Case Study – Appendicitis

I. DEFINITION/PREVALENCE knowing disease of the GI tract whitethorn be ca utilise by the pathogen itself or by a bacterial or other toxin. Acute unhealthy disorders such(prenominal) as appendicitis and peritoneal punk result from contamination of damaged or radiation diagramly sterile tissue by a nodes own endogenous or re arraynt bacteria (Lemone and Burke, 2008, page 766). Appendicitis is the dismissal of the vermi pattern (wormlike) appurtenance the appendix is a low-spirited fingerlike appendage ab turn up 10 cm (4 in) long, attached to the cecum just below the ileocecal valve, which is the beginning of the large intestine.It is ordinarily located in the adjust iliac region, at an force field designated as McBurneys point. McBurneys point, located mid substance between the belly unlesston and the previous iliac crest in the right turn down quarter-circle. It is the usual situate for place bruise and rebound philia receiv qualified to appendicitis during l ater stages of appendicitis. The sound of the appendix is non fully understood, although it regularly fills and empties digested food. most scientists baffle recently proposed that the appendix may harbor and protectbacteriathat be beneficial in the function of the hu small-arm colon.Appendicitisis the most common cause of acute inflammation in the right lower quadrant of the ab quarry. The lower quadrant bother is unremarkably accompanied by a low-grade fever, nausea, and often vomiting. Loss of appetite is common. In up to 50% of presenting cases, local soreness is elicited at Mc Burneys point applied located at halfway between the umbilicus and the anterior spine of the Ilium. Rebound tenderness (ex. Production or intensification of troubleful sensation when pres positive(predicate) is released) may be present.The accomplishment of tenderness and vigour spasm and the existence of the constipation or diarrhea depend not so much on the severity of the appendiceal co ntagious disease as on the location of the appendix. If the appendix curls around coffin nail the cecum, suffering and tenderness may be felt in the lumbar region. Rovsings sign may be elicited by palpating the left lower quadrant. If the appendix has ruptured, the chafe sensation become much diffuse, group AB distention develops as a result of paralytic ileus, and the diligents condition worsens.The disease is more prevalent in countries in which people consume a diet low in roughage and high in refined carbohydrates. It is the most common reason for emergency ab surgery, touch on 10% of the population. Although appendicitis affects a person at any age, the peak incidence is between the ages of 20 and 30 age old in which the vast major(ip)ity of clients are most common in adolescents and young and pretty more common in males than females. About 7% of the population go away gain appendicitis at roughly magazine in their lives (Lemone and Burke, 2008 page 766).The ma jor complication of appendicitis is perforation of the appendix, which feces lead to peritonitis, abscess formation (collection of purulent material), or portal Pyle phlebitis, which is septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines. Perforation universally occurs 24 hours later on the onset of inconvenience symptoms include a fever of 37. 7 degree Celsius or hundred degree Fahrenheit or greater, a toxic appearance and continued abdominal cark or tenderness. II. TYPES/CLASSIFICATIONAppendicitis john be classified as simple, humiliated, or perforated, depending on the stage of the process. In simple appendicitis, the appendix is inflamed but intact. When areas of tissue necrosis and microscopic perforations are present in the appendix, the disorder is called gangrenous appendicitis. A perforated appendix shows order of gross perforation and contamination of the peritoneal cavity (LeMone & Burke, 2008 page 766). peritonit is can be primary quill or sanctionary. Primary peritonitis is an acute bacterial infection that is not associated with perforated viscus, or electric organ.bacterial infection is the usual cause and may be associated with an infection by the like organism fewwhere else in the luggage compartment, which reaches the peritoneum via the vascular governing body. Tuberculosis peritonitis, which originates from tuberculosis elsewhere in the body, is a lineament of primary peritonitis. Clients with alcoholic cirrhosis and ascites, in the absence of a perforated organ, often manifest peritonitis, which may be due to leakage of bacteria through the wall of the intestine. Secondary peritonitis is usually caused by bacterial invasion as a result of perforation, or rupture of an abdominal viscus.It can as well as result from severe chemical reactions to pancreatic enzymes, digestive juices, or biles released into the peritoneal cavity (Gould & Dyer, 2011). III. DEMOGRAPHIC profile l onganimouss name is Mr. Ruptured Acute Appendicitis, 24 years old, male, residing at 820 General Kalentong, Daang Bakal, Mandaluyong urban center. He is the second child among 3 siblings, a Roman Catholic, single, a 3rd year college Information Technology student. IV. FAMILY medical checkup HISTORY (Family Genogram)COD TB COD TB A 83 -S, -D A 83 -S, -D non Recalled Not Recalled c c A 20 +S, +D A 20 S, +D A 24 +S, +D A 24 +S, +D A 27 -S, -D Skin allergy A 27 -S, -D Skin allergy A 42 +S, +D A 42 +S, +D A 64 +S, +D HPN, Stroke A 64 +S, +D HPN, Stroke c c A 46 -S, +D Asthma A 46 -S, +D Asthma A 51 -S, +D A 51 -S, +D long-suffering uncomplaining LEGEND LEGEND male male get hitched with married deceased male deceased male S- smoker D- reamer COD- cause of death S- smoker D- drinker COD- cause of death female female deceased female deceased female V. PAST medical checkup HISTORY He was first hospitalized give out 2006 due to dengue at the same hospital Mandaluyong City Medical Cen ter (MCMC).He has