Appendectomy (A Case Study)

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TABLE OF CONTENTS: I. INTRODUCTION.3 a. Current trends about the disease condition..4 b. Reasons or choosin! such case or "resentation..# II. NURSIN$ ASS%SS&%NT...' a. (ersona) *istory...' b. (ertinent +a,i)y *ea)th-I))ness *istory.. c. *istory o (ast I))ness../ d. *istory o (resent I))ness..../ e. (hysica) %0a,ination ..1 f. Dia!nostic and 2aboratory (rocedures..34 III. ANATO&5 and (*5SIO2O$5(6ith 7isua) aids)....34

IV. T*% (ATI%NT8S I22N%SS..3/ a. Synthesis o the disease......3/ a1. De inition o the disease....3/ b2. (redis"osin! 9 (reci"itatin! actors....3/ c . Si!ns and sy,"to,s 6ith rationa)e 31 d!. *ea)th "ro,otion and "re7enti7e As"ects o the Disease ....4: V. T*% (ATI%NT AND *IS CAR%43 a. &edica) &ana!e,ent. 43 a. I;+8s< =T< N$T eedin!< Nebu)i>ation< T(N< O0y!en thera"y< ...43 b. Dru!s.....43 c. Diet.4# d. Acti7ity 9 %0ercise....4' b. Sur!ica) &ana!e,ent (actua) SO(I%Rs).4. c. Nursin! &an!e,ent..4/ a. Nursin! Care ()an.4/ b. Actua) SOA(I%S ..41 VI. C2I%NTS DAI25 (RO$R%SS IN T*% *OS(ITA2.....33 a. C)ient8s dai)y (ro!ress Chart...33 b. Dischar!e ()annin!..33 a. $enera) Condition o C)ient u"on Dischar!e....33 b. &%T*OD....33 VII. CONC2USION and R%CO&&%NDATIONS..34

I. Int"oduction
The a""endi0 is a c)osed-ended< narro6 tube that attaches to the cecu, (the irst "art o the co)on) )i?e a 6or,. (The anato,ica) na,e or the a""endi0< 7er,i or, a""endi0< ,eans 6or,-)i?e a""enda!e.) The inner )inin! o the a""endi0 "roduces a s,a)) a,ount o ,ucus that )o6s throu!h the a""endi0 and into the cecu,. The 6a)) o the a""endi0 contains )y,"hatic tissue that is "art o the i,,une syste, or ,a?in! antibodies. 2i?e the rest o the co)on< the 6a)) o the a""endi0 a)so contains a )ayer o ,usc)e. A""endicitis is in )a,,ation o the a""endi0. It is thou!ht that a""endicitis be!ins

6hen the o"enin! ro, the a""endi0 into the cecu, beco,es b)oc?ed. The b)oc?a!e ,ay be due to a bui)d-u" o thic? ,ucus 6ithin the a""endi0 or to stoo) that enters the a""endi0 ro, the cecu,. The ,ucus or stoo) hardens< beco,es roc?-)i?e< and b)oc?s the o"enin!. This roc? is ca))ed a eca)ith ()itera))y< a roc? o stoo)). At other ti,es< the )y,"hatic tissue in the a""endi0 ,ay s6e)) and b)oc? the a""endi0. =acteria 6hich nor,a))y are ound 6ithin the a""endi0 then be!in to in7ade (in ect) the 6a)) o the a""endi0. The body res"onds to the in7asion by ,ountin! an attac? on the bacteria< an attac? ca))ed in )a,,ation. (An a)ternati7e theory or the cause o a""endicitis is an initia) ru"ture o the a""endi0 o))o6ed by s"read o bacteria outside the a""endi0.. The cause o such a ru"ture is unc)ear< but it ,ay re)ate to chan!es that occur in the )y,"hatic tissue that )ine the 6a)) o the a""endi0.) I the in )a,,ation and in ection s"read throu!h the 6a)) o the a""endi0< the a""endi0 can ru"ture. A ter ru"ture< in ection can s"read throu!hout the abdo,en@ ho6e7er< it usua))y is con ined to a s,a)) area surroundin! the a""endi0 ( or,in! a "eria""endicea) abscess). The treat,ent or a""endicitis is antibiotics and sur!ica) re,o7a) o the
a""endi0 (a""endecto,y). A""endecto,y is the re,o7a) by sur!ery o the a""endi0< the s,a)) 6or,-)i?e a""enda!e o the co)on (the )ar!e bo6e)). An a""endecto,y is "er or,ed because o "robab)e a""endicitis.

Acute a""endicitis is the ,ost co,,on cause in the USA o an attac? o se7ere< acute abdo,ina) "ain that reAuires abdo,ina) o"eration.

The incidence o acute a""endicitis is around .B o the "o"u)ation in the United States and in %uro"ean countries. In Asian and A rican countries< the incidence is "robab)y )o6er because o the dietary habits o the inhabitants o these !eo!ra"hic areas. A""endicitis can e ect any at any a!e< 6ith hi!hest incidence occurrin! durin! the second and third decades o )i e. Rare cases o neonata) and "renata) a""endicitis ha7ebeenre"orted. A""endicitis occurs ,ore reAuent)y in ,en than in 6o,en< 6ith a ,a)e-to- e,a)e ratio o 3..C3.

