Case Study: Nursing Management of Acute Appendicitis in a Patient

This case study essay examines the nursing management of a 29-year-old male patient, Josh, admitted with acute appendicitis and a history of asthma. The essay delves into the pathophysiology of appendicitis, including the mechanisms of luminal obstruction and the resulting clinical manifestations like abdominal pain, nausea, and vomiting. Pre-operative considerations, such as pain management and the risks associated with asthma, are discussed. The core of the essay focuses on post-operative nursing care, including the development of two nursing diagnoses: anxiety and distress due to nausea and pain, and the risk for ineffective breathing patterns. For each diagnosis, the essay outlines two SMART goals and one implementation strategy, such as the use of antiemetics and breathing exercises. The essay also considers the use of medications like ondansetron and paracetamol for pain and nausea, and Seretide to clear the airway. This case study emphasizes evidence-based practice to ensure effective patient care and recovery.

Running head: ACUTE APPENDICITIS 1
Assessment 2: Case study essay
Name
Institutional Affiliation

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Introduction
The aim of this paper is to explain the nursing management of Josh, a 29 year old
man, with a history of asthma and has been admitted for acute appendicitis. The paper
explains the management of the patient. The focus of the paper is to utilize evidence-based
information to develop clinical decisions in management of appendicitis among patients with
asthma.
Pathophysiology
There lacks clarity on the exact mechanism of acute appendicitis (Hori et al., 2017).
There are three identified causes of acute appendicitis which include genetic factors,
environmental factors and gastrointestinal infections (Bhangu, Søreide, Di Saverio,
Assarsson, & Drake, 2015). The primary cause of acute appendicitis results from malfunction
in the gastrointestinal system. Luminal obstruction is the primary factor that triggers acute
appendicitis (Petroianu, & Barroso, 2016). The luminal obstruction, which may either be
internal or external, plays a critical role in the pathophysiology of appendicitis. External
luminal obstruction refers to lymphoid hyperplasia while internal luminal obstruction refers
to appendicoliths and inspissated faecal material. The outcome of these factors is stasis, viral
infection, overgrowth of bacteria and mucus production, which results in increased tension of
the appendicular wall. Consequently, the flow of lymph and blood is diminished, followed by
perforation and necrosis. Acute appendicitis develops in an irreversible manner once it is
triggered. After the perforation of the walled-off appendix, an appendicular mass or tumour
developed. The tumour may be an abscess or phlegon (Hori et al., 2017). There are various
symptoms of appendicitis.
Clinical Manifestations of Appendicitis
The most common symptoms of acute appendicitis include abdominal pain, nausea
and vomiting, and anorexia. However, these factors are not specific to appendicitis and are

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not effective for diagnosing the condition. The most reliable symptom is abdominal pain in
the right lower quadrant. The patient may experience migration of the peri-umbilical pain to
the right lower quadrant. Other atypical symptoms that occur as a result of changes in the
location the appendix include malaise, diarrhoea, bowel changes, flatulence, and indigestion.
Clinical examination may also reveal general abdominal tenderness in the right lower
abdomen tenderness, abdominal rebound tenderness, and digital rectal examination
tenderness. Rebound tenderness is the most reliable sign in paediatric appendicitis (Timothy,
2017). Appendicitis can be diagnosed through ultrasound which is limited to obese patients,
raptured appendix and appendix that is abnormally located, radiography, proper taking of
patient history, physical examination, blood cell count, pregnancy test, and urinalysis
(Timothy, 2017).
Pre-operative Considerations
The first step to consider in pre-operation is to examine the detailed surgical program,
the risk of postoperative complications and emergencies, and the establishment of adequate
emergency measures (Jiaying, & Xiaoyan, 2016). Additionally, it is essential to inform the
patient on the surgical procedure to dispel any negative emotions and enhance the
adaptability of the patient towards the treatment (Jiaying & Xiaoyan, 2016). Therefore,
nurses need to explain the surgical process to the patients and ensure they are confortable.
They should also answer all the queries from the patients.
Pain management is critical in the perioperative and post-operative period. Prior to the
surgery, the use of painkillers and laxatives should be prohibited (Jiaying & Xiaoyan, 2016).
Chou et al. (2016) recommended that nurses and clinicians should collaborate through a
shared approach to decision-making in and conducting a preoperative evaluation as it
improves patient poutcomes. The pain management plan is critical in development of
evidence regarding the interventions that can be used for the surgical site, and the

