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Introduction to Acute Appendicitis

Describe the Report for Diagnosed with Acute Appendicitis.

The case study is on Ajay Mahajan, an 18 year old student who has been diagnosed with acute appendicitis and he has been operated for laparoscopic appendectomy. Appendix or vermiform is a blind-ended tube connected to the cecum located within the lower right abdomen. It acts as a storehouse that produces good bacteria that reboots the digestive system; however, it is regarded as a useless remnant organ from the evolutionary past. Inflammation and infection in this organ lead to appendicitis. The enlargement and inflammation of this organ might also be the reason that Ajay developed appendicitis. Clinical manifestation of appendicitis is severe pain in lower abdomen along with nausea and vomiting. Ajay also had continued pain overnight he felt nauseous and vomited many times. If untreated, the inflamed appendix might also burst and spread infectious material into the abdominal cavity. This will lead to the risk of developing peritonitis that can be fatal for patients (Papandria et al., 2013). Ajay’s appendix had also ruptured that is why he had to undergo open appendectomy.  

The pathophysiology of acute appendicitis is that occurs due to the multiplication of bacteria within appendiceal lumen and swelling of the appendix. It leads to increased intraluminal pressure and obstruction of venous drainage. In severe cases, the disease may progress to necrosis and gangrene due to the combination of bacterial infection and ischemia (Wolfe et al., 2013). Perforation of appendix takes place within 72 hours, and it is mostly seen in younger children than in adults. In the initial stage, the pain is normal, but as the inflammation worsens, more intense pain develops. After the progression of the disease, inflammatory fluid releases into the abdominal cavity, and then peritonitis develops. The location and seriousness of the condition depend on the degree of spillage of luminal contents (Bignel et al., 2016). Most of the time, surgery is the treatment options for this condition, but in very condition, antibiotics are given. Appendectomy is performed on patients to remove the appendix by open surgery. While open surgery involves creating a 2-4 inches long incision, laparoscopic surgery involved creating small incision by special surgical tools to remove the appendix. The advantage of laparoscopic surgery is that it helps patient to recover faster along with less pain and scarring. However, laparoscopic surgery is not appropriate during peritonitis. In the case of rupture of the appendix, open appendectomy helps to clean the abdominal cavity. That is why open appendectomy was appropriate for Ajay instead of laparoscopic appendectomy. Although appendectomy is the only curative treatment of appendicitis, management of appendiceal mass can also be done by intravenous antibiotic therapy. Salminen et al., (2015) compared antibiotic therapy with appendectomy in the treatment of uncomplicated acute appendicitis. The randomized controlled trial showed that patients randomized to antibiotic treatment for appendicitis did not required appendectomy during the one year follow-up period and those required surgey did not experienced any complications (Salminen et al., 2015). In case of patients with large, well-defined abscess, percutaneous drainage with IV antibiotic is performed, and catheter is attached to patient (Drake et al., 2014).

Clinical Manifestations of Acute Appendicitis

Ajay Mahajan was diagnosed with acute appendicitis after he was admitted to the hospital for acute pain and vomiting. He was recommended laparoscopic surgery, however, when the surgeon began the procedure it was found that his appendix has ruptured. Finally, he was operated on an open appendectomy with peritoneal lavage. Post the surgery he was transferred to the post-anaesthetic recovery room (PARU). Before Ajay's discharge from PARU, it is necessary for nurse to assess vital signs of patient. Ajay's readiness to discharge from PARU is dependent on the stability of vital signs compared to Ajay's preoperative data. The necessary outcome for discharge includes good body temperature control, proper ventilation and orientation to surroundings, minimal pain, nausea, adequate urine output and fluid and electrolyte balance (Rothrock, 2014). 

As Ajay was operated under anesthesia during an appendectomy, the surgery may have effect on his vital sign. It is necessary to assess his vital signs because anesthesia has effect on ventilation. Some complications were found after Ajay's vital signs were assessed. His blood pressure was low, and his body temperature was also below normal. The average oxygen saturation level is 90%, but Ajay O2 Saturation level was 94%. He was also hypoxic as his respiration rate was ten which are below normal rate. This is because anesthesia along with neuromuscular drugs results in the loss of airway potency in patients. It occurs because of relaxation of pharyngeal muscle and posterior displacement of tongue (Fox et al., 2014). Patients lose the ability to manage secretions. This cumulative effect of anesthesia results in airway obstruction and obstruction of gases in and out of lungs lead to hypoxia in patients. Post appendectomy, Ajay can also face problem due to reduced ventilation. The anesthetic drugs used during surgery causes reduction in ventilator minute volume according to the dose given to patients (Dahl & Spreng, 2016). For example, opioids lead to reduction in respiratory rate, volatile antibiotic causes reduction in tidal volume. Due to reduced ventilation, tachycardia, vasodilation, hypertension is seen in patients. Another possible effect of anesthetics on ventilation is it delays return of spontaneous ventilation and reduces patient ability to compensate (Cooper & Hutson, 2016). Therefore, due to this effect of anesthesia on patient's ventilation, assessment is necessary to check whether Ajay's vital signs have stabilized or not. Then only he can be discharged from PARU. 


