Holy Angel University

College of Nursing
Angeles City

In partial fulfillment
In the requirements
On NCM – RLE
JBLMRH – ER

Submitted to:
Mrs. Deleila Guevarra, RN

Submitted by:
Manalo, Sheila
Valdez, Joseph Angelo
Vergara, Vanessa
Yumul, John Derryl
Zamora, Erwin Juvenile

September, 2006
I. Introduction

A. Appendicitis

The appendix is a closed-ended, narrow tube that attaches to the cecum (the first part of
the colon) like a worm. (The anatomical name for the appendix, vermiform appendix, means
worm-like appendage.) The inner lining of the appendix produces a small amount of mucus that
flows through the appendix and into the cecum. The wall of the appendix contains lymphatic
tissue that is part of the immune system for making antibodies. Like the rest of the colon, the
wall of the appendix also contains a layer of muscle.

Appendicitis is inflammation of the appendix. It is thought that appendicitis begins when

the opening from the appendix into the cecum becomes blocked. The blockage may be due to a
build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum.
The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is called a
fecalith (literally, a rock of stool). At other times, the lymphatic tissue in the appendix may swell
and block the appendix. Bacteria which normally are found within the appendix then begin to
invade (infect) the wall of the appendix. The body responds to the invasion by mounting an
attack on the bacteria, an attack called inflammation. (An alternative theory for the cause of
appendicitis is an initial rupture of the appendix followed by spread of bacteria outside the
appendix. The cause of such a rupture is unclear, but it may relate to changes that occur in the
lymphatic tissue that line the wall of the appendix.)

If the inflammation and infection spread through the wall of the appendix, the appendix
can rupture. After rupture, infection can spread throughout the abdomen; however, it usually is
confined to a small area surrounding the appendix (forming a peri-appendiceal abscess).
 Prevalence and incidence statistics for Acute Appendicitis:

Incidence (annual) of Acute Appendicitis: 25 per 10,000 (age 10-17), 1-2 per per 10,000
(under 4)

Incidence Rate: approx 1 in 400 or 0.25% or 680,000 people in USA

Incidence extrapolations for USA for Acute Appendicitis: 680,000 per year, 56,666 per
month, 13,076 per week, 1,863 per day, 77 per hour, 1 per minute, 0 per second.

Lifetime risk for Acute Appendicitis: 8.6% risk for males, 6.7% for females (Rothrock et al,
2000).

Prevelance statistics about Acute Appendicitis: The following statistics relate to the
prevalence of Acute Appendicitis:

• 7-8% people affected by appendicitis at some stage in their life in the US

Death and mortality statistics for Acute Appendicitis:

Deaths from Acute Appendicitis: 390 deaths reported in USA 1999 for appendix conditions
(NVSR Sep 2001)

Death rate extrapolations for USA for Acute Appendicitis: 389 per year, 32 per month, 7 per
week, 1 per day, 0 per hour, 0 per minute, 0 per second.

Acute Appendicitis in Southeastern Asia (Extrapolated Statistics)

East Timor 2,548 1,019,2522
Indonesia 596,132 238,452,9522
Laos 15,170 6,068,1172
Malaysia 58,806 23,522,4822
Philippines 215,604 86,241,6972
Singapore 10,884 4,353,8932
Thailand 162,163 64,865,5232
Vietnam 206,657 82,662,8002
B. Peritonitis

Peritonitis is an inflammation of the peritoneum, the thin membrane that lines the
abdominal wall and covers most of the organs of the body. There are two major types of
peritonitis. Primary peritonitis is caused by the spread of an infection from the blood and lymph
nodes to the peritoneum. This type of peritonitis is rare – less than 1% of all cases of peritonitis
are primary. The more common type of peritonitis, called secondary peritonitis, is caused by the
entry of bacteria or enzymes into the peritoneum from the gastrointestinal or biliary tract. Both
cases of peritonitis are very serious and can be life-threatening if not treated properly.

