Appendicitis

Stacey AdamczykMariah DaRocha

Mariah KleinKathy O’Neil

Case Study

https://www.youtube.com/watch?v=zSzDbwkXeA4

Jake is a six year old male who had been feeling a dull pain near his belly button followed by nausea 12 hours prior to his soccer tournament.

Feeling well enough to attend his tournament the next day, Jake’s mother drove him to his elementary school where the soccer match was held.

Along the way, he noticed that when his mother went over a few potholes, he felt some pain in the right lower quadrant of his abdomen.

Not wanting to miss his game, he does not tell his mother about his symptoms.

Case Study

During the game, Jake begins to feel nauseous with increasing pain in the lower right quadrant.

As he and another player attempt to kick the ball at the same time, Jake gets kicked in the abdomen in the lower left quadrant and vomited a small amount of his breakfast.

The school nurse, who has a son on the same team as Jake, sat in the stands. She ran out onto the field and assisted Jake into her office in the school.

Let’s follow Jake on his journey from the nurse’s office, into the ambulance, the hospital, and his recovery back at home.

School Nurse’s Office

Jake’s condition has deteriorated: visibly in pain

Vital Signs:Pain: 10 (Wong Baker FACES Pain

Scale), sharp pain lower right quadrant

T: 102 degrees F, oralHeart Rate: 110Respiration Rate: 28O2: 100%

Height: 46 inches, weight: 48 lbs

Assessment Nurse tells Jake to lie down: he flexes his hip and draws his right knee to

his chest Inspection: abdomen is slightly distended, bruise developing in lower left

quadrant from kick Auscultation: hypoactive bowel sounds Upon percussion at McBurney’s point, Jake winces in pain and tightens

his abdominal muscles. The nurse suspects appendicitis (possible rupture)

Decides against deep palpation in this case but rebound tenderness would also be a key sign: pain level increases after removal of hand (release of pressure) from the area

School Nurse’s Office

Health History Last bowel movement: Two days ago

Jake’s mom explains that Jake is also frequently constipated as he has anxiety about using public restrooms

Mom also says he doesn’t eat his vegetables and prefers to eat chips and cookies

Jake also tells her about the nausea/ pain he felt yesterday and how the “bumps on the road” made the pain worse

No other significant medical issues Intervention: Applies ice to bruise/ abdomen

and call for EMS

School Nurse’s Office

I’m the EMT transferring Jake to the hospital. Jake’s V/S

Temperature 102 F Heart Rate 115 bpm Respiratory rate 28 Pulse oximetry 100% Pain 10 (Hurts Worst- using the Wong-

Baker FACES pain scale) The way Jake is presenting, I suspect an

appendix rupture due to appendicitis, so I start an IV with NS 0.9% apply ice to the right lower quadrant

Emergency Medical Services

Appendicitis: is an inflamed appendixThe obstruction

leads to mucus and bacteria build up that can cause an infection or perforation

Appendicitis

Tumor

Fecal Obstructio

n

Foreign Substanc

e

Excessive

TissueGrowth

Causes

Appendicitis

https://www.youtube.com/watch?v=z8VxphcTh6k

Signs and Symptomspersistent periumbilical painnausea, vomitingPain at the McBurney’s pointRebound tendernesspatient may want to lie stillpossible fevermoderately high WBC count

Diagnosis: CT scan or an ultrasound

Appendicitis

Complications: perforationperitonitisabscesses

Treatment: Pre-rupture: immediate

appendectomyPost-rupture: IV fluid and

antibiotics are used for 6-8 hours before an appendectomy

Appendicitis

Appendicitis

Appendicitis and rupture can result in secondary Peritonitis Since the peritoneum is normally sterile, the waste and

bacteria contents expelled from the rupture lead to a bacterial infection.

S/S: abdominal pain, muscular rigidity, rebound tenderness, spasm, abdominal distention, nausea, vomiting, and fever

Diagnosis: CBC to determine elevated WBC counts and hemoconcentrationPeritoneal aspiration to determine foreign contentsAbdominal x-ray which can help us visualize paralytic ileus,

perforation, or obstruction

Appendicitis

1) ____ A complication is shock and sepsis 2) ____ Elevated WBC3) ____ NPO status4) ____ Typically caused by an obstruction5)____ Inflammatory response leads to fluid shifts that result in edema and ascites6) ____IV fluid replacement for dehydration7) ____Pain 2/3 of the way to the ASIS from the umbilicus8) ____Surgery is performed as soon as diagnosis is made

Matching: Choose either Peritonitis (P), Appendicitis (A), or Both (B)

