A nurse is teaching a client who has constipation which of the following should the nurse discuss

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Learning Outcome

• Recognize the common signs and symptoms of appendicitis 

• Know the key points to assess in an appendicitis patient, both pre and postoperatively

• Recognize when it is necessary to alert the provider to specific patient findings

• Formulate nursing diagnosis related to appendicitis

• Develop and implement a plan of care within the scope of practice for the appendicitis patient

Appendicitis is inflammation of the vermiform appendix. This is a small, finger-like, hollow organ located at the tip of the cecum portion of the large intestines, usually in the right lower quadrant of the abdomen. However, it can be located in almost any area of the abdomen, depending on if there were any abnormal developmental issues or if there are any other concomitant conditions such as pregnancy or prior surgeries.  Because the appendix has a small lumen, it is prone to obstruction by fecalith (which is a stone-like substance made from hardened feces) and can subsequently become inflamed and then infected. Appendicitis is one of the most common causes of acute abdominal surgery and typically occurs between ages 5 and 45, but can occur at any age, with men having a slightly higher risk. Appendicitis is most often a disease of acute presentation, usually within 24 hours, but it can also present as a more chronic condition. If there has been a perforation with a contained abscess, then the presenting symptoms can have a slower and less painful onset. The exact function of the appendix has been a debated topic. Today it is accepted that this organ may have an immunoprotective function and acts as a lymphoid organ, especially in the younger person. Other theories contend that the appendix acts as a storage vessel for "good" colonic bacteria. Still, others argue that it is a mear developmental remnant and has no real function.[1][2][3]

Nursing Diagnosis

• Acute pain related to obstructed appendix

• Risk for fluid volume deficit related to nausea and/or vomiting/ decreased appetite/ decreased fluid intake

• Risk for infection related to ruptured appendix/ surgical incision

• Risk for deep venous thrombosis (DVT) related to immobility

• Risk for anxiety related to hospitalization

The cause of appendicitis likely stems from obstruction of the appendiceal opening or lumen. This results in inflammation, localized ischemia, perforation, and the development of a contained abscess or perforation with resultant peritonitis. This obstruction may be caused by lymphoid hyperplasia, infections (parasitic), fecaliths (stone-like structure made of hardened feces), or benign or malignant tumors. When an obstruction is the cause of appendicitis, it leads to an increase in pressure, resulting in small vessel occlusion and lymphatic stasis. Once obstructed, the appendix fills with mucus and becomes distended, leading to ischemia and necrosis. Bacterial overgrowth then occurs in the obstructed appendix, with aerobic organisms predominating in early appendicitis and mixed aerobes and anaerobes later in the course. Common organisms include Escherichia coli, Peptostreptococcus, Bacteroides, and Pseudomonas. Once significant inflammation and necrosis occur, the appendix is at risk of perforation, leading to a localized abscess and sometimes frank peritonitis.[4]

Appendicitis is one of the most common causes of acute abdominal surgery in the United States, with more than 200,000 cases occurring annually and typically occurs between ages 5 and 45, but can occur at any age, with men having a slightly higher risk. Family history of appendicitis seems to slightly increase risk, as well as a personal history of cystic fibrosis.

Classically, appendicitis presents as an initial generalized or periumbilical abdominal pain that then localizes to the right lower quadrant.  As the appendix becomes more inflamed, and the adjacent parietal peritoneum is irritated, the pain becomes more localized to the right lower quadrant. Pain may or may not be accompanied by any of the following symptoms:

• Decreased appetite

• Nausea/vomiting

• Fever (40% of patients)

• Diarrhea or constipation

• Generalize malaise

• Urinary frequency or urgency

Physical exam findings are often subtle, especially in early appendicitis.

As inflammation progresses, signs of peritoneal inflammation develop. Signs include:

• Right lower quadrant guarding and rebound tenderness

• Right lower quadrant pain elicited by palpation of the left lower quadrant

• Increased abdominal pain with coughing or movement

• Rigid abdomen and involuntary guarding

The time course of symptoms is variable but typically progresses from early appendicitis at 12 to 24 hours to perforation at greater than 48 hours. Seventy-five percent of patients present within 24 hours of the onset of symptoms.

