TARLAC STATE UNIVERSITY COLLEGE OF NURSING Lucinda Campus Brgy.

Ungot, Tarlac City

A Case Study on Acute Pyelonephritis

In Partial Fulfillment of the Requirements of the Subject Nursing Care Management 102 RLE

Presented to the Faculty Of the Tarlac State University College of Nursing Presented by: BSN III - C Group C4 Querido, Richen Raiz, Jayscent Rodriguez II, Rolando Sabat, Aprillyn Santos, Marivic Santos, Willa Milafrosa Sotelo, Jeffrey Suarez, Christine Karen Sumang, Jerico Sumaoang, Maria Luisa

I. INTRODUCTION

Appendicitis is inflammation of the vermiform appendix caused by an obstruction attributable to infection, structure, fecal mass, foreign body, or tumor. Appendicitis can affect either gender at any age, but is most common in males 10 to 30. Appendicitis is the most common disease requiring surgery. If left untreated, appendicitis may progress to abscess, perforation, subsequent peritonitis, and death. Appendicitis is a condition characterized by inflammation of the appendix. It is a medical emergency. All cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of peritonitis and shock. (www.wikipedia.com) Suspected acute appendicitis is the most frequent cause for emergency operations in visceral surgery, worldwide. The lifetime risk of acute appendicitis for men and women is 8.6% and 6.7%, respectively, however, the lifetime risk of having an appendectomy is 12% for men and 25% for women. A reported 250,000 appendectomies are performed annually, with approximately 15% of these resulting in the removal of normal appendices. A history of migratory pain together with physical findings and leukocytosis is generally percieved as accurate diagnostic clues for children and adults. (www.diagnostic pathology.org) Nationwide rate of patient with appendicitis shows an estimated 261 134 patients underwent non - incidental appendectomies, and 39 901 (15.3%) were negative for appendicitis. Women had a higher rate of non incidental appendicitis as did patients younger than 5 years and older than 60 years. When compared with patients with appendicitis, NA was associated with a significantly longer length of stay (5.8 vs 3.6 days, P<.001), total charge-admission ($18 780 vs $10 584, P<.001), case fatality rate (1.5% vs 0.2%, P<.001), and rate of infectious complications (2.6% vs 1.8%, P<.001). An estimated $741.5 million in total hospital charges resulted from admissions in which a non incidental appendectomies was performed. (www.google.com)

a. Reason for Choosing Our Case Study The group came up with this case, which demands deep understanding and patience because of our curiosity and interest. The student nurses had chosen this case because we want to disseminate information about appendicitis. In particular, to this, the group wants to discuss the risk factors that can trigger the occurrence of the disease and with the sign and symptoms of the said disease. b. Importance of the Study Conducting a case study is one of the requirements in Nursing Care Management 101 RLE. This case study is specifically planned to provide information in which both the patient and the student nurses will benefit. With this, the student nurses will be able to provide appropriate nursing interventions that would help in restoring the wellness of the patient in accordance to her condition. It provides broader understanding about the condition chosen through research and actual observation.

II. OBJECTIVES General: The objective of our case study is to develop and acquire understanding, skills, and knowledge about the disease, and health promotion to prevent further complication on the condition of the patient. Specific: Nurse Centered To assess the patients overall health status To impart necessary health teachings to the patient To perform appropriate nursing care in conjunction with the condition of the patient
To be more familiarized with the nurses roles in caring the patient and to educate

patient regarding her condition. To widen and enhance the student nurses knowledge and skills through additional research about the nature of the disease, its signs and symptoms, its pathophysiology, its diagnosis and treatment. Patient Centered To know when to seek help from the health care providers whenever the signs and symptoms may appear. To understand the occurrence of appendicitis. To gain information about the procedure, appendectomy. To know what other complications may arise, if left untreated.

 To gather information about the therapeutic regimen that may apply after the operation.

III.

PERSONAL DATA A. Demographic Data

Name: Age: Sex: Civil Status: Occupation: Religious Affiliation: Role position in the family: Address: Date and Place of birth: Nationality: Health Care Financing: Chief Complaint: Admitting Diagnosis: Date admitted:

Ms. A 19 y/o Female Single N/A Roman Catholic Daughter San Nicolas, Tarlac October 27, 1989 / San Nicholas, Tarlac Filipino Family RLQ pain Acute Appendicitis, Congestive September 14, 2009

B. Environmental Status Ms. A is currently residing at San Nicolas, Tarlac City. Their house is made up of cement and wood. Their source of water is through water pump, which is located 5 meters away from their house. She claimed that they have appliances that serve as entertainment such as: Television, radio, etc.; they have own electricity. Their house has three ventilated rooms. Their garbage is collected twice a week by local garbage collectors. The family maintains a good relationship with each other. In times of need, their relatives help them.

C. Lifestyle According to her, before she had this condition, she is socially active; she used to attend parties and fiestas in their Brgy. (San Nicolas, Tarlac City). She is fond on going out with her friends and family during weekends. According to the patient, she occasionally drinks alcoholic beverages. She is not an illegal drug user neither a smoker. She stated that she loves eating junk foods and street foods as well, like tokneneng,calamares and fish balls. She also stated that she usually carry heavy objects such as carrying a pail of water because their source of water is through water pump. Moreover, since she is the only person who is left at home during weekdays, she does all the household chores. At her present condition, she was not able to mingle with her neighbors, and go to other places.

