ACKNOWLEDGEMENT I would like to thank Mr Chuah for giving me opportunityto take him as my subject for my case study. He has beenvery helpful throughout my process of doing this case study.I would also like to thank my tutor’s for guiding methroughout the process of these case study. A speciathanksto the ward sister and staff’s for their support towards mycase study. PATIENTS PROFILE
NAME : CHUAH CHEONG KINAge : 19/yrsSex: MalePhysician : Mr Liew Fah KongRoom : Mawar 10/2Diagnosis : Acute appendicitisReason for admissionC/O abdomen pain since 23/7/08. Fever .No diarrheavomiting noted.Rebound tenderness. Pain right iliac fossa regionPast Medical HistoryNILPast Surgical HistoryNIL25/7/08(2000)
C/O abdomen pain since 23/7/08 9(RIF pain) fever sincemorning-no vomiting-no diarrhea-rebound tendernessIn emergency roomTemperature:38.3Pulse:88BP:130/90ORDEREDFull blood countBUSERBSUrine FEMEIV Hartmans over 2 hourThen D/Saline 1 pint 4 hour,D/Saline alternate D5% 1 pint over 6 hour4 hly observationNil by mouth25/7/08(2310)
Seen by Mr Liew , noted pain at right iliac fossa. No nauseaand vomiting. Temperature high tendernessOrdered for stat appendectomy
ANATOMYAND PHYSIOLOGY OFAPPENDIXThe appendix is a closed-ended, narrow tube up to severalinches in length that attaches to the cecum the first part ofthe colon like a worm. The anatomical name for theappendix, vermiform appendix, means worm-likeappendage.The inner lining of the appendix produces asmall amount of mucus that flows through the open center ofthe appendix and into the cecum. The wall of the appendixcontains lymphatic tissue that is part of the immune systemfor making antibodies. Like the rest of the colon, the wall ofthe appendix also contains a layer of muscle, but the muscleis poorly developed.
APPENDICITISAppendicitis means inflammation of the appendix
PATHOPHYSIOLOGY OFAPPENDICITISIt is thought that appendicitis begins when the opening from theappendix into the cecum becomes blocked. The blockage may bedue to a build-up of thick mucus within the appendix or to stool thatenters the appendix from the cecum. The mucus or stool hardens,becomes rock-like, and blocks the opening. This rock is called afecalith (literally, a rock of stool) . At other times, the lymphatic tissue in the appendix may swelland block the appendix. After the blockage occurs, bacteria whichnormally are found within the appendix begin to invade (infect) thewall of the appendix. The body responds to the invasion by mountingan attack on the bacteria, an attack called inflammation. Analternative theory for the cause of appendicitis is an initial rupture ofthe appendix followed by spread of bacteria outside the appendix..The cause of such a rupture is unclear, but it may relate to changesthat occur in the lymphatic tissue, for example, inflammation, that linethe wall of the appendix.
If the inflammation and infection spread through the wall of theappendix, the appendix can rupture. After rupture, infection canspread throughout the abdomen; however, it usually is confined to asmall area surrounding the appendix forming a peri-appendicealabscess. Sometimes, the body is successful in containing ("healing") theappendicitis without surgical treatment if the infection andaccompanying inflammation do not spread throughout the abdomen.The inflammation, pain and symptoms may disappear. This isparticularly true in elderly patients and when antibiotics are used. Thepatients then may come to the doctor long after the episode ofappendicitis with a lump or a mass in the right lower abdomen that isdue to the scarring that occurs during healing. This lump might raisethe suspicion of cancer.
COMPLICATION OFAPPENDICITISThe most frequent complication of appendicitis is perforation.Perforation of the appendix can lead to a periappendiceal abscess (acollection of infected pus) or diffuse peritonitis (infection of the entirelining of the abdomen and the pelvis).
