CAPITOL UNIVERSITY COLLEGE OF NURSING

Acute Appendicitis --a case study presented to the nursing as partial

fulfillment in the subject RLE 7

Submitted to:

Ms. Liwayway Salcedo, R.N Clinical Instructor Mr. Jim M. Labajan PCI Submitted by: Sierra Mae Gorres

TABLE OF CONTENTS

I. INTRODUCTION II. .CLIENTS PROFILE III. PHYSICAL ASSESSMENT IV. DIAGNOSTIC PROCEDURES V. VI. VII. DOCTORS ORDER ANATOMY AND PHYSIOLOGY PATHOPHYSIOLOGY

VIII. DRUG STUDY IX. NURSING CARE PLAN X. DISCHARGE PLAN XI. HEALTH TEACHINGS XII. REFERENCES.

I. 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. The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting. Loss of appetite is common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burneys point applied located at halfway between the umbilicus and the anterior spine of the Ilium. Rebound tenderness (ex. Production or intensification of pain when pressure is released) may be present. The extent of tenderness and muscle spasm and the existence of the constipation or diarrhea depend not so much on the severity of the appendiceal infection as on the location of the appendix.

III.PATIENTS PROFILE Name: Patient X Age: 18 Sex: Female Civil Status: Single Date of Birth: August 19. 1991 Address: Catarman Camiguin Religion: Roman Catholic Nationality: Filipino Place of Admission: Northern Mindanao Medical Center Date Admitted: July 08, 2010 Time: 6:30PM Ward: Surgical Ward Attending Physician: Dr. Glenn C. Hudieres Chief complaint: Right Lower Quadrant pain Final Diagnosis: Acute Appendicitis

IV.ASSESSMENT

DATE

JULY 9,2009

P
PSYCHOSOCIA L

>18 yrs old, single >lives at Catarman, Camiguin >Roman Catholic >Conscious and coherent >has good and harmonious relationship with her family members

E
ELIMINATION

>(-) vomiting >(-)diaphoresis >voids 5x a day with a clear and light yellow urine >(-) pain upon urinating >defecates 2x a day

A/R
REST & ACTIVITY

>sleeps 6-7 hours >works as a saleslady in a small store >works for 9 hours, from 8:00 am to 5:00 pm >considers watching TV at night with her family as a way of recreation

S
SAFE ENVIRONMENT

>afebrile, body temperature (BT) of 36.9 C/ax >denies allergy to foods or drugs >with dry and intact dressing on incision site >with binder at the abdominal area >cleans and changes the dressing regularly >with dry wound

>RR=18cpm >BP=120/80 mmHg >PR=72 bpm

DIAGNOSTIC WBC

NORMAL RESULT 5.0-10.0

ACTUAL RESULT 12.0 x10^9/L

NURSING IMPLICATION High-indicates infection

Lymph #

3.0-4.0

1.6x1069/L

Mid # Gran #

0.1-0.9 5.0-7.0

0.7x10^9/L 9.7x10^9/L

Lymph % Mid % Gran %

30.0-40.0 1.0-9.0 50.0-70.0

13.4% 5.8% 80.8%

NSG. RESPONSIBILITY >Instruct patient to increase intake of Vitamin C and increase fluid intake >Administer antibiotic as ordered High-indicates >Instruct patient to stress, pain and increase intake of acute systemic Vitamin C and increase infection fluid intake >Monitor signs of infection such as elevated Body Temp. >Administer antibiotic as ordered Normal High-indicates >Monitor signs of infection infection such as elevated Body Temp. >Administer antibiotic as ordered Low-indicates exhausted immune system Normal High-indicates >Instruct patient to infection increase intake of Vitamin C and increase fluid intake Normal Normal Mildly indicates blood loss Low-indicates anemia

HGB RBC HCT

120-160 4.04-5.48 37.0-47.0

131g/L 4.99x10^12/L 36.9%

low- >Instruct patient to mild increase intake of Vitamin C and increase fluid intake >Instruct patient to increase intake of Vitamin C and increase fluid intake

