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Diseases and Conditions: Appendicitis

Appendicitis
Overview
Inflammation of the vermiform appendix, a bulge from the apex of the cecum
Most common major abdominal surgical emergency
Fatal if left untreated; gangrene and perforation develop within 36 hours

Pathophysiology
Mucosal ulceration triggers inflammation, which temporarily obstructs the appendix.
Obstruction with stool, tumors, or foreign bodies causes mucus outflow, increasing pressure in the
distended appendix; the appendix then contracts. Fluids and mucus continue to be secreted and stagnate.
Bacteria multiply and inflammation and pressure increase, restricting blood flow and causing thrombus,
abdominal pain, and ischemia to the wall of the appendix.
Continued inflammation, pressure, and fluid collection can lead to perforation and spillage of the
appendiceal contents into the peritoneal cavity.

Causes
Barium ingestion
Fecal mass
Trauma
Foreign body
Mucosal ulceration
Neoplasm
Stricture
Viral, bacterial, or fungal infection
Inflammatory bowel disease

Risk Factors
Low-fiber, high-carbohydrate diet
Family history
Gastrointestinal infection
Inflammatory bowel disease

Incidence
Appendicitis can occur at any age but affects more people between the ages of 11 and 20 years.
The disorder affects men slightly more than women.
Approximately 250,000 cases per year occur in the United States.

Complications
Peritonitis (most common)
Wound infection or abscess
Dehiscence
Intra-abdominal infection
Fecal fistula
Intestinal obstruction
Incisional hernia
Paralytic ileus
Abdominal or pelvic abscess
Death (rare)

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Assessment

History
Abdominal periumbilical or epigastric pain that's initially generalized and then localizes in the right lower
abdomen (McBurney point)
Anorexia
Nausea and vomiting
Diarrhea or constipation

Physical Findings
Low-grade fever, diaphoresis, chills
Anorexia
Tachycardia
Fetal position to decrease pain
Guarding, voluntary and involuntary
Right lower quadrant tenderness
Normoactive bowel sounds, with possible constipation or diarrhea
Rebound tenderness and spasm of the abdominal muscles at McBurney point
Rovsing sign (pain in right lower quadrant that occurs with palpation of left lower quadrant)
Psoas sign (abdominal pain that occurs when the patient flexes the hip when pressure is applied to the
knee)
Obturator sign (abdominal pain that occurs when the hip is rotated)
Absent abdominal tenderness or flank tenderness in a patient with a rectocele or pelvic appendix
Inflamed hemiscrotum (male infants and children)

Diagnostic Test Results

Laboratory
White blood cell count and differential and neutrophils test results are moderately elevated, with increased
numbers of immature cells.
C-reactive protein test may be increased; very high levels indicate gangrenous activity.
Bilirubin level test results may be elevated.
Urinalysis may reveal elevated specific gravity, hematuria, and pyuria.

Imaging
Ultrasonography (pelvic area) or ultrasonography (transvaginal) may show appendiceal inflammation.
Computed tomography scanning (abdomen and pelvis) demonstrates suspected perforation or abscess.
Abdominal magnetic resonance imaging may show signs of inflammation, ruptured appendix, and
appendiceal lumen blockage.

Treatment

General
Incentive spirometry (postoperatively)
Venous thromboembolism (VTE) prophylaxis while hospitalized

Diet
Nothing by mouth (NPO) status until after surgery, then gradual return to a regular diet

Activity
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Early postoperative ambulation

Medications
IV fluids, such as normal saline or lactated Ringer solution
Analgesics, such as morphine sulfate (postoperatively)
Antibiotics preoperatively and if peritonitis develops
Single dose of broad-spectrum antibiotic, such as cefoxitin sodium or cefotetan, for uncomplicated
acute appendicitis
If gangrenous or ruptured appendicitis, fluoroquinolones, such as ciprofloxacin hydrochloride or
levofloxacin and metronidazole (oral; injection); alternatively, ampicillin sodium-sulbactam sodium,
ticarcillin disodium-clavulanate potassium, or piperacillin sodium-tazobactam sodium as second-line
agents

Surgery
Appendectomy (laparoscopically unless perforation is present)
Percutaneous or transrectal drainage of localized abscess

