APPENDICITIS AND

MANAGEMENT OF
PATIENT
UNDERGOING
APPENDECTOMY

HS2261 / HS2232
ADULT NURSING 2
Learning Outcomes
● Analyse significant information from patient assessment with
appendicitis.
● Recognise the sign and symptoms of patient with appendicitis.
● Determine the laboratory and diagnostic investigations that
deviates from normal physiological patterns of appendicitis.
● Identify patient problems based on assessment findings with
appendicitis.
● Develop an integrated management care plan for patient with
appendicitis based on the best evidences including management of
patient undergoing appendectomy.
Appendicitis
● Is an inflammation of the
vermiform appendix, is a
common cause of acute
abdominal pain.
● Appendicitis can occur at any
age, but is more common in
adolescents and young adults
and slightly more common in
males than in females.
An acutely inflamed and enlarged
appendix, sliced lengthwise.
 Pathophysiology of Appendicitis
● The appendix is a tubelike pouch attached to
the cecum just below the ileocecal valve.
● It is usually located in the right iliac region, at
an area designated as McBurney point.
● Obstruction of the proximal lumen of the
appendix is apparent in most acutely inflamed
appendices.
● The obstruction is often caused by a fecalith, or
a hard mass of feces.
● Other obstructive causes include a calculus or
stone, a foreign body, inflammation, a tumor,
parasites (e.g., pin-worms), or edema of
lymphoid tissue.
 Pathophysiology of Appendicitis
● Following obstruction, the appendix becomes distended with fluid
secreted by its mucosa.
● Pressure within the lumen of the appendix increases, impairing its blood
supply and leading to inflammation, edema, ulceration, and infection.
● Purulent exudate forms, further distending the appendix.
● Within 24 to 36 hours, tissue necrosis and gangrene result, leading to
perforation if treatment is not initiated.
● Perforation results in bacterial peritonitis.
 Classifications of Appendicitis
Simple appendicitis
● the appendix is inflamed but intact.

Gangrenous appendicitis
● When areas of tissue necrosis and microscopic perforations are
present in the appendix.

Perforated appendicitis
● shows evidence of gross perforation and contamination of the
peritoneal cavity.
 Clinical Manifestation of Appendicitis
● Continuous mild generalized or upper abdominal pain is the initial
characteristic manifestation of acute appendicitis.
● During the next 4 hours, the pain intensifies and localizes in the right
lower quadrant of the abdomen, aggravated by moving, walking, or
coughing.
● On palpation, localized and rebound tenderness are noted at McBurney
point.
● Rebound tenderness is demonstrated by relief of pain with direct
palpation of McBurney point followed by pain on release of pressure.
● Extension or internal rotation of the right hip increases the pain.
● In addition to pain, a low-grade temperature, anorexia, and nausea
and vomiting are often present.
● The older adult may report less severe pain, slight fever, and discomfort in
the right iliac fossa, delaying the diagnosis.
COMPLICATIONS OF APPENDICITIS
Complications of Appendicitis
● Perforation, peritonitis, and abscess are possible complications
of acute appendicitis.
● Perforation is manifested by increased pain and a high fever.
● It can lead to a small, localized abscess, local peritonitis, or
significant generalized peritonitis.
● A less common disorder is chronic appendicitis, characterized by
chronic abdominal pain and recurrent acute attacks at intervals of
several months or more.
● Other conditions, such as inflammatory bowel disease and renal
disorders, often cause manifestations attributed to chronic
appendicitis.
 Diagnostic Test for Appendicitis
Patient examination includes:
● A complete history
● Physical examination
● A urinalysis is done to rule out genitourinary conditions that mimic
appendicitis.
● FBC with a differential WBC count. Most patients have a mildly to
moderately elevated WBC count.
● CT scan is the preferred diagnostic procedure. However, ultrasound
and MRI are also used.
Medical Management of Appendicitis
● Prior to surgery, intravenous fluids are given to restore or maintain
vascular volume and prevent electrolyte imbalance.
● Antibiotic therapy with a third-generation cephalosporin effective
against many Gram-negative bacteria—such as cefoperazone
(Cefobid), cefotaxime (Claforan), ceftazidime (For-taz), or
ceftriaxone (Rocephin)—is initiated prior to surgery.
● The antibiotic is repeated during surgery and continued for at least
48 hours postoperatively.
● Pain medications are administered as prescribed.
● Prepare patient for surgery
 Surgical Management of Appendicitis
● The treatment of choice for acute appendicitis is an
appendectomy, surgical removal of the appendix.
● Either a laparoscopic approach (insertion of a laparoscope to view
abdominal contents) or laparotomy (surgical opening of the
abdomen) may be used for appendectomy.
Laparoscopic Appendectomy
A laparoscopic appendectomy is generally preferred because this
procedure requires a very small incision through which the laparoscope
is inserted.

