Assessment | Health Case Study

Running Head: Assessment 3- Case Study
Assessment 3- Case Study
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Assessment 3- Case Study
Introduction
The patient, is a female aged 20 years, brought to ED for severe pain in right lower quadrant of
abdomen, lack of appetite, fever and nausea for the last 2-3 days. The clinical examination and
ultrasound of the abdomen diagnosed perforated appendix. 36 hours post emergency
laparoscopic surgery, her observations identified low blood pressure 94/45 mmHg, faster
respiratory rate of 24 per min, bloating and abdominal pain of 7/10 scale with rigid distended
abdomen. Her symptoms identified Peritonitis.
Person’s Situation
The patient had a medical history of asthma and depression. She takes medications like
Salbutamol, Sertraline and Seretide regularly. Post operative, the patient reported increased
centralized pain in abdomen that worsen movement and respiration, and is at the intensity of
7/10. She is identified with distended rigid abdomen with generalized abdominal guarding and
no bowel movement. The bowel sounds disappear with the progression of inflammation in
abdomen. The patient is still under a medical emergency due to swelling in peritoneum and
severe abdominal pain. The patient is acutely distressed and lies in his bed with shallow
breathings and minimal movement to relieve the abdominal pain.
Collection, Processing and presentation of Related Health Problem
Data related to patient’s medical history was collected from patient’s past medical records. The
patient has a history of asthma which had become severe after the surgery. The pain was self
reported by the patient. The physical examinations confirmed the distended rigid abdomen post
operative. The assessment of tenderness and tension in abdomen, blood tests, imaging techniques
like X Rays and Ultrasound are effective assessment tools to collect the data about the patient.
The patient identified with generalized tensing of abdominal wall muscles guarding the inflamed
organs. It occurs due to pressure of pain over the abdominal muscles. The primary peritonitis

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Assessment 3- Case Study
mostly occurs due to rupture and perforations in appendix. Peritonitis generally occurs due to
bacterial infection or sepsis. There is possibility that the disease can spread to the organs
underlying abdominal peritoneum and blood resulting into multiple organ failure, if left
untreated.
For further investigations, the patient was subjected to FBC, blood cultures, electrolytes and X-
Ray of abdomen. The results of pathology identified increased WBC count (leukocytosis) which
is in response to the sepsis. The X Ray also disgnosed gaseous and oedematous distention of
small and large bowels.
Three Nursing Issues
The three main priorities of the patient are: 1. Sepsis; 2. High Pain and 3.Low Blood Pressure
The patient is identified with increased WBC count and it shows inflammation and infection
which occurred after the laparoscopic surgery. The post operative high WBC count may also be
associated with extraperitoneal infection of exit site, catheter leakage and abdominal pain
(Tantiyavarong, Traitanon, Chuengsaman, Patumanond & Tasanarong, 2016).
The patient reported high level of centralized abdominal post operative pain due to peritonitis
and surgery. The pain gets worsen with movement and respiration. She is already a patient of
asthma. Her diaphragm movement during the respiration is likely to touch the rest of the internal
organs and peritoneal lining of the abdomen having inflammation. She requires immediate
nursing care to relieve her pain.
The patient reported low blood pressure (94/45 mmHg) post surgery. It may be due to dilated
systemic arteries and vaso-constricted renal arteries in the patient’s body (Kaowdley, 2015). It
causes retention of fluids in the abdomen and increased infection.
Goals