I.

INTRODUCTION

Patient J.L.D is 31 year-old married woman who was admitted at the Surgery
Department last June 21, 2009 due to severe pain at her right lower quadrant, the patient
was diagnosed with acute appendicitis. The patient underwent emergency appendectomy
the next day, June 22, 2009.
Appendicitis is the inflammation of the vermiform appendix and was first
described as a pathologic condition by Reginald Fitz in 1886, it is caused by an
obstruction attributed to infection, stricture, fecal mass, foreign body or tumor.
Appendicitis can affect either gender at any age, but is most common in male ages 10-30.
Appendicitis is the most common disease requiring surgery and one of the most
commonly misdiagnosed diseases.
Appendectomy, removal of the appendix, is the standard treatment for acute
appendicitis, it is important to immediately remove the appendix after the diagnosis to
prevent the occurrence of the life-threatening complication of appendix. The most
frequent complication of appendicitis is perforation. Perforation of the appendix can lead
to a periappendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection
of the entire lining of the abdomen and the pelvis). The major reason for appendiceal
perforation is delay in diagnosis and treatment. In general, the longer the delay between
diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours
after the onset of symptoms is at least 15%. Therefore, once appendicitis is diagnosed,
surgery should be done without unnecessary delay.

II.NURSING OBJECTIVE

 To obtain necessary information regarding the patient and her condition

 To assess the patient’s overall health status
 To identify patient’s health care needs through analysis of all the data gathered
 To assist the patient throughout rehabilitation, recovery and discharge
 To impart necessary health teachings to the patient
 To perform appropriate nursing care in conjunction with the condition of the
patient
 To widen and enhance the student nurse’s knowledge and skills through additional
research about the nature of the disease, its signs and symptoms, its
pathophysiology, its diagnosis and treatment.
III.PATIENT’S PROFILE

Name: J.L.D
Age: 31
Sex: Female
Civil Status: Married
Date of Birth: October 03, 1977
Address: Never-ever Land
Religion: Roman Catholic
Nationality: Filipino
Category of the Patient: GM
Place of Admission: Aprilville General Hospital
Date Admitted: June 21, 2009
Time: 9:55 PM
Chief Complaint: Right Lower Quadrant Pain
Ward: St. Anthony
Attending Physician: Dr. House ^-^
Chief complaint: Right Lower Quadrant pain
Final Diagnosis: Acute Appendicitis
IV. HISTORY OF PAST AND PRESENT ILLNESS

A. History of Past Illness

Last September 2008, patient was diagnosed with kidney stones or renal calculi.
She underwent 3 sessions of Extracorporeal Shock Wave (ESWL) or simply known as
shockwave therapy, a non-invasive technique for removing obstructive renal calculi. The
patient believes that the occurrence of her kidney stones was due to her habit of eating
salty foods and soda or carbonated soft drinks. Her doctor prescribed her with the
following medications to reduce the risk of new calculi formation: Sambong forte,
Acalka, and Rowatinex.
The patient has also a surgical history, she delivered her two children through
Ceasarean Section (CS), her first CS delivery was on the year 2001, according to the
patient, her pregnancy was normal but her child had meconium-stained amniotic fluid
and was overdue that’s why she had to deliver her first child through CS, and the second
was on the year 2005.
The patient denies allergies to any medications, foods or animals. The patient
claims that she only suffered from two common childhood illnesses, chicken pox and
measles, when she was a kid. According to her she was completely immunized when she
was a child as evidenced by scars on the patient’s left and right deltoid.
The patient admits a family history of hypertension, according to the patient her
father died of heart attack.

