Bulacan State University College of Nursing City of Malolos, Bulacan

A Case Presentation of an 11- year old client with Acute Appendicitis

Submitted by: Reyes, Jenefer L. Reyes, Phoebegail Shayne E. Roque, Sarah Mae V. Sacdalan, Hazel Joy C. Salvador, Mary Grace S.D. Santos, Danpaul H. Taganas, Mary Lyann M. Tamayo, Camille F. Tan, Elaine Joy D. Usi,George Anthony P. BSN III-B, Group 4 Submitted to: 3nd level Clinical Instructors

I.Introduction

Patient CMG is 11 year old who was admitted at the surgery Department last August 20, 2012 due to severe pain at her right lower quadrant, the patient was diagnosed with acute appendicitis and underwent appendectomy last August 22, 2012. Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to peritonitis and shock. Appendectomy, removal of the appendix, is the standard treatment for acute appendicitis, it is important to immediately remove the appendix after the diagnoses to prevent the occurrence of the life-threatening complication of appendix. The most frequent complication of appendicitis is perforation. Perforation of the appendix can lead to 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 appediceal perforation is delay in diagnosis and treatment is 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.

Objective General Objective To be able to acquire knowledge and skills on how to deal with patient who has diagnosis of acute appendicitis

Specific Objectives Client based: To obtain necessary information regarding the patient and her condition To assess the patients overall health status To identify patient health care needs through analysis of all the data gathered. To assist the patient throughout rehabilitation, recovery and discharge To impart necessary health teachings to the patient To perform appropriate nursing care in conjunction w/ the condition of the patient

Student based: To widen and enhance the student nurses knowledge and skills through additional research about the nature of the disease, its pathophysio logy and treatment. To discuss and interpret the diagnostic results and compared to the normal values and relate them to the disease process.

II. Nursing Assessment A. Personal History Demographic Data of the Patient Name: CMG Age: 11 years old Gender: Female Address: Lawa, Meycauyan, Bulacan Birthday: May 15, 2001 Religion: Roman Catholic Nationality: Filipino Dialect Spoken: Tagalog Attending Physician: Dra. Maria Glenda D. Zilmar Surgeon: Dr. Teoxon Assistant surgeon: Dr. Lustre Date and time of admission: August 20, 2012 at 4:24 pm Date of surgery: August 22, 2012

B. CHIEF COMPLAINT Pain at the right lower quadrant C. History of Present Illness She was admitted in the hospital last August 20, 2012 at 4:24 pm at Bulacan Medical Center due to pain at the right lower quadrant. D. HISTORY OF THE PAST ILLNESS According to the clients mother, the client was hospitalized for 10 days when she was 5 years old because of Kawasaki disease. E. Family Health History Her mother has a history of UTI (Urinary Tract Infection), her grandmother has diabetes and her grandfather died because of heart attack or cardiac arrest.

Genogram RM PM AG VG

68

70

71

67

MM 47

AG 42

FG 40

RL

DG

SG
45 4O

NG
38

47

CMG

11

LEGEND: Female Patient Male

Deceased

Cardiac Arrest

Diabetes

F. Functional Health Pattern Health Perception/Health Management Pattern PRIOR When the client was asked to describe her previous health the client verbalized, DURING When I asked the client what she feels during the interview, she verbalized

Okay lang naman po yung health ko dati, pero nung sumakit yung tyan ko, minsan Nanghihina pa po ako pero po tinutulungan ako ni lola at hindi naman po nagsuka ko saka nilagnat din. She experienced colds thrice last year. She eats fruits ako nilalagnat ngayon.about her surgical incision hygiene, the client everyday to make her strong and healthy. She takes her vitamins every day. verbalized Yung nurse ang nag-linis ng sugat ko, tinitignan nga ni lola kasi Madalas nga siya kumain ng mga junkfood kaya nung sumakit na yung tiyan nya hindi din nga alam kung paano linisin pag nasa bahay na kami. saka lang namin nalaman na may sakit na siya, as verbalized by her grandmother.

Nutritional and Metabolic Pattern PRIOR DURING When it comes to her daily food intake, the client verbalized, Halos po lahat naman She doesnt eat any food since she was admitted to the hospital and after the kinakain ko. When we ask her to rank her appetite with 10 as the highest score, she surgery she took general liquid diet. The client has poor appetite as verbalized answered 10. According to our client she has vegetable in her daily meal. According by her grandmother, Medyo wala siyang gana kumain. to our client, sometimes she eats junk foods and soft drinks as her snacks. Her (We dont have the chance to weight the patient because of the decrease wound heals well and doesnt have dental problems and eating discomfort. mobility of the patient.)

Frequency Meat Fish Frozen food 2-3 times a week 4 times a week 6-7 times a week

Elimination Pattern PRIOR Output Urine Stool Frequency Amount Characteristics ( per day) 5-6 500mL Light yellow irregular ----Brownish in without blood color; Output Urine Stool Frequency 3 ----DURING Amount 500mL ----Characteristics Light yellow color -----

Hindi naman ako hirap sa pag ihi at pagtae dati, pero nung nagsimula na sumakit She experience difficulties upon urination because she felt the pain in her tyan ko, nahirapan na ako. as verbalized by the client. She doesnt perspire lower abdomen and she hasnt been defecating since after the surgery. Her excessively and she doesnt have odor problems. Sleep-Rest Pattern PRIOR The client verbalized mga 9 hours ako nakakatulog sa gabi, matutulog ako ng 8 ng DURING During hospitalization, she has no definite time of sleeping. Minsan, mother changes her diaper 3 times a day.

gabi tapos gigising ako ng 5 ng umaga. She has no problem in sleeping. She takes a paidlip idlip lang po ng mga 30mins, as verbalized by the client. nap every afternoon and watching T.V is her form of leisure and relaxation.

Activity Exercise Pattern PRIOR The patient does some of the household chores. It also serves as her exercise. Her leisure time would include watching television, computer gaming and sleeping. DURING Hindi ko po kayang umupo at tumayo, lalo na kung ako lang magisa, as verbalized by the client. The client experience 7 out of 10 pain scales.

_0_feeding _0_bathing _0_toileting _0_cooking _0_shopping

_0_dressing _0_grooming _0_bed mobility _0_home

_0_feeding _II_bathing _II_toileting _II_bed mobility _II_general mobility

_II_dressing _II_ grooming

_0_general mobility maintenance

Level 0- full self-care Level I- requires use of equipment/device Level II- requires assistance or supervision from another person

Level 0- full self-care Level I- requires use of equipment/device Level II- requires assistance or supervision from another person

Sexuality-Reproductive Pattern PRIOR The client is only 11 years old and doesnt have menstruation yet. DURING The client is only 11 years old and doesnt have menstruation yet.

