Appendicitis and Peritonitis

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Appendicitis & Peritonitis

Dr. Belal Hijji, RN, PhD April 25 & 27, 2011



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Learning Outcomes

At the end of this lecture, students will be able to:

• Describe the appendix and appendicitis along withits 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, clinicalmanifestations, 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 theileocecal 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’scondition 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 localizeddistention 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 andelectrolyte imbalance and dehydration could be throughantibiotics and intravenous fluids.

• Analgesics can be administered after the diagnosis ismade.



11 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 promoteadequate 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 theviscera.

• It results from bacterial infection; the organisms comefrom diseases of the GI tract or, in women, from theinternal reproductive organs.

• Peritonitis can also result from injury or trauma (eg,gunshot wound, stab wound).

• The most common bacteria implicated are Escherichiacoli, Klebsiella, Proteus, and Pseudomonas.

• Peritonitis may also be associated with abdominalsurgical procedures and peritoneal dialysis.



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Autopsy of infant showing abdominal distension,

intestinal necrosis and hemorrhage, and peritonitis due

to perforation .

http://en.wikipedia.org/wiki/File:Neonatal_necrotizing_enterocolitis,_gross_pathology_20G0021_lores.jpg



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Pathophysiology

• Peritonitis is caused by leakage of contents fromabdominal organs into the abdominal cavity due to

inflammation, infection, ischemia, trauma, or tumor

perforation.

• Edema of the tissues results, and exudation of fluiddevelops 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 theinflammation.

• 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 distendedbowel loops.

• An abdominal Computerised Tomography (CT) scanmay show abscess formation.

• Peritoneal aspiration and culture and sensitivity studiesof 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 boweladhesions.

• The two most common postoperative complications arewound 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 electrolytereplacement. Hypovolemia occurs because of massiveloss of fluid and electrolytes.

• Analgesics for pain; antiemetics for nausea andvomiting. Intestinal intubation and suction to relieveabdominal distention.

• Fluids in the abdominal cavity can affect lung expansionand causes respiratory distress. Oxygen therapy isindicated with or without airway intubation and ventilatoryassistance.

• Massive antibiotic therapy.

• Surgical objectives include removing the infectedmaterial and correcting the cause. Surgical treatment isdirected 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 inthe abdomen, and any shifts in location.

• Administering analgesic medication and positioning thepatient for comfort. The patient is placed on the side withknees flexed; this position decreases tension on theabdominal organs.

• Accurate recording of all intake and output and centralvenous pressure assists in calculating fluid replacement.

• The nurse administers and monitors closely intravenous

fluids.

Appendicitis and Peritonitis

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