off the inflamed appendix As a result, perforation leads to a more disseminated infection Although the mortality from appendicitis has decreased over the last several decades, the incidence of perforation in children has remained the same Clinical Assessment Within a few hours after perforation has occurred, the child begins to develop increasing signs of peritonitis and toxicity First, the lower abdomen and then the entire abdomen become rigid with extreme tenderness Bowel sounds are sparse to absent Other signs include pallor, dyspnea, grunting, significant tachycardia, and higher fever (39° to 41°C [102.2° to 105.8°F]) Rarely, the patient may develop septic shock from the overwhelming infection