CHAPTER ONE.

Man is a complex organism that is made up of billions of smaller

structures which are of four major kinds. The cells, tissues,organs and
the systems. A system is an organization of varying numbers and kinds
of the organs so arranged that together they can perform complex
functions for the body . Ten major systems include the skeletal,
muscular, Nervous, Endocrine, cardiovascular, lymphatic, respiratory,
gastrointestinal ( G.I.T) ,urinary and the reproductive system ( Netter's
Atlas of Human Anatomy by Frank H.Netter).

The Gastrointestinal (G.I.T) is one of the major systems of the

human body which also contributes to the continuity of life. The
principal functions of the gastrointestinal tract are to digest and absorb
ingested nutrients and to excrete waste products of digestion. The
organs that make- up the gastrointestinal tract in the order which they
are connected include; the mouth,oesophagus,stomach,small
intestine,large intestine,sigmoid colon,rectum and the anus. The
appendix can also be considered as part of digestive or gastrointestinal
tract.

The appendix is a small, tube-like structure attached to the large

intestine, specifically the Caecum ,which is the first part of the large
intestine. It is a narrow finger-like pouchi typically measuring 5-10cm
( 2-4 inches) in length and 1-2cm ( 0.4-0.8 cm inches) in diameter. The
appendix is relatively long in children but shorter in later life. The
appendix is otherwise known as "Tonsil of abdomen". This nickname is
due to the appendix's similar structure and function to the tonsils in the
throat . Like the tonsils,the appendix is a small, lymphoid organ that
contains immune cells called lymphocytes. It is thought to play a role in
the development of the gut- associated lymphoid tissue ( GALT)and the
immune system, particularly in early life..

However,it's worth mentioning that the appendix is not as clearly

understood as the tonsils,and its function is still a topic of debate
among medical professionals. When the tube that joins the large
intestine and appendix is blocked or trapped by stool can lead to
medical condition called "Appendicitis".

Appendicitis is an acute inflammatory process of the vermiform

appendix,characterized by invasion of the appendix by
polymorphonuclear leukocytes, lymphocytes and monocytes leading to
tissue damage,necrosis and potential perforation ( Sabiston Textbook
of Surgery: The biological basis of modern surgical practice,20th edition
by Courtney M. Townsend Jr 2017). As at 2019 ,there was an estimation
of 17.7 million cases of appendicitis worldwide with an incidence of
228cases per 100,000 population. In the same year ,there were over
33,400 deaths with 0.43 deaths per 100,000 population
( Springerlink,2022). While Appendicitis is a serious condition, ruptured
appendicitis presents unique challenges.

This case study will focus on a high- risk manifestation of appendicitis

which is " Ruptured appendicitis" and discuss its distinct clinical
features, treatment approaches and patient outcomes.

Ruptured appendicitis occur when:

-- Appendicitis is left untreated: Failure to treat appendicitis promptly

can lead to rupture.

-- Appendicitis is severe : Severe appendicitis can cause the appendix to

rupture.
-- Appendix is perforated: A hole in the appendix can lead to rupture.

--Appendix is blocked: Blockage of the appendix can cause pressure

buildup leading to rupture.

--Appendicitis is complicated by other conditions : Conditions like

cancer, Crohn's disease or Ulcerative colitis can increase risk of
ruptured.

Ruptured appendicitis is a serious medical condition that occurs

when the appendix, a small , finger-like pouchi attached to the large
intestine becomes inflamed and bursts, releasing bacteria and other
harmful substances into the abdominal cavity. It can occur at any
time,but it's more likely to happen with 24- 48 hours of appendicitis
symptoms. This could then result into " Peritonitis" which is the
inflammation of the peritoneum.

The clinical manifestations of ruptured appendicitis is severe

abdominal pain which begins from the abdomen and is later localized at
the right iliac fossa specifically at the Mc Burney point. Other signs and
symptoms includes; nausea,malaise,pain in the lower quadrant of the
abdominal region , constipation, diarrhoea,fever and chills.

Ruptured appendicitis which is the major focus of this study can be

treated through surgical intervention called " Exploratory Laparotomy".
There is no proven way to prevent appendicitis but research and
findings have that :

-- Knowing the signs and symptoms and when to contact a doctor can
be helpful.

--Regular health check up can also be helpful.

-- Eating food rich in fiber e.g Vegetables,oats, oranges and Beans.

Objectives of this care study.

-- To broaden my knowledge and the knowledge of other students

about the disease condition.

-- It will provide a medium for intensive research for further facts and
enquiry about the disease condition.

-- To know the possible causes , treatment , management, prevention

and control of this condition.

-- To improve my skills on the management of the disease condition

and care given to patient regardless of the patient's conditions.

Definition of Terms.

APPENDICITIS: Is the inflammation of the vermiform appendix .

APPENDICETOMY : This is the surgical removal of inflamed vermiform

appendix.

ABCESS: A cavity caused by tissue destruction usually because of

infection filled with pus and surrounded by inflamed tissue.

ACUTE : Is a term used to describe abnormal condition of recent or

sudden onset..

CHRONIC: Is a term used to describe a condition that usually lasts for 3

months or longer and may get worse over time .
PERITONITIS: Inflammation of the peritoneum.

EXPLORATORY LAPAROTOMY: A surgical procedure where the

abdomen is opened to examine and treat internal organs and
structures..

ANAESTHESIA: A substance used to cause loss of sensation in a part of

the body or all parts of the body .

ASEPSIS : Refers to the absence of disease causing micro organism,such

as Bacteria,viruses and fungi in a particular environment or situation..

COLICKY: Means severe pain that grips the abdomen or the disease that
causes such pain.

FAECOLITH : Also called appendi- colith ,it is a hardened lump of faeces

in varying sizes.

CAECUM: A blind pouch tube- like structure which is the

commencement of the large intestine with the vermiform appendix.

VERMIFORM APPENDIX: This is a worm- like structure which measures

about 7-12 cm long attached to the Caecum of the large intestine at the
right iliac fossa below the Ileo- Caecal valve.

RUPTURED APPENDICITIS: A life- threatening medical emergency where

the inflamed appendix bursts, releasing bacteria ,pus and faecal matter
in to the abdominal cavity

ILIAC FOSSA: This is a concave depression on the lateral side of the

abdominal region just above the pelvis, the right iliac fossa provides a
space for the vermiform appendix.
 CHAPTER TWO.

