Case Study – Appendicitis

I. DEFINITION/PREVALENCE Astute ache of the GI amplitude may be acquired by the antibody itself or by a bacterial or alternative toxin. Astute anarchic disorders such as appendicitis and peritonitis aftereffect from contagion of damaged or commonly antiseptic tissue by a client’s own autogenous or citizen bacilli (Lemone and Burke, 2008, folio 766). Appendicitis is the deepening of the vermiform (wormlike) appendix; the addendum is a baby fingerlike addendum about 10 cm (4 in) long, absorbed to the cecum aloof below the ileocecal valve, which is the alpha of the ample intestine. It is usually amid in the appropriate iliac region, at an breadth appointed as McBurney’s point. McBurney’s point, amid amid amid the umbilicus and the antecedent iliac acme in the appropriate lower quadrant. It is the accepted armpit for localized affliction and backlash amore due to appendicitis during afterwards stages of appendicitis. The action of the addendum is not absolutely understood, although it consistently fills and empties digested food. Some scientists accept afresh proposed that the addendum may anchorage and protect bacteria that are benign in the action of the animal colon. Appendicitis is the best accepted account of astute deepening in the appropriate lower division of the belly cavity. The lower division affliction is usually accompanied by a low-grade fever, nausea, and about vomiting. Accident of appetence is common. In up to 50% of presenting cases, bounded amore is elicited at Mc Burney’s point activated amid at center amid the umbilicus and the antecedent aback of the Ilium. Backlash amore (ex. Production or accession of affliction aback burden is released) may be present. The admeasurement of amore and beef access and the actuality of the ache or diarrhea depend not so abundant on the severity of the appendiceal infection as on the breadth of the appendix. If the addendum curls about abaft the cecum, affliction and amore may be acquainted in the lumbar region. Rovsing’s assurance may be elicited by palpating the larboard lower quadrant. If the addendum has ruptured, the affliction become added diffuse, belly addendum develops as a aftereffect of diplegic ileus, and the patient’s action worsens. The ache is added accustomed in countries in which bodies absorb a diet low in cilia and aerial in aesthetic carbohydrates. It is the best accepted acumen for emergency belly surgery, affecting 10% of the population. Although appendicitis affects a actuality at any age, the aiguille accident is amid the ages of 20 and 30 years old in which the all-inclusive majority of audience are best accepted in adolescents and adolescent and hardly added accepted in males than females. About 7% of the citizenry will accept appendicitis at some time in their lives (Lemone and Burke, 2008 folio 766). The aloft aggravation of appendicitis is breach of the appendix, which can advance to peritonitis, abscess accumulation (collection of purulent material), or aperture Pyle phlebitis, which is catchbasin occlusion of the aperture attitude acquired by abundant emboli that arise from catchbasin intestines. Breach about occurs 24 hours afterwards the access of affliction affection accommodate a agitation of 37. 7 amount Celsius or 100 amount Fahrenheit or greater, a baneful actualization and affiliated belly affliction or tenderness. II. TYPES/CLASSIFICATION Appendicitis can be classified as simple, gangrenous, or perforated, depending on the date of the process. In simple appendicitis, the addendum is affronted but intact. Aback areas of tissue afterlife and diminutive perforations are present in the appendix, the ataxia is alleged addle appendicitis. A perforated addendum shows affirmation of gross breach and contagion of the peritoneal atrium (LeMone & Burke, 2008 folio 766). Peritonitis can be primary or secondary. Primary peritonitis is an astute bacterial infection that is not associated with perforated viscus, or organ. Bacterial infection is the accepted account and may be associated with an infection by the aforementioned animal about abroad in the body, which alcove the abdominals via the vascular system. Tuberculosis peritonitis, which originates from tuberculosis abroad in the body, is a blazon of primary peritonitis. Audience with alcoholic cirrhosis and ascites, in the absence of a perforated organ, about credible peritonitis, which may be due to arising of bacilli through the bank of the intestine. Accessory peritonitis is usually acquired by bacterial aggression as a aftereffect of perforation, or breach of an belly viscus. It can additionally aftereffect from astringent actinic reactions to: pancreatic enzymes, digestive juices, or biles arise into the peritoneal atrium (Gould & Dyer, 2011). III. DEMOGRAPHIC PROFILE Patient’s name is Mr. Burst Astute Appendicitis, 24 years old, male, residing at 820 Accepted Kalentong, Daang Bakal, Mandaluyong City. He is the additional adolescent amid 3 siblings, a Roman Catholic, single, a 3rd year academy Advice Technology student. IV. FAMILY MEDICAL HISTORY (Family Genogram)COD: TB COD: TB A: 83 -S, -D A: 83 -S, -D Not 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 Bark abhorrence A: 27 -S, -D Bark abhorrence 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 accommodating accommodating LEGEND: LEGEND: macho macho affiliated affiliated asleep macho asleep macho S- smoker D- drinker COD- account of afterlife S- smoker D- drinker COD- account of afterlife changeable changeable asleep changeable asleep changeable V. PAST MEDICAL HISTORY He was aboriginal ailing aftermost 2006 due to dengue at the aforementioned hospital: Mandaluyong City Medical Center (MCMC). He has no alternative added illnesses except the archetypal fever, ahem and cold. Alternative than that, he has no allergies, hypertension, or diabetes mellitus. VI. HISTORY OF PRESENT ILLNESS 1 anniversary above-mentioned to acceptance accommodating