Appendicitis

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The appendix is a closed-ended, narrow tube that attaches to the cecum (the first part of the colon) like a worm. (The anatomical name for the appendix, vermiform appendix, means worm-like appendage.) The inner lining of the appendix produces a small amount of mucus that flows through the appendix and into the cecum.

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Etiology of Appendicitis

Appendicitis is a bacterial infection caused by obstruction or blockage due to:

1. Hyperplasia of lymphoid follicles 2. Fecalith presence in the lumen of the appendix 3. Appendix tumor 4. The presence of foreign objects such as ascariasis worm. 5. Appendix mucosal erosion due to
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The blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the opening. This rock is called a fecalith (literally, a rock of stool).

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Predisposing/Precipitati ng Factors

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Most affected by appendicitis are young people between the ages of 11 and 20. And, most cases of appendicitis occur in the winter months (cold season). Having a family history of appendicitis may increase the risk for the illness, especially in males, and having cystic fibrosis also seems to put a higher risk.

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Pathologic Changes

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White Blood Cell Count

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The white blood cell count in the blood usually becomes elevated with infection. In early appendicitis, before infection sets in, it can be normal, but most often there is at least a mild elevation even early.

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Urinalysis

Urinalysis is a microscopic examination of the urine that detects red blood cells, white blood cells and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or stones in the kidneys or bladder which sometimes can be confused with appendicitis.

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Abdominal X-Ray

An abdominal x-ray may detect the fecalith (the hardened and calcified, peasized piece of stool that blocks the appendiceal opening) that may be the cause of appendicitis. This is especially true in children.

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Ultrasound

An ultrasound is a painless procedure that uses sound waves to identify organs within the body. Ultrasound can identify an enlarged appendix or an abscess. Nevertheless, during appendicitis, the appendix can be seen in only 50% of patients.

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Laparoscopy
Laparoscopy is a surgical procedure wherein a small fiberoptic tube with a camera is inserted into the abdomen through a small puncture made on the abdominal wall. Laparoscopy allows a direct view of the appendix as well as other abdominal and pelvic organs. If appendicitis is found, the inflamed appendix can be removed at the same time. The disadvantage of laparoscopy compared to ultrasound and CT scanning is that it requires 3/25/12 a general anesthetic.

PATHOPHYSIOLOGY

Obstruction of the appendix (by fecalith, lymph node, tumour, foreign objects) Inflammation Increase intraluminal pressure 3/25/12

Distention of the Appendix causes pain Decrease venous drainage Blood flow and oxygen restriction 3/25/12

The wall of the appendix will thus start to break up and rot. Normal bacteria found in the gut gets all the inducement needed to multiply and attack the decaying appendix within 36 hours from the point of luminal obstruction, worsening the process of appendicitis. This leads to necrosis and perforation of the appendix. Pus formation occurs when nearby white blood cells are recruited to fight the bacterial invasion. 3/25/12

Sign and Symptoms of the Illness

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Abdominal pain
This pain typically starts from around the belly button (peri-umbilical region), or the upper central abdomen (epigastrium) and then move downwards and to the lower right abdomen (right iliac fossa). When the pain occurs in this pattern, it is the most dependable of all symptoms of appendicitis, as over 8 out 10(80%) cases that present this way is definitely due to the appendix. In some other individuals, the pain starts right way from the right 3/25/12 iliac fossa. Depending on where the tip of

When the appendix is severely inflamed, the pain can be localized to a spot on the outer one third of a line drawn between the belly button and front of the tip of the waist bone called the McBurneys point. The McBurneys point is also often the point of maximum tenderness when the abdomen is examined. The pain is even worse when the hand is suddenly removed from that spot because of the appendix rubbing on the covering of the abdomen (Rebound tenderness).
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There is also a sign referred to as the Rovsing sign. This is said to exist when the lower left abdomen is palpated by the doctor, but causes pain in the right. If the appendix is the pelvic type, examining the back passage (rectal examination) would cause some pain too.

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If the hip is moved and stretched, this can also cause pain to be felt at the spot where the appendix lies. This is referred to as the psoas sign. 3/25/12

The Alvarado score is a clinical scoring system used in the diagnosis of appendicitis. The score has 6 clinical items and 2 laboratory measurements with a total 10 points. A score of 5 or 6 is compatible with the diagnosis of acute appendicitis. A score of 7 or 8 indicates a probable appendicitis, and a score of 9 or 10 indicates a very probable acute appendicitis.

