FACULTY HEALTH AND LIFE SCIENCES

BACHELOR IN NURSING

CLINICAL PRACTICE 5

KCL20505

CASE STUDY: ACUTE APPENDICITIS

NAME: ROSALINDA ANGELIKA PUTRI

ID NUMBER: 012023091335
SESSION: SEPTEMBER 2023
CLINICAL INSTRUCTOR: PUAN NUARANI AG LAH

DATE OF SUBMISSION: 15 JANUARY 2024

 TABLE OF CONTENS

TABLE OF CONTENS 1
1. OBJECTIVE TOPIC 2
2. INTRODUCTION 3
3. DEFINITION OF ACUTE APPENDICITIS 4
4. ETIOLOGY OF ACUTE APPENDICITIS 5
5. NURSING ASSESSMENT FOR PATIENT WITH ACUTE APPENDICITIS 10
6. INVESTIGATION FOR PATIENT WITH ACUTE APPENDICITIS 11
7. TREATMENT FOR PATIENT WITH ACUTE APPENDICITIS 15
8. PHARMACOLOGICAL TREATMENT FOR PATIENT WITH ACUTE
APPENDICITIS 16
9. COMPLICATIONS OF ACUTE APPENDICITIS 27
10. HEALTH EDUCATION FOR PATIENT WITH ACUTE APPENDICITIS 28
11. NURSING CARE PLAN 29
12. CONCLUTION 31
13. APPENDIX 32
REFERENCES 33

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 1. OBJECTIVE TOPIC

At the end of this case study, I will be able to:

• Present an introduction about myself and my patient and her medical history.
• Define acute appendicitis.
• State the etiology of appendicitis regarding the signs, symtomps, and stages of
patient with appendicitis.
• State the clinical manifestations for patient with acute appendicitis.
• State the nursing assessment for patient with appendicitis.
• List the investigations of patient with appendicitis.
• Describe the surgical and medical treatment for patient with acute appendicitis.
• Describe the pharmacological for patient with appendicitis.
• Explain the complication of appendicitis.
• Explain the health education for patient with appendicitis.
• Provide nursing care plan with interventions for patient with appendicitis.

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 2. INTRODUCTION

My name Rosalinda Angelika Putri, ID number 012023091335, a student nurse

from Universitas Muhammadiyah Lamongan and GMP student nurse Management and
Science University (MSU). I already had my clinical posting for semester 5 at Hospital
MSU Medical Centre (MSUMC), Shah Alam from 11st December 2023 until 19th January
2024. The topic that I chose for my case study is about Appendicitis.

My patient's name is Mrs. A, RN 63XXX, female. She is 32 years old and her
ethnicity is Malay. The patient came to the surgical ward on 27th December 2023 at 11:30
am from OT post operation Laparoscopic Appendicectomy by DR Aznan, under GA by
DR Fadzlon. Accompanied by DR Fadzlon via bed. The general condition on arrival
conscious but unrousable. Branula intact at left dorsal vein with no phlebitis seen. The
patient's vital sign was taken and recorded. Blood pressure: 167/88 mmHg, respiratory
rate: 20 bpm, heart rate: 65 bpm, pain score: 5/10, temperature: 36’C, SPO2: 100%.
Received by SN Shu to pick up patience in OT.

Dressing infact of abdomen with opside dressing x3. Received 1 bottle specimen
HPE to sent to lap.

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 3. DEFINITION OF ACUTE APPENDICITIS

Acute means sudden (i.e., sudden onset of symptoms). The causes of acute
appendicitis are said to involve factors causing a blockage. This blockage creates
bacteria collection in the appendix, resulting in inflammation, infection, and/or severe pain
in your lower right abdomen area. Untreated, acute appendicitis can cause the appendix
to burst or rupture, causing bacteria to spill into your bloodstream, which can cause sepsis
and even death. For this reason, acute appendicitis should always be treated as a medical
emergency (Pugle, 2023).

Appendicitis is defined as an inflammation of the inner lining of the vermiform

appendix that spreads to its other parts. This condition is a common and urgent surgical
illness with protean manifestations, generous overlap with other clinical syndromes, and
significant morbidity, which increases with diagnostic delay. In fact, despite diagnostic and
therapeutic advancement in medicine, appendicitis remains a clinical emergency and is
one of the more common causes of acute abdominal pain (Overview Practice Essentials,
n.d.).

Appendicitis is inflammation of the appendix. Appendicitis is the leading cause of

emergency abdominal operations(Nddic, n.d.).