no other further illnesses except the typical fever, cough and cold. Other than that, he has no allergies, hypertension, or diabetes mellitus. VI. HISTORY OF PRESENT ILLNESS 1 week prior to admission price longanimous role startd abdominal upsetful sensation all over paunch. He consulted at ER MCMC signed out AUPD (Acute Peptic Ulcer Disease) and was given Omeprazole & HNBB (Buscopan). Whole abdominal ultrasound done and revealed tiny cholecystolethiasis. He was given Diclofenal and HNBB tab and eventually discharged. Few geezerhood prior to consultation, the patient still bringd abdominal pain.He consulted at Emergency Room and was opted for running(a) encumbrance EXPLORATORY LAPAROTOMY APPENDECTOMY under the service of Dr. Abram Del Valle, M. D. VII. GORDONS PHYSICAL ASSESSMENT i. Health Maintenance Perception Pattern Before admission The patient used to smoke cigarette 3 sticks per day. And he too drinks alcohol daily unique(predicate)ally beer of m ore than 2 bottles per session. He was not using drugs and he has no allergies at all. During quantify of care The patient is not smoking cigarette or drinking alcohol. ii. Nutritional Metabolic PatternBefore admission The patient was on a high protein diet because he was used to go to the gym 2-3 times a week. He was as well as taking vitamins (CENTRUM). He has normal appetite and has no difficulty swallowing. He usually eats 3 times a day (breakfast, lunch and dinner) and most of the time he also has his snacks. He also usually drinks 2-3 liters of water a day. e During time of care The patient is on NPO (nothing per orem) for 5 days due to post-operative appendectomy and he was on his 2nd day of NPO status when we cared for him. He has also NGT lavage connected. ii. exclusion Pattern Before admission The patients normal intestine movement was 3 BM a day and has no difficulty in bladder habits. His last bowel movement was last July 17, 2012. He usually urinates 6-7 times a day without difficulty. During time of care The patient has absence of bowel movement and even flatus and has no bowel sounds upon auscultation. He has foley catheter and with pissing payoff of 480 cc per shift. iv. body process and function Before admission The patient could do his activities independently without financial aidance.He usually goes to gym 2-3 times a week. During time of care The patients functional level or self-care ability level is 2 which mean he requires help from another person for assistance. v. Sleep/Rest Pattern Before admission The patient usually sleeps at 4 or 5 am and wakes up at 8 or 9 am. He has no difficulty in sleeping and he feels rested after sleep. During time of care The patient has regular sleeping habits. He sleeps at 10 am, wakes up at 6 am with uninterrupted sleep. vi. Cognitive Perceptual PatternBefore admission The patient was alert and tenacious, has normal speech, with dotty level of anxiety, has normal hearing, and with impaired vision of his left eye due to cataract. During time of care The patient is alert and coherent. He has normal speech (Filipino as his spoken language), he has moderate level of anxiety, has normal hearing, and with impaired vision of his left eye due to cataract. He also complained of acute pain and expound it as a cramping pain. Pain management (Tramadol) was given. vii. Role Relationship Pattern Before admission The patient was a student and single.His support system was his family, relatives & friends. During time of care The patients support system is his contract who is always at his bed side assisting him in whatever he needs. Upon asking his mother if she has any concerns regarding hospitalization, she verbalise that she is more concern about the fast recovery of her son. viii. Sexuality Reproductive system Before admission and during the time of care The patient still didnt encounter his testicular exam. ix. heading Stress Tolerance/Self Perception/Self Concept Pa ttern The patients major concern regarding his hospitalization is s all about self-care.Due to the contraptions attached to him, he cannot independently do his activities. His major loss was his stepfather when he died of kidney failure. His rated his outlook on future as 5, 1 being brusk and 10 being very optimistic. He further explained why he rated 5 because he is not sure if when he finished college he can be subject to find a job accommodate for him. x. Value Belief Pattern Our patient is a Roman Catholic and he always goes to perform every Sunday together with his family. VIII. GROWTH AND DEVELOPMENT DEVELOPMENTAL TASK THEORIST STATUS inter-group communication vs.Isolation * Develops commitments to others and to a life work (career)(Daniels, et. al. , 2010). Erikson The patient had a relationship with his opposite sex but he said that they just broke up a week before he was hospitalized due to some personal and private reasons. Currently, he is in 3rd year college, an I T student. Genital * Emergence of sexual interests and teaching of relationships with potential sexual business officeners (Daniels, et. al. , 2010). Freud As what had written above, the patient had a relationship with his opposite sex but because of some reasons they decided to end up their relationship. Formal Operations * Able to see relationships and to reason in the abstract (Daniels, et. al. , 2010). Piaget He perceived that relationships (any kind of relationship) are important especially at his age. He can also reason out in an abstract way. He can express his opinions intellectually and precisely. archean Adulthood * Select a partner, learn to live with a partner, start a family, manage a home, establish self in a career/occupation, assume civic responsibility, and become a part of a social group (Daniels, et. al. , 2010). Havighurst According to our patient, he didnt expected that something like that pass on go past to them (referring to his girlfriend). He was re ally expecting that they are really meant for each other and that she (his gf) will be his future wife. He is also establishing himself to a future career, thats why he is studying in preparation for his future. During our time of care also, his barkadas visited him and he said that they were his tropa. Postconventional * Individual understands the morality of having democratically established laws (Daniels, et. al. , 2010). Kohlberg Upon asking the patient if he is familiar with the democratically established laws in the Philippines, he immediately responded with a yes. He also said that these laws help us, Filipinos, to have safe and secure country though there may come a time that we may experience something unexpectedly. IX. PHYSICAL ASSESSMENT * racy Signs TIME Initial 8AM (07/24/12) 10 AM 12 NN 8 AM (07/25/12) 12 NN Last 8AM(07/26/12) T 36. 