TABLE OF CONTENTS

I. INTRODUCTION.. 2
II. ANATOMY AND PHYSIOLOGY 6
III. THE PATIENT AND HIS ILLNESS
A. PATHOPHYSIOLOGY (SCEHMATIC DIAGRAM). 9
B. SYNTHESIS OF THE DISEASE
B.1. DEFINITION OF THE DISEASE... 10
B.2. PREDISPOSING/PRECIPITATING FACTORS.. 10
B.3. SIGN AND SYMPTOMS..... 11
IV. CLINICAL INTERVENTION
1.1. DESCRIPTION OF PRESCRIBED SURGICAL TREATMENT PERFORMED..13
1.2. INDICATION OF PRESCRIBED SURGICAL TREATMENT.18

1.3. REQUIRED INSTRUMENTS, DEVICES, SUPPLIES, EQUIPMENTS, AND

FACILITIES.19
1.4. PERIOPERATIVE TASKS AND RESPONSIBILITIES OF THE NURSE.23
1.5. EXPECTED OUTCOMES OF SURGICAL TREATMENT PERFORMED 26
1.6. MEDICAL MANAGEMENT OF PHYSIOLOGIC OUTCOME.27

1.7. NURING MANAGEMENT OF PHYSIOLOGIC, PHYSICAL, AND

PSYCHOSOCIAL OUTCOMES...2
V.CONCLUSION3
VI. REFERENCES/ BIBLIOGRAPHY.3

1
I. Introduction

The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to

the cecum just below the ileocecal valve. No definite functions can be assigned to it in
humans. The appendix fills with food and empties as regularly as does the cecum, of
which it is small, so that it is prone to become obstructed and is particularly vulnerable to
infection (appendicitis).

Appendicitis is the most common cause of acute inflammation in the right lower
quadrant of the abdominal cavity. Appendicitis is the inflammation of the vermiform
appendix and was first described as a pathologic condition by Reginald Fitz in 1886, it is
caused by an obstruction attributed to infection, stricture, fecal mass, foreign body or
tumor. About 7% of the population will have appendicitis at some time in their lives, males
are affected more than females, and teenagers more than adults. It occurs most
frequently between the age of 10 and 30. The disease is more prevalent in countries in
which people consume a diet low in fiber and high in refined carbohydrates. The lower
quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting.
Loss of appetite is common. In up to 50% of presenting cases, local tenderness is elicited
at Mc Burneys point applied located at halfway between the umbilicus and the anterior
spine of the Ilium.
Rebound tenderness (ex. Production or intensification of pain when pressure is released)
may be present. The extent of tenderness and muscle spasm and the existence of the
constipation or diarrhea depend not so much on the severity of the appendiceal infection
as on the location of the appendix. If the appendix curls around behind the cecum, pain
and tenderness may be felt in the lumbar region. Rovsings sign maybe elicited by
palpating the left lower quadrant. If the appendix has ruptured, the pain become more
diffuse, abdominal distention develops as a result of paralytic ileus, and the patient
condition become worsens. It typically results in abdominal pain and tenderness and it is
thought to usually be the result of an obstruction of the appendiceal lumen by either

2
lymphoid hyperplasia, the growth of cells to create lymph tissue, a foreign body, or a
fecalith, a mass of feces, but it can also be caused by parasitic infection. This obstruction
leads to distention, bacterial growth, and inflammation. Typical symptoms include dull,
visceral abdominal pain accompanied with nausea and vomiting that shifts to concentrate
over McBurneys point with tenderness as well as a low- grade fever. These symptoms,
however, appear in less than 50% of the patients and often other diagnostic procedures,
such as ultrasound or laboratory tests can never rule out appendicitis. The treatment is
surgical removal, but if left untreated necrosis, gangrene and perforation occur (Ansari,
2007). Appendicitis is the most common disease requiring surgery and one of the most
commonly misdiagnosed diseases.

Appendectomy is the removal of the appendix, is the standard treatment for acute
appendicitis, it is important to immediately remove the appendix after the diagnosis to
prevent the occurrence of the life-threatening complication of appendix. The most
frequent complication of appendicitis is perforation. Perforation of the appendix can lead
to a periappendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection
of the entire lining of the abdomen and the pelvis). The major reason for appendiceal
perforation is delay in diagnosis and treatment. In general, the longer the delay between
diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours after
the onset of symptoms is at least 15%. Therefore, appendicitis is diagnosed, surgery
should be done without unnecessary delay.

