Appendicitis

Appendicitis (also known as epityphlitis) is the inflammation of the appendix which is a small finger-like appendage attached to the cecum.

The appendix is a small, finger-like appendage attached to the cecum just below the ileocecal valve. Because the appendix empties into the colon inefficiently and its lumen is small, it is prone to becoming obstructed and is vulnerable to infection (appendicitis).

Pathophysiology

The obstructed appendix becomes inflamed and edematous and eventually fills with pus. It is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity and the most common cause of emergency abdominal surgery. Although it can occur at any age, it more commonly occurs between the ages of 10 and 30 years.

Clinical Manifestations

• Lower right quadrant pain usually accompanied by low grade fever, nausea, and sometimes vomiting; loss of appetite is common; constipation can occur.
• At McBurney’s point, local tenderness with pressure and some rigidity of the lower portion of the right rectus muscle.

   

  

• Rebound tenderness may be present; location of appendix dictates amount of tenderness, muscle spasm, and occurrence of constipation or diarrhea.
• Rovsing’s sign (elicited by palpating left lower quadrant, which paradoxically causes pain in right lower quadrant).
• If appendix ruptures, pain becomes more diffuse; abdominal distention develops from paralytic ileus, and condition worsens.

Assessment and Diagnostic Findings

• Diagnosis is based on a complete physical examination and laboratory and imaging tests.
• Elevated WBC count with an elevation of the neutrophils; abdominal radiographs, ultrasound studies, and CT scans may reveal right lower quadrant density or localized distention of the bowel.
• C-reactive protein (CRP) – protein produced by the liver when bacterial infections occur and rapidly increases within the first 12 hours. CRP levels greater than 1mg/dL are commonly reported in clients with appendicitis. Very high levels (3mg/dL and up) indicates gangrenous evolution of the disease.

Gerontologic Considerations

In the elderly, signs and symptoms of appendicitis may vary greatly. Signs may be very vague and suggestive of bowel obstruction or another process; some patients may experience no symptoms until the appendix ruptures. The incidence of perforated appendix is higher in the elderly because many of these people do not seek health care as quickly as younger people.

Medical Management

• Surgery (conventional or laparoscopic) is indicated if appendicitis is diagnosed and should be performed as soon as possible to decrease risk of perforation.
• Administer antibiotics and IV fluids until surgery is performed.
• Analgesic agents can be given after diagnosis is made. These are not given before a suspected case of appendicitis to determine whether the patient has a ruptured appendix or not.

Nursing Diagnoses

Complications

• The major complication is perforation of the appendix, which can lead to peritonitis, abscess formation (collection of purulent material), or portal pylephlebitis.
• Perforation generally occurs 24 hours after the onset of pain.
• Symptoms include a fever of 37.7C (100F) or greater, a toxic appearance, and continued abdominal pain or tenderness.

Nursing Priorities

• Prevent complications
• Promote comfort
• Provide information about the upcoming surgical procedure, prognosis, treatment needs and potential complications.

Nursing Management

• Nursing goals include relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating infection due to the potential or actual disruption of the GI tract, maintaining skin integrity, and attaining optimal nutrition.
• Preoperatively, prepare patient for surgery, start IV line, administer antibiotic, and insert nasogastric tube (if evidence of paralytic ileus). Do not administer an enema or laxative (could cause perforation).
• Postoperatively, place patient in high Fowler’s position, give narcotic analgesic as ordered, administer oral fluids when tolerated, give food as desired on day of surgery (if tolerated). If dehydrated before surgery, administer IV fluids.
• If a drain is left in place at the area of the incision, monitor carefully for signs of intestinal obstruction, secondary hemorrhage, or secondary abscesses (eg, fever, tachycardia, and increased leukocyte count).

Discharge Goals

1. Complications are prevented or minimized.
2. Pain alleviated or controlled.
3. Surgical procedure, prognosis, treatment regimen,and possible complications understood.
4. Plan in place to meet needs after discharge (follow-up).

Home and Community Based Care

Teaching Patients Self-Care

• Teach patient and family to care for the wound and perform dressing changes and irrigations as prescribed.
• Reinforce need for follow-up appointment with surgeon.
• Discuss incision care and activity guidelines.
• Refer for home care nursing as indicated to assist with care and continued monitoring of complications and wound healing.