3 37. 3 37. 4 36. 4 37. 3 36 P 83 84 71 75 81 68 R 23 25 21 19 19 20 BP great hundred/80 120/80 120/80 120/80 120/80 one hundred ten/8 0 Sequence BY SYSTEMS NORMAL FINDINGS BOOK FINDINGS PATIENT FINDINGS SIGNIFICANCE I. NEUROLOCIGAL SYSTEM Alert and coherent with normal body temperature of 36. 3C 37. 6C * Fever (usually 38C although hypothermia may be present w/ severe sepsis) chills * Thirst * Pain * Complained of pain in the incision site (lower longitudinal midline of the abdomen) Pain results from the plusd atmospheric pressure of changeable on the nerves, especially in enclosed areas, and by the local displeasure of nerves by chemical mediators such as bradykinins (Gould, et al. 2011). II. RESPIRATORY Normal ventilation with a rate of 12-20 breaths per minute * Tachypnea shallow respirations * RR 23 bpm w/ shallow respiration Acute pain usually initiates physiologic stress rejoinder with increased respiratory rate (Gould & Dyer, 2011). III. INTEGUMENTARYPink or browned and in uniform color, no edema, no lesions, moistSkin temperature is normally warmIntact skinWhen pinched, skin springs back to prev ious state * modify lips and mucous membranes * Swollen tongue * Poor skin turgor * Dry lips and mucous membranes * Skin turgor3-5 seconds * battlefront of functional incision at lower longitudinal midline of the abdomen * Skin is warm to touch and is reddish Dry mucous membrane and poor skin turgor are signs of drying up (Gulanick, et al. 1994). Redness may signify inflammation (weber & Kelly, 2007). Redness and warmth are caused by increased blood settle into the damaged area (Gould & Dyer, 2011). IV. CARDIOVASCULAR Normal pulse rate of 60-100 bpm * Tachycardia * Diaphoresis * Pallor * Hypotension * Tissue edema * split second rate 83 bpm Acute pain usually initiates a physiologic stress response with increased heart rate (Gould & Dyer, 2011). V. MUSCOLOSKELETALAbility to do Activities of Daily Living (ADL) * Difficulty ambulating * Weakness * Difficulty ambulating due to post-op condition * Weakness Constant pain frequently affects daily activities and may become a prim ary focus in the life of an individual (Gould & Dyer, 2011). VI. GENITO-URINARY Normal urine produce of 30cc/hrColor Amber, transparent, clear * diminishd urinary output * Dark color urine * Dark color urine * Urine output 480 mL/shift * Specific gravity 1. 30 Decreasing output of concentrated urine with change magnitude specific gravity suggests dehydration/need for increased fluids (Doenges, et al. , 2006). VII. GASTROINTESTINAL Abdominal skin may be paler than the general skin tone because this skin is so seldom exposed to the natural elementsAbdomen is free of lesions or rashesA series of intermittent, soft clicks and gurgles are heard at a rate of 5-30 per minuteNormally no tenderness or pain is elicited or inform by the clientNo rebound tenderness is presentAbdomen is non-tender and soft.There is no guarding * Loss of appetite * illness & vomiting(usually projectile) * Constipation of recent onset * Diarrhea(occasional) * Sudden, severe, generalized abdominal pain * A bdominal distention rigidity * Decreased/absence of bowel sounds * Inability to pass stool/flatus * Muscle guarding (abdomen) * Psoas Sign (flexion of or pain on hyperextension of the hip due to contact between an inflammatory process & the psoas muscle) * Obturator Sign (the internal gyration of the right leg with the leg flexed to 90 degrees at the hip and knee and a resultant tighten of the internal obturator muscle may ause abdominal discomfort) * Rovsings Sign (pressure on the left lower quadrant of the abdomen causes pain in the right lower quadrant) * Rebound tenderness (a sign of inflammation of the peritoneum in which pain is elicited by the sudden release of the fingertips pressing on the abdomen) * Board-like abdomen * Sudden, severe, generalized abdominal pain * absence of bowel sounds in all four-spot quadrants * Absence of flatus/stool * Presence of surgical incision Signs indicating the onset of peritonitis include a rigid board-like abdomen (Gould & Dyer, 2011).P ain recurs as a steady, severe abdominal pain as peritonitis develops (Gould & Dyer, 2011). Absence of bowel sounds may be associated with peritonitis or paralytic ileus (Weber & Kelly, 2007). When inflammation persists, nerve conduction is impaired, and peristalsis slumps, leading to obstruction of the intestines (paralytic ileus) (Gould & Dyer, 2011). X. symptomatic TESTS DIAGNOSTIC TEST NORMAL RESULT SIGNIFICANCE WHOLE ABDOMINAL ULTRASOUND (July 21, 2012) The organs examined appear normal (Cosgrove, et al. , 2008). Liver is not enlarged.It has homogenous echopattern with smooth border. The intrahepatic ducts are not dilated. No evident central mass lesion seen. CD measures 3. 9mm. Gallbladder is normal in size and wall thickness. There are nine-fold tiny echogenic shadowing foci seen within the gallbladder lm. Pancreas & spleen are normal in size & echopattern. No focal mass lesion seen. Both kidneys are normal in size & echopattern. Right kidney measures 10. 