Definition

. Appendicitis is an inflammation of the appendix, which is the worm-shaped pouch attached to

the cecum, the beginning of the large intestine. The appendix has no known function in the body,
but it can become diseased. Appendicitis is a medical emergency, and if it is left untreated the
appendix may rupture and cause a potentially fatal infection
Chief Complaints
The most common symptoms of appendicitis are abdominal pain, loss of
appetite, nausea and vomiting, fever, and abdominal tenderness
Symptoms of Appendicitis
The main symptom of appendicitis is abdominal pain. Symptoms of appendicitis may take 4-48
hours to develop. Other symptoms include:

 loss of appetite,
 nausea,
 vomiting,
 lack of appetite, and
 fever.

System Affected

The appendix is a small, worm-like appendage attached to the colon.

It is a closed-ended, narrow tube up to several inches in length that attaches to the cecum (the
first part of the colon) like a worm. (The anatomical name for the appendix, vermiform
appendix, means worm-like appendage.) The open central core of the appendix drains into the
cecum. The inner lining of the appendix produces a small amount of mucus that flows through
the open central core of the appendix and into the cecum. The wall of the appendix contains
lymphatic tissue that is part of the immune system for making antibodies. Like the rest of the
colon, the wall of the appendix also contains a layer of muscle, but the layer of muscle is poorly
developed.
Disease Process

Appendicitis occurs when bacteria invade and infect the wall of the appendix. It is thought that
appendicitis begins when the opening from the appendix into the cecum becomes blocked. The
blockage may be due to a build-up of thick mucus within the appendix or to stool that enters the
appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks the
opening. This rock is called a fecalith (literally, a rock of stool). At other times, it might be that
the lymphatic tissue in the appendix swells and blocks the opening. After the blockage occurs,
bacteria which normally are found within the appendix begin to invade (infect) the wall of the
appendix. The body responds to the invasion by mounting an attack on the bacteria, an attack
called inflammation. An alternative theory for the cause of appendicitis is an initial rupture of the
appendix followed by spread of bacteria outside of the appendix. The cause of such a rupture is
unclear, but it may relate to changes that occur in the lymphatic tissue, for example,
inflammation, that lines the wall of the appendix.)
If the inflammation and infection spread through the wall of the appendix, the appendix can
rupture. After rupture, infection can spread throughout the abdomen; however, it usually is
confined to a small area surrounding the appendix (forming a peri-appendiceal abscess).

Laboratory
How is appendicitis diagnosed?
The diagnosis of appendicitis begins with a thorough history and physical examination. Patients
often have an elevated temperature, and there usually will be moderate to severe tenderness in
the right lower abdomen when the doctor pushes there. If inflammation has spread to the
peritoneum, there is frequently rebound tenderness. Rebound tenderness is pain that is worse
when the doctor quickly releases his or her hand after gently pressing on the abdomen over the
area of tenderness.
White Blood Cell Count
The white blood cell count in the blood usually becomes elevated with infection. In early
appendicitis, before infection sets in, it can be normal, but most often there is at least a mild
elevation even early in the process. Unfortunately, appendicitis is not the only condition that
causes elevated white blood cell counts. Almost any infection or inflammation can cause this
count to be abnormally high. Therefore, an elevated white blood cell count alone cannot be used
to confirm a diagnosis of appendicitis.
Urinalysis
Urinalysis is a microscopic examination of the urine that detects red blood cells, white blood
cells and bacteria in the urine. Urinalysis usually is abnormal when there is inflammation or
stones in the kidneys or bladder. The urinalysis also may be abnormal with appendicitis because
the appendix lies near the ureter and bladder. If the inflammation of appendicitis is great enough,
it can spread to the ureter and bladder leading to an abnormal urinalysis. Most patients with
appendicitis, however, have a normal urinalysis. Therefore, a normal urinalysis suggests
appendicitis more than a urinary tract problem.
Abdominal X-Ray
An abdominal x-ray may detect the fecalith (the hardened and calcified, pea-sized piece of stool
that blocks the appendiceal opening) that may be the cause of appendicitis. This is especially true
in children.
Ultrasound
An ultrasound is a painless procedure that uses sound waves to provide images of identify organs
within the body. Ultrasound can identify an enlarged appendix or an abscess. Nevertheless,
during appendicitis, the appendix can be seen in only 50% of patients. Therefore, not seeing the
appendix during an ultrasound does not exclude appendicitis. Ultrasound also is helpful in
women because it can exclude the presence of conditions involving the ovaries, Fallopian tubes
and uterus that can mimic appendicitis.
Barium Enema
A barium enema is an X-ray test in which liquid barium is inserted into the colon from the anus
to fill the colon. This test can, at times, show an impression on the colon in the area of the
appendix where the inflammation from the adjacent inflammation impinges on the colon. Barium
enema also can exclude other intestinal problems that mimic appendicitis, for exampleCrohn's
disease.
Computerized tomography (CT) Scan
In patients who are not pregnant, a CT scan of the area of the appendix is useful in diagnosing
appendicitis and peri-appendiceal abscesses as well as in excluding other diseases inside the
abdomen and pelvis that can mimic appendicitis.
Laparoscopy
Laparoscopy is a surgical procedure in which a small fiberoptic tube with a camera is inserted
into the abdomen through a small puncture made on the abdominal wall. Laparoscopy allows a
direct view of the appendix as well as other abdominal and pelvic organs. If appendicitis is
found, the inflamed appendix can be removed with the laparoscope. The disadvantage of
laparoscopy compared to ultrasound and CT is that it requires a general anesthetic.
There is no one test that will diagnose appendicitis with certainty. Therefore, the approach to
suspected appendicitis may include a period of observation, tests as previously discussed, or
surgery.

