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I. DEFINITION/PREVALENCE Acute disease of the GI tract might be caused by the pathogen alone or by a bacterial or perhaps other toxin. Acute inflammatory disorders such as appendicitis and peritonitis result from contamination of damaged or perhaps normally sterile and clean tissue with a client’s personal endogenous or perhaps resident bacterias (Lemone and Burke, 2008, page 766).

Appendicitis is the inflammation in the vermiform (wormlike) appendix, the appendix can be described as small fingerlike appendage about 10 centimeter (4 in) long, attached with the cecum just below the ileocecal device, which is quick the large gut.

It is usually found in the right iliac region, at an area specified as McBurney’s point. McBurney’s point, located midway between umbilicus as well as the anterior iliac crest in the right reduce quadrant. It’s the usual internet site for localized pain and rebound tenderness due to appendicitis during after stages of appendicitis. The function in the appendix is usually not fully understood, although it regularly fills and removes the contents digested foodstuff. Some experts have recently proposed the appendix may well harbor and protectbacteriathat will be beneficial inside the function in the human colon.

Appendicitisis the most frequent cause of serious inflammation inside the right reduced quadrant in the abdominal tooth cavity. The lower quadrant pain is generally accompanied by a low-quality fever, nausea, and often vomiting. Loss of appetite is common. In up to fifty percent of delivering cases, neighborhood tenderness is definitely elicited by Mc Burney’s point used located at halfway between the umbilicus and the anterior backbone of the Ilium. Rebound pain (ex. Production or intensification of soreness when pressure is released) may be present.

The level of pain and muscles spasm plus the existence in the constipation or diarrhea depend not so much around the severity from the appendiceal illness as around the location of the appendix. If the appendix curls about behind the cecum, pain and pain may be experienced in the back region. Rovsing’s sign can be elicited by palpating the left reduced quadrant. If the appendix offers ruptured, the pain be a little more diffuse, belly distention grows as a result of paralytic ileus, and the patient’s state worsens.

The illness is more frequent in countries in which persons consume a diet low in dietary fiber and high in refined carbs. It is the most popular reason for unexpected emergency abdominal surgical procedure, affecting 10% of the inhabitants. Although appendicitis affects a person any kind of time age, the height incidence is definitely between the age groups of 20 and 3 decades old where the vast majority of clients are most common in adolescents and young and slightly more common in males than females. About 7% with the population could have appendicitis sooner or later in their lives (Lemone and Burke, 2008 page 766).

The major complications of appendicitis is perforation of the appendix, which can lead to peritonitis, felon formation (collection of purulent material), or portal Pyle phlebitis, which can be septic thrombosis of the site vein caused by vegetative emboli that happen from septic intestines. Perforation generally happens 24 hours following your onset of pain symptoms incorporate a fever of 37. several degree Celsius or 95 degree Fahrenheit (f) or greater, a harmful appearance and continued abs pain or tenderness. II. TYPES/CLASSIFICATION

Appendicitis can be classified as simple, gangrenous, or punched, depending on the level of the process. In straightforward appendicitis, the appendix can be inflamed but intact. Once areas of tissues necrosis and microscopic perforations are present inside the appendix, the disorder is known as gangrenous appendicitis. A perforated appendix reveals evidence of gross perforation and contamination in the peritoneal tooth cavity (LeMone & Burke, 2008 page 766). Peritonitis can be primary or secondary. Major peritonitis is definitely an acute bacterial infection which is not associated with punched viscus, or organ.

Bacterial infection is the common cause and might be associated with an infection by same patient somewhere else in your body, which actually reaches the peritoneum via the vascular system. Tuberculosis peritonitis, which originates from tuberculosis elsewhere in your body, is a sort of primary peritonitis. Clients with alcoholic cirrhosis and ascites, in the absence of a permeated organ, typically manifest peritonitis, which may be because of leakage of bacteria through the wall in the intestine. Supplementary peritonitis is generally caused by microbial invasion because of perforation, or rupture of the abdominal viscus.

It can also derive from severe chemical reactions to: pancreatic enzymes, intestinal juices, or perhaps biles produced into the peritoneal cavity (Gould & Dyer, 2011). 3. DEMOGRAPHIC PROFILE Patient’s identity is Mister. Ruptured Serious Appendicitis, twenty four years old, man, residing for 820 Basic Kalentong, Daang Bakal, Mandaluyong City. Dr. murphy is the second kid among a few siblings, a Roman Catholic, single, a third year college or university Information Technology student. IV. FAMILY MEMBERS MEDICAL HISTORY (Family Genogram)COD: TB COD: TB A: 83 -S, -D A: 83 -S, -D Not Were recalled Not Recalled c c A: twenty +S, +D A: twenty S, +D A: twenty-four +S, +D A: twenty-four +S, +D A: 27 -S, -D Skin allergy or intolerance A: twenty seven -S, -D Skin allergy A: forty two +S, +D A: 42 +S, +D A: sixty four +S, +D HPN, Cerebrovascular accident A: sixty four +S, +D HPN, Heart stroke c c A: 46 -S, +D Asthma A: 46 -S, +D Bronchial asthma A: 51 -S, +D A: 51 -S, +D patient patient LEGEND: STAR: male men married hitched deceased male deceased men S- smoker D- consumer COD- source of death S- smoker D- drinker COD- cause of fatality female woman deceased woman deceased feminine V. PAST MEDICAL HISTORY Having been first hospitalized last 2006 due to dengue at the same clinic: Mandaluyong City Medical Center (MCMC).

He has no other even more illnesses other than the typical fever, cough and cold. Other than that, he does not have allergies, hypertonie, or diabetes mellitus. MIRE. HISTORY OF PRESENT ILLNESS 7 days prior to entry patient knowledgeable abdominal pain all over abdomen. He conferred with at SER MCMC fixed out AUPD (Acute Peptic Ulcer Disease) and was handed Omeprazole & HNBB (Buscopan). Whole belly ultrasound carried out and exposed tiny cholecystolethiasis. He was given Diclofenal and HNBB tabs and eventually released. Few days just before consultation, the individual still experienced abdominal discomfort.

