Week 12: Chp 58: Appendicitis

Question 1

What is Appendicitis

Answer 1

acute inflammation of the vermiform appendix

• affecting males over females
• occurs more frequently from 10 to 19 y/o
• if in older adults, its more serious
• no particular risk factors or preventative measures

Question 2

Appendix

Answer 2

a small hallow appendage that extends off the cecum, made of lymphatic tissue, but has no known function

Question 3

When does Appendicitis occur?

Answer 3

usually occurs as a result of fecalith or other foreign body blocking the opening, leading to inflammation and subsequent infection
-other less common causes: malignant tumors, twisting and kinking of the appendix, edema of the bowel wall, adhesions, and other infections

Question 4

What Happens when the opening to the appendix becomes blocked?

Answer 4

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 this process occurs slowly
• gangrene can occur 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 which is too life threatening

Question 5

Clinical Manifestations

Answer 5

• periumbilical abdominal pain, with complaints of anorexia, nausea, and vomiting
• while the inflammatory process progresses, the pain is shifted to the RLQ of the abdomen and becomes more severe in the area of McBurney’s Point
• Rovsing’s sign
• increased WBC
• if perforation, signs of sepsis as in elevated temperature, tachycardia, and decreased BP

Question 6

McBurney’s Point

Answer 6

located in the RLQ
-when applying and releasing pressure to this area, of the patient notes increasing pain when pressure is released, this is called rebound tenderness and is another indication of appendicitis

Question 7

Rovsing’s Sign

Answer 7

presents when palpation of the LLQ of the abdomen elicits pain in the RLQ

Question 8

Diagnosis

Answer 8

based on clinical presentations and specific physical assessment findings

• ultrasound (an enlarged appendix)
• CT scan (most commonly used)
• CBC and serum electrolyte

Question 9

What should be avoided with appendicitis?

Answer 9

Laxatives and enemas because they increase intra-abdominal pressure that may result in perforation of the appendix

Question 10

Surgical Management

Answer 10

Appendectomy (removal of appendix)

Question 11

Appendectomy

Answer 11

removal of the appendix

• may perform with laparoscopy, where several small incisions are made, and the laparoscope is placed
• if the appendix is suspected of being ruptured and/ or peritonitis is suspected, a laparotomy with a larger abdominal incision is made
• if there are no complications after surgery the patient may be discharged from the PACU
• if complications; admitted to the hospital to receive parenteral antibiotics

Question 12

Complications

Answer 12

secondary to appendicitis are associated with rupture that results in contamination of the peritoneal cavity with intestinal matter
-with rupture, the patient develops peritonitis that may deteriorate to sepsis and requires IV antibiotics to treat the infection

Question 13

Nursing Management: Assessment and Analysis

Answer 13

• may or may not present with elevated temperature, but while the inflammatory process progresses, the patient will develop a fever
• tachycardia because of the fever, fluid loss, and pain
• manifestations may begin with cramping periumbilical pain followed by anorexia, nausea, vomiting
• exhibit pain in the area of McBurney’s point
• Rovsing’s sign
• elevated WBC

Question 14

If the patient expresses increased pain with coughing and/or movement and indicates that pain is relieved with bending the right hip or knees, further assessment for what is required?

Answer 14

perforation and peritonitis

Question 15

An abrupt change in the character of the pain and change in blood pressure and/or pulse may indicate what?

