I. INTRODUCTION:

Appendicitis requires immediate medical attention so it's important to learn its

symptoms — and how they differ from a run-of-the-mill stomachache — so you can seek

medical care right away. The symptoms of appendicitis (which is inflammation of the

appendix) start with a mild fever and pain around the bellybutton, and can be accompanied

by vomiting, diarrhea, or constipation. The stomach pain usually worsens and moves to the

lower right side of the belly. The appendix is a small finger-like organ that's attached to the

large intestine in the lower right side of the abdomen. The inside of the appendix forms a cul-

de-sac that usually opens into the large intestine. When that opening gets blocked, the

appendix swells and can easily get infected by bacteria. If the infected appendix isn't

removed, it can burst and spread bacteria and infection throughout the abdomen and lead to

serious health problems. Appendicitis mostly affects kids between the ages of 11 and 20,

and is rare in infants. Most cases of appendicitis occur between October and May. A family

history of appendicitis may increase a child's risk, especially in males.

Appendicitis occurs in 7% of the US population, with an incidence of 1.1 cases per

1000 people per year. Some familial predisposition exists. Incidence of appendicitis

internationally is lower in cultures with a higher intake of dietary fiber. Dietary fiber is thought

to decrease the viscosity of feces, decrease bowel transit time, and discourage formation of

fecaliths, which predispose individuals to obstructions of the appendiceal lumen. The overall

mortality rate of 0.2-0.8% is attributable to complications of the disease rather than to

surgical intervention. Mortality rate rises above 20% in patients older than 70 years, primarily

because of diagnostic and therapeutic delay. Perforation rate is higher among patients

younger than 18 years and patients older than 50 years, possibly because of delays in

diagnosis. Appendiceal perforation is associated with a sharp increase in morbidity and

mortality rates.

According to an article that was sited at

http://www.sciencedaily.com/releases/2008/03/080317093904.html, on Wednesday, March

12, 2008, surgeons at UC San Diego Medical Center performed what is believed to be the

country's first removal of a diseased appendix through the mouth. This clinical trial procedure

received approval for a limited number of patients by UC San Diego's Institutional Review

Board (IRB) which oversees clinical research. "The purpose of this clinical trial is to test more

'patient-focused' techniques for minimally invasive surgery," said Mark A. Talamini, M.D.,

professor and chair of the Department of Surgery at UC San Diego Medical Center. "UC San

Diego Medical Center is testing groundbreaking ways in which to perform surgery with fewer

incisions, less pain, and more rapid recoveries." Santiago Horgan, M.D., professor and

director of UC San Diego's Center for the Future of Surgery, and Talamini, president elect of

the Society of American Gastrointestinal and Endoscopic Surgeons, performed the surgery

on Jeff Scholz, a 42-year old California resident. UC San Diego Medical Center is first U.S.-

based hospital to perform this procedure. India is the only other country to report such an

operation. "UC San Diego's Center for the Future of Surgery is advancing scarless

techniques by investigating, developing, testing, and teaching procedures that will

revolutionize the field of surgery," said Horgan, president of the Minimally Invasive Robotics

Association and a global leader in scarless procedures. "Only one small incision to insert a

small camera in the belly button was required to complete the surgery versus three incisions

required for a laparoscopic procedure," said Horgan. "The patient was discharged 20 hours

after surgery and is now reporting minimal pain which is a goal for all of our patients." "I had

to have my appendix removed and the opportunity to participate in something so innovative

sounded enticing. A day after surgery, I have little pain, a '2' on a scale of 1 to 10," said

Scholz, a resident of La Jolla. "My father had the conventional appendix removal. I didn't

want the standard issue scar on the abdomen." The procedure, called Natural Orifice

Translumenal Endoscopic Surgery (NOTES), involves passing surgical instruments, and a

tiny camera, through a natural orifice, such as the mouth, to the desired organ. By avoiding

major incisions through the abdomen, patients may experience a quicker recovery with less

pain while reducing the risk of post operative hernias. Horgan and Talamini used FDA-

cleared EndoSurgical Operating System (EOS) developed by USGI Medical, Inc. to perform

the procedure. EOS was passed through the patient's mouth and into the stomach where a

small incision was made in the stomach wall to pass the instrument through to the appendix

for removal. In addition to Horgan and Talamini, the surgical team included: John Cullen,

M.D., Garth Jacobsen, M.D., Karl Limmer, M.D., John McCarren, M.D., Bryan Sandler,

M.D.and Thomas Savides, M.D.

The group decided to study this case for them to widen their knowledge regarding the

disease condition and at the same time to be able to impart heath teachings regarding the

gained information. Many people are not aware of their present condition because of their

limited knowledge about it. The group would want to fill the gap about that for them to be able

o help each affected individual to increase their knowledge about the problem. Awareness is

really a must. One must be aware of their condition or to the problem in order for then to can

follow different precautionary measures. Early findings can cause early interventions and at

the same time can minimize impending alterations. Proper management is also needed to

avoid further complications and strict compliance in terms of prescribed therapeutic regimen

is also needed. This study may serve as an eye opener so that people may become aware of

this disease. Hope that this study can help you to minimize your confusions regarding

appendicitis and appendectomy.

