Upload
apol-rajahbuayan
View
262
Download
19
Embed Size (px)
Citation preview
7/27/2019 APPENDICITIS CASE.doc
1/38
TABLE OF CONTENTS
I. IntroductionII. Objectives
General Objectives Specific Objectives
III. Patients DataA) Vital InformationB) Family BackgroundC) History of Past illnessD) History of Present illnessE) Effects and Expectation
F) GenogramG) Developmental Data
IV. Review of SystemsPhysical Assessment
V. Textbook DiscussionsA) Complete DiagnosisB) Anatomy and PhysiologyC) Definition of terms
D) Etiology and SymptomatologyE) Pathophysiology
VI. Laboratory ExaminationVII. Complete Doctor's OrderVIII.List of Drugs
Drug StudyIX. List of Nursing Case PlanX. PrognosisXI. Bibliography
7/27/2019 APPENDICITIS CASE.doc
2/38
INTRODUCTION
This is a case of Mrs. Rose, female patient, was admitted at provincial hospital Last April 26, 2010 at
around 2:10 pm and was diagnosed of having acute appendicitis and was scheduled for operation forceasarian operation
The appendix is a finger-like appendage about 10 cm (4m) long that is attached to the ceccum just belowthe ileocecal valve. The appendix fills with food and empties regularly into the cecum, because it emptiesinefficiently and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable toinfection.
Appendicitis is an inflammation of the vermiform appendix that develop most commonly in
adolescents and young adults. It can occur at any age but is rare in clients younger than 2 years andreaches a peak incidence in clients between 20 and 30 years. It is not common in older adult however,when it does occur in such clients, rupture of the appendix is more common.
According to the statistics appendicitis affects 7% to 12% of the population. It is the most commonreason for emergency abdominal surgery in the United States.
The classic manifestations of appendicitis begin with acute acute abdominal pain that comes inwaves. At first, the pain may be perceived merely as discomfort that makes the client feel that passingflatus or having a bowel movement will bring relief.
Assessment may reveal vomiting that begins after the pain starts, loss of appetite, low-grade fever,coated-tongue and bad breath. Mild leukocytosis is usually present, with the white blood cell (WBC) countbetween 10,000 and 15,000/mm. Pain at Mcburney's point, which lies midway between the right anteriorsuperior iliac crest and the umbilicus, confirms the diagnosis.
This is what happened to Ms. Gev, a 21 years old patient, she was admitted because of the painperceived at right lower quadrant. Surgical management was done during his hospitalization.
This case was made to create awareness to the listener about appendicitis thereby impartingknowledge.
7/27/2019 APPENDICITIS CASE.doc
3/38
OBJECTIVE OF THE STUDY
General Objectives:
At the end of 2 hours presentation, the reader will be able to have adequate knowledge about
appendicitis.
Specific Objectives:
After the case presentation, the listener will be able to:
1. Know the important information regarding my patient.
2. Appreciate the result of physical assessment.
3. Know and understand the real meaning of appendicitis.
4. Understand the anatomy and physiology of the system affected with appendicitis.
5. Trace the pathophysiology of the disease.
6. Know the predisposing, factors and precipitation factors of the disease occurrence.
7. Interpret the laboratory result and know the nursing responsibility.
8. Know the signs and symptoms of the disease.
9. Identify the drugs that the physician ordered for the wellness of the patient
10. Identify the possible nursing diagnosis of the clients with appendicitis.
7/27/2019 APPENDICITIS CASE.doc
4/38
PATIENT'S VITAL INFORMATION
Patient's Name : Mrs. RoseAge : 21 years old
Sex : FemaleAddress : Purok Rosas, Barangay Dajay, Surallah, South CotabatoBirth Date : August 03, 1977Civil Status : SingleCitizenship : FilipinoReligion : Roman CatholicOccupation : NoneEducational Attainment : High School Graduate
Date Admitted : April 26, 2010Time Admitted : 2:00 amAdmitting Diagnosis : Acute AppendicitisAttending Physician : Jose June Tabanda, MDName of t he Institution : South Cotabato Provincial HospitalPost-operative Diagnosis : Acute appendicitis Procedure :Chief complaintName of Partner : Mr. JM
Age : 21 years old
Name of Father : Mr. DVOccupation : FarmerName of Mother : Mrs. MLOccupation : Housekeeper
SOURCE OF INFORMATIONPatient
7/27/2019 APPENDICITIS CASE.doc
5/38
FAMILY BACKGROUND
Ms. ROSE is the 4th daughter of Mr. D and Mrs. M. she is 33 years old at this age she already haveher first baby. Her grandparents are already dead but she doesn't know the reason behind it.
