APPENDECTOMY 1

Ronella Samuels

St Joseph Mercy Hospital

School of Nursing

Batch #69

Case study #8

Appendectomy

Nurse. Elsie Asabere

05/07/19
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Content pages

Acknowledgement ……………………………………………………………………3

Patient’s bio data ………………………………………………………………………4

History …………………………………………………………………………………5

Introduction to topic……………………………………………………………………6

Definition of medical diagnosis ………………………………………………. ……. 7

Incidence of condition …………………………………………………………………8

Etiology factors…………………………………………………………………………9

Pathophysiology of disease condition………………………………………………….10

Clinical manifestation…………………………………………………………………..11-12

Treatment ………………………………………………………………………………13-14

Diagnostic evaluation………………………………………………………………….14-15

Nursing management………………………………………………………………….16-20

References …………………………………………………………………………….21
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Acknowledgement

The researcher would like to express sincere gratitude to all those who aided in the completion of

this research. Thank God for blessing me with wisdom, strength and understanding so that I

could have completed this research. Special thanks to my batch mates, family, and the patient for

their time and knowledge.

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Patient Profile

Patient’s Name: Lay Away

Age: 32

Ethnicity: African

Religion: Christianity

Nationality: Guyanese

Sex: Male

Doctor: F.Lopez

Diagnosis: Appendicitis

Allergy: unknown

Admission: 22/06/2019 at 14:15am hrs

Date of discharge: 24/06/2019 at 15:45hrs

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Patient history

Chief Complaint: patient stated “ I was vomiting yellow all morning and I am having pain on
the right side of the abdomen”

Social History: nil

Past medical History:nil.

Surgical History: nil

Past Family History: nil

Allergy: nil
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Introduction

Appendectomy is the surgical removal of the appendix. An inflamed appendix may be removed
using a laparoscopic approach with laser. However, the presence of multiple adhesions,
retroperitoneal positioning of the appendix, or the likelihood of rupture necessitates an open
(traditional) procedure. Studies indicate that laparoscopic appendectomy results in significantly
less postoperative pain, earlier resumption of solid foods, a shorter hospital stay, lower wound
infection rate, and a faster return to normal activities than open appendectomy.
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Definition

Appendicitis is an inflammation of the appendix, a finger-shaped pouch that projects from your
colon on the lower right side of your abdomen.

Appendicitis causes pain in your lower right abdomen. However, in most people, pain begins
around the navel and then moves. As inflammation worsens, appendicitis pain typically increases
and eventually becomes severe.

Although anyone can develop appendicitis, most often it occurs in people between the ages of 10
and 30. Standard treatment is surgical removal of the appendix.
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Incidence

Appendicitis is actually a common disorder in the United States.

 Appendicitis is the most common cause of acute surgical abdomen in the United States.
 It is the most common reason for emergency abdominal surgery in the United States.
 Appendicitis commonly occurs between the ages 10 and 30 years.

approx 1 in 400 or 0.25% or 680,000 people in USA [Source statistic for calcuation: "25 per
10,000 (age 10-17), 1-2 per per 10,000 (under 4)" -
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Etiology

Appendicitis is thought to result from obstruction of the appendiceal lumen, typically by

lymphoid hyperplasia, but occasionally by a fecalith, foreign body, or even worms. The
obstruction leads to distention, bacterial overgrowth, ischemia, and inflammation. If untreated,
necrosis, gangrene, and perforation occur. If the perforation is contained by the omentum, an
appendiceal abscess results.

.
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Clinical manifestation

 Pain: Vague epigastric or periumbilical pain progresses to right lower quadrant pain
usually accompanied by low-grade fever, nausea,and sometimes vomiting.
 Tenderness: In 50% of presenting cases, local tenderness is elicited at McBurney’s
point when pressure is applied.
 Rebound tenderness: Rebound tenderness or the production or intensification of pain
when pressure is released.
 Rovsing’s sign: Rovsing’s sign may be elicited by palpating the left lower quadrant;
this paradoxically causes pain to be felt at the right lower quadrant.

