Suppurative Appendicitis

In Partial Fulfillment of the Requirements for the Subject

Care of Mother and Child at Risk or with Problem (Acute & Chronic) RLE

Submitted by:
Angel, KlienJean S.
Borromeo, Janette H.
Dorigo, Danilo Jr. R.
Faustino, Avegail D.
Guillermo, Kristine Faith V.
Gumaru, Kristine Ariane L.
Manuel, Mizylore P.
Rasquero, Faye Ingrid I.
Turaray, Lady Rose A.
Yap, Krizeth Cherel C.

Bachelor of Science in Nursing

April 2023

Czarina Jane Carpo Gervacio, RN

CLINICAL INSTRUCTOR
General Objectives
The purpose of this case study is to expand the knowledge of nursing students and enable
them to provide optimal care for patients with Appendicitis. It aims to enhance nursing
interventions that aid patients in comprehending their needs, raise awareness among others who
may have this condition, and implement appropriate nursing care for Appendicitis patients.
Specific objectives

These objectives aim to equip nursing students with the necessary knowledge and skills to
provide safe and effective care for patients with appendicitis.

1. Understand the pathophysiology of appendicitis, including its causes, signs and

symptoms, and complications.

2. Develop skills in assessing patients with appendicitis, including obtaining a thorough

history and performing a physical examination

3. Understand the medical and surgical management of appendicitis, including the use of
antibiotics and surgical interventions such as appendectomy.

4. Develop communication skills to effectively communicate with the patient, family,

and other healthcare professionals involved in the care of patients with appendicitis.

5. Develop critical thinking skills to evaluate patient data, identify potential

complications, and initiate appropriate interventions.

6. Understand the importance of patient education and discharge planning for patients
with appendicitis, including postoperative care, pain management, and prevention of
complications.

7. Understand the role of the student nurses in providing holistic care to the patient with
appendicitis, including addressing their physical, emotional, and psychological needs.

OVERVIEW

● Appendicitis is a medical condition that involves inflammation and infection of the

appendix. The appendix is a small, finger-shaped pouch that protrudes from the large
intestine on the lower right side of the abdomen. The exact function of the appendix is
still not well understood.
● A minor abdominal cramp which begins in the upper abdomen or belly button area
eventually spreads to the right lower quadrant of the abdomen is the sign of appendicitis.
● Often, appendicitis is the result of an obstruction of the area inside the appendix called
the appendiceal lumen (the interior of the tube of the appendix), or appendix lumen.

Cause

● Appendicoliths or fecaliths, which are calcified fecal deposits also known as “appendix
stones”
● Viral, bacterial, or fungal infection
● Parasitic infection- Intestinal worms or parasites, including pinworm (Enterobius
vermicularis)
● Irritation and ulcers in the gastrointestinal (GI) tract resulting from long-lasting disorders,
such as Crohn’s disease or ulcerative colitis.
● Abdominal injury or trauma
● Enlarged lymphatic tissue of the wall of the appendix, which is typically the result of
infections in the GI tract
● Benign or malignant tumors
● Various foreign objects, such as stones, bullets, air-gun pellets, and pins
Sign and Symptoms

● Stomach pain in lower right side of the abdomen

● Pain worse if experiencing cough, walking or make uncomfortable movements
● Loss of appetite
● Constipation or diarrhea
● Nausea or vomiting
● Bloating
● A high temperature and a flushed face
● Fever
● Pain during urination

Risk factors

● Age: most affected are teens and people above 20’s

● Sex: common in males than females
● Family History: People who have a family history of appendicitis have a high risk of
having appendicitis.

Complication

● Peritonitis- appendix bursts and bacteria spills into the abdominal cavity or peritoneum,
leading to infection and inflammation.
● Abscesses- a painful pocket of pus that forms around a burst appendix.
● Sepsis- bacteria from a ruptured abscess may travel through the bloodstream to other
parts of the body.

Treatment

● Medical management- treatment normally begins with antibiotics and intravenous fluid.
● Surgical management- Appendicitis treatment usually involves surgery to remove the
inflamed appendix, also known as an appendectomy. Removing the appendix decreases
the risk of it rupturing.
○ Laparoscopic surgery
○ Open surgery

Prevention

● Diet- high-fiber diet

○ Fruits
○ Vegetables such as okra, green beans, sweet potatoes, eggplant and cabbage.
○ Lentils, split peas, beans, and other legumes
○ Oatmeal, brown rice, whole wheat, and other whole grains

Nursing management

Nursing management for patients with appendicitis includes the following:

1. Assessment: The nurse should conduct a thorough assessment of the patient's condition,
including the severity of pain, fever, nausea, and vomiting.

2. Pain management: The nurse should provide adequate pain relief measures to the patient,
such as administering analgesics, using heat or cold therapy, and positioning the patient
in a comfortable position.

3. Fluid and electrolyte balance: The nurse should monitor the patient's fluid and electrolyte
balance to prevent dehydration, especially if the patient is experiencing vomiting or
diarrhea.
 4. NPO (nothing by mouth) status: The patient should be placed on NPO status to prevent
further irritation to the inflamed appendix.

5. Antibiotic therapy: The nurse should administer antibiotics as prescribed by the physician
to help control the infection.

6. Surgical intervention: The nurse should prepare the patient for surgical intervention,
including explaining the procedure and potential risks, obtaining informed consent, and
ensuring the patient's comfort and safety during the procedure.

7. Post-operative care: The nurse should monitor the patient's vital signs, administer pain
relief measures, and assess the surgical wound for signs of infection or complications.

8. Discharge planning: The nurse should provide education on post-operative care,

including wound care, pain management, and signs of complications. The nurse should also
ensure that the patient has adequate follow-up care with the physician.

DEMOGRAPHIC DATA

Name: X

Age: 65

Sex: Male

Weight: 52 kg

Height: 165 cm

BMI: 19.1

Date of birth: September 9, 1957

Address: Diasan, Echague, Isabela

Civil status: Married

Religion: Pentecost

Nationality: Filipino

Date/Time of admission: March 26, 2023 | 1 pm

Chief complaint: Periumbilical pain at RLQ

Admitting diagnosis: Acute appendicitis

Final diagnosis: Suppurative appendicitis

MEDICAL HISTORY

Past Medical History

Whenever the patient is experiencing a common illness such as fever, he takes 500 mg of
paracetamol and uses herbal medicines such as lagundi. Patient X never experienced any allergic
reaction to food or medicine. The patient has not undergone any previous operations or surgeries
and has never encountered any injuries or accidents. The patient has complete immunization and
has acquired two doses of COVID-19 vaccination last 2021.

