Appendicitis and Appendectomy

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Chapter 4 Appendicitis and Appendectomy

PATHOPHYSIOLOGY

Appendicitis is the most common condition requiring emergency abdominal surgery during childhood. Acute appendicitis is caused by the obstruction of the appendiceal lumen, resulting in compression of the blood vessels. Obstruction of the lumen can be caused by hyperplasia of the submucosal lymphoid tissue, appendiceal fecaliths, foreign bodies, and/or parasites. Bacteria then invade the layers of the appendiceal wall, causing local inflammation (acute appendicitis). Perforated appendicitis occurs when the inflamed wall becomes necrotic and “bursts” (perforates), resulting in peritonitis. In most cases, no definitive cause can be identified at the time of surgery. The prognosis is excellent, especially when surgery is performed before perforation occurs.

INCIDENCE

1. Approximately 80,000 children experience appendicitis per year.

2. Occurs in 1 per 1000 children younger than 14 years old

3. Incidence highest in later childhood, age 10 to 12 years.

4. Occurrence is unusual in children younger than 4 years of age and is rare in children younger than 1 year old.

5. Likelihood of perforation is related to age—it occurs more frequently in younger children, most probably because of difficulty in diagnosis.

6. Slightly higher incidence in males.

CLINICAL MANIFESTATIONS

1. Classic triad

a. Pain—cramping located in periumbilical area migrating to right lower quadrant, with most intense pain at McBurney’s point (located midway between right anterior superior iliac crest and umbilicus)
b. Vomiting (common early sign; less common in older children)
c. Fever—low-grade early in disease; can rise sharply with peritonitis

2. Anorexia

3. Nausea

4. Rebound tenderness

5. Decreased or absent bowel sounds

6. Constipation

7. Diarrhea (small, watery evacuations)

8. Difficulty walking or moving

9. Irritability

COMPLICATIONS

(In the absence of proper diagnosis or delay in treatment)

1. Perforation

2. Peritonitis

3. Abscess formation

4. Adhesions

5. Bowel obstruction

6. Death

LABORATORY AND DIAGNOSTIC TESTS

1. Complete blood count—leukocytosis, neutrophilia, absence of eosinophils

2. Urinalysis—to exclude urinary tract infection

3. Abdominal radiographic study—concave curvature of spine to right, calcified fecaliths

4. Ultrasonography (test of choice)—noncalcified fecaliths, nonperforated appendix, appendiceal abscess

5. Computed tomographic (CT) scan of abdomen—provides differential diagnosis for abdominal pain

SURGICAL MANAGEMENT

Children with suspected appendicitis are admitted to hospital for observation and are given antibiotics and intravenous (IV) fluids to correct electrolyte imbalances, especially if dehydrated; the rapid progression of symptoms will make the diagnosis obvious. A nasogastric tube is inserted if the child is vomiting. The child is taken to surgery, where the appendix is removed by one of two ways: (1) by open appendectomy, through an incision in the right lower quadrant; or (2) laparoscopically, which has been shown to reduce length of hospital stay. Perforated appendicitis is generally treated surgically: the appendix is removed, and the abdominal cavity is irrigated. A drain may be inserted and the wound left open to prevent wound infection and abscess formation. In some cases, a small catheter may be left in place to instill antibiotics. Postoperatively the child is put in semi-Fowler position for the first 24 hours. Gastric drainage and administration of IV fluids and antibiotics are continued. Narcotic and/or analgesic medications are used for pain. Oral feedings are started within 1 or 2 days and increased as tolerated when bowel function has returned. Interval appendectomy (medical therapy) is another treatment for perforated appendicitis: the child receives IV antibiotics for a determined length of time and is then scheduled to return for an elective appendectomy 4 weeks to 3 months after completion of antibiotic therapy.

NURSING ASSESSMENT

1. See the Gastrointestinal Assessment section in Appendix A.

2. Assess for rapid progression in severity of symptoms.

3. Assess for preoperative and postoperative pain.

4. Assess for symptoms of perforation, including sudden relief from pain.

5. Assess postoperatively for bowel sounds and abdominal distention.

6. Assess wound for drainage and signs of infection.

NURSING DIAGNOSES

• Pain, Acute

• Fluid volume, Risk for deficient

• Infection, Risk for

• Injury, Risk for

• Nutrition: less than body requirements

• Anxiety

• Knowledge, Deficient

• Family processes, Interrupted

NURSING INTERVENTIONS

Preoperative Care

1. Provide pain relief and comfort measures.

a. Positioning for comfort.
b. Avoidance of unnecessary movements and unnecessary palpation of abdomen.
c. Administration of pain medications as ordered.

