ANATOMY AND PHYSIO APPENDICITIS, Schemes and Mind Maps of Anatomy

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APPENDICITIS

I. Description

o Appendicitis is an inflammation of the appendix , a finger-shaped pouch that projects from your colon on the lower right side of your abdomen.

Appendicitis causes pain in your lower right abdomen. However, in most people, pain begins around the navel and then moves. As inflammation

worsens, appendicitis pain typically increases and eventually becomes severe.

o Appendicitis is the most common general surgical problem encountered during pregnancy. The diagnosis is particularly challenging during

pregnancy because of the relatively high prevalence of abdominal/gastrointestinal discomfort, anatomic changes related to the enlarged uterus,

and the physiologic leukocytosis of pregnancy. Appendiceal rupture occurs more frequently in pregnant women, especially in the third trimester,

possibly because these challenges and reluctance to operate on pregnant women delay diagnosis and treatment.

o Chronic appendicitis can have milder symptoms that last for a long time, and that disappear and reappear. It can go undiagnosed for several

weeks, months, or years.

o Acute appendicitis has more severe symptoms that appear suddenly within 24 to 48 hoursTrusted Source. Acute appendicitis requires immediate

treatment.

III. Diagnostic / Laboratory Tests

PROCEDURE/S INDICATION/S NORMAL VALUES NURSING RESPONSIBILITIES

Complete Blood Count Test (CBC)

1. Red Blood Cell Count (RBC)
2. Hemoglobin Count (Hgb)
3. Hematocrit Count (Hct)
4. White Blood Cell Count (WBC)
5. Platelet Count A group of tests that evaluate the cells that circulate in blood, including red blood cells (RBCs), white blood cells (WBCs), and platelets (PLTs). The CBC can evaluate your overall health and detect a variety of diseases and conditions, such as infections. Used as part of a health checkup to screen for a variety of conditions. This test may also be used to help diagnose and/or monitor a number of diseases that affect the production or lifespan of red blood cells. Indicated to help measure the severity of anemia or polycythemia and also monitors the effectiveness of therapeutic regimen. Represents the percentage of the total blood volume that is made up of the red blood cell. To determine the proportion of your blood that is made up of red blood cells (RBCs) in order to screen for, help diagnose, or monitor conditions that affect RBCs; as part of a routine health examination or if your healthcare practitioner suspects that you have anemia or polycythemia Screen for a wide range of diseases and conditions. Help diagnose an infection or inflammatory process or other diseases that affect the number of WBCs, such as allergies, leukemia or immune disorders, to name a few. A platelet blood count is a blood test that measures the average number of platelets in the blood. Platelets help the blood heal wounds and prevent excessive bleeding. High or low platelet levels can be a sign of a severe condition. Male: 4.35-5.65 trillion cells/L (4.35-5.65million cells/mcL) Female: 3.92-5.13 trillion cells/L (3.92-5.13 million cells/mcL) Male: 13.2-16.6 grams/dL (132-166 grams/L) Female: 11.6-15 grams/dL (116-150 grams/L) Male: 38.3-48.6 percent Female: 35.5-44.9 percent 3.4-9.6 billion cells/L (3,400 to 9,600 cells/mcL) 150,000 to 450,000 platelets/mcL

Before the Procedure:

• Educate and prepare the patient

regarding the procedure

During the Procedure:

• Advise the patient to cooperate and

follow instructions

After the Procedure:

• Perform proper handwashing to

eliminate microorganisms

• Provide information about availability of

the result

PROCEDURE/S INDICATION/S NORMAL VALUES NURSING RESPONSIBILITIES

Urine Test (Urinalysis) A urinalysis is a group of physical, chemical, and microscopic tests. The tests detect and/or measure several substances in the urine, such as byproducts of normal and abnormal metabolism, cells, cellular fragments, and bacteria. It may be used to screen for and/or help diagnose conditions such as a urinary tract infection, kidney disorders, liver problems, diabetes or other metabolic conditions as well as to assess hydration status. Color – Yellow (light/pale to dark/deep amber) Clarity/turbidity – Clear or cloudy pH – 4.5- 8 Specific gravity – 1.005-1. Glucose - ≤130 mg/d Ketones – None Nitrites – Negative Leukocyte esterase – Negative Bilirubin – Negative Urobilirubin – Small amount (0.5- 1 mg/dL) Squamous epithelial cells - ≤15- 20 squamous epithelial cells/hpf Casts – 0 - 5 hyaline casts/lpf Crystals – Occasionally Bacteria – None Yeast - None Blood - ≤3 RBCs Protein - ≤150 mg/d RBCs - ≤2 RBCs/hpf WBCs - ≤2-5 WBCs/hpf