Society statistics for Peritonitis

Hospitalization statistics for Peritonitis: The following are statistics from various sources
about hospitalizations and Peritonitis:

• 0.036% (4,562) of hospital consultant episodes were for peritonitis in England 2002-03
(Hospital Episode Statistics, Department of Health, England, 2002-03)
• 70% of hospital consultant episodes for peritonitis required hospital admission in
England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 51% of hospital consultant episodes for peritonitis were for men in England 2002-03
(Hospital Episode Statistics, Department of Health, England, 2002-03)
• 49% of hospital consultant episodes for peritonitis were for women in England 2002-03
(Hospital Episode Statistics, Department of Health, England, 2002-03)
• 87% of hospital consultant episodes for peritonitis required emergency hospital
admission in England 2002-03 (Hospital Episode Statistics, Department of Health,
England, 2002-03)
• 13.6 days was the mean length of stay in hospitals for peritonitis in England 2002-03
(Hospital Episode Statistics, Department of Health, England, 2002-03)
• 7 days was the median length of stay in hospitals for peritonitis in England 2002-03
(Hospital Episode Statistics, Department of Health, England, 2002-03)
• 60 was the mean age of patients hospitalised for peritonitis in England 2002-03 (Hospital
Episode Statistics, Department of Health, England, 2002-03)
• 37% of hospital consultant episodes for peritonitis occurred in 15-59 year olds in England
2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 32% of hospital consultant episodes for peritonitis occurred in people over 75 in England
2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 1% of hospital consultant episodes for peritonitis were single day episodes in England
2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0.082% (43,131) of hospital bed days were for peritonitis in England 2002-03 (Hospital
Episode Statistics, Department of Health, England, 2002-03)
II. NURSING ASSESSMENT

Personal History

Mr. Rolly Manzano Iyo, 37 years old, male, married, Filipino, born June 13, 1969 at
Balanga, Bataan, Jehovah’s Witnesses by faith, admitted last September 05, 2006 at JBLMRH.

History of Present Illness

Mr. Iyo was admitted with a chief complain of abdominal pain and vomiting. 1 week
prior to admission, Mr. Iyo consulted their physician in Bataan due to abdominal pain. After few
laboratory tests such as fecalysis and CBC, his doctor ruled out amoebiasis. Few days prior to
admission at JBLMRH, the patient experienced left lower quadrant pain and he started to vomit.
Two days prior to admission, the patient was febrile. According to the patient, his temperature
reached 39.40C. Last September 05, 2006, he experience severe abdominal pain and tenderness,
and vomiting. The patient skin was pale, experiences lethargy, and the sclera of his eyes are
color yellow, jaundice. His vital signs are taken us follows: BP= 130/70; TO= 38.8OC; PR= 96
bpm; RR= 28bpm.

History of Past Illness

Mr. Iyo did not experience any illness that may have aggravated his current illness. But
he experiences cough and colds every now and then. Also, last seven months ago, he suffered
from flu.

Soico-Economic and Cultural History

Mr. Iyo finished High School level. He works at a local construction as a window
maker. According to him, he earns around P4,000 - 5,000 per month. Their monthly expense
according to him is around P3,500. Mr. Iyo is a member of Jehovah’s witnesses. Jehovah’s
witnesses refuse blood transfusion. In his current medical management, he needed blood
transfusion but he refused to undergo the transfusion. He doesn’t believe on the “herbolaryo” or
“albularyo”. Every time he and his family experience any illnesses, they seek consultation to the
doctor.

Family Health History

According to Mr. Iyo, they do not have any hereditary illness such as asthma,
hypertension, or diabetes mellitus. His family currently doesn’t experience any illnesses.

III. THE PATIENT AND HIS ILLNESS

A.