Cognitive Pattern PRIOR DURING

According to our client she doesnt have vision and hearing problems. Madali While doing the interview, we observed that our client has a little problem in naman po ako makasaulo lalo na po sa school, as verbalized by the client. hearing because sometimes we need to repeat the question to her but she can still understand and answer appropriately.

Self-Perception-Self-Concept Pattern DURING PRIOR Ok lang naman po ako bago ako magkasakit, as verbalized by the client when she According to her she thinks she lost some weight. Masakit po dito sa baba, described herself prior to hospitalization. She was able to get along with her sibling hindi pa rin po kasi masyadong magaling ang sugat ko at saka masakit siya, and attend her class to school. as verbalized by the client while pointing at the right lower quadrant of her abdomen.

Role-Relationship Pattern PRIOR problem to her grandmother. She is a choir member in their church. She didnt feel being outcast with the other family member and in their barangay. Palakaibigan siya at malalahanin sa akin. as verbalized by her grandmother as we asked how is CMG as a grandchild. DURING

The patient is living with her grandmother. According to her, she always tells her Her grandmother is the one who takes care of her during her hospitalization.

Coping Stress Tolerance Pattern PRIOR DURING

According to our client whenever she is stressed, she watch movies, plays computer During hospitalization, the most stressful situation for her is her illness and games and sleep as well. the pain she feels.

Value-Belief Pattern PRIOR DURING

According to the client, her family is the most important people to her because it During hospitalization as verbalized by the client, Ang lola ko po ang naggives her strength and makes her happy. She always attends the mass once a week to papalakas sa akin ngayon. She is always praying to improve her health. increase her faith with God.

III. A. Growth and Development THEORY STAGE PSYCHOSOCIAL Industry vs. Inferiority (Erik Erikson) COGNITIVE Concrete Operation (Jean Piaget) PSYCHOSEXUAL Latency Stage (Sigmund Freud) MORAL Conventional Morality (Social Conformity Orientation) (Lawrence Kohlberg) DEFINITION Children need to cope with new social and academic demands. Success leads to a sense of competence, while failure During the concrete When the child represses sexual thoughts and engages in non-sexual activities, such as operations developing social and By adolescence, most individuals have

operation stage, children can perform a number of logicalmental operations. These mental

developed to this stage. There is a sense of what "good boys" and "nice girls" do and the

results in feelings of inferiority.

intellectual skills.

include the ability to classify objects according to some dimensions, such as height or length, and the ability to figure between out relationships such as

emphasis is on living up to social expectations

and norms because of how they impact day-today relationships.

objects

larger or smaller.

B. Theoretical Application THEORY Florence 1910) APPLICATION OF NURSING PRACTICE IN THEORIST Nightingale (1820

DESCRIPTION
Major Concepts and Definitions Environment - concepts of ventilation, warmth, light, diet, cleanliness and noise. She focus o the physical aspect of environment. She believed that "Healthy surroundings were necessary for proper nursing care." 5 essential components of healthy environment: 1. pure air 2. pure water 3. efficient drainage 4. cleanliness 5. Light

THE CARE OF CLIENT

Providing a non stimulating environment is essential especially for our patient in a way that it promotes faster recovery on her through minimizing external and stressful stimuli such as providing proper ventilation and clean environment. It is not only for promoting fast recovery but also a preventive for possible complications such as infection.

Nightingale's Environmental Theory

Twenty one nursing Faye Glenn Abdellah problem

Nursing is broadly grouped into 21 problem areas to guide care and promote the use of nursing judgement.

We must know the 21 nursing problem to provide a rationale for collecting reliable and valid data about the health status of clients, which are essential for effective decision making and implementation. We should

facilitate

the

maintenance of a supply of oxygen to all body cells, nutrition of all body cells, fluid and electrolyte balance, elimination, maintain good body mechanics and prevent and correct deformities, good hygiene and physical comfort, promote optimal activity: exercise, rest and sleep and to facilitate the maintenance of regulatory mechanisms and functions.

Maslow's hierarchy of Abraham needs 1970)

H.

Maslow

(1908-

Maslow's hierarchy explains human behavior in terms of basic requirements for survival and growth. These requirements, or needs, are arranged according to their importance for survival and their power to motivate the individual. The most basic physical

Maslow theory provides a guide lines in the prioritization of patient care needs in our case study. .

requirements, such as food, water, or oxygen, constitute the lowest level of the need hierarchy. These needs must be satisfied before other, higher needs become important to individuals. Needs at the higher levels of the hierarchy are less oriented towards physical survival and more toward psychological wellbeing and growth. These needs have less power to motivate persons, and they are more influenced by formal education and life experiences. The resulting hierarchy of needs is often depicted as a pyramid, with physical survival needs located at the base of the pyramid and needs for self-actualization

located at the top.

IV. ANATOMY AND PHYSIOLOGY of DIGESTIVE SYSTEM The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to excrete waste. Most of the digestive organs (like the stomach and intestines) are tube-like and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals. The Digestive Process: The start of the process - the mouth: The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches into smaller molecules).

On the way to the stomach: the esophagus: After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wavelike muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're upside-down.

In the stomach The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme.

In the small intestine After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food.

In the large intestine After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in the digestion process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon.

The end of the process Solid waste is then stored in the rectum until it is excreted via the anus.

Parts of digestive system and its functions

digestive system - (also called the gastrointestinal tract or GI tract) the system of the body that processes food and gets rid of waste. abdomen - the part of the body that contains the digestive organs. In human beings, this is between the diaphragm and the pelvis

alimentary canal - the passage through which food passes, including the mouth, esophagus, stomach, intestines, and anus. anus - the opening at the end of the digestive system from which feces (waste) exits the body. appendix - a small sac located on the cecum. ascending colon - the part of the large intestine that run upwards; it is located after the cecum. cecum - the first part of the large intestine; the appendix is connected to the cecum. descending colon - the part of the large intestine that run downwards after the transverse colon and before the sigmoid colon. duodenum - the first part of the small intestine; it is C-shaped and runs from the stomach to the jejunum. epiglottis - the flap at the back of the tongue that keeps chewed food from going down the windpipe to the lungs. When you swallow, the epiglottis automatically closes. When you breathe, the epiglottis opens so that air can go in and out of the windpipe. esophagus - the long tube between the mouth and the stomach. It uses rhythmic muscle movements (called peristalsis) to force food from the throat into the stomach. gall bladder - a small, sac-like organ located by the duodenum. It stores and releases bile (a digestive chemical which is produced in the liver) into the small intestine. gastrointestinal tract - (also called the GI tract or digestive system) the system of the body that processes food and gets rid of waste. ileum - the last part of the small intestine before the large intestine begins. intestines - the part of the alimentary canal located between the stomach and the anus. jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum and the ileum. liver - a large organ located above and in front of the stomach. It filters toxins from the blood, and makes bile (which breaks down fats) and some blood proteins. mouth - the first part of the digestive system, where food enters the body. Chewing and salivary enzymes in the mouth are the beginning of the digestive process (breaking down the food). pancreas - an enzyme-producing gland located below the stomach and above the intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats and proteins in the small intestine.\

