Download Appendectomy

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I. Introduction
As part of the health care team, it is very much challenging and critical for
us student nurses, to care for the patient with Appendicitis, since patient deserve
the ultimate care a nurse can render. The student nurse chose this disease as
her case study because she was curious of how this disease develop, from
simple tummy ache that can lead to death in just small span of time. This case
study also serves as a knowledge experience of the student nurse for her to be
able to utilize in the future if she will encounter the same disease. Above all,
among the definitions of Appendicitis the student nurse encountered, fatality is
very much attached to it, and because of this, the student nurse is very much
aware what the disease can do to the patient and that she needs to give her
optimum care.
Appendectomy is a surgical intervention, which involves the removal of the
appendix within 24 to 48 hours of the onset of manifestations in a patient who is
experiencing appendicitis. It is done as soon as possible to decrease the risk of
perforation.
The surgery is performed through a small open incision or a
laparoscope (a lighted scope used to visualize and remove the appendix) or
through a low abdominal incision under general or spinal anesthesia. When the
operation is performed in time, the mortality rate is less than 0.5%. Delay usually
causes rupture of the organ and resultant peritonitis. The primary goal of
treatment for patient’s undergoing appendectomy is the prevention of
complications such as perforation of the appendix which may lead to peritonitis. It
is also performed to remove an inflamed appendix. The surgeon cuts through
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layers of skin, fat, and muscle, and the peritoneal membrane that lines the
abdomen to reach the appendix, which is attached to the caecum, a rounded
pouch at the beginning of the large intestine. The caecum and appendix are lifted
out of the abdominal cavity through the incision. After tying off the blood vessels
in the base of the appendix, the surgeon cuts off the body of the appendix and
sutures the stump. The caecum and stump are then tucked back into the
abdominal cavity, and the incision is closed.
The student nurse also chose this case study to improve her management
skills to patients undergoing appendectomy. This will help her develop the use of
the nursing process appropriate in the care of such patients.
Expectations from this case study would include broadening the
knowledge and development of the student’s nurse skills about pre – operative
and post – operative management to a patient undergoing this surgical
procedure. This will also harness her decision making ability appropriate to the
care of such patients. And this will also help her in understanding the nature of
the operation, its complications, and measures that promote the quality of life that
patients deserve undergoing this surgical procedure.
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II. Objectives
Student- Nurse Centered
General
After 2 days of rendering holistic nursing care, the student nurse will be
able to develop and improve her knowledge, attitude, and skills in the care of a
patient who has undergone appendectomy.
Specific
After 2 days of rendering holistic nursing care, the student nurse will be
able to:
1. establish rapport with the patient
2. perform a thorough nursing assessment of the patient who has undergone
appendectomy
3. identify nursing problems experienced by the patient
4. discuss the following:
4.1the anatomy and physiology of the organ affected in
appendectomy
4.2 normal level of growth and development of patient and the ill
patient at particular age
5. impart health teaching regarding appendectomy as to its :
5.1complications
5.2 predisposing factors
5.3 management
6. trace the pathophysiology of the organ affected in appendectomy
7. formulate a comprehensive nursing care plan for the patient and implement it
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8. utilize the nursing process in caring patients who has undergone
appendectomy
9. terminate interaction with the patient
10. evaluate the effectiveness of care given to the patient
Patient Centered
General
After 2 days of student nurse-client interaction, the patient and family will
be able to gain knowledge, attitude, and skills in the care of a patient who has
undergone appendectomy.
Specific
After 2 days of student nurse – client interaction, the patient and family will
be able to :
1. establish and gain communication with the student nurse
2. identify the complications of appendectomy
3. verbalize feelings and concerns
4. develop a modified lifestyle appropriate before and after the surgical
operation
5. take appropriate measures for the pre-operative and post-operative
management of appendectomy
6. follow specific treatment regimen ordered or taught
7. demonstrate beginning skills in the management before and after the surgical
operation
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III. Nursing Assessment
1. Personal History
1.1 Patient’s Profile
Name: Mr. Cuizon, Demetrio
Age: 47 years old
Sex: Male
Civil Status: Married
Religion: Roman Catholic
Date of Admission: Jan 13, 2006
Hospital No.: 630359
Admission No.: 630359
Room no.: MS9
Chief complaint: Periumbilical Pain
Admitting Impression: Acute Appendicitis
Final Diagnosis: Ruptured Appendix with Periappendiceal Abscess
Physician: Dr. Embay, Selwyn
1.2 Family and Individual information, Social & Health History
Mr. Cuizon, Demetrio, 43 years of age, married with five siblings, is a
Roman Catholic & a Filipino citizen, and lives in Canasujan carcar cebu,
admitted in Cebu Doctors’ Unversity Hospital for the first time due to
periumbilical pain.
He is a non-hypertensive, non-diabetic, and is not asthmatic. The
patient does not have any history of food or drug allergies. He is a cigarette
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smoker (5 sticks per day) and drinks alcoholic beverages such as tanduay
