Colegio de San Juan de Letran

Brgy. Bucal, Calamba City

In partial fulfillment of the course requirement in

RLE 106 a mini Case Study on

Ruptured
Appendicitis
Submitted by:
Abuan, Jenna Marie O.

Area of Exposure: Dr. Jose Rizal Memorial Hospital

Surgical Ward

September 26, 2015

Submitted to: Ms. Eufemia L. Cortado, RN, MN

Clinical Instructor

TABLE OF CONTENTS

PAGE NUMBER
INTRODUCTION
Background of the study
Objectives of the Study (follow SMART method)
Scope and Limitation of the Study
DEFINITION OF TERMS..................................
(all terms related to the study:eg.Disease, Preocedure,common terms related to the
problem)
Narrative discussion on the disease process
Narrative discussion on the procedure perform with illustration(diagram/picture)
ANATOMY AND PHYSIOLOGY..........................
Discuss the normal function and physiology of affected organ, and show diagram
or illustration of the organ/s affected
Discuss the possible diagnostic procedures to identify the problem (e.g.
Cyctoscopy, mammogram, biopsy etc.)
PATHOPHYSIOLOGY................
Diagram of the disease process
Identify in tabular form the Etiologic (causes) factors main cause &
predisposing factors
Signs and symptoms
Possible complications
NURSING RESPONSIBILITIES.....................
(apply the METHOD approach, intra/post operative care nursing care, health
teachings)
Discuss the type of anesthesia used and its nursing responsibilities
SIGNIFICANCE OF THE STUDY.........
To the Nursing students
To the hospital
To the school

To the patient and family/significant others

CONCLUSION
BIBLIOGRAPHY....
INTRODUCTION
A. Background of the study
Appendicitis is an inflammation of the appendix, a 3 inch-long tube of tissue
that extends from the large intestine. No one is absolutely certain what the function of
the appendix is. Human can live without it.
Appendicitis is a medical emergency that requires prompt surgery to remove the
appendix. Left untreated, an inflamed appendix will eventually burst, spilling infectious
materials into abdominal cavity. This can lead to peritonitis, a serious inflammation of
the abdominal cavitys lining (the peritoneum) that can be fatal unless it is treated
quickly with strong antibiotics.
B. Objective of the study
This study can help the nursing profession in providing information about
proper management and care for patient who has ruptured appendicitis, it can also
educate people who lacks information about the disease and also those people who are
already experience a ruptured appendicitis. Every individual is vulnerable in acquiring
the disease, so everyone should be educated the importance of having a lifestyle
measures to prevent the disease.
C. Scope and limitations of the study
This study is focused on the nursing aspect of care to those patients who
have ruptured appendicitis. The researchers focused on the parts of the reproductive
system where there is hernia, the causes and effects of the disease and the
medications to be used. In addition the research discusses about the anatomy and
photo physiology of hernia and how it is diagnosed. This is not limited for those patients
who have hernias, but also for all people who want to gain knowledge about the disease
on how to prevent it.

DEFINITION OF TERMS

HERNIA - is protrusion of an organ or the muscular wall of an organ through the cavity
that normally contains it. A hiatal hernia occurs when the stomach protrudes upwards
into the mediastinum through the esophageal opening in the diaphragm.
HERNIORRHAPHY - (Hernioplasty, Hernia repair) is a surgical procedure for correcting
hernia. A hernia is a bulging of internal organs or tissues, which protrude through an
abnormal opening in the muscle wall. Hernias can occur in the abdomen, groin, and at
the site of a previous surgery.
INGUINAL - Inguinal hernias are further divided into the more common indirect inguinal
hernia (2/3, depicted here), in which the inguinal canal is entered via a congenital
weakness at its entrance (the internal inguinal ring), and the direct inguinal hernia type
(1/3), where the hernia contents push through a weak spot in the back wall of the
inguinal canal. Inguinal hernias are the most common type of hernia in both men and
women.
FEMORAL - Femoral hernias occur just below the inguinal ligament, when abdominal
contents pass into the weak area at the posterior wall of the femoral canal. They can be
hard to distinguish from the inguinal type (especially when ascending cephalad):
however, they generally appear more rounded, and, in contrast to inguinal hernias,
there is a strong female preponderance in femoral hernias.
UMBILICAL - Umbilical hernias are especially common in infants of African descent,
and occur more in boys. They involve protrusion of intra abdominal contents through a
weakness at the site of passage of the umbilical cord through the abdominal wall. These
hernias often resolve spontaneously. Umbilical hernias in adults are largely acquired,
and are more frequent in obese or pregnant women.
HIATAL - A hiatus hernia or hiatal hernia is the protrusion (or herniation) of the upper
part of the stomach into the thorax through a tear or weakness in the diaphragm.
INDIRECT INGUINAL HERNIA - indirect inguinal hernia is an inguinal hernia that
results from the failure of embryonic closure of the internal inguinal ring after the testicle
has passed through it. Like other inguinal hernias, it protrudes through the inguinal ring.
It is the most common cause of groin hernia.
DIRECT INGUINAL HERNIA - The direct inguinal hernia, a type of inguinal hernia,
enters through a weak point in the fascia of the abdominal wall, and its sac is noted to
be medial to the inferior epigastric vessels. Direct inguinal hernias are the same in men
and women.

