Pines City Colleges College of Nursing

OR WRITE UP (Appendectomy)

Prepared by:
Estacio, Enrico Carlo C. BSN IV-1

Submitted to:
Mrs. Buna Racal Clinical Instructress

I.

Patients profile
Age: 43 Address: Tublay, Benguet Sex: Female Civil Status: Single Religion: Roman Catholic Diagnosis: Appendicitis

Pathophysiology

Anatomy and Physiology Appendix It is a narrow pouch of tissue whose resemblance to a worm inspired its alternate name, vermiform (worm-like). It is a small, fingerlike appendage about 10 cm (4 in) long that is located in the right iliac region of the abdomen (in the lower right-hand abdominal area).

 Like the rest of the digestive tract, the appendix is made of an inner layer of mucosa with submucosa, muscularis, and serosa layers surrounding it, however, the submucosa of the appendix contains many masses of lymphoid tissue. The presence of lymphoid tissue suggests that the appendix may play a role in the immune system in addition to the digestive system. The appendix fills with food and empties regularly into the cecum. Because it empties inefficiently, and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable to infection (ie, appendicitis). Appendicitis is the most common reason for emergency abdominal surgery. Although it can occur at any age, it more commonly occurs between the ages of 10 and 30 years.

II.

Operation or Surgery Performed

APPENDECTOMY Definition: It is the surgical removal of the appendix, usually performed to remove the acutely inflamed organ. Types: a. Laparoscopic Appendectomy In most laparoscopic appendectomies, surgeons operate through 3 small incisions (each to inch) while watching an enlarged image of the patients internal organs on a television monitor. Surgical instruments called cannulas are inserted into other small openings and used to remove the appendix. Laparoscopic appendectomy is a safe alternative to the open technique. Advantages of Laparoscopic Appendectomy include less postoperative pain,

shorter hospital stays, quicker return to normal activities, and better cosmetic results. Although laparoscopic appendectomy has many benefits, it may not be appropriate for some patients. Early, non-ruptured appendicitis usually can be removed laparoscopically. Laparoscopic appendectomy is more difficult to perform if there is advanced infection or the appendix has ruptured. A traditional, open procedure using a larger incision may be required to safely remove the infected appendix in these patients. Regardless of the type of procedure you undergo, minimal postoperative discomfort is likely to occur after an appendectomy. The laparoscope cannot be used if the surgeon suspects that the appendix has ruptured.

b. Open Appendectomy Remains the most common approach due to operative time and cost. In this operation, the surgeon makes a small incision through the skin and underlying fat of the right lower side of the abdomen over the area of the appendix. The muscles of the wall are then separated, revealing the peritoneum, which is the lining of the abdominal cavity. The peritoneum is cut to reveal the cecum, the section of the large intestine to which the appendix is attached. The appendix is then identified and carefully freed from the surrounding structures. Blood vessels around the site are tied off. At this point, the appendix is tied off and transected. The appendix is then sent to the pathology laboratory for examination. The peritoneum, the muscle wall, and the skin incision are then closed. Closure of the skin is done either with sutures or tiny staples.

Indication: An appendectomy is performed to remove the appendix when appendicitis is strongly suspected. During other abdominal surgical procedures, the appendix may be removed as a precaution to prevent future inflammation or infection of the appendix. It is important to undergo the surgery before a hole or perforation develops in the wall of the appendix. This can lead to spreading of infection to the entire abdominal cavity causing what is known as Peritonitis

Discussion: Appendectomy is the excision of the appendix, usually performed to remove the acutely inflamed organ. When the appendix is acutely inflamed, it may rupture, spilling contents of the bowel into the peritoneal cavity; peritonitis and abscess formation ensues. Earlier diagnosis and appendectomy can prevent this potentially serious complication. Appendectomy is described as an incision made in the right lower abdomen either transversely, obliquely with a McBurney or a vertical incision for primary appendectomy. The appendix is identified and its vascular supply ligated. The appendix is ligated at its base, i.e., the stump is tied off with absorbable suture. The appendix is removed, and the stump maybe inverted in the cecum within a placed purse string suture, cauterized with chemicals or ESU, or simply left alone after ligation.

