Appendicitis
Content
I. INTRODUCTION
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OBJECTIVES
Student – Nurse Centered
General Objectives To gather additional knowledge from the patient’s condition and give proper nursing care on her post – operative state to prevent complications through the use of the nursing process.
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Specific Objectives At the end of the study the student nurse will: Understand and be knowledgeable about the patient’s condition. Assess the needs for care of the patient. Plan appropriate interventions related to the patient’s needs. Implement the planned nursing interventions. Evaluate whether the goals are met or not. Reassess if the care of plan was effective.
Patient – Centered
General Objectives The patient will be knowledgeable about the proper care needed on her post – operative state, to attain maximum level of care, and to prevent complications.
Specific Objectives At the end of the study, the patient will: Be knowledgeable about her condition. Understand the extent of restrictions of food and activities. Achieve the needed nursing care appropriate for her age and condition. Decrease the anxiety she is experiencing after the surgery and possible complications. Respond to the prescribed treatments or managements. 3
Become better and will live normally like with other people.
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I.
NURSING PROCESS
A. ASSESSMENT
1. Personal Data
a. Demographic Data Name Age Sex Birthday Address Religion Nationality Civil Status Occupation Height Weight Chief Complaint : Ms. F : 13 years old : Female : : Tacloban : Roman Catholic : Filipino : Single : Housewife : 5’1” : 48 kilograms : 5
Date of Admission
: Feb. 22, 2011
Admitting Diagnosis : Final Diagnosis :
b. Environmental Status Mr. F resides at Tacloban. Their house was a bungalow type which is made up of bamboo where there are mango trees around it. There are two rooms in their house which they use for sleeping. They are five living in their house. There is available sari – sari stores available in their place. The available means of transportation in their area are thru jeepney, tricycle, bus and taxi. Their source of water is in Nawasa. They have two cats and a dog which they allow to stay inside their house. They said that they have a good relationship with their neighborhood.
c. Lifestyle
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Ms. F is a second year high student. She usually sleeps at 8 or 9 in the evening and wakes up at around 6 in the morning to prepare herself to school. Every day, she usually plays badminton as her sports and exercise and as past time. According to her sister, their mother usually cooks meat or pork dishes, and sometimes vegetables. He usually drinks 8 - 10 glasses of water a day. She takes a bath every day, usually every morning before she goes to school. Her sister also stated that Ms. F started not to drink milk when she was 11 years old.
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2. FAMILY HISTORY OF HEALTH AND ILLNESS
PATERNAL
MATERNAL
8 7
78 TB
8 1
ASTHMA
76
5 3
5 0
48
4 0
38
3 6
56
5 3
50
4 8
45
v/a 2 2 2 2 BOY GIRL X DECEASED PATIENT POTT’s DISEASE TB V/A TUBERCULOSIS Vehicular Accident
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1 6
1 3
LEGEND
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3. History of Past Illness
According to Ms. F this is her first hospitalization. It was on She already had Chicken Pox and measles but the patient can no longer remember her age when she experienced those conditions. Ms. F did not know if she was fully immunized, she does not have any allergies to any foods, medication and pets. Ms. F never experienced any surgery procedure or injury when she was young. Cough and Colds, Diarrhea and fever are the usual condition that she acquired and she treated it with over the counter drugs like paracetamol, neozep and loperamide.
4. History of Present Illness Four months prior to admission, patient stated that she had experienced stiffening of her neck but without pain. Two to three months prior to admission, episodes of pain followed but can be tolerated by the patients One month prior to admission, pain severed and the pain scale of 10/10 was rated. No medicine was given to relieve the pain. She was then rushed to Taguig-Pateros Hospital last February 21, 2011 for immediate x-ray exam on the cervical and the exam revealed that there is a “melting bone on her C1 and C2” as stated by the doctor to her. She was referred to Philippine Orthopedic Center February 22 and was again ordered another x-ray examination to justify if the previous exam was accurate. They got the same results. She was examined by the physician, hence, admitted.
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5. 13 AREAS OF ASSESSMENT I. SOCIAL STATUS Ms. F is the youngest of the four siblings. The family resides at Tacloban. Ms. F belongs to a nuclear family. She is single, Roman Catholic and a high school student. She usually goes outside to play badminton and chat with their neighbors and do household chores. She has a good relationship with their neighbors. Her parent was earning an estimated salary of P12, 000 per month. They spend for their foods and groceries, electric bill, cellular phone load, and daily school allowance. Mrs. F’s medical expenses are supported by her family, relatives and health insurance (philhealth).
NORMS Social status included family relationship that serves as his support system especially at times of need and stress related conditions. It meets a fundamental human need for social ties making life less anxious. Also social support system buffers the negative effect of stress as means of achievement of a good health. (Friedman and Smith 1988)
ANALYSIS Ms. F has a normal social status because she is able to mingle with the other people and do the usual things a typical teenager does. They are also able to provide their basic needs.
II. MENTAL STATUS Ms. F is conscious and coherent. Oriented to time and date, she is able to read and write and follow instructions, able to maintain eye to eye contact. She is open to any questions, 10
approachable and is able to converse but slowly with the student nurses. During the assessment, Ms. F talks about her past memories showing that her long term memories are still active.
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NORMS To consider a person’s mental status is normal, he should be oriented. He should be able to evaluate and act appropriately in situations regarding judgment. (Health Assessment and Physical Examination 3rd Edition by Mary Ellen Zator Ester)
ANALYSIS Ms. F’s mental status is normal, it is usual that a patient in pain has a hard time when talking.
III. EMOTIONAL STATUS Prior to hospitalization according to her sister, she is very cheerful; she loves to make conversations to their neighbors, and siblings. Her mother also stated that they have financial problems but since their family and relatives are very supportive not just financially but also emotionally along with the health insurance they are able to lessen their burden regarding their expenses in the hospital. This shows that they have a good relationship status with her family. Ms. F was awake, she stated that she does not feel the pain on the affected part which has a crutch field tong, which was inserted on her skull and it is a normal response.
NORMS Integrity manifests with wisdom and feelings of satisfaction with one’s life while despair arises from remorse about what could have been. The presence of despair causes life to be viewed as meaningless. (Source: Nursing CEU.com: The process of human development) Carrying out emotional feelings through words and facial expressions are normal signs that client was aware of his physical conditions. (Nursing Fundamentals, Rick Daniels) Expression of self 12
control and self perception is just normal (Fundamentals of Nursing, Kozier, Erb, Berman, and Synder).
ANALYSIS Ms. F’s emotional status is considered normal, due to her condition it is normal not to feel pain and become unresponsive in some instances.
IV. SENSORY PERCEPTION
VISION In assessing the vision, Ms. F is instructed to look straight to observe the general appearance of her eyes. Her eyes are almond in shape, irises are black in color and scleras are whitish in color, eyebrows and eye lashes are equally distributed. Her conjunctiva is pale and moist. Ms. F was also instructed to follow the direction of a finger with her eyes following six cardinal positions. And her eyes were able to move in full ranges of motion and in all directions. With the use of penlight pupils are assessed, pupils are equally round and reactive to light accommodation. Ms. F does not use eyeglasses or contact lenses.
Visual acuity was assessed by asking Ms. F to read the word written on a piece of paper with a font size of approximately 12 at about 1 feet away from her using the right eye first then the left eye and then both eyes. Ms. F read all the samples correctly during the test. 13
NORMS For the test of the Cardinal Fields of Gaze, the extra ocular muscle movements are being assessed. Normally, both eyes of the patient should move smoothly and symmetrically in each of the six fields. Light and accommodation reading is possible in the distance of 14 inches for the assessment of near vision. (Health Assessment and Physical Examination 3rd edition by Estes)
Analysis The patient’s visual capacity or status is normal, extra ocular muscle movements and papillary response and visual acuity are normal.
SMELL
Ms. F’s nose has no deviations in terms of shape and size. Nose is pointed and no discharges were seen during the assessment. According to the patient she doesn’t have any history of sinus infection or epistaxis (nose bleeding). Before the next procedure, permission was asked to the Ms. F to do another test. Using a perfume and an orange peel without the patient’s knowledge we ask her to identify the two samples by smelling. After smelling she correctly identifies the perfume and orange peel. Test shows that there are no abnormalities or obstructions were identified in her sense of smell.
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Norms Nose must be symmetrical and along of the face. Each nostril must be patent and recognize the smell of an object. (Health assessment and physical examination, Mary Ellen Zator Estes)
Analysis Client was able to recognize the odor. She has normal sense of smell and normal breathing.
HEARING General appearance of Ms. F’s ears was parallel, symmetrically proportional to the size of the head, bean shape, has a firm cartilage. In assessing the hearing acuity of the patient, Ms. F is instructed to repeat the words that will be whisper at a distance of 2 feet away on the left ear first, and 12 inches away on the right ear because it has a limited space in the right side, after the test she was able to repeat the whispered words. Another test by the use of the beeping sound of the digital thermometer at the distance of 4 feet away and still she was able to hear the sound. She verbalized that she has no known auditory deficits nor ear infection history and unusual sensations like ringing or buzzing.
Norms
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For the auditory acuity, the patient should be able to repeat the whispered words from a distance of two feet. (Health assessment and physical examination, Mary Ellen Zator Estes)
Analysis Based on the given data, patient’s auditory acuity is normal.
TASTE Mrs. F’s lips are dry and symmetrical in shape, tongue is pale in color, no presence of tooth decay, but there is a presence of tooth cavities, no false dentures and no teeth loss, no sign of gingivitis, buccal area are pale. The patient was asked to open her mouth widely to assess the entire mouth. To assess her sense of taste, patient was asked to do some taste test. She was ask to taste a cotton ball soak with orange juice and cotton ball soaked in water with salt without knowing what the two samples are. After patting the cotton balls on the lips of the patient, Mrs. F identified the 2 samples correctly.
Norms Taste is intact in the posterior one third of the tongue. (Health Assessment and Physical Examination, Mary Ellen Zator Estes)
Analysis Client’s sense of taste is normal.
