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Acknowledgement

This case study report is prepared during Adult nursing clinical practicum in B&BHospital, Gwarko. The report is prepared as a practical fulfillment of post basic PB

curriculum. ! reali"ed that the re#uirement to do complete case study in the nursing areahas been an important opportunity for me to gain new e$perience and knowledge in thisfield.

! got myself complete in%ol%ed in the care and management of the patient duringthis period. Howe%er the work would not ha%e been accomplished successfully with myeffort alone.

! would like to e$press my sincere gratitude to all teachers of my colleges forpro%iding %aluable guidance, super%ision and suggestions in the clinical field area.

! am also thankful to my colleagues and my patient and his family who ga%e metheir %aluable time for pro%iding necessary information and kind cooperation duringhospitali"ation. ! am also thankful to doctors and nursing staffs of the hospitalthroughout the clinical practice without them the case would not ha%e been completed.

inally, ! would like to thank all of them who ga%e me their precious, %aluabletime and suggestions directly or indirectly while preparing this case study.

Background

epal is one of the de%eloping countries with the with many morbid surgicaldisease pre%alence.Acute appendicitis is the most common surgical emergencywhichseems to be most common in the second decade of life.the incidence of acuteappendicitis is '.()* in males and '.(+*in females with an o%eral life time risk of -'*.

.Acute appendicitis is the most common surgical emergency. /bstruction of the

lumen by fecolith is the usual cause of acute appendicitis.Though inspite of effecti%ecurati%e treatment ,if delayed in treatment it may lead to life threateningsituations.Thus, the study was to analy"e clinical presentation of acute appendicitis andits histopathological correlationis determined for the disease condition and itsmanagenent so as to diminish the disease pre%alence .


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According to post Basic ursing curriculum to function effecti%ely andindependently in the field at nursing care of adult re#uired to do 0 weeks of practical indifferent areas. 1uring the period, ! selected acute Appendicitis which is the mostcommon cause of adult disease conditions, in surgical ward of B&B Hospital. 2o this

case study was designed to gain and pro%ide comprehensi%e knowledge of AcuteAppendicitis and care to the patient.

Reason for case selectionThe general ob3ecti%es of the case study as suggested by the curriculum, is togain the comprehensi%e knowledge about the disease condition and to gain thepractical e$perience in adult nursing for pro%iding effecti%e nursing care.

! ha%e selected acut appendicitis as a case study because it is most commoncause of mordidity in adults4 nowdays. 5',''' per year, ), per month, (6,'7 perweek, (,56 per day, 77 per hour, ( per minute, is being suffered from appendicitis. !found this disease condition challenging and interesting so ! preferred this case to alertto related community at the right time then we can enhance our khnowledge about theappendicitis and reduces the incidence of morbidity and complications.ObjectivesGeneral objectives:

At the end of four weeks practicum we will be able to89 !dentify the disease condition pre%alent in the hospital9 Gain the knowledge about the disease condition and its comparati%e relation with the

patient.9 Pro%ide nursing care for the patient and family within the hospital by the application of

nursing process.9 Perform acti%ities to maintain and promote optimum health of the patient.9 Pro%ide health teaching and e%aluate total care study.

Specific objectives:9 To indentify the disease condition9 To take health history and record of finding and to physical e$amination.9 To formulate appropriate nursing diagnosis and nursing care plan according to the

nursing theory and priority the patients needs.9 To write nursing management to be performed during the patients hospitali"ation.9 To perform nursing acti%ities for reducing discomfort or pain of the patient.9 To indentify the needs of the patient.9 To conduct different health techni#ues according to the need and in the le%el of

understanding.


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9 To promote basic information to the patient and the family.

Part I

Biograpical data of m! patientame of Patient 8 :am Bahadhur Ghatri

Age 8 67 years

2e$ 8 ;ale

(

/perati%e Procedure 8 aproscopic Appendectomy

onsultant 1octor 8 1r.ira3 lal Baidya

1ate of discharge 8 '+>'6>()

"ealt istor! of patient

#ief complain:

9 Pain abdomen since days backCperi umbilical pain and later right side pain more thanleftD

9 ( episode of fe%er upto ('(E


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9 ( episode of %omitting

Present istor!:

Patient complaints of acute abdomen pain CgeneralisedD since e%ening a day back.Thepain was associated with an episode of fe%er and %omitting diminished by medicine lateron.ater on the pain persist on the right illac fossa of the patient so he was brought to thehospital for further management.

Socio$economic istor!:He belongs to a middle class family. He is the bussinessman and the bread owner of the family.Personal "istor!: He has no any history of allergy toward drugs and any foods. He isnon drinker and smoker.%edical surgical istor!: o history of tuberculosis, diabetes and hypertension .He

had not any infectious disease like HbsAg, H!F or 2T!.He has no any history of medical illness like T.B, asthma, renal disease, hypertension,heart disease etc.He was admitted at 3anamaitri hospital for ureteroscopy for T! Curinary tract infectionDfor a day ( year back.&amil! istor!: There was no significant history of chronic and hereditary diseasechronic illness.His mother was operated cholecystectomy for cholelithiasis almost ayear back."ealt seeking practice8 He belongs to the urban area of Iathmandu. Though, theybelie%ed in both traditional healer, dhami, 3hakri and hospital treatment. 2o if anybody inthe family gets ill they first go to the hospital first but also belie%e intraditional healers.

