Central Philippine Adventist College

SCHOOL OF NURSING
P.O. BOX 420, Bacolod City, Philippines 6100
Tel. No.: (034) 433-2407; Fax No.: (034) 433-2363
Website: www.cpacsn.info; Email: inquiry@cpacsn.info

BOARD OF NURSING

CASE STUDY

(To be submitted to the Professional Regulation Commission together with the application form)

I. PERSONAL DATA:
Name: Mess Ko
Age: 15 years old
Sex: female
Civil Status: Single
Address: Tabugon, Kabankalan city
Religion: SDA
Type of Community: Urban
Chief Complaints: right lower quadrant pain
Diagnosis/es: Ruptured appendicitis, Post appendectomy with generalized
Peritonitis
II. FAMILY BACKGROUND:
Occupation: student Father: (hypertensive)
Parents: Number of Siblings: 3
Mother: (asthmatic) Rank Among Siblings: youngest child (3rd child)

III. DEVELOPMENTAL DATA

Erickson
(Identity versus Role Confusion)
She is an Independent person, decides for herself .oftentimes,
when she has her menstrual period she has mood swings and
just get over it by staying quiet and eating chocolates. She can
get along with her friends and neighbors.
Havighurst
She loves the way she looks and is contended of her body
structure and what she has. When she has problem she prefers
to tell her older brother or her friends than her mother. she
considers herself lazy when t comes in doing house hold
chores.

IV. HEALTH HISTORY

Past History: Mess Ko has never been hospitalized before.Mess ko is fond of eating junk foods and sodas, can consume 3-4
bottle a day. Her mother prepares meat for their meals; she also stated that she does not drink plenty of water.

Present Illness: 2 days prior to admission she experienced Right lower quadrant pain, nausea and vomiting on the day of
admission she has fever and right lower quadrant pain persisted thus, prompted admission at Bacolod Adventist Medical
Center.

MEDICAL TREATMENT AND MANAGEMENT (Including Diagnostic Procedures and Implications to Nursing

Complete Blood Count- To provide valuable informations about abnormalities in the hematologic system. Lymphocytes-
0.07 (decreased; viral or some bacterial infections) Monocyte- 0.09 (Increased; indicates viral or bacterial infections,
Polys- 0.84 (increased; bacterial infections).

“Committed to the Development of the Whole Man.”

 Central Philippine Adventist College
SCHOOL OF NURSING
P.O. BOX 420, Bacolod City, Philippines 6100
Tel. No.: (034) 433-2407; Fax No.: (034) 433-2363
Website: www.cpacsn.info; Email: inquiry@cpacsn.info

Surgical Pathology -to detect the etiologic factor of certain condition. Diagnosis is done after the surgical procedure.
Impression: Appendix with approximately 0.3 cm defect at the proximal 3rd, adjacent area shows a yellowish
fibrinopurulent material on the serosa.
Exploratory laparotomy with Appendectomy- a diagnostic tool that allows physicians to examine
the abdominal organs (April 20,2009).
Serum Test- to measure enzyme in the blood.Sodium-131 mmol/L

V. DRUG STUDY

Generic/Trade Action Side Effects Contraindications

Names
Mtronidazole Disrupts DNA ,inhibiting nucleic acid synthesis Anorexia, nausea and vomiting, Hypersensitivity to other
dry mouth, metallic taste, metronidazole
diarrhea
Cefuroxime Bind to bacterial cell wall membrane which causes Mild diarrhea, mild abdominal Known allergy to
Zegen cell death cramping, discomfort with IM cephalosporins
injection
Reduces fever by acting directly on the Hematologic: hemolytic anemia; Hypersensitivity to drug
Paracetamol hypothalamic heat-regulator center to cause hepatic: jaundice, metabolic:
vasodilation and swelling, which helps dissipate hypoglycemia
heat.

VI. NURSING INTERVENTIONS

OBSERVATION: on bed in modified high back rest, conscious, coherent appears sleepy. with patent IVF D5NSS at left
arm, with NGT draining greenish fluid, with Foley bag catheter draining yellowish urine, dry lips and dry mucous
membrane noted, facial grimaces when moving noted ,rated pain as 9 from 0-10 pain scale. capillary refill of 2 seconds,
with moderate body weakness noted, evaluated patient’s actual and perceived limitations of deficit in light of usual status
during ambulation or mobilizing, noted client’s report of weakness , fatigue , pain , ascertained ability to stand and move
about and degree of assistance febrile.BP-90/60 ,RR- 18 , PR-89 ,T-38.2C˚.