THE ALVARADO SCORE FOR ACUTE APPENDICITIS

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Loss of Appetite, Nausea & Vomiting

This is another very important set of symptoms of appendicitis. It is said that loss of appetite is the most constant symptom of appendicitis. They may actually vomit. It is important to note that vomiting in appendicitis usually follows the pain. If you vomit before the pain commenced, it is not likely that the appendix is to blame.
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Change in Bowel Habit

There may be diarrhea or constipation, especially in young children. This could lead to a wrong diagnosis of food poisoning or gastroenteritis on the part of the unwary doctor. Up to 1 in 5 persons (20%) could have diarrhea or even constipation with appendicitis. 3/25/12

Fever
There is usually a low grade fever in most patients with this disease. Nevertheless, in up to 1 in 5 persons (20%), they have normal temperature, even with severe disease. Temperature above 38.5 degree centigrade with rigors is suggestive of a ruptured appendicitis.
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MEDICAL AND SURGICAL MANAGEMENT

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MEDICAL

Once a diagnosis of appendicitis is made, an appendectomy usually is performed. Antibiotics almost always are begun prior to surgery and as soon as appendicitis is suspected. The patient will be administered with D5LR 1 L regulated at 31-32 gtts/min. D5LR is actually 5% dextrose in lactated ringer's solution. it is a hypertonic solution which aids in replacement of lost body fluids.
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SURGICAL

First is the open method or through appendectomy. This is done by freeing the appendix from its mesenteric attachment to the abdomen and colon, cutting the appendix from the colon, and sewing over the hole in the colon

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Second is Laparoscopic Method. The laparoscope is a thin telescope attached to a video camera that allows the surgeon to inspect the inside of the abdomen through a small puncture wound (instead of a larger incision).

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Nursing Diagnosis Preoperative and Postoperative Appendectomy

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Preoperative Appendectomy
1. Risk for deficient fluid volume related to preoperative vomiting. -check hydration status -regulate IV fluids -monitor I/O 2. Acute pain related to distention of the intestinal tissue by inflammation. -provide a relaxing environment -administration of prescribed pain
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Postoperative Appendectomy
1. Acute pain related to the presence of postoperative wound appendectomy. -check for bleeding - provide a relaxing environment - administer prescribed pain relievers. -proper positioning 2. Impaired nutrition less than body requirements related to reduced anorexia, 3/25/12 nausea.

3. Risk for infection related to surgical incision. -Assess for presence, existence of, and history of risk factors of infection. - Monitor white blood count (WBC) -Observed/Monitor for signs and symptoms of infection. - Assess for nutritional status. -Assess immunization status.

4. Deficient knowledge: about3/25/12care the

Nursing responsibilities

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Preparation of general surgery This can be done by the nurse when the client entered the operating room nurse before surgery:

Introducing the client and close relatives of hospital facilities to reduce the anxiety of clients and their relatives (the orientation of the environment). Measuring vital signs. Measure weight and height.
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1. Preoperative Interventions

Observation of vital signs Assess fluid intake and output Auscultation of bowel sounds Assess the status of pain: the scale, location, characteristics Teach relaxation techniques Give fluids intervena Examine the level of anxiety3/25/12

2.Postoperative Iinterventions

Observation of vital signs Assess the scale of pain: characteristics, scale, location Assess the state of the wound Advise to change position as tilted to the right, left and sat down. Assess nutritional status
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Evaluation

Impaired sense of comfort: pain is resolved No infection Overcome nutritional deficiencies The client understands about care and illness Weight loss does not occur
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PANCREATITIS

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Pancreatitis is the inflammation of the pancreas. It occurs in acute or chronic forms; acute form has 10 % mortality. Acute pancreatitis can be a medical emergency associated with a high risk for life-threatening complications and mortality, whereas chronic pancreatitis often goes undetected until 80% or 90% of the exocrine and endocrine tissue is destroyed. Acute pancreatitis does not usually lead to chronic pancreatitis 3/25/12 unless complications develop. However,

Acute pancreatitis

a sudden inflammation of the pancreas caused by autodigestion and marked by symptoms of acute abdomen and escape of pancreatic enzymes into the pancreatic tissues. The condition is associated with biliary disease or alcoholism. The autodigestion is caused by premature activation of the digestive enzymes. Acute pancreatitis can also be of unknown cause.
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ACUTE PANCREATITIS PRECIPITATING FACTORS PREDISPOSING FACTORS

