SURGICAL EMERGENCIES

Topic Of Study; Appendicitis

Class: State Registered Nursing II
I. INTRODUCTION
Appendicitis is defined as an inflammation of the inner lining of the vermiform
appendix that spreads to its other parts. This condition is a common and urgent
surgical illness(surgical emergency) with protean manifestations, generous
overlap with other clinical syndromes, and significant morbidity, which
increases with diagnostic delay (see clinical presentation). In fact, despite
diagnostic and therapeutic advancement in medicine, appendicitis remains a
clinical emergency and is one of the more common causes of acute abdominal pain.

No single sign, symptom, or diagnostic test accurately confirms the diagnosis

of appendiceal inflammation in all cases, and the classic history of anorexia
and periumbilical pain followed by nausea, right lower quadrant (RLQ) pain, and
vomiting occurs in only 50% of cases.

Appendicitis may occur for several reasons, such as an infection of the

appendix, but the most important factor is the obstruction of the appendiceal
lumen (see Pathophysiology and Etiology subsequently). Left untreated,
appendicitis has the potential for severe complications, including perforation
or sepsis, and may even cause death (see Prognosis). However, the differential
diagnosis of appendicitis is often a clinical challenge because appendicitis
can mimic several abdominal conditions.

II. ANATOMY OF THE APPENDIX

The appendix is a worm-like extension of the cecum(The first part of the large
intestine) and, for this reason, has been called the vermiform appendix. 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 several lymphoid follicles are
scattered in its mucosa. Such follicles increase in number when individuals are
aged 8-20 years. A normal appendix is seen below.

Figure: The Cecum, showing the extension of the vermiform appendix with
its vasculature.
The appendix is contained within the visceral peritoneum that forms the serosa,
and its exterior layer is longitudinal and derived from the taenia coli; the
deeper, interior muscle layer is circular. Beneath these layers lies the
submucosal layer, which contains lymphoepithelial tissue. The mucosa consists
of columnar epithelium with few glandular elements and neuroendocrine
argentaffin cells.

Taenia coli converge on the posteromedial area of the cecum, which is the site
of the appendiceal base. The appendix runs into a serosal sheet of the
peritoneum called the mesoappendix, within which 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.
Appendiceal congenital disorders are extremely rare but occasionally reported
(e.g, agenesis, duplication, triplication). Appendicitis can be prevented by
the intake of high-fiber diet which helps reduce the odds of developing
appendicitis by creating softer stools which are less likely to be trapped in
the appendix.

III. PATHOPHYSIOLOGY

Reportedly, appendicitis is caused by obstruction of the appendiceal lumen from

a variety of causes (see Etiology). 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 blood cells and the
formation of pus and subsequent higher intraluminal pressure.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.

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.

IV. ETIOLOGY
Appendicitis is caused by obstruction of the appendiceal lumen. The most common
causes of luminal obstruction include lymphoid hyperplasia secondary to
inflammatory bowel disease (IBD) or infections (more common during childhood
and in young adults), fecal stasis and fecaliths (more common in elderly
patients), parasites, or, more rarely, foreign bodies and neoplasms.
Fecaliths form when calcium salts and fecal debris become layered around a
nidus of inspissated fecal material located within the appendix. Lymphoid
hyperplasia is associated with various inflammatory and infectious disorders
including: Crohn disease, gastroenteritis, amebiasis, respiratory infections,
measles, and mononucleosis.

Obstruction of the appendiceal lumen has less commonly been associated with
bacteria (Yersinia species, adenovirus, cytomegalovirus, actinomycosis,
Mycobacteria species, Histoplasma species), parasites (e.g, Schistosomes
species, pinworms, Strongyloides stercoralis), foreign material (e.g, shotgun
pellet, intrauterine device, tongue stud, activated charcoal), tuberculosis,
and tumors.

V. CLINICAL PRESENTATION(MANIFESTATION/SIGNS AND SYMPTOMS)

The classic history of anorexia and periumbilical pain followed by nausea,

right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases.
Nausea is present in 61-92% of patients; anorexia is present in 74-78% of
patients. Neither finding is statistically different from findings in patients
who present to the emergency department with other etiologies of abdominal pain.
In addition, when vomiting occurs, it nearly always follows the onset of pain.
Vomiting that precedes pain is suggestive of intestinal obstruction, and the
diagnosis of appendicitis should be reconsidered. Diarrhea or constipation is
noted in as many as 18% of patients and should not be used to discard the
possibility of appendicitis.

