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Acute Pain and Anxiety NCP for Peritonitis

Acute Pain and Anxiety : Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis: Acute Pain related to chemical irritation of the peripheral peritoneum.

Goal: reduce / eliminate the pain

Nursing Intervention:
a. Review the report of pain, record the location, duration, intensity (scale 0-10) and characteristics (shallow, sharp, constant).
Rational: the change in location / intensity is not common but may indicate the occurrence of complications.

b. Maintain semi-Fowler position as indicated
Rational: to facilitate drainage of fluids / injured because of gravity and helps minimize the pain due to movement.

c. Provide comfort measures, eg the back massage, deep breathing, relaxation exercises / visualization.
Rational: increase relaxation and may increase the patient's coping abilities by refocusing attention.

d. Give frequent mouth care. Eliminate unpleasant environmental stimuli.
Rational: reduce nausea / vomiting, which can increase the pressure / intra-abdominal pain.

Nursing Diagnosis for Peritonitis: Anxiety or fear related to the threat of death / change in health status.

Goal: to reduce or eliminate anxiety

Nursing Intervention:
a. Evaluation of anxiety levels, record verbal responses and non-verbal patients. Encourage the free expression of emotions.
Rational: fear can occur because of severe pain, increasing pain, it is important to the diagnostic procedures and possible surgery.

b. Provide information about the disease process and the anticipated action
Rational: knowing what is expected to reduce anxiety.

c. Schedule adequate rest and sleep periods stop
Rational: limiting weaknesses, save energy, and can enhance coping abilities.

Deficient Fluid Volume Nursing Care Plan for Peritonitis

Imbalanced Nutrition Less Than Body Requirements Nursing Care Plan for Peritonitis

Risk for Infection Nursing Care Plan for Peritonitis

Pathophysiology of Peritonitis

Pathophysiology of Peritonitis

The initial reaction of peritoneum to invasion by bacteria is a discharge of exudate fibrinosa. Pockets of pus (abscess) formed between fibrinosa adhesions, which stick together with the surrounding surface and limit the infection. Attachment usually disappears when the infection disappeared, but may persist as fibrous bands, which later can lead to intestinal obstruction.

Cause inflammation and fluid accumulation due to capillary membrane leak. If the fluid deficit is not corrected quickly and aggressively, it can cause cell death. The release of various mediators, such as interleukins, could start hyperinflammatory response, thus bringing to the subsequent development of many organ failure. Because the body tries to compensate by way of fluid and electrolyte retention by the kidneys, waste products also accumulate. Tachycardia initially improve cardiac output, but it soon failed so happens hypovolemia.

Organs including the peritoneal cavity in the abdominal wall edema experienced. Edema caused by capillary permeability organs is rising. Collection of fluid in the peritoneal cavity, and intestinal lumen and lumen-whole organ edema, intra-peritoneal and abdominal wall edema, including the retroperitoneal tissue causing hypovolemia. Hypovolemia increases with the increase in temperature, there is no input, and vomiting.
Entrapped liquid in the peritoneal cavity and intestinal lumen, further increasing intra-abdominal pressures, making full efforts into breathing difficult and cause a decrease in perfusion.

If the material is spread to infect the peritoneal surface or if the infection spreads, general peritonitis may arise. With the development of general peritonitis, peristaltic activity is reduced to arise paralytic ileus; intestine then becomes Atoni and stretch. Lost fluids and electrolytes into the intestinal lumen, resulting in dehydration, shock, circulatory disorders and oliguria. Adhesions can form between the arches are stretched intestines and can interfere with the recovery of bowel movements and cause intestinal obstruction.

Deficient Fluid Volume Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis Deficient Fluid Volume related to active fluid volume loss.

Deficient Fluid Volume NANDA Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium

Characteristics

Decreased urine output
Concentrated urine
Output greater than intake
Sudden weight loss
Decreased venous filling
Hemoconcentration
Increased serum sodium
Hypotension
Thirst
Increased pulse rate
Decreased skin turgor
Dry mucous membranes
Weakness
Possible weight gain
Changes in mental status

Goal:
To identify interventions to improve the balance of fluid and minimize the inflammatory process to improve comfort.

Expected outcomes:

Adequate urine output with normal specific gravity,
Stable vital signs
Mucous membranes moist
Good skin turgor
The capillary rise
Weight within the normal range.

Nursing Interventions Deficient Fluid Volume Nursing Care Plan for Peritonitis

Independent:

1. Monitor vital signs, note the presence of hypotension (including postural changes), tachycardia, tachypnea, fever. Measure CVP if any.
Rational: To assist in the evaluation of the degree of fluid deficit / effectiveness of fluid replacement therapy and response to treatment.

2. Maintain adequate intake and output and then connect with the body weight daily.
Rationale: Demonstrates overall hydration status.

3. Rehydration / resuscitation fluid
Rationale: To meet the need of fluid in the body (homeostasis).

4. Measure specific gravity of urine
Rationale: Demonstrates changes in hydration status and renal function.

5. Observation of skin / mucous membranes for dryness, turgor, note peripheral edema / sacral.
Rational: Hypovolemia, fluid displacement, and lack of nutrition aggravate skin turgor, adding tissue edema.

6. Eliminate the danger signs / smells from environment. Limit intake of ice cubes.
Rational: Lowering the gastric stimulation and vomiting response.

7. Change positions frequently give skin care with often, and keep the bed dry and free of folds.
Rational: tissue edema and circulatory disturbance tends to damage the skin.

