1. Systems Plus College Foundation
Balibago, Angeles City Pampanga
In partial fulfillment of the Course requirements in
Related Learning Experience
Medical-Surgical Nursing
1stSemester A.Y. 2012-2013
Case Report
“Appendectomy”
Presented to
Arnel Jay Sali, RM, RN, MSN
Presented by
Princess Hannah Kelly Gepte
July 24, 2012
2. I. Introduction
Surgery is an important technique used to diagnose or to treat illness or injury
with the goal of restoring patients to an acceptable state of health, or for cases in which
disease is nonrecoverable, to alleviate distress.
Appendectomy is the most common emergent surgical procedure performed
worldwide. It is a surgery to remove the appendix. There are two types of appendectomy,
the “open appendectomy” and the “laparoscopic appendectomy”. Most appendectomies are
now done laparoscopically, expect in cases where rupture is suspected. It is usually
performed on people with appendicitis (inflammation of the vermiform appendix). The
appendix is a small, finger-like shaped sac that attached to the cecum of the large intestine.
If the appendix ruptures or perforates before surgery, its infected contents spill into the
peritoneal cavity, possibly causing peritonitis. The perforation of the appendix is the most
common and fatal complication of appendicitis, with a mortality rate of 10%. Appendicitis
occurs in approximately 7% of the population and affects males more than females. It
occurs more in the teenagers than adults and most commonly occurs between the ages of
10 and 30 years. Statistics in the Philippines shows that about 215,604 of the 86,241,697
Filipinos had an incident of appendicitis.
According to the US national Library of Medicine National Institute of Health there
is a new method of mini invasive surgery called Natural Orifice Transluminal Endoscopic
Surgery it involves passing surgical instruments, and a tiny camera through a natural orifice,
such as the mouth, vagina, urethra or rectum, provides the access to the desired organ. An
operation called “Transvaginal Appendectomy” was performed in Caucasus- Academician
N. Kipshidze University Hospital in Tbilisi. They performed it on two patients the first case
was a 28-year old woman with 48 hours acute appendicitis and the second case was a 22-
year old woman with 24 hours acute appendicitis. Both operations were performed under
general anesthesia. The duration of the first procedure was 76 minutes and the second
operation lasted for 88 minutes. The operations were made without any technical difficulties
or complications. None of the patients had the need of non-narcotic analgesia during post-
operational period, no gynecological or surgical problems or any complications were
detected during observation period. The benefits of the procedure are less pain, quicker
recoveries, fewer complications and no scar. It can also avoid major incisions through the
3. skin, muscle and nerves of the abdomen. They also considered the procedure to be the
most safe and feasible for clinical application.
As a nursing student we must know how the procedure is performed, it is
important to know your role and responsibility in the operating room, to know what might me
the complications that may occur during the procedure.
(http://www.ncbi.nlm.nih.gov/pubmed/19359710Tabutsadze T, Kipshidze N.
Academician N. Kipshidze Central University Hospital, Tbilisi, Georgia, 2009
Contemporary Medical-Surgical Nursing 2nd Edition 2012 by Rick Daniels and Leslie Nicoll)
4. II. The Surgical procedure
A. Description of the Procedure
Appendectomy is a surgical procedure for patients diagnosed of appendicitis to remove
inflamed appendix. A common emergency surgery, an appendectomy aims to prevent rupture or
perforation of the appendix. The appendix sometimes gets blocked and becomes infected and
swollen. Signs of an infected appendix include abdominal pain in the lower right side, fever,
poor appetite, nausea and vomiting. If the appendix bursts, another complications will occur.
Appendectomy is usually performed before these complications occur, an appendectomy is
usually effective. If the appendix ruptures or perforates before surgery, its infected contents spill
into the peritoneal cavity, possible causing peritonitis. This is the most common and fatal
complications of appendicitis. There are two ways to do this surgery:
• Open appendectomy – a single
incision is made in the abdomen. The
doctor works through this larger
incision to remove the appendix. The
surgeon makes an incision about 2 to
4 inches long in the lower right side of
the abdomen and cuts through fat and
muscle layers to the appendix. The
appendix is removed from the
intestine. The area is washed with
sterile fluid to decrease the risk of
further infection. A small drainage
tube may be placed going from the
inside to the outside of the abdomen.
The drain is usually removed in the
hospital. The site is closed with
sutures or staples or covered with glue-like bandage and steri-strips.
5. • Laparoscopic appendectomy - 3 or 4
small incisions are made in the
abdomen. The doctor uses a camera
and tools through the small incisions to
remove the appendix. A port (nozzle) is
inserted into one of the slits, and carbon
dioxide gas inflates the abdomen. This
process allows the surgeon to see the
appendix more easily. A laparoscope is
inserted through another port. It looks
like a telescope with a light and camera
on the end so the surgeon can see
inside the abdomen. Surgical
instruments are placed in the other small
openings and used to remove the
appendix. The area is washed with
sterile fluid to decrease the risk of further infection. The carbon dioxide comes out through
the slits, and then the sites are closed with sutures or staples or covered with glue-like
bandage and steri-strips.With this type of surgery, you may recover faster, have less pain,
less scarring, fewer wound problems and often spends less time in the hospital.
• Non surgical - If you only have some of the signs of appendicitis, your surgeon may monitor
you to see if the symptoms get any worse. If you have an abscess (a collection of pus), your
surgeon may treat you with antibiotics first and may have you come back for elective surgery
in 4 to 6 weeks.
6. B. Indications
Appendicitis
- Is the inflammation of a narrow, blind protrusion called the vermiform appendix
located at the tip of the cecum in the right lower quadrant of the abdomen.
