ACUTE APPENDICITIS

Jayson Aban
BSN4
 I. Introduction
Patient A.N.P. is a 22 year old single woman who was admitted
at the Antipolo City Medical Hospital last September 19, 2016
due to severe pain at her right lower quadrant, the patient was
diagnosed with acute appendicitis. The patient underwent
emergency appendectomy on the same day.

The appendix acts as a storehouse for good bacteria,

rebooting the digestive system after diarrheal illnesses.

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 obstruction attributed to infection,
structure, fecal mass, foreign body or tumor. Appendicitis can
affect either gender at any age, but it is common in males
ages 10-30. Appendicitis is the most common disease requiring
surgery and one of the most commonly misdiagnosed
diseases.
 I. Introduction
Acute appendicitis, is a sudden onset usually resulting from bacterial infection,
which may be precipitated by obstruction of the lumen by a fecalith, variable
symptoms often consisting of periumbilical, colicky pain and vomiting may be
followed by fever, leukocytosis, persistent pain, and signs of peritoneal
inflammation in the right lower quadrant of the abdomen; perforation or abscess
formation is a frequent complication of delayed surgical intervention.

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 complications of appendicitis such
as 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 the 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. Objectives
General: At the end of my course in the ward I will be able to gain
knowledge about Acute Appendicitis and the appropriate nursing intervention
and management regarding the patients condition toward this Related
Learning Experience.

Specific:
Knowledge
To acquire additional information in regards in managing the patient
with appendicitis
To identify the risk factor causing appendicitis
To discuss the normal Anatomy and Physiology ofthe Appendix
Formulate an appropriate nursing care plan based on the assessment
identified needs and problems of the patient.
 A. Objectives
Skills
To properly and adequately perform nursing management for a
patient with appendicitis
To improve my skill in the minimizing the pain of the client with
appendicitis and the use of proper positioning

Attitude
To be able to use therapeutic communication with the client for
me to fully comprehend her condition to carry out proper nursing
intervention.
Establish a trusting nurse-patient relationship with the client
through provision of holistic care toward the client and use of
appropriate verbal and non-verbal therapeutic communication
skills with the client during the data gathering.

 B. Scope and limitation

The case study tackles the limits only to Acute Appendicitis, its
manifestations, nursing intervention, medical management and
some other useful facts about the condition of the patient. It was
based on a case of 22 year old female patient and the presenter
handled the client for 1 day from 6AM -130 PM at Antipolo City
Medical Hospital (ACMH). The presenter gathered the information
about the patient through interview, patient chart and medical
record.
 D. Theoretical framework

Dorothea Orem 1970-1985

Dorothea Orem developed the self-care and self-requisites
theory.
She defined self-care as the practice of activities that individuals
initiate and perform on their own behalf in maintaining life, health
and well-being.
She conceptualized three nursing systems as follow:
Wholly Compensatory: when the nurse is expected to accomplish all the
patients needs, continuous guidance in self-care.
Partially Compensatory: when both nurse and patient engage in meeting
self-care needs.
Supportive educative: the system that requires assistance in
decision-making, behavior control and acquisition of knowledge and
skills
 D. Theoretical framework

Partially Compensatory

= To perform, enhance, and be aware of self-care

and in proper choices of food.
 II. Clinical Summary

General Data
Name: ANP
Address: Antipolo, City
Age: 22
Religion: Catholic
Attainment: College Graduate
Civil status: Single
Occupation: Registered Nurse at Rizal Provincial Annex 2, Dalig, Antipolo
Nationality: Filipino
Date of Birth: Feb 12, 1994
Date of Admission: Sep 19, 2016
Ward and Room: 412
Admitting Diagnosis: Acute Appendicitis
Attending Physician: Dr. Hiwatig
Sources: Patient, patients chart, & lab tests
 II. Clinical Summary

Chief Complaint:
The patient came to the hospital with right lower quadrant pain

History of Present Illness: The patient was admitted last Sep

19, 2016, at Antipolo City Medical Hospital (ACMH) at 4AM.
1 day PTA the patient was experiencing flank pain (Prior to
admission) Blood Test and urinalysis done. She was advised for
admission and was given paracetamol as medication.

