# A 45-year-old patient is admitted to the emergency department with suspected acute appendicitis. Which nursing intervention should be the priority?

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> subject: Adult Health

## 문제

A 45-year-old patient is admitted to the emergency department with suspected acute appendicitis. Which nursing intervention should be the priority?

The patient reports severe right lower quadrant pain that started around the umbilicus and migrated to McBurney's point. Vital signs show temperature 100.8°F (38.2°C), pulse 105 bpm, respirations 20/min, and blood pressure 130/85 mmHg.

## 보기

1. Apply a heating pad to the abdomen to relieve pain
2. Maintain the patient in a position of comfort **✔ 정답**
3. Administer a Fleet enema to prepare for surgery
4. Encourage ambulation to promote peristalsis

**정답: 2**

## 해설

Maintaining comfort positioning and NPO status is the priority to prepare for potential emergency surgery and prevent complications like perforation. Other options may worsen inflammation or increase rupture risk.

## 심화 해설

Clinical Context and Priority Setting

This patient presents with a classic history and physical examination for acute appendicitis: periumbilical pain that has migrated to McBurney's point (right lower quadrant), accompanied by low-grade fever (38.2°C) and tachycardia (105 bpm). The immediate priority for the nurse is to implement interventions that promote safety and prevent complications while the patient awaits definitive surgical management. Appendicitis is a surgical emergency, and if left untreated, it can rapidly progress to perforation and peritonitis [1].

Analysis of Correct Answer

The correct answer is to maintain the patient in a position of comfort. The primary nursing goal at this stage is to manage pain and reduce restlessness without causing harm. Allowing the patient to assume a position that minimizes abdominal tension—often a side-lying position with hips flexed—can help relieve peritoneal irritation and muscle guarding. This aligns with the nursing role of addressing pain and ensuring patient safety as part of comprehensive preoperative care [1].

Rationale for Incorrect Options

Option 1: Apply a heating pad to the abdomen. This is contraindicated. Application of heat to an inflamed appendix can increase local vasodilation and blood flow, potentially accelerating the inflammatory process and increasing the risk of rupture. The safe, evidence-based approach is to withhold local heat application in suspected appendicitis.

Option 3: Administer a Fleet enema. This is a dangerous intervention in suspected appendicitis. An enema increases intraluminal pressure and stimulates peristalsis within the colon. This mechanical stress can precipitate perforation of an inflamed, friable appendix, converting a localized infection into generalized peritonitis. Bowel preparation is not a standard preoperative nursing intervention for emergency appendectomy.

Option 4: Encourage ambulation. While early mobility is generally beneficial, encouraging ambulation during the acute inflammatory phase of appendicitis is not a priority and may worsen pain. Movement can aggravate peritoneal irritation. The priority is to keep the patient comfortable and physiologically stable while preparing for surgery, which includes maintaining NPO status and establishing IV access.

Integration of Triage and Nursing Role

The nursing role in acute appendicitis begins at initial assessment. While a team triage model—where a physician and nurse collaboratively evaluate the patient—has been shown to improve time-based performance metrics such as door-to-analgesia and door-to-operating room times, the core nursing responsibilities remain consistent across triage models . These responsibilities include accurate assessment of pain characteristics and vital signs, recognizing the classic migration of pain to McBurney's point, providing non-pharmacologic comfort measures (such as positioning), administering prescribed analgesics and antiemetics, and preparing the patient physically and psychologically for laparoscopic or minimally invasive surgery [1]. The nurse’s clinical judgment in withholding harmful interventions—such as heat application, enemas, or unnecessary movement—is critical to preventing preoperative deterioration.References (research sources)

- [1]Appendicitis: Integrating evidence-based nursing care into clinical practice.Research articleStansell P, Francis-Johnson P. (2026) · DOI: 10.1097/nsg.0000000000000356

## 임상 시나리오

Preoperative Care for Suspected AppendicitisPrioritizing Safety and Preventing Perforation
The immediate nursing priority is to maintain the patient in a position of comfort, typically side-lying with hips flexed, to reduce abdominal tension and peritoneal irritation.

Local heat application is contraindicated as it causes vasodilation, increases blood flow, and can accelerate inflammation, raising the risk of rupture.

Do not administer laxatives or enemas; they increase peristalsis and intraluminal pressure, which can precipitate perforation.

CautionAvoid all gastrointestinal stimulation. Keep the patient NPO and on bed rest until surgical evaluation. Monitor for signs of perforation: sudden pain relief followed by diffuse, severe pain, a rigid abdomen, and signs of shock such as tachycardia and hypotension.

## 핵심 개념

- **McBurney's point** — A point on the right lower quadrant of the abdomen, one-third of the distance from the anterior superior iliac spine to the umbilicus, which is the classic location of tenderness in acute appendicitis.
- **Peritoneal irritation** — Inflammation of the peritoneum, the membrane lining the abdominal cavity, causing pain, rigidity, and guarding, often due to a condition like appendicitis.
- **Appendicitis** — Inflammation of the appendix, a small pouch attached to the large intestine, which is a surgical emergency due to the risk of perforation and peritonitis.
- **Fleet enema** — A brand of hypertonic saline laxative used to stimulate bowel evacuation, which is dangerous in suspected appendicitis as it can raise intraluminal pressure and cause perforation.
- **Perforation** — A hole that develops through the wall of a body organ, such as the appendix, leading to leakage of contents into the abdominal cavity and causing a severe infection like peritonitis.

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