II. Anatomy and Physiology:

The gastrointestinal tract (GI tract), also called

the digestive tract, alimentary canal, or gut, is the system

of organs within human body that takes in food, digests

it to extract energy and nutrients, and expels the

remaining waste. The major functions of the GI tract are

digestion and excretion.

The GI tract differs substantially from animal to animal. For instance, some animals

have multi-chambered stomachs, while some animals' stomachs contain a single chamber.

In a normal human adult male, the GI tract is approximately 6.5 meters (20 feet) long and

consists of the upper and lower GI tracts. The tract may also be divided into foregut, midgut,

and hindgut, reflecting the embryological origin of each segment of the tract.

In human anatomy, the appendix (or vermiform appendix; also cecal appendix) is

a blind ended tube connected to the cecum, from which it develops embryologically. The

cecum (or caecum) is a pouch-like structure of the colon. The appendix is near the junction

of the small intestine and the large intestine. It is also able to be removed.The term

"vermiform" comes from Latin and means "worm-like in appearance".

Size and location:

The appendix averages 10 cm in

length, but can range from 2 to 20 cm.

The diameter of the appendix is usually

between 7 and 8 mm. The longest

appendix ever removed measured 26

cm.

The appendix is located in the lower right quadrant of the abdomen, or more

specifically, the right iliac fossa. Its position within the abdomen corresponds to a point on the

surface known as McBurney's point. While the base of the appendix is at a fairly constant

location, 2 cm below the ileocaecal valve, the location of the tip of the appendix can vary

from being retrocaecal (74%) to being in the pelvis to being extra peritoneal. In rare

individuals with situs inversus, the appendix may be located in the lower left side.

Function:

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. The wall of the appendix contains

lymphatic tissue that is part of the immune system for making antibodies. Like the rest of the

colon, the wall of the appendix also contains a layer of muscle, but the muscle is poorly

developed.

III. The Patient and His Illness:

PATHOPHYSIOLOGY (Book-Centered)

a. Schematic diagram:

Fecalith, trauma, lymphadenitis, intestinal worm

Inflammation of the appendix

Obstruction of the appendix lumen that subsequently filled with mucus

bacteria which normally are found within the appendix begin to invade (infect) the wall of the appendix. The body responds to the invasion by mounting an attack on the bacteria, an

attack called inflammation

Swells due to inflammatory process psoas sign inflamed appendix lies on the psoas muscle

Obturator sign inflamed appendix comes in contact with obturator internus (muscle spasm by flexing and internally rotating hips

Rovsing’s sign deep palpation may cause pain in the right iliac fossa

Increase pressure within the lumen and the walls results to thrombosis and occlusion of the small vessels

Typical sign and symptom Lymphatic flow stasis

Appendix become necrotic and ischemicNausea and vomiting

Bacteria begin to leak out through the dying walls

Periumbilical pain Pus formation

Radiates to right iliac fossa Peritonitis

Atypical

Septicemia

Pain directed at right iliac fossaDeath

b. Synthesis of the Disease:

b.1 Definition of the Disease:

Appendicitis means inflammation of the appendix. It is thought that appendicitis begins

when the opening from the appendix into the cecum becomes blocked. The blockage may be

due to a build-up of thick mucus within the appendix or to stool that enters the appendix from

the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening.

This rock is called a fecalith (literally, a rock of stool). At other times, the lymphatic

tissue in the appendix may swell and block the appendix. After the blockage occurs, bacteria

which normally are found within the appendix begin to invade (infect) the wall of the

appendix. The body responds to the invasion by mounting an attack on the bacteria, an

attack called inflammation. An alternative theory for the cause of appendicitis is an initial

rupture of the appendix followed by spread of bacteria outside the appendix. The cause of

such a rupture is unclear, but it may relate to changes that occur in the lymphatic tissue, for

example, inflammation, that line the wall of the appendix.)

If the inflammation and infection spread through the wall of the appendix, the appendix

can rupture. After rupture, infection can spread throughout the abdomen; however, it usually

is confined to a small area surrounding the appendix (forming a peri-appendiceal abscess).

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.

A less common complication of appendicitis is blockage of the intestine. Blockage

occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop

working, and this prevents the intestinal contents from passing. If the intestine above the

blockage begins to fill with liquid and gas, the abdomen distends and nausea and vomiting

may occur. It then may be necessary to drain the contents of the intestine through a tube

passed through the nose and esophagus and into the stomach and intestine.

A feared complication of appendicitis is sepsis, a condition in which infecting bacteria

enter the blood and travel to other parts of the body. This is a very serious, even life-

threatening complication. Fortunately, it occurs infrequently.

