CASE PRESENTATION

ON
APPENDICITS

SUBMITTED TO: SUBMITTED BY:

Mr. Vasudevan N.J Ram Ninad Pattnaik

Assistant prof Msc nursing 2nd yr

Sum Nursing college Sum Nursing college

SUBMITTED ON:

IDENTIFICATION DATA
Client’s name : Mr. Pradyumna Bhoi
Age : 32 years
Sex : Male
IP No : 7077342363
Date of admission : 16/01/2024
Ward : GICU
Bed no. :1
Education : Graduation
Occupation : Businessman
Marital status : Married
Religion : Hinduism
Address : At/po- Padampur, Dist: - Bargarh
Provisional diagnosis : Appendicitis

I. Presenting Chief Complaints:

The patient complaints for –
 Abdomen pain since 1month (Abdomen pain was aggravated from 10 days)
 Pain radiating to epigastric region
 Fever for 2 days 10 days back

II. History of Present Illness

Mr. Pradyumna Bhoi came to Gastrology OPD, SUM Hospital due to abdomen pain and fever on
date (16/01/2024) after checkup in OPD and my patient was send to ward 5 at 02: 00pm . After
ultrasound my Patient was diagnosed Appendicitis, Then shift from Cath lab to GICU on date
(18/01/2024) at 7:15pm.

III. Past medical history

Mrs. Pradyumna Bhoi is having Hypothyroidism and taking Tab. Thyroxine 75mg
IV. Past surgical History
Mrs. Pradyumna Bhoi doesn’t have any past surgical history.
V. Family History
 Mrs. Pradyumna Bhoi family members have significant history of disease Gastro disease

VI. Family characteristics-

Mrs. Pradyumna Bhoi lives in nuclear family.

S. Name of the Relationship Age Educationa Occupation Health Status Age &
No. family members with the (yr.) / l Status mode of
Patient Sex death
1 Mrs. Ranjita Wife 28yr/F 10th Housewife Not significant -
Bhoi
2 Mr.Sagar Bhoi Son 16 yr/M 12th Student Healthy -

3 Mr. Sukant Bhoi Son 14yr/M 10th Student Not significant -

III. Socioeconomic history:

 My patient is the head of the family.
 He belongs to a middleclass family.
 He is a businessman.
 Electricity and water facilities are available in house.
 Drainage facility is proper.
 Income per month: The monthly income is approx. 50,000/-.
 Expenditure : approx.: 30,000 /- rupees
 Recreational facilities : Present
 Medical facilities : Available
IV. Personal History
 Habits & hobbies: He smokes cigarette since 20 years
His hobbies is spending time in farm house
 Elimination pattern:
 Bladder elimination:-He is catheterized with Foleys catheter on date (16/01/2024)
 Bowel elimination:- He passed stool since admission
 Sleeping pattern: Sleeping pattern is good 10hrs per day
 Nutritional history :
Vegetarian / non-vegetarian: Non-vegetarian
Likes / dislikes: He likes all kinds of vegetables &fish.
 Any change in the dietary pattern: Avoidance of irritant foods, fried, fast food and balance diet
is advice.
V. Vital Signs:
S.NO Vital Sign Normal Value Patient’s Value

1. Temperature 98.6 F 97.6 F

2. Pulse 60 – 80 Beats/M 82 Beats/M

3. Respiration 14 – 20 Breath/M 22 Breath/M

4. Blood Pressure 120/80 mmHg 135/80 mmHg

VI. Visual Analogue Scale: The pain score of my patient is (4 – 5) and the pain is radiating from left
upper limb to left lower limb.

