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  • 1. APPENDICITIS Appendicitis is a condition characterized by inflammation of the appendix. The appendix is a small, finger-like appendage attached to the cecum just below the ileocecal valve. Because it empties into the colon insufficiently and its lumen is small, it is prone to becoming obstructed and is vulnerable to infection. The obstructed appendix becomes inflamed and edematous and eventually fills with pus. It is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity and the most common cause of abdominal surgery. Males are affected more than females, teenagers more frequently than adults; the highest incidence is in those between the ages of 10 and 30 years. The disease is more prevalent in countries in which people consume a diet low in fiber and high in refined carbohydrates.
  • 2. Lower right quadrant pain usually accompanied low-grade fever, nausea, and sometimes vomiting. At McBurney,s 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. Rovsing’s sign (elicited by palpating the left lower quadrant, which paradoxically causes pain in right lower quadrant ) If appendix ruptures, pain more becomes diffuse; abdominal distention develops from paralytic ileus, and condition worsens.
  • 3. Rovsing's sign Continuous deep palpation starting from the left iliac fossa upwards (anti clockwise along the colon) may cause pain in the right iliac fossa, by pushing bowel contents towards the ileocaecal valve and thus increasing pressure around the appendix. This is the Rovsing's sign
  • 4. Psoas sign This is right lower- quadrant pain that is produced with the patient lying on his left side and then extending the hip. Because extension elicits pain, the patient will lie with the right hip flexed for pain relief
  • 5. Obturator sign If an inflamed appendix is in contact with the obturator internus, spasm of the muscle can be demonstrated by flexing and medial rotation of the hip. This maneuver will cause pain in the hypogastrium. Not all the conditions causing luminal obstruction causes appendicitis,resolution of inflammatory condition of appendix can occur and this is known as resolution or mucocele of appendix with appropriate antibiotic treatment .
  • 6. Blumberg sign Palpation of the left iliac fossa, followed by sudden release causes contralateral (right iliac fossa) rebound tenderness.
  • 7. I. PATIENTS PROFILE Name: Mr. Geronimo Q. Caluza Address: Caoayan, Burgos, La Union Age: 69 years old Birth date: August 25, 1940 Gender: Male Marital Status: Widow Nationality: Filipino Ethnic Origin: Ilocano Education: High School Graduate Occupation: Retired Police/ Security Guard / Farmer Religion: Roman Catholic
  • 8. II. HOSPITALIZATION PROFILE Chief Complaint:Right Lower Quadrant Pain in the abdomen, fever and headache Initial V/S upon Admission: BP: 100/70, PR: 96, RR: 28, T: 38.1 C Admitting Physician: Dr. Estela L. Talic, Admission Date: February 4, 2010 Admission Time: 4:30 pm Admitting Diagnosis: Right Lower Quadrant Pain T/C Acute Appendicitis Pre-Operative Diagnosis: Acute Appendicitis Ruptured Post- Operative Diagnosis: Acute Appendicitis Ruptured Surgeon: Dr. Dag-O Anesthesiologist: Dr. Antolin Anesthetic: Sub Arachnoid Block Date of Operation: February 5, 2010 Time Operation Started: 2:15 am Time Operation Ended: 2:50 am Title of Operation Performed: Emergency Appendectomy
  • 9. Patient’s condition started one day before admission to Ilocos Training and Regional Medical Center. On the night of February 3, 2010 the patient felt severe pain on the right lower quadrant of the abdomen and not radiating (aggravated when moving and decrease the rate of pain in supine position, a stabbing pain and with a rate of 8/10) accompanied by fever (warm to touch as verbalized by the patient and SO) and headache. There was no associated nausea and vomiting according to the patient. He tried to relieve the pain, by taking Mefenamic Acid 500 mg however the pain was not totally relieved by the medication. Since the hospital was far from their place, the patient decided to consult a physician on the next day.
  • 10. At around 10:00 in the morning of February 4, 2010, the patient together with his son arrived at Naguilian District Hospital for consultation. His chief complaint was still the pain on the right lower quadrant of his abdomen accompanied by fever and headache. After the assessment procedure done by the health care team in the hospital, the physician’s probable diagnosis reveals that the patient may be suffering from Urinary Tract Infection or Acute Appendicitis. The physician explained that if ever it is an acute appendicitis, emergency appendectomy should be performed immediately to prevent complications. So the physician decided to refer him on other more equipped hospital for further assessment and care because their hospital cannot handle complicated cases. One hour prior to admission, the patient still suffer from severe pain of the right lower quadrant of his abdomen accompanied by fever and headache, sought consult on this institution (ITRMC), hence admission.
  • 11. The patient has an incomplete immunization because during his childhood days, immunization was not yet initiated. The only vaccine that the patient received was BCG (seen on his right arm as evidence by a scar). He experiences usual illnesses like cough, colds and influenza. And according to the patient, he was first hospitalized in Baguio General Hospital 31 years ago and was diagnosed to have acute bronchitis. He also claimed to have no existing allergies to food and drugs and has no previous intake of maintenance drug for any serious health complication.