Before the Procedure:

• Educate and prepare the patient regarding

the procedure

During the Procedure:

• Advise the patient to cooperate and follow

instructions

After the Procedure:

• Perform proper handwashing to eliminate

microorganisms

• Provide information about availability of the

result

IV. Treatment Regimen

a. Medication - Most appendicitis cases are uncomplicated, which simply means the organ hasn't ruptured, so they can be treated with antibiotics.

Brand Name: ________________________________________________ Generic Name: ________________________ Drug Classification: ____ _________________________ Dosage, Route & Frequency Drug Action Drug-Drug & Drug- Food Interactions Indications Contraindications Side Effects (By System) Adverse Reactions (By Recommended Prescribed System) PO, IV (Adults): Most infections— 250 – 750 mg q 24 hr; inhalational anthrax (postexposure)— 500 mg once daily for 60 days. Renal Impairment PO, IV (Adults): Normal renal function dosing of 750 mg/day: CCr 20 – 49 mL/min— 750 mg q 48 hr; CCr 10– 19 mL/min—750 mg initially, then 500 mg q 48 hr; Normal renal function dosing of 500 mg/day: CCr 20– 49 mL/min—500 mg initially then 250 mg q 24 hr; CCr 10– 19 mL/min—500 mg Inhibit bacterial DNA synthesis by inhibiting DNA gyrase. Therapeutic Effects: Death of susceptible bacteria. Spectrum: Broad activity includes many grampositive pathogens: Staphylococci including methicillin- resistantStaphylococcus aureus, Staphylococcus epidermidis, Staphylococcus saprophyticus, Streptococcus pneumoniae, Streptococcus pyogenes, and Bacillus anthracis. Gram-negative spectrum notable for activity against: Escherichia coli, Klebsiella, Enterobacter, Salmonella, Shigella, Proteus, Providencia, Morganella Drug-Drug: Concurrent use of amiodarone, disopyramide, erythromycin, procainamide, dofetilide, quinidine, some antipsychotics, sotalol, or tricyclic antidepressants increase risk of torsade de pointes in susceptible individuals (avoid concurrent use). Administration with magnesium and aluminum- containing antacids, iron salts, bismuth subsalicylate, sucralfate, didanosine, and zinc salts decrease Treatment of the following bacterial infections: Urinary tract infections including cystitis and prostatitis (should be used for acute uncomplicated cystitis only when there are no other alternative treatment options) Skin and skin structure infections Treatment and prophylaxis of plague Contraindicated in: Hypersensitivity. Cross-sensitivity among agents within class may occur; History of myasthenia gravis (may worsen symptoms including muscle weakness and breathing problems) Use Cautiously in: Seizure disorder; Depression; Renal impairment (dose decreased if CCr lesser or equal than 50 mL/min, Cirrhosis CNS: Dizziness, headache, drowsiness GI: Diarrhea, nausea, abdominal pain Others: Local burning/discomfort, margin crusting, crystals/scales, foreign body sensation, ocular itching, altered taste CNS: agitation, anxiety, confusion, depression, dizziness, hallucinations, nightmares, paranoia, tremors, vertigo. GI: diarrhea Skin: rash, pruritus, blisters, edema, sensation of burning skin Levaquin Levofloxacin Fluoroquinolones or quinolones

initially then 250 mg q 48 hr. Normal renal function dosing of 250 mg/day: CCr 10– 19 mL/min—250 mg q 48 hr. morganii, Pseudomonas aeruginosa, Serratia, Haemophilus, Acinetobacter, Neisseria gonorrhoeae, Moraxella catarrhalis, Campylobacter, and Yersinia pestis. Additional spectrum includes: Chlamydia pneumoniae, Legionella pneumoniae, and Mycoplasma pneumonia Pharmacokinetics: A: Well absorbed after oral administration; 99% D: Widely distributed. High tissue and urinary levels are achieved, crosses the placenta M and E: small amounts metabolized; 87% excreted unchanged in urine Half-life: 8 hr Pharmacodynamics: R: PO absorption of fluoroquinolones. May increase the effects of warfarin. Levels of fluoroquinolones may be decreased by antineoplastics. Cimetidine may interfere with elimination of fluoroquinolones. Probenecid decreases renal elimination of fluoroquinolones. May increase risk of nephrotoxicity from cyclosporine. Concurrent therapy with corticosteroids may increase the risk of tendon rupture.