The abdominal wall becomes very sensitive to gentle pressure (palpation). Also, there is

rebound tenderness. In case of a retrocecal appendix, however, even deep pressure in the

right lower quadrant may fail to elicit tenderness (silent appendix), the reason being that the

cecum, distended with gas, prevents the pressure exerted by the palpating hand from

reaching the inflamed appendix. Similarly, if the appendix lies entirely within the pelvis, there

is usually complete absence of the abdominal rigidity. In such cases, a digital rectal

examination elicits tenderness in the rectovesical pouch. Coughing causes point tenderness

in this area (McBurney's Point) and this is the least painful way to localize the inflamed

appendix. If the abdomen on palpation is also involuntarily guarded (rigid), there should be a

strong suspicion of peritonitis requiring urgent surgical intervention. Other signs are:

Rovsing's sign

Deep palpation of the left iliac fossa may cause pain in the right iliac fossa. Also known

as: Rovsing's symptom named after Niels Thorkild Rovsing. This sign is used in the

diagnosis of acute appendicitis. Pressure over the descending colon causes pain in the

right lower quadrant of the abdomen.

Psoas sign

Occasionally, an inflamed appendix lies on the psoas muscle and the patient will lie with

the right hip flexed for pain relief.

Obturator sign

If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can

be demonstrated by flexing and internally rotating the hip. This manouvre will cause pain

in the hypogastrium.

Other symptoms of appendicitis include, but are not limited to, nausea and vomiting, loss

of appetite, fever and chills, constipation, diarrhea, inability to pass gas, and abdominal

swelling.

b.2 Predisposing factors and Precipitating Factors:

Predisposing Factors

• Sex: male to female ratio is approximately 2:1

• Age: appendicitis occurs in all age groups (children 2 years of age or younger and

people 70 years of age or older are at higher risk for a ruptured appendix)

• Classic history for appendicitis

>patients with a classic history for appendicitis require prompt surgical

consultation.

• Anatomical variations in the positioning of the appendix.

Precipitating Factors

• Present History of amoeba

• Invasion of Microorganisms

• Lymphoid Hyperplasia

b.3 Signs and Symptoms with rationale:

Sign And symptom Rationale

Rovsing's sign

Psoas sign

Obturator sign

Nausea and vomiting

Fever

Periumbilical pain that radiates to the right

iliac fossa

Deep palpation of the left iliac fossa may cause pain in

the right iliac fossa. Pressure over the descending

colon causes pain in the right lower quadrant of the

abdomen because of the inflammatory process.

An inflamed appendix lies on the psoas muscle,

If an inflamed appendix is in contact with the obturator

internus, spasm of the muscle can be demonstrated by

flexing and internally rotating the hip. This manouvre

will cause pain in the hypogastrium.

Because of lymphatic flow stasis, intestinal matter

tends to regurgitate. Although not really a

pathognomonic sign, it can be attributed due to

inflammatory process

This is due to the poor localizing spatial property of

visceral nerves from the mid-gut, followed by

involvement of somatic nerves as the inflammation

progresses.

IV. Clinical Intervention:

1.1 Description of prescribed surgical treatment performed:

An appendectomy is performed to remove the appendix when appendicitis is strongly

suspected. During other abdominal surgical procedures, the appendix may be removed as a

precaution to prevent future inflammation or infection of the appendix.

Open Appendectomy

Open appendectomy is the traditional method and the standard treatment for

appendicitis. The surgeon makes an incision in the lower right abdomen, pulls the appendix

through the incision, ties it off at its base, and removes it. Care is taken to avoid spilling

purulent material (pus) from the appendix while it is being removed. The incision is then

sutured.

1 Patient is supine, prepped, and draped.

2 Abdomen is entered through a McBurney's incision.

3 Appendix is identified and gently elevated with a Babcock and delivered into the

wound.

4 Moist laps are placed around the base of the appendix to prevent contamination of the

wound.

5 Appendix is dissected free from its attachment (mesoappendix).

6 Base of the appendix is crushed with a straight hemostat.

7 Hemostat is removed and base is ligated with 0 chromic tie in the groove left by the

clamp.

8 A silk purse string suture is placed in the cecal wall at the base of the appendix.

9 Hemostat is reapplied distal to the ligature and appendix is amputated between

ligature and clamp.

10 Appendix and dirty knife are delivered to specimen basin.

11 Stump of appendix is disinfected and inverted into the cecum, as the purse string

suture is tied.

12 Dirty instruments are passed off.

13 Wound is irrigated with antibiotic solution.

14 Counts are taken and abdomen is closed per surgeon's preference.

Open appendectomy

It is done by standard grid Iron Incision. Steps are shown below.

Open appendectomy steps 

Inflamed appendix delivered from a right iliac  Inflamed appendix being removed fossa incision. after ligature of appendicular mesentery.

1.2 Indication of prescribed surgical treatment:

Appendectomy is usually an emergency surgical procedure performed when the

patient suffers from appendicitis. It is important to undergo the surgery before a hole or

perforation develops in the wall of the appendix. This can lead to spreading of infection to the

entire abdominal cavity causing what is known as Peritonitis (i.e. the inflammation of the

lining of the abdomen).

Indications:

Appendicitis - acute or subacute process that causes the lumen of the appendix

(which is a blind sac) to become obstructed with buildup of pressure and eventual rupture.

Mass - rarely an appendiceal mass is found on CT scan or during intra-abdominal

surgery (laparotomy)

Abscess - if found secondary to appendicitis it must be drained. If it is diagnosed

preoperatively care currently is to have an interventional radiologist (a radiologist who does

procedures) drain the abscess via a percutaneously (through the skin) placed catheter that is

left in place to decompress the cavity and allow it to "heal from the inside out". The appendix

is then removed at about 6 weeks. If it is found during surgery it must be decompressed and

a drain left in place in the abcess cavity by the surgeon.

