Appendicitis GroupB Case Pres Copy (2)

8/8/2019 Appendicitis GroupB Case Pres Copy (2)

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A Case Presentation of:

Presented by: Group B

Clinical Instructor: Maria Teresa C. Gamo ,RN, MAN

APPENDICITIS


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INTRODUCTION


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OBJECTIVES

To gain knowledge of Appendicitis and be able toidentify the signs, symptoms and its differentialdiagnosis

To outline the diagnostic work up of a client withsuspected appendicitis and subsequent appendectomy

To explain how each can be prevented and/ormanaged

To meet the needs of the client and to promotewellness


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RATIONALE

A knowledge of what to expect helps lessen anxiety andpromote patient cooperation and compliance

Early detection of potential problem with prompt intervention

can prevent serious consequences The patient needs continuous support from the family to cope

with needed change


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SIGNIFICANCE of the CASE

It is the most common cause of intra-abdominal infection

Appendicitis is difficult to diagnose


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Nursing History


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GENERAL DATA

NAME: Mr. Apu

SEX: Male

RELIGION: Roman Catholic

CIVIL STATUS: Single

AGE: 20 y.o.

DATE of ADMISSION: 11th

of October 2010


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CHIEF COMPLAINT

Abdominal pain @ RLQ


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FAMILY HISTORY

(-) DM

(-) hospitalization

(-) HPN (-) blood transfusion


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SOCIAL HISTORY

VICES:

(-) smoker

(+) alcohol beverage drinker- occasional

OCCUPATION:

Military: active duty


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HISTORY of PRESENT ILLNESS

20th of July 2006,

3 hrs. PTC (+) abdominal pain, burning in character,tolerable, radiates to the whole abdomen associated vomiting

5x of the previously ingested food and liquids.

2 hrs. PTC (+) still abdominal pain, this time localized toRLQ, crampy in character, nonradiating, associated

vomiting, persistence prompted consult @ FBGH.


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Physical Assessment


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PHYSICAL EXAMINATION

Conscious, coherent & ambulatory not in CRD

BP: 110/80 mmHg

Wt: 73 kg

Eyes: Anecteric sclera, pink palpebral conjunctiva Skin: Warm, moist good skin tugor

Heart: AP, no murmurs

Abdomen: Flat, soft, bowel sounds: 2/min (+) tender @RLQ

Extremeties: No gross deformities, no cyanosis, no edema


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PHYSICAL EXAMINATION

Baseline V/S

BP: 120/80

RR: 21

T: 36.5

PR: 89

Weight: 55kg.

GCS: 15 upon arrival

Time of Admission: 11:05amDate: 10-11-10

D5LR x 8 (Left hand)


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REVIEW of the SYSTEM

GENERAL: (-) weight gain (-) weakness (-) weight loss(-) easy fatigability (+)fever

HEENT: (-) headache (-) colds (-) dizziness (-)sore throat

RESPIRATORY: (-) cough (-) dyspnea

CARDIOVASCULAR: (-) chest pain

GASTROINTESTINAL: (+) nausea (+)abdominal pain

GENITOURINARY: (-) dysuria

INTEGUMENTARY: (-) cyanosis (-) edema

SKELETAL: no problem

MASCULAR: no problem


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Anatomy and Physiology


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DIGESTIVE TRACT


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RELEVANT ANATOMY


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RELEVANT ANATOMY


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ETIOLOGY

Can be caused by:

Fecalith that occludes the lumen of the appendix

Kinking of the appendix

Swelling of the bowel wall Fibrous conditions in the bowel wall

External occlusion of the bowel by adhesion


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Pathophysiology


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PATHOLOGICAL SEQUENCE

Initiation of inflammation possibly

by fecalith obstruction

Acute inflammation of mucosa

Extension of inflammation

across appendiceal wall

Involvement of serosa

by inflammation

Spread of peritonitis to

adjacent structures

Gangrene of appendix wall

PERFORATION

Attempts at walling off perforation

by omentum and adjacent bowel

Inadequate containment leading

to spreading peritonitis

or

Intense and extensive

walling of production


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CLINICAL

MANIFESTATIONS


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SIGNS and SYMPTOMS of

APPENDICITIS Periumbilical pain

RLQ pain or tenderness

Anorexia

Low grade fever Nausea

Vomiting

Rebound tenderness

RLQ guarding

Constipation or diarrhea

Pain on defecation or urination


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CARDINAL FEATURES of ACUTE

APPENDICITIS Abdominal pain for less than 72 hours

Vomiting 1-3 times

Facial flush Tenderness concentrated on the right iliac fossa

Anterior tenderness on rectal examination

Fever between 37.3 and 38.5C No evidence of urinary tract infection


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COMMON SIGNS of ACUTE

APPENDICITIS McBurneys sign

Psoas sign

Obturator sign Rovsing sign

Dunphys sign

Hip flexion Others..


