I



I. Introduction

As part of the health care team, it is very much challenging and critical for us student nurses, to care for the patient with Appendicitis, since patient deserve the ultimate care a nurse can render. The student nurse chose this disease as her case study because she was curious of how this disease develop, from simple tummy ache that can lead to death in just small span of time. This case study also serves as a knowledge experience of the student nurse for her to be able to utilize in the future if she will encounter the same disease. Above all, among the definitions of Appendicitis the student nurse encountered, fatality is very much attached to it, and because of this, the student nurse is very much aware what the disease can do to the patient and that she needs to give her optimum care.

Appendectomy is a surgical intervention, which involves the removal of the appendix within 24 to 48 hours of the onset of manifestations in a patient who is experiencing appendicitis. It is done as soon as possible to decrease the risk of perforation. The surgery is performed through a small open incision or a laparoscope (a lighted scope used to visualize and remove the appendix) or through a low abdominal incision under general or spinal anesthesia. When the operation is performed in time, the mortality rate is less than 0.5%. Delay usually causes rupture of the organ and resultant peritonitis. The primary goal of treatment for patient’s undergoing appendectomy is the prevention of complications such as perforation of the appendix which may lead to peritonitis. It is also performed to remove an inflamed appendix. The surgeon cuts through layers of skin, fat, and muscle, and the peritoneal membrane that lines the abdomen to reach the appendix, which is attached to the caecum, a rounded pouch at the beginning of the large intestine. The caecum and appendix are lifted out of the abdominal cavity through the incision. After tying off the blood vessels in the base of the appendix, the surgeon cuts off the body of the appendix and sutures the stump. The caecum and stump are then tucked back into the abdominal cavity, and the incision is closed.

The student nurse also chose this case study to improve her management skills to patients undergoing appendectomy. This will help her develop the use of the nursing process appropriate in the care of such patients.

Expectations from this case study would include broadening the knowledge and development of the student’s nurse skills about pre – operative and post – operative management to a patient undergoing this surgical procedure. This will also harness her decision making ability appropriate to the care of such patients. And this will also help her in understanding the nature of the operation, its complications, and measures that promote the quality of life that patients deserve undergoing this surgical procedure.

II. Objectives

Student- Nurse Centered

General

After 2 days of rendering holistic nursing care, the student nurse will be able to develop and improve her knowledge, attitude, and skills in the care of a patient who has undergone appendectomy.

Specific

After 2 days of rendering holistic nursing care, the student nurse will be able to:

1. establish rapport with the patient

2. perform a thorough nursing assessment of the patient who has undergone appendectomy

3. identify nursing problems experienced by the patient

4. discuss the following:

4.1the anatomy and physiology of the organ affected in

appendectomy

4.2 normal level of growth and development of patient and the ill

patient at particular age

5. impart health teaching regarding appendectomy as to its :

5.1complications

5.2 predisposing factors

5.3 management

6. trace the pathophysiology of the organ affected in appendectomy

7. formulate a comprehensive nursing care plan for the patient and implement it

8. utilize the nursing process in caring patients who has undergone

appendectomy

9. terminate interaction with the patient

10. evaluate the effectiveness of care given to the patient

Patient Centered

General

After 2 days of student nurse-client interaction, the patient and family will be able to gain knowledge, attitude, and skills in the care of a patient who has undergone appendectomy.

Specific

After 2 days of student nurse – client interaction, the patient and family will

be able to :

1. establish and gain communication with the student nurse

2. identify the complications of appendectomy

3. verbalize feelings and concerns

4. develop a modified lifestyle appropriate before and after the surgical operation

5. take appropriate measures for the pre-operative and post-operative management of appendectomy

6. follow specific treatment regimen ordered or taught

7. demonstrate beginning skills in the management before and after the surgical operation

III. Nursing Assessment

1. Personal History

1.1 Patient’s Profile

Name: Mr. Cuizon, Demetrio

Age: 47 years old

Sex: Male

Civil Status: Married

Religion: Roman Catholic

Date of Admission: Jan 13, 2006

Hospital No.: 630359

Admission No.: 630359

Room no.: MS9

Chief complaint: Periumbilical Pain

Admitting Impression: Acute Appendicitis

Final Diagnosis: Ruptured Appendix with Periappendiceal Abscess

Physician: Dr. Embay, Selwyn

1.2 Family and Individual information, Social & Health History

Mr. Cuizon, Demetrio, 43 years of age, married with five siblings, is a Roman Catholic & a Filipino citizen, and lives in Canasujan carcar cebu, admitted in Cebu Doctors’ Unversity Hospital for the first time due to periumbilical pain.

