Appendicitis and Appendectomy: A Comprehensive Nursing Care Guide, Study notes of Nursing

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A CASE STUDY ON APPENDICITIS

Acknowledgement This case study report is prepared during Adult nursing clinical practicum in B&B Hospital, Gwarko. The report is prepared as a practical fulfillment of post basic PBN curriculum. I realized that the requirement to do complete case study in the nursing area has been an important opportunity for me to gain new experience and knowledge in this field. I got myself complete involved in the care and management of the patient during this period. However the work would not have been accomplished successfully with my effort alone. I would like to express my sincere gratitude to all teachers of my colleges for providing valuable guidance, supervision and suggestions in the clinical field area. I am also thankful to my colleagues and my patient and his family who gave me their valuable time for providing necessary information and kind cooperation during hospitalization. I am also thankful to doctors and nursing staffs of the hospital throughout the clinical practice without them the case would not have been completed. Finally, I would like to thank all of them who gave me their precious, valuable time and suggestions directly or indirectly while preparing this

Background Nepal is one of the developing countries with the with many morbid surgical disease prevalence. Acute appendicitis is the most common surgical emergency which seems to be most common in the second decade of life.the incidence of acute appendicitis is 0.15% in males and 0.19%in females with an overal life time risk of 6-20%. . Acute appendicitis is the most common surgical emergency. Obstruction of the lumen by fecolith is the usual cause of acute appendicitis.Though inspite of effective curative treatment ,if delayed in treatment it may lead to life threatening situations.Thus, the study was to analyze clinical presentation of acute appendicitis and its histopathological correlationis determined for the disease condition and its managenent so as to diminish the disease prevalence. According to post Basic Nursing curriculum to function effectively and independently in the field at nursing care of adult required to do 4 weeks of practical in different areas. During the period, I selected acute Appendicitis which is the most common cause of adult disease conditions, in surgical ward of B&B Hospital. So this case study was designed to gain and provide comprehensive knowledge of Acute Appendicitis and care to the patient.

Reason for case selection The general objectives of the case study as suggested by the curriculum, is to gain the comprehensive knowledge about the disease condition and to gain the practical experience in adult nursing for providing effective nursing care. I have selected acut appendicitis as a case study because it is most common cause of mordidity in adults’ nowdays. 680,000 per year, 56, per month, 13,076 per week, 1,863 per day, 77 per hour, 1 per minute,is being suffered from appendicitis. I found this disease condition challenging and interesting so I preferred this case to alert to related community at the right time then we can enhance our khnowledge about the appendicitis and reduces the incidence of morbidity and complications. Objectives General objectives: At the end of four weeks practicum we will be able to: Ø Identify the disease condition prevalent in the hospital Ø Gain the knowledge about the disease condition and its comparative relation with the patient. Ø Provide nursing care for the patient and family within the hospital by the application of nursing process. Ø Perform activities to maintain and promote optimum health of the patient. Ø Provide health teaching and evaluate total care study. Specific objectives: Ø To indentify the disease condition Ø To take health history and record of finding and to physical examination. Ø To formulate appropriate nursing diagnosis and nursing care plan according to the nursing theory and priority the patients needs.

Part I Biographical data of my patient Name of Patient : Ram Bahadhur Ghatri Age : 37 years Sex : Male Ethnic group : Janajati Religion : Hindu Education : Bachelor in Education Occupation : Bussiness Address : Balaju Nationality : Nepali Marital status : Married Date of admission : 2069/03/ Hospital : B &B hospital, Gwarko Ward : Surgical Ward Bed no : 410”A” Hospital No 1730

Provisional Diagnosis : Acute Appendicitis Date of operation : 2069/03/ Operative Procedure : Laproscopic Appendectomy

He was admitted at janamaitri hospital for ureteroscopy for UTI (urinary tract infection) for a day 1 year back. Family history: There was no significant history of chronic and hereditary disease; chronic illness.His mother was operated cholecystectomy for cholelithiasis almost a year back.

Health seeking practice: He belongs to the urban area of Kathmandu. Though, they believed in both traditional healer, dhami, jhakri and hospital treatment. So if anybody in the family gets ill they first go to the hospital first but also believe intraditional healers. Personal health history: Non smoker and Non alcoholic. No any food taboos practice in his family/home. So he eats every kind of food everyday. Environmental factors: they live in urban setting in Kathmandu valley with well accesibility of health facilities, education, water supply, and other facilities. 3 storyed houses with7 rooms, separate kitchen and seperate sanitary laterine. Appendicitis Case Study BY DAISY JANE ANTIPUESTO RN MN · FEBRUARY 16, 2010 Introduction The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the cecum just below the ileocecal valve. No definite functions can be assigned to it in humans. The appendix fills with food and empties as regularly as does the cecum, of which it is small, so that it is prone to become obstructed and is particularly vulnerable to infection (appendicitis). Appendicitis is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity. About 7% of the population will have appendicitis at some time in their lives, males are affected more than females, and teenagers more than adults. It occurs most frequently between the age of 10 and 30. The disease is more prevalent in countries in which people consume a diet low in fiber and high in refined carbohydrates. The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting. Loss of appetite is common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burney’s point applied located at halfway between the umbilicus and the anterior spine of the Ilium.