Present medical history

The patient had been suffering from periumbilical pain into the right lower quadrant area for 2
days, associated with anorexia, with no fever and no vomiting. 2 hours prior to admission,
patient X was still suffering from periumbilical pain at the right lower quadrant with a pain level
of 8 according to him. He was then consulted at Isabela South Specialists Hospital Inc. at
Echague. He was given antibiotics and was referred for admission to Southern Isabela Medical
Center on March 26, 2023, at 1pm. The admitting diagnosis was acute appendicitis. The final
diagnosis was suppurative appendicitis. The patient was then scheduled to undergo an
appendectomy on March 27, 2023.

Family History

Significant details were gathered from the patient upon interview. Patient X is the 2nd child in
the family. With regards to their health, the father of the patient and his older sister have
hypertension, which were all diagnosed by the physician whom they consult.

Genogram

Psychological history

The patient is not diagnosed with any psychological disorder.

Social history
The patient is a smoker and a nonalcoholic drinker. He usually consumes one pack of cigarettes
per day. The patient bonds with his friends and barangay officials after working in the farm.

PHYSICAL ASSESSMENT

Date and time of assessment: March 29, 2023 | 10am

General Appearance
 Patient X is awake, alert, and responsive. The patient stands 165 cm tall and weighs 52
kg, he has an ectomorphic body type (body types with a naturally high muscle-to-fat ratio). Upon
assessment, signs of poor hygiene are evident; oily hair and presence of dandruff flakes. During
the interview, the patient maintained eye contact and demonstrated good sitting body posture.

Vital signs

Blood pressure: 110/80 mmhg

Pulse rate: 73 bpm

Respiratory rate: 21 cpm

Temperature: 36°C

Oxygen 100%
saturation:

Height: 165 cm

Weight: 52 kg

BMI: 19.1 NORMAL

Area Modality Actual Findings Interpretation

● Skin Inspection ● The skin color of the Normal

and patient is brown,
palpation presence of moles are
seen.

● The skin is intact and

has a good skin turgor.
No signs of edema, and Normal
no presence of any foul
odor.

● Presence of surgical
incision at the abdomen

Abnormal. Due to presence

of surgical wound
● Upon palpation, the
skin’s temperature is
within normal.
 Normal
● Dryness of skin is
present.

Abnormal. Dryness of skin

due to frequent sun
exposure.

Head

● Hair Inspection ● Hair is black with Abnormal. Presence of

presence of white hair, 5
dandruff flakes and oil in
inches long, equally
distributed, with the hair due to poor
dandruff flakes and oily hygiene.
hair

Normal
● Head shape is round. No
masses and tenderness
● Skull Inspection upon palpation. No
and presence of lesion.
palpation

● Head shape is round. no

masses. When palpated Normal
there is no presence of
tenderness and lesions.

● Face Inspection
and ● Hair is evenly
palpation distributed, eyebrows
are symmetrically
aligned, absences of
pimples, eyebrows is Normal
black in color.

● Eyebrows Inspection
● Presence of dandruff is
seen.

● No lumps, no nodules.
No pain felt during
palpation.
Abnormal. Presence of
dandruff due to poor
● Eyelashes are equally hygiene.
distributed, curled
 slightly outward, and is
black in color.
Normal

● Eyes are symmetrically

in size and position,
black in color, sclera
appear white, no Normal
abnormal secretion.
PERRLA

● Eyelashes Inspection ● The sclera is in white

color, it is moist and has
no presence of lesions.

● Both conjunctivae are Normal

pinkish, no presence of
lesions, no swelling and
it is moist.
● Eyes Inspection

● The iris is moist and

shiny with no discharge
and cloudiness.

Normal

● The pupil is black in

color, rounded, and
● Sclera Inspection movement is normal.

Normal

● Conjunctivae Inspection

Normal

● Iris Inspection

Normal

● Pupil Inspection
Nose and sinuses

● External nose Inspection ● Symmetric, no Normal

and discoloration, swelling,
palpation flaring or lesions when
palpated.

● No abnormal secretion
or obstruction.

● Pink mucosa, no lesions,

nasal septum intact and
● Nasal cavity Inspection in middle without Normal
tenderness.
Mouth and lips

● Lips Inspection ● Symmetric, dry, pinkish Abnormal due to the

to color brown. dehydration.

● Yellow in color, tooth

● Teeth Inspection decay in the lower first Abnormal due to poor oral
molar and teeth absence hygiene.
in the second premolar.

● Pinkish color, without

the presence of cankers
sores.

● Gums Inspection Normal

● Pinkish color with white
coating in the center of
the tongue.

● Tongue Inspection ● The uvula is in the Abnormal. White coating in

midline of the mouth the tongue due to poor oral
and is pink, moist firm hygiene.
texture, no swelling or
bleeding.

Normal
● Uvula Inspection

Ear and hearing

● Ears Inspection ● No discoloration, Normal

and lesions. No abnormal
palpation secretion or any
tenderness.

● The color of the auricle

is the same as the facial
● Auricles Inspection skin, symmetric, firm, Normal
and non-tender and pinna
palpation recoils after being
folded.
 ● Presence of ear wax is
seen. The color of the
wax is yellow. Blockage
in the left ear.

● External ear Inspection Normal

canal
● Voice sounds audible on
the right ear. However,
on the left side the
patient cannot hear well
as we performed a
watch tick test.
ABNORMAL, this
● Hearing Inspection indicates blockage of ear
acuity test wax on the patient’s left
ear.

● Neck Inspection ● Positioned at the Normal

and midline. No masses,
palpation lesions, or any
tenderness when
palpated and flexes
easily.

● Head Inspection ● Coordinate, smooth Normal

movement movement with no
discomfort.