He is a non-hypertensive, non-diabetic, and is not asthmatic. The patient does not have any history of food or drug allergies. He is a cigarette smoker (5 sticks per day) and drinks alcoholic beverages such as tanduay and beer na beer. He has no history of heredofamilial diseases such as hypertension, CVA, myocardial infarction and atherosclerosis. He has no previous hospitalization.

The patient had sudden onset of periumbilical pain, sharp, on and off, at times radiating to epigastric and right upper quadrant area. This happened six days prior to admission. It was not associated with food intake, no vomiting but with anorexia. It was also associated with constipation for three days. So, he consulted a physician and was given unrecalled medicines for pain relief. But persistence of condition prompted the patient to seek further management here in Cebu and thus sought consult with attending physician in Cebu Doctors’ University Hospital and was admitted in the said institution.

1.3 Level of Growth and Development

1.3.1 Normal Development at Particular Stage

(Middle-Aged Adulthood 40-65)

Physical Development

A number of changes take place during the middle years. At 40, most adults can function as effectively as they did in their twenties. However, during ages 40 to 65, many physical changes take place.

Both men and women experience decreasing hormonal production during the middle years. The menopause refers to the so-called change of life in women, when menstruation ceases. It is aid to have occurred when a woman has not had a menstrual period within a year. The menopause usually occurs anywhere between ages 40 and 55.

The climacteric (andropause) refers to the change of life in men, when sexual activity decreases. In men, there is no change comparable to the menopause in women. Androgen levels decrease very slowly; however, men can father children even in late life.

Sexuality

After the departure of their last child from the home, many couples recultivate their relationships and find increased marital and sexual satisfaction during middle age. The onset of menopause and the climacteric can affect the sexual health of middle adult. A woman may desire increased sexual activity because pregnancy is no longer possible.

During middle age a man may notice changes in the strength of his erection and a decrease in his ability to experience repeated orgasm. Other factors influencing sexuality during this period include work, stress, diminished health of one or both partners, and the use of prescription medications, for example, antihypertensive agents, with side effects that may influence sexual desire or functioning. Both partners may experience stresses related to sexual changes or a conflict between their sexual needs and self-perceptions and social attitudes or expectations.

Psychosocial Development

Erikson viewed the development choice of the middle adult as generativity versus stagnation. Generativity is defined as the concern for establishing and guiding the next generation. In other words, there is concern about providing welfare of humankind that is equal to the concern of providing for self. People in their 20s or 30s tend to be self and family centered. In middle age, the self seems more altruistic actions, such as church work, social work, political work, community fund raising drives and cultural endeavors. Marriage partners have more time for companionship and recreation; thus marriages are more satisfying in the middle years of life. Generative middle-aged people are able to feel a sense of comfort in their lifestyle and receive gratification from charitable endeavors. Erikson believes that persons who are unable to expand their interest at this time and who do not assume the responsibility of middle age adult may suffer a sense of boredom and impoverishment that is stagnation. These people have difficulty accepting that their aging bodies and become withdrawn and isolated. They are preoccupied with their self and unable to give to others.

The middle-aged person looks older and feels older. People usually accept the fact that they are aging, however a few try to defy the years by their dress and even their actions. Some men and women have extramarital affair and marry younger partners. A new freedom to be independent and follow one’s individual interest arises. Prior to this period, the marriage partner or lover and other person were crucial to the definition of self. Now the middle-aged person who does not make comparison with others, no longer fears aging or death relaxes the sense of competitiveness and enjoys independence and freedom. Other people’s opinion becomes less important, and the earlier habit of trying to please everybody is overcome. The person establishes ethical and moral standards that are independent of the standards of others. The focus shifts from inner self and being to others and doing. Religious and philosophical concerns become important.

Hultsch and Deutsch suggest that it is not the events themselves that make midlife a crisis, but an individual’s response to these life events. How will an individual respond? According to Hultsch and Deutsch, the resources of the person, the ability to use effective coping strategies, and the life stage at which an event occurs will influence any changes in behavior. Internal and external resources include physical health, family income, the social support system, intelligence and personality. Thus, the crisis or transitions of middle are not just within the individual but also between the individual and the individual’s world.

Cognitive Development

The middle-aged adult’s cognitive and intellectual abilities change very little. Cognitive process includes reaction time, memory, perception, learning, problem solving and creativity. Reaction time during the middle years stays much the same or diminishes during the latter part of the middle years. Memory and problem solving are maintained through middle adulthood. Learning continues and can be enhanced by increased motivation at this time in life.

Middle-aged adults are able to carry out all the strategies described in Piaget’s phase of formal operation. Some may use post-formal operation strategies to assist them in understanding the contradictions that exist in both personal and physical aspects of reality. The experiences of the professional, social and personal life of middle-aged persons will be reflected in their cognitive performance. Thus, approaches problem solving and task completion will vary considerably in middle aged groups. The middle-aged adult can reflect on the past and current experience and can imagine, anticipate, plan and hope.

