4. APPENDICITIS
Appendicitis is a condition
characterized by inflammation of the
appendix. The appendix is a small,
finger-like appendage attached to the
cecum just below the ileocecal valve.
Because it empties into the colon
insufficiently and its lumen is small, it
is prone to becoming obstructed and
is vulnerable to infection. The
obstructed appendix becomes
inflamed and edematous and
eventually fills with pus. It is the most
common cause of acute inflammation
in the right lower quadrant of the
abdominal cavity and the most
common cause of abdominal surgery.
Males are affected more
than females, teenagers more
frequently than adults; the highest
incidence is in those between the
ages of 10 and 30 years. The disease
is more prevalent in countries in
which people consume a diet low in
fiber and high in refined
carbohydrates.

6. Lower right quadrant pain usually
accompanied low-grade fever, nausea,
and sometimes vomiting.
At McBurney,s point (located
halfway between the umbilicus and
the anterior spine of the ilium), local
tenderness with pressure and some
rigidity of the lower portion of the
right rectus muscle.
Rebound tenderness may be
present; location of appendix dictates
amount of tenderness, muscle spasm,
and occurrence of constipation or
diarrhea.
Rovsing’s sign (elicited by palpating
the left lower quadrant, which
paradoxically causes pain in right
lower quadrant )
If appendix ruptures, pain more
becomes diffuse; abdominal distention
develops from paralytic ileus, and
condition worsens.

8. Rovsing's sign
Continuous deep palpation starting
from the left iliac fossa upwards (anti
clockwise along the colon) may cause
pain in the right iliac fossa, by pushing
bowel contents towards the ileocaecal
valve and thus increasing pressure
around the appendix. This is the
Rovsing's sign

9. Psoas sign
This is right lower-
quadrant pain that
is produced with
the patient lying on
his left side and
then extending the
hip. Because
extension elicits
pain, the patient
will lie with the
right hip flexed for
pain relief

10. Obturator sign
If an inflamed appendix is
in contact with the
obturator internus, spasm
of the muscle can be
demonstrated by flexing
and medial rotation of the
hip. This maneuver will
cause pain in the
hypogastrium. Not all the
conditions causing luminal
obstruction causes
appendicitis,resolution of
inflammatory condition of
appendix can occur and
this is known as resolution
or mucocele of appendix
with appropriate antibiotic
treatment .

11. Blumberg sign
Palpation of the left iliac fossa,
followed by sudden release causes
contralateral (right iliac fossa) rebound
tenderness.

13. I. PATIENTS PROFILE
Name: Mr. Geronimo Q. Caluza
Address: Caoayan, Burgos, La Union
Age: 69 years old
Birth date: August 25, 1940
Gender: Male
Marital Status: Widow
Nationality: Filipino
Ethnic Origin: Ilocano
Education: High School Graduate
Occupation: Retired Police/ Security Guard / Farmer
Religion: Roman Catholic

14. II. HOSPITALIZATION PROFILE
Chief Complaint:Right Lower Quadrant Pain in the abdomen, fever
and headache
Initial V/S upon Admission: BP: 100/70, PR: 96, RR: 28, T: 38.1 C
Admitting Physician: Dr. Estela L. Talic,
Admission Date: February 4, 2010
Admission Time: 4:30 pm
Admitting Diagnosis: Right Lower Quadrant Pain T/C Acute
Appendicitis
Pre-Operative Diagnosis: Acute Appendicitis Ruptured
Post- Operative Diagnosis: Acute Appendicitis Ruptured
Surgeon: Dr. Dag-O
Anesthesiologist: Dr. Antolin
Anesthetic: Sub Arachnoid Block
Date of Operation: February 5, 2010
Time Operation Started: 2:15 am
Time Operation Ended: 2:50 am
Title of Operation Performed: Emergency Appendectomy

16. Patient’s condition started one day before admission to
Ilocos Training and Regional Medical Center. On the
night of February 3, 2010 the patient felt severe pain
on the right lower quadrant of the abdomen and not
radiating (aggravated when moving and decrease the
rate of pain in supine position, a stabbing pain and with
a rate of 8/10) accompanied by fever (warm to touch as
verbalized by the patient and SO) and headache. There
was no associated nausea and vomiting according to
the patient. He tried to relieve the pain, by taking
Mefenamic Acid 500 mg however the pain was not
totally relieved by the medication.
Since the hospital was far from their place, the patient
decided to consult a physician on the next day.

17. At around 10:00 in the morning of February 4, 2010, the patient
together with his son arrived at Naguilian District Hospital for
consultation. His chief complaint was still the pain on the right
lower quadrant of his abdomen accompanied by fever and
headache. After the assessment procedure done by the health
care team in the hospital, the physician’s probable diagnosis
reveals that the patient may be suffering from Urinary Tract
Infection or Acute Appendicitis. The physician explained that if
ever it is an acute appendicitis, emergency appendectomy
should be performed immediately to prevent complications. So
the physician decided to refer him on other more equipped
hospital for further assessment and care because their hospital
cannot handle complicated cases.
One hour prior to admission, the patient still suffer from severe
pain of the right lower quadrant of his abdomen accompanied
by fever and headache, sought consult on this institution
(ITRMC), hence admission.

19. The patient has an incomplete immunization because
during his childhood days, immunization was not yet
initiated. The only vaccine that the patient received
was BCG (seen on his right arm as evidence by a scar).
He experiences usual illnesses like cough, colds and
influenza. And according to the patient, he was first
hospitalized in Baguio General Hospital 31 years ago
and was diagnosed to have acute bronchitis. He also
claimed to have no existing allergies to food and drugs
and has no previous intake of maintenance drug for any
serious health complication.

21. The patient claimed that there was no history of
hereditary diseases on both sides of his mother or
father such as hypertension, cerebrovascular diseases,
asthma, diabetes mellitus, cancer, peptic ulcer disease,
hyperthyroidism, or arthritis. He has no family member
with an existing contagious disease such as with
pulmonary tuberculosis. Rather, his family usually
experiences common illnesses such as cough, colds and
influenza. Furthermore, he also claimed that there
were no histories of hospitalization among the
members of his family so far.