and beer na beer. He has no history of heredofamilial diseases such as
hypertension, CVA, myocardial infarction and atherosclerosis. He has no
previous hospitalization.
The patient had sudden onset of periumbilical pain, sharp, on and off,
at times radiating to epigastric and right upper quadrant area. This
happened six days prior to admission. It was not associated with food
intake, no vomiting but with anorexia. It was also associated with
constipation for three days. So, he consulted a physician and was given
unrecalled medicines for pain relief. But persistence of condition prompted
the patient to seek further management here in Cebu and thus sought
consult with attending physician in Cebu Doctors’ University Hospital and
was admitted in the said institution.
1.3 Level of Growth and Development
1.3.1 Normal Development at Particular Stage
(Middle-Aged Adulthood 40-65)
Physical Development
A number of changes take place during the middle years. At 40, most
adults can function as effectively as they did in their twenties. However,
during ages 40 to 65, many physical changes take place.
Both men and women experience decreasing hormonal production
during the middle years. The menopause refers to the so-called change of
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life in women, when menstruation ceases. It is aid to have occurred when
a woman has not had a menstrual period within a year. The menopause
usually occurs anywhere between ages 40 and 55.
The climacteric (andropause) refers to the change of life in men, when
sexual activity decreases. In men, there is no change comparable to the
menopause in women. Androgen levels decrease very slowly; however,
men can father children even in late life.
Sexuality
After the departure of their last child from the home, many couples
recultivate their relationships and find increased marital and sexual
satisfaction during middle age. The onset of menopause and the
climacteric can affect the sexual health of middle adult. A woman may
desire increased sexual activity because pregnancy is no longer possible.
During middle age a man may notice changes in the strength of his
erection and a decrease in his ability to experience repeated orgasm.
Other factors influencing sexuality during this period include work, stress,
diminished health of one or both partners, and the use of prescription
medications, for example, antihypertensive agents, with side effects that
may influence sexual desire or functioning. Both partners may experience
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stresses related to sexual changes or a conflict between their sexual
needs and self-perceptions and social attitudes or expectations.
Psychosocial Development
Erikson viewed the development choice of the middle adult as
generativity versus stagnation. Generativity is defined as the concern for
establishing and guiding the next generation. In other words, there is
concern about providing welfare of humankind that is equal to the concern
of providing for self. People in their 20s or 30s tend to be self and family
centered. In middle age, the self seems more altruistic actions, such as
church work, social work, political work, community fund raising drives and
cultural endeavors. Marriage partners have more time for companionship
and recreation; thus marriages are more satisfying in the middle years of
life. Generative middle-aged people are able to feel a sense of comfort in
their lifestyle and receive gratification from charitable endeavors. Erikson
believes that persons who are unable to expand their interest at this time
and who do not assume the responsibility of middle age adult may suffer a
sense of boredom and impoverishment that is stagnation. These people
have difficulty accepting that their aging bodies and become withdrawn
and isolated. They are preoccupied with their self and unable to give to
others.
The middle-aged person looks older and feels older. People usually
accept the fact that they are aging, however a few try to defy the years by
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their dress and even their actions. Some men and women have
extramarital affair and marry younger partners. A new freedom to be
independent and follow one’s individual interest arises. Prior to this period,
the marriage partner or lover and other person were crucial to the
definition of self. Now the middle-aged person who does not make
comparison with others, no longer fears aging or death relaxes the sense
of competitiveness and enjoys independence and freedom. Other people’s
opinion becomes less important, and the earlier habit of trying to please
everybody is overcome. The person establishes ethical and moral
standards that are independent of the standards of others. The focus
shifts from inner self and being to others and doing. Religious and
philosophical concerns become important.
Hultsch and Deutsch suggest that it is not the events themselves
that make midlife a crisis, but an individual’s response to these life events.
How will an individual respond? According to Hultsch and Deutsch, the
resources of the person, the ability to use effective coping strategies, and
the life stage at which an event occurs will influence any changes in
behavior. Internal and external resources include physical health, family
income, the social support system, intelligence and personality. Thus, the
crisis or transitions of middle are not just within the individual but also
between the individual and the individual’s world.
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Cognitive Development
The middle-aged adult’s cognitive and intellectual abilities change
very little. Cognitive process includes reaction time, memory, perception,
learning, problem solving and creativity. Reaction time during the middle
years stays much the same or diminishes during the latter part of the
middle years. Memory and problem solving are maintained through middle
adulthood. Learning continues and can be enhanced by increased