14. 25. 46cm w ith cortical thickness of 1. 7cm composition the left kidney measures 10. 54. 84. 1cm with thickness of 19cm. No evident caliectasis, lithiasis, seen bilaterally.Urinary bladder is unfilled. ImpressionTiny cholecystolithiasesNormal liver, pancreas, spleen, kidneys by UTZUnfilled urinary bladderNot dilated biliary tree Abdominal ultrasound is the most hard-hitting test for diagnosing acute appendicitis (LeMone & Burke, 2007). HEMATOLOGY REPORT/COUNT (July 21, 2012) RBC 4. 2-5. 6 M/uLPlatelets 150-400 x 10/L leukocyte 3. 8-11. 0 K/mm3Hemoglobin 135-180g/LHematocrit 0. 45-0. 52DifferentialNeutrophils 0. 50-0. 81Lymphocytes 0. 14-0. 44Monocytes0. 02-0. 06Eosinophils 0. 01-0. 05Basophils0. 00-0. 01 WBC enumerate 12. 6 K/mm3RBC 4. 1 M/uL (normal)Hematocrit 0. 45 (normal)Hemoglobin 153g/L (normal)Differential CountNeutrophils 0. 90Lymphocytes 0. 10 (normal) Elevated WBC is seen in acute infection (LeMone & Burke, 2007). Neutrophils elevated in bacterial infection (LeMone & Burke, 2007 ). URINALYSIS (July 21, 2012) Color Light straw to amber yellowAppearance ClearOdor AromaticpH 4. 5-8. 0Specific gravity 1. 005-1. 030Protein 2-8mg/dLGlucose NegativeKetones NegativeRBCs RareWBCs 3-4Casts Occasional clear Color Dark YellowTransparency TurbidUrine pH 6. 0 Specific gravity 1. 30Sugar NegativeProtein +4Microscopic examPus cells 4-6/HPFRBC 1-2/HPFCrystals Amorphous Sulfate Moderate A dark yellow to brownish color is seen with deficient fluid volume (LeMone & Burke, 2007). Hazy or indistinct urine indicates bacteria, pus, RBCs, WBCs, phosphates, prostatic fluid spermatozoa, or urates (LeMone & Burke, 2007). CLINICAL CHEMISTRY (July 21, 2012) Sodium (Na) 135-142 mmol/LPotassium (K) 3. 8-5 mmol/L Sodium 132 mmol/LPotassium 4. 02 mmol/L Sodium is decreased in SIADH & vomiting (LeMone & Burke, 2007). XI. ANATOMY & PHYSIOLOGY OF APPENDIX (LARGE INTESTINE)The large intestine, which is about 1. 5 m (5 ft) long and 6. 5 cm (2. 5 in. ) in diameter, extends from the ileum to the anus. It is attached to the posterior abdominal wall by its mesocolon, which is a double layer of peritoneum. Structurally, the four major regions of the large intestine are the cecum, colon, rectum, and anal canal. The orifice from the ileum into the large intestine is guarded by a fold of mucous membrane called the ileocecal sphincter (valve), which allows materials from the small intestine to pass into the large intestine. Hanging inferior to the ileocecal valve is the cecum, a small pouch about 6 cm (2. 4 in. ) long.Attached to the cecum is a twisted, coiled tube, measuring about 8 cm (3 in. ) in length, called the appendix or vermiform appendix (vermiform = worm-shaped appendix = appendage). The mesentery of the appendix, called the mesoappendix, attaches the appendix to the inferior part of the mesentery of the ileum. The afford end of the cecum merges with a long tube called colon, which is divided into ascending, thwartwise, descending colon are retroperitoneal the tr ansverse and sigmoid colon ascends on the right side of the abdomen, reaches the inferior surface of the liver, and turns abruptly to the left to form the right colic (hepatic) crimp.The colon continues across the abdomen to the left side as the transverse colon. It curves below the inferior end of the spleen on the left side as the left colic (splentic) flexure and passes inferiorly to the level of the iliac crest as the descending colon. The sigmoid colon begins near the left iliac crest, projects medially to the midline, and terminates as the rectum at about the level of the third sacral vertebra. The rectum, the last 20 cm (8 in. ) of the GI tract, lies anterior to the sacrum and coccyx. The terminal 2-3 cm (1 in. ) of the rectum is called the anal canal.The mucous membrane of the anal canal is set up longitudinal folds called anal columns that contain a network of arteries and veins. The opening of the anal canal to the exterior, called the anus, is guarded by an internal an al sphincter of smooth muscle (involuntary) and an external anal sphincter of the skeletal muscle (voluntary). Normally these sphincters keep the anus closed except during the elimination of feces (Tortora & Derrickson, 2006). XII. PATHOPHYSIOLOGY NARRATIVE Appendicitis, inflammation of the vermiform appendix, is a common cause of acute abdominal pain.It is the most common reason for emergency abdominal surgery, affecting 10% of the population (Tierney et al. , 2005). Appendicitis can occur at any age, but is more common in adolescents and young adults and slightly more common in males than females (LeMone & Burke, 2007). The development of appendicitis usually follows a pattern that correlates with the clinical signs, although variations may occur because of the altered location of the appendix or underlying factors (Gould & Dyer, 2011). Obstruction of the proximal lumen of the appendix is apparent in most acutely inflamed appendices.The obstruction is often caused by fecalith, or hard mass of feces. Other obstructive causes include a calculus or stone, a unconnected body, inflammation, a tumor, parasites (e. g. , pinworms), or edema of lymphoid tissue (LeMone & Burke, 2007). Following obstruction, the appendix becomes distended with fluid secreted by its mucous membrane and microorganisms proliferate. Pressure within the lumen of the appendix increases, impairing its blood supply because blood vessels in the wall are compressed thus the appendiceal wall becomes inflamed and purulent exudate forms.Within 24 to 36 hours, the increasing over-crowding and pressure within the appendix leads to ischemia and necrosis of the wall, resulting in increased permeability. Bacteria and toxins escape through the wall into the surrounding are. This breakout of bacteria leads to abscess formation or localized peritonitis. An abscess may develop when the neighboring omentum