Nursing Considerations

Nursing Interventions
Maintain NPO status until surgery is performed.
Initiate IV access and administer IV fluids, as ordered; maintain patent IV access.
Avoid administering cathartics or enemas that may rupture the appendix.
Screen for and assess the patient's pain using facility-defined criteria that are consistent with the patient's
age, condition, and ability to understand.
Treat the patient's pain, as needed and ordered, using nonpharmacologic, pharmacologic, or a combination
of approaches.
Monitor closely if the patient is at high risk for adverse outcomes related to opioid treatment if prescribed.
Reassess and respond to the patient's pain by evaluating the response to treatment and progress toward
pain management goals.
Place the patient in the Fowler position to decrease pain.
Minimize activity that may aggravate pain, such as coughing and ambulation.
Administer antibiotics, as ordered.
Auscultate bowel sounds for changes.

WARNING!
Never apply heat to the right lower abdomen; this can cause the appendix to
rupture.
Physically and psychologically prepare the patient and family for surgery.
Administer prescribed preoperative drugs.
Apply antiembolism or sequential compression stockings to prevent VTE.

Monitoring
Vital signs
Pain level and effectiveness of pain management
NPO status
Fluid balance

After Surgery
Vital signs

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Intake and output

Pain level and effectiveness of pain management
Bowel sounds, passing of flatus, and bowel movements
Wound healing
Laboratory test results, such as white blood cell count

Associated Nursing Procedures

Antiembolism stocking application, knee-length
Antiembolism stocking application, thigh-length
Coughing and diaphragmatic breathing exercises
General anesthesia patient care, PACU
General patient care, PACU
Incentive spirometry
Informed consent
Intake and output measurement
IV catheter insertion
IV catheter removal
IV pump use
IV secondary line drug infusion
Nutritional screening
Oral drug administration
Pain assessment
Pain management
Patient-controlled analgesia
Postoperative care
Preoperative care
Preparing a patient for abdominal surgery, OR
Pulse oximetry
Safe medication administration practices, general
Sequential compression therapy
Surgical wound dressing application
Wound assessment

Patient Teaching

General
Include the patient's family or caregiver in your teaching, when appropriate. Be sure to cover:
explanation of appendicitis and the planned treatment, including surgery
preoperative teaching, including the need for coughing and diaphragmatic breathing exercises and
incentive spirometry
possible complications, such as wound infection
surgical site care, including appropriate wound care and dressing changes, if indicated
prescribed medications, including administration, expected results, and possible adverse reactions
pain management plan and possible adverse effects of pain management treatment
safe use, storage, and disposal of opioids, if prescribed
postoperative activity limitations, typically for 4 to 6 weeks if an open approach is used
postoperative follow-up at 2 and 6 weeks
signs and symptoms to report to a practitioner after surgery, including anorexia, nausea, vomiting,
abdominal pain, fever, and chills.

Discharge Planning
Participate as part of a multidisciplinary team to coordinate discharge planning efforts. The team may
include the bedside nurse, a care manager, and a general surgeon.
Determine the appropriate posthospital setting to which the patient should be discharged.
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Assess the patient's and family's understanding of diagnosis, treatment, prognosis, follow-up, and warning
signs for which to seek medical attention.
Identify the patient's formal and informal supports.
Identify the patient's and family's goals, preferences, comprehension, and concerns about discharge.
Confirm arrangements for transportation to initial follow-ups.
Provide a list of prescribed drugs, including the dosage, prescribed time schedule, and adverse reactions to
report to the practitioner. Provide the patient (and family or caregiver, as needed) with written information
on the medications that the patient should take after discharge.
Assess the patient's and family's understanding of prescribed medication, including dosage, administration,
expected results, duration, and possible adverse effects.
Assess the patient's ability to obtain medications; identify the party responsible for obtaining medications.
Instruct the patient to provide a list of medications to the practitioner who will be caring for the patient
after discharge; to update the information when the practitioner discontinues medications, changes doses,
or adds new medications (including over-the-counter products); and to carry a medication list that contains
all of this information at all times in the event of an emergency.
Ensure that the patient and caregivers have been given medical contact information.
Ensure that the patient (and family or caregiver, as needed) receives a copy of the discharge instructions
and that a copy is placed in the patient's medical record.
Document the discharge planning evaluation in the patient's clinical record, including who was involved in
discharge planning and teaching, their understanding of the teaching provided, and any need for follow-up
teaching.
INSERT_HANDOUTS

