CHAPTER I INTRODUCTION The appendix is a closed-ended, narrow tube that attaches to the cecum (the first part of the

colon) like a worm. (The anatomical name for the appendix, vermiform appendix, means worm-like appendage.) The inner lining of the appendix produces a small amount of mucus that flows through the appendix and into the cecum. The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies. Like the rest of the colon, the wall of the appendix also contains a layer of muscle. Acute appendicitis can occur when a piece of food, stool or object becomes trapped in the appendix, causing irritation, inflammation, and the rapid growth of bacteria and infection. Acute appendicitis can also happen after a gastrointestinal infection. Rarely, a tumor may cause acute appendicitis. Sometimes the cause of acute appendicitis is not known. The inflammation is usually caused by a blockage, but may be caused by an infection. Without treatment, an inflamed appendix can rupture, causing infection of the peritoneal cavity (the lining around the abdominal organs) and even death. Appendicitis is one of the most common causes of emergency abdominal surgery. Up to 75,000 appendectomies are done each year
1

in the U.S. The estimated population in the Philippines is 86, 241, 6972 and the incident rate of acute appendicitis is 215,604 as of year 2011. Appendicitis is one of the more common surgical emergencies, and it is one of the most common causes of abdominal pain. In the United States, 250,000 cases of appendicitis are reported annually, representing 1 million patient-days of admission. The incidence of acute appendicitis has been declining steadily since the late 1940s, and the current annual incidence is 10 cases per 100,000 populations. Appendicitis occurs in 7% of the US population, with an incidence of 1.1 cases per 1000 people per year. Some familial predisposition exists. In Asian and African countries, the incidence of acute appendicitis is probably lower because of the dietary habits of the inhabitants of these geographic areas. The incidence of appendicitis is lower in cultures with a higher intake of dietary fiber. Dietary fiber is thought to decrease the viscosity of feces, decrease bowel transit time, and discourage formation of fecaliths, which predispose individuals to obstructions of the appendiceal lumen. In the last few years, a decrease in frequency of appendicitis in Western countries has been reported, which may be related to changes in dietary fiber intake. In fact, the higher incidence of appendicitis is believed to be related to poor fiber intake in such countries.
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There is a slight male preponderance of 3:2 in teenagers and young adults; in adults, the incidence of appendicitis is approximately 1.4 times greater in men than in women. The incidence of primary appendectomy is approximately equal in both sexes. The incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually declines in the geriatric years. The mean age when appendicitis occurs in the pediatric population is 6-10 years. Lymphoid hyperplasia is observed more often among infants and adults and is responsible for the increased incidence of appendicitis in these age groups. Younger children have a higher rate of perforation, with reported rates of 50-85%. The median age at appendectomy is 22 years. Although rare, neonatal and even prenatal appendicitis have been reported. Clinicians must maintain a high index of suspicion in all age groups. Acute appendicitis can occur in any age group or population. However, it most often occurs in teens and young adults. It is rare in children younger than two years of age. Classic symptoms of acute appendicitis include pain in the right lower abdomen, where the appendix is located, that gets progressively sharp and more intense. Pain increases when pressure is put on the area (called the McBurneys point), and the area becomes even more painful and tender when the pressure is released (rebound tenderness). This is one exam a health care provider uses to diagnosis acute appendicitis.
3

The symptoms of acute appendicitis can vary, and not all people with acute appendicitis will experience the typical symptoms of abdominal pain. In early acute appendicitis, the abdominal pain may be located around the navel or belly button area, then move to McBurneys point as acute appendicitis progresses. Acute appendicitis that is not treated promptly leads to lifethreatening complications. Complications of acute appendicitis include: Abdominal abscess, Peritonitis (infection of the lining that surrounds the abdomen), Ruptured appendix, Sepsis, Shock. As teen-agers living in a fast-phased world and governed by schedules, they too are predisposed to lifestyle modification especially diet and food preferences which can contribute to the disease. With this study, the student nurses hope to apply their learning in taking care not only of their patients but also of themselves. As nursing students and future nurses, they would want to understand and appreciate more on what is happening to a patient with acute appendicitis. Consequently, they are interested on what will be the necessary management that will be given. All in all, these will help them to become efficient nurses and better persons later on.

This case study presents the case study of a 23 year old woman who was diagnosed with Acute Appendicitis due to pain felt at right lower quadrant at Kidapawan Medical Specialist.

