INTRODUCTION:

Appendicitis means inflammation of the vermiform 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 periappendical abscess).

The appendix--like the tiny structures called Peyer's patches in other areas of the gastrointestinal tract--takes up antigens from the contents of the intestines and reacts to these contents. This local immune system plays a vital role in the physiological immune response and in the control of food, drug, microbial or viral antigens.

The connection between these local immune reactions and inflammatory bowel diseases, as well as autoimmune reactions in which the individual's own tissues are attacked by the immune system, is currently under investigation.

INFECTED ORGAN /
INFLAMED APPENDIX

INFECTED ORGAN

PATHOPHYSIOLO GY:
Non-modifiable
Age: 10-30 Gender: male and female but more often in male Age : 10-30 years old

Modifiable
Diet: People whose diet is low in fiber and rich in refined carbohydrates Infections: Gastrointestinal infections such as Amoebiasis, Bacterial Gastroenteritis

Occlusion of appendix by fecalith

Decreased flow/drainage of mucosal secretions vasoncongestion Decreased blood supply in the appendix Decreased O2 supply in the appendix Appendix starts to be necrotic: bacteria invade the appendix

Disruption of cell membrane of appendix

Start of Inflammatory Process

Release of Chemical Mediators Activation of the Vomiting center in the medulla Histamine, Prostaglandin, Leukotrienes, Bradykinin
Suppression of Sympathetic GI function

Neutrophils to area

Pus Formation (phagocytized bacteria and dead cells)

Swelling of Appendix
Prostaglandin, Bradykinin

Anorexia

Pain in the RLQ of Abdomen

Acute pain

Risk for Imbalanced Nutrition less than body requirements

Risk for infection (if appendix ruptures)

Inflammation of Appendix

Appendectomy Open wound

Tissue Trauma

Noriceptors of the Dermis

Send Impulse to CNS

Disruption of Cell Membrane

Start of Inflammatory Process

Pain on Surgical Site

Release of Prostaglandin/ Bradykinin

Activity Intolerance

ETIOLOGY
Racial & Dietary Factors:

Young males are affected more often Diet rich in meat precipitates appendicitis Age : 10-30 years old

Obstruction of the lumen A) in the lumen-intestinal warm e.G. Round worm,threadworm etc vegetable,fruit seed, Feces material, barium

SIGNS AND SYMPTOMS

REBOUND TENDERNESS
felt upon the release of the pressure Indicates rebound tenderness
Pain

Guarding
1. Voluntary guarding occurs the moment the doctor s hand touches the abdomen. 2. Involuntary guarding occurs before the doctor actually makes contact.

 Pressure to the lower left side of the abdomen. Pain felt on the lower right side of the abdomen upon the release of pressure on the left side.

Rovsings sign

Psoas sign
Check for the psoas sign by applying resistance to the right knee as the patient tries to lift the right thigh while lying down.

Obturator sign
sign by asking the patient to lie down with the right leg bent at the knee. Moving the bent knee left and right requires exing the obturator muscle and will cause abdominal pain if the appendix is in amed.

Local tenderness at McBurneyds point w/ pressure

OTHERS

Low-grade Fever Abdominal pain at RLQ

Anorexia

PATIENT DATA BASE:

A.

CLIENT PROFILE Name Age Rank # Gender Date of birth Civil status Address Nationality Religion Occupation Physician Date admitted Time admitted

: : : : : : : : : : : : :

patient J 33 years old CPL male July 15, 1977 single

Cabili Iligan City (57 MC, MBLT-7 Z.C)

Filipino Roman Catholic Navy Major R.V Calupitan Jr., MC September 13, 2010 01:20 pm

B. CHIEF COMPLAINT
Right

Lower Quadrant abdominal pain with pain scale of 8 out of 10, positive fever, and anorexia

C. HISTORY OF PRESENT ILLNESS

The

patient is currently on a good condition.

Since

then, the patient was noted to be

apparently well until 3 days PTA, the patient experienced a sudden dull, intermittent epigastric pain.He self medicated with antacid (kremil-s).

2 days PTA, still with the above condition, generalized abdominal pain was now noted with the pain scale of 7 out of 10 to be continuous. 1 day prior to admission still with the above condition. Upper abdominal pain intensifies and localizes on the RLQ of the abdomen pain increases with the pain scale of 8 out of 10. Accompanied by a low-grade fever, and loss of appetite. 5 hours PTA, persistence of the above condition, prompted to consult at CNGH ward 5. Patient was given an IVF D5 LR 1 L @ 20 gtts/min.

D. HISTORY OF PAST ILLNESS

The client experienced the common illnesses afflicting a child like cough and colds, and flu. He has no allergies to any food, drugs and any other environmental agents. He has no past hospitalization. Actually the patient undergo only one surgery (appendectomy), its his first time to be hospitalized, because if he felt the pain he usually take an OTC drug such as the antacid (kremil-s) and biogesic.

