Appendicitis: Pathophysiology, Assessment, and Nursing Management

Appendicitis is a common surgical emergency that nursing students must recognize quickly. This guide reviews the pathophysiology, hallmark assessment findings, scoring tools, and the priority nursing actions that prevent perforation and sepsis.

What Is Appendicitis?

• Appendicitis is acute inflammation of the appendix caused by obstruction of the appendiceal lumen.
• It is a surgical emergency requiring prompt intervention to prevent rupture, peritonitis, and sepsis.

Pathophysiology

• Obstruction is usually caused by a fecalith, lymphoid hyperplasia, or a foreign body.
• Increased intraluminal pressure leads to venous congestion, bacterial overgrowth, ischemia, and necrosis.
• Perforation typically occurs 24–48 hours after symptom onset if untreated.

Clinical Presentation

Why the Pain Migrates

• McBurney's point lies one-third of the way from the ASIS to the umbilicus.
• Early on, the distended, inflamed appendix stimulates visceral afferent nerves at T10, which the brain perceives as vague, midline periumbilical pain.
• As inflammation spreads to the parietal peritoneum, somatic nerves are activated, producing localized, sharp RLQ pain at McBurney's point.

Physical Examination Signs

Alvarado Score (MANTRELS)

Interpretation:

• 0–3 points: Appendicitis unlikely
• 4–6 points: Consider imaging (CT or ultrasound)
• 7–10 points: Surgical consultation recommended

Diagnostic Tests

• CT scan with IV contrast is the gold standard.
• Ultrasound is preferred in children and pregnant women.
• WBC and CRP are elevated but not diagnostic.
• Urinalysis helps rule out urinary causes.

Complications

• Perforation leads to peritonitis, characterized by a rigid, board-like abdomen, diffuse pain, and fever.
• Abscess formation or sepsis may follow perforation.
• Wound infection is the most common post-operative complication.

Management

Before Surgery

• Prioritize ABC stability and immediately assess for perforation or sepsis (rigid abdomen, fever, tachycardia) before diagnostics or surgery prep.
• The first nursing actions are NPO status, IV fluids, and IV antibiotics (e.g., ceftriaxone and metronidazole) before imaging or analgesic escalation.
• Morphine is safe for pain relief.
• Do not apply heat to the abdomen or give laxatives/enemas — these increase rupture risk.

Surgery

• Laparoscopic appendectomy is standard.
• Open appendectomy is used for perforated cases.

After Surgery

• Advance diet as tolerated once bowel function returns.
• Monitor for fever, increased pain, or wound drainage.
• Encourage early ambulation.

Nursing Assessment

• Assess pain migration, onset, and character.
• Monitor for anorexia, nausea, vomiting, and fever.
• Palpate for rebound tenderness, guarding, Rovsing's, psoas, and obturator signs.
• Watch for perforation signs: sudden pain relief followed by worsening diffuse pain, fever, and a rigid abdomen.

Nursing Interventions

• Maintain NPO status and administer IV fluids.
• Give IV antibiotics and analgesics as ordered.
• Do not apply heat or give laxatives/enemas.
• Prepare patient for surgery.
• Post-operatively: monitor incision, bowel function, and signs of infection.

Patient Teaching

• Do not eat or drink if appendicitis is suspected.
• Report worsening pain, fever, or vomiting immediately.
• Avoid laxatives, enemas, and heat application.
• After surgery, report fever, increased pain, or wound drainage.
• Avoid heavy lifting for 4–6 weeks after surgery.

Common Exam Traps

• Anorexia is often the first symptom, followed by pain.
• Nausea and vomiting occur after pain begins.
• Rovsing's sign is specific for appendicitis.
• Psoas sign → retrocecal appendix; obturator sign → pelvic appendix.
• Alvarado score ≥7 suggests surgical consultation.
• Do not apply heat, give laxatives, or delay pain relief (morphine is safe).
• Perforation causes sudden pain relief then worsening diffuse pain with a rigid abdomen.

Key Takeaways

• Classic presentation: periumbilical pain migrating to McBurney's point, anorexia, nausea, low-grade fever.
• Key physical findings: Rovsing's, psoas, obturator signs, rebound tenderness, and guarding.
• The Alvarado (MANTRELS) score stratifies risk; ≥7 warrants surgical consultation.
• First nursing priorities: NPO, IV fluids, IV antibiotics, surgical consultation — never apply heat or give laxatives/enemas.
• Sudden pain relief followed by diffuse pain and a rigid, board-like abdomen indicates perforation with peritonitis.
• Morphine is safe for pain control; wound infection is the most common post-op complication.