Appendicitis is the inflammation of the appendix, a small pouch attached to the large intestine in the right lower quadrant of the abdomen. The appendix has shown to have benefits in infants but the function in adults is largely unknown. Research suggests the appendix may help regulate intestinal bacteria.
If the appendix becomes blocked it will become inflamed and swollen leading to pain, nausea, vomiting, diarrhea, and fever. If not treated promptly, the appendix can burst which is a medical emergency requiring an appendectomy.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Ineffective Tissue Perfusion
- Risk For Deficient Fluid Volume
- Risk For Infection
- Risk for Shock
Nursing Process
Nurses may treat patients with appendicitis in several phases of their condition from arriving at the emergency department with sudden pain, to caring for them post-operatively, to reviewing their discharge instructions with them once they return home. Nurses must understand how to treat the symptoms and prevent infection and complications that can result from appendicitis.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section we will cover subjective and objective data related to appendicitis.
Review of Health History
1. Ask the patient about their general symptoms.
Determine the patient’s complaints and general symptoms, such as:
- Abdominal pain
- Loss of appetite (anorexia)
- Nausea/vomiting
- Low-grade fever (temperature of 38°C or 100.4°F)
- Chills
- Constipation
- Diarrhea
- Difficulty passing gas
- Generalized malaise
- Urinary frequency or urgency
2. Investigate the abdominal pain further.
Abdominal pain with appendicitis begins as generalized or periumbilical (around the belly button) pain. Pain can also come from the lower right quadrant of the abdomen where the appendix is located. The patient may also complain of pain during deep breathing, movement, coughing, or sneezing. If the appendix ruptures, pain may be felt throughout the abdomen.
3. Identify the underlying cause.
Appendicitis occurs when the appendix becomes obstructed. It can be caused by gastrointestinal infections (viruses, bacteria, or parasites) or when stool gets stuck in or blocks the tube connecting the large intestine and the appendix. Appendicitis can also result from malignancies.
4. Track the family history.
Most appendicitis cases affect those between the ages of 10 and 30. The risk may increase if the family has a history of appendicitis, especially for males. Having cystic fibrosis also appears to increase their risk of developing appendicitis.
Physical Assessment
1. Follow the IAPP sequence.
Inspection, auscultation, light palpation (starting at a spot away from the pain), and abdominal percussion should be performed in that order during the abdominal examination. It has been demonstrated that percussion of the abdomen is a more reliable method for detecting the rebound tenderness linked to peritoneal irritation than quick-release palpation.
2. Expect that pain is not only in the right lower quadrant.
Apart from the right lower quadrant, pain and tenderness can occur in other locations. A retroperitoneal location of the retrocecal appendix may induce flank pain. In this situation, stretching the iliopsoas muscle may be painful.
3. Check for signs of peritoneal inflammation.
Test for the following signs:
- Localized tenderness to percussion
- Right lower quadrant guarding
- McBurney’s sign (rebound tenderness over McBurney’s point – the center of the right lower quadrant)
- Rovsing’s sign (right lower quadrant pain upon palpation of the left lower quadrant)
- Dunphy’s sign (increased sharp abdominal pain with coughing)
4. Test for other appendicitis signs.
The psoas sign (pain when lifting the right leg against resistance) and the obturator sign (pain on internal rotation of the flexed right hip) are related findings.
Diagnostic Procedures
1. Obtain a sample for blood tests.
An elevated WBC count is expected, though up to one-third of patients will present with a normal WBC. An elevated C-reactive protein level and high WBC indicate complicated appendicitis.
2. Obtain a urine specimen.
A urinalysis may reveal abnormalities in appendicitis patients, including mild pus (pyuria), protein (proteinuria), and blood (hematuria). The urine test primarily aims to rule out urinary tract causes of abdominal pain rather than identify appendicitis.
