I.

INTRODUCTION

Appendicitis is an inflammation of the vermiform appendix that develops most

commonly in adolescents and young adults. It can occur at any age but is rare in clients younger
than 2 years and reaches a peak incidence in clients between 20 and 30 years. It is not common
in older adults; however, when it does occur in such clients, rupture of the appendix is most
common(Medical – Surgical Nursing: Clinical Management for Positive Outcome 8th by Joyce
Black and Jane Hokanson Hawks, page 683). It is classified as a medical emergency and many
cases require removal of the inflamed appendix, either by laparoscopy or laparotomy. If left
untreated, mortality is high, mainly because of peritonitis (inflammation of the peritoneum) and
shock. (http://www.wikipedia.org/wiki/Appendicitis?wasRedirected=true)

There is no specific test for appendicitis, but blood tests such as a white blood cell count
and x – rays may help a physician make a diagnosis. Abdominal ultrasound has proven to be
useful in differentiating causes of abdominal pain.
(http://www.healthscout.com/ency/68/658/main.html) The most specific physical finding is
rebound tenderness, pain on percussion, Rovsing’s sign (Right Lower Quadrant pain with
palpation of the Left Lower Quadrant), Psoas sign (Right Lower Quadrant pain is felt with
hyperextension of the right hip) are present in the patients with acute appendicitis.
(http://www.ufs.ph/tinig/mayjun02/05060225.html)

Anecdotal reports describe the success of intravenous antibiotics in treating acute

appendicitis in patients without access to surgical interventions
(http://www.ufs.ph/tinig/mayjun02/05060225.html). But in most cases, a surgical removal of the
appendix is more advisable to relieve the recurrence of pain and to prevent bursting of the
appendix. The surgery that corrects the appendicitis, called an appendectomy, is a procedure with
relatively little risk. Many surgeons are performing laparoscopic appendectomy in which the
appendix is removed through three small incisions less than an inch long using special
instrument and a special camera. With laparoscopic appendectomy, most patients can go home
within 24 hours of the operation. (http://www.healthscout.com/ency/68/658/main.html) Appendix
can also be removed through laparotomy. The surgeon makes a small incision at the Mcburney’s
point (Mcburney’s incision) to remove the appendix. Appendectomy is done under a general or
1
regional anesthesia, which means the patient will not feel any pain during the procedure.
(http://www.nlm.nih.gov/medlineplus/ency/arcticle/002921.html)

The incidence rate of appendicitis in the United States is approximately 680, 000 per year
or 56, 000 per month (http://www.diagnosis.com/a/acute_appendicitis/prevalence.html). In the
Philippines, there are approximately 215, 604 cases recorded annually (in the estimated
population of 88, 241, 697).

(http://wiki.answers.com/Q/What_is_the_appendicitis_rate_in_the_Philippines)

To gather more information about appendicitis and appendectomy, the group chose this case
for presentation; and to help future patients in improving their lives, and also this case study may
be used as reference for future researchers.

2
 OBJECTIVES

Student – Nurse Centered

General Objectives

To gather additional knowledge from the patient’s condition and give proper nursing care
on her post – operative state to prevent complications through the use of the nursing process.

Specific Objectives

At the end of the study the student nurse will:

 Understand and be knowledgeable about the patient’s condition.

 Assess the needs for care of the patient.
 Plan appropriate interventions related to the patient’s needs.
 Implement the planned nursing interventions.
 Evaluate whether the goals are met or not.
 Reassess if the care of plan was effective.

Patient – Centered

General Objectives

3
 The patient will be knowledgeable about the proper care needed on her post – operative
state, to attain maximum level of care, and to prevent complications.

Specific Objectives

At the end of the study, the patient will:

 Be knowledgeable about her condition.

 Understand the extent of restrictions of food and activities.
 Achieve the needed nursing care appropriate for her age and condition.
 Decrease the anxiety she is experiencing after the surgery and possible complications.
 Respond to the prescribed treatments or managements.
 Become better and will live normally like with other people.

4
I. NURSING PROCESS

A. ASSESSMENT

1. Personal Data

a. Demographic Data

Name : Adding J

Age : 12 years old

Sex : Male

Birthday :

Address : baldios, Sta. Ignacia Tarlac

Religion : Roman Catholic

Nationality : Filipino

Civil Status : Single

Occupation : N/A

Height :

Weight :

Chief Complaint : Abdominal pain – Right Lower Quadrant

5
 Date of Admission : January 4, 2011

Admitting Diagnosis : t/c Appendicitis

Final Diagnosis : Acute Appendicitis

b. Environmental Status

Ading J resides at Baldios,Sta. Ignacia, Tarlac. Their house was a bungalow type which is
made up of bamboo where there are mango trees around it. There are two rooms in their house
which they use for sleeping. They are five living in their house. There is available sari – sari
stores available in their place. The available means of transportation in their area are thru
jeepney, tricycle and mini bus. They also have a forced pump located at their backyard which
they also use for their drinking water. They have 2 cats and a dog which they allow to stay inside
their house. They said that they have a good relationship with their neighborhood.

c. Lifestyle

6
 Ading J is a grade six student. He usually sleeps at 8 or 9 in the evening and wakes up at
around 6 in the morning to prepare his self to school. Every day, he plays basketball as his
exercise and past time. According to his sister, their mother usually cooks meat or pork dishes,
and sometimes vegetables. He usually drinks 8 - 10 glasses of water a day. Right after he eats, he
goes back to his friends to play basketball. He takes a bath every day, usually every morning
before he goes to school. His sister also stated that adding J started eating junk foods and soft
drinks every afternoon.