Her parents are still alive but she doesn't know any disease that they possess. Her father is afarmer while her mother is a housekeeper. Their farm is the only source of their family's income They are10 in the family including her parents and seven siblings.
Her parents decide for them due to the fact that they are still young to make such decisions.
HISTORY OF PAST ILLNESS
Ms. Rose verbalized that this is her second time to be hospitalized, previously because of denguefever but she can't remember the date.
She also said that whenever she experienced diseases like cough, fever and flu. She just but over-the-counter drugs like paracetamol and biogesic. She said that she is not consulting quack doctorswhenever she is sick. They are not also taking herbal medicine except those drugs in a capsule and tabletform already.
She added that she has no allergies to any kind of food and medicine. She confessed that this isher first time to undergo a surgical operation. She haven't experienced any accidents and injuries.
She delivered her baby on the 31st day of October at home. She said that she had no complicationsduring her delivery.
HISTORY OF PRESENT ILLNESS
Two hours prior to admission, the patient experienced pain localized at right lower quadrant withvomiting within that span of time she also tried to take medicine but the pain did not disappeared So her
7/27/2019 APPENDICITIS CASE.doc
6/38
EXPECTATIONS TO SELF
The patient expects to recover very soon. She is also expecting, that they can settle her account sothat she can go home. Due to the fact, that she really wants to see her baby.
EXPECTATION FROM THE FAMILY
The family expects that the patients will recover soon and that they can settle the accountimmediately. They are also expecting that she will not be hospitalize again.
7/27/2019 APPENDICITIS CASE.doc
7/38
REVIEW OF SYSTEMS
GENERAL:
The patient said that she never experienced fever prior to April 26, 2010. She denies ofexperiencing weight loss. she also verbalize body weakness and due to pain.
SKIN:
The patient states that she experienced having skin darkening on her neck during her pregnancy..
She also said that she has no rashes/allergies to any food.
HEAD:
The patient verbalized that nagasakit ang ulo ko kis-a She also said that she doesn't experiencedany head injury and she never observed tenderness.
EYES:
The patient said that wala man problema sa mata ko, makakita man ko maayo. She denies ofexperiencing temporary loss of vision.
NOSE:
The patient said that she also has no allergies to any odor. She denies of having sinus problem andshe has no problem in term of her sense of smell.
7/27/2019 APPENDICITIS CASE.doc
8/38
hypertensive.
GASTROINTESTINAL:The patient said that she experienced vomiting on the day she was admitted to the hospital. She
also said that she experienced constipation.
GENITOURMARY:
She said that she has no problems in urination. And she voids 5-6 times a day. She also said thatthese are no presence of blood in her urine.
MUSCULOSKELETAL:
She denies of having problems in moving. One said that she doesn't have arthritis. She states thatshe is a little bit weak because of pain.
PSYCHIATRIC:
She admits that she is anxious and worried because of her baby.
7/27/2019 APPENDICITIS CASE.doc
9/38
PHYSICAL ASSESSMENT REPORT
November 13, 20073:00 PM
GENERAL:
A mesomorphic individual with an in IV fluid infusion of DSLR 30 gtts/min attached at leftmetacarpal vein. She is not distress looking individual, oriented to time and place but can't remember someinformation. Can speak well with audible voice and can understand my question.
SKIN, HAIR AND NAILS
She possesses brown color of the skin. Skin rashes are out present, no abrasions and lesionsnoted. She is wet with her sweat.
The nails are cut and clean. Clubbing are not observed-capillary refill within 3 second.
HEAD
The skull is rounded (normocephalic) and possesses symmetrical facial movement. No lesions andtenderness noted. Hair is evenly distributed which is straight and black in color. She has a poor memory.
EYES AND VISION
Eyes are bilateral to each other. No discharges noted. The eyeballs can move normally and round.Can see far objects. Eyeballs are distributed normally, eye brows are black and can elevate it, present in anormal condition. Conjunctiva is a little bit pinkish in color.
No deformities noted eyes are moist normally No discharge noted Pupils are equally round
7/27/2019 APPENDICITIS CASE.doc
10/38
MOUTH AND NECK
Outer lips are slightly dry, able to pursed lip. She can move her head without discomfort. Lymphnodes are not palpable. Uvula is found in the middle upper of the mouth. Gums is slightly pink in color.
