Bethlehem

University

Faculty of Nursing and Health Sciences NURS: 334-335 / Fall 2008

Case study
Pt. Name: M.F.R Age: 27 years Sex: Male. Date: 30/11/2008. Student Name: Mohammad AL-Hwareen Date Admitted: 3/11/2008. Informant: Pt & Pt's file. Room No.: 202

Diagnosis:
Acute Appendicitis.

Chief Compliant:
Sever abdominal pain.

History of Present Illness:

A72 years old male PT with free post medical surgical history was doing ,C\O abdominal pain since a few days .

Past Medical History:

No history of vomiting and fever. No history of any type of medical surgical.

Family History:
No family history of chronic diseases.

Nutritional History:
Pt. had good appetite before appendicitis but he experiences loss of appetite since illness .

Allergies:
No allergies to any type of food or drug as he said .

General Appearance:
Pt. looks clean and tidy, has good posture and balance. Good coordination of movements. Patient's mood is good. Weight: 73 Kg.

Skin:
- Skin is pink in color, with good vascularity, no lesions, no body odor, warm, moist, good turgor, and soft.

Lymphatic System:
Nodes: no enlargement or tenderness of lymphatic nodes.

Head:
The skull is bilateral symmetrical, normal shape and size. Hair is soft, and distributed well. Normal motion of opening and closing the jaw.

Nails:
Nails are pink in color, and soft.

Face:
Face is pink in color, symmetrical, no edema. Facial muscles seem good and coordinative.

Neck:
- Normal range of motion, no pain when extension, hyperextension or flexion. Normal size and no enlargement. - No neck vein distension. - Normal tracheal size and position, no enlargement of thyroid gland.

Eyes:
Normal eye structure. Normal extra ocular movements and react to light. Symmetrical and well distributed eye brows, eyelids, and eyelashes. No edema.

Ears:
- Smooth, symmetrical ear pinna, no pain or edema, no discharge. Ear canal is pink in color, moist. Tympanic membrane is smooth, intact, and gray in color. - Pt. has good hearing acuity.

Nose and Sinuses:

External nose is patence, no nasal deviations. Moist internal nose, pink in color. No tenderness when assessing maxillary and frontal sinuses.

Mouth and Throat:

- Lips are slightly dry. Gum, tongue, hard and soft palate are pink in color, intact, and moist. No lesions or discharge. - No edema or enlargement of uvula. - Pt. do not have decay. - Normal taste sensation.

Chest and Lungs:

Chest color and shape are normal. Normal lung expansion and symmetric movements while breathing.

Heart and Circulatory System:

Heart sounds are normal, normal pulse patterns, pulse rate is 82 beat/min. peripheral.

Abdomen:

Normal skin color. Soft, flat, and symmetrical, but he has RT iliac fossa tenderness.

Genitourinary System:
Normal size, no redness or edema, no discharge, no lesions. Urination patterns normal 3 times a day, no pain with urination, yellow urine color.

Neurological System:
Pt. alert and conscious. Full movement coordination and body balance. Normal reflexes. No history of trauma, and drinking.

Muscular-Skeletal System:
- Muscle: bilateral symmetrical muscles, good strength but the dominant Rt. side is slightly stronger than Lt... No tenderness, atrophy, swelling, pain. - Skeletal: normal contour, symmetrical, no joint diseases, normal extension and flexion

Life Style:
Smoking ,about 10 cigarettes/day. No drug or alcohol addiction. Normal sleep patterns 7 hrs/day.

Laboratory results:*Blood CBC

The CBC is used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood. *Lab Investigation WBC RBC HGB PLT Pt' s value 4.29 K/UL 5.19 15.4 203 Normal value 4.5-13.9 4.3-5.3 14-18 150-400 Comments Infection Normal Normal Normal

*Urine Analysis
The urinalysis is used as a screening and/or diagnostic tool because it can help detect substances or cellular material in the urine associated with different metabolic and kidney disorders. Lab Investigation Specific Gravity PH Glucose Color Pt' s value 1.030 7.31 72 Yellow Normal value 1.002-1.030 7.35 7.45 70 -100 Yellow Comments Normal Acidic Normal Normal

*Clinical chemistry
Lab investigation Comments Sodium Potassium Chloride 139 4.5 104 Pt's value 135-150 3.5-5.5 95-110 Normal value Normal Normal Normal

*Medication:*The pt is not for regular medication.