Past Medical History:

Patient was never admitted in any hospital in the past.
 II. Clinical Summary

Review of System
Systems Subjective Cues
General Masakit sa may tagiliran ko As verbalized by the
Description patient after surgery.
Skin tuyo po ang aking sugat kaso makirot As verbalized
by the patient after surgery.
EENT Okay naman ang mata ko nakakabasa naman po ako
ng maayos. Nakakarinig po ako ng mabuti at wala pong
masakit sa tenga at ilong ko. Maayos po ang aking
pangamoy at nakalulunok naman po ako ng walang
masakit. As verbalized by the patient after surgery.
Musculoskeletal hirap pa po ako maglakad. As verbalized by the
patient after surgery.
Respiratory Di naman masakit ang dibdib ko tsaka wala po akong
ubo at di naman ako nahihirapang huminga. As
verbalized by the patient after surgery.
Cardiovascular Wala naman pong masakit sa loob ng dibdib ko As
verbalized by the patient after surgery.
 II. Clinical Summary

Review of System

Systems Subjective Cues

Gastrointestinal Nangangasim po sikmura ko bago po ako i-admit dito, Hindi na po ako
pinakain noong akoy ihanda na po for appendectomy. As verbalized
by the patient interviewed after surgery.
Back and Spine Okay naman po yung likod ko. As verbalized by the patient after
surgery.

Reproductive Okay naman po wala pong masakit sa ibaba ko. As verbalized by the
patient ater surgery.

Excretory Wala pong problema sa pag-ihi ko pero sa pagdumi ko po ay

kumikirot ang aking tahi. As verbalized by the patient after surgery.
 II. Clinical Summary

F. Physical Assessment

General appearance/ survey September 19, 2016

Client is responsive but has complaints about her flank pain

A. Measurement
FINDINGS NORMAL VALUES ANALYSIS/
INTERPRETATION
Height: 52
42 Kg
Weight: 20.25 kg/m2 18-24.9kg/m2 Normal
BMI:
Vital signs
taken after
surgery
BP 100/70 mmHg 120-140/80-90 mmHg Low Blood Pressure
Temp 36.5oc 36.5-37.4oc Normal
PR 80 bpm 60-100 bpm Normal
RR 19 bpm 16-20 bpm Normal
Pain scale 7/10 0/10 Due to flank pain
 II. Clinical Summary

B. Head to Toe Assessment

System Techniqu Normal Actual Analysis/

es Used findings findings Interpretati
on
Integumentar
y Inspection Good Skin Good Skin Normal
Skin turgor turgor
Abdomen Inspection Flat, rounded Surgical wound Due to post
present surgery
Symmetric
contour Pain in the Due to
Audible lower flank inflammation
bowel of the
sounds; appendix



 II. Clinical Summary

C. Activities of Daily Living

Before During Hospitalization Analysis/

Hospitalization interpretation
Fluid & Patient usually - Regular liquid intake To avoid dehydration.
Nutrition consumes about 3-4 about 7-8 glasses of
glasses of water a water. To avoid nausea, and
day. Drinks softdrinks - Soft diet gas in the bowel that
and eats junk foods may cause
most of the time. abdominal pain and
discomfort.
EliminationUsually voids 5-6 times Voids 7-8 times a day Due to increased water
a day or more and and defecates 1-2x a intake
defecates 1-2 times a day.
day.
Exercise The patient can move The patient has very Due to flank pain and
around and do limited daily activity. post surgery.
walking exercises in
the morning
Hygiene and The patient takes a The patient was not able Due to pain in her
Comfort bath daily or when to take a bath every flank and still has
she feels she needs day. Brushes her teeth difficulty moving
to. Brushes her teeth only once. around and post
3 times a day. surgery.
Rest and Sleep The patient sleeps The patient has regular Due to her flank pain
 II. Clinical Summary

D. Course in the ward

Received the patient on September 20, 2016, sitting, fully awake,

weak and in pain. She has difficulty walking due to flank pain, pain
scale 7/10 assessed. Vital signs taken, recorded and monitored
the patients condition and listened to concerns.

Vital signs taken and recorded, monitored the patients condition,

listened to patients concerns and did health teaching.
 II. Clinical Summary

Laboratory / Diagnostic Examination (Hematology) Date: Sep 19, 2016

HEMATOLOGY
NAME: ANP DATE: Sep 19, 2016 Interpretation / Analysis

PARAMETER RESULT NORMAL RANGE

Hemoglobin 142 FEMALE: 120-160 g/L Within normal range

Hematocrit 0.42 FEMALE: 0.37 0.47 Within normal range

RBC count 4.48 FEMALE: 4.5 6.5 x 10/L Within normal range

WBC count 12.3 5-10 X 10 g/L Increased due to presence of

infection in the appendix

Differential Count

Neutrophils 0.86 0.51 0.67 Neutrophils are the first line of

defense and are greatly
elevated until the immunologic
response is finished.