DISEASE PROCESS
A hernia occurs when the contents of a body cavity bulge out of the area where they are
normally contained. These contents, usually portions of intestine or abdominal fatty
tissue, are enclosed in the thin membrane that naturally lines the inside of the cavity.
Although the term hernia can be used for bulges in other areas, it most often is used to
describe hernias of the lower torso (abdominal-wall hernias).
Hernias by themselves may be asymptomatic (produce no symptoms), but nearly all
have a potential risk of having their blood supply cut off (becoming strangulated). If the
blood supply is cut off at the hernia opening in the abdominal wall, it becomes a medical
and surgical emergency. Any condition that increases the pressure of the abdominal
cavity may contribute to the formation or worsening of a hernia.
No matter what you make or build, it's the seams that are the hardest part to get right.
On a piece of clothing, a loose seam will be prone to tear; make it too tight and it will
restrict movement. On a house, that loose board will cause the roof to leak, and if there
isn't enough room for expansion, stuff will start to buckle.
As it turns out, the body has numerous seams that need to be made just right so that
they don't pull apart and let body parts slide into places they don't belong. The abdomen
is surrounded by numerous muscles to keep the stomach, small intestine, and colon
where they belong, but if one of these organs starts to slip though a weakness or a hole
in the muscles, it's called a hernia. To be fair, many other parts of the body can have
organ herniation. By definition, a hernia is a bulge or protrusion of an organ through a
muscle or other structure that normally serves to keep it contained. But when people
talk about hernias, they are usually talking about the abdomen. And while there are
many types of abdominal hernias (hiatal, umbilical, or incisional), mentioning a hernia
usually means they are talking about one in about the groin.

NARATIVE DISCUSSION ON THE PROCEDURE OF HERNIA

The most common location for hernia is the abdomen. The abdominal wall - a sheet of
tough muscle and tendon that runs down from the ribs to the legs at the groins - acts as
'nature's corset'. Its function, amongst other things, is to hold in the abdominal contents,
principally the intestines.
If a weakness should open up in that wall, and it does not really matter how or why it
happened (more on this later), then the 'CORSET EFFECT' is lost and what pushes
against it from the inside (the intestines) simply pushes through the 'window'. The
ensuing bulge, which is often quite visible against the skin, is the hernia.
These 'windows of weakness' commonly occur where there are natural weaknesses in
our abdominal wall - such as where the 'plumbing' goes through it. Examples of these
are the canals (inguinal and femoral) which allow passage of vessels down to the
scrotum and the legs, respectively. The umbilical area (navel) is another area of natural
weakness frequently prone to hernia. Another area of potential weakness can be the
site(s) of any previous abdominal surgery.

ANATOMY AND PHYSIOLOGY

ILLUSTRATION OF THE ORGANS AFFECTED

The Inguinal Canal

* The anatomic space beneath the external oblique aponeurosis, between the
internal and external inguinal rings.
* In men, it contains the cremaster muscle and cord structures
(vas deferens, testicular vessels, and associated connective tissues).
* In women, it contains the cremaster muscle, round ligament of the uterus,
and some connective tissues.
Indirect Hernia
* Consists of sac of peritoneum coming through internal ring, antero-medial
to the spermatic cord (or round ligament) which omentum or bowel can enter.
* Usually congenital, but may be acquired.
* Virtually all hernias in patients under age 25 are indirect.
* Male/female ratio is about 9:1.
* Internal ring may be normal or dilated.

* Higher risk of incarceration/strangulation if large and extends into scrotum.