The risk of rupture is variable but is about 2% at 36 hours and increases about 5% every 12 hours after that.

Typically includes:

• Laboratory testing such as CBC. Elevated WBC is typically found, but CBC is normal in approximately one-third of patients with appendicitis.

• Typically a CT abdomen and pelvis is done while the patient is in the emergency room setting, but ultrasound and MRI are also used, particularly in pregnant women, and ultrasound is sometimes used in children to reduce radiation.

• Appendicitis is often a clinical diagnosis by the provider based on a thorough history and physical exam.

The gold-standard treatment for acute appendicitis is to perform an appendectomy. Laparoscopic appendectomy is preferred over the open approach. Most uncomplicated appendectomies are performed laparoscopically. In cases where there is an abscess or advanced infection, the open approach may be needed. The laparoscopic approach affords less pain, quicker recovery, and the ability to explore most of the abdomen through small incisions. Situations, where there is a known abscess from a perforated appendix, may require a percutaneous drainage procedure usually done by an interventional radiologist. This stabilizes the patient and allows the inflammation to subside over time enabling a less difficult laparoscopic appendectomy to be performed at a later date. Practitioners also start patients on broad-spectrum antibiotics. There is some disagreement regarding preoperative antibiotic administration for uncomplicated appendicitis. Some surgeons feel routine antibiotics in these cases are not warranted, while others give them routinely. There have also been several studies promoting the treatment of uncomplicated appendicitis solely with antibiotics and avoiding surgery altogether.[1][5]

Nursing interventions related to the appendicitis patient include:

• Assessing and relieving pain through medication administration as well as nonpharmacologic interventions.

• IMPORTANT: DO NOT APPLY HEAT TO THE APPENDICITIS PATIENT'S ABDOMEN AS THIS COULD LEAD TO RUPTURE.

• Prevent fluid volume deficit. If tolerated and the patient is not NPO, oral fluid intake should be encouraged, and intake and output recorded.

• Prevent infection. Maintain a clean environment, provide wound care to the postoperative patient, and assess incision frequently for signs of infection. Monitor patient temperature and heart rate for signs of potential infection. Administer antibiotics as prescribed by the provider.

• Reduce patient anxiety by keeping the patient informed of the plan of care and ensure the patient is aware of diagnosis and treatment options. 

• Encourage patients to walk as able/ permitted to maintain circulation. If the patient is immobile, the use of serial compression devices (SCD) and TED hose should be implemented to avoid DVT/clots.

• Monitor for adequate bowel movements. Opioids can be necessary for pain control, but they often lead to constipation. Encourage adequate water intake and use of a stool softener.

When To Seek Help

• Alert the health care provider to symptoms of peritonitis, as this could indicate a ruptured appendix. Symptoms to watch for include severe abdominal pain, typically these patients try not to move and hold their abdomen very still, often even avoiding deep breaths. They demonstrate what is called a board-like abdomen. When touched, the patient will tighten their abdominal muscles as a guarding mechanism, leading the abdomen to appear very firm to touch. If the patient demonstrates these symptoms, it is necessary to alert the provider right away.

• If there is a sudden change to the vital signs such as increased heart rate (tachycardia) or fever, as this could indicate infection or acute inflammation

• If the patient is postoperative, alert healthcare provider to any signs of wound infection such as redness, tenderness, increasing pain, or swelling at the incision site.

Outcome Identification

• Prevented fluid volume deficiency, adequate intake, and output

• Prevented/treated infection

• Maintained surgical incision integrity

• Patient anxiety relieved/received adequate education

• Maintained adequate elimination/prevented constipation

Monitoring

• Monitor vital signs for changes in temperature or heart rate. Fever and increased heart rate can both indicate infection or inflammation.