One thousand cases of appendicitis seen from 1963 to 1973 were reviewed. The overall
negative appendectomy rate was 20%, but in women between ages 20 and 40 it
exceeded 40%. Two thirds of the negative appendectomies were due to nonsurgical
lesions. Mesenteric adenitis, gastroenteritis, and abdominal pain of unknown cause
accounted for one third of the errors in females and two thirds in males. These diseases
were best distinguished from appendicitis on the basis of temperature and white blood
cell count. The remainder of the errors in females were due to pelvic inflammatory disease
or other gynecologic diagnoses and were best distinguished from appendicitis on the
basis of history and physical findings.
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The rate of perforation was 21% overall. The incidence of wound infection was 8.5%. Use
of systemic antibiotics did not affect the wound infection rate.

In 1984, 24,794 appendectomies and abscess drainage procedures were

performed for acute appendicitis in California hospitals. Analysis of hospital discharge
abstracts revealed age- and sex-specific incidence rates and in- hospital case fatality
rates for acute appendicitis lower than previously reported. In persons aged 60 years and
older, the case fatality rate for nonperforating appendicitis with appendectomy was 0.7%
and for perforating appendicitis and abscess 2.4%. Surgery was delayed beyond the day
of admission in 21% of persons aged 4059 years, 29% of persons aged 6079 years,
and 47% of persons aged 80 years and over. The proportion of cases with perforation
increased from 22% to 75% between ages 20 and 80 years. The population incidence of
perforating appendicitis changed little after age 20 years, while the incidence of
nonperforating cases declined sharply. The high proportion of appendicitis cases with
perforation among the elderly may be due to the decreased incidence of nonperforating
appendicitis in the elderly and not to a greater propensity for perforation, as previously
proposed. Most elderly in California receive timely surgery for appendicitis and tolerate it
better than previously reported. Diminished tolerance for intra-abdominal infection may
be the primary determinant of the increase in case fatality with age.

Historically, the diagnosis of appendicitis has been made based on clinical

findings. Diagnostic imaging has been used primarily to evaluate patients who have an
atypical clinical presentation. Over the past several years, improvements in imaging
technology have contributed to an increase in diagnostic accuracy in these patients.
Ultrasound has been suggested and used as the primary diagnostic imaging modality to
evaluate for appendicitis. However, sonography is known to be highly operator
dependent; large patient habitus and atypical appendiceal location are additional factors
that may reduce the reliability of a negative sonographic examination for appendicitis.
CT is more accurate than ultrasound in the diagnosis of acute appendicitis. When
dedicated CT examination of the appendix is performed to evaluate all patients with
clinically suspected appendicitis, the diagnostic accuracy is 98%.
4
Early and accurate diagnosis of appendicitis can decrease patient morbidity and hospital
costs by reducing the delay in diagnosis of appendicitis and its associated complications,
as well as by avoiding inpatient observation prior to surgery in patients who present with
atypical symptoms. Furthermore, both CT and ultrasound may rapidly provide alternative
diagnoses which can be treated on an outpatient basis.

We found this disease condition challenging and interesting so we preferred this

case to alert to related community at the right time then we can enhance our knowledge
about the appendicitis and reduces the incidence of morbidity and complications.

5
II. ANATOMY AND PHYSIOLOGY

DIGESTIVE SYSTEM

The human digestive system is a complex series of organs and glands that
processes food. The digestive system consists of the digestive tract or gastrointestinal
plus specific associated organs. Most of the digestive organs are tube-like and contain
the food as it makes its way through the body. The Digestive system is essentially a long
twisting tube that runs from the mouth to the anus plus few organs like liver and pancreas
that produce or store digestive chemicals.

The mouth- Where digestion begins, Food is partly broken down by the process of
chewing and by the chemical action of salivary enzymes.

6
 The esophagus- After the food being chewed and swallowed, it enters the esophagus.
Esophagus is a muscular tube, lined with moist stratified squamous epithelium that
extends from the pharynx to the stomach. It use uses rhythmic, wave like muscle
movements (called peristalsis) tp force food from the throat into the stomach.

1. The stomach- the internal organ in which the major part of the digestion of food occurs,
being (in humans and many mammals) a pear-shaped enlargement of the alimentary
canal linking the esophagus to the small intestine. It is a sac like organ that churns the
food and bathes it in a very strong acid (gastric acid). The opening from the esophagus
into the stomach is called the Gastroesophageal opening. The region of the stomach
around the gastroesophageal opening is called the cardiac region because it is near the
heart. The most superior part of the stomach is the Fundus. The largest part of the
stomach is the Body, Which turns to the right forming a greater curvature on the left and
a lesser curvature on the right. The opening from the stomach into the small intestine is
the Pyloric opening, Which is surrounded by a relatively thick ring of smooth muscle
near the pyloric opening is Pyloric region. The submucosa of the stomach are thrown
into large folds called Rugae.

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The small intestines- After being in the stomach, Food enters the Duodenum, The first
part of the small intestine. It then enters the Jejunum and then Ileums (The final part of
the small intestine). In the Small intestines, Bile (produced in the liver and stored in the
Gall bladder), Pancreatic enzymes, and other digestive enzymes produced by the inner
wall of the small intestine to help in the breakdown of food.