Appendicitis is one of the major common surgical emergencies characterized by

inflammation of the vermiform appendix. The condition typically presents with
acute abdominal pain,often requiring surgical intervention. The evolution of
understanding Appendicitis - from its etiology to diagnostic methods and
treatment options - has been shaped by a diverse body of the literature. This
review synthesizes key findings from prominent studies,providing an overview of
the historical and contemporary perspective in Appendicitis.

The understanding of appendicitis has evolved significantly since it's first

descriptions. The term " Appendicitis" was coined in the late 19th century,but
references to appendiceal diseases date back to ancient civilizations.
Notably,Reginald Herber Fitz,in 1886 was pivotal in describing the condition and
advocating for surgical intervention.His seminal paper " Perforating inflammation
of the vermiform appendix",laid the groundwork for the surgical management of
appendicitis ( FITZ 1886).

Epidemiological studies indicate that Appendicitis affects approximately 7-12% of

the population,with a higher incidence observed in males and individuals aged 10
to 30 years ( SORELIUS ETAL; 2014). A study by Ruhl and Everhart ( 2000)
highlighted that diets low in fiber may increase the risk of appendicitis, suggesting
a correlation between appendiceal obstruction and dietary habits. The clinical
presentation of appendicitis is typically characterized by a gradual onset of
abdominal pain, often starting around the periumbilical region and migrating to
the right lower quadrant.

According to the studies by Alvarado ( 1986) and later by Gholson et al

( 2006) ,additional symptoms such as nausea, vomiting and fever frequently
accompany the pain . The diagnostic process for appendicitis has been
significantly referred with the advent of imaging technologies. Ultrasound and
computed tomography ( CT) are pivotal in establishing a diagnosis. As at
2019,there was an estimation of 17.7 million cases of appendicitis worldwide with
an incidence of 228 cases per 100,000 population. In the same year ,there were
over 33,400 deaths with 0.43 deaths per 100,000 population ( Spingler
link ,2022) .

The Gastrointestinal tract is the tract or passage way of the digestive system that
leads from the mouth to the anus.The organs that collectively make up the
gastrointestinal tract are the mouth, oesophagus, stomach, small intestine, large
intestine, sigmoid colon,rectum and the anus.

The Gastrointestinal tract itself is subdivided into upper and Lower

gastrointestinal tracts.The upper gastrointestinal tract consist of the mouth,
oesophagus, stomach and duodenum while the lower gastrointestinal tract
consist of major parts of the small intestine,Large intestine, Rectum and the anus.

The activities of the gastrointestinal tract can be classified into four (4) headings;

-- Ingestion

-- Digestion

-- Absorption.

-- Elimination.

-- Ingestion: It is the action or process of taking food ,drink or substance into the
body by swallowing or absorbing it.

-- Digestion : It is the process of breaking down of food substance into smaller

substances the body can use for tissue growth and repair.

-- Absorption: It is the process of taking nutrients from the digestive system into
the blood so they can be used in the body.

-- Elimination: It is the removal or expulsion of waste matter from the digested

food from the body.

The wall of Gasto - Intestinal tracts are made up of four (4) layers which are ;

-- Mucosa.
-- Submucosa.

-- Muscularis Propria

-- Adventitia.

The structure of these layers varies in different regions of the digestive tract
depending on their functions.

-- Mucosa : A lining epithelium including glandular tissue,an underlaying layer of

loose connective tissue called LAMINA PROPRIA ,which provides vascular suppor
for the epithelium and often contains mucousal glands . Products of digestion
pass into these capillaries. Lymphoid follicle and plasma cells are also often found
here. Finally,a thin - double line layer of smooth muscle is often present which is
called " THE MUSCULARIS MUCOSA" for local movement of the mucosa.

-- Submucosa: It is located underneath the mucosa. It contains a loose connective

tissue layer with larger blood vessels,lymphatics ,nerves and can contain mucous
secreting glands.

-- Musculais Propria : It is also called smooth muscle layer .These are usually two
layers ; the inner layer is circular and the outer layer is longitudinal. These layers
of smooth muscle are used for peristalsis ( Rhythmic waves of contraction) to
move food down through the gut

-- Adventitia layer : It is also called the serosa layer . It is the outermost layer of
loose connective tissue. It is covered by the visceral peritoneum,contain blood
vessels, lymphatics and nerves ( Histology Guide ,2022).

-- Arterial blood Supply: The anterior part of the gastrointestinal are supplied
with blood by arteries branching off the aortic arch and thoracic aorta. Below this
point, the alimentary canal is supplied with blood by arteries branching from the
abdominal aorta . The celiac trunk supplies the liver, stomach and duodenum
while the superior and inferior mesenteric arteries supply the jejunum,ileum and
the large intestine ( Emergency Room Service,2022).
Venous drainage : The venous drainage is by the superior mesenteric vein which
then joins with various vein of other organs to empty their content into the portal
vein before finally getting to the inferior vena cava ( Emergency Room
Service,2022).

ANATOMY AND PHYSIOLOGY OF VERMIFORM APPENDIX.

The appendix also known as vermiform appendix . The word " Vermiform" is
derived from a Latin word and it means " word shaped " .The appendix is a finger-
like ,blind ended tube connected to the Caecum.

The human appendix averages 9cm in length but can range from 5-9 cm . The
diameter of the appendix is 6mm and more than 6mm us considered a thickened
or inflamed appendix. The appendix is usually located in the lower right quadrant
of the abdomen,near the right hip bone . The base of the appendix is located 2cm
beneath the Ileo-Caecal valve that separates the large intestine from the small
intestine. The appendix used to be considered as a vestigial organ ,but this
perspective has changed over the past decades . Research suggests that the
Appendix may serve an important purpose in particular,it may serve as a reservoir
for beneficial gut bacteria.

The appendix can get infected by virus, bacteria or deposit of stool blocking the
appendix,when infected it gets inflamed. This condition is called " APPENDICITIS" (
Wikipedia,2022 by John Bell).

MICROSCOPIC STRUCTURE OF VERMIFORM APPENDIX.

The vermiform apendix has structure similar to that of the large intestine. The
wall of the appendix is made up of four ( 4) layers as follows;

-- Peritoneum layer.

