143921866 case-study-bmc-surgical-ward

homework help,online homework help,online tutors,online tutoring,research paper help,do my homework,
https://www.homeworkping.com/

1. College of Nursing
City of Malolos, Bulacan

A Case Presentation of an 11- year old client with Acute Appendicitis
Submitted by:
Reyes, Jenefer L.
Reyes, Phoebegail Shayne E.
Roque, Sarah Mae V.
Sacdalan, Hazel Joy C.
Salvador, Mary Grace S.D.
Santos, DanpaulH.
Homework Help
https://www.homeworkping.com/

Research Paper help
https://www.homeworkping.com/

Online Tutoring
https://www.homeworkping.com/

click here for freelancing tutoring sites
Bulacan State University

2. Taganas, Mary Lyann M.
Tamayo, Camille F.
Tan, Elaine Joy D.
Usi,George Anthony P.

BSN III-B, Group 4
Submitted to:
3
nd
level Clinical Instructors

I.Introduction

Patient CMG is 11 year old who was admitted at the surgery Department last August 20, 2012due to severe pain at her right lower quadrant, the patient was
diagnosed with acute appendicitis and underwent appendectomy last August 22, 2012.
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed
appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to peritonitis and shock.
Appendectomy, removal of the appendix, is the standard treatment for acute appendicitis, it is important to immediately remove the appendix after the diagnoses to
prevent the occurrence of the life-threatening complication of appendix. The most frequent complication of appendicitis is perforation. Perforation of the appendix can lead
to periappendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection of the entire lining of the abdomen and the pelvis) the major reason for appediceal
perforation is delay in diagnosis and treatment is general the longer the delay between diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours
after the onset of symptoms is at least 15% therefore, once appendicitis is diagnosed, surgery should be done without unnecessary delay.

3. Objective
General Objective
 To be able to acquire knowledge and skills on how to deal with patient who has diagnosis of acute appendicitis
Specific Objectives
 Client based:
- To obtain necessary information regarding the patient and her condition
- To assess the patients overall health status
- To identify patient health care needs through analysis of all the data gathered.

4. - To assist the patient throughout rehabilitation, recovery and discharge
- To impart necessary health teachings to the patient
- To perform appropriate nursing care in conjunction w/ the condition of the patient
 Student based:
- To widen and enhance the student nurse’s knowledge and skills through additional research about the nature of the disease, its pathophysiology and
treatment.
- To discuss and interpret the diagnostic results and compared to the normal values and relate them to the disease process.
II. Nursing Assessment
A. Personal History
Demographic Data of the Patient
 Name: CMG
 Age: 11 years old
 Gender: Female
 Address: Lawa, Meycauyan, Bulacan
 Birthday: May 15, 2001
 Religion: Roman Catholic
 Nationality: Filipino
 Dialect Spoken: Tagalog

5.  Attending Physician: Dra. Maria Glenda D. Zilmar
 Surgeon: Dr. Teoxon
 Assistant surgeon: Dr. Lustre
 Date and time of admission: August 20, 2012 at 4:24 pm
 Date of surgery: August 22, 2012







B. CHIEF COMPLAINT
Pain at the right lower quadrant
C. History of Present Illness
She was admitted in the hospital last August 20, 2012 at 4:24 pm at Bulacan Medical Center due to pain at the right lower quadrant.
D. HISTORY OF THE PAST ILLNESS
According to the client’s mother, the client was hospitalized for 10 days when she was 5 years old because of Kawasaki disease.
E. Family Health History
Her mother has a history of UTI (Urinary Tract Infection), her grandmother has diabetes and her grandfather died because of heart attack or cardiac arrest.

6. Genogram










RM

PM

FG
AG VG
68


70

71

67

40
RL MM

42 47
DG NG
45 38 4O 47
AG SG

7. F. Functional Health Pattern
Health Perception/Health Management Pattern
PRIOR DURING
When the client was asked to describe her previous health the client verbalized,
“Okay lang naman po yung health ko dati, pero nung sumakit yung tyan ko, minsan
nagsuka ko saka nilagnat din.” She experienced colds thrice last year. She eats fruits
everyday to make her strong and healthy. She takes her vitamins every day.
“Madalas nga siya kumain ng mga junkfood kaya nung sumakit na yung tiyan nya
saka lang namin nalaman na may sakit na siya”, as verbalized by her grandmother.
When I asked the client what she feels during the interview, she verbalized
“Nanghihina pa po ako pero po tinutulungan ako ni lola at hindi naman po
ako nilalagnat ngayon.”about her surgical incision hygiene, the client
verbalized” Yung nurse ang nag-linis ng sugat ko, tinitignan nga ni lolakasi
hindi din nga alam kung paano linisin pagnasa bahay na kami.”

Nutritional and Metabolic Pattern

11

LEGEND:
Female Patient Male

Deceased Cardiac Arrest Diabetes







CMG

8. PRIOR DURING
When it comes to her daily food intake, the client verbalized, “Halos po lahat naman
kinakain ko.” When we ask her to rank her appetite with 10 as the highest score, she
answered 10. According to our client she has vegetable in her daily meal. According
to our client, sometimes she eats junk foods and soft drinks as her snacks. Her
wound heals well and doesn’t have dental problems and eating discomfort.

Frequency
Meat 2-3 times a week
Fish 4 times a week
Frozen food 6-7 times a week

She doesn’t eat any food since she was admitted to the hospital and after the
surgery she took general liquid diet. The client has poor appetite as verbalized
by her grandmother, “Medyo wala siyang gana kumain”.
(We don’t have the chance to weight the patient because of the decrease
mobility of the patient.)
Elimination Pattern
PRIOR DURING

“Hindi naman ako hirap sa pag ihi at pagtae dati, pero nung nagsimula na sumakit
tyan ko, nahirapan na ako.” as verbalized by the client. She doesn’t perspire
excessively and she doesn’t have odor problems.
Output Frequency
( per day)
Amount Characteristics
Urine

Stool

5-6

irregular
500mL

-----
Light yellow

Brownish in color;
without blood

She experience difficulties upon urination because she felt the pain in her
lower abdomen and she hasn’t been defecating since after the surgery. Her
mother changes her diaper 3 times a day.
Output Frequency Amount Characteristics
Urine

Stool
3

-----
500mL

-----
Light yellow color

-----

9. Sleep-Rest Pattern
PRIOR DURING
The client verbalized “mga 9 hours ako nakakatulog sa gabi, matutulog ako ng 8 ng
gabi tapos gigising ako ng 5 ng umaga. She has no problem in sleeping.She takes a
nap every afternoon and watching T.V is her form of leisure and relaxation.
During hospitalization, she has no definite time of sleeping. “Minsan,
paidlip idlip lang po ng mga 30mins,” as verbalized by the client.





Activity Exercise Pattern
PRIOR DURING

10. The patient does some of the household chores. It also serves as her exercise. Her leisure time would
include watching television, computer gaming and sleeping.

_0_feeding _0_dressing
_0_bathing _0_grooming
_0_toileting _0_bed mobility
_0_cooking _0_home
_0_shopping
_0_general mobility maintenance

Level 0- full self-care
Level I- requires use of equipment/device
Level II- requires assistance or supervision from another person
“Hindi ko pokayangumupo at tumayo, lalo na kung ako lang mag’isa”, as verbalized by the
client. The client experience 7 out of 10 pain scales.