  • 12. The patient claimed that there was no history of hereditary diseases on both sides of his mother or father such as hypertension, cerebrovascular diseases, asthma, diabetes mellitus, cancer, peptic ulcer disease, hyperthyroidism, or arthritis. He has no family member with an existing contagious disease such as with pulmonary tuberculosis. Rather, his family usually experiences common illnesses such as cough, colds and influenza. Furthermore, he also claimed that there were no histories of hospitalization among the members of his family so far.
  • 13. He is a good citizen in their barangay since he is the chairman of LUPON (LUPON were the one who mediates during a confrontation on the barangay when there are disputes of people in the barangay) and a member of senior citizen organization. It has been 20 years since he stopped smoking. He started smoking when he was 19 years old and he smoke 1-2 packs of cigarettes (Hope) per day. He also drinks alcoholic beverages. He started drinking alcohol when he was 19 years old. According to the patient, he drinks alcoholic beverages such as beer, “gin” and “emperador” at around 3 times a week and stop it 4 years ago. He was also a known kind neighbor according to his son.
  • 14. This was the first time he was admitted at Ilocos Training and Regional Medical Center.
  • 15. Day 1 – February 4, 2010 / 4:30 pm to 12:00 am (From the time of admission to the time he was prepared to have an emergency appendectomy)
  • 16. From Naguillan District Hospital, the patient was referred and admitted to ITRMC at 4:30pm of February 4, 2010. He was brought by an ambulance accompanied by his son and a nurse. The patient was admitted with the following diagnostic tests: hematology, complete blood count and urinalysis, all dated February 4, 2010. After a thorough interview, physical assessment and diagnostic procedures done, the doctor diagnosed the patient to have Right Lower Quadrant Pain T/C Acute Appendicitis. After a few hours of persistent Right Lower Quadrant pain, the doctor decided that the patient should undergo Appendectomy. The patient was then brought to surgery male ward for further assessments. Eventually he was scheduled for “E” Appendectomy at 2:00 am of February 5, 2010. The doctor also ordered D5LRS 1L x 8 hours, Cefuroxime 750 mg every 8 hours given via IV (ANST), Metronidazole 500 mg every 8 hours given via IV(ANST), Ranitidine 50 mg every 8 hours given via IV. Note: We handled the patient from Feb. 5- 6, 2010 of 7-3 shift.
  • 17. Day 2 (Feb. 5, 2010) (this is the 1st day we handled the patient) At around 2:00 am of February 5, 2010, the patient was brought to the operating room to undergo Appendectomy with duly accomplished consent forms with proper pre-operative preparation. The operation was started at 2:15 am and ended at 2:50 am. OR findings revealed the following results: dilated distal 3rd appendix ruptured appendix and generalized peritonitis.
  • 18. At 7 am, the patient was five hours post-operative. The patient is still flat on bed with an IVF of D5LRS 1L x 8 hours infusing well on his right arm at full level. The patient also has IFC connected to urine bag. We received the patient sleeping and at around 8 am, the patient woke up but still flat on bed because the order will due at 11 am. The patient is under NPO; however the doctor ordered to wet his lips with wet cotton balls for drying of lips. Also, the doctor orders were to continue his medications; Cefuroxime 750 mg every 8 hours given via IV, Metronidazole 500 mg every 8 hours given via IV, Ranitidine 50 mg every 8 hours given via IV, Ketorolac 15 mg every 4 hours for 6 doses given via IV and Tramadol 50 mg every 8 hours for 4 doses given via IV;continue monitoring vital signs, input and output and IFC may remove in the afternoon.
  • 19. When we received the patient, the following vital signs were taken: BP of 90/ 60, RR of 22, PR of 68 and a temperature of 36.5°C and since there are no abnormalities, we did not do any referral instead we just continue monitoring his vital signs and do NPI. At around 9 am, when we asked the patient if he has complaints, he just said that he feels pain on the operative site (P- surgical incision;Q-pricking; R- non- radiating pain on the operative site; S- rated as 7/ 10; T- “just this morning when I wake up”). We encouraged the patient to do deep breathing exercises to somehow relieve the pain since his Ketorolac will be given at 11 am. At around 10am, while the patient is lying on bed, we asked his permission if he could allow us to take him as our subject for the case presentation and fortunately, he agreed and said “agadal kayo nga nalaeng tapno pumasa kayo iti board exam iti nursing”. We acknowledged his advice through smiling and responsing “wen tatang”. At the moment he agreed, NPI was done to caught and establish trust then we did the 13 areas of assessment and asked some questions to the patient.
