Lyceum of the Philippines University

College of Nursing
Capitol Site, Batangas City

A Case Study on
Acute Appendicitis

Prepared by:
Culla, Jan Rubin M.
Deang, Czarina Jayne M.
De Asis, Kimberly Cherisse A.
De Guzman, Shayne Marie
De Roxas, Limwel Justine M.

Batch 2019
 TABLE OF CONTENTS

I. Introduction
II. Objectives
III. Patient’s Profile
IV. Clinical Appraisal
V. Physical Assessment
VI. Anatomy and Physiology
VII. Pathophysiology
VIII. Diagnostic and Laboratory Results
IX. Nursing Care Plan
X. Drug Study
XI. Discharge Plan
XII. Prognosis
XIII. Acknowledgement
XIV. Recommendation
Introduction:
Acute appendicitis is inflammation of the appendix, the narrow, finger-
shaped organ that branches off the first part of the large intestine on the right side
of the abdomen. Although the appendix is a vestigial organ with no known function,
it can become diseased. In fact, acute appendicitis is the most common reason for
abdominal surgery in the world.

Additionally, appendicitis is usually caused by a bacterial infection, although

the reason the appendix becomes infected is unknown. The appendix may become
obstructed by a lump of feces, calcium salts, and fecal debris (called fecaliths) or
tumors (rarely), leading to inflammation and infection. Swelling and
inflammation lead to infection, blood clot, or rupture of the appendix. Lymphoid
hyperplasia is associated with inflammatory and infectious disorders such as
Crohn disease, measles, amebiasis, gastroenteritis, respiratory infections, and
mononucleosis. (Remedy’s Healthcommunities.com 2014)

The clinical presentation of appendicitis is notoriously inconsistent. The

classic history of anorexia and periumbilical pain followed by nausea, right lower
quadrant (RLQ) pain, and vomiting occurs in only 50% of cases. (Sandy Craig
2017)

The incidence of appendicitis escalated in Western countries during the

1900s until without explanation the incidence decreased in the mid-part of the 20th
century. In contrast, appendicitis was relatively uncommon outside Western
countries during the 20th century. However, at the turn of the 21st century newly
industrialized countries are reporting a rising incidence of appendicitis. (Ferris, M.,
et al 2017)

The annual mortality rate per 100,000 people from appendicitis in

Philippines has decreased by 34.7% since 1990, an average of 1.5% a year. For
men, the deadliness of appendicitis in Philippines peaks at age 80+. It kills men at
the lowest rate at age 5-9. At 9.2 deaths per 100,000 men in 2013, the peak
mortality rate for men was higher than that of women, which was 5.3 per 100,000
women. Women are killed at the highest rate from appendicitis in Philippines at
age 80+. It was least deadly to women at age 5-9. (Health Grove 2016)

The group encountered a patient with a condition as such and their clinical
instructor gave them the opportunity to study the case; hence, this case study aims
to help understand the disease process of Acute Appendicitis and to orient one of
the appropriate nursing interventions that could be offered to patients.
GENERAL OBJECTIVES

This case presentation aims to identify and determine the general health
problems and needs of the patient diagnosed with Acute Appendicitis. This study
also intends to help promote health and medical understanding of such condition
through the application of nursing skills.

SPECIFIC OBJECTIVES

The case study will help the student nurses achieve significant information
about the case. Thus, being able to:

1. Familiarize themselves about Acute Appendicitis, its associated signs and

symptoms and its incidence rate for understanding the disease prevalence
and progress;
2. Gather data such as the patient’s profile including date of admission,
physician, chief complaint and admitting diagnosis;
3. Integrate information about the patient’s past and present health history as
well as family, personal, social, and psychological history as basis for
client’s mental health status;
4. Perform a physical assessment to completely assess client’s general
appearance and condition;
5. Determine the diagnostic and laboratory procedures, its results and relate
it to the condition of the client;
6. Review the anatomy and physiology of the heart that contributes to the
presenting signs and symptoms;
7. Develop and explain the pathophysiology of the disease, including its
etiology (modifiable and non-modifiable factors), process or illness, and
clinical manifestations;
8. Formulate an effective and efficient nursing care plan for the improvement
of patient’s health status;
9. Perform necessary nursing interventions and apply therapeutic
communication and therapies appropriate for the client;
10. Enumerate and discuss the drugs taken by the patient with their
corresponding doses, frequency, routes, contraindications, classification,
action, side effect, nursing responsibility and monitoring parameters;
11. Discuss information about the prognosis of the patient;
12. Formulate an appropriate discharge plan; and
13. Develop empathy and patience with client’s condition, learn and understand
the client’s attitude and behavior that are affected due to her condition.
Patient Profile

Patient Name: M.P.

Age: 32 years old

Gender: Female

Status: Married

Religion: Roman Catholic

Hospital No: 295346

Admission Date and Time: September 16, 2017

Admitting Diagnosis: Acute Appendicitis

Final Diagnosis: Acute Appendicitis

Reason for Admission

SUBJECTIVE DATA:

“SUmasakit itong bandang kanang t’yan sa may baba, sa sobrang sakit di na ako
makalakad.”

