Appendicitis Case Study: Pathophysiology, Growth and Development Theories, and Family Centred Care

This nursing case study discusses the case of Anne, who had been admitted to the emergency department with acute gangrenous appendicitis with peritonitis, the pathophysiology of the disease process, the growth and development oriented care planning and family centred interventions applicable to her case study.

Running head: APPENDICITIS CASE STUDY
Appendicitis case study
Name of the student:
Name of the university:
Author note:

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APPENDICITIS CASE STUDY
Introduction:
For a minor patient with adverse health complications, the care planning and
implementation is required to be holistic, taking into consideration the emotional and
psychological needs of the patient along with the growth and development oriented aspects, as
the disease process can significantly affect the growth and developmental pace as well (Regan,
Curtin & Vorderer, 2017). Furthermore, the impact of the disease and subsequent hospitalization
is extreme on the psychological wellbeing status of the patient and their family members. Hence
the care plan made for the patient should also incorporate family centred care principles to
ensure adequate interventions provided. This nursing case study will attempt to discuss the case
of Anne, who had been admitted to the emergency department (ED) of the facility with acute
gangrenous appendicitis with peritonitis, the pathophysiology of the disease process, the growth
and development oriented care planning and family centred interventions applicable to her case
study.
Pathophysiology:
Exploring the pathophysiology of the appendicitis (Alvarado, 2018). The most plausible
etiological pathway leading to inflammation of the appendix is due to the luminal obstruction.
Which leads to restricting the blood flow in the surrounding region completely, paving way for
bacterial overgrowth in the blocked region which distends the lumen and enhances the
intraluminal pressure causing lymphatic and venous obstruction and oedema and the resultant
inflammatory response (Bhangu et al., 2015). These series of events leads to necrosis of the
appendiceal wall and spills the bacterial mass into the peritoneal cavity giving rise to the
gangrenous perforated appendix. The lack of adequate and immediate interventions led to

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infection of the peritoneal cavity and the serosal membrane became infected leading to
peritonitis.
Cellular level
Approximately 95% of serotonin is found in the gastrointestinal tract, located primarily in
neuroendocrine cells. A rapid increase in serotonin secretion in the appendix plays a significant
function in the pathogenesis of inflammation. Once the blockage occurs, secretions released by
the epithelial mucosa cause an elevated luminal pressure. Pressure receptors found in the
enterochromafin cells upon detecting luminal pressure, they secrete 5-HT into the lamina
propria. This release worsens smooth muscle contraction, vasoconstriction and venous
engorgement. There is also an increase in vasoactive intestinal polypeptide and substance P in
the appendix which is the leading cause of pain on the right iliac fossa (Escolino et al., 2018).
During inflammation, white blood cell count rises rapidly with the advancement of appendicitis.
The leucocyte migrate from the peripheral circulation to the appendix to fight infection.
Organ level
Rapid increase in size ensues because of its little lumen capacity. The intraluminal pressure
can attain 50 to 65 mm Hg. The cecum enlarges due to this appendicle condition. The cecal
collection is stored and is not carried on to the right colon. An increase in luminal pressure leads
to increase in venous pressure resulting to mucosal ischemia. Venules that empty blood to the
appendix undergo thrombosis leading to the damage of the lymphatic and venous drainage. Due
to mucosal hypoxia, ulceration begins causing damage of the mucosal barrier. This leads to
invasion intraluminal bacteria such as Escherichia coli in the appendiceal wall.
Systemic level

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If the appendix is not removed immediately bacteria and inflammation in the appendix
causes a rapid increase in size and perforation may occur. Immediately perforation occurs the
contents are released in the abdominal cavity and peritonitis occurs. The inflammation broadens
to parietal peritoneum, serosa and lastly the adjacent organs. This results to the stimulation T8-
T10 nerve fibres that get in the spinal cord. This cause’s preumblical and epigastric pain. At this
phase somatic pain replaces the early mentioned pain, and clients usually experience a changing
on the area of greatest pain to the right lower quadrant. If this condition progresses the blood
flow in the arteries is compromised and localized necrosis occurs leading to a gangrene and
perforation (Yousef et al., 2018).
Growth and development theories:
Development psychology deals with changes that occur as individual age increases in
terms of behaviour and mental process. Developmental psychology theory that is going to be
discussed is social-emotional development theory by Erik Ericson (Cherry, 2017). Social
emotional development talks about our social interaction and how emotions grow and changes
overtime. The two most fundamental topics are attachment and parenting style. Attachment is
determined or actuated by emotions, the stronger the emotion the stronger the attachment.
Different methods parenting or the way our parents treats us as we grow affects our personality.
Parenting style are divided into three, permissive, authoritarian and lastly authoritative. The
attachment status of the child and the parenting style that they are accustomed with can play a
profound role in defining the care approach that will suit them the best. No child recovers
quickly without an attachment pattern based on the relationship with the care giver and the nurse.
Lack of proper attachment may lead to depression, anxiety or illness. The nurse can create a
strong bond with the client by introducing yourself to the client. This shows the patient that you