Benefits:

An appendectomy is performed to remove the appendix when appendicitis is strongly

suspected. During other abdominal surgical procedures, the appendix may be removed as a

precaution to prevent future inflammation or infection of the appendix. Appendectomies are

performed to treat appendicitis, an inflamed and infected appendix.

Risks:   

Risks for any anesthesia include the following:

Reactions to medications

Problems breathing

Risks for any surgery include the following:

Bleeding

Infection

Additional risks with an appendectomy with ruptured appendix include the following:

Longer hospital stays

Side effects from medications

Postoperative Complications;

Paralytic ileus may occur following the operation. The bowel is normally in

constant motion, digesting food and absorbing nutrients. Disturbing the bowel,

even by the surgeon's just touching it, can cause the motion to come to a

standstill. Fluid and gas may then cause the bowel to swell or distend. A

nasogastric tube is passed through the nose and into the stomach to relieve the

distension. When bowel function returns to normal (evident by passing gas or

having a bowel movement), the tube is removed. Until that time, food and liquid

are not permitted by mouth, and hydration is maintained intravenously.

Paralytic ileus is more common when the appendix has perforated.

Wound infection can cause the skin to become red and inflamed and pus to

leak from the incision site. In this case, antibiotics are started and discharge

from the hospital may be delayed, depending on the severity of the infection.

On rare occasions, the site must be reopened to allow the wound to drain.

Abscess, a collection of pus in the area of the appendix. Although abscesses

can be drained of their pus surgically, there are also non-surgical techniques,

1.4 Perioperative tasks and responsibilities of the nurse:

Preoperative Procedures:

A number of tests are ordered to assess the patient's health before surgery. Usually

these tests are done a few days ahead, but because of the urgency of an appendectomy, the

tests and surgery are frequently performed on the same day. Preoperative tests vary

according to the patient's age and health, but a blood test, chest x-ray, and

electrocardiogram (EKG) are standard.

An informed consent form must be signed acknowledging that the patient

understands the procedure, the potential risks, and that they will receive certain medications.

Before surgery, the anesthesiologist visits the patient to do a brief physical

examination and to obtain a medical history. He or she will want to know about any other

medical conditions; if the patient is taking any medication (prescription or over-the-counter); if

any dietary supplements or herbal products are being used; if there has been recent illicit

drug use; if the patient smokes cigarettes or drinks alcohol; if the patient has a history of

allergies, especially to medications; or has had a previous reaction to anesthesia, or a family

history of problems with anesthesia.

It is important that persons with symptoms of appendicitis not take laxatives or

enemas to relieve constipation, as these medications and procedures can cause the

appendix to burst. In addition, pain medication should be avoided, as this can mask other

symptoms.Your health care provider will:

Check your abdomen for tenderness and tightness

Check your rectum for tenderness and an enlarged appendix

Check your blood for an increase in white blood cells

Instruct Patients that they are required to refrain from eating or drinking after midnight

on the day before surgery; however, because an appendectomy is an emergency

procedure, that may not be possible. As soon as the decision is made to operate, the

patient must take nothing by mouth, including oral medications.

No analgesics prior to operation because it may misinterpret the diagnosis whether it

is ruptured or not.

Hair removal

Intraoperative Care:

The scrub nurse together with the instrument nurse should be alert in assisting the

surgeon during the procedures. Bed linens had been changed and patient puts on a clean

gown. Patient voids and pre meds had been given. Sterility should be frequently observed.

The circulating nurse should be mindful of the different supplies needed during the

procedure. Silence should be observed also. The CN ensure that all equipments are

functioning, performed surgical skin preparation, sterility principle observation, handling

specimens; assist anesthesia personnel with induction. The anesthesiologist will be the one

to monitor the patient’s condition. But nurses should be also observant about it. The scrub

nurse always assured alertness, observant on sterility principle, prepared all instruments

needed, cleaning them up and coordinates with the CN about the total number of materials

used.

Postoperative Care:

Following surgery, the patient is taken to the post anesthesia care unit (PACU) until

the anesthesia wears off. During this time, the nursing staff checks temperature, heart rate,

and breathing at frequent intervals. When the anesthesia wears off and vital signs stabilize,

the patient is transferred to their hospital room.

The morning after surgery, clear liquids are offered. Once those are tolerated, the diet

progresses to solid food. Once the patient is eating and drinking, the intravenous is removed.

Physical activity, such as getting out of bed, begins on the same day as surgery or the next

morning. Most patients need medication to relieve the pain in and around the incision.

The nurse continues to monitor the patient for signs of infection and checks that the

incision is healing. Deep breathing and coughing exercises should be indicated to promote

lung expansion. Turning exercise and extremity exercises can also be advisable if not

contraindicated to prevent thrombus and promote good circulatory function. Proper

positioning should be also added.

