ANDRES BONIFACIO COLLEGE

COLLEGE PARK, DIPOLOG CITY

SCHOOL OF NURSING

CARE OF PATIENT WITH ACUTE APPENDICITIS

Submitted by
Jay Marie T. Gonzaga Sumbitted to
BSN- IV Julyn Marie A. Gallardo
Clinical Instructor

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 ANDRES BONIFACIO COLLEGE School of Nursing Vision
INSTITUTIONAL VISION AND MISSION
Excellent Nursing Education

VISION:
School of Nursing Mission
A center of excellence in instruction, research, technology, extension,
athletics and arts. The School of Nursing shall generate, competent, safe and
compassionate professional nurses committed to:

MISSION: a.Practice high standards of nursing care utilizing research and

evidence-based practices that are culturally appropriate and sensitive.
We commit to provide affordable quality education with values in
industry, intelligence, integrity and undertake relevant research and b.Active involvement in local, national and global issues affecting
socially-responsive community service using innovative technologies. nursing, people’s health and the environment.
c.Ongoing holistic growth and development of the self and others.

Table of Contents

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I. Learning Objectives ----------------------------------------------------- 4
II. Introduction ----------------------------------------------------- 5 - 10
III. Anatomy and Physiology ----------------------------------------------------- 10 - 11
IV. Patient’s Profile ----------------------------------------------------- 12
V. Physical Assessment ----------------------------------------------------- 13
VI. Laboratory Results ----------------------------------------------------- 14
VII. Gordon’s functional health patterns ----------------------------------------------------- 14 - 15
VIII. Pathophysiology ----------------------------------------------------- 16 - 18
IX. Nursing Care plans ----------------------------------------------------- 19 - 22
X. Drug Study ----------------------------------------------------- 23 - 26
XI. Related articles ----------------------------------------------------- 27 - 28
XII. References ----------------------------------------------------- 29

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LEARNING OBJECTIVES

General Objectives:
At the end of the Case Presentation, the Learners shall improve their understanding, increase their knowledge, enhance their independent and
collaborative skills and manifest desirable attitude in providing immediate and holistic care to patients with acute appendicitis.

Specific Objectives:

Within 1 hour, the listeners will be able to:

1. Identify what is acute appendicitis

2. Identify factors that can lead to acute appendicitis
3. Identify signs and symptoms of acute appendicitis
4. Review the Anatomy and Physiology of the Gastrointestinal System
5. Discuss the disease process and its pathophysiology effectively.
6. Enumerate the manifestations of the disease appropriately.
7. Identify and discuss its appropriate management effectively.

INTRODUCTION

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 Appendicitis is inflammation of the vermiform appendix. Appendix a hollow organ located at the tip of the cecum, usually in the right lower
quadrant of the abdomen. However, it can be located in almost any area of the abdomen, depending on if there were any abnormal
developmental issues, including midgut malrotation, or if there are any other special conditions such as pregnancy
or prior abdominal surgeries.
The appendix develops embryonically in the fifth week. During this time, there is a rotation of the midgut to the
external umbilical cord with the eventual return to the abdomen and rotation of the cecum. This results in the usual
retrocecal location of the appendix. It is most often a disease of acute presentation, usually within 24 hours, but it
can also present as a more chronic condition. If there has been a perforation with a contained abscess, then the
presenting symptoms can be more indolent.
The exact function of the appendix has been a debated topic. Today it is accepted that this organ may have an
immunoprotective function and acts as a lymphoid organ, especially in the younger person. Other theories contend that the appendix acts as a
storage vessel for "good" colonic bacteria. Still, others argue that it is a mere developmental remnant and
has no reall function.
Appendicitis can be acute or chronic. In acute cases of appendicitis, the symptoms tend to be severe
and develop suddenly. In chronic cases, the symptoms may be milder and may come and go over several weeks,
months, or even years. The condition can also be simple or complex. In simple cases of appendicitis, there are no
complications. Complex cases involve complications, such as an abscess or ruptured appendix.
A most popular misconception occured around the story of the death of Harry Houdini. After being
unexpectedly punched in the abdomen, the rumor goes, his appendix ruptures, causing immediate sepsis and death.
The facts are that Houdini did die from sepsis and peritonitis from a ruptured appendix, but it had no connection to
him being struck in the abdomen. It was more related to widespread peritonitis and the limited availability of effective antibiotics  at the time. The
appendix contains a combination of aerobic and anaerobic bacteria, including Escherichia coli and Bacteroides spp. However, recent studies utilizing
next-generation sequencing revealed a significantly higher number of bacterial phyla in patients with complicated perforated appendicitis.
Epidemiology

