Acute Appendicitis
INTRODUCTION
Acute Appendicitis is a condition in which your appendix becomes inflamed and filled with pus.
The main symptom of appendicitis is dull, poorly localized, visceral pain that typically begins around your navel and then shifts to your lower right abdomen as inflammation progresses.
On palpation, localized and rebound tenderness are noted at McBurney’s point.
In addition to pain, a low-grade
temperature, loss of appetite, nausea, and vomiting are often present.
Predisposing Factors: Obstruction Infection
In both cases, bacteria may subsequently invade rapidly, causing the appendix to become inflamed and filled with pus.
If not treated promptly, your appendix is likely to rupture.
Acute appendicitis can occur at any age, but is more common in adolescents and young adults.
About 7% of the population will have
appendicitis.
The mortality rate in non-perforated appendicitis is less than 1 percent, but it may be as high as 5 percent or more in young and elderly patients, in whom diagnosis may often be delayed, thus making perforation more likely.
The diagnostic procedures for appendicitis are blood count, physical exam, and imaging studies (ultrasound, CT, xray).
OBJECTIVES
General Objectives
After Related Learning Experience, the students will be able to apply knowledge, skills, and attitude in handling patient with Acute Appendicitis. This study aims to help and guide nursing students, staff nurses and clinical instructors as well the patient himself to deal with curative and rehabilitative aspect of Acute Appendicitis.
Specific Objectives At the end of two days, the students will be able to:
Determine the probable causative factors and risk of Acute Appendicitis
Analyze potential complications that may develop following Acute Appendicitis.
Explain the diagnostic procedures and significant laboratory findings.
Devise and implement appropriate nursing care plan and health teachings applicable to the patient.
Evaluate effectiveness of nursing interventions and health teachings for patient with Acute Appendicitis through return demonstration and verbalized apprehension.
NURSING HISTORY
GENERAL DATA
J.L. 20 years old, male, Filipino, single, Roman Catholic. Born on January 9, 1988. Presently residing at San Jose Del Monte, Bulacan. A college student from St. Joseph College. Admitted for the first time at Rogaciano M. Mercado
Memorial Hospital (RMMMH) on August 27, 2008 at 5:10 pm.
HISTORY OF PRESENT ILLNESS The patient is currently on a good
condition. Since then, the patient was noted to be
apparently well until seven hours prior to admission, the patient experienced a sudden dull, intermittent epigastric pain.
Six hours prior to admission, still with the above condition, generalized abdominal pain was now noted to be continuous.
Four hours prior to admission still with the above condition.
Upper abdominal pain intensifies and localizes on the right lower quadrant of the abdomen.
Accompanied by a low-grade fever, loss of appetite and vomiting.
Two hours prior to admission, persistence of the above condition, prompted consults at Rogaciano M. Mercado Memorial Hospital hence admission.
PAST MEDICAL HISTORY J.L. experienced the common illnesses
afflicting a child like cough and colds, flu, and chickenpox.
He has no allergies to any food, drugs and any other environmental agents.
He has no past hospitalization. Immunization: Received Hepatitis B
vaccine, Oral Polio vaccine, BCG, DPT and MMR when he was still young.
FAMILIAL HISTORY Has familial history of hypertension on
paternal side.
PERSONAL AND SOCIAL HISTORY He is the youngest among five (5) siblings.
All are apparently well. During weekends, after going to church,
his family conducts a small gathering, like a small reunion, since most of his siblings are already married.
He has a sedentary lifestyle.
Primary compositions of his diet are rice, pork, beef, and chicken.
He seldom eats fruits and vegetables. He likes to drink juices and water for about 6-9
glasses a day. He also takes food supplement, Grow rich VCO
500 mg capsule once daily. Bowel movement is 3-4 times a week, typically,
stool consistency is hard. He sometimes experience pain on defecation. He urinates 6-10 times a day, depending on how
much fluid he consumes.
He is a 4 year-smoker, 5-8 sticks a day and 1-2 packs for special occasions together with his friends.
