ACUTE APPENDICITIS

Pediatric Nursing (NUR322)

2025-2026
 Objectives
By the end of this class, the students will be able to:
Define Appendicitis.
Identify the incidence in Bahrain & worldwide.
Explore the etiology of Appendicitis.
Discuss the risk factors of Appendicitis.
Correlate the pathophysiology and related clinical manifestations.
Identify the diagnostic tests done to diagnose Appendicitis.
Understand the collaborative management (Medical and Nursing) of
Appendicitis.
Identify the complications of Appendicitis.
Design the nursing care plan for a child with Appendicitis.
Provide health education & prepare the family for home management of child
with Appendicitis
In which abdominal quadrant is the
appendix located?
anatomy and physiology
Appendicitis is the inflammation of the appendix.
Where is the appendix?
It is found on the right lower side of the abdomen and connects to
the cecum of the large intestine (it looks like a protruding worm or
finger-like structure coming out of the large intestine, specifically the
ascending colon).
What is the role of the appendix?
is to store the "good" bacteria in your GI tract while the tract is
recovering from a diarrhea illness (so it helps maintain healthy GI
flora).
Overview
Definition
Appendicitis is a condition characterized by
inflammation of the appendix, a small finger-like
pouch attached to the large intestine. It usually
occurs due to obstruction, infection, or
inflammation within the appendix. If left untreated,
this can lead to rupture and serious complications
such as peritonitis.

Patients commonly present with symptoms

including abdominal pain, nausea, vomiting, loss of
appetite, and fever. Diagnosis is typically made
through physical examination, imaging studies, and
laboratory tests. Management often involves
antibiotic therapy and, in most cases, surgical
removal of the appendix (appendectomy).
Incidence
is the most common cause of emergency abdominal surgery in
childhood.
The peak incidence of appendicitis is 10 years, with boys and girls
equally affected before puberty.
In the United States, 70,000 cases are diagnosed each year.
Incidence worldwide
In 2021, the newly diagnosed appendicitis in children was estimated to be
2,193,020, accounting for 12.93% of all cases of appendicitis in the general
population. The corresponding incidence rate was estimated to be 109 per
100,000.
Incidence in Bahrain
136 pediatric appendectomy cases were reviewed (2012–2016) at King
Hamad University Hospital
85% had uncomplicated appendicitis
12% had complicated appendicitis
Perforation rate: 8.8%
Etiology
The cause of appendicitis is
obstruction of the lumen of the
appendix,
usually by hardened fecal material
(fecalith). Swollen lymphoid tissue,
frequently occurring after a viral
infection, can also obstruct the
appendix.
Etiology
Another rare cause of obstruction is a
parasite such as Enterobius vermicularis, or
pinworms, which can obstruct the appendiceal
lumen
 Age (10 years or older) Gender (male)

Children with Risk factors Summer season

cystic fibrosis

Diet low in fiber and high in Family history of

refined carbohydrates appendicitis
Pathophysiology necrosis then
perforation or
progressive peritoneal
inflammation➜
rupture with fecal functional intestinal
and bacterial obstruction of the small
pressure contamination of bowel (ileus)
builds within the peritoneal because intense GI reflexes
the lumen ischemia cavity severely inhibit bowel motility.

1 3 5 7 9

2 4 6 8
acute The peritoneum
compression ulceration of peritonitis represents a major
obstruction of blood the epithelial portion of the total body
and the lining and especially in young surface,
vessels children who are not So the loss of
outflow of Bacterial able to localize the extracellular fluid into
mucus invasion infection the peritoneal cavity
⟶ results in electrolyte
secretions is imbalance
blocked & hypovolemic shock
Pathophysiology
 A, Gross specimen of the enlarged appendix.
B, Opened appendix with a polyp inside the appendiceal lumen.
Clinical Manifestations
The first symptom is usually colicky, cramping abdominal pain around the umbilicus
( Referred pain is the term used for this vague periumbilical localization).
The midgut shares the same T10 dermatome, so pain is often perceived to be coming from
this area.
Generally, this pain progresses and becomes constant.
As the inflammation progresses to involve the serosa of the appendix and the
peritoneum of the abdominal wall, the pain may shift to the right lower quadrant.
Clinical Manifestations

• Nausea, vomiting, and anorexia typically occur

after the pain starts.

• Diarrhea, as well as other common signs of

childhood illness such as upper respiratory tract
congestion, poor feeding, lethargy, or irritability,
may accompany appendicitis.

• The child may not be able to walk well and may

complain of pain in the right hip caused by
inflammation in the psoas or iliopsoas muscles.
Clinical Manifestations
fever

• The absence of fever does not

exclude appendicitis.

