Republic of the Philippines

Southern Luzon State University

College of Allied Medicine
Lucban, Quezon
A.Y. 2021-2022

CASE STUDY:

APPENDICITIS
 Appendicitis

I. OBJECTIVES OF THE STUDY

This study aims to deliver and develop familiarity in providing an effective nursing care to
a patient with appendicitis through the phases of surgery thorough understanding and formulation
of a plan for interventions. Furthermore, this study also aims to develop and improve the
knowledge, skills, and attitude of the student in handling a patient with this condition.

Specifically, this study aims to satisfy the following objectives:

1. Illustrate the anatomy and physiology of the system involved.

2. Provide an overview of the condition through determining its definition, causes, risk
factors, prognosis, mortality, morbidity, signs and symptoms, laboratory studies,
diagnosis, treatment, surgical management, and current trends and issues.
3. Determine the general data of the patient.
4. Provide a comprehensive and thorough physical assessment of the patient.
5. Determine the past, present, and family medical health history of the patient.
6. Analyze the laboratory results of the patient and deliver appropriate nursing
interventions.
7. Create a pathophysiology of perforated appendicitis.
8. Formulate appropriate nursing care plans for the patient’s condition to facilitate
recovery.
9. Determine the drugs used in appendicitis and the nursing responsibilities for each drug.

II. INTRODUCTION

Proper elimination of wastes in the body is necessary to keep an individual’s optimum

health as a slight obstruction with this function may result to devastating effects which further
requires surgery. The appendix which is a small organ attached to the large intestine may still not
have a definite function but its inflammation or disruption may bring about a great change on how
the body systems work and function. A blockage of the organ leads to increased pressure and
results to inflammation or worse, its bursting, which may cause other further complications in the
body.
 It is very important for nurses to provide the patient the information they ought to know
and to be able to perform appropriate interventions from the preparation of the patient for the
treatment necessary, promotion of healing and recovery, and prevention of worsening or
development of other complications that may possible arise.

This study aims to gain knowledge about elimination, appendicitis, and other management
related and necessary to improve the skills and attitude towards providing care that will improve
patient outcomes, avoid further complications, and provide health education to patients or other
providers of care in this context.

III. ANATOMY OF THE DIGESTIVE SYSTEM

The organs of the digestive system can be separated into two main groups: those forming
the alimentary canal and the accessory digestive organs The alimentary canal performs the whole
menu of digestive functions (ingests, digests, absorbs, and defecates) as it propels the foodstuff
along its length. The accessory organs (teeth, tongue, and several large digestive glands) assist
digestion in various ways.
Organs of the Alimentary Canal
The alimentary canal, also called the gastrointestinal (GI) tract or gut, is a continuous,
coiled, hollow muscular tube that winds through the ventral body cavity from mouth to anus. Its
organs are the mouth, pharynx, esophagus, stomach, small intestine, and large intestine. The large
intestine leads to the terminal opening, or anus. In a cadaver, the alimentary canal is approximately
9 m (about 30 feet) long, but in a living person, it is considerably shorter because of its muscle
tone.

Mouth
Food enters the
digestive tract through the
mouth, or oral cavity, a
mucous membrane–lined
cavity. The lips, or labia,
protect its anterior opening;
the cheeks form its lateral
walls; the hard palate forms its anterior roof; and the soft palate forms its posterior roof. The uvula
is a fleshy fingerlike projection of the soft palate, which dangles from the posterior edge of the soft
palate. The space between the lips and cheeks externally and the teeth and gums internally is the
vestibule. The area contained by the teeth is the oral cavity proper. The muscular tongue occupies
the floor of the mouth. The tongue has several bony attachments—two of these are to the hyoid
bone and the styloid processes of the skull. The lingual frenulum, a fold of mucous membrane,
secures the tongue to the floor of the mouth and limits its posterior movements.

At the posterior end of the oral cavity are paired masses of lymphatic tissue, the palatine
tonsils. The lingual tonsil covers the base of the tongue just beyond. The tonsils, along with other
lymphatic tissues, are part of the body’s defense system. When the tonsils become inflamed and
enlarge, they partially block the entrance into the throat (pharynx), making swallowing difficult
and painful. As food enters the mouth, it is mixed with saliva and masticated. The cheeks and
closed lips hold the food between the teeth during chewing. The nimble tongue continuously mixes
food with saliva and initiates swallowing. Thus, the breakdown of food begins before it has even
left the mouth.

Pharynx
From the mouth, food passes posteriorly into the oropharynx and laryngopharynx, both of
which are common passageways for food, fluids, and air. The pharynx is subdivided into the
nasopharynx, part of the respiratory passageway; the oropharynx, posterior to the oral cavity; and
the laryngopharynx, which is continuous with the esophagus inferiorly. The walls of the pharynx
contain two skeletal muscle layers. The cells of the outer layer run longitudinally; those of the
inner layer (the constrictor muscles) run around the wall in a circular fashion. Alternating
contractions of these two muscle layers propel food through the pharynx inferiorly into the
esophagus called peristalsis.

Esophagus
The esophagus or gullet, runs from the pharynx through the diaphragm to the stomach.
About 25 cm (10 inches) long, it is essentially a passageway that conducts food (by peristalsis) to
the stomach. The walls of the alimentary canal organs from the esophagus to the large intestine
are made up of the same four tissue layers, or tunics
1. The mucosa is the innermost layer, a moist mucous membrane that lines the hollow
cavity, or lumen, of the organ. It consists primarily of surface epithelium plus a small
amount of connective tissue (lamina propria) and a scanty smooth muscle layer. Beyond
the esophagus, which has a friction-resisting stratified squamous epithelium, the epithelium
is mostly simple columnar.
2. The submucosa is found just beneath the mucosa. It is soft connective tissue containing
blood vessels, nerve endings, mucosa-associated lymphoid tissue (MALT), and lymphatic
vessels.
3. The muscularis externa is a muscle layer typically made up of an inner circular layer
and an outer longitudinal layer of smooth muscle cells.
4. The serosa is the outermost layer of the wall. As half of a serous membrane pair, the
visceral peritoneum consists of a single layer of flat, serous fluid–producing cells. The
 visceral peritoneum is continuous with the slippery parietal peritoneum, which lines the
abdominopelvic cavity by way of a membrane extension, the mesentery.

The alimentary canal wall contains two important intrinsic nerve plexuses—the
submucosal nerve plexus and the myenteric nerve plexus. These networks of nerve fibers are
actually part of the autonomic nervous system. They help regulate the mobility and secretory
activity of GI tract organs.

