Postoperative Care after Appendectomy

Following surgery, the patient is taken to the postanesthesia care unit (PACU) until the anesthesia wears off. During
this time, the nursing staff checks temperature, heart rate, and breathing at frequent intervals. When the anesthesia
wears off and vital signs stabilize, the patient is transferred to their hospital room.

Unruptured Appendix

With an unruptured appendix, the patient's recovery time is relatively quick. The morning after surgery, clear liquids
are offered. Once those are tolerated, the diet progresses to solid food. Once the patient is eating and drinking, the
intravenous is removed. Physical activity, such as getting out of bed, begins on the same day as surgery or the next
morning. Most patients need medication to relieve the pain in and around the incision. The smaller incisions of a
laparscopic procedure often cause less pain than the large incision made in open appendectomy.

The nursing staff continues to monitor the patient for signs of infection and checks that the incision is healing.
Patients with uncomplicated surgeries usually leave the hospital 1 or 2 days following surgery.

Once at home, the patient must check the incision site. It should be dry and the wound should be completely closed.
If the incision drains blood or pus, or if the edges are pulling apart, the physician should be notified immediately.
Fever and increasing pain at the incision site also should be reported to the physician.

Normal activities can be resumed within a few days, but it takes 4 to 6 weeks for full recovery. Heavy lifting and
strenuous activity should be avoided during recovery. If antibiotics and/or pain medication are prescribed, they should
be taken as directed.

The open procedure leaves a scar on the lower right side of the abdomen that is a few inches long and fades over
time. Scarring from laparoscopic appendectomy is minimal.

Ruptured Appendix

Recovery from surgery for a perforated appendix is longer, primarily because the infection must be treated. The
hospital stay is at least 4 days and can be longer, if complications develop. The drain remains in place until the pus
stops draining, and the nursing staff changes the gauze packing as needed. Intravenous antibiotics continue
throughout the hospitalization.

When discharged, oral antibiotics are prescribed and should be taken as directed. The drain and gauze pack remain
in place, and instructions are given on proper care of the area. It is important to inform the physician if the amount of
drainage suddenly increases, or if the color and consistency changes. The drain is removed on an outpatient basis
after the infection has resolved.
Postoperative Complications after Appendectomy
Paralytic ileus may occur following the operation. The bowel is normally in constant motion, digesting food and
absorbing nutrients. Disturbing the bowel, even by the surgeon's just touching it, can cause the motion to come to a
standstill. Fluid and gas may then cause the bowel to swell or distend. A nasogastric tube is passed through the nose
and into the stomach to relieve the distension.

When bowel function returns to normal (evident by passing gas or having a bowel movement), the tube is removed.
Until that time, food and liquid are not permitted by mouth, and hydration is maintained intravenously. Paralytic ileus
is more common when the appendix has perforated.

Postoperative care
The severity of the patient's pain needs to be assessed with the use of a pain scale. Appropriate pain
relief can then be administered. Vital signs should be regularly monitored at half-hourly intervals for
two hours postoperatively, hourly for two hours and, if stable, every four hours while the patient is
recovering in hospital.

If the patient has had a straightforward appendectomy the surgical team should review the patient on
recovery and decide when they may eat and drink.

A drain may have been inserted during surgery. If so, the output of the drain should be recorded
every 24 hours. The drain can be removed when there is minimal drainage - usually 50ml or less.

The wound should be managed aseptically. If the wound is covered with a dry dressing then it should
be changed every 1-2 days. Clips/stitches should be removed 10 days postoperatively. The patient
can go home with these in place and the district or practice nurse can remove them. If dissolvable
stitches have been used this is unnecessary, although a visit to check the wound will reduce anxiety.
Before discharge, the patient must be confident in how to manage their wound and have details of
who they should contact in case of concern.

The patient should be encouraged to get up and out of bed as soon as possible to prevent the
formation of emboli. Anticoagulants are usually administered in the form of subcutaneous injections
before surgery and postoperatively. Antiembolism stockings should be worn. If peritonitis has
developed, the patient's postoperative management will be over a longer period but will follow the
same principles.

The patient will not be able to commence food and fluids for a few days, this is to enable the bowel to
regain normal function. The convalescence period is almost invariably smooth and the patient recovers
rapidly (Colmer, 1986). The hospital stay for patients who have undergone an uncomplicated
appendectomy is usually 2-3 days. In most cases the patient will be discharged when their
temperature is normal and their bowels have started to function again (Peterson, 2002).

