Appendicitis Case Study 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. If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar region. Rovsings sign maybe elicited by palpating the left lower quadrant. 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 persons has fever, nausea or pain. Anatomy and Physiology of Digestive System The mouth, or oral cavity, is the first part of the digestive tract. It is adapted to receive food by ingestion, break it into small particles by mastication, and mix it with saliva. The lips, cheeks, and palate form the boundaries. The oral cavity contains the teeth and tongue and receives the secretions from the salivary glands. Lips and Cheeks The lips and cheeks help hold food in the mouth and keep it in place for chewing. They are also used in the formation of words for speech. The lips contain numerous sensory receptors that are useful for judging the temperature and texture of foods. Palate The palate is the roof of the oral cavity. It separates the oral cavity from the nasal cavity. The anterior portion, the hard palate, is supported by bone. The posterior portion, the soft palate, is skeletal muscle and connective tissue. Posteriorly, the soft palate ends in a projection called the uvula. During swallowing, the soft palate and uvula move upward to direct food away from the nasal cavity and into the oropharynx. Tongue The tongue manipulates food in the mouth and is used in speech. The surface is covered with papillae that provide friction and contain the taste buds. Teeth A complete set of deciduous (primary) teeth contains 20 teeth. There are 32 teeth in a complete permanent (secondary) set. The shape of each tooth type corresponds to the way it handles food. Pharynx The pharynx is a fibromuscular passageway that connects the nasal and oral cavities to the larynx and esophagus. It serves both the respiratory and digestive systems as a channel for air and food. The upper region, the nasopharynx, is posterior to the nasal cavity. It contains the pharyngeal tonsils, or adenoids, functions as a passageway for air, and has no function in the digestive system. The middle region posterior to the oral cavity is the oropharynx. This is the first region food enters when it is swallowed. The opening from the oral cavity into the oropharynx is called the fauces. Masses of lymphoid tissue, the palatine tonsils, are near the fauces. The lower region, posterior to the larynx, is the laryngopharynx, or hypopharynx. The laryngopharynx opens into both the esophagus and the larynx.

Esophagus The esophagus is a collapsible muscular tube that serves as a passageway between the pharynx and stomach. As it descends, it is posterior to the trachea and anterior to the vertebral column. It passes through an opening in the diaphragm, called the esophageal hiatus, and then empties into the stomach. The mucosa has glands that secrete mucus to keep the lining moist and well lubricated to ease the passage of food. Upper and lower esophageal sphincters control the movement of food into and out of the esophagus. The lower esophageal sphincter is sometimes called the cardiac sphincter and resides at the esophagogastric junction Stomach the stomach, which receives food from the esophagus, is located in the upper left quadrant of the abdomen. The stomach is divided into the fundic, cardiac, body, and pyloric regions. The lesser and greater curvatures are on the right and left sides, respectively, of the stomach. Small Intestine The small intestine extends from the pyloric sphincter to the ileocecal valve, where it empties into the large intestine. The small intestine finishes the process of digestion, absorbs the nutrients, and passes the residue on to the large intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive system that are closely associated with the small intestine. The small intestine is divided into the duodenum, jejunum, and ileum. The small intestine follows the general structure of the digestive tract in that the wall has a mucosa with simple columnar epithelium, submucosa, smooth muscle with inner circular and outer longitudinal layers, and serosa. The absorptive surface area of the small intestine is increased by plicae circulares, villi, and microvilli. Exocrine cells in the mucosa of the small intestine secrete mucus, peptidase, sucrase, maltase, lactase, lipase, and enterokinase. Endocrine cells secrete cholecystokinin and secretin. The most important factor for regulating secretions in the small intestine is the presence of chyme. This is largely a local reflex action in response to chemical and mechanical irritation from the chyme and in response to distention of the intestinal wall. This is a direct reflex action, thus the greater the amount of chyme, the greater the secretion. Large Intestine The large intestine is larger in diameter than the small intestine. It begins at the ileocecal junction, where the ileum enters the large intestine, and ends at the anus. The large intestine consists of the colon, rectum, and anal canal. The wall of the large intestine has the same types of tissue that are found in other parts of the digestive tract but there are some distinguishing characteristics. The mucosa has a large number of goblet cells but does not have any villi. The longitudinal muscle layer, although present, is incomplete. The longitudinal muscle is limited to three distinct bands, called teniae coli, that run the entire length of the colon. Contraction of the teniae coli exerts pressure on the wall and creates a series of pouches, called haustra, along the colon. Epiploic appendages, pieces of fatfilled connective tissue, are attached to the outer surface of the colon. Unlike the small intestine, the large intestine produces no digestive enzymes. Chemical digestion is completed in the small intestine before the chyme reaches the large intestine. Functions of the large intestine include the absorption of water and electrolytes and the elimination of feces. Rectum and Anus The rectum continues from the signoid colon to the anal canal and has a thick muscular layer. It follows the curvature of the sacrum and is firmly attached to it by connective tissue. The rectum and ends about 5 cm below the tip of the coccyx, at the beginning of the anal canal. The last 2 to 3 cm of the digestive tract is the anal canal, which continues from the rectum and opens to the outside at the anus. The mucosa of the rectum is folded to form longitudinal anal columns. The smooth muscle layer is thick and forms the internal anal sphincter at the superior end of the anal canal. This sphincter is under involuntary control. There is an external anal sphincter at the inferior end of the anal canal. This sphincter is composed of skeletal muscle and is under voluntary control. Clinical Manifestations