Received Hepatitis B vaccine, Oral Polio vaccine, BCG, DPT and MMR when he was still young. He is not smoking, but He is an alcoholic beverage drinker, consuming for about 8-12 bottles of beer per session.

Immunization:

E. MEDICAL DIAGNOSIS PRE-OPERATIVE: t/c acute appendicitis Final Pathologic Diagnosis (postop) Appendectomy: Acute Appendicitis Gangrenous

Nursing History (11 gordons functional pattern)

Health Perception Pattern

Before confinement:

The client rated his health 8 over 10 (1 as the lowest and 10 as the highest).He usually has an abdominal pain with a pain scale of 8 over 10 (1 as the lowest and 10 as the highest). According to the client hes not consulting a doctor when he has an abdominal pain, he just take an OTC drugs to kill/lessen the pain. He is doing daily exercise such as walking every morning and jogging. He does not smoke cigarette but an alcoholic drinker.

During confinement:

The client has limited body movements. The client stated Hindi ako pwede gumalaw galaw masyado kasi sumasakit ang tyan ko dito sa bandang kanan,sa baba and he always at his bed rest because of his body weakness and pain.

NUTRITIONAL METABOLIC PATTERN

Before confinement:

The client eats once a day with mild amount of food intake (1 cup of rice, serving of viand usually fish and vegetables(tomato mostly), and a glass of water).As he stated, when he was not yet experiencing the pain, he is fun of eating guavas when he has nothing to do. According to him he drinks 2-3 glasses of water. He doesnt drink milk but he does drink coffee sometimes. He doesnt take any of the vitamins. He does not have any problems/discomfort in swallowing solid foods. He does not have any denture.

During confinement: He was advised for NPO until the bowel functions return. After appendectomy: He was advised to increase his fluid intake and have a regular diet. He should then start on clear fluids, and the diet should be advanced as tolerated.

ELIMINATION PATTERN
Before confinement:

The client has no problems or complaints with the usual pattern of voiding. He voids frequently 9-10 (100cc per urine) times a day and defecates once a day (every morning). He does not use any laxatives and has no discomfort in voiding and defecating.

During confinement: The client has a difficulty in defecating due to abdominal pain (psoas part) , but he can defecate, he defecates every morning. He voids 4-6 times a day. He does not use any laxatives.

ACTIVITY-EXERCISE PATTERN
Before confinement: Client has sufficient energy for the next days work and activities. The client is doing daily exercise such as walking and jogging every morning 7am8am for 30 minutes to 1 hour. He does his chores like sweeping the leaves at the surroundings and wash his clothes and cooking as his form of exercise. His day starts by sweeping the dried leaves falling from the trees around the camp that servers his daily duty. On his spare-time, he likes watching television or listening to music, eating kikiam and tempura.

During confinement: The client usually stays on bed and doesnt want to ambulate. He usually watches television that serves as his exercise.

COGNITIVE PERCEPTUAL PATTERN

Before confinement:

The Client does not have any hearing and visual difficulty Or abnormalities. The Client is not using any eye glasses. Client is able to decide on things practically. Actually, he is the only one who decides to have an operation (due to his wife and family was not yet around/ arrived). His family usually shares those simple problems. His easiest way to learn things is through actions and experience as he verbalized.

During confinement:

Client does not have any hearing problem and his vision remains the same.

SLEEP-REST PATTERN
Before confinement:

Clients usual time of sleeping/ bedtime is from 10pm and wakes up at 4am because of the pain sometimes he felt as he stated and he goes back to sleep with difficulties. The client sleeps less than 6 hours a day.

During confinement: The client has difficulties in remaining and falling asleep nahihirapan akong matulog lalo na pag gabi hindi ako sanay dito e as verbalized by the client.

SELF-PERCEPTION- SELF-CONCEPT PATTERN

Before confinement: Client feels good and has positive affection toward himself. Never did he felt of losing hope even though problems arise every now and then.

During confinement: A client most concerned about, is his health. His goal is to improve his health while he is in the hospital so he can perform his daily activities when he gets home and so that his wife and family will not get worried. He promised to himself that he will always look after his self.

ROLE-RELATIONSHIP PATTERN
Before confinement: The client is living now in camp Navarro. Client encompasses good relationship with his mates. During confinement:

He still has a good relationship with his mates in the ward.

SEXUALITY-REPRODUCTIVE PATTERN
Before confinement:

Clients circumcisions start when he was 11 years old. The Client has a good sexual relationship with his wife. Client is satisfied and there are no noted changes with their relationship. (But now, he doesnt have sexual relationship to his wife due to a long distance affair. His wife lives at ILIGAN LANAO DEL NORTE.)They do not use any form of contraceptives and does not consult for family planning as he stated secretly.

