Professional Documents
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CASE STUDY
APPENDICITIS
PREPARED BY:
Joy Rachel D. Tabernilla
Edlene Joy A. Yulip
BSN III- A
MARCH, 2010
TABLE OF CONTENT
I. Objectives
a. General Objectives
b. Specific Objectives
II.
Patient Profile
a.
III.
History
a. Nursing History
i.
Chief Complain
ii.
Admitting Diagnosis
iii.
Physical Examination
iv.
Final Diagnosis
ii.
Hospitalizations
ii.
Surgical Managements
iii.
Allergies
1. Foods
2. Drugs
iv.
Others
IV.
Nutrition
a. 24 hours food recall
b. Regular/Routine diet
c. Intake and output
d. Vices and habits
V.
Disease Entity
a. Definition
b. Etiology
c. Transmission
d. Occurrence/Epidemiology
e. Anatomy of the organ involved
VI.
Pathophysiology
VII.
Management
a. Medical Management
b. Pharmacological Management
c. Nursing Management
VIII.
Laboratory
a. Blood analysis
IX.
X.
Discharge Plan
I. OBJECTIVES
a. GENERAL OBJECTIVES:
In the light of knowledge, the main goal is to present a case presentation about
appendicitis. Trough this, the group is hoping to gain more knowledgeable facts about
appendicitis.
b. SPECIFIC OBJECTIVES:
To gain more knowledge about the patients expectations and the effects of his
condition.
To gather significant data from the patients chart and the patient himself through
interview and assessment.
To review the anatomy and physiology of the client, specifically the GI system in
relation of the appendix.
Name: E.S.A.
Date of Birth: May 15, 1956
Civil Status: Married
Address: Comia, Brgy. Isabang, Lucena City
Religion: Roman Catholic
Educational Attainment: Elementary Graduate
Occupation: Maid
III. HISTORY
a. Nursing History
ii. Admitting Diagnosis: T/C acute appendicitis (March 20, 2010, 7:10
pm)
iii.
Physical Examination
HEAD:
Skull is symmetrical.
Hair is dry, not brittle and generally color black
EYES:
NOSE:
no nasal discharge
LIPS:
i. Hospitalizations: none
ii. Surgical Managements: Explore appendectomy, washing
iii. Allergies
1. Foods: none
2. Drugs: none
iv. Others
Decease
Deceas
e
Decease
-85
Decease
y/o
Kidney
problem
Kidney
problem
-63 y/o
- 53 y/o
Appendic
itiss
- 59 y/o
- 57 y/o
LEGEND:
- Male
- female
- patient
- 53 y/o
IV. Nutrition
(3-19-10)
Water melon
Breakfast- lugaw
(3-20-10)
b. Regular/Routine diet
Patient regular diet was more on vegetables. She was not used to eat meats
or processed foods.
DATE
March 20, 10
March 21, 10
post op
TIME
INTAKE
OUTPUT
12:00nn
40 cc
8:00pm
500cc
7-3
800 cc
3-11
592 cc
V. Disease Entity
a. Definition
b. Etiology
OBSTRUCTION
Anatomy:
wormed-shaped
Narrow
Plenty of lymp glands
Mechanical reasons:
food residue
Ascarid
Tumors
GASTROINTESTINAL DISEASE
c. Transmission
d. Occurrence/Epidemiology
About 7% of the population will have appendicitis at the same time in their lives;
males are affected more than females and teenagers more than adults.
The peak incidence of acute appendicitis has gradually defined to about half of
its peak incidence in the early 20th century, with the current annual incidence of 1 per
1000 population in the US and 86 cases for every 100,000 persons worldwide. The
extrapolated incidence of appendicitis in the Philippines is 215,604 of 86,241,697
estimated populations.
VI.
Pathophysiology
Bacteria, fecaliths
Inflammation
Exudates
( Calor)
I-mpaired function
R-edness ( Rubor
P-ain
( Dubor)
Hypogastric pain
Nausea &
vomiting
Edema- ischemic
necrosis
Explore Appendectomy
Surgical
Management
VII.
Management
a. Medical Management
DATE/TIME
PROGRESS NOTES
DOCTORS ORDER
>please admit to ROC under the
service of Dr. Villaluna
7:10 pm
>secure consent
>TPR q 4 hour
>NPO temporarily
>IVF- PNSS 1L x 8 hours
>Diagnostic procedures- CBC with
platelet count, urinalysis(done
@QMC)
>monitor vital signs q 2 hours
> I & O q shift
>refer to Dr. Achacoso for comanagemant
>refer accordingly
7:30 pm
SURGERY NOTES
LMP= menopause
Flarry soft(+)
3 years PTA
(+) anorexia
(-) fever
(-) mass
* acute appendicitis
Primary ruptured
>NPO
Treatment:
-fast drip 200cc present IVF &
regulate to 40gt/min
-cefotaxime 1gm IV ANST (-)
-Metronidazole 500mg IV q8 hour
ANST(-)
- Diclofenac 75mg IV q 12 hour x 2
doses ANST(-)
-for explore appendectomy- secure
consent
March 20, 2010
POST OP ORDERS
9:40 pm
>back to ward
>flat on bed until 5:00am
>monitor vital signs q15 min x 2
hours then q30 mins until stable
>O2 inhalation @ 2Lpm by nasal
cannula until stable
>regulate IVF @ 30gtt/min followed
by (1)D5NM 1L, (2) D5NR 1L, (3)
D5NM 1L to run @ same rate
> keep on NPO
Afebrile
10:30 pm
(-) cough
(-) dyspnea
(-) chest pain
BP= 90/60
Usual BP= 100/70
(-) pedal edema
March 21, 2010
(+) flatus
Tom in AM
1. Remove IFC
2. May have sips of clear liquid
>change dressing
>MGH
>Home Meds:
Metronidazole 500mg/tab 3x
Ciprofloxacin (Laitun)
500mg/tab 1 tab 3x a day for
7 days
b. harmacological Management
c.