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modification of factors that are unique for the patient. The plan also includes assessing
medication allergies, intolerances, preferences for patients and treatment goals.
Lin, Chang, Yeh, Chung, Chen, and Liao (2016) explained that asthma patients are at
risk of post-operative pneumonia, urinary tract infections, sepsis and subsequent mortality.
The reason for exposure to these infections is suggested to be impaired adaptive and innate
immune functions. Therefore, there is need to consider the risk factors of these conditions
during the pre-operative evaluation to enhance better perioperative care. The physical
examination of asthmatic patient before operation should include the physical examination of
critical signs such as assessment of breath sounds, level of hydration and accessory muscles
(Shaikh & Nilangekar, 2015). Further, the preoperative management of asthma patients
includes may include intravenous treatment with prednisone of hydrocortisone every 8 hours,
and chest physiotherapy to improve the clearance of sputum and bronchial drainage (Shaikh,
& Nilangekar, 2015).
Josh must undergo anaesthesia during the operation. Anaesthesia is often linked to
respiratory muscle dysfunction, which may start during induction and extend until post-
operative period. The dysfunction is identified to be a major cause of post-operative
pulmonary complications among asthma patients. Respiratory physiotherapy is essential for
optimizing the function of respiratory muscle. Respiratory physiotherapy includes the use of
tools such as incentive spirometry and inspiratory muscle training. Also, the optimization of
respiratory muscle can be achieved through breathing exercises, respiratory muscle training
and neuromuscular electrical stimulation (Azhar, 2015). Frequent breathing exercises are
appropriate for enhancing respiration in the case of Josh.
Nursing Management Post-op
Josh needs postoperative care to enhance comfort and recovery. Josh has a history of
asthma, has a moderate pain score of op 5/10, and is experiencing nausea. Post-surgery

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complications commonly affect the prognosis of appendicitis. Nursing care interventions
should focus in psychosocial care, dietary care and sports care among other recovery-related
care. The aim is to reduce the risk of postoperative complications and enhance effective
rehabilitation of the patients (Jiaying, & Xiaoyan, 2016). As a nurse, the aim is to ensure
effective breathing, pain management and treatment of nausea.
Nursing Diagnosis
I would use the DRSABCDE approach for diagnosis of the patient. The component sof the
framework include danger, response, send for help, airway, breathing, circulation, disability,
and exposure (Ambulance Tasmania, n.d). I would stat by assessing whether the patient is in
danger or any risks. I would then assess the response of the patient with regards to
consciousness, alteration in consciousness and alertness. I would then focus on assessment of
airway, breathing, circulation, disability, and exposure. The patient may be exposed to airway
and breathing problems due to the history of asthma. Therefore, my diagnosis would focus on
ensuring that the airway remains clear and breathing patterns are maintained throughout.
Nursing diagnosis 1: Anxiety and distress as evidences by nausea and pain
According to GGC Medicines (2018) nausea is a distressing symptom that occurs due
to surgery or following anaesthesia. Nausea may cause complications such as increased pain,
aspiration and dehydration, electrolyte imbalance and wound dehiscence. There are various
factors responsible for the aetiology of postoperative nausea; Postoperative causes include
pelvic pain, and ambulation especially among patients who have been treated with opioids
(Shaikh, Nagarekha, Hegade, & Marutheesh, 2016). GGC Medicines (2018) explained that
the assessment and monitoring of nausea may involve the use of a postoperative nausea and
vomiting score, assessment of perfusion and hydration. The most common causes may
include inadequate pain relief, anxiety or infection (GGC Medicines, 2018). In the case of
Josh, the main causes of nausea may be pain, and recovery from anaesthesia. The problem

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can be addressed by adequate pain relief and use of antiemetics. Ondansetron is the first-line
antiemetic is and is given every 8 hours (GGC Medicines, 2018).
Nursing diagnosis 2: Risk for ineffective breathing patterns as evidenced by a
history of asthma
Josh needs adequate attention to ensure the effective and normal breathing patterns.
Lin et al., 2016) explained that asthmatic patients are at a higher risk of postoperative adverse
events as compared to other patients. This could be due to the increased risk of airway-related
infections impaired adapting and innate immunity, and psychological stress. Also,
perioperative medications such as anaesthetics may cause allergic reactions through the
release of histamine. This can be achieved through
SMART Goals for each Nursing Diagnosis
Goal 1 for Diagnosis 1: The patient wills stops having nausea within 8 hours
Goal 2 for Diagnosis 1: The patient will have reduced pain (below op 2/10) within 8 three
hours
Goal 1 for diagnosis 2: To ensure effective breathing patterns of the patient within 8 hours
Goal 2 for diagnosis 2: To reduce the psychological stress of the patient by the end of the
shift.
One Implementation for each SMART Goal
Goal 1 for Diagnosis 1: the effectiveness of anti-emetics in reducing post-operative
nausea has been explored by various researchers. Agarkar and Chatterjee (2015) explored the
effectiveness of two antiemetic’s (ramosetron and ondansetron) among patients with a high
risk of postoperative nausea and vomiting. The findings of the study indicated that both
medications were equally effective in reducing the risk of postoperative nausea and vomiting
among high risk patients.
Goal 2 for Diagnosis 1: Use of Paracetamol for pain management