?What is the appendix

The appendix is a closed-ended, narrow tube up to several inches in length that attaches to the cecum (the first part of the colon). 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, the .wall of the appendix also contains a layer of muscle, but the muscle is poorly developed

?What is appendicitis and what causes appendicitis

Appendicitis means inflammation of the appendix. It is thought that appendicitis begins when the opening from the appendix into the cecum becomes blocked. The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. At other times, the lymphatic tissue in the appendix may swell and block the appendix. After the blockage occurs, bacteria which normally are found within the appendix begin to invade (infect) the wall of the appendix. The body responds to the invasion by mounting an attack on the bacteria, an attack called inflammation. An alternative theory for the cause of appendicitis is an initial rupture of the appendix followed by spread of bacteria outside the appendix.. The cause of such a rupture is unclear, but it may relate to changes (.that occur in the lymphatic tissue, for example, inflammation, that line the wall of the appendix If the inflammation and infection spread through the wall of the appendix, the appendix can rupture. After rupture, infection can spread throughout the abdomen; it usually is confined to a small area .(surrounding the appendix (forming a peri-appendiceal abscess Sometimes, the body is successful in containing ("healing") the appendicitis without surgical treatment if the infection and accompanying inflammation do not spread throughout the abdomen. The inflammation, pain and symptoms may disappear. This is particularly true in elderly patients and when antibiotics are used. The patients then may come to the doctor long after the episode of appendicitis with a lump or a mass in the right lower abdomen that is due to the scarring that occurs .during healing. This lump might raise the suspicion of cancer

?What are the complications 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 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

?What are the symptoms of appendicitis

Appendicitis typically begins with a vague pain in the middle of the abdomen often near the navel or "belly button" (umbilicus). The pain slowly moves to the right lower abdomen (toward the right hip) over the next 24 hours. In the classic description, abdominal pain is accompanied with nausea, vomiting, lack of appetite, and fever. All of these symptoms, however, occur in fewer than half of people who develop appendicitis. More commonly, people with appendicitis have any combination .of these symptoms Symptoms of appendicitis may take 4-48 hours to develop. During this time, someone developing appendicitis may have varying degrees of loss of appetite, vomiting, and abdominal pain. Some may .have constipation, diarrhea Early symptoms are often hard to separate from other conditions including gastroenteritis (an inflammation of the stomach and intestines). Many people admitted to the hospital for suspected appendicitis leave the hospital with a diagnosis of gastroenteritis; true appendicitis is often mis.diagnosed as gastroenteritis initially Children and the elderly often have fewer symptoms, which makes their diagnosis less obvious and .the incidence of complications more frequent

?How is appendicitis diagnosed

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

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. Therefore, a normal urinalysis suggests appendicitis more than a urinary tract .problem

Abdominal X-Ray
An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece of stool that blocks the appendiceal 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

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-appendiceal abscesses 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. The disadvantage of laparoscopy compared .to ultrasound and CT is that it requires a general anesthetic There is no one test that will diagnose appendicitis with certainty. Therefore, the approach to suspected appendicitis may include a period of observation, tests as previously discussed, or surgery

?Why can it be difficult to diagnose appendicitis

It can be difficult to diagnose appendicitis. The position of the appendix in the abdomen may vary. Most of the time the appendix is in the right lower abdomen, but the appendix, like other parts of the intestine, has a mesentery. This mesentery is a sheet-like membrane that attaches the appendix to other structures within the abdomen. If the mesentery is large, it allows the appendix to move around. In addition, the appendix may be longer than normal. The combination of a large mesentery and a long appendix allows the appendix to dip down into the pelvis. It also may allow the appendix to move behind the colon. In either case, inflammation of the appendix may act more like the .inflammation of other organs, for example, a woman's pelvic organs The diagnosis of appendicitis also can be difficult because other inflammatory problems may mimic appendicitis. Therefore, it is common to observe patients with suspected appendicitis for a period of time to see if the problem will resolve on its own or develop characteristics that more strongly .suggest appendicitis or, perhaps, another condition

People With Special Concerns

Patients with special conditions may not have the set of symptoms above and may simply experience a general feeling of being unwell. Patients with these conditions include people who use immunosuppressive therapy such as steroidspeople who have received a transplanted organpeople infected with the HIV viruspeople with diabetespeople who have cancer or who are receiving chemotherapyobese people-

Treatment Surgery
Acute appendicitis is treated by surgery to remove the appendix. The operation may be performed through a standard small incision in the right lower part of the abdomen, or it may be performed using a laparoscope, which requires three to four smaller incisions. If other conditions are suspected in addition to appendicitis, they may be identified using laparoscopy. In some patients, laparoscopy is preferable to open surgery because the incision is smaller, recovery time is quicker, and less pain medication is required. The appendix is almost always removed, even if it is found to be normal. .With complete removal, any later episodes of pain will not be attributed to appendicitis Recovery from appendectomy takes a few weeks. Doctors usually prescribe pain medication and ask patients to limit physical activity. Recovery from laparoscopic appendectomy is generally faster, but

limiting strenuous activity may still be necessary for 4 to 6 weeks after surgery. Most people treated for appendicitis recover excellently and rarely need to make any changes in their diet, exercise, or .lifestyle

Antibiotics and Other Treatments

If the diagnosis is uncertain, people may be watched and sometimes treated with antibiotics. This approach is taken when the doctor suspects that the patient's symptoms may have a nonsurgical or medically treatable cause. If the cause of the pain is infectious, symptoms resolve with intravenous antibiotics and intravenous fluids. In general, however, appendicitis cannot be treated with .antibiotics alone and will require surgery Occasionally the body is able to control an appendiceal perforation by forming an abscess. An abscess occurs when an infection is walled off in one part of the body. The doctor may choose to drain the abscess and leave the drain in the abscess cavity for several weeks. An appendectomy may .be scheduled after the abscess is drained

