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ST. MARY’S COLLEGE
NURSING PROGRAM
Tagum City
A CASE STUDY
On
PERITONITIS
Presented to:
Zaida S. Jo, RN, MN
In Partial Fulfillment of the Requirements
In
Related Learning Experience
(RLE)
By
Mia Charisse F. Lamparero
BSN 4
July 30, 2010
TABLE OF CONTENTS
I. INTRODUCTION 3
A Objectives 5
II. ASSESSMENT 7
A. Biographical Data 7
B. Chief Complaint 7
C. History of Present Illness 8
D. Past Medical and Nursing History 8
E. Personal, Family and Socio-Economic History 8
F. Developmental History 8
G. Patient Need Assessment 9
Physical Assessment
General survey 12
Vital signs 12
Nutritional status 13
Integumentary System 13
HEENT 13
Pulmonary System 14
Cardiovascular System 14
Gastrointestinal System 14
Musculoskeletal System 14
1
Genito-urinary System 14
Course in the Ward 14
III. LABORATORY AND DIAGNOSTIC EXAMINATIONS 19
IV. REVIEW OF ANATOMY AND PHYSIOLOGY 26
V. SYMPTOMATOLOGY 32
VI. ETIOLOGY OF THE DISEASE 34
VII. PATHOPHYSIOLOGY
A Written 35
B. Diagram of Pathophysiology 36
VIII. PLANNING
A Nursing Care Plan 38
B. Discharge Plan 45
IX. PHARMACOLOGICAL MANAGEMENT 46
X. SYNTHESIS OF CLIENT’S CONDITION/
STATUS FROM ADMISSION TO PRESENT
A Conclusion 62
B. Patient’s Prognosis 62
C. Recommendations 64
XI. EVALUATION OF THE OBJECTIVES OF
THE STUDY 65
XI. BIBLIOGRAPHY 66
A. Textbooks
B. Internet Download
2
I. INTRODUCTION
Background of the Study
Peritonitis is a serious disorder caused by an inflammation of the peritoneum, most often due to a
bacterial infection. The peritoneum is a two-layered membrane that lines the abdominal cavity
and encloses the stomach, intestines, and other abdominal organs. The membrane supports the
abdominal organs and protects them from infection. However, occasionally the peritoneum itself
may become infected by bacteria or other organisms.
Infection usually spreads from organs within the abdomen. The inflammation may affect the
entire peritoneum, or be confined to a walled-off, pus-filled cavity (abscess).
A rupture anywhere along the gastrointestinal tract is the most common pathway for entry of an
infectious agent into the peritoneum. Peritonitis is a medical emergency: the muscles within the
walls of the intestine become paralyzed and the forward movement of intestinal contents stops
(ileus). It is most often caused by introduction of an infection into the otherwise sterile peritoneal
environment through organ perforation, but it may also result from other irritants, such as foreign
bodies, bile from a perforated gall bladder or a lacerated liver, or gastric acid from a perforated
ulcer. Women also experience localized peritonitis from an infected fallopian tube or a ruptured
ovarian cyst. Patients may present with an acute or insidious onset of symptoms, limited and
mild disease, or systemic and severe disease with septic shock.
Untreated, acute peritonitis may be fatal. The fundamental role of operative therapy in the
treatment of peritonitis was documented in 1926 when Kirschner reported that the mortality rate
3
from intra-abdominal infections decreased from more than 90% to less than 40% during the
period from 1890-1924 with the introduction of operative management. Other elements, such as
advances in the understanding of damage control surgery, novel antibiotics, and improvements in
intensive care unit (ICU) treatment have now reduced mortality to approximately 20%.
(http://emedicine.medscape.com/article/192329-overview)
4
OBJECTIVES
The research for this case study, its data and substantial facts could not be attained
without the improvised objectives that are needed to be followed and observed that will guide us
in planning, preparing and arranging the information systematically. The objectives are devised
within the day of our clinical exposure. The objectives would serve us guiding principles for us
to arrive to our goals and aims.
A. General Objective:
Within the time-span of duty, the student nurse will complete the chosen case to be
studied with factual pertinent data gathered. As well as to know and familiarize other related
information connected to it and apply the nursing skills that had learned and practice not only or
the call of this study but also for the future reference.
B. Specific Objectives:
To obtain sufficient and relevant information regarding patient’s condition.
To present personal data of the patient.
To trace the present history of the patient’s health and illness and define the diagnosis of
the patient having a Peritonitis.
To conduct a thorough head-to-toe assessment serving as baseline data.
To view and discuss the anatomy and physiology of the affected organs and system
basing from the patient’s diagnosis.
To present the pathophysiology of the patient’s diagnosis, both in diagram and narrative
form and list down the actual laboratory results of the patient.
5
To identify the different drugs ordered and to know their action, indication, adverse
effects and nursing responsibilities.
To make nursing care plan appropriate for the span of care to the patient and which also
correspond his condition at least 2 actual problems and 1 risk problem.
To impart suitable and realistic health teachings to the watcher for the patient’s welfare.
To evaluate the outcome of the condition of the patient.
6
II. ASSESSMENT
A. BIOGRAPHICAL DATA
Name : Mr. Drain
Age : 25 years old
Sex : Male
Civil Status : Single
Birthdate : January 11, 1985
Birthplace : Bohol
Address: : Prk 5 Elizalde (Samil), Maco, Comval Province
Nationality : Filipino
Religion : Roman Catholic
Occupation : Miner
Attending Physician : Dr. Alvin C. Medina, M.D.
