PHILIPPINE MILITARY ACADEMY

FORT DEL PILAR STATION HOSPITAL

BAGUIO CITY

A Case Study on
Appendicitis
In Partial Fulfillment of the
Requirements in the Registered
Nurse Residency Training Program

Submitted to:
LTC Rebecca Ranches NC
Chief Nurse

Submitted by:
DeLara, Christine Sonja
Manzon, Ainah Kristiah
Munoz, Benedict

Table of Contents

Introduction
a)
b)
c)
d)

Background of the study ............................................................................................3

Objectives of the study ...............................................................................................4
Significance of the study ............................................................................................4
Scope and limitation....................................................................................................4

Nursing History
a) Patient profile .............................................................................................................5
b) Comprehensive nursing history .................................................................................5
1. History of present illness....................................................................................5
2. Past medical history ..........................................................................................6
3. Family and social history ..................................................................................6
c) Physical assessment ................................................................................................6-7
d) Gordons functional Patten.................................................................................7-9

a)
b)
c)
d)

Clinical Discussion
Anatomy and Physiology..................................................................................9-14
Pathophysiology....................................................................................................14-18
Course in the ward.....................................................................................................19
Medical management
1. Diagnostic and Laboratory Results.............................................................19-21
2. Drug study...................................................................................................22-25

Nursing management
a) Problem list.................................................................................................................26
b) Nursing care plan ...................................................................................................27-29
c) Discharge planning....................................................................................................30
Conclusion...................................................................................................... 31
References.........................................................................................................31

I.INTRODUCTION
A. BACKGROUND OF THE STUDY
Appendicitis is one of the most common causes of emergency abdominal surgery. Acute
appendicitis can also happen after a gastrointestinal infection. Rarely, a tumor may cause acute
appendicitis. Sometimes the cause of acute appendicitis is not known. The inflammation is
usually caused by a blockage, but may be caused by an infection. Without treatment, an
inflamed appendix can rupture, causing infection of the peritoneal cavity (the lining around the
abdominal organs) and even death.
Acute appendicitis can occur when a piece of food, stool or object becomes trapped in
the appendix, causing irritation, inflammation, and the rapid growth of bacteria and infection.
Up to 75,000 appendectomies are done each year in the U.S. The estimated population
in the Philippines is 86, 241, 697 and the incident rate of acute appendicitis is 215,604 as of
year 2011. Appendicitis is one of the more common surgical emergencies, and it is one of the
most common causes of abdominal pain.
In Asian and African countries, the incidence of acute appendicitis is probably lower
because of the dietary habits of the inhabitants of these geographic areas. The incidence of
appendicitis is lower in cultures with a higher intake of dietary fiber. Dietary fiber is thought to
decrease the viscosity of feces, decrease bowel transit time, and discourage formation of
fecaliths, which predispose individuals to obstructions of the appendiceal lumen.
There is a slight male preponderance of 2:1 in teenagers and young adults; in adults, the
incidence of appendicitis is approximately 1.4 times greater in men than in women. The
incidence of primary appendectomy is approximately equal in both sexes.
Acute appendicitis can occur in any age group or population. However, it most often
occurs in teens and young adults. It is rare in children younger than two years of age. Classic
symptoms of acute appendicitis include pain in the right lower abdomen, where the appendix is
located, that gets progressively sharp and more intense . Pain increases when pressure is put
on the area (called the McBurneys point), and the area becomes even more painful and tender
when the pressure is released (rebound tenderness). This is one exam a health care provider
uses to diagnosis acute appendicitis. The symptoms of acute appendicitis can vary, and not all
people with acute appendicitis will experience the typical symptoms of abdominal pain. In early
acute appendicitis, the abdominal pain may be located around the navel or belly button area,
then move to McBurneys point as acute appendicitis progresses. After abdominal pain begins,
a person with appendicitis may develop a slight fever, have a loss of appetite, feel nauseated, or
vomit.
Acute appendicitis that is not treated promptly leads to life-threatening complications.
Complications of acute appendicitis include: Abdominal abscess, Peritonitis (infection of the
lining that surrounds the abdomen), Ruptured appendix, Sepsis, Shock.
Appendectomy remains the only curative treatment of appendicitis. The surgeon's goals
are to evaluate a relatively small population of patients referred for suspected appendicitis and
to minimize the negative appendectomy rate without increasing the incidence of perforation. The
emergency department (ED) clinician must evaluate the larger group of patients who present to
the ED with abdominal pain of all etiologies with the goal of approaching 100% sensitivity for the
diagnosis in a time-, cost-, and consultation-efficient manner.

RATIONALE OF THE STUDY

We had chosen this case since we believe this could help us enhance our
knowledge about the case thus enhancing our skills and be familiar about its management and
patient care. We also find it interesting and challenging since this would test our teamwork and
patience.
B. OBJECTIVES OF THE STUDY

1.

General Objective
After the case presentation, the Nurses will be able to enhance awareness and
attitude in handling patients with such disease and to develop nursing skills in providing
appropriate care for patients with Appendicitis.

2. Specific Objectives
After the case presentation, the Nurses will be able to:
2.1 Present the patients demographic data and Health History with Gordons pattern of
functioning
2.2 Discuss the Pathophysiology of Appendicitis and its Anatomy and Physiology
2.3 Review the treatment and medications given associated with the patients condition
2.4 Discuss the course in the ward
2.5 Formulate an effective Nursing Care Plan appropriate for the case of the patient based
on the assessment findings according to the standards of Nursing practice
2.6 Plan appropriate discharge plan

C. SIGNIFICANCE OF THE STUDY

This aims to provide a deeper understanding about Appendicitis, the signs and
symptoms, and management. This aims to help health care practitioners, patients and the
community to be aware of its possible complications. This study contains necessary information
about the disease and how the health care practitioners managed the patient with such
condition. It could also serve as a reference or a guide to future researchers or people who have
interests in the study.

D. SCOPE AND LIMITATION

The scope of the study is merely focusing on the case of the patient which is
Ruptured Appendicitis. This study includes the course of action taken by our medical
practitioners, and its underlying nursing care relevant for the client. It includes clients
information and other relevant data during the entire hospitalization (16-18 January 2014) at
Fort Del Pilar Station Hospital. All relevant data such as his history of present illness was just
through History taking and we werent able to handle the patient when his condition started
because it all happened during his break and were hoping that we make a successful
presentation despite our different schedules. The data gathered came from the patient itself, the
patients chart, and the laboratory procedures done during patients admission to discharge.

