Gaston College NUR 112 Appendicitis

Risk factors:

Adolescent boys are at greatest risk, although fecaliths can occur in both genders at any age. Individuals whose diet is low in fiber or high in carbohydrates are at greater risk for developing fecaliths. GI infections also promote appendicitis.

Prevention:

Appendicitis cannot be prevented; however, certain dietary habits may reduce the risk of developing this condition. Eating foods that contain high fiber content, such as fresh fruits and vegetables, decreases the incidence of appendicitis

Lifespan considerations: Older adults

Because of less acute pain and local tenderness in older adults, the diagnosis is delayed. The course of acute appendicitis is more virulent in older adults, so complications can develop sooner and result in increased mortality.

Lifespan considerations: Children

Children under the age of 4 typically do not develop appendicitis. However, appendicitis in young children often progresses to rupture because they cannot accurately tell their parents how they feel and where it hurts.

Clinical manifestations of Peritonitis:

High fever, acute severe abdominal pain, abdominal distention, resultant death if not treated aggressively and rapidly Removal of the ruptured appendix Antibiotics Fluid resuscitation Supportive treatment to maintain vital signs

Nursing Diagnosis:

I. Gas Exchange, Impaired II. Fluid Volume, Risk for Deficient III. Infection, Risk for IV. Pain, Acute V. Anxiety VI. Fear

Definitions: Appendicitis

Inflammation of the vermiform appendix, is a common cause of acute abdominal pain.

Safety Note:

Keep the patient with suspected appendicitis NPO (nothing by mouth). Do not administer laxatives or enemas, which may cause perforation of the appendix. Do not apply heat to the abdomen, as this may increase circulation to the appendix and also cause perforation.

Textbook Notes:

Notes on appendicitis

Lifespan considerations: Pregnant Women

Pregnant women may develop right lower quadrant, periumbilical, or right subcostal (under the rib cage) pain due to possible displacement of the appendix by the distended uterus.

Treatment of Peritonitis:

Removal of the ruptured appendix Antibiotics Fluid resuscitation Supportive treatment to maintain vital signs

Definitions: McBurney point

This is located midway between the umbilicus and the anterior iliac crest in the right lower quadrant. It is the usual side for localized pain and rebound tenderness due to appendicitis.

Diagnosis:

· Abdominal ultrasound is the most effective test for diagnosing acute appendicitis. Other diagnostic tests used to diagnose appendicitis and rule out other possible conditions include abdominal x-rays, IV pyelogram, urinalysis, and pelvic examination. In addition, a WBC count with differential is obtained. With appendicitis, the total WBC count is elevated, with an increased number of immature WBCs (bands, this is also know as a left shift!)

Laparotomy:

· An open appendectomy is performed by laparotomy. A small transverse incision is made at McBurney point; the appendix is isolated and ligated (tied off) to prevent contamination of the site with bowel contents, and it is then removed. Laparotomy generally is used when the appendix has ruptured. It allows removal of contaminants from the peritoneal cavity by irrigation with sterile normal saline. The wound may occasionally be left unsutured for periodic irrigation. Recovery is generally uneventful.

Pharmacological Therapy: Antibiotic therapy

· Antibiotic therapy with a third-generation cephalosporin, such as cefoperazone (Cefobid), cefotaxime (Claforan), ceftazidime (Fortaz), or ceftriaxone (Rocephin), is initiated prior to surgery. Antibiotic administration is repeated during surgery and continued for at least 48 hours postoperatively.

Laparoscopic appendectomy:

· Laparoscopic appendectomy: requires a very small incision, through which the laparoscope is inserted. This procedure has several advantages: (1) Direct visualization of the appendix allows definitive diagnosis without laparotomy, (2) postoperative hospitalization is short, (3) postoperative complications are infrequent, and (4) recovery and resumption of normal activities are rapid.

Clinical Manifestations:

· The initial characteristic manifestation of acute appendicitis is continuous, mild, generalized or upper abdominal pain. Over the next 4 hours, the pain intensifies and localizes in the right lower quadrant of the abdomen. Pain associated with appendicitis is aggravated by moving, walking, or coughing. On palpation, localized and rebound tenderness are noted at McBurney point. In addition to pain, a low-grade fever, anorexia, nausea, and vomiting are often present.

Pathophysiology:

· The obstruction of the appendix is often caused by a hard mass of feces (fecalith). Other obstructive causes include a calculus or stone, parasites, edema of lymphoid tissue, a tumor, or a foreign body. Following obstruction, the appendix becomes distended with fluid secreted by its mucosa. Pressure within the lumen of the appendix increases, impairs its blood supply, and leads to inflammation, edema, ulceration, and infection. The purulent exudate formed causes further distention of the appendix. If treatment is not initiated, tissue necrosis and gangrene result within 24-36 hours, leading to perforation. This allows the contents of the GI tract to flow into the peritoneal space of the abdomen, resulting in peritonitis, inflammation and bacterial infection of the entire abdominal area.

Discharge Planning

· The patient whose appendix did not rupture is discharged once bowel function returns and the patient has a bowel movement. If the appendix was ruptured, the patient will be hospitalized for several days in order to administer IV antibiotics. Prior to discharge, the nurse should provide patient teaching.

Pharmacological Therapy: Pain meds

· The sudden disappearance of pain is an indication that the appendix has ruptured, so administration of strong analgesics is withheld preoperatively during assessment for this indicator. Once the diagnosis is established, an appendectomy is performed and analgesics are administered as ordered to maintain comfort.

Surgery:

· The treatment of choice for acute appendicitis is an appendectomy, surgical removal of the appendix. Either a laparoscopic approach (insertion of an endoscope to view abdominal contents) or laparotomy (surgical opening of the abdomen) is used for appendectomy.

What causes Peritonitis:

Peritonitis resulting from appendix rupture with bowel contents leaking into the abdominal cavity