Ruptured

Appendicitis
with Localized
Peritonitis
A Case
Study

Presented to the Faculty of School of Nursing

Northern Luzon Adventist College

In Partial Fulfillment of

The Requirements for the Course

Related Learning Experience NCM 107

1 | Page
 By:

Sanchez, Cherry Nolle A.

2 | Page
Table of
Contents

Introduction 4

Objectives 5

Baseline Data 6

Health History 6

Gordons Assessment 7

Family History (Genogram) 9

Physical Assessment 10

Summary of Abnormal Findings 13

Developmental Task Assessment 14

Laboratory/Diagnostic Exams 16

Anatomy & Physiology 18

Pathogenesis & Pathophysiology 20

Clinical Manifestations 21

Diagram 22

Medical Management 24

Drugs 24

Intravenous Infusion 28

Nursing Care Plan 29

Health Teaching 35

Conclusion 36

References 37

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Introduct
ion

This case study provides a thorough investigation of a person

diagnosed with a certain disease. This includes the background of the
patient, the cause, diagnosis, discussion of anatomy and physiology with its
pathophysiology, laboratory studies, drug study and nursing interventions.
This is an important tool to determine an effective nursing study and nursing
care to patients. This study can serve as a future reference and research.

This is a case of Harry, 10 years old, diagnosed with Ruptured

Appendicitis with Localized Peritonitis. Appendicitis is defined as an
inflammation of the inner lining of the vermiform appendix that spreads to its
other parts. This condition is a common and urgent surgical illness with
protean manifestations, generous overlap with other clinical syndromes, and
significant morbidity, which increases with diagnostic delay. In fact, despite
diagnostic and therapeutic advancement in medicine, appendicitis remains a
clinical emergency and is one of the more common causes of acute
abdominal pain (Craig, 2014).

Appendicitis is the most common reason for emergency abdominal

surgery. Although it can occur at any age, it more commonly occurs between
the ages of 10 and 30 years (NIH, 2007). The incidence of appendicitis is
lower in cultures with a higher intake of dietary fiber. Dietary fiber is thought
to decrease the viscosity of feces, decrease bowel transit time, and
discourage formation of fecaliths, which predispose individuals to
obstructions of the appendiceal lumen. Lymphoid hyperplasia is observed
more often among infants and adults and is responsible for the increased
incidence of appendicitis in these age groups. Younger children have a higher
rate of perforation, with reported rates of 50-85% (Craig, 2014).
Approximately 250,000 cases of appendicitis occurred annually in the United
States during this period. The highest incidence of primary positive
appendectomy (appendicitis) was found in persons aged 10-19 years old;
males had higher rates of appendicitis than females for all age groups.
Furthermore, the incident rate of appendicitis in the Philippines is
approximately 215,604 persons, out of estimated population of 86, 241, and
6972.

This study will only scope the disease process of Ruptured Appendicitis
with Localized Peritonitis; the complications associated with the disease; the
manifestations that were seen in my patient; the medications, laboratory,
and diagnostic tests done; and the nursing care plans, diagnoses,
interventions, and evaluations specific for my patient. My study started on

4 | Page
August 11, 2014, on my patients hospital day and ended on August 12,
2014.

With a short background of the focus disease in this case study,

readers will be able to learn various nursing managements that will enhance
their abilities and specially the student-nurses to perform nursing processes
in a situation where immediate interventions are needed.

5 | Page
Objectiv
es

| General Objectives

The study aims to widen the horizons of my nursing skills and

knowledge by understanding and imparting gathered information through
proper execution of nursing process pertaining to my chosen case, Ruptured
Appendicitis with Localized Peritonitis. Equipped with this knowledge and
skills, my goal is to provide the essential care and services that will
contribute in the improvement of my clients health status. Furthermore, to
apply the theories I have learned in school that could help in implementing
and rendering of care.

| Specific Objectives

After the case study and presentation we should be able to:

1. Define what Appendicitis is.

2. Understand and discuss the Anatomy and Physiology of the

underlying diseases of the patient that would later help in the
planning and rendering of care.

3. Understand the process by which Appendicitis develops.

4. Determine the various risk factors that contribute to the

development of Appendicitis.

5. Know the pathophysiology or the cause of the disease to give

correct health teaching on how the patient can avoid it.

6. Know the clinical significance of various laboratory and

diagnostic exams.

7. Formulate and implement appropriate nursing care plans.

8. Put into practice and impart essential health teachings for

achievement of patients optimal health.

9. Evaluate if the goals, plan of care, and objectives were met.

6 | Page
Demographic
Data

This case is about a 10-year old Filipino male, given the pseudonym,
Harry. He was born on August 26, 2003 in Urdaneta City, Pangasinan. He is
an elementary student and is currently residing in San Jose, Urdaneta City,
Pangasinan with his parents.
Harry was admitted on August 8, 2014 with RLQ abdominal pain,
vomiting, fever, and anorexia. Upon admission, his initial impression was
Acute Appendicitis.

