CASE STUDY

ON
APPENDICITIS

SUBMITTED BY:
MELISSA D. DAVID

I.

Introduction
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.
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. 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.
Appendicitis is one of the most common causes of emergency abdominal
surgery. Up to 75,000 appendectomies are done each year in the U.S. The
estimated population in the Philippines is 86, 241, 6972 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 the United States, 250,000 cases of appendicitis are reported
annually, representing 1 million patient-days of admission. The incidence of acute
appendicitis has been declining steadily since the late 1940s, and the current annual
incidence is 10 cases per 100,000 populations. Appendicitis occurs in 7% of the US
population, with an incidence of 1.1 cases per 1000 people per year. Some familial
predisposition exists.

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.
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.
As teen-agers living in a fast-phased world and governed by schedules, they
too are predisposed to lifestyle modification especially diet and food preferences
which can contribute to the disease. With this study, the student nurses hope to
apply their learning intaking care not only of their patients but also of themselves.
As nursing students and future nurses, they would want to understand and
appreciate more on what is happening to a patient with acute appendicitis.
Consequently, they are interested on what will be the necessary management that
will be given. All in all, these will help them to become efficient nurses and better
persons later on.

II.

OBJECTIVES
A. GENERAL

To widen and enhance the student nurses knowledge and skills through
additional research about the nature of the disease, its signs and symptoms, its

pathophysiology, its diagnosis and treatment.

Gather as much information and knowledge about appendicitis which is one of

the most common surgical emergencies in the country.

To formulate the appropriate nursing intervention and plan of care to prevent
further complications as well as to promote wellness

B. SPECIFIC

To obtain necessary information regarding the patient and her condition

To assess the patients overall health status
To identify patients health care needs through analysis of all the data gathered
To assist the patient throughout rehabilitation, recovery and discharge
To impart necessary health teachings to the patient
To perform appropriate nursing care in conjunction with the condition of the
patient

III.

Patients Profile

Clients Name: E. A. G.
Age: 54 y/o
Birthday: January 26, 1962
Address: Malabon City
Civil Status: Married
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: January 25, 2016
Chief complaint: Abdominal pain
Admitting diagnosis: Appendicitis

History of Present Illness

Five days PTC, patient experienced vague hypogastric pain described as
fullness, no dysuria, no fever, no vomiting. Three days PTC, patient felt more on
the RLQ area and right inguinal area. One day PTC, patient consulted at private
M.D. where analysis was requested and given analgesics. Few minutes PTC
patient experienced abdominal pain, increased in severity hence consultation.
Past Health History

(+) HPN
(-) previous surgery
(+) alcohol drinker
(-) smoker

IV.

Physical Assessment
VITAL SIGNS:
SKIN:
HEENT:
CHEST/LUNGS:

BP 180/120 PR 91 bpm RR 21 T 37.5

Good skin turgor, warm to touch, no lesion, no rashes
Anicteric Sclera, PERRLA, pink palpebral conjuntiva
Symmetric chest expansion, no retractions, no lagging,

HEART:

vesicular breath sounds

Adynamic precordium, normal rate, regular rhythm, (-)

ABDOMEN:

murmurs
Flabby abdomen, rebound tenderness RLQ area, (+)

EXTREMITIES:

obturator sign
Grossly normal extremities, no cyanosis, no edema, full and
equal pulse

V.

Anatomy and Physiology

The Appendix is a closed-ended, narrow tube up to several inches in

length that attaches to the cecum , the first part of the colon, like a worm. The
anatomical name for the appendix is vermiform appendix which means worm-like
appendage. It's pencil-thin and normally about 4 inches (7 cm) long.

The

appendix is usually located in the right iliac region, just below the ileocecal valve
(designated McBurney's point) and can be found at the midpoint of a straight line
drawn from the umbilicus to the right anterior iliac crest. The inner lining of the
appendix produces a small amount of mucus that flows through the open center
of the appendix and into the cecum.
The wall of the appendix contains lymphatic tissue that is part of the
immune system for making antibodies. During the first few years of life, the
appendix functions as a part of the immune system, it helps make
immunoglobulin. But after this time period, the appendix stops functioning.
However, immunoglobulins are made in many parts of the body; thus, removing
the appendix does not seem to result in problems with the immune system.
Like the rest of the colon, the wall of the appendix also contains a layer of
muscle, but the muscle is poorly developed.

VI.

