Presenting complaints: This is a presentation of a 14 year old female known as Mary X. who presented with a right side abdominal pain of 6 hours duration (started since 10am). Reason for admission/ History of presenting complaints: Mary’s abdominal pain begins near the belly button with tenderness around the central abdomen. This pain with a dull consistency at onset later increased in severity as it moves towards the right lower abdominal region. The pathophysiology that is associated with this condition is that which is caused by the fecalith blocking the appendix in about 50-80 percent of cases while in the remaining cases are those which are related to blockage by gallstone or tumor (Kumar, Abbas, & Fausto, 2005).
The obstruction is what results in the continuous secretion of mucin in this blocked appendix. This subsequently causes a progressive increase in intraluminal pressure which eventually affects the veins draining the region hence the collapse of those veins. The resultant effect of this is the ischemic injury which supports bacterial proliferation with inflammatory edema and exudation (Kumar, Abbas, & Fausto, 2005). The factor responsible for the pain moving from the region of the navel towards the lower right abdominal regions relates to pain referral which is usually due to nerve supply of that region. However, the movement down is basically due to the increased in severity of the pain which is due to cause by worsening of the condition. This lower right abdominal region is known as the McBurney's point (the main location of the appendicitis where the blockage and accumulation of mucin occurs).
One other effect of these changes can be linked to some other symptoms that get worsened with the appendicitis. These are the movement, jumping, coughing and deep breaths. These are part of the features that could be used to make an emergency diagnosis of the condition. There has not been any associated history of vomiting but there was nausea and decreased appetite. There is also no associated history of constipation or diarrhea (although there was a history of diarrhea in the past).
Mary actually presented earlier to her general practitioner (GP) at an emergency unit before she was referred here. According to the GP's report, while she presented there, the only noticeable symptoms were the right abdominal pain, past history of diarrhoea, temperature of 37.2 degree celcius. Laboratory test conducted by the GP showed a normal colour but unformed fecal faecal specimen. The calprotectin faeces conducted showed a result of 97. This is a biochemical test that is normally used as a form of sensitive marker to evaluate intestinal inflammation especially to distinguish between the inflammatory bowel disease occurrences from that of functional bowel disease. One major merit about this test can be associated with its discriminative power to help exclude the need for any form of invasive test that is usually done to diagnose inflammatory bowel disease. Calprotectin values around 55 percent shows that there is a need for invasive test while it is negative once it is in the region of 99 percent (Rheenen, Vijver, & Fidler, 2010).
The increased abdominal pain with decreased appetite is the only major feature that could be linked with any lower abdominal pain problem such as appendicitis. This is simply because of the fact that not all patients show all the classical appendicitis signs and symptoms. The faecal claprotectin test conducted by the GP also helps to narrow down the problem to help make a definitive nursing diagnosis. Past Medical History: There is no past medical history relating to the current presentation from the information presented by the client.
Allergies: From the patient’s history, there is no drug or other forms of allergies.
Medications: Cephazolin IV is an antibiotic that is normally used for treating a wide spectrum or variety of bacterial infections or during surgical procedures. It is also known as cephalosporin antibiotics which normally work by stopping the growth of the bacteria it acts on. Dosage is 800mg, 6hourly for 24hour. Codeine is an opioid analgesic that is used to treat mild to moderately severe pain. It is a narcotic agonist analgesic that works on mu receptor agonist. Dosage is 30 mg orally or IM 6hourly.
Paracetamol is acetaminophen that is used to relieve pain and reduce fever. Exact mechanism for this action is unknown. Some of the conditions in which it can be used to treat are the headache, muscle aches, arthritis and toothache. It should not be taken more than 4000mg per day to avoid damage to the liver. Do not use if you are allergic to it.
Tramadol is a narcotic-type of pain reliever which is used to treat moderate to severe pain. There is an extended-release version which is better to treat the moderate to severe chronic pain especially when such treatment is needed through out the day. Do not take if you are allergic to it. It is also not good for someone that is addicted to alcohol or have attempted suicide. It is more likely to cause seizure in patients with history of seizures or head injury. The good thing about it is that it can be taken without food.
Naloxone injection is the type used in post-op patients to prevent or reverse the effects of opiate overdose. Those effects are breathing difficulty, sleepiness, low blood pressure and death. The opiate has been given the patient during the surgery hence the effects needs to be reveres. This medication is also used to diagnose opiate overdose cases. It is an opiate antagonists. It is an intravenous or intramuscular injection. Adults and children has seperate doses. Some of the side effects include; nausea, vomiting, pain, sweating, flushing, chestpain, shortness of breath and loss of consciousness.
Ondansetron is a medication that is used to prevent nausea and vomiting situations which are related to cancer chemotherapy, radiation therapy and surgery. It belongs to the class of serotonin receptor antagonists. The action is via the blockage of serotonic receptors. It is made in form of tablets and this is taking by mouth.
Clinical diagnosis: Acute pain of lower abdominal pain secondary to appendicitis.