motivation at this time in life.
Middle-aged adults are able to carry out all the strategies described
in Piaget’s phase of formal operation. Some may use post-formal
operation strategies to assist them in understanding the contradictions that
exist in both personal and physical aspects of reality. The experiences of
the professional, social and personal life of middle-aged persons will be
reflected in their cognitive performance. Thus, approaches problem
solving and task completion will vary considerably in middle aged groups.
The middle-aged adult can reflect on the past and current experience and
can imagine, anticipate, plan and hope.
Moral Development
According to Kohlberg, the adult can move beyond the conventional
level to the postconventional level. Kohlberg believes that extensive
experience of personal moral choices and responsibility is required before
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people can reach the postconventional level. Kohlberg found that few of
his subjects achieved the highest level of moral reasoning. To move from
stage 4, a law and order orientation, to stage 5, a social contract
orientation, requires that the individual move to a stage in which rights of
others take precedence. People in stage 5 take steps to support other’s
rights.
Spiritual Development
Not all adults progress through Fowler’s stages to the fifth,
called the paradoxical-consolidative stage. At this stage, the individual can
view “truth” from a number of viewpoints. Fowler’s fifth stage corresponds
to the Kohlberg’s fifth stage of moral development. Fowler believes that
only some individuals after the age of 30 years reach this stage.
In middle age, people tend to be less dogmatic about religious
beliefs, and religion often offers more comfort to the middle-aged person
than it did previously. People in this age group often rely on spiritual
beliefs to help them deal with illness, death, and tragedy.
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1.3.2 The Ill Person At Particular Stage
The middle adult may not present in a "classical" manner. Altered
response to illness is common. Social and psychological factors may
further obscure this "classical" presentation. Frequently the presentation is
that of the "geriatric giants": confusion, falls, immobility and incontinence.
Each of these "giants" is an indication for a more detailed assessment.
Presentation may also be delayed because of various fears (such as that
of hospitalization), loss of faith in the health care system, denial or
depression. Illness response to even appropriate treatment may not
always show the same dramatic recovery as in the young, thereby also
impacting on the functional status.
The patient, when they feel tired and feel ache’s especially in their
abdomen, usually don’t pay much attention to these signs because they
believe it to be natural to aging.
A researched has revealed that patients
tend to underreport information about appendicitis symptoms primarily
because they lack knowledge of them but also because they inaccurately
diagnose for themselves. Patients often mistakenly identify appendicitis
symptoms as signs of simple stomachache.
Many middle adult patients readily recognize abdominal pain
(abdominal pain near navel - in earliest stages, right-side abdominal pain in later stages, abdominal pain on activity, abdominal pain on breathing,
abdominal pain on coughing, abdominal pain on sneezing, and abdominal
sensitivity - touching the area is painful), nausea, vomiting, constipation,
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diarrhea, loss of appetite, inability to pass gas, low fever, abdominal
swelling, and bad breath are often not recognized as being related to
appendicitis and are often ascribed to aging and just a simple
stomachache. Often the awareness that these symptoms might be related
to appendicitis is all that’s needed to motivate patients to undergo surgery.
2. Diagnostic Results
Diagnostic Test
Normal Values
Patient’s Results
Significance
June 13, 2006
CBC
Hemoglobin
14-17.5 g/dl
15 g/dl
Normal
Hematocrit
41.5-50.4 %
42%
Normal
Red Blood
Cell
4.5-5.9x10^8 /uL
4.60 10^8/uL
Normal
White Blood
Cell Count
1,10011,000/cumm
7.290/cumm
Normal
Mean
Corpuscular
Hemoglobin
27.5-33.2 pg
27.9 pg
Normal
81.4 fL
Normal
34.2 %
Normal
Mean
Corpuscular
Volume
80-96 fL
Mean
Corpuscular
Hemoglobin
Conc.
33.4-35.5 %
Platelet
150,000450,000/cumm
220,000/cumm
Normal
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Differential
Counts
Segmenters
40-70%
52 %
Normal
Alt
9.-72.
50. u/L
Normal
ALKP
38.-126.
100. u/L
Normal
Source: Medical-Surgical Nursing 10th Edition by Suzanne C. Smeltzer and
Brenda G. Bare
Ultrasound
Examination: whole abdomen
Interpretation:
The liver and spleen are not enlarged. There is a 1.9x1.4x1.2cm
cyst
seen at the right lobe of the liver. No solid mass seen. The gallbladder is
unremarkable with no evidence of calculi seen. The gallbladder wall is not
thickened and measures 3mm in thickness. The common duct is not dilated
and measures 3mm in its AP diameter. The rest of the intrahepatic ducts are
unremarkable.
The pancreas and abdominal aorta are unremarkable. The aorta
measures 1.7cm in its AP diameter. No masses seen in the paraaortic area.
Right Kidney10.1x3.8cm 1.2cm cortex
Left Kidney 1.0x4.3cm 1.4cm cortex
The central echo complexes and renal cortices are intact. There is a
4.2mm and 2.8mm calculi seen at the right middle and inferior calyces
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respectively. There is a 7mm calculus with localized cahectasia seen at the left
superior pole. No solid mass seen.
The filled urinary bladder is unremarkable with no evidence of calculi or
mass seen.
The prostate is not enlarged and measures 2.9x3.1x3.1cm with an
estimated weight of 15 grams. No focal lesion seen.
Note minimal ascites seen.
Remarks: Minimal Ascites
3. Physical Assessment (IPPA)
Body Part
I
P
Skin
dark brown
complexion
good turgor,
warm to touch
Head
normocephalic, no
irregularities
no lumps &
tenderness
scanty, black
short hair
smooth, not oily

