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

 1 st degree relative with history of appendicitis  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 > 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) 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

 No heavy lifting (>10 lbs) or strenuous physical activity for 4-6 weeks  May return to work 1-2 weeks  S/S infection