BATANGAS REGIONAL HOSPITAL

Appendicitis

CASE STUDY

In partial Fulfillment of the Requirements

In Nursing Care Management 102
Presented to:
Mrs. Annabelle Iturralde RN. MAN
Presented by:
BSN III - 5 Group C
Edmalyn Gozar
 I. Introduction

Acute appendicitis is the inflammation of the appendix

often cause by obstruction to its narrow opening, fallowed by
swelling and bacterial infection. Acute appendicitis can lead to
rupture of the organ, formation of an abscess or peritonitis.
Symptoms include abdominal pain (usually in RL abdomen)
nausea, vomiting and fever. Early surgical removal of the
appendix is essential; any abscess requires drainage of pus and
delayed removal.
Appendicitis is the most common abdominal emergency
found in children and young adults. One person in 15 develops
appendicitis in his or her lifetime. The incidence is highest
among males aged 10 to 14. And among females aged 15 to
19. More males than females develop appendicitis between
puberty and aged 25. It is rare in infants and children under the
the aged of two. In the United States, appendicitis occur in
four out of 1000 children. It occurs in 5 to 6% of its
population.
I chose this case because I want to understand and
have more information about appendicitis. I am very much
curious on how an acute appendicitis developed and what
are the signs and symptoms accompanied it.
 II. Objectives
General Objectives
At the end of the study I will be able to acquire knowledge,
skills and attitude regarding my patient’s case.

Specific Objectives
My specific objectives are to:
-Give an overview about the disease appendicitis.
-Know the personal data of the client
-Perform the Physical Assessment
-Familiarize with different laboratory test and its significance
to the disease
-Analyze the system that is being affected of this disorder
-Know the factors that lead to appendicitis
-Apply interventions that may help client’s condition
-Know the drugs that the client is taking
-Know the improvement of clients’ condition
 III. Patient’s Profile

Name: Mrs. X
Age: 39years old
Sex: Female
Birthday: September 13,1969
Civil Status: Female
Address: Quilo, Ibaan Batangas
Nationality: Filipino
Religion: Iglesia ni Cristo
Date of Admission: Dec. 9,2008
Physician’s Name: Dr. Reyes
Chief Complaint: Two days prior to admission the client
experienced RLQ pain,vomiting fever and loss of appetite
Admitting Diagnosis: Acute Appendicitis
Final Diagnosis: Periappendecial abscess
 IV. Clinical Appraisal

On December 9, 2008, Mrs. X, a 39 years old was

admitted in Batangas Regional Hospital due to Acute
Appendicitis.

A. Past Health History

According to Mrs. X, she completed her childhood
immunization. She has no allergies to drugs, foods
animals or any insects bites. Mrs. X didn’t experience
any accident or injury. According to her husband, she
had history of Pulmonary Tuberculosis treated for six
months. Mrs. X experienced common illnesses like
fever, cough and cold. She used over the counter drugs
like Paracetamol for fever, Solmux for cough and
neosep for cold.
B. Family History
Mrs. X has 9 siblings and twin sister. She was blessed
with 5 children which are all boys. According to her she and
her relatives has low blood pressure. Her family has no
history of diabetes, hypertension, heart diseases and asthma.

C. Personal History
Mrs. X was not choosy in her meal, she eat fish, meat
specially vegetables and fruits because it is available in the
farm. Mrs. X daily activities was cleaning the house, washing
clothes and manage their small sari-sari store. She had
enough sleep and resting hours.

D. Social History
Mrs. X and her family is living in a rural area. She finish
elementary and her husband finished high school. Mrs. X is
responsible in managing the house and their small
sari-sari store, while Mr. X her husband is a farmer. Mrs. X
has a belief not to take a bath during her menstrual period.
According to her, before she was admitted to the hospital she
has a menstruation for 5 days and she didn’t take a bath for
the said days. There is a health center available in their
community. She consulted first to their health center before
her husband decided to brought her to BRH.