23. He is a good citizen in their barangay since he is the
chairman of LUPON (LUPON were the one who
mediates during a confrontation on the barangay when
there are disputes of people in the barangay) and a
member of senior citizen organization.
It has been 20 years since he stopped smoking. He
started smoking when he was 19 years old and he
smoke 1-2 packs of cigarettes (Hope) per day. He also
drinks alcoholic beverages. He started drinking alcohol
when he was 19 years old. According to the patient, he
drinks alcoholic beverages such as beer, “gin” and
“emperador” at around 3 times a week and stop it 4
years ago.
He was also a known kind neighbor according to his
son.

24. This was the first time he was admitted at
Ilocos Training and Regional Medical Center.

25. Day 1 – February 4, 2010 / 4:30
pm to 12:00 am
(From the time of admission to the
time he was prepared to have an
emergency appendectomy)

26. From Naguillan District Hospital, the patient was referred and admitted
to ITRMC at 4:30pm of February 4, 2010. He was brought by an
ambulance accompanied by his son and a nurse. The patient was
admitted with the following diagnostic tests: hematology, complete
blood count and urinalysis, all dated February 4, 2010. After a
thorough interview, physical assessment and diagnostic procedures
done, the doctor diagnosed the patient to have Right Lower Quadrant
Pain T/C Acute Appendicitis. After a few hours of persistent Right
Lower Quadrant pain, the doctor decided that the patient should
undergo Appendectomy. The patient was then brought to surgery male
ward for further assessments. Eventually he was scheduled for “E”
Appendectomy at 2:00 am of February 5, 2010.
The doctor also ordered D5LRS 1L x 8 hours, Cefuroxime 750 mg every
8 hours given via IV (ANST), Metronidazole 500 mg every 8 hours given
via IV(ANST), Ranitidine 50 mg every 8 hours given via IV.
Note: We handled the patient from Feb. 5- 6, 2010 of 7-3 shift.

27. Day 2 (Feb. 5, 2010) (this is the 1st day we handled the
patient)
At around 2:00 am of February 5, 2010, the
patient was brought to the operating room to undergo
Appendectomy with duly accomplished consent forms
with proper pre-operative preparation. The operation
was started at 2:15 am and ended at 2:50 am. OR
findings revealed the following results: dilated distal 3rd
appendix ruptured appendix and generalized
peritonitis.

28. At 7 am, the patient was five hours post-operative. The patient is
still flat on bed with an IVF of D5LRS 1L x 8 hours infusing well on
his right arm at full level. The patient also has IFC connected to
urine bag. We received the patient sleeping and at around 8 am,
the patient woke up but still flat on bed because the order will
due at 11 am. The patient is under NPO; however the doctor
ordered to wet his lips with wet cotton balls for drying of lips.
Also, the doctor orders were to continue his medications;
Cefuroxime 750 mg every 8 hours given via IV, Metronidazole
500 mg every 8 hours given via IV, Ranitidine 50 mg every 8
hours given via IV, Ketorolac 15 mg every 4 hours for 6 doses
given via IV and Tramadol 50 mg every 8 hours for 4 doses given
via IV;continue monitoring vital signs, input and output and IFC
may remove in the afternoon.

29. When we received the patient, the following vital signs were taken: BP
of 90/ 60, RR of 22, PR of 68 and a temperature of 36.5°C and since
there are no abnormalities, we did not do any referral instead we just
continue monitoring his vital signs and do NPI. At around 9 am, when
we asked the patient if he has complaints, he just said that he feels
pain on the operative site (P- surgical incision;Q-pricking; R- non-
radiating pain on the operative site; S- rated as 7/ 10; T- “just this
morning when I wake up”). We encouraged the patient to do deep
breathing exercises to somehow relieve the pain since his Ketorolac
will be given at 11 am.
At around 10am, while the patient is lying on bed, we asked
his permission if he could allow us to take him as our subject for the
case presentation and fortunately, he agreed and said “agadal kayo nga
nalaeng tapno pumasa kayo iti board exam iti nursing”. We
acknowledged his advice through smiling and responsing “wen
tatang”. At the moment he agreed, NPI was done to caught and
establish trust then we did the 13 areas of assessment and asked some
questions to the patient.

30. At around 11 am (due time for FOB) we encourage the
patient to gradually ambulate to prevent complications
(adhesiolysis, pressure ulcer, improper tissue perfusion
etc). We also implemented appropriate nursing
intervention such as monitoring V/S; promoting proper
hygiene, rest and comfort; anticipating needs of the
patient to decrease body movement that may trigger
pain on abdominal area; administering medications as
ordered; ensuring safety by merely staying beside him
as frequent as possible; and encouraging diversional
activities like reading news paper and social interaction
to distract the patient from concentrating on the pain
he’s feeling.
Before our shift ended, we assessed again his
pain and he said that the rate was already 2/ 10.

31. Day 3 (Feb. 6, 2010)
On our second day of handling the patient, he can now
sit, stand or even walk slowly for few steps with assistance. He is
also smiling, reading newspaper and seems no problem at all.
He’s still with D5LRS 1L but now regulated at 8 hours. The
doctor’s orders were to continue his medications, continue
monitoring V/S of the patient and that the patient may have
general liquids to soft diet in the afternoon.
After they cleaned and dressed his wound, we asked the
patient if he had any complaints, “kaasi ni Apo umim-imbag toy
riknak”.
We promoted rest, good body and oral hygiene and diversional
techniques such as social interaction and reading newspaper. We
also attend to his needs such as accompanying him to the
comfort room.

32. Note: This was assessed during our first day on surgery ward
which was February 5, 2010 at around 10 am and beyond until
our shift last during this day however for the Gustatory Status,
since he was on a post operative status, we assessed this on our
2nd day which was February 6, 2010.

34. A. General Social Status
Mr. Caluza is a 64 years old, male, widow, Filipino citizen, and an
Ilocano. He lives in a mountainous place in Cauayan, Burgos La Union.
He lives with his three sons in his second wife in an unused “kiskisan”
which is made up of wood. The base of the house serves as their
kitchen and living room, while the upper portion serves as their
bedroom. He is a Roman Catholic and his family does not have
practices or belief in any way that may hinder the delivery of health
care services. His sons and daughters in his first wife also sometimes
support him financially. According to the patient they have just enough
income for a 3x a day meal (Their income varies because his sons
doesn’t have a permanent job and also sometimes his other children
give money in varying amount like 2,000 to 3000/month). He is a high
school graduate. He worked as a police officer for 11 years and security
guard for 17 years and at present as a farmer and does spraying of
mango trees.