Personal ealt istor!:on smoker and on alcoholic. o any food taboos practicein his family>home. 2o he eats e%ery kind of food e%eryday.'nvironmental factors8 they li%e in urban setting in Iathmandu %alley with wellaccesibility of health facilities, education, water supply, and other facilities.6 storyed houses with7 rooms, separate kitchen and seperate sanitary laterine.

P!sical e(amination of te patient!t is an important tool of assessing the patient4s health status and about ()* of theinformation used in assessment comes from the physical e$amination.The methods that ! ha%e applied in the physical e$amination of the patient are8

9 ;easurement9 2melling9 !nspection9 Palpation


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9 Percussion9 Auscultation

)ital signTemperature8 ++E

Pulse8 +>min

:espiration8 '>min

Blood Pressure8 ('>5'

%easurement:Height8 ) ft 0 inches

?eight8 )kg

General Appearance:He can walk straight CgaitD. His general state of health is normal. He appears healthy,well nourished. His reaction is appropriate to the stimuli. Hygiene and cleanliness are

maintained.

"ead to toe e(amination:(. "ead and face8 :ound and symmetrical. ondition of the scalp is clean and color and

te$ture of hair is black and silky. Any in3ury is not present, no swelling, no tender shapeis round and face is in round shape.

. '!es: discharge absent, mo%ement-bilateral e#ual mo%ement, color of con3uncti%a-normal, pink, color of sclera- white, transpired, pupil- normal in si"e and good reactionto light and no any abnormality found.

6. 'ars: leanliness- clean, discharge- absent but slightly wa$ present, pain J not found,Hearing problem- no, lymph node are not palpable.

0. *ose:ocation-centrally located, de%iation- not de%iated septum, blockage- not found,and in3ury- not presents, bleeding- not present, polyps- not present and infections notpresent.

). %out+ troat and neck8 ips- no cracks, looks pink, gums- not swelling and bleedingpresent, buccal mucosa is pink in color, not any sore or rashes present, no missingteeth, Tongue- normal, moist, no sore present, ma$illary lymph node is not palpable,

cer%ical lymph node are not palpable, thyroid glands are not enlarged, eck is freelymo%able and tonsils is normal and not any redness or enlargement.

. #est and lungs8 2i"e, shape and symmetry are normal, chest mo%ement is bilaterale#ual, respiratory rate is normal, dysponea, cough, haemoptysis, cyanosis are absent,resonant sound found all o%er the lungs area and no any dull sound on percussion,


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whee"ing, crept sounds are absent, normal breathing sound is present on auscultationand no any abnormality found.

7. Abdominal e(amination:A, Inspection- normal o%al in shape

B, Palpation-slightly tenderness in the right illac fossa.Presence of reboundtenderness.#, Auscultation- /n auscultation normal bowel sound heard

5. #ardiovascular s!stem8 pulse-+>min, BP-('>5' mmofhg, heart sound is normalsound Club-dubD present on auscultation.

+. %usculoskeletal s!stem8 ;uscle weakness is absent, 3oint pain or stiffness is absent,edema on 3oints or ankles are absent and any other fracture or deformity is not found.

('. Genitourinar! s!stem8 o any discharge present.normal e$ternal genitalias.

-evelopment task of !oung adult

The young adult period is started from ages of ( to 6+. By the age of (yrs, physicalgrowth is nearly complete. The young adult period is %ery important and precious forand indi%idual. This is the time to grasp new things to adopt in the society, to de%elopself confidence, to ha%e a sense of mastery anal self control o%er life e%ents and

surroundings.Koung adult is one of the most stable period of life which in%ol%es intellectual growth,becoming more knowledge, depth in analytic and systemic thinking, logical seasoning,there may be a transient #uality of the occupational choices and relationship which arebeing established at this time. The following are the de%elopmental task of young adults8

aD Accepting self establishment, self concept and body image.bD They establish personal set of %aluescD Becoming independent from parental controldD Becoming establishment in a %ocational or professional that pro%ides personal

satisfaction, economic independency and feeling of making a worth which contributingto society.

eD 1e%elop a sense of personal identityfD earning appraises and empress li%es, responsibilities through more than se$ual

contact.gD


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kD


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6. Appendectomies are the most common emergency surgical proceduresperformed

0. !t is unusual in third world countries and there is a #uestionable relationship tohigh fiber diets.

Risk factorsL Age:it can occur in all age groups common between the ages of (( and '.L Gender:A male preponderance e$ists, with a male to female ratio C012: 0D and the

o%erall lifetime risk is 5.* for males and .7* for females. A male child suffering fromcystic fibrosis is at a higher risk for de%eloping appendicitis.

L -iet:People whose diet is low in fiber and rich in refined carbohydrates ha%e anincreased risk of getting appendicitis.

