I.

INTRODUCTION

Mr. A is a 25 years old man, living in Purok San Isidro Poblacion, Polomolok, South Cotabato. He was admitted last November 12, 2007 at South Cotabato Provincial Hospital at the Surgical ward under the service of Dr. Jose June T. Tabanda, after a thorough assessment and examination, the patient was diagnosed of having Acute Appendicitis. Acute Appendicitis is an inflammation of the appendix and usually occurs because of obstruction, secretions from the appendix and cannot pass the obstruction and accumulate, causing enlargement and pain. Bacteria in the area can cause infection. Symptoms include sudden abdominal pain, particularly in the right lower quadrant of the abdomen, along with slight fever, loss of appetite, constipation or diarrhea and nausea and vomiting. If the appendix bursts, the infection can spread throughout the peritoneal cavity, causing peritonitis with life threatening result. Each year 500,000 people in the United States suffer from appendicitis. Acute appendicitis affects all person, specially males at the age between 10 to 30 years old. Most common cause of acute abdominal pain in the United States and most common abdominal surgery. About 7% of total are affected of appendicitis in the United States. The major complication is perforation of the appendix, which can lead to peritonitis or an abscess. The incidence of perforation is 10 to 30 percent, higher in young children and elderly. Perforation generally occurs 24 hours after the onset of pain. This study aims to know. Further what is Acute Appendicitis and knowing what medical intervention and nursing intervention should be rendered to the patient further discussion about the cause are on succeeding pages.

II.

OBJECTIVES

General Objectives: After 1 to 2 hours of presenting the case, I will be able to thoroughly explain content of the case and the listeners may be able to gain knowledge on what is Acute Appendicitis is all about.

Specific Objectives: After presenting the case, I will be able to:

Present the Vital Information of the patient for the case. Present the Physical Assessment correctly. Discuss the Acute Appendicitis in relation to my patients diagnosis. Illustrate clearly the anatomy and physiology of the system or organ involved in the disease condition. Enumerate completely the etiology of illness. Discuss precisely the symptoms present in the patient. Trace the pathopysiology of acute appendicitis in relation to the patients condition. Identify completely all laboratory procedures performed in diagnosing the patients condition. Discuss vividly the doctors order with rationale. Enumerate properly all the medication received by the patient. Prioritize precisely the nursing care plan for patients having such illness. State properly the prognosis of the patients condition. Present the Bibliography.

III.

PATIENTS DATA

A. Time: 9:45 am Name Age Sex Address Birthday Place of Birth Civil Status Tribe Citizenship Religion Occupation

Vital Information Date: 11-13-07 : : : : : : : : : : : : : : : Mr. A 25 Male Prk. San Isidro Poblacion, Polomolok, S.C. January 24, 1982 Banga, South Cotabato Married Ilonggo Filipino Roman Catholic Waiter High School Undergraduate (3rd level) 11-12-07 5:45 PM Acute Appendicitis Ruptured Appendix (Appendectomy RDI Drop Method) Chief Complaint Attending Physician Name of Spouse Age Religion Occupation Source of Information : : : : : : : Gasuka ako kag gasakit tiyan ko Jose June T. Tabanda M.D. Mrs. B. 22 Roman Catholic Housewife Patient, Patients wife, Patients Chart

Educational Attainment Date Admitted Time Admitted Admitting Diagnosis

Post Operating Diagnosis :

B.

Family Background Mr. A is the 6th child among the seven children of Mr. & Mrs. AP. He is 25 years old and now working as a waiter in a certain restaurant in their place, he is now married to Mrs. B and they were blessed with two boys, a 1 year old and 3 years old. His father is 59 years old, a farmer and his mother is 57 years old a housewife. The eldest child is 34 year old, also a farmer, the second child is 32 years old, also a farmer, the third child is 31 years old, a married one, the 4th child is 28 years old, a security guard in General Santos City. The fifth child is a driver of a jeep in their town and the sixth child my patient is a waiter and the youngest a 23 years old is just staying at home with their parents. According to the patients, the possible hereditary disease they have is hypertension, which both of his parent is now having and that there is no incidence of appendicitis or any gastrointestinal disorder like ulcer or gastritis in their family as of now.

C.

History of Past Illness According to the patient, he said that he was never admitted to any hospital until last November 12, 2007. He said that he only experienced common colds, mild cough, fever and diarrhea and it is usually been cured of drugs they bought in the pharmacy like biogesic, solmux, diatabs and paracetamol. They also use herbal medicines such as lagundi for cough and ulisimang bato which they usually boil and drink. They also seek the help of manghihilot. They also go to their health center and asked help. The patient also said that he has no allergies experience to any food or dust at the moment and verbalized that he has completed his immunization and he has never been to any hospital agencies or had any accidents that he knows until he was admitted last November 12, 2007. History of Present Illness 5 days prior to his admission, my patient experienced abdominal pain on the right lower quadrant of his abdomen, fever, vomiting, tenderness of the abdomen and constipation which he just manage it by drinking mefenamic acid to relieve pain and biogesic for fever. He said that his experienced this everyday between 10 to 20 minutes and sometimes he loses his appetite to eat his foods. He said that he did not went to their barangay health center that time but instead he went to the manghihilot to let him massage his abdominal area and his head as well. Despite all those medicines and help he got, the pain still comes back and did not subsided so his family decided to take him to South Cotabato Provincial Hospital last November 12, 2007 at around 5:45pm under the service of Dr. Tabanda and after a day of series assessment and laboratory examination, he was diagnosed of having Acute Appendicitis and was ordered that he would undergo operation to relieve him of his condition.

D.

E.

Effective and Expectation to Illness of Self and Family

Effects to: Self the patient said that he cannot do his usual activities because of his condition and that is work or income is not enough to support his condition, and feels that he is a burden to his family and misses his children. Family the patient wife is worried for his husbands condition because his is going to be operated. She is also worried for his husbands financial

support because their income is not enough to pay the bills and nobody is watching over their children at home.

Expectation to: Self the patient expects that after this experience he will have a normal life again. He is expecting that again he will regain his strength to go back to his work and live a happy life. He is expecting that this could not happened again. He was hoping for a fast recovery. Family the patients wife expects for his fast recovery and short stay in the hospital, so that he could go home to his children and go back to his work.

F.

GENOGRAM Maternal Side 82

No Known Disease

Paternal Side 84
No Known Disease

80
HTN

78
No Known Disease

55
No Known Disease

59
HTN

61
No Known Disease

53
No Known Disease

55
No Known Disease

57
HTN

58
No Known Disease

23
No Known Disease

25

27
No Known Disease

28
No Known Disease

31
No Known Disease

32
No Known Disease

34
No Known Disease

LEGEND:

Male

Female

Connected by not connected Deceased by Blood by Blood

No Known Disease

HTN

Patient

Hypertension

Narrative: The patients grandparents on the mother side died due to unknown disease as well as to the paternal side except for the Grandfather who has hypertension. His parent were both hypertensives. Almost of the family member have no known

disease because the patient said that he dont know the underlying diseases of his brother and sister due to far locations.

G.

Developmental Data Erik H. Erikson (1902-1996) Psychosocial Theories

Erikson envisions life as a sequence of levels of achievement. Each stage signal a task that must be achieved. The resolution of the task can be complete, partial, or successful. Erikson believes that the greater the task achievement the healthier the personality of the person; failure to achieve a task influence the persons ability to achieved the next task.

Central Task Intimacy VS isolation (18-25) -

Positive Resolution intimate relationship with another person commit ment to work and relationship creativit y, productivity, concern for others. -

Negative Resolution imperso nal relationship avoidan ce of relationship, career, or lifestyle.

