[prio Rabies]

INDIVIDUAL NURSING PROCESS I. INTRODUCTION •

Background of the Study Appendicitis is the inflammation of the vermiform appendix. The appendix is a tubelike pouch attached to the cecum just below the ileocecal valve. Appendicitis can occur at any age, with the incidence rate at 1 to 2 per 1000. It is more common in adolescents and young adults and slightly more common in males than in females

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Rationale for Choosing the Case As part of our responsibility of taking care of our patients, we were assigned by our student head nurse to our respective patient according to the level of care that the patient should be receiving. I use this case because I want to increase my knowledge about appendicitis. I would like to increase the client’s awareness and also his family about the risk factors that lead to the development of the disease and for the prevention of such cases.

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Significance of the Study This study will help the nursing profession by providing information about the proper management and care for a patient who suffer from appendicitis and who undergone appendectomy. This study would provide a better understanding of the case its origin and on how it will affect the patient physically and emotionally. It will help the health care provider address the needs of the patient and so as to deliver the proper nursing intervention appropriate for him. Another thing is that this study will help us in increasing our knowledge about the disease and with that we will be equipped with the necessary facts that we need to impart to our patient’s that will to lead to increasing awareness about the disease and through this it will enhance their willingness to comply with the orders given to them.

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Scope and limitation of the Study This study is focused on the nursing aspect of care to those patients who have appendicitis. This study will only be used in the nursing profession. The researchers only focused their attention on the medications, diagnostics, care plan, pathophysiology and discharge planning. This study is not limited to the patients with appendicitis only , but it is for all people who are interested in with the case. We are more focused on primary prevention through health education.

II. GENERAL DATA A. Client’s Demographic Profile Name: Mr. VRC Address: Marikina City

Age: 23 Birthday: September 24,1985 Birthplace: Pangasinan Religion: Roman Catholic Occupation before admission: sales boy B. Medical Profile a. Name of Medical Doctor prior to admission: none b. Name of current Attending physician during hospitalization: Dr. Pauline May Chan c. Source of referral: relatives d. Type of Admission: from admitting office of JRRMMC e. medical Insurance: none f. Admitted at Male surgical ward, Room A Bed #3 Date admitted: Dec. 3, 2008 Time: 5:15pm Chief complaints: vehicular accident Admitting diagnosis: Acute appendicitis Source of information: patient’s chart Blood type: O Rh(+) C. COMPRESENSIVE CLINICAL ASSESSMENT a. Brief History of Present Illness The condition of the client started one day prior to admission when he experienced abdominal pain. According to him, he cannot specify the exact location of the pain that time, all he knows is that he experienced a very painful feeling on his abdomen. When he experience that, he took OTC drugs such as Motilium and Kremil S. After taking those drug he still try to go to his work because he expected that his abdominal pain will be alleviated but when he was already at his work, his abdominal pain persist and it lead to a point wherein he cannot tolerate the pain that's why he decided to go home, he eat hamburger because he thought that it will help in alleviating pain but it didn’t happen instead, he vomited what he had eaten His board mate decided to brought him at the hospital, he was brought in one of the hospital in Marikina but due to increasing number of patients in the said hospital, his friends decided to transfer him at JRRMMC. According to the patient he was brought at the ER of JRRMMC and was put under observation and after a series of test the doctor declared that he has an appendicitis and needs to undergo a surgery.

b. Present Health Status According to the client he perceived his state of health as prone to ailments because he is still recovering from illness and he haven’t regain his usual energy like what he had before. There are no existing health problems on him aside from his present condition. He was currently taking oral meds and IV meds as prescribed by his attending physician. These drugs are Diclofenac, Mefenamic acid and Paracetamol. He took OTC meds prior to admission when he experienced signs and symptoms of his condition he didn’t take herbal meds and he haven’t undergone complimentary therapies. c. Past Personal History The client had chicken pox when he was 19 years old. He doesn’t have serious adult illness such as Diabetes Milletus or hypertension. He denied any history of accident or injury and he said that he haven’t hospitalized before. d. Family Medical History According to the client, his parents do not have any adult illness. His mother was 42years old and his father was 47years of age. His grandparents on his paternal side has a history of arthritis specifically rheumatoid arthritis and his grand father on his maternal side died of heart failure. The client said that there are ho history of communicable disease within his family.

GENOGRAM paternal side

maternal side

Macario + rheumatoid arthritis

Corazon + rheumatoid arthritis

Maximo + heart failure

Arsenia c: 42

Romeo c: 47

Rhoniel 23 E. CLINICAL ASSESSMENT a. General Survey • Over-all Physical Appearance

Francisca c: 70

Roderick c: 21

Rose Anne 17 asthma

Ruth Marie c: 5

The client looks younger than his age because he is small and thin. There are no signs of distress during the interview. He has a skinny body built. •

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Behavior The client was conscious and coherent. He has an affect and mood appropriate to the situation as manifested by being cooperative during the conversation, he promptly answers what is being asked to him. He was calm and there are no angry behavior nor signs of depression being observed. The client speaks slowly in Tagalog. Body Position and Movement The client has a good posture while standing and also when sitting. There is no involuntary movements on his face and limbs. He has an appropriate gait when walking and he moves slowly because he was very careful about his incision. Vital Signs Initial Temp: 36.3 PR: 68 bpm RR: 20 cpm BP: 110/60 mmHg

F. LIFESTYLE DATA Before hospitalization The client was able to perform ADL. He was very particular with his grooming. He use deodorant and cologne. He use leave on for his hair to maintain its shine. When it comes to bathing, he said that he takes a bath twice a day; in the morning before going to work and at the evening before sleeping. When it comes to toileting, he said that he urinates 4-5times a day and the amount was approximately 1530cc per hour, he defecates in the morning and he revealed that he does not defecate regularly and he frequently control his urge to defecate especially when he was in a hurry going to work. He walks every morning when going to work, he walks from their boarding