• Monitor patient pain level and location. Appendicitis typically presents as pain in the right lower quadrant. However, it is not always specific to those areas, particularly in small children, who may have difficulty localizing pain other than a generalized "belly pain." The appendix may also not be situated in a normal location, which can lead to pain felt in a different quadrant. It is important, as a nurse, to obtain as much information as possible about the location and quality of the pain in order to provide the doctor with as much information as possible. Questions such as "where is the pain located?" "How would you describe the pain, is it burning, stabbing, cramping, etc.?" and "How long has the pain lasted, is it constant or does it come and go?" are important to ask the patient and subsequently relay to the provider.

• Monitor for changes in eating and bowel habits. Appendicitis can lead to patient complaints of loss of appetite, nausea, and vomiting, as well as constipation.

• Monitor laboratory values, particularly the white blood cell count, as an increase can signal infection. Please note, however, appendicitis is still possible with normal laboratory values.

Health Teaching and Health Promotion

• If the patient had surgery, they need to continue to monitor the incision site for any signs of infection such as redness, swelling, drainage, or increased pain and report these to their surgeon. 

• They will likely have staples or sutures that will need to be removed in 5-7 days, but regardless they must have a follow-up appointment scheduled with their surgeon or primary provider before they are discharged to follow up for wound check and assessment.

• Normal activity can usually resume within a few days to a week. However, the patient should avoid any strenuous activity and heavy lifting for the first 4-6 weeks, unless otherwise noted by the provider. Frequent small walks should be encouraged.

• If antibiotics were prescribed, ensure adequate patient education to complete all antibiotics and to take with a meal should stomach upset occur.

• If pain medication such as opioids was prescribed, ensure the patient knows not to drive or operate machinery while taking and also to take a stool softener to avoid constipation.

• Encourage patient to unexpected findings to the clinician.

Make sure to document appropriately and timely in the appendicitis patient. Specific documentation for this patient includes:

• Patient description of pain and intensity. 

• Results of laboratory values and if these were called to the provider.

• Surgical site and wound care/dressing changes/any drainage noted if the drain is present and description of drainage (serosanguineous, etc.).

• Signs or symptoms of infection.

• Any patient education provided.

• Plan of care.

• Any time results, patient assessment, or concerns are addressed with the provider. This needs to be documented, including who was paged, who responded, and the time. 

Discharge Planning

• If the patient had surgery, they need to continue to monitor the incision site for any signs of infection such as redness, swelling, drainage, or increased pain and report these to their surgeon. 

• They will likely have staples or sutures, but regardless they must have a follow-up appointment scheduled with their surgeon or primary provider before they are discharged to follow up for wound check and assessment.

• Normal activity can usually resume within a few days to a week. However, the patient should avoid any strenuous activity and heavy lifting for the first 4-6 weeks, unless otherwise noted by the provider. Frequent small walks should be encouraged.

• If antibiotics were prescribed, ensure adequate patient education to complete all antibiotics and to take with a meal should stomach upset occur.

• If pain medication such as opioids was prescribed, ensure the patient knows not to drive or operate machinery while taking and also to take a stool softener to avoid constipation. 

Special consideration should be given to the treatment of patients with perforated appendicitis with an abscess. Those who present with an abscess and do not exhibit peritonitis may benefit from CT or ultrasound-guided percutaneous drain placement as well as antibiotics. Interval appendectomy is classically performed 6 to 10 weeks after recovery. Historically, 20% to 40 % of patients treated medically for perforated appendicitis with an abscess had recurrent appendicitis in historical literature. More recent studies suggest these rates be much lower.

Complications of appendicitis and appendectomy include surgical site infections, intra-abdominal abscess formation (3% to 4% in open appendectomy and 9% to 24% in laparoscopic appendectomy), prolonged ileus, enterocutaneous fistula, and small bowel obstruction.

Occasionally the incorrect diagnosis of acute appendicitis is made when, in reality, the correct diagnosis is Crohn disease of the cecum or terminal ileum. It is important to know that is this occurs that the appendix should be left in place if there is involvement at its base. The removal of the appendix in this situation has a high leak and fistula rate formation. On the other hand, if the base of the appendix is spared, then the appendix should be removed, even if it appears normal. This eliminates the future confusion of diagnosing acute Crohn disease versus acute appendicitis.

