Nursing Process
Content
UNIVERSITY OF ILOILO Phinma Education Network Rizal., Iloilo City
COLLEGE OF NURSING
WEST VISAYAS STATE UNIVERSITY-MEDICAL CENTER (SAN LORENZO RUIZ FEMALE SURGICAL WARD)
ACUTE APPENDICITIS
In Partial Fulfillment of the Requirements in Related Learning Experience Duty
Presented to: Mrs. Yolanda A. Lacalle-Moreno, R.N.,M.A.N. Clinical Instructor
Presented by: Genodia, Maria F. (student) BSN IV-C
January 19, 2012
NURSING PROCESS I. VITAL INFORMATION
Patient’s name Age Data Provided by Gender Address Civil Status Nationality Religion Educational level Occupation Ward Chief complaint Secondary language Primary language
:E. M. :21 y.o. :Patient :Female :Dumarao, Capiz :Single :Filipino :Roman Catholic :College Undergraduate :Sales Clerk :San Lorenzo Ruiz/Female surgical Ward :Epigastric Pain :Tagalog, English :Hiligaynon, Ilongo
Physician’s Initials :Cua. A. Diagnosis :Acute Appendicitis
Date and Time Admitted: Dec. 13, 2011
II. CLINICAL ASSESSMENT A. Nursing History 1. Reactions and Expectations 1.a. History of Present Illness Ten hours patient had sudden Right lower epigastric pain with associated vomiting ten times episode with undocumented fever which spontaneously unresolved. Patient self medicated with kremil-s to relief. There was anorexia without urinary and based changes of signs and symptoms persisted which prompted to seek medical help. 1.b. Past Health History
The patient had her check-up last November 2011 and found out that she has tooth decay to her lower lateral incisor and so she was advised to care and have a proper maintenance of cared of teeth and having regular check-up with the dentist every six month. She completed her immunizations but could no longer remember when it was given. She denies any allergies to drugs, animals, insects, and other environmental agents. She also denies previous hospitalizations due to serious illnesses. 1.c. Family History of Illness She verbalized that both of her paternal and maternal side has a history of hypertension, all other members of the family were alive and well. She denies any diseases within her family like cancer, diabetes mellitus, and mental illnesses. 1.d. patient expectations(verbalim) 1.d.1 Patient’s Expectations When asked what her expectations were during her present stay in the hospital, she verbalized that, “Ga-ekspektar ako nga mag-ayo samtang diri ako sa ospital kag para makabalik nako sa akon ubra.” 1.d.2. regarding nursing care When asked what were her expectations regarding nursing care, she verbalized that, “Gaekspektar ako nga mangin maayo ang pagtratar sa akon sang mga nurses samtang diri ako kag nabatyagan ko man nga mga mayo man sila, gina tatap gid ko nila.”
2. Pattern of Functioning A. Breathing Pattern With respiratory rate of 18 bpm, regular in rate and rhythm and doesn’t use any accessory muscles when breathing. B. Circulatory Pattern With blood pressure of 90/60 mm Hg as taken in her left arm in a comfortable moderate back rest position. Pulse rate of 85 cpm, 18bpm normal. C. Sleeping Pattern Usual Bedtime: She starts sleeping usually at 9:00 pm to 9:30pm and wakes up at 5-5:30am. The patient also takes a nap during noon breaktime. Number of Pillows: She uses one pillow under head and another one between her thighs.
Bedtime Rituals: She doesn’t have any rituals before sleeping. D. Drinking Pattern TIME MORNING AFTERNOON SNACKS EVENING E. Eating Pattern TIME BREAKFAST LUNCH KIND OF FOOD • milo • • • SNACK DINNER • • • • • noodles rice Putchero 1 pack piatos C2 Rice Vegetables Fried Fish AMOUNT • 1 cup • •
• •
KIND OF FLUID • Water • • • • milo Water/Juice C2 juice Water
AMOUNT • 1 glass •
•
•
•
1cup 2 glass 1 glass/bottle 2 glass
1 cup 1 cup 1 serve 1 pack 1 bottle 2 cup 1 small serving 1 medium size
• • • •
Food likes: Fruit salad, leche plan, Fried fish, and chicken barbecue.
F. Elimination Patterns 1) Bowel Movement Frequency: Everyday, usually at 6:00 am. Consistency: Soft and Yellow to Light Brown in color. Problems: She defecation. 2) Urination Frequency: Before she urinates 4-5 times a day, and could fill approximately halfway of a cup in every urination. But since she had her operation she urinates above 90 cc per hour as monitored on her intake and output. Appearance: Straw colored urine. Problems: She doesn’t feel problems considering her urination. G.) Exercise hadn’t encountered any problems during her
She execute exercises by walking from accommodation to working place with approximate of 350 meters distance within 15- 20 minutes done daily in the morning and evening. H. Personal Hygiene 1. Bath: 1 time per day (Full bath), from 5:00am-5:30am. 2. Oral Care: 2 times a day. 3. Shaving: No 4. Use of Cosmetics: she used makeup, lipticks, and facial cream. (e.g. Ponds, make up remover cream.) I. Recreation. Patient verbalizes her recreation are having hang out together with friends, listening music and roaming in plaza with friends. J. Health Supervision: Dr. C. 3. Brief social, cultural and Religious background. a. Educational Background. b. Occupation. Saleslady c. Religious practices. Roman Catholic d. Persons significant to patient. None College level Undergraduate
2. Clinical Inspection Date and Time taken: December 12, 2011/ 6:30 P.M. Functional Area General Survey Assessment Received this 21 years old., female, single, Roman Catholic, on a moderate back rest position, with GCS of 15, eyes open spontaneously, obeys command, and with oriented verbal response, awake, conscious, coherent, oriented to time place and person. The patient is approximately 5’2’’ in height, weighs approximately 42 Kg; clad with a clean dress with skin fair in color; with no unpleasant body odor noted; with dressing at post-op site dry and intact; with vital signs taken and recorded as follows, T=36.8 C; PR=85 bpm; RR=18cpm; BP=90/60mm Hg; With head symmetrically round, with shoulder level, black, lustrous, and
HEAD
FACE
EYES
NOSE
EARS
MOUTH
NECK
HEART AND VESSELS
THORAX AND LUNGS
