APPENDICITIS

GENERAL OBJECTIVES
At the end of One hour case presentation, the level IV and level III would be able to have a thorough understanding in the nature of Appendicitis in relation to patients condition and health status in such a way the students would be able to appreciate also the use of nursing process in giving care to patient with such condition.

SPECIFIC OBJECTIVES:
At the end of this case presentation students would be able to familiarize the topic through the utilization of the following domain:

COGNITIVE:
Define Appendicitis ; Identify the cause , signs and symptoms of Appendicitis ; Determine the anatomy and physiology of the affected system and trace the pathophysiology of the disease ; Interpret the significance of the laboratory test done to the patient and how this findings relate the disease process; Identify the medication given to the patient, its brand name , generic name ,classification ,mechanism of action , indication , dosage , route , contraindication , side effect and adverse effect and nursing responsibilities. Determine the appropriate nursing diagnosis and proper interventions for nursing independent role.

PSYCHOMOTOR :
Formulate an evaluative measure through question and answer portion Participate actively during the activities

AFFECTIVE :
Integrate information among the group related with such condition.

INTRODUCTION

 The group 1, Sec.B chose this case as a topic for our case presentation for many causative reasons. One of those which is the uniqueness of the topic. It was unique because we rarely have a topic like a ruptured appendicitis. Apart from that, we are still confuse of what really the function of our appendix. According to research, almost of the Filipino suffer of this noted disease. We also want to know the beneath etiology pertaining to its nature because until now, the main causative factor is unknown.

DEFINITION
Inflammation of the appendix Most common reason for emergency abdominal surgery

CAUSES
A fecalith (a fecal calculus, or a stone) that occludes the lumen of the appendix Kinking of the appendix Swelling of the bowel walls Fibrous conditions of the bowel wall External occlusion of the bowel by adhesions

 Vague epigastric or periumbilical pain progresses to right lower quadrant pain Low grade fever Nausea and vomiting Loss of appetite Rebound tenderness Rovsings sign- pressure on the left lower quadrant of the abdomen causes pain in the right lower quadrant Constipation Local tenderness at McBurneys point

CLINICAL MANIFESTATIONS:

DIAGNOSTIC PROCEDURES
Complete Blood Cell Count Demonstrates an elevated white blood cell count with an elevation of the neutrophils. Abdominal X-ray films, ultrasound studies, CT scans May reveal light lower quadrant density or localized distention of the bowel.

COMPLICATIONS
Perforation of the appendix which can lead to peritonitis Abscess formation collection of purulent material Portal pylephlebitis septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines

MEDICAL MANAGEMENT
Appendectomy surgical removal of the appendix Antibiotics and IV fluids to correct or prevent fluid and electrolyte imbalance, dehydration and sepsis

NURSING MANAGEMENT
Prepare the patient for surgery Administer IV fluids to replace fluid loss and promote adequate renal function Antibiotic therapy to prevent infection Do not administer an enema or laxative (could cause perforation) insert nasogastric tube (if evidence of paralytic ileus).

After the surgery Place the patient on high fowlers position reduces tension on the incision and abdominal organs Administer opiods (morphine sulfate) as prescribed to relieve pain Oral fluids when tolerated give food as desired on day of surgery (if tolerated)

If a drain is left in place at the area of the incision monitor carefully for signs of intestinal obstruction, secondary hemorrhage, or secondary abscesses (eg. fever, tachycardia, and increased leukocyte count).

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care Teach patient and family to care for the wound and perform dressing changes and irrigations as prescribed Reinforce need for follow-up appointment with surgeon. Discuss incision care and activity guidelines. Refer for home care nursing as indicated to assist with care and continued monitoring of complications and wound healing.

Anatomy of the Digestive System Introduction

 Our digestive system is made up of the body parts that change raw food into nutrients that the body can use and waste. It also moves the nutrients and waste through our body. It is made up of the mouth including the teeth, jaws, tongue and salivary glands, esophagus, stomach, liver, gall bladder, bile duct, pancreas, pancreatic duct, small intestine including the duodenum, jujenum and ileum, large intestine, rectum and anus.