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TOUCH In assessing Mrs. F’s sense of touch, she was asked to close her eyes a cotton ball was stroke to the back of her neck. Then using another cotton ball we poured alcohol on it and rub it on the same area. She started that she felt a sensation of wet and cold on her skin.
Norms The skin contains receptors for pain, touch, pressure and temperature. Sensory signals are transmitted along rapid sensory pathways, and less distinct signals such as pressure of localized touch are sent via slower sensory pathways. (Health Assessment and Physical Examination, Mary Ellen Zator Estes)
Analysis Mrs. F’s sensory transmission functions well as manifested by the data presented, it is considered normal.
V. MOTOR STABILITY Several hours after the surgery, the patient was asked to perform ROM exercise on the upper and lower extremities. She was asked to raise both of her arms. She performed it with ease and freely moved without any difficulty. She can bend and straightened her elbows and extend and spread her fingers. She performed it with ease. According to the patient she felt pain in the right lower quadrant of her abdomen when raising her right leg and cannot move it freely. There 17
is no presence of deformity. There are also proper symmetry between left and right on each extremity. Early ambulation was encouraged. Patient can bend his legs with limited range of motion and needs assistance when standing and going to the comfort room.
NORMS Fine motor skills involve the small muscle of the body that enables such functions as writing, grasping objects and fastening of clothes. Fine motor skill involves strength, fine motor controls and dexterity. Gross motor skills involve the large muscles of the body that enable such functions as walking, kicking, sitting upright, lifting and throwing a ball. A person’s gross motor skills depend on both muscle tone and strength. Low muscle tone is characteristics disabling conditions such as Down syndrome, genetics or muscle disorders, or central nervous system disorders.
ANALYSIS Mrs. F’s motor ability is not in good condition due to the presence of pain in the right lower quadrant of the abdomen when raising the right legs.
VI. BODY TEMPERATURE The table below shows the temperature of Mrs. F during the shift DATE September 30, 2010 TIME 3:35 pm 6:00 pm 10:00 pm TEMPERATURE 36.8°C 36.6°C ANALYSIS normal Normal Normal 18
36.8°C October 1, 2010 3:00 pm 6:00 pm 10:00 pm 38.5°C 38.2°C 37°C Above normal Above normal Normal
INTERPRETATION Mrs. F’s temperature on September 30, 2010 at 3:35 pm is 36.8°C, at 6:00 pm her temperature was 36.6°C, and at 10:00 pm her temperature was 36.8°C. On October 1, 2010 at 3:00 pm the patient’s temperature was elevated at 38.5°C, at 6:00 pm the temperature was 38.2°C, and at around 10:00 pm patient’s temperature is within the normal range at 37°C.
NORMS Normal temperature for axilla is within 35.4-37.4c (Fundamentals of Nursing by Kozier and Erbs 7th edition)
ANALYSIS According to the data gathered on September 30, 2010 at 6:00 pm Mrs. F’s body temperature is on normal range. The patient had altered body temperature on October 1, 2010 at 3:00 pm up to 6:00 pm, and became normal at 10:00 pm.
VII. Respiratory Rate 19
DATE September 30,2010 October 01, 2010
T IME 3:35 pm 9:30 pm
RESPIRATORY RATE 20 cpm 23 cpm
ANALYSIS Normal Tachypneic due to the pain she is experiencing.
Norms Respiration in the resting adult, the normal respiratory rate is 12 to 20 breaths per minute. This type of breathing is termed eupnea, or normal breathing. (Health Assessment and Physical Examination, 3rd edition by Estes, page 455)
(Analysis is presented on the table above)
VIII. Circulatory Rate DATE September 30, 2010 October 01, 2010 TIME 3:35 pm 9:30 pm B.P 90/70 100/80 P.R September 30, 2010 October 01, 2010 3:35 pm 9:30 pm 64 70 Normal Normal ANALYSIS Normal Normal
Norms Pulse 20
Normal pulse rate vary with age. The table below shows the normal range of pulse rate according to age: AGE 10 years 14 years Adult RESTING PULSE RATE 70 – 110 bpm 60 – 110 bpm 60 – 100 bpm AVERAGE 90 85 – 90 72
Source: Health Assessment and Physical Examination, 3rd edition by Estes, page 253
Normal blood pressure varies with age. As a person ages, blood pressure generally increases. The table below shows the general ranges of normal blood pressure at different ages and gender:
BLOOD PRESSURE: Normal Range According to Age and Gender
Female AGE 5 10 15 ≥18 SYSTOLIC (mm Hg) 103 – 109 112 – 118 120 – 127 <120 DIASTOLIC (mm Hg) 66 – 70 73 – 76 78 – 81 <80
Male AGE 5 SYSTOLIC (mm Hg) 104 – 102 DIASTOLIC (mm Hg) 65 – 70
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10 15 ≥18
111 – 119 122 – 131 <120
73 – 78 76 – 81 <80
Source: Health Assessment and Physical Examination, 3rd edition by Estes, page 260
IX. Nutritional Status Before she was confined to the hospital, Mrs. F eats 3 to 4 times per day and drinks 8 to 10 glasses of fluids. She also eats fruits like banana and mango. When the patient was admitted in the hospital, she was on a nothing by mouth state. Her BMI is in normal range.
BMI COMPUTATION: Weight: 48kg Height: 5”1’
BMI =
WEIGHT IN KILOGRAMS HEIGHT IN METER SQUARED
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= 48kg 2.4006 m BMI =19.99 - NORMAL
Norms According to the Health Asian Diet Pyramid, there should be a daily intake of rice, grains, bread, fruit and vegetables; optional daily for fish, shellfish, and dairy products; weekly for sweets, eggs and poultry, and monthly for meat. There should be an increase intake of a wide variety of fruits and vegetables. Include in the diet foods higher in vitamins C and E, and omega-3 fatty acid rich foods. (www.webmd.com)
Analysis Mrs. F nutritional status was affected because of the surgical procedure done to her (appendectomy). Her BMI is in the normal range.
X. Elimination Status Mrs. F usually defecates once every day and urinates 4 to 5 times per day with an approximately 30 to 40 cc of urine per urination. When she was admitted she voids 4 times and defecates once.
Norms 23
The frequency of defecation is highly individual, varying from several times per day to two or three times per week. The amount defecated also varies from person to person. (Fundamentals of Nursing 7th edition by Kozier, et. Al., page 1126) Average Daily Urine Output by Age AGE 5 to 8 years 8 to 14 years 14 years through adulthood Older adulthood AMOUNT(mL) 700 – 1000 800 – 1400 1500 1500 or less
Source: Fundamentals of Nursing 7th edition by Kozier, ET. Al., page 1261
ANALYSIS Mrs. F elimination status is affected. Because she was on nothing by mouth state after the operation, she has nothing to defecate.
XI. Reproductive Status Mrs. F had her first menstrual period at age of 14 and she has a regular menstruation. At least 1 - 2 pads of napkins a day was used when she have her menses. She had her first pregnancy when she was 20 years old. She also has 2 miscarriages, her fourth and sixth baby. Norms Menarche which is the first menstruation occurs at an average age of onset between 9 to 17 years old. Pregnancy may occur from stage of menarche up to duration of menstrual period. Menopause occurs with age range of 40 to 55. 24
(Maternal and Child health Nursing 4th Edition by Pilliteri)
ANALYSIS Based on the statement above Mrs. F has a normal reproductive status. She was able to conceive offspring.
XII. Sleep – Rest Pattern She usually sleeps at 8 to 9 in the evening and wakes up at 4 in the morning. She watches television during his rest hours to relax and she loves to wash their clothes. She also spends time to be with her family and neighbor. But when she was confined her sleep pattern was always interrupted.
Norms NORMAL HOURS OF CATEGORY Newborns Infants Toddlers Preschoolers School – age children Young adults SLEEP PER DAY 16 to 18 12 to 14 10 to 12 11 to 12 8 to 12 7 to 8
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Middle – aged adults Elders
6 to 8 About 6 hours
Source: Fundamentals of Nursing 7th edition by Kozier, ET. Al., page 1116
ANALYSIS Because of his condition, Mrs. F's sleep pattern was affected.
XIII. State of Skin and Appendages Mrs. F’s skin is light brown in color. Her skin in the foot is dry, some calluses are observed. She complains of some itchiness on her lower extremities. Her conjunctiva is pale. She has some scar on her lower extremities. Her nails are pale, short and clean. Her nail beds are slightly pale. Her capillary refill time is 2 seconds.
NORMS The palpebral conjunctiva should appear pink and moist. Normally the skin is a uniform whitish pink or brown color depending on the patient's race. Normally, the nails have pink cast light skinned individuals and are brown in dark-skinned individuals. (Health assessment and Physical Examination, 3rd edition by Mary Ellen Zator Estes).
Analysis Mrs. F skin appendages are affected due to decreased oxygen supply. The patient’s dry skin was due to restriction in fluid and any food. The Patient’s capillary refill is normal. 26
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6. Laboratory and Diagnostic Procedures DATE ORDERED: September 29, 2010
Urinalysis INDICATION RESULT Color: Yellow NORMAL RANGE Straw yellow – amber Transparent – turbid Absent 0.2 – 1.0 mg/dl Absent - Trace 5.0 – 8.5 Absent 1.010 – 1.015 Absent Absent Absent Negative or few Few ANALYSIS Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal High. An indicator that there is an infection present in the urinary tract. Normal Epitheleal Cells: Moderate Bacteria: Rare Urates/Phosphates: Moderate Few Normal Negative or Few Normal Few 28
>to detect renal Transparency: Turbid and metabolic diseases. Leukocytes/Nitrates: Negative Urobilirogen: Normal >diagnosis of Protein: Trace diseases or disorders of the pH: 6.0 kidney or urinary tract. Blood cells: negative Specific gravity: 1.010 Ketone: Negative Bilirubin: Negative Glucose: Negative Mucus threads: Moderate Pus cells: 3 - 4
RBC: 0 - 1
0 – 3/ HPF
Normal
NURSING RESPONSIBILITIES
Prior to procedure: Explain the procedure to the patient and family/relatives. Provide for patient’s privacy. Instruct the patient to go to the laboratory with the request form. Instruct the patient to dispose the first urine and catch the midstream urine. Educate the patient not to contaminate the inside part of the container. Instruct the patient to send the specimen to the laboratory immediately During the procedure: Maintain the sterility of the specimen container by not touching the inside part. Maintain the freshness and sterility of the urine specimen. After the procedure: 29
Interpret the result Refer to the physician if abnormalities are noted.
