acute appendicitis

Acute Appendicitis

INTRODUCTION

Acute Appendicitis is a condition in which your appendix becomes inflamed and filled with pus.

The main symptom of appendicitis is dull, poorly localized, visceral pain that typically begins around your navel and then shifts to your lower right abdomen as inflammation progresses.

On palpation, localized and rebound tenderness are noted at McBurney’s point.

In addition to pain, a low-grade

temperature, loss of appetite, nausea, and vomiting are often present.

Predisposing Factors: Obstruction Infection

In both cases, bacteria may subsequently invade rapidly, causing the appendix to become inflamed and filled with pus.

If not treated promptly, your appendix is likely to rupture.

Acute appendicitis can occur at any age, but is more common in adolescents and young adults.

About 7% of the population will have

appendicitis.

The mortality rate in non-perforated appendicitis is less than 1 percent, but it may be as high as 5 percent or more in young and elderly patients, in whom diagnosis may often be delayed, thus making perforation more likely.

The diagnostic procedures for appendicitis are blood count, physical exam, and imaging studies (ultrasound, CT, xray).

OBJECTIVES

General Objectives

After Related Learning Experience, the students will be able to apply knowledge, skills, and attitude in handling patient with Acute Appendicitis. This study aims to help and guide nursing students, staff nurses and clinical instructors as well the patient himself to deal with curative and rehabilitative aspect of Acute Appendicitis.

Specific Objectives At the end of two days, the students will be able to:

Determine the probable causative factors and risk of Acute Appendicitis

Analyze potential complications that may develop following Acute Appendicitis.

Explain the diagnostic procedures and significant laboratory findings.

Devise and implement appropriate nursing care plan and health teachings applicable to the patient.

Evaluate effectiveness of nursing interventions and health teachings for patient with Acute Appendicitis through return demonstration and verbalized apprehension.

NURSING HISTORY

GENERAL DATA

J.L. 20 years old, male, Filipino, single, Roman Catholic. Born on January 9, 1988. Presently residing at San Jose Del Monte, Bulacan. A college student from St. Joseph College. Admitted for the first time at Rogaciano M. Mercado

Memorial Hospital (RMMMH) on August 27, 2008 at 5:10 pm.

HISTORY OF PRESENT ILLNESS The patient is currently on a good

condition. Since then, the patient was noted to be

apparently well until seven hours prior to admission, the patient experienced a sudden dull, intermittent epigastric pain.

Six hours prior to admission, still with the above condition, generalized abdominal pain was now noted to be continuous.

Four hours prior to admission still with the above condition.

Upper abdominal pain intensifies and localizes on the right lower quadrant of the abdomen.

Accompanied by a low-grade fever, loss of appetite and vomiting.

Two hours prior to admission, persistence of the above condition, prompted consults at Rogaciano M. Mercado Memorial Hospital hence admission.

PAST MEDICAL HISTORY J.L. experienced the common illnesses

afflicting a child like cough and colds, flu, and chickenpox.

He has no allergies to any food, drugs and any other environmental agents.

He has no past hospitalization. Immunization: Received Hepatitis B

vaccine, Oral Polio vaccine, BCG, DPT and MMR when he was still young.

FAMILIAL HISTORY Has familial history of hypertension on

paternal side.

PERSONAL AND SOCIAL HISTORY He is the youngest among five (5) siblings.

All are apparently well. During weekends, after going to church,

his family conducts a small gathering, like a small reunion, since most of his siblings are already married.

He has a sedentary lifestyle.

Primary compositions of his diet are rice, pork, beef, and chicken.

He seldom eats fruits and vegetables. He likes to drink juices and water for about 6-9

glasses a day. He also takes food supplement, Grow rich VCO

500 mg capsule once daily. Bowel movement is 3-4 times a week, typically,

stool consistency is hard. He sometimes experience pain on defecation. He urinates 6-10 times a day, depending on how

much fluid he consumes.

He is a 4 year-smoker, 5-8 sticks a day and 1-2 packs for special occasions together with his friends.

He is an alcoholic beverage drinker, consuming for about 10-18 bottles of beer per session.

He sleeps at around ten in the evening and wakes up at six in the morning.

He takes a bath daily and brushes his teeth 2-3 times a day.

PHYSICAL ASSESSMENT & GENERAL APPEARANCE MEASUREMENTS FINDINGS

Weight 54.55 kg

Height 170.69 cm

Level of consciousness Spontaneous, conscious, coherent, oriented to time, place & person

Body build Medium

Overall hygiene & grooming Satisfactory

VITAL SIGNS DAY 1

(08/28)

DAY 2

(08/29)

Time 11:30 PM 11:30 PM

Temperature 38˚C 36.9˚C

Pulse Rate 63 beats/min 71 beats/min

Respiratory Rate

24 bpm 21 bpm

Blood Pressure 120/80 120/80

HEAD-TO-TOE ASSESSMENT (8/29/08 5:30 AM) Post-operative

Part Technique Findings

Skin Inspection & Palpation

Slightly pale in appearanceSkin is hot to touchGood skin turgorWith surgical incision at the right lower quadrant


Head and scalp Inspection & Palpation

NormocephalicThere is no bald spot.The scalp has no scars, abrasions, swelling or malformations.


