CASE STUDY OF A

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• CASE STUDY OF A
• PATIENT WITH
• ACUTE APPENDICITIS

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• Demographic Data
•  
• Name Patient Xs
• Age 22 Years old
• Sex Male
• Nationality Yemeni
• Date of Admission April 27, 2013
• Complaints fever,
  abdominal pain,
• 
  vomiting
• Diagnosis Acute appendicitis
•  

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• Physical Assessment
•  
• GCS 15/15
• E Opens eyes spontaneously
• V Oriented and converses normally
• M Obeys commands
• Dizziness and nausea upon
  as assessment
•  
• Vital signs
• Temperature
  3 8. c
• Heart rate
  74 bpm
• Respiration
  22 bpm
• Blood
  pressure 100/ 80 mmHg
• Spo2
  97 in room air

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• SKIN
  
• Normal skin color
• Hair soft and silky
• Warm to touch
•   NOSE
• Centrally located ,no devation. no infection and
  bleeding noted
•   MOUTH AND THROAT
• On lips no cracks ,looks pink , gums- no
  swelling and bleeding present, tongue normal
•   NECK
• Turns side to side easily
• No lymph node enlargement present
• CHEST
• Bilateral chest movement present
• Normal breathing sound present
• Dysponea, cyanosis are absent
•  
•  

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• ABDOMEN
• Rebound tenderness present on palpation
• Umbilicus is normal
• Bowel sound is normal on auscultation
•  
•  
• GENITALIA
•  Adequate voiding and defecation present
• BACK
• Spine is intact
• No spinal deformity present
•  
• EXTREMITIES
• Full range of motion present
• Ten fingers and ten toes present
• Nails are normal in shape and color
•  

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•  
• PATIENT HISTORY
•  
• Past Medical History
  No past medical history.
• Present medical history Patient was brought
  to ER by his relatives
• by
  private car, conscious and coherent with
  
• 
  chief complaints of high grade fever, severe
  
• 
  abdominal pain since 2 days, vomiting and
• 
  poor oral intake since one day. Seen and
  
• 
  examined by ER doctor , administered Inj.
  
• 
  Fentanyl iv , Inj.Paracetamol1gm IV and
• 
  Intravenous DNS .For the laboratory works
• 
  CBC, urine analysis was done. Complete
• 
  Abdominal Ultrasonography and CT Abdomen
• 
  with contrast was done. The patient was
• 
  admitted for further conservative management
• Past Surgical history Patient XS has no
  past surgical

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• 
  Investigations
• Laboratory Results
• WBC COUNT 13.7
• NEUTROPHIL 89
•  
•  
• Ultrasonography Result
• Abdomen is gazy. The liver is normal in size,
  shape and echogenecity. No focal lesion is seen.
  Intra hepatic biliary radical seen in the
  peripheral areas of the liver.
•  
•  
•  

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•  
• TOPIC PRESENTATION
• GASTROINTESTINAL SYSTEM
• 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. Food is propelled along
  the length of the GIT by peristaltic movements of
  the muscular wall.

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• LARGE INTESTINE
• 
  
  The large intestine is
  horse-shoe shaped and extends around appendix,
  caecum, ascending, transverse, descending and
  sigmoid colon, the rectum, and anal canal. It has
  a length of approximately 1.5m and a width of
  7.5cm. The
  functions of the large intestine can be
  summarized as
• Absorption The accumulation of unabsorbed
  material to form feces. Mineral salts, vitamins
  and some drugs are also absorbed into the blood
  capillaries from the large intestine
• Microbial activity The large intestine
  heavily colonized by certain type of bacteria,
  which synthesize vita k and folic acid E-coli
  Enterobacter aerogenes, streptococcus faecalis
  and clostridium perfringens. The bacteria are
  responsible for the formation of intestinal gas.
  

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• 1. the caecum
• It is the first part of the colon. It is a
  dilated region which has a blind end
• inferiorly and continuous with ascending colon
  superiorly. Just below the junction of
• the two the ileocaecal valve opens from the
  ileum. The vermiform appendix is a fine
• tube, closed at one end, which leads from the
  caecum.
• 2. THE ASCENDING COLON
• This passes upwards from the caecum to the
  level of the liver where it curves acutely to
• the left at the hepatic flexure to become the
  transverse colon.
• 3. TRANSVERSE COLON
• This is a loop of colon which extends across
  the abdominal cavity in front of the
• duodenum and the stomach to the area of the
  spleen where it forms the splenic flexure
• and curves acutely downwards to become the
  descending colon.
  