● Lymph Inspection ● The patient’s lymph Normal

nodes and nodes are not visible or
palpation inflamed
 ● Trachea Palpation ● The trachea of the Normal
patient is in central
placement and is equal
in both sides

● Abdomen Inspection ● With incision, not Normal caused of the

palpated, percussed, and undergone surgery
auscultated because the
patient underwent
surgery and there is a
wound dressing.

Extremities

● Upper Inspection ● Symmetrical, no lesions Normal

extremities and and tenderness with skin
palpation normal temperature,
ROM is good.

● Symmetrical, no lesions
and tenderness with skin
● Lower Inspection normal temperature, Normal
extremities and ROM is good.
palpation
11 GORDON’S FUNCTIONAL HEALTH PATTERN

Date/Time: March 29, 2023 | 1 pm

Before Hospitalization During Hospitalization

I.HEALTH According to the patient, The patient said that health

PERCEPTION-HEALTH health is very important to
should be taken seriously
MANAGEMENT him. Whenever he feels like
PATTERN his body feels tired from and requires attention. He
work, he takes a rest because wants to recover as soon as
he does not want to abuse his possible because he wants
body. He said he does not get to be with his family and
coughs, colds, or fevers get back to his work as a
easily. In times that the barangay official. He said
patient is sick, he uses herbal
medicines such as Lagundi. that he will follow the
He drinks fresh calamansi doctor’s suggestions and
juice when he has a cough. cooperate with his
According to the patient he healthcare providers.
takes paracetamol when he According to the patient,
has a fever and alaxan as a he will make changes in his
pain reliever. The patient has
lifestyle to keep his body
no known allergies. The
patient is an officer in their healthy.
barangay. He visits the
barangay health center
almost every day for
checkups. The patient
received his vaccine against
covid 19. The patient is a
smoker and an alcoholic
drinker. He started smoking
at the age of 25. He still
smokes cigarettes now. He
consumes 20 pieces or 1
pack of cigarettes per day.
Sometimes the patient
experiences pain in the right
lower part of his back but he
simply just ignores it. The
patient takes a bath daily but
rarely uses shampoo. His
hands and feet are also not
thoroughly cleaned and
groomed, the patient only
brushes his teeth once a day.
II. NUTRITIONAL – According to the patient, he According to the patient,
METABOLIC PATTERN eats 3 meals per day. His his appetite did not change
appetite is good, and there is and he has no difficulty in
no difficulty in swallowing. swallowing. The patient ate
He is not picky when it the food given by the
comes to food since he has hospital. The patient drinks
no food allergy. In his diet, 1 bottle of water 1000 ml
he includes meat, fish, per day. For his diet, NPO
vegetables, and rice. His was ordered last March 26
favorite foods are inabraw at 1 pm which lasted until
and pinakbet. He drinks March 27. On March 28 at
coffee 5x a day and 8 am, the doctor ordered
consumes 3 bottles of soft generalized liquid to a soft
drinks 16 oz per day. He also diet wherein he ate lugaw.
eats fruits like bananas and On March 29 at 8:30 am,
pineapples but only in the the doctor ordered DAT in
harvesting season. The last which he ate the food
food the patient ate before provided by the hospital,
admission is paksiw na
tilapia.

III. ELIMINATION Patient said he defecates After surgery he did not

PATTERN every other day. The color is poop for 4 days but he
usually black, and has a farted on the 2nd day. When
strong unpleasant odor he started eating a regular
sometimes. His stool texture diet he pooped which he
and shape is like a sausage described as smooth, soft,
with cracks in the surface. and sausage like. He does
He sometimes feels pain in not feel and experience any
defecating. He also said he pain in defecating. He was
never used laxatives. He hooked on IFC, his SO
urinates 5x a day which drained his urine of 1,300
varies depending on how ml of the total shift
many glasses of liquid he measured via empty bottle
will intake. His urine is of IV. IFC was removed
yellow in color and has no after the 1st day post-op.
strong odor. There is no pain
and no difficulty in
urination.
IV. ACTIVITY – He plants corn and rice on Since he is hospitalized, his
EXERCISE PATTERN their farm. He also dries rice activities are limited,
and corn everyday. He has a another factor is his
pet (cow,duck and chicken) post-operative condition
which he takes care of. which makes it difficult for
Sometimes, he does some of him to move. To ease his
the household chores. He boredom, he talks with his
also repairs the damaged daughter when he gets
furniture in their house. He bored. The patient can feed
walks 700 meters every himself. In grooming and
other day which serves as his bathing, she is being
exercise. The patient can assisted by his daughter.
feed, bath, and groom
himself. Moreover, he has no
difficulties in performing the
said activities.

V. SLEEP – REST The patient said that he The patient said that he
PATTERN sleeps at 9 pm and wakes sleeps at 8 pm and wakes
up at 4 pm. Sometimes he up at 5:00am. He takes a
talks to his family about his nap at noon for 30 mins to
duties in the barangay when 1 hour. He is a light sleeper
has trouble sleeping. He so he wakes up quickly
falls asleep quickly and especially if there are
early (7 pm), especially visitors and other members
when he is tired. He also of the healthcare team. The
takes a nap at noon for 1 to quality of sleep is still poor
and interrupted.
2 hours. The quality of his
sleep is poor and usually
interrupted.

VI. COGNITIVE The patient is oriented to The patient is oriented to

PERCEPTUAL PATTERN people, time and place
people, time and place
responses verbally. The responses verbally. He
stated that he understands
patient is able to read and
his condition but he is still
write however, the patient bothered because of his
stated that he does not have current situation. Since he
any formal education. is a farmer he says there is
Moreover, his Sense of sight a lot of work stuck,
is 20/30 based on visual because of his illness that
acuity, he is nearsighted. His was explained by the
physician. However, he has
 sense of taste is just as good that eagerness to recover to
as well as his sense of smell get back home and work
too. However, his sense of like before again since
farming is already his daily
hearing from his right ear is
routine. His 5 senses are
well heard loud and clear. normal except his sense of
But his left ear is unable to hearing on his left ear is
hear clearly. His sense of hard of hearing.
touch is normal, the
sensation is present.

VII. According to the patient, he During the interview, the

SELF-PERCEPTION/SELF feels good about himself in patient-maintained eye
CONCEPT PATTERN general. When asked contact, he was also
regarding his insecurities, he relaxed, his voice was clear
said that he is confident and and firm. When asked
content about himself. regarding his current
self-perception, he said that
nothing has changed, he
still feels good about
himself.