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 4. ETIOLOGY OF ACUTE APPENDICITIS

Appendicitis is caused by obstruction of the appendiceal lumen. The most common

causes of luminal obstruction include lymphoid hyperplasia secondary to inflammatory
bowel disease (IBD) or infections (more common during childhood and in young adults),
fecal stasis and fecaliths (more common in elderly patients), parasites (especially in
Eastern countries), or, more rarely, foreign bodies and neoplasms.

Fecaliths form when calcium salts and fecal debris become layered around a nidus
of inspissated fecal material located within the appendix.

Lymphoid hyperplasia is associated with various inflammatory and infectious

disorders including Crohn disease, gastroenteritis, amebiasis, respiratory infections,
measles, and mononucleosis.

Obstruction of the appendiceal lumen has less commonly been associated with
bacteria (Yersinia species, adenovirus, cytomegalovirus, actinomycosis, Mycobacteria
species, Histoplasma species), parasites (eg, Schistosomes species, pinworms,
Strongyloides stercoralis), foreign material (eg, shotgun pellet, intrauterine device, tongue
stud, activated charcoal), tuberculosis, and tumors.

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Signs and symptoms

The clinical presentation of appendicitis is notoriously inconsistent. The classic

history of anorexia and periumbilical pain followed by nausea, right lower quadrant (RLQ)
pain, and vomiting occurs in only 50% of cases. Features include the following:

• Abdominal pain: Most common symptom

• Nausea: 61-92% of patients
• Anorexia: 74-78% of patients
• Vomiting: Nearly always follows the onset of pain; vomiting that precedes pain
suggests intestinal obstruction
• Diarrhea or constipation: As many as 18% of patients
• Features of the abdominal pain are as follows:
• Typically begins as periumbilical or epigastric pain, then migrates to the RLQ
• Patients usually lie down, flex their hips, and draw their knees up to reduce
movements and to avoid worsening their pain
• The duration of symptoms is less than 48 hours in approximately 80% of adults but
tends to be longer in elderly persons and in those with perforation.

Physical examination findings include the following:

• Rebound tenderness, pain on percussion, rigidity, and guarding: Most specific

finding
• RLQ tenderness: Present in 96% of patients, but nonspecific
• Left lower quadrant (LLQ) tenderness: May be the major manifestation in patients
with situs inversus or in patients with a lengthy appendix that extends into the LLQ
• Male infants and children occasionally present with an inflamed hemiscrotum
• In pregnant women, RLQ pain and tenderness dominate in the first trimester, but
in the latter half of pregnancy, right upper quadrant (RUQ) or right flank pain may
occur

The following accessory signs may be present in a minority of patients:

• Rovsing sign (RLQ pain with palpation of the LLQ): Suggests peritoneal irritation

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 • Obturator sign (RLQ pain with internal and external rotation of the flexed right hip):
Suggests the inflamed appendix is located deep in the right hemipelvis
• Psoas sign (RLQ pain with extension of the right hip or with flexion of the right hip
against resistance): Suggests that an inflamed appendix is located along the
course of the right psoas muscle
• Dunphy sign (sharp pain in the RLQ elicited by a voluntary cough): Suggests
localized peritonitis
• RLQ pain in response to percussion of a remote quadrant of the abdomen or to
firm percussion of the patient's heel: Suggests peritoneal inflammation
• Markle sign (pain elicited in a certain area of the abdomen when the standing
patient drops from standing on toes to the heels with a jarring landing): Has a
sensitivity of 74%.

Stage of Appendicitis

The stages of appendicitis can be divided into early, suppurative, gangrenous,

perforated, phlegmonous, spontaneous resolving, recurrent, and chronic.

➢ Early stages appendicitis

In the early stage of appendicitis, obstruction of the appendiceal lumen leads to
mucosal edema, mucosal ulceration, bacterial diapedesis, appendiceal distention
due to accumulated fluid, and increasing intraluminal pressure. The visceral
afferent nerve fibers are stimulated, and the patient perceives mild visceral
periumbilical or epigastric pain, which usually lasts 4-6 hours.
➢ Suppurative appendicitis
Increasing intraluminal pressures eventually exceed capillary perfusion pressure,
which is associated with obstructed lymphatic and venous drainage and allows
bacterial and inflammatory fluid invasion of the tense appendiceal wall. Transmural
spread of bacteria causes acute suppurative appendicitis. When the inflamed
serosa of the appendix comes in contact with the parietal peritoneum, patients
typically experience the classic shift of pain from the periumbilicus to the right lower
abdominal quadrant (RLQ), which is continuous and more severe than the early
visceral pain.

