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Page 1: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

RUPTURED APPENDICITIS WITH LOCALIZE PERITONITIS

A CASE PRESENTATION

Presented to:

THE FACULTY OF THE COLLEGE OF ALLIED MEDICAL SCIENCESNURSING DEPARTMENT

SURIGAO EDUCATION CENTER

In FulfillmentOf the Requirements for the Degree

BACHELOR OF SCIENCE IN NURSINGLEVEL – 3

Presented by:

ARGUILLAS, Grace za T.CHUA, Emily L.

COSTINIANO, Daryll Richmond J.ENARIO, Cheryl C.

EVIOTA, Lanie Ann A.GIER, Rosemarie M.PADILLA, Ruth D.

PAQUEO, Michael M.RAMOS, Honna Bina N.

REPUTANA, Jane A.

OCTOBER 2011DEDICATION

SURIGAO EDUCATION CENTERKm. 2, 8400 Surigao City, Philippines

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This case presentation is indeed the fruit of our endeavor. A sweet success from the sweat

of our hard work that worth every single moment and time that we share in making this, precious

art of learning. Of all the sacrifices, we would heartily dedicate our case presentation to the

following people:

To our parents, who undyingly showed their moral and financial support to us, as we take

every fruitful steps of our endeavor.

To our clinical instructors, for imparting us their knowledge on how are we going to

perform all different procedures of the nursing process, to make us fully equipped as we embark

towards the realization of our chosen profession.

And most especially to our Heavenly Father, who showered us all the guidance and the

abundance of grace.

THE PRESENTORS

ACKNOWLEDGEMENT

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As the presenters of this group case presentation, with deep appreciation and heartfelt

gratitude, we would like to acknowledge the following people who have supported us and made

this study a successful one:

To our parents who morally and financially supported us. For their encouragement and

understanding why were always late in coming home.

To our instructors who undoubtedly impart their knowledge and showed their support to

us.

To all staff of Caraga Regional Hospital, who gave us the permit to copy all the

information necessary for this educational output to be completed from the patients chart.

To the patient and patient’s family who never ceased to answer whatever questions we

have raised.

And most especially, to our Heavenly Father for giving us all the blessings, strength,

wisdom and enlightenment that we are able to complete all the information needed.

Indeed, this case study has definitely enhanced and advanced our knowledge in our

chosen career.

THE PRESENTORS

CASE CONTENTS

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TITLE PAGE

DEDICATION

ACKNOWLEDGMENT

INTRODUCTION

REVIEW OF RELATED LITERATURE

PATIENT HEALTH HISTORY

PHYSICAL ASSESSMENT

12 CRANIAL NERVE ASSESSMENT

REVIEW OF SYSTEM

LABORATORY EXAM

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

DRUG STUDY

NURSING CARE PLAN

DISCHARGE PLAN

APPENDICES

A. INTRAVENOUS FLUID

B. FAMILY GENOGRAM

C. DEFINITION OF TERMS

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BIBLIOGRAPHY

INTRODUCTION

Our body has composed of twelve (12) different body systems; one of this is the digestive

system. Digestive system breaks down food into absorbable units that enter the blood for

distribution to body cells; indigestible foodstuffs are eliminated as feces. Digestion takes place

almost continuously in a watery, slush environment. The large intestine absorbs the water from

its inner contents and stores the rest until it is convenient to dispose of it. Attached to the first

portion of the large intestine is a pouch called the vermiform appendix. According to our

ancestors and even on the present time, appendix has no function in the human body but it is part

of the large intestine. However, many theories, that human appendix have a function; it carries

good bacteria. With function or without, appendix can be fatal when it gets infected and not

treated right away.

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

cecum just below the ileocecal valve. 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. It is thought that appendicitis

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

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

cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is

called Fecalith.

Mr. P., 16 years old, College student resides at Vasquez St. Surigao City while attending

school at SSCT. He grew up at Brgy. Villa Flor, Gigaguit, Surigao Del Norte. Admitted at

Caraga Regional Hospital last September 01, 2011 and diagnosed with ruptured appendicitis

with localized peritonitis. His chief complaint was severe abdominal pain scale of “10/10” and

vomiting 5-7 times in one day.

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According to oxfordjurnals.org, the author’s analyzed National Hospital discharge survey

data for the years 1979-1984. Approximately 250,000 cases of appendicitis occurred annually in

the United States during this period. The highest incidence of primary positive appendectomy

(appendicitis) was found in persons aged 10-19 years old; males had higher rates of appendicitis

than females for all age groups. Furthermore, the incident rate of appendicitis in the Philippines

is approximately 215,604 persons, out of estimated population of 86, 241, and 6972.

Appendicitis is an inflammation of the appendix, a 3 1/2-inch-long tube of tissue that

extends from the large intestine. If the inflammation and infection spread through the wall of the

appendix, the appendix can rupture, causing infection of the peritoneal cavity called peritonitis.

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

the patient’s condition become worsens.

In Mr. P’s case, he has ruptured appendicitis with localized peritonitis. We choose the

case of Mr. P, to know the nature of the disease the risk factors, its complications and

preventable measures; because, the complications of the disease cause many devastating health

problem if left untreated.

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REVIEW OF RELATED LITERATURE

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

of the abdomen, is the most common reason for emergency abdominal surgery especially when

ruptured occurs. According to Brunner & Suddarth, “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. Although it can occur at any age, it occurs most frequently between the ages of 10

and 30 years old”.

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

Appendicitis usually happens after an infection in the digestive tract, or when the tube

connecting the large intestine and appendix is blocked by trapped feces or food. Both situations

cause inflammation, which can lead to infection or rupture of the appendix. Untreated, mortality

is high, mainly because of the risk of rupture leading to peritonitis and shock. Also, if the

abdomen on palpation is also involuntary guarded (rigid) there should be a strong suspicion of

peritonitis.

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Signs and Symptoms:

Pain starting around the navel, then moving down and to the right side of the

abdomen. The pain gets worse when moving, taking deep breaths, coughing

sneezing or being touched (McBurney’s point).

Loss of appetite

Nausea, and Vomiting

Change in bowel movements, including diarrhea or constipation or unable to pass

gas.

Fever

Rovsing’s sign: continuous deep palpation starting from the left iliac fossa

upwards (counterclockwise along the colon) may cause pain in the right iliac

fossa, by pushing bowel contents towards the ileocaecal valve and thus increasing

pressure around the appendix.

Psoas sign: is the right lower-quadrant pain that is produced with either the

passive extension of the patients right hip (pt. lying on the left side, with knee in

flexion) or the patient’s active flexion of the right hip while supine. Straightening

out the legs causes pain because it stretches these muscles, while flexing the hip

activated the iliopsoas and therefore causes pain.

Obturator sign: if an inflamed appendix is in contact with the obturator

internus, spasm of the muscle can be demonstrated by flexing and internal

rotation of the hip. This maneuver will cause pain in the hypogastrium.

Dunphy’s sign: increased pain in the right lower quadrant with coughing.

Kocher’s Sign: the appearance of pain in the epigastric region or around the

stomach at the beginning of disease with a subsequent shift to the right iliac

region.

Stikovskiy (resenstein’s) sign: increased pain on palpation at the right iliac

region as patient lies on his/her left side.

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Blumberg sign: also referred as rebound tenderness. Deep palpation of the

viscera over the suspected inflamed appendix followed by sudden release of the

pessue causes the severe pain on the site indicating positing Blumberg’s sign and

peritonitis.

Risk Factors

Risk factors for Appendicitis are factors that do not seem to be a direct cause of the

disease, but seem to be associated in some way. Having a risk factor for Acute Appendicitis

makes the chances of getting the condition higher but does not always lead to Acute

Appendicitis.

Age: Appendicitis can occur in all age groups but it is more common between the ages of

11 and 20.

Gender: A male preponderance exists, with a male to female ratio (1.4: 1) and the

overall lifetime risk is 8.6% for males and 6.7% for females. A male child suffering from cystic

fibrosis is at a higher risk for developing appendicitis.

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Diet: People whose diet is low in fiber and rich in refined carbohydrates have an

increased risk getting appendicitis.

Hereditary: A particular position of the appendix, which predisposes it to infection, runs

in certain families. Having a family history of appendicitis may increase a child's risk for the

illness.

Seasonal variation: Most cases of appendicitis occur in the winter months - between the

months of October and May.

Infections: Gastrointestinal infections such as Amebiasis, Bacterial Gastroenteritis,

Mumps, Coxsackievirus B and Adenovirus can predispose an individual to Appendicitis.

Causes

On the basis of experimental evidence, acute appendicitis seems to be the end result of a

primary obstruction of the appendix lumen (the inside space of a tubular structure). Once this

obstruction occurs the appendix subsequently becomes filled with mucus and swells, increasing

pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion

of the small vessels, and stasis of lymphatic flow. Rarely, spontaneous recovery can occur at this

point. As the former progresses, the appendix becomes ischemic and then necrotic. As bacteria

begin to leak out through the dying walls, pus forms within and around the appendix

(suppuration). The end result of this cascade is appendiceal rupture (a 'burst appendix') causing

peritonitis, which may lead to septicemia and eventually death.

The causative agents include foreign bodies, trauma, intestinal worms, lymphadenitis,

and most commonly calcified fecal deposits known as appendicoliths or fecalith. The occurrence

of an obstructing fecalith has attracted attention since their presence in patients with appendicitis

is significantly higher in developed than in developing countries, and an appendiceal fecalith is

commonly associated with complicated appendicitis. Also, fecal stasis and arrest may play a role,

as demonstrated by a significantly lower number of bowel movements per week in patients with

acute appendicitis compared with healthy controls. The occurrence of a fecalith in the appendix

seems to be attributed to a right side fecal retention reservoir in the colon and a prolonged transit

time. From epidemiological data it has been stated that diverticular disease and adenomatous

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polyps were unknown and colon cancer exceedingly rare in communities exempt for

appendicitis. Also, acute appendicitis shown to occur antecedent to cancer in the colon and

rectum. Several studies offer evidence that a low fiber intake is involved in the pathogenesis of

appendicitis. This is in accordance with the occurrence of a right sided fecal reservoir and the

fact that dietary fiber reduces transit time.

Complications of Appendicitis

Rupture of the Appendix

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

appendix can lead to a peri-appendiceal abscess (a collection of infected pus) or diffuse

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

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

between diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours

after the onset of symptoms is at least 15%. Therefore, once appendicitis is diagnosed, surgery

should be done without unnecessary delay.

Peritonitis or Abscess

Peritonitis is a dangerous infection. This complication can occur when bacteria and other

contents of the torn appendix leak into the abdomen (stomach). A ruptured appendix can lead to

peritonitis and abscess. An abscess usually takes the form of a swollen mass filled with fluid and

bacteria.

 

Blockage or Obstruction of the intestine

A less common complication of appendicitis is blockage or obstruction of the intestine.

Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to

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

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

occur. It then may be necessary to drain the contents of the intestine through a tube passed

through the nose and esophagus and into the stomach and intestine.

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Sepsis

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

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

complication. Fortunately, it occurs infrequently.