evenly distributed hair, free from lice; scalp clear with no dandruff or lesions noted; no tenderness upon palpation With oval shaped, symmetrical face; with no involuntary muscle movements noted; intact cranial nerves No. 5 and 7. With fair visual acuity; both eyes move parallel to each other; with symmetrical eyebrows; lids are wrinkled and has the same color with the face; eyelashes are evenly distributed and slightly curled outward; blinks voluntarily; with white sclera; iris is dark brown in color; pupils equally round and both react to light and accommodation; conjunctiva is pale pink, glistening; no discharges noted; intact cranial nerves No. 2, 3, 4, and 6. Smooth, color is the same with the face; septum is in midline; both nostrils are patent and with no discharges noted; mucosa pink and moist; with uniform color and no lesions; no nodules, masses, or pain upon palpation; sinuses non-tender; intact cranial nerve no. 1. Ears are symmetrical in size, and in level with each other; the upper point of attachment is aligned with the outer canthus of the eyes; can hear whispered words, approximately 2ft away; warm and non-tender; with presence of waxy, nonodorous cerumen on both ears. Lips are pale and dry; gums are dull pink with no evidence of bleeding; tongue is at midline; buccal mucosa is pink, moist, without lesions; tonsils are visible and not inflamed. Movable with limited range of motion; jugular veins not distended; trachea at midline with identifiable landmarks; cervical lymph nodes nonpalpable; With BP of 90/60 mm Hg; taken at left arm in a comfortable moderate back rest position; with cardiac rate synchronous to the pulse rate of 85 bpm normal, regular in rate and rhythm; no murmurs noted; Skin is light brown without scars, pulsations, or lesions; with no hair noted; thorax expands evenly and bilaterally without retractions and
BREAST
ABDOMEN
EXTREMITIES
RECTUM AND GENITTALIA
bulging; With respiratory rate of 18 cpm, regular in rate and rhythm; no nasal flaring noted; no pain and tenderness; vibration decreased over periphery of lungs and increased over the major airways when client says “ninety-nine” (99). With symmetrical breast, round, and pendulous; warm, elastic, and non-tender upon palpation; lymph nodes are nonpalpable; areola are symmetrical and dark brown in color; with out hair in the axilla noted, with no rashes, lesions, or hyperpigmentations. With operated side located at lower epigastric area of the abdomen; color is the same with the entire skin; with hypoactive bowel sound noted on the four quadrants of the abdomen upon auscultation. With temp of 36.8 C, afebrile; with warm and dry skin; with skin turgor of <2 sec.; arms and legs are equal in size; able to move well; no deformities noted; able to identify light and deep touch; bilateral radial pulses are equal; few varicose veins on lower extremities noted. Refused to be inspected.
II. LABORATORIES
A.
CLINICAL CHEMISTRY
Dec 9, 2011 Dec. 10, 2011 Hgb(g/dL) Hct (%) Na RBC (X10^6/mL) K Na K
Result Result 11 g/dl 38% 142.7 mEQ/L 4.32 X10^6/mL 3.20 mEql/L 142.7 mol/L 3.44 mol/L
Reference Interval Reference F 12-15 g/dL Interval f- 36 – 46% 135-148 mEQl/L 4.0-4.9X^6 3.5-5.3 mEQ/L 135-148 mmol/L 3.5-5.3 mmol/L
Significance Significance Anemia normal normal normal hypokalemia normal normal
Dec. 19, 2011 Na K
Result 147.3 mEQ/L 3.20 mEQ/L
Reference Interval 135-145 mEQ/L 3.5-5.5 mEQ/L
Significance hypernatremia hypokalemia
B. RADIOLOGIC EXAMS AND OTHER SPECIAL EXAMS : None Appendicitis - is an inflammation of the appendix, which is the worm-shaped pouch attached to the cecum, the beginning of the large intestine. The appendix has no known function in the body, but it can become diseased. Appendicitis is a medical emergency, and if it is left untreated the appendix may rupture and cause a potentially fatal infection. symptoms of appendicitis:
middle/lower or right/lowerabdominal pain with fever and/or vomiting, abdominal pain continue for more than four hours, urgent medical evaluation should be performed at the hospital's emergency department.
Serum Sodium- is the most abundant electrolyte in the ECF. It is the primary determinant of ECF volume and osmolality. Sodium has a major role in controlling water distribution throughout the body, because it does not easily cross the cell membrane and because of its abundance and high concentration in the body. Serum Potassium- is the major intracellular electrolyte. It is important in the neuromuscular function, influences both skeletal and cardiac muscle activity.
•
HEMATOLOGY
Definition: It is a basic screening test and one of the most frequently ordered blood test. RBC It includes WBC hemoglobin RBC and hematocrit and a measurements, count, count, indices,
differential white cell count. Purpose: • • Significance • Decreased in RBC may indicate anemia and it may result from decreased production of RBC in spleen and kidney because of inflammatory response. Increase in no. concentration of leukocytes indicates inflammation. To serve as baseline data. To detect any abnormalities or disease process in the body
•
•
Increased in response to breakdown of RBCs marginated polymorphonuclear neutrophils mobilize and the spleenic reserve of PMNs is exhausted.
•
Clinical Chemistry a.Urinalysis
Provides important clinical information regarding kidney function and helps diagnose other diseases, such as diabetes. The urine culture determines whether bacteria are present in the urine, as well as their strains and concentrations.
Physical properties Color: pale straw Hazy
Microscopic findings: Pus cells: 0-1/hpf Red blood cells: 0-2/hpf Crystal: Amorphous Urates: few Squamous epithelial cells: Many Mucous threads: Few
Transparency:
Reaction: Acidic 7.5 Specific gravity: 1.005 Chemical test Sugar: 2+ Albumin: (-)
Albumin is important in determining the presence of glomerular damage. The glomerulus is the network of capillaries in the kidneys that filters low molecular weight solutes such as urea, glucose, and salts, but normally prevents passage of protein or cells from blood into filtrate. Albuminuria occurs when the glomerular membrane is damaged, a condition called glomerulonephritis. Red blood cells and hemoglobin may enter the urine from the kidney or lower urinary tract. Testing for blood in the urine detects abnormal levels of either red cells or hemoglobin, which may be caused by excessive red cell destruction, glomerular disease, kidney or urinary tract infection, malignancy, or urinary tract injury. White blood cells in the urine, usually signifies a urinary tract infection, such as cystitis, or renal disease, such as pyelonephritis or glomerulonephritis.
V. PROBLEM LIST 1. Acute Pain related to inflammation and distortion of tissues
Ineffective breathing pattern related to pain of the operation site as evidenced by respiratory depth changes, holding breath and reluctance to cough. 2. Knowledge deficit regarding condition, treatment, and selfcare related to lack of knowledge 3. Risk for fluid volume deficit related to nausea and vomiting.
