Case Study for Peri-appendiceal abcess

I. Patient’s Data

I. General Data

Patient’s. Name: Mrs Kliyente

Sex: female

Age: 53 y/o

Date of Birth: May 20, 1955

Civil status: Married

Citizenship: Filipino

Current Address: Magsaysay Area, Brgy. Sto. Cristo Tala Caloocan City

Religion: Catholic

Occupation: Employer (Carinderia owner)

Room and Bed number:

Hospital number: 52-56-34

Chief Complaint: Abdominal pain

Admitting Diagnosis: t/c Periappendical Abscess

Admission Date and Time: January 27, 2009- 5: 00 pm

Final Diagnosis: Periappendical abscess s/p Exploratory Laparotomy

II Chief Complaint: Abdominal pain

III History of Present illness:

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

abdomen with a pain scale of “10” accompanied by recurrent fever at night and resolved

by paracetamol affording temporary relief of fever. Patient also experienced nausea,

anorexia. Constipation was managed by taking suppository 3x a week. Pt. also took two

tablets of Buscupan in the morning and afternoon for abdominal pain once but didn’t take

effect. Persistence of the condition pt. consulted St. Peter hospital but no diagnosis and

medication given.

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3 weeks prior to admission patient experienced consistent Right Lower Quadrant

abdominal pain, recurrent fever, nausea constipation, and anorexia. With continuous pain

pt seek consultation at FEU Fairview but no clear diagnosis has been given but given

Cefuroxime and Metronidazole for UTI. Still with persistent abdominal pain pt still used

suppository for temporary relief.

2 weeks prior to admission persistence of above condition, as advised by

personnel’s from FEU Fairview, patient undergone CT scan and Health scan. Still patient

used suppository for temporary relief of constipation and abdominal pain.

A week prior to admission with unfailing occurrence of above condition, patient

prompted to seek consultation of EAMC OPD with the CT scan result. No diagnosis and

medication has been given. Patient still used suppository and stopped using UTI

medications.

Few hours prior to admission patient came back at EAMC still with the CT scan

result and above condition; patient is diagnosed with a leaked abcess from the appendix

T/C “periappendecal abscess” based on the CT scan result. Patient was given Cefuroxime

for abdominal pain w/c took effect and subsequently admitted. CBC laboratory procedure

done and no other exams was done.

IV Past Medical History

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

V Family Medical History

(+) DM – brother

(+) Appendicitis – daughter

VI Personal and Social Data

Non smoker nor alcoholic drinker

No specific sleeping pattern. The Client prefers vegetables and Fluid Intake one

glass per meal approximately 3-4 times a day.

Own a Carinderia

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VII Review of System

General/Constitutional

• (-)Weight loss or gain• (-)Fatigue• (-)Headache• (+)Weakness• (+)Restlessness• (-)Trouble sleeping• (+) Activity Intolerance

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

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

Cardiovascular • (-)Chest pain• (-) Substernal distress• (-) Palpitations• (-) SyncopeRespiratory • (-) Pain

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

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

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

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

Neurologic:

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

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

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VIII Physical Examination

Date of Assessment: January 29, 2009

Vital Signs:

Blood Pressure: 110/80 mmHg

Pulse Rate: 110 bpm

Respiratory Rate: 24 bpm

Temperature: 37.7 degrees Celsius (Febrile)

Stool: once a week

General Appearance:

Medium frame built, stooped posture, smooth rhythmic gait, appropriate

dressed, no body and breath odor and obvious physical deformity.

Mental Status/ Neurologic:

Conscious, oriented, anxious, uses simple words for communication.

Integument:

Flushed, warm and dry skin, no edema in extremities,

no lesions, decreased skin turgor, concave nail plate shape,

smooth pink nail bed color and capillary refill within 3 seconds.

Head and Face:

Skull is proportionate to body size, white scalp; partly black to gray shinny

evenly distributed hair. Face is symmetrically and easy facial movement.

Eyes:

Thin eyebrows, effective closure of eyelids and lashes,

bilateral blink response, eyeballs are symmetrical, pinkish bulbar

conjunctiva, white sclera, equal pupils and moist lacrimal apparatus.

Ears:

Auricle color is normal racial, symmetrical and elastic, pinna recoils when

folded, some cerumen in external canal, no aural discharge & responds to

normal voice.

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Nose:

Normal external racial tone, midline septum, pink mucosa, moist nasal

cavity, with non tender sinuses.

Mouth:

Pallor in the lips & mucosa, midline tongue, smooth and movable,

teeth incomplete.

Pharynx:

Pallor in mucosa, none inflamed tonsil, gag reflex present.

Neck:

ROM neck muscle; palpable non tender lymph nodes, midline trachea,

palpable thyroid gland.

Breast and Axilla:

Sagging, smooth & palpable non tender lymph nodes.

Chest and Lungs:

Symmetrical fremitus, shallow breathing, resonant percussion, heart rate at

110 cpm, pulmonic, aortic, tricuspid and apical heart sounds present.

Abdomen:

Normal racial tone of the skin, flat contour and symmetry, symmetrical

movement, hypoactive bowel sounds, negative in rovsing’s sign and Mc

Burney’s sign.(direct maneuver)

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X Course in the Ward

January 29, 2009 Received patient lying in bed, very anxious looking, waiting

for the impending surgery. On DAT diet and will progress

to NPO diet post midnight, with no contraptions attached.

Vital Signs taken and recorded. Patient was febrile (37.7 C)

January 30, 2009 The patient was scheduled for surgery (Exploratory

laprotomy), very anxious yet conscious and coherent

However the surgery was cancelled because she has no CP

clearance so the surgery was rescheduled on Tuesday (Feb.

02). V/S has been taken & recorded. Patient was febrile

(37.8 C)

February 05, 2009Received patient. on bed on its second day post-OP,

conscious and coherent. Tense and weak in appearance,

facial grimacing when surgery incision border is palpated,

and verbally reported pain at both sides of abdominal area

with the score of 6. With on going IVF of D5LR at 300cc

level infusing at KVO rate and heplock at the right arm kept

intact. With abdominal elastic bandage dressing then

changed to abdominal sterile gauze dressing kept dry and

clean. On NPO diet and progressed to sips of water.

February 06, 2009At 8:00 am the pt. was febrile (37.6*c) done TSB. The pt.

was on IVF of D5LR at 800cc level infusing at KVO rate

and instructed on moderate high back rest. Still on sips of

water diet, vital signs taken & recorded.

XI Final Diagnosis: Periappendical abscess s/p Explore Laparotomy

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II Review of Related Literature

What is Appendicitis?

The appendix is a closed-ended, narrow tube up to several inches in length that attaches

to the cecum (the first part of the colon) like a worm. (The anatomical name for the

appendix, vermiform appendix, means worm-like appendage.) The inner lining of the

appendix produces a small amount of mucus that flows through the open center of the

appendix and into the cecum. The wall of the appendix contains lymphatic tissue that is

part of the immune system for making antibodies. Like the rest of the colon, the wall of

the appendix also contains a layer of muscle, but the muscle is poorly developed.

What is appendicitis and what causes appendicitis?

Appendicitis means inflammation of the appendix. It is thought that appendicitis begins

when the opening from the appendix into the cecum becomes blocked. The blockage may

be due to a build-up of thick mucus within the appendix or to stool that enters the

appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the

opening. This rock is called a fecalith (literally, a rock of stool). At other times, the

lymphatic tissue in the appendix may swell and block the appendix. After the blockage

occurs, bacteria which normally are found within the appendix begin to invade (infect)

the wall of the appendix. The body responds to the invasion by mounting an attack on the

bacteria, an attack called inflammation. An alternative theory for the cause of

appendicitis is an initial rupture of the appendix followed by spread of bacteria outside

the appendix.. The cause of such a rupture is unclear, but it may relate to changes that

occur in the lymphatic tissue, for example, inflammation, that line the wall of the

appendix.)