35. B. Family or Peer Group Social Status
The patient is the third child of Mr. and Mrs Caluza. He got
married at the age of 23. He had 8 children, 5 on his legal wife
and 3 children on his previous live-in partner.
According to the patient his legal wife died because of heart
attack. His 5 children then lived on their mother’s relative. Three
years after his wife’s death, he was engaged in a relationship and
they had 3 children. However they separated three years ago
due to some family problems(He doesn’t want to elaborate this,
so we asked his daughter about it and we found out that his live
in partner went away to accompany her new boyfriend and at
the moment, the second wife now has a child to her new live-in
partner). Currently he is now living with his three sons. He has
good relationship with his children both in his first and second
wife. His three sons ages 21, 20, 18 years old respectively are
already working with him at home and in the farm and his
children in his first wife were sending him money too.

36. C. Social Developmental Status
At the age of 64 the patient is still able to work in the farm.
He is still the breadwinner of the family since his three sons
don’t have stable jobs yet. The patient is still active in
joining organizations. In fact, he is a chairman of LUPON in
their barangay (LUPON were the one who mediates during
a confrontation on the barangay when there are disputes of
people in the barangay). He is also a member of Philhealth
and Senior Citizen organizations.
The patient also stated that since he is ill at this moment,
he cannot be able to perform his duty and responsibility as
a chairman of LUPON in their barangay and also as a father
of his children.

37. A. Mental Status
Patient had been observed with no unpurposeful and
involuntary movements. Dress and grooming are
appropriate for setting, season, age and gender. He
appears slightly neat and clean. However, a slightly foul
odor could be smelled when you’re near to him, this
may be due to dried perspiration left on his clothing
and bed linen.. His hair is slightly matted and oily.

38. Patient is awake, alert, with clear and understandable
speech. With appropriate facial expression and verbal
responses. He responds appropriately to several stimuli
such as verbal, noise, light, touch and pain stimulus. Patient
is oriented to people, time and place. With good attention
span and able to cooperate during the interview. Recent
and remote memory are intact. Thought processes and
perceptions are logical, coherent, and relevant. Thought
content is consistent and logical. There was no suicidal
ideation.
He’s a high school graduate. He articulates himself in
Ilocano, and Tagalog. He’s able to read and write. He can
comprehend and follow directions.

39. B. Emotional Status
He exhibits positive affirmations regarding his present
health condition. He is not irritable upon interview and
assessment. However we observed a positive guarding
behavior towards his wound on the lower part of his
umbilicus. He said there is pain felt on the operative site
which he rated as 7/10 on a scale of 0-10, 10 being the
most painful. He shows appropriate mood and emotional
response. He is able to communicate well and verbalize his
needs and concerns regarding his health condition.
Generally, he’s optimistic about his current condition. No
substance taken to alter emotional response

40. He’s also cooperative in medical treatments done to him.
He stated that he’s afraid to ambulate because the
operative site might open which the doctor explained that
another operation is needed if that happens, however to
prevent complications, the doctor encouraged him to
ambulate gradually. He positively believes that he can soon
recover from the illness he’s experiencing and soon can
continue his goals and aspirations in life –to enhance their
living condition. However he verbalized that at the
moment, he cannot tolerate to perform ADL due to his
condition so he needs assistance to somehow carry it out.
Full support of his family members is needed for him to
cope up with his condition.

42. Patient’s house is located far from the national highway but
near the feather road of their barangay he said. It is an
unused “kiskisan” turned into a house. The walls is made up
of wood while the roof is made up of metal. They owned
the “kiskisan” however it is not utilized due to lack of
financial support to let it operate continuously. They
decided to live in there after renting a house near the
“kiskisan”. It is a two story structure with 10 stairs. They
have their own comfort room and it is located 1 meter away
from their house. Their water supply is from a pump well
that is regularly tested by the barangay health personnel as
stated by the patient. He lives with his three sons, all young
adults.

43. The patient is confined at the Male Surgical Ward of ITRMC.
He receives adequate assistance from his son, daughter and
nurses on duty. The patient is with intravenous line on his
right arm and also with an IFC connected to urine bag.
He stayed in a room with other patients approximately 1
meter away from each other. He stayed in a bed with no
side rails but with head and foot board. The ward provides
good lighting, there were 2 big rotating electric fan(180°)
found at each end of the room. Despite of inadequate
financial source at the moment that the patient was
hospitalized, his relatives provides the needed medications
for his treatment and it is found on the bedside table with
some food and reading materials like newspaper.

44. With regards to infection control, the family who regularly visits
the patient practices good hand and body hygiene like hand
washing and using alcohol whenever they touch the patient and
whenever they attend the needs of the patient. Though risk for
contamination are possible because he is staying in a room with
other patients.
Proper waste disposal were also practiced. Upon assessment,
the patient has an intact indwelling foley catheter that has been
regularly emptied by the nurse on duty as well as student nurses
on an 8 hours basis. The patient uses mineralized water to
prevent water borne diseases that could instigate
gastrointestinal problem such as infection.
With regards to his wound, it was regularly cleaned by doctors
attending him. It is covered by an OS following the suture lines. It
is located below the umbilicus.

46. A. Visual
The patient uses eyeglasses (O.D. 20/200, O.S. 20/70) when
reading articles which have small characters (font 5, 1 foot
distance) such as bible. He can read articles (newspapers
with font 12) without the aid of eyeglasses at a distance of
1 foot. He is a near sighted. The patient has a fair visual
acquity. He has a good visual lateralization. No blurring of
vision noted. He can spontaneously identify things at
distant. With the use of penlight, we assessed that the
patient’s pupils are equally round, and reactive to light
accommodation. No eye pain, no redness, no swelling, no
discharge, no tearing/lacrimation and no lesions noted.
Myopia, presbyopia, blindness, astigmatism as well as
unusual sensations like rainbows around light, blind spots,
and flashing light have not been noted.