In the past, it was commonplace to routinely remove the appendix at the time of other nonrelated surgeries to avoid developing appendicitis in the future. Today, however, most surgeons do not routinely remove a normal appendix at the time of other scheduled procedures. If a patient does go into surgery for an incorrect diagnosis of acute appendicitis, then it is advised to remove the appendix to avoid any future diagnostic issues.

Review Questions

CT Abdomen Acute Appendicitis. Contributed by Scott Dulebohn, MD

Ultrasound of the right lower quadrant with findings of acute appendicitis. There is a blind ending tubular structure measuring up to 7 mm in diameter. Contributed by Kevin Carter, DO

There is acute appendicitis with a dilated fluid filled tubular structure in the right lower quadrant on this axial and sagittal images with a surrounding fluid collection and stranding due to developing abscess. Contributed by Kevin Carter, DO

Appendectomy. Contributed by Sunil Munakomi, MD

1.

Vaos G, Dimopoulou A, Gkioka E, Zavras N. Immediate surgery or conservative treatment for complicated acute appendicitis in children? A meta-analysis. J Pediatr Surg. 2019 Jul;54(7):1365-1371. [PubMed: 30115448]

Gignoux B, Blanchet MC, Lanz T, Vulliez A, Saffarini M, Bothorel H, Robert M, Frering V. Should ambulatory appendectomy become the standard treatment for acute appendicitis? World J Emerg Surg. 2018;13:28. [PMC free article: PMC6025707] [PubMed: 29988464]

Eng KA, Abadeh A, Ligocki C, Lee YK, Moineddin R, Adams-Webber T, Schuh S, Doria AS. Acute Appendicitis: A Meta-Analysis of the Diagnostic Accuracy of US, CT, and MRI as Second-Line Imaging Tests after an Initial US. Radiology. 2018 Sep;288(3):717-727. [PubMed: 29916776]

Kartal İ. Childhood neuroendocrine tumors of the digestive system: A single center experience. Medicine (Baltimore). 2022 Feb 11;101(6):e28795. [PMC free article: PMC8830841] [PubMed: 35147110]

Khan MS, Chaudhry MBH, Shahzad N, Tariq M, Memon WA, Alvi AR. Risk of appendicitis in patients with incidentally discovered appendicoliths. J Surg Res. 2018 Jan;221:84-87. [PubMed: 29229158]

Stringer MD. Acute appendicitis. J Paediatr Child Health. 2017 Nov;53(11):1071-1076. [PubMed: 29044790]

Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015 Sep 26;386(10000):1278-1287. [PubMed: 26460662]

Addiss DG, Shaffer N, Fowler BS, Tauxe RV. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol. 1990 Nov;132(5):910-25. [PubMed: 2239906]

Hamilton AL, Kamm MA, Ng SC, Morrison M. Proteus spp. as Putative Gastrointestinal Pathogens. Clin Microbiol Rev. 2018 Jul;31(3) [PMC free article: PMC6056842] [PubMed: 29899011]

Redden M, Ghadiri M. Acute appendicitis with associated trichobezoar of feline hair. J Surg Case Rep. 2022 Mar;2022(3):rjac133. [PMC free article: PMC8963297] [PubMed: 35355580]

Snyder MJ, Guthrie M, Cagle S. Acute Appendicitis: Efficient Diagnosis and Management. Am Fam Physician. 2018 Jul 01;98(1):25-33. [PubMed: 30215950]

van Aerts RMM, van de Laarschot LFM, Banales JM, Drenth JPH. Clinical management of polycystic liver disease. J Hepatol. 2018 Apr;68(4):827-837. [PubMed: 29175241]

Awayshih MMA, Nofal MN, Yousef AJ. Evaluation of Alvarado score in diagnosing acute appendicitis. Pan Afr Med J. 2019;34:15. [PMC free article: PMC6859007] [PubMed: 31762884]

Yang HR, Wang YC, Chung PK, Chen WK, Jeng LB, Chen RJ. Laboratory tests in patients with acute appendicitis. ANZ J Surg. 2006 Jan-Feb;76(1-2):71-4. [PubMed: 16483301]