VIII. ROLE – The patient has a nuclear The patient maintained a

RELATIONSHIP family. She lives with her good relationship even if
PATTERN wife and their children. He his condition was not good.
is a public official He said that his
(kagawad) in his barangay. relationship with his
According to him, daughter developed since
misunderstandings and fights his daughter served as his
are not usual in his family. caretaker during
They support each other's hospitalization. He said
decisions. According to him, that when he talked to his
he has a good relationship workmates, they
with his wife, children, understood his situation
grandchildren, and and that they were hopeful
workmates which leaves him for his speedy recovery and
satisfied with the said return to the barangay.
relationships.

When he gets stressed, he According to him, when he

IX. COPING/ STRESS relaxes and gossips to relieve was hospitalized he was
TOLERANCE PATTERN his stress. He always talks to nervous and scared since it
the barangay officials, his was his first time to be
family, his neighbors and his admitted and the pain was
favorite grandson. He always so severe that he thought
presents problems to his that he was going to die. To
family so that they can solve ease his stress and
them together. His stress nervousness, he copes by
tolerance is high, according talking it out to his
to him, he deals with stress daughter, and by eliciting
and problems just fine. comfort through bible
reading which eventually
makes him feel better.
 Overall, he is satisfied with
his stress management

X. SEXUALITY – According to the patient, he Due to his condition, he is

REPRODUCTIVE was circumcised when he unable to perform any
PATTERN was 11 years old. His first sexual activity. However,
coitus occurred when he was the patient is hopeful that
18 y/o with his then his condition will not
girlfriend, now wife. He is drastically affect his sexual
only involved with one performance after
sexual partner which is his discharge.
wife. Despite his age of 65,
he is still sexually active.
The frequency of sexual
activity occurs at least once a
week. There are no reports
of sexual dissatisfaction and
he has never experienced
difficulties with sexual
functioning. Overall, he is
satisfied with his sexual
relationship.

XI. VALUE – BELIEF The patient’s religion is The patient says his prayers
PATTERN
United Pentecostal Church. every morning, noon, and
He said that his religion and night. He reads the bible
faith are important to him. every day. The patient
He attends Sunday masses. believes in superstitious
He, together with his wife beliefs and quack doctors.
and children are active in He holds a strong faith in
their church. According to God. He believes that God
the patient, his faith helps will help him in every
him in his day-to-day living. challenge in his life.
He says his prayers every
morning and night. He stated
that he puts God first before
he starts his day.
ANATOMY AND PHYSIOLOGY

The appendix is a small, finger-like extension located at the junction of the small and
large intestine. Despite being long considered a vestigial organ, recent research suggests that the
appendix may play a role in the immune system.

The lining of the appendix contains a high concentration of lymphatic tissue, which
produces immune cells that help fight infections. This tissue is similar to that found in the tonsils
and lymph nodes.

The appendix also contains a large number of bacteria, which may help in digestion and
contribute to overall gut health. However, if the appendix becomes inflamed or infected, it can
cause appendicitis, a serious condition that can lead to the rupture of the appendix and the spread
of infection to other parts of the body.

In conclusion, the appendix appears to have a role in the immune system and gut health,
but its exact function is still not fully understood.
PATHOPHYSIOLOGY
COURSE IN THE WARD

Date/Time Progress notes Doctor’s order Interpretation

3/26/2023 Please admit patient to To assess patient and

surgery ward manage properly
12:40PM

Secure consent for Free will to subject self of

admission and the possible management
management upon admission

NPO For safety of the patient

since for possible OR

To have easy access of IV

Ivf D5Lrs 1L x 8 hours meds and hydration

To have a recorded vital

signs and baseline data
Monitor vs q4 and record
Serves as a parameter to
ensure adequate renal
function, if there is
May insert IFC adequate intake and output

To assess and ensure

hydration and function of
Monitor intake and output
kidneys
every shift and record

Diagnostics
For diagnostic purposes to
Cbc with BT
properly diagnose the
Na patient’s condition

Crea

Rbs

Ua

Ptptt INR
 CXR PA

Abdominal xray upright/

supine

Therapeutic
For prophylaxis
1. Cefoxitin 2g IV 30-60
minutes prior to OR

2. Omeprazole 40 mg/iv
OD
An urgent management for
patient with acute
appendicitis
For emergency
Appendectomy

To ensure that the

anesthesiologist and OR
Informed AOD and OR team are prepared and
team ready prior the operation

3/26/2023 Pre op evaluation -Pre anesthesia orders- To ensure that there are no
discrepancies and patient is
8:13pm Attached Pt seen and examined safe to undergo an
history and physical operation
Examination reviewed

Anesthetic technique
explained and understood To ensure that the patient
by patient and watcher understood the course of
anesthesia, its pro’s and
con’s prior to giving
consent
 NPO

For gastric emptying and to

prevent aspiration

Ivf: D5LRS x 12 hours

To keep the patient
hydrated
Meds:

1. Omeprazole 40mg/iv
OD
To prevent vomiting

2. Odansentron 4mg/ IV
push 30 mins to 1 hour
prior to OR
Ensure the line are patent
for IV medication

Ensure pt IV fluid

3/26/23 S/p appendectomy -post anesthesia order-

To PACU To provide critical care and

monitor patient of the
possible postoperative
complications

O2 at 3LPM via nasal

cannula To assist patient in his
respiration

NPO
To ensure that patient will
not have an aspiration due
to anesthesia effect

IVF D5LRS x 8 hours

To keep the patient
hydrated

Meds:

1. Paracetamol 600mg IV
q 6 hours x 4 doses
 Will work as an analgesic
post op
2. Metoclopramide 10 mg /
IVP q 8 hours PRN

To prevent possible
vomiting
3. Morphine 2mg epidural
single dose

Ketorolac 30 mg SIVP q6 To relieve pain from post

x 4 doses op

4. Omeprazole 40 mg/iv
OD

5. Diphenhydramine 50mg
SIVP q8 PRN As standing order for
possible allergic reactions

Maintain IFC
To monitor urine output of
patient and avoid further
trauma when moving due
Monitor I and o to urination

