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565a-appendicitis

7 min read

References:

  1. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 15th Edition, ISBN 978-197-51-6103-3, by Janice L. Hinkle, Kerry H. Cheever, and Kristen J. Overbaugh ([ebook] pp. 3508-3511)

The appendix is a small, vermiform (i.e., wormlike) appendage about 8 to 10 cm (3 to 4 inches) long that is attached to the cecum just below the ileocecal valve. The appendix fills with byproducts of digestion and empties regularly into the cecum. Because it empties inefficiently and its lumen is small, the appendix is prone to obstruction and is particularly vulnerable to infection (i.e., appendicitis). Appendicitis, the most frequent cause of acute abdomen in the United States, is the most common reason for abdominal surgery.

  • This can occur at any age, though typically occurring between the ages of 10 and 30 years. Its incidence is slightly higher among males and there is a familial predisposition.

Pathophysiology

  1. The appendix becomes inflamed and edematous as a result of becoming kinked or occluded by a fecalith, lymphoid hyperplasia (secondary to inflammation or infection), or rarely, foreign bodies (e.g., fruit seeds) or tumors.
  2. The inflammation process increases intraluminal pressure, causing edema and obstruction of the orifice.
  3. Once obstructed, the appendix becomes ischemic, bacterial overgrowth occurs, and eventually gangrene or perforation occurs.

Clinical Manifestations

(a) Vague periumbilical pain with anorexia progresses to (b) right lower quadrant pain and nausea in approximately 50% of patients with appendicitis.

  • A low-grade fever may be present.
  • Local tenderness may be elicited at McBurney’s point when pressure is applied.
  • Rebound tenderness (Blumberg’s sign) may be present.
  • Rovsing’s sign may be elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right lower quadrant.
  • If the appendix has ruptured, the pain becomes consistent with peritonitis; abdominal distention develops as a result of paralytic ileus, and the patient’s condition worsens.
  • Constipation may occur with appendicitis. Laxatives given in this instance may result in perforation of the inflamed appendix In general, a laxative or cathartic should not be given when a person has fever, nausea, and abdominal pain.

Gerontologic Considerations

Acute appendicitis is uncommon in older adults. When appendicitis does occur, classic signs and symptoms are altered and may vary greatly. Pain may be absent or minimal. Symptoms may be vague, suggesting bowel obstruction or another process. Fever and leukocytosis may not be present. As a result, diagnosis and prompt treatment may be delayed, causing complications and mortality. The patient may have no symptoms until the appendix becomes gangrenous and perforates. The incidence of complications is higher in older adults because many of these patients do not seek health care as quickly as younger patients.

Assessment and Diagnostic Findings

Diagnosis is based on the results of a complete history and physical examination, laboratory findings, and imaging studies.

  1. The white blood cell count is useful when determining diagnosis; between 80% and 85% of adults with appendicitis will have a WBC count >10,500/mm3; 78% of patients have neutrophilia, where neutrophils compose >75% of the WBCs.
  2. C-reactive protein levels are typically elevated, especially within the first 12 hours of symptoms, but may return to normal in patients who are symptomatic longer than 24 hours.
  3. A CT scan or ultrasound is used to confirm the diagnosis.
  4. A pregnancy test may be ordered for women of childbearing age to rule out ectopic pregnancy and before radiologic studies are done. Alternatively, a transvaginal ultrasound may be used to confirm the diagnosis.
  5. A urinalysis is usually obtained to rule out urinary tract infection or renal calculi.

Complications

The major complications of appendicitis are gangrene or perforation of the appendix, which can lead to peritonitis, abscess formation, or portal pylephlebitis, which is septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines.

Perforation generally occurs within 6 to 24 hours after the onset of pain and leads to peritonitis.

Medical Management

Immediately surgery is typically indicated if appendicitis is diagnosed.

  1. To correct or prevent fluid and electrolyte imbalance, dehydration, and sepsis, antibiotics and IV fluids are given until surgery is performed.
  2. Appendectomy (i.e., surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation. While this procedure has historically been done in an open technique via transverse incision in the right lower quadrant (laparotomy), the laparoscopic approach is becoming the procedure of choice; it allows the patient an early return to normal activities. Both methods are safe and effective in treatment of appendicitis with or without perforation.
  3. Antibiotic prophylaxis is recommended for less than 24 hours for non-perforated appendicitis and for <5 days for perforated appendicitis.
  4. Abscess drainage (via percutaneously or surgically) of formations in the cecum or terminal ileum may be required before appendectomy is performed. The patient continues to receive treatment with antibiotics. After drainage and there is no further evidence of infection, an appendectomy is then performed.

Nursing Management

Goals include relieving pain, preventing fluid volume deficit, reducing anxiety, preventing or treating surgical site infection, preventing atelectasis, maintaining skin integrity, and attaining optimal nutrition.

  1. The nurse prepares the patient for surgery, which includes an IV infusion to replace fluid loss and promote adequate renal function, antibiotic therapy to prevent infection, and administration of analgesic agents for pain.
    • An enema is not given because it can lead to perforation.
  2. After surgery, the nurse places the patient in a high Fowler position to reduce tension on the incision and abdominal organs, helping to reduce pain. It also promotes thoracic expansion, diminishing the work of breathing, and decreasing the likelihood of atelectasis.
  3. The patient is educated on the use of an incentive spirometer and encouraged to use it at least every 2 hours while awake.
  4. A parenteral opioid (e.g., morphine) is typically prescribed to relieve pain; this is switched to an oral agent when the patient is able to tolerate oral fluids and foods.
  5. Any patient who was dehydrated before surgery receives IV fluids. When tolerated, oral fluids are given. Food is provided as desired and tolerated on the day of surgery when bowel sounds are present. The nurse auscultates for the return of bowel sounds and queries the patient for passing of flatus.
  6. Urine output is monitored to ensure that the patient is not hampered by postoperative urinary retention and to ensure that hydration status is adequate.
  7. The patient is encouraged to ambulate the day of the surgery to reduce risks of atelectasis and venous thromboembolism (VTE) formation.

The patient may be discharged on the day of surgery if the temperature is within normal limits, there is no undue discomfort in the operative area, and the appendectomy was performed laparoscopically. Discharge instruction for the patient and family is imperative.

  • The nurse instructs the patient to make an appointment to have the surgeon remove any sutures and inspect the wound between 1 and 2 weeks after surgery.
  • Incision care and activity guidelines are discussed; heavy lifting is to be avoided postoperatively, although normal activity can usually be resumed within 2 to 4 weeks.

Patients with gangrenous or perforated appendix are at greater risk for infection and peritonitis; therefore, they may be kept in the hospital for several days. Secondary abscesses may form in the pelvis, under the diaphragm, or in the liver, causing elevation of the temperature, pulse, rate, and white blood cell count. When the patient is ready for discharge, the patient and family are educated about how to care for the incision and perform dressing changes and irrigations are prescribed. A home health nurse may be needed to assist with this care and to monitor the patient for complications and wound healing.

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