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8/8/2019 Appendicitis GroupB Case Pres Copy (2)
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A Case Presentation of:
Presented by: Group B
Clinical Instructor: Maria Teresa C. Gamo ,RN, MAN
APPENDICITIS
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INTRODUCTION
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OBJECTIVES
To gain knowledge of Appendicitis and be able toidentify the signs, symptoms and its differentialdiagnosis
To outline the diagnostic work up of a client withsuspected appendicitis and subsequent appendectomy
To explain how each can be prevented and/ormanaged
To meet the needs of the client and to promotewellness
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RATIONALE
A knowledge of what to expect helps lessen anxiety andpromote patient cooperation and compliance
Early detection of potential problem with prompt intervention
can prevent serious consequences The patient needs continuous support from the family to cope
with needed change
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SIGNIFICANCE of the CASE
It is the most common cause of intra-abdominal infection
Appendicitis is difficult to diagnose
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Nursing History
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GENERAL DATA
NAME: Mr. Apu
SEX: Male
RELIGION: Roman Catholic
CIVIL STATUS: Single
AGE: 20 y.o.
DATE of ADMISSION: 11th
of October 2010
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CHIEF COMPLAINT
Abdominal pain @ RLQ
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FAMILY HISTORY
(-) DM
(-) hospitalization
(-) HPN (-) blood transfusion
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SOCIAL HISTORY
VICES:
(-) smoker
(+) alcohol beverage drinker- occasional
OCCUPATION:
Military: active duty
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HISTORY of PRESENT ILLNESS
20th of July 2006,
3 hrs. PTC (+) abdominal pain, burning in character,tolerable, radiates to the whole abdomen associated vomiting
5x of the previously ingested food and liquids.
2 hrs. PTC (+) still abdominal pain, this time localized toRLQ, crampy in character, nonradiating, associated
vomiting, persistence prompted consult @ FBGH.
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Physical Assessment
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PHYSICAL EXAMINATION
Conscious, coherent & ambulatory not in CRD
BP: 110/80 mmHg
Wt: 73 kg
Eyes: Anecteric sclera, pink palpebral conjunctiva Skin: Warm, moist good skin tugor
Heart: AP, no murmurs
Abdomen: Flat, soft, bowel sounds: 2/min (+) tender @RLQ
Extremeties: No gross deformities, no cyanosis, no edema
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PHYSICAL EXAMINATION
Baseline V/S
BP: 120/80
RR: 21
T: 36.5
PR: 89
Weight: 55kg.
GCS: 15 upon arrival
Time of Admission: 11:05amDate: 10-11-10
D5LR x 8 (Left hand)
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REVIEW of the SYSTEM
GENERAL: (-) weight gain (-) weakness (-) weight loss(-) easy fatigability (+)fever
HEENT: (-) headache (-) colds (-) dizziness (-)sore throat
RESPIRATORY: (-) cough (-) dyspnea
CARDIOVASCULAR: (-) chest pain
GASTROINTESTINAL: (+) nausea (+)abdominal pain
GENITOURINARY: (-) dysuria
INTEGUMENTARY: (-) cyanosis (-) edema
SKELETAL: no problem
MASCULAR: no problem
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Anatomy and Physiology
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DIGESTIVE TRACT
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RELEVANT ANATOMY
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RELEVANT ANATOMY
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ETIOLOGY
Can be caused by:
Fecalith that occludes the lumen of the appendix
Kinking of the appendix
Swelling of the bowel wall Fibrous conditions in the bowel wall
External occlusion of the bowel by adhesion
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Pathophysiology
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PATHOLOGICAL SEQUENCE
Initiation of inflammation possibly
by fecalith obstruction
Acute inflammation of mucosa
Extension of inflammation
across appendiceal wall
Involvement of serosa
by inflammation
Spread of peritonitis to
adjacent structures
Gangrene of appendix wall
PERFORATION
Attempts at walling off perforation
by omentum and adjacent bowel
Inadequate containment leading
to spreading peritonitis
or
Intense and extensive
walling of production
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CLINICAL
MANIFESTATIONS
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SIGNS and SYMPTOMS of
APPENDICITIS Periumbilical pain
RLQ pain or tenderness
Anorexia
Low grade fever Nausea
Vomiting
Rebound tenderness
RLQ guarding
Constipation or diarrhea
Pain on defecation or urination
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CARDINAL FEATURES of ACUTE
APPENDICITIS Abdominal pain for less than 72 hours
Vomiting 1-3 times
Facial flush Tenderness concentrated on the right iliac fossa
Anterior tenderness on rectal examination
Fever between 37.3 and 38.5C No evidence of urinary tract infection
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COMMON SIGNS of ACUTE
APPENDICITIS McBurneys sign
Psoas sign
Obturator sign Rovsing sign
Dunphys sign
Hip flexion Others..