47. B. Auditory Status
The patient states that he has a good hearing condition. The
patient is able to distinguish voices at distance of until 2 ft.
using the “whisper test” as an assessment tool. He also has
a good bilateral hearing. Ears are symmetrical, have smooth
texture and are same in color. No earaches, discharges,
tinnitus or vertigo noted. No known auditory deficit,
corrective device or unusual sensation such as ringing,
buzzing or dizziness noted

48. C. Olfactory
The patient can discriminate odors and could differentiate
them accurately as assessed by letting him smell different
types of odorous agent such as perfume and coffee with
closed eyes. Patent nostrils had been observed and no
airway obstruction or discharges had been noted.

49. D. Gustatory
NOTE: This is assessed during the 2nd day post-operative
due to NPO status of the patient on the 1st day we had
handle him.
The patient is able to discriminate sweet, sour, salty, and
bitter foods. No difficulty of swallowing has been noted as
evidenced by drinking of water. His three teeth (2 on the
upper incisors and 1 on the lower incisors) has silver jacket.
The patient reports no pain, lesions, sore throat, swollen or
bleeding gums, toothache, ulcerations or hoarseness. No
unusual sensations noted. Improper mouth hygiene had
been noticed (foul smelling breath).

50. E. Tactile Status
The patient is able to discriminate sharp and dull, light and
firm touch on the upper and lower extremities as evident
by rubbing tip of pencil against his skin as an assessment
method. He’s also able to perceive heat, cold and pain in
proportion to stimulus in the upper and lower extremities.
Upon assessment, the patient is not warm or hot to touch
(afebrile). He has been hospitalized with chief complaint of
right lower abdominal quadrant pain accompanied by fever.
Facial sensations are symmetrical.

51. F. Sensory Environment (Language Perception
Formation)
He’s able to understand and initiate speech without
difficulty. He reads and writes accurately and can
articulate well. He understands and comprehends
instructions.

53. Upon assessment, the patient is
on a post operative status. He
was advised by his physician to
ambulate gradually 8 hours after
the operation. While on post-op
state, his son attends on his
needs. The patient has muscle
strength of 5/5 on the upper
extremities, and 4/5 on the
lower extremities, both left and
right. No evidence of muscle
wasting. No muscle or joints pain
is verbalized by the patient.
5/5 5/5
4/5 4/5
Muscle Strength

55. Prior to confinement, the patient has poor appetite. He ate
variety of food comprises mixture of carbohydrate (rice), protein
(meat) and fat (frying oil, nuts) rich foods. He prefers vegetables
harvested from their backyard over meat as an everyday meal
and he also love to eat fish. He eats one and a half cup of rice.
The patient verbalizes that he had no food or drug allergies and
also there were no religious restrictions of food. They have
eggplants, tomatoes, pechay, etc. planted in their backyard and
they eat meat at least 2 times a week.
Upon hospitalization, he state that he loses good appetite. He is
5’4” in height and weights 52 kg; he has a BMI *kg/ht (m)2] of
19.55 which is within normal range. Also, despite of the sudden
decrease of appetite, the patient still looks good.

56. He was ordered NPO before the operation until we had
assessed the patient. He has a good swallowing reflex.
Bowel sounds was gurgling, cascading sounds, occurring
irregularly anywhere from 6 to 20 times per minute.
At present, patient had no occurrences of diarrhea or
constipation. However he told us that sometimes he feels
nauseated but with negative vomiting episodes. No
medications given that can alter patient’s digestion and
metabolism of foods.

58. Urine
Prior to hospitalization, the patient eliminates 1 to 1 1/2
liters of urine daily. He urinates 5 to 6x/day with clear,
straw-colored urine. No nocturia, dysuria or hesitancy upon
urination. No pain, lesions or unusual discharges from the
penis. Also, there was no history of genitourinary disease.
At the event of the disease, the patient eliminates urine at
about 700cc in our shift (7-3 shift) upon assessment during
the post operative status (pt. is with indwelling foley
catheter). His urine was yellow orange in color.

59. Stool
With regards to his bowel movement prior to admission,
the patient stated that there are times that he defecates
regularly with a yellowish to brown color in varying amount
(depends on the amount of food intake of the patient) but
there are also some times that he defecates infrequently
(usually every after 3 days) with hard and small feces and
dark colored stool (twice in a month). His feces usually have
a yellowish to brown color.
Upon assessment, the patient doesn’t defecate but he
stated that he had passed flatus for 2 times during our shift.
There are no artificial orifices for stool elimination.

61. Prior to hospitalization the patient normally consumes 1000
to 1500 liters of fluids daily and he normally urinates 5 to 6
times a day.
Prior and after operation he was ordered NPO. We had
assessed him on post-operative status. And he’s been
ordered to have volume hydration of D5LRS regulated at 30
gtts/ minute. During our shift, he has a 875 cc infused of IVF
and his urine was measured to reveal 700 cc output at the
end of our shift.
The patient verbalized no previous episodes of vomiting
despite of nauseated feeling prior to admission. The patient
skin is slightly oily and the skin returns quickly to its original
shape when pinched between two fingers and released
(good skin turgor). No edema is observed.

63. The patient told us that his usual Blood Pressure reading is
120/80 prior to admission. Upon assessment, his Blood
Pressure reading is at 90/60. Pulse rate is 68 beats per
minute with amplitude of 2+. No medications prescribed
that could alter heart rate or rhythm. The patient skin and
nails are not pale and with capillary refill of 2 second.

65. He has bilateral patent airway, with a respiratory rate
ranging from 18-22 cycles per minute, deep and regular.
Neither cough nor colds noted upon assessment. No
difficulty of breathing as verbalized by the patient. No
crackles, wheezes or any abnormal breath sounds noted.
The patient ceased smoking since 1990. No medications
prescribed that could alter respiratory rate or patency of
bronchial tree. Skin and nails are not pale. No clubbing of
nails noted. Also, no supportive devices such as
tracheostomy noted.

67. One day prior to hospitalization, the patient suddenly felt
warm body sensation while having a severe abdominal pain
that prompts him to consult a physician on the 4th day of
February 2010. When he was assessed in Naguilian District
hospital, his temperature reading was 38.3 C which signifies
a febrile condition. His temperature persisted until he was
admitted at ITRMC. Dr. Talic ordered TSB to reduce his
temperature. No antipyretic medications given.
Upon assessment, his temperature reveals a normal result
which is 36.5 C. Patient is able to verbalize feelings of
warmth and cold. He is in a slightly well ventilated room
due to presence of 2 big circulating electric fans and open
wide windows. He perspires minimally. No special
equipment such as hypo-hyperthermia blanket noted.