He conferred with at Er and was opted for surgical intervention ” EXPLORATORY LAPAROTOMY APPENDECTOMY within the service of Dr . Abram Del Vallejo, M. M. VII. GORDON’S PHYSICAL ASSESSMENT i. Overall health Maintenance ” Perception Style Before entry: The patient used to smoke cigarette 3 supports per day. And he as well drinks alcoholic beverages daily especially beer of more than 2 bottles per treatment. He was certainly not using prescription drugs and he has no hypersensitivity at all. During time of treatment: The patient can be not smoking cigarettes cigarette or perhaps drinking alcohol. 2. Nutritional ” Metabolic Design

Before entrance: The patient was on a high protein diet because he utilized to go to the health club 2-3 moments a week. Having been also currently taking vitamins (CENTRUM). He provides normal urge for food and does not have difficulty swallowing. He generally eats three times a day (breakfast, lunch and dinner) and most of the time this individual also has his snacks. He also usually drinks 2-3 liters of water every day. e During time of attention: The patient can be on NPO (nothing per orem) for 5 times due to post-operative appendectomy and he was on his 2nd working day of NPO status whenever we cared for him. He has also NGT lavage connected. 2. Elimination Design Before admission: The person’s normal bowel movement was 3 BM a day and has no trouble bladder habits. His last bowel movement was previous July 18, 2012. This individual usually urinates 6-7 times a day quite easily. During moments of care: The patient has absence of intestinal movement and flatus and has no intestinal sounds after auscultation. This individual has foley catheter and with urine output of 480 cc per shift. iv. Activity and Work out Before admission: The patient can do his activities independently without assistance.

He generally goes to gym 2-3 times a week. During time of proper care: The person’s functional level or self-care ability level is two which mean he requires help via another person intended for assistance. sixth is v. Sleep/Rest Pattern Before admission: The patient generally sleeps at 4 or 5 was and wakes at almost 8 or on the lookout for am. He has no difficulty in sleeping and he feels rested after sleep. During time of treatment: The patient has standard sleeping practices. He naps at 15 am, wakes at 6 am with uninterrupted rest. vi. Intellectual ” Perceptual Pattern

Ahead of admission: The person was warn and coherent, has typical speech, with mild level of anxiety, has normal reading, and with impaired perspective of his left vision due to cataract. During time of care: The patient is warn and logical. He features normal conversation (Filipino because his used language), this individual has modest level of anxiety, has usual hearing, and with damaged vision of his still left eye due to cataract. He also complained of severe pain and described it as a cramping pains pain. Soreness management (Tramadol) was given. vii. Role ” Relationship Pattern Before admission: The patient was a student and single.

His support program was his family, family & close friends. During moments of care: The patient’s support system is his mother who will be always by his bed side helping him in whatever he needs. After asking his mother in the event that she has any kind of concerns with regards to hospitalization, the lady said that the girl with more matter about the fast restoration of her son. viii. Sexuality ” Reproductive Program Before entry and during enough time of attention: The patient even now didn’t possess his testicular exam. ix. Coping ” Stress Tolerance/Self , Perception/Self , Concept Pattern The patient’s significant concern regarding his hospitalization is h all about self-care.

Due to the tools attached to him, he are unable to independently perform his activities. His main loss was his stepfather when he perished of renal failure. His rated his outlook on future as 5, one particular being poor and 15 being very optimistic. He further described why this individual rated a few because he is not sure when he finished college he can be able to get employed suited for him. x. Value ” Opinion Pattern The patient is a Roman Catholic and he always goes toward church every single Sunday along with his family. VIII. GROWTH AND DEVELOPMENT DEVELOPING TASK| THEORIST| STATUS| Intimacy vs .

Remoteness * Develops commitments to others and to a life work (career)(Daniels, ain. al., 2010). | Erikson| The patient a new relationship together with his opposite sexual intercourse but he said that they will just split up a week before he was in the hospital due to several personal and private reasons. Presently, he is in 3rd year college, a great IT pupil. | Penile * Breakthrough of intimate interests and development of associations with potential sexual associates (Daniels, et. al., 2010). | Freud| As what had written over, the patient had a relationship along with his opposite love-making but as a result of some reasons they made a decision to end up their particular relationship. Formal Operations 5. Able to find relationships and reason inside the abstract (Daniels, et. approach., 2010). | Piaget| He perceived that relationships (any kind of relationship) are important specifically at his age. He can also cause out in an abstract approach. He can communicate his viewpoints intellectually and precisely. | Early Adult life * Pick a partner, learn to live with somebody, start a family, manage a home, build self within a career/occupation, believe civic responsibility, and become an integral part of a social group (Daniels, et. al., 2010). Havighurst| According to the patient, this individual didn’t anticipated that something like that will eventually them (referring to his girlfriend). He was really planning on that they are seriously meant for each other and that the lady (his gf) will be his future better half. He is as well establishing him self to a upcoming career, therefore he is learning in prep for his future. During our moments of care also, his ‘barkadas’ visited him and he said that they were his ‘tropa’. | Postconventional * Person understands the morality of getting democratically founded laws (Daniels, et. approach., 2010). Kohlberg| Upon asking the patient in the event that he is familiar with the democratically established regulations in the Philippines, he immediately responded using a yes. This individual also declared these regulations help all of us, Filipinos, to have safe and secure country though right now there may come a time that we may experience a thing unexpectedly. | IX. PHYSICAL ASSESSMENT 2. Vital Indicators TIME| Preliminary 8AM (07/24/12)| 10 AM| 12 NN| 8 I AM (07/25/12)| doze NN| Previous 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 SIMPLY SYSTEMS REGULAR FINDINGS| BOOK FINDINGS| INDIVIDUAL FINDINGS| SIGNIFICANCE| I. NEUROLOCIGAL SYSTEM Alert and coherent, with normal body temperature of 36. 3C ” thirty seven. 6C| 2. Fever (usually &gt, 38C although hypothermia may be present w/ serious sepsis), chills * Thirst * Pain| * Complained of discomfort in the cut site (lower longitudinal midline of the abdomen)| Pain comes from the improved pressure of fluid for the nerves, especially in enclosed areas, and by the local irritation of nerves simply by chemical mediators such as bradykinins (Gould, et al. 2011). | 2. RESPIRATORY Typical respiration using a rate of 12-20 breaths per minute| * Tachypnea, shallow respirations| * RR: 23 bpm w/ short respiration| Acute pain generally initiates physiologic stress response with increased respiratory system rate (Gould & Dyer, 2011). | III. INTEGUMENTARY