Stomach
The J-shaped stomach is on the left
side of the abdominal cavity, nearly hidden
by the liver and diaphragm. Different
regions of the stomach have been named.
The cardial region, or cardia (named for its
position near the heart), surrounds the
cardioesophageal sphincter, through which
food enters the stomach from the esophagus.
The fundus is the expanded part of the
stomach lateral to the cardial region. The body is the midportion of the stomach; in the body, the
convex lateral surface is the greater curvature, and its concave medial surface is the lesser
curvature. As it narrows inferiorly, the body becomes the pyloric antrum and then the funnel-
shaped pylorus, the terminal part of the stomach. The pylorus is continuous with the small intestine
through the pyloric sphincter, or pyloric valve.
The stomach varies from 15 to 25 cm (6 to 10 inches) in length, but its diameter and volume
depend on how much food it contains. When it is full, it can hold about 4 liters (1 gallon) of food.
When it is empty, it collapses inward on itself, and its mucosa is thrown into large folds called
rugae.

Most digestive activity occurs in the pyloric region of the stomach. After food has been
processed in the stomach, it is thick like heavy cream and is called chyme. The chyme enters the
small intestine through the pyloric sphincter.
Small Intestine
The small intestine is the body’s major digestive organ. Within its twisted passageways,
usable nutrients are finally prepared for their journey into the cells of the body. The small intestine
is a muscular tube extending from the pyloric sphincter to the large intestine. It is the longest
section of the alimentary tube, with an average length of 2 to 4 m (7 to 13 feet) in a living person.
Except for the initial part of the small intestine, which mostly lies in a retroperitoneal position
(posterior to the parietal peritoneum), the small intestine hangs in sausage-like coils in the
abdominal cavity, suspended from the posterior abdominal wall by the fan-shaped mesentery. The
large intestine encircles and frames it in the abdominal cavity.
The small intestine has three subdivisions: the Duodenum, the jejunum, and the ileum,
which contribute 5 percent, nearly 40 percent, and almost 60 percent of the length of the small
intestine, respectively. The ileum joins the large intestine at the ileocecal valve. Chemical digestion
of foods begins in earnest in the small intestine. The small intestine is able to process only a small
amount of food at one time. The pyloric sphincter controls the movement of chyme into the small
intestine from the stomach and prevents the small intestine from being overwhelmed. In the J-
shaped duodenum, some enzymes are produced by the intestinal cells. More important are enzymes
that are produced by the pancreas and then delivered to the duodenum through the pancreatic ducts,
where they complete the chemical breakdown of foods in the small intestine. Bile (formed by the
liver) also enters the duodenum through the bile duct in the same area. The main pancreatic and
bile ducts join at the duodenum to form the flask-like hepatopancreatic ampulla, literally, the
“liver-pancreatic enlargement.” From there, the bile and pancreatic juice travel through the
duodenal papilla and enter the duodenum together.
Nearly all nutrient absorption occurs in the small intestine. The small intestine is well suited
for its function. Its wall has three structures that increase the absorptive surface tremendously—
villi, microvilli, and circular folds. Villi are fingerlike projections of the mucosa that give it a
velvety appearance and feel, much like the soft nap of a towel. Within each villus is a rich capillary
bed and a modified lymphatic capillary called a lacteal.
The nutrients are absorbed through the mucosal cells into both the capillaries and the
lacteal. Microvilli are tiny projections of the plasma membrane of the mucosa cells that give the
cell surface a fuzzy appearance, sometimes referred to as the brush border. The plasma membranes
bear enzymes (brush border enzymes) that complete the digestion of proteins and carbohydrates
in the small intestine. Circular folds, also called plicae circulares, are deep folds of both mucosa
and submucosa layers. Unlike the rugae of the stomach, the circular folds do not disappear when
food fills the small intestine. Instead, they form an internal “corkscrew slide” to increase surface
area and force chyme to travel slowly through the small intestine so nutrients can be absorbed
efficiently. All these structural modifications, which increase the surface area, decrease in number
toward the end of the small intestine. In contrast, local collections of lymphatic tissue (called
Peyer’s patches) found in the submucosa increase in number toward the end of the small intestine.
This reflects the fact that the remaining (undigested) food residue in the intestine contains huge
numbers of bacteria, which must be prevented from entering the bloodstream if at all possible.

Large Intestine
The large intestine is much larger in diameter than the small intestine (thus its name) but
shorter in length. About 1.5 m (5 feet) long, it extends from the ileocecal valve to the anus. Its
major functions are to dry out the indigestible food residue by absorbing water and to eliminate
these residues from the body as feces. It frames the small intestine on three sides and has these
subdivisions: cecum, appendix, colon, rectum, and anal canal.
The saclike cecum is the first part of
the large intestine. Hanging from the cecum
is the wormlike appendix, a potential trouble
spot. Because it is usually twisted, it is an
ideal location for bacteria to accumulate and
multiply. Inflammation of the appendix,
appendicitis, is the usual result.
The exact function of the appendix
has been a debated topic yet, today it is accepted that this organ may have an immune-protective
function and acts as a lymphoid organ, especially in the younger person. Other theories contend
that the appendix acts as a storage vessel for "good" colonic bacteria. But still, others argue that it
is a mere developmental remnant and has no real function.
The colon is divided into several distinct regions. The ascending colon travels up the right
side of the abdominal cavity and makes a turn, the right colic (or hepatic) flexure, to travel across
the abdominal cavity as the transverse colon. It then turns again at the left colic (or splenic) flexure
and continues down the left side as the descending colon to enter the pelvis, where it becomes the
S-shaped sigmoid colon. The sigmoid colon, rectum, and anal canal lie in the pelvis. The anal
canal ends at the anus, which opens to the exterior. The anal canal has two valves: the external
anal sphincter, composed of skeletal muscle, is voluntary, and the internal anal sphincter, formed
by smooth muscle, is involuntary. These sphincters, which act rather like purse strings to open and
close the anus, are ordinarily closed except during defecation, when feces are eliminated from the
body. Because most nutrients have been absorbed before the large intestine is reached, no villi are
present in the large intestine, but there are tremendous numbers of goblet cells in its mucosa that
produce alkaline (bicarbonate-rich) mucus. The mucus lubricates the passage of feces to the end
of the digestive tract. In the large intestine, the longitudinal layer of the muscularis externa is
reduced to three bands of muscle called teniae coli. Because these muscle bands usually display
some degree of tone (are partially contracted), they cause the wall to pucker into small pocket-like
sacs called haustra.

