PHILIPPINE MILITARY ACADEMY

FORT DEL PILAR STATION HOSPITAL

BAGUIO CITY

A Case Study on
Appendicitis
In Partial Fulfillment of the
Requirements in the Registered
Nurse Residency Training Program

Submitted by:

AL GINO B. BORINAGA

Submitted to:
MRS. ERLINDA GUZMAN RN MAN

I.INTRODUCTION
A. BACKGROUND OF THE STUDY

Appendicitis is one of the most common causes of emergency abdominal surgery. Acute
appendicitis can also happen after a gastrointestinal infection. Rarely, a tumor may cause acute
appendicitis. Sometimes the cause of acute appendicitis is not known. The inflammation is
usually caused by a blockage, but may be caused by an infection. Without treatment, an
inflamed appendix can rupture, causing infection of the peritoneal cavity (the lining around the
abdominal organs) and even death.

Acute appendicitis can occur when a piece of food, stool or object becomes trapped in
the appendix, causing irritation, inflammation, and the rapid growth of bacteria and infection.

Up to 75,000 appendectomies are done each year in the U.S. The estimated population
in the Philippines is 86, 241, 697 and the incident rate of acute appendicitis is 215,604 as of
year 2011. Appendicitis is one of the more common surgical emergencies, and it is one of the
most common causes of abdominal pain.

In Asian and African countries, the incidence of acute appendicitis is probably lower
because of the dietary habits of the inhabitants of these geographic areas. The incidence of
appendicitis 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.

There is a slight male preponderance of 2:1 in teenagers and young adults; in adults, the
incidence of appendicitis is approximately 1.4 times greater in men than in women. The
incidence of primary appendectomy is approximately equal in both sexes.

Acute appendicitis can occur in any age group or population. However, it most often
occurs in teens and young adults. It is rare in children younger than two years of age. Classic
symptoms of acute appendicitis include pain in the right lower abdomen, where the appendix is
located, that gets progressively sharp and more intense . Pain increases when pressure is put
on the area (called the McBurneys point), and the area becomes even more painful and tender
when the pressure is released (rebound tenderness). This is one exam a health care provider
uses to diagnosis acute appendicitis. The symptoms of acute appendicitis can vary, and not all
people with acute appendicitis will experience the typical symptoms of abdominal pain. In early
acute appendicitis, the abdominal pain may be located around the navel or belly button area,
then move to McBurneys point as acute appendicitis progresses. After abdominal pain begins,
a person with appendicitis may develop a slight fever, have a loss of appetite, feel nauseated, or
vomit.

Acute appendicitis that is not treated promptly leads to life-threatening complications.

Complications of acute appendicitis include: Abdominal abscess, Peritonitis (infection of the
lining that surrounds the abdomen), Ruptured appendix, Sepsis, Shock.

Appendectomy remains the only curative treatment of appendicitis. The surgeon's goals
are to evaluate a relatively small population of patients referred for suspected appendicitis and
to minimize the negative appendectomy rate without increasing the incidence of perforation. The
emergency department (ED) clinician must evaluate the larger group of patients who present to
the ED with abdominal pain of all etiologies with the goal of approaching 100% sensitivity for the
diagnosis in a time-, cost-, and consultation-efficient manner.

II. NURSING HISTORY

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a. PATIENT PROFILE
Name: Patient X
Age: 23 years old
Gender: Male
Birth date: 16 August 1990
Religion: Baptist
Civil Status: Single
Chief Complaint: incision wound, lower midline of the abdomen
Date/Time Admitted: January 2016
Diagnosis: Ruptured Appendicitis with generalized peritonitis (s/p
Appendectomy with Exploratory Laparotomy, 05 OCT 2016)

b. COMPREHENSIVE NURSING HISTORY

1. History of Present Illness
The condition started when he was having their break on 01 January
2014 when the patient felt an on and off pain sensation in his abdomen and the
pain became persistent on 03 January 2014. The patient vomited in the late
afternoon with a whitish and watery output hence, prompted the patient to consult
at Saint Paul Hospital and he was ordered for observation. During the course of
observation, at around 2300H, the patient had loose bowel movement of watery
stool of about three times and manifested a bloated abdomen. On 04 Jan 2014,
the patient was then advised to be admitted to Saint Paul Hospital.
On the day of patients confinement at around 1000H of 04 January
2014 the patient decided to have Home Against Medical Advise (HAMA) in order
to be transferred at military institution. Few hours after when he arrived at the
airport, the patient vomited again once with yellowish, mucoidal output.
The patient arrived in Palawan at around 1700H, and was seen and
examined by MAJ NABULA MC and noted that the patient was dehydrated so he
decided to admit the patient at WESTERN COM at 1800H in order to undergo
laboratory work ups including fecalysis and urinalysis. Laboratory result had
shown that the patient has Amoebiasis, UTI/AGE.
Upon confinement, the patient was also seen by CPT DONALD C
PALMA and added a diagnosis of T/C Appendicitis. The patient underwent series
of assessment to confirm the diagnosis. At around 2200H, the patient was
suspected to have Appendicitis. They eventually inserted Indwelling Foley
Catheter and Nasogastric tube and maintained it during the course of illness.
He was again transferred to another institution, Adventist Hospital for
scheduled operation. Upon his hospitalization, the pain persisted with a
manifestation of a bloated abdomen. He was then operated at 2000H 05 January
2014. The patient had undergone Appendectomy with Exploratory Laparotomy
due to ruptured appendicitis. The final diagnosis was Ruptured Appendicitis with
Generalized peritonitis.
After 3 days of hospitalization at Adventist Hospital, patient was then
transferred to Western Command Station Hospital for continuation of treatment.
After 8 days at Wes-Com, patient was then transferred to FDPSH, PMA, Baguio
City, hence, Admission (16 January 2014)

2. Past Medical History

The patient had his first hospitalization when he was 16 y/o with a
diagnosis of UTI but unable to recall the name of the institution. He also
verbalized that he received complete immunizations.