L "ereditar!:A particular position of the appendi$, which predisposes it to infection,runs in certain families. Ha%ing a family history of appendicitis may increase a childMsrisk for the illness.

L Seasonal variation:;ost cases of appendicitis occur in the winter months -

between the months of /ctober and ;ay.L Infections:Gastrointestinal infections such as Amebiasis, Bacterial Gastroenteritis,

;umps, o$sackie%irus B and Adeno%irus can predispose an indi%idual to Appendicitis.

Patop!siolog!:

!f appendiceal obstruction persists, intraluminal pressure rises ultimately abo%e that ofthe appendiceal %eins, leading to %enous outflow obstruction. As a conse#uence,appendiceal wall ischemia begins, resulting in a loss of epithelial integrity and allowingbacterial in%asion of the appendiceal wall.

?ithin a few hours, this locali"ed condition may worsen because of thrombosis of the

appendicular artery and %eins, leading to perforation and gangrene of the appendi$. Asthis process continues, a periappendicular abscess or peritonitismay occur.

Appendicitis means inflammation of the appendi$. !t is thought that appendicitis begins

when the opening from the appendi$ into the cecum becomes blocked. The blockage

may be due to a build-up of thick mucus within the appendi$ or to stool that enters the

appendi$ from the cecum. The mucus or stool hardens, becomes rock-like, and blocks

the opening. This rock is called a fecalith Cliterally, a rock of stoolD. At other times, it

might be that the lymphatic tissuein the appendi$ swells and blocks the opening. After

the blockage occurs, bacteria which normally are found within the appendi$ begin to

in%ade CinfectD the wall of the appendi$. The body responds to the in%asion by mounting

an attack on the bacteria, an attack called inflammation. An alternati%e theory for thecause of appendicitis is an initial rupture of the appendi$ followed by spread of bacteria

outside of the appendi$. The cause of such a rupture is unclear, but it may relate to

changes that occur in the lymphatic tissue, for e$ample, inflammation, that lines the wall

of the appendi$.D

!f the inflammation and infection spread through the wall of the appendi$, the appendi$

can rupture. After rupture, infection can spread throughout the abdomen howe%er, it
http://emedicine.medscape.com/article/1952823-overviewhttp://www.medicinenet.com/script/main/art.asp?articlekey=10347http://www.medicinenet.com/script/main/art.asp?articlekey=10347http://emedicine.medscape.com/article/1952823-overview


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usually is confined to a small area surrounding the appendi$ Cforming a peri-

appendiceal abscessD.

#linical Presentation

The main symptom of appendicitis is abdominal pain. Pain in the right side of the

abdomen. usually begins near the na%el and mo%es down and to the right. The pain

becomes worse when mo%ing, taking deep breaths, coughing, snee"ing, and being

touched in the area.

/ther symptoms of appendicitis may include

loss of appetite

nausea,%omiting

constipation or diarrhea

inability to pass gas

a low-grade fe%er that follows other symptoms

abdominal swelling

!n my patient8L abdomen pain was presentL anore$ia and %omiting presentL low grade fe%er a day back

-iagnosisThe most cases of appendicitis are diagnosed by taking a personMs medical history andperforming a physical e$amination. !f a person shows classic symptoms, surgery isdone right away to remo%e the appendi$ before it bursts. The other laboratory and

imaging testsis also done to confirm appendicitis if a person does not ha%e classicsymptoms. Tests may also help diagnose appendicitis in people who cannot ade#uatelydescribe their symptoms, such as children or the mentally impaired.Physical findings(. There is often diffuse abdominal tenderness.

. There may be slight abdominal distention with initially increased and thendecreased bowel sounds.

6. Point tenderness at ;cBurneyMs point which lies half-way between a lines drawnfrom the umbilicus to the anterior iliac spine.

0. :ebound tenderness

). :ectal e$am- %alue is #uestionable and should be done if suspect perforationand abscess.

. Psoas sign- pain on fle$ion of the hip and /bturator sign which is increased painon internal rotation of fle$ed thigh.

7. heck genitalia for possible incarcerated hernia or testicular pathology.

aboratory


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(. B may demonstrate an increased ?B count and :B morphology should bechecked

. rinalysis may ha%e increased white cells!maging 2tudies

(. Plain film of abdomen may show fecalith, ileus pattern, e%idence of constipation, or

pneumonia.. Barium enema will show absence of filling of the appendi$6. ltrasound and T ha%e been useful in certain situations.