Ability to perform ADL During Hospitalization The client cannot do his usual activities. He can only take a bath once a day, he is not practicing the things that he is doing before hospitalization like putting cologne and gel because he thought that it was not necessary for the reason that he was only confined on his bed in the hospital and there is no need for him to do those things. With regards to his toileting, he urinates 2-3times a day and he defecates in the morning whenever he feels an urge to defecate. He was encourage to ambulate and he eats twice a day, he doesn't eat breakfast according he combines his breakfast and lunch in one meal and he eat it during lunch time he do that due to his loss of appetite

Analysis and Interpretation Grooming is really an important aspect not only for hygienic purposes but also for the improvement of self-image. As with the patient, he was somewhat disappointed about his alteration in his body image. Normal bathing frequency usually varies from each person’s preference. However, daily bathing, if tolerated, is highly encouraged because of hygienic purposes as well as preventive ones. Normal urination and defecation varies from person to person. And that the usual pattern that the patient already established would be the one to be considered as normal. During hospitalization, however, certain environmental stresses may adhere to

house going to the jeepney terminal and according to him the distance was about 150m. With regards to eating, he said that he eat five times a day including his snacks. He go shopping once a month when he feels like doing it, he works as a service crew in SM that’s why he has a good access in shopping. He said that he is not used in taking medications simply because he doesn’t want it, according to him, he just increased his fluid intake whenever he is not feeling well. Before Hospitalization The client used to perform activities independently. He plays basketball with his friends during his day off.

during breakfast.

the patient. Walking is considered an essential type of exercise. Hence, the patient’s inability to perform this action may deprive patient from certain benefits of walking. Interpretation The client’s ability to perform ADL was affected by illness. Self care abilities were also compromised. This is not normal for a an adult person can perform self care.

Ability to Perform Usual Activities During Hospitalization He cannot perform his activities like playing basketball because he was confined in the hospital. He misses playing basketball.

Analysis and Interpretation Mobility and activity tolerance are affected by any disorder that impairs the ability of the nervous system, musculoskeletal system, cardiovascular system, respiratory system and vestibular apparatus. Failure to do things that give a person’s pleasure is a kind of mental torture and it is really essential to the patient’s faster convalescence. Interpretation: The client cannot perform his usual activities because he was is recovering from his illness. He needs to regain his energy for faster recovery.

Before hospitalization The client as a service crew in SM department store.

Work During Hospitalization n/a

Analysis and Interpretation Analysis A person’s belief about education, employment and home influences personal satisfaction and relationship with others. Interpretation Normal

Before hospitalization The client was the eldest among the 4 siblings. His role in the family was to help his parents whenever there is a problem and he do it by giving them advise that will help in solving the problem.

Perceived Role in the Family During hospitalization n/a

Analysis and Interpretation Analysis; According to the Role performance model, people who can fulfill their roles are healthy even they are clinically ill. It is assumed in this model that sickness is the inability to perform one’s work. Interpretation The client has inability to perform his role and it seems not normal for him.

Before Hospitalization According to the client his form of exercise was daily walking and sometimes he also engage himself to weight lifting

Exercise pattern During Hospitalization He was encourage to ambulate

Analysis and Interpretation Exercise is defined as a type of physical activity defined as a planned, structured and repetitive bodily movement done. Mobility and activity tolerance are affected by any disorder that impairs the ability of the nervous system, musculoskeletal system, cardiovascular system, respiratory system and vestibular apparatus. Interpretation The client cannot perform the type of exercise that he is having before hospitalization because his condition impose limitation on it. However he was encourage to ambulate and that can serve as a simple form of activity or exercise for him.

Before Hospitalization He did not attend to social groups but he said that he had many friends to count on.

Attending to Social Groups During Hospitalization His friends and co workers visits him in the hospital. He also interact with other patient’s significant others as form of socialization

Analysis and Interpretation Early socialization also plays an important role in early recovery. So it will also be highly encouraged that the patient’s family members communicate with him.

Interpretation The client has limited time for socialization, he can only socialize with his parents and other patient’s relative and these things might help to reduce his boredom. Before Hospitalization According to him he expresses himself as a fully grown man and is open in engaging in a relationship with the opposite sex.

Sexual Orientation During Hospitalization

Analysis and Interpretation Analysis Sex is the term most commonly used to identify biologic male or female status. Sexuality includes how you feel about your body, partner, and the ability to engage in satisfying sexual activity. (Fundamentals of nursing by Udan p. Interpretation: The client’s sexual orientation is appropriate at his age.

Before Hospitalization He has a girlfriend but according to him, they are not engage in sexual activities they just express their affection for each other through kissing and hugging.

Sexual Activity During Hospitalization His sexual activities was compromised.

Analysis and Interpretation ANALYSIS Sexual health is defined by the WHO as the integration of the somatic, emotional, intellectual and social aspects of sexual being, in ways that are possibly enriching and that enhance personality, communication and love. In young adulthood, many people begin to form intimate relationship with long-time implication. They are often concerned about normal sexual response for both themselves and their partners. One’s attraction to people of the same sex, other sex or both sexes is referred to as sexual orientation. Sexual activity is common in young adults. Interpretation:

The possess sexual health Before Hospitalization He usually had 5 to 7 hours of sleep, he sleeps at around 11 to 12pm and wake up at 7am and he is satisfied with that amount of sleep.

Rest and Sleep During Hospitalization He cannot sleep continuously. He can sleep only for 4 hours because he frequently wake up at night.

Analysis and Interpretation Young adults usually have an active lifestyle, and are thought to require 7 to 8hours of sleep each night but may do well on less. Environment can promote or hinder sleep. Any change in the environment can inhibit sleep. The absence of usual stimuli or the presence of unfamiliar stimuli can prevent people from sleeping. REFERENCE: Fundamentals of Nursing by: Delaune p. 1117 INTERPRETATION: The client’s hours of sleep does not meet the normal sleep hours requirement for his age. His sleeping pattern was affected by the hospital environment.

Before Hospitalization He doesn’t use prohibited drugs.

Use of Prohibited Drugs During Hospitalization n/a

Analysis and Interpretation It is normal for a person to avoid the use of prohibited drugs.