PHYSIOLOGY OF THE DIGESTIVE SYSTEM

The major functions of the digestive tract are usually summarized in two words—digestion
and absorption. The essential activities of the GI tract include the following six processes.
1. Ingestion. Food must be placed into the mouth before it can be acted on. This is an
active, voluntary process called ingestion.
2. Propulsion. To be processed by more than one digestive organ, foods must be propelled
from one organ to the next. Swallowing is one example of food movement that depends
largely on the propulsive process called peristalsis. Peristalsis is involuntary and involves
alternating waves of contraction and relaxation of the longitudinal muscles in the organ
wall. The net effect is to squeeze the food along the tract.
3. Food breakdown: Mechanical breakdown. Mechanical breakdown physically
fragments food into smaller particles, increasing surface area and preparing food for further
degradation by enzymes. Chewing and mixing of food in the mouth by the teeth and tongue,
and churning of food in the stomach are examples of processes contributing to mechanical
food breakdown. In addition, segmentation in the small intestine moves food back and forth
across the internal wall of the organ, mixing it with the digestive juices. Although
 segmentation may also help to propel foodstuff through the small intestine, it is more an
example of mechanical digestion than of propulsion.
4. Food breakdown: Digestion. The sequence of steps in which large food molecules are
chemically broken down to their building blocks
by enzymes (protein molecules that act as
catalysts) is called digestion.
5. Absorption. Absorption is the transport of
digestive end products from the lumen of the GI
tract to the blood or lymph. For absorption to
occur, the digested foods must first enter the
mucosal cells by active or passive transport
processes. The small intestine is the major
absorptive site.
6. Defecation. Defecation is the elimination of
indigestible residues from the GI tract via the
anus in the form of feces. Some of these processes
are the job of a single organ. For example, only
the mouth ingests, and only the large intestine
defecates. But most digestive system activities
occur bit by bit as food is moved along the tract.

Thus, in one sense, the digestive tract can be viewed as a “disassembly line” in which food
is carried from one stage of its processing to the next and its nutrients are made available to the
cells in the body along the way. Throughout this book we have stressed the body’s drive to
maintain a constant internal environment, particularly in terms of homeostasis of the blood, which
comes into contact with all body cells. The digestive system, however, creates an optimal
environment for itself to function in the lumen (cavity) of the alimentary canal, an area that is
actually outside the body.

Activities Occurring in the Mouth, Pharynx, and Esophagus

 Food Ingestion and Breakdown

  Food Propulsion—Swallowing and Peristalsis

Activities of the Stomach

 Food Breakdown
 Food Propulsion

Activities of the Small Intestine

 Chyme Breakdown and Absorption

 Chyme Propulsion

Activities of the Large Intestine

 Nutrient Breakdown and Absorption

 Propulsion of Food Residue and Defecation

IV. OVERVIEW OF THE DISEASE

REVIEW OF THE RELATED LITERATURE

Definition

Appendicitis is the inflammation of the vermiform appendix which is a hollow organ at the
tip of the cecum in the right lower quadrant of the abdomen. However, its location may change in
almost any area of the abdomen, depending on abnormal developmental issues, such as midgut
malrotation, or if there are any other special conditions such as pregnancy or prior abdominal
surgeries.

Appendicitis typically presents acutely, within 24 hours of onset, but can also present as a
more chronic condition. Most of the time, it initially presents with generalized or periumbilical
abdominal pain that later localizes to the right lower quadrant.

Causes

The exact etiology of acute appendicitis is still unknown. However, the cause of
appendicitis is usually an obstruction of the appendiceal lumen. This can be from an appendicolith
(stone of the appendix) or some other mechanical etiologies. Appendiceal tumors are also known
causes of appendiceal obstruction and appendicitis such as:

 carcinoid tumors
 appendiceal adenocarcinoma
 intestinal parasites
 hypertrophied lymphatic tissue

When the appendiceal lumen gets obstructed, bacteria build up in the appendix and cause
acute inflammation with perforation and abscess formation as the appendix contains a combination
of aerobic and anaerobic bacteria, including Escherichia coli and Bacteroides spp.

Risk Factors

Appendicitis may affect any individual. However, some people may have an increased
chance of developing this condition more than others. The risk factors for appendicitis include age,
sex, and family history; diet may also be another risk factor in developing appendicitis.

 Age: 15 to 30-year-old individuals are more likely to have appendicitis.

 Sex: Appendicitis is more common in males than in females.
 Family History: Individuals with a family history of having appendicitis have greater
risk of developing one.
 Low-fiber diet: Increases the risk of appendicitis according to research.

Prognosis

With early diagnosis and treatment, and a relatively safe surgical procedure, the recovery
within 24 to 48 hours, can be expected in patients with appendicitis. While cases that present with
advanced abscesses, sepsis, and peritonitis may have a more prolonged and complicated course,
which possibly requires additional surgery or other interventions.

Mortality

The mortality rate of nonperforated appendicitis is <1%; however, perforated appendicitis

carries a higher mortality rate. The overall mortality rate of 0.2-0.8% is attributed to complications
of the disease rather than surgical intervention. The mortality rate in children ranges from 0.1%
to 1%; in patients older than 70 years, the rate rises above 20%, primarily because of diagnostic
and therapeutic delay.

Morbidity

Although appendectomy for acute appendicitis is one of the most common intra-abdominal
surgical procedures performed by general surgeons, morbidity rates in the postoperative period
remain between 9% and 18%, respectively. The most common age group for suspected acute
appendicitis was 31–40 years of age, with female predominance female/male (F/M) ratio in this
age group was 1.5/1.0.

Appendiceal perforation is associated with increased morbidity and mortality. The rate of
perforation varies from 16% to 40%, with a higher frequency occurring in younger age groups (40-
57%) and in patients older than 50 years (55-70%), in whom misdiagnosis and delayed diagnosis
are common. Complications occur in 1-5% of patients with appendicitis, and postoperative wound
infections account for almost one third of the associated morbidity.

Signs and Symptoms

Signs and symptoms of appendicitis may include the following:

 Sudden pain that begins on the right side of the lower abdomen which may also vary
depending on the age and location of the appendix (such as in pregnant women)
 Sudden pain that begins around the navel and often shifts to the lower right abdomen
 Pain that worsens if with coughing, walking, movements
 Nausea and vomiting
 Loss of appetite
 Low-grade fever that may worsen as the disease progresses
 Constipation or diarrhea
 Abdominal bloating
 Flatulence

Laboratory Studies

The following laboratory tests may be done in order to help rule out the disease condition.
1. Lab Testing
Laboratory measurements are requested to proceed with diagnostic steps in patients
with suspected acute appendicitis. This includes total leucocyte or blood count, neutrophil
percentage, urinalysis, and C-reactive protein (CRP) concentration.

a. Total leucocyte or blood count: Elevated white blood cells count (WBC) with or
without a left shift or bandemia is classically present, but up to one-third of patients
with acute appendicitis will present with a normal WBC count.

b. Urinalysis: There are usually ketones found in the urine

c. C-reactive protein (CRP): C-reactive protein may be elevated.