Investigation done in m! patient:

Investigation item findings normal range '+>'6>((?B (',7''>cu mm C0,'''-((,'''Deutrophils 7)* C0'-7)*D

ymphocytes (* C'-0)*D;onocytes '(* C-('*DHr C(-DHb (0gm* C(6.)-(7.)D:B 0.77 C).)-.)DPF 0(* C((.)'-)'.0'D;F 5.' fl C5'.'-+D;H +.0pg C7.)-66.'D;H 60.(* C6-6*DPlatelets 0(,'''>cumm C()','''-0'','''D

Blood group / N%eBlood sugarC:andomD 76mg>dl C7'-(0' mg>dlDreatinine '.76mg>dl C'.-(.) mg>dlD :!<


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HbsAg on J:eacti%eAnti HF on-:eacti%e3ltrasonograp! :i%er 8normalGall Bladder8ormal

B18 ot dilatedPancreas8ormal2pleen8ormalIidney8ormalBilateral kidney8ormal4 suggestivel! %ildl! inflammed appendi(

5reatment and management

5reatments for Acute Appendicitis:

!f acute appendicitis is diagnosed and treated promptly before the appendi$ ruptures,

the outcome is generally %ery good. The treatment includes may include both surgical

and non surgical inter%entions.

2urgery8

2urgery to remo%e the appendi$ is called appendectomy and can be done two ways.The older method, called laparotomy, remo%es the appendi$ through a single incision inthe lower right area of the abdomen. The newer method, called laparoscopic surgery,uses se%eral smaller incisions and special surgical tools fed through the incisions to

remo%e the appendi$. aparoscopic surgery leads to fewer complications, such ashospital-related infections, and has a shorter reco%ery time.

;r.ghatri was undergone laproscopic Appendectomy for surgical treatment ofAppendicitis.

2urgery occasionally re%eals a normal appendi$. !n such cases, many surgeons willremo%e the healthy appendi$ to eliminate the future possibility of appendicitis./ccasionally, surgery re%eals a different problem, which may also be corrected duringsurgery.

2ometimes an abscess forms around a burst appendi$called an appendicealabscess. An abscess is a pus-filled mass that results from the bodyMs attempt to keep aninfection from spreading. An abscess may be addressed during surgery or, morecommonly, drained before surgery. To drain an abscess, a tube is placed in the abscessthrough the abdominal wall. T is used to help find the abscess. The drainage tube isleft in place for about weeks while antibiotics are gi%en to treat infection. 2i$ to 5weeks later, when infection and inflammation are under control, surgery is performed toremo%e what remains of the burst appendi$.


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onsurgical Treatment8onsurgical treatment may be used if surgery is not a%ailable, if a person is not wellenough to undergo surgery, or if the diagnosis is unclear. 2ome research suggests thatappendicitis can get better without surgery. onsurgical treatment includes analgesics

to relie%e pain and antibiotics to treat infection and a li#uid or soft diet until the infectionsubsides. A soft diet is low in fiber and easily breaks down in the gastrointestinal tract.

*ursing management:

*ursing AssessmentThe identity of the client

(. History of ursing

urrent medical history complaints of pain in postoperati%e wound

appendectomy, nausea, %omiting, increased body temperature, increased

leukocytes.

Past medical history

. Physical


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. :isk for deficient fluid %olume related to preoperati%e %omiting.

6. An$iety related to change in health status.

Postoperative Appendectom!

(. Acute pain related to the presence of postoperati%e wound appendectomy.

. !mpaired nutrition less than body re#uirements related to reduced anore$ia, nausea.

6. :isk for infection related to surgical incision.

0. 1eficient knowledge8 about the care and diseases related to lack of information.

*ursing Interventions

(. Preparation of general surgery

this can be done by the nurse when the client entered the operatingroom nurse beforesurgery8!ntroducing the client and close relati%es of hospital facilities to reduce the an$iety ofclients and their relati%es Cthe orientation of the en%ironmentD.

;easuring %ital signs.

;easure weight and height.

ollaboration is an important laboratory tests Chematocrit, serum glucose,

rinalisaD.

The inter%iew.

. Preoperati%e !nter%entions/bser%ation of %ital signs

Assess fluid intake and output

Auscultation of bowel sounds

Assess the status of pain8 the scale, location, characteristics

Teach rela$ation techni#ues

Gi%e fluids inter%ena


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/bser%ation of %ital signs

Assess the scale of pain8 characteristics, scale, location

Assess the state of the wound

Ad%ice to change position as tilted to the right, left and sat down.

Assess nutritional status

Auscultation of bowel sounds

Gi%e wound care information and disease

'valuation

(. !mpaired sense of comfort8 pain is resol%ed

. o infection

6. /%ercome nutritional deficiencies

0. The client understands about care and illness). ?eight loss does not occur

. Fital signs within normal limits

#omplications(. ?ound infection. !ntra-abdominal abscess- occurs in 0-* of perforations6. !ntestinal obstruction0. !ncreased incidence of infertility in females who ha%e had a perforation of the

appendi$ secondary to fallopian tube obstruction and adhesions). Appendi$ rupture

. Peritonitis7. 1eath

Impact on ospitali6ation on developmental needs and tasks:;r .Ghatri,a young man was admitted with the diagnosis acute appendicitis.!nitially heseems to be slight an$ious about his disease condition and the pain.Though he re#uiresassistance for counselling for the condition of hospital admissionand his diseasecondition and action being carried out. 2o he needs help in his e%ery steps, like nursingcare.

