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Appendicitis Nursing Guide

Content Creator: Rakesh Tripathi MBA, MPH, BSN, RN-CEN

Appendicitis Overview

This content is intended as a Quick Reference for Appendicitis and will cover an overview and nursing considerations utilizing the nursing process.

Etiology and Epidemiology

Appendicitis is an inflammation of the appendix caused by the obstruction of the appendiceal lumen by a fecalith, a foreign body, inflammation, stricture, a viral or bacterial infection, or neoplasm. Such obstructions cause bacteria to multiply and increase the pressure inside the appendix. This increased pressure can potentially lead to ischemia and the rupture of the appendix, and frank peritonitis (Hamilton et al., 2018).

Acute abdominal pain leads to 7 to 10% of all emergency department visits (Cervellin et al., 2016). Acute appendicitis is one of the most common causes of abdominal pain among individuals 10 to 30 years old who visit emergency departments. It is a surgical emergency.

The most common organisms that cause appendicitis are:

  • Escherichia coli
  • Peptostreptococcus
  • Bacteroides
  • Pseudomonas

The risk factors for appendicitis include:

  • Age and gender (adolescent male)
  • Familial predisposition
  • Gastrointestinal disorders (e.g., inflammatory bowel disorders)
  • Low-fiber diet
  • Abdominal/pelvic abscess
  • Dehiscence of surgical incision
  • Fecal fistula
  • Incisional hernia
  • Intestinal/bowel obstruction
  • Peritonitis
  • Wound or intra-abdominal infection

Appendicitis Diagnosis

In the majority of cases, an appendicitis diagnosis is made from history and clinical features, not lab test results (Gregory et al., 2016). Laboratory work-up is not specific but is done to rule out other conditions.

  • Complete blood count (CBC) with elevate white cell count
  • C-reactive protein (CRP)
  • Urinalysis
  • Urine pregnancy test
  • Liver and pancreas tests if diagnosis is unclear
  • Abdominal CT scan if diagnosis is unclear (Pooler et al., 2018)
  • Abdominal ultrasound
  • X-rays to assess for appendicolith or kidney stones

The American College of Radiology recommends an ultrasound in pregnant women, as well as an MRI in inconclusive cases (Kereshi et al., 2018).

Management

  • Individual is kept NPO and hydrated with IV fluids
  • Acetaminophen or NSAIDs for pain relief and/or fever after diagnosis is made.
  • Antiemetic, promethazine (Phenergan®)
  • Broad-spectrum antibiotics
    • Gram-negative and anaerobic antibiotic as ordered
  • Narcotic pain medications
    • May be necessary for abscess pain and post-surgical pain relief
  • Surgery: Appendectomy, open or laparoscopic
    • If abscess is suspected, delay appendectomy until IV antibiotic therapy is initiated.

 

Appendicitis Nursing Care Plan

Nursing Considerations

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnosis, interventions, expected outcomes, and education for individuals with appendicitis are listed below.

Appendicitis Assessment

  • History
    • Abdominal pain, especially in right lower quadrant
      • Pain often starts around umbilicus and then migrates to right lower quadrant.
    • Anorexia
      • Often the presenting symptom
    • Chills
    • Diarrhea or constipation
    • Nausea and vomiting
    • Nonspecific, atypical presentation in individuals older than age 40
  • Physical Examination
    • Tachycardia
    • Abdominal and/or flank pain
    • Guarding
    • Rebound tenderness
    • Localized right lower quadrant (RLQ) abdominal pain at McBurney’s point
    • Low-grade fever
    • Normoactive bowel sounds
    • Obturator sign
      • Abdominal pain with hip rotation
    • Psoas sign
      • Abdominal pain upon hip flexion while applying pressure to the knee
    • Dunphy's sign
      • Increased abdominal pain with coughing
    • Rovsing’s sign
      • Abdominal pain in right lower quadrant (RLQ) upon palpation of left lower quadrant (LLQ)

Appendicitis Nursing Diagnosis/Risk For

  • Acute pain due to ruptured appendix/peritonitis
  • Unbalanced nutrition, less than body requirements
  • Ineffective tissue perfusion due to severe infection
  • Fluid volume deficit due to nausea, anorexia, and vomiting
  • Impaired skin integrity related to appendectomy
  • Infection due to perforated appendix/surgical site infection

Interventions

  • NPO before surgery
  • Insert and maintain IV per order and organization policy.
  • Administer medications as prescribed:
    • Antipyretics
    • Analgesics
    • Antibiotics
    • Antiemetics
  • Keep individual afebrile.
  • Avoid administering cathartics or enemas or applying heat to lower abdomen as they may cause appendix to rupture.
  • Draw lab test samples, as ordered.
  • Explain diagnosis, treatment, and expectations to individual.
  • Follow infection precautions.
  • Maintain calm environment.
  • Place individual in Fowler position.
  • Monitor individual’s:
    • Adverse drug reactions
    • Bowel function
    • Input and output
    • Pain level
    • Vital signs
    • Wound

Expected Outcomes

  • Avoid complications
  • Maintain a normal fluid volume balance
  • Maintain adequate GI tissue perfusion
  • Maintain required caloric intake
  • Maintain skin integrity
  • No systemic progression of infection
  • Pain relief
  • Remain afebrile

Individual/Caregiver Education

  • Diagnosis and treatment
  • Medications and potential adverse reactions
  • Possible complications
  • Postoperative activity restrictions
  • Preoperative and postoperative teaching
  • Wound care and signs of infection

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Additional Information

Course Contributor

The content for this course was created by Relias external nursing content writer and editor Rakesh Tripathi MBA, MPH, BSN, RN-CEN. He is a Certified Emergency Nurse (CEN) with extensive experience primarily in acute care settings. Mr. Tripathi has considerable experience in travel nursing, as well as more than decade of general nursing experience. He has conducted nursing research for the European governments and worked as a nursing lecturer for Glasgow Caledonian University (GCU) Scotland, affiliated colleges, and has practiced nursing in Asia, the UK, and the U.S.

Resources

Acute Appendicitis

https://ada.com/conditions/acute-appendicitis

References

Cervellin, G., Mora, R., Ticinesi, A., Meschi, T., Comelli, I., Catena, F., & Lippi, G. (2016). Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases. Annals of translational medicine, 4(19). https://doi.org/10.21037/atm.2016.09.10

Gregory, S., Kuntz, K., Sainfort, F., & Kharbanda, A. (2016). Cost-effectiveness of integrating a clinical decision rule and staged imaging protocol for diagnosis of appendicitis. Value in Health, 19(1), 28-35. https://doi.org/10.1016/j.jval.2015.10.007

Hamilton, A. L., Kamm, M. A., Ng, S. C., & Morrison, M. (2018). Proteus spp. as putative gastrointestinal pathogens. Clinical microbiology reviews, 31(3), e00085-17. https://doi.org/10.1128/CMR.00085-17

Kereshi, B., Lee, K. S., Siewert, B., & Mortele, K. J. (2018). Clinical utility of magnetic resonance imaging in the evaluation of pregnant females with suspected acute appendicitis. Abdominal Radiology, 43(6), 1446-1455. https://doi.org/10.1007/s00261-017-1300-7

Pooler, B. D., Repplinger, M. D., Reeder, S. B., & Pickhardt, P. J. (2018). MRI of the nontraumatic acute abdomen: description of findings and multimodality correlation. Gastroenterology Clinics, 47(3), 667-690. https://doi.org/10.1016/j.gtc.2018.04.010

 

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