Responsibilities in the Nursing Process (ADPIE) Responsibilities in the Nursing Process (ADPIE) Assessment: ● Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC; urinalysis; frequency and urgency of urination; cloudy or foulsmelling urine) prior to and during therapy. ● Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results. ● Observe for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify health care professional immediately if these problems occur. ● Monitor bowel function. ● Assess for rash periodically during therapy. ● Assess for signs and symptoms of peripheral neuropathy (pain, burning, tingling, numbness, and/or weakness or other alterations of sensation including light touch, pain, temperature, position sense, and vibratory sensation) periodically during therapy. ● Assess for suicidal tendencies, depression, or changes in behavior periodically during therapy ● Monitor prothrombin time closely in patients receiving fluoroquinolones and warfarin; may enhance the anticoagulant effects of warfarin. Potential Nusing Diagnosis: ● Risk for infection (Patient/Family Teaching) ● Risk for impaired tissue integrity ● Noncompliance with drug regimen r/t lack of understanding of importance of drug regimen Planning: ● The patient’s infection will be controlled and ultimately eliminated. Interventions: ● Do not confuse levofloxacin with levetiracetam. ● PO: May be administered without regard to meals. Should be taken at least 2 hr before or 2 hr after antacids or other products containing calcium, iron, zinc, magnesium, or aluminum. ● Obtain a specimen from the infected site, and send it to the laboratory for C&S vefore initiating antibacterial drug therapy ● Monitor intake and output. ● Record vital signs and report any abnormal findings ● Check for signs and symptoms of superinfection: stomatitis (mouth ulcers), furry black tongue, and anal or genital discharge or itching Patient/Family Teaching ● Instruct patient to take drug exactly as prescribed. ● Teach patients to drink at least 6-8 glasses (8oz) of fluid daily ● Encourage patients to avoid caffeinated products ● Caution patient to avoid driving or other activities requiring alertness until response to medication is known. ● Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools). Evaluation: ● Resolution of the signs and symptoms of infection. Time for complete resolution depends on organism and site of infection. ● Post exposure treatment of inhalational anthrax or cutaneous anthrax (ciprofloxacin and levofloxacin). ● Prevention and treatment of plague (ciprofloxacin, levofloxacin, and moxifloxacin).

b. Surgery

o The surgical removal of the appendix is the primary treatment for acute appendicitis. This surgery is called an appendectomy or appendicectomy.

An appendectomy is the surgical removal of the appendix. It's a common emergency surgery that's performed to treat appendicitis. It is performed

as soon as possible to decrease risk of perforation.

c. Diet or Nutrition

Generally, doctors suggest liquid diet for appendicitis. An ideal diet for appendicitis (and a healthy liver) comprises:

o Fresh fruit and vegetable juice

o Steamed vegetables

o Whole grains

o Sprouted seeds

o Homemade cheese, milk

o Fiber rich food

There is a list of food items that should be strictly avoided in case of appendicitis or in the post-surgery phase. This list includes:

o High fat, high sugar food

o Aerated drinks

o Processed food

o Beans, broccoli, and vegetables that form gas

o Bakery items made from refined flour

o Spicy and fried food

o Alcohol and caffeine

d. Physical Exercise

These are the best physical exercises, after the recovery from appendectomy;

o Performing bed exercises to help improve blood flow and circulation in the lower portion of the body and also helps reduce the risk of blood clots

forming in the lower extremities.

o Take short walks, begin the post-appendicitis exercise regimen with short walks.

o After several weeks of recovery, perform gentle abdominal exercises to begin rebuilding the abdominal muscles.

o Swimming is a low impact exercise that puts low amounts of stress on your joints during exercise. After recovering from appendicitis, start with

short laps, using a freestyle swim technique to put less strain on your abdominal muscles.

V. Prevention / Prognosis

o There’s no proven way to prevent appendicitis. Eating a high-fiber diet with lots of whole grains and fresh fruits and vegetables may help, although

experts can’t explain why.

o With an early operation, the chance of death from appendicitis is very low. The person can usually leave the hospital in 1 to 3 days, and recovery is

normally quick and complete. However, older people often take longer to recover.

o Without surgery or antibiotics, more than 50% of people with appendicitis die.

o For a ruptured appendix, the prognosis is more serious. Decades ago, a rupture was often fatal. Surgery and antibiotics have lowered the death rate

to nearly zero, but repeated operations and a long recovery may be necessary.

