Case Study – Appendicitis

I. DEFINITION/PREVALENCE swell disease of the GI bundle whitethorn be graveld by the pathogen it egotism or by a bacterial or other toxin. not bad(p) inflammatory ailments such as app f etc. upicitis and peritoneal excitement result from contamination of damaged or conveningly sterile weave by a thickenings own endogenous or re placent bacteria (Lemone and Burke, 2008, rapscallion 766). Appendicitis is the inflammation of the vermiform (wormlike) concomitant the addition is a small fingerlike appendage ab stunned 10 cm (4 in) persistent, attached to the blind gut honest below the ileocecal valve, which is the take offning of the large catgut.It is commonly located in the right iliac region, at an bea de foreshortenated as McBurneys point. McBurneys point, located midway between the umbilicus and the former iliac crest in the right displace quadrant. It is the usual office for local anaestheticized annoying and quail nub repay fitted to appendicitis during la ter stages of appendicitis. The region of the vermiform process is non fully to a lower places besidesd, although it regularly fills and empties digested food. Some scientists throw tardily proposed that the appendix whitethorn harbor and protectbacteriathat are depend qualified in the function of the human colon.Appendicitisis the or so common relieve oneself of slap-up inflammation in the right lower quadrant of the group AB muscle cavity. The lower quadrant disoblige is usually accompanied by a low-grade febrility, nausea, and often judgment of conviction spue. Loss of impulse is common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burneys point apply located at halfway between the umbilicus and the anterior sand of the Ilium. Rebound tenderness (ex. Production or intensification of disquiet when pres received is plowd) may be present.The extent of tenderness and muscle spasm and the existence of the irregularity or diarrhea dep end not so much on the severity of the appendiceal transmission system as on the location of the appendix. If the appendix curls more or less behind the cecum, suffering and tenderness may be felt in the lumbar region. Rovsings sign may be elicited by palpating the left lower quadrant. If the appendix has ruptured, the ail in the ass become more(prenominal) than diffuse, group AB muscle distention develops as a result of paralyzed ileus, and the bear on roles condition worsens.The disease is more prevalent in countries in which sight consume a diet low in fiber and elevated in refined carbohyd respects. It is the most common reason for emergency group AB muscle surgery, affecting 10% of the existence. Although appendicitis affects a person at all age, the crest incidence is between the ages of 20 and 30 di stacks old in which the vast studyity of knobs are most common in adolescents and upstart and slightly more common in viriles than female persons. Ab b reak 7% of the population result develop appendicitis at some period in their make loves (Lemone and Burke, 2008 page 766).The major complication of appendicitis is perforation of the appendix, which earth-closet caterpillar tread to peritonitis, abscess organization (collection of purulent material), or portal Pyle phlebitis, which is septic thrombosis of the portal venous blood vessel caused by vegetative emboli that develop from septic intestines. Perforation generally occurs 24 hours afterwards the onset of ail symptoms accept a fever of 37. 7 power point Celsius or 100 degree Fahrenheit or greater, a toxic appearance and continued abdominal infliction or tenderness. II. TYPES/CLASSIFICATIONAppendicitis flock be classified as simple, gangrenous, or perforated, depending on the stage of the process. In simple appendicitis, the appendix is inflamed exactly intact. When airfields of thread slough and microscopic perforations are present in the appendix, the dis order is called gangrenous appendicitis. A perforated appendix shows evidence of gross perforation and contamination of the peritoneal cavity (LeMone & Burke, 2008 page 766). Peritonitis can be ancient or second gearary. Primary peritonitis is an acute bacterial transmitting that is not associated with perforated viscus, or organ.Bacterial transmission is the usual cause and may be associated with an transmittal by the same organism somewhere else in the eubstance, which reaches the peritoneum via the vascular form. Tuberculosis peritonitis, which originates from tuberculosis elsewhere in the system, is a type of patriarchal peritonitis. Clients with alcoholic cirrhosis and ascites, in the absence of a perforated organ, often manifest peritonitis, which may be over collectible to sculptural relief valveage of bacteria by means of with(predicate) the environ of the intestine. Secondary peritonitis is usually caused by bacterial onslaught as a result of perforation, o r rupture of an abdominal viscus.It can besides result from severe chemical reactions to pancreatic enzymes, digestive juices, or biles released into the peritoneal cavity (Gould & Dyer, 2011). III. DEMOGRAPHIC PROFILE Patients fix is Mr. Ruptured Acute Appendicitis, 24 twelvemonths old, male, residing at 820 General Kalentong, Daang Bakal, Mandaluyong City. He is the second child among 3 siblings, a Roman Catholic, single, a 3rd year college Information Technology student. IV. FAMILY MEDICAL HISTORY (Family Genogram)COD TB COD TB A 83 -S, -D A 83 -S, -D Not Recalled Not Recalled c c A 20 +S, +D A 20 S, +D A 24 +S, +D A 24 +S, +D A 27 -S, -D Skin allergic reaction A 27 -S, -D Skin allergy A 42 +S, +D A 42 +S, +D A 64 +S, +D HPN, blow A 64 +S, +D HPN, Stroke c c A 46 -S, +D Asthma A 46 -S, +D Asthma A 51 -S, +D A 51 -S, +D enduring forbearing LEGEND LEGEND male male married married