Appendicitis is a condition characterized by inflammation of the vermiform appendix’s inner lining, which can spread to other regions of the appendix. It is a common surgical emergency that presents with a number of symptoms and shares resembles with other clinical conditions. The importance of prompt diagnosis and treatment is crucial because delayed action can result in higher morbidity. While appendicitis usually manifests as an acute disease within 24 hours, it can potentially show as a chronic condition.
The appendix is a tiny, worm-shaped organ that is placed behind the ileocecal valve and gathers waste products after digestion before emptying into the cecum on a daily basis. Because of a narrow lumen and inefficient emptying, the appendix is highly susceptible to obstruction, making it prone to infection
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.
- Fecaliths. These form when calcium salts and fecal debris become layered around a nidus of inspissated fecal material located within the appendix.
- Lymphoid hyperplasia. This condition is associated with various inflammatory and infectious disorders including Crohn disease, gastroenteritis, amebiasis, respiratory infections, measles, and mononucleosis.
- Obstruction. Obstruction of the appendiceal lumen has less commonly been associated with bacteria, parasites, foreign material, tuberculosis, and tumors.
The incidence of acute appendicitis has been declining steadily since the late 1940s, and the current annual incidence is ten cases per 100,000 population. Appendicitis occurs in 7% of the US population, with an incidence of 1.1 cases per 1000 people per year.
In Asian and African countries, the incidence of appendicitis is probably lower because of the dietary habits of the inhabitants of these geographic areas. The incidence of appendicitis is lower in cultures with a higher intake of dietary fiber because it is thought to decrease the viscosity of feces, decrease bowel transit time, and discourage the formation of fecaliths. The higher incidence of appendicitis in Western countries is believed to be related to poor fiber intake.
Immediate surgery is typically indicated if appendicitis is diagnosed. However, conservative nonsurgical medical management for uncomplicated appendicitis has been instituted in some instances with a reduced risk of complications and similar hospital length of stay as appendectomy.
- Correct and prevent any fluid or electrolyte imbalance, dehydration, or sepsis.
- Administer antibiotics promptly.
- Promote comfort and pain relief
- Perform a successful appendectomy
When the appendix becomes twisted or obstructed by a hardened stool mass known as a fecalith, it causes inflammation and discomfort. Other causes include secondary inflammation or infection caused by lymphoid hyperplasia, as well as foreign substances or tumors in rare situations. This inflammatory process increases pressure inside the appendix, causing swelling and occlusion of the appendix’s opening. Once the appendix is blocked, it lacks sufficient blood supply, leading to the proliferation of bacteria and, eventually, gangrene or perforation.
Epidemiology of Appendicitis
- Appendicitis is a common surgical emergency and is frequently characterized by abdominal pain.
- The prevalence of appendicitis rises from birth, peaks in the late adolescent years, and then steadily declines as people get older.
- The typical age for appendicitis in children is between six and ten years old.
- In teenagers and young adults, there is a relatively small male preponderance (3:2), although, in adults, men are roughly 1.4 times more prevalent than women.
- Appendicitis affects about 7% of the US population, with an annual incidence of 1.1 cases per 1000 people.
Signs and Symptoms
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 pain, and vomiting occurs in only 50% of cases.
Common signs and symptoms
- Nausea and vomiting. Nausea is present in 61 to 92% of clients. This finding is not statistically different from findings in clients who present to the emergency department with other etiologies of abdominal pain. Vomiting that precedes pain is suggestive of intestinal obstruction.
- Abdominal pain. The most common symptom of appendicitis is abdominal pain. Typically, symptoms begin as periumbilical or epigastric pain migrating to the right lower quadrant of the abdomen. This pain migration is the most discriminating feature of the client’s history, with a sensitivity and specificity of approximately 80%.
- Diarrhea or constipation. Diarrhea or constipation is noted in as many as 18% of clients and should not be used to discard the possibility of appendicitis.
- Rovsing sign. The Rovsing sign (RLQ pain with palpation of the LLQ) suggests peritoneal irritation in the RLQ precipitated by palpation at a remote location.
- Obturator sign. The obturator sign (RLQ pain with internal and external rotation of the flexed right hip) suggests that the inflamed appendix is located deep in the right hemipelvis.
- Psoas sign. The 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. This is characterized by a sharp pain in the RLQ elicited by a voluntary cough and may be helpful in making the clinical diagnosis of localized peritonitis.
Appendectomy remains the only curative treatment of appendicitis, although non-operative management is increasingly recognized as being safe and effective for uncomplicated cases of acute appendicitis.
