Does This Child Have Appendicitis?

Watch Out For Key Signs

A 5-year-old with abdominal pain, nausea and fever may have appendicitis or any of a
number of other problems. But how does the child’s doctor decide whether to schedule an
emergency appendectomy to surgically remove a presumably inflamed appendix — a procedure
that carries its own risks like any surgery — or wait and observe what could be a ticking time
bomb that could rupture and kill the patient in a matter of hours?

It’s a classic physician’s dilemma, but a new study led by the Johns Hopkins Children’s
Center may ease the pediatrician’s problem-solving and parents’ anxiety.
Reporting on their review of the frequency of the most common symptoms of actual appendicitis
in children, the researchers concluded that beyond fever, the most telltale signs are “rebound”
tenderness or pain that occurs after pressure is removed abruptly from the lower right part of the
abdomen; abdominal pain that starts around the belly button and migrates down and to the right;
and an elevated white blood cell count (10,000 or more per microliter), which is a marker of
infection in the body. Notably, loss of appetite, nausea and vomiting, hallmark appendicitis
symptoms in adults, were NOT predictive of appendicitis in children.“These signs don’t give you
an absolute diagnosis, but they should prompt the doctor to refer the child to a surgeon for
evaluation,” said study lead author David Bundy, M.D., M.P.H., a pediatrician at the Johns
Hopkins Children’s Center.
Appendicitis is most common in teens and young adults in their early 20s. However,
children younger than 4 years are at the highest risk for a rupture. Up to 80 percent of
appendicitis cases in this age group end in rupture, partly because young children have fewer of
the classic symptoms of nausea, vomiting and pain localized in the lower right portion of the
abdomen than do teenagers and young adults, making the diagnosis easy to miss or delay.
In the study report, published in the July 25 issue of the Journal of the American Medical
Association, the researchers said ultrasound and CT scan images can be helpful, but are not
always conclusive, even if they are available on an emergency basis. And CT scans in particular
expose young children to radiation, which should be avoided if possible.
“In a very young child, the presentation of symptoms associated with appendicitis tends
to be different from adults, so when trying to decide between fast-track surgery versus watchful
observation, you’re often damned if you do and damned if you don’t,” Bundy said. “In our
analysis, we’ve identified some of the more powerful telltale signs that should help residents,
general pediatricians and ER doctors narrow down what is seldom a clear-cut diagnosis.”
The appendix is a small tube extending from the large intestine, and infections and
inflammation of the organ can be dangerous. The only absolute way to diagnose the condition is
surgery, and each year, appendicitis sends 77,000 American children to the hospital. An
estimated one-third of them suffer a ruptured appendix, a life-threatening complication, before
they reach the OR.
In their analysis of previous research, investigators searched hundreds of studies,
weeding out weak from solid science. The 25 studies that made the final cut examined
symptoms and outcomes in children who presented with abdominal pain and in whom
appendicitis was considered a possible diagnosis.
Abdominal pain in children is one of the most common and vaguest symptoms, and can
suggest anything from innocent constipation to serious infections or blockages of the intestines.
Doctors advise parents that any abdominal pain should be evaluated for appendicitis.
 “We really want parents to keep in mind that children with appendicitis don’t always
show up with the classic story that we see in adults,” Bundy says. “There isn’t a perfect formula,
but we think the signs we’ve identified can help.”