Pathophysiology

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 fecalith, enlarged lymph node, worms,
tumor, or indeed foreign objects, 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 intraluminal 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. A
combination of dead white blood cells, bacteria, and dead tissue makes up pus. The
content of the appendix (fecalith, pus and mucus secretions) are then released into
the general abdominal cavity, bringing causing peritonitis.

MEDICAL

Surgery is

MANAGEMENT
indicated if appendicitis is

diagnosed and should be performed as soon as possible to decrease risk of

perforation.
Administer antibiotics and intravenous fluids until surgery is performed
Analgesic agents can be given after diagnosis is made.

APPENDECTOMY
During an appendectomy, an incision two to three inches in length is made
through the skin and the layers of the abdominal wall over the area of the appendix. The
surgeon enters the abdomen and looks for the appendix which usually is in the right
lower abdomen. After examining the area around the appendix to be certain that no
additional problem is present, the appendix is removed. This is done by freeing the
appendix from its mesenteric attachment to the abdomen and colon, cutting the
appendix from the colon, and sewing over the hole in the colon. If an abscess is
present, the pus can be drained with drains that pass from the abscess and out through
the skin. The abdominal incision then is closed.

Newer techniques for removing

the appendix involve the use of the

laparoscope. The laparoscope is

a thin telescope attached to a

video camera that allows the

surgeon to inspect the inside of the

abdomen through a small puncture

wound (instead of a larger incision). If
appendicitis

is

found,

the

appendix can be removed with

special instruments that can be passed
into the abdomen, just like the laparoscope, through small puncture wounds. The
benefits of the laparoscopic technique include less post-operative pain (since much of
the post-surgery pain comes from incisions) and a speedier return to normal activities.
An additional advantage of laparoscopy is that it allows the surgeon to look inside the
abdomen to make a clear diagnosis in cases in which the diagnosis of appendicitis is in
doubt.
If the appendix is not ruptured (perforated) at the time of surgery, the patient
generally is sent home from the hospital after surgery in one or two days. Patients
whose appendix has perforated are sicker than patients without perforation, and their
hospital stay often is prolonged (four to seven days), particularly if peritonitis has
occurred. Intravenous antibiotics are given in the hospital to fight infection and assist in
resolving any abscess.
Occasionally, the surgeon may find a normal-appearing appendix and no other
cause for the patient's problem. In this situation, the surgeon may remove the appendix.
The reasoning in these cases is that it is better to remove a normal-appearing appendix
than to miss and not treat appropriately an early or mild case of appendicitis

VII.

Diagnostic Exams

Components

Normal values

Results

Interpretation

Clinical Sig

1. WBC

4.5 11x109/L

18.30 x 109/L

Increased

Presence of in

2. Neutrophils

0.45 0.73

0.90

Increased

Acute infection
surgery

3. Lymphocyte

0.2 0.4

0.10

Decreased

Aplastic anem
immunodeficie
including AIDS

4. Hematocrit

Males:
42 52 %
Females: 35 47 %

46 %

Normal

Balance propo
blood volume
occupied by R

Hematology

Urinalysis:
Components

Normal

Results

Interpretation

Clinical Sig

1. Color

Pale yellow to amber

Dark Yellow

Not normal

2. Transparency

Clear to slightly hazy

Turbid

Not normal

3. Specific gravity

1.015-1.025

1.025

Normal

Cystisis, pre
bacteria

4. PH

4.5-8.0

6.0

Normal

Properly dilu

Not risk for

calcification,
infection

5. Glucose

Negative

Negative

Normal

6. Albumin

Negative

Negative

Normal

Not enough
intake, prese
bilirubin

Absence of D
7. WBC

Negative or rare

2-3/hpf

Not normal

8. Bacteria

Negative

Moderate

Not normal, bacteremia

Proper filtrat
glumerolus

9. Casts

Occasionally hyaline
casts

Coarse granular: 01/hpf

Not normal

Cystisis, nep

Urinary tract
10.

Uric Acid

Normal
1.58-4.43 mmol/24 h

3.13 mmol/24 h

Presence of
infection or d

Absence of c

VIII.

Drug Study

Brand Name
Generic Name

Zantac
Ranitidine

Classification

Histamine H2
antagonists

Dosage and
Frequency

50mg 1 amp
IVTT every 8
hours

Mechanism
of
Action
Inhibits the
action of
histamine at
the H2
receptor site
located
primarily in
gastric parietal
cells, resulting
in inhibition of
gastric acid
secretion.

