APPENDICITIS

APPENDICITIS

Appendicitis is inflammation of the vermiform appendix caused by an obstruction of the intestinal lumen from infection, stricture, fecal mass, foreign body, or tumor

Pathophysiology and Etiology
A-Obstruction is followed by edema, infection, and ischemia
B-As intraluminal tension develops, necrosis and perforation usually occur
C-Appendicitis can affect any age-group; most common in adolescents/young adults, especially males

Clinical Manifestations
A-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
B-Anorexia, moderate malaise, mild fever, nausea and vomiting
C-Usually constipation occurs; occasionally diarrhea
D-Rebound tenderness, involuntary guarding, generalized abdominal rigidity

Diagnostic Evaluation
A-Physical examination consistent with clinical manifestations
B-WBC count reveals moderate leukocytosis (10,000 to 16,000/mm3) with shift to the left (increased immature neutrophils
C-Urinalysis to rule out urinary disorders
D-Abdominal X-ray may visualize shadow consistent with fecalith in appendix; perforation will reveal free air
E-Abdominal ultrasound or CT scan can visualize appendix and rule out other conditions, such as diverticulitis and Crohn's disease. Focused appendiceal CT can quickly evaluate for appendicitis

GERONTOLOGIC *****
In older adults, be aware of vague symptoms: milder pain, less pronounced fever, and leukocytosis with shift to the left on differential

Management
A-Surgery (appendectomy) is indicated
a-Simple appendectomy or laparoscopic appendectomy in absence of rupture or peritonitis
b-An incisional drain may be placed if an abscess or rupture occurs
B-Preoperatively maintain bed rest, NPO status, I.V. hydration, possible antibiotic prophylaxis, and analgesia
Complications
A-Perforation (in 95% of cases
B-Abscess
C-Peritonitis

Nursing Assessment
A-Obtain history for location and extent of pain
B-Auscultate for presence of bowel sounds; peristalsis may be absent or diminished
C-On palpation of the abdomen, assess for tenderness anywhere in the right lower quadrant, but usually localized over McBurney's point (point just below midpoint of line between umbilicus and iliac crest on the right side). Assess for rebound tenderness in the right lower quadrant as well as referred rebound when palpating the left lower quadrant
D-Assess for positive psoas sign by having the patient attempt to raise the right thigh against the pressure of your hand placed over the right knee. Inflammation of the psoas muscle in acute appendicitis will increase abdominal pain with this maneuver
E-Assess for positive obturator sign by flexing the patient's right hip and knee and rotating the leg internally. Hypogastric pain with this maneuver indicates inflammation of the obturator muscle

Nursing Diagnoses
A-cute Pain related to inflamed appendix
B-Risk for Infection related to perforation

Nursing Interventions
Relieving Pain
A-Monitor pain level, including location, intensity, pattern
B-Assist patient to comfortable positions, such as semi-Fowler's and knees up
C-Restrict activity that may aggravate pain, such as coughing and ambulation
D-Apply ice bag to abdomen for comfort
E-Give antiemetics and analgesics as ordered and evaluate response
F-Avoid indiscriminate palpation of the abdomen to avoid increasing the patient's discomfort

DRUG *****
Do not give analgesics/antipyretics to mask fever, and do not administer cathartics because they may cause rupture

Preventing Infection
A-Monitor frequently for signs and symptoms of worsening condition indicating perforation, abscess, or peritonitis: increasing severity of pain, tenderness, rigidity, distention, ileus, fever, malaise, tachycardia
B-Administer antibiotics as ordered
C-Promptly prepare patient for surgery

Patient Education and Health Maintenance
A-Instruct patient to avoid heavy lifting for 4 to 6 weeks after surgery
B-Instruct patient to report symptoms of anorexia, nausea, vomiting, fever, abdominal pain, incisional redness or drainage postoperatively

Evaluation: Expected Outcomes
A-Verbalizes decreased pain to 2 or 3 level on 0-to-10 scale with positioning and analgesics
B-Afebrile; no rigidity or distention