If the inflammation and infection spread through the wall of the appendix, the appendix

can rupture. After rupture, infection can spread throughout the abdomen; however, it

usually is confined to a small area surrounding the appendix (forming a peri-appendiceal

abscess).

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

surgical treatment if the infection and accompanying inflammation do not spread

throughout the abdomen. The inflammation, pain and symptoms may disappear. This is

particularly true in elderly patients and when antibiotics are used. The patients then may

come to the doctor long after the episode of appendicitis with a lump or a mass in the

right lower abdomen that is due to the scarring that occurs during healing. This lump

might raise the suspicion of cancer.

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What are the complications of appendicitis?

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

appendix can lead to a Periappendiceal abscess (a collection of infected pus) or diffuse

peritonitis (infection of the entire lining of the abdomen and the pelvis). The major reason

for appendiceal perforation is delay in diagnosis and treatment. In general, the longer the

delay between diagnosis and surgery, the more likely is perforation. The risk of

perforation 36 hours after the onset of symptoms is at least 15%. Therefore, once

appendicitis is diagnosed, surgery should be done without unnecessary delay.

A less common complication of appendicitis is blockage of the intestine. Blockage occurs

when the inflammation surrounding the appendix causes the intestinal muscle to stop

working, and this prevents the intestinal contents from passing. If the intestine above the

blockage begins to fill with liquid and gas, the abdomen distends and nausea and

vomiting may occur. It then may be necessary to drain the contents of the intestine

through a tube passed through the nose and esophagus and into the stomach and intestine.

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

enter the blood and travel to other parts of the body. This is a very serious, even life-

threatening complication. Fortunately, it occurs infrequently.

What are the symptoms of appendicitis?

The main symptom of appendicitis is abdominal pain. The pain is at first diffuse and

poorly localized, that is, not confined to one spot. (Poorly localized pain is typical

whenever a problem is confined to the small intestine or colon, including the appendix.)

The pain is so difficult to pinpoint that when asked to point to the area of the pain, most

people indicate the location of the pain with a circular motion of their hand around the

central part of their abdomen. A second, common, early symptom of appendicitis is loss

of appetite which may progress to nausea and even vomiting. Nausea and vomiting also

may occur later due to intestinal obstruction.

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

covering and then to the lining of the abdomen, a thin membrane called the peritoneum.

Once the peritoneum becomes inflamed, the pain changes and then can be localized

clearly to one small area. Generally, this area is between the front of the right hip bone

and the belly button. The exact point is named after Dr. Charles McBurney--McBurney's

point. If the appendix ruptures and infection spreads throughout the abdomen, the pain

becomes diffuse again as the entire lining of the abdomen becomes inflamed.

Rovsing's sign

Deep palpation of the left iliac fossa may cause pain in the right iliac fossa. This is the

Rovsing's sign, also known as the Rovsing's symptom. It is used in the diagnosis of acute

appendicitis. Pressure over the descending colon causes pain in the right lower quadrant

of the abdomen.

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McBurney’s Sign

McBurney's sign, is a sign of acute appendicitis.[2] The clinical sign of rebound pain

when pressure is applied is also known as Aaron's sign.

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

longer limited to the lumen of the bowel (which localizes pain poorly), and is irritating

the lining of the peritoneum at the place where the peritoneum comes into contact with

the appendix. Tenderness at McBurney's point suggests the evolution of acute

appendicitis to a later stage, and thus, the increased likelihood of rupture. Because the

location of the appendix is often different in different people, and can migrate within the

abdomen, many cases of appendicitis do not cause point tenderness at McBurney's point.

Other abdominal processes can also sometimes cause tenderness at McBurney's point.

Thus, this sign is highly useful but neither necessary nor sufficient to make a diagnosis of

acute appendicitis. Also, the anatomical position of the appendix is highly variable (for

example in retrocaecal appendix, an appendix behind the caecum), which also limits the

use of this sign.

Psoas sign

Occasionally, an inflamed appendix lies on the psoas muscle and the patient will lie with

the right hip flexed for pain relief.

Obturator sign

If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can

be demonstrated by flexing and internally rotating the hip. This maneuver will cause pain

in the hypogastrium.

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If the appendix curls around behind the cecum, pain and tenderness may be felt in the

lumbar region. If its tip is in the pelvis, these signs may be elicited only on rectal

examination. Pain on defecation suggests that the tip of the appendix is resting against the

rectum; pain on urination suggests that the tip is near the bladder or impinges on the

ureter.

How is appendicitis diagnosed?

The diagnosis of appendicitis begins with a thorough history and physical examination.

Patients often have an elevated temperature, and there usually will be moderate to severe

tenderness in the right lower abdomen when the doctor pushes there. If inflammation has

spread to the peritoneum, there is frequently rebound tenderness. Rebound tenderness is

pain that is worse when the doctor quickly releases his hand after gently pressing on the

abdomen over the area of tenderness.

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White Blood Cell Count

The white blood cell count in the blood usually becomes elevated with infection. In early

appendicitis, before infection sets in, it can be normal, but most often there is at least a

mild elevation even early. Unfortunately, appendicitis is not the only condition that

causes elevated white blood cell counts. Almost any infection or inflammation can cause

this count to be abnormally high. Therefore, an elevated white blood cell count alone

cannot be used as a sign of appendicitis.

Urinalysis

Urinalysis is a microscopic examination of the urine that detects red blood cells, white

blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is

inflammation or stones in the kidneys or bladder. The urinalysis also may be abnormal

with appendicitis because the appendix lies near the ureter and bladder. If the

inflammation of appendicitis is great enough, it can spread to the ureter and bladder

leading to an abnormal urinalysis. Most patients with appendicitis, however, have a

normal urinalysis. Therefore, a normal urinalysis suggests appendicitis more than a

urinary tract problem.

Abdominal X-Ray

An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece

of stool that blocks the appendiceal opening) that may be the cause of appendicitis. This

is especially true in children.

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Ultrasound

An ultrasound is a painless procedure that uses sound waves to identify organs within the

body. Ultrasound can identify an enlarged appendix or an abscess. Nevertheless, during

appendicitis, the appendix can be seen in only 50% of patients. Therefore, not seeing the

appendix during an ultrasound does not exclude appendicitis. Ultrasound also is helpful

in women because it can exclude the presence of conditions involving the ovaries,

fallopian tubes and uterus that can mimic appendicitis.

Barium Enema

A barium enema is an x-ray test where liquid barium is inserted into the colon from the

anus to fill the colon. This test can, at times, show an impression on the colon in the area

of the appendix where the inflammation from the adjacent inflammation impinges on the

colon. Barium enema also can exclude other intestinal problems that mimic appendicitis,

for example Crohn's disease.

Computerized tomography (CT) Scan

In patients who are not pregnant, a CT Scan of the area of the appendix is useful in

diagnosing appendicitis and peri-appendiceal abscesses as well as in excluding other

diseases inside the abdomen and pelvis that can mimic appendicitis.

Laparoscopy

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

inserted into the abdomen through a small puncture made on the abdominal wall.

Laparoscopy allows a direct view of the appendix as well as other abdominal and pelvic

organs. If appendicitis is found, the inflamed appendix can be removed with the

laparascope. The disadvantage of laparoscopy compared to ultrasound and CT is that it

requires a general anesthetic.4

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There is no one test that will diagnose appendicitis with certainty. Therefore, the

approach to suspected appendicitis may include a period of observation, tests as

previously discussed, or surgery.

Why can it be difficult to diagnose appendicitis?

