APPENDICITIS
A. DESCRIPTION
• Appendix is a small, vermiform (wormlike) appendage about 8-10 cm (3-4 inches)
long that is attach 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.
• Inflammation in the appendix.
• When the appendix become inflamed or infected, rupture may occur within a matter
of hours, leading to peritonitis and sepsis
B. CLINICAL MANIFESTATIONS
• Pain in the periumbilical area that descends to the right lower quadrant
• Abdominal pain that is most intense at McBurney's point
• Low-grade fever
• Elevated white blood cell count
• Client in side-lying position, with abdominal guarding and legs flexed
• Constipation or diarrhea
Pain may or may not be accompanied by any of the following symptoms:
• Decreased appetite
• Nausea/vomiting
• Fever (40% of patients)
• Diarrhea or constipation
• Generalize malaise
• Urinary frequency or urgency
As inflammation progresses, signs of peritoneal inflammation develop.
• Right lower quadrant guarding and rebound tenderness
• Right lower quadrant pain elicited by palpation of the left lower quadrant
• Increased abdominal pain with coughing or movement
• Rigid abdomen and involuntary guarding
C. ETIOLOGY
1. APPENDIX STONES - Stool can dry up and turn into hard stones that then get
stuck in the opening of the appendix. Since these stones carry bacteria and can
also trap other bacteria inside your appendix, they’re likely to cause inflammation.
2. LYMPHOID HYPERPLASIA - The lymphatic system is the part of your immune
system that helps your body regulate fluids, filter out bacteria, and create white
blood cells. In the case of lymphoid hyperplasia, your lymph nodes start to produce
extra cells in response to a virus or infection. Since your appendix has lymphatic
tissue, it might react by swelling — even if it’s not the source of the infection. That
swelling can cause an obstruction that leads to an infection.
3. COLITIS- Large intestine is inflamed, it could affect your appendix either through
the spread of an infection or because of irritation.
4. TUMORS - tumors can grow inside the appendix, leading to appendicitis.
5. PARASITES - A parasite blocks or partially blocks the opening of the appendix, it
can become inflamed.
6. CYSTIC FIBROSIS - Cystic fibrosis have a larger appendix, which may increase
their risk of appendicitis.
D. RISK FACTORS
1. Family history – those with known family history were more likely to have the
condition
2. Age – appendicitis mostly occur in adolescents
3. Sex – inflammation of the appendix is more common in males
4. Eating low fiber diet – low fiber diet can cause the blockage of the
appendiceal lumen.
5. Having long lasting inflammatory bowel disease – Crohn’s disease or
Ulcerative
E. PATHOPHYSIOLOGY
MODIFIABLE RISK FACTORS NON- MODIFIABLE RISK FACTORS
1. Diet 1. Age
2. Crohn’s Disease or Ulcerative 2. Sex
3. Family History
The appendix become inflamed and edematous
The appendix becomes kinked, or occluded by a
fecalities, tumor, or foreign body.
The inflammation process increases intraluminal
pressure
Initiating progressively severe generalized or
upper abdominal pain
Later the inflamed appendix fills with
APPENDICITIS
F. DIAGNOSTICS
1. Blood tests
white blood cell (WBC) 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 comprise >75% of the WBC.
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.
2. CT scan or ultrasound - is used to confirm the diagnosis.
3. Pregnancy test - may be ordered for women of childbearing age to rule out ectopic
pregnancy and before radiologic studies are done. As an alternative, a transvaginal
ultrasound may be used to confirm the diagnosis.
4. Urinalysis - is usually obtained to rule out urinary tract infection or renal calculi.
G. 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
H. NURSING DIAGNOSIS
1. Acute Pain related to inflammation secondary to acute appendicitis
2. Risk for fluid volume deficit related to nausea and vomiting/ decreased appetite/
decreased fluid intake
3. Risk for infection related to ruptured appendix/ surgical incision
4. Risk for deep venous thrombosis (DVT) related to immobility
5. Risk for anxiety related to hospitalization
I. MEDICAL MANAGEMENT
1. Immediate surgery - is typically indicated if appendicitis is diagnosed. To
correct or prevent fluid and electrolyte imbalance, dehydration, and sepsis,
antibiotics, and IV fluids are given until surgery is performed.