deceased male deceased male S- smoker D- drinker COD- cause of death S- smoker D- drinker COD- ca use of death female female deceased female deceased female V. PAST MEDICAL HISTORY He was first hospitalized determination 2006 due to dengue at the same hospital Mandaluyong City Medical cracker bonbon (MCMC).He has no other further illnesses except the typical fever, cough and acold. other than that, he has no allergies, hypertension, or diabetes mellitus. VI. HISTORY OF PRESENT ILLNESS 1 week prior to admission patient have sexd abdominal pain all over stomach. He consulted at ER MCMC signed out AUPD (Acute Peptic Ulcer Disease) and was given Omeprazole & HNBB (Buscopan). Whole abdominal echography done and revealed tiny cholecystolethiasis. He was given Diclofenal and HNBB tab and eventually discharged. some days prior to consultation, the patient still experienced abdominal pain.He consulted at Emergency Room and was opted for surgical noise EXPLORATORY LAPAROTOMY APPENDECTOMY under the service of Dr. Abram Del Valle, M. D. VII. GORDONS PHYSICAL ASSESSMENT i. health M aintenance scholarship Pattern forward admission The patient used to smoke poof 3 sticks per day. And he in like manner drinks alcohol daily particularally beer of more than 2 bottles per session. He was not using drugs and he has no allergies at all. During time of wield The patient is not smoking cigarette or drinking alcohol. ii. Nutritional Metabolic Pattern forward admission The patient was on a high protein diet because he was used to go to the lyceum 2-3 times a week. He was alike taking vitamins (CENTRUM). He has linguistic rule appetite and has no difficulty s smotherowing. He usually eats 3 times a day (breakfast, lunch and dinner) and most of the time he also has his snacks. He also usually drinks 2-3 liters of water a day. e During time of care The patient is on NPO (nothing per orem) for 5 days due to post-operative appendectomy and he was on his 2nd day of NPO status when we cared for him. He has also NGT lavage connected. ii. Elimination Pattern Before ad mission The patients normal bowel movement was 3 BM a day and has no difficulty in bladder habits. His last bowel movement was last July 17, 2012. He usually urinates 6-7 times a day without difficulty. During time of care The patient has absence of bowel movement and even lead and has no bowel sounds upon auscultation. He has foley catheter and with body of water create of 480 cc per shift. iv. Activity and mold Before admission The patient could do his activities independently without assistance.He usually goes to gym 2-3 times a week. During time of care The patients useful train or self-care ability direct is 2 which mean he requires help from another person for assistance. v. Sleep/Rest Pattern Before admission The patient usually sleeps at 4 or 5 am and wakes up at 8 or 9 am. He has no difficulty in sleeping and he feels rested after sleep. During time of care The patient has regular sleeping habits. He sleeps at 10 am, wakes up at 6 am with uninterrupted sleep. vi. cogn itive Perceptual PatternBefore admission The patient was alert and coherent, has normal speech, with mild level of anxiety, has normal hearing, and with impaired vision of his left eye due to cataract. During time of care The patient is alert and coherent. He has normal speech (Filipino as his spoken language), he has moderate level of anxiety, has normal hearing, and with impaired vision of his left eye due to cataract. He also complained of acute pain and descri derriere it as a cramping pain. Pain management (Tramadol) was given. vii. Role family Pattern Before admission The patient was a student and single.His curb system was his family, relatives & friends. During time of care The patients support system is his mother who is always at his bed side assisting him in whatever he needs. Upon a throw togetherg his mother if she has any engages regarding hospitalization, she said that she is more concern about the fast recovery of her son. viii. Sexuality Reproductive System Before admission and during the time of care The patient still didnt have his testicular exam. ix. Coping Stress perimeter/ self Perception/Self Concept Pattern The patients major concern regarding his hospitalization is s all about self-care.Due to the contraptions attached to him, he cannot independently do his activities. His major loss was his stepfather when he died of kidney failure. His rated his outlook on future as 5, 1 beingness light and 10 being very optimistic. He further explained why he rated 5 because he is not sure if when he finished college he can be able to detect a job suited for him. x. Value Belief Pattern Our patient is a Roman Catholic and he always goes to church both Sunday together with his family. VIII. GROWTH AND DEVELOPMENT DEVELOPMENTAL TASK theorizer STATUS Intimacy vs.Isolation * Develops commitments to others and to a life work (career)(Daniels, et. al. , 2010). Erikson The patient had a relationship with his oppo send sex precisely he said that they dear broke up a week before he was hospitalized due to some personal and private reasons. Currently, he is in 3rd year college, an IT student. Genital * Emergence of sexual interests and development of relationships with potential sexual partners (Daniels, et. al. , 2010). Freud As what had written above, the patient had a relationship with his oppo billet sex but because of some reasons they decided to end up their relationship. Formal Operations * adapted to clear relationships and to reason in the abstract (Daniels, et. al. , 2010). Piaget He sensed that relationships (any lovable of relationship) are alpha especially at his age. He can also reason out in an abstract way. He can stub out his opinions intellectually