_0_feeding _II_dressing
_II_bathing _II_ grooming
_II_toileting
_II_bed mobility
_II_general mobility


Level 0- full self-care
Level I- requires use of equipment/device
Level II- requires assistance or supervision from another person

Sexuality-Reproductive Pattern
PRIOR DURING
The client is only 11 years old and doesn’t have menstruation yet. The client is only 11 years old and doesn’t have menstruation yet.


Cognitive Pattern

11. PRIOR DURING
According to our client she doesn’t have vision and hearing problems. Madali
naman po ako makasaulo lalo na po sa school”, as verbalized by the client.
While doing the interview, we observed that our client has a little problem in
hearing because sometimes we need to repeat the question to her but she can
still understand and answer appropriately.

Self-Perception-Self-Concept Pattern

PRIOR
DURING
“Ok lang naman po ako bago ako magkasakit”, as verbalized by the client when she
described herself prior to hospitalization. She was able to get along with her sibling
and attend her class to school.
According to her she thinks she lostsome weight. “Masakit po dito sa baba,
hindi pa rin po kasi masyadong magaling ang sugat ko at sakamasakitsiya”,
as verbalized by the client while pointing at the right lower quadrant of her
abdomen.

Role-Relationship Pattern
PRIOR DURING
The patient is living with her grandmother.According to her, she always tells her
problem to her grandmother. She is a choir member in their church. She didn’t feel
being outcast with the other family member and in their barangay. “Palakaibigan
siya at malalahanin sa akin.” as verbalized by her grandmother as we asked how is
CMG as a grandchild.
Her grandmother is the one who takes care of her during her hospitalization.
Coping Stress Tolerance Pattern

12. PRIOR DURING
According to our client whenever she is stressed, she watch movies, plays computer
gamesand sleep as well.
During hospitalization, the most stressful situation for her is her illness and
the pain she feels.

Value-Belief Pattern
PRIOR DURING
According to the client, her family is the most important people to her because it
gives her strength and makes her happy.She always attends the mass once a week to
increase her faith with God.
During hospitalization as verbalized by the client, “Ang lola ko po ang nag-
papalakas sa akin ngayon”. She is always praying to improve her health.

















III. A. Growth and Development

13. THEORY PSYCHOSOCIAL COGNITIVE PSYCHOSEXUAL MORAL
STAGE Industry vs. Inferiority
(Erik Erikson)
Concrete Operation
(Jean Piaget)
Latency Stage
(Sigmund Freud)
Conventional Morality
(Social Conformity
Orientation)
(Lawrence Kohlberg)
DEFINITION  Children need to cope with new
social and academic demands.
Success leads to a sense of
competence, while failure
results in feelings of inferiority.
 During the concrete
operation stage, children can
perform a number of logical-
mental operations.
 These mental operations
include the ability to classify
objects according to some
dimensions, such as height or
length, and the ability to
figure out relationships
between objects such as
larger or smaller.
 When the child represses
sexual thoughts and engages
in non-sexual activities, such
as developing social and
intellectual skills.
 By adolescence, most
individuals have
developed to this stage.
There is a sense of what
"good boys" and "nice
girls" do and the
emphasis is on living up
to social expectations
and norms because of
how they impact day-to-
day relationships.

14. THEORY THEORIST DESCRIPTION
APPLICATION OF NURSING PRACTICE IN
THE CARE OF CLIENT
Nightingale's
Environmental Theory

Florence Nightingale (1820-
1910)
 Major Concepts and Definitions
Environment - concepts of ventilation, warmth,
light, diet, cleanliness and noise. She focus o
the physical aspect of environment.
 She believed that "Healthy surroundings were
necessary for proper nursing care."
 5 essential components of healthy environment:
1. pure air
2. pure water
3. efficient drainage
4. cleanliness
5. Light

 Providing a non –stimulating environment is
essential especially for our patient in a way that
it promotes faster recovery on her through
minimizing external and stressful stimuli such
as providing proper ventilation and clean
environment. It is not only for promoting fast
recovery but also a preventive for possible
complications such as infection.
B. Theoretical Application

15. Twenty –one nursing
problem
Faye –Glenn Abdellah  Nursing is broadly grouped into 21 problem areas
to guide care and promote the use of nursing
judgement.

 We must know the 21 nursing problem to provide
a rationale for collecting reliable and valid data
about the health status of clients, which are
essential for effective decision making and
implementation. We should facilitate the
maintenance of a supply of oxygen to all
body cells, nutrition of all body cells, fluid
and electrolyte balance, elimination, maintain
good body mechanics and prevent and
correct deformities, good hygiene and
physical comfort, promote optimal activity:
exercise, rest and sleep and to facilitate the
maintenance of regulatory mechanisms and
functions.

16. Maslow's hierarchy of
needs
Abraham H. Maslow (1908-
1970)
 Maslow's hierarchy explains human behavior
in terms of basic requirements for survival and
growth. These requirements, or needs, are
arranged according to their importance for
survival and their power to motivate the
individual. The most basic physical
requirements, such as food, water, or oxygen,
constitute the lowest level of the need
hierarchy. These needs must be satisfied before
other, higher needs become important to
individuals. Needs at the higher levels of the
hierarchy are less oriented towards physical
survival and more toward psychological well-
being and growth. These needs have less power
to motivate persons, and they are more
influenced by formal education and life
experiences. The resulting hierarchy of needs is
often depicted as a pyramid, with physical
survival needs located at the base of the
pyramid and needs for self-actualization
located at the top.
 Maslow theory provides a guide lines in the
prioritization of patient care needs in our case
study.
.

17. IV. ANATOMY AND PHYSIOLOGY of DIGESTIVE SYSTEM
The human digestive system is a complex series of organs and glands that processes food. In order to use
the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to
excrete waste.
Most of the digestive organs (like the stomach and intestines) are tube-like and contain the food as it makes
its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the
anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals.
The Digestive Process:
The start of the process - the mouth:
The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by
the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down
starches into smaller molecules).

On the way to the stomach: the esophagus:
After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-
like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're
upside-down.

18. In the stomach
The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed
with stomach acids is called chyme.

In the small intestine
After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small
intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of
the small intestine help in the breakdown of food.

In the large intestine
After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are
removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in the digestion
process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels
across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon.

The end of the process
Solid waste is then stored in the rectum until it is excreted via the anus.

Parts of digestive system and its functions

 digestive system - (also called the gastrointestinal tract or GI tract) the system of the body that processes food and gets rid of waste.
 abdomen - the part of the body that contains the digestive organs. In human beings, this is between the diaphragm and the pelvis

19.  alimentary canal - the passage through which food passes, including the mouth, esophagus, stomach, intestines, and anus.
 anus - the opening at the end of the digestive system from which feces (waste) exits the body.
 appendix - a small sac located on the cecum.
 ascending colon - the part of the large intestine that run upwards; it is located after the cecum.
 cecum - the first part of the large intestine; the appendix is connected to the cecum.
 descending colon - the part of the large intestine that run downwards after the transverse colon and before the sigmoid colon.
 duodenum - the first part of the small intestine; it is C-shaped and runs from the stomach to the jejunum.
 epiglottis - the flap at the back of the tongue that keeps chewed food from going down the windpipe to the lungs. When you swallow, the epiglottis automatically
closes. When you breathe, the epiglottis opens so that air can go in and out of the windpipe.
 esophagus - the long tube between the mouth and the stomach. It uses rhythmic muscle movements (called peristalsis) to force food from the throat into the
stomach.
 gall bladder - a small, sac-like organ located by the duodenum. It stores and releases bile (a digestive chemical which is produced in the liver) into the small
intestine.
 gastrointestinal tract - (also called the GI tract or digestive system) the system of the body that processes food and gets rid of waste.
 ileum - the last part of the small intestine before the large intestine begins.
 intestines - the part of the alimentary canal located between the stomach and the anus.
 jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum and the ileum.
 liver - a large organ located above and in front of the stomach. It filters toxins from the blood, and makes bile (which breaks down fats) and some blood proteins.
 mouth - the first part of the digestive system, where food enters the body. Chewing and salivary enzymes in the mouth are the beginning of the digestive process
(breaking down the food).
 pancreas - an enzyme-producing gland located below the stomach and above the intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats
and proteins in the small intestine.\

