Appendicitis Output

8/3/2019 Appendicitis Output

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PERSONAL PROFILE

Patients Name: MS

Address: Purok 2, Ibung Villaberde, Nueva Vizcaya

Sex: Female

Age: 13 years old

Civil status: Single

Birth Date: December 5, 1997

Birth Place: Ibung Villaberde, Nueva Vizcaya

Citizenship: Filipino

Primary Language: Tagalog

Educational Attainment: 2nd High School at present

Religion: Roman Catholic

Fathers Name: Mr. S

Mothers Name: Mrs. S

Admission Date: September 20, 2011

Admitting Physician: Welbert Reyes M.D.

Consulting Physician: Rodolfo Hidalgo M.D.

Admission Diagnosis: Acute Appendicitis

Principal Diagnosis: Acute Gangrenous Appendicitis

Principal Operation/Procedure: s/p E appendectomy

Date of Operation: September 21, 2011

Ward: Surgery

Name of Hospital: Veterans Regional Hospital


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PRESENT HEALTH PROBLEM

The complaint of the patient started 2 days prior to her hospitalization. As stated by her, last

Sunday afternoon, she felt pain suddenly at her abdomen located at her right lower quadrant. Initially,

she disregarded the pain thinking that it will subside after some time. But Monday came and the pain

was still present, and so she started to take pain reliever such as Buscopan given to her by her aunt. OnTuesday, she felt that the pain worsens and so she was encouraged by her Lola to take Herbaca which is

a herbal medicine. Still, the pain did not ease up. The medication and the herbal medicine she took up

did not help to alleviate the pain. She cannot remember any food she had eaten that might cause the

pain on her abdomen, she stated that it happened suddenly. The patient also tried to see a

manghihilot. She stated that the pain still felt the same. She cannot even eat well already. Thats the

time they decided to bring her to the hospital for a check up.

She came to the hospital because of the following reason: Pain at her right lower abdomen. She

was advised to be admitted for further treatment of her current illness. She was confined at Veterans

Regional Hospital (VRH). She was seen and examined by Dr. Welbert Reyes, forwarded to the surgery

ward via wheelchair accompanied by her father with the admission diagnosis of Acute Appendicitis. She

was given medications such as Cefoxitin, Ranitidine, Tramadol, Ketorolac, Metronidazole, Paracetamol

and Amino acid + Multivitamins.

Upon admission, she had the following vital signs: BP: 80/60 mmHg, Temp: 36.00C, RR: 16 cpm,

and PR: 82 bpm

PAST HEALTH PROBLEM

According to her significant other, the patient was born without any complication. But during

her childhood years, she has been hospitalized once due to her fever. Other than that, she did not have

or suffered from any serious illness aside from common colds and cough. She completed her

immunizations as a child which is very important especially nowadays.

The patient has no known allergy to any medication, food and to her environment. Neither did

she encounter any accidents before nor had any injuries.

Whenever she suffers from common colds or anybody from their family, they manage to treat it

by taking over the counter medications like Paracetamol and Solmux. They also use herbal medicines

such as Oregano and Dahong Maria, insisted by their lola. Another is that they also go to manghihilot,and also to some herbalist whenever the situation calls for it.

FAMILY HISTORY

The patient lives with her parents together with her younger brother. No history of any disease

was identified in their family. Both her parents are in good health. Her brother is also confined at the

same hospital due to his cough. Her brother also has completed his immunizations already.


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BRIEF DESCRIPTION OF THE DISEASE

The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the cecum just

below the ileocecal valve. No definite functions can be assigned to it in humans. The appendix fills with

food and empties as regularly as does the cecum, of which it is small, so that it is prone to become

obstructed and is particularly vulnerable to infection (appendicitis).

Appendicitis is the most common cause of acute inflammation in the right lower quadrant of

the abdominal cavity. About 7% of the population will have appendicitis at some time in their lives,

males are affected more than females, and teenagers more than adults. It occurs most frequently

between the age of 10 and 30.