3. Assist the patient in radiologic evaluation.
Imaging tests include:
- Plain radiographs lack specificity and are more helpful in identifying other causes of abdominal pain, even though they frequently show abnormalities in early appendicitis.
- Barium enema is sometimes utilized in patients with an atypical presentation.
- Ultrasound is recommended when the diagnosis is unclear after a patient’s medical history and physical examination. It is beneficial for evaluating the right lower quadrant or pelvic discomfort in young individuals and women.
- CT scan has a 95% accuracy when diagnosing appendicitis.
- MRI is used to diagnose appendicitis in pregnant women instead of a CT scan.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section you’ll learn more about possible nursing interventions for a patient with appendicitis.
Prepare for Appendix Removal
1. Prepare for an appendectomy.
It is urgent to get treatment for appendicitis. There is a high possibility that the appendix will rupture and lead to sepsis which can be fatal. Because of this, it is recommended to remove the appendix surgically.
2. Educate on recovery.
The recovery following an appendectomy will only take a few days if the appendix has not burst. If the appendix bursts, the patient may require inpatient admission and IV antibiotic treatment.
3. Perform pre-operative procedures.
The patient needs to be kept nothing by mouth (NPO), hydrated intravenously with crystalloid solution, and should receive prophylactic intravenous antibiotics as ordered. Ensure that the consent for the procedure is signed.
4. Anticipate an open surgery or laparoscopic method.
Laparoscopic surgery can be performed through a few tiny abdominal incisions. It enables patients to recuperate with less pain and scarring and to recover more quickly. However, not everyone should have laparoscopic surgery. An open appendectomy (laparotomy) allows cleaning of the abdominal cavity if the appendix has ruptured, the infection has spread, or there is an abscess.
Prevent Postoperative Complications
1. Refrain from performing strenuous activity.
Ambulation is important after surgery to prevent complications, but patients should be instructed not to perform strenuous activities or lift heavy items for at least two weeks.
2. Support the abdomen when coughing.
Before the patient coughs, laughs, or moves, they can use a pillow to support their abdomen to reduce pain and prevent damage to their incision.
3. Administer pain medication as ordered.
The preferred pain reliever for appendicitis is NSAIDs, although if the pain is severe, an opioid may also be provided after surgery.
4. Start the antibiotic treatment.
As soon as appendicitis is diagnosed, most patients receive intravenous antibiotics to prevent infection of surgical wounds. Intravenous antibiotics are typically given 24 hours after surgery to avoid post-op complications. The patient may be discharged with an oral antibiotic regimen to complete.
5. Answer inquiries about having no appendix.
Emphasize that the patient can continue to live everyday life without an appendix. Knowing that an organ will be removed can be stressful for the patient. Knowledge and awareness about removing the appendix can help the patient understand and accept life after appendectomy.
6. Advise when to resume regular activities.
While recovery after an open appendectomy may take two to four weeks, patients with laparoscopic surgery will feel well enough to resume school, work, and regular activities in one to two weeks.
7. Promote early ambulation.
Patients who ambulate shortly after surgery have fewer postoperative side effects, including nausea, vomiting, blood clots, and abdominal distention, and frequently need less narcotic pain medication.
8. Diet after appendectomy.
The patient can usually resume a regular diet, but may choose to eat bland or soft foods if experiencing nausea or GI upset.
9. Instruct on incision care.
For an open appendectomy, the surgeon will remove staples or sutures in 7-10 days. A laparoscopic procedure is often closed with steri-strips that will fall off on their own. The patient can be instructed on washing the area 1-2 days after surgery and if the incision should be kept open and dry or covered with a bandage.
10. Measure surgical drainage.
Complicated appendicitis may require surgical drains before or after surgery. The nurse is responsible for measuring drainage and ensuring the site remains free from redness and swelling.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for appendicitis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for appendicitis.
Acute Pain
Acute pain is an expected finding in appendicitis. Pain may start in the umbilical area and then shift to the right lower quadrant, becoming severe quickly.
