A CASE STUDY ON APPENDICITIS

PURBANCHAL UNIVERSITY 
ASIAN COLLEGE FOR ADVANCE STUDIES
SATDOBATO,LALITPUR




                            A

CASE STUDY ON

APPENDICITIS








SUBMITTED TO                                  SUBMITTED BY:
MRS. ARUNDHATI SHRESTHA                         SMRITI  MANANDHAR
MS.HELINA PYAKHUREL                                    PBBN 1st year
                                                   ROLL NO:37

                                    

Acknowledgement

This case study report is prepared during Adult nursing clinical practicum in B&B Hospital, Gwarko.  The report is prepared as a practical fulfillment of post basic PBN curriculum. I realized that the requirement to do complete case study in the nursing area has been an important opportunity for me to gain new experience and knowledge in this field.

I got myself complete involved in the care and management of the patient during this period. However the work would not have been accomplished successfully with my effort alone.

I would like to express my sincere gratitude to all teachers of my colleges for providing valuable guidance, supervision and suggestions in the clinical field area.

I am also thankful to my colleagues and my patient and his family who gave me their valuable time for providing necessary information and kind cooperation during hospitalization. I am also thankful to doctors and nursing staffs of the hospital throughout the clinical practice without them the case would not have been completed.

Finally, I would like to thank all of them who gave me their precious, valuable time and suggestions directly or indirectly while preparing this case study.

Background

Nepal is one of the developing countries with the with many morbid surgical disease prevalence. Acute appendicitis is the most common surgical emergency which seems to be most common in the second decade of life.the incidence of acute appendicitis is 0.15% in males and 0.19%in females with an overal life time risk of 6-20%.

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Acute appendicitis is the most common surgical emergency. Obstruction of the lumen by fecolith is the usual cause of acute appendicitis.Though inspite of effective curative treatment ,if delayed in treatment  it may lead to life threatening situations.Thus, the study was to analyze clinical presentation of acute appendicitis and its histopathological correlationis determined for the disease condition and its managenent so as to diminish the disease prevalence .

According to post Basic Nursing curriculum to function effectively and independently in the field at nursing care of adult required to do 4 weeks of practical in different areas. During the period, I selected acute Appendicitis which is the most common cause of adult disease conditions, in surgical ward of B&B Hospital. So this case study was designed to gain and provide comprehensive knowledge of Acute Appendicitis and care to the patient.

Reason for case selection

The general objectives of the case study as suggested by the curriculum, is to gain the comprehensive knowledge about the disease condition and to gain the practical experience in adult nursing for providing effective nursing care.

I have selected acut appendicitis as a case study because it is most common cause of mordidity in adults’ nowdays. 680,000 per year, 56,666 per month, 13,076 per week, 1,863 per day, 77 per hour, 1 per minute,is being suffered from appendicitis. I found this disease condition challenging and interesting so I preferred this case to alert to related community at the right time then we can enhance our khnowledge about the appendicitis and reduces the incidence of morbidity and complications.

Objectives

General objectives:

At the end of four weeks practicum we will be able to:

Ø  Identify the disease condition prevalent in the hospital

Ø  Gain the knowledge about the disease condition and its comparative relation with the patient.

Ø  Provide nursing care for the patient and family within the hospital by the application of nursing process.

Ø  Perform activities to maintain and promote optimum health of the patient.

Ø  Provide health teaching and evaluate total care study.

Specific objectives:

Ø  To indentify  the disease condition

Ø  To take health history and record of finding and to physical examination.

Ø  To formulate appropriate nursing diagnosis and nursing care plan according to the nursing theory and priority the patients needs.

Ø  To write nursing management to be performed during the patients hospitalization.

Ø  To perform nursing activities for reducing discomfort or pain of the patient.

Ø  To indentify the needs of the patient.

Ø  To conduct different health techniques according to the need and in the level of understanding.

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

Part I

Biographical data of my patient

Name of Patient         : Ram Bahadhur Ghatri

Age                             : 37 years

Sex                                : Male

Ethnic group               : Janajati

Religion                        : Hindu

Education                     : Bachelor in Education

Occupation                   : Bussiness

Address                        : Balaju

Nationality                    : Nepali

Marital status               : Married

Date of admission       : 2069/03/11

Hospital                        : B &B hospital, Gwarko

Ward                             : Surgical Ward

Bed no                             : 410”A”

Hospital No                   : 1730

Provisional Diagnosis   : Acute Appendicitis

Date of operation          : 2069/03/12

Operative Procedure    : Laproscopic Appendectomy

Consultant Doctor        : Dr.Niraj lal Baidya

Date of discharge         : 2069/03/15

Health history of patient

Chief complain:

Ø  Pain abdomen since 2 days back(peri umbilical pain and later right side pain more than left)

Ø  1 episode of fever upto 101°F

Ø  1 episode of vomitting

Present history:

Patient complaints of acute abdomen pain (generalised) since evening a day back.The pain was associated with an episode of fever and vomitting diminished by medicine later on.

Later on the pain persist on the right illac fossa of the patient so he was brought to the hospital for further management.

Socio-economic history: He belongs to a middle class family. He is the bussiness man and the bread owner of the family.

Personal History:  He has no any history of allergy toward drugs and any foods. He is non drinker and smoker.

Medical surgical history: No history of tuberculosis, diabetes and hypertension .He had not any infectious disease like HbsAg, HIV or STI.

He has no any history of medical illness like T.B, asthma, renal disease, hypertension, heart disease etc.

He was admitted at janamaitri hospital for ureteroscopy for UTI (urinary tract infection) for a day 1 year back.

Family history: There was no significant history of chronic and hereditary disease; chronic illness.His mother was operated cholecystectomy for cholelithiasis almost a year back.

Health seeking practice: He belongs to the urban area of Kathmandu. Though, they believed in both traditional healer, dhami, jhakri and hospital treatment. So if anybody in the family gets ill they first go to the hospital first but also believe intraditional healers.

Personal health history: Non smoker and Non alcoholic. No any food taboos practice in his family/home. So he eats every kind of food everyday.

Environmental factors: they live in urban setting in Kathmandu valley with well accesibility of health facilities, education, water supply, and other facilities.

3 storyed houses with7 rooms, separate kitchen and seperate sanitary laterine.

                                          

Physical examination of the patient

It is an important tool of assessing the patient’s health status and about 15% of the information used in assessment comes from the physical examination.