Moral Development

According to Kohlberg, the adult can move beyond the conventional level to the postconventional level. Kohlberg believes that extensive experience of personal moral choices and responsibility is required before people can reach the postconventional level. Kohlberg found that few of his subjects achieved the highest level of moral reasoning. To move from stage 4, a law and order orientation, to stage 5, a social contract orientation, requires that the individual move to a stage in which rights of others take precedence. People in stage 5 take steps to support other’s rights.

Spiritual Development

      Not all adults progress through Fowler’s stages to the fifth, called the paradoxical-consolidative stage. At this stage, the individual can view “truth” from a number of viewpoints. Fowler’s fifth stage corresponds to the Kohlberg’s fifth stage of moral development. Fowler believes that only some individuals after the age of 30 years reach this stage.

      In middle age, people tend to be less dogmatic about religious beliefs, and religion often offers more comfort to the middle-aged person than it did previously. People in this age group often rely on spiritual beliefs to help them deal with illness, death, and tragedy.

1.3.2 The Ill Person At Particular Stage

The middle adult may not present in a "classical" manner. Altered response to illness is common. Social and psychological factors may further obscure this "classical" presentation. Frequently the presentation is that of the "geriatric giants": confusion, falls, immobility and incontinence. Each of these "giants" is an indication for a more detailed assessment. Presentation may also be delayed because of various fears (such as that of hospitalization), loss of faith in the health care system, denial or depression. Illness response to even appropriate treatment may not always show the same dramatic recovery as in the young, thereby also impacting on the functional status.

The patient, when they feel tired and feel ache’s especially in their abdomen, usually don’t pay much attention to these signs because they believe it to be natural to aging. A researched has revealed that patients tend to underreport information about appendicitis symptoms primarily because they lack knowledge of them but also because they inaccurately diagnose for themselves. Patients often mistakenly identify appendicitis symptoms as signs of simple stomachache.

Many middle adult patients readily recognize abdominal pain (abdominal pain near navel - in earliest stages, right-side abdominal pain - in later stages, abdominal pain on activity, abdominal pain on breathing, abdominal pain on coughing, abdominal pain on sneezing, and abdominal sensitivity - touching the area is painful), nausea, vomiting, constipation, diarrhea, loss of appetite, inability to pass gas, low fever, abdominal swelling, and bad breath are often not recognized as being related to appendicitis and are often ascribed to aging and just a simple stomachache. Often the awareness that these symptoms might be related to appendicitis is all that’s needed to motivate patients to undergo surgery.

2. Diagnostic Results

|Diagnostic Test |Normal Values |Patient’s Results |Significance |

|June 13, 2006 | | | |

| | | | |

|CBC | | | |

| | | | |

|Hemoglobin |14-17.5 g/dl |15 g/dl |Normal |

| | | | |

|Hematocrit |41.5-50.4 % |42% |Normal |

| | | | |

|Red Blood Cell |4.5-5.9x10^8 /uL |4.60 10^8/uL |Normal |

| | | | |

|White Blood Cell Count | | | |

| |1,100-11,000/cumm |7.290/cumm |Normal |

|Mean | | | |

|Corpuscular Hemoglobin |27.5-33.2 pg | | |

| | |27.9 pg |Normal |

|Mean Corpuscular Volume | | | |

| | | | |

|Mean Corpuscular Hemoglobin |80-96 fL | | |

|Conc. | |81.4 fL |Normal |

| | | | |

|Platelet | | | |

| |33.4-35.5 % | | |

| | |34.2 % |Normal |

|Differential Counts | | | |

| | | | |

|Segmenters | | | |

| |150,000-450,000/cumm | | |

|Alt | |220,000/cumm |Normal |

| | | | |

|ALKP | | | |

| | | | |

| |40-70% | | |

| | | | |

| |9.-72. |52 % |Normal |

| | | | |

| |38.-126. |50. u/L |Normal |

| | | | |

| | |100. u/L |Normal |

Source: Medical-Surgical Nursing 10th Edition by Suzanne C. Smeltzer and

Brenda G. Bare

Ultrasound

Examination: whole abdomen

Interpretation:

The liver and spleen are not enlarged. There is a 1.9x1.4x1.2cm cyst seen at the right lobe of the liver. No solid mass seen. The gallbladder is unremarkable with no evidence of calculi seen. The gallbladder wall is not thickened and measures 3mm in thickness. The common duct is not dilated and measures 3mm in its AP diameter. The rest of the intrahepatic ducts are unremarkable.

The pancreas and abdominal aorta are unremarkable. The aorta measures 1.7cm in its AP diameter. No masses seen in the paraaortic area.

