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 1st 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 3rd 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 1. RESPIRATORY – (+) Hx of Asthma – Consumed 5 sticks of cigar/day – Started smoking since 17 y.o
CLINICAL INSPECTION – – – –
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
– – – –
– –
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
–
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
1. EXERCISE & LOCOMOTION – Take the daily activities as
– – – – –
–
Hematology: WBC: 18.30x10^9/L Neutrophil: .90 Lymphocyte: .10 Hematocrit: .46
Good skin turgor Dry lips With an IVF of D5LR @ 30gtts/min No NGT
1. REGULATORY MECHANISM – (+) mild fever during childhood 1. HYGIENE – Take a bath 12x/day – Seldom use shampoo – Change cloth everyday – No allergies to soap & shampoo – Combs hair
OTHER SOURCES
Impaired mobility due to
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 Uric acid: moderate
Components
Normal values
Results
Interpretation
1. WBC
4.5 – 11x109/L
18.30 x 109/L
Increased
2. Neutrophils
0.45 – 0.73
0.90
Increased
Clinical Significance Presence of inflammation Acute infection, trauma or surgery
3. Lymphocyte
0.2 – 0.4
0.10
Decreased Aplastic anemia, SLE, immunodeficiency including AIDS
4. Hematocrit
Males: 42 – 52 % Females: 35 – 47 %
46 %
Normal Balance proportion of blood volume that is occupied by RBC
LABORATORY RESULTS Hematology:
Urinalysis: Components
Normal
Results
Interpretation
Clinical Significance
1. Color
Pale yellow to amber
Dark Yellow
Not normal
Not enough water intake, presence of bilirubin
2. Transparency
Clear to slightly hazy
Turbid
Not normal
3. Specific gravity
1.015-1.025
1.025
Normal
Cystisis, presence of bacteria
4. PH
4.5-8.0
6.0
Normal
Properly diluted urine
5. Glucose
Negative
Negative
Normal
Not risk for calcification, and infection
6. Albumin
Negative
Negative
Normal
Absence of DM
7. WBC
Negative or rare
2-3/hpf
Not normal
Proper filtration of glumerolus
8. Bacteria
Negative
Moderate
Not normal, bacteremia Cystisis, nephritis,
9. Casts
Occasionally hyaline casts
10.Uric Acid
Coarse granular: 0-1/hpf
Urinary tract infection 3.13 mmol/24 h
1.58-4.43 mmol/24 h
Not normal Normal
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 : http://www.scribd.com/doc/46437230/Pathophysiology-of-Appendicitis
Nursing Diagnosis 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 oC PR - 53 bpm RR - 26 cpm BP - 110/70mmhg
• •
weakness
Scientific analysis 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.
Objectives
Nursing Interventions
Evaluation
INDEPENDENT: 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.
1. Instruct the client to
1. Activity that require
minimize activities
holding the breath and
that will put pressure
bearing down can result
on his abdomen.
in pain to surgical site in
2. Reposition
RLQ, bradycardia and
periodically and
rebound tachycardia
slowly and
with elevated BP.
encourage deep breathing exercises.
2. Prevent / reduces incidence of skin and
3. Encourage rest.
respiratory
4. Move patient
complications.
slowly and deliberately. 5. Administer analgesics as
facial grimace
Rationale
ordered
3. Reduces myocardial workload / oxygen consumption, reducing risk of complication.
•
guarding behavior
Reference:
•
incision on RLQ
Medical Surgical nursing by
tension or guarding,
Brunner and Suddarth 11th
which may help
edition; Vol.2 pages 1240-
minimize pain of
1242
movement.
4. Reduces muscle
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
Impaired skin integrity related to surgical incision
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.
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:
SUBJECTIVE: “katapus ko la ka operahe” as verbalize by the patient OBJECTIVE: - open wound - visible surgical incision - post-operative patient Temp - 36.6 oC PR - 53 bpm RR - 26 cpm BP - 110/70mmhg
1) Observe wound, note characteristics of drainage.
2) Change dressing as needed using aseptic technique.
Reference: Medical surgical nursing by brunner and suddarth, 11th edition volume 2 @ page: 1242
3) Encourage side lying position (on the leftside) or a semifowlers position. 4) Encourage guarding behavior. DEPENDENT 5) Administer antibiotics as doctor’s order
Rationale 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.
Evaluation 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
Risk for infection related to
After 8 hours of
surgical incision at right lower
The creation of surgical
quadrant of the body.
incision during appendectomy disrupts the skin integrity of
Objective:
Objectives
the skin and its protective
incised skin @ right
function. Exposure of deep
lower quadrant
body tissues to the pathogens
RR – 26 cpm
in the environment places the
PR – 53 bpm
patient at risk for infection of
Temp – 36.6 oC
the surgical site, a potentially
Incision pain
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.
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.
Nursing Interventions
Rationale
Evaluation
INDEPENDENT: 1. Fever and pain indicate 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.
After 8 hours of nursing
inflammatory
education and interventions,
responses, which
the patient was More
contribute to infection.
conscious about his
2. Reduces the risk for
environment and the patient
infection or cross
seems to be hesitated and
contamination of
confused or failed to
bacteria.
express some of the
3. Provides early detection
information imparted by the
of infection process, and
nursing students therefore:
presence of discharges
GOAL WAS PARTIALLY
may help to identify
MET.
whether there is an infection. 4. To reduce/ correct existing risk factors. 5. Promotes healing and prevents dehydration.