E. Psychological History
According to Mrs. X, Her major stressor s their financial
status. It was very difficult for her to budget their monthly
income to support all their needs. To cope with this problem
she keeps on praying and asking God for more blessings and
assistance.
F. History of Present Illness
Mrs. X brought to Batangas Regional Hospital last
December 9, 2008 because of experiencing abdominal pain,
fever, vomiting and loss of appetite for 2 days. She was
diagnosed of having acute appendicitis and scheduled for
emergency appendectomy.
 V. Physical Assessment

Done: December 9, 2008; 7:35pm

General Appearance Status

Mrs. X is a newly admitted client. She is on supine
position showing anxiety, body weakness, and pain felt
on the RLQ of her abdomen.

Vital Signs:
Temperature: 38.1°C
Pulse Rate: 72 Beats per minute
Respiratory Rate: 26 Breaths per minute
Blood Pressure: 100/60 mmHg
Body Parts Method Findings Analysis
Skin >Inspection >Varies from >Normal
light to deep
brown
>Good skin >Normal
turgor
>Not tender
 Palpation >Normal

>Short and
Hair  Inspection black with >Normal
normal
distribution
Body Parts Method Findings Analysis
Scalp >Inspection >Absence of >Normal
seborrhea

>No abrasion >Normal

Head >Inspection >rounded, >Normal

smooth skull
contour

>Absence of
>Palpation masses or >Normal
nodules
Body Parts Method Findings Analysis
Face >Inspection >facial features >Normal
& facial
movements are
symmetrical

>no
enlargement of
Neck >Inspection & lymph nodes >Normal
Palpation
>no
enlargement of
thyroid gland
Thyroid Gland >Inspection & >Normal
Palpation
Body Parts Methods Findings Analysis
Eyes
>Eyebrow >Inspection >symmetrically >Normal
aligned
>hair evenly >Normal
distributed

>normal
>Eyelashes >Inspection >Normal
distribution

>Conjunctiva >Inspection >Normal

>Pink palpebral
conjunctiva

>Auricles are
Ears >Inspection firm & not tender >Normal
Body Parts Methods Findings Analysis
>symmetrically >Normal
aligned
>no discharges >Normal
>color of the >Normal
auricle is the
same as the face

>no discharges
Nose >Inspection >Normal
>symmetrically
aligned
>color is the >Normal
same as the rest >Normal
of the face
>not tender
>Palpation >Normal
Body Parts Method Findings Analysis
Sinuses >Palpation >Frontal & >Normal
maxillary
sinuses are not
tender

Mouth
>uniform pink
>Lips >Inspection color, smooth >Normal
texture

>Tongue >Inspection >moves freely & >Normal

at the midline
>at the midline
>Uvula >Inspection >Normal
Body Parts Method Findings Analysis
Chest and >Inspection and >Equal chest >Normal
Lungs Auscultation expansion
>Quiet, rhythmic >Normal
& effortless
respiration
>Tachypnic 26
bpm >May be normal
response to fever
>Auscultation and anxiety
>65 beats per
Heart >Normal
minute
>Normal
>no murmur
Body parts Method Findings Analysis
Abdomen >Inspection >Uniform color >Normal
>Auscultation >audible bowel >Normal
sound, absence
of arterial bruit

>Tympanic >Normal
>Percussion
sound heard

>Flat and not >Normal

>Palpation tender
>Tenderness on
RLQ noted >Abnormal. Due
to inflammation
of the appendix.
Body Parts Method Findings Analysis
Upper extremities
>Hands
>Inspection >Presence of IV >Abnormal. Fluids
fluid are regulated to
prevent
>Pulse >Palpation
>distal pulses are dehydration and to
provide access for
palpable
>Nails >Inspection administration of
medication.
>Normal
Lower extremities >Abnormal. Due to
>Inspection & >Pink in color poor hygiene.
Palpation >Long dirty nails > Normal

