Peritonitis, inflammation of the peritoneum, is usually the result of bacterial infection, with the organisms coming from disease of the gastrointestinal tract, or, in women, the internal reproductive organs. It can also result from external sources, such as injury or trauma or an inflammation from an extraperitoneal organ, such as the kidney.
PATHOPHYSIOLOGY
Peritonitis is caused by leakage of contents from abdominal organs into the abdominal cavity, usually as a result of inflammation, infection , ischemia, trauma, or tumor perforation. The most common bacterial implicated are Escherichia coli, and Klebsiella, Proteus, and Pseudomonas species. Other common causes are appendicitis, perforated ulcer, diverticulitis, and bowerl perforation. Peritonitis may also be associated with abdomional surgical procedures and peritoneal dialysis. Sepsis is the major cause of death from peritonitis (shock, from sepsis or hypovolemia). Intestinal obstruction from bowel adhesions may develop.
CLINICAL MANIFESTATIONS
Clinical features depend on the location and extent of inflammation.
• Diffuse pain becomes constant, localized, and more intense near site of the process.
• Pain is aggravated by movement.
• Affected area of the abdomen becomes extremely tender and distended, and muscles become rigid.
• Rebound tenderness and ileus may be present.
• Temperature and pulse increase; leukocyte count is elevated.
• Nausea and vomiting occurs and peristalis is diminished.
ASSESSMENT AND DIAGNOSTIC METHODS
• Leukocytes (elevated), complete blood count, hemoglobin, hematocrit, and serum electrolytes (altered potassium, sodium and chloride).
• Abdominal radiographs, computer tomography (CT) scan, and peritoneal aspiration with culture and sensitivity studies.
MEDICAL MANAGEMENT
• Fluid, colloid, and electrolyte replacement is the major focus of medical management.
• Analgesics are administered for pain; antiemetics are administered for nausea and vomiting.
• Intestinal intubation and suction are used to relieve abdominal distention.
• Oxygen therapy by nasal cannula or mask is instituted to improve ventilatory function.
• Occasionally, airway intubation and ventilatory assistance are required.
• Massive antibiotic therapy may be instituted (sepsis is the major cause of death).
• Surgical objectives include removal of infected material; surgery is directed toward excision (appendix), resection (intestine), repair (perforation), or drainage (abscess).
NURSING MANAGEMENT
PAIN MANAGEMENT
• Assess nature of pain, location in the abdomen, and shifts of pain and location.
• Assess vital signs, gastrointestinal function, fluid and electrolyte balance.
• Administer analgesic medication and position for comfort (e.g. on side with knees flexed to decrease tension on abdominal organs).
• Record intake and output and central venous pressure.
• Administer and monitor intravenous fluids closely.
• Observe and record character of any surgical drainage.
• Observe for decrease in temperature and pulse rate, softening of the abdomen, return of peristaltic sounds, and passage of flatus and bowel movements, which indicate peritonitis is subsiding.
• Increase food and oral fluids gradually, and decrease parenteral fluid fluid intake when peritonitis subsides.
• Observe and record character of drainage from postoperative wound drains if inserted; take care to avoid dislodging drains.
• Postoperatively, prepare patient and family for discharge; teach care of of incision and drains if still in place at discharge.