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MANAGEMENT of SUSPECTED
APPENDICITIS
Right iliac fossa pain
Co
nclus
ive featur
es
of appendicitis inconclusive Othe
r
caus
eapparent
Review periodically
Still inconclusive
urine microscopy, full
blood count, plain X-ray
and serum amylase
APPENDICECTOMY Treat accordingly
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Diagnostic Procedures
AndLab Results
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DIAGNOSTIC PROCEDURES
Hematology
Urinalysis Appendectomy
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HEMATOLOGYNORMAL VALUE
Hemoglobin 172 M: 140-180
Hematocrit 0.52 M: 0.40-0.54
White Blood Cells 15.6 150-450 x 10 9/L
WBC Defferential
Segmenters 0.80 0.35-0.65
Lymphocytes 0.20 0.20-0.40
GRT DIAGNOSTIC CENTER
Date: 10-11-10
HEMATOLOGY
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URINALYSIS
PHYSICAL
EXAMINATIONPTS RESULT REFERENCE VALUE
Color Yellow Clear
Reaction Acidic (6) 4.5-8.0
Specific Gravity 1.030 1.005-1.025
Sugar Neg Neg
Protein Neg Neg
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MICROSCOPIC EXAMINATION
PHYSICAL
EXAMINATION
PTS RESULT REFERENCE VALUE
RBC 0-1 0-1/hpf
Pus cells 0-1 0-2/hpf
Epithelial Few Few present
Bacteria None none
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CBC TESTING
To determine the number of leukocytes & erythrocytes
Includes the RBC count, hemoglobin, red cell indices, WBCcount with/without differential, and platelet count
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RBC TESTS
Erythrocytes (RBC) count- carries hemoglobin.
Hemoglobin (Hgb or Hb) determination- evaluateshemoglobin content of RBC.
Decrease: anemia, Increase: polycythemia Hematocrit (Hct) test- known also as packed red cell
volume test, is often used in place of the RBC count. It
measures the volume of RBCs in whole blood.
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WBC TESTS
WBC count (4500-1100)Helps to detect infection or inflammation.
Neutrophils count (40-75% or 2500-7000)
Essential in preventing or limiting bacterial infection
(avg. life span: 2-4H):>8000 occurs w/ infection, corticosteroids, other
meds,myeloproliferative disease,
Decreased- neutropenia
ANC 180mg/ 100ml).
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ROUTINE ANALYSIS
MEASUREMENT andNORMAL VALUE
INTERPRETATION
Ketones (none) End products of fat metabolism. Presencedue to pts diabetes mellitus is poorlycontrolled experience breakdown of fatty
acids.
Blood (up to 2 RBCs) Increase may be due to damage to glomerulior tubules. Trauma, disease, or surgery ofthe lower urinary tract.
Specific Gravity (1.010-1.025) High SG- reflects concentrated one
Low SG- reflects diluted urine
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MICROSCOPIC EXAMINATION
MEASUREMENT and VALUE INTERPRETATION
WBCs
(O-4 per lower-power field)
Greatest # may indicate UTI
Bacteria (none) Indicates UTI if present
Casts (none) Types of casts includes:
Hyaline,WBCs,RBCs, granular cells, &epithelial cells. Presence is alwaysabnormal finding and indicates renalalterations
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GOALS of MANAGEMENT
Relieving pain
Preventing fluid volume deficit
Reducing anxiety
Eliminating infection Maintaining skin integrity
Attaining optimal nutrition
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TREATMENT: APPENDECTOMY
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PREOPERATIVE
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NURSING MANAGEMENT
Assess:
Pain
Presence of peritonitis
V/S, fluid and electrolyte status Laboratory data
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NURSING MANAGEMENT
NURSING DIAGNOSIS:
Pain, Acute R/T inflammation
PLANNING: EXPECTED OUTCOMES.
The client will understand why pain medication is held preoperatively
IMPLEMENTATION: The client will have pain medication withheld.
Never give enema or laxative, or apply heat
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NURSING MANAGEMENT
NURSING DIAGNOSIS:
Fluid volume deficit, high risk for R/T vomiting
PLANNING: EXPECTED OUTCOMES.
The client will have fluid and electrolyte balance maintained
IMPLEMENTATION:
IV fluids are started to maintain fluid balance
Intake and output should be carefully measured
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NURSING MANAGEMENT
NURSING DIAGNOSIS:
High risk for infection of R/T rupture of appendix
PLANNING: EXPECTED OUTCOMES.