temporarily walls off the inflamed area by adhering to the appendiceal surface. In some cases, the in flammation and pain nail down temporarily but then recur. Localized infection or peritonitis develops around the appendix and may spread along the peritoneal membranes.Increasing pressure inside the appendix causes increased necrosis and gangrene in the wall (infection in necrotic tissue). The wall of the appendix appears blackish. The appendix ruptures or perforates, releasing its contents into the peritoneal cavity. This leads to generalized peritonitis and would lead to septicemia and into septic shock and will result to death (Gould & Dyer, 2011). XIII. PATHOPHYSIOLOGY plat Risk Factors Non-modifiable * Age (Adolescents & young adults) * Gender (Male) Modifiable * Fecalith * Calculus/Stone * Foreign body * inflammation * Tumor * Parasites Edema of lymphoid tissue Obstruction of the appendiceal lumen Obstruction of the appendiceal lumen Buildup of fluid inside the appendix Buildup of fluid inside the appendix Proliferation of microorganisms Proliferation of microorganisms Abdom inal pain Abdominal pain increase pressure within the lumen of appendix change magnitude pressure within the lumen of appendix condensing of blood vessels Compression of blood vessels * Fever * Obturator Sign * Psoas Sign * Rovsings Sign * Rebound tenderness * Fever * Obturator Sign * Psoas Sign * Rovsings Sign * Rebound tenderness Decreased blood flow into the appendixDecreased blood flow into the appendix Inflammation of appendiceal wall Inflammation of appendiceal wall (July 21, 2012) Hematology Count * WBC count 12. 6 K/mm * Neutrophils 0. 90 Urinalysis * Transparency turbid (July 21, 2012) Hematology Count * WBC count 12. 6 K/mm * Neutrophils 0. 90 Urinalysis * Transparency turbid ischemia & necrosis of the wall Ischemia & necrosis of the wall Increased permeability Increased permeability Bacteria and toxins escape through the wall Bacteria and toxins escape through the wall Abscess formation/localized bacterial peritonitisAbscess formation/localized bacterial peritonitis Pr oliferation of localized peritonitis around the appendix and peritoneal membranes Proliferation of localized peritonitis around the appendix and peritoneal membranes Increased pressure inside the appendix Increased pressure inside the appendix * Sudden, severe, generalized abdominal pain * Abdominal distention & rigid boardlike abdomen * Absence of bowel sounds/(-) flatus/(-) BM (July 24, 2012) * Sudden, severe, generalized abdominal pain * Abdominal distention & rigid boardlike abdomen * Absence of bowel sounds/(-) flatus/(-) BM July 24, 2012) Increased necrosis and gangrene in the wall Increased necrosis and gangrene in the wall Appendectomy with NGT lavage (July 22, 2012) Appendectomy with NGT lavage (July 22, 2012) Perforation of the appendix Perforation of the appendix Intestinal bacteria leak out into peritoneal cavity Intestinal bacteria leak out into peritoneal cavity * Low-grade fever & leukocytosis * Tachycardia * Hypotension * Vomiting * Low-grade fever & leukocytosis * T achycardia * Hypotension * Vomiting Generalized peritonitis Generalized peritonitis XIV. NURSING PROCESSProblem 1 ABDOMINAL PAIN July 24, 2012 * Subjective actuates * Nurse await lang, ang sakit kasi parang nagcacramps, patient verbalized while having a conversation with him. How does it feel like Abdominal cramping Precipitating factor Kapag nililinisan pero kadalasan bigla-bigla na lang sumasakit (Whenever wound cleanup position is performed but oftentimes it just suddenly happened) Relieving factor Pain relief (but not all the time pain reliever is being given) Does it radiate to the other parts of the body (back, legs, chest, etc) No Duration of pain Paiba-iba din eh.Minsan sobrang tagal mga 2-3 legal proceeding, minsan naman mga ilang Segundo lang (It differs, sometimes its too long (2-3 minutes) and sometimes it just happened for a second) * Patient rated the pain as 8/10 where 0 signifies no pain and 10 signifies unbearable pain. * quarry Cues * Facial grimace * Guardin g of the incision site * Rigid (board-like) abdomen * Abdominal distention * Location of pain Surgical site * RR 25 bpm * treat diagnosis Acute Pain associate to inflammation of the tissues secondary to post-op surgical incision.Inflammation or nerve damage gives rise to changes in sensory processing at peripheral and central level with a resultant sensitization. In relation, prostaglandins are chemotactic substances drawing leukocytes to the inflamed tissue. It plays a vasoactive role it is also a pain and fever inducer (Lemone and Burke, 2007). Acute Pain related to infection & inflammation of the peritoneal membranes secondary to peritonitis The peritoneum consists of a large sterile expanse of highly vascular tissue that covers the viscera and lines of abdominal cavity.This peritoneal structure provides a mean of rapid dissemination of irritants or bacteria throughout the abdominal cavity. Abdominal distention is evident, and the typical rigid, board-like abdomen develops as reflex abdominal muscle spasm occurs in response to involvement of the parietal peritoneum (Gould & Dyer, 2011). * aspiration/NOC Pain Control Outcomes pitiable bound by and by 30 minutes of nursing discourse the patient will report a decrease in pain from pain scale of 8/10 to 4-5/10. recollective circumstance subsequently 8 hours of nursing intervention the patient will demonstrate an understanding about the proper way of controlling pain as evidenced by proper splinting and deep breathing exercise and will report a decrease or most probably will be free from pain from pain scale of 4-5/10 to 1-2/10. * NIC Pain Management Independent * Assessed pain including its character, location, severity, and duration. Both preoperatively and postoperatively, the clients pain provides important clues about the diagnosis and