II. NURSING HISTORY

a. PATIENT PROFILE
Name:
Patient X
Age:
23 years old
Gender:
Male
Birth date:
16 August 1990
Religion:
Baptist
Civil Status: Single
Chief Complaint: incision wound, lower midline of the abdomen
Date/Time Admitted: 16 2040H January 2014
Diagnosis: Ruptured Appendicitis with generalized peritonitis (s/p
Appendectomy with Exploratory Laparotomy, 05 January 2014)
Date of Discharge: 18 January 2014
b. COMPREHENSIVE NURSING HISTORY
1. History of Present Illness
The condition started when he was having their break on 01 January
2014 when the patient felt an on and off pain sensation in his abdomen and the
pain became persistent on 03 January 2014. The patient vomited in the late
afternoon with a whitish and watery output hence, prompted the patient to consult
at Saint Paul Hospital and he was ordered for observation. During the course of
observation, at around 2300H, the patient had loose bowel movement of watery
stool of about three times and manifested a bloated abdomen. On 04 Jan 2014,
the patient was then advised to be admitted to Saint Paul Hospital.
On the day of patients confinement at around 1000H of 04 January
2014 the patient decided to have Home Against Medical Advise (HAMA) in order
to be transferred at military institution. Few hours after when he arrived at the
airport, the patient vomited again once with yellowish, mucoidal output.
The patient arrived in Palawan at around 1700H, and was seen and
examined by MAJ NABULA MC and noted that the patient was dehydrated so he
decided to admit the patient at WESTERN COM at 1800H in order to undergo
laboratory work ups including fecalysis and urinalysis. Laboratory result had
shown that the patient has Amoebiasis, UTI/AGE.
Upon confinement, the patient was also seen by CPT DONALD C
PALMA and added a diagnosis of T/C Appendicitis. The patient underwent series
of assessment to confirm the diagnosis. At around 2200H, the patient was
suspected to have Appendicitis. They eventually inserted Indwelling Foley
Catheter and Nasogastric tube and maintained it during the course of illness.
He was again transferred to another institution, Adventist Hospital for
scheduled operation. Upon his hospitalization, the pain persisted with a
manifestation of a bloated abdomen. He was then operated at 2000H 05 January
2014. The patient had undergone Appendectomy with Exploratory Laparotomy
due to ruptured appendicitis. The final diagnosis was Ruptured Appendicitis with
Generalized peritonitis.
After 3 days of hospitalization at Adventist Hospital, patient was then
transferred to Western Command Station Hospital for continuation of treatment.
After 8 days at Wes-Com, patient was then transferred to FDPSH, PMA, Baguio
City, hence, Admission (16 January 2014)

2. Past Medical History

The patient had his first hospitalization when he was 16 y/o with a
diagnosis of UTI but unable to recall the name of the institution. He also
verbalized that he received complete immunizations.
October 2013, He came in to FDPSH Emergency Room due to abdominal
pain and he was given pain reliever but was not admitted because the pain was
relieved by medication.
3. Family and Social History
The patient claimed to have familial history of hypertension on his father
side but had no familial history of other diseases such as diabetes mellitus,
kidney diseases, heart diseases and asthma. The patient verbalized that his
father had a mild stroke last year. The patient speaks English and Tagalog as a
method of communication.

c. PHYSICAL ASSESSMENT
17 JANUARY 2014
BODY PARTS
General
Appearance

Head

Eyes

Nose

Ears

ACTUAL FINDINGS
>Body built: Mesomorph
>well groomed, fair in complexion
> with normal gait
>with vital signs of: BP of 110/80, PR: 73 bpm , RR of 18
cpm,
>Normocephalic,
> no involuntary movement noted
> hair is color black and well distributed, (-) dandruff, (-)
scaling
>No visible lesions, Lumps, nodules and masses
>no complaints of pain upon palpation
> face is symmetrical when asked to do different facial
expressions
> Pulsations are equal and regular on both temporal
arteries.
>The upper and lower lids are able to close completely,
(-) swelling, (-) lesions, (-) discharges, (-) redness
> His eyeballs are well aligned to the eye socket
>Anicteric sclera
> with pinkish palpebral conjunctiva and clear bulbar
conjunctiva, no redness and lesions seen
>movement of the eyeballs are symmetrical
>Able to distinguish colors, pupils equally round, about
2-3mm in size reactive to light and accommodation.
>Unilateral blinking of eyes
>with visual acuity of 20/20
> Located midline
>No discharges
>no lesions noted
>No tenderness upon palpation
>with pinkish nasal mucosa, no noted lesions
>septum located midline
>Able to determine mild aroma, Able to sniff through
each nostril while other is occluded
>Patent nares
>ears of equal size and with similar appearance
>Color same as facial skin
> Aligned with the outer canthus of eyes
> No tenderness, no lesions, no discharges
6

Mouth

Skin

Heart

Lungs

Abdomen

Upper and
Lower
Extremities

>canal walls pink and uniform, with tympanic membrane

visible, intact, transparent
> Able to hear sounds on both ears
> (-) ROMBERG TEST
>Lips are pinkish in color, no noted lesions or nodules
>Lips are Soft, moist
>lips are symmetrical in contour
>patient is able to purse lips
>with complete set of teeth
>no visible gum problems or bleeding
>with pinkish buccal mucosa, no noted lesions
>with pinkish tongue, no noted lesions
>able to move tongue
>(+) gag reflex
>tonsils are pinkish in color, no lesions or discharges
noted, (-) swelling of tonsils
>Varies from light to deep brown
> Skin is moist and smooth
>Good skin turgor
>With post- operative vertical incision
approximately 5 inches located on the lower midline
of the abdomen
>heart rhythm is regular
> no chest pains and murmurs
>with pulse pressure of 40 mmHg
>no visible chest pulsations
>normal heart sounds noted upon auscultation
> chest is symmetric during respirations
> chest wall intact
> not too shallow and not to deep breathing
>Tactile Fremitus: Vibrations best felt on the larger
airways
> No adventitious sounds heard upon auscultation
> No distention
> flat, non-tender
>(+) muscle rigidity
> Positive bowel sounds upon auscultation present
equally in all 4 quadrants
>with post-operative vertical incision at the lower
midline of the abdomen approximately 5 inches
>Equal in size on both sides of the body
>(-) contractures
>Smooth coordinated movement
> Equal strength
>Good capillary refill (<2 secs)
>no noted lesions and scars on the body

d. GORDONS FUNCTIONAL PATTERN

BEFORE CADETSHIP

DURING CADETSHIP/ DURING

HOSPITALIZATION
7

Health
Perception/
Health
Management

He stated that he has a positive outlook

towards health. He self-medicate at times
but he tends to seek medical consultation
at clinic when he think his condition
seems to worsen and becomes
unmanageable. He claimed to be
compliant to medical regimens and
whatever health teachings given to him.
He drinks 4 bottles of beer every week
and smokes 1 stick of cigarette per week.