1. 2. 3. 4. 1. 2. 3.

Generalized or localized abdominal pain in the epigastric or periumbilical areas and upper right abdomen. Within 2 to 12 Anorexia, moderate malaise, mild fever, nausea and vomiting. Usually constipation occurs ; occasionally diarrhea. Rebound tenderness, involuntary guarding, generalized abdominal rigidity. Physical examination consistent with clinical manifestations. WBC count reveal moderate leukocytosis (10,000 to 16,000/mm3) with shift to the left (increased immature neutrophils). Urinalysis rule out urinary disorders.

hours, the pain localizes in the right lower quadrant and intensity increases.

Diagnostic Evaluation

4. 5.

Abdominal x-ray may visualize shadow consistent with fecalith in appendix; perforation will reveal free air. Abdominal ultrasound or CT scan can visualize appendix and rule out other conditions, such as diverticulitis and crohns

disease. Focused appendiceal CT can quickly evaluate for appendicitis. Medications

Analgesics Intravenous fluids replacements Analgesics

Treatment 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. Complications The major complication of appendicitis is perforation of the appendix, which can lead to peritonitis, abscess formation (collection of purulent material), or portal pylephlebitis, which is septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines. Perforation generally occurs 24 hours after the onset of pain symptoms include a fever of 37.7 degree Celsius or 100 degree Fahrenheit or greater, a toxic appearance and continued abdominal pain or tenderness. Nursing Interventions

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Monitor frequently for signs and symptoms of worsening condition, indicating perforation, abscess, or peritonitis (increasing 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 report-elevated temperature, nausea and vomiting, or Instruct patient on turning, coughing, or deep breathing, use of incentive spirometer, and ambulation. Discuss purpose and 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

severity of pain, tenderness, rigidity, distention, absent bowel sounds, fever, malaise, and tachycardia).

abdominal distention; these may indicate infection. continued importance of these maneuvers during recovery period.

constipation. Discharge Planning M E T H Antibiotics for infection Analgesic agent (morphine) can be given for pain after the surgery 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. 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. 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

Ana and physio ANATOMYAND PHYSIOLOGY OF APPENDIX The appendix is a closed-ended, narrow tube up to several inches in length that attaches to the cecumthe 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 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. Like the rest of the colon, the wall of the appendix also contains a layer of muscle, but the muscle is poorly developed.

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 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

CLINICAL MANIFESTATION OF APPENDICITIS 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.

TEST 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 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 abscesses as well as in excluding other diseases inside the abdomen and pelvis that can mimic appendic 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. Why can it be difficult to diagnose appendicitis? It can be difficult to diagnose appendicitis. The position of the appendix in the abdomen may vary. Most of the time the appendix is in the right lower abdomen, but the appendix, like other parts of theintestine, has a mesentery. This mesentery is a sheet-like membrane that attaches the appendix to other structures within the abdomen. If the mesentery is large, it allows the appendix to move around. In addition, the appendix may be longer than normal. The combination of a large mesentery and a long appendix allows the appendix to dip down into the pelvis (among the pelvic organs in women). It also may allow the appendix to move behind the colon (called a retro-colic appendix). In either case, inflammation of the appendix may act more like the inflammation of other organs, for example, a woman's pelvic organs. The diagnosis of appendicitis also can be difficult because other inflammatory problems may mimic appendicitis. Therefore, it is common to observe patients with suspected appendicitis for a period of time to see if the problem will resolve on its own or develop characteristics that more strongly suggest appendicitis or, perhaps, another condition APPENDECTOMY