* [Technically, indirect hernias emerge lateral to the epigastric vessels. In
practical terms, this is an accurate but pretty useless definition.
Direct Hernia
* Bulging as a result of weakness or attenuation of the posterior floor of the
inguinal canal, anywhere from the internal ring to the pubic bone.
* [Technically, medial to the epigastric vessels.]
* The hernia consists primarily of retroperitoneal fat; a peritoneal sac
containing bowel is only infrequently present.
* Usually at low (but not zero) risk for incarceration or strangulation.
* Rarely occurs in women.
Sliding Hernia
* Hernia consisting of retroperitoneal fat and/or large bowel (cecum on the
right, sigmoid on the left) which 'slide' through the internal ring
(rather than into and out of an existing peritoneal sac)
* Occurs lateral to the cord, rather than antero-medial.
Femoral Hernia
* Hernia through the femoral space in the inguinal ligament, just medial to
the femoral vein. Emerges benealth the inguinal ligament, not at the
external ring.
* Virtually always in (thin) women. Rare in males.
* Almost always incarcerated, usually with retroperitoneal or omental fat,
sometimes bowel.
* May be mistaken for an inguinal lymph node and vice versa.
Recurrent Hernia
* Any inguinal canal hernia which occurs after prior inguinal hernia repair.
* Most often direct, but may also be indirect or sliding.
Lipoma of the Cord
* Frequently present in association with both indirect and direct hernias,
i.e., in lots of people, whether they have hernias or not.
* Lipomas originate postero-lateral to the cord, and are located inside the
cremaster muscle.
* Large lipomas of the cord may be hard to differentiate from true hernias.
Normally, however, they do not change in shape or configuration with coughing
or straining.
Hydrocele
* Fluid collection in scrotum, in peritoneal sac that may or may not communicate

with peritoneal cavity via processus vaginalis.

* Differentiated from true hernia by finding of normal (i.e., no bulge in)
inguinal canal.
Rare but interesting hernias:
* Richter: incarceration of a portion of the wall of the small bowel.
* Littre: hernia containing a Meckel's diverticulum.
* Unnamed: hernias containing appendix or ovary.

II. Nyhus Classification of Inguinal Hernias

I. Indirect sac, normal internal ring.
II. Indirect sac, dilated internal ring
IIIA. Direct hernia
IIIB. Indirect hernia with weak inguinal floor; sliding hernia.
IIIC. Femoral hernia.
IV. Recurrent hernia (A=direct; B=indirect; C=femoral; D=other)
IV. Etiology of Inguinal Hernia
Congenital
* All hernias in infants and children are indirect and occur as a result of
the failure of the processus vaginalis to undergo apoptosis.
Acqired
* In patients over the age of 25 the most common cause of inguinal hernia is
attenuation or degeneration and fatty transformation of the aponeurotic
tissues of the inguinal floor, leading either to direct weakness and
bulging of the inguinal floor, dilation of the internal ring, or both.
This is not work or activity related.
Relationship to "lifting" at work or other activity
* Lifting and straining make patients aware that they have a bulge.
Lifting and straining do not cause the attenuation or degeneration of the
inguinal floor, which is the underlying cause of the hernia.

DIAGNOSTIC PROCEDURES
* The sine qua non of hernia is a bulge.

* Almost all patients with inguinal hernia give a history of a bulge.

* If there is no bulge, then, in general, there is no hernia to be repaired.
Pain is sometimes associated with hernia.
* Most patients with inguinal hernia describe a vague feeling of pressure or
discomfort, usually late in the day, associated with standing or working.
It is associated with the feeling of a bulge and goes away when the patient
lies down and the hernia reduces.
* Patients with an indirect hernia may complain of a 'burning' discomfort.
This is the result of stretching of the peritoneal sac. Once the sac has
stretched fully, the pain dissipates.
* Chronic incarceration of a hernia, particularly if it consists of omentum,
frequently does not cause any discomfort.
* Sharp, severe, or visceral pain which is present when the hernia is prominent
and goes away when the hernia is reduced suggests incarcerating bowel and
urgent need for repair.
* Sharp pain in the groin that starts as the result of lifting or straining
and is felt during activities such as walking, bending, lifting is MOST OFTEN
the result of myofascial strain. If there is no bulge, there is no hernia.
* Risks of incarceration/strangulation ("rupture") are generally exaggerated
in the public mind, especially in patients with small hernias.
* Occasionally a patient will come in who has groin pain from an incipient
hernia (burning pain from stretching peritoneum) which has not yet become
palpable. There is no contraindication to observing such a patient and having
him/her return in 3 months or 6 months for re-examination, or when a bulge
develops.

