Appendicitis is an infection or inflammation of the appendix, a pinky-sized, tube-like structure part of the large intestine. The appendix is located in the right lower section of the abdomen in most children.
The appendix is a pinky-sized, tube-like structure located in the right lower section of the abdomen.
What causes appendicitis in a child?
Appendicitis is the result of a blockage of the appendix caused by hard mucus or stool, or swelling caused by a virus. The blockage causes the appendix to swell and become inflamed. If the swelling and infection are left untreated, the appendix can burst (perforate), causing the contents of the appendix to be released into the abdomen, spreading the infection.
When infected, the appendix becomes swollen and inflamed (pictured on the left). Sometimes, this is caused by a blockage with mucous or hard stool (pictured on the right).
Appendicitis is the most common cause of emergency abdominal surgery in children. Though it can happen at any age, appendicitis occurs more frequently in school-aged children, and rarely occurs under the age of 1.
Appendicitis symptoms
The signs and symptoms of appendicitis can vary from child to child. The most common symptoms of appendicitis in children are:
- Abdominal pain that begins around the belly button and moves to the right lower side of the abdomen. The pain typically increases when walking, jumping or coughing, and usually worsens as time goes on.
- Fever
- Nausea and/or vomiting
- Loss of appetite
- Diarrhea
Testing and diagnosis
Appendicitis is diagnosed with a thorough health history and physical examination. Your child may need to have an imaging study completed, such as an ultrasound, MRI or CT scan, to see the appendix. Your child may also have laboratory studies completed, such as a complete blood count (CBC), to determine the extent of the infection.
Appendicitis treatments
Appendectomy in Children
An appendectomy is the surgical removal of the appendix. It can be performed as a laparoscopic procedure or as an open surgery through a small incision.
Immediately following diagnosis, patients with appendicitis will receive antibiotics to treat the infection.
Ultimately, the treatment for appendicitis is a surgery to remove the appendix, called an appendectomy. Your child’s surgeon will help determine the best treatment for your child.
When to call the doctor after surgery
Please call us if your child has any of the following after appendicitis surgery:
- Fever greater than 101.5 degrees F
- Vomiting or inability to tolerate any food or liquids
- Increasing or continuous abdominal pain
- Abdominal distention (swollen or enlarged)
- Drainage from incision(s)
- Redness or swelling of the incision(s)
- If you have any further questions or concerns
Appendicitis is considered an emergent condition, requiring immediate attention. If you think that your child may have appendicitis, please have them evaluated at the Emergency Department.
Pain assessment in infants and children is also challenging due to the subjectivity and multidimensional nature of pain. The dependence on others to assess pain, limited language, comprehension and perception of pain expressed contextually. In some children it can be difficult to distinguish between pain, anxiety and distress.
Assessment and documenting pain is needed in order to improve management of pain. When assessing a child’s level of pain careful consideration needs to be given to their:
- cognitive ability
- environment (hospital)
- anxiety
- cause of pain (eg: post-operative)
Pain measurement quantifies pain intensity and enables the nurse to determine the efficacy of interventions aimed at reducing pain.
A pain assessment should be conducted during a patient’s admission. (link to Nursing Assessment nursing clinical guideline)
Points to consider:
- pain history
- location of pain
- intensity of pain
- cognitive development and understanding of pain
When to assess pain?
- Pain scores should be documented for all children at least once per shift in Flow Sheet: ( //www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Observation_and_Continuous_Monitoring/)
- Children with pain should have pain scores documented more frequently.
- Children who are receiving oral analgesia should have pain scores documented at least 4 hourly during waking hours.
- Children on complex analgesia such as intravenous opioid and/ or ketamine, epidurals or regional analgesia should have hourly pain and sedation scores documented.
- Assess and document pain before and after analgesia, and document effect.
- Assess and document pain on activity such as physiotherapy.
Pain Assessment Tools
Tools used for pain assessment at RCH have been selected on their validity, reliability and usability and are recognized by pain specialists to be clinically effective in assessing acute pain. All share a common numeric and recorded as values 0-10 and documented on the clinical observation chart as the 5th vital sign.
The importance of using the same numeric value (0-10) is that the number relates to the same pain intensity in each tool.
Three ways of measuring pain:
- Self report - what the child says ( the gold standard)
- Behavioural –how the child behaves
- Physiological –clinical observations
Pain Assessment Tools used at RCH
There are three main tools used for the neonate, infant and child 3-18 years these tools reflect a combination of self-report and behavioural assessment.
1. FLACC - The acronym FLACC stands for Face,Legs, Activity, Cry and Consolability.
Behavioural
- 2 months-8 years and also used up to 18 years for children with cognitive impairment and/or developmental disability (always elicit support from parents or carers to help with pain assessment)
- It may be difficult to assess children with cognitive impairment and/or are non-verbal. Ask the parent or carer to help you explain their child’s pain behaviour.
How to use FLACC
Each category (Face, Legs etc) is scored on a 0-2 scale, which results in a total pain score between 0 and 10. The person assessing the child should observe them briefly and then score each category according to the description supplied.
FLACC has a high degree of usefulness for cognitively impaired and many critically ill children
2. Wong-Baker faces pain scale 3-18yo
Self report
How to use?
Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn't hurt at all. Face 2 hurts just a little bit. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don't have to be crying to feel this bad. Ask the person to choose the face that best describes how he is feeling.
3. Visual Analogue scale 8-years and older
Self report
How to use?
Ask the child using numbers from 0 = no pain through to 10 being the worst pain
Physiological indicators
- heart rate may increase
- respiratory rate and pattern may shift from normal ie: increase, decrease or change pattern
- blood pressure may increase
- oxygen saturation may decrease
Physiological indicators in isolation cannot be used as a measurement for pain. A tool that incorporates physical, behavioural and self report is preferred when possible.
Key considerations
- assess pain using a developmentally and cognitively appropriate pain tool
- reassess pain after interventions given to reduce pain (eg. Analgesia) have had time to work
- assess pain at rest and on movement
- investigate higher pain scores from expectation
- document pain scores
- use parent/guardian pain behaviour knowledge for children with cognitive impairment.
Special Considerations
Multi language Wong Baker and Numeric tools are available if needed
//www.briggshealthcare.com/Wong-Baker-Faces-Pain-Rating-Scale-8-Languages
Modified PAT Tool is used in the Neonatal Intensive Care Unit
//www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Neonatal_Pain_Assessment/
Comfort B is used for Ventilated paediatric patients assessing both pain and sedation
//www.rch.org.au/picu_intranet/guidelines/Nursing_management_of_the_patient_with_invasive_mechanical_ventilation_in_PICU/
Companion Documents
Further information on pain management principles and assessing pain in children can be found here:
Links
Education
- Supported through the Anaesthesia and pain management web site
- Competencies
- Presentation to ward nurses
- Presentation to RCH nursing programs
- Pain tools supplied to all staff
Evidence Table
The evidence table for this guideline can be viewed by clicking here.
Please remember to read the disclaimer.
The development of this nursing guideline was coordinated by Sueann Penrose, CNC, Children's Pain Management Service, and approved by the Nursing Clinical Effectiveness Committee. Updated August 2022.