I.

Patient Profile
PATTERNS OF FUNCTIONING CLINICAL INSPECTION OTHER SOURCES

Na me: Age:
Mark Bien Gamrot 21 years old

Gender: male Occupation: construction worker Educational Attainment: High School Civil Status: single Nationality: filipino Address: 393 Cabugao Sto .Domingo ,Nueva Ecija Religion: catholic C/C: abdominal pain Date Admitted: January 15, 2013 @ 2:25 pm Admitting Diagnosis: Acute appendicitis Final Diagnosis : Peri appendical Abscess Attending Physician: Dr. Leonardo Flores Source of Information: patient and mother Reliability: 90%

II. Present Illness:

3 day prior to admission, the patient experienced mild pain on his right lower quadrant abdomen associated with constipation and vomiting but no fever. Few hours prior to admission still with abdominal pain now with fever consult at own laboratory of pillar. Has positive allergy to foods such as (pork). E E/L, appendectomy, Cecorlaphy, and Peritoneal Washing

III. Past Health History:

. Pain in the right lower abdomen 1st felt 3 days prior to admittion in Our Lady of the Pillar Medical Center in Cavite, but the result is now no pain and no history of hospitalization.

IV. Family History:

The mother claimed that her mother is asthma positive, and noted hypertension history on the paternal side.

V. Psychosocial history:
The patient sorrounding is good. They used a mineral at faucet for drinking and taking a bath. He smokes 5 sticks of cigar. Per day, and play basketball in freetime. He works in Cavite as Construction worker .

1. RESPIRATORY - (+) Hx of Asthma - Consumed 5 sticks of cigar/day - Started smoking since 17 y.o

RR = 26cpm No accessory muscle used No respiratory aids used No cough and cold BP = 110/70 mmHg PR = 53 bpm No presence of discoloured or swollen parts Good capillary refill Hematology: WBC: 18.30x10^9/L Neutrophil: .90 Lymphocyte: .10 Hematocrit: .46

2. CIRCULATORY - (+)Hx of HPN

3. FOODS AND FLUIDS INTAKE - Usual food taken: leafy vegetables, fish, rice, root crops - (-)food allergies - (-)food preferences & dislikes - Drink 4 glasses of water each day - Drink 10 glasses of tuba occasionally 4. ELIMINATION - Void more than 5x/day - Defecate 1x/day or sometimes 1 time every 2 days - Fun of retaining stools if at work

Good skin turgor Dry lips With an IVF of D5LR @ 30gtts/min No NGT

Not constipated Presence of indwelling catheter (-) nausea

URINALYSIS Color : Dark yellow Transparency: Turbid Specific gravity: 1.025 PH: 6.0 Glucose: negative Albumin: trace WBC: 2-3/hpf Bacteria: moderate Mucus threads: many Costs: coarse granular: 0-1/lpf Uric acid: moderate

5. REGULATORY MECHANISM - (+) mild fever during childhood

T = 36.6 Afebrile (-) chills

6. HYGIENE - Take a bath 1-2x/day - Seldom use shampoo - Change cloth everyday - No allergies to soap & shampoo - Combs hair

Untidy to look at (-)skin lesions Hair is equally distributed (+)Halitosis Poor dental care Presence of plaque

7. EXERCISE & LOCOMOTION - Take the daily activities as exercise

Impaired mobility due to pain

8. REST & SLEEP - Retire @ 9pm, rises @ 5am - Side lying position - Uses 2 pillow

Interrupted sleep due to pain

9. COMMUNICATION & SPECIAL SENSES - Right handed - No visual/auditory disturbances - Speaks waray - (-)ear, eye gadgets 10. SENSORY - (-) Hx of convulsions, Hx of epilepsy

Eyelashes are equally Distributed Whitish sclera Pinkish conjunctiva

(-) convulsions nor epilepsy

11. PAIN & DISCOMFORT - Pain experienced in the RLQ of the abdomen & used herbal oil & kerosene for relief 12. RECREATION/DIVERSION - Playing basketball for fun

Pain scale of 8 Impaired mobility due to pain

Throw jokes while interview process

13. RELIGIOUS LIFE - Roman Catholic 14. COPING MECHANISM - Self keeping of problem 15. SOCIAL OCCUPATION - Heavy type of work