• Because of the great variability in the presentation and location of appendicitis, any
child with focal tenderness, regardless of the location, should be considered to
potentially have acute appendicitis
Clinical Manifestations
Question
What is usually the first symptom of appendicitis?
A. Vomiting
B. Fever
C. Periumbilical abdominal pain
D. Diarrhea
Assessment and Diagnostic Evaluation

Appendicitis diagnosis is not always

straightforward because its symptoms
(fever, vomiting, abdominal pain, and Diagnosis is mainly based on history & physical
elevated WBC) are non-specific and examination
can occur in other conditions such as • Pain is the cardinal symptom
(IBD, PID, gastroenteritis, UTI, pneumonia,
- Starts generalized (periumbilical)
mesenteric adenitis, Meckel diverticulum,
and intussusception); - Then shifts to the right lower quadrant (RLQ)
- most intense pain at McBurney’s point
diagnosis is often delayed in young
children, increasing the risk of perforation
due to difficulty in expressing symptoms.
Assessment and Diagnostic Evaluation
Physical examination:
The most important physical finding is focal
Behavioral changes are a key indicator of pain
abdominal tenderness. severity
Localized abdominal tenderness (key finding) Child who:
Pain with movement or percussion Refuses to play
Lies down voluntarily
Referred pain (percussion): indicates peritoneal ➜ Likely experiencing significant pain
irritation Child playing normally ➜ Pain likely less severe
Rebound tenderness → not reliable & very painful
Signs in Young Children
• Associated symptoms: Fever, Anorexia, Vomiting....
Rigid, side-lying position
Knees flexed
Decreased movement of the right hip
Clinical Manifestations

Another helpful finding is Rovsing sign,

tenderness in the right lower quadrant that
The McBurney point, located two thirds the occurs during palpation or percussion of
distance along a line between the umbilicus and other abdominal quadrants (Pepper,
the anterosuperior iliac spine, is the most Stanfill, and Pearl, 2012).
common point of tenderness.
Assessment and Diagnostic Evaluation
Laboratory Studies
Complete Blood Count (CBC)
Urinalysis → to rule out urinary tract infection
Serum hCG (in adolescent females) → to rule out ectopic pregnancy

Laboratory Findings
White blood cell count (WBC) > 10,000/mm³
Elevated C-reactive protein (CRP)
These findings are not specific for appendicitis
Increased band cells (left shift) → suggests inflammation
CRP: Acute-phase reactant / Rises within 12 hours of infection onset
 Assessment and Diagnostic Evaluation

Imaging:

• CT scan = preferred (96% accuracy)

• CT findings( considered positive) in the presence of:
enlarged appendiceal diameter
appendiceal wall thickening
and periappendiceal inflammatory changes
like: fat stranding, phlegmon, fluid, extraluminal gas

• Ultrasound = helpful
Assessment and Diagnostic Evaluation

additional information
(general knowledge)

alvarado
score
appendicitis
 Medical Management
The treatment for appendicitis before perforation is surgical removal of the appendix
(appendectomy).
Usually, antibiotics are administered preoperatively. Intravenous (IV)
fluids and electrolytes are often required before surgery, especially if the
child is dehydrated as a result of the marked anorexia characteristic of
appendicitis.
Surgical Management
(appendectomy) : surgical removal of the appendix

Preoperative Care
Antibiotics before surgery
IV fluids & electrolytes Especially if dehydrated (due to anorexia)
Surgical Management
Types of Appendectomy

Laparoscopic
Appendectomy Open Appendectomy
Incision in right lower quadrant (RLQ)
Surgical Management
Surgical Management
Laparoscopic Appendectomy
Common in nonperforated cases (children)
3 cannulas inserted:
Umbilicus
Left lower quadrant
Suprapubic area

Procedure
Telescope → left lower quadrant
Stapler → umbilicus
Appendix ligated & removed via umbilical cannula

Advantages
Shorter surgery time
Less anesthesia exposure
Lower risk of wound infection
Question
A child is diagnosed with nonperforated acute appendicitis.
Which type of appendectomy is most commonly performed?
A. Open appendectomy
B. Laparoscopic appendectomy
 Ruptured Appendix
Once the appendix becomes infected it can rupture (perforate).
Management of the child diagnosed with peritonitis caused by
a ruptured appendix often begins preoperatively with:
IV administration of fluid and electrolytes
systemic antibiotics,
NG suction.
Postoperative Care
IV fluids
Continued antibiotics
and NG suction for abdominal decompression until intestinal activity returns.