7
 2. FAMILY HISTORY OF HEALTH AND ILLNESS

PATERNAL MATERNAL

8 78 8 ASTHMA

7 1
CA 76

6
7
4 7
7
54 7 71 6
9
60 6 64 69
8 4 3

v/a

4
47 4
9 4
3 1

LEGEND

BOY

GIRL

X DECEASED

PATIENT

APPENDICITIS

CA Cancer

V/A Vehicular Accident

8
3. History of Past Illness

According to Ading J this is his second time of hospitalization. He was 5 years old when
he was first hospitalized, that was when some of his body part (specifically his armpit) burned
because of the explosion of the gasoline when his parents was cooking. He already had Chicken
Pox and measles. Ading J did not know if he was fully immunized, he does not have any
allergies to any foods, medication and pets. Cough and Colds, Diarrhea and fever are the usual
condition that he acquired and his mother buys over the counter drugs like paracetamol, neozep
and loperamide.

4. History of Present Illness

Two weeks prior to admission, the patient felt an abdominal pain at the right lower
quadrant. Though Ading J experienced pain, he can still tolerate it and continued to play
basketball.

One week prior to admission, abdominal pain was still present and his mother decided to
seek consultation to Gilberto O. Teodoro Memorial Hospital Emergency Room. He was
diagnosed with Appendicitis and his physician prescribed cefalexin as the first course of
treatment.

After one week, she went to another clinic which is the Iglesia Clinic in Camiling, Tarlac.
The findings were also Appendicitis, and the physician prescribed diclofenac. She was referred
to Tarlac Provincial Hospital for further laboratory examination. Urinalysis was ordered, after
reading the result the physician decided to admit her for more evaluation. After certain
laboratory tests, the physician subjected the patient for appendectomy.

9
5. 13 AREAS OF ASSESSMENT
I. SOCIAL STATUS

Ading J is the third of the six siblings. The family resides at Baldios, Sta Ignacia Tarlac.
Ading J belongs to a nuclear family. He is a Roman Catholic and a grade six student. His mother
is a house wife and his father works in Tuguegarao as an auto technician earning P1,200 a week,
which they spend for their foods and groceries, electric bill, cellular phone load, and daily school
allowance of their children. Ading J’s medical expenses are supported by his family, relatives
and health insurance (philhealth). He usually goes to talk with their neighbors and play
basketball with his playmates. He has a good relationship with their neighbors.

NORMS

Social status included family relationship that serves as his support system especially at
times of need and stress related conditions. It meets a fundamental human need for social ties
making life less anxious. Also social support system buffers the negative effect of stress as
means of achievement of a good health. (Friedman and Smith 1988)

ANALYSIS

Ading J has a normal social status because he is able to mingle with the other people and
do the usual things a typical child does. They are also able to provide their basic needs.

II. MENTAL STATUS

10
 Adding J is conscious and coherent. Oriented to time and date, he is able to read and
write and follow instructions, able to maintain eye to eye contact. He is open to any questions,
approachable and is able to converse but slowly with the student nurses. During the assessment,
Ading J talks about his past memories showing that his long term memories are still active.

11
NORMS

To consider a person’s mental status is normal, he should be oriented. He should be able

to evaluate and act appropriately in situations regarding judgment. (Health Assessment and
Physical Examination 3rd Edition by Mary Ellen Zator Ester)

ANALYSIS

Ading J’s mental status is normal, it is usual that a patient in pain has a hard time when
talking.

III. EMOTIONAL STATUS

Prior to hospitalization according to his sister, he is very cheerful; he loves to make

conversations with his playmates, and siblings. His sister also stated that they have financial
problems but since their family and relatives are very supportive not just financially but also
emotionally along with the health insurance they are able to lessen their burden regarding their
expenses in the hospital. This shows that they have a good relationship status with her family.
Ading J’s after the procedure was still asleep due to the anesthesia. When Ading J’s was awake,
he stated that she can feel the pain on the incision site, which is a normal response several hours
after the operation.

NORMS

Integrity manifests with wisdom and feelings of satisfaction with one’s life while despair
arises from remorse about what could have been. The presence of despair causes life to be
viewed as meaningless. (Source: Nursing CEU.com: The process of human development)
Carrying out emotional feelings through words and facial expressions are normal signs that client

12
was aware of his physical conditions. (Nursing Fundamentals, Rick Daniels) Expression of self
control and self perception is just normal (Fundamentals of Nursing, Kozier, Erb, Berman, and
Synder).

ANALYSIS

Ading J’s emotional status is considered normal, due to his condition it is normal to feel
pain and become unresponsive in some instances.

IV. SENSORY PERCEPTION

VISION

In assessing the vision, Ading J is instructed to look straight to observe the general
appearance of her eyes. His eyes are almond in shape, irises are black in color and scleras are
whitish in color, eyebrows and eye lashes are equally distributed. His conjunctiva is pale and
moist. Ading J was also instructed to follow the direction of a finger with his eyes following six
cardinal positions. And his eyes were able to move in full ranges of motion and in all directions.
With the use of penlight pupils are assessed, pupils are equally round and reactive to light
accommodation. Ading J does not use eyeglasses or contact lenses.

13
 Visual acuity was assessed by asking Ading J to read the word written on a piece of paper
with a font size of approximately 12 at about 3 feet away from his using the right eye first then
the left eye and then both eyes. Mrs. F read all the samples correctly during the test.

NORMS

For the test of the Cardinal Fields of Gaze, the extra ocular muscle movements are being
assessed. Normally, both eyes of the patient should move smoothly and symmetrically in each of
the six fields. Light and accommodation reading is possible in the distance of 14 inches for the
assessment of near vision. (Health Assessment and Physical Examination 3rd edition by Estes)

Analysis

The patient’s visual capacity or status is normal, extra ocular muscle movements and
papillary response and visual acuity are normal.

SMELL

Ading J’s nose has no deviations in terms of shape and size. Nose is pointed and no
discharges were seen during the assessment. According to the patient he doesn’t have any history
of sinus infection or epistaxis (nose bleeding). Before the next procedure, permission was asked
to Ading J to do another test. Using a perfume and an orange peel without the patient’s
knowledge we ask him to identify the 2 samples by smelling. After smelling he correctly
identifies the perfume and orange peel. Test shows that there are no abnormalities or obstructions
were identified in his sense of smell.