Answer 15

perforation

Question 16

Perforation

Answer 16

a hole that develops through the wall of a body organ

Question 17

Nursing Diagnosis

Answer 17

• acute pain r/t inflammation of the appendix
• risk for deficient fluid volume r/t increased fluid loss (fever and vomiting)
• knowledge deficit r/t preoperative and postoperative care

Question 18

Nursing Assessments

Answer 18

• vital signs
• intake and output
• WBC count and differential
• pain
• rebound tenderness

Question 19

Assessments: Vital Signs

Answer 19

a fever may not be present initially but will develop as inflammation increases
-tachycardia may also be present with a fever

Question 20

Assessment: Intake and Output

Answer 20

because 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 need to urinate; urinary retention is more common with lower abdominal surgeries because of spasms and/or guarding related to pain
• if the patient is being discharged from the PACU, it is imperative that the patient urinate before discharge

Question 21

Assessment: WBC count and Differential

Answer 21

the patient with appendicitis will likely have an elevated WBC count with a left shift in the differential

Question 22

Assessment: Pain

Answer 22

patient with appendicitis experiences pain particularly in the RLQ
-changes in pain, particularly if abrupt, may indicate perforation

Question 23

Assessment: Rebound tenderness

Answer 23

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

Question 24

Nursing Actions

Answer 24

• make sure the patient is NPO
• administer prescribed IV fluids
• prepare patient for operating room
• provide comfort measures
• position patient supine with head of the bed elevated 30 to 45 degrees with knees flexed or side-lying with knees flexed
• advance diet as tolerated after surgical procedure

Question 25

Actions: Make sure patient is NPO

Answer 25

because surgical intervention is the definitive treatment for appendicitis, the patient must have nothing by mouth during the diagnostic work-up in the event the patient must emergently go to the operating room

Question 26

Actions: administer prescribed IV fluids

Answer 26

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

Question 27

Actions: prepare patient for operating room

Answer 27

there is no medical treatment for appendicitis

• the patient needs to be prepared for the operating room for removal of the appendix
• ensure that the surgical consent form is signed prior to the patient receiving any sedatives or narcotics

Question 28

Actions: Provide comfort measures

Answer 28

while the patient is prepared for the operating room, ice may be applied to the RLQ to impede blood flow to the area, which slows the inflammatory process

• the nurse should never apply heat, however, because this increases blood flow and inflammation to the area and may cause the appendix to rupture
• analgesics may be prescribed preoperatively but are generally withheld until a diagnosis is made to prevent masking of clinical manifestations
• postoperatively, the patient requires opioid analgesics

Question 29

Actions: Position patient supine with head of the bed elevated 30 to 45 degrees with knees flexed or side-lying with knees flexed

Answer 29

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

Question 30

Actions: advance diet as tolerated after surgical procedure

Answer 30

once bowel sounds have returned, begin diet with clear liquids, advancing as tolerated while assessing for nausea and/ or vomiting

Question 31

Nursing Teachings

Answer 31

• turning, coughing, deep breathing, and incentive spirometer 10 times every hour while awake
• early ambulation
• take full course antibiotics despite lack of fever or pain
• teach wound care if appropriate

Question 32

Teachings: turning, coughing, deep breathing, and incentive spirometer 10 times every hour while awake

Answer 32

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

Question 33

Teachings: early ambulation

Answer 33

promotes circulation and prevention of VTE and improves respiratory function

Question 34

Teachings: teach wound care if appropriate

Answer 34

if the appendix is ruptured, the incision will be left open by the surgery to heal by secondary intention

• wound care usually involves a moist saline dressing two or three times a day
• the patient/ family should be taught to change the dressing before discharge
• a home health referral should be included in the discharge planning to assist the patient and family at home with the dressing changes and assess for any complications that may arise

Question 35

If the patient has appendicitis, why should the nurse never apply heat?

Answer 35

because this increases blood flow and inflammation to the area may cause the appendix to rupture

Question 36

Evaluating care outcomes for the patient who had surgery without rupture

Answer 36

usually discharged from the PACU and can resume normal activities in 2 to 4 weeks

Question 37

Evaluating care outcomes for the patient who had surgery with rupture to the appendix

Answer 37

the patient is admitted to the hospital and treated with antibiotics and wound care
-family involved in wound care, and a home health nurse is ordered to monitor progress of healing and assist family with wound care

Question 38

Expected outcomes

Answer 38

stable vital signs, CBC within normal limits, and demonstrated understanding of postoperative discharge teaching