3
 October 2013, He came in to FDPSH Emergency Room due to abdominal
pain and he was given pain reliever but was not admitted because the pain was
relieved by medication.

3. Family and Social History

The patient claimed to have familial history of hypertension on his father

side but had no familial history of other diseases such as diabetes mellitus,
kidney diseases, heart diseases and asthma. The patient verbalized that his
father had a mild stroke last year. The patient speaks English and Tagalog as a
method of communication.

c. PHYSICAL ASSESSMENT
17 JANUARY 2014

BODY PARTS ACTUAL FINDINGS

General >Body built: Mesomorph
Appearance >well groomed, fair in complexion
> with normal gait
>with vital signs of: BP of 110/80, PR: 73 bpm , RR of 18
cpm,

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Head >Normocephalic,
> no involuntary movement noted
> hair is color black and well distributed, (-) dandruff, (-)
scaling
>No visible lesions, Lumps, nodules and masses
>no complaints of pain upon palpation
> face is symmetrical when asked to do different facial
expressions
> Pulsations are equal and regular on both temporal
arteries.
Eyes >The upper and lower lids are able to close completely,
(-) swelling, (-) lesions, (-) discharges, (-) redness
> His eyeballs are well aligned to the eye socket
>Anicteric sclera
> with pinkish palpebral conjunctiva and clear bulbar
conjunctiva, no redness and lesions seen
>movement of the eyeballs are symmetrical
>Able to distinguish colors, pupils equally round, about
2-3mm in size reactive to light and accommodation.
>Unilateral blinking of eyes
>with visual acuity of 20/20
Nose > Located midline
>No discharges
>no lesions noted
>No tenderness upon palpation
>with pinkish nasal mucosa, no noted lesions
>septum located midline
>Able to determine mild aroma, Able to sniff through
each nostril while other is occluded
>Patent nares
Ears >ears of equal size and with similar appearance
>Color same as facial skin
> Aligned with the outer canthus of eyes
> No tenderness, no lesions, no discharges
>canal walls pink and uniform, with tympanic membrane
visible, intact, transparent
> Able to hear sounds on both ears
> (-) ROMBERG TEST
Mouth >Lips are pinkish in color, no noted lesions or nodules
>Lips are Soft, moist
>lips are symmetrical in contour
>patient is able to purse lips
>with complete set of teeth
>no visible gum problems or bleeding
>with pinkish buccal mucosa, no noted lesions
>with pinkish tongue, no noted lesions
>able to move tongue
>(+) gag reflex
>tonsils are pinkish in color, no lesions or discharges
noted, (-) swelling of tonsils

Skin >Varies from light to deep brown

> Skin is moist and smooth
>Good skin turgor
>With post- operative vertical incision
approximately 5 inches located on the lower midline
of the abdomen
Heart >heart rhythm is regular
> no chest pains and murmurs
>with pulse pressure of 40 mmHg
>no visible chest pulsations
>normal heart sounds noted upon auscultation

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 Lungs > chest is symmetric during respirations
> chest wall intact
> not too shallow and not to deep breathing
>Tactile Fremitus: Vibrations best felt on the larger
airways
> No adventitious sounds heard upon auscultation

Abdomen > No distention

> flat, non-tender
>(+) muscle rigidity
> Positive bowel sounds upon auscultation present
equally in all 4 quadrants
>with post-operative vertical incision at the lower
midline of the abdomen approximately 5 inches
Upper and >Equal in size on both sides of the body
Lower >(-) contractures
Extremities >Smooth coordinated movement
> Equal strength
>Good capillary refill (<2 secs)
>no noted lesions and scars on the body

d. GORDONS FUNCTIONAL PATTERN

BEFORE CADETSHIP DURING CADETSHIP/ DURING

Health He stated that he has a positive outlook
Perception/ towards health. He self-medicate at times
Health but he tends to seek medical consultation
Management at clinic when he think his condition
seems to worsen and becomes
unmanageable. He claimed to be
compliant to medical regimens and
whatever health teachings given to him.
He drinks 4 bottles of beer every week
and smokes 1 stick of cigarette per week.
HOSPITALIZATION
Whenever he is sick, he self-
medicate but he tends to seek
consult at FDPSH when he feels
that his condition is worsening.
He claimed to be compliant to
medical regimens and whatever
health teachings given to him. He
stated that he is not drinking
alcohol because it is prohibited in
the academy but he drinks
alcohol when theyre on a break.