14
Norms

Nose must be symmetrical and along of the face. Each nostril must be patent and
recognize the smell of an object. (Health assessment and physical examination, Mary Ellen
Zator Estes)

Analysis

Client was able to recognize the odor. He has normal sense of smell but he has difficulty
of breathing that leads to the need of oxygen therapy.

HEARING

General appearance of Ading J’s ears was parallel, symmetrically proportional to the size
of the head, bean shape, has a firm cartilage and with the presence of cerumen. In assessing the
hearing acuity of the patient, Ading J is instructed to repeat the words that will be whisper at a
distance of 2 feet away on the left ear first, and then the right after the test he was able to repeat
the whispered words. Another test by the use of the beeping sound of the digital thermometer at
the distance of 4 feet away and still he was able to hear the sound. He verbalized that he has no
known auditory deficits nor ear infection history and unusual sensations like ringing or buzzing.

15
Norms

For the auditory acuity, the patient should be able to repeat the whispered words from a
distance of two feet. (Health assessment and physical examination, Mary Ellen Zator Estes)

Analysis

Based on the given data, patient’s auditory acuity is normal.

TASTE

Ading J’s lips are dry and symmetrical in shape, tongue is pale in color, no presence of
tooth decay, but there is a presence of tooth cavities, no false dentures and no teeth loss, no sign
of gingivitis, buccal area are pale. The patient was asked to open his mouth widely to assess the
entire mouth. To assess his sense of taste, patient was asked to do some taste test. He was ask to
taste a cotton ball soak with orange juice and cotton ball soaked in water with salt without
knowing what the two samples are. After patting the cotton balls on the lips of the patient, Ading
J identified the 2 samples correctly.

Norms

Taste is intact in the posterior one third of the tongue. (Health Assessment and Physical
Examination, Mary Ellen Zator Estes)

Analysis

Client’s sense of taste is normal.

16
TOUCH

In assessing’s sense Ading J’s of touch, he was asked to close his eyes a cotton ball was
stroke to the back of his neck. Then using another cotton ball we poured alcohol on it and rub it
on the same area. He stated that he felt a sensation of wet and cold on his skin.

Norms

The skin contains receptors for pain, touch, pressure and temperature. Sensory signals are
transmitted along rapid sensory pathways, and less distinct signals such as pressure of localized
touch are sent via slower sensory pathways. (Health Assessment and Physical Examination,
Mary Ellen Zator Estes)

Analysis

Ading J’s sensory transmission functions well as manifested by the data presented, it is
considered normal.

V. MOTOR STABILITY

Several hours after the surgery, the patient was asked to perform ROM exercise on the
upper and lower extremities. He was asked to raise both of his arms. He performed it with ease
and freely moved without any difficulty. He can bend and straightened his elbows and extend

17
and spread his fingers. He performed it with ease. According to the patient he felt pain in the
right lower quadrant of his abdomen when raising his right leg and cannot move it freely. There
is no presence of deformity. There are also proper symmetry between left and right on each
extremity. Early ambulation was encouraged. Patient can bend his legs with limited range of
motion and needs assistance when standing and going to the comfort room.

NORMS

Fine motor skills involve the small muscle of the body that enables such functions as
writing, grasping objects and fastening of clothes. Fine motor skill involves strength, fine motor
controls and dexterity. Gross motor skills involve the large muscles of the body that enable such
functions as walking, kicking, sitting upright, lifting and throwing a ball. A person’s gross motor
skills depend on both muscle tone and strength.

Low muscle tone is characteristics disabling conditions such as Down syndrome, genetics
or muscle disorders, or central nervous system disorders.

ANALYSIS

Ading J’s motor ability is not in good condition due to the presence of pain in the right
lower quadrant of the abdomen when raising the right legs.

VI. BODY TEMPERATURE

The table below shows the temperature of Mrs. F during the shift

DATE TIME TEMPERATURE ANALYSIS

18
 January 4, 2011 8:00 am 36.7°C Normal

9:00 am 36.9°C Normal

2:00 pm 36.8°C Normal

January 5, 2011 3:00 pm 38.5°C Above normal

January 6, 2011 8:00 pm 37°C Normal

INTERPRETATION

Ading J’s temperature at January 4 was normal, on January 5, he was febrile. On January
6, his temperature returned to normal.

NORMS

Normal temperature for axilla is within 35.4-37.4c (Fundamentals of Nursing by Kozier

and Erbs 7th edition)

ANALYSIS

According to the data gathered on September 30, 2010 at 6:00 pm Ading J’s body
temperature is on normal range. The patient had altered body temperature on October 1, 2010 at
3:00 pm up to 6:00 pm, and became normal at 10:00 pm.

19
VII. Respiratory Rate

RESPIRATORY
DATE T IME ANALYSIS
RATE
8:00 am 20cpm

January 4, 2010 9:00 am 18cpm Normal

2:00 pm 19cpm
January 5, 2010 9:30 pm 20 cpm Normal
January 6, 2010 8:00 am 19 cmp Normal

Norms

Respiration in the resting adult, the normal respiratory rate is 12 to 20 breaths per minute.
This type of breathing is termed eupnea, or normal breathing.