B. Synthesis of the Disease

1. Definition of the Disease

The appendix is a closed-ended, narrow tube that attaches to the cecum (the first part of
the colon) like a worm. (The anatomical name for the appendix, vermiform appendix, means
worm-like appendage.) The inner lining of the appendix produces a small amount of mucus that
flows through the appendix and into the cecum. The wall of the appendix contains lymphatic
tissue that is part of the immune system for making antibodies. Like the rest of the colon, the
wall of the appendix also contains a layer of muscle.

Appendicitis is inflammation of the appendix. It is thought that appendicitis begins when

the opening from the appendix into the cecum becomes blocked. The blockage may be due to a
build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum.
The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is called a
fecalith (literally, a rock of stool). At other times, the lymphatic tissue in the appendix may swell
and block the appendix. Bacteria which normally are found within the appendix then begin to
invade (infect) the wall of the appendix. The body responds to the invasion by mounting an
attack on the bacteria, an attack called inflammation. (An alternative theory for the cause of
appendicitis is an initial rupture of the appendix followed by spread of bacteria outside the
appendix. The cause of such a rupture is unclear, but it may relate to changes that occur in the
lymphatic tissue that line the wall of the appendix.)

2. Predisposing/Precipitating Factors

Most affected by appendicitis are young people between the ages of 11 and 20. And,
most cases of appendicitis occur in the winter months (cold season). Having a family history of
appendicitis may increase the risk for the illness, especially in males, and having cystic fibrosis
also seems to put a higher risk.

3. Pathologic Changes

White Blood Cell Count

The white blood cell count in the blood usually becomes elevated with infection. In early
appendicitis, before infection sets in, it can be normal, but most often there is at least a mild
elevation even early. Unfortunately, appendicitis is not the only condition that causes elevated
white blood cell counts. Almost any infection or inflammation can cause this count to be
abnormally high. Therefore, an elevated white blood cell count alone cannot be used as a sign of
appendicitis.

Urinalysis

Urinalysis is a microscopic examination of the urine that detects red blood cells, white blood
cells and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or
stones in the kidneys or bladder which sometimes can be confused with appendicitis. Therefore,
an abnormal urinalysis suggests that there is a kidney or bladder problem while a normal
urinalysis is more characteristic of appendicitis.
Abdominal X-Ray

An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece of stool
that blocks the appendiceal opening) that may be the cause of appendicitis. This is especially true
in children.

Ultrasound

An ultrasound is a painless procedure that uses sound waves to identify organs within the body.
Ultrasound can identify an enlarged appendix or an abscess. Nevertheless, during appendicitis,
the appendix can be seen in only 50% of patients. Therefore, not seeing the appendix during an
ultrasound does not exclude appendicitis. Ultrasound also is helpful in women because it can
exclude the presence of conditions involving the ovaries, fallopian tubes and uterus that can
mimic appendicitis.

Barium Enema

A barium enema is an x-ray test where liquid barium is inserted into the colon from the anus to
fill the colon. This test can, at times, show an impression on the colon in the area of the appendix
where the inflammation from the adjacent inflammation impinges on the colon. Barium enema
also can exclude other intestinal problems that mimic appendicitis, for example Crohn's disease.

CT Scan

In patients who are not pregnant, a CT Scan of the area of the appendix is useful in diagnosing
appendicitis and peri-appendiceal abscesses as well as in excluding other diseases inside the
abdomen and pelvis that can mimic appendicitis.

Laparoscopy

Laparoscopy is a surgical procedure wherein a small fiberoptic tube with a camera is inserted
into the abdomen through a small puncture made on the abdominal wall. Laparoscopy allows a
direct view of the appendix as well as other abdominal and pelvic organs. If appendicitis is
found, the inflamed appendix can be removed at the same time. The disadvantage of laparoscopy
compared to ultrasound and CT scanning is that it requires a general anesthetic.

There is no one test that will diagnose appendicitis with certainty. Therefore, the approach to
suspected appendicitis may include a period of observation, tests as previously discussed, or
surgery.

