A CARE STUDY ON A PATIENT WITH APPENDICITIS

BY

OGUNNIRAN SULIAT OPEYEMI

MATRIC NO: SON/2016/17/143

IN PARTIAL FUFILMENT FOR THE AWARD OF DIPLOMA

CERTIFICATE IN BASIC NURSING PROGRAM

AT

THE SCHOOL OF NURSING,

UNIVERSITY OF ILORIN TEACHING HOSPITAL,

ILORIN, KWARA STATE NIGERIA

APRIL, 2019.

i
 CERTIFICATION

This is to certify that this care study was carried out by Ogunniran Suliat Opeyemi of School

of Nursing, University of Ilorin Teaching Hospital, under my supervision.

..............................................

MRS. OGUNTOYE

SUPERVISOR

……………………………. …………………………...

MRS. BAMIDELE MRS. ABDUSSALAM

PROGRAMME CO-ORDINATOR Ag. PRINCIPAL

ii
 DEDICATION

This care study is dedicated to Almighty Allah, my parents and my siblings.

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 ACKNOWLEDGEMENT

All glory and adoration to Almighty Allah for his grace, mercy, favour and protection

for giving me the privilege of going through this training.

Big thanks to my parents, Mr. and Mrs. Ogunniran and my siblings, for their care,

advice, moral and financial support throughout the period of this course. I so much appreciate

you, honestly you are wonderful.

My gratitude goes to my supervisor in person of Mrs Oguntoye for the guidance and
encouragements she gave me at various stages of the study, and corrections which has made
this work a successful one. God bless u ma.

My appreciation goes to the acting principal of school of nursing, Mrs Abdussalam, I

appreciate you ma.

My appreciation also goes to my class coordinator, Mrs. Bamidele, and class adviser, Mrs.
Muktar, then to other lecturers of school of nursing, UITH, for all their immeasurable and
tremendous efforts which cannot be quantified towards the successful completion of my
programme, I say a big thank you.

Finally, my thanks go to the CNO of paediatric surgical ward of university of Ilorin Teaching

hospital and all the staffs of the same unit, and to my patient Master. T. H and his parents,

Thanks for your cooperation during the period of hospitalization.

May God bless you all. (AMEN)

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 TABLE OF CONTENTS

Title page i

Certification ii

Dedication iii

Acknowledgement iv

Table of content v

CHAPTER ONE

Introduction 1

Aims and objectives 2

Definition of terms 2

CHAPTER TWO

Literature review 4

Incidence 4

Aetiology 6

Predisposing factors 7

Anatomy and physiology of related organs 8

Pathophysiology 12

Clinical manifestations 13

General investigation 14

General Management (medical & nursing)

14

complications 16

prognosis 17

Differential Diagnosis 17
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 CHAPTER THREE

Patient’s biodata 19

Nursing history 20

Physical assessment

Investigations 23

Medical management 24

CHAPTER FOUR

General nursing management 26

Nursing diagnosis 31

Nursing care plan 32

Chemotherapy 35

Observation chart (Vital signs chart) 38

Rehabilitation 39

Advice on discharge 39

Follow up care 40

Summary and conclusion 40

Recommendations 40

References 42

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 CHAPTER ONE

INTRODUCTION

This is a care study carried out on Master T. H a 10years old boy who was diagnosed

with acute appendicitis. He was admitted into emergency pediatric ward on 3rd of September,

2018 in University of Ilorin Teaching Hospital, Ilorin.

Appendicitis is a painful swelling of the appendix. The appendix is a small thin pouch

about 5-10cm (2-4 inches) Long. It's connected to the large intestine, where stools are

formed. Appendicitis typically starts with a pain in the middle of the abdominal cavity that

may fluctuate. Within hours, the pain travels to the lower right hand side where the appendix

usually lies and becomes constant and severe. (Zana, 2016).

Acute appendicitis is a sudden inflammation of the appendix. Symptoms commonly

include right lower abdominal pain, nausea, vomiting, and decreased appetite. However,

approximately 40% of people do not have these typical symptoms. Severe complications of a

ruptured appendix include wide spread painful inflammation of the inner lining of the

abdominal wall and sepsis. (Graffeo, 2018)

Appendicitis is caused by blockage of the hollow portion of the appendix. This is

most commonly due to a calcified “stone “made of faeces (Longo, Dan L, 2012). Inflamed

lymphoid tissue from a viral infection, parasites, gall stones or tumors, may also cause the

blockage (Longo, Dan 2012). This blockage leads to increased pressures in the appendix,

decreased blood flow to the tissues of the appendix, and bacterial growth inside the appendix

causing inflammation. The combination of inflammation, reduced blood flow to the appendix

and distension of the appendix causes tissue injury and tissue death. If this process is left

untreated, the appendix may burst, releasing bacteria into the abdominal cavity, leading to

increased complications (Barrett, Andrews 2013).

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AIMS AND OBJECTIVES

1. To acquire an in-depth knowledge of Appendicitis

2. To provide useful information about appendicitis, the organ affected, signs and symptoms,

treatment and preventions

3. To provide the highest quality and most cost efficient nursing care possible in the

management of appendicitis

4.To conduct health teachings as one way of providing and promoting holistic care to the

Patient

5. In partial fulfilment of the award in diploma in nursing

DEFINITION OF TERMS

 Appendectomy - surgical operation to remove appendix.

 Appendicitis - inflammation of the appendix causing severe pain.

 Appendix - small outgrowth from large intestine, a bind ended tube leading from the

first of the large intestine (caecum), near its junction with the small intestine. In

humans, it is small, occurs in the lower right hand part of the abdomen and contains

cells of the immune system. Colic - severe pain in the bowel or the abdomen.

 Constipation - difficulty in passing stools or incomplete or infrequent passage of hard

stools.

 Fecalith - hardened mass of stool.

 Peritonitis - inflammation of the peritoneum caused by the spreading of infection.

 Sepsis - the condition or syndrome caused by the presence of microorganisms or their

toxins in the tissue or the bloodstream.

 Septicemia - systemic infection in which pathogens are present in the circulating

blood, having spread from an infection in any part of the body.

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 Shock - a state of physiologic collapse, marked by a weak pulse, coldness, sweating

and irregular breathing, and resulting from a situation such as blood loss.

 Mc Burney’s Sign- This is a point on the abdominal wall that lies between the navel

and right anterior superior iliac spine and that is the point where most pain is elicited

by pressure in acute appendicitis.

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 CHAPTER TWO

LITERATURE REVIEW

According to Brunner and Suddarth’s 2008, the appendix is a small, finger like

appendage attached to the cecum just below the ileocecal valve. Because it empties into the

colon inefficiently and it lumen is small, it is prone to becoming obstructed and is vulnerable

to infection (appendicitis).

