FIRST ASIA INSTITUTE OF TECHNOLOGY AND HUMANITIES

COLLEGE OF NURSING
S.Y. 2016-2017

Appendicitis

Submitted by:
Cantos, Lynette P.
BSN IV-A

CHAPTER I

I.

Introduction
Appendix is a save house for good bacteria and replenishing all the good
bacteria. Appendicitis occurs when the appendix becomes blocked, often by stool,
a foreign body, or cancer. Blockage may occur from rapid growth of bacteria and
infection. Acute appendicitis can also happen after a gastrointestinal infection.
Rarely, a tumor may cause acute appendicitis. Sometimes the cause of acute
appendicitis is not known. There is no way to prevent appendicitis. It is less
common in people who eat foods high in fiber. Appendicitis can be hard to
diagnose. You may have blood and urine tests to look for signs of infection. The
appendix can rupture as quickly as 48 to 72 hours after the onset of symptoms.

Statistical Data
The estimated population in the Philippines is 86, 241, 697 and the
incident rate of acute appendicitis is 215,604 as of year 2011. In the United States
250,000 cases of appendicitis are reported annually, representing 1 million patientdays of admission. The incidence of acute appendicitis has been declining steadily
since the late 1940s, and the current annual incidence is 10 cases per 100,000

populations. Appendicitis occurs in approximately 7% of the population and affects

males more than females. It occurs between the ages of 10 and 30 years. In Asian
and African countries, the incidence of acute appendicitis is probably lower
because of the dietary habits of the inhabitants of these geographic areas. The
incidence of appendicitis is lower in cultures with a higher intake of dietary fiber.
Dietary fiber is thought to decrease the viscosity of feces, decrease bowel transit
time, and discourage formation of fecaliths, which predispose individuals to
obstructions of the appendiceal lumen. In the last few years, a decrease in
frequency of appendicitis in Western countries has been reported, which may be
related to changes in dietary fiber intake. In fact, the higher incidence
of appendicitis is believed to be related to poor fiber intake in such countries.

Scope and limitation of the study

The researcher was assigned to have a hospital exposure last October 29, 30
& 31 at Batangas Medical Center Emergency Room. During the duration of the
hospital duty, the researcher found a commendable case reasonable to be presented
for case study. For further understanding of the case, the researcher followed the
patient at Male Surgical Ward. Performed a thorough physical assessment and
nurse-patient interaction, obtained subjective and objective data. Thorough reading

of the patients chart was also done to gain more knowledge and know all medical
procedures done to the patient.

Background of the study

The patient, to be mentioned as Patient MM, was one of the patient
admitted to the Batangas Medical Center-Male Surgical Ward on the days of the
researchers duty. She was admitted with the diagnosis of acute appendicitis.
The group chose Patient MM, as our subject primarily because this case
serves as an instrument for us to broaden our knowledge. It will be more
interesting to have a better understanding on this case in order to clear out some of
the groups presumption about the disorder process. This knowledge that the group
may gain will benefit every single student nurse who are taking care of with the
same disorder. As nursing students, the group believes that this case is very helpful
to become better nurses in the future, adhering the patients who unfortunately
suffered appendicitis requiring holistic care. We would want to understand and
appreciate more on what is happening to a patient with acute appendicitis and what
will be the necessary management that will be given.

Objectives:
A. General
Gather as much information and knowledge about acute appendicitis which is one
of the most common surgical emergencies in the country.
To formulate the appropriate nursing intervention and plan of care to prevent
further complications as well as to promote wellness

B. Specific
To identify patients health care needs through analysis of all the data gathered
To assist the patient throughout rehabilitation, recovery and discharge
To impart necessary health teachings to the patient
To perform appropriate nursing care in conjunction with the condition of the
patient

CHAPTER II

II.