Patient had all of the symptoms

Complications

Perforation of the appendix. This is a major complication of appendicitis, which can lead
to peritonitis, abscess formation, or portal pylephlebitis.

 Perforation generally occurs 24 hours after the onset of pain.

 Symptoms include a fever of 37.7⁰C or greater, a toxic appearance, and continued
abdominal pain or tenderness.
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Pathophysiology

Appendicitis occurs when the appendix becomes acutely inflamed. It’s not entirely known why
appendicitis occurs however it is thought to be due to the lumen of the appendix becoming
blocked by a faecolith, normal faecal matter or lymphoid hyperplasia due to a viral infection.
Once obstructed, there is reduced blood flow to the tissue and bacteria is able to multiply.
Due to the lumen being obstructed, the pressure within the appendix increases and this reduces
venous drainage, resulting in ischaemia. If untreated the ischaemia can lead to necrosis and
gangrene. At this stage, the appendix is at risk of perforating. It takes around 72hrs for
perforation to occur from when the appendix becomes obstructed. Once the appendix
perforates, bacteria and inflammatory cells are released into the surrounding structures. This then
causes inflammation of the peritoneum and the child develops peritonitis causing diffuse
abdominal pain.
By
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Assessment and Diagnostic Findings

Diagnosis is based on the results of a complete physical examination and on laboratory findings
and imaging studies.

 CBC count: A complete blood cell count shows an elevated WBC count, with an
elevation of the neutrophils.
 Imaging studies:Abdominal x-ray films, ultrasound studies, and CT scans may reveal a
right lower quadrant density or localized distention of the bowel.
 Pregnancy test: A pregnancy test may be performed for women of childbearing age to
rule out ectopic pregnancy and before x-rays are obtained.
 Laparoscopy: A diagnostic laparoscopy may be used to rule out acute appendicitis in
equivocal cases.
 C-reactive protein: Protein produced by the liver when bacterial infections occur and
rapidly increases within the first 12 hours.

Drawn on the 22/06/19

DESCRIPTION RESULTS UNITS NORMAL RANGE

Hemoglobin 13.0 L g/dl 12.0-16.0

PCV/HCT 36.0 L % 37.0-52.0

White Blood Cell count 8,100 mm³ 5,000—10,000

RBC 3.86 L 106/uL 4.2-6.1

Polymorphs 52 L % 55-70

Lymphocytes 46 H % 20-40

Monocytes 0 % 2-8

Esinophils 2 % 0-6
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Basophils 2H % 0-1

Platelet 184 103/uL 150- 400

MCHC 34.5 g/dl 32.0-36.0

MCH 28.6 pg 27.0-31.0

MCV 83 fL 80.0-95.0
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Assess pain, noting location, Useful in monitoring effectiveness of medication, progression

characteristics, severity (0–10 of healing. Changes in characteristics of pain may indicate
scale). Investigate and report developing abscess or peritonitis, requiring prompt medical
changes in pain as appropriate. evaluation and intervention.

Provide accurate, honest Being informed about progress of situation provides

information to patient and SO. emotional support, helping to decrease anxiety

To lessen the pain. Gravity localizes inflammatory exudate

Keep at rest in semi-Fowler’s
into lower abdomen or pelvis, relieving abdominal tension,
position.
which is accentuated by supineposition.

Promotes normalization of organ

Encourage early ambulation. function (stimulates peristalsis and passing of flatus, reducing
abdominal discomfort).

Refocuses attention, promotes relaxation, and may enhance

Provide diversional activities
coping abilities.

Keep NPO and maintain NG Decreases discomfort of early intestinal peristalsis, gastric
suction initially. irritation and vomiting.

Administer analgesics as Relief of pain facilitates cooperation with other therapeutic

indicated. interventions (ambulation, pulmonary toilet).