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MANAGEMENT of SUSPECTED

APPENDICITIS

Right iliac fossa pain

Co

nclus

ive featur

es

of appendicitis inconclusive Othe

r

caus

eapparent

Review periodically

Still inconclusive

urine microscopy, full

blood count, plain X-ray

and serum amylase

APPENDICECTOMY Treat accordingly


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Diagnostic Procedures

AndLab Results


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DIAGNOSTIC PROCEDURES

Hematology

Urinalysis Appendectomy


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HEMATOLOGYNORMAL VALUE

Hemoglobin 172 M: 140-180

Hematocrit 0.52 M: 0.40-0.54

White Blood Cells 15.6 150-450 x 10 9/L

WBC Defferential

Segmenters 0.80 0.35-0.65

Lymphocytes 0.20 0.20-0.40

GRT DIAGNOSTIC CENTER

Date: 10-11-10

HEMATOLOGY


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URINALYSIS

PHYSICAL

EXAMINATIONPTS RESULT REFERENCE VALUE

Color Yellow Clear

Reaction Acidic (6) 4.5-8.0

Specific Gravity 1.030 1.005-1.025

Sugar Neg Neg

Protein Neg Neg


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MICROSCOPIC EXAMINATION

PHYSICAL

EXAMINATION

PTS RESULT REFERENCE VALUE

RBC 0-1 0-1/hpf

Pus cells 0-1 0-2/hpf

Epithelial Few Few present

Bacteria None none


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CBC TESTING

To determine the number of leukocytes & erythrocytes

Includes the RBC count, hemoglobin, red cell indices, WBCcount with/without differential, and platelet count


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RBC TESTS

Erythrocytes (RBC) count- carries hemoglobin.

Hemoglobin (Hgb or Hb) determination- evaluateshemoglobin content of RBC.

Decrease: anemia, Increase: polycythemia Hematocrit (Hct) test- known also as packed red cell

volume test, is often used in place of the RBC count. It

measures the volume of RBCs in whole blood.


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WBC TESTS

WBC count (4500-1100)Helps to detect infection or inflammation.

Neutrophils count (40-75% or 2500-7000)

Essential in preventing or limiting bacterial infection

(avg. life span: 2-4H):>8000 occurs w/ infection, corticosteroids, other

meds,myeloproliferative disease,

Decreased- neutropenia

ANC 180mg/ 100ml).


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ROUTINE ANALYSIS

MEASUREMENT andNORMAL VALUE

INTERPRETATION

Ketones (none) End products of fat metabolism. Presencedue to pts diabetes mellitus is poorlycontrolled experience breakdown of fatty

acids.

Blood (up to 2 RBCs) Increase may be due to damage to glomerulior tubules. Trauma, disease, or surgery ofthe lower urinary tract.

Specific Gravity (1.010-1.025) High SG- reflects concentrated one

Low SG- reflects diluted urine


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MICROSCOPIC EXAMINATION

MEASUREMENT and VALUE INTERPRETATION

WBCs

(O-4 per lower-power field)

Greatest # may indicate UTI

Bacteria (none) Indicates UTI if present

Casts (none) Types of casts includes:

Hyaline,WBCs,RBCs, granular cells, &epithelial cells. Presence is alwaysabnormal finding and indicates renalalterations


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GOALS of MANAGEMENT

Relieving pain

Preventing fluid volume deficit

Reducing anxiety

Eliminating infection Maintaining skin integrity

Attaining optimal nutrition


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TREATMENT: APPENDECTOMY


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PREOPERATIVE


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NURSING MANAGEMENT

Assess:

Pain

Presence of peritonitis

V/S, fluid and electrolyte status Laboratory data


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NURSING MANAGEMENT

NURSING DIAGNOSIS:

Pain, Acute R/T inflammation

PLANNING: EXPECTED OUTCOMES.

The client will understand why pain medication is held preoperatively

IMPLEMENTATION: The client will have pain medication withheld.