NutritionalMetabolic
Pattern

He eats 3 meals a day. He usually eats 2

cups of rice per meal, he eat meat but
more on vegetables. He has good
appetite and is not significantly affected
when he is sick. He drinks 10 glasses of
fluids daily. He stated that he drinks
vitamins (Enervon). He also claimed that
he dont have any allergy to food, drugs,
etc.

Elimination
Pattern

He usually defecates every other day. His

stool characterized as yellowish to brown
in color and formed. He claimed to have
no discomfort in defecating. He usually
urinates 7 times in 24 hours characterized
as yellowish in color as verbalized. He
also claimed that there is no pain during
urination.

ActivityExercise
Pattern

He claimed that he is very active. His

usual activities include playing sports
such as basketball and football. He does
his daily routine, eating, going to school,
doing household chores, and on his free
time, he engages in the fore mentioned
sports. He also jogs in the morning. He
claimed that he always had sufficient
energy in executing his activities.

CognitivePerceptual

He was alert, conscious, oriented to

person, time and place. There were no
history of head injury or other illness that
can affect cognition and perception.

Self-Perception
and SelfConcept

He sees himself as a person who is

healthy. He claimed that he is not usually
stressed, but if he became stressed, it is

Whenever he is sick, he selfmedicate but he tends to seek

consult at FDPSH when he feels
that his condition is worsening.
He claimed to be compliant to
medical regimens and whatever
health teachings given to him. He
stated that he is not drinking
alcohol because it is prohibited in
the academy but he drinks
alcohol when theyre on a break.
He already quit smoking for
almost a year.
He eats what is served from the
mess. He eats three times a day
with 1-2 cups of rice with viand,
eats fruits and vegetables 3
servings as claimed. He drinks 2
liters of fluids per day. He also
claimed that he usually drinks 4
cups of coffee per day. His
appetite is good, and is not
affected when he get ill. But
during his hospitalization, before
the surgery, he claimed that his
appetite became poor. His Body
built is Mesomorph with a BMI of
23
He defecates at least twice a day;
stool is characterized as yellowish
to brown in color and formed. He
urinates 6 to 8 times per day
characterized as yellowish in
color and there is no pain during
urination as verbalized. But after
the surgery, He claimed that he
has difficulty in urinating. One day
post-surgery, he defecate watery
stool. His bowel movement
returned to normal 4 days postsurgery.
He claimed that he is more active
than he was a civilian. The
cadetship required certain
activities such as drills, athletics
and the like. He still played
sports, however, during the
course of his illness his activities
became limited due to the fear
that his surgical wound will open.
He feared moving too often so he
sits most of the time.
He was alert, conscious,
coherent, oriented to person, time
and place. There were no history
of head injury or other illness that
can affect cognition and
perception. He is able to recall
recent and remote memories.
He still considers himself as
healthy; however, he accepts that
he is limited because of his
8

usually because of academics. He is able

to handle stress by meditating on it and
through sleep.

Sleep-rest

He usually sleeps 6 to 7 hours every day

including naps. He goes to bed at around
2200H and wakes at 0500H. He doesnt
have any bedtime routines and hes not
taking any medications to promote sleep.

RoleRelationship

He is single. He has 2 siblings, he is the

2nd child. He claimed that he has a good
relationship with his parents and with his
siblings. Her mother works at DSWD as a
social worker and his father is retired
military personnel (Master Sergeant). He
stated that they always make time to have
bonding moment as a family.

SexualityReproductive

He claimed that he is sexually active. He

mentioned no sexual concerns.

Coping/Stress
Tolerance

Whenever he encounters problem, he

always share it to his family because it
lessens the burden for him. Sometimes
he also goes out with his friends to divert
his attention.
He is a Baptist and attends service every
Sunday. He stated that he always pray to
the Lord especially during times of
difficulties.

Value-Belief
Pattern

condition. During his first year in

the academy, his stressors are
usually academics, the trainings
he has to undergo. But he is able
to manage his stress through
adequate rest.
He usually sleeps 4-5 hours every
day. He goes to bed at 0100H
and wake up at 0500H. He sleeps
when he has free time, usually for
30 minutes. He doesnt have any
bedtime routines nor does he
take any medications to promote
sleep.
He stated that his parents are the
primary provider of their family.
Despite of being separated from
his family for 3 years, he said that
they still have communication and
they were able to gather and
have bonding during their break.
He claimed that he has a good
relationship with co-cadets and
they treated each other as
brothers. They also have gettogether at times, share their
stories, listen to each other and
help one another in times of
needs.
He is sexually active and he
claimed to have no sexual
problems and concerns.
He makes himself busy and finds
diversional activities like reading,
sleeping and sometimes
meditating to avoid from being
stressed.
He goes to church regularly and
he prays always before going to
sleep.

III. CLINICAL DISCUSSION

a. Anatomy and Physiology

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the
oral cavity, where food enters the mouth, continuing through the pharynx, esophagus, stomach
and intestines to the rectum and anus, where food is expelled. There are various accessory
organs that assist the tract by secreting enzymes to help break down food into its component
nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in
the digestive system. Food is propelled along the length of the GIT by peristaltic movements of
the muscular walls
The functions of the digestive system are:

Ingestion - eating food

Digestion - breakdown of the food

Absorption - extraction of nutrients from the food

Defecation - removal of waste products

The digestive system also builds and replaces cells and tissues that are constantly dying.
Digestive Organs
The digestive system is a group of organs (Buccal cavity (mouth), pharynx, oesophagus,
stomach, liver, gall bladder, jejunum, ileum and colon) that breakdown the chemical components
of food, with digestive juices, into tiny nutrients which can be absorbed to generate energy for
the body.
The Buccal Cavity
Food enters the mouth and is chewed by the teeth, turned over and mixed with saliva by the
tongue. The sensations of smell and taste from the food sets up reflexes which stimulate the
salivary glands.

