Appendicitis is one of the most common gastrointestinal conditions you’ll see in the clinical setting, and is most likely to occur in individuals age 10 to 30 years old, but can occur at any age. In this article you’ll learn the key things to know so you can develop a comprehensive appendicitis nursing care plan.
What is the appendix?
The appendix is a small hollow tube that is attached at the end of the large intestine. Its function has been a longstanding subject of debate and it was traditionally believed to be a vestigial organ. Current research in immunity suggests that the appendix is a lymphoid organ and may house symbiotic gut microbes which can replenish the GI tract as needed.
Though the appendix is fixed to the base of the cecum, its tip may be in a variety of positions, which accounts for variability in pain symptoms.
What is appendicitis?
Appendicitis is inflammation of the appendix (remember, “itis” means “inflammation.”) The cause is typically due to an obstruction, though the etiology is often unknown. When the appendix becomes obstructed, aerobic and anaerobic bacteria build up inside causing inflammation. Left untreated the appendix can perforate, which may cause serious complications such as peritonitis and sepsis.
L: How does the patient LOOK?
The patient with appendicitis generally has a distinct presentation which includes anorexia, right lower quadrant abdominal pain, and nausea/vomiting. Other signs and symptoms can include:
- Abdominal guarding
- Walking in a bent over position
- Urinary frequency
- Generalized malaise
Note that the pain in appendicitis typically begins as generalized abdominal pain that progresses to localized pain in the right lower quadrant (a location known as McBurney’s point). However, the position of the appendix plays a key role in the patient’s pain. For example, if the tip of the appendix is positioned more posteriorly, then the pain may not localize and may just be felt as a dull ache.
A: How do you ASSESS the patient?
Key assessments for a patient with appendicitis include:
- Assess for pain, which may be localized to the right lower quadrant. In addition to asking the patient the location of the pain, ask them to describe the quality and severity as well. The pain is often described as colicky or intense cramp-like pain. If the pain is intense and then suddenly ceases, this is a sign of perforation or rupture.
- Palpate the abdomen, noting tenderness that may be around the mid epigastric and umbilical areas or localized to the right lower quadrant.
- Assess for rebound tenderness by pressing on the right lower quadrant (McBurney’s point) and then releasing. Tenderness upon release is called “rebound tenderness” and it occurs when tissues of the abdominal cavity are inflamed or infected.
- Assess for Rovsing sign. This is pain that is elicited in the right lower quadrant when the left lower quadrant is palpated.
- Assess for psoas sign, which is pain that occurs when the right thigh is passively extended. Psoas sign may be present when the appendix is retrocecal and lying over the right psoas muscle.
- Take a full set of vital signs. Heart rate, respiratory rate and blood pressure may be elevated due to pain. Note that blood pressure may be low in individuals who have a fluid volume deficit secondary to decreased intake, vomiting or diarrhea. The patient may have a mild fever due to inflammation. A dramatic increase in temperature indicates possible perforation.
- Ask the patient about vomiting, diarrhea and constipation.
- Assess for poor skin turgor, which is a sign of dehydration.
T: What TESTS are conducted for appendicitis?
The key diagnostic tests for appendicitis are:
- CBC – Will show elevated WBC and most patients will have an increase in neutrophils and immature neutrophils in the differential.
- CRP – C-reactive protein is elevated in inflammatory states.
- Imaging studies – Imaging studies utilized to diagnose appendicitis include CT scan with contrast, ultrasound, and MRI. In adults, CT scan is the preferred imaging study, but MRI may be used in children to avoid excessive radiation exposure.
T: What TREATMENTS are utilized for appendicitis?
The main treatment for appendicitis is surgical removal of the appendix, so ensure the patient is NPO prior to the procedure and provide IV fluids to prevent dehydration. Pain management prior to surgery involves IV opioids such as morphine or hydromorphone. However, pain medication is generally held until after the patient can be assessed by the physician so as to not mask symptoms. Placing the patient in Fowler’s position can help reduce pain.
The surgical procedure is an appendectomy and is generally performed laparoscopically, which typically leaves one to four small incisions. If the appendix has ruptured, the surgeon may need to create a much larger incision and wash out the abdominal cavity. Adult patients who’ve had a ruptured appendix typically receive IV antibiotics for two to four days, though this can vary depending upon the patient’s condition. In children, IV antibiotics are generally utilized for a period of at least five days and continued until the child is afebrile, ambulating, eating a regular diet, and whose pain is well controlled on oral pain medication.
Pain is also managed postoperatively with IV medication initially, and then the patient is transitioned to PO medications such as hydrocodone or acetaminophen.
The diet will be resumed gradually and IV fluids discontinued when the patient is taking in adequate PO fluids.
E: How do you EDUCATE the patient/family?
Education elements to include in your plan of care are generally related to the post-operative period and include general post-op care.
- Do not lift anything heavier than 10 pounds until cleared by the physician
- Avoid strenuous activities or sports for two weeks.
- Resume diet slowly, starting with bland, low-fat foods such as mashed potatoes, bananas and cottage cheese.
- Keep incision clean and dry. It is okay to shower, but avoid baths, swimming and hot tubs until the incision is fully healed.
- The steri strips will fall off on their own in about a week, do not remove them.
- Wear loose fitting clothes to avoid irritating the incision site.
- Do not drive while taking prescription pain medication.
- Call your physician if pain worsens, the incision becomes red or has purulent drainage, temperature is elevated above 100.4, or nausea/vomiting are present.
- Seek medical care if pain is severe, the abdomen becomes rigid or if you have any difficulty breathing as these may be signs of serious complications.
Prior to surgical intervention, key teaching includes:
- Assuming the Fowler’s position may lessen pain
- Notify the nurse or physician immediately if pain suddenly resolves as this is a sign of perforation
Review appendicitis for your exams, clinicals, and NCLEX while you’re on the go by tuning in to episode 332 of the Straight A Nursing podcast. Tune in wherever you get your podcast fix, or straight from the website here.
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ScienceDirect. (2013). Rovsing’s Sign – an overview. ScienceDirect. https://www.sciencedirect.com/topics/medicine-and-dentistry/rovsings-sign
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UpToDate. (n.d.). Acute appendicitis in children: Clinical manifestations and diagnosis. UpToDate. Retrieved December 21, 2023, from https://www.uptodate.com/contents/acute-appendicitis-in-children-clinical-manifestations-and-diagnosis?search=appendicitis&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H6659006