(Health Assessment and Physical Examination, 3rd edition by Estes, page 455)

(Analysis is presented on the table above)

VIII. Circulatory Rate

DATE TIME B.P ANALYSIS

September 30, 2010 3:35 pm 90/70 Normal

October 01, 2010 9:30 pm 100/80 Normal

P.R

September 30, 2010 3:35 pm 64 Normal

October 01, 2010 9:30 pm 70 Normal

20
Norms

Pulse

Normal pulse rate vary with age. The table below shows the normal range of pulse rate
according to age:

AGE RESTING PULSE RATE AVERAGE

10 years 70 – 110 bpm 90
14 years 60 – 110 bpm 85 – 90
Adult 60 – 100 bpm 72

Source: Health Assessment and Physical Examination, 3rd edition by Estes, page 253

Normal blood pressure varies with age. As a person ages, blood pressure generally
increases. The table below shows the general ranges of normal blood pressure at different ages
and gender:

BLOOD PRESSURE: Normal Range According to Age and Gender

Female

AGE SYSTOLIC (mm Hg) DIASTOLIC (mm Hg)

5 103 – 109 66 – 70

10 112 – 118 73 – 76

15 120 – 127 78 – 81

≥18 <120 <80

21
Male

AGE SYSTOLIC (mm Hg) DIASTOLIC (mm Hg)

5 104 – 102 65 – 70

10 111 – 119 73 – 78

15 122 – 131 76 – 81

≥18 <120 <80

Source: Health Assessment and Physical Examination, 3rd edition by Estes, page 260

IX. Nutritional Status

Before he was confined to the hospital, adding J eats 3 to 4 times per day and drinks 8 to
10 glasses of fluids. He also eats fruits like banana and mango. When the patient was admitted in
the hospital, he was on a nothing by mouth state. His BMI is in normal range.

BMI COMPUTATION:

Weight: 48kg

Height: 5”1’

BMI = WEIGHT IN KILOGRAMS

HEIGHT IN METER SQUARED

22
 = 48kg

2.4006 m

BMI =19.99 - NORMAL

Norms

According to the Health Asian Diet Pyramid, there should be a daily intake of rice,
grains, bread, fruit and vegetables; optional daily for fish, shellfish, and dairy products; weekly
for sweets, eggs and poultry, and monthly for meat.

There should be an increase intake of a wide variety of fruits and vegetables. Include in
the diet foods higher in vitamins C and E, and omega-3 fatty acid rich foods. (www.webmd.com)

Analysis

Mrs. F nutritional status was affected because of the surgical procedure done to her
(appendectomy). Her BMI is in the normal range.

X. Elimination Status

Mrs. F usually defecates once every day with hard stools bur not painful and urinates 4 to 5
times per day with an approximately 30 to 40 cc of urine per urination. When she was admitted
she voids 4 times and defecates once.

Norms

23
 The frequency of defecation is highly individual, varying from several times per day to
two or three times per week. The amount defecated also varies from person to person.

(Fundamentals of Nursing 7th edition by Kozier, et. Al., page 1126)

Average Daily Urine Output by Age

AGE AMOUNT(mL)
5 to 8 years 700 – 1000

8 to 14 years 800 – 1400

14 years through adulthood 1500

Older adulthood 1500 or less

Source: Fundamentals of Nursing 7th edition by Kozier, ET. Al., page 1261

ANALYSIS

Mrs. F elimination status is affected. Because she was on nothing by mouth state after the
operation, she has nothing to defecate.

XI. Reproductive Status

Ading J had his circumcision at the age of 10. He does not had any sexual experience.

Norms:

(Maternal and Child health Nursing 4th Edition by Pilliteri)

ANALYSIS

24
 Based on the statement above Ading J has a normal reproductive status. He doesn’t have
sexually transmitted disease.

XII. Sleep – Rest Pattern

He usually sleeps at 8 to 9 in the evening and wakes up at 6 in the morning. He watches

television during his rest hours or play basketball with friends. He also spends time to be with his
family and playmates. But when he was confined his sleep pattern was always interrupted.

Norms

NORMAL HOURS OF
CATEGORY
SLEEP PER DAY
Newborns 16 to 18

Infants 12 to 14

Toddlers 10 to 12

Preschoolers 11 to 12

School – age children 8 to 12

Young adults 7 to 8

Middle – aged adults 6 to 8

Elders About 6 hours

Source: Fundamentals of Nursing 7th edition by Kozier, ET. Al., page 1116

ANALYSIS

Because of his condition, Ading J's sleep pattern was affected.

25
 XIII. State of Skin and Appendages

Ading J’s skin is brown in color. His skin in the foot is dry, some calluses are observed. He
complains of some itchiness on his lower extremities. His conjunctiva is pale. He has some scar
on his lower extremities. His nails are pale, short and clean. His nail beds are slightly pale. His
capillary refill time is 2 seconds.

NORMS

The palpebral conjunctiva should appear pink and moist. Normally the skin is a uniform
whitish pink or brown color depending on the patient's race. Normally, the nails have pink cast
light skinned individuals and are brown in dark-skinned individuals. (Health assessment and
Physical Examination, 3rd edition by Mary Ellen Zator Estes).

Analysis

Ading J’s skin appendages are affected due to decreased oxygen supply. The patient’s dry
skin was due to restriction in fluid and any food. The Patient’s capillary refill is normal.

6. Laboratory and Diagnostic Procedures

DATE ORDERED: September 29, 2010

Urinalysis

INDICATION RESULT NORMAL RANGE ANALYSIS

26
 Color: Yellow Straw yellow – amber Normal

>to detect renal Transparency: Turbid Transparent – turbid Normal

and metabolic
diseases. Leukocytes/Nitrates: Negative Absent Normal

Urobilirogen: Normal 0.2 – 1. 0 mg/dl Normal

>diagnosis of Protein: Trace Absent - Trace Normal

diseases or
disorders of the pH: 6.0 5.0 – 8.5 Normal
kidney or urinary
tract. Blood cells: negative Absent Normal

Specific gravity: 1.010 1.010 – 1.015 Normal

Ketone: Negative Absent Normal

Bilirubin: Negative Absent Normal

Glucose: Negative Absent Normal

Mucus threads: Moderate Negative or few Normal

Pus cells: 3 - 4 Few High. An

indicator that
there is an
infection
present in the
urinary tract.
RBC: 0 - 1 0 – 3/ HPF
Normal
Epitheleal Cells: Moderate Few
Normal
Bacteria: Rare Negative or Few
Normal
Urates/Phosphates: Moderate Few
Normal

NURSING RESPONSIBILITIES

Prior to procedure:
27
  Explain the procedure to the patient and family/relatives.
 Provide for patient’s privacy.
 Instruct the patient to go to the laboratory with the request form.
 Instruct the patient to dispose the first urine and catch the midstream urine.
 Educate the patient not to contaminate the inside part of the container.
 Instruct the patient to send the specimen to the laboratory immediately

During the procedure:

 Maintain the sterility of the specimen container by not touching the inside part.
 Maintain the freshness and sterility of the urine specimen.