No medals worn

Friendly

LABORATORY RESULTS
Hematology:
Components 1. WBC Normal values 4.5 11x109/L Results 18.30 x 109/L Interpretation Increased Clinical Significance Presence of inflammation

2. Neutrophils

0.45 0.73

0.90

Increased

Acute infection, trauma or surgery

3. Lymphocyte

0.2 0.4

0.10

Decreased

Aplastic anemia, SLE, immunodeficiency including AIDS

4. Hematocrit

Males: 42 52 % Females: 35 47 %

46 %

Normal

Balance proportion of blood volume that is occupied by RBC

Urinalysis:
Components 1. Color Normal Pale yellow to amber Results Dark Yellow Interpretation Not normal Clinical Significance Not enough water intake, presence of bilirubin Cystisis, presence of bacteria Properly diluted urine Not risk for calcification, and infection Absence of DM Proper filtration of glumerolus Cystisis, nephritis, Urinary tract infection Presence of renal infection or disease Absence of calculi

2. Transparency 3. Specific gravity 4. PH

Clear to slightly hazy 1.015-1.025 4.5-8.0

Turbid 1.025 6.0

Not normal Normal Normal

5. Glucose 6. Albumin 7. WBC 8. Bacteria 9. Casts

Negative Negative Negative or rare Negative Occasionally hyaline casts

Negative Negative 2-3/hpf Moderate Coarse granular: 0-1/hpf

Normal Normal Not normal Not normal, bacteremia Not normal

10. Uric Acid

1.58-4.43 mmol/24 h

3.13 mmol/24 h

Normal

ANATOMY AND PHYSIOLOGY Vermiform appendix In human anatomy, the appendix (or vermiform appendix; also cecal (or caecal) appendix; also vermix) is a blind-ended tube connected to the cecum (or caecum), from which it develops embryologically. The cecum is a pouchlike structure of the colon. The appendix is near the junction of the small intestine and the large intestine. The appendix averages 10 cm in length, but can range from 2 to 20 cm. The diameter of the appendix is usually between 7 and 8 mm. The appendix is located in the lower right quadrant of the abdomen, or more specifically, the right iliac fossa the position within the abdomen corresponds to a point on the surface known as McBurney's point. While the base of the appendix is at a fairly constant location, 2 cm below the ileocaecal valve, the location of the tip of the appendix can vary from being retrocaecal to being in the pelvis to being extraperitoneal. In rare individuals with situs inversus, the appendix may be located in the lower left side. Maintaining gut flora: major function Although it was long accepted that the immune tissue, called gut associated lymphoid tissue, surrounding the appendix and elsewhere in the gut carries out a number of important functions The digestive tract's immune system is often referred to as gut-associated lymphoid tissue (GALT) and works to protect the body from invasion. GALT is an example of mucosa-associated lymphoid tissue. The mucosa-associated lymphoid tissue (MALT) (also called mucosa-associated lymphatic tissue) is the diffuse system of small concentrations of lymphoid tissue found in various sites of the body such as the gastrointestinal tract, thyroid, breast, lung, salivary glands, eye, and skin.

FOR the PATHOPYSIOLOGY just go to this site :

http://www.scribd.com/doc/46437230/Pathophysiology-of-Appendicitis

Nursing Diagnosis
Limited movement related to pain as manifested by: Subjective: Anay, hinay hinay la ke ma ol-ol tak samad as verbalized by the patient.

Scientific analysis
Having an Appendectomy is a procedure that has the need to cause the tissue to be traumatized, which leads to the inflammatory process characterized by pain, redness, swelling and loss of function of some part, it is effective in the treatment of appendicitis with perforation, surgery leaves tissue damage that causes the release of chemical mediators, and WBCs which causes to form exudates then this exudates causes the nerve endings to be compressed thus making pain and this pain makes a person to have limited movement.

