I. INTRODUCTION Appendicitis is an inflammation of the vermiform appendix that develops most commonly in adolescents and young adults. It can occur at any age but is rare in clients younger than 2 years and reaches a peak incidence in clients between 20 and 30 years. It is not common in older adults; however, when it does occur in such clients, rupture of the appendix is most common(Medical – Surgical Nursing: Clinical Management for Positive Outcome 8 th by Joyce Black and Jane Hokanson Hawks, page 683). It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparoscopy or laparotomy. If left untreated, mortality is high, mainly because of peritonitis (inflammation of the peritoneum) and shock. (http://www.wikipedia.org/wiki/Appendicitis? wasRedirected=true) There is no specific test for appendicitis, but blood tests such as a white blood cell count and x – rays may help a physician make a diagnosis. Abdominal ultrasound has proven to be useful in differentiating causes of abdominal pain. (http://www.healthscout.com/ency/68/658/main.html) The most specific physical finding is rebound tenderness, pain on percussion, Rovsing’s sign (Right Lower Quadrant pain with palpation of the Left Lower Quadrant), Psoas sign (Right Lower Quadrant pain is felt with hyperextension of the right hip) are present in the patients with acute appendicitis. (http://www.ufs.ph/tinig/mayjun02/05060225.html) 1
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I. INTRODUCTION
Appendicitis is an inflammation of the vermiform appendix that develops most
commonly in adolescents and young adults. It can occur at any age but is rare in clients younger
than 2 years and reaches a peak incidence in clients between 20 and 30 years. It is not common
in older adults; however, when it does occur in such clients, rupture of the appendix is most
common(Medical – Surgical Nursing: Clinical Management for Positive Outcome 8 th by Joyce
Black and Jane Hokanson Hawks, page 683). It is classified as a medical emergency and many
cases require removal of the inflamed appendix, either by laparoscopy or laparotomy. If left
untreated, mortality is high, mainly because of peritonitis (inflammation of the peritoneum) and
NormalNormalNormalNormalNormalNormalNormalNormalNormalNormalNormalHigh. An indicator that there is an infection present in the urinary tract.NormalNormalNormal
Normal
NURSING RESPONSIBILITIES
Prior to procedure:
Explain the procedure to the patient and family/relatives.
Provide for patient’s privacy.
Instruct the patient to go to the laboratory with the request form.
Instruct the patient to dispose the first urine and catch the midstream urine.
Educate the patient not to contaminate the inside part of the container.
Instruct the patient to send the specimen to the laboratory immediately
During the procedure:
Maintain the sterility of the specimen container by not touching the inside part.
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Maintain the freshness and sterility of the urine specimen.
After the procedure:
Interpret the result
Refer to the physician if abnormalities are noted.
Appendectomy Inflammation of appendix (appendicitis)
Low grade fever
B. PLANNING
NURSING CARE PLAN
Acute Pain
Assessment Planning Intervention Expected outcome
Subjective: “Masakit ang sugat ko” P/S is 6/10.Objectives:
facial grimace increase ability to perspire
irritable at times
guarding behavior
limited movements and range of motion.
assisted with the significant others when turning in other position.
Within 30 minutes to 1 hour of giving proper nursing interventions, the patient will verbalize reduction of pain.
Monitor the pain scale. (to know if there is an improvement)
Position on a semi-fowlers position.(for the patient to feel comfortable)
Provide a clean bed. (to have a good relaxation.)
Encourage to have a bed rest.( to gain energy)
Encourage to continue limiting body movements. (to prevent pain)
Educate the importance of deep breathing exercises. (for the patient to feel calm and relax)
Within 30 minutes to 1 hour of giving proper nursing interventions, the patient will:
-verbalize a decrease of pain.-can move freely without assistance.-free from irritability.
-facial grimace will be absent.
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Nursing Diagnosis:Acute pain related to surgical incision on the abdomen.Scientific Explanation:
Unpleasant sensory and emotional experience arising fromactual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity frommild to severe with an anticipated or predictable end and a duration of less than 6 months. (Nurse’s Pocket Guide Edition 11 by F.A Davis, page 498)
Divert attention by instructing to read books.(to lessen and divert pain)
Instruct to increase fluid intake.(to prevent dehydration)
Instruct to guard the site when coughing. (to prevent from opening of the site)
Instruct to take medications that are prescribed by the physician. (for the patient safety to drugs)
Educate the patient to clean the site regularly. (to prevent any complications and infection)
Diagnosis:Altered body temperature related to inflammatory process.