After the procedure:

 Interpret the result

 Refer to the physician if abnormalities are noted.

28
DATE ORDERED: September 29, 2010

Complete Blood Count

INDICATION RESULT NORMAL RANGE ANALYSIS

BLOOD TYPE: A+

>to WBC: 13.9 G/L 4.1 – 10.9 G/L WBC is high because
detect/diagnose of the presence of
blood infection. WBC
disorders. defends our body
against infection.

>to detect
presence of LYM: 1.8 R2 12.9%L 0.6 – 4.1 10.0– 58.5%L Normal
infection.
*MID: 0.8 5.5%M 0.0 – 1.8 0.1 – 24 %M Normal

GRAN:7.0 81.6%G 2.0 – 7.8 37.0–92.0 %G Normal

>to screen for
fluid and RBC: 4.17 T/L 4.20 – 6.30 T/L Normal
electrolyte
problem. HGB: 113 g/L 120 – 180 g/L Normal

HCT: .373 L/L .370 - .510 L/L Normal

MCV: 82.6 fL 80.0 – 97.0 fL Normal

29
 MCH: 27.1 pg 26.0 – 32.0 pg Normal

MCHC: 328 g/L 310 – 360 g/L Normal

11.5 – 14.5 % Normal

PLT: 379 G/L 140 – 440 G/L Normal

NURSING RESPONSIBILITIES

Prior to procedure:

 Explain the procedure to the patient and family/relatives.

 Educate the patient about what to expect during the procedure.

During the procedure:

 Advise the patient to relax during the procedure.

30
After the procedure:

 Interpret the result

 Refer to the physician if abnormalities are noted.

7. Anatomy and Physiology

31
The Appendix

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 quadrant of
the abdomen, or, more specifically, the right iliac fossa. Its position within the abdomen
corresponds to a point on the surface known as McBurney's point (see below). While the base of
the appendix is at a fairly constant location, 2 cm below the ileocecal valve, the location of the
tip of the appendix can vary from being retrocecal (74%) to being in the pelvis to being
extraperitoneal. In rare individuals with situs inversus, the appendix may be located in the lower
left side.

New studies propose that the appendix may harbor and protect bacteria that are beneficial
in the function of the human colon. Some researchers argue that the appendix has a function in
fetuses and adults.[7] Endocrine cells have been found in the appendix of 11-week-old fetuses that
contribute to "biological control (homeostatic) mechanisms." In adults, Martin argues that the
appendix acts as a lymphatic organ. The appendix is experimentally verified as being rich in
infection-fighting lymphoid cells, suggesting that it might play a role in the immune system.

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,
32
 explanations were lacking for the distinctive shape of the appendix and its apparent lack of
importance as judged by an absence of side-effects following appendectomy.

8. PATHOPHYSIOLOGY

Book based

Non modifiable risk factors: Modifiable risk factors:

>age >constipation
Other common
symptoms>gender
include >activity 33
Concurrent infection can cause mucosal
Appendectomy is often Abdominal pain is process
The inflammatory present,ranges
usually
anorexia, nausea and Severity ofand
symptoms is related to
ulceration subsequent development of
suggested described
from mild asto being
severeinappendiceal
the right lower
vomiting,by thegrade
low the degree of inflammation
abscess, necrosis or rupture.
physician. quadrant, localized
swelling and at Mcburney’s point.
obstruction.
fever, elevated WBC present.
Patient – based

Modifiable Factors Non Modifiable Factors

 Constipation Age

 Low Fiber –

Occlusion of appendix by fecalith

Increased intra luminal pressure in the appendix

Start of the inflammatory process

Low grade fever

Appendectomy Inflammation of appendix (appendicitis)

Acute abdominal pain at

the Mcburney’s point.

Nausea and loss of

appetite
34
 B. PLANNING

NURSING CARE PLAN

Acute Pain

Assessment Planning Intervention Expected

outcome

Subjective: “Masakit ang sugat ko” P/S Within 30 minutes to  Monitor the pain scale. (to know if Within 30 minutes
is 6/10. 1 hour of giving there is an improvement) to 1 hour of giving
proper nursing  Position on a semi-fowlers proper nursing
Objectives: interventions, the position.(for the patient to feel interventions, the
patient will verbalize comfortable) patient will:
 facial grimace reduction of pain.  Provide a clean bed. (to have a
 increase ability to perspire good relaxation.)
 irritable at times  Encourage to have a bed rest.( to
 guarding behavior gain energy) -verbalize a
 limited movements and range of  Encourage to continue limiting decrease of pain.
motion. body movements. (to prevent
pain) -can move freely
 assisted with the significant others
without
when turning in other position.  Educate the importance of deep
assistance.
breathing exercises. (for the
Nursing Diagnosis: patient to feel calm and relax)
-free from
 Divert attention by instructing to
irritability.
Acute pain related to surgical incision on read books.(to lessen and divert
the abdomen. pain)
-facial grimace
 Instruct to increase fluid intake.(to will be absent.
Scientific Explanation: prevent dehydration)
 Instruct to guard the site when
35
 coughing. (to prevent from
Unpleasant sensory and emotional opening of the site)
experience arising fromactual or potential  Instruct to take medications that
tissue damage or described in terms of are prescribed by the physician.
such damage (International Association (for the patient safety to drugs)
for the Study of Pain); sudden or slow
onset of any intensity frommild to severe  Educate the patient to clean the site
with an anticipated or predictable end regularly. (to prevent any
and a duration of less than 6 months. complications and infection)
(Nurse’s Pocket Guide Edition 11 by F.A
Davis, page 498)