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➢ Gangrenous appendicitis
Intramural venous and arterial thromboses ensue, resulting in gangrenous
appendicitis.
➢ Perforated appendicitis
Persisting tissue ischemia results in appendiceal infarction and perforation.
Perforation can cause localized or generalized peritonitis.
➢ Phlegmonous appendicitis or abscess
An inflamed or perforated appendix can be walled off by the adjacent greater
omentum or small-bowel loops, resulting in phlegmonous appendicitis or focal
abscess.
➢ Spontaneously resolving appendicitis
If the obstruction of the appendiceal lumen is relieved, acute appendicitis may
resolve spontaneously. This occurs if the cause of the symptoms is lymphoid
hyperplasia or when a fecalith is expelled from the lumen.
➢ Recurrent appendicitis
The incidence of recurrent appendicitis is 10%. The diagnosis is accepted as such
if the patient underwent similar occurrences of RLQ pain at different times that,
after appendectomy, were histopathological proven to be the result of an inflamed
appendix.
➢ Chronic appendicitis
Chronic appendicitis occurs with an incidence of 1% and is defined by the
following: the patient has a history of RLQ pain of at least 3 weeks’ duration without
an alternative diagnosis; after appendectomy, the patient experiences complete
relief of symptoms; histopathologically, the symptoms were proven to be the result
of chronic active inflammation of the appendiceal wall or fibrosis of the appendix.

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Clinical Manifestation

As for my patient, Mrs. A, also having some signs and symptoms that related to
acute appendicitis such as abdominal pain, nausea, vomiting, loss of appetite,
constipation and RLQ pain like a sharp pain.

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 5. NURSING ASSESSMENT FOR PATIENT WITH ACUTE
APPENDICITIS

On December 27th 2023, when I interviewed the patient, I saw the patient was
conscious, alert, cooperative, and able to move and talk.

Here, a nursing assessment is performed. I took her vital signs, did a physical
examinations, monitoring the pain after operation and monitor of changes in eating and
bowel habits. Physical examination got 4 ways which are inspection, palpation,
percussion and auscultation. Among the physical examinations, I perform are pupil
examination, nerve examination, skin examination, head, mouth, neck, and breast
examination. I also analyze vision and hearing. During the physical examinations, I
noticed that the patient still in pain post laparoscopic appendectomy operation.

Patient vital sign was taken and recorded, refer Table 5.1. Patient complaint a bit pain.
Patient temperature is 36’C. I monitor patient vital sign every 4 hourly especially his
temperature to assess his body temperature. I also monitor the patient's vital signs every
4 hours to assess whether her condition is normal or abnormal.

Vital sign/Date 27th December 2023

Blood pressure 141/95
Heart rate 72 bpm
Respiratory rate 20 bpm
Pain score 5/10
Temperature 36’C
SpO2 100%
Table 5.1: Patient vital signs during an interview at ward 13B on 27 th December 2023

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 6. INVESTIGATION FOR PATIENT WITH ACUTE APPENDICITIS

A health care provider can diagnose most cases of appendicitis by taking a

person’s medical history and performing a physical exam.

If a person does not have the usual symptoms, health care providers may use
laboratory and imaging tests to confirm appendicitis. These tests also may help diagnose
appendicitis in people who cannot adequately describe their symptoms, such as children
or people who are mentally impaired.

Medical History

The health care provider will ask specific questions about symptoms and health
history. Answers to these questions will help rule out other conditions. The health care
provider will want to know

• when the abdominal pain began

• the exact location and severity of the pain
• when other symptoms appeared
• other medical conditions, previous illnesses, and surgical procedures
• whether the person uses medications, alcohol, or illegal drugs

Physical Exam

Details about the person’s abdominal pain are key to diagnosing appendicitis. The
health care provider will assess the pain by touching or applying pressure to specific areas
of the abdomen.

Responses that may indicate appendicitis include:

• Rovsing’s sign. A health care provider tests for Rovsing’s sign by applying hand
pressure to the lower left side of the abdomen. Pain felt on the lower right side of
the abdomen upon the release of pressure on the left side indicates the presence
of Rovsing’s sign.
• Psoas sign. The right psoas muscle runs over the pelvis near the appendix.
Flexing this muscle will cause abdominal pain if the appendix is inflamed. A health

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 care provider can check for the psoas sign by applying resistance to the right knee
as the patient tries to lift the right thigh while lying down.
• Obturator sign. The right obturator muscle also runs near the appendix. A health
care provider tests for the obturator sign by asking the patient to lie down with the
right leg bent at the knee. Moving the bent knee left and right requires flexing the
obturator muscle and will cause abdominal pain if the appendix is inflamed.
• Guarding. Guarding occurs when a person subconsciously tenses the abdominal
muscles during an exam. Voluntary guarding occurs the moment the health care
provider’s hand touches the abdomen. Involuntary guarding occurs before the
health care provider actually makes contact and is a sign the appendix is inflamed.
• Rebound tenderness. A health care provider tests for rebound tenderness by
applying hand pressure to a person’s lower right abdomen and then letting go. Pain
felt upon the release of the pressure indicates rebound tenderness and is a sign
the appendix is inflamed. A person may also experience rebound tenderness as
pain when the abdomen is jarred for example, when a person bumps into
something or goes over a bump in a car.

