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.

II.NURSING OBJECTIVE • • • • • • • To obtain necessary information regarding the patient and her condition To assess the patient’s overall health status To identify patient’s 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 nurse’s knowledge and skills through additional research about the nature of the disease, its signs and symptoms, its pathophysiology, its diagnosis and treatment.

She underwent 3 sessions of Extracorporeal Shock Wave (ESWL) or simply known as shockwave therapy. History of Past Illness Last September 2008. Her doctor prescribed her with the following medications to reduce the risk of new calculi formation: Sambong forte. patient was diagnosed with kidney stones or renal calculi. and Rowatinex. her pregnancy was normal but her child had meconium-stained amniotic fluid and was overdue that’s why she had to deliver her first child through CS. 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. The patient has also a surgical history. according to the patient. The patient denies allergies to any medications. The patient claims that she only suffered from two common childhood illnesses. HISTORY OF PAST AND PRESENT ILLNESS A. she delivered her two children through Ceasarean Section (CS). and the second was on the year 2005. foods or animals. chicken pox and . Acalka. a non-invasive technique for removing obstructive renal calculi. her first CS delivery was on the year 2001.++++++++++++++++++++++++++++++++ IV.

History of Present Illness Patient was in usual state of good health until June 21. she was diagnosed with acute appendicitis. she had been experiencing mild pain at her abdominal region since December 2008. when she was a kid. According to the patient. The patient admits a family history of hypertension. her surgeon was Dr. The patient’s vital signs during the shift were as follow: Temperature: 36. 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. June 22. according to the patient her father died of heart attack. Paat. 2009. 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.PEARSON ASSESSMENT .measles. 2009. She was immediately rushed to the hospital and was admitted at the surgery ward at 9:55 PM. Her operation begun at 12:50 PM and ended at 1:25 PM. According to her she was completely immunized when she was a child as evidenced by scars on the patient’s left and right deltoid. B. She underwent an emergency appendectomy the next day.6 °C Pulse Rate: 67 bpm Respiratory Rate: 16 cpm Blood Pressure: 100/80 mmHg V.

approximated wound edges >owns a pet dog which lives in a dog house outside their house >RR=14 cpm.2009 >31 years old. BT of 37. from 8:00 am to 5:00 am >considers watching TV at night with her family as a way of recreation >sleeps 6-7 hours >goes to work 5x a week. 2009.9 °C/ax >denies allergy to foods or drugs >with dry and intact dressing on incision site >with binder at the abdominal area >cleans and changes the dressing regularly >with dry wound >(-) pain at the incision site >with clean and quiet environment >RR=14 cpm.8 °C/ax > still with dry and intact dressing at incision site >still with binder at the abdominal area >(-) pain at the incision site > intact. eupneic >RR=16. body temperature (BT) of 36.36. Ilocos Sur >Roman Catholic >Conscious and coherent >has good and harmonious relationship with her family members JULY 12. eupneic >afebrile. from Monday to Friday >does household chores >refrained from doing strenuous activities such as carrying heavy objects >takes a short nap during weekends >works at the hospital Philhealth office >sleeps 6-7 hours a day >refrained from carrying her children after her operation >refrained from doing strenuous activities such as pushing heavy objects S SAFE ENVIRONMENT >afebrile. 9 days after her operation >works as a health clerk at a hospital >works for 9 hours.2009 >conscious and coherent >alert and responsive >has good relationship with co-workers E ELIMINATION >(-) vomiting >(-)diaphoresis >voids 5x a day with a clear and light yellow urine >(-) pain upon urinating >defecates 2x a day >(-) vomiting >(-) diaphoresis >voids 5x a day with a clear and light yellow urine >(-) pain upon urinating >defecates 2x a day >(-) vomiting >(-) diaphoresis voids 5x day with a clear and light yellow urine >(-) pain upon urinating >defecates 2x a day A/R REST & ACTIVITY >sleeps 6-7 hours >patient started going to work on July 6. eupnic . responsive and cheerful >has good relationship with her neighborhood >attends the mass every Sunday together with her family JULY 16.DATE P PSYCHOSOCIAL JULY 9.1 °C/ax >still with dry and intact dressing at incision site >still with binder at her abdominal area >with dry and leathery wound >(-) pain at the incision site >with strong house structure >afebrile. married woman >mother of 2 >lives at Cuta. 2009 >conscious and coherent >oriented. Vigan.