Part IIIAppl!ing )'RGI*IA "'*-'RSO*S 5"'OR7Application of nursing teor!8 my patient ;r.Ghatri, 67 years male was admitted witha diagnosis of Acute appendicitis. !n surgical ward to make her comfort and to reduce


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the an$iety,! ha%e applied %erginiaHenderson4s nursing theory to her according to hermain focus of theory is8

(. !ndependency of client. Assist indi%idual towards self care needs of the indi%idual and this is affected by9 Age8 de%elopment theory- newborn baby, child, adolescent, young adult, middle age and

old age.9 Background- cultural, family, friends status9


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of the a%ailable health facilities.

5e implement tese nursing diagnosis+ I ave made a nursing care plan1

Preoperative nursing care planS*

*ursingdiagnosis

*ursing goal *ursingintervention

Rationale evaluation

(. :isk for deficientfluid %olumerelated topreoperati%e %omiting.

The client will8;aintainade#uate fluidbalance ase%idenced bymoist mucousmembranes,good skin turgor,

stable %ital signs,and indi%iduallyade#uate urinaryoutput.

-Assess fluidandelectrolyteoutput;onitorbloodpressureCBPD and

pulse.

-inspectmucousmembranesassess skinturgor andcapillaryrefill.

- ;onitor intake andoutput C!&/Dnote urinecolor andconcentrationand specificgra%ity.

-auscultate

bowelsounds. otepassing offlatus andbowelmo%ement.

Fariations helpidentify fluctuatingintra%ascular%olumes or changesin %ital signsassociated withimmune response toinflammation.

- !ndicators of ade#uacy of peripheral circulationand cellular hydration.

- ;onitor intake andoutput C!&/D noteurine color andconcentration and

specific gra%ity.

-!ndicators of returnof peristalsis andreadiness to beginoral intake. ote8This may not occur inthe hospital if clienthas had alaparoscopicprocedure and been

discharged in lessthan 0 hours.

-:educes risk ofgastric irritation and%omiting to minimi"efluid loss.

;y goalwas metthe riskfor fluiddeficitwasminimi"ed.


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-Pro%ide

clear li#uidsin smallamountswhen oralintake isresumed,and progressdiet astolerate

. Acute pain

related todistention oftheintestinaltissue byinflammation.

:eportpain is

relie%ed>controlled.- Appear rela$ed,able to sleep>restappropriately.

-assess the

status of pain8thestate,location andcharacteristics

-Pro%ideaccurate,honestinformationto patient

-Administeranalgesicsas indicated.

-seful in monitoring

effecti%eness ofmedication, progression of healing.hanges incharacteristics ofpain may indicatede%elopingabscess>peritonitis,re#uiring promptmedical e%aluationand inter%ention.

-Being informedabout progress ofsituation pro%idesemotional support,helping to decreasean$iety

-:elief of painfacilitates

cooperation withother therapeuticinter%entions, e.g.,ambulation,pulmonary toilet

;y goal

waspartiallymet.thepatientwas #uietrelie%edby thetherapybut notcontrolled.


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-Pro%idedi%ersional

acti%ities

-IeepP/>maintain G suctioninitially.

-:efocuses attention,promotes rela$ation,and may enhancecoping abilities.

-1ecreasesdiscomfort of earlyintestinal peristalsisand gastricirritation>%omiting.

6. An$ietyrelated tochange inhealthstatus.

To relie%ean$iety

-e$amine thele%el of an$iety

-Gi%einformationabout thediseaseprocess and

actions

-:eassurethe client

--


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( . Acute painrelated tothepresence ofpostoperati%

e woundappendectomy

-:eportPain isrelie%ed>controlled.- Appear

rela$ed, ableto sleep>restappropriately.

-assess thestatus of pain8the state,location andcharacteristics

-Ieep at rest insemi-owler4sposition.

-peritonitis,re#uiring promptmedical e%aluationand inter%ention.

-Gra%ity locali"esinflammatory e$udateinto lower abdomen

or pel%is,

-Promotesnormali"ation oforgan function, e.g.,stimulates peristalsisand passing of flatus,reducingabdominal discomfort.

-:elief of painfacilitates cooperationwith other therapeuticinter%entions, e.g.,ambulation,pulmonary toilet

;y goalwas metthe painwasrelie%ed.

!mpairednutritionless thanbody

re#uirements related toreducedanore$ia,nausea

lient ?illmaintainnutritionalbalance

-gi%e fluidinter%entions

-?eigh thebody weighte%ery daymonitor theresults of laboratorye$amination.

-fluid replaces thebody nutritionalre#uirement

-indicators of ade#uacyn of nutritional intake

-facilitates to eateasily

;y goalwasmet.theappetite of

the patientslowlyestablished.


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-Planmaintenanceproceduresha%e anunpleasant or

painful not donebefore eating.

-/ffer to eatsmall portionsbut fre#uently toreduce feelingsof tension in thestomach

-:educes risk of gastric irritation and%omiting to minimi"efluid loss

6 :isk for infectionrelated tosurgicalincision.

lient ?ill?oundHealing8Primary!ntention

Achie%etimely woundhealing, freeof signsof infection and

inflammation,purulentdrainage,erythema,and fe%er.