Right Kidney10.1x3.8cm 1.2cm cortex

Left Kidney 1.0x4.3cm 1.4cm cortex

The central echo complexes and renal cortices are intact. There is a 4.2mm and 2.8mm calculi seen at the right middle and inferior calyces respectively. There is a 7mm calculus with localized cahectasia seen at the left superior pole. No solid mass seen.

The filled urinary bladder is unremarkable with no evidence of calculi or mass seen.

The prostate is not enlarged and measures 2.9x3.1x3.1cm with an estimated weight of 15 grams. No focal lesion seen.

Note minimal ascites seen.

Remarks: Minimal Ascites

3. Physical Assessment (IPPA)

|Body Part |I |P |P |A |

| | | | | |

|Skin |dark brown complexion |good turgor, warm to touch | | |

| | | | | |

| |normoce-phalic, no |no lumps & tenderness | | |

|Head |irregularities | | | |

| | | | | |

| |scanty, black short hair |smooth, not oily | | |

| | | | | |

|hair |absence of dandruff & |no lumps/mass | | |

| |parasites | | | |

| | | | | |

|scalp |symmetrical facial features|no tender areas & no pimples | | |

| |& movements, tired and | | | |

| |weary | | | |

| | | | | |

|Face |presence of wrinkles |no masses | | |

| | | | | |

| |thin, hair evenly | | | |

| |distributed, aligned |no lumps | | |

| |together | | | |

| | | | | |

|forehead |curves outward | | | |

| | | | | |

| |symmetrical movements, dark| | | |

|eyebrows |& sunken | | | |

| | | | | |

| |clear, corneal light | | | |

| |reflexes present, equal |no edema | | |

| |reactions of both sides | | | |

| | | | | |

|lashes | | | | |

| | | | | |

| | | | | |

|eye | | | | |

| | | | | |

| | | | | |

| | | | | |

|-cornea | | | | |

| | | | | |

|Body Part |I |P |P |A |

| | | | | |

|-conjunctiva |pink, moist | | | |

| | | | | |

|-sclera |aniscleric, white | | | |

| | | | | |

| |equally round reactive to| | | |

|-pupils |light & accommo-dation, | | | |

| |papillary high reflexes, | | | |

| |equal reactions of both | | | |

| |sides | | | |

| | | | | |

| |black | | | |

| | | | | |

| |followed moving objects | | | |

| |properly | | | |

| | | | | |

| |not strabismus | | | |

|-iris | | | | |

| |lids are color brown, | | | |

|Muscle Function |closes symmetrically, no | | | |

| |discharges | | | |

| | | | | |

| |no discharges | | | |

| | | | | |

|Muscle Balance |with eyeglasses, | | | |

| |nearsighted, can read | | | |

| | | | | |

|- upper & lower Lids | | | | |

| | | | | |

| | | | | |

| | | | | |

|-lacrimal ducts | | | | |

| | | | | |

|Visual Acuity | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

|Body Part |I |P |P |A |

| | | | | |

|nose |not obstructed, central |not painful | | |

| |position, no mucous | | | |

| |secretions, patent | | | |

| | | | | |

| |no occlusion when | | | |

| |transillu-mination is | | | |

| |done | | | |

| | | | | |

|- frontal & maxillary sinuses| |not tender | | |

| | | | | |

| | | | | |

| |dry, pink-brown | | | |

|mouth | | | | |

| |pink, moist | | | |

|- lips | | | | |

| |no dentures, 32 teeths | | | |

| | |smooth | | |

|- gums |pink | | | |

| | | | | |

|- teeth |pink |soft | | |

| | | | | |

| | |hard & stable | | |

|- hard palate | | | | |

| |straight & hanging | | | |

|- soft palate | |hard | | |

| |normal | | | |

| | |soft, gag reflex present | | |

| |not inflamed, pink | | | |

|- uvula | | | | |

| | | | | |

| | | | | |

|- frenulum | | | | |

| | | | | |

|-tonsils | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

|Body Part |I |P |P |A |

| | | | | |

|ears |no occlusion, symmetrical|not painful, no lumps / | | |

| |on both sides, upper |mass | | |

| |auricle in line with | | | |

| |outer contour of eye, | | | |

| |hearing is clear | | | |

| | | | | |

| | | | | |

| | | | | |

| |same as normal skin tone | | | |

| | | | | |

| | | | | |

| | | | | |

|Neck | |no lumps/mass | | |

| |central position | | | |

| | | | | |

| |not enlarged |not palpable | | |

|lymph nodes | | | | |

| | | | | |

|trachea |no skin lesions | | | |

| | | | | |

| | | | | |

|thyroid gland | | | | |

| | | | | |

|Chest | | | | |

| | |no masses | | |

| | | | | |

|heart | | | | |

| |equal lung expansion | | | |

| | | | |regular/normal rate and |

| | | | |rhythm = 78 bpm, no |

| | | | |murmurs |

| | | | | |

| | | | | |

|lungs | | | |normal breath sounds= |

| | |equal chest excursion | |20bpm, no crackles / |

| | | |resonant sound |wheezes |

| | | | | |

| | | | | |

|Body Part |I |P |P |A |

| | | | | |

|abdomen |flat with suture present |soft, smooth, warm to |tympanic sound |bowel sounds= 2 gurgling |