V. DRUG STUDY University of Iloilo Phinma Education Network DRUG STUDY Ward/Bed No.: SLR/FSW 4 Impression/Diagnosis: Acute Appendicitis Chief Complaints: abdominal pain Physician: Dr. C.
Patient’s Name: Age: 21 y.o
M.F
DRUGS Generic: Co-trimoxazole Brand:
CLASSIFICATION/ MECHANISM OF ACTION
INDICATION
CONTRAINDICATION
SIDE EFFECTS/ ADVERSE REACTION
SPECIAL PRECAUTION/ NURSING RESPONSIBILITY >You should ensure that you drink plenty of fluids while receiving treatment with this medicine. >People taking this medicine should have regular blood test. > Instruct pt to stop using this medicine and inform your doctor or pharmacist immediately. experienced an allergic reaction, > Take mediation as prescribed caution >Asthma >Blood disorders >Decreased kidney function
Antipyretics
>Chronic bronchitis >Ear infections >Infection of the bladder or tubes that pass urine (urinary tract infection) > The risk of this infection is increased in patients with decreased immune system function. >Treatment of pneumonia caused by the bacterium pneumocystis
Dosage:
Route: P.O Frequency: Bid
Timing: 8 6
Trimethoprim and sulfamethoxazol e both work inside the bacterial cell, where they stop the manufacture of a substance called folic acid (folate). Folic acid is necessary for the production of genetic material (DNA).
>Pregnancy and Breastfeeding >Kidney failure >Liver failure
>Headache >Rash >Diarrhoea >Blood disorders >Pain in the muscles (myalgia) >Seizures (convulsions) >Nausea and vomiting
carinii (PCP
>Decreased liver function >Elderly people > Kidney failure
University of Iloilo Phinma Education Network DRUG STUDY Patient’s Name: Age: 21 y.o M.F Ward/Bed No.: Chief Complaints: SLR/FSW 4 Impression/Diagnosis:Acute Appendicitis abdominal pain Physician: Dr. C. CONTRAINDICATION SIDE EFFECTS/ ADVERSE REACTION SPECIAL PRECAUTION/ NURSING RESPONSIBILITY
DRUGS Generic: Coamoxiclav Brand: Augmentin Dosage: Tablets
CLASSIFICATION/ MECHANISM OF ACTION
INDICATION
Penicillin antibiotic Co-amoxiclav is used to treat bacterial infections, such as infections of the chest and throat, by killing or stopping the growth of bacteria. It can also be used in highrisk patients to prevent infections occurring
> thrush > > > >
>Hypersensitivity to drug >Pregnancy and Breastfeeding >Kidney failure >Liver failure
Route: P.O Frequency: Bid Timing: 8 4
>Headache >stomach upset >Diarrhoea >Blood disorders >Pain in the muscles (myalgia) >Seizures (convulsions) >Nausea and vomiting
>Drink plenty of water to replace any lost fluids. >Try taking your dose just before a mealtime. >Notify Physician for any adverse reaction > Take mediation as prescribed caution >Asthma >Blood disorders >Decreased kidney function >Decreased liver function >Elderly people > Kidney failure
VII. NURSING CARE PLAN
Patient’s Name: Age: 21 y.o Nursing Diagnosis
M.F
University of Iloilo Phinma Education Network NURSING CARE PLAN Ward/Bed No.: SLR/FSW 4 Impression/Diagnosis: Acute Appendicitis Chief Complaints: abdominal pain Physician: Dr. C. Nursing Intervention Independent: Rationale Evaluatio n
Goal Outcome Criteria
Acute Pain r/t obstruction of pancreatic and biliary ducts AEB • • • • abdominal guarding, diaphores is facial grimacing verbaliza tion of intense pain, pain
After 30 mins of nursing intervention the patient will able to report relief of pain AEB • Absence of abdominal guarding and facial grimacing Pain scale lowered to 1-3 out of 10. With 1 as the least painful and 10 as the most
Investigate verbal reports of pain, noting specific location and intensity (0-10). Note factors that aggravate and relieve pain. Maintain bed rest during acute attack, provide quiet, restful environment. Promote position of comfort.
-Localized pain may indicate development of pseudocysts or abscesses.
Goal partially met After 30 mins of nursing intervention the patient was able to report that pain was relieved.
-Decreases metabolic rate and GI stimulation/ secretions, thereby reducing pancreatic activity. -Reduces abdominal pressure/tension, providing some measure of comfort and pain relief. Supine position often increases pain. -Promotes relaxation and enables client to refocus attention; may enhance coping. -Sensory stimulation can activate
•
Provide alternative comfort measures, encourage relaxation techniques, quiet diversional activities. Keep environment free of food
•
scale of 9 out 10 • • • BP of 140/90 RR of 28 CR of 108
•
severe. Stable vital signs
odors.
pancreatic enzymes, increasing pain. -May used the gastric tube with ileus or protracted vomiting to prevent accumulation of gastric secretions and pancreatic enzyme activity.
Maintain gastric suction
Dependent: Administer IV analgesics in timely manner, smaller, more frequent doses, during acute episode. Consider use of patient-controlled analgesia if appropriate.
Collaborative: Prepare for surgical intervention if indicated.
-Severe/prolonged pain can aggravate shock and is more difficult to relieve, requiring larger doses of medication, which can mask underlying problems/complications and may contribute to respiratory depression. -Surgical exploration may be required in presence of intractable pain/complications involving the biliary tract, such as pancreatic abscess or pseudocyst.
University of Iloilo Phinma Education Network NURSING CARE PLAN Patient’s Name: Age: 21 y.o Nursing Diagnosis M.F Ward/Bed No.: Chief Complaints: Goal Outcome Criteria SLR/FSW 4 Impression/Diagnosis: Acute Appendicitis abdominal pain Physician: Dr. C. Rationale Evaluation
Nursing Intervention
Independent: Deficient fluid volume related to dehydration secondary to vomiting AEB: After 4 of nursing intervention the patient will be able to maintain adequate hydration as evidenced by: -stable vital signs -good skin turgor -individually appropriate urinary output Assess changes in sensorium e.g., confusion, slowed responses. -Changes may be related to hypovolemia, hypoxia, electrolyte imbalance, or impending delirium tremens. -Indicators of replacement needs/effectiveness of therapy. After 4 of nursing intervention the client was be able to maintain adequate hydration as evidenced by:
• • • •
diaphoresis poor skin turgor dry skin pale conjunctiva and lips Vomited at approximately 200 cc bilious secretions
Monitor input and output including vomiting/gastric aspirate, diarrhea. Note poor skin turgor, dry skin/mucous membranes, and reports of thirst. Monitor blood pressure, noting trends. Measure CVP if available.