The methods that I have applied in the physical examination of the patient are:

Ø  Measurement

Ø  Smelling

Ø  Inspection

Ø  Palpation

Ø  Percussion

Ø  Auscultation

Vital sign

Temperature: 99°F

Pulse: 92/min

Respiration: 20/min

Blood Pressure: 120/80

Measurement:

Height: 5 ft 4 inches

Weight: 56kg

General Appearance:

He can walk straight (gait). His general state of health is normal. He appears healthy, well nourished. His reaction is appropriate to the stimuli. Hygiene and cleanliness are maintained.

Head to toe examination:

1.    Head and face:  Round and symmetrical. Condition of the scalp is clean and color and texture of hair is black and silky. Any injury is not present, no swelling, no tender shape is round and face is in round shape.

2.    Eyes:  discharge absent, movement-bilateral equal movement, color of conjunctiva- normal, pink, color of sclera- white, transpired, pupil- normal in size and good reaction to light and no any abnormality found.

3.    Ears:  Cleanliness- clean, discharge- absent but slightly wax present, pain – not found, Hearing problem- no, lymph node are not palpable.

4.    Nose: Location-centrally located, deviation- not deviated septum, blockage- not found, and injury- not presents, bleeding- not present, polyps- not present and infections not present.

5.    Mouth, throat and neck:  Lips- no cracks, looks pink, gums- not swelling and bleeding present, buccal mucosa is pink in color, not any sore or rashes present, no missing teeth, Tongue- normal, moist, no sore present, maxillary lymph node is not palpable, cervical lymph node are not palpable, thyroid glands are not enlarged, Neck is freely movable and tonsils is normal and not any redness or enlargement.

6.    Chest and lungs: Size, shape and symmetry are normal, chest movement is bilateral equal, respiratory rate is normal, dysponea, cough, haemoptysis, cyanosis are absent, resonant sound found all over the lungs area and no any dull sound on percussion,  wheezing,  crept sounds are absent, normal breathing sound is present on auscultation and no any abnormality found.

7.    Abdominal examination:

 A) Inspection- normal oval in shape

 B) Palpation-slightly tenderness in the right illac fossa.Presence of rebound tenderness.

 C) Auscultation- On auscultation normal bowel sound heard

8.    Cardiovascular system: pulse-92/min, BP-120/80 mmofhg, heart sound is normal sound (lub-dub) present on auscultation.

9.    Musculoskeletal system: Muscle weakness is absent, joint pain or stiffness is absent, edema on joints or ankles are absent and any other fracture or deformity is not found.

10. Genitourinary system: No any discharge present.normal external genitalias.

Development task of young adult

The young adult period is started from ages of 21 to 39. By the age of 21yrs, physical growth is nearly complete. The young adult period is very important and precious for and individual. This is the time to grasp new things to adopt in the society, to develop self confidence, to have a sense of mastery anal self control over life events and surroundings.

Young adult is one of the most stable period of life which involves intellectual growth, becoming more knowledge, depth in analytic and systemic thinking, logical seasoning, there may be a transient quality of the occupational choices and relationship which are being established at this time. The following are the developmental task of young adults:

a)    Accepting self establishment, self concept and body image.

b)    They establish personal set of values

c)    Becoming independent from parental control

d)    Becoming establishment in a vocational or professional that provides personal satisfaction, economic independency and feeling of making a worth which contributing to society.

e)    Develop a sense of personal identity

f)     Learning appraises and empress lives, responsibilities through more than sexual contact.

g)    Establishing an intimate bound with others either through marriage or with close friends.

h)   Managing a home and managing a tie schedule and life stress.

i)     Deciding tasks or not to have a family and carryout tasks of parenting.

j)     Becoming invaluable as a citizen in the community.

k)    Early detection of disease process

l)     Establishment of life ling health maintenance measures.

“In My Patient”

a)    By talking with him and analyzing his ideas or view, I have found that he is adjusting with her aging process.

b)    He is higher educated person and has establish personal set of values

c)    He has already establishment in his society and has established personal set of values. He is independent problem, earner of his family and a midlle class responsible man.

d)    He is able to manage a home and managing a time schedule and life stress.

e)    He has already developed a sense of personal identity and became a precious as a citizen in the community.

f)     His is well cope with his disease condition.Inspite of mild anxiety; he was well oriented about his health, as he was well expalain by the hospital personnels.

Part II

Disease profile:

Acute appendicitis:

Appendicitis is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts. This condition is a common and urgent surgical illness with protean manifestations, generous overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay. In fact, despite diagnostic and therapeutic advancement in medicine, appendicitis remains a clinical emergency and is one of the more common causes of acute abdominal pain.

Incubation period for Acute Appendicitis: 

Usually 2 to 48 hours for acute appendicitis

Epidemiology

1. Highest incidence is 10-19 year olds. It is unusual under the age of 1 year.
2. The risk of perforation is greatest in 1-4 year olds and least in 10-14 year olds. 
3. Appendectomies are the most common emergency surgical procedures performed 
4. It is unusual in third world countries and there is a questionable relationship to high fiber diets.

Risk factors

·         Age: it can occur in all age groups ; common between the ages of 11 and 20.

·         Gender: A male preponderance exists, with a male to female ratio (1.4: 1) and the overall lifetime risk is 8.6% for males and 6.7% for females. A male child suffering from cystic fibrosis is at a higher risk for developing appendicitis.

·         Diet: People whose diet is low in fiber and rich in refined carbohydrates have an increased risk of getting appendicitis.

·         Hereditary: A particular position of the appendix, which predisposes it to infection, runs in certain families. Having a family history of appendicitis may increase a child's risk for the illness.

·         Seasonal variation: Most cases of appendicitis occur in the winter months - between the months of October and May.

·         Infections: Gastrointestinal infections such as Amebiasis, Bacterial Gastroenteritis, Mumps, Coxsackievirus B and Adenovirus can predispose an individual to Appendicitis.

Pathophysiology:

If appendiceal obstruction persists, intraluminal pressure rises ultimately above that of the appendiceal veins, leading to venous outflow obstruction. As a consequence, appendiceal wall ischemia begins, resulting in a loss of epithelial integrity and allowing bacterial invasion of the appendiceal wall.

Within a few hours, this localized condition may worsen because of thrombosis of the appendicular artery and veins, leading to perforation and gangrene of the appendix. As this process continues, a periappendicular abscess or peritonitismay occur.

