Far Eastern University
Institute of Graduate Studies
Case Study # 1
24 year old healthy male with one day hx of abdominal pain.
Pain was generalized at first, now worse in the right lower abdomen radiates to his right groin. He has vomited twice today.
Denies any diarrhea, fevers, dysuria or other complaints.
No appetite today.
ROS otherwise negative
Past Medical History: negative
Past Surgical History: negative
Medications: none
NKDA
Social hx: no alcohol, tobacco or drug use
Family hx: non-contributory
Physical Exam:
T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat: 100% room air
Uncomfortable appearing, slightly pale
Abdomen: soft, non-distended, tender to palpation in RLQ
with mild guarding; hypoactive bowel sounds
Genital exam: Normal
Appendicitis
Appendicitis means inflammation of the appendix.
The main thrust of events leading to the development of acute appendicitis lies in the appendix developing a compromised blood supply due to obstruction of its lumen and becoming very vulnerable to invasion by bacteria.
Occlusion of appendix by fecalith
Decreased drainage of mucosal secretions
Increased ILP in the appendix
Vasocongestion
Decreased blood supply then 02 supply in the appendix
Necrosis, bacterial invasion
Disruption of cell membrane
Start of Inflammatory Process
Appendicitis
Age
24 years old
Gender
Male
Episodes of Constipation
Low-fiber Diet
RISK FOR FLUID VOLUME DEFICIT
- Vomited twice
- Temperature reading of 37.8 C
- Heart rate of 95 bpm
- Hypoactive bowel sounds
- Pale
IMBALANCED NUTRITION
- Loss of appetite
- Vomited twice
- Pale
ALTERED ELIMINATION
- Hypoactive bowel sounds
- Vomiting
RISK FOR DISCOMFORT
- Uncomfortable appearing
- Soft, non-distended,
- tender to palpation in RLQ
- Mild guarding
ACUTE PAIN
- Right lower quadrant abdominal
pain radiating to the right groin
- Uncomfortable appearing
- Soft, non-distended,
tender to palpation in RLQ
Aileen Joy M. Gonzales, RN