The major reason for appendiceal perforation is delay in diagnosisand treatment. In general, the longer the delay between diagnosisand surgery, the more likely is perforation. The risk of perforation 36hours after the onset of symptoms is at least 15%. Therefore, onceappendicitis is diagnosed, surgery should be done withoutunnecessary delay.A less common complication of appendicitis is blockage of theintestine. Blockage occurs when the inflammation surrounding theappendix causes the intestinal muscle to stop working, and thisprevents the intestinal contents from passing. If the intestine abovethe blockage begins to fill with liquid and gas, the abdomen distendsand nausea and vomiting may occur. It then may be necessary todrain the contents of the intestine through a tube passed through thenose and esophagus and into the stomach and intestine.A feared complication of appendicitis is sepsis, a condition in whichinfecting 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.CLINICAL MANIFESTATION OFAPPENDICITISThe main symptom of appendicitis is abdominal pain. Thepain is at first diffuse and poorly localized, that is, notconfined to one spot. (Poorly localized pain is typicalwhenever a problem is confined to the small intestine or
colon, including the appendix.) The pain is so difficult topinpoint that when asked to point to the area of the pain,most people indicate the location of the pain with a circularmotion of their hand around the central part of theirabdomen. A second, common, early symptom ofappendicitis is loss of appetite which may progress tonausea and even vomiting. Nausea and vomiting also mayoccur later due to intestinal obstruction.As appendiceal inflammation increases, it extends throughthe appendix to its outer covering and then to the lining ofthe abdomen, a thin membrane called the peritoneum. Oncethe peritoneum becomes inflamed, the pain changes andthen can be localized clearly to one small area. Generally,this area is between the front of the right hip bone and thebelly button. The exact point is named after Dr. CharlesMcBurney--McBurneys point. If the appendix ruptures andinfection spreads throughout the abdomen, the painbecomes diffuse again as the entire lining of the abdomenbecomes inflamed.
TEST AND DIAGNOSISThe diagnosis of appendicitis begins with a thorough history andphysical examination. Patients often have an elevated temperature,
and there usually will be moderate to severe tenderness in the rightlower abdomen when the doctor pushes there. If inflammation hasspread to the peritoneum, there is frequently rebound tenderness.Rebound tenderness is pain that is worse when the doctor quicklyreleases his hand after gently pressing on the abdomen over the areaof tenderness.White Blood Cell CountThe white blood cell count in the blood usually becomeselevated with infection. In early appendicitis, before infectionsets in, it can be normal, but most often there is at least amild elevation even early. Unfortunately, appendicitis is notthe only condition that causes elevated white blood cellcounts. Almost any infection or inflammation can cause thiscount to be abnormally high. Therefore, an elevated whiteblood cell count alone cannot be used as a sign ofappendicitis.
Abdominal X-RayAn abdominal x-ray may detect the fecalith (the hardened andcalcified, pea-sized piece of stool that blocks the appendicealopening) that may be the cause of appendicitis. This is especially truein children.UltrasoundAn ultrasound is a painless procedure that uses sound waves toidentify organs within the body. Ultrasound can identify an enlargedappendix or an abscess. Nevertheless, during appendicitis, the
appendix can be seen in only 50% of patients. Therefore, not seeingthe appendix during an ultrasound does not exclude appendicitis.Ultrasound also is helpful in women because it can exclude thepresence of conditions involving the ovaries, fallopian tubes anduterus that can mimic appendicitis.Barium EnemaA barium enema is an x-ray test where liquid barium is inserted intothe colon from the anus to fill the colon. This test can, at times, showan impression on the colon in the area of the appendix where theinflammation from the adjacent inflammation impinges on the colon.Barium enema also can exclude other intestinal problems that mimicappendicitis, for example Crohns disease.
Computerized tomography (CT) ScanIn patients who are not pregnant, a CT Scan of the area of theappendix is useful in diagnosing appendicitis and peri-appendicealabscesses as well as in excluding other diseases inside the abdomenand pelvis that can mimic appendicLaparoscopyLaparoscopy is a surgical procedure in which a small fiberoptic tubewith a camera is inserted into the abdomen through a small puncture
made on the abdominal wall. Laparoscopy allows a direct view of theappendix as well as other abdominal and pelvic organs. Ifappendicitis is found, the inflamed appendix can be removed with thelaparascope.UrinalysisUrinalysis is a microscopic examination of the urine that detects redblood cells, white blood cells and bacteria in the urine. Urinalysisusually is abnormal when there is inflammation or stones in thekidneys or bladder. The urinalysis also may be abnormal withappendicitis because the appendix lies near the ureter and bladder. Ifthe inflammation of appendicitis is great enough, it can spread to theureter and bladder leading to an abnormal urinalysis. Most patientswith appendicitis, however, have a normal urinalysis.WHY CAN IT bE DIFFICuLT TO DIAGNOSEAPPENDICITIS?It can be difficult to diagnose appendicitis. The position of theappendix in the abdomen may vary. Most of the time the appendix isin the right lower abdomen, but the appendix, like other parts of theintestine, has a mesentery. This mesentery is a sheet-like membranethat attaches the appendix to other structures within the abdomen. Ifthe mesentery is large, it allows the appendix to move around. Inaddition, the appendix may be longer than normal. The combinationof a large mesentery and a long appendix allows the appendix to dipdown into the pelvis (among the pelvic organs in women). It also may
allow the appendix to move behind the colon (called a retro-colicappendix). In either case, inflammation of the appendix may act morelike the inflammation of other organs, for example, a womans pelvicorgans.The diagnosis of appendicitis also can be difficult because otherinflammatory problems may mimic appendicitis. Therefore, it iscommon to observe patients with suspected appendicitis for a periodof time to see if the problem will resolve on its own or developcharacteristics that more strongly suggest appendicitis or, perhaps,another conditionWHAT OTHER CONDITIONS CAN MIMICAPPENDICITIS?Pelvic inflammatory disease.