G. PSYCHOSOCIAL ASSESSMENT: The client said that before hospitalization he perceive himself as a healthy person because he doesn’t experience any form of illness. He works hard to support himself for his basic needs for the reason that he doesn’t want to depend on his parents for his daily needs because he feels that he is already at the right age and he can already support himself. He wants to lessen the burden that his parents are experiencing. Financial problems are the common source of personal stress and he tries to cope by looking at the bright side of life, whenever he has a problem he use to think that it will always be solve at the right time. He tries to solve his problem by facing it and taking the necessary action for it. He confide with his boardmates when he has a problem. He has a good relationship with his family, his family was staying in the province while he was staying in Manila and they communicate with one another through the use of cellular phone. According to him he make a phone call with his family when he misses them. He also had a good relationship with his board mates, he has a girlfriend and they have a good relationship according to him, they love each other so much. The client lives in a 2 bedroom boarding house and it has a complete facility according to him and he was comfortable in staying there.

They were 5 living in that boarding house, the house was a 5 minutes jeepney ride to SM Marikina, that department store and also a nearby market in their place was their access for shopping. According to him he cannot go to church during Sundays. ANALYSIS: According to Erik Erikson, during this stage a personal lifestyle develops. A person establishes a relationship with a significant other and a commitment to something. Mature individuals are guided by an underlying philosophy of life, they are open to new experiences and continued growth, and they can adapt to change. They confront the tasks of life in realistic and mature manner, make decisions and accept responsibility for these roles. INTERPRETATION: The client possesses the characteristics that a mature individual has. He is guided by his philosophy that he need to strive to support himself. These attitudes are normal for his age. H.NUTRITIONAL ASSESSMENT The client eats 5 times a day including snacks. He likes food cook with soup like sinigang and nilaga he doesn’t like sea foods and vegetables because according to him he experiences stomach ache when eating sea food. He also loves eating fatty foods like chicharon and junk foods for his snacks. They eat together in their house, they usually buy food and brought it at home because they do not have enough time to cook and another reason is that they do not know how to cook. He was a high school graduate and he has a knowledge on the basic nutrition and food preparation. He revealed that he had a recent weight changes. He loss a 2kg of his weight for the previous month due to exercise and also due to illness. There are changes in his appetite and he said that he only eat twice a day in the hospital compared before hospitalization that he can eat 5 times a day. There are some changes in taste perception, according to him, the food serve to him are seems like not delicious. He doesn’t experience difficulty in chewing and swallowing, he doesn’t have eating disorders. There are no special diets prescribed to him. He doesn’t have food allergies. He drinks alcohol occasionally and he started when he was 16years old. ANALYSIS: The individual’s health status greatly affects eating habits and nutritional status. Difficulty in swallowing can prevent a person from obtaining adequate nourishment. Disease process can affect digestion, absorption, metabolism, and excretion of essential nutrients. (Fundamentals of Nursing by: Delaune p. 1178) INTERPRETATION: The client's nutritional intake was affected by his health condition. He is also at risk for having insufficient nutritional intake since he had changes on his appetite.

b. Computation BMI Weight Height in m2

55 1.62 = 21.48

The client’s BMI is within normal range. BODY COMPOSITION There are no signs of central obesity with the client. The client’s body composition is appropriate with his age. WAIST CIRCUMFERENCE His waist circumference was 30 and it does not indicate abdominal fatness a. Nutritional adequacy Breakfast

Lunch 1 serving of Nilagang baboy 1 cup of rice 1 glass of water

Dinner 1 serving of gulay na monggo 1 cup of rice 1 glass of water

b. BMI 21.48 c. Dietary Habits The client is on diet as tolerated and there are no diet restriction ordered for him, there are also no special diet and supplements given to him

I. Hematologic Assessment: With presence of skin rashes and small wounds in the arm No bruises on the skin in any parts of the body. No history of Anemia or any blood-related diseases No blood transfusion noted No anticoagulant use J. REVIEW OF BODY SYSTEM:

Date Of Assessment Dec 8, 2008

Assesssment Tool used inspection

Body parts

Inspection

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Skin color

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Skin turgor

GENERAL APPEARANCE Posture

Before hospitalization Relaxed, erect posture; coordinated movements Varies from light to deep brown; from yellow overtones to olive. When pinched, skin springs back to previous state Abscence of rashes

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Skin rashes

During hospitalization Slouched posture

Analysis

Interpretation

Not normal

Slouched posture due to restlessness and body weakness

Brown color,

normal normal

appearance of rashes and small wounds in the arm

Appearance of rash may be and indication of a developing disease condition.

Smooth ,soft • Inspection

Round, symmetric, moves easily from left to right, and up and down, soft and pliable

Round, symmetric

Normal

Dryness of the skin may be related to possible dehydration normal

Evenly distributed hair

Evenly distributed, silky resilient thick hair

Normal

normal

Dryness

Skin texture

HEAD General Appearance, size movement

Inspection •

HAIR evenness of growth over the scalp.

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hair thickness or thinness. • hair texture and oiliness. • presence of infection Skull And face Skull Inspection

Thick hair

Silky resilient Rounded, normocephalic and symmetrical Smooth ,uniform consistency; absence of nodules and masses

Round, absence of nodules

Normal

Normal

Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds No edema

Symmetric facial features No edema

Normal

Normal

Symmetric facial movements

Coordinated facial movements

Normal

normal

Bright & clear; even placement

Bright & clear; even placement

.

Above pupils but within iris; no drooping

Above pupils but within iris; no drooping

Facial features Inspection

Inspection Inspection

Symmetry of facial movements Eyes General Placement and Appearance Eyelids

Movement Blink reflex in response to light stimulus

Blink reflex in response to light stimulus

Clear

Clear

Equal in size, round, PERLA

Blinks, eyes open wide in dimly lighted room

Present; cry commonly tearless

Present; cry commonly tearless

Cornea normal

Normal

normal

normal

Pupil

Lashes and lacrimal gland

a. EYEBROWS

h. PUPILS 1. Color, shape, and symmetry of size

i. VISUAL ACUITY 1. Near vision j. LACRIMAL GLAND Palpability and tenderness of the lacrimal gland

Inspection Palpation

Pinkish or red in color; with presence of small capillaries; moist; no foreign bodies; no ulcers

Pale

Abnormal, pale conjunctiva may be related to the low RBC level of the patient

Inspection

Color depends on the person’s race; size ranges from 3-7 mm, and are equal in size; equally round

Pupil size is 3mm.