Teeth are in normal condition, no dentures and have a complete set of teeth.
There is no visible mass on the thyroid gland during inspection. The gland moves down whenswallowing but is not visible. No abnormalities noted.
CHEST AND LUNGSHas a respiratory rate of 25 breaths per minute. Can breath normally without using the accessory muscle.
No harsh sound noted during auscultation.
ABDOMEN
Abdomen is soft and flat. Presence of pain in the incision site is observed. Striae are still present.No lesions noted.
EXTREMITIES
UPPER: No deformities and swelling observed. Able to flex, extend and rotate..Rashes are not noted in both arms and hands.
LOWER: Normal range of motion is observed. There is no lesions present. Thenails are dirty in this extremities. There is no amputated parts of the body.
GENITALS
No deformities noted during the operation. The patient denies to show this part during assessment.
7/27/2019 APPENDICITIS CASE.doc
11/38
ANATOMY AND PHYSIOLOGY
The Large Intestine
Cecum is the proxional end of the large intestine and is where the large and small intestine meet atthe ileocecal junction. The cecum is located in the right lower quadrant of the abdomen near the iliac fossa.The cecum is a sac that extends inferiorly about 6 cm past the ileocecal junction. Attached to the cecum isa tube about 9 cm long called the appendix.
The colon is about 1.5-1.8 m long and consist of four parts: ascending colon, transverse colon,descending colon and the sigmoid colon.
RECTUM is a straight, muscular tube that begins at the termination of the sigmoid colon and endsat the anal canal. The muscular tunic is smooth muscle and it is relatively thick in the rectum compared with
the rest of the digestive tract.ANAL CANAL is the last 2-3 cm of the digestive tracts. It begins at the inferior end of the rectum
and ends at the anus. The smooth muscle layer of the anal canal is even thicker than that of the rectumand forms the internal and sphinotes.
In humans, the vermiform appendix is a small, finger-sized structure, found at the end of our smallcaecum and located near the beginning of the large intestine .The adjective "vermiform" literally means
"worm-like" and reflects the narrow, elongated shape of this intestinal appendage. The appendix is typicallybetween two and eight inches long, but its length can vary from less than an inch (when present) to over afoot. The appendix is longest in childhood and gradually shrinks throughout adult life. The wall of theappendix is composed of all layers typical of the intestine, but it is thickened and contains a concentrationof lymphoid tissue. Similar to the tonsils, the lymphatic tissue in the appendix is typically in a constant stateof chronic inflammation, and it is generally difficult to tell the difference between pathological disease andthe "normal" condition .The internal diameter of the appendix, when open, has been compared to the sizeof a matchstick. The small opening to the appendix eventually closes in most people by middle age. A
vermiform appendix is not unique to humans. It is found in all the hominoid apes, including humans,chimpanzees, gorillas, orangutans, and gibbons, and it exists to varying degrees in several species of NewWorld and Old World monkeys.
7/27/2019 APPENDICITIS CASE.doc
12/38
Throughout medical history many possible functions for the appendix have been offered, examined, andrefuted, including exocrine, endocrine, and neuromuscular functions (Williams and Myers 1994, pp. 28-29).
Today, a growing consensus of medical specialists holds that the most likely candidate for the function ofthe human appendix is as a part of the gastrointestinal immune system. Several reasonable argumentsexist for suspecting that the appendix may have a function in immunity. Like the rest of the caecum inhumans and other primates, the appendix is highly vascular, is lymphoid-rich, and produces immune
http://www.talkorigins.org/faqs/vestiges/appendix.html#WilliamsMyers1994http://www.talkorigins.org/faqs/vestiges/appendix.html#WilliamsMyers1994http://www.talkorigins.org/faqs/vestiges/appendix.html#WilliamsMyers19947/27/2019 APPENDICITIS CASE.doc
13/38
ETIOLOGY
PREDISPOSING
FACTORS
RATIONALE REMARKS
Age Appendicitis commonly occurs in personaging from 10-30 years. It reaches a peakincidence in clients between 20 and 30years. May patient is 21 years old.
Present
Sex In the United States 7% of the populationwill have appendicitis at one time in theirlives, males are affected more thanfemales.