Diagnosis

Diagnosis is based on patient history (symptoms) and physical examination backed by an

elevation of neutrophilic white blood cells. Histories fall into two categories, typical and

atypical. Typical appendicitis usually includes abdominal pain beginning in the region of the

umbilicus for several hours, associated with anorexia, nausea or vomiting. The pain then "settles"

into the right lower quadrant, where tenderness develops. Atypical histories lack this typical

progression and may include pain in the right lower quadrant as an initial symptom. Atypical

histories often require imaging with ultrasound and/or CT scanning.[23] A pregnancy test is vital

in all women of child bearing age, as ectopic pregnancies and appendicitis present with similar

symptoms. The consequences of missing an ectopic pregnancy are serious, and potentially life

threatening. Furthermore the general principles of approaching abdominal pain in women (in so

much that it is different from the approach in men) should be appreciated.

Blood Test

Most patients suspected of having appendicitis would be asked to do a blood test. 50% of

the time, the blood test may be normal, so it is not foolproof in diagnosing appendicitis. Two

forms of blood tests are commonly done: FBC (Full blood count) or CBC (Complete blood

count) is an inexpensive and commonly requested blood test. It involves measuring the blood for

its richness in red blood cells as well as the number of the various white blood cell constituents

in it. The number of white cells in the blood is a usually less than 10,000 cells per cubic

millimeter. An abnormal rise in the number of white blood cells in the blood is a crude indicator

of infection or inflammation going on in the body. Such rise is not specific to appendicitis alone.

If it is abnormally elevated, with a good history and examination findings pointing towards

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appendicitis, the likelihood of having the disease is higher. In pregnancy, there may be a normal

elevation of white blood cells, without any infection present.

CRP

CRP is an acronym for C-reactive protein. It is an acute phase response protein produced

by the liver in response to any infection or inflammatory process in the body. Again, like the

FBC, it is not a specific test. It is another crude marker of infection or inflammation.

Inflammation at ANY site can lead to the CRP to rise. A significant rise in CRP with

corresponding signs and symptoms of appendicitis is a useful indicator in the diagnosis of

appendicitis. It is said that if CRP continues to be normal after 72 hours of the onset of pain, it is

likely that the appendicitis will resolve on its own without intervention. A worsening CRP with

good history is a sure signal of impending perforation or ruptures and abscess formation.

Urine Test

Urine test in appendicitis is usually normal. It may however show blood if the appendix is

rubbing on the bladder, causing irritation a urine test or urinalysis is compulsory in women, to

rule out pregnancy in appendicitis, as well to help ensure that the abdominal pain felt and

thought to be acute appendicitis is not in fact, due to ectopic pregnancy.

X – Ray

In 10% of patients with appendicitis, plain abdominal x-ray may demonstrate hard

formed feces in the lumen of the appendix (Fecolith). It is agreed that the finding of Fecolith in

the appendix on X – ray alone is a reason to operate to remove the appendix, because of the

potential to cause worsening symptoms. In this respect, a plain abdominal X-ray may be useful

in the diagnosis of appendicitis, though plain abdominal x- ray is no longer requested routinely in

suspected cases of appendicitis. An abdominal X – ray may be done with a barium enema

contrast to diagnose appendicitis. Barium enema is whitish toothpaste like material that is passed

up into the rectum to act as a contrast. It will usually fill the whole of the large bowel. In normal

appendix, the lumen will be present and the barium fills it up and is seen when the x-ray film is

shot. In appendicitis, the lumen of the appendix will not be visible on the barium film.

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Ultrasound

Ultrasonography and Doppler sonography provide useful means to detect appendicitis,

especially in children and shows free fluid collection in right iliac fossa along with a visible

appendix without blood flow in color Doppler. In some cases (15% approximately), however,

ultrasonography of the iliac fossa does not reveal any abnormalities despite the presence of

appendicitis. This is especially true of early appendicitis before the appendix has become

significantly distended and in adults where larger amounts of fat and bowel gas make actually

seeing the appendix technically difficult. Despite these limitations, in experienced hands

sonographic imaging can often distinguish between appendicitis and other diseases with very

similar symptoms such as inflammation of lymph nodes near the appendix or pain originating

from other pelvic organs such as the ovaries or fallopian tubes.

Computed tomography

A cat scans demonstrating acute appendicitis (note the appendix has a diameter of

17.1mm and there is surrounding fat stranding.) In places where it is readily available, CT scan

has become frequently used, especially in adults whose diagnosis is not obvious on history and

physical. Concerns about radiation, however, tend to limit use of CT in pregnant women and

children. A properly performed CT scan with modern equipment has a detection rate (sensitivity)

of over 95% and a similar specificity. Signs of appendicitis on CT scan include lack of oral

contrast (oral dye) in the appendix, direct visualization of appendiceal enlargement (greater than

6 mm in cross sectional diameter), and appendiceal wall enhancement with IV contrast (IV dye).

The inflammation caused by appendicitis in the surrounding peritoneal fat (so called "fat

stranding") can also be observed on CT, providing a mechanism to detect early appendicitis and

a clue that appendicitis may be present even when the appendix is not well seen. Thus, diagnosis

of appendicitis by CT is made more difficult in very thin patients and in children, both of whom

tend to lack significant fat within the abdomen.

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Management

Before surgery

The treatment begins by keeping the patient from eating or drinking in preparation for

surgery. An intravenous drip is used to hydrate the patient. Antibiotics given intravenously such

as cefuroxime and metronidazole may be administered early to help kill bacteria and thus reduce

the spread of infection in the abdomen and postoperative complications in the abdomen or

wound. Equivocal cases may become more difficult to assess with antibiotic treatment and

benefit from serial examinations. If the stomach is empty (no food in the past six hours) general

anaesthesia is usually used. Otherwise, spinal anaesthesia may be used.

Once the decision to perform an appendectomy has been made, the preparation procedure

takes more or less one to two hours. Meanwhile, the surgeon will explain the surgery procedure

and will present the risks that must be considered when performing an appendectomy. With all

surgeries there are certain risks that must be evaluated before performing the procedures.

However, the risks are different depending on the state of the appendix. If the appendix has not

ruptured, the complication rate is only about 3% but if the appendix has ruptured, the

complication rate rises to almost 59%. The most usual complications that can occur are

pneumonia, hernia of the incision, thrombophlebitis, bleeding or adhesions. Recent evidence

indicates that a delay in obtaining surgery after admission results in no measurable difference in

patient outcomes.

The surgeon will also explain how long the recovery process should take. Abdomen hair

is usually removed in order to avoid complications that may appear regarding the incision. In

most of the cases patients experience nausea or vomiting which requires specific medication

before surgery. Antibiotics along with pain medication may also be administrated prior to

appendectomies.

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Pain management

Pain from appendicitis can be severe. Strong pain medications (i.e., narcotic pain

medications) are recommended for pain management prior to surgery. Morphine is generally the

standard of care in adults and children in the treatment of pain from appendicitis prior to surgery.

In the past (and in some medical textbooks that are still published today), it was commonly

accepted among the majority of academic sources that pain medication not be given until the

surgeon has the chance to evaluate the patient, so as to not "corrupt" the findings of the physical

examination. This line of practice, combined with the fact that surgeons may sometimes take

hours to come to evaluate the patient, especially if he or she is in the middle of surgery or has to

drive in from home, often leads to a situation that is ethically questionable at best. More recently,

due to better understanding of the importance of pain control in patients, it has been shown that

the physical examination is actually not that dramatically disturbed when pain medication is

given prior to medical evaluation. Individual hospitals and clinics have adapted to this new

approach of pain management of appendicitis by developing a compromise of allowing the

surgeon a maximum time to arrive for evaluation, such as 20 to 30 minutes, before active pain

management is initiated. Many surgeons also advocate this new approach of providing pain

management immediately rather than only after surgical evaluation.

Surgery

The surgical procedure for the removal of the appendix is called an appendicectomy (also

known as an appendectomy). Often now the operation can be performed via a laparoscopic

approach, or via three small incisions with a camera to visualize the area of interest in the

abdomen. If the findings reveal supportive appendicitis with complications such as rupture,

abscess, adhesions, etc., conversion to open laparotomy may be necessary. An open laparotomy

incision if required most often centers on the area of maximum tenderness, McBurney's point, in

the right lower quadrant. A transverse or a gridiron diagonal incision is used most commonly.

According to a meta-analysis from the Cochrane Collaboration comparing laparoscopic

and open procedures, laparoscopic procedures seem to have various advantages over the open

procedure. Wound infections were less likely after laparoscopic appendicectomy than after open

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appendicectomy (odds ratio (OR) 0.45; confidence interval (CI) 0.35 to 0.58), but the incidence

of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21). The duration of surgery

was 12 minutes (CI 7 to 16) longer for laparoscopic procedures. Pain on day 1 after surgery was

reduced after laparoscopic procedures by 9 mm (CI 5 to 13 mm) on a 100 millimeter visual

analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity,

work, and sport occurred earlier after laparoscopic procedures than after open procedures. While

the operation costs of laparoscopic procedures were significantly higher, the costs outside

hospital were reduced. Young female, obese, and employed patients seem to benefit from the

laparoscopic procedure more than other groups.

There is debate whether emergency appendicectomy (within 6 hours of admission)

reduces the risk of perforation or complication versus urgent appendicectomy (greater than 6

hours after admission). According to a retrospective case review study no significant differences

in perforation rate among the two groups were noted (P=.397). Various complications (abscess

formation, re-admission) showed no significant differences (P=0.667, 0.999). According to this

study, beginning antibiotic therapy and delaying appendicectomy from the middle of the night to

the next day does not significantly increase the risk of perforation or other complications. This

finding is important not simply for the convenience of the surgeons and staff involved but for the

fact that there have been other studies that have shown that surgeries taking place during the

night, when people may be more tired and there is fewer staff available, have higher rates of

surgical complications.

Findings at the time of surgery are less severe in typical appendicitis. With atypical

histories, perforation is more common and findings suggest perforation occurs at the beginning

of symptoms. These observations may fit a theory that acute (typical) appendicitis and

suppurative (atypical) appendicitis are two distinct disease processes.

Surgery may last from 30 minutes in typical appendicitis in thin patients to several hours

in complicated cases.

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Complications of Appendectomy

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

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

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

antibiotics and surgical treatment. Occasionally, the inflammation and infection of appendicitis

are so severe that the surgeon will not close the incision at the end of the surgery because of

concern that the wound is already infected. Instead, the surgical closing is postponed for several

days to allow the infection to subside with antibiotic therapy and make it less likely for infection

to occur within the incision.

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

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

surgical techniques.

Laparotomy

Laparotomy is the traditional type of surgery used for treating appendicitis. This

procedure consists in the removal of the infected appendix through a single larger incision in the

lower right area of the abdomen. The incision in a laparotomy is usually 2-3 inches long. This

type of surgery is used also for visualizing and examining structures inside the abdominal cavity

and it is called exploratory laparotomy.

