Unit 3: Appendicitis Flashcards
Appendicitis
acute inflammation of the appendix
- males more than females
- 10-19 age group
- only surgical management
Pathophysiology
- appendix is a small hollow appendage that extends off the cecum; has no known function
- appendicitis usually occurs as a result of fecalith or other foreign body blocking the opening, leading to inflammation and subsequent infection
- other causes: malignant tumors, twisting and kinking of the appendix, edema of the bowel wall, adhesions, and other infections
- When the opening to the appendix becomes blocked, the mucosa begins to secrete fluid, leading to venous engorgement that increases intraluminal pressure and restricts blood flow
- bacterial invasion occurs, and an abscess may develop if process occurs slowly
- Gangrene can occur in as little as 24 to 36 hours and is life threatening
- Perforation can occur in as few as 24 hours, but the risk increases after 48 hours and can result in peritonitis and is life-threatening
Clinical Manifestations
- periumbilical abdominal pain
- complaints of anorexia, nausea, and vomiting
- while inflammatory process progresses, pain is shifted to the RLQ of the abdomen and becomes more severe and steady in the area of McBurney’s point
- Rovsing’s sign
- Rebound tenderness
- WBC moderate increase (10,000-18000/mm3); if greater than 20,000/mm3 a perforated appendix should be suspected
- in event of perforation, may show signs of sepsis, including elevated temperature, tachycardia and decreased BP
McBurney’s Point
located in RLQ of abdomen
-pain increases at McBurney’s point w/ appendicitis
Rovsing’s sign
presents when palpation of the LLQ elicits pain in the RLQ
Rebound Tenderness
when applying and releasing pressure to this area, if the patient notes an increased pain when pressure is released
Diagnosis of Appendicitis
- based on clinical presentation and specific physical assessment findings
- Ultrasound may reveal an enlarged appendix
- CT most commonly used
- CBC and serum electrolytes
Surgical Management
- surgical consult should be obtained ASAP
- patient needs to be prepared for the OR for removal of appendix (appendectomy)
- laxatives and enemas avoided b/c they can result in perforation of the appendix
- may perform appendectomy with laparoscopy, where several small incisions are made and laparoscope is placed
- can be sent to PACU after in no complications arise
- if complications develop, admitted to hospital to receive parenteral antibiotics
Complications secondary to Appendicitis
associated w/ rupture that results in contamination of the peritoneal cavity w/ intestinal matter
-with rupture, patient develops peritonitis that may deteriorate to sepsis and requires IV antibiotics
Nursing Management: Assessment and Analysis
- patient may or may not initially present w/ elevated temp, but while inflammatory process progresses, pt will develop fever
- tachycardia results b/c of fever, fluid loss, and pain
- clinical manifestations may begin w/ cramping periumbilical pain followed by anorexia, nausea, and vomiting
- may exhibit pain in the area of McBurney’s point or Rovsing’s sign
- if expresses increased pain with coughing and/or movement and indicates that pain is relieved w/ bending the right hip or knees, further assessment for perforation and peritonitis is required
- abrupt change in the character of the pain and a change in BP and/or pulse may = perforation
- will likely have an elevated WBC count and a left shift in differential (increased # of immature WBC associated w/ inflammation and infection)
Nursing Diagnoses
- acute pain associated with inflammation of the appendix
- risk for deficient fluid volume associated w/ increased fluid loss (fever and vomiting)
- knowledge deficit associated with preoperative and postoperative care
Nursing Assessments
- Vital Signs
- Intake and Output
- WBC count and differential
- Pain
- Rebound Tenderness
Assessments: Vital Signs
fever may not present initially but will develop as inflammation increases
-tachycardia b/c of fever
Assessments: Intake and Output
- b/c of potential vomiting and fever, the patient is at risk for fluid volume deficit
- during the surgical procedure, anesthesia depresses the nervous system and the ability to assess the patient’s need to urinate
- if in PACU; patient needs to urinate before discharge
Assessments: WBC and differential