Proper wound cleaning is also recommended to reduce the risk of infection. Report

also if the incision has been removed to intervene immediately. Patients are allowed to eat

when the stomach and intestines begin to function again. Patients are asked to walk and

resume their normal physical activities as soon as possible.

Once at home, the patient must check the incision site. It should be dry and the wound

should be completely closed. If the incision drains blood or pus, or if the edges are pulling

apart, the physician should be notified immediately. Fever and increasing pain at the incision

site also should be reported to the physician.

Heavy lifting and strenuous activity should be avoided during recovery. If antibiotics

and/or pain medication are prescribed, they should be taken as directed.

1.5 Expected outcome of surgical treatment performed:

Normal results:

Most patients feel better immediately after an operation for appendicitis. Many patients

are discharged from the hospital within 24 hours after the appendectomy. Others may require

a longer stay--three to five days. Almost all patients are back to their normal activities within

three weeks.

The mortality rate of appendicitis has dramatically decreased over time. Currently, the

mortality rate is estimated at one to two per 1,000,000 cases of appendicitis. Death is usually

due to peritonitis, intra abdominal abscess or severe infection following rupture.

The complications associated with undiagnosed, misdiagnosised, or delayed

diagnosis of appendectomy is very significant. The diagnosis is of appendicitis is difficult and

never certain. This has led surgeons to perform an appendectomy any time that they feel

appendicitis is the diagnosis. Most surgeons feel that in approximately 20% of their patients,

a normal appendix will be removed. Rates much lower than this would seem to indicate that

the diagnosis of appendicitis was being frequently missed.

Recovery from an appendectomy is similar to other operations. Patients are allowed to

eat when the stomach and intestines begin to function again. Usually the first meal is a clear

liquid diet—broth, juice, soda pop, and gelatin. If patients tolerate this meal, the next meal

usually is a regular diet. Patients are asked to walk and resume their normal physical

activities as soon as possible. If TA was done, work and physical education classes may be

restricted for a full three weeks after the operation. If a LA was done, most patients are able

to return to work and strenuous activity within one to three weeks after the operation.

1.6 Medical management of physiologic outcomes:

a. IVF

MEDICAL

MANAGEMENT

TREATMENT

DATE ORDERED/

DATE

PERFORMED

GENERAL

DESCRIPTION

INDICATIONS OR

PURPOSES

CLIENTS RESPONSE

TO THE TREATMENT

D5 0.3NaCl 1L x 25

gtts/min

D5 IMB 500 cc

X 25 gtts/min

DO: 01-20-09

DP: 01-20-09

DO:01-21-09

DP:01-21-09 up to

01-23-09

For daily maintenance

of body fluids when Cl

and Na are required

D5 IMB is hypertonic

solutions, which makes

the cell shrink. It

exerts higher osmotic

pressure than that of

the blood

Used to treat fluid

volume deficit for daily

maintenance of body

fluids and nutrition

used to supply the

necessary nutrient to

the patient

Administration of this

fluid increases the

solute concentration

of plasma drawing

No untoward reaction

noted such as allergic

reaction

There were no signs and

symptoms noted upon

administration of fluid

such as pain – swelling

and tenderness at the

insertion site, patient

didn’t manifest S/SX of

water out of the cells

to restore osmotic

equilibrium, given to

protect patient the

necessary nutrient

and route for

administrating

medicines.

Serve as a medium

for patient in giving

medication.

fluid overload.

NURSING RESPONSIBILITIES:

PRIOR

Check the physician’s order on the patient chart.

Verify patient’s name in the chart with the actual patient

Assemble equipment

Gather supplies, alcohol, swabs, micro pore

Explain the procedure and purpose.

DURING

Clean area of insertion.

After needle insertion, open the damp and checked the drip chamber for the flow of

the fluid.

Set the drop rate as ordered.

AFTER

Assess IV sites, drop rate, volume infused at every hour.

Check IV line.

b. Drugs

NAME OF

DRUGS

GENERIC NAME

BRAND NAME

DATE ORDERED

DATE

TAKEN/GIVEN

DATE

CHANGED/D/C

ROUTE OF ADMI’N

DOSAGE AND

FREQUENCY OF

NOMI’N

GEN. ACTION

FXNAL CLASS’N

MECHANISM OF

ACTION

INDICATION(S)

OR PURPOSE(S)

(Patient

Centered)

CLIENT’S

RESPONSE

TO THE

MEDICATION

Ceftriaxone DO:01-20-09

DT:01-20-09 up to

01-23-09

600 mg IV + 200 cc

IV diluent to run for

30 mins q 12 by

soluset

Antibiotic

-a third

generation

cephalosporin

that inhibits cell

wall synthesis

promoting

osmotic instability

usually

bactericidal.

To decrease the

probability of

further infections

The patient

responded well

to the medicine

showing

loosening of

secretions.

Famotidine

Nubain

Ketorolac

DO:01-20-09

DT:01-20-09 up to

01-23-09

DO:01-20-09

DT:01-20-09 up to

01-23-09

DO:01-20-09

DT:01-20-09 up to

200 mg OD

3 mg slow IV diluted

to 5 cc q 6

SIVP RTC x 2 days

Type of

antihistamine that

blocks the release

of stomach acid.