DATE ORDERED: September 29, 2010
Complete Blood Count INDICATION RESULT NORMAL RANGE ANALYSIS 30
BLOOD TYPE: A+
>to WBC: 13.9 G/L detect/diagnose blood disorders.
4.1 – 10.9 G/L
WBC is high because of the presence of infection. WBC defends our body against infection.
>to detect presence of infection.
LYM: 1.8 R2 12.9%L 0.6 – 4.1 *MID: 0.8 GRAN:7.0 5.5%M 81.6%G 0.0 – 1.8 2.0 – 7.8
10.0– 58.5%L 0.1 – 24 %M
Normal Normal
37.0–92.0 %G Normal Normal Normal Normal Normal Normal Normal Normal Normal
>to screen for fluid and electrolyte problem.
RBC: 4.17 T/L HGB: 113 g/L HCT: .373 L/L MCV: 82.6 fL MCH: 27.1 pg MCHC: 328 g/L
4.20 – 6.30 T/L 120 – 180 g/L .370 - .510 L/L 80.0 – 97.0 fL 26.0 – 32.0 pg 310 – 360 g/L 11.5 – 14.5 %
PLT: 379 G/L
140 – 440 G/L
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NURSING RESPONSIBILITIES
Prior to procedure: Explain the procedure to the patient and family/relatives. Educate the patient about what to expect during the procedure. During the procedure: Advise the patient to relax during the procedure. After the procedure: Interpret the result Refer to the physician if abnormalities are noted.
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7. Anatomy and Physiology
The Appendix 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 quadrant of the abdomen, or, more specifically, the right iliac fossa. Its position within the abdomen corresponds to a point on the surface known as McBurney's point (see below). While the base of the appendix is at a fairly constant location, 2 cm below the ileocecal valve, the location of the 33
tip of the appendix can vary from being retrocecal (74%) to being in the pelvis to being extraperitoneal. In rare individuals with situs inversus, the appendix may be located in the lower left side. New studies propose that the appendix may harbor and protect bacteria that are beneficial in the function of the human colon. Some researchers argue that the appendix has a function in fetuses and adults.[7] Endocrine cells have been found in the appendix of 11-week-old fetuses that contribute to "biological control (homeostatic) mechanisms." In adults, Martin argues that the appendix acts as a lymphatic organ. The appendix is experimentally verified as being rich in infection-fighting lymphoid cells, suggesting that it might play a role in the immune system. 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, explanations were lacking for the distinctive shape of the appendix and its apparent lack of importance as judged by an absence of side-effects following appendectomy.
8. PATHOPHYSIOLOGY
Book based
Non modifiable risk factors: >age >gender
Modifiable risk factors: >constipation >activity
Severity of symptoms is related to the degree of inflammation Other common symptoms include Appendectomy is often anorexia, nausea and suggested by the vomiting, low grade physician. fever, elevated WBC present. Concurrent infection can cause mucosal Abdominal pain is present, usually The inflammatory process ranges ulceration and subsequent development of described to severe appendiceal from mild as being in the right lower abscess, necrosis or rupture. quadrant, localized at Mcburney’s point. swelling and obstruction. 34
Patient – based
Modifiable Factors Constipation Low Fiber – Occlusion of appendix by fecalith
Non Modifiable Factors Age
Increased intra luminal pressure in the appendix
Start of the inflammatory process Low grade fever Appendectomy Inflammation of appendix (appendicitis)
Acute abdominal pain at the Mcburney’s point.
Nausea and loss of appetite 35
B. PLANNING NURSING CARE PLAN Acute Pain Assessment Planning Intervention Expected outcome Within 30 minutes to 1 hour of giving proper nursing interventions, the patient will:
Subjective: “Masakit ang sugat ko” P/S is 6/10. Objectives: facial grimace increase ability to perspire irritable at times guarding behavior limited movements and range of motion. assisted with the significant others when turning in other position. Nursing Diagnosis: Acute pain related to surgical incision on the abdomen. Scientific Explanation:
Within 30 minutes to 1 hour of giving proper nursing interventions, the patient will verbalize reduction of pain.
Monitor the pain scale. (to know if there is an improvement) Position on a semi-fowlers position.(for the patient to feel comfortable) Provide a clean bed. (to have a good relaxation.) Encourage to have a bed rest.( to gain energy) Encourage to continue limiting body movements. (to prevent pain) Educate the importance of deep breathing exercises. (for the patient to feel calm and relax) Divert attention by instructing to read books.(to lessen and divert pain) Instruct to increase fluid intake.(to prevent dehydration) Instruct to guard the site when
-verbalize a decrease of pain. -can move freely without assistance. -free from irritability. -facial grimace will be absent. 36
Unpleasant sensory and emotional experience arising fromactual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity frommild to severe with an anticipated or predictable end and a duration of less than 6 months. (Nurse’s Pocket Guide Edition 11 by F.A Davis, page 498)
coughing. (to prevent from opening of the site) Instruct to take medications that are prescribed by the physician. (for the patient safety to drugs) Educate the patient to clean the site
regularly. (to prevent any complications and infection)
Hyperthermia Assessment Subjective:Ø Planning Within 1 hour of proper nursing interventions, the patient’s temperature will subside to 37.5 °c from 38.5 °c. Interventions Monitor vital signs especially temperature. (To know if it has an improvement of the patient’s temperature.) Perform Tepid Sponge bath. (To lower body temperature.) Provide clean and comfortable bed. (for the patient to have a good rest and feel comfortable) Provide clean and comfortable clothing. (for the patient not to feel irritable) Expected Outcomes Within 1 hour of proper nursing interventions, the patient’s temperature will subside to 37.5 °c from 38.5 °c.
Objective: warm to touch diaphoretic weak in appearance irritable at times vital signs taken as follows:
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BP-90/70 mmHg RR-20 cpm PR-64 bpm Temp- 38.5°c Diagnosis: Altered body temperature related to inflammatory process.
Instruct to increase fluid intake after NPO. (to prevent dehydration) Instruct to eat nutritious foods like green leafy vegetables after NPO. (to gain more energy) Instruct to take medications that are prescribed by the physician. (For safety purposes.)
Scientific Explanation: Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. It may also occur as assign of infection.
Risk for Infection 38
ASSESMENT S O O Irritable Poor hygiene Long fingernails Dirty surroundings Incision on the right lower quadrant of the abdomen
PLANNING Within 2 hours of proper nursing intervention the client risk for infection will decrease to achieve timely wound healing
INTERVENTION AND RATIONALE Instruct in good hand washing (Reduces risk of spread of bacteria) Instruct good body hygiene (Reduces risk of spread of bacteria and promote relaxation) Demonstrate aseptic wound care (Reduces risk of spread of bacteria) Inspect incision and dressings (Provides for early detection of developing infections process) Encourage to cut the fingernails (Reduce risk of spread of bacteria)
EXPECTED OUTCOME After 2 hours of proper nursing intervention the client risk for infection is decrease to achieve timely wound healing as evidenced by:
a. Washing the hands using soap
Diagnosis Risk for infection related to surgical incision on the right lower quadrant of the abdomen
b. Good body hygiene
SCIENTIFIC EXPLANATION There’s a risk for infection for a client who undergone a surgical incision because there is a break in the tissue or that would serve as an opening that can be
c. Well kept Encourage to keep the surrounding surroundings of the patient clean (To minimize the chance of getting infection through microorganisms around the ward) d. Short fingernails
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invaded by different kind of microorganisms.
Impaired Skin Integrity ASSESSMENT PLANNING INTERVENTIONS EXPECTED OUTCOME
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S “nangangati ang sugat ko” O with surgical incision at the mcburney’s point with suture noted with surgical dressing intact poor skin turgor limited movement
Within 1 hour of proper nursing interventions, the patient will regain integrity of the skin and demonstrate measures to protect care and heal the skin lesion.
Diagnosis Impaired skin integrity related to tissue damage. Scientific explanation Invasion of body structures, destruction of skin layers (dermis), disruption of skin surface (epidermis).
Assess site of skin impairment (the cause of the wound must be determined before appropriate interventions can be implemented). Monitor site of skin impairment for color change, redness, swelling, warmth, pain, or other signs of infections (systematic inspection can identify impending problem early). Clean the site aseptically (to decrease the production of bacteria). Select a topical treatment that will maintain a moist wound – healing environment and that is balanced with the need to absorb exudates ( keep peri wound skin dry and control exudates and eliminate dead space) Avoid massaging around the site of skin impairment and over bony prominences (massage may lead to tissue trauma). Monitor nutritional intake (Altered nutrition can prevent wound healing and put at risk for further skin breakdown).
After 1 hour of rendering proper nursing interventions, the patient will regain integrity of the skin and demonstrate measures to protect care and heal the skin lesion.
Fatigue 41
Assessment Subjective: Nanghihina ako” Objective: with limited body movements weak in appearance slow and low voice noted diaphoretic vital signs taken as follows: BP-80/70 mmHg
Planning Within 1 hour of proper nursing interventions, the patient will verbalize increase body strength.
RR-20 cpm PR-64 bpm Temp- 35.8 °c Diagnosis: Fatigue related to post surgical procedure. Scientific Explanation: An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.
Interventions Obtain vital signs. (for baseline purposes) Maintain on a flat position as an order of the physician. Encourage to have adequate rest. (to gain energy) Encourage to ask some help to the nurse or significant others if she want to move or change in position. (for the patients safety) Instruct to increase fluid intake after NPO. (to prevent dehydration) Instruct to eat nutritious foods like green leafy vegetables after NPO. (to gain more energy) Educate about the significant others to assist the patient when moving. (for safety and for the patient to move easily)
Expected Outcomes Within 1 hour of proper nursing interventions, the patient will verbalize increase body strength.
Instruct to take medications that are prescribed by the physician. (To avoid any drug accident such as overdosing.)