20.  rectum - the lower part of the large intestine, where feces are stored before they are excreted.
 salivary glands - glands located in the mouth that produce saliva. Saliva contains enzymes that break down carbohydrates (starch) into smaller molecules.
 sigmoid colon - the part of the large intestine between the descending colon and the rectum.
 stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical and mechanical digestion takes place in the stomach. When food enters the
stomach, it is churned in a bath of acids and enzymes.
 transverse colon - the part of the large intestine that runs horizontally across the abdomen
 peristalsis - rhythmic muscle movements that force food in the esophagus from the throat into the stomach. Peristalsis is involuntary - you cannot control it. It is
also what allows you to eat and drink while upside-down.
 bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and secreted into the small intestine.
 chyme - food in the stomach that is partly digested and mixed with stomach acids. Chyme goes on to the small intestine for further digestion.

21. Risk Factors
(modifiable)
 Diet
 Daily
lifestyle
 Low fiber
diet

Risk Factors
(Non
modifiable)
 Age

THE PATIENT AND HER ILLNESS
A. PATHOPHYSIOLOGY
1. Schematic Diagram






























Low fiber diet and Episodes of
constipation
Occlusion of Appendix by Fecalith
Decreased flow/drainage of mucosal
secretions

Increased ILP in the appendix

Vasocongestion

Decreased blood supply in the appendix

Decreased O2 supply in the appendix


Appendix starts to be necrotic; Bacteria invade the appendix

Appendix starts to be necrotic; Bacteria invade the appendix

Appendix starts to be necrotic; Bacteria invade the appendix



Disruption of Cell Membrane of Appendix

22. Start of Inflammatory Process


Neutrophils to area





























Leukotrienes, Bradykinin
Histamine, Prostaglandin
Swelling of Appendix
Prostaglandin, Bradykinin
Pain in the RLQ of
Abdomen
Acute Pain
Interleukin-1
Release of Chemical
Mediators

Activation of the Vomiting
Stimulation
of Vagus Nerve

Suppression of
sympathetic GI
functions

Anorexia
Risk for Deficient of
fluid volume

Nausea and Vomiting

Risk for Imbalanced
Nutrition
Neutrophils to area
Pus Formation
phagocytized bacteria
and dead cells
Risk for Infection
(if appendix ruptures)
Increased WBC

Inflammation of Appendix (Appendicitis)

23. Open wound

Inflammation of Appendix (Appendicitis)




Disruption of Cell
Membrane

Nociceptors on the dermis


Impaired
Tissue
Integrity
Tissue trauma

Appendectomy

Send impulses to CNS

Pain on surgical site

Release of Prostaglandin
Bradykinin

Start of Inflammatory
process

Activity intolerance


Risk for
infection

24. 2. Definition of the disease

APPENDICITIS
Appendicitis is an irritation, inflammation, and infection of the appendix (a narrow, hollow tube that branches off the large intestine). The appendix functions as a
part of the immune system during the first few years of life. After this time period, the appendix stops functioning and other organs continue helping fight infection.
Although the appendix does not seem to serve any purpose, it can become infected and, if untreated, can burst, causing more infection and even death.

3. Predisposing factors
 Ages of 10 and 30 years.
 Having a family history of appendicitis may
 Gender, especially in males, and
 Having cystic fibrosis also seems to put a child at higher risk.

4. Signs and symptoms
The following are the most common symptoms of appendicitis. However, each individual may experience symptoms differently. Symptoms may include:
>Pain in the abdomen which:
o May start in the area around the belly button, and move over to the lower right-hand side of the abdomen, but may also start in the lower right-hand
side of the abdomen.
o Usually increases in severity as time passes.
o May be worse with moving, taking deep breaths, being touched, and coughing or sneezing.
o May spread throughout the abdomen if the appendix ruptures.

>Nausea and vomitingDiarrhea >Inability to pass gas
>Abdominal swelling >Loss of appetite
>Fever and chills >Constipation

25. AREA OF ASSESSMENT ASSESSMENT
TECHNIQUES
NORMAL FINDINGS ACTUAL FINDINGS REMARKS
General Survey
Describe body built Inspection Arm span equals to height, crown
to pubis equal to length from
pubis to sole
Height and weight are
proportional.
Normal
Observe height and weight in
relation to client’s age
Inspection Proportionate, varies with lifestyle The client loss some weight due
to her poor appetite.
Deviation from normal
Posture and gait Observation Relaxed, erect posture;
coordinated movement
Unable to assess the clients
posture and gait due to her
decrease mobility
Not examined
Describe over all hygiene and
grooming in relation to the
person’s activities prior to the
assessment.
Inspection

Clean, neat Hair properly done; with clean
clothes
Normal
Note for body and breathe
odor in relation to the person’s
activities prior to the
assessment.
Inspection

No body odor or minor body odor
relative to work or exercise; no
breath odor
No body odor and no breath
odor
Normal

Mental state
Identify signs of distress Observation

No distress noted Client is bending over because
of abdominal pain.
Deviation from normal

Note obvious sign of health or
illness
Observation

Healthy appearance Sometimes she is frowning
maybe because of incisional
pain.
Deviation from Normal

Assess clients attitude Observation Cooperative, able to follow
instructions
Answers in our questions are
appropriate; cooperative
Normal

Describe clients affect or
mood
Observation

Appropriate to situation Client’s mood and affect is
appropriate to situation.
Normal

Assess appropriateness of
clients responses
Observation Appropriate to situation Answers of our client in our
questions are appropriate.
Normal

Describe quantity of speech
(amount and pace), quality
Observation

Understandable, moderate pace;
clear tone and inflection; exhibits
Speech is loud with a clear
diction.
Normal

V. Physical Examination

26. (loudness, clarity, inflection)
and organization (coherence of
thought, over generalization,
thought association
Listen for the relevance and
organization of thoughts.
Observation

Logical sequence; makes sense;
has sense of reality
Client’s answer has sense of
reality.
Normal

Hair
Inspect the evenness of growth
over the scalp
Inspection

Evenly distributed hair No presence of alopecia Normal

Inspect hair thickness or
thinness
Inspection

Thick hair With thick hair. Normal

Inspect hair texture and
oiliness
Inspection

Silky, resilient hair Slightly dull hair because client
hasn’ttaken a bath since
admitted to hospital.
Deviation from Normal

Note presence of infections or
infestations
Inspection No infection or infestation No observable signs of infection
or any infestations.
Normal
Inspect amount of body hair Inspection

Variable

Variable; hair is evenly
distributed all over the client’s
body.
Normal
Skull
Inspect the skull for size,
shaped and symmetry
Inspection