Never give enema or laxative, or apply heat


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NURSING MANAGEMENT

NURSING DIAGNOSIS:

Fluid volume deficit, high risk for R/T vomiting


The client will have fluid and electrolyte balance maintained

IMPLEMENTATION:

IV fluids are started to maintain fluid balance

Intake and output should be carefully measured


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NURSING MANAGEMENT

NURSING DIAGNOSIS:

High risk for infection of R/T rupture of appendix


The client will not develop an infection or will have a rupture

diagnosed early

IMPLEMENTATION:

Clients V/S must be checked regularly

Clients pain should be monitored


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PREOPERATIVE

Informed consent

Nurse instructs the client on postoperative exercises

Surgical shave may be performed

Communicates pertinent information to all members of thehealth care team

Place patient in comfortable position to relieve abdominal pain& tension- usually Fowlers position.


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PREOPERATIVE CARE

See that patient takes nothing by mouth Place ice bag to RLQ- NEVER HEAT

Do not administer cathartics

Frequently evaluate V/S When diagnose of acute appendicitis is made, administerchemotherapy &/or antibiotics.


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INTRAOPERATIVE


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INTRAOPERATIVE

Transfer to OR table

Attached to monitors

Induction of spinal anesthesia

Supine position, arms extended to arm board Surgical skin prep done using Betadine 7.5% and 10% soln

Sterile drapes applied aseptically in sequence


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RISK FACTORS and

GENERAL CONSIDERATIONS

Loss of function

Loss of Life

Hemorrhage Infection


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MEDICATION: INTRA-OP

Ampicillin 1 gm. TIV now then 500 mg TID q 8 hr

Metronidazole 500 mg IV now then 5oo mg IV q 8 hr


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APPENDECTOMY


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APPENDECTOMY

Open Appendectomy

Laparoscopic

Appendectomy


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LAPAROSCOPIC

APPENDECTOMY


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LAPAROSCOPIC

APPENDECTOMY


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APPENDECTOMY


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APPENDECTOMY


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APPENDECTOMY


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APPENDECTOMY


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APPENDECTOMY


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APPENDECTOMY


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APPENDECTOMY


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OPEN APPENDECTOMY


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OPEN APPENDECTOMY


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INTRAOPERATIVE

McBurneys incision 2-3 inches in length is made at the RLQ Surgeon enters the abdomen and looks for the appendix After examining the area around the appendix, the appendix is

pulled, ties it off as its based and removes it

Care is taken to avoid spilling pus from the appendix If the appendix has perforated, the pus can be drained with

drains (rubber tubes) and left open and packed with sterilegauze.


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INTRAOPERATIVE

Wash with sterile water Closure of incision done layer by layer

Initial & final counting of sponges, sharps & inst.

Incision is then sutured

Clean operative site clean & apply betadine

Apply and plaster surgical dressing

Transfer to RR per stretcher


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POSTOPERATIVE


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NURSING MANAGEMENT

Monitor V/S, urine output, level of consciousness, and IV Assess respiratory status and surgical wound

May have a drain

Assess the dressing Provide wound care

Reposition the client

Adequately manage the clients pain


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POSTOPERATIVE

Without drainage Following recovery from anesthetic, Fowlers position is

maintained, analgesic is given every 3 prn, & fluids & foodare given as tolerated.

Stitches removed between 5th & 7th day (usually inphysicians office)

With drainage

Treatment same as for peritonitis


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Nursing CareP

lan


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NURSING CARE PLAN

SUBJECTIVE:

Mabuti naman ang pakiramdam ko,medyo nakakain na kongayon. Kaya lang sumasakit pa rin ang inoperahan sakin

as verbalized by the patient.


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NURSING CARE PLAN

OBJECTIVE:

Conscious, coherent, not in CRD

IV contraption attached

Ambulatory Guarding the site of post operation

On DAT


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NURSING CARE PLAN

NURSING DIAGNOSIS: Pain related to S/P appendectomy manifested by guarding the incised part

ANALYSIS and RATIONALE:

Acute painMay contribute to pts abnormal behavior

Risk for volume deficit

May cause dehydration

Risk for Fluid volume deficitRisk for infection on the area of the wound is possible


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NURSING CARE PLAN

NURSING GOAL/S:

To relieve pain and discomforts

To assess potential risk for complications:

To maintain a fluid & electrolyte balance and return of normallevels of body fluids

Prevent infection

Pt will understand & verbalized why pain is controlled

postoperatively


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NURSING CARE PLAN

NURSING INTERVENTION: Assist in placing pt in a semi-Fowler position

Monitor V/S, urine output, level of consciousness

Monitor IV solutions, IV sites and client outcomes hourly

Observe for abdominal tenderness, fever, vomiting, abdominal rigidity &tachycardia