-stable vital signs -Indicator of dehydration. -Reduced cardiac output/poor organ perfusion secondary to a hypotensive episode can precipitate widespread systemic complications. -good skin turgor -individually appropriate urinary output
•
Dependent: -Decreased oral intake and Administer fluid replacement excessive losses greatly as indicated. Replace affect electrolyte/acid-base electrolytes. balance which is necessary to maintain optimal
•
increased hourly urine output BP of 140/90 PR of 108 RR of 28
cellular/ organ function. Collaborative: Monitor laboratory studies e.g., Hgb/Hct, protein, albumin, electrolytes, BUN, creatinine, urine osmolality, and sodium/potassium, coagulation studies. -Identifies deficits/replacement needs and developing complications.
• • •
University of Iloilo Phinma Education Network NURSING CARE PLAN Patient’s Name: Age: 21 y.o Nursing Diagnosis M.F Ward/Bed No.: Chief Complaints: SLR/FSW 4 Impression/Diagnosis: Acute Appendicitis abdominal pain Physician: Dr. C. Rationale Evaluation
Goal Outcome Criteria
Nursing Intervention Independent:
Imbalanced nutrition less than body requirements related to vomiting AEB
After 8 of nursing intervention the patient will be able to demonstrate progressive weight gain toward goal with normalization of laboratory values and experience no signs of malnutrition.
Assess abdomen, noting presence/character of bowel sounds, abdominal distention, and reports of nausea. Provide frequent oral care.
-Gastric distention and intestinal atony are frequently present, resulting in reduced/ absent bowel sounds.
Assist client in selecting food/fluids that meet nutritional needs and restrictions when diet is resumed. Resume oral intake with clear liquids and advance diet slowly to provide high-protein, carbohydrate diet, when indicated.
After 8 of nursing intervention the client will be able to demonstrate progressive weight -Decreases vomiting stimulus and gain toward goal inflammation/irritation of dry with normalization mucous membranes associated with of laboratory values dehydration and mouth breathing. and experience no signs of -Previous dietary habits may be malnutrition. unsatisfactory in meeting current needs for tissue regeneration and healing. -Oral feedings given too early in the course of illness may exacerbate symptoms.
-Indicator of insulin needs because hyperglycemia is frequently present, although not usually in levels high enough to
Monitor serum glucose. Administer enteral/parenteral feedings if indicated.
produce ketoacidosis. -Enteral feeding may be preferred to prevent gut atrophy when tolerated.
University of Iloilo
Phinma Education Network NURSING CARE PLAN
Patient’s Name: Age: 21 y.o Nursing Diagnosis
M.F
Ward/Bed No.: Chief Complaints:
SLR/FSW 4 Impression/Diagnosis: Acute Appendicitis abdominal pain Physician: Dr. C. Rationale Evaluation
Goal Outcome Criteria
Nursing Intervention Independent:
Ineffective breathing pattern related to pain/splinting of respirations, upper abdominal distention/eleva ted diaphragm AEB: • • • • Increased RR 28 Diaphoresis Irritabilit y dyspnea
After 30 mins of nursing intervention the patient will be able to maintain adequate ventilation with respiratory rate/rhythm normal for patient, clear breath sounds, and free of dyspnea
Evaluate respiratory rate and depth. Note respiratory effort and use of accessory muscles. Auscultate breath sounds. Note areas of diminished/ absent of breath sounds and presence of adventitious sounds.
-Rate and effort may be increased by pain, accumulation of secretions, or abdominal distention. -Loss of active breath sounds in an area of previous ventilation may reflect atelectasis. -Stimulates respiratory function/ lung expansion. Effective in preventing and resolving pulmonary congestion. -May indicate impaired gas exchange. -Increases available O2 for optimal oxygenation.
After 30 mins of nursing intervention the patient will be able to maintain adequate ventilation with respiratory rate/rhythm normal for client, clear breath sounds, and free of dyspnea/shortness of breath.
Encourage client participation/responsibilit y for deep breathing exercise. Note increasing restlessness, confusion, lethargy. Administer supplemental oxygen if indicated.
University of Iloilo Phinma Education Network NURSING CARE PLAN Patient’s Name: Age: 21 y.o Nursing Diagnosis M.F Ward/Bed No.: Chief Complaints: Goal Outcome Criteria SLR/FSW 4 Impression/Diagnosis: Acute Appendicitis abdominal pain Physician: Dr. C. Nursing Intervention Independent: Infection r/t immunosupression and nutrirional defenciencies secondary to inflammation AEB: After 8 of nursing intervention the client will be able to achieve timely healing and free from signs of infection. Observe for signs and symptoms of infections e.g., fever, respiratory distress in conjunction with jaundice, increased abdominal pain, rigidity/rebound tenderness, diminished/absent bowel sounds. -Indicates that the client is having an infection. After 8 of nursing intervention the client will be able to achieve timely healing and free from signs of infection. Rationale Evaluation
Use strict aseptic technique when changing surgical dressings or working with IV lines, indwelling catheters/tubes, drains. Change soiled dressings promptly. Dependent: Administer anti-infective
-Limits sources of infection, which lead to sepsis in a compromised client.
-Broad spectrum antiinfectives are generally recommended for pancreatitis sepsis.
therapies as indicated. Collaborative: Prepare surgical intervention as necessary.
-Abscess may be surgically drained with resection of necrotic tissue. Pseudocysts may be drained because of the risk and incidence of infection/rupture.
Deficient knowledge regarding condition, prognosis, treatment, self-care, and discharge needs related to unfamiliarity with information resources as manifested by inaccurate follow-through instructions/development of preventable complications.
After 8 of nursing intervention the client will be able to verbalize understanding of condition/disease process and potential complications.
Independent: Review specific cause of current episode and prognosis. Discuss other causative/associated factors. Stress the importance of follow-up care and review symptoms that need to be reported immediately to physician. Instruct in use of pancreatic enzyme replacements and bile salt therapy as indicated, avoiding concomitant ingestion of hot foods/fluids. - Provides knowledge base on which client can make informed choices. Avoidance may help limit damage and prevent development of a chronic condition. -Prolonged recovery period requires close monitoring to prevent recurrence/complications. After 8 of nursing intervention the client will be able to verbalize understanding of condition/disease process and potential complications.