The large intestine- Food passes into the large intestine after passing through the small
intestine. In the large intestine, some of the water and electrolytes are removed from the
food. The first part of the large intestine is called Cecum. Cecum is the proximal end of
the large intestine where it joins with the small intestine at the Ileocal junction. The Cecum
is located in the right lower quadrant of the abdomen near the iliac fossa. Then food
travels upward in the ascending colon, goes back down the other side of the body in the
descending colon, and then through the sigmoid colon.

8
The Appendix is a closed-ended, narrow tube up to several inches in length that attaches
to the cecum. It is 9cm long. The anatomical name of the appendix is vermiform appendix
which means worm like appendage. The appendix is usually located in the right iliac
region, just below the ileocecal valve (designated Mc Burneys point) and can be found
at the midpoint of a straight line drawn from the umbilicus to the right anterior iliac crest.
And located in the lower right quadrant of the abdomen. 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. The appendix function as the part of Immune
system. It helps tell lymphocytes where they need to go to fight an infection and it boosts
the large intestines immunity. And it latter helps keep your gastrointestinal tract from
getting inflamed in response to certain food and medication ingested.

9
THE PATIENT AND HIS ILLNESS
PATHOPHYSIOLOGY (SCHEMATIC DIAGRAM)

NON-MODIFIABLE RISK MODIFIABLE RISK FACTORS

FACTORS
Diet (Low-fiber diet)
Family History Occlusion of Fecal
Gender (Male) Materials
Age (Between 10-30 Fibrous Conditions (Cystic
years old) Fibrosis)
Season (Summer) Inflammatory Bowel
Disease (Chrons Disease)
Infection with Yersinia
organisms

Obstructed appendix

Increased intraluminal
pressure

Decreased venous
drainage

Thrombosis, edema, bacterial invasion (abscess formation)

Gangrene and perforation

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B. SYNTHESIS OF THE DISEASE

B.1. DEFINITION OF THE DISEASE

Appendicitis is the inflammation of the vermiform appendix that develops most

commonly in adolescents and young adults. It can occur at any age but is rare in clients
younger than 2 years and reaches a peak incidence in clients between 20-30 years old.
No particular risk factors for appendicitis have been identified. Because it is not
preventable, early detection of the condition is important.

B.2. PREDISPOSING/PRECIPITATING FACTORS

NON-MODIFIABLE FACTORS:

Family History A positive family history increases relative risk of having acute
appendicitis nearly 3 times
Gender Males are more prone to appendicitis compared to females with a risk
ration of 1.4:1. An American Journal of Epidemiology study in 1990 found that
appendicitis was a common condition affecting approximately 6.7% of females and
8.6% of males.
Age Appendicitis generally affects people aged between 10 and 30, but it can
strike at any age
Season - Studies suggests that people get appendicitis more during the summer
than other times of the year, likely due to a combination of increased air pollution,
more GI infections, and greater consumption of fast food.

MODIFIABLE FACTORS:

Diet - Research also suggests that the typical "Western diet," which is high in
carbohydrates and low in fiber, can increase your chances of developing
appendicitis. Without enough fiber in your diet, bowel movements slow down,
increasing the risk of appendix obstruction.

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 Occlusion of fecal material - Appendicitis is usually caused by a blockage of the
inside of the appendix, which is called the lumen. Most often, the lumen is blocked
by fecal material.
Fibrous Conditions - Appendicitis, once thought to be rare in patients with cystic
fibrosis, is increasingly recognized, with a reported incidence of 1%2%, compared
with an overall incidence of 7% in healthy subjects.
Inflammatory Bowel Disease - There are numerous issues that can cause
appendix lumen blockage. One could be cause by irritation and ulcers in the
gastrointestinal (GI) tract resulting from long-lasting disorders such as Chrons
disease
Infection with Yersinia organisms According to Surgical Pathology of
Gastrointestinal System, Yersinia, a Gram-negative coccobacilli, is responsible
for many cases of isolated granulomatous appendicitis

B.3. SIGN AND SYMPTOMS

Abdominal pain - As the appendix becomes more swollen and inflamed, it will
irritate the lining of the abdominal wall, known as the peritoneum. This causes
localized, sharp pain in the right lower part of the abdomen.

Point tenderness A cardinal sign of appendicitis is point tenderness. This is a

defined area of tenderness in the right lower quadrant which is called the
Mcburneys point.

Rebound tenderness This is a sign of inflammation in which pain is elicited by

the sudden release of the fingertips pressing on the right lower quadrant.

Mild fever- The bacteria trapped in the stool affects the appendix which can lead
to infection and manifest a mild fever.