Rounded, smooth skull contour Normocephalic and symmetric Normal

Palpate the skull for nodules
or masses and depressions
Palpation Smooth, uniform consistency;
absence of nodules or masses
No palpable nodules, lumps and
masses.
Normal

Face
Facial features Inspection

Symmetric or slightly asymmetric
facial features; palpebral fissures
equal in size; symmetric
nasolabial folds
Facial features are symmetric. Normal

Symmetry of the facial
movements



Inspection

Symmetric facial movements Eyebrows elevate at the same
time; eyes blink and closed at
the same time
Normal

27. Eyebrows and eyelashes
Evenness of distribution,
direction of curl and
movement
Inspection

Evenly distributed, eyebrows
symmetrically aligned; curled
slightly upward
Eyebrows raise and lower at the
same time; symmetrically
aligned; both eyebrows curled
slightly upward
Normal

Eyelids
Surface characteristics and
ability to blink
Inspection

Skin intact, no discharge, no
discoloration;
Lids closed symmetrically
Eyelids skin are intact; no
discharge and discoloration;
eyelids blink symmetrically
Normal

Conjunctiva
Inspect the bulbar conjunctiva
for color, texture and the
presence of lesions
Inspection Transparent

Bulbar conjunctiva are
transparent; no presence of
lesions; with evident capillaries
Normal

Inspect the palpebral
conjunctiva for color, texture
and the presence of lesions
Inspection Shiny, smooth and pink or red Palpebral conjunctiva is shiny;
pinkish in color
Normal

Sclera
Color and clarity Inspection

Sclera appears white Sclera is white and clear Normal

Cornea
Color and clarity Inspection Transparent, shiny and smooth Cornea’s surface is smooth
transparent and shiny
Normal

Iris
Shape and color Inspection Round Round, black in color Normal

Pupils
Color, shaped and symmetry
of size
Inspection

Black in color, equal in size Pupil is round black in color and
equal
Normal

Pupil light reaction and
accommodation
Inspection
Asking the client to look
first at a distant object and
then at a distant object
behind the penlight
Pupils constricts when looking at
near objects; pupils dilate when
looking at far object; pupil
converge when near object is
moved towards nose
Pupils are equally rounded. Normal

28. Pupils direct and consensual
reaction to light
Inspection
Asking the client to look
straight ahead, by using the
penlight and approaching
from the side, shining a
light on the pupil
Illuminated pupil constricts
(direct response)
Non illuminated pupil constricts
(consensual response)
Pupil constricts Normal

Visual acuity
Test near vision Asking the client to read
the newspaper held at a
distance of 36 cm
Able to read newsprint No difficulty reading newsprint Normal

Test distance vision Inspection

20/20 vision on Snellen–type
chart
Not examined Not examined
Lacrimal gland, lacrimal sac
and nasolacrimal duct

Presence of edema Inspection and palpation No edema or tenderness There are no presence of
tenderness and edema.
Normal
Extraocular muscles
Test each eye for alignment
and coordination
Inspection

Both eyes coordinated, move in
unison with parallel alignment
Both eyes are coordinated with
parallel alignment
Normal

Visual fields
Test for peripheral visual
fields
Inspection
noted
When looking straight ahead,
client can see objects in periphery
Client can see object using
peripheral vision
Normal

Ear auricle
Color and symmetry of size
and position
Inspection

Color same as facial skin,
symmetrical, auricle aligned with
outer canthus of the eye, about
10° from vertical.
Both ear auricle has the same
color with the skin
Normal

Texture, elasticity and areas of
tenderness
Palpation

Mobile, firm, and not tender;
pinna recoils after it is folded
There are no areas of
tenderness; no nodules or lump
Normal

External ear canal
Cerumen, skin lesions, pus
and blood
Inspection

Dry cerumen, grayish-tan color;
or sticky, wet cerumen in various
shades of brown
Dry cerumen; no skin lesions,
pus and blood
Normal

29. Hearing acuity test
Clients response to normal
voice tones
Inspection

Normal voices tones audible Has difficulty in hearing Deviation from Normal

Perform watch tick test Inspection

Able to hear ticking in both ears Not examined Not examined

Nose
Shape, size or color and
flaring or discharge from the
nares
Inspection

Symmetric and straight, uniform
color, no discharge or flaring
Symmetric uniform in skin
color; no presence of discharge
or flaring.
Normal

Presence of redness, swelling,
growths and discharge of
nares, using the flashlight
Inspection

Mucosa pink, clear, watery
discharge, no lesions
Mucosa is pinkish; no lesions Normal

Position of nasal septum Inspection Nasal septum intact and in
midline
Nasal septum in midline Normal
Test patency of both nasal
spectrum
Inspection

Air moves freely as the client
breath through the nares
Client can breath freely using
nasal nares.
Normal

Tenderness, masses and
displacement of bone and
cartilage
Palpation

No tenderness, masses and
displacement of bone and
cartilage
No presence of tenderness,
masses and displacement of
bone and cartilage
Normal

Sinuses
Presence of tenderness Palpation Not tender Sinuses are not tender. Normal
Lips
Symmetry of contour, color
and texture
Inspection

Uniform pink color, soft moist,
smooth texture, symmetry of
contour, ability to purse lips
Pinkish color of lips; symmetry
in contour
Normal

Buccal mucosa

Color, moisture, texture and
the presence of lesions
Inspection and palpation

Moist, firm texture, glistening and
elastic texture
Buccal mucosa is moist Normal
Teeth `
Inspect for color, number and
condition and presence of
dentures
Inspection

32 adult teeth, smooth, shiny,
white tooth enamel
No presence of dental problems Normal

30. Gums
Color and condition Inspection

No presence of lesions, no
retraction of gums, pink gums
No observable presence of
lesions; without retracted gums;
without bleeding gums
Normal
Tongue /floor of the mouth
Color and texture of the mouth
floor and frenulum
Inspection

Pink color, slightly rough, thin
whitish coating, smooth lateral
margins, no lesions
Pinkish in color Normal
Position, color and texture,
movement and base of the
tongue
Inspection

Central position, moves freely, no
tenderness
Tongue is in center; can moved
freely and without tenderness
Normal
Palates and uvula
Color, shape, texture and the
presence of bony prominences
Inspection

Light pink, smooth, soft palate,
lighter pink hard palate, more
irregular texture
Palates are pink Normal
Position of the uvula and
mobility
Inspection

Positioned in midline of soft
palate
In midline of soft palate Normal
Oropharynx and tonsils
Color and texture Inspection Pink and smooth posterior wall Pink posterior wall Normal
Size of the tonsils, color and
discharge
Inspection Pink and smooth, no discharge, of
normal size or not visible
No discharge; pink and smooth;
has normal size
Normal
Gag reflex Inspection

Present Not examined Not examined


Neck and lymph nodes

Symmetry and visible mass of
the thyroid gland
Inspection

Gland ascends during swallowing
but is not visible
No visible masses Normal
Presence of tenderness or
nodules in the lymph nodes
Palpation

Not palpable No nodules or tenderness Normal
Placement of the trachea Palpation

Central placement in midline of
neck; spaces are equal on both
sides
In midline of neck Normal

31. Smoothness and areas of
enlargement, masses or
nodules in the thyroid gland
Palpation
Asking the client to lower
the chin slightly
Lobes may not be palpable No areas of enlargement,
masses or nodules.
Normal
Skin
Inspect for color and
uniformity
Inspection