B. History of Present Illness

Patient was in usual state of good health until June 21, 2009, after having her
dinner she experienced a severe pain at her abdomen which started at the area around her
periumbilical area shifted to right lower quadrant region. She was immediately rushed to
the hospital and was admitted at the surgery ward at 9:55 PM, she was diagnosed with
acute appendicitis. She underwent an emergency appendectomy the next day, June 22,
2009. Her operation begun at 12:50 PM and ended at 1:25 PM, her surgeon was Dr. Paat.
According to the patient, she had been experiencing mild pain at her abdominal
region since December 2008, she even consulted it to the doctor but they did not pay
much attention to it thinking that it was just a manifestation of her kidney problem and
that it was nothing serious.
The patient’s vital signs during the shift were as follow:
Temperature: 36.6 °C
Pulse Rate: 67 bpm
Respiratory Rate: 16 cpm
Blood Pressure: 100/80 mmHg
V.PEARSON ASSESSMENT

DATE JULY 9,2009 JULY 12, 2009 JULY 16,2009

P
>31 years old, married >conscious and >conscious and
woman coherent coherent
>mother of 2 >oriented, responsive >alert and responsive
>lives at Cuta, Vigan, and cheerful >has good relationship
Ilocos Sur >has good relationship with co-workers
>Roman Catholic with her neighborhood
>Conscious and >attends the mass every
coherent Sunday together with
>has good and her family
harmonious relationship
with her family
members
PSYCHOSOCIAL

E
>(-) vomiting >(-) vomiting >(-) vomiting
>(-)diaphoresis >(-) diaphoresis >(-) diaphoresis
>voids 5x a day with a >voids 5x a day with a voids 5x day with a
clear and light yellow clear and light yellow clear and light yellow
urine urine urine
>(-) pain upon urinating >(-) pain upon urinating >(-) pain upon urinating
ELIMINATION >defecates 2x a day >defecates 2x a day >defecates 2x a day
A/R
>sleeps 6-7 hours >sleeps 6-7 hours >works at the hospital
>patient started going to >goes to work 5x a Philhealth office
work on July 6, 2009, 9 week, from Monday to >sleeps 6-7 hours a day
days after her operation Friday >refrained from
>works as a health clerk >does household chores carrying her children
at a hospital >refrained from doing after her operation
REST & >works for 9 hours, strenuous activities such >refrained from doing
from 8:00 am to 5:00 as carrying heavy strenuous activities such
ACTIVITY am objects as pushing heavy
>considers watching TV >takes a short nap objects
at night with her family during weekends
as a way of recreation

S
>afebrile, body >afebrile, BT of 37.1 >afebrile,36.8 °C/ax
temperature (BT) of °C/ax > still with dry and
36.9 °C/ax >still with dry and intact dressing at
>denies allergy to foods intact dressing at incision site
or drugs incision site >still with binder at the
>with dry and intact >still with binder at her abdominal area
SAFE dressing on incision site abdominal area >(-) pain at the incision
>with binder at the >with dry and leathery site
ENVIRONMENT abdominal area wound > intact, approximated
>cleans and changes the >(-) pain at the incision wound edges
dressing regularly site >owns a pet dog which
>with dry wound >with strong house lives in a dog house
>(-) pain at the incision structure outside their house
site
>with clean and quiet
environment

O
>RR=14 cpm; eupneic >RR=14 cpm; eupneic >RR=16; eupnic
>BP=120/80 mmHg >BP=110/80 >BP=120/80
>PR=72 bpm >PR=80 bpm >PR=75 bpm
>(-) DOB and Chest >(-) DOB and Chest >(-)DOB and chest pain
Pain pain >with good skin turgor
>with good skin turgor >with good skin turgor
OXYGENATION

N
>weighs 58 kg >with normal BMI of >eats regularly, with
>Food Preferences: 22.7 good appetite
Rice and vegetables >with good appetite >sometimes takes a
>eats 3x a day regularly snack of juice and bread
with low salt diet every afternoon
>refrained from
NUTRITION drinking carbonated
softdrinks
VI.DIAGNOSTIC PROCEDURE

A. Ideal

1.URINALYSIS

Urinalysis is a microscopic examination of the urine that detects red blood cells,
white blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is
inflammation or stones in the kidneys or bladder. The urinalysis also may be abnormal
with appendicitis because the appendix lies near the ureter and bladder. If the
inflammation of appendicitis is great enough, it can spread to the ureter and bladder
leading to an abnormal urinalysis. Most patients with appendicitis, however, have a
normal urinalysis. Therefore, a normal urinalysis suggests appendicitis more than a
urinary tract problem, it is also usually used in women to rule out pregnancy.