4. Sign and Symptoms of the Illness

The main symptom of appendicitis is abdominal pain. The pain is at first diffuse and
poorly localized, that is, not confined to one spot. (Poorly localized pain is typical whenever a
problem is confined to the small intestine or colon, including the appendix.) The pain is so
difficult to pinpoint that when asked to point to the area of the pain, most people indicate the
location of the pain with a circular motion of their hand around the central part of their abdomen.

As appendiceal inflammation increases, it extends through the appendix to its outer

covering and then to the lining of the abdomen, a thin membrane called the peritoneum. Once the
peritoneum becomes inflamed, the pain changes and then can be localized clearly to one small
area. Generally, this area is between the front of the right hip bone and the belly button. The
exact point is named after Dr. Charles McBurney--McBurney's point. If the appendix ruptures
and infection spreads throughout the abdomen, the pain becomes diffuse again as the entire
lining of the abdomen becomes inflamed.

Nausea and vomiting also occur in appendicitis and may be due to intestinal obstruction.
IV. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/laboratory Indication or Date ordered Results Normal Analysis and

procedure Purpose and Date Values (unit interpretation
results were used in the of the results
released hospital)
CBC Is a routine test Ordered 9-5-06 WBC: over Leukocytosis
to determine 50/hpf
any Released 9-5-06 Normal RBC
abnormalities in RBC 0-1/hpf count
the blood
sample.
Abdominal and CXR Ordered 9-5-06 --- --- ---

Released 9-5-06
CVP Used to Ordered 9-5-06 8 cmH2O 2-12 cmH2O Normal
estimate circulatory
circulatory Released 9-5-06 function and
function and blood volume
blood volume.

Diagnostic/laboratory Indication or Date ordered Impression

procedure Purpose and Date
results were
released

Ultrasound Used to Ordered 9-5-06 > Fatty Liver change

visualized the
structures of the Released 9-6-06 >Cholecystolithiasis
human body. It
is indicated to > normal size prostate with concretions
examine the
abdominal
organs to detect > normal spleen, kidney, and urinary bladder
any
abnormalities > suspicious segmental bowel wall thickening
present
V. THE PATIENT AND HIS CARE

1) Medical Management

a)

Medical Date ordered/ General Indication(s) or Client’s response

Management performed description Purposes to the treatment

IVF D 09-05-06

IVF D5LRS 09-05-06

NGT drainage 09-05-06 Drawing off fluid To prevent further The patient was
from a cavity in accumulation of little relieved from
the body, usually fluid that may his abdominal
fluid that has become infected. pain.
accumulated
abnormally

b) Drugs

Generic and Date ordered Route, dosage, Mechanism of Client response to

Brand name Date taken/given and frequency of action the medication
administration with actual side
effects

Generic Name:
Ceftriaxone Na Date ordered and 2gms IV q 12O Semisynthetic ---
given: 09-05-06 third-generation
Brand Name: cephalosporin
Rocephin antibiotic.
Preferentially
binds to one or
more of the
 penicillin-binding
proteins (PBP)
located on cell
walls of
susceptible
organisms. This
inhibits third and
final stage of
bacterial cell wall
synthesis, thus
killing the
bacterium.

Nursing Responsibilities:

• Determine history of hypersensitivity reactions to cephalosporins and penicillins and

history of other allergies, particularly to drugs, before therapy is initiated.
• Inspect injection sites for induration and inflammation. Rotate sites. Note IV injection
sites for signs of phlebitis (redness, swelling, pain).
• Monitor for manifestations of hypersensitivity. Report their appearance promptly and
discontinue drug.
• Watch for and report signs: petechiae, ecchymotic areas, epistaxis, or any unexplained
bleeding.
• Report any signs of bleeding.

