Vitamins & Minerals Dosage: 1 tab OD Mechanism of Action: Enhance immune function to increase resistance and maintain optimum health. Indication: helps ensure optimum energy and increases body resistance against infections and stress conditions. Contraindications: Allergies to medicine, foods, or other substances. Side Effects: Rash, itching, tightness in the chest, and swelling in mouth and lips. Adverse Reactions: Severe allergy reactions and DOB Nursing Implications: Assess if the patient is taking any prescription or herbal preparation because it may interact with multivitamin Assess patient if he/she has allergy of food, or any substances. Educate the patient that multivitamin may counteract with other medicine intake. Instruct the patient to check with health care provider before they start, stop, or change the medicine. If stomach upset occurs, take with food to reduce stomach irritation. Inform the patient/SO not to take the medicine twice a day.

NURSING CARE PLAN # 1 (PRE-OP) September 1, 2011 @ 9:00 am Subjective cue: Sakit ako tiyan as verbalized by the patient. Objective cue: Facial grimacing noted Pain scale of 7 out of 10 v/s taken: T: 36.9C P: 64 bpm R: 21 cpm BP: 100/60 mmHg Nursing Diagnosis: Acute pain related to inflammation of tissues Planning: Within 40 mins. of nursing intervention, the patient will reduce the pain from 7 to 0. Intervention: Independent: 1. Establish rapport on the client. Rationale: To establish trust and cooperation on the client 2. Monitor the vital signs Rationale: To obtain the baseline data 3. Perform a comprehensive assessment of pain to include location, characteristics, onset and duration, frequency, intensity or severity of pain and precipitating factor. Rationale: To have necessary information on the case of the client. 4. Help patient focus on activities rather than on pain and discomfort by providing diversion through radio and visitiors. Rationale: To focus more on activities rather than pain. 5. Provide comfort measure like back rubs and deep breathing Rationale: Promotes relaxation and may enhance patients coping abilities. Collaborative: Administer analgesics as prescribed by the physician. Rationale: Aids in pain relief Evaluation: Goal partially met. Patient was able to reduce the pain from 7 to 3.

NURSING CARE PLAN # 2 (PRE-OP) September 1, 2011 @ 10:12 am Subjective Cue: init ang pamati naku sa akung lawas as verbalized by the patient. Objective cues: Temperature: 38.8C Flushed skin General weakness noted Shivering Skin moist and warm to touch WBC above the normal range 13.1

Nursing Diagnosis: Altered body temperature related to inflammatory response as evidence by body temperature higher than the normal range. Planning: Within 30 mins. of nursing intervention patients temperature will decrease to within normal range. Intervention: Independent: Monitor V/S Increase oral fluid intake If not contraindicated w/ disease Promote bed rest Provide TSB as needed Rationales To have a baseline data To prevent dehydration To reduce metabolic demand and O2 consumption Heat is lost by evaporation &conduction Rationales Antipyretic medication helps lowers temp. to prevent dehydration

Dependent: Administer paracetamol as ordered By the M.D Administer IVF as ordered

Evaluation: Goal met. After 30 mins. of nursing intervention patients body temperature decreased to 37.5C.

NURSING CARE PLAN # 3 (PRE-OP) September 2, 2011 @ 8:45 am Subjective cue: 3 days nako ya makakalibang maam as verbalized by the patient. Objective cue: Distended abdomen and Percussed abdominal dullness Nursing Diagnosis: Constipation related to depressed gastrointestinal function accompanied by difficult or incomplete passage of stool. Planning: Within 6 hours of appropriate nursing intervention, patient will be able to defecate at least once before shift ends. Intervention: Independent Promote adequate fluid intake, including highfiber fruit juices; suggest drinking warm, stimulating fluids (e.g., coffee, hot water, tea) Rationale: To promote passage of stool Identify areas of stress (e.g., personal relationships, occupational factors, financial problems) Rationale: Individuals may fail to allow time for good bowel habits and/or suffer gastrointestinal effects from stress/tension. Encourage activity/exercise within limits of individual ability. Rationale: To stimulate contractions of the intestines Encourage increase mobility within patient exercise tolerance