Not Present
Race Asian and African less likely to developappendicitis as compared to Americans
Present
PRECIPITATINGFACTORS
RATIONALE REMARKS
Low-fiber dietPerson who has a low fiber diet is moreprone to appendicitis because they lackbulk which makes their stool to be refined,avoiding breakdown of small matters thatwill lodge into the lumen causing
Present ; The patient hasa low fiber diet.
7/27/2019 APPENDICITIS CASE.doc
14/38
COMPLETE DOCTOR'S ORDER
DATE AND
TIME
DOCTOR'S ORDER RATIONALE REMARKS
April 23, 201010:00 am Pls admit to P500 This is done for further evaluation of
patients condition and managementas well. To ensure patients safety.
This is doneimmediately.
TPR 98o
Getting the vital sign of the patientsaids the physicians to properlydiagnose the client thereby planningfor the treatment is done.
This is followed /carried out by theNOD.
NPO NPO is ordered to the patient due tothe fact that she will undergoneoperation which will require propervisualization of the field as well as itwill promote the cleansing of theabdominal part thereby reducing therisk for infection.
Patient was instructedand followed.
Labs: CBC stat
Urinalysis-stat
This is done to determine anyabnormalities that will manifest in the
blood.Urinalysis is done to confirm that it isreally an appendicitis or it is aninfection in the genitourinary system
Lab exam done, Labresult attached to the
chart, abnormalfindings reported tothe physician.
7/27/2019 APPENDICITIS CASE.doc
15/38
opioid to relief mild to severe pain.
Ranitidine 1 amp IVTT This decreases acid secretionthereby decreasing stomach pain toperson who are in NPO
Given to the patient
Ketorolac 30 mg IVTT nowthen q8 hr
This decreases feeling of pain frommild to moderate while having antiinflammatory and anti pyretics effects
Given to the patient
For Appendectomy This is ordered by the physician totreat underlying condition and to
prevent the occurrence ofcomplications
Done surgically inaseptic techniques
Appendectomyprep. Done
This is done to decrease the no. ofbacteria in that area therebydecreasing chance of infection.
Done carefully,avoiding to hurt/harmthe patient.
Inform OR /
anesthesiologist
This is done to inform the OR and
anesthesiologist and this is also doneto find out if there is an available slotfor this operation.
This is done prior
patient will go to OR.
Insert foleycatherer F 14
This is done to empty the patientsbladder as well as it will aids thenurse in monitoring the urine ouputperi-operatively.
This is doneaseptically
refer accordingly Referring the patient in a correctcondition will prevent the exhaustionof both,nurse & physician in givingth i t ti
Done
7/27/2019 APPENDICITIS CASE.doc
16/38
9:20 am To RR, then towardonce stable
room aids the nurse in propermonitoring of the condition of thepatient because patient who arepost operative are high risk for the
occurrence of complications.
RR.
VS q15 till stablethen q40
Vital sign monitoring every 15minutes is a must to postanesthetize client becausehomeostasis of the patinet wasdisrupted due to ansthesiaadministration.
Carried out by theNOD strictly.
NPO The patient is NPO post surgerybecause all muscles in theabdomen is relaxed in whichintroducing food can causeaspiration pneumonia.
Patient wasinstructed andfollowed.
Cont. IVF patientDSLR
This will correct hydration of thepatient that was disrupted by thesurgery.
IVF infused atdesired drops
Meds:1. betorlacIVTT now the age 98o
This decreases feeling of pain frommild to moderate while having antiinflammatory & anti pyretics effect.
Given to the patientat desired dosage.
2. Tramadol 50mgIVTT now then 98o
A centrally acting syntheticanalgesic compound notchemically related to opioids torelief mild to severe pain.
Given to the patient atdesired dosage.
3. Ranitadine 50mgIVTT 98o next dose 2 pm
This decreases acid secretionthereby decreasing stomach pain
Given to the patient atdesired dosage.
7/27/2019 APPENDICITIS CASE.doc
17/38
until awake supplemental oxygen to be able tosupport the intracellular &extracellular respiration therebymaintaining or regaining the
homeostasis Watch out for any
unusualityThis will aid the nurse indetermining any development ofcomplication.
Done
Refer This is done to avoid exhaustion ofenergy of the doctor .
Done
7/27/2019 APPENDICITIS CASE.doc
18/38
7/27/2019 APPENDICITIS CASE.doc
19/38
Bibliography
1. Black JM, Hawks, JH, (2005), Med-Surg Nursing:Clinical Management for positive Outcome (7 th Ed.)
Singapore, Elsevier Inc.