Wound management:
Sometimes surgeons close (primary closure) the wound after irrigation of the peritoneal cavity.
Other times, they leave the wound open (delayed closure) to prevent wound infection.
 The treatment of a localized perforation with an appendiceal
abscess is controversial. Some surgeons prefer to treat these
children with antibiotics and IV fluids and allow the abscess to
drain spontaneously. An elective appendectomy is then per-
formed 2 to 3 months later.
 The prognosis & Complications
Prognosis of Appendicitis:
• Complications are uncommon after a simple
appendectomy
• Recovery is usually rapid and complete

Mortality rate for perforated appendicitis:

• Decreased from almost certain death (historically) to 1%
or less currently
• However, some complications may still occur:
• Wound infection
• Intra-abdominal abscess
• Early recognition of appendicitis is important to:
• Prevent complications
Nursing Care Management
Assessment & Early Recognition Nursing Responsibilities
- Early recognition is essential for • Recognize possible appendicitis
successful treatment.
early.
• Refer promptly for medical /
- Primary goal: assist in establishing
surgical care.
diagnosis. • Take detailed history.
• Assess the severity of abdominal • Perform thorough abdominal
pain. assessment.
• Observe behavior changes (more
reliable indicator).
Nursing Care Management

Abdominal Examination Preparation for Surgery

• Delay palpation until other Psychological Care
assessments are done. • Physical prep same as any
surgical child. • Prepare child emotionally.
• Ask the child to point to the
pain location with one finger. • In complications (e.g., • Support parents
peritonitis): psychologically.
• Rebound tenderness: - Anticipate procedures early
- May be present
- Prepare equipment quickly
- Not always reliable in children • Similar approach to other
emergency situations.
• Avoid delays in surgical
• Use light palpation to avoid
preparation.
trauma and still assess pain.
 Postoperative care
General Postoperative
Fluids & Nutrition Gastrointestinal Care
Care

• Non-perforated appendix →
same care as other abdominal • Maintain low, intermittent
• Maintain on IV fluids.
surgeries. gastric decompression.

• Administer IV antibiotics.
• Ruptured appendix with • Continue until return of bowel
peritonitis → requires more motility.
• Keep the child NPO (nothing
complex care. by mouth).
• Monitor:
• May require: • Bowel sounds
• Longer hospitalization • Passage of stool
• Home care (IV antibiotics and
dressing changes)
 Postoperative care
Wound Care Pain Management Psychosocial Care

• Acute illness causes sudden

• A drain may be present. stress.
• Pain sources:
• Perform frequent dressing
• Surgical incision
changes.
• Dressing changes and irrigation • Allow child and parents to:
• Pain is continuous in early • Express feelings
• Provide meticulous skin care to
postoperative days. • Share concerns
prevent excoriation.

• Administer analgesics regularly • Nurse should:

• If wound is open:
(around-the-clock). • Provide education
• Use moist (saline-soaked)
dressings • Offer emotional support
• Perform procedures at the peak • Reduce anxiety
• Perform wound irrigation with
effect of analgesics. • Promote coping
antibacterial solution
 Nursing Diagnosis
1. Acute pain related to inflammation of the appendix as evidenced by right lower quadrant abdominal
pain, guarding, and irritability.

2. Risk for infection related to possible rupture of the inflamed appendix and contamination of the
peritoneal cavity as evidenced by fever, elevated white blood cell count, and localized tenderness.

3. Imbalanced nutrition: less than body requirements related to nausea and vomiting as evidenced by
decreased appetite and inadequate oral intake.

4. Deficient fluid volume related to vomiting and fever as evidenced by dry mucous membranes,
decreased urine output, and signs of dehydration.

5. Anxiety (child and parents) related to hospitalization and fear of surgery as evidenced by crying,
restlessness, and verbalization of fear.

6. Impaired physical mobility related to abdominal pain as evidenced by limited movement, reluctance
to walk, and guarding behavior.

7. Deficient knowledge (parents/child) related to lack of information about appendicitis and its
management as evidenced by questions, misconceptions, or inability to describe the care plan.
Nursing care plan
Nursing Diagnosis Goal Key Interventions Rationale

Allow child to choose To promote the most

Acute Pain related to
position most comfortable position
inflamed appendix
comfortable (usually
legs flexed).
As evidenced by : The child will have no
Crying pain or pain will be
Support abdomen To splint the abdomen
Guarding abdomen reduced to a level
(pillow)
Limited movement acceptable to child.
To provide pain relief
Withdrawal
Give regular
Refusal to eat or drink
analgesics To minimize
Fever
breakthrough pain
Increased pulse
Teach PCA use
Nursing care plan
Nursing Diagnosis Goal Key Interventions Rationale