Nausea and Vomiting- After the abdominal pain begins, a person with appendicitis
feels nauseated. This is also caused by the obstruction.
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IV. CLINICAL INTERVENTION

1.1. DESCRIPTION OF PRESCRIBED SURGICAL TREATMENT PERFORMED

An appendectomy is the surgical removal of the appendix. Its a common emergency

surgery thats performed to treat appendicitis, an inflammatory condition of the appendix.

Preoperative Workup and Preparation for Appendix Removal

Fluid Resuscitation this usually consists of crystalloid fluids intravenously to restore

any intravascular fluid depletion that might be present due to inflammation of the
peritoneum (peritonitis) and fluid sequestration in the intraabdominal tissues (third
spacing). The fluid given is usually normal saline solution or lactated Ringers solution.

Antibiotics uniformly given. Since the appendix comes off the terminal ileum at the
juncture of the colon, rupture leads to spillage into the peritoneal cavity of gram negative
and anaerobic bacteria. The type antibiotics given are Unasyn and Flagyl (metronidazole)
or Zosyn (pipercillin-tazobactam) or in the case of a person with a penicillin allergy
ciprofloxacin and Flagyl
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Incision for Appendix Removal

McBurney incision most appendix removal proceduree use this mall incision that runs
diagonally on the abdominal wall in the right lower quadrant (i.e., parallel to the edge of
the external oblique muscle or in the direction running from the hip bone to the pubic
bone.)

Rocky-Davis incision small incision that runs horizontally on the abdominal wall in the
right lower quadrant

Midline incision this is sometimes done is the patient is obese or if the surgeon is
anticipating the need for a formal resection of the terminal ileum and cecum (i.e., if the
appendix has ruptured at the base)

Surgical Details of Procedure for Appendix Removal

1. To start an appendix removal, the skin incision is made with a knife.

2. Bovie electrocautery is used to dissect through subcutaneous tissue and control small
skin bleeding.

3. The aponeurosis (muscle sheath) of the outer layer of the external oblique muscle is
visualized and split by a small incision with a knife and then further opened along the
direction of the fibers with a scissors or the Bovie.

14
4. The muscle belly of the external oblique is then bluntly retracted (but not cut) using the
classic muscle splitting technique via a hemostat or Kelly clamp until the aponeurosis of
the internal oblique is visualized.

5. The aponeurosis of the internal oblique is split in a similar manner as the external
oblique.

6. The muscle belly of the internal oblique is bluntly retracted in a similar manner as the
external oblique until the peritoneum is visualized.

7. The peritoneum is grasped on either side by two forceps, pulled up and into the wound,
and palpated to insure there is no bowel caught in the fold of the peritoneum.

8. The peritoneum is opened with a small incision using either a knife or scissors.

9. The peritoneal fluid is immediately inspected for amount and prurulence and cultures
are taken.

10. The opening in the peritoneum is widened and two hand-held retractors are placed to
expose the cecal area.

11. Manual and visual exploration for the appendix is performed by locating the
convergence of the cecum and the terminal ileum.

12. The appendix is delivered up into the wound either by digitally flipping it up or be
grasping the base with a Alice or Babcock and applying traction to allow dissection of any
adhesions holding it in the abdominal cavity.

13. The entire appendix is inspected with close attention to the base to insure that the
area of rupture is sufficiently distant from the base to allow a margin of healthy tissue.

14. If the base of the appendix is involved in the rupture a limited right hemicolectomy is
done (see right hemicolectomy).

15
15. If the base of the appendix is not involved, the mesoappendix or mesentery of the
appendix is divided, cross-clamped with Kelly clamps or hemostats and tied with 2-0 or
3-0 silk usually

16. When the appendix has been isolated from the mesoappendix, the appendix proximal
to the rupture is crushed with a straight clamp.

17. Two chromic ties are then placed on the area of crushed appendix.

18. The appendix is then resected off the stump distal to the ties using a knife.

19. The exposed mucosa is then ablated by the Bovie cautery.

20. Some surgeons then prefer to dunk the tied-off appendiceal stump by placing a
running pursestring suture around the stump.

21. The intraabdominal area is inspected for bleeding and pockets of remaining infection.

22. Most surgeons will irrigate the abdominal cavity with saline solution or antibiotic-
containing saline solution.

23. The edges of the peritoeum are reapproximated using a running 3-0 or 4-0 Vicryl
suture.

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24. The edges of the internal oblique aponeurosis are reapproximated using a 1-0 or 2-0
Vicryl suture.

25. The edges of the external oblique aponeurosis are likewise reapproximated.

26. The superficial wound is irrigated.

27. If the appendix has ruptured before the appendix removal surgery and there was frank
pus, many surgeons will leave the subcutaneous tissue and skin open to heal by
secondary intention.

28. If the appendicitis was in the early stages or was normal the subcutaneous tissue can
be closed at the level of Scarpas fascia with interrupted or running 2-0 Vicryl suture.

