Short

Appendicitis is a frequent digestive disease, an inflammation of the appendix hanging on incipient part of the intestines called Ilion. The inflammation can be caused by a foreign body obstructing the connection to the Ilion, or by an anatomic obstacle. In the beginning pain occur in the navel area known as hypogastria; after several hours they advance towards the right ileac fossa, where high sensibility appears and the patient desperately tries to protect it. Nausea, vomiting, fever and diarrhea are primer symptoms of appendicitis. Movements with the right inferior limb will also cause pain. If not treated in time, the inflamed appendix may perforate and cause A severe infection of the abdominal layer known as peritoneum; the patient’s status will worsen by high fever and generalized abdominal pain. Although pains in appendicitis usually start and then go away before a continuous pain installs, you should immediately call a doctor if you or your child accuse this kind of aches. The surgeon will need specific data about the début of pain, its character and their localization. The diagnosing process will be based also on blood analysis searching for signs of infection, rectal and abdominal examination. Abdominal X-ray or echography can also provide information about the obstruction or inflammation in the abdomen. The classical treatment for a confirmed appendicitis is removing the appendix through an incision in the ileac fossa. As the risk of perforation is present, the surgery must be done as an emergency, right after the proof of a positive diagnosis. In order to minimize the risk of major infection, antibiotherapy is required before and after surgical intervention. In case of perforation the administration of antibiotics will be intra venous and the time in the hospital might last for a week or two, according to the sever ness. Because of the traumatic intervention on the digestive system during the operation, the intestinal transit will slow down or stop for a period of time; a nasogastric sound will be introduced in the patient’s oral cavity down to the stomach to prevent nausea and vomiting that can damage the surgical incision and healing process. Until the transit is resumed, the child won’t be allowed to eat or drink, except for an ice-cube to help hydration. Patient’s handle in the post-operator stage include intra-venous fluids to nourish the body and prevent dehydration, and also pain-releasing medication to improve the comfort during the first days after the operation.

APPENDECTOMY An inflamed appendix may be removed using a laparoscopic approach with laser. However, the presence of multiple adhesions, retroperitoneal positioning of the appendix, or the likelihood of rupture necessitates an open (traditional) procedure. Studies indicate that laparoscopic appendectomy results in significantly less postoperative pain, earlier resumption of solid foods, a shorter hospital stay, lower wound infection rate, and a faster return to normal activities than open appendectomy. CARE SETTING Although many of the interventions included here are appropriate for the short-stay patient, this plan of care addresses the traditional appendectomy care provided on a surgical unit. RELATED CONCERNS

Peritonitis Psychosocial aspects of care Surgical intervention Patient Assessment Database (Preoperative) ACTIVITY/REST May report: Malaise CIRCULATION May exhibit: Tachycardia ELIMINATION May report: Constipation of recent onset Diarrhea (occasional) May exhibit: Abdominal distension, tenderness/rebound tenderness, rigidity Decreased or absent bowel sounds FOOD/FLUID May report: Anorexia Nausea/vomiting PAIN/DISCOMFORT May report: Abdominal pain around the epigastrium and umbilicus, which may have an insidious onset and become increasingly severe; pain may localize at McBurney’s point (halfway between umbilicus and crest of right ileum) and be aggravated by walking, sneezing, coughing, or deep respiration. Increasingly severe, generalized pain or the sudden cessation of severe pain (suggests perforation or infarction of the appendix). Varied reports of pain/vague symptoms (due to location of appendix [e.g., retrocecally or next to ureter] or due to onset of peritonitis) May exhibit: Guarding behavior; lying on side or back with knees flexed; increased right lower quadrant (RLQ) pain with extension of right leg/upright position Rebound tenderness on left side (suggests peritoneal inflammation) RESPIRATION

May exhibit: Tachypnea; shallow respirations SAFETY May exhibit: Fever (usually low-grade) TEACHING/LEARNING May report: History of other conditions associated with abdominal pain, e.g., acute pyelitis, ureteral stone, acute salpingitis, regional ileitis May occur at any age Discharge plan considerations: DRG projected mean length of inpatient stay: 4.2 days/short stay: 24 hours May need brief assistance with transportation, homemaker tasks Refer to section at end of plan for postdischarge considerations. DIAGNOSTIC STUDIES WBC: Leukocytosis above 12,000/mm3, neutrophil count often elevated to greater than 75%. Abdominal x-rays: May reveal hardened bit of fecal material in appendix (fecalith), localized ileus. Ultrasound or CT scan: May be done for differentiation of appendicitis from other causes of abdominal pain (e.g., perforating ulcer, cholecystitis, reproductive organ infections) or to localize drainable abscesses. NURSING PRIORITIES 1. Prevent complications. 2. Promote comfort. 3. Provide information about surgical procedure/prognosis, treatment needs, and potential complications. DISCHARGE GOALS 1. Complications prevented/minimized. 2. Pain alleviated/controlled. 3. Surgical procedure/prognosis, therapeutic regimen, and possible complications understood. 4. Plan in place to meet needs after discharge.