The right fallopian tube and ovary lie near the appendix. Sexuallyactive women may contract infectious diseases that involve the tubeand ovary. Usually, antibiotic therapy is sufficient treatment, andsurgical removal of the tube and ovary are not necessary.Right-sided diverticulitis. Although most diverticuli are located on the left side of the colon, they occasionally occur on the right side. When a right- sided diverticulum ruptures it can provoke inflammation they mimics appendicitis.Kidney diseases.
The right kidney is close enough to the appendix that inflammatory problems in the kidney-for example, an abscess- can mimic appendicitis.Meckels diverticulitis. A Meckels diverticulum is a small outpouching of the small intestine which usually is located in the right lower abdomen near the appendix. The diverticulum may become inflamed or even perforate (break open or rupture). If inflamed and/or perforated, it usually is removed surgically.CLINICAL INVESTIGATIONINVESTIGATION RESULTS UNIT REFERENCE RANGEFULL BLOOD COUNTRed Cell Count 5.57 x10^12/L ( 4.5 - 6.0 )Haemoglobin 17.9 g/dL ( 13.7 - 18.0 )Haematocrit 52 % ( 40 - 54 )MCV 94 fL ( 82 - 100 )MCH 32 pg ( 27 - 32 )MCHC 34 g/dL ( 32 - 36 )RDW 13.2 % ( 4.0 - 11.0 )
Epithelial Cells NILCasts NILCrrystals NILAPPENDECTOMYDuring an appendectomy, an incision two to three inches in length ismade through the skin and the layers of the abdominal wall over thearea of the appendix. The surgeon enters the abdomen and looks forthe appendix which usually is in the right lower abdomen. Afterexamining the area around the appendix to be certain that noadditional problem is present, the appendix is removed. This is doneby freeing the appendix from its mesenteric attachment to theabdomen and colon, cutting the appendix from the colon, and sewing
over the hole in the colon. If an abscess is present, the pus can bedrained with drains that pass from the abscess and out through theskin. The abdominal incision then is closed.Newer techniques for removing the appendix involve the use of thelaparoscope. The laparoscope is a thin telescope attached to a videocamera that allows the surgeon to inspect the inside of the abdomenthrough a small puncture wound (instead of a larger incision). Ifappendicitis is found, the appendix can be removed with specialinstruments that can be passed into the abdomen, just like thelaparoscope, through small puncture wounds. The benefits of the
laparoscopic technique include less post-operative pain (since muchof the post-surgery pain comes from incisions) and a speedier returnto normal activities. An additional advantage of laparoscopy is that itallows the surgeon to look inside the abdomen to make a cleardiagnosis in cases in which the diagnosis of appendicitis is in doubt.If the appendix is not ruptured (perforated) at the time of surgery, thepatient generally is sent home from the hospital after surgery in one
or two days. Patients whose appendix has perforated are sicker thanpatients 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 andassist in resolving any abscess.