People can live a full life without their appendix. Changes in diet, exercise or other lifestyle factors are
not necessary (NDDIC, 2004).

Conclusion

Appendicitis is a condition that is prevalent in the developed world and should have minimal
complications. Surgical action should be taken without delay. If left untreated there is a risk of
peritonitis, which is the main complication of this condition.

Medical awareness of appendicitis has improved and complications are less common. With the use of
laparoscopic surgery recovery time is rapid.

- Identify where the appendix is situated

- Recognise the signs and symptoms of appendicitis

- Understand pre and postoperative nursing care for a patient with appendicitis

- Know the possible complications for these patients

Below The Knee Amputation
WHAT YOU SHOULD KNOW:
 Below the knee amputation is surgery to remove all or part of your foot or your leg below the knee cap. It is also
called BKA. You may need a BKA for a health problem that causes poor blood flow, such as diabetes. You may have
a severe infection or a blood clot. You may have been in an accident that injured your leg beyond repair. You may
also need a BKA if you have cancer, or were born with a deformed leg. Amputations are either planned or done in an
emergency. Caregivers will only remove as much of your foot or leg as is absolutely necessary. After a BKA, you may
be fitted for a prosthesis (artificial leg) for your residual (remaining) limb.

 You and your caregiver will work together to decide if other treatments should be included in your treatment plan.
You may need hyperbaric oxygen treatment to help heal infections. You may need surgery to provide new blood
vessels to your leg if you have blood flow problems. If you have cancer, you may need surgery to remove the tumor
and graft a donor bone in its place.

Activity guidelines:

• You may feel like resting more after surgery. Slowly start to do more each day. Rest when you feel it is
needed, but try to exercise two to three times each day. Do not put weight on the residual limb until
caregivers tell you it is OK.

• Change your position often to move fluids in your lungs, decreasing your chances of getting pneumonia.
This also decreases the chance of pressure sores on your skin, and keeps your muscles and tendons from
tightening.

• Avoid lifting heavy objects.

• Ask your caregiver when you can shower, bathe and swim.

• Talk to your caregiver if you have questions or concerns.

 Exercises to improve your balance and increase your strength:

• The center of gravity in your body has changed because you suddenly weigh less after an amputation. You
will have to learn your new center of gravity so that you can keep your balance.

• The following exercises will help to strengthen your muscles and improve your balance. Do these exercises
while holding onto a chair. Be careful not to hit your residual limb on the chair while doing these exercises.

o Stand on your toes.

o Do knee bends.

o Hop on your foot.

o Practice standing without holding on to the chair.

Eat a healthy diet:

Eat healthy foods from all of the five food groups: fruits, vegetables, breads, dairy products, meat and fish. A healthy
diet may help you feel better and have more energy. It may also help you heal faster.

• Your caregiver may want you to eat a diet high in calcium. Foods high in calcium are milk, cheese, ice
cream, fish, and dark green vegetables like spinach. Eating high calcium foods helps prevent bone loss.

Occupational therapy:

• Having had your leg amputated changes many things about your life. It may also affect the type of work you
do or how you do it. An occupational therapist (OT) is a caregiver who helps you learn to live with a BKA.
This caregiver can teach you how to use tools to make up for only having one leg.

• This caregiver can also go to where you work and do a job site evaluation. An OT can make suggestions
about how you may continue doing the same work. If you cannot return to your previous job, call your state's
Office of Vocational Rehabilitation. They may be able to help you learn a new job.

Physical therapy:
Caregivers will start you on physical therapy after surgery. A physical therapist (PT) will help you with special
exercises. These exercises help make your bones and muscles stronger and help you learn to be independent after
an amputation. You may be fitted with a prosthesis (artificial leg). Your prosthesis may need to be adjusted several
times before it fits well. Physical therapists will also help you learn to walk with crutches and the prosthesi
Medical and complementary management of hypertension

There is still great uncertainty about the pathophysiology of hypertension (abnormally high blood
pressure). In a small number of cases (2-5%) the condition is caused by underlying renal or adrenal
disease, but for most patients there is no single identifiable cause and their condition is labelled as
'essential hypertension' (Beevers et al, 2001).