Indication

Adverse Reaction

Treatment and
prevention of
heartburn, acid
indigestion, and
sour stomach.

CNS:
Confusion, dizziness,
drowsiness,
hallucinations, headache
CV:
Arrhythmias
GI:
Altered taste, black
tongue, constipation,
dark stools, diarrhea,
drug-induced hepatitis,
nausea
HEMAT: Anemia,
neutropenia,
thrombocytopenia
LOCAL:
Pain at IM site
MISC:
Hypersensitivity
reactions, vasculitis

Nursing Management

Observe 11 rights in giving

medication.
Assess IV site and give the drug
slowly.
Assess patient for epigastric or
abdominal pain and frank or occult
blood in the stool, emesis, or
gastric aspirate.
Inform patient that it may cause
drowsiness or dizziness.
Inform patient that increased fluid
and fiber intake may minimize
constipation.
Advise patient to report onset of
black, tarry stools; fever, sore
throat; diarrhea; dizziness; rash;
confusion; or hallucinations to
health care professional promptly.
Inform patient that medication
may temporarily cause stools and
tongue to appear gray black.

Generic

Classification

Dosage and

Mechanism of

Indication

Adverse

Nursing

Name
Ampicin
Ampicillin

frequency
Penicillin,
antibiotic

1g every 6
hours IVTT

Action
A broad
spectrum
semisynthetic,
amino
penicillin is
highly
bactericidal
even at low
concentrations,
but inactivated
by
penicillinase.

Reaction
Infections of
gastrointestina
l tract and soft
tissues.

CNS:
convulsive
seizures with
higher doses

Management
Observe 11 rights
in giving medication.

Determine previous
hypersensitivity
GI: diarrhea,
reactions to
nausea and
penicillins,
vomiting
cephalosphorins
and other allergens
Dermatologic: prior to therapy.
rash
Inspect skin daily
and instruct patient
to do the same. The
appearance of rash
should be carefully
evaluated.
Give medication
around the clock.
Observe 11 rights
in giving medication.

Generic
Name
GENERIC
NAME:
Nicardipine

Classificati
on
Class:
Therapeutic:
Antihypertensive
Pharmacolo
gic: Calcium
channel
blockers

Mechanism of
Action
Inhibits the transport
of calcium into
myocardial and
vascular smooth
muscle cells,
resulting in the
inhibition of
excitation
contraction coupling
and subsequent
contraction.
Therapeutic effects:
systemic
vasodilation
resulting in the
decreased blood
pressure. Coronary
vasodilation
resulting in
decreased
frequency and
severity attacks of
angina

Indication
Alone or with other
agents in the
management of
hypertension, angina
pectoris and
vasospastic angina.

Adverse Reaction
CNS: headache,
dizziness, fatigue
CV: peripheral
edema, angina,
bradycardia,
hypotension,
palpitations
GI: gingival
hyperplasia,
nausea
DERM: flushing

Nursing Management
*Monitor blood pressure
and pulse before therapy,
during dose titration, and
periodically during therapy.
Monitor ECG during
prolonged therapy.
*Monitor intake and output
ratios and daily weight.
Assess for signs of CHF
(peripheral edema,
rales/crackles, dyspnea,
weight gain and jugular
venous distention
*Lab test considerations:
Total serum calcium is not
affected by calcium
channel blockers.

IX.

Nursing Care Plan

Pre op:
Assessment

Scientific Basis

Nursing
Diagnosis

Nursing Goal
Plan

Subjective:
Sumobra na
talaga sakit ng
tagiliran ko, as
patient verbalized.

Due to the presence

of inflammation and
mass on the RLQ of
the abdomen, it
causes some
obstruction in the
lumen of the
appendix in turn
causes s sharp
acute pain in the
Right Lower
Quadrant part of the
abdomen.

Acute pain related

to inflammation of
the appendix.

Within our 8
hour span of
care, patient
will be
alleviated from
pain.

Objective:
Conscious
Grimaced face
noted
Weakness
noted
Guarded
behavior noted
Pain scale:
7/10
Pale looking

Nursing Intervention

Establish rapport.

V/S taken and recorded.

Scientific Basis

Nursing
Diagnosis

Nursing Goal
Plan

To gain trust and

cooperation.

Evaluation

Goal partially
met.

Serves as baseline data.

To assess the level of pain.

Encourage verbalization of
feelings about pain.

Encourage patient to have

diversional activities such as
mobile internet and watching TV.