During confinement: Theres no significant changes with the clients sexuality reproductive pattern his beliefs with his sexual interest still stay the same, but client is advise not to engage to any sexual activities now up to 3-4 weeks.(since his wife was not around, so he cannot do any sexual intercourse.)

COPING-STRESS PATTERN
Before confinement: There are no big changes lately. If problem occurs. He just controls his temper and let it out through deep breathing or sometimes he just remains silent and does not think of it anymore. He believes that God and his family will always help him no matter what happens.

During confinement: Now that he is confined or admitted, he gets strength from his family, wife, to his friends and to GOD.

VALUES-BELIEFS PATTERN
Before confinement: Clients religion is catholic. He seldom goes to church but he maintains a personal relationship with God through prayers every night.

During confinement: Client still believes in God and has strengthened his faith and prays for his fast recovery. He believes in the sayings of God has a reason for allowing things to happen. We may never understand His wisdom, but we simply have to trust His will as he stated his motto.

II.PATIENT ASSESSMENT
A.Physical assessment Vital signs:

Temperature Respiration rate Pulse rate Blood pressure

38.2 degree Celsius 22 breathes per minute 81 beats per min 120 /90 mmHg

SYSTEM ASSESSMENT
Head and face

The skull of the patient is symmetrical. The hair is dry, no brittle and generally the color is black. Eyes

The eyebrows are symmetrical, normally aligned eyeballs, the conjunctiva is pink palpebral, anicteric sclera, normal ocular movements and pupil reacts to light. 20/20 vision.

Ears

External structure of the ear is symmetric

and proportion to the head, it has no masses and having no lesions. And for internal structure of the ear is with impacted cerumen, having no mass and no lesion.

Nose

The external structure of the nose is symmetric and

proportion to the facial features and no lesions and the internal structure is having no secretions. Mouth

The lips of the patient are pink and dry. Teeth are

complete, gum and bucal mucosa is pinkish, tongue is pinkish dry, tonsils are pink and smooth posterior wall.

Neck

The Pulsation is present, and the neck is non tender, Thorax

The rib cage is visible; the respiratory excursion is full and symmetric chest expansion. Not in respiratory distress. Skin

The color of the skin is brown or fair in complexion, and the texture is smooth.

Abdomen
Pre-op:

The patient is experiencing positive rebound tenderness at RLQ.

On palpation, localized and rebound tenderness are noted at McBurneys point. Post-op:

Appendectomy done; the patients abdomen is with abdomen with dry and intact dressing.

surgical incisions at mc Burneys point at RLQ of the

Arms

Right and left arms are symmetrical, nails are dirty smooth,long and no tenderness.the capillary goes back fastly.

Legs

Right and left legs are symmetrical and having no mass, no lesions and not swelling. The nails are smooth, long, dirty, and no tenderness.

Reflexes

Brachioradialis

: normal flexion : normal flexion : normal flexion : normal extension : normal extension : negative babinski

Biceps Triceps

Patellar Achilles Babinski

Neurologic
The

patient is awake, conscious

and coherent. The OPTIC- can visualize object clearly

Diagnostic and Laboratory Examinations

Gross/microscopic description:
The specimen consists of a vermi form appendix submitted in two fragments measuring 4.3 x 1.0 x 1.0 cm. & 3.5 x 1.4 x 1.1 cm. The serosa is gray brown and covered with cream yellofibrinopurutent exudates.The wall which averages 0.3 cm in thickness, is gangrenous and encloses a 0.4 cm in diameter . Lumen containing dark brown fecal material.Block 3. Microscopic Examination is done
Phil.Gen.Hospital Admitting Officer:Major Roberto V.Calupitan,MC Surgical

Pathology Sec.Department of Lab. Taft,ave.Ermita Manila

URINALYSIS
PHYSICAL EXAMINATION: Color : Transparency : Reaction PH : Specific gravity : Sugar : Protein : Pus cell RBC Mucous threads

dark yellow si.hazzy 6.0 1.030 (-) negative -3 increase 19-30 increase 1-4 moderate

Microscopic:
: : :

HEMATOLOGY RESULT

SEPTEMBER 13,2010

SEPTEMBER 19,2010

NORMAL RANGE

HGB HCT

17.0 .51

16.0 .48

(13.0-18.%0 CMS) (0.40-0.54 VOL.%) (4.5-10x10/L) (4.5-6.5X10L)

WBC

Increase 11.3 5.9

Increase 11.9 5.6

RBC

DIFFERENTIAL COUNT

.80
SEGMENTERS

.79

(0.50-0.70)

.20
LYMPHOCYTES

.21 261

(.20-.40)
(150-350 X 10/L)

PLATELET COUNT

296

Acute Pain
Risk for Imbalanced Nutrition: less than body requirements

Risk for infection

Impaired Tissue Integrity

Activity Intolerance

NURSING DIAGNOSIS
Actual:

Hyperthermia r/t increase metabolic state guarding behaviors

Acute pain r/t inflammation of tissues as evidenced by

Potential:

Acute pain r/t post operative surgery

Risk for infection r/t perforation of the appendix Imbalance nutrition less than body requirements Risk for activity intolerance r/t surgical procedure

TREATMENT MODALITIES & MANAGEMENT

PRE-OPERATIVE MANAGEMENT

NPO diet in preparation for surgery. An intravenous drip is used to hydrate the patient. Antibiotics given intravenously such as Cefuroxime and Metronidazole .