>No edema
Summary of Physical Assessment

She is a newly admitted client. Physical Assessment was

done by inspection, palpation, percussion and
auscultation. This will serve as a baseline guide for her
progress.
As I assessed her general appearance I noticed her
weak appearance, feeling anxious and pain felt on her
abdomen.
Her temperature was above normal due to the
inflammation of the appendix. Her respiratory rate was
increase it was a normal response to fever and anxiety.
Upon inspecting I noticed her dirty long nails which
indicates poor hygiene. She was tachypniec, it was a
normal response to fever and anxiety.
 Upon palpation tenderness on the RLQ was noted. It
was abnormal because it indicates inflammation of the
appendix. Upon inspecting her hand I noticed that there is a
presence of IV fluid on her right hand. It is abnormal
because IV fluid are regulated to prevent dehydration and
provide access for administration of medication.
 Laboratory and Diagnostic Test
Urinalysis Done: Dec. 9, 2008

Color: dark yellow

Sugar: negative Albumin: Plus 2 (++)
Pus Cells: 4-6/hpf Reaction: 6– acidic
RBC: too numerous to count
Sp. Gravity: 1.015
character: slightly turbid
Blood Chemistry Done: Dec. 9, 2008

Description Ref. Value Result Analysis

Erythroctes M:4.6-6.28x10/L 2.24 decrease. It indicates anemia
F:4.2-5.4 or dietary deficiency
Hgb M:140-180g/dl 127.2 normal
F:120-140
Hct M:0.40-0.54 0.377 normal
F:0.38-0.47
Leukocyte 4.5-11x10/L 26.00 increase. It indicates
infection or inflammation
Neutrophils 45-65% 0.869 increase. It indicates
inflammation.
Eosinophils 1-3% 0.012 decrease. It indicates
increase adrenosteroid
production.
Basophils 0-1% 0.007 decrease in acute phase of
infection.
Lymphocytes 25-40% .052 decrease. Indicate leukemia
Monocyte 3-7% .060 decrease may be due to drug
therapy
Thrombocyte 150-400x10/L 348 normal
MCH 27-31 pg 29.99 normal
MCV 80-96 f1 88.80 normal
MCHC .32-.36 .34 normal
RDW 11.5-14.5 10% normal

Dec. 10, 2008

Sodium 135-148mmol/L 140.3 normal
Potassium 3.5-5.5mmol/L 2.96 decrease. It indicates
hypokalemia.
Dec. 12, 2008
Sodium 135-148mmol/L 150.2 increase. It
indicates hypernatremia.
Potassium 3.5-5.5mmol/L 4.28 normal
Summary of Diagnostic and Laboratory Result

As the laboratory result has been released it shows

some abnormalities in the blood. The erythrocyte is
decreased which indicates anemia and dietary deficiency.
The patients hematocrit and hemoglobin are normal. The
leukocytes is elevated because it fight infection and defend
the body by the process called phagocytosis. The
neutrophils which is the most numerous and important type
of leukocytes in the body's reaction to inflammation such
as appendicitis was elevated. Decrease circulating
eosinophil is usually cause by increase adrenal steroid
production that accompanies most conditions of bodily
stress and is associated with Acute bacterial infection with
a marked shift to the left. Basophils is decrease in acute
phase of infection and may indicate hyperthyroidism.
Lymphocyte is decrease which indicate leukemia.
The other blood component are normal. The dark yellow
urine may indicate bilirubin in the urine. Slight turbid may
indicate UTI. The Potassium was decrease which indicate
electrolyte imbalance such as hypokalemia. The sodium was
increase which indicate hypernatremia.
VII. Anatomy and Physiology
 The appendix (or vermiform appendix; also cecal
(or caecal) appendix; also vermix) is a blind ended tube
connected to the cecum (or caecum), from which it develops
embryologicallly. The cecum is a pouch-like structure of the
colon. The appendix is near the junction of the small intestine
and the large intestine.The term "vermiform" comes from
Latin and means "worm-like in appearance".