It can be difficult to diagnose appendicitis. The position of the appendix in the abdomen

may vary. Most of the time the appendix is in the right lower abdomen, but the appendix,

like other parts of the intestine, has a mesentery. This mesentery is a sheet-like membrane

that attaches the appendix to other structures within the abdomen. If the mesentery is

large, it allows the appendix to move around. In addition, the appendix may be longer

than normal. The combination of a large mesentery and a long appendix allows the

appendix to dip down into the pelvis (among the pelvic organs in women). It also may

allow the appendix to move behind the colon (called a retro-colic appendix). In either

case, inflammation of the appendix may act more like the inflammation of other organs,

for example, a woman's pelvic organs.

The diagnosis of appendicitis also can be difficult because other inflammatory problems

may mimic appendicitis. Therefore, it is common to observe patients with suspected

appendicitis for a p

eriod of time to see if the problem will resolve on its own or develop characteristics that

more strongly suggest appendicitis or, perhaps, another condition.

What other conditions can mimic appendicitis?

The surgeon faced with a patient suspected of having appendicitis always must consider

and look for other conditions that can mimic appendicitis. Among the conditions that

mimic appendicitis are:

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* Meckel's diverticulitis. A Meckel's diverticulum is a small outpouching of the small

intestine which usually is located in the right lower abdomen near the appendix. The

diverticulum may become inflamed or even perforate (break open or rupture). If inflamed

and/or perforated, it usually is removed surgically.

* Pelvic inflammatory disease. The right fallopian tube and ovary lie near the

appendix. Sexually active women may contract infectious diseases that involve the tube

and ovary. Usually, antibiotic therapy is sufficient treatment, and surgical removal of the

tube and ovary are not necessary.

* Inflammatory diseases of the right upper abdomen. Fluids from the right upper

abdomen may drain into the lower abdomen where they stimulate inflammation and

mimic appendicitis. Such fluids may come from a perforated duodenal ulcer, gallbladder

disease, or inflammatory diseases of the liver, e.g., a liver abscess.

* Right-sided diverticulitis. Although most diverticuli are located on the left side of the

colon, they occasionally occur on the right side. When a right-sided diverticulum ruptures

it can provoke inflammation they mimics appendicitis.

* Kidney diseases. The right kidney is close enough to the appendix that inflammatory

problems in the kidney-for example, an abscess-can mimic appendicitis

How is appendicitis treated?

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

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

suspected.

There is a small group of patients in whom the inflammation and infection of appendicitis

remain mild and localized to a small area. The body is able not only to contain the

inflammation and infection but to resolve it as well. These patients usually are not very ill

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and improve during several days of observation. This type of appendicitis is referred to as

"confined appendicitis" and may be treated with antibiotics alone. The appendix may or

may not be removed at a later time.

On occasion, a person may not see their doctor until appendicitis with rupture has been

present for many days or even weeks. In this situation, an abscess usually has formed,

and the appendiceal perforation may have closed over. If the abscess is small, it initially

can be treated with antibiotics; however, the abscess usually requires drainage. A drain (a

small plastic or rubber tube) usually is inserted through the skin and into the abscess with

the aid of an ultrasound or CT scan that can determine the exact location of the abscess.

The drain allows pus to flow from the abscess out of the body. The appendix may be

removed several weeks or months after the abscess has resolved. This is called an interval

appendectomy and is done to prevent a second attack of appendicitis.

How is an appendectomy done?

During an appendectomy, an incision two to three inches in length is made through the

skin and the layers of the abdominal wall over the area of the appendix. The surgeon

enters the abdomen and looks for the appendix which usually is in the right lower

abdomen. After examining the area around the appendix to be certain that no additional

problem is present, the appendix is removed. This is done by freeing the appendix from

its mesenteric attachment to the abdomen and colon, cutting the appendix from the colon,

and sewing over the hole in the colon. If an abscess is present, the pus can be drained

with drains that pass from the abscess and out through the skin. The abdominal incision

then is closed.

Newer techniques for removing the appendix involve the use of the laparoscope. The

laparoscope is a thin telescope attached to a video camera that allows the surgeon to

inspect the inside of the abdomen through a small puncture wound (instead of a larger

incision). If appendicitis is found, the appendix can be removed with special instruments

that can be passed into the abdomen, just like the laparoscope, through small puncture

wounds. The benefits of the laparoscopic technique include less post-operative pain

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(since much of the post-surgery pain comes from incisions) and a speedier return to

normal activities. An additional advantage of laparoscopy is that it allows the surgeon to

look inside the abdomen to make a clear diagnosis in cases in which the diagnosis of

appendicitis is in doubt. For example, laparoscopy is especially helpful in menstruating

women in whom a rupture of an ovarian cysts may mimic appendicitis.

If the appendix is not ruptured (perforated) at the time of surgery, the patient generally is

sent home from the hospital after surgery in one or two days. Patients whose appendix

has perforated are sicker than patients without perforation, and their hospital stay often

is prolonged (four to seven days), particularly if peritonitis has occurred. Intravenous

antibiotics are given in the hospital to fight infection and assist in resolving any abscess.

Occasionally, the surgeon may find a normal-appearing appendix and no other cause for

the patient's problem. In this situation, the surgeon may remove the appendix. The

reasoning in these cases is that it is better to remove a normal-appearing appendix than to

miss and not treat appropriately an early or mild case of appendicitis.

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What are the complications of appendectomy?

The most common complication of appendectomy is infection of the wound, that is, of

the surgical incision. Such infections vary in severity from mild, with only redness and

perhaps some tenderness over the incision, to moderate, requiring only antibiotics, to

severe, requiring antibiotics and surgical treatment. Occasionally, the inflammation and

infection of appendicitis are so severe that the surgeon will not close the incision at the

end of the surgery because of concern that the wound is already infected. Instead, the

surgical closing is postponed for several days to allow the infection to subside with

antibiotic therapy and make it less likely for infection to occur within the incision.

Wound infections are less common with laparoscopic surgery.

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

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

non-surgical techniques, as previously discussed.

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Are there long-term consequences of appendectomy?

It is not clear if the appendix has an important role in the body in older children and

adults. There are no major, long-term health problems resulting from removing the

appendix although a slight increase in some diseases has been noted, for example,

Crohn's disease.

Gerontologic Considerations

Acute appendicitis does not occur frequently in the elderly population. Classic signs

and symptoms are altered and may vary greatly. Pain may be absent or minimal.

Symptoms may be vague, suggesting bowel obstruction or another process. Fever

and leukocytosis may not be present. As a result, diagnosis and prompt treatment

may be delayed, causing potential complications and mortality. The patient may

have no symptoms until the appendix ruptures. The incidence of perforated

appendix is higher in the elderly population because many of these patients do not

seek health care as quickly as younger patients.

PHARMACOLOGIC ASPECTS OF AGING

Older people use more medications than does any other age group: although they

comprise only 12.6% of the total population, they use 30% of all prescribed medications

and 40% of all over-the-counter medications. Medications have improved the

health and well-being of older people by alleviating symptoms of discomfort, treating

chronic illnesses, and curing infectious processes. Problems commonly occur, however,

because of medicationinteractions, multiple medication effects, multiple medication

use (polypharmacy), and noncompliance. Combinations of prescription medications and

some over-the-counter medications further complicate the problem.

Any medication is capable of altering nutritional status, which, in the elderly, may

already be compromised by a marginal diet or by chronic disease and its treatment.

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Medications can depress the appetite, cause nausea and vomiting, irritate the stomach,

cause constipation or diarrhea, and decrease absorption of nutrients. In addition, they can

alter electrolyte balance and carbohydrate and fat metabolism. A few examples of

medications capable of altering the nutritional status are antacids, which produce

thiamine

deficiency; cathartics, which diminish absorption; antibiotics and phenytoin, which

reduce utilization of folic acid; and phenothiazines, estrogens, and corticosteroids, which

increase food intake and cause weight gain.