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. This pain migration is the most discriminating
feature of the patient's history, with a sensitivity and specificity of
approximately 80%, a positive likelihood ratio of 3.18, and a negative
likelihood ratio of 0.5. Patients usually lie down, flex their hips, and draw
their knees up to reduce movements and to avoid worsening their pain. 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 but
fever sets in later(10-20%).

The duration of symptoms is less than 48 hours in approximately 80% of adults

but tends to be longer in elderly persons and in those with perforation.
Approximately 2% of patients report duration of pain in excess of 2 weeks. A
history of similar pain is reported in as many as 23% of cases, but this
history of similar pain, in and of itself, should not be used to rule out the
possibility of appendicitis.

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, as well as consider gynecologic
history in female patients. An inflamed appendix near the urinary bladder or
ureter can cause irritative voiding symptoms and hematuria or pyuria. Cystitis
in male patients is rare in the absence of instrumentation. Consider the
possibility of an inflamed pelvic appendix in male patients with apparent
cystitis. Also consider the possibility of appendicitis in pediatric or adult
patients who present with acute urinary retention.
VI. PHYSICAL EXAMINATION AND DIAGNOSTICS

History: Variations in the position of the appendix, age of the patient, and
degree of inflammation make the clinical presentation of appendicitis
notoriously inconsistent. Statistics report that 1 of 5 cases of appendicitis
is misdiagnosed; however, a normal appendix is found in 15-40% of patients who
have an emergency appendectomy.

Niwa et al(Researchers in the medical field) reported an interesting case of a

young woman with recurrent pain in who was referred for appendicitis, treated
with antibiotics, and was found to have an appendiceal diverticulitis
associated with a rare pelvic pseudocyst at laparotomy after 12 months. Her
condition was probably due to diverticular perforation of the pseudocyst.

It is important to remember that the position of the appendix is variable.

Of 100 patients undergoing 3-dimensional (3-D) multidetector computed
tomography (MDCT) scanning, the base of the appendix was located at the
McBurney point in only 4% of patients; in 36%, the base was within 3 cm of the
point; in 28%, it was 3-5 cm from that point; and, in 36% of patients, the base
of the appendix was more than 5 cm from the McBurney point.

Figure: Location of the appendix at the McBurney’s point, 2/3 of the diagonal
line drawn from the umbilicus to the anterior superior iliac
spine(ASIS), but 1/3 of the diagonal starting from the ASIS to the
umbilicus.
The most specific physical findings in appendicitis are rebound tenderness,
pain on percussion, rigidity, and guarding. Although RLQ tenderness is present
in 96% of patients, this is a nonspecific finding. Rarely, left lower quadrant
(LLQ) tenderness has been the major manifestation in patients with situs
inversus or in patients with a lengthy appendix that extends into the LLQ.
Tenderness on palpation in the RLQ over the McBurney point is the most
important sign in these patients.

A careful physical examination, not limited to the abdomen, must be performed

in any patient with suspected appendicitis. Gastrointestinal (GI),
genitourinary, and pulmonary systems must be studied. Male infants and children
occasionally present with an inflamed hemiscrotum due to migration of an
inflamed appendix or pus through a patent processus vaginalis. This is often
initially misdiagnosed as acute testicular torsion. In addition, perform a
rectal examination in any patient with an unclear clinical picture, and perform
a pelvic examination in all women with abdominal pain. According to the
American College of Emergency Physicians (ACEP) 2010 clinical policy update,
clinical signs and symptoms should be used to stratify patient risk and to
choose next steps for testing and management.

Physical examination findings include the following:

- Rebound tenderness, pain on percussion, rigidity, and guarding: Most

specific finding.
- RLQ tenderness: Present in 96% of patients, but nonspecific.
- Left lower quadrant (LLQ) tenderness: May be the major manifestation in
patients with situs inversus or in patients with a lengthy appendix that
extends into the LLQ.
- Male infants and children occasionally present with an inflamed hemiscrotum
- In pregnant women, RLQ pain and tenderness dominate in the first trimester,
but in the latter half of pregnancy, right upper quadrant (RUQ) or right
flank pain may occur.