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Nutritional- He eats 3 meals a day. He usually eats 2
Metabolic cups of rice per meal, he eat meat but
Pattern more on vegetables. He has good
appetite and is not significantly affected
when he is sick. He drinks 10 glasses of
fluids daily. He stated that he drinks
vitamins (Enervon). He also claimed that
he dont have any allergy to food, drugs,
etc.
Elimination He usually defecates every other day. His
Pattern stool characterized as yellowish to brown
in color and formed. He claimed to have
no discomfort in defecating. He usually
urinates 7 times in 24 hours characterized
as yellowish in color as verbalized. He
also claimed that there is no pain during
urination.
Activity- He claimed that he is very active. His
Exercise usual activities include playing sports
Pattern such as basketball and football. He does
his daily routine, eating, going to school,
doing household chores, and on his free
time, he engages in the fore mentioned
sports. He also jogs in the morning. He
claimed that he always had sufficient
energy in executing his activities.
Cognitive- He was alert, conscious, oriented to
Perceptual person, time and place. There were no
history of head injury or other illness that
can affect cognition and perception.
Self-Perception He sees himself as a person who is
and Self- healthy. He claimed that he is not usually
Concept stressed, but if he became stressed, it is
usually because of academics. He is able
to handle stress by meditating on it and
through sleep.
Sleep-rest He usually sleeps 6 to 7 hours every day
including naps. He goes to bed at around
2200H and wakes at 0500H. He doesnt
have any bedtime routines and hes not
taking any medications to promote sleep.
He already quit smoking for
almost a year.
He eats what is served from the
mess. He eats three times a day
with 1-2 cups of rice with viand,
eats fruits and vegetables 3
servings as claimed. He drinks 2
liters of fluids per day. He also
claimed that he usually drinks 4
cups of coffee per day. His
appetite is good, and is not
affected when he get ill. But
during his hospitalization, before
the surgery, he claimed that his
appetite became poor. His Body
built is Mesomorph with a BMI of
23
He defecates at least twice a day;
stool is characterized as yellowish
to brown in color and formed. He
urinates 6 to 8 times per day
characterized as yellowish in
color and there is no pain during
urination as verbalized. But after
the surgery, He claimed that he
has difficulty in urinating. One day
post-surgery, he defecate watery
stool. His bowel movement
returned to normal 4 days post-
surgery.
He claimed that he is more active
than he was a civilian. The
cadetship required certain
activities such as drills, athletics
and the like. He still played
sports, however, during the
course of his illness his activities
became limited due to the fear
that his surgical wound will open.
He feared moving too often so he
sits most of the time.
He was alert, conscious,
coherent, oriented to person, time
and place. There were no history
of head injury or other illness that
can affect cognition and
perception. He is able to recall
recent and remote memories.
He still considers himself as
healthy; however, he accepts that
he is limited because of his
condition. During his first year in
the academy, his stressors are
usually academics, the trainings
he has to undergo. But he is able
to manage his stress through
adequate rest.
He usually sleeps 4-5 hours every
day. He goes to bed at 0100H
and wake up at 0500H. He sleeps
when he has free time, usually for
30 minutes. He doesnt have any
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Role- He is single. He has 2 siblings, he is the
Relationship 2nd child. He claimed that he has a good
relationship with his parents and with his
siblings. Her mother works at DSWD as a
social worker and his father is retired
military personnel (Master Sergeant). He
stated that they always make time to have
bonding moment as a family.
Sexuality- He claimed that he is sexually active. He
Reproductive mentioned no sexual concerns.
Coping/Stress Whenever he encounters problem, he
Tolerance always share it to his family because it
lessens the burden for him. Sometimes
he also goes out with his friends to divert
his attention.
Value-Belief He is a Baptist and attends service every
Pattern Sunday. He stated that he always pray to
the Lord especially during times of
difficulties.
III. CLINICAL DISCUSSION
a. Anatomy and Physiology
bedtime routines nor does he
take any medications to promote
sleep.
He stated that his parents are the
primary provider of their family.
Despite of being separated from
his family for 3 years, he said that
they still have communication and
they were able to gather and
have bonding during their break.
He claimed that he has a good
relationship with co-cadets and
they treated each other as
brothers. They also have get-
together at times, share their
stories, listen to each other and
help one another in times of
needs.
He is sexually active and he
claimed to have no sexual
problems and concerns.
He makes himself busy and finds
diversional activities like reading,
sleeping and sometimes
meditating to avoid from being
stressed.
He goes to church regularly and
he prays always before going to
sleep.
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 The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the
oral cavity, where food enters the mouth, continuing through the pharynx, esophagus, stomach
and intestines to the rectum and anus, where food is expelled. There are various accessory
organs that assist the tract by secreting enzymes to help break down food into its component
nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in
the digestive system. Food is propelled along the length of the GIT by peristaltic movements of
the muscular walls
The functions of the digestive system are:
Ingestion - eating food
Digestion - breakdown of the food
Absorption - extraction of nutrients from the food
Defecation - removal of waste products
The digestive system also builds and replaces cells and tissues that are constantly dying.

Digestive Organs
The digestive system is a group of organs (Buccal cavity (mouth), pharynx, oesophagus,
stomach, liver, gall bladder, jejunum, ileum and colon) that breakdown the chemical components
of food, with digestive juices, into tiny nutrients which can be absorbed to generate energy for
the body.

The Buccal Cavity

Food enters the mouth and is chewed by the teeth, turned over and mixed with saliva by the
tongue. The sensations of smell and taste from the food sets up reflexes which stimulate the
salivary glands.

The Salivary glands

These glands increase their output of secretions through three pairs of ducts into the oral cavity,
and begin the process of digestion.
Saliva lubricates the food enabling it to be swallowed and contains the enzyme ptyalin which
serves to begin to break down starch.

The Pharynx
Situated at the back of the nose and oral cavity receives the softened food mass or bolus by the
tongue pushing it against the palate which initiates the swallowing action.
At the same time a small flap called the epiglottis moves over the trachea to prevent any food
particles getting into the windpipe.
From the pharynx onwards the alimentary canal is a simple tube starting with the salivary
glands.

9
The Esophagus
The oesophagus travels through the neck and thorax, behind the trachea and in front of the
aorta. The food is moved by rhythmical muscular contractions known as peristalsis (wave-like
motions) caused by contractions in longitudinal and circular bands of muscle. Antiperistalsis,
where the contractions travel upwards, is the reflex action of vomiting and is usually aided by
the contraction of the abdominal muscles and diaphragm.

The Stomach
The stomach lies below the diaphragm and to the left of the liver. It is the widest part of the
alimentary canal and acts as a reservoir for the food where it may remain for between 2 and 6
hours. Here the food is churned over and mixed with various hormones, enzymes including
pepsinogen which begins the digestion of protein, hydrochloric acid, and other chemicals; all of
which are also secreted further down the digestive tract.
The stomach has an average capacity of 1 litre, varies in shape, and is capable of considerable
distension. When expanding this sends stimuli to the hypothalamus which is the part of the brain
and nervous system controlling hunger and the desire to eat.
The wall of the stomach is impermeable to most substances, although does absorb some water,
electrolytes, certain drugs, and alcohol. At regular intervals a circular muscle at the lower end of
the stomach, the pylorus opens allowing small amounts of food, now known as chyme to enter
the small intestine.