PHYSICAL EXAMINATION
1. GENERAL APPEARANCE
 LEVEL OF CONSCIOUSNESS : Conscious and response to all my questions
 ORIENTATION : Oriented to time and person and oriented to place
 SKIN COLOUR : Brown
 MOOD : Alert
 ACTIVITY : Active but doctor order to take bed rest
 BODY BUILD : Obese
 NOURISHMENT : Well nourished
 SPEECH : Clear
2. ANTHROPOMETRIC MEASUREMENT
 WEIGHT : 93 kg
 HEIGHT : 159 cm
 BODY MASS INDEX : 36.8 kg/m2
3. HEAD TO FOOT EXAMINATION
I. HEAD
 SHAPE : Normocephalic
 SCALP : Clean
 HAIR : My patient having black hair and distributed all over the scalp.
 FACE : My patient doesn’t have any puffiness or swelling in face.
 SUBJECTIVE SYMPTOMS : No complaints
II. EYES
 EYE BROWS : Hair are equally distributed and both eyes brows are symmetric
 EYE LASHES : Eye lashes are clean and equally distributed
 EYE LIDS : Normal
 PUPILLARY REFLEX: Reacting to light
 PUPIL SIZE : Round
 SCLERA : White
 CONJUNCTIVA : Normal
 CORNEAL REFLEX : Present
 VISSION : Normal
 EYE MOVEMENT : Conjugate eye movement
 USE OF GLASSES/CONTACT LENSES : My patient is not using any type of
glasses/ contact lens.
 SUBJECTIVE SYMPTOMS : No complaints
III. EARS
 USE OF HEARING AIDS : No
 EAR CANAL : Both the canals are clean
 TYMPANIC MEMBRANE : Normal
 HEARING : Weber test is done and my patient can hear in both the ears
 SUBJECTIVE SYMPTOMS : No complaint
IV. NOSE
 EXTERNAL NOSE : Normal in shape and symmetry in size
 NASAL SEPTUM : Central
 NASAL POLYPS : Absent
 NASAL MUCOSA : There is no swelling, bleeding or any discharge
 FRONTAL & MAXILLARY SINUSES: Normal
 SMELL SENTATION : Present
 SUBJECTIVE SYMPTOMS : No complaint
V. MOUTH & THROAT
 LIPS : No redness and swelling and lip is symmetry
 TEETH : Dentures
 GUMS : No bleeding is present
 TONGUE : Clean, moist all around tongue without any redness
 UVULA : No tenderness or redness
 TASTE : Normal taste present
 BAD ODOUR : Present
  TONSIL : Enlargement is not present
 VOICE : Clear
 SUBJECTIVE SYMPTOMS : No complaint
VI. NECK
 NECK : No mass is present
 RANGE OF MOTION : Possible
 THYROID GLAND : Not enlarged
 JUGULAR VEIN : Not distended
 TRACHEA : Midline
 SUBJECTIVE SYMPTOMS : No complaints
VII. THORAX AND LUNGS
 THORAX : Symmetrical
 THORAX EXPAINSION : Normal & Equal
 BREATH SOUND : 22 breath/min
 COUGH : Absent
 SPUTUM : Absent
 SUBJECTIVE SYMPTOM : No complaints
VIII. HEART
 HEART SOUND : S1 , S2 , S3 & S4 sound are present
 APICAL PULSE : Absent
 PERIPHERIAL PULSE : 82 beat/min
 PACEMAKER : Absent
 OXEYGEN SUPPORT : On room air
 SUBJECTIVE SYMPTOMS : No complain
IX. GASTROINTESTINAL SYSTEM
 MOUTH : Clean
 TEETH : Clean
 TONGUE : Clean
 ORAL ULCER : Absent
 ABDOMEN : Tenderness
 PERISTALSIS : Present
 NUTITIONAL ROUTE : Oral feeding
 BOWEL OPENED : Present
 APPETITE : Normal
 PERCUSSION : Rigidity
 INGUINAL LYMPH NODE : No nodes are present
 LIVER : Normal in size
 SPLEEN : Normal in size
 KIDENY : Normal in size
 BOWEL SOUND : Present
 PERIANAL SKIN INTEGRITY : Intact
 SUBJECTIVE SYMPTOMS : Pain in abdomen
X. GENITOURINARY SYSTEM
 URINATION : Catheter
 URINE : No sediments are present
 GENITALIA : No discharge or edema is present
 SUBJECTIVE SYMPTOMS : Irritation due catheter
XI. INTEGUMENTARY SYSTEM
 SKIN : Intact
 COLOUR : Brown
 TEXTURE : Normal
 TURGOR : Normal
 HYDRATION : Good
 TEMPERATURE : 96.3F
 DISCOLOURATION : Absent
 CYANOSIS : Absent
 PERIPHERIES : Warm
 ICTERUS : Absent
 LESIONS/MASSES : No lesions/ masses are present
 SUBJECTIVE SYMPTOMS : No complaint
XII. MUSCULOSKELETAL SYSTEM
 POSTURAL CURVES : Normal
 MUSCLE TONE : Normal
 UPPER EXTRIMITIES
 SYMMETRY : Upper extremities are symmetrical
 MUSCLE STENGTH : Weakness
 RANGE OF MOTION : Possible
 BICEPS REFLEX : Normal
 TRICEPS REFLEX : Normal
 OEDEMA : Absent
 JOINTS : NO complaint
 DEFORMITY : Absent
 LOWER EXTERMITIES
 SYMMETRY : Lower extremities are symmetrical
 MUSCLE STRENGTH : Normal
 RANGE OF MOTION : Possible
 OEDEMA : Absent
 JOINTS : No Tenderness
 DEFORMITY : Absent
 GAIT : Normal
 VARICOSE VEINS : Absent
 DEPENDENCY LEVEL : Independent
 SUBJECTIVE SYMPTOMS : No complain
 APPENDICITIS

