ACUTE APPENDICITIS

A Case Study
Presented to the College of Nursing





In Partial Fulfillment of
The requirements for
Related Learning Experience
In Surgery Ward of QMC





Mr. Felipe Merano RN,MSN
Clinical Instructor



Klent Nikko G. Melencion
BSN-IV









i



FOREWORD/PREFACE

In creating this study, the authors share to life the experiences and differences
theyve made within these pages, by describing what they have studied and learned
during their clinical exposure in the Surgery Ward of Quezon Medical Center
And thus, not only did they become improved nursing students but also they
become more aware, open minded, found responsibility, help others and have move
forward together, ready to face whats coming next for them.
Their knowledge was enhanced as they encountered different cases and
procedures in the Surgery Ward. These form important learning experiences, creating
much new light for them from pre-conferences and post-conferences, computations and
medications, patients and significant others, assessments and laboratories, nasogastric
tubes and a whole lot more vital to their nursing careers.
ii



DEDICATION

This study is dedicated to our loved ones who serves as our inspiration and never
failed in giving us support financially, spiritually and morally, for guiding us through and
for showing us that even a big task can be accomplished as long as there is teamwork and
dedication. We also dedicate this to ourselves because of the hard work and dedication
we have showed in making this study and to Mr. Felipe Merano for guiding us and
believing in us.
Lastly, we dedicate this to the healthcare team of Quezon Medical Center because
without them, there will be no basis for this study. They have opened up their doors for
us to attain and broaden our knowledge in the health care industry.

iii






iv



OBJECTIVES

This study is conducted to provide information regarding Chronic Hypertension. Our
objective is to help and provide adequate knowledge to fellow nursing students as well.
This study has the answers for the following:
1) What is Acute appendicitis?
2) What are the risk factors of Acute appendicitis?
3) What are the diagnostic tests needed to determine Acute appendicitis?
4) What is the nursing care plan for Acute appendicitis?



1


CASE INTRODUCTION
A 18 year old female client admitted with chief complaint of RLQ pain and with
Diagnosis of Acute Appendicitis with pain at the Right Lower Quadrant for 1 night.
Appendicitis is a condition characterized by inflammation of the appendix. It is
classified as a medical emergency and many cases requires removal of the inflame
appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly
because of the risk of rupture leading to infection and inflammation of the intestinal
lining (peritoneum) and eventual sepsis, clinically known as peritonitis which can lead to
circulatory shock.

2


NAME: X
GENDER: Male
BIRTHDAY: July 03, 1995
Address: Balungay, Alabat Quezon
Chief Complain: RLQ pain since last night
Diagnosis: Acute Appendicitis
Admitting Physician: Dr. Combalicer

3


PHYSICAL ASSESSMENT

A. HEAD: symmetric, proportionate to body size, free from masses and lesions
B. HAIR: Black in color, thin and fine, uncombed and slightly clean.
C. EYES: White sclera, dark brown pupil, Pupil Equally Round Reactive to Light
Accommodation (PERRLA)
D. NOSE: no nasal flaring noted, nose is located at the midline of the face, without
lesions or masses noted,
E. NECK: neck is symmetrical with the head in central position
F. FACE: normal lining of the nose, eyes and ears; pinkish lips and not dry
G. EARS: patient ears are working normally and can hear clearly, minimal ear wax
noted
H. CHEST/THORAX: chest is symmetrical upon breathing, not in respiratory
distress, breast are engorged with minimal stretch marks with good milk lactation
I. ABDOMEN: : Non-tender abdomen, pain noted upon palpation, no signs of
abnormal sounds upon auscultation, not bloated
J. LOWER EXTREMITIES: with Homans Sign on both lower extremities
K. SKIN: skin is warm to touch, no rashes or dryness noted, no edema
L. NAILS: Good capillary refill of 2-3 sec, slightly long nails, no dead nails noted




4


LABORATORY WORK-UPS

COMPLETE BLOODCOUNT
Test Result Reference
Hemoglobin 15.20 g/dL 12.0-16.0 g/dL
Hematocrit 0.45 0.37-0.43
RBC count 5.15 x10^12/L 4.0-5.4
WBC 17.60 x10^9/L 4.0-10.0
Neutrophils 0.81 0.55-o.65
Lymphocytes .19 0.25-0.35
Platelet Count 349 150-400





Color Yellow RBC 3-4/hpf
Transparency Blurred WBC 15-20/hpf
Spec. Quantity 1.030 Epithelial Cells Moderate
Ph Reaction 6.5
Bacteria Few
Chemical Test
Sugar (-) A. Urates Many
Albumin (+) A. Phosphate Many
5


