Acute appendicitis

A Case Study

INTRODUCTION

According to studies, approximately 1 in every 400 or 0.25% or 680,000 people in USA have appendicitis. It occurs more frequently in men than in women, with a male-to-female ratio of 1.7:1. Appendicitis can affect any age but is more common before 40 years of age, particularly in young people between 8 and 14 years. Appendicitis is the inflammation of vermiform appendix. When the opening of the appendix blocked the mucosa, the pressure increases and blood flow to stops. The causative agents include foreign bodies, trauma, intestinal worms, lymphadenitis, and, most commonly, calcified fecal deposits known as appendicoliths or fecaliths. Once this obstruction occurs, the appendix subsequently becomes filled with mucus and swells, increasing pressures within the lumen and the walls of the appendix, resulting in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. The appendix becomes ischemic and necrotic. As bacteria begin to leak out through the dying walls, pus forms within and around the appendix (suppuration). The end result of this cascade is appendiceal rupture (a 'burst appendix') causing peritonitis, which may lead to septicemia and eventually death. Risk factors that would predispose a person to this pathology include age from 10-20 years old, gender of male, low fiber diet with rich in refined carbohydrates, hereditary history and other infections. Pain first, vomiting next and fever last has been described as the classic presentation of acute appendicitis. Other symptoms that suggest appendicitis are rebound tenderness, rovsing s sign, psoas sign, obturator sign, dunphy s sign, kocher s sign, Bartomier-Michelson's sign, Aure-Rozanova's sign, and Blumberg sign. When the doctor diagnoses appendicitis on the patient, they rely on the results of laboratories such as complete blood count which shows an increase in the number of white blood cells, abdominal x-ray, ultrasound or CT scan, and urinalysis to rule-out pregnancy in appendicitis. Actually, there is no definitive test for appendicitis; these laboratories are just suggestive for this disease. Usually the signs and symptoms that it presents are similar to the signs and symptoms of ectopic pregnancy in women, the reason why ruling out for pregnancy in potential female clients are important before diagnosing this disease. Medical interventions include the correction or prevention fluid and electrolyte imbalance, dehydration, and sepsis, antibiotics until surgery is performed. Appendectomy is performed as soon as possible to decrease the risk for perforation which may be performed with general or spinal anesthesia. Nursing goals include relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating infection due to potential or actual disruption of GI tract, maintaining skin integrity and attaining optimal nutrition. The nurse prepares the patient for surgery, which includes IV infusion to replace fluid loss and promote adequate renal function and antibiotic therapy to prevent infection. After surgery, nurse places the patient in a high-fowler s position to reduce the tension on the incision and abdominal organs, helping to reduce pain. An opioid, usually morphine sulfate is prescribed by the doctor to relieve pain.

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Acute appendicitis
A Case Study

Discharge teaching for the patient and family is imperative. The nurse instructs the patient to make an appointment to have the surgeon remove the sutures between fifth and seventh days after surgery. Incision care and guidelines are discussed; normal activity can usually be resumed within 2 to 4 weeks. If there is a possibility of peritonitis, a drain is left in place at the area of incision. Moreover, discussion for the prevention of appendicitis such as increase fluid intake, and high fiber diet should also be discussed to avoid a repeat of the incidence to the other family members.

OBJECTIVES

GENERAL: To formulate a case study under Dorothea Orem s Self Care Deficit Nursing Theory about acute appendicitis employing the theoretical foundation we acquire at school while developing our own strategy as part of skill-building, taking note of the right approach and manner towards the patient and his/her relatives of this pathology. To render efficient and effective nursing interventions towards the achievement of holistic development of the patient as well as the student nurses.

SPECIFIC:  To synthesize a framework of knowledge depending on clinical experience, to be able to delineate the theoretical and clinical wisdom about the disease.  To be able to organize priorities depending on the actual problem while having in mind the potential and risk problems for prevention.  To formulate the appropriate attitude in patients with acute appendicitis with the 6C s of nursing.  To inform the patient as well as the relatives on the prevention of the disease to prevent reoccurrence to other family members with evidence-based and proven healthteachings.  To document a particular incident of acute appendicitis and enlighten the community and prevent future morbidity.  To evaluate the present trend in caring for patients with acute appendicitis through experience and conclude possible addendums to the practices recognized in the books.

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Acute appendicitis
A Case Study

NURSING HEALTH HISTORY

Demographic Profile This is a case of R.Z., 10 year-old female, born on May 12, 2001, a Roman Catholic residing at Marilao, Bulacan. R.Z. is at her 3rd grade of elementary; her father who is a tricycle driver is the source of their medical expenses. Admitted for the first time at Bulacan Medical Center, Female Surgery Ward on January 10, 2012 with an admitting diagnosis of Acute Appendicitis and endorsed for appendectomy.

Chief Complaint Aray! ansakit ng tiyan ko. , as verbalized by the patient.