Varies from light to deep brown,
ruddy pink to light pink, yellow
overtones to olive; generally
uniform except in areas exposed
to the sun, areas of lighter
pigmentation in dark-skinned
people
Brown in color Normal
Inspect for the presence of
edema.
Inspection and palpation No edema No presence of edema Normal

Inspect and palpate for skin
lesions according to location,
distribution, color,
configuration, size, shape,
type or structure.
Inspection and palpation Freckles, some birthmarks, some
flat and raised nevi; no abrasions
or other lesions

No observable lesions, freckles
and birthmarks
Normal

Observe and palpate skin
moisture.
Inspection and palpation Moisture in the skin folds and
axillae
Moist skin Normal
Palpate skin temperature. Palpation

Uniform, within normal range Skin temperature is within
normal range
Normal

Note for skin turgor of the
client.
Inspection

Skin springs back to previous
state; may be slower in elders
Skin turgor is good. Normal


Nails

Inspect fingernail shape to
determine its curvature and
angle
Inspection

Convex curvature, angle of nail
plate about 160
0
No signs of early clubbing. Normal

Inspect fingernail and toenail
texture
Inspection

Smooth texture Skin is smooth Normal

Inspect fingernail and toenail
bed color
Inspection

Highly vascular and pink in light
skinned clients; dark skinned
Pink in color Normal

32. clients may have brown or black
pigmentation in longitudinal
streaks
Inspect tissues surrounding
nails
Inspection

Intact epidermis No presence of lesions Normal

Perform blanch test of
capillary refill
Inspection

Prompt return of pink or usual
color
Skin return to its normal color Normal

Posterior Thorax
Shape, symmetry, and
compare the diameter of the
antero posterior thorax to
tranverse diameter.
Inspection

Anteroposterior to transverse
diameter in ratio of 1:2, chest
symmetric
Symmetrically aligned Normal

Spinal alignment Observation Spine vertically aligned No observable signs of
osteoporosis and kyphosis
Normal
Breathing pattern Inspection Proper breathing pattern Can breathe properly Normal
Respiratory excursion Inspection

Full and symmetric chest
expansion
Chest expands at the same time. Normal
Temperature, tenderness,
masses
Palpation Uniform temperature, no
tenderness, no masses
With uniform temperature; no
signs of tenderness or masses
Normal

Vocal fremitus Palpation

Bilateral symmetry of vocal
fremitus, heard most clearly at the
apex of the lungs
Has good vocal fremitus Normal

Percuss the posterior thorax Percussion

Percussion notes resonate, except
over scapula, lowest point of
resonance is at the diaphragm
Not examined Not examined
Auscultate the posterior thorax Auscultation

Vesicular and bronchovesicular
breath sounds
Breath sounds are clear Normal

Anterior thorax
Breathing pattern Inspection Quiet, rhythmic, and effortless
respirations
No problems with regards to
respiration of the client.
Normal
Temperature, tenderness,
masses
Palpation Uniform temperature, no presence
of masses and tenderness
No observable presence of
masses
Normal

Respiratory excursion Inspection Full symmetric excursion; thumbs Has good respiratory excursion Normal

33. normally separate 3 to 5 cm
Vocal fremitus Inspection Same as posterior vocal fremitus;
Fremitus is normally decreased
over heart and breast tissue
Has good vocal fremitus Normal
Percuss the anterior thorax Percussion Percussion notes resonate down to
the sixth rib at the level of the
diaphragm but are flat over areas
of heavy muscle and bone, dull on
areas over the heart and the liver,
tympanic over the underlying
stomach
Not examined Not examined
Auscultation of the trachea Auscultation Bronchial and tubular breath
sounds
Breath sounds are clear Normal
Auscultate the anterior thorax Auscultation Bronchial and vesicular breath
sounds
Breath sounds are clear Normal
Abdomen Normal
Skin integrity Inspection Unblemished skin, uniform color,
stretch marks
Has an incision in the RLQ Deviation from Normal


Abdominal contour Inspection Flat, rounded(convex) or scaphoid
(concave)
Symmetrical

Normal
Enlarges liver or spleen Palpation Liver and spleen must not be
palpated.
Without enlarge liver and spleen Normal

Symmetry of contour Inspection Symmetric contour Symmetrical Normal
Abdominal movements Inspection Symmetric movements caused by
respiration
Symmetrical movements Normal

Vascular pattern Inspection No visible vascular pattern Not visible Normal
Bowel sounds, vascular
sounds and peritoneal friction
rubs
Auscultation Audible bowel sounds, absence of
bruits, absence of friction rub
Not examined Not examined
Percuss abdominal quadrants Percussion Tympany over the stomach and
gas-filled bowels; dullness,
especially over the liver and
Not examined Not examined

34. spleen, or a full bladder
Light palpation of abdominal
quadrants
Palpation No tenderness; relaxed abdomen
with smooth, consistent tension
Felt pain during palpation Deviation from Normal

Musculoskeletal system Normal
Muscle size, compare the
muscles on one side of the
body (arm, thigh, calf) to the
same muscle on the other side
Inspection Equal on both sides of body Muscle size are equal all
throughout the body.
Normal

Muscle tonicity Inspection Has good muscle tonicity. Normal
Muscle strength Inspection Equal strength on each body side Has equal muscle strength. Normal
Bones
Normal
structure
Inspection No deformities No observable bone deformities Normal
Edema or
tenderness
Palpation No tenderness or swelling No observable presence of
tenderness or swelling
Normal

35. Diagnostic Procedures
TEST Actual Values Normal Values Analysis Interpretation Nursing Responsibility
HEMATOLOGY
DATE: 8-17-12 8-18-12
Hgb

122 g/L 141 g/L 120-151 g/L

NORMAL  Monitor Vital Signs, intake and output.
 Observe standard precautions, and follow the
general guidelines. Positively identify the patient,
and label the appropriate tubes with the
corresponding patient demographics, date, and time
of collection.
 The specimen should be analyzed within 24 hr
when stored at room temperature or within 48 hr if
stored at refrigerated temperature.
 Remove the needle and apply direct pressure with
dry gauze to stop bleeding. Observe/assess
venipuncture site for bleeding or hematoma
formation and secure gauze with adhesive bandage.
 Promptly transport the specimen to the laboratory
for processing and analysis.


Hct 0.36 % 0.41 % 0.36-0.41 % NORMAL
Neutrophils 0.81 0.57 0.45-0.65 Within normal range on second test
Lymphocyte 0.19 0.43 17-48

NORMAL
Pus cells 3-5 hpf 0-2 hpf None Indication of inflammation or
infection
RBC 0-2 hpf 8-12 hpf Negative Indication of inflammation or
infection
Epithelial cells few rare Occasional / lpf Indication of inflammation or
infection
Amorphous
urates
few rare None Amorphous urates may cause urine
to appear more cloudy or hazy
Bacteria plenty rare None Indication of inflammation or
infection
URINALYSIS
Color yellow yellow Amber NORMAL  Instruct the patient to void directly into a clean, dry
container. Sterile, disposable containers are
recommended. Women should always have a clean-
catch specimen if a microscopic examination is ordered.
Feces, discharges, vaginal secretions and menstrual
blood will contaminate the urine specimen.
 Cover all specimens tightly, label properly and send
immediately to the laboratory.
 Observe standard precautions when handling urine
specimens.
Transparency turbid hazy Clear Purulent matter will make cloudy
{infection is present )
Reaction 6.0 5.0 4.6- 8.0 NORMAL
Specific Gravity 1.030 1.015 1.002-1.030 NORMAL
Sugar negative negative Negative NORMAL
Protein negative trace Negative Indication of inflammation or
infection