NORMAL ANATOMY AND PHYSIOLOGY



Small intestine
The small intestine is composed of the duodenum, jejunum, and
ileum. It averages approximately 6m in length, extending from the
pyloric sphincter of the stomach to the ileo-caecal valve separating
the ileum from the caecum. The small intestine is compressed into
numerous folds and occupies a large proportion of the abdominal
cavity.
The duodenum is the proximal C-shaped section that curves around
the head of the pancreas. The duodenum serves a mixing function as
it combines digestive secretions from the pancreas and liver with the
contents expelled from the stomach. The start of the jejunum is
marked by a sharp bend, the duodenojejunal flexure. It is in the
6


jejunum where the majority of digestion and absorption occurs. The
final portion, the ileum, is the longest segment and empties into the
caecum at the ileocaecal junction.

The small intestine performs the majority of digestion and absorption
of nutrients. Partly digested food from the stomach is further broken
down by enzymes from the pancreas and bile salts from the liver and
gallbladder. These secretions enter the duodenum at the Ampulla of
Vater. After further digestion, food constituents such as proteins, fats,
and carbohydrates are broken down to small building blocks and
absorbed into the body's blood stream.
The lining of the small intestine is made up of numerous permanent
folds called plicae circulares. Each plica has numerous villi (folds of
mucosa) and each villus is covered by epithelium with projecting
microvilli (brush border). This increases the surface area for
absorption by a factor of several hundred. The mucosa of the small
intestine contains several specialised cells. Some are responsible for
absorption, whilst others secrete digestive enzymes and mucous to
protect the intestinal lining from digestive actions.

Large intestine
The large intestine is horse-shoe shaped and extends around the
small intestine like a frame. It consists of the appendix, caecum,
ascending, transverse, descending and sigmoid colon, and the
rectum. It has a length of approximately 1.5m and a width of 7.5cm.
The caecum is the expanded pouch that receives material from the
ileum and starts to compress food products into faecal material. Food
then travels along the colon. The wall of the colon is made up of
7


several pouches (haustra) that are held under tension by three thick
bands of muscle (taenia coli).
The rectum is the final 15cm of the large intestine. It expands to hold
faecal matter before it passes through the anorectal canal to the
anus. Thick bands of muscle, known as sphincters, control the
passage of faeces.
8


Pathophysiology

9


COURSE IN THE WARD

Doctors Order Medical Intervention

Nursing
Responsibility
Actions
09/26/14
4:50 PM

Pls. admit to FSW



Secure consent for
admission & mgt.


TPR



NPO




CBC with UA








>Client was admitted for
further care and
management

>For legal purposes



>This serves as basis for
initial vital signs


>Nothing per Orem no food
intake prior to operation



>Baseline laboratory tests
for diagnosis.







>Admission of client



>Explain the medical
interventions and the
required consent

>Assess and get
clients initial vital
signs

>Instruct the client for
NPO



>Obtain request form,
specimen and refer to
the laboratory for the
test


10


IVF D5LR 1L x 8*




Cefuroxime 750 mg
q8* ANST (-)
Metronidazole 500
mg



For Appendectomy




Notify on ROD
Refer

9:24 PM
NPO



Pre Op meds





>is useful for daily
maintenance of body fluids
and nutrition, and for
rehydration.


>Anti bacterial drug

>Anti bacterial drug




>Removal of the appendix




>To notify the ROD.



>Nothing per orem No food
intake until bowel
movement returns







>Check physicians
order and start IV



>administer initial
doze and note in
medication sheet




>Check the clearance
and instruments
needed prior to the
operation

> to inform the ROD
prior to the operation


>Inform the client for
NPO





other


11


09/26/14

POST
ANESTHESIA
ORDERED

SLP
APPENDECTOMY


To PACU



O
2
inhalation via
Nasal Cannula @
2-3 lpm

NPO




Monitor VS q15



Pls. regulate
present IVF to 31-
32 gtts/mins.



> Post Anesthesia care
prior to post operative client


>Removal of appendix



>for fast recovery from
anesthesia


>to promote oxygenation



>nothing per orem No food
intake until the Bowel
Movement presents

>Monitors clients VS every
15 minutes



>Regulate IVF as desired





>Check the
physicians order and
counter signed





>Render pre
operative care


>check the
physicians order and
start oxygenation

>Instruct the client
about NPO


>get the client VS
every 15 minutes and
refer any
abnormalities

>Regulate IVF as
desired


12


IVF to follow
D5LR 1Lx8*
D5LR 1Lx8*
D5LR 1Lx8*
D5LR 1Lx8*
Meds
TDL 50 IV q8*


Paracetamol (IV)
1gm q8* for 15-
20mins. Duration x
3 dose
Continue present
antibiotics as
ordered

09/27/14

Ambulate
09/28/14
Ambulate


Cefuroxime IV
Refer

>It is useful for daily
maintenance of body fluids
and nutrition, and for
rehydration.