  • 20. At around 11 am (due time for FOB) we encourage the patient to gradually ambulate to prevent complications (adhesiolysis, pressure ulcer, improper tissue perfusion etc). We also implemented appropriate nursing intervention such as monitoring V/S; promoting proper hygiene, rest and comfort; anticipating needs of the patient to decrease body movement that may trigger pain on abdominal area; administering medications as ordered; ensuring safety by merely staying beside him as frequent as possible; and encouraging diversional activities like reading news paper and social interaction to distract the patient from concentrating on the pain he’s feeling. Before our shift ended, we assessed again his pain and he said that the rate was already 2/ 10.
  • 21. Day 3 (Feb. 6, 2010) On our second day of handling the patient, he can now sit, stand or even walk slowly for few steps with assistance. He is also smiling, reading newspaper and seems no problem at all. He’s still with D5LRS 1L but now regulated at 8 hours. The doctor’s orders were to continue his medications, continue monitoring V/S of the patient and that the patient may have general liquids to soft diet in the afternoon. After they cleaned and dressed his wound, we asked the patient if he had any complaints, “kaasi ni Apo umim-imbag toy riknak”. We promoted rest, good body and oral hygiene and diversional techniques such as social interaction and reading newspaper. We also attend to his needs such as accompanying him to the comfort room.
  • 22. Note: This was assessed during our first day on surgery ward which was February 5, 2010 at around 10 am and beyond until our shift last during this day however for the Gustatory Status, since he was on a post operative status, we assessed this on our 2nd day which was February 6, 2010.
  • 23. A. General Social Status Mr. Caluza is a 64 years old, male, widow, Filipino citizen, and an Ilocano. He lives in a mountainous place in Cauayan, Burgos La Union. He lives with his three sons in his second wife in an unused “kiskisan” which is made up of wood. The base of the house serves as their kitchen and living room, while the upper portion serves as their bedroom. He is a Roman Catholic and his family does not have practices or belief in any way that may hinder the delivery of health care services. His sons and daughters in his first wife also sometimes support him financially. According to the patient they have just enough income for a 3x a day meal (Their income varies because his sons doesn’t have a permanent job and also sometimes his other children give money in varying amount like 2,000 to 3000/month). He is a high school graduate. He worked as a police officer for 11 years and security guard for 17 years and at present as a farmer and does spraying of mango trees.
  • 24. B. Family or Peer Group Social Status The patient is the third child of Mr. and Mrs Caluza. He got married at the age of 23. He had 8 children, 5 on his legal wife and 3 children on his previous live-in partner. According to the patient his legal wife died because of heart attack. His 5 children then lived on their mother’s relative. Three years after his wife’s death, he was engaged in a relationship and they had 3 children. However they separated three years ago due to some family problems(He doesn’t want to elaborate this, so we asked his daughter about it and we found out that his live in partner went away to accompany her new boyfriend and at the moment, the second wife now has a child to her new live-in partner). Currently he is now living with his three sons. He has good relationship with his children both in his first and second wife. His three sons ages 21, 20, 18 years old respectively are already working with him at home and in the farm and his children in his first wife were sending him money too.
  • 25. C. Social Developmental Status At the age of 64 the patient is still able to work in the farm. He is still the breadwinner of the family since his three sons don’t have stable jobs yet. The patient is still active in joining organizations. In fact, he is a chairman of LUPON in their barangay (LUPON were the one who mediates during a confrontation on the barangay when there are disputes of people in the barangay). He is also a member of Philhealth and Senior Citizen organizations. The patient also stated that since he is ill at this moment, he cannot be able to perform his duty and responsibility as a chairman of LUPON in their barangay and also as a father of his children.
  • 26. A. Mental Status Patient had been observed with no unpurposeful and involuntary movements. Dress and grooming are appropriate for setting, season, age and gender. He appears slightly neat and clean. However, a slightly foul odor could be smelled when you’re near to him, this may be due to dried perspiration left on his clothing and bed linen.. His hair is slightly matted and oily.
  • 27. Patient is awake, alert, with clear and understandable speech. With appropriate facial expression and verbal responses. He responds appropriately to several stimuli such as verbal, noise, light, touch and pain stimulus. Patient is oriented to people, time and place. With good attention span and able to cooperate during the interview. Recent and remote memory are intact. Thought processes and perceptions are logical, coherent, and relevant. Thought content is consistent and logical. There was no suicidal ideation. He’s a high school graduate. He articulates himself in Ilocano, and Tagalog. He’s able to read and write. He can comprehend and follow directions.
  • 28. B. Emotional Status He exhibits positive affirmations regarding his present health condition. He is not irritable upon interview and assessment. However we observed a positive guarding behavior towards his wound on the lower part of his umbilicus. He said there is pain felt on the operative site which he rated as 7/10 on a scale of 0-10, 10 being the most painful. He shows appropriate mood and emotional response. He is able to communicate well and verbalize his needs and concerns regarding his health condition. Generally, he’s optimistic about his current condition. No substance taken to alter emotional response
  • 29. He’s also cooperative in medical treatments done to him. He stated that he’s afraid to ambulate because the operative site might open which the doctor explained that another operation is needed if that happens, however to prevent complications, the doctor encouraged him to ambulate gradually. He positively believes that he can soon recover from the illness he’s experiencing and soon can continue his goals and aspirations in life –to enhance their living condition. However he verbalized that at the moment, he cannot tolerate to perform ADL due to his condition so he needs assistance to somehow carry it out. Full support of his family members is needed for him to cope up with his condition.