Lymphocytes 0.14 0.21 0.35 Decreased

Platelet count 420 150-450 X 10g/L Within normal range

 III. Clinical Discussion of the Disease

A. Anatomy and Physiology

Anatomy and Physiology of the Appendix

The appendix sits at the

junction of the small intestine
and large intestine. Its a thin
tube about four inches long.
Normally, the appendix sits in
the lower right abdomen.
The function of the
appendix is to act as a
storehouse for good bacteria,
rebooting the digestive
system after diarrheal
illnesses. Other experts
believe the appendix is just a
useless remnant from our
evolutionary past. Surgical
removal of the appendix
causes no observable health
problems
 III. Clinical Discussion of the Disease

B. Pathophysiology of acute appendicitis

 III. Clinical Discussion of the Disease

IV. Nursing Care Plan

Nursing Assessment Planning Intervention Rationale Evaluation
Diagnosis

Acute pain Subjective: After 30 Assess pain, Useful in After 30

kumikirot po noting location, monitoring minutes of
related to minutes of characteristics, effectiveness
presence of ang tahi ko nursing nursing
severity (0-10 of medication,
surgical as verbalized intervention scale). progression of
intervention,
incision as by the patient , client will Investigate healing. client has
evidenced verbalize and report Changes in verbalized
Objective: changes in characteristic relief from
by facial relief from pain as of pain may
The client is pain.
grimace pain. appropriate indicate
expressing
facial grimace developing Goal met.
abscess or
peritonitis,
requiring
prompt
medical
evaluation and
intervention.
 III. Clinical Discussion of the Disease

IV. Nursing Care Plan

Nursing Assessment Planning Intervention Rationale Evaluation

Diagnosis

Provide accurate, Being informed

honest about progress of
information to situation provides
patient and emotional
significant other. support, helping
to decrease
anxiety

Keep at rest in To lessen the

semi-Fowlers pain. Gravity
position localizes
inflammatory
exudate into
lower abdomen
or pelvis,
relieving
abdominal
tension, which is
accentuated by
supine position
 III. Clinical Discussion of the Disease

IV. Nursing Care Plan

Nursing Assessment Planning Intervention Rationale Evaluation

Diagnosis

Encourage early Promotes

ambulation normalization of
organ
function (stimulat
es peristalsis and
passing of flatus,
reducing
abdominal
discomfort).

Provide Refocuses
diversional attention,
activities promotes
relaxation, and
may enhance
coping abilities.

Administer Relief of pain

analgesics as facilitates
indicated. cooperation with
other therapeutic
interventions
 III. Clinical Discussion of the Disease

IV. Nursing Care Plan

Nursing Assessment Planning Intervention Rationale Evaluation

Diagnosis

Place ice bag on Soothes and

abdomen relieves pain
periodically through
during initial 24 desensitization of
48hr as nerve endings.
appropriate. Note: Do not use
heat, because it
may cause tissue
congestion.

Never apply heat This may cause

to the right lower the appendix to
abdomen rupture.

Watch closely Continuing

for possible pain may signal
surgical an abscess
complications.
 III. Clinical Discussion of the Disease

IV. Nursing Care Plan

Nursing Assessment Planning Intervention Rationale Evaluation

Diagnosis

Risk for Subjective: After 45 Practice and Reduces risk After 45

maitim po instruct in of spread of minutes of
Infection minutes of good bacteria.
yung tahi ko nursing nursing
handwashing
as verbalized intervention and aseptic
intervention,
by the , skin wound care. skin
patient surrounding surrounding
Provides for the surgical
the surgical Inspect early detection
Objective: wound was
wound will incision and of developing
Dark lightened.
lighten. dressings. infectious
discoloration
Note process
surrounding characteristics
the surgical of drainage
wound from wound,
presence of
erythema.
 III. Clinical Discussion of the Disease

IV. Nursing Care Plan

Nursing Assessment Planning Intervention Rationale Evaluation

Diagnosis

Monitor vital Suggestive of

signs. Note onset presence of
of fever, chills, infection or
diaphoresis, developing
reports of sepsis abscess,
increasing peritonitis.
abdominal pain.

