La Patients

Abstract

The purpose of this paper is to perform a critical analysis into the research regarding the complications of inflamed appendices and procedures that seek to reduce mortality rates following appendectomy. To this end, the focus of this analysis is on comparing the efficacy of surgical interventions for appendectomy and the risk factors for complications following appendectomy in order to make recommendations for the appropriate approach to perform surgery. Two main techniques exist for appendectomy open appendectomy (OA) and laparoscopic appendectomy (LA). The discussion shows significant benefits of using LA including significantly less wound infections, requiring less preoperative and postoperative medications for pain management, having less hospital stays, and returning to normal bowel functioning more quickly. LA has been associated with shorter hospitalization, reduced postoperative complications (especially wound infections) and lessened costs. Thus, LA is a better option than OA.

Post-Operative Complications of Appendectomy

Although the prevalence of appendicitis has declined significantly, it still remains one of the most common emergencies in surgery. Appendicitis with no complications is treated using appendectomy. In the United States, the estimated 270000 appendectomy procedures are performed annually (Switzer, Gill, & Karmali, 2012). During the last two centuries, numerous open appendectomies have been performed. As a result, appendicitis-related morbidity and mortality have decreased gradually, particularly in the last few decades due to the development of antibiotics, advancements in surgical and anesthesiologic methods, and early diagnosis (Switzer, Gill, & Karmali, 2012). Surgical interventions for appendicitis have evolved from open procedures towards the procedures that are minimally invasive. The purpose of this paper is to perform a critical analysis into the research regarding the complications of inflamed appendices and procedures that seek to reduce mortality rates following appendectomy.

Problem

 

There exist various types of surgeries that can be used for appendix removal. Open appendectomy (OA) is considered to be the standard method, although there are other less invasive methods. The advent of the laparoscopic appendectomy (LA), which is marginally invasive, resulted in a gradual shift from OA. Presently, LA is the standard surgical practice for removing an inflamed appendix. This surgical technique is less invasive when compared to the OA, which implies that it is performed without large incision (Switzer et al., 2012).Whereas LA comprises the bulk of appendectomy procedures, the considerable amount of OA procedures still performed is somewhat surprising. The continued usage of OA is still an issue of debate. Regardless of the surgical technique used to perform appendectomy, there is the risk of complications such as bleeding, infection of the wound, blocked bowels, damage to the surrounding organs, swelling redness, and infection of the belly in the event of the appendix bursting when the surgery is being performed. There is an ongoing debate regarding the most effective surgical intervention for appendicitis. Therefore, there is the need for reviewing the literature in order to make recommendations regarding the most effective surgical procedure for performing appendectomy.

Review of the Literature

Author

Article

Literature Type

& Research Tools

Research Design & Sample Size

Key Findings

 

(Markar, et al., 2011)

Laparoscopic versus open appendectomy among obese patients

Meta-analysis

A systematic search of literature was conducted on databases. The final sample comprised of 2309 appendectomies 1122 LA and 1187 OA

The authors found that LA might be beneficial to obese patients with appendicitis with respect to shorter hospitalization durations and lower incidence of complications after the surgery; however, no significant differences between OA and LA were reported in terms of the length of operation and wound or intra-abdominal complications

(Mohamed & Mahran, 2013)

Laparoscopic appendectomy in complicated appendicitis: Is it safe?

Empirical evidence

The authors used a randomized controlled trial with 241 patients (132 LA patients and 82 OA patients)

LA was performed for longer durations albeit with less analgesics use, shorter hospitalization periods, shorter abdominal drainage duration, and lower wound infection incidence. The author concluded that using LA in complicated appendicitis is safe and feasible and results in lower complications incidence when compared to OA.

(Romano, Parikh, Byers, & Namias, 2014)

Outcomes and cost analysis of laparoscopic versus open appendectomy for treatment of acute appendicitis: 4-years of experience in a district hospital

Empirical evidence

Retrospective analysis with 230 patients (139 LA patients and 91 OA patients)

No differences were observed between LA and OA in terms of operative time and intra-abdominal abscess. LA had a significantly lower incidence of major and minor complications. LA had shorter hospital stay and a higher cost than OA.

(Southgate, et al., 2012)

Laparoscopic vs open appendectomy among older patients

Meta-analysis

The authors searched the databases (Cochrane, Web of Science, EMBASE, and MEDLINE) to locate comparative studies focusing on older patients diagnosed with appendicitis. The sample comprised of 15852 appendectomies 4398 LA and 11454 OA.