--Muscular layer

-- Submucosa layer .

-- Mucous membrane layer.

--Peritoneum layer : It is the outer layer covering the appendix. It has a complete
peritoneal covering with its proximal half attached by a mesentery called meso -
appendix to the lower part of the ileum , while it's distal half hung freely into the
peritoneal cavity.

--Muscular layer: This layer lies beneath the Peritoneum and it is made up of
longitudinal and inner circular muscle fibres

-- Submucosa layer: It lies beneath the muscular layer . This layer is quite thick
consisting of aerolar tissue,blood vessels,nerves and more lymphoid tissue with
abundant lymphocytes.

-- Mucous membrane layer: This is the innermost layer that is made up of

columnar epithelium with numerous goblet cells that secrete mucus.

ARTERIAL BLOOD SUPPLY: Ileocolic artery.

VENOUS DRAINAGE : Ileocolic vein.

NERVOUS SUPPLY: Superior mesenteric plexus.

Function of the appendix.

The appendix is designed to protect good bacteria in the gut by acting as a store
house for good bacteria.

RUPTURED APPENDICITIS.

Ruptured appendicitis is a life threatening medical emergency where the inflamed

appendix bursts releasing bacteria,pus and faecal matter into the abdominal
cavity.

INCIDENCE: Here are the incidence of ruptured appendicitis in terms of

demographics and other factors:

Age: -- Most common in children and young adults ( 10 - 30 yrs).

-- Peaks in incidence around 15- 19 years old.

 -- Can occur at any age including infants and the elderly.

Sex : -- slightly more common in males then female ( 1: 3:1 to 1:7:1 rato).

Race : Higher incidence in Caucasian compared to African Americans and

Hispanics.

Other factors:

-- Family history: Increased risk if a first- degree relative has had appendicitis.

-- Obesity : May increase the risk of appendicitis and rupture.

-- Delayed diagnosis: Increases the risk of rupture, especially in children and the
elderly.

TYPES OF RUPTURED APPENDICITIS.

1. Simple ruptured appendicitis: The appendix bursts , releasing pus into the
abdominal cavity.

2. Perforated Ruptured appendicitis: A hole develops in the Appendix,allowing

bacteria and pus to leak into the abdominal cavity

3. Gangrenous Ruptured appendicitis: The Appendix dies due to lack of blood

supply leading to rupture and infection.

4. Peri appendiceal abscess rupture : A collection of pus forms near the appendix
and ruptured , spreading infection.

5. Retrocecal rupture: The appendix ruptures behind the caecum ( first part of the
large intestine), leading to a retroperitoneal abscess.

6. Pelvic rupture: The appendix ruptures into the pelvic cavity leading to a pelvic
abscess.

7. Diffuse peritonitis rupture: Bacteria and pus spread throughout the abdominal
cavity ,leading to a widespread inflammation.
8. Localized peritonitis rupture: Bacteria and pus spread to a localized area of the
abdominal cavity leading to inflammation and abscess formation.

AETIOLOGY OF RUPTURED APPENDICITIS.

The aetiology of ruptured appendicitis involves a combinations of factors that

lead to the blockage of the appendicitis,followed by bacterial
overgrowth,increased pressure and eventual rupture. Here are some possible
causes :

1.Obstruction : Blockage of the appendix lumen by;

a.) Faecoliths ( hardened faeces).

b.) Lymphoid hyperplasia ( enlarged lymphoid follicles)

c.) Foreign bodies ( ingested objects).

d.) Tumours ( e.g Carcinoid).

2. Bacterial overgrowth: Increased numbers of bacteria,such as :

-- E.coli

--Bacteroides.

-- Streptococcus.

3. Increased pressure: Rise in intraluminal pressure due to:

-- Obstruction

-- Bacterial overgrowth

-- Inflammation.

4. Ischemia: Reduced blood flow to the appendix leading to:

--Gangrene

-- Perforation
5. Immunological factors : Abnormal immune responses such as:

-- Overactive immune responses.

-- Immunodeficiency.

6. Other factors: Trauma,stress and hormonal changes .

These factors can contribute to the development of ruptured appendicitis,but the

exact cause may vary from person to person.

CLINICAL MANIFESTATIONS OF RUPTURED APPENDICITIX.

A. Severe abdominal pain

B. Nausea

C. Malaise.

D. Pain in the lower quadrant of the abdominal region.

E. Constipation

F. Diarrhoea.

G. Fever

H. Chills.

I. Loss of appetite.

K. Vomiting.

PATHOPHYSIOLOGY OF RUPTURED APPENDICITIS.

The pathophysiology of ruptured appendicitis involves a series of events leading

to the perforation of the appendix and the release of infectious contents into the
abdominal cavity. Here is a step by step explanation.

1. Obstruction : The appendix lumen is blocked by faecoliths, lymphoid,

hyperplasia or other factors.
2. Increased pressure: The appendix becomes distended,causing venous
congestion.

3. Venous congestion: Blood flow out of the appendix and is impaired.

4. Ischaemia: Reduced blood flow causes tissue hypoxia.

5. Inflammation: White blood cells accumulate,releasing chemical mediators .

6. Bacterial overgrowth: Normal Flora bacteria multiply ,releasing toxins

7. Necrosis : Tissue death occurs weakening the appendix wall leading to

perforation.

8. Perforation: The appendix ruptures,releasing :

a. Bacteria

b.Toxins.

c.Fecal matter

d. Inflammatory mediators in to the abdominal cavity.

9. Peritonitis: This leads to inflamed of peritoneum and thereby causing

sepsis ,abscess formation and adhesions.

DIAGNOSTIC INVESTIGATION.

-- Blood test to check for infection.

-- Physical assessment: Abdominal palpation will reveal tenderness on Mc

Burney's point.

-- MRI (Magnetic Resonance Imaging) to check the structure of the ruptured

appendix.

-- CT scan ( Computed tomography)

-- Urine test to identify kidney or bladder infection

-- Through signs and symptoms.

Nursing and Medical management.

If the patient does not live nearby,best thing is to admit the patient into the
ward .Admit patient for proper observation and also to ensure that adequate care
is rendered to the patient.

Surgical Treatment.