possible complications.Abdominal distention and acute inflammation contribute to the pain associated with peritonitis. Surgery further disrupts abdominal muscles a nd other tissues, causing pain (LeMone & Burke, 2007). * Monitored vital signs every 2 hours. Vital Signs, especially respiratory rate (RR), are usually altered in acute pain. (Sparks and Taylor, 2005). * Kept the client at rest in semi-Fowlers position. Gravity localizes inflammatory exudate into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position (Doenges et al. , 2006). * Provided diversional activities (texting, sound trip, etc).Refocuses attention, get alongs relaxation, and may stir coping abilities and diverts attention from pain (Doenges et al. , 2006). * Taught post-op health teaching (e. g. , proper splinting & deep breathing exercises). The use of non-invasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications (LeMone & Burke, 2007). * promote too soon ambulation. Promotes normalization of organ function stimulates peristalsis and passing of flatus, reducin g abdominal discomfort (Doenges, et al. , 2006). Give hot and cold compress. Hot, moist compresses have a penetrating effect. The warm rushes blood to the affected area to promote healing. Cold compresses may reduce total edema and promote some numbing, thereby promoting comfort. (Doenges et al. , 2006). open * Administered analgesic as dictate (TRAMADOL 50 mg/IV Q 8 x 3 doses) Time given 8 AM. Post-operatively, analgesics are provided to maintain comfort and enhance mobility (LeMone & Burke, 2007). * Kept on NPO. Decreases discomfort of former(a) intestinal peristalsis and gastric irritation/vomiting (Doenges et al. 2006). * Evaluation slight end point Goal partially met. subsequently 30 minutes of nursing intervention the patient reported of a decrease in pain from a pain scale of 8/10 to 6/10 in which 4-5/10 was the expected outcome. considerable Term Goal met. After 8 hours of nursing intervention the patient displayed control of pain as evidence by deep breathing exercis e and proper splinting. He also reported of a decrease in pain with a pain scale of 2/10 from 6/10. Pain reliever TRAMADOL was given 8 am via IV. Problem 2 ABSENCE OF FLATUS July 24, 2012 * Subjective Cues Nurse wait lang, ang sakit kasi parang nagcacramps (referring to abdominal cramping), patient verbalized while having a conversation with him. * Pain scale of 8/10 * Objective Cues * (-) Flatulence * (-) BM (Last BM was July 17, 2012) * Absence of bowel sounds upon auscultation of all four quadrants * Nursing Diagnosis Dysfunctional gastrointestinal motility related to inflammatory process of peritonitis secondary to absence of flatulence. The inflammatory process of peritonitis often draws large amounts of fluid into the abdominal cavity and the bowel.In addition, peristaltic application of the bowel is slowed or halted by the inflammation, causing paralytic ileus, impaired propulsion of forward movement of bowel contents (LeMone & Burke, 2007). * Goal/NOC Ambulation Outcomes unawares Term After 8 hours of nursing intervention the client will report/experience flatus and will understand and demonstrate the need for aboriginal ambulation following abdominal surgery. persistent Term After 2 days of nursing intervention the client will report/experience every flatus or bowel movement or both. * NIC Impaction Management PositioningIndependent * Assessed abdomen including all four quadrants noting character to determine increased or decreased in motility Assessed for further abdominal tenderness & auscultated for any abdominal sounds. To help identify the cause of the alteration and guide development of nursing intervention (Sabol & Carlson, 2007). * Monitored and recorded ( expenditure) and output every hour or 2 hours. Intake and output records provide worthy information about fluid volume status (LeMone & Burke, 2007). * Encouraged early ambulation.Promotes normalization of organ function stimulates peristalsis and passing of flatus, reducing abdominal discomfort (Doenges, et al. , 2006). * Assisted in mournful from side to side or up in bed from time to time. Frequent repositioning helps in proper oxygenation and usually prevents complications like pressure ulcers, deep vein thrombosis, etc. (Gulanick, et. al. , 1994). Dependent * Administered antacid as ordered (RANITIDINE 50g/IV Q 12. Antacids either directly neutralize acidity, increasing thepH, or reversibly reduce or third power the secretion of acid by gastric cells to reduce acidity in the stomach (Gabriely, et al. 2008). * Evaluation Short Term Goal partially met. After 8 hours of nursing intervention the patient didnt experience flatus or even bowel movement but was able to have an understanding with regards to early ambulation as evidenced by letting his mother assist him in moving up in bed going to the chair but refused to walk because of complaint of having a lot of contraptions attached to him which causes him to have difficulty in moving. Long Term Goal met. Aft er 3 days of nursing intervention the patient reported of a flatus for 3 times.Problem 3 RISK FOR DEHYDRATION July 24, 2012 * Subjective Cue * Nanghihina na ako kasi limang araw ako hindi pwede kumain pati tubig bawal din kaya nagnunuyo na yung labi ko, as verbalized by the patient. * Objective Cues * NPO for 5 days * Dry mucous membrane * Dry lips * Capillary refill= 2 seconds * Skin turgor= 3-5 seconds * Urine output/shift= 480 mL * Urine color Dark Yellow * Urine specific gravity 1. 030 (Normal honour 1. 005-1. 