A combination of normal WBC and CRP results has a specificity of 98% for the
exclusion of acute appendicitis. Moreover, the WBC and CRP results have a positive
predictive value to differentiate uninflamed, uncomplicated, and complicated
appendicitis. Both increasing levels of CRP and WBC correlate with a significant increase
in the likelihood of complicated appendicitis.

The WBC count of 10,000 cells/mm^3 is highly predictable in patients with acute
appendicitis; however, the level would increase in patients with complicated appendicitis.
Accordingly, the WBC count of equal and or above 17,000 cells/mm^3 is associated with
complications of acute appendicitis, including perforated and gangrenous appendicitis.

2. Imaging

There are several imaging modalities used to proceed with the diagnostic steps,
including an abdominal CT scan, ultrasonography, and MRI.

a. CT-scan: An abdominal CT scan has greater than 95% accuracy for the
diagnosis of appendicitis and is used with increasing frequency. CT criteria for
appendicitis include an enlarged appendix (greater than 6 mm in diameter),
appendiceal wall thickening (greater than 2 mm), peri-appendiceal fat
stranding, appendiceal wall enhancement, the presence of appendicolith
(approximately 25% of patients). It is unusual to see air or contrast in the lumen
with appendicitis due to luminal distention and possible blockage in most cases
 of appendicitis. Nonvisualization of the appendix does not rule out appendicitis.
Occasionally appendicoliths are incidentally found on routine x-rays or CT
scans.
b. Ultrasonography: Is a widely used and available primary measure to evaluate
patients with acute abdominal pain. A specific index of compressibility along
with a diameter of less than 5 mm is used to exclude appendicitis. Patients who
are complicated with peritonitis would hardly tolerate the graded compression.
c. MRI: An abdominal MRI is expensive but and demands a high level of
expertise to interpret the results. It is indicated mainly to special groups of
patients such as pregnant women in whom an unacceptable risk of radiation
exposure is embedded.

Diagnosis

The best way to diagnose acute appendicitis is with a good history and detailed physical
exam performed by an experienced surgeon along with the confirmatory tests aforementioned.

Treatment

Treatment options for appendicitis varies depending on the doctors recommended plan of
treatment but treatment may include the following:

 Surgical removal of appendix

 Drainage to drain abscess in cases of rupture A percutaneous drainage procedure
is usually done by an interventional radiologist in cases of an abscess or advanced
infection to stabilize the patient and allow the inflammation to subside over time,
enabling a less difficult laparoscopic appendectomy to be performed at a later date.
 Antibiotics are administered intravenously as per order of the surgeon. There have
also been several studies promoting the treatment of uncomplicated appendicitis
solely with antibiotics and avoiding surgery altogether.
 Pain relievers
 Intravenous Fluids: The patient is kept on NPO and hydrated intravenously with
crystalloid in the emergency room.
 Liquid diet
Surgical Management

The gold-standard treatment for acute appendicitis is to perform an appendectomy.

Laparoscopic appendectomy is preferred over the open approach to prevent more complications.
Several studies have compared the outcomes with the laparoscopic appendectomy group and
patients who underwent open appendectomy. The results were suggestive of lower incidence of
wound infection, decreased level of postoperative analgesic requirement, and shorter postoperative
hospital stays in the former group. The main disadvantage of laparoscopic appendectomy is the
longer operative time. The laparoscopic approach affords less pain, quicker recovery, and the
ability to explore most of the abdomen through small incisions.

In patients with an appendiceal abscess, some surgeons continue antibiotics for several
weeks and then perform an elective appendectomy. When the appendix has ruptured, the procedure
can still be done laparoscopically, but extensive irrigation of the abdomen and pelvis is necessary.
In addition, the trocar sites may have to be left open.

In cases where there is an abscess or advanced infection, the open approach may be needed
and may require a percutaneous drainage procedure usually done by an interventional radiologist
This stabilizes the patient and allows the inflammation to subside over time, enabling a less
difficult laparoscopic appendectomy to be performed at a later date.

Open appendectomy might be selected as the practical choice, specifically in the

management of complicated appendicitis with phlegmon and in the patients who are subjected to
the conversion from the laparoscopic approach mainly due to the potential issues related to poor
visibility.

Several other alternative surgical approaches, including Natural Orifice Transluminal

Endoscopic Surgery (NOTES) and Single-incision Laparoscopic Surgery (SILS), have been
introduced recently. The idea of utilizing a flexible endoscope to enter the gastrointestinal or
vaginal tract and consequently traversing the mentioned organ to enter the peritoneal cavity is an
interesting alternative for patients who are considerate about the cosmetic aspects of the
procedures.
Current Trends and Issues

Appendectomy is the gold standard for treatment of acute appendicitis. However, recent
studies favor primary antibiotic therapy (Stob et al, 2021). Decisions on the treatment of acute
appendicitis in German hospitals follow the current trend towards non-surgical management in
selected patients. At the same time, the care of acute appendicitis has improved with regard to
overall hospital morbidity and hospital mortality.

References:

Jones MW, Lopez RA, Deppen JG. Appendicitis. [Updated 2021 Sep 9]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK493193/.
Healthline. (2021). Appendicitis. Retrieved on. November 15, 2021. From.
https://www.healthline.com/health/appendicitis.
Mayo Clinic. (2021). Appendicitis. Retrieved on. November 6, 2021. From.
https://www.mayoclinic.org/diseases-conditions/appendicitis/symptoms-causes/syc-
20369543.
Dr. D. Y. (2014). Retrieved on. November 6, 2021. From. Acute appendicitis: Common
surgical emergency. https://www.mjdrdypu.org/article.asp?issn=0975-
2870;year=2014;volume=7;issue=6;spage=749;epage=752;aulast=Dogra;aid=MedJ
DYPatilUniv_2014_7_6_749_144866.
Craig, S. (2018). Appendicitis. Retrieved on. November 6, 2021. From.
https://emedicine.medscape.com/article/773895-overview#a7.
Stöß, C., Nitsche, U., Neumann, P. A., Kehl, V., Wilhelm, D., Busse, R., Friess, H., &
Nimptsch, U. (2021). Acute Appendicitis: Trends in Surgical Treatment. Deutsches
Arzteblatt international, 118(14), 244–249.
https://doi.org/10.3238/arztebl.m2021.0118.
V. CASE STUDY

Given Case Scenario

Preoperative Assessment

A 60-year-old obese male patient presented with a 48-hour history of abdominal pain that
started as diffuse pain and became located in the right lower quadrant. He also experienced loss of
appetite, nausea and vomiting. He had undergone no previous abdominal or pelvic surgery. His
physical examination revealed tenderness in the right iliac fossa, local guarding and rebound
tenderness at the McBurney point, consistent with signs of complicated acute appendicitis. His
body temperature was 38°C, his pulse rate was 90 beats/minute and his blood pressure was 130/80
mmHg. His past medical history included heart disease, hyperlipidemia and hypertension. The
urine examination result was normal. Laboratory investigations, including serum electrolyte levels
and complete blood count, were within normal limits, except for a moderately elevated white cell
count (14,000/mm3). Plain chest showed no abnormal signs and abdominal ultrasound confirms
enlarged appendix.