Biliary Tract disorder Gallstone Trauma Post ERCP Idiopathy Other causes (infection, hereditary) Alcoholism Drug Interaction (Steroids and thiazide diuretics)

Obstruction/pancreatic duct hypertension Bile/pancreatic duct Reflux Premature activation of trypsin Activation of other enzymes Production and release of pancreatic enzymes

Direct Toxic Injury to Pancreatic Cells

Edema Necrosis Hemorrhage

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Elastase

Phospholipase A Lipase Fat necrosis cell membrane disruption

Kallikrein

Necrosis of blood vessels and ductal fibers

Fat Necrosis

Edema Vascular permeability Smooth muscle contraction Vasodilation

Hemorrhage

Shock

Signs Fever Weight loss General Malaise Tachycardia Abdominal tenderness, guarding, hypoactive BS Jaundice Severe: hemodynamic,

Symptoms Dull, mid epigastric Unusually sudden onset Nausea and vomiting 3/25/12

Etiology

Gallstones and alcohol are

the two most common causes of AP in western countries, accounting for 80% of cases. Gallstone pancreatitis results from transient obstruction of the ampulla of Vater by small
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Risk Factors for Acute Pancreatitis

Anatomic or functional disorders (e.g., pancreas divisum, sphincter of Oddi dysfunction) Autoimmune (e.g., systemic lupus erythematosus) Choledocholithiasis Chronic alcohol consumption Congenital anomalies Drug-induced hypertriglyceridemia 3/25/12 (triglycerides greater than 1,000 mg per

Clinical Presentation

The hallmark symptom of acute pancreatitis is the acute onset of persistent upper abdominal pain, usually with nausea and vomiting. The usual locations of the pain are the epigastric and periumbilical regions. The pain may radiate to the back, chest, flanks, and lower abdomen.

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Pathologic changes

Two blood tests that measure enzymes are used to diagnose an attack of pancreatitis. These tests are: Serum amylase. An increase of amylase in the blood usually indicates pancreatitis. Serum lipase. Sudden (acute) pancreatitis almost always raises the level of lipase in the blood.
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Other blood tests may be done, such as: A complete blood count (CBC). The number of white blood cells rises during an attack of pancreatitis, sometimes dramatically. Liver function tests. Increases in liver enzymes, particularly of alanine aminotransferase and alkaline phospatase, can be a sign of sudden pancreatitis caused by gallstones. Bilirubin. The level of bilirubin in the
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Imaging tests that may be done include: CT scanwith contrast dye. A CT scan can help rule out other causes of abdominal pain, determine whether tissue is dying (pancreatic necrosis), and find complications such as fluid around the pancreas, blocked veins, and obstructed bowels. Abdominal UTZ. This test can locate gallstones. It also can show an enlarged 3/25/12 common bile duct.

Endoscopic retrograde cholangiopancreatogram (ERCP). This procedure allows the doctor to see the structure of the common bile duct, other bile ducts, and the pancreatic duct. ERCP is the only diagnostic test that also can be used to treat narrow areas (strictures) of the bile ducts and remove gallstones from the common bile duct. Endoscopic UTZ. In this form of ultrasound, a probe attached to a lighted 3/25/12

Magnetic resonance cholangiopancreatogram (MRCP). This form of MRI can detect gallstones in the common bile duct. This test is not available everywhere.

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CT Severity Index
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CT grade A is normal pancreas (0 points) B is edematous pancreas (1 point) C is B plus mild extrapancreatic changes (2 points) D is severe extrapancreatic changes plus one fluid collection (3 points) E is multiple or extensive fluid collections (4 points) 3/25/12

Chronic pancreatitis

is an inflammatory disorder that is characterized by progressive anatomic and functional destruction of the pancreas. As cells are replaced by fibrous tissue with repeated attacks of pancreatitis, pressure within the pancreas increases. The end result is mechanical obstruction of the pancreatic and common bile ducts and the duodenum. Additionally, there is atrophy of the epithelium of the ducts, 3/25/12 inflammation, and destruction of the

MEDICAL MANAGEMENT

Acute Pancreatitis Management of acute pancreatitis is directed toward relieving symptoms and preventing or treating complications. All oral intake is withheld, to inhibit stimulation of the pancreas and its secretion of enzymes.