Encourage patient to use

relaxation techniques such as
deep breathing.

Provide comfort measures such as

touch, repositioning, quiet
environment and calm activities.

Encourage adequate rest periods.

Assessment

Rationale

Observe and document severity

(1-10 scale) and character of pain
(steady, intermittent, colicky).

Nursing Intervention

To alleviate pain.

Distract attention and

reduce tension.

To promote nonpharmacologic pain

management.

To promote wellness and

prevent fatigue.

To get a baseline data of

pain scale.
Rationale

Evaluation

Subjective:
Medyo natatakot
ako sa magiging
resulta nung
operation, as
verbalized by the
patient.
Objective:

Irritability noted
Anxious
looking
Discomfort
noted
Restlessness
noted

Vague uneasy
feeling of discomfort
or dread
accompanied by an
autonomic response
(the source often
nonspecific or
unknown to the
individual); a feeling
of apprehension
caused by
anticipation of
danger it is an
alerting signal that
warns of impending
danger and enables
the individual to take
measures to deal
with the threat.
(Gulanick/Myers
Nursing Care Plans,
6th Edition)

Anxiety related to
possible surgery
secondary to
Acute
Appendicitis.

Within our 8
hour span of
care, patient
will be able to
understand
and
demonstrate
positive coping
mechanism
and describe a
reduction in
the level of
anxiety.

Establish rapport.

V/S taken and recorded.

Assess awareness of patient

about anxiety.

Provide accurate information to

the client.

To gain trust and

cooperation.

Serves as baseline data.

Validate the feeling and
communicate acceptance
of the feelings.
Helps the client to identify
what is reality based.
To help the patient relax.

Provide comfort measures.

Provide and maintain quiet

environment.

Anxiety may escalate with

excessive conversation,
noise and equipment
about the patient.

Encourage patient to talk about

anxious feelings.

Talking about anxiety

producing situations and
anxious feelings can help
the person perceive the
situation in less
threatening manner.

Goal met.

Post-op:
Assessment

Nursing
Diagnosis

Subjective Data:
Di maganda
pakiramdam ko,
lagi talagang
mataas BP ko
eh. as claimed
by patient.

Risk for decreased

cardiac output
related to
increased vascular
vasoconstriction

The patient will

participate in
activities that
reduce cardiac
workload

Subjective Data: I
do not really feel
well, right now. My
blood pressure is
always high and I
feel light headed
when I suddenly
move. as claimed
by patient.

The patient will

maintain blood
pressure within
acceptable
range

Objective Data:
-Pale in color
-Skin cool and
moist to touch
-Jugular vein
can be easily
seen and
bounding upon
palpation
-Verbalized light
headedness on
sudden change
of position
-Easy fatigability

Objective Data:
-Pale in color
-Skin cool and
moist to touch
-Jugular vein can
be easily seen and
bounding upon
palpation
-Verbalized light

Patient
Outcomes

The patient will

demonstrate
stable cardiac
rhythm and rate
within patients
normal range

Nursing Interventions

Rationale

Goal was met

Independent:
1. Monitor blood pressure
periodically. Measure both arms
three times; 3-5 mins apart while
patient is at rest for initial
evaluation.
2. Note presence of, quality of
central and peripheral pulses.
3. Auscultate heart tones and breath
sounds
4. Observe skin color, moisture,
temperature and capillary refill
time.
5. Note independent or general
edema
6. Provide a calm environment;
minimizing noise; limiting visitors
and length of stay.
7. Maintain activity restrictions (bed
rest) and assist patient with selfcare activities.
8. Provide comfort measures, i.e.
elevation of head
9. Encourage relaxation techniques
like guided imagery and
distractions
10. Monitor response to medications
to control blood pressure

Evaluation

1. Bounding carotid, jugular,

radial, femoral pulses may
be observed/ palpated.
Pulses in the leg may be
diminished, implicating
effects of vasoconstriction
and venous congestion.
2. S3 and S4 heart sounds
may indicate atrial and
venous hypertrophy and
impaired functioning.
3. Presence of adventitious
breath sounds may indicate
pulmonary congestion
secondary to developing
heart failure.
4. Presence of pallor; cool and
moist skin and delayed
capillary refill may be due to
peripheral vasoconstriction
or decreased cardiac output.
5. It may indicate heart failure,
vascular or renal
impairment.
6. Promotes relaxation.
7. It reduces physical stress
and stimuli that affect the
blood pressure.
8. Decreases discomfort and
may reduce sympathetic

headedness on
sudden change of
position
-Easy fatigability
and occasional
dyspnic
occurrences upon
exertion
-Blood pressure
ranging from
140/90 to 150/100
mmHg, BP as of
6:00 A.M.
04/17/12 is 150/90
mmHg
-Pulse rate of 110
beats per minute
as of 6:00 A.M.
04/17/12
-Capillary refill of
2-3 seconds

