Case Study Acute Appendicitis

Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED
COLLEGE OF NURSING
Case Study:
Acute Appendicitis
Prepared by:
Ramirez, Karylle Joyce T.

Reguyal, Nicole C.
Salvador, Hannah Joy M.
Serrano, Cyrel Claire P.
Soriano, Erwin Daniel C.
S.Y. 2023-2024
Evaluated by:
JUNE CHRISTIAN REGUYAL, MAN, RN
Clinical Instructor, Self-Directed Learning
October 2023
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Transforming Communities through Science and Email: nursing@neust.edu.ph
Technology neustcollegeofnursing@gmail.com
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TABLE OF CONTENTS
Chapter 1
I. General Objectives
II. Specific Objectives
III. Introduction
IV. Patient Data
a. Demographic Profile
b. Medical History
c. Medications
d. Vital Signs
e. Diagnosis and Medical Conditions
f. Treatment Plans
g. Immunization Records
h. Consent Forms
V. Physical Assessment - Head-Toe (in table format)
Chapter 2
I. Definition of Case
II. Anatomy and Physiology
III. Pathophysiology (Book Based)
IV. Clinical Manifestations (Signs and Symptoms)
V. Medical Management
VI. Nursing Management
Chapter 3
I. Clinical Assessments
Chapter 4
I. Nursing Care Plan (ADOPIE) (in table format)
Chapter 5
I. Drug Study (in table format)
Chapter 6
I. Evaluation
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II. Findings
III. Recommendations (METHODS)
List of tables
List of Figures
References
Appendices
Curriculum Vitae
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CHAPTER 1
I. General Objectives
Case presentation seeks to demonstrate the student’s knowledge regarding the general
health and disease condition of a patient with diagnosis process, possible complications,
treatment plan, medical and nursing intervention.
II. Specific Objectives
• Accurately present a thorough general assessment of the client which includes physical
assessment and family history taking.
• Understand the pathophysiology and etiology of the case being presented.
• Understand the role of drug therapy in managing the client related to the patient’s diagnosis.
• Recognize the contributing factors associated in the development of the diagnosis.
• Systematically present the data pertinent to the case being gathered.
• Efficiently provide appropriate and proper nursing diagnosis in line with the client’s medical
condition and skillfully formulate nursing care plans for the problems identified.
• Appropriately apply nursing interventions necessary for the patient’s condition in reference
with the learned theories and concepts of the disease.
• Exhibit mastery and tact in answering relevant questions with a positive attitude towards
criticisms and suggestions.
III. Introduction
The appendix is a small, finger-like appendage attached to the cecum just below the ileocecal
valve. Because it empties into the colon inefficiently and its lumen is small, it is prone to becoming
obstructed and is vulnerable to infection (appendicitis).
According to Stringer (2017), Acute appendicitis is the most common reason for abdominal
surgery in children. Luminal obstruction of the appendix progresses to suppurative inflammation and
perforation, which causes generalised peritonitis or an appendix mass/abscess. Classical features include
periumbilical pain that migrates to the right iliac fossa, anorexia, fever, and tenderness and guarding in
the right iliac fossa. Atypical presentations are particularly common in preschool children. A clinical 4
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diagnosis is possible in most cases, after a period of active observation if necessary; inflammatory
markers and an ultrasound scan are useful investigations when the diagnosis is uncertain. Treatment is by
appendicectomy after appropriate fluid resuscitation, analgesia and intravenous antibiotics. Laparoscopic
appendicectomy is better than open appendicectomy in most cases because it is associated with less
postoperative pain and a shorter hospital stay, but recovery after acute appendicitis is mostly dictated by
whether the appendix was perforated or not.
IV. Patient Data

It was a chilly, evening, in a quiet suburban neighborhood, 32-year-old John Garcia was
blissfully enjoying his dinner when a sudden wave of excruciating pain swept over his abdomen. The
pain was sharp, intense, and seemed to be localized in the right lower quadrant. Doubled over in agony,
he dropped his fork, clutching his stomach.
John had always been a picture of good health. An avid runner, he maintained a balanced diet
and lived a fairly stress-free life. However, tonight, his world had turned upside down. The pain didn't
seem to ease, and soon, it was accompanied by waves of nausea and multiple episodes of vomiting.
John's wife, Emily, grew increasingly worried as she watched her husband's agony unfold.
The next morning, they rushed to the nearest hospital. John had never experienced such pain
before, and his distress was apparent. In the emergency room, the medical team took note of his
symptoms and medical history, which showed that he was usually healthy and rarely had any medical
issues. This abrupt onset of pain, combined with the nausea, vomiting, and low-grade fever, raised
concerns about acute appendicitis.
To confirm the diagnosis, the medical team ordered laboratory tests. The results showed an
elevated white blood cell count and increased C-reactive protein levels. A CT scan was also performed,
revealing an inflamed appendix with signs of an impending rupture.
John was quickly prepped for surgery to remove his inflamed appendix. His surgeon explained
the necessity of the procedure and assured him that it was a routine operation. Despite his anxiety, John
trusted the medical team's expertise and consented to the surgery.
In the operating room, the surgeon skillfully removed John's inflamed appendix, thus preventing
it from rupturing and causing a potentially life-threatening infection. The procedure went smoothly, and
John was on the road to recovery. He spent a few days in the hospital, receiving antibiotics and
monitoring to ensure no complications arose.
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As the days passed, John's strength slowly returned. He began walking around the hospital ward,
grateful for the timely intervention that had saved him from what could have been a much more serious
situation. Emily, who had been his pillar of support throughout the ordeal, watched with relief as her
husband regained his health and vitality.
The episode of acute appendicitis served as a stark reminder of how health can change in an
instant. John's experience taught him to appreciate the value of prompt medical attention and the
dedication of the health care professionals who worked tirelessly to ensure his recovery. It was a story of
resilience and the importance of early intervention in medical-surgical cases.
A. Demographic Profile
· Name: John Garcia
· Age: 32-year-old
· Gender: Male
· Address: suburban neighbourhood,
B. Medical History
· Been a picture of good health. An avid runner, he maintained a balanced diet and lived a fairly stress-free life
healthy and rarely had any medical issues.
C. Medications
· None
D. Vital Signs
· Excruciating pain swept over his abdomen, low-grade fever,
E. Diagnosis and Medical Conditions
· Diagnosis: Acute Appendicitis
· Coexisting condition: inflamed appendix, 6
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F. Treatment Plans
· Quickly prepped for surgery to remove his inflamed appendix.
· Antibiotics and monitoring to ensure no complications arose.
G. Immunization Records
· None
H. Consent Forms
· None
V. Physical Assessment
Body Parts Normal Findings Actual Findings Result
Skull He is alert but distressed due to No neurological abnormalities. Normal