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 Acute appendicitis is one of the most common acute surgical abdominal emergencies. More than
250,000 appendectomies are performed each year in the US; however, the incidence is lower in
populations where a high-fiber diet is consumed.
The overall lifetime risk of developing acute appendicitis is 8.6% for males and 6.7% for females;
lifetime risk of appendectomy is around 12% in males and 23% in females. Globally, the pooled incidence
of appendicitis or appendectomy is around 100 per 100,000 person years. Data suggest a rapid increase
in incidence in newly industrialized countries. Acute appendicitis most commonly occurs between the ages
of 10 and 30, with the highest incidence in children and adolescence. There is a slight male to female predominance (1.3:1).
According to the latest WHO data published in 2018 Appendicitis Deaths in Philippines reached 332 or 0.05% of total deaths. The age
adjusted Death Rate is 0.37 per 100,000 of population ranks Philippines #104 in the world.

Risk Factors
Appendicitis can affect anyone. But some people may be more likely to develop this condition than others. For
example, risk factors for appendicitis include:
Age: Appendicitis most often affects people between the ages of 15 and 30 years old.
Sex: Appendicitis is more common in males than females.
Family history: People who have a family history of appendicitis are at heightened risk of developing it.
Although more research is needed, low-fiber diets might also raise the risk of appendicitis

Clinical Manifestations
Typically, appendicitis presents as an initial generalized or periumbilical abdominal pain that then localizes
to the right lower quadrant. Initially, the visceral afferent nerve fibers at T8 through T10 are stimulated, and this

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leads to vague centralized pain. As the appendix becomes more inflamed and the adjacent parietal peritoneum is irritated, the pain becomes more
localized to the right lower quadrant. Pain may or may not be accompanied by any of the following symptoms:
 Anorexia
 Nausea/vomiting
 Fever (40% of patients)
 Diarrhea
 Generalize malaise
 Urinary frequency or urgency
Uncommon Presentations
 Some patients may present with uncommon features. In these patients, the pain may have woken the patient up from sleep. In addition,
the patients may complain of pain while walking or coughing.
 Pain upon passive extension of the right leg with the patient in the left lateral decubitus position is known as the psoas sign. This
maneuver stretches the psoas major muscle, which can be irritated by an inflamed retrocecal appendix. Patients often flex the hip to
shorten the psoas major muscle and relieve pain

Diagnostic tests and Examinations

Physical exam findings are often subtle, especially in early appendicitis. As inflammation progresses, signs of peritoneal inflammation develop. Signs
include:
 Right lower quadrant guarding and rebound tenderness over McBurney's point (1.5 to 2 inches from the anterior superior iliac spine
(ASIS) on a straight line from the ASIS to the umbilicus)
 Rovsing's sign (right lower quadrant pain elicited by palpation of the left lower quadrant)
 Dunphy's sign (increased abdominal pain with coughing)
 Alvarado score- The Alvarado score for predicting acute appendicitis. The method relies on a combination of factors derived from physical
signs, symptoms, and laboratory tests and produces a numerical score used to rule in or rule out acute appendicitis. It is a well-established
and widely-used clinical decision tool that may help reduce CT usage

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 Lab Testing - Laboratory measurements, including total leucocyte count, neutrophil percentage, and C-reactive
protein (CRP) concentration, are requested to proceed with diagnostic steps in patients with suspected acute
appendicitis. Elevated white blood cells count (WBC) with or without a left shift or bandemia is classically
present, but up to one-third of patients with acute appendicitis will present with a normal WBC count. There are
usually ketones found in the urine, and the C-reactive protein may be elevated. A combination of normal WBC
and CRP results has a specificity of 98% for the exclusion of acute appendicitis. 
Imaging - Appendicitis is traditionally a clinical diagnosis. However, several imaging modalities are used to
proceed with the diagnostic steps, including an abdominal CT scan, ultrasonography, and even MRI.
CT-scan - An abdominal CT scan has greater than 95% accuracy for the diagnosis of appendicitis and is used
with increasing frequency. CT criteria for appendicitis include an enlarged appendix (greater than 6 mm in
diameter), appendiceal wall thickening (greater than 2 mm), peri-appendiceal fat stranding, appendiceal wall enhancement, the presence
of appendicolith (approximately 25% of patients). It is unusual to see air or contrast in the lumen with appendicitis due to luminal distention and
possible blockage in most cases of appendicitis. Nonvisualization of the appendix does not rule out
appendicitis.
Ultrasonography - Abdominal ultrasonography is a widely used and available primary measure to evaluate
patients with acute abdominal pain. A specific index of compressibility along with a diameter of less than 5
mm is used to exclude appendicitis. On the contrary, several pieces of evidence, including an
anteroposterior diameter of above 6 mm, an appendicolith, abnormally increased echogenicity of the peri-
appendiceal fat, are suggestive of acute appendicitis.
MRI - Despite the high sensitivity and specificity of MRI in the context of acute appendicitis identification,
major concerns with obtaining an abdominal MRI exist. Performing an abdominal MRI is not only expensive
but also demands a high level of expertise to interpret the results. Therefore, its indications are mainly limited to special groups of patients,
including pregnant women in whom an unacceptable risk of radiation exposure is embedded.

