I.INTRODUCTION Patient J.L.

D is 31 year-old married woman who was admitted at the Surgery Department last June 21, 2009 due to severe pain at her right lower quadrant, the patient was diagnosed with acute appendicitis. The patient underwent emergency appendectomy the next day, June 22, 2009. Appendicitis is the inflammation of the vermiform appendix and was first described as a pathologic condition by Reginald Fitz in 1886, it is caused by an obstruction attributed to infection, stricture, fecal mass, foreign body or tumor. Appendicitis can affect either gender at any age, but is most common in male ages 10-30. Appendicitis is the most common disease requiring surgery and one of the most commonly misdiagnosed diseases. Appendectomy, removal of the appendix, is the standard treatment for acute appendicitis, it is important to immediately remove the appendix after the diagnosis to prevent the occurrence of the life-threatening complication of appendix. 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.

NURSING OBJECTIVE

To obtain necessary information regarding the patient and her condition To assess the patients overall health status To identify patients health care needs through analysis of all the data gathered To assist the patient throughout rehabilitation, recovery and discharge To impart necessary health teachings to the patient To perform appropriate nursing care in conjunction with the condition of the patient To widen and enhance the student nurses knowledge and skills through additional research about the nature of the disease, its signs and symptoms, its pathophysiology, its diagnosis and treatment.

II. PATHOPHYSIOLOGY

Obstruction of the appendix (by fecalith, lymph node, tumour, foreign objects) Inflammation Increase intraluminal pressure Distention of the Appendixcauses pain Decrease venous drainage Blood flow and oxygen restriction to the appendix Bacterial Invasion of the Blood wall causes fever

 Necrosis of the appendix The pathophysiology of appendicitis is the constellation of processes that leads to the development of acute appendicitis from a normal appendix. The main thrust of events leading to the development of acute appendicitis lies in the appendix developing a compromised blood supply due to obstruction of its lumen and becoming very vulnerable to invasion by bacteria found in the gut normally. Obstruction of the appendix lumen by fecalith, enlarged lymph node, worms, tumor, or indeed foreign objects, brings about a raised intra-luminal pressure, which causes the wall of the appendix to become distended. Normal mucus secretions continue within the lumen of the appendix, thus causing further build up of intra-luminal pressures. This in turn leads to the occlusion of the lymphatic channels, then the venous return, and finally the arterial supply becomes undermined. Reduced blood supply to the wall of the appendix means that the appendix gets little or no nutrition and oxygen. It also means a little or no supply of white blood cells and other natural fighters of infection found in the blood being made available to the appendix. The wall of the appendix will thus start to break up and rot. Normal bacteria found in the gut gets all the inducement needed to multiply and attack the decaying appendix within 36 hours from the point of luminal obstruction, worsening the process of appendicitis. This leads to necrosis and perforation of the appendix. Pus formation occurs when nearby white blood cells are recruited to fight the bacterial invasion. A combination of dead white blood cells, bacteria, and dead tissue makes up pus. The content of the appendix (fecalith, pus and mucus secretions) are then released into the general abdominal cavity, bringing causing peritonitis. So, in acute appendicitis, bacterial colonization follows only when the process have commenced. These events occur so rapidly, that the complete pathophysiology of appendicitis takes about one to three days. This is why delay can be deadly. Pain in appendicitis is thus caused, initially by the distension of the wall of the appendix, and later when the grossly inflamed appendix rubs on the overlying inner wall of the abdomen (parietal peritoneum) and then with the spillage of the content of the appendix into the general abdominal cavity (peritonitis). Fever is brought about by the release of toxic materials (endogenous pyrogens) following the necrosis of appendicael wall, and later by pus formation. Loss of appetite and nausea follows slowing and irritation of the bowel by the inflammatory process.

Early symptoms of appendicitis are those symptoms that most people with this condition may recognize and complain of. They include lower right sided abdominal pain of gradual onset, feeling sick (or nausea), and loss of appetite. Any one with these three symptoms can be assumed to have appendicitis until proven otherwise.

