Appendectomy/ Appendicitis Case study

I.INTRODUCTION Patient J.L.D is 31 year-old married woman who was admitted at the Surgery Department last June 21, 2009 due to severe pain at her right lower quadrant, the patient was diagnosed with acute appendicitis. The patient underwent emergency appendectomy the next day, June 22, 2009. Appendicitis is the inflammation of the vermiform appendix and was first described as a pathologic condition by Reginald Fitz in 1886, it is caused by an obstruction attributed to infection, stricture, fecal mass, foreign body or tumor. Appendicitis can affect either gender at any age, but is most common in male ages 10-30. Appendicitis is the most common disease requiring surgery and one of the most commonly misdiagnosed diseases. Appendectomy, removal of the appendix, is the standard treatment for acute appendicitis, it is important to immediately remove the appendix after the diagnosis to prevent the occurrence of the life-threatening complication of appendix. 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.

II.NURSING OBJECTIVE • • • • • • •

To obtain necessary information regarding the patient and her condition To assess the patient’s overall health status To identify patient’s 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 To widen and enhance the student nurse’s knowledge and skills through additional research about the nature of the disease, its signs and symptoms, its pathophysiology, its diagnosis and treatment.

III.PATIENT’S PROFILE Name: J.L.D Age: 31 Sex: Female Civil Status: Married Date of Birth: October 03, 1977 Address: Never-ever Land Religion: Roman Catholic Nationality: Filipino Category of the Patient: GM Place of Admission: Aprilville General Hospital Date Admitted: June 21, 2009 Time: 9:55 PM Chief Complaint: Right Lower Quadrant Pain Ward: St. Anthony Attending Physician: Dr. House ^-^ Chief complaint: Right Lower Quadrant pain Final Diagnosis: Acute Appendicitis

IV. HISTORY OF PAST AND PRESENT ILLNESS A. History of Past Illness Last September 2008, patient was diagnosed with kidney stones or renal calculi. She underwent 3 sessions of Extracorporeal Shock Wave (ESWL) or simply known as shockwave therapy, a non-invasive technique for removing obstructive renal calculi. The patient believes that the occurrence of her kidney stones was due to her habit of eating salty foods and soda or carbonated soft drinks. Her doctor prescribed her with the following medications to reduce the risk of new calculi formation: Sambong forte, Acalka, and Rowatinex. The patient has also a surgical history, she delivered her two children through Ceasarean Section (CS), her first CS delivery was on the year 2001, according to the patient, her pregnancy was normal but her child had meconium-stained amniotic fluid and was overdue that’s why she had to deliver her first child through CS, and the second was on the year 2005. The patient denies allergies to any medications, foods or animals. The patient claims that she only suffered from two common childhood illnesses, chicken pox and measles, when she was a kid. According to her she was completely immunized when she was a child as evidenced by scars on the patient’s left and right deltoid. The patient admits a family history of hypertension, according to the patient her father died of heart attack.

B. History of Present Illness Patient was in usual state of good health until June 21, 2009, after having her dinner she experienced a severe pain at her abdomen which started at the area around her periumbilical area shifted to right lower quadrant region. She was immediately rushed to the hospital and was admitted at the surgery ward at 9:55 PM, she was diagnosed with acute appendicitis. She underwent an emergency appendectomy the next day, June 22, 2009. Her operation begun at 12:50 PM and ended at 1:25 PM, her surgeon was Dr. Paat. According to the patient, she had been experiencing mild pain at her abdominal region since December 2008, she even consulted it to the doctor but they did not pay much attention to it thinking that it was just a manifestation of her kidney problem and that it was nothing serious. The patient’s vital signs during the shift were as follow: Temperature: 36.6 °C Pulse Rate: 67 bpm Respiratory Rate: 16 cpm Blood Pressure: 100/80 mmHg

V.PEARSON ASSESSMENT

DATE

P PSYCHOSOCIAL

E ELIMINATION

A/R REST & ACTIVITY

S SAFE ENVIRONMENT

JULY 9,2009 >31 years old, married woman >mother of 2 >lives at Cuta, Vigan, Ilocos Sur >Roman Catholic >Conscious and coherent >has good and harmonious relationship with her family members

JULY 12, 2009 >conscious and coherent >oriented, responsive and cheerful >has good relationship with her neighborhood >attends the mass every Sunday together with her family