accomplished belly affliction all over abdomen. He consulted at ER MCMC active out AUPD (Acute Peptic Ulcer Disease) and was accustomed Omeprazole & HNBB (Buscopan). Whole belly ultrasound done and arise tiny cholecystolethiasis. He was accustomed Diclofenal and HNBB tab and eventually discharged. Few canicule above-mentioned to consultation, the accommodating still accomplished belly pain. He consulted at Emergency Room and was autonomous for surgical action – EXPLORATORY LAPAROTOMY APPENDECTOMY below the account of Dr. Abram Del Valle, M. D. VII. GORDON’S PHYSICAL ASSESSMENT i. Bloom Maintenance – Perception Arrangement Afore admission: The accommodating acclimated to smoke cigarette 3 sticks per day. And he additionally drinks booze circadian accurately beer of added than 2 bottles per session. He was not application drugs and he has no allergies at all. During time of care: The accommodating is not smoker cigarette or bubbler alcohol. ii. Comestible – Metabolic Pattern Before admission: The accommodating was on a aerial protein diet because he was acclimated to go to the gym 2-3 times a week. He was additionally demography vitamins (CENTRUM). He has accustomed appetence and has no adversity swallowing. He usually eats 3 times a day (breakfast, cafeteria and dinner) and best of the time he additionally has his snacks. He additionally usually drinks 2-3 liters of baptize a day. e During time of care: The accommodating is on NPO (nothing per orem) for 5 canicule due to post-operative appendectomy and he was on his 2nd day of NPO cachet aback we cared for him. He has additionally NGT lavage connected. ii. Abolishment Arrangement Afore admission: The patient’s accustomed bowel movement was 3 BM a day and has no adversity in float habits. His aftermost bowel movement was aftermost July 17, 2012. He usually urinates 6-7 times a day afterwards difficulty. During time of care: The accommodating has absence of bowel movement and alike aroma and has no bowel sounds aloft auscultation. He has foley catheter and with urine achievement of 480 cc per shift. iv. Action and Exercise Afore admission: The accommodating could do his activities apart afterwards assistance. He usually goes to gym 2-3 times a week. During time of care: The patient’s anatomic affiliated or self-care adeptness affiliated is 2 which beggarly he requires advice from accession actuality for assistance. v. Sleep/Rest Arrangement Afore admission: The accommodating usually sleeps at 4 or 5 am and wakes up at 8 or 9 am. He has no adversity in sleeping and he feels able afterwards sleep. During time of care: The accommodating has approved sleeping habits. He sleeps at 10 am, wakes up at 6 am with ceaseless sleep. vi. Cognitive – Perceptual Pattern Before admission: The accommodating was active and coherent, has accustomed speech, with balmy affiliated of anxiety, has accustomed hearing, and with broken eyes of his larboard eye due to cataract. During time of care: The accommodating is active and coherent. He has accustomed accent (Filipino as his announced language), he has abstinent affiliated of anxiety, has accustomed hearing, and with broken eyes of his larboard eye due to cataract. He additionally complained of astute affliction and declared it as a airtight pain. Affliction administration (Tramadol) was given. vii. Role – Accord Arrangement Afore admission: The accommodating was a apprentice and single. His abutment arrangement was his family, ancestors & friends. During time of care: The patient’s abutment arrangement is his mother who is consistently at his bed ancillary acceptable him in whatever he needs. Aloft allurement his mother if she has any apropos apropos hospitalization, she said that she is added affair about the fast accretion of her son. viii. Sexuality – Reproductive Arrangement Afore acceptance and during the time of care: The accommodating still didn’t accept his testicular exam. ix. Arresting – Accent Tolerance/Self - Perception/Self - Concept Arrangement The patient’s aloft affair apropos his analysis is s all about self-care. Due to the accessories absorbed to him, he cannot apart do his activities. His aloft accident was his stepfather aback he died of branch failure. His rated his angle on approaching as 5, 1 actuality poor and 10 actuality absolute optimistic. He added explained why he rated 5 because he is not abiding if aback he accomplished academy he can be able to acquisition a job ill-fitted for him. x. Value – Belief Arrangement Our accommodating is a Roman Catholic and he consistently goes to abbey every Sunday calm with his family. VIII. GROWTH AND DEVELOPMENT DEVELOPMENTAL TASK| THEORIST| STATUS| Intimacy vs. Isolation * Develops commitments to others and to a action assignment (career)(Daniels, et. al. , 2010). | Erikson| The accommodating had a accord with his adverse sex but he said that they aloof bankrupt up a anniversary afore he was ailing due to some claimed and clandestine reasons. Currently, he is in 3rd year college, an IT student. | Genital * Emergence of animal interests and development of relationships with abeyant animal ally (Daniels, et. al. , 2010). | Freud| As what had accounting above, the accommodating had a accord with his adverse sex but because of some affidavit they absitively to end up their relationship. Formal Operations * Able to see relationships and to acumen in the abstruse (Daniels, et. al. , 2010). | Piaget| He perceived that relationships (any affectionate of relationship) are important abnormally at his age. He can additionally acumen out in an abstruse way. He can accurate his opinions intellectually and precisely. | Aboriginal Adulthood * Select a partner, apprentice to alive with a partner, alpha a family, administer a home, authorize cocky in a career/occupation, accept borough responsibility, and become a allotment of a amusing accumulation (Daniels, et. al. , 2010). Havighurst| According to our patient, he didn’t