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    Adela Susan
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    The document discusses peritonitis and interventions for a patient at risk of infection. Over three days, nursing interventions include: 1) Maintaining sterile technique, monitoring cultures, and encouraging cleansing to prevent infection. 2) Administering antimicrobials like cephalosporins and monitoring for signs of infection like fever or confusion. 3) Continuing antimicrobials and assessing vital signs and drainage daily to monitor infection status and ensure timely healing without purulent drainage or fever.

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    nursing care plans for peritonitis

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    peritonitis

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    The document discusses peritonitis and interventions for a patient at risk of infection. Over three days, nursing interventions include: 1) Maintaining sterile technique, monitoring cultures, and encouraging cleansing to prevent infection. 2) Administering antimicrobials like cephalosporins and monitoring for signs of infection like fever or confusion. 3) Continuing antimicrobials and assessing vital signs and drainage daily to monitor infection status and ensure timely healing without purulent drainage or fever.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    9 views3 pages

    Peritonitis

    Uploaded by

    Adela Susan
    The document discusses peritonitis and interventions for a patient at risk of infection. Over three days, nursing interventions include: 1) Maintaining sterile technique, monitoring cultures, and encouraging cleansing to prevent infection. 2) Administering antimicrobials like cephalosporins and monitoring for signs of infection like fever or confusion. 3) Continuing antimicrobials and assessing vital signs and drainage daily to monitor infection status and ensure timely healing without purulent drainage or fever.

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    © All Rights Reserved
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    of 3

    Peritonitis

    Nevoie afecta Diagnostic nursing Obiective Interventii autonome Interventii delegate Evaluare
    risk for Infection Desired Independent Collaborative Infection Status
    Outcomes/Evaluation Ziua 1 Ziua 1 Achieve timely healing, be free of
    [septicemia]  Maintain sterile technique  Obtain specimens for purulent drainage or erythema, and
    Risk Factors May Include Criteria—Client Will be afebrile.
    when catheterizing client, culture and monitor results
    Inadequate primary defenses— Infection Status provide of serial Risk Control
    broken skin, traumatized tissue, Achieve timely healing, be free of Verbalize understanding of the
    catheter care, and encourage blood, urine, and wound cultures.
    altered peristalsis purulent drainage or erythema, and individual causative or risk factor(s)
    be afebrile.
    perineal cleansing on a  Assist with peritoneal
    Inadequate secondary defenses— routine basis. aspiration, if indicated.
    immunosuppression Risk Control
    Verbalize understanding of the
     Monitor or restrict visitors  Administer antimicrobials, for
    Invasive procedures and staff, as appropriate.
    individual causative or risk factor(s) example, cephalosporins, such
    Possibly Evidenced By Provide as cefotetan (Cefotan); extended
    (Not applicable; presence of signs protective isolation if indicated. spectrum penicillins, such
    and symptoms establishes an actual
     Perform and model good as piperacillin/tazobactam (Zosyn);
    diagnosis)
    hand-washing technique.  carbapenems, such as
    Monitor meropenem (Merrem);
    staff and client compliance with fluoroquinolones, such as nor
    hand washing.  floxacin (Noroxin);
     Note individual risk factors: macrolides, such as
    abdominal trauma, acute clindamycin
    appendicitis, and peritoneal (Cleocin);
    dialysis.  antifungals, such as
     Maintain strict aseptic metronidazole (Flagyl);
    technique in caring for aminoglycosides, such as gentamicin
    abdominal (Garamycin).
    drains, incisions or open wounds,
    dressings, and invasive
    Ziua 2
    sites. Cleanse with appropriate
    solution.  Administer antimicrobials, for
    example, cephalosporins, such
     Assess vital signs frequently, as cefotetan (Cefotan); extended
    noting unresolved or
    spectrum penicillins, such
    progressing
    as piperacillin/tazobactam (Zosyn);
    hypotension, decreased pulse
    pressure, tachycardia, fever,  carbapenems, such as
    and tachypnea. meropenem (Merrem);
    fluoroquinolones, such as nor
     Note changes in mental status,
    such as new onset confusion  floxacin (Noroxin);
    and stupor. macrolides, such as
    clindamycin
     Note skin color, temperature, (Cleocin);
    and moisture.
     antifungals, such as
     Monitor urine output. metronidazole (Flagyl);
    aminoglycosides, such as gentamicin
     Observe drainage from (Garamycin)
    wounds or drains.
    Ziua 3
    Ziua 2  Administer antimicrobials, for
     Assess vital signs frequently, example, cephalosporins, such
    noting unresolved or as cefotetan (Cefotan); extended
    progressing spectrum penicillins, such
    hypotension, decreased pulse as piperacillin/tazobactam (Zosyn);
    pressure, tachycardia, fever,  carbapenems, such as
    and tachypnea. meropenem (Merrem);
     Note changes in mental status, fluoroquinolones, such as nor
    such as new onset confusion  floxacin (Noroxin);
    and stupor. macrolides, such as
     Note skin color, temperature, clindamycin
    and moisture. (Cleocin);
     Monitor urine output.  antifungals, such as
    metronidazole (Flagyl);
    aminoglycosides, such as gentamicin
     Observe drainage from
    (Garamycin)
    wounds or drains.