JULY 16,2009 >conscious and coherent >alert and responsive >has good relationship with co-workers

>(-) vomiting >(-)diaphoresis >voids 5x a day with a clear and light yellow urine >(-) pain upon urinating >defecates 2x a day

>(-) vomiting >(-) diaphoresis >voids 5x a day with a clear and light yellow urine >(-) pain upon urinating >defecates 2x a day

>(-) vomiting >(-) diaphoresis voids 5x day with a clear and light yellow urine >(-) pain upon urinating >defecates 2x a day

>sleeps 6-7 hours >patient started going to work on July 6, 2009, 9 days after her operation >works as a health clerk at a hospital >works for 9 hours, from 8:00 am to 5:00 am >considers watching TV at night with her family as a way of recreation

>sleeps 6-7 hours >goes to work 5x a week, from Monday to Friday >does household chores >refrained from doing strenuous activities such as carrying heavy objects >takes a short nap during weekends

>works at the hospital Philhealth office >sleeps 6-7 hours a day >refrained from carrying her children after her operation >refrained from doing strenuous activities such as pushing heavy objects

>afebrile, body temperature (BT) of 36.9 °C/ax >denies allergy to foods or drugs >with dry and intact dressing on incision site >with binder at the abdominal area >cleans and changes the dressing regularly >with dry wound >(-) pain at the incision site >with clean and quiet environment

>afebrile, BT of 37.1 °C/ax >still with dry and intact dressing at incision site >still with binder at her abdominal area >with dry and leathery wound >(-) pain at the incision site >with strong house structure

>afebrile,36.8 °C/ax > still with dry and intact dressing at incision site >still with binder at the abdominal area >(-) pain at the incision site > intact, approximated wound edges >owns a pet dog which lives in a dog house outside their house

>RR=14 cpm; eupneic

>RR=14 cpm; eupneic

>RR=16; eupnic

VI.DIAGNOSTIC PROCEDURE A. Ideal 1.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. Therefore, a normal urinalysis suggests appendicitis more than a urinary tract problem, it is also usually used in women to rule out pregnancy. 2. 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. 3.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. 4.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. Findings of acute appendicitis of ultrasound: • • • • • • •

Visualization of noncompressible appendix as a blind-ending tubular a peristaltic structure (seen only in 2% of normal adults, but in 50% of normal children) Laminated wall with target appearance of 6 mm in total diameter on cross section (81% SPECIFIC)/mural wall thickness 2 mm Lumen may be distended with anechoic/hyperechoic material Pericecal/periappendiceal fluid Increased periappendiceal echogenicity (= infiltration of mesoappendix/pericecal fat) Enlarged mesenteric lymph nodes Loss of wall layers = gangrenous appendix

False-negative US: • • • • •

Failure to visualize appendix Inability of adequate compression Aberrant location of appendix (eg, retrocecal) Appendiceal perforation Early inflammation limited to appendiceal tip

False-positive US: • • •

Normal appendix mistaken for appendicitis Alternate diagnosis: Crohn disease, pelvic inflammatory disease, inflamed Meckel diverticulum Spontaneous resolution of acute appendicitis

5. 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. 6. 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 appendicitis. CT findings of normal appendix

• • •

Visualized in 67-100%. At posterior-medial aspect of cecum. Diameter of up to 10 mm.

CT findings of Abnormal appendix • • • • •

Distended lumen (appendix >7 mm in diameter). Circumferential wall thickening. Target sign: homogeneously enhancing wall with mural stratification. Appendicolith: homogeneous/ringlike calcification (25%). Distal appendicitis: abnormal tip of appendix + normal proximal appendix and normal cecal apex.

7. LAPAROSCOPY Laparoscopy is a surgical procedure in which a small fiber optic 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. The disadvantage of laparoscopy compared to ultrasound and CT is that it requires a general anesthetic.

8. THE ALVARADO SCORE FOR ACUTE APPENDICITIS The Alvarado score is a clinical scoring system used in the diagnosis of appendicitis. The score has 6 clinical items and 2 laboratory measurements with a total 10 points. A score of 5 or 6 is compatible with the diagnosis of acute appendicitis. A score of 7 or 8 indicates a probable appendicitis, and a score of 9 or 10 indicates a very probable acute appendicitis. A popular mnemonic used to remember the Alvarado score factors is MANTRELS: Migration to the right iliac fossa Anorexia, Nausea/Vomiting Tenderness in the right iliac fossa Rebound pain Elevated temperature (fever) Leukocytosis Shift of leukocytes to the left

Despite numerous studies touting the advantages of newer diagnostic technologies, the most accurate and cost0effective diagnostic tool to diagnose

appendicitis remains for the physician to spend time performing an accurate history and physical examination.