69. The patient has a fair complexion. His skin is slightly pale.
He has a good skin turgor. It is not warm to touch. His nails
are pinkish in color; long and dirty nevertheless it is not
pale with capillary refill of 2 seconds. His hair is slightly
matted and oily. Patient is given daily sponge bath by his
son. No abnormal excretions but he’s slightly odorous due
to perspiration that is left into the bed sheet and on his
clothing.
With regards to his wound, it is located below the umbilicus
with a length of approximately 3 inches with no any
discharges. Skin surrounding the wound is pinkish in color. It
is covered with a bandage to avoid contamination. It is
regularly cleaned by doctors who do the morning rounds
after endorsement.

71. A. Sleep
He normally sleeps 7-8 hours a day, prior to hospitalization.
He described his sleep as continuous, uninterrupted sleep.
Patient verbalizes that he normally sleeps at about 10 pm
and wakes at 5 or 6 in the morning. When he was admitted,
his sleep is often interrupted due to frequent assessment
and interventions made by health care providers. He just
sleeps for 4 hours last night due to the operation performed
just few hours ago. No medications given that could alter
sleep pattern of the patient.

72. B. Comfort
He verbalizes pain on the abdominal area particularly at
wound site. He rated it as 7/10, 10 being the most painful
aggravated by sudden movements. He grimaces when in
pain and has been observed to have a positive guarding
behavior. Provocative – “surgical wound”, Quality -
“stabbing pain”, Region- “non-radiating pain on the
operative site” (below the umbilicus), Severity Scale – “rate
of 7/10”, 10 being the most painful, Timing – “just this
morning when I wake up” as verbalized by the patient.
(Note: The patients haven’t taken yet his pain relief
medication upon assessment.)

74. Test and Diagnosis
The diagnosis of appendicitis begins with a thorough
history and physical examination. Patients often have
an elevated temperature, and there usually will be
moderate to severe tenderness in the right lower
abdomen when the doctor pushes there. If
inflammation has spread to the peritoneum, there is
frequently rebound tenderness. Rebound tenderness
is pain that is worse when the doctor quickly releases
his hand after gently pressing on the abdomen over
the area of tenderness.

75. A. Ideal
1. URINALYSIS
Urinalysis is a microscopic examination of the urine that
detects red blood cells, white blood cells and bacteria in the
urine. Urinalysis usually is abnormal when there is
inflammation or stones in the kidneys or bladder. The
urinalysis also may be abnormal with appendicitis because
the appendix lies near the ureter and bladder. If the
inflammation of appendicitis is great enough, it can spread
to the ureter and bladder leading to an abnormal urinalysis.
Most patients with appendicitis, however, have a normal
urinalysis. Therefore, a normal urinalysis suggests
appendicitis more than a urinary tract problem, it is also
usually used in women to rule out pregnancy.

76. 2. WHITE BLOOD CELL COUNT
The white blood cell count in the blood usually becomes
elevated with infection. In early appendicitis, before
infection sets in, it can be normal, but most often there is at
least a mild elevation even early. Unfortunately,
appendicitis is not the only condition that causes elevated
white blood cell counts. Almost any infection or
inflammation can cause this count to be abnormally high.
Therefore, an elevated white blood cell count alone cannot
be used as a sign of appendicitis.

77. 3. ABDOMINAL X-RAY
An abdominal x-ray may detect the fecalith (the hardened
and calcified, pea sized piece of stool that blocks the
appendiceal opening) that may be the cause of
appendicitis. This is especially true in children.

78. 4. ULTRASOUND
An ultrasound is a painless procedure that uses sound
waves to identify organs within the body. Ultrasound can
identify an enlarged appendix or an abscess. Nevertheless,
during appendicitis, the appendix can be seen in only 50%
of patients. Therefore, not seeing the appendix during an
ultrasound does not exclude appendicitis. Ultrasound also is
helpful in women because it can exclude the presence of
conditions involving the ovaries, fallopian tubes and uterus
that can mimic appendicitis.

79. Findings of acute appendicitis of ultrasound:
> Visualization of noncompressible appendix as a blind-
ending tubular a peristaltic structure (seen only in 2% of
normal adults, but in 50% of normal children)
> Laminated wall with target appearance of 6 mm in total
diameter on cross section (81% SPECIFIC)/mural wall
thickness 2 mm
> Lumen may be distended with anechoic/hyperechoic
material
> Pericecal/periappendiceal fluid
> Increased periappendiceal echogenicity (= infiltration of
mesoappendix/pericecalfat)
> Enlarged mesenteric lymph nodes
> Loss of wall layers = gangrenous appendix

80. False-negative US:
Failure to visualize appendix
Inability of adequate compression
Aberrant location of appendix (eg, retrocecal)
Appendiceal perforation
Early inflammation limited to appendiceal tip
False-positive US:
Normal appendix mistaken for appendicitis
Alternate diagnosis: Crohn disease, pelvic inflammatory
disease, inflamed Meckel diverticulum
Spontaneous resolution of acute appendicitis

81. 5. BARIUM ENEMA
A barium enema is an x-ray test where liquid barium is
inserted into the colon from the anus to fill the colon. This
test can, at times, show an impression on the colon in the
area of the appendix where the inflammation from the
adjacent inflammation impinges on the colon. Barium
enema also can exclude other intestinal problems that
mimic appendicitis, for example Crohn's disease.

82. 6. COMPUTERIZED TOMOGRAPHY (CT) SCAN
In patients who are not pregnant, a CT Scan of the area of the
appendix is useful in diagnosing appendicitis and peri-
appendiceal abscesses as well as in excluding other diseases
inside the abdomen and pelvis that can mimic appendicitis.
CT findings of normal appendix
Visualized in 67-100%.
At posterior-medial aspect of cecum.
Diameter of up to 10 mm.
CT findings of Abnormal appendix
Distended lumen (appendix >7 mm in diameter).
Circumferential wall thickening.
Target sign: homogeneously enhancing wall with mural
stratification.
Appendicolith: homogeneous/ringlike calcification (25%).
Distal appendicitis: abnormal tip of appendix + normal proximal
appendix and normal cecal apex.