Nursing Diagnosis: Acute Pain
Related to:
- Inflammation
- Bloating/gas
- Ruptured appendix
- Infectious process
As evidenced by:
- Complaints of sudden abdominal pain
- Guarding of the abdominal area
- Restlessness, moaning, crying
- Diaphoresis
Expected outcomes:
- Patient will report a pain score of 0/10 by discharge.
- Patient will display signs of comfort as evidenced by resting with eyes closed and vital signs within normal limits.
- Patient will verbalize an understanding of their prescribed pharmacologic regimen to control pain.
Assessment:
1. Assess location and characteristics of pain.
Appendicitis pain occurs in the right lower quadrant of the abdomen. The patient will likely complain of sharp pain that started suddenly.
2. Palpate the abdomen.
The patient will likely have tenderness when the abdomen is palpated. Rebound tenderness may occur which is when pain is felt upon removal of pressure to the abdomen rather than application. The abdomen may also appear rigid.
3. Assess nonverbal signs of pain.
The patient will often guard against the pain and may be in the fetal position with their knees drawn up. They will likely grimace or moan when the area over the inflamed appendix is palpated.
Interventions:
1. Administer analgesics.
Appendicitis is very painful and patients should be given opioids, Acetaminophen, and NSAIDs to control inflammation.
2. Offer distraction.
Until pain relief occurs or surgery takes place the patient may need distractive measures to refocus their attention and promote relaxation.
3. Keep NPO.
Instruct the patient that not eating or drinking is important to prevent further gastric irritation and vomiting and as a safety measure in preparation for potential surgery.
4. Instruct on medications at discharge.
Some cases of uncomplicated appendicitis may not require surgery. Patients may continue a course of antibiotics and pain relief at discharge. Ensure the patient understands to complete the entire course of antibiotics and to contact their provider if symptoms worsen or do not improve.
Ineffective Tissue Perfusion
Appendicitis is characterized by decreased perfusion to the appendix, causing outflow obstruction of the appendiceal lumen, inflammation, and infection. If left untreated, the appendix can rupture and cause further perfusion complications like peritonitis, abscess formation, and sepsis.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Disease process
- Inflammatory process
- Acute gastrointestinal bleeding
- Appendix rupture
- Appendix obstruction
- Abdominal compartment syndrome
As evidenced by:
- Nausea and vomiting
- Hypoactive or absent bowel sounds
- Abdominal discomfort
- Abdominal distention
Expected outcomes:
- Patient will remain free from gastrointestinal complications from appendicitis like peritonitis, abscess formation, and sepsis.
- Patient will maintain active bowel sounds in all quadrants.
Assessment:
1. Conduct a comprehensive pain assessment.
Appendicitis causes pain that progresses to become severe, and shifts to the right lower quadrant. It is often followed by nausea and vomiting. Acute pain in appendicitis is often associated with damage and inflammation to the appendix and, if not promptly treated, can rupture, causing abscesses and fistulas that complicate perfusion.
2. Conduct a thorough abdominal assessment.
Appendicitis is characterized by rebound tenderness and pain upon percussion. Assessment of the abdomen may also reveal rigidity and guarding. Bowel sounds should be auscultated and monitored for changes.
3. Assess WBC count.
While laboratory findings do not establish the diagnosis of appendicitis, a WBC count of more than 17,000/mm3 may indicate a perforated appendix. An elevated C-reactive protein level with a high WBC signal complicated appendicitis.
4. Assess results of diagnostic procedures.
An ultrasound, MRI, or CT scan can show an enlarged appendix and determine if gastrointestinal tissue perfusion complications like peritonitis have developed.
Interventions:
1. Administer prophylactic antibiotics.
When appendicitis is diagnosed, antibiotics are started to prevent bacterial growth and complications before and after surgery.
2. Prepare the patient and assist in appendectomy.
Surgical intervention through appendectomy is indicated to help remove the appendix and prevent further complications with ineffective gastrointestinal tissue perfusion.