-/bser%ation ofthe %ital signs

-Practice andinstruct in goodhand-washingand asepticwound care.

-


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drainagespecimens, ifindicated.

-Administer antibiotics, asappropriate.

wound infection andare not usuallycontinuedpostoperati%ely.

-Therapeutic antibioticsare administered ifthe appendi$ isruptured or abscessed, or peritonitis hasde%eloped.

0 1eficientknowledge8about thecare and

diseasesrelated tolack of information

Ferbali"eunderstanding of diseaseprocess and

potentialcomplications.

Ferbali"eunderstanding oftherapeuticneeds.Participate intreatment

regimen.

-stoolsofteners asnecessary and

a%oidance ofenemas.

-1iscuss care ofincision,includingdressingchanges,bathingrestrictions, andreturn to

physician forsuture>stapleremo%al. .

-Pre%ents fatigue,promotes healing andfeeling of well-being,and facilitates

resumption of normalacti%ities.

- Assists with returnto usual bowelfunction pre%entsundue straining fordefecation.

-nderstanding

promotes cooperationwith therapeuticregimen, enhancinghealing and reco%eryprocess

;y goalwasmet.thelient was

able to%erbali"etheunderstanding aboutthediseaseconditionand thetreatment.

-ail! progress and management of m! case1ate8 '+>6>((


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;r.:am Bahadur Ghatri was admitted to the surgical ward.His general condition eRwas#uite weak and he was complaining of abdomen pain and mild fe%er.Fitals8Temperature8 ++degree ahrenheitBP8 ('>5'

:espiration8 '>minutePulse8 +>min/n physical e$amination8ormal physi#ue e$cept abdominal tenderness.;anagement8-Analgesices gi%en.-All the in%estigations done-patient well e$plained for the operati%e procedure tommorrow.-Preanasthetic check up done

;edications8

Tab.fle$on ( tab p>o 2/2

1ate8 '+>6>(;r.:am Bahadur Ghatri was prepared for operation.Pre operati%e Fital signs8Temperature8 +7.6degree ahrenheitBP8 (('>5':espiration8 0>minutePulse8 5>min

/n physical e$amination8ormal physi#ue e$cept abdominal tenderness.;anagement8-preoperati%e counselling-P/ from midnight/perati%e procedure Claporatomy appendectomy under general anaesthesiaD8Patient was kept in supine position.painting and drapping done.(' mm umbilical portmade and pneumoperitoneum created.Another (' mm created on left illac fossa alongleft ;

And ) mm port at supra pubic region.Appendicular base traced along the confluence ofthe tenia cli,below findings noted,peri appendicular artery clipped out withharmonic,appendicular base ligated with endolope.Haemostasis maintained and allports were closedindings8;ildly inflammed appendi$, especially at the tip.o peri appendicular collectionsadhension of ascending colon o%er right side of abdomen.The specimen was sent for Histopathological e$amination.

Post operati%e Fital signs8


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Temperature8 ++degree ahrenheitBP8 ('>5':espiration8 >minutePulse8 5>min2aturation8 +0* with out o$ygen

;edications8 ! pint in3ection :inger actate !n3ection ceftria$one ( gm !>F statTotal intake upto ( ;8 '' mlTotal output upto ( ;8 (6)' ml/n physical e$amination8o any soakage from the incision site.oley4s catheter present.;anagement8-Analgesices gi%en.-rest encouraged-patient well e$plained for the post operati%e complications and early ambulation.

;edications8!n3 12 !!!n3.)* de$trose i!n3 cifran '' mg B1!n3 :aciper 0' mg B1!n3 ketorolac 6' mg T12

'+>6>(6Patient general condition was #uite impro%ing.1rip off and oley4s out was

done.5':espiration8 0>minutePulse8 >min2aturation8 +* with out o$ygenTotal intake upto ( ;8 (5'' mlTotal output upto ( ;8 +' ml/n physical e$amination8o any soakage from the incision site.;anagement8-medicines gi%en as prescribed.-ambulation done-patient well %entilated to e$press his an$iety of the state and e$plained about thedisease condition.

;edications8Tab.cifran )'' mg P>/ B1


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Tab. :aciper 0' mg P>/ B1Tab. le$on ( tab P>/ 2/2

1ate8 '+>6>(0Patient general condition was #uite impro%ing.1rip off and oley4s out wasdone.minutePulse8 5>min2aturation8 ++* with out o$ygen/n physical e$amination8o any soakage from the incision site.

;anagement8-medicines gi%en as prescribed.-ambulation done-patient well %entilated to e$press his an$iety of the state and e$plained about thedisease condition.

;edications8Tab.cifran )'' mg P>/ B1Tab. :aciper 0' mg P>/ B1Tab. le$on ( tab P>/ 2/2

1ate8 '+>6>()Cdischarge dateDPatient general condition was #uite impro%ed.he was well adapted to his state.He wason normal diet, #uiet independent to achie%e his personal acti%ities.dressing was doneand discharge was done with the discharge instructions.