B. CHIEF COMPLAINT
The patient was admitted at Davao Regional Hospital last July 06, 2010 at 1:40 in the
dawn due to the complaint of Gunshot wound on the abdomen. He was attended at the
Emergency department and had taken a clinical history and physical assessment. He was
immediately transferred at the operating room for STAT Ex-lap. He was attended by Dr. Medina,
a resident physician of the said hospital.
7
C. HISTORY OF PRESENT ILLNESS
Patient was on his way home when he passed a check point at Mawab and was signaled to stop
but didn’t stop. The military suspected him and he was immediately was shot at the back. They
hurriedly ran the patient to the hospital and was attended and given immediate interventions.
D. PAST MEDICAL AND NURSING HISTORY
The patient had upper respiratory tract infection when he was an 8 years old. Previously
he was not hospitalized. He does have complete immunizations and has no history of
hypertension, Diabetes mellitus and PTB. Whenever he had any flu or cough, His mother uses
herbal plants. He does not have any regular medical and dental check-ups. He does not have
allergies to what ever kind of foods and medications as far as he knows. Whenever he had fever
he takes Paracetamol and Bioflu. He does not experience any severe accidents except this one.
E. PERSONAL, FAMILY AND SOCIO-ECONOMIC HISTORY
Aka Mr. Drain is a 25 years miner. He was the youngest of a family of 3. The
family of Mr. Drain belongs to a marginalized socio-economic status. In order to provide and
sustain the daily needs of their family, his father works as a carpenter and his mother is a plain
housewife. His 2 sisters were already married and have their own family.
F. DEVELOPMENTAL TASK
Robert J. Havighurst Developmental Task Theory
According to Havighurst developmental theory, Mr. Drain, 25 years of age, belongs to a
period of adulthood which was achieving mainly located in family, work, and social life. Family-
related developmental tasks are described as finding a mate, learning to live with a marriage
partner, having and rearing children, and managing the family home. Mr Drain was working and
8
suffers to be away from his family just to have money to help for their everyday expenses. He
doesn’t have time to face his own life due to attending the needs of his parents.
G. PATIENT NEED ASSESSMENT
Date: June 2
Name of Patient: Mr. Drain Age: 25 years oldSex: _Male Status: Single
Admission Date/Time: July 06, 2010/ 1:40 am
Admitting Medical Diagnosis: GSW through and through POEX® Mandibular area POEX ®
Male, GCS to level
Arrived on Unit by: per stretcher From: CENSICU Room
Accompanied by: He is accompanied by his mother
AdmittingWeight /VS: 48kgs BP- 100/60 RR-25 PR-114 Temp- 36.7
Client’s Perception of reason for Admission:
“Napusilan man gud ko maam mao naa ko dinhi sa ospital,” verbalized by the patient
How has problem been managed by client at home: NONE
Allergies: No allergies was being experience according to the patient
Medication (at home): NONE, (at the hospital): Cefoxitin, Ranitidine, Ketorolac, Tramadol,
Metronidazole, Paracetamol
Physiological Needs:
I. Oxygenation
BP _100/60 PR 114 bpm RR 25 cycles/min CR_________
Lungs (per auscultation: character: lung sound; symmetry of chest expansion; breathing
character and pattern.) fine, short, interrupted crackling sound was being heard upon
auscultation, symmetry chest expansion was being observe during breathing.
9
Cardiac status (per auscultation sounds character; chest pain?
Dull, low pitched and longer followed by a silent then higher pitch: no chest pain noted
Capillary Refill: Within 2 – 3 seconds using the blanched test
Skin Character and Color: dry, pale, dark brown in color
Life-supporting Apparatus: N-O-N-E
Other Observations (related): with colostomy to colostomy bag, JP drain, Eschar noted on
both legs.
II. Temperature Maintenance:
Temperature: 36.7º C
Skin Character: dry, pale, dark brown in color; with good skin turgor
Other Observations (related): N-O-N-E
III. Nutritional Fluid:
Height: 5’ 4’’/ 48kg. Amount of food consumed: ¼ of meal served consumed
Prescribed Diet: Diet as tolerated + 2 eggs/day
Eating Pattern: 3x a day; can only consume ¼ of served meal
Skin Character: dry, rough skin; with good skin turgor
Intake (IVF: Fluid/Water): Plain Nornal Saline Solution
Other Observations (related):slim, eschar noted on both legs
IV. Elimination:
Last Bowel Movement (frequency; amount, character): with colostomy to colostomy bag,
yellow to amber in color, few
Normal Pattern: every meal
10
Urination (frequency, amount, character, sensation): twice, with yellow ambered colored
urine, about 200 cc.
Other Observations (related): N-O-N-E
V. Rest-Sleep:
Bed Time: 6: 00PM Waking Up Time: 6:00 AM
Sleep (amount of sleep): 4-5 hours
Problems (as verbalized): “Wala ko katulog kagabii kay sakit akoang tahi og igang pud
kaayo”
Other Observations (related): N-O-N-E
VIII. Stimulation-Activity:
Work: Miner
Reaction/Past time: Drinking while chatting with other co-worker
Hobbies/Vices: Alcoholic Drinker/ Smoker
Safety-Security Need
Neuro V/S: 15/15
Mental Status (coherent, responsive, conscious, unconscious): Coherent, Responsive and
consciuos
Emotional Problem (diaphoretic, trembling, restless) Irritable, diaphoretic and fatigue.
Love-Belonging Need
Children (living with?) NONE
Husband (living with?) NONE
11
Self – Esteem Need
-Need to accept to be independent but still needs assistance to people around him. Appreciate the
care and love of family. Need to discuss feelings and concerns. Interact effectively to people.