History of Present Health Concern 4 days prior to admission patient had fever with noted loss of appetite. In response, TSB was rendered but does not take OTC drugs for fever. 3 days prior to admission, patient experienced right lower quadrant abdominal pain associated with nausea, still with fever and loss of appetite. Few hours prior to admission, R.Z. experienced severe abdominal pain with 1 episode of greenish vomitus; thus brought to Local Health Center, then to Bulacan Medical Center Emergency Department and admitted with a stat AP status.

Past Health History Patient had no history of previous hospitalizations. With no known allergies and history of previous illness. R.A. had BCG, 3 Hepa B, 3 OPV and 1 measles vaccine.

Family Health History R.A. was 6th among the 11 siblings of her parents. Her mother has asthma, had a history of Appendicitis and undergone appendectomy when she was 19 years old. On the other side, her father had a history of Pulmonary Tuberculosis which is also the cause of death of her grandfather. Her elder brother, 18 years old and the 2nd sibling, also has asthma. Her 8th sister, 6 years of age had a history of dehydration. Moreover, her 10th brother which is 2 years old has developmental problem. All the other siblings are healthy and active as verbalized by the mother.

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Acute appendicitis
A Case Study

GENOGRAM

72 y/o

55 y/o

42 y/o 45 y/o

39 y/o with history of appendicitis

19 y/o

18 y/o

15 y/o

14 y/o

12 y/o

R.Z. 10 y/o

8 y/o

6 y/o

3 y/o

2 y/o

1 y/o

Legends: Female Male Patient

with asthma

with Tuberculosis

dead due to stab wound

Dead

with Kidney Disease

with Developmental Problem

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Acute appendicitis
A Case Study

Environmental History The patient together with her family lives in a concrete house with 1 door and 1 window. The space is just enough for their number but there is no proper lighting and ventilation due to lack of electricity for over 1 year. The source of water is nawasa in which they use it for bathing, washing and drinking.

Developmental History

Theory and Theorist

Psychoanalytic Theory Sigmund Freud Latent Stage: Child s personality development appears to be nonactive or dormant. Sexual drive is repressed and normal homosexual. Goal-oriented and want to prove their best in school or in games. Psychosocial Theory Erik Erickson Developmental task is to form a sense of industry versus inferiority. Child learns to do things well. Cognitive Theory Jean Piaget Concrete Operational Thought.

Evidences
R.Z. has a lot of female friends, actually when she was hospitalized all of them provide moral support to their friend. She does not want to go to school at times rather wants to play jumping rope and ten-twenty. According to her mother R.Z. often initiates sweeping the floor and washing the dishes. She maintains the cleanliness of their house whenever she does not study ad play. R.Z. is in her 3rd grade of elementary; she can answer simple mathematical equations, can read, write, classify and sort objects accordingly.

Moral Development Theory Lawrence Kohlberg Conventional Level II. Client maintains social order, fixed rules. Follows rule of authority figures as well as parents in an effort to keep system working.

R.Z. as the 6th child among the 11 children also maintains orderliness with their relationship with one another. Whenever her siblings fight, she is the one who goes in between and stops it. She gives lesson to her younger siblings.

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Acute appendicitis
A Case Study

GORDON S FUNCTIONAL HEALTH PATTERNS

FUNCTIONAL HEALTH PATTERN

DURING HOSPITALIZATION

PRIOR TO HOSPITALIZATION

Health Perception and health management

Due to the healthcare workers advice they have learned the importance of hydration together with proper diet. They believed that with the right obedience to the doctors and nurses orders, recovery will become faster and possible. When the patient is in pain, they render therapeutic touch, and help the R.Z. to have her position of comfort.

The family believes that the key for a healthy life depends on the foods one eats such as fruits, vegetables and some meat. However, they are not informed that plenty of water should also be included in the diet. Additionally, rest and exercise would also help. Whenever sick, they go first to the health center. However sometimes, because of the elders influence, they sometimes refer to faith healers and manghihilots , plus the reason of lack of money. They only go to the hospital when there is no choice. But still, they believe more in medical interventions rather than superstitions. According to R.Z s mother, she preferably eats fatty foods, junk foods, and guava fruit as her breakfast. During lunch, she consumes 2-3 small cups of rice plus vegetable, meat or fish. Her mother prepares her food. She sometimes forgets to drink water, rather take coffee more often. R.A. does not drink milk and does not take any vitamin. 4 days PTA, patient had loss of appetite and only takes small amount of food. January 7, 2010 Breakfast 1 cup of coffee approximately 240 mL

Nutritional and Metabolic Pattern

The patient is under NPO from January 10-13, 2012. January 16, 2012, patient is in General Liquid diet January 17, 2012, patient is in Soft Diet January 18, 2012, patient is in DAT

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Acute appendicitis
A Case Study

Lunch 1 cup of rice Half of tilapia fish Half glass of water approximately 50 mL Dinner Half cup of rice Half of tilapia fish Half glass of water approximately 50 mL January 8, 2012 Breakfast 1 piece of pandesal 1 cup of coffee approximately 240 mL Lunch 1 pack of noodles 1 pandesal 1 Half glass of water approximately 50 mL Dinner 1 bowl of porraige Half glass of water, 50 mL January 9, 2012 Breakfast 1 cup of coffee Lunch 1 bowl of porraige Small sips of water Dinner
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Acute appendicitis
A Case Study

