Peritonitis is a serious condition that results from a generalized or localized inflammatory process in the peritoneum or abdomen with a primary or secondary cause.
Primary peritonitis is characterized by blood-borne organisms entering the peritoneal cavity. Secondary peritonitis, the more common type, occurs when abdominal organs rupture or perforate (Bowel Perforation) and release their contents into the peritoneal cavity. This is often caused by a ruptured appendix, perforated gastric ulcer, or a severely inflamed gallbladder.
When bacterial and other intestinal contents enter the peritoneum, they can irritate the sterile peritoneal cavity and initiate chemical peritonitis. Inflammation will start, which leads to massive fluid shifts (edema) and adhesions as the body will react to defend itself against infection.
Clinical manifestations of peritonitis include the following:
- Rebound tenderness in the affected area
- Abdominal pain
- Abdominal distension
- Fever
- Tachypnea
- Tachycardia
- Nausea
- Vomiting
- Altered bowel habits
Manifestations can vary depending on the severity and the acuity of the underlying condition. Peritonitis can be fatal if treatment is delayed. Complications include sepsis, hypovolemic shock, paralytic ileus, intraabdominal abscess formation, and acute respiratory distress syndrome.
This condition is confirmed by the following diagnostic tests:
- Complete blood count
- Serum electrolytes
- Abdominal x-ray
- Abdominal paracentesis
- CT scan or ultrasound
- Peritoneoscopy
Nursing Process
Patients with peritonitis require emergent treatment and skilled supportive care. The overall goal of peritonitis management and care includes resolving the inflammation, relieving abdominal pain, treating any bacterial infection, preserving skin and tissue integrity, and preventing complications like sepsis and hypovolemic shock.
Nursing Care Plans Related to Peritonitis
Acute Pain
Patients with peritonitis initially exhibit dull abdominal pain and tenderness. The abdominal pain can quickly become severe and persistent.
Nursing Diagnosis: Acute Pain
Related to:
- Biological injury agent
- Physical injury agent
- Peritoneal trauma
- Chemical irritation of the parietal peritoneum
- Fluid accumulation in the peritoneal cavity
- Inflammatory process
- Infection
As evidenced by:
- Expressive behavior
- Guarding behavior
- Tenderness on palpation
- Protective behavior
- Positioning to ease pain
- Reports pain intensity
- Reports pain characteristics
Expected outcomes:
- Patient will report pain relief.
- Patient will demonstrate interventions to help relieve pain and promote comfort.
Assessment:
1. Assess pain characteristics.
Pain characteristics, including intensity and location, may indicate the progression of the patient’s condition and possible complications. Peritonitis pain is often dull but becomes persistent and severe and is worsened by movement. A decreased appetite and nausea may accompany the pain.
2. Assess vital signs.
Alterations in vital signs can indicate worsening pain and possible complications.
Interventions:
1. Maintain an upright position.
Semi-Fowler’s position can help facilitate fluid drainage by gravity and reduce abdominal tension and diaphragmatic irritation, which can significantly reduce pain.
2. Assist the patient in slow movement and splinting.
Splinting of the abdominal area can reduce tension and the pain of movement.
3. Administer pain medications as indicated.
Narcotic analgesics are administered to help reduce pain in patients with peritonitis.
4. Reduce the discomfort of related symptoms.
Nausea and vomiting can be controlled with antiemetics. Fever can be reduced with antipyretics or nonpharmacologic interventions like cool rags.
Risk for Infection
If bacteria invades the peritoneum through a ruptured organ, trauma, or dialysis, an infectious process may occur and, if not recognized and treated, can progress to sepsis.
Nursing Diagnosis: Risk for Infection
Related to:
- Traumatized skin or tissues
- Invasive procedures
- Rupture of appendix, ulcer, colon, etc.
- Peritoneal dialysis
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions will be directed at the prevention of signs and symptoms.
Expected outcomes:
- Patient will remain free of infection.
- Patient will demonstrate how to properly care for their dialysis catheter.
- Patient will demonstrate vital signs within expected limits.
Assessment:
1. Monitor vital signs.
Hypotension, tachycardia, tachypnea, and fever are signs of sepsis.
2. Assess dialysis fluid.
Dialysis fluid that appears cloudy, has a foul odor, or has flecks or clumps in it, are signs of infection.
3. Review lab work and fluid analysis.
White blood counts will be elevated with infection. Peritoneal fluid can be obtained through a paracentesis and analyzed for bacteria.
Interventions:
1. Keep the skin around the dialysis catheter clean.
Patients who receive peritoneal dialysis should be instructed on keeping their PD catheter site clean and dry.
2. Maintain aseptic technique when accessing the PD catheter.
When performing PD, do not allow the catheter tip to touch the skin or another surface, as this will cause contamination. The nurse and patient should both wear masks during the procedure.
3. Administer antibiotics.
Broad-spectrum antibiotics should be administered until a specific pathogen is identified.
4. Prepare for surgery.
Emergency surgery may be required in cases such as trauma or a burst appendix or colon to remove tissue, repair the rupture, and prevent the spread of infectious materials.
Deficient Fluid Volume
Patients with peritonitis often have weak, injured, and inflamed peritoneum with an increased risk of infection spreading through the peritoneal cavity. When peristaltic action decreases, there is a tendency for bowel obstruction to develop, with large amounts of fluid shifting into the peritoneal cavity, leading to deficient fluid volume.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Fever
- Vomiting
- NPO status
- Fluid shifting into the peritoneal space
- Retention of fluid in the abdomen
As evidenced by:
- Dry mucous membranes
- Hypotension
- Tachycardia
- Slow capillary refill
- Weakness
- Weak peripheral pulses
- Altered skin turgor
- Decreased urine output
Expected outcomes:
- Patient will demonstrate improved fluid balance as evidenced by normal urinary output.
- Patient exhibits normal blood pressure, heart rate, and body temperature.
Assessment:
1. Assess and monitor vital signs.
Alterations in vital signs like hypotension and tachycardia can help evaluate the degree of fluid deficit and determine an appropriate treatment regimen.
2. Monitor and document the patient’s intake and output.
Intake and output can reflect the patient’s hydration status. Decreased or concentrated urinary output can indicate reduced renal perfusion, edema, or fluid accumulation in the peritoneal cavity.
Interventions:
1. Evaluate the patient’s skin integrity.
Fluid shifts in peritonitis, hypovolemia, and nutritional deficits can contribute to poor skin integrity and edematous tissues.
2. Administer fluid replacement as indicated.
Fluid replacement through blood, plasma, or electrolyte replacement, can help correct electrolyte balances, and circulating volume lost to the peritoneal cavity.
3. Administer medications as indicated.
Antiemetics may be prescribed to help reduce nausea and vomiting and prevent further loss of fluid and electrolytes.
4. Keep the patient on NPO and place a nasogastric tube as ordered.
A nasogastric tube can help decrease gastric distention and prevent further leakage of bowel contents into the peritoneal cavity.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Peritonitis. Cleveland Clinic. Reviewed: November 2, 2022. From: https://my.clevelandclinic.org/health/diseases/17831-peritonitis
- Peritonitis. Mayo Clinic. Reviewed: November 4, 2022. From: https://www.mayoclinic.org/diseases-conditions/peritonitis/symptoms-causes/syc-20376247
- Peritonitis. Johns Hopkins Medicine. 2022. From: https://www.hopkinsmedicine.org/health/conditions-and-diseases/peritonitis
- Peritonitis. WebMD. Reviewed: November 12, 2021. From: https://www.webmd.com/digestive-disorders/peritonitis-symptoms-causes-treatments
