ACUTE APPENDICITIS

A Case Study
Presented to the College of Nursing

In Partial Fulfillment of
The requirements for
Related Learning Experience
In Surgery Ward of QMC

Mr. Felipe Merano RN,MSN
Clinical Instructor

Klent Nikko G. Melencion
BSN-IV
FOREWORD/PREFACE

In creating this study, the authors share to life the experiences and differences they’ve made within these pages, by describing what they have studied and learned during their clinical exposure in the Surgery Ward of Quezon Medical Center
And thus, not only did they become improved nursing students but also they become more aware, open minded, found responsibility, help others and have move forward together, ready to face what’s coming next for them.
Their knowledge was enhanced as they encountered different cases and procedures in the Surgery Ward. These form important learning experiences, creating much new light for them from pre-conferences and post-conferences, computations and medications, patients and significant others, assessments and laboratories, nasogastric tubes and a whole lot more vital to their nursing careers.

DEDICATION

This study is dedicated to our loved ones who serves as our inspiration and never failed in giving us support financially, spiritually and morally, for guiding us through and for showing us that even a big task can be accomplished as long as there is teamwork and dedication. We also dedicate this to ourselves because of the hard work and dedication we have showed in making this study and to Mr. Felipe Meranofor guiding us and believing in us.
Lastly, we dedicate this to the healthcare team of Quezon Medical Center because without them, there will be no basis for this study. They have opened up their doors for us to attain and broaden our knowledge in the health care industry.

OBJECTIVES

This study is conducted to provide information regarding Chronic Hypertension. Our objective is to help and provide adequate knowledge to fellow nursing students as well. This study has the answers for the following:
1) What is Acute appendicitis?
2) What are the risk factors of Acute appendicitis?
3) What are the diagnostic tests needed to determine Acute appendicitis?
4) What is the nursing care plan for Acute appendicitis?
CASE INTRODUCTION
A 18 year old female client admitted with chief complaint of RLQ pain and with Diagnosis of Acute Appendicitis with pain at the Right Lower Quadrant for 1 night.
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases requires removal of the inflame appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to infection and inflammation of the intestinal lining (peritoneum) and eventual sepsis, clinically known as peritonitis which can lead to circulatory shock.
NAME: X
GENDER: Male
BIRTHDAY: July 03, 1995
Address: Balungay, Alabat Quezon
Chief Complain: RLQ pain since last night
Diagnosis: Acute Appendicitis
Admitting Physician: Dr. Combalicer
PHYSICAL ASSESSMENT

A. HEAD: symmetric, proportionate to body size, free from masses and lesions
B. HAIR: Black in color, thin and fine, uncombed and slightly clean.
C. EYES: White sclera, dark brown pupil, Pupil Equally Round Reactive to Light Accommodation (PERRLA)
D. NOSE: no nasal flaring noted, nose is located at the midline of the face, without lesions or masses noted,
E. NECK: neck is symmetrical with the head in central position
F. FACE: normal lining of the nose, eyes and ears; pinkish lips and not dry
G. EARS: patient ears are working normally and can hear clearly, minimal ear wax noted
H. CHEST/THORAX: chest is symmetrical upon breathing, not in respiratory distress, breast are engorged with minimal stretch marks with good milk lactation
I. ABDOMEN: : Non-tender abdomen, pain noted upon palpation, no signs of abnormal sounds upon auscultation, not bloated
J. LOWER EXTREMITIES: with Homan’s Sign on both lower extremities
K. SKIN: skin is warm to touch, no rashes or dryness noted, no edema
L. NAILS: Good capillary refill of 2-3 sec, slightly long nails, no dead nails noted
LABORATORY WORK-UPS

COMPLETE BLOODCOUNT
Test Result Reference Hemoglobin 15.20 g/dL 12.0-16.0 g/dL Hematocrit 0.45 0.37-0.43 RBC count 5.15 x10^12/L 4.0-5.4 WBC 17.60 x10^9/L 4.0-10.0 Neutrophils 0.81 0.55-o.65 Lymphocytes .19 0.25-0.35 Platelet Count 349 150-400
Color Yellow RBC 3-4/hpf Transparency Blurred WBC 15-20/hpf Spec. Quantity 1.030 Epithelial Cells Moderate Ph Reaction 6.5 Bacteria Few Chemical Test Sugar (-) A. Urates Many Albumin (+) A. Phosphate Many
NORMAL ANATOMY AND PHYSIOLOGY

