CHAPTER I

INTRODUCTION

The appendix is a closed-ended, narrow tube that

attaches to the cecum (the first part of the colon) like a

worm. (The anatomical name for the appendix,

vermiform appendix, means worm-like appendage.) The

inner lining of the appendix produces a small amount

of mucus that flows through the appendix and into the

cecum. The wall of the appendix contains lymphatic

tissue that is part of the immune system for making

antibodies. Like the rest of the colon, the wall of the

appendix also contains a layer of muscle.

Acute appendicitis can occur when a piece of food, stool

or object becomes trapped in the appendix, causing

irritation, inflammation, and the rapid growth of bacteria and

infection. Acute appendicitis can also happen after a

gastrointestinal infection. Rarely, a tumor may cause acute

appendicitis. Sometimes the cause of acute appendicitis is

not known. The inflammation is usually caused by a

blockage, but may be caused by an infection. Without

treatment, an inflamed appendix can rupture, causing

infection of the peritoneal cavity (the lining around the

abdominal organs) and even death.

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Appendicitis is one of the most common causes of

emergency abdominal surgery. Up to 75,000

appendectomies are done each year in the U.S. The

estimated population in the Philippines is 86, 241, 6972 and

the incident rate of acute appendicitis is 215,604 as of year

2011. Appendicitis is one of the more common surgical

emergencies, and it is one of the most common causes of

abdominal pain. In the United States, 250,000 cases of

appendicitis are reported annually, representing 1 million

patient-days of admission. The incidence of acute

appendicitis has been declining steadily since the late 1940s,

and the current annual incidence is 10 cases per 100,000

populations. Appendicitis occurs in 7% of the US population,

with an incidence of 1.1 cases per 1000 people per year.

Some familial predisposition exists.

In Asian and African countries, the incidence of acute

appendicitis is probably lower because of the dietary habits

of the inhabitants of these geographic areas. The incidence

of appendicitis is lower in cultures with a higher intake of

dietary fiber. Dietary fiber is thought to decrease the

viscosity of feces, decrease bowel transit time, and

discourage formation of fecaliths, which predispose

individuals to obstructions of the appendiceal lumen.

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In the last few years, a decrease in frequency of

appendicitis in Western countries has been reported, which

may be related to changes in dietary fiber intake. In fact, the

higher incidence of appendicitis is believed to be related to

poor fiber intake in such countries.

There is a slight male preponderance of 3:2 in

teenagers and young adults; in adults, the incidence of

appendicitis is approximately 1.4 times greater in men than

in women. The incidence of primary appendectomy is

approximately equal in both sexes.

The incidence of appendicitis gradually rises from birth,

peaks in the late teen years, and gradually declines in the

geriatric years. The mean age when appendicitis occurs in

the pediatric population is 6-10 years. Lymphoid hyperplasia

is observed more often among infants and adults and is

responsible for the increased incidence of appendicitis in

these age groups. Younger children have a higher rate of

perforation, with reported rates of 50-85%. The median age

at appendectomy is 22 years. Although rare, neonatal and

even prenatal appendicitis have been reported. Clinicians

must maintain a high index of suspicion in all age groups.

Acute appendicitis can occur in any age group or

population. However, it most often occurs in teens and

young adults. It is rare in children younger than two years of

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age.  Classic symptoms of acute appendicitis include pain in

the right lower abdomen, where the appendix is located, that

gets progressively sharp and more intense. Pain increases

when pressure is put on the area (called the McBurney’s

point), and the area becomes even more painful and tender

when the pressure is released (rebound tenderness). This is

one exam a health care provider uses to diagnosis acute

appendicitis. The symptoms of acute appendicitis can vary,

and not all people with acute appendicitis will experience the

typical symptoms of abdominal pain. In early acute

appendicitis, the abdominal pain may be located around the

navel or belly button area, then move to McBurney’s point as

acute appendicitis progresses.

Acute appendicitis that is not treated promptly leads to

life-threatening complications. Complications of acute

appendicitis include: Abdominal abscess,

Peritonitis (infection of the lining that surrounds the

abdomen), Ruptured appendix, Sepsis, Shock.

As teen-agers living in a fast-phased world and

governed by schedules, they too are predisposed to lifestyle

modification – especially diet and food preferences which

can contribute to the disease. With this study, the student

nurses hope to apply their learning in taking care not only of

their patients but also of themselves.

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As nursing students and future nurses, they would want

to understand and appreciate more on what is happening to

a patient with acute appendicitis. Consequently, they are

interested on what will be the necessary management that

will be given. All in all, these will help them to become

efficient nurses and better persons later on.

This case study presents the case study of a 23 year old

woman who was diagnosed with Acute Appendicitis – due to

pain felt at right lower quadrant at Kidapawan Medical

Specialist.

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OBJECTIVES OF THE STUDY

General Objective

To conduct a study and to have a better understanding

regarding acute appendicitis as well as to deal with patient

having this illness with the application of the nursing

process.

Specifically, the study aims to:

1. To conduct an interview with the patient, her family,

significant others and to gather essential information

regarding his case.

