appendicitis

INTRODUCTION

Appendicitis is an acute inflammation of the vermiform (wormlike) appendix, a blind tube projecting from the cecum,the beginning of the large intestine. Symptoms of appendicitis include pain and cramps in the area between the right hip bone and the navel, fever, nausea and vomiting, constipation, and diarrhea. The treatment is surgical removal of the appendix which is called appendectomy. Although the frequency of appendicitis is highest among young adults, the ailment can affect persons of any age.

Mr. R.C. was diagnosed with acute appendicitis. Before he was admitted at Gabriela Silang General Hospital, he was complaining of pain in the left lower epigastric area accompanied with vomiting, body malaise and fever. Because of his condition, Dr. Reynaldo Paz recommended him for appendectomy which is always indicated if acute appendicitis is suspected. Appendectomy is the surgical removal of the inflamed or ruptured appendix. After the operation, he still stayed in the hospital for his condition to be monitored and after four days, he went home. He took his medication at home and he returned at the hospital for check-up, three days after he went home. It is the objective of this case study to gain appropriate knowledge, attitude and skills towards patient who have this kind of disease and who have undergone with this kind of operation and to apply the specific nursing care for the patient.

OBJECTIVES:
This case study aims: 1. To know what is all about Appendicitis 2. To know what are the manifestation of Appendicitis 3. To be able to assess further a patient with Appendicitis 4. To be able to know what are the necessary treatment to be done for this case 5. To provide the necessary nursing care for the patients recovery

HISTORY OF PAST AND PRESENT ILLNESS

Past Illness :

Pt x asserted that he did not experience any other crucial diseases but he was once hospitalized. He said that her mother brought him to the hospital when he was still a child for the reason that he was very hot and chilling. he was diagnosed that day of having a fever. Since then, he never experienced to be confined in the hospital.

Present Illness :

Pt x said that his illness begun two days prior to admission as a stomachache accompanied with vomiting, loss of appetite, body malaise and fever. His mother taught that it was an ulcer so she decided to bring him to the hospital for check-up. They brought him at the Hospital and he was admitted and diagnosed of acute appendicitis.

DIAGNOSTIC PROCEDURES
A. IDEAL Laboratory Studies Other Tests:

The most important of these are the white blood cell count (WBC) and
the differential. Most patients with appendicitis have an abnormality in the WBC or differential.

A urinalysis should be included in the workup for suspected appendicitis.

The result is abnormal in up to 25% of patients with appendicitis because of ureteral inflammation from an adjacent inflamed appendix. Pyuria, albuminuria, and hematuria are common in appendicitis, but severe pyuria with at least 25 white cells per high-powered field suggests pyelonephritis.

C-reactive protein (CRP) is an acute-phase reactant synthesized by the liver

in response to bacterial infection. Serum levels begin to rise within 6-12 hours of acute tissue inflammation. A rapid assay is widely available. Several prospective studies have concluded that in adult patients who have had symptoms for longer than 24 hours, a normal CRP has a negative predictive value of approximately 100% for the presence of appendicitis.

Specificity has ranged from 50-87% in several series. CRP does not distinguish between various types of bacterial infection.

8 Imaging Studies

Ultrasonography is a noninvasive and relatively inexpensive. Disadvantages

include significant operator variability and occasional nonvisualization of the appendix. A positive finding is determined by the identification of a noncompressible tubular structure 6 mm or wider in the right lower quadrant. This structure is tender during palpation with the

ultrasonographic probe. Factors that add difficulty to the examination include obesity and gaseous distension of the intestines overlying the appendix. Published reports of abdominal ultrasonography have shown this to be a valuable study for diagnosing appendicitis. Most reports indicate a sensitivity of at least 90%, with a specificity and accuracy of at least 95%.

CT scanning is more expensive than ultrasonography and usually requires

the administration of oral and intravenous contrast. Focused appendiceal CT scanning with rectal contrast may be a cost-effective alternative. CT findings that are indicative of appendicitis include a thickened appendix, fat streaking around the appendix, or thickening of the cecal wall. CT scanning may be helpful in patients with obesity or in patients in whom a localized appendiceal abscess is clinically suspected. If this is the case, CT scanning may also be helpful in the CT-guided drainage of the abscess.