The following accessory signs may be present in a minority of patients:

- Rovsing sign (RLQ pain with palpation of the LLQ): Suggests peritoneal
irritation.
- Obturator sign (RLQ pain with internal and external rotation of the flexed
right hip): Suggests the inflamed appendix is located deep in the right
hemipelvis.
- Psoas sign (RLQ pain with extension of the right hip or with flexion of
the right hip against resistance): Suggests that an inflamed appendix is
located along the course of the right psoas muscle.
- Dunphy sign (sharp pain in the RLQ elicited by a voluntary cough):
Suggests localized peritonitis.
- RLQ pain in response to percussion of a remote quadrant of the abdomen or
to firm percussion of the patient's heel: Suggests peritoneal inflammation
- Markle sign (pain elicited in a certain area of the abdomen when the
standing patient drops from standing on toes to the heels with a jarring
landing): Has a sensitivity of 74%.
Diagnosis :The following laboratory tests do not have findings specific for
appendicitis, but they may be helpful to confirm diagnosis in patients with an
atypical presentation:
*CBC
- WBC >10,500 cells/µL: 80-85% of adults with appendicitis
- Neutrophilia >75-78% of patients
- Less than 4% of patients with appendicitis have a WBC count less than
10,500 cells/µL and neutrophilia less than 75%
In infants and elderly patients, a WBC count is especially unreliable because
these patients may not mount a normal response to infection. In pregnant women,
the physiologic leukocytosis renders the CBC count useless for the diagnosis of
appendicitis.
*C-reactive protein
- CRP levels >1 mg/dL are common in patients with appendicitis
- Very high levels of CRP in patients with appendicitis indicate gangrenous
evolution of the disease, especially if it is associated with leukocytosis
and neutrophilia
- In adults who have had symptoms for longer than 24 hours, a normal CRP
level has a negative predictive value of 97-100% for appendicitis
*CT scanning
- CT scanning with oral contrast medium or rectal Gastrografin enema has
become the most important imaging study in the evaluation of patients with
atypical presentations of appendicitis
- Low-dose abdominal CT may be preferable for diagnosing children and young
adults in whom exposure to CT radiation is of particular concern
*Ultrasonography
- Ultrasonography may offer a safer alternative as a primary diagnostic tool
for appendicitis, with CT scanning used in those cases in which
ultrasonograms are negative or inconclusive
- In pediatric patients, American College of Emergency Physicians (ACEP)
clinical policy recommends ultrasonography for confirmation, but not
exclusion, of acute appendicitis; to definitively exclude acute
appendicitis, the ACEP recommends CT.
- A healthy appendix usually cannot be viewed with ultrasonography; when
appendicitis occurs, the ultrasonogram typically demonstrates a
noncompressible tubular structure of 7-9 mm in diameter

- Vaginal ultrasonography alone or in combination with transabdominal scan

may be useful to determine the diagnosis in women of childbearing a

VII. RISK FACTORS

- Intestinal obstruction.
- Infection of the stomach that eventually travels to the site of the
vermiform appendix.
- Previous abdominal surgery.
- Low fiber-diet intake.
- High intake of refined carbohydrates.
VIII. COMPLICATIONS
Complications of appendicitis may include : Peritonitis, wound infection,
dehiscence, bowel obstruction, abdominal/pelvic abscess(if an infection seeps
out of the appendix and mixes with intestinal contents, it may form an abscess,
and if not treated, it can cause peritonitis. Sometimes abscesses are treated
with antibiotics but often surgically drained with the aid of a tube which is
placed into the abdomen), and, rarely, death. Stump appendicitis also occurs
rarely; however, at least 36 reported cases of appendicitis in the surgical
stump after previous appendectomy exist.