A. Cu""ent T"end# about Appendiciti#

Ca"e p"otoco$# "educe appendectomy comp$ication# % Tip# f"om Ot&e" 'ou"na$# 3

A""endecto,y is the ourth ,ost co,,on abdo,ina) sur!ery "er or,ed in the United States. U" to 3/ "ercent o "atients ha7e "osto"erati7e in ectious co,")ications ran!in! in si!ni icance ro, 6ound in ection to intra-abdo,ina) abscess. The rate o in ections de"ends on the de!ree o conta,ination durin! sur!ery and reaches near)y one third o cases 6hen the a""endi0 is "er orated or !an!renous. *e),er and co))ea!ues studied the e ect o an e7idence-based c)inica) "ractice !uide)ine in reducin! in ectious co,")ications o a""endecto,y. The c)inica) "ractice "rotoco) that 6as de7e)o"ed ro, a critica) re7ie6 o the )iterature (see acco,"anyin! i!ure) 6as a"")ied to 4:' "atients 6ith a "resu,"ti7e dia!nosis o a""endicitis 6ho "resented to a Te0as county hos"ita) durin! 3111. Outco,es in this cohort o "atients 6ere co,"ared 6ith those in 434 "atients treated or the sa,e condition at the hos"ita) durin! the "re7ious year. No "atients 6ere e0c)uded ro, the study. Data 6ere !athered on de,o!ra"hic and sur!ica) eatures< co,orbidities< use o antibiotics< e7idence o in ection< and other co,")ications durin! the hos"ita) stay. %i!ht "atients (4 "ercent) 6ho 6ere treated accordin! to the "rotoco) had "osto"erati7e sur!ica) in ections< co,"ared 6ith 4: "atients (1 "ercent) in the co,"arison !rou". The nu,ber o "atients 6ith intra-abdo,ina) abscesses dro""ed ro, 34 to i7e a ter introduction o the "rotoco)< and the nu,ber o 6ound in ections dro""ed ro, 34 to our. The i,"ro7e,ent 6as "articu)ar)y si!ni icant in "atients "resentin! 6ith a "er orated or !an!renous a""endi0. In these "atients< the tota) nu,ber o in ections dro""ed ro, 3' (33 "ercent) to i7e (33 "ercent). The authors conc)ude that use o an e7idence-based c)inica) "ractice !uide)ine can si!ni icant)y reduce sur!ica))y re)ated in ections o))o6in! a""endecto,y and is "articu)ar)y e ecti7e in "atients 6ith "er oration or !an!rene o the a""endi0.

B. (ea#on# fo" c&oo#in) #uc& ca#e

One o the or,idab)e "art in doin! a case study is choosin! 6hat case is to "resent. De had this unani,ous decision o choosin! $ir) A!nes8 case< irst and ore,ost because 6ith our initia) contact 6e a)ready estab)ished hor,onious re)ationshi" 6ith the "atient and her si!ni icant others. De had estab)ished the EtrustF 6e yearn ro,

the, and that ,a?es it easy or us to as? certain Auestions 6e need or our case and interact 6ith the, "ro"er)y. Another thin! is because 6e ind the, ?ind and hu,orous that is 6hy our "re7ious interaction 6ith the, is s,ooth and con7entiona). &ost i,"ortant)y< the ter, A""endicitis is not accusto,ed to us that ,uch. Dith that thou!ht a)one< 6e 6ant to urther enhance our ?no6)ed!e about the disease such as to ensure a""ro"riate e7a)uation o the etio)o!y< reassess and address the course the i))ness ta?es in its "ro!ression. A)so< to ha7e an e0"erience in hand)in! and "ro7idin! hu,anitarian hea)th ser7ices to a "atient 6ho has it and "ro7ide any inter7ention or treat,ent indicated based on the s"eci ic etio)o!y and the course it o))o6s in that s"eci ic "atient. Dith that scenario< it is not on)y the ?no6)ed!e that 6as enhanced but a)so our s?i))s as hea)th care "ractitioners.

II. Nu"#in) A##e##ment

A. *e"#ona$ +i#to"y
(atient G '# years o)d< e,a)e< current)y residin! at 3.' Do)ores< &a!a)an! (a"an!a. A ty"ica) +i)i"ina and "resent)y a "art o the Ro,an Catho)ic. She 6as born on Hanuary 3< 3131. She is ,arried 6ith ei!ht chi)dren< 6here so,e are ,arried. Current)y< she is Iust stayin! at ho,e and she is de"endent to his chi)dren or su""ort. So,eti,es she ta?es care o her !randchi)dren at ho,e. She a)so coo?s ood or the, and c)ean the house. Since he has this ?ind o )i esty)e< and because o his a!e< )ast +ebruary 4/< 4:34 she ,ani ested sy,"to,s o a""endicitis 6hich 6as the reason 6hy she 6as rushed to J&C.

B. *e"tinent Fami$y +ea$t&%I$$ne## +i#to"y

Ba Family

Jewel
o o o Mother Alcoholic Died of Tuberculosis o o o

Palace
Father Alcoholic Died of a ruptured appendicitis

Prince Stephen o husband

Princess Lulu
o o Patient Dignosed with appendicitis

Bu
!3 !Married !wor"ing

La !32
!single !#onstruction wor"er

Ba
!2$ !%arried !housewife

Jel
!2 !%arried construction wor"er

Tah
!15 !single !not going to school

Mah
-1 !single !college student

Ad !22
!single !&endor

Bon !24
!%arried !&endor

Li,in) Condition +ou#e: They )i7e in a bun!a)o6 ty"e o house< concrete and so,e o the ,arried ,e,bers o the a,i)y resides Food: Their ood is a)6ays a usua) +i)i"ino dish consistin! o rice< ish< ,eat and 7e!etab)es. Their source o 6ater is the "u,". Economic Statu#: (rincess 2u)u is not 6or?in!@ she is de"endent on his chi)dren or su""ort. *er dau!hter< to)d us that 3#:-4:: "esos a day is enou!h or the, to satis y the day. Be$ief#:

The =A +a,i)y be)ie7es in Eherbo)ariosF

and

Ehi)otsF

and

direct)y

see?

ad7ices ro, the, i any sic?ness occurred. They se)do, brin! ,e,bers o the a,i)y to doctors or to the hos"ita) or consu)tation or treat,ent o any disease.

C. +i#to"y of *a#t I$$ne##

She has a)6ays been hea)thy e7er since he 6as a ?id and he 6as ne7er been brou!ht to the hos"ita). She had nor,a) =)ood "ressure< 6ith no si!ns o hy"ertension< Diabetes &e))itus or e7en Tubercu)osis. Aside ro, e7er< co)ds and cou!h< nothin! hinders hi, ro, doin! his dai)y acti7ities.

-. +i#to"y of p"e#ent I$$ne##

It 6as +ebruary 4/< 4:34< . in the e7enin! 6hen she started to ee) so,e "ain in the abdo,ina) area< acco,"anied by e7er@ she 6as chi))in! and e)t nauseated and 7o,ited se7era) ti,es. At 33 ", o the sa,e ni!ht< she 6as sti)) e0"eriencin! the sa,e but the "ain is 6orsen. %ar)y in the &ornin!< they rushed hi, to the J&C. Dr. G assessed her and dia!nosed it as acute a""endicitis because o (K) ,usc)e !uardin!< (K)direct and rebound tenderness on the ri!ht )o6er Auadrant. The "atient 6as a)so assessed or (soas si!n and Obturator si!n and 6as ound out that the "atient 6as in "ain durin! the assess,ent hence he 6as ad,itted ri!ht a6ay and had an e,er!ency a""endecto,y.