Small Intestine
The small intestine measures about 7m in an average adult and consists of the duodenum,
jejunum, and ileum. Both the bile and pancreatic ducts open into the duodenum together. The
small intestine, because of its structure, provides a vast lining through which further absorption
takes place. There is a large lymph and blood supply to this area, ready to transport nutrients to
the rest of the body. Digestion in the small intestine relies on its own secretions plus those from
the pancreas, liver, and gall bladder.

The Pancreas
The Pancreas is connected to the duodenum via two ducts and has two main functions:
1. To produce enzymes to aid the process of digestion
2. To release insulin directly into the blood stream for the purpose of controlling blood sugar
levels
Enzymes suspended in the very alkaline pancreatic juices include amylase for breaking down
starch into sugar, and lipase which, when activated by bile salts, helps to break down fat. The
hormone insulin is produced by specialised cells, the islets of Langerhans, and plays an
important role in controlling the level of sugar in the blood and how much is allowed to pass to
the cells.

The Liver

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The liver, which acts as a large reservoir and filter for blood, occupies the upper right portion of
abdomen and has several important functions:
1. Secretion of bile to the gall bladder
2. Carbohydrate, protein and fat metabolism
3. The storage of glycogen ready for conversion into glucose when energy is required.
4. Storage of vitamins
5. Phagocytosis - ingestion of worn out red and white blood cells, and some bacteria

The Gall Bladder

The gall bladder stores and concentrates bile which emulsifies fats making them easier to break
down by the pancreatic juices.

The Large Intestine

The large intestine averages about 1.5m long and comprises the caecum, appendix, colon, and
rectum. After food is passed into the caecum a reflex action in response to the pressure causes
the contraction of the ileo-colic valve preventing any food returning to the ileum. Here most of
the water is absorbed, much of which was not ingested, but secreted by digestive glands further
up the digestive tract. The colon is divided into the ascending, transverse and descending
colons, before reaching the anal canal where the indigestible foods are expelled from the body.

ANATOMY OF THE APPENDIX

The appendix is a wormlike extension

of the cecum and, for this reason, has been
called the vermiform appendix. The average
length of the appendix is 8-10 cm (ranging
from 2-20 cm). The appendix appears during
the fifth month of gestation, and several
lymphoid follicles are scattered in its mucosa.
Such follicles increase in number when
individuals are aged 8-20 years.

11
 The appendix is contained within the visceral peritoneum that forms the serosa, and its
exterior layer is longitudinal and derived from the taenia coli; the deeper, interior muscle layer is
circular. Beneath these layers lies the submucosal layer, which contains lymphoepithelial tissue.
The mucosa consists of columnar epithelium with few glandular elements and neuroendocrine
argentaffin cells.

Taenia coli converge on the posteromedial area of the cecum, which is the site of the
appendiceal base. The appendix runs into a serosal sheet of the peritoneum called the
mesoappendix, within which courses the appendicular artery, which is derived from the ileocolic
artery. Sometimes, an accessory appendicular artery (deriving from the posterior cecal artery)
may be found.

I. Appendiceal vasculature
The vasculature of the appendix must be addressed to avoid intraoperative hemorrhages. The
appendicular artery is contained within the mesenteric fold that arises from a peritoneal
extension from the terminal ileum to the medial aspect of the cecum and appendix; it is a
terminal branch of the ileocolic artery and runs adjacent to the appendicular wall. Venous
drainage is via the ileocolic veins and the right colic vein into the portal vein; lymphatic drainage
occurs via the ileocolic nodes along the course of the superior mesenteric artery to the celiac
nodes and cisterna chyli.

II. Appendiceal location

The appendix has no fixed position. It originates 1.7-2.5 cm below the terminal ileum, either in a
dorsomedial location (most common) from the cecal fundus, directly beside the ileal orifice, or
as a funnel-shaped opening (2-3% of patients). The appendix has a retroperitoneal location in
65% of patients and may descend into the iliac fossa in 31%. In fact, many individuals may have
an appendix located in the retroperitoneal space; in the pelvis; or behind the terminal ileum,
cecum, ascending colon, or liver. Thus, the course of the appendix, the position of its tip, and
the difference in appendiceal position considerably changes clinical findings, accounting for the
nonspecific signs and symptoms of appendicitis.

Physiology of Appendix
The lumen of the appendix communicates with the cecum 3cm (about 1 inch) before the
ileocecal valve, thus making it an accessory organ of the digestive system. Its functions are not
certain, but some biologists believe that the appendix serves as a sort of breeding ground for
some of the nonpathogenic intestinal bacteria thought to aid in the digestion or absorption of
nutrients.

Follicles of lymphoid tissue appear in the wall of the appendix shortly a few birth,
become more prominent during the first 10 years of life and then progressively disappear. The

12
defense or immune system function of lymphatic tissue present in the appendix of young
children is not fully understood.

While the specific functions of the human appendix remain unclear, there is general
agreement among scientists that the appendix is gradually disappearing from the human
species over evolutionary time. Blockage of the appendix can lead to appendicitis, a painful
and potentially dangerous inflammation.

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b. PATHOPHYSIOLOGY

Modifiable Risk Factor

Non-modifiable risk
Infection: Amoebiasis
factor
(diagnosed oct3 2016-
Gender: Most common in
Fecalysis : E. Histolica
males
cyst- 1-2/hpf)
(M: F=2:1)
Obstruction of the appendix:
Age: 10-30y/o Diet: low fiber diet and
Lymphadenitis (inflammation of the lymphoid follicles) rich in refined
carbohydrates
in response to Gastrointestinal infection
Bowel elimination
Hardened stool (fecalith)
pattern: every other day
Trauma

Tumors

Intestinal worms

Increase in the luminal pressure of the appendix

Distension of the appendix

Impaired venous return (improper oxygen and nutrient supply)

Appendix starts to be necrotic; normal bacteria found in the

appendix begin to invade (infect) the lining of the wall

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 Inflammatory response (body response to the bacterial
invasion in the wall of the appendix

Release of chemical mediators Activation of the thermoregulatory center; Activation of the vomiting center
(histamine, prostaglandin, anterior preoptic hypothalamic area in the medulla
leukotrienes, bradykinin, etc.)