Scientific Explanation:Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. It may also occur as assign of infection.
Within 1 hour of proper nursing interventions, the patient’s temperature will subside to 37.5 °c from 38.5 °c.
Monitor vital signs especially temperature. (To know if it has an improvement of the patient’s temperature.)
Perform Tepid Sponge bath. (To lower body temperature.)
Provide clean and comfortable bed. (for the patient to have a good rest and feel comfortable)
Provide clean and comfortable clothing. (for the patient not to feel irritable)
Instruct to increase fluid intake after NPO. (to prevent dehydration)
Instruct to eat nutritious foods like green leafy vegetables after NPO. (to gain more energy)
Instruct to take medications that are prescribed by the physician. (For safety purposes.)
Within 1 hour of proper nursing interventions, the patient’s temperature will subside to 37.5 °c from 38.5 °c.
Irritable Poor hygiene Long fingernails Dirty surroundings Incision on the right
lower quadrant of the abdomen
DiagnosisRisk for infection related to surgical incision on the right lower quadrant of the abdomen
SCIENTIFIC EXPLANATION
There’s a risk for infection for a client who undergone a surgical incision because there is a break in the tissue or that would serve as an opening that can be
Within 2 hours of proper nursing intervention the client risk for infection will decrease to achieve timely wound healing
Instruct in good hand washing(Reduces risk of spread of bacteria)
Instruct good body hygiene(Reduces risk of spread of bacteria and promote relaxation)
Demonstrate aseptic wound care(Reduces risk of spread of bacteria)
Inspect incision and dressings(Provides for early detection of developing infections process)
Encourage to cut the fingernails(Reduce risk of spread of bacteria)
Encourage to keep the surroundings of the patient clean(To minimize the chance of getting infection through microorganisms around the ward)
After 2 hours of proper nursing intervention the client risk for infection is decrease to achieve timely wound healing as evidenced by:
a. Washing the hands using soap
b. Good body hygiene
c. Well kept surrounding
d. Short fingernails
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invaded by different kind of microorganisms.
Impaired Skin Integrity
ASSESSMENT PLANNING INTERVENTIONSEXPECTED OUTCOME
S
“nangangati ang sugat ko”O
with surgical incision at the mcburney’s point
with suture noted
with surgical dressing intact
poor skin turgor
limited movement
Within 1 hour of proper nursing interventions, the patient will regain integrity of the skin and demonstrate measures to protect care and heal the skin lesion.
Assess site of skin impairment (the cause of the wound must be determined before appropriate interventions can be implemented).
Monitor site of skin impairment for color change, redness, swelling, warmth, pain, or other signs of infections (systematic inspection can identify impending problem early).
Clean the site aseptically (to decrease the production of bacteria).
Select a topical treatment that will maintain a moist wound – healing environment and that is balanced with the need to absorb exudates ( keep peri wound skin dry and control
After 1 hour of rendering proper nursing interventions, the patient will regain integrity of the skin and demonstrate measures to protect care and heal the skin lesion.
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DiagnosisImpaired skin integrity related to tissue damage.Scientific explanation
Invasion of body structures, destruction of skin layers (dermis), disruption of skin surface (epidermis).
exudates and eliminate dead space) Avoid massaging around the site of
skin impairment and over bony prominences (massage may lead to tissue trauma).
Monitor nutritional intake (Altered nutrition can prevent wound healing and put at risk for further skin breakdown).
Within 1 hour of proper nursing interventions, the patient will verbalize increase body strength.
Obtain vital signs. (for baseline purposes)
Maintain on a flat position as an order of the physician.
Encourage to have adequate rest. (to gain energy)
Encourage to ask some help to the nurse or significant others if she want to move or change in position. (for the patients safety)
Instruct to increase fluid intake after
Within 1 hour of proper nursing interventions, the patient will verbalize increase body strength.
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RR-20 cpmPR-64 bpmTemp- 35.8 °cDiagnosis:Fatigue related to post surgical procedure.Scientific Explanation:
An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.
NPO. (to prevent dehydration)
Instruct to eat nutritious foods like green leafy vegetables after NPO. (to gain more energy)
Educate about the significant others to assist the patient when moving. (for safety and for the patient to move easily)
Instruct to take medications that are prescribed by the physician. (To avoid any drug accident such as overdosing.)