Women of childbearing age may be asked to undergo a pelvic exam to rule out
gynecological conditions, which sometimes cause abdominal pain similar to appendicitis.

The health care provider also may examine the rectum, which can be tender from
appendicitis

Laboratory Tests

Laboratory tests can help confirm the diagnosis of appendicitis or find other causes
of abdominal pain.

• Blood tests. A blood test involves drawing a person’s blood at a health care
provider’s office or a commercial facility and sending the sample to a laboratory for
analysis. Blood tests can show signs of infection, such as a high white blood cell
count. Blood tests also may show dehydration or fluid and electrolyte imbalances.
Electrolytes are chemicals in the body fluids, including sodium, potassium,
magnesium, and chloride.

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 • Urinalysis. Urinalysis is testing of a urine sample. The urine sample is collected
in a special container in a health care provider’s office, a commercial facility, or a
hospital and can be tested in the same location or sent to a laboratory for analysis.
Urinalysis is used to rule out a urinary tract infection or a kidney stone.
• Pregnancy test. Health care providers also may order a pregnancy test for
women, which can be done through a blood or urine test.

Imaging Tests

Imaging tests can confirm the diagnosis of appendicitis or find other causes of
abdominal pain.

• Abdominal ultrasound. Ultrasound uses a device, called a transducer, that

bounces safe, painless sound waves off organs to create an image of their
structure. The transducer can be moved to different angles to make it possible to
examine different organs. In abdominal ultrasound, the health care provider
applies gel to the patient’s abdomen and moves a handheld transducer over the
skin. The gel allows the transducer to glide easily, and it improves the transmission
of the signals. The procedure is performed in a health care provider’s office, an
outpatient center, or a hospital by a specially trained technician, and the images
are interpreted by a radiologist—a doctor who specializes in medical imaging;
anesthesia is not needed. Abdominal ultrasound creates images of the appendix
and can show signs of inflammation, a burst appendix, a blockage in the
appendiceal lumen, and other sources of abdominal pain. Ultrasound is the first
imaging test performed for suspected appendicitis in infants, children, young
adults, and pregnant women.
• Magnetic resonance imaging (MRI). MRI machines use radio waves and
magnets to produce detailed pictures of the body’s internal organs and soft tissues
without using x rays. The procedure is performed in an outpatient center or a
hospital by a specially trained technician, and the images are interpreted by a
radiologist. Anesthesia is not needed, though children and people with a fear of
confined spaces may receive light sedation, taken by mouth. An MRI may include
the injection of special dye, called contrast medium. With most MRI machines, the

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 person lies on a table that slides into a tunnel-shaped device that may be open
ended or closed at one end; some machines are designed to allow the person to
lie in a more open space. An MRI can show signs of inflammation, a burst
appendix, a blockage in the appendiceal lumen, and other sources of abdominal
pain. An MRI used to diagnose appendicitis and other sources of abdominal pain
is a safe, reliable alternative to a computerized tomography (CT) scan.2
• CT scan. CT scans use a combination of x rays and computer technology to create
three-dimensional (3-D) images. For a CT scan, the person may be given a
solution to drink and an injection of contrast medium. CT scans require the person
to lie on a table that slides into a tunnel-shaped device where the x rays are taken.
The procedure is performed in an outpatient center or a hospital by an x-ray
technician, and the images are interpreted by a radiologist; anesthesia is not
needed. Children may be given a sedative to help them fall asleep for the test. A
CT scan of the abdomen can show signs of inflammation, such as an enlarged
appendix or an abscess—a pus-filled mass that results from the body’s attempt to
keep an infection from spreading—and other sources of abdominal pain, such as
a burst appendix and a blockage in the appendiceal lumen. Women of childbearing
age should have a pregnancy test before undergoing a CT scan. The radiation
used in CT scans can be harmful to a developing fetus.