OBJECTIVES OF THE STUDY General Objective To conduct a study and to have a better understanding regarding acute appendicitis as well as to deal with patient having this illness with the application of the nursing process. Specifically, the study aims to: 1. To conduct an interview with the patient, her family, significant others and to gather essential information regarding his case. 2. To perform a cephalocaudal assessment to the patient. 3. To present an overview about Acute Appendicitis. 4. To determine the progression of the illness and to present its pathophysiology. 5. To gather and obtain progress notes and present doctors order. 6. To obtain and present the diagnostic test and the laboratory results of the patient. 7. To identify patients medication and determine its mechanism of action, indication, side-effects, contraindications and corresponding nursing responsibilities. 8. To conduct health teachings as one way of providing and promoting holistic care to the patient.

9. To identify problems based from subjective data gathered from patient and watchers to formulate appropriate nursing care plan.

DEFINITION OF TERMS Appendectomy Appendicitis - surgical operation to remove appendix. - inflammation of the appendix causing severe pain. Appendix - small outgrowth from large intestine, a bindended tube leading from the first of the large intestine (caecum), near its junction with the small intestine. In humans, it is small, occurs in the lower right hand part of the abdomen and contains cells of the immune system. Colic Constipation - severe pain in the bowel or the abdomen. - difficulty in passing stools or incomplete or infrequent passage of hard stools. Fecalith Mc Burneys Sign - hardened mass of stool. (Charles McBurney) a reaction of the patient indicating tenderness severe when pain and extreme point is McBurneys

palpated. Such reaction indicates appendicitis.

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Perforation

- a hole or opening made through the entire thickness of a membrane or other tissue or material.

Peritonitis

- inflammation of the peritoneum caused by the spreading of infection.

Sepsis

- the condition or syndrome caused by the presence of microorganisms or their toxins in the tissue or the bloodstream.

Septicemia

- systemic infection in which pathogens are present in the circulating blood, having spread from an infection in any part of the body.

Shock

- a state of physiologic collapse, marked by a weak pulse, coldness, sweating and irregular breathing, and resulting from a situation such as blood loss.

PATIENTS PROFILE PERSONAL DATA PATIENTS NAME CASE # AGE SEX ORIGINAL RANK CIVIL STATUS ADDRESS BIRTHDAY RELIGION NATIONALITY MEDICAL DATA CHIEF COMPLAINT : Right Lower Quadrant Pain ADMITTING DIAGNOSIS : T/C Acute Appendicitis FINAL DIAGNOSIS DATE OF ADMISSION : Acute Appendicitis : February 08, 2012 : Momoko : 12-1344 : 23 : Female : Second Child : Single : 054 Quirino Drive, Kidapawan City : January 01, 1989 : Roman Catholic : Filipino

ATTENDING PHYSICIAN : Dr. Edwin Mudanza

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Past Health History The patient was born on January 01, 1989. She was delivered full term through Normal Vagina Spontaneous Delivery. The patient was completely immunized. She was never admitted to a hospital but she experienced common illness such as cough and mefenamic acid for pain. She occasionally drinks liquors such as red wine and beer. Her usual diet includes food that are high in protein, junkfoods, softdrinks and canned goods. She prefers meat products in her meal than leafy vegetables.

Present Health History Several days prior to admission the patient experienced an abdominal pain at the right lower quadrant. These prompted her to seek medical advice, thus confined in Kidapawan Medical Specialist Incorporated last February 08, 2012 with the admitting diagnosis of Acute Appendicitis under the service of Dr. Edwin Mudanza. Her medications were Ranitidine, Metronidazole and Ampicillin. She was confined at private room #523.

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PHYSICAL ASSESSMENT

Genearal Appearance at First Sight Patient was received awake, responsive and coherent with an IVF D5LR 1L at 80 cc per hour, infusing well at the right metacarpal vein. Patient has a mesomorphic type of body built and weighs 54.5 kilograms and stands 54 tall. The patient was certainly oriented to time, place and persons. She was able to deal with her emotions appropriately as the interview went on. Wearing a cotton T-shirt and jogging pants, patient looked neat and tidy.

I.

Head, Ears, Eyes, Nose, Throat and Neck and Five Senses

Head Head was normocephalic and had a smooth skull contour. Hair was smooth, and was evenly distributed. The hair was black in color. The scalp was clean. No swelling or tenderness noted upon palpation.

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Ears Both ears were symmetrical; auricle aligned with outer canthus of the eye. The color of the outer ear was homogenous with that of the skin color. The external pinna was firm, and non-tender. No discharges, tenderness, masses, or swelling were noted upon inspection and palpation.

Eyes Both eyes were symmetrical. Eyelashes equally distributed, curled slightly outward. Pupil size is 3mm in diameter for both eyes. Reaction to light was brisk. There was a uniform reaction to accommodation. The pupil was black in color with pinkish conjunctiva. Lids closed symmetrically, skin intact, no discharges and no discoloration. Blinking reflex was functional. No ulceration or lesions noted on the area.

Nose The external was symmetrical. Nasal flaring noted, air felt when exhaled. Nasal mucosa was intact and pinkish in color and was free of purulent discharges.