Appendicitis means inflammation of the appendix. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is called a fecalith (literally, a rock of stool). At other times, it might be that the lymphatic tissue in the appendix swells and blocks the opening. After the blockage occurs, bacteria which normally are found within the appendix begin to invade (infect) the wall of the appendix. The body responds to the invasion by mounting an attack on the bacteria, an attack called inflammation. An alternative theory for the cause of appendicitis is an initial rupture of the appendix followed by spread of bacteria outside of the appendix. The cause of such a rupture is unclear, but it may relate to changes that occur in the lymphatic tissue, for example, inflammation, that lines the wall of the appendix.)

If the inflammation and infection spread through the wall of the appendix, the appendix can rupture. After rupture, infection can spread throughout the abdomen; however, it usually is confined to a small area surrounding the appendix (forming a peri-appendiceal abscess).

Clinical Presentation

The main symptom of appendicitis is abdominal pain. Pain in the right side of the abdomen.; usually begins near the navel and moves down and to the right. The pain becomes worse when moving, taking deep breaths, coughing, sneezing, and being touched in the area.

Other symptoms of appendicitis may include

• loss of appetite
• nausea,vomiting
• constipation or diarrhea
• inability to pass gas
• a low-grade fever that follows other symptoms
• abdominal swelling

In my patient:

·         abdomen pain was present

·         anorexia and vomiting present

·         low grade fever a day back

Diagnosis

 The most cases of appendicitis are diagnosed by taking a person's medical history and performing a physical examination. If a person shows classic symptoms, surgery is done right away to remove the appendix before it bursts. The other laboratory and imaging testsis also done to confirm appendicitis if a person does not have classic symptoms. Tests may also help diagnose appendicitis in people who cannot adequately describe their symptoms, such as children or the mentally impaired.

Physical findings

1. There is often diffuse abdominal tenderness.
2. There may be slight abdominal distention with initially increased and then decreased bowel sounds.
3. Point tenderness at McBurney's point which lies half-way between a lines drawn from the umbilicus to the anterior iliac spine. 
4. Rebound tenderness
5. Rectal exam- value is questionable and should be done if suspect perforation and abscess.
6. Psoas sign- pain on flexion of the hip and Obturator sign which is increased pain on internal rotation of flexed thigh.
7. Check genitalia for possible incarcerated hernia or testicular pathology.

Laboratory

1.     CBC may demonstrate an increased WBC count and RBC morphology should be checked

2.     Urinalysis may have increased white cells

Imaging Studies

1.     Plain film of abdomen may show fecalith, ileus pattern, evidence of constipation, or pneumonia.

2.     Barium enema will show absence of filling of the appendix

3.     Ultrasound and CT have been useful in certain situations.

Investigation done in my patient:

Investigation item                                 findings                  normal range

2069/03/11

WBC                                                   10,700/cu mm              (4,000-11,000)

Neutrophils                                          75%                             (40-75%)

Lymphocytes                                        21%                             (20-45%)

Monocytes                                           01%                              (2-10%)

Erythrocytes                                         03%                              (2-6%)

ESR                                                     05mm/Hr                       (1-6)

Hb                                                        14gm%                          (13.5-17.5)

RBC                                                     4.77                               (5.5-6.5)

PCV                                                     41%                               (11.50-50.40)

MCV                                                     86.0 fl                             (80.0-96)

MCH                                                    29.4pg                             (27.5-33.20)

MCHC                                                  34.1%                              (32-36%)

Platelets                                               241,000/cumm                (150,000-400,000)

Blood group                                        O +ve

Blood sugar(Random)                        73mg/dl                             (70-140 mg/dl)

Creatinine                                           0.73mg/dl                          (0.66-1.25 mg/dl)

URINE EXAMINATION

Macroscopic                                       Color  light yellow

pH                                                      Acidic

Sugar                                                  Nil

Appearance                                       clear

Albumin                                              Nil

Microscopic

Puscell                                               0-1

RBC                                                   Nil

Cast                                                    Nil

Crystal                                                 Nil

Epithial cells                                        0-2

Bacteria                                              Nil

2069/3/12

Anti HIV 1 and 2                                Non-Reactive

HbsAg                                                Non –Reactive

Anti HCV                                           Non-Reactive

Ultrasonography :

Liver :normal  Gall Bladder:Normal CBD: Not dilated Pancreas:Normal Spleen:Normal Kidney:Normal Bilateral kidney:Normal ? suggestively Mildly inflammed appendix

Treatment and management

Treatments for Acute Appendicitis:

If acute appendicitis is diagnosed and treated promptly before the appendix ruptures, the outcome is generally very good. The treatment includes may include both surgical and non surgical interventions.

Surgery:

Surgery to remove the appendix is called appendectomy and can be done two ways. The older method, called laparotomy, removes the appendix through a single incision in the lower right area of the abdomen. The newer method, called laparoscopic surgery, uses several smaller incisions and special surgical tools fed through the incisions to remove the appendix. Laparoscopic surgery leads to fewer complications, such as hospital-related infections, and has a shorter recovery time.

 Mr.ghatri was undergone laproscopic Appendectomy for surgical treatment of Appendicitis.

Surgery occasionally reveals a normal appendix. In such cases, many surgeons will remove the healthy appendix to eliminate the future possibility of appendicitis. Occasionally, surgery reveals a different problem, which may also be corrected during surgery.

Sometimes an abscess forms around a burst appendix—called an appendiceal abscess. An abscess is a pus-filled mass that results from the body's attempt to keep an infection from spreading. An abscess may be addressed during surgery or, more commonly, drained before surgery. To drain an abscess, a tube is placed in the abscess through the abdominal wall. CT is used to help find the abscess. The drainage tube is left in place for about 2 weeks while antibiotics are given to treat infection. Six to 8 weeks later, when infection and inflammation are under control, surgery is performed to remove what remains of the burst appendix.

Nonsurgical Treatment:

Nonsurgical treatment may be used if surgery is not available, if a person is not well enough to undergo surgery, or if the diagnosis is unclear. Some research suggests that appendicitis can get better without surgery. Nonsurgical treatment includes analgesics to relieve pain and antibiotics to treat infection and a liquid or soft diet until the infection subsides. A soft diet is low in fiber and easily breaks down in the gastrointestinal tract.