Correct dehydration as prescribed

Administer antibiotic agents as prescribed

Evaluate for anorexia, chills, fever & diaphoresis

Prepare pt for rectal examination

Replace fluids & electrolytes by IV as prescribed


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NURSING CARE PLAN

RATIONALE of NURSING INTERVENTION:

Position reduces the tension on the incision & abdominalorgans

Alleviate pain Sign in evaluating if there is a risk for complication

Medications-relieves pain & restores fluid balance

Prevent dehydration

Prevent peaks/valleys in fluid level

Maintain skin integrity & prevent excessive dryness


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NURSING CARE PLAN

EVALUATION:

Met: not experiencing any pain or tenderness

Fluid balance in normal values

Wound healed Pt understand & verbalized the necessary interventions made

Pt returned to his usual ADL and normal lifestyle


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Drug Study


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DRUG STUDY

GENERIC NAME:

tramadol

ranitidine

metronidazole

DRUG NAMECLASSIFI-

CATION

DOSAGE

AND

ROUTEACTION

INDICA-

TION

SIDE EFFECTS/

ADVERSE EFFECTS

CONTRA-

INDICA-

TION

NURSING

RESPONSIBILITY


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ROUTE TION

GENERIC

NAME:

tramadol

BRAND

NAME:

Ultram,

Ultram ER

narcotic

analgesic,

Tramadol

is a man-

made(synthetic)

analgesic

(pain

reliever)

100mg

IV q8

Its exact mechanism

of action is unknown

but similar morphine.

Like morphine,

tramadol binds toreceptors in the brain

(opioid receptors) that

are important for

transmitting the

sensation of pain from

throughout the body

to. Tramadol, like

other narcotics used

for the treatment ofpain, may be abused.

Tramadol

hydrochlo

ride

tablets are

indicatedfor the

managem

ent of

moderate

to

moderatel

y severe

pain in

adults.

Nausea, vomiting,

constipation,

lightheadedness,

dizziness, drowsiness,

headache, or weaknessmay occur,

mental/mood changes

(such as agitation,

hallucinations),

unusual restlessness,

loss of coordination,

fast heartbeat, severe

dizziness, unexplained

fever, severenausea/vomiting/diarr

hea, twitchy muscles.

slow/shallow

breathing, seizures,

fever/flu-like

symptoms.Avery

serious allergic

reaction to this drug

(which may occur asearly as the first dose)

is rare

Suicidal

patients,

acute

alcoholis

m; headinjuries;

raised

intracrani

al

pressure;

severe

renal

impairme

nt;lactation.

While not nearly as

dangerous a

respiratory

depressant as other

opioids or opiates, athigh doses, this may

be a consideration.

yTramadol is

metabolized in the

liver. Caregivers are

cautioned to

doublecheck for

meds that inhibhit

liver function, orwatch for

adminstration on

hepatic

compromised

patients.

yTramadol lowers

the seizure

threshold. It also

synergizes withSSRI's and

tricyclics, and may

have a stronger

effect on epileptics.

Ergo, seizure

warning.


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DRUG STUDY: Ranitidine

GENERIC NAME:


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DRUG STUDY: metronidazole

GENERIC NAME:


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DRUG STUDY

BRAND NAME:

AMPICILLIN METRONIDAZOLE

Marcillin

Omnipen

Penbritin

Principen

Polycillin

Totacillin

Flagyl

Flagyl ER

Metric 21

MetroCream

MetroGel

MetroGel- vaginal

Metrolotion MetroIV

Metryl

Notritate


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DRUG STUDY

CLASSIFICATION:


Anti-infective

Anti-biotic

Aminopenicillin

Anti-infective agent


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DRUG STUDY

DOSAGE:

AMPICILLIN METRONIDAZOLEAdult/child: IV/IM

40 kg, 1.5-3 g q6h

Child: IV 300

mg/kg/d divided q6h

Adult slow IVinfusion (30-60 mins)of 500 mg before

surgery & 2 IVinfusions of 500 mg 8& 16 hrs later


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DRUG STUDY

MECHANISM of ACTION:


Antibiotic agent with broadspectrum of activity resulting from

beta-lactamase inhibition. Sulbactam inhibits beta-lactamasesmost frequently resp. for transferreddrug resistance. Because of thisaction, a wide range of beta-

lactamases found in organismsresistant to penicillins &cephalosporins are inhibited.

Synthetic compound with directtrichomonacidal & amebicidal activity

as well as antibacterial activity againstanaerobic bacteria & some gram-negative bacteria

G ST


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DRUG STUDY

INDICATION:


Treatment of infections due to

susceptible organisms in skin &skin strucures & intra abdominalinfections & for gynecologicinfections.

