Appendicitis Overview and Clinical Features

Appendicitis

• Inflammation of the appendix
• Most common in young adults
• Morbidity and mortality rates higher in patients over 70

Etiology and Pathophysiology

• Most common cause is obstruction of the lumen by:
  • Fecalith (accumulated feces)
  • Foreign bodies
  • Tumor of the cecum or appendix
  • Excessive growth of lymphoid tissue
• Obstruction often results in:
  • Distention
  • Venous engorgement
  • Gangrene and perforation

Clinical Manifestations

• Periumbilical pain, right lower quadrant at McBurney's point
• Persistent and continuous pain
• Anorexia
• Nausea and vomiting
• Localized or rebound tenderness
• Muscle guarding
• Pain upon sneezing, coughing, or deep inhalation
• Rovsing's sign
• Possible fever

Diagnostic Studies

• History and physical examination (palpation)
• Differential WBC count (elevated)
• Urinalysis
• Rule out genitourinary conditions
• CT scan
• Ultrasound

Complications and Treatment

• If diagnosis and treatment are delayed, complications may occur:
  • Ruptured appendix
  • Peritonitis
  • Abscess
  • Sepsis and dehydration.
• Treatment: Immediate surgical removal (appendectomy)
• Antibiotics and parenteral fluids given 6-8 hours before surgery to prevent sepsis and dehydration.

Nursing Management

• Keep patient NPO until seen by a healthcare provider
• Administer antibiotics and fluid resuscitation before surgery
• Apply ice to the area (do not use heat)
• Enemas and laxatives are not recommended, as increased peristalsis may cause perforation of appendix.

Postoperative Care

• Patient will receive a laparotomy
• Observe for signs of peritonitis
• Ambulation begins as early as the day of surgery or the first postoperative day
• Advance diet as tolerated
• Short recovery
• Discharge 1-2 days postoperative
• Normal activities resumed in 2-3 weeks

Peritonitis

• Inflammation of the peritoneum
• Occurs when intestinal contents and/or bacteria irritate the normally sterile peritoneum
• Initially chemical peritonitis followed by bacterial peritonitis
• Inflammatory response results in massive fluid shifts (peritoneal edema) and adhesions as the body attempts to wall off the infection
• Primary and secondary causes:
  • Primary: Blood-borne organisms, genital tract organisms, cirrhosis with ascites
  • Secondary: Appendicitis with rupture, diverticulosis with rupture, blunt/penetrating trauma to abdominal organs, ischemic bowel disorders, pancreatitis, perforated intestine (peptic ulcer), postoperative complications (e.g., anastomosis breakage)

Peritonitis Clinical Manifestations

• Abdominal pain with tenderness over involved area (universal sign)
• Rebound tenderness
• Muscular rigidity and spasms
• Shallow breaths and lack of movement
• Abdominal distention or ascites
• Fever
• Tachycardia
• Tachypnea
• Nausea and vomiting
• Altered bowel habits

Peritonitis Complications

• Hypovolemic shock
• Sepsis
• Intra-abdominal abscess formation
• Paralytic ileus
• Acute respiratory distress
• Fatal if treatment is delayed

Peritonitis Diagnostic Studies

• CBC (elevated WBCs)
• Hemoconcentration (increased concentration of cells & solids)
• Analyze fluid in peritoneal cavity via peritoneal aspiration
• X-ray of abdomen (dilated loops of bowel, free air, or air and fluid levels)
• Ultrasound
• CT scan
• Peritoneoscopy (direct examination with biopsy)

Peritonitis Collaborative Care

• Surgery: Locate cause of inflammation, drain purulent fluid, repair damage
• Antibiotics
• NG suction
• Analgesics
• IV fluid administration

Nursing Assessments(Peritonitis)

• Patient's pain (location, level, length of time)
• Bowel sounds
• Presence and quality of abdominal guarding
• Appearance of abdomen
• Nausea
• Fever
• Manifestations of hypovolemic shock

Nursing Diagnoses (Peritonitis)

• Acute pain related to inflammation of the peritoneum and abdominal distention
• Risk for deficient fluid volume related to fluid shifts into the peritoneal cavity secondary to trauma, infection, or ischemia.
• Imbalanced nutrition: less than body requirements related to anorexia, nausea, and vomiting
• Anxiety related to uncertainty of cause, outcome of condition and pain

Planning (Peritonitis)

• Nursing goals: Resolution of inflammation, relief of abdominal pain, freedom from complications (especially hypovolemic shock), and normal nutritional status

Nursing Implementation (Peritonitis)

• IV line insertion and fluid replacement
• Access for antibiotics
• Monitor patient for pain and analgesic response
• Position patient with knees flexed for comfort
• Antiemetics to decrease nausea, vomiting, and resulting fluid and electrolyte loss
• NPO and possible NG tube insertion to decrease gastric distention and further leakage of contents
• Post-surgical patient will need drains in order to remove purulent drainage for surgical patients.

NCLEX Questions and Answers

• Question 1: A patient presents with acute abdominal pain, nausea, and vomiting. A nurse palpates the patient's left lower quadrant, causing pain in the right lower quadrant. Which of the following diagnostic signs of appendicitis is this?
  • Answer 1: Rovsing's sign
• Question 2: A patient with acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness in which location?
  • Answer 2: Right lower quadrant
• Question 3: A male client had abdominal surgery and the nurse suspects peritonitis. Which assessment data support the diagnosis of peritonitis? -Answer 3: Hard, rigid abdomen and elevated white blood cell count (22,000/mm³).