Acute appendicitis: a case study describing standards of care.
Ms. F. informs the ED nurse that the onset of pain has increased and became more severe over the past 12 hours; vomiting began about six hours ago and is described as bile in nature. She has taken no medication for her symptoms and has only used a heating pad to help relieve the pain in her abdomen. You instruct Ms. F. about not using a heating pad because she may have appendicitis and a heating pad increases the risk of perforation (Black & Hawks, 2009; Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011; National Digestive Diseases Information Clearinghouse [NDDIC], 2012). Upon exam, Ms. F. rates her pain at 10 out of 10 on the pain scale throughout her abdomen, with tenderness and guarding noted upon palpation. The patient also has positive psoas and obturator signs. She has hypoactive bowel sounds in all four quadrants. Ms. F. is febrile with a temperature of 101 degrees Fahrenheit tympanically, with a pulse of 120 and regular respirations of 24, blood pressure of 168/52, and Sa[O.sub.2] of 98%. Lung sounds are clear to auscultation with a poor inspiratory effort noted. Peripheral venous access and labs are obtained.
The patient is medicated with Zofran[TM] (4 mg IV) and morphine (3 mg IV) for nausea and pain. Based on the patient's presentation and history, an ovarian cyst versus an acute appendicitis (inflammation of the appendix) is suspected. A stat ultrasound of the abdomen is ordered. It shows no free fluid in the abdomen, an ovarian cyst with no rupture, and is inconclusive for appendicitis. Following a discussion with the ED attending physician, a Computerized Axial Tomography (CAT) scan is ordered and shows an acute appendicitis. Lab work reveals a white blood cell (WBC) count of 22,000 k/ul with 7% bands and a potassium level of 3.3 mmol/L, consistent with a possible appendicitis and dehydration. Based on the findings, normal saline solution (NSS) with 20 meqKCL/L is started at 125 ml/hr, the patient is kept nothing per oral (NPO), and a stat surgical consult is obtained consistent with health care standards (Lewis et al., 2011; NDDIC, 2012; Van Leeuwen, Poelhuis-Leth, & Bladh, 2013) .
To avoid perforation and sepsis, the patient is rushed to the operating room for an open appendectomy with the on-call general surgeon. The anesthesiologist utilizes general anesthesia. The surgeon removes the appendix to prevent future inflammation and infection, and Ms. F. spends two hours in the post-anesthesia care unit prior to being transferred to the medical-surgical unit. Upon receiving the patient, the med-surg RN completes an assessment, noting the surgical site dressing is dry and intact, and monitors vital signs every hour for the next four hours and then every four hours for the remainder of hospitalization. NSS with 20 meqKCL/L at 125 ml/hr is maintained and orders for Ancef[TM] (I g every eight hours IV), morphine (2 mg IV every two hours PRN), Vicodin[TM] (I tab PO every six hours PRN), Zofran (4 mg IV every six hours PRN), and Dulcolax[TM] (100 mg PO daily) are provided according to described standards of care (Black & Hawks, 2009; Lewis et al., 201 I; Vallerand, Sanoski, & Deglin, 2011). In addition, thromboguards are prescribed to prevent deep vein thrombosis, to be worn while in bed. Ms. F. is educated on maintaining Fowlers position, the proper use of the incentive spirometer (l/S), and use of a pillow splint to cough and take deep breaths each hour. A complete blood count (CBC) and comprehensive metabolic panel (CMP) are ordered to be completed each morning while in the hospital.