Age

Age has long been the focus of research on pain perception and pain tolerance, and again

the results have been inconsistent. For example, although some researchers have found

that older adults require a higher intensity of noxious stimuli than do younger adults

before they report pain (Washington, Gibson & Helme, 2000), others have found no

differences in responses of younger and older adults (Edwards & Filligim, 2000). Other

researchers have found that elderly patients (older than 50 years of age) reported

significantly less pain than younger patients (Li, Greenwald, Gennis et al., 2001).

Experts in the field of pain management have concluded that if pain perception is

diminished in the elderly person, it is most likely secondary to a disease process (eg,

diabetes) rather than to aging (American Geriatrics Society, 1998). More research is

needed in the area of aging and its effects on pain perception to understand what the

elderly are experiencing. Although many elderly people seek health care because of pain,

others are reluctant to seek help even when in severe pain because they consider pain to

be part of normal aging. Assessment of pain in older adults may be difficult because

of the physiologic, psychosocial, and cognitive changes that often accompany aging.

In one study, as many as 93% of nursing home residents reported being in pain daily for

the past 6 months (Weiner, Peterson, Ladd et al., 1999). Unrelieved pain contributes to

the problems of depression, sleep disturbances, delayed rehabilitation, malnutrition, and

cognitive dysfunction (Miaskowski, 2000). The way an older person responds to pain

may differ from the way a younger person responds.

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Because elderly people have a slower metabolism and a greater ratio of body fat to

muscle mass than younger people, small doses of analgesic agents may be sufficient

to relieve pain, and these doses may be effective longer (Buffum & Buffum, 2000).

Elderly patients deal with pain according to their lifestyle, personality, and cultural

background, as do younger adults. Many elderly people are fearful of addiction and,

as a result, will not report that they are in pain or ask for pain medication. Others

fail to seek care because they fear that the pain may indicate serious illness or they fear

loss of independence. Elderly patients must receive adequate pain relief after surgery or

trauma. When an elderly person becomes confused after surgery or trauma, the confusion

is often attributed to medications, which are then discontinued. However, confusion in

the elderly may be a result of untreated and unrelieved pain. In some cases postoperative

confusion clears once the pain is relieved. Judgments about pain and the adequacy of

treatment should be based on the patient’s report of pain and pain relief rather than on

age.

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Peri-appendiceal abscess

(Appendix, cut section, showing that pus fills the appendix lumen and spills out into the

fat, forming a peri-appendiceal abscess. This is a surgical emergency.)

If the inflammation and infection spread through the wall of the appendix, the

appendix can rupture. After rupture, infection can spread throughout the abdomen;

however, it usually is confined to a small area surrounding the appendix (forming a peri-

appendiceal abscess).

Treatment

A laparotomy is a large incision made into the abdomen. Exploratory laparotomy is used

to visualize and examine the structures inside of the abdominal cavity.

Purpose:

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

allows physicians to examine the abdominal organs. The procedure may be recommended

for a patient who has abdominal pain of unknown origin or who has sustained an injury to

the abdomen. Because of the nature of the abdominal organs, there is a high risk of

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infection if organs rupture or are perforated. In addition, bleeding into the abdominal

cavity is considered a medical emergency. Exploratory laparotomy is used to determine

the source of pain or the extent of injury and perform repairs if needed.

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

establish the extent of a disease.

Some other conditions that may be discovered or investigated during exploratory

laparotomy include:

cancer of the abdominal organs

peritonitis (inflammation of the peritoneum, the lining of the abdominal cavity)

appendicitis (inflammation of the appendix)

pancreatitis (inflammation of the pancreas)

abscesses (a localized area of infection)

adhesions (bands of scar tissue that form after trauma or surgery)

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

intestinal perforation

ectopic pregnancy (pregnancy occurring outside of the uterus)

foreign bodies (e.g., a bullet in a gunshot victim)

internal bleeding

Demographics

Because laparotomy may be performed under a number of circumstances to diagnose or

treat numerous conditions, no data exists as to the overall incidence of the procedure.

Description

The patient is usually placed under general anesthesia for the duration of surgery. The

advantages to general anesthesia are that the patient remains unconscious during the

29

procedure, no pain will be experienced nor will the patient have any memory of the

procedure, and the patient's muscles remain completely relaxed, allowing safer surgery.

Incision

Once an adequate level of anesthesia has been reached, the initial incision into the skin

may be made. A scalpel is first used to cut into the superficial layers of the skin. The

incision may be median (vertical down the patient's midline), paramedian (vertical

elsewhere on the abdomen), transverse (horizontal), T-shaped, or curved, according to the

needs of the surgery. The incision is then continued through the subcutaneous fat, the

abdominal muscles, and finally, the peritoneum. Electrocautery is often used to cut

through the subcutaneous tissue as it has the ability to stop bleeding as it cuts.

Instruments called retractors may be used to hold the incision open once the abdominal

cavity has been exposed.

Abdominal Exploration

The surgeon may then explore the abdominal cavity for disease or trauma. The abdominal

organs in question will be examined for evidence of infection, inflammation, perforation,

26

abnormal growths, or other conditions. Any fluid surrounding the abdominal organs will

be inspected; the presence of blood, bile, or other fluids may indicate specific diseases or

injuries. In some cases, an abnormal smell encountered upon entering the abdominal

cavity may be evidence of infection or a perforated gastrointestinal organ.

If an abnormality is found, the surgeon has the option of treating the patient before

closing the wound or initiating treatment after exploratory surgery. Alternatively, samples

of various tissues and/or fluids may be removed for further analysis. For example, if

cancer is suspected, biopsies may be obtained so that the tissues can be examined

microscopically for evidence of abnormal cells. If no abnormality is found, or if

immediate treatment is not needed, the incision may be closed without performing any

further surgical procedures.

During exploratory laparotomy for cancer, a pelvic washing may be performed; sterile

fluid is instilled into the abdominal cavity and washed around the abdominal organs, then

30

withdrawn and analyzed for the presence of abnormal cells. This may indicate that a

cancer has begun to spread (metastasize).

Closure

Upon completion of any exploration or procedures, the organs and related structures are

returned to their normal anatomical position. The incision may then be sutured (stitched

closed). The layers of the abdominal wall are sutured in reverse order, and the skin

incision closed with sutures or staples.

Diagnosis/Preparation

Various diagnostic tests may be performed to determine if exploratory laparotomy is

necessary. Blood tests or imaging techniques such as x ray, computed tomography (CT)

scan, and magnetic resonance imaging (MRI) are examples. The presence of

intraperitoneal fluid (IF) may be an indication that exploratory laparotomy is necessary;

one study indicated that IF was present in nearly three-quarters of patients with intra-

abdominal injuries.

Directly preceding the surgical procedure, an intravenous (IV) line will be placed so that

fluids and/or medications may be administered to the patient during and after surgery. A

Foley catheter will be inserted into the bladder to drain urine. The patient will also meet

with the anesthesiologist to go over details of the method of anesthesia to be used.

Aftercare

The patient will remain in the postoperative recovery room for several hours where his or

her recovery can be closely monitored. Discharge from the hospital may occur in as little

as one to two days after the procedure, but may be later if additional procedures were

performed or complications were encountered. The patient will be instructed to watch for

symptoms that may indicate infection, such as fever, redness or swelling around the

incision, drainage, and worsening pain.

31

Risks

Risks inherent to the use of general anesthesia include nausea, vomiting, sore throat,

fatigue, headache, and muscle soreness; more rarely, blood pressure problems, allergic

reaction, heart attack, or stroke may occur. Additional risks include bleeding, infection,

injury to the abdominal organs or structures, or formation of adhesions (bands of scar

tissue between organs).

Morbidity and Mortality Rates

The operative and postoperative complication rates associated with exploratory

laparotomy vary according to the patient's condition and any additional procedures

performed.

