Case Study

Of
Acute appendicitis

Submitted to:
MR. Raymond Dizon, RN
Clinical instructor

Submitted by:
Aguilar, Glenn Liel Dominique R.
BSN 3 Student
January 13, 2011
 TABLE OF CONTENTS

INTRODUCTION

CLIENT’S PROFILE

PHYSICAL ASSESSMENT

DIAGNOSTIC RESULTS

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

NURSING CARE PLAN

DRUG STUDY

HEALTH TEACHING AND DISCHARGE PLAN

RELATED LEARNING EXPERIENCE

The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached
to the cecum just below the ileocecal valve. No definite functions can be
assigned to it in humans. The appendix fills with food and empties as regularly
as does the cecum, of which it is small, so that it is prone to become
obstructed and is particularly vulnerable to infection (appendicitis).
Appendicitis is the most common cause of acute inflammation in the right lower
quadrant of the abdominal cavity. About 7% of the population will have
appendicitis at some time in their lives, males are affected more than females,
and teenagers more than adults. It occurs most frequently between the age of
10 and 30.
The disease is more prevalent in countries in which people consume a diet low
in fiber and high in refined carbohydrates.
The lower quadrant pain is usually accompanied by a low-grade fever, nausea,
and often vomiting. Loss of appetite is common. In up to 50% of presenting
cases, local tenderness is elicited at Mc Burney’s point applied located at
halfway between the umbilicus and the anterior spine of the Ilium.
 Rebound tenderness (ex. Production or intensification of pain when
pressure is released) may be present. The extent of tenderness and
muscle spasm and the existence of the constipation or diarrhea depend
not so much on the severity of the appendiceal infection as on the location
of the appendix.
If the appendix curls around behind the cecum, pain and tenderness may
be felt in the lumbar region. Rovsing’s sign maybe elicited by palpating the
left lower quadrant. If the appendix has ruptured, the pain become more
diffuse, abdominal distention develops as a result of paralytic ileus, and
the patient condition become worsens.
Constipation can also occur with an acute process such as appendicitis.
Laxative administered in the instance may result in perforation of the in
flared appendix. In general a laxative should never be given when a
person’s has fever, nausea or pain.
Acute Appendicitis in Southeastern Asia (Extrapolated Statistics)
East Timor 2,548 1,019,2522
Indonesia 596,132 238,452,9522
Laos 15,170 6,068,1172
Malaysia 58,806 23,522,4822
Philippines 215,604 86,241,6972
Singapore 10,884 4,353,8932
Thailand 162,163 64,865,5232
Vietnam 206,657 82,662,8002
 CLIENTS PROFILE
Biographical Data:
Patient X is 28year-old female born on November 7, 1982 and was baptized in
Roman Catholic Church. She’s single and residing at Gingoog, Misamis Oriental.

Chief Complaint
Chief complaint upon admission last December 1, 2010 was due to severe
pain experienced at right lower quadrant.

History of Present Illness:

Last January 16, patient X experienced pain at right lower quadrant since it was
just tolerable she just bought over the counter drug for self medication. After
twenty four hours pain still persisted and already experienced vomiting. They went
to their health center for consultation then she was referred at NMMC for some
laboratory tests and for further management.
Past Health History
Patient X had past history of Duenge Fever

Things Done to Manage Health

She’s taking medications as what the doctor prescribed for her. Patient X also
believes in alternative medicines.

Statement of Patient General Appearance

The patient was pale, conscious but weak.
 PHYSICAL ASSESMENT
VITAL SIGNS

Vital Signs Vital signs Vital signs

(during (during
admission) assessment)
December 12, December 13, 2010
2010

Blood Pressure 120/80 mmHg 110/70mmHg

Temperature 37.4 C 37.3 C
Pulse rate 68 bpm 87bpm
Respiratory Rate 22 cpm 24 cpm
 Physical Examination:
 Skin
General color was pallor. Temperature was warm with normal
supple and good skin turgor. Temperature is 37.3 C.

Nails
Her nails were smooth, nailbeds are pinkish. Capillary refill
of 2-3 seconds.