If the stomach is empty (no food in the past six hours) general anesthesia is usually used.

Otherwise, spinal anesthesia may be used.

 

Removal of the appendix. Performed as soon as possible to decrease the risk of perforation. Two ways performed:
is a surgical procedure involving an incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.

1.

Laparotomy-

2.

Laparoscopy- is a surgery that uses a thin, lighted

tube put through a cut (incision) in the belly to look at the abdominal organs.

POST- OPERATIVE MANAGEMENT

patient to position of comfort such as semi-fowlers with knees are flexed. Restrict activity that may aggravate pain, such as coughing and ambulation. Apply ice bag to abdomen for comfort. Advise avoidance of enemas or harsh laxatives; increased fluids and stool softeners may be used for postoperative constipation.
Assist

 Give

narcotic analgesic as ordered and

administer oral fluids when tolerated.

Monitor

frequently for signs and symptoms

of worsening condition, indicating perforation, abscess, or peritonitis (increasing severity of pain, tenderness, rigidity, distention, absent bowel sounds, fever, malaise, and tachycardia).

If a drain is left in place at the area of the incision, monitor carefully for signs of intestinal obstruction, secondary hemorrhage, or secondary abscesses (e.g. fever, tachycardia, and increased leukocyte count).

Date ordered NPO

Standing order

Date D/C

Ranitidine 500 mg IV q8 while on NPO Cefuroxime 700mg IV q8 ANST (-) Sep. 13, 2010 Plasil 10mg IVTT @ 24 hrs then q6 PRN Ketorolac 30 mg IVTT q6x a doses then PRN Nalbupine 10 mg IVTT q6 x a doses then PRN Metronidazole 500 mg IV q8 Sep.t.21,10

Sep. 14,10

Paracetamol 300 mg IV q4 for fever Paracetamol 500 mg tab.,1 tab q4 PRN for t-38degree celcius

Sep. 21,10 Sep. 23 , 10

Cefalexin 500 mg 1 tab q8 P.O Vitamin C, 500 mg 1 tab O.D

Sep.23,10

Drug Name Generic name: Cefuroxime Brand name: Ceftin Classification: Anti-infective; Antibiotic; Second Generation cephalosporin

Dosage 750mg IV q8hrs. ANST(-)

Mechanism of Action Inhibits synthesis of bacterial cell wall, causing cell death.

Indication/ Contraindication
Indication: Oral (Cefuroxime Axetil): Pharyngitis, tonsilitis caused by S. pyogenes Otitis media caused by S. pneumoniae, H. influenzae, M. catarrhalis, S. pyogenes Lower respiratory tract infections caused by S. pneumoniae, H. parainfluenxae, H. influenzae UTIs caused by E. coli, K. pneumoniae Dermatologic infections, including impetigo caused by S. aureus, S. pyogenes. Contraindications: Allergy to cephalosporins or penicillins Renal failure Lactation

Side Effects/ Adverse Effects Body as a Whole: Thrombophlebitis (IV site); pain, burning, cellulitis (IM site); superinfections, positive Coombs' test. GI: Diarrhea, nausea, antibioticassociated colitis. Skin: Rash, pruritus, urticaria. Urogenital: Increased serum creatinine and BUN, decreased creatinine clearance

Nursing Responsibilities 1. Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated. 2. Inspect IM and IV injection sites frequently for signs of phlebitis. 3. Report onset of loose stools or diarrhea. Although pseudomembranous colitis. 4. Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant changes.

Drug Name

Dosage

Mechanism of Action
Physiologic Mechanism: Decreased pain.