Etiology/Cause

CAUSE. If the tubelike appendix becomes plugged by a hard bit of fecal matter or by intestinal
worms, or becomes inflamed from other causes, normal drainage cannot take place. Because the
appendix is chiefly lymphatic tissue, an infection that produces enlarged lymph nodes elsewhere
in the body also can increase the glandular tissue in the appendix and obstruct its lumen.
Narrowing of the lumen makes the pouchlike organ more susceptible to bacterial
infection. Escherichia coli and other types of bacteria multiply and cause inflammation and
infection that spread to the peritoneal cavity unless the body's defenses are able to overcome the
infection or the appendix is removed before it ruptures.

Treatment

The treatment for appendicitis usually is antibiotics and appendectomy (appendectomy or

surgery to remove the appendix). Once a diagnosis of appendicitis is made, an appendectomy
usually is performed. Antibiotics almost always are begun prior to surgery and as soon as
appendicitis is suspected.

There is a small group of patients in whom the inflammation and infection of appendicitis remain
mild and localized to a small area. The body is able not only to contain the inflammation and
infection but to resolve it as well. These patients usually are not very ill and improve during
several days of observation. This type of appendicitis is referred to as "confined appendicitis"
and may be treated with antibiotics alone. The appendix may or may not be removed at a later
time.
On occasion, a person may not see their doctor until appendicitis with rupture has been present
for many days or even weeks. In this situation, an abscess usually has formed, and the
appendiceal perforation may have closed over. If the abscess is small, it initially can be treated
with antibiotics; however, the abscess usually requires drainage. A drain (a small plastic or
rubber tube) usually is inserted through the skin and into the abscess with the aid of an
ultrasound or CT scan that can determine the exact location of the abscess. The drain allows pus
to flow from the abscess out of the body. The appendix may be removed several weeks or
months after the abscess has resolved. This is called an interval appendectomy and is done to
prevent a second attack of appendicitis.

Nursing Intervention (Bold)

Nursing Intervention The nurse is alert to the signs and symptoms of rupture and peritonitis and
provides education about the diagnosis, treatment, and recovery.
interventions Treatment is appendectomy within 24 to 48 hours of the first symptoms
because delay usually results in rupture and peritonitis as fecal matter is released into the
peritoneal cavity. The fever rises sharply once peritonitis begins. The patient may have
sudden relief from pain immediately after rupture, followed by increased, diffuse pain.

PATIENT CARE. When appendicitis is suspected because of symptoms exhibited by the patient, a
health care provider should be notified immediately. The patient should lie down and remain
as quiet as possible. It is best to give him nothing by mouth, and because of the danger of
aggravating the condition and possibly causing rupture of the appendix, cathartics and
laxatives are contraindicated. Applications of heat and the administration of laxatives or
enemas are contraindicated for the same reasons. After the patient has been assessed and a
diagnosis of appendicitis has been established, appendectomy will probably be performed as
soon as possible.

During the preoperative phase it may be necessary to hydrate the patient with intravenous
fluid therapy, especially when there has been prolonged nausea and vomiting. Decompression
of the intestinal contents by suction via a nasogastric tube is also necessary in some cases.

Postoperative care is usually uneventful. The exception is when there has been a ruptured
appendix; this serious condition warrants diligent and aggressive nursing care to overcome the
effects of peritonitis with the resultant shifting of body fluids, hypovolemia (which can be life-
threatening), and septic shock. Antibacterial drugs are administered to combat the infection.
Gastric and intestinal decompression is maintained, and most surgeons advocate
intraperitoneal draining by means of Penrose drains in order to prevent formation of
abscesses and promote healing. The most common complications of appendectomy and
peritonitis are (1) infection of the surgical wound, (2) paralytic ileus due to irritation of the small
bowel, (3) abscesses, and (4) obstruction and adhesions.

Ongoing assessment of the patient includes observing the type and amount of drainage
from the intestinal tract via the nasogastric tube and from the Penrose drain in the wound;
appearance of the surgical incision; dressings applied and the frequency with which they
are changed; evidence that bowel function is returning to normal, e.g.,( presence of bowel
sounds, passing of flatus and fecal material; measurement of intake and output; tolerance
of foods and liquids once the nasogastric tube is removed and decompression discontinued;
and tolerance for physical activity, coughing and deep breathing, positioning, and
postoperative exercises.)
Diet
Fluid diet, consisting chiefly of nutritive broths. Beaten eggs may be allowed, and a moderate
quantity of pancreatinised milk, whey, or buttermilk. Cocoa may be given, and strained gruels
of rice orbarley.
In recurrent cases the patient should be cautioned to eat moderately and avoid all coarse or hard
food, such as grits, coarse oatmeal, tough meats, fibrous vegetables, the skin
of fruits or potatoes - in short, everything likely to overload the intestine with accumulated
waste.

Nursing Diagnosis
Acute pain related to inflammation of tissues.
Impaired skin integrity, related to surgical incisions
Anxiety, related to situational crisis

PLANNING AND IMPLEMENTATION

The following nursing interventions are planned
and implemented for Ms. Lynn.
• Assess pain using a pain scale; provide analgesics as needed.
• Teach pain management following discharge.
• Teach abdominal splinting during coughing, turning, or ambulating
as needed.
• Teach home care of incisions.
• Discuss activity limitations as ordered.
• Instruct to report fever or warmth, redness, or drainage from
the incisions.
EVALUATION
On discharge the following evening,Ms. Lynn is fully ambulatory.
Her appetite has returned, and she is tolerating food and fluids
well. Her temperature is normal.The nurse provides Ms. Lynn with
written and verbal information on postoperative care following an
appendectomy.