Hair Inspection The patient has short, straight, and black hairequal in distributionThere are no signs of dandruff, it is oily.


Eyes Inspection Eyebrows moves symmetrically as facial expression changes, present bilaterally.His eyelashes are equally distributed.


(..Eyes) The eyes are symmetrical, has normal shape and size and the color is black-brown. Pupils constrict with increasing light and dilate in dim light.He has pale conjunctiva.Teary eyes


Ears Inspection Clean with scant amount of cerumen and few cilia. Responds to normal conversation. No presence of foreign bodies, and no swelling and no unusual odor.


Nose Inspection There are no dischargesClean with few ciliaPatent


Mouth Inspection Lips are slightly red and dry. There is no presence of swelling, bleeding or discharges. Halitosis was noted. The tongue is slightly dry.


Neck Palpation No palpable swollen lymph nodes


Chest & Lungs Inspection & Auscultation

Has no difficulty in breathingHas symmetrical chest expansionRespiratory rate is 22 bpm


Abdomen Inspection & Palpation

With surgical incision and dry and intact dressing at the right lower quadrantDistended, tenderWith palpable pain


Upper & Lower Extremities

Inspection & Palpation

Slightly pale nail beds and smooth.He has the ability to do range of motion on his extremities but with weakness. Capillary refill in 2 seconds.With good and equal pulses.

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

Constipation, low fiber diet

Occlusion of fecalith

Obstruction of proximal lumen

Appendix becomes distended with fluid

Pressure within the lumen

Generalized, intermittent

abdominal pain

Cont..

Blood supply impaired

Inflammation, edema, ulceration,

infection

Pus fills the inflamed appendix

Low-grade fever, anorexia, nausea and

vomiting

ACUTE APPENDICITIS

Cont..

LABORATORY ANDDIAGNOSTIC PROCEDURES

RESULTS

Hematology

TEST FOUND VALUE

8/27

(Pre-operative)

FOUND VALUE

8/28

(Post-operative)

NORMAL VALUE

CLINICAL SIGNIFICANCE

Hemoglobin 162.8 g/L 156.4 g/L M=155-175 g/L Low:

hemorrhage,

anemia

High:

Polycythemia

TEST FOUND VALUE

8/27

(Pre-operative)

FOUND VALUE

8/28

(Post-operative)

NORMAL VALUE


Hematocrit 48 46 40-52 Low:

hemorrhage,

Anemia

High:

polycythemia,

dehydration

TEST FOUND VALUE

8/27

(Pre-operative)

FOUND VALUE

8/28

(Post-operative)

NORMAL VALUE


WBC 25.0 x 10/L 15.0 x 10/L 4.0-11.0x 10/L Low: aplastic

anemia, drug

toxicity, specific

infections

High:

inflammation,

trauma, toxicity,

leukemia

UrinalysisTEST FOUND VALUE

8/27

(Pre-operative)

FOUND VALUE

8/28

(Post-operative)

NORMAL VALUE


Color Bright yellow Yellow orange Amber Amber: due to

pigment called

urochrome, an

end product of

Hemoglobin

breakdown.

yellow orange

: urobilinogen is

produced in the

intestine by the

action of

bacteria on bile

pigment.

TEST FOUND VALUE

8/27

(Pre-operative)

FOUND VALUE

8/28

(Post-operative)

NORMAL VALUE


Transparency Turbid Turbid Clear Clear: normal,

but may

become cloudy

after standing

awhile.

Turbid:

phosphates,

urates, pus,

mucus,

bacteria,

epithelial cells

TEST FOUND VALUE

8/27

(Pre-operative)

FOUND VALUE

8/28

(Post-operative)

NORMAL VALUE


pH 6.0 6.5 6.0 to 7.5 Acidic:

diabetes,

acidosis,

prolonged fever

Alkaline: urinary

tract infection,

alkalosis

TEST FOUND VALUE

8/27

(Pre-operative)

FOUND VALUE

8/28

(Post-operative)

NORMAL VALUE


Specific gravity 1.032 1.026 1.015-1.025 Increase in

Diabetes

mellitus

Decrease in

acute nephritis,

Diabetes

insipidus,

aldosteronism

TEST FOUND VALUE

8/27

(Pre-operative)

FOUND VALUE

8/28

(Post-operative)

NORMAL VALUE


Pus cells 2-5 1-4 (-) Presence of

pus: urinary

tract infection

Diagnostic Procedures: Blood count, physical exam, imaging studies

(ultrasound)

Ultrasonography: (Preoperative) Revealed a right lower quadrant density Outer appendiceal diameter size of 6 mm on

cross section.

