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ategory 80:08
Tetanus Toxoid
For Booster Use Only
(Not recommended for primary immunization)
DESCRIPTION
Tetanus Toxoid, for intramuscular or subcutaneous use, is a sterile solution of toxoid in isotonic sodium
chloride solution. The
vaccine is clear or slightly turbid in appearance.
Clostridium tetani culture is grown in a peptone-based medium and detoxified with formaldehyde. The
detoxified material is
then purified by serial ammonium sulfate fractionation, followed by sterile filtration. The toxoid is then
diluted with
physiological saline solution (0.85%). Each dose contains the preservative thimerosal [(mercury
derivative), 25 g mercury/dose].
This product does not contain an aluminum-containing adjuvant.
Each 0.5 mL dose is formulated to contain 4 Lf (flocculation units) of tetanus toxoid and passes the
guinea pig potency test. The
residual formaldehyde content, by assay, is less than 0.02%.
CLINICAL PHARMACOLOGY
Tetanus manifests systemic toxicity primarily by neuromuscular dysfunction caused by a potent exotoxin
elaborated by
Clostridium tetani.
Following routine use of tetanus toxoid in the United States (US), the occurrence of tetanus decreased
dramatically from 560
reported cases in 1974 to an average of 50-100 cases reported annually from the mid 1970s through the
late 1990s. The
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case-fatality rate has been relatively constant at approximately 30%. During the years 1982-1998, 52%
of reported cases were
among persons 60 years of age or older. In the mid to late 1990s, the age distribution of reported cases
shifted to a younger age
group, in part due to an increased number of cases among injection drug users in California. From 1995-
1997, persons 20 to
59 years of age accounted for 60% of all cases, with persons 60 years of age or older accounting for only
35%. In the US, tetanus
occurs almost exclusively among unvaccinated or inadequately vaccinated persons.
1
In 4% of tetanus cases reported during 1987 and 1988, no wound or other condition was implicated.
Non-acute skin lesions,
such as ulcers, or medical conditions such as abscesses, were reported in association with 14% of cases.
2
Neonatal tetanus occurs among infants born under unhygienic conditions to inadequately vaccinated
mothers. Vaccinated
mothers confer protection to their infants through transplacental transfer of maternal antibody. From
1972 through 1984, 29 cases
of neonatal tetanus were reported in the US.
2
Since 1984, only three cases of neonatal tetanus have been reported in all infants of
unvaccinated or inadequately vaccinated mothers.
3
Spores of C tetani are ubiquitous. Serologic tests indicate that naturally acquired immunity to tetanus
toxin does not occur in the
US.
2
Thus, universal primary vaccination, with subsequent maintenance of adequate antitoxin levels by
means of appropriately
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timed boosters, is necessary to protect all age-groups. Tetanus toxoid is a highly effective antigen, and a
completed primary
series generally induces protective levels of serum antitoxin that persists for 10 or more years.
2
In a trial of 26 adults given a
booster dose of Tetanus Toxoid, 81% of the subjects demonstrated a 2-fold or greater rise in serum
antitoxin antibody
levels.
4
There are no studies of this product used as a primary series.
INDICATIONS AND USAGE
Tetanus Toxoid is indicated for booster injection only for persons 7 years of age or older against tetanus.
This vaccine is NOT
indicated for primary immunization.
Primary immunization schedule for children under 7 years of age (prior to seventh birthday) should
consist of five doses of a
vaccine containing tetanus toxoid. The initial three doses are given as Diphtheria and Tetanus Toxoids
and Acellular Pertussis
Vaccine Adsorbed (DTaP) vaccine, administered intramuscularly at intervals of 4 to 8 weeks. A fourth
dose of DTaP is
recommended at 15 to 20 months of age. The interval between the third and fourth dose should be at
least 6 months. A fifth
dose of DTaP is given before school entry (kindergarten or elementary school) at 4 to 6 years of age,
unless the fourth dose was
given after the fourth birthday.
5 , 6
In instances where the pertussis vaccine component is contraindicated, Diphtheria and
Tetanus Toxoids Adsorbed (For Pediatric Use) (DT) should be used for the remaining doses. For persons
7 years of age and older,
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Tetanus and Diphtheria Toxoids Adsorbed For Adult Use (Td) is preferred to tetanus toxoid alone.