030) * Absence of bowel sounds of all the four quadrants * (-) Flatus, (-) BM * BP 120/80 mmHg * PP 83 bpm * Nursing DiagnosisRisk for deficient fluid volume related to postoperative restriction secondary to NPO for 5 days Inflammation of the peritoneum with sequestration fluid and NPO status can lead to dehydration and electrolyte im offset (Doenges, et al. , 2008). * Goal/NOC Knowledge interposition Regimen Hydration Oral Hygiene Tissue Integrity Skin & Mucous Membran es Outcomes Short Term After 30 minutes of nursing intervention patient will have an understanding with regards to maintaining fluid balance as evidenced by willingness of following the prescribed regimen given by the medical staffs. Long TermAfter 3 days of nursing intervention the patient will be able to maintain adequate fluid balance as evidenced by moist mucous membrane, rock-steady skin turgor, stable vital signs, and individually adequate urine output. * NIC Fluid Management Fluid supervise Vital Signs Monitoring Independent * Monitored BP & Pulse. Variations help identify fluctuating intravascular volumes, or changes in vital signs associated with resistive response to inflammation (Doenges, et al. , 2006). * Inspected mucous membranes assessed skin turgor and capillary refill. Indicators of adequacy of peripheral circulation and cellular hydration (Doenges, et al. 2006). * Monitored intake and output noted urine color/concentration, specific gravity. Decreasing urine out put of concentrated urine with increasing specific gravity suggests dehydration/need for increased fluids (Doenges, et al. , 2006). * Auscultated bowel sounds. Noted passing of flatus, bowel movement. Indicators of emergence of peristalsis, readiness to begin oral intake (Doenges, et al. , 2006). * Provide clear liquids in small amounts when oral intake is resumed, and progress diet is tolerated. Reduces risk of gastric irritation/vomiting to minimize fluid loss (Doenges, et al. 2006). * disquieted the importance of having him on a NPO status and provided the necessary information with regards to his condition and the medications being administered (e. g. , IVF). It provides the patient a full understanding with regards to his condition thus encouraging him to participate and work manus in hand with the staff (Gulanick, et al. , 1994). * Gave frequent mouth care with special attention to protection of the lips. Dehydration results in drying and harrowing cracking of the lips and mouth (Doenges, et al. , 2006). Dependent * Maintained gastric suction as indicated.Although not frequently needed, an NG tube may be inserted preoperatively and maintained in immediate postoperatively phase to decompress the bowel, promote intestinal rest, and prevent vomiting (Doenges, et al. , 2006). * Administered IV fluids (D5LR 1L x 8 or 30 gtts/min) and electrolytes (D5 Balanced octuple Maintenance Solution w/ 5% dextrose 1L x 8 or 30 gtts/min). The peritoneum reacts to irritation/infection by producing large amounts of intestinal fluid, possibly reducing the circulating blood volume, resulting in dehydration and relative electrolyte imbalances (Doenges, et al. , 2006). * EvaluationShort Term Goal met. After 30 minutes of nursing intervention the patient was able to have a full understanding with regards to maintaining fluid balance as evidenced by verbalizing, So kaya pala hindi pa ako pwede kumain ngaun para maiwasan mairritate ang tiyan ko. Long Term Goal met. After 3 d ays of nursing intervention the patient was able to maintain adequate fluid balance as evidenced by moist mucous membrane, good skin turgor (1-2 seconds), stable vital signs (please see page __ ), and adequate urine output of 620 mL with an appearance of amber yellow. Problem 4 RISK FOR INFECTION July 24, 2012 Subjective Cues Nurse, sobrang kailangan ba talaga ang paghuhugas ng kamay bago linisan o hawakan sugat niya? , asked by the mother. * Objective Cues * Post-operative condition presence of surgical incision * Surgical site is warm to touch and reddened * Temp 36. 3C * Nursing Diagnosis Risk for infection related to inadequate primary defenses secondary to post-operative surgical incision It is risk to be invaded by pathogens especially if surgical site is near at the perineal area, pathogens can also develop by poor personal hygiene and poor wound cleaning (Doenges, et al. 2006). * Goal/NOC Risk Control (For contagious disease) Outcomes Short Term After 30 minutes of nursin g intervention the patient will be able to have partial understanding about infection control and will verbalize understanding of and willingness to follow up prescribed regimen. Long Term After 3 days ofnursing interventionthepatient will be free of sign and symptom r/t infection. * NIC Incision Site thrill Infection Control Wound Care Independent * Monitored vital signs. Noted onset of fever, chills, diaphoresis, changes in mentation, and reports of increasing abdominal pain.Suggestive of presence of infection/developing sepsis, abscess, peritonitis (Doenges, et al. , 2006). * Inspected incision and dressings. Noted characteristics of drainage from wound/drains, presence of erythema. Provides for early detection of developing infectious process, and/or monitors resolution of preexisting peritonitis (Doenges, et al. , 2006). * Instructed proper hand washing. honorable aseptic wound care. Reduces risk for infection (Doenges, et al. , 2006). * Encouraged adequate nutritional intake after the NPO status of the patient and when the patient is allowed to eat.Adequate intake of protein, Vitamin C and minerals is essential to promote tissue and wound healing (Sparks and Taylor, 2005). Dependent * Administered antibiotics (CEFUROXIME 750mg TID Q 8 x 2 doses & METRONIDAZOLE 500g/IV Q 8 x 2 doses) as ordered. healthful antibiotics are given if the appendix is ruptured or abscessed or peritonitis has developed (Doenges, et al. , 2006). * Prepare for/assist with incision and drainage (I&D) if indicated. May be necessary to drain contents of localized abscess (Doenges, et al. , 2006). * Evaluation Short TermGoal met. After 30 minutes of nursing intervention the patient was able to have an understanding about infection control as evidenced by verbalizing, Para maiwasan ang pagkaroon ng