2. To perform a cephalocaudal assessment to the patient.

3. To present an overview about Acute Appendicitis.

4. To determine the progression of the illness and to

present its pathophysiology.

5. To gather and obtain progress notes and present

doctor’s order.

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6. To obtain and present the diagnostic test and the

laboratory results of the patient.

7. To identify patient’s medication and determine its

mechanism of action, indication, side-effects,

contraindications and corresponding nursing

responsibilities.

8. To conduct health teachings as one way of providing

and promoting holistic care to the patient.

9. To identify problems based from subjective data

gathered from patient and watchers to formulate

appropriate nursing care plan.

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DEFINITION OF TERMS

Appendectomy - surgical operation to remove

appendix.

Appendicitis - inflammation of the appendix causing

severe pain.

Appendix - small outgrowth from large intestine, a

bind-ended tube leading from the first of

the large intestine (caecum), near its

junction with the small intestine. In

humans, it is small, occurs in the lower

right hand part of the abdomen and

contains cells of the immune system.

Colic - severe pain in the bowel or the

abdomen.

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Constipation - difficulty in passing stools or

incomplete or infrequent passage of

hard stools.

Fecalith - hardened mass of stool.

Mc Burney’s Sign – (Charles McBurney) a reaction of the

patient indicating severe pain and

extreme tenderness when McBurney’s

point is palpated. Such reaction

indicates appendicitis.

Perforation - a hole or opening made through the

entire thickness of a membrane or other

tissue or material.

Peritonitis - inflammation of the peritoneum caused

by the spreading of infection.

Sepsis - the condition or syndrome caused by

the presence of microorganisms or their

toxins in the tissue or the bloodstream.

Septicemia - systemic infection in which pathogens

are present in the circulating blood,

having spread from an infection in any

part of the body.

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Shock - a state of physiologic collapse, marked

by a weak pulse, coldness, sweating and

irregular breathing, and resulting from a

situation such as blood loss.

PATIENT’S PROFILE

PERSONAL DATA

PATIENT’S NAME : Momoko

CASE # : 12-1344

AGE : 23

SEX : Female

ORIGINAL RANK : Second Child

CIVIL STATUS : Single

ADDRESS : 054 Quirino Drive, Kidapawan City

BIRTHDAY : January 01, 1989

RELIGION : Roman Catholic

NATIONALITY : Filipino

MEDICAL DATA

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CHIEF COMPLAINT: Right Lower Quadrant Pain

ADMITTING DIAGNOSIS : T/C Acute Appendicitis

FINAL DIAGNOSIS : Acute Appendicitis

DATE OF ADMISSION : February 08, 2012

ATTENDING PHYSICIAN : Dr. Edwin Mudanza

Past Health History

The patient was born on January 01, 1989. She was

delivered full term through Normal Vagina Spontaneous

Delivery. The patient was completely immunized. She was

never admitted to a hospital but she experienced common

illness such as cough and mefenamic acid for pain. She

occasionally drinks liquors such as red wine and beer. Her

usual diet includes food that are high in protein, junkfoods,

softdrinks and canned goods. She prefers meat products in

her meal than leafy vegetables.

Present Health History

Several days prior to admission the patient experienced

an abdominal pain at the right lower quadrant. These

prompted her to seek medical advice, thus confined in

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Kidapawan Medical Specialist Incorporated last February 08,

2012 with the admitting diagnosis of Acute Appendicitis

under the service of Dr. Edwin Mudanza. Her medications

were Ranitidine, Metronidazole and Ampicillin. She was

confined at private room #523.

PHYSICAL ASSESSMENT

Genearal Appearance at First Sight

Patient was received awake, responsive and coherent

with an IVF D5LR 1L at 80 cc per hour, infusing well at the

right metacarpal vein. Patient has a mesomorphic type of

body built and weighs 54.5 kilograms and stands 5’4” tall.

The patient was certainly oriented to time, place and

persons. She was able to deal with her emotions

appropriately as the interview went on. Wearing a cotton T-

shirt and jogging pants, patient looked neat and tidy.

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I. Head, Ears, Eyes, Nose, Throat and Neck and

Five Senses

Head

Head was normocephalic and had a smooth skull

contour. Hair was smooth, and was evenly distributed. The

hair was black in color. The scalp was clean. No swelling or

tenderness noted upon palpation.

Ears

Both ears were symmetrical; auricle aligned with outer

canthus of the eye. The color of the outer ear was

homogenous with that of the skin color. The external pinna

was firm, and non-tender. No discharges, tenderness,

masses, or swelling were noted upon inspection and

palpation.

Eyes

Both eyes were symmetrical. Eyelashes equally

distributed, curled slightly outward. Pupil size is 3mm in

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diameter for both eyes. Reaction to light was brisk. There

was a uniform reaction to accommodation. The pupil was

black in color with pinkish conjunctiva. Lids closed

symmetrically, skin intact, no discharges and no

discoloration. Blinking reflex was functional. No ulceration or

lesions noted on the area.

Nose

The external was symmetrical. Nasal flaring noted, air

felt when exhaled. Nasal mucosa was intact and pinkish in

color and was free of purulent discharges.

