Transcript Slide 1

Demographic Data:
Name
Age
Sex
Nationality
Date of Admission
Complaints
Diagnosis
: Patient Xs
: 22 Years old
:Male
: Yemeni
: April 27, 2013
: fever, abdominal pain,
vomiting
: Acute appendicitis
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
Heart rate
Respiration
Blood pressure
Spo2
:
: 3 8. °c
: 74 bpm
: 22 bpm
:
100/ 80 mmHg
97 % in room air
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
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
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
history .
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.
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.
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.
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.
4.THE DESCENDING COLON:
This passes down the left side of the abdominal cavity then curves towards
the midline. After it enters the true pelvis it is known as the sigmoid colon.
. 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.
The vermiform appendix or appendix:
Sits at the junction of the small intestine and
large intestine. It’s 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.
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 Burney’s 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.
Mc Burney’s 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)
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.
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.
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.
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
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.
DIAGNOSTIC EVALUATIONS
Medical examination:
Auscultate for presence of bowel sounds; peristalsis may be
absent or diminished.
Positive signs of appendicitis :
Mc Burney’s , 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.
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).
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.
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.
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.
 Limitation of the movement of a loop of bowel which may twist around the adhesion ,
causing a type of bowel obstruction called volvulus
PRIORITIZATION OF NURSING PROBLEMS
Acute pain related to inflamed appendix
 Hyperthermia related to the inflammatory process
 Risk for infection related to perforation.

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
drainage post operately.
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.
BIBLIOGRAPHY:

LIPPINCOT MANUAL OF NURSING PRACTISE NINTH
EDITION.

ROSS AND WILSON

WWW.NURSESLABS . COM

WWW. WIKIPEDIA .COM
NURSING CARE PLAN
ASSESSMENT
Subjective:
“I have
abdominal
pain”
Objective:
Pain
score:
8/10
NURSING
DIAGNOSIS
PLANNING
INTERVENTIO
N
RATIONALE
EVALUATION
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.
NURSING CARE PLAN
ASSESSMENT
Subjective :
Increased
body
temperature
@38.8°c
Objective :
skin is warm
to touch
NUSING
DIAGNOSIS
Hyperthermia
related to the
inflammatory
process
PLANNING
After 3 hrs of
nursing
intervention
patient
temperature
will decrease
to normal limit
INTERVENTIO
N
RATIONALE
EVALUATION
-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
THANK
YOU