Final Case Press

8/14/2019 Final Case Press

1/18

Table of contents

....................................................................1

Introduction.2

Objectives.3

Patient Profile.4

Physical Assessment..5-

6

Anatomy and Physiology.7

Pathophysiology.8

-9

Laboratory.

9

Medical Surgical

Intervention.10-11

Gordons Pattern of functioning.12-

13

Drug

study14

Nursing Care Plan

15-16

DischargePlanning17

Reference

18

1


2/18

Introduction:

About AppendicitisThe appendix is a small finger-like organ that's attached to the large intestine in the lower right side of the

abdomen. The inside of the appendix forms a cul-de-sac that usually opens into the large intestine. When

that opening gets blocked, the appendix swells and can easily get infected by bacteria.

Appendicitis is a condition characterized by inflammation of the appendix. It is a medical emergency. All

cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is

high, mainly because of peritonitis and shock. Reginald Fitz first described acute and chronic appendicitis in

1886, and it has been recognized as one of the most common causes of severe acute abdominal pain

worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis".

2


3/18

Objectives:

General

After four weeks of Related Learning Experience, I will be able to acquire the knowledge, skills and

attitude regarding appendicitis.

This study will help us to learn more about appendicitis

To learn how to give quality nursing care to patients who are suffering from the disease itself.

It will also give us knowledge on what we can teach to the patients and their relatives on how to

prevent in acquiring the disease.

Specific

Within the days of case study, I will be able to construct a pathophysiology connecting the

conditions of Dengue Fever.

To be able to make two (2) appropriate NCPs for my patient.

To be able to deeply understand what is appendicitis.

To be able to know the signs and symptoms of the complication.

To be able to render quality nursing care to the patient with appendicitis.

3


4/18

PATIENTS PROFILE

NAME : MB

Age : 10/yrs

Sex: Male

Physician : Dr. Arcellana/zaen

Room : 533d

Chief complaint: abdominal pain

Diagnosis : Acute appendicitis

Past Medical History

(+)skin asthma

History f present illness:

A few hours prior to admission, the patient experienced severe amount of epigastric pain

Associated with 3x vomiting,(+) low grade fever.

At around 4pm ,increased pain in RLQ, patient was brought to the nearest hospital, thentransferred to the institution

4


5/18

Physical Assessment

5

Hair

Evenness Inspection Evenly

distributed

Evenly distributed Normal

Thickness Inspection, Thick hair Thick hair Normal

Texture Inspection, Silky, resilient

hair

Silky, resilient hair Normal

Presence of

infection or

infestation

Inspection, No infection or

infestation

No infection or

infestation

Normal

Amount of body

hair

Inspection Few Variable Normal

Nails

Fingernail plate

shape

Inspection Convex

curvature

Convex curvature Normal

Fingernail and

toenail texture

Palpation Smooth texture Smooth texture Normal

Tissues

surrounding nail

Inspection Intact

epidermis

Intact epidermis Normal

Nail Hygiene Inspection Dirty, long

nails

Clean, trimmed

nails

Poor nail hygiene

Assessment Technique Findings Normal Findings Analysis

General Appearance and Mental Status

Built Inspection Thin Proportionate to

height

Normal

Posture Inspection Bent Posture Erect Posture normal

Signs of distress Inspection No distress

noted

No distress noted Normal

Signs of health Inspection Healthy

appearance

Healthy

appearance

Normal

Attitude Inspection Cooperative Cooperative Normal

Affect Inspection Appropriate to

situation

Appropriate to

situation

Normal

Speech Inspection Understandable Understandable Normal


6/18

Skin

abdomen Inspection No laceration,

equal skin color

With suture in

the right lower

quadrant; dry and

intact

There is deviation on normal

skin contour because of the

laceration made for the

operation

6

Extremities

Arms Inspection No ecchymosis

noted. Full and

equal pulses.

Right metacarpal

connected to the IV

line.

Right arm has limited

movement due to the IV

connection

Legs Inspection No

deformities,

good ROM, no

edema and

ecchymosis

Absence of

deformities and good

ROM. Absence of

edema and

ecchymosis

Normal


7/18

ANATOMYAND PHYSIOLOGY OF APPENDIX

The appendix is a closed-ended, narrow tube up to several inches in length that attaches to the cecum the

first part of the colon like a worm. The anatomical name for the appendix, vermiform appendix, means

worm-like appendage. The inner lining of the appendix produces a small amount of mucus that flows

through the open center of the appendix and into the cecum. The wall of the appendix contains lymphatic

tissue that is part of the immune system for making antibodies. Like the rest of the colon, the wall of the

appendix also contains a layer of muscle, but the muscle is poorly developed.

7


8/18

Pathophysiology

Non modifiable: Modifiable

*gender(male) *lifestyle

*age(10-30) *food preferrence

Episodes of Constipation Low Fiber Diet

Occlusion of Appendix by Fecalith

Decreased flow/drainage of mucosal secretions

Increased ILP in the appendix

Vasocongestion

Decreased blood supply in the appendix

Decreased O2 supply in the appendix

Appendix starts to be necrotic; Bacteria invade the appendix

Disruption of Cell Membrane of Appendix

Start of Inflammatory Process

Release of Chemical Mediators Activation of the Vomiting Neutrophils to areaCenter in the Medulla

---> Histamine, Prostaglandin, Stimulation of Vagus Suppression of Pus Formation

Leukotrienes, Bradykinin Nerve Sympathetic (phagocytized bacteria

GI Function and dead cells)

Swelling of Appendix Risk for Infection

(if appendix ruptures)

---> Prostaglandin, Bradykinin Nausea & Vomiting Anorexia

Pain in the RLQ of Abdomen Risk for Deficient Risk for Imbalanced Nutrition

Fluid Volume less than body requirements

Acute Pain

---> Interleukin-1

Increased WBC

Inflammation of Appendix (Appendicitis)

Final Case Press

Documents

Transcript of Final Case Press