Also used for infections caused

by ampicillin- susceptibleorganisms

Treatment of serious infections

caused by susceptible anaerobicbacteria in intra abdominalinfections, skin infections,gynecologic infections, septicemia& for both pre & postoperative

prophylaxis, bacterial vaginosis

DRUG STUDY


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DRUG STUDY

CONTRAINDICATION:

AMPICILLIN METRONIDAZOL

E

Hypersensitivity topenicillins

Hypersensitivity

Hypersensitivity toparabens (topical

only)

DRUG STUDY


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DRUG STUDY

SIDE EFFECTS:


Nausea, vomiting, rashes GI: abdominal pain, nausea,dry mouth, furry tongue,unpleasant taste, vomiting

DERM: burning, milddryness, skin irritation,

transient redness

DRUG STUDY


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DRUG STUDY

NURSING RESPONSIBILTIES:


Instruct to take medicationaround the clock & to finish thedrug completely as directed, even iffeeling better

Advise to report the signs ofsuperinfections & allergy

Instruct to take medicationexactly as directed with evenlyspaced times between doses ordouble up on missed doses.

inform that the medication maycause urine to darken

inform that medication may causeunpleasant metallic taste


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REHABILITATION

Nursing

Management

NURSING MANAGEMENT


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NURSING MANAGEMENT

Monitor physical status for changes Once clients condition stabilizes, nurse focuses efforts on returning

the client to a functional level of wellness asap within the limitation

Speed of a clients recovery depends on how effectively the nurse

can anticipate potential complications, initiate necessary supportiveand preventive therapies, and actively involve client and family inthe recovery process

REHABILITATION


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REHABILITATION

In the hospital: After the procedure, pt will be taken to the recovery room for

observation

Recovery process will vary depending upon the type of procedure

performed and the type of anesthesia given Once V/S stable and pt alert, he will be taken to the hospital room

As a laparoscopy procedure may be performed on an outpatientbasis, he may be discharge home from the recovery room

May receive pain medication as needed, either by the nurse or byadministering it by himself through a device connected to his IV line

REHABILITATION


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REHABILITATION

May have a thin plastic tube inserted through the nose into yourstomach to remove air that you swallow. It will be removedwhen bowel resumes normal function. Not be able to eat ordrink until the tube is removed

Will be encouraged to get out of bed within a few hours after alaparoscopy or by the next day after an open procedure

Depending on the situation, may be given liquids to drink a few

hours after surgery. Diet may be gradually advanced to moresolid foods as tolerated

REHABILITATION


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REHABILITATION

At home: Important to keep the incision clean and dry. The physician will give

specific bathing instructions If stitches or surgical staples are used, they will be removed during a

follow-up visit. If adhesive strips, they should be kept dry and will fall off

within a few days Incision and the abdominal muscles may ache, especially after long periodsof standing. Take pain reliever for soreness as recommended by thephysician. Aspirin or other pain medications mat increase the chance ofbleeding


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RECOMMENDATIONS

RECOMMENDATION


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RECOMMENDATION

Incisions sites will be tender. Take pain medication as directed Make take shower two days after surgery May experience bloating or constipation. Resume a healthy, high fiber

diet Lift objects that are easy to handle. Use legs to handle most of the work.

Avoid strenuous activity Walking and stair climbing are good to improve circulation Avoid driving for seven days after surgery and when taking pain

medication

RECOMMENDATION


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RECOMMENDATION

Assume sexual intercourse as soon as you feel comfortable and havediscussed this with your surgeon

Call and schedule a follow-up appointment within one or two weeks aftersurgery. Schedule any additional follow-up appointments

Have any stitches removed depending upon the type your physicians uses

Health teaching regarding the signs and symptoms of appendicitis


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Health

Teach

ing


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Evaluation

Submitted by: GROUP B


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Submitted by: GROUP B

Gabasa, Kristine Charm

Guevara, Rina

Gultom, Yulien

Henson, Aileen Jean Humarang, Felipa May

Javier, Monique Anne

Manlangit, Jose Paulo Manzo, Michelle Joy

Martinez, Joan

Navarra, Adrian

Neri, Reve Angelie

Okorie, Ugo Salva, Sarah

Sasarari, Zusana

Xu, Wei Yi Fajardo, Ronaldo

Thank


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Thank

You for

Listening!

Documents

Appendicitis GroupB Case Pres Copy (2)