36. VI. PATIENT AND HIS CARE

A. IVF (Intravenous Fluid Therapy)
Medical
management
Date ordered/
Date
performed/
Date
changed/ DC
General Description Indication/ Purposes Client’s Response to the
Treatment
Nursing Responsibilities

D5O.3 NaCl
500cc x 60
ugtts/min

Date ordered:
August 20,
2012
 D5 0.3NaCl is a
hypertonic solution
owing to the higher than
normal amount of Na
and Cl ions. It pulls
fluid and electrolytes
from the intracellular
and interstitial
compartments into the
intravascular
compartments.
 To compensate
cellular
dehydration and
corrects
moderate fluid
loss, prevents
alkalosis,
provides calorie
and NaCl.
 The patient could
not verbalized
and distinguish
the possible side
effects of drugs
and manifestation
to her condition.
Before:
 Verify the doctor’s order indicating the
type of solution, the amount to be
administered, the rate of flow of the
infusion and any allergies.
 Explain the procedure and prepare the
client.
 Prepare the equipments needed.
 Wash hands thoroughly.
 Obtain IV solution and check for the
sediments and any crack or leak from
the container.
 Check also the expiration date.
 Check fluid discoloration or defect. If
noted, dispose the defected tubing and
get another.
 Assess client’s vital signs for baseline
data, skin turgor, bleeding tendencies,
disease, or injury to the extremities,
status of vein to determine the
appropriate puncture site.

37. During:
 Explain the importance and purpose
of IVF.
 Place the patient in a comfortable
position to facilitate easy insertion of
the IV line.
 Use the smallest gauge needle if
possible.
 Maintain aseptic technique
throughout the procedure.
 Follow proper procedures in infusing
IV solution.
 Watch out for fluid overload.
 Secure the needle properly after
insertions. Always check the needle
of the Iv, if it is in the vein:
 Bring the IV bottle lower
than the patient arm.
 Pinch the IV tubing.
 Observe the backflow of
the blood in the distal
portion

38. B. Drugs
Name of
Drug
Date

Route of
Administration
dosage,frequen
cy
General activities,
Classification,
Mechanism of
actions
Purpose/
Indication
Client’s response/
Side effect
Nursing responsibilities
Cefuroxime



























August
20,
2012
Oral  Bind to the
bacterial cell
wall
membrane
causing cell
death.
 Bactericidal
action.
 Treatment
of serious
life
threatening
infection
due to
susceptible
organisms.
 The patient could
not verbalized
and distinguish
the possible side
effects of drugs
and manifestation
to her condition.
ASSESSMENT:
 Assess the infection, (vital signs, and appearance
of wood, sputum, urine, and stool, WBC at the
beginning and during the therapy.
 Observe patient signs and symptoms of
anaphylaxis (rash, pruritus, wheezing, edema)
 Assess the patient renal dysfunction.
IMPLEMENTATION
 IF it is tablets don not swallow whole not
crushed, because of bitter taste.
EVALUATION
 Resolution of signs and symptoms of infection
 Decreased in the incidence of infection

39. Tramadol August
20,
2012
IM  Binds to mu-
opioid receptors
and inhibits the
reuptake of
norepinephrine,
and serotonin,
that has
analgesics
effects,
Acetaminophen
blocks the
activity of
cyclooxygenase
, an enzyme
necessary for
prostaglandin
synthesis. And
prostaglandins
are important
mediators of
inflammatory
response that
causes local
vasodilation,
swelling and
pain.




 Relief of
moderate to
moderately
severe pain.
 The patient could
not verbalized
and distinguish
the possible side
effects of drugs
and manifestation
to her condition.
 Know the 10 Rights in drug administration.
 Get patient’s history of allergy to tramadol or
opioids.
 Inform the patrient about the side effects if
sweating or CNS effects.
 Watch for some allergic reactions especially after
receiving the medication includin g
bronchospasm
 Assess the respiratory status of the client

40. Ketorolac August
20,
2012
IV  Anti-
inflammatory
and analgesic
activity;
inhibits
prostaglandins
and leukotriene
synthesis
 Short-term
management
of pain
 The patient
could not
verbalized and
distinguish the
possible side
effects of drugs
and
manifestation to
her condition
 Know the 10 Rights in drug administration.

 Do not mix with morphine, sulfate, mepiridine

 Instruct patient about the side effects.

 History: renal impairment, impaired hearing,
allergies, hepatic, lactation, pregnancy

 Physical: skin color and lesions, orientation,
reflexes, peripheral sensation, clotting times,
CBC, adventitious sounds

 Be aware that patient may be at risk for CV
events, GI bleeding, renal toxicity, monitor
accordingly.

 Do not use during labor, delivery, or while
nursing.

 Keep emergency equipment readily available at
time of initial dose, in case of severe
hypersensitivity reaction.

 Protect drug vials from light.

41. Metronidazole August
20,
2012
IV  Disrupts DNA
and protein
synthesis in
susceptible
organisms.
 Bactericidal, or
amebicidal
action
 Amebicide in
the
management
of amebic
dysentery
 The patient could
not verbalized
and distinguish
the possible side
effects of drugs
and manifestation
to her condition
 Administer with food or milk to minimize GI
irritation.

 Tablets may be crushed for patients with
difficulty swallowing.

 Instruct patient to take medication exactly as
directed evenly spaced times between dose, even
if feeling better. Do not skip doses or double up
on missed doses. If a dose is missed, take as soon
as remembered if not almost time for next dose.

 May cause dizziness or light-headedness. Caution
patient or other activities requiring alertness until
response to medication is known.

 Inform patient that medication may cause an
unpleasant metallic taste.

 Inform patient that medication may cause urine to
turn dark.

 Advise patient to consult health care professional
if no improvement in a few days or if signs and
symptoms of superinfection (black furry
overgrowth on tongue; loose or foul-smelling
stools develop).

42. C. Diet
TYPE OF
DIET
DATE STATED,
DATE CHANGED
GENERAL
DESCRIPTION
INDICATIONS, PURPOSES SPECIFIC FOOD TAKEN CLIENT’S RESPONSE
TO THE DIET
NPO August 20, 2012 Restriction of solid nor
liquid foods by mouth
This is done to avoid paralytic
ileum that occurs from bowel
handling during surgery.
The patient complied with
the prescribed diet..
Clear Liquid
Diet
August 22, 2012 Made up of clear liquid
foods which leave no
residue in the GIT. It is
non- stimulating, non gas
forming and non -
irritating.
It is mainly used for post operative
patients. Patient with acute illness
and infections, to relieve thirst, to
reduce colonic fecal matter. It is
done between 1-2 feeding intervals.
Water She seemed to have loss of
appetite with the ordered diet
Soft Diet August 23-24, 2012 A diet that is soft in
texture, low in residue,
easily digested, and well
tolerated.
This is given for the patient who is
recovering from a surgery as the
bowel is waking up.
Porridge and water The patient still not have
good appetite with the
prescribed diet. , but then
gradually took in the foods
that were ordered by the
physician.