accepted that article like that will arise to them (referring to his girlfriend). He was absolutely assured that they are absolutely meant for anniversary alternative and that she (his gf) will be his approaching wife. He is additionally establishing himself to a approaching career, that’s why he is belief in alertness for his future. During our time of affliction also, his ‘barkadas’ visited him and he said that they were his ‘tropa’. | Postconventional * Alone understands the chastity of accepting democratically accustomed laws (Daniels, et. al. , 2010). Kohlberg| Aloft allurement the accommodating if he is accustomed with the democratically accustomed laws in the Philippines, he anon responded with a yes. He additionally said that these laws advice us, Filipinos, to accept safe and defended country admitting there may arise a time that we may acquaintance article unexpectedly. | IX. PHYSICAL ASSESSMENT * Basic Signs TIME| Initial 8AM (07/24/12)| 10 AM| 12 NN| 8 AM (07/25/12)| 12 NN| Aftermost 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| 120/80| 120/80| 120/80| 120/80| 120/80| 110/80| Sequence: BY SYSTEMS NORMAL FINDINGS| BOOK FINDINGS| PATIENT FINDINGS| SIGNIFICANCE| I. NEUROLOCIGAL SYSTEM Active and coherent; with accustomed anatomy temperature of 36. 3°C – 37. 6°C| * Agitation (usually >38°C although hypothermia may be present w/ astringent sepsis); chills * Thirst * Pain| * Complained of affliction in the atrium armpit (lower longitudinal midline of the abdomen)| Affliction after-effects from the added burden of aqueous on the nerves, abnormally in amid areas, and by the bounded affliction of fretfulness by actinic mediators such as bradykinins (Gould, et al. 2011). | II. RESPIRATORY Accustomed respiration with a amount of 12-20 breaths per minute| * Tachypnea; bank respirations| * RR: 23 bpm w/ bank respiration| Astute affliction usually initiates physiologic accent acknowledgment with added respiratory amount (Gould & Dyer, 2011). | III. INTEGUMENTARY Pink or amber and in compatible color, no edema, no lesions, moistSkin temperature is commonly warmIntact skinWhen pinched, bark springs aback to antecedent state| * Dry aperture and close membranes * Swollen argot * Poor bark turgor| * Dry aperture and close membranes * Bark turgor:3-5 abnormal * Attendance of surgical atrium at lower longitudinal midline of the belly * Bark is balmy to blow and is reddened| Dry close film and poor bark turgor are signs of aridity (Gulanick, et al. 1994). Redness may announce deepening (Weber & Kelly, 2007). Redness and amore are acquired by added claret breeze into the damaged breadth (Gould & Dyer, 2011). | IV. CARDIOVASCULAR Accustomed beating amount of 60-100 bpm| * Tachycardia * Diaphoresis * Pallor * Hypotension * Tissue edema| * Beating rate: 83 bpm| Astute affliction usually initiates a physiologic accent acknowledgment with added affection amount (Gould & Dyer, 2011). | V. MUSCOLOSKELETAL Ability to do Activities of Circadian Living (ADL)| * Adversity ambulating * Weakness| * Adversity ambulating due to post-op action * Weakness| Constant affliction frequently affects circadian activities and may become a primary focus in the action of an alone (Gould & Dyer, 2011). | VI. GENITO-URINARY Accustomed urine achievement of 30cc/hrColor: Amber, transparent, clear| * Decreased urinary achievement * Aphotic blush urine| * Aphotic blush urine * Urine output: 480 mL/shift * Specific gravity: 1. 30| Decreasing achievement of concentrated urine with accretion specific force suggests dehydration/need for added fluids (Doenges, et al. , 2006). | VII. GASTROINTESTINAL Belly bark may be paler than the accepted bark accent because this bark is so hardly credible to the accustomed elementsAbdomen is chargeless of lesions or rashesA alternation of intermittent, bendable clicks and gurgles are heard at a amount of 5-30 per minuteNormally no amore or affliction is elicited or arise by the clientNo backlash amore is presentAbdomen is non-tender and soft. There is no guarding| * Accident of appetence * Abhorrence & vomiting(usually projectile) * Ache of contempo access * Diarrhea(occasional) * Sudden, severe, ambiguous belly affliction * Belly distention; acerbity * Decreased/absence of bowel sounds * Inability to canyon stool/flatus * Beef absorption (abdomen) * Psoas’ Assurance (flexion of or affliction on hyperextension of the hip due to acquaintance amid an anarchic action & the psoas muscle) * Obturator Assurance (the centralized circling of the appropriate leg with the leg channelled to 90 degrees at the hip and knee and a resultant abbreviating of the centralized obturator beef may ause belly discomfort) * Rovsing’s Assurance (pressure on the larboard lower division of the belly causes affliction in the appropriate lower quadrant) * Backlash amore (a assurance of deepening of the abdominals in which affliction is elicited by the abrupt absolution of the fingertips astute on the abdomen) | * Board-like belly * Sudden, severe, ambiguous belly affliction * Absence of bowel sounds in all four quadrants * Absence of flatus/stool * Attendance of surgical incision| Signs advertence the access of peritonitis accommodate a adamant “board-like” belly (Gould & Dyer, 2011). Pain recurs as a steady, astringent belly affliction as peritonitis develops (Gould & Dyer, 2011). Absence of bowel sounds may be associated with peritonitis or diplegic ileus (Weber & Kelly, 2007). Aback deepening persists, assumption advice is impaired, and peristalsis decreases, arch to obstruction of the belly (paralytic ileus) (Gould & Dyer, 2011). | X. DIAGNOSTIC TESTS DIAGNOSTIC TEST| NORMAL| RESULT| SIGNIFICANCE| WHOLE ABDOMINAL ULTRASOUND (July 21, 2012) | The organs advised arise accustomed (Cosgrove, et al. , 2008). | Alarmist is not enlarged. It has affiliated echopattern with bland border. The intrahepatic ducts are not dilated. No axiomatic focal accumulation bane seen. CD measures 3. 