The appendix is a hollow wormlike projection from the first part of the large intestine called the cecum. In less than 10% of individuals, the appendix can become inflamed. The result is appendicitis, a clinical emergency that can have grave consequences if treatment is delayed. Causes and Pathophysiology

The factor that triggers appendicitis is obstruction of the appendix. This can occur with fecal matter hardened into stones (fecaliths), foreign bodies, tumors, or swelling of lymphoid tissue in the appendix (lymphoid hyperplasia) in response to Crohn's disease or certain infections. Whatever the cause may be, this obstructed appendix cannot move secreted mucus and fluids out into the large intestine. Furthermore, bacteria within the appendix multiply significantly. The pressure within the appendix increases until it cuts off the blood supply to the appendix (ischemia). If this inflamed appendix is not removed, it becomes gangrenous, allowing the bacteria within to infect the abdominal cavity. Such an infection can result in inflammation of the membrane lining the abdominal cavity (peritonitis) and/or a collection of bacteria and fluid that is isolated from surrounding tissues by immune processes (abscess). Either way, the infection is a serious complication that can possibly lead to death. Diagnosis and Treatment A patient with appendicitis experiences abdominal pain. In general, the pain starts as a dull pain around the belly button (periumbilical pain) and becomes a sharp pain in the right lower quadrant of the abdomen. This pain may be relieved by lying down with the knees brought close to the abdomen. Other symptoms include loss of appetite (anorexia), nausea, and vomiting. The diagnosis of appendicitis requires a physical examination that carefully explores the nature of the abdominal pain and a computed tomography (CT) scan to image the inflamed appendix. The physician should also rule out other causes of abdominal pain, particularly in women who might have lower abdominal pain originating from the reproductive organs.

Etiology Appendicitis is caused by obstruction of the appendiceal lumen. The causes of the obstruction include lymphoid hyperplasia secondary to irritable bowel disease (IBD) or infections (more common during childhood and in young adults), fecal stasis and fecaliths (more common in elderly patients), parasites (especially in Eastern countries), or, more rarely, foreign bodies and neoplasms. Lymphoid hyperplasia of the appendix may be related to Crohn disease, mononucleosis, amebiasis, measles, and GI and respiratory infections. Fecaliths are solid bodies within the appendix that form after precipitation of calcium salts and undigested fiber in a matrix of dehydrated fecal material. Pathophysiology Reportedly, appendicitis is caused by obstruction of the appendiceal lumen from a variety of causes. Independent of the etiology, obstruction is believed to cause an increase in pressure within the lumen. Such an increase is related to continuous secretion of fluids and mucus from the mucosa and the stagnation of this material. At the same time, intestinal bacteria within the appendix multiply, leading to the recruitment of white cells and the formation of pus and subsequent higher intraluminal pressure. (See image below and Image 5.)

Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled white blood cells in the right lower quadrant, a finding that is consistent with acute appendicitis. [ CLOSE WINDOW ]

Technetium-99m radionuclide scan of the abdomen shows focal uptake of labeled white blood cells in the right lower quadrant, a finding that is consistent with acute appendicitis. If appendiceal obstruction persists, intraluminal pressure rises ultimately above that of the appendiceal veins, leading to venous outflow obstruction. As a consequence, appendiceal wall ischemia begins, resulting in a loss of epithelial integrity and allowing bacterial invasion of the appendiceal wall. Various specific bacteria, viruses, fungi, and parasites can be responsible agents of infection that affect the appendix, including Yersinia species, adenovirus, cytomegalovirus, actinomycosis, Mycobacteria species, Histoplasma species, Schistosoma species, pinworms, and Strongyloides stercoralis. Within a few hours, this localized condition may worsen because of thrombosis of the appendicular artery and veins, leading to perforation and gangrene of the appendix. As this process continues, a periappendicular abscess or peritonitis may occur. Presentation The most common symptom of appendicitis is abdominal pain. Typically, symptoms begin as periumbilical or epigastric pain migrating to the right lower quadrant (RLQ) of the abdomen. Later, a worsening progressive pain along with vomiting, nausea, and anorexia are described by the patient. Usually, a fever is not present at this stage. In addition to recording the history of the abdominal pain, obtain a complete summary of the recent personal history surrounding gastroenterologic, genitourinary, and pneumologic conditions. Also, consider gynecologic history in female patients.