rectum - the lower part of the large intestine, where feces are stored before they are excreted. salivary glands - glands located in the mouth that produce saliva. Saliva contains enzymes that break down carbohydrates (starch) into smaller molecules. sigmoid colon - the part of the large intestine between the descending colon and the rectum. stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical and mechanical digestion takes place in the stomach. When food enters the stomach, it is churned in a bath of acids and enzymes. transverse colon - the part of the large intestine that runs horizontally across the abdomen peristalsis - rhythmic muscle movements that force food in the esophagus from the throat into the stomach. Peristalsis is involuntary - you cannot control it. It is also what allows you to eat and drink while upside-down. bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and secreted into the small intestine. chyme - food in the stomach that is partly digested and mixed with stomach acids. Chyme goes on to the small intestine for further digestion.

THE PATIENT AND HER ILLNESS A. PATHOPHYSIOLOGY 1. Schematic Diagram Risk Factors (Non modifiable) Age Low fiber diet and Episodes of constipation Risk Factors (modifiable) Diet Daily lifestyle Low fiber diet

Occlusion of Appendix by Fecalith

Decreased flow/drainage of mucosal secretions Increased ILP in the appendix

Vasocongestion

Decreased blood supply in the appendix

Decreased O2 supply in the appendix

Appendix starts to be necrotic; Bacteria invade the appendix Appendix starts to be necrotic; Bacteria invade the appendix Disruption of Cell Membrane of Appendix Appendix starts to be necrotic; Bacteria invade the appendix

Start of Inflammatory Process

Release of Chemical Neutrophils to area Mediators Leukotrienes, Bradykinin Histamine, Prostaglandin Pus Formation phagocytized bacteria and dead cells

Neutrophils to area Activation of the Vomiting

Swelling of Appendix

Stimulation of Vagus Nerve

Suppression of sympathetic GI functions

Prostaglandin, Bradykinin

Nausea and Vomiting Anorexia

Risk for Infection (if appendix ruptures)

Pain in the RLQ of Abdomen

Risk for Deficient fluid volume

of Risk for Imbalanced Nutrition

Acute Pain Inflammation of Appendix (Appendicitis) Interleukin-1

Increased WBC

Inflammation of Appendix (Appendicitis)

Appendectomy

Tissue trauma Nociceptors on the dermis Open wound Disruption of Cell Membrane Send impulses to CNS Impaired Tissue Integrity Risk for infection Start of Inflammatory process

Pain on surgical site

Release of Prostaglandin Bradykinin

Activity intolerance

2. Definition of the disease APPENDICITIS Appendicitis is an irritation, inflammation, and infection of the appendix (a narrow, hollow tube that branches off the large intestine). The appendix functions as a part of the immune system during the first few years of life. After this time period, the appendix stops functioning and other organs continue helping fight infection. Although the appendix does not seem to serve any purpose, it can become infected and, if untreated, can burst, causing more infection and even death. 3. Predisposing factors Ages of 10 and 30 years. Having a family history of appendicitis may Gender, especially in males, and Having cystic fibrosis also seems to put a child at higher risk. 4. Signs and symptoms The following are the most common symptoms of appendicitis. However, each individual may experience symptoms differently. Symptoms may include: > Pain in the abdomen which: o May start in the area around the belly button, and move over to the lower right-hand side of the abdomen, but may also start in the lower right-hand side of the abdomen. o Usually increases in severity as time passes. o May be worse with moving, taking deep breaths, being touched, and coughing or sneezing. o May spread throughout the abdomen if the appendix ruptures.

> Nausea and vomiting Diarrhea > Abdominal swelling > Fever and chills

> Inability to pass gas > Loss of appetite > Constipation

V. Physical Examination AREA OF ASSESSMENT General Survey Describe body built ASSESSMENT TECHNIQUES Inspection NORMAL FINDINGS ACTUAL FINDINGS REMARKS

Observe height and weight in relation to clients age Posture and gait

Inspection Observation

Describe over all hygiene and grooming in relation to the persons activities prior to the assessment. Note for body and breathe odor in relation to the persons activities prior to the assessment. Mental state Identify signs of distress Note obvious sign of health or illness Assess clients attitude Describe clients affect or mood Assess appropriateness of clients responses Describe quantity of speech (amount and pace), quality

Inspection

Arm span equals to height, crown Height and weight are to pubis equal to length from proportional. pubis to sole Proportionate, varies with lifestyle The client loss some weight due to her poor appetite. Relaxed, erect posture; Unable to assess the clients coordinated movement posture and gait due to her decrease mobility Clean, neat Hair properly done; with clean clothes

Normal

Deviation from normal Not examined

Normal

Inspection

No body odor or minor body odor relative to work or exercise; no breath odor

No body odor and no breath odor

Normal

Observation Observation

No distress noted Healthy appearance

Observation Observation Observation Observation

Cooperative, able to follow instructions Appropriate to situation Appropriate to situation Understandable, moderate pace; clear tone and inflection; exhibits

Client is bending over because of abdominal pain. Sometimes she is frowning maybe because of incisional pain. Answers in our questions are appropriate; cooperative Clients mood and affect is appropriate to situation. Answers of our client in our questions are appropriate. Speech is loud with a clear diction.

Deviation from normal Deviation from Normal

Normal Normal Normal Normal

(loudness, clarity, inflection) and organization (coherence of thought, over generalization, Listen for the relevance and organization of thoughts. Hair Inspect the evenness of growth over the scalp Inspect hair thickness or thinness Inspect hair texture and oiliness Note presence of infections or infestations Inspect amount of body hair

thought association Clients answer has sense of reality. No presence of alopecia With thick hair. Slightly dull hair because client hasnt taken a bath since admitted to hospital. No observable signs of infection or any infestations. Variable; hair is evenly distributed all over the clients body. Normocephalic and symmetric No palpable nodules, lumps and masses. Facial features are symmetric.

