APPENDECTOMY

APPENDICITIS
 APPENDICITIS
• Appendicitis is the inflammation of the vermiform appendix and
was first described as a pathologic condition by American physician
Reginald Fits in 1886.
• Appendicitis is most commonly caused by the obstruction of the
appendix caused by a “fecalith”, which is a hard stony mass of feces
that finds its way into the lumen of the appendix. Some other
causes are undigested seeds, or a pinworm infection which are
intestinal parasytes.
RUPTURE OF THE APPENDIX
• Can result to bacteria and other fluid
contents inside escaping the appendix and
get into the peritoneum, leading to
peritonitis.

• The most common

complication of a ruptured
appendix is pus and fluid
getting out and forming an
abscess around the appendix,
called the periappendiceal
abscess.
• These lead to a more diffused pain, abdominal distention that
develops as a result of paralytic ileus, and the worsening of the
patient’s condition.
• The condition is a medical emergency that requires prompt
surgery to remove the appendix, also known as an
Appendectomy, which is the surgical removal of the appendix,
along with antibiotics.
• 4 STAGES OF APPENDICITIS
• Early stage appendicitis — In the early stage of appendicitis,
obstruction of the appendiceal lumen leads to mucosal edema,
mucosal ulceration, bacterial diapedesis, appendiceal distention due
to accumulated fluid, and increasing intraluminal pressure. The
visceral afferent nerve fibers are stimulated, and the patient
perceives mild visceral periumbilical or epigastric pain, which usually
lasts four to six hours.
• Suppurative Appendicitis – is caused by the transluminal spread of
bacteria. Increasing intraluminal pressures eventually exceed
capillary perfusion pressure, which is associated with obstructed
lymphatic and venous drainage and allows bacterial and
inflammatory fluid invasion of the tense appendiceal wall. When the
inflamed serosa of the appendix comes in contact with the parietal
peritoneum, patients typically experience the classic shift of pain
from the periumbilicus to the right lower abdominal quadrant (RLQ),
• Gangrenous appendicitis — Intramural venous and arterial
thromboses occur, resulting in gangrenous appendicitis.
• Perforated appendicitis — Persistent tissue ischemia results in
appendiceal infarction and perforation. Perforation can cause
localized or generalized peritonitis.
B. ETIOLOGY
NON-MODIFIABLE FACTORS:
• Family History – A positive family history increases relative risk of
having acute appendicitis nearly 3 times
• Gender – Appendicitis 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.
• Age – Appendicitis generally affects people aged between 10 and 30,
but it can strike at any age
• Season - Studies suggests that people get appendicitis more during
the summer than other times of the year, likely due to a combination
of increased air pollution, more GI infections, and greater food
spoilage.
MODIFIABLE FACTORS:
• Diet - Research also suggests that the typical "Western diet,"
which is high in carbohydrates and low in fiber, can increase your
chances of developing appendicitis. Without enough fiber in your
diet, bowel movements slow down, increasing the risk of
appendix obstruction.
• Occlusion of fecal material - Appendicitis is usually caused by a
blockage of the inside of the appendix, which is called the lumen.
Most often, the lumen is blocked by fecal material.
• Infection with Yersinia organisms – According to Surgical
Pathology of Gastrointestinal System, Yersinia, a Gram-negative
coccobacilli, is responsible for many cases of isolated
granulomatous appendicitis
C. INCIDENCE
• The incidence of acute appendicitis is around 7% of the population in the
United States and in European countries. In Asian and African countries,
the incidence is probably lower because of the dietary habits of the
inhabitants of these geographic areas.
• Appendicitis is the most common reason for a child to need emergency
abdominal surgery and up to 75,000 appendectomies are done each year
in the U.S.
• In the Philippines, the recorded incident rate of acute appendicitis is
215,604 back in 2011 and is increased to 4% per year.
D. GENERAL SIGNS AND SYMPTOMS
Acute Appendicitis
• Abdominal pain - As the appendix becomes more swollen and inflamed, it will
irritate the lining of the abdominal wall, known as the peritoneum. This causes
localized, sharp pain in the right lower part of the abdomen.
• Point tenderness – A cardinal sign of appendicitis is point tenderness. This is a