Administer Antibiotics given

antibiotics as before
appropriate. appendectomy
are primarily for
prophylaxis of
wound infection
and are not
continued
postoperatively.
Therapeutic
antibiotics are
administered if
the appendix is
ruptured or
abscessed or
perotonitis has
developed
 III. Clinical Discussion of the Disease

IV. Nursing Care Plan

Nursing Assessment Planning Intervention Rationale Evaluation

Diagnosis
Watch Continuing
closely for pain may
possible signal an
surgical abscess.
complication
s
Deficient Subjective: After 45 Identify Prompt After 45
hindi ko po minutes of symptoms intervention minutes of
Knowledge requiring medical reduces risk of
related to akalain na nursing nursing
evaluation (incre serious
lack of recall maappendecto intervention, the asing pain; complications intervention,
as evidenced -my ako sa client will edema or (delayed wound the client has
unang verbalize erythema of healing, verbalized
by
pagkakataong understanding wound; presence peritonitis). understanding
verbalization of drainage,
maappendicitis of disease of disease
of problem/ as verbalized process, fever).
concern process,
by the patient potential Provides potential
complications Review information for complications
Objective: The and postoperative patient to plan for
and
client appears understanding activity return to usual
troubled with of therapeutic restrictions (heav routines without understanding
disbelief needs and y lifting, exercise, untoward of therapeutic
participate in
sex, sports, incidents. needs and
driving). has
treatment
regimen participated in
treatment
 III. Clinical Discussion of the Disease

IV. Nursing Care Plan

Nursing Assessment Planning Intervention Rationale Evaluation

Diagnosis
Encourage Prevents fatigue,
progressive promotes healing
activities as and feeling of
tolerated with well-being, and
periodic rest facilitates
periods. resumption of
normal activities.

Discuss care of Understanding

incision including promotes
dressing cooperation with
changes, bathing therapeutic
restrictions and regimen,
return to enhancing
physician for healing and
suture and staple recovery process.
removal
 V. Drug Study
Name of Mechanism Indication Contra- Adverse reaction Nursing
Drugs of Action indication Respon-
sibilities
Generic Bactericidal: Dermatologic Contraindicated CNS: Avoid alcohol
name: Inhibits infections with allergy to headache,dizzy- while taking this
Cefoxitin synthesis causedby S. cephalosporins ness, drug and for3
Brand ofbacterial Aureus , orpenicillins. lethargy,paras- days
name: cell wall, S.Epidermis,str thesias afterbecause
Mefoxin causing cell eptococci, Use cautiously GI: severe reactions
Classificati death E.Coli. with renal Nausea,vomitting, often occur.
on: failure,lactation, diarrhea,anorexia,ab
Antibiotic UTIs caused by pregnancy dominal pain, You may
Dosage: E. Coli flatulence experience these

IM P.Mirabilis,Klebs GU: side effects:
IV(Adults)1 iella. Nephrotoxicity stomach upset,
-2g (6-8 HEMATOLOGIC: diarrhea.
hr) Intra- Bone marrows,
(Infants)80 abdominal depressions, Report severe
-160 infections decreased WBC, diarrhea,
mg/kg/dayI causedby E. decreased platelets, difficultybrea-
M&IV Coli,klebsiella deacreased Hct. thing,
dividedose Bone and joint LOCAL unusual
s q 4-6 hr. infections : Pain,abscess at tiredness
Do not causedby S. injections orfatigue, pain at
exceed Aureus site,inflammation at injection site
12g/day IV site
Perioperative OTHERS:
prophylaxis Superinfections,
disulfiram like
 V. Drug Study
Name of Mechanism Indication Contra- Adverse reaction Nursing
Drugs of Action indication Respon-
sibilities
Generic Decreases fever Symptomatic Contraindicated in Hermatologic: Advise patient that
Name: by inhibiting the relief of pain and patients hemolytic anemia drug is only for
Paracetamol effect of fever hypersensitive to Neutropenia, short term use and
pyrogens on the the drug. leucopenia, to consult the
Brand Name: hypothalamic pancytopenia physician if giving to
Alvedon heat regulating Use cautiously in children for longer
centers and by patients with long Hepatic: jaundice than 5 days or
Classification a hypothalamic term alcohol use adults for longer
: action leading to because Metabolic: than 10 days
Analgesic/ sweating and therapeutic doses hypoglycemia
Anti-pyretic vasodilation cause Advise the patient
hepatotoxicity in Skin: rash, urticaria or caregiver that
Dosage: these patients many over the
500mg every counter products
4 hours contain
acetaminophen; be
aware of this when
calculating total
daily dose