Nursing Management
A. PREOPERATIVE PHASE
The patient was admitted to the emergency room complaining of severe pain in
the right lower quadrant of the abdomen a number of tests were ordered to assess the
patients health. The nurse explains to the patient and the SO about the tests. These test
were the CBC, Platelet, and Urinalysis. After obtaining the results of the tests, the patient
was diagnosed to have a Appendicitis. The patient was then scheduled to have an
Explore-appendectomy. But before the surgery, an informed consent form was signed
acknowledging that the patient and SO understands the procedure, the potential risks, and
that they will receive certain medications. Before the signing, the nurse must ask the SO
whether she understood what the surgeon told her and as the patient will sign the
informed consent form the nurse was present to witness the signing.
B. INTRAOPERATIVE PHASE
As the patient arrived in the operating room, the anesthesiologist briefly
interviewed the patient to clarify some things that were needed before administering the
anesthesia. The patient was then positioned in as fetal position for the induction of
anesthesia. Then , patient was placed in supine position. The anesthesiologist then asked
the patient to raised his legs and used a pin to test whether the anesthesia has already
worked. After ensuring the effectiveness of the anesthesia, the nurse started to do skin
prep using antiseptic ( betadine).
The srub nurse prepared the surgical set-up and did the counting of the
instruments. In addition the scrub nurse maintained surgical asepsis while draping and
handling instruments and assisted the surgeon by passing instruments, sutures, and
supplies.
The circulating nurse responded to the request of the surgeon, anesthesiologist or
anesthethist, and from the other member of the surgical team. Moreover, the circulating
nurse obtained a sterile gown. Other responsibilities include:
1. Assissted the surgeon and the scrub nurse to do sterile gowns and gloves.
2. Anticipated the need for equipment, instruments, medications, and blood component
and opened these packages so that the scrub nurse can remove the sterile supplies,
preparing labels, and arranged for transfer of specimens to the laboratory for analysis.
3. Discarded used gauze sponges, and at the end of the operation, helped in counting the
number of sponges, instruments and needles were complete.
C. POSTOPERATIVE PHASE
Following surgery, the patient was taken to the (PACU) until the anesthesia were
off. During this time, the staff nurses checked the vital signs at frequent intervals. When
the anesthesia were off and vital signs stabilized, the patient was transferred to the
surgery ward. The nurse continued monitoring the patient for any unusualities and
postoperative complications and report immediately to the physician if any occur. Staff
nurses administered medications like antibiotic depending on the doctors order.
Other responsibilities:
1. Position and safety
2. Monitor vital sign
3. Level of consciousness
4. IVF
5. Wound
6. Color and temperature
7. Comfort
Ensure that the patient is warm and comfortable, and that bed is clean and safe.
VIII. Laboratory
a. Blood analysis
RESULTS
Hematocrit
0.36
F 0.37-0.45
=anemia,
hemodilution
RBC
3.94
F 4.2-5.4x10^12/L
=anemia, fluid
overload of >24 hours
WBC
12.5
5-10X10^g/L
=infection, tissue
necrosis
Segmenters
0.79
0.55-0.65
(increase)
M- METHOD
Metronidazole 500mg/tab 3x a day for 7 days
Ciprofloxacin (Laitun) 500mg/tab 1 tab 3x a day for 7 days
Mefenamic Acid 500mg/tab 1 tab 2x a a day for pain
E- EXERCISE/ENVIRONMENT
Encourage to have enough sleep and rest to promote faster recovery
Instruct to avoid strenuous activities such s lifting, running, playing.
Encourage to do simple exercise such as walking and playing heavy objects.
T- TREATMENT
Instruct the SO to comply with what the doctor had instructed to do.
Encourage the SO to change the dressing as often as necessary.
Instruct him to report immediately any unusual ties.
H- HEALTH TEACHING
Instruct him to keep the incision site dry and clean always to prevent infections to occur
Tell the SO to notify the physician immediately if there are unusual ties
Encourage to observe proper hygiene measures for past recovery.
Encourage to follow all the instructions including medications, diet regimen and do and
donts that was instructed to him by the physician
Inform the patient that he can return to his activities of daily living even without his
appendix.
O-OPD
Instruct patient and SO that they return to have a check-up atleast 7 days after discharged.
Encourage him to inform his physician about any unusualities on his incision site or with
beans
Peanut butter
butter
Lean meats
fresh coconut
Fish
potato