This procedure 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.
Disadvantages include increased cost and longer operating time
(about 20 minutes longer than an open appendectomy)
 Open Appendectomy
● An open appendectomy is performed by
laparotomy.
● A small transverse incision is made at
McBurney point
● The appendix is isolated and ligated (tied off) to
prevent contamination of the site with bowel
contents, and then removed.
● Laparotomy is generally used when the
appendix has ruptured.
● It allows removal of contaminants from the
peritoneal cavity by irrigation with sterile
normal saline.
● Occasionally the wound may be left unsutured
for periodic irrigation.
● Recovery is generally uneventful.
 Nursing Management: Nursing
Assessment of Appendicitis
Because appendicitis can rapidly progress from inflammation to
perforation, prompt assessment is vital.

Obtain the following assessment data:

● Health history: Current manifestations, including onset, duration,
progression, and aggravating or relieving factors; most recent food
or fluid intake; known medication or other allergies; current
medications; history of chronic diseases
● Physical assessment: Vital signs including temperature; apparent
general health; abdominal shape and contour, bowel sounds,
tenderness to light palpation.
Nursing Diagnosis for Appendicitis

Nursing diagnoses for the patient with upper GI

bleeding include, but are not limited to, the following:
● Acute pain related to inflammation of the appendix
● Risk of infection related to post-op complication
● Anxiety related to uncertainty of cause or outcome
of the condition and pain
 Nursing Care Goals of Appendicitis
The overall goals when nursing patients with appendicitis are:
1. Patient will not exhibit signs and symptoms of perforation and
peritonitis.
2. Patient will remain afebrile, and WBC will decrease or remain at
base-line.
3. Patient will remain free of pain associated with perforation and
peritonitis.
4. Patient will express tolerable pre-operative pain using pain scale.
5. Patient will report adequate pain control postoperatively.
Nursing Implementation of Appendicitis
(Manage Acute Pain)
The patient with appendicitis experiences pain before and after
surgery. Analgesia is limited until the diagnosis is established.
Postoperative pain is controlled by narcotic or nonnarcotic
analgesics.
Assess pain, including its character, location, severity, and
duration. Report any unexpected changes in the nature of pain.
● Both preoperatively and postoperatively, the patient’s pain
provides important clues about the diagnosis and possible
complications such as rupture of the appendix or peritonitis.
 Nursing Implementation of Appendicitis
(Manage Acute Pain)
Administer analgesics as ordered.

● Preoperatively, pain medication may be given cautiously until a diagnosis

is established.
● Postoperatively, provide analgesics to maintain comfort and enhance
mobility.

Assess effectiveness of medication 30 minutes after administration. Report

unrelieved pain.

● Pain unrelieved by prescribed analgesic may indicate a complication or the

need for further assessment.
● For example, continued abdominal discomfort and distention may indicate
excess intestinal gas that may be better relieved by ambulation.
 Nursing Implementation of Appendicitis
(Monitor signs & complications of infection)
Preventing complications during the preoperative and postoperative
periods is a primary nursing care goal.

Perforation and peritonitis are the most likely pre-operative

complications; postoperative complications include wound infection,
abscess, and possible peritonitis.

Monitor vital signs, including temperature.

● Tachycardia and rapid shallow respirations may indicate perforation
of the appendix with resulting peritonitis.
● Fever may develop as well, and the blood pressure may fall if sepsis
is present.
Nursing Implementation of Appendicitis
(Monitor signs & complications of infection)

Maintain intravenous infusion until oral intake is

adequate.
● Intravenous fluids are given to maintain vascular volume and
to provide a route for antibiotic administration.
Assess wound, abdominal girth, and postoperative pain.
● Swelling of the wound, increased abdominal girth, or an
increase in pain may indicate infection or peritonitis.
Nursing Implementation of Appendicitis
(Monitor signs & complications of infection)

Keep the patient with suspected appendicitis NPO, and do not

administer laxatives or enemas.
● Laxatives or enemas may cause perforation of the appendix.

No heat should be applied to the abdomen.

● Heat may increase circulation to the appendix and also cause
perforation.
Patient education
With uncomplicated appendectomy, the patient is often discharged
either the day of surgery or the day following surgery.

Postoperative teaching includes:

● Wound or incision care, including hand hygiene and dressing change
procedures as indicated
● Instructions to report fever, increased abdominal pain, swelling,
redness, drainage, bleeding, or warmth of the operative site to the
physician
● Activity limitations (e.g., lifting, driving), if any
● Returning to work, if appropriate.
Reference
● Sharon L. Lewis , Linda Bucher , Margaret M. Heitkemper , Mariann
M. Harding , Jeffrey Kwong and Dottie Roberts . (2016).
<em>Medical-Surgical Nursing - E-Book</em>. Elsevier Health
Sciences.
[Link]
alsurgical-nursing-ebook
● Carno, G.B.R.P.F.K.B.P.G. M. (2019). Medical-Surgical Nursing.
[VitalSource Bookshelf]. Retrieved from
[Link]