Collaboration:

1. Monitor laboratory examinations, eg Hb / hematocrit, electrolytes, protein, albumin, BUN, creatinine.
Rationale: Provides information about hydration and organ function.

2. Give the plasma / blood, fluids, electrolytes.
Rational: Charge / maintain circulating volume and electrolyte balance. Colloid (plasma, blood) to help move the water into the area by increasing intravascular osmotic pressure.

3. Keep fasting with nasogastric aspiration / intestinal
Rational: Lowering intestinal hyperactivity, and loss from diarrhea.

Imbalanced Nutrition Less Than Body Requirements Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis : Imbalanced Nutrition, Less Than Body Requirements related to anorexia and vomiting.

Imbalanced Nutrition, Less Than Body Requirements NANDA Definition: Intake of nutrients insufficient to meet metabolic needs.

Characteristics :

Loss of weight
Lack of interest in food
Pale conjunctiva and mucous membranes
Poor muscle tone
Amenorrhea
Poor skin turgor
Edema of extremities
Electrolyte imbalances
Weakness
Constipation
Anemias

Goals

Client will gain 2 pounds per week for the next 3 weeks.
Client will exhibit no signs or symptoms of malnutrition by time of discharge from treatment (e.g., electrolytes and blood counts will be within normal limits; a steady weight gain will be demonstrated; constipation will be corrected; client will exhibit increased energy in participation in activities).

Nursing Interventions Imbalanced Nutrition, Less Than Body Requirements for Peritonitis

Independent:

1. Monitor bow NG tube, and note the presence of vomiting or diarrhea.
Rational: The large number of gastric aspiration and vomiting or diarrhea is suspected bowel obstruction, requiring further evaluation.

2. Measure body weight each day.
Rationale: Loss of or increase in early showed further changes in hydration but loss is suspected nutritional deficit.

3. Auscultation bowel sounds, record sounds nothing or hyperactive.
Rationale: Although there is no frequent bowel sounds, bowel inflammation or irritation may accompany intestinal hyperactivity, decreased water absorption, and diarrhea.

4. Record the required calorie needs.
Rational: The calories (energy sources) will accelerate the healing process.

5. Monitor Hb and albumin
Rational: Indications adequate protein to the immune system.

6. Assess abdomen with frequent return to the gentle sound, the appearance of normal bowel sounds, flatus smooth dam.
Rationale: Indicates the return to normal bowel function.

Collaboration:

1. Collaborative installation NGT if the client can not eat and drink orally.
Rational: In order to keep the client nutrients are met.

2. Collaboration with a dietitian in your diet.
Rational: A healthy body is not easy for infection (inflammation).

3. Provide information about the food substances which are very important to balance the body's metabolism
Rationale: Clients can strive to meet the needs of eating nutritious food.

Risk for Infection Nursing Care Plan for Peritonitis

Nursing Diagnosis for Peritonitis : Risk for Infection related to tissue trauma

Risk for Infection NANDA Definition: At increased risk for being invaded by pathogenic organisms

Goal: Reduce infections, improve patient comfort.

Expected outcomes:

Increased healing in time, free of purulent drainage or erythema, no fever.
Stated understanding of the causes of individual / risk factors.

Nursing Interventions Risk for Infection for Peritonitis

Independent:

1. Note the example of individual risk factors abdominal trauma, acute appendicitis, peritoneal dialysis.
Rational: Affects choice of interventions

2. Assess vital signs with frequent, noted no improvement or continuing hypotension, decreased pulse pressure, tachycardia, fever, tachypnea.
Rationale: Signs of septic shock, endotoxin circulation causes vasodilation, loss of fluid from the circulation, and low cardiac output status.

3. Note the change in mental status (eg, confusion, fainting).
Rational: Hypoxaemia, hypotension, and acidosis can cause irregularities in mental status.

4. Note the color, temperature, humidity.
Rational: Warm, redness, dry skin is an early sign of septicemia. Further manifestations include cold, pale skin moist and cyanosis as a sign of shock.

5. Monitor urine output.
Rational: Oliguria occurred as a result of reduced renal perfusion, the toxin in the circulation affects the antibiotic.

6. Maintain strict aseptic technique in the treatment of abdominal drain, wound incision / open, and the invasive side.
Rationale: Prevent the spread and limit the spread of infectious organisms / cross contamination.

7. Observations on wound drainage.
Rationale: Provides information about the status of infection.

8. Maintain sterile technique when the patient is placed catheters, and catheter care provided / or perineal hygiene routine.
Rasonal: Preventing the spread, limiting the growth of bacteria in the urinary tract.

9. Supervise / limit visitors and staff as needed. Provide insulation protection when indicated.
Rational: Reduce the risk of exposure to / add a secondary infection in patients who experienced immune pressure.

Collaboration:

1. Take for example / watch the results of serial blood, urine, wound cultures.
Rationale: Identifying microorganisms and assist in assessing the effectiveness of antimicrobial program.

2. Assist in the peritoneal aspiration, if indicated.
Rational: Guide to drain fluids and to identify infectious organisms so that appropriate antibiotics but can be given.

3. Prepare for surgical intervention when indicated
Rationale: Treatment of choice (curative) in acute peritonitis or local, for example a local abscess drainage, peritoneal exudate throw, throw rupturapendiks / gall bladder, cope with perforated ulcer, or bowel resection.