Appendicitis

Nursing, Medical Surgical Nursing, Gastroenterology

1. SEMINAR ON APPENDICITIS By: Mr. RAHUL RANJAN M.Sc Nursing 2 nd Year

2. LEARNING OBJECTIVES On the completion of this seminar, the learner will be able to: Introduce the topic Appendix Define the topic Appendicitis Relate the epidemiology of Appendicitis Discuss the causes of appendicitis Describe pathophysiology of appendicitis

3. Cont .. 6. Enlist the types of appendicitis 7. Distinguish clinical manifestations of appendicitis 8. Demonstrate the assessment of patient with Appendicitis 9. Identify the management of Appendicitis 10. Design the nursing management of Appendicitis 11. Evaluate the complications of appendicitis

4. INTRODUCTION The appendix is a small, pouch-like sac of tissue that is located in the first part of the colon (cecum) in the lower- right abdomen. Vermiform appendix, is a vestigial hollow tube that is closed at one end and is attached at the other end to the cecum, a pouch like beginning of the large intestine into which the small intestine empties its contents. The function of the appendix is unknown.

5. Cont .. 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 receives its blood supply via the appendicular artery (derived from the ileocolic artery), and drains through the appendicular vein.

6. DEFINITION Appendicitis is an inflammation of appendix that develops most common in adolescents and young adults. Appendicitis is acute inflammation of the appendix, and is the most common cause for acute, severe abdominal pain. The abdomen is most tender at McBurney’s point – one third of the distance from the right anterior superior iliac spine to the umbilicus. This corresponds to the location of the base of the appendix

7. EPIDEMIOLOGY Approximately 9% of men and 7% of women will experience an episode during their lifetime. Appendicitis is more common in males, in those aged 21-30 years and in females, in those aged 11-20 years. Approximately 20% of all patients have evidence of perforation at presentation, but the percentage risk is much higher in patients under 5 or over 65 years of age. India: The overall lifetime risk of developing acute appendicitis is 8.6% for males and 6.7% for females. Current annual incidence is 10 cases per 10,0000 population.

8. RISK FACTORS Infection, possibly stomach infection that has traveled to the site of appendix. Obstruction such as a hard piece of stool getting trapped in the appendix leading to infection of the appendix. Extreme of age Previous abdominal surgery Position of Appendix ( Retrocecal 56.5%), HTN (15.5%), CAD (9.0%), DM (11.0%) ( Naderan , M. et al 2016)

9. CAUSES Acute appendicitis seems to be the end result of a primary obstruction of the appendix. Once this obstruction occurs, the appendix becomes filled with mucus and swells. This continued production of mucus leads to increased pressures within the lumen and the walls of the appendix. The increased pressure results in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow.

10. Common Causes 1. Fecal impaction and/or a fecality A layered buildup of calcium salts and fecal debris around a piece of fecal material within the appendix 2. Lymphoid Hyperplasia The appendix contains lymphoid (immune system) tissue that can become inflamed as a result of infection or inflammatory bowel disease (IBD) 3. Parasites Examples: Schistosomes species, pinworms, Strongyloides , stercoralis

11. Uncommon Causes: 1. Tumors 2. Foreign Material A wide variety of foreign objects can become lodged in the appendix. Some of these include: shotgun pellets, intrauterine devices, tongue studs, and activated charcoal T rauma , intestinal worms, lymphadenitis

12. TYPES Acute Appendicitis: Acute appendicitis, as its name implies, develops very fast, usually in a span of several days or hours. It is easier to detect and requires prompt medical treatment, usually surgery. Acute appendicitis occurs when the vermiform appendix is completely obstructed, either because of a bacterial infection, feces or other types of blockage. Infection may also cause swelling of the lymph nodes, which then adds pressure on the appendix, cutting off its blood supply.

