APPENDICITIS

Case Study
Submitted by: Shayne Marie C. Apon Group 1, BSN 4B

Submitted to: Ms. Jennifer Ledesma Clinical Instructor

ANATOMY AND PHYSIOLOGY Digestive system

The human digestive system is a complex series of organs and glands that processes food. In order to use the food we eat, our body has to break the food down into smaller molecules that it can process; it also has to excrete waste. Most of the digestive organs (like the stomach and intestines) are tube-like and contain the food as it makes its way through the body. The digestive system is essentially a long, twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver and pancreas) that produce or store digestive chemicals. The Digestive Process: The start of the process - the mouth: The digestive process begins in the mouth. Food is partly broken down by the process of chewing and by the chemical action of salivary enzymes (these enzymes are produced by the salivary glands and break down starches into smaller molecules).

On the way to the stomach: the esophagus - After being chewed and swallowed, the food enters the esophagus. The esophagus is a long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food from the throat into the stomach. This muscle movement gives us the ability to eat or drink even when we're upsidedown. In the stomach - The stomach is a large, sack-like organ that churns the food and bathes it in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed with stomach acids is called chyme. In the small intestine - After being in the stomach, food enters the duodenum, the first part of the small intestine. It then enters the jejunum and then the ileum (the final part of the small intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small intestine help in the breakdown of food. In the large intestine - After passing through the small intestine, food passes into the large intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium) are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in the digestion process. The first part of the large intestine is called the cecum (the appendix is connected to the cecum). Food then travels upward in the ascending colon. The food travels across the abdomen in the transverse colon, goes back down the other side of the body in the descending colon, and then through the sigmoid colon. The end of the process - Solid waste is then stored in the rectum until it is excreted via the anus. Digestive System Glossary: abdomen - the part of the body that contains the digestive organs. In human beings, this is between the diaphragm and the pelvis

alimentary canal - the passage through which food passes, including the mouth, esophagus, stomach, intestines, and anus. anus - the opening at the end of the digestive system from which feces (waste) exits the body. appendix - a small sac located on the cecum. ascending colon - the part of the large intestine that run upwards; it is located after the cecum. bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and secreted into the small intestine. cecum - the first part of the large intestine; the appendix is connected to the cecum. chyme - food in the stomach that is partly digested and mixed with stomach acids. Chyme goes on to the small intestine for further digestion. descending colon - the part of the large intestine that run downwards after the transverse colon and before the sigmoid colon. digestive system - (also called the gastrointestinal tract or GI tract) the system of the body that processes food and gets rid of waste. duodenum - the first part of the small intestine; it is C-shaped and runs from the stomach to the jejunum. epiglottis - the flap at the back of the tongue that keeps chewed food from going down the windpipe to the lungs. When you swallow, the epiglottis automatically closes. When you breathe, the epiglottis opens so that air can go in and out of the windpipe. esophagus - the long tube between the mouth and the stomach. It uses rhythmic muscle movements (called peristalsis) to force food from the throat into the stomach. gall bladder - a small, sac-like organ located by the duodenum. It stores and releases bile (a digestive chemical which is produced in the liver) into the small intestine. gastrointestinal tract - (also called the GI tract or digestive system) the system of the body that processes food and gets rid of waste. ileum - the last part of the small intestine before the large intestine begins. intestines - the part of the alimentary canal located between the stomach and the anus. jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum and the ileum.

liver - a large organ located above and in front of the stomach. It filters toxins from the blood, and makes bile (which breaks down fats) and some blood proteins. mouth - the first part of the digestive system, where food enters the body. Chewing and salivary enzymes in the mouth are the beginning of the digestive process (breaking down the food). pancreas - an enzyme-producing gland located below the stomach and above the intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats and proteins in the small intestine. peristalsis - rhythmic muscle movements that force food in the esophagus from the throat into the stomach. Peristalsis is involuntary - you cannot control it. It is also what allows you to eat and drink while upside-down. rectum - the lower part of the large intestine, where feces are stored before they are excreted. salivary glands - glands located in the mouth that produce saliva. Saliva contains enzymes that break down carbohydrates (starch) into smaller molecules. sigmoid colon - the part of the large intestine between the descending colon and the rectum. stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical and mechanical digestion takes place in the stomach. When food enters the stomach, it is churned in a bath of acids and enzymes. transverse colon - the part of the large intestine that runs horizontally across the abdomen.