Risk for Infection related to

possibility of rupture To detect infection and plan
before surgery and open Monitor wound & interventions
wound after surgery (if dressing
open procedure is To detect fever or hemodynamic
performed) Child will be free Check vital signs instability and plan necessary
of signs and intervention
As evidenced by: symptoms of
Abdominal pain
Fever
peritonitis Give antibiotics To prevent wound infection
Rebound tenderness
Nausea and vomiting Encourage To decrease accumulation of
Anorexia ambulation flatus and abdominal distention
Increased WBC count
Fluid around the appendix and promote early return of
visualized on ultrasound imaging proper bowel function
Nursing care plan
Nursing Diagnosis Goal Key Interventions Rationale

To minimize losses
Risk for Deficient Fluid Keep NPO initially
through vomiting and
Volume related to
minimize abdominal
decreased intake fluid
distention
and losses secondary to Child will receive
loss of appetite, vomiting sufficient fluids to replace
To promote fluid
losses. Start fluids gradually
intake and bowel
As evidenced by:
function
Dry mucous membranes Child will exhibit signs of
Loss of skin turgor adequate hydration Give IV fluids
To replace fluid losses
Sunken eyes, (specify).
sunken fontanel
To assess hydration
Rapid thready pulse, Monitor intake &
status and renal
rapid breathing output
function
Nursing care plan
Nursing Diagnosis Goal Key Interventions Rationale

Surgical Recovery, To prevent abdominal distention

Delayed because of and vomiting
Maintain NPO early
absence of bowel motility Child will not
experience To remove gastric acid and
Use NG tube if
As evidenced by: abdominal secretions
needed
Abdominal distention distention or
Nausea and vomiting vomiting caused To assess presence of peristalsis
Assess bowel sounds
Absence of bowel sounds by delayed bowel (bowel function)
Abdominal mobility
Encourage movement
tenderness To increase movement, systemic
No passage of stools circulation, and peristalsis
 prevention
1. EAT A HIGH-FIBER DIET 2. MAINTAIN HEALTHY BOWEL HABITS
Date: Populations with high fiber intake have lower Avoid chronic constipation
rates of appendicitis. • Stay hydrated
Fiber helps: • Respond to the urge to defecate (don’t
• Prevent constipation delay)
• Reduce the formation of fecalith (stool
Appendicitis blockage) that can block the appendix
Examples:
Rationale:
Helps reduce the risk of obstruction inside
cannot be Fruits, vegetables, legumes, and whole
grains.
the appendix.
completely 3. PRACTICE GOOD HYGIENE AND SAFE FOOD
4. SEEK EARLY MEDICAL ATTENTION
prevented, HABITS

but healthy Some cases of appendicitis are linked Not prevention, but very important!
to gastrointestinal infections. So, If you have symptoms like abdominal pain,
choices can practicing good hygiene can help. nausea, vomiting, or fever, seek medical care
lower the •• Wash your hands regularly
Handle and prepare food safely
early.
This helps prevent serious complications like
risk! rupture of the appendix.
Q&A
TRUE OR FALSE
1-The appendix is located in the left lower quadrant of the abdomen

2- Pain in appendicitis usually starts around the umbilicus and then moves to the
right lower quadrant

3-Appendicitis is most commonly caused by obstruction of the appendix lumen

4-The inflammatory process decreases mucus secretion in the appendix

5- Elevated white blood cell count can support the diagnosis of appendicitis

6-Appendectomy is the standard surgical treatment for appendicitis

7-Nurses should encourage the child to eat and drink before surgery.
References
Zaidan, H., Khalfan, F., Ahmed, H., & Corbally, M. T. (2018). Positive and negative
rates in children with acute appendicitis. Bahrain Medical Bulletin, 40(2), 82–85.
Gil, L. A., Deans, K. J., & Minneci, P. C. (2023). Appendicitis in children. Seminars in
Pediatric Surgery, 32(4), 151322. [Link]
Humes, D. J., & Simpson, J. (2023). Appendicitis. In StatPearls. StatPearls
[Link]://[Link]/books/NBK441864/
Lotfollahzadeh, S., Lopez, R. A., & Deppen, J. G. (2024). Appendicitis. In StatPearls. StatPearls
Publishing.
[Link]

Humes, D. J., & Simpson, J. (2023). Acute appendicitis. In StatPearls. StatPearls Publishing.
[Link]

Acute appendicitis in adults. (n.d.). U.S. Pharmacist.

[Link]

Appendicitis treatment & management. (n.d.). Medscape.

[Link]

Antibiotic therapy for appendicitis in children. (n.d.). U.S. Pharmacist.

[Link]

Acute appendicitis in adults. (n.d.). U.S. Pharmacist.

[Link]
Thank you