- Antibiotics. Antibiotics have an important role in the nonsurgical treatment of clients with acute appendicitis. Antibiotics considered for clients with appendicitis must offer full aerobic and anaerobic coverage. The duration of administration is closely related to the stage of appendicitis at the time of diagnosis. Antibiotic prophylaxis should be administered before every appendectomy.
- IV fluids. Establish intravenous access and administer aggressive crystalloid therapy to clients with clinical signs of dehydration or septicemia.
- Nothing per orem. Clients with suspected appendicitis should not receive anything by mouth. This is done in case the client needs immediate surgery to remove the inflamed or perforated appendix.
- Analgesics. Administer parenteral analgesic as needed for client comfort. At least eight randomized controlled studies have demonstrated that administering opioid analgesic medications to adult and pediatric clients is safe.
- Appendectomy. Laparoscopic appendectomy is successful in 90 to 94% of attempts. It has been demonstrated that laparoscopic appendectomy is successful in approximately 90% of cases of perforated appendicitis. Thai procedure is indicated for uncomplicated appendicitis, appendicitis in pediatric clients, and suspected appendicitis in pregnant women.
Assessment and Diagnosis
Variations in the position of the appendix, the age of the client, and the degree of inflammation make the clinical presentation of appendicitis notoriously inconsistent. Statistics report that one in five cases of appendicitis is misdiagnosed; however, a normal appendix is found in 15 to 40% of clients who have an emergency appendectomy. In line with this, assessment of the client must include recording their history of abdominal pain, obtaining a complete summary of the recent personal history surrounding gastroenterologic, genitourinary, and pneumologic conditions, as well as considering the gynecologic history of female clients.
It is important to remember that the position o the appendix is variable. Of 100 clients undergoing three-dimensional multidetector computed tomography scanning, the base of the appendix was located at the McBurney point in only 4% of clients; in 36%, the base was within three centimeters of the point; in 28%, it was three to five centimeters from that point; and in 36% of clients, the base of the appendix was more than five centimeters from the McBurney point. If the tenderness is palpated at the McBurney point, the following maneuvers to identify possible appendicitis should be performed
- Rovsing sign: While standing on the client’s right side, gradually perform deep palpation of the left lower quadrant.
- Psoas sign: The nurse must place their hand just above the client’s right knee and ask the client to push up against the nurse’s hand.
- Obturator sign: This is performed by flexing the client’s right thigh at the hip with the knee flexed and rotating internally.
Findings during the physical assessment for a client suspected of appendicitis include the following:
- Increased pain on the right during the performance of the Rovsing sign suggests right-sided peritoneal irritation.
- Performing the maneuver for eliciting the psoas sign results in the contraction of the psoas muscle, which causes pain if there is an underlying inflamed appendix.
- Increased pain at the right lower quadrant during the obturator sign maneuver suggests inflammation of the internal obturator muscle from overlying appendicitis or an abscess.
The client should not be given any pain medication until they are seen by a surgeon because analgesics can mask the peritoneal signs and lead to a delay in diagnosis or even a ruptured appendix.
- Laboratory testing. Laboratory measurements, including leukocyte count, neutrophil percentage, and C-reactive protein concentration, are requested to proceed with diagnostic steps in clients with suspected acute appendicitis. Elevated WBC is classically present, but up to one-third of clients with acute appendicitis will present with a normal WBC count. A combination of normal WBC and CRP results has a specificity of 98% for the exclusion of acute appendicitis, but increasing levels of both correlated with an increase in the likelihood of complicated appendicitis.
- CT scan. An abdominal CT scan has greater than 95% accuracy for the diagnosis of appendicitis and is used with increasing frequency. CT criteria for appendicitis include an enlarged appendix (greater than 2 mm), peri-appendiceal fat stranding, appendiceal wall enhancement, and the presence of appendicolith.
- Ultrasonography. Abdominal ultrasonography is a widely used and available primary measure to evaluate clients with acute abdominal pain. The major concerns with using abdominal ultrasonography to evaluate the potential diagnosis of acute appendicitis are the innate limitations of the sonography in obese clients and the operator-dependency to find the suggestive features.
- MRI. Performing an abdominal MRI is not only expensive but also demands a high level of expertise to interpret the results. Therefore, its indications are mainly limited to special groups of clients, including pregnant women in whom an unacceptable risk of radiation exposure is embedded.
Diagnosis is based on the results of a complete history and physical examination and on laboratory findings and imaging studies. Several diagnostic scoring systems may predict the likelihood of acute appendicitis. The best known of these scoring systems is the MANTRELS score, which tabulates migration of pain, anorexia, nausea and vomiting, tenderness in the RLQ, rebound tenderness, elevated temperature, leukocytosis, and shift to the left. Clinical scoring systems are attractive because of their simplicity; however, none has been shown prospectively to improve the clinician’s judgment in the subset of clients evaluated in the emergency department. On the other hand, computer-aided diagnosis consists of using retrospective data of clinical features of clients with appendicitis and then prospectively assessing the risk of appendicitis. Computer-aided diagnosis can achieve a sensitivity greater than 90% while reducing rates of perforation and negative laparotomy by as much as 50%.