Appendicitis is the most common causes of acute abdomen and a common surgical

problem. Its early diagnosis remains a problem because of other pathological conditions that

mimic acute appendicitis. It is common in children over 4 years, adolescents and young

adults. However, it affects all age groups (Famakinwa T. T 2002).

Appendicitis is an inflammation of the vermiform appendix. It is common in male

than I'm females. The peak is between ages 10 and 30 (Oloriegbe Ofunami 2004)

Appendicitis is thought to be an obstruction of the appendiceal lumen leading to

inflammation and bacteria overgrowth of the appendix. If not treated, the appendix becomes

ischemic leading to perforation and peritonitis (Dunphy, Winland-Brown, Porter, Thomas,

2011).

INCIDENCE

NATIONALLY, During the decade under study, there was a total of 1,006,078 outpatient

visits with a mean of about 100,000 per year comprising of 763,824 (76%) adults and

242,254 (24%) pediatric-aged patients defined as 12 years or younger. Of this total, 448,607

(44.5%) were males and 557,471 (55.5%) were females. There were a total of 104,873

admissions or about 10,000 admissions per year comprising of 44,417 (42.4%) males and

60,456 (57.6%) females.

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Data from the Nigerian Census of 2006 on seven local government areas within 30 km radius

of the hospital where patients with appendicitis have their specimens sent to this laboratory

for histological study were listed. Populations further away from this hospital where all cases

of acute appendicitis would have to come to ABUTH for treatment or their specimens would

have to be brought to the ABUTH histopathology laboratory for analysis were noted. The

total population count according to the 2006 census in the reference area was 1,423,469

There were a total of 16,267 surgical operations of which appendectomy accounts for 382

(2.6%). The histopathology department received a total of 23,127 solid tissue specimens

during the study period. This represents specimens received both from the ABUTH and from

other hospitals in the area. Of this total, there were 382 specimens of the appendix

representing 1.6% of all surgical solid specimens received.

Of the 382 specimens of appendix received diagnosis of appendicitis was established in 373

cases which form the study population. This gave a mean of 37.2 appendectomies per year or

around 3 appendectomies per month in a population of 1,423,469. Therefore, this represents a

population incidence for appendicitis of 2.6 per 100,000 per year. (Saad Aliyu Ahmed, 2014).

INTERNATIONALLY, Appendicitis is one of the more common surgical emergencies, and

it is one of the most common causes of abdominal pain. In the United States, 250,000 cases

of appendicitis are reported annually, representing 1 million patient-days of admission. The

incidence of acute appendicitis has been declining steadily since the late 1940s, and the

current annual incidence is 10 cases per 100,000 populations. Appendicitis occurs in 7% of

the US population, with an incidence of 1.1 cases per 1000 people per year. Some familial

predisposition exists. In Asian and African countries, the incidence of acute appendicitis is

probably lower because of the dietary habits of the inhabitants of these geographic areas. The

incidence of appendicitis is lower in cultures with a higher intake of dietary fiber. Dietary

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fiber is thought to decrease the viscosity of feces, decrease bowel transit time, and discourage

formation of fecaliths, which predispose individuals to obstructions of the appendiceal lumen.

In the last few years, a decrease in frequency of appendicitis in Western countries has

been reported, which may be related to changes in dietary fiber intake. In fact, the higher

incidence of appendicitis is believed to be related to poor fiber intake in such countries.

There is a slight male preponderance of 3:2 in teenagers and young adults; in adults,

the incidence of appendicitis is approximately 1.4 times greater in men than in women. The

incidence of primary appendectomy is approximately equal in both sexes. The incidence of

appendicitis gradually rises from birth, peaks in the late teen years, and gradually declines in

the geriatric years. The mean age when appendicitis occurs in the pediatric population is 6-10

years. Lymphoid hyperplasia is observed more often among infants and adults and is

responsible for the increased incidence of appendicitis in these age groups. Younger children

have a higher rate of perforation, with reported rates of 50-85%. The median age at

appendectomy is 22 years. Although rare, neonatal and even prenatal appendicitis have been

reported. Clinicians must maintain a high index of suspicion in all age groups. Acute

appendicitis can occur in any age group or population. However, it most often occurs in teens

and young adults. It is rare in children younger than two years of age. Classic symptoms of

acute appendicitis include pain in the right lower abdomen, where the gets progressively

sharp and more intense. Pain =increases when pressure is put on the area (called the

McBurney’s point), and the area becomes even more painful and tender when the pressure is

released (rebound tenderness). This is one exam a health care provider uses to diagnosis acute

appendicitis. (Priscilla lemone, 2015).

AETIOLOGY

 Obstruction of the lumen of the appendix is the main cause of acute appendicitis.

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  Fecalith (a hard mass of fecal matter), normal stool or lymphoid hyperplasia are the

main cause of obstruction. Fecalith alone causes simple appendicitis in 40%

 Gangrenous non perforated appendicitis in 65%

 Perforated appendicitis in 90% of cases

 Cancer

PREDISPOSING FACTORS

AGE

 Increases from birth

 Peaks in teenage years

 Decreases in geriatric

GENDER

 ~1.4 X greater risk in men than women

FAMILY HISTORY

 ~3X greater risk

ETHNICITY

 Cultures with low intake of dietary fibre are at greater risk

SEASONAL VARIATION

 Greater presentation in the summer because of increased ground level ozone air

pollution.

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LOW FIBRE DIET

 Increases the viscosity of feces which can cause fecal matter to get lodged in the

appendix.

ANATOMY AND PHYSIOLOGY OF RELATED ORGANS

ANATOMY AND PHYSIOLOGY OF THE GASTROINTESTINAL TRACT

The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the

oral cavity, where food enters the mouth, continuing through the pharynx, esophagus,

stomach and intestines to the rectum and anus, where food is expelled.

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There are various accessory organs that assist the tract by secreting enzymes to help break

down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall

bladder have important functions in the digestive system. Food is propelled along the length

of the GIT by peristaltic movements of the muscular walls.

The functions of the digestive system are:

 Ingestion - eating food

 Digestion - breakdown of the food

 Absorption - extraction of nutrients from the food

 Defecation - removal of waste products

 The digestive system also builds and replaces cells and tissues that are constantly dying.

The digestive system is a group of organs (Buccal cavity (mouth), pharynx,

esophagus, stomach, liver, gall bladder, jejunum, ileum and colon) that breakdown the

chemical components of food, with digestive juices, into tiny nutrients which can be absorbed

to generate energy for the body. The Buccal Cavity Food enters the mouth and is chewed by

the teeth, turned over and mixed with saliva by the tongue. The sensation of smell and taste

from the food sets up reflexes which stimulate the salivary glands.