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• . 5.SIGMOID COLON
• This part describes an S- shaped curve in the
  pelvis then continues
• downwards to become the rectum.
• 6. THE RECTUM
• The rectum is the final 13cm of the large
  intestine. It expands to
• hold fecal matter before it passes through the
  ano rectal canal to
• the anus. Thick bands of muscle, known as
  sphincters, control the
• passage of feces.
• 7. THE ANAL CANAL
• This is a short passage about 3.8 cm long in
  the adult and leads
• from the rectum to the exterior. The internal
  external sphincter
• muscle control the anal.
• 
  
  

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• The vermiform appendix or appendix
•  
• Sits at the junction of the small intestine and
  large intestine. Its a small narrow sac
  approximately 10cm long and 1cm wide . Normally,
  the appendix sits in the lower right abdomen. One
  theory is that the appendix acts as a storehouse
  for good bacteria, rebooting the digestive
  system after diarrheal illnesses.

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• The Location of appendix is
  not same in everybody, it different in each
  person. Most commonly it is found to be at or
  around the Mc Burneys point. The point is
  located at the lower right side of the abdomen,
  almost two thirds of the distance between the
  navel and upper part of pelvic bone. The location
  of the appendix tip can be retro cecal, or in the
  pelvis to being extra peritoneal. It is rare
  though but it can be found to be in the lower
  left side of the abdomen in people with situs
  inversus.

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• Mc Burneys point Line drawn between
  Umbilicus and Upper part of pelvic bone and the
  point is 2/3 rd distance from the Umbilicus and
  1/3 rd distance from the pelvic bone (upper part)
  
•  
•  

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• APPENDICITIS
• Appendicitis is
  inflammation of the
• vermiform appendix caused by an obstruction of
• the intestinal lumen from infection, stricture,
• fecal mass, foreign body, or tumor .When it gets
• inflamed it is filled with pus.
•  

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• Etiology
• Appendicitis is a bacterial infection
  caused by obstruction or blockage due to
• Fecalith presence in the lumen of the appendix
• Appendix tumor
• The presence of foreign objects such as
  ascariasis worm.
• Appendix mucosal erosion due to parasites
  such as
• 
  E.Histilitica.
• According to research,
  epidemiology suggests eating foods low in fiber
  will cause constipation which can cause
  appendicitis. This will increase intra- caecal
  pressure, causing a functional obstruction
  appendix and increase the growth of germs in the
  colon flora.
•  

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• Pathophysiology
• The series of consequences which leads to the
  enlargement of appendicitis from a normal
  vermiform appendix is termed as pathophysiology
  of appendicitis. A blockage of appendiceal lumen
  enhances the pressure within it. Such increased
  pressure in turn leads to secretion of mucus from
  the mucosa which ultimately begins to stagnate.
  The condition is worsened further by the
  bacterium found in gut and this transforms into
  the formation of pus after the recruitment of
  white blood cells to fight the bacterial
  invasion. The deadly combination of dead tissues,
  white blood cells and bacteria causes pus
  formation. A comprehensive pathophysiology takes
  about 24 to 72 hours, further delay can be fatal.
  
•  

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•  

Obstruction of the appendix (Fecalith, Lymph node
and Foreign bodies)
Increased intra luminal pressure
Distention of the appendix -causes pain
Decrease venous drainage
Blood flow and oxygen restriction to the appendix
Bacterial invasion of blood wall -causes fever
Necrosis of the appendix
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• CLINICAL MANIFESTATIONS
•  
• Generalized or localized pain in the epigastric
  or peri-umbilical areas and upper right abdomen.
  Within 2 to 12 hours, the pain localizes in the
  right upper quadrant and intensity increases.
• Anorexia, moderate malaise, mild fever, nausea
  and vomiting.
• Usually constipation occurs, occasionally
  diarrhea.
• Rebound tenderness, involuntary guarding,
  generalized abdominal rigidity.

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• DIAGNOSTIC EVALUATIONS
• Medical examination
• Auscultate for presence of bowel sounds
  peristalsis may be absent or diminished.
• Positive signs of appendicitis
• Mc Burneys , sign deep tenderness at Mc Burney
  ,s point
• Rovsing sign If gentle compression of the left
  of the lower abdomen is done and results in pain
  on right side .
• Psoas sign The patient is positioned on his
  left side and right leg is extended behind the
  patient and if this results in lower right
  sided abdominal pain.
• Obturator sign The patient lies on his back with
  right hip flexed at 9odegree.Rotates the hip by
  pulling right knee to and away from the patient
  body. This causes pain and is an evidence in
  support of an inflamed appendix.

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• Complete blood count (CBC)
• An increased number of white blood cells -- a
  sign of infection and inflammation -- are often
  seen on blood tests during appendicitis .
  
  
  Urine test to rule out a urinary tract
  infection
• Abdominal X-ray
• May visualize shadow consistent with fecalith in
  appendix perforation will reveal free air.
• CT scan (computed tomography)
• A CT scanner uses X-rays and a computer to
  create detailed images. In appendicitis, CT scans
  can show the inflamed appendix, and whether it
  has ruptured.
•  
• Ultrasound
• An ultrasound uses sound waves to detect signs of
  appendicitis, such as a swollen appendix.
• Other imaging tests When a rare tumor of the
  appendix is suspected, imaging exams may locate
  it. These include magnetic resonance imaging
  (MRI), positron emission tomography (PET).
  