During a traditional appendectomy procedure, the patient is placed under general

anesthesia in order to keep his/her muscles completely relaxed and to keep the patient

unconscious. The incision is two to three inches (76 mm) long and it is made in the right lower

abdomen, several inches above the hip bone. Once the incision opens the abdomen cavity and the

appendix is identified, the surgeon removes the infected tissue and cuts the appendix from the

surrounding tissue. After the surgeon inspects carefully and closely the infected area and there

are no signs that surrounding tissues are damaged or infected, he will start closing the incision.

This means sewing the muscles and using surgical staples or stitches to close the skin up. In

order to prevent infections the incision is covered with a sterile bandage. The entire procedure

does not last longer than an hour if complications do not occur.

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Laparoscopic surgery

The newer method to treat appendicitis is the laparoscopic surgery. This surgical

procedure consists of making three to four incisions in the abdomen, each 0.25 to 0.5 inch (6.3 to

13 mm) long. This type of appendectomy is made by inserting a special surgical tool called

laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the

patient's body and it is designed to help the surgeon to inspect the infected area in the abdomen.

The other two incisions are made for the specific removal of the appendix by using surgical

instruments. Laparoscopic surgery also requires general anesthesia and it can last up to two

hours. The latest methods are NOTES appendectomy pioneered in Coimbatore, India where there

is no incision on the external skin and SILS (Single incision laparoscopic Surgery) where a

single 2.5 cm incision is made to perform the surgery.

After surgery

Hospital lengths of stay typically range from a few hours to a few days, but can be a few

weeks if complications occur. The recovery process may vary depending on the severity of the

condition, if the appendix had ruptured or not before surgery. Appendix surgery recovery is

generally a lot faster if the appendix did not rupture. It is important that patients respect their

doctor's advice and limit their physical activity so the tissues can heal faster. Recovery after an

appendectomy may not require diet changes or a lifestyle change.

After surgery occurs, the patient will be transferred to a Post-anesthesia care unit so his or

her vital signs can be closely monitored in order to detect anesthesia and/or surgery related

complications. Pain medication may also be administrated if necessary. After patients are

completely awake, they are moved into a hospital room to recover. Most individuals will be

offered clear liquids the day after the surgery and then progress to a regular diet when the

intestines start to function properly. It is highly recommended that patients sit up on the edge of

the bed and walk short distances for several times a day. Moving is mandatory and pain

medication may be given if necessary. Full recovery from appendectomies takes about 4 to 6

weeks but it can prolong to up to 8 weeks if the appendix had ruptured.

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Prognosis

Most appendicitis patients recover easily with surgical treatment, but complications can

occur if treatment is delayed or if peritonitis occurs. Recovery time depends on age, condition,

complications, and other circumstances, including the amount of alcohol consumption, but

usually is between 10 and 28 days. For young children (around 10 years old), the recovery takes

three weeks.

The real possibility of life-threatening peritonitis is the reason why acute appendicitis

warrants speedy evaluation and treatment. The patient may have to undergo a medical

evacuation. Appendectomies have occasionally been performed in emergency conditions (i.e.,

outside of a proper hospital), when a timely medical evaluation was impossible.

Prevention

Appendicitis is probably not preventable, although there is some indication that a diet

high in green vegetables and tomatoes may help prevent appendicitis.

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PATIENT HEALTH HISTORY

Biographic Data:

Name of patient: Mr. P. G

Address: Prk 2, Brgy. Villa Flor, Gigaguit.

Age: 16 years old

Sex: Male

Civil Status: Single

Date of birth: November 20, 1995

Religion: Catholic

Source of information: Primary source- patient

Secondary source- chart and mother

Admission Data:

Hospital: Caraga Regional Hospital

Room #: Surgical Ward, S-2

Date admitted: September 1, 2011

Time admitted: 10:12 AM

Arrived via: Via Wheelchair

Vital Signs upon admission: Temperature: 37.8 C

Heart rate: 96 bpm

Respiratory rate: 28 cpm

Blood Pressure: 100/70

Weight: 47kg.

Height: 5’6

Admitting Physician: Dr. Glenn Alfred Baban

Attending Physician: Dr. Glenn Alfred Baban

Surgeon: Dr. Relliquette

Anesthesiologist: Dr. C. Dumas

Chief Complaints: Severe abdominal pain and vomiting 7-10x in a day

Impression: Intussisuption

Final Diagnoses: Ruptured Appendicitis with localize Peritonitis

Date of Discharge: September 8, 2011

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BODY MASS INDEX

Reference:

Underweight = <18.5Normal weight = 18.5–24.9 Overweight = 25–29.9 Obesity = BMI of 30 or greater

Given:

Weight: 47 kg. Height: 5 ft. 6 inches

Formula:

BMI = ____mass (lb.) x 703____[height (inches)] squared

Conversion:

703 = (constant value in BMI)47 kg. = (2.20 lb./ 1 kg) = 103.4 lb.5 ft. = (12 inches/ 1 ft.) = 60 inches6 inches = (no need to convert)

Solution:

BMI= _______103.4 lb. x 703_______(60 inches + 6 inches) squared

= ____72690.2 lb.___(66 inches) squared

= _72690.2 lb.4356 inches

= 16.69 BMI

Patient is Underweight.

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History of Present Illness:

Last August 30, 2011, two days prior to admission. Mr. P experienced on and off fever

(37.80C-38.70C), abdominal pain (scale of “10/10”), and vomiting 7x (clear and viscous). As a

management Mr. P took Biogesic one tab for fever and pain, he says it helped subside the fever

after few hours. However, after lunch time of August 31, his temperature spiked up again to

38.70C, that is when Mr. P’s mother decided to take him to see Dr Ycong the same day. On

September 1, 2011 Mr. P was admitted at Caraga Regional Hospital with the advice of Dr.

Ycong.

Past Health History

A. Childhood Illness

Mr. P. had chicken pox at age of 11 years old. He did not experience

mumps and measles. Sometimes he gets minor coughs for few days and uses over

the counter drugs like Solmux 500 mg once a day until his cough subsides. Also,

he uses Neozep for colds or paracetamol for fever occasionally.

B. Childhood Immunization

Since the patient is 16, and the EPI (Expanded Program on Immunization)

was launched on 1970’s. Mr. P’s mother claimed that his son is complete of his

childhood immunization. She takes him to Barangay Clinic for his immunization

shots. The following Immunization given to the patient during his mother visits in

a certain clinic are: BCG, 1 dose and Hep B, 3 doses – at birth; Measles – 9

months; DPT – week 6, 3 doses; and OPV – week 7, 3 doses.

C. History of Hospitalization

Mr. P claimed that as far as he can remember he is been admitted in the

hospital twice prior to the present hospitalization. First, last 2009 at Caraga

Regional Hospital due to appendicitis. Dr. Amoncio was his attending physician

and he was discharge after 1 week receiving of series of antibiotics, and take

home medications no surgical intervention was done. Second hospitalization, was

August 27, 2009 due to motorcycle accident, and admitted at Municipal Hospital

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in Gigaquit for observations and pain management. Only minor scrapes and small

open wound on the right and left knee.

a. Surgical History

Mr. P. claimed that he did not undergo any surgery in the past.

b. Accidents and Injuries

Mr. P. was involved in a motorcycle accident last August 27, 2009. He

was admitted at municipal Hospital in Gigaquit for minor open wound on the

right and left knee and minor scrapes on the right and left elbow.

c. Medications.

Mr. P. claimed that he uses over the counter drugs for occasionally cough,

fever, and or head ache.

D. Family Health History

Client is the 2nd child among 5 siblings. 3 boys, and 2 girls. His

grandmother on paternal side and grandfather on maternal side are deceased due

to hypertension. Also his father ha hypertension as well and taking medicine for

maintenance. (He forgot what the medications name)

E. Personal Health History

a. Life Style

Personal Habits: Mr. P claimed that he started drinking alcohol and smoke

cigarette at the age of 14years old. He can consume 73 cigarette packs a year.

Sometimes twice a month he consumed 3-5 glasses of hard liquor (tanduay). But

he claimed that by the age of 15and ½ years old he stop smoocking cigarette. But

still drink alcohol occasionally.

b. Diet

Before hospitalization, Mr. P. eats at least 1-2cups of plain rice, 1-2small fish

(could be fried sometimes grilled, paksiw.), and vegetables. He also claimed that

he loves to eat “kinilaw” sometimes 3x a week. He drinks 2-3 glasses ( small cup,

240cc) of water a day, and 12oz of carbonated drinks 3-4x a day.

During Hospitalization Mr. P was on NPO ( nothing per orem).

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c. Sleep and Rest Pattern

Before Hospitalization, he usually sleeps between 11 pm to 12 midnight, and

wakes up around 6:30 am. During hospitalization, he claimed that he has problem

sleeping because he is not comfortable with the bed and it is noisy in the ward. He

also claimed it is hard to sleep for more than 4 hours because nurse’s wakes him

up for medications and vital signs.

d. Elimination Pattern

Before hospitalization, Mr. P. urinates 3 times a day and defecates at least once

every other day and sometimes once every 3 days.

During Hospitalization, he urinated 3-4 times a day. However, no bowel

movement noted during our 2 days of assessment.

e. Activities with Daily living.

Before hospitalization, Patient claimed that he does not have problems with his

daily activities, such as; bathing, dressing, eating, and or any difficulty with his

locomotion.

During Hospitalization, Patient still able to perform daily activities but slow and

with assistance when dressing and setting up, due to abdominal pain on the right

lower quadrant.

f. Recreational Activities and Hobbies.

Mr. P. claimed that he loves to play basketball. He plays at least twice a week. He

hangs out with his friends on the weekend and sometimes drinks alcohol, like

tanduay. He listens to music and watch television when he is at home.

F. Social Data

a. Family Relationships/friendship.

With regards to their family relationship, Mr. P. has a strong family ties, and has a

very supportive siblings and parents. Client’s friends visited him in the hospital

and showed empathy to the client and client’s family. He has also an open

communication with his family and girlfriend.

b. Ethnic Affiliation.

Mr. P is a native Filipino. He assimilated the values, beliefs, and culture of

Filipinos. Filipinos are known to be loving, hardworking, religious, and

Page 26: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

hospitable. He stated that he uses herbal medicines. He verbalized also that if

some health problems will arise, they prefer to go to health care professionals.

c. Educational History

When Mr. P was on 6th grade he was on top 6 out of 10. He awarded Boy Scout of

the year. During High School he claimed, he did not received any special award

because he was a working student. Mr. P. is currently attending as a fulltime

college student at SSCT. Here in Surigao City.

d. Occupational History

Before attending College, he was working as a tricycle driver and put himself

through high school.

e. Economic Status

Mr. P. claimed that his family is able to afford the necessities at the household

and can support him going to college.

G. Environmental Data

According to Mr. P. he lives in a simple two story house. 1st floor is made of

concrete and 2nd floor made of wood materials in Gigaquit. His parents are

farmers and owned chickens and 4 pigs. They have 3 rooms that are separated

only by curtains. The toilet is flushed type and located inside. As a method of

garbage disposal they separate the recyclable from biodegradable and non-

biodegradable waste and collected by the garbage truck.

H. Psychological Data

Mr. P. claimed that he gets stress when time for major examination at school and

when his parents scolded him.