The major surgical treatment in this case study is " Exploratory Laparotomy". This
surgical interventions is used in case where:

a. Diagnosis is uncertain

b. Complexity or severity.

c. Failed Laparoscopic attempt.

During an exploratory laparotomy:

1. A larger incision is made in the abdomen to allow for thorough examination of

the abdominal cavity.

2. Direct visualization: The surgeon directly visualizes the appendix,surrounding

tissues and other organs to assess the extent of the rupture.

3. Appendectomy and repair.

4. Washout and drainage.

Nursing management ( Pre- operatively).

1. Admissions: The patient is admitted into the ward a day or two days before the
surgery ,so as to prepare the patient for the surgery and to ensure that the
patient receive adequate care and rest , except in emergency condition when the
surgery requires urgency. The patient is also placed on bed in an appropriate
position to promote comfort and to relieve pain.
2. Observations : Proper observations is done on the patient including taking and
recording the vital signs ( temperature,pulse,respiration and blood pressure) to
detect the condition of the patient . Physical examination such as inspection,
palpitations, percussion and auscultation is done to check if the patient is
anaemic ,any tenderness or swollen part.

3. Investigations: Laboratory investigations e.g Blood test,urine test,pack cell

volume etc is carried out to detect any abnormalities .

4. Consent form : After the procedure is explained to the patient and the reason
for the operation is known to the patient, a consent form is signed by the patient
or patients relative which serves as a legal backup for the surgeon and other
healthcare team. The consent form must be counter signed by a witness by the
staff nurse on duty and a doctor.

5. Diet: The patient is to be placed on nil per oral the night before the surgery,this
is about 8 hours before the surgery. Patient can be placed on 0.9% normal saline
because of extra fluid losses and typically longer fasting.

6. Physical care: Help the patient to maintain personal hygiene through bed
bath ,oral toileting to prevent oral infections or complications.Also,if patient is
hairy at the site of the operation,help the patient to shave and clean with
methylated spirit or Dettol to prevent infection.

7. Psychological care : Provide psychological care to the patient by relieving

anxiety and fear.This can be done by explaining the procedure of the surgery to
the patient, answering every question from the patient and his relative. Also,by
making example of previous patient that underwent the procedure and survived.
Diversional therapy which helps to allay fear includes: Reading of books and
newspaper,playing games etc.

8. Pre-operative teaching : The patient is encouraged and educated on some

exercise before the surgery e.g deep breathing exercise, coughing exercise to help
prevent pulmonary or lungs complications.
9. Bladder and bowel care : Ensure the patient empty her bladder and bowel
before going for the operation as this helps to improve access and reduce surgical
risk with Laparotomy.

10. Medication: Patient can be placed on analgesic such as Paracetamol 600mg

IM, minor tranquilizer e.g diazepam 10mg may be given the night before the
operation to promote rest and relaxation of the muscle if the patient seems
restless due to anxiety.

Post operative Nursing management.

Objectives of post operative Nursing care.

1. To prevent spread of infection.

2. To prevent post operative complications.

3. To promote healing and comfort.

4. To ensure adequate rest and nutritional need.

1.) Recovery room: After the surgery the patient is moved from the theatre room
to the recovery room also known as the post- anaesthetic care unit ( PACU) where
the nurse monitors the patient closely till she recovers from the anesthesia. This is
done to ensure that a life patient is brought back into the ward . Patient vital signs
are closely monitored every quarter hourly for at least one to two hours and this
must be recorded on the patient's folder. Airway clearance should be monitored
and the operated site noticed for any bleeding before moving the patient to the
ward

NOTE : There are accessories such as vital signs tray, resuscitating tray,function
machine and oxygen cylinder should be provided by the patient bedside for
monitoring and management of patient.
2. Positioning: Patient is placed on a lateral position with the head turned to one
side to prevent falling back of the tongue so as to prevent blocking the airway,this
also helps in draining or suctioning out secretions from the mouth.

3. Observation: When patient is welcomed back from the theatre,observe the

level of consciousness of the patient ,the vital signs ( temperature,pulse,
respiration and blood pressure) is observed for every quarter hourly for the next
one hour and hourly. Examine operation site ,if it is dry or there is bleeding.

4. Nutrition: Nothing is given by mouth for the first few days post operatively.
Nutritional status is maintained during this period with intravenous
administration of fluids . When bowel sounds returns oral intake of fluid
commences gradually first with Lipton then light balanced diet such as pap and
vegetables until patient is able to tolerate semi solid food e.g Rice and vegetables
and finally solids e.g Amala and Egusi.

NOTE: Carbonated fluids and gas forming foods should be avoided .

5. Care of Intravenous fluids: The infusion 5% dextrose or 9% normal saline should

be monitored and recorded on the fluid balance chart and also ensure the drop
regulated to the normal drop per minute ( 20 drop per minute). Ensure the
cannula site is in place if disloged replace immediately.

6. Physical care : Operation site should be regularly checked for bleeding,daily bed
bath,oral care should be done by the patient . Care of the pressure areas is very
important to prevent pressure sore which is done by changing patient position
every 2hours.

7. Elimination: Avoid constipation and straining during defecation.Mild purgatives

such as sodium sulphate may be given .

8. Ambulation and Exercise: Early ambulation is encouraged,breathing exercise,

coughing exercise and short distance walk is encouraged.

9. Medication: Check patient's folder to see the post- operative drugs. Administer
the drug as prescribed by the prescriber .IV ceftriaxone 1g once daily
( antibiotics) . Analgesics such as Paracetamol, Pentazocine to relief pain.
10. Site of incision: Patient incision site is cleaned with methylated spirit and a
new gauze applied. Aseptic technique is carried out while dressing the site to
prevent entrance of micro-organisms . Stitches removal is on the 7th day post
operatively, sometimes 12th day post operatively depending on the stitches used
and recovery process of the patient.

11. Health Education: Health educate the patient on the illness ,the cause,the
prevention,the treatment/management and also on how to promote good health.

12. Advice on discharge : Patient should be health educated,he should be told on

how to take better care of himself,the type of diet to take,how to take enough
rest,avoid lifting heavy load as this can cause abdominal burst or other
complications. Prescribed drugs should be completed and to keep the
appointment date or he can report to the hospital if he has any complain before
the date .

Complications of Ruptured appendicitis.