 Digestion is the process by which food is broken down into smaller pieces so that the body can use them to build and nourish cells and to provide energy. Digestion involves the mixing of food, its movement through the digestive tract (also known as the alimentary canal), and the chemical breakdown of larger molecules into smaller molecules.

 Digestion begins in the mouth, where chemical and mechanical digestion occurs. Saliva, produced by the salivary glands (located under the tongue and near the lower jaw), is released into the mouth. Saliva begins to break down the food, moistening it and making it easier to swallow. A digestive enzyme (called amylase) in the saliva begins to break down the carbohydrates (starches and sugars). One of the most important functions of the mouth is chewing.

The Mouth:

 Movements by the tongue and the mouth push the food to the back of the throat for it to be swallowed. A flexible flap called the epiglottis closes over the trachea ( windpipe) to ensure that food enters the esophagus and not the windpipe to prevent choking.

The Esophagus:
The food is then swallowed which takes the food from the mouth to the esophagus. The esophagus is a 6-foot long muscular tube that connects the small intestine and connects the mouth to the stomach. Food moves through the esophagus by peristalsis, which is a wave of muscle contractions that pushes the food down the tube.

 Four basic tissue layers: mucosa, submucosa, muscularis externa, and serosa. Two important nerve plexuses: submucosal and myenteric nerve plexus

The Stomach:
The stomach is a 25 cm (10 inches) long, muscular sac located on the left side of the upper abdomen. The stomach receives food from the esophagus. Stomach holds 4 liters (1 gal.) of food.

 Cardiac region - surrounds the cardioesophageal sphincter, through which food enters the stomach from the esophagus. Fundus is the expanded part of the stomach lateral to the cardiac region. Body- is the midportion of the stomach Pylorus- is continuous with the small intestine through the pyloric sphincter Lesser omentum a double layer of peritoneum, extends from the liver the liver to lesser curvature.

 Greater omentum an extension of the peritoneum that drapes downward and covers the abdominal organs like a lacy apron before attaching to the posterior body wall. Gastric glands produces Hydrochloric acid that aids protein digestion in the stomach. Chief cells produce protein digesting enzymes, mostly PEPSINOGENS. Parietal cells produce corrosive hydrochloric acid which makes the stomach contents acidic and activates the enzyme. After the food has been processed in the stomach, it ressembles heavy cream and is called CHYME. The chime enters the small intestine through the pyloric sphincter.

The Liver:
The liver has hundreds of functions. One of its main functions is to process fat and other nutrient-rich liquefied food that drains from the small intestine so it can be used. Another important function of the liver is that it produces sugars from proteins and fatty substances; and it secretes albumin which helps to keep fluid within the blood vessels. It also secretes bile which is a substance containing fatty materials. These help in the digestion, as well as the absorption of fatty products.

The Gall Bladder:

The gall bladder is a pouch-shaped organ which lies near the liver. It accepts bile from the liver, and stores it. When food is digested, the gallbladder releases bile into the small intestine where it is able to help dissolve fats.

The Pancreas:
The pancreas makes and delivers digestive juices through a tube called the pancreatic duct to the upper part of the small intestine.

The Small Intestine:

The small intestine is approximately 20 feet long and is divided into 3 segments the duodenum, jejunum, and ileum.

Rectum
The rectum (Latin for "straight") is an 8inch chamber that connects the colon to the anus. It is the rectum's job to receive stool from the colon, to let the person know that there is stool to be evacuated, and to hold the stool until evacuation happens.

Anus
The anus is the last part of the digestive tract. It is a 2-inch long canal consisting of the pelvic floor muscles and the two anal sphincters (internal and external). The lining of the upper anus is specialized to detect rectal contents. It lets you know whether the contents are liquid, gas, or solid. The anus is surrounded by sphincter muscles that are important in allowing control of stool.