I. Patterns of Health Care

Client’s family initially seeks the “quack doctor” in times of health problems and

would try to use herbal medicinal plants as remedy; for instance, “sambong” for

“panohot” and “karabo” for cough. However, if condition persist, they visits

health center for check-up.

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PHYSICAL ASSESSMENT

Date of Assessment: September 1, 2, and 3, 2011 (7am-1pm shift)

GENERAL SURVEY

Assessed lying on bed ( in supine position), conscious, responsive, coherent, not in

respiratory distress, complained of abdominal pain on his right lower quadrant , facial grimacing

noted, with an IVF of D5LR 1L (@550 ml receiving level) regulated @ 20 gtts/min infusing well

@ left metacarpal vein and with the following vital signs:

T: 38.10C PR: 73bpm RR: 19cpm B/P 110/70mmHg

INTEGUMENTARY:

Skin

Inspection:

Generally light-brown uniform in color.

Old scars are noted at the right knee (4 inches wide, upper) and at the back (lower

quadrant (2 inches wide)

Skin is intact.

Palpation:

Both lower and upper extremities has moist and warm skin to touch.

Good skin turgor when pinched it goes back to previous state after 1 second.

Elevated body temperature 38.1°C

Hair

Inspection:

Short and slightly silky black hair.

Evenly distributed hair on the scalp and all over the body.

Dandruff noted at the scalp.

No signs of infestations.

Palpation:

Smooth hair noted

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Nails

Inspection:

Nail color – slightly pale.

Convex curvature of nail plate.

Intact epidermis on both fingernails and toe nails.

Palpation:

Smooth texture noted.

The nails returned at its original color – slightly pale <2 seconds upon performing the

capillary refill test.

Head, Eyes, Ears, Nose and Throat (HEENT)

Skull and Face

Inspection:

Rounded and normocephalic skull contour.

Symmetric facial features.

Palpation:

Smooth, uniform consistency of the skull.

No inflammation, and lumps or masses noted at the skull.

Eyes and Vision

Inspection:

External structure, eyebrows, eyelashes, eyelids are evenly distributed

No abnormal discharges of the eyes noted.

Pupils are black, equal in sizes (about 2 mm) and responsive to light, (PERRLA).

Palpation:

Upon palpating the lacrimal gland, no edema noted and tenderness reported.

Ear and Hearing

Inspection:

Color same as facial noted.

Symmetric ear positions that lines with outer canthus of the eye

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Able to hear at both ears upon performing the watch tick and follows simple words

commanded.

Palpation:

Auricles are mobile and firm.

No tenderness noted.

Nose and Sinuses

Inspection:

Nose is symmetrical.

No discharges or flaring noted.

Air moves freely as the client breaths through the nares.

Nasal septum is intact and in middle.

No presence of discharges noted.

Palpation:

No tenderness and lesions on both nose and sinuses observed.

Oropharynx (mouth and throat)

Inspection:

Lips have symmetric contour, slightly pale in color. Soft and slightly dry.

Able to perform pursed lip breathing.

Tongue is positioned centrally.

Tongue moves freely.

Palpation:

No presence of lesions and tenderness.

Positive gag reflex upon touching the posterior part of the tongue with the use of

tongue depressor.

Neck

Inspection:

Neck muscles are equal with head positioned at the center.

Able to flex, extend and hyperextend his head when asked to do so.

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Palpation:

No tenderness reported and lesions observed upon palpation

Thorax and Lungs

Inspection:

Respiratory rate is 19 cpm

Spine vertically aligned

Chest is symmetric

No respiratory distress observed

Chest wall is intact

Palpation:

No tenderness noted upon palpation

Percussion:

Resonant sound at the posterior part of the shoulder

Auscultation:

Normal breath sounds heard upon auscultation.

Cardiovascular System and Peripheral Vascular System

Inspection:

Blood pressure of 110/70 mmHg

Pulse rate of 73 bpm

No edema noted

No palpitations observed all over the body

No jugular vein distention noted upon inspection

Palpation:

Capillary refill test-less than 2 seconds

Breast and Axillae

Inspection:

Same color as the skin of the abdomen and back

He had dark brown areola with nipple

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No discharges on nipple noted

Presence of hair at the axilla

Palpation:

No masses, nodules or tenderness noted.

Abdomen

Inspection:

Uniform in color

Abdominal distention is noted (28 inches in circumference)

Abdominal guarding noted

Auscultation:

Bowel sounds heard in 4 quadrants (10 bowel sounds per minute)

Percussion:

Dull sounds heard at the liver region

Tympanic sounds heard at the spleen region

Palpation:

Positive on rebound tenderness when palpate on the left lower quadrant. “sakit ako

tiyan sa kilid” scale of “7/10” he pointed on the right lower quadrant.

Musculoskeletal

Inspection:

Muscle are equal on both upper and lower extremities of the body

No contractures and deformities noted

Palpation:

Smooth coordinated movements when asked to perform the ROM in upper

extremities.

ROM on lower extremities performed with slight difficulty due to felt pain.

Genitals

Patient refused to perform physical examination on genital area.

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Neurologic System

Language

Client is able to speak clearly and had no difficulty speaking. He displays verbal and

non-verbal communication (ex. Gestures, facial expression). Client is able to

understand Visayan dialect.

Orientation

Client is oriented to self, time, and place. Able to identify the present location and can

easily recognize significant others “ jadto si mama”

Memory

Able to recall the nurse on duty who had just given him his medication. ( Immediate

memory).

Able to recall one of his relatives from Brgy. Villaflor, Gigaquit who called him 4

days ago asking about his condition (Recent memory).

Able to recall his closest friends in elementary years (Remote memory)

Attention Span

Client has approximately 30 minutes to 1 hour of conversation.

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REVIEW OF SYSTEM

Integumentary System

Patient claimed he did not experience any rashes or lesions in his skin. He also claimed

that sometimes he experienced skin itchiness and dry skin.

Head, Eyes, Ears, Nose, Throat (HEENT)

Patient experienced common colds occasionally. Also stated he had an eye irritation once

or twice when he was in high school.

Neck

He did not experience any lump, tenderness, distention in jugular veins or stiffness.

Breast and Axillae

Patient said that he has no previous experience of any abnormalities on his breasts and

axilla.

Thorax and Lungs

Client doesn’t have any thorax and lung abnormalities.

Cardiovascular System

Client denies of any problems pertains to his cardiovascular system. However, he states

that his father has hypertension.

Gastrointestinal System

Client claims that occasionally he experiences constipation (Color: dark-brown;

Frequency: once in 3 days; Appearance: dry; Consistency: hard stool) and minor

abdominal cramps and able to control it with over the counter medicine.

Musculoskeletal System

No musculoskeletal abnormalities and or deformities experienced by the patient.

Page 34: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

Neurologic System

The client is alert, attentive, and follows commands. He claimed that he can comprehend

well at school. He is an average student. No history of hallucinations and seizures as

verbalized by the patient.

Urinary System

Client claimed that he did not experience any difficulty and or problems urinating. Prior

to hospitalization he urinates 2-3x at day time and once at night time.

Reproductive System

Client reported that he did not experience any penile discharges or tenderness.

Endocrine

Client experience of any problems related to the endocrine system.

Page 35: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

LABORATORY EXAMS

SEPTEMBER 1, 2011

TEST RESULT NORMAL

VALUES

SIGNIFICANCE RATIONALES

WBC(white blood

count)

13.1 x 103

mm3

3.5-10 x 103

mm3

WBC fights

infection. Increase

in WBC signifies

bacterial infection..

Indicates presence

of infection

RBC(red blood

cells)

5.44 x 103

cellmm3

3.80-5.80 x 103

mm3

RBC transports

oxygen in the blood

Within Normal

Range

HGT(hemoglobin) 14.5 g/dl 11.0-16.5 g/dl Iron containing

Oxygen transport in

the blood

Within Normal

Range

HCT(hematocrit) 43.7% 35 -50% Percentage of RBC

in the blood.

Within Normal

Range

PLT(platelet

count)

255 x 103

mm3

150-390 x 103

mm3

Important factor for

blood to clot

Within Normal

Range

PCT 0.161% 0.100-0.500% Procalcitonin. To

determine from

bacterial to non-

bacterial

Within Normal

Range

MCV(mean cell

volume)

80 fl 70-97 fl The average size of

erythrocytes or

RBC

Within Normal

Range

MCH(mean cell

hemoglobin)

26.7 pg 26.5-33.5 pg Measure of the

mass of hemoglobin

contained by a RBC

Within Normal

Range

MCHC(mean cell

hemoglobin

concentration

33.2 g/dl 31.5-38.5 g/dl The average

hemoglobin

concentration in

Within Normal

Range

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RBC

RDW (red blood

cell distribution

width)

14.6 % 10.0-18.0 % Red Cell

Distribution Width-

standard Direct

measurement of

RDW at a certain

level.

Within Normal

Range

MPV (mean

platelet volume)

6.3 fl 6.5-11.0 fl Mean Platelet

Volume, typical

size of platelet in

blood

Indicates presence

of bleeding. Below

normal secondary

to platelet lyses

PDW ( platelet

distribution width)

12.7 % 10.0-18.0 % Direct measurement

of Platelet

Within Normal

Range

Lymphocytes % 8.6 % L 17.0-48.0 % Lymphocytes B and

T are the natural

cell killers.

Indicates presence

of viral infection

Monocytes % 1.0 % L 4.0-10.0 % Monocytopenia- not

enough cell to fight

infection.

Indicates presence

of infection

Granulocytes % 90.4 % H 43.0-76.0 # Granulocytosis:

abnormally high

Indicates presence

of infection.

Lymphocytes # 1.1

(10^3/mm3)

L

1.2-3.2

(10^3/mm3)

Lymphocytes B and

T are the natural

cell killers.

Indicates presence

of viral infection

Monocytes # 0.1

(10^3/mm3)

L

0.3-0.8

(10^3/mm3)

Monocytopenia- not

enough cell to fight

infection.

Indicates presence

of bone marrow

dysfunction

Granulocytes # 11.9

(10^3/mm3)

H

1.2-6.8

(10^3/mm3

Granulocytosis:

abnormally high

Indicates presence

of infection

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URINALYSIS

September 1, 2011

TEST RESULT NORMAL VALUES SIGNIFICANCE

Urine Yellow/cloudy Amber yellow

Creatinine 1.1 mg/dl 0.9-1.4 Normal

Specific gravity 1.030 1.002-1.030 Normal

pH 6.0 5-7 Normal

Glucose Negative Negative Normal

Protein Trace Negative

Bacteria Plenty Infection

Crystals Amorphous

Urates Few

Page 38: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

ULTRASOUND OF THE LOWER ABDOMEN

Patient: Mr. P. G

Date: September 1, 2011 Ordered by Dr. Ycong.

Findings: Both kidneys show a normal range in size with a mild to moderate

inhomogeneous parenchymal echogenicity with non-uniform echo pattern. The Right Kidney

measures 11.06 x 4.57 cm with a cortical thickness of 1.20cm. While the Left kidney measures

9.91x4.63 cm with a cortical thickness of 1.17cm. There are a few tiny high level echogenic

structures exhibiting posterior acoustic shadowing appreciated at both collecting structures,

namely at the Right Kidney ranging in measurement from 0.18cm to 0.31cm, while at the left

kidney ranging in measurement from 0.16cm to 0.25cm. There are few tiny rounded medium to

high level echoes seen at the calices with both kidneys without posterior acoustic shadowing.