Half bowl of porraige Small sips of water

Color

Frequency Consistency Odor Difficulty 2 3-5 7 Semi Solid Clear Clear Foul None Little None Stool Urine Vomit

Color Greenish Dark Yellow Greenish

Frequency 1 3-5 1

Consistency Semi Solid Clear

Odor Foul

Difficulty None None None

Elimination Pattern

Stool Urine

greenish

Dark yellow Orange/ Vomit Yellow Green

Pre-operatively, she tries to sleep whenever she has the time. She just focuses on herself and talks a little to her mother when Activity-Exercise she feels pain. Postoperatively, as advised, she sometimes takes a walk, and Pattern sits. She speaks more often than before and play with her mother s cellphone or conversing with her sisters through mobile call. Feeding Bathing Bed Mobility Dressing
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R.Z. usually wakes up ay 7:00-8:00 am, wherein the first thing she will do after waking up is to have her hygiene then even without breakfast, she will go outside and play with her friends. She goes to school from 12 noon to 6pm. Then again proceed outside and play. She takes her dinner with the family at 7:30 pm. She sleeps at 9:00pm.

Functional Ability

NPO 2 0 2

Feeding Bathing Bed Mobility Dressing

0 0 0 0

Acute appendicitis
A Case Study

Grooming Toileting

0 2

Grooming Toileting

0 0

LEGEND: LEGEND: y 0 Full Self Care y 0 Full Self Care y 1 Requires use of equipment y 1 Requires use of equipment y 2 Requires assistance or supervision from another y 2 Requires assistance or supervision from another person. person. y 3 Requires assistance or supervision from another device. y 3 Requires assistance or supervision from another y 4 dependent or does not appreciate device. As a 10 year old girl, she can perform things with herself, without the y 4 dependent or does not appreciate presence of illness. She is highly active and often plays most of her time. Pre-operatively and Post-operatively, due to the pain at her abdomen/incision site plus the IVF hooked at her, she cannot dress and bath alone and perform toileting. Her mother assists her. Preoperatively, patient sleeps only for a short period of time due to the pain she feels. She usually get awaken with severe pain R.Z. sleeps 10-12 hours at night and does not take her afternoon nap. She and cannot continue her sleep. spends most of her time playing with the other children outside their Postoperatively, she can sleep for long periods. Usually 8-10 house. hours at night and take her nap 1-3hours in the afternoon. Preoperatively, due to the pain she feels, she is self-focusing and does not communicate well. Postoperatively, she s coherent and active. Since she s hospitalized, she cannot perform the usual things and tasks she is doing at home. She is self-focusing and does not mind her environment even the people in it.
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Sleep and Rest Pattern

Cognitive and Perceptual Pattern Roles and Relationship Pattern

Currently, she is an average student at 3rd grade of elementary. No interest in doing home works and attending classes. Among the 11 siblings, she is the most devoted to cleaning their house. She was assigned to wash their dishes and sweep the floor. When with her brothers and sisters, she s just quiet and sometimes take command

Acute appendicitis
A Case Study

whenever her other siblings were quarreling. Sexuality and Reproductive Pattern Coping Stress Tolerance Values Belief Pattern R.Z. is not yet having menstruation. She experiences a little difficulty in urination. Preoperatively, when in pain, she just cries, change her position and cling her hands to her mother. Postoperatively, she just keep silent when she feels slight pain. The family was Roman Catholic. R.Z. prays at night. R.Z. is not yet having menstruation. When under stressed, she just go straightly to her mother to talk and ask for solutions. She does not make argue with other people instead just keep silent most of the time. The family was Roman Catholic. R.Z. attends Sunday masses and prays at night.

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Acute appendicitis
A Case Study

ANATOMY AND PHYSIOLOGY

The appendix is a finger-like projection from the beginning of the large bowel called the cecum. The appendix lies in the right lower portion of the abdomen. The length of the appendix may vary from one to eight inches (2 to 20 cms.) in length. The blood supply to the appendix is from the appendiceal artery a branch of the ileocolic artery, which supplies blood to the end of the small bowel and the beginning of the large bowel. The blood

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Acute appendicitis
A Case Study

supply lies in a fatty tissue called the mesoappendix.