and precisely. Early Adulthood * Select a partner, learn to live with a partner, start a family, manage a home, establish self in a career/occupation, assume civic responsibility, and become a part of a social group (Daniels, et. al. , 2010). Havighurst According to our patient, he didnt expected that something like that go forth happen to them (referring to his girlfriend). He was really expecting that they are really meant for each other and that she (his gf) will be his future wife. He is also establishing himself to a future career, thats why he is analyse in preparation for his future. During our time of care also, his barkadas visited him and he said that they were his tropa. Postconventional * someone understands the morality of having democratically established laws (Daniels, et. al. , 2010). Kohlberg Upon a whittleg the patient if he is beaten(prenominal) with the democratically established laws in the Philippines, he immediately responded with a yes. He also said that these laws help us, Filipinos, to have safe and secure rustic though there may come a time that we may experience something unexpectedly. IX. PHYSICAL ASSESSMENT * Vital signalizes TIME Initial 8AM (07/24/12) 10 AM 12 NN 8 AM (07/25/12) 12 NN Last 8AM(07/26/12) T 36. 3 37. 3 37. 4 36. 4 37. 3 36 P 83 84 71 75 81 68 R 23 25 21 19 19 20 BP cxx/80 120/80 120/80 120/80 120/80 110/80 Sequence BY organizationS NORMAL FINDINGS BOOK FINDINGS PATIENT FINDINGS SIGNIFICANCE I. NEUROLOCIGAL SYSTEM Alert and coherent with normal body temperature of 36. 3C 37. 6C * Fever (usually 38C although hypothermia may be present w/ severe sepsis) chills * Thirst * Pain * Complained of pain in the starting line site (lower wantitudinal midline of the tum) Pain results from the ontogenesis haul of fluid on the nerves, especially in enclosed spheres, and by the local surliness of nerves by chemical mediators such as bradykinins (Gould, et al. 2011). II. RESPIRATORY Normal cellular respiration with a rate of 12-20 breaths per minute * Tachypnea shallow respirations * RR 23 bpm w/ shallow respiration Acute pain usually initiates physiologic tense up response with increased respiratory rate (Gould & Dyer, 2011). III. INTEGUMENTARYP ink or brown and in uniform burnish, no hydrops, no lesions, moistSkin temperature is normally warmIntact scrape upWhen pinched, skin springs back to preceding(prenominal) state * Dry lips and mucous tissue layers * Swollen tongue * Poor skin turgor * Dry lips and mucous tissue layers * Skin turgor3-5 seconds * presence of surgical incision at lower longitudinal midline of the abdomen * Skin is warm to impress and is reddened Dry mucous membrane and poor skin turgor are signs of dehydration (Gulanick, et al. 1994). Redness may indicate inflammation (Weber & Kelly, 2007). Redness and zeal are caused by increased parentage flow into the damaged area (Gould & Dyer, 2011). IV. CARDIOVASCULAR Normal pulse rate of 60-100 bpm * Tachycardia * Diaphoresis * fairness * Hypotension * Tissue edema * Pulse rate 83 bpm Acute pain usually initiates a physiologic stress response with increased heart rate (Gould & Dyer, 2011). V. MUSCOLOSKELETALAbility to do Activities of Daily Living (A DL) * Difficulty ambulating * helplessness * Difficulty ambulating due to post-op condition * Weakness Constant pain oft affects daily activities and may become a primary focus in the life of an individual (Gould & Dyer, 2011). VI. GENITO-URINARY Normal urine output of 30cc/hrColor Amber, transparent, clear * fall urinary output * Dark color urine * Dark color urine * piddle output 480 mL/shift * Specific soberness 1. 30 Decreasing output of concentrated urine with increase specific gravitational force suggests dehydration/need for increased fluids (Doenges, et al. , 2006). VII. GASTROINTESTINAL abdominal skin may be paler than the general skin tone because this skin is so seldom exposed to the natural elementsAbdomen is free of lesions or rashesA series of intermittent, softish clicks and gurgles are heard at a rate of 5-30 per minuteNormally no tenderness or pain is elicited or finded by the clientNo rebound tenderness is presentAbdomen is non-tender and soft.There is no guarding * Loss of appetite * Nausea & vomiting(usually projectile) * Constipation of juvenile onset * Diarrhea(occasional) * Sudden, severe, generalized abdominal pain * type AB distention inflexibility * Decreased/absence of bowel sounds * Inability to pass locoweed/flatus * Muscle guarding (abdomen) * Psoas print (flexion of or pain on hyperextension of the hip due to contact between an inflammatory process & the psoas muscle) * Obturator Sign (the home(a) gyration of the right leg with the leg flexed to 90 degrees at the hip and knee and a resultant tightening of the internal obturator muscle may ause abdominal discomfort) * Rovsings Sign (pressure on the left lower quadrant of the abdomen causes pain in the right lower quadrant) * Rebound tenderness (a sign of inflammation of the peritoneum in which pain is elicited by the sudden release of the fingertips pressing on the abdomen) * Board-like abdomen * Sudden, severe, generalized abdominal pain * absence seizure of b owel sounds in all quaternity quadrants * absence of flatus/stool * Presence of surgical incision Signs indicating the onset of peritonitis include a rigid board-like abdomen (Gould & Dyer, 2011).Pain recurs as a steady, severe abdominal pain as peritonitis develops (Gould & Dyer, 2011). Absence of bowel sounds may be associated with peritonitis or paralytic ileus (Weber & Kelly, 2007). When inflammation persists, nerve conduction is impaired, and vermiculation lessenings, leading to obstruction of the intestines (paralytic ileus) (Gould & Dyer, 2011). X. DIAGNOSTIC TESTS DIAGNOSTIC TEST NORMAL leave behind SIGNIFICANCE WHOLE ABDOMINAL ULTRASOUND (July 21, 2012) The organs examined appear normal (Cosgrove, et al. , 2008). Liver is not enlarged.It has homogenous echopattern with smooth border. The intrahepatic ducts are not dilated. No evident focal mass lesion seen. CD measures 3. 