Peritonitis and apendicitis Med Surg 1

Nursing management with appendicitis

-relieving pain -preventing fluid deficient - reducing anxiety - preventing or treating surgical site infection -preventing atelectasis -maintaining skin integrity -obtaining optimal nutrition -preparing the patient for surgery includes IV fluids to replace fluid loss and promote renal function. -administering analgesic agent for pain (do not give enema) -place patient in high fowler position (This reduces the tension of the incision, promotes thoracic expansion (thus decreases atelectasis -educate patient on incentive spirometer use every two hours while awake. -parenteral opioid (morphine) IV then to PO once patient can tolerate oral fluids and foods. -can give food after surgery once bowel sounds are present. -ask patient if they passed gas. -Urine output is monitored to ensure that patient doesn't have urinary retention and hydration is adequate. -encourage the patient to ambulated reduce risk of atelectasis and clots. can be discharged if temp is normal. Discharge instruction is imperative: make an appointment with the surgeon to remove sutures and inspect wound between 1 and 2 weeks. incision care, heavy lifting is to be avoided. normal activity can resume in 2-4 weeks. -patient with gangrenous or perforated apendix are at high risk for infection and should stay in the hospital for several days. secondary abscess may form in pelvis, diaphragm, liver (this causes increased temp, PR, and WBC count) when patient is discharged they are taught how to irrigate wound, provide would care and dressing changes.

Signs and Symptoms of peritonitis

Early clinical manifestations: pain that is diffuse but then becomes constant, localized, and more intense over the site (intense pain) movement aggravates it. abdomen is tender and distended, muscles become rigid, rebound tenderness may be present. anorexia, nausea, and vomiting. temperature is 100-101, increased pule later manifestations: patients become hypotensive. mirror those of sepsis and septic shock.

medical management

Fluid, colloid, electrolyte replacement are the MAJOR focus. (give isotonic solution) antiemetic: for nausea and vomiting. intestinal intubation and suctioning: relieves abdominal distention. promoting abdominal function. (fluid in the abdominal can cause pressure not the lungs) oxygen therapy antibiotic therapy initiated early broad spectrum is given until causative organism is detected. with sepsis fecal diversion may need to be created.

Assessment and diagnostic findings

Increased WBC (elevated neutrophils), elevated C-reactive proteins. CT may reveal RLQ density pregnancy test may be ordered urinalysis is obtained to rule out kidney stones, UTI,

what are common bacteria bacteria for peritonitis?

Klebsiella, Proteus, Pseudomonas, and streptococcus.

assessment for peritonitis

WBC count is elevated (increase neutrophils) hemo and hemat levels may be low with blood loss serum electrolyte reveal altered levels of potassium, sodium, and chloride. abdominal x-ray: shows air and fluid, distended bowel loops. Abdominal ultrasound: may reveal access (localized collection of purulent drainage), fluid collection. CT- may show abscess.

How does peritonitis happen?

bacterial infection, fungal infection, or mycobacterial infection. External sources: abdominal surgery, trauma (gunshot, stab wound) or inflammation that extends outside the peritoneal area such as a kidney or from ambulatory peritoneal dialysis.

Complications with appendicitis

gangrene or perforation of appendix (usually occurs within 6-24 hours after the onset of pain) peritonitis, access formation, or septic thrombosis, or portal pylephlebitis

Nursing management

give intensive care for patient in septic shock signs indicating peritonitis is subsiding is: decreased temperature, pulse, softening of the abdomen, return of BS, passing flatus, and BM,. increase fluids and food gradually. if worsen symptoms occurs the nurse must prepare the patient for emergency surgery.

Tertiary peritonitis

occurs with superinfection common among people with AID's and tuberculosis (this is rare)

Secondary peritonitis

perforation of the abdominal organs with spillage that infects the serious peritoneum. Common cause: perforated appendix, perforated peptic ulcer, perforated sigmoid colon, strangulation of the small intestine. Pathophysiology: result of inflammation, infection, ischemia, trauma, or tumor perforation. bacteria reproduces-> edema occurs-> excudation of fluid develops->fluid becomes turbid (w/ increased amounts of protein, WBC, cell debris, and blood) -> response hyper motility-> paralytic ileus with air in the bowel.

Appendicitis

prone to obstruction, and vulnerable to infection. usually occurs within the age of 10-30 but can happen at any age. most common emergency surgery. Pathophysiology: becomes inflamed (causing intralumenal pressure, causing edema and obstruction) when gets kinked, or occluded by fecalith (handed mass of stool), lymphoid hyperplasia, rarely foreign bodies. once obstructed appendix becomes ischemic, bacterial overgrowth occurs and eventually gangrene or perforation occurs.

Primary peritonitis

spontaneous bacterial peritonitis occurs as a spontaneous bacterial infection of acidic fluid. (occurs commonly with liver failure)

peritonitis

the inflammation of the peritoneum which is the lining of the abdominal cavity.

Geriatric considerations for apendicitis

they have different signs and symptoms then the typical person, they don't have pain its either absent or minimal, and may suggest bowel obstruction. may not be fever or leukocytes present treatment therefore may be delayed no symptoms until the appendix becomes gangrenous or perforates.

Medical management

to prevent fluid and electrolyte balance give IV fluids and antibiotics appendectomy is performed ASAP to prevent perforation laparotomy and laparoscopy( this quicker healing) complicated appendicitis: treated with 3-5 day antibiotic postoperatively. if abscess formation perform abscess surgery. then after recovery perform appendectomy.

Clinical manifestations of appendicitis

visceral pain that is dull and poorly localized, anorexia to the right lower quadrant pain (sharp, discrete, well localized) nausea* low grade fever, local tenderness at mcburneys point when pressure is applied. rebound tenderness. pain can be felt in the right lower quadrant from palpating the left quadrant. if appendix ruptures pain becomes consistent with with peritonitis; abdominal distention develops from the paralytic ileus. constipation also occurs. do NOT give laxative or cathartic.