Case Study: Evidence-Based Nursing Care of a Patient with Appendicitis

This case study focuses on the nursing care of a 29-year-old male patient, Josh Kennedy, diagnosed with acute appendicitis. The study utilizes evidence-based practice to explore the pathophysiology of appendicitis, including the obstruction of the appendiceal lumen and subsequent inflammation. Pre-operative considerations involve necessary tests and informed consent, while the post-operative nursing management section details two key nursing diagnoses: acute pain and risk of infection. For each diagnosis, SMART goals are established, along with specific implementations for pain management and infection prevention. The case study also includes medication information, such as Unasyn, Zosyn, and Timentin, with their uses, side effects, and nursing considerations. Overall, the case study provides a comprehensive overview of the nursing care required for a patient undergoing an appendectomy, emphasizing evidence-based practices and patient-centered care.

Running head: CASE STUDY
Case Study Appendicitis
Name of the student
Name of the university
Author’s name

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Table of Contents
Introduction......................................................................................................................................2
Pathophysiology..............................................................................................................................2
Pre-Operative Considerations..........................................................................................................3
Nursing management post-operation...............................................................................................4
Two Post-OP Nursing Diagnosis.................................................................................................4
SMART goals for nursing diagnosis...........................................................................................5
Implementation............................................................................................................................6
Medications......................................................................................................................................8
Conclusion.......................................................................................................................................8

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Introduction
Evidence based practice refers to the diligent use of the best practice available. These treatments
are methodically verified and implemented to give positive outcomes (Harvey & Kitson, 2015).
The purpose of this case study is to use evidence based information for the pathophysiology of
the condition, analysis of the clinical manifestations, pre-operative considerations and the
development of nursing diagnosis relevant to the post op care of John Kennedy who is a 29 year
old man. He is suffering from acute appendicitis and he has a medical history of Asthma. He
uses Salbutamol and Seretide and is allergic to Latex and Penicillin.
Pathophysiology
When there is an obstruction of the appendiceal lumen by the fecalith, lymphoid hyperplasia,
fecal remains (like seeds or remains of bone), formation of true calculi (Forbes, & Lloyd-Davies,
1966) or tumor inside the appendix leads to the formation of mucous. Appendix continues to
secrete mucous during this phase. This causes a subsequent increase of intraluminal pressure and
impaired venous outflow with the mucosal damage. This leads to decreased supply of oxygen
which is a symptom of hypoxia. There is also low supply of blood flow to the appendix. After all
these the bacterial invasion elevates that causes it to spread to the surrounding appendix wall
with possible sign of mural necrosis, peritonitis or abscess formation (Petroianu & Barroso,
2016). According to a study there is a yield of 10 to 15 types of separate microorganisms. This
causes an inflammation and swelling of the appendix which gives rise to Appendicitis (Guinane
et al., 2013).

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Pre-Operative Considerations
Before a surgical procedure is implemented on a patient, a number of tests are conducted to
assess the health condition of the patient for if they are ready to undergo surgery or not.
Generally, the tests are conducted way few days ahead before conducting the appendectomy,
however due to the earnestness of the appendectomy procedure, the healthcare tests and surgeries
are conducted on same day. Pre-operative tests differ conferring upon the patient’s age and
condition of health, but there are certain common tests such as blood test, chest x-rays, and
electrocardiogram (EKG) are compulsory and will be conducted on Josh before he is sent for
operation. Before conducting the surgery an informed consent form will be contracted by Josh
accepting that he has a clear knowledge of every process, potential threats, and that he will
obtain certain medicines.
Before the surgery is conducted, the anesthesiologist pays a visit to the patient to have a
momentary physical checkup and to gather information of health status. During this time, the
Doctor may ask Josh about his medical conditions diagnosed during the past years or if he had
any surgeries; whether he is undertaking medications or dietary supplements or herbal products;
if he ever used or is using illicit drugs or has any other bad addiction to smoking or alcohol
consumption; or has any side effect to anesthesia, or any genetic problems related to anesthesia
(Cho & Maklad, 2017).
Patients are restricted to eat any meal or any medications or any drinks on the midnight before
the day of surgery; however, due to the emergency scenario of the appendectomy surgery, it may
not be possible. As the decision is made of conducting surgery, the patient is totally refrained
from having anything including medications into the mouth. Just a few moments before the