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•  

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• MANAGEMENT
•  
• APPENDECTOMY
• Surgery is the only treatment for appendicitis.
  Surgery to remove the appendix, which is
  called an appendectomy, is the standard
  treatment for appendicitis.. If the appendix has
  formed an abscess, you may have two procedures
  one to drain the abscess of pus and fluid, and a
  later one to remove the appendix in acute
  appendicitis, the best treatment is surgery the
  appendix. Within 48 hours must be performed.
  
  
•  
• Preoperative MANAGEMENT
• Maintain bed rest, NPO status, iv hydration,
  possible antibiotic prophylaxis, and analgesia.
• Postoperative Appendectomy
• One day post surgery clients are encouraged to
  sit upright in bed for 2 x 30 minutes, the next
  day soft food and stand upright outside the room,
  the seventh day stitches removed, the client's
  home.
•  

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• Antibiotics
  
• Antibiotics are given before an
  appendectomy to fight possible peritonitis.
  While the diagnosis is in question, antibiotics
  treat any potential infection that might be
  causing the symptoms.
• Prevention
•   There is no way to prevent
  appendicitis. However, appendicitis is less
  common in people who eat foods high in fiber,
  such as fresh fruits and vegetables.

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•  
• Complications
• PERITONITIS
• The peritoneum becomes
  acutely inflamed, the blood vessels dilate
  and
• excess serous fluid is secreted. It occurs
  as a complication of appendicitis when
• Microbes spread through the wall of the
  appendix and infect the peritoneum.
• An appendix abscess ruptures and pus enters
  the peritoneal cavity.
• The appendix becomes gangrenous and
  ruptures, discharging its contents
• into the peritoneal
• ABSCESS FORMATION.
• The most common abscesses cavity .are
• subphrenic abscess ,between the liver and
  diaphragm, from which infection may
• spread upwards to the pleura,
  pericardium and mediastinal structures.
•   pelvic abscess from which infection may
  spread to adjacent structures.
  
  
•   FIBROUS ADHESIONS
•   When healing takes place fibrous tissue forms
  and later shrinkage may cause
•   stricture or obstruction of the bowel.

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• PRIORITIZATION OF NURSING PROBLEMS
• Acute pain related to inflamed appendix
  
• Hyperthermia related to the inflammatory
  process
• Risk for infection related to perforation.
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• NURSING HEALTH TEACHINGS
•  
• Follow up the regimen as per order.
• Instruct the patient to avoid heavy lifting
  for 4 to 6 weeks after
• surgery.
• Instruct the patient to report symptoms of
  anorexia nausea,
• vomiting, fever, abdominal pain ,
  incisional redness or

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• CONCLUSION
•  
• Male patient, 22 years of age
  brought to ER with complaints of pain in
  abdomen - right lower quadrant ,associated with
  fever and vomiting. Treated with analgesics,
  antipyretics and intravenous fluids was
  administered. Laboratory works including
  ultrasonography of the abdomen was done and
  diagnosed to have appendicitis. Patient was
  admitted in the ward and undergone Appendectomy,
  after the course of antibiotics and other
  treatments, patient was discharged in stable
  condition and advised for follow up and suture
  removal after 7 days.
•  
•  

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• BIBLIOGRAPHY
•  
•  
• LIPPINCOT MANUAL OF NURSING PRACTISE
  NINTH
• EDITION.
•  
• ROSS AND WILSON
•  
• WWW.NURSESLABS . COM
•  
• WWW. WIKIPEDIA .COM
•  
•  
•  
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•  

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• NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective I have abdominal pain Objective Pain score 8/10 Acute Pain related to inflammation of appendix After 15-30 mins of nursing interventions, the patient will experience relief from pain as evidenced by a pain score of 8/10 decreased to at least 5/10, a relaxed position.. 1.Assessed the pain scale frequently and pain management given as per pain scale . 2. Provided patient. Optimal pain relief with prescribed analgesics. (inj. Fentanyl 50mcg iv stat). 3. Positioned patient comfortably on bed. 4. Provided diversional therapies. 1.It provides objective measurement. 2. It helps to reduce the pain and helps to sleep . 3. Proper positioning during times of pain may give comfort to the patient. 4. Helps less focus on pain. Goal partially met After 30 mits of nursing interventions, the patient manifested a slight relief of pain as evidenced by a pain score of 6/10 but still uncomfortable.

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• NURSING CARE PLAN

ASSESSMENT NUSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Increased body temperature _at_38.8c Objective skin is warm to touch Hyperthermia related to the inflammatory process After 3 hrs of nursing intervention patient temperature will decrease to normal limit -Assessed patient condition and monitor vitals -perform tepid sponge bath -Instruct to increase fluid intake -Maintain patent airways and provide blanket -Provide antipyretics as ordered -To know base line data -To promote heat loss by evaporation and conduction -To support circulatory volume and perfusion -To promote patient safety and reduce chills -To reduce fever After 3-4 hrs of nursing intervention patient temperature shall have decreased to normal limits

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THANK YOU