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APPENDECTOMY

DESCRIPTION OF THE PROCEDURE


Appendectomy is the removal of the inflamed appendix. In an open,
conventional, and uncomplicated appendectomy, the surgeon removes the appendix
through an incision approximately 3 inches (7.5cm) long in the right lower quadrant. The
incision is larger if the appendix is in an atypical position or if peritonitis is present. Most
uncomplicated appendectomies are done via laparoscopy.
Appendicitis is an acute inflammation of the veniform appendix-the blind pouch
attached to the cecum of the colon that is usually located in the right iliac region, just
below the ileocecal valve. The appendix has no known exact function aside that it
releases enzymes that fight back against invading foreign bodies. Inflammation of the
appendix can occur when the lumen (opening) of the appendix is obstructed. Calculi
composed of fecal material (fecaliths), calcium phosphate-rich mucus and inorganic
salts may be the most common cause of the initial obstruction. Other cause of
obstruction includes tumors, viral or fungal infections and parasitic worms.
INDICATIONS
Appendectomy is indicated to this patient who had appendicitis. It is an emergent
surgery that requires immediate intervention because of its life-threatening
consequences.
The most common symptom of appendicitis is abdominal pain due to the
contractions of the appendix or the distention of its lumen. Rebound tenderness is a
term used to describe a sensation of severe pain that occurs after deep pressure is
applied and release at a point away from the pain. Abdominal tenderness on palpation
is the most reliable symptom. Tenderness becomes more localized and the area is
referred to as the McBurneys Point. Nausea and vomiting follow after the pain. Fever
is also evident with the clients temperature that is usually normal or slightly elevated at
99 to 100.5 F (37.2 to 38C), but a temperature of 101F (38.2) or higher suggests
presence of peritonitis. When peritonitis occurs, the pain becomes more steady and
severe and the location shifts to the lower quadrant. Abdominal pain that increases with
cough or movement and is relieved by flexion of the right hip suggests perforated
appendix. Perforation (rupture) rarely occurs within 24 hours of the onset of
symptoms, but the incidence of peritonitis rises to as high as 80% after 48 hours.
Because the clinical manifestations associated with many other medical
conditions are similar to those of acute appendicitis, arriving to the diagnosis is difficult.
It is important to determine the sequence of symptoms. For example, nausea and

vomiting that precede abdominal pain often indicate gastroenteritis. An ultrasound study
may show the presence of enlarge appendi and a computed tomography (CT) scan may
improve diagnostic accuracy revealing presence of fecalith.
If the diagnosis is note definitive but the client is at hight risk for complications
from suspected appendicitis, the surgeon may perform an exploratory laparoscopy or
laparotomy to rule out appendicitis. Laparoscopy is a minimally invasive procedure
which the surgeon makes several incisions near the umbilicus, through which small
endoscope is placed. Laparotomy is an open approach in which a large abdominal
incision is made.
POSTOPERATIVE COMPLICATIONS OF APPENDECTOMY

Peritonitis - Peritonitis may follow after the appendectomy. When the appendix
is perforated, it releases bacteria into other parts of the body. This can cause a
condition called peritonitis, an infection that spreads to the peritoneum, the thin
layer of tissue that line the inside of the abdomen. Usually, inflamed appendix
ruptures within 24-36 hours from the onset of symptoms.

Crohns Disease - It is thought that chronic infection of the appendix can occur,
but it is not the usually the cause of abdominal pain that lasts for week or
months. Recurrent appendicitis does sometimes occur, often with complete
remission of inflammation between acute attacks. In rare instances, acute
appendicitis may be the first manifestation of Crohns Disease. Crohns Disease
is an idiopathic inflammatory disease of the small intestine (60%), the colon
(40%), or both. It involves all layers of the bowel but most commonly involves the
terminal ileum. Terminal ileum is adjacent of the appendix.

Paralytic or Adynamic ileus - It is a non-mechanical obstruction caused by


physiologic, neurologic and chemical imbalance associated with decrease
peristalsis from trauma or the effect of of a toxin on autonomic intestinal control.
Adynamic ileus occurs to some degree following abdominal surgery or trauma.
Paralytic ileus can be caused by handling of the intestines during abdominal
surgery; intestinal function is lost for a few hours to several days.

Wound infection - Wound infection can cause the skin to become red and
inflamed and pus to leak from the incision site. In this case, antibiotics are started
and discharge from the hospital may be delayed, depending on the severity of
the infection. On rare occasions, the site must be reopened to allow the wound to
drain.