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surgery, patients are provided IV to provide fluids, medicines, antibiotics and pain reducers
which are to be directly delivered to directly into the blood (Salminen et al., 2015). Before the
surgery is initiated sedatives are given to patient to help them relax. At last anesthesia is
provided in the operation theatre (Weis & Hamilton, 2019).
Nursing management post-operation
Two Post-OP Nursing Diagnosis
Appendectomy is the surgical process of removal of inflamed appendix. The basic nursing care
plan for the patients who underwent appendectomy are preventing post-operative complications,
providing comfort, and providing health information to the patient and their families
(Sammalkorpi, 2017). The nursing diagnosis for the patients who underwent appendectomy is –
 Acute Pain – These are the uncomfortable sensation and sensitive feeling rising due to the
tissue damage. It can be due to irritation in the intestinal tissues because of post-operative
inflammation or may be due to occurrence of surgical incision. The symptoms of this
post-operative acute pain reports of pain, interference in the behaviors, or may be
autonomic responses (Sammalkorpi, 2017).
 Risk of infection – There are chances of infection after the post-operative process which
can happen if there are any uncovered gaps in the surgical site. Through those site
microorganisms can invade the space. This may lead to inadequate defense system,
rupture of appendix, peritonitis, and abscess formation. There can be surgical incision
also (Sammalkorpi, 2017).

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SMART goals for nursing diagnosis
SMART GOALS ACUTE PAIN ACUTE PAIN RISK OF INFECTION RISK OF INFECTION
S (Specific) Reducing the acute
pain in the lower
abdomen.
Reducing the pain
and burning
sensation in the site
of appendectomy.
Reducing the risk of
infection in the site of
appendectomy.
Reducing the risk of
infection causing
abscess formation and
peritonitis in the inner
muscles.
M (measurable) The pain will be
assessed using the
descriptive scales
such as visual
analogue which is of
scale 1 to 10. 1 will
denote no pain and
10 will denote severe
pain.
The pain will be
assessed using the
pain scale of 1 to 10;
1 will denote no pain
and 10 will denote
severe pain.
The infection or the
trace of microorganisms
can be detected by
seeing the redness color
of the surrounding skin
of surgical site infection
and further can be done
through blood tests.
The abscess formation
can be measured by
physical examination
and if the abscess is
formed into deeper
layer than it can be
measured by imaging
process.
A (Achievable) It is achievable
through the use of
proper medications.
It is achievable
through the use of
proper medications.
It can be achieved by
surgical process and
through medications
It can be achieved by
surgical process and
through medications.
R (Realistic) This goal is
achievable as it is
usually seen that
people who undergo
appendectomy suffer
acute pain in the
portion of lower
abdomen.
This goal is
achievable as it is
usually seen that
people who undergo
appendectomy suffer
pain and burning
sensation in the in
the site of
appendectomy.
This goal is achievable
as it is usually seen that
people who undergo
appendectomy suffer
post-op risk of
infections.
This goal is achievable
as it is usually seen that
people who undergo
appendectomy suffer
post-op risk of
infections.
T (Time frame) The procedure will
require two week
time frame to be
completed.
The feeling of
burning sensation
will reduce within 1
week time frame.
The procedure will
require two week time
frame to be completed.
The procedure will
require two week time
frame to be completed.