He is an alcoholic beverage drinker, consuming for about 10-18 bottles of beer per session.
He sleeps at around ten in the evening and wakes up at six in the morning.
He takes a bath daily and brushes his teeth 2-3 times a day.
PHYSICAL ASSESSMENT & GENERAL APPEARANCE MEASUREMENTS FINDINGS
Weight 54.55 kg
Height 170.69 cm
Level of consciousness Spontaneous, conscious, coherent, oriented to time, place & person
Body build Medium
Overall hygiene & grooming Satisfactory
VITAL SIGNS DAY 1
(08/28)
DAY 2
(08/29)
Time 11:30 PM 11:30 PM
Temperature 38˚C 36.9˚C
Pulse Rate 63 beats/min 71 beats/min
Respiratory Rate
24 bpm 21 bpm
Blood Pressure 120/80 120/80
HEAD-TO-TOE ASSESSMENT (8/29/08 5:30 AM) Post-operative
Part Technique Findings
Skin Inspection & Palpation
Slightly pale in appearanceSkin is hot to touchGood skin turgorWith surgical incision at the right lower quadrant
Part Technique Findings
Head and scalp Inspection & Palpation
NormocephalicThere is no bald spot.The scalp has no scars, abrasions, swelling or malformations.
Part Technique Findings
Hair Inspection The patient has short, straight, and black hairequal in distributionThere are no signs of dandruff, it is oily.
Part Technique Findings
Eyes Inspection Eyebrows moves symmetrically as facial expression changes, present bilaterally.His eyelashes are equally distributed.
Part Technique Findings
(..Eyes) The eyes are symmetrical, has normal shape and size and the color is black-brown. Pupils constrict with increasing light and dilate in dim light.He has pale conjunctiva.Teary eyes
Part Technique Findings
Ears Inspection Clean with scant amount of cerumen and few cilia. Responds to normal conversation. No presence of foreign bodies, and no swelling and no unusual odor.
Part Technique Findings
Nose Inspection There are no dischargesClean with few ciliaPatent
Part Technique Findings
Mouth Inspection Lips are slightly red and dry. There is no presence of swelling, bleeding or discharges. Halitosis was noted. The tongue is slightly dry.
Part Technique Findings
Neck Palpation No palpable swollen lymph nodes
Part Technique Findings
Chest & Lungs Inspection & Auscultation
Has no difficulty in breathingHas symmetrical chest expansionRespiratory rate is 22 bpm
Part Technique Findings
Abdomen Inspection & Palpation
With surgical incision and dry and intact dressing at the right lower quadrantDistended, tenderWith palpable pain
Part Technique Findings
Upper & Lower Extremities
Inspection & Palpation
Slightly pale nail beds and smooth.He has the ability to do range of motion on his extremities but with weakness. Capillary refill in 2 seconds.With good and equal pulses.
ANATOMY AND PHYSIOLOGY
PATHOPHYSIOLOGY
Constipation, low fiber diet
Occlusion of fecalith
Obstruction of proximal lumen
Appendix becomes distended with fluid
Pressure within the lumen
Generalized, intermittent
abdominal pain
Cont..
Blood supply impaired
Inflammation, edema, ulceration,
infection
Pus fills the inflamed appendix
Low-grade fever, anorexia, nausea and
vomiting
ACUTE APPENDICITIS
Cont..