1. Peritonitis

2.Abcess formation

3. Sepsis

4. Adhesions.

Complications of Exploratory Laparotomy.

1. Bleeding

2. Wound infection

3. Blocked bowels

4. Injury to the nearby organs.

5. Inflammation of the belly.

6. Vomiting.
7. Shock

CHAPTER THERE.

CLIENT BIOGRAPHICAL DATA.

NAME: A.H

AGE: 19 years

DATE OF BIRTH : 20\6/2005.

SEX : Male

MARITAL STATUS : Single.

RELIGION: Islam.

NATIONALITY: Nigerian.

STATE OF ORIGIN: Kogi state.

LOCAL GOVERNMENT AREA: Okehi

HOME ADDRESS: Okengwe behind Charity Hospital.

OCCUPATION: Student.

ALLERGIES: No allergies

MEDICAL DIAGNOSIS: Ruptured appendicitis

DATE OF ADMISSION: 29/8/2024.

CONSULTANT: Doctor Audu.

WARD: Male medical ward.

BED NUMBER: Bed 3 ( annex).

DATE OF SURGERY: 1/9/2024.

SURGERY DONE: Exploratory Laparotomy.

DATE OF DISCHARGE: 8/9/2024.

HOSPITAL ADMITTED: Reference Hospital, Okene.

NEXT OF KIN.

NAME: A.S

RELATIONSHIP: Father

ADDRESS: Okengwe behind Charity Hospital.

PHONE NUMBER: 08164083323.

NURSING HISTORY.

Past Medical History: patient said to have repeatedly treated Malaria and Enteric
Fever on 26th of August 2024. He had no serious childhood sickness before and
had not been hospitalized for any serious illness before now.

Past Surgical History: He has no history of surgical case before until now.

Present Medical History: Patient was referred from Agape Clinic with complain of
Inability to void and inability to stand due to abdominal pain. Patient was
reviewed by Doctor Audu via a scan result and Ruptured appendicitis was
diagnosed and booked for surgery to be carried out on 1/9/2024. His vital signs on
admission are; Temperature of 36.2°c, 26c/m as respiration,94 b/m as pulse and
Blood pressure of 110/60mmHg.

Sleep and Rest: Patient sleeps for 8 hours before the illness but during the illness
patient's sleeping pattern became altered due to abdominal pain and discomfort
being experienced by him.
Nutritional pattern: He normally have his three square meal everyday in the
absence of disease condition. But as at now, his appetite for food is lost due to his
present condition.

Elimination pattern : Patient normally defecate everyday and urinate 3 times

during the day but once at night due to his present condition.

Communication and special senses: Patient has sound communication skills . He is

fluent in Ebira and English language.All his five senses are intact i.e he can
perceive any smell, he can hear well, he has a good sense of taste ,can see
perfectly fine and respond to any stimulus.

Coping with stress : Patient copes well with stress by visiting his friends and can
easily adapts with stress . He view stress as part of life that can be overcome
which enables him not to easily give up in situation.

Habits and personal hygiene: Patient does not smoke or drink ,He is very clean.
Personal hygiene is intact and he is been well taken care of.

Activity/ Exercise: Patient loves running early in the morning before going to
school. He enjoys exercising a lot and views it as a way to keep fit.

Recreational Hobbies: Patient is a member of Football team in his school . He

engages in Football practice three times a week and participates in weekend
matches. The patient aims to improve stamina and performance on the field.

Feeling about self concept/ Self image : Patient expresses a positive self
image ,demonstrating full confidence and self - worth about himself.

Family / Social Relationships: Patient's Family is actively involved in

care,demonstrating a supportive environment. He shares a great bond with his
family .

Occupation/ History/ Economic Status: He is a student and he relies on family for

financial stability.

Sexual / Reproduction: Patient reports no sexual activity or concerns.

Values and beliefs : Patient is a Muslim and he believes in the almighty Allah that
he will be fine.

CHAPTER FOUR.

Physician's view point : The physician assessed the patient and obtain history
about the patient . The patient had a complain of Lower abdominal
pain,generalized body discomfort and inability to void . He was seen at the
Doctor's office and abdominal palpitations was done revealing a tender abdomen.
The doctor ordered for ultrasound scan which was reviewed and made the
diagnosis of Ruptured appendicitis. He was booked for surgery on 1/9/2024 which
was carried out successfully.

Prior to the surgery,the doctor ordered for some test to be carried out which
includes; blood test,HIV and Hepatitis screening. The result of Hepatitis and HIV
screening came out negative.

General Observation ( Head to Toe).

General outlook: He looked very weak and unable to walk properly by himself
except when supported ,he is a little dehydrated but in serious pain with
rebounce abdominal pain.

Head : Patient's hair was well combed,looked neat with no ringworm.

Eyes: No discharge from the eye ( both right and left) no difficulty in seeing,no
redness of the eye and no observable eye defects noticed .

Ear : The two ears are intact ,no hearing loss or impairment,no pain.

Nose : No abnormal discharge and no epistaxis.

Mouth and teeth: No cracked lips ,well positioned lips,no bleeding gum,no
denture and no dysphagia.

Neck : No stiffness,no abnormal growth.

Skin : The patient's skin was assessed and there was no sore or any alteration on
the skin.

Limbs: Both upper and lower limbs are normal.

Abdomen: Rebound tenderness to touch ,no swelling.

Mental status: Patient was anxious but very friendly.

Systemic Review.

Respiratory system: No history of airway obstruction,no cough,or sign of

dyspnoea or abnormal breathing sound ,no chest pain and no sign of respiratory
defect.

Cardiovascular system: No history of cardiovascular disease or disorder . Pulse

rate reading 94b/m ,which is normal and pressure reading of 110/70 mmHg.

Urinary system: No urine retention/Incontinence.

Nervous System: There is consciousness of the environment,the patient feels

clear sensation and is very alert.

Integumentary system: Skin tugour is intact,no raised body temperature.

Temperature reading is 36.2°C. No swollen or walt seen on the skin.

Endocrine System: No enlarged thyroid gland seen and no history of diabetes

noted.

Musculoskeletal system: No generalized body pain, no deformity and wasting of

muscles.

Gastrointestinal System: There is tenderness at the right iliac fossa and presence
of nausea and vomiting.