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 7. TREATMENT FOR PATIENT WITH ACUTE APPENDICITIS

Appendicitis is typically treated with surgery to remove the appendix. The surgery
is performed in a hospital; general anesthesia is needed. If appendicitis is suspected,
especially in patients who have persistent abdominal pain and fever, or signs of a burst
appendix and infection, a health care provider will often suggest surgery without
conducting diagnostic testing. Prompt surgery decreases the chance that the appendix
will burst. Surgery to remove the appendix is called an appendectomy. A surgeon
performs the surgery using one of the following methods:

• Laparotomy. Laparotomy removes the appendix through a single incision in the

lower right area of the abdomen.
• Laparoscopic surgery. Laparoscopic surgery uses several smaller incisions and
special surgical tools fed through the incisions to remove the appendix.
Laparoscopic surgery leads to fewer complications, such as hospital-related
infections, and has a shorter recovery time.

With adequate care, most people recover from appendicitis and do not need to
make changes to diet, exercise, or lifestyle. Surgeons recommend limiting physical
activity for the first 10 to 14 days after a laparotomy and for the first 3 to 5 days after
laparoscopic surgery.

Nonsurgical treatment may be used if surgery is not available, a person is not well
enough to undergo surgery, or the diagnosis is unclear. Nonsurgical treatment includes
antibiotics to treat infection.

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 8. PHARMACOLOGICAL TREATMENT FOR PATIENT WITH ACUTE
APPENDICITIS
The doctor prescribed some medication for my patient. These include:

• IV Augmentin 1.2g stat

• IM Pethidine 50mg PRN
• IV Paracetamol 1g QID
• IV Dynastat 40mg BD

IV Augmentin 1.2g stat

Generic name • Amoxycillin and Potassium Clavulanate Injection IP

1.2g

Trade name • Augmentin

Drug class • Antibiotic penicillins

Indication • Augmentin intravenous is also indicated for prophylaxis

against infection which may be associated with major
surgical procedures such as gastrointestinal, pelvic,
head and neck, cardiac, renal, joint replacement and
biliary tract

Route • Intravenous

Dosage Dosage for the treatment of infections

• Adults and children over 12 years: Usually 1.2 g eight

hourly. In more serious infections, increase frequency
to six-hourly intervals.
• Children 3 months-12 years: Usually 30 mg/kg*
AUGMENTIN eight hourly. In more serious infections,
increase frequency to six-hourly intervals.
• Children 0-3 months: 30 mg/kg* AUGMENTIN every 12
hours in premature infants and in full term infants during

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 the perinatal period, increasing to eight hours
thereafter.

(Each 30 mg IV augmentin contains 25 mg amoxycillin and 5 mg

clavulanate)

Adult dosage for surgical prophylaxis

• The usual dose is 1.2 g IV augmentin given at the

induction of anaesthesia. Operations where there is a
high risk of infection, e.g. colorectal surgery, may
require three, and up to four, doses of 1.2 g IV
augmentin in a 24-hour period. These doses are usually
given at 0, 8, 16 (and 24) hours. This regimen can be
continued for several days if the procedure has a
significantly increased risk of infection.
• Clear clinical signs of infection at operation will require
a normal course of intravenous or oral augmentin
therapy post-operatively.

Contraindications • Augmentin is contraindicated in patients with a history

of hypersensitivity to beta-lactams, e.g. penicillins and
cephalosporins.
• Augmentin is contraindicated in patients with a previous
history of augmentin associated jaundice/hepatic
dysfunction.

Side effect • Diarrhea

• Dark urine
• Itching
• Stomach pain
• Bloating
• Nausea
• Dizziness

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 • Drowsiness

Nursing • Contraindicated with penicillin allergy

responsibilities • May cause seizures
• Assess for rash, anaphylaxis
• Excreted by kidneys – monitor renal labs
• Monitor patient for diarrhea – bloody stool should be
reported immediately

IM Pethidine 50mg PRN

Generic name • Meperidine hydrochloride

Trade name • Pethidine 50mg/ml & 100mg/2ml Solution for Injection

• Demerol

Drug class • Analgesics

Indication • Relief of moderate to severe pain.

• Premedication.
• Obstetric analgesia.
• Enhancement of analgesia

Route • Intramuscular

Dosage • By intramuscular injection. 0.5 - 2 mg per Kg of body

weight.
• Relief of pain: Individualize dosage; 50–150 mg IM,
subcutaneously, or PO q 3–4 hours as needed. Diluted
solution may be given by slow IV injection. IM route is
preferred for repeated injections.

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 • Preoperative medication: 50–100 mg IM or
subcutaneously, 30–90 min before beginning
anesthesia.
• Support of anesthesia: Dilute to 10 mg/mL, and give
repeated doses by slow IV injection, or dilute to 1
mg/mL and infuse continuously. Individualize dosage.
• Obstetric analgesia: When contractions become
regular, 50–100 mg IM or subcutaneously; repeat q 1–
3 hr.