hair
no lumps/mass

scalp

no tender areas
& no pimples
symmetrical
facial features
& movements,
tired and weary no masses
Face

absence of
dandruff &
parasites
forehead
eyebrows
presence of
wrinkles
thin, hair
evenly
distributed,
no lumps
P
A
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aligned
together
curves outward


no edema
lashes
eye
-cornea
symmetrical
movements,
dark & sunken
clear, corneal
light reflexes
present, equal
reactions of
both sides
Body Part
I
-conjunctiva
pink, moist
-sclera
aniscleric,
white
-pupils
equally round
reactive to
light &
accommodation,
papillary high
reflexes,
equal
reactions of
both sides
-iris
black
Muscle Function
followed
moving
objects
properly
Muscle Balance
not
strabismus
- upper & lower
Lids
lids are color
brown, closes
symmetrically,
P
P
A
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no discharges
-lacrimal ducts
no discharges
Visual Acuity
with
eyeglasses,
nearsighted,
can read
Body Part

nose
- frontal &
maxillary
sinuses

I
not
obstructed,
central
position, no
mucous
secretions,
patent
P
not painful
no occlusion
not tender
when transillumination is
done
mouth
- lips
dry, pinkbrown
smooth
- gums
pink, moist
soft
- teeth
no dentures,
32 teeths
hard & stable
- hard palate
pink
hard
- soft palate
pink
soft, gag
reflex present
P
A
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- uvula
straight &
hanging
- frenulum
normal
-tonsils
not inflamed,
pink
Body Part

ears
Neck
I
P
no occlusion,
symmetrical
on both sides,
upper auricle
in line with
outer contour
of eye,
hearing is
clear
not painful, no
lumps / mass
same as
normal skin
tone
no
lumps/mass

lymph
nodes

trachea
central
position

thyroid
gland
not enlarged

heart
A
not palpable
no skin
lesions
Chest
P
no masses
regular/normal
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rate and
rhythm = 78
bpm, no
murmurs

lungs
Body Part

abdomen
Genitalia
equal lung
expansion
equal chest
excursion
resonant
sound
P
normal breath
sounds=
20bpm, no
crackles /
wheezes
I
P
A
flat with suture
present in the
right lower
quadrant
soft, smooth,
warm to
touch,
painful(8/10
pain scale
where 10 is
the highest),
kidney and
spleen are not
palpable, liver
is not
enlarged
tympanic
sound
bowel
sounds= 2
gurgling
sounds/bowel
sounds per
minute
PR= 79bpm
Temp.=37.1
degrees
Celsius
Capillary
refill= 1 sec.
moderate
biceps and
wrist reflexes
BP= 130/80
without foley
bag catheter
Extremities

