Professional Documents
Culture Documents
Newkjnhbgfvdc
Newkjnhbgfvdc
INTRODUCTION
Patient J.L.D is 31 year-old married woman who was admitted at the Surgery
Department last June 21, 2009 due to severe pain at her right lower quadrant, the patient
was diagnosed with acute appendicitis. The patient underwent emergency appendectomy
the next day, June 22, 2009.
Appendicitis is the inflammation of the vermiform appendix and was first
described as a pathologic condition by Reginald Fitz in 1886, it is caused by an
obstruction attributed to infection, stricture, fecal mass, foreign body or tumor.
Appendicitis can affect either gender at any age, but is most common in male ages 10-30.
Appendicitis is the most common disease requiring surgery and one of the most
commonly misdiagnosed diseases.
Appendectomy, removal of the appendix, is the standard treatment for acute
appendicitis, it is important to immediately remove the appendix after the diagnosis to
prevent the occurrence of the life-threatening complication of appendix. The most
frequent complication of appendicitis is perforation. Perforation of the appendix can lead
to a periappendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection
of the entire lining of the abdomen and the pelvis). The major reason for appendiceal
perforation is delay in diagnosis and treatment. In general, the longer the delay between
diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours
after the onset of symptoms is at least 15%. Therefore, once appendicitis is diagnosed,
surgery should be done without unnecessary delay.
II.NURSING OBJECTIVE
III.PATIENTS PROFILE
Name: J.L.D
Age: 31
Sex: Female
Civil Status: Married
Date of Birth: October 03, 1977
Place of Birth: Bongabon, Nueva Ecija
Address: Bongabon, Nueva Ecija
Religion: Roman Catholic
Nationality: Filipino
VI.DIAGNOSTIC PROCEDURE
A. Ideal
1.URINALYSIS
Urinalysis is a microscopic examination of the urine that detects red blood cells,
white blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is
inflammation or stones in the kidneys or bladder. The urinalysis also may be abnormal
with appendicitis because the appendix lies near the ureter and bladder. If the
inflammation of appendicitis is great enough, it can spread to the ureter and bladder
leading to an abnormal urinalysis. Most patients with appendicitis, however, have a
normal urinalysis. Therefore, a normal urinalysis suggests appendicitis more than a
urinary tract problem, it is also usually used in women to rule out pregnancy.
2. WHITE BLOOD CELL COUNT
The white blood cell count in the blood usually becomes elevated with
infection. In early appendicitis, before infection sets in, it can be normal, but most often
there is at least a mild elevation even early. Unfortunately, appendicitis is not the only
condition that causes elevated white blood cell counts. Almost any infection or
inflammation can cause this count to be abnormally high. Therefore, an elevated white
blood cell count alone cannot be used as a sign of appendicitis.
3.ABDOMINAL X-RAY
An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized
piece of stool that blocks the appendiceal opening) that may be the cause of appendicitis.
This is especially true in children.
4.ULTRASOUND
An ultrasound is a painless procedure that uses sound waves to identify organs
within the body. Ultrasound can identify an enlarged appendix or an abscess.
Nevertheless, during appendicitis, the appendix can be seen in only 50% of patients.
Therefore, not seeing the appendix during an ultrasound does not exclude appendicitis.
Ultrasound also is helpful in women because it can exclude the presence of conditions
involving the ovaries, fallopian tubes and uterus that can mimic appendicitis.
Findings of acute appendicitis of ultrasound:
False-negative US:
False-positive US:
5. BARIUM ENEMA
A barium enema is an x-ray test where liquid barium is inserted into the colon
from the anus to fill the colon. This test can, at times, show an impression on the colon in
the area of the appendix where the inflammation from the adjacent inflammation
impinges on the colon. Barium enema also can exclude other intestinal problems that
mimic appendicitis, for example Crohn's disease.
6. COMPUTERIZED TOMOGRAPHY (CT) SCAN
In patients who are not pregnant, a CT Scan of the area of the appendix is useful
in diagnosing appendicitis and peri-appendiceal abscesses as well as in excluding other
diseases inside the abdomen and pelvis that can mimic appendicitis.
CT findings of normal appendix
Visualized in 67-100%.
At posterior-medial aspect of cecum.
Diameter of up to 10 mm.