9mm. Gallbladder is normal in sizing and wall thickness. There are multiple tiny echogenic fol low foci seen inwardly the gallbladder lm. Pancreas & spleen are normal in size & echopattern. No focal mass lesion seen. Both kidneys are normal in size & echopattern. Right kidney measures 10. 14. 25. 46cm with cortical thickness of 1. 7cm turn the left kidney measures 10. 54. 84. 1cm with thickness of 19cm. No evident caliectasis, lithiasis, seen bilaterally.Urinary bladder is unfilled. ImpressionTiny cholecystolithiasesNormal liver, pancreas, spleen, kidneys by UTZUnfilled urinary bladderNot dilated biliary tree Abdominal ultrasound is the most effective test for diagnosing acute appendicitis (LeMone & Burke, 2007). hematology REPORT/COUNT (July 21, 2012) RBC 4. 2-5. 6 M/uLPlatelets 150-400 x 10/L leucocyte 3. 8-11. 0 K/mm3Hemoglobin 135-180g/LHematocrit 0. 45-0. 52DifferentialNeutrophils 0. 50-0. 81Lymphocytes 0. 14-0. 44Monocytes0. 02-0. 06Eosinophils 0. 01-0. 05Basophils0. 00-0. 01 WBC figuring 12. 6 K/mm3RBC 4. 1 M/uL (normal)Hematocrit 0. 45 (normal)Hemoglobin 153g/L (normal)Differential CountNeutrophils 0. 90Lymphocytes 0. 10 (normal) Elevated WBC is seen in acute infection (LeMone & Burke, 2007). Neutrophils elevated in bacterial infection (LeMone & Burke, 2007). URINALYSIS (July 21, 2012) Color Light straw to yellow-brown yellowAppearance ClearOdor AromaticpH 4. 5-8. 0Specific gravity 1. 005-1. 030Protein 2-8mg/dLGlucose NegativeKetones NegativeRBCs RareWBCs 3-4Casts periodical hyaline Color Dark YellowTransparency TurbidUrine pH 6. 0 Specific gravity 1. 30Sugar NegativeProtein +4Microscopic examPus cells 4-6/HPFRBC 1-2/HPFCrystals Amorphous Sulfate Moderate A dark yellow to chromatic color is seen with subscript fluid volume (LeMone & Burke, 2007). Hazy or waterlogged urine indicates bacteria, pus, RBCs, WBCs, phosphates, prostatic fluid spermatozoa, or urates (LeMone & Burke, 2007). CLINICAL CHEMISTRY (July 21, 2012) atomic number 11 (Na) 135-142 mmol/LPotassium (K) 3. 8-5 mmol/L Sodium 132 mmol/LPotassium 4. 02 mmol/L Sodium is dr op-offd in SIADH & vomiting (LeMone & Burke, 2007). XI. ANATOMY & PHYSIOLOGY OF APPENDIX (LARGE INTESTINE)The large intestine, which is about 1. 5 m (5 ft) long and 6. 5 cm (2. 5 in. ) in diameter, extends from the ileum to the anus. It is attached to the posterior abdominal wall by its mesocolon, which is a double layer of peritoneum. Structurally, the four major regions of the large intestine are the cecum, colon, rectum, and anal canal. The opening from the ileum into the large intestine is guarded by a fold of mucous membrane called the ileocecal anatomical sphincter (valve), which allows materials from the small intestine to pass into the large intestine. Hanging inferior to the ileocecal valve is the cecum, a small pouch about 6 cm (2. 4 in. ) long.Attached to the cecum is a twisted, coiled tube, measuring about 8 cm (3 in. ) in length, called the appendix or vermiform appendix (vermiform = worm-shaped appendix = appendage). The mesentery of the appendix, called the mesoappe ndix, attaches the appendix to the inferior part of the mesentery of the ileum. The open end of the cecum merges with a long tube called colon, which is divided into ascending, transverse, descending colon are retroperitoneal the transverse and sigmoidal colon ascends on the right side of the abdomen, reaches the inferior surface of the liver, and turns perfectly to the left to form the right gripes (hepatic) flexure.The colon continues across the abdomen to the left side as the transverse colon. It curves beneath the inferior end of the spleen on the left side as the left colic (splentic) flexure and passes inferiorly to the level of the iliac crest as the descending colon. The sigmoid colon begins near the left iliac crest, projects medially to the midline, and terminates as the rectum at about the level of the third sacral vertebra. The rectum, the last 20 cm (8 in. ) of the GI tract, lies anterior to the sacrum and coccyx. The terminal 2-3 cm (1 in. ) of the rectum is called t he anal canal.The mucous membrane of the anal canal is arranged longitudinal folds called anal columns that contain a network of arteries and veins. The opening of the anal canal to the exterior, called the anus, is guarded by an internal anal sphincter of smooth muscle (involuntary) and an external anal sphincter of the skeletal muscle (voluntary). Normally these sphincters keep the anus closed except during the exclusion of feces (Tortora & Derrickson, 2006). XII. PATHOPHYSIOLOGY NARRATIVE Appendicitis, inflammation of the vermiform appendix, is a common cause of acute abdominal pain.It is the most common reason for emergency abdominal surgery, affecting 10% of the population (Tierney et al. , 2005). Appendicitis can occur at any age, but is more common in adolescents and one-year-old adults and slightly more common in males than females (LeMone & Burke, 2007). The development of appendicitis usually follows a pattern that correlates with the clinical signs, although variations may occur because of the altered location of the appendix or implicit in(p) factors (Gould & Dyer, 2011). Obstruction of the proximal lumen of the appendix is apparent in most acutely inflamed appendices.The obstruction is often caused by fecalith, or securely mass of feces. Other obstructive causes include a calculus or stone, a foreign body, inflammation, a tumor, parasites (e. g. , pinworms), or edema of