Case Study of Appendicitis

I. Patient Profile

Name:

Bernardo Matobato

Age:

26 years old

Gender:

male

Occupation:

construction worker

Educational Attainment:

grade 4

Civil Status:

single

Nationality:

filipino

Address:

brgy. Dapdap Alang-alang Leyte

Religion:

catholic

C/C:

abdominal pain

Date Admitted:

july 22, 2010 @ 9:00pm

Admitting Diagnosis:

ruptured appendicitis

Attending Physician:

Dr. Bañez

Source of Information:

patient and mother

Reliability:

90%

II. Present Illness:

14 hours prior to admission, the patient experienced mild pain on his right lower

quadrant abdomen while eating in the morning, followed by a severe pain. The client

tried to eliminate the pain using herbal oil but were not eradicated.

Persistence of the noticed pain, prompted his mother to bring him to EVRMC,

hence this admission.

III. Past

Health History:

The patient did not receive any vaccination as claimed by the mother, has

experienced acute respiratory infection such as cough, cold and mild fever and took

biogesic (250mg) every 4 hours for fever and some herbal plants (decoction of lagundi)

for cough relief. Pain in the right lower abdomen 1

_{felt when the client was 25 years old}

but were ignored no history of hospitalization.

IV. Family History:

The mother claimed that her mother is asthma positive, and noted hypertension

history on the paternal side.

V. Birth History:

The patient is 3

_{on eight siblings of Mr. and Mrs. Matobato. Born via normal}

vaginal delivery on their house.

VI.Psychosocial

history:

The patient sorrounding is good and there were no lakes, swamp or river nearby.

They used a deep well for drinking and taking a bath. He smokes 5 sticks of cigar. Per

day, and play basketball in freetime.

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

1. FOODS AND FLUIDS INTAKE

– Usual food taken: leafy vegetables, fish, rice, root crops – (-)food allergies – (-)food preferences

& dislikes

– Drink 4 glasses of water each day – Drink 10 glasses of

tuba occasionally 1. ELIMINATION

– Void more than 5x/day – Defecate 1x/day or sometimes 1 time every 2 days – Fun of retaining stools if at work 1. REGULATORY MECHANISM – (+) mild fever during childhood 1. HYGIENE – Take a bath 1-2x/day – Seldom use shampoo – Change cloth everyday – No allergies to soap & shampoo – Combs hair 1. EXERCISE & LOCOMOTION – Take the daily

activities as – RR = 26cpm – No accessory muscle used – No respiratory aids used – No cough and cold – BP = 110/70 mmHg – PR = 53 bpm – No presence of discoloured or swollen parts – Good capillary refill – Good skin turgor – Dry lips – With an IVF of D5LR @ 30gtts/min – No NGT – Not constipated – Presence of indwelling catheter – (-) nausea – T = 36.6 – Afebrile – (-) chills – Untidy to look at – (-)skin lesions – Hair is equally distributed – (+)Halitosis – Poor dental care – Presence of plaque – Impaired mobility due to Hematology: WBC: 18.30x10^9/L Neutrophil: .90 Lymphocyte: .10 Hematocrit: .46 URINALYSIS

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

LABORATORY RESULTS

Hematology:

Components

Normal values

Results

Interpretation

Clinical Significance

1. WBC

2. Neutrophils

3. Lymphocyte

4. Hematocrit

4.5 – 11x10

_/L

0.45 – 0.73

0.2 – 0.4

Males: 42 – 52 %

Females: 35 – 47 %

18.30 x 10

_/L

0.90

0.10

46 %

Increased

Increased

Decreased

Normal

Presence of

inflammation

Acute infection, trauma

or surgery

Aplastic anemia, SLE,

immunodeficiency

including AIDS

Balance proportion of

blood volume that is

occupied by RBC

Urinalysis:

1. Color

2. Transparency

3. Specific gravity

4. PH

5. Glucose

6. Albumin

7. WBC

8. Bacteria

9. Casts

10.Uric Acid

Pale yellow to amber

Clear to slightly hazy

1.015-1.025

4.5-8.0

Negative

Negative

Negative or rare

Negative

Occasionally hyaline

casts

1.58-4.43 mmol/24 h

Dark Yellow

Turbid

1.025

6.0

Negative

Negative

2-3/hpf

Moderate

Coarse granular: 0-1/hpf

3.13 mmol/24 h

Not normal

Not normal

Normal

Normal

Normal

Normal

Not normal

Not normal, bacteremia

Not normal

Normal

Not enough water

intake, presence of

bilirubin

Cystisis, presence of

bacteria

Properly diluted urine

Not risk for calcification,

and infection

Absence of DM

Proper filtration of

glumerolus

Cystisis, nephritis,

Urinary tract infection

Presence of renal

infection or disease

Absence of calculi

ANATOMY AND PHYSIOLOGY

Vermiform appendix

In human anatomy, the appendix (or vermiform appendix; also cecal (or caecal)

appendix; also vermix) is a blind-ended tube connected to the cecum (or caecum),

from which it develops embryologically. The cecum is a pouchlike structure of the

colon. The appendix is near the junction of the small intestine and the large intestine.

The appendix averages 10 cm in length, but can range from 2 to 20 cm. The

diameter of the appendix is usually between 7 and 8 mm. The appendix is located in

the lower right quadrant of the abdomen, or more specifically, the right iliac

fossa

the

position within the abdomen corresponds to a point on the surface known as

McBurney's

point

. While the base of the appendix is at a fairly constant location, 2 cm

below the ileocaecal

valve

, the location of the tip of the appendix can vary from being

retrocaecal to being in the pelvis to being extraperitoneal. In rare individuals with situs

inversus, the appendix may be located in the lower left side.