Health
History

| History of Present Illness

Two days prior to admission Harry started to have abdominal pain in the right
lower quadrant associated with vomiting, fever, and anorexia.

One day prior to admission, symptoms persisted. Consult sought at a private

clinic and was then referred to Region 1 Medical Center for further
management and evaluation.

| Past health History

Childhood Illness

As a child, Harry completed his immunizations and claimed no allergy or

hypersensitivity to any food or medication. According to his parents, he
seldom experience colds and cough. No other illnesses were expressed by
the client.

Past Hospitalization

Patient has not had any disease and was not confined to a hospital before.

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8 | Page
Gordons
Assessment

| Health Maintenance Pattern

Harry is a nonsmoker and nondrinker. He often eats junk foods and low fiber
foods such as meats, milk, and pastas. He stated that he does not want to
eat vegetables and complains if he does not get what food he wants to eat.
Patient has no allergy to medications, food, tapes, or dyes.

| Health Perception Pattern

Harry believes that he got his disease on his diet. He confessed that he really
loved to eat foods that are not good for his health before he got Appendicitis.
He said that if he had only obeyed his parents on which foods to eat, he
wouldnt have had suffered what he is suffering this time.

| Nutrition-Metabolic Pattern
Prior to admission, Harry eats rice, meat, and junk foods regularly. According
to him, he now refrains from eating junk foods because of his state. He had
decreased appetite. The patient was on DAT with SAP. Patient has decreased
appetite and has difficulty of swallowing noted upon assessment.

| Elimination Pattern
Harry has a regular bowel movement prior to admission. According to him,
he defecates once a day yellow to brown colored formed stool and
sometimes experiences constipation. He also urinates light yellow colored
urine with the amount of 500-700cc a day. After admission, he has an
irregular bowel movement; he defecates once every two days. He urinates
yellow colored urine with the same amount of 500-700cc a day.

| Activity-Exercise Pattern
Harry is independent in performing self-care activities prior to admission
such as bathing, grooming, toileting, and eating. Harry goes to school every
weekdays; he does not use any assistive device and has no exercise
activities. After admission and operation, Harry maintained on bed rest and
does self-care activities with the help of his mother.

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 | Sleep-Rest Pattern
Prior to admission, Harry sleeps for 8-10 hours a day. According to him, he
goes to bed early at 9:00pm and wakes up at 6:00 am. He sometimes has his
PM nap for 2 hours during weekends. He does not have any trouble sleeping.
He also expressed that he feels rested after his sleep. During admission,
patient claimed that he sleeps two times a day; during bedtime for 8 hours
and naptime for 1-2 hours. He complains of not being able to sleep because
of his post-op pain and environmental factors such as sound and lights in the
room.

| Cognitive-Perceptual Pattern
Harry is alert, oriented and has normal speaking ability during admission. He
speaks Tagalog and Ilokano. He can comprehend English. He is studying as a
grade 5 elementary student in Urdaneta City, Pangasinan. He is able to
communicate and comprehend effectively during the nurse-patient
interaction. Patient has not expressed any abnormalities in hearing and
taste.

| Role-Relationship Pattern

Harry is the only child in their family. Prior to admission, he goes to school
and back to their home. The patient has a good relationship with his parents
and other relatives who visit him frequently.

| Sexuality-Reproductive Pattern

Harry is on elementary level. He is circumcised on the age of 9 years old.

| Coping-Stress Pattern

As expressed by Harry, his major concern regarding his hospitalization and

his illness are his condition. He is afraid of what could happen to him without
his appendix. However, Harry has his parents that continuously guided and
supported him throughout his hospital stay. Moreover, he exhibited strong
faith in God.

| Value-Belief Pattern

Harry is a Roman Catholic and has no religious restrictions. He often goes to

church with his parents and always expressed his strong faith in God as his
healer and provider.

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| Family Medical History and Genogram

Grandfather Grandmother
*Heart disease *DM

Mother Father Uncle Aunt

*Asthma *Hypertensi
on

Harry
*Hypertensi
on
*DM
*CKD

LEGEND:

DECEASED DIAGNOSE WELL

D

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Physical
Assessment

| General Appearance

Harry is small built and weighs approximately 28 kg. He is approximately

47 tall. He has dark brown complexion and has a black thin hair. He has
incomplete teeth but does not have dentures. Patient has no offensive smell
and wears the hospital gown and shorts upon assessment. Harry is resting on
bed on a supine position and exhibited mild body weakness and pain.

| Vital Signs

Initial vital signs of the patient are as follows: BP: 90/60 mmHg, PR= 82bpm,
RR= 27cpm, Temperature= 36.7C. Blood pressure was taken at patients
right arm while lying on bed and pulse rate was palpated at right radial
artery.