Hyperthermia

Expected
Assessment Planning Interventions
Outcomes
Subjective:Ø Within 1 hour of Monitor vital signs especially Within 1 hour of
proper nursing temperature. (To know if it has an proper nursing
interventions, the improvement of the patient’s interventions, the
patient’s temperature temperature.) patient’s
Objective: will subside to 37.5 °c Perform Tepid Sponge bath. (To temperature will
from 38.5 °c. lower body temperature.) subside to 37.5 °c
 warm to touch Provide clean and comfortable from 38.5 °c.
 diaphoretic bed. (for the patient to have a good
 weak in appearance rest and feel comfortable)
 irritable at times Provide clean and comfortable
 vital signs taken as follows: clothing. (for the patient not to feel
irritable)

36
 Instruct to increase fluid intake
BP-90/70 mmHg after NPO. (to prevent dehydration)
Instruct to eat nutritious foods like
RR-20 cpm green leafy vegetables after NPO. (to
gain more energy)
PR-64 bpm
Instruct to take medications that
Temp- 38.5°c are prescribed by the physician. (For
safety purposes.)
Diagnosis:

Altered body temperature related to

inflammatory process.

Scientific Explanation:

Hyperthermia is an elevated body

temperature due to failed
thermoregulation. Hyperthermia occurs
when the body produces or absorbs more
heat than it can dissipate. It may also
occur as assign of infection.

Risk for Infection

37
 ASSESMENT
S O
O timely wound healing
 Irritable
 Poor hygiene
 Long fingernails
 Dirty surroundings
 Incision on the right
lower quadrant of the
abdomen
Diagnosis
Risk for infection related to
surgical incision on the right
lower quadrant of the abdomen
SCIENTIFIC
EXPLANATION
There’s a risk for infection for a
client who undergone a surgical
incision because there is a break
in the tissue or that would serve
as an opening that can be
PLANNING
Within 2 hours of proper nursing
intervention the client risk for
infection will decrease to achieve
INTERVENTION AND EXPECTED
RATIONALE OUTCOME
 Instruct in good hand washing After 2 hours of
(Reduces risk of spread of proper nursing
bacteria) intervention the client
risk for infection is
 Instruct good body hygiene decrease to achieve
(Reduces risk of spread of timely wound healing
bacteria and promote relaxation) as evidenced by:
 Demonstrate aseptic wound care
(Reduces risk of spread of
bacteria) a. Washing the hands
using soap
 Inspect incision and dressings
(Provides for early detection of
developing infections process)
b. Good body hygiene
 Encourage to cut the fingernails
(Reduce risk of spread of bacteria)
c. Well kept
 Encourage to keep the
surrounding
surroundings of the patient clean
(To minimize the chance of getting
infection through microorganisms
around the ward)
d. Short fingernails
38
invaded by different kind of
microorganisms.

Impaired Skin Integrity

EXPECTED
ASSESSMENT PLANNING INTERVENTIONS
OUTCOME

39
S Within 1 hour of  Assess site of skin impairment After 1 hour
proper nursing (the cause of the wound must be of rendering
“nangangati ang sugat ko” interventions, the determined before appropriate proper nursing
patient will regain interventions can be implemented). interventions,
O integrity of the  Monitor site of skin impairment the patient
skin and for color change, redness, swelling, will regain
 with surgical incision at the mcburney’s demonstrate warmth, pain, or other signs of integrity of the
point measures to infections (systematic inspection can skin and
 with suture noted protect care and identify impending problem early). demonstrate
 with surgical dressing intact heal the skin  Clean the site aseptically (to measures to
 poor skin turgor lesion. decrease the production of bacteria). protect care
 Select a topical treatment that will and heal the
 limited movement
maintain a moist wound – healing skin lesion.
environment and that is balanced with
the need to absorb exudates ( keep
Diagnosis peri wound skin dry and control
exudates and eliminate dead space)
Impaired skin integrity related to tissue damage.  Avoid massaging around the site
of skin impairment and over bony
Scientific explanation prominences (massage may lead to
tissue trauma).
Invasion of body structures, destruction of skin
layers (dermis), disruption of skin surface  Monitor nutritional intake (Altered
(epidermis). nutrition can prevent wound healing
and put at risk for further skin
breakdown).

Fatigue

40
 Assessment Planning Interventions Expected Outcomes
Subjective: Nanghihina ako” Within 1 hour of proper  Obtain vital signs. (for baseline Within 1 hour of
nursing interventions, purposes) proper nursing
Objective: the patient will verbalize  Maintain on a flat position as an order interventions, the
increase body strength. of the physician. patient will verbalize
 with limited body  Encourage to have adequate rest. (to increase body
movements gain energy) strength.
 weak in appearance  Encourage to ask some help to the
 slow and low voice noted nurse or significant others if she want
 diaphoretic to move or change in position. (for the
 vital signs taken as follows: patients safety)
 Instruct to increase fluid intake after
BP-80/70 mmHg NPO. (to prevent dehydration)
 Instruct to eat nutritious foods like
RR-20 cpm green leafy vegetables after NPO. (to
gain more energy)
PR-64 bpm  Educate about the significant others to
assist the patient when moving. (for
Temp- 35.8 °c safety and for the patient to move
easily)
Diagnosis:
 Instruct to take medications that are
Fatigue related to post surgical prescribed by the physician. (To avoid
procedure. any drug accident such as
overdosing.)
Scientific Explanation:

An overwhelming sustained sense

of exhaustion and decreased
capacity for physical and mental
work at usual level.