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C. IMPLEMENTATION 1. DRUGS Name of Drug Cefoxitin Date Administered October 1, 2010 6:00pm Route and Administration IVP 1g q 8 hours General Action Bactericidal: Inhibits synthesis of bacterial cell wall, causing cell death. • Indication Perioperative prophylaxis. Client’s actual response to medication Presence of pain was noted on the IV insertion site during the drug administration.
Nursing Responsibilities:
Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.
43
Name of Drug Ketorolac
Date Administered September 30, 2010 6:00pm
Route and Administration IVP 30mg q 6 hours
General Action anti-inflammatory, antipyretic and analgesic effects is the inhibition of prostaglandin synthesis by competitive blocking of the enzyme cyclooxygenase (COX)
Indication • Short-term management of pain due to surgical procedure done
Client’s actual response to medication • Pain scale of 8/10 decreases to 4/10 which is consider as bearable pain.
Nursing Responsibilities: 44
Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.
Name of Drug Omeprazole
Date Administered September 30, 2010 6:00pm
Route and Administration IVP 40mg q 12 hours
General Action Gastric acid-pump inhibitor. Suppresses gastric acid secretion by specific inhibition of the hydrogenpotassium ATPase •
Indication Perioperative client who is NPO
Client’s actual response to medication • Pain due to hypersecretion of hydrochloric acid in the stomach is lessen. 45
enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production.
Nursing Responsibilities:
Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.
46
Name of Drug Paracetamol
Date Administered October 1, 2010 6:00pm
Route and Administration IVP 30mg PRN
General Action The main mechanism of action of paracetamol is considered to be the inhibition of cyclooxygenase (COX) •
Indication For client who has elevated temperature (hyperthermia)
Client’s actual response to medication • Client’s temperature of 38.5oc decreases to 37.5oc
Nursing Responsibilities:
Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.
47
2.
MEDICAL MANAGEMENT
Medical Management
Date Ordered/ Performed/ Changed/ Discontinued
General Description
Indication/s or purpose/s
Client’s reaction to treatment
Changed: September 30, 2010 at 10:28 pm. Intravenous Fluid D5LRS @ 20gtts/min
D5LR is actually 5% dextrose in lactated ringer's solution. It is a hypertonic solution which means it pulls fluid out of the cells into the intravascular space (veins).
This solution is indicated for use in adults and pediatric patients as a source of electrolytes, calories and water
The patient was hydrated. The fluid and electrolytes level of her body is maintained.
48
5% Dextrose in Lactated for hydration. Ringer's Injection provides electrolytes and calories, and is a source of water for hydration. It is capable of inducing diuresis depending on the clinical condition of the patient. This solution also contains lactate which produces a metabolic alkalinizing effect.
49
Nursing Management Prior Before starting I.V therapy, consider duration of therapy, type of infusion condition of veins and medical condition of the patient to assist in choosing in I.V site and type of catheter. Ensure that you are competent in initiating the type of I.V therapy decided on and familiar with institutional policy and procedure before initiating therapy. Explain the procedure to the client and why is it necessary.
During Monitor the insertion site for signs of phlebitis or infiltration. Monitor the flow rate of the IV fluid. Maintain the cleanliness of the plaster. After After initiation of I.V therapy, monitor the patient frequently for: 1. Signs of infiltration of sluggish flow 2. Signs of phlebitis or infection 3. Correct solution, medication, volume and rate 4. Dwell time of catheter and need to be replace 5. Condition of catheter dressing and frequency of change 6. Fluid and electrolyte balance 7. Signs of fluid overload or dehydration 8. Patient satisfaction with mode therapy
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Medical Management
Date Ordered/Performed Changed/discontinued General Description Indication/s or purpose/s Client’s reaction to treatment
Oxygen Therapy 09-30-2010
08-30-2010
Oxygen may be classified as an element, a gas, and a drug. Oxygen therapy is the administration of oxygen at concentrations greater than that in room air to treat or prevent hypoxemia (not enough oxygen in the blood). Oxygen delivery systems are classified as stationary, portable, or ambulatory. Oxygen can be administered by nasal cannula, mask, and tent. Hyperbaric oxygen therapy involves placing the patient in an airtight chamber with oxygen under pressure.
The body is constantly taking in oxygen and releasing carbon dioxide. If this process is inadequate, oxygen levels in the blood decrease and the patient may need supplemental oxygen. Oxygen therapy is a key treatment in respiratory care. The purpose is to increase oxygen saturation in tissues where the saturation levels are too low due to illness or injury. Breathing prescribed oxygen increases the amount of oxygen in the blood, reduces the extra work of the heart, and decreases shortness of breath. Oxygen therapy is frequently ordered in the home care setting, as well as in acute (urgent) care facilities.
The patient’s oxygen need was sustained. Airway becomes easier. Breathing pattern becomes normal.
3. Surgical Management DATE PERFORMED: September 30, 2010 – 11:45 a.m Name of Procedure Brief Description Indication/ Purpose Client’s Response to Operation
51
Appendectomy
Surgical removal of the Appendix
To remove the inflamed appendix to prevent rupture - this will eventually lead to peritonitis.
The patient was asleep after the operation.
The patient was lying flat on bed 6 – 8 hours after the surgery.
The patient had chills few hours after the operation.
The patient had fever 1 day after the operation. Nursing Responsibilities Prior to the Surgery Check the vital signs for baseline data. Instruct the patient to be on nothing per Orem 8 hours prior to surgery. Educate the patient the patient about coughing, deep breathing exercises and turning side – to – side after the surgery. Let the patient voice out what she feels to relieve anxiety. Listen to what the patient says. During the surgery Promote sterility on the sterile field. Monitor the patient’s well being. Monitor patient’s vital signs After the Surgery 52
Keep the patient on NPO for 6 to 8 hours or until peristalsis occurs. Keep the patient lie flat on bed without pillow for 6 to 8 hours. Monitor for bleeding and signs of shock. Monitor for signs of infection.
4. DIET 53
5. ACTIVITY/EXERCISE
54
D. EVALUATION
III. CONCLUSION The group’s grand case study is about ruptured appendicitis. It was a good learning experience for our group to handle such case. The client manifest hyperthermia, fatigue, impaired physical mobility, and impaired skin integrity, the group therefore concludes that nursing intervention should be done to alleviate predicament on the client’s health. The highlight of our principle is to provide optimum nursing care primarily to our client and the significant others as well. The group believes that the first thing to consider for our client’s wellness to make them feel special and be sincere in rendering quality services. Susceptibility of the client to acquire complication is greatly at risk. Hence, client should be monitor carefully and medications must be maintained ideally.
IV. RECOMMENDATION The group recommends providing wound care aseptically as frequently as possible to prevent infection and apply cold compress to the abdomen when abdominal pain is experience. Advice regular consultation to the physician for it can be a factor for recovery and assess the patient’s progress. Advised the client who has to religiously take his medication prescribed to alleviate symptoms and prevent further complications. Instruct the patient normal activities can be resumed within a few days, but it takes four to six weeks for full recovery. Heavy lifting and strenuous activities should be avoided during recovery. Encourage continuous range of motion exercises. Eat healthy foods from all of the five food groups; fruits, vegetables, breads, dairy products, meats, fishes. Eating healthy foods may help the patient feel better and have more energy and also help recover faster from sickness. Emphasize the importance of increase dietary intake of fiber and vitamin C. Avoid foods that can cause constipation such as apple, guava and star apple. Encourage to increase fluid intake to maintain hydration and electrolyte balance. 55
V. REVIEW OF RELATED LITERATURE
Viral Infections Linked to Appendicitis By Rajshri on January 19, 2010 at 6:55 PM
A new study by UT Southwestern Medical Center surgeons and physicians says that appendicitis may also be caused by a virus and that you can actually "catch" it. The researchers evaluated data over a 36-year period from the National Hospital Discharge Survey and concluded in a paper appearing in the January issue of Archives of Surgery that appendicitis may be caused by undetermined viral infection or infections, said Dr. Edward Livingston, chief of GI/endocrine surgery at UT Southwestern and senior author of the report. The review of hospital discharge data runs counter to traditional thought, suggesting that appendicitis doesn't necessarily lead to a burst appendix if the organ is not removed quickly, Dr. Livingston said.
"Just as the traditional appendix scar across the abdomen is fast becoming history, thanks to new single-incision surgery techniques that hide a tiny scar in the bellybutton, so too may the conventional wisdom that patients with appendicitis need to be operated on as soon as they enter the hospital," said Dr. Livingston. "Patients still need to be seen quickly by a physician, but emergency surgery is now in question." Appendicitis is the most common reason for emergency general surgery, leading to some 280,000 appendectomies being performed annually.
Appendicitis was first identified in 1886. Since then, doctors have presumed quick removal of the appendix was a necessity to avoid a subsequent bursting, which can be an emergency. Because removing the appendix solves the problems and is generally safe, removal became the standard medical practice in the early 20th century. SOURCE: http://www.medindia.net/news/Viral-Infections-Linked-to-Appendicitis-63833-1.htm 56
VI. BIBLIOGRAPHY
Published Materials Medical – Surgical Nursing: Clinical Management for Positive Outcome 8th by Joyce Black and Jane Hokanson Hawks, Fundamentals of Nursing Practice 7th edition by Kozier and Erbs Health Assessment and Physical Examination 3rd edition by Estes Medical – Surgical Nursing 8th edition by Joyce Black 2010 Lippincotts Nursing Drug Guide by Amy Karch Prentice Hall Nursing Diagnosis Handbook by Judith M. Wilkinson and Nancy R. Ahern
Unpublished Materials http://www.wikipedia.org/wiki/Appendicitis?wasRedirected=true http://www.healthscout.com/ency/68/658/main.html http://www.ufs.ph/tinig/mayjun02/05060225.html http://www.nlm.nih.gov/medlineplus/ency/arcticle/002921.html http://www.diagnosis.com/a/acute_appendicitis/prevalence.html http://wiki.answers.com/Q/What_is_the_appendicitis_rate_in_the_Philippines 57
58
1
OBJECTIVES
Student – Nurse Centered
General Objectives To gather additional knowledge from the patient’s condition and give proper nursing care on her post – operative state to prevent complications through the use of the nursing process.