| |in the right lower |touch, painful(8/10 pain | |sounds/bowel sounds per |

| |quadrant |scale where 10 is the | |minute |

| | |highest), kidney and | | |

| | |spleen are not palpable, | | |

| | |liver is not enlarged | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| |without foley bag |PR= 79bpm | | |

|Genitalia |catheter |Temp.=37.1 degrees | | |

| | |Celsius | | |

| | |Capillary refill= 1 sec. | |BP= 130/80 |

|Extremities | | | | |

| |weak muscle strength but | |moderate biceps and wrist| |

|upper |able to give resistance, | |reflexes | |

| |with IV # 9 D5NM;L@30 | | | |

| |gtts/min infusing well at| | | |

| |dorsal left hand |weak muscle strength | | |

| | | | | |

| |able to walk but with | | | |

| |assistance and slowly, | | | |

| |pain and fatigue upon | | | |

| |standing and moving | | | |

| | | | | |

| | | | | |

|lower | | | | |

| | | | | |

| | | | | |

| | | | | |

4. Present Profile and Functional Health Patterns

Health Perception/Health Management Pattern

Before and after the operation patient described his health as fair when questioned. He used to perceive a perfect health before, when he actually did. He was only hospitalized now. Good nutrition keeps him healthy. Periumbilical pain is the reason for his hospitalization. He expected to feel well. He is not restricted to any foods. He was able to follow the prescribed instruction by the doctor and nurses. He had complete immunizations. There are no mobility problems and sensory deficits he possessed.

Nutritional/Metabolic Pattern

He doesn’t like to eat a lot and has lost his appetite especially since he is admitted in the hospital. Before his admission, the patient doesn’t eat as much because of his anorexia which is not associated with vomiting. His usual fluid intake is 8-10 glasses of water per day. At 12 midnight (Saturday) prior to his operation in the morning, he is NPO. After the operation, he is still in NPO state. He has no vitamins taken. He lose weight (4 lbs.) now because of his disease. He has no problem with ability to eat. He doesn’t have any allergies to any foods and medicines.

Elimination Pattern

Six days before his appendicitis occurred, he can void freely and normally. But when the disease occurred, he experienced constipation. After the surgical procedure, he remained constipated with 2 bowel sounds per minute. He has no problems or complaints with usual pattern of urinating. No assistive devices used in urinating and defecating.

Activity/Exercise Pattern

His usual activity at home is cleaning the house, watching television, and reading newspapers. His exercise is jogging and walking in the street. He has no complaints of dyspnea or fatigue before the operation. He can move freely without assistance. But after the surgery, there is pain and fatigue he felt upon standing and moving. Although, there are no limitations in his ability to move, he is assisted by his daughter because he has weak muscle strength on his lower extremities.

Cognitive/Perceptual Pattern

The patient is oriented to time, place and person (student nurse). He knows his health condition. He has no complaints of head problems. He is able to read and write. The patient is able to use all of his senses. The patient is nearsighted and uses eyeglasses when reading. The patient has keen visual and auditory acuity.

Sleep/Rest Pattern

He had no problems of sleeping before and after the operation. But sometimes awaken because of the pain felt at the sight of surgery .He usually gets 6-8 hours of sleep per day until after the operation is done. His usual time of sleeping is 9pm and wakes up at 7am.

Self-Perception Pattern

The patient is very much aware of the surgical procedure. He has come to accept the fact that he needs help with almost everything concerning his health, even the simplest task such as reminding himself of his medications. He stated that he is excited to go home. He wants to resume to his daily activities. I did inform the patient that he will not be able to resume to his usual activities for about 2 to 4 weeks.

Role Relationship Pattern

He verbalized that his role in life is being a loving husband and father as well. He has five children, two are girls and three are boys. They all have very loving relationship with each other. He speaks and understands the English, Filipino/Tagalog, and Cebuano dialect. His speech is clear and relevant. He freely expresses himself verbally, in writing and with gestures. He also understands other people.

Sexual Reproductive Pattern

The patient is not sexually active due to his age.

Coping-Stress Tolerance Pattern

The decision making in their home comes from him and his wife. He has no loss in his life in the past year. He likes about himself by being disciplinarian and working hard for his family.

Value-Belief System

The patient is a Roman Catholic as well as his family. God is his source of strength or meaning. Religion and God are important to him. He goes to church every Sundays and other special occasions together with his family. His values or moral beliefs have not been challenged of his condition but it strengthens.