Normal

Inspection

Able to read newsprint

Able to read newsprint

Normal

Palpation

No edema or tenderness over lacrimal gland

No tenderness and edema noted.

Normal

k. EXTRAOCULAR MUSCLES Eye alignment and coordination

Inspection

Both eyes coordinated, move in unison, with parallel alignment

Moves in Unison

Normal

l. VISUAL FIELDS Peripheral visual fields

Inspection

When looking straight ahead, client can see objects in the periphery

Can see objects in the periphery.

Normal

Inspection

Color same as facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10 degrees from vertical Mobile, firm, and not tender; pinna recoils after it is folded

Same color as the facial skin; tip of auricle aligned at the outer canthus of the eye.

Normal

Smooth in texture, flexible and elastic pinna; no tenderness

Normal

Inspection

Normal voice tones audible

Can hear normal volume tones or words.

Normal

Inspection

Symmetric and straight; no discharge or flaring; Uniform color Nasal septum intact and in midline Air moves freely as the

Symmetric and straight; Uniform color without nasal flaring. Nasal septum intact and in midline Both Nares are patent

Normal

E. EARS a. AURICLES 1. Color, symmetry of size, and position

2. Texture, elasticity and areas of tenderness b. HEARING ACUITY TESTS 1. Client’s response to normal voice tones F. NOSE 1.Any deviations in shape, size, or color and flaring or discharge from the nares 2. Nasal septum (between the nasal chambers) 3. Patency of both nasal

Palpation

Inspection Palpation Inspection

Normal Normal

cavities 4. Tenderness, masses, and displacements of bone and cartilage G. SINUSES Identification of the sinuses and for tenderness H. MOUTH a. LIPS Symmetry of contour, color and texture

b. BUCCAL MUCOSA Color, moisture, texture, and the presence of lesions

c. TEETH d. GUMS Color and condition

Palpation

client breathes through the nares Not tender; no lesions

palpation

Nor tenderness nor lesions.

Normal

Not tender

Not painful when palpated

Normal

Uniform pink color; soft, moist, smooth texture; symmetry of contour; ability to purse lips

pale in color, dry and cracked lips

Abnormal, May suggest cellular dehydration. (Black, Medical Surgical Nursing7th edition, page 208).

Inspection

Uniform pink color; moist, smooth, soft, glistening, and elastic texture

pale color and dry.

Abnormal, May suggests dehydration. (Black, Medical Surgical Nursing7th edition, page 208).

Inspection

Pink gums; no retraction

Pink gums; has no visible retractions

Normal

pink color; moist; slightly rough; thin whitish coating; moves freely; no tenderness Central position; pink color; smooth tongue

Pink and moist. Tongue moves freely and no pain felt.

Normal

Located and positioned in the center.

Normal

Inspection

e. TONGUE/FLOOR OF THE MOUTH 1. Color and texture of the Inspection mouth floor and frenulum.

2. Position, color and texture, movement and

Inspection

base of the tongue 3. Any nodules, lumps, or excoriated areas

Inspection

base with prominent veins Smooth with no palpable nodules, lumps, or excoriated areas

No tenderness nor masses

Normal

Light pink, smooth, soft palate; lighter pink hard palate , more irregular texture Positioned in midline of soft palate

The hard palate has a lighter color than the soft palate; has quite rough texture Positioned at the center of the oropharynx

Normal

Pink and smooth posterior wall Pink and smooth; no discharge; of normal size Present

Dry, pale in color. Has no discharge; pinkish

Abnormal, May suggests dehydration. (Black, Medical Surgical Nursing7th edition, page 208). Normal

Present

Normal

Quiet, rhythmic, and effortless respirations Skin intact; uniform temperature; chest wall

Quiet, rhythmic, and effortless breathing Has an intact skin; has equal warmth on both

Normal

f. PALATES and UVULA

1. Color, shape, texture and the presence of bony prominences

Inspection

2. Position of the uvula and Inspection mobility (while examining the palates) g. OROPHARYNX and TONSILS 1. Color and texture Inspection 2. Size, color, and discharge of the tonsils

Inspection

3. Gag reflex I. THORAX a. ANTERIOR THORAX 1. Breathing patterns

Inspection

2. Temperature, tenderness, masses

Palpation

Inspection

Normal

Normal

intact; no tenderness; no masses Bronchovesicular and vesicular breath sounds

sides. No masses. Bronchovesicular and vesicular breath sounds

Normal

Anteroposterior to transverse diameter in ratio 1:2; Chest symmetric Spine vertically aligned Skin intact; uniform temperature; chest wall intact; no tenderness; no masses Vesicular and bronchovesicular breath sounds

Has a anteroposterior to transverse diameter ratio of 1:2, elliptical in shape and symmetrical chest Has a vertical alignment No masses nor tenderness; has equal warmth on each side

Normal

Vesicular and bronchovesicular breath sounds

Normal

Auscultation

No pulsations

No pulsations felt

Normal

Auscultation

No pulsations; no lift or heave Pulsations visible in 50% of adults and palpable in most PMI in fifth LICS at or medial to MCL Aortic pulsations S1: Usually heard at all sites

No pulsations of lifts

Normal

Has full pulsation

Normal

Has pulsation Has full and rapid pulsation. 84 bpm/minute.

Normal Normal

3. Anterior thorax auscultation b. POSTERIOR THORAX 1. Shape, symmetry, and comparison of anteroposterior thorax to transverse diameter 2. Spinal alignment 3. Temperature, tenderness, and masses

Auscultation

7. Posterior thorax auscultation

Auscultation

J. CARDIOVASCULAR a. AORTIC and PULMONIC AREAS b. TRICUSPID AREA

Inspection Palpation

Inspection Palpation

c. APICAL AREA

Auscultation

d. EPIGASTRIC AREA e. CARDIOVASCULAR AREAS AUSCULTATION

Auscultation Auscultation

Normal Normal

K. CAROTID ARTERIES 1. Carotid artery palpation

L. AXILLAE 1. Axillary, subclavicular, and supraclavicular lymph

Usually louder at the apical area S2: Usually heard at all sites Usually louder at the base of heart Systole: silent interval; slightly shorter duration than diastole at normal heart rate (60 to 90 beats/min) Diastole: silent interval; slightly longer duration than systole at normal heart rates S3: in children and young adults S4: in many older adults

Sounds on the aortic and pulmonic areas; has a lub sound on the apex and dub sounds on the tricuspid area. Blood pressure is 120/80mm Hg.

