APPENDECTOMY

APPENDICITIS
 APPENDICITIS
• Appendicitis is the inflammation of the vermiform appendix and
was first described as a pathologic condition by American physician
Reginald Fits in 1886.
• Appendicitis is most commonly caused by the obstruction of the
appendix caused by a “fecalith”, which is a hard stony mass of feces
that finds its way into the lumen of the appendix. Some other
causes are undigested seeds, or a pinworm infection which are
intestinal parasytes.
RUPTURE OF THE APPENDIX
• Can result to bacteria and other fluid
contents inside escaping the appendix and
get into the peritoneum, leading to
peritonitis.

• The most common

complication of a ruptured
appendix is pus and fluid
getting out and forming an
abscess around the appendix,
called the periappendiceal
abscess.
• These lead to a more diffused pain, abdominal distention that
develops as a result of paralytic ileus, and the worsening of the
patient’s condition.
• The condition is a medical emergency that requires prompt
surgery to remove the appendix, also known as an
Appendectomy, which is the surgical removal of the appendix,
along with antibiotics.
B. ETIOLOGY
NON-MODIFIABLE FACTORS:
• Family History – A positive family history increases relative risk of
having acute appendicitis nearly 3 times
• Gender – Males are more prone to appendicitis compared to females
with a risk ration of 1.4:1. An American Journal of Epidemiology study
in 1990 found that appendicitis was a common condition affecting
approximately 6.7% of females and 8.6% of males.
• Age – Appendicitis generally affects people aged between 10 and 30,
but it can strike at any age
• Season - Studies suggests that people get appendicitis more during
the summer than other times of the year, likely due to a combination
of increased air pollution, more GI infections, and greater
consumption of fast food.
MODIFIABLE FACTORS:
• Diet - Research also suggests that the typical "Western diet,"
which is high in carbohydrates and low in fiber, can increase your
chances of developing appendicitis. Without enough fiber in your
diet, bowel movements slow down, increasing the risk of
appendix obstruction.
• Occlusion of fecal material - Appendicitis is usually caused by a
blockage of the inside of the appendix, which is called the lumen.
Most often, the lumen is blocked by fecal material.
• Infection with Yersinia organisms – According to Surgical
Pathology of Gastrointestinal System, Yersinia, a Gram-negative
coccobacilli, is responsible for many cases of isolated
granulomatous appendicitis
C. INCIDENCE
• 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. and 250,000 cases of appendicitis are reported annually
• And in the Philippines, the recorded incident rate of acute appendicitis
is 215,604 back in 2011 and is increased to 4% per year.
D. GENERAL SIGNS AND SYMPTOMS
Acute Appendicitis
• Abdominal pain - As the appendix becomes more swollen and inflamed, it will irritate
the lining of the abdominal wall, known as the peritoneum. This causes localized,
sharp pain in the right lower part of the abdomen.
• Point tenderness – A cardinal sign of appendicitis is point tenderness. This is a
defined area of tenderness in the right lower quadrant which is called the Mcburney’s
point.
• Rebound tenderness – This is a sign of inflammation in which pain is elicited by the
sudden release of the fingertips pressing on the right lower quadrant.
• Mild fever- The bacteria trapped in the stool affects the appendix which can lead to
infection and manifest a mild fever.
• Nausea and Vomiting- After the abdominal pain begins, a person with appendicitis
feels nauseated. This is also caused by the obstruction.
Rupture of Appendix (Abscess/ Peritonitis)
• Severe sharp abdominal pain or tenderness
• Bloating or a feeling of fullness (distention) in your
abdomen/ board like abdomen
• Loss of appetite
III. A. PATIENT’S DATA
• Patient’s name: Lisa
• Age: 15
• Date of Birth: June 15, 2002
• Sex: Female
• Marital Status: Single
• Nationality: Filipino
• Occupation: Student
• Religion: Catholic
• Address: Bamban, Tarlac