Nursing management:

Nursing Assessment
The identity of the client

1. History of Nursing
• Current medical history; complaints of pain in postoperative wound appendectomy, nausea, vomiting, increased body temperature, increased leukocytes.
• Past medical history
2. Physical Examination
• Cardiovascular System: To determine vital signs, presence or absence of jugular venous distension, pallor, edema, and abnormal heart sounds.
• Hematologic System: To determine whether there is an increase in leukocytes is a sign of infection and bleeding, nosebleeds splenomegaly.
• Urogenital System: Whether or not the tension of the bladder andlower back pain complaints.
• Musculoskeletal System: To determine whether there is difficulty in movement, pain in bones, joints and there is a fracture or not.
• The immune system: To determine whether there is lymph node enlargement.
3. Investigations 
•   Routine blood tests: to determine an increase in leukocytes is a sign of infection.
•   Abdominal examination photo: to know the existence of post-surgical complications.

Nursing Diagnosis Preoperative and Postoperative Appendectomy

Preoperative Appendectomy

1. Acute pain related to distention of the intestinal tissue by inflammation.

2. Risk for deficient fluid volume related to preoperative vomiting.

3. Anxiety related to change in health status.

Postoperative Appendectomy

1. Acute pain related to the presence of postoperative wound appendectomy.

2. Impaired nutrition less than body requirements related to reduced anorexia, nausea.

3. Risk for infection related to surgical incision.

4. Deficient knowledge: about the care and diseases related to lack of information.


Nursing Interventions

1. Preparation of general surgery

this can be done by the nurse when the client entered the operating room nurse before surgery:
Introducing the client and close relatives of hospital facilities to reduce the anxiety of clients and their relatives (the orientation of the environment).

• Measuring vital signs.
• Measure weight and height.
• Collaboration is an important laboratory tests (hematocrit, serum glucose, Urinalisa).
• The interview.

2. Preoperative Interventions
Observation of vital signs

• Assess fluid intake and output
• Auscultation of bowel sounds
• Assess the status of pain: the scale, location, characteristics
• Teach relaxation techniques
• Give fluids intervena
• Examine the level of anxiety
• Give information about the disease process and actions

PostoperativeIinterventions

• Observation of vital signs
• Assess the scale of pain: characteristics, scale, location
• Assess the state of the wound
• Advice to change position as tilted to the right, left and sat down.
• Assess nutritional status
• Auscultation of bowel sounds
• Give wound care information and disease

Evaluation

1. Impaired sense of comfort: pain is resolved
2. No infection
3. Overcome nutritional deficiencies
4. The client understands about care and illness
5. Weight loss does not occur
6. Vital signs within normal limits

Complications

1.     Wound infection

2.     Intra-abdominal abscess- occurs in 4-6% of perforations

3.     Intestinal obstruction

4.     Increased incidence of infertility in females who have had a perforation of the appendix secondary to fallopian tube obstruction and adhesions

5.     Appendix rupture

6.     Peritonitis

7.     Death

Impact on hospitalization on developmental needs and tasks:

Mr .Ghatri,a young man was admitted with the diagnosis acute appendicitis.Initially he seems to be slight anxious about his disease condition and the pain.Though he requires assistance for counselling for the condition of hospital admissionand his disease condition and action being carried out. So he needs help in his every steps, like nursing care.

Part III

Applying VERGINIA HENDERSONS THEORY

Application of nursing theory: my patient Mr.Ghatri, 37 years male was admitted  with a diagnosis of  Acute appendicitis. In surgical ward to make her comfort and to reduce the anxiety,I have applied verginiaHenderson’s nursing theory to her according to her main focus of theory is:

1.    Independency of client

2.    Assist individual towards self care needs of the individual and this is affected by;

Ø  Age: development theory- newborn baby, child, adolescent, young adult, middle age and old age.

Ø  Background- cultural, family, friends status

Ø  Emotional balance – normal anxious, hyperactive

Ø  Physical and intellectual capacities- physical handicap or mental illness.

Her main points are:

SN	According to V. Henderson	According to my patient
1	Breath normally	He wasn’t having any breathing diffivulty
2	Eat and drink adequately	Pleasant rooming,encouragement on intake and frequent small intake with intake output monitoring was done
3	Eliminate body wastes	Abdomen distension was reduced but no any bowel distrubances [resent.
4	Move and maintain desirable postures	He was encouraged for ambulanced and post operative exercises after operation.
5	Sleep and rest	Rest and sleep was encouraged to reduce anxiety.
6	Select suitable clothing dress and undress	Clean hygenic dress were assured to avoid risk for infection
7	Maintain body temperature within normal range by adjusting clothing and modifying the environment.	Mild fever persist but its well managed with cold sponging .No any medical intervention done
8	Keep the body clean and well groomed and protect the integument.	He was help to be well groomed and clean as usual
9	Avoid dangerous in the environment and avoid injury	Patient was safe in the hospital. I had put all the equipments which was used during procedure were kept in safe and proper place.
10	Communicating with others in  expressing emotions, needs, fears or opinions	As hospital admission is a crisi situaion for him, he was well ventilated to express his queries and well explain about the disease and its management.
11	Worship according to one’s faith	He was comforted in his hindu religion.
12	Work in such way that there is a sense of accomplishment	He was satisfied with the care provided and his progress with the disease
13	Play or participate in various forms of recreations	He was charming person well adjusted and adaptable to entertain like using laptops
14	Learn, discover or satisfy the curiosity that leads to normal development and health and use of the available health facilities.	Taught him about the uses of health facilities, health promotion, discharge teaching

The implement these nursing diagnosis, I have made a nursing care plan.

                   Preoperative nursing care plan

SN	Nursing diagnosis	Nursing goal	Nursing intervention	Rationale	evaluation
1.	Risk for deficient fluid volume related to preoperative vomiting.	The client will: Maintain adequate fluid balance as evidenced by moist mucous membranes, good skin turgor, stable vital signs, and individually adequate urinary output.	-Assess fluid and electrolyte output Monitor blood pressure (BP) and pulse. -inspect mucous membranes; assess skin turgor and capillary refill. - Monitor intake and output (I&O); note urine color and concentration and specific gravity. -auscultate bowel sounds. Note passing of flatus and bowel movement. -Provide clear liquids in small amounts when oral intake is resumed, and progress diet as tolerate	Variations help identify fluctuating intravascular volumes or changes in vital signs associated with immune response to inflammation. - Indicators of adequacy of peripheral circulation and cellular hydration. - Monitor intake and output (I&O); note urine color and concentration and specific gravity. -Indicators of return of peristalsis and readiness to begin oral intake. Note: This may not occur in the hospital if client has had a laparoscopic procedure and been discharged in less than 24 hours. -Reduces risk of gastric irritation and vomiting to minimize fluid loss.	My goal was met the risk for fluid deficit was minimized.
2.	Acute pain related to distention of the intestinal tissue by inflammation.	Report pain is relieved/controlled. - Appear relaxed, able to sleep/rest appropriately.	-assess the status of pain:the state, location and characteristics -Provide accurate, honest information to patient -Administer analgesics as indicated. -Provide diversional activities           -Keep NPO/maintain NG suction initially.	-Useful in monitoring effectiveness of medication, progression of healing. Changes in characteristics of pain may indicate developing abscess/peritonitis, requiring prompt medical evaluation and intervention. -Being informed about progress of situation provides emotional support, helping to decrease anxiety -Relief of pain facilitates cooperation with other therapeutic interventions, e.g., ambulation, pulmonary toilet -Refocuses attention, promotes relaxation, and may enhance coping abilities.  -Decreases discomfort of early intestinal peristalsis and gastric irritation/vomiting.	My goal was partially met.the patient was quiet relieved by the therapy but not controlled.
3.	Anxiety related to change in health status.	To relieve anxiety	-examine the level of anxiety -Give information about the disease process and actions -Reassure the client --Encourage the patient  -Spend time with client encourage him	Understanding promotes cooperation with therapeutic regimen, enhancing healing and recovery process	My goal was met the patient was less anxious and well oriented about his disease condition.