LABORATORY ANDDIAGNOSTIC PROCEDURES
RESULTS
Hematology
TEST FOUND VALUE
8/27
(Pre-operative)
FOUND VALUE
8/28
(Post-operative)
NORMAL VALUE
CLINICAL SIGNIFICANCE
Hemoglobin 162.8 g/L 156.4 g/L M=155-175 g/L Low:
hemorrhage,
anemia
High:
Polycythemia
TEST FOUND VALUE
8/27
(Pre-operative)
FOUND VALUE
8/28
(Post-operative)
NORMAL VALUE
CLINICAL SIGNIFICANCE
Hematocrit 48 46 40-52 Low:
hemorrhage,
Anemia
High:
polycythemia,
dehydration
TEST FOUND VALUE
8/27
(Pre-operative)
FOUND VALUE
8/28
(Post-operative)
NORMAL VALUE
CLINICAL SIGNIFICANCE
WBC 25.0 x 10/L 15.0 x 10/L 4.0-11.0x 10/L Low: aplastic
anemia, drug
toxicity, specific
infections
High:
inflammation,
trauma, toxicity,
leukemia
UrinalysisTEST FOUND VALUE
8/27
(Pre-operative)
FOUND VALUE
8/28
(Post-operative)
NORMAL VALUE
CLINICAL SIGNIFICANCE
Color Bright yellow Yellow orange Amber Amber: due to
pigment called
urochrome, an
end product of
Hemoglobin
breakdown.
yellow orange
: urobilinogen is
produced in the
intestine by the
action of
bacteria on bile
pigment.
TEST FOUND VALUE
8/27
(Pre-operative)
FOUND VALUE
8/28
(Post-operative)
NORMAL VALUE
CLINICAL SIGNIFICANCE
Transparency Turbid Turbid Clear Clear: normal,
but may
become cloudy
after standing
awhile.
Turbid:
phosphates,
urates, pus,
mucus,
bacteria,
epithelial cells
TEST FOUND VALUE
8/27
(Pre-operative)
FOUND VALUE
8/28
(Post-operative)
NORMAL VALUE
CLINICAL SIGNIFICANCE
pH 6.0 6.5 6.0 to 7.5 Acidic:
diabetes,
acidosis,
prolonged fever
Alkaline: urinary
tract infection,
alkalosis
TEST FOUND VALUE
8/27
(Pre-operative)
FOUND VALUE
8/28
(Post-operative)
NORMAL VALUE
CLINICAL SIGNIFICANCE
Specific gravity 1.032 1.026 1.015-1.025 Increase in
Diabetes
mellitus
Decrease in
acute nephritis,
Diabetes
insipidus,
aldosteronism
TEST FOUND VALUE
8/27
(Pre-operative)
FOUND VALUE
8/28
(Post-operative)
NORMAL VALUE
CLINICAL SIGNIFICANCE
Pus cells 2-5 1-4 (-) Presence of
pus: urinary
tract infection
Diagnostic Procedures: Blood count, physical exam, imaging studies
(ultrasound)
Ultrasonography: (Preoperative) Revealed a right lower quadrant density Outer appendiceal diameter size of 6 mm on
cross section.
NURSING CARE PLAN
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective:
“Sumasakit ang sugat ko” as patient verbalized.
Objective:Pain Scale: 6/10 -Moderate painIncision @ right
lower quadrant of
the abdomen Distraction behaviorGuarding behaviorFacial mask of pain
NURSING DX:
Acute Pain related to
surgical incision
Partial
compensatory
Short Term Goal
At the end of
1hour nursing
interventions,
patient’s pain
will decrease
from 6/10 to 4 or
less
Facilitate patient in a high Fowler’s positionFacilitated instruction and demonstration of deep breathing exerciseFacilitated the use of diversional activities such as reading newspapers, chatting with relatives & friends.Administer appropriate pain medication prescribed by the attending physician:
Mefenamic Acid
500 mg/tab every 4 hours per orem
Diclofenac Sodium
75 mg TIV every 12 hours
Reduces tension on the incision and abdominal organs, helping to reduce pain.Lessens the complications and provides as a relaxation technique.Diverts patient’s attention on others rather than the pain.Inhibits prostaglandin synthesis. Is an anti-inflammatory, antipyretic, and analgesic
Patient condition maintained.
Pain scale: 3/10
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective:
“Mainit ang pakiramdam ko”, as patient verbalized.
