COLLEGE OF NURSING

Acute
Appendicitis
Case Presentation

In Partial Fulfillment of the Requirement in the

This is a case presentation about Appendectomy presented by Jayson Aban BSN4 student, 1st semester of the SY 2016-2017.

Surgery Ward

JAYSON P. ABAN
BSN4
 AMA COLLEGE OF NURSING || 2016

ACKNOWLEDGEMENT

I would like to give my sincerest gratitude to the following people who never
ceased in helping me until this presentation was finished.

To my clinical instructor, Grace Magno, RN, MAN for motivating me in every

work that I do.

To my dean, Prof. Florante Z. Artienda, RN, MAN for his unwavering

guidance.

To all of my professors who contributed to my fundamental knowledge /skills

and honed the attitudes that I needed in my clinical rotations.

To my dear and love ones for their emotional and financial support.

Above all the rest, my utmost appreciation to Almighty God for all the talents,
and blessings that was bestowed upon me.

I. Introduction

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Patient A.N.P. is a 22 year old single woman who was admitted at the Antipolo City
Medical Hospital last September 19, 2016 due to severe pain at her right lower quadrant,
the patient was diagnosed with acute appendicitis. The patient underwent emergency
appendectomy on the same day.

The appendix acts as a storehouse for good bacteria, rebooting the

digestive system after diarrheal illnesses.

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 d obstruction attributed
to infection, structure, fecal mass, foreign body or tumor. Appendicitis can affect either
gender at any age, but it is common in males ages 10-30. Appendicitis is the most
common disease requiring surgery and one of the most commonly misdiagnosed
diseases.

Acute appendicitis, is a sudden onset usually resulting from bacterial infection,

which may be precipitated by obstruction of the lumen by a fecalith, variable symptoms
often consisting of periumbilical, colicky pain and vomiting may be followed by fever,
leukocytosis, persistent pain, and signs of peritoneal inflammation in the right lower
quadrant of the abdomen; perforation or abscess formation is a frequent complication of
delayed surgical intervention.

Appendectomy, 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 complications of appendicitis such as
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 the 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, once appendicitis is diagnosed, surgery should be done without unnecessary
delay.

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A. Objectives

General: At the end of my related learning experience at the surgery ward,

the presenter will be able to gain knowledge about Acute Appendicitis and the
appropriate nursing intervention and management regarding the patients condition.

Specific:

Knowledge
To acquire additional information with regards to managing the patient with
appendicitis
To identify the risk factor causing appendicitis
To discuss the normal Anatomy and Physiology of the Appendix
Formulate an appropriate nursing care plan based on the assessment
identified needs and problems of the patient.
Skills

To properly and adequately perform nursing management for a patient with

appendicitis
To improve my skill in minimizing the pain and prevention of complications
of a client with appendicitis.
Attitude

To be able to use therapeutic communication with the client for me to fully

comprehend her condition to carry out proper nursing intervention.
Establish a trusting nurse-patient relationship with the client through
provision of holistic care toward the client and use of appropriate verbal
and non-verbal therapeutic communication skills with the client during the
data gathering.

B. Scope and limitation

The case study tackles the limits only to Acute Appendicitis, its manifestations,
nursing intervention, medical management and some other useful facts about the
condition of the patient. It was based on a case of 22 year old female patient and the

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presenter handled the client for 1 day from 6AM -1:30PM at Antipolo City Medical
Hospital (ACMH). The presenter gathered the information about the patient through
interview, patient chart and medical record

D. Theoretical framework

Dorothea Orem
Dorothea Orem developed the self-care and self-requisites theory.
She defined self-care as the practice of activities that individuals initiate and perform

on their own behalf in maintaining life, health and well-being.

She conceptualized three nursing systems as follow:

1. Wholly Compensatory: when the nurse is expected to accomplish all

the patients needs, continuous guidance in self-care.

2. Partially Compensatory: when both nurse and patient engage in

meeting self-care needs.

3. Supportive educative: the system that requires assistance in

decision-making, behavior control and acquisition of knowledge and skills.

Partially Compensatory
Both nurse & patient
collaborate & engage in
meeting self-care needs.

NURSE PATIENT

= To perform, enhance, and be aware of self-care and in proper choices of food.