Place ice bag on abdomen Soothes and relieves pain through desensitization of nerve
periodically during initial 24– endings. Note: Do not use heat, because it may cause tissue
48 hr, as appropriate. congestion.

Never apply heat to the right

This may cause the appendix to rupture.
lower abdomen.

Watch closely for possible

Continuing pain and fever may signal an abscess.
surgical complications.

Nursing intervention Rationales

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Medical Management

Medical management should be performed carefully to avoid altering the presenting symptoms.

 IV fluids. To correct fluid and electrolyte imbalance and dehydration, IV fluids are
administered prior to surgery.
 Antibiotic therapy. To prevent sepsis, antibiotics are administered until surgery is
performed.
 Drainage. When perforation of the appendix occurs, an abscess may form and patient is
initially treated with antibiotics and the surgeon may place a drain in the abscess.

Surgical Management

Immediate surgery is typically indicated if appendicitis is diagnosed.

 Appendectomy. Appendectomy or the surgical removal of the appendix is performed as

soon as it is possible to decrease the risk of perforation.
 Laparotomy and laparoscopy. Both of these procedures are safe and effective in the
treatment of appendicitis with perforation.

Patient had Appendectomy, surgery was successful

Nursing Management

Nursing Assessment

Assessment of a patient with appendicitis may be both objective and subjective.

 Assess the level of pain.

 Assess relevant laboratory findings.
 Assess patient’s vital signs in preparation for surgery.
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Diagnosis

Based on the assessment data, the most appropriate diagnoses for a patient with appendicitis are:

 Acute pain related to obstructed appendix.

 Risk for deficient fluid volume related to preoperative vomiting, postoperative
restrictions.
 Risk for infection related to ruptured appendix.

Planning & Goals

Goals for a patient with appendicitis include:

 Relieving pain.

 Preventing fluid volume deficit.

 Reducing anxiety.

 Eliminating infection due to the potential or actual disruption of the GI tract.

 Maintaining skin integrity.

 Attaining optimal nutrition.

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Nursing Interventions

 IV infusion: An IV infusion is made to replace fluid loss and promote adequate renal
functioning.

 Antibiotic therapy:Antibiotic therapy is given to prevent infection.

 Positioning: After the surgery, the nurse places the patient on a High-fowler’sposition to
reduce the tension on the incision and abdominal organs, thereby reducing pain.

 Oral fluids:When tolerated, oral fluids could be administered.

Evaluation

 Relieved pain.
 Prevented fluid volume deficit.
 Reduced anxiety.
 Eliminated infection due to the potential or actual disruption of the GI tract.
 Maintained skin integrity.
 Attained optimal nutrition.

Discharge and Home Care

Discharge teaching for patient and family is imperative.

 Removal of sutures:The nurse instructs the patient to make an appointment with the
surgeon to remove the sutures between the 5th and 7th days after surgery.
 Activities: Heavy lifting is to be avoided postoperatively; however, normal activity can
be resumed within 2 to 4 weeks.
 Home care: A home care nurse may be needed to assist with incision care and to monitor
the patient for complications and wound healing.
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A Head to Toe Assessment

General appearance

A male patient was admitted to SWII via wheelchair in the company of relative and student nurse

with no respiratory distress observed. Patient awake, alert and oriented to person, place and time.

Patient well groomed. Patient negotiate with nurses well.

Vital signs:

Temperature: 36.1 ℃

Pulse: 84 beats per minute

Respiration: 22 breaths per minute

Blood Pressure: 120/80 mmHg

Oxygen Saturation: 99% with oxygen

Head:

Hair black and short, same evenly distributed about the head. Facial features symmetrical. Sclera

white, mucous membranes slightly pale but moist. Brisk pupillary reaction to light at 2mm.No

lesions noted on inspection. No exudates draining from ears. No discharge draining from nose,

both nares patent. The nasal mucosa is pinkish to red in color. No infection of the mouth seen.

No lymph nodes palpable. Carotid pulse palpated. No Jugular vein distention.