5. The Normal Anatomy and Physiology of Organ/System Affected

Appendix

It is formally vermiform appendix in anatomy, a vestigial hollow tube attached to the cecum; the blockage of the appendix can result in appendicitis. Appendix The appendix is a narrow, muscular tube that is closed at one end and is attached to and opens into the cecum at its other end. (The cecum is the pouchlike beginning of the large intestine; the small intestine empties into the cecum.) The appendix does not serve any useful purpose as a digestive organ in humans, and it is believed to be gradually disappearing in the human species over evolutionary time. (The vermiform appendix exists only in human beings and higher apes, but an appendix-like structure does exist in wombats, civets, rodents, and a few other lower animals.)The appendix is usually 8 to 10 cm (3 to 4 inches) long and less than 1.3 cm (0.5 inch) wide. The cavity of the appendix is much narrower where it joins the cecum than it is at its closed end. The appendix has muscular walls that are ordinarily capable of expelling into the cecum the mucous secretions of the appendiceal walls or any of the intestinal contents that have worked their way into the structure. If anything blocks the opening of the appendix, or prevents it from expelling its contents into the cecum, appendicitis may occur. The most common obstruction in the opening is a fecalith, a hardened piece of fecal matter. Swelling of the lining of the appendiceal walls themselves can also block the opening. When the appendix is prevented from emptying itself, a series of events occurs. Fluids and its own mucous secretions collect in the appendix, leading to edema, swelling, and the distention of the organ. As the distention increases, the blood vessels of the appendix become closed off, causing the necrosis (death) of appendiceal tissue. Meanwhile, the bacteria normally found in this part of the intestine begin to propagate in the closed-off pocket, worsening the inflammation. The appendix, weakened by necrosis and subject to increasing pressure from within by the distention, may burst; spilling its contents into the abdominal cavity and infecting the membranes that line the cavity and cover the abdominal organs (see peritonitis). Fortunately peritonitis is usually prevented by the protective mechanisms of the body. The omentum, a sheet of fatty tissue, often wraps itself about the inflamed appendix, and an exudate that normally develops in the areas of inflammation behaves like glue and seals off the appendix from the surrounding peritoneal cavity.

It is also a worm – shaped tube that arises from the medial side of the cecum. It is a potential trouble spot, since it is usually twisted, an ideal location for bacteria to accumulate and multiply. It is a narrow, muscular tube containing a large amount of lymphoid tissue. The appendix has no known function but it does contain immune cells, which plays a role in defending the body from infection. The appendix may serve a purpose in a diet including occasional raw meat. Specifically, it may allow bacteria useful in the digestion of raw meat to be retained, rather than flushed from the system during long intervals between raw meat meals. Though the organ is not a vital one, a patient survives perfectly well following the removal of the appendix. It varies in length from 3 to 5 inches (8 to 13 centimeters). The base is attached to the posteromedial surface of the cecum about 1 inch (2.5 centimeters) below the ileocecal junction. The remainder of the appendix is free. It has a complete peritoneal covering, which is attached to the lower layer of the mesentery of the small intestine by a short mesentery of its own, the mesoappendix. The mesoappendix contains the appendicular vessels and nerves.The appendix lies in the right iliac fossa, and in relation to the anterior abdominal wall, its base is situated one – third of the way up to the line joining the right anterior superior iliac spine to the umbilicus (McBurney’s point). Inside the abdomen, the base of the appendix is easily found by identifying the teniae coli of the cecum and tracing them to the base of the appendix, where they converge to form a continuous longitudinal muscle coat.

The tip of the appendix is subject to a considerable range of movement and may be found in the following positions:

1) hanging down into the pelvis against the right pelvic wall,

2) coiled up behind the cecum in the retrocecal fossa,

3) projecting upward along the lateral side of the cecum, and

4) in front of or behind the terminal part of the ileum.

The first and second positions are the most common sites. The arterial supply of the appendix is by means of the appendicular artery, a branch of the posterior cecal artery. It passes the tip of the appendix in the mesoappendix. The appendicular vein joins the posterior cecal vein. The lymph vessels drain into one or two nodes lying in the mesoappendix. From there, the lymph passes through a number of mesenteric nodes to reach the superior mesenteric nodes. The nerves of the appendix are derived from sympathetic and parasympathetic (vagus) nerves from the superior mesenteric plexus. Afferent nerve fibers concerned with the conduction of visceral pain from the appendix accompany the sympathetic nerves and enter the spinal cord at the level of the tenth thoracic segment.