E. *&y#ica$ E.amination
/a"c& 011 2012 =(L33: 9 1: TL 3..4M C S2IN a .$enera)C dar? bro6n in co)or@ dry s?in@ absence o ede,a@ 6hen "inched s?in s"rin!s bac? to "re7ious state< "oor tur!or RRL 4: b," (RL/4 b",

NAILS a. $enera)C con7erse cur7ature@ s,ooth te0ture@ )on! 6ith dirt@ "ro," return o "in? or usua) co)or +AI( a. e7en)y distributed@ thic? hair@ dry@ b)ac? in co)or +EA- AN- FACE a. sca)"C no e7idence o )a?in! or dandru b. s?u))C rounded@ s,ooth s?u)) contour@ absence o nodu)es or ,asses c. E3ES a. !enera)C sy,,etrica))y a)i!ned b. eyebro6sC sy,,etrica))y a)i!ned eAua) ,o7e,ent@ hair e7en)y distributed c. eye)ashesC eAua))y distributed cur)ed s)i!ht)y out6ard d. eye)idsC s?in intact@ no dischar!e@ no disco)oration@ in7o)untary b)in?s e. sc)eraC 6hitish 6ith ca"i))aries . conIuncti7aC shiny@ s,ooth !. "u"i)sC b)ac? in co)or@ eAua) si>e@ K (%RR2A@ round< s,ooth border h. 7isionC ab)e to read ne6s"rint@ sensiti7ity to )i!ht EA(S a. !enera)C ,obi)e@ ir,@ no tenderness@ "inna recoi)s a ter it is o)ded@ no in ection b. e0terna) ear cana)C "resence o hair o))ic)es@ "resence dischar!e NOSE a. e0terna)C sy,,etric and strai!ht@ not tender@ air ,o7es ree)y as the c)ient breaths b. interna)C "resence o hair /O4T+ AN- O(O*+A(3N5 a. )i"sC uni or, "in? co)or@ dry@ abi)ity to "ursue )i"s b. teethC ,issin! teeth due to ca7ities@ disco)oration o ena,e) c. ton!ueC no )esions@ 6ith thin 6hitish coatin!@ ab)e to ro)) the ton!ue u"6ard and side to side d. "a)ates and u7u)aC )i!ht "in?@ "ositioned in the ,idd)e o so t "a)ate e. tonsi)sC "in?@ no s6e))in! aceC "a)"abra) issures eAua) si>e

'

NEC2 a. ,usc)esC eAua) in si>e@ head centered@ eAua) stren!th b. ,o7e,entC coordinated s,ooth ,o7e,ents 6ithout disco, ort c .)y,"h nodesC not "a)"ab)e d.thyroid !)andC not 7isib)e C+EST a. e0terna)C sy,,etric@ s"ina) co)u,n is strai!ht@ s?in intact@ chest 6a)) intact@ no tenderness@ u)) sy,,etrica) chest e0"ansion b. )un!sC nor,a) breath sounds@ absence o DO= CA(-IOVASC4LA( a. heartC absence o heart sounds@ nor,a) beatin! "attern

AB-O/INAL a. !enera)C 6ith direct and rebound tenderness on the ri!ht )o6er Auadrant@ 6ith indirect tenderness@ /4SC4LOS2ELETAL a. !enera)C eAua) si>e on both sides o the body@ no contractures@ no tre,ors@ nor,a))y ir,@ no de or,ities C"ania$ Ne",e# I. O) actoryN ha7e the sense o s,e)) II. O"tic N nor,a) 7isua) acuity III. Ocu)o,otorN "ositi7e "a"i))ary re )e0 and eye con7er!ence test I; Troch)earN "ositi7e "a"i))ary re )e0 and eye con7er!ence test ;. Tri!e,ina) N can sense the sensation o "ain< touch< te,"erature and nor,a) ,usc)e stren!th. ;I. AbducensN "ositi7e "a"i))ary re )e0 and eye con7er!ence test ;II.+acia) N nor,a) ,usc)e stren!th o acia) e0"ressions ;III. ;estibu)ococh)earN nor,a) 7oice tones audib)e@ ab)e to hear tic?in! on the both ears. IG. $)osso"haryn!ea)N (K) !a! re )e0@ can s6a))o6 G. ;a!usN (K) !a! re )e0 GI. AccessoryN nor,a) ,usc)e stren!th GII. *y"o!)ossa) N nor,a) ton!ue ,o7e,ents

1(

F. -ia)no#tic and Labo"ato"y *"ocedu"e#

-ia)no#i#6 Lab p"ocedu"e

-ate o"de"ed -ate "e#u$t

Indication o" pu"po#e - to deter,ine urine co,"osition such as b)ood< !)ucose< "rotein

"e#u$t 5e))o6< c)ear Su!arC ( - ) (hC acidic S". $ra7ityC 3.:3: (us ce))sC :-3 *(+ R=CC 3-4 *(+

no"ma$ ,a$ue 5e))o6< c)ear Su!arC ( - ) (hC acidic S". $ra7ityC 3.::3-3.:3: (us ce))sC K3: *(+ R=CC :-3 *(+

OC :3-:3-34 Urina)ysis RC :3-:3-34

Ana$y#i# 7 inte"p"etati on of "e#u$t The ,icrosco"ic ana)ysis sho6s nor,a) )e7e)s.

Nu"#in) (e#pon#ibi$itie#: %0")ain the "rocedure and the "ur"ose to the c)ient. %0")ain to the c)ient the i,"ortance o the "rocedure %0")ain to the c)ient that urine sa,")e is needed

11

As? the c)ient i he9she had eaten< it can a)ter the resu)t As? the c)ient 6hat are the ,edication that he9she had ta?en. I there is in ection< te)) the "atient that the test 6i)) be re"eated to ,onitor any de7e)o",ent.