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 longest appendix ever removed
measured 26 cm in Zagreb, Croatia. The appendix is located
in the lower right 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. While the base of the appendix is at a
fairly constant location, 2 cm below the ileocaecal valve,
the location of the tip of the appendix can vary from being
retrocaecal (74%) to being in the pelvis to being extra
peritoneal. In rare individuals with situs inversus, the
appendix may be located in the lower left side.
 VIII. Pathophysiology
Non Modifiable Factor Modifiable
ACUTE APPENDICITIS

Age Gender Diet

Obstruction of the lumen

Obstruction of the outflow of the secretion

Increase mucosal secretions Increase intraluminal pressure

Distention of the appendix Abdominal pain

Tenderness on RLQ
Inflammation of the appendix Fever, vomiting
Loss of appetite
Localized Peritonitis

Periappendiceal Abscess
Summary of Pathophysiology
Appendicitis is the most common cause emergency,
abdominal surgery. It develops when the lumen of the
appendix becomes obstructed, usually by fecalith, foreign
body or tumors. The obstructed lumen does not allow
drainage of the appendix and the mucosal secretions
continues, intraluminal pressure increases. The resultant
increase pressure decreases mucosal blood flow and the
appendix becomes hypoxic. The obstructed appendix
become distended because of continued secretion of mucus
by the lining cell. Typically acute appendicitis progresses
from obstruction of the lumen and distention of the appendix
to spread
Of the inflammation beyond the appendix. The inflammatory
process increases intraluminal pressure, initiating a
progressively severe generalized or upper abdominal pain
which within a few hours becomes localized in the RLQ of
the abdomen. The pain is usually accompanied by a low
grade fever, nausea and often vomiting. Local tenderness is
noted when pressure is applied and loss of appetite is
common.
Initially there is a localized peritonitis confined to the
area of the appendix. If unrecognized and untreated, this
may lead to rupture and abscess.
 IX. Nursing Care Process

Assessment Nursing Diagnosis

S> ”Parang nahihiwa ang tyan Acute pain related to surgical
ko ” incision.

O>facial grimace connotes

pain.
>weak appearance
>pain scale 6/10
>provokes pain when moving
>dull pain
>RLQ of the abdomen
>intermittent
 Scientific Explanation Planning
Usually a recent onset associates a After 2 hours of nursing
specific injury, acute pain indicates that intervention the client level
cause pain may heal spontaneously or of pain from 6/10 will be
may require treatment. The system
involved in the perception of pain is minimized into tolerable
referred to as nociceptal system. The level.
sensitivity of this system component can
be affected by several factors and may
differ among individuals. A stimulus may
result on pain at one time but not in
another. Pain receptors are free nerve
endings in the skin that respond only to
intense potentially damaging stimuli. A
number of algogenic substances that affect
the sensitivity of nociceptors are released
into the extra cellular tissue as a result of
tissue damage. (Medical Surgical Nursing
Smeltzer et. al pp. 264)
 Nursing Interventions Rationale
> V/s taken and recorded. > To establish baseline data.
(NANDA, Doenges et. Al)

> Noted location of surgical >This can influence the amount

procedure.
>Used pain rating scale for
aged/cognition. (6/10)
of postoperative pain
experienced. (NANDA Doenges et. Al)
>It assist the patients perception
of pain.
(NANDA Doenges et al)

> Pain is subjective and cannot

>Accepted client description be felt by others. ( NANDA Doenges
et al)
of pain. (dull)
 Nursing Interventions Rationale
Provided comfort measures
>Promotes relaxation and may
such as therapeutic touch enhance patients coping abilities
and repositioning. by refocusing attention. ( NCP 6’th
edition Doenges et al)
Administered pain
>Reduce metabolic rate and
medication as ordered.
intestinal irritation from circulating/
Kotorolac local toxins, which aids in pain
Tromethamine 30 mg IV q8. relief and promotes healing.
Adminisred IV fluid as (NANDA Doenges et al)
ordered.
>Maintain Hydration and provides
access for administration of
medications. (Delmar's Critical Care NCP
Sheree Comer)
 Nursing Interventions Rationale
> placed the patient in high >This position reduces the
fowler position. tension on the incision and
abdominal organs helping to
reduce pain. (Medical Surgical
Nursing Smeltzer et al)
 Evaluation
The clients level of pain was minimized as
evidence by pain scale of 4/10.
 Assessment Nursing Diagnosis
S> “Kinakabahan ako dahil Anxiety related to
operasyon ko na mamaya.” preoperative procedure.