IV. FAMILY HISTORY OF HEALTH AND ILLNESS Paternal Side 77 RF 47 47 4 5 6 8 AST 42 38 6 3 HTN 6 0 A&W Maternal Side 77 HTN 52 7 2 HTN 49 4 7 4 5 4 1

4 6

5 7 A&W

5 5 AST

A&W A&W A&W A&W A&W A&W

A&W A&W

A&W A&W A&W

1 9

1 8 A&W

1 3 A&W

3 A&W

Legend: Male Female Patient - Deceased Male - Deceased Female HTN Hypertension A&W Alive & Well RF Renal Failure AST - Asthma
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V. HISTORY OF PAST ILLNESS During her childhood, Ms. A had experienced measles, mumps and chicken pox. She had also experienced cough, colds, fever and a serious condition of asthma. Her fever lasts for two days, and during those times, she usually take Over-the-counter (OTC) drugs such as Biogesic. With respect to her immunization record, according to her mother, Ms. A had completed her immunization in a health center in their Barangay at San Nicolas, Tarlac City. According to her, she does not have any allergies to environmental agents such as dusts, drugs, animals nor food. Ms. A also stated that she had never been admitted to hospital for any serious illness or accidents aside from her present condition. VI. HISTORY OF PRESENT ILLNESS According to the patient, she had been experiencing mild pain at her abdominal region since September 10, 2009. She even consulted it into the doctor but they did not pay much attention to it thinking that it was just a simple stomach ache and that it was nothing serious. She also stated that the pain she had experienced last September 10, 2009 lasted for 4 days and the pain was tolerable. September 14, 2009, after having her lunch, she experienced a severe attack of pain at her abdomen, which started at the area around her periumbilical area shifted to the right lower quadrant region. She was immediately rushed to the Tarlac Provincial Hospital and was admitted at the surgery ward at 04:03 PM of the same day. She was diagnosed with Acute Appendicitis, Congestive by the attending physician. She underwent an emergency appendectomy the next day, September 15, 2009.

VII. 13 AREAS OF ASSESSMENT 1. SOCIAL STATUS Ms. A is a 19 yr old woman residing at San Nicolas, Tarlac. She is a Roman Catholic and eldest among the four children in their family. They have a good family relationship. According to the patient, she occasionally drinks alcoholic beverages. She is not a drug user neither a smoker. She usually takes Over-the-Counter drugs, whenever she experience fever, cough, and colds. She could cope up to these stressors as she accepts her health condition and was hopeful to regain her good health condition. She was a high school graduate and not able to pursue her college degree due to financial problem. She does household chores everyday with the help of her siblings. STANDARD: Social status includes family relationships or friendships that state the patients support system in time of stress and in time of need. It meets a fundamental human need for social ties, making life less stressful and social support buffers the negative effects of stress, thus indicating indirectly contributing to good health outcomes. (Friedman and Smith, 1998) ANALYSIS AND INTERPRETATION: The patient developed interpersonal relationship within the family with a certain degree of satisfaction. She developed a good coping ability as evidenced by being hopeful to regain her normal functioning or health condition. 2. MENTAL STATUS Level of Consciousness During our interview, Ms. A acknowledges us and able to respond to the questions we asked, and were oriented with the time and place where she is, and understand about her present condition. On the following day, Ms. A is capable to established eye contact with us and can answer to all the questions being asked. Appearance and movement Ms. A is lying flat on bed during our first interview. She is well groomed and her things were organized. She is pale and weak in appearance and has limited movement due to her incision site. Mood Ms. A seems to be irritable at times and with facial grimace due to pain at her wound site, seeing her doing-guarding reflex, which is the cause of her unstable behavior.

Cognitive Abilities Ms. A is able to express her thoughts and understanding about her present condition. STANDARD: The patient should be able to correctly respond to questions and to be able to evaluate and act appropriately in situations requiring judgment. (Health Assessment and Physical Examination, 3rd edition by Mary Ellen Zator Estes) ANALYSIS AND INTERPRETATION: Based on the above statement, she is able to respond to questions and is oriented about the time and place where she is, and able to establish eye contact during the 1st interview. Due to the procedure done to her, she has limited movement, and pale and weak in appearance. Ms. A also seems irritable and with facial grimace, and able to express her thoughts. 3. EMOTIONAL STATUS During our conversation with Ms. A, we noticed her emotional status is good in a way that she is open with the questions we asked and she is also responsive during our interaction with her. We also noticed that her condition with regards to her emotional status does not totally affect her because she can divert her emotion or feeling when she is experiencing pain in doing deep breathing exercises or relaxation techniques and when she is having conversation with her family. STANDARD: Emotional wellness is the ability to manage stress and to express emotions clearly. (Health Assessment and Physical Examination, 3rd edition by Mary Ellen Zator Estes) ANALYSIS AND INTERPRETATION: Ms. A has the ability to manage stress by means of expressing her thoughts and feelings willingly. Her feeling of fear is due to her health condition because she was thinking of the complications and consequences that might to her. 4. SENSORY PERCEPTION Sense of Sight Ms. A is not experiencing difficulty in her vision. We assessed Ms. As vision by using paper with different shapes drawn on it, and she was able to distinguished it. And we were able to come up with the result regarding her vision as 20/20. The sclera of Ms. A was tested by using the penlight and it is whitish in color and the pupil is constricted when struck by light. She was able to have eye contact with us during the entire process of interview.