The disease is more prevalent in countries in which people consume a diet low in fiber and high

in refined carbohydrates.

The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting. Loss

of appetite is common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burneys

point applied located at halfway between the umbilicus and the anterior spine of the Ilium.

Rebound tenderness (ex. Production or intensification of pain when pressure is released) may

be present. The extent of tenderness and muscle spasm and the existence of the constipation or

diarrhea depend not so much on the severity of the appendiceal infection as on the location of the

appendix.

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

region. Rovsings sign maybe elicited by palpating the left lower quadrant. If the appendix has ruptured,

the pain become more diffuse, abdominal distention develops as a result of paralytic ileus, and the

patient condition become worsens.

Constipation can also occur with an acute process such as appendicitis. Laxative administered in

the instance may result in perforation of the in flared appendix. In general a laxative should never be

given

Clinical Manifestations

1. Generalized or localized abdominal pain in the epigastric or periumbilical areas and upper rightabdomen. Within 2 to 12 hours, the pain localizes in the right lower quadrant and intensity increases.


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2. Anorexia, moderate malaise, mild fever, nausea and vomiting.3. Usually constipation occurs ; occasionally diarrhea.4. Rebound tenderness, involuntary guarding, generalized abdominal rigidity.Diagnostic Evaluation

1. Physical examination consistent with clinical manifestations.2. WBC count reveal moderate leukocytosis (10,000 to 16,000/mm3) with shift to the left (increased

immature neutrophils).

3. Urinalysis rule out urinary disorders.4. Abdominal x-ray may visualize shadow consistent with fecalith in appendix; perforation will reveal

free air.

5. Abdominal ultrasound or CT scan can visualize appendix and rule out other conditions, such asdiverticulitis and crohns disease. Focused appendiceal CT can quickly evaluate for appendicitis.

6. Barium Enema is an x-ray test where liquid barium is inserted into the colon from the anus to fill thecolon. This test can, at times, show an impression on the colon in the area of the appendix where the

inflammation from the adjacent inflammation impinges on the colon. Barium enema also can exclude

other intestinal problems that mimic appendicitis, for example Crohn's disease


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Medications

Analgesics Intravenous fluids replacements AnalgesicsTreatment

Appendectomyis the effective treatment if peritonitis develops treatment involves.


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GI Intubation Parenteral replacement of IV fluids and electrolytes Administration of AntibioticsSurgery is indicated if appendicitis is diagnosed. Antibiotics and IV fluids are administered until surgery is

performed analgesics can be administered after the diagnosed is made.

An appendectomy (surgical removal of the appendix) is performed as soon as possible to decrease the

risk of perforation. T he appendectomy may be performed under a (general or spinal anesthetics) with a

low abdominal incisions or by (laparoscopy) which is recently highly effective method.

Complications

The major complication of appendicitis is perforation of the appendix, which can lead to peritonitis,

abscess formation (collection of purulent material), or portal pylephlebitis, which is septic thrombosis of

the portal vein caused by vegetative emboli that arise from septic intestines.

Perforation generally occurs 24 hours after the onset of pain symptoms include a fever of 37.7 degree

Celsius or 100 degree Fahrenheit or greater, a toxic appearance and continued abdominal pain or

tenderness.

Nursing Interventions

1. 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).

2. Notify health care provider immediately if pain suddenly ceases, this indicates perforation, which is amedical emergency.

3. Assist patient to position of comfort such as semi-fowlers with knees are flexed.4. Restrict activity that may aggravate pain, such as coughing and ambulation.5. Apply ice bag to abdomen for comfort.6. Avoid indiscriminate palpation of the abdomen to avoid increasing the patients discomfort.7. Promptly prepare patient for surgery once diagnosis is established.8. Explain signs and symptoms of postoperative complications to report-elevated temperature, nausea

and vomiting, or abdominal distention; these may indicate infection.9. Instruct patient on turning, coughing, or deep breathing, use of incentive spirometer, and

ambulation. Discuss purpose and continued importance of these maneuvers during recovery period.