- The most common cause of acute surgical abdomen. Although it can occur at any
age, it more commonly occurs between the ages of 10 to 30 years.
The patient with appendicitis has relatively predictable clinical manifestations.
o There is periumbilical pain that may initially be vague and generally spread
over the lower abdominal region. Later, the pain localizes in the RLQ at
Mcburney’s point. The pain is worse when manual pressure near the region is
suddenly released.
o Low-grade fever.
o It may also be possible to elicit Rovsing’s sign.
o Reduced appetite (anorexia)
o Nausea; vomiting
Classifications of Appendicitis
1. Simple – Appendix is inflamed but is still intact.
2. Gangrenous –There is tissue necrosis and microscopic areas of perforation.
3. Perforation –There is large perforation, which involves contents flowing into the
peritoneal cavity.
8. Instruments for Laparoscopy
Insufflator
Veress needle
Laparoscope
5mm claw grasper
5mm dolphin-nose grasper
Endo GIA™ 30 with cartridges (white/blue)
D. Perioperative Responsibilities
Preoperative management
• All diagnostic tests and procedures are explained to promote cooperation and relaxation.
• The patient is prepared for the type of surgical procedures as well as the post operative
care.
• Measures to prevent postoperative complication are taught, including coughing, turning,
and deep breathing using splint at the incision site.
• I.V fluids or total parenteral nutrition before surgery maybe ordered to improved fluid and
electrolyte balance and nutritional status.
• Intake and output is monitored.
• Preoperative laboratory are obtained.
• Bowel cleansing will be initiated 1 to 2 days before surgery for better visualization.
• Antibiotics are ordered to decrease the bacterial growth in the colon.
• Patient may not have anything by mouth after midnight the night before surgery.
Medication may be withheld, if ordered. This will keep the GI tract clear.
9. Intraoperative Management
• Position the patient on the OR table
• Skin preparation
• Induction of anesthesia
• Procedures done aseptically
• Closing of the incision
• Dressing of the site
Postoperative Management
• Monitor vital signs for sign of infection and shock such as fever, hypotension and
tachycardia.
• Monitor I and O for sign of imbalance, dehydration, and shock.
• Assess abdomen for increased pain, distention, rigidity, and rebound tenderness
because these may indicate postoperative complications.
• Evaluate dressing and incision.
• Evaluate the passing of flatus or feces
• Monitor for nausea and vomiting.
• Laboratory values are monitored and patient is evaluated for sign and symptoms
of electrolyte imbalances.
• Wound drains, I.V, and all other catheter are monitored and evaluated for signs
of infections.
• Turning, coughing, deep breathing and incentive spirometry is performed every 2 hours.
• Diet is advanced as ordered.
• Administration of medications as ordered
• Patient Education and Health Maintenance
• Instruct patient to avoid heavy lifting for 4 to 6 weeks after surgery.
• Instruct patient to report symptoms of anorexia, nausea, vomiting, fever,
abdominal pain, incisional redness and drainage postoperatively.
• Teach patient and family to care for the wound and perform dressing changes and
irrigations as prescribed.
• Reinforce need for follow-up appointment with surgeon.
E. General Effects of the procedure on the patient
- As we all know the appendix is part of the human immune system. A client who
undergoes appendectomy appears to cause no change in digestive function or
overall lifestyle, and living without the appendix does not cause any problems
regarding in our health.
10. a. Medical Management
1. Ceftriaxone – Bactericidal/Antibiotic
• Perioperative Prophylaxis
2. Tramadol – Analgesic
• Relief of moderate to severe pain
3. Ketorolac – NSAIDs
• Short term management of pain
4. Cefotiam Hydrochloride - Antibiotic
• Prophylaxis for surgical infection, postoperative infections
III. Conclusion
The surgical journey begins when the patient first becomes aware of the need for
surgery and ends when the patient is well enough to go home or to an intermediate care facility.
I have learned that the perioperative experience may be one if the most tension periods of
hospitalization. It is important to know your responsibilities. For the patient this is the period
where they are vulnerable and very afraid.
I have also learned that the duty of a scrub nurse is working directly with the surgeon
within the sterile filed, passing instruments and other things needed during the operation, and
always maintain sterility. The duty of the circulating nurse are done outside the sterile field,
he/she counts the instruments that was used, the nurse must have a critical thinking skills, as
he/she observes the operation and assist the surgical team to provide a safe and comfortable
environment.
I have also learned in this case report the responsibilities of the nurse during
appendectomy, the types of surgery, the purpose of the appendix in our body, the risk and
complications of appendicitis and how the procedure is performed.
References:
https://www.healthinfotranslations.org/pdfDocs/Appendectomy.pdf 2008
http://www.surgeons.org.uk/general-surgery-operation-howto/open-appendicectomy.html 2010
http://www.medical-tools.com/shop/appendectomy-set.html
Medical-Surgical Nursing by Wolters Kluwer| Lippincott Williams & Wilkins 2008 2nd Edition
11. Medical-Surgical Nursing Volume 2 Sixth Edition 2010 by Ignatavicius and Workman
Contemporary Medical-Surgical Nursing 2nd Edition 2012 by Rick Daniels and Leslie Nicoll
Introductory Medical-Surgical Nursing Ninth Edition 2007 by Barbara K. Timby and Nancy E.
Smith
http://www.umm.edu/patiented/articles/appendectomy_normal_anatomy_000104_1.htm 2009
http://www.scribd.com/doc/28298226/Appendicitis-Appendectomy-ppt 2010
http://www.webmd.com/digestive-disorders/picture-of-the-appendix 2008
Contemporary Medical-Surgical Nursing 2007 by Rick Daniels, Laura Nosek and Leslie Nicoll