2. WHITE BLOOD CELL COUNT

The white blood cell count in the blood usually becomes elevated with
infection. In early appendicitis, before infection sets in, it can be normal, but most often
there is at least a mild elevation even early. Unfortunately, appendicitis is not the only
condition that causes elevated white blood cell counts. Almost any infection or
inflammation can cause this count to be abnormally high. Therefore, an elevated white
blood cell count alone cannot be used as a sign of appendicitis.

3.ABDOMINAL X-RAY

An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized
piece of stool that blocks the appendiceal opening) that may be the cause of appendicitis.
This is especially true in children.

4.ULTRASOUND

An ultrasound is a painless procedure that uses sound waves to identify organs

within the body. Ultrasound can identify an enlarged appendix or an abscess.
Nevertheless, during appendicitis, the appendix can be seen in only 50% of patients.
Therefore, not seeing the appendix during an ultrasound does not exclude appendicitis.
Ultrasound also is helpful in women because it can exclude the presence of conditions
involving the ovaries, fallopian tubes and uterus that can mimic appendicitis.

Findings of acute appendicitis of ultrasound:

 Visualization of noncompressible appendix as a blind-ending tubular a peristaltic

structure (seen only in 2% of normal adults, but in 50% of normal children)
 Laminated wall with target appearance of 6 mm in total diameter on cross
section (81% SPECIFIC)/mural wall thickness 2 mm
 Lumen may be distended with anechoic/hyperechoic material
 Pericecal/periappendiceal fluid
 Increased periappendiceal echogenicity (= infiltration of mesoappendix/pericecal
fat)
 Enlarged mesenteric lymph nodes
 Loss of wall layers = gangrenous appendix

False-negative US:

 Failure to visualize appendix

 Inability of adequate compression
 Aberrant location of appendix (eg, retrocecal)
 Appendiceal perforation
 Early inflammation limited to appendiceal tip

False-positive US:

 Normal appendix mistaken for appendicitis

 Alternate diagnosis: Crohn disease, pelvic inflammatory disease, inflamed Meckel
diverticulum
 Spontaneous resolution of acute appendicitis

5. BARIUM ENEMA

A barium enema is an x-ray test where liquid barium is inserted into the colon
from the anus to fill the colon. This test can, at times, show an impression on the colon in
the area of the appendix where the inflammation from the adjacent inflammation
impinges on the colon. Barium enema also can exclude other intestinal problems that
mimic appendicitis, for example Crohn's disease.

6. COMPUTERIZED TOMOGRAPHY (CT) SCAN

In patients who are not pregnant, a CT Scan of the area of the appendix is useful
in diagnosing appendicitis and peri-appendiceal abscesses as well as in excluding other
diseases inside the abdomen and pelvis that can mimic appendicitis.

CT findings of normal appendix

 Visualized in 67-100%.
 At posterior-medial aspect of cecum.
 Diameter of up to 10 mm.
CT findings of Abnormal appendix

 Distended lumen (appendix >7 mm in diameter).

 Circumferential wall thickening.
 Target sign: homogeneously enhancing wall with mural stratification.
 Appendicolith: homogeneous/ringlike calcification (25%).
 Distal appendicitis: abnormal tip of appendix + normal proximal appendix and
normal cecal apex.

7. LAPAROSCOPY

Laparoscopy is a surgical procedure in which a small fiber optic tube with a

camera is inserted into the abdomen through a small puncture made on the abdominal
wall. Laparoscopy allows a direct view of the appendix as well as other abdominal and
pelvic organs. If appendicitis is found, the inflamed appendix can be removed with the
laparascope. The disadvantage of laparoscopy compared to ultrasound and CT is that it
requires a general anesthetic.

8. THE ALVARADO SCORE FOR ACUTE APPENDICITIS

The Alvarado score is a clinical scoring system used in the diagnosis of

appendicitis. The score has 6 clinical items and 2 laboratory measurements with a total 10
points.

A score of 5 or 6 is compatible with the diagnosis of acute appendicitis. A score

of 7 or 8 indicates a probable appendicitis, and a score of 9 or 10 indicates a very
probable acute appendicitis.

