Appendicitis: Early Sign & Symptoms, Treatment Nursing Care

Appendicitis: Early Sign & Symptoms, Treatment Nursing Care:

Appendicitis: Appendicitis is an inflammation of the vermiform appendix that develops most commonly in adolescents, young and adults. It can occur at any age but is rare in clients younger than 2 years and reaches a peak incidence in clients between 20 & 30 years. It is not common in older adults: however, when it does occur in such clients, rupture of the appendix is more common.

Etiology:

• Decreased dietary fibers and increased consumption of refined carbohydrates.
• Blockage of opening from the appendix into the caecum (may be due to thick mucus within the appendix or to the stool that enters the appendix from the caecum)
• Swelling of the lymphatic tissue in the appendix which may block the appendix. After the blockage occurs, bacteria which normally are found within the appendix begin to invade (infect) the wall of the appendix.
• Obstruction of the appendiceal orifice by the tumor, particularly carcinoma of the caecum is an occasional cause of acute appendicitis in middle age and elderly.
• Intestinal parasites, particularly pinworms can proliferate in the appendix and occlude the lumen.

Pathophysiology:

• Appendix becomes obstructed (mucus, stool, worms).
• Initiate the inflammatory process.
• Increases Intraluminal pressure.
• Decrease venous drainage, edema & bacterial Invasion of the bowel wall.
• Initiate a progressively severe, generalized or upper abdominal pain that becomes localized in the right lower quadrant of the abdomen within a few hours.
• Eventually, the inflamed appendix fills with pus, progressing to gangrene and perforation.

Symptoms of appendicitis:

• Acute abdominal pain that comes in waves. At first, the pain may be perceived merely as discomfort that makes the client feel that passing flatus or having a bowel movement will bring relief. Pain is usually accompanied by a low-grade fever, nausea and vomiting loss of appetite.
• Rebound tenderness in RIF usually present.
• Deep palpation of the left iliac fossa may cause pain in the right iliac fossa i.e. Rovsing’s sign.
• If the appendix has ruptured, the pain becomes more diffuse, abdominal distension develops.
• Nausea and vomiting also may occur later due to intestinal obstruction
• Deep tenderness at McBurney’s point, known as McBurney’s sign is a sign of acute appendicitis. McBurney’s point is the name given to the point over the right side of the human abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus.
• The clinical sign of rebound pain when pressure is applied is also known as Aaron’s sign.
• Positive obturator sign: The obturator sign is an indicator of irritation to the obturator internus muscle. First the patient lies on his back with the right hip flexed at 90 degrees. The examiner then holds the patient’s right ankle in his right hand. With his left hand, the examiner rotates the hip by pulling the right knee to and away from the patient’s body. This causes pain and is evidence in support of an inflamed appendix.
• Positive psoas sign: the patient is positioned on his/her left side and the right leg is extended behind the patient. If abdominal pain results, it is a positive psoas sign. “Positive psoas sign” may suggest appendicitis.

Diagnosis:

• History and physical examination.
• S/S: Elevated temperature and moderate to severe tenderness in the right lower abdomen, rebound tenderness (Rebound tenderness is pain that is worse when the doctor quickly releases his hand after gently pressing on the abdomen over the area of tenderness)

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Lab Investigations:

• White Blood Cell Count: usually elevated with infection.
• Urinalysis: if the inflammation of appendicitis is great enough, it can spread to the ureter and bladder leading to an abnormal urinalysis.
• 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.
• Ultrasound: Ultrasound can identify an enlarged appendix or an abscess.
• Computerized tomography (CT) Scan: useful in diagnosing appendicitis and peri-appendiceal abscesses as well as in excluding other diseases inside the abdomen and pelvis that can mimic appendicitis.

Treatment and management:

• Sometimes the body is successful in containing (“healing”) appendicitis without surgical treatment if the infection and accompanying inflammation do not spread throughout the abdomen. The inflammation, pain, and symptoms may disappear.
• If the inflammation and infection of appendicitis remain mild and localized to a small area 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.
• Appendectomy: it is a surgical procedure to remove the inflamed appendix. Antibiotics may be prescribed prior to surgery.
• In the case of abscess in the appendix, antibiotics are given prior to surgery. 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.

Complications of appendicitis:

• Perforation
• Peri appendiceal abscess or diffuse peritonitis
• Intestinal obstruction
• Fistula
• Pelvic or suprapubic abscess
• Sepsis, a very serious, even life-threatening complication
• Incisional Hernia

Nursing Care:

Pre-operative Nursing Management:

• Nursing goals include relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating infection due to the potential or actual disruption of the gastrointestinal tract, maintaining skin integrity, and attaining optimum nutrition.
• General preparation of abdomen.
• Informed consent
• Preoperative medications
• The bladder empties by asking the patient himself or by catheterization.
• Preoperatively, prepare the patient for surgery, start an intravenous line, administer antibiotic and insert nasogastric. Tube (if evidence of paralytic ileus). Do not administer an enema or laxative (could cause perforation).

Postoperative Nursing Management:

The postoperative bed should be made ready with hot water bags to keep the patient warm.

Postoperatively Nursing Management:

• Place the patient in semi-Fowler’s position
• Give narcotic analgesic as ordered
• Administer oral fluids when tolerated
• Give food as desired on day of surgery (if tolerated).
• If dehydrated before surgery, administer intravenous fluids.
• If a drain is left in place at the area of the incision, monitor carefully for signs of intestinal obstruction, secondary hemorrhage, or secondary abscesses (eg. fever, tachycardia, and increased leukocyte count).
• IV fluids to restore fluids and electrolytes
• Check vitals and record.
• Sedative and analgesic for pain, rest and sleep
• NG suctioning it needed to prevent vomiting
• Assess bowel sounds, and give fluids or foods as prescribed
• Early ambulation
• Dressing of wound, note the color, amount and odor of drainage.
• Observe the patients for possible complications

Oral hygiene (Of pt is in NPO)