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Peritonitis

Jay was walking in a deserted highway one night when he was mugged by two men and stabbed in the abdomen. He was found later in the morning and was brought to the emergency room and was examined by a physician. Upon examination, the abdomen is extremely tender and distended. The muscles are now rigid and Jay could not even feel the pain anymore. His laboratory results showed an elevation of the WBC and alterations in serum electrolyte levels. He was diagnosed with peritonitis as a result of his stab wound.

Description


Appendicitis and diverticulitis may both lead to peritonitis, and all of them are acute inflammatory intestinal disorders.
  • Peritonitis is the inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera.
  • Usually, it is a result of bacterial infection; the organisms come from diseases of the GI tract, or in women, from the internal reproductive organs.

Pathophysiology


The pathophysiology of peritonitis involves:
  • Leakage. Peritonitis is caused by leakage of contents from abdominal organs into the abdominal cavity.
  • Proliferation. Bacterial proliferation occurs.
  • Edema. Edema of the tissues occurs, and exudation of fluid develops in a short time.
  • Invasion. Fluid in the peritoneal cavity becomes turbid with increasing amounts of protein, white blood cells, cellular debris, and blood.
  • Response. The immediate response of the intestinal tract is hypermotility, soon followed by paralytic ileus with an accumulation of air and fluid in the bowel.

Causes


Peritonitis can be caused by internal and external factors.
  • Injury. Trauma like gunshot wound or stab wound could lead to peritonitis.
  • Inflammation. An inflammation that extends from an organ outside the peritoneal area such as the kidneys could cause peritonitis.
  • Bacteria. The most common bacteria implicated are Escherichia coli, Klebsiella, Proteus, Pseudomonas, and Streptococcus.

Clinical Manifestations


Symptoms depend on the extent and location of the inflammation.
  • Pain. At first, there is diffuse pain, which tends to become constant, localized, and more intense over the site of the pathologic process.
  • Tenderness. The affected area of the abdomen becomes extremely tender and distended, the muscles become rigid, and movement could aggravate it further.
  • Altered vital signs. A temperature of 37.8C to 38.3C can be expected along with an increased pulse rate.

Complications


The abdominal cavity shows widespread infection that can lead ti complications.
  • Sepsis. Sepsis is the major cause of death from peritonitis.
  • Shock. Shock may result from septicemia or hypovolemia.
  • Intestinal obstruction. The inflammatory process may cause intestinal obstruction, primarily from the development of bowel adhesions.

Assessment and Diagnostic Findings


Assessing and diagnosing peritonitis involves the following:
  • Increased WBC. The white blood cell count is almost always elevated.
  • Serum electrolyte studies. Serum electrolyte studies may reveal altered levels of potassium, sodium, and chloride.
  • Abdominal xray. An abdominal xray may show air and fluid levels as well as distended bowel loops.
  • Abdominal ultrasound. Abdominal ultrasound may reveal abscesses and fluid collections.
  • CT scan. A CT scan of the abdomen may reveal abscess formation.
  • MRI. MRI may be used for diagnosis of intra-abdominal abscesses.

Medical Management


Fluid, colloid, and electrolyte replacement is the major focus of medical management.
  • Fluid. The administration of several liters of an isotonic solution is prescribed.
  • Analgesics. Analgesics are prescribed for pain.
  • Intubation and suction. Intestinal intubation and suction assist in relieving abdominal distention and in promoting intestinal function.
  • Oxygen therapy. Oxygen therapy by nasal cannula or mask generally promotes adequate oxygenation.
  • Antibiotic therapy. Antibiotic therapy is initiated early in the treatment of peritonitis.

Surgical Management


Surgical objectives include removing the infected material and correcting the cause.
  • Excision. Surgical treatment is directed towards excision, especially if the appendix is involved.
  • Resection. Resection of the intestines may be done with or without anastomosis.
  • Fecal diversion. A fecal diversion may need to be created with extensive sepsis.

Nursing Management


Intensive care is often needed for patients with peritonitis.

Nursing Assessment

Assessment should be ongoing and precise.
  • Pain. Pain should be assessed continuously and should be acted upon.
  • GI function. GI function should be monitored to assess response to interventions.
  • Fluid and electrolyte. F&E should be balanced.

Nursing Diagnosis

Based on assessment data, the diagnoses appropriate for the patient are:
  • Acute pain related to peritoneal irritation.
  • Deficient fluid volume related to massive shifting of fluids towards the intestinal lumen and depletion in the vascular space.
  • Risk for shock related to septicemia or hypovolemia.