Observation

Logical sequence; makes sense; has sense of reality Evenly distributed hair Thick hair Silky, resilient hair

Normal

Inspection Inspection Inspection

Normal Normal Deviation from Normal

Inspection Inspection

No infection or infestation Variable

Normal Normal

Skull Inspect the skull for size, shaped and symmetry Palpate the skull for nodules or masses and depressions Face Facial features

Inspection Palpation

Rounded, smooth skull contour Smooth, uniform consistency; absence of nodules or masses Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds Symmetric facial movements

Normal Normal

Inspection

Normal

Symmetry of the facial movements

Inspection

Eyebrows elevate at the same time; eyes blink and closed at the same time

Normal

Eyebrows and eyelashes Evenness of distribution, direction of curl and movement Eyelids Surface characteristics and ability to blink Conjunctiva Inspect the bulbar conjunctiva for color, texture and the presence of lesions Inspect the palpebral conjunctiva for color, texture and the presence of lesions Sclera Color and clarity Cornea Color and clarity Iris Shape and color Pupils Color, shaped and symmetry of size Pupil light reaction and accommodation

Inspection

Evenly distributed, eyebrows symmetrically aligned; curled slightly upward

Eyebrows raise and lower at the same time; symmetrically aligned; both eyebrows curled slightly upward Eyelids skin are intact; no discharge and discoloration; eyelids blink symmetrically Bulbar conjunctiva are transparent; no presence of lesions; with evident capillaries Palpebral conjunctiva is shiny; pinkish in color

Normal

Inspection

Skin intact, no discharge, no discoloration; Lids closed symmetrically Transparent

Normal

Inspection

Normal

Inspection

Shiny, smooth and pink or red

Normal

Inspection

Sclera appears white

Sclera is white and clear Corneas surface is smooth transparent and shiny Round, black in color

Normal

Inspection

Transparent, shiny and smooth

Normal

Inspection

Round

Normal

Inspection Inspection Asking the client to look first at a distant object and then at a distant object behind the penlight

Black in color, equal in size Pupils constricts when looking at near objects; pupils dilate when looking at far object; pupil converge when near object is moved towards nose

Pupil is round black in color and equal Pupils are equally rounded.

Normal Normal

Pupils direct and consensual reaction to light

Inspection Asking the client to look straight ahead, by using the penlight and approaching from the side, shining a light on the pupil Asking the client to read the newspaper held at a distance of 36 cm Inspection

Illuminated pupil constricts (direct response) Non illuminated pupil constricts (consensual response)

Pupil constricts

Normal

Visual acuity Test near vision

Able to read newsprint 20/20 vision on Snellentype chart

No difficulty reading newsprint

Normal

Test distance vision Lacrimal gland, lacrimal sac and nasolacrimal duct Presence of edema Extraocular muscles Test each eye for alignment and coordination Visual fields Test for peripheral visual fields Ear auricle Color and symmetry of size and position

Not examined

Not examined

Inspection and palpation

No edema or tenderness

There are no presence of tenderness and edema. Both eyes are coordinated with parallel alignment Client can see object using peripheral vision Both ear auricle has the same color with the skin

Normal

Inspection

Both eyes coordinated, move in unison with parallel alignment When looking straight ahead, client can see objects in periphery Color same as facial skin, symmetrical, auricle aligned with outer canthus of the eye, about 10 from vertical. Mobile, firm, and not tender; pinna recoils after it is folded Dry cerumen, grayish-tan color; or sticky, wet cerumen in various shades of brown

Normal

Inspection noted Inspection

Normal

Normal

Texture, elasticity and areas of tenderness External ear canal Cerumen, skin lesions, pus and blood

Palpation

There are no areas of tenderness; no nodules or lump Dry cerumen; no skin lesions, pus and blood

Normal

Inspection

Normal

Hearing acuity test Clients response to normal voice tones Perform watch tick test Nose Shape, size or color and flaring or discharge from the nares Presence of redness, swelling, growths and discharge of nares, using the flashlight Position of nasal septum Test patency of both nasal spectrum Tenderness, masses and displacement of bone and cartilage Sinuses Presence of tenderness Lips Symmetry of contour, color and texture

Inspection Inspection

Normal voices tones audible Able to hear ticking in both ears

Has difficulty in hearing Not examined

Deviation from Normal Not examined

Inspection

Symmetric and straight, uniform color, no discharge or flaring Mucosa pink, clear, watery discharge, no lesions Nasal septum intact and in midline Air moves freely as the client breath through the nares No tenderness, masses and displacement of bone and cartilage Not tender Uniform pink color, soft moist, smooth texture, symmetry of contour, ability to purse lips

Inspection

Symmetric uniform in skin color; no presence of discharge or flaring. Mucosa is pinkish; no lesions

Normal

Normal

Inspection Inspection Palpation

Nasal septum in midline Client can breath freely using nasal nares. No presence of tenderness, masses and displacement of bone and cartilage Sinuses are not tender. Pinkish color of lips; symmetry in contour

Normal Normal Normal

Palpation Inspection

Normal Normal

Buccal mucosa Color, moisture, texture and the presence of lesions Teeth Inspect for color, number and condition and presence of dentures

Inspection and palpation

Moist, firm texture, glistening and elastic texture 32 adult teeth, smooth, shiny, white tooth enamel

Buccal mucosa is moist

Normal ` Normal

Inspection

No presence of dental problems

Gums Color and condition

Inspection

No presence of lesions, no retraction of gums, pink gums

No observable presence of lesions; without retracted gums; without bleeding gums Pinkish in color

Normal

Tongue /floor of the mouth Color and texture of the mouth floor and frenulum Position, color and texture, movement and base of the tongue Palates and uvula Color, shape, texture and the presence of bony prominences Position of the uvula and mobility Oropharynx and tonsils Color and texture Size of the tonsils, color and discharge Gag reflex

Inspection

Inspection

Pink color, slightly rough, thin whitish coating, smooth lateral margins, no lesions Central position, moves freely, no tenderness

Normal

Tongue is in center; can moved freely and without tenderness

Normal

Inspection

Inspection

Light pink, smooth, soft palate, lighter pink hard palate, more irregular texture Positioned in midline of soft palate Pink and smooth posterior wall Pink and smooth, no discharge, of normal size or not visible Present

Palates are pink

Normal

In midline of soft palate

Normal

Inspection Inspection Inspection

Pink posterior wall No discharge; pink and smooth; has normal size Not examined

Normal Normal Not examined

Neck and lymph nodes Symmetry and visible mass of the thyroid gland Presence of tenderness or nodules in the lymph nodes Placement of the trachea

Inspection Palpation Palpation

Gland ascends during swallowing but is not visible Not palpable Central placement in midline of neck; spaces are equal on both sides

No visible masses No nodules or tenderness In midline of neck

Normal Normal Normal

Smoothness and areas of enlargement, masses or nodules in the thyroid gland Skin Inspect for color and uniformity

Palpation Asking the client to lower the chin slightly Inspection

Lobes may not be palpable

No areas of enlargement, masses or nodules.