Another important feature relating to the pathophysiology is that of the recruitment of the white blood cells and formation of pus. This is what actually contributes to the increased intraluminal pressure that continues over time to a level that tends to lead to venous flow obstruction. Once this venous flow obstruction continues too, there is associated appendiceal wall ischemia which starts to cause a major problem around the region it tends to drain. The subsequent histological changes associated with this are the resultant loss of epithelial integrity. Once this changes starts, bacterial then takes over by invading the appendiceal wall resulting in inflammation. All this changes tend to occur within few hours. The thrombosis of the appendicular artery and veins at the region has been considered to also contribute to the localized condition. Later, there is risk of perforation and gangrene (Kumar, Abbas, & Fausto, 2005).
The factor responsible for the pain moving from the region of the navel towards the lower right abdominal regions relates to pain referral which is usually due to nerve supply of that region. However, the movement down is basically due to the increased in severity of the pain which is due to cause by worsening of the condition. This lower right abdominal region is known as the McBurney's point (the main location of the appendicitis where the blockage and accumulation of mucin occurs).
Nursing Assessment: From the medical history, a definitive diagnosis of acute appendicitis of the lower right abdomen is clear. This was linked all the relevant physical findings such as; acute lower abdominal pain, nausea, no vomiting, decrease appetite, No fever, no constipation, nor painful urination, or pain while moving, jumping or coughing all supports the diagnosis.
The results of the examination such as the tenderness of the abdomen that was initially dull but eventually increased in severity within few hours of onset. The feacal Calprotectin is also negative. All point towards the nursing diagnosis of acute lower abdominal pain secondary to appendicitis.
Priorities Nursing care
Pain management is an important nursing aspect of care that needs to be given the patient simply because this patient is a post-op patient with less few hours after surgery. One of the most important nursing care that need to be priorities for the patient.
Pain management is an important key to helping postoperative patients. Simply because this is usually the commonest patient's presenting symptoms or complaint's, it is essential that it must be properly managed. Nurse needs to manage the patient’s pain symptoms by using the available clinical information. The pain must also be managed wherever the patient is located (In case of Mary, in the ward). Nurse also ensures that the pain management is not delayed or patient is being transported to another location without analgesia. These are some of the reasons why it is usually the lead priority in nursing care. One other important technique that also needs to be considered when managing patients pain symptoms is to give analgesia gradually and monitor effects for about 5-10minutes before leaving the patient.
Patients need to be mobilized frequently. This might include moving Mary from bed to the chair. This frequent movement must be at least three times daily. The aspect of mobilization is an important aspect that needs to be implemented because it helps prevent bed sore and also help patient gets out of the bed easily and on time. This will also help the patient to have a fast recovery from the surgery considering the fact that one of the major problems associated with the symptoms of the appendicitis is the problem with movements considering the pain which always result from moving around.
Implementing the frequent small soft diet will be done based on the patient nursing care plan. It is essential to have this done as it helps the patient to cope with the healing process that involved the gastrointestinal region. The patient needs to maintain adequate nutrition only by soft and small diet however this must be somewhat frequent. The rationale for this type of soft diet early oral feeding for Mary is simply to prevent the concomitant weight loss and muscle wasting associated with diet restriction post-op. It also helps the patients to improve the organic responses to any form of stress and facilitate fast recovery.
Mary presented with acute lower right abdominal pain simply because of the pathophysiology of the appendicitis which occur as a result of blockage of the appendix structure by fecaliths. Since the appendix is located on the right side of the abdomen posteromedial to the cecum in most situation. It also found to lie beneath the peritoneum covering of the cecum. All these anatomy are not the permanent anatomical feature of the appendix. It is becauase of this special anatomy that causes the increased intraluminal pressure to damage the structure of the draining veins of the appendix. The obstruction is what results in the continuous secretion of mucin in this blocked appendix. This subsequently causes a progressive increase in intraluminal pressure which eventually affects the veins draining the region hence the collapse of those veins. The resultant effect of this is the ischemic injury which supports bacterial proliferation with inflammatory edema and exudation (Kumar, Abbas, & Fausto, 2005).
The factor responsible for the pain moving from the region of the navel towards the lower right abdominal regions relates to pain referral which is usually due to nerve supply of that region. However, the movement down is basically due to the increased in severity of the pain which is due to cause by worsening of the condition. This lower right abdominal region is known as the McBurney's point (the main location of the appendicitis where the blockage and accumulation of mucin occurs). One other effect of these changes can be linked to some other symptoms that get worsened with the appendicitis. These are the movement, jumping, coughing and deep breaths. These are part of the features that could be used to make an emergency diagnosis of the condition.
Discuss delegated aspects of collaborative care: This simply described the importance of having a form of delegated care which helps add satisfaction to the working environment. This is done in such a way that nursing care is delegated to nursing staff so as to achieve an effective job completion. The competency of each staff always influences the aspect of job delegation in a collaborative care. This will reduce the workload and create an effective collaborative care that gives the patient the best.
In this model, the team is led by an appropriately skilled nurse who tends to take the full responsibility of the team. The different level of nursing works are then shared among the various levels of nurses according to their skills and level but with a shared goal to meet the comprehensive holistic need of the patient or groups of patients. This delegated aspect helps to improve the patient outcomes and satisfactions. It also reduce incidence of risk of missed care that could be associated with an individual nursing care. One important point at this delegated aspect is that it also allows nurses that are at different levels of nursing training and expertise to perform their duty and functions more effectively. It also reduces any form of isolation thereby helping the nurse with delegated aspect to share their burden.