2 , 5
Tetanus Toxoid is interchangeable with Tetanus Toxoid Adsorbed (contains aluminum adjuvant) as a
booster, and would only be
preferred if aluminum was to be avoided. Although the rate of seroconversion is essentially equivalent
with either form,
adsorbed toxoids induce more persistent antitoxin titers.
2
Tetanus Toxoid would be preferred over diphtheria-containing
vaccines if there was a contraindication to the diphtheria component.
For the prevention of neonatal tetanus in unvaccinated pregnant women, see PREGNANCY CATEGORY C
section.
2
This vaccine is NOT to be used for the treatment of tetanus infection.
As with any vaccine, vaccination with Tetanus Toxoid may not protect 100% of individuals.
Page 2 of X
If pa s s i ve immuni z at ion i s requi red, Te t anus Immune Globul in ( T IG) (Human) should be
us ed ( s e e DOSAGE AND
ADMINISTRATION section).
CONTRAINDICATIONS
HYPERS ENS I T IVI T Y TO ANY COMPONENT OF THE VA C C INE , INC LUDING THIMEROSAL , A
MER CURY DERIVAT IVE , I S A
CONTRAINDICATION FOR FURTHER USE OF THIS VACCINE.
It is a contraindication to use this or any other related vaccine after a serious adverse event temporally
associated with a
previous dose including an anaphylactic reaction.
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A history of systemic allergic or neurologic reactions following a previous dose of Tetanus Toxoid is an
absolute contraindication
for further use.
2 , 5
If a contraindication to using tetanus toxoid-containing preparations exists in a person who has not
completed a primary
immunizing course of tetanus toxoid and other than a clean, minor wound is sustained, only passive
immunization should be
given using TIG (Human).
2
Elective immunization should be deferred during the course of any febrile illness or acute infection. Aminor afebrile illness such
as a mild upper respiratory infection should not preclude immunization.
2
Elective immunization procedures should be deferred during an outbreak of poliomyelitis.
8
It is a contraindication to use this or any other related vaccine after a serious adverse reaction
temporally associated with a
previous dose, including an anaphylactic reaction.
WARNINGS
Intramuscular injections should be given with great care in patients suffering from thrombocytopenia or
other coagulation
disorders. In this situation, subcutaneous administration of Tetanus Toxoid may be advisable.
A routine booster should not be given more frequently than every ten years. (This guideline should not
preclude wound
management considerations.)
Persons who experienced Arthus-type hypersensitivity reactions or temperature greater than 39.4C
(103F) after a previous dose
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of a tetanus toxoid-containing preparation usually have very high serum tetanus antibody levels and
should not be given even
emergency doses of tetanus toxoid-containing preparation more frequently than every 10 years, even if
they have a wound that
is neither clean nor minor.
9
Deaths have been reported in temporal association with the administration of Tetanus Toxoid (see
ADVERSE REACTIONS section).
PRECAUTIONS
GENERAL
Care is to be taken by the health-care provider for the safe and effective use of Tetanus Toxoid.
EPINEPHRINE INJECTION (1:1,000) MUST BE IMMEDIATELY AVAILABLE SHOULD AN ACUTE
ANAPHYLACTIC REACTION OCCUR
DUE TO ANY COMPONENT OF THE VACCINE.
There is an increased incidence of local and systemic reactions to booster doses of tetanus toxoid when
given to previously
immunized persons. (Refer to DOSAGE AND ADMINISTRATION section for timing of booster injections.)
Prior to an injection of
any vaccine, all known precautions should be taken to prevent adverse reactions. The physician should
have a current
knowledge of the literature concerning the use of the vaccine under consideration, including the nature
of the adverse reactions
that may follow its use. The patients medical history should be reviewed with respect to possiblesensitivity and any previous
adverse reactions to the vaccine or similar vaccines, possible sensitivity to dry natural latex rubber,
previous immunization
history, and current health status (see CONTRAINDICATIONS section).