9mm. Gallbladder is accustomed in admeasurement and bank thickness. There are assorted tiny echogenic shadowing foci credible aural the gallbladder lumen. Pancreas & annoyance are accustomed in admeasurement & echopattern. No focal accumulation bane seen. Both kidneys are accustomed in admeasurement & echopattern. Appropriate branch measures 10. 1x4. 2x5. 46cm with cortical array of 1. 7cm while the larboard branch measures 10. 5x4. 8x4. 1cm with array of 19cm. No axiomatic caliectasis, lithiasis, credible bilaterally. Urinary float is unfilled. Impression:Tiny cholecystolithiasesNormal liver, pancreas, spleen, kidneys by UTZUnfilled urinary bladderNot aggrandized biliary timberline | Belly ultrasound is the best able analysis for diagnosing astute appendicitis (LeMone & Burke, 2007). | HEMATOLOGY REPORT/COUNT (July 21, 2012)| RBC: 4. 2-5. 6 M/uLPlatelets: 150-400 x 10/LWBC: 3. 8-11. 0 K/mm3Hemoglobin: 135-180g/LHematocrit: 0. 45-0. 52DifferentialNeutrophils: 0. 50-0. 81Lymphocytes: 0. 14-0. 44Monocytes:0. 02-0. 06Eosinophils: 0. 01-0. 05Basophils:0. 00-0. 01| WBC Count: 12. 6 K/mm3RBC: 4. 1 M/uL (normal)Hematocrit: 0. 45 (normal)Hemoglobin: 153g/L (normal)Differential Count:Neutrophils 0. 90Lymphocytes 0. 10 (normal)| Animated WBC is credible in astute infection (LeMone & Burke, 2007). Neutrophils: animated in bacterial infection (LeMone & Burke, 2007). | URINALYSIS (July 21, 2012)| Color: Light harbinger to amber yellowAppearance: ClearOdor: AromaticpH: 4. 5-8. 0Specific gravity: 1. 005-1. 030Protein: 2-8mg/dLGlucose: NegativeKetones: NegativeRBCs: RareWBCs: 3-4Casts: Casual hyaline| Color: Aphotic YellowTransparency: TurbidUrine pH: 6. 0 Specific gravity: 1. 30Sugar: NegativeProtein: +4Microscopic examPus beef 4-6/HPFRBC 1-2/HPFCrystals: Amorphous Sulfate Moderate| A aphotic chicken to brownish blush is credible with amiss aqueous aggregate (LeMone & Burke, 2007). Hazy or blurred urine indicates bacteria, pus, RBCs, WBCs, phosphates, prostatic aqueous 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 & airsickness (LeMone & Burke, 2007). | XI. ANATOMY & PHYSIOLOGY OF APPENDIX (LARGE INTESTINE) The ample intestine, which is about 1. 5 m (5 ft) affiliated and 6. 5 cm (2. 5 in. ) in diameter, extends from the ileum to the anus. It is absorbed to the afterwards belly bank by its mesocolon, which is a bifold band of peritoneum. Structurally, the four aloft regions of the ample civil are the cecum, colon, rectum, and anal canal. The aperture from the ileum into the ample civil is attentive by a bend of close film alleged the ileocecal sphincter (valve), which allows abstracts from the baby civil to canyon into the ample intestine. Hanging inferior to the ileocecal valve is the cecum, a baby accessory about 6 cm (2. 4 in. ) long. Attached to the cecum is a twisted, coiled tube, barometer about 8 cm (3 in. ) in length, alleged the addendum or vermiform addendum (vermiform = worm-shaped; addendum = appendage). The mesentery of the appendix, alleged the mesoappendix, attaches the addendum to the inferior allotment of the mesentery of the ileum. The accessible end of the cecum merges with a affiliated tube alleged colon, which is disconnected into ascending, transverse, bottomward colon are retroperitoneal; the axle and arced colon ascends on the appropriate ancillary of the abdomen, alcove the inferior credible of the liver, and turns abruptly to the larboard to anatomy the appropriate colic (hepatic) flexure. The colon continues beyond the belly to the larboard ancillary as the axle colon. It curves below the inferior end of the annoyance on the larboard ancillary as the larboard colic (splentic) bend and passes inferiorly to the affiliated of the iliac acme as the bottomward colon. The arced colon begins abreast the larboard iliac crest, projects amid to the midline, and terminates as the rectum at about the affiliated of the third sacral vertebra. The rectum, the aftermost 20 cm (8 in. ) of the GI tract, lies antecedent to the sacrum and coccyx. The terminal 2-3 cm (1 in. ) of the rectum is alleged the anal canal. The close film of the anal aqueduct is abiding longitudinal folds alleged anal columns that accommodate a arrangement of arteries and veins. The aperture of the anal aqueduct to the exterior, alleged the anus, is attentive by an centralized anal sphincter of bland beef (involuntary) and an alien anal sphincter of the ashen beef (voluntary). Commonly these sphincters accumulate the anus bankrupt except during the abolishment of carrion (Tortora & Derrickson, 2006). XII. PATHOPHYSIOLOGY NARRATIVE Appendicitis, deepening of the vermiform appendix, is a accepted account of astute belly pain. It is the best accepted acumen for emergency belly surgery, affecting 10% of the citizenry (Tierney et al. , 2005). Appendicitis can action at any age, but is added accepted in adolescents and adolescent adults and hardly added accepted in males than females (LeMone & Burke, 2007). The development of appendicitis usually follows a arrangement that correlates with the analytic signs, although variations may action because of the adapted breadth of the addendum or basal factors (Gould & Dyer, 2011). Obstruction of the adjoining lumen of the addendum is credible in best acutely affronted appendices. The obstruction is about acquired by fecalith, or adamantine accumulation of feces. Alternative adverse causes accommodate a calculus or stone, a adopted body, inflammation, a tumor, parasites (e. g. , pinworms), or edema of lymphoid tissue (LeMone & Burke, 2007). Afterward obstruction, the addendum becomes beefy with aqueous buried by its film and microorganisms proliferate. Burden aural the lumen of the addendum increases, impairing its claret accumulation because claret argosy in the bank are aeroembolism appropriately the appendiceal bank becomes affronted and purulent address forms. Within 24 to 36 hours, the accretion bottleneck and burden aural the addendum leads to ischemia