43. Type of exercise General description Indication/ purpose Client’s response to
activity or exercise
Nursing responsibilities
Post surgery Bed Exercises  Starting off with basic leg pumps
and lifts of the lower and upper
extremities
 Help improve blood flow
and circulation in the
lower portions of your
body. In addition,
performing bed exercises
can also help reduce the
risk of blood clots
forming in your lower
extremities.

 The clients has no
response
 Assess the client on how to
perform the proper way of
this type of exercise.
Short Walks
 You should begin your post-
appendicitis exercise regimen
with short walks. During these
walks, be aware of your walking
form and posture,
 Trying to keep additional
weight off of your
abdominal muscles. Stop
walking as soon as you
feel fatigued and do not
push yourself to exercise
for extended periods of
time.

 The clients has no
response

 Assess the client on how to
perform the proper way of
this type of exercise.
Passive Abdominal Exercise

 Start by sitting down on the edge
of a bed with your feet hanging
off of the edge of the bed. With
your back straight and core
tightened, slowly lift up your legs
until they are parallel with the
floor. Hold this position for
several seconds before slowly
lowering your legs back to their
original position.
 Performing basic
abdominal exercise will
help return your
midsection to a stronger
place.
 The clients has no
response

 Assess the client on how to
perform the proper way of
this type of exercise.

D. Activity Exercise

44. VII. SURGICAL MANAGEMENT
BRIEF DESCRIPTION INDICATION/ PURPOSES CLIENT’S RESPONSE NURSING RESPONSIBILITIES

 Appendectomy is one of the most
commonly performed operations
with about 7% of the population
having that operation. It should be
an operation where every detail
has been examined in prospective
clinical trials but it is not. Of an
overwhelming number of scientific
reports on appendicitis (more than
5500 entries in the Medline) only a
few are about randomized trials.
We should have firm knowledge
about such things as antibiotic
treatment (initiation, route and
duration), wound management
(incision and closure) and excision
of the appendix (stump closure and
drains). It seems that much of the
surgical technique evolved from

- The main purpose of
appendectomy is to
remove the infected
appendix in order to
protect the patient‘s life.
When appendix got
infection, either it get pus
or sometimes it get
rupture before this
condition surgeon, after
diagnosing the patient
and reviewing his
medical reports, makes a
small surgery and they
will remove the
appendix. The main
symptom of this
appendix is severe pain
cause in lower abdomen

 The patient was asleep after the
operation.
 The patient was lying on bed 6-
8 hours after the surgery.
 The patient had chills few hours
after the operation.
 The patient had fever one day
after the operation.

Prior:
 Check vital signs.
 Instruct the patient to be on nothing per
Orem 8 hours prior to surgery
 Educate the patient about coughing,
deep breathing exercises and turn side to
side after the surgery.
 Let the patient to voice out what she
feels to decrease anxiety.
 Listen to the patient to what he says.
During:
 Promote sterility in the sterile field.
 Monitor the vital signs.
After:
 Keep the patient on NPO for 8 hours
after peristalsis occurs.
 Keep the patient lie flat on bed without
pillow for 6-8 hours.
 Monitor for bleeding and signs of

45. traditions and later knowledge has
been engaged in simplification.
For example, multiple drains with
or without continuous irrigation
are not used for perforated
appendicitis any longer but it must
have made sense at the time. Even
the single passive drain for a
periappendiceal abscess is thought
inappropriate by most surgeons
today. So, when speaking about
evidence here it must be viewed
against strong traditions that are
continuously changing regardless
of real scientific evidence. When
such evidence is available its
penetration is often slow. Further,
it must be accepted that the
underlying conditions have
changed so what seemed
reasonable at one time is no longer
appropriate. For instance, wounds
and patient feel vomiting
and last symptom is
fever which will continue
over a period of time.
shock.
 Monitor of signs for signs of infection.

46. used to be infected in the range of
30–50% in perforating
appendicitis. Infection is much less
frequent now for reasons that
patient care and surgical technique
are different.

47. VIII. Nursing Prioritization

DATE IDENTIFIED SUBJECTIVE CUES PROBLEM/NURSING
DIAGNOSIS
JUSTIFICATION
August 24, 2012 “Masakit dito sa baba”, while
pointing at RLQ of abdomen.

Acute pain related to presence of
surgical incision in RLQ

According to Maslow of hierarchy of needs physiological needs
must prioritize first. Acute pain is a physical health problem thus
belongs to physiological stage. Absence of pain may indicate that
the client’s health status is getting better.
August 24, 2012 “Hindi pa masyado magaling
ang sugat ko at saka masakit
siya.”
As verbalized by the client.

Impaired Skin Integrity related
to tissue trauma manifested by
appendectomy incision


The skin is considered as the primary defense of our body. Integrity
of our skin is vital to our physical and psychological health. Intact
and well healing wound has low risk of getting infection; because of
that impaired skin is the 2
nd
priority nursing diagnosis.
August 24, 2012 ”Yung nurse ang nag-linis ng
sugat, tinitignan nga ni lola.
Kasi hindi niya alam kung
paano linisin pag-nasa bahay
na kami.” As verbalized by
the client.
Risk for infection related to
insufficient knowledge regarding
proper wound care to avoid
exposure to pathogens.
To prevent complication for fast recovery we consider risk for
infection as 3
rd
priority problem.
August 24, 2012 “Medyo wala siyang gana
kumain” as verbalized by the
mother

Impaired nutrition less than body
requirements related to loss of
appetite.
Impaired nutrition was the 4
th
priority nursing problem. Because the
patient will not be able to commence food and fluids for a few days;
this is to enable the bowel to regain normal function. The pain feel
by the client added to reduce her appetite.
August 24, 2012 “Hindi ko po kayang umupo at
tumayo” as verbalized by the client
Activity intolerance associated
with the limitation of motion
secondary to pain
The patient should be encouraged to get up and out of bed as soon as
possible to prevent the formation of emboli. We make it 5
th
because
by resolving the 1
st
problem it will also resolve or manage

48. IX. . Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective cues :
“Masakit dito sa
baba”, while pointing
at RLQ of abdomen.

Objective cues:
Vital sign taken as
follow:
BP: 120/80mmHg
RR: 20cpm
PR: 105 bpm
T: 36.5 C

S/P Appendectomy
 With dry intact
dressing on the
surgical site.
 facial grimacing




 Acute pain related
to presence of
surgical incision in
RLQ

Within 1 hour of nursing
intervention, the client will be
able to manifest ability to cope
within pain as evidenced by:
a.) verbalization of decrease
pain form 7/10 to 2/10
b.) engagement in diversion
of activities such as,
watching TV, and
listening mellow music
c.) \Verbalize method that
provide pain reliving
 Taking pain
relieve medicines
 Avoiding
movement that
provide pressure
in the abdomen
 \provided splinting

 Assess pain
characteristics
including
location,
intensity, and
frequency.
 Assess surgical
site for swelling,
redness or loose
sutures.


\
\

 Promote
adequate rest
periods by
temporarily
limiting activity
 Encourage client
to verbalize pain
perception.



 Elevation in
intensity and
frequency may
indicate worsening
condition.

 Swelling, redness
, and loose
sutures may
contribute to the
pain felt by client
and are indicative
of further
management

 To lessen pain
felt.