defined area of tenderness in the right lower quadrant which is called the
Mcburney’s point.
• Rebound tenderness – This is a sign of inflammation in which pain is elicited
by the sudden release of the fingertips pressing on the right lower quadrant.
• Mild fever- The bacteria trapped in the stool affects the appendix which can
lead to infection and manifest a mild fever.
• Nausea and Vomiting- After the abdominal pain begins, a person with
appendicitis feels nauseated. This is also caused by the obstruction.
• Rovsing's sign - as classically described, is not simple palpation of the
left iliac fossa causing pain to be felt in the right iliac fossa.
• Psoas sign - is elicited by having the patient lie on his or her left side
while the right thigh is flexed backward. Pain may indicate an inflamed
appendix overlying the psoas muscle.
• Obturator sign - the technique for detecting the obturator sign, called
the obturator test, is carried out on each leg in succession. The patient
lies on her/his back with the hip and knee both flexed at ninety
degrees.
Rupture of Appendix (Abscess/ Peritonitis)
• Severe sharp abdominal pain or tenderness
• Bloating or a feeling of fullness (distention) in your
abdomen/ board like abdomen
• Loss of appetite
III. A. PATIENT’S DATA
• Patient’s name: Jake
• Age: 15
• Date of Birth: June 15, 2002
• Sex: Male
• Marital Status: Single
• Nationality: Filipino
• Occupation: Student
• Religion: Catholic
• Address: Bamban, Tarlac
B. NURSING HISTORY
CHIEF COMPLAINT
• “sobrang sakit po ng tiyan ko dito po sa kanang baba ng
tiyan ko” as verbalized by the patient
PRESENT HISTORY
• On Jan 2, 2018, 10 hours prior to admission, the patient
experienced mild pain on his right lower quadrant abdomen,
while eating in the morning, followed by a severe pain which was
identified as a scale of 8 out of 10. The patient tried to eliminate
the pain using herbal oil but was not eradicated. Because of the
persistence of the pain felt by the patient, his mother decided to
admit him at a tertiary hospital.
PAST HISTORY
• According to the mother, the patient had experienced
acute respiratory infections such as cough, cold and low grade
fever. Pain in the right lower abdomen was first felt when the
client was 14 years old but were ignored. The patient had no
history of hospitalization.
PERSONAL AND SOCIAL HISTORY
• Jake lives with his 3 siblings, his mother, and his father.
The patient’s surrounding is good and there were no lakes,
swamp or river nearby. The patient’s school is only a few
blocks away so he usually walks going to school and
returning home. He would go hang outside with his friends
and usually arrives at home around 7pm.
NUTRITIONAL STATUS
• His usual diet includes food that are high in protein, junk
foods, soft drinks which he buys at school during recess, also
processed foods. He also prefers meat products in his meal
than leafy vegetables.
PHYSICAL EXAMINATION
Upon Admission:
System Result
a. General /overall health -awake, conscious and coherent
-noted facial grimace, and abdominal
status guarding behavior
-(+) Rebound Tendernes, (+) Rovsing sign,
(+) psoas sign
-febrile with a Temp= 37.9°C
-PR= 76bpm
-RR= 20 cpm,
-BP=110/70 mmHg
b. Urinary -urine output of >30 cc/hr
-urine color amber yellow but turbid
-(-) bladder distention
c. Musculoskeletal -full ROM of upper extremities
-impaired mobility due to RLQ pain
vii. Gordon’s Functional Pattern
PATTERN BEFORE DURING ANALYSIS
HOSPITALIZATION HOSPITALIZATION
Health “Last year palang po “Sobrang sakit po Due to his
nakaramdam napo ako ng hndi ako makakilos
Perception pangingirot sa tiyan dito sa ng maayos” as illness
kanan” as verbalized by the verbalized by the
patient patient
Nutritional She eats 3 times a day, she She does not have The doctor
loves to eat processed food the appetite to eat
Metabolic such as tocino and hotdogs, anything. ordered NPO
junk foods and soft drinks, upon admission.
and foods high in protein.
Elimination She urinates 3-5 times a day She has no problems His condition
>30ml/hr and defecates once in urinating and
a day every afternoon. defecating. has does not
affect his
elimination.
Activity/ Her daily routine is walking She is unable to move Due to his
to school, eating street freely due to the pain
Exercise foods outside the school in her RLQ illness
after, then walking back
home.
Sleep/Rest She usually sleeps around Unable to sleep or rest Due to his
10 pm then wakes up at because of her pain in illness
5am. the RLQ.

