Kimberly Henry, RNC, FNP-S
SUNY Institute of Technology
Nursing 652
Thought to be obstruction of appendiceal lumen
↓
Inflammation
↓
Ischemia
↓
Perforation
↓
Abscess formation or Generalized Peritonitis
Pediatrics

Lymphoid hyperplasia
due to infections
Adults



Fecaliths (hard fecal
masses)
Calculi
Benign or malignant
tumors

1st degree relative with history of appendicitis

10-19 year old age group

Male (2:1)

Intra-abdominal tumors

Parasites
Classic presentation consists of vague
periumbilical pain which later migrates to RLQ as
inflammation progresses (within 4-48hrs)
 May or may not have a fever
 Anorexia
 Nausea or/or vomiting (after the onset of pain)
 Pain which is exacerbated by walking or
coughing
 Nonspecific signs: indigestion, flatulence, bowel
irregularity, diarrhea, generalized malaise


May have tachycardia and hypertension r/t pain
and fever

May display shallow breathing in an attempt to
not cause pain


Psoas sign: Pain when right thigh is extended
(retrocecal appendix) as a result, patient may lie
with knee bent to relieve tension on ilopsoas
muscle
Positive rebound tenderness


Rovsing sign: RLQ pain when palpating LLQ
Obturator sign: Right hip and knee flexed,
then rotated internally stretching obturator
muscle (pelvic appendix)

McBurney’s sign: Pressure applied to
McBurney’s Point

Bowels sounds can be present, absent, or
decreased



Retrocecal appendix: may only produce dull
abdominal tenderness but marked pain
during rectal/pelvic exam
Anterior appendix: Produces marked,
localized pain in the right lower quadrant
Pelvic appendix: Causes tenderness below
McBurney’s point. Also will have pain during
rectal/pevic exam
GI: Gastroenteritis, IBD, Divertulitis, Ileitis,
Cholecystitis, Pancreatitis, bowel obstruction,
Intussusception, Crohn’s Disease,
 Gynecological: PID, Ectopic Pregnancy,
Ruptured Ovarian Cyst, Tubo-Ovarian Cyst,
Ovarian and Fallopian Torsion, Mittelschmerz,
Endometriosis, Acute Endometritis
 Urological: Testicular Torsion, Epididymitis,
Renal Colic, kidney stones, Prostatitis,
Cystitis, Pylenephritis

CBC with Diff: mild to moderate leukocytosis
(10-20,000mcg/L) with a left shift of immature
neutrophils
 U/A: may show hematuria and/or pyuria
 C-Reactive Protein (CPR)- elevation in CPR
coupled with leukocytosis can be an indicator of
appendicitis
 CT scan is the most widely used imaging
modality, but should be used only when
diagnosis is uncertain
 Ultrasound is reliable to confirm, not exclude,
the diagnosis

Migratory right iliac fossa pain 1pt
 Anorexia 1pt
 Nausea/Vomiting 1pt
 Tenderness in RLQ 2pts
 Rebound tenderness 1 pt
 Fever >37.3 1 pt
 Leukocytosis 2pts
 Shift to the left 1 pt

1-4 discharge 5-6 observation/admission
>7 surgery
The standard of care for treating appendicitis
is appendectomy
Preop: NPO, IV fluids, IV antibiotics
Cefoxitin (1-2gms)
Cefazolin (2g if <120kg 3g if >120kg)
PCN and Cephalosporin allergy Clindamycin
900mg plus Gentamycin 5mg/kg
Less likely to present with classic appendicitis
signs
 Due to the enlarging uterus, McBurney’s Point
may be located more toward the mid or upper
right side of the abdomen
 Rebound tenderness and guarding may not
be present (due to uterus size)
 An increased WBC is a normal finding in
pregnancy, with the count rising to ~25,000
during labor

Lack of migratory pain in 50% of patients
 Absent of anorexia, with 50% reporting they are
hungry
 Infants may be lethargic, have increased
irritability with movement, and may flex their
hips for comfort
 Hoping on one foot or coughing usually elicits
abdominal pain
 Neonates display temperature instability
 May limp or have right hip pain
 May have right sided pelvic pain or mass on
palpation or rectal exam

The adult list plus:
 Intussusception
 Intestinal Malrotation
 Torsion of the Omentum
 Hemolytic Uremic Sydrome
 Primary Peritonitis
 Henoch-Schonlein Purpura
 Sickle cell-disease
 UTI




Perforation
Sepsis
Shock
Death
Peds: Rupture earlier and have a rupture rate of
15-60%
Pregnant patients: 40% rupture rate and fetal
mortality rate of 2-8.5%
Geriatrics: Rupture rate of 67-90%
Wound infection (increased risk if no
prophylactic antibiotics)
 Intestinal obstruction
 Paralytic Ileus
 Incisional Hernia
 Preterm labor



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No heavy lifting (>10 lbs) or strenuous
physical activity for 4-6 weeks
May return to work 1-2 weeks
S/S infection