Small intestine
The small intestine is composed of the duodenum, jejunum, and ileum. It averages approximately 6m in length, extending from the pyloric sphincter of the stomach to the ileo-caecal valve separating the ileum from the caecum. The small intestine is compressed into numerous folds and occupies a large proportion of the abdominal cavity.
The duodenum is the proximal C-shaped section that curves around the head of the pancreas. The duodenum serves a mixing function as it combines digestive secretions from the pancreas and liver with the contents expelled from the stomach. The start of the jejunum is marked by a sharp bend, the duodenojejunal flexure. It is in the jejunum where the majority of digestion and absorption occurs. The final portion, the ileum, is the longest segment and empties into the caecum at the ileocaecal junction.

The small intestine performs the majority of digestion and absorption of nutrients. Partly digested food from the stomach is further broken down by enzymes from the pancreas and bile salts from the liver and gallbladder. These secretions enter the duodenum at the Ampulla of Vater. After further digestion, food constituents such as proteins, fats, and carbohydrates are broken down to small building blocks and absorbed into the body’s blood stream.
The lining of the small intestine is made up of numerous permanent folds called plicaecirculares. Each plica has numerous villi (folds of mucosa) and each villus is covered by epithelium with projecting microvilli (brush border). This increases the surface area for absorption by a factor of several hundred. The mucosa of the small intestine contains several specialised cells. Some are responsible for absorption, whilst others secrete digestive enzymes and mucous to protect the intestinal lining from digestive actions.

Large intestine
The large intestine is horse-shoe shaped and extends around the small intestine like a frame. It consists of the appendix, caecum, ascending, transverse, descending and sigmoid colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm.
The caecum is the expanded pouch that receives material from the ileum and starts to compress food products into faecal material. Food then travels along the colon. The wall of the colon is made up of several pouches (haustra) that are held under tension by three thick bands of muscle (taenia coli).
The rectum is the final 15cm of the large intestine. It expands to hold faecal matter before it passes through the anorectal canal to the anus. Thick bands of muscle, known as sphincters, control the passage of faeces.

Pathophysiology
COURSE IN THE WARD

Doctor’s Order Medical Intervention
Nursing Responsibility
Actions 09/26/14
4:50 PM

> Pls. admit to FSW

> Secure consent for admission & mgt.
> TPR

> NPO
> CBC with UA

> IVF D5LR 1L x 8*
> Cefuroxime 750 mg q8* ANST (-)
> Metronidazole 500 mg

> For Appendectomy
> Notify on ROD
> Refer

9:24 PM
> NPO

> Pre Op meds
09/26/14

> POST ANESTHESIA ORDERED

> SLP APPENDECTOMY
> To PACU

> O2 inhalation via Nasal Cannula @ 2-3 lpm

> NPO
> Monitor VS q15

> Pls. regulate present IVF to 31-32 gtts/mins.

> IVF to follow
> D5LR 1Lx8*
> D5LR 1Lx8*
> D5LR 1Lx8*
> D5LR 1Lx8*
> Meds
> TDL 50 IV q8*
> Paracetamol (IV) 1gm q8* for 15-20mins. Duration x 3 dose
> Continue present antibiotics as ordered

09/27/14

> Ambulate
09/28/14
> Ambulate
> Cefuroxime IV
> Refer
>Client was admitted for further care and management

>For legal purposes

>This serves as basis for initial vital signs
>Nothing per Orem no food intake prior to operation

>Baseline laboratory tests for diagnosis.
>is useful for daily maintenance of body fluids and nutrition, and for rehydration.
>Anti bacterial drug

>Anti bacterial drug
>Removal of the appendix

>To notify the ROD.

>Nothing per orem No food intake until bowel movement returns

>Post Anesthesia care prior to post operative client
>Removal of appendix

>for fast recovery from anesthesia
>to promote oxygenation

>nothing per orem No food intake until the Bowel Movement presents

>Monitors clients VS every 15 minutes

>Regulate IVF as desired
>It is useful for daily maintenance of body fluids and nutrition, and for rehydration.
>Non steroidal anti inflammatory drugs

>Anti inflammatory and anti pyretic drug.