Nursing Care Planning & Goals

Main Article: 6 Peritonitis Nursing Care Plans

The goals appropriate for a patient with peritonitis include:
  • Reduce level of pain.
  • Restore fluid and electrolyte balance.
  • Prevent complications.
  • Restore normal GI functions.

Nursing Interventions

Nursing interventions focus on the following:
  • Blood pressure monitoring. The patient’s blood pressure is monitored by arterial line if shock is present.
  • Medications. Administration of analgesic and anti emetics can be done as prescribed.
  • Pain management. Analgesics and positioning could help in decreasing pain.
  • I&O monitoring. Accurate recording of all intake and output could help in the assessment of fluid replacement.
  • IV fluids. The nurse administers and closely monitors IV fluids.
  • Drainage monitoring. The nurse must monitor and record the character of the drainage postoperatively.

Evaluation

  • Reduced level of pain.
  • Restored fluid and electrolyte balance.
  • Prevented complications.
  • Restored normal GI functions.

Discharge and Home Care Guidelines

The nurse’s responsibilities during discharge and for home care include:
  • Education. The nurse should educate the patient and the family about the care for incisions and drains if the patient will be sent home with the drains still in place.
  • Referral. Referral for home care may be indicated for further monitoring and patient and family teaching.

Documentation Guidelines

The focus of documentation in a patient with peritonitis include:
  • Client’s description and response to pain.
  • Acceptable level of pain.
  • Prior medication use.
  • Degree of deficit.
  • Current sources of fluid intake.
  • I&O.
  • Fluid balance.
  • Presence of edema.
  • Results of diagnostic tests.
  • Vital signs.
  • Plan of care.
  • Teaching plan.
  • Response to interventions, teaching, and actions performed.
  • Attainment or progress toward desired outcome.
  • Modifications to plan of care.
  • Long term needs.
  • Specific referrals made.

Practice Quiz: Peritonitis


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1. During assessment, the nurse should be looking for additional symptoms diagnostic of peritonitis, which include: A. Abdominal rigidity. B. Diminished peristalsis. C. Leukocytosis. D. All of the above. 2. The nurse should continue to assess for the common complications of: A. Abscess formation. B. Respiratory arrest. C. Umbilical hernia. D. Urinary tract infection. 3. The major cause of death from peritonitis is: A. Hypovolemia. B. Sepsis. C. Shock. D. Abscess formation. 4. The following are results of diagnostic and imaging studies in a patient with peritonitis except: A. Elevated WBC. B. Air and fluid levels on abdominal xray. C. Leukopenia. D. Intra-abdominal abscess on MRI. 5. Peritonitis occurs in which part of the GI system? A. Peritoneum. B. Appendix. C. Duodenum. D. Sigmoid colon Answers and Rationale 1. Answer: D. All of the above.
  • D: All of the answers listed above are symptoms of peritonitis.
  • A: Abdominal rigidity is a symptom of peritonitis.
  • B: Diminishes peristalsis is a symptom of peritonitis.
  • C: Leukocytosis is a symptom of peritonitis.
2. Answer: A. Abscess formation.
  • A: Abscess formation is one of the complications of peritonitis.
  • B: Respiratory arrest is not a complication of peritonitis.
  • C: Umbilical hernia is not a complication of peritonitis.
  • D: Urinary tract infection is not a complication of peritonitis.
3. Answer: B. Sepsis.
  • B: The major cause of death from peritonitis is sepsis.
  • A: Hypovolemia is not the major cause of death from peritonitis.
  • C: Shock is not the major cause of death from peritonitis.
  • D: Abscess formation is not the major cause of death from peritonitis.
4. Answer: C. Leukopenia.
  • C: Decreased WBC cannot be found in a patient with peritonitis.
  • A: An elevated WBC is one of the results of diagnostic and imaging tests performed in a patient with peritonitis.
  • B: Air and fluid levels seen on abdominal xray is one of the results of diagnostic and imaging tests performed in a patient with peritonitis.
  • D: Intra-abdominal abscess on MRI is one of the results of diagnostic and imaging tests performed in a patient with peritonitis.
5. Answer: A. Peritoneum.
  • A: The site for peritonitis is in the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera.
  • B: The appendix is not the site for peritonitis.
  • C: The duodenum is not the site for peritonitis.
  • D: The sigmoid colon is not the site for peritonitis.

See Also


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