Pink or perhaps brown in addition to uniform color, no edema, no lesions, moistSkin temperatures is normally warmIntact skinWhen pinched, skin springs back to earlier state| * Dry lips and mucous membranes * Swollen tongue * Poor skin turgor| * Dried lips and mucous membranes * Pores and skin turgor: 3-5 seconds 5. Presence of surgical cut at reduce longitudinal midline of the abdomen * Skin is nice to feel and is reddened| Dry mucous membrane and poor skin turgor are signs of lacks (Gulanick, et al. 1994). Redness might indicate swelling (Weber & Kelly, 2007). Redness and warmth are caused by increased the flow of blood into the destroyed area (Gould & Dyer, 2011). | IV. HEART Normal heart beat rate of 60-100 bpm| * Tachycardia * Diaphoresis * Pallor * Hypotension * Tissues edema| 5. Pulse charge: 83 bpm| Acute discomfort usually starts a physiologic stress response with increased heartrate (Gould & Dyer, 2011). | Sixth is v. MUSCOLOSKELETAL

Capability to do Actions of Everyday living (ADL)| 2. Difficulty ambulating * Weakness| * Problems ambulating because of post-op state * Weakness| Constant pain frequently affects daily activities and may become a principal focus in the life of the individual (Gould & Dyer, 2011). | VI. GENITO-URINARY Normal urine output of 30cc/hrColor: Amber, transparent, clear| * Decreased urinary result * Darker color urine| * Dark color urine * Urine output: 480 mL/shift 5. Specific gravity: 1 . 30| Decreasing outcome of focused urine with increasing certain gravity advises dehydration/need intended for increased fluids (Doenges, et al., 2006). | VII. GASTROINTESTINAL Abdominal skin may be paler compared to the general skin tone because this epidermis is so hardly ever exposed to the natural elementsAbdomen is free of lesions or rashesA group of intermittent, gentle clicks and gurgles happen to be heard for a price of 5-30 per minuteNormally no pain or discomfort is elicited or reported by the clientNo rebound pain is presentAbdomen is non-tender and gentle.

There is no guarding| * Lack of appetite 2. Nausea & vomiting(usually projectile) * Congestion of the latest onset * Diarrhea(occasional) 5. Sudden, serious, generalized stomach pain * Abdominal distention, rigidity 2. Decreased/absence of bowel seems * Inability to pass stool/flatus * Muscles guarding (abdomen) * Psoas’ Sign (flexion of or pain on hyperextension with the hip because of contact among an inflammatory process & the psoas muscle) * Obturator Signal (the internal rotation with the right lower leg with the lower-leg flexed to 90 certifications at the hip and leg and a resultant tensing of the inside obturator muscle may ause abdominal discomfort) * Rovsing’s Sign (pressure on the left decrease quadrant of the abdomen triggers pain inside the right decrease quadrant) * Rebound tenderness (a sign of swelling of the peritoneum in which soreness is elicited by the immediate release from the fingertips pressing on the abdomen) | 5. Board-like stomach * Immediate, severe, generalized abdominal discomfort * Absence of bowel seems in all four quadrants 5. Absence of flatus/stool * Existence of operative incision| Indications indicating the onset of peritonitis include a strict “board-like abdominal (Gould & Dyer, 2011).

Pain recurs as a constant, severe abs pain because peritonitis evolves (Gould & Dyer, 2011). Absence of bowel sounds could possibly be associated with peritonitis or paralytic ileus (Weber & Kelly, 2007). Once inflammation is persistant, nerve leasing is reduced, and peristalsis decreases, leading to obstruction from the intestines (paralytic ileus) (Gould & Dyer, 2011). | X. ANALYSIS TESTS CLASSIFICATION TEST| NORMAL| RESULT| SIGNIFICANCE| WHOLE STOMACH ULTRASOUND (July 21, 2012) | The organs evaluated appear regular (Cosgrove, ainsi que al., 2008). | Hard working liver is certainly not enlarged.

It has homogenous echopattern with clean border. The intrahepatic system are not dilated. No obvious focal mass lesion viewed. CD measures 3. 9mm. Gallbladder is normal in size and wall fullness. There are multiple tiny echogenic shadowing foci seen inside the gallbladder lumen. Pancreas & spleen are normal in proportions & echopattern. No key mass lesion seen. Both equally kidneys are normal in dimensions & echopattern. Right kidney measures 12. 1, 5. 2, five. 46cm with cortical fullness of 1. 7cm while the left kidney actions 10. 5, 4. 8, 4. 1cm with width of 19cm. No obvious caliectasis, lithiasis, seen bilaterally.