The Salivary glands: These glands increase their output of secretions through three pairs of

ducts into the oral cavity, and begin the process of digestion. 24 Saliva lubricates the food

enabling it to be swallowed and contains the enzyme ptyalin which serves to begin to break

down starch.

The Pharynx: Situated at the back of the nose and oral cavity receives the softened food

mass or bolus by the tongue pushing it against the palate which initiates the swallowing

action. At the same time a small flap called the epiglottis moves over the trachea to prevent

any food particles getting into the windpipe. From the pharynx onwards the alimentary canal

is a simple tube starting with the salivary glands.

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The Esophagus: The esophagus travels through the neck and thorax, behind the trachea and

in front of the aorta. The food is moved by rhythmical muscular contractions known as

peristalsis (wave-like motions) caused by contractions in longitudinal and circular bands of

muscle. Antiperistalsis, where the contractions travel upwards, is the reflex action of

vomiting and is usually aided by the contraction of the abdominal muscles and diaphragm.

The Stomach: The stomach lies below the diaphragm and to the left of the liver. It is the

widest part of the alimentary canal and acts as a reservoir for the food where it may remain

for between 2 and 6 hours. Here the food is churned over and mixed with various hormones,

enzymes including pepsinogen which begins the digestion of protein, hydrochloric acid, and

other chemicals; all of which are also secreted further down the digestive tract. The stomach

has an average capacity of 1 litre, varies in shape, and is capable of considerable distension.

When expanding this sends stimuli to the hypothalamus which is the part of the brain and

nervous system controlling hunger and the desire to eat. The wall of the stomach is

impermeable to most substances, although does absorb some water, electrolytes, certain

drugs, and alcohol. At regular intervals a circular muscle at the lower end of the stomach, the

pylorus opens allowing small amounts of food, now known as chyme to enter the small

intestine.

Small Intestine: The small intestine measures about 7m in an average adult and consists of

the duodenum, jejunum, and ileum. Both the bile and pancreatic ducts open into the

duodenum together. The small intestine, because of its structure, provides a vast lining

through which further absorption takes place. There is a large lymph and blood supply to this

area, ready to transport nutrients to the rest of the body. Digestion in the small intestine relies

on its own secretions plus those from the pancreas, liver, and gall bladder.

The Pancreas: The Pancreas is connected to the duodenum via two ducts and has two main

functions:

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1. To produce enzymes to aid the process of digestion

2. To release insulin directly into the blood stream for the purpose of controlling blood sugar

levels Enzymes suspended in the very alkaline pancreatic juices include amylase for breaking

down starch into sugar, and lipase which, when activated by bile salts, helps to break down

fat. The hormone insulin is produced by specialised cells, the islets of Langerhans, and plays

an important role in controlling the level of sugar in the blood and how much is allowed to

pass to the cells.

The Liver: The liver, which acts as a large reservoir and filter for blood, occupies the upper

right portion of abdomen and has several important functions:

1. Secretion of bile to the gall bladder

2. Carbohydrate, protein and fat metabolism

3. The storage of glycogen ready for conversion into glucose when energy is required.

4. Storage of vitamins

5. Phagocytosis - ingestion of worn out red and white blood cells, and some bacteria.

The Gall Bladder: The gall bladder stores and concentrates bile which emulsifies fats

making them easier to break down by the pancreatic juices.

The Large Intestine: The large intestine averages about 1.5m long and comprises the

caecum, appendix, colon, and rectum. After food is passed into the caecum a reflex action in

response to the pressure causes the contraction of the ileo-colic valve preventing any food

returning to the ileum. Here most of the water is absorbed, much of which was not ingested,

but secreted by digestive glands further up the digestive tract.

The colon is divided into the ascending, transverse and descending colons, before

reaching the anal canal where the indigestible foods are expelled from the body.

(Ross and Wilson Anatomy and Physiology in Health and Illness. 2014)

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ANATOMY OF THE APPENDIX

The appendix is a wormlike extension of the cecum and, for this reason, has been called the

vermiform appendix. The average length of the appendix is 8-10 cm (ranging from 2-20 cm).

The appendix appears during the fifth month of gestation, and several lymphoid follicles are

scattered in its mucosa. Such follicles increase in number when individuals are aged 8-20

years

The function of the appendix is unknown. One theory is that the appendix acts as a

storehouse for good bacteria, “rebooting” the digestive system after diarrheal illnesses.

Other experts believe the appendix is just a useless remnant from our evolutionary past.

Surgical removal of the appendix causes no observable health problems.

PATHOPHYSIOLOGY

Appendicitis occurs when the appendix becomes acutely inflamed. It’s not entirely

known why appendicitis occurs however it is thought to be due to the lumen of the appendix

12
becoming blocked by a faecolith, normal faecal matter or lymphoid hyperplasia due to a viral

infection.

Once obstructed, there is reduced blood flow to the tissue and bacteria is able to multiply.

Due to the lumen being obstructed, the pressure within the appendix increases and this

reduces venous drainage, resulting in ischaemia. If untreated the ischaemia can lead to

necrosis and gangrene. At this stage, the appendix is at risk of perforating. It takes around

72hrs for perforation to occur from when the appendix becomes obstructed. Once the

appendix perforates, bacteria and inflammatory cells are released into the surrounding

structures. This then causes inflammation of the peritoneum and the child develops peritonitis

causing diffuse abdominal pain.

(Hussain Aluzri, 2018).

CLINICAL MANIFESTATION

According to Pramod Kerkar, 2018

 Nausea.

 Vomiting.

 Diarrhea.

 Constipation.

 Inability to pass gas.

 Appetite loss.

 Swelling in the abdomen.

 Pain in the lower right abdomen.

 Fever.

 Chills.

 Increased thirst.

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  Decreased urine output or patient may not pass urine at all.

 Weakness.

 Feeling of rectal fullness.

GENERAL INVESTIGATIONS

 Abdominal or pelvic ultrasound may be performed. Ultrasound is a type of imaging exam

that uses sound waves to create pictures of the inside of the abdomen and/or pelvis.

 CT scan of the abdomen and pelvis may be performed. During a CT scan, x-rays are used

to capture pictures of the inside of the abdomen and pelvis.

 In young patients or women who are pregnant, MRI of the pelvis may be performed. MRI

obtains pictures of the body using a strong magnet.

 In some cases, an abdominal or chest x-ray may be the initial imaging study. Constipation

and sometimes even pneumonia may be causing abdominal pain similar to that seen with

appendicitis.

