88887820 a-case-study-on-acute-appendicitis

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CHAPTER I
INTRODUCTION
The appendix is a closed-ended, narrow tube that attaches to
the cecum (the first part of the colon) like a worm. (The
anatomical name for the appendix, vermiform appendix,
means worm-like appendage.) The inner lining of the appendix
produces a small amount of mucus that flows through the
appendix and into the cecum. The wall of the appendix
contains lymphatic tissue that is part of the immune systemfor
making antibodies. Like the rest of the colon, the wall of the
appendix also contains a layer of muscle.

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Acute appendicitis can occur when a piece of food, stool or
object becomes trapped in the appendix, causing irritation,
inflammation, and the rapid growth of bacteria and infection. Acute
appendicitis can also happen after a gastrointestinal infection. Rarely,
a tumor may cause acute appendicitis. Sometimes the cause of acute
appendicitis is not known. The inflammation is usually caused by a
blockage, but may be caused by an infection. Without treatment, an
inflamed appendix can rupture, causing infection of the peritoneal
cavity (the lining around the abdominal organs) and even death.
Appendicitis is one of the most common causes of emergency
abdominal surgery. Up to 75,000 appendectomies are done each year
in the U.S. The estimated population in the Philippines is 86, 241,
6972 and the incident rate of acute appendicitis is 215,604 as of year
2011.Appendicitis is one of the more common surgical emergencies,
and it is one of the most common causes of abdominal pain. In the
United States, 250,000 cases of appendicitis are reported annually,
representing 1 million patient-days of admission. The incidence of
acute appendicitis has been declining steadily since the late 1940s,
and the current annual incidence is 10 cases per 100,000
populations. Appendicitis occurs in 7% of the US population, with an
incidence of 1.1 cases per 1000 people per year. Some familial
predisposition exists.

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In Asian and African countries, the incidence of acute
appendicitis is probably lower because of the dietary habits of the
inhabitants of these geographic areas. The incidence of appendicitis
is lower in cultures with a higher intake of dietary fiber. Dietary fiber
is thought to decrease the viscosity of feces, decrease bowel transit
time, and discourage formation of fecaliths, which predispose
individuals to obstructions of the appendiceal lumen.
In the last few years, a decrease in frequency of appendicitis in
Western countries has been reported, which may be related to
changes in dietary fiber intake. In fact, the higher incidence of
appendicitis is believed to be related to poor fiber intake in such
countries.
There is a slight male preponderance of 3:2 in teenagers and
young adults; in adults, the incidence of appendicitis is approximately
1.4 times greater in men than in women. The incidence of primary
appendectomy is approximately equal in both sexes.
The incidence of appendicitis gradually rises from birth, peaks
in the late teen years, and gradually declines in the geriatric years.
The mean age when appendicitis occurs in the pediatric population is
6-10 years. Lymphoid hyperplasia is observed more often among
infants and adults and is responsible for the increased incidence of
appendicitis in these age groups. Younger children have a higher rate
of perforation, with reported rates of 50-85%. The median age at

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appendectomy is 22 years. Although rare, neonatal and even
prenatal appendicitis have been reported. Clinicians must maintain a
high index of suspicion in all age groups.
Acute appendicitis can occur in any age group or population.
However, it most often occurs in teens and young adults. It is rare in
children younger than two years of age. Classic symptoms of acute
appendicitis include pain in the right lower abdomen, where the
appendix is located, that gets progressively sharp and more intense.
Pain increases when pressure is put on the area (called the
McBurney’s point), and the area becomes even more painful and
tender when the pressure is released (rebound tenderness). This is
one exam a health care provider uses to diagnosis acute appendicitis.
The symptoms of acute appendicitis can vary, and not all people with
acute appendicitis will experience the typical symptoms of abdominal
pain. In early acute appendicitis, the abdominal pain may be located
around the navel or belly button area, then move to McBurney’s point
as acute appendicitis progresses.
Acute appendicitis that is not treated promptly leads to life-
threatening complications. Complications of acute appendicitis
include: Abdominal abscess, Peritonitis (infection of the lining that
surrounds the abdomen), Ruptured appendix, Sepsis, Shock.

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As teen-agers living in a fast-phased world and governed by
schedules, they too are predisposed to lifestylemodification –
especially diet and food preferences which can contribute to the
disease. With this study, the student nurses hope to apply their
learning intaking care not only of their patients but also of
themselves.
As nursing students and future nurses, they would want to
understand and appreciate more on what is happening to a patient
with acute appendicitis. Consequently, they are interested on what
will be the necessary management that will be given. All in all, these
will help them to become efficient nurses and better persons later on.
This case study presents the case study of a 23 year old
woman who was diagnosed with Acute Appendicitis – due to pain felt
at right lower quadrant at Kidapawan Medical Specialist.

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OBJECTIVES OF THE STUDY
General Objective
To conduct a study and to have a better understanding
regarding acute appendicitis as well as to deal with patient having
this illness with the application of the nursing process.
Specifically, the study aims to:
1. To conduct an interview with the patient, her family, significant
others and to gather essential information regarding his case.
2. To perform a cephalocaudal assessment to the patient.
3. To present an overview aboutAcute Appendicitis.

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4. To determine the progression of the illness and to present its
pathophysiology.
5. To gather and obtain progress notes and present doctor’s
order.
6. To obtain and present the diagnostic test and the laboratory
results of the patient.
7. To identify patient’s medication and determine its mechanism
of action, indication, side-effects, contraindications and
corresponding nursing responsibilities.
8. To conduct health teachings as one way of providing and
promoting holistic care to the patient.
9. To identify problems based from subjective data gathered from
patient and watchers to formulate appropriate nursing care
plan.