INSTRUMENTS USED IN APPENDECTOMY


01 Metzenbaum Scissors 20cm TC Curved

01 Metzenbaum Scissors 20cm TC Straight

01 Mayo Scissors 20cm TC Straight

01 Mayo Scissors 20cm TC Curved

02 Scalpel handle #4

02 Allis Tissue Forceps 15cm

04 Kochers Tissure Forceps 15cm

01 Mcindoe Forceps 15cm

02 Babcocks Tissue Forceps 16cm

02 Needle Holder 16cm

02 Ovum Forceps

04 Towel Clamps 11cm

08 Kelly Forceps 14cm curved

06 Kelly Forceps 14cm straight

06 Spencer Wells Straight 18cm

08 spencer Wells Curved 18cm

02 Army navy retractor 21cm

02 Adson Forceps 12cm

02 Lane Forceps 12cm

02 Kidney basin

Surgical procedure
There are two ways to do Appendectomy:
1. Open appendectomy
For an open appendectomy, the surgeon first cleanses the skin of the abdomen with
an antiseptic solution. Then he or she makes an incision, about 2-4 inches long, through
the skin of the abdomen, past the abdominal muscles, and into the abdominal wall
(layers of tissue that protect the abdomen). The abdominal muscles are then separated
and the appendix is located. By using sutures (stitches) or a special stapling tool, the
surgeon closes the open area of the appendix connected to the large intestine to
prevent it from tearing and spreading bacteria through the abdomen while it's being
removed. (The stapling tool uses stainless steel staples that are slightly smaller than
those used in a standard office stapler.) The surgeon then cuts the appendix away from
the large intestine and pulls it out of the body through the incision. The appendix is
removed from the intestine. The area is washed with sterile fluid to decrease the risk of
further infection. A small drainage tube may be placed going from the inside to the
outside of the abdomen. Once the appendix is removed, the surgeon closes the
abdominal wall and abdominal muscles with dissolvable stitches. Then, the opening on
the skin is closed with stitches and is covered with a bandage.
2. Laparoscopic appendectomy
As with an open appendectomy, the surgeon first cleanses the skin with an antiseptic
solution and 3 or 4 small incisions are made in the abdomen. The doctor uses a camera
and tools through the small incisions to remove the appendix. A port (nozzle) is inserted
into one of the slits, and carbon dioxide gas inflates the abdomen. This process allows
the surgeon to see the appendix more easily. A laparoscope is inserted through another
port. It looks like a telescope with a light and camera on the end so the surgeon can see
inside the abdomen. Surgical instruments are placed in the other small openings and
used to remove the appendix. The area is washed with sterile fluid to decrease the risk
of further infection. The carbon dioxide comes out through the slits, and then the sites
are closed with sutures or staples or covered with glue-like bandage and steristrips.With this type of surgery, you may recover faster, have less pain, less scarring,
fewer wound problems and often spends less time in the hospital.

NURSING MANAGEMENT
Goals: relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating
infection due to potential/ actual disruption of the GI tract, maintaining skin integrity, &
attaining optimal nutrition
PRE-OP
Obtained informed consent form.
As an appendectomy is an emergency procedure, the patient must take nothing by
mouth as soon as the decision is made including medications. As restriction of food
and fluids after midnight on the day before surgery may not be possible.
IV infusion to replace fluid loss and promote adequate renal function.
Administer antibiotic therapy as prescribed to prevent infection
Inserted nasogastric tube if there is evidence or likelihood of paralytic ileum.
Enema IS NOT administered because it can lead to perforation.
Placed in a semi-fowlers position, as tolerated, to promote abdominal drainage can
be contained in the lower abdomen.
Heat should never be applied to the abdomen because this may increase
inflammation and perforation.
POST-OP
Monitor vital signs
Placed in a high Fowlers position to reduce the tension on the incision and abdominal
organs, helping to reduce pain.
Opioid, usually morphine sulfate, administered as ordered to relieve pain
Administer oral fluids as tolerated to keep patient hydrated
Food is provided as desired and tolerated on the day of surgery when normal bowel
sounds are present
If a drain is left in place at the area of incision, monitor carefully for signs of intestinal
obstruction, secondary hemorrhage, or secondary abscesses (eg, fever, tachycardia,
and increased leukocyte count
If peritonitis is present, IV antibiotic may be placed to relieved infection and
nasogastric tube (NGT) is placed to decompress the stomach and prevent abdominal
distention.
REFERENCES:
1. Ignatavicius, D., & Workman, M.L., (2006) Medical-Surgical Nursing Critical
Thinking for Collaborative Care (5th ed). Elsevier Saunders; St. Louis, Missouri.
2. Hinkle, J. & Cheever, K. (2014). Medical-Surgical Nursing (13th ed., Vol. 2).
Lippincott Williams & Wilkins

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