The client will not develop an infection or will have a rupture
diagnosed early
IMPLEMENTATION:
Clients V/S must be checked regularly
Clients pain should be monitored
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PREOPERATIVE
Informed consent
Nurse instructs the client on postoperative exercises
Surgical shave may be performed
Communicates pertinent information to all members of thehealth care team
Place patient in comfortable position to relieve abdominal pain& tension- usually Fowlers position.
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PREOPERATIVE CARE
See that patient takes nothing by mouth Place ice bag to RLQ- NEVER HEAT
Do not administer cathartics
Frequently evaluate V/S When diagnose of acute appendicitis is made, administerchemotherapy &/or antibiotics.
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INTRAOPERATIVE
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INTRAOPERATIVE
Transfer to OR table
Attached to monitors
Induction of spinal anesthesia
Supine position, arms extended to arm board Surgical skin prep done using Betadine 7.5% and 10% soln
Sterile drapes applied aseptically in sequence
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RISK FACTORS and
GENERAL CONSIDERATIONS
Loss of function
Loss of Life
Hemorrhage Infection
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MEDICATION: INTRA-OP
Ampicillin 1 gm. TIV now then 500 mg TID q 8 hr
Metronidazole 500 mg IV now then 5oo mg IV q 8 hr
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APPENDECTOMY
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APPENDECTOMY
Open Appendectomy
Laparoscopic
Appendectomy
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LAPAROSCOPIC
APPENDECTOMY
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LAPAROSCOPIC
APPENDECTOMY
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APPENDECTOMY
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APPENDECTOMY
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APPENDECTOMY
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APPENDECTOMY
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APPENDECTOMY
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APPENDECTOMY
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APPENDECTOMY
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OPEN APPENDECTOMY
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OPEN APPENDECTOMY
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INTRAOPERATIVE
McBurneys incision 2-3 inches in length is made at the RLQ Surgeon enters the abdomen and looks for the appendix After examining the area around the appendix, the appendix is
pulled, ties it off as its based and removes it
Care is taken to avoid spilling pus from the appendix If the appendix has perforated, the pus can be drained with
drains (rubber tubes) and left open and packed with sterilegauze.
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INTRAOPERATIVE
Wash with sterile water Closure of incision done layer by layer
Initial & final counting of sponges, sharps & inst.
Incision is then sutured
Clean operative site clean & apply betadine
Apply and plaster surgical dressing
Transfer to RR per stretcher
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POSTOPERATIVE
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NURSING MANAGEMENT
Monitor V/S, urine output, level of consciousness, and IV Assess respiratory status and surgical wound
May have a drain
Assess the dressing Provide wound care
Reposition the client
Adequately manage the clients pain
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POSTOPERATIVE
Without drainage Following recovery from anesthetic, Fowlers position is
maintained, analgesic is given every 3 prn, & fluids & foodare given as tolerated.
Stitches removed between 5th & 7th day (usually inphysicians office)
With drainage
Treatment same as for peritonitis
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Nursing CareP
lan
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NURSING CARE PLAN
SUBJECTIVE:
Mabuti naman ang pakiramdam ko,medyo nakakain na kongayon. Kaya lang sumasakit pa rin ang inoperahan sakin
as verbalized by the patient.