The differential diagnosis of appendicitis is often a clinical challenge because appendicitis can mimic several abdominal conditions. The differential diagnosis of appendicitis must include cholecystitis and biliary colic, gastroenteritis, enterocolitis, diverticulitis, pancreatitis, perforated duodenal ulcer, renal colic, and urinary tract infection (UTI). In pediatric patients, consider mesenteric lymphadenitis and intussusception. In women of childbearing age who are not pregnant, the differential diagnosis of appendicitis must also include ovarian cyst torsion, mittelschmerz, ectopic pregnancy, and pelvic inflammatory disease. Small bowel obstruction, Crohn disease, Meckel diverticulitis, tumors, Henoch-Schönlein purpura, and rectus sheath hematoma are more rare conditions that mimic appendicitis. Usually, patients are lying down, flexing their hips, and drawing their knees up to reduce movements and to avoid worsening the pain. A careful physical examination, not limited to the abdomen, must be performed in any patient with suspected appendicitis. GI, genitourinary, and pulmonary systems must be studied. Perform a rectal examination in any patient with an unclear clinical picture, and perform a pelvic examination in all women with abdominal pain. Tenderness on palpation in the RLQ over the McBurney point is the most important sign in these patients. Additional signs, such as increasing pain with cough (ie, Dunphy sign), rebound tenderness related to peritoneal irritation elicited by deep palpation with quick release (ie, Blumberg sign), and guarding, may or may not be present. Patients with appendicitis may not have the reported classic clinical picture 37-45% of the time, especially when the appendix is located in an unusual place (see Relevant Anatomy). In such cases, imaging studies may be important but not always available. Patients with appendicitis usually have accessory signs that may be helpful for diagnosis. For example, the obturator sign is present when the internal rotation of the thigh elicits pain (ie, pelvic appendicitis), and the psoas sign is present when the extension of the right thigh elicits pain (ie, retroperitoneal or retrocecal appendicitis). In regard to variations in clinical presentation, Niwa et al reported an interesting case of recurrent pain in a young woman referred for appendicitis and treated with antibiotics.1 After 12 months, the woman underwent a laparotomy, demonstrating appendiceal diverticulitis associated with a rare pelvic pseudocyst, probably due to diverticular perforation of the pseudocyst.1 Indications Consider an appendectomy for patients with a history of persistent abdominal pain, fever, and clinical signs of localized or diffuse peritonitis, especially if leukocytosis is present. If the clinical picture is unclear, a short period (4-6 h) of watchful waiting and a computed tomography (CT) scan may improve diagnostic accuracy and help to hasten diagnosis. However, if a patient is discharged from the medical center without a definite diagnosis at the end of the observation period, instruct the patient to return for continued or recurrent symptoms, and the patient may benefit from a follow-up examination in 24 hours. Relevant Anatomy The appendix is a wormlike extension of the cecum, and the average length of the appendix is 8-10 cm (ranging from 2-20 cm). The appendix appears during the fifth month of gestation, and its wall has an inner mucosal layer, 2 muscular layers, and a serosa. Several lymphoid follicles are scattered in its mucosa. The number of follicles increases when individuals are aged 8-20 years. The inner muscular layer is circular, and the outer layer is longitudinal and derives from the taenia coli. Taenia coli converge on the posteromedial area of the cecum. This site is the appendiceal base. The appendix runs into a serosal sheet of the peritoneum called the mesoappendix. Within the mesoappendix courses the appendicular artery, which is derived from the ileocolic artery. Sometimes, an accessory appendicular artery (deriving from the posterior cecal artery) may be found. The vasculature of the appendix must be addressed to avoid intraoperative hemorrhages. The course of the appendix and the position of its tip may vary widely, accounting for the nonspecific signs and symptoms of appendicitis. In fact, many individuals may have an appendix located in the retroperitoneal space; in the pelvis; or behind the terminal ileum, cecum, ascending colon, or liver.