Monitor vs q15 mins To closely monitor the

patient vital signs and
complication due to effect
of anesthetic drugs

Flat on bed

To prevent anesthesia
complications Ex. Spinal
headache
Watch out for; Nausea and
vomiting, dyspnea,
dizziness, headache,
oliguria, hypotension, These are the possible
desaturation, pruritus, post- anesthesia
allergic reaction complications
3/27/2023 s/p appendectomy
12:45 am NPO To ensure that patient will
not have an aspiration due
anesthesia effect
Send specimen to To identify the specimen if
histopathology it is benign or malignant to
confirm the identification
of the specimen

Daily wound care To prevent infection

Encourage ambulation To promote gastric

motility and prevent
adhesiveness
Wof: severe pain, bleeding, These are the possible
dob, chest pain post- anesthesia
complications

3/27/2023 1 day post op Completed dose of Therapeutic regimen

paracetamol and ketorolac
12:18pm - DOB
1. Start tramadol 50mg
- Headache SIVP q8 PRN
- Nausea 2. Start mefenamic acid
vomitin 500mg/tab 1tab
g
TID x 5 days after meals(
- Dizziness start when in DAT) Serves as a parameter to
headach ensure adequate renal
e function, if there is
adequate intake and output,
- Sensory May remove IFC hence the removal of IFC
motor
deficit
awake
coherent

3/27/2023 (-) BM Still on NPO To prevent aspiration

12:52am (+) flatus

(-) Dob Daily wound care To prevent infection,

inspection of post
operative site
Encourage ambulation To promote gastric
 motility and prevent
adhesion
1. Start celecoxib oral 200
mg PRN for pain
Pain management post-
operatively

3/28/2023 Day 2 Generalized liquid to soft It serves as a transition

diet from liquid to soft diet
7:57am Conscious, after recovering from
coherent surgery
(+) flatus

(-) BM Daily wound care

(-) abd. Pain To prevent infection,

inspection of post
(-) vomiting Continue management operative site
Dry, well coapted
wound, soft,
nontender, non
distended abdomen

Normal vs

3/29/2023 Day 3 DAT The patient is able to

tolerate the diet. Recovers
8:22am Conscious, from anesthesia there is
coherent presence of gastric motility
as evidence by having
(+) flatus flatus and bowel
Daily wound care movement
(+) BM

(-) abd. Pain

To prevent infection,
(-) vomiting inspection of post
Encourage ambulation
operative site
Dry, well coapted
wound, soft,
non-tender,
non-distended WOF abdominal pain,
abdomen DOB, Bleeding, fever

Normal vs
These are the possible
Continue management
post- anesthesia
complications
 Refer

3/30/2023 May go home Readiness to go home

Home meds

1. Cefuroxime 500mg BID Completion of antibiotics

x 7days and management of pain

2. Paracetamol + tramadol
TID PRN

3. Ascorbic acid 500mg

OD
To prevent infection,
inspection of post
Daily wound care with operative site
mild soap and water

Personal hygiene

Daily bathing
For management and
further evaluation due to
presence of nephrolithiasis
seen in x-ray of abdomen
Referred to Urology ( Dr.
Agtarap)

Follow up with urology

with xray plate and For re evaluation of post-
ultrasound results April 5, operative site and removal
2023 of suture

Follow up Surgery OPD

April 6,2023
LABORATORY RESULTS
Date/Time: March 25, 2023 | 2:29 am
Age: 65 Gender: Male
HEMATOLOGY CBC-5 PARTS

TEST RESULTS NORMAL INDICATIONS

VALUE
White blood cells 12.64 5.00-10.00 Significance: WBC are an important part
10^9/L of the immune system, they help the body
10^9/L
fight bacteria, viruses, and other foreign
invaders.
Indication: HIGH
Implication: High WBC count usually
indicates that the body is fighting an
infection.
Neutrophil % 71.9% 50.0-70.0% Significance: Neutrophils are a type of
white blood cell that help your immune
system fight infections and heal injuries.
Indication: HIGH
Implication: High neutrophil count is a
sign that your body has an infection.
Neutrophilia can point to a number of
underlying conditions and factors,
including: infection, most likely bacterial.
Lymphocyte % 14.9% 20.0-40.0% Significance: Lymphocytes are the cells
that determine the specificity of the
immune response to infectious
microorganisms and other foreign
substances.
Indication: Normal
Implication: There is nothing going on in
the patient’s body which may cause
alteration of lymphocyte %.
Monocyte % 9.4% 3.0-12.0% Significance: Monocytes turn into
macrophage or dendritic cells when an
invading germ or bacteria enters your body.
The cells either kill the invader or alert
other blood cells to help destroy it and
prevent infection.
Indication: Normal
Implication: There is nothing going on in
the patient’s body which may cause
alteration of monocyte %.
Eosinophil % 3.4 0.5-5.0% Significance: Eosinophils are a type of
white blood cell that play a role in the
immune system by helping fight infections
and boost inflammation in the body
Indication: Normal
Implication: There is nothing going on in
the patient’s body which may cause
alteration of eosinophil %.
Basophil % 0.4 0.00-1.0% Significance: The physiological role of
basophils is thought to be the release of
cytokines, leukotrienes and histamine to aid
immunity to pathogens.
Indication: Normal
Implication: There is nothing going on in
the patient’s body which may cause
alteration of basophil %.
RBC 4.46 4.00-5.50 Significance: Red blood cells, also known
10^12/L 10^12/L as erythrocytes, deliver oxygen to the
tissues in your body.
Indication: Normal
Implication: There is nothing going on in
the patient’s body which may cause
alteration of RBC.
Hemoglobin 12.3 g/dL 12.0-16.0 Significance: Hemoglobin is the protein
g/dL contained in red blood cells that is
responsible for delivery of oxygen to the
tissues.
Indication: Normal
Implication: There is nothing going on in
the patient’s body which may cause
alteration of hemoglobin value.
Hematocrit 37.5% 37-54.0% Significance: Hematocrit measures the
volume of red blood cells compared to the
total blood volume (red blood cells and
plasma).
Indication: Normal
Implication: There is nothing going on in
the patient’s body which may cause
alteration of hematocrit percentage.
MCV 84fL 80.0-100.0fL Significance: Mean corpuscular volume
(MCV) is a laboratory value that measures
the average size and volume of a red blood
cell.
 Indication: Normal
Implication: Low MCV indicates that the
RBC are smaller than normal and may be a
sign of certain types of anemia, including
iron-deficiency anemia, the most common
type.
MCH 27.5pg 27.0-34.0pg Significance: Mean corpuscular
hemoglobin (MCH) is a measurement of
the average amount of hemoglobin in each
red blood cell.
Indication: Normal
Implication: The patient has a sufficient
average amount of hemoglobin in each red
blood cell.
MCHC 32.7g/dL 32-36g/dL Significance: The purpose of an MCHC
test is to evaluate whether RBC are
carrying an appropriate amount of
hemoglobin.
Indication: Normal
Implication: The patient’s RBC carries an
appropriate amount of hemoglobin.
Platelet 442 10^9/L 150-450 Significance: Platelets are tiny blood cells
10^9/L that help your body form clots to stop
bleeding
Indication:Normal
Implication: The patient has a normal
platelet value of platelet.
RDW-CV 14.0% 11.0-16.0% Significance:The RDW value depicts
whether the red blood cells are of normal
size and shape.
Indication: Normal
Implication: The size and shape of the
patient’s RBC is normal.
RDW-SD 43.5 fL 35.0-56.0 fL Significance:The RDW value depicts
whether the red blood cells are of normal
size and shape.
Indication:Normal
Implication: The size and shape of the
patient’s RBC is normal.
MPV 7.8 fL 6.5-12.0 fL Significance:MPV test measures the
average size of the platelet
Indication:Normal
 Implication: The size of the patient’s
platelet is normal.
PDW 15.6 fL 15.0-17.0 fL Significance:PDW reflects how uniform
the platelets are in size.
Indication:Normal
Implication: A normal PDW indicates
platelets that are mostly the same size.
PCT 0.344% 0.108-0.282% Significance:Procalcitonin is a protein that
is produced by the body in response to
bacterial infections, and its level in the
blood can indicate the presence and
severity of a bacterial infection.
Indication:HIGH
Implication: High value of PCT indicates
that there is an infection in the body.
NRBC% 0.00% 0.00-9999.99 Significance:NRBCs are generally not
% present in the bloodstream, but they may be
seen in certain conditions such as fetal
circulation, bone marrow disorders, severe
anemia, or in response to stress such as a
heart attack or a severe infection.
Indication: Normal
Implication: The patient does not have
NRBC in his bloodstream.