DAY & Day 1 Day 2

DATE 08-11-14 08-12-
14
TIME 8am 12nn 2pm 8am 12nn 2pm
BP 90/60 90/60 90/60 90/60 90/60 90/60
mmHg mmHg mmHg mmHg mmHg mmHg
PR 82 bpm 84 bpm 82 bpm 80 bpm 81 bpm 80 bpm
RR 27 bpm 30 bpm 30 bpm 26 bpm 24 bpm 24 bpm
Temperat 36.7C 36.2C 36.4C 36.6C 36.2C 36.5C
ure

| Integumentary

Harrys skin is warm to touch at his upper and lower extremities. Patient has
dark brown complexion, and has dry skin. He has pale nail beds. Disruption
of tissue/skin was present on the patients site of incision; with dry and intact
dressing upon assessment. On his left arm, an intravenous catheter was
inserted and connected to 5% Dextrose in Lactated Ringers Solution.

| Cardiovascular

Harry has a normal, palpable pulse of 82 bpm, rhythm regular palpated at

right radial artery. Patients blood pressure is 90/60 taken at right arm in
supine position.

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13 | P a g e
 | Respiratory

Harry is breathing spontaneously to room air and has symmetrical rise and
fall of the chest. No presence of cough noted. Frequent breath sounds were
heard upon assessment. Patients respiration rate is 27 bpm.

| Abdomen

Harrys abdomen is flat, soft and non-tender. Color of the abdomen is of the
same tone with parts of the body. Disruption of tissue/skin was present on
the patients site of incision on the RLQ of abdomen; with dry and intact
dressing upon assessment. Abdominal pain with a scale of 5/10 was
expressed by the client upon assessment.

| Genitourinary

Harry was voiding with assistance of his mother to the comfort room. He has
voided yellowish colored urine approximately 300cc upon assessment.

| HEENT

Head: Head is round, erect and in midline. No visible lesions seen. Head is
held still and upright. Head is hard without lesion. Hair is black and evenly
distributed. No swelling or tenderness noted.

Eyes: Eyes are symmetrical. Pupils are equally round and reactive to light.

Ears: Ears are symmetrical. Earlobes are attached which are elongated. The
skin is smooth with no lesions, lumps, or nodules. Color is consistent with
facial color. No discharges noted. The patient doesnt complain of ear pain,
difficulty in hearing or any ear complications.

Nose and Sinuses: Color is same as the rest of the face; the nasal structure
is smooth and symmetric; the patient reports no tenderness. He is able to
sniff through each nostril while the other is occluded. The nasal mucosa is
dry and free from exudates.

Mouth and Throat: Lips are coarse and dry without lesions or swelling.
Patient expressed difficulty of swallowing upon assessment.

| Musculoskeletal

No musculoskeletal abnormalities and or deformities experienced by the

patient. Jaws moves laterally and opens mouth 1-2 inches. The patients
mouth opens and closes smoothly. There is no visible bony over growth,
swelling, or redness; joint is non-tender. Patient is still able to raise, extend,
flex, abduct, and adduct his both arm. Elbows are symmetric without

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deformities, redness, or swelling. Wrists are symmetric without redness or
swelling. No pain on examination.

| Neurological

Harrys memory is intact. He is conscious and has normal speaking ability.

Patient is oriented to persons and place. He is responsive to both verbal and
nonverbal stimuli. Patient exhibited facial expressions, and can feel
temperature changes by mouthing. Patient was cooperative and responsive
during the entire assessment.

| Endocrine

Harry does not experience any problem related to the endocrine system
upon assessment.

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Summary of Abnormal
Findings

Elimination pattern: constipation

Activity-Exercise pattern: malaise
Sleep-Rest pattern: trouble sleeping
Nutrition-Metabolic: anorexia
Integumentary: pain on the incision site
Respiratory: Tachypnea
Neurologic: weakness
Laboratory Exams:
CBC: () WBC

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Developmental Task
Assessment

| Sigmund Freuds Psychosexual Theory

Latency (6 y/o to puberty)

Energy is directed to physical & intellectual activities, Sexual impulses are

repressed, and Relationship between peers of same sex is common. (Rick
Daniels, Fredrick Wilkins, Ruth Grendell)

Harry seems to be physically and intellectually active, shows no interest in

any sexual activity and has alot of peers of the same sex.

| Erik Ericksons Psychosocial Theory

Industry vs Inferiority (School Age) (6 to 12 y/o)

The primary development task of school aged person revolves around the
conflict of Industry (Learns to create, develop & manipulate.Develop sense of
competence & perseverance) versus Inferiority (Loss of hope, sense of being
mediocre, withdrawal from school & peers). (Rick Daniels, Fredrick Wilkins, Ruth
Grendell)

My patient is on the side of Industry. He seems to have developed some

sense of competence and perseverance in school and studies.

| Lawrence Kohlbergs Moral Theory

Conventional Stage

Individual feels duty bound to maintain social order. Behavior is right

when it conforms to the rules. (Rick Daniels, Fredrick Wilkins, Ruth Grendell)

Patient has reached this stage as expressed by his certain behavior to follow
the rules and regulations of school because he has duty to do so to maintain
social order.

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| Jean Piagets Cognitive Theory

Concrete Operational Stage (7-11 years)

The Individual learns to reason about events in the here-and-now. (Rick Daniels,
Fredrick Wilkins, Ruth Grendell)

Patient has demonstrated awareness and understanding towards events. He

has developed an explanation why these events are happening.

| Robert Havighursts Developmental Theory

Middle childhood (6-12 y/o)

The individual is learning physical skills necessary for ordinary games.