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Implementation
1. Reducing the acute pain in the lower abdomen.
Determining the status of pain is the initial phase to determine the pain management strategy.
The most reliable source of pain is itself the patient. Descriptive scales such as the visual
analogue can be utilized to assess the level of pain. The pain can be better evaluated by
checking the symptoms of the person such as rise in blood pressure, temperature, color and
temperature of the skin. The nurse needs to assess the level of cultural, environmental,
intrapersonal, and intrapsychic factors that may cause or lead to the relief of pain. After that
the John should be measured on his expectation of pain relief. John should be given a brief
on the various types of methods which will help him in controlling the pain. He can also be
provided with IV fusion of opioid with the prescribed limits which will help him in managing
his acute pain (Chen et al., 2019).
2. Reducing the pain and burning sensation in the site of appendectomy.
Assessment of the level of pain and burning sensation can be determined by using the
descriptive scales such as the visual analogue. The pain and burning sensation can be better
evaluated by checking the portion where there is pain and burning sensation. John should be
given a brief on the different medicines and ointments which will help him in controlling the
pain. After that the John should be measured on his expectation of pain relief (Chen et al.,
2019).
3. Reducing the risk of infection in the site of appendectomy.
The nurse need to assess for the presence of any history risk factors which will help in
understanding whether there is a breach in the first line of defense. WBC count should be
monitored as they help in fighting the pathogens. John should also be monitored for his

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nutritional status as if the nutrition status is poor then it is failing to muster a cellular immune
response. Following symptoms like redness, swelling, increased pain, or pus discharge
should be monitored to determine the degree of infection. Also John’s temperature and urine
appearance need to be monitored. The patient should be taught asepsis for dressing changes
and wound care, peripheral IV and central venous management, and catheter care and
handling. Limited number of visitors should be allowed to meet the patients to reduce the
transmission of pathogen. If the infection condition is extreme then, the patient should be
kept at an isolated place (Chen et al., 2019).
4. Reducing the risk of infection causing abscess formation and peritonitis in the inner muscles.
The nurse need to assess for the presence of any history risk factors which will help in
understanding whether there is a breach in the first line of defense. WBC count should be
monitored as they help in fighting the pathogens. The patient should also be monitored for
his nutritional status as if the nutrition status is poor then it is failing to muster a cellular
immune response. Following symptoms like redness, swelling, increased pain, or pus
discharge should be monitored to determine the degree of infection. Also the patient’s
temperature and urine appearance need to be monitored. If there is a rupture in the appendix
then it may lead the infected contents to flow inside the abdominal cavity. This may lead to
formation of peritonitis and abscess. The abscess must be surgically drained. To treat
peritonitis, doctors suggest antibiotics. The surgeon will need to drain out the infected
material and disinfectant the abdominal cavity (Chen et al., 2019).

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Medications
MEDICATIONS USES SIDE-EFFECTS NURSING CONSIDERATIONS
Unasyn
(Ampicillin/Sulbactam)
Penicillin antibiotics
that fights bacteria.
Stops the growth of
bacteria.
Fever, sore throat,
headache, rash,
diarrhea, nausea,
vomiting
By IV – should be provided by
slow IV injections for 10-15
mins or can be delivered in
greater dilutions of 50-100 ml.
For IM – The recommended
dosage is 1.5 to 3 grams for
every six hours.
Zosyn
(Piperacillin/Tazobactam)
Treat bacterial
infections, including
pneumonia,
appendicitis, and
inflammatory disease.
Insomnia, vomiting,
diarrhea, constipation,
runny nose
The FDA approved dose is 3.375
g (3g piperacillin and 0.375 g
tazobactam) IV for every 6
hours.
Timentin
(Ticarcillin/Clavulanate)
This are used to treat or
prevent the infections
which are proven to be
caused by the bacteria.
Mild diarrhea, gas,
stomach pain, nausea,
vomiting, joint or
muscle pain
The approved dosage is 3.1
grams of TIMENTIN (3.1-gram
vial containing 3 grams
ticarcillin and 100 mg clavulanic
acid) given every 4 to 6 hours.
Conclusion
The appendicitis is the inflammation of the appendix. Appendicitis causes pain in the lower right
abdomen. The procedure of treating appendicitis is called as appendectomy. Before conducting
appendectomy process there are certain tests which are compulsory to be conducted such as
blood test, chest x-rays, and electrocardiogram (EKG). However, after the post-operative process
of appendectomy, there are chances of several complications like acute pain and risk of
infections which can give rise to further issues. However, there are certain issues which can
simply be treated with the help of antibiotics and there are certain issues which need surgical

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procedures. The main medicines which are allowed for the treatment of appendicitis are
ampicillin, ticarcillin, and tazobactam.

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