URINALYSIS REPORT
General sediment result: positive
General chemical result: abnormal
Dilution factor: 1.0

Particle Category p/HPF Ref.(p/HPF) Modified

RBC 25-50 36.2 0..2 NO

WBC 50-100 79.5 0..2 NO

Epithelial cells RARE <1.14 0..2 NO

Yeast cells NEGATIVE 0 0..1 NO

Bacteria FEW 19.8 0..1 NO

Mucus threads MANY 12.4 0..1 NO

 Analyte Result Note

Color Yellow

Clarity Clear

Specific gravity 1.016

pH 5.5

Urobilinogen 0.2 E.U./dL NEGATIVE

Glucose NEGATIVE

Bilirubin NEGATIVE

Ketones NEGATIVE

Blood 1+

Protein 2+

Nitrate NEGATIVE

Leukocytes 2+

Albumin 150 mg/L POSITIVE

CLINICAL CHEMISTRY REPORT

Date/Time: March 26, 2023 | 2:39 pm
HEMOLYSIS (H): 19 ICTERUS (I): 2 TURBIDITY(T): 21

ASSAY RESULT RANGES

Glucose 144.2 mg/dL 90-160

Potassium 3.67 mmol/L 3.50-5.10

Sodium 137.7 mmol/L 135.0-145.0

Creatinine 128.9 umol/L 58.0-110.0

XRAY RESULT
Case No: 2023-9211
Date/Time: March 26, 2023 | 9:28 am
Physician: Abalos, Rodrigo Sapiadante JR
ABDOMEN SUPINE/ UPRIGHT VIEWS
RESULT
ABDOMEN (UPRIGHT AND UPRIGHT)
DATE & TIME DONE: 3/26/2023 9:28 AM

There are calcific densities of varying shape and sizes in the upper abdomen, overlying the
bilateral kidney shadows.
Mottled fecal materials are seen in the ascending and descending colon. The rest of the bowel
loops are unremarkable.
No evidence of pneumoperitoneum seen.
Rectal gas is noted.
Psoas and preperitoneal outlines are intact.
Visualized osseous structures are intact.

IMPRESSION:
1. BILATERAL NEPHROLITHIASIS WITH SIGNS OF STAGHORN IN THE LEFT
2. MILD FECAL STASIS
___________________________________________________________________________

Case No: 2023-9211

Date/Time: March 28, 2023 | 11:18 am
Physician: Abalos, Rodrigo Sapiadante JR
CHEST PA-ADULT
Result
CHEST PA
DATE AND TIME DONE 3/28/23 11:18 AM

The lung fields are clear.

The heart is not enlarged. The aortic knob is calcified
The costophrenic sulci and diaphragm are intact.
There are crescent-shaped lucencies beneath the right and left hemidiaphragms, more in the right.
The bony thorax is unremarkable.
CONCLUSION: 1. ATHEROMATOUS AORTA
2. PNEUMOPERITONEUM, BILATERAL, MORE IN THE RIGHT
DRUG STUDY

DRUG NAME MECHANISM DOSAGE INDICATION CONTRAINDICATI ADVERSE NURSING

OF ACTION ON REACTION RESPONSIBILITIE
S

Brand name: Block gastric acid 40 mg IV Dyspepsia Hypersensitivity ∅

OMEVEX secretion by OD Take 1 hour before the
irreversibly meal. Do not use it
Generic name: binding to and with other antacids,
OMEPRAZOLE inhibiting the exclude possibility of
Na hydrogen-potassi Malignancy of gastric
um ATPase pump ulcer suspected. Avoid
Drug that resides on the high dose long-term
Classification: luminal surface of use. Hepatic
Antireflux the parietal cell impairment. Pregnancy
Agents & membrane. and lactation Children.
Antiulcerants

DRUG NAME MECHANISM DOSAGE INDICATION CONTRAINDICATI ADVERSE NURSING

OF ACTION ON REACTION RESPONSIBILITIE
S
Brand name: Acts through both 10mg IV Management of Known ∅
CLOZIL dopaminergic and Q8 PRN nausea and vomiting hypersensitivity to Monitor Vital signs,
serotonergic associated with metoclopramide or WOF hypersensitivity
Generic name: receptors. various GI disorders excipients reactions, Monitor
Metoclopramide intake and output,
advice patient to rest
Drug for at least 1-2 hours
Classification: this is to decrease
Antiemetics bowel movement.