  • 30. Patient’s house is located far from the national highway but near the feather road of their barangay he said. It is an unused “kiskisan” turned into a house. The walls is made up of wood while the roof is made up of metal. They owned the “kiskisan” however it is not utilized due to lack of financial support to let it operate continuously. They decided to live in there after renting a house near the “kiskisan”. It is a two story structure with 10 stairs. They have their own comfort room and it is located 1 meter away from their house. Their water supply is from a pump well that is regularly tested by the barangay health personnel as stated by the patient. He lives with his three sons, all young adults.
  • 31. The patient is confined at the Male Surgical Ward of ITRMC. He receives adequate assistance from his son, daughter and nurses on duty. The patient is with intravenous line on his right arm and also with an IFC connected to urine bag. He stayed in a room with other patients approximately 1 meter away from each other. He stayed in a bed with no side rails but with head and foot board. The ward provides good lighting, there were 2 big rotating electric fan(180°) found at each end of the room. Despite of inadequate financial source at the moment that the patient was hospitalized, his relatives provides the needed medications for his treatment and it is found on the bedside table with some food and reading materials like newspaper.
  • 32. With regards to infection control, the family who regularly visits the patient practices good hand and body hygiene like hand washing and using alcohol whenever they touch the patient and whenever they attend the needs of the patient. Though risk for contamination are possible because he is staying in a room with other patients. Proper waste disposal were also practiced. Upon assessment, the patient has an intact indwelling foley catheter that has been regularly emptied by the nurse on duty as well as student nurses on an 8 hours basis. The patient uses mineralized water to prevent water borne diseases that could instigate gastrointestinal problem such as infection. With regards to his wound, it was regularly cleaned by doctors attending him. It is covered by an OS following the suture lines. It is located below the umbilicus.
  • 33. A. Visual The patient uses eyeglasses (O.D. 20/200, O.S. 20/70) when reading articles which have small characters (font 5, 1 foot distance) such as bible. He can read articles (newspapers with font 12) without the aid of eyeglasses at a distance of 1 foot. He is a near sighted. The patient has a fair visual acquity. He has a good visual lateralization. No blurring of vision noted. He can spontaneously identify things at distant. With the use of penlight, we assessed that the patient’s pupils are equally round, and reactive to light accommodation. No eye pain, no redness, no swelling, no discharge, no tearing/lacrimation and no lesions noted. Myopia, presbyopia, blindness, astigmatism as well as unusual sensations like rainbows around light, blind spots, and flashing light have not been noted.
  • 34. B. Auditory Status The patient states that he has a good hearing condition. The patient is able to distinguish voices at distance of until 2 ft. using the “whisper test” as an assessment tool. He also has a good bilateral hearing. Ears are symmetrical, have smooth texture and are same in color. No earaches, discharges, tinnitus or vertigo noted. No known auditory deficit, corrective device or unusual sensation such as ringing, buzzing or dizziness noted
  • 35. C. Olfactory The patient can discriminate odors and could differentiate them accurately as assessed by letting him smell different types of odorous agent such as perfume and coffee with closed eyes. Patent nostrils had been observed and no airway obstruction or discharges had been noted.
  • 36. D. Gustatory NOTE: This is assessed during the 2nd day post-operative due to NPO status of the patient on the 1st day we had handle him. The patient is able to discriminate sweet, sour, salty, and bitter foods. No difficulty of swallowing has been noted as evidenced by drinking of water. His three teeth (2 on the upper incisors and 1 on the lower incisors) has silver jacket. The patient reports no pain, lesions, sore throat, swollen or bleeding gums, toothache, ulcerations or hoarseness. No unusual sensations noted. Improper mouth hygiene had been noticed (foul smelling breath).
  • 37. E. Tactile Status The patient is able to discriminate sharp and dull, light and firm touch on the upper and lower extremities as evident by rubbing tip of pencil against his skin as an assessment method. He’s also able to perceive heat, cold and pain in proportion to stimulus in the upper and lower extremities. Upon assessment, the patient is not warm or hot to touch (afebrile). He has been hospitalized with chief complaint of right lower abdominal quadrant pain accompanied by fever. Facial sensations are symmetrical.
  • 38. F. Sensory Environment (Language Perception Formation) He’s able to understand and initiate speech without difficulty. He reads and writes accurately and can articulate well. He understands and comprehends instructions.