Normal

Palpation

Symmetric pulse volumes; full pulsations, thrusting quality; quality remains same when the client breathes, turns head, and changes from sitting to supine position; elastic arterial wall

Symmetric pulse volume

Normal

Inspection

No tenderness, masses, or nodules

Have no masses and nodules. Presence of a

Abnormal, . The secretion of the apocrine glands is odorless,

Normal

nodes M. ABDOMEN 1. Skin integrity

Inspection

Unblemished skin; uniform color

2. Abdominal contour

Inspection

3. Enlargement of liver or spleen

Inspection

4.Symmetry of contour

Inspection

Flat, rounded(convex), or scaphoid(concave) No evidence of enlargement of liver or spleen Symmetric contour

5. Abdominal movements associated with respirations, peristalsis or aortic pulsations

Inspection

6. Vascular pattern

Inspection

N. MUSCULOSKELETAL SYSTEM a. MUSCLES 1. Muscle size and Inspection comparison on the other side

Symmetric movements caused by respiration; visible peristalsis in very lean people; aortic pulsations in thin persons at epigastric area No visible vascular pattern

Proportionate to the body; even in both sides

foul smelling odor.

but when decomposed or acted upon by bacteria in the skin, it takes on a musky, unpleasant odor.

Uniform color and has vertical incision due to surgery Has a flat abdomen.

Normal

No enlargement of the spleen and liver seen

Normal

Has a symmetrical abdominal contour Abdominal movements noted when inhaling.

Normal

Has no blood vessels visible

Normal

Proportionate to the body; even in both sides

Normal

Normal

Normal

2. Fasciculation and tremors in the muscles

Inspection

No fasciculation and tremors

Has no fasciculation and tremors

Normal

3. Muscle tonicity

Palpation

Even and firm muscle tone

Even and firm muscle tone

Normal

4. Muscle strength

Palpation

Has equal muscular strength on both sides

Has equal muscular strength on both sides

Normal

Inspection

No swelling, no warmth, no redness, no pain, no crepitus

No swelling, no warmth, no redness, no pain, no crepitus

Normal

Inspection, Palpation

No swelling, no warmth, no redness, no pain.

No edema, no pain when moved.

Normal

b. JOINTS 1. Joint swelling

c. EXTREMETIES

K. ECOLOGIC MODEL A. Hypothesis The susceptibility of the host in acquiring the disease is high because of his age and gender and it is further aggravated by some of the client's unhealthy lifestyle like unhealthy food preference and also his irregular bowel movement.

B. Predisposing Factors 1. Host a. Age: 23 years old b. Sex: Male c. Behavior: the client used to delay his urge of defecation 2. Agent

3. Environment The socio economic environment of the client contribute to some of the risk factors that contributes to the development of the disease. Since the client live in a boardinghaus there is a lesser time for him to cook food and he usually buy foods low in fiber. The type of his work also contribute to his condition, according to him he is always in hurry during morning that sometimes he ignore his urge to defecate and when he was already at his work he cannot immediately go to the CR when he needs because he needs an alternate for his work whenever he will leave the place for a while. C. Ecologic Model

Age: 23years old

unhealthy lifestyle

D. Analysis

Gender: Male

Unhealthy food preferences

The predisposing factors for having appendicitis are age, gender, unhealthy lifestyle and unhealthy food preference. Adolescence and young adults are more susceptible in acquiring the disease, it is also common in male, Unhealthy food preference like low intake of fiber are also considered as risk factors for having appendicitis. (Medical Surgical Nursing by Bruner) E. Conclusion and Recommendations I therefore conclude that the predisposing factors within the client really contributes to the development of the disease. I recommend that the client should increase intake of foods rich in fiber, there is a need for a well balance diet especially that he is now recovering from illness state. . We recommend the client to eat proper nutrition; increase intake of dietary fiber by eating more leafy green vegetables, fruits, foods rich in beta carotene, and vitamin A,C,E. Avoid fatty foods, and he should increase fluid intake.

L. ANATOMY AND PHYSIOLOGY

The Human Digestive System

The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to excrete waste. Most of the digestive organs (like the stomach and intestines) are tube-like and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals. The Digestive Process: The start of the process - the mouth: The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches into smaller molecules).

On the way to the stomach: the esophagus - After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're upside-down. In the stomach - The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme. In the small intestine - After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food. In the large intestine - After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in the digestion process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon. The end of the process - Solid waste is then stored in the rectum until it is excreted via the anus.

anus - the opening at the end of the digestive system from which feces (waste) exits the body. appendix - a small sac located on the cecum. In human anatomy, the appendix (or vermiform appendix; also cecal (or caecal) appendix; also vermix) is a blind ended tube connected to the cecum (or caecum), from which it develops embryologically. The cecum is a pouch-like structure of the colon. The appendix is near the junction of the small intestine and the large intestine. The term "vermiform" comes from Latin and means "worm-like in appearance". Peritoneum-In higher vertebrates, the peritoneum is the serous membrane that forms the lining of the abdominal cavity — it covers most of the intra-abdominal organs. It is composed of a layer of mesothelium supported by a thin layer of connective tissue. The peritoneum both supports the abdominal organs and serves as a conduit for their blood and lymph vessels and nerves.