Normal

Inspect for the presence of edema. Inspect and palpate for skin lesions according to location, distribution, color, configuration, size, shape, type or structure. Observe and palpate skin moisture. Palpate skin temperature. Note for skin turgor of the client. Nails Inspect fingernail shape to determine its curvature and angle Inspect fingernail and toenail texture Inspect fingernail and toenail bed color

Inspection and palpation Inspection and palpation

Varies from light to deep brown, ruddy pink to light pink, yellow overtones to olive; generally uniform except in areas exposed to the sun, areas of lighter pigmentation in dark-skinned people No edema Freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions

Brown in color

Normal

No presence of edema No observable lesions, freckles and birthmarks

Normal Normal

Inspection and palpation Palpation Inspection

Moisture in the skin folds and axillae Uniform, within normal range Skin springs back to previous state; may be slower in elders

Moist skin Skin temperature is within normal range Skin turgor is good.

Normal Normal Normal

Inspection

Convex curvature, angle of nail plate about 1600 Smooth texture Highly vascular and pink in light skinned clients; dark skinned

No signs of early clubbing.

Normal

Inspection Inspection

Skin is smooth Pink in color

Normal Normal

Inspect tissues surrounding nails Perform blanch test of capillary refill Posterior Thorax Shape, symmetry, and compare the diameter of the antero posterior thorax to tranverse diameter. Spinal alignment Breathing pattern Respiratory excursion Temperature, tenderness, masses Vocal fremitus

Inspection Inspection

clients may have brown or black pigmentation in longitudinal streaks Intact epidermis Prompt return of pink or usual color Anteroposterior to transverse diameter in ratio of 1:2, chest symmetric Spine vertically aligned Proper breathing pattern Full and symmetric chest expansion Uniform temperature, no tenderness, no masses Bilateral symmetry of vocal fremitus, heard most clearly at the apex of the lungs Percussion notes resonate, except over scapula, lowest point of resonance is at the diaphragm Vesicular and bronchovesicular breath sounds Quiet, rhythmic, and effortless respirations Uniform temperature, no presence of masses and tenderness Full symmetric excursion; thumbs

No presence of lesions Skin return to its normal color

Normal Normal

Inspection

Symmetrically aligned

Normal

Observation Inspection Inspection Palpation Palpation

No observable signs of osteoporosis and kyphosis Can breathe properly Chest expands at the same time. With uniform temperature; no signs of tenderness or masses Has good vocal fremitus

Normal Normal Normal Normal Normal

Percuss the posterior thorax

Percussion

Not examined

Not examined

Auscultate the posterior thorax Anterior thorax Breathing pattern Temperature, tenderness, masses Respiratory excursion

Auscultation

Breath sounds are clear

Normal

Inspection Palpation Inspection

No problems with regards to respiration of the client. No observable presence of masses Has good respiratory excursion

Normal Normal Normal

Vocal fremitus

Inspection

Percuss the anterior thorax

Percussion

Auscultation of the trachea Auscultate the anterior thorax Abdomen Skin integrity

Auscultation Auscultation

normally separate 3 to 5 cm Same as posterior vocal fremitus; Fremitus is normally decreased over heart and breast tissue Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, tympanic over the underlying stomach Bronchial and tubular breath sounds Bronchial and vesicular breath sounds Unblemished skin, uniform color, stretch marks Flat, rounded(convex) or scaphoid (concave) Liver and spleen must not be palpated. Symmetric contour Symmetric movements caused by respiration No visible vascular pattern Audible bowel sounds, absence of bruits, absence of friction rub Tympany over the stomach and gas-filled bowels; dullness, especially over the liver and

Has good vocal fremitus

Normal

Not examined

Not examined

Breath sounds are clear Breath sounds are clear

Normal Normal Normal Deviation from Normal

Inspection

Has an incision in the RLQ

Abdominal contour Enlarges liver or spleen Symmetry of contour Abdominal movements Vascular pattern Bowel sounds, vascular sounds and peritoneal friction rubs Percuss abdominal quadrants

Inspection Palpation Inspection Inspection Inspection Auscultation

Symmetrical Without enlarge liver and spleen Symmetrical Symmetrical movements Not visible Not examined

Normal Normal Normal Normal Normal Not examined

Percussion

Not examined

Not examined

Light palpation of abdominal quadrants Musculoskeletal system Muscle size, compare the muscles on one side of the body (arm, thigh, calf) to the same muscle on the other side Muscle tonicity Muscle strength Bones Normal structure Edema or tenderness

Palpation

spleen, or a full bladder No tenderness; relaxed abdomen with smooth, consistent tension Equal on both sides of body

Felt pain during palpation

Deviation from Normal Normal Normal

Inspection

Muscle size are equal all throughout the body.

Inspection Inspection Inspection Palpation

Equal strength on each body side No deformities No tenderness or swelling

Has good muscle tonicity. Has equal muscle strength. No observable bone deformities No observable presence of tenderness or swelling

Normal Normal Normal Normal

Diagnostic Procedures TEST HEMATOLOGY DATE: Hgb Hct Neutrophils Lymphocyte Pus cells RBC Epithelial cells Amorphous urates Bacteria URINALYSIS Color Transparency Reaction Specific Gravity Sugar Protein Actual Values 8-17-12 122 g/L 0.36 % 0.81 0.19 3-5 hpf 0-2 hpf few few plenty 8-18-12 141 g/L 0.41 % 0.57 0.43 0-2 hpf 8-12 hpf rare rare rare Normal Values Analysis Interpretation Nursing Responsibility

120-151 g/L 0.36-0.41 % 0.45-0.65 17-48 None Negative Occasional / lpf None None

NORMAL NORMAL Within normal range on second test NORMAL Indication of inflammation or infection Indication of inflammation or infection Indication of inflammation or infection Amorphous urates may cause urine to appear more cloudy or hazy Indication of inflammation or infection NORMAL Purulent matter will make cloudy {infection is present ) NORMAL NORMAL NORMAL Indication of inflammation or infection

Monitor Vital Signs, intake and output. Observe standard precautions, and follow the general guidelines. Positively identify the patient, and label the appropriate tubes with the corresponding patient demographics, date, and time of collection. The specimen should be analyzed within 24 hr when stored at room temperature or within 48 hr if stored at refrigerated temperature. Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage. Promptly transport the specimen to the laboratory for processing and analysis.

yellow turbid 6.0 1.030 negative negative

yellow hazy 5.0 1.015 negative trace

Amber Clear 4.6- 8.0 1.002-1.030 Negative Negative

Instruct the patient to void directly into a clean, dry container. Sterile, disposable containers are recommended. Women should always have a cleancatch specimen if a microscopic examination is ordered. Feces, discharges, vaginal secretions and menstrual blood will contaminate the urine specimen. Cover all specimens tightly, label properly and send immediately to the laboratory. Observe standard precautions when handling urine specimens.

