COLLABORATIVE

SURGICAL. An appendectomy (surgical removal of the appendix) is the preferred method of management for acute appendicitis if the inflammation is localized. An open appendectomy is completed with a transverse right lower quadrant incision, usually at the McBurney point. A laparoscopic appendectomy may be used in females of childbearing age, those in whom the diagnosis is in question, and for obese patients. If the appendix has ruptured and there is evidence of peritonitis or an abscess, conservative treatment consisting of antibiotics and intravenous (IV) fluids is given 6 to 8 hours prior to an appendectomy. Generally, an appendectomy is performed within 24 to 48 hours after the onset of symptoms under either general or spinal anesthesia. Preoperative management includes IV hydration, antipyretics, antibiotics, and, after definitive diagnosis, analgesics. Nonsurgical treatment may be required when it is temporarily a high-risk procedure. In this situation, IV antibiotics are administered.

POSTOPERATIVE. Postoperatively, patient recovery from an appendectomy is usually uncomplicated, with hospital discharge in 24 to 48 hours (sometimes sooner depending on the technique). The development of peritonitis complicates recovery, and hospitalization may extend 5 to 7 days. The physician generally orders oral fluids and diet as tolerated within 24 to 48 hours after surgery.

Prescribed pain medications are given by the IV or intramuscular routes until the patient can take them orally. Antibiotics may continue postoperatively as a prophylactic measure. Ambulation is started the day of surgery or the first postoperative day.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Crystalloid intravenous fluids	100–500 mL/hr of IV depending on volume state of the patient	Isotonic solutions such as normal saline solution or lactated Ringer's solution	Replace fluids and electrolytes lost through fever and vomiting; replacement continues until urine output is 1 mL/kg of body weight and electrolytes are replaced
Antibiotics (possible choices: metronidazole, gentamicin, cefotetan, cefoxitin)	Varies with drug	Broad-spectrum antibiotic coverage	Control local and systemic infection and reduces the incidence of postoperative wound infection

Other Drugs: Analgesics (several recent research studies show that administering opioid analgesics to patients with acute undifferentiated abdominal pain is safe).

INDEPENDENT

PREOPERATIVE. Preoperatively, several nursing interventions focus on promoting patient comfort. Avoid applying heat to the abdominal area, which may cause appendiceal rupture. Permit the patient to assume the position of comfort while maintaining bedrest. Reduce the patient's anxiety and fear by carefully explaining each test, what to expect, and the reasons for the tests. Answer the patient's questions concerning the impending surgery, and provide the patient with instructions regarding splinting the incision with pillows during coughing, deep breathing, and moving. Keep the patient NPO until a decision occurs about surgery.

POSTOPERATIVE. Postoperatively, assess the surgical incision for adequate wound healing. Note the color and odor of the drainage, any edema, the approximation of the wound edges, and the color of the incision. Encourage the patient to splint the incision during deep-breathing exercises. Assist the patient to maintain a healthy respiratory status by encouraging deep breathing and coughing 10 times every 1 to 2 hours for 72 hours. Turn the patient every 2 hours, and continue to monitor the breath sounds. Encourage the patient to assume a semi-Fowler position while in bed to promote lung expansion.