Dependent Collaborative

Administer laxatives prior to doctors order Rationale: To promote defecation

Discuss clients current medication regimen with physician to determine if drugs contributing to constipation can be discontinued or changed. Rationale: To determine if drugs contributing to constipation can be discontinue or changed. Evaluation: Goal met. Patient defecates once a day

NURSING CARE PLAN # 4 (PRE-OP) September 2, 2011 @ 9:12 am ASSESSMENT Subjective Cues: Kalain na sa ako gibati karon sa gilid sa akong tiyan, as verbalized by the patient prior to hospitalization. Objective Cues: The patient manifested: Weakness Irritability Moist skin Facial grimace

NURSING DIAGNOSIS Infection related to released of pathogenic organisms in peritoneal cavity. PLANNING Within 2 days of nursing intervention, the clients infection will ease. INTERVENTION INDEPENDENT Established rapport Monitored and recorded vital signs. Practiced and instructed in good hand-washing. Inspected incision and dressings. Provides for early detection of developing infectious process and monitors resolution of peritonitis. Monitored v/s Suggestive of presence of infection, developing sepsis, abscess, and Reduces the risk of spreading infection RATIONALE To gain trust of the patient. To obtain baseline data.

peritonitis. DEPENDENT Administered antibiotic as prescribed by doctor. Primarily for prophylaxis of wound infection.

EVALUATION Goal partially met. Clients infection eased a bit.

NURSING CARE PLAN # 5 (PRE-OP) September 2, 2011 @ 11:12 am ASSESSMENT Subjective Cues: Ang ako ra nahibaw-an na na-appendicitis ako tungod sa pirmi ako magduwa ng basketball human nako kaon, as verbalized by the patient. Objective Cues: Always asking question regarding to his condition.

NURSING DIAGNOSIS Knowledge deficient related to information misinterpretation

PLANNING Within at least 50 mins. of nursing intervention, patient will know the disease process. INTERVENTION INDEPENDENT Identified symptoms requiring medical intervention. Provided the client about the information of disease process Reviewed postoperative activity restrictions. RATIONALE Prompt intervention reduces risk of serious complication. Patient will be aware the process of his disease. Provides information for client to plan for return to usual routines without untoward incidents. Encouraged activities as tolerated with periodic rest periods. Discussed care of incision, including dressing changes. Prevents fatigue, promotes healing and feeling of well-being, and facilitates resumption of normal activities. Understanding promotes cooperation with therapeutic regimen, enhancing healing and recovery process. EVALUATION: Goal met. Patient knew already the disease process of appendicitis.

NURSING CARE PLAN # 6 (POST-OP) ASSESSMENT Subjective Cues: Kasakit sa ako operasyon, as verbalized by the patient after operation (appendectomy). Pain scale: 5/10 Objective Cues: The patient manifested: Facial Grimace Abdominal guarding Sweating P 68 bpm R 27 cpm BP 120/80 mmHg

v/s taken: T 36.9 C

NURSING DIAGNOSIS Pain related to post-appendectomy.

PLANNING Within 40 mins. of nursing intervention, pain will reduce from 5/10 to 0/10. INTERVENTION INDEPENDENT Established rapport Monitored and recorded vital signs. Assessed pain, location, and severity. Kept at rest in semi-fowlers position Useful in monitoring effectiveness of medication and progression of healing Gravity localizes inflammatory exudate into lower abdomen or relieving RATIONALE To gain trust of the patient. To obtain baseline data.

abdominal tension which is accentuated by supine position. Encouraged early ambulation. Promotes normalization of organ function and reducing abdominal discomfort.

Provided diversional activities.

