peritonitis
(Lewis, Sharon. Medical-Surgical Nursing (with Media), 8th Edition. Mosby pp. 1021 - 1022).
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A CBC is done to determine elevations in WBC count and hemoconcentration from fluid shifts (Table 43-13). Peritoneal aspiration may be performed and the fluid analyzed for blood, bile, pus, bacteria, fungus, and amylase content. An x-ray of the abdomen may show dilated loops of bowel consistent with paralytic ileus, free air if perforation has occurred, or air and fluid levels if an obstruction is present. Ultrasound and CT scans may be useful in identifying the presence of ascites and abscesses. Peritoneoscopy may be helpful in the patient without ascites. Direct examination of the peritoneum can be obtained along with biopsy specimens for diagnosis.
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Abdominal pain is the most common symptom of peritonitis. A universal sign of peritonitis is tenderness over the involved area. Rebound tenderness, muscular rigidity, and spasm are other major signs of irritation of the peritoneum. Patients may lie very still and take only shallow respirations because movement causes pain. Abdominal distention or ascites, fever, tachycardia, tachypnea, nausea, vomiting, and altered bowel habits may also be present. These manifestations vary depending on the severity and acuteness of the underlying cause. Complications of peritonitis include hypovolemic shock, sepsis, intraabdominal abscess formation, paralytic ileus, and acute respiratory distress syndrome. Peritonitis can be fatal if treatment is delayed.
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Abdominal paracentesis and culture of fluid
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Abdominal x-ray
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Accurate monitoring of fluid intake and output and electrolyte status is necessary to determine replacement therapy. Monitor vital signs frequently. Antiemetics may be administered to decrease nausea and vomiting and prevent further fluid and electrolyte losses. The patient is placed on NPO status and may need an NG tube to decrease gastric distention and further leakage of bowel contents into the peritoneum. Low-flow oxygen may be needed.
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Analgesics (e.g., morphine)
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Antibiotic therapy
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Assessment of the patient's pain, including the location, is important and may help in determining the cause of peritonitis. Assess the patient for the presence and quality of bowel sounds, increasing abdominal distention, abdominal guarding, nausea, fever, and manifestations of hypovolemic shock.
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Blood transfusions as needed
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CBC including WBC differential
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CBC, Complete blood count; CT, computed tomography; IV, intravenous; NG, nasogastric; NPO, nothing by mouth; PRN, as required; WBC, white blood cell.
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CT scan or ultrasound
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Clinical Manifestations
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Collaborative Care
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Collaborative Therapy
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Diagnostic
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Diagnostic Studies
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Etiology and Pathophysiology
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History and physical examination
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IV fluid replacement
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IV fluids with electrolyte replacement
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If the patient has an open surgical procedure, drains are inserted to remove purulent drainage and excessive fluid. Postoperative care of the patient is similar to the care of the patient with an exploratory laparotomy.
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Intestinal contents and bacteria irritate the normally sterile peritoneum and produce an initial chemical peritonitis that is followed a few hours later by a bacterial peritonitis. Patients who use peritoneal dialysis are also at high risk.32 (Peritoneal dialysis is described in Chapter 47.) The resulting inflammatory response leads to massive fluid shifts (peritoneal edema) and adhesions as the body attempts to wall off the infection.
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NG suction
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NG tube to low-intermittent suction
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NPO status
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Nursing Assessment
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Nursing Diagnoses
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Nursing Implementation
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Nursing Management
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Nursing diagnoses for the patient with peritonitis include, but are not limited to, the following.
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Oxygen PRN
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Parenteral nutrition as needed
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Peritoneoscopy
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Peritonitis
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Peritonitis results from a localized or generalized inflammatory process of the peritoneum. Causes of peritonitis are listed in Table 43-12. Primary peritonitis occurs when blood-borne organisms enter the peritoneal cavity. For example, the ascites that occurs with cirrhosis of the liver provides an excellent liquid environment for bacteria to flourish. Secondary peritonitis is much more common. It occurs when abdominal organs perforate or rupture and release their contents (bile, enzymes, and bacteria) into the peritoneal cavity. Common causes include a ruptured appendix, perforated gastric or duodenal ulcer, severely inflamed gallbladder, and trauma from gunshot or knife wounds.
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Planning
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Postoperative
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Preoperative or Nonoperative
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Preparation for surgery to include the above and parenteral nutrition
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Primary
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Secondary
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Sedatives and opioids
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Semi-Fowler's position
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Serum electrolytes
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Surgery is usually indicated to locate the cause of the inflammation, drain purulent fluid, and repair the damage. Patients with milder cases of peritonitis or those who are poor surgical risks may be managed medically. Treatment consists of antibiotics, NG suction, analgesics, and IV fluid administration. Patients who require surgery need preoperative preparation as previously described.
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The overall goals are that the patient with peritonitis will have (1) resolution of inflammation, (2) relief of abdominal pain, (3) freedom from complications (especially hypovolemic shock), and (4) normal nutritional status.
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The patient with peritonitis is extremely ill and needs skilled supportive care. An IV line is inserted to replace vascular fluids lost to the peritoneal cavity and as an access for antibiotic therapy. Monitor the patient for pain and response to analgesic therapy. The patient may be positioned with knees flexed to increase comfort. Sedatives may be given to allay anxiety.
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Acute pain related to inflammation of the peritoneum and abdominal distention
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Anxiety related to uncertainty of cause or outcome of condition and pain
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Appendicitis with rupture
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Blood-borne organisms
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Blunt or penetrating trauma to abdominal organs
TABLE 43-12
CAUSES OF PERITONITIS
TABLE 43-13
COLLABORATIVE CARE: Peritonitis
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Cirrhosis with ascites
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Diverticulitis with rupture
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Genital tract organisms
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Imbalanced nutrition: less than body requirements related to anorexia, nausea, and vomiting
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Ischemic bowel disorders
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Pancreatitis
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Perforated intestine
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Perforated peptic ulcer
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Peritoneal dialysis
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Postoperative (breakage of anastomosis)
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Risk for deficient fluid volume related to fluid shifts into the peritoneal cavity secondary to trauma, infection, or ischemia