Therefore. 4. it is also usually used in women to rule out pregnancy. This is especially true in children. white blood cells and bacteria in the urine. Ideal 1. Most patients with appendicitis. before infection sets in. In early appendicitis.ULTRASOUND An ultrasound is a painless procedure that uses sound waves to identify organs . Almost any infection or inflammation can cause this count to be abnormally high. Unfortunately. 3. have a normal urinalysis. Urinalysis usually is abnormal when there is inflammation or stones in the kidneys or bladder. Therefore. an elevated white blood cell count alone cannot be used as a sign of appendicitis. it can spread to the ureter and bladder leading to an abnormal urinalysis. however.URINALYSIS Urinalysis is a microscopic examination of the urine that detects red blood cells.ABDOMINAL X-RAY An abdominal x-ray may detect the fecalith (the hardened and calcified. WHITE BLOOD CELL COUNT The white blood cell count in the blood usually becomes elevated with infection.VI. The urinalysis also may be abnormal with appendicitis because the appendix lies near the ureter and bladder. a normal urinalysis suggests appendicitis more than a urinary tract problem. If the inflammation of appendicitis is great enough.DIAGNOSTIC PROCEDURE A. it can be normal. but most often there is at least a mild elevation even early. 2. appendicitis is not the only condition that causes elevated white blood cell counts. peasized piece of stool that blocks the appendiceal opening) that may be the cause of appendicitis.

retrocecal) Appendiceal perforation Early inflammation limited to appendiceal tip False-positive US: • • • Normal appendix mistaken for appendicitis Alternate diagnosis: Crohn disease. 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. Barium enema also can exclude other intestinal problems that mimic appendicitis. pelvic inflammatory disease.within the body. Ultrasound can identify an enlarged appendix or an abscess. during appendicitis. fallopian tubes and uterus that can mimic appendicitis. show an impression on the colon in the area of the appendix where the inflammation from the adjacent inflammation impinges on the colon. at times. 6. inflamed Meckel diverticulum Spontaneous resolution of acute appendicitis 5. CT findings of normal appendix . Nevertheless. for example Crohn's disease. 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. the appendix can be seen in only 50% of patients. COMPUTERIZED TOMOGRAPHY (CT) SCAN In patients who are not pregnant. This test can. 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. Therefore. 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. 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.

A popular mnemonic used to remember the Alvarado score factors is MANTRELS: Migration to the right iliac fossa Anorexia. If appendicitis is found. 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. Target sign: homogeneously enhancing wall with mural stratification. 7. THE ALVARADO SCORE FOR ACUTE APPENDICITIS The Alvarado score is a clinical scoring system used in the diagnosis of appendicitis. Distal appendicitis: abnormal tip of appendix + normal proximal appendix and normal cecal apex. the most accurate and cost0effective diagnostic tool to diagnose . Circumferential wall thickening. At posterior-medial aspect of cecum. The disadvantage of laparoscopy compared to ultrasound and CT is that it requires a general anesthetic. and a score of 9 or 10 indicates a very probable acute appendicitis. Nausea/Vomiting Tenderness in the right iliac fossa Rebound pain Elevated temperature (fever) Leukocytosis Shift of leukocytes to the left Despite numerous studies touting the advantages of newer diagnostic technologies. the inflamed appendix can be removed with the laparascope. Appendicolith: homogeneous/ringlike calcification (25%).• • • Visualized in 67-100%. Laparoscopy allows a direct view of the appendix as well as other abdominal and pelvic organs. CT findings of Abnormal appendix • • • • • Distended lumen (appendix >7 mm in diameter). 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. 8. Diameter of up to 10 mm.

Actual CBC .appendicitis remains for the physician to spend time performing an accurate history and physical examination. B.

0-10.0-40.48 37.0 x10^9/L NURSING IMPLICATION High-indicates infection Lymph # 3.0-4. >Administer antibiotic as ordered Normal High-indicates >Monitor signs of infection infection such as elevated Body Temp.0-9.0 1.>Instruct patient to mild increase intake of Vitamin C and increase fluid intake >Instruct patient to increase intake of Vitamin C and increase fluid intake MCV 82.99x10^12/L 36.9 5.8% 80.7x10^9/L Lymph % Mid % Gran % 30.6x1069/L Mid # Gran # 0.0-47.0% 38.0 74.0 0.0 0.1-0.0-7.0-17.2 pg MCHC RDW-CV RDW-SD PLT MPV PDW PCT 320-360 11.0 13.0 50.0-95. RESPONSIBILITY >Instruct patient to increase intake of Vitamin C and increase fluid intake >Administer antibiotic as ordered High-indicates >Instruct patient to stress.9% low.0-11.282 355 g/L 14.200% Low-indicates Iron >Instruct patient to deficiency increase intake of foods high in iron such as green leafy vegetables Normal Normal Normal Normal Normal Normal Normal .8% NSG.5-14.4% 5.0 131g/L 4.0-70.4 fL 16.0 1.7x10^9/L 9.0 150-400 7.108-0.04-5.0 26.5 35.8 0.3 fL 239 x10^9/L 8.0-31.DIAGNOSTIC WBC NORMAL RESULT 5.0 ACTUAL RESULT 12. pain and increase intake of acute systemic Vitamin C and increase infection fluid intake >Monitor signs of infection such as elevated Body Temp. >Administer antibiotic as ordered Low-indicates exhausted immune system Normal High-indicates >Instruct patient to infection increase intake of Vitamin C and increase fluid intake Normal Normal Mildly indicates blood loss Low-indicates anemia HGB RBC HCT 120-160 4.0-56.0 15.0 fL MCH 27.