The Salivary glands

10

These glands increase their output of secretions through three pairs of ducts into the oral cavity,
and begin the process of digestion.
Saliva lubricates the food enabling it to be swallowed and contains the enzyme ptyalin which
serves to begin to break down starch.
The Pharynx
Situated at the back of the nose and oral cavity receives the softened food mass or bolus by the
tongue pushing it against the palate which initiates the swallowing action.
At the same time a small flap called the epiglottis moves over the trachea to prevent any food
particles getting into the windpipe.
From the pharynx onwards the alimentary canal is a simple tube starting with the salivary
glands.
The Esophagus
The oesophagus travels through the neck and thorax, behind the trachea and in front of the
aorta. The food is moved by rhythmical muscular contractions known as peristalsis (wave-like
motions) caused by contractions in longitudinal and circular bands of muscle. Antiperistalsis,
where the contractions travel upwards, is the reflex action of vomiting and is usually aided by
the contraction of the abdominal muscles and diaphragm.
The Stomach
The stomach lies below the diaphragm and to the left of the liver. It is the widest part of the
alimentary canal and acts as a reservoir for the food where it may remain for between 2 and 6
hours. Here the food is churned over and mixed with various hormones, enzymes including
pepsinogen which begins the digestion of protein, hydrochloric acid, and other chemicals; all of
which are also secreted further down the digestive tract.
The stomach has an average capacity of 1 litre, varies in shape, and is capable of considerable
distension. When expanding this sends stimuli to the hypothalamus which is the part of the brain
and nervous system controlling hunger and the desire to eat.
The wall of the stomach is impermeable to most substances, although does absorb some water,
electrolytes, certain drugs, and alcohol. At regular intervals a circular muscle at the lower end of
the stomach, the pylorus opens allowing small amounts of food, now known as chyme to enter
the small intestine.
Small Intestine
The small intestine measures about 7m in an average adult and consists of the duodenum,
jejunum, and ileum. Both the bile and pancreatic ducts open into the duodenum together. The
small intestine, because of its structure, provides a vast lining through which further absorption
takes place. There is a large lymph and blood supply to this area, ready to transport nutrients to
the rest of the body. Digestion in the small intestine relies on its own secretions plus those from
the pancreas, liver, and gall bladder.

11

The Pancreas
The Pancreas is connected to the duodenum via two ducts and has two main functions:
1. To produce enzymes to aid the process of digestion
2. To release insulin directly into the blood stream for the purpose of controlling blood sugar
levels
Enzymes suspended in the very alkaline pancreatic juices include amylase for breaking down
starch into sugar, and lipase which, when activated by bile salts, helps to break down fat. The
hormone insulin is produced by specialised cells, the islets of Langerhans, and plays an
important role in controlling the level of sugar in the blood and how much is allowed to pass to
the cells.
The Liver
The liver, which acts as a large reservoir and filter for blood, occupies the upper right portion of
abdomen and has several important functions:
1. Secretion of bile to the gall bladder
2. Carbohydrate, protein and fat metabolism
3. The storage of glycogen ready for conversion into glucose when energy is required.
4. Storage of vitamins
5. Phagocytosis - ingestion of worn out red and white blood cells, and some bacteria
The Gall Bladder
The gall bladder stores and concentrates bile which emulsifies fats making them easier to break
down by the pancreatic juices.
The Large Intestine
The large intestine averages about 1.5m long and comprises the caecum, appendix, colon, and
rectum. After food is passed into the caecum a reflex action in response to the pressure causes
the contraction of the ileo-colic valve preventing any food returning to the ileum. Here most of
the water is absorbed, much of which was not ingested, but secreted by digestive glands further
up the digestive tract. The colon is divided into the ascending, transverse and descending
colons, before reaching the anal canal where the indigestible foods are expelled from the body.

ANATOMY OF THE APPENDIX

12

The appendix is a wormlike extension of the cecum and, for this reason, has been
called the vermiform appendix. The average length of the appendix is 8-10 cm (ranging from 220 cm). The appendix appears during the fifth month of gestation, and several lymphoid follicles
are scattered in its mucosa. Such follicles increase in number when individuals are aged 8-20
years.
The appendix is contained within the visceral peritoneum that forms the serosa, and its
exterior layer is longitudinal and derived from the taenia coli; the deeper, interior muscle layer is
circular. Beneath these layers lies the submucosal layer, which contains lymphoepithelial tissue.
The mucosa consists of columnar epithelium with few glandular elements and neuroendocrine
argentaffin cells.
Taenia coli converge on the posteromedial area of the cecum, which is the site of the
appendiceal base. The appendix runs into a serosal sheet of the peritoneum called the
mesoappendix, within which courses the appendicular artery, which is derived from the ileocolic
artery. Sometimes, an accessory appendicular artery (deriving from the posterior cecal artery)
may be found.
I.

Appendiceal vasculature

The vasculature of the appendix must be addressed to avoid intraoperative hemorrhages. The
appendicular artery is contained within the mesenteric fold that arises from a peritoneal
extension from the terminal ileum to the medial aspect of the cecum and appendix; it is a
terminal branch of the ileocolic artery and runs adjacent to the appendicular wall. Venous
drainage is via the ileocolic veins and the right colic vein into the portal vein; lymphatic drainage
occurs via the ileocolic nodes along the course of the superior mesenteric artery to the celiac
nodes and cisterna chyli.
II. Appendiceal location
The appendix has no fixed position. It originates 1.7-2.5 cm below the terminal ileum, either in a
dorsomedial location (most common) from the cecal fundus, directly beside the ileal orifice, or
as a funnel-shaped opening (2-3% of patients). The appendix has a retroperitoneal location in
65% of patients and may descend into the iliac fossa in 31%. In fact, many individuals may have
an appendix located in the retroperitoneal space; in the pelvis; or behind the terminal ileum,
cecum, ascending colon, or liver. Thus, the course of the appendix, the position of its tip, and
the difference in appendiceal position considerably changes clinical findings, accounting for the
nonspecific signs and symptoms of appendicitis.
Physiology of Appendix
The lumen of the appendix communicates with the cecum 3cm (about 1 inch) before the
ileocecal valve, thus making it an accessory organ of the digestive system. Its functions are not
13

certain, but some biologists believe that the appendix serves as a sort of breeding ground for
some of the nonpathogenic intestinal bacteria thought to aid in the digestion or absorption of
nutrients.
Follicles of lymphoid tissue appear in the wall of the appendix shortly a few birth,
become more prominent during the first 10 years of life and then progressively disappear. The
defense or immune system function of lymphatic tissue present in the appendix of young
children is not fully understood.