Mouth & Throat

The lips were dry and pale-looking. The gums were

pinkish in color. Her teeth were still intact, 32 pearly white

and shiny. Uvula was at the middle. Mucosa was pinkish.

Tonsils were uninflammed. No further abnormalities noted.

Neck

The neck was symmetrical and was proportion to head

and shoulder. The thyroids were smooth as palpated. She

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was able to turn her head in upward, sideward and

downward position with movement. The carotid artery has

mild pulsation. No sign of lesion or tenderness noted.

Five senses

A.Sense of sight

Patient can read normally. In the absence of Snellen’s

chart, functional vision was test; she can follow a hand

movement with a 3-4 feet distance. She can recognize

person and things.

B.Sense of taste

By offering different kinds of food like candy, vinegar,

ampalaya and salt patient’s taste buds can identify sweet,

sour, bitter, and salty food.

C.Sense of smell

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Patient has good smelling ability; she can distinguish

different odors such as fragrance or perfume and aroma of

beverages that she dinks.

D.Sense of hearing

She can recognize sounds and could hear clearly, she

responds to conversation normally. She becomes alert when

someone will open the door. She can hear the distance

particularly when someone enters the room.

E. Sense of touch

The patient responds when someone touches her, and

can distinguish soft from rough texture and can identify hot

from cold water.

II. Respiratory status

The patient breathing pattern ranges from 18cpm to

21cpm. No O2 cannula attached. No abnormal sounds (rales,

wheezing, etc.) noted upon auscultation.

III. Circulatory status

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Patient’s blood pressure was monitored every 4 hours

when she was under our care. BP ranges from 90/60 mmHg

to 100/80 mmHg. Her pulse from 76bpm to 80bpm. Capillary

refill time within 3-5 sec.

IV. Temperature status

Patient’s body temperature ranges from 37-39 degree

Celsius.

V. Skin/Skin appendages

Patient’s skin was warm to touch with fair complexion;

fingernails were trimmed and tidy. Hair was distributed

evenly no clubbing of fingers noted.

VI. Nutritional status

Patient usually eats food that is high in fat, salt and

protein such as fish, meat, lechon and junk foods. She eats

breakfast on time. She tends to drink liquor like red wine

and beer frequently with “pulutan”. She prefers eating meat

products than vegetables. Patient’s weight is 120 lbs and

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has height of 164cm which result to Body Mass Index (BMI)

of 20 which translates that the patient’s BMI is normal.

BMI Categories:

Underweight = <18.5 Overweight = 25 –

29. 9

Normal weight = 18.5 – 24.9 Obese = >30

VII. Rest and sleeping pattern

During regular days patient has a normal sleeping

pattern of six to eight hours a day. Upon admission,

patient’s sleeping pattern has been altered since her body

can’t adapt to hospital routine she often disturbed during

sleep due to continuous monitoring and giving of

medication.

VIII. Elimination status

The patient has an abnormal elimination pattern

regularly she defecated 3 times a week and urinated 4-5

times a day. Upon admission she defecated once a day and

urinates 2-3 times a day.

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IX. Mobility status

Patient is ambulatory. She can perform activities of

daily living such as eating, drinking and brushing her teeth.

Patient complains abdominal pain at right lower quadrant.

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GENEOGRAM

Grandparents Grandparents

Mother Father

LEGEND:Male Female HPN

Heart Disease DM

Appendicitis

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SYMPTOMATOLOGY

Signs and Symptoms

Present

Absent Rationale

Right Lower Quadrant Pain /

Right lower-quadrant pain that is produced with either the passive extension of the patient's right hip (patient lying on left side, with knee in flexion) or by the patient's active flexion of the right hip while supine. The pain elicited is due to inflammation of the peritoneum overlying the iliopsoas muscles and inflammation of the psoas muscles themselves. Straightening out the leg causes pain because it stretches these muscles, while flexing the hip activates the iliopsoas and therefore also causes pain.

Source: (http://www.free-ed.net/sweethaven/science/biology/anatomyphysiol/Human01_LessonMain.asp?iNum=1008)

McBurney's Sign /

Deep tenderness at McBurney's point, known as McBurney's sign, is a sign of acute appendicitis.[2] The clinical sign of referred pain in the epigastrium when pressure is applied is also known as Aaron's sign. Specific localization of tenderness to McBurney's point indicates that inflammation is no longer limited to the lumen of the

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bowel (which localizes pain poorly), and is irritating the lining of the peritoneum at the place where the peritoneum comes into contact with the appendix. Tenderness at McBurney's point suggests the evolution of acute appendicitis to a later stage, and thus, the increased likelihood of rupture.

Source: (http://en.wikipedia.org/wiki/McBurney's_point)

Fever/

Fever is a nonspecific response that is mediated by endogenous pyrogens released from host cells in response to infectious or non-infections disorders. It may be brought about by prostaglandins released during inflammation.

Source: Carol Mattson Porth (2005. Pathophysiology, Seventh edition page 205)

Constipation/

difficulty in defecation: a condition in which a personor animal has difficulty in eliminating solid waste from the body and the feces are hard and dry.