the pain.
no neurological abnormalities.
Scalp • Lighter in color No scars noted. Normal
than the No lesions should
complexion. be noted.
• Can be moist or No tenderness or
oily. masses on
• No scars noted. palpation.
• Free from lice,
nits and dandruff.
• No lesions should
be noted. 7
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• No tenderness or
masses on
palpation.
Hair • Can be black, Neither brittle nor Normal
brown or burgundy dry.
depending on the
race.
• Evenly distributed
covers the whole
scalp (No evidences
of Alopecia)
• Maybe thick or
thin, coarse or
smooth.
• Neither brittle nor
dry.
Face in pain, as evidenced by his facial Appear diaphoretic (sweating) and Abnorma
expressions and restless. l
body movements.
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Eyes • Evenly placed and Evenly placed and Normal
in line with each in line with each
other. other.
• None protruding. • None protruding.
• Equal palpebral • Equal palpebral
fissure. fissure.
The ear lobes are

Ears • The ear lobes are Normal

bean shaped,
bean shaped,
parallel, and
parallel, and
symmetrical.
symmetrical.
• The upper
• The upper
connection of the
connection of the
ear lobe is parallel
ear lobe is parallel
with the outer
with the outer
canthus of the eye.
canthus of the eye.
• Skin is same in
• Skin is same in
color as in the
color as in the
complexion.
complexion.
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Nose and • Nose in the No Discharges. Normal
Paranasal
sinuses midline • No flaring alae
• No Discharges. nasi.
• No flaring alae • Both nares are
nasi. patent.
• Both nares are
patent.
• No bone and
cartilage deviation
noted on palpation.
• No tenderness
noted on palpation.
• Nasal septum in
the mid line and not
perforated.
• The nasal mucosa
is pinkish to red in
color. (Increased
redness turbinates
are typical of
allergy).
• No tenderness
noted on palpation
of the paranasal
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sinuses.
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
Mouth • With visible Normal
Pinkish in color.
margin.

• Symmetrical in
• No edema.
appearance and
movement.
• Pinkish in color.
• No edema.

Neck • No difficulty in Normal
No tenderness along the neck
swallowing.

• No tilting of head.
• No masses, scars.
• Thyroid gland not
visible and
enlarged.
• No stiffness,
swelling, no tight of
neck muscles and
no tenderness along
the neck.
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· Inspection of the chest wall for
Chest symmetry, deformity, and · Percussion of all lung fields for Normal
trauma. normal resonance.
· Palpation of the chest wall for
tenderness.
· Examination of the respiratory
system for signs of distress.
· Auscultation of lung sounds in all
lobes bilaterally for rales,
ronchi, or wheezes.
· Percussion of all lung fields for
normal resonance.
Throrax respiratory distress due to acute Normal

appendicitis,
Abdomen a sudden wave of excruciating inflamed appendix. Abnorma

pain swept over his abdomen. The l
pain
was sharp, intense, and seemed to

be localized in the right lower
quadrant. Doubled over in agony,
he dropped his fork, clutching his

stomach.
Extremities Extremities are atraumatic in Extremities are atraumatic in Normal