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Mouth & Throat The lips were dry and pale-looking. The gums were pinkish in color. Her teeth were still intact, 32 pearly white and shiny. Uvula was at the middle. Mucosa was pinkish. Tonsils were uninflammed. No further abnormalities noted.

Neck The neck was symmetrical and was proportion to head and shoulder. The thyroids were smooth as palpated. She was able to turn her head in upward, sideward and downward position with movement. The carotid artery has mild pulsation. No sign of lesion or tenderness noted.

Five senses

A. Sense of sight Patient can read normally. In the absence of Snellens chart, functional vision was test; she can follow a hand movement with a 34 feet distance. She can recognize person and things.

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B. Sense of taste By offering different kinds of food like candy, vinegar, ampalaya and salt patients taste buds can identify sweet, sour, bitter, and salty food.

C. Sense of smell Patient has good smelling ability; she can distinguish different odors such as fragrance or perfume and aroma of beverages that she dinks.

D. Sense of hearing She can recognize sounds and could hear clearly, she responds to conversation normally. She becomes alert when someone will open the door. She can hear the distance particularly when someone enters the room.

E. Sense of touch The patient responds when someone touches her, and can distinguish soft from rough texture and can identify hot from cold water.

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II. Respiratory status The patient breathing pattern ranges from 18cpm to 21cpm. No O2 cannula attached. No abnormal sounds (rales, wheezing, etc.) noted upon auscultation.

III. Circulatory status Patients blood pressure was monitored every 4 hours when she was under our care. BP ranges from 90/60 mmHg to 100/80 mmHg. Her pulse from 76bpm to 80bpm. Capillary refill time within 3-5 sec.

IV. Temperature status Patients body temperature ranges from 37-39 degree Celsius.

V. Skin/Skin appendages Patients skin was warm to touch with fair complexion; fingernails were trimmed and tidy. Hair was distributed evenly no clubbing of fingers noted.

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VI. Nutritional status Patient usually eats food that is high in fat, salt and protein such as fish, meat, lechon and junk foods. She eats breakfast on time. She tends to drink liquor like red wine and beer frequently with

pulutan. She prefers eating meat products than vegetables.

Patients weight is 120 lbs and has height of 164cm which result to Body Mass Index (BMI) of 20 which translates that the patients BMI is normal.

BMI Categories: Underweight = <18.5 Normal weight = 18.5 24.9 Overweight = 25 29. 9 Obese = >30

VII. Rest and sleeping pattern During regular days patient has a normal sleeping pattern of six to eight hours a day. Upon admission, patients sleeping pattern has been altered since her body cant adapt to hospital routine she often disturbed during sleep due to continuous monitoring and giving of medication.

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VIII. Elimination status The patient has an abnormal elimination pattern regularly she defecated 3 times a week and urinated 4-5 times a day. Upon admission she defecated once a day and urinates 2-3 times a day.

IX. Mobility status Patient is ambulatory. She can perform activities of daily living such as eating, drinking and brushing her teeth. Patient complains abdominal pain at right lower quadrant.

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GENEOGRAM Grandparents Grandparents

Mother

Father

LEGEND: Male

Female DM

HPN

Heart Disease Appendicitis

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SYMPTOMATOLOGY Signs and Symptoms Right Lower Quadrant Pain Present Absent Rationale Right lower-quadrant pain that is produced with either the passive extension of the patient's right hip (patient lying on left side, with knee in flexion) or by the patient's active flexion of the right hip while supine. The pain elicited is due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes pain because it stretches these muscles, while flexing the hip activates the iliopsoas and therefore also causes pain. Source: (http://www.freeed.net/sweethaven/science/biology/anat omyphysiol/Human01_LessonMain.asp?i Num=1008) McBurney's Sign Deep tenderness at McBurney's point, known as McBurney's sign, is a sign of acute appendicitis.[2] The clinical sign of referred pain in the epigastrium when pressure is applied is also known as Aaron's sign. Specific localization of tenderness to McBurney's point indicates that inflammation is no longer limited to the lumen of the bowel (which localizes pain poorly), and is irritating the lining of the peritoneum at the place where the peritoneum comes into contact with the
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appendix. Tenderness at McBurney's point suggests the evolution of acute appendicitis to a later stage, and thus, the increased likelihood of rupture. Source: (http://en.wikipedia.org/wiki/McBurney's _point)

Fever

Fever is a nonspecific response that is mediated by endogenous pyrogens released from host cells in response to infectious or non-infections disorders. It may be brought about by prostaglandins released during inflammation. Source: Carol Mattson Porth (2005. Pathophysiology, Seventh edition page 205)

Constipation

difficulty in defecation: a condition in which or animal has difficulty in eliminating solid was the body and the feces are hard and dry.