Hair
Upon inspection smooth fine hair was noted and evenly
distributed.

Head
Non-tender, non-pulsating, normocephalic, facial movements
are symmetrical, fontanels are closed and there was no
dandruff seen on the scalp.

Eyes
Lids are symmetrical, conjunctiva is pale, anicteric sclera,
pupils are equally round with size of 3-4mm, and reactive to
light accommodation, grossly normal on visual acuity.
Peripheral version is intact and full.
Ears
No discharges were noted, tympanic membranes are intact,
gross hearing is normal.

Nose and Sinuses

Septum is midline. Mucosa is pinkish, nares are both patent,
gross smell is normal, sinuses are non-tender upon palpation.

Mouth and Throat

Lips, mucosa, and gums are pinkish. Tongue is midline, the
teeth are complete. Uvula is midline. Tonsils not inflamed.

Neck
Trachea is midline. Cervical lymph nodes non-tender.

Lung-Chest wall
Breathing pattern is regular with 22 breaths per minute.
Lungs expiration is symmetrical. Tactile fremitus is
symmetrical, resonant upon percussion.
Breath Sounds are vesicular with non-productive cough, with
clear colored sputum.
Heart and Neck Vessel
Pulse rate is 87 beats per minute, peripheral pulses are
symmetrical capillary refill is normal 2-3 seconds.

Abdomen
Normal bowel sound (20 per minute), symmetrical
auscultation. Tympanic upon percussion. There is a post op
wound dressing at right lower quadrant; dry and intact.

Extremities
Full and symmetrical range of motion (ROM), muscle tone
and strength are equally strong. Spine is midline and gait is
well-coordinated.
 FUNCTIONAL HEALTH PATTERNS

Activities of Daily Living (while confined)

During hospitalization patient X, is lying on bed conscious
and coherent txting and communicating with other patients.

Nutritional and Metabolic Pattern (while confined)

The doctor’s order for the patient was NPO since she just
had her operation which is appendectomy.

Elimination Pattern (while confined)

a.) Bowel movement
Defecates atleast 1-2 times/day with brownish formed
stool and with no discomforts.
b.) Urination
Urinates 4-5 times a day, yellowish in color without
problem in control.
Sleep/Rest Pattern (while confined)
According to patient X she has a hard time in sleeping since
she’s still adjusting in the environment of the hospital.
Sometimes she cannot sleep well because sometimes it’s noisy
and she’s not comfortable at the hospital. She sleeps almost
11pm and wakes up at 5am.

Role-Relationship Pattern
Patient X is single and currently in a relationship status.
Financially unstable. Without any known illnesses in the family.

Values Belief
Patient X is a Roman Catholic and her family goes to church
every Sunday. They also pray Rosary at least twice a month.
Complete Blood Count

TEST RESULT REFERENCE INTERPRETATION

VALUE
Hgb 13.4 11.7-14.5
Hct 39.2 34.1-44.3
WBC Count 3,800 5,000-10,000 It indicates that the patient
has an infection.
DIFFERENTIAL
COUNT
Segmenters 67.0 45-70
Lymphocyte 29.0 18-45 Lymphocytes is higher
than normal range which
may help in fighting
against infection.
Monocyte 4.0 4-8
Platelet Count 348,000 174,000-390,000
RBC 4.58 4.5-5.4
MCV 85.6 80.0-96.0
 URINALYSIS

TEST RESULT NORMAL VALUE

Color Yellow Yellow
Transp. Cloudy Clear
Reaction 6.0
Sp Gravity 1.060
Sugar Negative Negative
Protein Negative Negative
PUS Cells 2-5 / hpF
RBC 1-4 / hpF
Squamoius Epithelial Plenty
Bacteria Plenty
MUCOUS THREADS
Amorphous Urates
 Anatomy and Physiology