7. LAPAROSCOPY
Laparoscopy is a surgical procedure in which a small fiber optic tube with a
camera is inserted into the abdomen through a small puncture made on the abdominal
wall. Laparoscopy allows a direct view of the appendix as well as other abdominal and
pelvic organs. If appendicitis is found, the inflamed appendix can be removed with the
laparascope. The disadvantage of laparoscopy compared to ultrasound and CT is that it
requires a general anesthetic.
B.Actual
CBC
DIAGNOSTIC
WBC
NORMAL
RESULT
5.0-10.0
ACTUAL
RESULT
12.0 x10^9/L
NURSING
IMPLICATION
High-indicates
infection
NSG.
RESPONSIBILITY
>Instruct patient to
increase
intake
of
Vitamin C and increase
fluid intake
>Administer antibiotic
as ordered
High-indicates
>Instruct patient to
stress, pain and increase
intake
of
acute
systemic Vitamin C and increase
infection
fluid intake
>Monitor signs of
infection
such
as
elevated Body Temp.
>Administer antibiotic
as ordered
Normal
High-indicates
>Monitor signs of
infection
infection
such
as
elevated Body Temp.
>Administer antibiotic
as ordered
Low-indicates
exhausted immune
system
Normal
High-indicates
>Instruct patient to
infection
increase
intake
of
Vitamin C and increase
fluid intake
Lymph #
3.0-4.0
1.6x1069/L
Mid #
Gran #
0.1-0.9
5.0-7.0
0.7x10^9/L
9.7x10^9/L
Lymph %
30.0-40.0
13.4%
Mid %
Gran %
1.0-9.0
50.0-70.0
5.8%
80.8%
HGB
RBC
HCT
120-160
4.04-5.48
37.0-47.0
131g/L
4.99x10^12/L
36.9%
Normal
Normal
Mildly
indicates
blood loss
MCV
82.0-95.0
74.0 fL
Low-indicates
anemia
MCH
27.0-31.0
26.2 pg
MCHC
RDW-CV
RDW-SD
PLT
MPV
PDW
PCT
320-360
11.5-14.5
35.0-56.0
150-400
7.0-11.0
15.0-17.0
0.108-0.282
355 g/L
14.0%
38.3 fL
239 x10^9/L
8.4 fL
16.8
0.200%
Urinalysis
NORMAL
COLOR
ACTUAL
Implication
Normal
ALBUMIN
REACTION
SPECIFIC
GRAVITY
PUS CELL
(-)
4.6-8
1.010-1.025
(-)
6.5 pH
1.010
Normal
Normal
Normal
2-4
Abnormal
SQUAMOUS
(-)
(+)
Abnormal
BACTERIA
(-)
(+)
Abnormal
CHARACTER
Abnormal
Nursing
Responsibility
>Instruct patient
to increase fluid
intake
>Instruct patient
to increase fluid
intake
>Administer
antibiotic as
ordered
>Instruct patient
to increase fluid
intake
>Administer
antibiotic as
ordered
>Instruct patient
to increase fluid
intake
>Instruct patient
to increase intake
of Vitamin C
>Administer
antibiotic as
ordered
the appendix is vermiform appendix which means worm-like appendage. It's pencil-thin
and normally about 4 inches (7 cm) long. The appendix is usually located in the right
iliac region, just below the ileocecal valve (designated McBurney's point) and can be
found at the midpoint of a straight line drawn from the umbilicus to the right anterior iliac
crest. The inner lining of the appendix produces a small amount of mucus that flows
through the open center of the appendix and into the cecum.
The wall of the appendix contains lymphatic tissue that is part of the immune
system for making antibodies. During the first few years of life, the appendix functions as
a part of the immune system, it helps make immunogobulins. But after this time period,
the appendix stops functioning. However, immunoglobulins are made in many parts of
the body, thus, removing the appendix does not seem to result in problems with the
immune system.
Like the rest of the colon, the wall of the appendix also contains a layer of muscle,
but the muscle is poorly developed.