Stress management and diversion terap! 2tress is a state produced by change in en%ironment. !t is a factor whichpressuri"e mentally or physically and ad%ersely affects the functioning of body. ?henstresses more sense or prolonged, a person needs di%isional therapy or copingmechanism. !t is a change in the en%ironment that is percei%ed as a threat, challenge or harmto the person4s dynamic e#uilibrium.


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psychologically feels strange, conflicting and frightening isolated and lo%ely in spite ofmany people around.5e following understandable site effects ma! be seen:

9 orced dependency9 2trange authority figures

9 1ramatic change in physical en%ironment9 1isturbed daily routines9 !ncreased an$iety9 orced ad3ustment9 oss of pri%acy and freedom

ndergoing any surgery is like a crisis for any indi%idual.;r.Ghatri seems to becurious about his disease condition, operati%e procedure, and its management.5o minimi6e te stress of patient I provided te following activities:

9 Pro%ide psychological support showing another patient of appendectomy.9


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Indications:These intra%enous solutions are indicated for use in adults and pediatric patients assources of electrolytes, calories and water for hydration.#ontraindications:These solutions are contraindicated where the administration of sodium or chloride

could be clinically detrimental.2olutions containing de$trose may be contraindicated in patients with hypersensiti%ity tocorn products.Adverse effects:eactions which may occur because of the solution or the techni#ue of administrationinclude febrile response, infection at the site of in3ection, %enous thrombosis or phlebitise$tending from the site of in3ection, e$tra%asation and hyper%olemia.Too rapid infusion of hypertonic solutions may cause local pain and %enous irritation.:ate of administration should be ad3usted according to tolerance. se of the largestperipheral %ein and a small bore needle is recommended.

*ursing considerationheck for leaks by s#uee"ing container firmly. !f leaks are found, discard unit as sterilitymay be impaired. !f supplemental medication is desired, follow directions below beforepreparing for administration.5o Add %edication83se aseptic tecni9ue,(. :emo%e blue cap from sterile medication additi%e port at bottom of container.. ?ith a needle of appropriate length, puncture resealable additi%e port andin3ect. ?ithdraw needle after in3ecting medication.6. ;i$ container contents thoroughly.0. The additi%e port may be protected by an appropriate co%er.Preparation for Administration83se aseptic tecni9ue,*O5':2ee appropriate !.F. administration set !nstructions for se.(. lose flow control clamp of administration set.. :emo%e cap from sterile administration set port at bottom of container.6. !nsert piercing pin of administration set into port with a twisting motion until thepin is firmly seated.0. 2uspend container.). 2#uee"e and release drip chamber to establish proper fluid le%el in chamber.. /pen clamp.


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Injection ;de(trose)* 1e$trose !n3ection, 2P solution is sterile and nonpyrogenic. !t is a parenteralsolution containing de$trose in water for in3ection intended for intra%enousadministration.Group:intra%enous fluid and electrolyte infusion.

Indication:!ntra%enous solutions containing de$trose are indicated for parenteralreplenishment of fluid and minimal carbohydrate calories as re#uired by the clinicalcondition of the patient.

Adverse effects:eactions which may occur because of the solution or the techni#ue of administrationinclude febrile response, infection at the site of in3ection, %enous thrombosis or phlebitise$tending from the site of in3ection, e$tra%asation and hyper%olemia.!f an ad%erse reaction does occur, discontinue the infusion, e%aluate the patient,institute appropriate therapeutic countermeasures and sa%e the remainder of the fluidfor e$amination if deemed necessary.

Precautions:L Geriatric seL Pediatric seL arcinogenesis, ;utagenesis, !mpairment of ertility8L PregnancyCTeratogenic effectsD

*ursing considerationheck for leaks by s#uee"ing container firmly. !f leaks are found, discard unit as sterilitymay be impaired. !f supplemental medication is desired, follow directions below beforepreparing for administration.5o Add %edication83se aseptic tecni9ue,

(. :emo%e blue cap from sterile medication additi%e port at bottom of container.. ?ith a needle of appropriate length, puncture resealable additi%e port andin3ect. ?ithdraw needle after in3ecting medication.6. ;i$ container contents thoroughly.0. The additi%e port may be protected by an appropriate co%er.Preparation for Administration83se aseptic tecni9ue,*O5':2ee appropriate !.F. administration set !nstructions for se.(. lose flow control clamp of administration set.. :emo%e cap from sterile administration set port at bottom of container.6. !nsert piercing pin of administration set into port with a twisting motion until thepin is firmly seated.0. 2uspend container.). 2#uee"e and release drip chamber to establish proper fluid le%el in chamber.. /pen clamp.


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((. ;aintain drop pre minute(. ?atch for any side effects.Injection Ringer


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%ecanism:-inhibits bacterial cell wall synthesis

3ses:Gram positi%e infections resistant to

-septicemia

-T! by gram negati%e bacteria-Typhoid Prophyla$is-;eningitis caused by H.influen"a- 2urgical prophyla$is

-ose:-(- gram ( hourly !>F

Side effect:

- Pain and thrombhophlebitis on in3ection site, Anaphyla$is, 2kin rashes, fe%erdiarrhoea, li%er and kidney damage Cnephroto$icityD, neutropenia, and thrombhophlebitis

#ontra$indication:-hypersenti%ity.

