Apr 062014
 

Appendicitis: Definition


Appendicitis is the inflammation and obstruction of the vermiform appendix (a blind pouch attached to the cecum). It may occur at any age and affects both sexes equally; however, between puberty & age 25, it’s more prevalent in men in comparison to female. This disease is a serious and can be fatal if not timely diagnosis or treatment is not done. It is mainly cause due to inflammation on appendix, brust, causing deposition of pus into the abdomen.
appendicitis

Appendicitis: Inflammation of Appendix

Most common disease requires emergency surgery. Since the advent of antibiotics, the incidence and mortality rate from appendicitis have declined; if untreated, this disease is invariably fatal.

Causes of Appendicitis

  • Barium ingestion
  • Fecal mass
  • Mucosal ulceration, tumor, foreign body
  • Stricture
  • Viral infection/Bacterial/Fungal infection

Patho-physiology for Appendicitis:

Mucosal ulceration triggers inflammation which temporarily obstructs the appendix as a result of either becoming kinged or occluded by a fecalith (i.e., hardened mass of a stool), tumor or foreign body. The obstruction block mucus outflow. Pressure in the now distended appendix increases and the appendix contracts. Bacteria multiply and inflammation and pressure continue to increase, restricting blood flow to the pouch and causing abdominal pain.

Signs and Symptoms of Appendicitis:

1. Pain: Vague epigastric or periumbilical pain progresses to right lower quadrant pain, caused by inflammation of the appendix and bowel obstruction and distention, (begins in the epigastric region).

appendicitis

Symptoms of Appendicitis

2. Anorexia: After the onset of pain (common).

3. Nausea or Vomiting: Caused by inflammation.

4. Low grade fever: From systematic manifestations of inflammation and leucocytosis.

5. Tenderness From Inflammation: Local Tenderness is elicited at MC Burney’s point, when pressure is applied. MC Burney is the point which is between the umbilicus and the anterior superior iliac spine.

  • Rebound tenderness (i.e. production or intensification of pain when pressure is released) may be present.
  • If the appendix curts around behind the caecum, pain and tenderness may be felt in the lumbar region.
  • If its tip is in the pelvis, these signs may be elicit only on rectal examination.
  • Pain on defecation suggests that the tip of the appendix is resting against the rectum.
  • Pain on urination suggests that the tip is near the bladder or impinges on the ureter.
  • Rovsings signs may be elicited by palpating the left lower quadrant this paradoxically causes pain to be felt in the right lower quadrant.

6. Constipation:If the appendix has ruptured, the pain becomes more diffuse. Abdominal distention develops as a result of paralytic ileus, and the patient’s conditions worsen.

Diagnosis for Appendicitis:

Based on results of a complete physical examination and on laboratory findings:

appendicitis

Appendicitis: Inflammation of Appendix

i) Complete blood cell count- WBC id moderately high (10,000/µm π) i.e., an increased number of immature cells.

-Neutrophils count may exceed 75%π.

ii) Radiological Examination:

– Abdominal X-Rays
– Chest X-Rays
– USG
– CT Scans

These examinations reveal a RLQ density or localized distention of the bowel or failure of the appendix to full i.e., contrast.

Treatment/ Management for Appendicitis:

Medical Management:

  • Maintenance of nothing by mouth (NDO) status until surgery.
  • Fowler’s position to aid in pain relief.
  • GI intubation for decompression.
  • Emergency Appendectomy planned pt’s preparation.
  • An antibiotic to treat infection.
  • Parental replacement of fluid & electrolytes to reverse possible dehydration resulting from surgery or nausea & vomiting.

Surgical Management:
Appendectomy (surgical removal of the appendix) performed as soon as possible to decrease the risk of perforation. It may be performed under a general or spinal anesthetic with a low abdominal incision or by laparoscopy.

Special Consideration for Appendicitis:

If appendicitis is suspected, or during preparation for appendectomy.