Learning to get along with age mates. Building wholesome attitudes toward
oneself as a growing organism. Learning on appropriate masculine or
feminine social role. Developing concepts necessary for everyday living.
Developing concepts necessary for everyday living. Developing conscience,
morality and a scale of values. Achieving personal independence. Developing
attitudes toward social groups and institutions. (Rick Daniels, Fredrick Wilkins, Ruth
Grendell)

Patient seems to be capable of playing ordinary games which evidences

developed physical skills as well as the ability to socialize and communicate
effectively in groups and peers of the same age.

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Laboratory
Exams

A. Urinalysis

Urinalysis can be used to detect and measure the level of variety of

substances in the urine, including protein, glucose, ketones, blood and other
substances. This test use a thin strip of plastic (dipstick) impregnated with
chemicals that react with substances in the urine and change color.
Sometimes the test results are confirmed with more sophisticated and
accurate laboratory analysis of the urine. The urine is examined under a
microscope to check for the presence of the red and white blood cells.

Result Verified: August 06, 2014

Examination Result Normal Values Interpretation

Color Yellow Straw-dark yellow Normal
Transparency Turbid: 5.0 Clear 4.6-6.5 Normal
Glucose (-) Negative Normal
WBC 2-4/HPF 0-4/HPF Normal
Protein (+) Negative Proteinuria
pH 6.0 7.35-7.45 Acidity
Amorphous Few Normal
Mucus Threads Few Normal
Epithelial Cells Few None Contamination of
the sterile
specimen

B. Complete Blood Count

A complete blood count (CBC), also known as a complete blood cell count,
full blood count (FBC), or full blood exam (FBE), is a blood panel requested by
a doctor or other medical professional that gives information about the cells
in a patient's blood. A scientist or lab technician performs the requested
testing and provides the requesting medical professional with the results of
the CBC.

Result Verified: August 06, 2014

Examination Result Normal Values Interpretation

WBC (white 15.97 x 109/L 3.5-10 x 109/L Infection
blood count)

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RBC (red blood 4.91 x 1012/L 3.80-5.80 x 1012/L Normal
cells)
HGB 14.5 g/dl 11.0-16.5 g/dl Normal
(hemoglobin)
HCT(hematocri 43.7% 35 -50% Normal
t)
PLT(platelet 255 x 103 mm3 150-390 x 103 Normal
count) mm3
PCT 0.161% 0.100-0.500% Normal
MCV(mean cell 80 fl 70-97 fl Normal
volume)
MCH(mean cell 26.7 pg 26.5-33.5 pg Normal
hemoglobin)
MCHC(mean 33.2 g/dl 31.5-38.5 g/dl Normal
cell
hemoglobin
concentration)

Nursing Responsibilities

Before: Explain the procedure and purpose of the test to the patient/
patients immediate relative present and assess level of knowledge
regarding the test.
During: Adhere to standard precaution.
After: Monitor for signs of infection. Follow up results from laboratory.

Operation
Performed

Date: August 06, 2014

| Exploratory Laparotomy

An exploratory laparotomy (ex-lap) is the standard of care in various blunt

and penetrating trauma situations in which there may be multiple life-
threatening injuries, and in many diagnostic situations in which the operation
is undertaken in search of a unifying cause for multiple signs and symptoms
of disease.

| Appendectomy

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An appendectomy (sometimes called appendisectomy or appendicectomy)
(British English) 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.

Pre-operative Diagnosis: Acute Appendicitis probably ruptured

Post-operative Diagnosis: Ruptured Appendicitis with Localized

Peritonitis

Anatomy &
Physiology

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

attached to the cecum just below the ileocecal valve. The appendix fills with
food and empties as regularly as does the cecum, of which it is small, so that
it is prone to become
obstructed and is
particularly vulnerable to
infection (i.e,
appendicitis)
(Smeltzer,Bare, Hinkle,
Cheever, 2010).

Sometimes the position of

the appendix in the
abdomen may vary. Most
of the time the appendix
is in the right lower
abdomen, but the
appendix, like other parts
of the intestine has a
mesentery. This
mesentery is a sheet-like membrane that attaches the appendix to other
structures within the abdomen. If the mesentery is large it allows the
appendix to move around (ASSA).

In addition, the appendix may be longer than normal. The combination of a

large mesentery and a long appendix allows the appendix to dip down into
the pelvis (among the pelvic organs in women) it also may allow the
appendix to move behind the colon (a retrocolic appendix) (ASSA).

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In infants, the appendix is a conical diverticulum at the apex
of the cecum, but with differential growth and distention of
the cecum, the appendix ultimately arises on the left and
dorsally approximately 2.5 cm below the
ileocecal valve. The taeniae of the
colon converge at the base of the
appendix, an arrangement that helps in
locating this structure at operation
(Doherty, Current Diagnosis and Treatment).

