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Inflammation of the peritoneal cavity, caused by either bacteria or chemicals, can be primary or secondary, and acute or chronic. Primary peritonitis is a rare condition in which the peritoneum is infected via the blood/lymphatic circulation. Secondary sources of inflammation are the GI tract, ovaries/uterus, urinary system, traumatic injuries, or surgical contaminants. Surgical intervention may be curative in localized peritonitis, as occurs with appendicitis/appendectomy, ulcer plication, and bowel resection. If peritonitis is diffuse, medical management is necessary before or in place of surgical treatment.
Inpatient acute medical or surgical unit
Appendectomy, see Nursing Care Plan CD-ROM Inflammatory bowel disease: ulcerative colitis, regional enteritis (Crohn’s disease, ileocolitis) Pancreatitis Psychosocial aspects of care Renal dialysis: peritoneal Sepsis/speticemia Surgical intervention Total nutritional support: parenteral/enteral feeding Upper gastrointestinal/esophageal bleeding
Patient Assessment Database
May report: May exhibit: Weakness Difficulty ambulating
May exhibit: Tachycardia, diaphoresis, pallor, hypotension (signs of shock) Tissue edema
May report: May exhibit: Inability to pass stool or flatus Diarrhea (occasionally) Hiccups; abdominal distension; quiet abdomen Decreased urinary output, dark color Decreased/absent bowel sounds (ileus); intermittent loud, rushing bowel sounds (obstruction); abdominal rigidity, distension, rebound tenderness; hyperresonance/tympany (ileus); loss of dullness over liver (free air in abdomen)
May report: May exhibit: Anorexia, nausea/vomiting, thirst Projectile vomiting Dry mucous membranes, swollen tongue, poor skin turgor
May report: May exhibit: Sudden, severe abdominal pain, generalized or localized, referred to shoulder, intensified by movement Distention, rigidity, rebound tenderness; distraction behaviors; restlessness; self-focus Muscle guarding (abdomen); flexion of knees
2. Pelvic ultrasound: Can diagnose peritonitis caused by ruptured appendix or diverticulitis. septic abortion. or rarely. free air will be found in the abdomen. Serum protein/albumin: May be decreased because of fluid shifts. puerperal infection. and therapeutic regimen understood. bladder perforation/ruptured gallbladder. Serum amylase: Usually elevated. NURSING PRIORITIES 1. 5. ABGs: Respiratory alkalosis and metabolic acidosis may be noted.9 days Assistance with homemaker/maintenance tasks Refer to section at end of plan for postdischarge considerations. pus/exudate. 3. sometimes more than 20. and treatment needs. perforated gastric/duodenal ulcer. Disease process. DISCHARGE GOALS 1. pneumococcus) may be identified from blood. Discharge plan considerations: DIAGNOSTIC STUDIES CBC: WBCs elevated. exudate/secretions or ascitic fluid.. amylase. Complications presented/minimized. UC. . streptococci. Cultures: Causative organism (often Escherichia coli. Abdominal x-ray: May reveal gas distension of bowel/ileus. 4. and creatine. gangrenous obstruction of the bowel. regional ileitis.g. 4. cloudy peritoneal dialysate. 5. Serum electrolytes: Hypokalemia may be present. e. Pain relieved. chills SEXUALITY May report: History of pelvic organ inflammation (salpingitis). staphylococcus. Control infection. perforation of diverticulum. Infection resolved. Paracentesis: Peritoneal fluid samples may contain blood. indicating hemoconcentration. Maintain nutrition. RBC count may be increased. tachypnea SAFETY May report: Fever. Restore/maintain circulating volume. 3. potential complications. 2. perforated carcinoma of the stomach. retroperitoneal abscess TEACHING/LEARNING May report: History of recent trauma with abdominal penetration.000. Provide information about disease process. Plan in place to meet needs after discharge. Promote comfort. Chest x-ray: May reveal elevation of diaphragm. If a perforated viscera is the cause. bile.RESPIRATION May exhibit: Shallow respirations. strangulated hernia DRG projected length of inpatient stay: 4. gunshot/stab wound or blunt trauma to the abdomen. possible complications.