INTRODUCTION

Appendicitis is the infection or inflammation of the appendix the tiniest part of the bowel, a worm like out
pouching of the bowel at the junction of the small and large intestine. Appendicitis is one of the most
common causes of emergency abdominal surgery.

DEFINITION

Appendicitis is an inflammation of the vermiform appendix that develops most commonly in adolescents
and young adults.

ETIOLOGY-

L.NO ACCORDING TO BOOK ACCORDING TO PATIENT

1 NON MODIFIEABLE-
2. Age -10 -30 Years
Gender -men > women Men
MODIFIEABLE
OBSTRUCTIVE CAUSES- Swelling of bowel wall
 Fecalith that occlude lumen of the appendix
 Kinking of the appendix Diet lacking fibres
 Swelling of bowel wall
NON OBSTRUCTIVE CAUSES-
 Hematogenous spread of infection
 Vascular occlusion
 Trauma
 Diet lacking fibres

PATHOPHYSIOLOGY

Due to etiological factors obstruction of the appendix lumen by faecolith

Decreased flow/ drainage of mucosal secretion

Increased intra luminal pressure in appendix

Vasocongetion causes decreased blood supply in the appendix

Decreased supply of oxygen and nutrition in the appendix

Necrosis and perforation of the appendix; bacteria invade in appendix

 Disruption of cell membrane of the Appendix

Inflammation of Appendix

CLINICAL MANIFESTATION OF CORONARY ARTERY DISEASE

SL.NO ACCORDING TO BOOK ACCORDING TO PATIENT

1  Pain in abdomen  Radiating pain in
 Vomiting umbilical region
 Anorexia  Fever
 Fever
 Constipation
 Haematuria
 Constipation
EARLY SIGN
 Guarding sign
 Rebound tenderness
 Rovsing’s sign
 Aaron’s sign
 Psoas sign
 Obturator sign
 Blumberg’s sign

DIAGNOSTIC EVALUATION (ACCORDING TO BOOK)

 Physical examination
 History collection
 Abdominal ultrasound
 Endoscopy
 Blood test