ANATOMY OF GASTROINTESTINAL ORGAN

GASTROINTESTINAL PROCESS:
INGESTION food is placed into the mouth. PROPULSION this done through swallowing using the propulsive process called peristalsis. FOOD BREAKDOWN: MECHANICAL DIGESTION mixing of food in the mouth by the tongue, churning of food in the stomach, and segmentation in the small intestine. FOOD BREAKDOWN: CHEMICAL DIGESTION the foods are broken down into small particles by enzymes. ABSORPTION transport of digested end products from the lumen of the GI tract to the blood or lymph. DEFECATION elimination of the indigestible residues from the GI tract via the anus in the form of feces.

Accessory Organ (APPENDIX)

Appendix (vermiform appendix; cecal appendix; vermix) is a small, thin, 4 inch tube tube, situated at the junction of the small intestine and large intestine. It is a blind-ended tube connected to the cecum (or caecum), from which it develops embryologically Vermiform comes from Latin and means "worm-shaped".

FUNCTION:
The appendix in the fetus's body features (11th week) appearance of endocrine cells. These endocrine cells produce several biogenic amines and peptide hormones, which are compounds assisting homeostatic mechanisms in the fetal body. The appendix is believed to play a role in the immune system of the body. The lymphoid tissue begins accumulating in the appendix shortly after birth. This lymphoid tissue accumulation continues and reaches its peak by the time a person reaches his twenties or thirties. This accumulation enables the appendix to act as a lymphoid organ and assists with the maturation of one kind of white blood cells called B lymphocytes.

 It is also linked to the production of antibodies called immunoglobulin A (IgA) antibodies. The appendix produces and protects good bacteria for the gut, thereby acting as a reservoir for good bacteria.

LOCATIONS:
Lower right quadrant Appendix location falls on the Ileo-cecul junction, meaning the point where ileum, a part of small intestine meets the cecum from colon.

PATHOPHYSIOLOGY

HEALTH ASSESSMENT

PATIENT PROFILE
Patient Name Address Age Sex Civil Status Nationality Date Admitted Attending Psychian Cheif Complaint : : : : : : : : : X Kawayan, ZDS 36 years old Female Married Filipino September 4, 2011 Dr. Florence rence Fever Vomiting

HISTORY OF PRESENT ILLNESS

3 days prior to admission patient complains of abdominal pain and one day vomiting. She was referred from Aurora General Hospital to Pagadian City Medical Center due to ruptured appendicitis.

HISTORY OF PAST ILLNESS

According to the patient she has no past illness.

LABORATORY RESULT

Test

ELECTROLYTES 09-07-11
Results Normal values significanc e 134.9 mmol/L 135-148 mmol/L

Sodium

Potassium

2.51 mmol/L

3.5-5.3 mmol/L

Indicates vitamin D deficiency due to diuretic administrati on

Glycosylated Hemoglobin 09-0511

Result Normal value

6.1%

4.5-6.3%

Test Full Name

BLOOD CHEMISTRY RESULT 0905-2011

Conc. Unit Cholesterol 116.1 mg/dl mg/dl mg/dl LOW 0.0-200.0 30.0150.0

Resul Referenc Significan Nursing t e ce Resopn sibity

TC TG

Triglycerides 42.8

HDLC HDL 26.9 cholestero l

35.0-65.0 Increase Monitor risk for vital coronar signs of y heart the disease patient especiall y the RR and PR. 0.0-150.0

LDL

Low density 80.6

mg/dl

Parameter

COMPLETE BLOOD COUNT RESULT 09-04-11

Result Unit 13.16X10^9/L 3.00-10.00 High

Ref. Range InterpretatioSignificanceNursing n Responsibilt y Indicates Monitor acute temperatur infection e, redness and swelling in the incision site.

WBC

Neu%

95.0%

50.0-80.0

High

Increased Monitor during temperatur short e, redness term or and swelling acute in the infection incision s. site.