Resources
National Digestive Diseases Information Clearinghouse: https://www.niddk.nih.gov/health-
information/digestive-diseases?dkrd=lgdmn0027
INSERT_CONTENT_ASSOCIATION_LOGOS

Selected References
1. Atema, J. J., et al. (2015). Scoring system to distinguish uncomplicated from complicated appendicitis. British
Journal of Surgery, 102(8), 979–990. (Level VI)
Abstract | Complete Reference
2. Bhangu, A., et al. (2015). Acute appendicitis: modern understanding of pathogenesis, diagnosis, and
management. Lancet , 386(10000), 1278–1287.
Abstract | Complete Reference
3. Craig, S. (2018). “Appendicitis” [Online]. Accessed June 2020 via the Web at
http://emedicine.medscape.com/article/773895-overview
4. D'Souza, N., et al. (2016). Magnetic resonance imaging (MRI) for diagnosis of acute appendicitis. Cochrane
Database of Systematic Reviews, 2016(1), CD012028. (Level I)
5. Evans, M. M., & Curtin, M. (2014). Acute appendicitis: A case study describing standards of care. Medsurg
Nursing , 23(6, Suppl 3), 15.
Abstract | Complete Reference
6. Flum, D. R. (2015). Clinical practice: Acute appendicitis-appendectomy or the “antibiotics first” strategy. New
England Journal of Medicine, 372(20), 1937–1943.
Abstract | Complete Reference
7. Harnoss, J. C., et al. (2017). Antibiotics versus surgical therapy for uncomplicated appendicitis: Systematic
review and meta-analysis of controlled trials. Annals of Surgery, 265(5), 889–900. (Level I)
Abstract | Complete Reference
8. Mallinen, J., et al. (2019). Risk of appendiceal neoplasm in periappendicular abscess in patients treated with
interval appendectomy vs follow-up with magnetic resonance imaging: 1-year outcomes of the peri-
appendicitis acuta randomized clinical trial. JAMA Surgery, 154(3), 200–207. (Level II)
Abstract | Complete Reference | Full Text
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2/22/2021 View Monograph

9. Marshall, M. J., et al. (2015). Biomarkers for the diagnosis of acute appendicitis in adults. Cochrane Database
of Systematic Reviews, 2015(3), CD011592. (Level I)
10. Martin, R. F. Acute appendicitis in adults: Clinical manifestations and differential diagnosis. (2018). In:
UpToDate, Weiser, M., & Marx, J. A. (Eds.).
11. Nettina, S. M. (2019). Lippincott manual of nursing practice (11th ed.). Philadelphia, PA: Wolters Kluwer.
12. NIH National Institute of Diabetes and Digestive and Kidney Disease. (2014). Appendicitis. NIH Publication,
13, 1–8. Accessed June 2020 via the Web at https://www.niddk.nih.gov/health-information/digestive-
diseases/appendicitis
13. Pare, J. R., et al. (2015). Revival of the use of ultrasound in screening for appendicitis in young adult men.
Journal of Clinical Ultrasound, 44(1), 3–11. (Level VI)
Abstract | Complete Reference
14. Pasumarthi, V., et al. (2018). A comparative study of RIPASA score and ALVARADO score in diagnosis of
acute appendicitis. International Surgery Journal, 5(3), 796–801. (Level VI)
15. Rebarber, A., & Jacob, B. P. Acute appendicitis in pregnancy. (2019). In: UpToDate, Lockwood, C. J., et al.
(Eds.).
16. Rushing, A., et al. (2019). Management of acute appendicitis in adults: A practice management guideline
from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery, 87(1),
214–224. (Level VII)
Abstract | Complete Reference
17. Smink, D., & Soybel, D. Management of acute appendicitis in adults. (2098). In: UpToDate, Weiser, M. (Ed.).

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