An opiate pain

medication that

relieves moderate

to severe pain.

For short term

management of

moderately sever,

Famotidine is

used to treat

stomach and

intestinal ulcers. It

can relieve ulcer

pain and

discomfort.

Nubain helps

decreased

sensation of pain.

Ketorolac helps

decreased

sensation of pain.

The patient

responded well

to treatment

AEB no s/sx of

side effects

such as

diarrhea and

nausea.

Patient

experienced

decreased pain

sensation.

The patient

tolerated

treatment.

she experience

01-23-09 acute pain for

single dose

treatment

less pain on the

operative site

and it is

manage by

taking the drug,

thus he

experience

decrease of

pain.

Nursing Responsibilities:

Prior:

Obey the 10 rights in giving meds.

Verify doctor’s order.

Explain the importance of drug to the patient and SO.

Check the regulation of the deep factor of the IVF.

During:

Observe aseptic technique.

Administer the IV medication slowly.

After:

Inspect IV insertion sites for sign of phlebitis.

Document the time the drug was given.

Monitor and assess the patient’s reaction to the given drug.

c. Diet

Type of Diet Date

ordered/

Date

performed/

Date

changed

General

Description

Indication(s)

or Purposes

Specific

foods

taken

Client’s

response

and/or

reaction to

the diet

NPO

(May have soft

diet once with

flatus)

DO: 01-20-09

DP: 01-20-09

DC: 01-21-09

No food

intake as

well as water

or any fluid

by mouth.

Fluids and

foods are

withheld so

that GIT is at

rest and

empty. It also

prevents from

vomiting

during

surgery,

which may

cause the

patient to

aspirate from

vomiting.

No food

was

taken.

The patient

responded

well and

complied

properly

with the

given order.

Nursing Responsibilities

Prior:

Check the doctor’s order.

Check the right client.

Instruct client or SO to adhere with the doctor’s order.

During:

Monitor if the client complies with the given diet.

After:

Document response of the client.

d. Activity/Exercise

Type of

Exercise

Date ordered/

Date

performed/

Date changed

General

Description

Indication(s) or

Purposes

Client’s

response and/or

reaction to the

activity/exercise

Flat on

Bed

DO: 01- 20-09

DP: 01- 20-09

DC: 01-21-09

An individual

must be lying on

bed without

pillows.

The client must

be fob to

prevent spinal

headache and

vomiting

because of the

anaesthesia

effect.

The client

responded well to

the exercise

regimen.

Nursing Responsibilities:

Prior:

The benefits as well as the disadvantages should be explained well to the client.

The nurse should make sure that the patient adheres to the ordered exercise.

During:

The ordered exercise should be monitored.

After:

Continuous monitoring of the client’s exercise should be observed.

1.7 NURSING MANAGEMENT

a. NURSING CARE PLAN

Problem #1: Ineffective breathing pattern r/t incisional pain 2° to Appendectomy

Assessment Nursing

Diagnosis

Scientific

Explanation

Objectives Intervention Rationale Evaluation

S= Ø 

O= Patient

manifested:

tachypnea

respiratory

depth

changes

reduce

vital

capacity

holding

breath

Patient

may

manifest:

Ineffective

breathing

pattern r/t

incisional

pain 2° to

Appendect

omy

 Ineffective

breathing pattern

occurs when

inspiration and

expiration does not

provide adequate

ventilation. In the

case of the patient

involve, one

causative/contributi

ng factor is the

incisional pain

being experienced

by the patient as a

result of post-

operative

procedure which is

Short term:

After 2 to 4

hours of NI, pt.

will verbalize

awareness of

causative

factors and

demonstrate

appropriate

coping

behaviors and

establish

effective

breathing

pattern.

>monitor vital

signs

>observed

respiratory

rate/depth

>instruct

effective

breathing

techniques

>for baseline data

>shallow breathing,

splinting with

respiratory holding

breath may result to

hypoventilation/atele

ctasis

>promotes

ventilation of all lung

segments and

mobilization/expector

After 2 to 4

hours of NI,

pt. will be

able to

verbalize

awareness

of causative

factors and

demonstrate

appropriate

coping

behaviors

and

establish

effective

breathing

Restlessn

ess

Guarding

behavior

v/s taken

as follows:

BP:

120/80,

RR:30,

PR:80,

T:36.1.

 

Appendectomy.

Incisional pain

which is a

subjective

unpleasant feeling

that may be felt

when the patient

breathes or cough

thus resulting to

impaired breathing.

Long term:

After 3 days

of NI, patient

will initiate

needed

lifestyle

changes and

will experience

no signs of

respiratory

compromise.

>elevate HOB,

maintain low

fowler’s

position and

support

abdomen w/

coughing and

ambulation

>auscultate

breath sounds

ation of secretions

>facilitate lung

expansion

>areas

decrease/absent

breath sounds

suggest atelectasis

adventitious sounds,

reflect congestion

pattern.

After 3 days

of NI, patient

will be able

to initiate

needed

lifestyle

changes

and will

experience

no signs of

respiratory

compromise

.