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Pain Management: -adequate administration of analgesia, pain relief may require parenteral opioids suchas morphine; Meperidine had been the drug of choice, Hydromorphone may be also effective. Antiemetic agents may be prescribed to prevent vomiting

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Biliary Drainage: -placement of biliary drains and stents in the pancreatic duct through endoscopy has been performed to reestablish drainage of the pancreas. This has resulted in decreased pain and increased weight gain.

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Post-acute Management: -antacids after acute pancreatitis begins to resolve; oral feedings that are low in fat and protein are initiated gradually; caffeine and alcohol are eliminated from the diet; follow up may include ultrasound, x-ray studies to determine whether the pancreatitis is resolving and to assess for abscesses and pseudocyst.
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Chronic Pancreatitis The management of chronic pancreatitis depends on its probable cause in each patient. Treatment is directed toward preventing and managing acute attacks, relieving pain and discomfort, and managing exocrine and endocrine insufficiency of pancreatitis.

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Surgical Management
Pancreaticojejunoscopy (Roux-en-Y), which a side to side anastomosis or joining of the pancreatic duct to the jejunum, allow drainage of the pancreatic secretions into the jejunum.

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Other surgical procedures may be performed for different degrees and types of underlying disorders. These procedures include revision of the sphincter of the ampulla of Vater, internal drainage of the pancreatic cyst into the stomach, insertion of a stent, and wide resection or removal of the pancreas. A Whipple resection (pancreaticoduodenectomy) can be carried out to relieve the pain of chronic 3/25/12 pancreatitis.

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Nursing responsibilities

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Preparation of general surgery This can be done by the nurse when the client entered the operating room nurse before surgery:

Introducing the client and close relatives of hospital facilities to reduce the anxiety of clients and their relatives (the orientation of the environment). Secure signed consent Measuring vital signs.
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Preoperative Interventions

Observation of vital signs Assess fluid intake and output Auscultation of bowel sounds Assess the status of pain: the scale, location, characteristics Teach relaxation techniques Assess hydration status Examine the level of anxiety3/25/12

2.Postoperative Iinterventions

Observation of vital signs Assess for signs of bleeding Assess the scale of pain: characteristics, scale, location Assess the state of the wound Assess nutritional status Auscultation of bowel sounds
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Evaluation

Impaired sense of comfort: pain is resolved No infection No signs of bleeding The client understands about care and illness Normal wound recovery Vital signs within normal limits 3/25/12

cholecystitis

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Cholecystitis is caused by obstruction of stone in the bile duct leading to inflammation of the gallbladder. The gallbladder is an organ which aids in the digestive process. Its function is to store and concentrate bile. The bile in turn emulsifies fats and neutralizes acids in partly digested food.

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Etiology
Acute cholecystitis is usually associated with blockage of the cystic duct by a stone. Mechanical obstruction, chemical inflammation, and bacterial infection are believed to play a role. A vast majority of patients are believed to become symptomatic due to bacterial 3/25/12 infection.

Precipitating/Predisposi ng Factors

Diet (high cholesterol, high fats

Increased intake of cholesterol and saturated fats has all been postulated to cause cholesterol gallstones.

Gender

Women have twice the risk as men of developing cholesterol gallstones because estrogen increases biliary cholesterol secretion.
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Advancing Age

The incidence increases with age. Less than 5-6% of the population under age 60 has stones, in contrast to 25-30% of those over 80. It usually affects people with age of over 60 but it is more prevalent after 80 years of age.
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Primary Biliary Cirrhosis

Patients with primary biliary cirrhosis have an increased prevalence of gallstones. Stone analysis has not been performed, but the elevated cholesterol saturation of bile in these patients suggests that they form cholesterol stones.
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Heredity

Family history alone imparts increased risk, as do a variety of inborn errors of metabolism that lead to impaired bile salt synthesis and secretion or generate increased serum and biliary levels of cholesterol.
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Signs and Symptoms

Biliary Colic

The most common symptom is pain in the right upper part of the abdomen or epigastrium. This can cause an attack of abdominal pain, called biliary colic, which: develops quickly, is severe, lasts about one to three hours before fading gradually, isn't helped by over-the-counter drugs.
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Fever and chills

Fever occurs in about one third of people with acute cholecystitis. The fever tends to rise gradually to above 100.4 F (38 C) and may be accompanied by chills

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Loss of appetite and Anorexia

The pain often begins suddenly following a large or rich meal. Fat absorption is also impaired for the lack of bile salts; As a result, rapid loss of weight and anorexia can occur.