Urinary bladder is bare. Impression: Little cholecystolithiasesNormal hard working liver, pancreas, spleen, kidneys by simply UTZUnfilled urinary bladderNot dilated biliary woods | Abs ultrasound is the most effective test out for diagnosing acute appendicitis (LeMone & Burke, 2007). | HEMATOLOGY REPORT/COUNT (July 21, 2012)| RBC: 5. 2-5. 6 M/uLPlatelets: 150-400 x 10/LWBC: 3. 8-11. 0 K/mm3Hemoglobin: 135-180g/LHematocrit: zero. 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. forty five (normal)Hemoglobin: 153g/L (normal)Differential Depend: Neutrophils 0. 90Lymphocytes 0. 10 (normal)| Elevated WBC is seen in acute illness (LeMone & Burke, 2007). Neutrophils: enhanced in infection (LeMone & Burke, 2007). | URINALYSIS (July twenty one, 2012)| Color: Light hay to amber yellowAppearance: ClearOdor: AromaticpH: 4. 5-8. 0Specific gravity: 1 . 005-1. 030Protein: 2-8mg/dLGlucose: NegativeKetones: NegativeRBCs: RareWBCs: 3-4Casts: Irregular hyaline| Color: Dark YellowTransparency: TurbidUrine pH: 6. 0 Specific gravity: 1 . 30Sugar: NegativeProtein: +4Microscopic examPus skin cells 4-6/HPFRBC 1-2/HPFCrystals: Amorphous Sulfate Moderate| A dark yellow to brownish color is seen with deficient fluid volume (LeMone & Burke, 2007). Hazy or perhaps cloudy urine indicates bacterias, pus, RBCs, WBCs, phosphates, prostatic liquid spermatozoa, or perhaps urates (LeMone & Burkie, 2007). | CLINICAL BIOCHEMISTRY (July twenty one, 2012)| Salt (Na): 135-142 mmol/LPotassium (K): 3. 8-5 mmol/L| Salt: 132 mmol/LPotassium: 4. 02 mmol/L| Salt is decreased in SIADH & vomiting (LeMone & Burke, 2007). | XI. ANATOMY & PHYSIOLOGY OF APPENDIX (LARGE INTESTINE)

The large intestine, which can be about 1 ) 5 meters (5 ft) long and 6. 5 cm (2. 5 in. ) in diameter, stretches from the ileum to the trou. It is attached with the posterior abdominal wall membrane by it is mesocolon, the double coating of peritoneum. Structurally, the four significant regions of the large intestine are definitely the cecum, bowel, rectum, and anal cacera. The starting from the ileum into the large intestine is guarded with a fold of mucous membrane called the ileocecal sphincter (valve), that allows materials through the small is going to to pass into the large gut. Hanging poor to the ileocecal valve may be the cecum, a tiny pouch regarding 6 centimeter (2. 4 in. ) long.

Mounted on the cecum is a twisted, coiled tube, measuring about 8 centimeter (3 in. ) in length, called the appendix or perhaps vermiform appendix (vermiform = worm-shaped, appendix = appendage). The mesentery of the appendix, called the mesoappendix, connects the appendix to the inferior part of the mesentery of the ileum. The available end from the cecum merges with a extended tube called colon, which can be divided into ascending, transverse, descending colon happen to be retroperitoneal, the transverse and sigmoid colon ascends on the right part of the belly, reaches the inferior surface area of the hard working liver, and turns abruptly left to form the best colic (hepatic) flexure.

The colon goes on across the abdomen to the left part as the transverse bowel. It curves beneath the substandard end from the spleen on the left side as the left colic (splentic) flexure and passes inferiorly to the level of the iliac reputation as the descending digestive tract. The sigmoid colon starts near the still left iliac reputation, projects medially to the midline, and ends as the rectum at about the level of the third sacral vertebra. The rectum, the last 20 cm (8 in. ) of the GI tract, lies anterior to the sacrum and coccyx. The terminal two to three cm (1 in. ) of the rectum is called the anal canal.

The mucous membrane with the anal channel is arranged longitudinal folds up called anal columns which contain a network of arteries and blood vessels. The opening of the anal canal to the exterior, called the trou, is protected by an indoor anal sphincter of easy muscle (involuntary) and an external anal sphincter of the bone muscle (voluntary). Normally these types of sphincters keep the anus shut down except throughout the elimination of feces (Tortora & Derrickson, 2006). XII. PATHOPHYSIOLOGY NARRATIVE Appendicitis, infection of the vermiform appendix, is a frequent cause of serious abdominal pain.

It is the most usual reason for urgent abdominal surgical procedure, affecting 10% of the populace (Tierney et al., 2005). Appendicitis can happen at any grow older, but much more common in adolescents and young adults and slightly more prevalent in males than females (LeMone & Burke, 2007). The development of appendicitis usually uses a pattern that correlates with the clinical signs, though variations may occur as a result of altered location of the appendix or perhaps underlying elements (Gould & Dyer, 2011). Obstruction with the proximal lumen of the appendix is noticeable in most acutely inflamed bout.

The obstruction is often brought on by fecalith, or hard mass of feces. Other obstructive causes will include a calculus or stone, a foreign body, irritation, a tumor, parasites (e. g., pinworms), or edema of lymphoid tissue (LeMone & Burke, 2007). Subsequent obstruction, the appendix becomes distended with fluid released by its mucosa and microorganisms proliferate. Pressure in the lumen from the appendix improves, impairing the blood supply since blood vessels in the wall will be compressed hence the appendiceal wall turns into inflamed and purulent exudate forms.

Inside 24 to 36 hours, the raising congestion and pressure in the appendix contributes to ischemia and necrosis from the wall, causing increased permeability. Bacteria and toxins break free through the wall structure into the surrounding are. This breakout of bacteria causes abscess development or local peritonitis. An abscess may develop when the adjacent omentum temporarily surfaces off the inflamed area by adhering to the appendiceal area. In some cases, the inflammation and pain diminish temporarily however recur. Localized infection or peritonitis evolves around the appendix and may spread along the peritoneal membranes.