Objectives

Nursing Interventions
INDEPENDENT:

Rationale

Evaluation
After 8 hours of nursing interventions the patient is able to Rest quietly Sit in a high-fowlers position from lying in bed, and know the proper way in seating from a supine position. therefore: GOAL MET

After 8 hours of nursing interventions, the patient will be able to Regain / maintain mobility at the higher possible level, Demonstrate techniques that enable resumption of activities, and Increase strength/ function of affected and compensatory body parts. 1. Instruct the client to minimize activities that will put pressure on his abdomen. 2. Reposition periodically and slowly and encourage deep breathing exercises. 3. Encourage rest. 4. Move patient slowly and deliberately. 5. Administer analgesics as 1. Activity that require holding the breath and bearing down can result in pain to surgical site in RLQ, bradycardia and rebound tachycardia with elevated BP. 2. Prevent / reduces incidence of skin and respiratory complications. 3. Reduces myocardial workload / oxygen consumption, reducing risk of complication. 4. Reduces muscle tension or guarding, which may help minimize pain of movement. 5. To maintain acceptable level in pain. Notify physician if regimen is inadequate to meet pain control goal.

Objective: Temp - 36.6 oC PR - 53 bpm RR - 26 cpm BP - 110/70mmhg

weakness facial grimace guarding behavior incision on RLQ

Reference: Medical Surgical nursing by Brunner and Suddarth 11th edition; Vol.2 pages 12401242

ordered

Nursing Diagnosis
Impaired skin integrity related to surgical incision SUBJECTIVE: katapus ko la ka operahe as verbalize by the patient OBJECTIVE: - open wound - visible surgical incision - post-operative patient Temp - 36.6 oC PR - 53 bpm RR - 26 cpm BP - 110/70mmhg

Scientific analysis
Surgical intervention involves removal of appendix within 24 to 28 hours in which surgery can be performed through a small incision that causes a disruption or damage to the skin tissues. Which will leads to impairment of the first protective layer from infections or foreign object. Reference: Medical surgical nursing by brunner and suddarth, 11th edition volume 2 @ page: 1242

Objectives
After 8 hours of nursing intervention the patient will Achieve timely wound healing and be free of infection, demonstrate how to keep wound dry and promote healing.

Nursing Interventions
DEPENDENT: 1) Observe wound, note characteristics of drainage.

Rationale
1. Post-operative hemorrhage is likely to occur during first 2 days, whereas infection may develop anytime. 2. Reduce skin irritation and potential infection, also to prevent soaking the dressing by any discharges. 3. May decrease pressure to operated site, thus relieving abdominal distention. 4. Promote protection to the incision site. 5. Hasten the healing of the wound.

Evaluation
After 8 hours of nursing interventions the patients wound appears to be dry and freed from drainage or purulent substances therefore goal was met.

2) Change dressing as needed using aseptic technique.

3) Encourage side lying position (on the leftside) or a semifowlers position.

4) Encourage guarding behavior. DEPENDENT 5) Administer antibiotics as doctors order

Nursing Diagnosis Risk for infection related to surgical incision at right lower quadrant of the body. Objective: incised skin @ right lower quadrant RR 26 cpm PR 53 bpm Temp 36.6 oC Incision pain

Scientific analysis

Objectives After 8 hours of

Nursing Interventions INDEPENDENT:

Rationale

Evaluation

The creation of surgical incision during appendectomy disrupts the skin integrity of the skin and its protective function. Exposure of deep body tissues to the pathogens in the environment places the patient at risk for infection of the surgical site, a potentially threatening complication. Factors related to the surgical procedure include the method of preoperative skin preparation, surgical attire of the team, method of sterile draping, duration of surgery and length of procedure.

nursing intervention, the patient will be able to Verbalize and understand the causative/risk factor for the infection. Demonstrate techniques in minimizing infection. Remove all possible factors that may contribute to the infection process. Achieve timely wound healing; be free of purulent drainage or erythema.

1. Fever and pain indicate 1. Monitor vital signs, onset of fever with chills, and pain. 2. Practice/ instruct good hand washing and aseptic wound care. 3. Inspect incision site. Note characteristics of drainage from wound. 4. Change wound dressing as indicated, using proper technique for changing/ disposing of contaminated materials. 5. Encourage intake of fluid and food that is rich in Vitamin C. inflammatory responses, which contribute to infection. 2. Reduces the risk for infection or cross contamination of bacteria. 3. Provides early detection of infection process, and presence of discharges may help to identify whether there is an infection. 4. To reduce/ correct existing risk factors. 5. Promotes healing and prevents dehydration.

After 8 hours of nursing education and interventions, the patient was More conscious about his environment and the patient seems to be hesitated and confused or failed to express some of the information imparted by the nursing students therefore: GOAL WAS PARTIALLY MET.