GENERAL MANAGEMENT

MEDICAL MANAGEMENT

1. Metronidazole : it is an anti amoebic or anti microbial or anti protozoan or anti

trichomonal drug which helps to alter the biosynthesis of the cell wall of protozoan or

microbe thereby altering cell permeability with loss if intracellular constituents.

2. Ciprofloxacin: it is an antibiotic drug which inhibit the Enzymes DNA gyrasewhuch

is needed for the synthesis of bacterial DNA

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3. paracetamol : it is an anti inflammatory and an analgesic which inhibits

prostalgladin synthesis in the CNS and works peripherally to block pain impulse

generation.

4. Augmentin : it is a broad spectrum antibiotics which exhibits the synthesis of

bacterial cell wall.

SURGICAL PROCEDURE:

Appendectomy: An appendectomy is the surgical removal of the appendix.

An appendectomy is a common surgical procedure that surgeons can usually perform

using keyhole surgery, also called laparoscopic surgery. This procedure is less invasive

than open surgery.

A laparoscopic appendectomy procedure typically includes the following steps:

A surgeon makes between one and three small incisions in the abdomen, into which they

insert a special tool called a port.

The sugeon pumps carbon dioxide through this port to inflate the stomach and make

the organs in the abdomen easier to see.

The surgeon then inserts a lighted camera, called laparoscope, through one of the

incisions.

The surgeon use other instruments to identify, position, and remove the appendix.

The surgeon removes the appendix through one of incisions and instills sterile fluid to

remove any remaining infectious material.

The surgeon removes the surgical instruments, which allows the carbon dioxide gas to

escape. The sugeon then closes the incisions with sutures or bandages.

(Daniel Murrell, MD, 2018).

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NURSING MANAGEMENT

Pre Operatively,

 Admit patient into a surgical ward

 Meet the patient and create a nurse patient relationship

 Identify the present problem requiring surgery.

 Obtain vital signs for baseline data.

 Any adverse drug reaction and current medications.

 Examine the patient and in particular assess the airway.

 Review any investigations carried out on the patient.

 Provide information for the patient and relatives about the anesthetic and

postoperative care including pain management.

 Patient should sign consent form.

 Order any pre-medications required and all essential routine medications to be given

preoperatively.

 Administer intravenous infusion to replace fluid loss and promote adequate renal

function and antibiotics therapy to prevent infection.

 Ensure the patient is on nil per oral for 6-8 hours

 Ensure adequate postoperative care is available.

 On the day of the surgery, ensure the patient had his bath early enough.

 Check the vital signs and record in the appropriate document.

 Give the patient theatre gown to wear, check through the theatre requirements

if complete.

 Accompany patient to the theatre and hand over to the theatre nurse.

 Reassure patient and relatives

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 Post operatively

 Make a post-operative bed

 Immediately after surgery, the patient remain in the recovery room for few

hours. He is monitored for discomfort and is given medication to prevent pain

and infection

 The vital signs monitored closely quarter hourly till it is stable

 Monitor operation site for bleeding, if this occur, inform the surgeon promptly

 Ensure proper documentation when taking over the patient

 Give the prescribed post-operative medication and monitor for side effects

 Give the prescribed iv infusion at the required rate and interval

 Encourage patient to move her leg frequently to prevent embolism and prevent

formation of embolus

 Encourage early ambulation to prevent DVT (deep vein thrombosis). i.e.

walking in the ward

 Empty the urine bag as necessary and take intake and output at the end of each

shift and every 24 hours

 Diet rich in protein and vitamin is served to aid healing process

 Dress wound aseptically

 Advise on discharge

 Patient should follow up hospital appointment, take drugs as prescribed, report

any sign in the hospital

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COMPLICATION

According to Pramod Kerkar, 2018.

When the appendix ruptures, the patient may start to feel better, as the original pain of

the appendix starts to subside. However, this does not last long, as a ruptured appendix

rapidly leads to other medical issues. There is formation of pus-filled abscesses around the

appendix. There is formation of scar tissue which helps in "walling off" the abscessed

appendix, so that the seepage is stopped and prevents the infection from spreading.

In some cases, the infected contents of the ruptured appendix spill out into the

abdomen and cause peritonitis, which is an infection of the peritoneum, the membrane which

lines the abdominal cavity. The pain and inflammation spreads throughout the abdomen, and

pain becomes worse with any type of movement. A ruptured appendix can also lead to

septicemia which is a fatal and life threatening blood infection.

A ruptured appendix, if left untreated, can be very fatal and can also lead to death.

Peritonitis, if left untreated quickly spreads causing septicemia, which is presence of bacteria

in the blood. There is release of chemicals in the bloodstream to fight the infection, which

triggers an inflammatory response all over the body known as sepsis. This is followed by a

cascade of reactions, which eventually lead to septic shock (severe hypotension), which may

ultimately lead to multiple organ failure and even death.

PROGNOSIS

Most cases of appendicitis with timely diagnosis and surgery recover well, but it can

get complicated if it is not diagnosed timely or treated appropriately. Experts say that delay in

diagnosis and treatment significantly increases death rate and complications associated with

appendicitis. Surgery for appendicitis is safe and carries a low rate of complication.

18
Therefore, the aim of appendicitis treatment is to make an accurate diagnosis as early as

possible and remove it surgically. (Poonam Sachdev, 2012).

DIFFERENTIAL DIAGNOSIS

Children may find it difficult to communicate their symptoms and may complain of

vague abdominal pain therefore it is important to exclude other diagnoses.

Other GI causes of abdominal pain which are important to exclude are

 Gastroenteritis – vomiting before pain is usually a symptom of gastroenteritis rather

than appendicitis. Often presents with profuse watery diarrhoea which occurs after the

abdominal pain.

 Acute mesenteric adenitis – usually presents after an upper respiratory infection and

abdominal pain is diffuse.

 Constipation – patients may present with fewer than 3 complete stools a week and

parents may say there is soiling (in children over the age of 1 years). Child may be

distressed or be in pain when passing stool. However, this is a diagnosis of exclusion.

 Crohns disease – major differential for appendiceal abscess or mass.

 Intussusception – severe colicky abdominal pain. Stool may be mixed with blood and

mucus (redcurrant stools) and there may be a sausage shaped mass in the abdomen.

 Urinary tract infection – pain and tenderness is in the suprapubic area and there is

burning on urination with increased frequency and urgency.