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STANDARD: The patient should have a visual acuity of 20/20; the eyes must be symmetrical during the six cardinal gazes; sclera should be white with some small blood vessels; and papillary constriction should occur during struck by light. (Health Assessment and physical assessment, Mary Ellen Zator Estes) ANALYSIS AND INTERPRETATION: The patient has a normal eye vision for having a visual acuity of 20/20 and the eyes are symmetrical. The sclera of Ms. A is whitish in color and the pupil is constricted when struck by light. She was able to have eye contact with us during the entire process of interview. Sense of Taste Ms. A is able to determine the foods taste, and can differentiate various tastes such as sour, bitter, sweet and others with the use of water or tea, crackers. The tongue of Ms. A was assessed and it is in the midline of the mouth, pinkish in color, moist, and rough without lesions. STANDARD: The tongue is in the midline of the mouth. The dorsum of the tongue should be pink, moist and rough without lesions. (Health assessment and physical assessment, Mary Ellen Zator Estes) ANALYSIS AND INTERPRETATION: The patient can determine foods taste, and can differentiate various tastes. The tongue is in the midline of the mouth, it is pinkish in color, was moist, rough without lesions and therefore revealed normal findings. Auditory Acuity Ms. A can hear our voices clearly and responds whenever her name was called. We did some acuity test to Ms. A and she can repeat the words clearly in the distance of 2 inches. And there is no pain experienced during palpation behind the ears. STANDARD: The patient should be able to hear words within 2 inches away. The pt. should not complain of pain upon palpation. (Health assessment and physical assessment, Mary Ellen Zator Estes) ANALYSIS AND INTERPRETATION: Based on the above statements, Ms. U can hear our voices clearly and responds whenever her name was called. She can repeat the words clearly in the distance of 2 inches through some acuity test. There is no pain experienced during palpation behind the ears
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Sense of Smell Ms. A can distinguish different odors. Upon assessing her sense of smell, we instructed her to inhale deeply and close her eyes to identify the smell of cologne and alcohol. She is able to differentiate the scents of alcohol and cologne. STANDARD: The patient should be able to determine the different smells of different objects. (Health assessment and physical assessment, Mary Ellen Zator Estes) ANALYSIS AND INTERPRETATION: Based on the given standard, Ms. A can distinguish different odors. She is able to differentiate the scents of alcohol and cologne. Pain Sensation Ms. A expresses her sensation of pain by pointing her abdomen and cannot fully verbalize what she is feeling. We asked her to rate the pain from 0 10 and she rated it as 6/10 by sign language using her fingers. She also stated that she can tolerate the pain she is experiencing. STANDARD: Rating of Pain: 10 Severely Painful, and 1 Least Painful (Fundamentals of Nursing: Process, Concepts and Practice, 7th Edition). ANALYSIS AND INTERPRETATION: The patient is able to express her sensation of pain and that she can tolerate the pain at her incision site. 5. MOTOR STABILITY Ms. As gait is slight staggering with weakness on legs so she needs support when standing or walking. She is not comfortable in her condition. She finds walking, or changing positions difficult and admitted that she needs the help of another person when ambulation. STANDARD: A person should move freely with no assistance and no alterations in movement. (Health Assessment and Physical Examination, 3rd edition by Mary Ellen Zator Estes) ANALYSIS AND INTERPRETATION: Based on the given statement, Ms. As motor stability is affected resulting her to get limited movements and needs for assistance during ambulation.

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6. BODY TEMPERATURE The table below shows the temperature of Ms. A during the shift: Date September 17, 2009 Time 04:00 pm 06:00 pm 10:00 pm September 18, 2009 September 19, 2009 September 21, 2009 04:30 pm 02:00 pm 10:00 am Body Temperature (axilla) 36.8 C 36.5 C 37.9 C 36.8 C 37.3 C 37.0 C

STANDARD: The hypothalamus is the one that controls the body temperature. Normal range of body temperature of an adult is 36.5C to 37.5C (per Axilla). (Fundamentals of Nursing, Daniels) ANALYSIS AND INTERPRETATION: As the data shows, Ms. As body temperature is in normal state. 7. RESPIRATORY STATUS The table below shows the respiratory rate of Ms. U during the shift: Date September 17, 2009 Time 04:00 pm 06:00 pm 10:00 pm September 18, 2009 September 19, 2009 September 21, 2009 04:30 pm 02:00 pm 10:00 am Respiratory Rate 18 cpm 15 cpm 19 cpm 20 cpm 17 cpm 16 cpm

STANDARD: A respiratory assessment can provide valuable information about clients physical and emotional health. The normal respiratory range of an adult is 12-20 bpm. (Fundamentals of Nursing, Daniels). ANALYSIS AND INTERPRETATION: Based on the data shown, Ms. A has normal respiratory pattern and does not experiencing difficulty in breathing.
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8. CIRCULATORY STATUS The table below shows the pulse rate and blood pressure of Ms. A during the shift: Date September 17, 2009 Time 04:00pm 06:00pm 10:00pm 04:30pm 02:00pm 10:00am Pulse Rate 87 bpm 77 bpm 82 bpm 80 bpm 74 bpm 81 bpm Blood Pressure 110/80 mmHg 100/70 mmHg 110/80 mmHg 110/70 mmHg 100/90 mmHg 110/80 mmHg

September 18, 2009 September 19, 2009 September 21, 2009

STANDARD: Normal cardiac rate of an adult is 60 100 beats per minute. And the normal blood pressure is 120/80 mmHg. (Health Assessment and Physical Examination, 3rd edition by Mary Ellen Zator Estes) ANALYSIS AND INTERPRETATION: Based on the above statements, Ms. A has a normal pulse rate which ranges on the given normal limit. The blood pressure of Ms. A is appropriate for her age and is in the normal range 9. NUTRITIONAL STATUS Height Weight BMI Diet Appearance I.V.F The patient is 145 cm tall The patient is 47 kg Her body mass index is 18.67 The patient is on SOFT Diet. She could consume 5 6 glasses of water a day. The patient is regular in built. An I.V infusion of D5LR 1L + 2amp Vit. B complex was administered respectively to her.