ACCORDING TO PATIENT

 History was collected and known that my patient having the history of Appendicitis and due to
lacking diet fibres.
 Physical examination-on palpation abdomen is tenderness and pain present.
 Abdominal ultrasound- Appendix appears mildly bulky in appearance trans-serosal diameter
measuring 6mm near the base and proximal body with surrounding minimal fluid . Few
subcentimetric lymph nodes noted in RIF, largest measuring upto 5.7mm in short axis diameter.
SL.N INVESTIGATION PATIENT’S VALUE NORMAL INTERPRETATION
O VALUE
1. Complete blood
count
Blood studies
Haemoglobin 14.2gm/dl 13-17 Normal.
Total Red blood 3.95ul 5.5-5.9 Decreased
cell count 33% 36- 52 Decreased
PCV 83.5fl 81-97 Normal
MCV 25.8pg 26.0-34.0 Decreased
MCH 1.5-4.5 Normal
Platelets 1.75 lakhs 4.4-11.3 Increased
Total WBC 13.26 mil/ul 40-80% Normal
different count 80% 24-40% Decreased
Neutrophil 14.7% 0-3% Normal
Lymphocytes 0.1% 4-8% Normal
Eosinophil 0.55 1-2% Decreased
Monocytes 0.3% 0-20 Increased
Basophils 60mm/1hr Increased
ESR
120-140mg/
Routine dl Increased
2. Investigation 161mg/dl <7 Fair control
RBS 6.7% 13-45mg/dl Increased
Hba1c 60mg/dl 0.5-1.5 Normal
Blood urea 1.04mg/dl 135-145 Decreased
S.creatinine 132mg/l 3.5-5 Normal
S.sodium 3.6meq/l Normal
S.potassium 95-115 Decreased
96meq/l
S.Chloride 12.4sec
PT control 1.00
INR 7.35-7.45 Normal
3. ABG 7.433 35-45mmhg Decreased
PH 32.7 70-100mmhg Normal
PCO2 72.2 22-26mmol/l Low
PO2 21.9
HCO3
Urine test (on Yellow
4. 12.02.2020) Clear
Colour 2-3hpf Normal
Appearance 2-3hpf 4.8-7.5 Normal
Pus cell 5.5 1.003-1.060 Normal
PH 1.020 2-20 increased
Specific gravity Negative <10
Sugar 1+50mg/dl M-2-5,f-8-10 Increased
Protein 2-3hpf 0-2 Increased
Epith cell 4-5hpf 0.3-1.0
RBC 0.55mg/dl
5. LFT 0.1-0.4
Bilirubin(T) 5-40 Normal
 BIilirubin(D) 0.20 40-129 Increased
12.40 IU/L 6.8-8.3 Normal
SGPT 888.00lU/L Increased
Alkaline 6.3gm/dl 3.3-5.2
phosphate 2.5-3.6 Decreased
Protein 3.3gm/dl Normal
Albumin 3.0gm/dl
Globulin

6 Lipid profile
Total cholesterol 150-200 Normal
HDL 190mg/dl 40-60 Normal
LDL 44mg/dl 70-130 Normal
VLDL 123mg/dl 20-40 normal
Triglycerides 24mg/dl 50-150 normal
121mg/dl

BLOOD GROUPING - A positive

Rh typing- Positive

COMPLICATION-

SL NO ACCORDING TO BOOK ACCORDING TO PATIENT

1 Appendicular infiltrate Wound infection
2 Appendicular abscess
3 Peritonitis
4 Pilephlebitis
5 Wound infection
6 Adhesive intestinal obstruction

MANAGEMENT

1 ACCORDING TO BOOK ACCORDING TO PATIENT

Non pharmacological measure-
 Promote bed rest.
 Ensure hydration.  Complete bed rest
 Low fat diet.  Ensure hydration
 Eat high fiber diet
 Eat high fiber foods.
2.  Avoid spicy food
 Pharmacological management-
 Antiemetics(To prevent or supress vomiting)  Inj. ondansetron
 Proton pump inhibitor(Supresses gastric (4mg) IV SOS
secretion)  Inj. Pantoprazole
(40mg) IVBD
 Analgesic(To reduce pain)
 Inj. Paracetamol ( 1gm
 Antibiotic(Antimicrobial substance active )IV SOS
against bacteria)  Inj. Tramadol 100mg
 IV Fluid with 100 ml NS
 Inj. Piperacillin (1gm )
IV BD
 Inj. Metronidazole
(500mg) IV TDS
 DNS 500 ML
 RL 500 ML

3.
Surgical management-  Open Appendectomy
 Open Appendectomy
 Laparoscopic Appendectomy

NUTRITIONAL PLAN-
Calories- 1000kcl /day

Protein- 1gm /kg/bodyweight

Fibers-30-35gms

Carbohydrate-180gm

Fat-25 gm

Fluids- 1.5lit/day

PROGRESS NOTE

SL.N DATE NURSE’S NOTES

O
1. 23.02.2023 Patient was conscious and Pain. The patient had semi fowler position and
medication as ordered.
Bp- 120/80mmhg
Pulse 82/min
RR-26/min
 Temp-98.4F
Spo2-100% in room air
Patient maintained urination and BP.

2. 24.03.2023 Today patient is conscious .generalised weakness.

Pain on surgical site.Dressing done no soakage.
BP-130/80mmhg
PR-80/min
Temp-98.4F
SPO2-98%
Advice for CBC,LFT,RFT,T3,T4 and TSH
Administrate IV Fluid.