Jaundice

Due to obstruction of the bile flow.

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Clay-colored stool

may result from problems in the biliary system; due to absence of bile in the duodenum; warning signal thats something wrong with digestion

Nausea and vomiting Facial grimace and Guarding behavior

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may accompany a gallbladder attack

Accompanied by pain

ANATOMY AND PHYSIOLOGY

BILE DUCTS Right hepatic duct- drains bile from the right functional lobe of the liver Left hepatic duct- drains bile from the left functional lobe of the liver Common hepatic duct-is the duct formed by the convergence of the right hepatic duct and the left hepatic duct ; Length: Usually 68 cm. Approximate width: 6 mm in adults; merges with 3/25/12 cystic duct to form common bile duct,

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BILE Bile is the greenish-yellow fluid (consisting of waste products, cholesterol, and bile salts) that is secreted by the liver cells to perform two primary functions, including the following: Bile salt is the actual component which helps break down and absorb fats. Bile, 3/25/12 which is excreted from the body in the

GALLBLADDER The gallbladder is a small

organ whose function in the body is to store bile and aid in the digestive process.

A hallow pear- shaped sac

from 7- 10 cm (3-4 inches) long and 3 cm broad. It consists of a fundus, body and a 3/25/12 neck.

PATHOPHYSIOLOGY

Fixed obstruction or passage of gallstones into the gallbladder neck or cystic duct causes acute inflammation of the gallbladder wall. The impacted gallstone causes bile to become trapped in the gallbladder, which causes irritation and increases pressure in the gallbladder. Trauma caused by the gallstone stimulates prostaglandin synthesis (PGI2, PGE2), which mediates the inflammatory response. This can 3/25/12 result in secondary bacterial infection

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MANAGEMENT

Non-surgical

cholecystitis are conditions which will usually respond to an opioid such as morphine or pethidine given parenterally and/or diclofenac by suppository. These routes will overcome difficulties in absorption caused by vomiting. Pain continuing for over 24 hours or accompanied by fever usually necessitates hospital admission.
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Surgical

Laparoscopic cholecystectomy is the preferred procedure. A Cochrane review found that there was no difference in mortality, postoperative complications, or operative time compared with open
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Open cholecystectomy

Surgery in which the abdomen is opened to permit cholecystectomy -- removal of the gallbladder. Open cholecystectomy is the standard against which other treatments must be compared and remains a safe surgical alternative.
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Percutaneous cholecystostomy

Percutaneous cholecystostomy (PC), a technique that consists of percutaneous catheter placement in the gallbladder lumen under imaging guidance, has become an alternative to surgical cholecystostomy in recent years.
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Preoperative Cholecystectomy
1. Risk for deficient fluid volume related to preoperative vomiting. -check hydration status -regulate IV fluids -monitor I/O 2. Acute pain related to inflammation. -provide a relaxing environment -administration of prescribed pain 3/25/12 relievers as ordered.

Postoperative Cholecystectomy
1. Acute pain related to the presence of postoperative wound appendectomy. -check for bleeding - provide a relaxing environment - administer prescribed pain relievers. -proper positioning 2. Impaired nutrition less than body requirements related to reduced anorexia, 3/25/12 nausea.

3. Risk for infection related to surgical incision. -Assess for presence, existence of, and history of risk factors of infection. - Monitor white blood count (WBC) -Observed/Monitor for signs and symptoms of infection. - Assess for nutritional status. -Assess immunization status.

4. Deficient knowledge: about3/25/12care the

Preparation of general surgery This can be done by the nurse when the client entered the operating room nurse before surgery:

Introducing the client and close relatives of hospital facilities to reduce the anxiety of clients and their relatives (the orientation of the environment). Explain why the procedure is done Obtain baseline data.
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1. Preoperative Interventions

Observation of vital signs Nothing per orem Auscultation of bowel sounds Assess the status of pain: the scale, location, characteristics Teach relaxation techniques Give fluids intervena Examine the level of anxiety3/25/12

2.Postoperative Iinterventions

Observation of vital signs Assess the scale of pain: characteristics, scale, location Assess the state of the wound Advise to change position as tilted to the right, left and sat down. Assess nutritional status
3/25/12 Auscultation of bowel sounds

Evaluation

Impaired sense of comfort: pain is resolved No infection No signs of bleeding The client understands about care and illness Weight loss does not occur
3/25/12 Vital signs within normal limits