(Microsoft® Encarta® 2009. © 1993-2008 Microsoft

Corporation. All rights reserved.)

Nausea /Nausea sometimes occurs with biliary colic. The inflammation of the appendix causes pain and spasms of the abdominal muscles which may

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make one feel nauseated.

Source: Understanding Medical Surgical Nursing by Williams

and Hopper (page 742)ANATOMY AND PHYSIOLOGY

The

gastrointestinal tract (GIT) consists of a hollow muscular

tube starting from the oral cavity, where food enters the

mouth, continuing through the pharynx, esophagus, stomach

and intestines to the rectum and anus, where food is

expelled. There are various accessory organs that assist

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the tract by secreting enzymes to help break down food into

its component nutrients. Thus the salivary glands, liver,

pancreas and gall bladder have important functions in the

digestive system. Food is propelled along the length of the

GIT by peristaltic movements of the muscular walls

The functions of the digestive system are:

Ingestion - eating food

Digestion - breakdown of the food

Absorption - extraction of nutrients from the food

Defecation - removal of waste products

The digestive system also builds and replaces cells and

tissues that are constantly dying.

Digestive Organs

The digestive system is a group of organs (Buccal cavity

(mouth), pharynx, oesophagus, stomach, liver, gall bladder,

jejunum, ileum and colon) that breakdown the chemical

components of food, with digestive juices, into tiny nutrients

which can be absorbed to generate energy for the body.

The Buccal Cavity

Food enters the mouth and is chewed by the teeth, turned

over and mixed with saliva by the tongue. The sensations of

smell and taste from the food sets up reflexes which

stimulate the salivary glands.

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The Salivary glands

These glands increase their output of secretions through

three pairs of ducts into the oral cavity, and begin the

process of digestion.

Saliva lubricates the food enabling it to be swallowed and

contains the enzyme ptyalin which serves to begin to break

down starch.

The Pharynx

Situated at the back of the nose and oral cavity receives the

softened food mass or bolus by the tongue pushing it against

the palate which initiates the swallowing action.

At the same time a small flap called the epiglottis moves

over the trachea to prevent any food particles getting into

the windpipe.

From the pharynx onwards the alimentary canal is a simple

tube starting with the salivary glands.

The Oesophagus

The oesophagus travels through the neck and thorax, behind

the trachea and in front of the aorta. The food is moved by

rhythmical muscular contractions known as peristalsis

(wave-like motions) caused by contractions in longitudinal

and circular bands of muscle. Antiperistalsis, where the

contractions travel upwards, is the reflex action of vomiting

and is usually aided by the contraction of the abdominal

muscles and diaphragm.

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The Stomach

The stomach lies below the diaphragm and to the left of the

liver. It is the widest part of the alimentary canal and acts as

a reservoir for the food where it may remain for between 2

and 6 hours. Here the food is churned over and mixed with

various hormones, enzymes including pepsinogen which

begins the digestion of protein, hydrochloric acid, and other

chemicals; all of which are also secreted further down the

digestive tract.

The stomach has an average capacity of 1 litre, varies in

shape, and is capable of considerable distension. When

expanding this sends stimuli to the hypothalamus which is

the part of the brain and nervous system controlling hunger

and the desire to eat.

The wall of the stomach is impermeable to most substances,

although does absorb some water, electrolytes, certain

drugs, and alcohol. At regular intervals a circular muscle at

the lower end of the stomach, the pylorus opens allowing

small amounts of food, now known as chyme to enter the

small intestine.

Small Intestine

The small intestine measures about 7m in an average adult

and consists of the duodenum, jejunum, and ileum. Both the

bile and pancreatic ducts open into the duodenum together.

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The small intestine, because of its structure, provides a vast

lining through which further absorption takes place. There is

a large lymph and blood supply to this area, ready to

transport nutrients to the rest of the body. Digestion in the

small intestine relies on its own secretions plus those from

the pancreas, liver, and gall bladder.

The Pancreas

The Pancreas is connected to the duodenum via two ducts

and has two main functions:

1. To produce enzymes to aid the process of digestion

2. To release insulin directly into the blood stream for the

purpose of controlling blood sugar levels

Enzymes suspended in the very alkaline pancreatic juices

include amylase for breaking down starch into sugar, and

lipase which, when activated by bile salts, helps to break

down fat. The hormone insulin is produced by specialised

cells, the islets of Langerhans, and plays an important role in

controlling the level of sugar in the blood and how much is

allowed to pass to the cells.

The Liver

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The liver, which acts as a large reservoir and filter for blood,

occupies the upper right portion of abdomen and has several

important functions:

1. Secretion of bile to the gall bladder

2. Carbohydrate, protein and fat metabolism

3. The storage of glycogen ready for conversion into

glucose when energy is required.

4. Storage of vitamins

5. Phagocytosis - ingestion of worn out red and white

blood cells, and some bacteria

The Gall Bladder

The gall bladder stores and concentrates bile which

emulsifies fats making them easier to break down by the

pancreatic juices.