41
C. IMPLEMENTATION

1. DRUGS
Name of Drug Date Route and General Action Indication Client’s actual
Administered Administration response to
medication
Cefoxitin October 1, 2010 IVP Bactericidal: • Perioperative Presence of pain
Inhibits synthesis prophylaxis. was noted on the
6:00pm 1g of bacterial cell IV insertion site
wall, causing cell during the drug
q 8 hours death. administration.

Nursing Responsibilities:

 Check the doctor’s order.

 Check the right drug, right patient, right time, right frequency and right route of drug administration.
 Explain to the patient and/or relatives the purpose of the drug.
 Document The Drug administration done.
 Check the patient for any possible adverse reaction to the drug.

42
 Name of Drug Date Administered Route and General Action Indication Client’s actual
Administration response to
medication
Ketorolac September 30, 2010 IVP anti-inflammatory, • Short-term • Pain scale of
antipyretic and management of 8/10 decreases
6:00pm 30mg analgesic effects is pain due to to 4/10 which is
the inhibition of surgical consider as
q 6 hours prostaglandin procedure done bearable pain.
synthesis by
competitive
blocking of the
enzyme
cyclooxygenase
(COX)

Nursing Responsibilities:

43
  Check the doctor’s order.
 Check the right drug, right patient, right time, right frequency and right route of drug administration.
 Explain to the patient and/or relatives the purpose of the drug.
 Document The Drug administration done.
 Check the patient for any possible adverse reaction to the drug.

Name of Drug Date Route and General Action Indication Client’s actual
Administered Administration response to
medication
Omeprazole September 30, IVP Gastric acid-pump • Perioperative • Pain due to
2010 inhibitor. client who is hypersecretion
40mg Suppresses gastric NPO of
6:00pm acid secretion by hydrochloric
q 12 hours specific inhibition acid in the
of the hydrogen- stomach is
potassium ATPase lessen.

44
 enzyme system at
the secretory
surface of the
gastric parietal
cells; blocks the
final step of acid
production.

Nursing Responsibilities:

 Check the doctor’s order.

 Check the right drug, right patient, right time, right frequency and right route of drug administration.
 Explain to the patient and/or relatives the purpose of the drug.
 Document The Drug administration done.
 Check the patient for any possible adverse reaction to the drug.

45
 Name of Drug Date Route and General Action Indication Client’s actual
Administered Administration response to
medication
Paracetamol October 1, 2010 IVP The main • For client who • Client’s
mechanism of has elevated temperature of
6:00pm 30mg action of temperature 38.5oc
paracetamol is (hyperthermia) decreases to
PRN considered to be the 37.5oc
inhibition of
cyclooxygenase
(COX)

Nursing Responsibilities:

 Check the doctor’s order.

 Check the right drug, right patient, right time, right frequency and right route of drug administration.
 Explain to the patient and/or relatives the purpose of the drug.
 Document The Drug administration done.
 Check the patient for any possible adverse reaction to the drug.

46
 2. MEDICAL MANAGEMENT

Medical Date Ordered/ Performed/ General Description Indication/s or Client’s reaction to

purpose/s treatment
Management Changed/ Discontinued

Changed: September 30, 2010 D5LR is actually 5% dextrose This solution is The patient was
at 10:28 pm. in lactated ringer's solution. It indicated for use hydrated. The fluid
Intravenous Fluid is a hypertonic solution which in adults and and electrolytes level
means it pulls fluid out of the pediatric patients of her body is
D5LRS @ cells into the intravascular as a source of maintained.
20gtts/min space (veins). electrolytes,
calories and water
47
5% Dextrose in Lactated for hydration.
Ringer's Injection provides
electrolytes and calories, and is
a source of water for
hydration. It is capable of
inducing diuresis depending on
the clinical condition of the
patient. This solution also
contains lactate which
produces a metabolic
alkalinizing effect.

48
Nursing Management

Prior

 Before starting I.V therapy, consider duration of therapy, type of infusion

condition of veins and medical condition of the patient to assist in choosing in I.V site
and type of catheter.
 Ensure that you are competent in initiating the type of I.V therapy decided on and
familiar with institutional policy and procedure before initiating therapy.
 Explain the procedure to the client and why is it necessary.

During

 Monitor the insertion site for signs of phlebitis or infiltration.

 Monitor the flow rate of the IV fluid.
 Maintain the cleanliness of the plaster.

After

 After initiation of I.V therapy, monitor the patient frequently for:

1. Signs of infiltration of sluggish flow
2. Signs of phlebitis or infection
3. Correct solution, medication, volume and rate
4. Dwell time of catheter and need to be replace
5. Condition of catheter dressing and frequency of change
6. Fluid and electrolyte balance
7. Signs of fluid overload or dehydration
8. Patient satisfaction with mode therapy

49
 Date
Ordered/Performed
Medical
Changed/discontinued Client’s reaction
Management General Description Indication/s or purpose/s
to treatment

Oxygen Oxygen may be The body is constantly taking in The patient’s

Therapy classified as an oxygen and releasing carbon oxygen need was
09-30-2010 element, a gas, and a dioxide. If this process is sustained. Airway
drug. Oxygen therapy inadequate, oxygen levels in the becomes easier.
is the administration of blood decrease and the patient Breathing pattern
oxygen at may need supplemental oxygen. becomes normal.
08-30-2010 concentrations greater
than that in room air to Oxygen therapy is a key
treat or prevent treatment in respiratory care. The
hypoxemia (not enough purpose is to increase oxygen
oxygen in the blood). saturation in tissues where the
Oxygen delivery saturation levels are too low due
systems are classified to illness or injury.
as stationary, portable,
or ambulatory. Oxygen Breathing prescribed oxygen
can be administered by increases the amount of oxygen
nasal cannula, mask, in the blood, reduces the extra
and tent. Hyperbaric work of the heart, and decreases
oxygen therapy shortness of breath. Oxygen
involves placing the therapy is frequently ordered in
patient in an airtight the home care setting, as well as
chamber with oxygen in acute (urgent) care facilities.
under pressure.

