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Appendicitis is one of the commonest inflammatory diseases that affect the appendix. According to Almaramhy (2017), the appendix is located in the lower right abdominal quadrant in most people; it is a tube-like diverticulum arising from the cecum with a mean length of 4.5 cm and 9.5 cm in neonates and adults respectively. Despite the fact that many scholars argue that the exact etiology of appendicitis is unknown, it is irrefutable that luminal obstruction is present in all patients suffering from the disease (Almaramhy, 2017). Primarily, the cause of appendicitis is the obstruction of the appendix due to many causes. In regard to the etiologies of this obstruction, some researchers name submucosal follicularlymphoid hyperplasia; however, the concept of hyperplasia remains controversial despite viral infection and dehydration being observed (Alder, 2017). According to Almaramhy (2017), the likelihood of lymphoid hyperplasia obstruction increases with age, with excessive lymphoid tissue in the mucosa of the appendix reaching the maximum number and size during teenage years, hence the higher probability of developing this inflammatory disease between the ages of 10 and 20. Other causes of obstruction triggering appendicitis include foreign bodies, fecoliths inflammatory strictures, and parasitic infestations such as the ones caused by nematodes (Alder, 2017). After the obstruction, the pathogenesis follows, causing the occurrence of disease symptoms.
Appendiceal obstruction provides an opportunity for gastrointestinal bacteria to spread, causing a severe infection that fosters the subsequent process of inflammation. Almaramhy (2017) explains that luminal obstruction causes not only continuous fluid and mucus secretion from epithelial cells but also stagnation. Accordingly, distension of the appendix occurs due to the increase of intraluminal pressure of the appendix. Most importantly, lymphoid hyperplasia is associated with many infectious and inflammatory disorders that include amebiasis and gastroenteritis due to the presence of Bacteroides fragilis, peptostreptococcus, Klebsiella pneumoniae, Pseudomonas species, and Escherichia coli among others (Almaramhy, 2017). As a result of the obstruction and creation of a favorable environment for infections, intestinal bacteria multiply in the appendix, with the edematous epithelium precipitating bacterial invasion (Alder, 2017). Further, this process affects the blood supply to the appendix with the subsequent reduction in venous return as well as the eventual thrombosis on appendicular arteries and veins, which are essential in increasing the process of inflammation (Almaramhy, 2017). Consequently, ischemia and gangrene ensue, predisposing the appendicular mucosa to perforation. The following nursing care plan is for a 10-year-old hospitalized male patient with appendicitis requiring preoperative care.
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Nursing Care Plan for Patient X
Age: 10 years
Gender: male
Weight: 33 kg
Height: 139 cm
Medication diagnosis: Acute appendicitis
Chief Complaint
X complained of “pain in the stomach, vomiting, and high body temperatures.” He also experiences reduced appetite.
History of Presenting Illness
Two days ago, X started experiencing abdominal discomfort that later translated into abdominal pain. The same day, he started experiencing on and off fever, which could not completely resolve using over the counter paracetamol. Vomiting started to manifest a day ago. The mother says his temperature spiked up again, but upon the uptake of paracetamol, it subsided for about three hours. The disease worsened during the night, with high vomiting frequencies, fevers, and with the boy vocalizing an increase in abdominal pain. In the morning, the mother brought X to the hospital.
Past Medical History
The mother reports that X suffered from chickenpox at the age of eight. Further, the boy completed his vaccinations as per the recommended schedule. At the age of two, X was admitted for pneumonia and remained hospitalized for five days during which he received treatment before discharge; since then, he has never been hospitalized. However, the patient uses over the counter medications to treat minor health problems such as normal colds and occasional fevers. The mother did not report any history of surgery.
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Family-Social History
X is the second of four Latino siblings (three boys and one girl). His paternal grandmother died three years ago from hypertension, a disease that his maternal grandfather and two of the uncles also have. Furthermore, X’s father smokes heavily in addition to consuming alcohol. His family affords regular meals in addition to other family basics. However, the family struggles financially to meet any luxurious needs since the father, who is the sole breadwinner, earns little as a truck driver. X states that he defecates once a day. Despite the mother being a housewife, all the children go to school.
