The document is a presentation on appendicitis by a nursing group that outlines the anatomy of the appendix, its pathophysiology, clinical manifestations, assessment findings, and management strategies. Key learning outcomes for students include understanding the condition's causes, symptoms, diagnostic methods, and treatment options, including surgery. It also describes the nursing care needed before and after an appendectomy, emphasizing pain management and infection prevention.

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COLLEGE OF HEALTH
SCIENCES
DEPARTMENT OF NURSING
PRESENTATION ON
December 16/2014
APPENDICITIS
Group-3

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MEMBERS
Addisu Besfat………. 1972/05
Ammanuel Kassa…..1978/05
Aynaye Mengiste…….1986/05
Biniyam Demisse……1990/05
Bizunesh Debebe……1991/05
Siraj Hiyar………………
Tesfaw Alemu………….2063/05
Yohannes H/giorgis….2081/05
GROUP=3

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APPENDIX

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APPENDICITIS

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LEARNING OUTCOMES
At the end of this lecture, students will be able to:
 Describe the appendix and appendicitis along with its
patho-physiology.
 Identify the clinical manifestations of appendicitis.
 Discuss assessment and diagnostic findings of
appendicitis.
 Describe the medical and nursing care of a patient
with appendicitis.

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APPENDICITIS
 The appendix is a small, finger-like tube about 10 cm (4 in)
long that is attached to the cecum just below the ileocecal
valve.
 The appendix fills with food and empties regularly into the
cecum.
 Because it empties inefficiently and its lumen is small, the
appendix is prone to obstruction and is particularly
vulnerable to infection =appendicitis.

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EPIDEMIOLOGY
 In USA;
 More than 250000 appendectomies performed
annually
 Appendicitis is the most common abdominal
surgical emergency
 Occurs at any age, more between 10-30

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PATHOPHYSIOLOGY
 The appendix becomes inflamed and edematous as a result
of either becoming kinked or occluded by a fecalith (ie,
hardened mass of stool), tumor, or foreign body.
 Obstruction has multiple causes,
 Lymphoid hyperplasia(related to viral illnesses,
URTI,mononucleosis,gastroenteritis)
 fecaliths,
 Parasites(pinworm),
 foreign bodies,
 primary or metastatic cancer and
 carcinoid syndrome.
 Lymphoid hyperplasia is more common in children and
young adults

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PATHOPHYSIOLOGY
 The inflammatory process increases intraluminal pressure,
initiating a progressively severe, generalized or upper
abdominal pain that becomes localized in the RUQ of the
abdomen within a few hours and feels with pus.
 Mucosal secretions continue to increase intraluminal
pressure
 Eventually the pressure exceeds capillary perfusion pressure
and venous and lymphatic drainage are obstructed.
 With vascular compromise, epithelial mucosa breaks down
and bacterial invasion by bowel flora occurs.
 Increased pressure also leads to arterial stasis and tissue
infarction
 End result is perforation and spillage of infected appendiceal
contents into the peritoneum

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PATHOPHYSIOLOGY
 Initial luminal distention triggers visceral
afferent pain fibers, which enter at the 10th
thoracic vertebral level.
 This pain is generally vague and poorly
localized.
 Pain is typically felt in the periumbilical or
epigastric area.

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PATHOPHYSIOLOGY
 As inflammation continues, the serosa and
adjacent structures become inflamed
 This triggers somatic pain fibers, innervating the
peritoneal structures.
 Typically causing pain in the RLQ
 The change in stimulation form visceral to somatic
pain fibers explains the classic migration of pain
in the periumbilical area to the RLQ seen with
acute appendicitis

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PATHOPHYSIOLOGY
 Exceptions exist in the classic presentation due to
anatomic variability of the appendix
 Appendix can be retrocecal causing the pain to localize to
the right flank
 In pregnancy, the appendix can be shifted and patients can
present with RUQ pain
 In some males, retroileal appendicitis can irritate the ureter
and cause testicular pain.
 Pelvic appendix may irritate the bladder or rectum causing
suprapubic pain, pain with urination, or feeling the need to
defecate

