[right]CASE STUDY
Medical Diagnosis: Appendicitis Allergy: non
Temp: 37 ْ C Pulse: 80 beat\minute BP: 110 / 70 mmgh RR: 19 rate\minute
Past History (Reason for admission):
A 27 year old male patient, complain of sever pain (7/10 on pain scale) from 4 days, like needle stick begin in the right lower quadrant and after one day radiation to left quadrant and then he return to right quadrant and the pain # with movement and after eating and with$ sleeping in the last day after one day the patient received admission to hospital and submit to appendicitis physical examination (the results: +ev Rebound and Rovsing's sign and the WBC result above normal rang -12000-) after that he was entered to surgical room and make appendectomy in 7-12-2005.
Hospitalize history
For rheumatism after 10 years
Family history
Free from any disease as diabetes mellitus or hypertension
Present complain:
Subjective Data:
Pt said “I’m feeling pain in the surgical incision increase with cough and movement and decrease with rest".
Pt said "like needle sick and 3/10 on pain scale".
Pt said "I smoke 1 packet per days".
Pt said "I’m felling dizziness and nausea when I want to stand or walk".
Pt said "this is the first surgery I make it”.
Pt said "bad feeling my appetite is decrease I want to vomit”.
Objective Data:
Temp: 37 ْ C Pulse: 80 beat\minute BP: 110 / 70 mmgh RR: 19 rate\minute
High protein diet.
During cough or walking: the facial expression become tension and the patient put his hand above surgical incision.
Fatigue patient and spend more time on the bed.
Abnormal lab result: WBC above normal 11,100 *10^3\mm3 (5-10 *10^3\mm3) à surgical site infection.
Physical examination:
§ Conscious and oriented patient.
§ Surgical incision:
· Pain with touch.
· Temperature: warmth.
· No pus discharged.
· No redness.
· Slightly swelling.
· Mobility and turgor: easy and speed with which it returns into place.
· Moisture: dryness.
§ Abdomen: flat skin and no tender area (only in the surgical site).
§ No masses or enlarged organ.
§ Bowel sound: not detected.
Lap Results / Diagnostic tests:
Type Results Normal range Nursing consideration
WBC
RBC
HB
PLT
Na
K
Urea
Glucose
Creatinine 11,100 *10^3\mm3
5,5 *10^6\mm3
16.1 gm\dl
254 *10^3\mm3
140 meq\L
4.0 meq\L
1.7-8.3 mmol\L
5.4 mmol\L
66 mmol/L 5-10*10^3\mm3
3.8-5.8*10^6\mm3
11-16.5 gm\dl
150-500*10^3\mm3
135-148 meq\L
3.5-5.3 meq\L
1.7-8.3 mmol\L
4.2-6.4 mmol\L
62–115 mmol/L Infection (surgical site)
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Urine lap result
Type Results Normal range Nursing consideration
Ph
Glucose
Protein
WBC
RBC 8
Nil
Nil
0.2
0.2 4.6–8
< 0.3 g/24 hr
1–14 mg/dl in 24 hr's
0–4/HPF
0–3/HPF Normal
Normal
Normal
Normal
Normal
Fluid intake:
N\S 1000 cc Q8h.
G\W 2000 cc Q8h.
Medication
1- Flagyl - metronidazole - 500 mg IV Q8h)
Drug classes
Antibiotic
Antibacterial
Amebicide
Antiprotozoal
Therapeutic actions
Bactericidal: inhibits DNA synthesis in specific (obligate) anaerobes, causing cell death; antiprotozoal-trichomonacidal, amebicidal: biochemical mechanism of action is not known.
Adverse effects
•CNS: Headache, dizziness, ataxia, vertigo, incoordination, insomnia, seizures, peripheral neuropathy, fatigue
•GI: npleasant metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset, cramps.
•CU: Dysuria, incontinence, darkening of the urine.
•Hematologic: Leukopenia, granulocytopenia, thrombocytopenia, pancytopenia
•Dermatologic: Rash, alopecia
•Local: Thrombophlebitis (IV); redness, burning, dryness, and skin irritation (topical)
•Other: evere disulfiram-like interaction with alcohol, candidiasis (super infection)
Nursing Considerations
Assessment
•History: CNS or hepatic disease; candidiasis (moniliasis); blood dyscrasias; pregnancy; lactation
•Physical: Reflexes affect; skin lesions, color (with topical application); abdominal exam, liver palpation; urinalysis, CBC, liver function tests
Implementation
• Avoid use unless necessary. Metronidazole is carcinogenic in some rodents.
•Administer oral doses with food.
•Apply topically (MetroGel) after cleansing the area. Advise patient that cosmetics may be used over the area after application.
•Reduce dosage in hepatic disease..