-If permanent damage to the pancreas has occurred, exocrine deficiencies will occur, requiring long-term replacement.
COLLEGE OF NURSING
WEST VISAYAS STATE UNIVERSITY-MEDICAL CENTER (SAN LORENZO RUIZ FEMALE SURGICAL WARD)
ACUTE APPENDICITIS
In Partial Fulfillment of the Requirements in Related Learning Experience Duty
Presented to: Mrs. Yolanda A. Lacalle-Moreno, R.N.,M.A.N. Clinical Instructor
Presented by: Genodia, Maria F. (student) BSN IV-C
January 19, 2012
NURSING PROCESS I. VITAL INFORMATION
Patient’s name Age Data Provided by Gender Address Civil Status Nationality Religion Educational level Occupation Ward Chief complaint Secondary language Primary language
:E. M. :21 y.o. :Patient :Female :Dumarao, Capiz :Single :Filipino :Roman Catholic :College Undergraduate :Sales Clerk :San Lorenzo Ruiz/Female surgical Ward :Epigastric Pain :Tagalog, English :Hiligaynon, Ilongo
Physician’s Initials :Cua. A. Diagnosis :Acute Appendicitis
Date and Time Admitted: Dec. 13, 2011
II. CLINICAL ASSESSMENT A. Nursing History 1. Reactions and Expectations 1.a. History of Present Illness Ten hours patient had sudden Right lower epigastric pain with associated vomiting ten times episode with undocumented fever which spontaneously unresolved. Patient self medicated with kremil-s to relief. There was anorexia without urinary and based changes of signs and symptoms persisted which prompted to seek medical help. 1.b. Past Health History
The patient had her check-up last November 2011 and found out that she has tooth decay to her lower lateral incisor and so she was advised to care and have a proper maintenance of cared of teeth and having regular check-up with the dentist every six month. She completed her immunizations but could no longer remember when it was given. She denies any allergies to drugs, animals, insects, and other environmental agents. She also denies previous hospitalizations due to serious illnesses. 1.c. Family History of Illness She verbalized that both of her paternal and maternal side has a history of hypertension, all other members of the family were alive and well. She denies any diseases within her family like cancer, diabetes mellitus, and mental illnesses. 1.d. patient expectations(verbalim) 1.d.1 Patient’s Expectations When asked what her expectations were during her present stay in the hospital, she verbalized that, “Ga-ekspektar ako nga mag-ayo samtang diri ako sa ospital kag para makabalik nako sa akon ubra.” 1.d.2. regarding nursing care When asked what were her expectations regarding nursing care, she verbalized that, “Gaekspektar ako nga mangin maayo ang pagtratar sa akon sang mga nurses samtang diri ako kag nabatyagan ko man nga mga mayo man sila, gina tatap gid ko nila.”
2. Pattern of Functioning A. Breathing Pattern With respiratory rate of 18 bpm, regular in rate and rhythm and doesn’t use any accessory muscles when breathing. B. Circulatory Pattern With blood pressure of 90/60 mm Hg as taken in her left arm in a comfortable moderate back rest position. Pulse rate of 85 cpm, 18bpm normal. C. Sleeping Pattern Usual Bedtime: She starts sleeping usually at 9:00 pm to 9:30pm and wakes up at 5-5:30am. The patient also takes a nap during noon breaktime. Number of Pillows: She uses one pillow under head and another one between her thighs.
Bedtime Rituals: She doesn’t have any rituals before sleeping. D. Drinking Pattern TIME MORNING AFTERNOON SNACKS EVENING E. Eating Pattern TIME BREAKFAST LUNCH KIND OF FOOD • milo • • • SNACK DINNER • • • • • noodles rice Putchero 1 pack piatos C2 Rice Vegetables Fried Fish AMOUNT • 1 cup • •
• •
KIND OF FLUID • Water • • • • milo Water/Juice C2 juice Water
AMOUNT • 1 glass •
•
•
•
1cup 2 glass 1 glass/bottle 2 glass
1 cup 1 cup 1 serve 1 pack 1 bottle 2 cup 1 small serving 1 medium size
• • • •
Food likes: Fruit salad, leche plan, Fried fish, and chicken barbecue.
F. Elimination Patterns 1) Bowel Movement Frequency: Everyday, usually at 6:00 am. Consistency: Soft and Yellow to Light Brown in color. Problems: She defecation. 2) Urination Frequency: Before she urinates 4-5 times a day, and could fill approximately halfway of a cup in every urination. But since she had her operation she urinates above 90 cc per hour as monitored on her intake and output. Appearance: Straw colored urine. Problems: She doesn’t feel problems considering her urination. G.) Exercise hadn’t encountered any problems during her
She execute exercises by walking from accommodation to working place with approximate of 350 meters distance within 15- 20 minutes done daily in the morning and evening. H. Personal Hygiene 1. Bath: 1 time per day (Full bath), from 5:00am-5:30am. 2. Oral Care: 2 times a day. 3. Shaving: No 4. Use of Cosmetics: she used makeup, lipticks, and facial cream. (e.g. Ponds, make up remover cream.) I. Recreation. Patient verbalizes her recreation are having hang out together with friends, listening music and roaming in plaza with friends. J. Health Supervision: Dr. C. 3. Brief social, cultural and Religious background. a. Educational Background. b. Occupation. Saleslady c. Religious practices. Roman Catholic d. Persons significant to patient. None College level Undergraduate
2. Clinical Inspection Date and Time taken: December 12, 2011/ 6:30 P.M. Functional Area General Survey Assessment Received this 21 years old., female, single, Roman Catholic, on a moderate back rest position, with GCS of 15, eyes open spontaneously, obeys command, and with oriented verbal response, awake, conscious, coherent, oriented to time place and person. The patient is approximately 5’2’’ in height, weighs approximately 42 Kg; clad with a clean dress with skin fair in color; with no unpleasant body odor noted; with dressing at post-op site dry and intact; with vital signs taken and recorded as follows, T=36.8 C; PR=85 bpm; RR=18cpm; BP=90/60mm Hg; With head symmetrically round, with shoulder level, black, lustrous, and
HEAD
FACE
EYES
NOSE
EARS
MOUTH
NECK
HEART AND VESSELS
THORAX AND LUNGS