Alternatives

Laparoscopy is a relatively recent alternative to laparotomy that has many advantages.

Also called minimally invasive surgery, laparoscopy is a surgical procedure in which a

laparoscope (a thin, lighted tube) and other instruments are inserted into the abdomen

through small incisions.

The internal operating field may then be visualized on a video monitor that is connected

to the scope. In some patients, the technique may be used for abdominal exploration in

place of a laparotomy. Laparoscopy is associated with faster recovery times, shorter

hospital stays, and smaller surgical scars.

32

During a laparotomy, and an incision is made into the patient's abdomen (A). Skin and

connective tissue called fascia is divided (B). The lining of the abdominal cavity, the peritoneum, is cut, and any exploratory procedures are undertaken (C). To close the incision, the peritoneum, fascia, and skin are stitched (E). (Illustration by GGS Inc.)

33

III Anatomy and Physiology

Large Intestine:.

Its primary purpose is to extract water from feces. About 1.5 M (5 feet) long, it

extends from the ileocecal valve to the anus.

Major functions are to dry out the indigestible food residue by absorbing water &

to eliminate these residues from the body as feces.

It frames the small intestine on these sides & has the following subdivisions:

cecum, appendix, colon, rectum & anal canal.

Cecum

The cecum (also spelled caecum), the first portion of the large bowel, situated in

the lower right quadrant of the abdomen.

The cecum receives fecal material from the small bowel (ileum) which opens into

it. The appendix is attached to the cecum.

The bottom of the cecum is a blind pouch (a cul de sac) leading nowhere.A pouch

connected to the ascending colon of the large intestine and the ileum. It is separated from

the ileum by the ileocecal valve (ICV) or Bauhin's valve, and is considered to be the

beginning of the large

34

Appendix

The appendix is a branch of the cecum, like the appendix, the cecum was once

believed to have no function.

The appendix is a small, finger-like appendage about 10 cm (4 in) long that is

attached to the cecum just below the ileocecal valve. The appendix fills with food and

empties regularly into the cecum. Because it empties inefficiently and its lumen is small,

the appendix is prone to obstruction and is particularly vulnerable to infection.

Ascending colon

Smaller in caliber than the cecum, with which it is continuous.It passes upward,

from its commencement at the cecum, opposite the colic valve, to the under surface of the

right lobe of the liver, on the right of the gall-bladderyeo, where it is lodged in a shallow

depression, the colic impression; here it bends abruptly forward and to the left, forming

the right colic flexure (hepatic).

Transverse Colon

Longest and most movable part of the colon, passes with a downward convexity

from the right hypochondrium region across the abdomen, opposite the confines of the

epigastric and umbilical zones, into the left hypochondrium region, where it curves

sharply on itself beneath the lower end of the spleen, forming the splenic or left colic

flexure. The right colic flexure is adjacent to the liver.

.

Rectum

The last 6 to 8 inches of the large intestine. The rectum stores solid waste until it

leaves the body through the anus.

Anus

Termination of Rectum formed of spichnter which relaxes to allow fecal matter to

pass through.

35

IV Pathophyisiology

A. Written Report:

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

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

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

was diagnosed with Periappendical abscess s/p Exploratomy Laparotomy.

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

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

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

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

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

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

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

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

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

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

manifestation of fever.

36

Obstruction of the lumen

↑ mucosal secretion

↑ intraluminal pressure

Bacterial Invasion( resident Bacteria from intestine)

Mucosal damage

Spillage of infected appendical contents

outside appendix

Confined to a small area surrounding appendix

( peri-appendiceal abscess)

37

Inflammation of parietal peritoneum

FEVER

Anticipatory for Surgery (Exploratory

Laparotomy)

anxiety Activity Intolerance

Acute painHyperthermia

Idiopathic(Constipation/Fecalith)

Inflammation

B. Diagram

V Problem List

Pre-operative:

1. Fever – Hyperthermia

2. Anxiety

Post-operative:

1. Acute Pain

2. Activity Intolerance

3. Anxiety

38

VI Laboratory and Diagnostic Procedures

January 27. 2009

LABORATORY PROCEDURE: Complete Blood Count

Hemoglobin

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

A. Test and ResultTest Result Reference Value

Hemoglobin (Hgb) 123 Male: 140-170/L Female: 120-150/L

B. InterpretationHemoglobin count was within the normal range

C. SignificanceIncrease in normal range

Polycythemia, Chronic Obstructive Pulmonary Disease Congestive Heart Failure

Decrease in normal range Anemia Hemorrhage

Hematocrit

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

A, Test and Result

Test Result Reference Value

Hematocrit (Hct) 37% Male:42-51%Female:37-47%

B. Interpretation

Hematocrit count was within the normal range

39

C. Significance

Increase in normal range Erythrocytosis Dehydration

Decrease in normal range Hemorrhage Anemia Pregnancy

RBC Count

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

A. Test and ResultTest Result Reference Value

RBC count 4.3 Male:4.5-5.9 x 106g/LFemale:4.5-5.1 x 106g/L

B. InterpretationRBC count was .2 lower that the normal range which may indicate dietary

deficiency because the client was anorexic.

C. SignificanceIncrease in normal range

Dehydration Pulmonary Fibrosis Erythrocytosis Polycythemia Congenital Heart Disease Chronic Obstructive Pulmonary Disease

Decrease in normal range Hemorrhage Anemia Pregnancy Dietary Deficiency

40

WBC CountIt is the count of the actual number of white blood cells per volume of blood.

A. Test and ResultTest Result Reference Value

WBC Count 6.1 5.0-10.0x103/L

B. InterpretationWBC count was within the normal range

C. SignificanceIncrease in normal range

Infection Steroid use

Decrease in normal range Bone Marrow failure Iron Deficiency

Platelet Count

A. Test and ResultTest Result Reference Value

Platelet Count Adequate 150-400x106/L

B. SignificanceIncrease in normal range

Rheumatoid arthritis Malignant Disorder Polycythemia Iron Deficiency Anemia

Decrease in normal range Thrombocytopenic Purpura, Acute leukemia, Aplastic anemia, Cancer chemotherapy.

41

Differential Count

NeutrophilsMake up 50% to 60% of leukocytes in the blood and are responsible for

phagocytosis of bacteria and cellular debris.

LymphocytesMake up 20% to 30% of the total white blood cells and are responsible in

producing antibody

MonocytesAre phagocytic cell.It can be produced rapidly and make up about 5% of the total

white blood cell count.

EosinophilsMake up 1%-4% of the total leukocytes. Increases in number during allergic

states and infestation with worms.

BasophilsIncreased in numbers in such pathological conditions and make up approximately

0.5%-1.0% of leukocytes.A. Test and Result

Test Result Reference Value

Neutrophils 0.63 0.45-0.65

Lymphocytes 0.37 0.25-0.35

Monocytes -- 0.03-0.06

Stabs -- 0.02-0.04

Eosinophils -- 0.02-0.04

Basophils-- 00-0.05

Blasts-- 0.0

ABO/RH Typing B+

42

B. Interpretations

The result for Neutrophils count was within the normal range. Lymphocytes count

was .0.02 more than the normal range which may indicate chronic bacterial infection or

viral infection. The patient blood type appeared to be B+.