IX. MANAGEMENT OF APPENDICITIS

A. MEDICAL AND SURGICAL MANAGEMENT.
Approach Considerations

An appendectomy (surgical removal of the appendix) is the preferred method of

management for acute appendicitis if the inflammation is localized. An open
appendectomy is completed with a transverse right lower quadrant incision,
usually at the McBurney point. A laparoscopic appendectomy may be used in
females of childbearing age, those in whom the diagnosis is in question, and
for obese.patients. If the appendix has ruptured and there is evidence of
peritonitis or an abscess, conservative treatment consisting of antibiotics and
intravenous (IV) fluids is given 6 to 8 hours prior to an appendectomy.
Generally, an appendectomy is performed within 24 to 48 hours after the onset
of symptoms under either general or spinal anesthesia. Preoperative management
includes IV hydration, antipyretics, antibiotics, and, after definitive
diagnosis, analgesics.Appendectomy remains the only curative treatment of
appendicitis, but management of patients with an appendiceal mass can usually
be divided into the following 3 treatment categories:

- Patients with a phlegmon or a small abscess: After intravenous (IV)

antibiotic therapy, an interval appendectomy can be performed 4-6 weeks
later.
- Patients with a larger well-defined abscess: After percutaneous drainage
with IV antibiotics is performed, the patient can be discharged with the
catheter in place. Interval appendectomy can be performed after the fistula
is closed.
- Patients with a multicompartmental abscess: These patients require early
surgical drainage.
Although many controversies exist over the nonoperative management of acute
appendicitis, antibiotics have an important role in the treatment of patients
with this condition. Antibiotics considered for patients with appendicitis must
offer full aerobic and anaerobic coverage. The duration of the administration
is closely related to the stage of appendicitis at the time of the diagnosis,
considering either intraoperative findings or postoperative evolution.
According to several studies, antibiotic prophylaxis should be administered
before every appendectomy. When the patient becomes afebrile and the white
blood cell (WBC) count normalizes, antibiotic treatment may be stopped.
Cefotetan and cefoxitin (Cephalosporins) seem to be the best choices of
antibiotics.

- Antibiotic prophylaxis should be administered before every appendectomy

- Preoperative antibiotics should be administered in conjunction with the
surgical consultant
- Broad-spectrum gram-negative and anaerobic coverage is indicated
- Cefotetan and cefoxitin seem to be the best choices of antibiotics
- In penicillin-allergic patients, Carbapenems are a good option
- Pregnant patients should receive pregnancy category A or B antibiotics
- Antibiotic treatment may be stopped when the patient becomes afebrile and
the WBC count normalizes
B. NURSING MANAGEMENT