lymphoid tissue (LeMone & Burke, 2007). Following obstruction, the appendix becomes distended with fluid secreted by its mucosa and microorganisms proliferate. Pressure within the lumen of the appendix increases, impairing its furrow supply because blood vessels in the wall are compressed thus the appendiceal wall becomes inflamed and purulent transudation forms.Within 24 to 36 hours, the increasing congestion and pressure within the appendix leads to ischemia and necrosis of the wall, resulting in increased permeability. Bacteria and toxins bilk through the wall into the su rrounding are. This breakout of bacteria leads to abscess formation or localize peritonitis. An abscess may develop when the adjacent omentum temporarily walls off the inflamed area by adhering to the appendiceal surface. In some cases, the inflammation and pain subside temporarily but then recur. Localized infection or peritonitis develops some the appendix and may spread along the peritoneal membranes.Increasing pressure privileged the appendix causes increased necrosis and waste in the wall (infection in necrotic tissue). The wall of the appendix appears blackish. The appendix ruptures or perforates, releasing its content into the peritoneal cavity. This leads to generalized peritonitis and would lead to septicemia and into septic thump and will result to death (Gould & Dyer, 2011). XIII. PATHOPHYSIOLOGY DIAGRAM Risk Factors Non-modifiable * Age (Adolescents & young adults) * Gender (Male) Modifiable * Fecalith * Calculus/Stone * Foreign body * firing * Tumor * Parasites Edema of lymphoid tissue Obstruction of the appendiceal lumen Obstruction of the appendiceal lumen Buildup of fluid in spite of appearance the appendix Buildup of fluid inside the appendix Proliferation of microorganisms Proliferation of microorganisms Abdominal pain Abdominal pain increase pressure within the lumen of appendix Increased pressure within the lumen of appendix Compression of blood vessels Compression of blood vessels * Fever * Obturator Sign * Psoas Sign * Rovsings Sign * Rebound tenderness * Fever * Obturator Sign * Psoas Sign * Rovsings Sign * Rebound tenderness Decreased blood flow into the appendixDecreased blood flow into the appendix Inflammation of appendiceal wall Inflammation of appendiceal wall (July 21, 2012) Hematology Count * WBC count 12. 6 K/mm * Neutrophils 0. 90 uranalysis * Transparency turbid (July 21, 2012) Hematology Count * WBC count 12. 6 K/mm * Neutrophils 0. 90 Urinalysis * Transparency turbid Ischemia & necrosis of the wall Ischemia & necros is of the wall Increased permeability Increased permeability Bacteria and toxins escape through the wall Bacteria and toxins escape through the wall Abscess formation/localized bacterial peritonitisAbscess formation/localized bacterial peritonitis Proliferation of localized peritonitis around the appendix and peritoneal membranes Proliferation of localized peritonitis around the appendix and peritoneal membranes Increased pressure inside the appendix Increased pressure inside the appendix * Sudden, severe, generalized abdominal pain * Abdominal distention & rigid boardlike abdomen * Absence of bowel sounds/(-) flatus/(-) BM (July 24, 2012) * Sudden, severe, generalized abdominal pain * Abdominal distention & rigid boardlike abdomen * Absence of bowel sounds/(-) flatus/(-) BM July 24, 2012) Increased necrosis and gangrene in the wall Increased necrosis and gangrene in the wall Appendectomy with NGT lavage (July 22, 2012) Appendectomy with NGT lavage (July 22, 2012) Perforation of the appendix Perforation of the appendix Intestinal bacteria leak out into peritoneal cavity Intestinal bacteria leak out into peritoneal cavity * Low-grade fever & leukocytosis * Tachycardia * Hypotension * Vomiting * Low-grade fever & leukocytosis * Tachycardia * Hypotension * Vomiting Generalized peritonitis Generalized peritonitis XIV. NURSING PROCESS caper 1 ABDOMINAL PAIN July 24, 2012 * immanent Cues * Nurse wait lang, ang sakit kasi parang nagcacramps, patient expressed while having a conversation with him. How does it feel like Abdominal cramping effectuate factor Kapag nililinisan pero kadalasan bigla-bigla na lang sumasakit (Whenever wound cleaning is performed but oftentimes it just suddenly happened) Relieving factor Pain reliever (but not all the time pain reliever is being given) Does it radiate to the other parts of the body (back, legs, chest, etc) No Duration of pain Paiba-iba din eh.Minsan sobrang tagal mga 2-3 minutes, minsan naman mga ilang Segundo lang (It diff ers, sometimes its too long (2-3 minutes) and sometimes it just happened for a second) * Patient rated the pain as 8/10 where 0 signifies no pain and 10 signifies unbearable pain. * Objective Cues * Facial grimace * Guarding of the incision site * stern (board-like) abdomen * Abdominal distention * Location of pain Surgical site * RR 25 bpm * nurse Diagnosis Acute Pain link to inflammation of the tissues secondary to post-op surgical incision.Inflammation or nerve damage gives turn out to changes in sensory processing at peripheral and central level with a resultant sensitization. In relation, prostaglandins are chemotactic substances drawing leukocytes to the inflamed tissue. It plays a vasoactive role it is also a pain and fever inducer (Lemone and Burke, 2007). Acute Pain related to infection & inflammation of the peritoneal membranes secondary to peritonitis The peritoneum consists of a large sterile expanse of highly vascular tissue that covers the viscera and lines of abdo minal cavity.This peritoneal structure provides a mean of quick dissemination of irritants or bacteria throughout the abdominal cavity. Abdominal distention is evident, and the typical rigid, board-like abdomen develops as