83. 7. LAPAROSCOPY
Laparoscopy is a surgical procedure in which a small fiber
optic tube with a camera is inserted into the abdomen
through a small puncture made on the abdominal wall.
Laparoscopy allows a direct view of the appendix as well as
other abdominal and pelvic organs. If appendicitis is found,
the inflamed appendix can be removed with the
laparascope. The disadvantage of laparoscopy compared to
ultrasound and CT is that it requires a general anesthetic.

84. 8. THE ALVARADO SCORE FOR ACUTE APPENDICITIS
The Alvarado score is a clinical scoring system used in the
diagnosis of appendicitis. The score has 6 clinical items and
2 laboratory measurements with a total 10 points.
A score of 5 or 6 is compatible with the diagnosis of acute
appendicitis. A score of 7 or 8 indicates a probable
appendicitis, and a score of 9 or 10 indicates a very
probable acute appendicitis.

85. A popular mnemonic used
to remember the Alvarado
score factors is MANTRELS:
Migration to the right iliac
fossa
Anorexia, Nausea/Vomiting
Tenderness in the right iliac
fossa
Rebound pain
Elevated temperature
(fever)
Leukocytosis
Shift of leukocytes to the
left

86. Test Result Reference Interpretation
Hgb 114 ( M- 130-180gm/L F-
120-160gm/L )
Decrease – due to
infection & internal
hemorrhage brought by
ruptured appendix
WBC 10.1 ( 5.00-10.00x109/L ) Increase - due to
presence of bacterial
infectious process
Platelet 136 ( 150-450 x 109/L ) Decrease – due to
infection & internal
hemorrhage brought by
ruptured appendix
Lymphocytes 15.5 19.0 – 48.0 Decrease – due to tissue
trauma
B. Actual
Note: Only CBC and Urinalysis were the diagnostics done to the patient.
Naguilian District Hospital
HEMATOLOGY REPORT
NAME OF PATIENT: CALUZA, Geronimo Room: ER Date: 2-4-10

87. Test Result Reference Implication
Color yellow Light or pale yellow Abnormal – may indicate a concentrated urine
Transparency turbid Clear Abnormal – indicates presence of infection
Reaction alkaline ph 8.5 6.5 pH Abnormal – due to infection
Pus cells 1-3/hpf 0 Abnormal – may be indicative of urinary tract
infection
Red cells 2-4/hpf ( - ) Abnormal – can be due to bleeding in the
genitourinary tract as a result of systemic bleeding
disorders or bacterial infections
Epith. cells few ( - ) Abnormal – presence of epithelial cells indicates
infection
Bacteria plenty ( - ) Abnormal – indicates infection
Albumin trace ( - ) Abnormal – due to renal distress associated to tissue
trauma
Sp. Gravity 1.010 1.010-1.025 Normal
Amorp. Phosphates plenty ( - ) Abnormal – indicates infection
Naguilian District Hospital
CLINICAL MICROSCOPY REPORT
Name of Patient: CALUZA, Geronimo Room: ER Date: 2/4/2010

88. ITRMC
Name: CALUZA, Geronimo Age: 69 y/o
Sex: Male Ward: Surgery
Date: 2-4-10 9:23PM Sample ID: 0204-91
Mode: OV-WB-CBC

89. Parameter
Range
Result Unit Reference
Range
Interpretation
WBC
4.50-11.00
13.64 10^9/L 4.50-11.00 Increase - due to presence of bacterial infectious process
Neu%
40.0-74.0
85.7 % 40.0-74.0 Increase - due to presence of bacterial infectious process
Lym%
19.0-48.o
9.7 % 19.0-48.0 Decrease – due to tissue trauma brought by ruptured appendix
Mon%
9.0
4.3 % 3.4-9.0 Normal
Eos%
0.0-7.0
0.2 % 0.0-7.0 Normal
Bas%
0.0-1.5
0.1 % 0.0-1.5 Normal
RBC
4.20-6.20
3.77 10^12/L 4.20-6.20 Decrease – Increased WBC leads to destruction of RBC in the blood;
- due to infection & internal hemorrhage brought by ruptured appendix
HGB
120-180
115 g/L 120-180 Decrease – due to infection & internal hemorrhage brought by ruptured
appendix
HCT
38.0-54.0
33.6 % 38.0-54.0 Decrease – due to infection & internal hemorrhage brought by ruptured
appendix
MCV
80.0-96.0
89.0 fL 80.0-96.0 Normal
MCH
27.0-31.0
30.5 Pg 27.0-31.0 Normal
MCHC
320-360
342 g/L 320-360 Normal
PLT 136 10^9/L 150-450 Decrease – due to infection & internal hemorrhage brought by ruptured
appendix

90. Test Reference Result Interpretation
Sodium, Na+ 135-148 mmol/L 136.9 mmol/L Normal
Potassium, K+ 3.50-5.30 mmol/L 4.32 mmol/L Normal
Chloride, Cl- 96-107 mmol/L 100.8 mmol/L Normal
ITRMC
Name: CALUZA, Geronimo Age: 69 y/o Sex:
Male Ward: Surgery Date: 2/4/2010
CLINICAL CHEMISTRY SECTION

92. The mouth, or oral cavity, is the first part of the digestive tract. It is adapted
to receive food by ingestion, break it into small particles by mastication,
and mix it with saliva. The lips, cheeks, and palate form the boundaries. The
oral cavity contains the teeth and tongue and receives the secretions from
the salivary glands.

93. Lips and Cheeks
The lips and cheeks help hold food in the mouth and keep it
in place for chewing. They are also used in the formation of
words for speech. The lips contain numerous sensory
receptors that are useful for judging the temperature and
texture of foods.
Palate
The palate is the roof of the oral cavity. It separates the oral
cavity from the nasal cavity. The anterior portion, the hard
palate, is supported by bone. The posterior portion, the soft
palate, is skeletal muscle and connective tissue. Posteriorly,
the soft palate ends in a projection called the uvula. During
swallowing, the soft palate and uvula move upward to direct
food away from the nasal cavity and into the oropharynx.

94. Tongue
The tongue manipulates food in the mouth and is used in
speech. The surface is covered with papillae that provide
friction and contain the taste buds.
Teeth
A complete set of deciduous (primary) teeth contains 20
teeth. There are 32 teeth in a complete permanent
(secondary) set. The shape of each tooth type corresponds
to the way it handles food.