Pharmacological intervention include:Crystalloid intravenous fluids an isotonic

solutions such as normal saline solution or lactated Ringer’s solution 100–
500 mL/hr of IV, depending on volume state of the patient, is used to replaces
fluids and electrolytes lost through fever and vomiting; replacement continues
until urine output is 1 cc/kg of body weight and electrolytes are replaced
Antibiotics (broad-spectrum antibiotic coverage) to control local and systemic
infection and reduces the incidence of postoperative wound infection
-Other Drugs: Analgesics.
Preoperative Management
- Maintain NPO status.
- Administer fluids intravenously to prevent dehydration.
- Monitor for changes in level of pain.
- Monitor for signs of ruptured appendix and peritonitis
- Position right-side lying or low to semi fowler position to promote comfort.
- Monitor bowel sounds.
- Apply ice packs to abdomen every hour for 20-30 minutes as prescribed.
- Administer antibiotics as prescribed
- Avoid the application of heat in the abdomen.
- Avoid laxatives or enema.
Postperative Management
- Monitor temperature for signs of infection.
- Assess incision for signs of infection such as redness, swelling and pain.
- Maintain NPO status until bowel function has returned.
- Advance diet gradually or as tolerated or as prescribed when bowel sound
return.
- If ruptured of appendix occurred, expect a Penros drain to be inserted, or
the incision maybe left to heal inside out.
- Expect that drainage from the Penros drain maybe profuse for the first 2
hours.
Discharge and Home Healthcare Guidelines
- MEDICATIONS. Be sure the patient understands any pain medication
prescribed, including doses, route, action, and side effects. Make certain
the patient understands that he or she should avoid operating a motor
vehicle or heavy machinery while taking such medication.
- INCISION. Sutures are generally removed in the physician’s office in 5 to
7 days. Explain the need to keep the surgical wound clean and dry. Teach
the patient to observe the wound and report to the physician any increased
swelling, redness, drainage, odor, or separation of the wound edges. Also
instruct the patient to notify the doctor if a fever develops. The patient
needs to know these may be symptoms of wound infection. Explain that the
 patient should avoid heavy lifting and should question the physician about
when lifting can be resumed.
- COMPLICATIONS. Instruct the patient that a possible complication of
appendicitis is peritonitis. Discuss with the patient symptoms that
indicate peritonitis, including sharp abdominal pains, fever, nausea and
vomiting, and increased pulse and respiration. The patient must know to
seek medical attention immediately should these symptoms occur.
- NUTRITION. Instruct the patient that diet can be advanced to her or his
normal food pattern as long as no gastrointestinal distress is experienced.
C. NURSING CARE PLAN(The nurse’s working tool)
- Nursing Diagnosis: #1 Acute Pain
May be related to
- Distension of intestinal tissues by inflammation
- Presence of surgical incision
Possibly evidenced by
- Reports of pain(Verbalization)
- Facial grimacing, muscle guarding; distraction behaviors
- Expressive behavior (restlessness, moaning, crying, vigilance, irritability,
sighing)
- Autonomic responses
Desired Outcomes
- Report pain is relieved/controlled.
- Appear relaxed, able to sleep/rest appropriately.
- Demonstrate use of relaxation skills and diversional activities, as
indicates, for individual situation.
Nursing Interventions
- Assess pain, noting location, characteristics, severity (0–10 scale).
Investigate and report changes in pain as appropriate.
Rationale: Useful in monitoring effectiveness of medication, progression of
healing. Changes in characteristics of pain may indicate developing abscess or
peritonitis, requiring prompt medical evaluation and intervention.
- Provide accurate, honest information to patient and SO.
Rationale: Being informed about progress of situation provides emotional
support, helping to decrease anxiety
- Keep at rest in semi-Fowler’s position.
Rationale: To lessen the pain. Gravity localizes inflammatory exudate into
lower abdomen or pelvis, relieving abdominal tension, which is accentuated by
supine position.
- Encourage early ambulation.
Rationale: Promotes normalization of organ function (stimulates peristalsis and
passing of flatus, reducing abdominal discomfort).
- Provide diversional activities
Rationale: Refocuses attention, promotes relaxation, and may enhance coping
abilities.
- Keep NPO and maintain NG suction initially.
Rationale: Decreases discomfort of early intestinal peristalsis, gastric
irritation and vomiting.
- Administer analgesics as indicated.
Rationale: Relief of pain facilitates cooperation with other therapeutic
interventions (ambulation, pulmonary toilet).
- Place ice bag on abdomen periodically during initial 24–48 hr, as
appropriate.
Rationale: Soothes and relieves pain through desensitization of nerve endings.
Note: Do not use heat, because it may cause tissue congestion.
- Never apply heat to the right lower abdomen.
Rationale: This may cause the appendix to rupture.
- Watch closely for possible surgical complications.
Rationale: Continuing pain and fever may signal an abscess.

Nursing Diagnosis: #2 Risk for Fluid Volume Deficit

Risk factors may include
- Preoperative vomiting, postoperative restrictions (e.g., NPO)
- Hypermetabolic state (e.g., fever, healing process)
- Inflammation of peritoneum with sequestration of fluid.
Desired Outcomes
- Hydration (NOC)
- Maintain adequate fluid balance as evidenced by moist mucous membranes,
good skin turgor, stable vital signs, and individually adequate urinary
output.
Nursing Interventions
- Monitor BP and pulse.
Rationale: Variations help identify fluctuating intravascular volumes
- Inspect mucous membranes; assess skin turgor and capillary refill.
Rationale:Indicators of adequacy of peripheral circulation and cellular
hydration.
- Monitor I&O; note urine color and concentration, specific gravity.
Rationale: Decreasing output of concentrated urine with increasing specific
gravity suggests dehydration and need for increased fluids.
- Auscultate and document bowel sounds. Note passing of flatus, bowel
movement.
Rationale: Indicators of return of peristalsis, readiness to begin oral intake.
Note: This may not occur in the hospital if patient has had a laparoscopic
procedure and been discharged in less than 24 hr.
- Provide clear liquids in small amounts when oral intake is resumed, and
progress diet as tolerated.
Rationale: Reduces risk of gastric irritation and vomiting to minimize fluid
loss.
- Give frequent mouth care with special attention to protection of the lips.
Rationale: Dehydration results in drying and painful cracking of the lips and
mouth.
- Maintain gastric and intestinal suction, as indicated.
Rationale: An NG tube may be inserted preoperatively and maintained in
immediate postoperative phase to decompress the bowel, promote intestinal rest,
prevent vomiting.
- Administer IV fluids and electrolytes.
Rationale: The peritoneum reacts to irritation and infection by producing large
amounts of intestinal fluid, possibly reducing the circulating blood volume,
resulting in dehydration and relative electrolyte imbalances.
- Never administer cathartics or enemas.
Rationale: Cathartics and enemas may rupture the appendix.
- Give the patient nothing by mouth, and administer analgesics judiciously.
Rationale: This may mask symptoms.