PATHOPHYSIOLOGY

Non Modifiable Risk Factors

Genetics Age of 10 years

Modifiable Risk Factors

Diet: Low Fiber Low Fluid intake

Slowed metabolism
Opening of the appendix become blocked with a fecalith

Mucinous/thin-like jelly build up in the mucosa of the appendix

Bacteria within the appendix begin to invade (infect) the wall of the appendix

Inflammation
Build-up of pressure within the appendix Thrombosis and occlusion of the small vessels, and stasis of lymphatic flow

Appendix becomes rotten and its wall dies

Right Lower Quadrant Pain anorexia

fever

(+) rebound tenderness

(+) rovsing s sign

(+) Psoas sign

Nausea vomiting

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Acute appendicitis
A Case Study

PHYSICAL ASSESSMENT

VITAL SIGNS
Date: January 12, 2012 (4:00pm) 80/60 mmHg 37.9OC 98 23

Blood Pressure Temperature Pulse Rate Respiratory Rate

Area of Assessment General Appearance

Skin, Hair and Nails

Head and Neck

Eyes

Ears

Result Patient is conscious and coherent had crying episodes whenever feeling pain, with body weakness observed. Selffocusing, with guarding behavior noted and facial grimace. Looks ill and weak, flat on bed, looks slightly neat with non-smelly clothes. Patient has dry fair skin that is free from lesions, nodules and other irregularities. Patient has a good skin turgor of less than two seconds. Nails are not clean. Hair is dry, free from dandruff and lice. Scalp is white, clean, and free from masses, lumps, nits, dandruff & lesions, with no areas of tenderness. Face is symmetric and round, head and neck are also symmetric. Trachea is at midline. No swelling of lymph nodes without visible pulses. Eyes are symmetrical. Red in color without swelling and drainage. Patient has a black iris with positive pupillary constriction. Ears are symmetrical without lesions, or any irregularities. Auricle, Tragus and Mastoid
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Method Used Inspection

Significance Due to the inflammation of her appendix

Inspection and Palpation

Due to prolonged stay in the hospital

Inspection and Palpation

Normal

Inspection

Normal

Inspection

Normal

Acute appendicitis
A Case Study

Nose

Mouth

Thorax Heart Abdomen

Process are non-tender with no swelling of pre-auricular and post-auricular lymph nodes. Color is the same as the rest of the face. Nasal septum is intact without lesions, swellings, drainage or any irregularities. Lips are pale and dry without lesions and swellings. Tongue is in midline. Skin is intact. Patient has clear lung sounds. No visible pulsations, without heart murmurs. Abdomen is flat; color is paler than the rest of the body, nontender with no enlargement of the underlying organs. With positive rebound tenderness, positive Rovsing s and Psoas sign. Patient felt pain even without palpation on RLQ of the abdomen. Shoulders, arms, elbows, hands & wrists can be moved in different range of motion without relative ease and marks of petechial rashes on both arms. Palms are pinkish, warm, soft & elastic legs, knees, ankles, & toes can be moved in different range of motion with relative ease. With slow and weak pulse.

Inspection

Normal

Inspection

Due to NPO status Normal Normal Due to the inflammation of appendix

Inspection and Auscultation Inspection and Auscultation Inspection and Palpation

Peripheral Vascular (Upper and Lower Extremeties)

Inspection and Palpation

Normal

VITAL SIGNS
Date: January 18, 2012 (4:00pm) 80/60 mmHg 37.4oC 103 27

Blood Pressure Temperature Pulse Rate Respiratory Rate

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Acute appendicitis
A Case Study

Area of Assessment General Appearance

Skin, Hair and Nails

Head and Neck

Eyes

Ears

Nose

Mouth Thorax Heart Abdomen

Result Patient is conscious, coherent and active. Patient is flat on bed, looks slightly neat with non-smelly clothes. Patient has dry fair skin that is free from lesions, nodules and other irregularities. Patient has a good skin turgor of less than two seconds. Nails are not clean. Hair is dry, free from dandruff and lice. Scalp is white, clean, and free from masses, lumps, nits, dandruff & lesions, with no areas of tenderness. Face is symmetric and round, head and neck are also symmetric. Trachea is at midline. No swelling of lymph nodes without visible pulses. Eyes are symmetrical. Red in color without swelling and drainage. Patient has a black iris with positive pupillary constriction. Ears are symmetrical without lesions, or any irregularities. Auricle, Tragus and Mastoid Process are non-tender with no swelling of pre-auricular and post-auricular lymph nodes. Color is the same as the rest of the face. Nasal septum is intact without lesions, swellings, drainage or any irregularities. Lips without lesions and swellings. Tongue is in midline. Skin is intact. Patient has clear lung sounds. No visible pulsations, without heart murmurs. Abdomen is flat; color is paler than the rest of the body, nonPage 15

Method Used Inspection

Significance None

Inspection and Palpation

Due to prolonged stay in the hospital

Inspection and Palpation

Normal

Inspection

Normal

Inspection

Normal

Inspection

Normal

Inspection Inspection and Auscultation Inspection and Auscultation Inspection and Palpation

Normal Normal Normal

Acute appendicitis
A Case Study

tender with no enlargement of the underlying organs. With incision on lower midline part of the abdomen, with dry and intact dressing. Peripheral Vascular (Upper and Lower Extremeties) Shoulders, arms, elbows, hands & wrists can be moved in different range of motion without relative ease and marks of petechial rashes on both arms. Palms are pinkish, warm, soft & elastic legs, knees, ankles, & toes can be moved in different range of motion with relative ease. With slow and weak pulse. Inspection and Palpation

Due to the operation done.