Elevating pressure in the appendix triggers increased necrosis and gangrene in the wall (infection in necrotic tissue). The wall of the appendix appears blackish. The appendix ruptures or perhaps perforates, publishing its articles into the peritoneal cavity. This leads to generalized peritonitis and will lead to septicemia and in septic impact and will result to death (Gould & Dyer, 2011). XIII. PATHOPHYSIOLOGY DIAGRAM Risk Elements Non-modifiable: * Age (Adolescents & small adults) 2. Gender (Male) Modifiable: 2. Fecalith 5. Calculus/Stone 5. Foreign physique * Inflammation * Tumor * Parasites Edema of lymphoid cells Obstruction with the appendiceal lumen Obstruction of the appendiceal lumen Buildup of fluid inside the appendix Build up of substance inside the appendix Proliferation of microorganisms Proliferation of organisms Abdominal soreness Abdominal soreness Increased pressure within the lumen of appendix Increased pressure within the lumen of appendix Compression of blood vessels Compression of bloodstream * Fever * Obturator Sign * Psoas Indication * Rovsing’s Sign 5. Rebound tenderness * Fever * Obturator Sign 5. Psoas Sign * Rovsing’s Sign * Rebound tenderness Decreased blood flow into the appendix

Decreased blood flow into the appendix Inflammation of appendiceal wall Inflammation of appendiceal wall (July twenty-one, 2012) Hematology Count * WBC count: 12. 6th K/mm 2. Neutrophils: 0. 90 Urinalysis * Openness: turbid (July 21, 2012) Hematology Count number * WBC count: doze. 6 K/mm * Neutrophils: 0. 90 Urinalysis 2. Transparency: turbid Ischemia & necrosis of the wall Ischemia & necrosis of the wall Increased permeability Increased permeability Bacteria and toxins get away through the wall structure Bacteria and toxins avoid through the wall structure Abscess formation/localized bacterial peritonitis

Abscess formation/localized bacterial peritonitis Proliferation of localized peritonitis around the appendix and peritoneal membranes Growth of localized peritonitis around the appendix and peritoneal membranes Increased pressure inside the appendix Increased pressure inside the appendix * Sudden, severe, general abdominal discomfort * Stomach distention & rigid “boardlike abdomen 2. Absence of intestinal sounds/(-) flatus/(-) BM (July 24, 2012) * Immediate, severe, general abdominal discomfort * Belly distention & rigid “boardlike abdomen 2. Absence of intestinal sounds/(-) flatus/(-) BM This summer 24, 2012) Increased necrosis and gangrene in the wall membrane Increased necrosis and gangrene in the wall structure Appendectomy with NGT lavage (July 22, 2012) Appendectomy with NGT lavage (July 22, 2012) Perforation of the appendix Perforation of the appendix Intestinal bacteria leak away into peritoneal cavity Intestinal bacteria flow out into peritoneal tooth cavity * Low-quality fever & leukocytosis * Tachycardia * Hypotension * Vomiting 5. Low-grade fever & leukocytosis * Tachycardia * Hypotension * Vomiting Generalized peritonitis Generalized peritonitis XIV. NURSING PROCESS

Issue #1: ABDOMINAL PAIN , July 24, 2012 * Subjective Cues: * “Nurse wait lang, ang sakit kasi parang nagcacramps,  patient verbalized while having a conversation with him. How can it seem like: Abdominal cramps Precipitating aspect: “Kapag nililinisan pero kadalasan bigla-bigla bist du lang sumasakit (“Whenever twisted cleaning is performed but frequently it just instantly happened) Relieving factor: Pain reliever (but not all the time pain reliever is being given) Does it radiate to the other parts of the human body (back, legs, chest, etc): No Duration of pain: “Paiba-iba din right.

Minsan sobrang tagal mga 2-3 moments, minsan naman mga ilang Segundo lang (“It is different, sometimes really too long (2-3 minutes) and often it just happened for a second) * Sufferer rated the pain since 8/10 exactly where 0 implies no discomfort and 15 signifies intolerable pain. 5. Objective Cues: * Cosmetic grimace * Guarding in the incision web page * Stiff (board-like) abdominal * Stomach distention * Location of pain: Operative site * RR: 25 bpm 5. Nursing Analysis Acute Discomfort related to swelling of the tissue secondary to post-op surgical incision.

Inflammation or nerve damage gives rise to changes in sensory processing for peripheral and central level with a resulting sensitization. Associated, prostaglandins are chemotactic chemicals drawing leukocytes to the swollen tissue. It plays a vasoactive position, it is also a pain and fever inducer (Lemone and Burkie, 2007). Acute Pain relevant to infection & inflammation with the peritoneal membranes secondary to peritonitis The peritoneum includes a large sterile expanse of highly vascular tissue that covers the viscera and lines of abdominal cavity.

This peritoneal framework provides a indicate of speedy dissemination of irritants or perhaps bacteria throughout the abdominal cavity. Abdominal distention is noticeable, and the normal rigid, board-like abdomen builds up as reflex abdominal muscles spasm takes place in response to involvement with the parietal peritoneum (Gould & Dyer, 2011). * Goal/NOC: Pain Control Outcomes Short-run: After 30 minutes of medical intervention the person will statement a decrease in pain via pain range of 8/10 to 4-5/10. Long Term:

Following 8 hours of medical intervention the person will show an understanding regarding the proper way of controlling discomfort as confirmed by proper splinting and deep breathing work out and will survey a reduce or most likely will be totally free of pain by pain size of 4-5/10 to 1-2/10. * NIC: Pain Managing Independent: 5. Assessed soreness including their character, site, severity, and duration. Both preoperatively and postoperatively, the client’s soreness provides essential clues regarding the prognosis and feasible complications.