appearance without tenderness or appearance without tenderness or
deformity. Extremities are deformity. Extremities are without
without swelling or erythema. swelling or erythema. Full range of
Full range of motion is noted to motion is noted to all joints.
all joints.
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Skin skin is examined for signs of be indicative of a Abnorma
pallor, diaphoresis, or cyanosis, l
worsening condition.
Genital Area Adequate Pubic o presence of Normal
Hair Development Condyloma
(estimate Tanner acuminata,
Stage). Condyloma lata,
• Inguinal Herpes, or Primary
Adenopathy (No Syphilis Lesions)
enlarged nodes)
• No Perineum
Lacerations
• There is No
Vaginal or Urethral
Discharge
• Sexually
Transmitted
Disease (There is
no presence of
Condyloma
acuminata,
Condyloma lata,
Herpes, or Primary
Syphilis Lesions)
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CHAPTER 2
I. Definition of Case
Acute appendicitis is an acute inflammation of the vermiform appendix, most likely caused by blockage
of the appendix lumen (lymphoid hyperplasia, fecalith, normal stool, or infectious pathogens). Acute abdominal
discomfort begins in the middle of the abdomen and eventually localizes to the right lower quadrant where it
typically occurs. This can be from an appendicolith (stone of the appendix) or some other mechanical etiologies.
Appendiceal tumors such as carcinoid tumors, appendiceal adenocarcinoma, intestinal parasites, and
hypertrophied lymphatic tissue are all known causes of appendiceal obstruction and appendicitis. Often, the exact
etiology of acute appendicitis is unknown. When the appendiceal lumen gets obstructed, bacteria build up in the
appendix and cause acute inflammation with perforation and abscess formation. The appendix contains aerobic
and anaerobic bacteria, including Escherichia coli and Bacteroides spp. However, recent next-generation
sequencing studies revealed a significantly higher number of bacterial species in patients with complicated
perforated appendicitis. (Jones, 2023)
In Mr. John’s case, he is in pain and distress as evidenced by his facial grimace and body movements.
For the assessment of vital signs, there is an elevated heart and respiratory rate due to his distress. The signs and
symptoms of acute appendicitis had clearly manifested in him, the waves of nausea, multiple episodes of
vomiting, and low-grade fever. Another, the laboratory showed elevated white blood cell count (WBC) with a
level of 15,800/mm³ (normal range: 4,000-11,000/mm³) and C-reactive protein (CRP) with a level of 18.5 mg/L
(normal range: <5 mg/L). Moreover, the result of John’s CT scan of the abdomen and pelvis with contrast
revealed that there was an inflamed appendix (measuring 1.2 cm in diameter) in the right lower quadrant.
II. Anatomy and Physiology
APPENDIX
An anatomical term for a vestige hollow tube that is closed at
one end and connects to the cecum, the pouch like opening of the large
intestine into which the small intestine discharges its contents, at the
other end is the appendix, also known as the vermiform appendix. It is
unclear whether the human appendix has any useful functions. There are
several possible roles for the GI tract, including housing and maintaining healthy gut flora that can replenish the
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digestive system after an illness that eliminates normal populations of these flora; hosting endocrine cells in the
fetus that produce molecules crucial to maintaining homeostasis; and possibly aiding in immune function during
the first three decades of life by exposing leukocytes (white blood cells) to antigens in the gastrointestine.
The appendix is typically less than 1.3 cm (0.5 inch) wide and 8 to 10 cm (3 to 4 inches) long. The
appendix's cavity is considerably smaller where it connects to the cecum than it is at its closed end. The appendix
possesses muscular walls that are often capable of ejecting any intestinal contents that have managed to get
within the organ, as well as the mucous secretions from the appendiceal walls, into the cecum. Appendicitis may
develop if something obstructs the appendix's opening or prevents it from releasing its contents into the cecum.
A fecalith, or hardened particle of fecal matter, is the most typical impediment in the entrance. The entrance may
potentially become blocked if the appendiceal walls' lining swells. A series of things happen when the appendix
is prevented from emptying by itself. The appendix becomes engorged with fluids and its own mucous
secretions, which causes swelling, edema, and distention of the organ. The appendix's blood arteries seal up as
the distention worsens, which results in the necrosis (death) of appendiceal tissue. In the meantime, the
inflammation gets worse as the bacteria typically present in this region of the intestine start to spread inside the
sealed pocket. The appendix may burst, discharging its contents into the abdominal cavity and infecting the
membranes that line the cavity and cover the abdominal organs because it is weak from necrosis and is under
growing internal pressure from distention. Fortunately, the body's defenses typically stop peritonitis from
occurring. An exudate that typically forms in the areas of inflammation acts like glue and shuts off the inflamed
appendix from the surrounding peritoneal cavity. The omentum, a strip of fatty tissue, frequently wraps itself
around the inflamed appendix.
LARGE INTESTINE
The cecum, colon, rectum, and anus are the traditional four
sections that make up the large intestine, which is the segment of the
intestine at the back. Sometimes the entire big intestine is referred to as
the "colon." The large intestine has a smooth inner wall and is both
broader and shorter than the small intestine (measuring roughly 1.5
meters, or 5 feet, as opposed to 6.7 to 7.6 meters, or 22 to 25 feet).
Enzymes from the small intestine finish the digestion in the proximal,
or upper, portion of the large intestine, where microorganisms also create vitamin K and the B vitamins (B12,
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thiamin, and riboflavin).
However, the large intestine's main job is to store feces until they can be ejected and absorb water and
electrolytes from digestive wastes, a process that typically takes 24 to 30 hours. The large intestine's churning
motions gradually expose digested waste to the absorbent walls. The material is propelled into the anus by an
increasing and more active movement known as the gastrocolic reflex, which only happens two or three times
every day.
CECUM
Cecum, often spelled caecum, is a pouch or big tubelike structure in the lower abdominal cavity that
absorbs undigested food particles from the small intestine and is thought to be the beginning of the large
intestine. The ileocecal valve, also known as the Bauhin valve, which controls the rate of food flow into the
cecum and may aid in preventing material from returning to the small intestine, separates it from the ileum, the
last section of the small intestine.
The cecum's primary roles are to mix its contents with mucus, a lubricant, and to absorb fluids and salts
that are left over after intestine digestion and absorption are complete. A thick mucous membrane makes up the
inside wall of the cecum, through which salts and water are absorbed. A thick layer of muscular tissue that
generates churning and kneading actions lies beneath that lining.
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III. Pathophysiology (Book Based)
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IV. Clinical Manifestations
Abdominal pain is the main sign of appendicitis. Traditionally, this would start as a dull, poorly localized
peri-umbilical pain (caused by visceral peritoneum inflammation), but it will eventually migrate to the right iliac
fossa and become localized and acute (caused by parietal peritoneum inflammation). But patients can present in
many different ways, particularly in kids. Other symptoms include nausea, diarrhoea, anorexia, and vomiting
(which usually occurs after the pain, not before it).
Symptoms of appendicitis may include:

 Sudden pain that begins on the right side of the lower abdomen
 Sudden pain that begins around the navel and often shifts to the lower right abdomen
 Pain that worsens with coughing, walking or making other jarring movements
 Nausea and vomiting
 Loss of appetite
 Low-grade fever that may rise as the illness worsens
 Constipation or diarrhea
 Abdominal bloating
 Gas
Depending on the patient's age and the position of the appendix, the pain's location may change. Due to
the pregnancy's elevated appendix, pain may appear to originate in the upper abdomen.
V. Medical Management
With a lifetime risk of 8.6% for men and 6.9% for women, acute appendicitis is the most prevalent
abdominal surgical emergency worldwide. commonly accepted treatment for appendicitis for more than a
century was an open appendectomy. Appendectomy is the surgical procedure used to treat appendicitis, and it
can be done either openly or laparoscopically. It is now possible to treat uncomplicated appendicitis non-
operatively with antibiotics alone, laparoscopic appendectomy exceeds open appendectomy in popularity, and
some patients with perforated appendicitis may benefit from initial antibiotic therapy followed by interval
appendectomy.
Nonperforated appendicitis, also known as simple or uncomplicated appendicitis, is acute appendicitis
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that manifests without radiographic or clinical symptoms of perforation (such as an inflammatory mass,
phlegmon, or abscess). At the time of presentation, appendicitis occurs in around 80% of cases without
perforation. Antibiotics are given to patients as part of a nonoperative treatment plan to prevent surgery.
Appendectomy is only performed on these patients if they do not respond to antibiotics or experience a
recurrence of appendicitis. Patients with perforated appendicitis may appear critically unwell, and have severe
electrolyte imbalances and dehydration, especially if fever and vomiting have been present for a while. The
course of treatment for perforated appendicitis is determined by the patient's status (stable versus unstable), the
kind of perforation (contained versus free), and the presence or absence of an abscess or phlegmon on imaging
examinations. Anticoagulation should be quickly reversed before surgery since appendectomy is a true surgical
emergency and can involve a significant risk of bleeding in individuals who are unstable or readily perforated.
VI. Nursing Management
A. Pre-operative Surgery Nursing Interventions
The patient must be ready several hours before the operation, according to the nurse. To guarantee a
successful procedure and a favorable result after surgery, the primary objective at this time is often to sufficiently
prepare the patient for surgery (appendectomy). However, if necessary, the patient may undergo a brief health
assessment. Taking the appropriate action after admission will assist in identifying symptoms that were absent at
admission and those overlooked during normal care following admission. For instance, the patient may be
dehydrated as a result of ongoing nausea and vomiting or maybe worried as a result of not receiving enough
information about their illness and the procedure. As a result, the nurse is expected to act appropriately while
continuously monitoring the patient.
B. During Surgery
In addition to directly supporting the surgeon during surgery, the nurse also serves as the scrub nurse,
instrument nurse, or circulation nurse. The instrument nurse also referred to as the scrub nurse, establishes the
sterile field while adhering to strict aseptic procedures. The scrub nurse hands the surgeon's surgical instruments
during the procedure and helps the surgeon scrub and get dressed in theatre attire. As part of the sterile team, the
instrument nurse puts on gloves, scrubs, and gowns for the surgical process. She is in charge of setting up and
giving the surgeon sterile supplies and equipment.
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The operating room is kept sterile by the circulating nurse, who also supervises nursing care during the
procedure. Making sure surgical asepsis is followed during the surgical operation, keeping track of and
conducting an inventory of the materials and equipment utilized throughout and after the surgical procedure, or
calling a timeout are all examples of responsibilities. The contact between the patient, the patient's family, and
the medical staff is also performed by an operating nurse. The nurse can also serve as an anesthetic; she or he
evaluates the patient, administers anesthesia, and keeps a careful eye on the patient throughout the operation.
C. Post-operative Surgery Nursing Interventions
Following surgery, the nurse typically compiles a list of the patient's concerns by performing a modified
health assessment. An assessment has the benefit of enabling the nurse to evaluate the surgical patient in more
detail in time. If a symptom appears or the patient exhibits any signs of discomfort, a problem-focused
assessment may be carried out. A particular injury or medical condition, as well as vital indicators such as blood
pressure, pulse, respirations, skin signs, and pupils, are the main subjects of the health assessment. The nurse
concentrates the physical examination on that specific injury or new complaint when performing the focused
health assessment. In general, only the desired bodily area or system is evaluated during an individual's physical
examination.
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CHAPTER 3
I. Clinical Assessments
Clinical assessments for appendicitis include a physical examination, blood tests, urine tests, and
imaging tests such as ultrasound or computed tomography (CT) scans. The physical examination involves
checking for signs of inflammation in the abdomen, such as tenderness or swelling. Right lower quadrant pain,
abdominal rigidity, and periumbilical pain radiating to the right lower quadrant are the best signs for ruling in
acute appendicitis in adults. Blood tests like Complete blood count (CBC) can help detect signs of infection.
Imaging tests can help visualize the appendix and detect any abnormalities.
Normal range/Reference
Component/Parameter Actual findings Interpretation
range
Complete Blood Count The result is higher