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Formula Of BMI
BMI = weight in kg height in m2

Equation
BMI = 47 kg . = 22.35 2.1025 m2 Result: Normal weight

Standard Scoring
< 18.5..................underweight 18.5 24.9.......normal weight 25.0 29.9.............overweight 30.0 39.9..................obesity 40 > ..............extreme obesity

STANDARD: The nutritional condition of a patient is a good determinant of the possible health condition. Nutrition can even be a prevention and treatment for some diseases. Normal body mass index (BMI) is 18.5 - 24.9. Less than 18.5 is associated with health
problem in some People, and more than 25 indicates higher risk for developing health problems. (Health Assessment and Physical Examination, 3rd edition by Mary Ellen

Zator Estes) ANALYSIS AND INTERPRETATION: Based on the data given, the patients BMI is normal compared to the standard scoring. 10. SLEEP-REST PATTERN Ms. A normally sleeps at around 09:00 pm and will wake up in 08:00 in the morning (consuming 8 10 hours of sleep). When admitted to the hospital, she sleeps for at least 2 hours in the afternoon because of the noisy environment in the hospital and on the pain in her incision site. STANDARD: There is a wide range of sleep time that is considered normal. The average sleep of an individual is 8 hours per night. (www.umm.edu/sleep/normal_sleep.html) ANALYSIS AND INTERPRETATION: At her present condition, Ms. A has difficulty in sleeping in the hospital and only sleeps for at least 2 hours in the afternoon, causing her to have minimal rest. 11. ELIMINATION STATUS According to her, she usually voids at least 3 4 times a day depending on the amount of fluid she takes. She stated that she had 1 bowel movement per day, and has brownish in color stool, intact, and in moderate amount. STANDARD: The normal bowel movement of a person must be 1 2 times a day and voiding of 2 3 times a day. The normal color of stool is brown and well
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formed. The urine is clear and yellowish in color. (Health Assessment and Physical Examination, 3rd edition by Mary Ellen Zator Estes) ANALYSIS AND INTERPRETATION: Based on the data given, Ms. As bowel movement and voiding is normal as compared to the standard norm. 12. REPRODUCTIVE STATUS Ms. A had her menarche when she was 13 years old. Her cycle usually lasts for 5 days. She is experiencing headaches and with pain on the pelvic area during her cycle. According to her, she is not sexually active because she does not have any boyfriend at this moment. STANDARD: Menarche, which is the first menstruation occur at an average age of onset between 9 to 17 years old. (Maternal and Child Health Nursing 4th Edition by Pilliterri) ANALYSIS AND INTERPRETATION: The patient had a normal reproductive system since she had her menarche at the right age. 13. STATE OF SKIN AND APPENDAGES Generalized color Texture Moisture Temperature Capillary Refill Ms. A had a fair complexion. There is redness noted at the incision site of Ms. As abdomen. There are no bedsores found. The skin is dry. Perspiration was observed on her. The patients skin is warm and dry. Nail beds vascularization goes back to normal after almost 2 seconds when pinched.

STANDARD: Skin is warm to touch, and returns to its original state immediately within 2 -3 seconds. (Health Assessment and Physical Examination, 3rd edition by Mary Ellen Zator Estes) ANALYSIS AND INTERPRETATION: Ms. As skin and appendages status was affected due to the incision site. There is also presence of redness at the site, skin is warm to touch, and returns to its original state immediately within 2 seconds.

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Patients name: Ms. A Sex: Female VIII. DIAGNOSTIC AND LABORATORY PROCEDURES

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Diagnostic/ Laboratory procedures

Date Ordered and Date Resulted

Indication/s or purposes

Normal Values (units used in the hospital) WBC 4.5-11X10 /L LYM 0.23-0.35%

Result/s

Analysis and interpretation of Results Normal Increased Normal Normal Normal Normal Normal

WBC

9.9 G/L

Hematology Report

September 14, 2009

Complete blood count (CBC) is a determination of the MID 0.01.8 MID 0.4 4.2%M number of red and white blood cells per cubic millimeter GRAN 2.0 7.8 GRAN 6.8 68.8%G of blood. A CBC is one of the most routinely performed RBC 4.206.30X10 RBC 4.65 T/L test in a clinical /L laboratory and one of the most valuable HGB 120-180 g/L HGB 127 g/L screening and diagnostic techniques. It also HCT 0.370HCT 0.411L/L helps the health 0.5%/L professional to check the patients condition, such as anemia, infection MCH 26.0-32.0/g MCH 27.3 pg and some symptoms like fatigue. And weakness the MCHC 310-360 MCHC 309 g/L patients have. g/L PLT 140-940 g/L PLT 247 g/L

LYM 2.7 27.0%L

Normal Decreased
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Normal

NURSING RESPONSIBILITIES: Before, during and after diagnostic and laboratory test/s done: 1. Inform the pt. and the family about the procedure. 2. Explain the importance of the procedures to be done to the pt.

Diagnostic/ Laboratory procedures

Date Ordered and Date Resulted

Indication/s or purposes

Normal Values (units used in the hospital)

Result/s

Analysis and interpretation of Results

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Clear Straw Urinalysis September 14, 2009 For detection of any bacteria in the urine, glucose, albumin, blood, protein presence of infection.