The appendix in youth is

characterized by a large
concentration of lymphoid follicles that appear 2 weeks
after birth and number
about 200 or more at age 15.
Thereafter, progressive atrophy of
lymphoid tissue proceeds
concomitantly with fibrosis of the
wall and partial or total obliteration
of the lumen.

Appendix is blooded by appendicular

artery which is a branch of the artery
ileocolica. Arterial appendix is end
arteries. Appendix has more than 6
mesoappendix obstruct lymph
channels leading to lymph nodes
ileocaecal. Although the appendix
has less functionality, the appendix
can function like any other organ.
Appendix produces mucus 1-2ml per
day.

The mucus poured into the caecum. If there is resistance there will be a
pathogenesis of acute appendicitis. GALT (Gut Associated Lymphoid Tissue)
in the appendix produce Ig-A. However, if the appendix is removed, none
affect the immune body system.

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Pathophysio
logy

The appendix becomes inflamed and edematous as a result of becoming

kinked or occluded by a fecalith (ie, hardened mass of stool), tumor, or
foreign body. The inflammatory process increases intraluminal pressure,
initiating a progressively severe, generalized, or periumbilical pain that
becomes localized to the right lower quadrant of the abdomen within a few
hours. Eventually, the inflamed appendix fills with pus (Smeltzer,Bare, Hinkle,
Cheever, 2010).

If appendiceal obstruction persists, intraluminal pressure rises ultimately

above that of the appendiceal veins, leading to venous outflow obstruction.
As a consequence, appendiceal wall ischemia begins, resulting in a loss of
epithelial integrity and allowing bacterial invasion of the appendiceal wall.

Within a few hours, this localized condition may worsen because of

thrombosis of the appendicular artery and veins, leading to perforation and
gangrene of the appendix. As this process continues, a periappendicular
abscess or peritonitis may occur (Craig, 2014).

Perforation results in the release of inflammatory fluid and bacteria into the
abdominal cavity. This further inflames the peritoneal surface, and peritonitis
develops. The location and extent of peritonitis (diffuse or localized) depends
on the degree to which the omentum and adjacent bowel loops can contain
the spillage of luminal contents (Minkes, Pediatric Appendicitis, 2014).

Book
Comparison

ACCORDING TO BOOK ACCORDING TO PATIENT

Abdominal distention
Abdominal swelling
Anorexia
Constipation
Diarrhea
Dunphys sign
Elevated WBC (Neutrophils)
Hyperthermia
Local tenderness at McBurneys point

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 Nausea
Obturators sign
Pain in lumbar region
Pain on defecation
Pain on urination
Psoas sign
Rebound tenderness
RLQ pain
Rovsings sign
Vomiting

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Diagra
m

Precipitating factors: Predisposing factors:

1. Diet (low-fiber) 1. Age (10-30 y/o)

2. Constipation 2. Gender (Male)

Obstruction of the
appendix by
fecalithe

Flow/drainage of

Intraluminal pressure
RLQ pain,
Rovsings sign,
rebound
Distention
tenderness

Normal bacteria found in appendix

begin to invade (infect) the lining of the

08.06.14 Body inflammatory

WBC: 15.97 x response
109/L Abdominal pain,
Swelling of tissue fever, increased
swelling of
appendix,
APPENDICITIS vomiting, and

Inflammation and infection

spread through the wall of the

25 | P a g e
 RUPTURE OF APPENDIX

Open wound Perforation

Fecal materials exits to

peritoneal cavity
Site: lower part distal from naval area; 8 inches longitudinal incision with 9 transverse stit
Appendectomy Explore Laparotomy
Impaired skin integrity
Formation of abscess
(periappendical
Tissue trauma abscess)

Risk for infection Spread of infection in

Disruption of the peritoneal cavity
cell membrane

Bacterial invasion of
Start of peritoneal cavity
inflammatory
process Abdominal
PERITONITIS swelling,
abdominal
Pain on Release of pain, fever
surgical site chemical
mediators: If Treated If Not
prostaglandin Treated
and bradykinin
Acute pain

| LEGEND: Septic shock

Risk BP,
Factors Ranitidine, Ketorolac, Cefuroxime, Metronidazole, Paracetamol
Medical Mngt. Blood
volume
Pathology
Prescribed drugs:

Medical Coma
Diagnosis D5LRS Nursing Diagnosis
Fluid volume replacement therapy:
DEATH
Clinical
Manifestatio
RECOVERY
ns