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Persons who have a history of Guillain-Barr syndrome (GBS) may be at increased risk of recurrent GBS
after subsequent doses of
Tetanus Toxoid vaccines. However, in a study in which an estimated 1.2 million doses of tetanus-
containing toxoid were
administered to persons >18 years of age, two cases of GBS were expected by chance alone during the 6
weeks after vaccination,
and only one case was reported. This finding suggests that the risk of GBS after administration of
tetanus toxoid is extremely low.
The decision to administer tetanus-toxoid-containing vaccine to persons who have had GBS within 6
weeks after receiving
tetanus toxoid should be based on the benefits of subsequent vaccination and the risk of the recurrence
of GBS.
9
The expected immune response to Tetanus Toxoid may not be obtained in immunosuppressed patients.
Administration of
Tetanus Toxoid is not contraindicated in patients with HIV infection.
10
Special care should be taken to ensure that the injection does not enter a blood vessel.
Immunosuppressive therapies including radiation, corticosteroids, antimetabolites, alkylating agents,
and cytotoxic drugs may
reduce the immune response to vaccines. Therefore, routine vaccination should be deferred, if possible,
while patients are
receiving such therapy.
2
If Tetanus Toxoid has been administered to persons receiving immunosuppressive therapy, or having an
immunodeficiency disorder, an adequate antibody response may not be obtained.
5
When possible, immunosuppressive
treatment should be interrupted when immunization is required due to a tetanus-prone wound.
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It is advisable to use DT (For Pediatric Use 6 years of age and younger) or Td (For Adult Use 7 years of
age and older) in
wound prophylaxis instead of tetanus toxoid alone in order to maintain adequate levels of diphtheria
immunity.
5
A separate, sterile syringe and needle or a sterile disposable unit must be used for each patient to
prevent transmission of
hepatitis or other infectious agents from person to person. Needles should not be recapped and should
be properly disposed.
Page 3 of 5
Caution: The stopper of the vial contains dry natural latex rubber, that may cause allergic reactions.
INFORMATION FOR PATIENTS
As part of the child's or adult's immunization record, the date, lot number and manufacturer of the
vaccine administered MUST
be recorded.
1 1 - 1 3
Patients should be fully informed of the benefits and risks of immunization with Tetanus Toxoid vaccine.
The physician should inform the patients about the potential for adverse reactions that have been
temporally associated with
Tetanus Toxoid administration. The health-care provider should provide the Vaccine Information
Statements (VISs) which are
required by the National Childhood Vaccine Injury Act of 1986 to be given with each immunization.
Parents or guardians should
be instructed to report any adverse reactions to their health-care provider.
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IT IS EXTREMELY IMPORTANT WHEN THE CHILD OR ADULT PATIENT RETURNS FOR THE NEXT DOSE IN
THE SERIES, THE PARENT,
GUARDIAN, OR ADULT PATIENT SHOULD BE QUESTIONED CONCERNING OCCURRENCE OF ANY
SYMPTOMS AND/OR SIGNS OF AN
ADVERSE REACTION AFTER THE PREVIOUS DOSE (SEE CONTRAINDICATIONS AND ADVERSE REACTIONS
SECTIONS).
The health-care provider should inform the parent, guardian, or adult patient of the importance of
completing the
immunization series, unless a contraindication to further immunization exists.
The US Department of Health and Human Services has established a Vaccine Adverse Event Reporting
System (VAERS) to accept
all reports of suspected adverse events after the administration of any vaccine, including but not limited
to the reporting of
events required by the National Childhood Vaccine Injury Act of 1986.
5
The toll-free number for VAERS forms and information is
1-800-822-7967.
DRUG INTERACTIONS
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If passive immunization for tetanus is needed, TIG (Human) is the product of choice. It provides longer
protection than antitoxin
of animal origin and causes few adverse reactions. The currently recommended prophylactic dose of TIG
(Human) for wounds of
average severity is 250 units intramuscularly. When a vaccine containing tetanus toxoid is given at the
same time as TIG (Human),
separate syringes and separate sites should be used. The ACIP recommends the use of only adsorbed
toxoid in this situation.