Abdominal pain This pain typically starts from around the belly button (peri-umbilical region), or the upper central abdomen (epigastrium) and then move downwards and to the lower right abdomen (right iliac fossa). When the pain occurs in this pattern, it is the most dependable of all symptoms of appendicitis, as over 8 out 10 (80%) cases that present this way is definitely due to the appendix. In some other individuals, the pain starts right way from the right iliac fossa. Depending on where the tip of the appendix is, the pain could even be on the right flank (retro-caecal appendix). If the appendix is quite long, and in the pelvic cavity, it could as well cause lower left abdominal pain, with frequent passage of urine if the inflamed appendix irritates the bladder. When the appendix is severely inflamed, the pain can be localized to a spot on the outer one third of a line drawn between the belly button and front of the tip of the waist bone called the McBurneys point. The Mc Burneys point is also often the point of maximum tenderness when the abdomen is examined. The pain is even worse when the hand is suddenly removed from that spot because of the appendix rubbing on the covering of the abdomen (Rebound tenderness). There is also a sign referred to as the Rovsign sign. This is said to exist when the lower left abdomen is palpated by the doctor, but causes pain in the right. If the appendix is the pelvic type, examining the back passage (rectal examination) would cause some pain too. If the hip is moved and stretched, this can also cause pain to be felt at the spot where the appendix lies. This is referred to as the psoas sign.

Loss of Appetite, Nausea & Vomiting This is another very important set of symptoms of appendicitis. It is said that loss of appetite is the most constant symptom of appendicitis.

They may actually vomit. It is important to note that vomiting in appendicitis usually follows the pain. If you vomit before the pain commenced, it is not likely that the appendix is to blame.

Change in Bowel Habit There may be diarrhea or constipation, especially in young children. This could lead to a wrong diagnosis of food poisoning or gastroenteritis on the part of the unwary doctor. Up to 1 in 5 persons (20%) could have diarrhea or even constipation with appendicitis.

Fever There is usually a low grade fever in most patients with this disease. Nevertheless, in up to 1 in 5 persons (20%), they have normal temperature, even with severe disease. Temperature above 38.5 degree centigrade with rigors is suggestive of a ruptured appendicitis.

III. HISTORY OF PAST AND PRESENT ILLNESS A. History of Past Illness Last September 2008, patient was diagnosed with kidney stones or renal calculi. She underwent 3 sessions of Extracorporeal Shock Wave (ESWL) or simply known as shockwave therapy, a non-invasive technique for removing obstructive renal calculi. The patient believes that the occurrence of her kidney stones was due to her habit of eating salty foods and soda or carbonated soft drinks. Her doctor prescribed her with the following medications to reduce the risk of new calculi formation: Sambong forte, Acalka, and Rowatinex. The patient has also a surgical history, she delivered her two children through Ceasarean Section (CS), her first CS delivery was on the year 2001, according to the patient, her pregnancy was normal but her child had meconium-stained amniotic fluid and was overdue thats why she had to deliver her first child through CS, and the second was on the year 2005.

The patient denies allergies to any medications, foods or animals. The patient claims that she only suffered from two common childhood illnesses, chicken pox and measles, when she was a kid. According to her she was completely immunized when she was a child as evidenced by scars on the patients left and right deltoid. The patient admits a family history of hypertension, according to the patient her father died of heart attack.

B. History of Present Illness Patient was in usual state of good health until June 21, 2009, after having her dinner she experienced a severe pain at her abdomen which started at the area around her periumbilical area shifted to right lower quadrant region. She was immediately rushed to the hospital and was admitted at the surgery ward at 9:55 PM, she was diagnosed with acute appendicitis. She underwent an emergency appendectomy the next day, June 22, 2009. Her operation begun at 12:50 PM and ended at 1:25 PM, her surgeon was Dr. Paat. According to the patient, she had been experiencing mild pain at her abdominal region since December 2008, she even consulted it to the doctor but they did not pay much attention to it thinking that it was just a manifestation of her kidney problem and that it was nothing serious. The patients vital signs during the shift were as follow: Temperature: 36.6 C Pulse Rate: 67 bpm Respiratory Rate: 16 cpm Blood Pressure: 100/80 mmHg

IV. NURSING PHYSICAL ASSESSMENT

DATE P PSYCHOSOCIAL

JULY 9,2009 woman >mother of 2 Ilocos Sur >Roman Catholic >Conscious and coherent relationship with her family members

JULY 12, 2009

JULY 16,2009 >conscious and coherent >has good relationship with

>31 years old, married >conscious and coherent cheerful her neighborhood >attends the mass every Sunday together with her

>oriented, responsive and >alert and responsive

>lives at Cuta, Vigan, >has good relationship with co-workers

>has good and harmonious family

E ELIMINATION

>(-) vomiting >(-)diaphoresis >voids 5x a clear and light yellow urine >(-) pain upon urinating >defecates 2x a day