MCV

82.0-95.0

74.0 fL

MCH

27.0-31.0

26.2 pg

MCHC RDW-CV RDW-SD PLT MPV PDW PCT

320-360 11.5-14.5 35.0-56.0 150-400 7.0-11.0 15.0-17.0 0.108-0.282

355 g/L 14.0% 38.3 fL 239 x10^9/L 8.4 fL 16.8 0.200%

Low-indicates Iron >Instruct patient to deficiency increase intake of foods high in iron such as green leafy vegetables Normal Normal Normal Normal Normal Normal Normal

Urinalysis NORMAL COLOR CHARACTER ALBUMIN REACTION SPECIFIC GRAVITY PUS CELL ACTUAL Implication Normal Abnormal Normal Normal Normal Abnormal >Instruct patient to increase fluid intake >Administer antibiotic as ordered >Instruct patient to increase fluid intake >Administer antibiotic as ordered >Instruct patient to increase fluid intake Nursing Responsibility

Light or pale Light Yellow Yellow Clear Slightly turbid (-) 4.6-8 1.010-1.025 0 (-) 6.5 pH 1.010 2-4

SQUAMOUS

(-)

(+)

Abnormal

VI.ANATOMY AND PHYSIOLOGY

The appendix is a closed-ended, narrow tube up to several inches in length that attaches to the cecum , the first part of the colon, like a worm. The anatomical name for the appendix is vermiform appendix which means worm-like

appendage. It's pencil-thin and normally about 4 inches (7 cm) long.

The

appendix is usually located in the right iliac region, just below the ileocecal valve (designated McBurney's point) and can be found at the midpoint of a straight line drawn from the umbilicus to the right anterior iliac crest. The inner lining of the appendix produces a small amount of mucus that flows through the open center of the appendix and into the cecum. The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies. During the first few years of life, the appendix functions as a part of the immune system, it helps make immunogobulins. But after this time period, the appendix stops functioning. However, immunoglobulins are made in many parts of the body, thus, removing the appendix does not seem to result in problems with the immune system. Like the rest of the colon, the wall of the appendix also contains a layer of muscle, but the muscle is poorly developed.

VII.PATHOPHYSIOLOGY

Obstruction of the appendix (by fecalith, lymph node, tumour, foreign objects) Inflammation

Increase intraluminal pressure Distention of the Appendix causes pain Decrease venous drainage Blood flow and oxygen restriction to the appendix Bacterial Invasion of the Blood wallcauses fever Necrosis of the appendix

The pathophysiology of appendicitis is the constellation of processes that leads to the development of acute appendicitis from a normal appendix. The main thrust of events leading to the development of acute appendicitis lies in the appendix developing a compromised blood supply due to obstruction of its lumen and becoming very vulnerable to invasion by bacteria found in the gut normally. Obstruction of the appendix lumen by fecalith, enlarged lymph node, worms, tumor, or indeed foreign objects, brings about a raised intra-luminal pressure, which causes the wall of the appendix to become distended. Normal mucus secretions continue within the lumen of the appendix, thus causing further

build up of intra-luminal pressures. This in turn leads to the occlusion of the lymphatic channels, then the venous return, and finally the arterial supply becomes undermined. Reduced blood supply to the wall of the appendix means that the appendix gets little or no nutrition and oxygen. It also means a little or no supply of white blood cells and other natural fighters of infection found in the blood being made available to the appendix. The wall of the appendix will thus start to break up and rot. Normal bacteria found in the gut gets all the inducement needed to multiply and attack the decaying appendix within 36 hours from the point of luminal obstruction, worsening the process of appendicitis. This leads to necrosis and perforation of the appendix. Pus formation occurs when nearby white blood cells are recruited to fight the bacterial invasion. A combination of dead white blood cells, bacteria, and dead tissue makes up pus. The content of the appendix (fecalith, pus and mucus secretions) are then released into the general abdominal cavity, bringing causing peritonitis. So, in acute appendicitis, bacterial colonization follows only when the process have commenced. These events occur so rapidly, that the complete pathophysiology of appendicitis takes about one to three days. This is why delay can be deadly. Pain in appendicitis is thus caused, initially by the distension of the wall of the appendix, and later when the grossly inflamed appendix rubs on the overlying inner wall of the abdomen (parietal peritoneum) and then with the spillage of the content of the appendix into the general abdominal cavity (peritonitis). Fever is

brought about by the release of toxic materials (endogenous pyrogens) following the necrosis of appendicael wall, and later by pus formation. Loss of appetite and nausea follows slowing and irritation of the bowel by the inflammatory process. Early symptoms of appendicitis are those symptoms that most people with this condition may recognize and complain of. They include lower right sided abdominal pain of gradual onset, feeling sick (or nausea), and loss of appetite. Any one with these three symptoms can be assumed to have appendicitis until proven otherwise.