10.Teach incisional care and avoidance of heavy lifting or driving until advised by the surgeon.11.Advise avoidance of enemas or harsh laxatives; increased fluids and stool softeners may be used for

postoperative constipation.


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Discharge Planning

M Antibiotics for infection

Analgesic agent (morphine) can be given for pain after the surgery

E Within 12 hrs of surgery you may get up and move around.

You can usually return to normal activities in 2-3 weeks after laparoscopic surgery.

T 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.

H 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

O 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)D Liquid or soft diet until the infection subsides

Soft diet is low in fiber and easily breaks down in the gastrointestinal tract


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ANATOMY AND PHYSIOLOGY

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

cecum the first part of the colon like a worm. The anatomical name for the appendix, vermiform

appendix, means worm-like appendage. The inner lining of the appendix produces a small amount of

mucus that flows through the open center of the appendix and into the cecum. The wall of the appendix

contains lymphatic tissue that is part of the immune system for making antibodies. Like the rest of the

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

The appendix is a worm-shaped appendage that sticks out from the top portion of the l

intestine. The main function of the appendix is unknown. The human appendix p0 attached to the large

intestine where it joins the small intestine does not directly assist digestion. Biologists believe it is a

vestigial organ left behind from a plan-eating ancestor. Interestingly, it been noted by palcontologistAlfred Sherwood Romer in his text The vertebrae Body that the major importance of the appendix

would appear to be a financial support of the surgical profession referring to, of course, the large

numbers of appendectomies performed annually. In 2000 in fact, there were nearly 300,000

appendectomies performed in the United States and 37.1 death from appendicitis. Any secondary

function that the appendix might perform certainly is not missed in who had removed before it might

have ruptured.

The clue to the appendixs function is its strategic position where the small bowel meets colon.

The colon is loaded with bacteria and is useful there. But which must be kept away other areas. The

appendixs main role is likely to be in early childhood. The organs highly concentrated lymphoid follicles,

which play an important role in the immune system, develops about two weeks after birth- at the same

time the colon begins to be colonized with the necessary bacteria.

The appendix is highly specialized organ with a rich blood support, not what you would expect

from a degenerate, useless structure. It has long been known that the appendix contains lymphatic

tissue and has a role in controlling bacteria entering the intestines.


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PERSON ASSESSMENT

September 23, 2011

PSYCHOSOCIAL

Assessment Significance

Significant Others

Caring father who is always

ready to comfort the patient in

times of difficulties

The presence of her significant

others helps her to cope and

recover from her

illness/condition

Coping Mechanism

She faces her problems and tries

to find for solutions to solve or

eliminate the problem

Religion Roman catholic

It helps us, as health care

providers to determine what

procedures or treatments mustbe implemented that are

accepted to their beliefs

Primary Language Tagalog

Knowing the primary language

will help us communicate with

the patient/significant other thus

gaining more information

Primary Source of Health Care Hospital

It is important in choosing what

kind of services are preferred

and usually utilized by the family

Financial Resources related toIllness

They are insured to Philhealth

To determine the extent of the

familys ability to confine a

member for treatment or to

support their expenses during

hospitalization

General Appearance

Appropriately dressed for her

age

Appears to be her stated age

With proper hygiene(nails are

properly cut)

Very weak in appearance

With minimal responses to

questions being asked

Objective cues are very

important to determine the need

for immediate interventions and

to identify improvement on the

condition

Affect Blunted affect

Due to her weakness the patientcannot fully express verbally and

nonverbally her mood and

emotions

Orientation

Oriented to time: Hapon na po

ngayon

Oriented to place: Nandito po

ako sa ospital nung Tuesday pa

ng gabi

Oriented to person: Si papa po

yung kasama ko

Oriented to event: Nagsimulapo nung Sunday nung sumakit

yung tyan ko bigla

Rules out any neurologic alterations

Memory

The patient has an intact

immediate, recent and remote

memory

Speech Slowly paced and in low tone but To identify the need for the


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shows associated with thoughts