DRUG NAME MECHANISM DOSAGE INDICATION CONTRAINDICAT ADVERSE NURSING

OF ACTION ION REACTION RESPONSIBILITIES

Brand name: Prevents the 50mg Relief of mild Hypersensitivity ∅

RITEMED release of Q8 PRN uncomplicated WOF Drug interaction
DIPHENHYDR histamine, allergic skin or Hypersensitivity.
AMINE HCL competes with manifestations. Administer w/ meals,
free histamine for Assess stomach pain,
binding at H1 decrease dosage in
Generic name: receptors sites, renal and liver failure.
Diphenhydramin Suppresses the Administer over at
e formation of least 5 minutes
edema, flare and RATIONALE: rapid
Drug pruritus that result administration may
Classification: from histaminic cause hypotension and
Anti-allergy and activity. arrhythmias.
Antihistamines
DRUG NAME MECHANISM DOSAGE INDICATION CONTRAINDICAT ADVERSE NURSING
OF ACTION ION REACTION RESPONSIBILITIES

Brand name: Anti-inflammator 30mg IV Short term Hypersensitivity to ∅

KETERO y Q6 x 4 management of ketorolac, aspirin and Assessing the patient's
and Doses moderate to severe other NSAIDs pain level and
Generic name: analgesic activity; post-op pain. determining the
Ketorolac inhibits appropriate dose of
Tromethamine prostaglandins ketorolac to administer.
and leukotriene
Drug synthesis Monitoring the
Classification: patient's vital signs and
NSAIDs assessing for adverse
reactions or side
effects, such as
bleeding, stomach
pain, or kidney
problems.

DRUG NAME MECHANISM DOSAGE INDICATION CONTRAINDICAT ADVERSE NURSING

OF ACTION ION REACTION RESPONSIBILITIES

Brand name: Central analgesic 600mg IV Relief of mild to Hypersensitivity to ∅

AEKNIL effect that is Q6 x moderate pain paracetamol Do not exceed the
mediated through 4Doses including headache. recommendation
Generic name: activation of dosage. Reduce dosage
Paracetamol descending w/ hepatic impairment,
serotonergic discontinue drug if
Drug pathways. hypersensitivity.
Classification:
Analgesic/
antipyretic/
non-opioid

DRUG NAME MECHANISM DOSAGE INDICATION CONTRAINDICAT ADVERSE NURSING

OF ACTION ION REACTION RESPONSIBILITIES

Brand name: Bind to bacterial 1g IV Treatment and Hypersensitivity to ∅

CEFOVEX cell wall Q8 prophylaxis of cephalosporins Monitor for possible
membrane, anaerobic and mixed drug induced adverse
Generic name: causing cell bacterial infections reactions. Discontinue
Cefoxitin death. especially drug if
Therapeutics intra-abdominal and hypersensitivity.
Drug effects; pelvic infections,
Classification: Bactericidal prophylaxis of
Cephalosporins action against endometritis surgical
susceptible infection.
bacteria. Active
against
bacteroides
fragilis.
NURSING CARE PLAN
Date/Time: March 29, 2023 | 7:30 am

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain due to post Within 6-8 hours of Independent:

“Masakit dito sa baba, appendectomy as nursing intervention, the -Assessed pain -Elevation in intensity After 6-8 hours of
lalo na kapag evidenced by post pt will be able to characteristics including and frequency may nursing intervention, the
gumagalaw ako”, while surgical wound manifest ability to cope location, intensity and indicate worsening pt was able to manifest
pointing at RLQ of with incompletely frequency condition ability to cope with
abdomen. relieved pain by incompletely relieved
-rated pain as 5/10 -Assessed surgical site pain as evidenced by
-characterized pain as a. verbalization of for swelling, redness, or -Swelling, redness , and
pricking/ “tusok-tusok” decreased pain loose sutures loose sutures may a. ) verbalization of
-reported that pain from 5/10 to 0/10 contribute to the pain felt decrease pain from 5/10
intensifies when the pt b. engagement in by pt and are indicative to 0/10
moves. diversional of further management
activities such as b.) engagement in
Objective: socialization, and -Promoted adequate rest diversional activities
-S/P appendectomy listening to periods by temporarily -To lessen pain felt such as socialization,
-with dry intact dressing mellow music limiting activity aggravated by and listening to mellow
on the surgical site movements music
-with guarding behavior -Encouraged pt to
>verbal report that pain
-(+) facial grimace verbalize pain perception
is completely relieved,
-To allow further
“Hindi na masakit sa
assessment of pain
bandang tahi ko.”
characteristics and
evaluation of treatment / >absence of facial
intervention grimace upon
-Provided pt with performance of activities
diversional activities such as changing
such as socialization and - Diversional activities position, sitting ,standing
 listening to mellow distract pt’s attention and walking
music from the pain
> absence of guarding
- Encouraged SO to behavior over surgical
continue provision of site
diversional activities to -To allow pt continue
patient divert his attention

Dependent:
-Administer prescribed
medications for pain as -For therapeutic
ordered management

Date/Time: March 29, 2023 | 8 am

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for infection related Within 5 hours of -Monitor v/s and record -Elevation in rates may Within 5 hours of
”Hindi naman ako to impaired skin nursing intervention the indicate infection nursing intervention the
nilalagnat” verbalized by integrity due to surgical pt will be able verbalize pt was able to manifest
the patient incision ways in preventing -Assessed operative site -to provide baseline data the following:
infection/contamination for signs of infection for comparison and a.) intact sutures
Objective: specifically proper hand identify need for further b.) dry and intact wound
Temperature: 36.5°C washing, and proper management dressing
- S/P Appendectomy wound care as evidenced c.) participation in
-with dry intact dressing by: passive ROM exercises
on the surgical site -maintain stable v/s -Change linens as -to prevent growth of
-absence of swelling necessary microorganisms on
redness and pain on linens and beds
operative site
-Provided regular -to prevent unnecessary
dressing care exposure and
 contamination of
operative site
which may delay wound
healing