and afterlife of the wall, consistent in added permeability. Bacilli and toxins escape through the bank into the surrounding are. This blemish of bacilli leads to abscess accumulation or localized peritonitis. An abscess may advance aback the adjoining omentum briefly walls off the affronted breadth by adhering to the appendiceal surface. In some cases, the deepening and affliction abate briefly but again recur. Localized infection or peritonitis develops about the addendum and may advance forth the peritoneal membranes. Increasing burden axial the addendum causes added afterlife and adulteration in the bank (infection in baleful tissue). The bank of the addendum appears blackish. The addendum ruptures or perforates, absolution its capacity into the peritoneal cavity. This leads to ambiguous peritonitis and would advance to septicemia and into catchbasin shock and will aftereffect to afterlife (Gould & Dyer, 2011). XIII. PATHOPHYSIOLOGY DIAGRAM Accident Factors Non-modifiable: * Age (Adolescents & adolescent adults) * Gender (Male) Modifiable: * Fecalith * Calculus/Stone * Adopted anatomy * Deepening * Bump * Parasites Edema of lymphoid tissue Obstruction of the appendiceal lumen Obstruction of the appendiceal lumen Buildup of aqueous axial the addendum Buildup of aqueous axial the addendum Proliferation of microorganisms Proliferation of microorganisms Belly affliction Belly affliction Added burden aural the lumen of addendum Added burden aural the lumen of addendum Compression of claret argosy Compression of claret argosy * Agitation * Obturator Assurance * Psoas Assurance * Rovsing’s Assurance * Backlash amore * Agitation * Obturator Assurance * Psoas Assurance * Rovsing’s Assurance * Backlash amore Decreased claret breeze into the appendix Decreased claret breeze into the addendum Deepening of appendiceal bank Deepening of appendiceal bank (July 21, 2012) Hematology Count * WBC count: 12. 6 K/mm * Neutrophils: 0. 90 Urinalysis * Transparency: anarchic (July 21, 2012) Hematology Count * WBC count: 12. 6 K/mm * Neutrophils: 0. 90 Urinalysis * Transparency: anarchic Ischemia & afterlife of the bank Ischemia & afterlife of the bank Added permeability Added permeability Bacilli and toxins escape through the bank Bacilli and toxins escape through the bank Abscess formation/localized bacterial peritonitis Abscess formation/localized bacterial peritonitis Proliferation of localized peritonitis about the addendum and peritoneal membranes Proliferation of localized peritonitis about the addendum and peritoneal membranes Added burden axial the addendum Added burden axial the addendum * Sudden, severe, ambiguous belly affliction * Belly addendum & adamant “boardlike” belly * Absence of bowel sounds/(-) flatus/(-) BM (July 24, 2012) * Sudden, severe, ambiguous belly affliction * Belly addendum & adamant “boardlike” belly * Absence of bowel sounds/(-) flatus/(-) BM July 24, 2012) Added afterlife and adulteration in the bank Added afterlife and adulteration in the bank Appendectomy with NGT lavage (July 22, 2012) Appendectomy with NGT lavage (July 22, 2012) Breach of the addendum Breach of the addendum Belly bacilli aperture out into peritoneal atrium Belly bacilli aperture out into peritoneal atrium * Low-grade agitation & leukocytosis * Tachycardia * Hypotension * Airsickness * Low-grade agitation & leukocytosis * Tachycardia * Hypotension * Airsickness Ambiguous peritonitis Ambiguous peritonitis XIV. NURSING PROCESS Problem #1: ABDOMINAL PAIN - July 24, 2012 * Subjective Cues: * “Nurse delay lang, ang sakit kasi parang nagcacramps,” accommodating verbalized while accepting a chat with him. How does it feel like: Belly airtight Precipitating factor: “Kapag nililinisan pero kadalasan bigla-bigla na lang sumasakit” (“Whenever anguish charwoman is performed but oftentimes it aloof aback happened”) Abating factor: Affliction analgesic (but not all the time affliction analgesic is actuality given) Does it afford to the alternative genitalia of the anatomy (back, legs, chest, etc): No Continuance of pain: “Paiba-iba din eh. Minsan sobrang tagal mga 2-3 minutes, minsan naman mga ilang Segundo lang” (“It differs, sometimes it’s too affiliated (2-3 minutes) and sometimes it aloof happened for a second”) * Accommodating rated the affliction as 8/10 breadth 0 signifies no affliction and 10 signifies enough pain. * Objective Cues: * Facial face * Absorption of the atrium armpit * Adamant (board-like) belly * Belly addendum * Breadth of pain: Surgical armpit * RR: 25 bpm * Nursing Analysis Astute Affliction accompanying to deepening of the tissues accessory to post-op surgical incision. Inflammation or assumption accident gives acceleration to changes in acoustic processing at borderline and axial affiliated with a resultant sensitization. In relation, prostaglandins are chemotactic substances cartoon leukocytes to the affronted tissue. It plays a vasoactive role; it is additionally a affliction and agitation inducer (Lemone and Burke, 2007). Astute Affliction accompanying to infection & deepening of the peritoneal membranes accessory to peritonitis The abdominals consists of a ample antiseptic amplitude of awful vascular tissue that covers the abdominals and curve of belly cavity. This peritoneal anatomy provides a beggarly of accelerated broadcasting of irritants or bacilli throughout the belly cavity. Belly addendum is evident, and the archetypal rigid, board-like belly develops as reflex belly beef access occurs in acknowledgment to captivation of the parietal abdominals (Gould & Dyer, 2011). * Goal/NOC: Affliction Ascendancy Outcomes Short Term: Afterwards 30 account of nursing action the accommodating will address a abatement in affliction from affliction calibration of 8/10 to 4-5/10. Affiliated Term: After 8 hours of nursing action the accommodating will authenticate an compassionate about the able way of authoritative affliction as apparent by able splinting and abysmal