-ia)no#i#6 Lab p"ocedu"e

-ate o"de"ed -ate "e#u$t in

Indication o" pu"po#e

"e#u$t

No"ma$ ,a$ue

Ana$y#i# 7 inte"p"etati on of t&e "e#u$t Dhite b)ood ce)) is abo7e the nor,a) ran!e< there is syste,ic in ection. 2eu?ocytosi s indicates a""endicitis.

OC :3-:3-34 *e,ato)o!ic test RC :3-:3-34

-to indicate ane,ia and "o)ycythe,i a

*!bC 3.#:

D=CC 34.' *ctC :.4#

R=CC #.4#

*!bC &C 34:-3/: !,92 +C 34:-3': !,92 D=CC #.3: 0 3:92 *ctC &C :.4:-:.#4 292 +C :.3.-:.4. 292 R=CC &C 4.#-'.3 0 3:92 +C 4.4-#.4 0 3:92

12

-ia)no#i#6 Lab p"ocedu"e

-ate o"de"ed -ate "e#u$t in

Indication o" pu"po#e

"e#u$t

No"ma$ ,a$ue

Ana$y#i# 7 inte"p"etati on of t&e "e#u$t A decrease in he,o!)obin indicates ane,ia. Dhite b)ood ce)) is abo7e the nor,a) ran!e< there is syste,ic in ection. 2eu?ocytosi s indicates a""endicitis.

OC :3-:3-34 *e,ato)o!ic test RC :3-:3-34

-to indicate ane,ia and "o)ycythe,i a

*!bC 331

D=CC 34.4 *ctC :.43

R=CC #.4#

*!bC &C 34:-3/: !,92 +C 34:-3': !,92 D=CC #.3: 0 3:92 *ctC &C :.4:-:.#4 292 +C :.3.-:.4. 292 R=CC &C 4.#-'.3 0 3:92 +C 4.4-#.4 0 3:92

Nu"#in) (e#pon#ibi$itie#C %0")ain the "rocedure and the "ur"ose to the "atient. %0")ain to the "atient that it reAuires b)ood sa,")e and it can cause "ain and disco, ort due to the need)e "uncture. As? the "atient i he9she had eaten ood because it can a)ter the resu)t. As? the "atient i he9she had ta?en so,e dru!s because it can a)ter the resu)t. As? or the re)i!ion and cu)ture o the "atient.

III. Anatomy and *&y#io$o)y

In a nor,a) hu,an e,a)e< the $I tract is a""ro0i,ate)y 4# eet or . and a ha) ,eters )on! and consists o the o))o6in! co,"onents /out& (Ora) ca7ity9 =uca) Ca7ity< inc)udes ton!ue< teeth< sa)i7ary !)ands and ,ucosa) The ,outh is the irst o the di!esti7e tract. It is the o"enin! throu!h

13

6hich ta?es in ood. It is )ined by strati ied sAua,ous non-corni ied e"ithe)iu,< e0ce"t the hard "a)ate< !in!i7a) and i)i or, "a"i))ae o ton!ue 6hich are corni ied. It is bound in ront by the )i"s< abo7e by the hard and so t "a)ate< be)o6 by the )oor o the ,outh inc)udin! the ton!ue and behind by the aucia) isth,us. *&a"yn. The "haryn0 is the "art o the di!esti7e syste, 6hich connects the ,outh 6ith eso"ha!us. It is 6here the di!esti7e tract and the res"iratory tract cross< co,,on)y ca))ed the t&"oat. The hu,an "haryn0 is bent at a shar"er an!)e. E#op&a)u# 89u$$et6 Oe#op&a)u#: The eso"ha!us is a ,uscu)ar tube< )ined 6ith ,oist strati ied sAua,ous e"ithe)iu, that e0tends ro, the "haryn0 to the sto,ach. It is about 4# c,s. 2on! and )ies anterior to the 7ertebrae and "osterior to the trachea 6ithin the ,ediastinu,. It "asses throu!h the dia"hra!, and ends at the sto,ach. It trans"orts ood ro, the "haryn0 to the sto,ach. Stomac& The sto,ach is an en)ar!ed se!,ent o the di!esti7e tract in the )e t su"erior "art o the abdo,en. It is an a)i,entary cana) used to strore and di!est ood. It8s "ri,ary unction is as a stora!e and ,i0in! cha,ber or in!ested ood. It is )ined 6ith si,")e co)u,nar e"ithe)iu,. 2atin na,es or the sto,ach inc)ude ;entricu)us and $asti< ,any ,edica) ter,s re)ated to the sto,ach "art in E!astroF or E!astricF. In hu,ans the sto,ach is a hi!h)y acidic en7iron,ent (,aintained by the hydroch)oric acid secretion) 6it "e"tidase di!esti7e en>y,es.

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In ru,inants< the sto,ach is a )ar!e ,u)ticha,bered or!an that hosts sy,biotic bacteria 6hich "roduced en>y,es reAuired or the di!estion o ce))u)ose ro, ")ant ,atter. The "artia))y di!esti7e ")ant ,atter "asses throu!h each o the sto,ach8s cha,bers in seAuence< bein! re!ur!itated and reche6ed at )east once in the "rocess. Bo;e$6Inte#tine Sma$$ Inte#tine S,a)) intestine is the "ortion o the a)i,entary tract bet6een the sto,ach and the )ar!e intestines 6hose ,ain unction is or absor"tion. It is about ' ,eters )on! and consists o 3 "artsC duodenu,@ IeIunu, and i)eu,. -uodenum Duodenu, is a ho))o6 Iointed tube that connects the sto,ach to the IeIunu,< it is the shortest< the 6idest and ,ost i0ed "art o the s,a)) intestine and is )ar!e)y retro-"eritonea) c)ose)y attached to the dorsa) 6a)). 'e<unum HeIunu, is about 4.# ,eters )on! and ,a?es u" 49# o the tota) )en!th o the s,a)) intestine. I$eum The i)eu, Ioins 6ith the cecu, at i)eoca) Iunction. It is about 3.# ,eters )on! and it ,a?es u" 39# o the s,a)) intestine. La")e Inte#tine The )ar!e intestine e0tends ro, the i)eoca) Iunction u" to the ana) o"enin! in the "eritoneu,. It is about #-' eet )on!. It is subdi7ided intoC cecu, and a""endi0< co)on< rectu, and ana) cana). Cecum and Appendi.

