ST.

ANNE COLLEGE LUCENA INCORPORATED

DIVERSION ROAD GULANG- GULANG
LUCENA CITY
SY: 2009-2010

IN PARTIAL FULFILLMENT FOR RLE REQUIREMENTS

CASE STUDY
“APPENDICITIS”

PREPARED BY:

Joy Rachel D. Tabernilla

Edlene Joy A. Yulip

BSN III- A

MARCH, 2010
 TABLE OF CONTENT
I. Objectives

a. General Objectives

b. Specific Objectives

II. Patient Profile

a. Biographical data of the patient

III. History

a. Nursing History

i. Chief Complain

ii. Admitting Diagnosis

iii. Physical Examination

iv. Final Diagnosis

b. Present Health History

i. 24 hours recall of events

ii. Signs and symptoms experienced by the patient

c. Past Health History

i. Hospitalizations

ii. Surgical Managements

iii. Allergies

1. Foods

2. Drugs

iv. Others

d. Family Health Background

i. Include indications and Health tree

IV. Nutrition

a. 24 hours food recall

b. Regular/Routine diet

c. Intake and output

d. Vices and habits

V. Disease Entity

a. Definition

b. Etiology

c. Transmission

d. Occurrence/Epidemiology

e. Anatomy of the organ involved

VI. Pathophysiology

VII. Management

a. Medical Management

b. Pharmacological Management

c. Nursing Management

VIII. Laboratory

a. Blood analysis

IX. Nursing Care Plan

X. Discharge Plan
I. OBJECTIVES

a. GENERAL OBJECTIVES:

In the light of knowledge, the main goal is to present a case presentation about
appendicitis. Trough this, the group is hoping to gain more knowledgeable facts about
appendicitis.

b. SPECIFIC OBJECTIVES:

 To gain more knowledge about the patients expectations and the effects of his
condition.

 To gather significant data from the patients chart and the patient himself through
interview and assessment.

 To define the clients complete diagnosis

 To review the anatomy and physiology of the client, specifically the GI system in
relation of the appendix.

II. PATIENT PROFILE

a. Biographical Data of the Patient

Name: E.S.A.

Date of Birth: May 15, 1956

Civil Status: Married

Address: Comia, Brgy. Isabang, Lucena City

Religion: Roman Catholic

Educational Attainment: Elementary Graduate

Occupation: Maid

III. HISTORY

a. Nursing History

i. Chief Complain: Hypogastric pain

 ii. Admitting Diagnosis: T/C acute appendicitis (March 20, 2010, 7:10
pm)

iii. Physical Examination

HEAD: Skull is symmetrical.

Hair is dry, not brittle and generally color black

EYES: with pinkish conjunctiva and with an ichteric sclera

NOSE: no nasal discharge

LIPS: with dry pinkish lips

CHEST & LUNGS: with symmetrical chest expansion

Not in respiratory distress

ABDOMEN: with surgical incision at Mc Burneys point at RLQ of the

abdomen with dry and intact dressing.

EXTREMITIES: range of motion is normal

No inflammation or edema noted

iv. Final Diagnosis: Ruptured Appendicitis; S/P explore appendectomy

b. Present Health History

i. 24 hours recall of events

2 days PTA, patient experienced epigastric pain radiating to hypogastric

area accompanied by nausea and vomiting. No consult was done or med taken.

1 day PTA, with above chief of complain, patient sought consult to

QMC. CBC and urinalysis were done. Patient was diagnosed to have UTI.
Floxagen and HNBB were given.

ii. Signs and symptoms experienced by the patient

 Patient experienced epigastric pain radiating to hypogastric area

accompanied by nausea and vomiting.
 c. Past Health History

i. Hospitalizations: none

ii. Surgical Managements: Explore appendectomy, washing

iii. Allergies

1. Foods: none

2. Drugs: none

iv. Others

d. Family Health Background

Dece Deceas
ase e
Decease Decease

Decease -85
y/o

Kidney
Kidney problem Appendic
problem itiss

-63 y/o - 53 y/o - 59 y/o - 57 y/o - 53 y/o

LEGEND:

- Male - female - patient

IV. Nutrition

a. 24 hour food recall

24 hours prior to admission patient had taken the following foods:

 Dinner– rice, vegetables with fish (3-19-10)

- Water melon

 Breakfast- lugaw (3-20-10)

 Lunch- rice with sabaw ng bulanglang na upo

b. Regular/Routine diet

Patient regular diet was more on vegetables. She was not used to eat meats
or processed foods.