Cognitive/ Has no problem with her Has impaired His condition

Perceptual senses. attention. does not
Able to comprehend and Unable to comprehend affect his
respond to questions and and respond properly senses and
information to questions and comprehensiv
information. eness.
COURSE IN THE WARD
• Day 1
• A 15 year old male was admitted at 3:00 pm last January 2, 2018
accompanied by his mother, with a chief complaint of severe sharp pain
on his RLQ and low grade fever. He was seen by a doctor, vital signs (BP,
Temp., PR, RR, O²sat.) taken while retrieving past and present medical
historyand physical examination. Test for rebound tenderness, psoas
sign, and rovsing’s sign was performed then the physician ordered NPO
for the diet and requested for CBC test and Ultrasound. After confirming
with the diagnosis of Appendicitis the patient was scheduled for
immediate surgical removal off the appendix, Appendectomy. Signed
informed consent was witnessed and obtained by the NOD. The patient
was then transferred to the OR.
ANATOMY AND PHYSIOLOGY
• The Appendix is a closed-ended, narrow tube up to several inches in length that attaches
to the cecum. It is 9cm long.
• The appendix is usually located in the right iliac region, just below the ileocecal valve
(designated Mc Burney’s point) and can be found at the midpoint of a straight line drawn
from the umbilicus to the right anterior iliac crest located in the lower right quadrant of
the abdomen.
• 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.
• It helps tell lymphocytes where they need to go to fight an infection and it boosts the
large intestines immunity.
• And it latter helps keep your gastrointestinal tract from getting inflamed in response to
certain food and medication ingested.
PATHOPHYSIOLOGY
LABORATORY STUDIES AND DIAGNOSTICS
HEMATOLOGY
Components Results Normal values Clinical significance Clinical
Manifestations

WBC 18.30 x 4.5 – 11x109/L It measures the no. of WBCs in a cubic mm of blood. It is to detect . Presence of
109/L infection or inflammation inside the brain or meninges This test was inflammation
indicated for the patient in order to identify the presence of infection.

Neutrophils defend against bacterial or fungal infection and other very

Neutrophils 0.90 0.45 – 0.73 small inflammatory processes that are usually first responders to Acute infection,
microbial infection; their activity and death in large numbers forms trauma or
pus. surgery
Lymphocytes are a type of white blood cell that is part of the immune
system. Viruses and toxins.
This was used to evaluate if the is resistance to infection
 Components Results Normal values Clinical significance Clinical
Manifestations

Lymphocyte 0.10 0.2 – 0.4 Lymphocytes are a type of Sever stress,

white blood cell that is part malnutrition, or
of the immune system. possible infection
Viruses and toxins.
This was used to evaluate if
the is resistance to
infection

Hematocrit 46 % Males: 42 – It is a measure of the RBCs Balance proportion of

52 % in the whole blood blood volume that is

Females: 35 – expressed as percentage. occupied by RBC

47 %
 Nursing Responsibilities
• Check the Doctor’s order.
 Verify the name of the patient in the chart with the actual patient.
 Explain to the patient the procedure and the purpose of the test.
Explanation could be brief such as, “to determine the amount of
hemoglobin, hematocrit, and lymphocyte in the blood.”
 Inform the patient that foods and drinks are not allowed.
 Inform the patient that small amount of blood will be drawn from him /
her.
 Inform the patient that he/she will experience mild pain at the extraction
site.
 Tell that there will be discomfort from the needle that will be inserted and
pressure from the tourniquet.
 Ensure that the patient understands the procedure.
Prepare the laboratory request and inform the laboratory.
Ultrasound:
Results Normal Clinical Clinical
values significance Manifestations
 Laminated wall with • appendix: • To reveal • Ultrasound of the
appearance of 7mm on CT <6 enlargeme right lower
in total diameter on mm nt in the quadrant reveals
cross section/mural caliber. area of the a non-
wall thickness 2mm cecum compressible,
enlarged appendix
 non-compressible,
enlarged appendix
 Nursing Responsibilities
 Assess level of anxiety and possible coping mechanisms to
mitigate that anxiety; allow verbalization of fears
 Assess for clear understanding of provided information related to
disease process
DRUG STUDY
MEDICAL-SURGICAL MANAGEMENT
APPENDECTOMY
Procedure/Date Indication/Analysis Nursing Responsibilites (PRE, INTRA, POST)
Appendectomy – Appendictis Pre:
January 2, 2018 - Reduce the anxiety of the patient and their relatives by orientation of the
environment.
- Check results of lab
- Obtain informed consent
- Monitor VS
- Assess I and O
- Examine level of anxiety
- Teach relaxation techniques
- Bowel preparation
-Light dinner, NPO
-Cleansing enema
- Prophylactic antibiotics
- IV fluids