Withers AS, Grieve A, Loveland JA. Correlation of white cell count and CRP in acute appendicitis in paediatric patients. S Afr J Surg. 2019 Dec;57(4):40. [PubMed: 31773931]

Pooler BD, Repplinger MD, Reeder SB, Pickhardt PJ. MRI of the Nontraumatic Acute Abdomen: Description of Findings and Multimodality Correlation. Gastroenterol Clin North Am. 2018 Sep;47(3):667-690. [PubMed: 30115443]

Swenson DW, Ayyala RS, Sams C, Lee EY. Practical Imaging Strategies for Acute Appendicitis in Children. AJR Am J Roentgenol. 2018 Oct;211(4):901-909. [PubMed: 30106612]

Kim DW, Suh CH, Yoon HM, Kim JR, Jung AY, Lee JS, Cho YA. Visibility of Normal Appendix on CT, MRI, and Sonography: A Systematic Review and Meta-Analysis. AJR Am J Roentgenol. 2018 Sep;211(3):W140-W150. [PubMed: 30040469]

Hwang ME. Sonography and Computed Tomography in Diagnosing Acute Appendicitis. Radiol Technol. 2018 Jan;89(3):224-237. [PubMed: 29298941]

Kave M, Parooie F, Salarzaei M. Pregnancy and appendicitis: a systematic review and meta-analysis on the clinical use of MRI in diagnosis of appendicitis in pregnant women. World J Emerg Surg. 2019;14:37. [PMC free article: PMC6647167] [PubMed: 31367227]

Kumar S, Jalan A, Patowary BN, Shrestha S. Laparoscopic Appendectomy Versus Open Appendectomy for Acute Appendicitis: A Prospective Comparative Study. 2016 Jul-Sept.Kathmandu Univ Med J (KUMJ). 14(55):244-248. [PubMed: 28814687]

Zani A, Hall NJ, Rahman A, Morini F, Pini Prato A, Friedmacher F, Koivusalo A, van Heurn E, Pierro A. European Paediatric Surgeons' Association Survey on the Management of Pediatric Appendicitis. Eur J Pediatr Surg. 2019 Feb;29(1):53-61. [PubMed: 30112745]

Antonacci N, Ricci C, Taffurelli G, Monari F, Del Governatore M, Caira A, Leone A, Cervellera M, Minni F, Cola B. Laparoscopic appendectomy: Which factors are predictors of conversion? A high-volume prospective cohort study. Int J Surg. 2015 Sep;21:103-7. [PubMed: 26231996]

Thambidorai CR, Aman Fuad Y. Laparoscopic appendicectomy for complicated appendicitis in children. Singapore Med J. 2008 Dec;49(12):994-7. [PubMed: 19122949]

Siribumrungwong B, Chantip A, Noorit P, Wilasrusmee C, Ungpinitpong W, Chotiya P, Leerapan B, Woratanarat P, McEvoy M, Attia J, Thakkinstian A. Comparison of Superficial Surgical Site Infection Between Delayed Primary Versus Primary Wound Closure in Complicated Appendicitis: A Randomized Controlled Trial. Ann Surg. 2018 Apr;267(4):631-637. [PMC free article: PMC5865487] [PubMed: 28796014]

Turk E, Acimis NM, Karaca F, Edirne Y, Tan A, Kilic C. The effect on postoperative pain of pulling the rectus muscle medially during open appendectomy surgery. Minerva Chir. 2014 Jun;69(3):141-6. [PubMed: 24970302]

Hucl T, Benes M, Kocik M, Splichalova A, Maluskova J, Krak M, Lanska V, Heczkova M, Kieslichova E, Oliverius M, Spicak J. Comparison of Inflammatory Response to Transgastric and Transcolonic NOTES. Gastroenterol Res Pract. 2016;2016:7320275. [PMC free article: PMC4923531] [PubMed: 27403157]

Khashab MA, Kalloo AN. NOTES: current status and new horizons. Gastroenterology. 2012 Apr;142(4):704-710.e1. [PubMed: 22349111]