Contraindications Patients with appendicitis always need urgent referral and prompt treatment. No contraindications to appendectomy are known for patients with suspected appendicitis, except in the case of a patient with a long history of symptoms and signs of a large phlegmon. If a periappendiceal abscess or phlegmon exists secondary to appendiceal perforation or rupture, some clinicians may choose a conservative approach with broad-spectrum antibiotics and percutaneous drainage followed by appendectomy later. Certain contraindications exist for laparoscopic appendectomy. These contraindications are extensive adhesions, radiation or immunosuppressive therapy, severe portal hypertension, and coagulopathies. Laparoscopic appendectomy is contraindicated in the first trimester of pregnancy. Rarely, an appendiceal mucocele may occur. It is a collection of mucus within the appendiceal lumen. Occasionally, patients may present with a low-grade carcinoma of the appendix or the cecum. In such cases, the surgeon must avoid perforation during dissection because it may cause seeding of the peritoneum with viable cells, leading to pseudomyxoma peritonei.

Symptoms Pain 1.

Ruptured appendix symptoms usually start with severe pain in the location of the appendix (starting in the navel and then usually moving toward the lower right abdomen). Usually, the pain starts off mild and becomes increasingly more severe and sharper as time passes. Other Symptoms

2.

Severe abdominal ache is not the only symptom. Other common symptoms associated with a ruptured appendix include feelings of nausea accompanied by occasional vomiting, appetite loss and a mild, dull fever that appears shortly after the initial symptoms of pain and nausea. Rupturing

3. During the actual rupturing of the appendix, some might experience a brief lessening of pain. However, shortly afterward the lining of the abdominal cavity starts to become inflamed and infected (which is called peritonis) and the pain starts to get worse again. Later Symptoms 4.

After the ruptured appendix occurs, the person might experience other symptoms. Some of these symptoms include severe digestive issues, body chills, fever, vomiting, nausea, shakiness or tremors and appetite loss. These symptoms are usually accompanied with the aforementioned intense abdominal aching. Warning

5.

After the appendix bursts and ruptures, in terms of abdominal pain, it might feel a lot worse during times of physical activity even including walking. Also, any abdominal aching becomes a lot sharper with coughing. Sudden movements lead to a lot of pain, so stay as still as possible.

Appendix Bursting Symptoms The appendix is a narrow, dead-end tube attached to the beginning of the colon. It is believed that a condition called appendicitis occurs when the area connecting the appendix and colon (cecum) becomes blocked. This causes the appendix to become inflamed and infected by bacteria, which can lead to its rupture. Another theory is that the appendix ruptures first, causing a bacterial infection. A ruptured appendix can lead to peritonitis, a dangerous infection of the stomach lining and pelvis. A burst appendix can lead to various complications and even death if not promptly treated. Abdominal Pain and Tenderness

1. Severe abdominal pain occurs with both appendicitis (an inflamed appendix) and a burst appendix. You would normally feel the pain from a burst appendix across the whole area of the stomach as the entire stomach lining becomes inflamed. If you press on your abdomen, you will feel pain as you release the pressure. Especially in children 2 years and younger, the stomach can appear swollen. Fever 2.

After your appendix has burst, your body is in full alert to ward away bacterial infection. A fever is a sign that your body is attempting to protect itself against bacteria. With a burst appendix, bacteria may be spreading quickly, leading to an unusually high fever that can exceed 104 degrees Fahrenheit. Loss of Appetite

3.

Because of the stress being placed upon that area of the body by infection and its closeness to the stomach area, you will not feel like eating. It is best not to eat or drink anything if you are experiencing abdominal pain that may be from a burst appendix or appendicitis because surgery will likely be needed to remove the troublesome appendage. Nausea/Vomiting

4.

If infection spreads from the burst appendix to the stomach, a feeling of nausea or stage of vomiting can occur because of the stress on the stomach. If the intestine becomes blocked, its muscles can no longer work properly to pass its contents. Liquid and gas begin to build up in the intestines and produce a swelling of the stomach that triggers nausea and vomiting. Urge to Urinate/Constipation

5.

Because the infected appendix is located near the bladder and anus, you may feel a lot of uncomfortable pressure in the area. It may feel like you constantly need to go to the bathroom. Diarrhea

6. Infection spreading to the stomach or intestines may trigger an attack of diarrhea. The stool may contain a mucus-like substance produced by the appendix, which some believe can cause the blockage that begins the symptoms of appendicitis. Stool from the colon is may be a possibility as the cause of the obstruction.