2
Specific Objectives At the end of the study the student nurse will: Understand and be knowledgeable about the patient’s condition. Assess the needs for care of the patient. Plan appropriate interventions related to the patient’s needs. Implement the planned nursing interventions. Evaluate whether the goals are met or not. Reassess if the care of plan was effective.
Patient – Centered
General Objectives The patient will be knowledgeable about the proper care needed on her post – operative state, to attain maximum level of care, and to prevent complications.
Specific Objectives At the end of the study, the patient will: Be knowledgeable about her condition. Understand the extent of restrictions of food and activities. Achieve the needed nursing care appropriate for her age and condition. Decrease the anxiety she is experiencing after the surgery and possible complications. Respond to the prescribed treatments or managements. 3
Become better and will live normally like with other people.
4
I.
NURSING PROCESS
A. ASSESSMENT
1. Personal Data
a. Demographic Data Name Age Sex Birthday Address Religion Nationality Civil Status Occupation Height Weight Chief Complaint : Ms. F : 13 years old : Female : : Tacloban : Roman Catholic : Filipino : Single : Housewife : 5’1” : 48 kilograms : 5
Date of Admission
: Feb. 22, 2011
Admitting Diagnosis : Final Diagnosis :
b. Environmental Status Mr. F resides at Tacloban. Their house was a bungalow type which is made up of bamboo where there are mango trees around it. There are two rooms in their house which they use for sleeping. They are five living in their house. There is available sari – sari stores available in their place. The available means of transportation in their area are thru jeepney, tricycle, bus and taxi. Their source of water is in Nawasa. They have two cats and a dog which they allow to stay inside their house. They said that they have a good relationship with their neighborhood.
c. Lifestyle
6
Ms. F is a second year high student. She usually sleeps at 8 or 9 in the evening and wakes up at around 6 in the morning to prepare herself to school. Every day, she usually plays badminton as her sports and exercise and as past time. According to her sister, their mother usually cooks meat or pork dishes, and sometimes vegetables. He usually drinks 8 - 10 glasses of water a day. She takes a bath every day, usually every morning before she goes to school. Her sister also stated that Ms. F started not to drink milk when she was 11 years old.
7
2. FAMILY HISTORY OF HEALTH AND ILLNESS
PATERNAL
MATERNAL
8 7
78 TB
8 1
ASTHMA
76
5 3
5 0
48
4 0
38
3 6
56
5 3
50
4 8
45
v/a 2 2 2 2 BOY GIRL X DECEASED PATIENT POTT’s DISEASE TB V/A TUBERCULOSIS Vehicular Accident
18
1 6
1 3
LEGEND
8
3. History of Past Illness
According to Ms. F this is her first hospitalization. It was on She already had Chicken Pox and measles but the patient can no longer remember her age when she experienced those conditions. Ms. F did not know if she was fully immunized, she does not have any allergies to any foods, medication and pets. Ms. F never experienced any surgery procedure or injury when she was young. Cough and Colds, Diarrhea and fever are the usual condition that she acquired and she treated it with over the counter drugs like paracetamol, neozep and loperamide.
4. History of Present Illness Four months prior to admission, patient stated that she had experienced stiffening of her neck but without pain. Two to three months prior to admission, episodes of pain followed but can be tolerated by the patients One month prior to admission, pain severed and the pain scale of 10/10 was rated. No medicine was given to relieve the pain. She was then rushed to Taguig-Pateros Hospital last February 21, 2011 for immediate x-ray exam on the cervical and the exam revealed that there is a “melting bone on her C1 and C2” as stated by the doctor to her. She was referred to Philippine Orthopedic Center February 22 and was again ordered another x-ray examination to justify if the previous exam was accurate. They got the same results. She was examined by the physician, hence, admitted.
9
5. 13 AREAS OF ASSESSMENT I. SOCIAL STATUS Ms. F is the youngest of the four siblings. The family resides at Tacloban. Ms. F belongs to a nuclear family. She is single, Roman Catholic and a high school student. She usually goes outside to play badminton and chat with their neighbors and do household chores. She has a good relationship with their neighbors. Her parent was earning an estimated salary of P12, 000 per month. They spend for their foods and groceries, electric bill, cellular phone load, and daily school allowance. Mrs. F’s medical expenses are supported by her family, relatives and health insurance (philhealth).
NORMS Social status included family relationship that serves as his support system especially at times of need and stress related conditions. It meets a fundamental human need for social ties making life less anxious. Also social support system buffers the negative effect of stress as means of achievement of a good health. (Friedman and Smith 1988)
ANALYSIS Ms. F has a normal social status because she is able to mingle with the other people and do the usual things a typical teenager does. They are also able to provide their basic needs.
II. MENTAL STATUS Ms. F is conscious and coherent. Oriented to time and date, she is able to read and write and follow instructions, able to maintain eye to eye contact. She is open to any questions, 10
approachable and is able to converse but slowly with the student nurses. During the assessment, Ms. F talks about her past memories showing that her long term memories are still active.
11
NORMS To consider a person’s mental status is normal, he should be oriented. He should be able to evaluate and act appropriately in situations regarding judgment. (Health Assessment and Physical Examination 3rd Edition by Mary Ellen Zator Ester)
ANALYSIS Ms. F’s mental status is normal, it is usual that a patient in pain has a hard time when talking.
III. EMOTIONAL STATUS Prior to hospitalization according to her sister, she is very cheerful; she loves to make conversations to their neighbors, and siblings. Her mother also stated that they have financial problems but since their family and relatives are very supportive not just financially but also emotionally along with the health insurance they are able to lessen their burden regarding their expenses in the hospital. This shows that they have a good relationship status with her family. Ms. F was awake, she stated that she does not feel the pain on the affected part which has a crutch field tong, which was inserted on her skull and it is a normal response.
NORMS Integrity manifests with wisdom and feelings of satisfaction with one’s life while despair arises from remorse about what could have been. The presence of despair causes life to be viewed as meaningless. (Source: Nursing CEU.com: The process of human development) Carrying out emotional feelings through words and facial expressions are normal signs that client was aware of his physical conditions. (Nursing Fundamentals, Rick Daniels) Expression of self 12
control and self perception is just normal (Fundamentals of Nursing, Kozier, Erb, Berman, and Synder).
ANALYSIS Ms. F’s emotional status is considered normal, due to her condition it is normal not to feel pain and become unresponsive in some instances.
IV. SENSORY PERCEPTION
VISION In assessing the vision, Ms. F is instructed to look straight to observe the general appearance of her eyes. Her eyes are almond in shape, irises are black in color and scleras are whitish in color, eyebrows and eye lashes are equally distributed. Her conjunctiva is pale and moist. Ms. F was also instructed to follow the direction of a finger with her eyes following six cardinal positions. And her eyes were able to move in full ranges of motion and in all directions. With the use of penlight pupils are assessed, pupils are equally round and reactive to light accommodation. Ms. F does not use eyeglasses or contact lenses.
Visual acuity was assessed by asking Ms. F to read the word written on a piece of paper with a font size of approximately 12 at about 1 feet away from her using the right eye first then the left eye and then both eyes. Ms. F read all the samples correctly during the test. 13
NORMS For the test of the Cardinal Fields of Gaze, the extra ocular muscle movements are being assessed. Normally, both eyes of the patient should move smoothly and symmetrically in each of the six fields. Light and accommodation reading is possible in the distance of 14 inches for the assessment of near vision. (Health Assessment and Physical Examination 3rd edition by Estes)
Analysis The patient’s visual capacity or status is normal, extra ocular muscle movements and papillary response and visual acuity are normal.
SMELL
Ms. F’s nose has no deviations in terms of shape and size. Nose is pointed and no discharges were seen during the assessment. According to the patient she doesn’t have any history of sinus infection or epistaxis (nose bleeding). Before the next procedure, permission was asked to the Ms. F to do another test. Using a perfume and an orange peel without the patient’s knowledge we ask her to identify the two samples by smelling. After smelling she correctly identifies the perfume and orange peel. Test shows that there are no abnormalities or obstructions were identified in her sense of smell.
14
Norms Nose must be symmetrical and along of the face. Each nostril must be patent and recognize the smell of an object. (Health assessment and physical examination, Mary Ellen Zator Estes)
Analysis Client was able to recognize the odor. She has normal sense of smell and normal breathing.
HEARING General appearance of Ms. F’s ears was parallel, symmetrically proportional to the size of the head, bean shape, has a firm cartilage. In assessing the hearing acuity of the patient, Ms. F is instructed to repeat the words that will be whisper at a distance of 2 feet away on the left ear first, and 12 inches away on the right ear because it has a limited space in the right side, after the test she was able to repeat the whispered words. Another test by the use of the beeping sound of the digital thermometer at the distance of 4 feet away and still she was able to hear the sound. She verbalized that she has no known auditory deficits nor ear infection history and unusual sensations like ringing or buzzing.
Norms
15
For the auditory acuity, the patient should be able to repeat the whispered words from a distance of two feet. (Health assessment and physical examination, Mary Ellen Zator Estes)
Analysis Based on the given data, patient’s auditory acuity is normal.
TASTE Mrs. F’s lips are dry and symmetrical in shape, tongue is pale in color, no presence of tooth decay, but there is a presence of tooth cavities, no false dentures and no teeth loss, no sign of gingivitis, buccal area are pale. The patient was asked to open her mouth widely to assess the entire mouth. To assess her sense of taste, patient was asked to do some taste test. She was ask to taste a cotton ball soak with orange juice and cotton ball soaked in water with salt without knowing what the two samples are. After patting the cotton balls on the lips of the patient, Mrs. F identified the 2 samples correctly.
Norms Taste is intact in the posterior one third of the tongue. (Health Assessment and Physical Examination, Mary Ellen Zator Estes)
Analysis Client’s sense of taste is normal.
16
TOUCH In assessing Mrs. F’s sense of touch, she was asked to close her eyes a cotton ball was stroke to the back of her neck. Then using another cotton ball we poured alcohol on it and rub it on the same area. She started that she felt a sensation of wet and cold on her skin.