*ursing managementL Properly dissol%e the solute by shaking the %ial wellL or !>F in3ection,the solution should be ade#uatedly dilutedL 1on4t in3ect more than ( gram into single !>; site to pre%ent pain and tissue reactionL :econstituted solution is stable for 0 hours at room temperature under refrigaration

thereafter it should be discarded.L ontinue taking medicine for the full course of treatment

5ab1&le(onGroup8!buprofen8onsteroidal anti-inflammatory drug C2A!1DParacetamol or acetaminophen 8o%er-the-counter analgesic and antipyretic%ecanism:

- blocks prostaglandin synthesis, inhibits platelet aggregation, and prolongsbleeding time, but does not affect prothrombin or whole blood clotting times.3ses:

--fe%er-pain

-ose:&


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#ontra$indication:- urticaria, se%ere rhinitis, bronchospasm, angioedema, nasal polyps are

precipitated by aspirinor other 2A!1s acti%e peptic ulcer, bleeding abnormalities.sewith caution in patients with hypertension, history of G! ulceration, impaired hepatic orrenal function, chronic renalfailure, cardiac decompensation

*ursing managementL Gi%e on an empty stomach, ( hr before or hr after meals.L !f G! intolerance occurs, ibuprofen may be taken with mealsor milk.L Tablet may be crushed if patient is unable to swallow it whole and mi$ed with food or

li#uid before swallowing.L Patients with history of cardiac decompensation should be obser%ed closely for

e%idence of fluid retention and edema.L ;onitor for G! distress and signs of G! bleeding.L 2ymptoms of acute to$icity in children are apnea, cyanosis,

Injection>5ab cifranGroup8 antibacterial%ecanism:

-inhibits bacterial 1A gyrase3ses:

-enteric fe%er-septicemia-prophyla$is Cpost operati%elyD

-ose:-''mg !>F B1-)'mg orally B1

Side effect:- ausea, %omitting, diarrhoea, 3oint pain, headache, di""iness, %ertigo, 3aundice,

renal failure.#ontra$indication:

-hypersenti%ity.

*ursing managementL !nstruct well that not to chew the medicine before swallowing.This medicine may be

taken on an empty stomach or with food.1rink plenty of water or other fluidsL !nstruct well that not to continue the medicine taking medicine for the full course of

treatment

Injection>5ab RaciperGroup8 'somepra6ole magnesium+ tri!drateCa deri%ati%e of


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- blocks the production of acid by the stomach.

3ses:

- Gastroesophageal reflu$ disease CG


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D. As a result, pain as well as inflammation and its signs and symptoms - redness,swelling, fe%er, and pain - are reduced.

3ses:-2hort-term management Cup to ) daysD of moderately se%ere acute pain

-ose:Adult8 /ral- ;oderate to se%ere pain (' mg 0- hourly. ;a$8 0' mg>day. ;a$ duration8 7days.!F>!; -;oderate to se%ere pain ' mg %ia !; in3ection or 6' mg %ia !F in3ection./cular itching- As '.)* solution8 !nstill ( drop 0 times>day. Post-operati%e eyeinflammation as '.)* solution8 !nstill ( drop 0 times>day for weeks, starting 0 hoursafter surgery for weeks.

Side effect: $:ash,

-ringing in the ears,-headaches,- 1i""iness,-drowsiness,-Abdominal pain,- ausea,-diarrhea,-constipation,- Heartburn,- luid retention.-reduce the ability of blood to clot and therefore increase bleeding after an in3ury

Ccause ulcers and bleeding in the stomach and intestinesD#ontra$indication:

-allergic to aspirin or other 2A!1s,-gastrointestinal bleeding,- Iidney or li%er disease,-asthma,- 1ehydration,- Pregnancy,- actation.-postoperati%ely to patients with high risk of bleeding.

*ursing managementL !t comes as a tablet to be taken by mouth. !t is usually taken e%ery 0 to hours on a

schedule or as needed for pain.L !t also comes as eye drops to instill into the affected eyes, as directed by your

physician.


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L Special Instruction to te patient tat:it make drowsy or di""y. 2o a%oid to dri%e a car or operate machinery

L 1o not drink alcohol while taking this medication.aution should be e$ercised in patients with history of heart failure, predisposition toreduced blood %olume or kidney blood flow might lead to mild kidney disease monitor

kidney function closely, elderly, weight abo%e )' kg, li%er dysfunction.

"ealt education to patient and visitors Health education and maintenance are important since health status is goodindicator of the one4s ability to adapt to rapid changes. Health education to ;r. Ghatriwas %ery important because she was post operati%e patient. He was discharge on'+>'6>(). 1uring discharge ! had gi%en health on following topics.*utritious diet:1iet is %ery impotant for the post operati%e patient.He was encourage to intake the soft

to normal diet with high fibre diet to reduce constipation which might be due to beingbedridden.

initial cp

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