>(-) vomiting >(-) diaphoresis day with a >voids 5x clear and light yellow urine >(-) pain upon urinating >defecates 2x a day

>(-) vomiting >(-) diaphoresis and light yellow urine >(-) pain upon urinating >defecates 2x a day a day with a voids 5x day with a clear

A/R REST & ACTIVITY

>sleeps 6-7 hours

>sleeps 6-7 hours

>works at the hospital >sleeps 6-7 hours a day >refrained from carrying children after her doing

>patient started going to >goes to work 5x a week, Philhealth office work on July 6, 2009, 9 from Monday to Friday days after her operation a hospital 8:00 am to 5:00 am night with her family as a way of recreation >does household chores from >works as a health clerk at >refrained

doing her

strenuous activities such operation >refrained from >takes a short nap during strenuous activities such as pushing heavy objects

>works for 9 hours, from as carrying heavy objects >considers watching TV at weekends

S SAFE ENVIRONMENT

>afebrile, C/ax drugs >with >with dry binder and at

body >afebrile, BT of 37.1 C/ax >afebrile,36.8 C/ax dressing at incision site abdominal area wound site strong structure dressing at incision site abdominal area site intact, approximated wound edges house >owns a pet dog which lives in a dog house outside their house

temperature (BT) of 36.9 >still with dry and intact > still with dry and intact >denies allergy to foods or >still with binder at her >still with binder at the intact >with dry and leathery >(-) pain at the incision the >(-) pain at the incision >

dressing on incision site abdominal area dressing regularly >with dry wound >(-) pain at the incision site >with clean and quiet environment O OXYGENATION >RR=14 cpm; eupneic >BP=120/80 mmHg >PR=72 bpm >(-) DOB and Chest Pain >with good skin turgor N NUTRITION >weighs 58 kg and vegetables >eats 3x a day regularly with low salt diet >refrained from drinking carbonated softdrinks

>cleans and changes the >with

>RR=14 cpm; eupneic >BP=110/80 >PR=80 bpm >(-) DOB and Chest pain >with good skin turgor >with normal BMI of 22.7

>RR=16; eupnic >BP=120/80 >PR=75 bpm >(-)DOB and chest pain >with good skin turgor >eats regularly, with good appetite >sometimes takes a snack of juice and bread every afternoon

>Food Preferences: Rice >with good appetite

V. RELATED TREATMEANTS A. Ideal 1. URINALYSIS Urinalysis is a microscopic examination of the urine that detects red blood cells, white blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or stones in the kidneys or bladder. The urinalysis also may be abnormal with appendicitis because the appendix lies near the ureter and bladder. If the inflammation of appendicitis is great enough, it can spread to the ureter and bladder leading to an abnormal urinalysis. Most patients with appendicitis, however, have a normal urinalysis. Therefore, a normal urinalysis suggests appendicitis more than a urinary tract problem, it is also usually used in women to rule out pregnancy.

2. 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. 3. 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. 4. ULTRASOUND An ultrasound is a painless procedure that uses sound waves to identify organs within the body. Ultrasound can identify an enlarged appendix or an abscess. Nevertheless, during appendicitis, the appendix can be seen in only 50% of patients. Therefore, not seeing the appendix

during an ultrasound does not exclude appendicitis. Ultrasound also is helpful in women because it can exclude the presence of conditions involving the ovaries, fallopian tubes and uterus that can mimic appendicitis.

Findings of acute appendicitis of ultrasound:

Visualization of noncompressible appendix as a blind-ending tubular a peristaltic structure (seen only in 2% of normal adults, but in 50% of normal children) Laminated wall with target appearance of 6 mm in total diameter on cross section (81% SPECIFIC)/mural wall thickness 2 mm Lumen may be distended with anechoic/hyperechoic material Pericecal/periappendiceal fluid Increased periappendiceal echogenicity (= infiltration of mesoappendix/pericecal fat) Enlarged mesenteric lymph nodes Loss of wall layers = gangrenous appendix

False-negative US:

Failure to visualize appendix Inability of adequate compression Aberrant location of appendix (eg, retrocecal) Appendiceal perforation Early inflammation limited to appendiceal tip

False-positive US:

Normal appendix mistaken for appendicitis Alternate diagnosis: Crohn disease, pelvic inflammatory disease, inflamed Meckel diverticulum Spontaneous resolution of acute appendicitis

5. 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. 6. 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. CT findings of normal appendix

Visualized in 67-100%. At posterior-medial aspect of cecum. Diameter of up to 10 mm.