A popular mnemonic used to remember the

Alvarado score factors is MANTRELS:
Migration to the right iliac fossa
Anorexia, Nausea/Vomiting
Tenderness in the right iliac fossa
Rebound pain
Elevated temperature (fever)
Leukocytosis
Shift of leukocytes to the left

Despite numerous studies touting the advantages of newer diagnostic

technologies, the most accurate and cost0effective diagnostic tool to diagnose
appendicitis remains for the physician to spend time performing an accurate history and
physical examination.
B.Actual

CBC

DIAGNOSTIC NORMAL ACTUAL NURSING NSG.

RESULT RESULT IMPLICATION RESPONSIBILITY
WBC 5.0-10.0 12.0 x10^9/L High-indicates >Instruct patient to
infection increase intake of
Vitamin C and increase
fluid intake
>Administer antibiotic
as ordered
Lymph # 3.0-4.0 1.6x1069/L High-indicates >Instruct patient to
stress, pain and increase intake of
acute systemic Vitamin C and increase
infection fluid intake
>Monitor signs of
infection such as
elevated Body Temp.
>Administer antibiotic
as ordered
Mid # 0.1-0.9 0.7x10^9/L Normal
Gran # 5.0-7.0 9.7x10^9/L High-indicates >Monitor signs of
infection infection such as
elevated Body Temp.
>Administer antibiotic
as ordered
Lymph % 30.0-40.0 13.4% Low-indicates
exhausted immune
system
Mid % 1.0-9.0 5.8% Normal
Gran % 50.0-70.0 80.8% High-indicates >Instruct patient to
infection increase intake of
Vitamin C and increase
fluid intake
HGB 120-160 131g/L Normal
RBC 4.04-5.48 4.99x10^12/L Normal
HCT 37.0-47.0 36.9% Mildly low- >Instruct patient to
indicates mild increase intake of
blood loss Vitamin C and increase
fluid intake

MCV 82.0-95.0 74.0 fL Low-indicates >Instruct patient to

anemia increase intake of
Vitamin C and increase
fluid intake

MCH 27.0-31.0 26.2 pg Low-indicates Iron >Instruct patient to

deficiency increase intake of foods
high in iron such as
green leafy vegetables
MCHC 320-360 355 g/L Normal
RDW-CV 11.5-14.5 14.0% Normal
RDW-SD 35.0-56.0 38.3 fL Normal
PLT 150-400 239 x10^9/L Normal
MPV 7.0-11.0 8.4 fL Normal
PDW 15.0-17.0 16.8 Normal
PCT 0.108-0.282 0.200% Normal

Urinalysis

NORMAL ACTUAL Implication Nursing

Responsibility
COLOR Light or pale Light Yellow Normal
Yellow
CHARACTER Clear Slightly turbid Abnormal >Instruct patient
to increase fluid
intake
ALBUMIN (-) (-) Normal
REACTION 4.6-8 6.5 pH Normal
SPECIFIC 1.010-1.025 1.010 Normal
GRAVITY
PUS CELL 0 2-4 Abnormal >Instruct patient
to increase fluid
intake
>Administer
antibiotic as
ordered
SQUAMOUS (-) (+) Abnormal >Instruct patient
to increase fluid
intake
>Administer
 antibiotic as
ordered
BACTERIA (-) (+) Abnormal >Instruct patient
to increase fluid
intake
>Instruct patient
to increase intake
of Vitamin C
>Administer
antibiotic as
ordered

VII.ANATOMY AND PHYSIOLOGY OF ORGAN INVOLVED

The appendix is a closed-ended, narrow tube up to several inches in length that

attaches to the cecum , the first part of the colon, like a worm. The anatomical name for
the appendix is vermiform appendix which means worm-like appendage. It's pencil-thin
and normally about 4 inches (7 cm) long. The appendix is usually located in the right
iliac region, just below the ileocecal valve (designated McBurney's point) and can be
found at the midpoint of a straight line drawn from the umbilicus to the right anterior iliac
crest. The inner lining of the appendix produces a small amount of mucus that flows
through the open center of the appendix and into the cecum.