2. Bullock, BL Henze, R.L (2000) Focus on PathophysiologyPhiladelphia, Lippincoot William and Wilkins
3. Doenges, ME, Moorhouse, MF, Geissler Burr, Ac. (2005)Nursing Diagnosis Manual, Planning, IndividualsDocumenting Client Care, USA F.A. Davis Company
4. Smeltzer, S.C Bare, B.S. Hinkle, JL et al, Brunner and Suddarthstextbook of head-surg Nursing (Hth Ed.)Philadelphia, Lippincott William and Wilkins
5. Wynsberghe, D.V; Noback C.R.; Carola, R. (1995)Human Anatomy and Physiology (3rd ed)United States of America, McGraw-Hill, Inc.
7/27/2019 APPENDICITIS CASE.doc
20/38
Bibliography
2. Black JM, Hawks, JH, (2005), Med-Surg Nursing:Clinical Management for positive Outcome (7 th Ed.)Singapore, Elsevier Inc.
5. Bullock, BL Henze, R.L (2000) Focus on PathophysiologyPhiladelphia, Lippincoot William and Wilkins
6. Doenges, ME, Moorhouse, MF, Geissler Burr, Ac. (2005)Nursing Diagnosis Manual, Planning, IndividualsDocumenting Client Care, USA F.A. Davis Company
7. Smeltzer, S.C Bare, B.S. Hinkle, JL et al, Brunner and Suddarthstextbook of head-surg Nursing (Hth Ed.)Philadelphia, Lippincott William and Wilkins
6. Wynsberghe, D.V; Noback C.R.; Carola, R. (1995)Human Anatomy and Physiology (3rd ed)United States of America, McGraw-Hill, Inc.
7/27/2019 APPENDICITIS CASE.doc
21/38
Problem List
1. Pain related to surgical incision as manifested by facial grimace.2. Risk for infection related to surgical wound3. Risk for injury related to effects of anesthesia4. Fear related to impending surgery and prognosis.
7/27/2019 APPENDICITIS CASE.doc
22/38
7/27/2019 APPENDICITIS CASE.doc
23/38
Notre Dame of Tacurong College
City of Tacurong
Drug Study
Name of Patient: Mrs. Rose Prepared by: Group 4
Yr. &Sec: BSN-3
Age: 33 years old Checked by: Gina Cuenca, RN, MN
Diagnosis: acute appendecitis
Attending Physician: Dr. Tabanda M.D
NAME DRUGACTION
SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES
Generic:Ranitidine
Brand:Zantac
Classification:Anti-ulcerdrug
MODE OFADMINISTR
ATION
Route:IVTT
Dosage:50mg
Time:q 8
Mechanismsof Action:Potent anti-
ulcer drug thatcompetitivelyand reversiblyinhibitshistamineaction at H2receptor sitesparietal cellsdecreasinggastric acidsecretions.
Bibliography:Nursing DrugHandbook2005, Page712, 713
Indication;Duodenal andgastric ulcer
CNS: dizziness,headacheGI: Nausea,
vomiting,GIirritation,constipation.EENT: blurredvisionHepatic: JaundiceOthers: burning anditching at injectionsite.
ADVERSEEFFECT
Anaphylaxis, angioedema
Contraindicated in patienthypersensitivity to drugand those with acute
prophyria
SPECIALPRECAUTION
Use cautiously in patientwith hepatic dysfunctions
DRUG INTERACTION
Drug-DrugAntacids: May interferewith ramitidine absorptionstragger doses, if possible.Diazepam: may decreasedabsorption of diazepammonitor patient closely.
1. Before giving the drug, Practice Proper handwashing
R: proper hand washing will reduce presence of
microorganism in your hands, thus it willprevent another complication to your pt.2. Check the patency of the IV tube, before
giving the medicine.R: checking the patency of the IV tube will
facilitate easy administration of the drug thusreducing discomfort to the patient
3. Administer the medicine once it has beenprepared.R: Administering the drug after preparing will
reduce incidence of mistake and ensuring thesterility and effectiveness of the medication.
4. Offer pt. some ice ships and small amount ofcrackers to prevent occurrence of nausea andvomiting.
R: This will provide comfort to the pt sincenausea and vomiting are considered as sideeffect of the said drug.
5. Infuse the medication at slow rate about 10-15minutes.
R: this will prevent or lessen the burning anditching sensation at the injection site which isseen as the usual complains of the patient,
7/27/2019 APPENDICITIS CASE.doc
24/38
therefore give it slowly to prevent it.6. Before giving the drug, educate first the
patient about the purpose of it.R: Giving information to the patient will
facilitate cooperation and relieve their
anxiety.7. Instruct patient to rest after administering thedrug.
