Appendicitis

*Perforation Indications*

*If patient has severe pain then all of a sudden goes away could mean PERFORATION*

*Appendicitis Major Complications*

-*Perforation* -*Peritonitis:* Inflammation of the membrane lining the abdominal wall and covering the abdominal organs -*Abscess*

Traditional Triple Antibiotic Regimen

-Amoxicillin -Gentamicin -Clindamycin

Patients presenting with appendicitis two necessary steps to take are ______ & ________

-Clarify if the patient should be NPO -See if you can get an IV going

*Diagnostic Studies for Appendicitis*

-Differential WBC Count: WBCs increased in 90% of cases (10-16 w/increased neutrophils) -Urinalysis: Want to rule out any other condition such as UTI that might be causing the same symptoms -*ABDOMINAL X-RAY: Looking for presence of FREE AIR that would indicate the PERFORATION OF THE APPENDIX* -Abdominal Computed Tomography (CT) Scan: Can actually see the appendix and see if it is inflamed -IV Pyelogram: Really more for stones, not usually seen -Ultrasonography/CT Scans: Can assist in differentiating appendicitis from perforated ulcer or cholecystitis

Early vs. Intermediate Stage Appendicitis

-Early Stage - May just start out as generalized pain not necessarily in the RLQ, can have N/V, but not always, could be fever, Elevated WBCs may not be there -Intermediate Stage - Pain Right Side @ Mcburney's point, 2 inches from inferior iliac crest may feel Diarrhea or need to use restroom, Malaise, may not feel like eating, Diminished Peristalsis

Physical Assessment Is performed in Four Steps

-Inspect/Assess First -Auscultate -Percussion -Palpation (don't want to stir up Bowel Sounds before auscultation)

Pain Medications for Appendicitis

-Morphine standard medication in the acute care setting -Eventually move towards to things that they can take at home, Narco/Tylenol, other meds

Physical Assessment Appendicitis Findings

-Pain in the RLQ elicited by light palpation of the abdomen (Physician can often use 1 finger to find) -Presence of rebound tenderness RLQ -RLQ guarding -Rigidity -Muscle spasms -Tachycardia -Low-grade fever -Pain elicited with rectal examination -*Children will often feel Anorexic & ill & They often cannot walk or climb up onto the examination table without assistance

Clinical Manifestations Acute appendicitis w/Perforation

-Typically, patient remains rigid with flexed knees -Presence of abscess can result in a tender, palpable mass & possibly fever & leukeocytosis -The abdomen may be distended

Appendicitis

An acute inflammation of the appendix, is the most common cause of emergent abdominal surgery in children

Rovsing's Sign

If palpation of the LLG of a person's abdomen increases the pain felt in the RLQ, the patient is said to have a positive Rovsing's sign and may have appendicitis

Appendicitis Pathophysiology

It is thought that the obstruction is due to fecal material impacted into the relatively narrow appendix, though other causes such as ingested foreign bodies may exist. This causes a subsequent increase in the intraluminal pressure of the appendix, resulting in mucosal edema, bacterial overgrowth, and eventual perforation.

Appendicitis Surgery

Laparoscopic Appendectomy - Gas has got to come out and It's not going to get out by just sitting around (Patient's who've never really experienced pain, you will have difficulty getting them up and moving sometimes)

Appendicitis Stay in the Health Care Setting

Patients will be on the Acute care surgical unit for ruptured appendix with peritonitis Only 1-day length of stay: For suspected acute appendicitis (Only applies if there is no gangrenous/infectious issue, if there is then patients will need to be on antibiotics for 72 hours)

Appendicitis Antibiotics Moving Forward

Trying to condense them and give these medications Once a day -Ceftriaxone -Metronidazole

McBurney's Point

Point midway between the anterior superior iliac crest and the umbilicus where pain is often felt during appendicitis

Nursing Problem List Appendicitis

○ Risk for infection r/t inadequate primary defenses ○ Abdominal pain r/t injury, pathological process ○ Dysfunctional gastrointestinal motility r/t decreased perfusion, medication effect ○ Constipation r/t decreased activity, decreased fluid intake, anesthesia, opioids ○ Body Image Issues especially in younger patients ○ Decreased bowel motility ○ Imbalanced nutrition ○ Check Foley, Monitor V/S (look at temperature for sepsis), Monitor surgical incision & wound drainage ○ Impaired Gas Exchange (due to being in pain & quick shallow breathing) ○ Impaired Tissue Integrity ○ DO NOT DO ENEMAS OR GIVE LAXATIVES, can enhance the perforation process ○ Finish Antibiotics on admission ○ N/V - possibly have an antiemetic along the way ○ Best to get pain medicines before the patient is in severe pain, better to be proactive ○ NPO - May need NG tube ○ May have to have a drain put in, may need patient teaching ○ Splint stomach at incision sites ○ Incentive Spirometer