2- Maxil - Cefuroxime- (750 mg IV Q8h)
Drug classes
Antibiotic
Cephalosporin (second generation)
Therapeutic actions
Bactericidal: inhibits synthesis of bacterial cell wall, causing cell death.
Adverse effects
• CNS: Headache, dizziness, lethargy, paresthesias
• GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, pseudomembranous colitis, liver toxicity
• Hematologic: Bone marrow depression: decreased WBC, decreased platelets, decreased Hct
• GU: Nephrotoxicity
• Hypersensitivity: Ranging from rash to fever to anaphylaxis, serum sickness reaction
• Local: Pain, abscess at injection site; phlebitis, inflammation at IV site
• Other: Superinfections, disulfiram-like reaction with alcohol
Nursing Considerations
Assessment
•History: Liver and kidney dysfunction, lactation, pregnancy
•Physical: Skin status, liver and kidney function test, culture of affected area, sensitivity tests
Implementation
•Culture infection, arrange for sensitivity tests before and during therapy if expected response is not seen.
•Discontinue if hypersensitivy reaction occurs.
Drug-specific teaching points
•The following side effects may occur: stomach upset, diarrhea.
•Report severe diarrhea, difficulty breathing, unusual tiredness or fatigue, pain at injection site.
3- Pethidine - meperidine hydrochloride - 75 mg im PRN)
Drug classes
Narcotic agonist analgesic
Therapeutic actions
Acts as agonist at specific opioid receptors in the CNS to produce analgesia, euphoria, sedation; the receptors mediating these effects are thought to be the same as those mediating the effects of endogenous opioids (enkephalins, endorphins).
Adverse effects*
May produce less intense smooth muscle spasm, less constipation, less cough reflex suppression than equianalgesic doses of morphine.
• CNS: Lightheadedness, dizziness, sedation, euphoria, dysphoria, delirium, insomnia, agitation, anxiety, fear, hallucinations, disorientation, drowsiness, lethargy, impaired mental and physical performance, coma, mood changes, weakness, headache, tremor, convulsions, miosis, visual disturbances, suppression of cough reflex
• GI: Nausea, vomiting, dry mouth, anorexia, constipation, biliary tract spasm, increased colonic motility in patients with chronic ulcerative colitis
• CV: Facial flushing, peripheral circulatory collapse, tachycardia, bradycardia, arrhythmia, palpitations, chest wall rigidity, hypertension, hypotension, orthostatic hypotension, syncope
• GU: Ureteral spasm, spasm of vesical sphincters, urinary retention or hesitancy, oliguria, antidiuretic effect, reduced libido or potency
• Dermatologic: Pruritus, urticaria, laryngospasm, bronchospasm, edema
• Local: tissue irritation and induration (SC injection)
• Major hazards: Respiratory depression, apnea, circulatory depression, respiratory arrest, shock, cardiac arrest
• Other: Sweating, physical tolerance and dependence, psychological dependence)
Nursing Considerations
Assessment
•History: Hypersensitivity to narcotics, diarrhea caused by poisoning, bronchial asthma, COPD, cor pulmonale, respiratory depression, anoxia, kyphoscoliosis, acute alcoholism, increased intracranial pressure; acute abdominal conditions, CV disease, supraventricular tachycardias, myxedema, convulsive disorders, delirium tremens, cerebral arteriosclerosis, ulcerative colitis, fever, Addison’s disease, prostatic hypertrophy, urethral stricture, recent GI or GU surgery, toxic psychosis, renal or hepatic dysfunction, pregnancy.
•Physical: T; skin color, texture, lesions; orientation, reflexes, bilateral grip strength, affect, pupil size; P, auscultation, BP, orthostatic BP, perfusion; R, adventitious sounds; bowel sounds, normal output; frequency and pattern of voiding, normal output; ECG; EEG; thyroid, liver, kidney function tests
mplementation
• Administer to lactating women 4–6 h before the next feeding to minimize the amount in milk.
• Provide narcotic antagonist, facilities for assisted or controlled respiration on standby during parenteral administration.
• Use caution when injecting SC into chilled areas or in patients with hypotension or in shock; impaired perfusion may delay absorption; with repeated doses, an excessive amount may be absorbed when circulation is restored.
• Reduce dosage of meperidine by 25%–50% in patients receiving phenothiazines or other tranquilizers.
• Give each dose of the oral syrup in half glass of water. If taken undiluted, it may exert a slight local anesthetic effect on mucous membranes.
• Reassure patient about addiction liability; most patients who receive opiates for medical reasons do not develop dependence syndromes.
Diagnosis:
Pain R\T surgical incision AMB patient verbalizes (3/10 on pain scale).
Impaired Skin Integrity R\T surgical incision AMB My observation (surgical incision).