Warn patient that

high doses or
unsupervised long
term use can cause
liver damage
 V. Drug Study
Name of Mechanism Indication Contra- Adverse reaction Nursing
Drugs of Action indication Respon-
sibilities
Generic Anti- Short term Contraindicated CNS: headache, Assessment:
name: inflammatory management of with significant dizziness, 1. History: renal
Ketorolac and analgesic pain (up to 5 renal impairment, somnolence, impairment;
tromethamine activity; days) during labor and insomnia, fatigue, impaired
delivery, lactation, tinnitus,
Brand name: Inhibits Ophthalmic: aspirin allergy, ophthalmologic hearing;
toradol prostaglandins Relief of ocular recent GI bleed or effects allergies,
and leukotriene itching due to perforation hepatic,
Classification synthesis seasonal lactation,
: conjunctivitis and Use cautiously pregnancy
Anti- relief of post- with impaired 2. Physical: skin
pyretic/anti- operative hearing; allergies;
color and
inflammatory inflammation hepatic conditions
Dosage: after cataract lesions,
1 AMP q 6 hrs surgery orientation,
and PRN for reflexes,
pain peripherals
sensation,
clotting times,
CBC,
adventitious
sounds
V. Drug Study
Name of Mechanis Indication Contra- Adverse Nursing
Drugs m indication reaction Respon-sibilities
of Action
Intervention:
1. Be aware that patient maybe
at risk for CV events, GI
bleeding, renal toxicity,
monitor accordingly
2. Do not use during labor,
delivery, or while nursing.
3. Keep emergency equipment
readily available at time of
initial dose, in case of
severe hypersensitivity
reaction
4. Protect drug vials from
light
5. Administer every 6 hrs to
maintain serum levels and
control pain
 V. Drug Study
Name of Mechanism Indication Contra- Adverse reaction Nursing
Drugs of Action indication Respon-
sibilities
Generic name: Gastric-acid pump Short term treatment of Contraindicated with CNS: headache, Assessment:
omeprazole inhibitor; suppresses active duodenal cancer hypersensitivity to dizziness, asthenia, 1. History hyper-
gastric acid secretion omeprazole or its vertigo, insomnia, apathy, sensitivity to
Brand name: by specific inhibition Short term treatment of components anxiety, paresthesias,
omeprazole or any
tansinel of the hydrogen- active benign gastric dream abnormalities
potassium ATPase ulcer Use cautiously with of its components;
Classification: enzyme system at pregnancy, lactation Dermatologic: rash, pregnancy;
Anti-secretory the secretory surface Eradication of inflammation, urticarial, lactation
drug of the gastric parietal helicobacter pylori pruritus, alopecia, dry skin 2. Physical: skin
cells; blocks the final lesions, reflexes,
Dosage: step of acid First line therapy for GI: diarrhea, abdominal urinary output,
20mg 1 cap for production treatment of heartburn pain, nausea, vomiting,
abdominal
two weeks or symptoms of constipation, dry mouth,
GERD. tongue atrophy examination,
respiratory
Respiratory: auscultation
URI
Symptoms, cough, Intervention:
Epistaxis, 3. Administer before
meals.
4. Administer antacids
with, if needed
5. Have regular
medical follow up
visits
6. Report severe
headache,
worsening of
symptoms, fever,
chills
VI. Discharge Planning
Medicine
Explained and emphasized to the patient and to significant others the importance of drug
compliance and the possible outcomes if not taken.
Explained to the client and immediate family members to administer the prescribed medication
at right time, right route, and right dosage.
Explained the adverse effect of drugs to the patient and family members then advised to consult
physician immediately if any side effects are experienced.

Exercise
Advised client to do deep breathing exercises

Treatment
Explained to the client and immediate family members how to properly clean and
dress the surgical wound.

Health Teaching
Advised handwashing before and after meals.
Encouraged oral hygiene.
Advised to avoid drinking carbonated drinks
VI. Discharge Planning
Out Patient follow-up
Advised patient to follow what her physician instructed, to have
communication between them and have an update regarding her condition.

Diet
Encouraged increase in fluid intake at least 8glasses of water a day.
Advised patient to eat anti-oxidant foods
Advised to limit intake of salty foods

Spiritual
Encouraged patient and relatives to seek guidance from God and maintain
constant prayers to him.
Spiritual counseling