Post operative nursing care plan

SN	Nursing diagnosis	Nursing goal	Nursing intervention	Rationale	evaluation
1	. Acute pain related to the presence of postoperative wound appendectomy	-Report  Pain is relieved/controlled. - Appear relaxed, able to sleep/rest appropriately.	-assess the status of pain:the state, location and characteristics - Keep at rest in semi-Fowler’s position. -Encourage early ambulation. -Administer analgesics as indicated.	-Useful in monitoring effectiveness of medication, progression of healing. Changes in characteristics of pain may indicate developing abscess/peritonitis, requiring prompt medical evaluation and intervention. -Gravity localizes inflammatory exudate into lower abdomen or pelvis,  -Promotes normalization of organ function, e.g., stimulates peristalsis and passing of flatus, reducing abdominal discomfort. -Relief of pain facilitates cooperation with other therapeutic interventions, e.g., ambulation, pulmonary toilet	My goal was met the pain was relieved.
2	Impaired nutrition less than body requirements related to reduced anorexia,nausea	Client Will maintain nutritional balance	-give fluid interventions -Weigh the body weight every day; monitor the results of laboratory examination. -Plan maintenance procedures have an unpleasant or painful not done before eating. -Offer to eat small portions but frequently to reduce feelings of tension in the stomach	-fluid replaces the body nutritional requirement -indicators of adequacyn of nutritional intake -facilitates to eat easily -Reduces risk of gastric irritation and vomiting to minimize fluid loss	My goal was met.the appetite of the patient slowly established.
3	Risk for infection related to surgical incision.	Client Will Wound Healing: Primary Intention Achieve timely wound healing, free of signs of infection and inflammation, purulent drainage, erythema, and fever.	-Observation of the vital signs - Practice and instruct in good hand-washing and aseptic wound care. -Encourage and provide perineal care. -Inspect incision and dressings. Note characteristics of drainage from wound or drains (if inserted) and presence of erythema. - Obtain drainage specimens, if indicated. - Administer antibiotics, as appropriate.	- Suggestive of presence of infection, developing sepsis, abscess, and peritonitis. -Reduces risk of spread of bacteria. - Provides for early detection of developing infectious process and monitors resolution of preexisting peritonitis. - Gram’s stain, culture, and sensitivity testing is useful in identifying causative organism and choice of therapy. - Antibiotics given before appendectomy are primarily for prophylaxis of wound infection and are not usually continued postoperatively. -Therapeutic antibioticsare administered if the appendix is ruptured or abscessed, or peritonitis has developed.	My goal was met.the risk for infection was minimised.
4	Deficient knowledge: about the care and diseases related to lack of information	Verbalize understanding of disease process and potential complications. Verbalize understanding of therapeutic needs. Participate in treatment regimen.	-Encourage progressive activities as tolerated with periodic rest periods. - Recommend use of mild laxative/stool softeners as necessary and avoidance of enemas.       -Discuss care of incision, including dressing changes, bathing restrictions, and return to physician for suture/staple removal.           .	-Prevents fatigue, promotes healing and feeling of well-being, and facilitates resumption of normal activities. - Assists with return to usual bowel function; prevents undue straining for defecation.  -Understanding promotes cooperation with therapeutic regimen, enhancing healing and recovery process	My goal was met.the Client was able to verbalize the understanding about the disease condition and the treatment.

Daily progress and management of my case

Date: 2069/3/11

Mr.Ram Bahadur Ghatri was admitted to the surgical ward.His general condition e\was quite weak and he was complaining of abdomen pain and mild fever.

Vitals:

Temperature:           99degree Fahrenheit

BP:                              120/80

Respiration:              20/minute

Pulse:                         92/min

On physical examination:

Normal physique except abdominal tenderness.

Management:

-Analgesices given.

-All the investigations done

-patient well explained for the operative procedure tommorrow.

-Preanasthetic check up done

Medications:

 Tab.flexon 1 tab p/o SOS

Date: 2069/3/12

Mr.Ram Bahadur Ghatri was prepared for operation.

Pre operative Vital signs:

Temperature:           97.3degree Fahrenheit

BP:                              110/80

Respiration:              24/minute

Pulse:                         82/min

On physical examination:

Normal physique except abdominal tenderness.

Management:

-preoperative counselling

-NPO from midnight

Operative procedure (laporatomy appendectomy under general anaesthesia):

Patient was kept in supine position.painting and drapping done.10 mm umbilical port made and pneumoperitoneum created.Another 10 mm created on left illac fossa along left MCC

And 5 mm port at supra pubic region.Appendicular base traced along the confluence of the tenia cli,below findings noted,peri appendicular artery clipped out with harmonic,appendicular base ligated with endolope.Haemostasis maintained and all ports were closed

Findings:

Mildly inflammed appendix, especially at the tip.No peri appendicular collections; adhension of ascending colon over right side of abdomen.

The specimen was sent for Histopathological examination.

Post operative Vital signs:

Temperature:           99degree Fahrenheit

BP:                              120/80

Respiration:              22/minute

Pulse:                         68/min

Saturation:                94% with out oxygen

Medications:          I pint injection Ringer Lactate

                                 Injection ceftriaxone 1 gm I/V stat

Total intake upto 12 MN: 2200 ml

Total output upto 12 NM: 1350 ml

On physical examination:

No any soakage from the incision site.

Foley’s catheter present.