Increase temperature- Hyperthermia Stimulation of the vagus

Increase permeability of the capillaries to WBCs/ nerve
other proteins in order to engage foreign invaders
in affected tissues
Nausea and vomiting

Increases swelling of
the appendix Dehydration Loss of appetite

Abdominal pain
(increases in RLQ) Urinalysis: Specific
Gravity: 1.030 (High)

Inflammation and infection spread through the

wall of the appendix causing death of the tissue

Continuous increase in pressure

Perforation (rupture of the

appendix)

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 Fecal materials, phagocytized bacteria, dead cells exits to peritoneal
cavity causing formation abscess (periappendiceal abscess)

Infection spread throughout the abdomen

(peritoneal cavity)

Bacterial invasion of peritoneal cavity causing

inflammation of the membrane that lines the abdomen

PERITONITIS

Signs and symptoms:

Bloated abdomen

Severe pain

Emesis

WBC count of: 20.8x109/L as of 03 october 2016

MANAGEMENT: If left untreated:

APPENDECTOMY with EXPLORATORY May lead to SEPSIS (condition caused by

LAPAROTOMY the pressure of microorganisms in the tissues
or blood stream)
Strong antibiotic treatment
SEPTIC SHOCK (decrease BP, increase HR,
Fluid volume replacement therapy increase RR)
Pain medications COMA DEATH

RECOVERY
16
 Acute appendicitis is an inflammation of the appendix and is one of the most frequent causes
of acute abdominal pain. It is often treated surgically as an emergency. As we still do not know the real reason
behind the occurrence of acute appendicitis, it needs to be treated cautiously. Although acute appendicitis is
more common and develops quickly, chronic appendicitis is more rare and much slower. Therefore, when it
comes to chronic appendicitis, timely recognition of the condition and treatment becomes a difficult job. Some
people with chronic appendicitis may only feel fatigue and mild pain in their stomach

Due to the slow progress of chronic appendicitis, you will find that infection may spread all over
the abdominal area. The symptoms often vary from patient to patient; therefore, only a doctor can diagnose it
correctly. The only real difference between acute and chronic appendicitis is that chronic appendicitis
takes longer to develop but is just as lethal.

The main thrust of events leading to the development of acute appendicitis lies in the appendix
developing a compromised blood supply due to obstruction of its lumen and becoming very vulnerable to
invasion by bacteria found in the gut normally.

Obstruction of the appendix lumen by enlarged lymphoid follicles, brings about a raised intra-luminal
pressure, which causes the wall of the appendix to become distended.

Normal mucus secretions continue within the lumen of the appendix, thus causing further build up of
intra-luminal pressures. This in turn leads to the occlusion of the lymphatic channels, then the venous return,
and finally the arterial supply becomes undermined.

Reduced blood supply to the wall of the appendix means that the appendix gets little or no nutrition and
oxygen. It also means a little or no supply of white blood cells and other natural fighters of infection found in the
blood being made available to the appendix.

The wall of the appendix will thus start to break up and rot. Normal bacteria found in the gut gets all the
inducement needed to multiply and attack the decaying appendix within 36 hours from the point of luminal
obstruction, worsening the process of appendicitis.

This leads to necrosis and perforation of the appendix. Pus formation occurs when nearby white blood
cells are recruited to fight the bacterial invasion.

The content of the appendix are then released into the general abdominal cavity, bringing causing
peritonitis.

Appendectomy with Exploratory Laparotomy is then performed to remove the appendix and to
determine the cause of a patient's symptoms or to establish the extent of a disease. A Laparotomy is a large
incision made into the abdomen. Exploratory laparotomy is used to visualize and examine the structures inside
of the abdominal cavity.

17
C. COURSE IN THE WARD

16 January 2014
Impaired skin integrity

At 2140H, the patient was brought to Fort Del Pilar Station Hospital retro-evacuated from
Western Command Station Hospital with the diagnosis of s/p appendectomy with Exploratory
Laparotomy on the lower midline abdomen area with clean and dry surgical site approximately 5 inches
in length and with no discharges noted. Vital signs were taken and recorded with initial VS of Pulse
rate: 78 beats per minute; Respiratory rate; 18 cycles per minute; Temperature; 36.5C; Blood Pressure;
110/80mmHg. The RMT collected blood specimen for CBC and the patient was instructed to collect
urine specimen for urinalysis. Diagnostic results were seen and evaluated by MOD. The following
medications were ordered by the MOD, Diclofenac Sodium 50mg/tab 1 tab P.O. 3x a day as needed for
pain, Ciprofloxacin 500mg/tab 1 tab P.O. 2x a day for 4 more days, Metronidazole 500mg/tab 1 tab P.O.
3x a day for 4 more days.

17 January 2014
Impaired skin integrity

The patient was afebrile, with surgical wound on the lower midline of the abdomen area. There
were no signs of post-op complications such as discharges and foul smelling odour and with and clean
and dry wound. There were no complaints of pain made. The patient was able to do ADLs
independently. Ciprofloxacin 500mg/tab 1 tab P.O 2x a day, Metronidazole 500mg/tab 1 tab P.O. 3x a
day were administered. Vital signs were taken and recorded every shift. Daily wound care was done.

