Case study 2: Acute appendicitis

Appendicitis is a most common abdominal surgical emergency presenting with an acute abdomen (Nushti et al., 2014). The lifetime risk of acquiring and appendicitis is 8.6% in male and 6.7% in females (Jaschinki et al. 2015). The classical signs of appendicitis are present in approximately 60 – 70% of the cases and this sometimes results in difficulty in making a diagnosis. Diagnostic difficulty is usually more common in women of reproductive age (Alvarado, 2016). In the case scenario provided Lucy Liu presents with signs of severe pain, guarding and pain at right lower abdominal quadrant pain in a point referred to as the McBurney’s point. She further presents with non-specific signs of nausea and vomiting and a temperature of 38.90c (Hinkle & Cheever, 2014).

According to Williams, Bulstrode, and O’Connel (2008), the symptoms of appendicitis are peri-umbilical colic, pain that shifts to the right iliac fossa, anorexia, and nausea. The clinical signs are pyrexia, localized tenderness in the right iliac fossa, muscle guarding, and rebound tenderness. The classical signs elicited in appendicitis on examination are the pointing sign, rovsings sign, psoas sign, and the obturator sign.

The pathology of appendicitis begins with the obstruction of the lumen as a result of luminal hyperplasia. Subsequently, there occurs continued mucous secretion with inflammatory exudates production which further increases the intraluminal pressure. The bacteria present extend to the submucosal wall. Consequently, there is venous obstructions and ischemia. Eventually, there is the development of ischemic gangrene which often leads to appendix rupture and a life-threatening sequel (Williams, Bulstrode and O’Connel, 2008).

The use of computerized tomography, CT – scan, has high sensitivity and specificity in the diagnosis of appendicitis. A clinical scoring system known as Alvarado score is also used (Sammalkorpi, 2014). The treatment of choice for appendicitis is a laparoscopic appendectomy. Delayed treatment for Lucy Liu may have resulted in life-threatening complications (Jaschinki et al. 2015). The major complication is perforation of the appendix which occurs in approximately 10 – 32%. Perforation usually occurs 24 hours after the onset of abdominal pain presenting with fever above 37.7oc with toxic appearance, with continued severe abdominal pains and tenderness (Hinkle & Cheever, 2014). Other complications include inflammatory mass, abscess, generalized peritonitis following rupture (Nushti et al., 2014).

The risk factors for appendix perforation include extreme of ages, immunosuppressed patients, diabetes mellitus, faecolith obstruction, pelvic appendix, and previous abdominal surgery. The differential diagnosis for Lucy Liu presentation could have been pelvic inflammatory disease, ectopic pregnancy, and endometriosis. Other differentials include mittelschmerz, torsion or ruptured ovarian cyst, or pyelonephritis (Williams, Bulstrode & O’Connel, 2008).

Contributing factors

Appendicitis prevalence is usually high between the ages of 10 to 30 years within which Lucy is grouped. However, the disease can occur in all age groups.

There is no specific identifiable cause of acute appendicitis but a myriad of factors that lead to acute appendicitis. Among the factors is the decrease in the intake of dietary fiber with increased intake of refined carbohydrates. Increased absorption of water from the intestines due to low fiber lead to the occurrence of constipation which may form a faecolith. The combination of inspissated fecal matter, calcium phosphate, bacteria, and epithelial debris constitute a faecolith which is a contributing factor to acute appendicitis (Williams, Bulstrode, & O’Connel, 2008).

Other factors contributing to appendicitis include poor hygiene, the presence of a stricture, foreign matter, and bacterial proliferation within the appendix. The presence of a stricture in the appendix is usually an indicator of a previous appendicitis that resolved without treatment. The proliferation of intestinal parasites especially the pinworm (Oxyuris vermicularis) within the appendix lumen leads to obstruction and subsequently appendicitis (Williams, Bulstrode, and O’Connel, 2008).

Nursing care interventions

The initial nursing care intervention for the patient is preparation for surgery. It includes fixing an intravenous cannula, infusion with intravenous fluids to replace fluid lost and initiate antibiotic therapy for infection prevention. Vital signs measurement and baseline investigations testing are done. Further, a nasogastric tube is inserted and the patient remains at nil per oral (NPO). A urinary catheter is inserted for monitoring of input-output to assist in determining the amount of intravenous fluids required. Due to the risk of intestinal perforation, an enema is avoided. The patient is offered pain relief pre and post-surgery in order to offer comfort. Injectable non-steroidal antibiotics and opioids may be used (Luca, 2014; Hinkle & Cheever, 2014).

An acute appendicitis episode presents with a lot of anxiety for the patient. The nurse has a great role to play in the reduction of anxiety. This is done through reassurance the patient, explaining to the patient about the care plan, having an informed consent signed. After appendectomy has been conducted the patient is positioned in a semi-Fowler position to reduce tension in abdominal organs reduce pain. Pain relief preferably using an opioid analgesic is done while antibiotics are continued to ensure complete elimination of infection. Preparation for discharge occurs post-surgery where the Lucy Liu is advised on the expected day of discharge. Discharge occurs within 2 days post appendectomy if temperatures are within the normal limits. The patient is educated on wound care and maintenance of skin integrity. These include advice on surgical appointment management, incision cleaning, and care, and resumption of normal activity not before 2 – 4 weeks post-surgery (Hinkle & Cheever, 2014).

Hinkle and Cheever (2014) further indicate that while in the acute episode the patient is put on NPO until the bowel sounds resume. Soft foods in small amounts are started per oral for the patient. Health education is given to the patient on the importance of high fiber diet, balanced diet, use of fruits and adequate water intake.

