Introduction

Appendicitis

Appendicitis is an inflammation of the appendix, a 3 1/2-inch-long tube of tissue that

extends from the large intestine. No one is absolutely certain what the function of the
appendix is. One thing we do know: We can live without it, without apparent
consequences.

Appendicitis is a medical emergency that requires prompt surgery to remove the

appendix. Left untreated, an inflamed appendix will eventually burst, or perforate, spilling
infectious materials into the abdominal cavity. This can lead to peritonitis, a serious
inflammation of the abdominal cavity's lining (the peritoneum) that can be fatal unless it is
treated quickly with strong antibiotics.

Appendectomy

Appendectomy is the surgical removal of the appendix, a small, finger-shaped pouch that
is located at the cecum (the junction between the large and small intestines). The surgery
is the standard treatment for appendicitis (inflammation and infection of the appendix) and
patients usually recover from appendectomy without experiencing complications. A
ruptured appendix is considered a medical emergency.

Objectives;

• To be able to know the signs and symptoms of appendicitis for early prevention.
• To know the necessary nursing management for a patient having the said
condition.
• To have a wide range of knowledge regarding the medications to be given as well
as the nursing responsibilities associated in giving such medications.
Reason on choosing the case;

The reason why we prefer to choose appendicitis as our main case for this case
presentation is for us all to be aware and familiarize on this condition so that we as
nurses will know the appropriate actions to be done on handling patients having this
disease, and for us to have additional knowledge regarding the prevention of appendicitis
that will help us to effective and efficient nurses.

Patient’s profile

Name: Delis Marissa

Address: Poblacion 1, Sto. Tomas Batangas

Birth Date: May 27, 1972

Age: 37 years old

Gender: Female

Civil Status: Married

Religion: Roman Catholic

Citizenship: Filipino

Height: 5”5

Weight: 75 kg

LMP: October 10,2009

Occupation: Laundry woman

Educational Attainment: High school Graduate

Date and Time Admitted: Nov.11,09; 02:02 A.M.

Chief Complaint: abdominal pain on epigastric area

History of Present Illness: Patient’s condition started few hours prior to admission, she
experienced abdominal pain on epigastric area, the pain was intermittent, she also
experienced vomiting for 3 times, previously ingested food. She also experienced
dizziness.

Diagnosis: To consider Appendicitis ;Post Appendectomy

Past Medical History: The patient verbalize to have been hospitalized at STGH, the final
diagnosis was UTI.

Family History: The patient has a family history of Asthma, Father Side.

Lifestyle Assessment: She was fun of eating of vegetables especially tomatoes and
eggplant, she said it was her favorite that’s why she always eat it instead of meat. She
drink maximum of 3 glasses per day. She also loves to eat foods which are salty. She has
no pattern of sleep. She doesn’t spent time for exercise every time she go to her work
through walking that’s her only exercise.

Laboratory Result:

Pregnancy Test: Positive

Pus cell (WBC) 5-10 /hpf Normal: 0-2/hpf

Urinalysis is a diagnostic physical, chemical, and microscopic examination of a urine

sample.
Physical Assessment

General: Weakness and pale

Skin: pale, poor skin turgor

Nails: poor capillary refill test, nail bed is pale

Face: Facial grimace

Eyes: eye appears dry, palpebral conjunctiva – pale

Mouth: dry and crack lips

Abdomen: soft to touch, tenderness when palpated

Review of System

GI System: Nausea, vomiting, abdominal pain with pain scale of 5/10

Cardiovascular System: Nail bed is pale and has poor capillary refill as an indication of
impaired circulatory function

Musculoskeletal Function: Muscular pain

Neurologic System: Irritability and restlessness

Nervous System: Dizziness

 DISEASE PROCESS

Appendicitis is a condition characterized by inflammation of the appendix.

Causes

Obstruction of the appendiceal lumen causes appendicitis. Mucus backs up in the

appendiceal lumen, causing bacteria that normally live inside the appendix to multiply. As a
result, the appendix swells and becomes infected. Sources of obstruction include

• feces, parasites, or growths that clog the appendiceal lumen

• enlarged lymph tissue in the wall of the appendix, caused by infection in the
gastrointestinal tract or elsewhere in the body
• inflammatory bowel disease, including Crohn’s disease and ulcerative colitis
• trauma to the abdomen

An inflamed appendix will likely burst if not removed. Bursting spreads infection throughout the
abdomen—a potentially dangerous condition called peritonitis.
Symptoms

Most people with appendicitis have classic symptoms that can easily identify. The
main symptom of appendicitis is abdominal pain.