(Microsoft Encarta 2009. 1993-200 Corporation. All rights reserved.) Nausea / Nausea sometimes occurs with biliary colic. The inflammation of the appendix causes pain and spasms of the abdominal muscles which may make one feel nauseated. Source: Understanding Medical Surgical Nursing by Williams and Hopper (page 742)
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ANATOMY AND PHYSIOLOGY

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, esophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important

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functions in the digestive system. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls The functions of the digestive system are:

Ingestion - eating food Digestion - breakdown of the food Absorption - extraction of nutrients from the food Defecation - removal of waste products

The digestive system also builds and replaces cells and tissues that are constantly dying. Digestive Organs The digestive system is a group of organs (Buccal cavity (mouth), pharynx, oesophagus, stomach, liver, gall bladder, jejunum, ileum and colon) that breakdown the chemical components of food, with digestive juices, into tiny nutrients which can be absorbed to generate energy for the body. The Buccal Cavity Food enters the mouth and is chewed by the teeth, turned over and mixed with saliva by the tongue. The sensations of smell and taste from the food sets up reflexes which stimulate the salivary glands. The Salivary glands These glands increase their output of secretions through three pairs of ducts into the oral cavity, and begin the process of digestion.
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Saliva lubricates the food enabling it to be swallowed and contains the enzyme ptyalin which serves to begin to break down starch. The Pharynx Situated at the back of the nose and oral cavity receives the softened food mass or bolus by the tongue pushing it against the palate which initiates the swallowing action. At the same time a small flap called the epiglottis moves over the trachea to prevent any food particles getting into the windpipe. From the pharynx onwards the alimentary canal is a simple tube starting with the salivary glands. The Oesophagus The oesophagus travels through the neck and thorax, behind the trachea and in front of the aorta. The food is moved by rhythmical muscular contractions known as peristalsis (wave-like motions) caused by contractions in longitudinal and circular bands of muscle. Antiperistalsis, where the contractions travel upwards, is the reflex action of vomiting and is usually aided by the contraction of the abdominal muscles and diaphragm. The Stomach The stomach lies below the diaphragm and to the left of the liver. It is the widest part of the alimentary canal and acts as a reservoir for the food where it may remain for between 2 and 6 hours. Here the food is churned over and mixed with various hormones, enzymes
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including pepsinogen which begins the digestion of protein, hydrochloric acid, and other chemicals; all of which are also secreted further down the digestive tract. The stomach has an average capacity of 1 litre, varies in shape, and is capable of considerable distension. When expanding this sends stimuli to the hypothalamus which is the part of the brain and nervous system controlling hunger and the desire to eat. The wall of the stomach is impermeable to most substances, although does absorb some water, electrolytes, certain drugs, and alcohol. At regular intervals a circular muscle at the lower end of the stomach, the pylorus opens allowing small amounts of food, now known as chyme to enter the small intestine. Small Intestine The small intestine measures about 7m in an average adult and consists of the duodenum, jejunum, and ileum. Both the bile and pancreatic ducts open into the duodenum together. The small intestine, because of its structure, provides a vast lining through which further absorption takes place. There is a large lymph and blood supply to this area, ready to transport nutrients to the rest of the body. Digestion in the small intestine relies on its own secretions plus those from the pancreas, liver, and gall bladder.

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The Pancreas The Pancreas is connected to the duodenum via two ducts and has two main functions: 1. To produce enzymes to aid the process of digestion 2. To release insulin directly into the blood stream for the purpose of controlling blood sugar levels Enzymes suspended in the very alkaline pancreatic juices include amylase for breaking down starch into sugar, and lipase which, when activated by bile salts, helps to break down fat. The hormone insulin is produced by specialised cells, the islets of Langerhans, and plays an important role in controlling the level of sugar in the blood and how much is allowed to pass to the cells. The Liver The liver, which acts as a large reservoir and filter for blood, occupies the upper right portion of abdomen and has several important functions: 1. Secretion of bile to the gall bladder 2. Carbohydrate, protein and fat metabolism 3. The storage of glycogen ready for conversion into glucose when energy is required. 4. Storage of vitamins 5. Phagocytosis - ingestion of worn out red and white blood cells, and some bacteria

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The Gall Bladder The gall bladder stores and concentrates bile which emulsifies fats making them easier to break down by the pancreatic juices. The Large Intestine The large intestine averages about 1.5m long and comprises the caecum, appendix, colon, and rectum. After food is passed into the caecum a reflex action in response to the pressure causes the contraction of the ileo-colic valve preventing any food returning to the ileum. Here most of the water is absorbed, much of which was not ingested, but secreted by digestive glands further up the digestive tract. The colon is divided into the ascending, transverse and descending colons, before reaching the anal canal where the indigestible foods are expelled from the body.