Mon%

2.9%

2.010.0

Eos%

0.8%

0.0-5.0 normal

Bas%

0.0%

0.0-2.0 normal

LIC%

1.7%

0.0-2.0 normal

Parameter Result Unit

Ref. Range

Interpreta Significanc Nursing tion e Respon sibilty Slightly indicates Monitor decreas anemia signs of ed anemia such as fatigue and palenes s

RBC

3.17x10^12/ 4.00-6.00 L

HGB HCT MCV PLT

16.2g/dL 44.1% 85.3fL 198x10^9/L

12.0-17.0 37.0-50.0 80.0-100.0 150-450

normal normal normal normal

Color:

Urinalysis 09-04-11 Nursing Amber Interpretat Significanc

ion e Responsi bilty Cloudy abnormal Presence Monitor for of pus, signs of indicates infection infection

Appearance:

Ph: Glucose:

6.0 +4

Slightly acidic abnormal Indicates Conduct diabetes health mellitus teaching related to diet of the patient.

Blood Chemistry 09-07-11

Exam result name unit Normal Interpret Significan Nursing values ation ce Respon sibilty mg/d .6-1.2 l mg/d 70-110 l normal increased Indicates Monitor diabete glucos s e level mellitu s Slightly Indicates Monitor increas diabete glucos ed s e level mellitu s

creatinin 1.02 e Glucose 196 (post-op)

Glucose 136 (pre-op)

Mg/dl70-110

Ultrasound 09-04-11
Impression: Hypoactive fluid- filled small bowels suggestive of ileus Minimal ascites Normal sonogram of the liver, gallbladder, pancreas, spleen, kidneys and uterus

DOCTORS ORDER

TIME/DATE 9-4-11 4:35PM

ORDERS Admit to room under the service of Dr. Florence Rence TPR q4h NPO Secure consent D5LR 1L @ 30gtts/min CBC, U/A Refer accordingly

4:45PM

Metoclopramide 1 amp IVTT now

5:00PM

Tramadol 50mg IVTT now. Hold if BP 90/60mm/Hg TF: D5LR 1L @ 30gtts/min MEDS: Ceftriaxone 1g IVTT q8h ANST Metronidazole 500mg IVTT q8h ANST Ranitidine 50mg IVTT q8h. ANST ( ) For Explore Lap - Secure consent Refer to billing office for orientation/clearance Once cleared by billing office: Refer to Dr. Foo for pre-op meds. Inform OR Prepare: - Surgical gloves size 7,6 - Vicryl 1/0 - Silk 3/0 multistrand - Chromic 2/0, 3/0 - Urine bag Refer CBC result once in

9-5-11 12:25AM

Paracetamol 300mg IVTT q4h for Temp. 38 C

12:27AM

For FBS, Creatinine Give Paracetamol 300mg IVTT

7:38AM

UTZ of whole abdomen for patient request

10:00AM

Refer to Dr. Tan for co management

PRE-OP ORDER
9-5-11 11:35AM NPO Continue ranitidine meds. 50mg IVTT Metoclopramide 10mg, 1hr after transfer to OR Prepare: Propofol 1vial Fentanyl 1amp Isoflurane Atropine sulfate Midazolam Syringe 1cc #3, 5cc #2, 10cc #2 Level GETA Inform OR personnel

9-5-11 12:35PM

Thanks for the referral Give 1 dose metropolol 1 tab now Inform undersigned once transferred to and from OR

9-5-11 1:30PM

Repeat 12 lead ECG post-op

POST-OP ORDER
TIME/DATE 9-5-11 6:40PM ORDER To observe RR until alert and stable 30 mode high back rest NPO temporarily O2 inhalation by nasal cannula until alert and stable Hook to pulse oximeter Monitor V/S q15 mins. until alert and stable Measure I&O qH Assess pain scale q6h. Regulate present IVF of PLRS 40gtts/min Meds: 1. humilin R 1cu subcutaneous now 2. hold cefuroxime temporarily 3. continue metronidazole 500 mg q8h 4. tramadol 30 mg in 500ml D5W @ 20gtts/min. 5. fentanyl 50ugm (1ml) in nalbuphine 5mg slow IVTT q6 PRN for severe post-op pain 6. paracetamol 300mg IVTT q4h for Temp. 38 C 7. ranitidine 50 mg IVTT q8h Lab. CBC as ordered serum Na, K Refer to Dra. Ungad for further orders

9-5-11 7:45 PM

Relay output by 12am

9-6-11 12 MN

Give furosemide 20 mg IVTT now Relay I&O Q shift

9:59 AM

Metoclopramide 10mg IVTT now

Drugs

NURSING CARE PLAN

Nursning Diagnosis Hyperthermia related to increased metabolic rate due to Surgery.

