PERITONITIS

PERITONITIS
PERITONITIS
H.AKOUM
PERITONITIS
Peritonitis is a generalized or localized
inflammation of the peritoneum, the
membrane lining the abdominal cavity
and covering visceral organs.
Pathophysiology and Etiology
Primary Peritonitis
• Acute, spontaneous condition; relatively rare
• People with nephrosis or cirrhosis; the offending organism is usually
Escherichia coli.
• May occur in young females; introduced through uterine tubes or blood due
to pathogenic bacteria, such as streptococci, pneumococci, or gonococci.
Secondary Peritonitis
• Contamination of peritoneal cavity by GI fluid and microorganisms.
• Complication of appendicitis, diverticulitis, peptic ulceration, biliary tract
disease, colon inflammation, volvulus, strangulated obstruction, perforation,
abdominal cancers.
• May occur after abdominal trauma: gunshot wound, stab wound, or blunt
trauma from motor vehicle accident.
• May occur as postoperative complication.
– May occur after intraoperative intestinal spillage.
– Compromised patients are vulnerable (those with diabetes, malignancy,
malnutrition, or steroids).
• May result from continuous ambulatory peritoneal dialysis.
Clinical Manifestations
• Initially, local type of abdominal pain tends to become constant, diffuse,
and more intense.
• Abdomen becomes extremely tender and muscles become rigid; rebound
tenderness and ileus may be present; patient lies very still, usually with
legs drawn up.
• Percussion: resonance and tympany due to paralytic ileus; loss of liver
dullness may indicate free air in abdomen.
• Auscultation: decreased bowel sounds.
• Nausea and vomiting often occur; peristalsis diminishes; anorexia is
present.
• Elevation of temperature and pulse as well as leukocytosis.
• Fever; thirst; oliguria; dry, swollen tongue; signs of dehydration.
• Weakness, pallor, diaphoresis, and cold skin are a result of the loss of
fluid, electrolytes, and protein into the abdomen.
• Hypotension, tachycardia, and hypokalemia may occur.
• Shallow respirations may result from abdominal distention and upward
displacement of the diaphragm.
• Note: With generalized peritonitis, large volumes of fluid may be lost into
abdominal cavity (can account for losses to 5 L/day).
• Ascites
Diagnostic Evaluation
• WBC to show leukocytosis (leukopenia if severe).
• ABG levels may show hypoxemia or metabolic acidosis with
respiratory compensation.
• Urinalysis may indicate urinary tract problems as primary source.
• Peritoneal aspiration (paracentesis) to demonstrate blood, pus,
bile, bacteria (Gram's stain), amylase.
• Abdominal X-rays may show free air in peritoneal cavity, gas and
fluid collection in small and large intestines, generalized bowel
dilatation, intestinal wall edema.
• CT scan of abdomen or sonography may reveal intra-abdominal
mass, abscess, ascites.
• Radionuclide scans (gallium, HIDA, and liver/spleen scan) may
identify an intra-abdominal abscess.
• Chest X-ray may show elevated diaphragm.
• Exploratory laparotomy is performed to identify the underlying
cause.
Management
• Treatment of inflammatory conditions preoperatively and postoperatively
with antibiotic therapy may prevent peritonitis. Broad-spectrum antibiotic
therapy to cover aerobic and anaerobic organisms is initial treatment,
followed by specific antibiotic therapy after culture and sensitivity results.
• Bed rest, NPO status, respiratory support if needed.
• I.V. fluids and electrolytes, possibly TPN.
• Analgesics for pain; antiemetics for nausea and vomiting.
• NG intubation to decompress the bowel.
• Possibly rectal tube to facilitate passage of gas.
• Operative procedures to close perforations, remove infection source (ie,
inflamed organ, necrotic tissue), drain abscesses, and lavage peritoneal
cavity.
• Abdominal paracentesis may be done to remove accumulating fluid.
• Blood transfusions, if appropriate.
• Oral feedings after return of bowel sounds and passage of gas and/or
feces.
Complications
• Intra-abdominal abscess formation

(ie, pelvic subphrenic space)
• Septicemia
• Hypovolemic problems
• Renal or liver failure
• Respiratory insufficiency
Nursing Assessment
• Assess for abdominal distention and tenderness,

guarding, rebound, hypoactive or absent bowel
sounds to determine bowel function.
• Observe for signs of shock tachycardia and
hypotension.
• Monitor vital signs, ABG levels, CBC, electrolytes,
and central venous pressure to monitor
hemodynamic status and assess for complications
Nursing Diagnoses
• Acute Pain related to peritoneal

inflammation
• Deficient Fluid Volume related to vomiting
and interstitial fluid shift
• Imbalanced Nutrition: Less Than Body
Requirements related to GI
symptomatology
Nursing Interventions
Achieving Pain Relief
• Place the patient in semi-Fowler's position before surgery to
enable less painful breathing.
• After surgery, place the patient in Fowler's position to promote
drainage by gravity.
• Provide analgesics as prescribed.
Maintaining Fluid and Electrolyte Volume
• Keep patient NPO to reduce peristalsis.
• Provide I.V. fluids to establish adequate fluid intake and to
promote adequate urine output, as prescribed.
• Record accurately intake and output, including the measurement of
vomitus and NG drainage.
• Minimize nausea, vomiting, and distention by use of NG suction,
antiemetics.
• Monitor for signs of hypovolemia: dry mucous membranes, oliguria,
postural hypotension, tachycardia, diminished skin turgor.
Nursing Interventions
Achieving Adequate Nutrition
• Administer TPN, as ordered, to maintain positive nitrogen
balance until patient can resume oral diet.
• Reduce parenteral fluids and give oral food and fluids per
order, when the following occur:
– Temperature and pulse return to normal.
– Abdomen becomes soft.
– Peristaltic sounds return (determined by abdominal
auscultation).
– Flatus is passed, and patient has bowel movements.
Patient Education and Health Maintenance
• Teach patient and family how to care for open wounds and
drain sites, if appropriate.
• Assess the need for home care nursing to assist with wound
care and assess healing; refer as necessary.
Evaluation: Expected Outcomes
• Minimal analgesics needed; abdomen

soft, nontender, and no distention
• Balanced intake and output, no
evidence of dehydration or
electrolyte imbalances
• Bowel sounds present; tolerating soft
diet

PERITONITIS

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PERITONITIS

• Intra-abdominal abscess formation

• Assess for abdominal distention and tenderness,

• Acute Pain related to peritoneal

• Minimal analgesics needed; abdomen

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