Justification My patient is already married for 3 years and that enjoys his work because he meets different people. He has a positive outlook in life that he will overcome his condition. He said that even though they are financially unstable he find ways to attend his family needs because he loves them so much.

Remarks A C H I E V E

Robert Havighurst (1900-1991) Developmental Task Theory

He believe that learning is basic to life and that people continue to learn throughout life, his developmental task provide a frame work use to evaluate a persons general accomplishments.

Early Adulthood
TASK Early Adulthood Selecting a mate Learning to live with a partner JUSTIFICATION My patient is already been married for almost 3 years and said that he loves his wife a lot and that she is already the right one for him that he is going to be spending the rest of his life. My patient said that they are living independently with their own house for almost 3 years. He stated that he is already adjusted to his wife attitude and the way she behave. And they are both happy to each others company as they share their ups and downs. The patient said that at first he had a hard time in adjusting to his family because of his low income. But as time goes by he found solution to his problem that lead him to a happy family he has now, he said that he is haply and very blessed. My patient started already his family with two boys. He said that at first he had a hard time to adjust and provide their need because of his status in life. But as a further he was able to provide his children needs because of his love for them. The patient verbalized that being a father is not easy because he is the only one working to provide his families needs. And as a father he said that he ask his wife to help him budget their money well because of his low income to provide their everyday needs. My patient is already working for almost 4 years and that until now he has a hard time because of his income. But he said that he has to do his part and has extra effort to earn money to provide his families need because he is only the one providing their needs. Patient said that he has already accepted his roles as a father, as husband to his wife and as a part of their community and society, he has also accepted the changes in his life and that he can be a good citizen by following the law. The patient said that they have a good relationship with his neighbor and sometimes they drink liquor to have socialization to each other to share their life. The patient also goes to church to express his faith and love to God. REMARKS Achieved

Achieved

Starting a family

Achieved

Rearing a children

Achieved

Managing a home

Achieved

Getting started in an occupation

Achieved

Taking on civic responsibility

Achieved

Finding a congenial group

Achieved

Jean Piaget (1896 1980)

Cognitive Theory

Refers to the manner in which people learned to think, reason and use of language. It involves a persons intelligence, perceptual ability and the ability to process information. A progressive of mental ability from illogical to logical thinking from simple to complex problem solving and from understanding concrete ideas to understanding abstract concepts.

Formal Operational Phase

TASK Uses rational thinking Reasoning is deductive and futuristic JUSTIFICATION My patient is Illongo and uses it as his primary way of communicating to others. Even if he is a high school undergraduate. He takes with a sense and answers to the question I ask him properly without being suspicious. REMARKS Achieved

IV.

R.O.S.: General: The patient verbalized felling of weakness and fatigue when he is doing something strenuous at home.

Skin & Nails: Patient denies experience of rashes or lumps or other abnormal growth. Head: Patient denies feeling of dizziness but admits to have fever before admission. Patient denies visual correction. Patient denies of hearing loss, having discharges and pain. Patient admit that he experienced cold and difficulty of breathing because of common colds 2 months ago.

Eyes: Ears: Nose:

Mouth/Throat: patient denies having dentures and gun problems. Neck: Denies having goiter but he experience pain and stiff neck after waking up in the morning two weeks ago.

Lymph Nodes: Denies having enlargement and tenderness. Respiratory: Patient denies having difficulty in breathing, asthma, dyspnea and smoking. Cardiovascular: patient denies having chest pain, hypertension or exercise intolerance. Gastrointestinal: Patient admit loss of appetite after not eating on the right time and constipation once every three weeks and denies to experience ulcer or abdominal enlargement. Endocrine: patient denies having thyroid enlargement, tenderness, weight change and D.M. Male Reproductive: patient denies having experience of hernia, erection problems testicular masses. Genitourinary: patient verbalized feeling of pain, sometimes during urination but denies to have UTI Masculoskeletal: Patient denies of having pain but admit felling of weakness when working. Hematologic: Patient denies of having anemia but sometimes feeling of fatigue when tired after working.

Neuroligic: Patient verbalized dizziness, headache, and weakness after working at night. Psychiatric: Patient feels that he is already a burden to his wife because of his condition and patient is irritable.

Concluding Statement: None

V.

PHYSICAL ASSESSMENT Time: 9:45 am Observation Patient lying on bed with IVF of D5LR, IL at 750cc regulated at 40gtts/min hooked at @ hand, weak and ill. Not comfortable, weak looking The patient is alert and responsive In mild pain but cooperates Facial expression appropriate to situation Speaks with clear and audible voice Patient is oriented to time, place and person Dressed with t-shirt and short, unkempt Middle Adulthood Male Asian Brown in color No body odor noted

Date: November 13, 2007 General Appearance Overall apparent state of health

Apparent state of comfort or distress Consciousness, state of awareness Mood, manner, relationship to surroundings Facial expression Speech Orientation Dress, grooming, personal hygiene Age Category Sex Race Skin Color Breath, Body Odor

VITAL SIGNS
Temperature Respiration Pulse BP O2 Saturation 37.1oC 20cpm 75cpm 120/90mmHg 99%

VI.

TEXTBOOK DISCUSSION
A. Complete Diagnosis Acute appendicitis is an inflammation of the vermiform appendix, usually acute, that if undiagnosed leads to rapidly to perforation and peritonitis. The inflammation is caused by an obstruction such as a hard mass of feces or a foreign body in the lumen of the appendix, fibrous disease of the bowel wall, an adhesion, or a parasitic infestation. The most common symptom is constant pain in the right lower quadrant of the abdomen around the Mcburneys point. Extreme tenderness occurs over the right rectus muscle. Appendicitis is also characterized by vomiting, a low grade fever of 99 o to 102oF, an elevated WBC count, rebound tenderness, a rigid abdomen, and decreased or absent bowel sound. Treatment is appendectomy within 24 to 48 hours of the first symptoms because delay usually results in rupture and peritonitis as fecal matter is released into the peritoneal cavity. Mosbys Pocket Dictionary of Medicine, Nursing, & Health Professions 5th Education Page: 106 Acute appendicitis The appendix is a small, finger-like appendage about 10cm (4 inches) long that is attached to the cecum just below the ileocecal value. The appendix fills with food and empties regularly into the cecum. Because it empties inefficiently and its lumen is small, the appendix is prone to obstruction and is particularly venerable to infection. The most common cause of Acute abdomen in United States is the most common reason for emergency abdominal surgery. About 7% of the population will have appendicitis at same 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 10 and 30 years old. Brunner and Suddarths Textbook of Medical Surgical Nursing Volume 1, 10th Edition Suzanne C. Smelter, Brenda G. Bare Lippincott Williams & Wilkins Page 1034 1036 Acute appendicitis is an inflammation of the appendix and usually occurs because of obstruction. Secretions from the appendix cannot pass the obstruction and accumulate, causing enlargement and pain. Bacteria in the area can cause infection. Symptoms include sudden abdominal pain, particularly in the right lower quadrant of the abdomen, along with a slight fever, loss of appetite, constipation or diarrhea, nausea and vomiting. If the appendix bursts, the infection can spread throughout the peritoneal cavity, causing peritonitis, with life threatening results. Each year, 500,000 people in the United States suffer from appendicitis. An appendectomy is removal of the appendix. Essentials of Anatomy and Physiology 5th Edition Mcgraw Hill International Edition Page: 474

B.

ANATOMY AND PHYSIOLOGY OF APPENDIX

The appendix is a closed-end, narrow tube up to several inches in length that attaches to the cecum (the first part of the colon) like a worm. (The anatomical name for the appendix, vermiform appendix, means worm-like appendage.) The inner lining of the appendix produces a small amount of mucus that flows through the open center of the appendix and into the cecum. The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies. Like the rest of the colon, the wall of the appendix also contains a layer of muscle, but the muscle is poorly developed.