2
The vaccine should be administered subcutaneously in patients on anticoagulant therapy.
Immunosuppressive therapies may reduce the response to vaccines (see PRECAUTIONS section).
CARCINOGENESIS, MUTAGENESIS, IMPAIRMENT OF FERTILITY
No studies have been performed to evaluate carcinogenicity, mutagenic potential, or impact on fertility.
PREGNANCY CATEGORY C
Adequate immunization by routine boosters in non-pregnant women of child-bearing age can obviate
the need to vaccinate
women during pregnancy (see DOSAGE AND ADMINISTRATION section).
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Animal reproduction studies have not been conducted with Tetanus Toxoid. The risk to the fetus from
tetanus toxoid is
unknown. The ACIP recommends that an appropriate tetanus toxoid-containing preparation be given to
inadequately
immunized pregnant women because it affords protection against neonatal tetanus.
10
Waiting until the second trimester is a
reasonable precaution to minimize any theoretical teratogenic concern.
5
It has been reported that Tetanus Toxoid administered to pregnant women prevents neonatal tetanus in
newborns.
1 4 , 1 5
However, the data reported on the safety of Tetanus Toxoid when so used is inconclusive because the
incidence of neonatal
deaths in New Guinea was significantly higher than in the US. A prospective study in the US has not been
done to confirm these
reports.
14
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NURSING MOTHERS
Tetanus Toxoid does not affect the safety of mothers who are breastfeeding or their infants.
Breastfeeding does not adversely
affect immune response and is not a contraindication for vaccination.
10
PEDIATRIC USE
SAFETY AND EFFECTIVENESS OF TETANUS TOXOID IN INFANTS BELOW THE AGE OF SIX WEEKS HAS NOT
BEEN ESTABLISHED.
HOWEVER, THIS VACCINE IS NOT INDICATED FOR CHILDREN UNDER 7 YEARS OF AGE.
GERIATRIC USE
Tetanus Toxoid should only be used in geriatric patients known to have received a primary series (at
least 2 doses) of tetanuscontaining vaccine, since many such persons have no prior immunity.
1 6
Clinical studies of Tetanus Toxoid did not include
sufficient numbers of subjects aged 65 and over to determine whether they respond differently from
younger subjects. Other
reported clinical experience has not identified differences in responses between the elderly and younger
patients.
ADVERSE REACTIONS
BODY SYSTEM AS A WHOLE
Adverse reactions may be local and include redness, warmth, edema, induration with or without
tenderness as well as urticaria,
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and rash. Malaise, transient fever, pain, hypotension, nausea and arthralgia may develop in some
patients after the injection.
Arthus-type hypersensitivity reactions, characterized by severe local reactions (generally starting 2 to 8
hours after an injection)
may occur, particularly in persons who have received multiple prior boosters.
2
On rare occasions, anaphylaxis has been reported
following administration of products containing tetanus toxoid. Upon review, a report by the Institute of
Medicine (IOM)
concluded the evidence established a causal relationship between tetanus toxoid and anaphylaxis.
17
Deaths have been reported
in temporal association with the administration of tetanus toxoid-containing vaccines.
Page 4 of 5
NERVOUS SYSTEM
The following neurologic illnesses have been reported as temporally associated with vaccines containing
tetanus toxoid:
neurological complications
18 , 1 9
including cochlear lesion,
2 0
brachial plexus neuropathies,
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20 , 2 1
paralysis of the radial
nerve,
2 2
paralysis of the recurrent nerve,
2 0
accommodation paresis, Guillain-Barr syndrome, and EEG disturbances with
encephalopathy. The IOM, following review of the reports of neurologic events following vaccination
with tetanus toxoid, DT or
Td, concluded the evidence favored acceptance of a causal relationship between tetanus toxoid and
brachial neuritis and GBS.
17,23
Reporting of Adverse Events
The National Vaccine Injury Compensation Program, established by the National Childhood Vaccine
Injury Act of 1986, requires
physicians and other health-care providers who administer vaccines to maintain permanent vaccination
records and to report
occurrences of certain adverse events to the US Department of Health and Human Services.