M. LABORATORY 1. Hematology Date extracted

Normal values

Actual results

Interpretation

Analysis

135-180 0.40-0.54 4.6-6.2 80-96 27-31 33-36 11.6-14 5-10

173g/L 0.51 5.82x10^12/L 88fL 30g/L 34g/dL 12% 20.10x 10^g/L

Normal Normal Normal Normal normal Nomal Normal Abnormal

Neutrophils

0.55

0.92%

Abnormal

Lymphocytes Basophils

0.34 0.01

0.30% 0.0%

normal Abnormal

Monocytes

0.01

0.04%

Abnormal

Eosinophils

0.03

0.0%

Abnormal

Platelet count 140-400 Reference: Medical Surgical Nursing by: Joyce Black

286x10^g/L

Normal

Normal Normal Normal Normal Normal Normal Normal Increase by infection due to peritonitis Increased due to inflammatory response of the body. Normal Decrease due to acute infection Increase due to the body’s defense in preventing infection. Decrease duet o stress response. Normal

Date extracted

Dec.3,2008

Types of Laboratory tests Hematology Hemoglobin Hematocrit RBC count MCV MCH MCHC RDW-CV WBC count

Types of Laboratory tests

Normal values

Actual results

Interpretation

Analysis

Creatinine

44.2-106.08

72.8umol/L

Normal

Normal

Sodium

135-145

134.50mmol/L

Normal

Normal

Dec.3,2008

Potassium 2. DIAGNOSTIC STUDY Date ordered Diagnostic Procedure Dec.3,2008 CBC with platelet count

3.6-5.51

3.81mmol/L

Normal

Normal

Purpose The CBC includes the RBC count, hemoglobin, hematocrit, RBC indices, WBC count with or without differential and platelet count. Platelet count is valuable in assessing the severity of abnormally low platelet count which can result in spontaneous bleeding, as well as abnormally high platelet count. Fluid and electrolyte should be monitored to determine cardiovascular disorders

Indication Used to determine problems associated with the hematological system. In the case of the patient, this can be use to determine if the patient is at risk or having infection.

Nursing Consideration Prepare the client for the test. Explain the purpose of the procedure and what to expect. Advise the client that there will be pain during the procedure. Apply standard precaution. Practice asepsis

For assessment of cardiovascular disorders.

Creatinine

Use to examine renal function, specifically the ability of the kidney to excrete urea and protein.

Use to evaluate the indicators of renal function

Urinalysis

Urinalysis yields a large amount of information about possible disorders of the kidney and the lower urinary tract and systemic disorders that alter urine composition.

Use to assess if there is a disorder on the client’s urinary system.

Prepare the client for the test. Explain the purpose of the procedure and what to expect. Advise the client that there will be pain during the procedure. Apply standard precaution. Practice asepsis Prepare the client for the test. Explain the purpose of the procedure and what to expect. Advise the client that there will be pain during the procedure. Apply standard precaution. Practice asepsis Generally, no specific client preparation is needed. Collect the urine in a clean container.

Na, K,

N.DRUG STUDY Date Started

Brand name

Generic Name

Drug Classificatio n

Dec.6, 2008

Diclofenac

Diclofenac

NSAID

Route of Administratio n Dosage 50mg TIV every 12hours

Action Adverse reaction May inhibit prostaglandin synthesis to produce antiinflammatory analgesic, and antipyretic Effects. Adverse Effects: Dizziness, headache, insomnia, edema, joint pain, rash, urticaria

Indication Applicable to the client’s condition Use as analagesia for pain

Contraindication

Nursing consideration

Contraindicated in patients hypersensitive to drug and in those with hepatic prophyria or history of asthma, urticaria or other allergic reactions as after taking aspirin

-Monitor patient with renal or heart failure or liver dysfunction because NSAID impair the synthesis of renal prostaglandins they can decrease renal blood flow and lead to reversible renal impairment.

ApoMetronidazol e

Metronidazol e

Amebecides

500mg IV every 8hours

Direct acting trichomonacide and amebecide that works inside and outside the intestines. Its thought to enter the cells of microorganisms that contain nitorreductase, forming unstable compounds that bind DNA and inhibit synthesis causing death.

To prevent post-operative infection in contaminated or potentially contaminated colorectal surgery.

Contraindicated in patients hypersensitive to drug or other other nitroimidazole derivatives.

-Monitor liver function test result in elderly patients. -Observe patient for edema especially if he’s receiving corticosteroids.

Perioperative prevention

Contraindicated in patients hypersensitive to drug or other cephalosporins.

-before giving drug ask patient if he is allergic to penicillins or cepolosphorins. -Obtain culture and sensitivity before giving the first dose.

Adverse Effects: Fever, vertigo, headache, ataxia, weakness, edema, abdominal pain

Mefoxin

Cefoxitin

Cephalospori n

1gm/IV every 8hours

Second generation cephalosporin that inhibits cell wall synthesis, promoting osmotic instability usually bactericidal Adverse reaction: Fever, hypotension, nausea, vomiting,

Reglan

Tempra

Metoclopromi de

Paracetamol

Anti emetic

Anti pyretic

10mg IV for vomiting

300mg IV for T >38degrees

diarrhea, dyspnea. Stimulates motility of upper GI tract, increases lower esophageal sphincter tone, and blocks dopamine receptors at the chemoreceptor trigger zone. Adverse reaction: Fever, drowsiness, restlessness, headache, dizziness, nausea, diarrhea Unknown. Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to simulation. Adverse effects: Rash, urticaria, hypoglycemia, jaundice

Reference: Nursing2007 Drug Handbook O.INTRAVENOUS FLUID

To prevent or reduce post operative nausea and vomiting

Contraindicated in patients hypersensitive to drug.

Monitor bowel sounds.

For mild pain or fever

- Contraindicated in patient s with hypersensitivity to drug -Use cautiously in patient’s with long term alcohol use because therapeutic doses cause hepatotoxicity in these patients

-Advise patients that drug is for short-term use. -Warn patient or caregiver that high doses or unsupervised long term use can cause liver damage

Date Started

Name of IVF

Type of Solution

Dec. 3, 2008

Dextrose 5% in Lactated Ringer Solution

Hypertonic solution

P. PRIORITY NURSING PROBLEMS Nursing Problem Acute pain related (rhabdovirus)

to

chemical

Rank

Computation a. # gtts/min b. # of cc per hour 30 gtts/min

Indication applicable to the client A hypertonic solution has an osmolarity higher than serum osmolarity. When a patient receives a htpertonic IV solution, serum osmolarity initially increases causing fluid to be pulled from the interstitial and intracellular compartments into the blood vessels