Picture/Illustration of Vermiform Appendix

[pic]

6. Pathophysiology and Rationale

6.1 Schematic Drawing (Pathophysiology of Appendicitis)

Predisposing Factors Precipitating Factors

- obstruction of the appendix - age (between10 and

by a fecalith, inflammation, 30 years old)

foreign body or neoplasm - adolescents and

- kinking of the appendix young adults

- swelling of the bound wall - older adults (ruptured

- fibrous conditions in the of the appendix)

bound wall

- external occlusion of the

bowel by adhesions

[pic]

Signs Symptoms

- nausea - constipation

- vomiting - diarrhea

- low grade fever - Rovsing’s sign

- bad breath - muscle spasm

- microscopic hematuria - Psoa’s sign

- mild leukocytosis - inability to pass

- pyuria gas

- coated-tongue - loss of appetite

- vague epigastric pain on right lower quadrant

Nursing Management Medical Management Surgical Management

- relieving pain - prevent fluid and - appendectomy (surgi-

- preventing fluid electrolyte imbalance cal removal of the

volume deficit and dehydration appendix) is perfor-

- reducing anxiety - antibiotics and intravenous med to decrease the

- eliminating fluid is administered risk of perforation

infection from the until surgery is performed

potential or actual - analgesics can be

disruption of the administered after the

GI tract diagnosis is made

- maintaining skin

integrity

- attaining optimal

nutrition

6.2 The Disease Process

Appendicitis is the inflammation of the appendix, a small portion of the large intestine that hangs down from the lower right side. Although the appendix does not seem to serve any purpose, it can still become diseased. If untreated, an inflamed appendix can burst, causing infection and even death. It may occur after a viral infection in the digestive tract or when the tube connecting the large intestine and appendix is blocked by trapped stool. The inflammation can cause infection, a blood clot, or rupture of the appendix. Because of the risk of rupture, appendicitis is considered an emergency. Anyone with symptoms needs to see a doctor immediately.

A person experiencing an attack of appendicitis may feel pain all over the abdomen or only in the upper abdomen or about the navel. This pain is usually not very severe. After one to six hours or more the pain may become localized to the right lower abdomen. Nausea and vomiting may develop some time after the onset of the pain. Fever is usually present but is seldom high in the early phases of the attack. The patient's leukocytes (white blood cells) are usually increased from a normal count of 5,000–10,000 in an adult to an abnormal count of 12,000–20,000; this phenomenon can be caused by many other acute inflammatory conditions that occur in the abdomen. In a person with a normally sited appendix, the pain of appendicitis is situated at a point between the navel and the front edge of the right hipbone. But many people have their appendix lying in an abnormal position, and they thus may feel the pain of an appendicitis attack in a different or misleading location, making their symptoms difficult to distinguish from the abdominal pain caused by a variety of other diseases. Careful diagnostic examination by a physician can usually determine if acute appendicitis is indeed causing a patient's abdominal pain.The basic treatment of appendicitis is the surgical removal of the appendix in a minor operation called an appendectomy. The operation itself requires little more than a half hour to carry out under anesthesia and produces relatively little postoperative discomfort. If a diagnosis of acute appendicitis cannot immediately be made with reasonable certainty, it is now customary to wait and observe the patient's symptoms for a period from 10 to 24 hours so that a definitive diagnosis can be made. This wait does slightly increase the risk that the appendix will rupture and peritonitis set in, so the patient is kept under careful medical surveillance at this time.

An appendectomy is a surgical intervention, which involves the removal of the appendix within 24 to 48 hours of the onset of manifestations in a patient who is experiencing appendicitis. It is done as soon as possible to decrease the risk of perforation. The surgery is performed through a small open incision or a laparoscope (a lighted scope used to visualize and remove the appendix) or through a low abdominal incision under general or spinal anesthesia. When the operation is performed in time, the mortality rate is less than 0.5%. Delay usually causes rupture of the organ and resultant peritonitis. The primary goal of treatment for patient’s undergoing appendectomy is the prevention of complications such as perforation of the appendix which may lead to peritonitis. It is also performed to remove an inflamed appendix. The surgeon cuts through layers of skin, fat, and muscle, and the peritoneal membrane that lines the abdomen to reach the appendix, which is attached to the cecum, a rounded pouch at the beginning of the large intestine. The cacum and appendix are lifted out of the abdominal cavity through the incision. After tying off the blood vessels in the base of the appendix, the surgeon cuts off the body of the appendix and sutures the stump. The cecum and stump are then tucked back into the abdominal cavity, and the incision is closed.