>Continue the Cefuroxime and metronidazole

>Ambulate to promote Bowel movement

>anti bacterial drug.
>Admission of client

>Explain the medical interventions and the required consent

>Assess and get clients initial vital signs

>Instruct the client for NPO

>Obtain request form, specimen and refer to the laboratory for the test
>Check physicians order and start IV

>administer initial doze and note in medication sheet
>Check the clearance and instruments needed prior to the operation

> to inform the ROD prior to the operation
>Inform the client for NPO

other
>Check the physicians order and counter signed

>Render pre operative care
>check the physicians order and start oxygenation

>Instruct the client about NPO
>get the client VS every 15 minutes and refer any abnormalities

>Regulate IVF as desired

>Check the physicians order and start the IV.
>Administer initial doze and note at the medication sheet
>Administer the drug and note at the medication sheet.

>Instruct the client and assist to ambulate.
Administer initial doze and note at the medication sheet

NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION Subjective:

“Nanghihinaako at di masyadomakatindig” as verbalized by the client.

Objective:
>With facial grimace.
>Pale and weak in appearance.
>Always lying on bed
>with good capillary refill
>BP 100/80mmHg
?Activity intolerance related to the operation
After 8 hours of nursing intervention,The patient will be able to:
>demonstrate and perform the exercise (ROM)
>The patient will increase his activity tolerance
X > Assessed patient’s ability to perform tasks/noting reports of weakness, fatigue and difficulty accomplishing task

>Recommended quiet atmosphere; bed rest if indicated stress-need to monitor and limit visitors, phone calls and repeated unplanned interruptions.

>Elevated head of bed as tolerated.

>Provided/ recommended assistance with activities /ambulation as necessary, allowing doing as much as possible.

>Assisted patient to prioritize ADLs/desired activities.
>Influence of choice of interventions assistance.

>Enhances rest to lower body’s oxygen requirements, and reduces strain on the heart and lungs.

>Enhances lung expansion to maximize oxygenation for cellular uptake.

>Although help maybe necessary, self esteem is enhanced when patients does things for self.

>Promotes adequate rest energy level, and alleviates strain on the cardiac and respiratory systems
After eight hours nursing interventions, the patient was able to cope with fatigue and verbalization of feelings of comfort and increase activity participation

After eight hours nursing intervention the client demonstrate an increase activity tolerance.

Assessment Diagnosis Planning Intervention Rationale Evaluation Subjective:

“nananakitangtiyankosa may bandangkananibabang parte” as verbalized by the patient.

Objective:
>With facial grimace.
>pain scale of 8/10
>Pale and weak in appearance.
Acute pain related to Acute Appendicitis
After 8 hours of non-stop caring to the patient. The patient will be able to:
>lessen the pain
>demonstrate diverticulative techniques to divert pain
> Assessed the general condition of the client

>Recommended quiet atmosphere; bed rest if indicated stress-need to monitor and limit visitors, phone calls and repeated unplanned interruptions.

>Demonstrate diverticular activities.

>Administer medications such as pain killer and pain reliever to relieve pain.
>To provide baseline data

> To lessen the consumption of oxygen and promote rest and to avoid stress.

> To divert and relieve the pain
> To relieve or lessen the pain
After eight hours nursing interventions, the patient was able to demonstrate diverticular activities.
Pain lessen from 8/10 to 3/10.
DRUG STUDY