26 | P a g e
Medical
Management
A. Drugs

A. GENERIC
NAME (BRAND A. INDICATION
A. SIDE EFFECTS
TO PATIENT
NAME) B. PRECAUTIONS AND
B. OTHER DRUG ACTION
B. GENERAL INDICATIONS
SPECIAL
CLASSIFICATI CONSIDERATION
C. DOSAGE
ON OF DRUGS
A Ranitidine A Treatment of Competitively A CNS: Confusion,
hydrochloride heartburn, inhibits the dizziness, drowsiness,
(Zantac) acid action of hallucinations,
B H2 antagonist indigestion, histamine at headache
sour the H2 receptor CV: Arrhythmias
stomach of the parietal GI: Altered taste,
B Anti-ulcer cells of the black tongue,
C 25mg IVP stomach, constipation, dark
every 8 inhibiting basal stools, diarrhea, drug-
hours gastric induced hepatitis,
secretions and nausea
gastric acid ENDO: Gynecomastia
secretion that HEMAT:
stimulated by Agranulocytosis,
food, insulin, Aplastic Anemia,
histamine, neutropenia,
cholinergic thrombocytopenia
agonist and LOCAL: Pain at IM site
gastrin. MISC:
Hypersensitivity
reactions,
vasculitisperipheral
edma, bradycardia,
hypotension,
palpitations, syncope,
chest pain
B Assess patient for
epigastric or
abdominal pain and
frank or occult blood
in the stool, emesis,
or gastric aspirate.
Nurse should know
that it may cause

27 | P a g e
 false-positive results
for urine protein; test
with sulfosalicylic
acid.
Inform patient that it
may cause drowsiness
or dizziness.

A. GENERIC
NAME (BRAND A. INDICATION
A. SIDE EFFECTS
TO PATIENT
NAME) DRUG B. PRECAUTIONS AND
B. OTHER
B. GENERAL ACTION SPECIAL
INDICATIONS
CLASSIFICATI CONSIDERATION
C. DOSAGE
ON OF DRUGS
A Ketorolac A Management Anti- A Fatigue, sweating, dry
tromethamine of pain inflammatory mucous membrane,
(Toradol) B Anti- and analgesic vomiting, diarrhea,
B NSAID inflammatory activity; dyspnea
C 15mg IVP inhibits B Patient may be at
every 8 prostaglandin increased risk for CV
hours and events, GI bleeding;
leukotriene monitor accordingly.
synthesis Take drug with food;
take only the
prescribed dosage; do
not take the drug
longer than 1 week.
Dizziness or drowsiness
can occur.
Advised patient to
report onset of black
tarry stools, severe
diarrhea, fever, rash,
itching.

A. GENERIC
NAME (BRAND A. INDICATION
A. SIDE EFFECTS
TO PATIENT
NAME) B. PRECAUTIONS
B. OTHER DRUG ACTION
B. GENERAL AND SPECIAL
INDICATIONS
CLASSIFICATIO CONSIDERATION
C. DOSAGE
N OF DRUGS
A Cefuroxime A Perioperativ Inhibits cell- A. CV: phlebitis,
Sodium e prevention wall thrombocytopenia
B Second-class B For severe synthesis, GI: diarrhea
cephalosporin or promoting pseudomembraneous

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 complicated osmotic colitis, nausea,
infections, instability; vomiting
renal usually HEMA: hemolytic
impairment, bactericidal. anemia,
and thrombocytopenia
susceptible SKIN: maculopapular
organisms and erythematous
C 500 mg IV rashes, urticaria, pain,
every 8 induration, sterile
hours ANST abscesses, temperature
elevation
OTHERS: anaphylaxis
B. Monitor signs and
symptoms of
superinfection, rash,
loose stools, diarrhea.

A. GENERIC A. SIDE EFFECTS

NAME (BRAND A. INDICATION
B. PRECAUTIONS AND
TO PATIENT
NAME) SPECIAL
B. OTHER DRUG ACTION
B. GENERAL CONSIDERATION
INDICATIONS
CLASSIFICATI C. NURSING
C. DOSAGE
ON OF DRUGS CONSIDERATION
A. Metronidazole A. Prophylactic A. Inhibit nucleic A. CNS: headache,
(Zolnid) for colorectal acid synthesis numbness, seizures
B. Nitroimidazole surgical by disrupting GI: nausea, loss of
, antibiotic infection DNA and appetite, metallic
B. Treatment for causing taste
infection of strand B. Contraindicated in
the colon breakage; patients
caused by C. amaebicidal, hypersensitive to
difficile and bactericidal, drug or its
infections trichomonocid ingredients, such as
caused by H. al parabens, and other
pylori nitroimidazole
C. 200 mg IV derivatives. Use
drip every 8 cautiously in patients
hours with history or
evidence of blood
dyscrasia and in
those with hepatic
impairment.
C. Discontinue therapy
immediately if
symptoms of CNS
toxicity develop.
Monitor especially for

29 | P a g e
seizures and
peripheral
neuropathy.
Lab tests: Obtain
total and differential
WBC counts before,
during, and after
therapy, especially if
a second course is
necessary.