Hypertension occurs more often in people with a family history of the condition, diabetes or obesity.
The incidence is also higher in Afro-Caribbeans than in other ethnic groups, and in urban rather than
rural dwellers (Drummond, 2000; O'Brien et al, 1995). It is one of the main risk factors for coronary
and cardiovascular diseases in most developed countries and has been shown to be a public health
problem in many developing countries since the 1970s (Fuentes et al, 2000).

All approved hypertensive drugs lower blood pressure (BP) but, in terms of reducing the risk of long-

term complications such as myocardial infarction, stroke or heart failure, only low-dose diuretics and
beta-blockers are consistently successful (Psaty and Furberg, 1999). This article evaluates the role of
bendrofluazide (a low-dose diuretic) and metoprolol (a beta-blocker), which are considered the
optimum treatment for hypertension. The use of non-pharmacological measures and hawthorn in the
treatment of hypertension are also discussed.

Management of hypertension

All adults should have their BP measured at least every five years until the age of 80, while those with
normal or high values (135-139/85-89mmHg) and those who have had high readings previously
should be measured annually (Ramsay et al, 1999).

Only two groups of drugs - low-dose diuretics and beta-blockers - have been shown to reduce long-
term mortality from the complications of hypertension. There is general support for their use as first-
line treatments and concern that newer, more expensive drugs should not replace them until they
have been shown to be as beneficial.

Since all antihypertensives reduce BP by about the same extent, the same long-term benefits might
reasonably be expected regardless of which class of drug is used (National Prescribing Centre, 1995).
However, replacing thiazides and beta-blockers with newer agents could cost millions of pounds and
would not represent an evidence-based approach to treatment. Given the current emphasis on
evidence-based practice, it seems logical to select antihypertensive agents that have been shown to
prevent long-term complications (Hicks and Hennessy, 1997).
Bendrofluazide is a thiazide diuretic that is widely used, alone or with a beta-blocker, for mild,
moderate and severe hypertension. However, it can provoke acute gouty arthritis as it raises serum
uric acid by inhibiting renal urate excretion. Long-term therapy may also impair glucose tolerance by
inhibiting the release of insulin from the pancreas, decreasing diabetic control (Reid et al, 1992).

The British National Formulary advises that bendrofluazide should not be used during pregnancy as it
can cause neonatal thrombocytopenia. Increases in total cholesterol, low-density lipoprotein and
triglyceride levels have also been reported after long-term use. Other side-effects include low
magnesium levels, dizziness, headaches, nausea, vomiting, urticaria, blood dyscrasias and mild
hypocalcaemia (Kee and Hayes, 2000).

Although beta-blockers are effective antihypertensives, their mode of action is not fully understood
(Parish, 1992). They decrease the effects of the sympathetic nervous system by blocking the release
of adrenaline and noradrenaline at the receptor site. Metoprolol is a competitive beta-adrenoceptor
antagonist that inhibits beta1-adrenoceptors, is devoid of intrinsic sympathomimetic activity and
possesses beta-adrenoceptor blocking activity comparable to propranolol.

A negative chronotropic effect on the heart is a consistent feature of metoprolol administration, so

cardiac output and systolic BP rapidly decrease after acute administration. However, some beta-
blockers are non-selective, blocking both beta1 and beta2 receptors, decreasing the heart rate and
BP, and causing bronchoconstriction (Kee and Hayes, 2000).

Fat-soluble beta-blockers such as metoprolol can cross the blood-brain barrier and the placenta, and
be distributed into breast milk. By entering the brain the drug may produce adverse effects such as
poor sleep and nightmares (Parish, 1992).

Complementary therapies

Many practitioners, both orthodox and complementary, recommend that hypertensive patients take
courses in relaxation. In the relaxed state adrenaline levels are lowered, which reduces muscle
tension, induces regular diaphragmatic breathing and promotes mental calm. The body uses less
energy than usual and there is less work for the heart, lungs and brain. Regular relaxation exercises
have been shown to lower BP, but this is used mainly as an adjunct to treatment (Vincent and
Furnham, 1997).

Complementary therapy is widely used in Australasia, Britain, Europe and the USA. The reaction of
medical professionals has varied. Some have incorporated various therapies into their own practice,
while others dismiss them as, at best, harmless forms of comfort and, at worst, dangerous quackery
that may deprive people of effective medical treatment (Ernst, 1996).