II. Clinical Summary

A General Data

Name: ANP
Address: Antipolo, City
Age: 22
Religion: Catholic

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Attainment: College Graduate
Civil status: Single
Occupation: Registered Nurse at Rizal Provincial Annex 2, Dalig, Antipolo
Nationality: Filipino
Date of Birth: Feb 12, 1994
Date of Admission: Sep 19, 2016
Ward and Room: 412
Admitting Diagnosis: Acute Appendicitis
Attending Physician: Dr. Hiwatig
Sources: Patient, patients chart, & lab tests

B. Chief Complaint: The patient came to the hospital with right lower quadrant
pain

C. History of Present Illness: The patient was admitted last Sep 19, 2016, at
Antipolo City Medical Hospital (ACMH) at 4AM. 1 day PTA the patient was
experiencing right lower quadrant pain (Prior to admission) Blood Test and
urinalysis was taken at ACMH. She was advised for admission and was given
paracetamol as medication.

D. Past Medical History:

Patient was never admitted in any hospital in the past.

E. Review of System

Systems Subjective Cues

General Masakit sa may tagiliran ko As verbalized by the patient after surgery.
Description
Skin Tuyo po ang aking sugat kaso makirotAs verbalized by the patient
after surgery.
EENT Okay naman ang mata ko nakakabasa naman po ako ng maayos.
Nakakarinig po ako ng mabuti at wala pong masakit sa tenga at ilong ko.
Maayos po ang aking pangamoy at nakalulunok naman po ako ng walang
masakit. As verbalized by the patient after surgery.
Musculoskeletal Hirap pa po ako maglakad. As verbalized by the patient after surgery.

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Respiratory Di naman masakit ang dibdib ko, tsaka wala po akong ubo at di naman
ako nahihirapang huminga. As verbalized by the patient after surgery.
Cardiovascular Wala naman pong masakit sa loob ng dibdib ko As verbalized by the
patient after surgery.
Gastrointestinal Nangangasim po sikmura ko bago po ako i-admit dito, Hindi na po ako
pinakain noong akoy ihanda na po for appendectomy. As verbalized by
the patient interviewed after surgery.
Back and Spine Okay naman po yung likod ko. As verbalized by the patient after surgery.

Reproductive Okay naman po wala pong masakit sa ibaba ko. As verbalized by the
patient after surgery.

Excretory Wala pong problema sa pag-ihi ko pero sa pagdumi ko po ay kumikirot ang

aking tahi. As verbalized by the patient after surgery.

F. Physical Assessment

General appearance/ survey September 19, 2016

Client is responsive but has complaints about her right lower quadrant pain

a. Measurement

FINDINGS NORMAL VALUES ANALYSIS/

INTERPRETATION
Height: 52
Weight: 42 Kg
BMI: 17.07 kg/m2 18-24.9kg/m2 Underweight
Vital signs Date: Sept. Time:
taken after 19,2016 8am
surgery
BP 100/70 mmHg 120-140/80-90 mmHg Low Blood Pressure
Temp 36.5oc 36.5-37.4oc Normal
PR 80 bpm 60-100 bpm Normal
RR 19 cpm 16-20 cpm Normal
Pain scale 7/10 0/10 Due to right lower quadrant

b. Head to Toe Assessment

System Techniques Normal findings Actual findings Analysis/

Used Interpretation
Integumentary
Skin Inspection Good Skin turgor Good Skin turgor Normal

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Abdomen Inspection Flat, rounded Surgical wound present at Due to post surgery
right lower quadrant

Symmetric contour Pain at right lower Surgery was performed

Audible bowel sounds; quadrant - Appendectomy

Before Hospitalization During Hospitalization Analysis/ interpretation

Fluid & Nutrition Patient usually consumes - Regular liquid intake about To avoid dehydration.
about 3-4 glasses of 7-8 glasses of water.
water a day. Drinks soft - DAT To avoid nausea, and gas
drinks and eats junk - 2nd day post op in the bowel that may
foods most of the time. cause abdominal pain
and discomfort.
Elimination Usually voids 5-6 times a Voids 7-8 times a day and Due to increased water
day or more and defecates 1-2x a day. intake
defecates 1-2 times a
day.
Exercise The patient can move The patient has very limited Due to right lower quadrant
around and do walking daily activity. pain and post surgery.
exercises in the morning
Hygiene and The patient takes a bath The patient was not able to Due to pain in her right
Comfort daily or when she feels take a bath every day. lower quadrant and still
she needs to. Brushes Brushes her teeth only has difficulty moving
her teeth 3 times a day. once. around post surgery.
Rest and Sleep The patient sleeps The patient has minimal sleep Due to her right lower
6-7 hours a day 4-5 hours 2 days post op. quadrant pain post
surgery.
C. Activities of Daily Living

D. Course in the ward

Received patient in bed on September 20, 2016, sitting, fully awake,

weak and in pain with an IV fluid of D5LRS. She has difficulty walking due to right
lower quadrant pain, pain scale 7/10 assessed. Vital signs taken, recorded and
monitored the patients condition and listened to concerns.
Vital signs taken and recorded, monitored the patients condition, listened to

patient concerns and did health teaching.