Bilateral prominence with the pelvocaliceal structures are seen with a splitting with the central

echo complex.

The urinary bladder is physiologically distensible and sub-optimally filled with a pre-

voiding urine volume with 85.83cc. There are few tiny rounded medium to high level in

traluminal echogenic structures seen that settle at the dependent portion. No transducer

tenderness is elicited. The bladder wall is mildly thickened measuring 0.66cm. There are

pockets with free fluid noted at the interserosal surfaces of the pelvic region. There is a an

echowic tubular structure noted at the right lower quadrant that is compressible measuring

0.63cm at rest and 0.45cm with compression suspected with being the vermiform appendix.

The lumen of the tubular structure contains fecal materials. The region adjacent the cecum

shows another tubular structure with accompanying vascular pedicle that appears to enter the

lumen with the cecum and is suggestive with intussusceptions (ilio-colic type). Correlation with

laboratory findings is imperative. The rest of the right lower quadrant exhibits small bowel loops

that are distended and fluid filled and showing sluggish peristalsis.

Page 39: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

IMPRESSION:

NORMAL SIZE KIDNEYS WITH BILATERAL MILD HYDRONEPHROSIS, GRAD

1, THAT MAY ONLY BE TRANSIENT IN NATURE; TINY ROUNDED MEDIUM TO

HIGH LEVEL ECHOES WITHIN THE CALICES THAT MAY BE DUE TO SLOUGHED

OFF RENAL PAPILLAE, URINARY SEDIMENT, AND/OR FAT GLOBULES; AND, FEW

TINY LITHIASES AT BILATERAL COLLECTING STRUCTURES, AS DESCREBED.

NO SONOGRAPHIC EVIDENCE SUPPORTING ACUTE APPENDICITIS WITH A

DISTENDED AND COMPRESSIBLE TUBULAR STRUCTURE AT THE RIGHT LOWER

QUADRANT THAT IS PRESUMED TO BE THE VERMIFORM APPENDIX. THERE IS

HOWEVER SONOGRAPHIC EVIDENCE OF INTUSSUCEPTION (ILIO-COLIC TYPE).

KINDLY CORRELATE WITH CLINICAL AND LABORATORY FINDINGS.

MINIMAL NON-SPECIFIC ASCITES NOTED AT THE PELVIC REGION.

PHYSIOLOGICALLY DISTENSIBLE AND SUB-OPTIMALLY FILLED URINARY

BLADDER WITH MILD THICKENING OF THE ANTERIOR WALL MAY REPRESENT

EVIDENCE CURRENT/RECENT CYTITIS VERSUS SUB-OPTIMAL FILLING; AND,

MINIMAL TINY INTRALUMINAL ECHOES THAT MAY REPRESENT SLOUGHED OFF

CELLS URINARY SEDIMENT, AND /OR BLOOD PRODUCTS, KINDLY CORRELATE

WITH CLINICAL AND LABORATORY FINDINGS.

READ BY: ANGELO S. CO, M.D., D.P.B.R

RADIOLOGIST/SONOLOGIST

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ANATOMY AND PHYSIOLOGY

(DIGESTIVE SYSTEM)

The digestive tract, also called the alimentary canal or gastrointestinal (GI) tract, consists

of a long continuous tube that extends from the mouth to the anus. It includes the mouth,

pharynx, esophagus, stomach, small intestine, and large intestine. The tongue and teeth are

accessory structures located in the mouth. The salivary glands, liver, gallbladder, and pancreas

are major accessory organs that have a role in digestion.

Food undergoes three types of processes in the body:

Digestion

Absorption

Elimination

Digestion and absorption occur in the digestive tract. After the nutrients are absorbed,

they are available to all cells in the body and are utilized by the body cells in metabolism.

The digestive system prepares nutrients for utilization by body cells through six activities, or

functions.

1. Ingestion. The first activity of the digestive system is to take in food through the mouth. This

process, called ingestion, has to take place before anything else can happen.

2. Mechanical Digestion. The large pieces of food that are ingested have to be broken into

smaller particles that can be acted upon by various enzymes.

3. Chemical Digestion. Through a process called hydrolysis, uses water and digestive enzymes

to break down the complex molecules. Digestive enzymes speed up the hydrolysis process,

which is otherwise very slow.

4. Movements. After ingestion and mastication, the food particles move from the mouth into

the pharynx, then into the esophagus. This movement is deglutition, or swallowing. Mixing

movements occur in the stomach as a result of smooth muscle contraction.

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5. Absorption. The simple molecules that result from chemical digestion pass through cell

membranes of the lining in the small intestine into the blood or lymph capillaries. This

process is called absorption.

6. Elimination. The food molecules that cannot be digested or absorbed need to be eliminated

from the body. The removal of indigestible wastes through the anus, in the form of feces, is

defecation or elimination.

Digestive Organs

The digestive system is a group of organs (Buccal cavity (mouth), pharynx, oesophagus,

stomach, liver, gall bladder, jejunum, ileum and colon) that breakdown the chemical components

of food, with digestive juices, into tiny nutrients which can be absorbed to generate energy for

the body.

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The Buccal Cavity

Food enters the mouth and is chewed by the teeth, turned over and mixed with saliva by the

tongue. The sensations of smell and taste from the food sets up reflexes which stimulate the

salivary glands.

The Salivary glands

Saliva lubricates the food enabling it to be swallowed and contains the enzyme ptyalin which

serves to begin to break down starch.

The Pharynx

Situated at the back of the nose and oral cavity receives the softened food mass or bolus by the

tongue pushing it against the palate which initiates the swallowing action.

The Oesophagus

The oesophagus travels through the neck and thorax, behind the trachea and in front of

the aorta. The food is moved by rhythmical muscular contractions known as peristalsis (wave-

like motions) caused by contractions in longitudinal and circular bands of muscle.

The Stomach

The stomach lies below the diaphragm and to the left of the liver. It is the widest part of

the alimentary canal and acts as a reservoir for the food where it may remain for between 2 and 6

hours. Here the food is churned over and mixed with various hormones, enzymes including

pepsinogen which begins the digestion of protein, hydrochloric acid, and other chemicals; all of

which are also secreted further down the digestive tract.

Small Intestine

The small intestine measures about 7m in an average adult and consists of the duodenum,

jejunum, and ileum. Both the bile and pancreatic ducts open into the duodenum together. The

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small intestine, because of its structure, provides a vast lining through which further absorption

takes place.

The Pancreas

The Pancreas is connected to the duodenum via two ducts and has two main functions:

1. To produce enzymes to aid the process of digestion

2. To release insulin directly into the blood stream for the purpose of controlling blood

sugar levels

The Liver

The liver, which acts as a large reservoir and filter for blood, occupies the upper right portion

of abdomen and has several important functions:

1. Secretion of bile to the gall bladder

2. Carbohydrate, protein and fat metabolism

3. The storage of glycogen ready for conversion into glucose when energy is required.

4. Storage of vitamins

5. Phagocytosis - ingestion of worn out red and white blood cells, and some bacteria

The Gall Bladder

The gall bladder stores and concentrates bile which emulsifies fats making them easier to

break down by the pancreatic juices.

The Large Intestine

The large intestine averages about 1.5m long and comprises the caecum, appendix, colon,

and rectum. After food is passed into the caecum a reflex action in response to the pressure

causes the contraction of the ileo-colic valve preventing any food returning to the ileum. Here

most of the water is absorbed, much of which was not ingested, but secreted by digestive glands

further up the digestive tract.

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ANATOMY AND PHYSIOLOGY

(APPENDIX)

Appendix is a tube-shaped

organ with a length of approximately

10 cm and the stem on the cecum. It

sits at the junction of the small intestine and large intestine. Sometimes the position of the

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

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

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

large it allows the appendix to move around.

In addition, the appendix may be

longer than normal. The combination of a

large mesentery and a long appendix

allows the appendix to dip down into the

pelvis (among the pelvic organs in

women) it also may allow the appendix to

move behind the colon (a retrocolic

appendix).

Page 45: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

In infants, the appendix is a conical diverticulum at the apex of the cecum, but with

differential growth and distention of the cecum, the appendix ultimately arises on the left and

dorsally approximately 2.5 cm below the ileocecal valve. The taeniae of the colon converge at

the base of the appendix, an arrangement that helps in locating this structure at operation.

The appendix in youth is characterized by a large concentration of lymphoid follicles that

appear 2 weeks after birth and number about 200 or more at age 15. Thereafter, progressive

atrophy of lymphoid tissue proceeds concomitantly with fibrosis of the wall and partial or total

obliteration of the lumen.

Appendix is blooded by apendicular artery which is a branch of the artery ileocolica.

Arterial appendix is end arteries. Appendix has more than 6 mesoapendiks obstruct lymph

channels leading to lymph nodes ileocaecal. Although the appendix has less functionality, but the

appendix can function like any other organ. Appendix produces mucus 1-2ml per day. 

The mucus poured into the caecum. If there is resistance there will be a pathogenesis of acute

appendicitis. GALT (Gut Associated Lymphoid Tissue) in the appendix produce Ig-A. 

However, if the appendix removed, none affect the immune body system.

Page 46: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

PREDISPOSING FACTORS Age (11-20y.o.) Sex (Male)

PRECIPITATING FACTORS Diet (raw foods, guava) History of appendicitis Constipation (Fecalithe

matter)

Pale, facial grimace, and abdominal guarding

Abdominal Ultrasound

↑ WBC result (13.1 x 103

mm3)

s/sx: abdominal pain scale 7/10,guarding, fever, and

increased swelling of appendixvomiting, and loss of appetite

PATHOPHYSIOLOGY OF RUPTURED APPENDICITIS WITH LOCALIZE

PERITONITIS

(SCHEMATIC DIAGRAM)

Obstruction of the appendix by fecalithe (hardened stool), lymph nodes, tumor, and foreign objects

Increased intraluminar pressure inside the appendix that result to distention of

appendix

Normal bacteria found in appendix begin to invade (infect) the lining of the

wall

Inflammatory response – body response to the bacterial invasion in the wall of

appendix.Increased immune complex (disease

plus antibody) causes swelling of tissue resulting to inflammation of appendix.

