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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

  • Mild guarding

INFECTION

  • Temperature reading

of 37.8 C

Aileen Joy M. Gonzales, RN

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