The Large Intestine

The large intestine averages about 1.5m long and comprises

the caecum, appendix, colon, and rectum. After food is

passed into the caecum a reflex action in response to the

pressure causes the contraction of the ileo-colic valve

preventing any food returning to the ileum. Here most of the

water is absorbed, much of which was not ingested, but

secreted by digestive glands further up the digestive tract.

The colon is divided into the ascending, transverse and

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descending colons, before reaching the anal canal where the

indigestible foods are expelled from the body.

ANATOMY OF THE APPENDIX

29

The appendix is a wormlike extension of the cecum

and, for this reason, has been called the vermiform

appendix. The average length of the appendix is 8-10 cm

(ranging from 2-20 cm). The appendix appears during the

fifth month of gestation, and several lymphoid follicles are

scattered in its mucosa. Such follicles increase in number

when individuals are aged 8-20 years.

The appendix is contained within the visceral

peritoneum that forms the serosa, and its exterior layer is

longitudinal and derived from the taenia coli; the deeper,

interior muscle layer is circular. Beneath these layers lies the

submucosal layer, which contains lymphoepithelial tissue.

The mucosa consists of columnar epithelium with few

glandular elements and neuroendocrine argentaffin cells.

Taenia coli converge on the posteromedial area of the

cecum, which is the site of the appendiceal base. The

appendix runs into a serosal sheet of the peritoneum called

the mesoappendix, within which courses the appendicular

artery, which is derived from the ileocolic artery. Sometimes,

an accessory appendicular artery (deriving from the

posterior cecal artery) may be found.

Appendiceal vasculature

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The vasculature of the appendix must be addressed to avoid

intraoperative hemorrhages. The appendicular artery is

contained within the mesenteric fold that arises from a

peritoneal extension from the terminal ileum to the medial

aspect of the cecum and appendix; it is a terminal branch of

the ileocolic artery and runs adjacent to the appendicular

wall. Venous drainage is via the ileocolic veins and the right

colic vein into the portal vein; lymphatic drainage occurs via

the ileocolic nodes along the course of the superior

mesenteric artery to the celiac nodes and cisterna chyli.

Appendiceal location

The appendix has no fixed position. It originates 1.7-2.5 cm

below the terminal ileum, either in a dorsomedial location

(most common) from the cecal fundus, directly beside the

ileal orifice, or as a funnel-shaped opening (2-3% of

patients). The appendix has a retroperitoneal location in 65%

of patients and may descend into the iliac fossa in 31%. In

fact, many individuals may have an appendix located in the

retroperitoneal space; in the pelvis; or behind the terminal

ileum, cecum, ascending colon, or liver. Thus, the course of

the appendix, the position of its tip, and the difference in

appendiceal position considerably changes clinical findings,

accounting for the nonspecific signs and symptoms of

appendicitis.

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Physiology of Appendix

The lumen of the appendix communicates with the

cecum 3cm (about 1 inch) before the ileoccal valve, thus

making it an accessory organ of the digestive system. Its

functions are not certain, but some biologists believe that

the appendix serves as a sort of “breeding ground” for some

of the nonpathogenic intestinal bacteria thought to aid in the

digestion or absorption of nutrients.

Follicles of lymphoid tissue appear in the wall of the

appendix shortly a few birth, become more prominent during

the first 10 years of life and then progressively disappear.

The defense or immune system function of lymphatic tissue

present in the appendix of young children is not fully

understood.

PATHOPHYSIOLOGY

Predisposing Factor Precipitating Factor

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Age (23 y/o) Bowel movement: 3 times a week.

Sedentary Lifestyle Low Fiber Diet

Obstruction to lumen of the appendix.

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Occlusion/kinking of the lumen.

Inflammation of the serosa of the

appendix.Signs and Symptoms: Acute RLQ Pain of the Abdomen Fever McBurney’s Sign Nausea Constipation

Intraluminal pressure.

Muscle Spasm

Pus Formation as evidenced by

increased White Blood Cell.

Rupture of the Appendix

If treated: If not treated:

PATHOPHYSIOLOGY NARRATIVE

The client was diagnosed of acute appendicitis; she had

a predisposing factor; her age (23 y/o), which is according to

research adult age has the higher risk of incidence. Her

gender didn’t serve as a factor because males are more

prone to the disease rather than in females.

Prior to admission, she experienced irregularity in her

bowel habit; she only defecates three times a week. Her diet

which is low in fiber, high in cholesterol and protein and her

sedentary lifestyle attributed to her illness.

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Medications: Ranitidine Ampicillin Flagyl

Metronidazole

Surgical Procedure: Appendectomy

Metastasize to the blood stream and throughout the

organ

Shock

Septicemia

Wellness

Death

The two factors: precipitating and predisposing, led to

the obstruction of the lumen of the appendix. As the

obstruction was lengthened, it resulted in the kinking of the

lumen, causing her pain. The occlusion caused an

inflammation of the serosa of the appendix which produced

an intraluminal pressure, causing muscle spasm on the

client.