13. Cont.. Appendicitis Can Be Chronic (But It's a Rare Condition) Chronic appendicitis is an inflammation that can last for a long time. This is rare according to a report published in Therapeutic Advances in Gastroenterology, it only occurs in only 1.5 percent of recorded acute appendicitis cases. Basically, chronic appendicitis means that the appendiceal lumen is only partially obstructed, causing inflammation. The inflammation worsens over time, causing internal pressure to buildup.

14. Cont.. Stump Appendicitis: A Rare Appendectomy Side Effect In most instances of appendicitis, an appendectomy is the usual procedure recommended, and it works by completely taking out the appendix to prevent it from rupturing. If the appendix has already ruptured, additional treatment measures are performed during an appendectomy, as the infection needs to be prevented from spreading.

15. CLINICAL MANIFESTATIONS Local tenderness is elicited at McBurney’s point when pressure is applied. Rebound tenderness ( ie , production or intensification of pain when pressure is released) may be present. Symptoms Abdominal pain >95% Anorexia >70% Constipation 4-16% Diarrhea 4-16%

16. Cont... Fever 10-20% Migration of pain to right lower quadrant 50-60% Nausea Vomiting >65%

17. Signs Abdominal tenderness >95% Right lower quadrant tenderness >90% Rebound tenderness 30-70% Rectal tenderness 30-40% Cervical motion tenderness 30% Rigidity 10%

18. Cont … Psoas sign 3-5% Obturator sign 5-10% Rovsing's sign 5% Palpable mass <5%

19. ASSESSMENT AND DIAGNOSTIC FINDINGS

20. Cont.. Rovsing’s sign: Palpating in the left lower quadrant causes pain in the right lower quadrant Obturator’s sign: Internal rotation of the hip causes pain, suggesting the possibility of an inflamed appendix located in the pelvis

21. Dunphy's sign: Increased pain in the right lower quadrant with coughing . Iliopsoas sign: Extending the right hip causes pain along posterolateral back and hip , suggesting Retrocecal appendicitis.

22. Sitkovskiy (Rosenstein)'s sign: Increased pain in the right iliac region as the person is being examined lies on his/her left side.

23. Diagnosis Diagnosis is based on results of a complete physical examination and on laboratory and x-ray findings. The complete blood cell count demonstrates an elevated white blood cell count. The leukocyte count may exceed 10,000 cells/mm3, and the neutrophil count may exceed 75%.

24. ALVARADO SCORE The Alvarado score is the most widely used scoring system. A score below 5 suggests against a diagnosis of appendicitis, whereas a score of 7 or more is predictive of acute appendicitis

25. Abdominal x-ray films

26. Ultrasound studies Aperistaltic , non-compressible, dilated appendix (>6 mm outer diameter) Distinct appendiceal wall layers Periappendiceal fluid collection/enlargement

27. CT scans Dilated appendix with distended lumen ( >6 mm diameter) Thickened and enhancing wall Thickening of the caecal apex (up to 80%)

28. MANAGEMENT Surgery is indicated if appendicitis is diagnosed. To correct or prevent fluid and electrolyte imbalance and dehydration, antibiotics and intravenous fluids are administered until surgery is performed. Analgesics can be administered after the diagnosis is made. (Morphine sulphate 10 mg/ml) Antibiotics Cefotaxime 250mg, 500mg Levofloxacin 500 mg Metronidazole 500mg/100ml, 400 mg tablet

29. Appendectomy ( ie , surgical removal of the appendix) is performed as soon as possible to decrease the risk of perforation. It may be performed under a general or spinal anesthetic with a low abdominal incision or by laparoscopy.

30. Open Appendectomy

31. https:// www.youtube.com/watch?v=E1ljClS0DhM https :// www.youtube.com/watch?v=18eYVp244mQ

32. NURSING MANAGEMENT Goals include relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating infection from the potential or actual disruption of the GI tract, maintaining skin integrity, and attaining optimal nutrition. The nurse prepares the patient for surgery, which includes an intravenous infusion to replace fluid loss and promote adequate renal function and antibiotic therapy to prevent infection.

