Med-Surgical Case Study (Appendicitis)

Format for Med-Surgical Case Study (Appendicitis) A. Introduction: 1. Personal Information; - Name (pseudonym), age, sex, gender, ethnicity, religion. - Wt, ht, any chidren 2. Medical & Surgical History. - Past medical Hx. - Past Surgical Hx. - Obstetric hx(female) B. Present Chief Complaints - Events leading to complaints - Explain what interventions (if any) were taken by patient from the time of getting ill leading up to the time of entering casualty. - What medical management and nursing management were given to the patient in casualty prior to the patient coming up to the ward. - State briefly how patient presented on the ward - Assessment of patient on admission C. Medical /Surgical Management. - What was the patient diagnosed as? - Discuss the pathophysiology of the patient’s condition briefly. - What was the medical (doctor’s) management ordered for this patient. - What medication was ordered for this patient, list and say how each drug ordered assisted patient to feel better/ improved patients condition. - What Investigations/diagnostic tests were done? State briefly why you think these tests were done. - What is/ surgical management performed on this patient. - Describe briefly procedure and findings from surgical intervention done. D. Nursing Management - List the nursing problems identified in this patient - State the nursing diagnosis formulated to address this problem - What was your desired outcome for your patient. - What nursing measures were done to meet your desired outcome/ alleviate this problem. (PRE-OP preparations, post –op care: IV, drains, tubes etc) - What are the possible complications the patient face and what interventions were done to prevent them from occurring. - State what topics will be taught to patient on discharge and discuss each briefly.. Recommendations: Explain what the patient should do in the future to continue recovery/ improve his or her condition..