Belly distention and acute inflammation contribute to the pain associated with peritonitis. Surgery additional disrupts stomach muscles and other damaged tissues, causing discomfort (LeMone & Burke, 2007). * Supervised vital indicators every two hours. Vital Indicators, especially breathing rate (RR), are usually changed in serious pain. (Sparks and Taylor, 2005). * Kept your customer at rest in semi-Fowler’s location. Gravity localizes inflammatory exudate into lower abdomen or pelvis, alleviating abdominal pressure, which is accentuated by supine position (Doenges et ‘s., 2006). * Provided diversional activities (texting, sound trip, etc).

Refocuses attention, encourages relaxation, and could enhance coping abilities and diverts focus from discomfort (Doenges et al., 2006). * Educated post-op health teaching (e. g., right splinting & deep breathing exercises). The use of noninvasive pain relief actions can raise the release of endorphins and enhance the beneficial effects of pain alleviation medications (LeMone & Burkie, 2007). * Encouraged early on ambulation. Stimulates normalization of organ function, stimulates peristalsis and transferring of flatus, reducing abs discomfort (Doenges, et ‘s., 2006). Provide hot and cold shrink. Hot, wet compresses have got a breaking through effect. The warm pushes blood for the affected location to promote treatment. Cold gaze may reduce total edema and promote some mind-numbing, thereby promoting comfort. (Doenges et ing., 2006). Based mostly: * Given analgesic since prescribed (TRAMADOL 50 mg/IV Q 8 x three or more doses) Time given: almost 8 AM. Post-operatively, analgesics are supplied to maintain enjoyment enhance flexibility (LeMone & Burke, 2007). * Maintained NPO. Lessens discomfort of early intestinal peristalsis and gastric irritation/vomiting (Doenges ain al. 2006). * Analysis Short Term: Target partially met. After thirty minutes of nursing jobs intervention the individual reported of the decrease in pain from a problem scale of 8/10 to 6/10 in which 4-5/10 was the expected final result. Long Term: Objective met. Following 8 hours of breastfeeding intervention the sufferer displayed control of pain while evidence simply by deep breathing exercise and right splinting. This individual also reported of a reduction in pain which has a pain size of 2/10 from 6/10. Pain reliever ” TRAMADOL was given snabel-a 8 am via 4. Problem #2: ABSENCE OF FLATUS” July 24, 2012 * Subjective Cues: “Nurse wait around lang, ang sakit kasi parang nagcacramps (referring to abdominal cramping),  individual verbalized with a discussion with him. * Discomfort scale of 8/10 * Objective Cues: * (-) Flatulence 5. (-) BM (Last BM was This summer 17, 2012) * Absence of bowel sounds upon prospection of all 4 quadrants * Nursing Diagnosis Dysfunctional stomach motility associated with inflammatory means of peritonitis secondary to absence of flatulence. The inflammatory process of peritonitis frequently draws huge amounts of smooth into the stomach cavity as well as the bowel.

In addition , peristaltic activity of the intestinal is slowed down or halted by the swelling, causing paralytic ileus, damaged propulsion of forward movement of intestinal contents (LeMone & Burke, 2007). 2. Goal/NOC: Ambulation Outcomes Temporary: After 8 hours of nursing treatment the client can report/experience flatus and will appreciate and show the need for early on ambulation next abdominal medical procedures. Long Term: Following 2 days of nursing involvement the client can report/experience either flatus or bowel activity or the two. * NIC: Impaction Managing, Positioning

Independent: * Examined abdomen which include all four quadrants noting character to determine increased or lowered in motility, Assessed for more abdominal tenderness & auscultated for any stomach sounds. To assist identify the cause of the modification and guidebook development of breastfeeding intervention (Sabol & Carlson, 2007). * Monitored and recorded (intake) and output every hour or 2 hours. Intake and output documents provide useful information about liquid volume position (LeMone & Burke, 2007). * Urged early ambulation.

Promotes normalization of appendage function, induces peristalsis and passing of flatus, minimizing abdominal distress (Doenges, et al., 2006). * Assisted in shifting from side to side or up in foundation from time to time. Frequent repositioning can be useful for proper oxygenation and usually helps prevent complications like pressure ulcers, deep line of thinking thrombosis, and so forth (Gulanick, ou. al., 1994). Dependent: 5. Administered antacid as ordered (RANITIDINE 50g/IV Q 12. Antacids either directly counteract acidity, raising thepH, or reversibly decrease or obstruct the secretion of acid by gastric cells to lower acidity in the stomach (Gabriely, et approach. 2008). * Evaluation Temporary: Goal somewhat met. After 8 hours of medical intervention the patient didn’t experience flatus or even bowel movement but was in a position to have an understanding with regards to early ambulation as confirmed by enabling his mother assist him in moving up in bed see the chair yet refused to walk because of complaint of experiencing a lot of contraptions attached to him which causes him to have difficulty in moving. Long Term: Aim met. Following 3 days of nursing input the patient reported of a flatus for three times.

Problem #3: RISK FOR DEHYDRATION ” Come july 1st 24, 2012 * Subjective Cue: 5. “Nanghihina bist du ako kasi limang araw ako hindi pwede kumain pati tubig bawal noise kaya nagnunuyo na yung labi ko,  as verbalized by the patient. * Objective Cues: * NPO for 5 days 2. Dry mucous membrane 5. Dry lips * Capillary refill= two seconds * Skin turgor= 3-5 secs * Urine output/shift= 480 mL 5. Urine color: Dark Discolored * Urine specific the law of gravity: 1 . 030 (Normal worth: 1 . 005-1. 030) * Absence of intestinal sounds of all of the four quadrants * (-) Flatus, (-) BM * BP: 120/80 mmHg * PP: 83 bpm 5. Nursing Prognosis