Intraoperative Assessment

After induction of general anesthesia by the anesthesiologist on duty, the patient is

positioned in the lithotomy position. A warming blanket is placed over his upper body. Throughout
the surgery his temperature fluctuates between 36.6 and 37.4 C. Intraoperatively the lowest
recording of his systolic blood pressure was measured at 90 mmHg. The entire appendix was
removed and there were no complications. Two drains were placed. Patient was transferred to
PACU. The total time in the OR suite was 4 hours.

Postoperative Assessment

While the patient was in the PACU, the Jackson-Pratt drains were emptied of 50 mL
serosanguineous fluid and no frank bleeding was noted. His recovery time was 2 hours, however
the inpatient unit room was not available and his departure from the unit was delayed by 45
minutes.

Course Ward History

Upon arrival in the ward, the surgeon in duty have ordered the following:
  Nothing per orem for 12 hours or, then begin with clear liquid diet for 8 hourswith
(+) BM, then soft diet
 Hook to O2 inhalation via facemask @ 2-3l/min
 IVF: D5 LR IL x 80, for 24 hours then shift to D5 IMB 1L for 12 hours.
 Monitor Intake and Output every shift
 Monitor vital signs every hour

Medications

 Cefuroxime 750mg IV q8hr after ANST for 7 days

 Ranitidine 50mg/2ml IV q8
 Tramadol 50 mg IV q 8 for pain

General Data

Name: Oscar Ligaya
Age: 60y/o
Sex: Male
Height: 5’3”
Place of Birth: Lucena, City
Educational Level: High school level
Marital status: Married
Contact person: Robert Ligaya
Contact no.: 09245786325
Biographical Data
Address: Brgy. San Isidro Zone 4 Tayabas
City
Birthdate: 03/29/1961 Nationality: Filipino
Religion: Roman Catholic
Weight: 98 kgs
Languages spoken: Filipino, English
Occupation: Self- employed
Spouse: Maria Ligaya
Relationship: Son

Physical Assessment

Physical Assessment
Patient Name: Oscar Ligaya Age: 60 y/o
Height: 5’3” Weight: 98 kgs
BMI: 38.2 = Obese
General Assessment Awake on bed; intact skin; appropriately dressed for
season; muscle tone and mass decrease with aging, loss
of subcutaneous fat noted; Vital signs as follows: T:
38°C, PR: 90 bpm, RR: 15 bpm, BP: 130/80mmHg.
Mental Status Alert and oriented to name, time and place, maintains
eye contact, speech is moderate in tone and clear,
inability to recall recent event.
Skin Skin is dry, warm to touch, matches whole skin
coloration; poor skin turgor, no presence of any wound
or lesion; sagging presented in facial, neck, and arm
areas.
Hair Black hair color with some white colored strands
appropriate to age, scalp is dry and clean.
Nails Clean, well-groomed, with slight vertical ridges,
capillary refill at 4 seconds.
Head Normocephalic and atraumatic, head can be held still
and upright; hard and smooth without lesions noted;
round in appearance and no abnormal movements noted,
decreased pulsation in temporal artery;
temporomandibular joint palpated with full range of
motion without tenderness.
Neck Symmetric with head; centered and no bulging masses,
thyroid cartilage and cricoid cartilage move upward
symmetrically as the client swallows; trachea and
landmarks in midline; no bruits auscultated, no swelling
or enlargement noted.
Eyes Conjunctiva and EOM are normal; pupils are equal,
round, and reactive to light; no scleral icterus; no
redness, swelling or lesions on both eyelids, iris round
and evenly colored.
Ears With elongated earlobes; skin is smooth no lesions,
lumps or nodules noted; color is consistent with facial
color; auricle, tragus and mastoid process are not tender;
small amount of odorless cerumen is noted.
Nose and Sinuses Color is the same with the rest of the face; nasal
structure is smooth and symmetric; client report no
tenderness; able to sniff through each nostril while other
is occluded; nasal mucosa is slight pink, moist and free
of exudate; nasal septum is intact and free of ulcers;
Frontal and maxillary sinuses are non-tender to
palpation and no crepitus is evident.
Mouth and Throat Lips and gums are smooth and moist without lesions;
jaws are aligned with no deviation seen when biting
down; color and consistency of tissues along cheeks and
gums are even; teeth appear longer; oral mucosa in
slightly pink in color and dry; stensen ducts are visible
with flow of saliva and no redness, swelling, pain or
moistness in area; tongue is slightly pink; frenulum is in
midline; no lesions, ulcers or nodules are apparent;
tongue offers strong resistance; acidic breath; tonsils are
pink, symmetric and no swelling; throat is patent and
moist.
Thorax and Lungs No nasal flaring; client has evenly colored skin tone in
the face, lips and chest; scapulae are symmetric and
non-protruding; Pulmonary/Chest shows no respiratory
status distress; Skin and subcutaneous tissue are free of
lesions and masses.
Breasts Skin and subcutaneous tissue are free of lesions and
masses; no swelling and bulging lymph nodes noted.
 Heart Rate near elevated; regular rhythm, and normal heart
sound with no murmur noted upon auscultation; external
chest is normal in appearance without lifts.
Abdomen Patient complains of abdominal pain on RLQ; right iliac
fossa is tender, with local guarding and tenderness at
McBurney point; with hyperactive bowel sounds; no
visible lesions or scars; Aorta is in midline without bruit
or visible pulsation; Umbilicus in midline without
herniation; No masses, hepatomegaly, or splenomegaly
noted.
Musculoskeletal – Upper and Limited ROM against gravity and resistance; Cervical
Lower Extremities
thoracic and lumbar spine slightly curve; Paravertebral
non-tender; with limited movement of cervical and
lumbar spine; upper and lower extremities are
symmetric, no lesions or swelling.

Present Medical History of Client

Upon admission on November 14,2021, Oscar Ligaya, 60 y/o male with obesity presented
with a 48-hour history of abdominal pain that started as diffuse pain and became located in the
right lower quadrant. The patient has loss of appetite, nausea and vomiting. His physical
examination revealed tenderness in the right iliac fossa, local guarding and rebound tenderness at
the McBurney point, consistent with signs of complicated acute appendicitis. With the following
initial vital signs Temp: 38°C, PR: 90 bpm, RR: 15 bpm BP: 130/80 mmHg.

