Appendicitis Nursing Care Management: Study Guide

Appendicitis is the classic surgical abdomen. A small appendage off the cecum gets obstructed, inflames, fills with pus, and will perforate if nobody acts. The bedside pattern is vague periumbilical pain that migrates to the right lower quadrant. Recognize it, get the patient to surgery, and protect against the complication that kills, which is rupture and peritonitis.

What is Appendicitis?

Any part of the lower GI tract can inflame from bacterial, viral, or fungal infection. Appendicitis (also called epityphlitis) is inflammation of the appendix, the small finger-like appendage attached to the cecum just below the ileocecal valve. Because the appendix empties into the colon inefficiently and its lumen is small, it is prone to obstruction and vulnerable to infection.

Pathophysiology

• Obstruction. The appendix becomes inflamed and edematous after it is kinked or occluded by a fecalith, tumor, or foreign body.
• Inflammation. Rising intraluminal pressure starts progressively severe, generalized or periumbilical pain.
• Pain. Within a few hours the pain localizes to the right lower quadrant.
• Pus formation. The inflamed appendix fills with pus.

Statistics and Epidemiology

Appendicitis is the most common cause of acute surgical abdomen and the most common reason for emergency abdominal surgery in the United States. It commonly occurs between ages 10 and 30 years.

Clinical Manifestations

• Pain. Vague epigastric or periumbilical pain progresses to right lower quadrant pain, usually with low-grade fever, nausea, and sometimes vomiting.
• Tenderness. In 50% of cases, local tenderness is elicited at McBurney's point on pressure.
• Rebound tenderness. Pain produced or intensified when pressure is released.
• Rovsing's sign. Palpating the left lower quadrant paradoxically causes pain in the right lower quadrant.

Complications

Perforation is the major complication, and it leads to peritonitis, abscess formation, or portal pylephlebitis. Perforation generally occurs 24 hours after the onset of pain. Watch for a fever of 37.7°C or greater, a toxic appearance, and continued abdominal pain or tenderness.

Assessment and Diagnostic Findings

• CBC count. Elevated WBC count with a neutrophil elevation.
• Imaging studies. Abdominal x-ray, ultrasound, and CT may show a right lower quadrant density or localized bowel distention.
• Pregnancy test. For women of childbearing age, rule out ectopic pregnancy before x-rays are obtained.
• Laparoscopy. Diagnostic laparoscopy rules out acute appendicitis in equivocal cases.
• C-reactive protein. Produced by the liver during bacterial infection, it rises rapidly within the first 12 hours.

Medical Management

Manage carefully so you do not mask the presenting symptoms.

• IV fluids. Correct fluid and electrolyte imbalance and dehydration before surgery.
• Antibiotic therapy. Given to prevent sepsis until surgery is performed.
• Drainage. If the appendix perforates and an abscess forms, treat initially with antibiotics; the surgeon may place a drain in the abscess.

Surgical Management

Immediate surgery is the rule once appendicitis is diagnosed.

• Appendectomy. Surgical removal of the appendix, done as soon as possible to cut the risk of perforation.
• Laparotomy and laparoscopy. Both are safe and effective even with perforation.

Nursing Management

The nurse's focus is preparing the patient for surgery.

Nursing Assessment

Assess the level of pain, relevant laboratory findings, and vital signs in preparation for surgery.

Diagnosis

• Acute pain related to obstructed appendix.
• Risk for deficient fluid volume related to preoperative vomiting and postoperative restrictions.
• Risk for infection related to ruptured appendix.

Nursing Care Planning & Goals

Goals include relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating infection from actual or potential GI disruption, maintaining skin integrity, and attaining optimal nutrition.

Nursing Interventions

• IV infusion. Replaces fluid loss and supports renal function.
• Antibiotic therapy. Prevents infection.
• Positioning. After surgery, place the patient in High-Fowler's to reduce tension on the incision and abdominal organs and ease pain.
• Oral fluids. Give when tolerated.

Evaluation

Confirm relieved pain, no fluid volume deficit, reduced anxiety, controlled infection, intact skin, and adequate nutrition.

Discharge and Home Care Guidelines

• Removal of sutures. Have the patient schedule suture removal with the surgeon between the 5th and 7th days after surgery.
• Activities. Avoid heavy lifting postoperatively; normal activity can resume within 2 to 4 weeks.
• Home care. A home care nurse may help with incision care and monitor for complications and wound healing.

Documentation Guidelines

Document the patient's description of and acceptable level of pain, prior medication use, laboratory results, surgical site, signs of infection, current or recent antibiotic therapy, the plan and teaching plan, response to interventions and teaching, progress toward outcomes, plan modifications, and long-term needs.