O>voice quivering
>anxious
>restless
>poor eye contact
>increase respiration
 Scientific Explanation Planning

Vague uneasy feeling of After an hour of nursing

discomfort or dried intervention the clients anxiety
accompanied by an will be lessened in a tolerable
autonomic response (the level.
source often non specific or
unknown to the individual); a
feeling of apprehension
caused by anticipation of
danger. It is an altering signal
that warns of impending
danger and enables the
individual to take measures to
deal with treat. (NANDA
Doenges et al)
 Nursing Interventions Rationale
V/s taken and recorded. To identify physical

responses associated with

both physical and emotional
conditions. (NANDA Doenges et al)

Helps client to identify what is

Provided accurate reality based. (NANDA Doenges et
information about the situation. al)
Can point the client level of
 Observed behaviors. consciousness. (NANDA Doenges
et al)
 Nursing Interventions Rationale
>Stayed with client, > To decrease anxiety and
maintaining a calm, confident provide comfort. (NANDA Doenges et
manner. al)

> Provided preoperative >Can provide reassurance and

education. Discuss routine alleviate patients anxiety as well
procedures that frightened as provide information for
the patient. formulating intraoperative care.
(NANDA Doenges et al)
 Evaluation
The clients anxiety was lessened as
evidenced by being able to communicate her
feeling to her significant others.
 Assessment Nursing Diagnosis
O>T: 38.1 C Elevated body temperature
>warm to touch related to inflammation of the
appendix.
>weak
>teary eyed
 Scientific Explanation Planning
Inflammation is a local and After 2 hour of nursing
non specific defensive intervention the clients body
response of the tissues to an temperature will decrease to
injurious or an infectious normal range.
agent. It is an adaptive
mechanisms that destroys or
dilutes a injurious agent,
prevents further spread of the
injury, and promotes the repair
of damage tissue. The
inflammatory process causes
elevation of the body
temperature to fight infection.
(Fundamentals of Nursing,
Kozier et al page 634)
.
 Nursing Interventions Rationale
>Monitored the client >provide information about the
temperature. effectiveness of care. (NANDA
Doenges et al)

>Provided tepid sponge bath. >To increase heat loss through

conduction. (Fundamentals of
Nursing 8’th edition Kozier et al)

>To minimize shivering. (NANDA

> Monitored use of Hypothermia Doenges et al)
blanket and wrap extremities
with bath towels.
 Nursing Interventions
>Reduced physical activity.
>Maintained and regulated IV
fluid as ordered.
D5 LR 1L@30 gtts/min
>Administered antipyretic
medicine as ordered.
Paracetamol 300 mg IV q6.
Rationale
>To limit heat production.
(Fundamentals of nursing 8th edition
Kozier et al)
>To met the increase
metabolic demand and prevent
dehydration. (Fundamentals of
nursing 8th edition Kozier et al)
> May relieve fever through
central action to the
hypothalamic regulating
center. (Nursing 2008 Drug Handbook
Williams and Wilkins)
 Evaluation
The clients body temperature back to
normal range.
 X. Drug Study
Drug Name Classification and Mechanism
of Action
Generic Name: Anti-infective Drugs
Cefoxitine Sodium
Second generation
Dose: cephalosporins that inhibits
cell wall synthesis, promoting
1g
osmotic instability: usually
bactericidal.
Route:
Through IV