Color: yellow Appearance: slightly turbid Normal Reaction: acidic

1.010-1.030

Specific gravity 1. 010 Albumin: (-) Glucose: (-)

usually (-) Usually (-)

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IX. ANATOMY AND PHYSIOLOGY

The appendix is a closed-ended, narrow tube up to several inches in length that attaches to the cecum , the first part of the colon, like a worm. The anatomical name for the appendix is vermiform appendix which means worm-like appendage. It's pencil-thin and normally about 4 inches (7 cm) long. The appendix is usually located in the right iliac region, just below the ileocecal valve (designated McBurney's point) and can be found at the midpoint of a straight line drawn from the umbilicus to the right anterior iliac crest. The inner lining of the appendix produces a small amount of mucus that flows through the open center of the appendix and into the cecum. The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies. During the first few years of life, the appendix functions as a part of the immune system, it helps make immunogobulins. But after this time period, the appendix stops functioning. However, immunoglobulins are made in many parts of the body, thus, removing the appendix does not seem to result in problems with the immune system.
www.scribd.com www.google.com Anatomy and Physiology

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Predisposing Factor: Age Sex Race Family history

X. PATHOPHYSIOLOGY (Book Based)

Precipitating Factor: Diet

Occlusion of fecalith, tumor, or foreign body and bacterial invasion Intraluminal Obstruction Distention of the appendix Decreased venous drainage Blood flow and oxygen restriction to the appendix Bacterial Invasion of the Blood wall Necrosis of the appendix S/Sx - Progressively severe, localized pain in the epigastric region that becomes localized in the RLQ, nausea, vomiting, fever PATHOPHYSIOLOGY
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Causes pain

(Patient Based) NON- MODIFIABLE FACTORS: Age (19y/o) MODIFIABLE FACTORS: Lifestyle such as carrying heavy objects Eating unsafe foods such as street foods.

Bacterial invasion

Occlusion of fecalith

Increase intraluminal pressure

Obstruction of the appendix

Inflammation of the appendix

Right Lower Quadrant abdominal pain, Nausea and vomiting Fever

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XI. NURSING CARE PLANS

ASSESSMENT

PLANNING

IMPLEMENTATION

EXPECTED OUTCOME > After 2 of rendering appropriate nsg. intervention, the pts pain scale was lessen.

S> Masakit ang >Within 2 of > Monitor vital signs of sugat ko rendering the pt. appropriate O > grimace nursing Rationale: To obtain > irritable intervention, the baseline data. >restless pts pain scale will >pale looking be lessen. > Dress the wound. > guarding behavior >redness on the Rationale: To prevent incision site noted occurrence of infection. >PS NURSING > Provide comfort like DIAGNOSIS: back rubbing. Acute pain r/t surgical procedure. SCIENTIFIC EXPLANATION: An unpleasant sensation caused by noxious stimulation of the sensory nerve ending. It is a subjective feeling and an individual response to the cause. Pain is subjective in which the pt. inhibits a feeling of distress. Stimulating or trauma to certain nerve endings as a result of surgery causes pain. Rationale: To increase relaxation of the pt. > Help pt. to divert his attention by using of deviational activities like listening to radio and talking to her visitors. Rationale: To focus more in activities and reduce the pain. >Administer pain reliever as prescribed by the doctor. Rationale: To improve the pt.s control of pain.

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ASSESSMENT

PLANNING

IMPLEMENTATION

EXPECTED OUTCOME

S> Nahihirapan > Within 3 of akong gumalaw ng rendering maayos appropriate nursing O > with limited intervention, the movements noted. patient will be able > weak in to increase appearance. physical activity. >restless > pale looking >irritable NURSING DIAGNOSIS: Activity intolerance r/t decrease muscle strength 2 surgical procedure SCIENTIFIC EXPLANATION: Insufficient physiologic or physiologic energy to endure or complete require or desire daily activities.

> Encourage deep > After 3 of breathing exercises. rendering appropriate nsg. Rationale: To increase intervention, the relaxation of the pt. patient is able to increase physical > Provide therapeutic activity from lying conversation towards to sitting to patients status. standing position. Rationale: To divert the patients attention on the pain she is experiencing. > Assist the pt in ambulation. Rationale: To promote comfort to the pt and increase activity tolerance. >Turn the pt from side to side every 30 minutes. Rationale: To prevent pressure ulcers and promote proper circulation. > Apply therapeutic massage and soothing touch therapy. Rationale: Massage helps for better circulation, thus increasing energy supply to the patient.
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ASSESSMENT

PLANNING

IMPLEMENTATION

EXPECTED OUTCOME

S> Mainit ang > Within 1 of pakiramdam ko rendering appropriate O nursing >weak in intervention, the appearance patients >warm to touch temperature will >hot or humid subside. environment >restless >irritable >pale looking >sweating noted NURSING DIAGNOSIS: Hyperthermia r/t environmental factors (hot or humid environment)

> Monitor vital signs of >After 1 of the patient. rendering appropriate nsg. Rationale: To obtain intervention, the baseline data. patients temperature > Render Tepid Sponge subsided. Bath. Rationale: To reduce heat within the pts body. > Provide ventilation. proper

Rationale: To provide comfortable environment. > Instruct the pt. to increase fluid intake. Rationale: To replace fluid loss and maintain adequate fluid. > Apply cold compress to the forehead. Rationale: To reduce body heat of the pt.

SCIENTIFIC EXPLANATION: The condition defines as a state in which body temperature is elevated above his or her normal range.

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ASSESSMENT

PLANNING

IMPLEMENTATION

EXPECTED OUTCOME > After 3 of rendering appropriate nsg. intervention, the pt. is able to sleep and feel comfortable.

S> Nahihirapan akong matulog ng maayos kasi maingay dito

> Within 3 of rendering appropriate nursing intervention, the O> frequent pt. will able to yawning noted. sleep and feel >sleepy in comfortable. appearance. >weak in appearance. >restless >irritable NURSING DIAGNOSIS: Disturbed sleep pattern r/t physical discomfort

> Render sponge bath to provide better circulation. Rationale: To maintain freshness. > Change loosens clothing. Rationale: To provide comfort > Provide proper ventilation. Rationale: To maintain a cool environment suitable for sleeping. > Render back rubs. Rationale: To promote and give relaxation techniques. > Arrange bedside linens. Rationale: To provide comfortable and clean environment.

SCIENTIFIC EXPLANATION: Time limited disruption of sleep (natural, periodic, suspension of consciousness) amount and quality.