While the specific functions of the human appendix remain unclear, there is general
agreement among scientists that the appendix is gradually disappearing from the human
species over evolutionary time. Blockage of the appendix can lead to appendicitis, a painful
and potentially dangerous inflammation.

14

b. PATHOPHYSIOLOGY

Modifiable Risk Factor

Non-modifiable risk
factor
Gender: Most common in
males
(M: F=2:1)
Age: 10-30y/o

Obstruction of the appendix:

Lymphadenitis (inflammation of the lymphoid follicles)

in response to Gastrointestinal infection

Hardened stool (fecalith)

Trauma

Tumors

Intestinal worms

Infection: Amoebiasis
(diagnosed 04 January
2014- Fecalysis : E.
Histolica cyst12/hpf)
Diet: low fiber diet and
rich in refined
carbohydrates
Bowel elimination

Increase in the luminal pressure of the appendix

Distension of the appendix

Impaired venous return (improper oxygen and nutrient supply)

Appendix starts to be necrotic; normal bacteria found in the

appendix begin to invade (infect) the lining of the wall
15

Inflammatory response (body response to the bacterial

invasion in the wall of the appendix

Release of chemical mediators

(histamine, prostaglandin,
leukotrienes, bradykinin, etc.)

Increase permeability of the capillaries to WBCs/

other proteins in order to engage foreign invaders
in affected tissues

Activation of the thermoregulatory center;

anterior preoptic hypothalamic area

Increase temperature- Hyperthermia

Activation of the vomiting center

in the medulla

Stimulation of the vagus

nerve

Nausea and vomiting

Increases swelling of
the appendix

Abdominal pain
(increases in RLQ)

Dehydration

Loss of appetite

Urinalysis: Specific
Gravity: 1.030 (High)

Inflammation and infection spread through the

wall of the appendix causing death of the tissue

Continuous increase in pressure

Perforation (rupture of the

appendix)
16

Fecal materials, phagocytized bacteria, dead cells exits to peritoneal

cavity causing formation abscess (periappendiceal abscess)

Infection spread throughout the abdomen

(peritoneal cavity)

Bacterial invasion of peritoneal cavity causing

inflammation of the membrane that lines the abdomen

PERITONITIS

Signs and symptoms:

Bloated abdomen

Severe pain

Emesis

WBC count of: 20.8x109/L as of 04 January 2014

MANAGEMENT:
APPENDECTOMY with EXPLORATORY
LAPAROTOMY
Strong antibiotic treatment
Fluid volume replacement therapy
Pain medications
RECOVERY

If left untreated:
May lead to SEPSIS (condition caused by
the pressure of microorganisms in the tissues
or blood stream)
SEPTIC SHOCK (decrease BP, increase HR,
increase RR)
COMA

DEATH
17

Acute appendicitis is an inflammation of the appendix and is one of the most frequent causes
of acute abdominal pain. It is often treated surgically as an emergency. As we still do not know the real reason
behind the occurrence of acute appendicitis, it needs to be treated cautiously. Although acute appendicitis is
more common and develops quickly, chronic appendicitis is more rare and much slower. Therefore, when it
comes to chronic appendicitis, timely recognition of the condition and treatment becomes a difficult job. Some
people with chronic appendicitis may only feel fatigue and mild pain in their stomach
Due to the slow progress of chronic appendicitis, you will find that infection may spread all over
the abdominal area. The symptoms often vary from patient to patient; therefore, only a doctor can diagnose it
correctly. The only real difference between acute and chronic appendicitis is that chronic appendicitis
takes longer to develop but is just as lethal.
The main thrust of events leading to the development of acute appendicitis lies in the appendix
developing a compromised blood supply due to obstruction of its lumen and becoming very vulnerable to
invasion by bacteria found in the gut normally.
Obstruction of the appendix lumen by enlarged lymphoid follicles, brings about a raised intra-luminal
pressure, which causes the wall of the appendix to become distended.
Normal mucus secretions continue within the lumen of the appendix, thus causing further build up of
intra-luminal pressures. This in turn leads to the occlusion of the lymphatic channels, then the venous return,
and finally the arterial supply becomes undermined.
Reduced blood supply to the wall of the appendix means that the appendix gets little or no nutrition and
oxygen. It also means a little or no supply of white blood cells and other natural fighters of infection found in the
blood being made available to the appendix.
The wall of the appendix will thus start to break up and rot. Normal bacteria found in the gut gets all the
inducement needed to multiply and attack the decaying appendix within 36 hours from the point of luminal
obstruction, worsening the process of appendicitis.
This leads to necrosis and perforation of the appendix. Pus formation occurs when nearby white blood
cells are recruited to fight the bacterial invasion.
The content of the appendix are then released into the general abdominal cavity, bringing causing
peritonitis.
Appendectomy with Exploratory Laparotomy is then performed to remove the appendix and to
determine the cause of a patient's symptoms or to establish the extent of a disease. A Laparotomy is a large
incision made into the abdomen. Exploratory laparotomy is used to visualize and examine the structures inside
of the abdominal cavity.

18

C. COURSE IN THE WARD

16 January 2014
Impaired skin integrity
At 2140H, the patient was brought to Fort Del Pilar Station Hospital retro-evacuated from
Western Command Station Hospital with the diagnosis of s/p appendectomy with Exploratory
Laparotomy on the lower midline abdomen area with clean and dry surgical site approximately 5 inches
in length and with no discharges noted. Vital signs were taken and recorded with initial VS of Pulse
rate: 78 beats per minute; Respiratory rate; 18 cycles per minute; Temperature; 36.5C; Blood Pressure;
110/80mmHg. The RMT collected blood specimen for CBC and the patient was instructed to collect
urine specimen for urinalysis. Diagnostic results were seen and evaluated by MOD. The following
medications were ordered by the MOD, Diclofenac Sodium 50mg/tab 1 tab P.O. 3x a day as needed for
pain, Ciprofloxacin 500mg/tab 1 tab P.O. 2x a day for 4 more days, Metronidazole 500mg/tab 1 tab P.O.
3x a day for 4 more days.