29. The skin is closed with staples, interrupted Nylon sutures, or a subcuticular
absorbably suture such as Monocryl

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 1.2 INDICATION OF PRESCRIBED SURGICAL TREATMENT

AppendicitisThis is the most common indication for appendix removal

(appendectomy). A blockage in the lining of the appendix that results in infection
is the likely cause of appendicitis. The bacteria multiply rapidly, causing the
appendix to become inflamed, swollen and filled with pus. If not treated promptly,
the appendix can rupture.
Mass If it remains localized, it does so by forming an ''appendix mass' of adherent
coils of gut. This may then resolve, or pus may gather, so that an abscess forms.
The distinction between: (1) a ''mass' which is not tender, or is only minimally
tender, and over which there is no guarding or rigidity, and (2) an obviously tender
''abscess' is important, because an abscess may need draining, but a mass can
be treated nonoperatively.
Severe Stomach Pain Severe stomach pain that lasts up to 6 hours and is
focused on the right lower quadrant of the abdomen. If you are concerned that you
may have appendicitis it is important to seek medical attention quickly, as if it is
left untreated it may lead to infection and further complications
Abscess if found secondary to appendicitis it must be drained. May resolve or it
may enlarge until it drains spontaneously to the surface, or into the patient's gut,
or into his peritoneal cavity, where it causes generalized peritonitis.
Peritoneal inflammation- Is responsible for the most important sign of
appendicitis, tenderness in the right iliac fossa. Significant rigidity is a sign that
peritonitis is spreading.
Risk:

Bleeding

Infection

Injury to nearby organs/ perforation

Blocked bowels/ paralytic ileus

Benefits:
Relief of pain
Back to the normal life

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1.3 REQUIRED INSTRUMENTS, DEVICES, SUPPLIES, EQUIPMENTS, AND
FACILITIES INSTRUMENTS:

Appendectomy Set

An appendectomy (appendisectomy or appendicectomy) is the surgical removal of the

vermiform appendix. Medical Tools comprehensive 67 Pcs Appendectomy Set is
designed for clinical needs and practical challenges.Kit has all necessary tools to
perform Appendectomy Surgery. All tools are made from high grade surgical stainless
steel used by professionals.

Kelly clamp - used to clamp larger vessels and tissue

Bobcock - used to grasp delicate tissues

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 Scalpel - Cuts tissue with fewer traumas than any other instrument

Tissue Forceps - bladed instrument with a handle, used for compressing or

grasping tissues in surgical operations, handling sterile
dressings, and other purposes

20
 Allis - used for lifting, holding and retracting slippery dense tissue that is being
removed

Needle holder - used to grasp and guide the needle when suturing

Army-Navy retractor - used to retract shallow or superficial incisions

21
 Thumb forceps - used to hold tissue in place when applying sutures, to gently move
tissues out of the way during exploratory surgery and to move dressings or draping
without using the hands or fingers

Cautery machine -application of a high-frequency electric current to biological

tissue as a means to cut, coagulate, desiccate, or fulgurate tissue.

Operating sponge - useful for everything from wound debriding to prepping, packing
and dressing wounds as well as all-around general wound care.

22
 Operating room - also known as operating theater, operating room (OR) or
operating suite, is a facility within a hospital where surgical operations are carried
out in a sterile environment

23
1.4. PERIOPERATIVE TASKS AND RESPONSIBILITIES OF THE NURSE

SCRUB NURSE
Pre-operative Responsibilities:
Assist with the preparation of the room for the designated surgical procedure,
including gathering supplies for the procedure.
Scrub, Dry hands, and Glove.
Assist person scrubbed in first position with:
Setting up back table, mayo, and basins
Arrangement of instruments
Preparation of sutures and needles
Preparation and counting sponges
Arrangement and preparation of other necessary items
Gowning and gloving surgeon and assistants
Assist with draping
Arrangement of sterile field
Assure the electrosurgical dispersive pad is attached to the patient.

Intra-operative Responsibilities:
During the procedure, train self to keep eyes on field, and learn steps of procedure.
Begin developing methods of anticipating needs of surgeon and assistant.
Give the instrument needed by the surgeon.
After closing the skin:
Assist with care of instruments and counts if necessary
Care of specimen
Assist with wound dressing

Post-operative Responsibilities:
After the completion of the procedure:
Assist with the gathering of all materials used in the procedure
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 Discard items as necessary being careful to discard sharp items in designated
Return all items to respective area
Assist with cleaning of room
Clean the materials used properly and arrange them after drying
Perform any duties which will speed up surgical procedure to follow in that room.