DIAGRAM
1.The inguinal ligament spans between the anterior superior iliac spine and the pubic
tubercle. The iliopsoas muscle fills the lateral space between inguinal ligament and

iliopubic ramus, and the iliac vessels pass beneath inguinal ligament midway between
its bony attachments. The internal spermatic vessels, genital branch of the
genitofemoral nerve and vas pass through the abdominal wall via the deep inguinal ring
just cephalad to the vessels and lateral to their inferior epigastric branches. Pectineal
(Cooper's) ligament is the thickened periosteum on the pectineal ridge of the superior
pubic ramus passing behind the iliac vessels. The medial umbilical ligament is the
remnant of the umbilical artery crossing deep to the inguinal floor just lateral to the
bladder.

2.The parietal peritoneum covers the deep side of theinguinal floor and reflects onto the
iliac vessels and iliopsoas muscleposteriorly. The inferior epigastric vessels, vas, iliac
and internal spermaticvessels and medial umbilical ligament lie just outside the
peritoneum and can usually be discerned beneath its surface when viewed from inside
the abdomen.

3.The transversus abdominus muscle is the first of the three flank muscles of the
abdominal wall. transversalis fascia is its deep fascial covering. Its medial and inferior
borders become aponeurotic. The medial aponeurosis contributes to the deep layer of
anterior rectus sheath. The inferior aponeurotic edge is the transversus aponeurotic
arch which is fused to the underlying transversalis fascia. The iliopubic tract is the
thickened strip of transversalis fascia attached to inguinal ligament. The transversalis

fascia between the arch and iliopubic tract covers the "direct space" portion of the
inguinal floor.

4.The internal oblique muscle is the next abdominal wall layer and its medial
aponeurotic portion fuses with the underlying transversus aponeurosis to complete the
deep layer of anterior rectus sheath. Only a small number of individuals have complete
fusion at the lateral edge of the rectus muscle forming a "conjoined tendon". The genital
branch of the genitofemoral nerve and the external spermatic vessels from the inferior
epigastrics penetrate transversalis fascia near the deep ring and lie lateral to the
spermatic cord between internal spermatic fascia and cremaster muscle.

5.The hypogastric branch of the iliohypogastric nerve lies on the surface of the internal
oblique muscle in the inguinal region and the ilioinguinal nerve lies on the surface of the
cremaster muscle in the inguinal canal.

6.The aponeurotic portion of the external oblique muscle forms the anterior wall of the
inguinal canal. Its lower fibers constitute the inguinal ligament. It splits into medial and
lateral crura around the spermatic cord at the pubic tubercle. The medial continuation of
the aponeurosis fuses with the deep layer of anterior rectus sheath, The fusion takes
place over the middle of the muscle, not at its edge, thus leaving a fascial cleft over the
lateral portion of rectus muscle.

7.A hernia is a defect in a boundary layer the transversalis fascia in the case of the
inguinal region through which contents can protrude. The protrusions stretch the
surrounding abdominal wall layers. Patency and dilatation of the embryonic processus
vaginalis results in an indirect hernia which opens through the deep ring lateral to the
inferior epigastric vessels. A direct hernia is a weakness of the inguinal floor between
epigastric vessels, falx and inguinal ligament (Hesselbach's triangle). A femoral hernia is
a dilatation of the femoral canal medial to the femoral vessels within the femoral
sheath.

NURSING RESPONSIBILITIES
In a patient with hiatal hernias, nurses prepare him for diagnostic tests, as needed. After
endoscopy, signs of perforation (falling blood pressure, rapid pulse rate, shock, sudden
pain) are being observed. After surgery, fluid intake and output are carefully recorded,
including nasogastric or wound drainage.

In a patient with inguinal hernias, truss is applied only after hernia has been reduced. It
is applied before patient gets out of bed. Signs of incarceration and strangulation are
immediately reported. If severe intestinal obstruction arises, the doctor is informed
immediately.
A nasogastric tube is inserted promptly to empty stomach and relieve pressure on
hernia sac. Before surgery, vital signs are monitored. Administration of I.V. fluids and
analgesics for pain are performed, as ordered. Fever is controlled with acetaminophen
or tepid sponge baths, as ordered. The patient is placed in the Trendelenburg position
to reduce pressure on the hernia site.
A special reassurance and support is given to a child scheduled for hernia repair. After
surgery, the patient must have voided within 12 hours. The incision and dressing are
checked at least three times a day. Normal bowel sounds are auscultated.
To reduce scrotal swelling, scrotum is supported with rolled towel; and ice bag is
applied. Fluid intake is encouraged to maintain hydration and prevent constipation.
Hernias occur through a combination of weak abdominal muscles and increased
pressure within the abdominal cavity. They can result from overweight or coughing. As a
result, small parts of the bowel herniated (rupture) outward through the inguinal or
femoral canals in the general area of the groin.
Prevention
Exercise is critical to maintain the strength of the abdominal muscles. Walking, running,
bicycling and swimming are at least as important as direct exercise to strengthen the
abdomen. Weight control helps improve muscle tone and decreases stress. Stopping to
smoke is extremely important because the chronic smoker's cough more than doubles
the risk of these conditions.