impeksyon kailangan kong maghugas ng kamay palagi at kinakailangan din ang araw-araw na paglilinis ng sugat ko kahit na sa tuwing nililinisan ito makirot sa pakiramdam. Long Term Goal me t. After 3 days ofnursing interventionthepatient was free of sign and symptom r/t infection. Problem 5 INABILITY TO PERFORM ACTIVITY/IES OF DAILY LIVING (ADL) JULY 24, 2012 * Subjective Cues Hirap talaga ako gumalaw, maglakadlakad, o kahit man lang umupo dahil sa mga nakakabit na ito sa akin, as verbalized by the patient. Nakakapanghina pa kasi masakit nga yung tahi tapos madalas din nagcacramps ang tiyan ko, he added. * Objective Cues * Presence of surgical incision * Presence of contraptions (urinary catheter, NGT lavage & IV fluid left hand) * Nursing Diagnosis Impaired physical mobility related to body weakness, presence of surgical incision, pain, & presence of contraptions attached Physical immobility can be usually associated with post-operative conditions (Gulanick, et al. 1994). * Goal/NOC Activity Tolerance Outcomes Short Term After 30-45 minutes of nursing intervention the patient will be able to have a clear understanding with the use of identified techniques to enhanc e activity border and to apply it as well as evidenced by participating in ROM exercises, lower leg & ankle exercise, ambulation, or even moving up in bed. Long Term After 2-3 days of nursing intervention the patient will be able to continually participate in a simple form of activity and will report an improvement with regards to his activities. * NIC Exercise Therapy BalanceIndependent * Performed passive ROM exercises. ROM exercises and good body mechanics strengthen abdominal muscles and flexors of spine (Gulanick, et al. , 1994). * Encouraged lower leg and ankle exercises. Evaluated for edema, erythema of lower extremities, and calf pain or tenderness. These exercises stimulate venous return, decrease venous stasis, and reduce risk of thrombus formation (Gulanick, et al. , 1994). * Noted emotional and behavioral responses to immobility. Provided diversional activities. Forced immobility may heighten restlessness and irritability.The Cardiovascular SystemDiversional activity ai ds in refocusing attention and enhances coping with essential and perceived limitations (Gulanick, et al. , 1994). * Assisted with activity, progressive ambulation, and therapeutic exercises. Activity depends on individual situation. It should begin as early as possible and usually progresses slowly, based on client tolerance (Gulanick, et al. , 1994). * Assisted in moving from side to side or up in bed from time to time. Frequent repositioning helps in proper oxygenation and usually prevents complications like pressure ulcers, deep vein thrombosis, etc. Gulanick, et al. , 1994). * Noted client reports of weakness, fatigue, pain and difficulty accomplishing tasks. Symptoms may be result of/or contribute to intolerance of activity (Gulanick, et al. , 1994). Dependent * Administered pain medication (TRAMADOL 50 mg/IV Q 8 x 3 doses, time given 8 AM) as prescribed and on a regular schedule. Clients anticipation of pain can increase muscle tension. Medications can help relax the client, enhance comfort, and improve motivation to increase activity (Gulanick, et al. , 1994). * Evaluation Short TermGoal partially met. After 30-45 minutes of nursing intervention the patient was able to have a clear understanding with the use of identified techniques to enhance activity tolerance and was able to use all of the techniques except for the ambulation. He refused to walk because he complained of pain whenever the catheter tube slipped into his legs. Long Term Goal partially met. After 2-3 days of nursing intervention the patient was able to continually participate in all of the identified techniques but still refused to participate in ambulation.He also reported of an improvement with regards to his activities as evidence by his verbalization, Medyo natotolerate ko na rin yung mga activities kahit pautay-utay muna. Hindi ko lang talaga muna kaya maglakad pero pagnaalis na siguro yung catheter baka kayanin ko na. XV. BIBLIOGRAPHY * Cosgrove DO, Meire HB, Lim A, & Eckersley RJ. (2008). Grainger & Allisonns Diagnostic Radiology A Textbook of Medical Imaging (5th edition). brand-new York, NY Churchill Livingstone * Doenges M. , Moorhouse, M. Murr, A. (2006).Nursing Care Plans Guidelines for Individualizing Client Care across the Life Span (7th Edition). F. A. Davis Company, Philadelphia * Doenges, M. , Moorhouse, M. Murr, A. (2006). Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th Edition). F. A. Davis Company, Philadelphia * Gabriely I, Leu, J. P. , Barky, N. (2008). Clinical problem-solving, back to basics. New England Journal of Medicine * Gould, B. Dyer, R. (2011). Pathophysiology for the Health Professions (4th Edition). Saunders Elsevier Inc. * Gulanick, M. Klopp, A. , Galanes, S. , Gradishar, D. Puzas, M. (1994). Nursing Care Plans Nursing Diagnosis and Intervention (3rd Edition). Mosby-Year Book, Inc. * LeMone P. Burke, K. (2007). Principles of Medical-Surgical Nursing faultfinding Thinking in Client Care (4th Edition). Pearson International Edition * LeMone P. Burke, K. (2008). Principles of Medical-Surgical Nursing Critical Thinking in Client Care (5th Edition). Pearson International Edition * Mosbys Pocket Dictionary of Medicine, Nursing Allied heath (4th Edition) 2002, Mosby Inc. Palma G. Oseda A. (2009). GA Notes Clinical Pocket Guide for Medical and Allied Health Professionals (2nd edition). GA Notes Publishing Co. , Philippines * Sabol, V. K. Carlson, K. K. (2007). Diarrhea Applying research to bedside practice. AACN Advanced Critical Care * Tortora G. Derrickson B. (2006). Principles of Anatomy and Physiology 11th edition. Biological Sciences Textbooks, Inc. * Weber J. Kelley J. (2007). Health Assessment in Nursing (3rd Edition). Lippincott Williams Wilkins