Self- Actualization Need
- Control one’s emotions and discipline self particularly in taking care of health. Need to learn to
listen and follow what is advised for easy recovery.
PHYSICAL ASSESSMENT
General Survey
Patient received lying on bed, awake, responsive, coherent to verbal communication, dry lips,
with normal capillary refill (less than 3 sec) with heplock ; fatigue and weakness noted
Vital Signs
Date/Shift Time Temp BP PR RR O2 SAT OUTPUT OUTPUT
7/6/10
11-7
1:20 am 36.5 100/60 114 25 96
7-3 8:15 am 36 80/50 128 20 98
8:45 am 36 90/60 100 20 100
7/8/10
7-3
9:30 am 38.4 150/90 108 26 94
7/9/10
11-7
1:18 pm 38.5 120/80 93 22
7-3 9:20 am 39.1 140/90 106 23
7/10/10 4:20pm 38 120/80 92 20
12
3-11
7/16/10
7-3
2:15 am 38.1 120/70 89 22
7/17/10
7-3
10:50
am
38 130/80 101 23
3-11 6:00pm 35.5 140/90 98 22
07/18/10
11-7
2:30 38.2 140/70 90 25
Nutritional Status
Upon admission, patient was on NPO diet until he was transferred to CENSICU. He was then
on DAT when he already expel flatus and that was when he was already transferred at Surgery
Male Ward Normally takes meal 3 times a day. Depending on varied conditions, he consumes
moderate amount of food per meal. No known hypersensitivity to food allergens and other
problems related to food consumption.
Integumentary System
Fine and thin yet dry hair was noted. His nails were in convex shape, smooth in texture,
capillary refill of less than 3 seconds with pale nail beds. With good skin turgor, dry, and brown
in color. Eschar was noted on both legs. Incision at the abdomen and at the lateral side of the
back noted with colostomy to colostomy bag attached with JP drain.
HEENT
The size of head was in proportion with the body. The eyes were symmetrical with the ears
(pinna); pupils react spontaneously to light, with pale conjunctiva. Eyebrows symmetrically
13
aligned, eyelashes equally distributed, lids closed symmetrically. With approximately 15 to 20
blinks per minute. No discharges noted on ears. Nasal septum was intact and in the midline, no
discharges or flaring, air moves freely through the nares. Non-pitting edema noted at both feet.
Pulmonary System
With symmetrical chest expansion; crackles sound heard upon auscultation; RR: 25 cpm
Cardiovascular System
Cardiac sound from dull, low pitched (“lub”) to higher pitch (“dub”) sound , with irregular
cardiac rhythm ; 114 beats per minute abnormal. Capillary refill time takes less than 3 seconds .
Gastrointestinal System
With colostomy to colostomy bag, with fecal content brownish to yellowish in color.
Musculoskeletal System
Weakness and fatigue noted as manifestation of the disease process, marked reluctant to
move. With limited range of motion.
Genito-urinary System
Patient voided after meal in our shift. Urine appears amber in color, moderate in amount.
Client’s normal voiding pattern is 4 times a day. Palpation on kidneys reveals no evidence of
tenderness and distention.
H. COURSE IN THE WARD
Date/Shift Nurse’s
Assessment
Nurse
Intervention
Rationale Medical
Management
Rationale.
07/06/10
3-11
2PM
-awake,
palor
-V/S: T:36.5
-labs forwarded
X-ray done
- to diagnose
pt condition
-Labs: CBC
X-RAY abd.
(STAT)
- to diagnose
pt condition
14
BP: 100/60
RR: 25
PR:114
-Gunshot
wound on
periumbilical
area
-consciuos,
coherent and
body
weakness
noted
-on NPO
instructed
-IVF started @
left arm @160
cc/hr
-PNSS @ right
arm @ 20 cc/hr
-consent
secured for ex-
lap
-abdominal
perineal prep
shaving done
- to prevent
aspiration
- When
infused into
the body it
acts
(temporarily)
to increase
the blood
volume, and
bring up the
blood
pressure.
- protocol to
promote
safety to the
medical
team on
whatever
will happen
-NPO
-IVF: PLR @
160 cc/hr
PNSS @20
cc/hr
-Meds:
Cefuxity 1g
IVTT
Metronidazole
Ranitidine
-For STAT
exlap
-secure
consent
-secure 4 units
of blood
-to prevent
aspiration
- When
infused into
the body it
acts
(temporarily)
to increase
the blood
volume, and
bring up the
blood
pressure.
- People with
peritonitis
often need
surgery to
remove
infected
tissue and
repair
damaged
organs.
15
-FC To UB
inserted
-NGT inserted
with distal end
keep opened
-to have an
accurate
monitoring
of urine
I&O every
hour
- to
determine
decrease UO
6:40 AM - with FC to
UB
-output of
yellow
colored urine
-Post –exlap
-NGT open
to drain
-no output
upon
received
-with BT
-abdominal
tape dressing
intact with
ileostomy
-BT regulated
to 120cc/hr
-keep
thermoregulated
-hurled for 02
inhalation
-v/s checked
and recorded
-to replace
loss of blood
during
operation
-to prevent
chills,
normal due
to anesthetic
effect.
-to PACU
-NPO
V/S q 15
Meds:
Ketorolac
Tramadol
-Keep warm
-Transfuse 2
units of blood
-Repeat Hgh
and Hct
-I & O q hr
- Avoid
aspiration
precaution
- to have
baseline
data, for
close
monitoring
- to prevent
chills,
normal due
to anesthetic
effect.