1 1 - 1 3
Reportable events include those
listed in the Act for each vaccine and events such as anaphylaxis or anaphylactic shock within 7 days,
brachial neuritis within
28 days; any acute complication or sequela (including death) of an illness,
5
disability, injury, or condition referred to above, or any
events that would contraindicate further doses of vaccine, according to this Tetanus Toxoid for Booster
Use Only package insert.
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Adverse events following immunization with vaccine should be reported by health-care providers to the
US Department
of Health and Human Services (DHHS) Vaccine Adverse Event Reporting System (VAERS). Reporting
forms and information
about reporting requirements or completion of the form can be obtained from VAERS through a toll-free
number
1-800-822-7967.
11 - 1 3
Health-care providers also should report these events to the Pharmacovigilance Department, Sanofi
Pasteur Inc.,
Discovery Drive, Swiftwater, PA 18370 or call 1-800-822-2463.
DOSAGE AND ADMINISTRATION
2, 5
Parenteral drug products should be inspected visually for extraneous particulate matter and/or
discoloration prior to administration
whenever solution and container permit. The vaccine should not be used if particulate matter or
discoloration is found.
FOR BOOSTER USE ONLY NOT RECOMMENDED FOR PRIMARY IMMUNIZATION
SHAKE VIAL WELL before withdrawing each dose.
Inject intramuscularly or subcutaneously in the area of the vastus lateralis (lateral mid-thigh) or deltoid.
The vaccine should not
be injected into the gluteal area or areas where there may be a major nerve trunk.
A needle length one inch is preferred for these age groups because needles less than one inch might be
of insufficient length to
penetrate muscle tissue in certain adults and older children.
10
Before injection, the skin over the site to be injected should be cleansed with a suitable germicide. After
insertion of the needle,
aspirate to ensure that the needle has not entered a blood vessel.
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After the initial immunization series is completed (see INDICATIONS AND USAGE section), a booster dose
of 0.5 mL of Tetanus
Toxoid should be given intramuscularly every 10 years to maintain adequate immunity. This 10-year
period is determined from
the last dose administered irrespective of whether it was given earlier in routine childhood
immunization or as part of wound
management.
5
Booster Injection After Injury:
A thorough attempt must be made to determine whether a patient has completed primary
immunization. Patients with
unknown or uncertain previous immunization histories should be considered to have no previous
tetanus toxoid doses. Persons
who had military service since 1941 can be considered to have received at least one dose. Although
most people in the military
since 1941 may have completed a primary series of tetanus toxoid, this cannot be assumed for each
individual. Patients who
have not completed a primary series may require tetanus toxoid and passive immunization (TIG
Human) at the time of wound
cleaning and debridement (TABLE 1).
2
Available evidence indicates that complete primary vaccination with tetanus toxoid provides long-lasting
protection 10 years
for most recipients. Consequently, after complete primary tetanus vaccination, boosters, even for
wound management, need to
be given only every 10 years when wounds are minor and uncontaminated. For other wounds, a booster
is appropriate if the
patient has not received tetanus toxoid within the preceding five years. Persons who have received at
least two doses of tetanus
toxoid rapidly develop antitoxin antibodies.
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2
Tetanus and Diphtheria Toxoids Adsorbed for Adult Use (Td) is the preferred vaccine for active tetanus
immunization in wound
management of patients 7 years of age. Because a large proportion of adults are susceptible to
diphtheria, this vaccine
enhances diphtheria protection. Thus, by taking advantage of acute health-care visits, such as for wound
management, some
patients can be protected who otherwise would remain susceptible. For inadequately vaccinated
patients of all ages, completion
of primary vaccination at the time of discharge or at follow-up visits should be ensured.
2
Tetanus Toxoid is interchangeable with Tetanus Toxoid Adsorbed (contains aluminum adjuvant) as a
booster, and would only be
preferred if aluminum was to be avoided. Tetanus Toxoid would be preferred over diphtheria-containing
vaccines if there was a
contraindication to the diphtheria component. Page 5 of 5
TABLE 1
2,5
Summary Guide to Tetanus Prophylaxis in Routine Wound Management*
History of Adsorbed Tetanus
Toxoid (Doses)
Clean, Minor Wounds
Td TIG
All Other Wounds**
Td TIG
Unknown or < three
Three
Yes No
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No No
Yes Yes
No No
* Important details are in the text of the insert.