Intra:
-Appendectomy

Post:
-clear liquids are offered.
-Once those are tolerated, the diet is progressed. Once the patient is eating and
drinking, the IV fluid is removed.
Assist patient during physical activities especially when climbing stairs and not to
strain abdominal muscle.
-Fever and increasing pain at the incision site also should be reported to the
physician.
Equipment  PPE
 Electrocautery
Instruments  Appendectomy Set
Supplies  Routine supplies for appendectomy
Operative Preparation Anesthesia
 Local
Position
 Supine
Prep
 Abdominal Prep
 Placement of Indwelling Foley Catheter/straight
catheter
Draping
 RLQ
Incision
 McBurney/ Lanz Incision
PROCEDURE
• The position of the incision is based upon the location of the McBurney’s
point
• Make the incision with a no. 20 blade; use a electrocautery to incise
through both the superficial and the deep fascia
• Expose the external oblique aponeurosis, incising in the direction of
fibers, and split the external oblique muscle bluntly with alternating Kelly
clamps and army navy retractors
• This blunt muscle spreading, along with appropriate retraction allows
visualization of the transversalis fascia and the peritoneum
• Perform the incision on peritoneum in a craniocaudal direction with
Metzenbaum scissors, allowing access to the peritoneal cavity; once
the cavity is opened, any fluid encountered should be sent for Gram
stain and culture
• Use a series of Babcock surgical clamps to follow them to their
convergence, identifying the base of the appendix. Free the appendix-
mesoappendix complex from its adjacent, often inflamed, tissue, and
deliver it into the wound. The mesoappendix, containing the
appendiceal artery, is then ligated and separated from the appendix
• Completion of appendectomy by dividing appendix between 2
ligatures, closer to cecum
NURSING CARE PLAN
PRE-OPERATIVE:
Problem #1: ACUTE PAIN RELATED TO DISTENTION OF THE INTESTINAL TISSUE BY INFLAMMATION
Problem #2: ANXIETY RELATED TO CHANGE IN HEALTH STATUS
DISCHARGE PLANNING
Medications:
• For pain, one of the Ibuprofen compounds (Advil, Nuprin, etc.) or Tylenol
is suggested. Should these not be effective in managing your
discomfort, notify your physician. Prescription pain medication will be
given on an individual basis.

Exercise:
• Gradually increase activity level to help with your recovery. Start by
doing light activities around your home once you feel able to do so..
• Avoid lifting heavy objects.
• Limit sports and strenuous activities for 1 or 2 weeks.
Treatment:
• Incision Care
• Wear loose-fitting clothes. This will help you be more comfortable and cause less
irritation around your incision.
• Shower as usual.
• Gently wash around your incision with soap and water.
• Don't bathe or soak in a tub or swim in a pool until your incisions are well healed.
• Leave the Steri-Strips (little white strips of tape) in place for 10 days
Health Teaching: Teach the patient and family about the treatment plan including
the need to avoid all alcohol intakes, take medications as prescribe and check with
the physician before taking any new medications. Patient and family teaching
addresses skin and wound care and to watch for and report signs and symptoms of
complications.
Out-Patient Follow-Up Care: Regular consultation to the
physician can be factor for recovery and to assess and
monitor the patient’s condition.

• Diet (after discharge):

• Drink 6 to 8 glasses of water a day, unless directed
otherwise.
• Take a fiber-based laxative, such as Metamucil, if you
are constipated.
• Eat a bland, low-fat diet
THANK YOU