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With regard to pain management, Ismail, Siddiqui, and Rehman (2018) assessed the
effectiveness, safety and strategy for postoperative pain management in patients who
underwent gynaecological surgery. Opioids are commonly used for post-operation pain
management. The findings indicated that opioids increase nausea and vomiting among
patients. Therefore, I would consider using non-opioid pain control for Josh’s case such as
Paracetamol (acetaminophen). Horita et al. (2018) investigated the safety and frequency of
postoperative intravenous acetaminophen among patients with colon cancer. The findings
indicated that the use of intravenous acetaminophen after the surgery was effective in the
alleviation and control of pain and postoperative discomfort from the first day of surgery to
two days after surgery.
Goal 1 for diagnosis 2: Use of breathing exercises to enhance the breathing
patterns
Respiratory physiotherapy activities have been explored by various researchers as
strategies for minimizing respiratory complications. Gloeckl, Schneeberger, Jarosch and
Kenn, (2018) conducted a review of literature to determine the impact of exercise training
and pulmonary rehabilitation of chronic obstructive pulmonary disease. The findings
indicated that pulmonary rehabilitation is a cost-effective and therapeutic intervention for
improving shortness of breath, physical performance ability and patients’ quality of life.
From the evidence; it is clear that respiratory physiotherapy is essential for restoring the
respiratory function of Josh after the operation.
Goal 1 for diagnosis 2: Use of Seretide to enhance clear the airway
Josh can also use Seretide, which he has been using, to clear the airway in case of
blockage. Marshal (2018) recommended the frequent use of seretide even in absence of
asthma symptoms to keep the airways open. Subutamol is used in case of asthma attacks as it

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quickly opens the airways. Therefore, I believe Josh should use seretide frequently to clear
the airway.
Medications
Antiemetic drugs
Antiemetic drugs are effective in the treatment of postoperative nausea. Examples
include ondansetron, prochlorperazine, cyclizine dexamethasone, and droperidol.
GGC Medicines (2018) explained that ondansetron is the first line treatment for nausea.
Therefore, I would prefer using it in the case of Josh.
Ondansetron
Ondansetron is a 5HT3 receptor antagonist. It is administered at the rate of 4mg intravenous
every 8 hours (GGC Medicines, 2018). In intravenous form, the drug is in 2 mg/ml Solution.
The side effects include prolonges QT interval, Hypokalaemia and hypomagnesaemia,
increased bowel transit time (Hameln pharmaceuticals ltd., 2016). Importyant considerations
are that it should not be administered with morphine, alfentanil, furosemide, ignocaine,
propofol, hiopental, and temazepam.
Analgesics
Analgesia is an effective strategy for pain management among asthma patients.
However, opioids which are the most common treatment for postoperative pain management
are not applicable for the case of Josh as he is complaining of nausea. Therefore, non-opioid
analgesics are effective in this case. Paracetamol is a good option of pain management
Intravenous Paracetamol (Acetaminophen)
Paracetamol is an analgesic that lacks anti-inflammatory properties. It is suitable for both
adults and children and has good gastrointestinal tolerability. It is used for the management of
mild and moderate pain during post-operative analgesia. Intravenous paracetamol is
administered in a 15-minutes intravenous infusion at minimum intervals of at least 4 hours

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(Málek, Ševčík, & Bejšovec, 2017). The side effects of paracetamol include anaphylactic/
anaphylactoid reaction and leukopenia (Málek et al., 2017). An important consideration is
that paracetamol should not be administered with any 5-HT3 antagonists apart from
ondansetron as it reduces the effectiveness of the medications (Málek et al., 2017).
Carsicosteroids
Inhaled corticosteroids (ICS) may be important for Josh in the post-operation period.
Inhaled corticosteroids (ICS) are an effective medication for preventing bronchospasm
among patients with stable and mild asthma (Numata, et al., 2018). ICS have an excellent
anti-inflammatory effect and are the first line treatment for asthma (Azhar, 2015). Regulator
use of ICS reduces the asthma symptoms. They are administered through inhalation directly
to their action sites. They can also be administered in a liquid capsule formulation through a
nebulizer machine, dry powder inhalers, and metered dose inhalers that are administered
through spacer (Liang & Chao, 2019). For the case of Josh, the use of the nebulizer machine
is more effective as it does not require patient coordination.
Josh is already using Salbutamol and Seretide. In this case, I would prefer the use of
Seretide since there is no reported case of asthma exacerbations. The adverse effects of ICS
include reflex cough, oral candidiasis, bronchospasm and dysphonia, Dysphomnia occurs as a
result of mucosal irritation and myopathy of laryngeal muscles (Liang & Chao, 2019).
However, it is important that nurses consider the dosage of ICS. There have been
debates on the risk of using ICS among patients with pulmonary complications. For instance,
Azhar (2015) cited that the fear that the use of corticosteroids increased pneumonia risk is
unsubstantiated based on existing evidence. It is important to ensure that the patient is not
exposed to such risks.

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Conclusions
Appendicitis is a condition caused by several factors. The primary cause is luminal
obstruction which results in the inflammation of the appendix and surrounding tissues. There
is enormous evidence demonstrating how patients with appendicitis are managed. Unique
attention is given to asthma patients admitted for appendicitis as they may experience
pulmonary complications during surgery and treatment.

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