** Such as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva; puncture
wounds; avulsions;
and wounds resulting from missiles, crushing, burns, and frostbite.
Yes, if >10 years since last dose.
Yes, if >5 years since last dose. (More frequent boosters are not needed and can accentuate side
effects.)
If passive immunization for tetanus is needed, TIG (Human) is the product of choice. It provides longer
protection than antitoxin
of animal origin and causes few adverse reactions. The currently recommended prophylactic dose of TIG
(Human) for wounds of
average severity is 250 units intramuscularly. When tetanus toxoid and TIG (Human) are given
concurrently, separate syringes and
separate sites should be used. TIG should not be given with Tetanus Toxoid, but only with Tetanus
Toxoid Adsorbed.
2
HOW SUPPLIED
Vial, 15 Doses (7.5 mL) Product No. 49281-812-84
CPT Code: 90749
CPT is a registered trademark of the American Medical Association.
STORAGE
Store at 2 to 8C (35 to 46F). DO NOT FREEZ
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Introduction
The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the cecum just below the ileocecal
valve. No definite functions can be assigned to it in humans. The appendix fills with food and empties as regularly as
does the cecum, of which it is small, so that it is prone to become obstructed and is particularly vulnerable to infection
(appendicitis).
Appendicitis is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity.
About 7% of the population will have appendicitis at some time in their lives, males are affected more than females,
and teenagers more than adults. It occurs most frequently between the age of 10 and 30.
The disease is more prevalent in countries in which people consume a diet low in fiber and high in refined
carbohydrates.
The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting. Loss of appetite is
common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burneys point applied located at
halfway between the umbilicus and the anterior spine of the Ilium.
Rebound tenderness (ex. Production or intensification of pain when pressure is released) may be present. The extent
of tenderness and muscle spasm and the existence of the constipation or diarrhea depend not so much on the
severity of the appendiceal infection as on the location of the appendix.
If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar region. Rovsings sign
maybe elicited by palpating the left lower quadrant. If the appendix has ruptured, the pain become more diffuse,
abdominal distention develops as a result of paralytic ileus, and the patient condition become worsens.
Constipation can also occur with an acute process such as appendicitis. Laxative administered in the instance may
result in perforation of the in flared appendix. In general a laxative should never be given when a persons has fever,
nausea or pain.
Anatomy and Physiology of Digestive System
The mouth, or oral cavity, is the first part of the digestive tract. It is adapted to receive food by ingestion, break it into
small particles by mastication, and mix it with saliva. The lips, cheeks, and palate form the boundaries. The oral cavity
contains the teeth and tongue and receives the secretions from the salivary glands.
Lips and Cheeks
The lips and cheeks help hold food in the mouth and keep it in place for chewing. They are also used in the formation
of words for speech. The lips contain numerous sensory receptors that are useful for judging the temperature andtexture of foods.
Palate
The palate is the roof of the oral cavity. It separates the oral cavity from the nasal cavity. The anterior portion, the
hard palate, is supported by bone. The posterior portion, the soft palate, is skeletal muscle and connective tissue.
Posteriorly, the soft palate ends in a projection called the uvula. During swallowing, the soft palate and uvula move
upward to direct food away from the nasal cavity and into the oropharynx.
Tongue
The tongue manipulates food in the mouth and is used in speech. The surface is covered with papillae that provide
friction and contain the taste buds.
Teeth
A complete set of deciduous (primary) teeth contains 20 teeth. There are 32 teeth in a complete permanent(secondary) set. The shape of each tooth type corresponds to the way it handles food.
Pharynx
The pharynx is a fibromuscular passageway that connects the nasal and oral cavities to the larynx and esophagus. It
serves both the respiratory and digestive systems as a channel for air and food. The upper region, the nasopharynx,
is posterior to the nasal cavity. It contains the pharyngeal tonsils, or adenoids, functions as a passageway for air, and
has no function in the digestive system. The middle region posterior to the oral cavity is the oropharynx. This is the
first region food enters when it is swallowed. The opening from the oral cavity into the oropharynx is called the
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fauces. Masses of lymphoid tissue, the palatine tonsils, are near the fauces. The lower region, posterior to the larynx,
is the laryngopharynx, or hypopharynx. The laryngopharynx opens into both the esophagus and the larynx.