2. The laparoscopic approach - is becoming the procedure of choice; it allows
the patient an earlier return to normal activities. Both laparotomy and
laparoscopy are safe and effective in the treatment of appendicitis with or
without perforation.
3. Antibiotic prophylaxis - is recommended for less than 24 hours for
nonperforated appendicitis and for <5 days for perforated appendicitis.
Antibiotic selection should follow guidelines outlined by the CDC to prevent
surgical site infections.
4. Some patients may have abscess formation that involves the cecum or terminal
ileum. In these select cases, appendectomy may be referred until the mass is
drained. Most commonly, these abscesses are drained percutaneously or
surgically. The patient continues to receive treatment with antibiotics. After the
abscess is drained and there is no further evidence of infection, an
appendectomy is then performed.
J. SURGICAL MANAGEMENT
1. Appendectomy (surgical removal of the appendix) - is performed as soon as
possible to decrease the risk of perforation. Appendectomy has traditionally
been performed under general anesthesia with an open technique via
transverse incision in the right lower quadrant (laparotomy).
K. NURSING MANAGEMENT
1. 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.
2. 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.
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. Food is provided as desired and tolerated on the day of surgery when bowel
sounds are present.
PREOPERATIVE INTERVENTIONS:
1. Maintain NPO status.
2. Administer fluids intravenously to prevent dehydration.
3. Monitor for changes in level of pain.
4. Monitor for signs of ruptured appendix and peritonitis.
5. Position the client in a right side-lying or low to semi-Fowler's position to
promote comfort.
6. Monitor bowel sounds.
7. Avoid the application of heat to the abdomen.
8. Apply ice packs to the abdomen for 20 to 30 minutes every hour as prescribed.
9. Administer antibiotics as prescribed.
10. Avoid laxatives or enemas.
POSTOPERATIVE INTERVENTIONS:
1. Monitor temperature for signs of infection.
2. Assess incision for signs of infection such as redness, swelling, and pain.
3. Maintain NPO status until bowel function has returned.
4. Advance diet gradually as tolerated and as prescribed, when bowel sounds
return.
5. If rupture of the appendix occurred, expect a Penrose drain to be inserted, or
the incision may be left open to heal from the inside out.
6. Expect that drainage from the Penrose drain may be profuse for the first 12
hours.
7. Position the client in a right side-lying or low to semi-Fowler's position, with
legs flexed, to facilitate drainage.
8. Change the dressing as prescribed and record the type and amount of
drainage.
9. Perform wound irrigations if prescribed.
10. Maintain nasogastric suction and patency of the nasogastric tube if present.
11. Administer antibiotics and analgesics as prescribed.
12. Auscultates for the return of bowel sounds and queries the patient for passing
of flatus.
13. 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.
L. EVALUATION
1. Laboratory testing such as CBC. Elevated WBC is typically found, but CBC is
normal in approximately one-third of patients with appendicitis.
2. Typically a CT abdomen and pelvis is done while the patient is in the
emergency room setting, but ultrasound and MRI are also used, particularly in
pregnant women, and ultrasound is sometimes used in children to reduce
radiation.
3. Appendicitis is often a clinical diagnosis by the provider based on a thorough
history and physical exam.
4. Pain decreased/relieved
5. Prevented fluid volume deficiency, adequate intake, and output
6. Prevented/treated infection
7. Maintained surgical incision integrity
8. Patient anxiety relieved/received adequate education
9. Maintained adequate elimination/prevented constipation
M. REFERENCES
Brunner & Suddarth’s
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Saunders Comprehensive Review for the NCLEX-RN Examination 6th edition
Prepared by:
AGAM, Angela Maye C.
VITE, Juliana Michelle N.
BSN 3-B