3. Administer oxygen as needed.
Supplemental oxygenation helps ensure adequate oxygenation to the gastrointestinal tract and other parts of the body.
4. Manage surgical drains.
Surgical drains may be necessary if an abscess or perforation is present before surgery can be safely completed. The nurse is responsible for monitoring drain output and alerting the provider to abnormalities.
5. Ensure that the patient will not receive laxatives or enemas.
Administration of enemas and laxatives can cause perforation of the appendix, disrupting gastrointestinal tissue perfusion.
Risk For Deficient Fluid Volume
Symptoms of appendicitis can place the patient at risk for dehydration.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Vomiting
- Diarrhea
- Loss of appetite
- NPO status
Note: A risk for diagnosis is not evidenced by signs and symptoms as the problem has not occurred. Nursing interventions are directed at prevention.
Expected outcomes:
- Patient will maintain an adequate fluid balance as evidenced by stable vital signs and adequate urine output.
- Patient will report an absence of vomiting or diarrhea by discharge.
Assessment:
1. Assess skin turgor and mucous membranes.
Severe dehydration manifests as poor skin turgor and dry mucous membranes.
2. Monitor I&O.
Monitor the patient’s IV intake to their urine output. A urinary catheter can make monitoring more accurate.
3. Monitor lab values.
Dehydration is likely to be corrected quickly and without last concerns. The nurse can monitor electrolyte levels and replace as needed.
Interventions:
1. Administer IV fluids.
Replacing fluids lost through vomiting or diarrhea will be an initial intervention. The patient may also be prescribed NPO status and will not be able to take in oral fluids.
2. Administer antiemetics.
Nausea and vomiting are common symptoms of appendicitis and also contribute to pain and discomfort along with fluid loss. An antiemetic can prevent further nausea and vomiting.
3. Progress diet as prescribed.
After surgery or once symptoms are controlled, the patient will likely start on a liquid diet and then advance as tolerated to bland foods and then a normal diet. Once cleared to consume liquids, the patient should drink plenty of fluids.
Risk For Infection
Appendicitis can become life-threatening if the appendix ruptures causing peritonitis and the leaking of pus into the abdomen.
Nursing Diagnosis: Risk for Infection
Related to:
- Appendix rupture
- Abscess formation
- Surgical incision infection following appendectomy
Note: A risk for diagnosis is not evidenced by signs and symptoms as the problem has not occurred. Nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain free of infection as evidenced by vital signs and white blood count within expected limits.
- Patient will display appropriate healing of surgical incision as evidenced by an absence of redness, warmth, or drainage.
Assessment:
1. Monitor lab work.
An elevated WBC and CRP levels are usual findings with appendicitis. In the instance of perforation, these values will be even more elevated.
2. Obtain imaging.
A CT scan is the most common imaging test used to evaluate and diagnose appendicitis. If the appendix has ruptured, this will show as free abdominal fluid on ultrasound and the perforation may be visualized.
3. Assess vital signs.
Signs of worsening infection and sepsis include fever, tachycardia, and hypotension.
Interventions:
1. Administer antibiotics.
Antibiotics are a first-line treatment option for appendicitis. Antibiotics may be given prophylactically prior to surgery. Peritonitis or abscess formation will be treated with IV antibiotics.
2. Perform decolonization.
Before surgery, the nurse will decolonize the patient of bacteria by removing body hair and washing with chlorhexidine or another antiseptic soap. This decreases the risk of infection during surgery.
3. Instruct on surgical site care.
After surgery, the nurse will instruct on how to care for surgical incisions such as when to change the dressings and how to clean the area as well as educating on signs and symptoms of infection and when to notify the provider.
4. Handwashing.
Handwashing is the #1 way to prevent infection. Nurses and healthcare staff should always perform hand hygiene before touching the patient or performing tasks. The patient should also be instructed to wash their hands frequently, especially before and after touching their surgical site.