Ms. F. is able to tolerate small amounts of water without symptoms of nausea for the remainder of Day One post-surgery and a soft diet is permitted the next morning. Ms. F. begins to ambulate 150 feet with assistance by the end of the day without discomfort after premedication. Day Two post-op, Ms. F.'s temperature is 99 degrees Fahrenheit tympanically, with a pulse of 88, and regular respirations of 20, blood pressure of 130/76, and Sa[O.sub.2] of 98%. Lung sounds remain clear to auscultation with some incisional pain noted intermittently; bowel sounds are active. Lab work reveals a WBC count of 14,000 k/ul and a potassium level of 3.6 mmol/L. The surgical wound dressing has a scant amount of blood, and upon dressing change by the surgeon, the wound is well approximated. Medication orders are changed to: NSS at 50 ml/hr, Vicodin (every 4-6 hours PRN), Dulcolax (100 mg PO daily), and continue with current treatment with Ancef (I g every eight hours IV). Ambulation as tolerated is encouraged with assistance at minimum twice per day and evening shifts. Continued use of l/S, coughing and deep breathing with pillow splint, and use of thromboguards while in bed are maintained. Ms. F. ambulates to a chair for meals and to the bathroom with assistance. It is noted that the patient has not had a bowel movement at the conclusion of Day Two, but the RN explains that this is an expected temporary outcome to both anesthesia and pain medication. The patient is encouraged to continue drinking fluids and ambulating to stimulate peristalsis per described standards of care (Black & Hawks, 2009; Lewis et al., 2011; Vallerand et al., 2011).
Ms. F. responded well to treatment and at 72 hours post-op, the IV of NSS was decreased to 10 ml/hr and maintained for antibiotic therapy. All other medication orders remained the same. The patient was tolerating a normal diet and drinking fluids. Lab results were within normal limits. Vital signs were stable and the patient's pain level continued to decrease as expected. In addition, Ms. F. had a soft, brown bowel movement. She was reviewed and approved for discharge by the operating surgeon. Ms. F. was given individualized instructions to prepare for discharge and instructed to contact the surgeon for a post-op appointment in 7-14 days. She was to continue use of Vicodin, but instructed to try Tylenol[TM] (650 mg every six hours) as an alternative to the narcotic. Constipation and some nausea could continue, but the decrease in narcotics and continued ambulation and fluid intake would counteract this symptom. The incision was closed with dissolvable sutures and covered with steri-strips. The incision could form a hard knot beneath the skin and some bruising would occur, but this should subside. In the event that she noticed any areas of increasing warmth or redness, fevers, or chills, Ms. F. should call her surgeon immediately. It was recommended that she shower and not soak in a bathtub or hot tub until she is cleared in her follow-up appointment. With the approval of her surgeon, driving may only be resumed when off all narcotic pain medication and when she is able to turn and twist her body without hesitation (Black & Hawks, 2009; Lewis et al., 2011; NDDIC, 2012; Vallerand et al., 2011). Ms. F. was discharged to home with her mother, who picked her up.
Black, J.M., & Hawks, J.H. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, MO: Saunders, Elsevier.
Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Camera, I.M. (2011). Medical-surgical nursing. Assessment and management of clinical problems (8th ed.). St. Louis, MO: Elsevier Mosby.
National Digestive Diseases Information Clearinghouse (NDDIC). (2012). Appendicitis. Retrieved from http://digestive.mddk. nih.gov/ddiseases/pubs/appendicitis/index.aspx
Vallerand, A.H., Sanoski, C.A., & Deglin, J.H. (2011). Davis's drug guide for nurses (12th ed.). Philadelphia: F.A. Davis Company.
Van Leeuwen. A.H., Poelhuis-Leth, D.J., & Bladh, M.L. (2013). Davis's comprehensive handbook of laboratory diagnostic tests with nursing implications (5th ed.). Philadelphia: F.A. Davis.
Michael M. Evans, MSN, MSEd, RN, ACNS, CMSRN, CNE, is an Instructor of Nursing and Assistant Chief Academic Officer, Penn State University Worthington Scranton Campus, Dunmore, PA, and a Doctoral Candidate, College of Nursing, The Pennsylvania State University, University Park, PA. He is a member of the MedSurg Matters! Editorial Committee.
Marissa Curtin, MSEd, ASN, RN, is an RN--BS Student, Penn State University Worthington Scranton Campus, Dunmore, PA.
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|Author:||Evans, Michael M.; Curtin, Marissa|
|Article Type:||Clinical report|
|Date:||Nov 1, 2014|
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