Occasionally, the surgeon may find a normal-appearing appendix andno other cause for the patients problem. In this situation, the surgeonmay remove the appendix. The reasoning in these cases is that it isbetter to remove a normal-appearing appendix than to miss and not
treat appropriately an early or mild case of appendicitis
COMPLICATION OFAPPENDECTOMYThe most common complication of appendectomy is infection of thewound, that is, of the surgical incision. Such infections vary in severityfrom mild, with only redness and perhaps some tenderness over theincision, to moderate, requiring only antibiotics, to severe, requiringantibiotics and surgical treatment. Occasionally, the inflammation andinfection of appendicitis are so severe that the surgeon will not closethe incision at the end of the surgery because of concern that thewound is already infected. Instead, the surgical closing is postponedfor several days to allow the infection to subside with antibiotictherapy and make it less likely for infection to occur within theincision. Wound infections are less common with laparoscopicsurgery.Another complication of appendectomy is an abscess, a collection ofpus in the area of the appendix. Although abscesses can be drainedof their pus surgically, there are also non-surgical techniques, aspreviously discussed
OPERATION RECORDSurgeon : Mr Liew Fah KongAnaesthetist: Dr Hoe Kah SiongIndication: AppendicitisNature Of Operation: AppendectomyFinding: Appendicitis 1. Lanz Incision 2. Specimen sent for HPE 3. Appendectomy donePost Op Order-nil orally-2 pint D/saline alt 2 pint D5% 24 hour-IV Zinacef 750mg 8 hour-IV Flagyl 500mg 8 hour-IM pethidine 3cc 6 hour and PRN
MEDICATION IV Zinacef 750mg Generic Name : Cefuroxime Na Group : Antibiotic Indication ; Resp, ENT, GUT, soft tissue, OnG, bone and joint infection, gonorrhea, septicemia,meningitis, surgical prophylaxis.IV Flagyl 500 mg Generic Name: Metronidazole Group : antibiotic Indication: treatment of prophylaxis against anaerobic InfectionIM Pethidine 3cc Generic name; Pethidine HCL Group: analgesic Indication: short term relief of moderate to severe pain
CLINICAL PROGRESS NOTE26/7/08(0210)Return to ward ,observation stable T37.2, Pulse 98,Respiration: 22. Dressing dry and intact. Corrugated draininsitu.26/7/08(0910)Seen by Mr Liew temperature high, abdomen soft noteddressing dry and intact.OrderedIV Netromycin 300mg stat and dailyBUSE27/7/08Seen by Mr Liew . dressing inspected ordered tochange dressing clean with normal saline and coverwith gauze and tegaderm. Sign off same said patientcan go back , ordered STO on the 5/8/08.
NuRSING DIAGNOSIS1.Acute pain dan discomfort related to surgical incision.Objective : To reduce and minimize surgical pain at woundsite.Nursing Intervention 1. Asses level of pain using pain scale ( 0 - 10 ) ) 0- no pain, 10- maximum pain so that nurses would be able to take precise action to prevent furthur 2. pain and complication 3. Asses and plan nursing intervention to minimize disturbance towards patient. 4. Observe patients pain though facial exprssion,conciousness and sweating so that nurses will be able take immediate action to reduce pain. 5. Monitor vital esepecialy high BP ( 140/90 above ) , increased pulse rate ( above 100 bpm ) and respiratori ( above 24 breath per min ) so that nurses will be able to take imediate action once detecting early abnormalities such as above abnormalities that indicate increase pain on patient.
6. Teach patient to take shallow breaths and deep breathing excersice to prevent pain. 7. Serve patient analgesic medication such as IM Pethedine 50mg to reduce pain. 8. Teach patient to use pillow to press on wound site while coughing to reduce pain and wound gapping. Place patient in supine position in order patient to rest fully and to avoid turning and moving so to minimize patients pain. 9. Keep room tempreture cool and well venitilated so that patient will be able to rest comfortabel. 10.Place call bell and patient nessesery items at cardiac table beside him and within reach so that patient wont use extra strenght that will increase pain on wound site.Evaluation : Patient had minimum pain
2.Potential infection related to surgical incision.Objective : To prevent infection towards patient.Nursing Intervention 1. Asses patients wound sitse for abnormalities such as bleeding,swelling,increased pain and swelling as these indicates early infection and nurses will be able to take action to prevent further complications. 2. Monitor vital signs BP ( 120/80 mmHg - 140/90 mmHg ), pulse rate ( 60 - 100 bpm), respiratory rate ( 18 - 24 breath per min ) and especialy tempreture ( 36.6c - 37.5c ) as fever indicates infection,so that nurses can report abnormalities to doctor. 3. Ensure dressing is always dry,clean and intact to avoid infection as dirty dressing enviroment attracts bacteria. 4. Wash hands using effective hand washing before and after nursing patient and before doing dressing to minimize contamination to wound site. 5. Maintain aseptic technique while doing dressing to prevent cross contamination. 6. Serve patient well balanced diet especialy high in protein and Vitamin C as protien helps in producing new cells for wound healing while Vitamin C helps in building patients immune system to fight againts any bacteria. 7. Advice patient to drink sufficiant water ( at least 2.5 L per day ) to keep patient hydrated and maintain bodys well being.Evalutation : Patient did not had any infection on surgicalincision.
REFERENCE1. Brunner and Suddarth’s Textbook of Medical Surgical Nursing. Eleventh Edition2. Priscilla lemone medical surgical nursing .3. Ross and Wilson Anatomy and Physiology in Health and Illness. Tenth Edition.4. http://www.gastro.org/wmspage. American Gasteroenterogical Association5. Medical Surgical Nursing Critical Thinking in client care Third Edition6. MIMS and MIMS Annual7. Baillers nursing dictionary8. Pictures www.google.com