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ANATOMY OF THE APPENDIX

The appendix is a wormlike extension of the cecum and, for this reason, has been called the vermiform appendix. The average length of the appendix is 8-10 cm (ranging from 2-20 cm). The appendix appears during the fifth month of gestation, and several lymphoid follicles are scattered in its mucosa. Such follicles increase in number when individuals are aged 8-20 years. The appendix is contained within the visceral peritoneum that forms the serosa, and its exterior layer is longitudinal and derived from the taenia coli; the deeper, interior muscle layer is circular. Beneath these layers lies the submucosal layer, which contains

28

lymphoepithelial tissue. The mucosa consists of columnar epithelium with few glandular elements and neuroendocrine argentaffin cells. Taenia coli converge on the posteromedial area of the cecum, which is the site of the appendiceal base. The appendix runs into a serosal sheet of the peritoneum called the mesoappendix, within which courses the appendicular artery, which is derived from the ileocolic artery. Sometimes, an accessory appendicular artery (deriving from the posterior cecal artery) may be found. Appendiceal vasculature The vasculature of the appendix must be addressed to avoid intraoperative hemorrhages. The appendicular artery is contained within the mesenteric fold that arises from a peritoneal extension from the terminal ileum to the medial aspect of the cecum and appendix; it is a terminal branch of the ileocolic artery and runs adjacent to the appendicular wall. Venous drainage is via the ileocolic veins and the right colic vein into the portal vein; lymphatic drainage occurs via the ileocolic nodes along the course of the superior mesenteric artery to the celiac nodes and cisterna chyli. Appendiceal location The appendix has no fixed position. It originates 1.7-2.5 cm below the terminal ileum, either in a dorsomedial location (most common) from the cecal fundus, directly beside the ileal orifice, or as a funnel29

shaped

opening

(2-3%

of

patients).

The

appendix

has

retroperitoneal location in 65% of patients and may descend into the iliac fossa in 31%. In fact, many individuals may have an appendix located in the retroperitoneal space; in the pelvis; or behind the terminal ileum, cecum, ascending colon, or liver. Thus, the course of the appendix, the position of its tip, and the difference in appendiceal position considerably changes clinical findings, accounting for the nonspecific signs and symptoms of appendicitis. Physiology of Appendix The lumen of the appendix communicates with the cecum 3cm (about 1 inch) before the ileoccal valve, thus making it an accessory organ of the digestive system. Its functions are not certain, but some biologists believe that the appendix serves as a sort of breeding

ground for some of the nonpathogenic intestinal bacteria thought to

aid in the digestion or absorption of nutrients. Follicles of lymphoid tissue appear in the wall of the appendix shortly a few birth, become more prominent during the first 10 years of life and then progressively disappear. The defense or immune system function of lymphatic tissue present in the appendix of young children is not fully understood.

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PATHOPHYSIOLOGY Predisposing Factor Precipitating Factor

Age (23 y/o)

Bowel movement: 3 times a week. Sedentary Lifestyle Low Fiber Diet

Obstruction to lumen of the appendix.

Occlusion/kinking of the lumen.

Inflammation of the serosa of the appendix. Signs and Symptoms: Acute RLQ Pain of the Abdomen Fever McBurneys Sign Nausea Constipation

Intraluminal pressure.

Muscle Spasm

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Pus Formation as evidenced by increased White Blood Cell.

Rupture of the Appendix

If treated:

If not treated:

Medications: Ranitidine Ampicillin Flagyl Metronidazole Surgical Procedure: Appendectomy

Metastasize to the blood stream and throughout the organ

Septicemia

Shock Wellness

Death

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PATHOPHYSIOLOGY NARRATIVE The client was diagnosed of acute appendicitis; she had a predisposing factor; her age (23 y/o), which is according to research adult age has the higher risk of incidence. Her gender didnt serve as a factor because males are more prone to the disease rather than in females. Prior to admission, she experienced irregularity in her bowel habit; she only defecates three times a week. Her diet which is low in fiber, high in cholesterol and protein and her sedentary lifestyle attributed to her illness. The two factors: precipitating and predisposing, led to the obstruction of the lumen of the appendix. As the obstruction was lengthened, it resulted in the kinking of the lumen, causing her pain. The occlusion caused an inflammation of the serosa of the appendix which produced an intraluminal pressure, causing muscle spasm on the client. The inflammation of the serosa of the appendix was characterized by signs and symptoms of fever, acute pain in the right lower quadrant of her abdomen, McBurneys sign, nausea and constipation which causes increase in the intraluminal pressure thus resulting to muscle spasm.
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As there is presence of inflammation, it resulted in presence of pus formation evidenced by increased in white blood cells to fight against infection. Furthermore, if inflammation will not be cured it can result to a rupture of the appendix. If rupture is to be treated, the client will need surgery (appendectomy) and medications. If treatment will be successful, it will lead to wellness of life. If the rupture is not treated, it would metastasize to the blood stream and throughout the organ and further complicate to septicemia leading to shock, which may result to DEATH.