18 January 2014
Impaired Skin integrity

The patient was afebrile with temperature of 36.5C and with clean and dry surgical wound on
the lower midline abdomen area. There were no complaints of pain made. There were no signs of post-
op complication noted. The patient was ordered to go back to barracks at 1600H by MOD. The patient
was instructed on the following home medications: Diclofenac Sodium 50mg/tab 1 tab P.O. 3x a day as
needed for pain, Ciprofloxacin 500mg/tab 1 tab P.O. 2x a day for 2 more to complete the 7 days,
Metronidazole 500mg/tab 1 tab P.O. 3x a day for 2 more days to complete the 7 days. The patient was
instructed to continue proper wound care and was instructed to come back for follow-up check-up on 23
Jan 2014.

D. MEDICAL MANAGEMENT

1. Laboratory and Diagnostic Procedures

CBC 04 January 05 January 2014 16 January 2014

2014

RBC 5.05x1012/L 5.05x1012/L -----

WBC ( 5-10x 10 9/L) 20.8x109/L 20.4x109/L 9.0 X 109/L

HEMOGLOBIN 143 g/L 143 g/L -----

Significance: Increase in WBC count may signify that there is an ongoing

inflammatory response or infection inside the persons body.

18
 Urinalysis 04 January 05 January 2014 16 January
2014 2014

Physical
Properties:

Color Amber Amber Dark Yellow

Transparency Slightly hazy Slightly hazy Slightly Turbid

Reaction Acidic Acidic Acidic

Specific Gravity 1.030 1.030 1.010

(1.010-1.025)

Chemical
Properties:

Sugar trace trace negative

Fecalysis 04 January 2014 05 January 2014
Albumin trace trace trace

Microscopic
examination:
Color Yellowish-brown Yellowish-green

Pus cells 6-12/hpf 6-10/hpf 1-2/hpf

Consistency mucoid Watery/ mucoid
RBC 3-6/hpf 2-4/hpf 0-1/hpf
WBC 3-6/hpf 15-20/hpf
Am.Urates many many Few
RBC 1-2/hpf 2-4/hpf
Mucus threads moderate moderate rare
E. Histolica cyst 1-2/hpf --------
Hyaline cast 1-4/hpf 1-2/hpf -----
Significance: Stool analysis refers to a series of laboratory tests done on
Significance:
fecal samples Urinalysis
to analyzedetermines
the condition presence of infection,
of a person's tissue
digestive tract damage,
in
and/or presence
general. Based on ofthe
excessive
findings,body
theelements likeof
consistency albumin,
his stoolsugar, urates and
is mucoidal.
the
Mucuslikes. Theout
come result
withofthe
thestool
urinalysis
due toindicates presence
the bacterial of infection
reaction that happened or RBC
destruction. The Specific
inside the stomach and theGravity determines
intestines. how of
Presence concentrated
E. Histolytica the in urine
the is
and based
stool on the
signifies finding, Sp.Gr.
an ongoing parasiticis high and itand
infection signifies
would that
mean thethatpatient
the is
dehydrated.
patient has Amoebiasis as evidence by the increase amount of WBC from
The presence of albumin indicates the waste materials present the
destruction
in the stool. of cells or tissues. The presence of casts, urates, mucus threads
and pus cells is not normal and may be suggestive of kidney issues.

19
2. DRUG STUDY

20
 DRUG NAME CLASSIFICATION DOSAGE INDICATION CONTRAINDICATION MECHANISM OF ADVERSE NURSING
ACTION REACTION CONSIDERATION

Ceftriaxone Anti-infective 1g IV every 8 surgical prophylaxis; Hypersensitivity to Interferes with Headache, Monitor
Sodium hours ANST skin and skin cephalosporins or bacterial cell wall hypotension, coagulation.
(-) structure infections penicillins, allergies, synthesis and palpitations, Assessed for
renal impairment, division by binding nausea and hypersensitivity/
hepatic disease, to cell wall, causing vomiting, anaphylactic
gallbladder disease, cell to die. Active abdominal reaction through
history of diarrhea against gram- cramps, bleeding skin test.
following antibiotic negative and gram- tendency, Monitor for signs
therapy. positive bacteria, hepatomegaly and symptoms of
with expanded superinfections
activity against and other serious
gram-negative adverse reactions.
bacteria. Exhibits Instruct patient to
minimal report persistent
immunosuppressant diarrhea, bruising,
activity. or bleeding.
Caution patient not
to use herbs
unless prescriber
approves.

Ranitidine Anti-ulcer Drug 50mg IV Active duodenal Hypersensitivity to drug Reduces gastric Headache; nausea Assess VS
Hydrochloride every 8 ulcer; benign gastric or tis components; acid and increases and vomiting; Tell patient he may
hours ulcers; alcohol intolerance gastric mucus and diarrhea, take oral drugs
gastroesophageal (with some oral bicarbonate constipation, with or without
reflux products); production, creating abdominal food
a protective coating discomfort or pain, Advise him to take
on gastric mucosa. rash; pain at IM once daily
injection site, prescription drug
burning or itching at bedtime
at IV site; Tell patient
hypersensitivity smoking may
reaction decrease drug
effects

Paracetamol Non-opioid 300mg IV Relieve of fever, Anemia, cardiac and Unclear. Pain relief Allergic skin Advise patient,
Analgesic; every 4 minor ache and pulmonary diseases may result from reactions and GI parents, or other
21
 Analgesic, Anti- hours as pains inhibition of disturbances caregivers to
pyretic needed for prostaglandin contact prescriber
fever synthesis in CNS, if fever or other
with subsequent symptoms persist
blockage of pain despite taking
impulses. Fever recommended
reduction may result amount of drug.
from vasodilation Inform patients
and increased with chronic
peripheral blood flow alcoholism that
in hypothalamus, drug may increase
which dissipates risk of severe liver
heat and lowers damage.
body temperature.