Normal

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Acute appendicitis
A Case Study

COURSE IN THE WARD

R.Z. was brought into the female surgery ward on January 10, 2012 with an IVF of D50.3NaCl 500cc at full level regulated at 40 gtss/minute infusing well on left arm. Patient is conscious but weak, complains of pain at RLQ part of the abdomen. Patient s BP was 80/60 thus 360 of PNSS was pushed TIV at 4:15 pm, as ordered. Patient s lips are dry, therefore instructed to moisturize the lips with small amount of water. R.Z. is under NPO, for stat appendectomy, still for referral for AOD for O.R. meds, with CXR result and Na, K, Creatinine results secured and attached to chart. K level is 3.02 mmol/L (Normal Value: 3.5-5.3 mmol/L). Prescribed medications of Cefuroxime 500 mg TIV q8h, Metronidazole 500mg TIV q8h and Ranitidine 25 mg TIV q8h are all given. Patient was encouraged to do deep breathing exercises, and informed about proper wound care and positioning after the surgery. On January 11, 2012 the doctor ordered K correction of PLR plus 15mEq of KCl @ 41 mgtss/minute for 2 doses; thus hooked by the NOD for the 1st dose and 2nd dose is given at 7:40 pm. Patient is still for PPD, as ordered. January 12, 2012, Dr. Crisostomo ordered IVF of D5LR 1L to run for 18 gtts/minute for 2 doses then repeat serum Na and K after correction. At 4:30 pm 1st dose of D5LR was given. R.Z already has CP clearance, OR meds are secured with the doctor s order of may proceed at the contemplated procedure . Moreover, Cefuroxime of 500 mg is modified to 750 mg TIV q8h and Ranitidine 25mg was also modified to 20mg TIV q8h, as ordered; given with Metronidazole still at 500mg TIV q8h. On January 13, 2012 patient had undergone appendectomy. January 16, 2012 doctor ordered to start with FeSo4 once started with DAT, but the patient is on General Liquid diet, as ordered. Patient is received awake on bed with ongoing IVF of D50.3NaCl 500cc at 150cc level regulated at 15 gtss/minute, infusing well on Left hand. Patient has dressing on the lower midline part of the abdomen, dry and intact. R.Z. is still on PPD as ordered, for repeat serum Na and K after 3rd dose of D50.3NaCl is given with request. VS monitoring is q4h as ordered and I and O monitoring of q shift, as ordered. At 8:00 above IVF of D50.3NaCl was consumed and replaces with the same IVF regulated at 20 gtss/minute, infusing well on Left hand. On January 17, 2012 doctor advised R.Z to have soft diet, to ambulate and do deep breathing exercises carried out right after the time ordered. January 18, 2012 patient is under DAT diet, as ordered. Medications of Cefuroxime 750mg TIV q8h is modified to Cefuroxime 250 mg/5ml TID, as well as Metronidazole of 125mg/5ml, added with Mefenamic acid 20mg/5ml TID, as ordered. T/C IVF of D50.3NaCl at 15 gtss/minute. IVF was removed at 9:30 pm.

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Acute appendicitis
A Case Study

LABORATORY FINDINGS

HEMATOLOGY
January 9, 2012 Normal Values 5-10 17-48 4-10 43-76 3.8-5.8 110-165 0.35-0.5 80-97 26.5-35.5 315-350 10.0-15.0 15-390 6.5-11 0.100-0.500 10-18

WBC LYM MON GRA RBC HGB HCT MCV MCH MCHC RDW PLT MOV PCT PDW

18.6 10.1 3.7 86.2 4.02 109 0.338 84 27.1 322 12.6 465 6.2 0.289 12.7

H 10.1 L % L % H % 2 10 /l L g/l L l/l fl pg g/l % H 109/L L fl 2 10 /l %

January 14, 2012 109/l 1012/l g/l l/l 9 10 /l -2 10 l/l Normal Values 5-10 4.5-5.5 120-170 0.350-0.500 150-400 0.100-0.500 Normal Values 80-97 26.5-33.5 315-350 10.0-15.0 6.5-11.0 10.0-18.0

WBC RBC HGB HCT PLT PCT

12.0 3.23 90 0.273 423 0.286

H L L L H

MCV MCH MCHC RDW MPV PDW

84 fl 27.8 pg 329 g/l 13.6 % 6.8 fl 11.4 %

This increase of the WBC components as well as the platelets can be attributed to the inflammatory process happening in R.Z. The body is trying to combat the bacterial invasion occurring at the appendicitis as it invades the appendix. Moreover, since the appendix, as time goes on is being destructed, platelets are also compensating, trying to heal the progreesively deteriorating vernifrom appendix.