A Laboratory / Diagnostic Examination (Hematology) Date: Sep 19, 2016

HEMATOLOGY

NAME: ANP DATE: Sep 19, 2016 Interpretation / Analysis

PARAMETER RESULT NORMAL RANGE
Hemoglobin 142 FEMALE: 120-160 g/L Within normal range
Hematocrit 0.42 FEMALE: 0.37 0.47 Within normal range

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RBC count 4.48 FEMALE: 4.5 6.5 x 10/L Within normal range
WBC count 12.3 5-10 X 10 g/L Increased due to presence of

infection in the appendix

Differential Count
Neutrophils 0.86 0.51 0.67 Neutrophils are the first line of
defense and are greatly
elevated until the immunologic
response is finished.
Lymphocytes 0.14 0.21 0.35 Decreased due to cefoxitin
Platelet count 420 150-450 X 10g/L Within normal range

III. Clinical Discussion of the Disease

A. Anatomy and Physiology

Anatomy and Physiology of the Appendix

The appendix sits at the junction of the small intestine and large intestine. Its a
thin tube about four inches long. Normally, the appendix sits in the lower right abdomen.
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The function of the appendix is to act as a storehouse for good bacteria,
rebooting the digestive system after diarrheal illnesses. Other experts believe the appendix
is just a useless remnant from our evolutionary past. Surgical removal of the appendix causes
no observable health problems.

B. Pathophysiology of acute appendicitis

Predisposing Precipitating
Factors: Factors:
Obstruction of the appendix
Age (by fecalith, lymph node, tumor or foreign objects) Low Fiber Diet
Gender

Inflammation

Increase intraluminal pressure

Distention of the Appendix Causes Pain

Decrease venous drainage

Blood flow and oxygen restriction to the appendix

Bacterial invasion of the blood wall

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Necrosis of the appendix

IV. Nursing Care Plan

Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis

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Increased mucus
production
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Subjective: Acute pain After 30 minutes Independent: After 30 minutes
Kumikirot po ang related to of nursing Keep at rest in To lessen the of nursing
tahi ko as presence of intervention, semi-Fowlers pain. Gravity intervention,
verbalized by the surgical incision client will position localizes client has
patient as evidenced verbalize relief inflammatory verbalized relief
by facial from pain. exudate into from pain.
Objective: grimace lower
The client is abdomen or Pain Scale of
expressing facial pelvis, 0/10
grimace relieving
abdominal Facial grimace
Surgical wound at tension, from frown to
right lower which is smile
quadrant of the accentuated
abdomen by supine
position
Dry & without
secretions Independent:
Encourage early Promotes
Pain Scale of 7/10 ambulation normalization
of organ
BP: 100/70 function
PR: 80 bpm (stimulates
RR: 19 cpm peristalsis
Temp: 36.5C and passing
of flatus,
reducing
abdominal
discomfort)
Independent:
Place ice bag on Soothes and
abdomen relieves pain
periodically during through
initial 2448hr as desensitizatio
appropriate. n of nerve
endings.
Independent:
Provide diversional Refocuses
activities such as attention,
reading, use of promotes
devices such as cell relaxation,
phones, tablets or and may
laptops, etc. enhance
coping
abilities.

Interdependent:
Assess pain, noting Useful in
location, monitoring
characteristics, effectiveness
severity (0-10 of
scale). Investigate medication,
and report changes progression
in pain as of healing.
appropriate Changes in
characteristic

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of pain may
indicate
developing
abscess or
peritonitis,
requiring
prompt
medical
evaluation
and
intervention.

Continuing
pain may
Interdependent:
signal an
Watch closely for
abscess.
possible surgical
complications.