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ASSESSMENT

PLANNING

IMPLEMENTATION

EXPECTED OUTCOME

S>

After 2 of rendering O> dirty nails appropriate >elevated nursing temperature intervention, the > warm to touch pt. will be able to > redness in the site understand about of incision the prevention and control of NURSING infection. DIAGNOSIS: Risk for infection r/t tissue destruction and increased environmental exposure

> Monitor vital signs of After 2 of the patient. rendering appropriate nursing Rationale: To obtain intervention, the pt baseline data. able to verbalize the information > Change dressings as that is given to her. needed or indicated. R: To remove any microorganism that is opportunistic and may cause of infection. > Instruct the pt. to do proper hand washing. Rationale: To prevent growth of micro organism. > Encourage the patient to clean the incision site daily. Rationale: To prevent the spread and growth of microorganisms. > Instruct to patient and the family about the needed for good nutrition, especially protein, and vitamin C. Rationale: Eating nutritious foods will aid in fighting infection.

SCIENTIFIC EXPLANATION: An infection is the detrimental colonization of a host organism by a foreign species. In an infection, the infecting organism seeks to utilize the host's resources to multiply (usually at the expense of the host).

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XII. Medical Management/Treatment Date ordered / Date performed / Date changed / Date discontinued

Medical Management / Treatment

General Description

Indication/s or Purpose/s

Clients reaction to treatment

1. D5LR 1L Date ordered: 30gtts + 2 amps Sep. 14, 2009 Vit. B complex (04:00 pm) 2. D5LR 1L Date ordered: 30gtts + 2 amps Sep. 15, 2009 Vit. B complex (12:00 am) 3. D5NM 30gtts Date ordered: Sep. 16, 2009 (12:00 am) A hypertonic solution with greater concentration of solutes than plasma and can draw fluids out of the cells and interstitial spaces into the vascular system. To increase the volume of blood following severe loss of blood or plasma and is used for fluid and electrolyte replenishment and caloric supply. There were no signs of inflammation or infiltration during the infusion.

4. D5LR 1L Date ordered: 30gtts + 2 amps Sep. 17, 2009 Vit. B complex (04:00 pm)

NURSING RESPONSIBILITIES: Before, during and after the treatment: 1. Explain the procedure to the patient. 2. Secure consent from patient before IV infusion. 3. Verify physicians order indicating the type of solution, amount to be administered, and rate of flow of the infusion. 4. Inspect IV site for signs of infiltration or inflammation. 5. Check IV flow rate and monitor fluid volume overload. 6. Monitor intake and output.
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Names of Drugs (Generic and Brand Names)

Date ordered, Date Taken / Given, Date Changed / D/C

Route of Admin. & Frequency of Admin.

Gen. Action, Mech. of Action

Indication/s or Purpose/s

Clients Response to Med with Actual S/E

Cefoxitin

September I.V 15, 2009

Broad spectrum cephalosphorin that is penicillinase and cephalosporinateresistant in the presence of prolactamases

Intra abdominal No infections, response perioperative prophylaxis including GI surgery

Omeprazole

September I.V 15, 2009

Thought to be a gastric pump inhibitor in that it blocks. The final step of acid production by inhibiting the H+ ion or K+ attase system at the circulatory surface of the gastric parietal cell. Both basal and stimulated acid secretion are inhibited. Serum gastrin level are increased during the first 1 or 2 weeks of therapy and are maintained at such levels

Short term treatment of No active response duodenal ulcer. Short term (4-8 weeks) treatment of active benign gastric ulcer.

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during the course of therapy. Short term (4-8 weeks) Pain at the and IV site maintenance treatment of duodenal ulcer. Short term treatment of active, benign gastric ulcers and maintenance treatment after healing of the acute ulcer. Short term (up to 5 days) Pain, management sweating of sever acute pain in adults that requires analgesia at the opiate level, usually in a postoperative setting

Ranitidine

September I.V 15, 2009

Competitively inhibits gastric acid secretion by blocking the effect of histamine on histamine H2 receptors. Both daytime and nocturnal basal gastric acid secretion, as well as food and pentagastrinstimulated gastric acid are inhibited.

Ketorolac

September I.V 15, 2009

Possesses in anti inflammatory, analgesic and anti pyretic effect.

Celecoxib

September I.V 15, 2009

Inhibits prostaglandin synthesis,

Relief signs and symptoms of rheumatoid No arthritis and response osteoarthritis

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primarily by inhibiting cyclooxyginase-2 (COX-2), thus decreasing inflammation does not inhibit. The COX-1 isoenzyme does not affect platelet aggravation, renal effects similar to other NSAIDS. Causes fewer GI complications, such as bleeding and perforation, compared with other NSAIDS. NURSING RESPONSIBILITIES: Before and after giving medications to the client: 1. Ask the pt. if she is allergic to certain drugs. 2. Monitor the pt. for adverse reactions. Date Ordered, date Started, Date Changed Ordered: 09-14-09

in adults. Acute pain in adults.

Type of Diet

General Description

Indication/s or Purpose/s

Specific Foods Taken

Clients Response and/or Reaction to the Diet After explaining to the patient, she understood the procedure.

NPO

Strictly, not allowed to take any kind Started: of food or 09-14-09 post liquids by midnight mouth. Discontinued: 09-16-09

NONE To avoid patient vomit during operation.

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Full Liquid Diet

Full liquid diet allows only foods in Started: liquid form or 09-16-09 those which readily Discontinued: become liquid 09-16-09 at body temperature. A diet that allows fruits and Started: vegetables 09-17-09 with lowcellulose Discontinued: content as 09-18-09 well as fish and meat with no or very little connective tissues. Ordered: 09-17-09

Ordered: 09-16-09

The diet aims to prevent dehydration or for some reasons, to clear the gastrointestinal tract.