  • 39. Upon assessment, the patient is on a post operative status. He was advised by his physician to ambulate gradually 8 hours after the operation. While on post-op state, his son attends on his needs. The patient has muscle strength of 5/5 on the upper extremities, and 4/5 on the lower extremities, both left and right. No evidence of muscle wasting. No muscle or joints pain is verbalized by the patient. 5/5 5/5 4/5 4/5 Muscle Strength
  • 40. Prior to confinement, the patient has poor appetite. He ate variety of food comprises mixture of carbohydrate (rice), protein (meat) and fat (frying oil, nuts) rich foods. He prefers vegetables harvested from their backyard over meat as an everyday meal and he also love to eat fish. He eats one and a half cup of rice. The patient verbalizes that he had no food or drug allergies and also there were no religious restrictions of food. They have eggplants, tomatoes, pechay, etc. planted in their backyard and they eat meat at least 2 times a week. Upon hospitalization, he state that he loses good appetite. He is 5’4” in height and weights 52 kg; he has a BMI *kg/ht (m)2] of 19.55 which is within normal range. Also, despite of the sudden decrease of appetite, the patient still looks good.
  • 41. He was ordered NPO before the operation until we had assessed the patient. He has a good swallowing reflex. Bowel sounds was gurgling, cascading sounds, occurring irregularly anywhere from 6 to 20 times per minute. At present, patient had no occurrences of diarrhea or constipation. However he told us that sometimes he feels nauseated but with negative vomiting episodes. No medications given that can alter patient’s digestion and metabolism of foods.
  • 42. Urine Prior to hospitalization, the patient eliminates 1 to 1 1/2 liters of urine daily. He urinates 5 to 6x/day with clear, straw-colored urine. No nocturia, dysuria or hesitancy upon urination. No pain, lesions or unusual discharges from the penis. Also, there was no history of genitourinary disease. At the event of the disease, the patient eliminates urine at about 700cc in our shift (7-3 shift) upon assessment during the post operative status (pt. is with indwelling foley catheter). His urine was yellow orange in color.
  • 43. Stool With regards to his bowel movement prior to admission, the patient stated that there are times that he defecates regularly with a yellowish to brown color in varying amount (depends on the amount of food intake of the patient) but there are also some times that he defecates infrequently (usually every after 3 days) with hard and small feces and dark colored stool (twice in a month). His feces usually have a yellowish to brown color. Upon assessment, the patient doesn’t defecate but he stated that he had passed flatus for 2 times during our shift. There are no artificial orifices for stool elimination.
  • 44. Prior to hospitalization the patient normally consumes 1000 to 1500 liters of fluids daily and he normally urinates 5 to 6 times a day. Prior and after operation he was ordered NPO. We had assessed him on post-operative status. And he’s been ordered to have volume hydration of D5LRS regulated at 30 gtts/ minute. During our shift, he has a 875 cc infused of IVF and his urine was measured to reveal 700 cc output at the end of our shift. The patient verbalized no previous episodes of vomiting despite of nauseated feeling prior to admission. The patient skin is slightly oily and the skin returns quickly to its original shape when pinched between two fingers and released (good skin turgor). No edema is observed.
  • 45. The patient told us that his usual Blood Pressure reading is 120/80 prior to admission. Upon assessment, his Blood Pressure reading is at 90/60. Pulse rate is 68 beats per minute with amplitude of 2+. No medications prescribed that could alter heart rate or rhythm. The patient skin and nails are not pale and with capillary refill of 2 second.
  • 46. He has bilateral patent airway, with a respiratory rate ranging from 18-22 cycles per minute, deep and regular. Neither cough nor colds noted upon assessment. No difficulty of breathing as verbalized by the patient. No crackles, wheezes or any abnormal breath sounds noted. The patient ceased smoking since 1990. No medications prescribed that could alter respiratory rate or patency of bronchial tree. Skin and nails are not pale. No clubbing of nails noted. Also, no supportive devices such as tracheostomy noted.
  • 47. One day prior to hospitalization, the patient suddenly felt warm body sensation while having a severe abdominal pain that prompts him to consult a physician on the 4th day of February 2010. When he was assessed in Naguilian District hospital, his temperature reading was 38.3 C which signifies a febrile condition. His temperature persisted until he was admitted at ITRMC. Dr. Talic ordered TSB to reduce his temperature. No antipyretic medications given. Upon assessment, his temperature reveals a normal result which is 36.5 C. Patient is able to verbalize feelings of warmth and cold. He is in a slightly well ventilated room due to presence of 2 big circulating electric fans and open wide windows. He perspires minimally. No special equipment such as hypo-hyperthermia blanket noted.
  • 48. The patient has a fair complexion. His skin is slightly pale. He has a good skin turgor. It is not warm to touch. His nails are pinkish in color; long and dirty nevertheless it is not pale with capillary refill of 2 seconds. His hair is slightly matted and oily. Patient is given daily sponge bath by his son. No abnormal excretions but he’s slightly odorous due to perspiration that is left into the bed sheet and on his clothing. With regards to his wound, it is located below the umbilicus with a length of approximately 3 inches with no any discharges. Skin surrounding the wound is pinkish in color. It is covered with a bandage to avoid contamination. It is regularly cleaned by doctors who do the morning rounds after endorsement.