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DEFINITION OF TERMS
Appendectomy - surgical operation to remove appendix.
Appendicitis - inflammation of the appendix causing severe
pain.
Appendix - small outgrowth from large intestine, a bind-
ended tube leading from the first of the large
intestine (caecum), near its junction with the
small intestine. In humans, it is small, occurs
in the lower right hand part of the abdomen
and contains cells of the immune system.

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Colic - severe pain in the bowel or the abdomen.
Constipation -difficulty in passing stools or incomplete or
infrequent passage of hard stools.
Fecalith - hardened mass of stool.
Mc Burney’s Sign – (Charles McBurney) a reaction of the patient
indicating severe pain and extreme
tenderness when McBurney’s point is
palpated. Such reaction indicates appendicitis.
Perforation -a hole or opening made through the entire
thickness of a membrane or other tissue or
material.
Peritonitis - inflammation of the peritoneum caused by
the spreading of infection.
Sepsis - the condition or syndrome caused by the
presence of microorganisms or their toxins in
the tissue or the bloodstream.
Septicemia -systemic infection in which pathogens are
present in the circulating blood, having spread
from an infection in any part of the body.

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Shock - a state of physiologic collapse, marked by a
weak pulse, coldness, sweating and irregular
breathing, and resulting from a situation such
as blood loss.
PATIENT’S PROFILE
PERSONAL DATA
PATIENT’S NAME : Momoko
CASE # : 12-1344
AGE : 23
SEX : Female
ORIGINAL RANK : Second Child
CIVIL STATUS : Single
ADDRESS : 054 Quirino Drive, Kidapawan City
BIRTHDAY : January 01, 1989
RELIGION : Roman Catholic
NATIONALITY : Filipino

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MEDICAL DATA
CHIEF COMPLAINT : Right Lower Quadrant Pain
ADMITTING DIAGNOSIS : T/C Acute Appendicitis
FINAL DIAGNOSIS : Acute Appendicitis
DATE OF ADMISSION : February 08, 2012
ATTENDING PHYSICIAN : Dr. Edwin Mudanza
Past Health History
The patient was born on January 01, 1989. She was delivered
full term through Normal Vagina Spontaneous Delivery. The patient
was completely immunized. She was never admitted to a hospital but
she experienced common illness such as cough and mefenamic acid
for pain. She occasionally drinks liquors such as red wine and beer.
Her usual diet includes food that are high in protein, junkfoods,
softdrinks and canned goods. She prefers meat products in her meal
than leafy vegetables.
Present Health History
Several days prior to admission the patient experienced an
abdominal pain at the right lower quadrant. These prompted her to

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seek medical advice, thus confined in Kidapawan Medical Specialist
Incorporated last February 08, 2012 with the admitting diagnosis of
Acute Appendicitis under the service of Dr. Edwin Mudanza. Her
medications were Ranitidine, Metronidazole and Ampicillin. She was
confined at private room #523.
PHYSICAL ASSESSMENT
Genearal Appearance at First Sight
Patient was received awake, responsive and coherent with an
IVF D5LR 1L at 80 cc per hour, infusing well at the right metacarpal
vein. Patient has a mesomorphic type of body built and weighs 54.5
kilograms and stands 5’4” tall. The patient was certainly oriented to
time, place and persons. She was able to deal with her emotions
appropriately as the interview went on. Wearing a cotton T-shirt and
jogging pants, patient looked neat and tidy.

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I. Head, Ears, Eyes, Nose, Throat and Neck and Five
Senses
Head
Head was normocephalic and had a smooth skull contour. Hair
was smooth, and was evenly distributed. The hair was black in color.
The scalp was clean. No swelling or tenderness noted upon palpation.
Ears
Both ears were symmetrical; auricle aligned with outer canthus
of the eye. The color of the outer ear was homogenous with that of
the skin color. The external pinna was firm, and non-tender. No
discharges, tenderness, masses, or swelling were noted upon
inspection and palpation.
Eyes
Both eyes were symmetrical. Eyelashes equally distributed,
curled slightly outward. Pupil size is 3mm in diameter for both eyes.
Reaction to light was brisk. There was a uniform reaction to

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accommodation. The pupil was black in color with pinkish
conjunctiva. Lids closed symmetrically, skin intact, no discharges and
no discoloration. Blinking reflex was functional. No ulceration or
lesions noted on the area.
Nose
The external was symmetrical. Nasal flaring noted, air felt when
exhaled. Nasal mucosa was intact and pinkish in color and was free
of purulent discharges.
Mouth & Throat
The lips were dry and pale-looking. The gums were pinkish in
color. Her teeth were still intact, 32 pearly white and shiny. Uvula
was at the middle. Mucosa was pinkish. Tonsils were uninflammed.
No further abnormalities noted.
Neck
The neck was symmetrical and was proportion to head and
shoulder. The thyroids were smooth as palpated. She was able to
turn her head in upward, sideward and downward position with

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movement. The carotid artery has mild pulsation. No sign of lesion or
tenderness noted.
Five senses
A. Sense of sight
Patient can read normally. In the absence of Snellen’s chart,
functional vision was test; she can follow a hand movement with a 3-
4 feet distance. She can recognize person and things.
B. Sense of taste
By offering different kinds of food like candy, vinegar, ampalaya
and salt patient’s taste buds can identify sweet, sour, bitter, and
salty food.
C. Sense of smell
Patient has good smelling ability; she can distinguish different
odors such as fragrance or perfume and aroma of beverages that she
dinks.