Right Iliac Pain

Page 47: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

Diagnostic Test:Abdominal Ultrasound

s/sx: swelling of the abdomen, acute pain, and

weight loss

Risk Factor ManifestationDiagnostic/ Lab

Tests

LEGENDS:

Inflammation and infection spread through the wall of the appendix

causing death of tissue. The appendix ruptures due to increased pressureAppendectomy explore laparotomy

(site: lower part distal from naval area; 8 inches longitudinal incision

with 9 transverse stitchesPerforation (formation of a hole in an

organ), fecal materials exits to peritoneal cavity causing formation of

abscess (periappendical abscess).Infection spreads throughout the

abdomen (peritoneal cavity)

Bacteria invasion of peritoneal cavity causing inflammation of the membrane

that lines the abdomen peritoneum (peritonitis)

If not treated If treated

Septic shocks/sx: 1. Decrease blood

pressure2. decrease blood volume

Coma

DEATH

Prescribed antibiotic (lomefloxacin HCL; Maxaquin)

Fluid volume replacement therapy (D5NSS 50 gtts/min)

RECOVERY

Management

Pathology

Page 48: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

DRUG STUDY

ranitidine hydrochloride (Zantac)

Date Ordered: September 1, 2011 (During Hospitalization)

Classification: H2 receptor blocker

Dosage Ordered: 50 mg IVTT q 8 hours

Mechanism of Action: Competitively inhibits action of histamine on the H2 at the receptor sites

if the parietal cells, decreasing gastric acid secretion.

Indication: Treatment for active duodenal and gastric ulcer, GERD, erosive esophagitis, and

heartburn.

Contraindication: Contraindicated in patients hypersensitive to drug and those with acute

porphyria. Use cautiously in patients with hepatic dysfunction. Adjust dosage in

patients with impaired renal function.

Adverse Reaction: CNS: headache, malaise, vertigo

EENT: blurred vision

Hepatic: jaundice

Other: anaphylaxis, burning and itching at the injection site

Nursing Responsibilities:

Assess patient for abdominal pain. Note presence of blood in emesis, stool, or

gastric aspirate.

Remind patient to take once-daily prescription drug at bedtime for best results.

Instruct patient to take without regard to meals because absorption isn’t affected by

food.

Urge patient to avoid cigarette smoking because this may increase gastric acid

secretion and worsen disease.

Advise patient to report abdominal pain and blood in stool and emesis.

Page 49: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

tramadol hydrochloride (Ultram)

Date ordered: September 1, 2011 (During Hospitalization)

Classification: Synthetic, centrally active analgesic

Dosage Ordered: 50 mg IVTT PRN for pain

Mechanism of action: Unknown. Thought to bind to opioid receptors and inhibit reuptake of

norepinephrine and serotonin.

Indication: To relieve from moderate to moderately severe pain.

Contraindication: Contraindicated in patients hypersensitive to drug or other opioids, and in

those with intoxication from alcohol, hypnotics, centrally acting analgesic, opioids

or psychotropic drugs. Serious hypersensitive reactions can occur, usually after the

first dose. Patients with history of anaphylactic reaction to codeine and other

opioids may be at increased risk. Use cautiously in patients at risk for seizures or

respiratory depression; in patients with increased intracranial pressure or head

injury, acute abdominal conditions, or renal or hepatic impairment; or in patients

with physical dependence on opioids.

Adverse Reaction: CNS: dizziness, headache, somnolence, vertigo, seizure

GI: constipation, nausea, vomiting

Respiratory: respiratory depression

Nursing Responsibilities:

Reassess patient’s level of pain at least 30 minutes after administration.

Monitor CV and respiratory status. Withhold dose and notify prescriber if

respirations are shallow or rate is below 12 breaths/minute

Monitor bowel and bladder function. Anticipate for stimulant laxative.

Monitor patients at risk for seizures. Drug may reduce seizure threshold.

Withdrawal symptoms may occur if stopped abruptly. Reduce dosage gradually.

Tell patient to take drug as prescribed and not to increase dose or dosage interval

unless ordered by prescriber.

Caution ambulatory patient to be careful when rising and walking. Warn outpatient

to avoid driving and other potentially hazardous activities that require mental

alertness until drug’s CNS effects are known.

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metronidazole (Zolnid)

Date ordered: September 1, 2011 (During Hospitalization)

Classification: Nitroimidazole, antibiotic

Dosage ordered: 500 mg IV drip q 8 hours

Mechanism of action: Unknown. May cause bactericidal effect by interacting with DNA.

Indication: Treatment for infection of the colon caused by C. difficile and infections caused

by H. pylori.

Contraindication: Contraindicated in patients hypersensitive to drug or its ingredients, such

as parabens, and other nitroimidazole derivatives. Use cautiously in patients with

history or evidence of blood dyscrasia and in those with hepatic impairment.

Adverse action: CNS: headache, numbness, seizures

GI: nausea, loss of appetite, metallic taste,

Nursing Implications:

Discontinue therapy immediately if symptoms of CNS toxicity develop.

Monitor especially for seizures and peripheral neuropathy.

Lab tests: Obtain total and differential WBC counts before, during, and after

therapy, especially if a second course is necessary.

Monitor for S&S of sodium retention, especially in patients on corticosteroid

therapy or with a history of CHF.

Monitor patients on lithium for elevated lithium levels.

Caution to patient to avoid alcohol while in therapy.

Page 51: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

ketorolac tromethamine (Acular)

Date ordered: September 1, 2011 (During Hospitalization)

Classification: NSAID

Dosage Ordered: 30 mg IVTT q 8 hours

Mechanism of action: May inhibit prostaglandin synthesis, to produce anti-inflammatory,

analgesic, and antipyretic effects.

Indication: For short-term management of moderately severe acute pain

Contraindication: Contraindicated in patients hypersensitive to drug and in those with active

peptic ulcer disease, recent GI bleeding or perforation, advanced renal impairment,

cerebrovascular bleeding, hemorrhagic diathesis, or incomplete hemostasis, and

those at risk for renal impairment from volume depletion or at risk for bleeding.

Contraindicated as prophylactic analgesic before major surgery or intraoperatively

when hemostasis is critical; and inpatients currently receiving aspirin, an NSAID, or

probenecid. Contraindicated for treatment of perioperative pain in patients requiring

coronary bypass graft surgery. Use cautiously in patients who are elderly or have

hepatic or renal impairment or cardiac decompensation.

Adverse Reaction: CNS: dizziness, headache, drowsiness

CV: arrhythmias, edema, hypertension

GI: dyspepsia, GI pain, nausea, diarrhea, vomiting

Skin: pruritus, rash

Other: pain at injection site

Nursing Responsibilities:

Correct hypovolemia before giving.

Don’t give drug epidurally or intrathecally because of alcohol content.

NSAIDs may mask signs and symptoms of infection because of their antipyretic and

anti-inflammatory actions.

Teach patient signs and symptoms of GI bleeding, including blood in vomit, urine,

or stool; coffee-ground vomit; and black, tarry stool. Tell him to notify prescriber

immediately if any of these occurs.

Page 52: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

cefuroxime sodium

Date ordered: September 1, 2011 (During Hospitalization)

Classification: Second-class cephalosporin

Dosage Ordered: 750 mg IVTT q 8 hours ANST

Mechanism of action: Inhibits cell-wall synthesis, promoting osmotic instability; usually

bactericidal.

Indication: Perioperative prevention

Contraindication: Contraindicated to patients hypersensitive to drug and other form of

cephalosporins. Use cautiously in patients hypersensitive to penicillin because of

possibility of cross-sensitivity with other beta-lactam antibiotics.

Adverse Reaction: CV: phlebitis, thrombocytopenia

GI: diarrhea pseudomembraneous colitis, nausea, vomiting

Hematologic: hemolytic anemia, thrombocytopenia

Skin: maculopapular and erythematous rashes, urticaria, pain, induration, sterile

abscesses, temperature elevation

Other: anaphylaxis

Nursing Responsibilities:

Monitor signs and symptoms of superinfection.

Tell patient to take drug as prescribed, even after he feels better.

Instruct patient to notify prescriber about rash, loose stools, diarrhea or evidence of

superinfection.

Advise patient receiving drug I.V. to report discomfort at I.V. insertion site.

Page 53: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

Generic name: ranitidine (Home Med)Brand name: RaxideClassification: Therapeutic: Anti-ulcer agents; Pharmacologic: Histamine H2 antagonistsDosage: 150 mg bid POMechanism 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.Indication:•Treatment and prevention of heartburn, acid indigestion, and sour stomach.Contraindications•Hypersensitivity, Cross-sensitivity may occur; some oral liquids contain alcohol and should be avoided in patients with known intolerance.Use Cautiously in:• Renal impair- ment• Geriatric patients (moresusceptible to adverse CNS reactions)• Pregnancy or LactationSide Effects• CNS: Confusion, dizziness, drowsiness, hallucinations, headache• CV: Arrhythmias• GI: Altered taste, black tongue, constipation, dark stools, diarrhea, drug-induced hepatitis, nausea• GU: Decreased sperm count, impotence• ENDO: Gynecomastia• HEMAT: Agranulocytosis, Aplastic Anemia, neutropenia, thrombocytopenia• LOCAL: Pain at IM site• MISC: Hypersensitivity reactions, vasculitisNursing Implications/Responsibilities:• Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate.• Nurse should know that it may cause false-positive results for urine protein; test with sulfosalicylic acid.• Inform patient that it may cause drowsiness or dizziness.• Inform patient that increased fluid and fiber intake may minimize constipation.• Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health car professional promptly.• Inform patient that medication may temporarily cause stools and tongue to appear gray black.

Page 54: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

Generic name: lomefloxacin hydrochloride and/or lomecin (Home Med)

Brand name: Maxaquin

Classification: Antibiotic, Flouroquinolone

Indication : Treatment of infectious in adults caused by susceptible organism: Lower

respiratory tract infections caused by Haemophilus influenzae, Moraxella catarrhalis.

Contraindications:

Contraindicated in:

Allergy to lomefloxacin, or any fluoroquinolone; lactation

Use cautiously with renal impairement and seizures, pregnancy.

Dosage: 400 mg tab 2x/day PO total of 16 tabs.

Mechanism of Action: Interferes with DNA replication by inhibiting DNA gyrase in susceptible

gram negative and gram positive bacteria, preventing cell reproduction and causing cell death.

Nursing Implication/Responsibilities:

Arrange for culture and sensitivity tests before beginning the therapy.

Continue therapy for full prescription, even if the signs and symptoms of infection have

disappeared.

Give oral drug without regard to meals

Drink plenty of fluids

Advised patient to report presence of rash, visual changes, severe GI problems,

weakness, tremors.

Page 55: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

Generic name: mefenamic acid (Home Med)

Brand name: Ponstel

Classification: NSAID

Mechanism of action:

Anti inflammatory, analgesic, and antipyretic activities related to inhibition of

prostaglandin synthesis; exact mechanisms of action are not known.

Indication:

Relief of moderate pain when therapy will not exceed 1 week.

Contraindications:

Contraindicated in:

Hypersensitivity to mefenamic acid, aspirin allergy, and as treatment of perioperative

pain with coronary artery bypass grafting.

Use cautiously with asthma, renal or hepatic impairment, peptic ulcer disease, GI

bleeding, hypertension, heart failure, pregnancy, lactation.

Dosage: 500mg capsule once a day PO for 16 days total

Nursing Implication/Responsibilities

Patient may be at increased risk for CV events, GI bleeding; monitor accordingly.

Take drug with food; take only the prescribed dosage; do not take the drug longer than 1

week.

Dizziness or drowsiness can occur.

Advised patient to report onset of black tarry stools, severe diarrhea, fever, rash, itching.