30 | P a g e
A. GENERIC A. SIDE EFFECTS
NAME (BRAND A. INDICATION
B. PRECAUTIONS AND
TO PATIENT
NAME) SPECIAL
B. OTHER DRUG ACTION
B. GENERAL CONSIDERATION
INDICATIONS
CLASSIFICATI C. NURSING
C. DOSAGE
ON OF DRUGS CONSIDERATION
A. Paracetamol A. For mild-to- A. Decreases A. Minimal GI upset.
B. Analgesics, moderate fever by a Methemoglobine
antibiotic pain and hypothalamic mia,Hemolytic,
moderate-to- effect leading Anemia,
severe pain; to sweating Neutropenia,
for fever. and Thrombocytopeni
B. As a vasodilation a, Pancytopenia,
substitute for Inhibits Leukopenia,
aspirin in pyrogen Urticaria, CNS
upper GI effect on the stimulation,
disease, hypothalamic- Hypoglycemic
bleeding heat- coma, Jaundice,
disorders regulating Glissitis,
clients in centers Drowsiness, Liver
anticoagulant Inhibits CNS Damage
therapy and prostaglandin B. Liver toxicity
gouty arthritis synthesis with (hepatocyte
C. 300 mg IVP minimal necrosis) may
every 6 hours effects on occur with doses
peripheral not far beyond
prostaglandin labeled dosing. If
synthesis 3 or more
Does not alcoholic drinks
cause per day is
ulceration of consumed,
the GI tract consult a
and causes no physician prior
anticoagulant use.
action. C. Report N&V.
cyanosis,
shortness of
breath and
abdominal pain as
these are signs of
toxicity. Report
paleness,
weakness and
heart beat skips
Report abdominal
pain, jaundice,
dark urine,
itchiness or clay-
colored stools.

31 | P a g e
 B. Intravenous Fluid Therapy
Medical General Indications Nursing Responsibilities Client's
Manageme Descriptio reaction
nt n to the
treatme
nt
IV Therapy IV Therapy IV Therapy is A. Before: The
is the usually Understand why the patient
D5LRS giving of performed therapy is needed. did not
regulated at liquid for fluid Determine potential reported
31-32 directly volume outcomes for the client pain in
ugtts/min into a vein. maintenance Understand the fluid and the IV
, fluid electrolyte and acid base site and
volume status of the client consume
replacement Provide an explanation to d with no
, medication the client and gain adverse
administrati cooperation reaction.
on, blood Select the appropriate IV
administrati set
on, total B. During:
parenteral Assess the following: right
nutrition and intravenous fluids infusing,
serves as an right intravenous fluids for
emergency the client, date on the
line tubing, right rate according
to the rate prescribed and
the clients condition,
absence of kinks in the
tubing that could result in
occlusion of the fluid flow,
date on the intravenous
access device, insertion
site and vein access for
evidence of pain, redness,
warmth, or coolness, and
swelling
C. After:
Discard the administration
set accordingly
Document relevant data.

32 | P a g e
Nursing Care
Plan

Priority # 1: Risk for infection related to presence of surgical incision.

Assessment Nursing Scientific Planning Interventions Rationale

Diagnos Backgroun
is d
>S/P Risk for Inflammatio After 6-7 >Instructed patient >reduces ri
Exploratory infection n of hours of and mother in good spread of b
laparotomy, related to appendix rendering hand washing and (Doenges, 2
appendectom presence nursing aseptic wound care.
y of Acute interventio
surgical Appendicitis ns, the >Maintained dry, >prevents
>With surgical incision patient will intact, and clean developing
incision in Appendecto be free of incision dressings infectious p
RLQ covered my signs of (Doenges, 2
with dry and infection or >Observed
intact Tissue inflammati drainage from >provides
dressing trauma on wounds/drains information
status of inf
>Skin is warm Open wound (Doenges, 2
to touch Collaborative:
Risk for >Administered > reduces i
infection antibiotics as acquiring se
ordered infection (D
(Doenges, 2006)
2006)

33 | P a g e
Priority # 2: Impaired skin integrity related to invasion of body structures as evidenced by disruption of
tissue/skin and presence of surgical incision and sutures

Assessment Nursing Scientific Planning Interventions Rationale Evaluation

Diagnos Backgroun
is d
Subjecti Impaired Inflam After 6-7 > > To check Goal met.
ve: skin matio hours of Frequently skin After 6-7
Hindi integrity n of rendering assessed integrity, hours of
pa related appen nursing operative monitor rendering
humihil to dix interventio site for progress of nursing
om invasion ns, the redness, healing and interventio
yung of body Acute patient will swelling, or identify ns, the
sugat structure Appe be free of soaked need for patient was
ng anak s as ndiciti signs of dressings. further free of
ko, as evidence s infection (Doenges, signs of
verbaliz d by 2006) infection.
ed by disruptio Appe
the n of ndect > Assisted > To
mother. tissue/ski omy in passive promote
n and movements circulation
Objectiv presence Disse such as bed to the
e: of ction turning and surgical
>prese surgical of passive site.
nce of incision right ROM (Doenges,
surgical and lower exercise 2006)
incision sutures abdo and active
at right minal exercise
lower tissue thereafter,
abdomi s movement
nal area such as bed
>dry Disru position, >To allow
intact ption sitting, and continuous
dressin of standing. monitoring
g on skin and
the surfac > assessment
surgical e and Encouraged of patient
site destr patient to condition.
>disrup uction verbalize (Doenges,
tion of of for any 2006)
tissue/s skin untoward
kin layers feelings
especially
Impair pain, >To
ed discomfort promote
skin/T as well as normalizatio
issue changes n of organ
integr noted on function;
ity the e.g.,
operative stimulates
(Doenges, site. peristalsis
2006) and passing
>Encourag of flatus,
ed patient reducing
to engage abdominal
early discomfort.
ambulation (Doenges,
if possible 2006)
and have
guardian to >To prevent
assist him skin
in such breakdown
activities. and
contaminati
 on of
operative
>Instructed site.
patient and (Doenges,
guardians 2006)
to refrain
from
touching or >To prevent
scratching bacteria
the harbor on
operative operative
site. site.
(Doenges,
Collaborative: 2006)
>
Administere
d antibiotics
as ordered.
Priority # 3: Acute pain related to presence of surgical incision.

