Pa - Appendicitis

SYSTEM EXPECTED FINDINGS ACTUAL FINDINGS RATIONALE
Integumentary Elevation of temperature 36.8 ºC temperature Elevation of temperature

indicates infection
Dry skin Slightly dry skin
Dry skin indicates dehydration
HEENT Head is equal and round Head is round, normocephalic Breathing difficulty due to
and symmetrical. No areas of abdominal pain
Hair is smooth and evenly deformity.
distributed
Hair is distributed evenly, no
Eyes are symmetrical. Pupils infestations
are equal, round and reactive
to light Eyes are symmetrical. Pupils
are equal, round and reactive
Nose is symmetrical. Nasal to light
flaring. Nasal mucosa intact
and pinkish in color Nasal flaring is present
Respiratory Rapid breathing or shortness Increase in pain intensity will

of breath cause shortness of breath as
deep breathing will become
Increased respiratory rate painful
Nasal flaring
Musculoskeletal Presence of psoas sign The right iliopsoas muscle lies

under the appendix when the
patient is supine; thus, a
positive psoas sign on the
right may suggest acute
appendicitis.
Cardiovascular
Genitourinary Frequent urination
Diarrhea
Gastrointestinal Pain and tenderness in RLQ Rosving’s sign rfers to the

pain felt in the right lower
Rebound tenderness abdomen upon palpation of
the left side of the abdomen.
Vomiting
Rovsing’s sign
Hypoactive bowel sounds

Name of Patient: Jose Gomez Age: 3 y/o Diagnosis: Acute Appendicitis
Date of Admission: 03/30/2022 Sex: M Attending Physician: Dr. Lao
Date of Assessment: 03/30/2022 Civil Status: Single SN: Martina Eunice Arguelles\
EXPECTED ACTUAL
BODY SYSTEM RATIONALE
FINDINGS FINDINGS
People with appendicitis feel
General Survey Symptoms associated with Patient D pain in their abdominal area
appendix perforation and appeared agitated that they experience anxiety
rupture include loss of during the and acts withdrawn
Level of consciousness. assessment.
Consciousness
Slurred speech Talked in People with appendicitis

Speech short phrases experience pain in the
only. abdomen when there is
movement such as deep
breathing and talking
Overall Appearance Patient may feel Patient Movement may cause an

pain in abdominal area and is complained that increase in pain intensity
in guarding behavior. Bent his abdominal area hurts and which increases over time
posture. Patient looks weak is walking bent over. Pain
with facial grimace. scale is 8/10
2. Vital Signs
Temperature Low grade fever 37.3 C A small tear in the appendix

may cause infection in the
abdomen which results to
fever if left untreated
Heart Rate 60-100 bpm 82 bpm an increase in heart rate may

mean that the appendix has
ruptured.
Blood pressure 95-110 systolic, 60-70 90/60 mmHg The blockage in the appendix
diastolic may lead to increased
pressure, impaired blood flow,
and inflammation.
Respiratory rate 18-30 cpm 25 cpm Rapid breathing is one of the

symptoms in peritonitis
3. Growth Parameters
Height 4.5 ft 4.7 ft Average height for 10 years

old is 4.5 ft in both males and
females
Weight Patient may have Patient’s current weight is 28 Loss of appetite occur when
relatively loss of kg and below the average and there is infection which often
weight due to lack recommended weight for male progresses to nausea and
of appetite. 10 years olds vomiting. This also reduce
energy levels and may
experience weakness.
4. Integumentary System
Skin Skin is intact, brown, evenly Skin is brown, uniform in color. Minor lesions are considered
colored, warm to touch and Skin slightly hot. No edema. in 10 yer olds due to their high
smooth. Minor lesions. Minor abrasions on knees and level of activity.
arms.
Good skin turgor. When pinched, skin comes Skin staying pinched or tented
back before 2 seconds. or moves back slowly indicate
dehydration
Hair Hair is smooth, silky, and Hair is smooth, silky, and Healthy hair indicates proper
evenly distributed. Scalp is evenly distributed. Scalp is nutrients and vitamins are
clean with no infestations and clean with no infestations and distributed in the body.
dandruff. dandruff.

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SYSTEM EXPECTED FINDINGS ACTUAL FINDINGS RATIONALE

Integumentary Elevation of temperature 36.8 ºC temperature Elevation of temperature

Respiratory Rapid breathing or shortness Increase in pain intensity will

Musculoskeletal Presence of psoas sign The right iliopsoas muscle lies

Genitourinary Frequent urination

Gastrointestinal Pain and tenderness in RLQ Rosving’s sign rfers to the

Hypoactive bowel sounds

Slurred speech Talked in People with appendicitis

Overall Appearance Patient may feel Patient Movement may cause an

Temperature Low grade fever 37.3 C A small tear in the appendix

Heart Rate 60-100 bpm 82 bpm an increase in heart rate may

Respiratory rate 18-30 cpm 25 cpm Rapid breathing is one of the

Height 4.5 ft 4.7 ft Average height for 10 years

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