Appendicitis Case Study Scribd

Introduction

The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the cecum just below the ileocecal valve. No definite functions can be assigned to it in humans. The appendix fills with food and empties as regularly as does the cecum, of which it is small, so that it is prone to become obstructed and is particularly vulnerable to infection (appendicitis).

Appendicitis is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity. About 7% of the population will have appendicitis at some time in their lives, males are affected more than females, and teenagers more than adults. It occurs most frequently between the age of 10 and 30.

The disease is more prevalent in countries in which people consume a diet low in fiber and high in refined carbohydrates.

The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting. Loss of appetite is common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burney’s point applied located at halfway between the umbilicus and the anterior spine of the Ilium.

Rebound tenderness (ex. Production or intensification of pain when pressure is released) may be present. The extent of tenderness and muscle spasm and the existence of the constipation or diarrhea depend not so much on the severity of the appendiceal infection as on the location of the appendix.

If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar region. Rovsing’s sign maybe elicited by palpating the left lower quadrant. If the appendix has ruptured, the pain become more diffuse, abdominal distention develops as a result of paralytic ileus, and the patient condition become worsens.

Constipation can also occur with an acute process such as appendicitis. Laxative administered in the instance may result in perforation of the in flared appendix. In general a laxative should never be given when a person’s has fever, nausea or pain.

Anatomy and Physiology of Digestive System

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.

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.

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.

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.

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

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.

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. 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.

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. 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.

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.

Clinical Manifestations

  1. Generalized or localized abdominal pain in the epigastric or periumbilical areas and upper right abdomen. Within 2 to 12 hours, the pain localizes in the right lower quadrant and intensity increases.
  2. Anorexia, moderate malaise, mild fever, nausea and vomiting.
  3. Usually constipation occurs ; occasionally diarrhea.
  4. Rebound tenderness, involuntary guarding, generalized abdominal rigidity.

Diagnostic Evaluation

  1. Physical examination consistent with clinical manifestations.
  2. WBC count reveal moderate leukocytosis (10,000 to 16,000/mm3) with shift to the left (increased immature neutrophils).
  3. Urinalysis rule out urinary disorders.
  4. Abdominal x-ray may visualize shadow consistent with fecalith in appendix; perforation will reveal free air.
  5. Abdominal ultrasound or CT scan can visualize appendix and rule out other conditions, such as diverticulitis and crohn’s disease. Focused appendiceal CT can quickly evaluate for appendicitis.

Medications

  • Analgesics
  • Intravenous fluids replacements
  • Analgesics

Treatment

Appendectomy is the effective treatment if peritonitis develops treatment involves.

  • GI Intubation
  • Parenteral replacement of IV fluids and electrolytes
  • Administration of Antibiotics

Surgery is indicated if appendicitis is diagnosed. Antibiotics and IV fluids are administered until surgery is performed analgesics can be administered after the diagnosed is made.

An appendectomy (surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation. T he appendectomy may be performed under a (general or spinal anesthetics) with a low abdominal incisions or by (laparoscopy) which is recently highly effective method.

Complications

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.

Nursing Interventions

  1. Monitor frequently for signs and symptoms of worsening condition, indicating perforation, abscess, or peritonitis (increasing severity of pain, tenderness, rigidity, distention, absent bowel sounds, fever, malaise, and tachycardia).
  2. Notify health care provider immediately if pain suddenly ceases, this indicates perforation, which is a medical emergency.
  3. Assist patient to position of comfort such as semi-fowlers with knees are flexed.
  4. Restrict activity that may aggravate pain, such as coughing and ambulation.
  5. Apply ice bag to abdomen for comfort.
  6. Avoid indiscriminate palpation of the abdomen to avoid increasing the patients discomfort.
  7. Promptly prepare patient for surgery once diagnosis is established.
  8. Explain signs and symptoms of postoperative complications to report-elevated temperature, nausea and vomiting, or abdominal distention; these may indicate infection.
  9. Instruct patient on turning, coughing, or deep breathing, use of incentive spirometer, and ambulation. Discuss purpose and continued importance of these maneuvers during recovery period.
  10. Teach incisional care and avoidance of heavy lifting or driving until advised by the surgeon.
  11. Advise avoidance of enemas or harsh laxatives; increased fluids and stool softeners may be used for postoperative constipation.

Discharge Planning

M     Antibiotics for infection
        Analgesic agent (morphine) can be given for pain after the surgery

E     Within 12 hrs of surgery you may get up and move around.
       You can usually return to normal activities in 2-3 weeks after laparoscopic surgery.

T     Pretreatment of foods with lactase preparations (e.g. lactacid drops) before ingestion can reduce symptoms.
       Ingestion of lactase enzyme tablets with the first bite of food can reduce symptoms.

H     To care wound perform dressing changes and irrigations as prescribe avoid taking laxative or applying heat to abdomen when abdominal pain of unknown cause is experienced.
       Reinforce need for follow-up appointment with the surgeon
       Call your physician for increased pain at the incision site

O     Document bowel sounds and the passing of flatus or bowel movements (these are signs of the return of peristalsis)
       Watch for surgical complications such as continuing pain or fever, which indicate an abscess or wound dehiscence
       Stitches removed between fifth and seventh day (usually in physicians office)

D    Liquid or soft diet until the infection subsides
      Soft diet is low in fiber and easily breaks down in the gastrointestinal tract

Pathophysiology of Appendicitis
Nursing Care Plan – Appendicitis

 

References:

Medical and Surgical Nursing by Brunner and Suddarth’s
Medical Surgical Nursing by Josie Quiambao Udan
Manuals of Nursing Practice by Lippincott
Mosby’s Medical Surgical Nursing

Daisy Jane Antipuesto RN MN

Currently a Nursing Local Board Examination Reviewer. Subjects handled are Pediatric, Obstetric and Psychiatric Nursing. Previous work experiences include: Clinical instructor/lecturer, clinical coordinator (Level II), caregiver instructor/lecturer, NC2 examination reviewer and staff/clinic nurse. Areas of specialization: Emergency room, Orthopedic Ward and Delivery Room. Also an IELTS passer.

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