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D. Sense of hearing
She can recognize sounds and could hear clearly, she responds to
conversation normally. She becomes alert when someone will open
the door. She can hear the distance particularly when someone
enters the room.
E. Sense of touch
The patient responds when someone touches her, and can
distinguish soft from rough texture and can identify hot from cold
water.
II. Respiratory status
The patient breathing pattern ranges from 18cpm to 21cpm. No
O2 cannula attached. No abnormal sounds (rales, wheezing, etc.)
noted upon auscultation.
III. Circulatory status
Patient’s blood pressure was monitored every 4 hours when she
was under our care. BP ranges from 90/60 mmHg to 100/80 mmHg.
Her pulse from 76bpm to 80bpm.Capillary refill time within 3-5 sec.

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IV. Temperature status
Patient’s body temperature ranges from 37-39 degree Celsius.
V. Skin/Skin appendages
Patient’s skin was warm to touch with fair complexion;
fingernails were trimmed and tidy. Hair was distributed evenly no
clubbing of fingers noted.
VI. Nutritional status
Patient usually eats food that is high in fat, salt and protein
such as fish, meat, lechon and junk foods. She eats breakfast on
time. She tends to drink liquor like red wine and beer frequently with
“pulutan”.She prefers eating meat products than vegetables.
Patient’s weight is 120 lbs and has height of 164cm which result to
Body Mass Index (BMI) of 20 which translates that the patient’s BMI
is normal.
BMI Categories:

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Underweight = <18.5 Overweight = 25 – 29. 9
Normal weight = 18.5 – 24.9 Obese = >30
VII. Rest and sleeping pattern
During regular days patient has a normal sleeping pattern of six
to eight hours a day. Upon admission, patient’s sleeping pattern has
been altered since her body can’t adapt to hospital routine she often
disturbed during sleep due to continuous monitoring and giving of
medication.
VIII. Elimination status
The patient has an abnormal elimination pattern regularly she
defecated 3 times a week and urinated 4-5 times a day. Upon
admission she defecated once a day and urinates 2-3 times a day.
IX. Mobility status
Patient is ambulatory. She can perform activities of daily living
such as eating, drinking and brushing her teeth. Patient complains
abdominal pain at right lower quadrant.

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GENEOGRAM
Grandparents Grandparents
Mother Father
LEGEND:
Male Female HPN
Heart Disease DM
Appendicitis

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SYMPTOMATOLOGY
Signs and
Symptoms
Present Absent Rationale
Right Lower
Quadrant Pain /
Right lower-quadrant pain that is
produced with either the passive
extension of the patient's right hip
(patient lying on left side, with knee in
flexion) or by the patient's active flexion
of the right hip while supine. The pain
elicited is due to inflammation of the
peritoneum overlying the iliopsoas
muscles and inflammation of the psoas
muscles themselves. Straightening out
the leg causes pain because it stretches
these muscles, while flexing the hip
activates the iliopsoas and therefore also
causes pain.
Source: (http://www.free-
ed.net/sweethaven/science/biology/anat
omyphysiol/Human01_LessonMain.asp?i
Num=1008)
McBurney's Sign
/
Deep tenderness at McBurney's point,
known as McBurney's sign, is a sign
of acute appendicitis.[2]
The clinical sign
of referred pain in the epigastrium when
pressure is applied is also known
as Aaron's sign. Specific localization of
tenderness to McBurney's point indicates
that inflammation is no longer limited to
the lumen of the bowel (which localizes
pain poorly), and is irritating the lining of
the peritoneum at the place where the
peritoneum comes into contact with the

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appendix. Tenderness at McBurney's
point suggests the evolution of acute
appendicitis to a later stage, and thus,
the increased likelihood of rupture.
Source:
(http://en.wikipedia.org/wiki/McBurney's
_point)
Fever
/
Fever is a nonspecificresponse that is
mediatedby endogenouspyrogensreleased
from host cells in response to infectious
or non-infectionsdisorders.It may be brought
aboutbyprostaglandinsreleased
during inflammation.
Source: Carol Mattson Porth (2005.
Pathophysiology, Seventh edition page205)
Constipation
/
difficulty in defecation: a condition in which
or animal has difficulty in eliminating solid was
the body and the feces are hard and dry.
(Microsoft® Encarta® 2009. © 1993-200
Corporation. All rights reserved.)
Nausea /
Nauseasometimes occurswith biliary colic.
The inflammation of the appendixcauses
pain andspasms of the abdominalmuscles
whichmay make one feelnauseated.
Source: Understanding Medical Surgical
Nursing by Williams and Hopper (page 742)

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ANATOMY AND PHYSIOLOGY
The gastrointestinal tract (GIT) consists of a hollow
muscular tube starting from the oral cavity, where food enters the
mouth, continuing through the pharynx, esophagus, stomach and
intestines to the rectum and anus, where food is expelled. There are
various accessory organs that assist the tract by secreting enzymes
to help break down food into its component nutrients. Thus the
salivary glands, liver, pancreas and gall bladder have important

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functions in the digestive system. Food is propelled along the
length of the GIT by peristaltic movements of the muscular walls
The functions of the digestive system are:
 Ingestion - eating food
 Digestion - breakdown of the food
 Absorption - extraction of nutrients from the food
 Defecation - removal of waste products
The digestive system also builds and replaces cells and tissues that
are constantly dying.
Digestive Organs
The digestive system is a group of organs (Buccal cavity (mouth),
pharynx, oesophagus, stomach, liver, gall bladder, jejunum, ileum
and colon) that breakdown the chemical components of food, with
digestive juices, into tiny nutrients which can be absorbed to
generate energy for the body.
The Buccal Cavity
Food enters the mouth and is chewed by the teeth, turned over and
mixed with saliva by the tongue. The sensations of smell and taste
from the food sets up reflexes which stimulate the salivary glands.
The Salivary glands
These glands increase their output of secretions through three pairs
of ducts into the oral cavity, and begin the process of digestion.