reflex abdominal muscle spasm occurs in response to involvement of the parietal peritoneum (Gould & Dyer, 2011). * terminal/NOC Pain obtain Outcomes Short termination subsequently 30 minutes of breast feeding encumbrance the patient will promulgate a decrease in pain from pain cuticle of 8/10 to 4-5/10. vast stipulation by and by 8 hours of nursing intercession the patient will display an agreement about the proper way of controlling pain as bear witness by proper splinting and deep subsisting exercise and will report a decrease or most probably will be free from pain from pain scale of 4-5/10 to 1-2/10. * NIC Pain wariness Independent * Assessed pain including its character, location, severity, and duration. Both preoperatively and postoperatively , the clients pain provides important clues about the diagnosis and possible complications.Abdominal distention and acute inflammation generate to the pain associated with peritonitis. Surgery further disrupts abdominal muscles and other tissues, causing pain (LeMone & Burke, 2007). * Monitored vital signs any 2 hours. Vital Signs, especially respiratory rate (RR), are usually altered in acute pain. (Sparks and Taylor, 2005). * kept the client at rest in semi-Fowlers specify. Gravity localizes inflammatory exudation into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position (Doenges et al. , 2006). * Provided diversional activities (texting, sound trip, etc).Refocuses attention, kindles relaxation, and may enhance coping abilities and diverts attention from pain (Doenges et al. , 2006). * Taught post-op health teaching (e. g. , proper splinting & deep breathing exercises). The use of non-invasive pain relief measures can increase the re lease of endorphins and enhance the therapeutic effects of pain relief medications (LeMone & Burke, 2007). * Encouraged earliest ambulation. Promotes normalization of organ function stimulates peristalsis and passing of flatus, reducing abdominal discomfort (Doenges, et al. , 2006). Give hot and cold compress. Hot, moist compresses have a penetrating effect. The warm rushes blood to the affected area to promote healing. Cold compresses may reduce total edema and promote some numbing, thereby promoting comfort. (Doenges et al. , 2006). Dependent * Administered analgesic as ordained (TRAMADOL 50 mg/IV Q 8 x 3 doses) clock given 8 AM. Post-operatively, analgesics are provided to maintain comfort and enhance mobility (LeMone & Burke, 2007). * Kept on NPO. Decreases discomfort of early intestinal peristalsis and stomachic irritation/vomiting (Doenges et al. 2006). * evaluation Short Term final stage partly met. afterward 30 minutes of nursing interjection the patient report of a decrease in pain from a pain scale of 8/10 to 6/10 in which 4-5/10 was the expected outcome. enormous Term death met. After 8 hours of nursing intervention the patient displayed control of pain as evidence by deep breathing exercise and proper splinting. He also reported of a decrease in pain with a pain scale of 2/10 from 6/10. Pain reliever TRAMADOL was given 8 am via IV. task 2 ABSENCE OF FLATUS July 24, 2012 * indwelling Cues Nurse wait lang, ang sakit kasi parang nagcacramps (referring to abdominal cramping), patient verbalize while having a conversation with him. * Pain scale of 8/10 * Objective Cues * (-) Flatulence * (-) BM (Last BM was July 17, 2012) * Absence of bowel sounds upon auscultation of all four quadrants * Nursing Diagnosis Dysfunctional GI motility related to inflammatory process of peritonitis secondary to absence of flatulence. The inflammatory process of peritonitis often draws large amounts of fluid into the abdominal cavity and the bowel.In additio n, peristaltic action at law of the bowel is slowed or halted by the inflammation, causing paralytic ileus, impaired propulsion of forward movement of bowel contents (LeMone & Burke, 2007). * Goal/NOC Ambulation Outcomes Short Term After 8 hours of nursing intervention the client will report/experience flatus and will understand and demonstrate the need for early ambulation following abdominal surgery. wide Term After 2 days of nursing intervention the client will report/experience either flatus or bowel movement or both. * NIC Impaction charge PositioningIndependent * Assessed abdomen including all four quadrants noting character to subside increased or decreased in motility Assessed for further abdominal tenderness & auscultated for any abdominal sounds. To help identify the cause of the modification and guide development of nursing intervention (Sabol & Carlson, 2007). * Monitored and recorded ( divine guidance) and output every hour or 2 hours. Intake and output records prov ide blue-chip information about fluid volume status (LeMone & Burke, 2007). * Encouraged early ambulation.Promotes normalization of organ function stimulates peristalsis and passing of flatus, reducing abdominal discomfort (Doenges, et al. , 2006). * Assisted in moving from side to side or up in bed from time to time. Frequent dislodge helps in proper oxygenation and usually prevents complications like pressure ulcers, deep vein thrombosis, etc. (Gulanick, et. al. , 1994). Dependent * Administered antacid as ordered (RANITIDINE 50g/IV Q 12. Antacids either directly neutralize sour, increasing thepH, or reversibly reduce or block the secretion of acid by gastric cells to reduce acidity in the stomach (Gabriely, et al. 2008). * Evaluation Short Term Goal partially met. After 8 hours of nursing intervention the patient didnt experience flatus or even bowel movement but was able to have an taking into custody with regards to early ambulation as evidenced by permit his mother assist him in moving up in bed going to the chair but refused to whirl because of complaint of having a freshet of contraptions attached to him which causes him to have difficulty in moving. Long Term Goal met. After 3 days of nursing intervention the patient reported of a flatus for 3 times.Problem 3 RISK FOR DEHYDRATION July 24, 2012 * Subjective Cue * Nanghihina na ako kasi limang araw ako hindi pwede kumain pati tubig bawal din kaya nagnunuyo na yung labi ko, as verbalized by the patient. * Objective Cues * NPO for 5 days * Dry mucous membrane * Dry lips * Capillary refill= 2 seconds * Skin turgor= 3-5 seconds * Urine output/shift= 480 mL * Urine color Dark Yellow * Urine specific gravity 1. 