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PATHOPHYSIOLOGY
 Lymphoid hyperplasia leads to luminal
obstruction(Often follows viral
illness)=Epithelial cells secrete
mucus=Appendix distends, bacteria
multiply=Visceral pain begins an average of 17
hours after obstruction=Increased pressure
compromises blood supply=Somatic pain
develops=Average time to perforation = 34 hrs

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CLINICAL MANIFESTATIONS
 Epigastric or periumbilical pain progresses to the right lower
quadrant.
 Low-grade fever, nausea and sometimes vomiting. Loss of
appetite.
 Local tenderness is elicited at Mc Burney’s point when
pressure is applied
 Rebound tenderness (i.e., production or intensification of
pain when pressure is released) may be present.
 Rovsing’s sign(palpating the left lower quadrant; this
causes pain to be felt in the right lower quadrant)
 If the appendix has ruptured, the pain becomes more
diffuse; abdominal distention develops, and the patient’s
condition worsens.

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Location of McBurney's point (1), located two thirds the distance from the
umbilicus (2) to the anterior superior iliac spine (3).

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ASSESSMENT AND DIAGNOSTIC FINDINGS
 Health history and physical exam.
 Ask the patient to point where the pain begun and
where it is now.
 Ask to cough. Determine weather and where pain
results.
 Search for area of local tenderness
 Feel muscular rigidity and differentiate between
voluntary guarding involuntary muscle rigidity
 Preform rectal examination for men and vaginal
examination for women

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PHYSICAL EXAM
 Findings depend on duration of illness prior
to exam.
 Early on patients may not have localized
tenderness
 With progression there is tenderness to deep
palpation over Mc Burney's point

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PHYSICAL EXAM
 McBurney’s Point: just below the middle of a
line connecting the umbilicus
 Rovsing’s: pain in RLQ with palpation to LLQ
 Rectal exam: pain can be most pronounced
if the patient has pelvic appendix

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PHYSICAL EXAM
 Psoas sign: extend R leg at the hip makes psoas muscle
contract. If there is pain with this movement, then the
sign is positive.
 Obturator sign: passively flex the R hip and knee and
internally rotate the hip. If there is increased pain then
the sign is positive
 Rebound tenderness: pain on quick withdrawal on RLQ
 Cutaneous hyperesthesia: gently pick up a fold of skin
b/n thumb &index finger with out pinching=localized
pain in RLQ

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PHYSICAL EXAM
 Additional components that may be helpful in
diagnosis:
 rebound tenderness,
 voluntary guarding,
 muscular rigidity,
 tenderness on rectal
 Fever: another late finding.
 At the onset of pain fever is usually not found.
 Temperatures >39 C are uncommon in first 24 h, but
common after rupture

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MANTRELS SCORE
 Migration of pain
 Anorexia
 Nausea / vomiting
 Tenderness RLQ
 Rebound
 Elevated temp.
 Leukocytosis
 Shift to left

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SCORE CONT..
 RLQ tenderness and leukocytosis = 2 points
each ; all others 1 point
 Score of 5 to 6 = possible appendicitis
 Score of 7 to 8 = probable appendicitis
 Score of 9 to 10 = very probable appendicitis

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LABORATORY FINDINGS
CBC
 Elevated WBC (> 10,000 cells/mm3).
 Neutrophil count >75%.-85%
 WBC normal in 80 % in the first 24 hrs.
 WBC usually 12 to 18,000 in appendicitis
Chemistry panel
 May help with diagnosis of dehydration
Urinalysis:
 Specific gravity, ketones:
 pyuria, hematuria, bacteruria
 Can see WBC’s, RBC’s, bacteria if inflamed appendix close to
ureter
 > 30 WBC’s = probable UTI