The appendix averages 10cm in length, but can range from 2 to 20 cm. the diameter of the appendix is usually between 7 and 8 mm.

Functions of the Appendix The appendix acts as a good safe house for bacteria. Being involve primarily in immune functions. Functioning as a lymphoid organ, assisting with the maturation of B lymphocytes (one variety of white blood cell) and in the production of the class of antibodies known as immunoglobulin A (IgA) antibodies. Helping with the production of molecules that help to direct the movement of lymphocyte to various other locations in the body. Suppressing potentially destructive humoral (blood-and lymph borne) antibody responses while promoting local immunity. Additionally it is an important backup that can be used in variety of reconstructive surgical techniques.

Source:
http://www.evolutionnews.org/2007/10/for_decades_darwinists_have-be-html

C 1. Etiology Predisposing Factors Factors Age (25 y.o.) Rationale The incidence of appendicitis gradually rises from birth, peaks in the late teen years and gradually declines in the geriatric years. Person at any age may be effected, with the highest incidence occurring during the 2nd or 3rd decades of life, rare cases of neonatal and perinatal appendicitis have been reported. Remarks Present

Source: Medical Surgical Nursing by Brunner and Suddarths page 1034-1036 Sex (Male) Appendicitis occurs more frequently in males that with the female with male to female ration of 2:1 Present

Source: Harrisons Principle of Internal Medicine page 1805-1808. Race (Asian) Asians have much probably high incidence of appendicitis because of their dietary habits of the inhabitant of these geographic area. Present

Source: Medical Surgical Nursing by Brunner and Suddarths page 1034-1036

C 2. Precipitating Factor

Factors A fecalith that occludes the lunen of the appendix

Rationale When the appendix is obstructed not all fecal matter can pass through the intestines, thus it will lodge to the appendix resulting in inflammation.

Remarks Present

Source: Medical Surgical Nursing by Joyce and Black, page 812-814

Dietary habit

Due to his dietary habit and decreased level of fiber intake the organ responsible for elimination of waste is not capable to function well.

Present

Source: Medical Surgical Nursing by Joyce and Black, page 812-814 Irregular bowel movement Due to the inflammation of appendix there is alteration of bowel movement thus resulting to irregular elimination of waste product in the body. Present

Source: Medical Surgical Nursing by Joyce and Black, page 812-814

D. Symptomatology

Factors Low-grade fever Nausea & vomiting Abdominal Pain Constipation

Rationale Results from the imbalance between the elimination and the production of heat in the body. Due to the increase tension of the walls of the stomach, duodenum and lower ends of the esophagus This is due to the inflammation of the appendix resulting to a swollen appendix. Due to the increase amount of sodium in the body, then less fluid and fiver in the bowel thus resulting to decrease peristalsis. Is due to a series of nausea and vomiting the appetite of the individual is affected. Due to the location of the affected body part as a pressure is being applied it will be compassed thus resulting to intensification of pain. Due to curling of the inflammation appendix behind the cecum. Due to the tension and absence of peristalsis in the GI tract.

Remarks Present Present

Present

Anorexia Rebound tenderness in the right lower quadrant Lumber pain Pain of defecation Source:

Not Present Present

Not Present Not Present

Medical Surgical Nursing by Joyce and Black, page 812-814 Medical Surgical Nursing by Brunner and Suddarths page 1034-1036 Harrisons Principle of Internal Medicine page 1805-1808.

E. PATHOPHYSIOLOGY OF ACUTE APPENDICITIS Predisposing Factors Age Sex Race Precipitating Factors A fecalith that occludes the lumen of the appendix Dietary habit Irregular bowel movement

Entrance of a foreign matter to the appendix

Irritation of the appendiceal wall

Inflammation of the appendicial wall

Obstruction of the foreign matter to the appendix Hydrogen ions move into the tissue
Accumulation of hydrogen ions in the mucosal cell

Increase pressure with the appendiceal lumen d

Intra Cellular pH increase Acidosis Bacterial Multiplication Inflammation s/s pain s/s fever
Continuous secretion of fluids and mucosa from mucosa and stagnation of this material

Appendiceal distention Increase intramuninal pressure

Increase WBC
PUS formation Multiplication of Bacterial in the Appendiceal lumen

Obstructed lymphatic and venous drainage Decrease blood supply Decease Oxygen

Beginning of appendiceal ischemia s/s rebound tenderness

Loss of epithelial integrity

Bacterial invasion of Appendiceal wall
Appendicitis

s/s nausea vomiting

Continuous multiplication of bacteria Excessive increase pressure in the appendiceal lumen Ruptured Appendicitis

IF TREATED
Patient will regain his proper function a. Medical treatment - Administration of antibiotics and analgesic b. Surgical treatment - Appendectomy - Laparoscopy c. Nursing Interventions - Increase intake of foods rich if fiber - Encourage adequate intake of water - Encourage pt. to avoid eating salty foods

IF NOT TREATED
Complications will occur such as: spread of PUS in the adjacent tissue and organ Infection Peritonitis Gangrene spread to adjacent organ Accumulation to adjacent organ Spillage of GI content Multi intra abdominal infection Septecemia

WELLNESS

DEATH

VII. DIAGNOSTIC/LABORATORY EXAMINATION Urinalysis a physical or microscopic or chemical examination of urine Normal Nursing Components Result Interpretation Values Responsibilities Color Yellow Colorless to Normal Encourage patient to dark maintain healthy diet Appearance Hazy Clear May indicate Encourage patient to impaired Increase fluid intake. absorption in the renal system. Reaction 5.0 ph 4.6-8.0 Normal Maintain healthy diet Specific 1.000 1.016-1.022 Decrease: may Maintain or increase gravity indicate fluid intake and dehydration. regulate IVF. Sugar Negative Negative Normal Maintain healthy diet Albumin +1 Negative May indicate Encourage patient impaired renal maintain healthy diet function especially in protein intake. Pus Cells 2-5 Negative May indicate Encourage to infection maintain healthy diet increase fluid intake RBC 2-4 Negative May indicate Note for bleeding bleeding of kidney or UTI Amorphous Few Negative May indicate Administer medication Cells infection as ordered. Hematology a study in the blood component for any significant to the patients condition. Normal Components Result Interpretation Values Hemoglobin 138g/L M:140-180g/L Slightly decreased mass F:120-160g/L concentration Leukocyte 9.7x10g/L 5-10x10g/L Normal number concentration Segmenter 0.67 0.55-0.65 Slightly increase may indicate infection Lymphocyte 0.25 0.25-0.35 Normal Monocyte 0.01 0.03-0.06 May indicate infection Normal changes that is related Nursing Responsibilities Maintain healthy diet Encourage to eat healthy diet Maintain healthy diet and administer antibiotic as ordered. Encourage to have adequate rest and sleep periods. Encourage to take food and zinc to boost immune system against infection Encourage to take healthy diet.