C. SignificanceIncrease in normal range

Neutrophils

Acute infections

Trauma or surgery

Leukemia,

Malignant disease

Necrosis

Stress

Lymphocytes

Chronic Infection

Viral Infection

Mononecleosis

Monocytes

Chronic Inflammatory Disorder

Tuberculosis

Parasitic disease

Eosinophils

Parasitic Infections

Allergic reactions

Leukemia

Basophils

Leukemia

Decrease in normal range

Neutrophils

43

Aplastic Anemia

Dietary Deficiency

Radiation Therapy

Bone marrow suppression

Lymphocytes

Leukemia

Sepsis

Immunodeficiency disease

SLE

Immunodeficiency including AIDS

Monocytes

Drug therapy: Prednisone

Eosinophils

Stress

Use of some medications (ACTH, epinephrine, thyroxine)

Basophils

Allergic reactions

Stress

Nursing Considerations

1. Make sure that the vital signs are stable.

2. Choose non-dominant hand for the site when getting the specimen

3. Clean the site

4. Apply tourniquet to the site but not more than two minutes

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

6. If failed to the first attempt, change the site from distal to proximal

7. Release the tourniquet once there is blood in the hub

44

8. Transfer immediately the collected blood to the specimen container with purple

cap and deliver to the laboratory not more that 30 minutes.

9. To prevent coagulation turn the container upside down.

Diagnostic Procedures

A. Test and Result

CT Scan

Painless diagnostic procedure for examining soft tissue. It allows

visualization of grey matter, necrotic tissue, and tumors.

EXAM: CT SCAN of the whole abdomenDate: January 15, 2009

CT SCAN Report

History: 1 Month. History of Intermittent right Quadrant pain. Multiple axial tomograpic

sections of the whole abdomen with oral contrast and intravenous contrast were obtained.

A peripherally enhancing complex predominantly cystic mass is seen in the Right Lower

abdomen, adjacent to the ileo-cecal junction, most likely extra-luminal. It measures 5 cm

x 7cm x 5 cm. Surrounding fat stranding is seen. The visualized small and large bowels

appear unremarkable. The liver, gall bladder, pancreas, adrenal glands and spleen show

no unusual findings. The kidney and its collecting structures including the urinary

bladder are intact. The uterus is normal in size with no focal lesions noted. No adrenal

masses seen. The abdominal aorta shows no dilatation. Minimal curvilinear are seen in

the included lung bases. The rest of the soft tissues, vascular and osseous structures are

unremarkable.

Impression:Complex mass at the right lower abdomen; consider a Periappendiceal periceal

abscess- Minimal fibrotic changes, bilateral lower lungs.

B. Nursing Considerations

45

1. Secure Consent of the client.

2. Inform client that the procedure will take 30 minutes to 1 hour.

3. Explain test purpose and procedure. Provide written instructions. Reinforce

knowledge regarding possible adverse effects such as radiation.

4. Inform the client that there will be clicking and whirring noise and that he/she

may use earplugs.

5. Provide medications as ordered.

6. Reassure the patient that scanning procedures no greater radiation than

conventional x-ray studies

7. Check for patient allergies such as nausea, vomiting, warmth, and flushing of the

face may signal possible allergy for iodine.

8. Check for signs of claustrophobia

9. Be aware that abdominal cramping and diarrhea may occur; therefore medication

may be given as ordered to decrease these side effects.

10. Inform the patient that solid foods are usually withheld on the day of examination.

Clear liquids may be taken up to 2 hours before examination.

11. For CT of the abdomen, the patient usually can take nothing by mouth.

12. Notify physician immediately if allergic reaction occurs.

13. Secure Consent of the client.

14. Inform client that the procedure will take 30 minutes to 1 hour.

15. Inform the client that there will be clicking and whirring noise and that he/she

may use earplug.

A. Test and Result

46

Roentegnographic

Roentenographic Report

Date: January 10, 2009

Abdomen:

Shows gas in the visualize bowel loops. Minimal feces are seen in the rectum. Gas

pattern is non obstructive. Osseous structures & soft tissue outline are intact.

Impression:

Unremarkable abdomen

B. Nursing Considerations

1. The patient should be given a brief explanation of the purpose of and procedure

for the test and assured that there will be no discomfort.

2. Remove all jewelry and other ornamentation in the abdomen area before the X-

ray

3. Remind the patient of need to remain motionless during the procedure.

47

VII Drug Study

Name of Drug Action Indication Route and Dosage

Availability Contraindications Adverse Effects

Nursing Indications

Hyoscine N-

Butykbromide

Inhibits

acetycholine

at receptor

sites in

autonomic

nervous

system, which

controls

secretions,

free acids in

stomach;

blocks central

muscarinic

receptors,

which

decreases

involuntary

Used in the

management of

various

gastrointestinal

disorders.

Tablet:

adult and

children >6

yrs: 10-

20mg 3-5

times daily.

Injection: 0.3

mg/ml and 1

mg/ml in 1-

ml vials, 0.4

mg/ml in 0.5-

ml ampules

and 1-ml

vials, 0.86

mg/ml in 0.5-

ml ampules

Tablets: 0.4 mg

Transdermal

system

Myasthenia gravi,

megacolon,

hypersensitivity.

Xerostomia,

tachycardia,

urinary

retention..

-Tell patient

to avoid

hazardous

activities

requiring

alertness;

dizziness

may occur.

-Advice

patient to

avoid use of

alcohol or

other CNS

depressants

while taking

medication.

48

movements..(Transderm-

Scop): 1.5

mg/patch

(releases 0.5

mg

scopolamine

over 3 days)

-Explain that

rinsing the

mouth, good

oral hygiene,

and sugarless

gum or candy

will help to

counteract

dryness.

Started: December 28, 2008

Discontinued: December 28, 2008

49

Name of Drug Action Indication Route and

Dosage

Availability Contraindications Adverse Effects Nursing Indications

Acetaminophen May cause

analgesia by

inhibiting

CNS

prostaglandin

synthesis.

Relief mild-

to-moderate

pain:

treatment of

fever.

25 to 650

mg P.O. q

4 to 6

hours, or

1,000 mg

three or

four times

daily.

Caplets,

capsules: 160

mg, 500 mg,

650 mg

(Drops: 100

mg/ml

Elixir: 80

mg/2.5 ml, 80

mg/5 ml, 120

mg/5 ml, 160

mg/5 ml

Gelcaps: 500

mg

Liquid: 160

mg/5 ml, 500

mg/15 ml

Solution: 80

mg/1.66 ml,

Hypersensitivity:

Intolerance to

tartrazine, alcohol,

table sugar,

saccharin.

Stimulation,

drowiness,

nausea,vomiting,

abdominal pain,

heapatotoxicity,

hepatic seizure,

renal failure,

thrombocytopenia,

pancytopenia,

rash, uticaria and

hypersensitivity,

cyanosis, anemia,

neutropenia,

jaundice, CNS

stimulation,

delirium followed

by vascular

collapse,

-Tell the

patient to

read label on

the other

OTC.

-Advised the

client to

avoid

alcohol.

-Inform

patient to

recognized

signs of

chronic

overdose,

bleeding,

50

100 mg/1 ml,

120 mg/2.5

ml, 160 mg/5

ml, 167 mg/5

ml

Suppositories:

80 mg, 120

mg, 125 mg,

300 mg, 325

mg, 650 mg

Suspension:

32 mg/ml, 160

mg/5 ml

Syrup: 160

mg/5 ml

Tablets

(chewable): 80

mg, 160 mg

Tablets

(extended-

release): 160

convulsion,

trauma, death.

.

bruising,

malaise,

fever.

-Tell patient

to notify

physician for

pain or fever

lasting for 3

days.

51

mg, 325 mg,

500 mg, 650

mg

Tablets (film-

coated): 160

mg, 325 mg,

500 mg.

Started: December 29, 2008

Discontinued: January 12, 2009

Name of Drug

Action Indication Route and Dosage

Availability Contraindications Adverse Effects

Nursing Indications

Metronidazole Direct-acting

amebicide or

trichomobacide.