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Saliva lubricates the food enabling it to be swallowed and contains
the enzyme ptyalin which serves to begin to break down starch.
The Pharynx
Situated at the back of the nose and oral cavity receives the softened
food mass or bolus by the tongue pushing it against the palate which
initiates the swallowing action.
At the same time a small flap called the epiglottis moves over the
trachea to prevent any food particles getting into the windpipe.
From the pharynx onwards the alimentary canal is a simple tube
starting with the salivary glands.
The Oesophagus
The oesophagus travels through the neck and thorax, behind the
trachea and in front of the aorta. The food is moved by rhythmical
muscular contractions known as peristalsis (wave-like motions)
caused by contractions in longitudinal and circular bands of muscle.
Antiperistalsis, where the contractions travel upwards, is the reflex
action of vomiting and is usually aided by the contraction of the
abdominal muscles and diaphragm.
The Stomach
The stomach lies below the diaphragm and to the left of the liver. It
is the widest part of the alimentary canal and acts as a reservoir for
the food where it may remain for between 2 and 6 hours. Here the
food is churned over and mixed with various hormones, enzymes

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including pepsinogen which begins the digestion of protein,
hydrochloric acid, and other chemicals; all of which are also secreted
further down the digestive tract.
The stomach has an average capacity of 1 litre, varies in shape, and
is capable of considerable distension. When expanding this sends
stimuli to the hypothalamus which is the part of the brain and
nervous system controlling hunger and the desire to eat.
The wall of the stomach is impermeable to most substances,
although does absorb some water, electrolytes, certain drugs, and
alcohol. At regular intervals a circular muscle at the lower end of the
stomach, the pylorus opens allowing small amounts of food, now
known as chyme to enter the small intestine.
Small Intestine
The small intestine measures about 7m in an average adult and
consists of the duodenum, jejunum, and ileum. Both the bile and
pancreatic ducts open into the duodenum together. The small
intestine, because of its structure, provides a vast lining through
which further absorption takes place. There is a large lymph and
blood supply to this area, ready to transport nutrients to the rest of
the body. Digestion in the small intestine relies on its own secretions
plus those from the pancreas, liver, and gall bladder.

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The Pancreas
The Pancreas is connected to the duodenum via two ducts and has
two main functions:
1. To produce enzymes to aid the process of digestion
2. To release insulin directly into the blood stream for the purpose
of controlling blood sugar levels
Enzymes suspended in the very alkaline pancreatic juices include
amylase for breaking down starch into sugar, and lipase which, when
activated by bile salts, helps to break down fat. The hormone insulin
is produced by specialised cells, the islets of Langerhans, and plays
an important role in controlling the level of sugar in the blood and
how much is allowed to pass to the cells.
The Liver
The liver, which acts as a large reservoir and filter for blood, occupies
the upper right portion of abdomen and has several important
functions:
1. Secretion of bile to the gall bladder
2. Carbohydrate, protein and fat metabolism
3. The storage of glycogen ready for conversion into glucose
when energy is required.
4. Storage of vitamins
5. Phagocytosis - ingestion of worn out red and white blood cells,
and some bacteria

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The Gall Bladder
The gall bladder stores and concentrates bile which emulsifies fats
making them easier to break down by the pancreatic juices.
The Large Intestine
The large intestine averages about 1.5m long and comprises the
caecum, appendix, colon, and rectum. After food is passed into the
caecum a reflex action in response to the pressure causes the
contraction of the ileo-colic valve preventing any food returning to
the ileum. Here most of the water is absorbed, much of which was
not ingested, but secreted by digestive glands further up the
digestive tract. The colon is divided into the ascending, transverse
and descending colons, before reaching the anal canal where the
indigestible foods are expelled from the body.

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ANATOMY OF THE APPENDIX
The appendix is a wormlike extension of the cecum and, for
this reason, has been called the vermiform appendix. The average
length of the appendix is 8-10 cm (ranging from 2-20 cm). The
appendix appears during the fifth month of gestation, and several
lymphoid follicles are scattered in its mucosa. Such follicles increase
in number when individuals are aged 8-20 years.
The appendix is contained within the visceral peritoneum that
forms the serosa, and its exterior layer is longitudinal and derived
from the taenia coli; the deeper, interior muscle layer is circular.
Beneath these layers lies the submucosal layer, which contains

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lymphoepithelial tissue. The mucosa consists of columnar epithelium
with few glandular elements and neuroendocrine argentaffin cells.
Taenia coli converge on the posteromedial area of the cecum,
which is the site of the appendiceal base. The appendix runs into a
serosal sheet of the peritoneum called the mesoappendix, within
which courses the appendicular artery, which is derived from the
ileocolic artery. Sometimes, an accessory appendicular artery
(deriving from the posterior cecal artery) may be found.
Appendiceal vasculature
The vasculature of the appendix must be addressed to avoid
intraoperative hemorrhages. The appendicular artery is contained
within the mesenteric fold that arises from a peritoneal extension
from the terminal ileum to the medial aspect of the cecum and
appendix; it is a terminal branch of the ileocolic artery and runs
adjacent to the appendicular wall. Venous drainage is via the ileocolic
veins and the right colic vein into the portal vein; lymphatic drainage
occurs via the ileocolic nodes along the course of the superior
mesenteric artery to the celiac nodes and cisterna chyli.
Appendiceal location
The appendix has no fixed position. It originates 1.7-2.5 cm below
the terminal ileum, either in a dorsomedial location (most common)
from the cecal fundus, directly beside the ileal orifice, or as a funnel-