 Abdominal radiography is typically used. Visualization of an appendicolith

in a patient with symptoms consistent with appendicitis is highly suggestive of appendicitis, but this occurs in fewer than 10% of cases. 9

Barium enema is a single contrast study that can be performed on an

unprepared bowel. Nonfilling or incomplete filling of the appendix coupled with pressure effect or spasm in the cecum suggests appendicitis. Multiple studies have found that the sensitivity of a barium enema is in the range of 80-100%. However, as many as 16% of examinations in adults (and 22-39% of examinations in children) were technically unsuitable for interpretation and were excluded from data analysis. Advantages of barium enema are its wide availability, use of simple equipment, and potential for diagnosis of other diseases (eg, Crohn disease, colon cancer, ischemic colitis) that may mimic appendicitis. Disadvantages include its high incidence of

nondiagnostic examination, radiation exposure, insufficient sensitivity, and invasiveness. These disadvantages make barium enema a poor screening examination for use by emergency physicians.

Radionuclide scanning is a procedure wherein whole blood is withdrawn.

Neutrophils and macrophages are labeled with technetium 99m albumin and administered intravenously. Images of the abdomen and pelvis are obtained serially over 4 hours. Localized uptake of tracer in the RLQ suggests appendiceal inflammation.

Other Studies

Clinical diagnostic scores are diagnostic scoring systems in which a finite

number of clinical variables is elicited from the patient and each is given a numerical value. The sum of these values is used to predict the likelihood of 10 acute appendicitis. The best known of these is the MANTRELS score, which tabulates presence or absence of migration of pain, anorexia, nausea/vomiting, tenderness in the RLQ, rebound tenderness, elevated temperature,

leukocytosis, and shift to the left.

Computer-aided diagnosis is a retrospective database of clinical features of

patients with appendicitis and other causes of abdominal pain is entered into a computer. It is then utilized in prospectively assessing the risk of appendicitis. Computer-aided diagnosis can achieve sensitivity greater than 90% while reducing rates of perforation and negative laparotomy by as much as 50%.The principle disadvantages are that each institution must generate its own unique database to reflect local population characteristics. Specialized equipment and significant initiation time are required.

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ANATOMY AND PHYSIOLOGY OF THE ORGAN INVOLVED

Appendix

is a worm-shaped tube branching off the cecum, the first part of the large intestine.

it is located on the lower right side of the abdomen. is usually about 9 cm (about 3.5 in) long, with a thick wall. only humans and apes have an appendix. it has no known function in human biology, but it does contain a large amount of lymphoid tissue, which may provide a defense against local infection.

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PATHOPHYSIOLOGY

A. ALGORITHM

FOREIGN BODY

OBSTRUCTION OF THE APPENDICEAL LUMEN

INFLAMMATION

ANOREXIA, LOW GRADE FEVER, ABDOMINAL PAIN, VOMITING, INCREASED WBC

INCREASED INTRALUMINAL PRESSURE

DECREASED VENOUS DRAINAGE

BACTERIAL INVASION

-WBC COUNT -IVF INSERTION -PHYSICAL EXAMINATION -CAREFUL HISTORY OF PROGRESSION, DURATION & TYPE OF SYMPTOMS

INCREASED HEAT AND EXTERNAL PRESSURE

APPENDICITIS APPENDECTOMY

16 B. EXPLANATION On pt xs case he got his appendicitis by a foreign body. This foreign body causes an obstruction of the appendiceal lumen which leads to swelling and inflammation. This will cause now the abdominal pain, anorexia, fever, vomiting and slight increase in the number of WBC. There is also an increased intraluminal pressure which causes decreased venous drainage and bacterial invasion. Due to the the invasion of bacteria, there is an increased heat and external pressure on the appendix which sometimes lead to rupture of the appendix but on the case of pt x, appendectomy, surgical removal of the appendix, is performed in order to prevent the rupture of the appendix which may cause complications that may cause more danger to his life.