It binds to

Infections in

the intra-

abdominal

skin and skin

750 mg P.O.

q 8 hours for

5 to 10 days

Tabs:

250, 375

500mg

Blood dyscrasias,

active CNS

diseases,

hypersebsitivity to

Convulsive

seizures,

peripheral

neuropathy,

-Obtain C&S

before

beginning

drug therapy

52

bacterial and

protozoan DNA

to cause loss of

helical

structurem

strand

breakage,

inhibition if

nucleic acid

synthesis and

cell death.

structure. Ext Rel tabs:

750mg

Injection

500mg/100ml:

Powder for

Injection:

500mg single

dose

imidazole,

tuberculosis if

mucous

membranes and

certain viral

conditions and first

trimester if

pregnancy.

rash,

pruritus, GI

comfort,

anorexia,

nausea,

furred

tongue, dry

mouth and

unpleasant

metallic

taste,

headache,

less

frequently

vomiting,

diarrhea,

weakness,

dizziness

and

darkening

of the

to identify if

correct

treatment has

been initiated.

-Assess for

allergic

reactions:

rash, urticaria

and pruritus.

-Monitor for

possible drug

induced

adverse

reactions.

-Monitor

renal

function:

urine output,

53

urine. input and

output ratio.

Started: January 13, 2008

Discontinued: January 20, 2008

Name of Drug

Action Indication Route and Dosage

Availability Contraindications Adverse Effects Nursing Indications

Cefuroxime Inhibits

bacterial

cell wall

synthesis,

rendering

cell wall

osmotically

Uncomplicated

UTI due to

E.coli or K.

pneumoniae.

Preoperative

prophylaxis in

clients

Tablets:

250 mg

Standing

Order:

750 mg

IV q8

Oral

suspension:

125 mg/5 ml

Powder for

injection:

750 mg, 1.5

g, 7.5 g

Diarrhea/loose

stool, nausea and

vomiting,

abdominal pain.

Adverse reactions

CNS: headache,

hyperactivity,

hypertonia, seizures

GI: nausea,

- Give in even

doses around

the clock; If

GI upset

occurs, give

with food;

drug must be

54

unstable,

leading to

cell death

by binding

to cell wall

membrane

undergoing

surgical

procedures

classified as

clean-

contaminated

or potentially

contaminated.

.

(ANST) Premixed

containers:

750 mg/50

ml, 1.5 g/50

ml

Tablets: 125

mg, 250 mg,

500 mg

vomiting, diarrhea,

abdominal pain,

dyspepsia,

pseudomembranous

colitis

GU: hematuria,

vaginal candidiasis,

renal dysfunction,

acute renal failure

Hematologic:

hemolytic anemia,

aplastic anemia,

hemorrhage

Hepatic: hepatic

dysfunction

Metabolic:

given for 10-

14 days to

ensure

organism

death and

prevent

superinfection

55

hyperglycemia

Skin: toxic

epidermal

necrolysis,

erythema

multiforme,

Stevens-Johnson

syndrome

Other: allergic

reaction, drug

fever,

superinfection,

anaphylaxis

Interactions

Drug-drug.

Antacids

containing

aluminum or

56

magnesium,

histamine2-receptor

antagonists:

increased

cefuroxime

absorption

Probenecid:

decreased excretion

and increased blood

level of cefuroxime

Drug-diagnostic

tests. Blood

glucose, Coombs'

test, urine glucose

tests using

Benedict's solution:

false-positive

results

57

Glucose,

hematocrit:

decreased levels

White blood cells

in urine: increased

level

Drug-food.

Moderate- or high-

fat meal: increased

drug

bioavailability

Name of Drug

Action Indication Route and Dosage

Availability Contraindications Adverse Effects Nursing Indications

58

Ranitidine Inhibits

histamine at

H2 receptor

site in the

gastric

parietal

cells, which

inhibits

gastric acid

secretion.

Used in the

management

of various

gastrointestinal

disorders such

as dyspepsia

gastrointestinal

reflux disease

[GERD],

peptic ulcer

and zolunger-

ellisou

syndrome.

Prophylaxis

of GI

hemorrhage

from the

stress

ulceration

and in

Standing

Order : 50

mg IV q8

Capsules

(liquid-filled):

150 mg, 300

mg

Solution for

injection: 25

mg/ml in 2-,

6-, and 40-ml

vials

Solution for

injection (pre-

mixed): 50

mg/50 ml in

0.45% sodium

chloride

Syrup: 15

mg/ml

Tablets: 150

mg, 300 mg

Tablets

Hypersensitivity to

drug or its

components

• Alcohol

intolerance (with

some oral

products)

• History of acute

porphyria.

Cardiac

arrythmias,

bradycardia,

headache,

somnolence,

fatigue, dizziness,

hallucinations,

depression,

insomnia,

alopecia, rash,

erythema

multiforme,

nausea and

vomiting,

abdominal

discomfort,

diarrhea,

constipation,

pancreatitis,

agranulocytosis,

-Monitor ASL,

ALT and serum

creatinine when

used to prevent

stress-related

GI tract

bleeding.

-Evaluate

results of

laboratory tests,

therapeutic

effectiveness

and adverse

reactions

(bradycardia,

PVC’s,

tachycardia,

CNS changes,

rash,

59

patients at

risk of

developing

acid

aspiration

during

general

anesthesia

prophylaxis

of mendelson

syndrome.

.

(effervescent):

150 mg

autoimmune

hemolytic or

aplastic anemia,

thrombocytopeni

a

granulocytopenia,

cholestatic or

hepatocellular

effects,

hypersensitivity

reactions.

gynecomasticia,

GI disturbance

and hepatic

failure.)

- Assess

knowledge and

teach patient

appropriate use,

possible side

effects or

appropriate

interventions

and adverse

symptoms to

report.

Started: February 3, 2009

Standing Order : 50 mg IV q8

60

Name of Drug

Action Indication Route and Dosage

Availability Contraindications Adverse Effects

Nursing Indications

61

Keterolac

(tromethamine)

Possesses anti-

inflammatory,

analgesics and

antipyretic

effects

Management

of severe,

acute pain in

adults that

requires

analgesia and

the opiate

level, usually

in a

postoperative

setting

Standing

Order: 30 mg

IV q6

Tablets: Each

white, round,

film-coated

tablet, with one

side printed in

black ink with

KET10 on one

side, contains:

ketorolac

tromethamine

10 mg.

Nonmedicinal

ingredients:

hydroxypropyl-

methylcellulose,

lactose,

magnesium

stearate,

microcrystalline

cellulose,

-Hypersensitivity

to the drug or

allergic symptoms

to aspirin or other

NSAID’s.

-Active peptic

ulcer , recent GI

bleeding or

perforation, history

of peptic ulcer or

GI beeding.

-Advanced renal

impairement

-High risk of

bleeding.

Systemic

use:

headache,

dizziness,

drowsiness,

diarrhea,

nausea,

dyspepsia/

indigestion,

epigastric/

GI pain and

edema,

Purpura,

asthma,

abnormal

visio,

abnormal

liver

function.

-Use as part

of a regular

analgesic

schedule

rather than on

as needed

basis.

-If pain

returns within

3-5 hours, the

next dose can

be increased

by up to 50 %

-Do not mix

IV/IM

ketorolac in a

small volume

with morpine

sulfate,

62

polyethylene

glycol and

titanium

dioxide. Bottles

of 100 and 500.

Store at room

temperature

with protection

from light.

Parenteral:

10 mg/mL:

Each mL of

clear, slightly

yellow, sterile

solution

contains:

ketorolac

tromethamine

10 mg.

Nonmedicinal

. meperinide

HCL,

promethazine

HCL, or

hydroxyzine

HCL, will

precipitate

from solution.

-the IV bolus

must be given

over no less

than 15 sec.

give IM

slowly and

deeply into

the muscle.

63

ingredients:

alcohol 10%

w/v and sodium

chloride in

sterile water.

The pH is

adjusted with

sodium

hydroxide or

hydrochloric

acid. Ampuls of

1 mL, trays of

5. Store at room

temperature

with protection

from light.

