Case Study- Ajay Mahajan (Appendicitis)

Appendix is a narrow blind ended pouch that extends from inferior part of the large intestine’s cecum. It is about four inches long, located in right iliac region (Waugh, 2015). The sub mucosa layer of the appendix has lymphoid tissue masses which implies that it play a role in our immune system.  Few suggest that it stores beneficial bacteria and helps in re-booting the digestive tract after an illness whereas others suggest that it is a vestigial organ and serves no purpose (Waugh, 2015).

Appendix often gets inflamed of its inner lining and parts called as appendicitis (Lewis, 2013). Its incidence is high among pediatrics caused by an infection (Marilyn, 2015). Due to a bacterial/ viral infection, the inner lining of appendix gets inflamed and lymphoid tissue swells. This obstructs the appendiceal lumen and so increases intra luminal pressure and causes continuous secretion and stagnation of fluids and mucus. It leads to distention of the appendix and multiplication of bacteria that stimulates production of white blood cells to fight against the infection. This increases body temperature as Mr. Ajay manifests (Martin, 2014). This also causes formation of pus which again increases intra luminal pressure causing severe increasing abdominal pain, nausea and vomiting as Mr. Ajay manifests.

If obstruction increases further above that of the appendiceal veins, venous outflow obstruction occur leading to ischemia. This causes loss of epithelial integrity allowing invasion of bacteria into the wall. After few hours, thrombosis may develop in the appendicular artery and veins, leading to formation of abscess causing gangrene (Lewis, 2013) and perforation in 24-36 hours (Hinkle, 2014). Finally the appendix ruptures and infected material spills into the abdominal cavity causing peritonitis which is a life threatening condition requiring immediate surgery to remove appendix (Hinkle, 2014, Bennington, 2014). Mr. Ajay was febrile due to ruptured appendix. If untreated, affects the homeostasis of the patient leading to septic shock and death.

The only option in appendicitis is removal of appendix called appendectomy which is done by two methods. Laproscopic appendectomy involves making three incisions on the abdomen and insertion of tubes through each incision and removal of appendix is done. This could be feasible in developing countries as fewer narcotics are used (Ali, 2011, Smink, 2014). Laproscopy is best performed but it takes more time and is costly (Kahil, 2011, Ohtani, 2012).In certain cases open appendectomy is performed in which appendix is removed through a single large incision. It is mostly done in case of ruptured appendix (Wong, 2012). Laproscopy was planned for Mr. Ajay but then converted to open type due to ruptured appendix which was supported by a study that 14.7% needs conversion (Ali, 2011).

Mr. Ajay should be assessed for airway patency by checking position of tongue and presence of secretions as he produces snoring sound. He should be assessed for rate, rhythm, depth and pattern of respiration as it is decreased due to anesthetic effects. The forcefulness of exhaled air should be assessed by placing cupped hand over the patient’s nose and mouth (Lewis, 2013). He should be observed for symmetry of chest wall movement which helps to detect improper ventilation. Note for the use of accessory and abdominal muscles during respiration to rule out respiratory distress.

Auscultate the breath sounds to indentify obstructed airway. He is known asthmatic and so note for the presence of wheezes and crackles which indicates bronchospasm. Connect pulse oximetry to oxygen saturation as the PaO2 is 96% (Wong, 2012). Note the characteristics of sputum and mucus to identify pulmonary edema. Monitor vital signs once in every 15 minutes to understand the progress of the patient. To determine the stability of the patient compare the pre and post operative vital signs. The pulse pressure should be noted. Cardiac monitor should be connected (Lewis, 2013).

Note for cyanosis and dehydration by assessing the color, moisture and temperature of the skin. He has hypotension, rapid pulse, cold, clammy skin indicating progressing hypovolemic shock (Hinkle, 2014). He is in semiconscious state, so assess his level of consciousness, orientation to place, person and time, memory and ability to follow instructions. Assess for size and equal reactivity of the pupil to know the motor and sensory status.