CT findings of Abnormal appendix

Distended lumen (appendix >7 mm in diameter). Circumferential wall thickening. Target sign: homogeneously enhancing wall with mural stratification. Appendicolith: homogeneous/ringlike calcification (25%). Distal appendicitis: abnormal tip of appendix + normal proximal appendix and normal cecal apex.

7. LAPAROSCOPY

Laparoscopy is a surgical procedure in which a small fiber optic tube with a camera is inserted into the abdomen through a small puncture made on the abdominal wall. Laparoscopy allows a direct view of the appendix as well as other abdominal and pelvic organs. If appendicitis is found, the inflamed appendix can be removed with the laparascope. The disadvantage of laparoscopy compared to ultrasound and CT is that it requires a general anesthetic.

8. THE ALVARADO SCORE FOR ACUTE APPENDICITIS The Alvarado score is a clinical scoring system used in the diagnosis of appendicitis. The score has 6 clinical items and 2 laboratory measurements with a total 10 points. A score of 5 or 6 is compatible with the diagnosis of acute appendicitis. A score of 7 or 8 indicates a probable appendicitis, and a score of 9 or 10 indicates a very probable acute appendicitis. A popular mnemonic used to remember the Alvarado Migration Anorexia, Tenderness Rebound Elevated Leukocytosis Shift of leukocytes to the left temperature in the right score to factors the right is MANTRELS: iliac iliac fossa fossa pain (fever)

Nausea/Vomiting

Despite numerous studies touting the advantages of newer diagnostic technologies, the most accurate and cost effective diagnostic tool to diagnose appendicitis remains for the physician to spend time performing an accurate history and physical examination.

B. Actual CBC DIAGNOSTIC WBC NORMAL RESULT 5.0-10.0 12.0 x10^9/L ACTUAL RESULT NURSING IMPLICATION High-indicates infection >Instruct patient to increase intake of Vitamin C and increase fluid intake >Administer antibiotic as ordered Lymph # 3.0-4.0 1.6x1069/L High-indicates stress, >Instruct pain and systemic infection patient to acute increase intake of Vitamin C and increase fluid intake >Monitor signs of infection such as elevated Body Temp. >Administer antibiotic as ordered Mid # Gran # 0.1-0.9 5.0-7.0 0.7x10^9/L 9.7x10^9/L Normal High-indicates infection >Monitor signs of infection such as elevated Body Temp. >Administer antibiotic as ordered Lymph % 30.0-40.0 13.4% Low-indicates exhausted system Mid % Gran % 1.0-9.0 50.0-70.0 5.8% 80.8% Normal High-indicates infection >Instruct patient to increase intake of Vitamin C and increase fluid intake HGB RBC HCT 120-160 4.04-5.48 37.0-47.0 131g/L 4.99x10^12/L 36.9% Normal Normal Mildly low-indicates >Instruct patient to mild blood loss increase intake of Vitamin immune NSG. RESPONSIBILITY

C and increase fluid intake MCV 82.0-95.0 74.0 fL Low-indicates anemia >Instruct patient to

increase intake of Vitamin C and increase fluid intake MCH 27.0-31.0 26.2 pg Low-indicates deficiency Iron >Instruct patient to

increase intake of foods high in iron such as green leafy vegetables

MCHC RDW-CV RDW-SD PLT MPV PDW PCT

320-360 11.5-14.5 35.0-56.0 150-400 7.0-11.0 15.0-17.0 0.108-0.282

355 g/L 14.0% 38.3 fL 239 x10^9/L 8.4 fL 16.8 0.200%

Normal Normal Normal Normal Normal Normal Normal

Urinalysis NORMAL COLOR CHARACTER Light Yellow Clear Slightly turbid Abnormal >Instruct patient to increase intake ALBUMIN REACTION SPECIFIC GRAVITY PUS CELL (-) 4.6-8 1.010-1.025 0 (-) 6.5 pH 1.010 2-4 Normal Normal Normal Abnormal >Instruct patient to increase fluid fluid or ACTUAL pale Light Yellow Implication Normal Nursing Responsibility

intake >Administer antibiotic ordered SQUAMOUS (-) (+) Abnormal >Instruct patient to increase intake >Administer antibiotic ordered BACTERIA (-) (+) Abnormal >Instruct patient to increase intake >Instruct patient to increase intake of Vitamin C >Administer antibiotic ordered as fluid as fluid as