Contraindications • Hypersensitivity to the active substance or to any of the

excipients
• Severe respiratory depression, severe obstructive
airways disease or acute asthma.
• It should not be administered to patients with severe
renal impairment or severe hepatic impairment.
• Should be avoided in patients with acute alcoholism,
delirium tremens, raised intracranial pressure or in
those with convulsive states such as status epilepticus.
• It should not be administered to patients receiving
monoamine oxidase inhibitors (including moclobemide,
and the monoamine B inhibitors selegiline and
rasagiline) or within two weeks of their withdrawal.
• Pethidine should not be administered to patients
receiving ritonavir.
• Use of pethidine should be avoided in patients with
supraventricular tachycardia.
• Use of pethidine in patients with phaechromocytoma
may result in hypertensive crisis.
• Use of pethidine should be avoided in patients with
diabetic acidosis where there is danger of coma.

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 • In comatose patients
• In patients with a risk of paralytic ileus
• In patients with head injuries.

Side effect • constipation

• headache or dizziness
• fatigue or drowsiness (especially soon after taking a
dose)
• loss of appetite, nausea and vomiting

Nursing Assessment
responsibilities
• History: Hypersensitivity to opioids, diarrhea caused by
poisoning, bronchial asthma, COPD, cor pulmonale,
respiratory depression, anoxia, kyphoscoliosis, acute
alcoholism, increased intracranial pressure; acute
abdominal conditions, CV disease, supraventricular
tachycardias, myxedema, seizure disorders, delirium
tremens, cerebral arteriosclerosis, ulcerative colitis,
fever, Addison’s disease, prostatic hypertrophy, urethral
stricture, recent GI or GU surgery, toxic psychosis,
renal or hepatic impairment, pregnancy, lactation
• Physical: T; skin color, texture, lesions; orientation,
reflexes, bilateral grip strength, affect, pupil size; P,
auscultation, BP, orthostatic BP, perfusion; R,
adventitious sounds; bowel sounds, normal output;
frequency and pattern of voiding, normal output; ECG;
EEG; LFTs, renal and thyroid function tests

Interventions

• Administer to lactating women 4–6 hr before the next

feeding to minimize the amount in milk.

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 • WARNING: Keep opioid antagonist and facilities for
assisted or controlled respiration readily available
during parenteral administration.
• WARNING: Use caution when injecting subcutaneously
into chilled areas of the body or in patients with
hypotension or in shock; impaired perfusion may delay
absorption; with repeated doses, an excessive amount
may be absorbed when circulation is restored.
• Reduce dosage of meperidine by 25%–50% in patients
receiving phenothiazines or other tranquilizers.
• Give each dose of the oral syrup in half glass of water.
If taken undiluted, it may exert a slight local anesthetic
effect on mucous membranes.
• Reassure patient that addiction is unlikely; most
patients who receive opiates for medical reasons do not
develop dependence syndromes.
• WARNING: Use meperidine with extreme caution in
patients with renal impairment or those requiring
repeated dosing due to accumulation of normeperidine,
a toxic metabolite that may cause seizures.

Teaching points

• Take drug exactly as prescribed.

• Avoid alcohol, antihistamines, sedatives, tranquilizers,
over-the-counter drugs.
• Do not take leftover medication for other disorders, and
do not let anyone else take this prescription.
• You may experience these side effects: Nausea, loss of
appetite (take with food and lie quietly, eat frequent
small meals); constipation (request a laxative);
dizziness, sedation, drowsiness, impaired visual acuity

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 (avoid driving, performing other tasks that require
alertness, visual acuity).
• Report severe nausea, vomiting, constipation,
shortness of breath, or difficulty breathing.

IV Paracetamol 1g QID

Generic name • Paracetamol or acetaminophen

Trade name • IV Paracetamol 1g

Drug class • Analgesic

• Antipyretic

Indication • Very high fever, only when oral administration is not

possible
• Mild pain, only when oral administration is not possible

Route • Intravenous

Dosage • Neonate: 7.5 mg/kg (0.75 ml/kg) every 6 hours, to be

administered over 15 minutes (max. 30 mg/kg daily)
• Child ≥ 1 month and < 10 kg: 10 mg/kg (1 ml/kg) every
6 hours, to be administered over 15 minutes (max. 30
mg/kg daily)
• Patient ≥ 10 kg and < 50 kg: 15 mg/kg (1.5 ml/kg)
every 6 hours, to be administered over 15 minutes
(max. 60 mg/kg daily)
• Patient ≥ 50 kg: 1 g (100 ml) every 6 hours, to be
administered over 15 minutes (max. 4 g daily)