17 January 2014
Impaired skin integrity
The patient was afebrile, with surgical wound on the lower midline of the abdomen area. There
were no signs of post-op complications such as discharges and foul smelling odour and with and clean
and dry wound. There were no complaints of pain made. The patient was able to do ADLs
independently. Ciprofloxacin 500mg/tab 1 tab P.O 2x a day, Metronidazole 500mg/tab 1 tab P.O. 3x a
day were administered. Vital signs were taken and recorded every shift. Daily wound care was done.

18 January 2014
Impaired Skin integrity
The patient was afebrile with temperature of 36.5C and with clean and dry surgical wound on
the lower midline abdomen area. There were no complaints of pain made. There were no signs of postop complication noted. The patient was ordered to go back to barracks at 1600H by MOD. The patient
was instructed on the following home medications: Diclofenac Sodium 50mg/tab 1 tab P.O. 3x a day as
needed for pain, Ciprofloxacin 500mg/tab 1 tab P.O. 2x a day for 2 more to complete the 7 days,
Metronidazole 500mg/tab 1 tab P.O. 3x a day for 2 more days to complete the 7 days. The patient was
instructed to continue proper wound care and was instructed to come back for follow-up check-up on 23
Jan 2014.

D. MEDICAL MANAGEMENT
1. Laboratory and Diagnostic Procedures
CBC

RBC
WBC

( 5-10x 10 9/L)

HEMOGLOBIN

04 January
2014

05 January 2014

16 January 2014

5.05x1012/L

5.05x1012/L

-----

20.8x109/L

20.4x109/L

9.0 X 109/L

143 g/L

143 g/L

-----

Significance: Increase in WBC count may signify that there is an ongoing

inflammatory response or infection inside the persons body.

19

Urinalysis

04 January
2014

05 January 2014

16 January
2014

Physical
Properties:
Color

Amber

Amber

Dark Yellow

Slightly hazy

Slightly hazy

Slightly Turbid

Reaction

Acidic

Acidic

Acidic

Specific Gravity
(1.010-1.025)

1.030

1.030

1.010

trace
04 January 2014
trace

trace
05 January 2014
trace

Transparency

Chemical
Properties:
Sugar

Fecalysis
Albumin

Microscopic
examination:
Color

Yellowish-brown

negative
trace

Yellowish-green

Pus cells

6-12/hpf
6-10/hpf
1-2/hpf
mucoid
Watery/ mucoid
RBC
3-6/hpf
2-4/hpf
0-1/hpf
WBC
3-6/hpf
15-20/hpf
Am.Urates
many
many
Few
RBC
1-2/hpf
2-4/hpf
Mucus threads
moderate
moderate
rare
E. Histolica cyst
1-2/hpf
-------Hyaline cast
1-4/hpf
1-2/hpf
----Significance: Stool analysis refers to a series of laboratory tests done on
Significance:
presence
of infection,
tissue
damage,
fecal samples Urinalysis
to analyzedetermines
the condition
of a person's
digestive
tract
in
and/or presence
ofthe
excessive
body
likeof
albumin,
urates and
general.
Based on
findings,
theelements
consistency
his stoolsugar,
is mucoidal.
the
likes.
Theout
result
thestool
urinalysis
presence
of infection
or RBC
Mucus
come
withofthe
due toindicates
the bacterial
reaction
that happened
destruction.
The Specific
Gravity
determines
how of
concentrated
the
inside the stomach
and the
intestines.
Presence
E. Histolytica
in urine
the is
and based
on the
finding, Sp.Gr.
is high
and itand
signifies
the
patient
stool
signifies
an ongoing
parasitic
infection
would that
mean
that
the is
dehydrated.
The
presence
of
albumin
indicates
the
waste
materials
the
patient has Amoebiasis as evidence by the increase amount of WBC from
present
destruction
in the stool. of cells or tissues. The presence of casts, urates, mucus threads
and pus cells is not normal and may be suggestive of kidney issues.
Consistency

20

2. DRUG STUDY

21

DRUG NAME

CLASSIFICATION

DOSAGE

INDICATION

CONTRAINDICATION

MECHANISM OF
ACTION

ADVERSE
REACTION

NURSING
CONSIDERATION

Ceftriaxone
Sodium

Anti-infective

1g IV every 8
hours ANST
(-)

surgical prophylaxis;
skin and skin
structure infections

Hypersensitivity to
cephalosporins or
penicillins, allergies,
renal impairment,
hepatic disease,
gallbladder disease,
history of diarrhea
following antibiotic
therapy.

Interferes with
bacterial cell wall
synthesis and
division by binding
to cell wall, causing
cell to die. Active
against gramnegative and grampositive bacteria,
with expanded
activity against
gram-negative
bacteria. Exhibits
minimal
immunosuppressant
activity.

Headache,
hypotension,
palpitations,
nausea and
vomiting,
abdominal
cramps, bleeding
tendency,
hepatomegaly

Monitor
coagulation.
Assessed for
hypersensitivity/
anaphylactic
reaction through
skin test.
Monitor for signs
and symptoms of
superinfections
and other serious
adverse reactions.
Instruct patient to
report persistent
diarrhea, bruising,
or bleeding.
Caution patient not
to use herbs
unless prescriber
approves.

Ranitidine
Hydrochloride

Anti-ulcer Drug

50mg IV
every 8
hours

Active duodenal
ulcer; benign gastric
ulcers;
gastroesophageal
reflux

Hypersensitivity to drug
or tis components;
alcohol intolerance
(with some oral
products);

Reduces gastric
acid and increases
gastric mucus and
bicarbonate
production, creating
a protective coating
on gastric mucosa.

Headache; nausea
and vomiting;
diarrhea,
constipation,
abdominal
discomfort or pain,
rash; pain at IM
injection site,
burning or itching
at IV site;
hypersensitivity
reaction

Assess VS
Tell patient he may
take oral drugs
with or without
food
Advise him to take
once daily
prescription drug
at bedtime
Tell patient
smoking may
decrease drug
effects

Paracetamol

Non-opioid
Analgesic;

300mg IV
every 4

Relieve of fever,
minor ache and

Anemia, cardiac and

pulmonary diseases

Unclear. Pain relief

may result from

Allergic skin
reactions and GI

Advise patient,
parents, or other
22

Analgesic, Antipyretic

hours as
needed for
fever

pains

Metronidazole
Hydrochloride

Anti-infective; antiprotozoal

500mg IV
every 6
hours

Bacterial infections;
amoebiasis

Ciprofloxacin
Hydrochloride

Anti-infective

500mg 1 tab
2x a day for
7 days

Intra-abdominal
infections, Infectious
diarrhea, Urinary
tract infections

inhibition of
disturbances
prostaglandin
synthesis in CNS,
with subsequent
blockage of pain
impulses. Fever
reduction may result
from vasodilation
and increased
peripheral blood flow
in hypothalamus,
which dissipates
heat and lowers
body temperature.

caregivers to
contact prescriber
if fever or other
symptoms persist
despite taking
recommended
amount of drug.
Inform patients
with chronic
alcoholism that
drug may increase
risk of severe liver
damage.

