Appendicitis: Nursing process (ADPIE)

16-year-old Manny Correa is admitted to the pediatric inpatient unit from the urgent care clinic.

Manny’s father George brought him to the clinic after Manny experienced pain around his belly button for the past 24 hours.

An abdominal ultrasound confirmed an inflamed appendix. Manny is scheduled for an appendectomy today.

Appendicitis is a condition where the appendix, a finger-like projection that hangs off of the cecum of the large intestine, becomes obstructed and inflamed.

Appendicitis can be caused by lymphoid hyperplasia, where overgrown lymphoid follicles obstruct the appendix, or when a hard lump of stool called a fecalith, a tumor, or even parasites like pinworms cause an obstruction, resulting in appendicitis.

Appendicitis is more common in the second and third decades of life, with the highest incidence between the ages of 10 and 19.

It is more common in men than in women.

Now, when the appendix becomes obstructed, mucosal secretions and the bacteria that normally live in the appendix build up inside, causing the appendix to expand and press against the visceral nerve fibers, resulting in pain that is often felt in the periumbilical area.

Multiplication of bacteria inside the appendix leads to inflammation, which is accompanied by fever, anorexia, nausea, and sometimes vomiting.

Eventually, the appendix starts to irritate the nearby parietal membrane lining the walls of the abdominal cavity, causing the pain to intensify and migrate to the right lower quadrant, an area known as McBurney’s point, which is located 1.5 to 2 inches from the navel to the anterior superior iliac spine.

Palpating McBurney’s point and quickly releasing pressure will demonstrate rebound tenderness, and the person may show guarding, where their abdominal muscles tense up when pressed in an attempt to avoid pain.

Rovsing's sign is elicited if pressure over the person’s left lower abdominal quadrant causes pain in the right lower abdominal quadrant.

The psoas sign is when pain occurs with passive extension of the right hip.

Lastly, the obturator sign is elicited by flexing the right knee to a 90 degree angle while internally rotating the hip.

Complications can develop as the appendix continues to swell, compress the venous and arterial blood flow.

This leads to edema, ischemia and eventual necrosis of the appendiceal wall.

As cells die, the wall becomes weaker and weaker, until it eventually ruptures, allowing bacteria, pus, and fluid to escape into the peritoneum.

The result is the formation of abscesses around the appendix, or peritoneal inflammation, referred to as peritonitis.

At first, the person may notice a sudden decrease in pain as the pressure inside the appendix is relieved.

However, as infection and inflammation continues to develop inside the peritoneal cavity, the person can develop severe abdominal pain and rigidity, vomiting, tachycardia, and hypotension.

If untreated, peritonitis can progress to shock or septicemia.

After a client history and physical examination is complete, laboratory and other diagnostic tests can help confirm a diagnosis of appendicitis.

Abdominal ultrasound can be used to visualize inflammatory changes.

Abdominal CT scans are more sensitive, and can show a more precise view of these findings.

An MRI is useful in diagnosing appendicitis in pregnancy or when contrast must be avoided.

A CBC will often show leukocytosis with a left shift, or an increased number of immature neutrophils.

A C-reactive protein, which is an indication of inflammation, is often elevated.

Sometimes, uncomplicated appendicitis is treated with a course of antibiotics, but the definitive treatment for appendicitis is the surgical removal of the appendix, referred to as an appendectomy.

If an abscess has formed and there is no evidence of peritonitis, treatment may involve draining the abscess with a needle.

Sometimes a tube may be left in place to allow ongoing drainage.

Manny and George have arrived on the pediatric inpatient unit, and it’s time for you to begin your assessment.

After introducing yourself, confirming Manny’s identity, and performing hand hygiene, you note that Manny is laying on his right side with his knees drawn up towards his chest.