CHAPTER THREE

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PATIENT BIO DATA

NAME: Mr. T.H

AGE: 10 years

SEX: Male

MARITAL STATUS: Single

HOSPITAL NO: 679610

WARD: Pediatrics surgical ward

RELIGION: Islam

TRIBE: Yoruba

NATIONALITY: Nigerian

STATE OF ORIGIN: Kwara state

LOCAL GOVERNMENT AREA: Ilorin east

HOME ADDRESS: No 14, Jinadu street, igando, Lagos state

PHONE NO: 0803 368 4789

NAME OF NEXT OF KIN: Mr. A.H

CONSULTANT: Dr N

MEDICAL DIAGNOSIS: Appendicitis

DATE OF ADMISSION: 03/09/2018

DATE OF DISCHARGE: 12/09/18

ALLERGIES: Nil

INFORMANT: Patient and parent

CNO INCHARGE: CNO A.

3.2 NURSING HISTORY:

PAST SURGICAL AND MEDICAL HISTORY:

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No history of surgery and blood transfusion. He was never admitted to a hospital but he

experienced common illness such as cough and body pain.

PRESENT HISTORY:

Several days prior to admission the patient experienced an abdominal pain at the right lower

quadrant. These prompted his parent to seek medical advice and diagnosis of appendicitis

was made and was admitted into the pediatric ward.

NUTRITION

He doesn’t eat swallow food such as amala, he doesn’t eat fish & meat but tolerate all other

type of food.

ELIMINATION

He defecates and urinates on regular basis. He empties bowel almost every morning

ACTIVITIES/EXERCISE

He loves playing ball. He goes to school and madrasah, he is very active and likes playing

around.

REST AND SLEEPING PATTERN

During regular days patient has a normal sleeping pattern of eight to ten hours a day. Upon

admission, patient’s sleeping pattern has been altered since his body can’t adapt to hospital

routine he often disturbed during sleep due to continuous monitoring and giving of

medication.

COMMUNICATION/SPECIAL SENSES

He communicates well in English and Yoruba, he relates well with his family. His special

senses are active.

FEELINGS ABOUT SELF/IMAGE

He doesn’t feel depressed but not happy about his current condition

21
FAMILY AND SOCIAL RELATIONSHIP

He is the second born of four children in a nuclear family. She relates well with family and

people of her neighborhood.

SEXUALITY/REPRODUCTION:

Patient is a boy of 10 years old. He doesn't know if he's sexually active or not. However, has

a little knowledge about sex but has a female best friend.

COPING WITH STRESS:

He sleeps whenever he’s stressed.

VALUES AND BELIEFS:

He is a Muslim and believes in Allah for everything, he observes his 5 daily prayers.

PHYSICAL ASSESSMENT

TEMPERATURE: 36⁰C

PULSE: 80b/m

RESPIRATION: 28c/m

WEIGHT:22kg

GENERAL ASSESSMENT:

Head, Ears, Eyes, Nose, Throat and Neck and Five Senses

Head

Hair is smooth. The hair is black in color. The scalp is clean. No swelling or tenderness

noted upon palpation.

Ears

22
Both ears are; auricle aligned with outer canthus of the eye. The color of the outer ear was the

same with that of the skin color. The external pinna was firm, and non-tender. No discharges,

tenderness, masses, or swelling were noted upon inspection and palpation.

Eyes

Both eyes were symmetrical. Eyelashes equally distributed, curled slightly outward. There

was a uniform reaction to accommodation. The pupil was black in color. Lids closed

symmetrically, skin intact, no discharges and no discoloration. Blinking reflex was

functional. No ulceration or lesions noted on the area.

Nose

The external was symmetrical. Nasal flaring noted, air felt when exhaled. Nasal mucosa was

intact and pinkish in color and was free of purulent discharges.

Mouth & Throat

The lips were dry and pale-looking. The gums were pinkish in color. His teeth were still

intact. Uvula was at the middle. Tonsils were uninflammed. No further abnormalities noted.

Neck

The neck was symmetrical and was proportion to head and shoulder. The thyroids were

smooth as palpated. She was able to turn her head in upward, sideward and downward

position with movement. The carotid artery has mild pulsation. No sign of lesion or

tenderness noted.

Five senses

A. Sense of sight

Patient can read normally with functional vision.

B. Sense of taste

23
 By offering different kinds of food patient’s taste buds can identify sweet, sour, bitter, and

salty food.

C. Sense of smell

Patient has good smelling ability; he can distinguish different odors such as fragrance or

perfume and aroma of beverages that he dinks.

D. Sense of hearing

He can recognize sounds and could hear clearly, he responds to conversation normally.

E. Sense of touch

The patient responds when someone touches him, and can distinguish soft from rough texture

and can identify hot from cold water.

PHYSICAL EXAMINATION

PALPATION: abdomen was palpated and it was tender to touch

PERCUSSION: normal abdominal sound heard and no fluid retention.

AUSCULTATION: heart sound and breath sound is normal on auscultation. Bowel sound

present and chest is cleared

INVESTIGATIONS

DATE SPECIMEN INVESTIGATION NORMAL OBTAINABLE REMARK

SAMPLE REQUESTED VALUE RESULT

5/9/11 Blood Pack cell volume Female 36- 40% Normal

42%

Male 40-45

Red blood cell Male:4.5- 4.48x10^2/l Normal

24
 5.5x10^2/L

Female:4.0-

4.9x10^2/l

White blood cell count 3.9-10.9x10^9/L 2.3x10^9/l Low

N e u t r o p h i l 2 5 - 7 0 % 23% Low

Haemoglobin 12.0-15.0g/dl 10.3g/dl Normal

10/9/18 Blood P ack cel l vol um e 33% Normal

S o d i u m 135-145mmol/l 129mmol/l Low

P o t a s s i u m 2.9-5.0mmol/l 3.5mmol/l Normal

U r e a 2.5-6.5mmol/l 6.4mmol/l Normal

C r e a t i n i n e 53-106mmol/l 74mmol/l Normal

Urine U r i n a l y s i s

G l u c o s e negative

B i l i r u b i n negative

K e t o n e s negative

B l o o d negative

P r o t e i n negative

MEDICAL MANAGEMENT

A 10 years old boy was admitted into the emergency paediatric unit on the 3/09/18

with the complaint of abdominal pain at the illiac fossa of the abdomen 8 days earlier. He was

diagnosed of appendicitis and booked for appendectomy.

25
PRE OPERATIVE PLAN

Blood sample was taken for packed cell volume, full blood count, grouping and cross

matching, blood electrolyte and urinalysis was also done. Consent form was obtained and

signed by the patient parent and vital signs were observed.

Temperature: 36.5OC

Pulse: 92b/m

Respiration: 24b/m

IV Paractamol 210 mg was given and placed on nil per oral.