Anesthesia is defined as a total or partial loss of consciousness (Douglas, 2012). There are various types as general, local, regional anesthesia and conscious sedation. For Mr. Ajay open appendectomy was done under general anesthesia in which there is loss of sensation, unconsciousness, skeletal muscles relaxation, inability to feel pain and eliminating responses like coughing, vomiting, gagging and sympathetic nervous system responsiveness (Lewis, 2013).

Mr. Ajay produced snoring sound which is more common in post operative period due to airway compromise caused by obstruction, hypoxemia and hypoventilation. It was supported by Hedenstirena in 2012 that anesthesia affects respiration causing changes in matching of alveolar ventilation, lung perfusion and oxygenation of arterial blood. There will be a fall in resting lung volume and reduction of functional residual capacity occurs due to loss of muscle tone caused by anesthesia. This fall causes closure of airway leading to alveolar collapse (atelectasis).

He is a heavy smoker and substance abuser, so is at high risk for developing airway obstruction (Lewis, 2013). In case of decreased consciousness, the tongue falls back due to flaccid muscles and blocks the airway (Hinkle, 2014). The base of the tongue falls backward against the soft palate and occludes the pharynx which is mostly present in supine position causing snoring sound (Lewis, 2013).  He develops snoring due to obstruction of airway. Obstruction is caused by the retained thick secretions due to stimulation by anesthetic agents (Hinkle, 2014). Due to irritation of larynx by anesthetic agents and endotracheal tube, laryngeal edema and laryngospasm may occur (Douglas, 2012).

He had snoring which could also be due to hypoxemia caused by alveolar collapse. He also has hypotension with blood pressure 90/50 mm Hg due to bronchial obstruction caused by retained secretions and manifests decreased breath sounds and oxygen saturation. It also develops in case of hypoxemia and low cardiac output due to suppression of respiratory centre.

Mr. Ajay is in semiconscious state due to the effect of anesthesia. This may cause aspiration of gastric contents into the lungs causing closure of airways. This is a serious emergency by causing dyspnea, tachypnea and decreased oxygen saturation. It is common among asthma and Chronic Obstructive Pulmonary Disorder patients. As Mr. Ajay is known asthmatic, he is at risk for developing bronchospasm causing snoring sound.

Mr. Ajay has decreased respiratory rate-10 breaths/min, Blood pressure-90/50 mmHg and Oxygen saturation- 94% as he has hypoventilation which is a common complication in the post anesthetic period. This is evidenced by a study conducted by Saraswat in 2015.  It occurs as a result of medullary depression and poor muscle tone of respiratory muscles (Lewis, 2013).

He has hypotension with blood pressure 90/50 mm Hg due to unreplaced fluid and blood losses during surgery (Hinkle, 2014). He is infused with 1 L Normal Saline for 6 hours to replace fluid and maintain homeostasis. He is drowsy as anesthesia depresses central nervous system. He felt cold with body temperature 35°C due to the loss of heat from exposed body organs to outside air and so Bair Hugger warmer was applied. He felt pain due to surgical manipulation (Lewis, 2013). 

3. Discharge involves leaving of the patient from the hospital or any other health care setting to the home or is transferred to another setting (Douglas, 2012). Discharge should be planned from the time of return of patient from operating room and should be based on physician’s order. Discharge planning is a multidisciplinary process that involves action by various health care professionals. This ensures that the patient has a plan for continuing care after leaving the hospital (Douglas, 2012). For Mr. Ajay, the discharge plan should include description of client’s condition at discharge, current medication to take, diet modifications, activity level, restrictions, incision care, planned appointment at the physician’s office and signs and symptoms of complications or drug reactions to be observed.

At the time of discharge, he should be explained about his condition and the entire course of treatment. Advice to quit smoking as it may delay wound healing process and may irritate the incision area. Instruct to avoid use of drugs as it may affect the healing process and respiratory effort in post anesthetic period.