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shaped opening (2-3% of patients). The appendix has a
retroperitoneal location in 65% of patients and may descend into the
iliac fossa in 31%. In fact, many individuals may have an appendix
located in the retroperitoneal space; in the pelvis; or behind the
terminal ileum, cecum, ascending colon, or liver. Thus, the course of
the appendix, the position of its tip, and the difference in appendiceal
position considerably changes clinical findings, accounting for the
nonspecific signs and symptoms of appendicitis.
Physiology of Appendix
The lumen of the appendix communicates with the cecum 3cm
(about 1 inch) before the ileoccal valve, thus making it an accessory
organ of the digestive system. Its functions are not certain, but some
biologists believe that the appendix serves as a sort of “breeding
ground” for some of the nonpathogenic intestinal bacteria thought to
aid in the digestion or absorption of nutrients.
Follicles of lymphoid tissue appear in the wall of the appendix
shortly a few birth, become more prominent during the first 10 years
of life and then progressively disappear. The defense or immune
system function of lymphatic tissue present in the appendix of young
children is not fully understood.

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PATHOPHYSIOLOGY
Predisposing Factor Precipitating Factor
 Age (23 y/o)  Bowel movement: 3
times a week.
 Sedentary Lifestyle
 Low Fiber Diet
Obstruction to lumen of
the appendix.
Occlusion/kinking of the
lumen.
Inflammation of the
serosa of the appendix.
Signs and Symptoms:
 Acute RLQ Pain of
the Abdomen
 Fever
 McBurney’s Sign
 Nausea
 Constipation
Intraluminal
pressure.
Muscle Spasm

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Pus Formation as
evidenced by increased
White Blood Cell.
Rupture of the Appendix
If treated: If not treated:
Medications:
 Ranitidine
 Ampicillin
 Flagyl
Metronidazole
Surgical Procedure:
 Appendectomy
Metastasize to the
blood stream and
throughout the organ
Shock
Septicemia
Wellness
Death

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PATHOPHYSIOLOGY NARRATIVE
The client was diagnosed of acute appendicitis; she had a
predisposing factor; her age (23 y/o), which is according to research
adult age has the higher risk of incidence. Her gender didn’t serve as
a factor because males are more prone to the disease rather than in
females.
Prior to admission, she experienced irregularity in her bowel
habit; she only defecates three times a week. Her diet which is low in
fiber, high in cholesterol and protein and her sedentary lifestyle
attributed to her illness.
The two factors: precipitating and predisposing, led to the
obstruction of the lumen of the appendix. As the obstruction was
lengthened, it resulted in the kinking of the lumen, causing her pain.
The occlusion caused an inflammation of the serosa of the appendix
which produced an intraluminal pressure, causing muscle spasm on
the client.
The inflammation of the serosa of the appendix was
characterized by signs and symptoms of fever, acute pain in the right
lower quadrant of her abdomen, McBurney’s sign, nausea and
constipation which causes increase in the intraluminal pressure thus
resulting to muscle spasm.

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As there is presence of inflammation, it resulted in presence of
pus formation evidenced by increased in white blood cells to fight
against infection.
Furthermore, if inflammation will not be cured it can result to a
rupture of the appendix. If rupture is to be treated, the client will
need surgery (appendectomy) and medications. If treatment will be
successful, it will lead to wellness of life.
If the rupture is not treated, it would metastasize to the blood
stream and throughout the organ and further complicate to
septicemia leading to shock, which may result to DEATH.

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COMPLICATION OF APPENDICITIS
The most frequent complication of appendicitis is perforation.
Perforation of the appendix can lead to a periappendiceal abscess (a
collection of infected pus) or diffuse peritonitis (infection of the
entire lining of the abdomen and the pelvis). The major reason for
appendiceal perforation is delay in diagnosis and treatment. In
general, the longer the delay between diagnosis and surgery, the
more likely is perforation. The risk of perforation 36 hours after the
onset of symptoms is at least 15%. Therefore, once appendicitis is
diagnosed, surgery should be done without unnecessary delay.
A less common complication of appendicitis is blockage of the
intestine. Blockage occurs when the inflammation surrounding the

36
appendix causes the intestinal muscle to stop working, and this
prevents the intestinal contents from passing. If the intestine above
the blockage begins to fill with liquid and gas, the abdomen distends
and nausea and vomiting may occur. It then may be necessary to
drain the contents of the intestine through a tube passed through the
nose and esophagus and into the stomach and intestine.
A feared complication of appendicitis is sepsis, a condition in which
infecting bacteria enter the blood and travel to other parts of the
body. This is a very serious, even life-threatening complication.
Fortunately, it occurs infrequently.
CLINICAL MANIFESTATION OF APPENDICITIS

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The main symptom of appendicitis is abdominal pain. The pain is at
first diffuse and poorly localized, that is, not confined to one spot.
(Poorly localized pain is typical whenever a problem is confined to the
small intestine or colon, including the appendix.) The pain is so
difficult to pinpoint that when asked to point to the area of the pain,
most people indicate the location of the pain with a circular motion of
their hand around the central part of their abdomen. A second,
common, early symptom of appendicitis is loss of appetite which may
progress to nausea and even vomiting. Nausea and vomiting also
may occur later due to intestinal obstruction.
As appendiceal inflammation increases, it extends through the
appendix to its outer covering and then to the lining of the abdomen,
a thin membrane called the peritoneum. Once the peritoneum
becomes inflamed, the pain changes and then can be localized clearly
to one small area. Generally, this area is between the front of the
right hip bone and the belly button. The exact point is named after
Dr. Charles McBurney--McBurney's point. If the appendix ruptures
and infection spreads throughout the abdomen, the pain becomes
diffuse again as the entire lining of the abdomen becomes inflamed.

