HARAMAYA UNIVERSITY

COLLEGE OF HEALTH AND MEDICAL

SCIENCES
SCHOOL OF NURSING AND MIDWIFERY
MSC IN NURSING (MAJOR IN ADULT
HEALTH NURSING)

APPENDICITIS

By: Helina Heluf HARAR,

ETHIOPIA
1 Supervisor: Teshager Worku by Helina H. 07/27/202120 APRIL, 2019
 Contents
2

 Introduction
 Pathophysiology
 Classification
 Clinical manifestation
 Management
 Nursing interventions
 Complication
by Helina H. 07/27/2021
 Objectives
3

At the end of this session you will be able to:

 Define appendicitis.
 Explain the clinical manifestations of appendicitis.
 Describe the managements for appendicitis.
 Explain the major nursing responsibilities for a
patient with appendicitis.

by Helina H. 07/27/2021
 Appendicitis
4

Introduction
 The appendix is a small, fingerlike appendage about 10 cm (4 in)
long that is attached to the cecum just below the ileocecal valve.
 The appendix fills with food and empties regularly into the
cecum.
 Because it empties inefficiently and its lumen is small, the
appendix is prone to obstruction and is particularly vulnerable to
infection (ie, appendicitis).
by Helina H. 07/27/2021
 Introduction cont’d
5

by Helina H. 07/27/2021
 Introduction cont’d
6

 Appendicitis is an inflammation of the appendix.

 Appendicitis occurs in approximately 10% of the
population.
 affects males more than females.
 It occurs more in teenagers than adults and mostly
between the ages of 10 and 30 years.

by Helina H. 07/27/2021
 Pathophysiology of appendicitis
7

Obstruction of the appendiceal lumen by lymphoid

hyperplasia, or by a fecalith, foreign body, or even worm

bacterial
Distension of
overgrowt Ischemia
the appendix
h

Inflammatio
Gangrene Necrosis
n
If the perforation is contained
by the omentum, an appendiceal abscess
Perforation results
If containment does not occur, generalized
by Helina H. 07/27/2021
peritonitis results
 Classification of appendicitis
8

 Simple - is inflamed but still intact

 Gangrenous - There is tissue necrosis and
microscopic areas of perforation.
 Perforation - There is large perforation, which
involves contents flowing into the peritoneal cavity,

by Helina H. 07/27/2021
 Clinical manifestation
9

 Vague epigastric or periumbilical pain progresses to RLQ

along with
 low grade fever
 Nausea and vomiting
 Loss of appetite
 Local tenderness at MC Burney’s point
 Rebound tenderness
by Helina H. 07/27/2021
 Clinical manifestations cont’d
10

by Helina H. 07/27/2021
 Clinical manifestation cont’d
11

 If the appendix curls around behind the cecum, pain and

tenderness may be felt in the lumbar region.
 If its tip is in the pelvis, pain may be elicited only on
rectal examination.
 If appendix is resting against the rectum, pain on
defecation.
 If the tip is near the bladder/the ureter, pain on urination.
by Helina H. 07/27/2021
 Clinical manifestation cont’d
12

Rovsing’s sign
 Pain may be elicited by palpating the LLQ; this causes
pain to be felt in the RLQ.
 Continuous deep palpation starting from the left iliac
fossa counterclockwise along the colon may push
bowel contents towards the ileocaecal valve and thus
increasing pressure around the appendix.
by Helina H. 07/27/2021
 Clinical manifestation cont’d
13

Obturator sign
• If an inflamed appendix is
in contact with the
Obturator internus, spasm
of the muscle
• Flexing and internal
rotation of the hip will
cause pain in the
by Helina H. 07/27/2021
hypogastrium.
 Clinical manifestation cont’d
14

Psoas sign
• Pain is on the RLQ with passive extension of the patient's right hip .
– This reveals inflammation of the peritoneum overlying the
iliopsoas muscles and inflammation of the Psoas muscles
themselves.

• Straightening out the leg causes pain because it stretches these

muscles, while flexing the hip activates the iliopsoas and therefore
by Helina H. 07/27/2021
also causes pain.
 Clinical manifestation cont’d
15

by Helina H. 07/27/2021
 Clinical manifestation cont’d
16

Sitkovskiy(Rosenstein)'s sign
 Increased pain in the right iliac region as patient lies on left side.