7/07/10 -with O2 @ -placed on bed - To promote - NPO - To promote
16
7-3
7 am
5 LPM via
face mask.
comfortably
-hooked to
cardiac monitor
-due meds
given
proper
distribution
of oxygen
throughout
the body
-to have
baseline data
for close
monitoring
-MHBR
-Meds:
Furosemide
Salbutamol
proper
distribution
of oxygen
throughout
the body
7/08/10
7-3
7:50 am
-awake,
coherent and
responsive to
verbal
command
-ileostomy
out put
yellowish in
color
-monitor I& O -for close
monitoring
-May sit on
bed
-remove FBC
-Retain NGT
-encourage
ambulation
-monitor
ileostomy
output
7/11/10 -Encouraged to
observe good
hygiene,
encouraged to
- to promote
relaxation
and comfort
- promote
-Shift
Cefoxitin to
Co-amoxiclav
17
have a full body
bath, increase
OFI and eat
nutritious foods
-Due meds
given
wound
haeling
7/13/10
3-11
7pm
- febrile
T:39.9
-Monitor V/S
-Labs for
approval
V/S referred to
Dr Corpuz
-HOLD MGH
as ordered
-reinserted with
D5LR 1 Liter
@ 30 gtts/min.
- to have
baseline date
for close
monitoring.
-HOLD MGH
-labs: CBC
-STAT:
createnine,
Na, K
-for STAT
IVP once with
normal crea
to have
baseline date
for close
monitoring
7/20/10
7-3
10:15 am
-on HBR,
asleep, dry
and cyanotic
lips with
wound @
Right lower
extremities.
-Encouraged
full body bath
-Health
teachings on
eating nutritious
foods such as
fruits and
- To promote
proper
distribution
of oxygen
throughout
the body
-to promote
-high protein
diet
to promote
early wound
healing
18
vegetables early wound
healing
III. LABORATORY AND DIAGNOSTIC EXAMINATIONS
LAB EXAM NORMAL
VALUE
RESULTY INTERPRETATION/IMPLICATION
Hematology 07/ 11/10
Hemoglobin 134-136g/L 105 DECREASE. The primary cause could be
the disorders of the bone marrow. However,
there are other common factors such as poor
nutrition that is associated with the vitamin
(B 12, folic acid) and mineral deficiency
like Iron should not be overlooked. Some
time any malabsorption syndrome of the
gastrointestinal tract could lead to poor
absorption of these vitamins and minerals
even though these are adequately supplied
via the food.( http://www.labtestsonline.org/
understanding/analytes/hematocrit/test.html)
Leukocyte
Concentration
5.0-10.0 13.6 INCREASE. This increase in leukocytes
(primarily neutrophils) is usually
19
accompanied by a "left shift" in the ratio of
immature to mature neutrophils. The
increase in immature leukocytes increases
due to proliferation and release of
granulocyte and monocyte precursors in the
bone marrow which is stimulated by several
products of inflammation including C3a and
G-CSF.
( http://en.wikipedia.org/wiki/Leukocytosis)
Segmenters 0.40-0.60 0.81 INCREASE. indicates viral infection
Lymphocytes 0.25-0.40 0.19 DECREASE. Indicate diseases that affect
the immune system, such as lupus, and the
later stages of HIV infection.
Hematology 07/ 16/10
Hemoglobin 134-136g/L 98 DECREASE. The primary cause could be
the disorders of the bone marrow. However,
there are other common factors such as poor
nutrition that is associated with the vitamin
(B 12, folic acid) and mineral deficiency
like Iron should not be overlooked. Some
time any malabsorption syndrome of the
gastrointestinal tract could lead to poor
absorption of these vitamins and minerals
20
even though these are adequately supplied
via the food.( http://www.labtestsonline.org/
understanding/analytes/hematocrit/test.html)
Leukocyte
Concentration
5.0-10.0 17.9 INCREASE. This increase in leukocytes
(primarily neutrophils) is usually
accompanied by a "left shift" in the ratio of
immature to mature neutrophils. The
increase in immature leukocytes increases
due to proliferation and release of
granulocyte and monocyte precursors in the
bone marrow which is stimulated by several
products of inflammation including C3a and
G-CSF.
( http://en.wikipedia.org/wiki/Leukocytosis)
Lymphocytes 0.25-0.40 0.19 DECREASE. Indicate diseases that affect
the immune system, such as lupus, and the
later stages of HIV infection.
Hematology 07/ 20/10
Hemoglobin 134-136g/L 112 DECREASE. The primary cause could be
the disorders of the bone marrow. However,
there are other common factors such as poor
nutrition that is associated with the vitamin
(B 12, folic acid) and mineral deficiency
21
like Iron should not be overlooked. Some
time any malabsorption syndrome of the
gastrointestinal tract could lead to poor
absorption of these vitamins and minerals
even though these are adequately supplied
via the food.( http://www.labtestsonline.org/
understanding/analytes/hematocrit/test.html)
Leukocyte
Concentration
5.0-10.0 15.7 INCREASE. This increase in leukocytes
(primarily neutrophils) is usually
accompanied by a "left shift" in the ratio of
immature to mature neutrophils. The
increase in immature leukocytes increases
due to proliferation and release of
granulocyte and monocyte precursors in the
bone marrow which is stimulated by several
products of inflammation including C3a and
G-CSF.
( http://en.wikipedia.org/wiki/Leukocytosis)
Segmenters 0.40-0.60 0.92 INCREASE. indicates viral infection
Lymphocytes 0.25-0.40 0.07 DECREASE. Indicate diseases that affect
the immune system, such as lupus, and the
later stages of HIV infection.