4,000-11,000/mm3 15,800/mm3
(CBC) than normal range.
The result is higher

Neutrophils 40-70% 80%
than normal range.
The result is lower

Lymphocytes 20-40% 15%
than normal range.
The result is in normal

Hemoglobin (Hb) 13.5-17.5 g/dL 13.4 g/dL
range.
The result is in normal
Platelet Count 150,000-450,000/mm3 220,000/mm3
range.
The result is higher

C-Reactive Protein (CRP) <5 mg/L 18.5 mg/L
than normal range.
1.2 cm in
Imaging (CT scan) 0.6 cm in diameter Inflamed appendix
diameter
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CHAPTER 4
I. Nursing Care Plan for Acute Appendicitis
NURSING
ASSESSMENT OUTCOME PLANNING INTERVENTION EVALUATION
DIAGNOSIS
Subjective: Acute pain At the end of 2 Short-term goal: Independent Short-term goal:
“Masakit ang kanang related to days of nursing After 4 hours of After 4 hours of
bahagi ng tiyan ko inflammation and intervention, the nursing Monitor and document the nursing intervention,
nahihirapang ako
distention of the patient will intervention, the characteristics of the client's the patient was able
kumilos dahil sa sakit” as
appendix as verbalize relief patient will pain, including location, to verbalize relief of
verbalized by the patient
evidenced by and minimal signs verbalize relief of intensity, duration, and any pain
severe abdominal of pain in the right pain from 9/10 to factors that worsen or alleviate At 6/10 pain scale
Pain scale: 9/10 pain, lower quadrant 6/10 pain scale. the pain as much as possible. from 9/10
guarding abdomen.
Objective: tenderness in the Long-term goal: Rationale: For the patient’s Goal was fully met.
 Severe abdominal right lower After 2 days of baseline data and to monitor
pain quadrant nursing the recurrence of pain Long-term goal:
 Guarding tenderness intervention, the After 2 days of
in the right lower patient will show Position the client in a right nursing intervention,
quadrant minimal signs of lateral decubitus position with the patient showed
 Vital signs: pain and slight hip flexion, and provide minimal signs of pain
T: 37.8°C tenderness in the a quiet and resting environment and tenderness in the
PR: 105 bpm right lower right lower quadrant
RR: 25 bpm quadrant Rationale: To give adequate abdomen.
BP:130/80 mmHg abdomen. comfort and relaxation
Goal was fully met
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Provide information about the
surgical procedure, including
the purpose, expected
outcomes, and potential risks
and side effects. Assist with
pre-operative procedures, such
as maintaining NPO status,
obtaining informed consent,
prepping the client, and
administering pre-operative
medications.
Rationale: To give emotional

support and reduce anxiety in
preparing for surgery.
Dependent
Administer prescribed
antibiotic medications
(Metronidazole and
Ceftriaxone)
Rationale: To relieve pain and

promote client comfort.
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CHAPTER 5
I. Drug Study
DRUG AND Ceftriaxone (Cephalosporins)

CLASSIFICATION
INDICATION Used to treat a wide variety of bacterial infections.
MECHANISM OF ACTION Cefazolin binds to 1 or more of the penicillin-binding

proteins (PBPs) which inhibit the final transpeptidation step of peptidoglycan
synthesis in bacterial cell walls, thus inhibiting biosynthesis and arresting cell
wall assembly resulting in bacterial cell death.
PHARMACOKINETICS Absorption: Well absorbed (IM). Time to peak plasma concentration: 2-3 hours
(IM).
Distribution: Widely distributed in the body including gallbladder, lungs, bone,
bile, and CSF (higher concentrations when the meninges are inflamed). Crosses
the placenta; enters breast milk (low concentrations). Volume of distribution:
Approx 6-14 L. Plasma protein binding: Approx 85-95%.
Excretion: Via urine (approx 40-65% as unchanged drug); faeces (as inactive
drug). Elimination half-life: Approx 5-9 hours.
DOSAGE AND Adult: 1-2 g as a single dose given 30 minutes to 2 hours before surgery via slow
ADMINISTRATION IV inj over 5 minutes, IV infusion over at least 30 minutes, or deep IM inj.
For IM doses, not more than 1 g must be administered at one site. Consideration
must be given to local treatment guidelines.
CONTRAINDICATIONS Hypersensitivity to ceftriaxone, other cephalosporins, or history of severe