VI.

PATIENT AND HIS CARE

A. IVF (Intravenous Fluid Therapy) Medical Date ordered/ General Description management Date performed/ Date changed/ DC D5 0.3NaCl is a D5 O.3 NaCl Date ordered: hypertonic solution 500cc x 60 August 20, owing to the higher than ugtts/min 2012 normal amount of Na and Cl ions. It pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartments.

Indication/ Purposes

Clients Response to the Treatment

Nursing Responsibilities

To compensate cellular dehydration and corrects moderate fluid loss, prevents alkalosis, provides calorie and NaCl.

The patient could not verbalized and distinguish the possible side effects of drugs and manifestation to her condition.

Before: Verify the doctors order indicating the type of solution, the amount to be administered, the rate of flow of the infusion and any allergies. Explain the procedure and prepare the client. Prepare the equipments needed. Wash hands thoroughly. Obtain IV solution and check for the sediments and any crack or leak from the container. Check also the expiration date. Check fluid discoloration or defect. If noted, dispose the defected tubing and get another. Assess clients vital signs for baseline data, skin turgor, bleeding tendencies, disease, or injury to the extremities, status of vein to determine the appropriate puncture site.

During: Explain the importance and purpose of IVF. Place the patient in a comfortable position to facilitate easy insertion of the IV line. Use the smallest gauge needle if possible. Maintain aseptic technique throughout the procedure. Follow proper procedures in infusing IV solution. Watch out for fluid overload. Secure the needle properly after insertions. Always check the needle of the Iv, if it is in the vein: Bring the IV bottle lower than the patient arm. Pinch the IV tubing. Observe the backflow of the blood in the distal portion

B. Drugs Name of Drug Date Route of Administration dosage, frequency Oral General activities, Classification, Mechanism of actions Bind to the bacterial cell wall membrane causing cell death. Bactericidal action. Purpose/ Indication Clients response/ Side effect Nursing responsibilities

Cefuroxime

August 20, 2012

Treatment of serious life threatening infection due to susceptible organisms.

The patient could not verbalized and distinguish the possible side effects of drugs and manifestation to her condition.

ASSESSMENT: Assess the infection, (vital signs, and appearance of wood, sputum, urine, and stool, WBC at the beginning and during the therapy. Observe patient signs and symptoms of anaphylaxis (rash, pruritus, wheezing, edema) Assess the patient renal dysfunction.

IMPLEMENTATION IF it is tablets don not swallow whole not crushed, because of bitter taste.

EVALUATION Resolution of signs and symptoms of infection Decreased in the incidence of infection

Tramadol

August 20, 2012

IM

Binds to muopioid receptors and inhibits the reuptake of norepinephrine, and serotonin, that has analgesics effects, Acetaminophen blocks the activity of cyclooxygenase , an enzyme necessary for prostaglandin synthesis. And prostaglandins are important mediators of inflammatory response that causes local vasodilation, swelling and pain.

Relief of moderate to moderately severe pain.

The patient could not verbalized and distinguish the possible side effects of drugs and manifestation to her condition.

Know the 10 Rights in drug administration. Get patients history of allergy to tramadol or opioids. Inform the patrient about the side effects if sweating or CNS effects. Watch for some allergic reactions especially after receiving the medication including bronchospasm Assess the respiratory status of the client

Ketorolac

August 20, 2012

IV

Antiinflammatory and analgesic activity; inhibits prostaglandins and leukotriene synthesis

Short-term management of pain

The patient could not verbalized and distinguish the possible side effects of drugs and manifestation to her condition

Know the 10 Rights in drug administration. Do not mix with morphine, sulfate, mepiridine Instruct patient about the side effects. History: renal impairment, impaired hearing, allergies, hepatic, lactation, pregnancy Physical: skin color and lesions, orientation, reflexes, peripheral sensation, clotting times, CBC, adventitious sounds Be aware that patient may be at risk for CV events, GI bleeding, renal toxicity, monitor accordingly. Do not use during labor, delivery, or while nursing. Keep emergency equipment readily available at time of initial dose, in case of severe hypersensitivity reaction. Protect drug vials from light.

Metronidazole August 20, 2012

IV

Disrupts DNA and protein synthesis in susceptible organisms. Bactericidal, or amebicidal action

Amebicide in the management of amebic dysentery

The patient could not verbalized and distinguish the possible side effects of drugs and manifestation to her condition

Administer with food or milk to minimize GI irritation. Tablets may be crushed for patients with difficulty swallowing. Instruct patient to take medication exactly as directed evenly spaced times between dose, even if feeling better. Do not skip doses or double up on missed doses. If a dose is missed, take as soon as remembered if not almost time for next dose. May cause dizziness or light-headedness. Caution patient or other activities requiring alertness until response to medication is known. Inform patient that medication may cause an unpleasant metallic taste. Inform patient that medication may cause urine to turn dark. Advise patient to consult health care professional if no improvement in a few days or if signs and symptoms of superinfection (black furry overgrowth on tongue; loose or foul-smelling stools develop).

C. Diet TYPE DIET NPO OF DATE STATED, GENERAL DATE CHANGED DESCRIPTION August 20, 2012 INDICATIONS, PURPOSES SPECIFIC FOOD TAKEN CLIENTS RESPONSE TO THE DIET The patient complied with the prescribed diet.. She seemed to have loss of appetite with the ordered diet

Clear Diet

Liquid August 22, 2012

Soft Diet

August 23-24, 2012

Restriction of solid nor This is done to avoid paralytic liquid foods by mouth ileum that occurs from bowel handling during surgery. Made up of clear liquid It is mainly used for post operative Water foods which leave no patients. Patient with acute illness residue in the GIT. It is and infections, to relieve thirst, to non- stimulating, non gas reduce colonic fecal matter. It is forming and non- done between 1-2 feeding intervals. irritating. A diet that is soft in This is given for the patient who is Porridge and water texture, low in residue, recovering from a surgery as the easily digested, and well bowel is waking up. tolerated.

The patient still not have good appetite with the prescribed diet. , but then gradually took in the foods that were ordered by the physician.