VIII.PATHOPHYSIOLOGY
Obstruction of the appendix
(by fecalith, lymph node, tumour, foreign objects)
Inflammation
causes pain
Bacterial Invasion of the Blood wall
causes fever
Abdominal pain
This pain typically starts from around the belly button (peri-umbilical
region), or the upper central abdomen (epigastrium) and then move downwards
and to the lower right abdomen (right iliac fossa). When the pain occurs in this
pattern, it is the most dependable of all symptoms of appendicitis, as over 8 out 10
(80%) cases that present this way is definitely due to the appendix. In some other
individuals, the pain starts right way from the right iliac fossa. Depending on
where the tip of the appendix is, the pain could even be on the right flank (retrocaecal appendix). If the appendix is quite long, and in the pelvic cavity, it could as
well cause lower left abdominal pain, with frequent passage of urine if the
inflamed appendix irritates the bladder.
When the appendix is severely inflamed, the pain can be localized to a
spot on the outer one third of a line drawn between the belly button and front of
the tip of the waist bone called the McBurneys point. The Mc Burneys point is
also often the point of maximum tenderness when the abdomen is examined. The
pain is even worse when the hand is suddenly removed from that spot because of
the appendix rubbing on the covering of the abdomen (Rebound tenderness).
There is also a sign referred to as the Rovsign sign. This is said to exist
when the lower left abdomen is palpated by the doctor, but causes pain in the
right. If the appendix is the pelvic type, examining the back passage (rectal
examination) would cause some pain too. If the hip is moved and stretched, this
can also cause pain to be felt at the spot where the appendix lies. This is referred
to as the psoas sign.
Loss of Appetite, Nausea & Vomiting
C. Abdominal X-ray
D. Ultrasound
E. Barium Enema
F. CT Scan
G. Laparoscopy
H. The Alvarado Score for Acute Appendicitis
I.
Once a diagnosis of appendicitis is made, an appendectomy usually is performed.
Antibiotics almost always are begun prior to surgery and as soon as appendicitis is
suspected
b. Actual
The diagnostic procedure done to the patient were Urinalysis and CBC.
Patient was given the following medications:
Ceftriaxone 1 gm,IV,Q 12 hrs x 4 doses:an antibiotic which inhibits synthesis of
Bacterial cell wall, causing cell death
Tramadol 50 mg, IV, q 8 hrs: an analgesic which binds to mu-opioid receptors and
inhibits the reuptake of norepinephrine and serotonin; causes many effects similar
to the opioids,dizziness, constipation
Ketorolac 30 mg, IV, q 8 hrs: it has Anti-inflammatory and analgesic activity;
inhibits prostaglandins and leukotriene synthesis
The patient was administered with D5LR 1 L regulated at 31-32 gtts/min. D5LR is
actually 5% dextrose in lactated ringer's solution. it is a hypertonic solution which aids in
replacement of lost body fluids.
B. SURGICAL
A.IDEAL
Surgery is the only treatment for acute appendicitis. The appendix may be removed in
two ways:
First is the open method or through appendectomy. During an appendectomy, an incision
two to three inches in length is made through the skin and the layers of the abdominal
wall over the area of the appendix. The surgeon enters the abdomen and looks for the
appendix which usually is in the right lower abdomen. After examining the area around
the appendix to be certain that no additional problem is present, the appendix is removed.
This is done by freeing the appendix from its mesenteric attachment to the abdomen and
colon, cutting the appendix from the colon, and sewing over the hole in the colon. If an
abscess is present, the pus can be drained with drains that pass from the abscess and out
through the skin. The abdominal incision then is closed.
Second is Laparoscopic Method. Laparoscopy is a new technique for removing the
appendix which involves the use of the laparoscope. The laparoscope is a thin telescope
attached to a video camera that allows the surgeon to inspect the inside of the abdomen
through a small puncture wound (instead of a larger incision). If appendicitis is found, the
appendix can be removed with special instruments that can be passed into the abdomen,
just like the laparoscope, through small puncture wounds. The benefits of the
laparoscopic technique include less post-operative pain (since much of the post-surgery
pain comes from incisions) and a speedier return to normal activities. An additional
advantage of laparoscopy is that it allows the surgeon to look inside the abdomen to make
a clear diagnosis in cases in which the diagnosis of appendicitis is in doubt. For example,
laparoscopy is especially helpful in menstruating women in whom a rupture of an ovarian
cysts may mimic appendicitis.
B.ACTUAL
The procedure done to the Patient is Appendectomy, she was operated on June 22, 2009..
Her operation begun at 12:50 PM and ended at 1:25 PM. Her surgeon was Dr. Paat