The inflammation of the serosa of the appendix was

characterized by signs and symptoms of fever, acute pain in

the right lower quadrant of her abdomen, McBurney’s sign,

nausea and constipation which causes increase in the

intraluminal pressure thus resulting to muscle spasm.

As there is presence of inflammation, it resulted in

presence of pus formation evidenced by increased in white

blood cells to fight against infection.

Furthermore, if inflammation will not be cured it can

result to a rupture of the appendix. If rupture is to be

treated, the client will need surgery (appendectomy) and

medications. If treatment will be successful, it will lead to

wellness of life.

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If the rupture is not treated, it would metastasize to the

blood stream and throughout the organ and further

complicate to septicemia leading to shock, which may result

to DEATH.

COMPLICATION OF APPENDICITIS

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The most frequent complication of appendicitis is

perforation. Perforation of the appendix can lead to a

periappendiceal abscess (a collection of infected pus) or

diffuse peritonitis (infection of the entire lining of the

abdomen and the pelvis). The major reason for appendiceal

perforation is delay in diagnosis and treatment. In general,

the longer the delay between diagnosis and surgery, the

more likely is perforation. The risk of perforation 36 hours

after the onset of symptoms is at least 15%. Therefore, once

appendicitis is diagnosed, surgery should be done without

unnecessary delay.

A less common complication of appendicitis is blockage of

the intestine. Blockage occurs when the inflammation

surrounding the appendix causes the intestinal muscle to

stop working, and this prevents the intestinal contents from

passing. If the intestine above the blockage begins to fill with

liquid and gas, the abdomen distends and nausea and

vomiting may occur. It then may be necessary to drain the

contents of the intestine through a tube passed through the

nose and esophagus and into the stomach and intestine.

A feared complication of appendicitis is sepsis, a condition in

which infecting bacteria enter the blood and travel to other

37

parts of the body. This is a very serious, even life-

threatening complication. Fortunately, it occurs infrequently.

CLINICAL MANIFESTATION OF APPENDICITIS

The main symptom of appendicitis is abdominal pain. The

pain is at first diffuse and poorly localized, that is, not

confined to one spot. (Poorly localized pain is typical

whenever a problem is confined to the small intestine or

colon, including the appendix.) The pain is so difficult to

pinpoint that when asked to point to the area of the pain,

most people indicate the location of the pain with a circular

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motion of their hand around the central part of their

abdomen. A second, common, early symptom of appendicitis

is loss of appetite which may progress to nausea and even

vomiting. Nausea and vomiting also may occur later due to

intestinal obstruction.

As appendiceal inflammation increases, it extends through

the appendix to its outer covering and then to the lining of

the abdomen, a thin membrane called the peritoneum. Once

the peritoneum becomes inflamed, the pain changes and

then can be localized clearly to one small area. Generally,

this area is between the front of the right hip bone and the

belly button. The exact point is named after Dr. Charles

McBurney--McBurney's point. If the appendix ruptures and

infection spreads throughout the abdomen, the pain

becomes diffuse again as the entire lining of the abdomen

becomes inflamed.

TESTS AND 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

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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.

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

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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

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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.

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.

DOCTOR’S ORDER

02/08/2012

08:55 pm - Please admit to room of choice under

the service of Dr. Mudanza.

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- NPO

- Labs – CBC with plt. count, UA.,

- Start venoclysis with D5LR 1L @ 80 cc/

hr.

Meds:

- Ranitidine 50g q 8ᴼ IVTT.

- Watch out for unusualities.

10:00 pm - Ampicillin 1g q 6ᴼ IVTT ANST.

- Metronidazole 500 mg 8ᴼ IVTT.

- IV rate @ 120-150 cc/ hr.

11:20 pm - D5LR (#2) 1L @ 80 cc/ hr.

02/09/2012 -D5LR 1L @150 cc/ hr.

-Cont. meds.

-Run IVF @ 150 cc/ hr.

9:00am - Do UTZ of abdomen.

LABORATORY RESULTS

U.A: (02/08/2012)

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Admission No.: 2464

Color - Yellow

Transparency - Clear

Reaction - Acidic

Spec. Gravity - 1.020

Chemical Element

Sugar - (-)

Albumin - (-)

Microscopic Element

Pus Cells - 0-1 / hpf

RBC - 0-1 / hpf

Mucous Threads - occasional

Epithelial Cell - squamous-occasional

Hematology (02/08/2012)

Admission No.: 2464

Test Result Normal

Values

Rationale

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Hemoglobin 105 120.00-140

g/L

May indicate

anemia.

WBC 12 5.00-10.00 x

10 g/L

May indicate

infection,

inflammatio

n.

RBC 4.14 4.50-5.50 x

10 12/L

Indicates

anemia.

HCT 0.13 0.37-0.43 vol

%

Indicates

anemia.

PLT. CT 330 150.00-

350.00 x 10

g/L

Normal

SEGS 0.58 0.55-0.65 Normal

LYMPHO 0.33 0.25-0.35 Normal

Ultrasound Report

Case Number:

45

Patient Name: Momoko

Admitting Diagnosis: T/C Appendicitis

Complaint: RLQ Pain

Part Examined: Whole Abdomen Ultrasound

USD of the Abdomen:

Liver is normal size. No focal lesions are noted.