Review of Systems
Integumentary: the intact skin is moist, warm, and restores its normal condition when pinched within one second. His evenly distributed clean hair is short and black. The slightly curved nails are pink-colored with a capillary refill of 2 seconds.
Head, face, eyes, and nose: symmetrical facial structures and skull without any sign of swelling, lesion, deformity, or tenderness. No abnormal discharges noted from the eyes, nose, and ears. The pupils are black, of equal size of about 2 mm, and respond to light. Further, the nostrils are symmetrical with a midline nasal septum; pink-colored mucosa lines the nostrils. No noted sign of nasal flaring or inflammation.
Neck: the neck if symmetrical with a centrally placed palpable trachea and without thyroid enlargement, lesions, or tenderness. On command, X can extend, flex or hyperextend the neck.
Thorax and the respiratory system: the chest is symmetrical with bilateral movements on breathing. Normal breath sounds are present on auscultation. On percussion, resonant sounds are heard at the posterior shoulder; on palpation, no tenderness or masses identified.
Cardiovascular system: on observation, no palpitations, jugular vein distensions, or edema noted. Capillary refill takes a maximum of two seconds. S1 and S2 sounds of the heart present without any murmurs.
Breasts and axillae: the breasts have a central nipple surrounded by the dark brown areola without any discharge.
Abdomen: the abdomen is symmetrical and uniform in color on observation. However, abdominal distention and guarding are noted. Bowel sounds are uniform in all the four quadrants. Dull sounds were heard on percussing the liver region compared to tympanic ones at the spleen region. Palpation reveals positive rebound tenderness from the left low quadrant that was subjectively rated 8 on a scale of 0-10.
Musculoskeletal system: no contractures or deformities noted. X can comfortably move upper limbs, but he is unable to freely move lower limbs due to the abdominal pain.
Urogenital system: Clean genitalia without any lesion, discharge, or mass.
Nervous system: X can appropriately communicate both verbally and non-verbally. Additionally, he is oriented to self, place, and time as well as recognizes his family. He has intact memory and no visible problems.
Vital Signs
RR: 19 breaths/minute
T: 38.1oC
PR: 80 beats/minute
BP: 90/65 mmHg
Pain: 8/10
Laboratory Investigations
| Hall (2016): Standard Values | X’s Investigation Values | |
| Red blood cell count | 4.0-5.2 x1012/L | 4.43×1012/L |
| Hematocrit | 35-45% | 36.8% |
| Hemoglobin | 10.9-14.9 g/dl | 11.7g/dl |
| Lymphocyte count | 4.5-14.5 ?10 9 | 15.7 ?10 9 |
| C-reactive protein | 0-10mg/L | 16.15 mg/dL |
Laboratory investigations reveal normal parameters, including hemoglobin, hematocrit, and red blood cell count. However, lymphocytosis and high levels of C-reactive protein indicate the presence of inflammation with a fever of 38.1oC.
Other Investigations
Plain Abdominal X-ray: To confirm acute appendicitis, radiographic examination that the patient underwent at the radiology department indicated the presence of right-sided scoliosis and localized ileus. Further, the x-ray revealed bowel obstructions, soft tissue mass, and fecolith as well as free peritoneal fluid.
Ultrasonography: the enlarged appendix has obstructed and distended lumen. Perivesical free fluid and appendicolith are noted with thickened loops of the bowel. According to Almaramhy (2017), such x-ray and ultrasonography findings confirm the presence of acute appendicitis.
Medications
150mg IV paracetamol QID: Acetaminophen is an antipyretic medication with mild analgesic properties (Katzung & Trevor, 2014). In this case, it will help reduce pyrexia (high fevers).
2 mg morphine sulfate 2-hourly: morphine is an effective drug in treating severe pain associated with acute abdomen pain (Aghamohammadi et al., 2012). Therefore, it is the drug of choice in treating pain caused by acute appendiceal inflammation.
Cefotaxime 150 mg/kg/day QID: Cefotaxime is a wide spectrum antibiotic (Katzung & Trevor, 2014). The drug will eliminate bacterial agents responsible for the inflammation of the appendix.