Frequency:
q8
 Indication Adverse Reaction
>Perioperative prevention. CNS: fever
CV: hypotention
GI: nausea and vomoting
Hematologic:
Thrombocytopenia, transient
neutropenia, eosinophilia,
hymolitic anemia, anemia
Respiratory: Dyspnea
 Contraindication
>Contraindicated in
patients hypersensitive to
drugs and other
cephalosporin's.
>Use cautiously in patients
hypersensitive to penicillin
because of possibility od
cross sensitivity to with
other beta lactam
antibiotics.
Nursing Responsibilities
>Tell the patient to report
adverse reactions and s/s of
super infection.
>Instructed the patient to
report discomfort at IV site.
>Advise patient to notify
prescriber about loose stools
or diarrhea.
 Monitoring Parameters
>May increase alkaline phosphate, ALT,
AST,bilirubin and LDH levels. May decrease
hemoglobin level.
> May increase eosiniphil count. May decrease
neutrophil and platelet count.
 Drug Name Classification & Mechanism of action

Generic Name: Nonophioid Analgesics

Acetaminophen (APAP and antipyretics
Paracetamol) Thought to produce
analgesia by blocking pain
Dose: impulses by inhibiting synthesis
of prostaglandin in the CNS or
300mg of other substances that
synthesize pain receptors to
Route: stimulation. The drug may
IV relieve fever through central
action in the hypothalamic
regulatory center.
Frequency:
q6
 Indication Adverse Reaction
>Mild pain or fever Hematologic: hymolitic anemia,
leukopenia, pancytophenia.
Hepatic: jaundice
Metabolic: hypoglycemia
 Contraindication
>Contraindicated to patients hypersensitive to drugs.
>Use cautiously in patient with long term alcohol use
because therapeutic dose can cause hepatotoxicity in
these patients.
 Nursing Responsibilities Monitoring Parameters
> Advice patient and >May decrease glucose and
caregiver that many OTC hgb levels and hct.
products contain >May decrease nuetrophils,
acetaminophen and should WBC, RBC, and platelet count.
be counted when calculating
total daily dose.
> Tell patient not to used for
marked fever (temperature
higher than 103 F.
>Warn patient that high
doses or unsupervised long
term used can cause liver
damage. Excessive alcohol
used may increase the risk of
liver damage.
 Drug Name Classification & Mechanism of
action
Generic Name: Nonsteroidal Inflammatory
Ketorolac Drugs (NSAIDs)
May inhibit prostaglandin
Dose: synthesis, to produce anti-
inflammatory, analgesics and
30mg anti pyretic effects.

Route:
Through IV

Frequency:
q8
 Indication Side Effects
Short term management of CNS: headache, dizziness,
moderately severe, acute drowsiness, sedation
pain for single dose treatment CV: arrythmias, edema,
hypertension, palpitations
GI: dyspepsia, GI pain, nausea,
constipation, diarrhea,
flatulence, peptic ulceration,
vomiting, stomatitis
Skin: rash, pruritis, diaphoresis
Hematologic: decreased
platelet adhesion, prolonged
bleeding time, purpura
Other: pain in the injection site
 Contraindication Nursing Responsibilities
Contraindicated in patients Correct hypovolemia
hypersensitive to drugs and before giving
in those with active peptic Don’t give epidurally
ulcer disease and recent GI because of alcohol content
bleeding NSAIDs may mask sign
Contraindicated as and symptoms of infection
prophylactic analgesic before because of their antipyretic
major surgery of and anti inflammatory
intraoperatively when actions
hemostasis is critical Serious GI toxicity
Use cautiously in patients including bleeding and peptic
who are elderly or have ulcers, can occur in patients
hepatic or renal impairment taking NSAIDs, despite lack
of symptoms
 Contraindication Nursing Responsibilities
Contraindicated to children Carefully observe patients
younger than age of two and with coagulopathies and those
in patients with history of taking anticoagulants
peptic ulcer disease, past
allergic reactions to aspirin
and during labor and delivery
or breastfeeding
 Monitoring Parameters

May increase ALT and AST level

May increase bleeding time
 XI. Prognosis

After four days of confinement at Batangas Regional

Hospital the client prognosis is good because the patient
was recovering well after the surgery. According to the
doctor the patient will be discharge after three more
days.
 XII. Discharge Planning

M- Instructed the significant others to continue giving the

patients medications as ordered.
1. Paracetamol 30 mg as necessary for fever.
2. Ketorolac 30 mg three times a day
3. Metronidazole 500 mg three times a day

E- Advised the client to exercise in moderation with a

gradual build up in intensity. Explained to the client that her
normal activity can be resumed after 2 to 4 weeks.

