Introduction

The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to

the cecum just below the ileocecal valve. No definite functions can be assigned to
it in humans. The appendix fills with food and empties as regularly as does the
cecum, of which it is small, so that it is prone to become obstructed and is
particularly vulnerable to infection (appendicitis).

Appendicitis is the most common cause of acute inflammation in the right lower
quadrant of the abdominal cavity. About 7% of the population will have
appendicitis at some time in their lives, males are affected more than females, and
teenagers more than adults. It occurs most frequently between the age of 10 and
30.

The disease is more prevalent in countries in which people consume a diet low in
fiber and high in refined carbohydrates.

If the appendix has ruptured, the pain become more diffuse, abdominal distention
develops as a result of paralytic ileus, and the patient condition become worsens.
Constipation can also occur with an acute process such as appendicitis. Laxative
administered in the instance may result in perforation of the in flared appendix. In
general a laxative should never be given when a person’s has fever, nausea or pain.

CURRENT TRENDS

Treating Appendicitis By Laparoscopic Surgery Might Not Be

Worth the Cost
Analysis in Journal of the American College of Surgeons shows newer method results in high costs and
increased complications

New research published in the February issue of the Journal of the American College of Surgeons suggests that a
traditional, "open" appendectomy may be preferable to a less-invasive laparoscopic appendectomy for the majority of
patients with acute appendicitis, contrary to recent trends.

Approximately 250,000 appendectomies are performed in the United States each year to treat appendicitis, an
inflammation of the appendix that is considered a medical emergency. If treatment is delayed, the appendix can
rupture, causing infection and even death.

For almost a century, open appendectomy was the standard treatment for appendicitis, until the 1980s when
laparoscopic appendectomy first gained popularity. This transition was based on data that suggested the operation, in
which an instrument called a laparoscope is inserted through small incisions in the abdomen, was associated with
reduced pain, faster recovery and better cosmetic results.
The results of this study challenge the current trend toward increased use of laparoscopic appendectomy," said Klaus
Thaler, MD, FACS, department of surgery, University of Missouri, Kansas City

. "Although laparoscopic surgery is associated with shorter hospital stays, it actually increases costs and may raise
the risk of complications in the majority of appendectomy patients."

This retrospective study examined 235,473 patients who underwent open or laparoscopic appendectomy between
2000 and 2005. Length-of-stay, costs and complications were assessed by stratified analysis for uncomplicated
(n=169,094) and complicated (n=66,379) appendicitis. Regression methods were used to adjust for covariates and to
detect trends.

The study demonstrated that the odds of having any kind of complication were significantly higher in the laparoscopic
group among patients with uncomplicated appendicitis (p<0.05, odds ratio = 1.07), and that there was no difference
among patients with complicated appendicitis (p=0.74). The only complications reduced by using the laparoscopic
approach were infections in the uncomplicated group, and infections and pulmonary complications in the complicated
group.

The adjusted costs for laparoscopic appendectomy were 22 percent higher in uncomplicated appendicitis and 9
percent higher in patients with complicated appendicitis (p<0.001). The increased expense for laparoscopic
appendectomy are likely related to higher operating room costs, including greater expense for operative instruments
and longer operative times. According to the study, laparoscopic appendectomy did result in a reduced length of
hospital stay for both the uncomplicated and complicated groups (p<0.001 and p<0.0001, respectively).

HISTORY
S/SX
• pain in the epigastric or periumbilical areas and upper right abdomen.
Within 2 to 12 hours, the pain localizes in the right lower quadrant and
intensity increases.
• Acute abdominal pain, usually in the right lower quadrant (i.e., Mc Burney’s
point)
• low-grade fever
• Anorexia
• moderate malaise
• nausea
• often vomiting
• Loss of appetite
• local tenderness
• Usually constipation occurs ; occasionally diarrhea
• Rebound tenderness, involuntary guarding, generalized abdominal rigidity.
ANATOMY

Appendicitis is inflammation of the vermiform appendix caused

by an obstruction attributable to infection, stricture, fecal mass,
foreign body or tumor. Appendicitis can affect either gender at
any age, but is most common in males ages 10 to 30.
Appendicitis is the most common disease requiring surgery. If
left untreated, appendicitis may progress to abscess,
perforation, subsequent peritonitis, and death.
Laboratory exam
Complete Blood Count (June 11, 2008)

Normal values Patient Value

Hgb 120-160 g/L 127 g/L

Hct 0.37-0.47 Vol % 0.38 Vol%

Leukocyte 5-10 10^9/L 10.15 10^9/L

Neutrophils 0.5-0.7 0.82

Lymphocytes 0.2-0.4 0.17

Eosinophils 0-0.07 0.01

Platelet 150-440 x10^9/L 383 x 10^9/L

Urinalysis (June 11, 2008)

Color: dark yellow Pus cells: 40-50/hpf

Appearance: turbid RBC: 20-30/hpf

Reaction: acidic (ph6) Bacteria: some/hpf

Specific Gravity: 1.015 Yeast Cells: none found

Albumin: (+) Mucus threads: loaded

Sugar: (-) Epithelial cells: some

Amorphous Urates/Phosphates: few

Medications
Ranitidine (50mg)