Nursing Diagnosis: #3 Risk for Infection

Risk factors may include:
- Inadequate primary defenses; perforation/rupture of the appendix;
peritonitis; abscess formation
- Invasive procedures, surgical incision
Desired Outcomes
- Achieve timely wound healing; free of signs of infection/inflammation,
purulent drainage, erythema, and fever.
Nursing Priorities
- Prevent complications.
- Promote comfort.
- Provide information about surgical procedure/prognosis, treatment needs,
and potential complications.
Discharge Goals
- Complications prevented/minimized.
- Pain alleviated/controlled.
- Surgical procedure/prognosis, therapeutic regimen, and possible
complications understood.
- Plan in place to meet needs after discharge.
Nursing Interventions
- Practice and instruct in good hand washing and aseptic wound care.
Encourage and provide perineal care.
Rationale: Reduces risk of spread of bacteria.
- Inspect incision and dressings. Note characteristics of drainage from wound
(if inserted), presence of erythema.
Rationale: Provides for early detection of developing infectious process and
monitors resolution of preexisting peritonitis.
- Monitor vital signs. Note onset of fever, chills, diaphoresis, changes in
mentation, reports of increasing abdominal pain.
Rationale: Suggestive of presence of infection or developing sepsis, abscess,
peritonitis.
- Obtain drainage specimens if indicated.
Rationale: Gram’s stain, culture, and sensitivity testing is useful in
identifying causative organism and choice of therapy.
- Administer antibiotics as appropriate.
Rationale: Antibiotics given before appendectomy are primarily for prophylaxis
of wound infection and are not continued postoperatively. Therapeutic
antibiotics are administered if the appendix is ruptured or abscessed or
peritonitis has developed.
- Prepare and assist with incision and drainage (I&D) if indicated.
Rationale: May be necessary to drain contents of localized abscess.
- Watch closely for possible surgical complications.
Rationale: Continuing pain and fever may signal an abscess.

Nursing Diagnosis:#4 Deficient Knowledge

May be related to
- Lack of exposure/recall; information misinterpretation
- Unfamiliarity with information resources
Possibly evidenced by
- Questions; request for information; verbalization of problem/concerns
- Statement of misconception
- Inaccurate follow-through of instruction
- Development of preventable complications
Desired Outcomes
- Verbalize understanding of disease process and potential complications.
- Verbalize understanding of therapeutic needs.
- Participate in treatment regimen.
Nursing Interventions
- Identify symptoms requiring medical evaluation (increasing pain; edema or
erythema of wound; presence of drainage, fever).
Rationale: Prompt intervention reduces risk of serious complications (delayed
wound healing, peritonitis).
- Review postoperative activity restrictions (heavy lifting, exercise, sex,
sports, driving).
Rationale: Provides information for patient to plan for return to usual
routines without untoward incidents.
- Encourage progressive activities as tolerated with periodic rest periods.
Rationale: Prevents fatigue, promotes healing and feeling of well-being, and
facilitates resumption of normal activities.
- Recommend use of mild laxative or stool softeners as necessary and
avoidance of enemas.
Rationale: Assists with return to usual bowel function; prevents undue
straining for defecation.
- Discuss care of incision, including dressing changes, bathing restrictions,
and return to physician for suture and staple removal.
Rationale: Understanding promotes cooperation with therapeutic regimen,
enhancing healing and recovery process.
- Encourage the patient to cough, breathe deeply, and turn frequently.
Rationale: To prevent pulmonary complication