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 Treatment and Prevention
The gold-standard treatment for acute appendicitis is to perform an appendectomy. Laparoscopic
appendectomy is preferred over the open approach. Most uncomplicated appendectomies are performed
laparoscopically. Several studies have compared the outcomes with the laparoscopic appendectomy group and
patients who underwent open appendectomy. The results were suggestive of lower incidence of wound infection,
decreased level of postoperative analgesic requirement, and shorter postoperative hospital stays in the former
group. The main disadvantage of laparoscopic appendectomy is the longer operative time.
Open appendectomy might also be selected as the practical choice, specifically in the management of
complicated appendicitis with phlegmon and in the patients who are
subjected to the conversion from the laparoscopic approach mainly due to
the potential issues related to poor visibility. 
Several other alternative surgical approaches, including Natural
Orifice Transluminal Endoscopic Surgery (NOTES) and Single-incision Laparoscopic Surgery (SILS).
Practitioners also start patients on broad-spectrum antibiotics.
There's no proven way to prevent appendicitis. Eating a high-fiber diet with lots of whole grains and
fresh fruits and vegetables may help, although experts can't explain why.
Complications
If the appendix is not resected in time, it may perforate and put the patient at a greater risk of death. Other complications associated with
appendicitis include:
 Pylephlebitis
 portal venous thrombosis
 liver abscess
 bacteremia. 
The most common complication associated with both open and laparoscopic appendectomy is wound infection. There is an increased risk of wound
infection if the appendix has been perforated or if pus was present. Another postsurgical complication is the formation of a pelvic abscess. In this

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case, patients usually present several days after discharge with fever, malaise, abdominal pain, and loose stools. Depending on the size of the
abscess, management includes antibiotics and/or drainage. Rare postsurgical complications include bleeding, fecal fistula, and incisional hernia.

ANATOMY AND PHYSIOLOGY

The gastrointestinal tract is essentially a tube that extends from the mouth to the anus. It has generally the
same structure throughout. There is a hollow portion of the tube known as the lumen, a muscular layer in the
middle, and a layer of epithelial cells. These layers are responsible for maintaining the mucosal integrity of the tract.
There are three main functions of the gastrointestinal tract, including transportation, digestion, and absorption
of food. Components of the gastrointestinal system include the mouth, esophagus, stomach, small intestine, and
large intestine. The gastrointestinal tract’s accessory organs include the liver, pancreas, and gallbladder, appendix.
Mouth- functions to break down food into smaller parts. The esophagus is the tube that allows the passage of the
food bolus from the mouth to the stomach. It plays no part in the digestive process.
Stomach- functions to store, churn, and puree food into a substance known as chime. Gastric juices are secreted
by the cells of the stomach, contributing to chemical digestion
Small intestine- extends from the pylorus to the ileocecal valve. The small intestine is composed of the duodenum,
jejunum, and ileum. The primary function of the small intestine is the absorption of vitamins and nutrients, including
electrolytes, iron, carbohydrates, proteins, and fats. Most digestion of nutrients happens here
Large Intestine- extends from the terminal ileum at the ileocecal valve to the rectum. At the terminal ileum, the
large intestine becomes the ascending colon, the transverse colon, and then the descending colon. Following the
descending colon is the sigmoid colon and the rectum. The main function of the large intestine is water absorption.
Typically, the large intestine absorbs about one and one-half liters of water per day. It can, however, absorb up to
six liters
Gallbladder- is a pear-shaped, sac-like organ attached to the liver that serves as a storage facility for bile. When a large or fatty meal is consumed,
nerve and chemical signals (release of the enzyme CCK) cause the gallbladder to contract. This contraction releases bile into the digestive system.