POST OPERATIVE MANAGEMENT

Patient was made comfortable in post-operative bed.

Patient was on nil per oral for 3 days.

Vital signs were observed; Temperature: 35.4OC, Pulse: 110b/m, Respiration: 30c/m

Intake and output monitored and chart was maintained.

Intravenous infusion of Normal saline 500mls altered with 5% dextrose saline 12hrly at

12drops/min and later to IVF 5% dextrose saline 2,150mls over 24hrs at 30 drops per minute,

IV PCM 210mg, IV ciprofloxacin 200mg, IV metronidazole 150mg

Urinary catheter insitu draining clear urine

Drainage tube insitu draining serosangenous fluid

Operation site was observed and patient commenced oral sips after, he started with water

about 20mls, followed by tea and other fluid diets which were well tolerated. Patient

commenced oral medications on 5th day post operation

Tab augmentin 625mg b.d

Tab paracetamol 1g tds

Tab flagyl 20mg tds

26
Vitamin c 100mg tds

CHAPTER 4

GENERAL NURSING MANAGEMENT

AIMS

 To create a therapeutic environment for the patient

 To relieve patient’s pain and discomfort

 To allay patient’s anxiety

Goals include relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating

infection due to the potential or actual disruption of the gastrointestinal tract, maintaining

skin integrity and attaining optimal nutrition.

The Nurse prepares the patient for surgery which includes an intravenous infusion to

replace fluid loss and promote adequate renal function and antibiotics therapy to prevent

infection. If there is evidence or likelihood paralitic ileus, a nasogastric tube is inserted. An

enema is not administered because it can lead to perforation.

After surgery, the nurse places the patient in a high Fowler's position. This position

reduces the tension on the incision and abdominal organs, helping to reduce pain. When

tolerated, oral fluids are administered. Any patient who was dehydrated before surgery

receives intravenous fluid. Food is provided as desired and tolerated on the day of surgery

when normal bowel sounds are present.

The patient may be discharged on the day of surgery if the temperature is within normal

limits, there is no undue discomfort in the operative area, and the appendectomy was

uncomplicated. Discharge instructions for the patient to make an appointment to have the

surgeon remove any sutures and inspect the wound between the fifth and seventh days after

27
surgery. Incision care and activity guidelines are discussed; heavy lifting is to be avoided post

operatively, although normal activity can usually be resumed within 2-4 weeks.

If there is possibility of peritonitis, a drain is left in place at the area of the incision.

Patients at risk for this complication may be kept in the hospital for several days and are

monitored carefully for signs of intestinal obstruction or secondary haemorrhage. Secondary

abscess may form in the pelvis under the diaphragm or in the live, causing elevation of the

temperature, pulse rate and white blood cell count.

When the patient is ready for discharge, the patient and family are educated about how

to care for the incision and perform dressing changes and irrigations as prescribed. A home

care nurse may be needed to assist with this care and monitor the patient for complications

and wound healing.

(Brunner and Suddarth 2008)

ADMISSION

A 10 years old boy was admitted into the emergency paediatric unit on the 3/09/18 with the

complaint of abdominal pain at the illiac fossa of the abdomen 8 days earlier. He was

diagnosed of appendicitis and booked for appendectomy. He was taken to the theater on the

6/09/18 where appendectomy was done and transferred to paediatric surgical ward

Vital signs on admission

Temperature: 36.5OC

Pulse: 80b/m

Respiration: 24c/m

PREOPERATIVE PREPARATION

28
 Preoperative preparation was made such as s signing of consent form by the patient,

intravenous line was set and IV paracetamol 210mg was given. Patient and relatives were

reassured, patient blood was sent to the lab for and his PCV was 35.

Preoperative vital signs;

Temperature: 36.5OC

Pulse: 92b/m

Respiration: 24c/m

He was transferred from the emergency pediatric ward to the theatre on 06 /09/2018 and was

transferred to pediatric surgical ward after d surgery

POSTOPERATIVE CARE

Patient was brought into the pediatric emergency ward with intravenous normal saline

500mg. He was received into a warm postoperative bed and made comfortable in bed. Post-

operative vital signs were checked and recorded.

Temperature: 35.4OC

Pulse: 110b/m

Respiration: 30c/m

Intake and output monitored and chart was maintained. Intravenous infusion of

Normal saline 500mls altered with 5% dextrose saline 12hrly at 12drops/min and later to IVF

5% dextrose saline 2,150mls over 24hrs at 30 drops per minute, Urinary catheter insitu

draining clear urine, Drainage tube insitu draining serosangenous fluid.

FIRSTDAY POST OPERATION (07/09/2018)

Patient was given bed bath and oral care in the morning and he was made comfortable in bed.

He looks stable, conscious and still on nil per oral Catheter was insitu and draining clear

urine. Drainage tube intact draining seruos fluid. Intravenous fluid administered. Vital signs

29
were taken and strict input and output were monitored. Patient was seen by the managing

team during ward round.

Vital signs observations

Temperature: 36.2OC

Pulse: 110b/m

Respiration: 24c/m

SECOND DAY POST OPERATION (08/09/2018)

Patient was given assisted bed bath, oral care and was made comfortable in bed, bed linen

was changed, vital signs was normal. Ambulation was encouraged and patient was able to

move out of bed and sit on chair for up to 20minutes and was later assisted back to bed.

Blood sample was taken for post-operative packed cell volume. 7ml kcl in each 500mls of

intravenous dextrose saline was administered

. Vital signs observation;

Temperature: 36.6⁰𝑐

Pulse: 116 b/m

Respiration: 30 c/m

THIRD DAY POST OPERATION (09/09/18)

Patient was stable, no new complaint, assisted bath and oral care was done. He passes flatus

but no faeces yet. Abdominal drainage and catheter was removed. Patient lied calm on bed,

not pale, afribile. Wound site was cleaned with normal saline, no undue tenderness and oral

sips was commenced and was tolerated

Vital signs observed

Temperature: 36.0⁰𝑐

30
Pulse: 98b/m

Respiration:28 c/m

FOURTH DAY POST OPERATION (10/09/18)

Patient is fine and condition is good, not pale, afebrile, not cyanosed, well hydration and no

oedema. Bed linen changed and post-operative PCV result was taken from the laboratory and

it was 33%. He was seen by the managing team. Patient moved around.

Vital signs observed

Temperature: 37.0⁰𝑐

Pulse:100b/m

Respiration:30c/m

FIFTH DAY POST OPERATION (11/09/18)

Patient was able to perform bathroom bath by himself, his condition was good, not pale,

acyanosed, well hydrated and no faeces yet, he has moved bowel and oral sips, oral

medication and food commenced and well tolerated. No side or adverse effect noticed. No

few complain.