breath exercise and will address a abatement or best apparently will be chargeless from affliction from affliction calibration of 4-5/10 to 1-2/10. * NIC: Affliction Administration Independent: * Adjourned affliction including its character, location, severity, and duration. Both preoperatively and postoperatively, the client’s affliction provides important clues about the analysis and accessible complications. Abdominal addendum and astute deepening accord to the affliction associated with peritonitis. Anaplasty added disrupts belly anatomy and alternative tissues, causing affliction (LeMone & Burke, 2007). * Monitored basic signs every 2 hours. Basic Signs, abnormally respiratory amount (RR), are usually adapted in astute pain. (Sparks and Taylor, 2005). * Kept the applicant at blow in semi-Fowler’s position. Force localizes anarchic address into lower belly or pelvis, abating belly tension, which is accentuated by collapsed position (Doenges et al. , 2006). * Provided diversional activities (texting, complete trip, etc). Refocuses attention, promotes relaxation, and may enhance arresting abilities and diverts absorption from affliction (Doenges et al. , 2006). * Taught post-op bloom teaching (e. g. , able splinting & abysmal breath exercises). The use of non-invasive affliction abatement measures can access the absolution of endorphins and enhance the ameliorative furnishings of affliction abatement medications (LeMone & Burke, 2007). * Encouraged aboriginal ambulation. Promotes normalization of agency function; stimulates peristalsis and casual of flatus, abbreviation belly ache (Doenges, et al. , 2006). Give hot and algid compress. Hot, clammy compresses accept a biting effect. The balmy rushes claret to the afflicted breadth to advance healing. Algid compresses may abate absolute edema and advance some numbing, thereby announcement comfort. (Doenges et al. , 2006). Dependent: * Administered analgesic as assigned (TRAMADOL 50 mg/IV Q 8° x 3 doses) Time given: 8 AM. Post-operatively, analgesics are provided to advance abundance and enhance advancement (LeMone & Burke, 2007). * Kept on NPO. Decreases ache of aboriginal belly peristalsis and belly irritation/vomiting (Doenges et al. 2006). * Evaluation Short Term: Goal partially met. Afterwards 30 account of nursing action the accommodating arise of a abatement in affliction from a affliction calibration of 8/10 to 6/10 in which 4-5/10 was the accepted outcome. Affiliated Term: Goal met. Afterwards 8 hours of nursing action the accommodating displayed ascendancy of affliction as affirmation by abysmal breath exercise and able splinting. He additionally arise of a abatement in affliction with a affliction calibration of 2/10 from 6/10. Affliction analgesic – TRAMADOL was accustomed @ 8 am via IV. Problem #2: ABSENCE OF FLATUS– July 24, 2012 * Subjective Cues: “Nurse delay lang, ang sakit kasi parang nagcacramps (referring to belly cramping),” accommodating verbalized while accepting a chat with him. * Affliction calibration of 8/10 * Objective Cues: * (-) Flatulence * (-) BM (Last BM was July 17, 2012) * Absence of bowel sounds aloft auscultation of all four quadrants * Nursing Analysis Dysfunctional gastrointestinal action accompanying to anarchic action of peritonitis accessory to absence of flatulence. The anarchic action of peritonitis about draws ample amounts of aqueous into the belly atrium and the bowel. In addition, peristaltic action of the bowel is slowed or apoplectic by the inflammation, causing diplegic ileus, broken propulsion of advanced movement of bowel capacity (LeMone & Burke, 2007). * Goal/NOC: Airing Outcomes Short Term: Afterwards 8 hours of nursing action the applicant will report/experience aroma and will accept and authenticate the charge for aboriginal airing afterward belly surgery. Affiliated Term: Afterwards 2 canicule of nursing action the applicant will report/experience either aroma or bowel movement or both. * NIC: Impaction Management; Positioning Independent: * Adjourned belly including all four quadrants acquainted actualization to actuate added or decreased in motility; Adjourned for added belly amore & auscultated for any belly sounds. To advice analyze the account of the about-face and adviser development of nursing action (Sabol & Carlson, 2007). * Monitored and recorded (intake) and achievement every hour or 2 hours. Assimilation and achievement annal accommodate admired advice about aqueous aggregate cachet (LeMone & Burke, 2007). * Encouraged aboriginal ambulation. Promotes normalization of agency function; stimulates peristalsis and casual of flatus, abbreviation belly ache (Doenges, et al. , 2006). * Assisted in affective from ancillary to ancillary or up in bed from time to time. Common repositioning helps in able oxygenation and usually prevents complications like burden ulcers, abysmal attitude thrombosis, etc. (Gulanick, et. al. , 1994). Dependent: * Administered acrid as ordered (RANITIDINE 50g/IV Q 12°. Antacids either anon abrogate acidity, accretion the pH, or reversibly abate or block the beard of acerbic by belly beef to abate acidity in the abdomen (Gabriely, et al. 2008). * Evaluation Short Term: Goal partially met. Afterwards 8 hours of nursing action the accommodating didn’t acquaintance aroma or alike bowel movement but was able to accept an compassionate with commendations to aboriginal airing as apparent by absolution his mother abetment him in affective up in bed action to the armchair but banned to airing because of complaint of accepting a lot of accessories absorbed to him which causes him to accept adversity in moving. Affiliated Term: Goal met. Afterwards 3 canicule of nursing action the accommodating arise of a aroma 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 canicule * Dry close film * Dry aperture * Capillary refill= 2 abnormal * Bark turgor= 3-5 abnormal * Urine output/shift= 480 mL * Urine color: Aphotic Chicken * Urine specific gravity: 1. 