22
ARTERIAL BLOOD GAS RESULTS 07/ 20/10
Lab Exam Normal Result Interpretation/ Implication
Ph 7.35-7.45 7.33 WITHIN NORMAL RANGE
PCO2 35-45 21.7 DECREASE.
PO2 80-100 131.1 INCREASE
HCO3 22-26 15.2 DECREASE
B.E + or -2 12.2 INCREASE
O2 SAT 95-100% 98.5 WITHIN NORMAL RANGE
IMPRESSION: Respiratory Alkalosis and Metabolic Acidosis, Hypovolemic shock.
SERUM ELECTROLYTES 07/ 07/10
Lab Exam Normal Result Interpretation/ Implication
Createnine 53.0-115.0 159.6 INCREASE. Increased creatinine levels in
the blood suggest diseases or conditions that
affect kidney function. These can include:
Damage to or swelling of blood vessels in
the kidneys (glomerulonephritis) caused by,
for example, infection or autoimmune
diseases. Bacterial infection of the kidneys
(pyelonephritis) . Death of cells in the
kidneys’ small tubes (acute tubular necrosis)
caused, for example, by drugs or
toxins .Prostate disease, kidney stone, or
23
other causes of urinary tract obstruction.
Reduced blood flow to the kidney due to
shock, dehydration, congestive heart failure,
atherosclerosis, or complications of diabetes
(http://www.labtestsonline.org/understanding
/analytes/creatinine/test.html)
Calcium 1.13-1.32 1.14 WITHIN NORMAL RANGE
Sodium 135-148 146.7 WITHIN NORMAL RANGE
Potassium 3.50-5.00 3.91 WITHIN NORMAL RANGE
SERUM ELECTROLYTES 07/ 16/10
Lab Exam Normal Result Interpretation/ Implication
Createnine 53.0-115.0 159.6 INCREASE. Increased creatinine levels in
the blood suggest diseases or conditions that
affect kidney function. These can include:
Damage to or swelling of blood vessels in
the kidneys (glomerulonephritis) caused by,
for example, infection or autoimmune
diseases. Bacterial infection of the kidneys
(pyelonephritis) . Death of cells in the
kidneys’ small tubes (acute tubular necrosis)
caused, for example, by drugs or
toxins .Prostate disease, kidney stone, or
24
other causes of urinary tract obstruction.
Reduced blood flow to the kidney due to
shock, dehydration, congestive heart failure,
atherosclerosis, or complications of diabetes
(http://www.labtestsonline.org/understanding
/analytes/creatinine/test.html)
Calcium 1.13-1.32 1.24 WITHIN NORMAL RANGE
Sodium 135-148 134 WITHIN NORMAL RANGE
Potassium 3.50-5.00 4.99 WITHIN NORMAL RANGE
SERUM ELECTROLYTES 07/ 18/10
Lab Exam Normal Result Interpretation/ Implication
Createnine 53.0-115.0 108.7 WITHIN NORMAL RANGE
Calcium 1.13-1.32 1.24 WIHTIN NORMAL RANGE
Sodium 135-148 131.8 WITHIN NORMAL RANGE
Potassium 3.50-5.00 4.27 WITHIN NORMAL RANGE
SERUM ELECTROLYTES 07/ 20/10
Lab Exam Normal Result Interpretation/ Implication
Createnine 53.0-115.0 96.3 WITHIN NORMAL RANGE
25
IV. REVIEW OF ANATOMY AND PHYSIOLOGY
A. Anatomy and Physiology
THE DIGESTIVE SYSTEM
The functions of the
digestive system are:
Ingestion - eating
food
Digestion -
breakdown of the
food
Absorption -
extraction of
nutrients from the
food
Defecation -
removal of waste
products
The digestive system also
builds and replaces cells
and tissues that are constantly dying.
26
Digestive Organs
The digestive system is a group of organs (Buccal cavity (mouth), pharynx, oesophagus,
stomach, liver, gall bladder, jejunum, ileum and colon) that breakdown the chemical components
of food, with digestive juices, into tiny nutrients which can be absorbed to generate energy for
the body.
The Buccal Cavity
Food enters the mouth and is chewed by the teeth, turned over and mixed with saliva by the
tongue. The sensations of smell and taste from the food sets up reflexes which stimulate the
salivary glands.
The Salivary glands
These glands increase their output of secretions through three pairs of ducts into the oral cavity,
and begin the process of digestion.
Saliva lubricates the food enabling it to be swallowed and contains the enzyme ptyalin which
serves to begin to break down starch.
The Pharynx
Situated at the back of the nose and oral cavity receives the softened food mass or bolus by the
tongue pushing it against the palate which initiates the swallowing action.
At the same time a small flap called the epiglottis moves over the trachea to prevent any food
particles getting into the windpipe.
27
From the pharynx onwards the alimentary canal is a simple tube starting with the salivary glands.
The Oesophagus
The oesophagus travels through the neck and thorax, behind the trachea and in front of the aorta.
The food is moved by rhythmical muscular contractions known as peristalsis (wave-like
motions) caused by contractions in longitudinal and circular bands of muscle. Antiperistalsis,
where the contractions travel upwards, is the reflex action of vomiting and is usually aided by the
contraction of the abdominal muscles and diaphragm.
The Stomach
The stomach lies below the diaphragm and to the left of the liver. It is the widest part of the
alimentary canal and acts as a reservoir for the food where it may remain for between 2 and 6
hours. Here the food is churned over and mixed with various hormones, enzymes including
pepsinogen which begins the digestion of protein, hydrochloric acid, and other chemicals; all of
which are also secreted further down the digestive tract.