 Histamine H2 receptor antagonist

 Indication: Relief of heartburn associated with acid indigestion and sour

stomach. Treatment of GERD.
 Action: competitively inhibits gastric acid secretion by blocking the effect of
histamine on H2 receptors. Both daytime and nocturnal basal gastric acid
secretion, as well as food- and pentagastrin – stimulated gastric acid are
inhibited.
 Contraindications: cirrhosis of the liver, impaired renal or hepatic function
 Side effects: Headache, abdominal pain, consitipation, diarrhea, nausea and
vomiting.
 Nursing Considerations:
o Give antacids concomitantly for gastric pain although they may interfere
with ranitidine absorption.
o Assess stomach pain
o Avoid alcohol, aspirin – containing products, caffeine containing products
(may increase stomach acid)

Nalbuphine (10 mg)

 Brand name: Nubain

 Drug Classification: Opioid analgesic
 Indications: Management of moderate to severe pain. Also used as an
analgesic during labor, as a sedative prior to surgery, and as a supplement in
balanced anesthesia.
 Action: Binds to opiate receptors in the CNS. Alters the perception of and
response to painful stimuli, while producing generalized CNS depression. In
 addition, has a partial antagonist property, which may result in opioid
withdrawal in physically dependent patients.
 Contraindications: Hypersensitivity to nalbuphine or bisulfites. Patients who
are physically dependent on opioid analgesics and have not been detoxified
(may precipitate withdrawal).
 Caution: Head trauma, increased intracranial pressure; severe renal, hepatic,
or pulmonary disease; hypothyroidism; geriatric/debilitated patients.
 Adverse reactions: Sedation, headache, dizziness, vertigo, respiratory
depression, nausea and vomiting, clammy feeling.
 Nursing Considerations:
o Assess type, location, and intensity of pain.
o Assess BP, PR, and RR before and periodically during administration.
o Prolonged use may lead to physical and psychological dependence and
tolerance.
o Patient teaching:
 Instruct on how and when to ask for pain medication.
 Advise to call for assistance when ambulating.

Ketorolac (30 mg)

 Brand name: Toradol, Ketomed

 Drug Classification: Non-opioid analgesic; NSAID
 Indications: Short term management of pain. Management of ocular itching
due to seasonal allergic conjunctivitis.
 Action: Inhibits prostaglandin synthesis producing peripherally mediated
analgesia. It also has an antipyretic and an anti-inflammatory property.
 Contraindications: Cross-sensitivity with other NSAIDs may exist. Lactation.
 Caution: History of GI bleeding, CVD, and renal impairment.
 Adverse reactions: Drowsiness, abnormal vision, asthma, pallor.
 Nursing Considerations:
o Assess pain, noting type, location, and intensity.
 o Patients with asthma, aspirin-induced therapy, and those with nasal
polyps are at increased risk for developing hypersensitivity reactions.
o Patient Teaching:
 Instruct on how and when to ask for pain medications.

Metoclopramide (10 mg)

 Brand name: Plasil

 Drug Classification: Anti-emetic
 Indications: It is used short-term to treat heartburn caused by
gastroesophageal reflux in people who have used other medications without
relief of symptoms. It is also used to treat slow gastric emptying in people
with diabetes (also called diabetic gastroparesis), which can cause nausea,
vomiting, heartburn, loss of appetite, and a feeling of fullness after meals.
 Action: Metoclopramide increases muscle contractions in upper digestive
tract. This speeds up the rate at which the stomach empties into the
intestines.
 Contraindications: In patients with a history of hypersensitivity to
metoclopramide or any of the components. In the presence of GI
hemorrhage, mechanical obstruction, or perforation. In those with
pheochromocytoma, in epileptics and in those with extrapyramidal reactions.
 Caution: Pregnancy and lactation.
 Adverse reactions: Restlessness, drowsiness, fatigue and lassitude. Less
frequent reactions are insomnia, extrapyramidal symptoms, headache,
dizziness, nausea, galactorrhea, gynecomastia, rash and urticaria, or bowel
disturbances.
 Nursing Considerations:
o Extract from history if the patient has epilepsy, GI perforation,
pheochromocytoma, or bleeding in the intestines.
o The drug can pass into the breast milk and may harm the baby.
o Metoclopramide is usually taken before meals and at bedtime.
o Patient Teaching:
 Instruct to take with a full glass of water.
Medical ang surgical management
Appendectomy is the effective treatment if peritonitis develops treatment involves.
 GI Intubation
 Parenteral replacement of IV fluids and electrolytes
 Administration of Antibiotics