hypersensitivity reaction to any other type of β-lactam antibiotic (e.g. penicillins,
monobactams, carbapenems). Premature neonates up to a postmenstrual age of
41 weeks (gestational age and chronological age); full-term neonates (up to 28
days of age) with hyperbilirubinemia, jaundice, hypoalbuminemia, or acidosis,
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and if they require IV Ca treatment or Ca-containing infusions. IV administration
of ceftriaxone solutions containing lidocaine.
PRECAUTIONS AND Patient with history of non-severe hypersensitivity to other β-lactam agents,
WARNINGS history of gastrointestinal disease (particularly colitis) or renal lithiasis;
hypercalciuria, impaired vitamin K synthesis or low vitamin K stores (e.g.
malnutrition, chronic hepatic disease); risk factors for biliary stasis and sludge
(e.g. preceding major therapy, severe illness and TPN). Severe renal and hepatic
impairment. Neonates and children. Pregnancy and lactation.
ADVERSE EFFECTS AND Significant: Biliary lithiasis, gallbladder sludge, pseudolithiasis, pancreatitis
SIDE EFFECTS (possibly secondary to biliary obstruction), renal lithiasis (reversible),
urolithiasis, acute renal failure; Jarisch-Herxheimer reaction, encephalopathy,
kernicterus in neonates; fungal or bacterial superinfection (prolonged use).
Rarely, increased INR (particularly during prolonged use, or in patients with
nutritional deficiency, renal and hepatic impairment).
DRUG INTERACTION May increase the risk of bleeding with vitamin K antagonists (e.g. warfarin).
May increase the nephrotoxicity of aminoglycosides. May diminish the
therapeutic effects of BCG, typhoid vaccine, and Na picosulfate.
Potentially Fatal: May cause precipitation of ceftriaxone-Ca in the lungs, kidneys
or gallbladder when administered simultaneously with Ca-containing IV
solutions or infusions (e.g. Ringer's solution, Hartmann's solution, TPN) even at
different infusion lines or sites.
PATIENT EDUCATION Notify physicians immediately of signs of superinfection, including black, furry
overgrowth on tongue, vaginal itching or discharge, and loose or foul-smelling
stools.
Purpose of medication: to prevent surgical site infection
MONITORING AND Perform culture and susceptibility tests; consult local institutional
EVALUATION recommendations before treatment initiation due to antibiotic resistance risks.
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Monitor prothrombin time/INR, renal function tests, and LFTs; CBC regularly
during prolonged use. Assess for signs and symptoms of hypersensitivity
reactions (especially anaphylaxis) during the 1st dose, haemolytic anaemia, and
pancreatitis.
NURSING Assessment
CONSIDERATIONS
Weight
Vital signs
Fluid intake and output
Laboratory test results: CBC, renal and hepatic function, electrolytes
Monitoring / interventions
Ensure adequate hydration
Patient IV
Indwelling urinary catheter
Confirm ordered dose
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Monitor
Insertion site for extravasation
Hypersensitivity reaction
Vital signs
Urine output
Evaluate therapeutic response: absence of postoperative surgical site;

approximated wound edges, infection, stable vital signs
DRUG AND Metronidazole (Nitroimidazole)

CLASSIFICATION
INDICATION Metronidazole is an antibiotic that is used to treat various infections caused by

bacteria or parasites
MECHANISM OF ACTION Metronidazole diffuses into the organism, inhibits protein synthesis by
interacting with DNA, and causes a loss of helical DNA structure and strand
breakage. Therefore, it causes cell death in susceptible organisms.
PHARMACOKINETICS Absorption:
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Bioavailability: 80% absorption from GI tract (PO)
Protein binding: (<20%)
Peak serum time: 1-2 hr
Distribution: Widely distributed; similar pattern for PO and IV
Elimination: Urine (77%); Feces (14%)
DOSAGE AND Loading dose: 15 mg/kg IV once as a single dose

ADMINISTRATION Maintenance dose: 7.5 mg/kg IV or orally every 6 hours
Maximum dose: 4 g/day
Usual duration of therapy: 7 to 10 days
CONTRAINDICATIONS Metronidazole is contraindicated in patients with documented hypersensitivity to

the drug or its components, and it should be avoided in first-trimester pregnancy.
Patients should also avoid consuming alcohol or products containing propylene
glycol while taking metronidazole and within three days of therapy completion.
Metronidazole is likewise contraindicated if there has been recent disulfiram use
within the past two weeks.
PRECAUTIONS AND To reduce the development of drug-resistant bacteria, do not use metronidazole
WARNINGS to treat any condition that has not been checked by the doctor. Seizures and other
nervous system abnormalities have been reported in patients treated with
metronidazole. You should stop using this medicine immediately if you
experience any neurological symptoms such as seizures, headaches, visual
changes, weakness, numbness, or tingling.
.
ADVERSE EFFECTS AND The primary adverse effects of metronidazole include confusion, peripheral
SIDE EFFECTS neuropathy, metallic taste, nausea, vomiting, and diarrhea. Adverse events seen
in greater than 10% of the population include headache (18%), vaginitis (15%),
and nausea (10% to 12%). Adverse events affecting less than 10% of the
population are metallic taste (9%), dizziness (4%), genital pruritus (5%),
abdominal pain (4%), diarrhea (4%), xerostomia (2%), dysmenorrhea (3%),
urine abnormality (3%), urinary tract infection (2%), bacterial infection (7%),
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candidiasis (3%), flu-like symptoms (6%), upper respiratory tract infection (4%),
pharyngitis (3%), and sinusitis (3%).
DRUG INTERACTION Metronidazole is a medication that can treat certain infections, but it can also
interact with alcohol and other drugs. Some of the drugs that may interact with
metronidazole include alcohol that can cause abdominal cramps. Nausea,
vomiting, headaches, and flushing.
Disulfiram, which can cause psychotic reactions
Warfarin and other anticoagulants, which can cause bleeding problems
Astemizole, busulfan, cimetidine, lithium, phenytoin, and phenobarbital, which
can affect the metabolism of metronidazole or vice versa
PATIENT EDUCATION Do not drink alcohol or consume foods or medicines that contain propylene
glycol while you are taking metronidazole and for at least 3 days after taking it.
Report severe GI upset, dizziness, unusual fatigue or weakness, fever, chills.
Report if there are seizures, changes in vision, numbness or tingling of the

fingers or toes.
MONITORING AND During and after prolonged therapy or repeated courses, complete blood count
EVALUATION (CBC) with differential requires monitoring. Carefully observe patients for the
onset of neurologic symptoms and consider discontinuing metronidazole when
or if new neurologic symptoms occur. Elderly patients and previously diagnosed
patients with severe hepatic impairment and/or end-stage renal disease should
also be monitored closely.
NURSING Assess for infection before and during treatment

CONSIDERATIONS
Monitor neurologic status: parasthesia, weakness, ataxia, or seizures
Monitor intake and output, daily weights.