Problem #2: Acute pain r/t disruption of skin/ tissue layers 2º to Appendectomy

Assessment Nursing

Diagnosis

Scientific

Explanation

Objectives Intervention Rationale Evaluation

S= Patient

may verbalize

feeling of

incisional pain

and

discomfort.

O= Patient

manifested:

guarded

behavior

facial

grimaces

distraction

behaviors

restlessne

ss

Patient may

manifest:

Acute

pain r/t

disruption

of skin/

tissue

layers 2º to

Appendect

omy

Pain is a subjective

and unpleasant

feeling, emotional

experience arising

from actual or

potential tissue

damage. The

patient having

undergone a major

invasive procedure

has a disruption of

skin and tissue

layers. With this,

there is the

affectation of the

nerve ending in the

surgical site that

causes the

sensation of pain.

Short term:

After 2 to 4

hours of

Nursing

Intervention,

patient will

identify and

verbalize

understanding

of methods

that provide

relief.

Long term:

After 3 days

of NI, patient

will report pain

is relieved/

>establish

rapport

>monitor and

record vital

signs

>perform

comprehensiv

e assessment

of patient’s

feeling of pain.

>note for

location of

surgical

procedures

>for effective nurse-

patient interaction

>for baseline data

>to determine the

characteristics,

severity of pain and

underlying cause

>may influence

amount of post-

operative pain

After 2 to

4 hours of

Nursing

Intervention,

patient will

be able to

identify and

verbalize

understandi

ng of

methods

that provide

relief.

After 3

days of NI,

patient will

be able

irritability

narrowed

focus

sleep

disturbanc

e

controlled.

>provide

comfort

measures.

E.g. back rub

changes of

position

>administer

analgesics as

prescribed

>encourage

adequate rest

>for non-

pharmacologic pain

management.

>to maintain the

acceptable level of

pain.

>to prevent fatigue

report pain

is relieved/

controlled.

Problem #3: Risk for Infection r/t tissue destruction 2° to Appendectomy

Assessment Nursing

Diagnosis

Scientific

Explanation

Objectives Intervention Rationale Evaluation

S= Ø

O= Patient

manifested:

body

malaise

irritability

facial

grimace

Patient may

manifest:

Restlessn

ess

Guarding

behavior

v/s taken

as follows:

BP:

Risk for

Infection

r/t tissue

destruction

2° to

Appendect

omy

Appendectomy

which is the

removal of the

appendicitis is a

major invasive

procedure done as

a surgical

management for

the patient

involved, having

diagnosed with

appendicitis. With

this there is a

break in the skin, a

surgical incision

that may serve as

a point of entry of

harmful agents that

may cause

infection if

Short term:

After 2 to 4

hours of

Nursing

Intervention,

patient will

identify

intervention to

prevent/reduce

risk of

infection.

Long term:

After 3 days

of NI, patient

will achieve

timely wound

healing.

>establish

rapport

>monitor and

record vital

signs

>observe for

localized signs

of infection at

surgical

wound

>maintain

cleanliness

and dryness of

dressing at all

>for effective

nurse-patient

interaction

>for baseline data

>for timely

intervention

>moisture may

harbor growth of

After 2 to 4

hours of

Nursing

Intervention,

patient will be

able to identify

intervention to

prevent/reduc

e risk of

infection.

After 3 days of

NI, patient will

be able to

achieve timely

wound

healing.

120/80,

RR:30,

PR:80,

T:36.1.

neglected.times

>perform

proper hand

washing

before

performing

interventions

>instruct the

client to take

proper

nutrition and

increase

Vitamin C

intake

microorganisms

>to prevent cross-

contamination and

nosocomial

infections

>to prevent

infection and

strengthen immune

system

Problem #4: Risk for Impaired Skin Integrity r/t abdominal incision 2° to Appendicitis

Assessment Nursing

Diagnosis

Scientific

Explanation

Objectives Intervention Rationale Evaluation

S= Ø

O= Patient

manifested:

disruption

of skin

surface

destructio

n of layers

itching

pain

irritability

Patient may

manifest:

weakness

guarding

behaviour

on his

right upper

Risk for

Impaired

Skin

Integrity

r/t

abdominal

incision 2°

to

Appendiciti

s

Skin is an organ of

the integumentary

system made up of

multiple layers of

epithelial tissues

that guard

underlying muscles

and organs. As the

interface with the

surroundings, it

plays the most

important role in

protecting against

pathogens. Its

other main

functions are

insulation and

temperature

regulation,

sensation and

Short term:

After 2 to 4

hours of

Nursing

Intervention,

patient will

identify

individual risk

factors.

Long term:

After 2 days of

NI, patient will

demonstrate

behaviors,

techniques to

prevent skin

breakdown.

>establish

rapport

>monitor and

record vital

signs

>provide

adequate

clothing/cover

s

>observe for

reddened

areas and

institute

treatment

>to gain patient’s

trust for effective

nurse-patient

interaction.

>for baseline data

>to prevent

vasoconstriction

>reduces likelihood

of progression to

skin breakdown

After 2 to 4

hours of

Nursing

Intervention,

patient will be

able to identify

individual risk

factors.