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Acute appendicitis
A Case Study

ELECTROLYTES
January 10, 2012 Normal Values 135-148 3.5-5.3 1.1-1.32 mmol/L 96-107 mmol/L

Na K Ca Cl

129.2 mmol/L 3.02 mmol/L -

January 12, 2012 Normal Values 135-148 3.5-5.3 1.1-1.32 mmol/L 96-107 mmol/L

Na K Ca Cl

128.8 mmol/L 4.14 mmol/L 95.7 mmol/L

January 12, 2012 Interpretation LOW Normal Value 44.20-150.28 umo/L

Creatinine

43.95 umo/L

January 14, 2012 Normal Values 135-148 3.5-5.3 1.1-1.32 mmol/L 96-107 mmol/L

Na K Ca Cl

129.3 mmol/L 4.30 mmol/L -

January 16, 2012 Normal Values 135-148 3.5-5.3 1.1-1.32 mmol/L 96-107 mmol/L

Na K Ca Cl

134.9 mmol/L 3.77 mmol/L -

These decline in the levels of electrolytes particularly Na and K can be directed to the patient s loss of appetite prior to hospitalization as well as her NPO status prior to surgery.

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Acute appendicitis
A Case Study

URINALYSIS
color: yellow Physical Examination Transparency urobilinogen: Normal glucose: bilirubin: ketone: specific gravity: 1.020 Microscopic Examination RBC: 0-2 hpf crystals: amorphous urates: few epithelial cell: few bacteria: few blood: pH: 5.0 protein: nitrite: leukocytes:

WBC: 30-40/hpf

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Acute appendicitis
A Case Study

OPERATIVE PROCEDURE AND ANESTHESIA USED

An appendectomy (sometimes called appendisectomy or appendicectomy) is the surgical removal of the vermiform appendix. This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or avoid the onset of sepsis. It may be performed laparoscopically or as an open operation. During operation, patient is in supine, with arms extended on armboards. Spinal Anesthesia is an extensive conduction nerve block that is produced when a local anesthetic is introduced to the subarachnoid space at the lumber level, usually between L4 and L5. It produces anesthesia of the lower extremities, perineum, and lower abdomen. For the lumbar puncture procedure, the patient usually lies on the side in a knee-chest position. Sterile technique is used as a spinal puncture is made and the medication is injected through the needle. A few minutes after induction of a spinal anesthetic, anesthesia and paralysis affect the toes and perineum and then gradually the legs and abdomen. If the anesthetic reaches the upper thoracic and cervical spinal cord in high concentrations, a temporary partial or complete respiratory paralysis results. Paralysis of the respiratory muscles is managed by mechanical ventilation until the effects of the anesthetic on the cranial and thoracic nerves have worn-off. Most appendicitis patients recover easily with surgical treatment, but complications can occur if treatment is delayed or if peritonitis occurs. Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around 10 years old), the recovery takes three weeks. The real possibility of life-threatening peritonitis is the reason why acute appendicitis warrants speedy evaluation and treatment. The patient may have to undergo a medical evacuation. PostOperative Care in unruptured appendix includes putting the patient on a liquid diet progressing to a soft and then regular diet. Additional antibiotics are also given to prevent wound infection. Often the patient can leave the hospital in 1-2 days after the surgery. However if there is ruptured appendix, the hospital stay is usually at least 4 days and possibly longer. If there was spilling of bacteria from the appendix, recurrent abdominal abscesses and infections may occur. The patient is then be started on a liquid diet which is advanced to a regular diet as tolerated. Moreover, a drain is placed in the region of the appendix to allow bacteria to drain out and the skin is left open and packed with gauze. The gauze and drain are removed when the infection is cleared. Antibiotics are continued for approximately one week after the surgery. Initially this will be through a vein while in the hospital and then typically by pill after being sent home.

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Acute appendicitis
A Case Study

ASSESSMENT

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION
Patient s condition improved

S: Ansakit , as verbalized - short-term goal  Facilitate the provision of calm  To prevent worsening by the client and quiet environment. of the condition and - partially compensatory reduce stress level. O:  Facilitate on the provision of - with guarding - After 15 minutes of non-pharmacologic  To provide comfort nursing interventions behavior noted interventions such as: - with facial grimace patient will report a pain y Back rubbing scale from 8/10 to 3-4/10. noted y Change of position - pain scale of 8/10 - crying episodes  Facilitate on encouraging the  To promote wellness - self-focusing and prevent fatigue. patient to have adequate rest periods.  Facilitate on teaching the  To teach the client way to control pain. client about deep-breathing exercises.  Facilitate on encouraging the  To assist the client to explore methods for patient the use of diversionary alleviation of pain and activities such as socialization redirect her attention. or chatting.

NURSING DIAGNOSIS

Acute Pain related to inflammation of the appendix

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Acute appendicitis
A Case Study

ASSESSMENT

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION
Patient s condition improved

S: Natatakot kasi siya - short-term goal  Facilitate on providing comfort  To provide nonpag nadidinig niya yung measures such as: pharmacologic salitang opera , as - partially compensatory interventions. y Warm bath verbalized by the client s y Back Rubbing mother. - After 1h of nursing interventions, patient will  Facilitate on establishing  To assist patient to O: be able to demonstrate identify feelings and therapeutic relationship, begin to deal with - with guarding ways to handle anxiety. conveying empathy and problems. behavior noted unconditional positive regard - Crying with the client. - Self focusing  Facilitate on acknowledging  To help the patient cope with pending the anxiety. Do not deny or problems. reassure patient that NURSING everything will be alright. DIAGNOSIS promote  Facilitate on being available to  To therapeutic the patient for listening and relationship with the talking. client.  Facilitate on accepting the  To provide emotional lift to the client. patient as she is.

