Appendicitis & Appendectomy: Jenny Juniora Ajoc

Appendicitis &
Appendectomy
Jenny Juniora Ajoc
Appendicitis
Appendicitis is an inflammation
of the appendix, a finger-shaped
pouch that projects from your
colon on the lower right side of
your abdomen. Although anyone
can develop appendicitis, most
often it occurs in people between
the ages of 10 and 30. Standard
treatment is surgical removal of
the appendix.
Pathophysiology
The appendix is a small, vermiform (wormlike) appendage about 8-10
cm long that is attached to the cecum just below the ileocecal valve.
The appendix fills with by-products of digestion 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. The appendix becomes inflamed and edematous as a result
of becoming kinked or occluded by a fecalith, lymphoid hyperplasia, or
foreign bodies (e.g., fruit seeds) or tumors. The inflammatory process
increases intraluminal pressure, causing edema and obstruction of the
orifice. Once obstructed, the appendix becomes ischemic, bacterial
overgrowth occurs, and eventually, gangrene or perforation occurs.
Symptoms
Sudden pain that begins on the right side of the lower abdomen
Sudden pain that begins around your navel and often shifts to your
lower right abdomen
Pain that worsens if you cough, walk or make other jarring movements
Nausea and vomiting
Loss of appetite
Low-grade fever that may worsen as the illness progresses
Constipation or diarrhea
Abdominal bloating
Flatulence
Assessment
Psoas Sign
Psoas sign is elicited by having the patient lie on his or her left side
while the right thigh is flexed backward. Pain may indicate an
inflamed appendix overlying the psoas muscle. The psoas sign, also
known as Cope's psoas test or Obraztsova's sign, is a medical sign
that indicates irritation to the iliopsoas group of hip flexors in the
abdomen.
Assessment
Assessment
Rovsing's Sign
This is positive when pressure over the patient’s left lower quadrant
causes pain in the right lower quadrant. It is also referred to as the
Perman-Rovsing sign, or the Perman sign. Rovsing suggests that if
pain is elicited, then this isolates the source to the caecum or
appendix, and rules out other structures in the right iliac fossa.
Assessment
Rovsing's Sign
Assessment
Obturator's Sign
This is an indicator of irritation to the obturator internus muscle. The
technique for detecting the obturator sign is carried out on each leg in
succession. The patient lies on their back with the hip and knee both flexed
at 90 degrees. The examiner holds the patient's ankle with one hand and the
knee with the other. The examiner internally rotates the hip by moving the
patient's ankle away from their body while allowing the knee to move only
inward. The appendix may come into physical contact with the obturator
internus muscle, which will be stretched when this maneuver is performed
on the right leg. This causes pain and is evident of an inflamed appendix. The
principles of the obturator sign are similar to that of the psoas sign.
Assessment
Assessment
McBurney's Point
McBurney's point is the most tender area of the abdomen of
patients in the case of appendicitis. Dr. McBurney in 1889 showed
that incipient appendicitis could be detected by applying pressure to
a particular point in the right lower abdomen, an area he called the
"seat of greatest pain." Five years later, Dr. McBurney described the
surgical incision he made in the right lower part of the abdomen to
remove the inflamed appendix. This is now referred to as
"McBurney's incision."
Assessment
Laboratory Findings
The CBC demonstrates an elevated white blood cell count with an
elevation of the neutrophils. C-reactive protein levels are typically
elevated. A CT scan may reveal a right lower quadrant density or
localized distention of the bowel; enlargement of the appendix by at
least 6 mm is suggestive of appendicitis.
A pregnancy test may be ordered for women of childbearing age to

rule out ectopic pregnancy and before radiologic studies are done.
Complications
Left untreated, an inflamed appendix will burst, spilling
bacteria and debris into the abdominal cavity, the central part
of your body that holds your liver, stomach, and intestines.
This can lead to peritonitis, a serious inflammation of the
abdominal cavity's lining (the peritoneum). It can be deadly
unless it is treated quickly with strong antibiotics.
Surgical
Intervention:
Appendectomy
Definition
An appendectomy is the surgical removal of the appendix,

which is located in the right lower side of the abdomen. This
operation is usually carried out on an emergency basis to
treat appendicitis (inflamed appendix). This may occur as a
result of an obstruction in part of the appendix. Another
name for this operation is an appendicectomy.
Definition
Some patients may have abscess formation that involves the