evenly distributed hair, free from lice; scalp clear with no dandruff or lesions noted; no tenderness upon palpation With oval shaped, symmetrical face; with no involuntary muscle movements noted; intact cranial nerves No. 5 and 7. With fair visual acuity; both eyes move parallel to each other; with symmetrical eyebrows; lids are wrinkled and has the same color with the face; eyelashes are evenly distributed and slightly curled outward; blinks voluntarily; with white sclera; iris is dark brown in color; pupils equally round and both react to light and accommodation; conjunctiva is pale pink, glistening; no discharges noted; intact cranial nerves No. 2, 3, 4, and 6. Smooth, color is the same with the face; septum is in midline; both nostrils are patent and with no discharges noted; mucosa pink and moist; with uniform color and no lesions; no nodules, masses, or pain upon palpation; sinuses non-tender; intact cranial nerve no. 1. Ears are symmetrical in size, and in level with each other; the upper point of attachment is aligned with the outer canthus of the eyes; can hear whispered words, approximately 2ft away; warm and non-tender; with presence of waxy, nonodorous cerumen on both ears. Lips are pale and dry; gums are dull pink with no evidence of bleeding; tongue is at midline; buccal mucosa is pink, moist, without lesions; tonsils are visible and not inflamed. Movable with limited range of motion; jugular veins not distended; trachea at midline with identifiable landmarks; cervical lymph nodes nonpalpable; With BP of 90/60 mm Hg; taken at left arm in a comfortable moderate back rest position; with cardiac rate synchronous to the pulse rate of 85 bpm normal, regular in rate and rhythm; no murmurs noted; Skin is light brown without scars, pulsations, or lesions; with no hair noted; thorax expands evenly and bilaterally without retractions and
BREAST
ABDOMEN
EXTREMITIES
RECTUM AND GENITTALIA
bulging; With respiratory rate of 18 cpm, regular in rate and rhythm; no nasal flaring noted; no pain and tenderness; vibration decreased over periphery of lungs and increased over the major airways when client says “ninety-nine” (99). With symmetrical breast, round, and pendulous; warm, elastic, and non-tender upon palpation; lymph nodes are nonpalpable; areola are symmetrical and dark brown in color; with out hair in the axilla noted, with no rashes, lesions, or hyperpigmentations. With operated side located at lower epigastric area of the abdomen; color is the same with the entire skin; with hypoactive bowel sound noted on the four quadrants of the abdomen upon auscultation. With temp of 36.8 C, afebrile; with warm and dry skin; with skin turgor of <2 sec.; arms and legs are equal in size; able to move well; no deformities noted; able to identify light and deep touch; bilateral radial pulses are equal; few varicose veins on lower extremities noted. Refused to be inspected.
II. LABORATORIES
A.
CLINICAL CHEMISTRY
Dec 9, 2011 Dec. 10, 2011 Hgb(g/dL) Hct (%) Na RBC (X10^6/mL) K Na K
Result Result 11 g/dl 38% 142.7 mEQ/L 4.32 X10^6/mL 3.20 mEql/L 142.7 mol/L 3.44 mol/L
Reference Interval Reference F 12-15 g/dL Interval f- 36 – 46% 135-148 mEQl/L 4.0-4.9X^6 3.5-5.3 mEQ/L 135-148 mmol/L 3.5-5.3 mmol/L
Significance Significance Anemia normal normal normal hypokalemia normal normal
Dec. 19, 2011 Na K
Result 147.3 mEQ/L 3.20 mEQ/L
Reference Interval 135-145 mEQ/L 3.5-5.5 mEQ/L
Significance hypernatremia hypokalemia
B. RADIOLOGIC EXAMS AND OTHER SPECIAL EXAMS : None Appendicitis - is an inflammation of the appendix, which is the worm-shaped pouch attached to the cecum, the beginning of the large intestine. The appendix has no known function in the body, but it can become diseased. Appendicitis is a medical emergency, and if it is left untreated the appendix may rupture and cause a potentially fatal infection. symptoms of appendicitis:
middle/lower or right/lowerabdominal pain with fever and/or vomiting, abdominal pain continue for more than four hours, urgent medical evaluation should be performed at the hospital's emergency department.
Serum Sodium- is the most abundant electrolyte in the ECF. It is the primary determinant of ECF volume and osmolality. Sodium has a major role in controlling water distribution throughout the body, because it does not easily cross the cell membrane and because of its abundance and high concentration in the body. Serum Potassium- is the major intracellular electrolyte. It is important in the neuromuscular function, influences both skeletal and cardiac muscle activity.
•
HEMATOLOGY
Definition: It is a basic screening test and one of the most frequently ordered blood test. RBC It includes WBC hemoglobin RBC and hematocrit and a measurements, count, count, indices,
differential white cell count. Purpose: • • Significance • Decreased in RBC may indicate anemia and it may result from decreased production of RBC in spleen and kidney because of inflammatory response. Increase in no. concentration of leukocytes indicates inflammation. To serve as baseline data. To detect any abnormalities or disease process in the body
•
•
Increased in response to breakdown of RBCs marginated polymorphonuclear neutrophils mobilize and the spleenic reserve of PMNs is exhausted.
•
Clinical Chemistry a.Urinalysis
Provides important clinical information regarding kidney function and helps diagnose other diseases, such as diabetes. The urine culture determines whether bacteria are present in the urine, as well as their strains and concentrations.
Physical properties Color: pale straw Hazy
Microscopic findings: Pus cells: 0-1/hpf Red blood cells: 0-2/hpf Crystal: Amorphous Urates: few Squamous epithelial cells: Many Mucous threads: Few
Transparency:
Reaction: Acidic 7.5 Specific gravity: 1.005 Chemical test Sugar: 2+ Albumin: (-)
Albumin is important in determining the presence of glomerular damage. The glomerulus is the network of capillaries in the kidneys that filters low molecular weight solutes such as urea, glucose, and salts, but normally prevents passage of protein or cells from blood into filtrate. Albuminuria occurs when the glomerular membrane is damaged, a condition called glomerulonephritis. Red blood cells and hemoglobin may enter the urine from the kidney or lower urinary tract. Testing for blood in the urine detects abnormal levels of either red cells or hemoglobin, which may be caused by excessive red cell destruction, glomerular disease, kidney or urinary tract infection, malignancy, or urinary tract injury. White blood cells in the urine, usually signifies a urinary tract infection, such as cystitis, or renal disease, such as pyelonephritis or glomerulonephritis.
V. PROBLEM LIST 1. Acute Pain related to inflammation and distortion of tissues
Ineffective breathing pattern related to pain of the operation site as evidenced by respiratory depth changes, holding breath and reluctance to cough. 2. Knowledge deficit regarding condition, treatment, and selfcare related to lack of knowledge 3. Risk for fluid volume deficit related to nausea and vomiting.