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Liver- is a very large organ located in the upper right abdomen. Blood supply to the liver arises from both the portal vein and hepatic artery. Nearly
one-quarter of our cardiac output is delivered through the liver per minute, most of which travels through the portal vein. The blood is filtered through
the liver, which destroy debris and unwanted organisms.
Pancreas- is both an endocrine and exocrine gland. The exocrine function of the pancreas is mainly digestive in nature and involves the secretion of
pancreatic enzymes and bicarbonate
APPENDIX
 a true diverticulum arising from the posteromedial cecal border, is in close proximity to the ileocecal valve. The base of the appendix can be
reliably located near the convergence of the taeniae coli at the tip of the cecum.
 have a variable length, ranging from 5 to 35 cm, an average of 9 cm
 While the location of the appendicular orifice at the base of the cecum is a consistent anatomical
feature, the position of its tip is not. Variations in the position include retrocecal (but
intraperitoneal), subcecal, pre-ileal and post-ileal, pelvic and as far as into the hepatorenal
recess. In addition, factors such as posture, respiration, and distention of adjacent bowels can
influence the position of the appendix. 
 Due to improvement of understanding of gut immunity, a theory that the appendix is a “safe
house” for symbiotic gut microbes has emerged. Extreme bouts of diarrhea that may clear the
gut of commensal bacteria can be replaced by that contained in the appendix. This suggests an evolutionary advantage for the maintenance of
the vermiform appendix and weakens the theory that the organ is vestigial.
PATIENT’S PROFILE

Age: 20

Name: Patient X Gender: Male

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Civil status: Single Attending physician: Dr. Lamdag

Address: Polo, Dapitan City Chief Complaint: Abdominal pain

Date of Birth: 12-26-2000 Final Diagnosis: Acute Appendicitis

Place of Birth: Bohol Hx of present illness: 1 day hx of RLQ abdominal pain with anorexia,

Religion: Roman Catholic vomiting and fever. Morning PTA onset of abdominal pain worsening

Nationality: Filipino prompted on admission

Ward: Orthopedic, Male Ward Family health history: asthma, diabetes mellitus, blood dyscrasia,
hypertension
Admission date: Sept 14, 2021

Admission Time: 3:10 AM

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 PHYSICAL ASSESSMENT

Mental Status Alert, Oriented

Prosthesis none
Dentures none
Speech normal
Allergies none
Sleeping habits good
Color normal
Skin warm
Nailbeds pale
Lips pale
Eyes normal
Pupils Equal
Spontaneous Respiratory Effort YES
Chest Movement Normal
Breath Sounds No adventitious sounds
Apical Heart tones clear
Abdomen Soft & tender
Genitourinary Voided freely
Urine yellow
Baseline VS: 130/80 mmHg, PR: 95 bpm RR: 20 cpm T: 37c O2 sat: 97% Pain level: 5

LABORATORY RESULTS

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 HEMATOLOGY
EXAMINATIONS RESULTS REFERENCE VALUES
Hemoglobin 15.9 14.0-17.0 gms %
Hematocrit 47.3 42.0-52.0 vol%
RBC 53 4.7-6.1 x10^12/L
White Cells count H 11.77 5-10 x10^9/L
Differential count
Neutrophils H 90.6 40.0-73.0 %
Lymphocytes L 5.6 15.0-45.0 %
Eosinophils L 0.2 0.50-7.0 %
Monocytes L 2.6 4.0-12.0 %
Basophils 1.0 0.0-2.0 %
Platelet count 206 175-350 10^9/L
GORDON’S FUNCTIONAL HEALTH PATTERNS
USUAL INITIAL ONGOING
Health perception Admitted before due to dengue The symptoms felt were worsening Has no idea of possible
Only get medical check-up if so patient was brought to ER postoperative complications
symptoms of a condition get severe
Believes in OTC meds
Nutrition-metabolic Eat solid foods such as rice, fish, Liquid diet DAT
pork, chicken, vegetables
Elimination Urinates atleast 4x a day Urinates atleast twice a day Urinates atleast twice a day
Bowel movement: atleast 1x a day Bowel Movement: 0 Bowel Movement: 1
Activity-exercise Exercise by doing household No exercise done, mostly lying-in No exercise done; mostly lying and
chores, jogging atleast 1x a week, bed all day sitting in bed all day
playing basketball with friends
Conitive-Perceptual No difficulties with vision and No difficulties with vision and No difficulties with vision and
hearing hearing hearing

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 LEGEND
Predisposing factors
Precipitating factors
No regular eye and ear check-up
Disease processSleep-Rest Regular sleeping pattern Irregular sleeping pattern Irregular sleeping pattern
Complications Sleep at 11 pm Sleep at 9 pm Sleep at 8 pm
Wake up at 8 am Wake up during 12 am Wake up during 2 am
Signs and symptoms Sometimes take nap during the Goes back to sleep Goes back to sleep
Laboratory values afternoon Wake up at 7 am Wake up at 6:30-7:00 am
Take naps during morning and Takes nap during morning and
Nursing management afternoon afternoon
Self-perception
Nursing diagnosis Optimistic and confident Still feels optimistic but eels Still feels optimistic but feels
vulnerable due to condition vulnerable due to condition
Medical/Surgical management
Role-Relationship Lives with parents and 5 siblings Lives with parents and 5 siblings Lives with parents and 5 siblings
Sexuality-Reproductive has not yet engaged in sexual has not yet engaged in sexual has not yet engaged in sexual
activity activity activity
Coping/Stress Tolerance Handles stress by playing Scrolls through facebook and other Scrolls through facebook and other
basketball or scrolling through social media apps to handle stress social media apps to handle stress
facebook and looking at memes r/t condition r/t condition
Value-Belief Roman catholic; goes to church Prays before surgery Prays before sleeping at night
during special days like Christmas,
Birthdays or Holy week