Reproductive system: No history of reproductive diseases and no signs of it on

admission.
 Daily Nursing Management Pre- operatively.

29/8/2024 : Patient was wheeled in accompanied by his pareny into the Male
medical ward at around 4:00pm . Patient's bed was made and he was instructed
to lie on the bed. Patient vital signs were checked Immediately at around 4:15 pm
with the temperature reading 36.3°C, Pulse 94b/m, respiration of 26c/m, SPO2
98% and blood pressure of 110/60mmHg. Psychological support was given to the
patient and patient was placed on these following medications.

IVF Normal saline to alternate Dextrose Saline 509mls ×8hourly.

IV ceftriaxone 1g 12 hourly × 48 hours.

IV Metronidazole 500mg 8h hourly × 48 hours.

IV Artesunate 120mg × 24 hours.

All of these medication were commenced at exactly 4: 30Pm .

30/8/2024: Patient was met lying on bed with IVF N/S 500mls in situ. He
complained of pain at the abdominal region and IV Pentazocine 600mg was given
with good effects. Patient had difficulty in standing up from bed ,so assisted bed
bath was done and oral care so as to prevent the complications of a neglected
mouth. Patient Vitals were checked at 7: 30am which read ; temperature of
36.8°C ,Pulse 78b/m , Respiration 22c/m and blood pressure reading of
110/70mmHg. All due medications which includes IV Ceftriaxone 1g,IV
Metronidazole 500mg Nf IV Artesunate 120mg was served at exactly 8: 30am.

31/8/2024 : Patient was met Calm on bed. He was reviewed by the doctor of
which the patient's relatives were informed about the surgery to be carried out
tomorrow. The doctor ordered for HIV test,blood test and Hepatitis screening to
be done to which the result came out all negative. The patient himself was also
informed about the surgery and detailed explanations were given to the patient.
Patient anxiety was alleviated by explaining the procedure to him and the
questions were answered truthfully. Consent form was strictly signed by the
patient after explaining the procedure which serves as a legal backup for the
patient, surgeon and the nurses including other health workers . Patient was
placed on nil per oral die to the surgery. Operation site was shaved and cleaned
with antiseptic solution. Catheterization was done for the patient and the vitals
were taken which reqda temperature 36.2°C , Pulse 94b/m , respiration 20c/m
and blood pressure 110/60mmHg.

Post Operative Treatments.

---Placed on nil per oral.

---- Monitor Vitals closely.

--- IVF Normal saline to alternate Dextrose Saline 500mls 6hrly × 48 hours.

--IV metronidazole 500mg 8hourly × 72 hours.

-- IV Paracetamol 600mg 8hourly × 48 hours.

--IV Gentamycin 80mg 12 hourly × 72 hours.

---IV Pentazocine 60mg 12 hourly × 48 hours.

--- IV Rocephine 625mg 12 hourly × 72 hours.

Daily Nursing Management Post Operatively.

01/9/2024 : Patient was brought back into the ward from the theatre at 11am
with IVF N/S 500mls in situ in a semi - conscious state due to the effects of
anesthesia with an Indwelling Urethral Cathether draining fine. He was placed on
a left lateral position with the head turned to one side to prevent the tongue from
falling back and obstructing the airway thereby affecting his respiration .

Vitals at 11: 30 am read temperature 36.3°C,Pulse 92b/m , respiration 22c/m and

Blood pressure 110/70 mmHg with SPO2 of 95 % .Patient was on nil per
oral ,incision site was checked and intact. Patient was fully conscious at 3: 00pm
and his post operative drugs were commenced which includes : IVF Normal saline
500mls,IV Metronidazole 500mg,IV Paracetamol 600mg ,IV Pentazocine 60mg ,IV
Rocephine 625mg were served
02/9/2024 ( First day post operative): Patient was still on bed in a full conscious
state and his condition improved. Intravenous fluid was still in situ.Patient
complained of pain at the operated site and IM Pentazocine 60mg was given at
11:00am with good effects. Patient was still in nil per oral . Incision site was
dressed,oral care was done to prevent oral complications . Assisted bed bath was
done in the bathroom to prevent skin infection, operation site was cleaned and
new gauze applied. All due medications were served at 3:00pm which includes IVF
D/S 500mls ,IV Gentamicin 160mg,IM PCM 600mg and IV Rocephine 625mg .
Vitals were taken at 3: 40 pm which reads temperature 36.5°C ,Pulse 97b/m,
respiration 22c/m ,SPO2 of 98% and blood pressure of 120/70 mmHg. Patient was
encouraged to ambulate by the Doctor and nil complain from him.

3/09/2024 ( Second day post operative) : Patient was met on the chair by his
bedside,happy and full of smiles. He also looks healthier. Nil fresh complains,he
was able to bath himself and brush his teeth . Operation site was cleaned,nil
discharge and no debris .All due medications were served at 8: 00am which
includes IV Gentamycin 160mg,IV Rocephine 625mg ,IV Metronidazole 509mg.
Vital signs was recorded at 8: 40 am which read temperature 37.2° C , Pulse
80b/m , respiration 24c/m and blood pressure of 110/70mmHg. Bowel sounds
was present in the evening at 2: 00pm .Doctor was informed and he placed him
on Oral fluid such as Lipton which was taken and well tolerated.

4/9/2024 ( Third day post operative): Patient was met sitting on the chair. Had his
bath and oral care by himself . Doctor reviewed him and said he was fine, no
abdominal tenderness.All due medications were served at 12 : 00am which
includes IV Gentamycin 160mg ,IV Rocephine 625mg ,IM PCM 600mg . Vitals were
taken at 1: 00pm reads temperature of 36.5° C ,Pulse 72b/m , respiration of
18c/m and blood pressure of 110/60mmHg.

5/9/2024 ( Fourth day post operative) : Patient had his bath early in the
morning,looking fresh. No fresh complaint from patient. Psychological re-
assurance was given to patient All due medications were served which includes IV
Rocephine 625mg , IVF Normal saline 500mls ,IV Metronidazole 500mg at 8 : 30
am and vitals were taken which reads temperature 36.7°C , respiration of 20c/m ,
Pulse 82b/m,SPO2 of 95% and blood pressure of 110/60 mmHg.

