the appendix

Appendix
The appendix is a small, finger-like appendage 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 (ie, appendicitis).
Appendicitis is inflammation of the vermiform appendix caused by an obstruction of the intestinal lumen from infection, stricture, fecal mass, foreign body, or tumor.
It’s the most common reason for emergency abdominal surgery. Males are affected more than females and teenagers more than adults.
Pathophysiology/Etiology
1. Obstruction is followed by edema, infection, and ischemia.
2. As intraluminal tension develops, necrosis and perforation usually occur.
3. Appendicitis can affect any age group, but is most common in males 10 to 30 years old.
Clinical Manifestations
1. Generalized or localized abdominal pain in the epigastric or periumbilical areas and the upper right abdomen. Within 2 to 12 hours, the pain localizes in the right lower quadrant and intensity increases.
2. Anorexia, moderate malaise, mild fever, nausea and vomiting.
3. Usually constipation occurs; occasionally diarrhea.
4. Positive Physical examination.
Physical examination
1. Rebound tenderness: deep palpate on right lower quadrant, and then remove hand quickly.
2. Rovsing's sign: deep palpate on left lower quadrant, and then remove hand quickly.
3. Psoas sign: place hand above right pt's knee and ask the pt to flex his thigh.
4. Obturator sign: flex the pt's right thigh and rotate the leg internally.
5. Cutaneous hyperesthesia: fold the abdomen skin without pinching.
à Appendicitis pt in all last technique feels painful in the side of inflammation.
Diagnostic Evaluation
1. Physical examination consistent with clinical manifestations.
2. Elevated white blood cell count. The leukocyte count may exceed 10,000 cells/mm3, and the neutrophil count may exceed 75%.
3. Abdominal x-ray films, ultrasound studies, and CT scans may reveal a right lower quadrant density or localized distention of the bowel.
Management
-Surgery
a. Simple appendectomy or laparoscopic appendectomy.
b. Preoperatively maintain bed rest, NPO status, IV hydration, possible antibiotic prophylaxis, and analgesia.
Complications
1. Perforation (in 95% of cases)
2. Abscess
3. Peritonitis
Nursing Assessment
1. Obtain history for location and extent of pain.
2. Auscultate for presence of bowel sounds; peristalsis may be absent or diminished.
3. On palpation of the abdomen, assess for tenderness anywhere in the right lower quadrant, but often localized over McBurney’s point (point just below midpoint of line between umbilicus and iliac crest on the right side). Assess for rebound tenderness in the right lower quadrant as well as referred rebound when palpating the left lower quadrant.
4. Assess for positive psoas sign by having the patient attempt to raise the right thigh against the pressure of your hand placed over the right knee. Inflammation of the psoas muscle in acute appendicitis will increase abdominal pain with this maneuver.
5. Assess for positive obturator sign by flexing the patient’s right hip and knee and rotating the leg internally. Hypogastric pain with this maneuver indicates inflammation of the obturator muscle.
Nursing alert:
Do not give antipyretics to mask fever and do not administer cathartics, because they may cause rupture.
Preoperative nursing care is listed; for postoperative care
Preoperative Management/ Nursing Care
1. Explain all diagnostic tests and procedures to promote cooperation and relaxation.
2. Describe the reason for and type of surgical procedure as well as postoperative care.
3. Explain the rationale for deep breathing, and teach the patient how to turn, cough, deep-breathe, and splint the incision. These measures will minimize postoperative complications.
4. Administer IV fluids or total parenteral nutrition (TPN) before surgery, as ordered, to improve fluid and electrolyte balance and nutritional status.
5. Monitor intake and output.
6. Send blood samples, as ordered, for preoperative laboratory studies, and monitor results.
7. Administer antibiotics, as ordered, to decrease the bacterial growth in the colon.
8. Explain that patient may not have anything by mouth after midnight the night before surgery. Medications may be withheld, if ordered. This will keep the GI tract clear.
Postoperative Management/Nursing Care
1. Complete a physical assessment at least once per shift, or more frequently, as indicated.
a. Monitor vital signs for signs of infection and shock—fever, hypotension, tachycardia.
b. Monitor intake and output for signs of imbalance, dehydration, and shock. Include all drains in evaluating intake and output.
c. Assess abdomen for increased pain, distention, rigidity, and rebound tenderness, because these may indicate postoperative complications. Report abnormal findings.
d. Expect diminished or absent bowel sounds in the immediate postoperative phase.
e. Evaluate dressing and incision. Check for purulent or bloody drainage, odor, and unusual tenderness or redness at incision site, which may indicate bleeding or infection.
f. Evaluate for passing of flatus or feces.
g. Monitor for nausea and vomiting. Note the presence of fecal smell or material in vomitus, because it may indicate an obstruction.
3. Monitor lab values and assess patient for signs and symptoms of electrolyte imbalance.
4. Maintain wound drains, IVs, and all other catheters. Assess sites for signs of infection or infiltration.
5. Encourage and assist patient with turning, coughing, deep breathing, and incentive spirometry every 2 hours. Assist patient to dangle at bedside the night of surgery and attempt ambulation the first postoperative day, unless ordered otherwise.
6. Instruct patient on use of patient-controlled analgesia for pain control, or provide other analgesics, as ordered, to promote comfort. 7. Change wound dressing every day or as needed, maintaining aseptic technique. 8. Advance diet as ordered, after presence of bowel sounds indicates GI tract has regained motility. the usual diet progression is ice chips, sips of water, clear liquids, full liquids, or soft or regular diet. 9. Teach dietary habits to include fiber, avoid gas-producing foods, and maintain adequate fluid intake.
10. Administer medications, as ordered, which may include a stool softener or laxative when bowel function has returned.