Justification

agent

1

Impaired swallowing related to neuromuscular impairment

2

Mild anxiety related to threat to health status

3

It is an actual problem that needs immediate attention. This is the prioritized problem. It is partially modifiable, since the resources are available and the nurse can facilitate intervention that will help in alleviating the pain of the client. Pain, in the sense of physical pain,[1] is a typical sensory experience that may be described as the unpleasant awareness of a noxious stimulus or bodily harm. If the problem is not solved, it will lead to other complications such as restlessness. In Maslow’s Hierarchy of needs, it is a physiologic need to maintain homeostasis because if not, it can cause people to feel sick, pain and discomfort. This is an actual problem that needs immediate attention. This is our third prioritized problem since it puts the client This is an actual problem that needs immediate attention. It is partially modifiable since the resources are available and the nurse can facilitate intervention that will help in alleviating the anxiety of the client, however, the outcome of the intervention will also depend on the client. Anxiety is a

psychological and physiological state characterized by cognitive, somatic, emotional, and behavioral components. These components combine to create an unpleasant feeling that is typically associated with uneasiness, fear, or worry. It is not the priority problem because if the problem of acute pain was Addressed then this problem will also be alleviated. If the client has anxiety his activities of daily living will also are affected. If the problem is not solved, it will lead to other complications such as restlessness. In Maslow’s Hierarchy of needs, safe and security is secondary to physiologic or basic needs. The client needs to feel safe and comfortable both in physical and environmental. Risk for Deficient Fluid Volume related to Hydrophobia

4

Q. NURSING CARE PLAN Assessment I- “ Masakit po yung tahi ko O- with facial grimace - with signs of distress -irritable M- pain scale 5

Nursing Diagnosis Acute pain related to presence of surgical incision

Background Knowledge Immediate Cause: Surgical incision Intermediate cause: surgery Root cause: Surgical repair Implication: Acute pain was considered as having a limited and often predictable duration such as post-operative pain, which usually disappear as the wound

Goals and Objectives

Intervention

Rationale

Goal: After 8 hours of nursing intervention, the client’s level of pain will be alleviated as evidenced by verbal report of pain scale reduction from 6 to 2. Objectives: 1. After 10 minutes of discussion about pain the client will be able to express hi s feelings regarding the pain he is experiencing.

Evaluation Effectiveness: 1. Was the client’s level of pain alleviated? __yes __no __why?

INDEPENDENT: -Encourage verbalization of feelings about pain.

Pain is a multidimensional phenomenon and is difficult to define. Encouraging the client to verbalize feeling

2.Was the client able to express his feelings regarding the pain he is experiencing? __yes? __no __why?

heals. It is considered a useful and limiting pain in that it indicates injury and motivates the person to obtain relief by treatment of the cause. Pain is more than a symptom of a problem. It is a high priority problem in itself. It presents both physiologic and psychologic dangers to health and recovery. Unrelieved acute postoperative pain leads to development of chronic pain syndromes and increased complications.

about pain felt is important for us to explore their thoughts about pain. (Medical Surgical Nursing by Joyce Black p. 442) -Assess client’s perception along with behavioral and physiological responses.

It is important to assess the client’s perception to pain because pain perception is an important component of the pain experience. (Medical Surgical Nursing by Joyce Black p. 442)

-Note client’s attitude toward pain.

To assess if the client has misconception or misinformation about pain. Misinformation about pain is one of the major blocks to accurate assessment (Medical Surgical Nursing by Black)

Reference: Medical Surgical Nursing by Joyce Black p. 440

3. Was the client able to participate on the activities that promote comfort and help in alleviation of pain? __yes __no __why? 4. Was the client able to have a verbal report regarding pain scale reduction? __yes __no __why?

5. Was the client able to promote wellness? __yes __no __why? Efficiency:

2. After 15minutes of demonstration of techniques that will aid in reducing pain, the client will be able to participate on the activities that will promote comfort and help in alleviation of

-Discuss the appropriate activities that will help in reducing the client’s level of pain.

To promote client’s awareness regarding the activities that will aid in reducing pain. (Nurses Pocket Guide by Doenges)

Was the client and the health care provider able to use the maximum amount of resources in the given time frame?

pain.

Yes___ No___ Why? -Assist client to explore method that would help in reducing pain.

-Demonstrate deep breathing exercises.

-Encourage client to have divertional activities

To ensure that the proper way of executing the activities was delivered accordingly to the client. (Nurses Pocket Guide by Doenges) Deep breathing contributes to pain reduction by reducing muscle tension and anxiety. Reference: Medical Surgical Nursing by Joyce Black: p.479) To promote client’s relaxation. Progressive relaxation training is used to treat various physical and psychological problems, including pain. The deep relaxation produced by this method can decrease anxiety and excessive muscle contraction and promote the onset of sleep: (Medical Surgical Nursing by Joyce Black p.479)

Adequacy: Were the numbers of interventions sufficient enough to solve the problem? Yes___ No___ Why? Appropriateness: Were the interventions setting and time frame realistic to the client’s situation? Yes___ No___ Why? Acceptability: Were the interventions suitable for the client’s situation? Yes___ No___ _why?

3. After 30 minutes of providing comfort measures the client will be able to report pain reduction as manifested by verbal report of pain scale from 6 down to 2.

-Provide quiet environment and calm activities.

Promote comfort measures such as back rub, and change of position. -Instruct the use of relaxation exercises such as deep breathing exercises and listening to music if possible.

DEPENDENT: Administer analgesic as prescribed.

Comfort and quiet environment promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external distractions. (Fundamentals of Nursing by Kozier p. 11650 To provide nonpharmacologic pain management. (Nurses Pocket Guide by Doenges) Deep breathing contributes to pain relief and reduction by reducing muscle tension and anxiety. Music has been used to reduce pain in numbers of setting (Medical Surgical Nursing by Joyce Black: p478) To maintain acceptable level of pain. (Nurses Pocket Guide by Doenges p.390) To evaluate the

effectiveness of the interventions given. Reassess the pain scale. To prevent fatigue (Nurses Pocket Guide by Doenges) 4. After 30 minutes of nursing intervention, the client will be able to promote wellness.