Ahmed K, Wang TT, Patel VM, Nagpal K, Clark J, Ali M, Deeba S, Ashrafian H, Darzi A, Athanasiou T, Paraskeva P. The role of single-incision laparoscopic surgery in abdominal and pelvic surgery: a systematic review. Surg Endosc. 2011 Feb;25(2):378-96. [PubMed: 20623239]

Jiang J, Wu Y, Tang Y, Shen Z, Chen G, Huang Y, Zheng S, Zheng Y, Dong R. A novel nomogram for the differential diagnosis between advanced and early appendicitis in pediatric patients. Biomark Med. 2019 Oct;13(14):1157-1173. [PubMed: 31559834]

Van de Moortele M, De Hertogh G, Sagaert X, Van Cutsem E. Appendiceal cancer : a review of the literature. Acta Gastroenterol Belg. 2020 Jul-Sep;83(3):441-448. [PubMed: 33094592]

Zhang K, Meyerson C, Kassardjian A, Westbrook LM, Zheng W, Wang HL. Goblet Cell Carcinoid/Carcinoma: An Update. Adv Anat Pathol. 2019 Mar;26(2):75-83. [PubMed: 30601149]

Marte A, Sabatino MD, Cautiero P, Accardo M, Romano M, Parmeggiani P. Unexpected finding of laparoscopic appendectomy: appendix MALT lymphoma in children. Pediatr Surg Int. 2008 Apr;24(4):471-3. [PubMed: 17628810]

Xie X, Zhou Z, Song Y, Li W, Diao D, Dang C, Zhang H. The Management and Prognostic Prediction of Adenocarcinoma of Appendix. Sci Rep. 2016 Dec 16;6:39027. [PMC free article: PMC5159879] [PubMed: 27982068]

Morano WF, Gleeson EM, Sullivan SH, Padmanaban V, Mapow BL, Shewokis PA, Esquivel J, Bowne WB. Clinicopathological Features and Management of Appendiceal Mucoceles: A Systematic Review. Am Surg. 2018 Feb 01;84(2):273-281. [PubMed: 29580358]

Gorter RR, Eker HH, Gorter-Stam MA, Abis GS, Acharya A, Ankersmit M, Antoniou SA, Arolfo S, Babic B, Boni L, Bruntink M, van Dam DA, Defoort B, Deijen CL, DeLacy FB, Go PM, Harmsen AM, van den Helder RS, Iordache F, Ket JC, Muysoms FE, Ozmen MM, Papoulas M, Rhodes M, Straatman J, Tenhagen M, Turrado V, Vereczkei A, Vilallonga R, Deelder JD, Bonjer J. Diagnosis and management of acute appendicitis. EAES consensus development conference 2015. Surg Endosc. 2016 Nov;30(11):4668-4690. [PMC free article: PMC5082605] [PubMed: 27660247]

Smith MP, Katz DS, Lalani T, Carucci LR, Cash BD, Kim DH, Piorkowski RJ, Small WC, Spottswood SE, Tulchinsky M, Yaghmai V, Yee J, Rosen MP. ACR Appropriateness Criteria® Right Lower Quadrant Pain--Suspected Appendicitis. Ultrasound Q. 2015 Jun;31(2):85-91. [PubMed: 25364964]

Schoel L, Maizlin II, Koppelmann T, Onwubiko C, Shroyer M, Douglas A, Russell RT. Improving imaging strategies in pediatric appendicitis: a quality improvement initiative. J Surg Res. 2018 Oct;230:131-136. [PubMed: 30100029]

Zosimas D, Lykoudis PM, Pilavas A, Burke J, Leung P, Strano G, Shatkar V. Open versus laparoscopic appendicectomy in acute appendicitis: results of a district general hospital. S Afr J Surg. 2018 Jun;56(2):59-62. [PubMed: 30010266]

Schneuer FJ, Adams SE, Bentley JP, Holland AJ, Huckel Schneider C, White L, Nassar N. A population-based comparison of the post-operative outcomes of open and laparoscopic appendicectomy in children. Med J Aust. 2018 Jul 16;209(2):80-85. [PubMed: 29976133]