Tarlac State University College of Nursing Lucinda Campus, Brgy.

Ungot, Tarlac City

Narrative Charting on Appendectomy

In Partial Fulfillment of the requirements in NCM 103 RLE

Presented to: Raul Franco G. Tomas RN, MAN Clinical Instructor

Presented By: Rosemarie M. Guiang BSN IIIA- Group A1

TABLE OF CONTENTS

I INTRODUCTION

II DEMOGRAPHIC DATA

III PRESENT HEALTH HISTORY

IV NARRATIVE CHARTING

V ANATOMY AND PHYSIOLOGY

VI PATHOPHYSIOLOGY

I INTRODUCTION Appendectomy is said to be the most common emergent surgical procedure performed worldwide, with appendicitis accounting for approximately 1 million hospital days annually and remains to be only curative treatment for appendicitis. Appendicitis is an inflammation of the vermiform appendix that develops most commonly in adolescents and young adults. (Medical-Surgical Nursing, Black, Hawks and Keene, 6th edition). No single sign, symptom, or diagnostic test accurately confirms the diagnosis of appendiceal inflammation in all cases, and the classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases. It has the potential for severe complications, including perforation or sepsis, and may even cause death. It has slight male preponderance of 3:2 in teenagers and young adults; in adults, the incidence of appendicitis is approximately 1.4 times greater in men than in women. The incidence of primary appendectomy is approximately equal in both sexes. Lower incidence of appendicitis is also found in Asian and African Countries because of the dietary habits in these areas. The incidence of appendicitis gradually rises from birth, peaks in the late teen years, and gradually declines in the geriatric years. The mean age when appendicitis occurs in the pediatric population is 6-10 years. Lymphoid hyperplasia is observed more often among infants and adults and is responsible for the increased incidence of appendicitis in these age groups. Younger children have a higher rate of perforation, with reported rates of 50-85%. The median age at appendectomy is 22 years. Although rare, neonatal and even prenatal appendicitis have been reported. Clinicians must maintain a high index of suspicion in all age groups.( http://emedicine.medscape.com/article/773895overview#a0156)

For the past years appendicitis is known as a common and urgent surgical illness with protean manifestations, generous overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay. But recent researches had found out that Delay in Performing Appendectomy is not Associated With Adverse Outcomes in a study conducted by Angela M. Ingraham, M.D., M.S., of the American College of Surgeons (ACS), Chicago, and colleagues who studied data from 32,782 patients treated at hospitals participating in the ACS National Surgical Quality Improvement Program who underwent an appendectomy for acute appendicitis between 2005 and 2008. After 30 days, there were no significant differences in complications or deaths between the three groups.(Archives of journals) But still Appendectomy remains the only curative treatment of appendicitis since no medical treatment has been discovered yet to replaced appendectomy for treating appendicitis. IMPORTANCE OF THE STUDY The goal of using the study method is to describe as accurately as Surgery: JAMA/Archives

possible the most complete, specific and comprehensible description of the case. It is hoped that interrelation of each stage of the process will be identified and by conducting such kind of case study will developed or uplift our knowledge , skills and future practice. it is a way of reflecting what has been learned through the application of all what has been learned and while being acquainted with other new experiences. I have choose to come up with this case study because I want to learn about this condition, since I do have only few knowledge regarding this condition and since we have not still have a discussion with such case.

II DEMOGRAPHIC DATA Name: Boy Labo Age: 27 Sex: Male Date of Birth: January 31, 1984 Address: Brgy, Walo-Walo, Siyam City Nationality: Filipino Place of Admission: Tarlac Provincial Hospital Date Admitted: August 12, 2011 Chief Complaint: Right Lower Quadrant Pain Ward: Surgical Ward Attending Physician: Dr. House Chief complaint: Right Lower Quadrant pain Final Diagnosis: Acute Appendicitis

III PRESENT HEALTH HISTORY Patient experienced a severe pain at his abdomen which started at the area around his periumbilical area shifted to right lower quadrant region. He was rushed to the hospital and was admitted at the surgery ward and was diagnosed with acute appendicitis.

IV NARRATIVE CHARTING Name: Boy Labo Age: 27 years old Birthday: January 31, 1984 Case No: 179163 Address: Brgy. Walo-walo, Siyam City Chief complaint:Right Lower Quadrant Pain Medical Diagnosis: Acute appendicitis Attending physician: Dr. House Date: August 12, 2011 Admitted at 10:35 p.m., a 27 years old male from surgical ward via stretcher with a chief complaint of Right Lower Quadrant pain. Concious and coherent With ongoing D5LR 1L, received at 950 cc level inserted at Right metacarpal vein regulated at 30 drops per minute, intact and infusing well. Explained the procedure and obtained inform consent (by the physician) Transferred to Operating table Administered Bupivacaine thru Subarachnoid Block >Turned to left side with knee touching the chest > Skin on the lumbar area is cleaned > Palpated the subarachnoid space > inserted the needle > Confirmed the insertion to the subarachnoid space with the flow of a clear iquid > Administered anesthesia Turned to supine position Inserted Foley catheter Placed Pulse oximeter in the index finger of the right hand