38
TESTS AND DIAGNOSIS
The diagnosis of appendicitis begins with a thorough history and
physical examination. Patients often have an elevated temperature,
and there usually will be moderate to severe tenderness in the right
lower abdomen when the doctor pushes there. If inflammation has
spread to the peritoneum, there is frequently rebound tenderness.
Rebound tenderness is pain that is worse when the doctor quickly
releases his hand after gently pressing on the abdomen over the area
of tenderness.
White Blood Cell Count
The white blood cell count in the blood usually becomes elevated
with infection. In early appendicitis, before infection sets in, it can be
normal, but most often there is at least a mild elevation even early.
Unfortunately, appendicitis is not the only condition that causes
elevated white blood cell counts. Almost any infection or
inflammation can cause this count to be abnormally high. Therefore,
an elevated white blood cell count alone cannot be used as a sign of
appendicitis.
Abdominal X-Ray
An abdominal x-ray may detect the fecalith (the hardened and
calcified, pea-sized piece of stool that blocks the appendiceal

39
opening) that may be the cause of appendicitis. This is especially true
in children.
Ultrasound
An ultrasound is a painless procedure that uses sound waves to
identify organs within the body. Ultrasound can identify an enlarged
appendix or an abscess. Nevertheless, during appendicitis, the
appendix can be seen in only 50% of patients. Therefore, not seeing
the appendix during an ultrasound does not exclude appendicitis.
Ultrasound also is helpful in women because it can exclude the
presence of conditions involving the ovaries, fallopian tubes and
uterus that can mimic appendicitis.
Barium Enema
A barium enema is an x-ray test where liquid barium is inserted into
the colon from the anus to fill the colon. This test can, at times, show
an impression on the colon in the area of the appendix where the
inflammation from the adjacent inflammation impinges on the colon.
Barium enema also can exclude other intestinal problems that mimic
appendicitis, for example Crohn's disease.
Computerized tomography (CT) Scan
In patients who are not pregnant, a CT Scan of the area of the
appendix is useful in diagnosing appendicitis and peri-

40
appendicealabscesses as well as in excluding other diseases inside
the abdomen and pelvis that can mimic appendicitis.
Laparoscopy
Laparoscopy is a surgical procedure in which a small fiberoptic tube
with a camera is inserted into the abdomen through a small puncture
made on the abdominal wall. Laparoscopy allows a direct view of the
appendix as well as other abdominal and pelvic organs. If
appendicitis is found, the inflamed appendix can be removed with the
laparascope.
Urinalysis
Urinalysis is a microscopic examination of the urine that detects red
blood cells, white blood cells and bacteria in the urine. Urinalysis
usually is abnormal when there is inflammation or stones in the
kidneys or bladder. The urinalysis also may be abnormal with
appendicitis because the appendix lies near the ureter and bladder. If
the inflammation of appendicitis is great enough, it can spread to the
ureter and bladder leading to an abnormal urinalysis. Most patients
with appendicitis, however, have a normal urinalysis.

41
DOCTOR’S ORDER
02/08/2012
08:55 pm - Please admit to room of choice under the
service of Dr.Mudanza.
- NPO
- Labs – CBC with plt. count, UA.,
- Start venoclysis with D5LR 1L @ 80 cc/ hr.
Meds:
- Ranitidine 50g q 8ᴼ IVTT.
- Watch out for unusualities.
10:00 pm - Ampicillin 1g q 6ᴼ IVTT ANST.
- Metronidazole 500 mg 8ᴼ IVTT.
- IV rate @ 120-150 cc/ hr.
11:20 pm - D5LR (#2) 1L @ 80 cc/ hr.
02/09/2012 -D5LR 1L @150 cc/ hr.
-Cont. meds.
-Run IVF @ 150 cc/ hr.
9:00am - Do UTZ of abdomen.

42
LABORATORY RESULTS
U.A: (02/08/2012)
Admission No.: 2464
Color - Yellow
Transparency - Clear
Reaction - Acidic
Spec. Gravity - 1.020
Chemical Element
Sugar - (-)
Albumin - (-)
Microscopic Element
Pus Cells - 0-1 / hpf
RBC - 0-1 / hpf
Mucous Threads - occasional
Epithelial Cell - squamous-occasional

43
Hematology (02/08/2012)
Admission No.: 2464
Test Result Normal
Values
Rationale
Hemoglobin 105 120.00-140 g/L May indicate
anemia.
WBC 12 5.00-10.00 x 10
g/L
May indicate
infection,
inflammation.
RBC 4.14 4.50-5.50 x 10
12/L
Indicates
anemia.
HCT 0.13 0.37-0.43 vol % Indicates
anemia.
PLT. CT 330 150.00-350.00
x 10 g/L
Normal
SEGS 0.58 0.55-0.65 Normal
LYMPHO 0.33 0.25-0.35 Normal

44
Ultrasound Report
Case Number:
Patient Name: Momoko
Admitting Diagnosis: T/C Appendicitis
Complaint: RLQ Pain
Part Examined: Whole Abdomen Ultrasound
USD of the Abdomen:
Liver is normal size. No focal lesions are noted. Intrahepatic
ducts and CBD are not dilated. Hepatic vessels are normal. Gall
bladder is physiologically distended with normal wall. No internal
echoes are seen. Pancreas, spleen and left kidney are normal. There
is lobulated, well defined, anechoric focus in superior pole of the right
kidney measuring 3.6 x 3.8 x 3.5 cm. urinary bladder and uterus are
remarkable. Both adnexae are free. No pelvic fluid noted. There is
well defined, ovoid predominantly complex mass in the RLQ
measuring 5.9 x 6.1 x 6 cm. the hypoechoic component measures 4.4
x 2.6 x 3.9 cm. minimal surrounding fluid is present.