    Ziua 3
     Assess vital signs frequently,
    noting unresolved or
    progressing
    hypotension, decreased pulse
    pressure, tachycardia, fever,
    and tachypnea.
     Note changes in mental status,
    such as new onset confusion
    and stupor.
     Note skin color, temperature,
    and moisture.
     Monitor urine output.

     Observe drainage from


    wounds or drains.

    deficient Fluid Volume Desired Independent Collaborative Fluid Balance


    Outcomes/Evaluation Monitor vital signs, noting presence Monitor laboratory studies: Hgb/Hct, Demonstrate improved fluid balance
    May Be Related To
    of hypotension (including electrolytes, protein, as evidenced by adequate urinary
    Active fluid volume loss—vomiting; Criteria—Client Will postural changes), tachycardia, albumin, BUN, and creatinine (Cr). output with normal specific gravity,
    medically restricted intake; Fluid Balance tachypnea, and fever. Administer plasma, blood, fluids, stable vital signs,
    nasogastric (NG) or intestinal Demonstrate improved fluid balance Measure central venous pressure electrolytes, and diuretics, moist mucous membranes, good
    aspiration as evidenced by adequate urinary (CVP) if available. as indicated. skin turgor, prompt capillary refill,
    Failure of regulatory mechanisms— output with normal specific gravity, Maintain accurate intake and output Maintain NPO status with and weight within acceptable range.
    fever, hypermetabolic state, fluid stable vital signs, (I&O) and correlate with nasogastric (NG) or intestinal
    shifts from extracellular, moist mucous membranes, good skin daily weights. Include measured and aspiration.
    intravascular, and interstitial turgor, prompt capillary refill, and estimated losses,
    compartments into intestines and/or weight within acceptable range. such as with gastric suction, drains,
    peritoneal space
    dressings, Hemovacs,
    Possibly Evidenced By diaphoresis, and abdominal girth for
    Dry mucous membranes, decreased third spacing of fluid.
    skin turgor, decreased pulse volume Measure urine specific gravity.
    Decreased urinary output; increased Observe skin and mucous membrane
    urine concentration dryness and turgor. Note
    Hypotension; tachycardia peripheral and sacral edema.
    Eliminate noxious sights or smells
    from environment. Limit
    intake of ice chips.
    Change position frequently, provide
    frequent skin care, and
    maintain dry, wrinkle-free bedding.

    acute Pain Desired Independent Collaborative Pain Control


    Outcomes/Evaluation Note client’s age, developmental Administer medications, as Report pain is relieved or controlled.
    May Be Related To
    level, and current condition indicated, for example: Demonstrate use of relaxation skills
    Chemical agent—irritation of the Criteria—Client Will (infant/child, critically ill, ventilated, Analgesics and opioids or other methods to promote
    parietal peritoneum (toxins) Pain Control sedated, or cognitively Antiemetics, such as dolasetron comfort.
    Physical agent—tissue trauma, Report pain is relieved or controlled. impaired). (Azemet), metoclopramide
    accumulation of fluid in abdominal Demonstrate use of relaxation skills Investigate pain reports, noting (Reglan)
    and peritoneal cavity (abdominal or other methods to promote location, duration, intensity Antipyretics, such as acetaminophen
    distention) comfort. (0 to 10 [or similar] scale), and (Tylenol)
    Possibly Evidenced By characteristics such as dull,
    Verbalized/coded reports of pain sharp, or constant.
    Guarding behavior; expressive Observe nonverbal cues and pain
    behavior—restlessness, irritability behaviors (e.g., how client
    Facial mask, self-focus holds body, facial expressions such
    Changes in vital signs as grimacing, withdrawal,
    narrowed focus, crying).
    Maintain semi-Fowler’s position as
    indicated.
    Move client slowly and deliberately,
    splinting painful area.
    Provide comfort measures, such as
    massage, back rubs, and
    deep breathing. Instruct in relaxation
    and visualization
    exercises.
    Provide frequent oral care. Remove
    noxious environmental
    stimuli.

    risk for imbalanced Desired Independent Collaborative


    Outcomes/Evaluation Auscultate bowel sounds, noting Monitor BUN, protein, prealbumin
    Nutrition: less than absent and hyperactive or albumin, glucose, and
    Criteria—Client Will
    body Nutritional Status
    sounds. nitrogen balance, as indicated.
    Monitor NG tube output. Note Administer enteral or parenteral
    requirements Maintain usual weight and positive presence of vomiting and feedings, as indicated.
    Risk Factors May Include nitrogen balance diarrhea. Advance diet as tolerated—clear
    Inability to ingest—nausea, vomiting Measure abdominal girth. liquids to soft food.
    Inability to digest food/absorb Assess abdomen frequently for
    nutrients—intestinal dysfunction, return to softness, reappear
    metabolic abnormalities ance of normal bowel sounds, and
    [Increased metabolic needs] passage of flatus.
    Possibly Evidenced By Weigh regularly.
    (Not applicable; presence of signs
    and symptoms establishes an actual
    diagnosis)

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