Page 56: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

Generic Name: Multivitamins (Home Med)

Brand Name: Enervon - C

Classification: Vitamins & Minerals

Dosage: 1 tab OD

Mechanism of Action: Enhance immune function to increase resistance and maintain optimum

health.

Indication: helps ensure optimum energy and increases body resistance against infections and

stress conditions.

Contraindications: Allergies to medicine, foods, or other substances.

Side Effects: Rash, itching, tightness in the chest, and swelling in mouth and lips.

Adverse Reactions: Severe allergy reactions and DOB

Nursing Implications:

Assess if the patient is taking any prescription or herbal preparation because it may

interact with multivitamin

Assess patient if he/she has allergy of food, or any substances.

Educate the patient that multivitamin may counteract with other medicine intake.

Instruct the patient to check with health care provider before they start, stop, or change

the medicine.

If stomach upset occurs, take with food to reduce stomach irritation.

Inform the patient/SO not to take the medicine twice a day.

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NURSING CARE PLAN # 1

(PRE-OP)

September 1, 2011 @ 9:00 am

Subjective cue:

“ Sakit ako tiyan” as verbalized by the patient.

Objective cue:

Facial grimacing noted

Pain scale of 7 out of 10

v/s taken: T: 36.9C

P: 64 bpm

R: 21 cpm

BP: 100/60 mmHg

Nursing Diagnosis: Acute pain related to inflammation of tissues

Planning: Within 40 mins. of nursing intervention, the patient will reduce the pain from 7 to 0.

Intervention:

Independent:

1. Establish rapport on the client.Rationale: To establish trust and cooperation on the client

2. Monitor the vital signsRationale: To obtain the baseline data

3. Perform a comprehensive assessment of pain to include location, characteristics, onset and duration, frequency, intensity or severity of pain and precipitating factor.Rationale: To have necessary information on the case of the client.

4. Help patient focus on activities rather than on pain and discomfort by providing diversion through radio and visitiors.Rationale: To focus more on activities rather than pain.

5. Provide comfort measure like back rubs and deep breathingRationale: Promotes relaxation and may enhance patient’s coping abilities.

Collaborative:

Administer analgesics as prescribed by the physician.

Rationale: Aids in pain relief

Evaluation: Goal partially met. Patient was able to reduce the pain from 7 to 3.

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NURSING CARE PLAN # 2

(PRE-OP)

September 1, 2011 @ 10:12 am

Subjective Cue:

“init ang pamati naku sa akung lawas” as verbalized by the patient.

Objective cues:

Temperature: 38.8C Flushed skin General weakness noted Shivering Skin moist and warm to touch WBC above the normal range 13.1

Nursing Diagnosis:

Altered body temperature related to inflammatory response as evidence by body temperature higher than the normal range.

Planning:

Within 30 mins. of nursing intervention patient’s temperature will decrease to within normal range.

Intervention:

Independent: Rationales

Monitor V/S To have a baseline data Increase oral fluid intake

If not contraindicated w/ disease To prevent dehydration

Promote bed rest To reduce metabolic demand and O2 consumption

Provide TSB as needed Heat is lost by evaporation &conduction

Dependent: Rationales

Administer paracetamol as ordered By the M.D Antipyretic medication helps lowers temp.

Administer IVF as ordered to prevent dehydration

Evaluation: Goal met. After 30 mins. of nursing intervention patient’s body temperature decreased to 37.5C.

NURSING CARE PLAN # 3

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(PRE-OP)

September 2, 2011 @ 8:45 am

Subjective cue:

“3 days nako ya makakalibang ma’am” as verbalized by the patient.

Objective cue: Distended abdomen and Percussed abdominal dullness

Nursing Diagnosis:

Constipation related to depressed gastrointestinal function accompanied by difficult or incomplete passage of stool.

Planning:

Within 6 hours of appropriate nursing intervention, patient will be able to defecate at least once before shift ends.

Intervention:

Independent

Promote adequate fluid intake, including highfiber fruit juices; suggest drinking warm, stimulating fluids (e.g., coffee, hot water, tea)Rationale: To promote passage of stool

Identify areas of stress (e.g., personal relationships, occupational factors, financial problems)Rationale: Individuals may fail to allow time for good bowel habits and/or suffer gastrointestinal effects from stress/tension.

Encourage activity/exercise within limits of individual ability.Rationale: To stimulate contractions of the intestines

Encourage increase mobility within patient exercise tolerance

Dependent

Administer laxatives prior to doctor’s orderRationale: To promote defecation

Collaborative

Discuss client’s current medication regimen with physician to determine if drugs contributing to constipation can be discontinued or changed.

Rationale: To determine if drugs contributing to constipation can be discontinue or changed.

Evaluation: Goal met. Patient defecates once a day

NURSING CARE PLAN # 4

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(PRE-OP)

September 2, 2011 @ 9:12 am

ASSESSMENT

Subjective Cues:

“Kalain na sa ako gibati karon sa gilid sa akong tiyan,” as verbalized by the

patient prior to hospitalization.

Objective Cues:

The patient manifested:

Weakness

Irritability

Moist skin

Facial grimace

NURSING DIAGNOSIS

Infection related to released of pathogenic organisms in peritoneal cavity.

PLANNING

Within 2 days of nursing intervention, the client’s infection will ease.

INTERVENTION

INDEPENDENT

Established rapport

Monitored and recorded vital

signs.

Practiced and instructed in good

hand-washing.

Inspected incision and

dressings.

Monitored v/s

DEPENDENT

RATIONALE

To gain trust of the patient.

To obtain baseline data.

Reduces the risk of spreading infection

Provides for early detection of

developing infectious process and

monitors resolution of peritonitis.

Suggestive of presence of infection,

developing sepsis, abscess, and

peritonitis.

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Administered antibiotic as

prescribed by doctor.

Primarily for prophylaxis of wound

infection.

EVALUATION

Goal partially met. Client’s infection eased a bit.

NURSING CARE PLAN # 5

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(PRE-OP)

September 2, 2011 @ 11:12 am

ASSESSMENT

Subjective Cues:

“Ang ako ra nahibaw-an na na-appendicitis ako tungod sa pirmi ako magduwa ng

basketball human nako kaon,” as verbalized by the patient.

Objective Cues:

Always asking question regarding to his condition.

NURSING DIAGNOSIS

Knowledge deficient related to information misinterpretation

PLANNING

Within at least 50 mins. of nursing intervention, patient will know the disease process.

INTERVENTION

INDEPENDENT

Identified symptoms requiring

medical intervention.

Provided the client about the

information of disease process

Reviewed postoperative activity

restrictions.

Encouraged activities as

tolerated with periodic rest

periods.

Discussed care of incision,

including dressing changes.

RATIONALE

Prompt intervention reduces risk of

serious complication.

Patient will be aware the process of his

disease.

Provides information for client to plan

for return to usual routines without

untoward incidents.

Prevents fatigue, promotes healing and

feeling of well-being, and facilitates

resumption of normal activities.

Understanding promotes cooperation

with therapeutic regimen, enhancing

healing and recovery process.

EVALUATION: Goal met. Patient knew already the disease process of appendicitis.

NURSING CARE PLAN # 6

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(POST-OP)

ASSESSMENT

Subjective Cues:

“Kasakit sa ako operasyon,” as verbalized by the patient after operation

(appendectomy). Pain scale: 5/10

Objective Cues:

The patient manifested:

Facial Grimace

Abdominal guarding

Sweating

v/s taken: T – 36.9 C

P – 68 bpm

R – 27 cpm

BP – 120/80 mmHg

NURSING DIAGNOSIS

Pain related to post-appendectomy.

PLANNING

Within 40 mins. of nursing intervention, pain will reduce from 5/10 to 0/10.

INTERVENTION

INDEPENDENT

Established rapport

Monitored and recorded vital

signs.

Assessed pain, location, and

severity.

Kept at rest in semi-fowler’s

position

RATIONALE

To gain trust of the patient.

To obtain baseline data.

Useful in monitoring effectiveness of

medication and progression of healing

Gravity localizes inflammatory exudate

into lower abdomen or relieving

abdominal tension which is accentuated

by supine position.

Page 64: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

Encouraged early ambulation.

Provided diversional activities.

DEPENDENT

Administered prescribed

analgesic.

Promotes normalization of organ

function and reducing abdominal

discomfort.

Refocuses attention, promotes

relaxation, and enhance coping

abilities.

Relief pain.

EVALUATION

Goal met. Patient pain (pain scale) reduced from 5/10 – 0/10.

NURSING CARE PLAN # 7(POST-OP)

Page 65: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

Subjective Cues: “sige ako nag mata mata kay init ug sakit ako tag operahan ug ngotngot”, as verbalized by the patient.

Objective Cues: RestlessnessIrritabilitySlowed Reaction

Nursing Diagnosis: Sleep deprivation related to prolonged discomfort.

Planning: The patient will report improvement in sleep pattern within the shift.

Interventions:1. Determined presence of physical or psychological stressors

Rationale: To know the reasons why the patient can’t sleep.2. Noted environmental factors that affect sleep.

Rationale: To help the client have a better rest and sleep.3. Determined patient’s usual sleep pattern.

Rationale: To provide comparative baseline.4. Observed physical signs of fatigue.

Rationale: To know if the client will not get stressed5. Recommended quiet activities such as, listening to soothing music.

Rationale: To help the client have a better rest and sleep.6. Provided calm, quiet environment and manage controllable sleep disrupting factors.

Evaluation: Goal met. After 6 hours of nursing intervention, the patient was able to report sleep that day and there is a decrease over all body malaise.

NURSING CARE PLAN # 8

(POST-OP)

Page 66: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

ASSESSMENT

Subjective Cues:

“Waya pa karajaw nadajaw ang ako samad sukad na gi-operahan ako,” as

verbalized by the patient.

Objective Cues:

The patient manifested:

Epidermis (disruption of the skin surface)

Surgical incision at right lower abdominal area.

NURSING DIAGNOSIS

Impaired skin integrity related to skin/tissue trauma as evidenced by the surgical incision

at right lower abdominal area due to appendectomy.

PLANNING

Within 3 days of nursing intervention, the client will be able to manifest intact sutures,

dry and intact wound dressing, and active/passive participation in ROM exercise.

INTERVENTION

INDEPENDENT

Established rapport

Monitored and recorded vital

signs.

Assessed operative site for

redness, swelling, loose sutures

and soaked dressings.

Assisted passive/active ROM

exercise

Instructed the patient to refrain

from scratching/touching the

surgical site.

Provided regular dressing care.

RATIONALE

To gain trust of the patient.

To obtain baseline data.

To check skin integrity and monitor the

progress of healing.

To promote circulation to the surgical

site and healing.

To avoid accumulation of moisture at

the operative site which may led to skin

breakdown.

To prevent bacteria harbor in the

operative site.

Page 67: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

DEPENDENT

Administered antibiotic therapy

as prescribed by the physician.

To promote wound healing.

EVALUATION

Goal was partially met. Client manifested intact sutures, dry and intact wound dressing,

and slightly followed passive/active ROM exercise.

NURSING CARE PLAN # 9

(POST-OP)

Page 68: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

Subjective cue:

“tag operahan ako kahapon” as verbalized by patient.

