Case Study of Appendicitis

I. Patient Profile Name: Bernardo Matobato Age: 26 years old Gender: male Occupation: construction worker Educational Attainment: grade 4 Civil Status: single Nationality: filipino Address: brgy. Dapdap Alang-alang Leyte Religion: catholic C/C: abdominal pain Date Admitted: july 22, 2010 @ 9:00pm Admitting Diagnosis: ruptured appendicitis Attending Physician: Dr. Bañez Source of Information: patient and mother Reliability: 90%

II. Present Illness: 14 hours prior to admission, the patient experienced mild pain on his right lower quadrant abdomen while eating in the morning, followed by a severe pain. The client tried to eliminate the pain using herbal oil but were not eradicated. Persistence of the noticed pain, prompted his mother to bring him to EVRMC, hence this admission.

III. Past Health History: The patient did not receive any vaccination as claimed by the mother, has experienced acute respiratory infection such as cough, cold and mild fever and took biogesic (250mg) every 4 hours for fever and some herbal plants (decoction of lagundi) for cough relief. Pain in the right lower abdomen 1st felt when the client was 25 years old but were ignored no history of hospitalization.

IV. Family History: The mother claimed that her mother is asthma positive, and noted hypertension history on the paternal side.

V. Birth History: The patient is 3rd on eight siblings of Mr. and Mrs. Matobato. Born via normal vaginal delivery on their house.

VI.Psychosocial history: The patient sorrounding is good and there were no lakes, swamp or river nearby. They used a deep well for drinking and taking a bath. He smokes 5 sticks of cigar. Per day, and play basketball in freetime.

PATTERNS OF FUNCTIONING 1. RESPIRATORY – (+) Hx of Asthma – Consumed 5 sticks of cigar/day – Started smoking since 17 y.o

CLINICAL INSPECTION – – – –

1. CIRCULATORY – (+)Hx of HPN

– – – –

1. FOODS AND FLUIDS INTAKE – Usual food taken: leafy vegetables, fish, rice, root crops – (-)food allergies – (-)food preferences & dislikes – Drink 4 glasses of water each day – Drink 10 glasses of tuba occasionally 1. ELIMINATION – Void more than 5x/day – Defecate 1x/day or sometimes 1 time every 2 days – Fun of retaining stools if at work

– – – –

– –

RR = 26cpm No accessory muscle used No respiratory aids used No cough and cold BP = 110/70 mmHg PR = 53 bpm No presence of discoloured or swollen parts Good capillary refill

–

Not constipated Presence of indwelling catheter (-) nausea

– – –

T = 36.6 Afebrile (-) chills

–

Untidy to look at (-)skin lesions Hair is equally distributed (+)Halitosis Poor dental care Presence of plaque

1. EXERCISE & LOCOMOTION – Take the daily activities as

– – – – –

–

Hematology: WBC: 18.30x10^9/L Neutrophil: .90 Lymphocyte: .10 Hematocrit: .46

Good skin turgor Dry lips With an IVF of D5LR @ 30gtts/min No NGT

1. REGULATORY MECHANISM – (+) mild fever during childhood 1. HYGIENE – Take a bath 12x/day – Seldom use shampoo – Change cloth everyday – No allergies to soap & shampoo – Combs hair

OTHER SOURCES

Impaired mobility due to

URINALYSIS Color : Dark yellow Transparency: Turbid Specific gravity: 1.025 PH: 6.0 Glucose: negative Albumin: trace WBC: 2-3/hpf Bacteria: moderate Mucus threads: many Costs: coarse granular: 0-1/lpf Uric acid: moderate

Components

Normal values

Results

Interpretation

1. WBC

4.5 – 11x109/L

18.30 x 109/L

Increased

2. Neutrophils

0.45 – 0.73

0.90

Increased

Clinical Significance Presence of inflammation Acute infection, trauma or surgery

3. Lymphocyte

0.2 – 0.4

0.10

Decreased Aplastic anemia, SLE, immunodeficiency including AIDS

4. Hematocrit

Males: 42 – 52 % Females: 35 – 47 %

46 %

Normal Balance proportion of blood volume that is occupied by RBC

LABORATORY RESULTS Hematology:

Urinalysis: Components

Normal

Results

Interpretation

Clinical Significance

1. Color

Pale yellow to amber

Dark Yellow

Not normal

Not enough water intake, presence of bilirubin

2. Transparency

Clear to slightly hazy

Turbid

Not normal

3. Specific gravity

1.015-1.025

1.025

Normal

Cystisis, presence of bacteria

4. PH

4.5-8.0

6.0

Normal

Properly diluted urine

5. Glucose

Negative

Negative

Normal

Not risk for calcification, and infection

6. Albumin

Negative

Negative

Normal

Absence of DM

7. WBC

Negative or rare

2-3/hpf

Not normal

Proper filtration of glumerolus

8. Bacteria

Negative

Moderate

Not normal, bacteremia Cystisis, nephritis,

9. Casts

Occasionally hyaline casts

10.Uric Acid

Coarse granular: 0-1/hpf

Urinary tract infection 3.13 mmol/24 h

1.58-4.43 mmol/24 h

Not normal Normal

Presence of renal infection or disease Absence of calculi

ANATOMY AND PHYSIOLOGY Vermiform appendix In human anatomy, the appendix (or vermiform appendix; also cecal (or caecal) appendix; also vermix) is a blind-ended tube connected to the cecum (or caecum), from which it develops embryologically. The cecum is a pouchlike structure of the colon. The appendix is near the junction of the small intestine and the large intestine. The appendix averages 10 cm in length, but can range from 2 to 20 cm. The diameter of the appendix is usually between 7 and 8 mm. The appendix is located in the lower right quadrant of the abdomen, or more specifically, the right iliac fossa the position within the abdomen corresponds to a point on the surface known as McBurney's point. While the base of the appendix is at a fairly constant location, 2 cm below the ileocaecal valve, the location of the tip of the appendix can vary from being retrocaecal to being in the pelvis to being extraperitoneal. In rare individuals with situs inversus, the appendix may be located in the lower left side. Maintaining gut flora: major function Although it was long accepted that the immune tissue, called gut associated lymphoid tissue, surrounding the appendix and elsewhere in the gut carries out a number of important functions The digestive tract's immune system is often referred to as gut-associated lymphoid tissue (GALT) and works to protect the body from invasion. GALT is an example of mucosa-associated lymphoid tissue. The mucosa-associated lymphoid tissue (MALT) (also called mucosa-associated lymphatic tissue) is the diffuse system of small concentrations of lymphoid tissue found in various sites of the body such as the gastrointestinal tract, thyroid, breast, lung, salivary glands, eye, and skin.

FOR the PATHOPYSIOLOGY just go to this site : http://www.scribd.com/doc/46437230/Pathophysiology-of-Appendicitis

Nursing Diagnosis Limited movement related to pain as manifested by: Subjective: “Anay, hinay hinay la ke ma ol-ol tak samad” as verbalized by the patient.

Objective: Temp - 36.6 oC PR - 53 bpm RR - 26 cpm BP - 110/70mmhg

• •

weakness

Scientific analysis Having an Appendectomy is a procedure that has the need to cause the tissue to be traumatized, which leads to the inflammatory process characterized by pain, redness, swelling and loss of function of some part, it is effective in the treatment of appendicitis with perforation, surgery leaves tissue damage that causes the release of chemical mediators, and WBC’s which causes to form exudates then this exudates causes the nerve endings to be compressed thus making pain and this pain makes a person to have limited movement.

Objectives

Nursing Interventions

Evaluation

INDEPENDENT: After 8 hours of nursing interventions, the patient will be able to Regain / maintain mobility at the higher possible level, Demonstrate techniques that enable resumption of activities, and Increase strength/ function of affected and compensatory body parts.

1. Instruct the client to

1. Activity that require

minimize activities

holding the breath and

that will put pressure

bearing down can result

on his abdomen.

in pain to surgical site in

2. Reposition

RLQ, bradycardia and

periodically and

rebound tachycardia

slowly and

with elevated BP.

encourage deep breathing exercises.