Observe drainage from wounds/drains. temperature. effects of antibiotics. moisture. Circulating endotoxins eventually produce vasodilation. incisions/open wounds. dry skin is early sign of septicemia. and acidosis can cause deteriorating mental status. Reduces risk of exposure to/acquisition of secondary infection in immunosuppressed patient. Reduces risk of cross-contamination/spread of infection. e. Assess vital signs frequently. Provide protective isolation if indicated. confusion. be afebrile.g.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Infection Status (NOC) Achieve timely healing. Monitor/restrict visitors and staff as appropriate. Hypoxemia. and provide catheter care/encourage perineal cleansing on a routine basis. presence of signs and symptoms establishes an actual diagnosis. peritoneal dialysis. acute appendicitis. noting unresolved or progressing hypotension.. Monitor urine output. Perform/model good handwashing technique. and invasive sites.NURSING DIAGNOSIS: Infection. Influences choice of interventions. circulating toxins. traumatized tissue. Prevents access or limits spread of infecting organisms/cross-contamination. tachycardia. Later manifestations include cool. Provides information about status of infection. clammy. . abdominal trauma. pale skin and cyanosis as shock becomes refractory.g. Note skin color. Prevents access. tachypnea. Risk Control (NOC) Verbalize understanding of the individual causative/risk factor(s). ACTIONS/INTERVENTIONS Infection Control (NIC) RATIONALE Independent Note individual risk factors. decreased pulse pressure. fever. Oliguria develops as a result of decreased renal perfusion. dressings. hypotension. flushed. Maintain sterile technique when catheterizing patient. be free of purulent drainage or erythema. Note changes in mental status (e. limits bacterial growth in urinary tract. Maintain strict aseptic technique in care of abdominal drains. altered peristalsis) Inadequate secondary defenses (immunosuppression) Invasive procedures Possibly evidenced by [Not applicable.. Monitor staff/patient compliance. stupor). and a low cardiac output state. shift of fluid from circulation. Warm. risk for (septicemia) Risk factors may include Inadequate primary defenses (broken skin. Signs of impending septic shock. Cleanse with appropriate solution.
tachypnea. Therapy is directed at anaerobic bacteria and aerobic Gram-negative bacilli. clindamycin (Cleocin). prompt capillary refill. e. weak peripheral pulses Diminished urinary output.. to drain localized abscess. dark/concentrated urine Hypotension. localized peritonitis. ACTIONS/INTERVENTIONS Fluid/Electrolyte Management (NIC) RATIONALE Independent Monitor vital signs.ACTIONS/INTERVENTIONS Infection Control (NIC) RATIONALE Collaborative Obtain specimens/monitor results of serial blood. amikacin (Amikin). urine.g. medically restricted intake. remove peritoneal exudates. Aids in evaluating degree of fluid deficit/effectiveness of fluid replacement therapy and response to medications. noting presence of hypotension (including postural changes). ruptured appendix/ gallbladder. and weight within acceptable range. moist mucous membranes. stable vital signs. NG/intestinal aspiration Fever/hypermetabolic state Possibly evidenced by Dry mucous membranes. NURSING DIAGNOSIS: Fluid Volume. Assist with peritoneal aspiration. if indicated. gentamicin (Garamycin). poor skin turgor. fever. Lavage may be used to remove necrotic debris and treat inflammation that is poorly localized/diffuse. wound cultures. good skin turgor.. and interstitial compartments into intestines and/or peritoneal space Vomiting. via IV/peritoneal lavage. delayed capillary refill. Administer antimicrobials. intravascular. deficient [mixed] May be related to Fluid shifts from extracellular. or resect bowel. May be done to remove fluid and to identify infecting organisms so appropriate antibiotic therapy can be instituted. Measure central venous pressure (CVP) if available.g. e. Prepare for surgical intervention if indicated. tachycardia DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Fluid Balance (NOC) Demonstrate improved fluid balance as evidenced by adequate urinary output with normal specific gravity. tachycardia. Surgery may be treatment of choice (curative) in acute. plicate perforated ulcer. Identifies causative microorganisms and helps in assessing effectiveness of antimicrobial regimen. .