15

Cecu, is the "ro0i,a) end o the )ar!e intestine and is 6here the )ar!e and the s,a)) intestine ,eet at the i)eoca) Iunction. It is )ocated in the ri!ht )o6er Auadrant o the abdo,en near the i)iac ossa. It is a sac that e0tends in erior)y about ' c,s. "ast i)eoca) Iunction. Attached to the cecu, is a tube about 1 c,s. )on! ca))ed the A((%NDIG. Co$on

The co)on is about 3.#-3./ ,eters )on! and consists o our "artsC Ascendin! co)on Trans7erse co)on Descendin! co)on and si!,oid co)on A#cendin) Co$on

The ascendin! co)on e0tends su"erior)y ro, the cecu, to the ri!ht co)ic )e0ure near the )i7er< 6here it turns )e t T"an#,e"#e Co$on The trans7erse co)on e0tends ro, the ri!ht co)ic )e0ure to the )e t co)ic )e0ure near the s")een< 6here the co)on turns in erior)y. -e#cendin) Co$on and Si)moid Co$on

The descendin! co)on e0tends ro, the )e t co)ic )e0ure to the "e)7is< 6here it beco,es the SI$&OID CO2ON. The si!,oid co)on or,s an S-sha"ed tube that e0tends ,edica))y and the in erior)y into the "e)7ic ca7ity and ends at the rectu,. (ectum The rectu, is a strai!ht ,uscu)ar tube that be!ins at the ter,ination o the si!,oid co)on and ends at the ana) cana). Ana$ Cana$ The ana) cana) re"resents the ter,ina) "ortion o the )ar!e intestines and it is about 4-3 c,s. )on!

16

IV. T&e *atient=# I$$ne##e#

A. Synt&e#i# of t&e -i#ea#e

a1. -efinition of t&e -i#ea#e

A""endicitis is the in )a,,ation o the 7er,i or, a""endi0< 6hich is attached to the cecu, and )ies in the ri!ht )o6er Auadrant< the a""endi0 can )ie ,edia)< )atera)< anterior or "osterior to the cecu,< it is behind the bo6e) or ,esentery or in the "e)7is. The a7era!e adu)t a""endi0 is 1-3: c, in )en!th 6ith a dia,eter o :.# to 3 c,. Its b)ood su"")y< the a""endicea) artery< is a ter,ina) branch o the i)eoco)ic artery 6hich trans7erses the )en!th o the a""endi0. This s,a)) in!er sha"ed tube branches o the )ar!e intestine. There is no s"eci ic cause o a""endicitis< a)thou!h in )a,,ation can occur s"ontaneous)y

ro, an in ection or ro, eca) 6aste that ha7e been tra""ed in the )u,en o the a""endi0. The a""endi0 can a)so beco,e ?in?ed< obstructin! the circu)ation. Abscess or,ation !enera))y occurs and dan!er o ru"ture is o,ni"resent. A""endicitis is characteri>ed by a shar" abdo,ina) "ain that ,ay be )oca)i>ed at &c=urney8s "oint (ha) 6ay bet6een the u,bi)icus and ri!ht i)iac crest). (a)"ation o the abdo,en causes "ain in the ri!ht Auadrant. (ressin! the abdo,en at &c=urneyOs "oint causes tenderness in a "atient 6ith a""endicitis. Dhen the abdo,en is "ressed< he)d ,o,entari)y< and then ra"id)y re)eased< the "atient ,ay e0"erience a ,o,entary increase in "ain. This Prebound tendernessP su!!ests in )a,,ation has s"read to the "eritoneu,. I the a""endi0 ru"tures< the "ain ,ay disa""ear or a short "eriod and the "atient ,ay ee) sudden)y better. *o6e7er< once "eritonitis sets in< the "ain returns and the "atient beco,es "ro!ressi7e)y ,ore i)). At this ti,e the abdo,en ,ay beco,e ri!id and e0tre,e)y tender. A""endi0 occurs ,ost co,,on)y on chi)dren< ado)escents and youn! adu)ts but indi7idua)s o any a!e ,ay ha7e a""endicitis.

a.2.*"edi#po#in) 6 *"ecipitatin) Facto"#

*"edi#po#in) Facto"#: C)assic history o a""endicitis Se0C A""endicitis is 3.3 to 3.' ti,es ,ore co,,on in ,a)es than in e,a)es A!eC the "ea? incidence is in the second and third decades 6ith /: B o cases occurrin! in "ersons youn!er than 4# years o a!e but indi7idua)s o any a!e ,ay ha7e a""endicitis. Anato,ica) ;ariations in the "osition o the a""endi0.

*"ecipitatin) Facto"#: 2y,"hoid +o))icu)ar *y"er")asia In ections by 7iruses< "arasites or bacteria Diet de icient in iber

a. . Si)n and Symptom#

1$

A""endicitis o ten starts 6ith ,i)d "ain near the na7e). The "ain !radua))y ,o7es to the ri!ht )o6er "art o the abdo,en. It 6orsens 6ith ti,e< and is ,ore intense 6hen the "erson ,o7es. Other sy,"to,s o a""endicitis ,ay inc)udeC Q Nausea or 7o,itin!. Q %)e7ated te,"erature. Q Increased "u)se rate. Q 2oss o a""etite. Q Consti"ation. Q Abdo,ina) s6e))in!. I the in ection continues< the a""endi0 ,ay ru"ture. Dhen this occurs< there is o ten re)ie o the "ain or a short 6hi)e. This i,"ro7e,ent is o))o6ed by ,ore intense but si,i)ar "ain. Chronic a""endicitis is rare. It causes a ,i)der "ain in the ri!ht )o6er abdo,en that ,ay co,e and !o.

d. . +ea$t& p"omotion and *"e,enti,e A#pect# of t&e -i#ea#e

A-7oid too ,uch acti7ity(eatin! then 6or?in! or ")ayin! ri!ht a6ay) (-eo")e o any a!e are susce"tib)e< ,a)e are ,ore "rone (-re7ent obstruction o the )u,en %-0ercise N-oti y "hysician i any si!ns and sy,"to,s occur D-iet shou)d be hi!h in iber@ so to..