OBJECTIVE DATA:
 Facial grimace

 Holding of area in pain

 Sweating

 P – with or without movement

 Q – sharp pain

 R – RLQ

 S – 10/10

 T – continuous
Clinical Appraisal

General Survey:

Admitted last September 16, 2017, a 32 year old female accompanied by her
husband with chief complaint of pain at right lower quadrant of the abdomen.
Received client on bed wearing appropriate clothing according to the weather. Her
skin is evenly colored. She is awake and afebrile.

 BP – 100/60
 Temp – 36 C
 PR – 86 bpm
 RR – 20

Past Health History:

Last September 13, 2017, client complains of hypogastric pain shifted to

RLQ. She has a difficulty of urination. Last September 15, 2017, she went to a
hospital in Cabuyao Laguna for a check up. According to the check up, there is a
seventy percent (70%) chance that her diagnosis would be appendicitis. The client
and her husband decided to admit her in the hospital. However, she was referred
to Batangas Medical Center for its complete services.

Family History:

However, there is a history of hypertension on both sides of the family.

According to her, her mother has a heart disease.

Personal History:

The client is a mother of two children. She is unemployed. She possesses

a jolly personality. She is responsible for all the household chores together with
her husband. She admitted that she likes eating street foods, but she never forgets
to eat vegetables. She was a previous alcohol drinker.

Social History:

The client said that in her free time, she used to interact with her neighbors.
She participates in community activities if there is any. They also go to church
during Sundays and special occasions.

Psychological History:

In handling problems, she consults her husband. But according to her,

there is a minimal chance of problems to arise; little misunderstandings only. They
find time to solve every problem as soon as possible.
History of Present Illness:

Her condition Acute AP is not traced to her family nor her husband’s. It
was only her and her husband who had the condition.

Physical Assessment

PHYSICAL ASSESMENT

DATE September 18, 2017

General Client is wearing casual clothes. Client is with IVF of D5LR
Appearance @ L metacarpal. Wound of incision due to appendectomy
is present and is complaining of intermittent/ on and off
pain.
VITAL SINGS T 37.9 C
BP 80/60 mmHg
PR 85 bpm
RR 21

Body Pats Methods Findings Analysis

Skin Inspection &  Even Skin  Normal Findings

Palpation tone
 Sweaty  Due to
stimulation of
the
parasympathetic
nervous system
in response to
pain and stress
the client is
experiencing.

Head and Hair Inspection &  No lesions  Normal Findings

Palpation
 Dry coarse  Resulted from
hair poor hygiene

Eyes Inspection  Pupils  Normal

(PERRLA) constrict response of
when hit healthy eyes to
by light light

Nose Inspection  Reddish  Indicates cold

with clear
watery
discharge
 Ears Inspection  Few ear  Indicates normal
wax findings

Nails Palpation  Returns to  Normal findings

(CRT) normal
pinkish Range: not
color after more than 3
2 seconds seconds

Extremities Inspection  No lesion  Normal

Palpation no edema Findings

 With IVF of  For nutritional

D5LR @L function and to
metacarpal keep client
hydrated

Abdomen Inspection  Presence  Wound due to

of incision post
wound with  Appendectomy
stitches
@RLQ

 15  Indicates normal
Neurological GCS
findings

Summary of Physical Assessment

The client experiences sweating which is due to the stimulation of the

parasympathetic nervous system in response to pain and stress the client is
experiencing. She has dry coarse hair due to improper hygiene practices related
to her inability to move from bed to bathroom for a couple of times. Her eyes
respond to light normally. She is experiencing colds due to the weather. There is
no lesions nor edema on extremities. However, she has an IVF of D5LR at left
metacarpal for prevention of dehydration. Wound is present at RLQ due to post
appendectomy.
Anatomy and Physiology

The function of the digestive system is to break down the foods you eat,
release their nutrients, and absorb those nutrients into the body. Although the small
intestine is the workhorse of the system, where the majority of digestion occurs,
and where most of the released nutrients are absorbed into the blood or lymph,
each of the digestive system organs makes a vital contribution to this process.

The appendix is a small tubular extension of the right side of the colon, right
near where the small intestine also inserts into the colon. Its length is quite
variable, from an inch or so to up to 8 or nine inches in length. Most of the time is
looks like a stubby #2 pencil.

The colon has three outer longitudinal muscle bands, called the tenia, that
run the length of the colon as strips, equidistant around the circumference of the
colon. The appendix arises from the blind pouch of the cecum where the three
tenia merge. In fact, the easiest way of finding the appendix in surgery is usually
to pull up the colon, find a tenia, then run it backwards until the appendix is found.

The appendix has its own blood supply in leaves of fat arising off the
mesentery of the cecum. There is a small appendiceal artery that runs as an
arcade along the lower edge of the organ.