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C. IMPLEMENTATION
1. DRUGSName of Drug Date
AdministeredRoute and
AdministrationGeneral Action Indication Client’s actual
response to medication
Cefoxitin October 1, 2010
6:00pm
IVP
1gq 8 hours
Bactericidal: Inhibits synthesis of bacterial cell
wall, causing cell death.
Perioperative prophylaxis.
Presence of pain was noted on the IV insertion site during the drug administration.
Nursing Responsibilities:
Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.
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Name of Drug Date Administered Route and Administration
General Action Indication Client’s actual response to medication
Ketorolac September 30, 2010
6:00pm
IVP
30mgq 6 hours
anti-inflammatory, antipyretic and analgesic effects is the inhibition of prostaglandin synthesis by competitive blocking of the enzyme cyclooxygenase (COX)
Short-term management of pain due to surgical procedure done
Pain scale of 8/10 decreases to 4/10 which is consider as bearable pain.
Nursing Responsibilities:
Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.
General Action Indication Client’s actual response to medication
Omeprazole September 30, 2010
6:00pm
IVP
40mgq 12 hours
Gastric acid-pump inhibitor. Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production.
Perioperative client who is NPO
Pain due to hypersecretion of hydrochloric acid in the stomach is lessen.
Nursing Responsibilities:
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Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.
Name of Drug Date Administered
Route and Administration
General Action Indication Client’s actual response to medication
Paracetamol October 1, 2010
6:00pm
IVP
30mgPRN
The main mechanism of action of paracetamol is considered to be the inhibition of cyclooxygenase (COX)
For client who has elevated temperature (hyperthermia)
Client’s temperature of 38.5oc decreases to 37.5oc
Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.
2. MEDICAL MANAGEMENT
Medical Management
Date Ordered/ Performed/ Changed/ Discontinued
General Description Indication/s or purpose/s
Client’s reaction to treatment
Intravenous FluidD5LRS @
Changed: September 30, 2010 at 10:28 pm.
D5LR is actually 5% dextrose in lactated ringer's solution. It is a hypertonic solution which
This solution is indicated for use in adults and
The patient was hydrated. The fluid and electrolytes level
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20gtts/min means it pulls fluid out of the cells into the intravascular space (veins).
5% Dextrose in Lactated Ringer's Injection provides electrolytes and calories, and is a source of water for hydration. It is capable of inducing diuresis depending on the clinical condition of the patient. This solution also contains lactate which produces a metabolic alkalinizing effect.
pediatric patients as a source of electrolytes, calories and water for hydration.
of her body is maintained.
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Nursing Management
Prior
Before starting I.V therapy, consider duration of therapy, type of infusion condition
of veins and medical condition of the patient to assist in choosing in I.V site and type
of catheter.
Ensure that you are competent in initiating the type of I.V therapy decided on and
familiar with institutional policy and procedure before initiating therapy.
Explain the procedure to the client and why is it necessary.
During
Monitor the insertion site for signs of phlebitis or infiltration.
Monitor the flow rate of the IV fluid.
Maintain the cleanliness of the plaster.
After
After initiation of I.V therapy, monitor the patient frequently for:
1. Signs of infiltration of sluggish flow
2. Signs of phlebitis or infection
3. Correct solution, medication, volume and rate
4. Dwell time of catheter and need to be replace
5. Condition of catheter dressing and frequency of change
6. Fluid and electrolyte balance
7. Signs of fluid overload or dehydration
8. Patient satisfaction with mode therapy
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MedicalManagement
Date Ordered/Performed
Changed/discontinuedGeneral Description Indication/s or purpose/s
Client’s reaction to treatment
Oxygen Therapy 09-30-2010
08-30-2010
Oxygen may be classified as an element, a gas, and a drug. Oxygen therapy is the administration of oxygen at concentrations greater than that in room air to treat or prevent hypoxemia (not enough oxygen in the blood). Oxygen delivery systems are classified as stationary, portable, or ambulatory. Oxygen can be administered by nasal cannula, mask, and tent. Hyperbaric oxygen therapy involves placing the patient in an airtight chamber with oxygen under pressure.
The body is constantly taking in oxygen and releasing carbon dioxide. If this process is inadequate, oxygen levels in the blood decrease and the patient may need supplemental oxygen. Oxygen therapy is a key treatment in respiratory care. The purpose is to increase oxygen saturation in tissues where the saturation levels are too low due to illness or injury.
Breathing prescribed oxygen increases the amount of oxygen in the blood, reduces the extra work of the heart, and decreases shortness of breath. Oxygen therapy is frequently ordered in the home care setting, as well as in acute (urgent) care facilities.