Basophils

0.01

0-0.01

VIII. SUMMARY PHYSICIANS ORDER Date/Time 11-12-07 5:46pm Order Please admit to room of choice Rationale The patient is admitted because he needs to be evaluated and needs to undergo series of assessment and examination to diagnose condition and prepare him to any surgical procedure. Taking VS is important to find out current status of the patient and to monitor for any significant changes and to have baseline date. NPO before surgery prevents vomiting, aspiration of difficulty of breathing during surgery, for the physician to have a perfect view on the organ to be removed and prevent peristalsis to occur during operation. CBC, BT Stat CBC and BT is done to know if there is presence of infection by the leukocyte count and assess if there is any abnormalities in patients condition to check the coagulation factor ability to carry up oxygen and if the fluid and electrolyte balance is altered. Urinalysis this is done to know if there is an impaired function in the kidney or genitourinary system, to note for infection in the urine as well as to the dehydration in the body and rule out if it is just UTI. D5LR is a hypertonic solution that causes cell to shrink, also increases the degree of osmotic pressure on a semi permeable membrane thereby withdrawing fluids of red blood cells, causing into shrink thus maintaining vascular volume. Exact mechanism is unknown. An aminoglycosides that disrupt bacterial protein synthesis by binding ribosome. A direct acting trichonomacide and amebicide that works at booth intestinal and extraintestinal sites. Its thought to enter the cells of microorganisms that contain nitroreductase Unstable compound are then formed to bind to DNA and inhibit synthesis causing cell death. Remarks Done/the patient is admitted

Shift

TPR q 8

Monitored

NPO

Instructed

Labs: CBC, BT stat, urinalysis

Requested 11-12-07

IVF of D5LR 1L x 8 hrs. D5LR SR

Given and regulated/ Done 11/123/07

Meds: Gentamycin 80mg IVTT q 8 hrs. ANST ( - ) Metronidazo le 500ng IV q 8 hrs. ANST ( - )

Done

Done

For Stat AP

Secure consent Inform O.R./ Anesthesiologist

Refer PRN

7:10pm

Ranitidine 50mg IVTT 1o prior to O.R.

Stat AP is ordered because they have found out that the appendix of my patient has ruptured and if not treated as soon as possible it may lead to a more serious condition like spreading of pus, infection, peritonitis or it will even lead to septicemia or death, it is ordered to avoid a more serious complication to the adjacent organ in their by preventing it to occur. This gives awareness to the patient and family on the procedure to be done and for legal purposes for the medical team. In forming the anesthesiologist is important to find out if can still accommodate the patient and the procedure and for how to prepare. Also inform the O.R. to prepare them and clarify if there is any pack and equipment still available or lacking. Referring is necessary for it facilities collaboration between nurse and doctors to ensure better management arrangement of the patient. A gastro intestine drug use to decreased acid secretions

Done/ Ordered

Done

Informed

To referred as necessary Done

Date/Time 11-13-07

Order Post-op-Order To recovery room, then back to room once stable.

Rationale Placing the patient in the recovery room is important for observation and evaluation purposes because the homeostasis of the patient did not yet returned because of the effects of anesthesia, thus preventing pot op complication and protecting the patient life. To assist current vital status of the patient and for immediate management because post op complication like dropping to bp respiratory depression might occur. To provide the return of homeostasis of the patient due to disruption of anesthesia. This will prevent aspiration and prevent abrupt changes in GI function, reduce further injury and allow ample time for the anesthesia to ware off. This provides fluid supplementation because during operating fluid and electrolyte loss this is given to patients to maintain dehydration. Produce anti inflammatory analgesics and antipyretic effects, possibly by inhibiting prostaglandin synthesis. A centrally acting synthetic analgesic or compound not chemically related to opiates. Thought to bind to opioids receptor and inhibit reuptake norepinephrine and serotonin. A gastrointestinal drugs use to decreased acid secretions. Some patient is NPO, this drug is continued to maintain therapeutic level of drug and prevent resistance of bacteria to this drug. This is essential because, thermoregulating tend to deplete some essential fluids thereby maintaining the patient temperature is important and because anesthesia post op can cause chilling effect. O2 is given to sedated patient to aid supplement or to be able to support intracellular and extra cellular respiration thereby maintaining or regaining homeostatis of the patient brought by anesthesia. For immediate management For further evaluation and management

Remarks Done

V/s q 15 till stable then q 4

Monitored

NPO

Done/ Monitored

Cont IVF D5LR 40gtts/min IVF TF w/ D5LR 3L at 30gtts/min Meds: Ketorolac 30g IVTT now then q Tramadol 50g IVTT noow then q 8, slow IVTT Ranitidine 50g IVTT q 8 next dose 2 pm Continue gentamycin and metronidazole Keep warm, thermoregulated

Done

Done

Done

Done

Given

Done

O2 inhalation at 2pm until awake

Done

Refer for unusualities Refer

Done Done

7:00am

Ampicillin 1g q 8 ANST ( - )

Inhibits cells wall synthesis during bacterial multiplication and supplement the effects of antibiotic.

Done

IX. DRUG LIST TAKEN

1. Ampicilin, 1 gm IVTT ANST (-) q 8 2. Gentamycin 800mg IVTT ANST (-) q 8 3. Ketorolac 30mg IVTT q 8 4. Metronidazole 500mg IVTT, ANST (-) q 8 5. Ranitidine 500 mg IVTT, q 8 6. Tramadol 50mg IVTT q 8 7. Bupivacaine, Epidural Route

NOTRE NAME OF TACURONG COLLEGE City of Tacurong

DRUG STUDY
Name of the Patient: Attending Physician: Diagnosis: Date: NAME Generic: Tramadol Brand: Ultram Classification: Opioids Analgesic MODE OF ADMINISTRATION Route: IVTT ANST (-) Dosage: 50mg Time: q8 Mr. A Jose June T. Tabanda, MD Acute Appendicitis November 24, 2007 DRUG ACTION Mechanisms of Action: Unknown. A centrally acting synthetic analgesic compound not chemically related to opiates. Thought to bind to opioids receptor and inhibit reuptake of norepinephrine and serotonin. Bibliography: Nursing Drug Handbook 2005, Page 405, 406 Indication; Moderate to moderately severe pain SIDE EFFECT CNS: Dizziness, vertigo headache, malaise, sleep disorder CV: vasolidation EENT: visual disturbance GI: nausea, constipation, vomiting dyspepsia, dry mouth, diarrhea, abdominal pain, anorexia, flatulence. GU: urine retention, urinary frequency, proteinuria. Musculoskeletal: hypertonic SkinL pruritus, diaphoresis rash. Prepared by: Checked by: Stanley G. Belgira Year & Section: BSN 3 Date:

CONTRAINDICATION NURSING RESPONSIBILITIES Contraindicated in the patient 1. Consider the patients 10 rights hypersensitivity to drug or other R: to ensure proper administration of drug opioid breastfeeding woman, and and most of all to avoid mistakes. in those with acute intoxification 2. Practice proper hand washing from alcohol, hypnotics centrally R: Hand washing deters the spread of acting analgesic, opioids or microorganism thus preventing psychotropic drug. Serious nosocomial infections. hypersensitivity reaction can occur, 3. Reassess patient level of pain at least usually after the first dose. Patient 30 minutes after administering. with history of anaphylaxis to R: to assess patients conditions and codeine and other opioids may be effectiveness of drug at an increase risk. 4. Assess the breathing pattern of the patient SPECIAL PRECAUTION R: Assessing the respiratory rate of the patient is important to prevent respiratory Use cautiously in patient at risk for depression and have immediate actions. seizures or respiratory depression, 5. Monitor bowel and bladder function, in patient with increased anticipate the need for laxatives intracronial pressure or head injury, R: Monitoring these function will aide the ADVERSE EFFECT acute abdominal coordination or patient if he/she as feeling of constipation. renal or hepatic impairment; or in 6. For better analgesic effects, give drug CNS: CNS stimulation, patient with physical dependence before onset of intense pain asthenia, anxiety, an opioids. R: Giving the drug this way will minimize confusion coordination effect of intense pain thus promoting disturbance euphoria, comfort to the client. nervousness, seizure DRUG INTERACTION 7. Monitor patient for drug dependence Respiratory: Respiratory depression. R: Drug can produce dependence similar to Drug-Drug that of codiene and dextropropoxyphene Carbomazepine: May increased and thus potential for abuse. tramadol metaboism, patients 8. Educate the patient about the purpose receiving long term and administration of drug carbamazephine therapy at up to R: doing this will relieve patients anxiety, 800mg daily may need up to twice making them aware and facilitate the recommended dose of cooperation tremadol. 9. Instruct patient to rest after R: resting promotes relaxation and comfort to the patient 10. Assess the patient sleep pattern before giving the drug. R: Sleep disturbance its one of the side effect of tramadol by doing this proper intervention and action should be done. NOTRE NAME OF TACURONG COLLEGE City of Tacurong