On patient’s entry into PARU, nurses first need to monitor Ajay’s current status. They go through the surgery report regarding what type of anesthetics was given to patient. Assessment of ventilation, consciousness and circulation help to anticipate how quickly patient can recover and discharge from PARU. They determine the fluid and electrolyte balance in patients by the report on IV fluid and blood products administered to patient. On admission to PARU, Ajay was drowsy and supine. His mouth was dry and he felt cold. Different vital signs are checked because surgery and anesthesia have many effects on the vital signs of patient. After appendectomy, anesthesia also has effect on circulation. The process of circulation is dependent on overall effect of the cardiac output, blood volume, and peripheral vascular resistance. Different types of anesthesia may affect circulatory control in Ajay by having impact on left ventricular function and distribution of cardiac output. It decreases cardiac output and peripheral resistance due to the concentration of anesthetic agents in blood (Moitra et al., 2012). General anesthesia also modifies physiological and pharmacological stimuli. Ajay may also have problem because of anesthesia and surgical intervention effects splanchnic and hepatic circulation. The degree to which circulation is altered by anesthesia in patient is determined by status of ventilation, degree of hypoxia, relaxants, and the metabolic acidosis. Assessment of vital sign helps to determine the level of improvement required in patients and how they can recover. Most of the anesthetics decrease portal blood flow and lead to reduced cardiac output (Mundiyanapurath et al., 2015). Thus, surgical procedure plays key role in the circulatory disturbance, and the anesthesia plays a modifying role in it. 

Treatment Options for Acute Appendicitis

In different type of surgeries, anesthesia is used to dissect the nervous system and block pain in the selected area. The degree of consciousness is determined by the dose and type of anesthesia. Therefore assessment of airway potency, vital signs, and level of consciousness are the first priority for patients. In some cases, the immediate effect will be that it acts on the brain cortex and abolish responsiveness, but not consciousness. However, unconsciousness may ensue when posterior parietal region of brain is inactivated. It interrupts cortical communication and loss of stability (Constant & Sabourdin, 2015). Due to the effect of anesthesia also, patients develop muscle ache, hypothermia post surgery after patient gain consciousness. Post appendectomy, Ajay had poor body temperature control. This was found during assessment of his vital signs when his body temperature was found to be 35° C. This might have also occurred because of the effect of surgery/anesthetics as anesthesia impairs thermoregulation (Sessler, 2016). However, suppression of this defense mechanism depends on dose of agent. It results in perioperative hypothermia. Hypothermia can also have adverse effects on patients such as increase in postoperative wound infection and morbid cardiac events. Fluid management is also essential after appendectomy because patient may have imbalance of fluids and blood due to surgical procedure. Administration of excess fluid may increase postoperative cardiac morbidity.

Ajay has undergone open appendectomy following acute abdominal pain and vomiting. After Ajay had been transferred to the PARU, it was found that drowsy, his body felt cold, and his respirations rate was also low. After stability of his condition, he was transferred to the ward. He was able to ambulate and take fluids. A nicotine patch was also prescribed to him. At the time of discharge, Ajay was worried about how he will manage his activity as his family is not present in Australia. He realized that his life is out of control as he has been taking too many drugs and alcohol. Another concern was that he had no idea how he would manage his studies and cope with the situations. Based on the identification of current problems in patient, the discharge plan can be designed to aid him to manage his ailments properly at home. Ajay needs to put the dressing on his abdomen two times a day because of possible drainage from wounds. The patient needs to leave the Steri-strips in place for another ten days and gently wash his incision with warm water soap. He should apply any ointment till six weeks. Ajay is also advised not to bath or soak in swimming pool. While taking shower, he must be careful to pat dry the incision area (Putnam et al., 2014). However, it is advisable that he does not take bath for few days after discharge. Ajay has also been prescribed nicotine replacement therapy by nicotine patch since he smokes a lot. It will act as a deterrent for him and help him to tackle withdrawal symptoms like mood swings, trouble in concentrating and restlessness. Ajay should apply this patch in the upper area of his body such as underarms. He can continue this therapy for four weeks (Sisler et al., 2015). Since Ajay has been operated by open laparoscopy surgery, he needs to take bland, low-fat diets like mashed potatoes, soup, rice, cottage cheese, yogurt, milk, bananas and other foods. He should also avoid food that makes him constipated. In case he suffers from constipation he takes mild laxatives such as Metamucil and Citrucel (Christensen et al., 2016). To recover quickly, Ajay is advised not to increase his activity gradually by attending rehabilitation session post discharged. Physiotherapist will help them to manages ADLs (assistance with daily living) by preventing contractures, giving advice about post-surgery management and help him strenghthen his  muscles by different exercises (Adams et al., 2015).  It will not be good for him to lift heavy objects over 15 pounds as it may cause pain and stress in the area of incision.  Therefore, he should avoid lifting object for six weeks. In case of abdominal pain, he can take oral Tramadol and Metronidazole. If the pain does not subside even after this medication, then he should immediately notify physician. In case of swelling drainage, bleeding of incision and signs of infection, he should immediately meet the physician (Anderson et al., 2016).

