Clinical symptoms of appendicitis
Appendicitis is a condition that occurs due to inflammation within the inner tissues of the vermiform appendix. Though the biological function of the appendix was previously unknown, it is today associated with the formation of immunoglobulin (Tsung-Ju et al., 2013). Despite the discovery of antibiotic therapy and the use of correctional surgery in the management of this condition, it is still common in people of various age groups.
David has a number of clinical symptoms that have guided his diagnosis with acute appendicitis. Appendicitis is characterized by prolonged phases of diarrhoea or constipation, which is normally accompanied by gaseous stool. David has aptly stated that he has been experiencing continuous diarrhoea which is common in appendicitis (Omari, Khammash, Qasaimeh, Shammari, Yaseen & Hammori, 2014).
Though appendicitis pain takes a period of two hours, an extension can occur depending on the nature of the infection. Based on the statement provided by David, the pain began while he was watching TV, but failed to subside despite using Panadol and Nurofen painkillers. According to David’s statement, the pain radiated from the right flank area, an indication of a progressive infection. Appendicitis is also characterized by nausea and vomiting with a mild level of fever. David indicated that he had been vomiting since the pain began with a temperature of 38.7°c (Şener Bahçe, Haslak, Büyükkaya, Karakoyun Demirci & Özçınar, 2014).
Though these symptoms are common in adolescent and young adult patients of appendicitis, other advanced clinical symptoms can also be witnessed. For example, extended abdominal swelling and increase in rigidity indicates an advanced level of infection.
Pressing the lower flank of the abdomen releases a sharp pain common in patients of acute appendicitis. However, increasing the pressure on the left side increases the level of pain, a further indication of advanced level of appendicitis infection. David was clutching his right side when he visited the facility, an indication that he was attempting to reduce the level of pain by applying pressure on the tender section, a process known as rebound tenderness in acute appendicitis. Unattended appendicitis can spread the infection to other tissues of the abdominal cavity (Tsung-Ju et al., 2013).
Necessary assessments for confirmation of appendicitis
Before confirming that David is suffering from acute appendicitis, different levels of assessment and diagnostic tests must be conducted. Nursing assessment of the patient provides an opportunity to examine the early symptoms and signs of appendicitis. Nursing examination indicates the physical state of the patient, including septic and shock status. During this assessment, the ability of David to lie still or otherwise will be examined as a way of determining the level of infection. Patients who can lie still have the possibility of peritonitis levelled appendicitis while those who are restless may be suffering from extensive inflammation in the intestinal and renal tissues (Shen, Ye, Yin & Wang, 2012).
An examination of the airway passage, breathing pattern and blood circulation in David is a critical stage of nursing assessment. Assessment of the level of shock and sepsis of David in the emergency department is critical in the arrangement of early investigation and treatment. The results of physical physician assessment are not adequate in the diagnosis of appendicitis. Research has shown that patients of appendicitis have 96% possibility of possessing RLQ tenderness.
Finally, diagnostic tests and scans give an accurate indication of the presence of appendicitis in David. With the use of medical digital rectal examination, the level of tenderness of the appendix can be determined. During this examination, lubricated gloved fingers are used to examine the lower rectum of David and the status of his appendix. Further tests can; however, be conducted to determine the biochemical properties of the patient in relation to the condition (Shen, Ye, Yin & Wang, 2012).
For example, blood test is done to monitor the level of white blood cells. Abnormally high level of white blood cells in the patient indicates progressive development of appendicitis. The presence of lower abdominal pain can be as a result of kidney stones or urinary tract infection. As a result, an elimination urinalysis test is conducted to eliminate the possibility of these conditions. Without urinary tract infection and kidney stones, appendicitis remains the only possible source of lower abdominal pain as witnessed in David (Singh, Kadian, Rattan & Jangra, 2014).
Therapeutic medications for appendicitis
The management of appendicitis is affected by the length of infection and the adoption of prompt operative procedures. However, surgical operation is not the only approach that can be adopted to control or even eliminate the situation. A number of non-operative management approaches have been developed and are in use across the globe. Based on the clinical and physical symptoms presented by David, the infection is still considered non-perforated and can be managed through non-operative approaches (Ciarrocchi & Amicucci, 2014).
Antibiotic therapy is one of the most established therapeutic approaches used in the management of appendicitis and can thus be applied in the case of David. Examination of perforated appendix shows a high level of E. coli, an indication of bacterial infection. The elimination of enteric gram-negative bacteria such as E. coli can be effectively done through intravenous antibiotic therapy. In the case of David, IV antibiotic therapy should be promptly initiated before the decision on appendectomy can be made (Ryan, 2010).
Antibiotic management of non-perforated appendicitis can be effectively done with the use of a single dose antibiotic due to low levels of resistance. For example, second and third generation antibiotics have been successfully used in the pre-operative and post-operative management of appendicitis. David’s case cannot be classified as complicated due to the lack of perforation. As a result, simple cephalosporin based antibiotics such as cefroxitin and cefotetan can be used immediately after diagnosis. However, perforated appendicitis requires more advanced antibiotic therapeutic approach. For example, broad spectrum antibiotics such as ampicillin-sulbactamal can be used (Singh, Kadian, Rattan & Jangra, 2014).
Side effects of antibiotic therapy in the management of appendicitis
Despite the success of antibiotic therapy in the management of early appendicitis, a number of side effects have limited their applications. For example, penicillin based antibiotics cannot be used in the management of appendicitis unless the hypersensitivity level and history of the patient is provided. Otherwise, the use of this category of antibiotic will create other secondary conditions and syndromes such as anaphylaxis, angioedema among others. In later stages of appendicitis, the use of penicillin based antibiotic in hypersensitive patients can increase the occurrence of haemolytic anaemia and serum sickness. Oral administration of this antibiotic in appendicitis patients also increases infection of the gastrointestinal tract. Other beta-lactam based antibiotics also increases the risks of developing neutropenia in patients (Ciarrocchi & Amicucci, 2014).