Objective:Watery eyesDry and red lipsSkin hot to touchIncision site @ right lower quadrant of the abdomenTemperature: 38˚C
NURSING DX:
Alteration in body temperature related to post surgical procedure
Supportive
educative
Short Term Goal
At the end of 45
minutes nursing
interventions,
patient’s body
Temperature
decreases to 36-37˚C
Facilitate tepid sponge bath.Facilitate fluid intakeRestrict tight clothingFocus on temperature takingAdminister paracetamol as prescribed by the physician.
Biogesic 500 mg 4-6 hr as needed.
Cools down body temperature because of the concept of conductionAvoids fluid and electrolyte imbalanceProvides good ventilationTo recheck the temperatureAntipyreticInhibition of the enzyme COX-3 in the brain and spinal cord.
Patient condition improved.
Temperature: 36.8˚C.
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective:
“Mahirap dumumi, matigas at kakaunti parang meron pa,” as pt. verbalized.
Objective:Dry, hard, formed stoolsStraining with defecationPercussed abdominal dullness
NURSING DX:
Constipation related to insufficient physical activity, low fiber intake, and lack of privacy.
Partial
compensatory
Short Term Goal
At the end of 1
hour nursing
interventions,
patient will be
able to verbalize
understanding of
etiology and
appropriate
interventions for
Individual
situation and
demonstrate
behaviors or
lifestyle changes
to prevent
recurrence of
problem.
Facilitate identification of causative factorsFacilitate privacy and routinely scheduled time to defecate.Focus on increasing intake of fiber and bulk in dietFocus on adequate fluid intake, including high-fiber fruit juices and suggest drinking warm, stimulating fluids.Focus on providing information about relationship of diet, exercise, fluid, and appropriate use of laxatives as indicated.
For prevention or modification of such causes.
Provides privacy to perform self-care activities wherein he can be comfortable, safe and relaxed and to stop ignoring his urge
To improve consistency of stool and facilitate passage through colon.
To promote soft/moist stool.
For him to identify specific actions to be taken if problem recurs, to promote timely intervention, enhancing client’s independence.
Patient condition
maintained.
HEALTH TEACHINGSMedication All medications must be
explained in detail as prescribed to client and family. Inform them on the purposes and side effects of the medications. Advise patient to take his medicines on time and as prescribed by the physician. Cefalexin 500 mg/tab per orem three x a day. Mefenamic Acid 500 mg/tab per orem for pain.
For continuous improvement of patient condition.
Environment Instruct the patient’s relatives to provide a conducive environment.
Client should have good sleeping habits to avoid fatigue. His room should be clean, properly ventilated, peaceful, and free from insects.
To have adequate rest and sleep.
Treatment Educate the patient how to care for the incision. Demonstrate how to change it properly. Instruct him to observe the incision daily and to report any swelling, redness, bleeding, drainage, and warmth at the site.
To prevent infection and any complications after the operation.
Health Teaching Teach the patient relaxation techniques such as deep breathing exercises. Teach the importance of maintaining good personal hygiene.
This prevents strain on abdominal muscles until healing is complete.
Encourage the patient to gradually quit smoking as well as drinking alcohol.
Out Patient Advise to comeback for follow-up check up upon dismissal.
To know if the patient’s condition improved; to know the follow up instructions of the attending physician; and to make an appointment to have the surgeon remove the sutures between the fifth and seventh days after surgery.
Diet When normal bowel sounds are present, soft diet can be given. Encourage to eat foods that are high in fiber such as whole grain cereals, fresh fruits especially rich in vitamin C and vegetables.
To combat constipation and for body resistance.
Safety Demonstrate appropriate activity restrictions. Normal activity can usually be resumed within 2 to 4 weeks.
Discuss postoperative activity limitations with the patient. Caution him to avoid lifting heavy objects for 6 weeks after surgery.
Place in Fowler’s position to reduce the pain. Never apply heat to the lower right abdomen.
Frequently assess the dressing for wound drainage and other complications possible to come out after the operation.
EVALUATIONAfter rendering Nursing Interventions, the student
nurses were able to achieve general and specific objectives of this study.