Reference

Adams, R. J., Lichter, M. D., Krepkovich, E. T., Ellington, A., White, M., & Diamond, P. T. (2015). Assessing upper extremity motor function in practice of virtual activities of daily living. IEEE Transactions on Neural Systems and Rehabilitation Engineering, 23(2), 287-296.

Anderson, K. A., Abernathy, S. W., Jupiter, D., & Frazee, R. C. (2016). Patient Satisfaction After Outpatient Appendectomy. Journal of Laparoendoscopic & Advanced Surgical Techniques.

Bignell, M., Carr, N. J., & Mohamed, F. (2016). Pathophysiology and classification of pseudomyxoma peritonei. Pleura and Peritoneum, 1(1), 3-13.

Christensen, H. N., Olsson, U., From, J., & Breivik, H. (2016). Opioid-induced constipation, use of laxatives, and health-related quality of life.Scandinavian Journal of Pain, 11, 104-110.

Constant, I., & Sabourdin, N. (2015). Monitoring depth of anesthesia: from consciousness to nociception. A window on subcortical brain activity.Pediatric Anesthesia, 25(1), 73-82.

Cooper, L., & Hutson, L. R. (2016). 3 Anesthesia and intraoperative positioning. Improved Outcomes in Colon and Rectal Surgery, 19.

Dahl, V., & Spreng, U. J. (2016). Anaesthesia for non-obstetric surgery.Oxford Textbook of Obstetric Anaesthesia, 157.

Drake, F. T., Mottey, N. E., Farrokhi, E. T., Florence, M. G., Johnson, M. G., Mock, C., ... & Flum, D. R. (2014). Time to appendectomy and risk of perforation in acute appendicitis. JAMA surgery, 149(8), 837-844.

Fox, C. J., Kaye, A. D., Hummel, J. C., & Sidransky, M. (2014). Perioperative Pediatric Anesthesia Trauma Considerations. In Anesthesia for Trauma (pp. 321-333). Springer New York.

Moitra, V. K., Gabrielli, A., Maccioli, G. A., & O’Connor, M. F. (2012). Anesthesia advanced circulatory life support. Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 59(6), 586-603.

Mundiyanapurath, S., Schönenberger, S., Rosales, M. L., Romeiro, A. M. C., Möhlenbruch, M., Bendszus, M., ... & Bösel, J. (2015). Circulatory and respiratory parameters during acute endovascular stroke therapy in conscious sedation or general anesthesia. Journal of Stroke and Cerebrovascular Diseases, 24(6), 1244-1249.

Papandria, D., Goldstein, S. D., Rhee, D., Salazar, J. H., Arlikar, J., Gorgy, A., ... & Abdullah, F. (2013). Risk of perforation increases with delay in recognition and surgery for acute appendicitis. journal of surgical research, 184(2), 723-729.

Putnam, L. R., Levy, S. M., Johnson, E., Williams, K., Taylor, K., Kao, L. S., ... & Tsao, K. (2014). Impact of a 24-hour discharge pathway on outcomes of pediatric appendectomy. Surgery, 156(2), 455-461.

Rothrock, J. C. (2014). Alexander's Care of the Patient in Surgery. Elsevier Health Sciences.

Salminen, P., Paajanen, H., Rautio, T., Nordström, P., Aarnio, M., Rantanen, T., ... & Sand, J. (2015). Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial.Jama, 313(23), 2340-2348.

Sessler, D. I. (2016). Perioperative thermoregulation and heat balance. The Lancet.

Sisler, L., Trout, S., Ripley-Moffitt, C., & Goldstein, A. O. (2015). Case Report: Nicotine Replacement Therapy (NRT) in Hospitalized Surgical Patient. Journal of Smoking Cessation, 10(01), 2-4.

Wolfe, J. M., & Henneman, P. L. (2013). Acute appendicitis. women, 1, 2.

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