R: Having the patient to rest will promotecomfort and prevent injury since one of theside effect of the drug is dizziness.
8. Provide safety to the patient by raising the siderails and always stay at the bedside givingassistance during ambulation.
R: this will provide comfort to the pt. duringthe occurrence of
Temporary blurred vision as a side effect
of the drug.9. Instruct patient to report any unusualities.R: Instructing our patient to report unusualities
will help us to provide proper and prompttreatment.
10. Before giving the drug asses if the patient hastaken a meal.
R: Assessing if the patient has taken any food,because the drug works better when thestomach is empty.
11.encourage patient to include fibers in the
diet to preventconstipation.
R: Increase in fiber intake will prevent thept from experiencing constipation as a sideeffect of the drug.
7/27/2019 APPENDICITIS CASE.doc
25/38
7/27/2019 APPENDICITIS CASE.doc
26/38
7/27/2019 APPENDICITIS CASE.doc
27/38
7/27/2019 APPENDICITIS CASE.doc
28/38
Notre Dame of Tacurong College
City of Tacurong
Drug Study
Name of Patient: Mrs. rose Prepared by: Group 4
Yr. &Sec: BSN-3
Age: 33 years old Checked by: Gina Cuenca, RN, MN
Diagnosis: acute appendecitis
Attending Physician: Dr. Tabanda M.D
NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIESGeneric:
Metoclopramide
Brand name:
Reglan
Classification:
Anti ulcer
drug
Mode of
Administration:
Route:IVTT
Dosage:
- 5mg/ml
Time:
-
Mechanism of
Action:
Stimulates motility
of upper GI tract,Increasesesophageal
sphincter tone,
andblocksdopamine
receptors at thechemoreceptor
trigger zone.
Bibliography:
Nursing 2007
drug handbook.
PPDs Nuring
drug Guide
Indication:
Restlessness,anxiety,
drowsiness, fatigue,
lassitude,dystonicreaction,sedation,
Adverse Effect:
Fever,
depression,akathisia,insomia,confusion,su
icide
ideation,seizures,neurolepti malignant
syndrome,hallucinations,headache,extra
pyramidalsymptoms,tardivedyskinesia.
CV: transienthypertension,suprave
ntricular tachycardia,bradycardia.
GI: nausea, bowel
Contraindicated in patients
with hypersensitivity to
drugand in those withpheochromocytoma or
seizure disorders.
Patients with presence of
GI hemorrhage.
Catraindicated to patients
who are lactating and pts
with breast cancerSpecial Precaution:
Use cautiously in pts with
history of depression,parkinsons disease,or
hypertension.
Drug Interaction:
Drug-drug:
anticholinergics, opiod
analgesics: may
antagonize GI motilityeffects of
Assess pt first for any GI
complaints such as nausea and
vomiting.
R: this drus is only given to pt.experiencing nausea and vomiting
and assessment is needed prior togiving it.
Assess pts Blood pressure prior to
administering the drug.
R: drug may cause transienthypertension and pt. must be
monitored closely.
Check for patency of the IV line before
administration and infuse the drug in
abou 1-2 minutes.
R: this may cause irritation of the
7/27/2019 APPENDICITIS CASE.doc
29/38
Antiemetics disorders, diarrhea.GU: urinary frequency,
incontinence.Hematologic:
neutropenia,
agranulocytosis.Skin: rash, urticaria.
Other:prolactinsecretion, loss oflibido.
metoclopramide. Usetogether cautiously.
CNS depressant: may
cause additive.
CNS effects: avoidusing together.
Levodopa: Levodopa
and metoclopramide haveopposite effects on
dopamine receptors.Avoid using together.
MAO inhibitors: may
increase release ofcatecholamines in pts
with hypertension.Phenothiazines: may
increase risk oftrapyramidal effects,monitor pt closely.
vein if infused in fast rate.
Give appropriate dose ordered by the
physician.
R: Giving the drug in higher dose willproduce drug induced advesr reaction
such as hypertension.
Educate pt. and SO that drug may cause
temporarily neurological disorder such
as involuntarily twisting of limb.R: this will let the pt. know that it is just
temporary and pt. will feel at ease.
Encourage pt. to do energy savingtechniques that would help her not to
feel fatigue such as sit instead ofstanding.
