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Appendicitis:
An inflammation of the appendix; a finger-shaped pouch…
Appendicitis:
- An inflammation of the appendix; a finger-shaped pouch that projects from your colon on the lower right side of your abdomen
Pathophysiology:
- Occurs when the appendix bcmes acutely inflamed.
- Due to the lumen of appendix bcmg blocked by a faecolith (faecal concretions/pellets), normal faecal matter/lymphoid hyperplasia due to a viral infection.
- When lumen blocked, the pressure within the appendix increases & this reduces venous drainage, resulting in ischaemia, which can lead to necrosis & gangrene if untreated.
- At this rate, appendix is at risk of perforating (takes around 72 hrs to occur).
- Then, bacteria & inflammatory cells are released into the surrounding structures.
- Then, it causes inflammation of the peritoneum.
Priority Nsg Care
Nsg diagnosis:
- Acute pain related to obstructed appendix as evidenced by patient’s pain score.
- Risk for deficient fluid volume related to preoperative vomiting, postoperative restrictions.
- Risk for infection related to ruptured appendix.
- Acute pain related to obstructive appendix as evidenced by patient's pain score.
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Nsg intervention:
- Assess patient’s vital sign (e.g: blood pressure, temperature, etc..) and pain score as a baseline data and to detect for any abnormalities.
- Assess patient’s characteristic of pain (e.g : severity, location, onset, etc..). This is because, the most reliable source of information of the pain itself is the patient and assessing the pain characteristics is the first step in planning pain management strategies.
- Assess for the sign and symptoms related to pain because some patient deny the existence of pain (e.g : an increase in blood pressure may indicate that the patient is in pain).
- Evaluate patient’s response to pain and management strategies because it is essential to assist patients express as factually as possible (i.e., without the effect of mood, emotion, or anxiety) the effect of pain relief measures.
- Get rid of additional stressors or sources of discomfort whenever possible because patients may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing them.
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- Risk for deficient fluid volume related to preoperative vomiting, postoperative restrictions.
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Nsg intervention:
- Monitor intake & output to monitor fluid balance in body needed for daily metabolism.
- Assess color and amount of urine. Report urine output less than 30 ml/hr for 2 consecutive hours. A normal urine output is considered normal not less than 30ml/hour. Concentrated urine denotes fluid deficit.
- Urge the patient to drink prescribed amount of fluid. Oral fluid replacement is indicated for mild fluid deficit and is a cost-effective method for replacement treatment. Being creative in selecting fluid sources can facilitate fluid replacement.
- Establish IV access and replace GI losses to restore electrolytes lost via IV since oral intake is limited due to vomiting and nausea.
- Administer antiemetic as ordered to reduce vomiting as prescribed.
- Educate patient about possible cause and effect of fluid losses or decreased fluid intake. Enough knowledge aids the patient to take part in his or her plan of care.
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Contributing factors:
- A buildup of hardened stool.
- Enlarged lymphoid follicles.
- Intestinal worms.
- Traumatic injury.
- Tumors
Clinical manifestation:
- Pt complaint of sudden pain on rt. side of lower abdomen.
- Pt complaint of nausea, anorexia & diarrhea.
- Positive of Rovsing's sign - during palpation on Lt. lower quadrant, pt feel increase pain at the rt. lower quadrant.
- Positive of McBurney sign - tenderness at the junction of lateral 3rd & medical two 3rd of line drawn from rt. anterior superior iliac spine to umbilical & increase of pain when assessor removes hand after deep palpation at the area.
- Positive of Psoas sign - increase of pain when flexing rt. hip against resistance.
Complication:
- Ruptured appendix - rupture spread infection (Peritonitis) throughout abdomen; can be life-threatening & require immediate surgery to remove the appendix & clean the abdominal cavity.
- Packet of pus that forms in the abdomen - if appendix burst, pocket of infection (abscess) may develop; surgeon will drain the abscess by placing tube through the abdominal wall & left it in place for 2 weeks; antibiotic will be prescribed to clear the infection; after that, pt ae scheduled for appendectomy immediately.
Surgical intervention:
Appendectomy
- removing the inflamed appendix.
- abscess formed around ruptured appendix needs to be drained before performing surgery.
1. Laparoscopic appendectomy (appendix removal)
- performed by doing 3 or 4 small incision in the abdomen to insert laparoscopic instrument and a bit more complicated.
- small camera is inserted to view inside the abdomen when performing this surgery procedure.
- Open surgery
- done by making a single incision 2-4 inch long at the lower right of the abdomen.
- usually done when there is widespread infection of the inner lining of abdomen after appendix ruptured.
- preferred to those with history of an open abdominal surgery.
- pt need to NPO at least 6 hrs before surgery to reduce the risk of complications from anesthesia drugs.
- nurses to identify if pt has: any allergies, heart disease, neurologic disease (stoke/mini stroke), kidney disease, diabetes & lung disease (incl. asthma, emphysema/obstructive sleep apnea).
Medical tx:
Pre-operative:
- Monitor v/s & note for pain score of pt's complaint. Pt's pain is suddenly relieved which will be followed by intense abdominal pain indicate ruptured appendicitis.
- Give the pt nothing by mouth (NPO) to avoid further irritation of the intestinal area & as bowel preparation for surgery.
- Nvr administer cathartics/enemas that can increases risk of ruptured appendicitis.
- Administer IV fluids prescribed to prevent dehydration & correct the fluid & electrolyte abnormalities prior to surgery.
- Administer antibiotic therapy as prescribed for ruptured appendicitis to prevent sepsis prior to surgery.
- Encourage non-pharmacology pain relief by place the pt in Fowler's position to reduce the pain. Pain med is used cautiously preoperatively to maintain awareness of increase in pain due to possible ruptured appendix.
- Nvr apply heat/perform palpation to the lower rt. abdomen that may cause the appendix to rupture.
- Draining an abscess before appendix surgery for ruptured appendicitis & pt is initially treated with antibiotics.
Post-operative:
- Monitor v/s & note for temp. which can indicate infection.
- Assess infection of surgical incision (such as purulent discharge, redness, pain/itching).
- Maintain drain after surgery as prescribed for ruptured appendicitis by keeping the pt on the rt. side which will allow gravity to help with drainage.
- Encourage incentive spirometer usage, coughing & deep breathing to decrease the risk of lung complications & to reduce the pain.
- Place the pt on a high-Fowler's position after surgery to reduce the tension on the incision & abdominal organs, thereby reducing pain.
- Administering antibiotic therapy as prescribed for ruptures appendicitis.
- Diet will start out slow with clears, then fulls, & solids as tolerated. Encourage pt to eat a high fibre diet (decreases straining during bowel movements).
Pharmacotherapheutic:
Antibiotic
- Cefotan (cefotetan)
- Cefotaxime (Claforan, Mefotoxin)
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IV antibiotics
- To treat abdominal infection caused by ruptured appendix.
- Pt may be sent home after several days with oral antibiotics.
- Pt may undergo appendectomy after 6-8 weeks after infection has cleared up.