X. DIFFENTIAL DIAGNOSIS
The overall accuracy for diagnosing acute appendicitis is approximately 80%,
which corresponds to a mean negative appendectomy rate of 20%. Diagnostic
accuracy varies by sex, with a range of 78-92% in male patients and 58-85% in
female patients.
The classic history of anorexia and periumbilical pain followed by nausea,
right lower quadrant (RLQ) pain, and vomiting occurs in only 50% of cases.
Vomiting that precedes pain is suggestive of intestinal obstruction, and the
diagnosis of appendicitis should be reconsidered.
The differential diagnosis of appendicitis is often a clinical challenge
because appendicitis can mimic several abdominal conditions (see the
Differentials section). Patients with many other disorders present with
symptoms similar to those of appendicitis, such as the following:
- Pelvic inflammatory disease (PID) or tubo-ovarian abscess
- Endometriosis
- Ovarian cyst or torsion
- Ureterolithiasis and renal colic
- Degenerating uterine leiomyomata
- Diverticulitis
- Crohn disease
- Colonic carcinoma
- Rectus sheath hematoma
- Cholecystitis
- Bacterial enteritis
- Mesenteric adenitis and ischemia
- Omental torsion
- Biliary colic
- Renal colic
- Urinary tract infection (UTI)
- Gastroenteritis
- Enterocolitis
- Pancreatitis
- Perforated duodenal ulcer
Other problems that should be considered in a patient with suspected
appendicitis include appendiceal stump appendicitis, typhlitis, epiploic
appendagitis, psoas abscess, and yersiniosis.

Misdiagnosis in women of childbearing age

Appendicitis is misdiagnosed in 33% of nonpregnant women of childbearing age.
The most frequent misdiagnoses are PID, followed by gastroenteritis and urinary
tract infection. In distinguishing appendiceal pain from that of PID, anorexia
and onset of pain more than 14 days after menses suggests appendicitis.
Previous PID, vaginal discharge, or urinary symptoms indicates PID. On physical
examination, tenderness outside the RLQ, cervical motion tenderness, vaginal
discharge, and positive urinalysis support the diagnosis of PID.

Although negative appendectomy does not appear to adversely affect maternal or

fetal health, diagnostic delay with perforation does increase fetal and
maternal morbidity. Therefore, aggressive evaluation of the appendix is
warranted in pregnant women.

The level of urinary beta–human chorionic gonadotropin (beta-hCG) is useful in

differentiating appendicitis from early ectopic pregnancy. However, with regard
to the WBC count, physiologic leukocytosis during pregnancy makes this study
less useful in the diagnosis than at other times, and no reliable
distinguishing WBC parameters are cited in the literature.
Misdiagnosis in children
Appendicitis is misdiagnosed in 25-30% of children, and the rate of initial
misdiagnosis is inversely related to the age of the patient. The most common
misdiagnosis is gastroenteritis, followed by upper respiratory infection and
lower respiratory infection.

Children with misdiagnosed appendicitis are more likely than their counterparts
to have vomiting before pain onset, diarrhea, constipation, dysuria, signs and
symptoms of upper respiratory infection, and lethargy or irritability. Physical
findings less likely to be documented in children with a misdiagnosis than in
others include bowel sounds; peritoneal signs; rectal findings; and ear, nose,
and throat findings.
Considerations in elderly patients
Appendicitis in patients older than 60 years accounts for 10% of all
appendectomies. The incidence of misdiagnosis is increased in elderly patients.
Older patients tend to seek medical attention later in the course of illness;
therefore, a duration of symptoms in excess of 24-48 hours should not dissuade
the clinician from the diagnosis. In patients with co-morbid conditions,
diagnostic delay is correlated with increased morbidity and mortality.

- Differential Diagnoses
- Abdominal Abscess
- Bacterial Gastroenteritis
- Cholecystitis and Biliary Colic
- Constipation
- Crohn Disease
- Urinary Tract Infection (UTI) and Cystitis (Bladder Infection) in Females
- Diverticulitis
-
XI. PROGNOSIS
If patients are treated in a timely fashion, the prognosis is good. Wound
infection and intra-abdominal abscess are potential complications associated
with appendectomy. Laparoscopic appendectomy has been shown to decrease the
incidence of overall complications.

REFERENCES
https://emedicine.medscape.com/article/773895-overview#a7
https://emedicine.medscape.com/article/773895-clinical
https://emedicine.medscape.com/article/773895-differential
https://www.nursingpath.in/2018/05/appendicitis-management-and-nursing.html?m=1