upper
weak muscle
strength but
able to give
resistance,
with IV # 9
D5NM;L@30
gtts/min
infusing well
at dorsal left
hand
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
lower
able to walk
but with
assistance
and slowly,
pain and
fatigue upon
standing and
moving
weak muscle
strength
4. Present Profile and Functional Health Patterns
Health Perception/Health Management Pattern
Before and after the operation patient described his health as fair when
questioned. He used to perceive a perfect health before, when he actually
did. He was only hospitalized now. Good nutrition keeps him healthy.
Periumbilical pain is the reason for his hospitalization. He expected to feel
well. He is not restricted to any foods. He was able to follow the prescribed
instruction by the doctor and nurses. He had complete immunizations.
There are no mobility problems and sensory deficits he possessed.
Nutritional/Metabolic Pattern
He doesn’t like to eat a lot and has lost his appetite especially since he
is admitted in the hospital. Before his admission, the patient doesn’t eat as
much because of his anorexia which is not associated with vomiting. His
usual fluid intake is 8-10 glasses of water per day. At 12 midnight
(Saturday) prior to his operation in the morning, he is NPO. After the
operation, he is still in NPO state. He has no vitamins taken. He lose weight
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(4 lbs.) now because of his disease. He has no problem with ability to eat.
He doesn’t have any allergies to any foods and medicines.
Elimination Pattern
Six days before his appendicitis occurred, he can void freely and
normally. But
when the disease occurred, he experienced constipation.
After the surgical procedure, he remained constipated with 2 bowel sounds
per minute.
He has no problems or complaints with usual pattern of
urinating. No assistive devices used in urinating and defecating.
Activity/Exercise Pattern
His usual activity at home is cleaning the house, watching television,
and reading newspapers. His exercise is jogging and walking in the street.
He has no complaints of dyspnea or fatigue before the operation. He can
move freely without assistance. But after the surgery, there is pain and
fatigue he felt upon standing and moving. Although, there are no limitations
in his ability to move, he is assisted by his daughter because he has weak
muscle strength on his lower extremities.
Cognitive/Perceptual Pattern
The patient is oriented to time, place and person (student nurse). He
knows his health condition. He has no complaints of head problems. He is
able to read and write. The patient is able to use all of his senses. The
patient is nearsighted and uses eyeglasses when reading. The patient has
keen visual and auditory acuity.
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Sleep/Rest Pattern
He had no problems of sleeping before and after the operation. But
sometimes awaken because of the pain felt at the sight of surgery .He
usually gets 6-8 hours of sleep per day until after the operation is done. His
usual time of sleeping is 9pm and wakes up at 7am.
Self-Perception Pattern
The patient is very much aware of the surgical procedure. He has
come to accept the fact that he needs help with almost everything
concerning his health, even the simplest task such as reminding himself of
his medications. He stated that he is excited to go home. He wants to
resume to his daily activities. I did inform the patient that he will not be able
to resume to his usual activities for about 2 to 4 weeks.
Role Relationship Pattern
He verbalized that his role in life is being a loving husband and father
as well. He has five children, two are girls and three are boys. They all have
very loving relationship with each other. He speaks and understands the
English, Filipino/Tagalog, and Cebuano dialect. His speech is clear and
relevant. He freely expresses himself verbally, in writing and with gestures.
He also understands other people.
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Sexual Reproductive Pattern
The patient is not sexually active due to his age.
Coping-Stress Tolerance Pattern
The decision making in their home comes from him and his wife.
He has no loss in his life in the past year. He likes about himself by being
disciplinarian and working hard for his family.
Value-Belief System
The patient is a Roman Catholic as well as his family. God is his
source of strength or meaning. Religion and God are important to him. He
goes to church every Sundays and other special occasions together with his
family. His values or moral beliefs have not been challenged of his condition
but it strengthens.
5. The Normal Anatomy and Physiology of Organ/System Affected
Appendix
It is formally vermiform appendix in anatomy, a vestigial hollow tube
attached to the cecum; the blockage of the appendix can result in appendicitis.
Appendix The appendix is a narrow, muscular tube that is closed at one end
and is attached to and opens into the cecum at its other end. (The cecum is the
pouchlike beginning of the large intestine; the small intestine empties into the
cecum.) The appendix does not serve any useful purpose as a digestive organ
in humans, and it is believed to be gradually disappearing in the human species
over evolutionary time. (The vermiform appendix exists only in human beings
and higher apes, but an appendix-like structure does exist in wombats, civets,
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rodents, and a few other lower animals.)The appendix is usually 8 to 10 cm (3
to 4 inches) long and less than 1.3 cm (0.5 inch) wide. The cavity of the
appendix is much narrower where it joins the cecum than it is at its closed end.
The appendix has muscular walls that are ordinarily capable of expelling into
the cecum the mucous secretions of the appendiceal walls or any of the
intestinal contents that have worked their way into the structure. If anything
blocks the opening of the appendix, or prevents it from expelling its contents
into the cecum, appendicitis may occur. The most common obstruction in the
opening is a fecalith, a hardened piece of fecal matter. Swelling of the lining of
the appendiceal walls themselves can also block the opening. When the
appendix is prevented from emptying itself, a series of events occurs. Fluids