The abdominal pain usually

• occurs suddenly, often causing a person to wake up at night

• occurs before other symptoms
• begins near the belly button and then moves lower and to the right
• is new and unlike any pain felt before
• gets worse in a matter of hours
• gets worse when moving around, taking deep breaths, coughing, or sneezing

Other symptoms of appendicitis may include

• loss of appetite
• nausea
• vomiting
• constipation or diarrhea
• inability to pass gas
• a low-grade fever that follows other symptoms
• abdominal swelling
• the feeling that passing stool will relieve discomfort

Symptoms vary and can mimic other sources of abdominal pain, including

• intestinal obstruction
• inflammatory bowel disease
• pelvic inflammatory disease and other gynecological disorders
• intestinal adhesions
• constipation
Diagnosis

The diagnosis of appendicitis begins with a thorough history and physical

examination. Patients often have an elevated temperature, and there usually will be
moderate to severe tenderness in the right lower abdomen when the doctor pushes there. If
inflammation has spread to the peritoneum, there is frequently rebound tenderness.
Rebound tenderness is pain that is worse when the doctor quickly releases his hand after
gently pressing on the abdomen over the area of tenderness.

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.

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.
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.

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.

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.

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.

Laparoscopy

Laparoscopy is a surgical procedure in which a small fiberoptic 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.

There is no one test that will diagnose appendicitis with certainty. Therefore, the
approach to suspected appendicitis may include a period of observation, tests as previously
discussed, or surgery.

Treatment

Surgery

Typically, appendicitis is treated by removing the appendix. If appendicitis is

suspected, a doctor will often suggest surgery without conducting extensive diagnostic
testing. Prompt surgery decreases the likelihood the appendix will burst.

Surgery to remove the appendix is called appendectomy and can be done two ways.
The older method, called laparotomy, removes the appendix through a single incision in the
lower right area of the abdomen. The newer method, called laparoscopic surgery, uses
several smaller incisions and special surgical tools fed through the incisions to remove the
appendix. Laparoscopic surgery leads to fewer complications, such as hospital-related
infections, and has a shorter recovery time.

Surgery occasionally reveals a normal appendix. In such cases, many surgeons will
remove the healthy appendix to eliminate the future possibility of appendicitis. Occasionally,
surgery reveals a different problem, which may also be corrected during surgery.
 Sometimes an abscess forms around a burst appendix—called an appendiceal
abscess. An abscess is a pus-filled mass that results from the body’s attempt to keep an
infection from spreading. An abscess may be addressed during surgery or, more commonly,
drained before surgery. To drain an abscess, a tube is placed in the abscess through the
abdominal wall. CT is used to help find the abscess. The drainage tube is left in place for
about 2 weeks while antibiotics are given to treat infection. Six to 8 weeks later, when
infection and inflammation are under control, surgery is performed to remove what remains
of the burst appendix.

Nonsurgical Treatment

Nonsurgical treatment may be used if surgery is not available, if a person is not well
enough to undergo surgery, or if the diagnosis is unclear. Some research suggests that
appendicitis can get better without surgery. Nonsurgical treatment includes antibiotics to treat
infection and a liquid or soft diet until the infection subsides. A soft diet is low in fiber and
easily breaks down in the gastrointestinal tract.
 Drug Study

Generic Name
~ Brand Name Adverse Effect Action Indication Contraindication Nursing Responsibility

Cefuroxime Diarrhea, Inhibits bacterial wall Urinary tract Hypersensitivity to Assess patient’s incision site
nausea, synthesis, rendering infections, Otitis cephalosporin and for sign and symptom of
vomiting, cell wall osmotically media, tonsillitis, related antibiotics, infection.
Ceftin, Zinacef stomach unstable, leading to lower respiratory pregnancy, lactation.
cramps, cell death by binding to tract infection, Assess bowel pattern.
pyuria, cell wall membrane. surgical prophylaxis
dysuria. Identify urine output.
Severe infections
Determine history of
hypersensitivity reactions to
cephalosporin.
Generic Name
~ Brand Name Adverse Effect Action Indication Contraindication Nursing Responsibility

Ranitidine Headache, Inhibits the action of Short term treatment Allergy to ranitidine, Administer drug HS.
malaise, histamine at the H2- of active duodenal lactation.
dizziness, receptor site located ulcer. Decreases doses in renal and
Zantac somonolence, primarily in gastric Use cautiously with liver failure patients.
insomnia, parietal cells, resulting Short term treatment impaired renal or
vertigo. in inhibition of gastric of active, benign hepatic function, Monitor V/S
acid secretion. gastric ulcer. pregnancy.
Tachycardia,
bradycardia. Treatment of
heartburn, acid
indigestion.

GERD, esophagitis.

Generic Name
~ Brand Name Adverse Effect Action Indication Contraindication Nursing Responsibility

Nalbuphine Sedation, Binds with opiate Management of Hypersensitivity to Reassess patient’s level of
HCL dizziness, receptors in the CNS, moderate to severe drug. pain at least 15 to 30 minutes
vertigo, altering perception of pain. after parenteral
headache, and emotional Use cautiously in administration.
Nubain agitation, response to pain. Preoperative and patient with history of
confusion, postoperative drug abuse and in Assess respiratory
seizures. analgesia. those with emotional depression.
instability, head injury
Bradycardia, Supplement to and hepatic or renal Monitor circulatory and
hypertension, balanced anesthesia. disease. respiratory status, bladder
tachycardia. and bowel function.
Obstetrical analgesia
Nausea, during labor and Psychological and physical
vomiting. delivery. dependence may occur with
prolonged use.
Respiratory
depression,
asthma,
dyspnea.
Generic Name
~ Brand Name Adverse Effect Action Indication Contraindication Nursing Responsibility