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COMPLICATION OF APPENDICITIS

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. A less common complication of appendicitis is blockage of the intestine. Blockage occurs when the inflammation surrounding the
35

appendix causes the intestinal muscle to stop working, and this prevents the intestinal contents from passing. If the intestine above the blockage begins to fill with liquid and gas, the abdomen distends and nausea and vomiting may occur. It then may be necessary to drain the contents of the intestine through a tube passed through the nose and esophagus and into the stomach and intestine. A feared complication of appendicitis is sepsis, a condition in which infecting bacteria enter the blood and travel to other parts of the body. This is a very serious, even life-threatening complication. Fortunately, it occurs infrequently.

CLINICAL MANIFESTATION OF APPENDICITIS

36

The main symptom of appendicitis is abdominal pain. The pain is at first diffuse and poorly localized, that is, not confined to one spot. (Poorly localized pain is typical whenever a problem is confined to the small intestine or colon, including the appendix.) The pain is so difficult to pinpoint that when asked to point to the area of the pain, most people indicate the location of the pain with a circular motion of their hand around the central part of their abdomen. A second, common, early symptom of appendicitis is loss of appetite which may progress to nausea and even vomiting. Nausea and vomiting also may occur later due to intestinal obstruction. As appendiceal inflammation increases, it extends through the appendix to its outer covering and then to the lining of the abdomen, a thin membrane called the peritoneum. Once the peritoneum becomes inflamed, the pain changes and then can be localized clearly to one small area. Generally, this area is between the front of the right hip bone and the belly button. The exact point is named after Dr. Charles McBurney--McBurney's point. If the appendix ruptures and infection spreads throughout the abdomen, the pain becomes diffuse again as the entire lining of the abdomen becomes inflamed.

37

TESTS AND DIAGNOSIS The diagnosis of appendicitis begins with a thorough history and physical examination. Patients often have an elevated temperature, and there usually will be moderate to severe tenderness in the right lower abdomen when the doctor pushes there. If inflammation has spread to the peritoneum, there is frequently rebound tenderness. Rebound tenderness is pain that is worse when the doctor quickly releases his hand after gently pressing on the abdomen over the area of tenderness. 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. Abdominal X-Ray An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece of stool that blocks the appendiceal

38

opening) that may be the cause of appendicitis. This is especially true in children. 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. 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. 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

39

abscesses as well as in excluding other diseases inside the abdomen and pelvis that can mimic appendicitis. Laparoscopy Laparoscopy is a surgical procedure in which a small fiberoptic 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. 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.

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DOCTORS ORDER 02/08/2012 08:55 pm - Please admit to room of choice under the service - NPO - Labs CBC with plt. count, UA., - Start venoclysis with D5LR 1L @ 80 cc/ hr. Meds: - Ranitidine 50g q 8 IVTT. - Watch out for unusualities. 10:00 pm - Ampicillin 1g q 6 IVTT ANST. - Metronidazole 500 mg 8 IVTT. 11:20 pm 02/09/2012 IV rate @ 120-150 cc/ hr. of Dr. Mudanza.

- D5LR (#2) 1L @ 80 cc/ hr. -D5LR 1L @150 cc/ hr. -Cont. meds. -Run IVF @ 150 cc/ hr.

9:00am

- Do UTZ of abdomen.

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LABORATORY RESULTS

U.A: (02/08/2012) Admission No.: 2464 Color Transparency Reaction Spec. Gravity Chemical Element Sugar Albumin - (-) - (-) - Yellow - Clear - Acidic - 1.020

Microscopic Element Pus Cells RBC - 0-1 / hpf - 0-1 / hpf

Mucous Threads Epithelial Cell

- occasional - squamous-occasional

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Hematology (02/08/2012) Admission No.: 2464 Test Hemoglobin WBC Result 105 12 Normal Values 120.00-140 g/L 5.00-10.00 x 10 g/L RBC HCT PLT. CT SEGS LYMPHO 4.14 0.13 330 0.58 0.33 4.50-5.50 x 10 12/L 0.37-0.43 vol % 150.00-350.00 x 10 g/L 0.55-0.65 0.25-0.35 Normal Normal May indicate anemia. May indicate infection, inflammation. Indicates anemia. Indicates anemia. Normal Rationale

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Ultrasound Report

Case Number: Patient Name: Momoko Admitting Diagnosis: T/C Appendicitis Complaint: RLQ Pain Part Examined: Whole Abdomen Ultrasound

USD of the Abdomen: Liver is normal size. No focal lesions are noted. Intrahepatic ducts and CBD are not dilated. Hepatic vessels are normal. Gall bladder is physiologically distended with normal wall. No internal echoes are seen. Pancreas, spleen and left kidney are normal. There is lobulated, well defined, anechoric focus in superior pole of the right kidney measuring 3.6 x 3.8 x 3.5 cm. urinary bladder and uterus are remarkable. Both adnexae are free. No pelvic fluid noted. There is well defined, ovoid predominantly complex mass in the RLQ measuring 5.9 x 6.1 x 6 cm. the hypoechoic component measures 4.4 x 2.6 x 3.9 cm. minimal surrounding fluid is present.