1'

I-increase "erista)sis to "re7ent consti"ation G-ray< u)trasound and other )ab test shou)d be ta?e into consideration to a7oid ru"ture o the a""endi0

V. T+E *ATIENT AN- +IS CA(E

1. /edica$ mana)ement
A. IVF=#

2(

Indication6# /edica$ /ana)eme nt6 T"eatment -ate o"de"e d> pe"fo" med> c&an)e d 9ene"a$ -e#c"iption O" *u"po#e6#

C$ient=# Initia$ (eaction to t&e T"eatment

C$ient=# "e#pon#e to t&e T"eatment

D#2RS 32 0 / R 3:33 !tts.9,in S3 OC :3-:3-34 CC :3-:3-34 OC:3-:4-34 CC:3-:4-34 OC:3-:4-34 CC:3-:3-34 OC:3-:3-34 CC:3-:4-34 OC:3-:4-34 CC:3-:#-34 OC:3-:#-34 CC:3-:#-34

S4

S3

S4

S#

S'

S)i!ht)y hy"ertonic so)ution< this so)ution e0erts hi!her os,otic "ressure than o the b)ood ")as,a. D#2RS 6i)) increase the so)ute concentration o ")as,a< drainin! 6ater out o the ce))s into the e0trace))u)ar co,"art,ent to restore os,otic eAui)ibriu,. D#2RS contains 33: ,%A92 Sodiu,< 4 ,%A92 o (otassiu,. 3:1 ,%A92 Ch)oride< 3.: ,%A92 o Ca)ciu,. It has 34: ca)ories.

C)ient has a !uardin! re")ace beha7ior but 6as de icits in the coo"erati7e e0trace))u)ar 6ith the treat,ent co,"art,ent "rocedure. in "atients *e res"onded that are 6e)) to the dehydrated treat,ent. Used to and 7o)u,e de")eted. D#2RS is ad,inistered and !i7en to "atient to !i7e the necessary nutrients to re")ace any )ost )uids since the "atient is in N(O. It is a)so used as a ,ain )ine to ad,inister Antibiotics and ,edications I;.

TChec? Tubin! the

I; or

"resence o air TChec? Inte!rity o the In usion T&onitor I; )o6 rate TAdIust rate o )o6 o )uids a""ro"riate to need o "atient as "rescribed

21

/edica$ /ana)em ent6 T"eatmen t

-ate o"de"e d> pe"fo" med> c&an)e d

9ene"a$ -e#c"iption

Indication6# O" *u"po#e6#

C$ient=# Initia$ (eaction to t&e T"eatment

C$ient=# "e#pon#e to t&e T"eatment

D#N& 320 3# !tts9,in S4 OC :3-33-34 CC :3-33-34

*y"otonic so)ution it ,aybe isoos,o)ar since de0trose is ra"id)y ,etabo)i>ed. Nor,oso) & contains de0trose #:!< dehydrated a)coho) 4:,)< "otassiu, acetate 3.4/!< ructose 3#:!<NaC) 4.34!< &! acetate :.3!

(ro7ides "rinci"a) ions o nor,a) ")as,a is a),ost the sa,e "ro"ortions as 6ith nor,a) ")as,a. Re")ace,ent o acute )ooses o e0tra0ce))u)ar )uid 7o)u,e in sur!ery< it 6as !i7en to the "atient to "re7ent dehydration and contains ")as,a 7o)u,e.

C)ient has a !uardin! beha7ior but 6as coo"erati7e 6ith the treat,ent "rocedure. *e res"onded 6e)) to the treat,ent.

No si!ns o abnor,a)ities obser7ed or e)t by the "atient.

Nu"#in) (e#pon#ibi$itie# =e ore ad,inisterin! the I;< identi y irst the "ationt %0")ain the "rocedure (re"are the eAui",ent Dash hands Chec? the )uid to be in used Use the s,a))est !au!e need)e "ossib)e Dri" the tubin! be ore connectin! to the need)e once bein! in used AdIust the I;+ as indicated

22

 Re"ort any "ain< in u usion or dis)ocation e)t by the "atient B. -"u)# Name of t&e -"u)# 9ene"ic Name B"and Name -ate (oute and Indication6 O"de"ed F"e@uency of *u"po#e# -ate admini#t"ation Ta?en -ate C&an)ed :3-:3-34 :3-:3-34 :3-:'-34 3 a,". I; A 4U <non narcotic ana)!esics decreases e7er Specifi C$ient=# Food# "e#pon#e to ta?en medication

N(O (araceta,o)

The "atient too? the dru!s "ro"er)y< in ection reduced< no side e ects obser7ed The "atient too? the dru!s "ro"er)y< in ection reduced< no side e ects obser7ed

Ce uro0i,e

:3-:4-34 :3-:4-34 :3-:4-34

.#:,! I; A /U

-Antiin ecti7e -4nd !eneration ce"ha)os"or ins -inhibits bacteria) ce)) 6a)) synthesis renderin! ce)) 6a)) os,otica))y unstab)e< )eadin! to ce)) death by bindin! to ce)) 6a)) ,e,brane

N(O

&etronida>o)e

:3-:4-34 :3-:3-34 :3-:'-34

#::,! I; A/ ANST(-)

TA,becide N(O TAnti-in ecti7e T?i))s susce"tib)e a,oeba< tricho,onas and bacteria N(OC)ear )iAuid

(atient had no ,ani estations o any side e ects

Tra,ado)

:3-:4-34 :3-:3-34 :3-:'-34

3::,! I; A 'M TAna)!esic< RTC centra))y actin! T

(atient had no ,ani estations o any side e ects

()asi)

:3-:4-34 :3-:4-34

#,!9,) A /U 0 Tanti-e,etic 4 doses

N(O

(atient had no ,ani estation re!ardin! any

23

:3-:3-34

side e ects

+a,otidine

:3-:4-34 :3-:4-34 :3-:3-34

4: ,! I; A 34M 0 3 doses

*ista,ine *4 N(O anta!onist

(atient had no ,ani estation re!ardin! any side e ects (atient had no ,ani estation re!ardin! any side e ects

Vorte>or

:3-:4-34 :3-:4-34 :3-:3-34

3: ,! I; A /M 0 (ain re)ie7er 4 doses

N(O

Ca"to"ri)