Past Medical History of Client

Patient’s past medical history included heart disease, hyperlipidemia and hypertension.
Patient has no previous abdominal or pelvic surgery, no congenital disease/s.
Family Medical History of Client

Patient’s family history is notable of several diseases. Father and uncle has hypertension
and heart attack, mother had appendicitis, Diabetes mellitus type 2, and hypertension. The patient
has two siblings, one with hypertension and other had undergone appendectomy on his early 30s.

Laboratory Analysis

Laboratory and Imaging

Patient Name: Oscar Ligaya Age: 60 y/o APPENDICITIS
Laboratory Result Normal Interpretation Nursing
Test Values Responsibilities
Imaging Tests
Abdominal Appendix Normal Inflammation >Assist patient in the
ultrasound enlarged at findings of the procedures to be done.
7mm Appendix >Instruct the patient
Chest x-ray Normal Normal Normal properly about the
findings procedures and keep
patient NPO for 8 to 12
hours for the procedure
and keep bladder full.
>Explain the procedures
after the information
from the physician.
>Answer patient’s
questions and support
patient.
CBC
WBC 14, 000/μl 4,500 – 11,000 Elevated >Assess for signs and
/μl symptoms of infection,
such as elevate
RBC 4.4 4.1 - 5.1 Normal temperature, tachycardia,
million/mc million/mcL chills, and anorexia
L >Assess for source of
HGB 12g/dL 12 – 16 g/dL Normal infection.
>Provide rest, adequate
nutrition, and increased
HCT 38% 36 - 46% Normal fluids
>Administer antibiotics
as prescribed

Total 140 mg/dL <200mg/dL Normal >Assist patient on the

Cholesterol procedures.
 HDL 84 mg/dL >40mg/dL Normal >Encourage and
recommend to patient
eating foods low in
LDL 72 mg/dL <100mg/dL Normal saturated fat such as
yogurt and avoid too
much red meat to keep
normal levels of
cholesterol.
BMP
BUN 14mg/dL 7-22mg/dL Normal >Assist patient on the
procedures.
>Instruct patient properly
Glucose 118mg/dL <120 mg/dL Normal on the procedures to be
done and prepare
instructions for
Creatinine 1.1 mg/dL 0.6 – Normal preparation for the tests.
1.35mg/dL

Sodium 138 mEq/L 135-145mEq/L Normal

Potassium 4.0 mEq/L 3.5-5.5 mEq/L Normal

Chloride 100mEq/L 96-106mEq/L Normal

Lipase 50u/L 10 – 140 U/L Normal >As with any medical

test, follow the advice
and instructions of
doctors and technicians.
>Explain that the doctor
usually advises fasting
for a specified period,
typically between 8 and
12 hours, before the
blood test
Liver function test
Bilirubin 0.9mg/dL 0.1 – 1.2 Normal >Instruct patient to
mg/dL remain on NPO for at
least 8 hours for the test.
AST 20U/L 8 – 48 U/L Normal >Explain the importance
of the test/procedure to
be done.
ALT 20U/L 7 – 55 U/L Normal >Answer patient’s
questions if possible.
 Urinalysis
Specific 1.012 1.010 – 1.025 Normal >Explain to the patient
the importance of the
Gravity
procedure.
pH 5.0 4.6 – 8.0 Normal >Instruct patient properly
on what to do.
>Make sure that
Ketone Negative Normally not Normal midstream urine is
present collected and in adequate
amount.
leukocytes Negative Normally not Normal >Deliver specimen
immediately to the lab or
present to low
within an hour for
levels (<5) testing.
nitrite Negative Normally not Normal
present
Urobilinogen Negative Normally Normal
present
Blood Negative Normally not Normal
present to low
levels (<5)
bilirubin Negative Normally not Normal
present
glucose Negative Normally not Normal
present
160 – 180
mg/dL
 Risk Factors
 Aging and Development
Pathophysiology  Family Hx of appendicitis

Lymphoid follicle in appendix

grows

Increased lymphocytes

Hyperplasia of lymphocytes

Excessive growth of the Fecalith, undigested seeds,

lymphoid tissue pinworm infection Intestinal lumen secretes mucus
and fluid
Obstruction of the Appendix

Flora and gut bacteria (e.g. E.- Mucus secretion continues;

coli) is trapped becomes thick and creates
buildup of fluid and mucus

Flora and gut bacteria multiply Increased pressure Anorexia, Nausea and vomiting

Chemotaxis: Signals other Inflammation of the Appendix Compression of blood vessels

macrophages
Puts pressure against the Less oxygen is received in the
visceral nerve fibers cell walls
White blood cells will increase
(WBC: 14, 000/mm3) Cell walls die
Pain in the RLQ at the
McBurney’s Point
Macrophage within the alveoli Bacteria accumulates Appendiceal walls
recognizes causative agent in the wall of the become weaker
appendix
Phagocytosis occurs
 Appendix ruptures
Macrophage excretes
cytokines (TNFa and
Interleukin 1) Bacteria escapes the appendix

Abscess forms around the Bacteria reaches the

Interleukin 1 will signal the
appendix peritoneum
hypothalamus to increase
(Periappendiceal abcess)
body temperature
Peritonitis/

Temp: 38C inflammation of the

peritoneum

 Pain in the RLQ at the

McBurney’s Point
 Rebound tenderness
 Abdominal guarding
Nursing Care Plan (Preoperative)

NURSING CARE PLAN

Patient Name: Oscar Ligaya APPENDICITIS
Age: 60 y/o
ASSESSMENT NURSING NURSING NURSING RATIONALE EVALUATION
DIAGNOSIS GOAL INTERVENTIONS
S: “Napakasakit - Acute pain -After 8 hours of 1. Established rapport 1. To gain the patient After 4 hours, the
ng t’yan ko.” As related to continuous with the patient and the and the family’s trust. patient reported
verbalized by the inflammation. nursing family. decreased pain as
patient. interventions, the evidenced by
patient will 2. Assessed the patient’s 2. To obtain baseline patient’s
Pain scale: 9/10 report decrease pain and overall data. verbalization,
of pain. condition. “Medyo
nabawasan na po
O: 3. Obtained and 3. To track important yung sakit kahit
>with rebound monitored vital signs. changes. papaano”
tenderness at
McBurney’s point 4. Positioned the patient 4. To lessen the pain Pain scale: 6/10
>facial grimace in a semi-fowler’s as gravity localizes
>guarding position. inflammatory exudate
behavior into the lower VS:
abdomen that -Temp: 37.5C
increases by the supine -BP: 125/85
VS: position. mmHg
-Temp: 38C -HR: 88/min
-BP: 130/80 5. Placed ice bag on the 5. To help relieve pain -RR: 18/min
mmHg patient’s abdomen. through
-HR: 90/min desensitization of
-RR: 20/min nerve endings.
6. Provided diversional 6. To refocus attention
activities such as and promote
television. relaxation.