and still understandable

significant other to supplement

the needed data

Nonverbal Behavior

Furrowed forehead

Poor eye contact

Restlessness

IrritabilityGrimacing when in pain

Distraction behaviors

Aids in verbal communication and

any suggest hidden problems which

cannot be expressed verbally

ELIMINATION


Stool

Pattern: 3x a week

Consistency and shape: soft

Amount: moderate

Odor: no unusual odor

Color: yellow to brown

Normal bowel movement for the

patient

Urine

Quantity per voiding: 200-220ml

Frequency: 5-6x/day

Color: yellow

Clarity: turbid

Specific gravity: 1.010

pH: 6.0

Normal for the patient

Abdomen

Shape: flat

Bowel sound: normoactive

Surgical incision noted due to

previous appendectomy (1 day

post)Wound has still drains

Due to appendectomy

Toileting ability Assisted when going to toilet

Due to her previous operation,

the patient is still dependent to

her significant other

REST AND ACTIVITY


Current Activity LevelOn bedrest

With limited activity

Because of her previous

operation, the patient is

expected to stay always in bed

ADLs

Scale (0-4)

0 completely independent

1 requires devices or

equipment

2 requires supervision,

direction or assistance

3 requires both devices andassistance

4 totally dependent

Activity

Bathing

Hygiene

Toileting

Dressing

Transferring

AmbulatingFeeding

Score

4

4

4

4

4

40

At her condition, the patient is

still dependent to her significant

other

Sleep

Usual bedtime: 9-10 pm

Usual waking time: 5-6 am

Preferred environment for

sleeping: at her bedroom with

her own pillows


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Duration:7-8 hors a night

Quality: easily awakened

Body Frame Endomorph

Posture

n/a due to hindrances like the

patient cannot stand alone due

to her weakness

Gait

n/a due to hindrances like the

patient cannot walk alone due to

her weakness

Coordination Good motor coordination

Balance

Patient can stand alone

With complaints of room/ceiling

spinning around

The patient still needs assistance

Muscle

5 100% of normal strength against

full gravity and resistance

4 75% normal full movement

against gravity and minimal

resistance

3 50% normal movement against

gravity

2 25% full muscle movement

against gravity with full support

1 10% no movement; contraction

of muscle

0 0% normal strength with

complete paralysis

3/5 3/5

3/5 3/5

There is perceived body

weakness that impedes muscle

movement on extremities

Motor Function

Gross: can flex and extend

extremities in a low level

Fine: n/a

Range of MotionLegs and arms: limited

movement (90 degrees)

Pain Relief Measures

Tries to sleep

Takes pain reliever medications

ordered by the doctor

SAFE ENVIRONMENT


Allergies/Reaction

Medications: none

Food: none

Environment: none

Eyes/Vision

PERRLA

Glasses: none

Visual acuity: can recognize

familiar facesSymmetry: symmetrical

Blinking reflex: present

No redness of the conjunctiva

and sclera

It indicates that the patient isalert to external stimuli

Hearing

Structure: no mass noted

Hearing acuity: responds to

normal voice

The patient is able to hear

normally


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Skin

Scars: none

Temperature: warm to touch

(37.8)

Temperature of the patient

indicates hyperthermia

Mucous Membranes Moist and intact

Temperature 37.8 celsius

OXYGENATION


Activity Tolerance

Easy fatigability after an activity

Totally dependent when

performing ADLs

Experiences sudden headache

when standing

It is due to her present condition

Airway Clearance

No presence of secretion, mass

No inflammationNo redness

Respiration

Rate: 14 cpm

Rhythm: regular

Position assumed: supine

position

Lung Sounds

Normal breath sounds

No presence of crackles or rales,

or wheezes

Color

(-) pale

(-) cyanosis

(-) jaundiceCapillary Refill 1-2 seconds

PulseRate:80 bpm

Rhythm: regular

Blood Pressure 90/60 mmHg

Edema None

Homans Sign Negative

NUTRITIONAssessment Significance

Hospital Diet/Restrictions Clear Liquids

As ordered by the physician for

nourishment and also

appropriate for her previous

surgery which is appendectomy

IVFs

Location: left hand

Solution: D5LRS

Rate: 21 gtts/min

Side drips: none

Height and Weight45 kg

54Tissue Turgor Well hydrated

Ability to

Swallow: positive

Gag reflex: positive

Can tolerate food: on clear liquid

diet


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LABORATORY RESULTS

HEMAT

OLOG

Y

Is a series of test used to evaluate the composition and concentration of the cellular components ofblood.