APPENDIX

The appendix is a narrow, dead-end tube about three-to-four inches long that hangs off of the cecum. Although it's commonly referred to as the "appendix," the real name for it is "vermiform appendix." In the past, the appendix was considered an evolutionary leftover. Now however, scientists acknowledge that the appendix helps support the immune system in two ways. It helps tell lymphocytes where they need to go to fight an infection and it boosts the large intestine's immunity to a variety of foods and drugs. The latter helps keep your gastrointestinal tract from getting inflamed in response to certain food and medications you ingest.

Diagram
Non- Modifiable Factor Modifiable Factor Appendicitis

Age

Gender

Diet

Occlusion of appendix by fecalith, enlarged lymph node, worms, tumor.

Compromised blood supply due to obstruction of its lumen

Raised intra-luminal pressure in the appendix

Normal mucus secretions continue within the lumen of the appendix, thus causing further build up of intra-luminal pressures

Occlusion of the lymphatic channels, then the venous return, and finally the arterial supply becomes undermined

Little or no supply of nutrients and oxygen reaches the appendix, wbc and other phagocytes reaching the area

The wall of the appendix will thus start to break up and rot

Appendix start to be necrotic; bacteria invade the appendix

Appendix start to be necrotic; bacteria invade the appendix

Disruption of Cell membrane of appendix

Start of inflammatory process.

Pain in the RLQ of abdomen

Fever

Nausea and Vomiting

Loss of appetite

Constip ation

Inflammation of appendix (Appendicitis)

Appendicitis
The appendix is a small, finger-like appendage about 10 cm (4in) long that is attached to the cecum just below the ileocecal valve. The appendix fills with food and empties regularly into the cecum. Because it empties inefficiently and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable to infection.

PATHOPHYSIOLOGY of APPENDICITIS
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

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. 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.

Signs and symptoms of appendicitis may include:

y y y y

Aching pain that begins around your navel and often shifts to your lower right abdomen Pain that becomes sharper over several hours Tenderness that occurs when you apply pressure to your lower right abdomen Sharp pain in your lower right abdomen that occurs when the area is pressed on and then the pressure is quickly released (rebound tenderness)

y y y y y y y y y

Pain that worsens if you cough, walk or make other jarring movements Nausea Vomiting Loss of appetite Low-grade fever Constipation Inability to pass gas Diarrhea Abdominal swelling

CLINICAL MANIFESTATION OF APPENDICITIS

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. A second, common, early symptom of appendicitis is loss of appetite which may progress to nausea and even vomiting. Nausea and vomiting also may occur later due to intestinal obstruction. 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.

CLINICAL MANIFESTATIONS Lower right quadrant pain usually accompanied by low-grade fever, nausea, and sometimes

vomiting. At McBurneys point (located halfway between the umbilicus and the anterior spine of the

ilium), local tenderness with pressure and some rigidity of the lower portion of the right rectus muscle. Rebound tenderness may be present; location of appendix dictates amount of tenderness,

muscle spasm, and occurrence of constipation or diarrhea. Rovsings sign (elicited by palpating left lower quadrant, which paradoxically causes pain in

right lower quadrant). If appendix ruptures, pain becomes more diffuse; abdominal distention develops from

paralytic ileus, and condition worsens.

COMPLICATION OF APPENDICITIS

The most frequent complication of appendicitis is perforation. Perforation of the appendix can lead to a periappendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection of the entire lining of the abdomen and the pelvis).

The major reason for appendiceal perforation is delay in diagnosis and treatment. In general, the longer the delay between diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours after the onset of symptoms is at least 15%. Therefore, once appendicitis is diagnosed, surgery should be done without unnecessary delay. A less common complication of appendicitis is blockage of the intestine. Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop working, and this prevents the intestinal contents from passing. If the intestine above the blockage begins to fill with liquid and gas, the abdomen distends and nausea and vomiting may occur. It then may be necessary to drain the contents of the intestine through a tube passed through the nose and esophagus and into the stomach and intestine. A feared complication of appendicitis is sepsis, a condition in which infecting bacteria enter the blood and travel to other parts of the body. This is a very serious, even life-threatening complication. Fortunately, it occurs infrequently.