In handling a patient with Acute Appendicitis, we were able to: apply knowledge, skills, and attitude in handling an AP patient; determined the probable causative factors and risks; analyzed potential complications that may develop following the illness; explained the diagnostic procedures results and as well as significant laboratory findings; devised and implemented appropriate nursing care plan and health teachings applicable to the patient; and evaluate the effectiveness of nursing interventions and health teachings through patient’s demonstration of the use of relaxation skills, proper wound dressing techniques and verbalized apprehension about his condition. The patient showed an improvement in perception and attitude towards ways to promote comfort and to restore his health.
DRUG STUDY
GENERIC NAME
BRAND NAME
CLASSIFICATION
DOSAGE MECHANISM OF
ACTION
INDICATION
CONTRAINDICATIO
N
SIDE EFFECTS
NURSING RESPONSIBILITIE
S
D
I
C
L
O
F
E
N
A
C
SODIUM
Cataflam NSAID 75 mg TIV
every 12 hrs for 2 doses
Produces anti-
inflammatory,
analgesic &
antipyretic effects, possibly
by inhibits
prostaglandin
synthesis
Management of acute & chronic types of
pain
Use cautiousl
y in patient
with history of
peptic ulcers
disease hepatic
dysfunctional,
cardiac disease, hyperten
sion, fluid
retention, or
impaired renal
function
(None was
noted)
Instruct patient to take drugs
with milk, meals or antacids
to minimize
GI distress
GENERIC NAME
BRAND NAME
CLASSIFICATION
DOSAGE MECHANISM OF
ACTION
INDICATION
CONTRAINDICATIO
N
SIDE EFFECTS
NURSING RESPONSIBILITIE
S
C
E
F
A
L
E
X
I
N
Keflex Anti-
Infective
500 mg/tab
per orem three x a day
Third generation cephalosporin that inhibit its cell-wall synthesis, promoting osmotic instability usually bacteri-cidal
Infections of the urinary tract, biliary tract,
respiratory tract,
bones, joints, soft
tissue, and skin
Contraindicated with pregnant mother,
with hypersens
itivity to food & drugs
Drowsiness
Report
adverse
reactions
or sign &
symptom
of
super-
infection
promptly
Advised
patient to
notify
prescriber
about
loose
stools or
diarrhea
GENERIC NAME
BRAND NAME
CLASSIFICATION
DOSAGE MECHANISM OF
ACTION
INDICATION
CONTRAINDICATIO
N
SIDE EFFECTS
NURSING RESPONSIBILITIE
S
P
A
R
A
C
E
T
A
M
O
L
Biogesic Antipyretic/
analgesic
500 mg/tab
per orem 4-6
hours
Inhibition of the
enzyme COX-3 in the brain
and spinal cord.
Used to relieve
pain and fever
Anemia, cardiac
& pulmona
ry disease. Hepatic
or severe renal
disease.
(None was
noted)
Monitor
intake,
maxi-
mum of
8 tablets
per 24
hours
only.
Can be
given
with or
without
food.
Dis-
continue
if fever
persists
for more
than 3
days.
GENERIC NAME
BRAND NAME
CLASSIFICATION
DOSAGE MECHANISM OF
ACTION
INDICATION
CONTRAINDICATIO
N
SIDE EFFECTS
NURSING RESPONSIBILITIE
S
M
E
F
E
N
A
M
I
C
ACID
Ponstel Analgesic/
NSAID
500 mg/tab
per orem every 4 hours
Third generati
on cephalos
porin that
inhibit its cell-wall synthesi
s, promotin
g osmotic instability usually bacterici
dal
Infections of the urinary tract, biliary tract,
respiratory tract, bones, joints, soft
tissue, and skin
Contraindicated
with pregnant mother,
with hypersensitive to food & drugs
Drowsiness
Report
adverse
reactions
or sign &
symptom
of
super-
infection
promptly
Advised
patient to
notify
prescriber
about
loose
stools or
diarrhea.