PATHOPHYSIOLOGY

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 Genetics Low fiber diet
Male
Adolescent
Obstruction in the appendix

Decreased flow/drainage of mucosal

secretions

Increased ILP in the appendix

Vasocongestion

Decreased blood supply in the

appendix

Decreased oxygen supply in the

appendixin the appendix;
Start of tissue necrosis
bacteria invade the appendix

Disruption of appendix cell membrane

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 Start of inflammatory process

Risk for
infection

Chemical mediator release Activation of the vomiting Neutrophils to area Pus

center in medulla formation
Histamine, Prostaglandin,
Leukotrienes, Bradykinin

Stimulation of Suppression
Swelling of appendix vagus nerve of sympathetic
GI function
Prostaglandin, Bradykinin
Nausea &
vomiting
RLQ abdominal pain
Risk for Anorexia
Acute pain
deficient fluid
volume
Interleukin - I Risk for
imbalanced
N o treatment
Increased WBC nutrition less
Appendectomy and antibiotics
Inhibition ofthan
lymphatic
body and blood flow
requirements

Tissue trauma Inflammation of appendix (appendicitis)

Necrosis
Open wound
sepsis
Disruption of Ischemia
cell
membrane
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 Septic shock
Impaired tissue
Risk for Start of
integrity Rupture of appendix
infection inflammatory
d dressings. process
s of drainage Leak of contents into the
rted), omentum and surrounding tissues
ma. Prostaglandin and peritonitis
ct in good bradykinin release
septic wound
Abscess formation Small bowel
obstruction
Acute pain
Pain on surgical
Activity intolerance site

-Keep at rest in semi- death

Fowler’s position.
Good prognosis
-Provide and teach the
use of diversional
activities
-Teach patient on the
use and application of
splinting
Nursing Care Plan
Acute pain r/t surgical incision amb facial mask of pain and guarding
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective cues: At the of 8 hrs. Duty, the INDEPENDENT: At the of 8 hrs. Duty,
patient will be have the goals were:
“wait sa ma’am kay decreased pain level as  Assess pain, noting  Useful in monitoring 1. MET; Pt showed
sakit akong tahi” as evidenced by: location, characteristics, effectiveness of medication and

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stated by the patient and severity (0 to10 scale). progression of healing. Changes relaxed and well-rested
1. Relaxed and well- Investigate and report in characteristics of pain may appearance
rested appearance changes in pain, as indicate developing abscess or
Objective cues: appropriate. peritonitis, requiring prompt 2. MET; Patient
 Guarding at 2. Performs
medical evaluation and performed
incision site (RLQ nonpharmacologic pain- intervention. nonpharmacologic pain-
of abdomen) mediating techniques  Keep at rest in semi-  To lessen the pain. Gravity
 Facial grimace Fowler’s position. mediating techniques
such as deep breathing, localizes inflammatory exudate
 Pain rating of 5 into lower abdomen or pelvis, such as deep breathing,
out of 10 (10 application of splinting, relieving abdominal tension, application of splinting,
highest and 1 as use of calming music etc.  which is accentuated
Provide and teach the use use of calming music
lowest) by supine position.
3. Reports pain level from of diversional activities
 Refocuses attention, promotes etc.
VITAL SIGNS taken 5 to 2/10 (10 highest and
relaxation, and may enhance 3. MET; Reported pain
as follows: 1 as lowest) coping abilities. level from 5 to 2/10 (10
BP: 140/80 mmHg  Teach patient on the use
T:37 and application of splinting  Splinting supports the incision highest and 1 as
P:99bpm and surrounding tissues and lowest)
R: 27 cpm reduces pain during coughing,
O2:94% or strenuous movement.
Collaborative

 Administer analgesics, as
indicated:
> Tramadol 50 mg IV
>acts on pain receptors in the
central nervous system and the
brain to block pain signals to the
> Ketorolac 30 mg IV rest of the body
> block body's production of certain
natural substances that cause
 Place ice bag on abdomen inflammation.