V. DRUG STUDY University of Iloilo Phinma Education Network DRUG STUDY Ward/Bed No.: SLR/FSW 4 Impression/Diagnosis: Acute Appendicitis Chief Complaints: abdominal pain Physician: Dr. C.
Patient’s Name: Age: 21 y.o
M.F
DRUGS Generic: Co-trimoxazole Brand:
CLASSIFICATION/ MECHANISM OF ACTION
INDICATION
CONTRAINDICATION
SIDE EFFECTS/ ADVERSE REACTION
SPECIAL PRECAUTION/ NURSING RESPONSIBILITY >You should ensure that you drink plenty of fluids while receiving treatment with this medicine. >People taking this medicine should have regular blood test. > Instruct pt to stop using this medicine and inform your doctor or pharmacist immediately. experienced an allergic reaction, > Take mediation as prescribed caution >Asthma >Blood disorders >Decreased kidney function
Antipyretics
>Chronic bronchitis >Ear infections >Infection of the bladder or tubes that pass urine (urinary tract infection) > The risk of this infection is increased in patients with decreased immune system function. >Treatment of pneumonia caused by the bacterium pneumocystis
Dosage:
Route: P.O Frequency: Bid
Timing: 8 6
Trimethoprim and sulfamethoxazol e both work inside the bacterial cell, where they stop the manufacture of a substance called folic acid (folate). Folic acid is necessary for the production of genetic material (DNA).
>Pregnancy and Breastfeeding >Kidney failure >Liver failure
>Headache >Rash >Diarrhoea >Blood disorders >Pain in the muscles (myalgia) >Seizures (convulsions) >Nausea and vomiting
carinii (PCP
>Decreased liver function >Elderly people > Kidney failure
University of Iloilo Phinma Education Network DRUG STUDY Patient’s Name: Age: 21 y.o M.F Ward/Bed No.: Chief Complaints: SLR/FSW 4 Impression/Diagnosis:Acute Appendicitis abdominal pain Physician: Dr. C. CONTRAINDICATION SIDE EFFECTS/ ADVERSE REACTION SPECIAL PRECAUTION/ NURSING RESPONSIBILITY
DRUGS Generic: Coamoxiclav Brand: Augmentin Dosage: Tablets
CLASSIFICATION/ MECHANISM OF ACTION
INDICATION
Penicillin antibiotic Co-amoxiclav is used to treat bacterial infections, such as infections of the chest and throat, by killing or stopping the growth of bacteria. It can also be used in highrisk patients to prevent infections occurring
> thrush > > > >
>Hypersensitivity to drug >Pregnancy and Breastfeeding >Kidney failure >Liver failure
Route: P.O Frequency: Bid Timing: 8 4
>Headache >stomach upset >Diarrhoea >Blood disorders >Pain in the muscles (myalgia) >Seizures (convulsions) >Nausea and vomiting
>Drink plenty of water to replace any lost fluids. >Try taking your dose just before a mealtime. >Notify Physician for any adverse reaction > Take mediation as prescribed caution >Asthma >Blood disorders >Decreased kidney function >Decreased liver function >Elderly people > Kidney failure
VII. NURSING CARE PLAN
Patient’s Name: Age: 21 y.o Nursing Diagnosis
M.F
University of Iloilo Phinma Education Network NURSING CARE PLAN Ward/Bed No.: SLR/FSW 4 Impression/Diagnosis: Acute Appendicitis Chief Complaints: abdominal pain Physician: Dr. C. Nursing Intervention Independent: Rationale Evaluatio n
Goal Outcome Criteria
Acute Pain r/t obstruction of pancreatic and biliary ducts AEB • • • • abdominal guarding, diaphores is facial grimacing verbaliza tion of intense pain, pain
After 30 mins of nursing intervention the patient will able to report relief of pain AEB • Absence of abdominal guarding and facial grimacing Pain scale lowered to 1-3 out of 10. With 1 as the least painful and 10 as the most
Investigate verbal reports of pain, noting specific location and intensity (0-10). Note factors that aggravate and relieve pain. Maintain bed rest during acute attack, provide quiet, restful environment. Promote position of comfort.
-Localized pain may indicate development of pseudocysts or abscesses.
Goal partially met After 30 mins of nursing intervention the patient was able to report that pain was relieved.
-Decreases metabolic rate and GI stimulation/ secretions, thereby reducing pancreatic activity. -Reduces abdominal pressure/tension, providing some measure of comfort and pain relief. Supine position often increases pain. -Promotes relaxation and enables client to refocus attention; may enhance coping. -Sensory stimulation can activate
•
Provide alternative comfort measures, encourage relaxation techniques, quiet diversional activities. Keep environment free of food
•
scale of 9 out 10 • • • BP of 140/90 RR of 28 CR of 108
•
severe. Stable vital signs
odors.
pancreatic enzymes, increasing pain. -May used the gastric tube with ileus or protracted vomiting to prevent accumulation of gastric secretions and pancreatic enzyme activity.
Maintain gastric suction
Dependent: Administer IV analgesics in timely manner, smaller, more frequent doses, during acute episode. Consider use of patient-controlled analgesia if appropriate.
Collaborative: Prepare for surgical intervention if indicated.
-Severe/prolonged pain can aggravate shock and is more difficult to relieve, requiring larger doses of medication, which can mask underlying problems/complications and may contribute to respiratory depression. -Surgical exploration may be required in presence of intractable pain/complications involving the biliary tract, such as pancreatic abscess or pseudocyst.
University of Iloilo Phinma Education Network NURSING CARE PLAN Patient’s Name: Age: 21 y.o Nursing Diagnosis M.F Ward/Bed No.: Chief Complaints: Goal Outcome Criteria SLR/FSW 4 Impression/Diagnosis: Acute Appendicitis abdominal pain Physician: Dr. C. Rationale Evaluation
Nursing Intervention
Independent: Deficient fluid volume related to dehydration secondary to vomiting AEB: After 4 of nursing intervention the patient will be able to maintain adequate hydration as evidenced by: -stable vital signs -good skin turgor -individually appropriate urinary output Assess changes in sensorium e.g., confusion, slowed responses. -Changes may be related to hypovolemia, hypoxia, electrolyte imbalance, or impending delirium tremens. -Indicators of replacement needs/effectiveness of therapy. After 4 of nursing intervention the client was be able to maintain adequate hydration as evidenced by:
• • • •
diaphoresis poor skin turgor dry skin pale conjunctiva and lips Vomited at approximately 200 cc bilious secretions
Monitor input and output including vomiting/gastric aspirate, diarrhea. Note poor skin turgor, dry skin/mucous membranes, and reports of thirst. Monitor blood pressure, noting trends. Measure CVP if available.