MANAGEMENT: assessed general condition, cephalocaudal assessment done, noted presence of contributing factor to
pain, noted changes in usual behavior function abilities, noted skin color, texture and turgor ,noted and ausculatated
bowel sound monitored vital signs, regulated IVF, monitored intake and output, assisted during ambulation, bed shampoo
done ,Oral care done ,assisted in IVF reinsertion changed linens ,raised side rails to provide safety, provided a clean and
safe environment, due meds given, maintained NPO as ordered ,encouraged early ambulation, taught deep breathing
exercises, encouraged diversional activities such as listening to music, reading books.
EVALUATION: patient was able to ambulate with assistance, was able to manage pain through deep breathing exercises
and was report decrease of pain, rated pain as 3 as of a 10 pain scale.

“Committed to the Development of the Whole Man.”

 Central Philippine Adventist College
SCHOOL OF NURSING
P.O. BOX 420, Bacolod City, Philippines 6100
Tel. No.: (034) 433-2407; Fax No.: (034) 433-2363
Website: www.cpacsn.info; Email: inquiry@cpacsn.info

EVALUATION AND IMPLICATIONS OF THIS CASE STUDY TO:

a. Nursing Practice: It is acknowledged in this study that student nurses should be knowledgeable enough on dealing
with clients or individuals with appendicitis and post appendectomy patients. One should use specific interventions
that the client should need in order to attain the maximum level of care specifically in managing pain and in early
ambulation and should have the ability to establish a good and strong interpersonal relationship with individuals since
the nurse is required to collaborate with family members and teachers for the suitable management of clients or
individuals with Ruptured appendicitis with generalized peritonitis.

b. Nursing Education: Better comprehension could enhance the nurse’s skills and knowledge. It is important to have
awareness of the subject matter as it can help nurses classify the pathophysiology of ruptured appendicitis with
generalized peritonitis and to find out the exact causes of the disease. Overview of the subject matter is a means of
providing the client better management.
.
c. Nursing Research: Definition of the study regarding the etiology, risk factors, preventive measures and management
of clients or individuals with Ruptured appendicitis. A research study is suggested to determine and to update a
disease such as that Ruptured Appendicitis with generalized Peritonitis.

Submitted by: Chede Anne Chonette C. Robles

Student

Discussed with: Ms. Danna Lei Z.Zabala R.N

Clinical Instructor

Certified by: Joebenie L. De Villa, R.N., M.S.N.

Dean, CPAC School of Nursing

Date: September 24, 2009

“Committed to the Development of the Whole Man.”

 Central Philippine Adventist College
SCHOOL OF NURSING
P.O. BOX 420, Bacolod City, Philippines 6100
Tel. No.: (034) 433-2407; Fax No.: (034) 433-2363
Website: www.cpacsn.info; Email: inquiry@cpacsn.info

Nursing Diagnosis/es and Interventions:

1. Acute pain related to surgical incision

Observation:

 Observed general condition of patient

 Noted clients age and current condition
 Noted location of surgical incision/procedures
 Observed non verbal cues

Management

 Used pain rating scale as appropriate for age

 Monitored and check vital signs
 Provided comfort measures and quiet environment

Education

 Encouraged verbalization of feeling about pain

 Encouraged diversional activities like socialization to others
 Instructed use of relaxation technique such as deep breathing exercises

2. Impaired mobility r/t pain upon moving 2˚ post exlploratory lapaotomy with appendectomy

Observation:

 Observed general condition of patient

 Noted clients age and current condition
 Noted location of surgical incision/procedures
 Observed non verbal cues
 Classified functional level

Management

 Used pain rating scale as appropriate for age

 Monitored and check vital signs
 Provided comfort measures and quiet environment
 Assisted client in repositioning
 Raised side rails

Education

 Encouraged verbalization of feeling about pain

 Encouraged diversional activities like socialization to others
 Instructed use of relaxation technique such as deep breathing exercises
 Encouraged participation in self-care and recreational /diversional activities

3. Activity intolerance r/t moderate body weakness

Observation:

 Noted presence of factors

 Evaluated client’s actual and perceived limitation of deficit in light of usual status

Management:
“Committed to the Development of the Whole Man.”
 Central Philippine Adventist College
SCHOOL OF NURSING
P.O. BOX 420, Bacolod City, Philippines 6100
Tel. No.: (034) 433-2407; Fax No.: (034) 433-2363
Website: www.cpacsn.info; Email: inquiry@cpacsn.info

 Monitor vital signs

 Provided comfort measures and
 Positive atmosphere
 Assisted in ambulation
 Auscultated and noted bowel sounds

Education:

 Encouraged early ambulation

 Instructed client to stay in a semi- fowler’s position when in bed
 Encouraged deep breathing exercises

“Committed to the Development of the Whole Man.”