NURSING CARE PLAN

ASSESSMENT
Subjective: Masaki tang tiyan ko as verbalized by the patient Objective: Facial Mask of pain Guarding behavior. Rebound tenderness V/S taken as follows of

DIAGNOSIS
Acute pain to related inflammation tissues of

INFERENCE
Appendicitis vermiform caused obstruction attributable infection, to structure, is appendix by an inflammation of the

PLANNING
After 4 hours of nursing interventions, patient relaxation the will skills,

INTERVENTION
Independent Investigate reports, pain nothing

RATIONALE
Changes location intensity but and reflected developing complications Reducing abdominal distention, thereby reduces tensions. in or are may

EVALUATION
After 4 hours of nursing interventions, the patient was able to demonstrate use of relaxation skills, other methods to promote comfort.

location, duration, intensity(010scale), characteristics(dull , sharp, constant) Maintain Move slowly deliberately. Provide comfort semi patient and fowlers position.

not uncommon

demonstrate use of other methods to promote comfort.

fecal mass, foreign body or tumor. Appendicitis can affect either gender at any age, but is most common in males ages 10 to 30.

T: 37.3 P: 80 R: 18 Bp: 110/90

Appendicitis is the most diseases surgery. may common requiring If left to

measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Provide diversional activities. Provide oral Remove environmental stimuli. Collaborative: Adminisster analgesic prescribe as frequent care.

Reduces muscle tension or guarding, the of which may help minimize pain movement.

untreated appendicitis progress abscess, perforation, subsequent, peritonitis, and death

Promotes relaxation and may enhance by patients coping abilities refocusing attention

Reduces nausea can and increase or vomiting, which intra-abdominal pressure pain

Reduces metabolic rate and aids in pain relief and promotes healing

VII. NURSING DIAGNOSIS AND PATIENT GOAL Patients often complain of anorexia, nausea, vomiting, abdominal distension, and temporary constipation. Temperature elevations may also be reported (usually 100F to 101F). Palpation of the abdomen reveals slight muscular rigidity and diffuse tenderness around the umbilicus and midepigastrium. Later, as the pain shifts to the right lower quadrant, palpation generally elicits tenderness at McBurneys point. Right lower quadrant rebound tenderness is typical. Also, a positive Rovsings sign may be elicited by palpating the left lower quadrant, which results in pain in the right lower quadrant. Diagnoses Nursing Care Plans For Appendicitis Acute pain Imbalanced nutrition: Less than body requirements Impaired skin integrity Ineffective tissue perfusion: GI Risk for deficient fluid volume Risk for infection Risk for injury

Key outcomes Patient will express feelings of comfort. Patient will maintain adequate caloric intake. Patients skin integrity will remain intact. Patient will maintain adequate GI perfusion. Patients fluid volume will remain within normal parameters. Patient will remain free from signs and symptoms of infection. Patient will avoid or minimize complications.

VIII. NURSING INTERVENTION

1. Monitor frequently for signs and symptoms of worsening condition, indicating perforation, abscess, or peritonitis (increasing severity of pain, tenderness, rigidity, distention, absent bowel sounds, fever, malaise, and tachycardia). 2. Notify health care provider immediately if pain suddenly ceases, this indicates perforation, which is a medical emergency. 3. Assist patient to position of comfort such as semi-fowlers with knees are flexed. 4. Restrict activity that may aggravate pain, such as coughing and ambulation. 5. Apply ice bag to abdomen for comfort. 6. Avoid indiscriminate palpation of the abdomen to avoid increasing the patients discomfort. 7. Promptly prepare patient for surgery once diagnosis is established. 8. Explain signs and symptoms of postoperative complications to report-elevated temperature, nausea and vomiting, or abdominal distention; these may indicate infection. 9. Instruct patient on turning, coughing, or deep breathing, use of incentive spirometer, and ambulation. Discuss purpose and continued importance of these maneuvers during recovery period. 10. Teach incisional care and avoidance of heavy lifting or driving until advised by the surgeon. 11. Advice avoidance of enemas or harsh laxatives; increased fluids and stool softeners may be used for postoperative constipation.