D. Activity Exercise Type of exercise Post surgery Bed Exercises General description Starting off with basic leg pumps and lifts of the lower and upper extremities Indication/ purpose Help improve blood flow and circulation in the lower portions of your body. In addition, performing bed exercises can also help reduce the risk of blood clots forming in your lower extremities. Trying to keep additional weight off of your abdominal muscles. Stop walking as soon as you feel fatigued and do not push yourself to exercise for extended periods of time. Performing basic abdominal exercise will help return your midsection to a stronger place. Clients response to activity or exercise The clients has no response Nursing responsibilities Assess the client on how to perform the proper way of this type of exercise.

Short Walks

You should begin your postappendicitis exercise regimen with short walks. During these walks, be aware of your walking form and posture,

The clients has no response

Assess the client on how to perform the proper way of this type of exercise.

Passive Abdominal Exercise

Start by sitting down on the edge of a bed with your feet hanging off of the edge of the bed. With your back straight and core tightened, slowly lift up your legs until they are parallel with the floor. Hold this position for several seconds before slowly lowering your legs back to their original position.

The clients has no response

Assess the client on how to perform the proper way of this type of exercise.

VII.

SURGICAL MANAGEMENT INDICATION/ PURPOSES CLIENTS RESPONSE NURSING RESPONSIBILITIES

BRIEF DESCRIPTION

Appendectomy is one of the most commonly performed operations with about 7% of the population having that operation. It should be an operation where every detail has been examined in prospective clinical trials but it is not. Of an overwhelming number of scientific reports on appendicitis (more than 5500 entries in the Medline) only a few are about randomized trials. We should have firm knowledge about such things as antibiotic treatment (initiation, route and duration), wound management

The main purpose of appendectomy is to remove the infected appendix in order to protect the patients life. When appendix got infection, either it get pus or sometimes it get rupture before this condition surgeon, after diagnosing the patient and reviewing his medical reports, makes a small surgery and they will remove the appendix. The main symptom of this appendix is severe pain cause in lower abdomen

The patient was asleep after the operation. The patient was lying on bed 68 hours after the surgery. The patient had chills few hours after the operation. The patient had fever one day after the operation.

Prior: Check vital signs. Instruct the patient to be on nothing per Orem 8 hours prior to surgery Educate the patient about coughing, deep breathing exercises and turn side to side after the surgery. After: Keep the patient on NPO for 8 hours after peristalsis occurs. Keep the patient lie flat on bed without pillow for 6-8 hours. Monitor for bleeding and signs of Let the patient to voice out what she feels to decrease anxiety. Listen to the patient to what he says.

During: Promote sterility in the sterile field. Monitor the vital signs.

(incision and closure) and excision of the appendix (stump closure and drains). It seems that much of the surgical technique evolved from

traditions and later knowledge has been engaged in simplification. For example, multiple drains with or without continuous irrigation are not used for perforated

and patient feel vomiting and last symptom is fever which will continue over a period of time.

shock. Monitor of signs for signs of infection.

appendicitis any longer but it must have made sense at the time. Even the single passive drain for a periappendiceal abscess is thought inappropriate by most surgeons today. So, when speaking about evidence here it must be viewed against strong traditions that are continuously changing regardless of real scientific evidence. When such evidence is available its penetration is often slow. Further, it must be accepted that the underlying changed so conditions what have seemed

reasonable at one time is no longer appropriate. For instance, wounds

used to be infected in the range of 3050% in perforating

appendicitis. Infection is much less frequent now for reasons that patient care and surgical technique are different.

VIII. Nursing Prioritization DATE IDENTIFIED August 24, 2012 PROBLEM/NURSING JUSTIFICATION DIAGNOSIS Masakit dito sa baba, while Acute pain related to presence of According to Maslow of hierarchy of needs physiological needs pointing at RLQ of abdomen. surgical incision in RLQ must prioritize first. Acute pain is a physical health problem thus belongs to physiological stage. Absence of pain may indicate that the clients health status is getting better. Hindi pa masyado magaling Impaired Skin Integrity related ang sugat ko at saka masakit to tissue trauma manifested by siya. appendectomy incision As verbalized by the client. Yung nurse ang nag-linis ng sugat, tinitignan nga ni lola. Kasi hindi niya alam kung paano linisin pag-nasa bahay na kami. As verbalized by the client. Medyo wala siyang gana The skin is considered as the primary defense of our body. Integrity of our skin is vital to our physical and psychological health. Intact and well healing wound has low risk of getting infection; because of that impaired skin is the 2nd priority nursing diagnosis. SUBJECTIVE CUES

August 24, 2012

August 24, 2012

Risk for infection related to To prevent complication for fast recovery we consider risk for insufficient knowledge regarding infection as 3rd priority problem. proper wound care to avoid exposure to pathogens.

August 24, 2012

Impaired nutrition less than body Impaired nutrition was the 4th priority nursing problem. Because the kumain as verbalized by the requirements related to loss of patient will not be able to commence food and fluids for a few days; appetite. this is to enable the bowel to regain normal function. The pain feel mother by the client added to reduce her appetite. Hindi ko po kayang umupo at Activity intolerance associated The patient should be encouraged to get up and out of bed as soon as tumayo as verbalized by the client with the limitation of motion possible to prevent the formation of emboli. We make it 5th because secondary to pain by resolving the 1st problem it will also resolve or manage

August 24, 2012

IX.

. Nursing Care Plan DIAGNOSIS

Acute pain related to presence of surgical incision in RLQ

ASSESSMENT Subjective cues : Masakit dito sa baba, while pointing at RLQ of abdomen. Objective cues: Vital sign taken as follow: BP: 120/80mmHg RR: 20cpm PR: 105 bpm T: 36.5 C S/P Appendectomy With dry intact
dressing on surgical site. the

facial grimacing

PLANNING INTERVENTION Within 1 hour of nursing Assess pain intervention, the client will be characteristics able to manifest ability to cope including within pain as evidenced by: location, a.) verbalization of decrease intensity, and pain form 7/10 to 2/10 frequency. b.) engagement in diversion Assess surgical of activities such as, site for swelling, watching TV, and redness or loose listening mellow music sutures. c.) \Verbalize method that provide pain reliving Taking pain \ relieve medicines \ Avoiding movement that Promote provide pressure adequate rest in the abdomen periods by \provided splinting temporarily limiting activity Encourage client to verbalize pain perception.

RATIONALE Elevation in intensity and frequency may indicate worsening condition. Swelling, redness , and loose sutures may contribute to the pain felt by client and are indicative of further management To lessen pain felt.

EVALUATION Within 1 hour of nursing intervention, the client will be able to manifest ability to cope within completely relieved pain as evidenced by a.) verbalization of decrease pain form 5/10 to 2/10 b.) engagement in diversional activities such as watching TV, and listening mellow music c.) Verbalize method that provide pain reliving Taking pain relieve medicines Avoiding movement that provide pressure in the abdomen \provided splinting

To allow continuous monitoring and assessment of clients condition.