NURSING CARE PLAN

Nursing Diagnosis
Risk for fluid volume Deficit Related to Postoperative vomiting and Body Fluids loss During the Surgery.

NURSING CARE PLAN

* Nursing Diagnosis - Risk for infection related to tissue destruction from invasive Procedure.

DISCHARGE PLAN

M-Medication should be taken regularly as prescribed on exact dosage, time and frequency , making sure that the purpose of medication is fully disclose by the health care provider. Antibiotics and analgesics are advised to take to prevent complications and discomfort. *Tramadol 30 mg for pain. *Paracetamol 500 for temperature greater than 38.2 degrees centigrade.

E- Encouraged early ambulation to prevent post op complications. You can usually return to normal activities in 2-3 weeks after laparoscopic surgery. Encouraged proper hygiene like taking a bath every day, maintain cleanliness and provide safe environment for early recovery.

TEncouraged the patient to maintain the medications given and when to come back for further evaluation of the procedure done to the patient. HEncouraged deep breathing exercise. 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

ORegular and follow up check-up should be greatly encouraged to patient as ordered by physician to ensure the continuing management and treatment. Encouraged the patient to come back after 4-7 days for suture removal. DClear Liquids

 After any surgery, the gastrointestinal tract may wake up slowly. Sticking with a clear liquid diet is best until all nausea and vomiting pass after waking up from anesthesia. Clear liquids consist of foods and beverages such as apple juice, clear soda, broth and gelatin. If a medical professional hears normal bowel sounds with a stethoscope and the person tolerates clear liquids, advancing the diet to bland foods is usually okay.

 Soft Diet As the body continues to recover from surgery, eating soft, bland foods will allow the intestines to heal without additional stress. Bland foods include potatoes, rice and cooked chicken. Avoiding spicy, greasy and fatty foods may help prevent gastrointestinal distress when recovering from an appendectomy. Foods that produce intestinal gas, such as beans, may increase the pain associated with having a laparoscopic appendectomy because the surgeon fills the abdomen with air during the operation. After surgery, people may feel gas pains. Eating a healthy diet will help speed the healing process and lower the risk of a postoperative infection.

High-Fiber Foods Risk factors, such as decreased walking and pain medications, may cause a person to experience constipation after an appendectomy. Slowly adding high-fiber foods to the diet may help prevent the constipation. Highfiber foods include whole grains, beans, dried fruit and raspberries. Adding too many high-fiber foods to the diet all at one time may increase the risk of developing uncomfortable intestinal gas.

Considerations Eating small, frequent meals after an appendectomy may help decrease stress on the intestines while the area heals. Eating before taking medications such as pain medicine or antibiotics may help decrease potential side effects, such as nausea and vomiting. Without any complications, a person who undergoes an appendectomy should return to a normal diet within a week or two after surgery.

SEncouraged the patient to maintain her communication to God. Encouraged her to ask help to her pastor for spiritual guidance. Encouraged her to pray always and have faith on God especially in the hard times.

EVALUATION

Patient X, a 36y/o, female admitted last September 4, 2011 around 4:35 pm at Pagadian City Medical Center with chief complaints of Fever, vomiting with admitting diagnosis of Ruptured Appendicitis. She sought for medical assistance for further medical treatment and management. She was under the service of Doctor Florence Rence.

Patient X was able to undergo appendectomy last September 5, 2011. Post-operatively, Patient X demonstrated improvement from being fatigue to active. She doesnt have pain felt in her incision accordingly. There was no redness and swelling on the incision site. Her urine output increased due to diuretic medication. Patient X was also given metoclopromide, ceftriaxone, tramadol and other medications for treatment. Patient X was discharged last September 11, 2011. Presently, she was still on her recovery stage and she needs attended.