Objective cue:

Abdominal dressing noted Incision on the abdomen area noted.

Nursing Diagnosis:

Risk for infection related to surgical incision.

Planning:

Within 6 hours of nursing intervention, Patient and SO will be able to identify signs and symptoms of infection.

Intervention:

Independent

Instruct Patient and SO how to identify signs and symptoms of infection (fever, chills, redness and burning sensation around, surgical site, and or drainage.)

o Rationale: so they will be able to notify Nurse and or MD and to prevent sepsis

Assess and document skin condition around surgical site. Note for any abnormalities.

o Rationale: to monitor and prevent potential post op complications. Keep dressing dry and intact and proper hand washing

o Rationale: to prevent infection

Dependent:

Give antibiotic per M.D’s ordero Rationale: to help prevent infection

Cleanse surgical site and dressing change per M.D ordero Rationale: to keep surgical site dry and intact.

Evaluation:

Patient and SO verbalized understanding by restating the given instructions.

NURSING CARE PLAN # 10

(POST-OP)

Page 69: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

Subjective cue:

“luya ako lawas ma’am” as verbalized by the patient.

Objective cue:

Weakness noted Needs assistance in sitting down, standing and walking Prefers to stay on bed

Nursing diagnosis:

Activity intolerance related to post appendectomy.

Planning:

Within 3days of nursing interventions, patient will be able to use identified techniques to enhance activity tolerance.

Nursing intervention:

Independent:

Provide bed resto Rationales: Promotes periods of rest and relaxation. Available energy is

used for healing Provided environment conducive to relief fatigue.

o Rationales: fatigue affects both the clients actual and perceived ability to participate in activities.

Recommended changing position every 2 hours.o Rationales: to prevent bed sores and promotes optimal respiratory

function. Instructed energy conserving techniques such as sitting instead of standing

during shower and any activities.o Rationales: helps minimize fatigue allowing client to accomplish more

and feel better about self Increased activity as tolerated. Demonstrate active ROM exercise. Rationales: prolong bed rest can be debilitating and causes muscle atrophy Encourage use of stress management technique such as guided imagery.

o Rationales: promotes relaxation and conserves energy, redirect attention and may enhance coping.

Evaluation:

Goal partially met, as evidenced by patient understanding and following instructions and techniques that would enhance activity tolerance.

DISCHARGE PLAN

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Upon discharge from Caraga Regional Hospital, the patient as well as the SO will be

given a home care instruction which contains the following:

MEDICATION:

Take home medicines

o lomefloxacin hydrochloride: 400mg one tab by mouth twice a day total of

16tablets only

o ranitidine:150mg one tab by mouth three times a day, total of 16 tablets only

o ponstel (mefinamic acid): 500mg 1 cap by mouth three times a day total of 16

caps only.

o Multivitamins (Enervon – C): 1 tab OD

ENVIRONMENTAL CONCERNS:

Instructed patient to provide a peaceful relaxing, comfortable and well ventilated room

Instructed patient to provide a stress free environment

Instructed patient to follow the prescribed meal plan

Instructed to provide clean environment to prevent lodging of infectious microorganisms.

Changes in his environment can aid in his recovery by making it easier for him to bathe,

dress and prepare meals while his muscles return to normal levels of strength

TREATMENTS:

Discussed on the importance of strict adherence to medication regime to ensure complete

healing.

Instructed patient to understand and follow discharge instruction religiously and

accurately.

Instructed patient to follow proper instruction on medication prescribed by the physician

Reinforced proper incision care.

HEALTH TEACHINGS:

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Review information about medications to be taken at home, including name, dosage,

frequency and possible side effects, discussed the importance of continuing to take

Patient is counseled regarding importance of eating meals on time and in a relaxed

setting.

Instructed Patient to avoid any strenuous activities, until the incision completely healed.

Keep incision site dry and clean.

Notify MD if s/sx of infection noted. (ex: fever, chills, redness around the incision, and

any discharges.)

OUT PATIENT (FOLLOW UP CHECK-UP)

Patient is advised for follow up check up to his physician one (1) week after discharge

Instructed patient to notify physician of there is any undesired feeling about the disease

DIET

Advised patient to avoid raw foods, fruits and vegetables that contain seeds (e.g. guava,

tomatoes, )

Advised to eat foods rich in protein and Vitamin C for wound healing.

SPIRITUAL

Encourage patient to go church and pray regularly together with his whole family. Never

forget to thank god for all the blessings he and his family has been receiving.

Advised patient to find time with his family members and friends and share the good

news written in the bible.

Encouraged SO to pray for the health of the patient.

INTRAVENOUS FLUID

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Date/time

started

Intravenous

fluid and

volume

Drop Rate /min Number of

hours to be

infused

Date /time

consumed

09-01-11 D5LR/1L 20 drops 16hrs &39mins 09/01/11

12:39pm

09-01-11 D5LR/1L 20 drops 16hrs&39mins 09/03/11

5:30am

09-03-11 D5LR/1L 50 drops 6hrs & 39 mins 09/03/11

12:09pm

09-03-11 D5NSS/1L 50drops 6hrs & 39 mins 09/03/11

6:48pm

09-03-11 D5LR/1L +

Multivitamins

50drops 6hrs & 39 mins 09/04/11

1:27 am

09-04-11 D5LR /1L 50drops 6hrs & 39 mins 09/04/11

8:08am

09-04-11 D5NSS /1L 50drops 6hrs & 39 mins 09/04/11

2:27pm

09-04-11 D5LR/1L 50drops 6hrs & 39 mins 09/04/11

9:26pm

Page 73: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

Grandmother, 59Hypertension Grandmother

1st Sibling 2nd Sibling 5th Sibling 8th Sibling 1st Sibling, 32Eclampsia

Mother

1st Sibling 3rd Sibling

Female Female Deceased

FAMILY GENOGRAM

LEGENDS:

PATERNAL SIDE MATERNAL SIDE

Grandfather, 79Hypertension/Stroke

Grandfather

Father, has Hypertension 4th Sibling 6th Sibling 7th Sibling 3rd Sibling

Patient, 17 4th Sibling 5th Sibling

Male MaleDecease

Patient

Page 74: Case Study of Ruptured Appendicitis With Localize Peritonitis (Final)

DEFINITION OF TERMS

1. Appendectomy – surgical removal of the vermiform of appendix.

2. Appendicitis - inflammation of the vermiform appendix called also

epityphlitis.

3. Appendix – a bodily outgrowth or specifically processed.

4. Blumberg sign - also referred as rebound tenderness. Deep palpation of the viscera over

the suspected inflamed appendix followed by sudden release of the pessue causes the

severe pain on the site indicating positing Blumberg’s sign and peritonitis.

5. Dunphy’s sign - increased pain in the right lower quadrant with coughing.

6. Fecalithe - a concretion of dry compact feces formed in the intestine

or vermiform appendix.

7. Hematocrit (Ht or HCT) or packed cell volume (PCV) or erythrocyte volume

fraction (EVF) - is the proportion of blood volume that is occupied by red blood cells. It

is normally about 48% for men and 38% for women. It is considered an integral part of a

person'scomplete blood count results, along with hemoglobin concentration, white blood

cell count, and platelet count.

8. IgA - has two subclasses (IgA1 and IgA2) and can exist in a dimeric form called

secretory IgA (sIgA). In its secretory form, IgA is the main immunoglobulin found in

mucous secretions, including tears, saliva, colostrum and secretions from the

genitourinary tract, gastrointestinal tract, prostate and respiratory epithelium. It is also

found in small amounts in blood.

9. Kocher’s Sign - the appearance of pain in the epigastric region or around the stomach at

the beginning of disease with a subsequent shift to the right iliac region.

10. Laparotomy – surgical section of the abdominal wall.

11. Obturator sign - if an inflamed appendix is in contact with the obturator internus, spasm

of the muscle can be demonstrated by flexing and internal rotation of the hip. This

maneuver will cause pain in the hypogastrium.

12. Perforation - a rupture in a body part caused especially by accident or disease

and/or a natural opening in an organ or body part.

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13. Peritoneum - the smooth transparent serous membrane that lines the

cavity of the abdomen of a mammal, is folded inward over the

abdominal and pelvic viscera, and consists of an outer layer closely

adherent to the walls of the abdomen and an inner layer that folds to

invest the viscera.

14. Peritonitis – inflammation of the peritoneum.

15. Psoas sign - is the right lower-quadrant pain that is produced with either the passive

extension of the patients right hip (pt. lying on the left side, with knee in flexion) or the

patient’s active flexion of the right hip while supine. Straightening out the legs causes

pain because it stretches these muscles, while flexing the hip activated the iliopsoas and

therefore causes pain.

16. Rovsing’s sign - continuous deep palpation starting from the left iliac fossa upwards

(counterclockwise along the colon) may cause pain in the right iliac fossa, by pushing

bowel contents towards the ileocaecal valve and thus increasing pressure around the

appendix.

17. Stikovskiy (resenstein’s) sign - increased pain on palpation at the right iliac region as

patient lies on his/her left side.

18. Ultrasound - is cyclic sound pressure with a frequency greater than the upper limit of

human hearing. Although this limit varies from person to person, it is approximately 20

kilohertz (20,000 hertz) in healthy, young adults and thus, 20 kHz serves as a useful

lower limit in describing ultrasound. The production of ultrasound is used in many

different fields, typically to penetrate a medium and measure the reflection signature or

supply focused energy. The most well known application of ultrasound is its use in

sonography to produce pictures of fetuses in the human womb. There are a vast number

of other applications as well.

19. Vermiform – a resembling worm in shape.

20. Vermiform Appendix -  a narrow blind tube usually about three or

four inches (7.6 to 10.2 centimeters) long that extends from the cecum

in the lower right-hand part of the abdomen, has much lymphoid wall

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tissue, normally communicates with the cavity of the cecum, and

represents an atrophied terminal part of the cecum.

BIBLIOGRAPHY

A. Textbook References/Primary References:

Assessment: Lippincott; 2007 Edition.

Taber’s Cyclopedic Medical Dictionary: 18th edition

Fundamentals of Nursing: Kozier and Erb; 8th Edition.

Medical-Surgical of Nursing: Bunner and Suddarth; 12th Edition.

NANDA: Doenges, Moorhouse and Murr; 12th Edition.

Nursing Care Plans: Doenges, Moorhouse and Murr; 8th Edition.

Nursing Drug Guide: Lippincott; 2010 Edition.

PDQ for RN:Mosby; 2nd Edition.

PPD for Registered Nurses: Mosby; 2nd Edition.

Principles of Internal Medicine: Harrison and Braunswald; 11th Edition.

Public Health Nursing: Nurses Contributors; 2007 Edition.

B. Electronic References/Secondary References:

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001302/

http://www.webmd.com/digestive-disorders/digestive-diseases-appendicitis

http://kidshealth.org/parent/infections/stomach/appendicitis.html

http://en.wikipedia.org/wiki/Appendectomy

http://www.appendicitisreview.com/laparoscopic-appendectomy/

http://medical-dictionary.thefreedictionary.com/Ruptured+appendix

www.sciencedaily.com

www.healthycase.com


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