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 periodically during initial 24
to 48 hours, as  Soothes and relieves pain
appropriate. through desensitization of nerve
endings.

Deficient knowledge related to unfamiliarity with information resources amb questions regarding postop complications
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective cues: At the of 8 hrs. duty the INDEPENDENT: At the of 8 hrs. Duty,
“unsa pa diay possible patient will develop the goals were:
mahitabo ma’am? As adequate knowledge  Identify symptoms requiring  Prompt intervention reduces
stated by the patient. regarding disease medical evaluation— risk of serious
process and potential increasing pain, edema and 1. Met; patient
complications, such as
complications as erythema of wound, delayed wound healing and verbalized
Objective cues: evidenced by: presence of drainage, and peritonitis. understanding of
 Request for 1. Verbalize fever.
 Provides information for disease process
 Review postoperative

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 information understanding of activity restrictions—heavy client to plan for return to and potential
disease process lifting, exercise, sexual usual routines without complications.
VITAL SIGNS taken activity, sports, and driving. untoward incidents.
as follows: and potential  Encourage progressive 2. Met; patient
BP: 140/80 mmHg complications. activities as tolerated with
 Prevents fatigue, promotes verbalized
T:37 periodic rest periods. healing and feeling of well-
2. Verbalize being, and facilitates understanding of
P:99bpm
R: 27 cpm understanding of resumption of normal therapeutic
O2:94% therapeutic needs. activities. needs.
3. Participate in  Recommend use of mild 3. Met; patient
treatment regimen. laxative or stool softeners  Assists with return to usual
participated fully
as necessary and bowel function; prevents
undue straining for in treatment
avoidance of enemas.
 Discuss care of incision, defecation. regimen.
including dressing changes,  Understanding promotes
bathing restrictions, and cooperation with therapeutic
return to physician for regimen, enhancing healing
suture and staple removal. and recovery process.
Risk for infection r/t increased environmental exposure to pathogens-surgical incision
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective cues: At the of 8 hrs. Duty, the INDEPENDENT: At the of 8 hrs. Duty,
patient will no longer be the goals were:
at risk for infection as  Monitor vital signs. Note  Suggestive of presence of
Objective cues: manifested by: onset of fever, chills, infection or
 Presence of diaphoresis, changes in developing sepsis, abscess, 1. Met; Signs of
incision site 1. Timely wound mentation, reports of peritonitis. timely wound
 Elevated WBC increasing abdominal pain.
healing  Provides for early detection healing evident
count on lab  Inspect incision and
values pre-op 2. Free of signs of dressings. Note of developing infectious 2. Met; Incision site
infection and characteristics of drainage process and monitors was free of signs

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VITAL SIGNS taken inflammation, from wound (if inserted), resolution of preexisting of infection and
as follows: purulent drainage, presence of erythema. peritonitis. inflammation,
BP: 140/80 mmHg  Practice and instruct in
T:37 erythema and good handwashing and  Reduces risk of spread of purulent
P:99bpm fever. aseptic wound care bacteria. drainage,
R: 27 cpm 3. Able to erythema and
O2:94% Collaborative
demonstrate fever.
proper wound care  Administer antibiotics as 3. Met: patient was
 acts by inhibiting bacterial
and infection indicated: able to practice
cell wall synthesis.
>Cefuroxime 750 mg IV
control (proper  Stops the growth of certain proper wound
>Metronidazole 500 mg bacteria and parasites
handwashing) care and
IV
infection control
  May be necessary to (proper
 Prepare and assist with
drain contents of localized
incision and drainage handwashing)
abscess.
(I&D) if indicated.

DRUG STUDY
GENERIC (TRADE) NAME/ MECHANISM OF ACTION  SIDE EFECTS NURSING RESPONSIBILITIES
CLASSIFICATION

 Ketorolac inhibits key Common side effects of Toradol  Watch for S&S of GI
pathways in prostaglandin include: ulceration and bleeding
synthesis which is crucial to (e.g., bloody emesis, black
it's mechanism of  headache, tarry stools) during long-
action. Although ketorolac  heartburn, term therapy.