Therapeutic Classification Action Contraindicaiton Toxicity/ Side Effects Intervention Safe Doze Tramadol
– narcotic like pain reliever
NSAIDS
Anti-inflammatory. The overall analgesic profile of tramadol supports use in the treatment of intermediate pain, especially chronic pain. It is slightly less effective for acute pain than hydrocodone, but more effective than codeine. It has a dosage ceiling similar to codeine, a risk of seizures when overdosed, and a relatively long half-life making its potential for misuse relatively low amongst intermediate strength analgesics. Tramadol hydrochloride should not be administered to patients who have previously demonstrated hypersensitivity to tramadol, any other component of this product or opioids. Tramadol hydrochloride is contraindicated in any situation where opioids are contraindicated, including acute intoxication with any of the following: alcohol, hypnotics, and narcotics, centrally acting analgesics, opioids or psychotropic drugs. Tramadol may worsen central nervous system and respiratory depression in these patients. Tramadol is generally well tolerated, and side effects are usually transient. Commonly reported side effects include nausea, constipation, dizziness, headache, drowsiness, and vomiting. Less commonly reported side effects include itching, sweating, dry mouth, diarrhea, rash, visual disturbances, and vertigo. Some patients who received tramadol have reported seizures. Abrupt withdrawal of tramadol may result in anxiety, sweating, insomnia, rigors, pain, nausea, diarrhea, tremors, and hallucinations. Monitor V/S 50-100mg Therapeutic Classification Action Contraindicaiton Toxicity/ Side Effects Intervention Safe Doze Paracetamol
Anti Pyretic, Pain reliever Paracetamol reduces the synthesis of prostaglandins which are responsible for the mediation of pain and fever. Paracetamol is contraindicated in hypersensitivity, analgesic nephropathy, renal and hepatic impairment. is caused by excessive use or overdose of the analgesic drugparacetamol (called acetaminophen in North America). Mainly causing liver injury, paracetamol toxicity is one of the most common causes of poisoning worldwide. In the United States and the United Kingdom it is the most common cause of acute liver failure. Monitor V/S 500mg Therapeutic Classification Action Contraindicaiton Toxicity/ Side Effects Intervention Safe Doze Cefuroxime
Antibiotic/ Antibacterial Cefuroxime is a semisynthetic cephalosporin antibiotic, chemically similar to penicillin. Cephalosporins stop or slow the growth of bacterial cells by preventing bacteria from forming the cell wall that surrounds each cell. The cell wall protects bacteria from the external environment and keeps the contents of the cell together. Without a cell wall, bacteria are not able to survive. Hypersensitivity to cephalosporins. Swelling, redness, pain, or soreness at the injection site may occur. This medication may also infrequently cause loss of appetite, nausea, vomiting, diarrhea, irritability, orheadache. monitor V/S – Powder for Injection 750 mg (2.4 mEq sodium/g)
– Powder for Injection 1.5 g (2.4?mEq sodium/g)
– Powder for Injection 7.5 g (2.4 mEq sodium/g)
– Injection 750 mg (2.4?mEq sodium/g)
– Injection 1.5 g (2.4 mEq sodium/g)
Health Education
Appendicitis Assessment:
A year old female cilent was admitted at the Surgery ward with chief complaint of Right Lower Quadrant pain since Last Night . General Objective:
After 8 hours of nurse-patient-significant others interaction. The patient will be able to acquire knowledge, skills and attitude in the care of patient with Acute Appendicitis
Specific Objectives Content Outline Teaching Method 1.Define Acute Appendicitis
2.Enumerate some manifestations of Acute Appendicitis

3.. Enumerate different ways to relieve pain
Appendicitis is a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases requires removal of the inflame appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to infection and inflammation of the intestinal lining (peritoneum) and eventual sepsis, clinically known as peritonitis which can lead to circulatory shock

Manifestations of Acute Appendicitis
– RLQ Pain at first
– Vomimtting
– Fever

Diverticular Techniques
* Diverticular activities
* Pain Reliever
* Encourage S.O. to give the medications on right time -Formal and informal discussions
-Lecture
-Leaflets
-Flashcards
-Images

Discharge Planning
M Medication -MefenamicAcidthrice a day for pain in one week
-Cephalexin Thrice a day in one week
-Ferrous Sulfate Once a day in one month E Environment -Ensure safety precautions outside and inside the house
-Keep patient away from materials or equipments that may harm him
-Make sure that the patient’s bed is near the restroom
-Remove floor mats or anything that may cause injury T Treatment -Follow up check up after 2 weeks for repeat FBS H Health Teaching -Provide adequate knowledge regarding postpartum prescribed by the dietician
-Encourage SO to give medications at home on the right time and right dose
-Explain the importance of eating foods that prevents constipation O Observation -No further complaints noted. Patient started to show good signs of recovery. D Diet -Refer to dietician for diet
Prognosis

After the patient had undergone the surgery, and have removed her appendix by surgical procedure called appendectomy the patient is now at state of wellness. It takes 3-4 days to be totally recovered after the procedure. The client is now well and discharged from the QMC Surgery Ward. The patient is now free from appendicitis and has no further chance to occur again.
IMPLICATION OF THE STUDY
The implication of this study in the practice of nursing serves as a guide or a tool for the fellow nursing students and staff nurses. It provides a detailed background, management, interpretations and documentations for patients who have Acute Appendicitis. It will help broaden the knowledge and skills of the healthcare team.
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