and its own mucous secretions collect in the appendix, leading to edema,
swelling, and the distention of the organ. As the distention increases, the blood
vessels of the appendix become closed off, causing the necrosis (death) of
appendiceal tissue. Meanwhile, the bacteria normally found in this part of the
intestine begin to propagate in the closed-off pocket, worsening the
inflammation. The appendix, weakened by necrosis and subject to increasing
pressure from within by the distention, may burst; spilling its contents into the
abdominal cavity and infecting the membranes that line the cavity and cover the
abdominal organs (see peritonitis). Fortunately peritonitis is usually prevented
by the protective mechanisms of the body. The omentum, a sheet of fatty
tissue, often wraps itself about the inflamed appendix, and an exudate that
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normally develops in the areas of inflammation behaves like glue and seals off
the appendix from the surrounding peritoneal cavity.
It is also a worm – shaped tube that arises from the medial side of the
cecum. It is a potential trouble spot, since it is usually twisted, an ideal location
for bacteria to accumulate and multiply. It is a narrow, muscular tube containing
a large amount of lymphoid tissue. The appendix has no known function but it
does contain immune cells, which plays a role in defending the body from
infection. The appendix may serve a purpose in a diet including occasional raw
meat. Specifically, it may allow bacteria useful in the digestion of raw meat to
be retained, rather than flushed from the system during long intervals between
raw meat meals.
Though the organ is not a vital one, a patient survives
perfectly well following the removal of the appendix. It varies in length from 3 to
5 inches (8 to 13 centimeters). The base is attached to the posteromedial
surface of the cecum about 1 inch (2.5 centimeters) below the ileocecal
junction. The remainder of the appendix is free. It has a complete peritoneal
covering, which is attached to the lower layer of the mesentery of the small
intestine by a short mesentery of its own, the mesoappendix.
The
mesoappendix contains the appendicular vessels and nerves.The appendix lies
in the right iliac fossa, and in relation to the anterior abdominal wall, its base is
situated one – third of the way up to the line joining the right anterior superior
iliac spine to the umbilicus (McBurney’s point). Inside the abdomen, the base
of the appendix is easily found by identifying the teniae coli of the cecum and
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tracing them to the base of the appendix, where they converge to form a
continuous longitudinal muscle coat.
The tip of the appendix is subject to a considerable range of movement
and may be found in the following positions:
1) hanging down into the pelvis against the right pelvic wall,
2) coiled up behind the cecum in the retrocecal fossa,
3) projecting upward along the lateral side of the cecum, and
4) in front of or behind the terminal part of the ileum.
The first and second positions are the most common sites. The
arterial supply of the appendix is by means of the appendicular artery, a
branch of the posterior cecal artery. It passes the tip of the appendix in
the mesoappendix. The appendicular vein joins the posterior cecal vein.
The lymph vessels drain into one or two nodes lying in the mesoappendix.
From there, the lymph passes through a number of mesenteric nodes to
reach the superior mesenteric nodes. The nerves of the appendix are
derived from sympathetic and parasympathetic (vagus) nerves from the
superior mesenteric plexus.
Afferent nerve fibers concerned with the
conduction of visceral pain from the appendix accompany the sympathetic
nerves and enter the spinal cord at the level of the tenth thoracic segment.
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Picture/Illustration of Vermiform Appendix
6. Pathophysiology and Rationale
6.1 Schematic Drawing (Pathophysiology of Appendicitis)
Predisposing Factors
Precipitating Factors
-
- age (between10 and
30 years old)
- adolescents and
young adults
- older adults (ruptured
of the appendix)
-
obstruction of the appendix
by a fecalith, inflammation,
foreign body or neoplasm
kinking of the appendix
swelling of the bound wall
fibrous conditions in the
bound wall
external occlusion of the
bowel by adhesions
28
Obstruction of the narrow appendiceal lumen
Obstructed lymphatic and venous drainage
Suppurative appendicitis
(increasing intraluminal pressures eventually exceed capillary
perfusion matter)
Bacterial and inflammatory fluid invasion of the tense
appendiceal wall
Transmural spread of bacteria
Signs
-
Symptoms
nausea
vomiting
low grade fever
bad breath
microscopic hematuria
mild leukocytosis
pyuria
coated-tongue
- constipation
- diarrhea
- Rovsing’s sign
- muscle spasm
- Psoa’s sign
- inability to pass
gas
- loss of appetite
- vague epigastric
pain on right lower
quadrant
Nursing Management
Medical Management
Surgical Management
- relieving pain
- preventing fluid
volume deficit
- prevent fluid and
electrolyte imbalance
and dehydration
- appendectomy (surgical removal of the
appendix) is perfor-
29
- reducing anxiety
- eliminating
infection from the
potential or actual
disruption of the
GI tract
- maintaining skin
integrity
- attaining optimal
nutrition
- antibiotics and intravenous
fluid is administered
until surgery is performed
- analgesics can be
administered after the
diagnosis is made
med to decrease the
risk of perforation
6.2 The Disease Process
Appendicitis is the inflammation of the appendix, a small portion of the
large intestine that hangs down from the lower right side. Although the
appendix does not seem to serve any purpose, it can still become diseased.
If untreated, an inflamed appendix can burst, causing infection and even
death. It may occur after a viral infection in the digestive tract or when the
tube connecting the large intestine and appendix is blocked by trapped
stool. The inflammation can cause infection, a blood clot, or rupture of the
appendix. Because of the risk of rupture, appendicitis is considered an
emergency. Anyone with symptoms needs to see a doctor immediately.
A person experiencing an attack of appendicitis may feel pain all over