Anxiety related to preoperative status

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Acute appendicitis
A Case Study

ASSESSMENT
S: Hindi siya nakakakain simula ng sumakit ang tiyan niya, bawal pa din siyang kumain ngayon sabi ng doktor , as verbalized by the patient s mother O: - NPO - Dry mouth - Pale conjunctiva - Weakness - Weight: 18 kg - Serum potassium: 128.8 (Normal: 13518 mmol/L)

PLANNING
- short-term goal

INTERVENTIONS

RATIONALE

EVALUATION
Risk for imbalanced nutrition less than body requirements prevented.

 Facilitate on stressing the  - partially compensatory importance of well-balanced nutritious intake after the - After 1 hour of nursing surgery, when allowed. interventions, patient s mother will be able to  Facilitate on identifying with  verbalize ways how to the mother foods that a prevent nutritional healthy person should eat. imbalances.  Facilitate on teaching the mother on the possible  sources of free vitamins and health care facility.

To promote wellness.

To promote wellness and provide long-term solution to the problem. To promote independence in promoting wellness.

NURSING DIAGNOSIS

 Depend on the administration of potassium chloride  To increase serum incorporated in PLR1L, as potassium level. ordered by the physician.

Risk for imbalanced nutrition less than body requirement related to NPO status
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Acute appendicitis
A Case Study

ASSESSMENT
O: -

PLANNING
- short-term goal

INTERVENTIONS

RATIONALE

EVALUATION
Risk for infection prevented

Incision on lower  Facilitate on proper hand  To reduce risk for crossmidline part of the - supportive educative washing techniques. contamination of abdomen; with microorganisms. dressing - After 15 minutes of  Facilitate on monitoring  To reduce risk for crossnursing interventions, visitors. contamination of patient together with her microorganisms. mother will demonstrate  Facilitate on encouraging the  To promote wound healing. technique to prevent risk patient to have adequate NURSING for infection/ hydration. DIAGNOSIS  To promote hygiene.  Focus on changing dressings as needed.  To reduce existing risk factors Risk for infection  Depend on cleansing incision for infection. daily with povidone iodine, as related to the ordered. interference of  Interfering with bacterial cell body defense  Depend on administering wall synthesis thereby altering Cefuroxime 5ml TID p.o., as the osmotic stability of the secondary to ordered. actively growing bacterial cell surgery and resulting in its death.  A direct-acting trichomonacide and amebicide that works at  Depend on administering both intestinal and Metronidazole 125mg/5ml, extraintestinal sites. 10ml TID, as ordered.

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Acute appendicitis
A Case Study

Generic Name

Mechanism of Action

Indications

Contraindications

Side Effects

Nursing Considerations

RANITIDINE

Brand Name

Inhibits the action of  Preoperative histamine at the patients under histamine-sensitive H2 NPO receptor sites of the parietal cells in the stomach; thus contraindicates acidity.

Contraindicated patients hypersensitive drug.

to CNS: headache, malaise,  10 drug administration rights. dizziness to  Use cautiously in hepatic CV: bradycardia dysfunction. GI: nausea constipation Skin: rash Local: Burning and itching sensations at injection site. and  Avoid administration of antacids at the same time as ranitidine.

Zantac

 Avoid foods and factors that may

increase gastric acid secretion.

Classification

H2 receptor antagonist
Dosage

25 mg TIV q 8h

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Acute appendicitis
A Case Study

Generic Name

Mechanism of Action

Indications

Contraindications

Side Effects

Nursing Considerations

CEFUROXIME SODIUM
Brand Name

Zinacef

Interfering with  Prophylaxis for bacterial cell wall preoperative synthesis thereby patients. altering the osmotic stability of the actively growing bacterial cell and resulting in its death.

Contraindicated to patients hypersensitive to drug.

CNS: headache, malaise, paresthesia, and dizziness GI: nausea and constipation, nausea, anorexia, vomiting, diarrhea, and abdominal cramps. Skin: erythematous rashes, urticaria Local: at injection sitepain, temperature elevation, phlebitis and thrombophlebitis with I.V. injection.

 10 drug administration rights.  Contraindicated hypersensitivity cephalosporins. in other

to

 Use cautiously in patients with renal impairment.  With large doses or prolonged therapy, monitor for superinfection, especially in highrisk patients.

Classification

Cephalosporin

Dosage
Other: hypersensitivity and dyspnea

250 mg/5ml, 5ml p.o. TID

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Acute appendicitis
A Case Study

Generic Name

Mechanism of Action

Indications

Contraindications

Side Effects

Nursing Considerations

METRONIDAZOLE

Brand Name

Flagyl

A direct-acting  Prevention of trichomonacide and postoperative amebicide that works infection in at both intestinal and contaminated extraintestinal sites. or potentially contaminated colorectal surgery.