Risk for Shock
Appendicitis can increase the patient’s risk of developing septic shock. If left untreated, the inflamed appendix can burst and spread the infection to the abdomen leading to septic shock.
Nursing Diagnosis: Risk for Shock
Related to:
- Disease process
- Inflammatory process
- Infection
- Acute gastrointestinal bleeding
- Appendix rupture
- Appendix obstruction
- Delayed treatment
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at preventing signs and symptoms.
Expected outcomes:
- Patient will maintain blood pressure and pulse rate within acceptable limits.
- Patient will not experience any signs of infection (elevated WBC, fever, mental status changes, decreased urine output).
Assessment:
1. Assess factors that can increase the patient’s vulnerability to developing septic shock.
Age, medical conditions, immunosuppression, the severity of the condition, and any hemodynamic instability can increase the patient’s risk of developing shock. Untreated appendicitis increases the patient’s risk of developing septic shock as the appendix can rupture, resulting in widespread infection, peritonitis, and death.
2. Assess the patient’s circulatory status.
The initial phase of shock is manifested with decreased tissue perfusion and cardiac output, resulting in immediate compensatory mechanisms like changes in blood pressure, increased heart rate, pale and damp skin, and decreased peripheral pulses.
3. Assess signs and symptoms of sepsis.
Appendicitis can result in septic shock as the infection and abscess spread to the bloodstream. Initial signs and symptoms of septic shock include hyperthermia or hypothermia, tachycardia, and tachypnea. Severe sepsis may manifest with altered mental status, cyanosis, ileus, oliguria or anuria, and hypoxia.
Interventions:
1. Assist in percutaneous drainage procedure.
Percutaneous abscess drainage is indicated for patients with known abscesses from the perforated appendix. This procedure reduces inflammation and drains abscesses before laparoscopic appendectomy can be performed at a later date.
2. Instruct the patient to avoid placing a warm compress on the abdomen.
Applying heat on an appendicitis patient’s abdomen can result in rupture of the appendix, resulting in serious complications, including septic shock.
3. Administer antibiotics as indicated.
Antibiotic therapy is essential in resolving or preventing an infection in patients with appendicitis who are at risk for developing septic shock.
4. Administer intravenous fluid as indicated.
Patients with suspected appendicitis are placed on NPO status and given intravenous fluids for resuscitation.
5. Use an aseptic technique in providing surgical wound care.
Complicated wound infections may require wound irrigation and packing. Nurses must adhere to strict aseptic techniques to prevent introducing pathogens.
References
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- Bradley, A. C., Hutson, M. S., & Kyle, J. A. (2019, December 17). Acute Appendicitis in Adults. US Pharmacist. Retrieved March 15, 2022, from https://www.uspharmacist.com/article/acute-appendicitis-in-adults
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- Hardin, Jr., D. M. (1999, November 1). Acute appendicitis: Review and update. AAFP. https://www.aafp.org/pubs/afp/issues/1999/1101/p2027.html
- Johns Hopkins Medicine. (2021, December 9). Appendicitis. Johns Hopkins Medicine, based in Baltimore, Maryland. Retrieved March 2023, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/appendicitis
- Mayo Clinic. (2021, August 7). Appendicitis – Diagnosis and treatment – Mayo Clinic. Retrieved March 2023, from https://www.mayoclinic.org/diseases-conditions/appendicitis/diagnosis-treatment/drc-20369549
- National Center for Biotechnology Information. (2022, May 1). Appendicitis – StatPearls – NCBI bookshelf. Retrieved March 2023, from https://www.ncbi.nlm.nih.gov/books/NBK493193/
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- Wirth-Tomaszewski, E. (2022, March 25). The appendix to appendicitis: Know the signs of appendicitis. Lippincott NursingCenter | Professional Development for Nurses. Retrieved March 2023, from https://www.nursingcenter.com/ncblog/march-2022/appendicitis