95. Pharynx
The pharynx is a fibromuscular passageway that connects
the nasal and oral cavities to the larynx and esophagus. It
serves both the respiratory and digestive systems as a
channel for air and food. The upper region, the
nasopharynx, is posterior to the nasal cavity. It contains the
pharyngeal tonsils, or adenoids, functions as a passageway
for air, and has no function in the digestive system. The
middle region posterior to the oral cavity is the oropharynx.
This is the first region food enters when it is swallowed. The
opening from the oral cavity into the oropharynx is called
the fauces. Masses of lymphoid tissue, the palatine tonsils,
are near the fauces. The lower region, posterior to the
larynx, is the laryngopharynx, or hypopharynx. The
laryngopharynx opens into both the esophagus and the
larynx.

96. Esophagus
The esophagus is a collapsible muscular tube that serves as
a passageway between the pharynx and stomach. As it
descends, it is posterior to the trachea and anterior to the
vertebral column. It passes through an opening in the
diaphragm, called the esophageal hiatus, and then empties
into the stomach. The mucosa has glands that secrete
mucus to keep the lining moist and well lubricated to ease
the passage of food. Upper and lower esophageal
sphincters control the movement of food into and out of
the esophagus. The lower esophageal sphincter is
sometimes called the cardiac sphincter and resides at the
esophagogastric junction

97. Stomach
The stomach, which receives food from the esophagus,
is located in the upper left quadrant of the abdomen.
The stomach is divided into the fundic, cardiac, body,
and pyloric regions. The lesser and greater curvatures
are on the right and left sides, respectively, of the
stomach.

98. Small Intestine
The small intestine extends from the pyloric sphincter to
the ileocecal valve, where it empties into the large
intestine. The small intestine finishes the process of
digestion, absorbs the nutrients, and passes the residue on
to the large intestine. The liver, gallbladder, and pancreas
are accessory organs of the digestive system that are closely
associated with the small intestine. The small intestine is
divided into the duodenum, jejunum, and ileum. The small
intestine follows the general structure of the digestive tract
in that the wall has a mucosa with simple columnar
epithelium, submucosa, smooth muscle with inner circular
and outer longitudinal layers, and serosa. The absorptive
surface area of the small intestine is increased by plicae
circulares, villi, and microvilli.

99. Exocrine cells in the mucosa of the small intestine secrete
mucus, peptidase, sucrase, maltase, lactase, lipase, and
enterokinase. Endocrine cells secrete cholecystokinin and
secretin. The most important factor for regulating
secretions in the small intestine is the presence of chyme.
This is largely a local reflex action in response to chemical
and mechanical irritation from the chyme and in response
to distention of the intestinal wall. This is a direct reflex
action, thus the greater the amount of chyme, the greater
the secretion.

100. Large Intestine
The large intestine is larger in diameter than the small intestine.
It begins at the ileocecal junction, where the ileum enters the
large intestine, and ends at the anus. The large intestine consists
of the colon, rectum, and anal canal. The wall of the large
intestine has the same types of tissue that are found in other
parts of the digestive tract but there are some distinguishing
characteristics. The mucosa has a large number of goblet cells
but does not have any villi. The longitudinal muscle layer,
although present, is incomplete. The longitudinal muscle is
limited to three distinct bands, called teniae coli, that run the
entire length of the colon. Contraction of the teniae coli exerts
pressure on the wall and creates a series of pouches, called
haustra, along the colon.

101. Epiploic appendages, pieces of fat-filled connective
tissue, are attached to the outer surface of the colon.
Unlike the small intestine, the large intestine produces
no digestive enzymes. Chemical digestion is completed
in the small intestine before the chyme reaches the
large intestine. Functions of the large intestine include
the absorption of water and electrolytes and the
elimination of feces.

102. Rectum and Anus
The rectum continues from the signoid colon to the anal
canal and has a thick muscular layer. It follows the
curvature of the sacrum and is firmly attached to it by
connective tissue. The rectum and ends about 5 cm below
the tip of the coccyx, at the beginning of the anal canal. The
last 2 to 3 cm of the digestive tract is the anal canal, which
continues from the rectum and opens to the outside at the
anus. The mucosa of the rectum is folded to form
longitudinal anal columns. The smooth muscle layer is thick
and forms the internal anal sphincter at the superior end of
the anal canal. This sphincter is under involuntary control.
There is an external anal sphincter at the inferior end of the
anal canal. This sphincter is composed of skeletal muscle
and is under voluntary control.

105. The appendix is a closed-ended, narrow tube up to
several inches in length that attaches to the cecum , the
first part of the colon, like a worm. The anatomical
name for the appendix is vermiform appendix which
means worm-like appendage. It's pencil-thin and
normally about 4 inches (7 cm) long. The appendix is
usually located in the right iliac region, just below the
ileocecal valve (designated McBurney's point) and can
be found at the midpoint of a straight line drawn from
the umbilicus to the right anterior iliac crest.

106. The inner lining of the appendix produces a small
amount of mucus that flows through the open center
of the appendix and into the cecum. The wall of the
appendix contains lymphatic tissue that is part of the
immune system for making antibodies. During the first
few years of life, the appendix functions as a part of the
immune system, it helps make immunogobulins. But
after this time period, the appendix stops functioning.
However, immunoglobulins are made in many parts of
the body, thus, removing the appendix does not seem
to result in problems with the immune system. Like the
rest of the colon, the wall of the appendix also contains
a layer of muscle, but the muscle is poorly developed

108. MEDICAL
A. Ideal
The following are the ideal diagnostic procedures done to the patient
which were already explained thoroughly on the previous pages:
A. Urinalysis
B. WBC count
C. Abdominal X-ray
D. Ultrasound
E. Barium Enema
F. CT Scan
G. Laparoscopy
H. The Alvarado Score for Acute Appendicitis
Once a diagnosis of appendicitis is made, an appendectomy usually is
performed. Antibiotics almost always are begun prior to surgery and as
soon as appendicitis is suspected

109. B. Actual
The diagnostic procedure done to the patient were Urinalysis
and CBC. Patient was given the following medications:
* Cefuroxime 750 mg every 8 hours given via IV – prophylactic
antibiotic which inhibits synthesis of bacterial cell wall, causing
cell death
* Metronidazole 500 mg every 8 hours given via IV - prophylactic
antibiotic which inhibits synthesis of bacterial cell wall, causing
cell death
* Ranitidine 50 mg every 8 hours given via IV – to block H2
receptor that triggers production of stomach acid; to counteract
the two antibiotics which are both gastric irritants
* Ketorolac 15 mg every 4 hours for 6 doses given via IV - it has
anti-inflammatory and analgesic activity; inhibits prostaglandins
and leukotriene synthesis.