T-Instructed the significant others to cleanse and change the

dressing of the client wound regularly.

H-Instructed the significant others to always bath the patient

but avoid soaking the wound in the water.
Advised the patient to always cut the nails. Instructed
the significant others to provide clean and safe
environment for the clients early recovery.

O- Instructed the patient to have a follow up check up to

Dr. Reyes after one week for the removal of the sutures.

D- Instructed to eat foods rich in protein and Vit. C.

S- Advised the client to strengthen her faith in GOD.

Because Jesus is the only source of healing.

S- Provided health teaching of sexual responsibility.

Acknowledgement
I would like to extend my deepest and
heartfelt gratitude to all those people who helped
and supported me while I’m doing this study.
First of all to our Almighty God for the
strength ,knowledge and wisdom He gave me while
I’ doing this study.
To my parents who always there for me and
supported me emotionally and financially.
To my dear clinical instructor, Mrs. Annabelle
Iturralde for sharing us her knowledge and guiding
us in the clinical area.
To the staff of the IMC, for allowing me to
borrow books and use their internet.
 To all my friends, classmates, and group mates for all
the ideas and advices you shared to me.
To all of you THANK YOU SO MUCH AND
GODBLESS.
Bibliography
Delmar's Critical Care NCP Sheree Comer
Essentials Anatomy and Physiology by Seeley, Tate & Stephens
Fundamentals of Nursing, Kozier et al
Laboratory and Diagnostic Test with Nursing Implication;
7th edition by Joyce Lefever Lee
Medical Surgical Nursing 7th edition by Joyce Black & Jane Hokanson
Medical Surgical Nursing 8th edition by Brunner & Suddarths
Medical Surgical Nursing Smeltzer et. al
NCP 6’th edition Doenges et al
MIMS17th edition2005
NANDA Doenges et al
Nursing Care Plan 7th edition by Marilynn Doenges et.al
Nursing Drug Handbook 28th edition
Nursing 2008 Drug Handbook Williams and Wilkins

Electronic References
www.yahoo.com
 Nurse Patient Interaction
Therapeutic Communication
>it promotes understanding and helped establish a
constructive relationship between the nurse and the
client.
>Unlike the social relationship, where there may not
be a specific purpose or direction, the therapeutic
helping relationship is client and goal oriented.
Therapeutic communications technique
1.Using silence – Accepting pauses or silences that may extend for several
seconds or minutes without interjecting any verbal response.
Ex. Sitting quietly and waiting attentively until the client is able to
put thoughts and feelings into words.

2.Providing general leads – Using statements or questions that encourage

the person to verbalize , choose a topic of conversation and facilitate
continued verbalization.
Ex. “Can you tell me how it is for you?”
“Perhaps you would like to talk about…”
“And then what….”

3.Being specific and tentative – Making statements that are specific rather
than general and tentative rather than absolute.
Ex. Rate your pain on a scale of 0-10. (specific statements)
Are you in pain? (general statements)
4.Using open ended question – asking broad questions that lead or invite
the client to explore thoughts and feelings.
Ex. “I’d like to hear more about that.”
“Tell me about…”
“How have you been feeling lately?”

5.Using touch – providing appropriate form of touch to reinforce caring

feelings.
Ex. “Putting an arm over the clients shoulder. Putting your hand
over the clients hand.”

6.Restating or paraphrasing – Actively listening to the client’s basic

message and then repeating those thoughts or feeling in similar words.
Ex. “Client: I couldn't manage to eat any dinner last night – not
even the dessert.
“Nurse: You had difficulty eating yesterday.

7. Seeking clarification – A method of making a clients broad overall

meaning of the message more understandable.
Ex. “I’m puzzled”.
“I’m not sure I understand that.”
8.Perception checking or seeking conceptual validation – A method similar
to clarifying that verifies the meaning of specific words rather than the
overall meaning of the message.
Ex. Client: “My husband never gives me any present”
Nurse: “You mean he has never given you a present for your
birthday or Christmas?”