2. Prevent / reduces incidence of skin and

3. Encourage rest.

respiratory

4. Move patient

complications.

slowly and deliberately. 5. Administer analgesics as

facial grimace

Rationale

ordered

3. Reduces myocardial workload / oxygen consumption, reducing risk of complication.

•

guarding behavior

Reference:

•

incision on RLQ

Medical Surgical nursing by

tension or guarding,

Brunner and Suddarth 11th

which may help

edition; Vol.2 pages 1240-

minimize pain of

1242

movement.

4. Reduces muscle

5. To maintain “acceptable” level in pain. Notify physician if regimen is inadequate to meet pain control goal.

After 8 hours of nursing interventions the patient is able to Rest quietly Sit in a high-fowlers position from lying in bed, and know the proper way in seating from a supine position. therefore: GOAL MET

Nursing Diagnosis

Scientific analysis

Objectives

Nursing Interventions

Impaired skin integrity related to surgical incision

Surgical intervention involves removal of appendix within 24 to 28 hours in which surgery can be performed through a small incision that causes a disruption or damage to the skin tissues. Which will leads to impairment of the first protective layer from infections or foreign object.

After 8 hours of nursing intervention the patient will Achieve timely wound healing and be free of infection, demonstrate how to keep wound dry and promote healing.

DEPENDENT:

SUBJECTIVE: “katapus ko la ka operahe” as verbalize by the patient OBJECTIVE: - open wound - visible surgical incision - post-operative patient Temp - 36.6 oC PR - 53 bpm RR - 26 cpm BP - 110/70mmhg

1) Observe wound, note characteristics of drainage.

2) Change dressing as needed using aseptic technique.

Reference: Medical surgical nursing by brunner and suddarth, 11th edition volume 2 @ page: 1242

3) Encourage side lying position (on the leftside) or a semifowlers position. 4) Encourage guarding behavior. DEPENDENT 5) Administer antibiotics as doctor’s order

Rationale 1. Post-operative hemorrhage is likely to occur during first 2 days, whereas infection may develop anytime. 2. Reduce skin irritation and potential infection, also to prevent soaking the dressing by any discharges. 3. May decrease pressure to operated site, thus relieving abdominal distention. 4. Promote protection to the incision site. 5. Hasten the healing of the wound.

Evaluation After 8 hours of nursing interventions the patient’s wound appears to be dry and freed from drainage or purulent substances therefore goal was met.

Nursing Diagnosis

Scientific analysis

Risk for infection related to

After 8 hours of

surgical incision at right lower

The creation of surgical

quadrant of the body.

incision during appendectomy disrupts the skin integrity of

Objective:

Objectives

the skin and its protective

incised skin @ right

function. Exposure of deep

lower quadrant

body tissues to the pathogens

RR – 26 cpm

in the environment places the

PR – 53 bpm

patient at risk for infection of

Temp – 36.6 oC

the surgical site, a potentially

Incision pain

threatening complication. Factors related to the surgical procedure include the method of preoperative skin preparation, surgical attire of the team, method of sterile draping, duration of surgery and length of procedure.

nursing intervention, the patient will be able to Verbalize and understand the causative/risk factor for the infection. Demonstrate techniques in minimizing infection. Remove all possible factors that may contribute to the infection process. Achieve timely wound healing; be free of purulent drainage or erythema.

Nursing Interventions

Rationale

Evaluation

INDEPENDENT: 1. Fever and pain indicate 1. Monitor vital signs, onset of fever with chills, and pain. 2. Practice/ instruct good hand washing and aseptic wound care. 3. Inspect incision site. Note characteristics of drainage from wound. 4. Change wound dressing as indicated, using proper technique for changing/ disposing of contaminated materials. 5. Encourage intake of fluid and food that is rich in Vitamin C.

After 8 hours of nursing

inflammatory

education and interventions,

responses, which

the patient was More

contribute to infection.

conscious about his

2. Reduces the risk for

environment and the patient

infection or cross

seems to be hesitated and

contamination of

confused or failed to

bacteria.

express some of the

3. Provides early detection

information imparted by the

of infection process, and

nursing students therefore:

presence of discharges

GOAL WAS PARTIALLY

may help to identify

MET.

whether there is an infection. 4. To reduce/ correct existing risk factors. 5. Promotes healing and prevents dehydration.