PRESENTATION OF THE CLIENT

A. PATIENTS PROFILE
Patients Name:

Patient MM

Age:

15 yrs. old

Address:

Poblacion Brgy 3, Tanauan City, Batangas

Sex:

Female

Nationality:

Filipino

Religion:

Roman Catholic

Status:

Single

Date of Birth:

March 05, 2001

Birthplace:

Ragay, Camarines Sur

Occupation:

Student(Grade 10)

Mother:

WM

Father

MM

Clinical Admitting Data:

Date of Admission:
Time of admission:

August 30, 2016

2:27 pm

Chief complaint:

Right Lower Quadrant pain

Hospital and Ward:

Batangas Medical Center- Station 4

Admitting Diagnosis:

Acute Appendicitis

Attending Physician:

Dr. R

Operation Performed:

Appendectomy

Date of Operation:

August 31, 2016

Vital Signs upon Admission:

Blood Pressure:

110/70 mmHg

Temperature:

37.1 C

Respiratory Rate:

19cpm

Pulse Rate:

86 bpm

Patient's History
Present Illness:
Patient MM,

a 15-years old female patient, was admitted at Batangas

Medical Center last August 31, 2016 at exactly 2:27 pm with a chief complaint of
pain at his right lower quadrant (a pain scale: 8/10). She was under the supervision
of Dr. R. Her admitting diagnosis was acute appendicitis.
Past Illness:

The patient has no past serious illness. She does not have any food and drug
allergies. Other illnesses or conditions experienced by the patient were just coughs,
colds and fever. She did not undergo any medical interventions years ago
Family History:
There is no any other diseases on her family that can be passed to the patient
genetically.

Patterns of Functioning
A. Psychological
The patient was conscious and coherent. She is in the proper state and well
coordinate to answer all of our questions clearly.
Analysis: The patient has an effective coping because through open
communication and active listening. She expressed what she feels and verbalized
positive things and accepts her condition, she is cooperative in the entire
interaction.
Interpretation: Effective Coping Pattern
B. Socio-cultural

According to the patient, the social values she was brought up to were
respect a sense of responsibility and fear of god. The traditions in her family are
birthday and New Year. Her family is the significant person in her life. They have
harmonious relationship with her family and relatives. The patient is having good
communication to the other children when they're in homes.
Analysis: They have harmonious relationship with her family and relatives. The
patient is having good communication to the other children when they're in
homes.
Interpretation: Effective Significant Relationship
C. Spiritual
Patient MM is a Roman Catholic. But sometimes she cannot attend mass.
Analysis: Some people tend to be more of a spiritual rather than a religious
person. Even though the patient cannot make time to go to church every Sunday,
she still makes time for God through her daily prayers.
Interpretation: Proper practice of Religious Beliefs

D. Nutrition
Before Hospitalization:

According to the clients mother, the client is not eating three times a day;
the client is fasting her food. She is fond of eating fruits and vegetables. She
sometimes eat preservatives food such like noodles.
During Hospitalization:
The patient stated that she does not met her proper nutrition because there
was a little decrease in the patients appetite upon her stay in the hospital.
Analysis: The patient is fond of fruits and vegetables. She sometimes eat
preservatives food such like noodles. The patient does not met his proper nutrition
during hospitalization
Interpretation: Inadequate nutritional intake

E. Elimination
Before Hospitalization:
The client said that she defecates and urinates regularly and there is no
burning or foul smell in his urine.
During Hospitalization:
During the stay of patient in the hospital. She stated that she never defecate
since after appendectomy procedure.