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DRUG STUDY

Brand Name Generic Name Zantac Ranitidine

Classification Histamine H2 antagonists

Dosage and Frequency 50mg 1 amp IVTT every 8 hours

Mechanism of Action Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion.

Indication Treatment and prevention of heartburn, acid indigestion, and sour stomach.

Adverse Reaction CNS: Confusion, dizziness, drowsiness, hallucinations, headache CV: Arrhythmias GI: Altered taste, black tongue, constipation, dark stools, diarrhea, drug-induced hepatitis, nausea HEMAT: Anemia, neutropenia, thrombocytopenia LOCAL: Pain at IM site MISC: Hypersensitivity reactions, vasculitis

Nursing Management Observe 11 rights in giving medication. Assess IV site and give the drug slowly. Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. Inform patient that it may cause drowsiness or dizziness. Inform patient that increased fluid and fiber intake may minimize constipation. Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health care professional promptly. Inform patient that medication may temporarily cause stools and tongue to appear gray black.

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DRUG STUDY

Generic Name Ampicin Ampicillin

Classification Penicillin, antibiotic

Dosage and frequency 1g every 6 hours IVTT

Mechanism of Action A broad spectrum semisynthetic, amino penicillin is highly bactericidal even at low concentrations, but inactivated by penicillinase.

Indication Infections of gastrointestinal tract and soft tissues.

Adverse Reaction CNS: convulsive seizures with higher doses

Nursing Management Observe 11 rights in giving medication.

Determine previous hypersensitivity GI: diarrhea, reactions to nausea and penicillins, vomiting cephalosphorins and other allergens prior Dermatologic: to therapy. rash Inspect skin daily and instruct patient to do the same. The appearance of rash should be carefully evaluated. Give medication around the clock. Observe 11 rights in giving medication.

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DRUG STUDY

Generic Name Flagyl Metronidazole

Classification Antibacterial, Anti-protozoals

Dosage and Frequency 500mg every 8 hours IVTT

Mechanism of Action Disrupts DNA and protein synthesis in susceptible organisms Bactericidal, or amebicidal action

Indication Acute infection with susceptible anaerobic bacteria.

Adverse Reaction CNS: seizures, dizziness, headache

Nursing Management Observe 11 rights in giving medication. Administer with food or milk to minimize GI irritation. Tablets may be crushed for patients with difficulty swallowing.

GI: abdominal pain, anorexia, nausea, diarrhea, dry mouth, furry tongue, glossitis, Instruct patient to take unpleasant taste, medication exactly as vomiting directed evenly spaced times between dose, Hematologic: even if feeling better. leukopenia May cause dizziness or Skin: rashes, light-headedness. urticarial Caution patient or other activities requiring alertness until response to medication is known.

Inform patient that medication may cause an unpleasant metallic taste. Inform patient that medication may cause urine to turn dark.

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NURSING CARE PLAN Date and Time 02- 09- 2012 (7-3) Assessment Scientific Basis Due to the presence of inflammation and mass on the RLQ of the abdomen, it causes some obstruction in the lumen of the appendix in turn causes s sharp acute pain in the Right Lower Quadrant part of the abdomen. Nursing Diagnosis Acute pain related to inflammation of the appendix. Nursing Goal Plan Within our 8 hour span of care, patient will be alleviated from pain. Nursing Intervention Rationale Evaluation

Subjective: Sakit akoang kilid, as patient verbalized. Objective: Conscious Grimaced face noted Weakness noted Guarded behavior noted Pain scale: 7/10 Pale looking

Establish rapport. V/S taken and recorded. Encourage verbalization of feelings about pain. Encourage patient to have diversional activities such as mobile internet and watching TV. Encourage patient to use relaxation techniques such as deep breathing. Provide comfort measures such as touch, repositioning, quiet environment and calm activities. Encourage adequate rest periods. Observe and document severity (1-10 scale) and character of pain (steady, intermittent, colicky).

To gain trust and cooperation. Serves as baseline data. To assess the level of pain. To alleviate pain.

Goal partially met.

Distract attention and reduce tension. To promote nonpharmacologic pain management.