Indication/ Contraindication
Indication: Moderate to moderately severe pain Contraindication:

Side Effects/ Adverse Effects

Nursing Responsibilities
1. Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration. 2. Assess BP & RR before and periodically during administration. Respiratory depression has not occurred with recommended doses. 3. Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and with laxatives to minimize constipating effects. 4. Assess previous analgesic history. Tramadol is not recommended for patients dependent on opioids or who have previously received opioids for more than 1 wk; may cause opioid withdrawal symptoms. 5. Prolonged use may lead to physical and psychological dependence and tolerance, although these may be milder than with opioids. This should not prevent patient from receiving adequate analgesia. Most patients who receive tramadol for pain d not develop psychological dependence. If tolerance develops, changing to an opioid agonist may be required to relieve pain. 6. Tramadol is considered to provide more analgesia than codeine 60 mg but less than combined aspirin 650mg/codeine 60 mg for acute postoperative pain. 7. Monitor patient for seizures. May occur within recommended dose range. Risk increased with higher doses and inpatients taking antidepressants (SSRIs, tricyclics, or Mao inhibitors), opioid analgesics, or other durgs that decrese the seizure threshold. 8. Overdose may cause respiratory depression and seizures. Naloxone (Narcan) may reverse some, but not all, of the symptoms of overdose. Treatment should be symptomatic and supportive. Maintain adequate respiratory exchange.

Generic name: Tramadol Brand name: Ultram Classification: Analgesics

50 mg IV q8

Pharmacologic Mechanism: Binds to mu-opioid receptors. Inhibits reuptake of serotonin and norepinephrine in the CNS.

Drug name Generic name: Ranitidine Brand name: Zantac Classification:

Dosage
50mg I q8 while on NPO

Mechanism of Action
Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. In addition, ranitidine bismuth citrate has some antibacterial action against H. pylori.

Indications/ Contraindication
Indication: Treatment and prevention of heartburn, acid indigestion, and sour stomach. Contraindication: Hypersensitivity, Crosssensitivity may occur; some oral liquids contain alcohol and should be avoided in patients with known intolerance. Use Cautiously in: Renal impair- ment Geriatric patients (more susceptible to adverse CNS reactions) Pregnancy or Lactation

Side effects/ Adverse Effects

CNS: Confusion, dizziness, drowsiness, hallucinations, headache CV: Arrhythmias GI: Altered taste, black tongue, constipation, dark stools, diarrhea, druginduced hepatitis, nausea GU: Decreased sperm count, impotence ENDO: Gynecomastia HEMAT: Agranulocytosis, Aplastic Anemia, neutropenia, thrombocytopenia LOCAL: Pain at IM site

Nursing Responsibilities
1. Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. 2. Nurse should know that it may cause false-positive results for urine protein; test with sulfosalicylic acid. 3. Inform patient that it may cause drowsiness or dizziness. 4. Inform patient that increased fluid and fiber intake may minimize constipation. 5. Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health car professional promptly. 6. Inform patient that medication may temporarily cause stools and tongue to appear gray black.

Anti-ulcer agents; Histamine H2 antagonists

Drug name Generic Name: Metoclopramide Brand name: Plasil Classification: Antiemetics

Dosage 10mg IVTT

Mechanism of Action Physiologic Mechanism: Decreased nausea and vomiting. Decreased symptoms of gastric stasis. Pharmacologic Mechanism: Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates motility of the upper GI tract and accelerates gastric emptying.

Indications / Contraindication

Side effects / Adverse effects

Nursing responsibilities 1. Assess patient for nausea, vomiting, abdominal distention, and bowel sounds before and after administration. 2. May cause drowsiness. 3. Advise patient to avoid concurrent use of alcohol and other CNS depressant while taking this medication. 4. Advise patient to notify health care professional immediately if involuntary movement of eyes, face or limbs occurs.

Management of esophageal reflux Treatment and prevention of postoperative nausea and vomiting

Drug Name

Dosage 30mg IVTT q6 x 4 doses

Mechanism of Action

Indications/ Contraindication
Indication: Short term management of pain (not to exceed 5 days total for all routes combined) Contraindication: Hypersensitivity. Crosssensitivity with other NSAIDs may exist Preor perioperative use. Known alcohol intolerance Use cautiously in: 1. History of GI bleeding 2. Renal impairment (dosage reduction may be required) 3. Cardiovascular disease

Side effects / Adverse effects

CNS: Drowsiness. Abnormal thinking. Dizziness. Euphoria. Headache. RESP: Asthma. Dyspnea CV: Edema. Pallor. Vasodilation GI: GI Bleeding. Abnormal taste. Diarrhea. Dry mouth. Dyspepsia. GI pain. Nausea GU: Oliguria. Renal toxicity. Urinary frequency. DERM: Pruritis. Purpura. Sweating. Urticaria HEMAT: Prolonged bleeding time LOCAL: Injection site pain NEURO: Paresthesia MISC: Allergic reaction, anaphylaxis

Nursing Responsibilities
1. Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria. 2. Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration. 3. Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy. 4. Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional. 5. Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur. 6. Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients who do not respond to one NSAIDs may respond to another.