CIRCULATING NURSE
Pre-operative Responsibilities
Care for the patient before surgery by:
Greeting patient and assist nurse with identification
Checking of patients chart, preparation, etc.
Checking IV Patency
Prepare room by:
Obtaining instruments, supplies, and equipment for the designated operative
procedure
Opening unsterile supplies
Assisting in gowning
Observing breaks in sterile technique
Assisting anesthesiologist as necessary
Assisting with skin preparation and positioning
Assisting with forming of the sterile field
Count the instruments, sharps, and sponges before the procedure and confirm with
the scrub nurse.

Intra-operative Responsibilities
During the procedure:
Remain in room and dispense materials as necessary
Observe procedure as closely as possible
Begin establishing method of anticipating needs of surgical team
Care of specimen as indicated
Care of operative records as indicated
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 Before the closing of the organ or peritoneum, count all instruments, sharps, and
sponges and confirm with the scrub nurse.
Inform the surgeon and assistant surgeon of a report of the instruments.

Post-operative Responsibilities
Properly document all the necessary information on the patients chart.
Assist in the cleaning of the Operation room as necessary.

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1.5. EXPECTED OUTCOMES OF SURGICAL TREATMENT PERFORMED

healing within a few weeks is the usual outcome after an uncomplicated

appendectomy.
Clear liquids are offered, once tolerated, the diet is progressed. If the patient is
eating and drinking, the Intravenous fluid is removed.
Most patients need medication to relieve the pain in and around the incision.
Physical activity, such as getting out of bed, begins on the same day as the
surgery or the next morning. Early movement is desirable for fast recovery, but
caution is needed for climbing stairs so as not to strain the abdominal muscles.
Patients with uncomplicated surgeries usually leave the hospital 1 or 2 days
following surgery.
Normal activities can be resumed within a few days, but it takes 4 to 6 weeks for
full recovery. Heavy lifting and strenuous activity should be avoided during
recovery.
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 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.
If antibiotics and/or pain medication are prescribed, they should be taken as
directed.
The open procedure leaves a scar on the lower right side of the abdomen that is
a few inches long and fades over time.
Overall, patients may return to their activities soon after the operation. Once the
patient has recovered, no changes in lifestyle (eg, diet, exercise) are required
after appendectomy.
According to an article from the Journal of Pediatric Surgery, families experience
significant parenting distress related to patients functioning and disruption in
quality of life in fully resolving the medical condition.

27
1.6 Medical Management of Physiologic Outcomes

28
1.7. NURSING MANAGEMENT OF PHYSIOLOGIC, PHYSICAL, AND PSYCHOSOCIAL OUTCOMES
PRE-OPERATIVE:
ANXIETY RELATED TO THREAT TO CHANGE IN HEALTH STATUS
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES INTERVENTION EXPECTED
DIAGNOSIS RATIONALE S OUTCOME
S= Anxiety r/t threat Anxiety is a Short-term: Monitor and Short-term:
O= to change in multisystem record vital signs
health status response to After 4hrs. of - to obtain After 4hrs. of
Patient may nursing baseline data nursing
perceived threat or
manifest the interventions, the interventions, the
following: danger. It reflects to patient will patient shall have
the biochemical verbalize Asses level of verbalized
- Irritability change of the body. awareness of anxiety awareness of
- Increased And it was feelings of - to determine feelings of
perspiration described as an anxiety level of anxiety anxiety.
- decreased unpleasant state of and intervention
BP
tension or
- restlessness Long-term: Long-term:
- poor eye uneasiness that Identify and
contact result to fear. After 2 days of promote coping After 2 days of
- altered nursing skills nursing
attention interventions, the - to help the interventions, the
patient will patient in patient shall have
appear relaxed managing anxiety appeared relaxed
and report that and report that
anxiety is anxiety is reduced
reduced to a

29
manageable Always be to a manageable
level. available to client level.
for listening and
talking
- to minimize
anxiety

Be truthful and
provide physical
comfort
- to soothe fears
and provide
assurance

Provide accurate
information about
the situation
- helps the client
identify what is
reality based

Instruct to do
diversional
activities such as
listening to
music, reading
newspapers and
etc.
30
- to divert the
focus of the
patient and
lessen anxiety