?How is an appendectomy done

During an appendectomy, an incision two to three inches in length is made through the skin and the layers of the abdominal wall over the area of the appendix. The surgeon enters the abdomen and looks for the appendix which usually is in the right lower abdomen. After examining the area around the appendix to be certain that no additional problem is present, the appendix is removed. This is done by freeing the appendix from its mesenteric attachment to the abdomen and colon, cutting the appendix from the colon, and sewing over the hole in the colon. If an abscess is present, the pus can be drained with drains that pass from the abscess and out through the skin. The abdominal incision .then is closed Newer techniques for removing the appendix involve the use of the laparoscope. The laparoscope is a thin telescope attached to a video camera that allows the surgeon to inspect the inside of the abdomen through a small puncture wound (instead of a larger incision). If appendicitis is found, the appendix can be removed with special instruments that can be passed into the abdomen, just like the laparoscope, through small puncture wounds. The benefits of the laparoscopic technique include less post-operative pain, and a speedier return to normal activities. An additional advantage of laparoscopy is that it allows the surgeon to look inside the abdomen to make a clear diagnosis in .cases in which the diagnosis of appendicitis is in doubt If the appendix is not ruptured (perforated) at the time of surgery, the patient generally is sent home from the hospital after surgery in one or two days. Patients whose appendix has perforated are sicker than patients without perforation, and their hospital stay often is prolonged (four to seven days), particularly if peritonitis has occurred. Intravenous antibiotics are given in the hospital to fight .infection and assist in resolving any abscess Occasionally, the surgeon may find a normal-appearing appendix and no other cause for the patient's problem. In this situation, the surgeon may remove the appendix. The reasoning in these cases is that it is better to remove a normal-appearing appendix than to miss and not treat appropriately an early .or mild case of appendicitis

?What are the complications of appendectomy

The most common complication of appendectomy is infection of the wound, that is, of the surgical incision. Such infections vary in severity from mild, with only redness and perhaps some tenderness over the incision, to moderate, requiring only antibiotics, to severe, requiring antibiotics and surgical treatment. Occasionally, the inflammation and infection of appendicitis are so severe that the surgeon will not close the incision at the end of the surgery because of concern that the wound is already infected. Instead, the surgical closing is postponed for several days to allow the infection to subside with antibiotic therapy and make it less likely for infection to occur within the incision. .Wound infections are less common with laparoscopic surgery Another complication of appendectomy is an abscess, a collection of pus in the area of the appendix. Although abscesses can be drained of their pus surgically, there are also non-surgical techniques, as previously discussed

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-:After surgery
Place the pt in semi fowler position after surgery , to reduce the tension on the incision and-1 .abdominal organs , and to reduce pain .Observe for bleeding-2 .Morphine sulfate is prescribed to relieve pain-3 .The pt who was dehydrated before surgery receives I.V fluid-4

-:Discharge plane
. Teache the pt and his family to care for the incision and perform dressing changes-1 .Monitor the pt for complication and wound healing-2 .Take medications as order-3 .Normal activity can usually be resumed within 2 to 4 weeks-4

Introduction
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I choose this case because it is common between people , and I saw many cases at hospital , so I prepared this presentation to show some information about it specially after I worked with pt who has this disease , also after I saw the surgery . in Bait Jala hospital

Conclusion
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I hope you get the massage and interested in this presentation ,and also I hope I . covered most of the information related to this disease At the end I want to thank all teachers at hospital because they were very nice .with us and they presented all things we were wanted especially T.Fathi .I am sorry for any mistake I made it to any person and I hope he will forgive me

Pt Problems

Nursing Action

Rational

Evaluation

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- Abdominal pain related to appendicitis as manifested by patients statement I feel acute pain when I try to move my self. - Risk for fluid and electrolyte balance related to vomiting as manifested by dry lips and thick mucous. Loss of appetite related to abdominal pain as manifested by general weakness , and as the pt said.

- Place pt in comfortable - To reduce pain . position(supine ), To increase pt Decrease tiring activities. comfort. -Medication as order .

- Pain relived but not completely.

- give pt IV fluids. - Measure blood electrolytes levels. - apply lubricant. -Encourage him to eat with his family. (His mother). -Describe to him the effect of poor eating. -Supply the pt with meals that he likes.

- To prevent dehydration, and to mentain body fluid balance.

- Normal electrolyte level and no vomiting.

-To feel comfort The pt accepted the while he is eating. hospital food , and -To know the risks of gradually feels better. poor eating. -To encourage him to eat, so he can improve his health status.

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Bethlehem

University

Faculty of Nursing and Health Sciences

Case Study

(Appendicitis )

Medical 334 335

INSTR: Fathi AL-Froukh Done by :Mohammad AL-Hwareen

Fall 2008
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