Esophagus
The esophagus is a collapsible muscular tube that serves as a passageway between the pharynx and stomach. As it
descends, it is posterior to the trachea and anterior to the vertebral column. It passes through an opening in the
diaphragm, called the esophageal hiatus, and then empties into the stomach. The mucosa has glands that secrete
mucus to keep the lining moist and well lubricated to ease the passage of food. Upper and lower esophageal
sphincters control the movement of food into and out of the esophagus. The lower esophageal sphincter is
sometimes called the cardiac sphincter and resides at the esophagogastric junction
Stomach
the stomach, which receives food from the esophagus, is located in the upper left quadrant of the abdomen. The
stomach is divided into the fundic, cardiac, body, and pyloric regions. The lesser and greater curvatures are on the
right and left sides, respectively, of the stomach.
Small Intestine
The small intestine extends from the pyloric sphincter to the ileocecal valve, where it empties into the large intestine.
The small intestine finishes the process of digestion, absorbs the nutrients, and passes the residue on to the large
intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive system that are closely
associated with the small intestine. The small intestine is divided into the duodenum, jejunum, and ileum. The small
intestine follows the general structure of the digestive tract in that the wall has a mucosa with simple columnar
epithelium, submucosa, smooth muscle with inner circular and outer longitudinal layers, and serosa. The absorptive
surface area of the small intestine is increased by plicae circulares, villi, and microvilli. Exocrine cells in the mucosa of
the small intestine secrete mucus, peptidase, sucrase, maltase, lactase, lipase, and enterokinase. Endocrine cells
secrete cholecystokinin and secretin. The most important factor for regulating secretions in the small intestine is the
presence of chyme. This is largely a local reflex action in response to chemical and mechanical irritation from the
chyme and in response to distention of the intestinal wall. This is a direct reflex action, thus the greater the amount of
chyme, the greater the secretion.
Large Intestine
The large intestine is larger in diameter than the small intestine. It begins at the ileocecal junction, where the ileum
enters the large intestine, and ends at the anus. The large intestine consists of the colon, rectum, and anal canal. Thewall of the large intestine has the same types of tissue that are found in other parts of the digestive tract but there are
some distinguishing characteristics. The mucosa has a large number of goblet cells but does not have any villi. The
longitudinal muscle layer, although present, is incomplete. The longitudinal muscle is limited to three distinct bands,
called teniae coli, that run the entire length of the colon. Contraction of the teniae coli exerts pressure on the wall and
creates a series of pouches, called haustra, along the colon. Epiploic appendages, pieces of fat-filled connective
tissue, are attached to the outer surface of the colon. Unlike the small intestine, the large intestine produces no
digestive enzymes. Chemical digestion is completed in the small intestine before the chyme reaches the large
intestine. Functions of the large intestine include the absorption of water and electrolytes and the elimination of feces.
Rectum and Anus
The rectum continues from the signoid colon to the anal canal and has a thick muscular layer. It follows the curvature
of the sacrum and is firmly attached to it by connective tissue. The rectum and ends about 5 cm below the tip of thecoccyx, at the beginning of the anal canal. The last 2 to 3 cm of the digestive tract is the anal canal, which continues
from the rectum and opens to the outside at the anus. The mucosa of the rectum is folded to form longitudinal anal
columns. The smooth muscle layer is thick and forms the internal anal sphincter at the superior end of the anal canal.
This sphincter is under involuntary control. There is an external anal sphincter at the inferior end of the anal canal.
This sphincter is composed of skeletal muscle and is under voluntary control.
Clinical Manifestations
1. Generalized or localized abdominal pain in the epigastric or periumbilical areas and upper right abdomen. Within
2 to 12 hours, the pain localizes in the right lower quadrant and intensity increases.
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2. Anorexia, moderate malaise, mild fever, nausea and vomiting.