Matching: Answers

1) Peritonitis: A complication is shock and sepsis 2) Both: Elevated WBC3) Both: NPO status4) Appendicitis: Typically caused by an obstruction5) Peritonitis: Inflammatory response leads to fluid shifts that result in edema and ascites6) Peritonitis: IV fluid replacement for dehydration7) Appendicitis: Pain 2/3 of the way to the ASIS from the umbilicus8) Appendicitis: Surgery is performed as soon as diagnosis is made

• Appendectomy: removal of the appendix– Spinal or General anesthesia is used during

surgery– If the appendix has ruptured previous to surgery,

drains may be placed to remove excess fluid and pus

– Risks associated with surgery are infection and bleeding

– Post-rupture risks related to surgery are pus build-up within the peritoneum (requires draining and antibiotics), and longer hospital stays

Appendectomy

Types of Appendectomies Laparoscopic Appendectomy Open Appendectomy

3 small incisions, one is used for the camera

and the other two are used to access and

remove the appendix

 

single right lower quadrant abdominal

incision

Preferred procedure for uncomplicated;

According to Lukish (2012), this procedure for

uncomplicated appendicitis lead to less

associated infections or paralytic ileus. (p. 22)

Increased risk for infection

Better cosmetic outcome, less postoperative

pain, and shorter recovery time

Muscle splitting; surgical scar

Longer procedure Shorter procedure

Debate whether LA is preferred for

complicated appendicitis (example:

perforation)

For complicated appendicitis infection risk is

similar to LA

Types of Appendectomies

Types of Appendectomies

Hospital: Vitals

Admission:102*

Oral115 bpm28 rr100% RA10 pain15.5 kg

Toradol IV 7.75 mg q6h

Pre-Op102* Oral105 bpm26 rr100% RA6 pain95/65 BP

Hospital: Vitals

Surgical Preparation

• Change into hospital clothing• NPO to prevent vomiting/aspiration and rest GI system• IV insertion and antibiotics 6-8hrs prior to surgery to prevent sepsis/infection• IVF to rehydrate• NGT suction to prevent vomiting and rest GI system• WBC count drawn and results are elevated (170,000)• CT scan / US confirm ruptured appendix• Antiemetic• Antipyretic• Pain medication: Toradol 7.75 mg IV q6h• Antibiotics: Ampicillin 775 mg q6h, Clindamycin 115 mg q6h, and Gentamicin

31 mg q8h

Surgical Preparation

Open Appendectomy

General Anesthesia

Intubation

3 incisions

Appendectomy

Post-Operative Assessment

Lungs/throat/mouth r/t intubation

Abdomen for bowel sounds/distention

Check incision site for redness, swelling, oozing,

NG tube – remove when baseline bowel function returns

Post-Operative Assessment

Risk for Infection related to ruptured appendix as evidenced by fever 102*• Patient will reduce fever to at least 100* by end of shift• Oral or tympanic thermometers may be used to assess temperature

– The use of tympanic thermometers in addition to oral thermometers in obtaining temperatures is supported (Gilbert, Barton, & Counsell, 2002; Mains, 2008).

• Encourage fluid intake – Fluid intake helps thin secretions and replace fluid lost during fever (CDC,

2004). • Recommend responsible use of antibiotics; use antibiotics sparingly

– Widespread use of certain antibiotics has been shown to foster development of generalized beta-lactam resistance in previously susceptible bacterial populations (Tillotson, Blondeau, & Carroll, (2007).

Post-Operative Diagnosis

• Parent will demonstrate appropriate care of incision site/dressing by discharge

• Teach appropriate hand hygiene – Lower rate of MRSA linked to good hand hygiene (Mears et al, 2009).

• Review standards of surveillance of infections in home care – Infection surveillance, prevention, and control have lagged behind

home care expansion (Rhinehart, 2001).

• Maintain strong infection-prevention policies. – Strong guidelines are important to avoid infection in the home setting,

especially addressing issues such as storage and use of irrigation solutions and supplies (Friedman, 2003).

Post-Operative Diagnosis

Asessment: • Subjective Data:• Mother States, “Jake still hasn’t

had a movement since surgery” ( 4 days)

• Jake states, “I don’t feel like eating”

• Jake states, “I just want to go play soccer and see my friends”

Home Care Nurse

Objective Data: Vitals: Temp: 99.5 F, HR: 95, RR: 26, O2:

100% Weight: 48lbs Height: 45” Incision is pink around border, minimal

swelling, with no active discharge Incision intact with dissolvable sutures

and surgical glue Pt. is eating and drinking as tolerated. Pain rates a 4. (“ Hurts a little more”,

Wong Bakers FACES pain scale) Facial grimacing

Eating and drinking: restriction to clear liquids immediately after

surgery likely nausea and constipation (decreases appetite) Introduce regular foods as tolerated