The major complications of appendicitis include the following:
- Gangrene or perforation of the appendix. Perforation generally occurs within 6 to 24 hours after the onset of pain and leads to peritonitis.
- Peritonitis. This refers to the inflammation of the peritoneum, usually caused by bacterial infections either via the blood or after the rupture of the appendix.
- Abscess formation. If left untreated, appendicitis can lead to abscess formation with the development of an enterocutaneous fistula.
- Portal pylephlebitis. This refers to septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines.
- Recurrent or stump appendicitis. This can occur if too much of the appendiceal stump is left after an appendectomy. This acts just like an appendix and can become occluded and infected just as with the initial episode.
The goals of nursing management include relieving pain, preventing fluid volume deficit, reducing anxiety, preventing or treating surgical infection, preventing atelectasis, maintaining skin integrity, and attaining optimal nutrition.
Classically, appendicitis presents as an initial generalized or periumbilical abdominal pain that then localizes to the RLQ. As the appendix becomes more inflamed and the adjacent parietal peritoneum is irritated, the pain becomes more localized to the RLQ. it can be accompanied by the following symptoms:
- Decreased appetite
- Nausea or vomiting
- Fever in 40% of clients
- Diarrhea or constipation
- Generalized malaise
- Urinary frequency or urgency
- RLQ guarding and rebound tenderness
- RLQ pain elicited by palpation of the LLQ
- Increase abdominal pain with coughing or movement
- Rigid abdomen and involuntary guarding
Nursing diagnoses applicable for a client diagnosed with appendicitis include:
- Acute pain related to obstruction in the appendix
- Risk for fluid volume deficit related to nausea/vomiting, decreased appetite, or decreased fluid intake
- Risk for infection related to rupture or perforated appendix and surgical incision
- Risk for deep vein thrombosis related to immobility
- Risk for anxiety related to hospitalization and imminent threat to health status
Nursing Care Planning and Goals
The goals appropriate for the care of a client diagnosed with appendicitis are:
- The client will demonstrate behaviors to control infection and prevent complications.
- The client will achieve relief from pain or discomfort.
- The client will maintain or improve their nutrition.
- The client will understand information about the disease process, prognosis, treatment needs, surgical procedures, and potential complications.
Nursing Interventions for Appendectomy
- Assess and manage the client’s pain with medication and nonpharmacologic interventions: Pain assessment is critical in appendicitis for determining the intensity and location of pain. Appropriate pain management (analgesics) relieves discomfort, promotes patient comfort, and improves general well-being. Pain management may also benefit from nonpharmacologic methods such as relaxation techniques or posture.
- Continuously monitor the client’s pain level and location: Continuous monitoring of pain levels and location aids in determining the success of pain management actions. It provides timely adjustments in pain relief measures, ensuring the client’s optimal pain control.
- Changes in eating and bowel behaviors should be monitored: Appendicitis can impact the digestive tract, causing changes in feeding patterns and bowel habits. Monitoring these changes helps in assessing the condition’s change and can provide useful information for diagnostic purposes.
- Monitor laboratory values, particularly the white blood cell (WBC) count: Laboratory values, particularly the WBC count, can indicate the presence of infection or inflammation. A high WBC count is frequently observed in appendicitis and can help verify the diagnosis.
- Monitor the client’s bowel movements since opioids can cause constipation: Opioids, which are routinely used to treat pain, may cause constipation as a side effect. Monitoring the client’s bowel movements aids in the detection of potential issues and enables timely intervention to prevent or manage constipation.
- Examine the postoperative client’s incision for signs and symptoms of infection on a regular basis: Postoperative wound infections are a potential outcome of appendectomy. Frequent examination of the incision site enables for early diagnosis of infection-related signs and symptoms, such as redness, swelling, growing discomfort, or drainage, resulting in appropriate treatment.
- Monitor the client’s temperature and heart rate for signs of infection: An elevated temperature (fever) and a rapid heart rate can be signs of infection or inflammation. Monitoring these vital signs helps in identifying early signs of infection, leading to timely intervention and management.
- To prevent rupture, avoid applying heat to the client’s belly: Applying heat to the abdomen might increase blood flow and potentially lead to the rupture of the inflamed appendix. Heat should be avoided to avoid worsening the condition and corresponding complications.