45
DRUG STUDY
Brand Name
Generic
Name
Classification
Dosage and
Frequency
Mechanism
of
Action
Indication Adverse Reaction Nursing Management
Zantac
Ranitidine
Histamine H2
antagonists
50mg 1 amp
IVTT every 8
hours
Inhibits the
action of
histamine at
the H2
receptor site
located
primarily in
gastric
parietal cells,
resulting in
inhibition of
gastric acid
secretion.
Treatment
and
prevention of
heartburn,
acid
indigestion,
and sour
stomach.
• CNS:
Confusion, dizziness,
drowsiness,
hallucinations,
headache
• CV:
Arrhythmias
• GI:
Altered taste, black
tongue, constipation,
dark stools, diarrhea,
drug-induced
hepatitis, nausea
• HEMAT: Anemia,
neutropenia,
thrombocytopenia
• LOCAL:
Pain at IM site
• MISC:
Hypersensitivity
reactions, vasculitis
•Observe 11 rights in giving
medication.
• Assess IV site and give the
drug slowly.
• Assess patient for epigastric
or abdominal pain and frank or
occult blood in the stool,
emesis, or gastric aspirate.
• Inform patient that it may
cause drowsiness or dizziness.
• Inform patient that increased
fluid and fiber intake may
minimize constipation.
• Advise patient to report onset
of black, tarry stools; fever,
sore throat; diarrhea; dizziness;
rash; confusion; or
hallucinations to health care
professional promptly.
• Inform patient that
medication may temporarily
cause stools and tongue to
appear gray black.

46
DRUG STUDY
Generic
Name
Classification Dosage and
frequency
Mechanism of
Action
Indication Adverse
Reaction
Nursing
Management
Ampicin
Ampicillin
Penicillin,
antibiotic
1g every 6 hours
IVTT
A broad
spectrum semi-
synthetic, amino
penicillin is
highly
bactericidal
even at low
concentrations,
but inactivated
by penicillinase.
Infections of
gastrointestinal
tract and soft
tissues.
•CNS:
convulsive
seizures with
higher doses
•GI: diarrhea,
nausea and
vomiting
•Dermatologic:
rash
•Observe 11 rights in
giving medication.
•Determine previous
hypersensitivity
reactions to
penicillins,
cephalosphorins and
other allergens prior
to therapy.
•Inspect skin daily
and instruct patient to
do the same. The
appearance of rash
should be carefully
evaluated.
•Give medication
around the clock.
giving medication.

47
DRUG STUDY
Generic
Name
Classification Dosage and
Frequency
Mechanism of
Action
Indication Adverse
Reaction
Nursing Management
Flagyl
Metronidazole
Antibacterial,
Anti-protozoals
500mg every 8
hours IVTT
• Disrupts DNA
and protein
synthesis in
susceptible
organisms
•Bactericidal, or
amebicidal
action
Acute
infection
with
susceptible
anaerobic
bacteria.
•CNS: seizures,
dizziness,
headache
• GI: abdominal
pain, anorexia,
nausea,
diarrhea, dry
mouth, furry
tongue, glossitis,
unpleasant taste,
vomiting
•Hematologic:
leukopenia
• Skin: rashes,
urticarial
giving medication.
• Administer with food or
milk to minimize GI
irritation. Tablets may be
crushed for patients with
difficulty swallowing.
• Instruct patient to take
medication exactly as
directed evenly spaced
times between dose,
even if feeling better.
•May cause dizziness or
light-headedness.
Caution patient or other
activities requiring
alertness until response
to medication is known.
medication may cause an
unpleasant metallic taste.
medication may cause
urine to turn dark.

48
NURSING CARE PLAN
Date and
Time
Assessment Scientific
Basis
Nursing
Diagnosis
Nursing
Goal
Plan
Nursing Intervention Rationale Evaluation
02- 09- 2012
(7-3)
Subjective:
“Sakitakoang
kilid”, as
patient
verbalized.
Objective:
 Conscious
 Grimaced
face
noted
 Weakness
noted
 Guarded
behavior
noted
 Pain
scale:
7/10
 Pale
looking
Due to the
presence of
inflammation
and mass on
the RLQ of
the abdomen,
it causes
some
obstruction in
the lumen of
the appendix
in turn causes
s sharp acute
pain in the
Right Lower
Quadrant part
of the
abdomen.
Acute pain
related to
inflammation
of the
appendix.
Within
our 8
hour
span of
care,
patient
will be
alleviated
from
pain.
 Establish rapport.
 V/S taken and recorded.
 Encourage verbalization
of feelings about pain.
 Encourage patient to
have diversional activities
such as mobile internet
and watching TV.
 Encourage patient to use
relaxation techniques
such as deep breathing.
 Provide comfort measures
such as touch,
repositioning, quiet
environment and calm
activities.
 Encourage adequate rest
periods.
 Observe and document
severity (1-10 scale) and
character of pain (steady,
intermittent, colicky).
 To gain trust and
cooperation.
 Serves as baseline
data.
 To assess the level
of pain.
 To alleviate pain.
 Distract attention
and reduce tension.
 To promote non-
pharmacologic pain
management.
 To promote wellness
and prevent fatigue.
 To get a baseline
data of pain scale.
Goal
partially
met.