Analysis: Before hospitalization the patient states that her bowel habit is regular
but during hospitalization she has not yet defecate.
Interpretation: Inadequate Elimination

F. Exercise
Before Hospitalization:
The client stated that walking and playing are her form of exercise

During Hospitalization:
The patient verbalized that,di ako makatayo at makakilos dahil sa
operado ako.
Analysis: Before hospitalization she can exercise regularly like walking and
playing but during hospitalization she stays in bed especially on the first day postoperative.
Interpretation: Ineffective exercise

G. Hygiene
Before Hospitalization:
The client stated that she takes a bath every day, brush her teeth twice a day.
During Hospitalization:
She sponge baths everyday and brushes her teeth twice a day. Her hair is
well combed. Her fingernails and toe nails are clean and short.
Analysis: Hygiene is important during Hospitalization. The patient is well
groomed. She states that she has regular sponge bath and mouth care.
Interpretation: Proper Hygiene

H. Sleep and rest

Before Hospitalization:
The client said that she sleeps 6-8 hours a day.
During Hospitalization:
The patient has adequate sleep and rest as a means for her to receive the
strength once more.

Analysis: There was no alteration in the patients sleeping pattern. She met the
proper sleep pattern.
Interpretation: Adequate sleep pattern

Physical assessment
(August 31, 2016)

Assess

Procedure

Result

Significance

Hair

Inspection

Black color hair with Normal

even distribution, thin
and shinny

Eyes

Inspection

With normal sclera

Normal

Ears

Inspection

normal Normal

Lips

Inspection

Respond to
voice
Pink in color

Normal

Tongue

Inspection

Pink in color

Normal

Nail

Inspection

Capillary refill within Normal

3 seconds.

Upper
Extremities

Inspection

With D5LR in Right To increase

hand metacarpal vein fluid intake
regulated
at
30gtts/min

Abdominal
contour

Inspection

With
post-operative Due
to
dressing at RLQ dry appendecto
and intact
my

Course in the Ward

Day 1
By 8:00 am in the morning, the nurse received patient MM in Emergency
Room with a chief complaints of RLQ abdominal pain. The patient was diagnose
with Acute Appendicitis. Upon admission vital signs were taken: BP=110/70,
PR=86bpm, RR=19cpm, T=37.1 C, Pain scale= 8/10. The physician administered
IV fluid D5LR 1L, regulated @ 40 gtts/min, inserted on the left bacillic vein.

Chapter III

III.Analysis and Interpretation

Overview of Anatomy and physiology

Appendix
Is a closed-ended, narrow tube up to several inches in length that attaches to
the cecum, the first part of the colon. The anatomical name for 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 immunoglobulin. 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.

Cecum
- beginning of the large intestine or ascending colon of the large intestine and is
connected to the junction of the small and large intestines .Absorb fluids and salts
that remain after completion of intestinal digestion and absorption and to mix its
contents with a lubricating substance, mucus.

Ileum
- is the final section of the small intestine. The ileum is about 3.5 meters (11.5 feet)
long (or about three-fifths the length of the small intestine). The function of the
ileum is mainly to absorb vitamin B12 and bile salts and whatever products of
digestion were not absorbed by the jejunum.
Anus
- is the external opening of the rectum. Its function is to absorb water from the
remaining indigestible food matter, and then to pass useless waste material from
the body. The large intestine consists of the cecum and colon.

Pathophysiology
Non-Modifiable:

Modifiable:

Lymphoid hyperplesia

Age (15 years old)

Low fiber diet

Gender (female)

Increased fecal viscosity

Obstruction of the appendix (by fecalith)

Bacterial invasion into lumen

Inflammation

Lumphatic drainage obstructed

Increase intraluminal pressure

Distention of the Appendix

Causes pain

Decrease venous drainage

Blood flow and oxygen restriction to the appendix

Bacterial Invasion of the Blood wall


Causes fever

Obstruction of the appendix

Acute pain on RLQ

Loss of appetite
Nausea and vomiting
Increase WBC in CBC
Increase Neutrophils in CBC
Fever

Laboratory Results
The following laboratory examinations were done for the patient as part of the
careful assessment for the diagnosis of her condition:
(August 30, 2016)
A. Urinalysis
Components
Color
Transparency
Specific Gravity
pH

B.Hematology

Normal Value
Yellow/Amber
Clear
1.005-1.025
5.8

Result
Light Yellow
Clear
1.015
7.8

Findings
Normal
Normal
Normal
Normal

Components

Normal

Result

WBC

Values
5.0-10.0

15.54

May

Female:120-

10^9/L
114
g/L

inflammation.
Decrease concentration of

Hemoglobin

Unit Findings

140

indicate

infection,

oxygen in the blood.