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MANAGEMENT

A. MEDICAL AND SURGICAL MANAGEMENT MEDICAL MANAGEMENT If the diagnosis is uncertain, people may be watched and sometimes treated with antibiotics. This approach is taken when the doctor suspects that the patient's symptoms may have a nonsurgical or medically treatable cause. If the cause of the pain is infectious, symptoms resolve with intravenous antibiotics and intravenous fluids. In general, however, appendicitis cannot be treated with antibiotics alone and will require surgery. Occasionally the body is able to control an appendiceal perforation by forming an abscess. An abscess occurs when an infection is walled off in one part of the body. The doctor may choose to drain the abscess and leave the drain in the abscess cavity for several weeks. An appendectomy may be scheduled after the abscess is drained. SURGICAL MANAGEMENT Acute appendicitis is treated by surgery to remove the appendix. The operation may be performed through a standard small incision in the right lower part of the abdomen, or it may be performed using a laparoscope, which requires three to four smaller incisions. If other conditions are suspected in addition to appendicitis, they may be identified using laparoscopy. In some patients, laparoscopy is preferable to open surgery because the incision is smaller, recovery time is quicker, and less pain medication is required. The appendix is almost always removed, even if it is found to be normal. With complete removal, any later episodes of pain will not be attributed to appendicitis.

18 C. PROMOTIVE AND PREVENTIVE MANAGEMENT

Treatment guidelines for patients with suspected acute appendicitis include the following: Establish IV access and administer aggressive crystalloid therapy to patients with clinical signs of dehydration or septicemia. Do not give anything by mouth to patients with suspected appendicitis. Administration of analgesics to patients with acute undifferentiated abdominal pain has historically been discouraged and criticized because of concerns that they would render the physical examination less reliable. At least 8 randomized controlled studies now report that administering opioid analgesic medications to adult and pediatric patients with acute undifferentiated abdominal pain is safe; no study has found that analgesics adversely effect the accuracy of the physical examination. Administer IV antibiotics to those with signs of septicemia and those who are to proceed to laparotomy.

Nonsurgical treatment of appendicitis Anecdotal reports describe the success of IV antibiotics in treating acute appendicitis in patients without access to surgical intervention. In one prospective study of 20 patients with ultrasound-proven appendicitis, 95% had resolution of symptoms with antibiotics alone, but 37% of these patients experienced recurrent appendicitis within 14 months.

31 This may be useful when appendectomy is not accessible or when it is temporarily a high-risk procedure.

Preoperative antibiotics
o

Preoperative antibiotics have a demonstrated efficacy in decreasing postoperative wound infection rates in numerous prospective controlled studies.

o o

Broad-spectrum gram-negative and anaerobic coverage is indicated. These should be given in conjunction with the surgical consultant.

Consultations: General surgeon

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BIBLIOGRAPHY
BOOKS:

Bruner, L. S. & Suddarth, D. S. 1988, Textbook of Medical-Surgical Nursing, 6th edn, Lippincott, Philadelphia. Deglin, J. H. & Vallerand, A. H. 1997, Daviss Drug Guide for Nurses, 5th edn, F. A. Davis, Philippines. Doenges, M. E., Moorhouse, M. F. & Geissler-Murr, A. C. 2002, Nursing Care Plans: Guidelines for Individualizing Patient Care, 6th edn, F. A. Davis, Bangkok. Kozier, B., Erb, G. & Olivieri, R. 1992, Fundamentals of Nursing: Concepts, Process and Practice. 4th edn, Addison- Wesley, Philippines. Patrick, M. L. et. al. 1991, Medical-Surgical Nursing: Pathophysiological Concepts, 2nd edn, vol. II, Lippincott, Philadelphia. COMPUTER: Microsoft Encarta Premium Suite 2005 INTERNET: www. emedicine. com www. mayoclinic. Com