the abdomen or only in the upper abdomen or about the navel. This pain is
usually not very severe. After one to six hours or more the pain may
become localized to the right lower abdomen. Nausea and vomiting may
develop some time after the onset of the pain. Fever is usually present but
is seldom high in the early phases of the attack. The patient's leukocytes
(white blood cells) are usually increased from a normal count of 5,000–
30
10,000 in an adult to an abnormal count of 12,000–20,000; this
phenomenon can be caused by many other acute inflammatory conditions
that occur in the abdomen. In a person with a normally sited appendix, the
pain of appendicitis is situated at a point between the navel and the front
edge of the right hipbone. But many people have their appendix lying in an
abnormal position, and they thus may feel the pain of an appendicitis attack
in a different or misleading location, making their symptoms difficult to
distinguish from the abdominal pain caused by a variety of other diseases.
Careful diagnostic examination by a physician can usually determine if
acute appendicitis is indeed causing a patient's abdominal pain.The basic
treatment of appendicitis is the surgical removal of the appendix in a minor
operation called an appendectomy. The operation itself requires little more
than a half hour to carry out under anesthesia and produces relatively little
postoperative discomfort. If a diagnosis of acute appendicitis cannot
immediately be made with reasonable certainty, it is now customary to wait
and observe the patient's symptoms for a period from 10 to 24 hours so that
a definitive diagnosis can be made. This wait does slightly increase the risk
that the appendix will rupture and peritonitis set in, so the patient is kept
under careful medical surveillance at this time.
An appendectomy is a surgical intervention, which involves the
removal of the appendix within 24 to 48 hours of the onset of manifestations
in a patient who is experiencing appendicitis. It is done as soon as possible
to decrease the risk of perforation. The surgery is performed through a
31
small open incision or a laparoscope (a lighted scope used to visualize and
remove the appendix) or through a low abdominal incision under general or
spinal anesthesia. When the operation is performed in time, the mortality
rate is less than 0.5%.
Delay usually causes rupture of the organ and
resultant peritonitis. The primary goal of treatment for patient’s undergoing
appendectomy is the prevention of complications such as perforation of the
appendix which may lead to peritonitis. It is also performed to remove an
inflamed appendix. The surgeon cuts through layers of skin, fat, and
muscle, and the peritoneal membrane that lines the abdomen to reach the
appendix, which is attached to the cecum, a rounded pouch at the beginning
of the large intestine. The cacum and appendix are lifted out of the
abdominal cavity through the incision. After tying off the blood vessels in the
base of the appendix, the surgeon cuts off the body of the appendix and
sutures the stump. The cecum and stump are then tucked back into the
abdominal cavity, and the incision is closed.
6.3 Comparative Chart
Classical
Low grade fever
Clinical
Not Manifested
Rationale
-
Due to inflamed
appendix.
Source:
Medical-Surgical
Nursing 10th Edition by
Suzanne C. Smeltzer
and Brenda G. Bare
Abdominal pain
Manifested
-
Inflammation of the
appendix.
32
- Patient has
periumbilical pain
radiating to epigastric
and right upper quadrant
area.
Constipation
Manifested
Source:
Medical-Surgical
Nursing 10th Edition by
Suzanne C. Smeltzer
and Brenda G. Bare
-
- Patient experienced
constipation six days
prior to admission and
after the surgical
procedure
Abdominal wall & the
intestine is
compressed by the
acute appendicitis
causing decreased GI
tract motility or
peristalsis.
Source:
Medical-Surgical
Nursing 10th Edition by
Suzanne C. Smeltzer
and Brenda G. Bare
Diarrhea
Not Manifested
-
Increased
gastrointestinal tract
motility/peristalsis due
to compressed
abdominal wall and
intestine.
Source:
Medical-Surgical
Nursing 10th Edition by
Suzanne C. Smeltzer
and Brenda G. Bare
Anorexia
Manifested
- Patients lost his
appetite because of his
condition.
Nausea and vomiting
Not Manifested
-
Poor appetite
Source:
Medical-Surgical
Nursing 10th Edition by
Suzanne C. Smeltzer
and Brenda G. Bare
-
Nausea and vomiting
is also common
33
during Appendicitis
due to inflammation of
the vermiform
appendix and the
feeling of fullness.
Source:
Medical-Surgical
Nursing 10th Edition by
Suzanne C. Smeltzer
and Brenda G. Bare
Manifested
Extreme tiredness
(fatigue)
- Patient feels fatigue
upon standing.
-
Because of the
disease process.
Source:
Medical-Surgical
Nursing 10th Edition by
Suzanne C. Smeltzer
and Brenda G. Bare
IV. Nursing Intervention
1. Surgical Management
Appendectomy is a surgical intervention, which involves the removal of
the appendix within 24 to 48 hours of the onset of manifestations in a patient
who is experiencing appendicitis.
Procedure:
It is done as soon as possible to decrease the risk of perforation. The
surgery is performed through a small open incision or a laparoscope (a
lighted scope used to visualize and remove the appendix) or through a low
34
abdominal incision under general or spinal anesthesia. When the operation is
performed in time, the mortality rate is less than 0.5%. Delay usually causes
rupture of the organ and resultant peritonitis. The primary goal of treatment
for patient’s undergoing appendectomy is the prevention of complications
such as perforation of the appendix which may lead to peritonitis. It is also
performed to remove an inflamed appendix. The surgeon cuts through layers
of skin, fat, and muscle, and the peritoneal membrane that lines the abdomen
to reach the appendix, which is attached to the caecum, a rounded pouch at
the beginning of the large intestine. The caecum and appendix are lifted out
of the abdominal cavity through the incision. After tying off the blood vessels
in the base of the appendix, the surgeon cuts off the body of the appendix
and sutures the stump. The caecum and stump are then tucked back into the
abdominal cavity, and the incision is closed.
Indication:
- appendicitis
Contraindication:
- none
Complications:

perforation of the appendix or abscess

peritonitis

ileus (paralytic and mechanical)

pelvic abscess
35

subphrenic abscess( abscess under the diaphragm)
2. Care Guide for Pre and Post- Appendectomy Patients
a. Fever
- tepid sponge bath
- wear light clothing
- increase fluid intake
- administer antipyretics as ordered by the doctor
b. Nausea, Vomiting, and Anorexia
- increase fluid intake
- small frequent feedings
- intravenous fluid therapy
- enteral feedings
c. Peritonitis
- observe for abdominal tenderness, fever, vomiting, abdominal rigidity,
and tachycardia
- employ constant nasogastric suction
- correct dehydration as prescribed
- administer antibiotic agents as prescribed
d. Pelvic Abscess
- evaluate for anorexia, chills, fever, and diaphoresis
- observe for diarrhea, which may indicate pelvic abscess
- prepare patient for rectal examination
- prepare patient for surgical drainage procedure
36
e. Subphrenic Abscess(abscess under the diaphragm)
-
assess patient for chills, fever, and diaphoresis
-
prepare for x-ray examination
-
prepare for surgical drainage of abscess
f. Ileus(paralytic and mechanical)
-
assess for bowel sounds
-
employ nasogastric intubation and suction
-
replace fluids and electrolytes by intravenous route as prescribed
-
prepare for surgery, if diagnosis of mechanical ileus is established
37