>Non steroidal anti
inflammatory drugs

>Anti inflammatory and anti
pyretic drug.



>Continue the Cefuroxime
and metronidazole



>Ambulate to promote
Bowel movement



>anti bacterial drug.

>Check the
physicians order and
start the IV.


>Administer initial
doze and note at the
medication sheet




>Administer the drug
and note at the
medication sheet.



>Instruct the client
and assist to
ambulate.


Administer initial doze
and note at the
medication sheet




13


NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:

Nanghihina ako at
di masyado
makatindig as
verbalized by the
client.

Objective:
>With facial
grimace.
>Pale and weak in
appearance.
>Always lying on
bed
>with good
capillary refill
>BP 100/80mmHg

Activity
intolerance related
to the operation

After 8 hours of
nursing
intervention,The
patient will be able
to:
>demonstrate and
perform the
exercise (ROM)
>The patient will
increase his activity
tolerance
X
> Assessed
patients ability to
perform
tasks/noting reports
of weakness,
fatigue and
difficulty
accomplishing task

>Recommended
quiet atmosphere;
bed rest if indicated
stress-need to
monitor and limit
visitors, phone calls
and repeated
unplanned
interruptions.

>Elevated head of
bed as tolerated.

>Provided/
recommended
assistance with
activities
/ambulation as
necessary, allowing
>Influence of choice
of interventions
assistance.


>Enhances rest to
lower bodys oxygen
requirements, and
reduces strain on the
heart and lungs.


>Enhances lung
expansion to
maximize
oxygenation
for cellular uptake.

>Although help
maybe necessary,
self esteem is
enhanced when
patients does things
for self.

>Promotes adequate
rest energy level, and
alleviates strain on
After eight hours
nursing
interventions, the
patient was able to
cope with fatigue
and verbalization of
feelings of comfort
and increase
activity participation

After eight hours
nursing intervention
the client
demonstrate an
increase activity
tolerance.

14




Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:

nananakit
ang tiyan ko
sa may
bandang
kanan
ibabang
parte as
verbalized
by the
Acute pain
related to
Acute
Appendicitis

After 8 hours of
non-stop caring
to the patient.
The patient will
be able to:
>lessen the
pain
>demonstrate
diverticulative
techniques to
divert pain
> Assessed the
general condition of
the client

>Recommended
quiet atmosphere;
bed rest if indicated
stress-need to
monitor and limit
visitors, phone calls
and repeated
>To provide baseline data



To lessen the
consumption of
oxygen and promote
rest and to avoid
stress.


After eight hours
nursing interventions,
the patient was able
to demonstrate
diverticular activities.
Pain lessen from
8/10 to 3/10.

doing as much as
possible.

>Assisted patient to
prioritize
ADLs/desired
activities.

the cardiac and
respiratory systems

15


patient.

Objective:
>With facial
grimace.
>pain scale
of 8/10
>Pale and
weak in
appearance.

unplanned
interruptions.

>Demonstrate
diverticular
activities.

>Administer
medications such
as pain killer and
pain reliever to
relieve pain.




To divert and relieve
the pain


To relieve or lessen
the pain










16


DRUG STUDY

Therapeutic
Classification
Action Contraindicaiton Toxicity/ Side Effects Intervention Safe Doze
Tramadol
- narcotic like pain
reliever
NSAIDS
Anti-
inflammatory.
The
overall analgesic profile of
tramadol supports use in
the treatment of
intermediate pain,
especially chronic pain. It
is slightly less effective for
acute pain
than hydrocodone, but
more effective
than codeine. It has a
dosage ceiling similar
to codeine, a risk of
seizures when overdosed,
and a relatively long half-
life making its potential
for misuse relatively low
amongst intermediate
strength analgesics.
Tramadol
hydrochloride
should not be
administered to
patients who have
previously
demonstrated
hypersensitivity to
tramadol, any other
component of this
product or opioids.
Tramadol
hydrochloride is
contraindicated in
any situation where
opioids are
contraindicated,
including acute
intoxication with any
of the following:
alcohol, hypnotics,
and narcotics,
centrally acting
analgesics, opioids
or psychotropic
drugs. Tramadol
may worsen central
Tramadol is generally well tolerated,
and side effects are usually transient.
Commonly reported side effects
include nausea,
constipation, dizziness, headache,
drowsiness, and vomiting. Less
commonly reported side effects include
itching, sweating, dry mouth,
diarrhea, rash, visual disturbances,
and vertigo. Some patients who
received tramadol have reported
seizures. Abrupt withdrawal of tramadol
may result in anxiety,
sweating, insomnia, rigors, pain,
nausea, diarrhea, tremors, and
hallucinations.
Monitor V/S 50-100mg
17