49
Date and
Time
Assessment Scientific
Basis
Nursing
Diagnosis
Nursing
Goal Plan
Nursing Intervention Rationale Evaluation
02-09-2012
(7-3)
Subjective:
“Worried
kosaakong
situationbasig
operahan man
gudko”, as
verbalized by
the patient.
Objective:
Irritability
noted
Anxious
looking
Discomfort
noted
Restlessnes
s noted
Vague uneasy
feeling of
discomfort or
dread
accompanied
by an
autonomic
response (the
source often
nonspecific or
unknown to the
individual); a
feeling of
apprehension
caused by
anticipation of
danger it is an
alerting signal
that warns of
impending
danger and
enables the
individual to
take measures
to deal with the
threat.
(Gulanick/Myers
Nursing Care
Plans, 6th
Edition)
Anxiety
related to
possible
surgery
secondary
to Acute
Appendicitis.
Within our 8
hour span
of care,
patient will
be able to
understand
and
demonstrat
e positive
coping
mechanism
and
describe a
reduction in
the level of
anxiety.
 Establish rapport.
 V/S taken and
recorded.
 Assess awareness of
patient about anxiety.
 Provide accurate
information to the
client.
 Provide comfort
measures.
 Provide and maintain
quiet environment.
 Encourage patient to
talk about anxious
feelings.
 To gain trust and
cooperation.
 Serves as baseline
data.
 Validate the feeling
and communicate
acceptance of the
feelings.
 Helps the client to
identify what is
reality based.
 To help the patient
relax.
 Anxiety may
escalate with
excessive
conversation, noise
and equipment about
the patient.
 Talking about
anxiety producing
situations and
anxious feelings can
help the person
perceive the situation
in less threatening
manner.
Goal met.

50
PROGNOSIS
CRITERIA POOR FAIR GOOD JUSTIFICATION
Onset of
Illness /
Onset of illness is fair
because symptoms have
progressed rapidly and
patient gives less attention
and no medical
consultation was done.
Duration of
illness /
Recognition of the disease
is delayed. The patient
manifested pain in the
right lower quadrant.
Predisposing
Factors /
The client has two
predisposing factors out of
three.
Precipitating
Factors /
Precipitating factors is poor
since the patient is
constipated, has a low
fiber diet and has a
sedentary lifestyle.
Willingness
to take
medication
/
The patient is compliant
with medication regimen
and other interventions.
Age /
Physical
Condition
/
The patient is in the
adulthood stage.
Envionmental
/ support
Group
/
She has the circle of
supportive friends who
visits and cares about her.
Family
Support
/
The patient’s family is very
supportive. They are very
receptive to the medical
advices and cooperative to
the interventions and
management.

51
COMPUTATION FOR OVER-ALL PROGNOSIS
Good 4/8 x 100%= 50%
Fair 3/8 x 100%= 37.5%
Poor 1/8 x 100%= 12.5%
GENERAL PROGNOSIS
With the overall percentage of 100, the client exhibited a higher
percentage of good with fifty percent (50%) while fair prognosis has
a percentage of thirty seven point five (37.5%) and poor with a
twelve point five percentage (12.5%).
The patient shows very good indication in willingness to take
her available medications. The patient’s family on the other hand was
very supportive to ease the client’s illness.

52
Discharge planning
Medication
1. Instruct patient and the family to comply with the prescribe
medication.
2. Instruct patient’s family to place medicine in places out of children
reach.
3. Instruct patient and the family to complete the whole duration of
the drug.
4. Teach the patient and the family regarding the name of the drugs,
right dosage, and proper manner of taking as well possible side
effects.
Environment/exercise
1. Advice patient to take regular breaks from any activity that
demands to give stress pressure on back.
2. Encourage patient to involve in exercise to enhance circulation.
3. Encourage the patient to have adequate rest and sleep.

53
Treatment
1. Orient the patient’s family about the patient’s condition and
necessary information/treatment and recovery process.
2. Teach patient and the family about the importance of conducive
environment for better recovery.
3. Encourage to comply with treatment regimen.
Health Teachings
1. Advice to take medications on time and with the right dose.
2. Instruct the patient to eat nutritious food such as vegetables and
fruits.
3. Advice the patient to limit consumption of fatty foods.
4. Encourage client to choose food/ have family member bring food
that seem appealing to stimulate appetite.
5. Instruct client to provide oral care before and after meals and at
bedtime.
Out patient
1. Instruct the patient to take the medications ordered by the
physician.
2. Encourage the patient to comply with the scheduled check-up.

54
3. Instruct the patient and the family to comply with the prescribed
medications.
4. Encourage patient to visit physician one to two weeks after
discharged from the hospital.
5. Instruct the patient to visit physician immediately if any
unusualities arise.
DIET
1. Encourage patient to eat nutritious and well balance meal.
2. Instruct the patient to increase oral fluid intake.
3. Diet as tolerated is advice by attending physician to sustain her
nutritional needs.

55
BIBLIOGRAPHY
BOOKS:
Brunner and Suddarth’s Textbook of Medical Surgical Nursing.
Eleventh Edition
Priscilla lemone medical surgical nursing
Ross and Wilson Anatomy and Physiology in Health and Illness.Tenth
Edition.
Medical Surgical Nursing Critical Thinking in client care
Third Edition
MIMS and MIMS Annual
Baillers nursing dictionary
INTERNET
http://www.gastro.org/wmspage.
American Gasteroenterogical Association
Pictures www.google.com

56
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