Surgery is indicated if appendicitis is diagnosed. Antibiotics and IV fluids are

administered until surgery is performed analgesics can be administered after the
diagnosed is made.
An appendectomy (surgical removal of the appendix) is performed as soon as
possible to decrease the risk of perforation. T he appendectomy may be performed
under a (general or spinal anesthetics) with a low abdominal incisions or by
(laparoscopy) which is recently highly effective method
PATHOPHYSIOLOGY
 Obstruction of the appendix lumen causes increased intralumenal pressure and
triggers an inflammatory process that can lead to infection, necrosis, and
peroration. Perforation and rupture can cause peritonitis, a life threatening
complication.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS
 INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: • Acute pain
“Masakit ang related to • Appendicitis • After 4 independent: • Changes in • After 4
tiyan ko” as inflammation is hours • Investigate pain location or hours of
verbalized by of tissues inflammation of of nursing reports, noting intensity are not nursing
patient. the vermiform location, duration,
interventions uncommon but intervention
appendix
Objective: , the patient intensity (0-10 may reflect s, the
caused by an
• Facial mask obstruction will scale), and developing patient was
of pain. attributable to demonstrate characteristics complications. able to
• Guarding infection, use of (dull, sharp, • Reduces demonstrate
behavior. stricture, fecal relaxation constant). abdominal use of
• Rebound mass, foreign skills, other • Maintain distention, relaxation
tenderness. body or tumor. methods to semifowler’s thereby skills, other
• V/S taken promote position. reduces methods to
as comfort. • Move patient tension. promote
follows: slowly and • Reduces comfort.
T: 37.3 deliberately. muscle tension
P: 80 • Provide comfort or guarding,
R: 18 measure like which may help
Bp: 110/90 back rubs, deep minimize pain
breathing. of movement.
Instruct in • Promotes
relaxation or relaxation and
visualization may enhance
exercises. patient’s coping
Provide abilities by
diversional refocusing
activities. attention.

Collaborative:
• Administer • Reduce
analgesics as metabolic rate
prescribed. and aids in pain
relief and
promotes
healing.

ASSESSMENT DIAGNOSIS
INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
S: >Impaired
“Kakatapos tissue After 8 >Monitor for >infection, -the patient’s
lang ng integrity hours of signs of through surgical site
operasyon related to nursing infection production of will not have
ko kanina” trauma to intervention toxins and any
integument s the wastes complications
ary and patient’s increases the such as
subcutaneo suture site probability of infection
O : >Status
us tissues will remain tissue
post -the patient’s
secondary intact and >Monitor vital damage.
Salpingecto wound will
to free from signs every 4
my, and heal normally
abdominal contaminati hours >Provides a
Elective and well
surgery on the baseline that
Appendecto approximated
patient or a allows quick
my , day 1 .
skilled recognition of
significant deviations in
other will be subsequent
>With dry able to >Assess skin measurement
and intact demonstrat integrity s
abdominal e at least 4-
dressing 7 steps of >Serves as
and binder proper baseline data
wound to evaluate
dressing the efficiency
> No foul techniques >Assess wound of nursing
odor noted dressing for intervention
in the drainage
surgical site >early
recognition of
undesirable
signs and
>(+) facial
symptoms
grimace and
such as
guarding
profuse
behavior
Therapeutics: bleeding is
noted when
vital in
ambulating
>Avoid preventing
>Vital signs: handling and further
placing direct complications
BP: pressure on the
110/70 suture area
mmHg Therapeutics:
>Ensure safety
RR: 25
by constantly >pressure
cpm checking on the predisposes
patient and skin
PR: 75 assisting when breakdown
bpm patient is
T: 36.5 ambulating
C >to maintain
the patency
of the
patient’s
tubings like
the Epidural
>Perform deep catheter and
breathing and IFC and
coughing prevent any
exercises with complications
the patient that may
arise if the
>Perform tubes are
passive disconnected
exercises or
have the >Mobilizes
patient perform static
active range of pulmonary
motion secretions
exercises

>stimulates
circulation,
which
>Use sterile provides
technique when nourishment
changing/ and carries
assessing waste away,
dressing or thus reducing
performing the likelihood
invasive of skin
procedures breakdown.

>Promote rest >protects

and comfort by patient from
clustering exposure to
nursing pathogens
interventions
> Wash hands >adequate
thoroughly rest coupled
before and with the right
after each diet promotes
intervention faster wound
healing

Educative >prevents
interventions: cross-
contamination
>Teach the and
patient and nosocomial
significant infections
others about
proper wound Educative
care interventions:

>Basic care
measures for
>Teach and impaired skin
explain to the integrity are
patient the important toe
benefits of prevent
early infection
ambulation and
how to >early
ambulated ambulation
using proper prevents
techniques to inadequate
avoid trauma to tissue
the wound perfusion to
the surgical
>Encourage site which
patient to may lead to
increase intake other
of food rich in complications
protein such as
organ meats
and food rich in >protein is
Vitamin C such needed for
as pineapple tissue
and oranges building and
 wound
healing and
>Teach the vitamin C
patient and enhances the
family the absorption of
purpose and protein and
techniques of other
universal nutrients
precautions needed for
wound
healing

>protects the
patient and
the family
from infection