6/9/2024 ( Fifth day post operative) : Patient was met sitting on bed. He had his
bath and oral care himself.Cathether was removed and discarded. Patient was
taught bladder training ,all due medications which includes IV Rocephine 625mg ,
IVF Normal saline 500mls ,IV Metronidazole 500mg were served at 2::00am and
vitals reads temperature 35.6°C, respiration 20c/m ,Pulse 77b/m , SPO2 of 98%
and blood pressure 110/80 mmHg.

7/9/2024 ( Sixth day post operative) : Patient was met Calm on bed.His conditions
much improved ,he has exhausted all his parenterally medications.Doctor Ogirima
reviewed him and he was told to prepare for possible discharge tomorrow.Vitals
at 12:00pm read , temperature 35.3°C , respiration 22c/m,Pulse 72b/m, SPO2 of
98% and blood pressure of 110/70 mmHg.

8/9/2024 ( Seventh day post operative) : Patient had his bath early in the morning
looking fresh . On review by Doctor he was discharged home with the following
medications;

--- Tab Ciprofloxacin 500mg b.i.d for five days

--- Tab Flagyl 400mg three times daily for five days.

--- Tab Vitamin C 200mg three times daily for five days.

---Tab PCM 1g three times daily for three days.

Patient was advised to come for daily dressing and removal of stitches was
scheduled for 12/9/2024 . Vital signs reads temperature 36.9° C, Pulse 84b/m,
respiration 18c/m and blood pressure 100/60 mmHg.

Advice on Discharge.

--Patient was advised to ensure adequate sleep and rest

--To improve personal and environmental hygiene.

-- To adhere and keep to the time of drug

-- To take adequate balanced diet especially food rich in carbohydrates,protein
and vegetables with fruits like Watermelon,Orange,Apple etc

-- To avoid strenuous activities.

-- Ti ensure not to miss his appointment date.

-- To report immediately to the hospital and if he has any complain before the
appointment date.

NURSING DIAGNOSIS PRE-OPERATIVELY.

1. Acute pain related to inflammation of the vermiform appendix evidenced by

patient verbalization .

2. Anxiety related to unknown outcome of the surgery evidenced by patient

verbalization of fear and facial expressions.

NURSING DIAGNOSIS POST OPERATIVELY.

1. Ineffective airway clearance related to increased abdominal pressure and

discomfort evidenced by dyspnoea or coughing due to abdominal pain.

2. Acute pain related to Surgical incision evidenced by facial expressions and

verbalization.

3. Risk for nutritional imbalance less than body requirements related to patient
placed on nil per oral.
PRE_OP

NURSING NURSING NURSING SCIENTIFIC EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE
Acute pain Patient will 1) Patient's level of 1. To serve as Patient verbalized
related to verbalize less pain pain was assessed baseline data for less pain at 25
inflammation of within 30 mins of using the facial the subsequent mins of nursing
the vermiform nursing scale( 1-10). treatment. intervention.
appendix intervention.
evidenced by 2) Patient was 2. To relieve
patient's assisted to a pressure on
verbalization comfortable position organ pressing on
e.g left lateral the affected part.
position.
3. To reassure the
3)Give Psychological patient.
support by talking
with the patient will4. To help in
help him to verbalizeblocking the pain
his mind pathway thereby
reducing pain
4) Administration of immediately.
prescribed analgesic
drug such as IM
Pentazocine 30mg
8hourly ×24 hours.

Anxiety related Patient will be 1. Patient questions 1. To make the Patient verbalized
to unknown allayed of anxiety were answered and patient more no fear and
outcome of the within 30-40 mins thereby creatingknowledgeable anxiety was
surgery of nursing nurse- patientabout the surgery allayed at 40 mins
evidenced by intervention. relationship. and also to of nursing
patient's relieve anxiety intervention.
verbalization of 2. Provide level .
fear and facial psychological care to
patient. 2.This is to help
NURSING NURSING NURSING SCIENTIFIC EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE
expressions. 3.Deep passive or build the
active exercise was patient's
encouraged. confidence.

4.Administer 3. To prevent
prescribed anxiolytics complications
e.g diazepam that could arise
after the surgery.

4. It helps the
patient to sleep
by acting on the
brain.

POST_ OPERATIVE

NURSING NURSING NURSING SCIENTIFIC EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE

Ineffective Patient will 1. Position the 1. This

airway demonstrate patient in an position
clearance airway optimal position improves
related to clearance ( e.g Semi Fowler ventilation
increased within 45 to 50 or Fowler's and airway
abdominal minutes of position) clearance by
pressure and nursing enhancing
2. Encourage
discomfort intervention diaphragmatic
active
evidenced by movement
( e.gdiaphgrama
dyspnoea or and reducing
tic or pursed lip
coughing the likelihood
breathing)
due to of airway
abdominal 3. Monitor
pain oxygen obstruction.
saturation levels
2. To promote
and provide
lung
supplemental
expansion,
oxygen if
increase
necessary.
oxygenation
4. Administer and help clear
prescribed for secretions by
abdominal pain facilating a
as ordered more
effective
cough.

3. To prevent
hypoxia and
improving
overall
respiratory
function.

4. To allow
the patient to
engage in
deep
breathing and
coughing
without fear
of
exacerbating
pain,ultimatel
y improving
airway
 clearance.

Acute pain Patient will 1. Assess the 1. This Patient

related to verbalize and pain level using a prompt reported
surgical experience facial scale of 1- intervention decrease in
incision less pain 10. serves as pain within
evidenced by within 30-40 baseline data 25 mins of
2. Place patient
facial mins of nursing
in a comfortable 2. To reduce
expressions nursing intervention.
position ( Semi- the tension
and patient's intervention.
Fowler). on the
verbalization
incision site
. 3. Give
and prevent
diversional
complications
therapy e.g
.
watching
TV,Reading 3. To distract
newspaper. the attention
of patient
4. Administer
from pain.
prescribed
analgesic drug 4. To help in
such a as IM blocking the
Pentazocine pain pathway
30mg 8hourly × thereby
24 hrs. reducing pain
immediately

Risk for Patient will not 1. Check patient 1. To serve as The patient's
nutritional show sign of vitals and weight baseline data nutritional
imbalance nutritional with emphasis and also to status is
less than defficiency on temperature. know the maintained or
body within the progress of improved
2. Monitor
requirement period placed intervention evidenced by
laboratory
related to on nil per oral and to know stable
patient and the period results including whether the increasing
placed on nil of electrolyte patient is weight,norma
per oral. hospitalization levels,liver loosing l laboratory
. function tests weight. values and
and complete adequate
2. Monitoring
blood counts. urine output.
laboratory
3. Provide results can
Education to the help identify
patient and their any
family on nutritional
importance of deficiencies or
nutritional imbalances.
support while on
3. Education
NPO.
can help the
4. Administer patient and
total parenteral family
nutrition ( TPN) understand
or enteral the
nutrition as importance of
prescribed by the nutritional
health provider. support and
promote
adherence to
the treatment
plan.