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HYPERTHERMIA
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS EXPECTED
DIAGNOSIS RATIONALE OUTCOME
S= Hyperthermia Hyperthermia is a Short-term: Monitor and record Short-term:
Patient may condition wherein vital signs
verbalize: After 4hrs. of - to obtain baseline After 4hrs. of
masakit ang ulo the bodys nursing data nursing
ko temperature rises. interventions, the interventions, the
Illness may result to patient will Identify underlying patient shall have
hyperthermia/fever maintain a core cause maintained a core
O= due to increased temperature - to note infection or temperature within
within normal complications normal range.
Patient may metabolism. range.
manifest the A fever is a Assess neurologic
following: responses Long-term:
- weakness temporary increase Long-term: - to avoid seizure
- dizziness in your body activity After 2 days of
- nausea temperature, often After 2 days of nursing
- increased body due to an illness. nursing Provide TSB interventions, the
temperature Having a fever is a interventions, the - to decrease patient shall have
- warm to touch patient will be temperature been free of seizure
- unstable blood sign that something free of seizure activity.
pressure out of the ordinary activity. Administer fluids
is going on in your - to replaced fluids
body. Administer
antipyretics as
ordered
- to decrease
temperature
32
RISK FOR DEFICIENT FLUID VOLUME RELATED TO PREOPERATIVE VOMITING
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES INTERVENTION EXPECTED
DIAGNOSIS EXPLANATION S OUTCOMES
S= Risk for deficient Preoperative Short Term: >Monitor and Short Term:
fluid volume vomiting is the record vital signs
After 4 hours of After 4 hours of
related to actual oral
nursing -to obtain nursing
O= preoperative expulsion of
intervention the baseline data intervention the
vomiting gastrointestinal
patient will be patient shall have
contents, It is the
able to demonstrated
Patient may manifest result of contraction
demonstrate >Assess general behaviors or
the following: of the gut and the
behaviors or condition lifestyle changes
thoracoabdominal
lifestyle changes to prevent
wall musculature - to identify
to prevent development of
>decreased urine cause
development of fluid volume
output
fluid volume deficit.
deficit.
>Note clients
>sudden weight loss level of
Long term:
consciousness
Long term: After 2 days of
and mentation
After 2 days of nursing
>decreased blood
nursing -to evaluate intervention the
pressure
intervention the ability to express patient shall have
patient will be needs identified
able to identify individual risk

33
>increased pulse rate individual risk factors and
factors and appropriate
>Monitor I&O
appropriate interventions.
>decreased skin or interventions. - ensure
tongue turgor accurate picture
of fluids status

>dry skin and

mucous membranes >Evaluate
nutritional status,
noting current
>change in mental intake, type of
state diet

- to note problem
that can
negatively affect
fluid intake

>Encourage the
client to drink
prescribed fluid
amounts
- oral fluid
replacement is

34
indicated for mild
fluid deficit and is
a cost-effective
method for
replacement
treatment.

35
POST-OPERATIVE
ACUTE PAIN RELATED TO POST SURGICAL INCISION

ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING EVALUATION

DIAGNOSIS EXPLANATION RESPONSIBILITES
S= Acute pain related The patient Short-term: Establish Short-term:
Patient may to post surgical experiencing pain After 8 hours of therapeutic After 8 hours of
verbalize: incision due to the presence nursing relationship nursing
Ang sakit ng of surgical incision intervention the -to gain trust and intervention the
tahi sa tyan ko on the RLQ of the patient will cooperation of the patient will
abdomen. Acute reduced pain patient reduced pain
Pain scale <6/10 pain is describe as scale from 6 to scale from 6 to
unpleasant sensory 4/10 Assess for referred 4/10
O= or emotional pain
Patient may experience -to help determine
manifest: associated with Long-term: possibility of Long-term:
-restlessness actual or potential underlying condition
and irritability tissue damage or After 4 days of or organ dysfunction After 4 days of
-facial grimace injury as lasting nursing requiring treatment nursing
-guarding from seconds to 6 interventions the interventions the
behavior months. patient will be free Maintain patient shall have
-wincing upon from pain. immobilization of been free from
movement affected part by pain.
-(+) moaning and means of bed rest
crying -to relieve pain and
prevents bone and
36
-Altered ability to displacement and
continue extension of tissue
previous injury
activities
-Fatigue Elevate bed covers
-Anorexia and keep linens off
-Atrophy of toes
involved muscle -maintain body
groups warmth without
comfort due to
pressure of bed
clothes on affected
area

Provide alternative
comfort measures
like gradually
changing of position
-improves general
circulation and
reduces areas of
local pressure and
muscle fatigue

37
Provide emotional
support and stress
management
- promotes sense of
control and may
enhance coping
abilities

Identify diversional
activities for patient
age, physical
abilities and
personal
preferences
-to divert attention to
pain

Investigate any
reports of unusual or
sudden pain or
deep, progressive
and poorly localized
pain unrelieved by
analgesics
-may signal
developing
complications like
infection, tissue

38
ischemia,
compartmental
syndrome

Administer
analgesic as
indicated
-to maintain
acceptable level of
pain. Notify the
physician if regimen
is inadequate to
meet pain control
goal

Collaborate in
treatment of
underlying condition
or disease
processes causing
pain and proactive
management of pain
-to assess the
general condition of
the patient