Dunphy's sign
 Increased pain in the RUQ with coughing.

Kocher's (Kosher's) sign

 The history pain in the epigastric region at the beginning of
disease with a subsequent shift to the right iliac region.
by Helina H. 07/27/2021
 Clinical manifestation cont’d
17

 Some rigidity of the lower portion of the right rectus muscle

may occur.
 Pregnant women may develop right lower quadrant,
periumbilical, or right subcostal pain.
 Diffused pain If the appendix has ruptured
 Abdominal distention as a result of paralytic ileus
 Constipation
 Laxatives may produce perforationby Helina H. 07/27/2021
 Diagnostic tests
18

 A CBC will reveal an elevated WBC (10,000/mm3 to 20,000/mm3) and

elevation of neutrophil.
 Abdominal ultrasound
 CT of the abdomen and pelvis.
 abdominal x-rays
 intravenous pyelogram
 pregnancy test
 diagnostic laparoscopy
 Urinalysis
by Helina H. 07/27/2021
 Pelvic examination
 Management
19

 Immediate surgery is typically indicated if

appendicitis is diagnosed.
 An appendectomy is performed either with a
laparoscopic approach or an open appendectomy by
laparotomy.

by Helina H. 07/27/2021
 Management cont’d
20

Pre operative
 The patient is kept NPO
 Ice to the site of pain and maintaining semi-Fowler’s
position to reduce pain.
 the patient will be on IV fluids.
 Antibiotic therapy is initiated prophylactically (e.g., third
generation cephalosporins).
by Helina H. 07/27/2021
 Management cont’d
21

Surgery

laparoscopy has several advantages:

 Direct visualization of the appendix allows definitive
diagnosis without laparotomy.
 postoperative hospitalization is short.
 postoperative complications are infrequent
 recovery and resumption of normal activities is rapid.
by Helina H. 07/27/2021
 less pain (Wei, B et al, 2011).
 Management cont’d
22

 Laparotomy generally is used when the appendix has

ruptured.
 It allows removal of contaminants from the peritoneal
cavity by irrigation with sterile normal saline.

by Helina H. 07/27/2021
 Management cont’d
23

 When perforation of the appendix occurs, an abscess may

form.
 The patient may be initially treated with antibiotics, a drain is
placed in the abscess.
 After the abscess is drained and there is no further evidence of
infection, an appendectomy is then typically performed.

by Helina H. 07/27/2021
 Management cont’d
24

After surgery
 the patient is managed with normal postoperative care measures
 Ensuring good respiratory effort free of lung consolidation,
 Taking frequent vital signs
 maintaining IV fluids
 Assessing the wound
 Treating for pain
 Preventing infection. by Helina H. 07/27/2021
 Management cont’d
25

After surgery
 The patient is usually NPO until GI functioning returns.
 The patient is placed in a semi fowler’s position.
 If the appendix has ruptured, the patient may have an
orogastric or nasogastric tube placed to decompress the
stomach.
 Discharge will likely occur within 24 hours.
by Helina H. 07/27/2021
 Complications
26

Perforation of the appendix

 which can lead to peritonitis, abscess formation, or portal
pylephlebitis.
 Occurs 24 hours after the onset of pain.
 Symptoms include fever 37.7oc or greater, toxic
appearance, continued abdominal pain or tenderness.

by Helina H. 07/27/2021
 Potential complications and nursing
interventions after appendectomy
27

1. Peritonitis
 Interventions
 Monitor for abdominal tenderness, fever, vomiting,
abdominal
 rigidity, and tachycardia.
 Employ constant nasogastric suction.
 Correct dehydration as prescribed.
 Administer antibiotic agents asby prescribed.
Helina H. 07/27/2021
 Potential complications and nursing
interventions after appendectomy
28

2. Pelvic abscess
 Interventions
 Evaluate for anorexia, chills, fever, and diaphoresis.
 Observe for diarrhea, which may indicate pelvic abscess.
 Prepare patient for rectal examination.
 Prepare patient for surgical drainage procedure.

by Helina H. 07/27/2021
 Potential complications and nursing
interventions after appendectomy
29

3. Subphrenic abscess
 Interventions
 Assess patient for chills, fever, and diaphoresis.
 Prepare for x-ray examination.
 Prepare for surgical drainage of abscess.