Generic and Date ordered Route, dosage, Mechanism of Client response to

Brand name Date taken/given and frequency of action the medication
administration with actual side
effects

Generic Name:
Paracetamol Date ordered and 3mg IV q 4O Produces analgesia Lowered the core
given: 09-05-06 by blocking temperature of the
Brand Name: generation of pain patient, from
Aeknil impulses. This 38.8OC to 37.9OC
action is prboably
caused by
inhibition of
prostaglandin
synthesis; it may
also be caused by
inhitition of
synthesis or action
 fo other substances
that sensitize pain
receptors to
mechanical or
chemical
stimulation. It
relives fever by
central action in
the hypothalamic
heat-regulating
center.

Nursing Responsibilities:

• Warn patient that high doses or unsupervised chronic use can cause hepatic damage.
• Has no significant antiinflammatory effect.
• Should not beused for self medicaiton of marked fever (greater thatn 103.1oF
[39.5oC]),fever persisting longer than 3 days or recurrent fever unless directed by the doctor.
• Recommend the liquid form for children and for all patients who have difficulty
swallowing.

Generic and Date ordered Route, dosage, Mechanism of Client response to

Brand name Date taken/given and frequency of action the medication
administration with actual side
effects

Generic Name:
Metronidazole Date ordered and 750mg IV q 8O A direct-acting ---
given: 09-05-06 trichomonacide
Brand Name: and amebicide that
Flagyl works at both
intestinal and
extraintestinal
sites. It's thought
to enter the cells of
microorganisms
that contain
nitroreductase.
Unstable
compounds are
then formed that
bind to DNA and
inhibit synthesis,
 causing cell death.

Nursing considerations:

• Use cautiously in patients with history of blood dyscrasia or CNS disorder and in those
with retinal or visual field changes. Also use cautiously in patients with hepatic disease or
alcoholism and in conjunction with hepatotoxic drugs.
• Monitor liver function test results carefully in geriatric patients. If test results are altered,
metronidazole levels should be monitored closely to prevent toxicity.
• Observe for edema, especially in patients receiving corticosteroids; Flagyl IV RTU
(ready to use) may cause sodium retention.
• Record number and character of stools when used to treat amebiasis. Metronidazole
should be used only after Trichomonas vaginalis infection has been confirmed by wet smear
or culture, or Entamoeba histolytica has been identified. Asymptomatic sexual partners of
patients being treated for T. vaginalis infection should be treated simultaneously to avoid
reinfection.

Patient teaching

• Instruct patient in proper hygiene.

• Tell patient to avoid alcohol or drugs containing alcohol during therapy and for at least 3
days after therapy is completed.
• Tell patient metallic taste and dark or red-brown urine may occur.

c) Diet

Type of Diet Date ordered and General Indication / Client’s response

date started description Purpose and / or reaction
to the diet

Nothing Per
Orem (NPO)

d) Activity / Exercise

Type of activity Date ordered General Indication(s) or Client’s response

 Date started description Purposes & / or reaction to
the activity /
exercise

Complete Bed 09-05-06

Rest

VI. CONCLUSION

Appendicitis, as discussed, is the inflammation of the appendix

VII. RECOMMENDATION

Appendicitis, a

VIII. BIBILIOGRAPHY

Electronic Media

URL 1: http://www.wrongdiagnosis.com/a /stats.htm

URL 2: http://www.medicinenet.com/appendicitis/article.htm

URL 3: http://www.emedicine.com/MED/topic3430.htm

URL 4: http://www.aafp.org/afp/20040301/1161.html

URL 5: http://www.wrongdiagnosis.com/a /stats-country.htm

URL 6: http://www.medicinenet.com/appendicitis/page5.htm

MsDict Viewer. Version 2.00. (2003).

Books

Joyce M. Black & Jane Hokanson Hawks. Medical Surgical Nursing, Clinical Management for
Positive Outcomes, vol. 1 & 2, 7th edition. ELSEVIER (SINGAPORE) PTE LTD. (2005).

Joyce Young Hokanson. Brunner & Suddarth’s Textbook of Medical Surgical Nursing, 10th
Edition. Lippincott Williams & Wilkins, 2004.