VI. Nursing Care Plan

Identified Problem: Abdominal Pain (Pre-Operative) Nursing Diagnosis: Risk for Infection related to perforation or rupture of the appendix CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION Subjective: Objective: Short Term Objectives: After 1 hour of nursing intervention, patient will verbalize understanding of the need or importance of appendectomy in his/her situation to prevent further infection. Long Term Objectives: Within the 16 hours of nursing intervention, patient have successfully finished the surgical procedure for appendicitis with normal vital signs and no signs of infection. Independent:

1. Establish rapport
2. Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in mentation, reports of increasing abdominal pain.
3. Maintain NPO status of the patient.
4. Administer fluids intravenously.
5. Monitor for changes in level of pain.
6. Perform a focused assessment on the abdominal region, particularly checking for abdominal pain, abdominal rigidity, diminishes or absent bowel sounds and rebound tenderness.
7. Prepare the patient for appendectomy. If the appendix ruptured and an abscess has formed, prepare for abscess drain. Dependent:
8. Administer antibiotics as prescribed by the physician. 1. To gain trust and foster cooperation 2. Suggestive of presence of infection or developing sepsis, abscess, peritonitis. 3. In preparation for the appendectomy procedure for the patient. 4. To prevent dehydration 5. Worsening inflammation can be determined when the intensity of pain increases 6. Appendicitis happens in the abdominal region evidenced by sudden abdominal pain, rigidity, nausea and vomiting, and loss of appetite. 7. For surgical removal of the appendix. If the appendix has ruptured and an abdominal abscess have formed, the latter needs to be drained first before performing appendectomy. 1. To treat underlying infection with antibiotics. To prevent the risk of developing sepsis. Short Term: Goal met. After 1 hour of nursing intervention, patient has verbalized understanding of the need or importance of appendectomy in his/her situation to prevent further infection. Long Term: Goal met. After 16 hours of nursing intervention, patient have successfully finished the surgical procedure for appendicitis with normal vital signs and no signs of infection.

Dependent:

1. Administer analgesics as prescribed by the physician. 9. Promotes normalization of organ function (stimulates peristalsis and passing of flatus, reducing abdominal discomfort). 10. Refocuses attention, promotes relaxation, and may enhance coping abilities. 11. Decreases discomfort of early intestinal peristalsis, gastric irritation and vomiting. 12. Soothes and relieves pain through desensitization of nerve endings. Note: Do not use heat, because it may cause tissue congestion. 13. This may cause the appendix to rupture. 14. Continuing pain and fever may signal an abscess. 1. Relief of pain facilitates cooperation with other therapeutic interventions. This is also to maintain an “acceptable” level of pain. Notify physician if regimen is inadequate to meet pain control goal.

Identified Problem: Abdominal Pain (Post-Operative) Nursing Diagnosis: Pain related to surgical incision due to appendectomy CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION Subjective: Objective: Short Term Objectives: After 8 hours of nursing intervention, patient will perform non pharmacological methods that can provide relief such as relaxation techniques. Long Term Objectives: After 16 hours of nursing intervention, patient will report that pain is relieved or controlled as evidenced by a pain rating scale of 3/10. Independent:

1. Establish rapport
2. Monitor vital signs
3. Assess for potential types of pain that may be affecting client
4. Note client’s age and developmental level and current condition
5. Assess client’s perceptions of pain, along with behaviors and cultural expectations regarding pain
6. Note client’s attitude toward pain and use of pain medications, including any history of substance abuse
7. Observe nonverbal cues and pain behaviors
8. Monitor skin color and temperature and vital signs
9. Work with clients to prevent pain. Use a flow sheet to document pain, therapeutic interventions, response, and length of time before pain recurs. Instruct client to report pain as soon as it begins
10. Provide or promote non pharmacological pain management such as the use of relaxation exercises (deep breathing and coughing exercises) and comfort measures
    1. To gain trust and foster cooperation
    2. To establish baseline data
    3. To aid in understanding the reason for severity of pain associated with client’s condition, and point toward needed interventions for pain management.
    4. Affecting ability to report pain parameters or response to pain and pain management interventions.
    5. Client’s perception of and expression of pain are influenced by age, developmental stage, underlying problem causing pain, cognitive, and behavioral and sociocultural factors
    6. Client may have beliefs restricting use of medications, may have a high tolerance for drugs because of recent or current use, or may not be able to take pain medications at all if participating in a substance abuse recovery program
    7. Observations may not be congruent with verbal reports or may be the only Short Term: Goal met. After 8 hours of nursing care, patient was able to perform non pharmacological methods that provide relief such as relaxation techniques. Long Term: After 16 hours of nursing intervention, patient will report that pain is relieved or controlled as evidenced by a pain rating scale of 3/10.