Management:

-Analgesices given.

-rest encouraged

-patient well explained for the post operative complications and early ambulation.

Medications:

Inj DNS II

Inj.5% dextrose i

Inj cifran 200 mg BD

Inj Raciper 40 mg BD

Inj ketorolac 30 mg TDS

2069/3/13

Patient general condition was quite improving.Drip off and Foley’s out was done.Encouraged for ambulation and sips intake.

Vital signs:

Temperature:           97.2degree Fahrenheit

BP:                              100/80

Respiration:              24/minute

Pulse:                         66/min

Saturation:                92% with out oxygen

Total intake upto 12 MN: 1800 ml

Total output upto 12 NM: 2920 ml

On physical examination:

No any soakage from the incision site.

Management:

-medicines given as prescribed.

-ambulation done

-patient well ventilated to express his anxiety of the state and explained about the disease condition.

Medications:

Tab.cifran 500 mg P/O BD

Tab. Raciper 40 mg P/O BD

Tab. Flexon 1 tab P/O SOS

Date: 2069/3/14

Patient general condition was quite improving.Drip off and Foley’s out was done.Encouraged for ambulation and soft diet intake.

Vital signs:

Temperature:           98.2degree Fahrenheit

BP:                              120/70

Respiration:              24/minute

Pulse:                         86/min

Saturation:                99% with out oxygen

On physical examination:

No any soakage from the incision site.

Management:

-medicines given as prescribed.

-ambulation done

-patient well ventilated to express his anxiety of the state and explained about the disease condition.

Medications:

Tab.cifran 500 mg P/O BD

Tab. Raciper 40 mg P/O BD

Tab. Flexon 1 tab P/O SOS

Date: 2069/3/15(discharge date)

Patient general condition was quite improved.he was well adapted to his state.He was on normal diet, quiet independent to achieve his personal activities.dressing was done and discharge was done with the discharge instructions.

Stress management and diversion therapy

            Stress is a state produced by change in environment. It is a factor which pressurize mentally or physically and adversely affects the functioning of body. When stresses more sense or prolonged, a person needs divisional therapy or coping mechanism.

            It is a change in the environment that is perceived as a threat, challenge or harm to the person’s dynamic equilibrium. Every person finds it difficult to adjust I new environment. It takes came time to adjust. In these conditions one feels anxious and wants to demand safety and security. Even in the best hospital setting a patient psychologically feels strange, conflicting and frightening isolated and lovely in spite of many people around.

The following understandable site effects may be seen:

Ø  Forced dependency

Ø  Strange authority figures

Ø  Dramatic change in physical environment

Ø  Disturbed daily routines

Ø  Increased anxiety

Ø  Forced adjustment

Ø  Loss of privacy and freedom

            Undergoing any surgery is like a crisis for any individual.Mr.Ghatri seems to be curious about his disease condition, operative procedure, and its management.

To minimize the stress of patient I provided the following activities:

Ø  Provide psychological support showing another patient of appendectomy.

Ø  Encourage his family member to stay with him as possible.

Ø  Providing time to express his feelings about disease and hospitalization fear and emotion.

Ø  Try to provide calm and quiet environment.

Ø  Providing informal health teaching as patient’s need

Ø  Encourage family members to visit the patient frequently.

Ø  Give information about the disease condition.

Progressive muscles relaxation: it helps in relieving muscle tension related to stress. I have advised my patient to tense muscle than relax slowly alternately until the entire muscle feels relax.

Distraction therapy: In this technique I have advised family members to visit patient for sometime one by one and talk to him.

Diversion therapy: The therapy which divert the mind of patient.In this therapy I have advised the patient to talk on other interesting topics which he likes, rapport building.

Relaxation breathing: this is simple technique that can be performed at any time. For relaxation breathing I encouraged my patient to breathe slowly and deeply until relaxation is achieved.

Drugs used in my patient

Ø  Injection DNS

Ø  Injection 5%dextrose

Ø  Injection Ringer lactate

Ø  Injection ceftriaxone

Ø  Tab.Flexon

Ø  Injection/Tab cifran

Ø  Injection/Tab Raciper

Ø  Injection Ketorolac 30 mg

Injection DNS

Dextrose and Sodium Chloride Injections USP are sterile, nonpyrogenic and contain no bacteriostatic or antimicrobial agents. These products are intended for intravenous administration.

Indications:

These intravenous solutions are indicated for use in adults and pediatric patients as sources of electrolytes, calories and water for hydration.

Contraindications:

These solutions are contraindicated where the administration of sodium or chloride could be clinically detrimental.

Solutions containing dextrose may be contraindicated in patients with hypersensitivity to corn products.

Adverse effects

Reactions which may occur because of the solution or the technique of administration include febrile response, infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation and hypervolemia.

Too rapid infusion of hypertonic solutions may cause local pain and venous irritation. Rate of administration should be adjusted according to tolerance. Use of the largest peripheral vein and a small bore needle is recommended. 

Nursing consideration

Check for leaks by squeezing container firmly. If leaks are found, discard unit as sterility may be impaired. If supplemental medication is desired, follow directions below before preparing for administration.

To Add Medication

(Use aseptic technique)

1.            Remove blue cap from sterile medication additive port at bottom of container.

2.            With a needle of appropriate length, puncture resealable additive port and inject. Withdraw needle after injecting medication.

3.            Mix container contents thoroughly.

4.            The additive port may be protected by an appropriate cover.

Preparation for Administration

(Use aseptic technique)

NOTE: See appropriate I.V. administration set Instructions for Use.

1.            Close flow control clamp of administration set.

2.            Remove cap from sterile administration set port at bottom of container.

3.            Insert piercing pin of administration set into port with a twisting motion until the pin is firmly seated.

4.            Suspend container.

5.            Squeeze and release drip chamber to establish proper fluid level in chamber.

6.            Open clamp. Eliminate air from remainder of set.

7.            Attach set to patient access device.

8.            Begin infusion.

9.            Watch for fluid overload

10.         Monitor vitals timely

11.         Maintain drop pre minute

12.         Watch for any side effects.

Injection 5%dextrose

5% Dextrose Injection, USP solution is sterile and nonpyrogenic. It is a parenteral solution containing dextrose in water for injection intended for intravenous administration.

Group: intravenous fluid and electrolyte infusion.

Indication: Intravenous solutions containing dextrose are indicated for parenteral replenishment of fluid and minimal carbohydrate calories as required by the clinical condition of the patient.

Adverse effects

Reactions which may occur because of the solution or the technique of administration include febrile response, infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation and hypervolemia.