To promote wellness and prevent fatigue. To get a baseline data of pain scale.

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Date and Time 02-09-2012 (7-3)

Assessment

Scientific Basis Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger it is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat. (Gulanick/Myers Nursing Care Plans, 6th Edition)

Nursing Diagnosis Anxiety related to possible surgery secondary to Acute Appendicitis.

Nursing Goal Plan Within our 8 hour span of care, patient will be able to understand and demonstrat e positive coping mechanism and describe a reduction in the level of anxiety.

Nursing Intervention

Rationale

Evaluation

Subjective: Worried ko sa akong situation basig operahan man gud ko, as verbalized by the patient. Objective: Irritability noted Anxious looking Discomfort noted Restlessnes s noted

Establish rapport. V/S taken and recorded. Assess awareness of patient about anxiety.

To gain trust and cooperation. Serves as baseline data. Validate the feeling and communicate acceptance of the feelings. Helps the client to identify what is reality based. To help the patient relax. Anxiety may escalate with excessive conversation, noise and equipment about the patient. Talking about anxiety producing situations and anxious feelings can help the person perceive the situation in less threatening manner.

Goal met.

Provide accurate information to the client. Provide comfort measures. Provide and maintain quiet environment.

Encourage patient to talk about anxious feelings.

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PROGNOSIS CRITERIA Onset of Illness POOR FAIR / GOOD JUSTIFICATION Onset of illness is fair because symptoms have progressed rapidly and patient gives less attention and no medical consultation was done. Recognition of the disease is delayed. The patient manifested pain in the right lower quadrant. The client has two predisposing factors out of three. Precipitating factors is poor since the patient is constipated, has a low fiber diet and has a sedentary lifestyle. The patient is compliant with medication regimen and other interventions. The patient is in the adulthood stage. She has the circle of supportive friends who visits and cares about her. The patients family is very supportive. They are very receptive to the medical advices and cooperative to the interventions and management.

Duration of illness Predisposing Factors Precipitating Factors /

Willingness to take medication Age / Physical Condition Envionmental / support Group Family Support

/ / / /

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COMPUTATION FOR OVER-ALL PROGNOSIS Good Fair Poor 4/8 x 100%= 50% 3/8 x 100%= 37.5% 1/8 x 100%= 12.5%

GENERAL PROGNOSIS

With the overall percentage of 100, the client exhibited a higher percentage of good with fifty percent (50%) while fair prognosis has a percentage of thirty seven point five (37.5%) and poor with a twelve point five percentage (12.5%). The patient shows very good indication in willingness to take her available medications. The patients family on the other hand was very supportive to ease the clients illness.

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Discharge planning

Medication 1. Instruct patient and the family to comply with the prescribe medication. 2. Instruct patients family to place medicine in places out of children reach. 3. Instruct patient and the family to complete the whole duration of the drug. 4. Teach the patient and the family regarding the name of the drugs, right dosage, and proper manner of taking as well possible side effects.

Environment/exercise 1. Advice patient to take regular breaks from any activity that demands to give stress pressure on back. 2. Encourage patient to involve in exercise to enhance circulation. 3. Encourage the patient to have adequate rest and sleep.

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Treatment 1. Orient the patients family about the patients condition and necessary information/treatment and recovery process. 2. Teach patient and the family about the importance of conducive environment for better recovery. 3. Encourage to comply with treatment regimen.

Health Teachings 1. Advice to take medications on time and with the right dose. 2. Instruct the patient to eat nutritious food such as vegetables and fruits. 3. Advice the patient to limit consumption of fatty foods. 4. Encourage client to choose food/ have family member bring food that seem appealing to stimulate appetite. 5. Instruct client to provide oral care before and after meals and at bedtime.

Out patient

1. Instruct the patient to take the medications ordered by the physician. 2. Encourage the patient to comply with the scheduled check-up.
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3. Instruct the patient and the family to comply with the prescribed medications. 4. Encourage patient to visit physician one to two weeks after discharged from the hospital. 5. Instruct the patient to visit physician immediately if any unusualities arise.

DIET

1. Encourage patient to eat nutritious and well balance meal. 2. Instruct the patient to increase oral fluid intake. 3. Diet as tolerated is advice by attending physician to sustain her nutritional needs.

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BIBLIOGRAPHY BOOKS: Brunner and Suddarths Textbook of Medical Surgical Nursing. Eleventh Edition Priscilla lemone medical surgical nursing Ross and Wilson Anatomy and Physiology in Health and Illness. Tenth Edition. Medical Surgical Nursing Critical Thinking in client care Third Edition MIMS and MIMS Annual Baillers nursing dictionary

INTERNET

http://www.gastro.org/wmspage. American Gasteroenterogical Association Pictures www.google.com

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