B.Actual CBC

DIAGNOSTIC WBC

NORMAL RESULT 5.0-10.0

ACTUAL RESULT 12.0 x10^9/L

NURSING IMPLICATION High-indicates infection

NSG. RESPONSIBILITY >Instruct patient to increase intake of Vitamin C and increase fluid intake >Administer antibiotic as ordered High-indicates >Instruct patient to stress, pain and increase intake of acute systemic Vitamin C and increase infection fluid intake >Monitor signs of infection such as elevated Body Temp. >Administer antibiotic as ordered Normal High-indicates >Monitor signs of infection infection such as elevated Body Temp. >Administer antibiotic as ordered Low-indicates exhausted immune system Normal High-indicates >Instruct patient to infection increase intake of Vitamin C and increase fluid intake

Lymph #

3.0-4.0

1.6x1069/L

Mid # Gran #

0.1-0.9 5.0-7.0

0.7x10^9/L 9.7x10^9/L

Lymph %

30.0-40.0

13.4%

Mid % Gran %

1.0-9.0 50.0-70.0

5.8% 80.8%

HGB RBC HCT

120-160 4.04-5.48 37.0-47.0

131g/L 4.99x10^12/L 36.9%

Normal Normal Mildly indicates blood loss

MCV

82.0-95.0

74.0 fL

Low-indicates anemia

MCH

27.0-31.0

26.2 pg

MCHC RDW-CV RDW-SD PLT MPV PDW PCT

320-360 11.5-14.5 35.0-56.0 150-400 7.0-11.0 15.0-17.0 0.108-0.282

355 g/L 14.0% 38.3 fL 239 x10^9/L 8.4 fL 16.8 0.200%

Low-indicates Iron >Instruct patient to deficiency increase intake of foods high in iron such as green leafy vegetables Normal Normal Normal Normal Normal Normal Normal

low- >Instruct patient to mild increase intake of Vitamin C and increase fluid intake >Instruct patient to increase intake of Vitamin C and increase fluid intake

Urinalysis NORMAL COLOR

ACTUAL

Implication

Light or pale Light Yellow Yellow Clear Slightly turbid

Normal

ALBUMIN REACTION SPECIFIC GRAVITY PUS CELL

(-) 4.6-8 1.010-1.025

(-) 6.5 pH 1.010

Normal Normal Normal

0

2-4

Abnormal

SQUAMOUS

(-)

(+)

Abnormal

BACTERIA

(-)

(+)

Abnormal

CHARACTER

Abnormal

Nursing Responsibility >Instruct patient to increase fluid intake

>Instruct patient to increase fluid intake >Administer antibiotic as ordered >Instruct patient to increase fluid intake >Administer antibiotic as ordered >Instruct patient to increase fluid intake >Instruct patient to increase intake of Vitamin C >Administer antibiotic as ordered

VII.ANATOMY AND PHYSIOLOGY OF ORGAN INVOLVED 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 immunogobulins. 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.

VIII.PATHOPHYSIOLOGY Obstruction of the appendix (by fecalith, lymph node, tumour, foreign objects)

↓ Inflammation

↓ Increase intraluminal pressure

↓ → causes pain

Distention of the Appendix

↓ Decrease venous drainage

↓ Blood flow and oxygen restriction to the appendix

↓

→causes fever

Bacterial Invasion of the Blood wall

↓ Necrosis of the appendix The pathophysiology of appendicitis is the constellation of processes that leads to the development of acute appendicitis from a normal appendix. 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. So, in acute appendicitis, bacterial colonization follows only when the process have commenced. These events occur so rapidly, that the complete pathophysiology of appendicitis takes about one to three days. This is why delay can be deadly. Pain in appendicitis is thus caused, initially by the distension of the wall of the appendix, and later when the grossly inflamed appendix rubs on the overlying inner wall of the abdomen (parietal peritoneum) and then with the spillage of the content of the appendix into the general abdominal cavity (peritonitis). Fever is brought about by the release of toxic materials (endogenous pyrogens) following the necrosis of appendicael wall, and later by pus formation. Loss of appetite and nausea follows slowing and irritation of the bowel by the inflammatory process. Early symptoms of appendicitis are those symptoms that most people with this condition may recognize and complain of. They include lower right sided abdominal pain of gradual onset, feeling sick (or nausea), and loss of appetite. Any one with these three symptoms can be assumed to have appendicitis until proven otherwise. •