This lad study is also indicated to know any suspected anaemia and the response to treatment, blood lossand the response to blood replacement.

NURSING CONSIDERATIONS:

1. The nurse inserting the needle should clean the skin first. The tourniquet should be removed from the arm

as soon as the blood flows.2. If a finger stick is used to collect the blood, care must be taken to wipe away the first drop, and not to

squeeze the finger excessively as this causes the blood to be diluted by tissue fluid.

3. Discomfort or bruising may occur at the puncture site. Apply pressure to the puncture site until the bleeding

stops help to reduce bruising; warm packs relieve discomfort. Some people feel dizzy or faint blood has been

drawn and should be treated by resting awhile.

HEMATOLOGY

TEST RESULT RANGES REMARKS

Hemoglobin 133M: 135-180 g/l

F: 120-160g/lNormal

Hematocrit 40 M: 40-54F: 37-47

Normal

WBC count 13.0 5-10x109/L Increased

Neutrophils 0.81 0.40-0.70 Increased

Lymphocyte 0.19 0.20-0.40 Decreased

Platelet 282 150-400x109/L Normal

URINALYSIS

PHYSICAL EXAMINAT

IONColor Light Yellow

Transparency Slightly Turbid

Protein Negative

Sugar Negative

pH 6.0

Specific Gravity 1.010

MICROSCOPIC EXAMINATION

Epithelial Cells Moderate

Pus Cells 0.1/hpf

Mucus Threads III

Amorphous Urates IIII


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COURSE IN THE WARD

DATE ORDERS INTERVENTIONSSeptember 20, 2011

BP: 80/60

10:00 pm

yAdmit patient under surgeryySecure consent for admission

and management

yNPO temporarily, may wet lipsyIVF D5LRS 1Lx80yDiagnostics

-CBC typing

-Urinalysis

yTherapeutics-Cefoxitin 1gm IV q 8

0

(-) ANST

-Ranitidine 50g IV q 8

0

yPlan: E RLQ ExploratoryySecure consent for operation

and anesthesia

yNotify OR/NOD/AnesthesiologistyPrepare areayRefer accordingly

Focus: ADMISSION

10:00 pm

D: BP 80/60, wt. 45 kgs.,

conscious and coherent, vital

signs taken, with abdominal pain

2days PTA

A: Seen and examined by Dr.

Reyes with orders made and

carried out, consent for

hospitalization secured signed

by father, CBC typing done,

urinalysis done, result attached

to chart of patient, patient with

D5LRS 1L hooked

Focus: E RLQ EXPLORATION

A: OR notified, consent for said

procedure secured, signed by

father, NPO motivated,

preparation done

Focus: ADMISSION CARE

11:00 pmD: inform OR/wheelchair with

same IVF, conscious and

coherent

A: placed on bed comfortably, on

NPO maintained, on call to OR,

medications started

R: no other complaints made

September 21, 2011 6:25 am

yMaintain NPOyFor OR todayySpecimen received by father

7:45 am

yPost op ordersyTo PACUx4hrsyFlat on bed for 80yMonitor v/s every 15 minutesuntil stable then every 1

0

thereafter

yAdminister O2 inhalation @2LPM

yNPOyIVF of D5LRS 1Lx30gtts/minyMedications-Cefoxitin 1gm IV q 8

0

-Tramadol 50mg IV q 80

x 3 doses

-Ketorolac 30mg IV q 80

x 3 doses

(-) ANST

-Ranitidine 50mg IV q 80 x 3

Focus: E RLQ EXPLORATION

6:45 am

-in from OR/wheelchair with

ongoing IVF of D5LRS 1L @ fulllevel

-conscious and coherent, afebrile

-transferred to OR table safely

-positioned to supine BP- 100/60

-hooked to O2 inhalation @

3LPM

-pulse oximeter sensor to left

thumb reading to PR-82 O2-99%

-positioned to right lateral

decubitus

-skin preparation done in lumbar

area

7:00 am

-SAB inducted by Dr.