030 (Normal value: 1. 005-1. 030) * Absence of bowel sounds of all the four quadrants * (-) Flatus, (-) BM * BP: 120/80 mmHg * PP: 83 bpm * Nursing Diagnosis Risk for amiss aqueous aggregate accompanying to postoperative brake accessory to NPO for 5 canicule Deepening of the abdominals with aloofness aqueous and NPO cachet can advance to aridity and electrolyte alterity (Doenges, et al. , 2008). * Goal/NOC: Knowledge: Treatment Regimen; Hydration; Articulate Hygiene; Tissue Integrity: Bark & Close Membranes Outcomes Short Term: Afterwards 30 account of nursing action accommodating will accept an compassionate with commendations to advancement aqueous antithesis as apparent by alertness of afterward the assigned dieting accustomed by the medical staffs. Affiliated Term: After 3 canicule of nursing action the accommodating will be able to advance able aqueous antithesis as apparent by clammy close membrane, acceptable bark turgor, abiding basic signs, and alone able urine output. * NIC: Aqueous Management; Aqueous Monitoring; Basic Signs Monitoring Independent: * Monitored BP & Pulse. Variations advice analyze clashing intravascular volumes, or changes in basic signs associated with accustomed acknowledgment to deepening (Doenges, et al. , 2006). * Inspected close membranes; adjourned bark turgor and capillary refill. Indicators of capability of borderline apportionment and cellular hydration (Doenges, et al. 2006). * Monitored assimilation and output; acclaimed urine color/concentration, specific gravity. Decreasing urine achievement of concentrated urine with accretion specific force suggests dehydration/need for added fluids (Doenges, et al. , 2006). * Auscultated bowel sounds. Acclaimed casual of flatus, bowel movement. Indicators of acknowledgment of peristalsis, address to activate articulate assimilation (Doenges, et al. , 2006). * Accommodate bright liquids in baby amounts aback articulate assimilation is resumed, and advance diet is tolerated. Reduces accident of belly irritation/vomiting to abbreviate aqueous accident (Doenges, et al. 2006). * Stressed the accent of accepting him on a NPO cachet and provided the all-important advice with commendations to his action and the medications actuality administered (e. g. , IVF). It provides the accommodating a abounding compassionate with commendations to his action appropriately auspicious him to participate and assignment duke in duke with the agents (Gulanick, et al. , 1994). * Gave common aperture affliction with appropriate absorption to aegis of the lips. Aridity after-effects in aridity and aching arise of the aperture and aperture (Doenges, et al. , 2006). Dependent: * Maintained belly assimilation as indicated. Although not frequently needed, an NG tube may be amid preoperatively and maintained in absolute postoperatively actualization to decompress the bowel, advance belly rest, and anticipate airsickness (Doenges, et al. , 2006). * Administered IV fluids (D5LR 1L x 8° or 30 gtts/min) and electrolytes (D5 Balanced Assorted Maintenance Solution w/ 5% dextrose 1L x 8° or 30 gtts/min). The abdominals reacts to irritation/infection by bearing ample amounts of belly fluid, possibly abbreviation the circulating claret volume, consistent in aridity and about electrolyte imbalances (Doenges, et al. , 2006). * Evaluation Short Term: Goal met. Afterwards 30 account of nursing action the accommodating was able to accept a abounding compassionate with commendations to advancement aqueous antithesis as apparent by verbalizing, “So kaya pala hindi pa ako pwede kumain ngaun para maiwasan mairritate ang tiyan ko. ” Affiliated Term: Goal met. Afterwards 3 canicule of nursing action the accommodating was able to advance able aqueous antithesis as apparent by clammy close membrane, acceptable bark turgor (1-2 seconds), abiding basic signs (please see folio __ ), and able urine achievement of 620 mL with an actualization 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 action – attendance of surgical atrium * Surgical armpit is balmy to blow and black * Temp: 36. 3°C * Nursing Analysis Accident for infection accompanying to bare primary defenses accessory to post-operative surgical atrium It is accident to be invaded by bacilli abnormally if surgical armpit is abreast at the perineal area, bacilli can additionally advance by poor claimed hygiene and poor anguish charwoman (Doenges, et al. 2006). * Goal/NOC: Accident Ascendancy (For Infection) Outcomes Short Term: Afterwards 30 account of nursing action the accommodating will be able to accept fractional compassionate about infection ascendancy and will enunciate compassionate of and alertness to chase up assigned regimen. Affiliated Term: Afterwards 3 canicule of nursing intervention the patient will be chargeless of assurance and affirmation r/t infection. * NIC: Atrium Armpit Care; Infection Control; Anguish Affliction Independent: * Monitored basic signs. Acclaimed access of fever, chills, diaphoresis, changes in mentation, and letters of accretion belly pain. Suggestive of attendance of infection/developing sepsis, abscess, peritonitis (Doenges, et al. , 2006). * Inspected atrium and dressings. Acclaimed characteristics of arising from wound/drains, attendance of erythema. Provides for aboriginal apprehension of developing communicable process, and/or monitors resolution of preexisting peritonitis (Doenges, et al. , 2006). * Instructed able duke washing. Practiced antibacterial anguish care. Reduces accident for infection (Doenges, et al. , 2006). * Encouraged able comestible assimilation afterwards the NPO cachet of the accommodating and aback the accommodating is accustomed to eat. Adequate assimilation of protein, Vitamin C and minerals is capital to advance tissue and anguish 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. Ameliorative antibiotics are accustomed if the addendum is burst or abscessed or peritonitis has developed (Doenges, et al. , 2006). * Prepare for/assist with atrium and arising (I&D) if indicated. May be all-important to cesspool capacity of localized abscess (Doenges, et al. , 2006). * Evaluation Short Term: Goal met. Afterwards 30 account of nursing action the accommodating was able to accept an compassionate about infection ascendancy as apparent 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. ” Affiliated Term: Goal met. Afterwards 3 canicule of nursing intervention the patient was chargeless of assurance and affirmation 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: * Attendance of surgical atrium * Attendance of accessories (urinary catheter, NGT lavage & IV aqueous @ larboard hand) * Nursing Analysis Broken concrete advancement accompanying to anatomy weakness, attendance of surgical incision, pain, & attendance of accessories absorbed Concrete apathy can be usually associated with post-operative altitude (Gulanick, et al. 1994). * Goal/NOC: Action Altruism Outcomes Short Term: Afterwards 30-45 account of nursing action the accommodating will be able to accept a bright compassionate with the use of articular techniques to enhance action altruism and to administer it as able-bodied as apparent by accommodating in ROM exercises, lower leg & abate exercise, ambulation, or alike affective up in bed. Affiliated Term: Afterwards 2-3 canicule of nursing action the accommodating will be able to always participate in a simple anatomy of action and will address an advance with commendations to his activities. * NIC: Exercise Therapy: Balance Independent: * Performed acquiescent ROM exercises. ROM contest and acceptable anatomy mechanics strengthen belly anatomy and flexors of aback (Gulanick, et al. , 1994). * Encouraged lower leg and abate exercises. Evaluated for edema, erythema of lower extremities, and dogie affliction or tenderness. These contest activate venous return, abatement venous stasis, and abate accident of array accumulation (Gulanick, et al. , 1994). * Acclaimed affecting and behavioral responses to immobility. Provided diversional activities. Forced apathy may heighten action and irritability. https://phdessay.com/the-cardiovascular-system-intrinsic-conduction-system/ Diversional action aids in refocusing absorption and enhances arresting with absolute and perceived limitations (Gulanick, et al. , 1994). * Assisted with activity, accelerating ambulation, and ameliorative exercises. Action depends on alone situation. It should activate as aboriginal as accessible and usually progresses slowly, based on applicant altruism (Gulanick, et al. , 1994). * Assisted in affective from ancillary to ancillary or up in bed from time to time. Common repositioning helps in able oxygenation and usually prevents complications like burden ulcers, abysmal attitude thrombosis, etc. Gulanick, et al. , 1994). * Acclaimed applicant letters of weakness, fatigue, affliction and adversity accomplishing tasks. Affection may be aftereffect of/or accord to bent of action (Gulanick, et al. , 1994). Dependent: * Administered affliction medication (TRAMADOL 50 mg/IV Q 8° x 3 doses, time given: 8 AM) as assigned and on a approved schedule. Client’s apprehension of affliction can access beef tension. Medications can advice relax the client, enhance comfort, and advance action to access action (Gulanick, et al. , 1994). * Evaluation Short Term: Goal partially met. Afterwards 30-45 account of nursing action the accommodating was able to accept a bright compassionate with the use of articular techniques to enhance action altruism and was able to use all of the techniques except for the ambulation. He banned to airing because he complained of affliction whenever the catheter tube slipped into his legs. Affiliated Term: Goal partially met. Afterwards 2-3 canicule of nursing action the accommodating was able to always participate in all of the articular techniques but still banned to participate in ambulation. He additionally arise of an advance with commendations to his activities as affirmation 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 & Allisonn's Diagnostic Radiology: A Textbook of Medical Imaging (5th edition). New York, NY: Churchill Livingstone * Doenges M. , Moorhouse, M. ; Murr, A. (2006). Nursing Affliction Plans Guidelines for Individualizing Applicant Affliction beyond the Action Span (7th Edition). F. A. Davis Company, Philadelphia * Doenges, M. , Moorhouse, M. ; Murr, A. (2006). Nurse’s Pocket Adviser Diagnoses, Prioritized Interventions, and Rationales (11th Edition). F. A. Davis Company, Philadelphia * Gabriely I, Leu, J. P. , Barky, N. (2008). Analytic problem-solving, aback to basics. New England Journal of Medicine * Gould, B. ; Dyer, R. (2011). Pathophysiology for the Bloom Professions (4th Edition). Saunders Elsevier Inc. * Gulanick, M. Klopp, A. , Galanes, S. , Gradishar, D. ; Puzas, M. (1994). Nursing Affliction Plans Nursing Analysis and Action (3rd Edition). Mosby-Year Book, Inc. * LeMone P. ; Burke, K. (2007). Principles of Medical-Surgical Nursing: Critical Thinking in Applicant Affliction (4th Edition). Pearson International Copy * LeMone P. ; Burke, K. (2008). Principles of Medical-Surgical Nursing: Critical Thinking in Applicant Affliction (5th Edition). Pearson International Copy * Mosby’s Pocket Dictionary of Medicine, Nursing ; Allied Heath (4th Edition) 2002, Mosby Inc. Palma G. ; Oseda A. (2009). G;A Notes Analytic Pocket Adviser for Medical and Allied Bloom Professionals (2nd edition). G;A Notes Publishing Co. , Philippines * Sabol, V. K. ; Carlson, K. K. (2007). Diarrhea: Applying analysis to bedside practice. AACN Advanced Critical Affliction * Tortora G. ; Derrickson B. (2006). Principles of Anatomy and Physiology 11th edition. Biological Sciences Textbooks, Inc. * Weber J. ; Kelley J. (2007). Bloom Assessment in Nursing (3rd Edition). Lippincott Williams ; Wilkins

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