uvula move upward to direct food away from the nasal cavity and into the oropharynx. Tongue The tongue manipulates food in the mouth and is used in speech. The surface is covered with papillae that provide friction and contain the taste buds. Teeth A complete set of deciduous (primary) teeth contains 20 teeth. There are 32 teeth in a complete permanent (secondary) set. The shape of each tooth type corresponds to the way it handles food. Pharynx The pharynx is a fibromuscular passageway that connects the nasal and oral cavities to the larynx and esophagus. It serves both the respiratory and digestive systems as a channel for air and food. The upper region, the nasopharynx, is posterior to the nasal cavity. It contains the pharyngeal tonsils, or adenoids, functions as a passageway for air, and has no function in the digestive system. The middle region posterior to the oral cavity is the oropharynx. This is the first region food enters when it is swallowed. The opening from the oral cavity into the oropharynx is called the fauces. Masses of lymphoid tissue, the palatine tonsils, are near the fauces. The lower region, posterior to the larynx, is the laryngopharynx, or hypopharynx. The laryngopharynx opens into both the esophagus and the larynx. Esophagus The esophagus is a collapsible muscular tube that serves as a passageway between the pharynx and stomach. As it descends, it is posterior to the trachea and anterior to the vertebral column. It passes through an opening in the diaphragm, called the esophageal hiatus, and then empties into the stomach. The mucosa has glands that secrete mucus to keep the lining moist and well lubricated to ease the passage of food. Upper and lower esophageal sphincters control the movement of food into and out of the esophagus. The

lower esophageal sphincter is sometimes called the cardiac sphincter and resides at the esophagogastric junction Stomach the stomach, which receives food from the esophagus, is located in the upper left quadrant of the abdomen. The stomach is divided into the fundic, cardiac, body, and pyloric regions. The lesser and greater curvatures are on the right and left sides, respectively, of the stomach. Small Intestine The small intestine extends from the pyloric sphincter to the ileocecal valve, where it empties into the large intestine. The small intestine finishes the process of digestion, absorbs the nutrients, and passes the residue on to the large intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive system that are closely associated with the small intestine. The small intestine is divided into the duodenum, jejunum, and ileum. The small intestine follows the general structure of the digestive tract in that the wall has a mucosa with simple columnar epithelium, submucosa, smooth muscle with inner circular and outer longitudinal layers, and serosa. The absorptive surface area of the small intestine is increased by plicae circulares, villi, and microvilli. Exocrine cells in the mucosa of the small intestine secrete mucus, peptidase, sucrase, maltase, lactase, lipase, and enterokinase. Endocrine cells secrete cholecystokinin and secretin. The most important factor for regulating secretions in the small intestine is the presence of chyme. This is largely a local reflex action in response to chemical and mechanical irritation from the chyme and in response to distention of the intestinal wall. This is a direct reflex action, thus the greater the amount of chyme, the greater the secretion. Large Intestine The large intestine is larger in diameter than the small intestine. It begins at the ileocecal junction, where the ileum enters the large

hours, the pain localizes in the right lower quadrant and intensity increases.

2. Anorexia, moderate malaise, mild fever, nausea and vomiting.
3. Usually constipation occurs ; occasionally diarrhea.
4. Rebound tenderness, involuntary guarding, generalized abdominal rigidity. Diagnostic Evaluation
5. Physical examination consistent with clinical manifestations.
6. WBC count reveal moderate leukocytosis (10,000 to 16,000/mm3) with shift to the left (increased immature neutrophils).
7. Urinalysis rule out urinary disorders.
8. Abdominal x-ray may visualize shadow consistent with fecalith in appendix; perforation will reveal free air.
9. Abdominal ultrasound or CT scan can visualize appendix and rule out other conditions, such as diverticulitis and crohn’s disease. Focused appendiceal CT can quickly evaluate for appendicitis. Medications ▪ Analgesics ▪ Intravenous fluids replacements ▪ Analgesics Treatment Appendectomy is the effective treatment if peritonitis develops treatment involves. ▪ GI Intubation ▪ Parenteral replacement of IV fluids and electrolytes ▪ Administration of Antibiotics Surgery is indicated if appendicitis is diagnosed. Antibiotics and IV fluids are administered until surgery is performed analgesics can be administered after the diagnosed is made. An appendectomy (surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation. T he

appendectomy may be performed under a (general or spinal anesthetics) with a low abdominal incisions or by (laparoscopy) which is recently highly effective method. Complications The major complication of appendicitis is perforation of the appendix, which can lead to peritonitis, abscess formation (collection of purulent material), or portal pylephlebitis, which is septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines. Perforation generally occurs 24 hours after the onset of pain symptoms include a fever of 37.7 degree Celsius or 100 degree Fahrenheit or greater, a toxic appearance and continued abdominal pain or tenderness. Nursing Interventions

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.

fever, which indicate an abscess or wound dehiscence Stitches removed between fifth and seventh day (usually in physicians office) D Liquid or soft diet until the infection subsides Soft diet is low in fiber and easily breaks down in the gastrointestinal tract Pathophysiology of Appendicitis Nursing Care Plan – Appendicitis Physical examination of the patient It is an important tool of assessing the patient’s health status and about 15% of the information used in assessment comes from the physical examination. The methods that I have applied in the physical examination of the patient are: Ø Measurement Ø Smelling Ø Inspectio n Ø Palpation Ø Percussio

n Ø Auscultati on Vital sign Temperature: 99°F Pulse: 92/min