Hypersensitivity to
drug, other
metronidazole
derivatives.

Disturbs DNA
synthesis in
susceptible
orgaisms

Dizziness, vertigo,
nausea and
vomiting,
abdominal pain,
anoexia,
leukopenia, mild
skin dryness, skin
irritaton,
unpleasant
metallic taste

Monitor IV site.
Avoid prolong use
of indwelling
catheter.
Advise patient to
take drug with food
if it causes GI
upset.
Advise patient to
report fever, sore
throat, bleeding or
bruising.
Inform patient that
drug may cause
metallic taste and
may discolour
urine urine
brownish-red.

Hypersensitivity to drug
or other
Fluoroquinolones;
Comcomitant
administration of

Inhibits bacterial
DNA synthesis by
inhibiting DNA
gyrase in
susceptible gramnegative and gram-

headache,
restlessness,
confusion,
orthostatic
hypotension,
nausea, vomiting,

Watch for signs

and symptoms of
serious adverse
reactions,
including GI
problems,
23

Diclofenac
Sodium

Nonopioid
analgesic

50mg 1 tab
3x a day as
needed for
pain

Analgesia

Tizanidine.

positive organisms.

diarrhea,
constipation,
abdominal pain or
discomfort, rash,
altered taste

jaundice, tendon
problems, and
hypersensitivity
reactions.
Tell patient to take
drug 2 hours after
a meal.
Advise patient not
to take drug with
dairy products
alone or with
caffeinated
beverages.
Instruct patient to
stop taking drug
and notify
prescriber at first
sign of rash or
tendon pain,
swelling, or
inflammation.

Hypersensitivity to drug
or its components,
other NSAIDs, or
aspirin; Active GI
bleeding or ulcer
disease

Unclear. Thought to
block activity of
cyclooxygenase,
thereby inhibiting
inflammatory
responses of
vasodilation and
swelling and
blocking
transmission of
painful stimuli.

dizziness,
drowsiness,
headache,
hypertension,
diarrhea,
abdominal pain,
dyspepsia,
heartburn, peptic
ulcer, GI bleeding,
GI perforation,

Observe for and

report signs and
symptoms of
bleeding.
Assess for
hypertension.
Instruct patient to
take drug on
empty stomach 1
hour before or
after a meal.
Advise patient not
to lie down for 15
to 30 minutes after
taking drug, to
minimize
esophageal
24

irritation.
Instruct patient to
immediately report
signs or symptoms
of hypersensitivity
reactions (rash,
swelling of face or
throat, shortness
of breath) or liver
impairment
(unusual tiredness,
weakness, and
nausea, yellowing
of skin or eyes,
tenderness on
right upper side of
abdomen, flulike
symptoms).
Instruct patient to
stop taking drug
and contact
prescriber
promptly if he
experiences
ringing or buzzing
in ears, dizziness,
GI discomfort, or
bleeding.

25

IV. NURSING MANAGEMENT

a. Problem List
Approximate
Date of Onset
05 Jan 2014

16 Sept 2013

05 Jan 2014

16 Sept 2013

Date Identified

Active Problem

DATE INACTIVE

DATE RESOLVED

Impaired tissue integrity

Activity Intolerance

Risk for Infection

Long Term Objective:

Upon discharge, the patient will be able to regain optimum level of functioning holistically in collaboration with the health care team.

Prioritization of the problem:

1. Impaired tissue integrity related to trauma secondary to surgical procedure.
2. Activity intolerance related to limitation imposed by condition.
3. Risk for infection related to inadequate primary defences (broken skin) secondary to surgical incision (S/P Ex-Lap; Appendectomy).

26

Nursing Diagnosis
Date Identified:
16 January 2014
Nursing diagnosis:
Impaired tissue integrity r/t
tissue trauma secondary to
surgical procedure (s/p
Appendectomy with ExLap)
Objective:
>s/p appendectomy with
Exploratory Laparotomy (05
January 2014)
>with clean and surgical
wound at the lower midline of
the abdomen, approximately
5 inches in length
>(-)erythema, swelling and
discharge
>(-) tenderness upon
palpation
>(+) abdominal rigidity

Objectives
Within 2 days of nursing
interventions, the
patient will be able to
achieve timely wound
healing as evidenced
by:
a. clean and dry
wound
b. absence of
discharges on
the surgical site
c. absence of signs
of infections
such as swelling,
erythema, pain
on the surgical
area.

Nursing Interventions
Assessed general status
Assessed characteristics of surgical wound
Assessed wound for signs of infection and other complications
Reviewed laboratory results for any changes that may determine
extent of impairment
Administered Ciprofloxacin Hydrochloride 500 mg/tab 1 tab P.O. 2x
a day as prescribed (0800H- 1800H)

Evaluation
Goal met. Within 2
days of effective
medical and nursing
interventions, patient X
was able to manifest an
improved condition as
manifested by having a
clean and dry wound,
absence of swelling
and discharges, free
from signs of infection.

Promoted optimum nutrition with high protein like poultry products

and fish, vitamins and mineral supplements to facilitate healing
Rendered appropriate wound care and kept the area clean and dry
Promoted early mobility and simple exercises to promote circulation
Promoted adequate rest and comfort
Reinforced importance of early detection and reporting of changes
in condition or any unusual physical discomforts
Emphasized need for adequate nutritional/fluid intake to optimize
healing potential
Instructed on proper wound care
Instructed on required changes in lifestyle necessitated by
limitations imposed by condition.