Pathophysiology
 Non-Modifiable Factors
Modifiable Factors
 Age (32)
 Lifestyle (Street foods)  Gender (female)
 Environment

Lifestyle: Increase intake of

unhealthy foods like street
foods

Increase production of
body wastes

Impaired filtering
function of the kidney

Wastes in the appendix

Inflammation of S/S
Appendix
Pain at RLQ
(+) rovsing’s sign
Appendicitis

Laboratory Results
Date: September 16, 2017 : 12:33 PM
Hematology
Complete Blood Count
Normal Values Result Significance
WBC 4.5 - 11 10^9/L 10.83 Within normal range.
RBC 4.2 – 5.4 10^12/L 3.59 Indicates low production of RBC in
the bone marrow.
Hgb 120 - 140 g/L 111 Indicates insufficient oxygen enters
the blood.
Hct 0.38 – 0.47 0.332 Indicates low viscosity of the blood.
MCV 80-96 Fl 92.5 Within normal range.
MCH 27-31 pg 30.9 Within normal range.
MCHC 0.32-0.36 0.33 Within normal range.
Platelet Count 150 - 400 10^9/L 265 Within normal range.
Neutrophils 0.37 - 0.72% 0.730 Slightly high this indicates fight off
of infection.
Lymphocytes 0.20 - 0.50% 0.178 High result indicates that the body
is fighting infection.
Eosinophils 0.0 - 0.06% 0.012 Indicates that the body is fighting
infection.
Monocytes 0.0 - 0.14% 0.077 Indicates that the body is fighting
infection.
Basophils 0.0 - 0.01% 0.003 Indicates body’s response to
infection.

Date: September 16, 2017 12:19 pm

Laboratory Exams
Urinalysis
Test Normal Values Result Significance
Color Light yellow Light yellow Normal
Character Slightly turbid Slightly turbid Normal
Sp. Gravity 1.005 – 1.030 1.020 Normal
pH 4.5 – 8 6.5 Normal.
Albumin (-) No presence of albumin in
urine.
Sugar (-) No presence of sugar in
urine.
Pus Cells 8 – 10 p.v.t 5 – 10 Normal.
RBC 4 RBC 0.2 Slightly low due to
decrease in RBC
production.
Epithelial cells Moderate
Bacteria Moderate

Diagnostic Exams
Date: September 17, 2017
Operation Record

Appendectomy
Tissue Removed: Appendix

Findings:
10cms appendix with fibrous deposits

Summary of Diagnostic and Laboratory Results

The result of RBC which is lower than normal value indicates low production
of RBC in the bone marrow. The hemoglobin level is low which means that there
is insufficient oxygen that enters the blood. Decreased hematocrit values indicate
low viscosity of the blood. High result in neutrophil, lymphocyte, eosinophil,
monocyte, and basophil indicates that the body is fighting infection. The RBC result
in urinalysis is slightly low due to decease production of red blood cells.

Discharge Plan
MEDICATION:
Advised to continue taking client’s prescribed medication on time.

ENVIRONMENT:
Advised and ensured to maintain a clean and safe environment.

TREATMENT:
Instructed about moderate/tolerable ADL. Avoid strenuous activities.

HYGIENE:
Advised client to enhance proper hygiene practices.

OPD: (follow up check-up)

Advised to come back on September 26, 2017 for follow-up check up.

DIET:
Advised to eat nutritious foods and soft diet. Instructed to continue on refraining
from alcohol intake.

SPIRITUAL:
Advised client and the family to continue rituals in praying.

Prognosis

It was a good prognosis for patient M.P. since she was able to recover his
vitals and remove inflamed tissue in her body. She was discharged and afvised by
student nurse on what to do and not to do following the “METHODS” for discharge
planning.

Acknowledgement

In the fulfilment of our tasks as student nurses, especially in the

accomplishment of this case study, we would like to extend our deepest gratitude
to those people who helped us.

First of all, we thank God for giving us the strength and courage to accept
this opportunity of doing our case study and also in guiding us in everything that
we do especially during our duty hours.

We would like to acknowledge the Batangas Medical Center, the doctors

and nurses, for letting us perform our duties as student nurses. Also to our client,
M.P., and her relatives for trusting us in providing necessary care for the
improvement of her condition.

To our clinical instructors, for being approachable at all times who

accompanies all our queries and also for imparting their knowledge and
experiences as nurses to us which definitely contributed to the development of our
skills and attitudes towards our profession, to the Dean of the College of Nursing,
Dr. Cecilia C. Pring and to our fellow classmates for a job well done.

Recommendation

Batangas Medical Center, being our base hospital offers interesting and
significant cases and opportunities for the enhancement of student’s knowledge,
skills and attitudes. We recommend the improvement of their facilities for better
execution of quality care to patients who are in need.

For the Client

We recommend her and her family to develop and promote a healthier

lifestyle with appropriate diet and activities. Encourage one another to eat
nutritious food and to comply with the interventions given and to be given to her.
And also, avoid vices which will affect the health of a family member.

For the College of Nursing

We recommend enhancing the knowledge and skills of both clinical

instructors and students through longer clinical exposures, increase in the
availability of interventions to students and this case presentation.

For the Clinical Instructors

With all the efforts given by the clinical instructors, we recommend them to
be more certain on the information and teachings on what should be done to
studies like this and to continue the quality service they are rendering to students.

For the Students

To our fellow nursing students, we recommend to give all efforts in doing

case presentations for them to apply all the knowledge and skills they have
acquired in the future.