Aminoglycosides are also effective gram-negative antibiotics that are used in the management of appendicitis. For example, gentamicin is a common aminoglycoside used for therapeutic management of appendicitis. However, continued use of this antibiotic increases the development of cumulative ototoxicity. The cochlea and the vestibular system of the patient are affected, and this affects their normal auditory functions. Reversible nephrotoxicity is also common with extensive use of gentamycin and other categories of aminoglycosides (Singh, Kadian, Rattan & Jangra, 2014).
Other antibiotic categories such as metronidazole, clindamycin and cephalosporin have negative impacts on patients. Metronidazole is associated with increased gastrointestinal disturbances, ataxia and mood swings in patients. Clindamycin affects the normal functioning of the ear, causes muscle cramps in advanced age patients and abdominal upsets (Park, Kim & Lee, 2014).
Laparoscopic Appendectomy pre-operation care for David
Pre-operative evaluation and assessment must first be conducted before one is sent to the theatre. In the case of David, most of these tests have been conducted, and his level of appendicitis infection determined. After initial treatment, David is readmitted for Laparoscopic Appendectomy, and this will act as the preoperative care plan. First, the informed consent form must be signed by David and countersigned by the mother as an indication that they understands the process, benefits, risks and the level of medication that accompanies the procedure. After this stage, an anaesthesiologist visit is arranged with the aim of conducting a final assessment and acquiring the medical history of David (Romain, Chemaly, Meyer, Brigand, Steinmetz & Rohr, 2012).
During this period, information on any medication that is currently used by David will be provided to the surgical team. Information on other chemicals used by David such as supplements, ointments among other over-the-counter medications will be provided.
Nutritional guidance will be provided to David to ensure that he refrains from heavy meals a day before the operation. Twelve hours before the operation, David must refrain from orally consuming any food and medication. The anaesthetic and sedation stage is the final preoperative care that David will be subjected to before the actual operation (Park, Kim & Lee, 2014).
Post-operation care for David
Immediately after operation, David will be taken to post anaesthesia care unit where gradual decline in the strength of the operative anaesthesia occurs. While within the PACU, nurses will monitor David’s vital signs such as his temperature, cardiac-respiratory and breathing properties. Once the effect of the anaesthesia wears out, David will be transferred to the normal recovery wards. The recovery of David is expected to progress faster as his appendix was intact during the operation (Ciarrocchi & Amicucci, 2014).
At this recovery stage, David must limit his activities and take pain management medications. Driving and the operation of machines must also be avoided until he attends the first post-operation examination.
Deep cough practices after every two hours will also help David to eliminate the threat of lung and pneumococcal infection. Finally, David must ensure that he uses the post-operative medication as indicated by the physician in order to achieve full recovery. Drugs such as Tylenol can cause constipation and restrict bowel movement, thus increasing discomfort. To decrease the discomfort associated with lack of bowel movement, David should take an ounce of milk magnesia by the fourth day after surgery (Venter, Rahota, Straciuc & Pirte, 2014).
References
Ciarrocchi, A., & Amicucci, G. (2014). Laparoscopic versus open appendectomy in obese patients: A meta-analysis of prospective and retrospective studies. Journal of Minimal Access Surgery, 10(1), 4-9. Web.
Omari, A. H., Khammash, M. R., Qasaimeh, G. R., Shammari, A. K., Yaseen, M. K., & Hammori, S. K. (2014). Acute appendicitis in the elderly: risk factors for perforation. World Journal of Emergency Surgery, 9(1), 1-13. Web.
Park, H., Kim, M., & Lee, B. (2014). Antibiotic therapy for appendicitis in patients aged ≥80 years. The American Journal of Medicine, 127(6), 562-564. Web.
Romain, B., Chemaly, R., Meyer, N., Brigand, C., Steinmetz, J., & Rohr, S. (2012). Value of a preoperative checklist for laparoscopic appendectomy and cholecystectomy. Journal of Visceral Surgery, 149(6), 408-411. Web.
Ryan, W. L. (2010). Appendicitis: Symptoms, Diagnosis, and Treatments. New York: Nova Science Publisher’s.
Şener Bahçe, Z., Haslak, A., Büyükkaya, R., Karakoyun Demirci, R., & Özçınar, B. (2014). A Case Report of Recurrent Acute Appendicitis. Medical Journal of Bakirkoy, 10(2), 85-87. Web.
Shen, Z., Ye, Y., Yin, M., & Wang, S. (2012). Laparoscopic Appendectomy for Acute Appendicitis versus Chronic Appendicitis. Journal of Investigative Surgery, 25(4), 209-213. Web.
Singh, M., Kadian, Y., Rattan, K., & Jangra, B. (2014). Complicated appendicitis: Analysis of risk factors in children. African Journal of Paediatric Surgery, 11(2), 109-113. Web.
Tsung-Ju, C., Chun-Wen, C., Hsin-Yuan, L., Wen-Hsiu, H., Shou-Cheng, W., & Chuan-Chou, T. (2013). Acute Appendicitis Presenting as Unusual Left Upper Quadrant Pain. Iranian Journal of Radiology, 10(3), 156-159. Web.
Venter, A., Rahota, D., Straciuc, O., & Pirte, A. (2014). CT Evaluation of Acute Appendicitis. Acta Medica Transilvanica, 19(2), 256-258.