The stomach has an average capacity of 1 litre, varies in shape, and is capable of considerable
distension. When expanding this sends stimuli to the hypothalamus which is the part of the brain
and nervous system controlling hunger and the desire to eat.
The wall of the stomach is impermeable to most substances, although does absorb some water,
electrolytes, certain drugs, and alcohol. At regular intervals a circular muscle at the lower end of
the stomach, the pylorus opens allowing small amounts of food, now known as chyme to enter
the small intestine.
28
Small Intestine
The small intestine measures about 7m in an average adult and consists of the duodenum,
jejunum, and ileum. Both the bile and pancreatic ducts open into the duodenum together. The
small intestine, because of its structure, provides a vast lining through which further absorption
takes place. There is a large lymph and blood supply to this area, ready to transport nutrients to
the rest of the body. Digestion in the small intestine relies on its own secretions plus those from
the pancreas, liver, and gall bladder.
The Pancreas
The Pancreas is connected to the duodenum via two ducts and has two main functions:
1. To produce enzymes to aid the process of digestion
2. To release insulin directly into the blood stream for the purpose of controlling blood
sugar levels
Enzymes suspended in the very alkaline pancreatic juices include amylase for breaking down
starch into sugar, and lipase which, when activated by bile salts, helps to break down fat. The
hormone insulin is produced by specialised cells, the islets of Langerhans, and plays an
important role in controlling the level of sugar in the blood and how much is allowed to pass to
the cells.
The Liver
The liver, which acts as a large reservoir and filter for blood, occupies the upper right portion of
abdomen and has several important functions:
29
1. Secretion of bile to the gall bladder
2. Carbohydrate, protein and fat metabolism
3. The storage of glycogen ready for conversion into glucose when energy is required.
4. Storage of vitamins
5. Phagocytosis - ingestion of worn out red and white blood cells, and some bacteria
The Gall Bladder
The gall bladder stores and concentrates bile which emulsifies fats making them easier to break
down by the pancreatic juices.
The Large Intestine
The large intestine averages about 1.5m long and comprises the caecum, appendix, colon, and
rectum. After food is passed into the caecum a reflex action in response to the pressure causes
the contraction of the ileo-colic valve preventing any food returning to the ileum. Here most of
the water is absorbed, much of which was not ingested, but secreted by digestive glands further
up the digestive tract. The colon is divided into the ascending, transverse and descending colons,
before reaching the anal canal where the indigestible foods are expelled from the body.
THE PERITONEUM
The peritoneal membrane is a semi-permeable membrane that lines the abdominal wall (parietal
peritoneum) and covers the abdominal organs (visceral peritoneum). The membrane is a closed
sac in males. The fallopian tubes and ovaries open into the peritoneal cavity in females. The size
30
of the membrane approximates the body surface area (1-2 m2). There are about 100 cc of
transudate that is contained in the cavity in normal individuals.
A. Blood Supply
The parietal peritoneum derives its blood supply from the arteries in the abdominal wall. This
blood drains into the systemic circulation. The visceral peritoneum is supplied by blood from the
mesenteric and coeliac arteries which drain into the portal vein.
B. Lymphatics
Subdiaphragmatic lymphatics are responsible for 80% of the drainage from the peritoneal cavity.
31
The drainage is then absorbed into the venous circulation through the right lymph duct and the
left thoracic lymph duct. A balance of solutes and fluid in the interstitial tissue is maintained by
absorption of fluid from the peritoneal cavity. The average lymphatic rate of absorption in the
PD patient is 0.5-1.0 ml/min. Factors that affect the rate of absorption are respiratory rate,
posture, and intra-abdominal pressure.
V. SYMPTOMATOLOGY
Symptoms Actual
symptoms
Rationale
Swelling Swelling is considered one of the five characteristics of
inflammation; along with pain, heat, redness, and loss of
function.( http://en.wikipedia.org/wiki/Swelling_%28medical
%29)
Redness Redness and heat are due to increased blood flow at body core
temperature to the inflamed site; swelling is caused by
accumulation of fluid.(
http://en.wikipedia.org/wiki/Inflammation#Cardinal_signs)
Pain Pain is due to release of chemicals that stimulate nerve endings.
Loss of function has multiple causes
(http://en.wikipedia.org/wiki/Inflammation#Cardinal_signs)
Fever Redness and heat are due to increased blood flow at body core
temperature to the inflamed site; swelling is caused by
accumulation of fluid.(
32
http://en.wikipedia.org/wiki/Inflammation#Cardinal_signs)
Rigid
abdomen
As soon as infection sets in, the whole peritoneum becomes
inflamed or pus-filled abscesses may form. When this happens,
the muscles of the intestine walls become rigid and the
digestive process is hampered as the contents of the intestines
cease their forward movement.( http://www.medical-
look.com/Digestive_system/Peritonitis.html)
Dehydration fluids and electrolytes are lost into the lumen of the abdomen. .(
http://www.medical-look.com/Digestive_system/Peritonitis.htm
l)
Difficulty
expelling
feces
Due to contraction of the muscles of the abdominal wall.
(http://www.healthscout.com/ency/68/473/main.html#cont)
Nausea and
vomiting
X Development of ileus paralyticus (i.e. intestinal paralysis),
which also causes nausea and vomiting.