The mouth, or oral cavity, is the first part of the digestive tract. It is
adapted to receive food by ingestion, break it into small particles by
mastication, and mix it with saliva. The lips, cheeks, and palate.
Large Intestine
The large intestine is larger in diameter than the small intestine. It begins at
the ileocecal junction, where the ileum enters the large intestine, and ends at
the anus. The large intestine consists of the colon, rectum, and anal canal.
The wall of the large intestine has the same types of tissue that are found in
other parts of the digestive tract but there are some distinguishing
characteristics. The mucosa has a large number of goblet cells but does not
have any villi. The longitudinal muscle layer, although present, is incomplete.
The longitudinal muscle is limited to three distinct bands, called teniae coli,
that run the entire length of the colon. Contraction of the teniae coli exerts
pressure on the wall and creates a series of pouches, called haustra, along the
colon. Epiploic appendages, pieces of fat-filled connective tissue, are attached
to the outer surface of the colon. Unlike the small intestine, the large
intestine produces no digestive enzymes. Chemical digestion is completed in the
small intestine before the chyme reaches the large intestine. Functions of the
large intestine include the absorption of water and electrolytes and the
elimination of feces.
Pathophysiology
 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.
 Health Teaching and Discharge Planning
 
The primary goals that guide the patient for their management in the disease
process are reducing and controlling risk factors for complications and restoring
systemic functions by stabilizing deficits. The following are some self management
education guide:
 
M Antibiotics for infection
Analgesic agent (morphine) can be given for pain after the surgery

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

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

T Pretreatment of foods with lactase preparations (e.g. lactacid drops)

before ingestion can reduce symptoms.
Ingestion of lactase enzyme tablets with the first bite of food can reduce
symptoms.
H To care wound perform dressing changes and irrigations as prescribe avoid
taking laxative or applying heat to abdomen when abdominal pain of unknown cause
is experienced.
Reinforce need for follow-up appointment with the surgeon
Call your physician for increased pain at the incision site

O Document bowel sounds and the passing of flatus or bowel movements (these
are signs of the return of peristalsis)
Watch for surgical complications such as continuing pain or fever, which
indicate an abscess or wound dehiscence
Stitches removed between fifth and seventh day (usually in physicians office)