3. 25.03.2023 The patient is conscious, oriented. His vitals are stable.

Na+= 128meq/l
K+= 3.9meq/l
CL-44meq/l
HGT-134mg/dl
ABG Value
PH-7.38
PCO2-40mmhg
Po2-89mmhg
Hco3-23.01mmol/L
Na+ -142meq/L
K+ -3.4meq/L
Cl -48meq/l
HGT-124mg/dl

APPLICATON OF VERGINIA HENDERSON’S NEED THEORY IN NURSING PROCESS-

Henderson was born on 30th November, 1897 in Kansas City, Missouri and dies on 17th march 1996.

She called as “the Nightingale of modern nursing”, “Modern -day mother of nursing”

She earned her Diploma in nursing .from the army school of nursing in 1921, Bsc .in 1932, M.A in 1934.

She worked as a teaching nursing in 1923, member of faculty. And research associate.
She was honored at the annual meeting of the nursing and allied health section on the medical library
association.

She created basic nursing curriculum for nursing in 1937

She developed the theory in 1950 -1970.

She proposed 14 components of basic nursing care.

 Breathe normally
 Eat and drink adequately.
 Eliminate body waste
 Move and maintain desirable posture
 sleep and maintain desirable posture
 sleep and rest
 select suitable clothes-dress and undress
 Maintain body temperature within normal range
 Keep body clean and well groomed and protect from injury.
 Avoid dangers in the environment and avoid injuries others
 Communicating with others in expressing feeling
 worship according to one’s faith
 work in such a way that there is a sense of accomplishment
 Play and participate in various forms of recreation, learn, discover, or satisfy the curiosity that
leads to normal development.

Nursing care plan :( By q application of nursing theory)

ASSESSMENT

 patient had abdomen pain , assess the location, severity(0-10 scale) and character of pain.
 Eat inadequate diet ,he was thirsty demanded more orally fluids
 Elimination Patient was self void ,no bowel movement, since two days
 Moving: Able to move self in bed without support.
 Dressing and undressing appropriately: he was dressed independently.
 Avoiding dangers and injury to others: he was conscious and orientated and able to follow the
instruction regarding safety.
 Communication: he was able to express self clearly. Hear and saw clearly.

NURSING DIAGNOSIS:-

 Acute pain related to presence of surgical incision as evidenced by patient’s verbalization and
facial expression
  Imbalanced nutrition less than body requirements related to loss of appetite as evidenced
by weakness
 Risk for deficient fluid volume related to postoperative restriction
 Anxiety related to surgery as evidenced by insomnia and irritability.
 Risk for infection related to surgical incision

ASSESSMEN NURSING GOAL PLANNING IMPLEMENTATIO RATIONAL EVALUATIO

T DIAGNOSIS N E N
Based on
Virginia
Henderson’s
Theory
Subjective Acute pain Patient will Assess the -monitored To identify Patient pain
data: related to be relief cause ,locati location, type and was relieved
Patient says presence of abdominal on and duration, severity of . She feel
that feel pain surgical pain and severity of intensity of pain, pain. comfort.
in abdomen incision as decreased in pain by using 0 to 10
on surgical evidenced by pain scale . scale in pain
site patient’s scale.
-To obtain
verbalization
Monitor -Monitored blood baseline
Objective data: and facial
vital signs pressure, pulse data.
Facial expression and respiration.
expression Provide
VAS-4-5 comfortable -Provide - To feel
position comfortable comfort.
position by lying
on left lateral
position.

Administere -Administered
d Analgesic Analgesic as per To relieve
doctor’s advice- pain
Diclofenac.