-stable vital signs -Indicator of dehydration. -Reduced cardiac output/poor organ perfusion secondary to a hypotensive episode can precipitate widespread systemic complications. -good skin turgor -individually appropriate urinary output
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Dependent: -Decreased oral intake and Administer fluid replacement excessive losses greatly as indicated. Replace affect electrolyte/acid-base electrolytes. balance which is necessary to maintain optimal
•
increased hourly urine output BP of 140/90 PR of 108 RR of 28
cellular/ organ function. Collaborative: Monitor laboratory studies e.g., Hgb/Hct, protein, albumin, electrolytes, BUN, creatinine, urine osmolality, and sodium/potassium, coagulation studies. -Identifies deficits/replacement needs and developing complications.
• • •
University of Iloilo Phinma Education Network NURSING CARE PLAN Patient’s Name: Age: 21 y.o Nursing Diagnosis M.F Ward/Bed No.: Chief Complaints: SLR/FSW 4 Impression/Diagnosis: Acute Appendicitis abdominal pain Physician: Dr. C. Rationale Evaluation
Goal Outcome Criteria
Nursing Intervention Independent:
Imbalanced nutrition less than body requirements related to vomiting AEB
After 8 of nursing intervention the patient will be able to demonstrate progressive weight gain toward goal with normalization of laboratory values and experience no signs of malnutrition.
Assess abdomen, noting presence/character of bowel sounds, abdominal distention, and reports of nausea. Provide frequent oral care.
-Gastric distention and intestinal atony are frequently present, resulting in reduced/ absent bowel sounds.
Assist client in selecting food/fluids that meet nutritional needs and restrictions when diet is resumed. Resume oral intake with clear liquids and advance diet slowly to provide high-protein, carbohydrate diet, when indicated.
After 8 of nursing intervention the client will be able to demonstrate progressive weight -Decreases vomiting stimulus and gain toward goal inflammation/irritation of dry with normalization mucous membranes associated with of laboratory values dehydration and mouth breathing. and experience no signs of -Previous dietary habits may be malnutrition. unsatisfactory in meeting current needs for tissue regeneration and healing. -Oral feedings given too early in the course of illness may exacerbate symptoms.
-Indicator of insulin needs because hyperglycemia is frequently present, although not usually in levels high enough to
Monitor serum glucose. Administer enteral/parenteral feedings if indicated.
produce ketoacidosis. -Enteral feeding may be preferred to prevent gut atrophy when tolerated.
University of Iloilo
Phinma Education Network NURSING CARE PLAN
Patient’s Name: Age: 21 y.o Nursing Diagnosis
M.F
Ward/Bed No.: Chief Complaints:
SLR/FSW 4 Impression/Diagnosis: Acute Appendicitis abdominal pain Physician: Dr. C. Rationale Evaluation
Goal Outcome Criteria
Nursing Intervention Independent:
Ineffective breathing pattern related to pain/splinting of respirations, upper abdominal distention/eleva ted diaphragm AEB: • • • • Increased RR 28 Diaphoresis Irritabilit y dyspnea
After 30 mins of nursing intervention the patient will be able to maintain adequate ventilation with respiratory rate/rhythm normal for patient, clear breath sounds, and free of dyspnea
Evaluate respiratory rate and depth. Note respiratory effort and use of accessory muscles. Auscultate breath sounds. Note areas of diminished/ absent of breath sounds and presence of adventitious sounds.
-Rate and effort may be increased by pain, accumulation of secretions, or abdominal distention. -Loss of active breath sounds in an area of previous ventilation may reflect atelectasis. -Stimulates respiratory function/ lung expansion. Effective in preventing and resolving pulmonary congestion. -May indicate impaired gas exchange. -Increases available O2 for optimal oxygenation.
After 30 mins of nursing intervention the patient will be able to maintain adequate ventilation with respiratory rate/rhythm normal for client, clear breath sounds, and free of dyspnea/shortness of breath.
Encourage client participation/responsibilit y for deep breathing exercise. Note increasing restlessness, confusion, lethargy. Administer supplemental oxygen if indicated.
University of Iloilo Phinma Education Network NURSING CARE PLAN Patient’s Name: Age: 21 y.o Nursing Diagnosis M.F Ward/Bed No.: Chief Complaints: Goal Outcome Criteria SLR/FSW 4 Impression/Diagnosis: Acute Appendicitis abdominal pain Physician: Dr. C. Nursing Intervention Independent: Infection r/t immunosupression and nutrirional defenciencies secondary to inflammation AEB: After 8 of nursing intervention the client will be able to achieve timely healing and free from signs of infection. Observe for signs and symptoms of infections e.g., fever, respiratory distress in conjunction with jaundice, increased abdominal pain, rigidity/rebound tenderness, diminished/absent bowel sounds. -Indicates that the client is having an infection. After 8 of nursing intervention the client will be able to achieve timely healing and free from signs of infection. Rationale Evaluation
Use strict aseptic technique when changing surgical dressings or working with IV lines, indwelling catheters/tubes, drains. Change soiled dressings promptly. Dependent: Administer anti-infective
-Limits sources of infection, which lead to sepsis in a compromised client.
-Broad spectrum antiinfectives are generally recommended for pancreatitis sepsis.
therapies as indicated. Collaborative: Prepare surgical intervention as necessary.
-Abscess may be surgically drained with resection of necrotic tissue. Pseudocysts may be drained because of the risk and incidence of infection/rupture.
Deficient knowledge regarding condition, prognosis, treatment, self-care, and discharge needs related to unfamiliarity with information resources as manifested by inaccurate follow-through instructions/development of preventable complications.
After 8 of nursing intervention the client will be able to verbalize understanding of condition/disease process and potential complications.
Independent: Review specific cause of current episode and prognosis. Discuss other causative/associated factors. Stress the importance of follow-up care and review symptoms that need to be reported immediately to physician. Instruct in use of pancreatic enzyme replacements and bile salt therapy as indicated, avoiding concomitant ingestion of hot foods/fluids. - Provides knowledge base on which client can make informed choices. Avoidance may help limit damage and prevent development of a chronic condition. -Prolonged recovery period requires close monitoring to prevent recurrence/complications. After 8 of nursing intervention the client will be able to verbalize understanding of condition/disease process and potential complications.
-If permanent damage to the pancreas has occurred, exocrine deficiencies will occur, requiring long-term replacement.