Contraindicated to patients hypersensitive to drug.

CNS: vertigo, headache,  10 drug administration rights. confusion, irritability, depression, restlessness,  The I.V. form should be weakness, fatigue, administered by slow infusion drowsiness, insomnia. only. Don t give I.V. push. GI: cramping, nausea, vomiting, anorexia, diarrhea, dry mouth Skin: pruritus, flushing

 Don t refrigerate Flagyl I.V. RTU.  Flagyl I.V. RTU may cause
sodium retention.

Classification

GU: darkened urine Local: thrombophlebitis after I.V. infusion

 Observe carefully for edema.  Drug may cause darkening of the

urine.

Antiparasitic

 Monitor client for development

of neurological symptoms.

Dosage

125mg/5ml, 10ml TID

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Acute appendicitis
A Case Study

Generic Name

Mechanism of Action

Indications

Contraindications

Side Effects

Nursing Considerations

POTASSIUM CHLORIDE
Brand Name

Replaces and maintans  Hypokalemia potassium level.

CNS: paresthesias of the  10 drug administration rights. extremities, mental confusion, weakness or  Contraindicated in severe renal heaviness of limbs, impairment. flaccid paralysis. CV: peripheral vascular collapse with fall in blood pressure, cardiac arrhythmias, heart block, possible cardiac  arrest GI: nausea, vomiting, abdominal pain, diarrhea, GI ulcerations GU: oliguria

 Potassium should not be given

during immediate postoperative period until urine flow is established. Parenteral potassium is given by infusion only; never I.V. push or I.M.

Classification

Electrolyte

Dosage

Skin: cold skin, gray pallor Local: phlebitis postinfusuion

15 mEq incorporated in PLR 1L

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Acute appendicitis
A Case Study

Generic Name

Mechanism of Action

Indications

Contraindications

Side Effects

Nursing Considerations

KETOROLAC TROMETHAMINE
Brand Name

An NSAID that acts by  Short-term inhibiting the synthesis management of prostaglandins of pain

Contraindicated patients hypersensitive drug

to CNS: dizziness, to sweating CV: edema

drowsiness  10 drug administration rights. headache,  Use caution with patient who has hepatic or renal impairments.

Toradol
Classification

GI: nausea, dyspepsia, GI  This drug is inetended only for pain, diarrhea short term management of pain. The rate and severity of adverse Local: pain in the reactions should be less than injection site that observed in patients taking NSAIDS on a chronic basis.

NSAID

Dosage

10 mg TIV q6h x 4 doses

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Acute appendicitis
A Case Study

HEALTH TEACHINGS

M E T H O D S

 Instruct the mother to comply with the medication regime.  Provide clear, simple, and understandable explanation on each medication s name, indication, patient-appropriate dose, side, and adverse effects.  Reinforce to mother/caregiver that administering medications without doctor s prescription would result to serious complications; explain that when the patient manifests adverse effects or requires medication, it is best to seek professional help immediately.  Reiterate the importance of a clean environment where food and drinking water is handled/prepared or stored.  Instruct mother to always keep the toilet facilities clean/sanitary.  Instruct the mother to maintain clean environment to prevent post-opeartive infection and complication.

 Explain to mother the importance of hydration maintenance.  Provide clear, simple and understandable factual information to the family members regarding the disease process and the importance of operation.

 Emphasize the importance of proper hygiene such as bathing, meticulous hand washing and oral hygiene in the prevention of the complications other diseases.  Reinforce the need for sanitary food handling and water handling processes.  Instructed to have oral hygiene.

 Emphasized the need for regular check up and wellness checkups.  Instruct mother on how to recognize and when and where to report unusual signs and symptoms that could signal complication.

 Emphasize the need for a well balanced diet and initially a high calorie, high protein, high carbohydrate diet to hasten recovery from the disease effects.  Reiterate the importance of HIGH FIBER DIET to prevent recurrence of appendicitis to other members of the family.  Reinforce the need and importance of regular multivitamins to prevent recurrence of the disease.  Instruct the mother to increase the patient s fluid intake with clean fluids to hasten recovery from the effects of the disease.  Assure that the patient will already have her breakfast together with the whole family as much as possible.  Instruct the mother to encourage her children to take a 5-15 minute rest after eating.

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Acute appendicitis
A Case Study

EVALUATION

At the end the case study, the student was able to employ Dorothea Orem s Self Care Deficit Nursing Theory through rendering efficient, accurate, and effective nursing interventions that is based on the theories acquired. Framework of skills and priorities towards handling patient with acute appendicitis were also established. Holistic development was promoted through applying the 6C s of Nursing. Moreover, evidence-based and proven health teachings are rendered amplifying the nursing care and promote R.Z s well being. A case study was formulated and will be documented for the purpose of informing its readers and enlightening them with the current clinical experiences. Although the student nurse was not able to update the present trend in caring with the patients of this pathology, the student nurse come up with a deeper understanding and will continue to study for possible contributions and updates in the future.

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