(http://en.wikipedia.org/wiki/Peritonitis)
Increase
heart rate
Sequestration of fluid and electrolytes, as revealed by decreased
central venous pressure, may cause electrolyte disturbances, as
well as significant hypovolemia, possibly leading to shock and
acute renal failure.( http://en.wikipedia.org/wiki/Peritonitis)
Decrease BP Sequestration of fluid and electrolytes, as revealed by decreased
central venous pressure, may cause electrolyte disturbances, as
well as significant hypovolemia, possibly leading to shock and
33
acute renal failure.( http://en.wikipedia.org/wiki/Peritonitis)
VI. ETIOLOGY OF THE DISEASE
Etiology Actual
Etiology
Rationale
PREDISPOSING FACTORS
Delayed medical
intervention due to
Place of incident
Peritonitis is a medical emergency: the muscles
within the walls of the intestine become paralyzed
and the forward movement of intestinal contents
stops (ileus). Early treatment of GI inflammatory
conditions and preoperative and postoperative
antibiotic therapy help prevent peritonitis.
(http://www.healthscout.com/ency/68/473/main.ht
ml#cont)
PRECIPITATING FACTORS
Gunshot wound
(Abdominal
Trauma
Peritonitis is an inflammation of the peritoneum, the
serous membrane which lines part of the abdominal
cavity and viscera. Peritonitis may be localised or
generalised, and may result from infection (often due
to rupture of a hollow organ as may occur in
abdominal trauma or appendicitis) or from a non-
infectious process.(
34
http://en.wikipedia.org/wiki/Peritonitis)
VII. PATHOPHYSIOLOGY
A. Written
Peritonitis, inflammation of the peritoneum, was precipitated by an abdominal trauma resulting
from gunshot wound and was predisposed by the delaye to seek medical intervention due to the
place of incident. With this, there is now the invasion of foreign material into the peritoneum
wherein there is now an out poring of fibrinous exudates and pockets of pus (absess) form
between the fibrinous adhesions. Signs of swelling, redness and pain will be experienced by the
patient. Pockets of pus glue together to the surrounding surface and a localized infection then
will took place. Patient will manifest elevated temperature, pain, stomach rigidity and a sudden
increase in leukocyte level. The infected material will be distributed widely over the surface of
the peritoneum and fluids and electrolytes are lost into the lumen of the abdomen where patient
will manifest signs of shock, dehydration and diminished peristaltic movement. This will then
lead to peritonitis that can be diagnosed through alteration of serum electrolyte levels: creatinine,
sodium and potassium. Laboratories in blood indicate increase in leukocytes, hemoglobin and
hematocrit. ABG results of Respiratory Alkalosis and Metabolic Acidosis, Hypovolemic shock.
If treated with medical and surgical management of Removal of infected material,
administration of fluids and electrolytes replacement, Oxygen therapy to improve ventilatory
fxn and drainage to the outside. (JP drain). Nursing Mgt of Monitoring vital signs and drainage,
Recording intake and output and central venous pressure, observing and record character of any
35
surgical drainage, increase foods and oral fluids gradually, Postoperatively, teach care of incision
and drains and observe proper hygiene and encourage early ambulation and given with:
Cefoxitin, Ketorolac, Ranitidine, Tramadol, Celebrex, Metronidazole, Co-amoxiclav,
Loperamide, Cipro floxacint, Salbutamol will lead to a fair prognosis.
If not treated with medical and surgical mgt, nursing mgt, and pharmacological mgt it will lead
to poor prognosis and complications of intestinal obstruction and sepsis that leads to death
B. Diagram of Pathophysiology
36
Precipitating FactorGunshot wound
(Abdominal trauma)
Predisposing FactorDelayed medical intervention due to Place of incident
Invasion of foreign material into the
peritonium
Out poring of fibrinous exudates
Pockets of pus (absess) form between the fibrinous
adhesions s/s: swelling, redness, pain
LOCALIZED INFECTION
Infected material distributed widely over the surface of the peritoneum
Fluids and electrolytes are lost into the lumen of the abdomen
s/s: fever, pain, rigid abdomen, increase
leukoctes
s/s: shock,dehydration,
diminished peristalsis
PERITONITIS
If treated with:
Medical and Surgical Mgt:- Removal of infected material- administered fluids and electrolytes replacement.- Oxygen therapy to improve ventilatory fxn.-drainage to the outside. (JP drain)
Nursing Mgt:- Monitor vital signs and drainage.-Record intake and output and central venous pressure-observe and record character of any surgical drainage- increase foods and oral fluids gradually-Postoperatively, teach care of incision and drains and observe proper hygiene.-encourage early ambulation
Pharmacological Mgt:CefoxitinKetorolacRanitidineTramadolCelebrexMetronidazoleCo-amoxiclavLoperamideCipro floxacintSalbutamol
If not treated with:
Medical and Surgical MgtNursing MgtPharmacological Mgt
COMPLICATIONS:
Intestinal ObstructionSepsis
POOR PROGNOSIS
DEATH
Serum electrolytes: altered potassium, sodium and creatinine.
Labs: Increase leukocytes, hemoglobin, hematocrit
FAIR PROGNOSIS
VIII. PLANNING
A. Nursing Care Plan
37FAIR PROGNOSIS
38
39
40
41
42
43
B. Discharge Plan
44
To the patient who is diagnose of having peritonitis post ex-lap, it is deemed necessary that
after the hospital stay, compliance of the following action must be strictly observed for
rehabilitation.
Medications - Advise the client to take the medications on time to preserve the efficacy
of the drug. Instruct the client to take the medication with food to avoid GI irritation.
Exercise/Economic Factor - Encourage to do a routine ambulation as a light exercise.