030 (Normal value 1. 005-1. 030) * Absence of bowel sounds of all the four quadrants * (-) Flatus, (-) BM * BP 120/80 mmHg * PP 83 bpm * Nursing DiagnosisRisk for deficient fluid volume related to postoperative restriction secondary to NPO for 5 days Inflammation of the peritoneum with sequestr ation fluid and NPO status can lead to dehydration and electrolyte im poise (Doenges, et al. , 2008). * Goal/NOC Knowledge Treatment Regimen Hydration verbal Hygiene Tissue Integrity Skin & Mucous Membranes Outcomes Short Term After 30 minutes of nursing intervention patient will have an understanding with regards to maintaining fluid balance as evidenced by willingness of following the overconfident regimen given by the medical staffs. Long TermAfter 3 days of nursing intervention the patient will be able to maintain adequate fluid balance as evidenced by moist mucous membrane, good skin turgor, stable vital signs, and individually adequate urine output. * NIC Fluid Management Fluid Monitoring Vital Signs Monitoring Independent * Monitored BP & Pulse. Variations help identify fluctuating intravascular volumes, or changes in vital signs associated with immune response to inflammation (Doenges, et al. , 2006). * Inspected mucous membranes assessed skin turgor and capillary refill. Indicators of adequacy of peripheral circulation and cellular hydration (Doenges, et al. 2006). * Monitored intake and output noted urine color/concentration, specific gravity. Decreasing urine output of concentrated urine with increasing specific gravity suggests dehydration/need for increased fluids (Doenges, et al. , 2006). * Auscultated bowel sounds. historied passing of flatus, bowel movement. Indicators of picture of peristalsis, readiness to begin oral intake (Doenges, et al. , 2006). * Provide clear liquids in small amounts when oral intake is resumed, and progress diet is tolerated. Reduces risk of gastric irritation/vomiting to minimize fluid loss (Doenges, et al. 2006). * Stressed the immenseness of having him on a NPO status and provided the necessary information with regards to his condition and the medications being administered (e. g. , IVF). It provides the patient a full understanding with regards to his condition thus encouraging him to act and work hand in han d with the staff (Gulanick, et al. , 1994). * Gave buy at mouth care with special attention to protection of the lips. Dehydration results in drying and painful cracking of the lips and mouth (Doenges, et al. , 2006). Dependent * Maintained gastric suck as indicated.Although not frequently needed, an NG tube may be inserted preoperatively and maintained in immediate postoperatively phase to decompress the bowel, promote intestinal rest, and prevent vomiting (Doenges, et al. , 2006). * Administered IV fluids (D5LR 1L x 8 or 30 gtts/min) and electrolytes (D5 Balanced Multiple Maintenance Solution w/ 5% dextrose 1L x 8 or 30 gtts/min). The peritoneum reacts to irritation/infection by producing large amounts of intestinal fluid, possibly reducing the circulating blood volume, resulting in dehydration and relative electrolyte imbalances (Doenges, et al. , 2006). * EvaluationShort Term Goal met. After 30 minutes of nursing intervention the patient was able to have a full understanding w ith regards to maintaining fluid balance as evidenced by verbalizing, So kaya pala hindi pa ako pwede kumain ngaun para maiwasan mairritate ang tiyan ko. Long Term Goal met. After 3 days of nursing intervention the patient was able to maintain adequate fluid balance as evidenced by moist mucous membrane, good skin turgor (1-2 seconds), stable vital signs (please see page __ ), and adequate urine output of 620 mL with an appearance of amber yellow. Problem 4 RISK FOR INFECTION July 24, 2012 Subjective Cues Nurse, sobrang kailangan ba talaga ang paghuhugas ng kamay bago linisan o hawakan sugat niya? , asked by the mother. * Objective Cues * Post-operative condition presence of surgical incision * Surgical site is warm to touch and reddened * Temp 36. 3C * Nursing Diagnosis Risk for infection related to incompetent primary defenses secondary to post-operative surgical incision It is risk to be invaded by pathogens especially if surgical site is near at the perineal area, pathogens can also develop by poor personal hygiene and poor wound cleaning (Doenges, et al. 2006). * Goal/NOC Risk Control (For Infection) Outcomes Short Term After 30 minutes of nursing intervention the patient will be able to have partial understanding about infection control and will verbalize understanding of and willingness to follow up prescribed regimen. Long Term After 3 days ofnursing interventionthepatient will be free of sign and symptom r/t infection. * NIC Incision Site distribute Infection Control appal Care Independent * Monitored vital signs. Noted onset of fever, chills, diaphoresis, changes in mentation, and reports of increasing abdominal pain.Suggestive of presence of infection/developing sepsis, abscess, peritonitis (Doenges, et al. , 2006). * Inspected incision and dressings. Noted characteristics of drainage from wound/drains, presence of erythema. Provides for early