The wall of the appendix contains lymphatic tissue that is part of the immune
system for making antibodies. During the first few years of life, the appendix functions as
a part of the immune system, it helps make immunogobulins. But after this time period,
the appendix stops functioning. However, immunoglobulins are made in many parts of
the body, thus, removing the appendix does not seem to result in problems with the
immune system.
Like the rest of the colon, the wall of the appendix also contains a layer of muscle,
but the muscle is poorly developed.
VIII.PATHOPHYSIOLOGY

Obstruction of the appendix

(by fecalith, lymph node, tumour, foreign objects)

↓
Inflammation

↓
Increase intraluminal pressure

↓
Distention of the Appendix → causes pain
↓
Decrease venous drainage

↓
Blood flow and oxygen restriction to the appendix

↓
Bacterial Invasion of the Blood wall →causes fever
↓
Necrosis of the appendix

The pathophysiology of appendicitis is the constellation of processes that leads to

the development of acute appendicitis from a normal 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 found in the gut normally.

Obstruction of the appendix lumen by fecalith, enlarged lymph node, worms,

tumor, or indeed foreign objects, brings about a raised intra-luminal pressure, which
causes the wall of the appendix to become distended. Normal mucus secretions continue
within the lumen of the appendix, thus causing further build up of intra-luminal
pressures. This in turn leads to the occlusion of the lymphatic channels, then the venous
return, and finally the arterial supply becomes undermined. Reduced blood supply to the
wall of the appendix means that the appendix gets little or no nutrition and oxygen. It also
means a little or no supply of white blood cells and other natural fighters of infection
found in the blood being made available to the appendix. The wall of the appendix will
thus start to break up and rot. Normal bacteria found in the gut gets all the inducement
needed to multiply and attack the decaying appendix within 36 hours from the point of
luminal obstruction, worsening the process of appendicitis. This leads to necrosis and
perforation of the appendix. Pus formation occurs when nearby white blood cells are
recruited to fight the bacterial invasion. A combination of dead white blood cells,
bacteria, and dead tissue makes up pus. The content of the appendix (fecalith, pus and
mucus secretions) are then released into the general abdominal cavity, bringing causing
peritonitis.
 So, in acute appendicitis, bacterial colonization follows only when the process
have commenced.

These events occur so rapidly, that the complete pathophysiology of appendicitis takes
about one to three days. This is why delay can be deadly.

Pain in appendicitis is thus caused, initially by the distension of the wall of the
appendix, and later when the grossly inflamed appendix rubs on the overlying inner wall
of the abdomen (parietal peritoneum) and then with the spillage of the content of the
appendix into the general abdominal cavity (peritonitis). Fever is brought about by the
release of toxic materials (endogenous pyrogens) following the necrosis of appendicael
wall, and later by pus formation. Loss of appetite and nausea follows slowing and
irritation of the bowel by the inflammatory process.

Early symptoms of appendicitis are those symptoms that most people with this
condition may recognize and complain of.

They include lower right sided abdominal pain of gradual onset, feeling sick (or
nausea), and loss of appetite.

Any one with these three symptoms can be assumed to have appendicitis until proven
otherwise.

 Abdominal pain

This pain typically starts from around the belly button (peri-umbilical
region), or the upper central abdomen (epigastrium) and then move downwards
and to the lower right abdomen (right iliac fossa). When the pain occurs in this
pattern, it is the most dependable of all symptoms of appendicitis, as over 8 out 10
(80%) cases that present this way is definitely due to the appendix. In some other
individuals, the pain starts right way from the right iliac fossa. Depending on
where the tip of the appendix is, the pain could even be on the right flank (retro-
caecal appendix). If the appendix is quite long, and in the pelvic cavity, it could as
well cause lower left abdominal pain, with frequent passage of urine if the
inflamed appendix irritates the bladder.

When the appendix is severely inflamed, the pain can be localized to a

spot on the outer one third of a line drawn between the belly button and front of
the tip of the waist bone called the McBurney’s point. The Mc Burney’s point is
also often the point of maximum tenderness when the abdomen is examined. The
pain is even worse when the hand is suddenly removed from that spot because of
the appendix rubbing on the covering of the abdomen (Rebound tenderness).

There is also a sign referred to as the Rovsign sign. This is said to exist
when the lower left abdomen is palpated by the doctor, but causes pain in the
right. If the appendix is the pelvic type, examining the back passage (rectal
examination) would cause some pain too. If the hip is moved and stretched, this
can also cause pain to be felt at the spot where the appendix lies. This is referred
to as the psoas sign.