Preoperative Care

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Most hernia repairs are same day surgeries, which means that patients can go home on
the same day that they undergo the operation.If a patient needs to remain in the
hospital, they are usually discharged the following day.
The most common preoperative tests are blood and urine tests, but a chest x-ray and
EKG may also be required, depending on the patient's health history. These tests are
normally done a few days prior to surgery.
Medications that "thin" the blood, including aspirin, are usually discontinued before a
scheduled surgery. Some drugs, such as the prescription medication Coumadin
(warfarin), usually are discontinued at least 3 or 4 days prior to a surgical procedure.
This is done to avoid abnormal or excessive bleeding during the surgery.
On the day of surgery, other prescription drug regimens may also be interrupted. The
anesthesiologist may instruct the patient to take regular medications with a sip of water.
The proper timing of discontinuing medications needs to be discussed with the
physician before the operation.
Dietary Restrictions
If general anesthesia is going to be used, nothing is permitted to be eaten from midnight
on the evening before surgery until the procedure is completed. This includes food,
water, chewing gum, and candy. This necessary precaution is taken to decrease the
possibility of vomiting during and after surgery.
For local and spinal anesthetics, dietary restrictions may vary. Some doctors require
their patients to follow the guidelines for general anesthesia, regardless of which
anesthetic they are receiving. One reason for this is that it may be necessary to switch
to a general anesthetic during surgery. Dietary preparations should be discussed with
the physician in advance.

Consent
Check-in is usually the same day as the surgery, and at this time the patient must sign
an informed consent form. By signing this legal document, the patient acknowledges

that they understand the procedure, that the doctor has discussed the operation and its
potential risks, and that they know what medications they will be receiving.
The anesthesiologist (the doctor who administers the anesthesia) performs a brief
physical examination and takes a patient history. It is important the anesthesiologist is
aware of all medications that the patient is taking, any allergies, and if there has been a
prior adverse reaction to anesthesia. This information helps the anesthesiologist select
the most suitable anesthetic agents and dosages and avoid possible complications.
Hospitals usually have an area reserved for same day or ambulatory surgical patients.
Instead of checking into a room, all same day patients go to this unit prior to and after
their procedure.
In preparation for surgery, patients have an intravenous line put in to receive both fluids
and medication during and after surgery. They also receive a sedative, by injection or
through the intravenous line, to help them relax.
Same day surgical patients may go directly from this area to the operating room, or they
may be taken to the preoperative or holding area for a short time. Sometimes the
intravenous is started here, depending on hospital protocol. Anesthesia, regardless of
type, is administered in the operating room.

SIGNIFICANCE OF THE STUDY

To the Nursing Students, this study will serve as added information for them
about the disease; help them enhance their vocabulary and knowledge by the important
contents of this work like the nursing responsibilities that they can use in their future
duties.
To the Hospital, it can be useful for them because the students that are having
their duty there have enough knowledge that will not affect their reputation and quality.
To the School, this mini case study can contribute on the students learning and
then broaden up their knowledge. It can also contribute for the schools good quality of
study.
To the Patient and Family/Significant Others, this study would be most significant
for them not only because they will be more aware of danger signs and symptoms about
their disease but also they will be more secured because we are now educated enough
to handle them and take good care of them as their student nurse.

CONCLUSION
As we go on to our study about Hernia which is the protrusion of an organ or the
muscular wall of an organ through the cavity that normally contains it. The most

common hernias are the so-called inguinal hernias. Inguinal hernia is a protrusion of
abdominal cavity contents through the inguinal canal. Although there are many types of
hernias, the following are the most common: Abdominal wall hernia, Indirect inguinal
hernia, Direct inguinal hernia, Femoral hernia, Umbilical hernia, Hiatal hernia, Incisional
hernia
Symptoms of hernias vary, depending on the cause and the structures involved.
Most begin as small, hardly noticeable breakthroughs. At first, they may be soft lumps
under the skin, a little larger than a marble; there usually is no pain. Gradually, the
pressure of the internal contents against the weak wall increases, and the size of the
lump increases.