D Liquid or soft diet until the infection subsides

Soft diet is low in fiber and easily breaks down in the gastrointestinal tract.
 Nursing is a course which is very different from other fields. It’s not just
about mere learning and a good venue of earning but it’s significantly about valuing
someone else’s life.
In my short period of stay at NMMC Surgical ward, I’ve experienced the life
of being the student nurse on action. It is where I had extreme preparations. I
cannot deny the fact that I am anxious in our first day of duty. I knew that what
will concern me deeply is the life of my patients.
Having this experience I knew that I have big responsibilities even though I am
still labeled as student nurse. It’s difficult because I always make adjustments, we
are required to study the case of our patients and we are encouraged to be
mentally and physically ready but at the end of our duty there is still a sense of
fulfillment because I am able to care for other people. What is rewarding is the
fact that not everyone has the chance to do this job to other people.
As our duty progresses, I have established a great bond with my dutymates.
We learn together, we work together and care for each other. That is the beauty
in our group. We never fail to connect and relate with each other. We are more
than just a group formed for the sake of compliance, we became a family.
Whatever trials and difficulties that may come along our way I can say that we
can surpass them because we chose this field not just for ourselves but also for
others. We want to share the goodness in us that is why we want to care.
 NURSING CARE PLAN
NURSING GOALS AND NURSING INTERVENTIONS EVALUATION
ASSESSMENT DIAGNOSIS OBLECTIVES AND
DATA (Problem & Etiology) RATIONALE
(Subjective &
Objective Cues)
SUBJECTIVE: -ACUTE PAIN -AFTER 1 HOUR -ASSES VITAL SIGNS EVERY GOALS MET AS EVIDENCED BY :
“GA SAKIT UG RELATED TO OF NURSING 4 HOURS -PAIN SCALE HAS REDUCED
GANGOTNGOT SURGICAL INTERVENTIONS -PERFORM FROM 5-3
AKONG TAHI INCISION IN THE THE PATIENT COMPREHENSIVE BECAUSE OF METHODS
PERO MAKAYA RIGHT LOWER WILL VERBALIZE ASSESSMENT OF PAIN TO INSTRUCTED SUCH AS DEEP
PMAN.” As QUADRANT METHODS THAT INCLUDE LOCATION, BREATHING EXERCISES TO
Verbalized SECONDARY TO PROVIDE RELIEF. CHARACTERISTICS AND DIVERT ATTENTION AWAY
OBJECTIVE: APPENDECTOMY. -DEMONSTRATE SEVERITY BY USING PAIN FROM PAIN.
-WITH PAIN SCALE USE OF SCALE. -DUE MEDS GIVEN AS PER
OF 5 WHICH IS RELAXATION -PROVIDE QUIET DOCTORS ORDER.
BEARABLE SKILLS AND ENVIRONMENT AND
-SLEEP DIVERTIONAL ENCOURAGE DIVERTIONAL
DISTURBANCES ACTIVITIES. ACTIVITIES.
-EXPRESSIVE -ENCOURAGE ADEQUATE
BEHAVIOR LIKE REST PERIODS.
FACIAL GRIMACE. -PROVIDE COMFORT
MEASURES SUCH AS
POSITIONING PATIENT TO
ITS COMFORTABLE
POSITION.
 NURSING CARE PLAN
NURSING GOALS AND NURSING INTERVENTIONS EVALUATION
ASSESSMENT DIAGNOSIS OBLECTIVES AND
DATA (Problem & Etiology) RATIONALE
(Subjective &
Objective
Cues)
SUBJECTIVE: -ACTIVITY -AFTER 3 HOURS -ESTABLISH RAPPORT ON -AFTER 3 HOURS OF NURSING
“DILI P INTOLERANCE OF NURSING THE CLIENT TO ESTABLISH INTERVENTION GOALS MET, THE
KAAYO KO RELATED TO INTERVENTION, TRUST AND COOPERATION PATIENT WAS ABLE TO REPORT
KA LIHOK SURGICAL THE PATIENT WILL ON THE CLIENT. ACTIVITY TOLERANCE WITH
LIHOK UG OPERATION DUE REPORT ACTIVITY -PROVIDE HEALTH ENHANCED ENERGY AND THE
AYO KAY TO APPENDECITIS INTOLERANCE TEACHING ON THE CLIENT PATIENT WAS ABLE TO
BAG.O PAKO SECONDARY TO WITH ENHANCE REGARDING THE PARTICIPATE WILLINGLY IN
G APPENDECTOMY. ENERGY. ORGANIZATION AND TIME NECESSARY OR DESIRED
OPERAHAN MANAGEMENT TECHNIQUE ACTIVITIES.
UG GKA TO PREVENT OTHER
BALAKA P INJURIES.
POD KO KAY -DEVELOP AND ADJUST
BASIN MO SIMPLE ACTIVITY LIKE
BUKA.” AS BRUSHING HER TEETH TO
VERBALIZED MONITOR CLIENTS RESPOND
OBJECTIVE: TO ACTIVITIES.
-TIRED -ASSISST CLIENT WITH
FACIAL ACTIVITIES TO PREVENT
EXPRESSION OVER EXERTION
DUE TO -PROMOTE COMFORT
SLEEP MEASURES ON THE
DISTURBANC ACTIVITY TO PROTECT
ES AND CLIENT FROM INJURY.
WORRYING
ABOUT HER
SURGEY.
 NURSING CARE PLAN
NURSING GOALS AND NURSING INTERVENTIONS AND EVALUATION
ASSESSMENT DIAGNOSIS OBLECTIVES RATIONALE
DATA (Problem & Etiology)
(Subjective &
Objective Cues)
SUBJECTIVE: -RISK FOR -AFTER 8 HOURS OF -MONITOR VITAL SIGNS GOALS MET PATIENT WAS
- INFECTION NURSING ESPECIALLY TEMPERATURE. ABLE TO DEMONSTRATE NO
OBJECTIVE: RELATED TO INTERVENTIONS -PROMOTE THOROUGH SIGNS OF INFECTION.
SURGICAL PATIENT WILL HANDWASHING BY
OPERATION DUE TO DEMONSTRATE NO CAREGIVERS AND PATIENTS.
APPENDECITIS SIGNS OF -PROVIDE METICULOUS SKIN,
INFECTION. ORAL, AND PERINIAL CARE.
-ENCOURAGE FREQUENT
POSITION CHANGES/
AMBULATION, COUGHING,
AND DEEP BREATHING
EXERCISES.
-PROMOTE ADEQUATE FLUID
INTAKE.
 DRUG STUDY
MECHANISM OF INDICATIONS CONTRAINDICATIONS ADDVERSE EFFECTS NURSING
DRUG ORDER ACTION OF RESPONSIBILITI
(Generic, brand, THE DRUG ES/PRE
classification, CAUTIONS
dosage, route,
frequency
GENERIC Cefoxitin can induce Treatment and Hypersensitivity to Nausea; vomiting; • Tramadol is
cefoxitin β-lactamase prophylaxis of cephalosporins. diarrhoea; considered to
BRAND production by some anaerobic and hypersensitivity reactions; provide more
Dintaxin bacteria. It is mixed bacterial nephrotoxicity; analgesia than
CLASS resistant to a wide infections convulsions; CNS toxicity; codeine 60 mg but
Cephalosporins range of β-lactamases, hepatic dysfunction; less than combined
DOSAGE including those haematologic disorders; aspirin
30-50ML produced by pain at Inj site (IM); 650mg/codeine 60
ROTE Bacteroides spp. thrombophloebitis (IV mg for acute
Parenteral infusion); superinfection postoperative pain.
FREQUENCY with prolonged use. • Monitor patient
1-2 g every 8-12 hr. Headache. for seizures. May
Potentially Fatal: occur within
Pseudomembranous recommended dose
collitis. range. Risk
increased with
higher doses and
inpatients taking
antidepressants
(SSRIs, tricyclics,
or Mao inhibitors),
opioid analgesics, or
other durgs that
decrese the seizure
threshold.
 DRUG STUDY