Generic name: Ketorolac Brand name: Toradol Classification: Nonsteroidal antiinflammatory agents;

 Inhibits prostaglandin synthesis, producing peripherally mediated analgesia. Also has antipyretic and antiinflammatory properties.  Therapeutic effect:Decrease d pain

Drug Name

Dosage
I liter @ 20gtts/min. @ RMV

Mechanism of Action
Hypertonic Solutions are those that have an effective osmolarity greater than the body fluids. This pulls the fluid into the vascular by osmosis resulting in an Increase vascular volume. It raises intravascular osmotic pressure and provides fluids, electrolytes and calories for energy

Indication/ Contraindications
Indication: Treatmentfor personsneeding extracalorieswhocannot toleratefluidoverload. Treatment of shock. Contraindication: Hypersensitivity to any of the Components

Side effects / Adverse effect

Anxiety. Conduction Disorder of the Heart. Dyspnea. Fatigue. Hyperkalemia, Hypesthesia. Impaired Cognition. Muscle Weakness in Limbs. Tingling Sensation of Hands or Feet.

Nursing Responsibilities
1. Do not administer unless solution is clear and container is undamaged. 2. Caution must be exercised in the administration of parenteral fluids, especially those containing sodium ions to patients receiving corticosteroids or corticotrophin. 3. Solution containing acetate should be used with caution as excess administration may result in metabolic alkalosis. 4. Solution containing dextrose should be used with caution in patients with known subclinical or overt diabetes mellitus. 5. Discard unused portion. 6. In very low birth weight infants, excessive or rapid administration of dextrose injection may result in increased serum osmolality and possible intracerebral hemorrhage.

D5LR
Classification: Hypertonic Solution

Drug Name
Generic name: Nalbuphine Brand name: Nubain Classification: Opoid analgesics 

Dosage
 10 mg Route:  IVTT Frequency: q6 x 4 doses

Mechanism of Action
Alters the perception of an response to painful stimuli while producing generalized CNS depression. In addition, has partial antagonists properties which may result with opoids withdrawal in physically dependent patients.

Indication/ Contraindication
Moderate to severe pain, also provide analgesia during labor, sedation before surgery, supplement to balance anesthesia

Side effects/ Adverse effects

Hypersensitivity to nalbuphine or bisulfate patient who are physically dependent on opoids and have not been detoxified. CNS: dizziness, headache, sedation, confusion, dysphoria, euphoria, floating feeling, hallucinations GI: dry mouth, nausea and vomiting, constipation GU: urinary urgency.

Nursing Responsibility
1.Assess type, location and intensity of pain before ang 1hr after IM or 30minutes after IV administration. 2. Assess BP ,pulse and respiratory before and periodically during administration. 3.Assess patient for abdominal pain. Note presence of blood in emesis, stool, or gastric aspirate Ranitidine may be added to total parenteral nutrition solution 4.Remind patient to take once daily prescription drug at bedtime for best results 5.Instruct patient to take without regard to meals because absorption isn t

Drug Name
Generic name: Metronidazole Brand name: Novonidzol Classification: Anti ulcer agent 

Dosage
500mg Route:  IV Frequency:  q8

Mechanism of Action
Disrupts DNA protein synthesis in susceptible organism. SIDE EFFECTS: CNS: seizures, dizziness, headache. GI: abdominal pain, anorexia, nausea.

Indication/ Contraindication
Perioperative prophylactic agent in colorectal surgery

Side effects/ Adverse effects

Hypersensitivity to parabens (topical only) First trimester in pregnancy CNS: seizures, dizziness, headache. GI: abdominal pain, anorexia, nausea.

Nursing Responsibility
1. Assess patient for infection (v/s; appearance of wound of wound, sputum, urine and stool: WBC) at beginning of and through \ therapy.\ 2. Obtain specimen culture and sensitivity before initiating therapy. First dose may be given before receiving therapy. 3. Monitor neurologic status during and after IV infusions. 4. Monitor I and O and daily wt. especially for patients on sodium restriction.

Drug Name
Generic name: Paracetamol Brand name: Acetaminophen Classification: Analgesic 

Dosage
300m amp. Route:  IV Frequency:  q 4hrs. for fever

Mechanism of Action
Reduces the oxidized form of the COX enzyme, preventing it from forming proinflammatory chemicals This leads to a reduced amount of Prostaglandin E2 in the CNS, thus lowering the hypothalamic set-point in the thermoregulatory centre.

Indication/ Contraindication
It is commonly used for the relief of fever, headaches, and other minor aches and pains, and is a major ingredient in numerous cold and flu remedies. In combination with non-steroidal antiinflammatory drugs (NSAIDs) and opioid analgesics, paracetamol is used also in the management of more severe pain (such as cancer or postoperative pain).

Side effects/ Adverse effects

Hypersensitivity to paracetamol) analgesic nephropathy, renal and hepatic impairment. Low fever with nausea, stomach pain, and loss of appetite. Dark urine, clay-colored stools; or jaundice (yellowing of the skin or eyes).