Remegio/W. Laguerta, then to

supine position

-incision site prepared


15/18

doses aseptically

-sterile draped applied

7:10 am

-procedure started by Dr. Reyes

with A. Torres and G. Domingo

as scrub nurses with R. Santiago

as instrument nurse

-needed sutures provided

Focus: SPECIMEN OUT

7:31 am

-specimen placed in a sterile

bottle and labeled properly

- specimen handed to relative

with instructions given

-suturing done

-counting of instruments,sponges and needles done

complete

-closing of incision done

-procedure ended

-sterile dressing applied near the

incision site

Focus: TO PACU

-v/s 100/60 O2-99% RR-16

-O2 inhalation weared off

-pulse oximeter sensor removed

7:55 am

-transferred/stretcher with same

IVF on still sedated

-endorsed to NOD

Focus: IN FROM OR S/P E

APPENDECTOMY VIA STRETCHER

8:05 am

D: sedated, with dry and intact

dressing

A: v/s monitored and recorded,

monitored for any untoward

signs, kept thermoregulated,

administered O2 inhalation @

3LPM via nasal cannula as

ordered, medications started

R: no untoward signs noted

Focus: ENDORSED TO SURGERY

WARD

2:00 pm

D: latest v/s BP 100/70, P 76,R 20, T - 36.8, with same IVF on

Focus: IN FROM PACU

2:10 pm

D: received awake, conscious

and coherent, s/p E


16/18

appendectomy, with bearable

post op pain, with intact

dressing, on NPO

A: placed on bed comfortably,

due meds given, NPO

maintained, needs attended

7:00 pm

D: awake, with IVF on NPO, with

intact dressing, with post op pain

A: NPO maintained, kept

comfortable, needs attended


yAfebrileyMay wet lipsyContinue medications

D: on bed awake, sitting

A: wound care done, hygiene

emphasized

7:00 pm

D: swelling at incision site, withtenderness

A: deep breathing exercises,

encouraged ambulation


yMay have clear liquidy(+) febrileyMetronidazole 500mg IV q 60yParacetamol 300mg IV q 40-for temp 37.8

yAmino acid + multivitamins500ml to run for 6hours ODyChange dressing PRNyRefer accordingly

Focus: FEBRILE

5:00 am

D : warm to touch, flushing of

skin, temp -38.5

6:00 am

A: TSB done, loosen tight

clothing

7:00 am

D: on bed, awake with loose

dressing

A: encouraged to take a bath,

hand care done, may have clear

liquid diet, encouraged

ambulation

9:00 am

D: seen by Dr. Reyes with new

orders made and carried out


17/18

Saint Marys University

School of Health and Sciences

Bayombong, Nueva Vizcaya

INDIVIDUAL

CASE STUDYAcute Gangrenous Appendicitis

In partial fulfillment of the requirements in NCM 103 RLE

Submitted by:

Alma Nympha G. Bertos

Student

Submitted to:

Mr. Joman Baliton RN MSN

Clinical instructor


18/18

CONTENTS

I. PERSONAL PROFILE

II. PAST AND PRESENT HEALTH HISTORY

III. BRIEF DESCRIPTION OF THE DISEASE

IV. ANATOMY AND PHYSIOLOGY OF ORGANS INVOLVED

V. PATHOPHYSIOLOGYVI. LABORATORY ANALYSIS

VII. PERSON ASSESSMENT

VIII. COURSE IN THE WARD

IX. DRUG STUDY

X. NURSING CARE PLAN

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Appendicitis Output

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