Identified Problem: Abdominal Pain (Post-Operative) Nursing Diagnosis: Risk for Infection related to post-operative incision due to appendectomy CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION Subjective: Objective: Short Term Objectives: After 8 hours of nursing intervention, patient will verbalize understanding of individual causative or risk factor Long Term Objectives: Within 2-3 days of nursing intervention, patient will identify and demonstrate interventions to prevent or reduce the risk of infection Independent:

1. Establish rapport
2. Monitor patient’s vital signs
3. Provide therapeutic environment
4. Monitor patient for any signs of swelling, purulent discharge or presence of pain from the incision site
5. Stress proper hand hygiene for both patient and caregivers/nurses
6. Keep the incision site clean and dry. This is important after urination and bowel movements
7. Educate the patient about the importance of would care
8. Encourage intake of protein-rich foods and calorie-rich foods Dependent:
9. Administer antibiotics as prescribed by the physician. 1. To gain trust and foster cooperation 2. To establish baseline data 3. To provide comfort 4. These are classic signs of infection 5. Hand hygiene is a first line of defense against infection 6. Moistures harbor microorganisms which could lead to infection 7. To instill awareness to the patient about the importance of caring for the incision site and the risk of not caring for the incision site in a proper manner. 8. Proper nutrition places a part in supporting the immune system’s responsiveness 1. To treat underlying infection with antibiotics. To prevent the risk of developing sepsis. Short Term: Goal met. After 8 hours of nursing intervention, patient has verbalized understanding of individual causative or risk factor Long Term: Goal met. Within 2-3 days of giving nursing intervention, patient identified and demonstrated interventions to prevent or reduce the risk of infection

Identified Problem: Abdominal Pain (Post-Operative) Nursing Diagnosis: Impaired Skin Integrity related to surgical incision due to appendectomy CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION Subjective: Objective: Short Term Objectives: After 2 hours of nursing intervention, patient will verbalize understanding of the causative factors of having an impaired skin after surgical incision. Long Term Objectives: After 16 hours of nursing intervention, patient will be able to display timely healing of surgical wound. Independent:

1. Establish rapport
2. Provide therapeutic environment
3. Assess skin, noting type(s) of disruption and general health of skin
4. Note presence of compromised mobility, sensation, vision, hearing, or speech
5. Monitor patient’s vital signs
6. Review laboratory results pertinent to causative factors
7. Perform routine skin inspections, describing observed changes. Note skin color, texture, and turgor. Assess areas of least pigmentation for color changes
8. Note character and color of drainage, when present
9. Maintain and instruct in good skin hygiene
10. Keep surgical area clean and dry, carefully dress wounds, support incision
11. Apply appropriate dressing
12. Encourage early ambulation or mobilization
13. Provide optimum nutrition, including vitamins (e.g., A, C, D, E) and protein
    1. To gain trust and foster cooperation
    2. To provide comfort
    3. To provide comparative baseline and opportunity for timely intervention when problems are noted
    4. May impact client’s self-care as relates to skin care
    5. To establish baseline data
    6. To establish baseline data
    7. Systematic inspection can identify improvement or changes for timely intervention
    8. This can cause or exacerbate skin irritation or excoriation
    9. To reduce risk of dermal trauma, improve circulation, and promote comfort
    10. To assist body’s natural process of repair
    11. For wound healing and to best meet needs of client and caregiver or care setting
    12. Promotes circulation and reduces risks associated with immobility
    13. To provide a positive nitrogen balance to aid in skin and tissue healing and to maintain general good health Short Term: Goal met. After 2 hours of nursing intervention, patient have verbalized understanding of the causative factors of having an impaired skin after surgical incision. Long Term: Goal not met. After 16 hours of nursing intervention, patient was not able to display timely healing of surgical wound.