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NURSING CARE PLAN
OBJECTIVE:
Conscious, coherent, not in CRD
IV contraption attached
Ambulatory Guarding the site of post operation
On DAT
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NURSING CARE PLAN
NURSING DIAGNOSIS: Pain related to S/P appendectomy manifested by guarding the incised part
ANALYSIS and RATIONALE:
Acute painMay contribute to pts abnormal behavior
Risk for volume deficit
May cause dehydration
Risk for Fluid volume deficitRisk for infection on the area of the wound is possible
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NURSING CARE PLAN
NURSING GOAL/S:
To relieve pain and discomforts
To assess potential risk for complications:
To maintain a fluid & electrolyte balance and return of normallevels of body fluids
Prevent infection
Pt will understand & verbalized why pain is controlled
postoperatively
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NURSING CARE PLAN
NURSING INTERVENTION: Assist in placing pt in a semi-Fowler position
Monitor V/S, urine output, level of consciousness
Monitor IV solutions, IV sites and client outcomes hourly
Observe for abdominal tenderness, fever, vomiting, abdominal rigidity &tachycardia
Correct dehydration as prescribed
Administer antibiotic agents as prescribed
Evaluate for anorexia, chills, fever & diaphoresis
Prepare pt for rectal examination
Replace fluids & electrolytes by IV as prescribed
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NURSING CARE PLAN
RATIONALE of NURSING INTERVENTION:
Position reduces the tension on the incision & abdominalorgans
Alleviate pain Sign in evaluating if there is a risk for complication
Medications-relieves pain & restores fluid balance
Prevent dehydration
Prevent peaks/valleys in fluid level
Maintain skin integrity & prevent excessive dryness
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NURSING CARE PLAN
EVALUATION:
Met: not experiencing any pain or tenderness
Fluid balance in normal values
Wound healed Pt understand & verbalized the necessary interventions made
Pt returned to his usual ADL and normal lifestyle
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Drug Study
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DRUG STUDY
GENERIC NAME:
tramadol
ranitidine
metronidazole
DRUG NAMECLASSIFI-
CATION
DOSAGE
AND
ROUTEACTION
INDICA-
TION
SIDE EFFECTS/
ADVERSE EFFECTS
CONTRA-
INDICA-
TION
NURSING
RESPONSIBILITY
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ROUTE TION
GENERIC
NAME:
tramadol
BRAND
NAME:
Ultram,
Ultram ER
narcotic
analgesic,
Tramadol
is a man-
made(synthetic)
analgesic
(pain
reliever)
100mg
IV q8
Its exact mechanism
of action is unknown
but similar morphine.
Like morphine,
tramadol binds toreceptors in the brain
(opioid receptors) that
are important for
transmitting the
sensation of pain from
throughout the body
to. Tramadol, like
other narcotics used
for the treatment ofpain, may be abused.
Tramadol
hydrochlo
ride
tablets are
indicatedfor the
managem
ent of
moderate
to
moderatel
y severe
pain in
adults.
Nausea, vomiting,
constipation,
lightheadedness,
dizziness, drowsiness,
headache, or weaknessmay occur,
mental/mood changes
(such as agitation,
hallucinations),
unusual restlessness,
loss of coordination,
fast heartbeat, severe
dizziness, unexplained
fever, severenausea/vomiting/diarr
hea, twitchy muscles.
slow/shallow
breathing, seizures,
fever/flu-like
symptoms.Avery
serious allergic
reaction to this drug
(which may occur asearly as the first dose)
is rare
Suicidal
patients,
acute
alcoholis
m; headinjuries;
raised
intracrani
al
pressure;
severe
renal
impairme
nt;lactation.
While not nearly as
dangerous a
respiratory
depressant as other
opioids or opiates, athigh doses, this may
be a consideration.
yTramadol is
metabolized in the
liver. Caregivers are
cautioned to
doublecheck for
meds that inhibhit
liver function, orwatch for
adminstration on
hepatic
compromised
patients.
yTramadol lowers
the seizure
threshold. It also
synergizes withSSRI's and
tricyclics, and may
have a stronger
effect on epileptics.
Ergo, seizure
warning.
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DRUG STUDY: Ranitidine
GENERIC NAME:
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DRUG STUDY: metronidazole
GENERIC NAME:
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DRUG STUDY
BRAND NAME:
AMPICILLIN METRONIDAZOLE
Marcillin
Omnipen
Penbritin
Principen
Polycillin
Totacillin
Flagyl
Flagyl ER
Metric 21
MetroCream
MetroGel
MetroGel- vaginal
Metrolotion MetroIV
Metryl
Notritate
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DRUG STUDY
CLASSIFICATION:
AMPICILLIN METRONIDAZOLE
Anti-infective
Anti-biotic
Aminopenicillin
Anti-infective agent
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DRUG STUDY
DOSAGE:
AMPICILLIN METRONIDAZOLEAdult/child: IV/IM
40 kg, 1.5-3 g q6h
Child: IV 300
mg/kg/d divided q6h
Adult slow IVinfusion (30-60 mins)of 500 mg before
surgery & 2 IVinfusions of 500 mg 8& 16 hrs later
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DRUG STUDY
MECHANISM of ACTION:
AMPICILLIN METRONIDAZOLE
Antibiotic agent with broadspectrum of activity resulting from
beta-lactamase inhibition. Sulbactam inhibits beta-lactamasesmost frequently resp. for transferreddrug resistance. Because of thisaction, a wide range of beta-
lactamases found in organismsresistant to penicillins &cephalosporins are inhibited.
Synthetic compound with directtrichomonacidal & amebicidal activity
as well as antibacterial activity againstanaerobic bacteria & some gram-negative bacteria
G ST
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DRUG STUDY
INDICATION:
AMPICILLIN METRONIDAZOLE
Treatment of infections due to
susceptible organisms in skin &skin strucures & intra abdominalinfections & for gynecologicinfections.