Metronidazole Anti-infective; anti- 500mg IV Bacterial infections; Hypersensitivity to Disturbs DNA Dizziness, vertigo, Monitor IV site.
Hydrochloride protozoal every 6 amoebiasis drug, other synthesis in nausea and Avoid prolong use
hours metronidazole susceptible vomiting, of indwelling
derivatives. orgaisms abdominal pain, catheter.
anoexia, Advise patient to
leukopenia, mild take drug with food
skin dryness, skin if it causes GI
irritaton, upset.
unpleasant Advise patient to
metallic taste report fever, sore
throat, bleeding or
bruising.
Inform patient that
drug may cause
metallic taste and
may discolour
urine urine
brownish-red.

Ciprofloxacin Anti-infective 500mg 1 tab Intra-abdominal Hypersensitivity to drug Inhibits bacterial headache, Watch for signs
Hydrochloride 2x a day for infections, Infectious or other DNA synthesis by restlessness, and symptoms of
7 days diarrhea, Urinary Fluoroquinolones; inhibiting DNA confusion, serious adverse
tract infections Comcomitant gyrase in orthostatic reactions,
administration of susceptible gram- hypotension, including GI
negative and gram- nausea, vomiting, problems,
22
 Tizanidine. positive organisms. diarrhea, jaundice, tendon
constipation, problems, and
abdominal pain or hypersensitivity
discomfort, rash, reactions.
altered taste Tell patient to take
drug 2 hours after
a meal.
Advise patient not
to take drug with
dairy products
alone or with
caffeinated
beverages.
Instruct patient to
stop taking drug
and notify
prescriber at first
sign of rash or
tendon pain,
swelling, or
inflammation.

Diclofenac Nonopioid 50mg 1 tab Analgesia Hypersensitivity to drug Unclear. Thought to dizziness, Observe for and
Sodium analgesic 3x a day as or its components, block activity of drowsiness, report signs and
needed for other NSAIDs, or cyclooxygenase, headache, symptoms of
pain aspirin; Active GI thereby inhibiting hypertension, bleeding.
bleeding or ulcer inflammatory diarrhea, Assess for
disease responses of abdominal pain, hypertension.
vasodilation and dyspepsia, Instruct patient to
swelling and heartburn, peptic take drug on
blocking ulcer, GI bleeding, empty stomach 1
transmission of GI perforation, hour before or
painful stimuli. after a meal.
Advise patient not
to lie down for 15
to 30 minutes after
taking drug, to
minimize
esophageal
23
 irritation.
Instruct patient to
immediately report
signs or symptoms
of hypersensitivity
reactions (rash,
swelling of face or
throat, shortness
of breath) or liver
impairment
(unusual tiredness,
weakness, and
nausea, yellowing
of skin or eyes,
tenderness on
right upper side of
abdomen, flulike
symptoms).
Instruct patient to
stop taking drug
and contact
prescriber
promptly if he
experiences
ringing or buzzing
in ears, dizziness,
GI discomfort, or
bleeding.

24
IV. NURSING MANAGEMENT

a. Problem List

Approximate Date Identified Active Problem DATE INACTIVE DATE RESOLVED

Date of Onset
05 Jan 2014 16 Sept 2013 Impaired tissue integrity - -

05 Jan 2014 16 Sept 2013 Activity Intolerance - -

- - Risk for Infection - -

Long Term Objective:

Upon discharge, the patient will be able to regain optimum level of functioning holistically in collaboration with the health care team.

Prioritization of the problem:

1. Impaired tissue integrity related to trauma secondary to surgical procedure.

2. Activity intolerance related to limitation imposed by condition.

3. Risk for infection related to inadequate primary defences (broken skin) secondary to surgical incision (S/P Ex-Lap; Appendectomy).

25
 Nursing Diagnosis
Date Identified:
16 January 2014
Nursing diagnosis:
Impaired tissue integrity r/t
tissue trauma secondary to
surgical procedure (s/p
Appendectomy with Ex-
Lap)
Objective:
>s/p appendectomy with
Exploratory Laparotomy (05
January 2014)
>with clean and surgical
wound at the lower midline of
the abdomen, approximately
5 inches in length
>(-)erythema, swelling and
discharge
>(-) tenderness upon
palpation
>(+) abdominal rigidity
Objectives Nursing Interventions Evaluation
Assessed general status Goal met. Within 2
Within 2 days of nursing days of effective
interventions, the Assessed characteristics of surgical wound medical and nursing
patient will be able to interventions, patient X
achieve timely wound Assessed wound for signs of infection and other complications was able to manifest an
improved condition as
healing as evidenced
Reviewed laboratory results for any changes that may determine manifested by having a
by: clean and dry wound,
extent of impairment
absence of swelling
a. clean and dry and discharges, free
wound Administered Ciprofloxacin Hydrochloride 500 mg/tab 1 tab P.O. 2x
from signs of infection.
a day as prescribed (0800H- 1800H)
b. absence of
discharges on Promoted optimum nutrition with high protein like poultry products
and fish, vitamins and mineral supplements to facilitate healing
the surgical site
c. absence of signs Rendered appropriate wound care and kept the area clean and dry
of infections
Promoted early mobility and simple exercises to promote circulation
such as swelling,
erythema, pain Promoted adequate rest and comfort
on the surgical
area. Reinforced importance of early detection and reporting of changes
in condition or any unusual physical discomforts
Emphasized need for adequate nutritional/fluid intake to optimize
healing potential
Instructed on proper wound care
Instructed on required changes in lifestyle necessitated by
limitations imposed by condition.
26
 Nursing diagnosis Objectives Nursing Interventions Evaluation

Date Identified: 16 January 2014 Within 48 hours of Assessed general status. Goal met. Within 48 hours of
nursing intervention, effective medical and nursing
Nursing Diagnosis: Patient X will be able to Assessed level of activity to do ADLs. interventions, the patient
report measurable reported measurable increase
Activity Intolerance r/t limitation imposed by increase in activity Noted factors affecting intolerance to in activity tolerance as
condition tolerance as evidenced activities. evidenced by:
by:
Subjective: Assisted in doing activities such as Subjective data;
a. Absence of Mas nakakagalaw na po ako
Hindi ako masyadong naggagagalaw maam carrying heavy objects.
guarding on the ng maayos ngayon kaysa dati
kasi baka bumukas yung sugat ko. surgical site when Assisted patient in increasing activity kasi mas magaling na yung
ambulating sugat ko ngayon.
Objective: b. Able to walk at level gradually.
regular pace Objective:
S/P Appendectomy with exploratory c. Able to move Promoted rest and comfort. > able to do ADLs independently
Laparotomy (05 Jan 2014) without limitations >absence of guarding on the
Promoted comfort measures such as surgical site when ambulating
With dry surgical wound at the lower splinting if the surgical wound when > able to walk at regular pace
midline of the abdomen, performing activities. > able to move without limitations
approximately 5 inches in length
Planned for maximal activity within
(+) abdominal rigidity clients ability.