  • 49. A. Sleep He normally sleeps 7-8 hours a day, prior to hospitalization. He described his sleep as continuous, uninterrupted sleep. Patient verbalizes that he normally sleeps at about 10 pm and wakes at 5 or 6 in the morning. When he was admitted, his sleep is often interrupted due to frequent assessment and interventions made by health care providers. He just sleeps for 4 hours last night due to the operation performed just few hours ago. No medications given that could alter sleep pattern of the patient.
  • 50. B. Comfort He verbalizes pain on the abdominal area particularly at wound site. He rated it as 7/10, 10 being the most painful aggravated by sudden movements. He grimaces when in pain and has been observed to have a positive guarding behavior. Provocative – “surgical wound”, Quality - “stabbing pain”, Region- “non-radiating pain on the operative site” (below the umbilicus), Severity Scale – “rate of 7/10”, 10 being the most painful, Timing – “just this morning when I wake up” as verbalized by the patient. (Note: The patients haven’t taken yet his pain relief medication upon assessment.)
  • 51. 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.
  • 52. 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.
  • 53. 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.
  • 54. 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.
  • 55. 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.
  • 56. 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/pericecalfat) > Enlarged mesenteric lymph nodes > Loss of wall layers = gangrenous appendix
  • 57. 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
  • 58. 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.
  • 59. 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.
  • 60. 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.
  • 61. 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.
  • 62. 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
  • 63. Test Result Reference Interpretation Hgb 114 ( M- 130-180gm/L F- 120-160gm/L ) Decrease – due to infection & internal hemorrhage brought by ruptured appendix WBC 10.1 ( 5.00-10.00x109/L ) Increase - due to presence of bacterial infectious process Platelet 136 ( 150-450 x 109/L ) Decrease – due to infection & internal hemorrhage brought by ruptured appendix Lymphocytes 15.5 19.0 – 48.0 Decrease – due to tissue trauma B. Actual Note: Only CBC and Urinalysis were the diagnostics done to the patient. Naguilian District Hospital HEMATOLOGY REPORT NAME OF PATIENT: CALUZA, Geronimo Room: ER Date: 2-4-10
  • 64. Test Result Reference Implication Color yellow Light or pale yellow Abnormal – may indicate a concentrated urine Transparency turbid Clear Abnormal – indicates presence of infection Reaction alkaline ph 8.5 6.5 pH Abnormal – due to infection Pus cells 1-3/hpf 0 Abnormal – may be indicative of urinary tract infection Red cells 2-4/hpf ( - ) Abnormal – can be due to bleeding in the genitourinary tract as a result of systemic bleeding disorders or bacterial infections Epith. cells few ( - ) Abnormal – presence of epithelial cells indicates infection Bacteria plenty ( - ) Abnormal – indicates infection Albumin trace ( - ) Abnormal – due to renal distress associated to tissue trauma Sp. Gravity 1.010 1.010-1.025 Normal Amorp. Phosphates plenty ( - ) Abnormal – indicates infection Naguilian District Hospital CLINICAL MICROSCOPY REPORT Name of Patient: CALUZA, Geronimo Room: ER Date: 2/4/2010
  • 65. ITRMC Name: CALUZA, Geronimo Age: 69 y/o Sex: Male Ward: Surgery Date: 2-4-10 9:23PM Sample ID: 0204-91 Mode: OV-WB-CBC
  • 66. Parameter Range Result Unit Reference Range Interpretation WBC 4.50-11.00 13.64 10^9/L 4.50-11.00 Increase - due to presence of bacterial infectious process Neu% 40.0-74.0 85.7 % 40.0-74.0 Increase - due to presence of bacterial infectious process Lym% 19.0-48.o 9.7 % 19.0-48.0 Decrease – due to tissue trauma brought by ruptured appendix Mon% 9.0 4.3 % 3.4-9.0 Normal Eos% 0.0-7.0 0.2 % 0.0-7.0 Normal Bas% 0.0-1.5 0.1 % 0.0-1.5 Normal RBC 4.20-6.20 3.77 10^12/L 4.20-6.20 Decrease – Increased WBC leads to destruction of RBC in the blood; - due to infection & internal hemorrhage brought by ruptured appendix HGB 120-180 115 g/L 120-180 Decrease – due to infection & internal hemorrhage brought by ruptured appendix HCT 38.0-54.0 33.6 % 38.0-54.0 Decrease – due to infection & internal hemorrhage brought by ruptured appendix MCV 80.0-96.0 89.0 fL 80.0-96.0 Normal MCH 27.0-31.0 30.5 Pg 27.0-31.0 Normal MCHC 320-360 342 g/L 320-360 Normal PLT 136 10^9/L 150-450 Decrease – due to infection & internal hemorrhage brought by ruptured appendix
  • 67. Test Reference Result Interpretation Sodium, Na+ 135-148 mmol/L 136.9 mmol/L Normal Potassium, K+ 3.50-5.30 mmol/L 4.32 mmol/L Normal Chloride, Cl- 96-107 mmol/L 100.8 mmol/L Normal ITRMC Name: CALUZA, Geronimo Age: 69 y/o Sex: Male Ward: Surgery Date: 2/4/2010 CLINICAL CHEMISTRY SECTION
  • 68. The mouth, or oral cavity, is the first part of the digestive tract. It is adapted to receive food by ingestion, break it into small particles by mastication, and mix it with saliva. The lips, cheeks, and palate form the boundaries. The oral cavity contains the teeth and tongue and receives the secretions from the salivary glands.