Tab augmentin 625mg b.d

Tab paracetamol 1g tds

Tab flagyl 20mg tds

Vitamin c 100mg tds

Vital signs observed

Temperature:36.8⁰𝑐

31
Pulse: 82b/m

Respiration:26c/m

SIXTH DAY POST OPERATION (12/09/18)

Patient general condition is stable, not pale, afebrile, not hydrated, he was seen by the

managing team and was discharged home. Patient was told to come back for inspection of

wound and removal of stitches on 16/09/18. Patient was health educated and vital signs were

observed on discharge.

Vital signs observed

Temperature:36.1 ⁰𝑐

Pulse:80b/m

Respiration:26c/m

Pain assessment: mild

NURSING DIAGNOSIS

PREOPERATIVE

Pain related to disease process evidenced by patient’s verbalization and facial expression.

Anxiety related to outcome of surgery evidenced by patient asking too many question.

Deficient knowledge related to unfamiliarity with information resources evidenced by request

for information.

POST OPERATIVE

32
Ineffective airway clearance related to surgical procedure evidenced by abnormal breathe

sound (crackles)

Pain related to disease process evidenced by patient’s verbalization and facial expression.

Risk for infection related to invasive procedures, surgical incision

Impaired shin integrity related to surgical incision evidenced by breakage in continuity of the

skin

33
 NURSING CARE PLAN

PREOPERATIVE NURSING CARE PLAN

S/N Date/time Nursing Objectives Interventions rationale Evaluation Sign

diagnosis

1 4/8/18 Pain related to Patient will express 1. Assess the patient pain 1. TO serve as baseline patient verbalized and

10am disease process less pain within 30 scale and perception data express less pain

evidenced by minute of nursing 2. Obtain vital signs 2. For comparison after within 30 minute of

patient interventions intervention nursing interventions

verbalization and 3. Advise breathing 3. To allow proper

facial expression exercise oxygenation in the body

4. Administer prescribed 4. to relieve patient pain

analgesic

2 6/8/18 Anxiety related Patient’s fear will 1.Assess patient level of 1.seves as base line data Patient fear was

2pm to outcome of be allayed and anxiety. allayed after 1hour of

surgery patient will identify 2. validate observations by 2. anxiety is a highly nursing interventions.

evidenced by strategies to reduce asking patient, ‘are you individualized, normal

34
 patient asking anxiety after one feeling anxious now’ physical and

too many hour of nursing physiological response

questions interventions to internal or external

life events.

3. Reassure patient 3. to allay patient fear

POST OPERATIVE NURSING CARE PLAN

S/N Date Nursing Objectives Interventions Rationales Evaluation Sign

/ diagnosis

time

1. 7/8/ Ineffective Patient will 1. Assess airway for 1. To check for obstruction Patient maintained

18 airway maintain clear, patency. and make the airway patent clear and open

10 clearance open airways as 2 place patient in an 2. It promotes better lung airway as

am related to evidence by upright position. expansion and improved air evidenced by

surgical normal breath exchange. normal breath

procedure sounds within 30- 3. Suctioning 3. Suctioning clears mucus sound after 40

35
 evidenced 45 minutes of from the tube and is essential minutes of nursing

by nursing for proper breathing. interventions.

abnormal interventions. 4. Oxygen therapy 4. It improve oxygen

breathe saturation and reduce possible

sound complications

(crackles)

2 7/8/ Risk for Patient will be 1.Practice and instruct in 1.reduces risk of spread of Patient was free of

18 infection free of signs of good hand washing and infection infection during

related to infection, aseptic wound care hospitalization

2pm invasive purulent drainage 2. inspect incision and 2. provides early detection of

procedure/ and fever during dressing developing infectious process

surgical hospitalization 3.administer prescribed 3. to serve as prophylaxis

incision. antibiotics measures

36
CHEMOTHERAPY

METRONIDAZOLE

Group: it is an anti-amoebic or anti-microbial or anti-protozoal or anti-trichomonal drug

Mode of action: it is a synthetic derivative of imidazole group helping to alter the

biosynthesis of the cell wall of the protozoan or microbe thereby altering cell permeability

with loss of intracellular constituents.

Indications: amoebic dysentery, ulcerative gingivitis, vaginal and urethra trichomoniasis,

appendicitis, septic abortion, liver abscess.

Dosage: Adult and children over 10years old 400-800mg thrice daily for 7days.

Intravenously 500mg thrice daily for 5days.

Route of Administration: Orally, suppository, intravenously.

Side Effects: gastrointestinal disturbances, urticaria, drowsiness, dizziness, headache,

darkening of urine.

Contraindications: CNS diseases, blood dyscrasias, hepatic encephalopathy, pregnancy

known hypersensitivity reaction.

Nursing Responsibilities: not to be administered to pregnant women, lactating mothers or

patients with known hypersensitivity reaction. Intake of alcohol is toS be avoided within 24

hours of flagyl intake because it may produce disulfiram like reaction.

CIPROFLOXACIN

Group: it is a broad spectrum anti-infective or anti-biotic drug and an anti-diarrhoea agent.

Mode of Action: it is bactericidal in action by inhibiting the enzymes DNA gyrase which is

needed for the synthesis of bacterial DNA.

37
Indications: Respiratory tract infections except pneumonia caused by streptococcus

pneumonia, ear, nose and throat infections, gastrointestinal tract infections, bone and joint

infections.

Dosage: 250-500mg twice daily for 5-10days. Intravenously 200mg twice daily for 5days.

Route of Administration: orally and intravenously

Side Effects: nausea, vomiting, diarrhoea, anorexia, abdominal pain, infrequent visual

disturbances, haemolytic anaemia.

Contraindications: pregnant and lactating mothers, children and adolescents up to 18years,

patients with hypersensitivity to ciprofloxacin.

Nursing Responsibilities: it should be used with caution in patient with disorders of the

central nervous system e.g epilepsy. Patient should adequately be hydrated or drink enough

water for prevention of possible crystallnuria. It should not be administered with antacid

containing aluminum or magnesium hydroxide.

PARACETAMOL

Group: it is a non-steroidal, anti-inflammatory, analgesic and anti-pyretic.

Mode of Action: inhibits prostagladin synthesis in the CNS and works peripherally to block

pain impulse generation, acts on the hypothalamus to produce anti-pyresis.

Indications: painful inflammatory conditions, and fever

Dosage: 500mg- 1000mg orally thrice daily for 10years and above for 5days. Intramuscularly

600mg thrice daily.