 To allow
continuous
monitoring and
assessment
of client’s
condition.
Within 1 hour of nursing
intervention, the client will be
able to manifest ability to cope
within completely relieved pain
as evidenced by

a.) verbalization of decrease
pain form 5/10 to 2/10
b.) engagement in
diversional activities
such as watching TV,
and listening mellow
music
c.) Verbalize method that
provide pain reliving
 Taking pain
relieve medicines
 Avoiding
movement that
provide pressure
in the abdomen
 \provided splinting

49.  Provide client
with diversional
activities such as
socialization,
watching TV,
and listening
mellow music.
 Encourage SO’s
to continue
provision
of diversional
activities and a
quiet
environment.
 Administer
analgesics as
indicated.


 To help client
divert his
attention to other
matters than pain
felt.


 Refocuses
attention,
promotes
relaxation, and
may enhance
coping abilities.

 Relief of pain
facilitates
cooperation with
other therapeutic
interventions,
e.g., ambulation,
pulmonary toilet





\

50. ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective cues :
“ Hindi pa masyado
magaling ang sugat ko at
masakit pa ”
As verbalized by the
client.

Objective cues :
S/P: Appendectomy
 With surgical
incision at right
lower abdominal
area
 With dry intact
dressing on the
surgical site



Impaired Skin Integrity
related to tissue trauma
manifested by
appendectomy incision


After 30 minutes of
nursing intervention the
patient will be able to
gain knowledge on how
to improve skin integrity
in ways such as:
a) \keeping the
incision area
clean.
b) \maintain optimal
nutrition that
deals in proper
wound healing.
c) Exercises to
provide good
blood circulation.

 Assess operative site
for redness, swelling,
loose sutures, or
soaked dressing.

 Encourage the client
on keeping the
incision clean
 Discuss with the
client proper wound
healing such as
 Food rich in
vit. E \
 Food rich in
protein.
 Assist in passive
movements (while
7hrs. flat on bed) such
as bed turning and
passive ROM exercise
and active exercise
there after movements
such as bed position,
sitting, standing, and
walking.

 To check skin
integrity, monitor
progress of healing
and identify need for
further
 To prevent infection.


 For fast recovery







 To promote
circulation to the
surgical site for
timely healing. For
early ambulation also



\

After 30 minutes of
nursing intervention the
patient is able to gain
knowledge on how to
improve skin integrity in
ways such as:
d) \keeping the
incision area
clean.
e) \maintain optimal
nutrition that
deals in proper
wound healing.
f) Exercises to
provide good
blood circulation.

Nursing Care Plan

51.  Support incision as in
splinting when
coughing and during
movement.
 Encourage pt to
verbalize his for any
untoward feelings
especially pain,
discomfort as well as
changes noted on
operative site.
 Instruct pt and SO’s to
immediately report
when dressing are
soaked.


 Instruct pt and SO’s to
refrain from
touching/scratching
operative site.

 To reduce pressure
on the operative site.


 To allow continuous
monitoring and
assessment of pt.
Condition.

.
\
 For immediate
replacement to
prevent skin break
down and
contamination
of operative site.
 To prevent or
reduced the risk of
cross contamination

52. ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective cues:
Yung nurse ang nag-linis
ng sugat, tinitignan nga ni
lola. Kasi hindi niya alam
kung paano linisin pag-
nasa bahay na kami.” As
verbalized by the client.
\
Objective cues:
Vital sign taken as
follow:
BP: 120/80mmHg
RR: 20cpm
PR: 105 bpm
T: 36.5 C

S/P Appendectomy
 With dry intact
dressing on the
surgical site



Risk for infection
related to insufficient
knowledge regarding
proper wound care to
avoid exposure to
pathogens.
After 1 hour of nursing
intervention the
significant others will be
able to:
a) Provide the client
proper wound
care at home.
b) Determine signs
that indicate
infection and
complication.
Demonstrate and enumerate
to the significant other the
proper ways of wound care
such as
 Assess operative site for
signs of infection.

 Provide regular dressing
care.




 Instruct pt and SO’s to
refrain from
touching/scratching
operative site.
 Encourage pt to
verbalized any changes
noted on operative site such
as redness, swelling and
unusual/odorous drainage.
 Stress proper hand
washing techniques by




 Identify need for further
management.
 To prevent unnecessary
exposure and
contamination of
operative site which
may delay wound
healing.
 To prevent bacteria
harbor in operative site.

 to allow continuous
monitoring and
assessment of pt.
condition



 A first-liner defense
against nosocomial
After 1 hour of nursing
intervention the significant
others will be able to:
a.) Provide the client
proper wound care
at home.
b.) Determine signs
that indicate
infection and
complication.

53. all caregivers between
therapies/ clients.


 Clean the incisions site
daily
withpovidoneiodine or
other appropriate
solution.

 Instruct client/ SO(s) in
techniques to protect
the integrity of the skin,
care for lesions, and
prevention of spread of
infection.
infection/cross-
contamination.

 To prevent
contamination.



 To promote wellness

54. X. Discharge Planning
Medication
Advice the patient to continue the prescribed medication to obtain her total recovery such as antibiotics and analgesics.

Exercise
Within 12 hours of surgery the client may get up and move around. The client can usually return to normal activities in 2-3 weeks after laparoscopic surgery

Environment
Provide client a well-ventilated and relaxing environment to provide comfortable environment while recovering.
Treatment
Pretreatment of foods with lactase preparations (e.g. lactacid drops) before ingestion can reduce symptoms. Ingestion of lactase enzyme tablets with the first bite of
food can reduce symptoms.

Health Teaching
To care wound perform dressing changes and irrigations as prescribe avoid taking laxative or applying heat to abdomen when abdominal pain of unknown cause is
experienced. Reinforce need for follow-up appointment with the surgeon. Call your physician for increased pain at the incision site

Out Patient
Document bowel sounds and the passing of flatus or bowel movements (these are signs of the return of peristalsis) Watch for surgical complications such as
continuing pain or fever, which indicate an abscess or wound dehiscence .Stitches removed between fifth and seventh day (usually in physicians office)

Diet
Liquid or soft diet until the infection subsides. Soft diet is low in fiber and easily breaks down in the gastrointestinal tract

55. XI. Conclusion

In this study, the clinical and nursing procedures performed at the Bulacan Medical Center on August 24 ,2012 were described in detail. Case studies were also
presented to exemplify these procedures and see how every case is unique in this way, appendicitis and appendectomy were fully explored by using methods of participant
observation, informal interviews, research of the nature of disease and other information about the patient health condition. Although, this is a thorough examination of
appendectomy and appendicitis, this study could not possibly capture our experiences in the surgical ward. The most significant lesson we learned throughout the study was
the ambiguity of diagnosis and nursing care. The results of our study with interpretations made with secondary sources reveals that a better and assessment action in the
hospital.

Can take to better diagnosis of appendicitis patients, construct an effective procedure for assessment, diagnosis, and nursing intervention, and health teaching before and
after the surgery, however these things may aid in improving the rate of negative appendectomies and improving post surgical care.
This only leaves one very important lesson nurses and patients must realize, that each case must be taken as its own. An assembly line approach to diagnosing and treating
appendicitis is not the solution: no appendicitis presents itself in the same way.

56. Bibliography:

Books:
 Sparks and Taylor’s Nursing Diagnosis, Reference Manual 6th edition, 2005
 Tomey,AnnMarriner ,Nursing Theorists and their Work: 6
th
Edition, 2002
 Kozier&Erb’s, Fundamentals of Nursing., 8th edition.
 Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 10th Edition

Internet:

 www.medicinenet.com/appendicitis/article.htm
 digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/
 http://nurseslabs.com/4-appendectomy-nursing-care-plans/