 Administered Oxygen Abdomen was prepped and draped Surgical team scrubbed Instruments are prepared and initial instrument and sponge count done An incision is made in the right lower abdomen with a knife(skin) followed by a cautery: >Identified the appendix > The mesoappendix is separated off of the appendix, clamped and tied off > The remainder of the appendix is clamped, cut and removed > Repeat sponge and instrument count done >Final Sponge and instrument count done >Skin layers are sutured back. Cleaned the incision site Applied povidine iodine Applied dressing Removed pulse oximeter and oxygen Collected specimen and placed in a specimen bottle Transferred to PACU VI ANATOMY AND PHYSIOLOGY

Appendix is a small, finger-like appendage about 10 cm (4 inches) long that is attached to the cecum just below the ileocecal valve. The appendix fills with food and empties regularly into the cecum. Because it empties inefficiently and its lumen is small, it is prone to obstruction and particularly vulnerable to infection such as ppendicitis.(Brunner and Suddharta, 10th edition, medicalsurgical nursing) The appendix is a wormlike extension of the cecum and, for this reason, has been called the vermiform appendix. The appendix appears during the fifth month of gestation, and several lymphoid follicles are scattered in its mucosa. Such follicles increase in number when individuals are aged 8-20 years. Normal appendix; barium enema radiographic examination. A complete contrast-filled appendix is observed (arrows), which effectively excludes the diagnosis of appendicitis. The appendix is contained within the visceral peritoneum that forms the serosa, and its exterior layer is longitudinal and derived from the taenia coli; the deeper, interior muscle layer is circular. Beneath these layers lies the submucosal layer, which contains lymphoepithelial tissue. The mucosa consists of columnar epithelium with few glandular elements and neuroendocrine argentaffin cells. Taenia coli converge on the posteromedial area of the cecum, which is the site of the appendiceal base. The appendix runs into a serosal sheet of the peritoneum called the mesoappendix, within which courses the appendicular artery, which is derived from the ileocolic artery. Sometimes, an accessory appendicular artery (deriving from the posterior cecal artery) may be found. Appendiceal vasculature The vasculature of the appendix must be addressed to avoid intraoperative hemorrhages. The appendicular artery is contained within the

mesenteric fold that arises from a peritoneal extension from the terminal ileum to the medial aspect of the cecum and appendix; it is a terminal branch of the ileocolic artery and runs adjacent to the appendicular wall. Venous drainage is via the ileocolic veins and the right colic vein into the portal vein; lymphatic drainage occurs via the ileocolic nodes along the course of the superior mesenteric artery to the celiac nodes and cisterna chyli. Appendiceal location The appendix has no fixed position. It originates 1.7-2.5 cm below the terminal ileum, either in a dorsomedial location (most common) from the cecal fundus, directly beside the ileal orifice, or as a funnel-shaped opening (2-3% of patients). The appendix has a retroperitoneal location in 65% of patients and may descend into the iliac fossa in 31%. In fact, many individuals may have an appendix located in the retroperitoneal space; in the pelvis; or behind the terminal ileum, cecum, ascending colon, or liver. Thus, the course of the appendix, the position of its tip, and the difference in appendiceal position considerably changes clinical findings, accounting for the nonspecific signs and symptoms of appendicitis. VII PATHOPHYSIOLOGY Book Based Obstruction of the appendix (by fecalith, lymph node, tumour, foreign objects) Inflammation Increase intraluminal pressure Distention of the Appendix Decrease venous drainage Blood flow and oxygen restriction to the appendix Bacterial Invasion of the Blood wall

 Necrosis of the appendix Source: Medical-Surgical Nursing: Black, Hawks and Keene, 6th edition

Patient Based: Modifiable: Diet: Low in Fiber Non-modifiable: >Age: 27 years old (peak incidence 20-30 years old) >Male (1.4 times greater in male)

Fecal obstruction, swelled lymph nodes, bacteria viruses, protozoa etc. Occlusion of Appendix by Fecalith Decreased flow/drainage of mucosal secetions Increased ILP in the appendix Vasocongestion SWELLING and PAIN

Decreased perfusion in the appendix Hypoxia in the appendix Appendix starts to be necrotic; Bacteria invade the appendix Disruption of Cell Membrane of Appendix Start of Inflammatory Process

Release of Chemical Activation of vomiting inflammation mediators of the Appendix

Impaired tissue integrity

Tissue trauma infection

Risk for

Appendectomy

Nociceptors in the dermis Start of inflammatory process

disruption of the cell membrane sends impulse to CNS

Release of prostaglandin, bradykinin, Histamine, leukotrienes and other che Mical mediatorsa PAIN AND SWELLING