Du)co)a0

:3-:3-34 :3-:3-34 :3-:3-34 :3-:#-34 :3-:#-34 :3-:#-34

4#,! S2

N(OC)ear )iAuid (atient had no ,ani estation re!ardin! any side e ects

Su"" 4 su"") -)a0ati7e< rectu, sti,u)ant So t diet di"heny),ethane -acts direct)y on the intestine by increasin! ,otor acti7ity@ thou!ht o irritate co)onic intra,ura) ")e0us@ increases ater in the co)on

Nu"#in) (e#pon#ibi$itie#: Assess "atient ro, a))er!ic reaction (ANST) Assess the "atient or any si!n and sy,"to,s Identi y Urine out"ut< i decreasin!< noti y the "hysician Caution "atient to re"ort b)eedin!< bruisin! or ati!ue &onitor "atient bo6e) and consistency o stoo) %7a)uate or thera"eutic res"onseC re)ease o "ain< sti ness< s6e))in! Docu,ent indications or thera"y.)ocation< onset< and charcteristic o sy,"to,s

24

 Assess or history o dru! addiction< a))er!y to any ,edicine &onitor 7ita) si!ns Obtain C=C and necessary cu)tures be ore ad,inisterin! %ncoura!e increased )uid inta?e Docu,ent C. -iet Type# Of -iet N(O -ate o"de"ed -ate #ta"ted -ate c&an)ed :3-:3-34 :3-:3-34 :3-:3-34 9ene"a$ -e#c"iption Indication# *u"po#e o" Specific Food# ta?en C$ient=# "e#pon#e to t&e t"eatment She e0hibited so,e )oss o a""etite.

C)ear 2iAuid Diet

:3-:3-34 :3-:3-34 :3-:3-34

So t Diet

:3-:4-34 :3-:4-34 :3-:'34

Restriction o so)id U"on ad,ission nor )iAuid oods by to "ro7ide ,ore ,outh accurate obser7ation in the condition o the c)ient and or "re and "ost o"erati7e "atient to "re7ent as"iration o the ood ta?en in as an e ect o the anesthesia. &ade u" o c)ear It is ,ain)y used )iAuid oods 6hich or "ost o"erati7e )ea7e no residue in "atients< "atients the $IT. It is non- 6ith acute i))ness sti,u)atin!< non- and in ections< to !as or,in!< and re)ie7e thirst< to non-irritatin!. reduce co)onic eca) ,atter. It is done bet6een 3-4 eedin! inter7a)s. It is si,i)ar to the It is used or re!u)ar diet e0ce"t "atients 6ith that the te0ture o acute in ections< the oods has been so,e $IT ,odi ied. It is a diet disturbances or ,odi ied in che6in! consistency to ha7e "rob)e,s and ne6 rou!ha!e< o))o6in! sur!ery )iAue ied oods< se,i-so)id oods and those 6hich are easi)y di!ested. This cou)d o er an entire)y adeAuate<

Dater (inea"")e Iuice He))y ace

she irst see,ed to ha7e a )oss o a""etite 6ith the ordered diet< but then !radua))y too? in the oods that 6ere ordered by the "hysician. The "atient ,ani ested an i,"ro7ed a""etite.

Sou" 2u!a6 Crac?ers &a,,on (inea"")e Iuice 6ater

25

)ibera) diet.

Nu"#in) (e#pon#ibi$itie#: The bene its as 6e)) as the disad7anta!es shou)d be e0")ained 6e)) to the c)ient. The nurse shou)d ,a?e sure that the "atient adheres to the ordered diet. The ordered diet shou)d be ,onitored. Continuous ,onitorin! o the c)ient8s diet shou)d be obser7ed d. Acti,ity6E.e"ci#e Type of -ate e.e"ci#e o"de"ed1 date #ta"ted1 date c&an)ed Date ordered :3- :3 -34 Date started :3-:3-34 Date chan!ed :3-:3-34 Date ordered :3-:4-34 Date started :3-:4-34 9ene"a$ de#c"iption Indication pu"po#e o" C$ient=# "e#pon#e to t&e acti,ity o" e.e"ci#e

=ed rest

(t. is restricted To decrease (t. 6as ab)e to ro, any stress u) o0y!en and a7oid any acti7ities ener!y de,and. stress u) acti7ities.

A,bu)ation (6a)?in!)

(t. "er or,ed AD2s< ,aintain !ood body a)i!n,ent and carry out acti7e RO& e0ercises.

To be ab)e )i,it (t. 6as ab)e ,o7e,ents and "er or,ed her stren!then the AD2s )i?e 6a)?in! ,usc)es.

Nu"#in) "e#pon#ibi$itie#: Chec? or the doctors order %0")ain the "ur"ose o the e0ercise to the c)ient

26

 Instruct c)ient to ,aintain the e0ercise ordered by the "hysician Assist the "atient in ,o7in! and 6a)?in! (ro7ide co, ort ,easures to a7oid inIury o the "atient

B. Su")ica$ /ana)ement a. B"ief -e#c"iption A sur!ica) "rocedure ca))ed an a""endecto,y is necessary be ore the a""endi0 ru"tures. Atte,"ts are ,ade to re,o7e the in )a,ed a""endi0 be ore it ru"tures and "reo"erati7e care is directed to6ard restin! the co)on. No ene,as< heatin! or )a0ati7es shou)d be used be ore sur!ery because they cou)d sti,u)ate "erista)sis and cause a ru"ture o the a""endi0. The a""endi0 is re,o7ed throu!h a s,a)) incision o7er &c=urney8s "oint or throu!h a ri!ht "ara,edica) incision. The incision usua))y hea)s 6ith no draina!e. Drains are used 6hen an abscess is disco7ered 6hen the a""endi0 has ru"ture and so,eti,es 6hen the a""endi0 6as ede,atous and ready to ru"ture and 6as surrounded by c)ear )uid. I no ru"ture has occurred< a )a"arosco"ic a""endecto,y< in 6hich the a""endi0 is re,o7ed throu!h a sco"e ,aybe done. A )a"arosco"ic a""endecto,y reAuires on)y s,a)) incision and a))o6s c)ient to be dischar!ed 44 hours a ter sur!ery. =o6e) unction is usua))y nor,a) soon a ter sur!ery and con7a)escence is short.