110. * Tramadol 50 mg every 8 hours for 4 doses given via IV - an
analgesic which binds to mu-opioid receptors andinhibits
the reuptake of norepinephrine and serotonin; causes many
effects similar to the opioids,dizziness, constipation
The patient was administered with D5LR 1 L regulated at 30
gtts/min. D5LR is actually 5% dextrose in lactated ringer's
solution. It is a hypertonic solution which aids in
replacement of lost body fluids.

111. SURGICAL
A. Ideal
Surgery is the only treatment for acute appendicitis. The
appendix may be removed intwo ways:
** First is the open method or through appendectomy. During an
appendectomy, an incisiontwo to three inches in length is made
through the skin and the layers of the abdominalwall over the area of
the appendix. The surgeon enters the abdomen and looks for
theappendix which usually is in the right lower abdomen. After
examining the area aroundthe appendix to be certain that no
additional problem is present, the appendix is removed. This is done
by freeing the appendix from its mesenteric attachment to the
abdomen andcolon, cutting the appendix from the colon, and sewing
over the hole in the colon. If anabscess is present, the pus can be
drained with drains that pass from the abscess and outthrough the
skin. The abdominal incision then is closed.

112. ** Second is Laparoscopic Method. Laparoscopy is a new
technique for removing theappendix which involves the use of
the laparoscope. The laparoscope is a thin telescopeattached to
a video camera that allows the surgeon to inspect the inside of
the abdomenthrough a small puncture wound (instead of a
larger incision). If appendicitis is found, theappendix can be
removed with special instruments that can be passed into the
abdomen,just like the laparoscope, through small puncture
wounds. The benefits of thelaparoscopic technique include less
post-operative pain (since much of the post-surgerypain comes
from incisions) and a speedier return to normal activities. An
additionaladvantage of laparoscopy is that it allows the surgeon
to look inside the abdomen to makea clear diagnosis in cases in
which the diagnosis of appendicitis is in doubt. For
example,laparoscopy is especially helpful in menstruating
women in whom a rupture of an ovariancysts may mimic
appendicitis.

113. B. Actual
The procedure done to the Patient is
Appendectomy, he was operated on February
5, 2010. His operation begun at 2:15 am and
ended at 2:50 am. His surgeon was Dr. Dag-O.

114. APPENDECTOMY
During an appendectomy, an incision two to three inches in
length is made through the skin and the layers of the
abdominal wall over the area of the appendix. The surgeon
enters the abdomen and looks for the appendix which
usually is in the right lower abdomen. After examining the
area around the appendix to be certain that no additional
problem is present, the appendix is removed. This is done
by freeing the appendix from its mesenteric attachment to
the abdomen and colon, cutting the appendix from the
colon, and sewing over the hole in the colon. If an abscess is
present, the pus can be drained with drains that pass from
the abscess and out through the skin. The abdominal
incision then is closed.

115. Appendectomy

116. Newer techniques for removing the appendix involve the
use of the laparoscope. The laparoscope is a thin telescope
attached to a video camera that allows the surgeon to
inspect the inside of the abdomen through a small puncture
wound (instead of a larger incision). If appendicitis is found,
the appendix can be removed with special instruments that
can be passed into the abdomen, just like the laparoscope,
through small puncture wounds. The benefits of the
laparoscopic technique include less post-operative pain
(since much of the post-surgery pain comes from incisions)
and a speedier return to normal activities. An additional
advantage of laparoscopy is that it allows the surgeon to
look inside the abdomen to make a clear diagnosis in cases
in which the diagnosis of appendicitis is in doubt.

118. If the appendix is not ruptured (perforated) at the time
of surgery, the patient generally is sent home from the
hospital after surgery in one or two days. Patients
whose appendix has perforated are sicker than patients
without perforation, and their hospital stay often is
prolonged (four to seven days), particularly if peritonitis
has occurred. Intravenous antibiotics are given in the
hospital to fight infection and assist in resolving any
abscess.

120. Occasionally, the surgeon may find a normal-appearing
appendix and no other cause for the patient's problem.
In this situation, the surgeon may remove the
appendix. The reasoning in these cases is that it is
better to remove a normal-appearing appendix than to
miss and not treat appropriately an early or mild case
of appendicitis

123. The major complication of appendicitis is perforation of the
appendix, which can lead to peritonitis, abscess formation
(collection of purulent material), or portal pylephlebitis,
which is septic thrombosis of the portal vein caused by
vegetative emboli that arise from septic intestines.
Perforation generally occurs 24 hours after the onset of
pain symptoms include a fever of 37.7 degree Celsius or 100
degree Fahrenheit or greater, a toxic appearance and
continued abdominal pain or tenderness.

124. REFERENCE
Books
> Brunner and Suddarth’s Textbook of Medical
Surgical Nursing (11th Edition, Joyce Young
Johnson)
> 2009 LIPPINCOTT’S Nursing Drug Guide (Amy M.
Karch)
> Nurse’s Pocket Guide by Marilynn E. Doenges et.
al
> Health Assessment and Physical Examination by
Josie Quiambao Udan, RN,MAN

125. Internet
> http://www.abdopain.com/history-of-appendicitis.html
> Amazon.com Widgets
> http://www.abdopain.com/causes-of-appendicitis.html
> http://www.abdopain.com/Pathophysiology-of-> >
appendicitis.html
> http://www.abdopain.com/symptoms-of-appendicitis.html
> http://www.abdopain.com/diagnosis-of-appendicitis.html
> http://www.abdopain.com/differential-diagnosis-of->
appendicitis.html
> http://www.scribd.com/doc/20794198/NCP-S-P->
Appendectomy
> http://www.wikipedia.com
> http://www.medscape .com