protein. Administer plasma/blood. Replenishes/maintains circulating volume and electrolyte balance. but weight may still increase. Gastric suction losses may be large. organ function.. hypovolemia. Colloids (plasma. BUN. blood) help move water back into intravascular compartment by increasing osmotic pressure gradient. provide frequent skin care. which may warn of developing acute renal failure in response to hypovolemia and effect of toxins. e. e. and a great deal of fluid can be sequestered in the bowel and peritoneal space (ascites).g. and maintain dry/wrinkle-free bedding. Reflects hydration status and changes in renal function. circulating toxins. drains. Edematous tissue with compromised circulation is prone to breakdown. Provides information about hydration. taut edematous tissues. Limit intake of ice chips. Collaborative Monitor laboratory studies. hypoxemia. Change position frequently. Reflects overall hydration status. electrolytes. Eliminate noxious sights/smells from environment. Varied alterations with significant consequences to systemic function are possible as a result of fluid shifts. Include measured/estimated losses. Hemovacs. Note:Excessive use of ice chips during gastric aspiration can increase gastric washout of electrolytes. Diuretics may be used to assist in excretion of toxins and to enhance renal function. turgor. and necrotic tissue products. Note peripheral/sacral edema. Hb/Hct.ACTIONS/INTERVENTIONS Fluid/Electrolyte Management (NIC) RATIONALE Independent Maintain accurate I&O and correlate with daily weights. Note: Many antibiotics also have nephrotoxic effects that may further affect kidney function/urine output. Reduces gastric stimulation and vomiting response. electrolytes. and nutritional deficits contribute to poor skin turgor. reflecting tissue edema/ascites accumulation. diuretics as indicated. Measure urine specific gravity. albumin. fluids. diaphoresis.. Urine output may be diminished because of hypovolemia and decreased renal perfusion. Cr. and abdominal girth for third spacing of fluid. Maintain NPO with nasogastric/intestinal aspiration. fluid shifts. Observe skin/mucous membrane dryness. Hypovolemia.g. . gastric suction. dressings. Reduces hyperactivity of bowel and diarrhea losses.
pain may localize if an abscess develops. which may help minimize pain of movement. which aids in pain relief and promotes healing. duration. rebound tenderness Facial mask of pain. Move patient slowly and deliberately. and thereby reducing pain.g. noting location. reducing diaphragmatic irritation/abdominal tension. splinting painful area. Provide comfort measures. narcotics. back rubs. intensity(0–10 scale). Facilitates fluid/wound drainage by gravity. constant). Reduces nausea/vomiting. . Demonstrate use of relaxation skills. autonomic/emotional responses (anxiety) DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Pain Control (NOC) Report pain is relieved/controlled. and characteristics (dull. massage. Reduces muscle tension/guarding. self-focus Distraction behavior. e. Analgesics may be withheld during initial diagnostic process because they can mask signs/symptoms.. Note: Pain is usually severe and may require narcotic pain control. sharp. Maintain semi-Fowler’s position as indicated. Provide diversional activities. Promotes relaxation and may enhance patient’s coping abilities by refocusing attention. ACTIONS/INTERVENTIONS Pain Management (NIC) RATIONALE Independent Investigate pain reports.NURSING DIAGNOSIS: Pain. which can increase intraabdominal pressure/pain. Changes in location/intensity are not uncommon but may reflect developing complications. deep breathing. other methods to promote comfort. Collaborative Administer medications as indicated Analgesics. Reduce metabolic rate and intestinal irritation from circulating/local toxins. Instruct in relaxation/visualization exercises. Pain tends to become constant. more intense. and diffuse over the entire abdomen as inflammatory process accelerates. Remove noxious environmental stimuli. Provide frequent oral care. acute May be related to Chemical irritation of the parietal peritoneum (toxins) Trauma to tissues Accumulation of fluid in abdominal/peritoneal cavity (abdominal distension) Possibly evidenced by Verbalizations of pain Muscle guarding.