Nursing Responsibility
1. Do not exceed the recommended dosage. 2. Consult physician below 3 year old if needed for longer for ten days. If continued fever sever recurrent pain occurs. 3. Avoid using multiple preparation containing acetaminophen carefully check all OTC products 4. Give drugs with food if GI upset occurred 5.Discontinue the drug if hypersensitivity reaction occurred.

Drug Name
Generic name: Tramadol Brand name: Ultram Classification: Analgesic 

Dosage
50mg Route:  IV Frequency:  q8

Mechanism of Action
Binds to mu-opiod receptors. Inhibits reuptake of serotonin and nor epinephrine.

Indication/ Contraindication
Moderate to moderately severe pain.

Side effects/ Adverse effects

Hypersensitivity: cross sensitivity with opiods may occurs. Patients who are acutely intoxication with alcohol, sedative/ hypnotics, centrally acting analgesic, opiods analgesics, or psychotropic agents. Patient who are physically dependent on opiods analgesics( may precipitate withdrawal). Not recommended for use during pregnancy or lactation. CNS: seizures, dizziness, headache. Somnolence GI: constipation, nausea

Nursing Responsibility
1. Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration. 2. Assess blood pressure and respiratory rate before and periodically during administration. Respiratory depression has not occurred with recommended doses. 3. Assess bowel function routinely. 4. Assess previous analgesic history

Drug Name
Genric name: Vitamin C

Dosage
Dosage:  10mg 1tab. Route:  PO Frequency:  OD

Mechanism of Action
Needed for wound healing, collagen synthesis antioxidant, carbohydrate metabolism, protein, lipid synthesis, prevention of infection.

Indication/ Contraindication
Enhance body s natural immune function

Side effects/ Adverse effects

Burning, stinging, or swelling at the injection site. Seek medical attention right away if any of these SEVERE side effects occur: Severe allergic reactions (rash; hives; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue).

Nursing Responsibility
1.Assess nutritional status for inclusion of food high in vitamin C: citrus fruits, cantaloupe, tomatoes. 2. Assess for vitamin C deficiency before, during and after treatment: Scurvy ( gingivitis, bleeding gums, losse teeth; poor bone development. 3. Monitor I&O ratio; polyuria; in patient receiving large doses renal stone may occur. 4. Monitor ascorbic acid levels throughout treatment if continue deficiency is suspected. 5. Assess infection sites for inflammation pain, and redness.

Brand name: Ascorbic acid

Classification: Dietary and nutritional preparation action

Assessment
Subjectives: sakit gyud akong tiyan day as verbalized by the patient. Objective: Facial mask pain y Guarding behavior y Rebound tenderness y V/s :  T-36.8  P-68  R-23  Bp-110/80  Right iliac pain 8/10 pain scale

Nursing Problem
Acute pain r/t inflammation of appendix as evidenced by guarding behaviors

Goal of Care
After nursing intervention the patient will be able to: y Verbalized understanding of specific interventions for appendicitis y Demonstrate behaviors to monitor and promote alleviation of the problem y Identify the underlying cause or contributing factors and importance of treatment as well as the signs and symptoms requiring further interventions

Nursing Intervention
Independent:  Monitor the degree of Pain

Rationale

Expected Outcome
The patient will be able to:

Evaluation

Notes progress in changes of condition

y Report pain is relieved.

Goal partially met; Pain decreased from pain scale of 8 out of 10 to 7 out of 10. Goal met; patient has been instructed to maintain semifowlers position. y Goal met; Patient maintained bed res.

 Maintain semifowlers position

Reduces abdominal distention thereby reduces tension

y Maintain semifowlers position until surgical procedure.

 Move patient slowly and deliberately

y Reduce muscle tension or guarding which help minimize pain of movement y Promotes relaxation and may enhance the patients coping abilities by refocusing attention y To divert attention on pain

y Patient avoid vigorous activity

Duration: Frequency:

 Provide comfort measures like back rubs and deep breathing

y Patients anxiety will be alleviated.

y Goal met; Patient maintained relaxation.

 Provide diversional activities

y Patient will not complain of any pain.

y Not met: Patient still complained pain with pain scale of 7 out of 10

Provide frequent oral care.

y To maintain oral hygiene

y Patient will gurgle at least 2-3 times a day.

y Goal met; Patient maintain oral hygiene.

Assessment
CUES: SUBJECTIVE: gihilantan man ku,wah ku kabalu nganu ni as verbalized by the patient. OBJECTIVE: T -38.2 P- 81 R- 22 BP- 120/90 -warm to touch

Nursing Problem
Elevated body temperature r/t increased metabolic rate

Goal of Care
At the end of nursing interventions , patient will be able to :

Nursing Intervention
Independent:  Monitor vital signs especially temperature

Rationale

Expected Outcome
y Patient vital signs will return to normal range.