The LA was linked to significant reductions in hospital stay lengths, postoperative mortality, and postoperative complications. No significant differences were documented with respect to intra-abdominal collection, wound infection, and operative time. Thus, LA is beneficial to geriatric patients.

(Thomson, et al., 2015)

Laparoscopic vs open surgery for complicated appendicitis: a randomized controlled trial (RCT) to prove safety

Empirical study

Prospective RCT with 115 patients

No significant differences were reported between OA and LA patients in terms of readmissions rate, hospital stay length, reoperations number, wound sepsis rates, and intra-operative durations. The author concluded that LA is a safe procedure in complicated cases of appendicitis

         

Empirical studies have revealed significant advantages of using the LA technique to remove inflamed appendices. Patients whose appendices have been removed using this technique have significantly less wound infections, require less preoperative and postoperative medications for pain management, have less hospital stays, return to normal bowel functioning more quickly, and have enhanced cosmetic outcome due to the avoidance of a large laparotomy scar. Mohamed and Mahran (2013) showed that LA was performed for longer durations albeit with less analgesics use and had shorter hospitalization periods that resulted in shorter abdominal drainage duration and lower wound infection incidence. The authors concluded that using LA in complicated appendicitis is safe and feasible and results in lower complications incidence when compared to OA.

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The efficacy of LA and OA has also been compared among special patients such as obese people and the pediatric population. Meta-analysis performed by Markar et al. (2011) to compare the OA and LA approaches revealed that LA might be beneficial to obese patients with appendicitis with respect to shorter hospitalization durations and lower incidence of complications after the surgery; however, no significant differences between OA and LA were reported in terms of the length of operation and wound or intra-abdominal complications. Among older patients, the LA was linked to significant reductions in hospital stay lengths, postoperative mortality, and postoperative complications. No significant differences were documented with respect to intra-abdominal collection, wound infection, and operative time (Southgate et al., 2012). Thus, LA is beneficial to geriatric patients.

Still, some researchers have not found differences between OA and LA. For instance, Thomson et al. (2015) stated that no significant differences were reported between OA and LA patients in terms of readmissions rate, hospital stay length, reoperations number, wound sepsis rates, and intraoperative durations. The author concluded that LA is a safe procedure in complicated appendicitis. Romano, Parikh, Byers, and Namias (2014) also reported no differences observed between LA and OA in terms of operative time and intra-abdominal abscess. LA had a significantly lower incidence of major and minor complications. LA had shorter hospital stay and a higher cost than OA. Overall, although the evidence on the efficacy of OA and LA is not conclusive, it is clear that the existing evidence tends to favor the use of LA.

Various Contributions and Roles the Nurse Plays in Healthcare

Nurses play crucial roles in ensuring the coordination and delivery of high quality care. Nurses are involved in care processes that seek to enhance the health outcomes for patients as well as facilitate effecting interdisciplinary collaboration while steer effective and efficient utilization of the healthcare resources at the same time. As Kemppainen, Tossavainen, and Turunen (2013) explain, accountability a component of coordination of care has been clearly identified as an important part of the responsibilities of nurses and a practice standard. Empirical evidence shows the contributions of nurses in terms of improving and delivering effective coordination of care. Some of the activities performed by nurses relating to their contributions to effective coordination of care include care planning, management of care, care transitions, establishing partnerships with and linkages to community resources, and monitoring and follow-up (Lowe, Plummer, OBrien, & Boyd, 2012). As a result of effective care coordination, the nurses also make significant contributions to healthcare by providing safe, effective, patient-centered, timely, efficient, and equitable care. This happens because nurses are in a better position to lessen medical errors and adverse risks, ensure that patients are provided with the proper treatment, and provide them with the needed safeguards from likely problems such as falls since patients spend the bulk of their time with nurses.

Besides the aforesaid contributions of nurses to healthcare, they play pivotal roles in healthcare system including being advocates for the patient, caregiving, and patient education (Kemppainen et al, 2013). As a patient advocate, the nurse must protect and uphold patients rights and channel the concerns raised by patients to the relevant authorities (e.g. hospital administration). As a patient educator, the nurse helps patients to acquire knowledge regarding their present health status and ways of staying healthy. The nurses role as an educator is aligned with the health promotion and preventive care objectives of the healthcare system (Lowe et al., 2012). As a caregiver, the nurse ensures that the needs and the requirements of the patient are satisfied including their cultural, spiritual, mental, and physical needs.