Refocuses attention, promotes relaxation, and enhance coping

DEPENDENT Administered prescribed analgesic.

abilities. Relief pain.

EVALUATION Goal met. Patient pain (pain scale) reduced from 5/10 0/10.

NURSING CARE PLAN # 7 (POST-OP) Subjective Cues: sige ako nag mata mata kay init ug sakit ako tag operahan ug ngotngot, as verbalized by the patient. Objective Cues: Restlessness Irritability Slowed Reaction Nursing Diagnosis: Sleep deprivation related to prolonged discomfort. Planning: The patient will report improvement in sleep pattern within the shift. Interventions: 1. Determined presence of physical or psychological stressors Rationale: To know the reasons why the patient cant sleep. 2. Noted environmental factors that affect sleep. Rationale: To help the client have a better rest and sleep. 3. Determined patients usual sleep pattern. Rationale: To provide comparative baseline. 4. Observed physical signs of fatigue. Rationale: To know if the client will not get stressed 5. Recommended quiet activities such as, listening to soothing music. Rationale: To help the client have a better rest and sleep. 6. Provided calm, quiet environment and manage controllable sleep disrupting factors. Evaluation: Goal met. After 6 hours of nursing intervention, the patient was able to report sleep that day and there is a decrease over all body malaise.

NURSING CARE PLAN # 8 (POST-OP)

ASSESSMENT Subjective Cues: Waya pa karajaw nadajaw ang ako samad sukad na gi-operahan ako, as verbalized by the patient. Objective Cues: The patient manifested: Epidermis (disruption of the skin surface) Surgical incision at right lower abdominal area.

NURSING DIAGNOSIS Impaired skin integrity related to skin/tissue trauma as evidenced by the surgical incision at right lower abdominal area due to appendectomy. PLANNING Within 3 days of nursing intervention, the client will be able to manifest intact sutures, dry and intact wound dressing, and active/passive participation in ROM exercise. INTERVENTION INDEPENDENT Established rapport Monitored and recorded vital signs. Assessed operative site for redness, swelling, loose sutures and soaked dressings. Assisted passive/active ROM exercise To promote circulation to the surgical site and healing. To check skin integrity and monitor the progress of healing. RATIONALE To gain trust of the patient. To obtain baseline data.

Instructed the patient to refrain from scratching/touching the

To avoid accumulation of moisture at the operative site which may led to skin

surgical site. Provided regular dressing care.

breakdown. To prevent bacteria harbor in the operative site.

DEPENDENT Administered antibiotic therapy as prescribed by the physician. To promote wound healing.

EVALUATION Goal was partially met. Client manifested intact sutures, dry and intact wound dressing, and slightly followed passive/active ROM exercise.

NURSING CARE PLAN # 9 (POST-OP)

Subjective cue: tag operahan ako kahapon as verbalized by patient. Objective cue: Abdominal dressing noted Incision on the abdomen area noted.

Nursing Diagnosis: Risk for infection related to surgical incision. Planning: Within 6 hours of nursing intervention, Patient and SO will be able to identify signs and symptoms of infection. Intervention: Independent Instruct Patient and SO how to identify signs and symptoms of infection (fever, chills, redness and burning sensation around, surgical site, and or drainage.) o Rationale: so they will be able to notify Nurse and or MD and to prevent sepsis Assess and document skin condition around surgical site. Note for any abnormalities. o Rationale: to monitor and prevent potential post op complications. Keep dressing dry and intact and proper hand washing o Rationale: to prevent infection

Dependent: Evaluation: Patient and SO verbalized understanding by restating the given instructions. Give antibiotic per M.Ds order o Rationale: to help prevent infection Cleanse surgical site and dressing change per M.D order o Rationale: to keep surgical site dry and intact.