1 cup noodle soup or Broth only, tea

Since patient hungry thirsty, was glad finally could foods.

the is and she that she eat

Soft Diet

> Designed for Porridge or The patient the patients lugaw is happy who cannot about the tolerate a diet as she general diet verbalized > Aims to Sa wakas, reduce the work makakakain load of na rin ako. digestive system

NURSING RESPONSIBILITIES: Before, during and after the administration of the diet: 1. Explain the procedure. 2. Be sure that the patient flatus before giving the diet. 3. Teach the family about the diet. 4. Check the patients food. 5. Observe tolerance for eating. 6. Check the patients readiness for the next diet. 7. Document the procedure.

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Type of Exercise

Date Ordered, Date Started, Date Changed

General Description

Indication/s or Purpose/s

Clients response / reaction to the activity / exercise

Bed Rest

Date ordered: Feb. 15, 2009

Is a medical For fast treatment refers recovery of the to staying in patient. bed day and night as a treatment for an illness or medical condition. Ambulation is the recommended for a healthy lifestyle, and has numerous environmental benefits.

Relaxed and comfortable.

Ambulation

Date ordered: Feb. 16, 2009

For progress She can tolerate and early walking without recovery of the assistance. patient.

NURSING RESPONSIBILITIES: 1. Educate the patient about the importance of ambulation and bed rest, and the appropriate way of doing the exercise. 2. Assisted the patient in ambulation

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XIII. SURGICAL MANAGEMENT Clients response to the operation

Name of procedure

Date performed

Brief Description

Indication/s or Purpose/s

Appendectomy

September 15, 2009

Appendectomy is the surgical removal of the vermiform appendix. This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis; it is now recognized that many cases will resolve when treated nonoperatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix.

Client understood the An risk and benefit appendectomy of the treats operation. Thus appendicitis. Patients who do accepting the not undergo postoperative outcome. appendectomy are at greater risk of complications such as perforation of the appendix with development of an abscess and severe infection.

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NURSING RESPONSIBILITY: Before, during and after the surgical procedure: 1. Explain procedure to the patient. 2. Advise the patient to not eat or drink for several hours before the examination. 3. Provide patient privacy 4. Observe for patients response to the procedure 5. Assist patient to move from supine to sitting position 6. Follow up for the result of the procedure

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XIV. SOAPIE/R

DATE September 17, 2009

SUBJECTIVE CUE/S Masakit tahi ko

OBJECTIVES CUE/S

ASSESSMENT PLAN

IMPLEMENTATION / INTERVENTION

EVALUATION

ang > dirty nails >Acute pain r/t > elevated surgical >Within 2 of temperature procedure rendering > warm to touch appropriate > redness in the nursing site of incision intervention, the >PS 7/10 pts pain scale will be lessen.

> Monitored vital signs > After 2 of of the pt. rendering appropriate Rationale: To obtain nursing baseline data. intervention, the pts pain scale > Dressed the wound. was lessened. Rationale: To prevent occurrence of infection. > Provided comfort like back rubbing. Rationale: To increase relaxation of the pt. > Helped the pt. to divert his attention by using of deviational activities like listening to radio and talking to her visitors.
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Rationale: To focus more in activities and reduce the pain. >Administered pain reliever as prescribed by the doctor. Rationale: To improve the pt.s control of pain.

DATE

SUBJECTIVE

ASSESSMENT PLAN

IMPLEMENTATION

EVALUATION
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CUE/S September 17, 2009

OBJECTIVES CUE/S Activity intolerance r/t decrease muscle strength 2 surgical procedure > Within 3 of rendering appropriate nursing intervention, the patient will be able to increase physical activity.

/ INTERVENTION > After 3 of > Encouraged deep rendering breathing exercises. appropriate nursing Rationale: To increase intervention, the relaxation of the pt. patient is able to increase > Provided therapeutic physical activity conversation towards from lying to patients status. sitting to Rationale: To divert the standing patients attention on the position. pain she is experiencing. > Assisted the pt in ambulation. Rationale: To promote comfort to the pt and increase activity tolerance. >Turned the pt from side to side every 30 minutes. Rationale: To prevent pressure ulcers and promote proper
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Nahihirapan > Weak in akong gumalaw appearance. ng maayos > with limited movements >restless > pale looking

circulation. > Applied therapeutic massage and soothing touch therapy. Rationale: Massage helps for better circulation, thus increasing energy supply to the patient.

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DATE September 18, 2009

SUBJECTIVE CUE/S

OBJECTIVES CUE/S

ASSESSMENT PLAN Hyperthermia r/t environmental factors (hot or humid environment) > Within 1 of rendering appropriate nursing intervention, the patients temperature will subside.

IMPLEMENTATION / INTERVENTION

EVALUATION

Mainit ang >weak in pakiramdam appearance ko >hot or humid environment >warm to touch >restless >irritable >pale looking >sweating noted

> Monitored vital signs >After 1 of of the patient. rendering appropriate Rationale: To obtain nursing baseline data. intervention, the pts temperature > Rendered Tepid subsided. Sponge Bath. Rationale: To reduce heat within the pts body. > Provided ventilation. proper

Rationale: To provide comfortable environment. > Instructed the pt. to increase fluid intake. Rationale: To replace fluid loss and maintain adequate fluid.
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> Applied compress to forehead.

cold the

Rationale: To reduce body heat of the pt.

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DATE September 17, 2009

SUBJECTIVE CUE/S Nahihirapan akong matulog ng maayos kasi maingay dito

OBJECTIVES CUE/S >frequent yawning noted. >sleepy in appearance. >weak in appearance. >restless >irritable.

ASSESSMENT PLAN Disturbed sleep pattern r/t environmental factors > Within 3 of rendering appropriate nursing intervention, the pt. will able to sleep and feel comfortable.