-Instructed pt and SO to -for immediate

refrain from replacement to prevent
touching/scratching skin breakdown and
operative site contamination of
operative site

-Encouraged pt to -to allow continuous

verbalized any changes monitoring and
noted on operative site assessment of pt.
such as redness, swelling condition
and unusual/odorous
drainage

-Encouraged pt to
engage early ambulation -to promote circulation
and have SO’s assist him to the surgical site for
in such activities timely healing

Dependent:
-Administer antibiotics
as ordered -serve as prophylactic
treatment and prevent
bacteria to harbor on
operative site
Date/Time: March 29, 2023 | 9 am

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired skin integrity Within 4 hours of -Assessed operative site -to check skin integrity, Within 4 hours of
“ Hindi pa masyado related to surgical nursing intervention the for redness, swelling, monitor progress of nursing intervention the
magaling ang sugat ko.” incision as evidenced by pt will be able to loose sutures, or soaked healing and identify pt was able to manifest
as verbalized by the post surgical wound manifest the following: dressing need for further the following:
patient. a.) intact sutures a.) intact sutures
b.) dry and intact wound b.) dry and intact wound
Objective: dressing -Assisted in passive -to promote circulation dressing
-S/P Appendectomy c.) participation in movements(while 8hrs. to the surgical site for c.) participation in
-with surgical incision at passive ROM exercises flat on bed) such as bed timely healing passive ROM exercises
right lower abdominal turning and passive
area ROM exercise and
-with dry intact dressing active exercise thereafter
on the surgical site movements such as bed
position, sitting,
standing, walking

-Encourage pt to support -to reduce pressure on

incision when coughing the operative site
and during movement

-Encouraged pt to
verbalize his for any -to allow continuous
untoward feelings monitoring and
especially pain, assessment of pt.
discomfort as well as condition
changes noted on
operative site

-Encouraged pt to -to promote circulation

engage early ambulation to the surgical site for
and have SO assist him timely healing
in such activities

-Instructed pt and SO to -to promote circulation

immediately report when to the surgical site for
dressing are soaked timely healing

>Instructed pt and SO to -to prevent skin

refrain from breakdown and
touching/scratching contamination of
operative site operative site

-Provided regular -to avoid accumulation

dressing care of moisture at the
operative site
which may lead to skin
breakdown
Date/Time: March 30, 2023 | 8 am

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S= “kinaadu iti trabaho Self-Care Deficit in At the end of the shift 1. Assess client's ability > Use of observation of Goal was met. Patient
jay taltalon, haan ko bathing/hygiene related related learning to bathe self through function provides was able to do self-care
maasikason ti panag to decreased or lack of experience, patient will direct observation (in complementary activities without
kuko lalo ket bannog ko motivation. be able to perform usual bathing setting assessment data for goal someone prompting or
paynu agawid nak ken personal hygiene within only) noting specific and intervention telling him to do so.
kanayon nak met taltalon Scientific Basis: the level of own ability. deficits and their causes. planning.
masapol pay ba nga ag to lack of
dalos nuka, usto nan jay interest in personal
agbuggo nuka”, as hygiene. 2. Plan activities to
verbalized by the patient. prevent fatigue during > Energy conservation
bathing increases activity
O>received patient tolerance and promotes
sitting on the bedside self-care.
with s.o
3. Instruct patient to
> finger and toe nails select bath time when he > Hurrying may result
are dirty and long noted is rested and unhurried. in accidents and the
energy required for these
> dandruff on hair and activities may be
skin noted substantial.
4. Encourage
> unpleasant dryness of independence, but
skin noted intervene when patient > An appropriate level of
cannot perform. assistive care can
>Presence of cavity and prevent injury with
tartar on teeth activities without
 causing frustration.
5. Use consistent
routines and allow
adequate time for patient
to complete tasks. > This helps patient
organize and carry out
self-care skills.
6. Provide privacy
during bathing/dressing
as appropriate.
> The need for privacy is
fundamental for most
patients.
7. Encourage use of
clothing one size larger.

> This ensures easier

dressing and comfort.

8. Assist patient with

care of fingernails and
toenails as required.
> Patients may require
nail care to prevent
injury to feet during nail
trimming or because
special implements are
9. Provide supervision required to cut nails.
for each activity until the
patient performs skill
competently and is safe > The patient’s ability to
in independent care; perform self-care
reevaluate regularly to measures may change
be certain that the patient often over time and will
is maintaining skill level need to be assessed
and remains safe in the regularly.
environment.

10. Provide positive

reinforcement for every
accomplishment made.
> Positive reinforcement
enhances self-esteem
and encourages
repetition of desirable
behaviors.
DISCHARGE PLAN
DATE DISCHARGED: 3/30/2023

MEDICATION:
● Paracetamol + tramadol tab, 1 tablet 3x a day as needed for pain
● Cefuroxime 500mg tab, 1 tablet 2x a day to complete for 7 days , 8am & 6pm
● Ascorbic Acid 500mg 1 tablet 1x a day, 8am
ENVIRONMENT:
● Should be kept dry, clean, well ventilated
EXERCISE:
● Avoid sudden movements and heavy work
● Avoid force
HEALTH TEACHING:
● Clean the wound twice.
● Keep the wound clean and dry.
● When fever is high, prolonged wound healing, bad smell of the wound arise.

OUTPATIENT:
● To come back to out patient department on APRIL 05, 2023 8am-5pm to remove
the suture.
DIET:
● Diet as tolerated
● Do not drink alcohol and smoke
SPIRITUAL:
● Encouraged to continue to seek God’s guidance & enlightenment.
● Emphasized the importance of prayers in healing.
● Encouraged the patient to ask for divine assistance in everything.
● Encouraged the patient to continue to have a positive outlook in life.