  • 69. Lips and Cheeks The lips and cheeks help hold food in the mouth and keep it in place for chewing. They are also used in the formation of words for speech. The lips contain numerous sensory receptors that are useful for judging the temperature and texture of foods. Palate The palate is the roof of the oral cavity. It separates the oral cavity from the nasal cavity. The anterior portion, the hard palate, is supported by bone. The posterior portion, the soft palate, is skeletal muscle and connective tissue. Posteriorly, the soft palate ends in a projection called the uvula. During swallowing, the soft palate and uvula move upward to direct food away from the nasal cavity and into the oropharynx.
  • 70. Tongue The tongue manipulates food in the mouth and is used in speech. The surface is covered with papillae that provide friction and contain the taste buds. Teeth A complete set of deciduous (primary) teeth contains 20 teeth. There are 32 teeth in a complete permanent (secondary) set. The shape of each tooth type corresponds to the way it handles food.
  • 71. Pharynx The pharynx is a fibromuscular passageway that connects the nasal and oral cavities to the larynx and esophagus. It serves both the respiratory and digestive systems as a channel for air and food. The upper region, the nasopharynx, is posterior to the nasal cavity. It contains the pharyngeal tonsils, or adenoids, functions as a passageway for air, and has no function in the digestive system. The middle region posterior to the oral cavity is the oropharynx. This is the first region food enters when it is swallowed. The opening from the oral cavity into the oropharynx is called the fauces. Masses of lymphoid tissue, the palatine tonsils, are near the fauces. The lower region, posterior to the larynx, is the laryngopharynx, or hypopharynx. The laryngopharynx opens into both the esophagus and the larynx.
  • 72. Esophagus The esophagus is a collapsible muscular tube that serves as a passageway between the pharynx and stomach. As it descends, it is posterior to the trachea and anterior to the vertebral column. It passes through an opening in the diaphragm, called the esophageal hiatus, and then empties into the stomach. The mucosa has glands that secrete mucus to keep the lining moist and well lubricated to ease the passage of food. Upper and lower esophageal sphincters control the movement of food into and out of the esophagus. The lower esophageal sphincter is sometimes called the cardiac sphincter and resides at the esophagogastric junction
  • 73. Stomach The stomach, which receives food from the esophagus, is located in the upper left quadrant of the abdomen. The stomach is divided into the fundic, cardiac, body, and pyloric regions. The lesser and greater curvatures are on the right and left sides, respectively, of the stomach.
  • 74. Small Intestine The small intestine extends from the pyloric sphincter to the ileocecal valve, where it empties into the large intestine. The small intestine finishes the process of digestion, absorbs the nutrients, and passes the residue on to the large intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive system that are closely associated with the small intestine. The small intestine is divided into the duodenum, jejunum, and ileum. The small intestine follows the general structure of the digestive tract in that the wall has a mucosa with simple columnar epithelium, submucosa, smooth muscle with inner circular and outer longitudinal layers, and serosa. The absorptive surface area of the small intestine is increased by plicae circulares, villi, and microvilli.
  • 75. Exocrine cells in the mucosa of the small intestine secrete mucus, peptidase, sucrase, maltase, lactase, lipase, and enterokinase. Endocrine cells secrete cholecystokinin and secretin. The most important factor for regulating secretions in the small intestine is the presence of chyme. This is largely a local reflex action in response to chemical and mechanical irritation from the chyme and in response to distention of the intestinal wall. This is a direct reflex action, thus the greater the amount of chyme, the greater the secretion.
  • 76. Large Intestine The large intestine is larger in diameter than the small intestine. It begins at the ileocecal junction, where the ileum enters the large intestine, and ends at the anus. The large intestine consists of the colon, rectum, and anal canal. The wall of the large intestine has the same types of tissue that are found in other parts of the digestive tract but there are some distinguishing characteristics. The mucosa has a large number of goblet cells but does not have any villi. The longitudinal muscle layer, although present, is incomplete. The longitudinal muscle is limited to three distinct bands, called teniae coli, that run the entire length of the colon. Contraction of the teniae coli exerts pressure on the wall and creates a series of pouches, called haustra, along the colon.
  • 77. Epiploic appendages, pieces of fat-filled connective tissue, are attached to the outer surface of the colon. Unlike the small intestine, the large intestine produces no digestive enzymes. Chemical digestion is completed in the small intestine before the chyme reaches the large intestine. Functions of the large intestine include the absorption of water and electrolytes and the elimination of feces.