B. NURSING HISTORY
CHIEF COMPLAINT
Received patient complaining of sharp abdominal pain with
a scale of 8/10 on the right lower quadrant (RLQ), and mild fever.
PRESENT HISTORY
On Jan 2, 2018, 10 hours prior to admission (3pm), the
patient experienced mild dull pain on her right lower quadrant
abdomen, while eating in the morning, followed by a severe sharp
pain which was at a scale of 8 out of 10. The client tried to
eliminate the pain using herbal oil but was not eradicated.
Because of the persistence of the pain felt by Lisa, her mother
decided to admit her the closest a tertiary hospital.
PAST HISTORY
They used a water pump for drinking and taking a bath.
Her usual diet includes food that are high in protein, junk foods,
soft drinks which she buys at school during recess, also
processed foods. She also prefers meat products in her meal
than leafy vegetables.
She has experienced acute respiratory infections such as
cough, cold and mild fever and usually eliminated these by
taking biogesic (250mg) every 4 hours for fever and some herbal
plants (decoction of lagundi)for cough relief.
Pain in the right lower abdomen was first felt when the
client was 14 years old but were ignored. The patient had no
history of hospitalization.
PHYSICAL EXAMINATION
Upon Admission:
System Result
a. General /overall health -awake, conscious and coherent
-noted facial grimace, and abdominal
status guarding behavior
-(+) Rebound Tendernes, (+) Rovsing sign,
(+) psoas sign
-febrile with a Temp= 37.9°C
-PR= 76bpm
-RR= 20 cpm,
-BP=110/70 mmHg
b. Urinary -urine output of >30 cc/hr
-urine color amber yellow but turbid
-(-) bladder distention
c. Musculoskeletal -full ROM of upper extremities
-impaired mobility due to RLQ pain
vii. Gordon’s Functional Pattern
PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION
“Last year palang po “Sobrang sakit po hndi ako
Health Perception nakaramdam napo ako ng makakilos ng maayos” as
pangingirot sa tiyan dito sa verbalized by the patient
kanan” as verbalized by the
patient
She eats 3 times a day, she She does not have the
Nutritional loves to eat processed food appetite to eat anything.
such as tocino and hotdogs,
Metabolic junk foods and soft drinks,
and foods high in protein.
She urinates 3-5 times a day She has no problems in
Elimination >30ml/hr and defecates urinating and defecating.
once a day every afternoon.
Her daily routine is walking She is unable to move freely
Activity/ Exercise to school, eating street due to the pain in her RLQ
foods outside the school
after, then walking back
home.
Sleep/Rest She usually sleeps Unable to sleep or
around 10 pm then rest because of her
wakes up at 5am. pain in the RLQ.
Cognitive/ Has no problem with Has impaired
Perceptual her senses. attention.
Able to comprehend Unable to
and respond to comprehend and
questions and respond properly to
information questions and
information.
ANATOMY AND PHYSIOLOGY
• The Appendix is a closed-ended, narrow tube up to several inches in length that attaches
to the cecum. It is 9cm long.
• The appendix is usually located in the right iliac region, just below the ileocecal valve
(designated Mc Burney’s point) and can be found at the midpoint of a straight line drawn
from the umbilicus to the right anterior iliac crest located in the lower right quadrant of
the abdomen.
• The inner lining of the appendix produces a small amount of mucus that flows through
the open center of the appendix and into the cecum.
• The wall of the appendix contains lymphatic tissue that is part of the immune system
for making antibodies.
• It helps tell lymphocytes where they need to go to fight an infection and it boosts the
large intestines immunity.
• And it latter helps keep your gastrointestinal tract from getting inflamed in response to
certain food and medication ingested.
PATHOPHYSIOLOGY
LABORATORY STUDIES AND DIAGNOSTICS
HEMATOLOGY
Components Normal values Results Interpretation Clinical Significance

WBC 4.5 – 11x109/L 18.30 x Increased • Presence of inflammation

109/L
Neutrophils 0.45 – 0.73 0.90 Increased • Acute infection, trauma or surgery