30 mg/mL:

Each mL of

clear, slightly

yellow, sterile

64

solution

contains:

ketorolac

tromethamine

30 mg.

Nonmedicinal

ingredients:

alcohol 10%

w/v and sodium

chloride in

sterile water.

The pH is

adjusted with

sodium

hydroxide or

hydrochloric

acid. Ampuls of

1 mL, trays of

5. Store at room

temperature

with protection

65

from light.

Started: Feb 3, 2009

Discontinued: Feb 4, 2009

Standing Order: 30 mg IV q6

66

VIII NCP

67

PRE-OPERATIVE NURSING CARE PLAN

Assessment Diagnosis Planning Nursing Interventions

Rationale Evaluation

Subjective:

“ Masakit ang ulo

ko at mainit ang

pakiramdam ko” as

verbalized by the

patient.

Objective:

> Increased in body

surface temperature

above normal range

of 36.5-37.4 C

(37.7 C)

>warm to touch

>Flushed skin

Hyperthermia

related to

inflammatory

response as

evidenced by

increased body

temperature ( 37. 7

C)

Rationale:

Fever is caused by

secretion of cytokines

by cells that appear in

the inflammatory

reaction (e.g.

macrophages). Two

common cytokines

are interleukin-1 (Il-1)

Short term

Planning:

Within one hour of

nursing

interventions the

patient will reduce

the body

temperature from

37.6 C to 37. 4 C

Diagnostic

Underlying cause of

excessive heat

production

Identified

Surface

Temperature

Monitored

Therapeutic

Surface cooling by

means of doing

TSB, heat loss by

evaporation and

conduction

>To assess

causative or

contributing factors

>To evaluate effects

or degree of

hyperthermia

>To reduce heat

Within one hour of

nursing

interventions the

patient’s body

temperature of 37.7

C reduced to 37. 4C

>Goal is met

68

and tumor necrosis

factor (TNF). Given

that these factors

cause fever and are

produced by

inflammatory cells, it

follows that a large

number of cells

produce large

amounts of cytokines

resulting in higher

fever. There is, then, a

direct relationship

between the severity

of the inflammatory

response and fever.

Promoted.

Educative

Instructed to

Maintain bed rest.

Advised to increase

Fluid intake.

.

>This will help in

reducing metabolic

demands and

oxygen

Consumption.

>Increase in oral

fluids will prevent

dehydration.

69

Assessment Nursing

Diagnosis

Goal Nursing

Interventions

Rationale Evaluation

Subjective:

“Natatakot ako sa

gagawing

operasyon sa akin”

as verbalized by the

patient.

Objective:

> poor eye contact

>Extraneous

movement (rocking

movements)

>Restlessness

Anxiety related to

impending surgery

as evidenced by

restlessness

Rationale:

Disturbed behavior

is due to

apprehension of the

outcome of the

surgery and

imagined threat to

one’s health.

Short term

Planning

After 8 hours of

rendering nursing

care and

interventions the

client will be able

to Verbalize

awareness of

feelings of anxiety.

Long Term

Planning

The patient will

appear relax and

will reduce anxiety

Diagnostic:

Vital Signs

Monitored

Therapeutic

Established a

therapeutic

relationship to the

client.

To identify physical

responses

associated with

both medical and

emotional

conditions.

To gain client’s

trust.

After 8 hours of

rendering nursing

care and

interventions the

client was able to

verbalize awareness

of feelings of

anxiety.

Goal is met

70

>Difficulty of

concentrating

>Confusion

V/S:

BP: 110/80 mmHg

RR: 24 bpm

PR: 110 cpm

Temp: 37.7 C

to a manageable

level. Encouraged the client

for participation in

relaxation exercise

(Deep breathing

exercise, progressive

muscle

relaxation,meditation)

and provide comfort

measures.g

environmental

factors).

Educative:

Encourage client to

acknowledge and to

express feelings

about the procedure/

operation that will be

done.

These are effective

non-chemical ways

to reduce anxiety

and client’s ability

to deal with

excessive stimuli is

impaired.

To determine her

feelings towards the

procedure or

conditions

71

Encourage client to

have an exercise/

activity program such

as reading books

To divert patients

attention and reduce

level of anxiety

about the surgery

POST-OPERATIVE NURSING CARE PLAN

72

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:”Masakit ang tahi

ko”as verbalized by

the client

Objective:>Facial Grimace

>Guarding behavior

>Cannot ambulate

>Pain score of 6

>Incision site in the

abdomen (7 inches)

is erythematous.

Acute pain related

to tissue injury

secondary to

surgical intervention

as evidenced by

report of 6 pain

scale.

Rationale:Acute Pain is

common to the

client who

undergone

surgery procedure

because there is a

break in the skin.

Short Term GoalAfter 1 hour of

Nursing Care, client

will be able to

verbalize reduction

of pain from 6 to 4.

and will be able to

ambulate

Long Term Goal:The Client will be

able to demonstrate

nonpharmacological

technique for

relaxation.

Diagnostic:Duration, frequency,

intensity

and precipitating

factors Assessed.

Therapeutic:

The Client

positioned to Semi-

Fowler’s and Deep

breathing exercise

Instructed with a

pillow to support the

inscision wound

Educative:

>This is a base to

plan the intervention

>DBE can make the

client feel relaxed; it

helps in coping up

with pain. In semi-

fowlers position

pressure in the

abdomen is reduced.

After 8 hours of

Nursing Care, the

client verbalized

reduction of pain

from 6 to 4. and

able to ambulate

Goal is Met

73

Advised the client to

apply

nonpharmacological

technique such as

relaxation technique

before,during and

after pain occur

> It helps to reduce

pain by increasing

the release of

endorphins

74

IX Discharge Plan

MEDICATION:

The Patient and the relatives are provided information about the time of

medication to be taken as ordered by her doctor.

ENVIRONMENT

Provide information to patient and significant others that the environment must be

clean and use clean materials because the surrounding may contribute to the client of risk

of infection.

EXERCISE:

Instruct the client to do leg exercise to promote blood circulation,Moderate

exercise in the morning within the patient’s limit and with rest.Inform client that the

normal activity can be resumed after 3-4 weeks.

HEALTH TEACHING:

Instruct the patient and significant others of proper way to clean the incision

wound,from incision site to the surrounding area of wound with cottons and betadine

or alcohol,one cotton each stroke and use sterile dressings.Inform client that the

Semi-fowler’s position may help to reduce tension to the incision site

Inform client and Instruct Deep Breathing Exercise and that she may use a pillow

to support abdomen because Deep Breathing Exercise promotes heeling.

DIET

Inform the patient to increased her intake of water a day(8-12glasses) and intake

of fiber must be increased too to treat her constipation.

OUT-PATIENT FOLLOW-UP:

Inform patient to make an appointment to have the surgeon remove the sutures

between 5th and 4th days.

SPIRITUAL

The Patient and the significant others are advised to have a deep Faith to Devine

God for Guidance.

75

X Bibliography

1. Brunner and Suddarth's Textbook of Medical-Surgical Nursing

i. by Suzanne C. Smeltzer and Brenda G. Brade

2. Fundamentals of Nursing by Kozier

3. Nurses’s Drug Handbook by George R. Spratto and Adrienne L. Woods

4. Essentials of Human Anatomy And Physiology by Elaine N. Marieb

5. Blackwell’s Nursing Dictionary

6. Nurse’s Pocket Guide by Marilyn E. Doenges

7. Pathophysiology by Thomas J. Nowak

8. (http://www.radiology.rsnajnls.org

)http://radiology.rsnajnls.org/cgi/content-nw/full/215/2/337/

9. http://www.aafp.org/afp/991101ap/2027.html

10. www.medicinenet.com

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