Evaluation

 Notes progress and changes of condition

 Maintain core temperature within normal range.  Demonstrate behaviors to monitor and promote normothermia.  Be free from chills.

y Goal partially met; Patient temperature has returned to normothermia. y Goal met; Patient temperature decreased to 37. y Goal met; Patient has kept in a desired room y Goal met; Patient was educated regarding clothing

 Apply tepid sponge bath

 To reduce body temperature

y Patient temperature will decrease to within 36.5 to 37.5. y Place patient in a ROC.

 Monitor environmental / room temperature  Change wet clothes / blankets

 To maintain core temperature

 To avoid heat lost

y Patient will able to change clothes 1-2 times a day

 AdministeDependent:  r antibiotic such as

 For infection and prevent the growth of organism.

y Patient will take medication as ordered

y Goal met; Patient was able to take his antibiotic medication on time.

Assessment

Nursing Problem

Goal of Care

Nursing Intervention

Rationale

Expected Outcome

Evaluation

Risk for activity intolerance r/t surgical procedure

After nursing intervention the patient will: 1. Verbalize understanding of potential loss of ability in relation to existing condition 2. Participate in conditioning teaching to enhance ability to perform

Independent:  Note presence of medical diagnosis and/or therapeutic regimen.

y That has potential interfering which client s ability to perform at a desired level of activity. y Provide opportunity to track changes

y Patient will not manifest any untoward signs of complication.

 Determine baseline activity level & physical condition  Instruct client in unfamiliar activities and in alternate ways of doing familiar activities
Dependent:  Refer to appropriate sources for assistance and/or equipment as needed.

y Patient will be ambulated

y To conserve energy & promote safety

y Patient will be knowledgeable about conserving energy and its alternative ways to do it

y To sustain activity level.

y Patient will ask for assistance such as walking, or with wheelchair.

Enabling objectives At the end of 30minutes, the patients will be able to: 1. Identify appendicitis

Content

Time

Activities

Teaching strategies

Resources

Evaluation The patients will be able to;

Appendicitis is an inflammation of the vermiform appendix that develops most commonly in adults and young adults. It can cause by;  a fecalith (a fecal calculus or stone) that occludes the lumen of the appendix  kinking of the appendix  swelling of the bowel wall  fibrous conditions in the bowel wall  External occlusion of the bowel by adhesion.

5 min.

One-on-one discussion

Visual aid

http;//www.medindia.n e/patient/lpatientsinfol appendicitis-aftercare. http;//www.medindia.n e/patient/lpatientsinfol appendicitis-aftercare.

Understand appendicitis

2. What causes appendicitis

One-on-one discussion

Determine the causes of appendicitis.

5 min.

Visual aid

3. Determine the signs and symptoms

One-on-one discussion

Visual aid

 acute abdominal pain  anorexia  low-grade fever  Coated tongue.  halitosis

http;//www.medindia.n e/patient/lpatientsinfol appendicitis-aftercare.

Identify the signs & symptoms of appendicitis

5 min.

4. Impart the importance of having the lab test before the procedure

Pre-operative care  Informed consent.  blood test  routine  urine test  chest x-ray  NPO after midnight on the day of the procedure.  Post-operative care  diet; can t take anything to eat or drink after 24hrs of appendectomy  Small amount of water, then clear liquid and then some solid foods, until finally they are able to handle to a regular diet.

One-on-one discussion

Visual aid

http;//www.medindia.n e/patient/lpatientsinfola ppendicitis-aftercare.

Determine the importance of having the laboratory test.

5 min.

Interventions
PERITONITIS

Observe for abdominal tenderness, fever, vomiting, abdominal rigidity, and tachycardia. Employ constant nasogastric suction Correct dehydration

Admin. Antibiotics as prescribed. PELVIC ABSCESS

Evaluate for anorexia, chills, fever, and diaphoresis

Observe for diarrhea, which may indicate pelvic abscess Prepare pt for rectal exam Prepare pt for surgical drainage procedure SUPHRENIC ABSCESS

Assess pt for chills, fever, diaphoresis

Prepare for x-ray exam and surgical drainage of abscess PARALYTIC ILEUS

Assess bowel sounds Replace fluids and electrolytes by IV route Employ nasogastric intubation and suction.

PRESENTED BY :
Leader: Sedano, Jay An R. Members: Ajan, Amira H. Amil, Jehan A. Badilla, Rovelyn C Canagan, Kerk Russel G. Haber, Farwisa I. Jalad, Fatima-Regine B. Jumala, Nurnihar T. Landingin, Newliegay J. Lustria , Loviejane S. Macrohon, Alexander P. Pereyra, Gretchen F. Porol, Rose Ann S. Villanueva, McRichard S.