Advise not to engage in strenuous activities. Encourage to take rest every after activity.
Treatment - Encourage to ask proper explanation before starting a procedure to
properly understand what is going to happen. Instruct client to ask and properly understand
before signing the consent.
Health Teaching - Encourage patient to take a bath and do ADL’s within limits if her
safety. Tell the patient to notify the physician immediately if there are unusualities. Follow all
instructions including medications, diet regimen and do’s and don’ts that was instructed to her by
the physician..
Out patient Follow-up - Advise to have a follow up check up any time after discharge.
Diet - Instruct patient to eat nutritious, high protein diet to promote healing and eat smaller, more frequent meals to decrease feeling of fullness and bloating.
Spiritual/Sexual Activities - Encourage to reflect on her life situations and properly
understand these situations. To pray every day to help in coping up ones spirituality.
IX. PHARMACOLOGICAL MANAGEMENT
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
X. SYNTHESIS OF CLIENT’S CONDITION/ STATUS FROM ADMISSION TO
PRESENT
A Conclusion
As for the fact that his condition is reversible, the condition of Mr. Drain
aggravated due to poor compliance of the medical regimen. The medical team
gave the due care needed but still under observation. Thus prolong stay in the
hospital happens.
B. Patient’s Prognosis
Criteria Poor Fair Good Justification
Duration of Illness
Patient was still admitted and was
still under observation Conditions
still the same with complicatins.
Onset of Illness
Rated it as fair because although
patient doesn’t willing to
cooperate patient immediately
seek medical interventions and
was immediately cared for after
the pushed of the mother.
Rated it as good because patient
62
Age
was still 25 years old and the said
condition doesn’t choose any age.
Willingness to Take
Medication/Complian
ce to Medical
Procedure
Rated as good because he
complied in all medication and
treatment. Even if he stayed in the
hospital for almost a month
already.
Lifestyle
Rated it as fair because although
the condition arise from
complications of gunshot trauma
still the patient doesn’t comply
with health teachings regarding
importance of ambulating and
hygiene.
Family Support
We rated it good since that the
emotional and physical support
from the family is good and also
he is well cared for.
COMPUTATION:
63
POOR 1 X 1 = 1
FAIR 2 X 3 = 6
GOOD 3 X 2 = 6
1 + 6 + 6 = 13/18 FAIR Prognosis
C. Recommendations
With this study, the student nurses were able to gain more knowledge and wider view and
perspective of the complication of peritonitis. Thus, the student nurses would like recommend
and share some pointers on how to deal with different diseases with gastrointestinal tract such as
peritonitis..
To the government, primarily they should allocate sufficient budget to sustain and provide
better facilities. They must be responsible enough to create awareness program for care and
management for all the Filipino people.
To the health care team, they should righteously implementing basic and ideal procedures
regardless of the health care facilities where they belong. They must observe and always
remember to keep in line with their duties.
To the community and the family, that they must be insufficient coordination with the
government and the health care team regarding promotion of health and wellness.
Through the course of interaction with Mr. Drain, some limitations were noticed that made
us to recommend some interactions to aid in recovering those limitations such as:
Emphasize the importance of compliance of medical regimen and interventions
related to the process of care.
XI. EVALUATION OF THE OBJECTIVES OF THE STUDY
64
The student nurse was able to meet the objectives of this case on peritonitis. Based on the
gathered data regarding the client’s chief complaint, history of present illness, personal, family
and socio-economic history and actual interview to the client, and able to determine the factors
that affect the patient’s condition.
Upon performing the cephalocaudal assessment, able to identify the systems affected that
showed the signs and symptoms, and its manifestations of the said condition. Nursing
interventions were provided to the patient like health teaching regarding the importance on the
compliance of the medical regimen and the infection control procedures such as proper draining
of colostomy bag, changing of dressing regularly, ambulating and hand hygiene. Series of
laboratory test such as CBC and U/A were being made and interpreted which lead to the
diagnosis of peritonitis.
During the period of his hospitalization, problems were identified and prioritized,
then, nursing care plan were formulated.
65
XII. BIBLIOGRAPHY
A. Textbooks
Douges, M.E. et.al., (2002). Nurse’s pocket guide: diagnosis, interventions & rationales.
(8th Edition). Philadelphia: F.A. Davis Company.
Douges, M.E. et.al., (2002). Nursing care plan: guidelines for individualizing patient
care (6th Edition) Philadelphia: F.A. Davis Company.
Gulandick, M. et.al., Nursing care plan. (3rd Edition)
Ignatavicius, D.D. & Workman, M.L. (2006). Medical-surgical nursing: critical thinking
for collaborative care. (5th Edition). St. Louis, Missouri: Elsevier Saunders.
Kozier, B. et.al., (2004). Fundamentals of nursing: concepts, process & practice. (7th
Edition). Philippines: Pearson Education South Asia PTE Ltd.
Smeltzer, S.C. & Bare, B.G. (2004).Textbook of medical-surgical nursing(10th Edition,
Volume 2). Philadelphia: Lippincott Williams and Wilkins. pp 553-538.
Spratto, G.R. & Woods, A.L. (1994). Nurse’s drug reference. USA: Delmar Publishers
Incorporated.
Ulrich & Canale. (2005). Nursing care planning guides. (6th Edition).
B. Internet Downloads
http://www.labtestsonline.org/understanding/analytes/hematocrit/test.html
http://en.wikipedia.org/wiki/Leukocytosis
http://www.healthline.com/adamcontent/fatigue#hl2
http://www.emedicinehealth.com/chest_pain/page3_em.htm
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