  • 78. Rectum and Anus The rectum continues from the signoid colon to the anal canal and has a thick muscular layer. It follows the curvature of the sacrum and is firmly attached to it by connective tissue. The rectum and ends about 5 cm below the tip of the coccyx, at the beginning of the anal canal. The last 2 to 3 cm of the digestive tract is the anal canal, which continues from the rectum and opens to the outside at the anus. The mucosa of the rectum is folded to form longitudinal anal columns. The smooth muscle layer is thick and forms the internal anal sphincter at the superior end of the anal canal. This sphincter is under involuntary control. There is an external anal sphincter at the inferior end of the anal canal. This sphincter is composed of skeletal muscle and is under voluntary control.
  • 79. 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.
  • 80. 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
  • 81. 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 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
  • 82. B. Actual The diagnostic procedure done to the patient were Urinalysis and CBC. Patient was given the following medications: * Cefuroxime 750 mg every 8 hours given via IV – prophylactic antibiotic which inhibits synthesis of bacterial cell wall, causing cell death * Metronidazole 500 mg every 8 hours given via IV - prophylactic antibiotic which inhibits synthesis of bacterial cell wall, causing cell death * Ranitidine 50 mg every 8 hours given via IV – to block H2 receptor that triggers production of stomach acid; to counteract the two antibiotics which are both gastric irritants * Ketorolac 15 mg every 4 hours for 6 doses given via IV - it has anti-inflammatory and analgesic activity; inhibits prostaglandins and leukotriene synthesis.
  • 83. * Tramadol 50 mg every 8 hours for 4 doses given via IV - an analgesic which binds to mu-opioid receptors andinhibits the reuptake of norepinephrine and serotonin; causes many effects similar to the opioids,dizziness, constipation The patient was administered with D5LR 1 L regulated at 30 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.
  • 84. SURGICAL A. Ideal Surgery is the only treatment for acute appendicitis. The appendix may be removed intwo ways: ** First is the open method or through appendectomy. During an appendectomy, an incisiontwo to three inches in length is made through the skin and the layers of the abdominalwall over the area of the appendix. The surgeon enters the abdomen and looks for theappendix which usually is in the right lower abdomen. After examining the area aroundthe 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 andcolon, cutting the appendix from the colon, and sewing over the hole in the colon. If anabscess is present, the pus can be drained with drains that pass from the abscess and outthrough the skin. The abdominal incision then is closed.
  • 85. ** Second is Laparoscopic Method. Laparoscopy is a new technique for removing theappendix which involves the use of the laparoscope. The laparoscope is a thin telescopeattached to a video camera that allows the surgeon to inspect the inside of the abdomenthrough a small puncture wound (instead of a larger incision). If appendicitis is found, theappendix can be removed with special instruments that can be passed into the abdomen,just like the laparoscope, through small puncture wounds. The benefits of thelaparoscopic technique include less post-operative pain (since much of the post-surgerypain comes from incisions) and a speedier return to normal activities. An additionaladvantage of laparoscopy is that it allows the surgeon to look inside the abdomen to makea 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 ovariancysts may mimic appendicitis.
  • 86. B. Actual The procedure done to the Patient is Appendectomy, he was operated on February 5, 2010. His operation begun at 2:15 am and ended at 2:50 am. His surgeon was Dr. Dag-O.
  • 87. 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.
  • 88. Appendectomy
  • 89. 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.
  • 90. 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.
  • 91. 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
  • 92. The major complication of appendicitis is perforation of the appendix, which can lead to peritonitis, abscess formation (collection of purulent material), or portal pylephlebitis, which is septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines. Perforation generally occurs 24 hours after the onset of pain symptoms include a fever of 37.7 degree Celsius or 100 degree Fahrenheit or greater, a toxic appearance and continued abdominal pain or tenderness.
  • 93. REFERENCE Books > Brunner and Suddarth’s Textbook of Medical Surgical Nursing (11th Edition, Joyce Young Johnson) > 2009 LIPPINCOTT’S Nursing Drug Guide (Amy M. Karch) > Nurse’s Pocket Guide by Marilynn E. Doenges et. al > Health Assessment and Physical Examination by Josie Quiambao Udan, RN,MAN
  • 94. Internet > http://www.abdopain.com/history-of-appendicitis.html > Amazon.com Widgets > http://www.abdopain.com/causes-of-appendicitis.html > http://www.abdopain.com/Pathophysiology-of-> > appendicitis.html > http://www.abdopain.com/symptoms-of-appendicitis.html > http://www.abdopain.com/diagnosis-of-appendicitis.html > http://www.abdopain.com/differential-diagnosis-of-> appendicitis.html > http://www.scribd.com/doc/20794198/NCP-S-P-> Appendectomy > http://www.wikipedia.com > http://www.medscape .com