Provide client with diversional activities such as socialization, watching TV, and listening mellow music. Encourage SOs to continue provision of diversional activities and a quiet environment. Administer analgesics as indicated.

To help client divert his attention to other matters than pain felt.

Refocuses attention, promotes relaxation, and may enhance coping abilities. Relief of pain facilitates cooperation with other therapeutic interventions, e.g., ambulation, pulmonary toilet

Nursing Care Plan

ASSESSMENT Subjective cues : Hindi pa masyado magaling ang sugat ko at masakit pa As verbalized by the client. Objective cues : S/P: Appendectomy With surgical incision at right lower abdominal area With dry intact dressing on the surgical site DIAGNOSIS Impaired Skin Integrity related to tissue trauma manifested by appendectomy incision PLANNING INTERVENTION After 30 minutes of Assess operative site nursing intervention the for redness, swelling, patient will be able to loose sutures, or gain knowledge on how soaked dressing. to improve skin integrity in ways such as: Encourage the client a) \keeping the on keeping the incision area incision clean clean. Discuss with the b) \maintain optimal client proper wound nutrition that healing such as deals in proper Food rich in wound healing. vit. E \ c) Exercises to Food rich in provide good protein. blood circulation. Assist in passive movements (while 7hrs. flat on bed) such as bed turning and passive ROM exercise and active exercise there after movements such as bed position, sitting, standing, and walking. RATIONALE To check skin integrity, monitor progress of healing and identify need for further To prevent infection. EVALUATION After 30 minutes of nursing intervention the patient is able to gain knowledge on how to improve skin integrity in ways such as: d) \keeping the incision area clean. e) \maintain optimal nutrition that deals in proper wound healing. f) Exercises to provide good blood circulation.

For fast recovery

To promote circulation to the surgical site for timely healing. For early ambulation also

 Support incision as in splinting when coughing and during movement. Encourage pt to verbalize his for any untoward feelings especially pain, discomfort as well as changes noted on operative site. Instruct pt and SOs to immediately report when dressing are soaked.

To reduce pressure on the operative site.

To allow continuous monitoring and assessment of pt. Condition.

. \ For immediate replacement to prevent skin break down and contamination of operative site. prevent or Instruct pt and SOs to To reduced the risk of refrain from cross contamination touching/scratching operative site.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective cues: Yung nurse ang nag-linis ng sugat, tinitignan nga ni lola. Kasi hindi niya alam kung paano linisin pagnasa bahay na kami. As verbalized by the client. \ Objective cues: Vital sign taken as follow: BP: 120/80mmHg RR: 20cpm PR: 105 bpm T: 36.5 C S/P Appendectomy With dry intact dressing on the surgical site

Risk for infection related to insufficient knowledge regarding proper wound care to avoid exposure to pathogens.

After 1 hour of nursing intervention the significant others will be able to: a) Provide the client proper wound care at home. b) Determine signs that indicate infection and complication.

After 1 hour of nursing Demonstrate and enumerate intervention the significant to the significant other the others will be able to: proper ways of wound care a.) Provide the client such as proper wound care Assess operative site for Identify need for further at home. management. signs of infection. b.) Determine signs To prevent unnecessary that indicate Provide regular dressing exposure and infection and care. contamination of complication. operative site which may delay wound healing. To prevent bacteria harbor in operative site. Instruct pt and SOs to refrain from to allow continuous touching/scratching monitoring and operative site. assessment of pt. Encourage pt to condition verbalized any changes noted on operative site such as redness, swelling and unusual/odorous drainage. A first-liner defense Stress proper hand washing techniques by against nosocomial

all caregivers between therapies/ clients. Clean the incisions site daily with povidoneiodine or other appropriate solution. Instruct client/ SO(s) in techniques to protect the integrity of the skin, care for lesions, and prevention of spread of
infection.

infection/crosscontamination. To prevent contamination.

To promote wellness

X.

Discharge Planning

Medication Advice the patient to continue the prescribed medication to obtain her total recovery such as antibiotics and analgesics. Exercise Within 12 hours of surgery the client may get up and move around. The client can usually return to normal activities in 2-3 weeks after laparoscopic surgery Environment Provide client a well-ventilated and relaxing environment to provide comfortable environment while recovering. Treatment Pretreatment of foods with lactase preparations (e.g. lactacid drops) before ingestion can reduce symptoms. Ingestion of lactase enzyme tablets with the first bite of food can reduce symptoms. Health Teaching To care wound perform dressing changes and irrigations as prescribe avoid taking laxative or applying heat to abdomen when abdominal pain of unknown cause is experienced. Reinforce need for follow-up appointment with the surgeon. Call your physician for increased pain at the incision site Out Patient Document bowel sounds and the passing of flatus or bowel movements (these are signs of the return of peristalsis) Watch for surgical complications such as continuing pain or fever, which indicate an abscess or wound dehiscence .Stitches removed between fifth and seventh day (usually in physicians office) Diet Liquid or soft diet until the infection subsides. Soft diet is low in fiber and easily breaks down in the gastrointestinal tract

XI.

Conclusion

In this study, the clinical and nursing procedures performed at the Bulacan Medical Center on August 24 ,2012 were described in detail. Case studies were also presented to exemplify these procedures and see how every case is unique in this way, appendicitis and appendectomy were fully explored by using methods of participant observation, informal interviews, research of the nature of disease and other information about the patient health condition. Although, this is a thorough examination of appendectomy and appendicitis, this study could not possibly capture our experiences in the surgical ward. The most significant lesson we learned throughout the study was the ambiguity of diagnosis and nursing care. The results of our study with interpretations made with secondary sources reveals that a better and assessment action in the hospital.

Can take to better diagnosis of appendicitis patients, construct an effective procedure for assessment, diagnosis, and nursing intervention, and health teaching before and after the surgery, however these things may aid in improving the rate of negative appendectomies and improving post surgical care. This only leaves one very important lesson nurses and patients must realize, that each case must be taken as its own. An assembly line approach to diagnosing and treating appendicitis is not the solution: no appendicitis presents itself in the same way.

Bibliography:
Books: Internet: www.medicinenet.com/appendicitis/article.htm digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/ http://nurseslabs.com/4-appendectomy-nursing-care-plans/ Sparks and Taylors Nursing Diagnosis, Reference Manual 6th edition, 2005 Tomey,Ann Marriner ,Nursing Theorists and their Work: 6th Edition, 2002 Kozier & Erbs, Fundamentals of Nursing., 8th edition. Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 10th Edition