Lymphocyte 0.2 – 0.4 0.10 Decreased • Severe stress, malnutrition, or

possible infection
Hematocrit Males: 42 – 52 % 46 % Normal • Balance proportion of blood volume
Females: 35 – 47 % that is occupied by RBC
 URINALYSIS
Components Normal Results Interpretation Clinical Significance
Color Pale yellow to amber Amber Normal • Enough water intake
Transparency Clear to slightly hazy Turbid Not normal • Cystisis, presence of bacteria
Specific gravity 1.015-1.025 1.025 Normal • Properly diluted urine
PH 4.5-8.0 6.0 Normal • Not risk for calcification, and
infection
Glucose Negative Negative Normal • Absence of DM
Albumin Negative Negative Normal • Proper filtration of glumerolus
WBC Negative or rare Negative Normal • No inflammation in the urinary
tract or kidneys
Bacteria Negative Moderate Not normal • No urinary tract infection,

Uric Acid 1.58-4.43 mmol/24 h 3.13 mmol/24 h Normal

• Absence of calculi
DRUG STUDY
Generic Classificati Dosage Mechanism Indication Adverse Nursing Management
Name on and of Action Reaction
frequency

Ampicin Penicillin, 1g every 6 A broad Infections of •CNS: •Observe 11 rights in giving

Ampicillin antibiotic hours spectrum gastrointest convulsive medication.
through semi- inal tract seizures with
•Determine previous
oral route synthetic, and soft higher doses
hypersensitivity reactions to
amino tissues. penicillins, cephalosphorins
penicillin is •GI: and other allergens prior to
highly diarrhea, therapy.
bactericidal nausea and •Inspect skin daily and
even at low vomiting instruct patient to do the
concentratio same. The appearance of
ns, but •Dermatolo rash should be carefully
inactivated gic: rash evaluated.
by •Give medication around
penicillinase. the clock.
 Brand Name Dosage and Mechanism of
Generic Name Classification Frequency Action Indication Adverse Reaction Nursing Management
Zantac
Ranitidine Histamine H2 50mg 1 amp Inhibits the Treatment • CNS: •Observe 11 rights in giving
antagonists IVTT every 8 action of and Confusion, dizziness, medication.
hours histamine at prevention drowsiness, • Assess IV site and give the drug
the H2 receptor of hallucinations, slowly.
site located heartburn, headache • Assess patient for epigastric or
primarily in acid • CV: abdominal pain and frank or occult
gastric parietal indigestion, Arrhythmias blood in the stool, emesis, or gastric
cells, resulting and sour • GI: aspirate.
in inhibition of stomach. Altered taste, black • Inform patient that it may cause
gastric acid tongue, drowsiness or dizziness.
secretion. constipation, dark • Inform patient that increased fluid
stools, diarrhea, and fiber intake may minimize
drug-induced constipation.
hepatitis, nausea • Advise patient to report onset of
• HEMAT: Anemia, black, tarry stools; fever, sore throat;
neutropenia, diarrhea; dizziness; rash; confusion; or
thrombocytopenia hallucinations to health care
• LOCAL: professional promptly.
Pain at IM site • Inform patient that medication may
• MISC: temporarily cause stools and tongue
Hypersensitivity to appear gray black.
reactions, vasculitis
Generic Classification Dosage Mechanism of Indication Adverse Nursing Management
Name and Action Reaction
Frequency

Flagyl Antibacterial, 500mg • Disrupts Acute •CNS: seizures, •Observe 11 rights in giving
Metronid Anti-protozoals every 8 DNA and infection dizziness, medication.
azole hours protein with headache • Administer with food or milk to
through synthesis in susceptible • GI: abdominal minimize GI irritation. Tablets may
oral route susceptible anaerobic pain, anorexia, be crushed for patients with
organisms bacteria. nausea, difficulty swallowing
diarrhea, dry • Instruct patient to take
•Bactericidal, mouth, furry medication exactly as directed
or amebicidal tongue, evenly spaced times between dose,
action glossitis, even if feeling better.
unpleasant •May cause dizziness or light-
taste, vomiting headedness. Caution patient or
•Hematologic: other activities requiring alertness
leukopenia until response to medication is
• Skin: rashes, known.
urticarial • Inform patient that medication
may cause an unpleasant metallic
taste.
• Inform patient that medication
may cause urine to turn dark.
MEDICAL-SURGICAL MANAGEMENT
APPENDECTOMY
Procedure/Date Indication/Analysis Nursing Responsibilites (PRE, INTRA, POST)
Appendectomy – Appendictis Pre:
January 2, 2018 - Reduce the anxiety of the patient and their relatives by orientation of the
environment.
- Check results of lab
- Obtain informed consent
- Monitor VS
- Assess I and O
- Examine level of anxiety
- Teach relaxation techniques
- Bowel preparation
-Light dinner, NPO
-Cleansing enema
- Prophylactic antibiotics
- IV fluids