During an appendectomy, an incision two to three inches in length is made through the skin and the layers of the abdominal wall over the area of the appendix. The surgeon enters the abdomen and looks for the appendix which usually is in the right lower abdomen. After examining the area around the appendix to be certain that no additional problem is present, the appendix is removed. This is done by freeing the appendix from its mesenteric attachment to the abdomen and colon, cutting the appendix from the colon, and sewing over the hole in the colon. If an abscess is present, the pus can be drained with drains that pass from the abscess and out through the skin. The abdominal incision then is closed.

Newer techniques for removing the appendix involve the use of the laparoscope. The laparoscope is a thin telescope attached to a video camera that allows the surgeon to inspect the inside of the abdomen through a small puncture wound (instead of a larger incision). If appendicitis is found, the appendix can be removed with special instruments that can be passed into the abdomen, just like the laparoscope, through small puncture wounds. The benefits of the laparoscopic technique include less post-operative pain (since much of the post-surgery pain comes from incisions) and a speedier return to normal activities. An additional advantage of laparoscopy is that it allows the surgeon to look inside the abdomen to make a clear diagnosis in cases in which the diagnosis of appendicitis is in doubt.

If the appendix is not ruptured (perforated) at the time of surgery, the patient generally is sent home from the hospital after surgery in one or two days. Patients whose appendix has perforated are sicker than patients without perforation, and their hospital stay often is prolonged (four to seven days), particularly if peritonitis has occurred. Intravenous antibiotics are given in the hospital to fight infection and assist in resolving any abscess.

Nursing diagnosis 1.Acute pain and discomfort related to surgical incision. Objective : To reduce and minimize surgical pain at wound site. Nursing Intervention 1. Asses level of pain using pain scale ( 0 - 10 ) ) 0- no pain, 10- maximum pain so thatnurses would be able to take precise action to prevent furthur 2. pain and complication 3. Asses and plan nursing intervention to minimize disturbance towards patient. 4. Observe patients pain though facial exprssion,conciousness and sweating so that nurses will be able take immediate action to reduce pain.

5. Monitor vital esepecialy high BP ( 140/90 above ) , increased pulse rate ( above 100 bpm ) and respiratori ( above 24 breath per min ) so that nurses will be able to take imediate action once detecting early abnormalities such as above abnormalities that indicate increase pain on patient. 6. Teach patient to take shallow breaths and deep breathing excersice to prevent pain. 7. Serve patient analgesic medication such as IM Pethedine 50mg to reduce pain. 8.Teach patient to use pillow to press on wound site while coughing to reduce pain and wound gapping. Place patient in supine position in order patient to rest fully and to avoid turning and moving so to minimize patients pain. 9. Keep room tempreture cool and well venitilated so that patient will be able to rest comfortabel. 10.Place call bell and patient nessesery items at cardiac table beside him and within reach so that patient won't use extra strenght that will increase pain on wound site. Evaluation : Patient had minimum pain 2.Potential infection related to surgical incision. Objective : To prevent infection towards patient. Nursing Intervention 1.Asses patients wound sitse for abnormalities such asbleeding,swelling,increased pain and swelling as theseindicates early infection and nurses will beable to takeaction to prevent further complications. 2.Monitor vital signs BP ( 120/80 mmHg - 140/90mmHg ), pulse rate ( 60 - 100 bpm), respiratory rate( 18 - 24 breath per min ) and especialytempreture( 36.6c - 37.5c ) as fever indicates infection,so thatnurses can report abnormalities to doctor. 3. Ensure dressing is always dry,clean and intact to avoid infection as dirty dressing enviroment attracts bacteria. 4.Wash hands using effective hand washing before andafter nursing patient and before doing dressing tominimize contamination to wound site. 5.Maintain aseptic technique while doing dressing to prevent cross contamination. 6.Serve patient well balanced diet especialy high inprotein and Vitamin C as protien helps in producingnew cells for wound healing while Vitamin C helps inbuilding patients immune system to fight againts anybacteria. 7.Advice patient to drink sufficiant water ( at least 2.5 Lper day ) to keep patient hydrated and maintain body'swell being. Evalutation : Patient did not had any infection on surgical incision