This journal focuses on the signs and symptoms and possible treatment of appendicitis:
Inflammation (a cellular response to injury or blockage) of the appendix (a tube of tissue
that extends from a portion of the large intestine, usually along the lower right-hand side of the
abdomen) can cause abdominal pain and is considered a medical emergency. Although it can
strike at any age, appendicitis is rare under 2 years of age and most commonly occurs between
the ages of 10 and 30 years. The appendix has no apparent function, but if an inflamed appendix
is not treated, it can rupture and release its contents into the surrounding abdominal cavity. This
can cause peritonitis (painful inflammation of the lining of the intestines and abdominal cavity).
The July 25, 2007, issue of JAMA includes an article that discusses the clinical features of
children with this potentially life-threatening condition.
Symptoms includes the following dull pain near the navel or upper abdomen that
becomes sharp as it moves to the lower right abdominal area , Fever , Loss of appetite , Vomiting
after the onset of abdominal pain, Inability to walk normally because of pain, or pain when
asked to cough or jump, Abdominal swelling , Constipation (inability to pass feces) or diarrhea
Diagnosis can be difficult since the symptoms can be similar to other ailments. Because
of the threat of rupture, appendicitis is considered an emergency. If your child has these
symptoms, you should seek immediate medical attention. Do not allow your child to eat, drink or
use any medications before the evaluation.
The following tests are helpful in making the diagnosis:
Medical history , Complete physical examination, including abdominal and pelvic
examinations , Urine test to exclude a urinary tract infection ,Blood tests to identify an infectious
process ,Diagnostic imaging tests, such as CT scans (X-ray tests) and ultrasound (using sound
waves)
If appendicitis is suspected, appendectomy (surgical removal of the appendix) is the
treatment of choice. Antibiotics are given prior to surgery, general anesthesia is used, and the
appendix is removed through a single incision or by laparoscopy (removal of the organ through
a scope). If the appendix has not ruptured, recovery is usually quick, and children usually leave
the hospital one or two days after surgery. Most children can usually return to normal activities
in two to three weeks. If rupture occurs, the recovery process can be more complicated.
References:
• (Aug. 2, 2007) —http://www.articleteller.com/Article/Useful-information-about-acute-
appendicitis/45379 (
• http://www.emedicine.com/MED/topic3430.html

I. INTRODUCTION
Acute appendicitis is a surgical emergency most frequently caused by an obstruction of
the communication between Ilion and appendix. It causes an inflammation of the mucous layer
because of the colonization with intestinal bacterial flora. In case of appendix perforation, fecal
matter and infected intestinal bodies pierce into the peritoneum and cause acute septic peritonitis.
Depending on the infected area, the peritonitis can be local or general; around the inflamed
appendix an abscess can appear. About 10% of the population is expected to develop
appendicitis in the near future but the incidence is decreasing. Appendicitis is commonly
resolved by appendectomy, the removal of the appendix. The occurrence of normal appendix
removal is10-20% of the suspected cases.

The inflammation of the appendix usually occurs in men but the chance of removing a
healthy appendix is higher in young women. The trickiest situations of appendicitis are seen in
children and old people who don’t always develop the classical symptoms; this is the major
reason for wrong and false diagnosis of appendicitis. The pain usually appears around the navel
or in the epigastria and moves down and right in the right ileal fossa after several hours, when
the inflammation process involves the peritoneum. Pains get worse as hours pass, they can awake
or keep awaken a patient. The pain tends to get worse while moving or coughing.

II. RELEVANCE TO ASSIGNED AREA

Appendicitis is one of the cases being reported to surgery ward, some patients have been
experiencing from pain because of appendectomy and some are from exploratory laparotomy.
Appendicitis is an emergency situation which needs immediate focus on intervention in order to
prevent further complication such as peritonitis which is considered toxic and may mortality.
For us nurses assigned into surgery ward having the necessary information regarding
appendicitis/appendectomy will able us to know its major risk which will to further diseases.
Also having enough knowledge with appendectomy will help us to determine the necessary
nursing management, precautions and therapeutic interventions for the recovery of our patients
during post operative period. Journals, visual aids , educational equipment and supplemental
readings play a great role in providing us information to prevent, treat, manage and know the
possible complications of appendicitis as well as appendectomy.
 III. SUMMARY