2. Maintain fluid and electrolyte balance.

a. Maintain nothing by mouth (NPO) status.
b. Monitor infusion of IV solution at maintenance rate.
c. Monitor and record output of vomitus, urine, stool, and nasogastric drainage.

3. Monitor child’s status for progression of symptoms and complications.

a. Signs of shock—decreased blood pressure, decreased respiratory rate, pallor, diaphoresis, rapid and thready pulse.
b. Perforation or peritonitis—sudden relief from pain with subsequent increase of diffuse pain with rigid guarding of abdomen, absent bowel sounds, increased apical pulse, increased temperature, rapid and shallow breathing, abdominal splinting, pallor, chills, irritability, restlessness.
c. Intestinal obstruction—decreased or absent bowel sounds, abdominal distention, pain, vomiting, no stools.

4. Prepare child for surgery.

a. Maintain NPO status.
b. Administer antibiotics if ordered.
c. Collect specimens preoperatively for analysis.
d. Prepare child for and support child during laboratory and diagnostic testing.
e. Explain anticipated preoperative and postoperative events (e.g., dressing, nasogastric tube).

Postoperative Care

1. Assess pain and institute pain relief measures as needed.

a. Administer analgesics as needed.
b. Use distraction to alleviate pain.
c. Use comfort measures such as cold and positioning (e.g., right side–lying or low Fowler’s to semi-Fowler position).

2. Prevent and monitor for abdominal distention.

a. Maintain NPO status.
b. Maintain patency of nasogastric tube.
c. Monitor output of nasogastric tube (amount, color).
d. Assess abdominal tenseness (firm, soft).

3. Monitor hydration and nutritional status.

a. Monitor intake and output.
b. Maintain NPO status; then advance as tolerated.
c. Maintain total parenteral nutrition if child is unable to eat for several days.
d. Maintain IV infusions and IV site as ordered.

4. Promote and maintain respiratory function.

a. Have child turn, cough, and deep breathe.
b. Perform postural drainage and percussion.
c. Change child’s position every 2 hours.
d. Keep head of bed in semi-Fowler position.

5. Monitor for signs of infection, and prevent spread of infection.

a. Monitor vital signs as ordered.
b. Observe wound for signs of infection—warmth, drainage, pain, swelling, and redness.
c. Administer antibiotics; monitor child’s response.
d. Perform wound care as indicated and dispose of dressings appropriately.
e. Encourage ambulation and have child ambulate when able.

6. Promote wound healing.

a. Perform wound care—maintain site, keeping it clean and dry.
b. Position child in semi-Fowler position to promote drainage if drain is present.

7. Support child and parents to help them deal with emotional stresses of hospitalization and surgery.

a. Provide age-appropriate information before and after procedures.
b. Encourage quiet diversional activities.
c. Promote family contacts and visits with peers.
d. Incorporate child’s home routine into daily activities.

Discharge Planning and Home Care

1. Instruct parents to observe for and report signs of complications.

a. Infection
b. Obstruction

2. Instruct parents regarding wound care.

3. Involve discharge planning team (such as social worker) if patient is to be discharged with orders for home IV antibiotic therapy.

4. Instruct parents to have child avoid strenuous activities for a few weeks.

5. Instruct parents about follow-up appointment.

a. Name and phone number of physician.
b. Date and time of follow-up appointment.

CLIENT OUTCOMES

1. Child will have return to normal gastrointestinal function, including presurgery dietary intake and normal bowel function.

2. Child will have minimal pain.

3. Child will be free from infection.

4. Child and family will understand home care and follow-up needs.

REFERENCES

Behrman RE, Kiegman R, Jenson HB. Nelson textbook of pediatrics, ed 17. Philadelphia: WB Saunders, 2004.

Chen C, et al. Current practice patterns in the treatment of perforated appendicitis in children. J Am Coll Surg. 2003;196(2):212.

Hockenberry MJ, et al. Wong’s nursing care of infants and children, ed 7. St. Louis: Mosby, 2004.

McCollough M, Sharieff GQ. Abdominal pain in children. Pediatr Clin North Am. 2006;53(1):107.

McCollough M, Sharieff GQ. Abdominal surgical emergencies in infants and young children. Emerg Med Clin North Am. 2003;21(4):909.

Meguerditchian AN, et al. Laparoscopic appendectomy in children: A favorable alternative in simple and complicated appendicitis. J Pediatr Surg. 2002;37(5):695.

Vasavada P. Ultrasound evaluation of acute abdominal emergencies in infants and children. Radiol Clin North Am. 2004;42(2):445.

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