NURSING CARE PLAN

ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective:

“Sumasakit ang sugat ko” as patient verbalized.

Objective:Pain Scale: 6/10 -Moderate painIncision @ right

lower quadrant of

the abdomen Distraction behaviorGuarding behaviorFacial mask of pain

NURSING DX:

Acute Pain related to

surgical incision

Partial

compensatory

Short Term Goal

At the end of

1hour nursing

interventions,

patient’s pain

will decrease

from 6/10 to 4 or

less

Facilitate patient in a high Fowler’s positionFacilitated instruction and demonstration of deep breathing exerciseFacilitated the use of diversional activities such as reading newspapers, chatting with relatives & friends.Administer appropriate pain medication prescribed by the attending physician:

Mefenamic Acid

500 mg/tab every 4 hours per orem

Diclofenac Sodium

75 mg TIV every 12 hours

Reduces tension on the incision and abdominal organs, helping to reduce pain.Lessens the complications and provides as a relaxation technique.Diverts patient’s attention on others rather than the pain.Inhibits prostaglandin synthesis. Is an anti-inflammatory, antipyretic, and analgesic

Patient condition maintained.

Pain scale: 3/10


Subjective:

“Mainit ang pakiramdam ko”, as patient verbalized.

Objective:Watery eyesDry and red lipsSkin hot to touchIncision site @ right lower quadrant of the abdomenTemperature: 38˚C

NURSING DX:

Alteration in body temperature related to post surgical procedure

Supportive

educative

Short Term Goal

At the end of 45

minutes nursing

interventions,

patient’s body

Temperature

decreases to 36-37˚C

Facilitate tepid sponge bath.Facilitate fluid intakeRestrict tight clothingFocus on temperature takingAdminister paracetamol as prescribed by the physician.

Biogesic 500 mg 4-6 hr as needed.

Cools down body temperature because of the concept of conductionAvoids fluid and electrolyte imbalanceProvides good ventilationTo recheck the temperatureAntipyreticInhibition of the enzyme COX-3 in the brain and spinal cord.

Patient condition improved.

Temperature: 36.8˚C.


Subjective:

“Mahirap dumumi, matigas at kakaunti parang meron pa,” as pt. verbalized.

Objective:Dry, hard, formed stoolsStraining with defecationPercussed abdominal dullness

NURSING DX:

Constipation related to insufficient physical activity, low fiber intake, and lack of privacy.

Partial

compensatory

Short Term Goal

At the end of 1

hour nursing

interventions,

patient will be

able to verbalize

understanding of

etiology and

appropriate

interventions for

Individual

situation and

demonstrate

behaviors or

lifestyle changes

to prevent

recurrence of

problem.

Facilitate identification of causative factorsFacilitate privacy and routinely scheduled time to defecate.Focus on increasing intake of fiber and bulk in dietFocus on adequate fluid intake, including high-fiber fruit juices and suggest drinking warm, stimulating fluids.Focus on providing information about relationship of diet, exercise, fluid, and appropriate use of laxatives as indicated.

For prevention or modification of such causes.

Provides privacy to perform self-care activities wherein he can be comfortable, safe and relaxed and to stop ignoring his urge

To improve consistency of stool and facilitate passage through colon.

To promote soft/moist stool.

For him to identify specific actions to be taken if problem recurs, to promote timely intervention, enhancing client’s independence.

Patient condition

maintained.

HEALTH TEACHINGSMedication All medications must be

explained in detail as prescribed to client and family. Inform them on the purposes and side effects of the medications. Advise patient to take his medicines on time and as prescribed by the physician. Cefalexin 500 mg/tab per orem three x a day. Mefenamic Acid 500 mg/tab per orem for pain.

For continuous improvement of patient condition.

Environment Instruct the patient’s relatives to provide a conducive environment.

Client should have good sleeping habits to avoid fatigue. His room should be clean, properly ventilated, peaceful, and free from insects.

To have adequate rest and sleep.

Treatment Educate the patient how to care for the incision. Demonstrate how to change it properly. Instruct him to observe the incision daily and to report any swelling, redness, bleeding, drainage, and warmth at the site.

To prevent infection and any complications after the operation.

Health Teaching Teach the patient relaxation techniques such as deep breathing exercises. Teach the importance of maintaining good personal hygiene.

This prevents strain on abdominal muscles until healing is complete.

Encourage the patient to gradually quit smoking as well as drinking alcohol.

Out Patient Advise to comeback for follow-up check up upon dismissal.

To know if the patient’s condition improved; to know the follow up instructions of the attending physician; and to make an appointment to have the surgeon remove the sutures between the fifth and seventh days after surgery.

