Unit 3: Appendicitis

Question 1

Appendicitis

Answer 1

acute inflammation of the appendix

• males more than females
• 10-19 age group
• only surgical management

Question 2

Pathophysiology

Answer 2

• 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

Question 3

Clinical Manifestations

Answer 3

• 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

Question 4

McBurney’s Point

Answer 4

located in RLQ of abdomen

-pain increases at McBurney’s point w/ appendicitis

Question 5

Rovsing’s sign

Answer 5

presents when palpation of the LLQ elicits pain in the RLQ

Question 6

Rebound Tenderness

Answer 6

when applying and releasing pressure to this area, if the patient notes an increased pain when pressure is released

Question 7

Diagnosis of Appendicitis

Answer 7

• based on clinical presentation and specific physical assessment findings
• Ultrasound may reveal an enlarged appendix
• CT most commonly used
• CBC and serum electrolytes

Question 8

Surgical Management

Answer 8

• 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

Question 9

Complications secondary to Appendicitis

Answer 9

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

Question 10

Nursing Management: Assessment and Analysis

Answer 10

• 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)

Question 11

Nursing Diagnoses

Answer 11

• 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

Question 12

Nursing Assessments

Answer 12

• Vital Signs
• Intake and Output
• WBC count and differential
• Pain
• Rebound Tenderness

Question 13

Assessments: Vital Signs

Answer 13

fever may not present initially but will develop as inflammation increases
-tachycardia b/c of fever

Question 14

Assessments: Intake and Output

Answer 14

• 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

Question 15

Assessments: WBC and differential

Answer 15

with appendicitis, will most likely have an elevated WBC count w/ a left shift in the differential

Question 16

Assessment: Pain

Answer 16

patient with appendicitis experiences pain in RLQ

-changes in pain, if abrupt, may indicate perforation

Question 17

Assessment: Rebound tenderness

Answer 17

when applying and releasing pressure to McBurney’s point, the patient notes increased pain when pressure is released; indicates appendicitis

Question 18

Nursing Actions

Answer 18

• 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

Question 19

Actions: Make sure patient is NPO

Answer 19

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

Question 20

Actions: Administer prescribed IV fluids

Answer 20

b/c of an increase in fluid loss secondary to vomiting and fever, IV fluids are maintained preoperatively and postoperatively to maintain fluid balance

Question 21

Actions: Prepare patient for OR

Answer 21

• 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

Question 22

Actions: Provide Comfort Measures

Answer 22

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

Question 23

Actions: Position patient supine w/ HOB elevated 30-45 degrees with knees flexed or side-lying with knees flexed

Answer 23

decreases the strain (pull) on the abdominal muscles and may decrease pain secondary to inflammation in the peritoneal cavity

Question 24

Actions: Advance diet as tolerated after surgical procedure

Answer 24

once bowel sounds have returned, begin diet with clear liquids, advancing as tolerated while assessing for N/V

Question 25

Patient Teaching

Answer 25

• 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

Question 26

Teaching: Turning, coughing, deep breathing, and incentive spirometer 10 times every hour while awake

Answer 26

• promotes lung expansion
• prevents atelectasis
• helps mobilize any secretions to be expectorated

Question 27

Teaching: Early ambulation

Answer 27

• promotes circulation
• prevention of VTE
• improves respiratory function

Question 28

Teaching: Wound care if appropriate

Answer 28

• 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

Question 29

Safety Alert: Heat

Answer 29

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

Question 30

Evaluating Care Outcomes

Answer 30

• 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

Question 31

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)

Answer 31

B. CT scan, complete blood count (CBC), abdominal assessment for rebound tenderness