by Helina H. 07/27/2021
 Potential complications and nursing
interventions after appendectomy
30

4. Ileus
 Interventions
 Assess for bowel sounds.
 Employ nasogastric intubation and suction.
 Replace fluids and electrolytes by intravenous route as
prescribed.
 Prepare for surgery, if diagnosis of mechanical ileus is
established. by Helina H. 07/27/2021
 Prevention
31

 A bounty of fresh, fiber-rich vegetables and fruits

into meals is a wonderful prevention strategy against
appendicitis.
 Maintain good immune system.

by Helina H. 07/27/2021
 Nursing diagnosis, NOC and NIC
32

NURSING DIAGNOSIS: Infection, risk for

 Risk factors may include: Inadequate primary defenses;
perforation/rupture of the appendix; peritonitis; abscess
formation
 Invasive procedures, surgical incision
 Possibly evidenced by: [Not applicable; presence of signs
and symptoms establishes an actual diagnosis.]
by Helina H. 07/27/2021
 Nursing diagnosis, NOC and NIC
33

NOC
 DESIRED OUTCOMES/EVALUATION CRITERIA
 Wound Healing: Primary Intention (NOC)
 PATIENT WILL: Achieve timely wound healing; free
of signs of infection/inflammation, purulent drainage,
erythema, and fever

by Helina H. 07/27/2021
 Nursing diagnosis, NOC and NIC
ACTIONS/INTERVENTIONS RATIONALE 
Infection
34 Control (NIC)
Independent
Practice/instruct in good handwashing and Reduces risk of spread of bacteria.
aseptic wound care. Encourage/provide
perineal care.
Inspect incision and dressings. Note Provides for early detection of developing
characteristics of drainage from infectious process, and/or monitors
wound/drains (if inserted), presence of resolution of preexisting peritonitis.
erythema.
Monitor vital signs. Note onset of fever, Suggestive of presence of
chills, diaphoresis, changes in mentation, infection/developing sepsis, abscess,
reports of increasing abdominal pain. peritonitis.

Obtain drainage specimens if indicated. Gram’s stain, culture, and sensitivity

testing isuseful in identifying causative
organism and choice of therapy.
by Helina H. 07/27/2021
 Nursing diagnosis, NOC and NIC
35

ACTIONS/INTERVENTIONS RATIONALE 

Infection Control (NIC)

Collaborative

Administer antibiotics as Antibiotics given before appendectomy are

appropriate. primarily for prophylaxis of wound infection
and are not continued postoperatively.
Therapeutic antibiotics are administered if the
appendix is ruptured/abscessed or peritonitis
has developed.

Prepare for/assist with incision and May be necessary to drain contents of

drainage (I&D) if indicated. localized abscess.
by Helina H. 07/27/2021
 Nursing diagnosis, NOC and NIC
36

NURSING DIAGNOSIS: Fluid Volume, risk for deficient

 Risk factors may include
 Preoperative vomiting, postoperative restrictions (e.g.,
NPO)
 Hypermetabolic state (e.g., fever, healing process)
 Inflammation of peritoneum with sequestration of fluid

by Helina H. 07/27/2021
 Nursing diagnosis, NOC and NIC
37

NOC
 DESIRED OUTCOMES/EVALUATION CRITERIA
 Hydration (NOC)
 PATIENT WILL: Maintain adequate fluid balance as
evidenced by moist mucous membranes, good skin turgor,
stable vital signs, and individually adequate urinary
output.
by Helina H. 07/27/2021
 Nursing diagnosis, NOC and NIC
ACTIONS/INTERVENTIONS
Fluid
38 Monitoring (NIC)
Independent
Monitor BP and pulse.
Inspect mucous membranes; assess skin
turgor and capillary refill.
Monitor I&O; note urine
color/concentration, specific gravity.
Auscultate bowel sounds. Note passing of
flatus, bowel movement.
Provide clear liquids in small amounts
when oral intake is resumed, and progress
diet as tolerated.
RATIONALE 
Variations help identify fluctuating
intravascular volumes.
Indicators of adequacy of peripheral
circulation and cellular hydration.
Decreasing output of concentrated urine
with increasing specific gravity suggests
dehydration/need for increased fluids.
Indicators of return of peristalsis,
readiness to begin oral intake. Note: This
may not occur in the hospital if patient has
had a laparoscopic procedure and been
discharged in less than 24 hr
Reduces risk of gastric irritation/vomiting
to minimize fluid loss
by Helina H. 07/27/2021
 Nursing diagnosis, NOC and NIC
ACTIONS/INTERVENTIONS
39
Fluid Monitoring (NIC)
Independent
Give frequent mouth care with special
attention to protection of the lips.
Collaborative
Maintain gastric/intestinal suction, as
indicated.
Administer IV fluids and electrolytes.
RATIONALE 
Dehydration results in drying and painful
cracking of the lips and mouth.
An NG tube may be inserted
preoperatively and maintained in
immediate postoperative phase to
decompress the bowel, promote intestinal
rest, prevent vomiting.
The peritoneum reacts to
irritation/infection by producing large
amounts of intestinal fluid, possibly
reducing the circulating blood volume,
resulting inH.dehydration
by Helina 07/27/2021 and relative
electrolyte imbalances.
 Nursing diagnosis, NOC and NIC
40