If an adverse reaction does occur, discontinue the infusion, evaluate the patient, institute appropriate therapeutic countermeasures and save the remainder of the fluid for examination if deemed necessary.

Precautions:

·         Geriatric Use

·         Pediatric Use

·         Carcinogenesis, Mutagenesis, Impairment of Fertility:

·         Pregnancy(Teratogenic effects)

Nursing consideration

Check for leaks by squeezing container firmly. If leaks are found, discard unit as sterility may be impaired. If supplemental medication is desired, follow directions below before preparing for administration.

To Add Medication

(Use aseptic technique)

1.          Remove blue cap from sterile medication additive port at bottom of container.

2.            With a needle of appropriate length, puncture resealable additive port and inject. Withdraw needle after injecting medication.

3.            Mix container contents thoroughly.

4.            The additive port may be protected by an appropriate cover.

Preparation for Administration

(Use aseptic technique)

NOTE: See appropriate I.V. administration set Instructions for Use.

1.            Close flow control clamp of administration set.

2.            Remove cap from sterile administration set port at bottom of container.

3.            Insert piercing pin of administration set into port with a twisting motion until the pin is firmly seated.

4.            Suspend container.

5.            Squeeze and release drip chamber to establish proper fluid level in chamber.

6.            Open clamp. Eliminate air from remainder of set.

7.            Attach set to patient access device.

8.            Begin infusion.

9.            Watch for fluid overload

10.         Monitor vitals timely

11.         Maintain drop pre minute

12.         Watch for any side effects.

Injection Ringer Lactate

Group: intravenous fluid and electrolyte infusion.

Indication: Ringer lactate is an alkalinizing agent whose activity depends on conversion to bicarbonate sodium lactate is oxidized in the liver of bicarbonate and glycogen.

Adverse effects and cautions:

Reaction including fever infection at the site of injection venous thrombosis or phlebitis and extravasations changes in fluid balance, electrolyte concentrations and acid-base balance should be evaluated clinically and by periodic laboratory determination during prolonged therapy and in patients whose condition warrants such evaluation.

Sodium lactate should be used with extreme caution in patient with congestion heart failure either edematous or sodium retaining conditions in patients with oliguria or anuria and in patient receiving corticosteroid.

Nursing consideration

Check for leaks by squeezing container firmly. If leaks are found, discard unit as sterility may be impaired. If supplemental medication is desired, follow directions below before preparing for administration.

To Add Medication

(Use aseptic technique)

1.            Remove blue cap from sterile medication additive port at bottom of container.

2.            With a needle of appropriate length, puncture resealable additive port and inject. Withdraw needle after injecting medication.

3.            Mix container contents thoroughly.

4.            The additive port may be protected by an appropriate cover.

Preparation for Administration

(Use aseptic technique)

NOTE: See appropriate I.V. administration set Instructions for Use.

1.            Close flow control clamp of administration set.

2.            Remove cap from sterile administration set port at bottom of container.

3.            Insert piercing pin of administration set into port with a twisting motion until the pin is firmly seated.

4.            Suspend container.

5.            Squeeze and release drip chamber to establish proper fluid level in chamber.

6.            Open clamp. Eliminate air from remainder of set.

7.            Attach set to patient access device.

8.            Begin infusion.

9.            Watch for fluid overload

10.         Monitor vitals timely

11.         Maintain drop pre minute

12.         Watch for any side effects.

Injection ceftriaxone

Group: Third generation chephalosporins (Antibiotics)

Mechanism:

-inhibits bacterial cell wall synthesis

Uses:

Gram positive infections resistant to

-septicemia

-UTI by gram negative bacteria

-Typhoid Prophylaxis

-Meningitis caused by H.influenza

- Surgical prophylaxis

Dose:

-1-2 gram 12 hourly I/V

                  

Side effect:

- Pain and thrombhophlebitis on injection site, Anaphylaxis, Skin rashes, fever diarrhoea, liver and kidney damage (nephrotoxicity), neutropenia, and thrombhophlebitis

           

Contra-indication:

-hypersentivity.

Nursing management

·         Properly dissolve the solute by shaking the vial well

·         For I/V injection,the solution should be adequatedly diluted

·         Don’t inject more than 1 gram into single I/M site to prevent pain and tissue reaction

·         Reconstituted solution is stable for 24 hours at room temperature under refrigaration thereafter it should be discarded.

·         Continue taking medicine for the full course of treatment

Tab.Flexon

Group:

Ibuprofen: Nonsteroidal anti-inflammatory drug (NSAID)

Paracetamol or acetaminophen :over-the-counter analgesic and antipyretic 

 Mechanism:

- blocks prostaglandin synthesis, inhibits platelet aggregation, and prolongs bleeding time, but does not affect prothrombin or whole blood clotting times.

Uses:

--fever

-pain 

Dose:

 FLEXON tab: ibuprofen 400 mg, paracetamol 500 mg. FLEXON susp: ibuprofen 100 mg, paracetamol 125 mg.

Side effect:

- Rash,ringing in the ears, headaches,Dizziness,drowsiness, Abdominal pain, Nausea,diarrhea, constipation,  Heartburn, Fluid retention.

-reduce the ability of blood to clot and therefore increase bleeding after an injury (cause ulcers and bleeding in the stomach and intestines)

           

Contra-indication:

- urticaria, severe rhinitis, bronchospasm, angioedema, nasal polyps are precipitated by aspirinor other NSAIDs; active peptic ulcer, bleeding abnormalities.Use with caution in patients with hypertension, history of GI ulceration, impaired hepatic or renal function, chronic renalfailure, cardiac decompensation

Nursing management

·         Give on an empty stomach, 1 hr before or 2 hr after meals.

·         If GI intolerance occurs, ibuprofen may be taken with mealsor milk.

·         Tablet may be crushed if patient is unable to swallow it whole and mixed with food or liquid before swallowing.

·          Patients with history of cardiac decompensation should be observed closely for evidence of fluid retention and edema.

·        Monitor for GI distress and signs of GI bleeding.

·         Symptoms of acute toxicity in children are apnea, cyanosis,

Injection/Tab cifran

Group: antibacterial

Mechanism:

-inhibits bacterial DNA gyrase

Uses:

-enteric fever

-septicemia

-prophylaxis (post operatively)

Dose:

-200mg I/V BD

-50mg orally BD

                  

Side effect:

- Nausea, vomitting, diarrhoea, joint pain, headache, dizziness, vertigo, jaundice, renal failure.