Imbalanced Patient Assess the Checked To collect

Subjective nutrition less nutritional nutritional nutritional status the baseline Patient’s
data: than body status will status and data nutritional
Patient says requirement be improved needs of the status was
that feel related to patient improved as
weakness, loss of To identify evidenced
indigestion appetite as Assess the Checked weight- BMI by increase
and nausea evidenced by weight and 45 KG weight
Objective weakness BMI BMI-63.4kg/m2 To prevent
data: Advice for indigestion
Abdominal healthy diet Advice for
pain score healthy diet like
increased, high-fiber food
Weight and avoid fat diet
decreased
BMI- Rest for 6-7
underweight Encourage hours To easily
patient for digestion
bed rest Administered IV
fluid like
NS,DNS and RL
Administere as per doctor’s To improve
d IV fliud order hydration
As per
doctor’s
order

Subjective Patient will Assess Assessed the To know Patient was

data: Risk for be improved source of vomiting- the fluid improved
Patient says deficient in fluid and fluid and Episode, colour and fluid and
that she is fluid electrolyte electrolyte electrolyte electrolyte
feel nausea volume status loss status BP-
120/76mmH
related to
Objective Monitor Monitor vital g
data ;
postoperativ vital sign sign-BP, pulse To collect
BP- e restriction and respiration the baseline
100/65mmHg Monitor data
Dull face input and Maintain input
Fatigue output and output chart To know
hourly volume
Administer status
IV Fluid as Administered IV
per doctor’s Fluid like To maintain
advice NS,DNS and RL electrolyte
as per doctor balance
advice

Subjective Anxiety Patient Asses the Assessed To know Patient

data: related to anxiety will patient behavioural the baseline anxiety was
Patient surgery as be reduced anxiety level response. data reduced
having stress evidenced some exent.
and worried Encourage
by insomnia
about disease to take rest Encouraged to
and take 6-7 hours To reduce
Objective irritability. Provide stress
data: divertional Provided
Anxiety and therapy divertional
insomnia therapy like To feel
listening music, relax
Provide reading book etc
psychologic
al support Provided
psychological
support To maintain
good
Interperson
al
relationship
Subjective Risk for Providing Assess the Assessed no To know Patient was
data: infection comfort and surgical site redness and no the baseline wound
Patient says related to preventing pus formation data healing and
that having surgical complicatio Practice / free of signs
pain and ns instruct in Practiced/ of infection
incision
itching on good instructed to To reduces
surgical site handwashin follow 7 steps of risk of
g and handwashing and spread of
Objective aseptic provided aseptic infection
data : wound care wound care
Assess
surgical site Monitor Monitor vitals- To know
stitched vital sign BP, pulse, RR the general
and Temp condition
Administer
Antibiotics Administered
as per Antibiotic- To reduce
Doctor’s Metronidazole, infection
order Piperacillin

HEALTH EDUCATION-

DIET-

- Advice do not skip meals.

- Instruct for take 1.2 to 1.5 lit water per day.
- Advice to eat high- fibre diet.
- Avoid high spicy and fatty food.
- Teach maintain about input and out put chart.
- vital signs and weight regularly.

Management of disease condition

 - Teach the patient and family members about cause ,effects,treatment,prognosis and complication
of Appendicitis.
- Teach the patient to recognize and report complication like pain , weakness, nausea and vomiting,
- Advice to avoid strees and strain.
- Advice the family members for provide home care to the patient.
- Teach relaxation techniques i.e like watching TV ,reading news paper,meditation.
- Do regular exercise to maintain healthy weight.
- Teach the family members about support the patient psychologically and physically
- Teach them about sign and symptoms of disease and complications ,if any occur then
immediately consult with physician.

Medication

- Teach the patient and family member about time and frequency of taking medication.
- Teach the family members for skip of drug may induce serious complication.
- Teach about side effects of medication.
- Advice to complete the course of medication.

Follow up-

- Instruct the patient to review for re-checkup as a prescribed.

- Advise that if any side effects occur then report to the physician.
- Advice for regular CBC ,TSH,T3 and T4.

CONCLUSION

Appendicitis is an inflammation of the appendix, a finger-shaped pouch that projects colon on the lower
right side of the abdomen. It causes pain in the lower right abdomen. However in most people, pain
begins around the navel and then moves. As inflammation worsens, appendicitis pain typically increases
and eventually becomes sever.

BIBLIOGRAPHY

 Brunner & Suddharth’s. Textbook of Medical Surgical Nursing; 11th edition; New Delhi: Reed
elseiver .- (p) LTD PG-854
 Black M joyce . clinical management for positive outcomes medical -surgical nursing Volume-2
8th edition.Published New Delhi: Reed elseiver .- (p) LTD PG-1406
 SmeltzerC.Suzane, Textbook of medical surgical nursing, Published by Lippincott, 9 th Edition,
Page no-789