Walks slowly Reinforced importance of early

ambulation
Lies or sits most of the time
Instructed to avoid strenuous activities
Able to do ADLs without assistance
Instructed patient that bending and
stretching are fine unless it hurts (this
may be putting too much strain on the
incision if this is the case)

27
 Nursing diagnosis Objectives Nursing Interventions Evaluation
Risk for Infection r/t Within 2 days of nursing Assessed integumentary status and documented Goal met. Within 2 days of
inadequate primary interventions, the patient will effective medical and nursing
defenses (traumatized be able to achieve timely Noted risk factors for occurrences of infection interventions, the patient was
tissue) able to manifest an improved
wound healing as evidenced
Observed for localized signs of infection at the operative integumentary status as
Objective: by: manifested by having a clean
site such as presence of discharges and redness
and dry wound, absence of
a. clean and dry wound
S/p Reviewed laboratory results for any abnormalities swelling and discharges, free
appendectomy from signs of infection.
b. absence of
with Explore Administered Ciprofloxacin Hydrochloride 500 mg/tab 1
discharges on the
Laparotomy (05 tab P.O. 2x a day as prescribed (0800H- 1800H)
January 2014) surgical site
With latest WBC Promoted optimal nutrition to facilitate healing
c. Absence of signs of
result of :
9.0x109/L infections such as
Maintained the surgical wound clean and dry
With clean and swelling, erythema,
dry wound of pain on the surgical
Maintained adequate hydration and nutritional status
approximately 5 area.
inches in length Instructed patient on how to clean the surgical wound
No signs of post-
aseptically
op complications :
(-) discharges, Advised regarding proper personal hygiene including
redness and foul
Handwashing
smelling odor
noted
Encouraged patient to have adequate fluid and
nutritional intake

Emphasized importance of early ambulation, deep

breathing exercises, coughing and positional changes

Encouraged to report for any signs and symptoms of

infection

28
 Encouraged to adhere to treatment regimen

29
C. Discharge Plan

Medication:
Instructed on the following medications:
Diclofenac Sodium 50mg/tab 1 tab 3x a day as needed for pain
Ciprofloxacin 500mg/tab 1 tab 2x a day for 2 more days (0800H and 1800H)
Metronidazole 500mg/tab 1 tab 3x a day (0800H, 1300H and 1800H)

Exercise:
Instructed patient to avoid lifting heavy objects (10-15 lbs) until after post-op
checkup
Instructed patient that bending and stretching are fine unless it hurts (this
may be putting too much strain on the incision if this is the case)
Advised patient to avoid vigorous exercise until after post-op appointment
Encouraged patient to ambulate, however he might get fatigued faster than
usual
Excuse from Formation, Athletic and Drill (FAD) as ordered.

Treatment:
Instructed to resume medications as ordered.
Encourage to comply with treatment regimen.
Instructed on proper daily wound care

Health Teaching: (for prevention)

Advised to avoid touching the wound to prevent further injury.
Advised to seek medical care or to report any of the following:
a. Foul smelling drainage from the surgical wound
b. Fever within 24-48 hours
c. New symptoms such as nausea, vomiting, constipation, abdominal swelling or severe
pain
d. Inability to urinate
e. Redness, pus, swelling, or more than usual tenderness from incision

Out-Patient Follow-Up Care:

Instructed the patient to have check-up or on 23 Jan 2014 to monitor condition or re-evaluate
condition.

Diet:
Encouraged to increased oral fluid intake and to eat foods rich in fibre such as fruits, vegetables and
cereals to prevent constipation.
Encouraged to eat foods rich in vitamin C such as pineapple, grapes and oranges to
boost the immune system.
Encouraged to eat foods rich in protein milk, meat products and eggs to promote tissue
repair.
Instructed patient to have a well-balanced diet.

Spirituality:
Encouraged to strengthen his belief by allowing him to practice religious activities such as attending
service regularly.

Sexuality:
No coitus until follow-up check-up reveals healing.

Socialization:
May engage in social activities but avoid stressful events, excessive or strenuous physical activities.

30
V. Conclusion:

In handling specific cases such as Ruptured Appendicitis, it is important to have a

broad and versatile knowledge, skills, and attitude. Accurate physical assessment, proper
implementation of the nursing process based on evidence-based clinical practice together
with the advancement of medicine will aid with the optimum functioning of clients. The
management of such case is based on surgical treatment and timely wound healing. Hence,
our role in the health care team is still very significant in achieving the goal of aiding patients
in full recovery.

VI. References:

Doenges M, Moorhouse M, et al: Nurses Pocket Guide (Diagnoses, Prioritized

Interventions, and Rationales), 12th edition. 2008

http://emedicine.medscape.com/article/773895-overview

http://www.sarpyobgyn.com/downloads/post-op/PostopExpLap.pdf

http://www.abdopain.com/Pathophysiology-of-appendicitis.html

http://www.rightdiagnosis.com/a/appendicitis_acute_appendicitis_chronic_appendicitis/s
ymptoms.htm

http://www.surgeryencyclopedia.com/La-Pa/Laparotomy-
Exploratory.html#b#ixzz2vZ8fzdSu

31