MECHANISM INDICATIONS CONTRAINDICATIONS ADDVERSE EFFECTS OF NURSING

DRUG ORDER OF THE DRUG RESPONSIBI
(Generic, brand, ACTION LITIES/PRE
classification, CAUTIONS
dosage, route,
frequency
GENERIC Ketorolac Moderate to severe pain, Hypersensitivity to aspirin GI ulcer, bleeding and - Patients who
ketorolac inhibits Renal impairment or other NSAIDs, asthma. perforation, drowsiness, have asthma,
BRAND prostaglandin Prophylaxis and Hypovolaemia or rash, bronchospasm, aspirin-
Ketanov synthesis by reduction of dehydration. Do not give hypotension, psychosis, dry induced
CLASS decreasing the postoperative ocular postoperatively to patients mouth, fever, bradycardia, allergy, and
Nonsteroidal Anti- activity of the inflammation with high risk of chest pain, dizziness, nasal polyps
inflammatory cyclooxygenase haemorrhage. History of headache, sweating, oedema, are at
DOSAGE enzyme. peptic ulcer or pallor, liver function increased risk
40 mg coagulation disorders. changes. Transient stinging for developing
ROTE Nasal polyps, angioedema, and local irritation hypersensitivit
Oral bronchospasm. Labour. (ophthalmic). y reactions.
FREQUENCY Moderate to severe renal Potentially Fatal: Assess for
every 4-6 hr impairment. GI bleeding, Anaphylaxis. Severe skin rhinitis,
cerebrovascular bleeding. reactions. MI, stroke, GI asthma, and
As prophylactic analgesic bleeding. urticaria.
before surgery. - Assess pain
(note type,
location, and
intensity)
prior to and 1-
2 hr following
administratio
n.
 DRUG STUDY