Compare and Contrast Select Healthcare Policies

An important theme in healthcare policies of countries is the financing and providing care, which is characterized by the intimate involvement of governments in the healthcare system despite playing differing roles across various countries. In most countries, governments play the role of regulators (Frenk & Moon, 2013). The authorities can also fund and/or offer care. For instance, in the UK, the government finances and provides care. The Canadian government offers universal care to all citizens that is financed by government-run insurance and offered by private entities. In the United States, the healthcare insurance coverage is limited to specific populations including the poor, those in armed forces, and the elderly (Frenk & Moon, 2013). Moreover, in most countries, the access to health is considered a human right.

Ethical Issues and Decisions Faced in Healthcare

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Nurses encounter numerous ethical dilemmas when dealing with patients, who require them to uphold ethical principles in harsh situations. One of the likely ethical issues in healthcare relates to conflicting interests. There is no doubt that nurses and doctors are the key targets for the manufacturers of medical and pharmaceutical equipment and devices (Pavlish, Brown?Saltzman, Hersh, Shirk, & Nudelman, 2011). This is a potential explanation as to why healthcare institutions are prohibiting free-meal presentations, notepads, pens and other items containing the logos of these manufacturers. Pharmaceutical companies must uphold ethical conduct when interacting with healthcare practitioners. Clinicians are often encouraged to refuse taking compensations and offers that are likely to influence their decisions. At the same time, the board of directors of hospitals is not allowed to have financial interests in the healthcare system or the institution such as engaging in the sale of their services (Frenk & Moon, 2013). The second ethical issue in the healthcare system related to balancing the need for making profit and offering charity care. There is no doubt that healthcare institutions operate with scarce resources, be it nurses, physicians, or overall funding. For healthcare institutions to be sustainable, they have to make profits. However, an ethical challenge emerges in the manner in which the scarce resources are allocated. As Pavlish et al. (2011) point out, hospitals are in ethical dilemma as to whether they should allocate their scarce resources in areas that might drive up the margins while serving small patient population or make investments in offering basic care to serve larger population. Another ethical issue in healthcare sector is the management of geriatric and pediatric patients lacking the decision-making capacity. In situations whereby the patient is not in a position to provide an informed consent, his/her legally authorized representative must ensure that the decision is based on the best interest of the patient (Frenk & Moon, 2013). Another ethical issue is the moral dilemma associated with continually providing care while the expected benefit is minimal. An example is maintaining patients on life support, while the resources could be allocated to other patients who have better chances of their health improving. Other areas in healthcare that present ethical dilemmas include the use of aggressive marketing techniques by providers, engaging in unwanted services to make profit such as unnecessary referrals, and providing non-discriminative care irrespective of the providers personal values and beliefs.

Various Global Healthcare Delivery Systems

Across the globe, the healthcare systems face a similar set of challenges which relate to the need for providing higher quality care at lower costs. Whereas healthcare appears to be mainly organized within national borders, the market trends in the sector are global including a change in the demographic profiles of patients, the population that is aging, the adoption of novel technologies, and an increase in demands from consumers. All these factors are resulting in vast fiscal pressures for healthcare systems across the globe (Frenk & Moon, 2013). The change in patient demographics, especially among aging population, has significantly changed the nature of healthcare services demanded and has increased the prevalence of costs to treat chronic diseases. These changes in the nature of healthcare service affect the type of care required; as a result, healthcare delivery systems across the globe are shifting from the provision of acute care towards a continuum of care characterized by providing a full-range of care services (Frenk & Moon, 2013). This advances the demand for coordination among the healthcare providers and the presence of integrated healthcare delivery system.

Program Level Student Learning Outcomes

The selected SLO used in this research is to perform a rigorous critique of evidence derived from scholarly articles to generate meaningful evidence for nursing practice. To this end, the review of evidence revealed that the LA is better option for appendectomy when compared to OA because the former results in less wound infections, less postoperative pain, less hospital days, and quicker resumption of work.

Conclusion

Over the last century, surgical interventions for treating appendectomy have evolved considerably. The most common approaches are OA and LA. The literature reviewed tends to favor the use of LA for appendectomy since it results in fewer incidents of complications and wound infections, reduced number of hospital days, and a speedier resumption of work after surgery when compared to OA. The nurses are crucial in ensuring the delivery and coordination of quality care through educating patients, managing care, and acting as caregivers. Furthermore, a number of ethical issues exist in healthcare; they include balancing the need for making profit and offering charity care, allocating scarce resources, managing geriatric and pediatric patients that lack the decision-making capacity, and aggressive marketing techniques by providers.

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