NURSING DIAGNOSIS: Pain, acute

 May be related to
 Distension of intestinal tissues by inflammation
 Presence of surgical incision
 Possibly evidenced by
 Reports of pain
 Facial grimacing, muscle guarding; distraction behaviors
 Autonomic responses by Helina H. 07/27/2021
 Nursing diagnosis, NOC and NIC
ACTIONS/INTERVENTIONS
Pain
41 Management (NIC)
Independent
Assess pain, noting location,
characteristics, severity (0–10 scale).
Investigate and report changes in pain
as appropriate.
Provide accurate, honest information to Being informed about progress of situation
patient/SO.
Keep at rest in semi-Fowler’s position
Provide diversional activities
RATIONALE 
Useful in monitoring effectiveness of
medication, progression of healing. Changes
in characteristics of pain may indicate
developing abscess/peritonitis, requiring
prompt medical evaluation and intervention.
provides emotional support, helping to
decrease anxiety
Gravity localizes inflammatory exudate into
lower abdomen or pelvis, relieving
abdominal tension, which is accentuated by
supine position.
Refocuses attention, promotes relaxation, and
may enhance
by Helina coping abilities.
H. 07/27/2021
 Nursing diagnosis, NOC and NIC
ACTIONS/INTERVENTIONS RATIONALE 
42

Pain Management (NIC)

Independent
Encourage early ambulation. Promotes normalization of organ function, e.g.,
stimulates peristalsis and passing of flatus,
reducing abdominal discomfort.
Collaborative
Keep NPO/maintain NG suction Decreases discomfort of early intestinal
initially peristalsis and gastric irritation/vomiting.
Administer analgesics as indicated. Relief of pain facilitates cooperation with other
therapeutic interventions, e.g., ambulation,
pulmonary toilet.
Place ice bag on abdomen Soothes and relieves pain through desensitization
periodically during initial 24–48 hr, of nerve endings. Note: Do not use heat, because
by Helina H. 07/27/2021
as appropriate. it may cause tissue congestion.
 Nursing diagnosis, NOC and NIC
43

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need]

regarding condition, prognosis, treatment, self-care, and discharge needs

 May be related to
 Lack of exposure/recall; information misinterpretation
 Unfamiliarity with information resources

 Possibly evidenced by
 Questions; request for information; verbalization of problem/concerns,

Statement of misconception, Inaccurate follow-through of instruction,

by Helina H. 07/27/2021
Development of preventable complications
 Nursing diagnosis, NOC and NIC
44

NOC
 DESIRED OUTCOMES/EVALUATION CRITERIA
 Knowledge: Illness Care (NOC)
 PATIENT WILL:
 Verbalize understanding of disease process and potential
complications.
 Verbalize understanding of therapeutic needs.
 Participate in treatment regimen.
by Helina H. 07/27/2021
 Nursing diagnosis, NOC and NIC
45
ACTIONS/INTERVENTIONS
Teaching: Disease Process (NIC)
Independent
Identify symptoms requiring medical
evaluation, e.g., increasing pain;
edema/erythema of wound; presence of
drainage, fever.
Review postoperative activity restrictions,
e.g., heavy lifting, exercise, sex, sports,
driving
Encourage progressive activities as
tolerated with periodic rest periods.
RATIONALE 
Prompt intervention reduces risk of
serious complications, e.g., delayed
wound healing, peritonitis.
Provides information for patient to plan
for return to usual routines without
untoward incidents.
Prevents fatigue, promotes healing and
feeling of well-being, and facilitates
resumption of normal activities.
by Helina H. 07/27/2021
 Nursing diagnosis, NOC and NIC
46