with appendicitis, will most likely have an elevated WBC count w/ a left shift in the differential
Assessment: Pain
patient with appendicitis experiences pain in RLQ
-changes in pain, if abrupt, may indicate perforation
Assessment: Rebound tenderness
when applying and releasing pressure to McBurney’s point, the patient notes increased pain when pressure is released; indicates appendicitis
Nursing Actions
- Keep patient NPO
- Administer prescribed IV fluids
- Prepare patient for OR
- Provide Comfort Measures
- Position supine w/ HOB elevated 30 to 45 degrees with knees flexed or side-lying with knees flexed
- Advance diet as tolerated after surgical procedure
Actions: Make sure patient is NPO
b/c surgical intervention is definitive treatment for appendicitis, the patient must have nothing by mouth during the diagnostic workup in the event the patient must emergently go to the OR
Actions: Administer prescribed IV fluids
b/c of an increase in fluid loss secondary to vomiting and fever, IV fluids are maintained preoperatively and postoperatively to maintain fluid balance
Actions: Prepare patient for OR
- there is no medical tx for appendicitis
- needs to be prepared for the operating room for removal of the appendix
- ensure surgical consent form is signed prior to receiving any sedatives or narcotics
Actions: Provide Comfort Measures
while the patient is prepared for the OR, ice may be applied to the RLQ to impede blood flow to the area, which slows the inflammatory process
- NEVER apply heat
- analgesics may be prescribed preoperatively but are generally withheld until a diagnosis is made to prevent masking of manifestations
- post-op opioid analgesics required
Actions: Position patient supine w/ HOB elevated 30-45 degrees with knees flexed or side-lying with knees flexed
decreases the strain (pull) on the abdominal muscles and may decrease pain secondary to inflammation in the peritoneal cavity
Actions: Advance diet as tolerated after surgical procedure
once bowel sounds have returned, begin diet with clear liquids, advancing as tolerated while assessing for N/V
Patient Teaching
- Turning, coughing, deep breathing, and incentive spirometer 10 times every hour while awake
- Early ambulation
- Take full course of antibiotics despite lack of fever or pain
- Teach wound care if appropriate
Teaching: Turning, coughing, deep breathing, and incentive spirometer 10 times every hour while awake
- promotes lung expansion
- prevents atelectasis
- helps mobilize any secretions to be expectorated
Teaching: Early ambulation
- promotes circulation
- prevention of VTE
- improves respiratory function
Teaching: Wound care if appropriate
- if the appendix is ruptured, the incision will be left open by the surgery to heal secondary intention
- involves a moist saline dressing two or three times a day
- patient/family should be taught before discharge
- home health referral should be included in the discharge planning to assist the patient and family at home w/ the dressing changes and asses for any complications that may arise
Safety Alert: Heat
if the patient is suspected of having appendicitis, never apply heat b/c this increases blood flow and inflammation to the area and may cause appendix to rupture
Evaluating Care Outcomes
- the patient who has had surgery for appendicitis w/o rupture is usually discharged from the PACU on the first postoperative day
- most have an uneventful recovery, and can resume normal activities in 2 to 4 weeks
- if appendix has ruptured, patient is admitted to the hospital and treated with antibiotics and wound care
- the family is involved in wound care, and a home health nurse is ordered to monitor progress of healing and assist the family with wound care
- expected outcomes: stable vital signs, CBC within normal limits, and demonstrated understanding of postoperative and discharge teaching
Connection Check: The nurse is caring for a patient in the ER with abdominal pain, fever, nausea, and vomiting. Patient is suspected of having appendicitis. What intervention may the provider order to confirm diagnosis?
A. Flat-plate x-ray of the abdomen, chemistry panel
B. CT scan, complete blood count (CBC), abdominal assessment for rebound tenderness
C. Administer a laxative to see if symptoms improve
D. Colonoscopy, esophagogastroduodenoscopy (EGD), and endoscopic retrograde cholangiopancreatogram (ERCP)
B. CT scan, complete blood count (CBC), abdominal assessment for rebound tenderness