4. TPN or
enteral
nutrition can
provide
necessary
nutrients for
 Patient
nutritional
need.

PHARMACOLOGY.

Name Grou Mode of Indica Dos Ro Side Contra- Nursing

p action tion age ute effects indication Responsi
s bility

Ceftria Ceph It inhibits 1. Adul IV. 1. Hypersen 1.

xone alosp synthesis Infec t 1g Abdomin sitivity. Observe
IM.
orins of bacteria tion. dail al pain. patient
cell y with
2. 2.
wall ,mito hypersen
URTIs Diarrhoe
sis and sitivity.
a.
growth of 3.
2.
bacteria Meni 3.
Instrucy
ngitis Nephrot
client to
oxicity.
take full
4. course of
Hepatic the drug
dysfuncti to
on. maintain
therapeu
tic blood
vessels.

3.Empha
size the
need for
good
 hygiene
to
prevent
candida.

4. For
long
term
therapy,l
arger
doses or
patient's
with
kidney
function,
blood
count
should
be
monitore
d.

Genta Amin They 1. 160 Int 1. 1. 1.

mycin. o inhibit Septic mg rav Ototoxici
Hypersen Observe
glyco protein emia. dail en ty. sitivity. Patient
sides synthesis y ous vitals.
2. 2. 2 Long
of
Bacte Nephrot term 2.
infecting
remia oxicity.therapy . Observe
organisms
. intraveno
by binding 3.
us
to the 30S 3.Infe Headach
infusion
Ribosomal cted e
site for
unit. surgic
4. inflamma
al
 woun Rashes. tion.
d.
5. 3.
4. Drowsin Increase
Burn ess fluid
and intake to
sever minimize
e chemical
infecti irritation
on of of the
the renal
skin tubules
and unless
soft contra-
tissue indicated
. .

4.
Observe
for
nephroto
xicity as
renal
functions
are
monitore
d.

Parace Non- It inhibits 1. 600 Or 1. Liver 1. 1.

tamol narc the Fever mg al. damage Hypersen Observe
otic synthesis b.d on sitivity for
2. IV
analg of prolonge hypersen
Head
esic prostaglan d use. sitivity
ache
dins that
2. 2.
 serves as 3. Vertigo. Observe
mediators Tooth for any
3. Skin
of pain ache possible
rash.
and fever. sde
4.dys
effects or
meno
toxic
rrhoe
effects
a
3. Warn
patient
to avoid
use in
high
fever,fev
er
persisting
longer
than
three
days or
recurrent
fever
without
consultin
ga
doctor.

CHAPTER FIVE.

SUMMRRY.

Ruptured appendicitis is a serious medical condition that occurs when the

vermiform appendix,a small,finger- like pouchi attached to the large
intestine,became inflamed and bursts releasing bacteria and other harmful
substances into the abdominal cavity. The vermiform appendix is a small finger-
like,blind tube which is about 5-10 cm in length and 1-2cm in diameter. The
vermiform appendix is also called TONSILS OF ABDOMEN and also the most
common reason for emergency abdominal surgery. Late treatment of this
condition could lead to other complications such as Peritonitis, Septicemia,
Intestinal obstruction etc.

This care study is written on Mr. A.H who was diagnosed of Ruptured appendicitis
by Doctor Audu. He was admitted into Male medical ward, Reference Hospital
Okene on 29/8/2024. He was prepared pre- operatively and taken to the theatre
had the surgery done within 2 hours and was successfully brought out of the
theatre ,all post operative care given which are all nursing care includes activities
of daily living, Physical care, Psychological care,Proper treatment of incision
site,bed bath,oral care,all drugs were given which extends from antibiotics to pain
reliever. There was no post operative complications noticed till patient was
discharged home and was given some post operative advice to follow.

This care study was written and compiled under close supervision regarding the
diagnosis ,pre- operative and post operative Nursing and medical care rendered
during hospitalization.

CONCLUSION.

I hereby concluded that the occurrence of Ruptured appendicitis can be

prevented by mass Health Education on preventive measures such as avoidance
of constipation,reporting to hospital when they noticed pain in the abdomen that
localize to the right iliac fossa,eating high adequate with high roughages intake.

Conclusively,this care study has broaden my knowledge of on. Ruptured

appendicitis and since it's early treatment brings about a good prognosis any
victim should report early to the Hospital for possible treatment and to prevent
further complications.

RECOMMENDATIONS.
Given the study carried out on Ruptured appendicitis,I recommend this care study
to general nursing because it supplies the disease ,diagnosis and it's prompt
treatment.

I recommend this study to the government and it's agencies to use this to create
awareness to the public on early detection, diagnosis and treatment of Ruptured
appendicitis.

I recommend this study based on the level of poverty in the country,that the
treatment of Ruptured appendicitis should be cost reduced so as to be affordable
to people at the grass root level.

REFERENCES.

Mustapha R.O ( 2010) a textbook on Anatomy and Physiology and medical

surgical nursing Ilorin,Adewumi printing press.

Oloriegbe.O. (2014) a textbook on medical surgical nursing and related anatomy

and physiology,Benin city,Ruyi prints.

Ukwuije G.O (2011) student guide to nursing and midwifery examination

council,Owerri ,our savior printing press.

Famakinwa, T.T. ( 2002) a textbook on medical surgical nursing delta Bayosoye

printing service.

Brunner and suddarths (2010) a textbook on medical surgical nursing

china,Wolters Kluwer health/ lippcott Williams and Wilkins limited.

EMDEX (2010) a textbook on pharmacology of drugs Canada Lindox books

internationals.