IMPLEMENTATION / INTERVENTION > Rendered sponge bath to provide better circulation. Rationale: To maintain freshness. > Changed loosens clothing. Rationale: To provide comfort > Provided proper ventilation. Rationale: To maintain a cool environment suitable for sleeping. > Rendered back rubs. Rationale: To promote and give relaxation techniques. > Arranged bedside linens. Rationale: To provide comfortable and clean environment.

EVALUATION > After 3 of rendering appropriate nursing intervention, the pt. is able to sleep and feel comfortable.

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DATE September 19, 2009

SUBJECTIVE CUE/S

OBJECTIVES CUE/S > dirty nails > elevated temperature > warm to touch > redness in the site of incision

ASSESSMENT PLAN Risk for infection r/t tissue destruction and increase environmental exposure After 2 of rendering appropriate nursing intervention, the pt. will be able to understand about the prevention and control of infection.

IMPLEMENTATION / INTERVENTION

EVALUATION

> Monitored vital signs After 2 of of the patient. rendering appropriate Rationale: To obtain nursing baseline data. intervention, the pt able to > Changed dressings as verbalize the needed or indicated. information that R: To remove any is given to her microorganism that is opportunistic and may cause of infection. > Instructed the pt. to do proper hand washing. Rationale: To prevent growth of micro organism. > Encouraged patient to clean incision site daily. the the

Rationale: To prevent the spread and growth of microorganisms.

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> Instructed to patient and the family about the needed for good nutrition, especially protein, and vitamin C. Rationale: Eating nutritious foods will aid in fighting infection.

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XV. EVALUATION 1. Patients daily program in the hospital: Daily Program Nursing problems: 1. Acute pain r/t surgical procedure 2. Activity intolerance r/t decrease muscle strength 2 surgical procedure 3.Hypertherm ia r/t tissue injury 4. Disturbed sleep pattern r/t physical discomfort Not present Not Present Present Present Present Not present Not present ADMISSION Date: 09-1409 2nd Date: 09-15-09 3rd Date: 09-16-09 4th Date: 09-17-09 5th Date: 09-18-09 (Follow-up) DISCHARGE : 09-19-09 (follow-up) FOLLOW-UP DATE: 09-2109

Not present

Not Present

Present

Present

Present

Present

Present

Not Present

Not Present

Present

Not Present

Present

Not Present

Not Present

Not present

Present

Present

Present

Present

Not Present

Not Present

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5. Risk for infection r/t tissue destruction and increase environmental exposure Vital Signs

Not Present

Not Present

Not Present

Not Present

Not present

Present

Not present

BP- 110/80 PR-87 bpm RR-18 bpm Temp.-37.9 C -

BP- 110/70 PR-80 bpm RR-20 bpm Temp.-36.8 C -

BP- 110/90 PR- 74 bpm RR- 17 bpm Temp.-37.3 C -

BP-110/80 PR- 81 bpm RR- 16 bpm Temp.- 37.0 C -

Diagnostic & Lab. Procedures Medical & Surgical Mgt. Drugs Diet

Hematology and Urinalysis Appendectom y

NPO

NPO

Full Liquid

Soft Diet

Soft Diet

Soft Diet

DAT
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diet Activity / Exercise _ Bed rest Ambulation Ambulation Ambulation Ambulation Ambulation

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Discharge Planning I. General condition of the client upon discharge On the day of patients discharge, theres a presence of mild pain in her incision site and the patient was able to ambulate without assistance and her diet was tolerated. II. METHOD Approach

Medication: The patients medications upon discharge are Co-Amoxiclab, Meloxicam and Multi-vitamins. Exercise: The patient was advice to have deep breathing exercises,

ambulation and increase activity in daily living. Treatment: Upon the day of discharge, she was advised to clean and change

the dressing of the incision site daily. Health teachings: The following health teachings were given to the patient: a) importance of having proper hygiene b) proper management of wound dressing c) importance of taking medicine in right dosage and at right time Out Patient: Return to Tarlac Provincial Hospital (TPH) OPD after 1 week for her follow-up check up. Diet: Diet as tolerated by the patient such as rice, soup, fruits and vegetables.

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XVI. CONCLUSION: The therapeutic management for this problem the patient is placed on bed rest either in the hospital or at home and administers medications as prescribed. All objectives were constructed for our patients benefit in able for the group to have prioritized nursing action. The group constructed and considered all the objectives that we gathered from our patient. For our objectives, the group had evaluated it as good and successful actions because the goals were achieved and all appropriate nursing interventions are rendered to our patient.

XVII. RECOMMENDATIONS: The group recommended that after the operation, the patient should be aware for the problems that may occur in her incision site, especially for the risk of infection. The groups also recommend that the pt. must continue her medication as prescribed by

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the doctor that will help for her faster recovery. The pt. was advice to avoid her past lifestyle for the mean time, which may cause arising of problem in her situation. The cleaning of her incision site and changing the dressing daily was recommended to the patient. On her discharge, the pt. was recommended to have a follow-up check up, to know if the treatment is effective, if there is changes during her recovery and to know if there is a progress and an improvement of the patients condition.

BIBLIOGRAPHY: Fundamentals of Nursing, Daniels Fundamentals of Nursing: Process, Concepts and Practice, 7th Edition Health Assessment and Physical Examination, 3rd edition by Mary Ellen Zator Estes Friedman and Smith, 1998 Nursing Diagnosis Handbook, 5th Edition 2006 by Ackley and Ludwig http://medical-dictionary.thefreedictionary.com/nutritional+status www.umm.edu/sleep/normal_sleep.html www.yahoo.com
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 www.google.com www.scribd.com www.nursingcrib.com

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