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Contraindications • In cases of hypersensitivity to paracetamol or to
propacetamol hydrochloride (prodrug of paracetamol)
or to any of the excipients
• In cases of severe hepatocellular insufficiency
• In patients with hepatic failure or decompensated active
liver disease

Side effect • An allergic reaction, which can cause a rash and

swelling
• Flushing, low blood pressure and a fast heartbeat – this
can sometimes happen when paracetamol is given in
hospital into a vein in your arm
• Blood disorders, such as thrombocytopenia (low
number of platelet cells) and leukopenia (low number of
white blood cells)
• Liver and kidney damage, if you take too much
(overdose) – this can be fatal in severe cases

Nursing • Check that the patient is not taking any other

responsibilities medication containing paracetamol.
• For children who may refuse medicine off a spoon try
using a medicine syringe to squirt liquid slowly into the
side of the child’s mouth or use soluble paracetamol
mixed with a drink.
• Some children may be happy to take one paracetamol
product but dislike the taste of another.
• There are no known harmful effects when used during
pregnancy.
• Small amounts may pass into breast milk. However,
there are no known harmful effects when used by
breastfeeding mothers.

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 • Alcohol increases the risk of liver damage that can
occur if an overdose of paracetamol is taken. The
hazards of paracetamol overdose are greater in
persistent heavy drinkers and in people with alcoholic
liver disease.
• Evaluate therapeutic response.

IV Dynastat 40mg BD

Generic name • Parecoxib sodium

Trade name • Dynastat 40 mg powder for solution for injection

Drug class • Parecoxib

Indication • For the short-term treatment of postoperative pain in

adults.
• The decision to prescribe a selective cyclooxygenase-
2 (COX-2) inhibitor should be based on an assessment
of the individual patient's overall risk

Route • Intravenous

Dosage • The recommended dose is 40 mg administered

intravenously (IV) or intramuscularly (IM), followed
every 6 to 12 hours by 20 mg or 40 mg as required, not
to exceed 80 mg/day.

Contraindications • Hypersensitivity to the active substance or to any of the

excipients
• History of previous serious allergic drug reaction of any
type, especially cutaneous reactions such as Stevens-
Johnson syndrome, drug reaction with eosinophilia and
systemic symptoms syndrome (DRESS syndrome),

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 toxic epidermal necrolysis, erythema multiforme or
patients with known hypersensitivity to sulfonamides.
• Active peptic ulceration or gastrointestinal (GI)
bleeding.
• Patients who have experienced bronchospasm, acute
rhinitis, nasal polyps, angioneurotic oedema, urticaria
or other allergic-type reactions after taking
acetylsalicylic acid or nonsteroidal anti-inflammatory
drugs (NSAIDs) including COX-2 inhibitors.
• The third trimester of pregnancy and breast-feeding
• Severe hepatic impairment (serum albumin <25 g/l or
Child-Pugh score ≥10)
• Inflammatory bowel disease.
• Congestive heart failure (NYHA II-IV).
• Treatment of post-operative pain following coronary
artery bypass graft (CABG) surgery.
• Established ischaemic heart disease, peripheral arterial
disease and/or cerebrovascular disease.

Side effect • Nausea

• Vertigo
• Back pain
• Dizziness
• Dry mouth
• Anemia
• Hypokalemia
• Agitation
• Insomnia
• Hypoesthesia
• hypotension

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Nursing • Assess for conditions that may be contraindications to
responsibilities therapy.
• Assess patient s hypersensitivity to drug.
• Obtain accurate history of drug allergies.
• Monitor for possible drug induced adverse reactions:
post-op anemia, hypokalemia, agitation, insomnia,
hypoesthesia, HTN, hypotension, resp insufficiency,
alveolar osteitis, dyspepsia, flatulence, back pain,
arthralgia, oliguria.

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 9. COMPLICATIONS OF ACUTE APPENDICITIS
The main complication from acute appendicitis is a ruptured or burst appendix. If
your appendix bursts, it opens a path for infection to spread. A burst appendix spreads
infection throughout the abdomen a potentially dangerous condition called peritonitis. A
person with peritonitis may be extremely ill and have nausea, vomiting, fever, and severe
abdominal tenderness. This condition requires immediate surgery through laparotomy to
clean the abdominal cavity and remove the appendix. Without prompt treatment,
peritonitis can cause death.

Sometimes an abscess forms around a burst appendix called an appendiceal

abscess. A surgeon may drain the pus from the abscess during surgery or, more
commonly, before surgery. To drain an abscess, a tube is placed in the abscess through
the abdominal wall. The drainage tube is left in place for about 2 weeks while antibiotics
are given to treat infection. Six to 8 weeks later, when infection and inflammation are
under control, surgeons operate to remove what remains of the burst appendix.