- Encourage oral fluid intake as tolerated and when not contraindicated: Adequate fluid intake is critical for maintaining hydration and promoting healthy recovery. Encouragement of oral fluid intake helps in the prevention of dehydration and the normal functioning of body systems.
- Maintain a clean environment to reduce the risk of infection: A clean environment reduces the presence of pathogens, reducing the risk of diseases. Keeping the client’s surroundings clean promotes a secure and healthy environment, which contributes to better recovery outcomes.
- Provide wound care to the appendectomy patient: Proper wound care is critical for preventing infection and facilitating healing. Providing appropriate wound care, such as cleaning, dressing changes, and monitoring for symptoms of infection, aids in the recovery process.
- Antibiotics should be administered as directed: Antibiotics are frequently prescribed to treat or prevent infection in appendicitis. Antibiotics administered on time help to clear the infection and limit its spread, lowering the risk of complications.
- Involve the client in their care plan and keep them informed about diagnostic and treatment choices to reduce anxiety: Involving the client in their care plan and keeping them informed about diagnostic and treatment options helps to reduce anxiety and increase their understanding of the condition. This collaborative method increases patient engagement while also promoting a sense of control and well-being.
- Encourage the client to walk as instructed. If the client is immobile, serial compression devices and a TED hose should be used to avoid DVT: Early ambulation promotes blood circulation and prevents blood pooling, which helps prevent problems such as deep vein thrombosis (DVT). When ambulation is not practicable, compression devices and TED (thromboembolism deterrent) hose are used to prevent DVT formation.
- Inform the healthcare provider immediately when signs of peritonitis are elicited, such as severe abdominal pain, guarding of the abdomen, and a board-like abdomen: Peritonitis is a severe complication of appendicitis that requires immediate medical intervention. Recognizing and reporting symptoms of peritonitis, such as acute abdominal pain, abdominal guarding, and a board-like abdomen, aids in prompt treatment and diagnosis.
- Inform your healthcare professional as soon as possible if you notice a rapid change in vital signs, such as fever or tachycardia, as this might indicate infection or inflammation. Informing the healthcare professional as soon as possible allows for an immediate evaluation and appropriate management for preventing complications.
- Establish intravenous access and administer aggressive crystalloid therapy.
- Place the client on NPO as indicated.
- Administer analgesics and antiemetic as needed.
- Obtain a qualitative beta-hCG for female clients of childbearing age.
- Administer intravenous antibiotics to those with signs of septicemia and who are to proceed to laparotomy.
After the implementation of nursing interventions, the nurse evaluates if the desired goals and outcomes were achieved. The nurse needs to ensure that:
- Pain is decreased or relieved.
- Dehydration is prevented and adequate intake and output is restored.
- Infection is prevented or treated.
- Surgical incision integrity is maintained.
- Anxiety is relieved.
- Adequate client education is received.
- Adequate elimination is maintained dan constipation is prevented.
Discharge and Home Care Guidelines
For clients discharged to their homes, monitoring should be performed on a continual basis based on the following parameters, which help in the overall management of the disease.
- If the client had surgery, they need to continue to monitor the incision site for signs of infection.
- The client must have a follow-up appointment scheduled before discharge for the removal of sutures or staples and for wound assessment.
- Normal activity can resume in a few days to a week. The client should avoid any strenuous activity and heavy lifting for the first 4 to 6 weeks.
- Ensure adequate client education is given to complete all antibiotics and to take them with meals to avoid gastric irritation.
- Ensure that the client knows to avoid driving or operating machinery while taking opioids and other pain medications.
The focus of documentation on a client diagnosed with appendicitis should include the following:
- Client description of pain and intensity
- Results of laboratory values
- Surgical site and wound care, dressing changes, or any drainage noted
- Signs and symptoms of infection
- Any client education provided
- The plan of care and changes to it
- Any time results, client assessment, or concerns are addressed with the provider, including who was contacted, who responded, and the time.
- Castañeda, V., Steiner, M., Bustos, C., & Duarte, Z. (2023, April 24). Appendicitis (Nursing) – StatPearls. NCBI. Retrieved June 20, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK568712/
- Craig, S., & Brenner, B. E. (2022, November 9). Appendicitis: Practice Essentials, Background, Anatomy. Medscape Reference. Retrieved June 19, 2023, from https://emedicine.medscape.com/article/773895-overview
- Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-surgical Nursing. Wolters Kluwer.
- Jones, M. W., Lopez, R. A., & Deppen, J. G. (2023, April 24). Appendicitis – StatPearls. NCBI. Retrieved June 19, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK493193/
- Mealie, C. A., Ali, R., & Manthey, D. E. (2022, October 10). Abdominal Exam – StatPearls. NCBI. Retrieved June 20, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK459220/