Peritonitis is the inflammation of the peritoneal cavity. The peritoneum is a double-layered, semipermeable sac that lines the abdominal cavity and covers all the organs in the abdominal cavity. Between its visceral and its parietal layers is the peritoneal cavity. Although the peritoneum walls off areas of contamination to prevent the spread of infection, if the contamination is massive or continuous, this defense mechanism may fail, resulting in peritonitis. Perhaps the most serious complication caused by peritonitis is intestinal obstruction, which results in death in 10% of patients. Other complications include abscess formation, bacteremia, respiratory failure, and shock.
The most common cause is infection with Escherichia coli, but streptococci, staphylococci, and pneumococci may also cause the inflammation. The main sources of inflammation are the gastrointestinal (GI) tract, external environment, and bloodstream. Entry of a foreign body—such as a bullet, knife, or indwelling abdominal catheter—and contaminated peritoneal dialysate may precipitate peritonitis. Acute pancreatitis may also cause peritonitis.
Nursing care plan assessment and physical examination
Obtain a thorough history and try to determine the possible sources of peritoneal infection. Ascertain any history of GI disorders, penetrating or blunt trauma to the abdomen, or recent abdominal surgery. Ask if the patient has any inability to pass flatulence or stools. Ask if the patient has experienced any weakness, nausea, or vomiting or a recent history of dehydration and high temperatures. The parietal peritoneum is well supplied with somatic nerves, whereas the visceral peritoneum is relatively insensitive. With peritonitis, stimulation of the parietal peritoneum causes sharp, localized pain, whereas stimulation of the visceral peritoneum results in a more generalized abdominal pain. The pain is a steady ache that occurs directly over the area of inflammation. The intensity depends on the type and amount of foreign substances that are irritating the peritoneum and the somatic nerves supplying the parietal pentoneum. Peritoneal pain is almost always increased by pressure or tension of the peritoneum, such as coughing, sneezing, and palpation. Ask whether abdominal pain is generalized or localized. Inflamed diaphragmatic peritonitis can cause shoulder pain as well.
Visually inspect the abdomen for size and shape. Peritonitis leads to abdominal distension. When assessing the GI system, auscultate before palpation. Bowel sounds are decreased or absent. Palpation reveals abdominal rigidity and elicits rebound tenderness with guarding. The patient may keep movement to a minimum to reduce the pain. Well-localized pain may cause rigidity of the abdominal muscles. The patient is generally in a knee-flexed position with shallow respirations in an attempt to minimize pain. Check the patient for signs of dehydration, such as a dry and swollen tongue, dry mucous membranes, and thirst. High fever may result in rapid heart rate. The patient may experience hiccups in cases of diaphragmatic peritonitis. Observe the patient for pallor, excessive sweating, or cold skin, which are signs of electrolyte and fluid loss.
Patients with peritonitis have often been coping with a serious illness or traumatic injury to the abdomen and may already be weary of discomfort and pain. Besides dealing with intensified pain and new complications, the patient with peritonitis is also at risk for life-threatening complications such as shock, renal problems, and respiratory problems. Assess the patient’s and family’s anxiety and feelings of powerlessness about the illness and potential complications.
Nursing care plan primary nursing diagnosis: Pain (acute) related to inflammation of the peritoneal cavity.
Nursing care plan intervention and treatment plan
Interventions are supportive and include fluid and electrolyte replacement. To rest the GI tract, a nasogastric (NG) or intestinal tube is inserted to reduce pressure within the bowel. Food and fluids are prohibited. Parenteral nutrition is often indicated for nutritional support. Monitor fluid volume by checking the patient’s skin turgor, urine output, weight, vital signs, mucous membrane condition, and intake and output including NG tube drainage.
If the peritonitis has been caused by a perforation of the peritoneum, surgery is necessary as soon as the patient’s condition has been stabilized to eliminate the source of the infection by removing the foreign contents from the peritoneal cavity and inserting drains. Paracentesis (abdominocentesis) to remove excess fluids may be necessary as well. After surgery, it is important to assess the patient frequently for peristaltic activity. Auscultate for bowel sounds, and check for flatus, bowel movements, and a soft abdomen. When peristalsis resumes, and the patient’s temperature and pulse rate become normal, treatment generally calls for a decrease in parenteral fluids and an increase in oral fluids. If the patient has an NG tube in place, clamp it for short intervals. If the patient does not experience nausea or vomiting, begin oral fluids as ordered and tolerated.
Nursing care focuses on providing a stable, comfortable environment for the patient, who is experiencing both physical and psychological stress. To provide relief from pain, maintain bedrest and place the patient in the semi-Fowler position, which helps the patient breathe more deeply. Offer regular oral hygiene and lubrications to counteract mouth and nose dryness that are caused by fever, dehydration, and NG intubation. Provide psychological support by encouraging questions and verbalization of the patient’s anxieties and concerns. Teach the patient about peritonitis and what caused it in his or her case, explaining the necessary treatment.
For patients who are undergoing surgery, provide teaching before surgery. Answer questions about the surgical procedure and the potential complications. Review postoperative care procedures. Teach the patient deep-breathing and coughing exercises. Explain the duration of the patient’s hospital stay after surgery, which varies depending on the underlying cause. Postoperatively, because even slight movements intensify the patient’s pain, move the patient carefully. Keep the bed’s side rails up and implement other safety measures, particularly if fever and pain disorient the patient. Teach the patient how to care for the incision; describe signs of infection. If convalescent services are required after discharge, refer the patient to the hospital’s social service department or to a home healthcare agency.
Nursing care plan discharge and home health care guidelines
Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. If the patient is to be discharged while she or he is still on antibiotics, emphasize the need to complete the medication regimen. Teach the patient the signs of resistance (new onset of fever and abdominal pain) and superinfection (oral candida infection, yeast infection in the moist areas of the skin). Teach the patient to report any nausea; vomiting; abdominal pain; abdominal distension, bloating, or swelling; or bleeding, odor, redness, drainage, or warmth from a surgical incision. Advise the patient to seek emergency treatment for respiratory problems such as dyspnea. Teach the patient to avoid heavy lifting for 6 weeks. Review dietary and activity limitations.