Also used for infections caused
by ampicillin- susceptibleorganisms
Treatment of serious infections
caused by susceptible anaerobicbacteria in intra abdominalinfections, skin infections,gynecologic infections, septicemia& for both pre & postoperative
prophylaxis, bacterial vaginosis
DRUG STUDY
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DRUG STUDY
CONTRAINDICATION:
AMPICILLIN METRONIDAZOL
E
Hypersensitivity topenicillins
Hypersensitivity
Hypersensitivity toparabens (topical
only)
DRUG STUDY
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DRUG STUDY
SIDE EFFECTS:
AMPICILLIN METRONIDAZOLE
Nausea, vomiting, rashes GI: abdominal pain, nausea,dry mouth, furry tongue,unpleasant taste, vomiting
DERM: burning, milddryness, skin irritation,
transient redness
DRUG STUDY
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DRUG STUDY
NURSING RESPONSIBILTIES:
AMPICILLIN METRONIDAZOLE
Instruct to take medicationaround the clock & to finish thedrug completely as directed, even iffeeling better
Advise to report the signs ofsuperinfections & allergy
Instruct to take medicationexactly as directed with evenlyspaced times between doses ordouble up on missed doses.
inform that the medication maycause urine to darken
inform that medication may causeunpleasant metallic taste
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REHABILITATION
Nursing
Management
NURSING MANAGEMENT
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NURSING MANAGEMENT
Monitor physical status for changes Once clients condition stabilizes, nurse focuses efforts on returning
the client to a functional level of wellness asap within the limitation
Speed of a clients recovery depends on how effectively the nurse
can anticipate potential complications, initiate necessary supportiveand preventive therapies, and actively involve client and family inthe recovery process
REHABILITATION
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REHABILITATION
In the hospital: After the procedure, pt will be taken to the recovery room for
observation
Recovery process will vary depending upon the type of procedure
performed and the type of anesthesia given Once V/S stable and pt alert, he will be taken to the hospital room
As a laparoscopy procedure may be performed on an outpatientbasis, he may be discharge home from the recovery room
May receive pain medication as needed, either by the nurse or byadministering it by himself through a device connected to his IV line
REHABILITATION
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REHABILITATION
May have a thin plastic tube inserted through the nose into yourstomach to remove air that you swallow. It will be removedwhen bowel resumes normal function. Not be able to eat ordrink until the tube is removed
Will be encouraged to get out of bed within a few hours after alaparoscopy or by the next day after an open procedure
Depending on the situation, may be given liquids to drink a few
hours after surgery. Diet may be gradually advanced to moresolid foods as tolerated
REHABILITATION
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REHABILITATION
At home: Important to keep the incision clean and dry. The physician will give
specific bathing instructions If stitches or surgical staples are used, they will be removed during a
follow-up visit. If adhesive strips, they should be kept dry and will fall off
within a few days Incision and the abdominal muscles may ache, especially after long periodsof standing. Take pain reliever for soreness as recommended by thephysician. Aspirin or other pain medications mat increase the chance ofbleeding
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RECOMMENDATIONS
RECOMMENDATION
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RECOMMENDATION
Incisions sites will be tender. Take pain medication as directed Make take shower two days after surgery May experience bloating or constipation. Resume a healthy, high fiber
diet Lift objects that are easy to handle. Use legs to handle most of the work.
Avoid strenuous activity Walking and stair climbing are good to improve circulation Avoid driving for seven days after surgery and when taking pain
medication
RECOMMENDATION
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RECOMMENDATION
Assume sexual intercourse as soon as you feel comfortable and havediscussed this with your surgeon
Call and schedule a follow-up appointment within one or two weeks aftersurgery. Schedule any additional follow-up appointments
Have any stitches removed depending upon the type your physicians uses
Health teaching regarding the signs and symptoms of appendicitis
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Health
Teach
ing
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Evaluation
Submitted by: GROUP B
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Submitted by: GROUP B
Gabasa, Kristine Charm
Guevara, Rina
Gultom, Yulien
Henson, Aileen Jean Humarang, Felipa May
Javier, Monique Anne
Manlangit, Jose Paulo Manzo, Michelle Joy
Martinez, Joan
Navarra, Adrian
Neri, Reve Angelie
Okorie, Ugo Salva, Sarah
Sasarari, Zusana
Xu, Wei Yi Fajardo, Ronaldo
Thank
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Thank
You for
Listening!
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