Intrahepatic ducts and CBD are not dilated. Hepatic vessels

are normal. Gall bladder is physiologically distended with

normal wall. No internal echoes are seen. Pancreas, spleen

and left kidney are normal. There is lobulated, well defined,

anechoric focus in superior pole of the right kidney

measuring 3.6 x 3.8 x 3.5 cm. urinary bladder and uterus are

remarkable. Both adnexae are free. No pelvic fluid noted.

There is well defined, ovoid predominantly complex mass in

the RLQ measuring 5.9 x 6.1 x 6 cm. the hypoechoic

component measures 4.4 x 2.6 x 3.9 cm. minimal

surrounding fluid is present.

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DRUG STUDYBrand Name

Generic Name

Classification

Dosage and

Frequency

Mechanism of

ActionIndication Adverse Reaction Nursing Management

Zantac

Ranitidine

Histamine H2 antagonists

50mg 1 amp IVTT every 8 hours

Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion.

Treatment and prevention of heartburn, acid indigestion, and sour stomach.

• CNS:Confusion, dizziness, drowsiness, hallucinations, headache

• CV:Arrhythmias

• GI:Altered taste, black tongue, constipation, dark stools, diarrhea, drug-induced hepatitis, nausea

• HEMAT: Anemia, neutropenia, thrombocytopenia

• LOCAL:Pain at IM site

• MISC:Hypersensitivity reactions, vasculitis

•Observe 11 rights in giving medication.

• Assess IV site and give the drug slowly.

• Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate.

• Inform patient that it may cause drowsiness or dizziness.

• Inform patient that increased fluid and fiber intake may minimize constipation.

• Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health care professional promptly.

• Inform patient that medication may temporarily cause stools and tongue to appear gray black.

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DRUG STUDY

DRUG STUDY

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Generic Name

Classification Dosage and frequency

Mechanism of Action

Indication Adverse Reaction

Nursing Management

AmpicinAmpicillin

Penicillin, antibiotic

1g every 6 hours IVTT

A broad spectrum semi- synthetic, amino penicillin is highly bactericidal even at low concentrations, but inactivated by penicillinase.

Infections of gastrointestinal tract and soft tissues.

•CNS: convulsive seizures with higher doses

•GI: diarrhea, nausea and vomiting

•Dermatologic: rash

•Observe 11 rights in giving medication.

•Determine previous hypersensitivity reactions to penicillins, cephalosphorins and other allergens prior to therapy.

•Inspect skin daily and instruct patient to do the same. The appearance of rash should be carefully evaluated.

•Give medication around the clock.

•Observe 11 rights in giving medication.

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Generic Name

Classification

Dosage and Frequency

Mechanism of Action

Indication

Adverse Reaction

Nursing Management

FlagylMetronidazol

e

Antibacterial,Anti-

protozoals

500mg every 8 hours IVTT

• Disrupts DNA and protein synthesis in susceptible organisms

•Bactericidal, or amebicidal action

Acute infection with susceptible anaerobic bacteria.

•CNS: seizures, dizziness, headache

• GI: abdominal pain, anorexia, nausea, diarrhea, dry mouth, furry tongue, glossitis, unpleasant taste, vomiting

•Hematologic: leukopenia

• Skin: rashes, urticarial

•Observe 11 rights in giving medication.

• Administer with food or milk to minimize GI irritation. Tablets may be crushed for patients with difficulty swallowing.

• Instruct patient to take medication exactly as directed evenly spaced times between dose, even if feeling better.

•May cause dizziness or light-headedness. Caution patient or other activities requiring alertness until response to medication is known.

• Inform patient that medication may cause an unpleasant metallic taste.

• Inform patient that medication may cause urine to turn dark.

NURSING CARE PLAN

Date and Time

Assessment

Scientific Basis

Nursing Diagnosis

Nursing Goal Plan

Nursing Intervention Rationale Evaluation

02- 09- 2012

(7-3)

Subjective:“Sakit akoang kilid”, as patient verbalized.

Objective: Conscio

us Grimace

d face noted

Weakness noted

Guarded behavior noted

Pain scale: 7/10

Pale looking

Due to the presence of inflammation and mass on the RLQ of the abdomen, it causes some obstruction in the lumen of the appendix in turn causes s sharp acute pain in the Right Lower Quadrant part of the abdomen.

Acute pain related to inflammation of the appendix.

Within our 8 hour span of care, patient will be alleviated from pain.

Establish rapport.

V/S taken and recorded.

Encourage verbalization of feelings about pain.

Encourage patient to have diversional activities such as mobile internet and watching TV.

Encourage patient to use relaxation techniques such as deep breathing.

Provide comfort measures such as touch, repositioning, quiet environment and calm activities.

Encourage adequate rest periods.

Observe and document severity (1-

To gain trust and cooperation.

Serves as baseline data.

To assess the level of pain.

To alleviate pain.

Distract attention and reduce tension.