Norms The skin contains receptors for pain, touch, pressure and temperature. Sensory signals are transmitted along rapid sensory pathways, and less distinct signals such as pressure of localized touch are sent via slower sensory pathways. (Health Assessment and Physical Examination, Mary Ellen Zator Estes)
Analysis Mrs. F’s sensory transmission functions well as manifested by the data presented, it is considered normal.
V. MOTOR STABILITY Several hours after the surgery, the patient was asked to perform ROM exercise on the upper and lower extremities. She was asked to raise both of her arms. She performed it with ease and freely moved without any difficulty. She can bend and straightened her elbows and extend and spread her fingers. She performed it with ease. According to the patient she felt pain in the right lower quadrant of her abdomen when raising her right leg and cannot move it freely. There 17
is no presence of deformity. There are also proper symmetry between left and right on each extremity. Early ambulation was encouraged. Patient can bend his legs with limited range of motion and needs assistance when standing and going to the comfort room.
NORMS Fine motor skills involve the small muscle of the body that enables such functions as writing, grasping objects and fastening of clothes. Fine motor skill involves strength, fine motor controls and dexterity. Gross motor skills involve the large muscles of the body that enable such functions as walking, kicking, sitting upright, lifting and throwing a ball. A person’s gross motor skills depend on both muscle tone and strength. Low muscle tone is characteristics disabling conditions such as Down syndrome, genetics or muscle disorders, or central nervous system disorders.
ANALYSIS Mrs. F’s motor ability is not in good condition due to the presence of pain in the right lower quadrant of the abdomen when raising the right legs.
VI. BODY TEMPERATURE The table below shows the temperature of Mrs. F during the shift DATE September 30, 2010 TIME 3:35 pm 6:00 pm 10:00 pm TEMPERATURE 36.8°C 36.6°C ANALYSIS normal Normal Normal 18
36.8°C October 1, 2010 3:00 pm 6:00 pm 10:00 pm 38.5°C 38.2°C 37°C Above normal Above normal Normal
INTERPRETATION Mrs. F’s temperature on September 30, 2010 at 3:35 pm is 36.8°C, at 6:00 pm her temperature was 36.6°C, and at 10:00 pm her temperature was 36.8°C. On October 1, 2010 at 3:00 pm the patient’s temperature was elevated at 38.5°C, at 6:00 pm the temperature was 38.2°C, and at around 10:00 pm patient’s temperature is within the normal range at 37°C.
NORMS Normal temperature for axilla is within 35.4-37.4c (Fundamentals of Nursing by Kozier and Erbs 7th edition)
ANALYSIS According to the data gathered on September 30, 2010 at 6:00 pm Mrs. F’s body temperature is on normal range. The patient had altered body temperature on October 1, 2010 at 3:00 pm up to 6:00 pm, and became normal at 10:00 pm.
VII. Respiratory Rate 19
DATE September 30,2010 October 01, 2010
T IME 3:35 pm 9:30 pm
RESPIRATORY RATE 20 cpm 23 cpm
ANALYSIS Normal Tachypneic due to the pain she is experiencing.
Norms Respiration in the resting adult, the normal respiratory rate is 12 to 20 breaths per minute. This type of breathing is termed eupnea, or normal breathing. (Health Assessment and Physical Examination, 3rd edition by Estes, page 455)
(Analysis is presented on the table above)
VIII. Circulatory Rate DATE September 30, 2010 October 01, 2010 TIME 3:35 pm 9:30 pm B.P 90/70 100/80 P.R September 30, 2010 October 01, 2010 3:35 pm 9:30 pm 64 70 Normal Normal ANALYSIS Normal Normal
Norms Pulse 20
Normal pulse rate vary with age. The table below shows the normal range of pulse rate according to age: AGE 10 years 14 years Adult RESTING PULSE RATE 70 – 110 bpm 60 – 110 bpm 60 – 100 bpm AVERAGE 90 85 – 90 72
Source: Health Assessment and Physical Examination, 3rd edition by Estes, page 253
Normal blood pressure varies with age. As a person ages, blood pressure generally increases. The table below shows the general ranges of normal blood pressure at different ages and gender:
BLOOD PRESSURE: Normal Range According to Age and Gender
Female AGE 5 10 15 ≥18 SYSTOLIC (mm Hg) 103 – 109 112 – 118 120 – 127 <120 DIASTOLIC (mm Hg) 66 – 70 73 – 76 78 – 81 <80
Male AGE 5 SYSTOLIC (mm Hg) 104 – 102 DIASTOLIC (mm Hg) 65 – 70
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10 15 ≥18
111 – 119 122 – 131 <120
73 – 78 76 – 81 <80
Source: Health Assessment and Physical Examination, 3rd edition by Estes, page 260
IX. Nutritional Status Before she was confined to the hospital, Mrs. F eats 3 to 4 times per day and drinks 8 to 10 glasses of fluids. She also eats fruits like banana and mango. When the patient was admitted in the hospital, she was on a nothing by mouth state. Her BMI is in normal range.
BMI COMPUTATION: Weight: 48kg Height: 5”1’
BMI =
WEIGHT IN KILOGRAMS HEIGHT IN METER SQUARED
22
= 48kg 2.4006 m BMI =19.99 - NORMAL
Norms According to the Health Asian Diet Pyramid, there should be a daily intake of rice, grains, bread, fruit and vegetables; optional daily for fish, shellfish, and dairy products; weekly for sweets, eggs and poultry, and monthly for meat. There should be an increase intake of a wide variety of fruits and vegetables. Include in the diet foods higher in vitamins C and E, and omega-3 fatty acid rich foods. (www.webmd.com)
Analysis Mrs. F nutritional status was affected because of the surgical procedure done to her (appendectomy). Her BMI is in the normal range.
X. Elimination Status Mrs. F usually defecates once every day and urinates 4 to 5 times per day with an approximately 30 to 40 cc of urine per urination. When she was admitted she voids 4 times and defecates once.
Norms 23
The frequency of defecation is highly individual, varying from several times per day to two or three times per week. The amount defecated also varies from person to person. (Fundamentals of Nursing 7th edition by Kozier, et. Al., page 1126) Average Daily Urine Output by Age AGE 5 to 8 years 8 to 14 years 14 years through adulthood Older adulthood AMOUNT(mL) 700 – 1000 800 – 1400 1500 1500 or less
Source: Fundamentals of Nursing 7th edition by Kozier, ET. Al., page 1261
ANALYSIS Mrs. F elimination status is affected. Because she was on nothing by mouth state after the operation, she has nothing to defecate.
XI. Reproductive Status Mrs. F had her first menstrual period at age of 14 and she has a regular menstruation. At least 1 - 2 pads of napkins a day was used when she have her menses. She had her first pregnancy when she was 20 years old. She also has 2 miscarriages, her fourth and sixth baby. Norms Menarche which is the first menstruation occurs at an average age of onset between 9 to 17 years old. Pregnancy may occur from stage of menarche up to duration of menstrual period. Menopause occurs with age range of 40 to 55. 24
(Maternal and Child health Nursing 4th Edition by Pilliteri)
ANALYSIS Based on the statement above Mrs. F has a normal reproductive status. She was able to conceive offspring.
XII. Sleep – Rest Pattern She usually sleeps at 8 to 9 in the evening and wakes up at 4 in the morning. She watches television during his rest hours to relax and she loves to wash their clothes. She also spends time to be with her family and neighbor. But when she was confined her sleep pattern was always interrupted.
Norms NORMAL HOURS OF CATEGORY Newborns Infants Toddlers Preschoolers School – age children Young adults SLEEP PER DAY 16 to 18 12 to 14 10 to 12 11 to 12 8 to 12 7 to 8
25
Middle – aged adults Elders
6 to 8 About 6 hours
Source: Fundamentals of Nursing 7th edition by Kozier, ET. Al., page 1116
ANALYSIS Because of his condition, Mrs. F's sleep pattern was affected.
XIII. State of Skin and Appendages Mrs. F’s skin is light brown in color. Her skin in the foot is dry, some calluses are observed. She complains of some itchiness on her lower extremities. Her conjunctiva is pale. She has some scar on her lower extremities. Her nails are pale, short and clean. Her nail beds are slightly pale. Her capillary refill time is 2 seconds.
NORMS The palpebral conjunctiva should appear pink and moist. Normally the skin is a uniform whitish pink or brown color depending on the patient's race. Normally, the nails have pink cast light skinned individuals and are brown in dark-skinned individuals. (Health assessment and Physical Examination, 3rd edition by Mary Ellen Zator Estes).
Analysis Mrs. F skin appendages are affected due to decreased oxygen supply. The patient’s dry skin was due to restriction in fluid and any food. The Patient’s capillary refill is normal. 26
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6. Laboratory and Diagnostic Procedures DATE ORDERED: September 29, 2010
Urinalysis INDICATION RESULT Color: Yellow NORMAL RANGE Straw yellow – amber Transparent – turbid Absent 0.2 – 1.0 mg/dl Absent - Trace 5.0 – 8.5 Absent 1.010 – 1.015 Absent Absent Absent Negative or few Few ANALYSIS Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal High. An indicator that there is an infection present in the urinary tract. Normal Epitheleal Cells: Moderate Bacteria: Rare Urates/Phosphates: Moderate Few Normal Negative or Few Normal Few 28
>to detect renal Transparency: Turbid and metabolic diseases. Leukocytes/Nitrates: Negative Urobilirogen: Normal >diagnosis of Protein: Trace diseases or disorders of the pH: 6.0 kidney or urinary tract. Blood cells: negative Specific gravity: 1.010 Ketone: Negative Bilirubin: Negative Glucose: Negative Mucus threads: Moderate Pus cells: 3 - 4
RBC: 0 - 1
0 – 3/ HPF
Normal
NURSING RESPONSIBILITIES
Prior to procedure: Explain the procedure to the patient and family/relatives. Provide for patient’s privacy. Instruct the patient to go to the laboratory with the request form. Instruct the patient to dispose the first urine and catch the midstream urine. Educate the patient not to contaminate the inside part of the container. Instruct the patient to send the specimen to the laboratory immediately During the procedure: Maintain the sterility of the specimen container by not touching the inside part. Maintain the freshness and sterility of the urine specimen. After the procedure: 29
Interpret the result Refer to the physician if abnormalities are noted.