ACTIONS/INTERVENTIONS
Teaching: Disease Process (NIC)
Independent
Recommend use of mild laxative/stool
softeners as necessary and avoidance of
enemas.
RATIONALE 
Assists with return to usual bowel
function; prevents undue straining for
defecation.

Discuss care of incision, including Understanding promotes cooperation with

dressing changes, bathing restrictions, and therapeutic regimen, enhancing healing
return to physician for suture/staple and recovery process.
removal.

by Helina H. 07/27/2021
 Nursing diagnosis, NOC and NIC
47

POTENTIAL CONSIDERATIONS following acute

hospitalization (dependent on patient’s age, physical
condition/presence of complications, personal resources, and
life responsibilities)
 Therapeutic Regimen: ineffective management—perceived
seriousness/susceptibility, perceived benefit, demands made
on individual (family, work).

by Helina H. 07/27/2021
 EBP
48

 Among patients who were initially treated with antibiotics for

uncomplicated acute appendicitis, the likelihood of late
recurrence within 5 years was 39.1%. And those who
ultimately developed recurrent disease did not experience any
adverse outcomes related to the delay in appendectomy.
 This long-term follow-up supports the feasibility of antibiotic
treatment alone as an alternative to surgery for uncomplicated
acute appendicitis. (Paulina S, et al, 2018).
by Helina H. 07/27/2021
 EBP cont’d
49

 For appendicitis which is associated with abscess the

conservative management is better than emergency
appendectomy, regarding short period of functional recovery,
mean hospital stay, technical success rate, clinical success rate
and fewer incidence of complication in the form of wound
infection, dehiscence, seroma and ugly scar.
 The incidence of complications was high in the emergency group
in the form of wound infections, fecal fistula and burst abdomen.
(Fady M, et al, 2018). by Helina H. 07/27/2021
 Rehabilitation
50

Fast track rehabilitation in patients with acute appendicitis.

 Protocol included informing, no premedication, glucose infusion prior
to surgery, antibiotics administration, mesoappendix excision, limited
deployment of drainage tubes, intraabdominal prolonged anesthesia,
minimal pneumoperitoneum, limited irrigation, minimum power
monopolar electrocautery, antiemetics, early activation and eating

 There are some advantages of FTR for AA including reduced pain

syndrome, morbidity and less lengthbyofHelina
hospital-stay.
H. 07/27/2021
 Summery
51

 What is appendicitis
 What are the clinical manifestations of appendicitis
 What is the best management for appendicitis
 What the majer nursing activities for a patient with
appendicitis

by Helina H. 07/27/2021
 References
52

 LINDA S and PAULA D. (2007). UNDERSTANDING Medical Surgical

Nursing.3rd edi.
 LeMone P, Burke K & Bauldoff G. 2011. Medical-surgical nursing : critical
thinking in client care.5th Edi. Pearson Education, Inc., publishing as Pearson
 Fady M et al. (2018). “A Comparative Study Between; Conservative
Management of Appendicular Abscess by Percutaneous Drainage and
Emergency Operation”. Journal of Medicine and Surgical Sciences.
 Paulina S, et al. 2018, Five-Year Follow-up of Antibiotic Therapy for
Uncomplicated Acute Appendicitis in the APPAC Randomized Clinical Trial
Journal of American Medical Association.
by Helina H. 07/27/2021
 References
53

 Rick D and Leslie H. (2012)Contemporary Medical-Surgical

Nursing, 2nd edi. Clifton Park, NY,
 Smeltzer,S.C.,and Bare,B.(2010).Brunner and Suddarth’s
Textbook of Medical Surgical Nursing 12th edi. lippincott
com. Pheladelphia
 Wei, B., Qi, CL., Chen, TF. et al. (2011), Laparoscopic versus
open appendectomy for acute appendicitis: a metaanalysis

by Helina H. 07/27/2021
54

by Helina H. 07/27/2021