Other complications include:

• Abscess or pus-filled pockets resulting from infection

• Sepsis if bacteria get into bloodstream
• Peritonitis (severe abdominal infection)

Both sepsis and peritonitis are serious medical emergencies that can result in
death if not treated promptly.

There is no known way to prevent acute appendicitis or appendix rupture, but

getting to the emergency room as soon as you detect symptoms is the best way to help
reduce the risk of complications associated with acute appendicitis.

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 10. HEALTH EDUCATION FOR PATIENT WITH ACUTE
APPENDICITIS

Appendicitis is a medical emergency that requires immediate care. People who

think they have appendicitis should see a health care provider or go to the emergency
room right away. Swift diagnosis and treatment can reduce the chances the appendix will
burst and improve recovery time.

Eating, Diet, and Nutrition

Researchers have not found that eating, diet, and nutrition play a role in causing
or preventing appendicitis. If a health care provider prescribes nonsurgical treatment for
a person with appendicitis, the person will be asked to follow a liquid or soft diet until the
infection subsides. A soft diet is low in fiber and is easily digested in the GI tract. A soft
diet includes foods such as milk, fruit juices, eggs, puddings, strained soups, rice, ground
meats, fish, and mashed, boiled, or baked potatoes. People can talk with their health care
provider to discuss dietary changes.

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 11. NURSING CARE PLAN

Nursing diagnosis: Acute pain is related to a physical injurious agent as evidenced by

the patient complaining of pain
Outcome: It is hoped that the pain level will decrease
Nursing interventions
• identify the location, characteristics, duration, frequency, quality and intensity of
pain
rationale: quantifies pain intensity and allows nurses to determine the efficacy of
interventions aimed at reducing pain
• provide non-pharmacological techniques to reduce pain
rationale: to better manage and reduce pain without medication.
• facilitate sleep rest
rationale: to reduce pain

Nursing diagnosis: Anxiety is related to health status as evidenced by post-operative

appendicitis
outcome: Anxiety self-control
• Assess level of anxiety
Rationale: to improve assessment of anxiety symptoms in a clinical setting
• Always allow relative when levels of anxiety are high(severe or panic) reassure
client of his or her sefety and security
Rationale: Reassurance is the removal of fears and concerns about illness.
• Give anxiety medication indicated for high levels of anxiety
rationale: calm the nervous system, providing short term relief of anxiety and panic
disorder symptoms.
Nursing diagnosis: nausea associated with pharmacological agents as evidenced by
complaints of nausea and the urge to vomit
Outcome: to provide comfort level and hydration status. Nutritional status: food and fluid
intake. Symptom Severity
• Carry out a complete assessment of nausea including frequency, duration, level of
nausea, and factors that cause the patient to feel nauseous
Rationale: help determine interventions to lessen or ease the problem.
• Suggest eating little but often and warm

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 Rationale: To help break down food, your stomach produces hydrochloric acid. If
you don't eat for a long period of time, that acid can build up in your stomach and
potentially lead to acid reflux and nausea
• Collaborative administration of antiemetics: ondansetron 4 mg IV if nausea
Rationale: To relieves symptoms of nausea and vomiting in various conditions.

The risk of infection is marked by invasive procedures

outcome: Immune Status Knowledge,Infection control, Risk control
• Wash your hands before and after every nursing procedure
• Give antibiotic therapy if necessary
• Infection Protection (protection against infection)
• Monitor for signs and symptoms of systemic and local infections
• Monitor granulocyte count, WBC
• Monitor susceptibility to infection
• Limit visitors

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 • CONCLUTION

In conclusion, the knowledge I gained from this case study is that, appendicitis is
inflammation of the appendix, a small, tubular organ in the right lower abdomen that is
attached to the large intestine. Known the sign and symptom and can be more aware in
eating, habits and lifestyle to get healthy life.
I will apply my level of understanding about taking care of the appendicitis in my
daily life with family, friends and society. From this case study, I able to know more about
what medication is suitable to give for patient with appendicitis. I also need to identify
correctly about the medication to prevent any mistakes that can trigger patient’s care.
Diet, lifestyle and medication is very important when taking care appendicitis
patient to avoid any complication from occur. Now, I know an appendicitis should be care
and handle carefully at early stage before it getting worse and become severe.

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• APPENDIX

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 REFERENCES

Nddic. (n.d.). Appendicitis.

Overview Practice Essentials. (n.d.). https://emedicine.medscape.com/article/773895-

print1/42emedicine.medscape.com

Pugle, M. (2023). What Is Acute Appendicitis?

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