Abdominal pain This pain typically starts from around the belly button (peri-umbilical region), or the upper central abdomen (epigastrium) and then move downwards

and to the lower right abdomen (right iliac fossa). When the pain occurs in this pattern, it is the most dependable of all symptoms of appendicitis, as over 8 out 10 (80%) cases that present this way is definitely due to the appendix. In some other individuals, the pain starts right way from the right iliac fossa. Depending on where the tip of the appendix is, the pain could even be on the right flank (retrocaecal appendix). If the appendix is quite long, and in the pelvic cavity, it could as well cause lower left abdominal pain, with frequent passage of urine if the inflamed appendix irritates the bladder. When the appendix is severely inflamed, the pain can be localized to a spot on the outer one third of a line drawn between the belly button and front of the tip of the waist bone called the McBurney’s point. The Mc Burney’s point is also often the point of maximum tenderness when the abdomen is examined. The pain is even worse when the hand is suddenly removed from that spot because of the appendix rubbing on the covering of the abdomen (Rebound tenderness). There is also a sign referred to as the Rovsign sign. This is said to exist when the lower left abdomen is palpated by the doctor, but causes pain in the right. If the appendix is the pelvic type, examining the back passage (rectal examination) would cause some pain too. If the hip is moved and stretched, this can also cause pain to be felt at the spot where the appendix lies. This is referred to as the psoas sign. Loss of Appetite, Nausea & Vomiting

•

This is another very important set of symptoms of appendicitis. It is said that loss of appetite is the most constant symptom of appendicitis. They may actually vomit. It is important to note that vomiting in appendicitis usually follows the pain. If you vomit before the pain commenced, it is not likely that the appendix is to blame. Change in Bowel Habit

•

There may be diarrhea or constipation, especially in young children. This could lead to a wrong diagnosis of food poisoning or gastroenteritis on the part of the unwary doctor. Up to 1 in 5 persons (20%) could have diarrhea or even constipation with appendicitis. •

Fever There is usually a low grade fever in most patients with this disease. Nevertheless, in up to 1 in 5 persons (20%), they have normal temperature, even with severe disease. Temperature above 38.5 degree centigrade with rigors is suggestive of a ruptured appendicitis.

IX.MEDICAL AND SURGICAL MANAGEMENT A. MEDICAL a.Ideal The following are the ideal diagnostic procedures done to the patient which were already explained thoroughly on the previous pages: A. Urinalysis B. WBC count C. Abdominal X-ray

D. Ultrasound E. Barium Enema F. CT Scan G. Laparoscopy H. The Alvarado Score for Acute Appendicitis I. Once a diagnosis of appendicitis is made, an appendectomy usually is performed. Antibiotics almost always are begun prior to surgery and as soon as appendicitis is suspected b. Actual The diagnostic procedure done to the patient were Urinalysis and CBC. Patient was given the following medications:  Ceftriaxone 1 gm,IV,Q 12 hrs x 4 doses:an antibiotic which inhibits synthesis of Bacterial cell wall, causing cell death  Tramadol 50 mg, IV, q 8 hrs: an analgesic which binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to the opioids,dizziness, constipation  Ketorolac 30 mg, IV, q 8 hrs: it has Anti-inflammatory and analgesic activity; inhibits prostaglandins and leukotriene synthesis The patient was administered with D5LR 1 L regulated at 31-32 gtts/min. D5LR is actually 5% dextrose in lactated ringer's solution. it is a hypertonic solution which aids in replacement of lost body fluids.

B. SURGICAL A.IDEAL Surgery is the only treatment for acute appendicitis. The appendix may be removed in two ways: First is the open method or through 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. Second is Laparoscopic Method. Laparoscopy is a new technique for removing the appendix which involves 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. For example, laparoscopy is especially helpful in menstruating women in whom a rupture of an ovarian cysts may mimic appendicitis. B.ACTUAL The procedure done to the Patient is Appendectomy, she was operated on June 22, 2009.. Her operation begun at 12:50 PM and ended at 1:25 PM. Her surgeon was Dr. Paat