Route of Administration: orally in tablet form, intramuscularly, intravenously.

Side Effects: nausea and vomiting, liver damage, post immunization reactions,

hypersensitivity to paracetamol.

38
Contraindications: peptic ulcer, hypersensitivity to acetyl salicylic acid, prostagladin

synthetase, renal and hepatic impairment

Nursing Responsibilities: not be administered to group of persons mentioned above.

Augmentin (Amoxicillin/clavulante)

Group: it is a broad spectrum antibiotic

Mode of action: It is a semi synthetic penicillin which exhibits the synthesis of bacterial cell

wall.

Indications: upper respiratory tract infection, lower respiratory tract infections, skin and soft

tissue infections, genitourinary tract infections, bone and joint infections. Others include

septic abortion, peuperial sepsis, otitis media.

Dosage: Adult and children over 12 years= a tablet of 375mg trice daily or a tablet of 625mg

twice daily. Children over 2 years (2-6 years) =5mls augmentin syrup twice daily

Route of administration: Orally

Side effect: leucopenia, thrombocytopenia, prolonged bleeding and clotting time,

angioneurotic oedema, hypersensitivity, diarrhea, nausea, vomiting

Contraindication: history of hypersensitivity, history of augmentin associated jaundice or

hepatic dysfunction, pregnancy.

Nursing Responsibility: Before administration of Augmentin, enquire about previous

hypersensitivity reactions to penicillin, cephalosporins or other allergens.

Patient on contraceptives should be warned against it since Augmentin reduces the efficacy

of oral contraceptives.

OBSERVATION CHART (VITAL SIGNS)

39
DATE&TIME TEMPERATURES PULSE (b/m) RESPIRATION

(⁰c) (c/m)

3/9/18: 6pm 36.5 80 24

10pm 36.7 88 24

4/9/18: 10 a.m 36.0 86 28

2pm 35.6 90 30

6pm 35.5 88 26

5/9/18 10a.m 35.5 86 26

2pm 36.8 90 28

6pm 36.1 88 34

6/9/18 2am 36.5 92 24

6am 35.4 110 30

10am 35.8 100 28

2pm 35.9 100 28

6pm 36.1 98 28

10pm 36.4 90 26

7/9/18 10am 36.2 110 24

2pm 35.9 100 26

6pm 36.1 98 26

10pm 36.8 96 28

8/9/18 10am 36.2 116 30

2pm 36.5 110 28

6pm 36.5 100 24

9/9/18 10am 36.0 98 28

40
 2pm 36.6 96 24

6pm 36.5 90 24

10/9/18 10am 37.0 100 30

2pm 36.8 100 30

6pm 35.5 90 24

11/9/18 10am 36.8 82 26

2pm 36.5 80 26

6pm 35.5 80 24

12/9/18 10am 36.1 80 26

REHABILITATION

The aim of rehabilitation is to prevent complication and to restore to optimal level of

physical, social and psychological well-being. Rehabilitation was commenced from the time

of admission to the time he was discharged home. He was educated on the possible cause,

prevention, signs and symptoms, treatments and possible complications. Early ambulation

was encouraged after surgery and she was educated on intake of balanced nutrition, personal

hygiene and adequate exercise.

Patient was also given psychological support to allay fear and anxiety. Adequate rest

and sleep, avoid lifting of heavy objects and holding the abdomen when coughing was

emphasized.

ADVICE ON DISCHARGE

Patient was advised on discharge to keep the surgery site dry by not allowing water to

reach the area while bathing, intake of balanced diet and to complete drug dosages. He was

41
advised to keep appointment for follow up care and to return back to the hospital if there is

any complain before the appointment day. He was also advised to hold his abdomen when

coughing and to avoid lifting of heavy loads. Drugs on discharge were given with full

explanation on the use and possible side effects and to avoid unprescribed medications.

FOLLOW UP CARE

Patient was discharged on 12/09/2018 and was given 4days appointment for wound

inspection. He came back to the clinic on 16/06/2017. There was no new complain, operation

site was assessed and stitches were removed. There was no sign of infection. The site was

cleaned with normal saline; parents were advised to clean the site with spirit every day. He

was reminded on the care of surgery site, good nutrition, and personal hygiene and was

advised to come back for the next appointment which is 2 weeks after.

SUMMARY AND CONCLUSION

This care study was written on Mr. T.H, a 10 years old boy who was admitted into the

emergency pediatric unit of University of Ilorin Teaching Hospital on 03/09/2018 with

diagnosis of appendicitis. Various laboratory investigations were done and had

appendectomy done on the 06/09/2018, then was transferred to pediatric surgical ward.

Adequate nursing and medical management was ensured throughout the period of

hospitalization and was discharged home on 12/09/2018.

RECOMMENDATIONS

1. Educate the public especially on the risk factors and early signs and symptoms

of appendicitis with possible complications.

42
2. Government should provide sophisticated equipment that are specifically

meant for care of appendectomy in health facilities (e.g. ultrasound machine,

laparoscopy equipment, medical microscopes e.t.c.).

3. Public enlightenment on early detection and immediate report to the hospital

to prevent complication such as peritonitis

4. Advice on balance diet rich in protein and vitamins and importance of

maintaining personal hygiene.

43
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Anne Waugh and Allison Grant. (2014). Ross and Wilson Anatomy and Physiology (12th ed).

China.Elsevier Ltd. 285-391

Baillers Nursing Dictionary.

Bhangu, A., Soreide, K., Di Saverio, S., Assarsson, JH., Drake, FT. (2015). Acute

appendicitis: modern understanding of pathogenesis, diagnosis, and management. Zana

2016

Bollinger, R. R., Barbas, A. S., Bush, E. L., Lin, S. S., & Parker, W. (2007). Biofilms in the

large bowel suggest an apparent function of the human vermiform appendix.

Craig, S. (2015). Appendicitis.

Daniel Murrell, MD, Healthline Media UK Ltd, Brighton, UK.© 2004-2019.

Dunphy, Winland-Brown, Porter, & Thomas, 2011.

Graffeo 2018, introduction to appendicitis. Longo, Dan L. 2012, Barrett, Andrew 2013.

McCance, K.L. & Huether, S.E.. (2014, 7th Ed). Maryland Heighs, MO: Mosby Elsevier.

Mustapha R.O. (2012). The Easier Approach To Pharmacology For All Health Professionals
(3rd ed). Sabo- oke Ilorin. Adewumi printing press. 92-108.

Priscilla lemone medical surgical nursing, 2015.

Ross and Wilson Anatomy and Physiology in Health and Illness. 2014

Saad Aliyu Ahmed medical surgical nursing, 2014.

44