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

When the appendix is severely inflamed, the pain can be localized to a spot on the outer one third of a line drawn between the belly button and front of the tip of the waist bone called the McBurneys point. The Mc Burneys point is also often the point of maximum tenderness when the abdomen is examined. The pain is even worse when the hand is suddenly removed from that spot because of the appendix rubbing on the covering of the abdomen (Rebound tenderness). There is also a sign referred to as the Rovsign sign. This is said to exist when the lower left abdomen is palpated by the doctor, but causes pain in the right. If the appendix is the pelvic type, examining the back passage (rectal examination) would cause some pain too. If the hip is moved and stretched, this can also cause pain to be felt at the spot where the appendix lies. This is referred to as the psoas sign.

Loss of Appetite, Nausea & Vomiting This is another very important set of symptoms of appendicitis. It is said that loss of appetite is the most constant symptom of appendicitis.

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

Change in Bowel Habit There may be diarrhea or constipation, especially in young children. This could lead to a wrong diagnosis of food poisoning or gastroenteritis on the part of the unwary doctor. Up to 1 in 5 persons (20%) could have diarrhea or even constipation with appendicitis.

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

DRUG STUDY

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency)

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICA TIONS

ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIE S/ PRECAUTIONS

Tramadol (trama-dol) brand name: Ultra m, Zydol Classi ficatio ns: centra l nervo us syste m (cns) agent; analg esic; narcot ic (opiat e) agoni st Protot

Binds to muopoid receptors and inhibits the reuptake of norepinephrin e and serotonin:; causes may effect similar to the opoidsdizziness, somnolence

Relief of moderate to moderately severe pain

Containdicated w/ allergy to tramadol Use cautiously in pregnancy, lactation, seizures

CNS: sedation, dizziness,head ache,cofusion, dreaming CV:hypotension tachycardia, bradycardia GI: nausea, vomiting,dry mouth

-Control environment if sweating or cns effects occur -Instructed patient to avoid driving or performing tasks that required alertness

ype: Morph ine sulfat e Pregn ancy Categ ory: C

DRUG STUDY

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency)

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICA TIONS

ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIE S/ PRECAUTIONS

Generic name Ranitide Brand name: Zantac Drug class: Hestamine Dosage: Tablets: 75,150,300 mg Syrup: 15mg/ml Injection: 1,25mg/ml Route: oral,IM.IV Frequency: q 6-8

Competively inhibits the action of hestamine at the h2 receptor of the parietal cells of the stomach, inhibiting basal gastric acid secretion and gastric acid secretion that stimulated by food, gastrin and pentagastrin

-short term treatment of active doudenal ulcer -short terment of gerd Treatment of heartburn, acid ingestion

Containdicated with allergy to ranitidine lactation

CNS: Headache,mala ise, dizziness, somnolence,ins omnia and vertigo CV: tachycardia, bradycardia GI: gynecomnasia. Impotence or decrease libido

Instructed patient to take drugs w/ meals and at bedtime Encouraged patient to have a medical follow-up care Provide concurrent antacid therapy to relieve pain

DRUG STUDY
DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency)

MECHANISM OF ACTION

INDICATIONS

CONTRAINDI CATIONS

ADVERSE EFFECTS OF THE DRUG

NURSING RESPONSIBILITIE S/ PRECAUTIONS

Bactericidal: Inhibits DNA synthesis in specific anaerobes causing cell death

-Acute infection w/ susceptible anaerobic bacteria -Acute intestinal amebiases Amebic liver abscess -Trchomoniasis

Containdicate d w/ hypersensivity to metronidazole ,pregnancy -Use cautiously w/ CNS disease, lactation

CNS: headache, dizziness,ataxia ,vertigo GI: unpleasant metallic taste, vomiting, diarrhea GU: dysuria.incontin ence

Administer oral doses w/ food Do not drink alcohol: severe reaction may occur

IV NURSING CARE PLAN

ASSESSMENT DATA (Subjective & Objective Cues)

NURSING DIAGN OSIS (Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective: sakit akong tiyan as verbalized by patient. Objective: Facial mask of pain. Guarding behavior. Rebound tenderness. V/S taken as follows: T: 37.3 P: 80 R: 18 Bp: 120/70

Acute pain related to inflammation of tissues

After 4 hours of nursing interventions , the patient will demonstrate use of relaxation promote comfort.