nervous system and
respiratory
depression in these
patients.
Therapeutic
Classification
Action Contraindicaiton Toxicity/ Side Effects Intervention Safe Doze
Paracetamol
Anti Pyretic, Pain
reliever
Paracetamol reduces the
synthesis of
prostaglandins which are
responsible for the
mediation of pain and
fever.
Paracetamol is
contraindicated in
hypersensitivity,
analgesic
nephropathy, renal
and hepatic
impairment.
is caused by excessive use or overdose
of the analgesic drugparacetamol (called
acetaminophen in North America).
Mainly causing liver injury, paracetamol
toxicity is one of the most common
causes of poisoning worldwide. In the
United States and the United Kingdom it
is the most common cause of acute liver
failure.
Monitor V/S 500mg
Therapeutic
Classification
Action Contraindicaiton Toxicity/ Side Effects Intervention Safe Doze
Cefuroxime
Antibiotic/
Antibacterial
Cefuroxime is a
semisynthetic
cephalosporin antibiotic,
chemically similar to
penicillin. Cephalosporins
stop or slow the growth of
bacterial cells by
preventing bacteria from
forming the cell wall that
surrounds each cell. The
cell wall protects bacteria
from the external
environment and keeps
the contents of the cell
Hypersensitivity to
cephalosporins.
Swelling, redness, pain, or soreness at
the injection site may occur. This
medication may also infrequently cause
loss of appetite, nausea,
vomiting, diarrhea, irritability,
orheadache.
monitor V/S - Powder
for
Injection
750 mg
(2.4 mEq
sodium/g)
- Powder
for
Injection
1.5 g
(2.4mEq
sodium/g)
- Powder
for
18


together. Without a cell
wall, bacteria are not able
to survive.
Injection
7.5 g (2.4
mEq
sodium/g)
- Injection
750 mg
(2.4mEq
sodium/g)
- Injection
1.5 g (2.4
mEq
sodium/g)
19


Health Education
Appendicitis
Assessment:
A year old female cilent was
admitted at the Surgery ward
with chief complaint of Right
Lower Quadrant pain since Last
Night
. General Objective:
After 8 hours of nurse-patient-significant others
interaction. The patient will be able to acquire
knowledge, skills and attitude in the care of patient
with Acute Appendicitis

Specific Objectives Content Outline Teaching Method
1.Define Acute
Appendicitis


















2.Enumerate some
manifestations of Acute
Appendicitis



3. . Enumerate different
ways to relieve pain

Appendicitis is a condition
characterized
by inflammation of
the appendix. It is classified
as a medical emergency and
many cases
requires removal of the
inflame appendix, either
by laparotomy
or laparoscopy. Untreated,
mortality is high, mainly
because of the risk of
rupture leading to infection
and inflammation of the
intestinal lining
(peritoneum) and
eventual sepsis, clinically
known as peritonitis which
can lead to circulatory shock

Manifestations of Acute
Appendicitis
- RLQ Pain at first
- Vomimtting
- Fever

Diverticular Techniques
Diverticular activities
Pain Reliever
Encourage S.O. to
give the medications
on right time
-Formal and informal
discussions
-Lecture
-Leaflets
-Flashcards
-Images







20


Discharge Planning
M Medication -Mefenamic Acidthrice a day for pain in one week
-Cephalexin Thrice a day in one week
-Ferrous Sulfate Once a day in one month
E Environment -Ensure safety precautions outside and inside the house
-Keep patient away from materials or equipments that
may harm him
-Make sure that the patients bed is near the restroom
-Remove floor mats or anything that may cause injury
T Treatment -Follow up check up after 2 weeks for repeat FBS
H Health Teaching -Provide adequate knowledge regarding postpartum
prescribed by the dietician
-Encourage SO to give medications at home on the right
time and right dose
-Explain the importance of eating foods that prevents
constipation
O Observation -No further complaints noted. Patient started to show
good signs of recovery.
D Diet -Refer to dietician for diet
21


Prognosis

After the patient had undergone the surgery, and have removed her
appendix by surgical procedure called appendectomy the patient is now at
state of wellness. It takes 3-4 days to be totally recovered after the
procedure. The client is now well and discharged from the QMC Surgery
Ward. The patient is now free from appendicitis and has no further chance
to occur again.

22


IMPLICATION OF THE STUDY
The implication of this study in the practice of nursing serves as a
guide or a tool for the fellow nursing students and staff nurses. It provides a
detailed background, management, interpretations and documentations for
patients who have Acute Appendicitis. It will help broaden the knowledge
and skills of the healthcare team.