Depedent
11. Administer medications like
diuretics, alpha and beta
antagonists, calcium channel
blockers, and vasodilators.
Collaborative
12. Instruct and implement to patient
dietary restrictions in sodium, fat
and cholesterol

stimulation
9. It helps reduce stressful
stimuli, thereby decreases
blood pressure.
10. Response to drug is
dependent on both the
individual and the synergistic
effect of the drug. It is also
important to check for any
untoward signs and
symptoms of the
medications.
11. These medications should
be medically prescribed by
the physician and dose and
timing of medications should
be followed. Checking BP
prior to giving of medications
is always a must to prevent
hypotension.
12. This restrictions help
manage fluid retention and
decrease myocardial
workload.

Assessment

Nursing
Diagnosis

Scientific
analysis

Objectives

OBJECTIVE:
- open wound
- visible surgical
incision
- post-operative
patient

Impaired skin
integrity related to
surgical incision

Surgical
intervention
involves
removal of
appendix within
24 to 28 hours
in which surgery
can be
performed
through a small
incision that
causes a
disruption or
damage to the
skin tissues.
Which will leads
to impairment of
the first
protective layer
from infections
or foreign
object.

After 8 hours
of nursing
intervention
the patient
will Achieve
timely wound
healing and
be free of
infection,
demonstrate
how to keep
wound dry
and promote
healing.

Temp - 36.6 oC
PR - 53 bpm
RR - 26 cpm
BP 180/100mmhg

Reference:
Medical surgical
nursing by
brunner and
suddarth, 11th
edition volume 2
@ page: 1242

Nursing Interventions
DEPENDENT:
1) Observe wound, note
characteristics of drainage.

2) Change dressing as
needed using aseptic
technique.

3) Encourage side lying

position (on the left-side)
or a semi-fowlers position.
4) Encourage guarding
behavior.
DEPENDENT
5) Administer antibiotics as
doctors order

Rationale
1. Post-operative
hemorrhage is
likely to occur
during first 2
days, whereas
infection may
develop anytime.
2. Reduce skin
irritation and
potential
infection, also to
prevent soaking
the dressing by
any discharges.
3. May decrease
pressure to
operated site,
thus relieving
abdominal
distention.
4. Promote
protection to the
incision site.
5. Hasten the
healing of the
wound.

Evaluation
After 8 hours
of nursing
interventions
the patients
wound
appears to be
dry and freed
from
drainage or
purulent
substances
therefore
goal was
met.

X.

Discharge Planning

Medication

Instruct patient and the family to comply with the prescribe medication.
Instruct patients family to place medicine in places out of children reach.
Instruct patient and the family to complete the whole duration of the drug.
Teach the patient and the family regarding the name of the drugs, right dosage,
and proper manner of taking as well possible side effects.

Environment/Exercise

Advice patient to take regular breaks from any activity that demands to give

stress pressure on back.

Encourage patient to involve in exercise to enhance circulation.
Encourage the patient to have adequate rest and sleep.

Treatment

Orient the patients family about the patients condition and necessary

information/treatment and recovery process.

Teach patient and the family about the importance of conducive environment for

better recovery.
Encourage to comply with treatment regimen.

Health Teachings

Advice to take medications on time and with the right dose.

Instruct the patient to eat nutritious food such as vegetables and fruits.

Advice the patient to limit consumption of fatty foods.

Encourage client to choose food/ have family member bring food that seem
appealing to stimulate appetite.

Instruct client to provide oral care before and after meals and at bedtime.

Out patient

Instruct the patient to take the medications ordered by the physician.

Encourage the patient to comply with the scheduled check-up.

Instruct the patient and the family to comply with the prescribed medications.

Encourage patient to visit physician one to two weeks after discharged from the
hospital.

Instruct the patient to visit physician immediately if anything unusual happens

Diet

Encourage patient to eat nutritious and well balance meal.

Instruct the patient to increase oral fluid intake.

Diet as tolerated is advice by attending physician to sustain her nutritional needs.