c. Intake and output

DATE TIME INTAKE OUTPUT

March 20, ‘10 12:00nn 40 cc

8:00pm 500cc

March 21, ’10 7-3 800 cc

post op

3-11 592 cc

d. Vices and habits

V. Disease Entity

a. Definition

“Appendicitis”-the appendix is small, finger-like appendage attached to

the cecum just below the ileocecal valve. Because it empties into the colon
 inefficiently and its lumen is small, it is prone to becoming obstructed and is
vulnerable to infection (appendicitis). The obstructed appendix becomes inflamed
and edematous and eventually fills with pus. It is the most common cause of acute
inflammation in the RLQ of the abdominal cavity and the most common cause of
emergency abdominal surgery. Male are affected more than females, teenagers
more frequently than adults; the highest incidence in those between the ages of 10
and 30 years old.

b. Etiology

 OBSTRUCTION

Anatomy:

 wormed-shaped

 Narrow

 Plenty of lymp glands

Mechanical reasons:

 food residue

 Ascarid

 Tumors

 GASTROINTESTINAL DISEASE

 BACTERIAL INVASION: all kinds of G-bacillus

c. Transmission

d. Occurrence/Epidemiology

About 7% of the population will have appendicitis at the same time in their lives;
males are affected more than females and teenagers more than adults.

The peak incidence of acute appendicitis has gradually defined to about half of
its peak incidence in the early 20th century, with the current annual incidence of 1 per
1000 population in the US and 86 cases for every 100,000 persons worldwide. The
extrapolated incidence of appendicitis in the Philippines is 215,604 of 86,241,697
estimated populations.
e. Anatomy of the organ involved

The appendix is a closed-ended, narrow tube up to several inches in length

that attaches to the cecum the first part of the colon like a worm. The anatomical
name for the appendix, vermiform appendix, means worm-like appendage. The
inner lining of the appendix produces a small amount of mucus that flows through
the open center of the appendix and into the cecum. The wall of the appendix
contains lymphatic tissue that is part of the immune system for making antibodies.
Like the rest of the colon, the wall of the appendix also contains a layer of muscle,
but the muscle is poorly developed.
 VI. Pathophysiology

Bacteria, fecaliths
High fiber diet

Obstruction to proximal lumen of the

appendix

Distention of the appendix

General signs and Inflammation

symptoms:

S-welling ( tumor)
Exudates
H-eat ( Calor)

I-mpaired function
Impaired blood supply to the appendix
R-edness ( Rubor

P-ain ( Dubor)
Hypogastric pain Nausea &
vomiting

Edema- ischemic

necrosis

Rupture and perforation

Sudden relief of pain

On and off pain

Generalize abdominal pain

Explore Appendectomy Surgical

Management
VII. Management

a. Medical Management

DATE/TIME PROGRESS NOTES DOCTORS ORDER

March 20, 2010, >please admit to ROC under the

service of Dr. Villaluna
7:10 pm
>secure consent

>TPR q 4 hour

>NPO temporarily

>IVF- PNSS 1L x 8 hours

>Diagnostic procedures- CBC with

platelet count, urinalysis(done
@QMC)

>monitor vital signs q 2 hours

> I & O q shift

>refer to Dr. Achacoso for co-

managemant

>refer accordingly

7:30 pm SURGERY NOTES

>epigastric pain 2 days

PTA later shifting to
LMP= menopause RLQ Flarry soft(+)

3 years PTA (+) nausea & vomiting Tenderness RLQ LLQ

(+) anorexia (+) removal RLQ LLQ

(-) fever (-) mass

* acute appendicitis

Primary ruptured

>NPO

Treatment:

-fast drip 200cc present IVF &

regulate to 40gt/min

-cefotaxime 1gm IV ANST (-)

-Metronidazole 500mg IV q8 hour

 ANST(-)

- Diclofenac 75mg IV q 12 hour x 2

doses ANST(-)

-for explore appendectomy- secure

consent

March 20, 2010 POST OP ORDERS

9:40 pm >back to ward

>flat on bed until 5:00am

>monitor vital signs q15 min x 2

hours then q30 mins until stable

>O2 inhalation @ 2Lpm by nasal

cannula until stable

>regulate IVF @ 30gtt/min followed

by (1)D5NM 1L, (2) D5NR 1L, (3)
D5NM 1L to run @ same rate

> keep on NPO

March 20, 2010 Afebrile > continue meds

10:30 pm (-) cough

(-) dyspnea

(-) chest pain

BP= 90/60

Usual BP= 100/70

(-) pedal edema

March 21, 2010 (+) flatus Tom in AM

1. Remove IFC

2. May have sips of clear liquid

>change dressing

March 22, 2010 >shift IV meds to:

• Mefenamic (Ponstan SF)

500mg TID

• Metronidazole 500mg TID

March 23, 2010 >MGH

>Home Meds:

• Metronidazole 500mg/tab 3x
 a day for 7 days

• Ciprofloxacin (Laitun)
500mg/tab 1 tab 3x a day for
7 days

• Mefenamic Acid 500mg/tab 1

tab 2x a a day for pain

>Check-up @ clinic March30,2010

2pm for follow up

b. harmacological Management

c. Nursing Management

A. PREOPERATIVE PHASE

The patient was admitted to the emergency room complaining of severe pain in
the right lower quadrant of the abdomen a number of tests were ordered to assess the
patients health. The nurse explains to the patient and the SO about the tests. These test
were the CBC, Platelet, and Urinalysis. After obtaining the results of the tests, the patient
was diagnosed to have a “Appendicitis”. The patient was then scheduled to have an
Explore-appendectomy. But before the surgery, an informed consent form was signed
acknowledging that the patient and SO understands the procedure, the potential risks, and
that they will receive certain medications. Before the signing, the nurse must ask the SO
whether she understood what the surgeon told her and as the patient will sign the
informed consent form the nurse was present to witness the signing.

B. INTRAOPERATIVE PHASE

As the patient arrived in the operating room, the anesthesiologist briefly

interviewed the patient to clarify some things that were needed before administering the
anesthesia. The patient was then positioned in as fetal position for the induction of
anesthesia. Then , patient was placed in supine position. The anesthesiologist then asked
the patient to raised his legs and used a pin to test whether the anesthesia has already
worked. After ensuring the effectiveness of the anesthesia, the nurse started to do skin
prep using antiseptic ( betadine).

The srub nurse prepared the surgical set-up and did the counting of the
instruments. In addition the scrub nurse maintained surgical asepsis while draping and
handling instruments and assisted the surgeon by passing instruments, sutures, and
supplies.

The circulating nurse responded to the request of the surgeon, anesthesiologist or

anesthethist, and from the other member of the surgical team. Moreover, the circulating
nurse obtained a sterile gown. Other responsibilities include:

1. Assissted the surgeon and the scrub nurse to do sterile gowns and gloves.

2. Anticipated the need for equipment, instruments, medications, and blood component
and opened these packages so that the scrub nurse can remove the sterile supplies,
preparing labels, and arranged for transfer of specimens to the laboratory for analysis.
 3. Discarded used gauze sponges, and at the end of the operation, helped in counting the
number of sponges, instruments and needles were complete.

C. POSTOPERATIVE PHASE

Following surgery, the patient was taken to the (PACU) until the anesthesia were
off. During this time, the staff nurses checked the vital signs at frequent intervals. When
the anesthesia were off and vital signs stabilized, the patient was transferred to the
surgery ward. The nurse continued monitoring the patient for any unusualities and
postoperative complications and report immediately to the physician if any occur. Staff
nurses administered medications like antibiotic depending on the doctors order.

Other responsibilities:

1. Position and safety

2. Monitor vital sign
3. Level of consciousness
4. IVF
5. Wound
6. Color and temperature
7. Comfort
Ensure that the patient is warm and comfortable, and that bed is clean and safe.

VIII. Laboratory

a. Blood analysis

Hematology (March 20, 2010/7:27pm)

SPECIFICATION RESULTS NORMAL RANGE INTERPRETATION

Hematocrit 0.36 F 0.37-0.45 =anemia,

hemodilution

RBC 3.94 F 4.2-5.4x10^12/L =anemia, fluid

overload of >24 hours

WBC 12.5 5-10X10^g/L =infection, tissue

necrosis

Segmenters 0.79 0.55-0.65 (increase)

 IX. Discharge Plan

M- METHOD

 Metronidazole 500mg/tab 3x a day for 7 days

 Ciprofloxacin (Laitun) 500mg/tab 1 tab 3x a day for 7 days

 Mefenamic Acid 500mg/tab 1 tab 2x a a day for pain

E- EXERCISE/ENVIRONMENT

 Encourage to have enough sleep and rest to promote faster recovery

 Instruct to avoid strenuous activities such s lifting, running, playing.
 Encourage to do simple exercise such as walking and playing heavy objects.

T- TREATMENT

 Instruct the SO to comply with what the doctor had instructed to do.
 Encourage the SO to change the dressing as often as necessary.
 Instruct him to report immediately any unusual ties.

H- HEALTH TEACHING

 Instruct him to keep the incision site dry and clean always to prevent infections to occur
 Tell the SO to notify the physician immediately if there are unusual ties
 Encourage to observe proper hygiene measures for past recovery.
 Encourage to follow all the instructions including medications, diet regimen and do and
dont’s that was instructed to him by the physician
 Inform the patient that he can return to his activities of daily living even without his
appendix.

O-OPD

 Instruct patient and SO that they return to have a check-up atleast 7 days after discharged.
 Encourage him to inform his physician about any unusualities on his incision site or with
regard to his health.

D-DIET

 Encourage patient to eat high protein and high calorie foods to fast tract healing.
 Food such as:
Egg poultry products

Milk beans

Peanut butter butter

Lean meats fresh coconut

Fish potato