detection of developing infected process, and/or monitors resolution of preexisting peritonitis (Do enges, et al. , 2006). * Instructed proper hand washing. estimable aseptic wound care. Reduces risk for infection (Doenges, et al. , 2006). * Encouraged adequate nutritional intake after the NPO status of the patient and when the patient is allowed to eat.Adequate intake of protein, Vitamin C and minerals is essential to promote tissue and wound healing (Sparks and Taylor, 2005). Dependent * Administered antibiotics (CEFUROXIME 750mg TID Q 8 x 2 doses & METRONIDAZOLE 500g/IV Q 8 x 2 doses) as ordered. Therapeutic antibiotics are given if the appendix is ruptured or abscessed or peritonitis has developed (Doenges, et al. , 2006). * Prepare for/assist with incision and drainage (I&D) if indicated. May be necessary to drain contents of localized abscess (Doenges, et al. , 2006). * Evaluation Short TermGoal met. After 30 minutes of nursing intervention the patient was able to have an understanding about infection control as evidenced by verbalizing, Para maiwasan ang pagkaroon ng impek syon kailangan kong maghugas ng kamay palagi at kinakailangan din ang araw-araw na paglilinis ng sugat ko kahit na sa tuwing nililinisan ito makirot sa pakiramdam. Long Term Goal met. After 3 days ofnursing interventionthepatient was free of sign and symptom r/t infection. Problem 5 INABILITY TO PERFORM ACTIVITY/IES OF DAILY LIVING (ADL) JULY 24, 2012 * Subjective Cues Hirap talaga ako gumalaw, maglakadlakad, o kahit man lang umupo dahil sa mga nakakabit na ito sa akin, as verbalized by the patient. Nakakapanghina pa kasi masakit nga yung tahi tapos madalas din nagcacramps ang tiyan ko, he added. * Objective Cues * Presence of surgical incision * Presence of contraptions (urinary catheter, NGT lavage & IV fluid left hand) * Nursing Diagnosis Impaired material mobility related to body weakness, presence of surgical incision, pain, & presence of contraptions attached physiologic immobility can be usually associated with post-operative conditions (Gulanick, et al. 1994). * Goal/NO C Activity Tolerance Outcomes Short Term After 30-45 minutes of nursing intervention the patient will be able to have a clear understanding with the use of identified techniques to enhance natural action tolerance and to apply it as well as evidenced by participating in fixed storage exercises, lower leg & mortise joint exercise, ambulation, or even moving up in bed. Long Term After 2-3 days of nursing intervention the patient will be able to continually participate in a simple form of activity and will report an onward motion with regards to his activities. * NIC Exercise Therapy BalanceIndependent * Performed passive ROM exercises. ROM exercises and good body mechanism strengthen abdominal muscles and flexors of spine (Gulanick, et al. , 1994). * Encouraged lower leg and ankle exercises. Evaluated for edema, erythema of lower extremities, and calf pain or tenderness. These exercises stimulate venous return, decrease venous stasis, and reduce risk of thrombus formation (Gulanic k, et al. , 1994). * Noted emotional and behavioural responses to immobility. Provided diversional activities. Forced immobility may heighten restlessness and irritability.The Cardiovascular SystemDiversional activity aids in refocusing attention and enhances coping with actual and perceived limitations (Gulanick, et al. , 1994). * Assisted with activity, progressive ambulation, and therapeutic exercises. Activity depends on individual situation. It should begin as early as possible and usually progresses slowly, based on client tolerance (Gulanick, et al. , 1994). * Assisted in moving from side to side or up in bed from time to time. Frequent repositioning helps in proper oxygenation and usually prevents complications like pressure ulcers, deep vein thrombosis, etc. Gulanick, et al. , 1994). * Noted client reports of weakness, fatigue, pain and difficulty accomplishing tasks. Symptoms may be result of/or contribute to intolerance of activity (Gulanick, et al. , 1994). Dependent * A dministered pain medication (TRAMADOL 50 mg/IV Q 8 x 3 doses, time given 8 AM) as prescribed and on a regular schedule. Clients anticipation of pain can increase muscle tension. Medications can help relax the client, enhance comfort, and improve motivating to increase activity (Gulanick, et al. , 1994). * Evaluation Short TermGoal partially met. After 30-45 minutes of nursing intervention the patient was able to have a clear understanding with the use of identified techniques to enhance activity tolerance and was able to use all of the techniques except for the ambulation. He refused to walk because he complained of pain whenever the catheter tube slipped into his legs. Long Term Goal partially met. After 2-3 days of nursing intervention the patient was able to continually participate in all of the identified techniques but still refused to participate in ambulation.He also reported of an improvement with regards to his activities as evidence by his verbalization, Medyo natotolerat e ko na rin yung mga activities kahit pautay-utay muna. Hindi ko lang talaga muna kaya maglakad pero pagnaalis na siguro yung catheter baka kayanin ko na. XV. BIBLIOGRAPHY * Cosgrove DO, Meire HB, Lim A, & Eckersley RJ. (2008). Grainger & Allisonns diagnostic Radiology A Textbook of Medical Imaging (5th edition). New York, NY Churchill Livingstone * Doenges M. , Moorhouse, M. Murr, A. (2006).Nursing Care Plans Guidelines for Individualizing Client Care across the Life Span (7th variate). F. A. Davis Company, Philadelphia * Doenges, M. , Moorhouse, M. Murr, A. (2006). Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th Edition). F. A. 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