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 is non-selective and inhibits  upset stomach,  Note: Possible CNS
both COX-1 and COX-2  nausea, adverse effects (e.g., light-
enzymes, it's clinical  vomiting, headedness, dizziness,
efficacy is derived from it's  diarrhea, drowsiness).
COX-2 inhibition. The  stomach pain,  Do not drive or engage in
COX-2 enzyme is inducible  bloating, potentially hazardous
and is responsible for activities until response to
 gas,
converting arachidonic acid drug is known.
 constipation,
to prostaglandins that  Do not use other NSAIDs
mediate inflammation and  dizziness, while taking this drug.
pain.  drowsiness,  Do not breast feed while
 sweating, taking this drug.
 and ringing in the ears.
GENERIC NAME:
 Ketorolac

BRAND NAME:
 Toradol

CLASSIFICATION:
 Penicillins, Amino

GENERIC (TRADE) NAME/ MECHANISM OF ACTION  ADVERSE EFFECTS NURSING RESPONSIBILITIES

CLASSIFICATION

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  Binds to mu-opioid Frequent (25%–15%): Monitor pulse, B/P, renal/hepatic
receptors, inhibits reuptake Dizziness, vertigo, nausea, function.
of norepinephrine, constipation, headache, Assist with ambulation if dizziness,
serotonin, inhibiting drowsiness. vertigo occurs.
ascending and descending Occasional (10%–5%): Dry crackers, cola may relieve
pain pathways. Vomiting, pruritus, CNS nausea.
 Therapeutic Effect: stimulation (e.g., Palpate bladder for
Reduces pain nervousness, anxiety, urinary retention.
agitation, tremor, euphoria, Monitor daily pattern of bowel
mood swings, hallucinations), activity, stool consistency.
GENERIC NAME: asthenia, diaphoresis, Sips
 TRAMADOL dyspepsia, dry mouth, of water may relieve dry mouth.
BRAND NAME: diarrhea. Assess for clinical improvement,
 ConZip Rare (less than 5%): record onset of relief of pain.
Malaise, vasodilation, Patient/family teaching
 Synapryn FusePaq
anorexia, flatulence, rash, • May cause dependence.
 Ultram blurred vision, urinary • Avoid alcohol, OTC medications
CLASSIFICATION: retention/frequency, (analgesics, sedatives).
Centrally acting synthetic opioid. menopausal symptoms. • May cause drowsiness,
CLINICAL: Analgesic. dizziness, blurred vision.

GENERIC (TRADE) NAME/ MECHANISM OF ACTION  ADVERSE EFFECTS NURSING RESPONSIBILITIES

CLASSIFICATION

24
  Binds to bacterial cell Frequent: Discomfort with IM Assess oral cavity for white
membranes, inhibits cell administration, oral candidiasis patches on mucous membranes,
wall synthesis. (thrush), mild diarrhea, mild tongue (thrush).
 Therapeutic Effect: abdominal cramping, vaginal Monitor daily pattern of bowel
Bactericidal. candidiasis. activity, stool consistency.
Occasional: Nausea, Mild GI effects may be tolerable
serum sickness–like reaction (increasing severity may indicate
(fever, joint pain; usually onset of antibiotic-associated
occurs after second course of colitis).
therapy and resolves after Monitor I&O, renal function tests
GENERIC NAME: drug is discontinued). for nephrotoxicity.
 CEFUROXIME Rare: Allergic reaction (rash, Be alert for superinfection: fever,
pruritus, urticaria), vomiting, diarrhea, anal/genital
BRAND NAME:
thrombophlebitis (pain, pruritus, oral mucosal changes
 Ceftin redness, swelling at (ulceration, pain, erythema).
 Zinacef injection site).
CLASSIFICATION:
Second-generation cephalosporin.
CLINICAL: Antibiotic.

GENERIC (TRADE) NAME/ MECHANISM OF ACTION  ADVERSE EFFECTS NURSING RESPONSIBILITIES

CLASSIFICATION

25
  Disrupts DNA, inhibiting Frequent: Systemic: Anorexia, Monitor daily pattern of bowel
nucleic acid synthesis. nausea, dry mouth, metallic activity, stool consistency.
Therapeutic Effect: Produces taste. Monitor I&O, assess for urinary
bactericidal, antiprotozoal, Vaginal: Symptomatic problems.
amebicidal, trichomonacidal cervicitis/vaginitis, abdominal Be alert to neurologic symptoms
effects. Produce anti- cramps, uterine pain. (dizziness, paresthesia of
inflammatory, Occasional: extremities).
immunosuppressive effects Systemic: Diarrhea, Assess for rash, urticaria.
when applied topically constipation, vomiting, Urine may be red-brown or dark.
dizziness, erythematous rash, Avoid alcohol, alcohol-containing
urticaria, reddish-brown urine. preparations (cough syrups,
GENERIC NAME: Topical: Transient erythema, elixirs) for atleast 48 hrs after last
 METRONIDAZOLE mild dryness, burning, dose.
BRAND NAME: irritation, stinging, tearing Avoid tasks that require alertness,
 Flagyl when applied too close to motor skills until response to drug
eyes. is established.
 Metro
Vaginal: Vaginal, perineal,
 Noritate vulvar itching; vulvar swelling.
 Vandazole Rare: Mild, transient
CLASSIFICATION: leukopenia; thrombophlebitis
Nitroimidazole derivative. with IV therapy.
CLINICAL: Antibacterial,
antiprotozoal.