Assessment Nursing Scientific Planning Intervention Rationale Evaluatio

Diagnos Backgroun s n
is d
Subjective: Acute Appendecto After 4-6 >provided >being informed about Goal met.
Masakit pa pain my hours of accurate, progress of situation After 4-6
po yung sugat related nursing honest provides emotional hours of
ko, as to Tissue interventi information to support, helping to nursing
verbalized by presence trauma ons, the the patient. decrease anxiety interventio
the patient. of patient (Doenges, 2006) ns, the
surgical Disruption will report >Reinforced patient
Pain scale: incision. of cell decrease diversional >refocuses attention, reported
5/10 membrane of pain activities such promotes relaxation and decrease
from 5/10 as chatting, may enhance coping of pain
Objective: Start of to 1/10; watching abilities (Doenges, 2006) from 5/10
Facial inflammator will movies in to 1/10;
grimace y process appear mobile phone, appeared
Guardin relaxed, and listening relaxed
g behavior; Release of and able to music. and able
knees flexed prostagland to to
in and sleep/rest >Kept at rest >gravity localizes sleep/rest
Weak in
bradykinin appropria in semi- inflammatory exudates appropriat
appearance into lower abdomen,
tely. Fowlers ely.
Trouble relieving abdominal
Pain on position
d sleeping tension, which is
surgical site
accentuated by supine
Acute pain position (Doenges, 2006)

(Doenges, >Encouraged >to help reduce the

2006) to do deep pain by relaxation of
breathing muscles (Doenges, 2006)
 exercise

Collaborativ
e: >relief of pain facilitates
cooperation with other
>Administere therapeutic
d analgesics interventions. (Doenges,
as ordered. 2006)

Priority # 4: Risk for deficient fluid volume related to hypermetabolic state (healing process).

Assessment Nursing Planning Interventions Rationale Evaluatio

Diagnosis n
Objective: Risk for After 6-7 > Monitored I&O. > Decreasing output of Goal met.
>weakness deficient hours of concentrated urine with After 6-7
>decreased fluid rendering increasing specific hours of
skin turgor volume nursing gravity suggests rendering
>dry skin related to intervention dehydration/need for nursing
hypermetab s, the increased fluids. interventi
olic state patient will (Doenges, 2006) ons, the
(healing maintain > Gave frequent mouth patient
process). adequate care with special > Dehydration results in was able
fluid attention to protection drying and painful to
balance as of the lips. cracking of the lips and maintain
evidenced mouth. (Doenges, 2006) adequate
by moist fluid
mucous > Encouraged frequent >Maintains fluid balance
membranes oral intake of at least balance, reduces thirst, as
and good 2000-2500 ml per day. and keeps mucus evidenced
 skin turgor. membranes moist. by moist
(Doenges, 2006) mucous
>Made fluids easily membran
accessible to client. >Enhances intake. es and
(Doenges, 2006) good skin
turgor.
Priority # 5: Knowledge deficit related to unfamiliarity with information resources.

Assessmen Evaluation
Diagnosis Planning Intervention Rationale
t

Subjective: Knowledge After 6-8 >Identified >To assess the patient and Goal met.
ano po ba deficit hours of motivating factor mothers motivation After 6-8
ang dapat related to rendering for the patient and (Doenges, 2006) hours of
naming unfamiliari nursing mother rendering
gawin para ty with interventi >Prompt intervention nursing
gumaling informatio on the >Identified reduces risk of serious intervention
agad ang n patients symptoms requiring complications, e.g., delayed the patients
anak ko as resources parents medical evaluation, wound healing. (Doenges, parents is
verbalized will be e.g., increasing 2006) able to
by the able to pain; presence of verbalize
mother verbalize drainage from the understandi
understan wound. ng of
Objective: ding of >Provides information for therapeutic
>seeking therapeuti >Reviewed patient to plan for return to needs for
information c needs postoperative usual routines without their son.
>inaccurate for their activity restrictions, untoward incidents. Patient
follow- son. e.g., heavy lifting, (Doenges, 2006) participated
through of Patient exercise, sports. in treatment
instruction participate >Prevents fatigue, regimen.
>request for in >Encouraged promotes healing and
information treatment progressive feeling of well-being, and
about the regimen activities as facilitates resumption of
disease tolerated with normal activities.
periodic rest (Doenges, 2006)
periods.