7.Administered analgesic 7. To facilitate pain

as ordered. relief.
 NURSING CARE PLAN
Patient Name: Oscar Ligaya APPENDICITIS
Age: 60 y/o
ASSESSMENT NURSING NURSING NURSING RATIONALE EVALUATION
DIAGNOSIS GOAL INTERVENTIONS
S: “Ako po ay - Hyperthermia -After 8 hours of 1. Established rapport 1. To gain the patient After 8 hours of
nanginginit ang related to nursing with the patient and the and the family’s trust. nursing
pakiramdam. inflammation interventions the family. intervention, the
Nilalagnat po ata secondary to patient’s patient’s body
ako.” disease temperature will 2. Assessed the patient’s 2. To obtain baseline temperature
condition. decrease. overall condition. data. decreased as
evidenced by:
O: 3. Obtained and 3. To track important
>skin warm to monitored vital signs. changes. VS:
touch -Temp: 37.5C
4. Provided TSB. 4. To help reduce -BP: 125/85
Laboratory: increased body mmHg
WBC: 14, 000 temperature. -HR: 92/min
/mm3 -RR: 18/min
5. Applied ice packs to 5. To provide surface
VS: the patient. cooling.
-Temp: 38C
-BP: 130/80 6. Encouraged patient to 6. To reduce
mmHg increase fluid intake. temperature of the
-HR: 90/min body.
-RR: 20/min
7.Administered 7. To treat
antipyretic as ordered. hyperthermia.
 NURSING CARE PLAN
Patient Name: Oscar Ligaya APPENDICITIS
Age: 60 y/o
ASSESSMENT NURSING NURSING NURSING RATIONALE EVALUATION
DIAGNOSIS GOAL INTERVENTIONS
S: None. - Risk for -After 8 hours of 1. Established rapport 1. To gain the patient After 8 hours of
deficient fluid nursing with the patient and the and the family’s trust. nursing
volume related interventions the family. intervention, the
O: to fluid volume patient’s fluid patient’s fluid
>vomiting loss. volume will 2. Assessed the patient’s 2. To obtain baseline volume improved
>diarrhea improve. overall condition. data. as evidenced by:
>anorexia
>poor skin turgor 3. Obtained and 3. To track important >decreased
>capillary refill at monitored vital signs. changes. capillary refill
4 sec. time at 2 sec
>dry mucosa 4. Monitored physical 4. To evaluate the >moist mucus
signs of dehydration. degree of fluid deficit. membranes
>Input: 800mL
VS: 5. Kept fluids (oral H20) 5. To help replace >Urine Output:
-Temp: 38C within patient’s reach fluid volume loss. 270mL
-BP: 130/80 and encouraged increased
mmHg intake. VS:
-HR: 90/min -Temp: 37.5C
-RR: 20/min 6. Monitored patient’s 6. To track important -BP: 125/85
input and output. changes. mmHg
-HR: 92/min
-RR: 18/min
7. Administered IV fluids 7. To replace volume
as ordered. loss.
(Post-operative)

NURSING CARE PLAN

Patient Name: Oscar Ligaya APPENDICITIS
Age: 60 y/o
ASSESSMENT NURSING NURSING NURSING RATIONALE EVALUATION
DIAGNOSIS GOAL INTERVENTIONS
S: None. - Risk for -Patient will 1. Established rapport 1. To gain the patient After 8 hours, the
infection related remain free from with the patient and the and the family’s trust. patient remained
to surgical any signs of family. free from any
O: incision. infection. signs of infection
>post-operative: 2. Assessed the patient’s 2. To obtain baseline as evidenced by
exploratory overall condition. data. the absence of
laparotomy fever or any signs
appendectomy 3. Obtained and 3. To track important of infection;
>surgical incision monitored vital signs. changes. incision is free
on the midline of from any
abdomen 4. Demonstrated good 4. To reduce spread of drainage.
handwashing technique bacteria.
VS: to patient and S.O.
-Temp: 36.2C 5. To provide early VS:
-BP: 110/70 5. Inspected incisions and detection of -Temp: 36.5C
mmHg dressings. developing infectious -BP: 112/70
-HR: 88/min process. mmHg
-RR: 15/min -HR: 85/min
-RR: 15/min
6. Administered 6. To reduce incidence
antibiotics as prescribed. of wound infection.
 NURSING CARE PLAN
Patient Name: Oscar Ligaya APPENDICITIS
Age: 60 y/o
ASSESSMENT NURSING NURSING NURSING RATIONALE EVALUATION
DIAGNOSIS GOAL INTERVENTIONS
S: “Oo nini, first - Deficient -After 8 1. Established rapport with 1. To gain the patient After 8 hours, the
time ko lang knowledge hours of the patient and the family. and the family’s trust. patient verbalized
maoperahan kaya related to lack of nursing understanding of
‘di ko alam kung exposure and interventions, 2. Assessed the patient’s post-operative
kelan ba ako pede inability to recall the patient overall condition and 2. To obtain baseline practices as
na tumayo at information. will verbalize readiness for the information data. evidenced by,
kumain at sabi understandin to be given. “Sige nurse,
bago ako g of post- aantabayanan ko
operahan ay yung operative 3. Obtained and monitored 3. To track important rin kung kelan
maayos daw na practices. vital signs. changes. ako’y makakautot
mga paghinga ay na at nang
kaso ay limot ko 4. Explained the necessary 4. To provide makasimula na
na.”As verbalized practices after surgery such information in kumain at ako ay
by the patient. as coughing and deep accordance to plan mag prapractice
breathing exercises, leg after surgery. nung paghinga na
exercises, and re- sa ilong tas labas
O: emphasized physician’s sa bibig para iwas
>post-operative: order for diet. komplikasyon.”
exploratory
laparotomy 5. Encouraged patient to 5. To prevent
appendectomy practice exercises and turn pulmonary
sides frequently. complication and skin
breakdown.