9.Offering Self – Suggesting ones presence, interest or wish to understand

the client without making any demands or attaching conditions that the
client must comply with to receive the nurses attention.
Ex. “I’ll stay with you until your daughters arrives.”
“I’ll helped you to dress to go home if you like.”

10.Giving Information – Providing in a simple and direct manner , specific

factual information the client may or may not request.
Ex. “Your surgery is scheduled for 11 am tomorrow.”

11.Acknowledging –Giving recognition , in a non judgmental way, of a

change of behavior, an effort the client has made, or a contribution to a
communication.
Ex. “You trimmed your beard and mustache and washed your hair.”
12. Clarifying time or sequence – Helping the client clarify an event,
situation or happening in relationship to time.
Ex. Client: “I vomited this morning.”
Nurse: ”Was that after breakfast?”
13. Presenting Reality – Helping the client to differentiate the real from the
unreal.
Ex. ”The telephone ring came from the television.”
14Focusing – Helping the client expand on and develop a topic of
importance.
Ex. Client: “My wife says she will look after me, but I don’t think she
can, what with the children to take care of, and they’re
always after her about something- clothes, homework,
what’s for dinner that night.
Nurse: “Sounds like you are worried how she can manage.”
15. Reflecting – Directing ideas, feelings, questions, or content back to
clients to enable them to explore their own ideas and feelings about the
situation.
EX. Client: “What can I do?”
Nurse: “What do you think would be helpful?”

16. Summarizing and planning – Stating the main points of a discussion to

clarify the relevant points discussed.
EX. “During the past half hour we have talk about……”
“Tomorrow afternoon we will explore this further.”
Attentive listening
It is listening actively using all the senses, as
opposed to listening passively with just the ear. It is
probably the most important technique in nursing and is
basic to all other techniques. Attentive listening is an
active process that requires energy and concentration. It
involves paying attention to the total message, both verbal
and nonverbal, and noting whether this communication is
congruent . Attentive listening means absorbing both the
content and the feeling the person is conveying, without
selectivity.

The Helping Relationship

Nurse-client relationship are referred to by some as
interpersonal relationships, by others as therapeutic
relationships,
The Helping Relationship
Nurse-client relationship are referred to by some as
interpersonal relationships, by others as therapeutic
relationships, and by still others as Helping relationships.
Helping is a growth facilitating process that strive to achieve
to basic goals.
1.Helps client manage their problems in living more
effectively and develop unused or underused opportunities
more fully.
2.Helps client become better at helping themselves in
their everyday lives.

The key to the helping relationship are:

a. the development of trust and acceptance between
the nurse and the client.
b. an underlying belief that the nurse caresabout and
wants to help the client.
Phases of helping relationship

1. Preinteraction phase
>it is similar to the planning stage before the interview.
>the nurse has information about the client before the
first face to face meeting. Such information may
include, the clients name, address, age, medical
history and social history.
2.Inroductory Phase
>also referred to as the orientation phase or the
prehelping phase.
>it is important because it sets tone to the relationship.
>the client and the nurse closely observed each other
and form judgments about the others behavior.
>getting to know each other and developing a degree
of trust.
3. Working Phase
>the nurse and the client begin to view each other as
unique individuals, they begin to appreciate this uniqueness
and care about each other . Caring is sharing deep and
genuine concern about the welfare of another person.

4. Termination Phase
>often expected to be difficult and filled with
ambivalence.
>the client generally has a positive outlook and feels
able to handle problems independently.
>it is natural to expect some feeling of loss, and each
person needs to developed a way of saying goodbye.
Developing a Helping Relationship

1.Listen actively.
2.Help to identify what the person is feeling.
3.Put yourself in the other persons shoes.
4.Be honest.
5.Be genuine and credible.
6.Use your ingenuity.
7.Be aware of cultural differences that may affect meaning and
understanding.
8.Maintain client confidentiality.
9.Know your roles and your limitations.