Diet When normal bowel sounds are present, soft diet can be given. Encourage to eat foods that are high in fiber such as whole grain cereals, fresh fruits especially rich in vitamin C and vegetables.

To combat constipation and for body resistance.

Safety Demonstrate appropriate activity restrictions. Normal activity can usually be resumed within 2 to 4 weeks.

Discuss postoperative activity limitations with the patient. Caution him to avoid lifting heavy objects for 6 weeks after surgery.

Place in Fowler’s position to reduce the pain. Never apply heat to the lower right abdomen.

Frequently assess the dressing for wound drainage and other complications possible to come out after the operation.

EVALUATIONAfter rendering Nursing Interventions, the student

nurses were able to achieve general and specific objectives of this study.

In handling a patient with Acute Appendicitis, we were able to: apply knowledge, skills, and attitude in handling an AP patient; determined the probable causative factors and risks; analyzed potential complications that may develop following the illness; explained the diagnostic procedures results and as well as significant laboratory findings; devised and implemented appropriate nursing care plan and health teachings applicable to the patient; and evaluate the effectiveness of nursing interventions and health teachings through patient’s demonstration of the use of relaxation skills, proper wound dressing techniques and verbalized apprehension about his condition. The patient showed an improvement in perception and attitude towards ways to promote comfort and to restore his health.

DRUG STUDY

GENERIC NAME

BRAND NAME

CLASSIFICATION

DOSAGE MECHANISM OF

ACTION

INDICATION

CONTRAINDICATIO

N

SIDE EFFECTS

NURSING RESPONSIBILITIE

S

D

I

C

L

O

F

E

N

A

C

SODIUM

Cataflam NSAID 75 mg TIV

every 12 hrs for 2 doses

Produces anti-

inflammatory,

analgesic &

antipyretic effects, possibly

by inhibits

prostaglandin

synthesis

Management of acute & chronic types of

pain

Use cautiousl

y in patient

with history of

peptic ulcers

disease hepatic

dysfunctional,

cardiac disease, hyperten

sion, fluid

retention, or

impaired renal

function

(None was

noted)

Instruct patient to take drugs

with milk, meals or antacids

to minimize

GI distress

GENERIC NAME

BRAND NAME

CLASSIFICATION

DOSAGE MECHANISM OF

ACTION

INDICATION

CONTRAINDICATIO

N

SIDE EFFECTS


S

C

E

F

A

L

E

X

I

N

Keflex Anti-

Infective

500 mg/tab

per orem three x a day

Third generation cephalosporin that inhibit its cell-wall synthesis, promoting osmotic instability usually bacteri-cidal

Infections of the urinary tract, biliary tract,

respiratory tract,

bones, joints, soft

tissue, and skin

Contraindicated with pregnant mother,

with hypersens

itivity to food & drugs

Drowsiness

Report

adverse

reactions

or sign &

symptom

of

super-

infection

promptly

Advised

patient to

notify

prescriber

about

loose

stools or

diarrhea

GENERIC NAME

BRAND NAME

CLASSIFICATION

DOSAGE MECHANISM OF

ACTION

INDICATION

CONTRAINDICATIO

N

SIDE EFFECTS


S

P

A

R

A

C

E

T

A

M

O

L

Biogesic Antipyretic/

analgesic

500 mg/tab

per orem 4-6

hours

Inhibition of the

enzyme COX-3 in the brain

and spinal cord.

Used to relieve

pain and fever

Anemia, cardiac

& pulmona

ry disease. Hepatic

or severe renal

disease.

(None was

noted)

Monitor

intake,

maxi-

mum of

8 tablets

per 24

hours

only.

Can be

given

with or

without

food.

Dis-

continue

if fever

persists

for more

than 3

days.

GENERIC NAME

BRAND NAME

CLASSIFICATION

DOSAGE MECHANISM OF

ACTION

INDICATION

CONTRAINDICATIO

N

SIDE EFFECTS


S

M

E

F

E

N

A

M

I

C

ACID

Ponstel Analgesic/

NSAID

500 mg/tab

per orem every 4 hours

Third generati

on cephalos

porin that

inhibit its cell-wall synthesi

s, promotin

g osmotic instability usually bacterici

dal

Infections of the urinary tract, biliary tract,

respiratory tract, bones, joints, soft

tissue, and skin

Contraindicated

with pregnant mother,

with hypersensitive to food & drugs

Drowsiness

Report

adverse

reactions

or sign &

symptom

of

super-

infection

promptly

Advised

patient to

notify

prescriber

about

loose

stools or

diarrhea.

acute appendicitis

Documents

risk of acute appendicitis

following acute appendicitis

nonperforated appendicitis

main symptom of appendicitis

handling patient

visceral pain

social history

good condition