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IMAGING STUDIES
 Abdominal x-ray films, ultrasound studies, and
CT scans may reveal a right lower quadrant
density or localized distention of the bowel

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IMAGING CONT..
 Ultrasound
75 to 90 % sensitive, 86 to 100 % specific
Noninvasive, low cost, but operator-dependent
3 criteria for diagnosis
 Tender, non compressible appendix
 No peristalsis of appendix
 Overall diameter > 6 mm
Appendix may not be seen, due to obesity,
guarding, bowel gas, perforation, retrocecal
location
2.4 to 56 % of normal appendixes seen

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US…

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COMPUTED TOPOGRAPHY(CT)
 Sensitivity 97 to 100 %, specificity 95 %
 More expensive, radiation exposure
 Criteria for appendicitis :
 Diameter > 6 mm
 Failure to completely fill with contrast or air
 Wall thickening or enhancement
 Other contributory signs include fat stranding,
fluid, inflammatory mass, adenopathy

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CT….

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X-RAY
 X-rays of abdomen are abnormal in 24-95%
 Abnormal findings include: fecalith, appendiceal
gas, localized paralytic ileus, and free air
 Abdominal x-rays have limited use b/c the
findings are seen in multiple other processes
N.B ectopic pregnancy can be rule out before
x-ray are obtained

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COMPLICATIONS
 Perforation of appendix can result;
 peritonitis
 Abscess formation
 Portal Pylephlebitis
It occurs 24hrs after the onset of pain with
fever(37.7c),toxicity, abdominal pain and tenderness.

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GERONTOLOGIC CONSIDERATION
 Uncommon in elders, but when it occurs,
 Pain is minimal or absent
 Fever and leukocyte is not present
As a result difficult to Dx &Rx which cause complication
and mortality.

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MEDICAL MANAGEMENT
 Surgical intervention (appendectomy), as soon as
possible after diagnosis to decrease the risk of
perforation.
 Before surgery, correction or prevention of fluid and
electrolyte imbalance and dehydration could be
through antibiotics and intravenous fluids.
 Analgesics can be administered after the diagnosis
is made.
 If perforation occurs and abscess is formed, treat
the underlying cause before surgery.

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An appendectomy in progress

38. Steps of operation in appendicitis
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39. Steps of operation in appendicitis
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40. Steps of operation in appendicitis
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41. Steps of operation in appendicitis
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42. Steps of operation in retrocaecal
appendicitis
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43. Steps of operation in retrocaecal
retroperitoneal appendicitis
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NURSING MANAGEMENT;
 Goals
 Relieving pain
 Preventing fluid volume deficit
 Reducing anxiety
 Eliminating infection
 Maintain skin integrity
 Attaining optimal nutrition

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NURSING MANAGEMENT
 Prepare the patient for surgery, which includes an
intravenous infusion to replace fluid loss and promote
adequate renal function and antibiotic therapy to prevent
infection.
 Post-operatively, Place the patient in a semi-Fowler position
to reduce the tension on the incision and, thus, reduce
pain.
 Administer pain killers (usually morphine sulfate), as
prescribed.
 Start oral fluids when tolerated and intravenous fluids as
indicated. Food is provided as desired and tolerated on the
day of surgery.

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NURSING MANAGEMENT (CONTINUED…..)
 Instruct the patient to make an appointment to have the
surgeon remove the sutures between the fifth and seventh
days after surgery.
 Teach incision care (dressing) and activity guidelines;
normal activity can usually be resumed within 2 to 4 weeks.
 If there was possibility of peritonitis, the patient is kept in
hospital otherwise discharged with HE.
N.B Laxatives and enema should never be given when a
person has constipation because of a risk for perforation

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REFERENCES…
 Burner and Suddarth’s text Book of medical surgical
Nursing 12th
edition
 Harrisons principle of Internal medicine 18th
edition
 BATE’s guide to physical examination and history taking

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ANY QUESTIONS????????

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Thank you!!!