After 2 days of

NI, patient will

be able to

demonstrate

behaviors,

techniques to

prevent skin

breakdown.

quadrant

v/s taken

as follows:

BP:

100/70,

RR:16,

PR:66,

T:36.7.

vitamin D and B

synthesis. Skin is

considered one of

the most important

parts of the body. It

must be regularly

cleaned. Unless

enough care is

taken it will

become cracked or

inflamed. Unclean

skin favors the

development of

pathogenic

organisms. The

constantly peeling

off dead cells of the

epidermis mix with

the secretions of

the sweat and

sebaceous glands

and the dust found

on the skin to form

immediately

>emphasize

importance of

adequate

nutritional,

fluid intake

>recommend

elevation of

lower

extremities

when sitting

>to maintain

general good health

and skin turgor

>to enhance

venous return and

reduce edema

formation

a filthy layer on its

surface. Functions

of the skin are

disturbed when it is

dirty and it

becomes more

easily damaged.

Problem #5: Risk for Deficient Fluid Volume r/t impaired gastric mobility

Assessment Nursing

Diagnosis

Scientific

Explanation

Objectives Intervention Rationale Evaluation

S= Ø

O= Patient

manifested:

decreased

urine

output

sudden

weight

loss

decreased

BP

dry

sjin/mucou

s

membrane

elevated

Hct

Risk for

Deficient

Fluid

Volume r/t

impaired

gastric

mobility

Our bodies are

about two thirds

water. When

someone gets

dehydrated, it

means the amount

of water in his or

her body has

dropped below the

level needed for

normal body

function. Small

decreases don't

cause problems,

and in most cases,

they go completely

unnoticed. But

losing larger

amounts of water

can sometimes

Short term:

After 2 to 4

hours of

Nursing

Intervention,

patient will

identify

individual risks

and

appropriate

interventions.

Long term:

After 2 days of

NI, patient will

demonstrate

behaviors or

lifestyle

changes to

prevent

>establish

rapport

>monitor and

record vital

signs

>encourage

oral intake

>monitor I/O

balance being

aware of

insensible

>to gain patient’s

trust for effective

nurse-patient

interaction.

>for baseline data

>to maximize

intake

>to ensure

accurate picture of

fluid stats

After 2 to 4

hours of

Nursing

Intervention,

patient will be

able to identify

individual risks

and

appropriate

interventions.\

After 2 days of

NI, patient will

be able to

demonstrate

behaviors or

lifestyle

changes to

Patient may

manifest:

Irritability

Weakness

Facial

grimaces

v/s of t:

37, RR:

28, PR:75,

BP:

100/70

make a person feel

quite sick.

development

of fluid volume

deficit.

losses

>perform

serial weights

>distribute

fluids over 24-

hour period

>to note trends

>prevents

peaks/valleys in

fluid level

prevent

development

of fluid volume

deficit.

V. Conclusion

Appendicitis is the inflammation of the appendix. There are many factors that could

cause appendicitis. Many people neglect pain felt over right lower quadrant that may mean

the rupture of the inflamed appendix. Appendectomy is the procedure done to remove the

affected appendix in order to avoid severe pain or any further complication in the body.

They say prevention is always better than cure. You see health habits play a very

important role in acquiring or preventing such diseases. Habit modification is necessary to

prevent the occurrence of the disease and its possible complications. Early diagnosis and

awareness of risk factors is also important.

As future nurses, the student nurses play a major role in the prevention, treatment and

promotion of wellness regarding the disease and any other kind of illness. Imparting health

teachings on the clients and helping them to identify the causes of the disease are just few of

the independent Nursing responsibilities. Brief explanation of signs and symptoms and easy

home remedies are also of great importance. However, on rendering care, Health Care

Providers must be patient enough in giving the appropriate interventions needed by each

patient. Understanding the feelings of the patient may help or contribute in their faster

healing and promotions of their health and also restoration of wellness.

The student nurses recommend this to all nursing students to have a further study

regarding this matter to broaden their minds on the effects of this disease condition in our

body. Also, to be able to give health teachings to the people on how to prevent certain

diseases like this.

VI. BIBLIOGRAPHY:

Books:

Schwartz, Seymour I. "Appendix." In Principles of Surgery, ed. Seymour Schwartz, et al. New York: McGraw-Hill, 1994.

Silen, William. "Acute Appendicitis." In Harrison's Principles of Internal Medicine, ed. Anthony S. Fauci, et al. New York: McGraw-Hill, 1997.

Other:

"Appendectomy." ThriveOnline. http://thriveonline.oxygen.com "The Appendix." Mayo Clinic Online. http://www.mayohealth.org

Websites:

http://www.medicinenet.com/appendicitis/article.htm

http://en.wikipedia.org/wiki/Appendix_(anatomy)

http://www.sciencedaily.com/releases/2008/03/080317093904.html,

http://kidshealth.org/parent/infections/stomach/appendicitis.html

http://www.nlm.nih.gov/medlineplus/ency/article/002921.htm

http://www.surgerychannel.com/appendectomy/postop.shtml#complications

http://insidesurgery.com/index.php?itemid=122

http://www.ahealthyme.com/article/gale/100084250

http://www.surgeryencyclopedia.com/A-Ce/Appendectomy.html