Appendicitis affects more than 1 billion people worldwide, and is a major risk factor for
peritonitis. Clinical trial data indicate that check-up and lifestyle modification can prevent its
onset. Appendicitis is caused by obstruction of the appendiceal lumen. The causes of the
obstruction include lymphoid hyperplasia secondary to irritable bowel disease (IBD) or
infections (more common during childhood and in young adults), fecal stasis and fecaliths (more
common in elderly patients), parasites (especially in Eastern countries), or, more rarely, foreign
bodies and neoplasms. The most common symptom of appendicitis is abdominal pain. Typically,
symptoms begin as periumbilical or epigastric pain migrating to the right lower quadrant (RLQ)
of the abdomen. Later, a worsening progressive pain along with vomiting, nausea, and anorexia
are described by the patient. Usually, a fever is not present at this stage. careful physical
examination, not limited to the abdomen, must be performed in any patient with suspected
appendicitis. GI, genitourinary, and pulmonary systems must be studied. Perform a rectal
examination in any patient with an unclear clinical picture, and perform a pelvic examination in
all women with abdominal pain.
Tenderness on palpation in the RLQ over the McBurney point is the most important sign in
these patients. Additional signs such as increasing pain with cough (ie, Dunphy sign), rebound
tenderness related to peritoneal irritation elicited by deep palpation with quick release (ie,
Blumberg sign), and guarding may or may not be present. Consider an appendectomy for
patients with a history of persistent abdominal pain, fever, and clinical signs of localized or
diffuse peritonitis, especially if leukocytosis is present.

IV. NURSING IMPLICATION

A. NURSING PRACTICE - as a student nurse, we should knowledgeable enough to know
the nature/etiology of appendicitis and on how to deal with the management during post
operative period. Aside from knowing the symptom and possible complication of such disease it
is a must for us to prevent or possible avoid complications which will be more dangerous to the
recovery of the patient.
B. NURSING EDUCATION- From this research I learned a lot of things regarding
appendicitis, some of which are its symptoms, nature, etiology and treatment. With the aid of this
journal it will help a lot of nurses and also the public to clearly understand that this disease needs
immediate attention or intervention for it not to become dangerous and complicated. This
research plays a great role in nursing education since it is intended to help the public to gain
information and inputs which they will be utilizing.

C. NURSING RESEARCH- This journal plays a major role in contributing ideas and
information for the nurses in profession, and for the public. This journal does not only implicates
its purpose as my project or a requirement to be passed but I do believe that this journal will help
us all in developing and acquiring necessary information just to solve the rampant cases of
appendicitis. Also this journal will guide us to determine that appendicitis is not only a disease
that doesn’t need focus and immediate attention instead this journal will educate us to treat the
disease immediately, properly and accurately.
LEARNING INSIGHTS

This research is such an interesting and educational activity, though it is not that easy, it
helps me to gained additional information regarding this disease. I therefore conclude that this
research doesn’t only need to be submitted as a requirement instead I’ll rather value its
implication to my course and into my future career. I do admit that this research was so difficult
to find out since most of the magazines and websites I had visited don’t contain exact and
complete information regarding such disease but I didn’t stop searching instead I used my critical
thinking, patience and eagerness just to put up this journal. This journal is where I started to
explore and at the same time enhance my knowledge and skills.

This journal is not merely copying from magazines but also it aids me to integrate and
intervene with the necessary information. Thus, it takes a lot of effort, courage, patience,
sacrifice, guts, and hard work to do so. I would like to extend my heartfelt gratitude to our CI in
the person of Mr. Emilson P Veneracion, because without his patience, support, advice and
proper direction this research would not be possible. Again sir thank you very much….
 BAGUIO CENTRAL UNIVERSITY
College of Nursing and School of Midwifery
Magsaysay Avenue, Baguio City

___________________________________

Journal
Presented to the faculty of the
College of Nursing and School of Midwifery
In partial fulfillment of the course
RLE 104

___________________________________

Submitted to:

Mr. VENERACION, Emilson P. BSN-RN,

Clinical Instructor

Submitted by:

GALANGEY, Je-an B.
BCU-SN IV-A
A2 GROUP

August 17, 2009