           

Contra-indication:

-hypersentivity.

Nursing management

·         Instruct well that not to chew the medicine before swallowing.This medicine may be taken on an empty stomach or with food.Drink plenty of water or other fluids

·         Instruct well that not to continue the medicine taking medicine for the full course of treatment

Injection/Tab Raciper

Group: Esomeprazole magnesium, trihydrate (a derivative of Esomeprazole)

-       proton pump inhibitor (PPI)

Mechanism:

- blocks the production of acid by the stomach.

Uses:

-  Gastroesophageal reflux disease (GERD).

- With amoxicillin and clarithromycin it is used for treatment of Helicobacter pylori infection and duodenal ulcer.

- Reduction in occurrence of gastric ulcers associated with continuous NSAID therapy and in Zollinger-Ellison syndrome.

Dose:

GERD: 20 or 40 mg is given once daily for 4-8 weeks. In children ages 1-11, the dose is 10 or                        20 mg daily.
H. pylori: 40 mg is administered once daily in combination with amoxicillin and clarithromycin for 10 days.
NSAID-induced ulcers: 20 to 40 mg daily for 6 months.
Zollinger-Ellison syndrome is treated with 40 mg twice daily.

      

Side effect:

            -  Diarrhea, nausea, vomiting, headaches, rash anddizziness. Nervousness, abnormal heartbeat, muscle pain, weakness, leg cramps, and water retention occur infrequently.

           

Contra-indication:

- Hypersensitivity along with atazanavir.

Nursing management

·         Caution needed for children, pregnancy and breastfeeding women.
*It may cause malignancy and liver impairment. 
*While taking this medication, there is an increased risk of developing certain infections such as community-acquired pneumonia

Injection Ketorolac 30 mg

Group: Non steriodal anti inflammatory drugs

Mechanism:

- Ketorolac reduces the production of prostaglandins, chemicals that cells of the immune system make that cause the redness, fever, and pain of inflammation and that also are believed to be important in the production of non-inflammatory pain. It does this by blocking the enzymes that cells use to make prostaglandins (cyclooxygenase 1 and 2). As a result, pain as well as inflammation and its signs and symptoms - redness, swelling, fever, and pain - are reduced.

Uses:

- Short-term management (up to 5 days) of moderately severe acute pain

Dose:

Adult: Oral- Moderate to severe pain 10 mg 4-6 hourly. Max: 40 mg/day. Max duration: 7 days. 
IV/IM -Moderate to severe pain 60 mg via IM injection or 30 mg via IV injection. 
Ocular itching- As 0.5% solution: Instill 1 drop 4 times/day. Post-operative eye inflammation as 0.5% solution: Instill 1 drop 4 times/day for 2 weeks, starting 24 hours after surgery for 2 weeks.

                  

Side effect:

            - Rash,

-ringing in the ears, 

-headaches,

- Dizziness,

-drowsiness,

- Abdominal pain,

- Nausea,

-diarrhea, 

-constipation,

- Heartburn,

- Fluid retention.

-reduce the ability of blood to clot and therefore increase bleeding after an injury (cause ulcers and bleeding in the stomach and intestines)

           

Contra-indication:

-allergic to aspirin or other NSAIDs,

-gastrointestinal bleeding,

- Kidney or liver disease,

-asthma,

- Dehydration,

- Pregnancy,

- Lactation.

-postoperatively to patients with high risk of bleeding.

Nursing management

·         It comes as a tablet to be taken by mouth. It is usually taken every 4 to 6 hours on a schedule or as needed for pain.

·         It also comes as eye drops to instill into the affected eyes, as directed by your physician.

·         Special Instruction to the patient that: 
*it make drowsy or dizzy. So avoid to drive a car or operate machinery

·         *Do not drink alcohol while taking this medication. 
*Caution should be exercised in patients with history of heart failure, predisposition to reduced blood volume or kidney blood flow might lead to mild kidney disease; monitor kidney function closely, elderly, weight above 50 kg, liver dysfunction.

Health education to patient and visitors

            Health education and maintenance are important since health status is good indicator of the one’s ability to adapt to rapid changes. Health education to Mr. Ghatri was very important because she was post operative patient. He was discharge on 2069/03/15.  During discharge I had given health on following topics.

Nutritious diet:

Diet is very impotant for the post operative patient.He was encourage to intake the soft to normal diet with high fibre diet to reduce constipation which might be due to being bedridden.Encouraged fluid intake.

             I also suggested her to take nutritious diet everyday like high protein diet such as egg, milk, meat and large amount of green leafy vegetables.

Rest and exercise: Rest and exercise helps to strengthen the body tissues but heavy exercise should be avoided.adequate rest was enhanced with early ambulation is encouraged. He was instructed to avoid heavy lifting, coughing, straining and strenous activity for atleast 6 weeks.

Hygiene: personal hygiene is important to prevent infection. So, essentiality of personal hygiene was explained.

Care of the wound: The wound was instructed to keep dry and alternate day dressing was instructed and suture removal at 2069/03/22.

Follow up: come on the advised date for follow up visit that is within on 7 days.Regular contact with health personnel if he feels any uneasy and discomfort, soakageon the incision site.

Post face

Summary of the case study:

During our 4 weeks practicum in B&B hospital, I got many opportunities to observe the cases and provide nursing care according to their needs.

I selected a case of Ram Bahadur Ghatri who was diagnosed acute appendicitis and admitted in Surgical Ward bed no 410(A).

During the whole period of hospitalization, I provided holistic nursing care to him, considering his physical, mental, socio-cultural aspects. I provided nursing care based on Vergenia Henderson theory that helped me providing nursing care to him thoroughly.

His condition was improved and recovered so he was discharge as per plan. During hospitalization I gave health education regarding the disease condition, preoperative teachings about the hospital, operative procedure and post operative teachings on post operative complications, exercises, stress management, nutrtion and hygiene.

Learning from the case study

            While doing case study, I got many opportunities to gain scientific knowledge and theories in patient and evaluate the outcome and finally write the result.

            Case study helps to gain a lot of theoretical as well as practical knowledge and improves writing skill. I got chance to study the patient and family background, socio-cultural, environmental background of patient. I am very pleased that I have confident in talking and teaching in acute appendicitis because it was so practical.

Bibliography

1.    Textbook Of Adult nursing

2.      http://www.webmd.com/

3.      http://emedicine.medscape.com

4.      http://digestive.niddk.nih.gov/

5.      http://www.rightdiagnosis.com

6.      http://www.medindia.net