3. Usually constipation occurs ; occasionally diarrhea.
4. Rebound tenderness, involuntary guarding, generalized abdominal rigidity.
Diagnostic Evaluation
1. Physical examination consistent with clinical manifestations.
2. WBC count reveal moderate leukocytosis (10,000 to 16,000/mm3) with shift to the left (increased immature
neutrophils).
3. Urinalysis rule out urinary disorders.
4. Abdominal x-ray may visualize shadow consistent with fecalith in appendix; perforation will reveal free air.
5. Abdominal ultrasound or CT scan can visualize appendix and rule out other conditions, such as diverticulitis and
crohns disease. Focused appendiceal CT can quickly evaluate for appendicitis.
Medications
Analgesics
Intravenous fluids replacements
Analgesics
Treatment
Appendectomy is the effective treatment if peritonitis develops treatment involves.
GI Intubation
Parenteral replacement of IV fluids and electrolytes
Administration of Antibiotics
Surgery is indicated if appendicitis is diagnosed. Antibiotics and IV fluids are administered until surgery is performed
analgesics can be administered after the diagnosed is made.
An appendectomy (surgical removal of the appendix) is performed as soon as possible to decrease the risk of
perforation. T he appendectomy may be performed under a (general or spinal anesthetics) with a low abdominal
incisions or by (laparoscopy) which is recently highly effective method.
Complications
The major complication of appendicitis is perforation of the appendix, which can lead to peritonitis, abscess formation
(collection of purulent material), or portal pylephlebitis, which is septic thrombosis of the portal vein caused by
vegetative emboli that arise from septic intestines.Perforation generally occurs 24 hours after the onset of pain symptoms include a fever of 37.7 degree Celsius or 100
degree Fahrenheit or greater, a toxic appearance and continued abdominal pain or tenderness.
Nursing Interventions
1. Monitor frequently for signs and symptoms of worsening condition, indicating perforation, abscess, or peritonitis
(increasing severity of pain, tenderness, rigidity, distention, absent bowel sounds, fever, malaise, and
tachycardia).
2. Notify health care provider immediately if pain suddenly ceases, this indicates perforation, which is a medical
emergency.
3. Assist patient to position of comfort such as semi-fowlers with knees are flexed.
4. Restrict activity that may aggravate pain, such as coughing and ambulation.
5. Apply ice bag to abdomen for comfort.6. Avoid indiscriminate palpation of the abdomen to avoid increasing the patients discomfort.
7. Promptly prepare patient for surgery once diagnosis is established.
8. Explain signs and symptoms ofpostoperative complications to report-elevated temperature, nausea and vomiting,
or abdominal distention; these may indicate infection.
9. Instruct patient on turning, coughing, or deep breathing, use of incentive spirometer, and ambulation. Discuss
purpose and continued importance of these maneuvers during recovery period.
10. Teach incisional care and avoidance of heavy lifting or driving until advised by the surgeon.
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11. Advise avoidance of enemas or harsh laxatives; increased fluids and stool softeners may be used for
postoperative constipation.
Discharge Planning
M Antibiotics for infection
Analgesic agent (morphine) can be given for pain after the surgery
E Within 12 hrs of surgery you may get up and move around.
You can usually return to normal activities in 2-3 weeks after laparoscopic surgery.
T Pretreatment of foods with lactase preparations (e.g. lactacid drops) before ingestion can reduce symptoms.
Ingestion of lactase enzyme tablets with the first bite of food can reduce symptoms.
H To care wound perform dressing changes and irrigations as prescribe avoid taking laxative or applying heat to
abdomen when abdominal pain of unknown cause is experienced.
Reinforce need for follow-up appointment with the surgeon
Call your physician for increased pain at the incision site
O Document bowel sounds and the passing of flatus or bowel movements (these are signs of the return of
peristalsis)
Watch for surgical complications such as continuing pain or fever, which indicate an abscess or wound
dehiscence
Stitches removed between fifth and seventh day (usually in physicians office)
D Liquid or soft diet until the infection subsides
Soft diet is low in fiber and easily breaks down in the gastrointestinal tract
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