The patient’s oxygen need was sustained. Airway becomes easier. Breathing pattern becomes normal.
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3. Surgical Management
DATE PERFORMED: September 30, 2010 – 11:45 a.m
Name of Procedure Brief Description Indication/ PurposeClient’s Response to
Operation
Appendectomy Surgical removal of the Appendix
To remove the inflamed appendix to prevent rupture - this will eventually lead to peritonitis.
The patient was asleep after the operation.
The patient was lying flat on bed 6 – 8 hours after the surgery.
The patient had chills few hours after the operation.
The patient had fever 1 day after the operation.
Nursing Responsibilities
Prior to the Surgery
Check the vital signs for baseline data.
Instruct the patient to be on nothing per Orem 8 hours prior to surgery.
Educate the patient the patient about coughing, deep breathing exercises and turning side
– to – side after the surgery.
Let the patient voice out what she feels to relieve anxiety.
Listen to what the patient says.
During the surgery
Promote sterility on the sterile field.
Monitor the patient’s well being.
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Monitor patient’s vital signs
After the Surgery
Keep the patient on NPO for 6 to 8 hours or until peristalsis occurs.
Keep the patient lie flat on bed without pillow for 6 to 8 hours.
Monitor for bleeding and signs of shock.
Monitor for signs of infection.
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4. DIET
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5. ACTIVITY/EXERCISE
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D. EVALUATION
III. CONCLUSION
The group’s grand case study is about ruptured appendicitis. It was a good learning
experience for our group to handle such case.
The client manifest hyperthermia, fatigue, impaired physical mobility, and impaired skin
integrity, the group therefore concludes that nursing intervention should be done to alleviate
predicament on the client’s health. The highlight of our principle is to provide optimum nursing
care primarily to our client and the significant others as well. The group believes that the first
thing to consider for our client’s wellness to make them feel special and be sincere in rendering
quality services.
Susceptibility of the client to acquire complication is greatly at risk. Hence, client should
be monitor carefully and medications must be maintained ideally.
IV. RECOMMENDATION
The group recommends providing wound care aseptically as frequently as possible to
prevent infection and apply cold compress to the abdomen when abdominal pain is experience.
Advice regular consultation to the physician for it can be a factor for recovery and assess the
patient’s progress. Advised the client who has to religiously take his medication prescribed to
alleviate symptoms and prevent further complications. Instruct the patient normal activities can
be resumed within a few days, but it takes four to six weeks for full recovery. Heavy lifting and
strenuous activities should be avoided during recovery. Encourage continuous range of motion
exercises. Eat healthy foods from all of the five food groups; fruits, vegetables, breads, dairy
products, meats, fishes. Eating healthy foods may help the patient feel better and have more
energy and also help recover faster from sickness. Emphasize the importance of increase dietary
intake of fiber and vitamin C. Avoid foods that can cause constipation such as apple, guava and
star apple. Encourage to increase fluid intake to maintain hydration and electrolyte balance.
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V. REVIEW OF RELATED LITERATURE
Viral Infections Linked to Appendicitis
By Rajshri on January 19, 2010 at 6:55 PM
A new study by UT Southwestern Medical Center surgeons and physicians says that appendicitis may also be caused by a virus and that you can actually "catch" it.
The researchers evaluated data over a 36-year period from the National Hospital Discharge Survey and concluded in a paper appearing in the January issue of Archives of Surgery that appendicitis may be caused by undetermined viral infection or infections, said Dr. Edward Livingston, chief of GI/endocrine surgery at UT Southwestern and senior author of the report.
The review of hospital discharge data runs counter to traditional thought, suggesting that appendicitis doesn't necessarily lead to a burst appendix if the organ is not removed quickly, Dr. Livingston said.
"Just as the traditional appendix scar across the abdomen is fast becoming history, thanks to new single-incision surgery techniques that hide a tiny scar in the bellybutton, so too may the conventional wisdom that patients with appendicitis need to be operated on as soon as they enter the hospital," said Dr. Livingston. "Patients still need to be seen quickly by a physician, but emergency surgery is now in question."
Appendicitis is the most common reason for emergency general surgery, leading to some 280,000 appendectomies being performed annually.
Appendicitis was first identified in 1886. Since then, doctors
have presumed quick removal of the appendix was a necessity to avoid a subsequent bursting,
which can be an emergency. Because removing the appendix solves the problems and is
generally safe, removal became the standard medical practice in the early 20th century.