Appendicitis & Peritonitis
Dr. Belal Hijji, RN, PhD
April 25 & 27, 2011
Learning Outcomes
At the end of this lecture, students will be able to:
• Describe the appendix and appendicitis along with
its pathophysiology.
• Identify the clinical manifestations of appendicitis.
• Discuss assessment and diagnostic findings of
appendicitis.
• Describe the medical and nursing care of a patient
with appendicitis.
• Define peritonitis, its pathophysiology, clinical
manifestations, and its diagnosis.
• Discuss the complications, and medical and nursing
management of peritonitis.
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Appendix
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Appendicitis
• The appendix is a small, finger-like tube 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).
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Pathophysiology
• The appendix becomes inflamed and edematous as a
result of either becoming kinked or occluded by a fecalith
(ie, hardened mass of stool), tumor, or foreign body. The
inflammatory process increases intraluminal pressure,
initiating a progressively severe, generalized or upper
abdominal pain that becomes localized in the right lower
quadrant of the abdomen within a few hours.
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Clinical Manifestations
• Epigastric or periumbilical pain progresses to the right
lower quadrant.
• Low-grade fever, nausea and sometimes vomiting. Loss
of appetite.
• Local tenderness is elicited at McBurney’s point when
pressure is applied (next 2 slides).
• Rebound tenderness (ie, production or intensification of
pain when pressure is released) may be present.
• Rovsing’s sign may be elicited by palpating the left lower
quadrant; this causes pain to be felt in the right lower
quadrant.
• If the appendix has ruptured, the pain becomes more
diffuse; abdominal distention develops, and the patient’s
condition worsens.
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Location of McBurney's point (1), located two thirds the distance from
the umbilicus (2) to the anterior superior iliac spine (3).
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Assessment and Diagnostic Findings
• Health history and physical exam.
• Complete blood cell count demonstrates an elevated
white blood cell count (> 10,000 cells/mm3). The
neutrophil count may exceed 75%.
• Abdominal x-ray films, ultrasound studies, and CT scans
may reveal a right lower quadrant density or localized
distention of the bowel.
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Medical Management
• Surgical intervention (appendectomy), next slide, as
soon as possible after diagnosis to decrease the risk of
perforation.
• Before surgery, correction or prevention of fluid and
electrolyte imbalance and dehydration could be through
antibiotics and intravenous fluids.
• Analgesics can be administered after the diagnosis is
made.
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An appendectomy in progress
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Nursing Management
• Prepare the patient for surgery, which includes an
intravenous infusion to replace fluid loss and promote
adequate renal function and antibiotic therapy to prevent
infection.
• Post-operatively, Place the patient in a semi-Fowler
position to reduce the tension on the incision and, thus,
reduce pain.
• Administer pain killers (usually morphine sulfate), as
prescribed.
• Start oral fluids when tolerated and intravenous fluids as
indicated. Food is provided as desired and tolerated on
the day of surgery.
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Nursing Management (Continued…..)
• Instruct the patient to make an appointment to have the
surgeon remove the sutures between the fifth and
seventh days after surgery.
• Teach incision care (dressing) and activity guidelines;
normal activity can usually be resumed within 2 to 4
weeks.
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Peritonitis
• Peritonitis is inflammation of the peritoneum, the serous
membrane lining the abdominal cavity and covering the
viscera.
• It results from bacterial infection; the organisms come
from diseases of the GI tract or, in women, from the
internal reproductive organs.
• Peritonitis can also result from injury or trauma (eg,
gunshot wound, stab wound).
• The most common bacteria implicated are Escherichia
coli, Klebsiella, Proteus, and Pseudomonas.
• Peritonitis may also be associated with abdominal
surgical procedures and peritoneal dialysis.
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Autopsy of infant showing abdominal distension,
intestinal necrosis and hemorrhage, and peritonitis due
to perforation .
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Pathophysiology
• Peritonitis is caused by leakage of contents from
abdominal organs into the abdominal cavity due to
inflammation, infection, ischemia, trauma, or tumor
perforation.
• Edema of the tissues results, and exudation of fluid
develops in a short time. Fluid in the peritoneal cavity
becomes turbid with increasing amounts of protein, white
blood cells, cellular debris, and blood.
• The immediate response of the intestinal tract is
hypermotility, followed by paralytic ileus with an
accumulation of air and fluid in the bowel.
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Clinical Manifestations
• Diffuse abdominal pain is felt. The pain tends to become
constant, localized, and more intense near the site of the
inflammation.
• Movement usually aggravates pain.
• The affected area becomes extremely tender and
distended, and the muscles become rigid.
• Usually, nausea and vomiting occur and peristalsis is
diminished.
• Fever, tachycardia, and leukocytosis.
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Assessment and Diagnostic Findings
• Leukocytosis.
• The hemoglobin and hematocrit levels may be low if
blood loss has occurred.
• An abdominal x-ray shows air, fluid levels, and distended
bowel loops.
• An abdominal Computerised Tomography (CT) scan may
show abscess formation.
• Peritoneal aspiration and culture and sensitivity studies
of the aspirated.
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Complications
• Generalized sepsis, frequently, affects the whole
abdominal cavity.
• Sepsis is the major cause of death from peritonitis.
• Shock may result from septicemia or hypovolemia.
• The inflammatory process may cause intestinal
obstruction, primarily from the development of bowel
adhesions.
• The two most common postoperative complications are
wound evisceration (next slide) and abscess formation.
Any suggestion from the patient that an area of the
abdomen is tender or painful must be reported.
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Caecal evisceration following stab wound
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Medical Management
• Fluid, colloid (blood, plasma) , and electrolyte
replacement. Hypovolemia occurs because of massive
loss of fluid and electrolytes.
• Analgesics for pain; antiemetics for nausea and
vomiting. Intestinal intubation and suction to relieve
abdominal distention.
• Fluids in the abdominal cavity can affect lung expansion
and causes respiratory distress. Oxygen therapy is
indicated with or without airway intubation and ventilatory
assistance.
• Massive antibiotic therapy.
• Surgical objectives include removing the infected
material and correcting the cause. Surgical treatment is
directed toward excision (ie, appendix), resection with or
without anastomosis (ie, intestine), repair (ie,
perforation), and drainage (ie, abscess).
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Nursing Management
• Ongoing assessment of pain, vital signs, GI function.
• The nurse reports the nature of the pain, its location in
the abdomen, and any shifts in location.
• Administering analgesic medication and positioning the
patient for comfort. The patient is placed on the side with
knees flexed; this position decreases tension on the
abdominal organs.
• Accurate recording of all intake and output and central
venous pressure assists in calculating fluid replacement.
• The nurse administers and monitors closely intravenous
fluids.
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