ASSESSMENT AND DIAGNOSTIC METHOD

Diagnosis is based on a complete physical examination and laboratory and radiologic tests. Leukocyte count greater than 10,000/mm3; neutrophil count greater than 75%; abdominal

radiographs, ultrasound studies, and CT scans may reveal right lower quadrant density or localized distention of the bowel.

TEST AND DIAGNOSIS

The diagnosis of appendicitis begins with a thorough history and physical examination. Patients often have an elevated temperature, and there usually will be moderate to severe tenderness in the right lower abdomen when the doctor pushes there. If inflammation has spread to the peritoneum, there is frequently rebound tenderness. Rebound tenderness is pain that is worse when the doctor quickly releases his hand after gently pressing on the abdomen over the area of tenderness.

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.

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.

Computerized

tomography

(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 appendic

Laparoscopy

Laparoscopy is a surgical procedure in which 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 with the laparascope.

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. The urinalysis also may be abnormal with appendicitis because the appendix lies near the ureter and bladder. If the inflammation of appendicitis is great enough, it can spread to the ureter and bladder leading to an abnormal urinalysis. Most patients with appendicitis, however, have a normal urinalysis.

MEDICAL MANAGEMENT
Surgery is 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 normalappearing 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

COMPLICATION OF APPENDECTOMY

The most common complication of appendectomy is infection of the wound, that is, of the surgical incision. Such infections vary in severity from mild, with only redness and perhaps some tenderness over the incision, to moderate, requiring only antibiotics, to severe, requiring antibiotics and surgical treatment. Occasionally, the inflammation and infection of appendicitis are so severe that the surgeon will not close the incision at the end of the surgery because of concern that the wound is already infected. Instead, the surgical closing is postponed for several days to allow the infection to subside with antibiotic therapy and make it less likely for infection to occur within the incision. Wound infections are less common with laparoscopic surgery. Another complication of appendectomy is an abscess, a collection of pus in the area of the appendix. The major complication is perforation of the appendix, which can lead to peritonitis or an

abscess. Perforation generally occurs 24 hours after onset of pain (symptoms include fever (37.7C

[100F] or greater), toxic appearance, and continued pain or tenderness).

NURSING MANAGEMENT
Nursing goals include relieving pain, preventing fluid volume deficit, reducing anxiety,

eliminating infection due to the potential or actual disruption of the gastrointestinal tract, maintaining skin integrity, and attaining optimum nutrition. Preoperatively, prepare patient for surgery, start intravenous line, administer antibiotic, and

insert nasogastric tube (if evidence of paralytic ileus). Do not administer an enema or laxative (could cause perforation). Postoperatively, place patient in semi-Fowlers position, give narcotic analgesic as ordered,

administer oral fluids when tolerated, give food as desired on day of surgery (if tolerated). If dehydrated before surgery, administer intravenous fluids. If a drain is left in place at the area of the incision, monitor carefully for signs of intestinal

obstruction, secondary hemorrhage, or secondary abscesses (eg. fever, tachycardia, and increased leukocyte count).

PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care Teach patient and family to care for the wound and perform dressing changes and irrigations

as prescribed. Reinforce need for follow-up appointment with surgeon. Discuss incision care and activity guidelines. Refer for home care nursing as indicated to assist with care and continued monitoring of

complications and wound healing.

Nursing Diagnosis for Appendicitis

Nursing Diagnosis for Appendicitis Preoperative

1. Imbalanced Nutrition: Less Than Body Requirements related to vomiting pre surgery.

2. Acute Pain related to distention of intestinal tissue by inflammation.

3. Anxiety related to changes in health status.

Nursing Diagnosis for Appendicitis Postoperative

1. Acute Pain related to the existence of postoperative wound.

2. Imbalanced Nutrition: Less Than Body Requirements related to anorexia, nausea.

3. Risk for Infection related to surgical incisions, less knowledge about treatments and diseases associated with lack of information.