b. Nu"#in) (e#pon#ibi$itie# *"eope"ati,e Assess the )ocation< se7erity< onset< duration< "reci"itatin! actors and a))e7iatin! ,easures in re)ation to the "ain Intra7enous )uids as "rescribed to ,aintain )uid and e)ectro)yte ba)ance Instruct nothin! by ,outh to the "atient "rior to sur!ery Record a))er!ies and ,edications as 6e)) ()ace the "atient in se,i o6)ers or side )yin! "osition to "ro7ide co, ort Ana)!esics are 6ithhe)d unti) "hysicians deter,ines dia!nosis

*o#t Ope"ati,e Deter,ine (K) )atus C)ear 2iAuid a ter +)atus So t Diet a ter Assist "atient in turnin!< cou!hin! and dee" breathin! to "ro,ote e0"ansion o the )un!s Assess abdo,ina) 6ound or redness< s6e))in! and ou) dischar!e (ro7ide 6ound care (ro,ote ear)y a,bu)ation

2$

b. Actua$ SO*IE
STW OT the "atient ,ani est the o))o6in! (K) !uarded beha7ior (K) acia) !ri,aces (K) rest)essness (K) "u"i))ary di)atation (K) narro6ed ocus Onset o "ainC o ten@ Jua)ityC Stabbin! and throbbin!@ Re!ion on R2J@ se7ere)yC a)6ays@ 2e7e) o "ain o 3:93: AT Acute "ain R9T sti,u)ation o ner7e endin!s (T A ter 4-3U o Nursin! Inter7ention and hea)th teachin! the "t 6i)) be ab)e to decrease "ain ro, 3: to ' usin! a sca)e o 3: as e7idence by usin! o re)a0ation techniAue and di7ersiona) acti7ities. IT &onitored and recorded 7ita) si!ns Assessed "atient condition (er or,ed co,"rehensi7e assess,ent o "ain Acce"ted "atient "erce"tion o "ain Obser7ed non-7erba) cues %ncoura!ed 7erba)i>ation o ee)in! about "ain (ro7ided Auiet and ca), en7iron,ent

2'

 (ro7ided "atient co, ort ,easures %ncoura!ed re)a0ation e0ercise such as dee" breathin! %ncoura!ed di7ersiona) acti7ities %ncoura!ed adeAuate rest Discussed 6ith SO 6ay on ho6 to assist "atient to reduce "ain

%T $oa) ,et A%= reducin! o "ain ro, 3: to ' usin! a sca)e o 3:

3(

VI.CLIENT=S -AIL3 *(O9(ESS IN T+E +OS*ITAL

a.C$ient=# dai$y p"o)"e## c&a"t
Days Nursin! (rob)e,s Acute (ain Ris? or de icient )uid 7o)u,e I,"aired s?in Inte!rity (hysica) I,,obi)ity Ris? or In ection ;ita) Si!ns =)ood (ressure Te,"erature Res"iratory Rate (u)se Rate 2ab (rocedures &edica) &ana!e,ents 3. I;+8s D#2RS -"u)#: (araceta,o) Ce uro0i,e &etronida>o)e Tra,ado) ()asi) +a,otidine Vorte>or Ca"to"ri) Du)co)a0 -iet N(O Ad,ission 9 9 :3-:4-34 9 9 9 9 9 /a, 33:9/: 3'.1 4: /4 9 9 9 /a, 3::9.: 3. 43 /4 9 :3-:3-34 9 9 9 9 /a, 33:9': 3. 43 /1 9 :3-:4-34 9 9 9 9 /a, 33:9/: 3'.' 43 '' 9 :3-:#-34 9 9 9 9 /a, 1:9': 3'.3 4: .: 9

9 9

9 9 9 9 9 9 9 9

9 9 9 9

9 9 9 9

9 9 9 9 9

31

C)ear Diet So t Diet

9 9 9 9

B.-i#c&a")e *$annin) a. 9ene"a$ Condition Of c$ient upon -i#c&a")e

Since 6e 6ere not ab)e to see the c)ient 6hen she 6as dischar!ed ro, the *os"ita)< 6ith e6 days o nursin! inter7ention< the c)ient8s !enera) condition has i,"ro7edC 3. She is s)o6)y re!ainin! his stren!th 4. She can a,bu)ate 6ith assistance

b. /ET+O/% ta?e the ,edicines "rescribed E- e0ercise such as 6a)?in! and "ro"er breathin! T- dai)y 6ound c)eanin! +- increase )uid inta?e< 7ita,in C< a"")y hot co,"ress O- be bac? at O(D as ordered by the doctor -- Diet as to)erated 6ith an increase inta?e o ;ita,in C

VII. Conc$u#ion and (ecommendation

%7ery indi7idua) o any a!e are "rone to a""endicitis thou!h its ,ore co,,on 6ith ,a)es< sti)) e7eryone is susce"tib)e< ,i)d u,bi)ica) "ain ,aybe 7a!ue at irst< but it

32

increases intensity. O7er a "eriod o ti,e< si!ns and sy,"to,s occur ra"id)y< it cannot be "resented an e0"erience o this sha)) be contented 6ith "ro"er "re7ention. +au)ty diet es"ecia))y )o6 in iber is one cause o the obser7ation there ore by eatin! iber- rich ood 6i)) increase "erista)sis. So there is re!u)ar bo6e) ,o7e,ent. So there is no eca) ,ateria) that 6i)) be or,ed. Not e7eryone 6ith a""endicitis has a)) the sy,"to,s. The "ain ,ay intensi y and 6orsens other ,ay ha7e a sensation ca))ed Edo6n 6ard ur!eF "ain ,edication and other )a0ati7es shou)d not be ta?en in their situation. Anyone 6ith these sy,"to,s need to see a Aua)i ied "hysician i,,ediate)y. (ecommendation One shou)d a)6ays re,e,ber the hea)th "ro,otion and "re7ention o a""endicitis. Hust re,e,ber the acrony, A((%NDIG< 6hich is a7oidin! too ,uch acti7ity< that "eo")e o any a!e and se0 are susce"tib)e. One shou)d a)6ays ")ay sa e in "re7entin! obstruction o the )u,en. %0ercise is i,"ortant. Noti y "hysician i any si!ns and sy,"to,s occur. Diet shou)d a)6ays be hi!h in iber to increase "erista)sis and to "re7ent consti"ation. 2ast)y 0-ray< u)trasound and other )aboratory test shou)d be ta?en into consideration to a7oid res"onse o the a""endi0.

33