-Encourage adequate rest period. -Review ways to lessen pain felt, including techniques such as therapeutic touch, proper breathing exercises, positioning and other relaxation skills. .

Discuss the impact of pain on lifestyle, independence and ways to maximize levels of functioning.

The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications. (Fundamentals of Nursing by Barbara Kozier p.1164)

To provide knowledge and reduce misconceptions about pain.

Support persons often need assistance to respond positively to then client experiencing pain. (Fundamentals of

-Discuss with significant others ways in which they can assist client and reduce precipitating factors that may cause or increase pain.

Nursing by Kozier p. 1150)

R. DISCHARGE PLAN a. Date of Discharge b. Medicines Instruct the patient to take the mediation as prescribed by his physician. Stress the importance of taking the right dose and right time of taking the medication. c. Exercise/economic consideration. Avoid exhaustion and try to reduce stress. If possible, maintain bed rest to regain energy. d. Treatment Take supplements everyday as prescribed by the physician. e. Health teachings Provide health teachings about wound care and instruct the patient and significant others to report to the health care provider any unusual observation within the client's incision like swelling, redness, drainage, bleeding and also fever and abdominal pain. Discuss to the patient that heavy lifting should be avoided 6 weeks to allow healing of the abdominal tissues and muscles. f. Out patient follow up Instruct about the importance of out patient follow up. Discuss that its purpose is for proper monitoring of the client condition and to determine if the patient is recovering well or if there is a need for further treatment like giving medications or supplements. g. Diet Instruct the need for adequate nutritional intake that will help in his recovery and also for faster wound healing.

h. Spiritual Advice Advise the client as well as the family to always pray and to seek guidance of the Lord.

PATHOPHYSIOLOGY hard mass of hard feces mass of feces

obstructionobstruction

appendix becomes appendix distended becomes distended with fluids with secreted fluids bysecreted its by its mucisa mucisa

increase pressure increase within pressure the within the lumen lumen

impaired blood supply

inflammation

edema

ulceration

infection

formulation of purulent exudate

further distention of the appendix

tissue necrosis

gangrene

perforation

localized peritonitis

generalized or upper abdominal pain

Far Eastern University Institute of Nursing Fabunan, Annalyn A. BSN906 group3a/3b Evidenced based Nursing

I. Clinical Question: How does the risk for ruptured appendix changes with passing time? II. Citation: How time affects the risk of rupture in appendicitis? By: Bickell NA; Aufses AH; Rojas M; Bodian C Department of Health Policy, Mount Sinai School of Medicine, New York, NY 10029, USA.

III. Study Characteristics: a. Patients included (population and sample) a random sample of 219 of 731 appendicitis patients operated on between 1996 and 1998 at 2 inner-city tertiary referral and municipal hospitals b. Intervention compared How the risk changes for a ruptured appendix with passing time c. Outcome Monitored: This study aimed to determine the changes in risk of rupture in patients with appendicitis with increasing time from symptom onset to treatment to help guide the swiftness of surgical intervention d. Does the study focus on the significant problem in clinical practice? Yes this study focus on the significant problem in clinical practice. IV. Methodology/ Design: a. Methodology Retrospective study, random sampling b. Design Retrospective chart review of physician office, clinic, emergency room, and inpatient records c. Setting: New York, USA d. Data Sources A random sample of 219 of 731 appendicitis patients operated on between 1996 and 1998 at 2 inner-city tertiary referral and municipal hospitals. Conditional risks of rupture were calculated using life table methods. Logistic regression was used to assess factors associated with rupture, and linear regression was used to assess factors affecting time from first examination to treatment.

e. Has the original study been replicated? It was not stated if the study has been replicated f. What were the risk and benefits of the nursing actions/ interventions tested in the study? The benefits of the actions done in the study is that it provides information about the changes in risk of rupture in patients with appendicitis with increasing time from symptom onset to treatment to help guide the swiftness of surgical V. Results of the Study Rupture risk was < or = 2% in patients with less than 36 hours of untreated symptoms. For patients with untreated symptoms beyond 36 hours, the risk of rupture rose to and remained steady at 5% for each ensuing 12-hour period. Rupture was greater in patients with 36 hours or more of untreated symptoms (estimated relative risk [RR]=6.6; 95% CI: 1.9 to 8.3), age 65 years and older (RR=4.2; 95% CI: 1.9 to 6.1), fever > 38.9 degrees C (RR=3.6; 95% CI: 1.2 to 5.7), and tachycardia (heart rate > or = 100 beats/minute; RR=3.4; 95% CI: 1.8 to 5.4). Time between first physician examination and treatment was shorter among patients presenting to the emergency department (median, 7.1 hours versus 10.9 hours; p<0.0001), and those for whom a physician's leading diagnostic impression was appendicitis (6.3 hours versus 11.3 hours; p<0.0001). Patients sent for CT scan experienced longer times to operation (18.6 hours versus 7.1 hours; p<0.0001). VI. Author’s Conclusions/ recommendations Risk of rupture in ensuing 12-hour periods rises to 5% after 36 hours of untreated symptoms. Physicians should be cautious about delaying surgery beyond 36 hours from symptom onset in patients with appendicitis. VII. Applicability: This study is applicable in the clinical practice because the concept of this study concentrates on preventing harm with the patients who are experiencing appendicitis. VIII. Reviewer’s Conclusion/Commentary This study is very informative, and I think it is really applicable for patient who are suffering from appendicitis because if the information discussed in the study will be acquired by practitioners and the delay of surgical procedure during the day of the surgery will be minimized then the danger imposed on the client will be lessen IX. Evaluating Nursing Care Practice a. Safety: The study promotes safety for the patients since it investigates on the factors that increase the risk of having rupture of appendix. They want to inform the public about the danger of having a delay surgery for appendicitis. b. Competence The study possesses competence because I think the people behind the study were competent and professional enough to come up with such results. c. Acceptability The study is acceptable since in concentrates on the welfare of the patient. d. Effectiveness The study will be effective in the clinical setting if the practitioners will comply on it.

e. Appropriateness This study is appropriate for patients having appendicitis since the aim of it was to prevent danger on the client who are suffering from that kind of disease.

Reference: http://www.medscape.com/medline/abstract/16500243