6. Reassessed patient’s 6. To ensure the

knowledge through patient understood the
reiteration of what is information provided.
learned.
 Drug Study

DRUG STUDY
Patient Name: Oscar Ligaya APPENDICITIS
Age: 60 y/o
DRUG DRUG MECHANISM INDICATIONS CONTRA- ADVERSE EFFECTS NURSING
NAME CLASS OF ACTION INDICATIONS CONSIDERATIONS
1. >Inhibits cell > Perioperative >CI to patients >CV: thrombophlebitis. >Before giving drug,
Generic Therapeu wall synthesis, prevention hypersensitive >GI: diarrhea, colitis, nausea, ask patient if he’s
Name: tic: promoting >Serious LRTI, to drug or other anorexia, vomiting. allergic to penicillins or
cefuroxime Antibiotic osmotic UTI, skin, bone cephalosporins. >Hematologic: hemolytic cephalosporins.
instability; or joint anemia, thrombocytopenia, >Reconstitute each 750-
Brand Name: Pharmac usually infection, transient neutropenia, mg vial with 8 ml of
Zinacef ologic: bactericidal. septicemia, eosinophilia. sterile water for
2nd meningitis, and >Skin: urticaria, pain, injection. Withdraw
Generatio gonorrhea induration, sterile abscesses, entire contents of vial
n >Bacterial temperature elevation. for a dose.
cephalosp exacerbations of >Other: anaphylaxis, >For direct injection,
orin chronic hypersensitivity reactions, inject over 3 to 5
bronchitis serum sickness. minutes into a large vein
>Acute bacterial or into the tubing of a
maxillary EFFECTS ON LAB TEST free-flowing I.V.
sinusitis RESULTS solution.
>Pharyngitis and >May increase alkaline >Monitor patient for
tonsillitis phosphatase, ALT, signs and symptoms of
>Otitis media AST, bilirubin, LDH, PT, INR, superinfection.
Uncomplicated and eosinophil levels.
gonorrhea >May decrease hgb, hct,
>Early Lyme neutrophil and platelet counts.
disease and
Impetigo
 DRUG STUDY
Patient Name: Oscar Ligaya APPENDICITIS
Age: 60 y/o
DRUG DRUG MECHANISM INDICATIONS CONTRA- ADVERSE EFFECTS NURSING
NAME CLASS OF ACTION INDICATIONS CONSIDERATIONS
2. >Competitively >Heartburn >CI to patients >CNS: headache, >To prepare I.V. injection,
Generic Therapeu inhibits action >Active hypersensitive malaise, vertigo. dilute 2 ml (50 mg) ranitidine
Name: tic: of histamine on duodenal and to drug and those >EENT: blurred vision. with compatible I.V. solution to
ranitidine antiulcer the H2 at gastric ulcer with acute >Hepatic: jaundice. a total volume of 20 ml, and
receptor sites of >Maintenance porphyria. >Other: anaphylaxis, inject over at least 5 minutes.
Brand Name: Pharmac parietal cells, therapy for >Use cautiously angioedema, burning >Compatible solutions include
Zantac ologic: decreasing duodenal or in patients with and itching at injection sterile water for injection,
H2 gastric acid gastric ulcer hepatic site. normal saline solution for
receptor secretion. >Pathologic dysfunction and injection, D5W, or lactated
antagonist hypersecretory impaired renal EFFECTS ON LAB Ringer’s injection.
conditions, such function. TEST RESULTS >To give drug by intermittent
as Zollinger- >May increase I.V. infusion, dilute 50 mg (2
Ellison creatinine and ALT ml) in 100 ml compatible
syndrome (ZES) levels. solution and infuse at a rate of 5
>GERD >May cause false- to 7 ml/minute. Infuse over 15
>Erosive positive results in urine to 20 minutes.
esophagitis protein tests using >Assess and advise patient to
Multistix. report for abdominal pain. Note
presence of blood in emesis,
stool, or gastric aspirate.
>Urge patient to avoid cigarette
smoking because this may
increase gastric acid secretion.
 DRUG STUDY
Patient Name: Oscar Ligaya APPENDICITIS
Age: 60 y/o
DRUG DRUG MECHANISM INDICATIONS CONTRA- ADVERSE EFFECTS NURSING
NAME CLASS OF ACTION INDICATIONS CONSIDERATIONS
3. >Unknown. >Moderate to >CI to patients >CNS: dizziness, headache, >Reassess patient’s
Generic Therapeu Thought to bind moderately hypersensitive somnolence, vertigo, seizures, level of pain at least
Name: tic: to opioid severe chronic to drug or other anxiety, asthenia, CNS 30 minutes after
tramadol Analgesic receptors and pain opioids. stimulation, confusion, administration.
inhibit reuptake coordination disturbance, >Monitor CV and
Brand Name: Pharmac of euphoria, malaise, nervousness, respiratory status.
Ultram ologic: norepinephrine sleep disorder. Withhold dose and
Synthetic and serotonin. >CV: vasodilation. notify prescriber if
Centrally >EENT: visual disturbances. respirations are
Active >GI: constipation, nausea, shallow or rate is
analgesic vomiting, abdominal pain, below 12 bpm.
anorexia, diarrhea, dry mouth, >Monitor bowel and
dyspepsia, flatulence. bladder function.
>GU: proteinuria, urinary >For better analgesic
frequency, urine retention. effect, give drug
>Musculoskeletal: hypertonia. before onset of intense
>Respiratory: respiratory pain.
depression. >Caution ambulatory
>Skin: diaphoresis, pruritus, rash. patient to be careful
when rising and
EFFECTS ON LAB TEST walking.
RESULTS
>May increase liver enzyme
level.
>May decrease creatinine and
hemoglobin levels.
VI. Evaluation

Expected Outcome After Intervention

After the nursing interventions, the patient is expected to improve his condition, receive
appropriate management for disease condition, and recover from the surgery free from infection
and other possible complications. Further, the patient is expected to fully recover and adhere to
the health teachings given pre- and post-operatively, progress towards wellness by having enough
knowledge in the importance and application of proper nutrient intake, and compliance to other
medical procedures to prevent complications that may develop.

Learnings

Appendicitis is a very common disease condition and topic in the school of nursing.
However, this case study becomes a tool for the student nurse to enhance more her knowledge of
the system involved such as the digestive system, the disease, its clinical manifestations, etiology,
pathophysiology, and everything associated with the presentation or case study.

Moreover, the pillars of the college of allied medicine despite the current situation, were
achieved by the student though this case study. As following the knowledge of the case is
improved, the skills of the students were enhanced as well despite the lack of exposure to the actual
setting, the student was able to enhance her skills of properly tracing and making the
pathophysiology of the disease, formulating appropriate nursing interventions, and preparing for
the actual setting to face an actual patient with such disease/s. The students become equipped of
knowledge and skills despite the hindrance [COVID-19] to learning.

As the time to accomplish the case given has been a huge challenge as the student nurse
simultaneously accomplishes given tasks and tasks as a team leader in the assigned area, the
attitude of the student nurse was also challenged and developed as more time, effort, patience, and
understanding is required. This case study facilitated and created a large room for improvement as
the student was able to learn things that has not been seen personally and be resourceful and smart
to adapt in the new normal or new approach to learning.

Being a nurse requires a lot of knowledge, skills, strength, hard work, determination,
values, and attitude. Furthermore, being able to adapt to changes and overcome challenges will be
one of the greatest foundations as well and the great takeaways in this journey of being a student
nurse and a nurse leader. This pandemic may have taken a lot from everyone but the eagerness to
push forward and persevere more towards the chosen path becomes more ignited and zeal.