Name of the Patient: Attending Physician: Diagnosis: Date: NAME Generic: Ampicillin Brand: Ampicin Classification: Antibiotics

Mr. A Jose June T. Tabanda, MD Acute Appendicitis November 24, 2007 DRUG ACTION Mechanisms of Action: Inhibits cell wall synthesis during bacterial multiplication

DRUG STUDY
Prepared by: Checked by: CONTRAINDICATION Contraindicated in patient hypersensitivity to drug Stanley G. Belgira Year & Section: BSN 3 Date:

SIDE EFFECT CNS: anxiety, dizziness and fatigue CV: thrombophlebitis GI: nausea, and vomiting abdominal pain, diarrhea, gastritis GU: vaginitis Skin: Pain at the injection site

MODE OF ADMINISTRATION Route: IVTT ANST (-) Dosage: 1 grm Time: q8

Bibliography: Nursing Drug Handbook 2005, Page 78, 80

Indication; Respiratory tract or skin structure infections.

NURSING RESPONSIBILITIES 1. Consider the patients 10 rights R: considering this will ensure that the medication is given correctly and most all avoid unnecessary mistakes. 2. Explain to the client about the administration of the drug R: Explaining this to the client facilitate awareness and cooperation 3. Practice proper hand washing first R: Proper hand washing deters the spread of microorganisms and transferring of microorganism to the patient 4. Administer the drug right away after being ADVERSE EFFECT prepared SPECIAL PRECAUTION R: to promote sterility and effectives of the drugs CNS: Lethargy, 5. Conduct skin testing first hallucination, agitation, Use cautiously in patient with R: Skin testing is important to avoid allergic seizures, depression. other drug allergies because of reaction CV: vein irritation possible cross-sensitivity and 6. Give the drug 10-15 minutes in those with mononucleosis GI: diarrhea, glossitis, R: Giving the drug at the right span of time will because of high risk of stomatisis, enterocolitis prevent pain at injection site. vein irritation maculopopular rash. and black hairy tongue. thus promoting comfort GU: Interstitial nephiritis, 7. Instruct patient to rest after administration and nephropathy raise side rails Hematologic: Anemia R: Lethergy, hallucination, dizziness and agitation thrombocytopenia, DRUG INTERACTION may occur swallowing patient to rest and eosinophilia. raising side raise promotes comfort and further injury. Drug-Drug Hormonal contraceptives: may 8. Watch sign and symptoms of hypersensitivity such as sythematous, maculopopular rash, decrease hormonal urticaria and snaphylaxis. contraceptive effectiveness. R: This factors will indicate adverse reaction to the drug. 9. Advise patient to report discomfort at injection site R: For immediate management and action, for comfort measures. 10. At home instruct patient to take drug 1 to 2 hours before or 2 to 3 hours after meal R: When give orally, drug may cause GI disturbance, found may interfere with absorption. NOTRE NAME OF TACURONG COLLEGE City of Tacurong

DRUG STUDY

Name of the Patient: Attending Physician: Diagnosis: Date: NAME Generic: Ranitidine Brand: Zantac Classification: Anti-ulcer drug MODE OF ADMINISTRATION Route: IVTT Dosage: 50mg Time: q8

Mr. A Jose June T. Tabanda, MD Acute Appendicitis November 24, 2007 DRUG ACTION Mechanisms of Action: Potent anti-ulcer drug that competitively and reversibly inhibits histamine action at H2 receptor sites parietal cells decreasing gastric acid secretions. Bibliography: Nursing Drug Handbook 2005, Page 712, 713 Indication; Duodenal and gastric ulcer SIDE EFFECT CNS: vertigo, malaise headache EENT: blurred vision Hepatic: Jaundice Others: burning and itching at injection site.

Prepared by: Checked by: CONTRAINDICATION Contraindicated in patient hypersensitivity to drug and those with acute prophyria

Stanley G. Belgira

Year & Section: BSN 3 Date:

ADVERSE EFFECT Anaphylaxis, angio edema

SPECIAL PRECAUTION Use cautiously in patient with hepatic dysfunctions

DRUG INTERACTION Drug-Drug Antacids: May interfere with ramitidine absorption stragger doses, if possible. Diazepam: may decreased absorption of diazepam monitor patient closely.

NOTRE NAME OF TACURONG COLLEGE City of Tacurong Name of the Patient: Attending Physician: Diagnosis: Date: Mr. A Jose June T. Tabanda, MD Acute Appendicitis November 24, 2007

NURSING RESPONSIBILITIES 1. Before giving the drug, Practice Proper hand washing R: proper hand washing will reduce presence of microorganism in your hands, thus it will prevent another complication to your pt. 2. Check the patency of the IV tube, before reducing the medicine. R: checking the patency of the IV tube will facilitate easy administration of the drug thus reducing discomfort to the patient 3. Administer the medicine once it has been prepared. R: Administering the drug after preparing will reduce incidence of mistake and ensuring the sterility and effectiveness of the medication 4. Assess patient for abdominal pain, advice to report blood and stool R: These factors may indicate internal bleeding 5. Give the medication slowly about 10-15 minutes R: burning and itching at the injection site, usually the complains of the patient, therefore give it slowly to prevent it. 6. Before giving the drug, educate first the patient about the purpose of it. R: Giving information to the patient will facilitate cooperation and relieve their anxiety. 7. Instruct patient to rest after taking the drug R: Having the patient to rest will promote relaxation and comfort. 8. Instruct patient to report any unusualities R: Instructing our patient to report unusualities will help us to provide proper and prompt treatment 9. Before giving the drug asses if the patient has taken a meal. R: Assessing if the patient has taken any food, because the drug works better when the stomach is empty.

DRUG STUDY
Prepared by: Checked by: Stanley G. Belgira Year & Section: BSN 3 Date:

NAME Generic: Gentamycin Brand: Garamycin Classification: Anti infectives MODE OF ADMINISTRATION Route: IVTT Dosage: 800mg Time: q8

DRUG ACTION Mechanisms of Action: Generally bactericidal, inhibits protein synthesis by binding directly to the 305 ribosomal sbmit. Bibliography: Nursing Drug Handbook 2005, Page 67, 70 Indication; To prevent endocarditis for GI or GU procedure or surgery

SIDE EFFECT CNS: fever, headache, lethargy, confusion, dizziness, numbness, vertigo, ataxia CV: hypotension EENT: blurred vision, tirnitus GI: vomiting, nausea GU: possible increase in urinary excretion of cast. Skin: rash, urticaria, pruritus, pian in the injection site.