NURSING
DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATION ADDVERSE EFFECTS OF RESPONSIBILITI
(Generic, brand, ACTION S THE DRUG ES/PRE
classification, CAUTIONS
dosage, route,
frequency
GENERIC Paracetamol exhibits Mild to moderate Renal or hepatic Nausea, allergic reactions, - Advise patient to
Paracetamol analgesic action by pain and fever impairment; alcohol- skin rashes, acute renal consult if rash,
BRAND peripheral blockage dependent patients; tubular necrosis. itching, visual
Alvedon of pain impulse G6PD deficiency. Potentially Fatal: Very rare, disturbances,
CLASS generation. It blood dyscrasias (e.g. tinnitus, weight
Analgesics (Non- produces antipyresis thrombocytopenia, gain, edema, black
Opioid) & by inhibiting the leucopenia, neutropenia, stools, persistent
Antipyretics hypothalamic heat- agranulocytosis); liver headche, or
DOSAGE regulating centre. Its damage. influenza-like
10-50mg weak anti- syndromes
ROTE inflammatory (chills,fever,muscl
Oral activity is related to es aches, pain)
FREQUENCY inhibition of occur.
4-6 hrly prostaglandin - Effectiveness of
synthesis in the CNS. therapy can be
demonstrated by
decrease in
severity of pain.
Patients who do
not respond to one
NSAIDs may
respond to
another.
 DRUG STUDY
MECHANISM INDICATIONS CONTRAINDICATION ADDVERSE EFFECTS OF NURSING
DRUG ORDER OF S THE DRUG RESPONSIBILITI
(Generic, brand, ACTION ES/PRE
classification, CAUTIONS
dosage, route,
frequency
GENERIC Ranitidine Benign gastric and Porphyria. Headache, dizziness. Rarely • Assess BP & RR
ranitidine blocks duodenal ulceration hepatitis, before and
BRAND histamine H2- H.pylori infection thrombocytopaenia, periodically
aceptin receptors in the Gastro-oesophageal leucopaenia, hypersensitivity, during
CLASS stomach and reflux disease confusion, gynaecomastia, administration.
Antacids, prevents Hypersecretory impotence, somnolence, Respiratory
Antireflux Agents histamine- conditions vertigo, hallucinations. depression has not
& Antiulcerants mediated Acid aspiration during occurred with
DOSAGE gastric acid general anaesthesia recommended
300 mg secretion. It Dyspepsia doses.
ROTE does not affect • Assess bowel
oral pepsin function routinely.
FREQUENCY secretion, Prevention of
bid; pentagastrin- constipation
stimulated should be
factor secretion instituted with
or serum increased intake of
gastrin. fluids and bulk
and with laxatives
to minimize
constipating
effects.
 DRUG
STUDY

MECHANISM OF INDICATIONS CONTRAINDICATION ADDVERSE EFFECTS OF NURSING

DRUG ORDER ACTION S THE DRUG RESPONSIBILITI
(Generic, ES/PRE
brand, CAUTIONS
classification,
dosage, route,
frequency
GENERIC Tramadol inhibits Moderate to severe Suicidal patients, acute Sweating, dizziness, nausea, • Assess type,
tramadol reuptake of pain alcoholism; head vomiting, dry mouth, fatigue, location, and
BRAND norepinephrine, Hepatic impairment: injuries; raised asthenia, somnolence, intensity of pain
Clomadol serotonin and intracranial pressure; confusion, constipation, before and 2-3 hr
CLASS enhances serotonin severe renal flushing, headache, vertigo, (peak) after
Analgesics release. It alters impairment; lactation. tachycardia, palpitations, administration.
(Opioid) perception and miosis, insomnia, orthostatic • Assess BP & RR
DOSAGE response to pain by hypotension, seizures, CNS before and
300 mg binding to mu-opiate stimulation e.g. periodically
ROTE receptors in the hallucinations. during
oral CNS. administration.
FREQUENCY Respiratory
every 4-6 hr depression has not
occurred with
recommended
doses.
• Assess bowel
function routinely.
Prevention of
constipation
should be
instituted with
increased intake of
fluids and bulk
and with laxatives
to minimize
constipating
effects.