 Loss of Appetite, Nausea & Vomiting

This is another very important set of symptoms of appendicitis. It is said

that loss of appetite is the most constant symptom of appendicitis.
 They may actually vomit. It is important to note that vomiting in appendicitis
usually follows the pain. If you vomit before the pain commenced, it is not likely
that the appendix is to blame.

 Change in Bowel Habit

There may be diarrhea or constipation, especially in young children. This

could lead to a wrong diagnosis of food poisoning or gastroenteritis on the part of
the unwary doctor. Up to 1 in 5 persons (20%) could have diarrhea or even
constipation with appendicitis.
 Fever

There is usually a low grade fever in most patients with this disease.
Nevertheless, in up to 1 in 5 persons (20%), they have normal temperature, even
with severe disease. Temperature above 38.5 degree centigrade with rigors is
suggestive of a ruptured appendicitis.

IX.MEDICAL AND SURGICAL MANAGEMENT

A. MEDICAL

a.Ideal
The following are the ideal diagnostic procedures done to the patient which were
already explained thoroughly on the previous pages:
A. Urinalysis
B. WBC count
C. Abdominal X-ray
D. Ultrasound
E. Barium Enema
F. CT Scan
G. Laparoscopy
H. The Alvarado Score for Acute Appendicitis
I.
Once a diagnosis of appendicitis is made, an appendectomy usually is performed.
Antibiotics almost always are begun prior to surgery and as soon as appendicitis is
suspected

b. Actual
The diagnostic procedure done to the patient were Urinalysis and CBC.

Patient was given the following medications:

 Ceftriaxone 1 gm,IV,Q 12 hrs x 4 doses:an antibiotic which inhibits synthesis of
Bacterial cell wall, causing cell death
 Tramadol 50 mg, IV, q 8 hrs: an analgesic which binds to mu-opioid receptors and
inhibits the reuptake of norepinephrine and serotonin; causes many effects similar
to the opioids,dizziness, constipation
 Ketorolac 30 mg, IV, q 8 hrs: it has Anti-inflammatory and analgesic activity;
inhibits prostaglandins and leukotriene synthesis

The patient was administered with D5LR 1 L regulated at 31-32 gtts/min. D5LR is
actually 5% dextrose in lactated ringer's solution. it is a hypertonic solution which aids in
replacement of lost body fluids.
B. SURGICAL

A.IDEAL

Surgery is the only treatment for acute appendicitis. The appendix may be removed in
two ways:

First is the open method or through appendectomy. During an appendectomy, an incision

two to three inches in length is made through the skin and the layers of the abdominal
wall over the area of the appendix. The surgeon enters the abdomen and looks for the
appendix which usually is in the right lower abdomen. After examining the area around
the appendix to be certain that no additional problem is present, the appendix is removed.
This is done by freeing the appendix from its mesenteric attachment to the abdomen and
colon, cutting the appendix from the colon, and sewing over the hole in the colon. If an
abscess is present, the pus can be drained with drains that pass from the abscess and out
through the skin. The abdominal incision then is closed.

Second is Laparoscopic Method. Laparoscopy is a new technique for removing the

appendix which involves the use of the laparoscope. The laparoscope is a thin telescope
attached to a video camera that allows the surgeon to inspect the inside of the abdomen
through a small puncture wound (instead of a larger incision). If appendicitis is found, the
appendix can be removed with special instruments that can be passed into the abdomen,
just like the laparoscope, through small puncture wounds. The benefits of the
laparoscopic technique include less post-operative pain (since much of the post-surgery
pain comes from incisions) and a speedier return to normal activities. An additional
advantage of laparoscopy is that it allows the surgeon to look inside the abdomen to make
a clear diagnosis in cases in which the diagnosis of appendicitis is in doubt. For example,
laparoscopy is especially helpful in menstruating women in whom a rupture of an ovarian
cysts may mimic appendicitis.

B.ACTUAL

The procedure done to the Patient is Appendectomy, she was operated on June 22, 2009..
Her operation begun at 12:50 PM and ended at 1:25 PM. Her surgeon was Dr. Paat