3. Surgical Management

DATE PERFORMED: September 30, 2010 – 11:45 a.m

Client’s Response to
Name of Procedure Brief Description Indication/ Purpose
Operation

50
Appendectomy Surgical removal of To remove the The patient was asleep
the Appendix inflamed appendix to after the operation.
prevent rupture - this
will eventually lead to
peritonitis.
The patient was lying
flat on bed 6 – 8 hours
after the surgery.

The patient had chills

few hours after the
operation.

The patient had fever

1 day after the
operation.

Nursing Responsibilities

Prior to the Surgery

 Check the vital signs for baseline data.

 Instruct the patient to be on nothing per Orem 8 hours prior to surgery.
 Educate the patient the patient about coughing, deep breathing exercises and turning side
– to – side after the surgery.
 Let the patient voice out what she feels to relieve anxiety.
 Listen to what the patient says.

During the surgery

 Promote sterility on the sterile field.

 Monitor the patient’s well being.
 Monitor patient’s vital signs

After the Surgery

51
 Keep the patient on NPO for 6 to 8 hours or until peristalsis occurs.
 Keep the patient lie flat on bed without pillow for 6 to 8 hours.
 Monitor for bleeding and signs of shock.
 Monitor for signs of infection.

4. DIET

52
5. ACTIVITY/EXERCISE

53
D. EVALUATION

III. CONCLUSION

The group’s grand case study is about ruptured appendicitis. It was a good learning
experience for our group to handle such case.

The client manifest hyperthermia, fatigue, impaired physical mobility, and impaired skin
integrity, the group therefore concludes that nursing intervention should be done to alleviate
predicament on the client’s health. The highlight of our principle is to provide optimum nursing
care primarily to our client and the significant others as well. The group believes that the first
thing to consider for our client’s wellness to make them feel special and be sincere in rendering
quality services.

Susceptibility of the client to acquire complication is greatly at risk. Hence, client should
be monitor carefully and medications must be maintained ideally.

IV. RECOMMENDATION

The group recommends providing wound care aseptically as frequently as possible to

prevent infection and apply cold compress to the abdomen when abdominal pain is experience.
Advice regular consultation to the physician for it can be a factor for recovery and assess the
patient’s progress. Advised the client who has to religiously take his medication prescribed to
alleviate symptoms and prevent further complications. Instruct the patient normal activities can
be resumed within a few days, but it takes four to six weeks for full recovery. Heavy lifting and
strenuous activities should be avoided during recovery. Encourage continuous range of motion
exercises. Eat healthy foods from all of the five food groups; fruits, vegetables, breads, dairy
products, meats, fishes. Eating healthy foods may help the patient feel better and have more
energy and also help recover faster from sickness. Emphasize the importance of increase dietary
intake of fiber and vitamin C. Avoid foods that can cause constipation such as apple, guava and
star apple. Encourage to increase fluid intake to maintain hydration and electrolyte balance.

54
V. REVIEW OF RELATED LITERATURE

Viral Infections Linked to Appendicitis

By Rajshri on January 19, 2010 at 6:55 PM

A new study by UT Southwestern Medical Center surgeons and physicians says that
appendicitis may also be caused by a virus and that you can actually "catch" it.

The researchers evaluated data over a 36-year period from the National Hospital Discharge
Survey and concluded in a paper appearing in the January issue of Archives of Surgery that
appendicitis may be caused by undetermined viral infection or infections, said Dr. Edward
Livingston, chief of GI/endocrine surgery at UT Southwestern and senior author of the report.

The review of hospital discharge data runs counter to traditional thought, suggesting that
appendicitis doesn't necessarily lead to a burst appendix if the organ is not removed quickly, Dr.
Livingston said.

"Just as the traditional appendix scar across the abdomen is fast becoming history, thanks to new
single-incision surgery techniques that hide a tiny scar in the bellybutton, so too may the
conventional wisdom that patients with appendicitis need to be operated on as soon as they enter
the hospital," said Dr. Livingston. "Patients still need to be seen quickly by a physician, but
emergency surgery is now in question."

Appendicitis is the most common reason for emergency general surgery, leading to some
280,000 appendectomies being performed annually.

Appendicitis was first identified in 1886. Since then, doctors

have presumed quick removal of the appendix was a necessity to avoid a subsequent bursting,
which can be an emergency. Because removing the appendix solves the problems and is
generally safe, removal became the standard medical practice in the early 20th century.

SOURCE: http://www.medindia.net/news/Viral-Infections-Linked-to-Appendicitis-63833-1.htm

55
VI. BIBLIOGRAPHY

Published Materials

Medical – Surgical Nursing: Clinical Management for Positive Outcome 8th by Joyce Black and
Jane Hokanson Hawks,

Fundamentals of Nursing Practice 7th edition by Kozier and Erbs

Health Assessment and Physical Examination 3rd edition by Estes

Medical – Surgical Nursing 8th edition by Joyce Black

2010 Lippincotts Nursing Drug Guide by Amy Karch

Prentice Hall Nursing Diagnosis Handbook by Judith M. Wilkinson and Nancy R. Ahern

Unpublished Materials

http://www.wikipedia.org/wiki/Appendicitis?wasRedirected=true

http://www.healthscout.com/ency/68/658/main.html

http://www.ufs.ph/tinig/mayjun02/05060225.html

http://www.nlm.nih.gov/medlineplus/ency/arcticle/002921.html

http://www.diagnosis.com/a/acute_appendicitis/prevalence.html

http://wiki.answers.com/Q/What_is_the_appendicitis_rate_in_the_Philippines

56
57