  • Administer I.V. fluids to prevent dehydration. Never administer a cathartic organ enema, which may rupture the appendix. Maintain NPO status, and administer the analgesic judiciously because it may mask the symptoms. An opiod usually, morphine sulphate is used to relieve pain.
  • To lessen the pain, place the patient in Fowler’s position. Never apply heat to the right lower abdomen; this may cause the appendix to rupture. An ice bag may be used for pain relief.

 

Potential Complications after Appendectomy

Complications and Nursing Interventions
 Peritonitis

  • Observe for abdominal tenderness, fever, vomiting, abdominal rigidity and tachycardia.
  • Employ constant nasogastric suction.
  • Correct dehydration as prescribed.
  • Administer antibiotics agents as prescribed.
  • NPO

 Pelvic Abscess

  • Evaluate for anorexia, chills, fever & diaphoresis.
  • Observe for diarrhea, which may indicate pelvic abscess.
  • Prepare patient for rectal examination.
  • Prepare patient for surgical drainage procedure.

Subphrenic Abscess – Abscess underv diaphragm

  • Assess for chills, fever and diaphoresis.
  • Prepare for x-ray examination.
  • Prepare for surgical drainage of abscess.

 Ileus (pasalytic and mechanical)

  • Assess for bowel sounds
  • Employ nasogastric intubation & suction.
  • Replace fluids & electrolytes by intravenous route as prescribed.
  • Prepare for surgery, if diagnosis of mechanical ileus is established.

Nursing Management for Appendicitis



Goal includes relieving pain, preventing fluid volume defecit, reducing anxiety, eliminating infection from the potential or actual disruption of the GI tract, maintaining skin integrity and attaining optimal nutrition.

The nurse prepare a patient for surgery which includes intravenous infusion to replace fluid loss and promote the renal function & antibiotic therapy to prevent infection. If there is evidence or likelihood of paralytic ileus, a nasogastric tube is inserted. An enema is not administered.

After Appendectomy

  • Monitor vital signs and intake output. Give and analgesics as ordered.
  • Encourage the patient to cough, breathe deeply and turn frequently to prevent pulmonary complications.
  • Document bowel sounds, passing of flatus and bowel movements. In a patient whose nausea and abdominal rigidity have subsided, these signs indicate readiness to resume taking in oral fluids.
  • Watch closely for possible surgical complications continuing pain and fever may signal an abscess. The complain that some thing gave way may mean wound dehiscence. If an abscess or peritonitis develops incision and drainage may be necessary. Frequently assess the dressing for wound drainage.
  • Help the patient ambulate as soon as possible after surgery.
  • In appendicitis complicated by peritonitis, a nasogastric tube may be needed to decompress the stomach and reduce nausea and vomiting. If so, record drainage and give good mouth and nose care.
  • Discharge teaching for the patient and family is imperative. The nurse instruct the patient to make an appointment to have the surgeon remove the sutures between the fifth and seventh days after surgery. Incision care and activity guidelines are discussed; normal activity can usually be resumed within two weeks.

Potential Complications after Appendectomy

 Peritonitis

  • Observe for abdominal tenderness, fever, vomiting, abdominal rigidity and tachycardia.
  • Employ constant nasogastric suction.
  • Correct dehydration as prescribed.
  • Administer antibiotics agents as prescribed.
  • NPO

Pelvic Abscess

  • Evaluate for anorexia, chills, fever & diaphoresis.
  • Observe for diarrhea, which may indicate pelvic abscess.
  • Prepare patient for rectal examination.
  • Prepare patient for surgical drainage procedure.

Subphrenic Abscess

  • Assess for chills, fever and diaphoresis.
  • Abscess under diaphragm – Prepare for x-ray examination.
  • Prepare for surgical drainage of abscess.

Ileus (pasalytic and mechanical)

  • Assess for bowel sounds
  • Employ nasogastric intubation & suction.
  • Replace fluids & electrolytes by intravenous route as prescribed.
  • Prepare for surgery, if diagnosis of mechanical ileus is established.
 Posted by at 4:43 pm