Maintaining gut flora: major function

Although it was long accepted that the immune tissue, called gut

associated lymphoid

tissue, surrounding the appendix and elsewhere in the gut carries out a number of

important functions

The digestive tract's immune system is often referred to as gut-associated lymphoid

tissue (GALT) and works to protect the body from invasion. GALT is an example of

mucosa-associated lymphoid tissue.

The mucosa-associated lymphoid tissue (MALT) (also called mucosa-associated

lymphatic tissue) is the diffuse system of small concentrations of lymphoid tissue found

in various sites of the body such as the gastrointestinal tract, thyroid, breast, lung,

salivary glands, eye, and skin.

FOR the PATHOPYSIOLOGY just go to this site :

Nursing Diagnosis

Scientific analysis

Objectives

Nursing Interventions

Rationale

Evaluation

Limited movement related to pain as manifested by:

Subjective:

“Anay, hinay hinay la ke ma ol-ol tak samad” as

verbalized by the patient.

Objective: Temp - 36.6 o_C PR - 53 bpm RR - 26 cpm BP - 110/70mmhg • weakness • facial grimace • guarding behavior • incision on RLQ Having an Appendectomy is a procedure that has the need to cause the tissue to be traumatized, which leads to the inflammatory process characterized by pain, redness, swelling and loss of function of some part, it is effective in the treatment of appendicitis with perforation, surgery leaves tissue

damage that causes the release of chemical

mediators, and WBC’s which causes to form exudates then this exudates causes the nerve endings to be compressed thus making pain and this pain makes a person to have limited movement.

Reference:

Medical Surgical nursing by Brunner and Suddarth 11th

edition; Vol.2 pages 1240- 1242

After 8 hours of nursing

interventions, the patient will be able to Regain / maintain mobility at the higher

possible level, Demonstrate techniques that enable resumption of activities, and Increase strength/ function of affected and

compensatory body parts.

INDEPENDENT:

1. Instruct the client to minimize activities that will put pressure on his abdomen. 2. Reposition periodically and slowly and encourage deep breathing exercises. 3. Encourage rest. 4. Move patient slowly and deliberately. 5. Administer analgesics as ordered

1. Activity that require holding the breath and bearing down can result in pain to surgical site in RLQ, bradycardia and rebound tachycardia with elevated BP. 2. Prevent / reduces

incidence of skin and respiratory complications. 3. Reduces myocardial workload / oxygen consumption, reducing risk of complication. 4. Reduces muscle tension or guarding, which may help minimize pain of movement. 5. To maintain

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

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

Nursing Diagnosis

Scientific analysis

Objectives

Nursing Interventions

Rationale

Evaluation

Impaired skin integrity related to surgical incision SUBJECTIVE:

“katapus ko la ka operahe” as verbalize by the patient OBJECTIVE:

- open wound

- visible surgical incision - post-operative patient Temp - 36.6 o_C

PR - 53 bpm RR - 26 cpm BP - 110/70mmhg

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

Medical surgical nursing by brunner and suddarth, 11th

edition volume 2 @ page: 1242

After 8 hours of nursing intervention the patient will Achieve timely wound healing and be free of infection, demonstrate how to keep wound dry and promote healing. DEPENDENT: 1) Observe wound, note characteristics of drainage. 2) Change dressing as needed using aseptic technique.

3) Encourage side lying position (on the left-side) or a semi-fowlers position. 4) Encourage guarding behavior. DEPENDENT 5) Administer antibiotics as doctor’s order 1. Post-operative hemorrhage is likely to occur during first 2 days, whereas infection may develop anytime. 2. Reduce skin irritation

and potential infection, also to prevent soaking the dressing by any discharges. 3. May decrease

pressure to operated site, thus relieving abdominal distention. 4. Promote protection to

the incision site. 5. Hasten the healing of

the wound.

After 8 hours of nursing interventions the patient’s wound appears to be dry and freed from drainage or

purulent substances therefore goal was met.

Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation Risk for infection related to

surgical incision at right lower quadrant of the body.

Objective:

incised skin @ right lower quadrant RR – 26 cpm PR – 53 bpm Temp – 36.6 o_C

Incision pain

The creation of surgical incision during appendectomy disrupts the skin integrity of the skin and its protective function. Exposure of deep body tissues to the pathogens in the environment places the patient at risk for infection of the surgical site, a potentially threatening complication. Factors related to the surgical procedure include the method of preoperative skin

preparation, surgical attire of the team, method of sterile draping, duration of surgery and length of procedure.

After 8 hours of nursing intervention, the patient will be able to Verbalize and understand the

causative/risk factor for the infection.

Demonstrate techniques in

minimizing infection. Remove all possible factors that may contribute to the infection process. Achieve timely wound healing; be free of purulent drainage or erythema.

INDEPENDENT:

1. Monitor vital signs, onset of fever with chills, and pain.

2. Practice/ instruct good hand washing and aseptic wound care. 3. Inspect incision site.

Note characteristics of drainage from wound. 4. Change wound dressing as indicated, using proper technique for changing/ disposing of contaminated materials. 5. Encourage intake of fluid and food that is rich in Vitamin C.

1. Fever and pain indicate inflammatory

responses, which contribute to infection. 2. Reduces the risk for

infection or cross contamination of bacteria.

3. Provides early detection of infection process, and presence of discharges may help to identify whether there is an infection.

4. To reduce/ correct existing risk factors. 5. Promotes healing and

prevents dehydration.

After 8 hours of nursing education and interventions, the patient was More

conscious about his

environment and the patient seems to be hesitated and confused or failed to express some of the

information imparted by the nursing students therefore: GOAL WAS PARTIALLY MET.