Isoxsuprine Frequency not Increases muscle Treatment of cerebral Hypersensitivity to May cause skin rash,
HCL defined. blood flow, but skin vascular isoxsuprine or any discontinue use if rash
blood flow is usually insufficiency, component of the occurs.
Hypotension,
unaffected. Rather dysmenorrhea, and formulation;
tachycardia,
Duvadilan than increasing muscle premature labor, but presence of arterial Arise slowly from prolonged
chest pain
blood flow by beta- efficacies is bleeding; do not sitting or lying position
receptor stimulation, unproven for these administer
Dizziness
isoxsuprine probably indications. immediately Monitor vital signs q 30 mins
Rash has a direct action on postpartum
vascular smooth
Nausea,
muscle.
vomiting

The generally
Body
accepted mechanism
weakness
of action of isoxsuprine
on the uterus is beta-
adrenergic stimulation.
Anatomy and
Small Physiology
intestines  Duodenum-
Structure extends  Peptidases
Secretions – break
/ Enzymes  Is the major site of digestion
Function
from the pyloric theproduced
peptide bond to and absorption of food, which
sphincter, 25 cm in protect by amino acid are accomplished by the
Oral cavity  mouth
length  mucin
 – acts as–
Disaccharides  First stageofoflarge
presence foodsurface
breakdownarea.
 tongue
 Jejunum- 2.5 m long lubricant
breakdown of  Mixing and propulsion of chime
 teeth
 Ileum- 3.5 m long  Amylase- protein
disaccharides that
such as  Mechanical
via peristalticdigestion of food via
contraction
 salivary glands starts breakdown
maltose and of mastication or chewing
simply comb.
isomaltose into
 Lysozyme-loosening
monosaccharides.  Breakdown of complex
 enzymes have a weak
Mucus produced by carbohydrates with aid of
antibacterial
duodenal gland.action. salivary enzymes

Liver  Large, reddish-  Bile salts- aid in Digestion

brown organ situated emulsification of fats Excretion of fat and cholesterol
Oro pharynx  throat
at the connects
right upperfrom  Thick lubricating
and cholesterol  Responsible
Nutrient storage for swallowing or
Esophagus
And mouth to esophagus
quadrant of the mucus moving of food from pharynx to
Nutrient conversion
 muscular
abdomen. tube esophagus to stomach.
Detoxification
 15 cm in
 Surrounded lengthwith
x 2 Synthesis of new molecule
cm diameter
strong capsule and
Gallbladder  dividedupintooflobes.
Made circular
and outer sac
 Small longitudinal
on
layer
inferior surface of the
liver.
StomachPancreas  J-shaped
 Lobular, pinkish- hallow  Endocrine –  Short term storage
 Produces enzymesof digesting
that aids
muscular
gray organ organthat lies (insulin, Glucagons) food
in digestion of, carbohydrate,
behind the stomach  Exocrine – protein andbreakdown
 Mechanical fats. of food
 Located
 Complex justorgan
left of  Pancreatic by peristalsis
mid line between
composed of boththe amylase  Chemical digestion of protein by
esophagus
endocrine and small
and  Lipase acid and enzymes
intestine
exocrine tissue.  Carbohydrase  Stomach acid kills micro
 Nucleases organisms present in the in
Large intestines  Gastric
 Extends from glands
the jested food
Accumulation of unabsorbed materials
includes:
small intestines,  Some
to form feces. absorption of substance
• Surface  Mucus
consistsmucus cell
of appendix, such as alcohol
Reabsorption od water and
• Mucus  Hydrochloric acid
cecum,check cell
ascending, electrolytes.
• Parietal cell
transverse,  Pepsin, protein
• Chief cell
descending, sigmoid digesting enzyme
• Endocrine
colon, anuscelland  Gastrin
rectum.  Intrinsic factor
 Length of 1.5m x
7.5 cm in diameter.
 Appendix is 9cm
long attached to the
NCP

Assessment Diagnosis Planning Intervention Evaluation

> Pain scale 5/10 Pain related to surgical After 2 hours of nursing >position the patient After 2 hours of nursing
incision secondary to intervention the patient semi-fowlers position interventions the patient
(+) guarded behavior
appendectomy will report decrease or reports decrease of pain
>encouraged deep
relief of pain from 5/10 to 2/10
(+) expressive
breathing exercise
behavior
(restlessness) >encouraged divertional
activities

>encouraged
ambulation
 >apply cold compress

>provide frequent oral

care

>administer medications

Assessment Diagnosis Planning Intervention Evaluation

(+) dry and cracked After 2 hours of nursing
lips intervention the patient

> Poor skin turgor

> Dry mouth

> Muscle weakness

Prognosis of the patient:

The procedure that the patient undergone was quite successful as evidenced by no
active bleeding and her ability to tolerate the pain. She was on general liquid diet.