Returning to school: Your doctor will let you know Usually return within a week, longer for

ruptures

At Home Instructions

Resuming physical activity: Recommended to wait a few weeks before returning to physical activityEarly ambulation speeds recovery Resume normal activity gradually w/ rest periodsNo heavy lifting

Coughing/ Straining: • Practice 10 deep breaths and 2 coughs/ hour, (12 hours/ day), for 1st

week post-op• Place a pillow over incision site and gently press inward to reduce

pressure when coughing Caring for the incision: • keep clean/ watch for infection: call Doc if redness, swelling, discharge

from the incision, or fever greater than 101 F• Clean incision site in the shower: let mild soap and tempered water run

on to the incision. DO NOT SCRUB. Do not soak. • The incisions had been closed with dissolvable stitches and surgical glue.

Do not try to peel of the surgical glue, it will dissolve on its own. • No ointments or lotions on site• Cold ice pack 20 minutes 3x/day for the first 5 days

At Home Instructions

• Pain related to presence of surgical incision as evidence by a pain rated a 4 out of 10 (Wong Bakers FACES Pain Scale) and facial grimacing

• Short Term Goal: Patient will perform ADLs easily with the assistance of the caregiver without reports of pain by day three.

• Intervention: Nurse will in addition to administering analgesics, support the client’s use of nonpharmacological methods to help control pain, such as distraction, imagery, relaxation, and application of ice.– Rational: “Cognitive- behavioral strategies can restore the

client’s sense of self-control, personal efficacy, and active participation in care.” (Lassetter, 2006, APS, 2008).

Home Nursing Diagnosis

• Long Term Goal: Patient will state that pain is a 0 out of 10 (Wong Bakers FACES Pain Scale) in two weeks

• Intervention: Nurse will teach patient’s caregiver about adverse effects of unrelieved pain– Rational: “Unrelieved acute pain

can have physical and psychological consequences that facilitate negative client outcomes.” (Brennan, Carr, &Cousins, 2007).

Home Nursing Diagnosis

Children's MOTRIN® Oral Suspension 100 mg/5 mL (Dye-Free Berry Flavor): 2tsp or 10ml Q6-8 hrs PRN for pain. * Shake well before use ** Do not use more than 4 times

a day Pedia-Lax® Chewable Tablets

(Magnesium Hydroxide 400mg): 1 (170 mg) tablet TID for one day Drink with full 8 once glass of water Do not continue medication if B.M is

passed Triple Antibiotic Course continued

PO

At Home Medications

Be aware of signs/symptoms! Sudden pain that begins around your

navel and shifts to your lower right abdomen

Pain that worsens if you cough, walk, etc.

Nausea and vomiting, loss of appetite, low-grade fever, Constipation or diarrhea, bloating

** If your child has worrisome signs and symptoms make an appointment with their health care provide ASAP

** If your child is experiencing severe pain seek medical attention immediately

Community Implications

Risk Factors: Family history: Age: Children 2 years of age or

younger and people 70 years of age or older are at higher risk

Causes: Infection - a stomach infection

may have found its way to the appendix

Obstruction - A hard piece of stool can get trapped in the appendix which can cause and infection

** Parcopresis (fear of defecating in public places) and paruresis (fear of urinating in public places) is common in young children. This can lead to constipation and bowel obstructions.

Parcopresis/Paruresis

Tips to Help a Child overcome Parcopresis and ParuresisGo to the bathroom before leaving the

homeHave them see you use a public

bathroomReduce noise level Take and insert or potty seat for

familiarityStart in a familiar public placeDon’t belittle their fearsCommunicate and be honest

NCLEX Questions

1) The nurse wants to decrease discomfort and pain for a patient with appendicitis by:

A) Keeping the patients in a High-Fowlers positionB) Positioning the patient on their left sideC) Have the patient stand with arms

resting on the tableD) Encourage the patient to lie still and flex the right leg

NCLEX Question

1) The nurse wants to decrease discomfort and pain for a patient with appendicitis by:

A) Keeping the patients in a High-Fowlers position

B) Positioning the patient on their left sideC) Have the patient stand with arms resting on the tableD) Encourage the patient to lie still and flex the right leg: the best position to decrease pain for someone with appendicitis is to let them lie still and flex their right knee up.

NCLEX Question: Answer

NCLEX Questions

2) The nurse has just admitted a patient to the hospital with acute appendicitis, and an appendectomy will be performed as soon as possible, and the patients states his pain as a 10, what should the nurse implement?

A) Place the patient on NPO status: Since this is an emergency surgery, it is important to place the patient as NPO status as soon as possible.

