Figure 103.1 Signs and symptoms of appendicitis Figure 103.2 History and assessment Figure 103.3 Key observations and investigations
103
Appendicitis
The appendix is a narrow tube that is attached to the end of the caecum. Appendicitis, or inflammation of the appendix, is a common childhood condition, often caused by an obstruction associated with a kink in the bowel, a faecolith or a foreign body. Subsequent inflammation causes an accumulation of purulent exudate within the lumen of the bowel. As the appendix swells, the blood supply may become compromised and cause the appendix to become gangrenous. Perforation may occur, resulting in peritonitis and the potential for septicaemia. Sudden relief of pain is usually an indication that perforation has occurred.
Principles of care
As with any aspect of children’s nursing, care should be family centred. Involving the child and family in decisions and negotiating care in accordance with their wishes will help to build trusting relationships and a sense of control over what is a stressful (and, for some, a new) situation. Good communication, a calm, caring and unhurried approach, will help to alleviate anxiety. Accurate documentation by all involved and good multidisciplinary working is key to quality care. Treatment involves appendicectomy and associated preoperative and postoperative care.
Preoperative care
The aim of preoperative care is to prepare the child and family for appendicectomy safely and effectively. Information should be given to the child in a developmentally appropriate and caring manner. The play specialist has important role in preparing the child for what will happen. Written consent must be obtained by medical staff from the parent (or person with parental responsibility or young person if they have reached the age of consent). Assessment of the child should be ongoing and any change reported to the surgical team. Baseline observations should be recorded for comparison postoperatively and the child’s identity checked. Pain relief should be administered according to local policy and clinical guidelines and the effect evaluated and documented. Preoperative fasting is required in accordance with local policy. The Royal College of Nursing guidance (RCN 2005) suggests that water may be given up to 2 hours, breast milk up to 4 hours and solids up to 6 hours preoperatively, although this is currently being reviewed. Intravenous therapy will be commenced (see Chapter 77). The child should be encouraged to pass urine preoperatively and all jewellery, hairpins and prostheses should be removed and stored in a safe place. Make-up and nail varnish should also be removed so that perfusion can be assessed during and after the procedure. These details, along with the child’s weight, any allergies or loose teeth/crowns, etc. should be recorded on the preoperative checklist. In many cases, parents are permitted to accompany the child into the anaesthetic room.
Postoperative care
The nurse should accompany the child and parent(s) back to the ward and set out clearly what will happen. The aim of postoperative care is to provide support, minimize pain and to monitor the child’s condition, while being vigilant about potential postoperative complications. Oxygen and suction should be available if needed and the child should be advised not to get out of bed unaccompanied. Bed sides should be used if appropriate and a call bell should be left within easy reach if the parent is not present. Postoperative observations, such as temperature, pulse, respirations, blood pressure and pulse oxymetry, should be recorded in line with local policy and any anomalies reported to medical staff. A rapid thready pulse, accompanied by a falling blood pressure and a restless child, may indicate the presence of shock or haemorrhage. Paediatric Early Warning Systems (PEWS) should be in place to detect signs of the deteriorating child. Morphine, either patient or nurse controlled, is normally used for pain relief. Accurate ongoing pain and fluid assessment and management is key during the postoperative period. Intravenous antibiotics may also be required. The commencement of oral fluids should be based upon direction from the surgical team and this is normally detailed in the operation notes. Once tolerated, a light diet may then be offered. Intravenous therapy is discontinued as directed by medical staff. The wound should be observed for signs of infection (redness, swelling, exudate, local tenderness) or dehiscence. Discharge advice should include information about the recovery period and a wound check by the community team.
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