Risk for deficient fluid quantity related to postoperative restriction second to NPO for a few days Infection of the peritoneum with sequestration fluid and NPO status can lead to lacks and electrolyte imbalance (Doenges, et approach., 2008). 5. Goal/NOC: Knowledge: Treatment Routine, Hydration, Dental Hygiene, Tissue Integrity: Skin area & Mucous Membranes Outcomes Short Term: After 30 minutes of nursing treatment patient may have an understanding in relation to maintaining substance balance because evidenced by simply willingness of following the prescribed regimen given by the medical staffs. Long Term:

After several days of breastfeeding intervention the individual will be able to keep adequate substance balance because evidenced simply by moist mucous membrane, great skin turgor, stable vital signs, and individually enough urine outcome. * NIC: Fluid Supervision, Fluid Monitoring, Vital Symptoms Monitoring 3rd party: * Supervised BP & Pulse. Different versions help determine fluctuating intravascular volumes, or changes in essential signs linked to immune response to inflammation (Doenges, et ing., 2006). 5. Inspected mucous membranes, evaluated skin turgor and capillary refill. Indications of adequacy of peripheral circulation and cellular water balance (Doenges, ain al. 2006). * Supervised intake and output, known urine color/concentration, specific gravity. Decreasing urine output of concentrated urine with elevating specific gravity suggests dehydration/need for elevated fluids (Doenges, et al., 2006). * Auscultated bowel sounds. Known passing of flatus, bowel movement. Indicators of go back of peristalsis, readiness to start with oral absorption (Doenges, ainsi que al., 2006). * Provide clear fluids in a small amount when mouth intake is resumed, and progress diet is suffered. Reduces risk of gastric irritation/vomiting to minimize substance loss (Doenges, et ing. 2006). * Stressed the importance of having him on a NPO status and provided the necessary information in relation to his condition and the prescription drugs being implemented (e. g., IVF). It offers the patient a full understanding regarding his condition thus motivating him to participate and work hand in hand with the personnel (Gulanick, ainsi que al., 1994). * Offered frequent mouth care with special attention to protection of the lips. Dehydration results in blow drying and unpleasant cracking with the lips and mouth (Doenges, et ing., 2006). Reliant: * Taken care of gastric suction as indicated.

Although not regularly needed, a great NG conduit may be placed preoperatively and maintained in immediate postoperatively phase to decompress the bowel, encourage intestinal snooze, and prevent nausea (Doenges, ain al., 2006). * Used IV liquids (D5LR 1L x 8 or 30 gtts/min) and electrolytes (D5 Balanced Multiple Maintenance Solution w/ 5% dextrose 1L back button 8 or 30th gtts/min). The peritoneum reacts to irritation/infection simply by producing huge amounts of intestinal tract fluid, quite possibly reducing the circulating blood volume, leading to dehydration and relative electrolyte imbalances (Doenges, et approach., 2006). * Evaluation

Short-term: Goal attained. After thirty minutes of breastfeeding intervention the individual was able to have a full understanding with regards to maintaining fluid equilibrium as confirmed by verbalizing, “So kaya pala hindi pa ako pwede kumain ngaun para maiwasan mairritate ang tiyan ko.  Long Term: Aim met. Following 3 times of nursing intervention the patient surely could maintain enough fluid equilibrium as confirmed by moist mucous membrane, good epidermis turgor (1-2 seconds), secure vital indicators (please find page __ ), and adequate urine output of 620 cubic centimeters with a great appearance of amber yellow. Problem #4: RISK FOR CONTAMINATION , July 24, 2012 Subjective Cues: “Nurse, sobrang kailangan handbag talaga ang paghuhugas ng kamay bago linisan um hawakan sugat niya? , asked by mother. 5. Objective Cues: * Post-operative condition ” presence of surgical incision * Operative site is definitely warm to touch and reddened * Temp: thirty six. 3C 2. Nursing Medical diagnosis Risk for disease related to not enough primary defenses secondary to post-operative medical incision It can be risk to be invaded by simply pathogens particularly if surgical site is close to at the perineal area, pathogens can also develop by poor personal hygiene and poor wound cleaning (Doenges, ain al. 2006). * Goal/NOC: Risk Control (For Infection) Outcomes Temporary: After thirty minutes of medical intervention the person will be able to have got partial understanding about infection control and will verbalize understanding of and willingness to follow along with up prescribed regimen. Permanent: After a few days ofnursing interventionthepatient will probably be free of indication and indicator r/t illness. * NIC: Incision Site Care, Infection Control, Wound Care Independent: 2. Monitored essential signs. Mentioned onset of fever, chills, diaphoresis, changes in mentation, and reports of increasing abs pain.

Suggestive of presence of infection/developing sepsis, eschar, peritonitis (Doenges, et al., 2006). 2. Inspected incision and dressings. Noted attributes of drainage from wound/drains, presence of erythema. Provides for early diagnosis of growing infectious process, and/or watches resolution of preexisting peritonitis (Doenges, ainsi que al., 2006). * Instructed proper hand washing. Practiced aseptic injury care. Decreases risk for infection (Doenges, et al., 2006). * Motivated adequate health intake after the NPO position of the individual and when the sufferer is permitted to eat.

Satisfactory intake of proteins, Vitamin C and nutrients is essential to market tissue and wound recovery (Sparks and Taylor, 2005). Dependent: * Administered antibiotics (CEFUROXIME 750mg TID Queen 8 x 2 amounts & METRONIDAZOLE 500g/IV Q 8 back button 2 doses) as ordered. Therapeutic antibiotics are given in the event the appendix is definitely ruptured or abscessed or peritonitis has developed (Doenges, ou al., 2006). * Put together for/assist with incision and drainage (I&D) if mentioned. May be important to drain material of localized abscess (Doenges, et al., 2006). 5. Evaluation Short Term:

Goal achieved. After 30 minutes of medical intervention the person was able to understand about infection control as evidenced 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 em sa tuwing nililinisan ito makirot social fear pakiramdam.  Long Term: Target met. Following 3 times ofnursing interventionthepatient was clear of sign and symptom r/t infection. Problem #5: INABILITY TO PERFORM ACTIVITY/IES OF EVERYDAY LIVING (ADL) ” JULY twenty-four, 2012 * Subjective Tips: “Hirap talaga ako gumalaw, maglakadlakad, to kahit gentleman lang umupo dahil sa mga nakakabit na ito sa a bit like,  as verbalized by the patient. “Nakakapanghina pa kasi masakit nga yung tahi tapos madalas din nagcacramps ang tiyan ko,  he added. * Target Cues: 2. Presence of surgical incision * Presence of contraptions (urinary catheter, NGT lavage & IV fluid snabel-a left hand) * Nursing Diagnosis Damaged physical freedom related to physique weakness, existence of medical incision, pain, & presence of gadgets attached Physical immobility could be usually connected with post-operative circumstances (Gulanick, ain al. 1994). * Goal/NOC: Activity Patience Outcomes Short-term: After 30-45 minutes of nursing input the patient can have an obvious understanding with the use of identified methods to enhance activity tolerance and to apply it as well as evidenced simply by participating in RANGE OF MOTION exercises, leg & rearfoot exercise, ambulation, or even moving up in bed. Long-term: After 2-3 days of nursing intervention the sufferer will be able to constantly participate in a basic form of activity and will report an improvement with regards to his actions. * NIC: Exercise Remedy: Balance

3rd party: * Performed passive ROM exercises. ROM exercises and good human body mechanics improve abdominal muscles and flexors of spine (Gulanick, et approach., 1994). * Encouraged lower leg and ankle exercises. Examined for edema, erythema of lower extremities, and shaft pain or tenderness. These exercises activate venous returning, decrease venous stasis, and reduce risk of thrombus formation (Gulanick, et approach., 1994). * Noted psychological and behavioral responses to immobility. Offered diversional activities. Forced immobility may increase restlessness and irritability.

The Cardiovascular System

Diversional activity aids in refocusing interest and improves coping with actual and recognized limitations (Gulanick, et approach., 1994). 2. Assisted with activity, progressive ambulation, and therapeutic physical exercises. Activity will depend on individual scenario. It should commence as early as possible and generally progresses little by little, based on client tolerance (Gulanick, et ing., 1994). 2. Assisted in moving laterally or in bed from time to time. Frequent repositioning helps in right oxygenation and usually prevents difficulties like pressure ulcers, deep vein thrombosis, etc . Gulanick, et al., 1994). 5. Noted customer reports of weakness, exhaustion, pain and difficulty achieving tasks. Symptoms may be effect of/or bring about intolerance of activity (Gulanick, et ‘s., 1994). Centered: * Administered pain medicine (TRAMADOL 40 mg/IV Queen 8 x 3 doses, time given: 8 AM) as recommended and on a regular schedule. Client’s anticipation of pain can easily increase muscle tension. Medicines can help relax the client, boost comfort, and improve inspiration to increase activity (Gulanick, ainsi que al., 1994). * Analysis Short Term:

Target partially achieved. After 30-45 minutes of nursing involvement the patient surely could have a clear understanding with the aid of identified techniques to enhance activity tolerance and was able to use all of the methods except for the ambulation. This individual refused to walk because he complained of pain when the catheter tube graded at his thighs. Long Term: Goal partially fulfilled. After 2 – 3 days of breastfeeding intervention the person was able to continually participate in each of the identified approaches but still rejected to engage in ambulation.

He also reported of an improvement with regards to his activities while evidence by simply his verbalization, “Medyo natotolerate ko mhh rin yung mga actions kahit pautay-utay muna. Hindi ko lang talaga muna kaya maglakad pero pagnaalis na siguro yung catheter baka kayanin ko mhh.  XV. BIBLIOGRAPHY 5. Cosgrove CARRY OUT, Meire HB, Lim A, & Eckersley RJ. (2008). Grainger & Allisonn’s Diagnostic Radiology: A Textbook of Medical The image (5th edition). New York, NEW YORK: Churchill Livingstone * Doenges M., Moorhouse, M., Murr, A. (2006).

Nursing Attention Plans Rules for Individualizing Client Proper care across the Life time (7th Edition). F. A. Davis Organization, Philadelphia 2. Doenges, Meters., Moorhouse, Meters., Murr, A. (2006). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th Edition). Farrenheit. A. Davis Company, Philadelphia * Gabriely I, Leu, J. P., Barky, D. (2008). Clinical problem-solving, back in basics. New England Journal of Medicine 2. Gould, N., Dyer, L. (2011). Pathophysiology for the Health Professions (4th Edition). Saunders Elsevier Incorporation. * Gulanick, M. Klopp, A., Galanes, S., Gradishar, D., Puzas, M. (1994). Nursing Treatment Plans Medical Diagnosis and Intervention (3rd Edition). Mosby-Year Book, Inc. * LeMone P., Burke, K. (2007). Principles of Medical-Surgical Medical: Critical Pondering in Client Care (4th Edition). Pearson International Edition * LeMone P., Burke, K. (2008). Principles of Medical-Surgical Medical: Critical Considering in Client Care (5th Edition). Pearson International Edition * Mosby’s Pocket Book of Medicine, Nursing jobs, Allied Heath (4th Edition) 2002, Mosby Inc. Palma G., Oseda A. (2009). G, A Notes Specialized medical Pocket Guide for As well as Allied Health Professionals (2nd edition). G, A Notes Submitting Co., Israel * Sabol, V. T., Carlson, K. K. (2007). Diarrhea: Making use of research to bedside practice. AACN Advanced Critical Attention * Tortora G., Derrickson B. (2006). Principles of Anatomy and Physiology 11th edition. Natural Sciences Textbooks, Inc. 2. Weber T., Kelley M. (2007). Wellness Assessment in Nursing (3rd Edition). Lippincott Williams, Wilkins

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