B) Obtain opiod pain medications C) Apply a warm compress to the right lower

abdominal quadrantD) Offer the patient ice water and saltines

NCLEX Question

NCLEX Questions

2) The nurse has just admitted a patient to the hospital with acute appendicitis, and an appendectomy will be performed as soon as possible, and the patients states his pain as a 10, what should the nurse implement?

A) Place the patient on NPO status: Since this is an emergency surgery, it is important to place the patient as NPO status as soon as possible.

B) Obtain opiod pain medications C) Apply a warm compress to the right lower

abdominal quadrantD) Offer the patient ice water and saltines

NCLEX Question: Answer

3) You are a home nurse going to visit Jake and his mother at their home. Jake has only been discharged from the hospital less than 24 hours ago, and his mother was given specific discharge instructions. What comment given by Jake’s mother indicated a need for further teaching?

A) Jake shouldn’t lift more than a few pounds. B) If Jake experiences vomiting, pain, or change in bowel

function I should notify his health care provider.C) Jake should only consume clear liquids until he can

tolerate regular meals. D) Jake should resume normal play and sport activities as

soon as possible.

NCLEX Question

3) You are a home nurse going to visit Jake and his mother at their home. Jake has only been discharged from the hospital less than 24 hours ago, and his mother was given specific discharge instructions. What comment given by Jake’s mother indicated a need for further teaching?

A) Jake shouldn’t lift more than a few pounds. B) If Jake experiences vomiting, pain, or change in bowel function should notify his health care provider.C) Jake should only consume clear liquids until he can tolerate regular meals. D) Jake should resume normal play and sport activities as soon

as possible: Although, early ambulation speeds recovery with abdominal surgery, normal activities should resume gradually and with planned rest periods. A, B, C are correct instruction post abdominal surgery. (Lewis et al, 2011)

NCLEX Question: Answer

4) A nurse is caring for a child who had a laproscopic appendectomy. Which of the following interventions should the nurse document in the patient’s clinical record? Select all that apply.

A) Intake and Output B) Measurement of Pain C) Condition of incision siteD) Measurement of abdominal girth every 2 hours E) Auscultation of bowel sounds

NCLEX Question

4) A nurse is caring for a child who had a laparoscopic appendectomy. Which of the following interventions should the nurse document in the patient’s clinical record? Select all that apply.

A) Intake and Output B) Measurement of Pain C) Condition of incision siteD) Measurement of abdominal girth every 2 hours: this is unnecessaryE) Auscultation of bowel sounds

NCLEX Question: Answer

a. Indwelling catheterb. Gastrostomy tubec. Hemovacd. T-tubee. Nasogastric tube

1. Wound drainage2. Urine3. Bile4. Gastric contents

NCLEX Question

5) Match the following tubes and drains with their expected drainage (answers may be used more than once).

a. Indwelling catheterb. Gastrostomy tubec. Hemovacd. T-tubee. Nasogastric tube

1. Wound drainage2. Urine3. Bile4. Gastric contents

NCLEX Question Answer

5) Match the following tubes and drains with their expected drainage (answers may be used more than once).

References • Appendectomy - Better Health Channel. (2012, December 3). Retrieved

February 10, 2015, from http://www.betterhealth.vic.gov.au/bhcv2/bhca• Appendicitis - Symptoms of Appendicitis Video.mp4. (2012). Retrieved

February 7, 2015, from https://www.youtube.com/watch?v=z8VxphcTh6k• Kosloske, A., Love, C., Rohrer, J., Goldthorn, J., & Lacey, S. (2004). The Diagnosis of appendicitis in children: outcomes of a strategy based on pediatric surgical evaluation. Pediatrics, 113(1 Part 1), 29-34.• Laparoscopic Appendectomy: Post-Operative Instructions. (2010, January

1). Retrieved February 10, 2015, from https://health.ucsd.edu/specialties/surgery/gi/Documents/FMPH266-LapApp.pdf

• Lewis, S., Dirksen, S., Heitkemper,M., Bucher, L., & Camera, I. (2011). Medical surgical nursing (8th ed.). St. Louis, MO: Mosby Elsevier.

References

• Lukish, J.R. (2012). Minimal access surgery in infants and children. Contemporary Pediatrics, 29(1), 18-27.

• Madeline-Trailer Video.mp4 (1998). Retrieved February 10, 2015. https://www.youtube.com/watch?v=zSzDbwkXeA4

• Minkes, R. (2014, November 18). Pediatric Appendicitis Treatment & Management. Retrieved February 12, 2015, from http://emedicine.medscape.com/article/926795-treatment

• Muscle Splinting Psychology & Foot Keystones. (2014). Retrieved February 7, 2015, from http://icanrunaminute.com/tag/mcburneys-point/

• Verghese, S. T., & Hannallah, R. S. (2010). Acute pain management in children. Journal of Pain Research, 3, 105–123.

References