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care about them, it also removes the tension and anxiety from the client. Strong bond can also be
created by saying what you are going to in every procedure and the importance of it. This
increase trust and reduces any fears during the procedures (Coyne, Hallström & Söderbäck,
2016).
According to the stages of social emotional development coined by Ericson, there are 8
total stages of development, and each developmental stage represents different developmental
milestones for the child which is intricately linked with the psychological wellbeing (Cherry,
2017). Hence, when a nurse is expected to provide care interventions to a minor patient, the
developmental milestones of the child also is needed to be considered in the care. Anne is a 10
year old girl born to Indian Parents and is the eldest of 5 children, according to the social
emotional development theory, it can be considered that she has grown through first 4 stages of
development, namely Hope, Will, purpose and competence. Across these developmental stages a
child understand to differentiate between trust and mistrust, autonomy and shame, initiative and
guilt, and industry and inferiority. The nature of treatment provided can be easily recognized by
a child that is past the first stage helps the child make a decision between trust and mistrust;
hence, the impact of treatment provided and the communication approach taken by the nurse
will help gain her trust and it will facilitate the establishment of a sound therapeutic relationship
(Knight, 2017).
The second milestone is associated with autonomy and independence, where the child
learns to exert independence and self-possession. Hence, in this case, the nurse providing care to
Anne, the nurse will have to ensure providing independence and empowerment to her while
respecting her autonomy to ensure optimal psycho-social wellbeing. The third milestone helps
the child to assert a sense of purpose and feel useful by taking different initiatives. For Anne as

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well the ability to her own decisions and certain initiatives in her acre planning will be extremely
helpful. Hence the nurse will have to ensure letting Anne take initiatives in her own care like
feeding and self-care activities to help her feel purposeful and empowered. The fourth stage or
milestone crossed by Anne as per her age is associated with competence as per Ericson’s stages,
and this is the most important milestone that is needed to be considered while planning her care
(Cherry, 2017). As Anne is a school age girl, the need for feeling competent will be most
pertinent in her nature and hence it will influence her thought process, behaviour and character.
In this case, the nursing care provider will need to consider encouraging her to employ
competence such as encouraging her to feed on her own, engage in self-care ADLs and taking
her medication under supervision of the nurse. Lastly, the growth appropriate care delivery is
incomplete without adequate information sharing; as per Anne’s age, she might be curious and
inquisitive, hence, the nurse will have to consider responding to her questions patiently and
carefully regarding medical information sharing so as to not scare or alarm her as per the ethical
guidelines (McAdams & Zapata-Gietl, 2015).
Family centred care:
Family centred care can be defined as the care program that is designed and led by the
patients with collaboration of the health care consulting, encouraging medical information
sharing and effective communication to address each of the care need of the patient
(Childrens.health.qld.gov.au, 2018). The nurse is needed to respect the individuality of the
family, the culture and tradition and the wishes and demands of the family into planning and
implementing care. For Anne, the traditional concepts of health and healing will need to be
considered. In this case, the aid of a cultural diversity expert or language interpreter can be taken
in case of any language barrier. The health information is needed to be shared with Anne’s