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CHAPTER 6
I. Evaluation
The outcome and goal assessment of the nursing care plan is “At the end of 2 days of nursing
intervention, the patient will verbalize relief and minimal signs of pain in the right lower quadrant abdomen.”
This proved the effectiveness of nursing implementation followed by the performed surgery.
For the short-term goal, “After 4 hours of nursing intervention, the patient will verbalize relief of pain from 9/10
to 6/10 pain scale.” The pain does not go away that easily which is why the focus is to at least lessen the pain that
the patient is feeling for comfort and relaxation.
On the other hand, the long-term goal is, “After 2 days of nursing intervention, the patient will show
minimal signs of pain and tenderness in the right lower quadrant abdomen.” After the appendix has been
removed, pain may still be at present but the severe pain the patient has experienced before has already been
reduced through the surgery.
Fortunately, the condition has been taken into action earlier and does not lead to any complications. This
can be a reminder that health matters more than we could ever think of. We do not have to wait for the time that
our life will be taken for granted, but hence, make our lifestyle healthier than ever before.
II. Findings
The focus of nursing care is patient-centered as shown through assessment, planning, and interventions.
Evaluating the patient's response to care and interventions is one of the main goals of the evaluation process. In
order to determine if a patient's condition is getting better, becoming worse, or staying stable, nurses routinely
check and assess the patient's vital signs, symptoms, and other clinical indicators. The principle of nursing
interventions' effectiveness is elaborate and encompasses a number of activities, including patient-centered care,
evidence-based decision-making, ongoing assessment and evaluation of care, safety, and cooperation. Best
nursing care raises the bar for healthcare delivery, improves patient outcomes, and increases care quality.
In Mr. John’s surgery journey, through the emotional support of his wife and a leap of faith, surgery has
been successfully performed by doctors. John’s resiliency and positive mindset changed his life to be able to
recover. A person’s will can make a difference to fulfill his goal. A manifestation can only happen if he walks his
talk.
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III. Recommendations (METHODS)
Medications
Oral antibiotics must be administered up to a total of seven to ten days after the initial intravenous
antibiotics for one to three days. Antibiotic selection is not standardized; nevertheless, for low-risk intra-
abdominal infections obtained in the community, one of our intravenous regimens should be enough. Early
discharge may be made possible by the administration of metronidazole and a long-acting medication, such as
ceftriaxone. Higher doses of antibiotics should be used in higher-risk individuals, whereas standard dosages
should be given in lower-risk patients who are not obese and have normal renal or hepatic function. When
treating pain in patients suspected of having acute appendicitis, acetaminophen and nonsteroidal anti-
inflammatory medications (NSAIDs) should be taken into consideration, particularly if the patient is not suitable
for opioid therapy.
Recent data indicates that in certain patients with simple appendicitis, antibiotic therapy may be the first-
line and even the only treatment option. Since intravenous antibiotics have a high incidence of resolution
compared to open and laparoscopic appendectomies, antibiotic therapy should be regarded as a viable treatment
option for both adults and children.
Given the level of pain that most people with acute appendicitis will feel, analgesic therapy should be a
part of the therapeutic strategy. The use of analgesics had historically been avoided due to worries that their
therapeutic effects would conceal appendicitis symptoms.
Exercise
Following an appendectomy, patients should take it easy and refrain from any activities that can cause
discomfort for the first two to four weeks. At this time, overtraining is not encouraged. Additionally, for a period
after the appendectomy, he or she should avoid hard lifting. Be aware that for at least a week following surgery,
may have pain and feel weary. Try taking a short stroll several times a day as the first type of exercise; this will
not only enhance your cardiovascular health but also lower the risk of blood clots. The doctor will determine
when to start exercising again after having the surgery. See a doctor before starting any new fitness regimen in
case someone experiences any health issues. Remember that starting too early could be risky and that getting
enough sleep is essential for tissue healing. When a patient decides to begin exercising, start with something as
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easy as walking and progress to higher-level workouts as the body adjusts.
Treatment
The standard method of treatment for acute appendicitis is appendectomy, which can be performed by
laparoscopy or open laparotomy via the right lower quadrant incision. Uncomplicated appendicitis can be treated
with laparoscopy, a procedure that involves inserting a thin tube into the belly through a tiny incision known as a
laparotomy. When an advanced infection or abdominal abscess accompanies complicated appendicitis, an open
appendectomy may be necessary.
A laparoscopic appendectomy had a longer recovery period but a lower rate of wound infection, fewer
postoperative complications, a shorter duration of stay, and a quicker return to normal than an open laparotomy.
Health Teaching
To prevent an infection, it's necessary to keep the wound dry and clean. Before contacting the incision,
thoroughly wash your hands, and then replace the dressing as prescribed. Consult the doctor if it's unclear
whether to take a shower, bath or soak. If the patient is having any problems, please call the doctor right away.
Possible problems include coughing, shortness of breath, chest pain, increased abdominal pain, fever, chills,
edema, increased discomfort, and excessive bleeding at the site of the incision.
OPD Instructions
According to Di Saverio et al. (2020), acute abdominal pain accounts for 7–10% of all emergency
department accesses. Acute appendicitis (AA) is among the most common causes of lower abdominal pain
leading patients to attend the emergency department and the most common diagnosis made in young patients
admitted to the hospital with an acute abdomen. A person should go to the emergency department right away if
they think they have acute appendicitis. The patient's temperature, pulse, breathing pattern, and blood pressure
will all be recorded following their arrival at the hospital. The patient will be brought as soon as possible to the
operating room if the surgeon believes the appendix is displaying signs of rupture. Before a decision to operate
may be made in cases where the diagnosis is less certain, more testing utilizing techniques like CT scans or
ultrasounds as well as blood tests may be required. A rectal examination can show tenderness, although this does
not necessarily mean that appendicitis is present. A diagnosis of acute appendicitis can be made most reliably by
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percussion discomfort, guarding, and rebound tenderness.
Diet
Concerning foods to avoid, do not worry. Appendicitis cannot be prevented, worsened, or helped by any
one meal. If they can stomach it, patients can resume their regular diets after surgery. If eating produces nausea,
gas, or pain in the abdomen, bland food is recommended.
Spirituality
Insight State (2021) stated, “Morally, appendicitis represents the suffering that comes with change for
people who see themselves as an "appendix" in their families or among their friends. Letting go of suppressed
emotions, particularly those connected to solitude, is one treatment before ingravescence (when surgery is
necessary). According to Siska Natalia (2016), “Patients who are spiritually well are those who are looking for
life's meaning and purpose. Both physically and spiritually, patients with life-threatening illnesses endure
distress. Finding current research on spiritual therapies that support nurses in promoting spiritual health in light
of patients' needs in hospital settings is important.
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REFERENCES
Department of Health & Human Services. (n.d.). Appendectomy. Better Health Channel.
https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/appendectomy#immediately-after-
appendectomy
Di Saverio, S., Podda, M., De Simone, B., Ceresoli, M., Augustin, G., Gori, A., Boermeester, M. A., Sartelli, M.,
Coccolini, F., Tarasconi, A., De Angelis, N., Weber, D., Tolonen, M., Birindelli, A., Biffl, W. L., Moore, E. E.,
Kelly, M. E., Søreide, K., Kashuk, J. L., . . . Catena, F. (2020). Diagnosis and treatment of acute appendicitis:
2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery, 15(1).
https://doi.org/10.1186/s13017-020-00306-3
Eta, V. E. (2023). Nursing Management of Patients with Appendicitis. IntechOpen.