NURSING RESPONSIBILITIES 1. Conduct skin testing as ordered R: conducting skin testing before giving the drugs will help prevent allergies for their complication to the patient and will know what treatment to give. 2. Practice proper hand washing before giving the drug R: proper hand washing will prevent transfer of microorganism from 1 patient to another 3. Evaluate patients hearing before and during therapy SPECIAL PRECAUTION R: to notify the physician if the patient complains of tinitus, vertigo or hearing loss Use cautiously in neonates, 4. Weight patient and review renal function studies infants, elderly patient and patient with impaired renal R: Reviewing those important data is essential function or neuromuscular because the drug will possibly increase urinary ADVERSE EFFECT disorder. excretion of cast 5. Instruct patient to report any unusualities CNS: encephalorathy R: Unusualities happens any time after drug seizures administration, so instructing the pt. to do so GU: nephrotoxicity will help prevent further complication Hematologic: leukofenia, 6. provide bedpan or empty bucket at the patients thrombocytopenia, bedside agranulocytosis DRUG INTERACTION R: providing bedpan or empty bucket will help Respiratory: apnea because once the patient experience vomiting, Others: Anaphylaxis Drug-Drug just give it to the patient so the she bed of the patient will not be messy Acyclovir, comphotericin B cephalosporins, cisplatin, 7. Raise the side rails of the patients bed methroxfluane, vancomycin R: Once the patient has taken the drug, advise other aminosylosides. May reaction occurs, like dizziness, vertigo, blurred increase ototoxicity and vision and lethargy occurs, so patient safety nephrotoxicity monitoy hearing should be practiced. and renal function test results. 8. Monitor vital signs q 4 or as ordered. R: Monitoring vital signs of the patient is essential because this drug can cause hyptension. 9. Instruct patient to rest R: resting will help minimize the side effects of the drug 10. Monitor patients breathing pattern R: assessing the breathing pattern is essential because this drug will cause apnea as its adverse reaction. NOTRE NAME OF TACURONG COLLEGE City of Tacurong

CONTRAINDICATION Contraindicated to patient hypersensitivity to drug and other aminoglycosides

Name of the Patient: Attending Physician: Diagnosis: Date: NAME Generic:

Mr. A Jose June T. Tabanda, MD Acute Appendicitis November 24, 2007 DRUG ACTION Mechanisms of SIDE EFFECT CNS: drowsiness,

DRUG STUDY
Prepared by: Checked by: CONTRAINDICATION Contraindicated in patients Stanley G. Belgira Year & Section: BSN 3 Date:

NURSING RESPONSIBILITIES 1. Conduct skin testing before drug administration

Ketorolac Brand: Toradol Classification: NSAID

Action: Unknown. Produces anti-inflammatory analgesic and antipyretic effects possibly by inhibiting prostaglandin synthesis Bibliography: Nursing Drug Handbook 2005, Page 369, 371 Indication; Short term management of moderately severe, acute pain.

sedation, dizziness, headache CV: edema, hypertension palpitation GI: nausea, dyspepsia GI pain, diarrhea, peptic ulceration on vomiting constipation, flatulence, stomatitis Skin: pruritus, rash diaphoresis Others: pain at injection site ADVERSE EFFECT CV: Arhytmias Hematologic adhesion, purpura, prolongned bleeding time Parethesia

hypersensitive to drug and in those with active peptic ulcer disease, recent GI bleeding or perforation advance renal impairment, cerebrovascular bleeding, hemorrhagic diathesis or incomplete hemostasis, and in those at risk for renal impairment from volume defection or at risk for bleeding

2.

3.

MODE OF ADMINISTRATION Route: IVTT Dosage: 30mg Time: q8

4. SPECIAL PRECAUTION Use cautiously in patient with hepatic or renal impairment or cardiac decomposition 5.

6. DRUG INTERACTION 7. Drug-Drug Ace inhibitor: May cause renal impairment, particular in 8. volume depleted patients avoid using together in volume 9. depleted patient

R: Conducting skin testing before giving the drug will prevent allergic reaction, this granting the patient safety. Assess the client if he had peptic ulcer or GI bleeding before or prior to admission R: Assessing these factor to the client will be essential because ketorolac is contraindicated to patient who has this factor because it prolonged the bleeding time, therefore patient is a risk for bleeding Give the drug 10-15 minutes R: Burning and pain at injection site, usually the complains of the client, therefore give the drug slowly to avoid the situations Before administration, check first if there is a bad flow R: Checking if there is a back flow is important because it provide sterility and comfort to the client Monitor patients vital signs q 4 or as ordered specially the blood pressure, before and after R: Monitoring this is very important to know if patient, hypertensive, because ketorolac can cause hypertension Raise the rails after giving to drug R: drowsiness, sedation and headache, dizziness might occur for raising the side rails will prevent patient from falling thus preventing further injuries Instruct patient to increase fluid intake R: Taking this drug can cause renal impairment, maintaining hydration will prevent this Instruct the watcher to report any unusualities R: for immediate action and management Before giving the drug, carefully observe patient with coagulopathis and those taking anticoagulant R: Drug inhibits platelet aggregation and can prolong and bleeding time.

NOTRE NAME OF TACURONG COLLEGE City of Tacurong Name of the Patient: Attending Physician: Diagnosis: Date: NAME Generic: Metronidazole Mr. A Jose June T. Tabanda, MD Acute Appendicitis November 24, 2007 DRUG ACTION Mechanisms of Action: A direct acting trichomonacide and

DRUG STUDY
Prepared by: Checked by: Stanley G. Belgira Year & Section: BSN 3 Date:

SIDE EFFECT CNS: fever, vertigo, head ache, ataxia, dizziness, weakness, insomia. CV: edema, flushing

CONTRAINDICATION NURSING RESPONSIBILITIES Contraindicated in patients 1. Conduct skin testing as ordered hypersensitivity to drug or R: conducting skin testing will tell you if the other nitromidazole derivatives patients is allergic to drug or not thus reducing and in patients in first trimister further injury to the patient

Brand: Flagyl Classification: Anti-infectives

MODE OF ADMINISTRATION Route: IVTT ANST (-) Dosage: 500mg Time: q8

anebicide that works at both intestinal and extra-intestinal sites. Its thought to enter the cells of microorganisms that contain introreductuse unstable compounds are than formed to bind to DNA and inhibit synthesis causing cell death. Bibliography: Nursing Drug Handbook 2005, Page 21, 23 Indication; To prevent post operative infection in contaminated or potentially contaminated colorectal surgery

EENT: sinusitis, phamangitis rhinitis GI: abdominal cramping or pain, stomatitis, epigastric distress, nausea and vomiting aurexia, diarrhea, constipation, dry mouth GU: Darkened urine, polyria, dyseria, cyrstitis, dryness of vagina and vulva, vaginitis Skin: rash

of pregnancy

ADVERSE EFFECT CNS: confusion, irritability depression, seizures, peripheral neuropaty. CV: flattened T wave, thrombophebitis after IV infusion GI: metallic taste, proctitis GU: dysparenia, vaginal cardidiasis Hematologic: transiet leukopenia, neutropenia Muscoloskeletal: upper respiratory tract infection Others: Decrease libido, overgrowth of non succefide organism.

2. Practice proper hand hygiene before giving the drug R: Proper hand washing before giving the drug will prevent nasoconial infections from one patient to another 3. Educate the patient about the purpose of the drug R: supplying enough information to the patient SPECIAL PRECAUTION will relieve their anxiety and facilitate cooperate Use cautiously in patients with 4. Monitor liver function test results carefully in history of blood dysorasia or elderly patients CNS disorder and in those with R: Metronidazole can cause hepatoxicity, retinal or visual field changes. therefore carefully assess in elderly patient Also in patient with hepatic because liver function decrease as we get disease or alcoholism and in older, thus elderly patient is prove to those who take hepatotoxic hepatoxicity drug. 5. Observe patient for edema, especially if receiving controsteroids. R: Flagyl IV RTV may cause sodium retention, thus at is from to edema. 6. Check the site if there is a bck flow before medicating R: Checking if there is a back low is essential to DRUG INTERACTION promote comfort during administration to the patient and minimize untoward mistakes Drug-Drug 7. Instruct patient to report any unusualities Cimetidine: May increase risk R: Instructing the patient to do so will provide of metronidazole toxicity drug prompt management and prevent further inhibits hepatic metabolism complication monitor patient for toxicity 8. Monitor vital signs q 4 or as ordered R: Monitoring vital signs is important because it allows to know the current condition of the patient and if there is untoward changes in patients vital sign. 9. Assess patient neurologic functions. R: Assessing patients neurologic functions like feeling of depression, hallucination, confusion or seizure is important to know if it is present to the patient and to provide proper action.