reappearance of normal bowel sounds. e. but sustained losses suggest nutritional deficit. Measure abdominal girth. Monitor NG tube output. intestinal dysfunction Metabolic abnormalities. Although bowel sounds are frequently absent.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Nutritional status (NOC) Maintain usual weight and positive nitrogen balance. Reduce nausea and vomiting. Note presence of vomiting. and passage of flatus. Reduce discomfort associated with fever/chills. ACTIONS/INTERVENTIONS Nutrition Management (NIC) RATIONALE Independent Auscultate bowel sounds. and diarrhea.g.. Weigh regularly. noting absent/hyperactive sounds. requiring further evaluation. inflammation/irritation of the intestine may be accompanied by intestinal hyperactivity. Initial losses/gains reflect changes in hydration. NURSING DIAGNOSIS: Nutrition: imbalanced.ACTIONS/INTERVENTIONS Pain Management (NIC) RATIONALE Collaborative Antiemetics. which can increase abdominal pain. hydroxyzine (Vistaril). e. Large amounts of gastric aspirant and vomiting/diarrhea suggest bowel obstruction. increased metabolic needs Possibly evidenced by [Not applicable. Provides quantitative evidence of changes in gastric/intestinal distension and/or accumulation of ascites. Assess abdomen frequently for return to softness. presence of signs and symptoms establishes an actual diagnosis.. ACTIONS/INTERVENTIONS RATIONALE .g. Antipyretics. diminished water absorption. acetaminophen (Tylenol). Indicates return of normal bowel function and ability to resume oral intake. risk for less than body requirements Risk factors may include Nausea/vomiting. diarrhea.
Schedule adequate rest and uninterrupted periods for sleep. hypermetabolic state Possibly evidenced by Increased tension/helplessness Apprehension. sense of impending doom Sympathetic stimulation. ACTIONS/INTERVENTIONS Anxiety Reduction (NIC) RATIONALE Independent Evaluate anxiety level. Refer to CP: Psychosocial Aspects for Care. Reflects organ function and nutritional status/needs.Nutrition Management (NIC) Collaborative Monitor BUN. NURSING DIAGNOSIS: Anxiety [specify level]/Fear May be related to Situational crisis Threat of death/change in health status Physiological factors. Careful progression of diet when intake is resumed reduces risk of gastric irritation. increasingly ill feeling. . Provide information regarding disease process and anticipated treatment. and possibility of surgery. worry. urgency of diagnostic procedures. and can enhance coping ability. e. Apprehension may be escalated by severe pain. focus on self DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Anxiety Control (NOC) Verbalize awareness of feelings and healthy ways to deal with them. glucose. Report anxiety is reduced to a manageable level.. Advance diet as tolerated. for additional interventions. Appear relaxed. Promotes nutrient utilization and positive nitrogen balance in patients who are unable to assimilate nutrients in a normal fashion. protein. Knowing what to expect can reduce anxiety. Encourage free expression of emotions. Administer TPN as indicated. restlessness. Limits fatigue. prealbumin/albumin.g. conserves energy. noting patient’s verbal and nonverbal response. uncertainty. nitrogen balance as indicated. clear liquids to soft food.
Avoids unnecessary increase of intra-abdominal pressure and muscle tension. Correctly perform necessary procedures and explain reasons for actions. states of discomfort. Antibiotics may be continued after discharge. treatment. Provides knowledge base from which patient can make informed choices. physical condition/presence of complications. increased energy requirements to perform ADLs. Necessary to monitor resolution of infection and resumption of usual activities. Knowledge: Treatment Regimen (NOC) Verbalize understanding of therapeutic needs. wound care. ACTIONS/INTERVENTIONS Teaching: Disease Process (NIC) RATIONALE Independent Review underlying disease process and recovery expectations. prolonged healing process. Demonstrate aseptic dressing change. Discuss medication regimen.g. or presence of purulent drainage. enhances feeling of well-being. . recurrent abdominal pain/distension. acute—chemical irritation of the peritoneum. and possible side effects. POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patient’s age.. allowing for adequate rest. avoid heavy lifting. depending on length of stay. e. constipation. swelling/erythema of surgical incision (if present). Identify signs/symptoms requiring medical evaluation. e. Recommend gradual resumption of usual activities as tolerated. and life responsibilities) Fatigue—decreased metabolic energy production. request for information Statement of misconception Inaccurate follow-through of instruction DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Knowledge: Disease Process (NOC) Verbalize understanding of disease process and potential complications. Provides opportunity to evaluate healing process. self-care. vomiting. and discharge needs May be related to Lack of exposure/recall Information misinterpretation Unfamiliarity with information resources Possibly evidenced by Questions. deficient [Learning Need] regarding condition. Pain. Emphasize importance of medical follow-up. Prevents fatigue.NURSING DIAGNOSIS: Knowledge. Review activity restrictions/limitations. Early recognition and treatment of developing complications may prevent more serious illness/injury. Identify relationship of signs/symptoms to the disease process and correlate symptoms with causative factors. prognosis. Reduces risk of contamination..g. chills. schedule. personal resources. fever.
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