III. Nursing Management or Intervention 1. Pre-operative Preparation a) Physical Skin Preparation The hair near the incision may be shaved The skin may need to be shaved either the night before or the day of the surgery. For shaving, the skin is lathered with liquid soap and shaving is done in the direction of the hair growth. The skin is cleaned with a betadine that reduces the risk of wound infection The skin of the abdomen is washed and then swabbed with a solution that kills germs. These solutions may be an iodine solution, or a povidoneiodine solution Special Preparation The patient is supine with the right side slightly elevated to displace pressure from the inferior vena cava. Arms may be extended on padded armboards. A pillow may be placed under the lumbar spine and/ or under the knees (to avoid straining back muscles) pad all bony prominences and areas vulnerable to skin and neurovascular trauma or pressure. A catheter is placed in the bladder before the surgery to remove the urine during the surgery 2. Intra-operative Anesthesia or Technique a) Anesthesia Spinals anesthesia are pain medications delivered via the spinal column in one dose. The medication is fast acting and can achieve a complete block of pain in as little as 2-3 minutes. Spinal anesthesia result in the lower portion of your body becoming anesthetized (or "numb") so that the surgery can be completed without any pain. The fact that the mother can remain awake, see the baby and interact with the baby as soon as it is born and does not require a breathing tube are all advantages. b) Skin Preparation The skin of the abdomen is washed and then swabbed with a solution that kills germs. These solutions may be an iodine solution, or a povidoneiodine solution The boundaries should be much wider than the planned incision Prepping always progresses from the clean to the dirty area and start with

the umbilicus, which although must be considered contaminated, can harbor debris Circulator turns back the patient's blanket and gown to expose area to be prepped. Check to see that safety strap is secured. Using prep solution of surgeons preference and saturated sponge, the RN Circulator covers the entire prep area, beginning at the incision site and extending to the periphery. Apply a second application if appropriate, beginning at the area of the intended incision and extending to the periphery. Be sure linen and gown are out from under the patient to prevent pressure points and area for solutions to pool. Excess prep solution collects on towels and not under patient. Use sterile cloth towels or towels provided in tray. Umbilicus is considered a "dirty" area and should be cleaned prior to the surgical prep. Be sure not to bring sponge back to center once it reaches the periphery. Use a second sponge if needed. Surgical Skin Preparation c) Draping Once the skin has been thoroughly cleaned and disinfected, sterile clothes, called surgical drapes, are used to help keep the area clean. These drapes isolate the surgical area, demarcating it from the rest of the body and exposing only the surgical site. In addition, a plastic layer on the drapes provides a barrier against liquids, which can give microbes a direct path to the incision site. d) Instrument Used i. Straight and Curve clamp> use to hold tissue or clamp blood vessel

ii. Allis> use to hold tissue gently but securely

iv. Knife > use for incision of skin and delicate tissues

iii. Babcock> to fit around a structure or grasp a delicate tissue

v. Mayo scissors> use to cut suture

vi. Metzenbaum Scissor> use to cut tissues

vii. Tissue forcep> use to provide a firm hold on tough tissue including the skin

xi. Right Angle or Mixter >used to clamp hard-to-reach vessels and to place sutures behind or around a vessel.

viii. Thumb Forcep> use to hold soft tissues or vessels without injuring them

xii. Army-Navy Retractor>used to retract shallow or superficial incisions ix. needle holder > use to hold the needle for suturing

x. towel clip> use to hold the towel e.) Equipment needed I. Cautery > A device or agent used in the coagulation of tissue by heat or caustic substances. > To burn tissues by thermal heat, including steam, hot metal, or solar radiation.

f.) Supplies Needed Drape >used to cover the patient Cutting Needle Round Needle

3.Post-operative care After the procedure, the patient will be taken to the recovery room for observation. Routine observation of heart rate, blood pressure and temperature Allow free fluids orally and full diet the next day DVT prophylaxis should be commenced immediately Two further doses of the antibiotic used on induction can be given postoperatively Effect of anesthesia is also monitored Once blood pressure, pulse, and breathing are stable and the patient is alert, he/she will be taken back to ward. The patient will be encouraged to get out of bed within a few hours after a laparoscopic procedure or by the next day after an open procedure. Depending on the situation, the patient may be given liquids to drink a few hours after surgery. The diet may be gradually advanced to more solid foods as tolerated.