The nursing care interventions for complications include monitoring and carrying out preventive or mitigation interventions for the specific complications.

Peritonitis – the care nurse is required to continuously assess for abdominal tenderness, fever, vomiting, abdominal rigidity, and tachycardia. During the acute episode, constant nasogastric suction should be carried out. Administration of intravenous fluids and antibiotic, pre, and post-surgery, intervention measures assist in the prevention of peritonitis (Macaluso & McNamara, 2012; Hinkle & Cheever, 2014).

Another major complication of appendicitis is the development of a pelvic abscess. The patient is evaluated for anorexia, chills, fever, and diaphoresis. Further, the patient is observed for diarrhea, which may indicate a pelvic abscess. If the above signs and symptoms are present the patient should be prepared for rectal examination. If a pelvic abscess is diagnosed the patient is prepared for surgical drainage procedure. The patient may also suffer a subphrenic abscess which forms under the diaphragm following a ruptured appendix. Thus the patient is assessed for chills, fever, and diaphoresis. An abdominal and chest x-ray examination is done to confirm the diagnosis. If present the patient is prepared for surgical drainage of abscess (Macaluso & McNamara, 2012; Hinkle & Cheever, 2014).

The risk and complication ileus are determined by assessment for bowel sounds. In ileus bowel sounds are absent (Longo et al. 2012; Glynn & Drake, 2012). Nasogastric intubation and suction are done. Other interventions include administration of fluids and electrolytes by intravenous route as prescribed. Prepare for surgery, if the diagnosis of mechanical ileus is established (Hinkle & Cheever, 2014).

Interdisciplinary team

Interdisciplinary teams in healthcare have become an essential part in healthcare to ensure quality, patient-centered and wholesome care to the patient and healthcare provider satisfaction (Kutash et al. 2014). These teams comprise of members with different education and professional competencies working together to achieve a common goal (Ambrose-Miller & Ashcroft, 2016). The purpose of interdisciplinary care in the surgical department in this scenario is to help in reducing errors, maximize effectiveness, and ensure quality care. However, these teams require to be effectively trained, good communication, and collaborative teamwork to effectively achieve the set objectives ((Kutash et al. 2014).

The nursing care team essential in the care of the patient pre, intra, and post-operatively. The nursing care team are involved in direct care of the patient, maintaining good inter-professional relationship with the patient, and carrying out assessment as for vital signs, pain, wound, and nutritional status. The nursing care team also assist in analyzing the position of the patient needs and administer or refer for appropriate care (Luca, 2014). The surgeon carries out the task of an appendectomy. The physiotherapy professionals assist in the early mobilization of the patient. The nutritionist is involved in nutritional advice for the patient (Hinkle & Cheever, 2014; Ruffolo et al. 2013). All health care providers are supposed to provide professional care adhering to duty of care, medical ethics, and quality care provision (Luca, 2014; Hinkle & Cheever, 2014).

 

 

 

 

 

 

 

 

 

 

 

References

Alvarado, A. (2016). How to improve the clinical diagnosis of acute appendicitis in resource         limited settings. World journal of emergency surgery, 11(16). DOI: 10.1186/s13017-016-    0071-8

Ambrose-Miller, W. & Ashcroft, R. (2016). Challenges faced by social workers as members of     inter-professional collaborative health care teams. Health & social work, 41(2): 101 – 109.

Glynn, M. & Drake, W. 2012. Hutchison’s Clinical Methods: An Integrated Approach to Clinical Practice 23rd Edition. Philadelphia, PA. Saunders Elsevier.

Hinkle, J. & Cheever, K. (2014). Brunner & Suddath’s Textbook of medical – surgical nursing.     13th edition. Philadelphia, PA. Lisa McAllister.

Jaschinski, T., Mosch, C., Eikermann, M. & Neugebauer, E. (2015). Laparoscopic versus open      appendectomy in patients with suspected appendicitis: a systematic review of meta-   analyses of randomised controlled trials. BMC gastroenterology, 15(48).        DOI: 10.1186/s12876-015-0277-3.

Kutash, K., Acri, M. et al. (2014). Quality indicators for multidisciplinary team functioning in      community-based children’s mental health services. Administration and policy in mental          health, 41(1): 55 – 68.

Longo, D., Fauci, A., Kasper, D.et al. (2012). Harrison’s principles of internal medicine vol.1.      18th edition. New York, NY. McGraw-Hill.

Luca, A. (2014). Care management process in appendectomy nursing. European scientific             journal, 7(26); 202 – 227.

Macaluso, C. & McNamara, R. (2012). Evaluation and management of acute abdominal pain in    the emergency department. International journal of general medicine, 2012(2): 789 –         797.

Nushti, R., Kruger, D. & Luvhengo, T. (2014). Clinical presentation of acute appendicitis in         adults at the Chris Hani Baragwanath academic hospital. International journal of          emergency medicine, 7(12). doi:  10.1186/1865-1380-7-12

Ruffolo, C., Fiorot, A. et al. (2013). Acute appendicitis: What is the gold standard of treatment? World journal of gastroenterology, 19(47): 8799 – 8809.

Sammalkorpi, H., Mentula, P. & Leppaniemi, A. (2014). A new adult appendicitis score    improves diagnostic accuracy of acute appendicitis – a prospective study. BMC   gastroenterology, 14(114). DOI: 10.1186/1471-230X-14-114

Williams, N., Bulstrode, C. & O’Connel, P. 2008. Bailey & Love’s Short Practice of Surgery.        London. Edward Arnold (Publishers) Ltd.

 

 

 

 

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