DATE ORDERED: September 29, 2010
Complete Blood Count INDICATION RESULT NORMAL RANGE ANALYSIS 30
BLOOD TYPE: A+
>to WBC: 13.9 G/L detect/diagnose blood disorders.
4.1 – 10.9 G/L
WBC is high because of the presence of infection. WBC defends our body against infection.
>to detect presence of infection.
LYM: 1.8 R2 12.9%L 0.6 – 4.1 *MID: 0.8 GRAN:7.0 5.5%M 81.6%G 0.0 – 1.8 2.0 – 7.8
10.0– 58.5%L 0.1 – 24 %M
Normal Normal
37.0–92.0 %G Normal Normal Normal Normal Normal Normal Normal Normal Normal
>to screen for fluid and electrolyte problem.
RBC: 4.17 T/L HGB: 113 g/L HCT: .373 L/L MCV: 82.6 fL MCH: 27.1 pg MCHC: 328 g/L
4.20 – 6.30 T/L 120 – 180 g/L .370 - .510 L/L 80.0 – 97.0 fL 26.0 – 32.0 pg 310 – 360 g/L 11.5 – 14.5 %
PLT: 379 G/L
140 – 440 G/L
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NURSING RESPONSIBILITIES
Prior to procedure: Explain the procedure to the patient and family/relatives. Educate the patient about what to expect during the procedure. During the procedure: Advise the patient to relax during the procedure. After the procedure: Interpret the result Refer to the physician if abnormalities are noted.
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7. Anatomy and Physiology
The Appendix 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 quadrant of the abdomen, or, more specifically, the right iliac fossa. Its position within the abdomen corresponds to a point on the surface known as McBurney's point (see below). While the base of the appendix is at a fairly constant location, 2 cm below the ileocecal valve, the location of the 33
tip of the appendix can vary from being retrocecal (74%) to being in the pelvis to being extraperitoneal. In rare individuals with situs inversus, the appendix may be located in the lower left side. New studies propose that the appendix may harbor and protect bacteria that are beneficial in the function of the human colon. Some researchers argue that the appendix has a function in fetuses and adults.[7] Endocrine cells have been found in the appendix of 11-week-old fetuses that contribute to "biological control (homeostatic) mechanisms." In adults, Martin argues that the appendix acts as a lymphatic organ. The appendix is experimentally verified as being rich in infection-fighting lymphoid cells, suggesting that it might play a role in the immune system. 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, explanations were lacking for the distinctive shape of the appendix and its apparent lack of importance as judged by an absence of side-effects following appendectomy.
8. PATHOPHYSIOLOGY
Book based
Non modifiable risk factors: >age >gender
Modifiable risk factors: >constipation >activity
Severity of symptoms is related to the degree of inflammation Other common symptoms include Appendectomy is often anorexia, nausea and suggested by the vomiting, low grade physician. fever, elevated WBC present. Concurrent infection can cause mucosal Abdominal pain is present, usually The inflammatory process ranges ulceration and subsequent development of described to severe appendiceal from mild as being in the right lower abscess, necrosis or rupture. quadrant, localized at Mcburney’s point. swelling and obstruction. 34
Patient – based
Modifiable Factors Constipation Low Fiber – Occlusion of appendix by fecalith
Non Modifiable Factors Age
Increased intra luminal pressure in the appendix
Start of the inflammatory process Low grade fever Appendectomy Inflammation of appendix (appendicitis)
Acute abdominal pain at the Mcburney’s point.
Nausea and loss of appetite 35
B. PLANNING NURSING CARE PLAN Acute Pain Assessment Planning Intervention Expected outcome Within 30 minutes to 1 hour of giving proper nursing interventions, the patient will:
Subjective: “Masakit ang sugat ko” P/S is 6/10. Objectives: facial grimace increase ability to perspire irritable at times guarding behavior limited movements and range of motion. assisted with the significant others when turning in other position. Nursing Diagnosis: Acute pain related to surgical incision on the abdomen. Scientific Explanation:
Within 30 minutes to 1 hour of giving proper nursing interventions, the patient will verbalize reduction of pain.
Monitor the pain scale. (to know if there is an improvement) Position on a semi-fowlers position.(for the patient to feel comfortable) Provide a clean bed. (to have a good relaxation.) Encourage to have a bed rest.( to gain energy) Encourage to continue limiting body movements. (to prevent pain) Educate the importance of deep breathing exercises. (for the patient to feel calm and relax) Divert attention by instructing to read books.(to lessen and divert pain) Instruct to increase fluid intake.(to prevent dehydration) Instruct to guard the site when
-verbalize a decrease of pain. -can move freely without assistance. -free from irritability. -facial grimace will be absent. 36
Unpleasant sensory and emotional experience arising fromactual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity frommild to severe with an anticipated or predictable end and a duration of less than 6 months. (Nurse’s Pocket Guide Edition 11 by F.A Davis, page 498)
coughing. (to prevent from opening of the site) Instruct to take medications that are prescribed by the physician. (for the patient safety to drugs) Educate the patient to clean the site
regularly. (to prevent any complications and infection)
Hyperthermia Assessment Subjective:Ø Planning Within 1 hour of proper nursing interventions, the patient’s temperature will subside to 37.5 °c from 38.5 °c. Interventions Monitor vital signs especially temperature. (To know if it has an improvement of the patient’s temperature.) Perform Tepid Sponge bath. (To lower body temperature.) Provide clean and comfortable bed. (for the patient to have a good rest and feel comfortable) Provide clean and comfortable clothing. (for the patient not to feel irritable) Expected Outcomes Within 1 hour of proper nursing interventions, the patient’s temperature will subside to 37.5 °c from 38.5 °c.
Objective: warm to touch diaphoretic weak in appearance irritable at times vital signs taken as follows:
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BP-90/70 mmHg RR-20 cpm PR-64 bpm Temp- 38.5°c Diagnosis: Altered body temperature related to inflammatory process.
Instruct to increase fluid intake after NPO. (to prevent dehydration) Instruct to eat nutritious foods like green leafy vegetables after NPO. (to gain more energy) Instruct to take medications that are prescribed by the physician. (For safety purposes.)
Scientific Explanation: Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. It may also occur as assign of infection.
Risk for Infection 38
ASSESMENT S O O Irritable Poor hygiene Long fingernails Dirty surroundings Incision on the right lower quadrant of the abdomen
PLANNING Within 2 hours of proper nursing intervention the client risk for infection will decrease to achieve timely wound healing
INTERVENTION AND RATIONALE Instruct in good hand washing (Reduces risk of spread of bacteria) Instruct good body hygiene (Reduces risk of spread of bacteria and promote relaxation) Demonstrate aseptic wound care (Reduces risk of spread of bacteria) Inspect incision and dressings (Provides for early detection of developing infections process) Encourage to cut the fingernails (Reduce risk of spread of bacteria)
EXPECTED OUTCOME After 2 hours of proper nursing intervention the client risk for infection is decrease to achieve timely wound healing as evidenced by:
a. Washing the hands using soap
Diagnosis Risk for infection related to surgical incision on the right lower quadrant of the abdomen
b. Good body hygiene
SCIENTIFIC EXPLANATION There’s a risk for infection for a client who undergone a surgical incision because there is a break in the tissue or that would serve as an opening that can be
c. Well kept Encourage to keep the surrounding surroundings of the patient clean (To minimize the chance of getting infection through microorganisms around the ward) d. Short fingernails
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invaded by different kind of microorganisms.
Impaired Skin Integrity ASSESSMENT PLANNING INTERVENTIONS EXPECTED OUTCOME
40
S “nangangati ang sugat ko” O with surgical incision at the mcburney’s point with suture noted with surgical dressing intact poor skin turgor limited movement
Within 1 hour of proper nursing interventions, the patient will regain integrity of the skin and demonstrate measures to protect care and heal the skin lesion.
Diagnosis Impaired skin integrity related to tissue damage. Scientific explanation Invasion of body structures, destruction of skin layers (dermis), disruption of skin surface (epidermis).
Assess site of skin impairment (the cause of the wound must be determined before appropriate interventions can be implemented). Monitor site of skin impairment for color change, redness, swelling, warmth, pain, or other signs of infections (systematic inspection can identify impending problem early). Clean the site aseptically (to decrease the production of bacteria). Select a topical treatment that will maintain a moist wound – healing environment and that is balanced with the need to absorb exudates ( keep peri wound skin dry and control exudates and eliminate dead space) Avoid massaging around the site of skin impairment and over bony prominences (massage may lead to tissue trauma). Monitor nutritional intake (Altered nutrition can prevent wound healing and put at risk for further skin breakdown).
After 1 hour of rendering proper nursing interventions, the patient will regain integrity of the skin and demonstrate measures to protect care and heal the skin lesion.
Fatigue 41
Assessment Subjective: Nanghihina ako” Objective: with limited body movements weak in appearance slow and low voice noted diaphoretic vital signs taken as follows: BP-80/70 mmHg
Planning Within 1 hour of proper nursing interventions, the patient will verbalize increase body strength.
RR-20 cpm PR-64 bpm Temp- 35.8 °c Diagnosis: Fatigue related to post surgical procedure. Scientific Explanation: An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.
Interventions Obtain vital signs. (for baseline purposes) Maintain on a flat position as an order of the physician. Encourage to have adequate rest. (to gain energy) Encourage to ask some help to the nurse or significant others if she want to move or change in position. (for the patients safety) Instruct to increase fluid intake after NPO. (to prevent dehydration) Instruct to eat nutritious foods like green leafy vegetables after NPO. (to gain more energy) Educate about the significant others to assist the patient when moving. (for safety and for the patient to move easily)
Expected Outcomes Within 1 hour of proper nursing interventions, the patient will verbalize increase body strength.
Instruct to take medications that are prescribed by the physician. (To avoid any drug accident such as overdosing.)