33. Pre-Operative care: Assessment History taking physical examinations, Regarding pain, nausea vomiting, abdominal rebound tenderness, Anorexia Monitor vital signs B.P., Temperature for baseline data NPO and I.V. Fluids be started Naso -gastric aspiration Monitor for signs of ruptured appendix and peritonitis Position right-side lying or low to semi fowler position to promote comfort.

34. Cont.. Auscultate Bowel Sounds Administer antibiotics as prescribed Preparation for surgery i.e. physically & psychologically Alley anxiety & fears Written consent for surgery Prepare and send the patient for surgery without delay OT clothes and pre medications to be given 45 minutes before operation

35. Post-Operative Nursing care: Clear airway Proper breathing and adequate tissue perfusion by IVF Naso -gastric suction to be done regularly to relieve tension on sutures Provide safety & effective care environment to the patient Care of all drainage tubes Care of surgical wounds. Watch for soapage /bleeding Daily A.S. dressing and watch for signs of infections Nutritional status maintained by I.V. fluids

36. Observe for return of bowel sounds, Intake and output maintained Monitor vital signs & fluid, electrolytes balance Encourage early ambulation to prevent post operation complications. Maintain NPO till bowel sounds return then start clear fluids orally Medication as per prescription to be given by using 6 rt of Nursing standards of medication Drugs – Antibiotics, analgesic & Anticholenergies i.e. Injection Aciloc as per prescription After surgery, the nurse places the patient in a semi-Fowler position. This position reduces the tension on the incision and abdominal organs, helping to reduce pain.

37. NURSING DIAGNOSIS Acute Pain May be related to, Distension of intestinal tissues by inflammation, Presence of surgical incision Risk for Fluid Volume Deficit , Risk factors may include, Preoperative vomiting, postoperative restrictions (e.g., NPO), Hypermetabolic state (e.g., fever, healing process) Inflammation of peritoneum with sequestration of fluid Risk for Infection , Risk factors may include, Inadequate primary defenses; perforation/rupture of the appendix; peritonitis; abscess formation, Invasive procedures, surgical incision Deficient Knowledge May be related to Lack of exposure/recall; information misinterpretation, Unfamiliarity with information resources

38. Discharge and Home Healthcare Guidelines MEDICATIONS. Be sure the patient understands any pain medication prescribed, including doses, route, action, and side effects. INCISION. Sutures are generally removed in the physician’s office in 5 to 7 days. COMPLICATIONS. Instruct the patient that a possible complication of appendicitis is peritonitis. NUTRITION. Instruct the patient that diet can be advanced to her or his normal food pattern as long as no gastrointestinal distress is experienced.

39. SUMMARY

40. CONCLUSION Appendicitis is a condition that is prevalent in the developed world and should have minimal complications. Surgical action should be taken without delay. If left untreated there is a risk of peritonitis, which is the main complication of this condition. Medical awareness of appendicitis has improved and complications are less common.

41. REFERENCES Smeltzer , S.C, Bare, B.G, Hinkle, J.L, Cheever,K.H , (2010), Brunner and Suddarth’s Textbook of Medical Surgical Nursing (12th ed .), LippincottWilliams and Wilkins , 976-1067 Longo,D.L , Kasper,D.L , Fauci,A.S , Hauser,S.L , et al.(2012), Harrison’s Principles of Internal Medicine (18th ed ), McGraw Hill Companies , Inc.Vol .(1), 299-322 Jayce, M, Black, et al. (2004), Medical Surgical Nursing, Published by Saunder’s Company , 7th Edition-, PP 809-14 Teach me anatomy (2017), The cecum and appendix, Retrieved from: http://teachmeanatomy.info/abdomen/gi-tract/cecum appendix/

42. Any questions ?

43. Thank You!