Activity Intolerance R\T limited mobility secondary to pain AMB my observation (Fatigue patient and spend more time on the bed).
Risk for Infection R\T surgical incision (increased susceptibility to bacteria secondary to wound) AMB my observation (elevated WBC level – warmth incision and pain with touch)
Risk for Altered Nutrition: Less Than Body Requirements R\T increased protein and vitamin requirements for wound healing and decreased intake secondary to pain and nausea AMB patient verbalize (loss of appetite -anorexia-).
Risk for Colonic Constipation R\T decreased peristalsis secondary to immobility AMP my observation (spend more time on the bed)
Planning and interventions
1- Goal: Promoting comfort.
Objectives: the patient will able to:
-Report progressive reduction of pain from 3 – 1 on pain scale during my shift
Interventions:
Assess pain location, intensity, and characteristics.
Administer prescribed pain medications.
Explain and assist with nonpharmacological pain relief measures:
a. Encourage the patient to change positions frequently and to splint incision when turning, coughing, or deep breathing to minimize discomfort (proper positing reduce the stress on the incision area).
b. Breathing exercises and relaxation techniques (Breathing exercises and relaxation techniques decrease oxygen consumption, respiratory rate, heart rate, and muscle tension, which interrupt the cycle of pain–anxiety–muscle tension)
Progress the client to ambulating without assistance if possible (Walking will increase venous return, prevent venous stasis, expand lung tissue and reduce the incidence of atelectasis).
Teach the client to expel flatus by the following measures (Postoperatively, sluggish peristalsis results in accumulation of nonabsorbable gas. Pain occurs when unaffected bowel segments contract in an attempt to expel gas. Activity speeds the return of peristalsis and the expulsion of flatus; proper positioning helps gas rise for expulsion)
c. Walking as soon as possible after surgery
d. Changing positions regularly, as possible.
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2+4- Goal: Improving skin integrity and preventing infection
Objectives: the patient will able to:
Demonstrates restored skin integrity during 1-2 weeks..
Demonstrate healing with evidence of intact during patient hospitalization
No evidence of further skin breakdown or infection during patient hospitalization.
Intervention:
Monitor for signs and symptoms of wound infection (Tissue responds to pathogen infiltration with increased blood and lymph flow (manifested by edema, redness, and increased drainage) and reduced epithelialization (marked by wound separation). Circulating pathogens trigger the hypothalamus to elevate the body temperature; certain pathogens cannot survive at higher temperatures).
a. Increased swelling and redness
b. Wound separation
c. Increased or purulent drainage
d. Prolonged subnormal temperature or significantly elevated temperature.
Monitor wound healing by noting the following: (A surgical wound with edges approximated by sutures usually heals by primary intention. Granulation tissue is not visible and scar formation is minimal. In contrast, a surgical wound with a drain or an abscess heals by secondary intention or granulation, with more distinct scar formation. A restructured wound heals by tertiary intention and results in a wider and deeper scar)
e. Evidence of intact, approximated wound edges (primary intention)
f. Evidence of granulation tissue (secondary and tertiary intention)
Teach the client about factors that can delay wound healing:
g. Dehydrated wound tissue (Studies report that epithelial migration is impeded under dry crust; movement is three times faster over moist tissue)
h. Wound infection (The exudate in infected wounds impairs epithelialization and wound closure)
i. Inadequate nutrition and hydration (To repair tissue, the body needs increased protein and carbohydrate intake and adequate hydration for vascular transport of oxygen and wastes.)
j. Compromised blood supply (Blood supply to injured tissue must be adequate to transport leukocytes and remove wastes)
Take steps to prevent infection (These measures help prevent introduction of microorganisms into the wound, and they also reduce the risk of transmitting infection to others).
k. Wash hands before and after dressing changes.
l. Wear gloves until the wound is sealed.
Minimize skin irritation (Preventing skin irritation eliminates a potential source of microorganism entry).
Teach and assist the client in the following (A wound typically requires 3 weeks for strong scar formation. Stress on the suture line before this occurs can cause disruption).
m. Supporting the surgical site when moving
n. Splinting the area when coughing, sneezing, or vomiting
o. Reducing flatus accumulation.
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3- Goal: increase tolerance
Objectives: the patient will able to:
- Demonstrate self-care activities during my shift.
Intervention:
Encourage progress in the client’s activity level each shift, as indicated (gradual increase in activity allows the client’s cardiopulmonary system to return to its preoperative state without excessive strain.).
a. Allow the client’s legs to dangle first; support him from the side (Dangling the legs helps minimize orthostatic hypotension)
b. Increase the client’s time out of bed by 15 minutes each time. Allow him to set a comfortable rate of ambulation, and agree on a distance goal for each shift.(Gradual increases toward mutually established, realistic goals can promote compliance and prevent overexertion).
c. Encourage the client to increase activity when pain is at a minimum or after pain relief measures take effect.