Relief of pain
Dependent: facilitates
Administer cooperation
analgesics as with other
indicated. therapeutic
interventions

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Subjective: Risk for skin After 1 hour of Interdependent: After 1 hour of
maitim po yung integrity related nursing Support and Reduces nursing
paligid ng tahi ko to post surgery intervention, instruct client in possibility of intervention,
as verbalized by as evidenced client will display incisional support dehiscence client has
the patient by disruption of intact skin free of when turning, and incisional displayed intact
clients skin signs of coughing, deep hernia skin free of
Objective: surface pressure or breathing, and signs of
Dark discoloration breakdown ambulating pressure or
surrounding the breakdown
surgical wound at Interdependent:
right lower Observe incision Verifies -Skin around
quadrant of the periodically, noting status of surgical wound
abdomen approximation of healing, lightened in
wound edges, provides for color.
BP: 100/70 hematoma early
PR: 80 bpm formation and detection of Goal met
RR: 19 cpm presence of developing
Temp: 36.5C bleeding or complications
drainage requiring
prompt
evaluation
and
influencing
choice of
interventions

Interdependent:
Provide routine Promotes
incisional care, healing.
being careful to Accumulation
keep dressing dry of secretions
and sterile. increases
tension on
suture line,
may delay
wound
healing, and
serves as a
medium for
bacterial
growth

Dependent: Relief of pain

Administer facilitates
analgesics as cooperation
indicated. with other
therapeutic
interventions

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Subjective: Risk for After 1 hour of Independent: After 1 hour of
Hindi naman po infection related nursing Monitored vital Elevation in nursing
ako nilalagnat as to tissue intervention signs and recorded. rates may intervention
verbalized by the trauma client will be able indicate sign client was able
patient to verbalize of infection to verbalize
ways of ways of
Objective: preventing Independent: preventing
Vital signs taken infection/contami Assess surgical To provide infection/contam
as follows: nation wound for signs of baseline data ination
specifically infection. for specifically
BP: 100/70 proper hand comparison proper hand
PR: 80 bpm washing and and identify washing and
RR: 19 cpm proper wound need for proper wound
Temp: 36.5C care as further care as
evidenced by: management evidenced by:

-Maintain stable Interdependent: -Maintain stable

vital signs Change linens as To prevent vital signs
necessary growth of
-Good skin microorganis -Good skin
integrity ms on integrity
linens/bed
-Absence of -Absence of
swelling, Interdependent: swelling and
redness and Provide regular To prevent redness
pain on surgical wound dressing unnecessary
wound exposure and
contaminatio
n of surgical
wound which
may delay
wound
healing.

Dependent: Serves as
Administer prophylactic
antibiotics as treatment and
indicated. prevent the
harboring and
proliferation
of bacteria on
surgical
wound

V. Drug Study

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Name of Mechanism Indication Contra- Adverse reaction N
Drugs of Action indication u
r
s
i
n
g
R
e
s
p
o
n
s
i
b
il
it
i
e
s
Generic Bactericidal: Dermatologic Contraindicated CNS: Avoid alcohol
name: Inhibits infections with allergy to Headache, while taking this
Cefoxitin synthesis caused by S. cephalosporin dizziness, lethargy, drug and for 3
Brand of bacterial Aureus, or penicillin. paresthesias days
name: cell wall, S.Epidermis, GI: Nausea, after because
Mefoxin causing cell streptococci, vomiting, diarrhea, severe reactions
Classificat death E.coli. anorexia, abdominal often occur.
ion: pain,
Antibiotic UTIs caused flatulence You may
Dosage: by E. Coli GU: experience these
Through IV P.Mirabilis, Nephrotoxicity side effects:
1-2g q6hrs Klebsiella. HEMATOLOGIC: stomach upset,
Bone marrows, diarrhea.
Intra- depressions,
abdominal decreased WBC, Report severe
infections decreased platelets, diarrhea,
caused by E. decreased Hct. difficulty breathi
Coli, klebsiella LOCAL ng,
Bone and joint : Pain, abscess at unusual
infections injections site, tiredness
caused by S. inflammation at IV or fatigue, pain at
Aureus site injection site
OTHERS:
Perioperative Superinfections,
prophylaxis disulfiram like
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reaction with alcohol

Upon Decreases Symptomatic Contraindicated Hermatologic: Advise patient

Admission: fever by relief of pain in patients hemolytic anemia that drug is only
Generic inhibiting the and fever hypersensitive Neutropenia, for short term use
Name: effect of to the drug. leucopenia, and to consult the
Paracetamol pyrogens on pancytopenia physician if giving
the Use cautiously to children for
Brand hypothalamic in patients with Hepatic: jaundice longer than 5
Name: heat long term days or adults for
Alvedon regulating alcohol use Metabolic: longer than 10
centers and because hypoglycemia days
Classificati by a therapeutic
on: hypothalamic doses cause Skin: rash, Advise the
Analgesic/ action leading hepatotoxicity in urticaria patient or
Anti-pyretic to sweating these patients caregiver that
and many over the
Dosage: vasodilation counter products
500mg every contain
4 hours per acetaminophen;
orem be aware of this
when calculating
total daily dose