like a worm. the first part of the colon.5 pH 1. narrow tube up to several inches in length that attaches to the cecum .ANATOMY AND PHYSIOLOGY OF ORGAN INVOLVED The appendix is a closed-ended. The anatomical name for the appendix is vermiform appendix which means worm-like appendage. It's pencil-thin .Urinalysis NORMAL COLOR CHARACTER ALBUMIN REACTION SPECIFIC GRAVITY PUS CELL ACTUAL Implication Normal Abnormal Normal Normal Normal Abnormal >Instruct patient to increase fluid intake >Administer antibiotic as ordered >Instruct patient to increase fluid intake >Administer antibiotic as ordered >Instruct patient to increase fluid intake >Instruct patient to increase intake of Vitamin C >Administer antibiotic as ordered >Instruct patient to increase fluid intake Nursing Responsibility Light or pale Light Yellow Yellow Clear Slightly turbid (-) 4.6-8 1.010-1.025 0 (-) 6.010 2-4 SQUAMOUS (-) (+) Abnormal BACTERIA (-) (+) Abnormal VII.

removing the appendix does not seem to result in problems with the immune system. lymph node. foreign objects) ↓ Inflammation ↓ Increase intraluminal pressure ↓ Distention of the Appendix → causes pain ↓ Decrease venous drainage ↓ Blood flow and oxygen restriction to the appendix ↓ . the appendix stops functioning. The appendix is usually located in the right iliac region. The inner lining of the appendix produces a small amount of mucus that flows through the open center of the appendix and into the cecum. tumour. thus. VIII. immunoglobulins are made in many parts of the body. just below the ileocecal valve (designated McBurney's point) and can be found at the midpoint of a straight line drawn from the umbilicus to the right anterior iliac crest. However. it helps make immunogobulins. but the muscle is poorly developed. the appendix functions as a part of the immune system.and normally about 4 inches (7 cm) long. But after this time period. the wall of the appendix also contains a layer of muscle. During the first few years of life.PATHOPHYSIOLOGY Obstruction of the appendix (by fecalith. The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies. Like the rest of the colon.

and finally the arterial supply becomes undermined. then the venous return. or indeed foreign objects. bacteria. initially by the distension of the wall of the appendix. • Abdominal pain This pain typically starts from around the belly button (peri-umbilical region). and dead tissue makes up pus. worms. They include lower right sided abdominal pain of gradual onset. and loss of appetite. 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). These events occur so rapidly. The content of the appendix (fecalith. thus causing further build up of intra-luminal pressures. that the complete pathophysiology of appendicitis takes about one to three days. Loss of appetite and nausea follows slowing and irritation of the bowel by the inflammatory process. A combination of dead white blood cells. Any one with these three symptoms can be assumed to have appendicitis until proven otherwise. feeling sick (or nausea). So. in acute appendicitis. bringing causing peritonitis. Pus formation occurs when nearby white blood cells are recruited to fight the bacterial invasion. which causes the wall of the appendix to become distended. or the upper central abdomen (epigastrium) and then move downwards . 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. This is why delay can be deadly.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. Obstruction of the appendix lumen by fecalith. brings about a raised intra-luminal pressure. Early symptoms of appendicitis are those symptoms that most people with this condition may recognize and complain of. pus and mucus secretions) are then released into the general abdominal cavity. enlarged lymph node. The wall of the appendix will thus start to break up and rot. Reduced blood supply to the wall of the appendix means that the appendix gets little or no nutrition and oxygen. This in turn leads to the occlusion of the lymphatic channels. bacterial colonization follows only when the process have commenced. worsening the process of appendicitis. Pain in appendicitis is thus caused. Fever is brought about by the release of toxic materials (endogenous pyrogens) following the necrosis of appendicael wall. Normal mucus secretions continue within the lumen of the appendix. tumor. 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. This leads to necrosis and perforation of the appendix. and later by pus formation. 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.