R: the drug may cause fatigue as aside effect and this would help to
alleviate the pt. from feeling it.
Encourage patient not to engage in
activities that require alertness.
R: The drug may cause temporary
impairment of mental status.
Assist pt. during ambulation and
provide a period for rest.
R: this will prevent the occurrenceof unnecessary injury since the drug
7/27/2019 APPENDICITIS CASE.doc
30/38
may cause drowsiness.
Instruct pts SO to report any unusual
feeling after receiving the medication.
R: this is to provide prompt care and
management to the patient.
7/27/2019 APPENDICITIS CASE.doc
31/38
NOTRE DAME OF TACURONG COLLEGECity of Tacurong
DRUG STUDYName of the Patient: Mrs. Rose
Attending Physician: Dr. Tabanda M.D Diagnosis: Acute appendecitis Prepared by: Group 4 Year & Section: BSN 3Checked By: Gina Cuenca RN, MN
NAME DRUGACTION
SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES
Generic:
Tramadol
Brand:
Vitram
Classification:Opioid Analgesic
MODE OF
ADMINISTRAT
ION:
ROUTE:
IVTT
DOSAGE:300mg
Frequency:
24 hrs.
Mechanism of
Action:
Unknown that acentrally acting
synthetic analgesicchemically related
to opioids.
Thought to bind toopioids receptors
and inhibitreuptake and
norepinephrine andserotonin.
Bibliography:
Lippincott
Williams &Wilkins NursingDrug Handbook
2005, 25th edition,
pgs. 405-406
Indication:
Moderate to
moderately severe
Dizziness, headache,
malaise, diarrhea,
N&V, visualdisturbances,
constipation, drymouth, urine
retention, rash
ADVERSE
EFFECTIVE
CNS stimulation,asthenia,coordinationdisturbance,respiratorydepression,hypertonia, and
pruritus
If the drug was tolerated itcan cause diarrhea nausea,vomiting, headache, ormigraine, dizziness andabdominal pain.
SPECIAL PRECAUTION
Use cautiously in pts
hypersensitivity drug and otheropiods, in breast feeding women,
and patient intoxicated withalcohol. And also in pt with renal
and hepatic impairment.
DRUG INTERACTION
Diuretics: May risk of adverse
renal reactions.
DRUG-DRUG:
Carbomazepine may increaseTramadol metabolism, patient longterm carbomazepine therapy at upto 800mg daily may used to twice
to recommend those Tramadol
Stay at patients bedside and raised siderails.
Drug causes dizziness, thus puttingpatient high risk for injury.
Limit activities that requires excursion. To prevent headache and, and to lessenmalaise Encourage patient to control oral fluid
intake if diarrhea occurs. Fluid is restricted to pt. with urine retentionand fluid excess in tissue spaces. Small amountof fluid can prevent dehydration as caused bydiarrhea. Encourage patient to consume crackers and
ice chips if nauseated. To allay feeling of nausea, thus preventsvomiting Assess clients visual acuity by asking
patient if she can see object with in 5meters To check if patient manifest visualdisturbances. Encourage patient to include fiber in the
diet Drug causes constipation, fiber facilitatesvowel movement. Note for rashes on the skin after giving the
medicine.
7/27/2019 APPENDICITIS CASE.doc
32/38
pain. This may be a sign of allergic reaction Always keep O2 at bedside. For immediate
management of respiratory depression.
7/27/2019 APPENDICITIS CASE.doc
33/38
NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
NURSING CARE PLANName of Patient: Mrs. Rose
Age: 33 yrs. oldDiagnosis: acute appendecitis
Attending Physician: Dr. Tabando M.D
ASSESSMENT NEEDS NURSING
DIAGNOSIS
GOALS/OBJECTIVES NURSING
INTERVENTION
RATIONALE EVALUATION
Date: APRIL 26,
2010
Subjective Data:
no verbal cues.
Objective Data:
Irritabilitynoted
Guardingbehavior
facial
grimacenoted.
C
O
G
NI
T
I
V
E
P
E
R
CE
P
T
U
A
L
Acute pain
related tosurgical
procedure as
evidenced byfacialgrimacing,
guarding
behavior andirritability
Rationale:
Unpleasant
sensation and
emotional
experiencefrom actualtissue damage.
> pt.experiences
piercing pain
on the surgicalwound due to
expose
General:
After rendering effectivenursing intervention the
pt. will be able to
verbalize reduce in painwith scale of 8 to 3 outof 10
Specific:
After 8hrs. of nsg.