Warn patient that

high doses or
unsupervised
long term use
can cause liver
damage
Generic Anti- Short term Contraindicated CNS: headache, Assessment:
name: inflammatory management with significant dizziness, 1. History: renal
Ketorolac and analgesic of pain (up to 5 renal somnolence, impairment;
tromethamin activity; days) impairment, insomnia, fatigue, impaired
e aspirin allergy, tinnitus,
hearing;
Inhibits Ophthalmic: recent GI bleed ophthalmologic
Brand prostaglandin Relief of ocular or perforation effects allergies,
name: s and itching due to hepatic,
toradol leukotriene seasonal Use cautiously lactation,
synthesis conjunctivitis with impaired pregnancy
Classificatio and relief of hearing; 2. Physical: skin
n: post-operative allergies; hepatic color and
Anti- inflammation conditions lesions,
pyretic/anti- after cataract
orientation,
inflammatory surgery
Dosage: reflexes,
1 AMP q 6 peripherals
hrs and PRN sensation,
for pain clotting times,
CBC,
adventitious
sounds

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Intervention:
1. Be aware that
patient maybe
at risk for CV
events, GI
bleeding, renal
toxicity, monitor
accordingly
2. Keep emergency
equipment
readily
available at
time of initial
dose, in case of
severe
hypersensitivity
reaction
3. Protect drug vials
from light
4. Administer every
6 hrs to
maintain serum
levels and
control pain

Generic Gastric-acid Short term Contraindicated CNS: headache, Assessment:

name: pump treatment of with dizziness, 1. History hyper-
omeprazole inhibitor; active hypersensitivity asthenia, vertigo, sensitivity to
suppresses duodenal to omeprazole insomnia, apathy, omeprazole or
Brand gastric acid cancer or its anxiety, any of its
name: secretion by components paresthesias,
tansinel specific Short term dream components
inhibition of treatment of abnormalities 2. Physical: skin
Classificatio the hydrogen- active benign lesions,
n: potassium gastric ulcer Dermatologic: reflexes,
Anti- ATPase rash, urinary output,
secretory enzyme Eradication of inflammation, abdominal
drug system at the helicobacter urticarial, pruritus, examination,
secretory pylori alopecia, dry skin
respiratory
Dosage: surface of the
20mg per gastric parietal First line GI: diarrhea, auscultation
orem OD for cells; blocks therapy for abdominal pain,
1 week the final step treatment of nausea, vomiting, Intervention:
of acid heartburn or constipation, dry 1. Administer
production symptoms of mouth, tongue before
GERD. atrophy meals.
2. Have
Respiratory: regular
URI medical
Symptoms, follow up
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cough, visits
Epistaxis, 3. Report
severe
headache,
worsening
of
symptoms,
fever, chills

19 | A c u t e A p p e n d i c i t i s
I Discharge Planning

Medicine

Explained and emphasized to the patient and to significant others the importance of drug
compliance and the possible outcomes if not taken.
Explained to the client and immediate family members to administer the prescribed medication at
right time, right route, and right dosage.
Explained the adverse effect of drugs to the patient and family members then advised to consult
physician immediately if any side effects are experienced.
Exercise
Explained to the client to gradually increase activity level to help with her recovery. Start by doing
light activities around the house once she feels able to do so.
Advised client to do ROM exercises

Treatment
Explained to the client and immediate family members how to properly clean and dress the surgical wound.

Health Teaching

Explained to the client to wear loose clothing, this will help keep her comfortable and cause less
irritation around her surgical wound.
Advised the client not to soak in a tub or swim in a pool until her surgical wound is fully healed.
Advised handwashing before and after wound dressing.

Out Patient follow-up

Advised patient to follow what her physician instructed, to have communication between them
and have an update regarding her condition.
Diet
Advised client to consume food that are easy to digest.
Advised client to avoid fatty foods.
Explained to the client to limit intake of foods rich in sugar as to prevent diarrhea.

Spiritual
Encouraged patient and relatives to seek guidance from God and maintain constant prayers to
him.

Spiritual counseling