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family in a culturally appropriate manner. Information sharing and shared decision making are
integral aspects of family centred care, nurse will have to provide medical information
periodically and frequently, in a manner that is easily understood with medication safety
education as well, preferably with pamphlets for future assistance (Coyne, 2015).
Impact of hospitalization:
The impact of hospitalization is generally acute on a minor patient, the detachment from
parents and siblings, the sterile ambience of the hospital, and the exhaustion of the treatment
procedure has been reported to enhance fear and anxiety among children affectively (Franck et
al., 2015). The impact of living in the impersonal ambience of the hospital can affect the
psychological wellbeing of the child and can affect the family as well. The fear of the prognosis,
the safety of the child in the hospital and the detachment of the child instils fear, irritability and
anxiety in the patients which further depresses them and leads to hyper-reactive response. As
Anne is eldest to 4 other siblings they will also be affected by watching her in pain and detached
from them, they will be anxious, distressed and confused. These psychological impact will also
lead to physical issues such as exhaustion due to excessive crying, fatigue from not eating well
and sleeplessness as well. The nurse will have to address the impact of hospitalization on Anne,
her parents and the siblings. For Anne, the nursing care will need to focus on compassion,
empathy and resilience providing nurturing support and comfort to her. For the parents, the nurse
will require to repeatedly reassure them and involve them in the care planning and decision
making along with sharing timely information regarding Anne’s recovery progress (McAdams &
Zapata-Gietl, 2015). The nurse will also need to instruct the parents to consider child support for
caring for the siblings and also orchestrate opportunities for the entire family to visit Anne all the

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while following the safety guidelines which will help calm and assure them and will also help
Anne recover faster.
Conclusion:
A chronic acute illness is often associated with various complications and the nursing
care plan for the patients suffering from the chronic complicated illness or adverse conditions
needs to be individualized and optimally patient centred. Especially for the patients that are
paediatric and minor, the care planning that the nursing professional that is addressing the
patient, needs to focus on various factors other than just addressing the physical health issues for
the patient. This case study illustrated developmentally appropriate care for Anne, a 10 year old
patient suffering from gangrenous perforated appendicitis with peritonitis along with family
centred care with emphasis on impact of hospitalization on the paediatric patient and their
families.

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References:
Alvarado, A. (2018). Clinical Approach in the Diagnosis of Acute Appendicitis.
Bhangu, A., Søreide, K., Di Saverio, S., Assarsson, J. H., & Drake, F. T. (2015). Acute
appendicitis: modern understanding of pathogenesis, diagnosis, and management. The
Lancet, 386(10000), 1278-1287.
Childrens.health.qld.gov.au. (2018). Family Centred Care in Queensland. [online] Available at:
https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/qcycn/qcycn-fcc-sd.pdf
[Accessed 26 Aug. 2018].
Coyne, I. (2015). Families and health‐care professionals' perspectives and expectations of
family‐centred care: hidden expectations and unclear roles. Health expectations, 18(5),
796-808.
Coyne, I., Hallström, I., & Söderbäck, M. (2016). Reframing the focus from a family-centred to a
child-centred care approach for children’s healthcare. Journal of Child Health
Care, 20(4), 494-502.
Regan, K. M., Curtin, C., & Vorderer, L. (2017). Paradigm shifts in inpatient psychiatric care of
children: approaching child‐and family‐centered care. Journal of Child and Adolescent
Psychiatric Nursing, 30(4), 186-194.
Escolino, M., Becmeur, F., Saxena, A., Till, H., Masieri, L., Cortese, G., ... & Esposito, C.
(2018). Infectious Complications After Laparoscopic Appendectomy in Pediatric Patients
with Perforated Appendicitis: Is There a Difference in the Outcome Using Irrigation and

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Suction Versus Suction Only? Results of a Multicentric International Retrospective
Study. Journal of Laparoendoscopic & Advanced Surgical Techniques.
Yousef, Y., Youssef, F., Dinh, T., Pandya, K., Stagg, H., Homsy, M., ... & Shaw, K. (2018). Risk
stratification in pediatric perforated appendicitis: Prospective correlation with outcomes
and resource utilization. Journal of pediatric surgery, 53(2), 250-255.
Cherry, K. (2017). Erik Erikson's Stages of Psychosocial Development. Psychology.
Psychosocial Theories. Päivitetty, 14, 2017.
Knight, Z. G. (2017). A proposed model of psychodynamic psychotherapy linked to Erik
Erikson's eight stages of psychosocial development. Clinical psychology &
psychotherapy, 24(5), 1047-1058.
McAdams, D. P., & Zapata-Gietl, C. (2015). Three strands of identity development across the
human life course: Reading Erik Erikson in full. The Oxford handbook of identity
development, 81-94.
Franck, L. S., Wray, J., Gay, C., Dearmun, A. K., Lee, K., & Cooper, B. A. (2015). Predictors of
parent post-traumatic stress symptoms after child hospitalization on general pediatric
wards: A prospective cohort study. International journal of nursing studies, 52(1), 10-21.