Male: 140-160
RBC

Female:4.2-5.4 4.0 10^12/L

A low hemoglobin count can

Male: 4.6-6.2

be associated with many

diseases and conditions that
cause the body to have few
red blood cells. It indicates

HCT

Neutrophils
Lymphocyte
Monocyte
Basinophils
Basophils

Male:

0.40- 0.36

anemia.
Percentage of the red blood

0.54

cells is below the lower

Female:0.37-

limits of normal. It indicates

0.47
0.45-0.65

anemia.
May indicate

0.20-0.50
0.02-0.04
0.00-5.00
0.00-1.00

0.69
0.07
0.05
0.04
0.02

%
%
%
%
%

infection,

inflammation.
Low production of RBC
May indicate infection.
Normal
Normal

Surgical Management

Appendectomy
- is the surgical removal of the appendix. It is one of the most common
emergency surgical procedures.
The Risks of an Appendectomy
All surgeries carry the risk of rare complications, including excessive
bleeding and infection. However, the risks associated with an appendectomy are far
lower than the risk of leaving an infected appendix untreated. Left untreated, the
appendix can burst and spread infection throughout your abdomen. This can be
fatal.
How to Prepare for an Appendectomy
The doctor will ask the patient about medical history and perform a
physical examination. During the exam, the doctor will gently push against the
patients abdomen to pinpoint the source of the patients abdominal pain.

The doctor may order blood tests and imaging tests if appendicitis is
caught early. These could include CT scans or an abdominal X-ray. However, the
doctor may skip these tests if he or she believes an emergency appendectomy is
necessary.
Before surgery, the patient will be hooked up to an IV so you can receive
fluids and medication. The patient will likely be put under general anesthesia so
that he/she will be unconscious during surgery.
How an Appendectomy Is Performed
There are two types of appendectomy: open and laparoscopic. The kind of
operation your doctor chooses depends on several factors, including the extent of
the infection and your medical history.
-Open Appendectomy
During an open appendectomy, a surgeon makes one incision into the
lower right portion of the abdomen. The appendix is removed and the wound is
closed.
Reasons why doctor may choose an open appendectomy include:
Bleeding problems during the operation
extensive infection
a history of prior abdominal surgery
obesity
a perforated appendix

-Laparoscopic Appendectomy
During a laparoscopic appendectomy, the surgeon accesses the appendix
through several small incisions in your abdomen. The surgeon uses narrow, tubelike instruments to operate on the infected organ. A camera in one of the tubes
allows the surgeon to see inside your abdomen to guide the instruments.
After the appendix is removed, the small incisions are cleaned, closed, and
dressed. The risk of infection from laparoscopic appendectomy is lower than from
open appendectomy because the incision wounds are smaller.

After the procedure

In the hospital
After the procedure, the patient will be taken to the recovery room for
observation. Recovery process will vary depending on the type of procedure
performed and the type of anesthesia that is given. Once the blood pressure, pulse,
and breathing are stable and the patients are alert, they will be taken to hospital
room. As a laparoscopic appendectomy procedure may be performed on an
outpatient basis, you may be discharged home from the recovery room.
The patient may receive pain medication as needed through a device
connected to your intravenous line.
The patient may have a thin plastic tube inserted through the nose into
stomach to remove gastric secretions and air that he/she swallow. The tube will be

removed when your bowels resume normal function. The patient will not be able to
eat or drink until the tube is removed.
The patient will be encouraged to get out of bed within a few hours after a
laparoscopic procedure or by the next day after an open procedure.
Depending on the patients situation, if the patient may be given liquids to drink a
few hours after surgery. Patients diet may be gradually advanced to more solid
foods as tolerated.
Arrangements will be made for a follow-up visit with doctor, usually two to three
weeks after the procedure.