The patient should be advised as not to take pain medications unnecessarily without the prescription of doctor. Demonstrate the pain management techniques such as splinting the incision with pillows during coughing and sneezing to prevent removal of sutures (Lewis, 2013). Instruct the patient to perform deep breathing exercise to promote ventilation. Advice the patient to take semi fowler’s position as it relieves abdominal tension and prevents pain (Vera, 2013). Instruct Mr. Ajay to avoid bending, moving and lifting heavy objects as it may irritate the incision site and lead to removal of sutures.

Advice the patient to take a small and frequent diet meal with high calories initially. Ask him to increase the amount of food gradually as tolerated. Instruct to take fluids at least 2-3 L/ day to compensate fluid and blood losses during surgery and also to prevent constipation. Normal activities could be resumed as early as possible (after 5 days) and can plan for alternate periods of rest and activities. This promotes normalization of organ function and stimulates peristalsis (Vera, 2013). Demonstrate the techniques of wound care.

Instruct the patient to follow up after 10 days to note the progress of the patient. Inform him to consult the physician in between in case of complications such as increased body temperature, vomiting, severe pain, bleeding in incision site, weight loss or changes in bowel and bladder function.

Ali, S.M.  (2011). Laproscopy versus open appendectomy: Saudi Journal of gastroenterology. 17 (4). Retrieved from www.ncbi.nlm.nih.gov >PMC3023097.

Appendectomy: (2014). Surgical removal of the appendix. American College of Surgeons. https://search2. facs.org/search?q=appendectomy&sa=search&site=my_collection &client=my_collection&proxystylesheet=my_collection&output=xml_no_dtd.

Appendicitis.  (2014). National Institute of Diabetes mellitus and digestive and kidney diseases. Retrieved from https:// digestive. niddk.nih.gov/diseases /pubs/appendicitis.

Bennington, C. (2014). Ruptured appendix: Everyday health. Retrieved from www.everydayhealth.com>guide>rupt.

Douglas, C. (2012). Potter and Perry’s Fundamentals of Nursing- Australian version. (4^th ed.). St. Louis, Missouri: Elsevier

Hedenstirena, G. (2012). Respiratory Function During Anesthesia: Effects On Gas Exchange. 2 (1). doi: 10.1002/cphy.c080111.

Hinkle, J.L. (2014). Brunner’s and Suddarth’s Textbook of Medical Surgical Nursing. (13^th ed.). Philadelphia: Lippincott Williams and Wilkins.

Kahil, j. (2011). Laproscopy versus open appendectomy: A comparison of primary outcome measures: Saudi Journal of gastroenterology. Retrieved from https://www.saudijgastro.com/text.asp?

Lewis, S.M., Heitkemper, M. M., & Dirksen, S.R. (2013). Medical Surgical Nursing: Assessment and Management of Clinical Problems. (9^th ed.). Missouri: Mosby.

Martin, R.F. (2014). Acute appendicitis: clinical manifestations and diagnosis. Retrieved from https://www.uptodate. com/home.

Ohtani, H. (2012). Meta- analysis of the results of randomized controlled trials that compared Laproscopic and open Surgery for acute appendicitis: Journal of Gastrointestinal surgery. 16(10), 1929-1939. doi:10.1007/s11605-012-1972-9

Saraswat,V. (2015). Effects of anesthesia techniques and drugs: Indian Journal of Anesthesia. 59(9). Retrieved from www.ijaweb.org>article.

Smink, D. (2014). Acute appendicitis: management. Retrieved from https://www.uptodate. com/home.

Vera, M. (2013). 4 Appendectomy Nursing Care Plans- Nurse Labs. Retrieved from nurses labs. com> Nursing care plans.

Waugh, A. (2015). Ross and Wilson Anatomy and Physiology in Health and illness. (12^th ed.). Philadelphia: Churchill Livingstone.

Wong, L. (2013). Wong’s Essentials of pediatric nursing. (9^th ed.). Churchill livingstone: Elsevier.