27

Nursing diagnosis
Date Identified: 16 January 2014
Nursing Diagnosis:
Activity Intolerance r/t limitation imposed by
condition
Subjective:
Hindi ako masyadong naggagagalaw maam
kasi baka bumukas yung sugat ko.
Objective:
S/P Appendectomy with exploratory
Laparotomy (05 Jan 2014)
With dry surgical wound at the lower
midline of the abdomen,
approximately 5 inches in length
(+) abdominal rigidity
Walks slowly
Lies or sits most of the time
Able to do ADLs without assistance

Objectives
Within 48 hours of
nursing intervention,
Patient X will be able to
report measurable
increase in activity
tolerance as evidenced
by:
a. Absence of
guarding on the
surgical site when
ambulating
b. Able to walk at
regular pace
c. Able to move
without limitations

Nursing Interventions
Assessed general status.
Assessed level of activity to do ADLs.
Noted factors affecting intolerance to
activities.
Assisted in doing activities such as
carrying heavy objects.
Assisted patient in increasing activity
level gradually.
Promoted rest and comfort.
Promoted comfort measures such as
splinting if the surgical wound when
performing activities.

Evaluation
Goal met. Within 48 hours of
effective medical and nursing
interventions, the patient
reported measurable increase
in activity tolerance as
evidenced by:
Subjective data;
Mas nakakagalaw na po ako
ng maayos ngayon kaysa dati
kasi mas magaling na yung
sugat ko ngayon.
Objective:
> able to do ADLs independently
>absence of guarding on the
surgical site when ambulating
> able to walk at regular pace
> able to move without limitations

Planned for maximal activity within

clients ability.
Reinforced importance of early
ambulation
Instructed to avoid strenuous activities

Instructed patient that bending and

stretching are fine unless it hurts (this
may be putting too much strain on the
incision if this is the case)
28

Nursing diagnosis
Risk for Infection r/t
inadequate primary
defenses (traumatized
tissue)
Objective:
S/p
appendectomy
with Explore
Laparotomy (05
January 2014)
With latest WBC
result of :
9.0x109/L
With clean and
dry wound of
approximately 5
inches in length
No signs of postop complications :
(-) discharges,
redness and foul
smelling odor
noted

Objectives
Within 2 days of nursing
interventions, the patient will
be able to achieve timely
wound healing as evidenced
by:
a. clean and dry wound
b. absence of
discharges on the
surgical site
c. Absence of signs of
infections such as
swelling, erythema,
pain on the surgical
area.

Nursing Interventions
Assessed integumentary status and documented
Noted risk factors for occurrences of infection
Observed for localized signs of infection at the operative
site such as presence of discharges and redness
Reviewed laboratory results for any abnormalities

Evaluation
Goal met. Within 2 days of
effective medical and nursing
interventions, the patient was
able to manifest an improved
integumentary status as
manifested by having a clean
and dry wound, absence of
swelling and discharges, free
from signs of infection.

Administered Ciprofloxacin Hydrochloride 500 mg/tab 1

tab P.O. 2x a day as prescribed (0800H- 1800H)
Promoted optimal nutrition to facilitate healing
Maintained the surgical wound clean and dry
Maintained adequate hydration and nutritional status
Instructed patient on how to clean the surgical wound
aseptically
Advised regarding proper personal hygiene including
Handwashing
Encouraged patient to have adequate fluid and
nutritional intake
Emphasized importance of early ambulation, deep
breathing exercises, coughing and positional changes
Encouraged to report for any signs and symptoms of
infection

29

 Encouraged to adhere to treatment regimen

30

C. Discharge Plan
Medication:
Instructed on the following medications:
Diclofenac Sodium 50mg/tab 1 tab 3x a day as needed for pain
Ciprofloxacin 500mg/tab 1 tab 2x a day for 2 more days (0800H and 1800H)
Metronidazole 500mg/tab 1 tab 3x a day (0800H, 1300H and 1800H)
Exercise:
Instructed patient to avoid lifting heavy objects (10-15 lbs) until after post-op
checkup
Instructed patient that bending and stretching are fine unless it hurts (this
may be putting too much strain on the incision if this is the case)
Advised patient to avoid vigorous exercise until after post-op appointment
Encouraged patient to ambulate, however he might get fatigued faster than
usual
Excuse from Formation, Athletic and Drill (FAD) as ordered.
Treatment:
Instructed to resume medications as ordered.
Encourage to comply with treatment regimen.
Instructed on proper daily wound care
Health Teaching: (for prevention)
Advised to avoid touching the wound to prevent further injury.
Advised to seek medical care or to report any of the following:
a. Foul smelling drainage from the surgical wound
b. Fever within 24-48 hours
c. New symptoms such as nausea, vomiting, constipation, abdominal swelling or severe
pain
d. Inability to urinate
e. Redness, pus, swelling, or more than usual tenderness from incision
Out-Patient Follow-Up Care:
Instructed the patient to have check-up or on 23 Jan 2014 to monitor condition or re-evaluate
condition.

Diet:
Encouraged to increased oral fluid intake and to eat foods rich in fibre such as fruits, vegetables and
cereals to prevent constipation.
Encouraged to eat foods rich in vitamin C such as pineapple, grapes and oranges to
boost the immune system.
Encouraged to eat foods rich in protein milk, meat products and eggs to promote tissue
repair.
Instructed patient to have a well-balanced diet.

Spirituality:
Encouraged to strengthen his belief by allowing him to practice religious activities such as attending
service regularly.
Sexuality:
No coitus until follow-up check-up reveals healing.
Socialization:
May engage in social activities but avoid stressful events, excessive or strenuous physical activities.

31

V. Conclusion:

In handling specific cases such as Ruptured Appendicitis, it is important to have a

broad and versatile knowledge, skills, and attitude. Accurate physical assessment, proper
implementation of the nursing process based on evidence-based clinical practice together
with the advancement of medicine will aid with the optimum functioning of clients. The
management of such case is based on surgical treatment and timely wound healing. Hence,
our role in the health care team is still very significant in achieving the goal of aiding patients
in full recovery.

VI. References:
Doenges M, Moorhouse M, et al: Nurses Pocket Guide (Diagnoses, Prioritized
Interventions, and Rationales), 12th edition. 2008
http://emedicine.medscape.com/article/773895-overview
http://www.sarpyobgyn.com/downloads/post-op/PostopExpLap.pdf
http://www.abdopain.com/Pathophysiology-of-appendicitis.html
http://www.rightdiagnosis.com/a/appendicitis_acute_appendicitis_chronic_appendicitis/s
ymptoms.htm
http://www.surgeryencyclopedia.com/La-Pa/LaparotomyExploratory.html#b#ixzz2vZ8fzdSu

32