At home
It is important to keep the incision clean and dry. The doctor will give the
patient specific bathing instructions. If stitches or surgical staples are used, they
will be removed during a follow-up office visit. If adhesive strips are used, they
should be kept dry and generally will fall off within a few days.The incision and
the abdominal muscles may ache, especially after long periods of standing. Take a
pain reliever for soreness as recommended by your doctor. Aspirin or certain other
pain medications may increase the chance of bleeding. Be sure to take only
recommended medications.Walking and limited movement are generally
encouraged, but strenuous activity should be avoided. The doctor will instruct the
patient about when you can return to work and resume normal activities.

Notify your doctor to report any of the following:

Persistent fever over 101 degrees F (39 C) and/or chills
Redness, swelling, or bleeding or other drainage from the incision site(s)
Increased pain around the incision site(s)
Loss of appetite and inability to eat or drink fluids
Persistent coughing, difficulty breathing, or shortness of breath
Abdominal pain, cramping, or swelling
Failure to have a bowel movement after two days or longer
Following an appendectomy, your doctor may give you additional or alternate
instructions, depending on your particular situation.

Nursing Management

Pre-operative care
Monitor vital signs hourly.
Rationale: To obtain baseline data.

 Assess pain, noting location, characteristics, severity (010 scale).

Investigate and report changes in pain as appropriate.
Rationale: Useful in monitoring effectiveness of medication, progression of
healing. Changes in characteristics of pain may indicate developing abscess or
peritonitis, requiring prompt medical evaluation and intervention.
Provide diversional activities
Rationale: Refocuses attention, promotes relaxation, and may enhance coping
abilities.
Keep Nothing Per Orem (NPO).
Rationale: Decreases discomfort of early intestinal peristalsis, gastric irritation
and vomiting.
Advise the patient to never apply heat to the right lower abdomen.
Rationale: This may cause the appendix to rupture.

Post-operative care:

Keep at rest in semi-Fowlers position.

Rationale: To lessen the pain. Gravity localizes inflammatory exudate into

lower abdomen or pelvis, relieving abdominal tension, which is accentuated by
supine position.
Encourage early ambulation.
Rationale: Promotes normalization of organ function (stimulates peristalsis and
passing of flatus, reducing abdominal discomfort).
Auscultate and document bowel sounds. Note passing of flatus, bowel
movement.
Rationale: Indicators of return of peristalsis, readiness to begin oral intake.
Note: This may not occur in the hospital if patient has had a laparoscopic
procedure and been discharged in less than 24 hr.
Provide clear liquids in small amounts when oral intake is resumed, and
progress diet as tolerated.
Rationale: Reduces risk of gastric irritation and vomiting to minimize fluid loss.
Watch closely for possible surgical complications.
Rationale: Continuing pain and fever may signal an abscess.

PRIORITIZATION OF THE PROBLEM

1st

Impaired physical

This is the first priority

mobility related to

because other problems

decrease muscle strength

may arise if the patient

secondary to surgical

cannot move. Circulatory

procedure performed

problems to the lower

limb, contractures and
pressure ulcer may arise
if not immediately

nd

Self-care deficit related

managed.
This is the second

to post-operative

priority, proper hygiene

condition.

promotes confidence and

well-being to the patient.
This also helps to
promote independence
and control. By providing
her simple activities of
self-care, she will be able

rd

Impaired physical

to feel her worth.

This is the third priority

mobility related to

because other problems

decrease muscle strength

may arise if the patient

secondary to surgical

cannot move. Circulatory

procedure performed

problems to the lower

limb, contractures and
pressure ulcer may arise
if not immediately
managed.