6.3 Comparative Chart

| | | |

|Classical |Clinical |Rationale |

|Low grade fever |Not Manifested |Due to inflamed appendix. |

| | | |

| | |Source: |

| | |Medical-Surgical Nursing 10th |

| | |Edition by Suzanne C. Smeltzer and Brenda |

| | |G. Bare |

|Abdominal pain |Manifested |Inflammation of the appendix. |

| | | |

| |- Patient has periumbilical pain radiating |Source: |

| |to epigastric and right upper quadrant |Medical-Surgical Nursing 10th |

| |area. |Edition by Suzanne C. Smeltzer and Brenda |

| | |G. Bare |

|Constipation |Manifested |Abdominal wall & the intestine is |

| | |compressed by the acute appendicitis |

| |- Patient experienced constipation six days|causing decreased GI tract motility or |

| |prior to admission and after the surgical |peristalsis. |

| |procedure | |

| | |Source: |

| | |Medical-Surgical Nursing 10th |

| | |Edition by Suzanne C. Smeltzer and Brenda |

| | |G. Bare |

| | | |

|Diarrhea |Not Manifested |Increased gastrointestinal tract |

| | |motility/peristalsis due to compressed |

| | |abdominal wall and intestine. |

| | | |

| | |Source: |

| | |Medical-Surgical Nursing 10th |

| | |Edition by Suzanne C. Smeltzer and Brenda |

| | |G. Bare |

| | | |

|Anorexia |Manifested |Poor appetite |

| | | |

| |- Patients lost his appetite because of his|Source: |

| |condition. |Medical-Surgical Nursing 10th |

| | |Edition by Suzanne C. Smeltzer and Brenda |

| | |G. Bare |

|Nausea and vomiting |Not Manifested |Nausea and vomiting is also common during |

| | |Appendicitis due to inflammation of the |

| | |vermiform appendix and the feeling of |

| | |fullness. |

| | | |

| | |Source: |

| | |Medical-Surgical Nursing 10th |

| | |Edition by Suzanne C. Smeltzer and Brenda |

| | |G. Bare |

| | | |

|Extreme tiredness (fatigue) |Manifested |Because of the disease process. |

| | | |

| |- Patient feels fatigue upon standing. |Source: |

| | |Medical-Surgical Nursing 10th |

| | |Edition by Suzanne C. Smeltzer and Brenda |

| | |G. Bare |

| | | |

IV. Nursing Intervention

1. Surgical Management

Appendectomy is a surgical intervention, which involves the removal of the appendix within 24 to 48 hours of the onset of manifestations in a patient who is experiencing appendicitis.

Procedure:

It is done as soon as possible to decrease the risk of perforation. The surgery is performed through a small open incision or a laparoscope (a lighted scope used to visualize and remove the appendix) or through a low abdominal incision under general or spinal anesthesia. When the operation is performed in time, the mortality rate is less than 0.5%. Delay usually causes rupture of the organ and resultant peritonitis. The primary goal of treatment for patient’s undergoing appendectomy is the prevention of complications such as perforation of the appendix which may lead to peritonitis. It is also performed to remove an inflamed appendix. The surgeon cuts through layers of skin, fat, and muscle, and the peritoneal membrane that lines the abdomen to reach the appendix, which is attached to the caecum, a rounded pouch at the beginning of the large intestine. The caecum and appendix are lifted out of the abdominal cavity through the incision. After tying off the blood vessels in the base of the appendix, the surgeon cuts off the body of the appendix and sutures the stump. The caecum and stump are then tucked back into the abdominal cavity, and the incision is closed.

Indication:

- appendicitis

Contraindication:

- none

Complications:

• perforation of the appendix or abscess

• peritonitis

• ileus (paralytic and mechanical)

• pelvic abscess

• subphrenic abscess( abscess under the diaphragm)

2. Care Guide for Pre and Post- Appendectomy Patients

a. Fever

- tepid sponge bath

- wear light clothing

- increase fluid intake

- administer antipyretics as ordered by the doctor

b. Nausea, Vomiting, and Anorexia

- increase fluid intake

- small frequent feedings

- intravenous fluid therapy

- enteral feedings

c. Peritonitis

- observe for abdominal tenderness, fever, vomiting, abdominal rigidity, and tachycardia

- employ constant nasogastric suction

- correct dehydration as prescribed

- administer antibiotic agents as prescribed

d. Pelvic Abscess

- evaluate for anorexia, chills, fever, and diaphoresis

- observe for diarrhea, which may indicate pelvic abscess

- prepare patient for rectal examination

- prepare patient for surgical drainage procedure

e. Subphrenic Abscess(abscess under the diaphragm)

- assess patient for chills, fever, and diaphoresis

- prepare for x-ray examination

- prepare for surgical drainage of abscess

f. Ileus(paralytic and mechanical)

- assess for bowel sounds

- employ nasogastric intubation and suction

- replace fluids and electrolytes by intravenous route as prescribed

- prepare for surgery, if diagnosis of mechanical ileus is established

-----------------------

Transmural spread of bacteria

Obstruction of the narrow appendiceal lumen

Obstructed lymphatic and venous drainage

Suppurative appendicitis

(increasing intraluminal pressures eventually exceed capillary perfusion matter)

Bacterial and inflammatory fluid invasion of the tense appendiceal wall

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