Relevant referrals/patient advocacy/family and/or whanau support: The relevant referrals in case of Mary is for the GP to help assess the surgical wound after a week post-op. Patient will be given post-op instruction as regards the use of medication, avoiding stress and continue eating soft diet. Family was advice on how to cooperate with the patient and care for her.
Atahan, K., Aslan, E., Ureyen, O., Cokmez, A., & Tarcan, E. (2012). Effect of Time in the development of perforated Appendicitis. Journal of Current Surgery. Vol 2, Number 1, Feb 2012, pages 11-16.
Ashdown et al, (2012). Pain over speed bumps in diagnosis of acute appendicitis: diagnostic accuracy study. British medical journal. Research. BMJ 2012: Vol 345: e8012
Retrieved 5 November, 2013 from http://www.bmj.com/content/345/bmj.e8012
Bouassria et al (2013). Traumatic appendicitis: a case report and literature review. Review. World Journal of emergency surgery.
Retrieved 29 October, 2013 from http://www.wjes.org/content/8/1/31
Chow, A., Aziz, O., Purkayastha, S., Darzi, A., & Paraskevas. (2010). Single incision laparoscopic surgery for acute appendicitis: Feasibility in pediatric patients. Research Article. Diagnostic and Therapeutic Endoscopy Volume 2010(2010), Article 294958.
Retrieved 5 November, 2013 from http://www.hindawi.com/journals/dte/2010/294958/
Dugdale, D.C. (2011). Appendicitis. MedlinePlus.
Retrieved 29 October, 2013 from http://www.nlm.nih.gov/medlineplus/ency/article/000256.htm
Humes, D.J. & Simpson, J. (2006). Acute Appendicitis. Clinical Review.
Retrieved 29 October, 2013 from http://www.bmj.com/content/333/7567/530
Kumar, V. Abbas, A.K., & Fausto, N. (2005). Appendicitis. Robbins and Cotran pathologic basis of disease, 7th Edition. Elsevier. Page 927
Kyuseok et al, (2012). Low-Dose Abdominal CT for evaluating suspected appendicitis. The New England Journal of Medicine. Original Article. N Engl J Med 2012; 366:1596-1605
Lowenfels, A.B. (2013). Single-Port Umbilical vs Conventional Laparoscopic Appendectomy. Pathology and Lab medicine.
Retrieved 29 October, 2013 from http://www.medscape.com/viewarticle/804825
Medscape (2013). Dosing and Uses. Cefazolin (Rx). Reference.
Retrieved 29 October, 2013 from http://reference.medscape.com/drug/kefzol-cefazolin-342492
Medscape (2013). Pharmacology. Codeine (Rx). Reference.
Retrieved 29 October, 2013 from http://reference.medscape.com/drug/codeine-343310#10
Retrieved 28 October, 2013 from http://digestive.niddk.nih.gov/ddiseases/pubs/appendicitis/
NIH, (2013). Naloxon Injection. MedlinePlus.
Retrieved 4 November, 2013 from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a612022.html
NIH, (2013). Ondansetron. MedlinePlus.
Retrieved 4 November, 2013 from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a601209.html
Panidis et al, (2011). Acute appendicitis secondary to Enterobius vermicularis infection in a middle-aged man: a case report. Case Report. Journal of Medical Case Reports. Vol 5.
Retrieved 4 November, 2013 from http://www.jmedicalcasereports.com/content/5/1/559
Rheenen, P.F., Vijver, E.V., & Fidler, V., (2010). Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis. Research. BMJ.
Retrieved 29 October, 2013 from http://www.bmj.com/content/341/bmj.c3369
Roberts, K.E., & Kulkarni, R. (2013). Single-Port Appendectomy. Medscape.
Retrieved 29 October, 2013 from http://emedicine.medscape.com/article/1533419-overview
Sanjay et al (2009). Acute appendicitis presenting as small bowel obstruction: two case reports. Cases Journal.
Retrieved 28 October, 2013 from http://www.casesjournal.com/content/2/1/9106
Shuhatovich Y & Roberts, K.E., (2011). Laparoscopic Appendectomy. Medscape.
Retrieved 29 October, 2013 from http://emedicine.medscape.com/article/1582228-overview
Stoppler, M.C. & Marks, J.W (2013). Appendicitis facts. MedicineNet.
Retrieved 28 October, 2013 from http://www.medicinenet.com/appendicitis/article.htm
Styliani et al, (2011). Acute appendicitis caused by endometriosis: a case report. Journal of medical case reports. Vol 5.
Retrieved 5 November, 2013 from http://www.jmedicalcasereports.com/content/5/1/144
Tibble et al, (2001). Faecal calprotectin and faecal occult blood tests in the diagnosis of colorectal carcinoma and adenoma. International Journal of Gastroenterology and Hepatology.
Retrieved 28 October, 2013 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1728420/