Investigate pain reports, noting location, duration, intensity (0-10 scale), and characteristics (dull, sharp, constant). Maintain semifowlers position. Move patient slowly and deliberately. Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Provide diversional activities. Provide frequent oral care. Remove noxious environmental stimuli. Changes in location or intensity are not uncommon but may reflectdeveloping complications. Reduces abdominal distention, thereby reduces tension

After 4 hours of nursing intervention s, the patient was able to demonstrate use of relaxation skills, other methods to promote comfort.

ASSESSMENT DATA (Subjective & Objective Cues)

NURSING DIAGN OSIS (Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective: dli kay ko ganhan mukaon as verbalized by the patient Objective: Loss of weight w/ adequate food intake Evidence of lack of food Poor muscletone Weakness of muscle

Imbalanced nutrition: Less than body requirements R/T inability to ingest food

After 8 hours of nursing intervention the patient will able to: Demonstrate progressive weight gain Show interest to food Will have a strong muscle tone

Encourageclient to choose foods that are appealing to his appetite Avoid food tha causes intolerances Promote pleasant & relaxing environment to inhance intake Emhasize importance of well balanced, nutritious intake Discuss eating habits, including food preferences to appeal client desires.

After 8 hours of nursing intervention goals are partially meet as evidenced by: (+) muscle tone (-) weight gain (+) interest of food

X. Discharge Planning M Antibiotics for infection Analgesic agent (morphine) can be given for pain after the surgery E Within 12 hrs of surgery you may get up and move around. You can usually return to normal activities in 2-3 weeks after laparoscopic surgery. T Pretreatment of foods with lactase preparations (e.g. lactacid drops) before

ingestion can reduce symptoms. Ingestion of lactase enzyme tablets with the first bite of food can reduce symptoms. H To care wound perform dressing changes and irrigations as prescribe avoid

taking laxative or applying heat to abdomen when abdominal pain of unknown cause is experienced. Reinforce need for follow-up appointment with the surgeon Call your physician for increased pain at the incision site O Document bowel sounds and the passing of flatus or bowel movements

(these are signs of the return of peristalsis) Watch for surgical complications such as continuing pain or fever, which indicate an abscess or wound dehiscence Stitches removed between fifth and seventh day (usually in physicians office) D Liquid or soft diet until the infection subsides Soft diet is low in fiber and easily breaks down in the gastrointestinal tract

XI. HEALTH TEACHING Monitor frequently for signs and symptoms of worsening condition, indicating perforation, abscess, or peritonitis (increasing severity of pain, tenderness, rigidity, distention, absent bowel sounds, fever, malaise, and tachycardia). Notify health care provider immediately if pain suddenly ceases, this indicates perforation, which is a medical emergency. Assist patient to position of comfort such as semi-fowlers with knees are flexed. Restrict activity that may aggravate pain, such as coughing and ambulation. Apply ice bag to abdomen for comfort. Avoid indiscriminate palpation of the abdomen to avoid increasing the patients discomfort. Promptly prepare patient for surgery once diagnosis is established. Explain signs and symptoms of postoperative complications to reportelevated temperature, nausea and vomiting, or abdominal distention; these may indicate infection. Instruct patient on turning, coughing, or deep breathing, use of incentive spirometer, and ambulation. Discuss purpose and continued importance of these maneuvers during recovery period. Teach incisional care and avoidance of heavy lifting or driving until advised by the surgeon. Advise avoidance of enemas or harsh laxatives; increased fluids and stool softeners may be used for postoperative constipation.

XII. References http://nursingcrib.com http://www.scribd.com http://emedicine.medscape.com http://google.com http://yahoo.com Lippincotts Drug Handbook Nursing Diagnoses Handbook