39
IMPAIRED COMFORT RELATED TO POST SURGICAL PROCEDURE

ASSESSMENT NURSING BACKGROUND PLANNING NURSING EVALUATION

DIAGNOSIS KNOWLEDGE RESPONSIBILITES
S= Impaired comfort Impaired comfort Short-term: Independent: Short-term:
related to post perceived lack of Establish therapeutic
Hindi ako surgical ease and relief. After 4 hours of relationship After 4 hours of
makatulog dahil procedure The client has a nursing nursing
-to gain trust and
masakit ang tahi surgical interventions the interventions the
cooperation of the
sa tyan ko. management of patient will engage patient shall have
patient
appendectomy in behaviors or engaged in
O= which alters his lifestyle changes to Explain all the behaviors or
Patient may comfort because increase level of procedures to the lifestyle changes
manifest: of the presence of ease. patient to increase level
pain in the of ease.
-to be aware to
- (+) surgical area. Long-term:
different procedure
restlessness After 3 days of Long-term:
that will be done to
and irritability nursing After 3 days of
him and to also lessen
- (+) numbness interventions the nursing
his anxiety
on lower patient shall have interventions the
extremities verbalized sense of Assess vital signs and patient shall have
- (+) guarding comfort or record verbalized sense
behavior contentment. of comfort or
-to obtain baseline
- (+) moaning contentment.
data
and crying
- Changes in
sleeping pattern

40
Fatigue Evaluate clients
ability to provide self-
care

-self-care places an
important part in
maintaining integrity
of the skin

Encourage the patient

to increase fluids

-to prevent
dehydration
Encourage the patient
to do ROM exercise

-to maintain muscle

and bone integrity and
to prevent muscle
atrophy on both lower
and upper extremities
Review knowledge
base and note coping
skills that have been
used previously

41
-to change behavior
and promote well-
being

Provide age-
appropriate comfort
measures like change
of position
-to promote non-
pharmacological pain
management

Encourage/plan care
to allow individually
adequate rest periods
-to prevent fatigue

Schedule activities for

periods when client
has the most energy
-to maximize
participation

Assists client to use

and modify
medication regimen

42
-to make best use of
pharmacological pain
or symptom
management

Collaborate in treating
or managing medical
condition involving
oxygenation,
electrolyte balance
and hydration ---to
promote physical
stability

Discuss intervention
such as TT or
therapeutic touch

-to non
pharmacological pain
management

Make appropriate
referrals

-to available support

groups and service
organization

Collaborate with
others when client

43
expresses interest in
counseling

-to enhance emotional

and spiritual comfort

44
V. CONCLUSION

Camille Jamaica S. Busick

Keren Michal B. Capitulo

Christine Kate R. Dayrit

Appendicitis is a very common diagnosis here in the Philippines. Appendicitis does

not respond well to antibiotics. That is why the most common treatment is removal of the
appendix. Knowing about such risks and their signs may help you detect and treat them
early. And we can irradicate complication easily. Unfortunately, we cant prevent
appendicitis but according to study, it occurs less to those who eat high-fiber foods,
including fresh fruits and vegetables. So proper diet one key to prevent this disease. I
learned that once you there is pain, you should always consult your doctor and avoid self-
medicating in order to avoid aggravating your condition. Its always better to be safe than
sorry.

Rachelle Dianne A. Enriquez

I have learned how to proper assess the patient with appendicitis, the signs and
symptoms, the risk factors and the proper management for the said disease condition.
Thorough assessment is the key in order to arrive in the right diagnosis.

Raidis Naomi M. Pangilinan

Justine Kenneth Z. Ramos
Chrisha Kaye Sunga
Tai-yuan R. Yeh
Eleazar P. Tapnio Jr.
James Francis B. Tuvera

45
IV. References/Bibliography
Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical management for
positive outcomes. St. Louis, MO: Saunders/Elsevier.

Wise, Barbara Vollenhover. Nursing Care of the General Pediatric Surgical Patient.
Gaithersburg, MD: Aspen, 2000
Seeley, R. R. (2011). Seeley's anatomy & physiology. New York, NY: McGraw-Hill.
Online References:

http://nursingcrib.com/case-study/appendicitis-case-study/

http://smritimanandhar.com/2012/07/a-case-study-on-appendicitis.html

http://aje.oxfordjournals.org/content/129/5/905.short

http://archsurg.jamanetwork.com/article.aspx?articleid=580485

http://www.medindia.net/patients/patientinfo/appendicitis.htm
http://www.healthcommunities.com/appendicitis/postoperative-care-
appendectomy.shtml
http://www.ncbi.nlm.nih.gov
http://www.everydayhealth.com/appendicitis/guide/children
http://www.medicalnewstoday.com/articles/158806.php
http://sites.psu.edu/medicinewithtravis/2014/02/07/surgery-1-open-appendectomy/

http://insidesurgery.com/2006/04/appendix-removal-appendectomy/

http://www.surgeons.org.uk/general-surgery-operation-howto/open-
appendicectomy.html

http://www.healthline.com/health/appendectomy#Recovery6

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