Tag: rovsing's sign

Abdominal pain is most commonly caused by appendicitis, which may lead to the most frequently performed surgical procedure – Appendicectomy. While this can happen at any age, it is a common occurrence in the young.

The appendix is a closed ended narrow tube measuring about 6mm in diameter and 7cm long. It is found in the right iliac region of the abdomen, beneath the ileocecal valve (McBurney’s point).

Appendicitis = Inflammation of the appendix:

1. Acute Appendicitis
2. Acute Appendicitis with mass
3. Acute Appendicitis with Peritonitis

Management of Appendicitis:

• PROMPT TREATMENT: prevents morbidity and mortality
• PREOPERATIVE CARE: supporting patient and management of symptoms
• INTRAOPERATIVE CARE: appendicectomy
• POSTOPERATIVE CARE: preventing complications and providing reassurance and comfort

Appendicectomy & Appendectomy = same procedure, different terminology.

Appendicectomy Preoperative Care

Apart from following the normal preoperative care techniques, an appendicectomy requires the following as well:

• NIL BY MOUTH – no foods, drinks or oral medications should be taken as soon as decision is taken for an appendicectomy
• IV FLUIDS ADMINISTRATION – dehydration is probable due to vomiting being a normal symptom of appendicitis
• VITAL SIGNS MONITORING – a fever over 38.5°C may be due to the rupture of the appendix
• NO ANALGESIA – pain needs to be monitored, not subsided, as it indicates what is happening with the appendix; regular analgesia should be administered to help the patient feel more comfortable prior to appendicectomy
• NO HEAT – increases the risk of perforation and rupture of the appendix
• NO LAXATIVES – induced peristalsis increases the risk of perforation and rupture of the appendix
• VOIDING – patient should be encouraged to void if undergoing surgery for which no bowel preparation is recommended such as in appendicectomy, as avoiding incontinence during the operation leads to a lesser chance of infection

Intraoperative Negligence:

If a foreign body such as a swab is left accidentally in the patient during surgery, the patient may experience symptoms such as sepsis, localised discomfort, skin protrusion, nausea and constipation. If this goes unnoticed for a longer time, more serious complications may arise, such as abscess formation, fistulas, bowel perforation, and extreme localised pain.

To avoid such complications:

1. count instruments and swabs during setup prior to surgery commencement
2. count again before surgery begins
3. count again as closure begins
4. count again during skin closure

Pay special attention in the case of obese patients.

Appendicectomy: Open Method

Preferred method of surgery in the case of:

• perforated appendicitis
• peritonitis
• history of abdominal surgery
• paediatric patients
• appendicular abscess

An open method appendicectomy provides good exposure, is easier to perform and straightforward. However, pelvic structures cannot be seen well, it takes longer for the patient to recover post-operation, it increases the risk of hernias and adhesions due to the weakening of the abdomen tissue by the manipulation of the bowels.

Appendicectomy: Laparoscopy

Preferred method of surgery in the case of:

• lower complication rate
• helps diagnose other conditions especially in women
• preferred method for women, obese patients and athletes
• provides better cosmetic results
• causes less postoperative pain
• patient can return to normal activity early

However, a laparoscopic appendicectomy takes longer to be performed, and comes at a much higher cost. Not all surgeons use this method as it requires experience. Carbon Dioxide is used to inflate the abdomen to allow surgeons to work, which may cause shoulder pain. Additionally, lack of mobilisation may lead to a needed open procedure nonetheless.

Appendicectomy Postoperative Care

If patient experiences peritonitis, antibiotics are administered IV to treat infection.

Peritonitis may develop after an appendicitis. This happens due to bacteria spread which may go unnoticed during appendicitis.

A drain may be inserted during surgery. Monitor drainage, which should decrease in time…if not, patient could be experiencing a haemorrhage.

Patient should be encouraged to mobilise as soon as possible to prevent the formation of emboli. In addition, anti-coagulants may be administered subcutaneously post-operatively, and anti-embolism stockings should be worn.

Patient may be started on food slowly only after bowel sounds can be heard, which proves good function of bowels.

The patient is discharged once no fever is recorded and bowels are functioning well. Drain is removed once infection is fully resolved. Stitches are removed 7-10 days post-surgery; this can be done at a health centre. A histopathology report is later given during an outpatient visit.

No need of special diets, exercise or other lifestyle factors are required post appendicectomy.

Below you can find a collection of videos that can help provide a more visual approach to appendecectomy preoperative, intraoperative and postoperative nursing care.

Clinical Presentation of Appendicitis

Appendicitis Symptoms, Examination and Nursing Assessment

Rovsing’s Sign

Psoas Sign

Obturator Sign

Special thanks to the creators of the featured videos on this post, specifically Youtube Channels Medscape, RegisteredNurseRN, Surgical Teaching and MDforAll.

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