Increase the client’s self-care activities from partial to complete self-care, as indicated (The client’s participation in self-care improves his physiological functioning and reduces fatigue from inactivity, and also improves his sense of self-esteem and well-being).
Plan regular rest periods according to the client’s daily schedule (Regular rest periods allow the body to conserve and restore energy).
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5- Goal: Improving nutritional status
Objectives: the patient will able to:
Eat proper food during my shift.
Drink 2000 to 3000 mL of fluids during my shift.
Intervention:
Explain the need for an optimal daily nutritional intake, including these items: (Wound healing requires sufficient intake of protein, carbohydrates, vitamins, and minerals for fibroblast formation and granulation tissue and collagen production)
a. Increased protein and carbohydrate intake
b. Increased intake of vitamins A, B, B2, B6, B12, C, D, and E and niacin
c. Adequate intake of minerals (zinc, magnesium, calcium, copper)
Take measures to reduce pain (Pain causes fatigue and nausea, which can reduce appetite) by administer pain medication 30 minutes before meals, as ordered
Take steps to reduce nausea and vomiting:
d. Restrict fluids before meals and large amounts of fluids at any time; instead, encourage the client to ingest small amounts of ice chips or cool clear frequently, unless vomiting persists. (Gastric distention from fluid ingestion can trigger the vagal visceral afferent pathways that stimulate the medulla oblongata (vomiting center))
e. Teach the client to move slowly. (Rapid movements stimulate the vomiting center by triggering vestibulocerebellar afferents.).
Maintain good oral hygiene at all times. (A clean, refreshed mouth can stimulate appetite and reduce nausea).
Administer an antiemetic agent before meals, if indicated. (Antiemetics prevent nausea and vomiting).
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6- Goal: Promoting normal bowel elimination
Objectives: the patient will able to:
- Resume effective preoperative bowel function during patient hospitalization.
Intervention:
Assess bowel sounds to determine when to introduce liquids. Allow the client to progress to solid food when liquids are tolerated. (Presence of bowel sounds indicates return of peristalsis).
Explain the effects of daily activity on elimination. Assist with ambulation when possible (Activity influences bowel elimination by improving abdominal muscle tone and stimulating appetite and peristalsis).
Promote factors that contribute to optimal elimination:
a. Balanced diet (A well-balanced diet high in fiber content stimulates peristalsis.)
i. Review a list of foods high in bulk, e.g., fresh fruits with skins, bran, nuts and seeds, whole grain breads and cereals, cooked fruits and vegetables, and fruit juices.
ii. Discuss dietary preferences.
iii. Encourage intake of approximately 800 g of fruits and for normal daily bowel movement.
b. Adequate fluid intake (Sufficient fluid intake is necessary to maintain bowel patterns and promote proper stool consistency).
i. Encourage intake of at least 8 to 10 glasses (about 2,000 mL) daily,.
ii. Discuss fluid preferences.
c. Regular time for defecation (Taking advantage of circadian rhythms may aid in establishing a regular defecation schedule).
i. Identify the normal defecation pattern before the onset of constipation.
ii. Review daily routine.
iii. Include time for defecation as part of the regular daily routine.
iv. Discuss a suitable time, based on responsibilities, availability of facilities, and so on.
v. Suggest that the client attempt defecation about 1 hour following a meal and remain in the bathroom a suitable length of time.
d. Simulation of the environment (Privacy and a sense of normalcy can promote relaxation, which can enhance defecation).
Patient Education/ Health Maintenance
1. Review signs and symptoms of wound infection, so that early intervention may be instituted.
2. Explain signs and symptoms of other postoperative complications to report- elevated temperature, nausea or vomiting, abdominal distention, changes in bowel function and stool consistency.
3. Instruct patient regarding wound care or ostomy care if applicable to promote healing and self-confidence.
4. Instruct patient on turning, coughing, deep breathing, use of incentive spirometer, ambulation. Discuss their purpose and continued importance during the recovery period.
5. Review dietary changes, such as increased fiber content and fluid intake, and their importance in improving bowel function.
6. Instruct patient on prescribed medications to encourage compliance and understanding of management.
Evaluation
Goal met:
Paine decrease: patient verbalizes and demonstrate increased comfort
No evidence infection
Tolerates diet: the patient eats his diet and verbalizes no evidence of nausea and vomiting.
Reports normal bowel function; no constipation
Goal partial met:
Slightly improve in normal skin integrity à need more time - not detect during one shift.
Slightly increase in activity and à it comes gradually. And the patient go to bathroom and return without help by other but the facial expression
Goal not met:
Nil [/right]
موضوع: nursing care plan / appendicitis 
17/11/2009, 02:35