RELATED ARTICLES

The Decreasing Incidence of Acute Appendicitis During COVID-19: A Retrospective Multi-centre Study
By James Tankel, Aner Keinan, Ori Blich, Michael Koussa, Brigitte Helou, Shahaf Shay, Diaa Zugayar, Alon Pikarsky, Haggi Mazeh, Spira, Petachia Reissman
Published online: 26 May 2020

26
 Abstract
Background
As the novel coronavirus disease 19 (COVID-19) spreads, a decrease in the number of patients with acute appendicitis (AA) has been noted
in our institutions. The aim of this study was to compare the incidence and severity of AA before and during the COVID-19 pandemic.

Methods
A retrospective cohort analysis was performed between December 2019 and April 2020 in the four highvolume centres that provide
healthcare to the municipality of Jerusalem, Israel. Two groups were created. Group A consisted of patients who presented in the 7 weeks prior to
COVID-19 first being diagnosed, whilst those in the 7 weeks after were allocated to Group B. A comparison was performed between the
clinicopathological features of the patients in each group as was the changing incidence of AA.

Results
A total of 378 patients were identified, 237 in Group A and 141 in Group B (62.7% vs. 37.3%). Following the onset of COVID-19, the weekly
incidence of AA decreased by 40.7% (p = 0.02). There was no significant difference between the groups in terms of the length of preoperative
symptoms or surgery, need for postoperative peritoneal drainage or the distribution of complicated versus uncomplicated appendicitis.

Conclusions
The significant decrease in the number of patients admitted with AA during the onset of COVID-19 possibly represents successful resolution of
mild appendicitis treated symptomatically by patients at home. Further research is needed to corroborate this assumption and identify those patients
who may benefit from this treatment pathway
Global attitudes in the management of acute appendicitis during COVID‐19 pandemic: ACIE Appy Study
B Ielpo, M Podda, G Pellino, F Pata, R Caruso, G Gravante, S Di Saverio, ACIE Appy Study Collaborative Published: 08 October 2020
Abstract

27
Background
Surgical strategies are being adapted to face the COVID‐19 pandemic. Recommendations on the management of acute appendicitis have
been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to
appendicitis.

Methods
The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the
management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and
screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic.

Results
Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and
those without COVID. There was variation in screening indications and modality used, with chest X ‐ray plus molecular testing (PCR) being the
commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent
respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P < 0·001). One‐third changed their approach from laparoscopic to open
surgery owing to the popular (but evidence‐lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter
surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and
one‐third felt that patients who did present had more severe appendicitis than they usually observe.

Conclusion
Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open
appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS‐CoV19

REFERENCES

BOOKS

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1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2006). Nursing care plans: Guidelines for individualizing client care across the life span.
Philadelphia: F.A. Davis Co
2. Hodgson, B. B., & Kizior, R. J. (1998). Saunders nursing drug handbook. Philadelphia: Saunders.
3. McCance, K.L. & Huether, S.E. (2017). Understanding Pathophysiology: The Biologic Basis for Disease in Adults and Children (6th ed.). St.
Louis: Elsevier/Mosby
4. Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2019). Essentials for Nursing Practice (9th ed.). St. Louis: Elsevier.
JOURNALS & ARTICLES

5. B Ielpo, M Podda, G Pellino, F Pata, R Caruso, G Gravante, S Di Saverio, ACIE Appy Study Collaborative, Global attitudes in the
management of acute appendicitis during COVID‐19 pandemic: ACIE Appy Study, British Journal of Surgery, Volume 108, Issue 6, June
2021, Pages 717–726, https://doi.org/10.1002/bjs.11999
6. Breeding, E., & Conran, R. M. (2020). Educational Case: Acute Appendicitis. Academic Pathology. https://doi.org/10.1177/2374289520926640
7. Humes, D. J., & Simpson, J. (2006). Acute appendicitis. BMJ (Clinical research ed.), 333(7567), 530–534.
https://doi.org/10.1136/bmj.38940.664363.AE
8. Hodge BD, Kashyap S, Khorasani-Zadeh A. Anatomy, Abdomen and Pelvis, Appendix. [Updated 2021 Aug 11]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459205/
9. Tankel, J., Keinan, A., Blich, O., Koussa, M., Helou, B., Shay, S., ... & Reissman, P. (2020). The decreasing incidence of acute appendicitis
during COVID-19: a retrospective multi-centre study. World Journal of Surgery, 44, 2458-2463.

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