https://doi.org/10.5772/intechopen.1001067
Humes, D. J., & Simpson, J. (2006). Acute appendicitis. BMJ, 333(7567), 530–534.
https://doi.org/10.1136/bmj.38940.664363.ae
Insight State. (2021, March 14). Appendicitis – Spiritual Meaning, Symptoms, Causes and Prevention.
https://www.insightstate.com/health/appendicitis/
Jones, M. W. (2023, April 24). Appendicitis. StatPearls - NCBI Bookshelf.

https://www.ncbi.nlm.nih.gov/books/NBK493193/
Management of acute appendicitis in adults - UpToDate. (n.d.). UpToDate.

https://www.uptodate.com/contents/management-of-acute-appendicitis-in-adults#H26003216
SingleCare. (2021, November 17). Appendicitis treatment and medications. SingleCare.

https://www.singlecare.com/conditions/appendicitis-treatment-and-medications
Sophie. (2023, April 16). When can I exercise after appendectomy? Southlake General Surgery.
https://www.southlakegeneralsurgery.com/when-can-i-exercise-after-appendectomy/
Snyder, M. J. (2018, July 1). Acute Appendicitis: Efficient Diagnosis and Management. AAFP.
https://www.aafp.org/pubs/afp/issues/2018/0701/p25.html
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Case Study Acute Appendicitis

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Case Study Acute Appendicitis

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Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

Ramirez, Karylle Joyce T.

JUNE CHRISTIAN REGUYAL, MAN, RN

Clinical Instructor, Self-Directed Learning

Contact No. (044) 600-3970

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II. Specific Objectives

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IV. Patient Data

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· Name: John Garcia

· Address: suburban neighbourhood,

· Excruciating pain swept over his abdomen, low-grade fever,

E. Diagnosis and Medical Conditions

· Diagnosis: Acute Appendicitis

· Coexisting condition: inflamed appendix, 6

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· Quickly prepped for surgery to remove his inflamed appendix.

· Antibiotics and monitoring to ensure no complications arose.

Body Parts Normal Findings Actual Findings Result

Skull He is alert but distressed due to No neurological abnormalities. Normal

Scalp • Lighter in color No scars noted. Normal

than the No lesions should

• Can be moist or No tenderness or

• No scars noted. palpation.

• Free from lice,

nits and dandruff.

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Hair • Can be black, Neither brittle nor Normal

brown or burgundy dry.

covers the whole

scalp (No evidences

• Neither brittle nor

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in line with each in line with each

• None protruding. • None protruding.

• Equal palpebral • Equal palpebral

The ear lobes are

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• No flaring alae • Both nares are

• Both nares are

the mid line and not

• The nasal mucosa

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• Thyroid gland not

neck muscles and

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Throrax respiratory distress due to acute Normal

Abdomen a sudden wave of excruciating inflamed appendix. Abnorma

was sharp, intense, and seemed to

he dropped his fork, clutching his

Extremities Extremities are atraumatic in Extremities are atraumatic in Normal

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Genital Area Adequate Pubic o presence of Normal

Hair Development Condyloma

(estimate Tanner acuminata,

Stage). Condyloma lata,

• Inguinal Herpes, or Primary

Adenopathy (No Syphilis Lesions)

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II. Anatomy and Physiology

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