Intervention the pt. willbe able to:
1.) Report that pain
is controlled.
2.) Verbalizemethods thatprovide relief,
such asdiversional
activities.
3.) Demonstrate useof relaxation
skills as well as
O1
Administerpain.
medication as
ordered. Instruct pt. to
splintincision when
coughing.
O2
Providediversional
activities such
as readingarticles, &
talking topeople.
Have the pt.perform
breathing &coughing
exercise if pain
To relievepain.
To reducepain due to
muscle
contraction.
To preoccupy
pain
perception by
focus in otherareas.
To reduce the
pain she fails.
Date: a
Goal met asevidenced by
pts.
Verbalization ofa in such assplinting the
surgical wound
whenrepositioning,
and pt. have talkparticipative
during
therapeutic
communication.
7/27/2019 APPENDICITIS CASE.doc
34/38
P
A
T
T
E
R
N
By:Gordons
FunctionalHealth
Patterns
nociceptorswhich detects
pain sensation.
Bibliography:
Nurses PocketGuide (Edition
11)by: Doenges,
Moorhouse,Murr
diversionalactivities.
occurs.
Encourage pt.
to keep self ina dim lighted
room.
Assess pts.Perception of
pain & howshe feels it.
Limit activities
that requires
exertion.
Healthteachings.
To reduce
stimuli andstress.
This mayreduce feeling
of anxiety thuspromotes
relaxation.This provides
adequate bed
rest.
To reinforce
pts. Skills indiverting pain.
7/27/2019 APPENDICITIS CASE.doc
35/38
NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
NURSING CARE PLANName of Patient: Mrs. Rose
Age: 33 yrs. oldDiagnosis: Acute appendecitis
Attending Physician: Dr. Tabando M.D
ASSESSMENT NEEDS NURSING
DIAGNOSIS
GOALS/OBJECTIVES NURSING
INTERVENTION
RATIONALE EVALUATION
Date: april 26,
2010Subjective Data:
sakit ang tinahian
ka ang sugatmismo asverbalized pt.
- pain scale of
(severe)
Objective Data:
FacialGrimace
noted
GuardingBehavior
noted
Level of
ADLs.
Exudates on
incisionnoted
Diaphoresis
N
U
T
RI
O
N
A
L
M
E
T
AB
O
L
I
C
Fluid volume
excess r/tvasospasm
secondary to
preeclampsia asevidenced byedema of the
lower
extremities, adecreased in
urine output &presence of
protein in
urine.
Rationale:Increaseisotonic fluid
retention.> pt.
experiences
increased BP of140/110 mmHg
and has a
General:
After rendering effectivenursing intervention the
pt. will be able to have a
stabilize fluid volume asevidenced by balancedI/O, v/s in the normal
range, and with signs of
edema. Specific:
After 8hrs. of nsg.Intervention the pt. will
be able to:
1.) verbalize
understanding ofindividualdieatary/ fluid
restrictions.2.) Demonstrate
behaviors to
monitor fluidstatus and
recurrence of
O1
Healthteachings on
balance diet.
Inform pt. that
she will berestricted on
fluids.
Restrict &
rationalizedlow fat and
low salt diet as
indicated.
O2
Instruct pt. to
keep urineoutput in
container for24 hours.
This provides pt.with cognizance
on healthy diet.
For awarenessand complianceto care.
For clients
understandingon dietary
plan.
A 24 hrs. urine
collection willdetermine pts.
Urine output.
For changes
Date:
Goal met asevidenced by
lessened pedal
edema.> pt. was able todemonstrate to
behaviors to
prevent of fluidexcess such as
compliance todietary protocol
[ low salt diet],
controlled fluid
intake. And pt.manifest stableBP of 110/80
mmHg
7/27/2019 APPENDICITIS CASE.doc
36/38
noted
v/s: BP:
140/110mmHg
T: 36
P: 75 bpm
RR: 24 cpm
P
A
T
T
E
RN
By:Gordons
FunctionalHealth
Patterns
bipedal edema.
Bibliography:
Nurses Pocket
Guide (Edition
11)by: Doenges,
Moorhouse,Murr
fluid excess. Measure
abdominal
girth.
may indicateincreasing
fluid retention/edema.
7/27/2019 APPENDICITIS CASE.doc
37/38
7/27/2019 APPENDICITIS CASE.doc
38/38