Chest: Patient had a non- productive cough. Symmetrical rise and fall of the chest observed. No

shortness of breath or labored respiration noted at present. Lungs auscultated bilaterally.S₁, S₂

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and S3 heart sounds heard upon auscultation. No heart mummers. No fibrillation seen upon

examination of heart.

Abdomen :Abdomen non-distended. Bowel sounds hypoactive in all four quadrant of the

abdomen. Abdomen soft upon palpation. No abdominal mass felt upon palpation that includes no

enlarge spleen or liver. Sensitive to touch on right lower quadrant.

Extremities: Intravenous fluid 1 L Normal Saline infusing to left hand, no signs of infiltration

seen. No edema to extremities. Peripheral pulses bounding. Capillary refill return 3seconds. Skin

warm to touch, afebrile. Skin integrity intact.. No rashes, ecchymosis or lesions observed. Skin

colour due to ethnicity remain throughout body.

Musloskeleton: Good muscle tone and skin turgor. Good range of motions in both extremities.

No complaints made of joint pains.

Neuroskeleton: Patient awake, alert and oriented to place and person, converse well with nurses.

GCS 15/15.
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Patient needs according to Maslow Heirarchy of needs

Oxygen

 Monitor vital signs, that is, temperature, pulse, respiration and blood pressure every 4 hrs for

sudden change in condition or for evidence of shock.

 Monitor oxygen saturation with pulse oximeter to detect abnormal (normal- 95-100% drop

in saturation), since patient hemoglobin level is mildy low.

 Keep oxygen materials readily available at bedside, incase patient observed having

respiratory distress. This is to promptly deliver oxygen when in need.

 Open windows and turn on fan to promote ventilation which will aid in effective breathing.

Elimination

 Monitor the patient’s intake and output of fluids to maintain a fluid balance. Input should be

equal to output to prevent over hydration and dehydration.

Rest and activity

 Provide a quiet and comfortable environment which will reduce anxiety levels and promote

rest and sleep; also decreased anxiety will reduce the heart work load.

 Promote of rest and sleep which are essential to physical and mental restoration.

 Maintain a calm and friendly approach while attending to patient. This is to reduce anxiety

and alleviate fear.

 When patient is comfortable, teach ways to control anxiety and avoid anxiety-provoking

situations (relaxation techniques).

 Assess for factors contributing to a sense of powerlessness, and intervene accordingly.

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 Listen actively to patient often; encourage patient to express concerns and questions.

 Ensure bed linens are changed regularly. To promote comfort.

Emotional security

 Ensure you always introduce yourself to the patient who will increase participation and

co-operation.

 Establish a trusting relationship by displaying warmth. These therapeutic skills put the

patient at ease.

 Inform the patient about all procedures before performing them to obtain consent which

preserves autonomy.

 When patient exhibits anxiety, promote physical comfort and psychological support; a

family member’s presence may provide reassurance; pet visitation or animal-assisted

therapy can also be beneficial.

Safety and security

 Take vital signs, especially temperature every 4 hrs. malaria parasite affects the thermo

regulating center casing a rise in body temperature which can cause febrile seizures if not

controlled.

 Wash hands thoroughly before and after patient contact to prevent the spread of micro-

organisms and cross contamination.

 Keep bed rails up at all times to promote safety and prevent falls out of bed.

 Ensure intravenous line is patent, well secured with tape and no sign of infection is present.

 Observe the client for medication compliance and adverse effect.

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References

https://teachmepaediatrics.com/surgery/abdominal/acute-appendicitis/#Pathophysiology

https://www.mayoclinic.org/diseases-conditions/appendicitis/symptoms-causes/syc-20369543

https://www.merckmanuals.com/professional/gastrointestinal-disorders/acute-abdomen-and-surgical-
gastroenterology/appendicitis

https://www.webmd.com/digestive-disorders/picture-of-the-appendix

https://nurseslabs.com/4-appendectomy-nursing-care-plans/