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C. IMPLEMENTATION 1. DRUGS Name of Drug Cefoxitin Date Administered October 1, 2010 6:00pm Route and Administration IVP 1g q 8 hours General Action Bactericidal: Inhibits synthesis of bacterial cell wall, causing cell death. • Indication Perioperative prophylaxis. Client’s actual response to medication Presence of pain was noted on the IV insertion site during the drug administration.
Nursing Responsibilities:
Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.
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Name of Drug Ketorolac
Date Administered September 30, 2010 6:00pm
Route and Administration IVP 30mg q 6 hours
General Action anti-inflammatory, antipyretic and analgesic effects is the inhibition of prostaglandin synthesis by competitive blocking of the enzyme cyclooxygenase (COX)
Indication • Short-term management of pain due to surgical procedure done
Client’s actual response to medication • Pain scale of 8/10 decreases to 4/10 which is consider as bearable pain.
Nursing Responsibilities: 44
Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.
Name of Drug Omeprazole
Date Administered September 30, 2010 6:00pm
Route and Administration IVP 40mg q 12 hours
General Action Gastric acid-pump inhibitor. Suppresses gastric acid secretion by specific inhibition of the hydrogenpotassium ATPase •
Indication Perioperative client who is NPO
Client’s actual response to medication • Pain due to hypersecretion of hydrochloric acid in the stomach is lessen. 45
enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production.
Nursing Responsibilities:
Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.
46
Name of Drug Paracetamol
Date Administered October 1, 2010 6:00pm
Route and Administration IVP 30mg PRN
General Action The main mechanism of action of paracetamol is considered to be the inhibition of cyclooxygenase (COX) •
Indication For client who has elevated temperature (hyperthermia)
Client’s actual response to medication • Client’s temperature of 38.5oc decreases to 37.5oc
Nursing Responsibilities:
Check the doctor’s order. Check the right drug, right patient, right time, right frequency and right route of drug administration. Explain to the patient and/or relatives the purpose of the drug. Document The Drug administration done. Check the patient for any possible adverse reaction to the drug.
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2.
MEDICAL MANAGEMENT
Medical Management
Date Ordered/ Performed/ Changed/ Discontinued
General Description
Indication/s or purpose/s
Client’s reaction to treatment
Changed: September 30, 2010 at 10:28 pm. Intravenous Fluid D5LRS @ 20gtts/min
D5LR is actually 5% dextrose in lactated ringer's solution. It is a hypertonic solution which means it pulls fluid out of the cells into the intravascular space (veins).
This solution is indicated for use in adults and pediatric patients as a source of electrolytes, calories and water
The patient was hydrated. The fluid and electrolytes level of her body is maintained.
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5% Dextrose in Lactated for hydration. Ringer's Injection provides electrolytes and calories, and is a source of water for hydration. It is capable of inducing diuresis depending on the clinical condition of the patient. This solution also contains lactate which produces a metabolic alkalinizing effect.
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Nursing Management Prior Before starting I.V therapy, consider duration of therapy, type of infusion condition of veins and medical condition of the patient to assist in choosing in I.V site and type of catheter. Ensure that you are competent in initiating the type of I.V therapy decided on and familiar with institutional policy and procedure before initiating therapy. Explain the procedure to the client and why is it necessary.
During Monitor the insertion site for signs of phlebitis or infiltration. Monitor the flow rate of the IV fluid. Maintain the cleanliness of the plaster. After After initiation of I.V therapy, monitor the patient frequently for: 1. Signs of infiltration of sluggish flow 2. Signs of phlebitis or infection 3. Correct solution, medication, volume and rate 4. Dwell time of catheter and need to be replace 5. Condition of catheter dressing and frequency of change 6. Fluid and electrolyte balance 7. Signs of fluid overload or dehydration 8. Patient satisfaction with mode therapy
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Medical Management
Date Ordered/Performed Changed/discontinued General Description Indication/s or purpose/s Client’s reaction to treatment
Oxygen Therapy 09-30-2010
08-30-2010
Oxygen may be classified as an element, a gas, and a drug. Oxygen therapy is the administration of oxygen at concentrations greater than that in room air to treat or prevent hypoxemia (not enough oxygen in the blood). Oxygen delivery systems are classified as stationary, portable, or ambulatory. Oxygen can be administered by nasal cannula, mask, and tent. Hyperbaric oxygen therapy involves placing the patient in an airtight chamber with oxygen under pressure.
The body is constantly taking in oxygen and releasing carbon dioxide. If this process is inadequate, oxygen levels in the blood decrease and the patient may need supplemental oxygen. Oxygen therapy is a key treatment in respiratory care. The purpose is to increase oxygen saturation in tissues where the saturation levels are too low due to illness or injury. Breathing prescribed oxygen increases the amount of oxygen in the blood, reduces the extra work of the heart, and decreases shortness of breath. Oxygen therapy is frequently ordered in the home care setting, as well as in acute (urgent) care facilities.
The patient’s oxygen need was sustained. Airway becomes easier. Breathing pattern becomes normal.
3. Surgical Management DATE PERFORMED: September 30, 2010 – 11:45 a.m Name of Procedure Brief Description Indication/ Purpose Client’s Response to Operation
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Appendectomy
Surgical removal of the Appendix
To remove the inflamed appendix to prevent rupture - this will eventually lead to peritonitis.
The patient was asleep after the operation.
The patient was lying flat on bed 6 – 8 hours after the surgery.
The patient had chills few hours after the operation.
The patient had fever 1 day after the operation. Nursing Responsibilities Prior to the Surgery Check the vital signs for baseline data. Instruct the patient to be on nothing per Orem 8 hours prior to surgery. Educate the patient the patient about coughing, deep breathing exercises and turning side – to – side after the surgery. Let the patient voice out what she feels to relieve anxiety. Listen to what the patient says. During the surgery Promote sterility on the sterile field. Monitor the patient’s well being. Monitor patient’s vital signs After the Surgery 52
Keep the patient on NPO for 6 to 8 hours or until peristalsis occurs. Keep the patient lie flat on bed without pillow for 6 to 8 hours. Monitor for bleeding and signs of shock. Monitor for signs of infection.
4. DIET 53
5. ACTIVITY/EXERCISE
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D. EVALUATION
III. CONCLUSION The group’s grand case study is about ruptured appendicitis. It was a good learning experience for our group to handle such case. The client manifest hyperthermia, fatigue, impaired physical mobility, and impaired skin integrity, the group therefore concludes that nursing intervention should be done to alleviate predicament on the client’s health. The highlight of our principle is to provide optimum nursing care primarily to our client and the significant others as well. The group believes that the first thing to consider for our client’s wellness to make them feel special and be sincere in rendering quality services. Susceptibility of the client to acquire complication is greatly at risk. Hence, client should be monitor carefully and medications must be maintained ideally.
IV. RECOMMENDATION The group recommends providing wound care aseptically as frequently as possible to prevent infection and apply cold compress to the abdomen when abdominal pain is experience. Advice regular consultation to the physician for it can be a factor for recovery and assess the patient’s progress. Advised the client who has to religiously take his medication prescribed to alleviate symptoms and prevent further complications. Instruct the patient normal activities can be resumed within a few days, but it takes four to six weeks for full recovery. Heavy lifting and strenuous activities should be avoided during recovery. Encourage continuous range of motion exercises. Eat healthy foods from all of the five food groups; fruits, vegetables, breads, dairy products, meats, fishes. Eating healthy foods may help the patient feel better and have more energy and also help recover faster from sickness. Emphasize the importance of increase dietary intake of fiber and vitamin C. Avoid foods that can cause constipation such as apple, guava and star apple. Encourage to increase fluid intake to maintain hydration and electrolyte balance. 55
V. REVIEW OF RELATED LITERATURE
Viral Infections Linked to Appendicitis By Rajshri on January 19, 2010 at 6:55 PM
A new study by UT Southwestern Medical Center surgeons and physicians says that appendicitis may also be caused by a virus and that you can actually "catch" it. The researchers evaluated data over a 36-year period from the National Hospital Discharge Survey and concluded in a paper appearing in the January issue of Archives of Surgery that appendicitis may be caused by undetermined viral infection or infections, said Dr. Edward Livingston, chief of GI/endocrine surgery at UT Southwestern and senior author of the report. The review of hospital discharge data runs counter to traditional thought, suggesting that appendicitis doesn't necessarily lead to a burst appendix if the organ is not removed quickly, Dr. Livingston said.
"Just as the traditional appendix scar across the abdomen is fast becoming history, thanks to new single-incision surgery techniques that hide a tiny scar in the bellybutton, so too may the conventional wisdom that patients with appendicitis need to be operated on as soon as they enter the hospital," said Dr. Livingston. "Patients still need to be seen quickly by a physician, but emergency surgery is now in question." Appendicitis is the most common reason for emergency general surgery, leading to some 280,000 appendectomies being performed annually.
Appendicitis was first identified in 1886. Since then, doctors have presumed quick removal of the appendix was a necessity to avoid a subsequent bursting, which can be an emergency. Because removing the appendix solves the problems and is generally safe, removal became the standard medical practice in the early 20th century. SOURCE: http://www.medindia.net/news/Viral-Infections-Linked-to-Appendicitis-63833-1.htm 56
VI. BIBLIOGRAPHY
Published Materials Medical – Surgical Nursing: Clinical Management for Positive Outcome 8th by Joyce Black and Jane Hokanson Hawks, Fundamentals of Nursing Practice 7th edition by Kozier and Erbs Health Assessment and Physical Examination 3rd edition by Estes Medical – Surgical Nursing 8th edition by Joyce Black 2010 Lippincotts Nursing Drug Guide by Amy Karch Prentice Hall Nursing Diagnosis Handbook by Judith M. Wilkinson and Nancy R. Ahern
Unpublished Materials http://www.wikipedia.org/wiki/Appendicitis?wasRedirected=true http://www.healthscout.com/ency/68/658/main.html http://www.ufs.ph/tinig/mayjun02/05060225.html http://www.nlm.nih.gov/medlineplus/ency/arcticle/002921.html http://www.diagnosis.com/a/acute_appendicitis/prevalence.html http://wiki.answers.com/Q/What_is_the_appendicitis_rate_in_the_Philippines 57
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