NURSING CARE PLAN # 10 (POST-OP) Subjective cue: luya ako lawas maam as verbalized by the patient. Objective cue: Weakness noted Needs assistance in sitting down, standing and walking Prefers to stay on bed

Nursing diagnosis: Activity intolerance related to post appendectomy. Planning: Within 3days of nursing interventions, patient will be able to use identified techniques to enhance activity tolerance. Nursing intervention: Independent: Provide bed rest o Rationales: Promotes periods of rest and relaxation. Available energy is used for healing Provided environment conducive to relief fatigue. o Rationales: fatigue affects both the clients actual and perceived ability to participate in activities. Recommended changing position every 2 hours. o Rationales: to prevent bed sores and promotes optimal respiratory function. Instructed energy conserving techniques such as sitting instead of standing during shower and any activities. o Rationales: helps minimize fatigue allowing client to accomplish more and feel better about self Increased activity as tolerated. Demonstrate active ROM exercise. Rationales: prolong bed rest can be debilitating and causes muscle atrophy Encourage use of stress management technique such as guided imagery. o Rationales: promotes relaxation and conserves energy, redirect attention and may enhance coping.

Evaluation: Goal partially met, as evidenced by patient understanding and following instructions and techniques that would enhance activity tolerance.

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: Take home medicines o lomefloxacin hydrochloride: 400mg one tab by mouth twice a day total of 16tablets only o ranitidine:150mg one tab by mouth three times a day, total of 16 tablets only o ponstel (mefinamic acid): 500mg 1 cap by mouth three times a day total of 16 caps only. o Multivitamins (Enervon C): 1 tab OD 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 regime to ensure complete 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) 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.

INTRAVENOUS FLUID

Date/time started

Intravenous fluid and volume

Drop Rate /min

Number of hours to be infused

Date /time consumed

09-01-11

D5LR/1L

20 drops

16hrs &39mins

09/01/11 12:39pm

09-01-11

D5LR/1L

20 drops

16hrs&39mins

09/03/11 5:30am

09-03-11

D5LR/1L

50 drops

6hrs & 39 mins

09/03/11 12:09pm

09-03-11

D5NSS/1L

50drops

6hrs & 39 mins

09/03/11 6:48pm

09-03-11

D5LR/1L + Multivitamins

50drops

6hrs & 39 mins

09/04/11 1:27 am

09-04-11

D5LR /1L

50drops

6hrs & 39 mins

09/04/11 8:08am

09-04-11

D5NSS /1L

50drops

6hrs & 39 mins

09/04/11 2:27pm

09-04-11

D5LR/1L

50drops

6hrs & 39 mins

09/04/11 9:26pm

FAMILY GENOGRAM
PATERNAL SIDE MATERNAL SIDE

Grandfather

Grandmother, 59 Hypertension

Grandfather, 79 Hypertension/Stroke

Grandmother

1 Sibling

st

2 Sibling

nd

Father, has Hypertension

4 Sibling

th

5 Sibling

th

6 Sibling

th

7 Sibling

th

8 Sibling

th

1st Sibling, 32 Eclampsia

Mother

3 Sibling

rd

1 Sibling

st

Patient, 17

3 Sibling

rd

4 Sibling

th

5 Sibling

th

LEGENDS:
Male Female Male Deceased Female Deceased

Patient

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 Blumbergs sign and peritonitis. 5. Dunphys 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. Kochers 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. 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 patients 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. Rovsings 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 (resensteins) 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.

BIBLIOGRAPHY

A. Textbook References/Primary References:

Assessment: Lippincott; 2007 Edition. Tabers Cyclopedic Medical Dictionary: 18th 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 Care Plans: Doenges, Moorhouse and Murr; 8th Edition. Nursing Drug Guide: Lippincott; 2010 Edition. PDQ for RN:Mosby; 2nd Edition. PPD for Registered Nurses: Mosby; 2nd Edition. Principles of Internal Medicine: Harrison and Braunswald; 11th Edition. Public Health Nursing: Nurses Contributors; 2007 Edition.

B. Electronic References/Secondary References:

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 www.sciencedaily.com www.healthycase.com