To promote non-pharmacologic pain management.

To promote wellness and prevent fatigue.

To get a baseline data of pain scale.

Goal partially met.

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10 scale) and character of pain (steady, intermittent, colicky).

Date and Time

Assessment

Scientific Basis

Nursing Diagnosis

Nursing Goal Plan

Nursing Intervention

Rationale Evaluation

02-09-2012

(7-3)

Subjective:“Worried ko sa akong situation basig operahan man gud ko”, as verbalized by the patient.

Objective:

Irritability noted

Anxious looking

Discomfort noted

Restlessness noted

Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger it is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.

Anxiety related to possible surgery secondary to Acute Appendicitis.

Within our 8 hour span of care, patient will be able to understand and demonstrate positive coping mechanism and describe a reduction in the level of anxiety.

Establish rapport.

V/S taken and recorded.

Assess awareness of patient about anxiety.

Provide accurate information to the client.

Provide comfort measures.

Provide and maintain quiet environment.

Encourage patient to talk about anxious feelings.

To gain trust and cooperation.

Serves as baseline data.

Validate the feeling and communicate acceptance of the feelings.

Helps the client to identify what is reality based.

To help the patient relax.

Anxiety may escalate with excessive conversation, noise and equipment about the patient.

Talking about anxiety producing situations and anxious feelings

Goal met.

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(Gulanick/Myers Nursing Care Plans, 6th Edition)

can help the person perceive the situation in less threatening manner.

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PROGNOSIS

CRITERIA POOR FAIR GOOD JUSTIFICATIONOnset of Illness /

Onset of illness is fair because symptoms have progressed rapidly and patient gives less attention and no medical consultation was done.

Duration of illness /

Recognition of the disease is delayed. The patient manifested pain in the right lower quadrant.

Predisposing Factors /

The client has two predisposing factors out of three.

Precipitating Factors /

Precipitating factors is poor since the patient is constipated, has a low fiber diet and has a sedentary lifestyle.

Willingness to take medication

/The patient is compliant with medication regimen and other interventions.

Age / Physical Condition

/The patient is in the adulthood stage.

Envionmental / support Group

/She has the circle of supportive friends who visits and cares about her.

Family Support

/The patient’s family is very supportive. They are very receptive to the medical advices

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and cooperative to the interventions and management.

COMPUTATION FOR OVER-ALL PROGNOSIS

Good 4/8 x 100%= 50%

Fair 3/8 x 100%= 37.5%

Poor 1/8 x 100%= 12.5%

GENERAL PROGNOSIS

With the overall percentage of 100, the client exhibited

a higher percentage of good with fifty percent (50%) while

fair prognosis has a percentage of thirty seven point five

(37.5%) and poor with a twelve point five percentage

(12.5%).

The patient shows very good indication in willingness to

take her available medications. The patient’s family on the

other hand was very supportive to ease the client’s illness.

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Discharge planning

Medication

1. Instruct patient and the family to comply with the

prescribe medication.

2. Instruct patient’s family to place medicine in places out of

children reach.

3. Instruct patient and the family to complete the whole

duration of the drug.

4. Teach the patient and the family regarding the name of

the drugs, right dosage, and proper manner of taking as well

possible side effects.

Environment/exercise

1. Advice patient to take regular breaks from any activity

that demands to give stress pressure on back.

2. Encourage patient to involve in exercise to enhance

circulation.

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3. Encourage the patient to have adequate rest and sleep.

Treatment

1. Orient the patient’s family about the patient’s condition

and necessary information/treatment and recovery process.

2. Teach patient and the family about the importance of

conducive environment for better recovery.

3. Encourage to comply with treatment regimen.

Health Teachings

1. Advice to take medications on time and with the right

dose.

2. Instruct the patient to eat nutritious food such as

vegetables and fruits.

3. Advice the patient to limit consumption of fatty foods.

4. Encourage client to choose food/ have family member

bring food that seem appealing to stimulate appetite.

5. Instruct client to provide oral care before and after meals

and at bedtime.

Out patient

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1. Instruct the patient to take the medications ordered by the

physician.

2. Encourage the patient to comply with the scheduled check-

up.

3. Instruct the patient and the family to comply with the

prescribed medications.

4. Encourage patient to visit physician one to two weeks after

discharged from the hospital.

5. Instruct the patient to visit physician immediately if any

unusualities arise.

DIET

1. Encourage patient to eat nutritious and well balance meal.

2. Instruct the patient to increase oral fluid intake.

3. Diet as tolerated is advice by attending physician to

sustain her nutritional needs.

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BIBLIOGRAPHY

BOOKS:

Brunner and Suddarth’s Textbook of Medical Surgical

Nursing. Eleventh Edition

Priscilla lemone medical surgical nursing

Ross and Wilson Anatomy and Physiology in Health and

Illness. Tenth Edition.

Medical Surgical Nursing Critical Thinking in client care

Third Edition

MIMS and MIMS Annual

Baillers nursing dictionary

INTERNET

http://www.gastro.org/wmspage.American Gasteroenterogical Association

Pictures www.google.com

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