X. PRIORITIZE NURSING PROBLEM

1.

Pain related to tissue trauma secondary to appendectomy as evidence by facial grimacing and patients verbalization. Fluid volume deficit related to vomiting as evidence by poor skin turgor, dry mucous membrane, paleness and sucken eyeballs, Disturbed sleep pattern related to environmental factors such as lighting, ambient temperature and frequent taking of VS as evidence by patients verbalization. Alteration in comfort related to surgical experience secondary to new environment as evidence by patients irritable behavior and verbalization. Impaired tissue integrity related to ruptured appendicitis as evidence by actual visualization of ruptured Appendicitis.

2.

3.

4.

5.

NOTRE DAME OF TACURONG COLLEGE City of Tacurong Name of Patient: Mr. A Age: 25 Diagnosis: Acute Appendicitis Attending Physician: Dr. Tabanda ASSESSMENT Date: 11-24-07 9:45am Subjective Data: Masaki tang inagyan ka tahi sa akon as verbalized Objective Data: with IVF of D5LR IL @ 30gtts/min weak looking facial grimacing noted pain scale of 5 in scale of 10. NPO Guarding pain Restless Short attention span Uncomfor table With RDI incision Initial v/s of T 37.1oC BP 120/90mmHg RR 20cpm PR 75 bpm O2 Sat 99% Rationale: Due to the tissue damage brought by surgical incision, pain receptor send impulses to the brain and back to the affected part and thats why patient feel the pain. NEEDS Cognitive perceptual pattern by Gordon NURSING DIAGNOSIS Acute pain related to tissue trauma secondary to Appendectomy

NURSING CARE PLAN

GOAL/OBJECTIVE General Objective: To promote safety through prevention of accident, injury or other trauma and through the prevention of spread of infection. Specific Objective: After 6 hours of nursing intervention patient will be able to: 1. Verbalized pain is reduced. 2. Verbalized method that provide relief. 3. Demonstrat e use of relaxation skills. 4. Appear relaxed and able to have rest and sleep. 5. Patient will manifest increase in comfort. NURSING INTERVENTIONS Independent: 1. Monitor vital sign q 4 and record. 2. Carefully assess location of surgical procedure. 3. Accept client description of pain 4. Provide additional comfort such as back rub. 5. Move patient slowly and deliberately, splinting painful area. 6. Maintain semi fowler position as indicated. Dependent: 1. Regulate IVF as ordered. 2. Administer medication as indicated such as analgesic; narcotics. 3. Administer medicine such as antiemetics eg. Hydroxyzine (vistaril) 4. Administer O2 as indicated 2-3 liters. RATIONALE Changes in VS often indicate acute pain and discomfort. As this can influenced the amount of post op pain experience. Pain is subjective experienced and cannot be felt by others. Improves circulation, reduce muscle tension and anxiety associated with pain. Reduce muscle tension/ guarding, which may help minimize pain of movement. EVALUATION Date: 11-24-07 2:30 pm Goal partially met as evidence by patients verbalization of reduce pain felt from the scale of 2

Prepared by: Stanley G. Belgira Signature: Yr. & Sec. BSN 3 Checked by: Signature: Date:

Facilitate fluid/wound drainage by gravity reducing diaphragmatic irritation/ Abdominal tension and thereby reducing pain. This provides hydration and main the fluid and electrolyte balance of the patient. Reduce metabolic rate and intestinal irritation from circulating/local toxin, which aids in pain relief and promotes healing. Reduce nausea and vomiting, which can increase abdominal pain This will maintain the oxygen status of the client and supplement the internal and external expiration of different

cell.
NOTRE DAME OF TACURONG COLLEGE City of Tacurong Name of Patient: Mr. A Age: 25 Diagnosis: Acute Appendicitis Attending Physician: Dr. Tabanda ASSESSMENT Date: 11-24-07 10:15 am Subjective Data: Cge ako kasuka kag daw galibot pananawan ko as verbalized Objective Data: Vomited Pale Dry skin Sunken eyeballs Weak Restless Dry mucous membrane Poor skin turgor Initial vital sign of T 37.1oC BP 120/90mmHg RR 20cpm PR 75 bpm O2 Sat 99% NEEDS Nutritional metabolic pattern NURSING DIAGNOSIS Fluid volume deficit related to vomiting secondary to appendicitis. General Objective: To facilitate the maintenance of fluid and electrolyte balance.

NURSING CARE PLAN GOAL/OBJECTIVE NURSING INTERVENTIONS Independent: 1. Establish rapport to the patient and S.O. 2. Monitor VS, moting presence of hypotension, tachycardia, tachypnea, fever, measure central venous pressure if available. 3. Monitor I & O such as drains, dressing, IVF or daily fluid intake. 4. Measure urine specific gravity. RATIONALE Establishing rapport will facilitate cooperation, expression of feelings and trust to the patient. Aids in evaluating degree of fluid deficit/effectiveness of fluid replacement, therapy and response to medication. Reflects overall hydration EVALUATION Date: 11-24-07 2:30 pm Goal partially met as evidence by patients urine output remains at specific volume.

Rationale: Due to the increase tension of the walls of the stomach, duodenum and lower ends of the esophagus patent is triggered to vomit causing fluid and electrolyte imbalance.

Specific Objective: After 6 hours of nursing intervention patient will be able to: 1. Demonstrate improve fluid balance and electrolyte balance. 2. Maintain fluid volume at functional level 3. Verbalized understanding of causative factor. 4. Demonstrate behaviors to monitor and correct deficit as indicated. 5. Stabilize fluid volume by balance I & O and vital signs.

status.

Prepared by: Stanley G. Belgira Signature: Yr. & Sec. BSN 3 Checked by: Signature: Date:

5. 6.

Observe skin/ mucous membrane dryness, turgor.

Change position frequently, provide frequent skin care and maintain dry wrinkle-free bedding. 7. Keep oral fluid at bedside within pts reach & encourage patient to drink. Dependent: 1. Regulate IVF as ordered.

Reflects changes in renal function which may warn in developing acute renal failure in response to hypovolemia and effect to toxin. Hypovolemia, fluid shifts and nutritional deficits contribute to poor skin turgor, taut edematous tissue. Edematous tissue with is compromised circulation is prone to breakdown. This will give patient some control over fluid intake and supplement parenteral fluid intake. This will maintain fluid status of the patient by supplying enough fluid to the body and prevents occurrence of dehydration. Provides information about hydration, organ function, varied alteration with significant consequences to systemic function are possible as a result

2. Monitor laboratory studies such as Hb/Hct, electrolyte, protein, albumin, BUN and creatinine

3.

Administer and monitor

medication such as antiemetic and anti-diarrheals. -

of fluid shifts, hypovolemia, hypoxemia and necrotic tissue products. This drugs prevent occurrence of fluid loss.