Dextrose 5% alternating with normal saline at 80ml/hour: Normal saline and dextrose 5% replace lost electrolytes and fluids (Johnson, 2010). Conversely, dextrose 5% provides sugars for patients with reduced energy levels in addition to providing fluids to the body.
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Nursing Diagnosis
The nursing diagnoses are arranged in the order of prioritization according to the NANDA standards, which are attributed to Dorothea Orem, a nursing theorist.
1. Acute pain related to the process inflammation of the appendix as evidenced by the fever of 38.1oC, swollen and obstructed appendix, and tenderness in the right lower abdominal quadrant.
2. Altered body temperature secondary to the disease inflammatory response as evidenced by warm skin and fever of 38.1oC.
3. Fluid volume deficit secondary to excessive fluid loss and reduced intake as evidenced by vomiting and reduced appetite.
Planning
X should report increased comfort, including the cessation of vomiting once the treatment begins. Furthermore, his appetite should increase immediately as the treatment commences; notwithstanding that, his pain should start becoming less intense before resolving entirely upon inquiry as analgesic treatment continues. Moreover, he should vocalize the reduction of not only pain in the lower left quadrant but also fevers that should correlate with normal temperature findings. Other vital signs the nurse should diagnose fall within the normal physiological limits. Additionally, the patient should remain nil per oral as a preoperative requirement before appendectomy is performed. Most importantly, the mother should assist X to maintain his hygiene through activities such as hand washing and proper waste disposal.
Interventions
Acute pain: The nurse will administer 2 mg of morphine sulfate every two hours until the pain resolves. Aghamohammadi et al. (2012) explain that morphine is the most appropriate analgesic for mitigating acute abdominal pain without eliminating diagnostic data. What is more, it is one of the most potent analgesics to curb severe pains associated with appendicitis. Furthermore, the nurse will thoroughly assess for pain every four hours to determine its responsiveness to the medication.
Altered body temperature: The nurse will administer 150 mg of intravenous paracetamol 6-hourly. Katzung and Trevor (2014) explain that acetaminophen is an antipyretic agent with mild analgesic properties. In addition, the nurse will take vital signs, including the temperature, every four hours to determine improvements as treatment continues. Most importantly, intravenous cefotaxime 150 mg/kg/day will be administered 6-hourly. Cefotaxime is a wide spectrum cephalosporin that works against both gram-positive and gram-negative bacteria (Katzung& Trevor, 2014). In this case, it will be utilized to eliminate the inflammation-causing bacteria in the appendix.
Fluid volume deficit: the nurse will administer 80 ml of normal saline to alternate with 80 ml of dextrose 5% every one hour to reach a maximum of 2000 mls per day before the performance of appendectomy. Furthermore, vital signs, including pulse rate and blood pressure, will be taken every four hours to help ascertain the fluid body status and to avoid fluid volume overload. Johnson (2010) explains that normal saline helps replace fluids and electrolytes in vomiting patients. Additionally, dextrose provides sugars, which are critical for X, a patient who is nil per oral as a preoperative intervention.
Evaluation
The patient noted marked improvements as the treatment continued. Within four hours from the beginning of the treatment, X vocalized a reduction of pain from 8 to 4 on the scale of 0-10. After 24 hours, the pain had resolved except on palpation when the patient vocalized mild abdominal pain in the left lower quadrant. Further, fevers were eliminated as the vital signs revealed a gradual decline in temperature from 38.1oC before treatment to 36.9oC in 12 hours after the treatment had commenced. Other vital signs taken by the nurse were within the normal physiological ranges, meaning that the inflammatory process had subsided. Moreover, fluid volume restored their normal condition, with blood pressure reaching 105/70 mmHg from 90/65 mmHg. The patient was also instructed on several issues, including the need for maintaining personal hygiene to prevent nosocomial infections and the role of the mother in his care. Further, X was informed to vocalize any improvement or health change to the mother, the nurse, or any other clinician. Most importantly, he was educated on why he was requested to be nil per oral as he awaited appendectomy. Both the patient and his mother received detailed information from the nurse on what appendectomy is, the peculiarities of its performance, and its subsequent effects.