cecum and/or terminal ileum. In these selected cases,
appendectomy may be deferred until the mass is drained.
Most commonly, these abscesses are drained percutaneously
or surgically. The patient continues to receive treatment with
antibiotics. After the abscess is drained and there is no further
evidence of infection, an appendectomy is then performed
Types of Appendectomy
The two main surgical techniques include:
Open appendectomy – an incision is made through the skin, the

underlying tissue and the abdominal wall in order to access the appendix.
Laparoscopic (‘keyhole’) appendectomy – this involves making three

small incisions in the abdomen, through which particular instruments are
inserted. A gas is gently pumped into the abdominal cavity to separate
the abdominal wall from the organs. This makes it easier to examine the
appendix and internal organs.
Pre-operative
Maintain NPO status.
Administer fluids intravenously to prevent dehydration.
Monitor for changes in level of pain.
Monitor for signs of ruptured appendix and peritonitis
Position right-side lying or low to semi fowler position to promote comfort.
Monitor bowel sounds.
Apply ice packs to abdomen every hour for 20-30 minutes as prescribed.
Administer antibiotics as prescribed
Avoid the application of heat in the abdomen.
Avoid laxatives or enema.
Perform pre-operative assessment and accomplish forms.
Intraoperative
Intraoperative
Intraoperative
Intraoperative
1. An incision is made in the right lower abdomen, either transversely oblique

(McBurney) or vertically (for a primary appendectomy).
2. The surgeon’s assistant retracts the wound edges with a Richardson or
similar retractor.
3. The appendix is identifies and its vascular supply ligated.
4. The surgeon grasps the appendix with a Babcock clamp, and delivers it into
the wound site.
Intraoperative
5. The tip of the appendix may then be grasped with a Kelly clamp to hold it up,
and a moist Lap sponge is placed around the base of the appendix (stump) to
prevent contamination of bowel contents, in case any spill out occurs during the
procedure.
6. The surgeon isolates the appendix from its attachments to the bowel
(mesoappendix) using a Metzenbaum scissors.
Intraoperative
7. Taking small bits of tissue along the appendix, the mesoappendix is double-
clamped, and ligated with free ties.
8. The base of the appendix is grasped with a straight Kelly clamp, and the
appendix is removed.
9. The stump may be inverted into the cecum, using a purse-string suture on a
fine needle, cauterize with chemicals, or simply left alone after ligation.
10. Another technique is to devascularize the appendix and invert the entire
appendix into the cecum.
Intraoperative
11. The appendix, knife, needle holder, and any clamps or scissors that have
come in contact with the appendix are delivered in a basin in the circulating
nurse.
12. The wound is irrigated with warm saline, and is closed in layers, except
when an abscess has occurred, as with acute appendicitis.
13. A drain may be placed into the abscess cavity, exiting through the incision or
a stab wound.
Intraoperative
14. An alternative technique may be use the internal stapling device, by placing
the stapling instrument around the tissue at the appendiocecum junction.
15. By using the technique, the possibility of contamination from spillage is
greatly reduced.
Postoperative
the nurse places the patient in a high Fowler position. This position reduces
the tension on the incision and abdominal organs, helping to reduce pain.
Monitor temperature for signs of infection.
Assess incision for signs of infection such as redness, swelling, and pain.
Maintain NPO status until bowel function has returned.
Auscultate for return of bowel sounds.
Advance diet gradually or as tolerated or as prescribed when bowel sound
returns.
If a ruptured appendix occurred, expect a Penrose drain to be inserted, or the
incision may be left to heal inside out.
Postoperative
Expect that drainage from the Penrose drain may be profuse for the first 2
hours.
The patient may be discharged by the physician on the day of surgery if the
temperature is within normal limits, there is no undue discomfort in the
operative area, and the appendectomy was performed laparoscopically. The
nurse instructs the patient to make an appointment to have the surgeon
remove any sutures and inspect the wound between 1 and 2 weeks after
surgery
Incision care and activity guidelines are discussed; heavy lifting is to be
avoided postoperatively, although normal activity can usually be resumed
within 2 to 4 weeks.
Postoperative
Documentation Guidelines:
Location, intensity, frequency, and duration of pain

Response to pain medication, ice applications, and position changes
Patient’s ability to ambulate and tolerate food
Appearance of abdominal incision (color, temperature, intactness, drainage)

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Appendicitis &

A pregnancy test may be ordered for women of childbearing age to

An appendectomy is the surgical removal of the appendix,

Some patients may have abscess formation that involves the

Open appendectomy – an incision is made through the skin, the

Laparoscopic (‘keyhole’) appendectomy – this involves making three

1. An incision is made in the right lower abdomen, either transversely oblique

Location, intensity, frequency, and duration of pain

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