NOTRE DAME OF TACURONG COLLEGE City of Tacurong Name of Patient: Mr. A Age: 25 Diagnosis: Acute Appendicitis Attending Physician: Dr. Tabanda ASSESSMENT Date: 11-24-07 9:50 am Subjective Data: Hindi ako kayo katolog kag namag-ohan ako ka lugar as verbalized Objective Data: Restless Weak looking Irritable Yawning noted Lethargic Disoriente d Initial vital signs of: T 37.1oC BP 120/90mmHg RR 20cpm PR 75 bpm O2 Sat 99% NEEDS Sleep and rest pattern NURSING DIAGNOSIS Disturbed sleep pattern related to environmental factors (lighting, ambient temperature and frequent taking of VS) secondary to post appendectomy Rationale: Due to the extenal factor such as light, ambient temperature, frequent taking of VS patient is sleep pattern is disturbed.

NURSING CARE PLAN

GOAL/OBJECTIVE General Objective: To promote optimal activity; exercise, rest and sleep. NURSING INTERVENTIONS Independent: 1. Established rapport to the patient and S.O. 2. Allow patient to discuss any concern that maybe preventing sleep. 3. Create a quite environment conducive to sleep (ex. Closing light and adjusting temperature 4. Ask patient to describe in specific terms each morning the quality of sleep during previous nights. 5. Educate patient in such relaxation technique as imagery, progressive muscle relaxation, meditation. 6. Explain the necessity of taking VS. 7. Instruct to avoid too much intake of fluid before sleep Dependent: 1. Administer medication that promote normal sleep patterns as ordered, monitor and record side effect and effectiveness. 2. Administer O2 2-3 liter or as ordered. 3. Regulate IVF as ordered. RATIONALE Establishing rapport to the patient will facilitate cooperation and remove patients anxiety. Active listening aids determination of causes of difficulty with sleep. These measure promote rest and sleep. This helps detect presence of sleep related behavioral pattern. Purposeful relaxation effort often help promote sleep. Prepared by: Stanley G. Belgira Signature: Yr. & Sec. BSN 3 Checked by: Signature: Date: EVALUATION Date: 11-24-07 2:30 pm Goal partially met as evidence by patients verbalization of increased of feeling of rest and sleep.

Specific Objective: After 6 hours of nursing intervention patient will be able to: 1. Verbalized understanding of sleep disturbance. 2. Report improvement of sleep and rest pattern 3. Adjust lifestyle to accommodate change in sleep pattern 4. Report good sleep pattern 5. Report an increased of feeling rested.

This will facilitate awareness, cooperation a prevent fights against patient and nurses. Taking a lot of fluid during sleep will facilitate need for voiding this disrupting the sleep pattern of patient. This can promote sleep by maintaining the patients O2 supply in the body promoting sleep and reducing discomfort. A hypotic agents induce sleep; a tranquilizer -

reduce anxiety. This will facilitate hydration status of the patient thus promoting comfort and promoting sleep.

XI. PROGNOSIS
PROGNOSIS GOOD FAIR BAD JUSTIFICATION 5 days prior to his admission patient felt abdominal pain as well as vomiting. After taking drugs and consulting the manghihilot the pain did not subsided thats why he was taken to hospital. The patient experienced his discomfort 5 days ago because he tried to treat himself before going to the hospital without knowing that it has already been ruptured. Patient has body odor and cannot perform ADLs without assistance but he is dressed appropriate. The patient has not taken food by mouth but he only just given IVF and ranitidine. The patient is 25 years old young and strong to fight the disease but this age is also prone in having Acute Appendicitis. The patients compliances and performance is good because he is young and willing to get well because he follows all the instruction given to him faithfully. May patient is post-op and is willing to undergo any treatment related to his condition in spite of difficulties due to financial status. The family support is fair as well as to the emotional support because only his wife is watching over him as well as to the financial support because even though their family tries to help him financially still they find it hard to do so.

Onset of illness

Duration of illness

Hygiene Diet

Age

Performance level

Willingness to undergo treatment

Family support

3/8 Computation Good: 3/8 x 100 = 37.5% Fair: 5/8 x 100 = 62.5% Bad: 0/8 x 100 = 0% Interpretation:

5/8

0/8

Based on the criteria given the patient reveal fair prognosis because he has taken treatment to relieve him from his condition that lead him to the progression of his illness. XII. BIBLIOGRAPHY

1. Nurses Diagnosis reference manual; third edition; Sheila M. Sparks, Cynthia M. Taylor; Spring House Corporation, Springhouse Pennsylvania; Page 203204; 284-285; 101 -103. 2. Medical-Surgical Nursing; 7th edition, Joyce M. Black, Jane Hokanson Hawks; Volume 1, Copyright 2005 by Elsevier Inc; pages 812-814. 3. Focus on Pathophysiology; Barbara L. Bullock, Reet L. Hence; Copyright 2000 by Lippincott Willians & Wilkins; page 741-742. 4. Nursing Care Plan; 6th Edition; Marilynn E. Doenges, Mary Frances Moorhouse and Alice C. Geissler - Murr; Copyright 2000 by FA Davis Company; Page 346-348. 5. Harrisons Principle of Internal Medicine; Denis L. Kasper, Anthony S. Fauci, Dan L. Longo, Eugene Braunwald; Stephen L. Hauser, J. Larry Jameson; Volume 2; 16th Edition; Copyright 2005 by the Mcgraw Hill Companies Inc; Page 1805-1808. 6. Mosbys Pocket Dictionary of Medicine; Nursing and Health Professional; 5th Edition; reprinted edition 2006; Elsevier (Singapore) Pte Ltd. Page 106. 7. Nursing 2005 Drug Handbook; 7th Edition, Lippincott Williams and Wilkins; A Wolters Kluwer Company; pages 78-80, Ampicillin, 78-80,Gentamycin 369371, Ketorolac; 21-23, Metronidazole 712-713, Ranitidine 405-406; Tramadol. 8. Nurses Pocket Guide; Diagnosis, Intervention and Rationales, 9th Edition, Marilyn E. doenges; Mary Fances Moorhouse; Alice C. Murr; Copyright 2004 by FA Davis Company; pages 365-369 pain, 242-245 fluid volume, 472-477 sleep pattern. 9. Essential of Anatomy and Physiology; 5th Edition, Rod R. Seely; Trent D. Stephens; Philip Tate; Copyright 2005 by the McGraw Hill Companies, Inc. page 474-476. 10. Fundamentals of Nursing Concept, Process and Practice; 7th Edition; Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder; Copyright 2004 Pearson Education Inc; page 352-367. 11. Brunner & Suddarths Textbook of Medical-Surgical Nursing; Volume 1, 10th Edition, Suzanne C. Smelter, Brenda G. Bare; Copyright 2004 by Lippincott Williams and Wilkins; page 1034-1036. 12. Luigi Santacrose, M.D. Appendicitis September 12, 2006 date retrieved; November 23, 2007, http//www.emedicine.come/MED/topic3430.htm 13. Lutti Incesu, M.D., Appendicitis, June 4, 2007, date retrieved: Nove 23, 2007, http//www.emedicine.come/radio/topic47.htm 14. www.yahoo.com TABLE OF CONTENTS

I. II. III. a. b. c. d. e. f. g. IV. V. VI. a. b. c. d. e. VII. VIII. IX. X. XI. XII.

INTRODUCTION OBJECTIVES General Objectives Specific Objectives PATIENT DATA Vital Information Family Background History of Past Illness History of Present Illness Effects and Expectation of Illness to Self & Family Genogram Developmental Data REVIEW OF SYSTEM PHYSICAL ASSESSMENT TEXTBOOK DISCUSSION Complete Diagnosis Anatomy and Physiology Etiology Symptomatology Pathophysiology DIAGNOSTIC LABORATORY EXAMINATION SUMMARY OF PHYSICIANS ORDER DRUG STUDY NURSING CARE PLAN WITH PRIORITIZATION PROGNOSIS BIBLIOGRAPHY

ANATOMY OF THE APPENDIX