SOLUTION

Critical Appraisal of A Case Study: Clinical Scenario 1

            The purpose of this paper is to critically analyze clinical scenario 1. In this scenario William (Bill) Giovanni has been diagnosed with acute appendicitis and is booked for emergency surgical removal of his appendix. The scope of this discussion include pathophysiology of acute appendicitis, William’s growth and development milestones, informed consent and the roles of a nurse with respect to his case. Use of opioid medications to manage pain in acute appendicitis may be challenged by previous opioid addiction or abuse.

Pathophysiology

            Appendicitis is inflammation of the vermiform appendix. The condition usually presents in an acute manner, with the onset of symptoms occurring within 24 hour; however, it can also occur as a chronic condition (Jones et al., 2021). Snyder et al. (2018) describe appendicitis as the most common etiology of acute abdominal pain in children and adults with a lifetime risk of 6.7% in females and 8.6% in males. The appendix is a hollow organ, which is situated at the tip of the cecum, often in the right lower abdomen. The common location of the appendix is described as retrocecal. Previous abdominal surgeries, pregnancy and developmental abnormalities such as midgut malrotation can significantly dislocate the appendix. Classically, acute appendicitis initially manifests with periumbilical or generalized pain, which later localizes to the right lower quadrant (Jones et al., 2021).  Periumbilical pain which radiates to the right lower quadrant, right lower quadrant pain, and abdominal rigidity are considered as some of the best signs and symptoms for ruling in acute appendicitis (Snyder et al., 2018). Acute appendicitis is the most common cause of abdominal surgical emergencies globally (Moris et al., 2021). Consistently, William presented with mild bilateral abdominal pain for one day, which later localized to the right lower abdominal area. The pain is associated with nausea, rebound tenderness, diaphoresis, and hot flashes. In addition, as he waits for surgical removal of the appendix, the patient is lying on the bed with bent knees, grimacing in discomfort, and guarding his abdomen.

            The major cause of appendicitis is often due to obstruction of the appendiceal lumen. Obstruction can be caused by mechanical etiologies such as presence of an appendicolith. Other important causes of obstruction the appendiceal lumen include appendceal tumors such as appendiceal adenocarcinoma, carcinoid tumors, hypertrophied lymphatic tissues and intestinal parasites (Jones et al., 2021). The definitive cause of acute appendicitis remains unknown. Obstruction of the appendiceal lumen results in buildup of bacteria in the appendix leading to acute inflammation with abscess formation and perforation. The appendix harbors a combination of anaerobic and aerobic bacteria, including Bacteroides spp., and Escherichia coli. Bacterial overgrowth following an obstruction is predominated by common organisms such as Peptostreptococcus spp., E. coli, Pseudomonas spp., and Bacteroides spp. Once significant necrosis and inflammation has occurred, the appendix then stands a great risk of perforating, resulting in a localized abscess and sometimes frank peritonitis (Jones et al., 2021).

            Obstruction is the key in pathophysiology of acute appendicitis. Regardless of the cause of obstruction, it will result in lymphoid hyperplasia, which later lead to localized ischemia, frank perforation resulting in peritonitis, or a contain abscess (Jones et al., 2021). Considering the nature of the pain that William is experiencing, he may have experienced a rupture appendix resulting in acute peritonitis. If the appendix is not yet ruptured, then the obstructed appendix may have experienced increased intraluminal pressure as well as intramural pressure leading to lymphatic stasis and small vessel occlusion. On another hand, an obstructed appendix is associated with buildup that distends the appendix furthermore, thus, making the appendix ischemic and necrotic (Jones et al., 2021).  Symptoms of acute appendicitis include nausea/vomiting, anorexia, fever in 40% of cases, generalized malaise, diarrhea, and urinary frequency or urgency (Jones et al., 2021). Consistently, William has complained of nausea, rebound tenderness, diaphoresis, and hot flashes.  Elevated white blood cell count is an indication of an infection.

            On physical exam, signs of peritoneal inflammation as an indication of a ruptured appendix include Rovsing’s sign, which is the eliciting of right lower quadrant by palpation of the left lower quadrant. In addition, there is guarding as the right lower quadrant with rebound tenderness over the McBurney’s points, which are both positive in this case. There is also Dunphy’s sign, which is increased abdominal pain with coughing; this sign has not been tested in this case. Other important signs include having a positive psoas signs and obturator sign, which are rare signs of acute appendicitis (Jones et al., 2021). Rovsing’s sing is considered as the most reliable sign for ruling in acute appendicitis specifically in children (Snyder et al., 2018). Given that is just 16 years and 11 months in terms of age, there is high likelihood of a perforated appendix or a ruptured appendix, thus the need for urgent emergency surgery. Di Saverio et al. (2020) state that the rate of perforation tend to vary from 16-40%, with a higher frequency observed among younger age group (40% to 57%) and in older patients who age aged over 50 years (55% to 70%). Apart from these signs, abdominal ultrasound is positive for appendicitis.

Growth and Development Milestones

            William is at the adolescent stage of growth and development. At the age of 16 years and 11 months it is expected that he is experiencing sexual maturation with enlargement of the penis and testicular enlargement. In addition, he is expected to have grown hairs on the face, under the arms, acne, and depending of the voice by the age of 15 years. At this particular moment he should be able to think abstractly, think in the long-term, set goals, compare one-self to peers, and may be concerned with social issues, politics, and philosophy (Johns Hopkins, 2022). William may be facing social challenges such as trying to be independent from patent/elder brother, peer influences and the attempt  to be accepted by his peers, romantic and sexual relationship issues, he may be in love, and may have  long-term commitment in a relationship (Johns Hopkins, 2022).  He should be interviewed about his sexual life and be advised on safe sex practices. In addition, he should be queried about alcohol use and use of illicit drugs. Besides, he should be educated about the risks of cigarette smoking and advised on smoking cessation.