Intra:
-Appendectomy

Post:
-clear liquids are offered.
-Once those are tolerated, the diet is progressed. Once the patient is eating and
drinking, the IV fluid is removed.
Assist patient during physical activities especially when climbing stairs and not to
strain abdominal muscle.
-Fever and increasing pain at the incision site also should be reported to the
physician.
Equipment  PPE
 Electrocautery
Instruments  Appendectomy Set
Supplies  Routine supplies for appendectomy
Operative Preparation Anesthesia
 Local
Position
 Supine
Prep
 Abdominal Prep
 Placement of Indwelling Foley Catheter/straight
catheter
Draping
 RLQ
Incision
 McBurney/ Lanz Incision
PROCEDURE
• The position of the incision is based upon the location of the McBurney’s
point
• Make the incision with a no. 20 blade; use a electrocautery to incise
through both the superficial and the deep fascia
• Expose the external oblique aponeurosis, incising in the direction of
fibers, and split the external oblique muscle bluntly with alternating Kelly
clamps and army navy retractors
• This blunt muscle spreading, along with appropriate retraction allows
visualization of the transversalis fascia and the peritoneum
• Perform the incision on peritoneum in a craniocaudal direction with
Metzenbaum scissors, allowing access to the peritoneal cavity; once
the cavity is opened, any fluid encountered should be sent for Gram
stain and culture
• Use a series of Babcock surgical clamps to follow them to their
convergence, identifying the base of the appendix. Free the appendix-
mesoappendix complex from its adjacent, often inflamed, tissue, and
deliver it into the wound. The mesoappendix, containing the
appendiceal artery, is then ligated and separated from the appendix
• Completion of appendectomy by dividing appendix between 2
ligatures, closer to cecum
NURSING CARE PLAN
PRE-OPERATIVE:
Problem #1: ACUTE PAIN RELATED TO DISTENTION OF THE INTESTINAL TISSUE BY INFLAMMATION
Problem #2: ANXIETY RELATED TO CHANGE IN HEALTH STATUS
DISCHARGE PLANNING
Medications:
• For pain, one of the Ibuprofen compounds (Advil, Nuprin, etc.) or Tylenol
is suggested. Should these not be effective in managing your
discomfort, notify your physician. Prescription pain medication will be
given on an individual basis.

Exercise:
• Gradually increase activity level to help with your recovery. Start by
doing light activities around your home once you feel able to do so..
• Avoid lifting heavy objects.
• Limit sports and strenuous activities for 1 or 2 weeks.
Treatment:
• Incision Care
• Wear loose-fitting clothes. This will help you be more comfortable and cause less
irritation around your incision.
• Shower as usual.
• Gently wash around your incision with soap and water.
• Don't bathe or soak in a tub or swim in a pool until your incisions are well healed.
• Leave the Steri-Strips (little white strips of tape) in place for 10 days
Health Teaching: Teach the patient and family about the treatment plan including
the need to avoid all alcohol intakes, take medications as prescribe and check with
the physician before taking any new medications. Patient and family teaching
addresses skin and wound care and to watch for and report signs and symptoms of
complications.
Out-Patient Follow-Up Care: Regular consultation to the
physician can be factor for recovery and to assess and
monitor the patient’s condition.

• Diet (after discharge):

• Drink 6 to 8 glasses of water a day, unless directed
otherwise.
• Take a fiber-based laxative, such as Metamucil, if you
are constipated.
• Eat a bland, low-fat diet
THANK YOU