with frequent passage of urine if the inflamed appendix irritates the bladder. IX. 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). this can also cause pain to be felt at the spot where the appendix lies. even with severe disease.MEDICAL AND SURGICAL MANAGEMENT A. especially in young children. they have normal temperature. In some other individuals. it could as well cause lower left abdominal pain. Nevertheless. It is said that loss of appetite is the most constant symptom of appendicitis. it is not likely that the appendix is to blame.and to the lower right abdomen (right iliac fossa). This could lead to a wrong diagnosis of food poisoning or gastroenteritis on the part of the unwary doctor. Nausea & Vomiting+++ This is another very important set of symptoms of appendicitis.Ideal The following are the ideal diagnostic procedures done to the patient which were already explained thoroughly on the previous pages: A. Abdominal X-ray . as over 8 out 10 (80%) cases that present this way is definitely due to the appendix.5 degree centigrade with rigors is suggestive of a ruptured appendicitis. it is the most dependable of all symptoms of appendicitis. • Fever There is usually a low grade fever in most patients with this disease. MEDICAL a. If the hip is moved and stretched. When the pain occurs in this pattern. Up to 1 in 5 persons (20%) could have diarrhea or even constipation with appendicitis. There is also a sign referred to as the Rovsign sign. Urinalysis B. and in the pelvic cavity. in up to 1 in 5 persons (20%). WBC count C. The Mc Burney’s point is also often the point of maximum tenderness when the abdomen is examined. This is referred to as the psoas sign. If the appendix is the pelvic type. This is said to exist when the lower left abdomen is palpated by the doctor. Temperature above 38. the pain could even be on the right flank (retrocaecal appendix). 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 McBurney’s point. When the appendix is severely inflamed. examining the back passage (rectal examination) would cause some pain too. • Loss of Appetite. If you vomit before the pain commenced. Depending on where the tip of the appendix is. but causes pain in the right. It is important to note that vomiting in appendicitis usually follows the pain. the pain starts right way from the right iliac fossa. They may actually vomit. • Change in Bowel Habit There may be diarrhea or constipation. If the appendix is quite long.

The abdominal incision then is closed. Antibiotics almost always are begun prior to surgery and as soon as appendicitis is suspected b. D5LR is actually 5% dextrose in lactated ringer's solution. This is done by freeing the appendix from its mesenteric attachment to the abdomen and colon. and sewing over the hole in the colon. Once a diagnosis of appendicitis is made. If appendicitis is found. causes many effects similar to the opioids.IDEAL Surgery is the only treatment for acute appendicitis. IV.Q 12 hrs x 4 doses:an antibiotic which inhibits synthesis of Bacterial cell wall. q 8 hrs: it has Anti-inflammatory and analgesic activity. During an appendectomy. The laparoscope is a thin telescope attached to a video camera that allows the surgeon to inspect the inside of the abdomen through a small puncture wound (instead of a larger incision). the appendix can be removed with special instruments that can be passed into the abdomen.dizziness.D. SURGICAL A. Ultrasound E. After examining the area around the appendix to be certain that no additional problem is present. the appendix is removed. B.IV. an incision two to three inches in length is made through the skin and the layers of the abdominal wall over the area of the appendix. an appendectomy usually is performed. causing cell death  Tramadol 50 mg. IV. . inhibits prostaglandins and leukotriene synthesis The patient was administered with D5LR 1 L regulated at 31-32 gtts/min. cutting the appendix from the colon. Patient was given the following medications:  Ceftriaxone 1 gm. q 8 hrs: an analgesic which binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and serotonin. Laparoscopy is a new technique for removing the appendix which involves the use of the laparoscope. CT Scan G. constipation  Ketorolac 30 mg. If an abscess is present. The surgeon enters the abdomen and looks for the appendix which usually is in the right lower abdomen. The Alvarado Score for Acute Appendicitis I. The appendix may be removed in two ways: First is the open method or through appendectomy. the pus can be drained with drains that pass from the abscess and out through the skin. Actual The diagnostic procedure done to the patient were Urinalysis and CBC. Barium Enema F. Laparoscopy H. it is a hypertonic solution which aids in replacement of lost body fluids. Second is Laparoscopic Method.

An additional advantage of laparoscopy is that it allows the surgeon to look inside the abdomen to make a clear diagnosis in cases in which the diagnosis of appendicitis is in doubt. Paat . Her surgeon was Dr. B. For example. she was operated on June 22. laparoscopy is especially helpful in menstruating women in whom a rupture of an ovarian cysts may mimic appendicitis. Her operation begun at 12:50 PM and ended at 1:25 PM.just like the laparoscope. through small puncture wounds. 2009. The benefits of the laparoscopic technique include less post-operative pain (since much of the post-surgery pain comes from incisions) and a speedier return to normal activities..ACTUAL The procedure done to the Patient is Appendectomy.

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