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Inflammation of the peritoneum (serosal membrane that lines the abdominal cavity); possibly extending throughout the peritoneum or localized as an abscess
Commonly causing decreased intestinal motility and intestinal distention with gas
Fatal in 10% of cases, with bowel obstruction the usual cause of death
Acute or chronic
Three forms: primary (usually due to hematogenous dissemination such as with immunocompromise), called spontaneous bacterial peritonitis (SBP) ; secondary (usually due to a pathologic process in an organ, trauma, or surgery), the most common type; and tertiary (recurrent or persistent infection after initial therapy)
Bacteria invade the peritoneum after inflammation and perforation of the GI tract.
Fluid containing protein and electrolytes accumulates in the peritoneal cavity; normally transparent, the peritoneum becomes opaque, red, inflamed, and edematous.
Infection may localize as an abscess rather than disseminate as a generalized infection.
Bacterial or chemical inflammation (see Causes of peritonitis)

Causes of peritonitis

Typically the cause of peritonitis depends on the type of peritonitis the patient is experiencing.

Primary peritonitis (spontaneous bacterial peritonitis or SBP )
Invasion of bacteria from the gut wall or mesenteric lymphatics

Complication of any disease state, but most commonly patients with cirrhosis who are debilitated

Gram-negative: Escherichia coli, Klebsiella pneumonia, Pseudomonas, Proteus
Gram-positive: Streptococcus pneumoniae, other Streptococcus species, and Staphylococcus species

Secondary peritonitis
Perforated appendicitis

Perforated gastric or duodenal ulcer

Perforated colon secondary to diverticulitis, volvulus, or cancer

Strangulation of small bowel

Necrotizing pancreatitis

Gram-negative: E. coli, Enterobacter, Proteus, Pseudomonas
Gram-positive: streptococci, staphylococci
Anaerobic: Bacteroides, Clostridia
Fungi: Candida

Tertiary peritonitis
Most common in immunocompromised patients and those with significant pre-existing conditions

Tuberculosis (rare in U.S.)

Patients with human immunodeficiency virus infection

Other Causes:
GI tract perforation (from appendicitis, diverticulitis, peptic ulcer, or ulcerative colitis)
Ruptured ectopic pregnancy
Peritoneal dialysis
Peritonitis occurs equally in men and women.
Abscess, fistula formation
Respiratory compromise
Bowel obstruction
Liver failure
Vague, generalized abdominal pain
If localized, pain over a specific area (usually the inflammation site)
If generalized, diffuse pain over the abdomen
Assessment-Early phase
Vague, generalized abdominal pain
If localized, pain over a specific area (usually the inflammation site)
If generalized, diffuse pain over the abdomen
Assessment-With progression
Increasingly severe and constant localized abdominal pain that increases with movement and respirations
Possible referral of pain to the shoulder or thoracic area
Anorexia, nausea, and vomiting
Inability to pass stools and flatus
Assessment-Physical Findings
Shallow breathing
Signs of dehydration
Positive bowel sounds (early); absent bowel sounds (later)
Abdominal rigidity
General abdominal tenderness
Rebound tenderness
Typical patient positioning: lying very still with knees flexed
Diagnostic Test Results-Laboratory
Complete blood count shows leukocytosis.
Blood chemistries may reveal dehydration and acidosis.
Blood cultures are positive for the offending organism.
Diagnostic Test Results-Imaging
Abdominal X-rays show edematous and gaseous distention of the small and large bowel. With perforation of a visceral organ, X-rays show air in the abdominal cavity.
Chest X-rays may reveal elevation of the diaphragm.
Computed tomography reveals an intra-abdominal mass, fluid, and inflammation.
Magnetic resonance imaging may reveal abscesses.
Ultrasonography may reveal increased peritoneal fluid levels.
Diagnostic Test Results-Diagnostic Procedures
Paracentesis shows the exudate's nature, leukocytosis, low pH and glucose levels, and elevated protein and lactate dehydrogenase levels and permits bacterial culture testing.
Nasogastric (NG) intubation
Hemodynamic monitoring
Nothing by mouth (NPO) until bowel function returns
Gradual increase in diet
Total parenteral nutrition if necessary
Bed rest until the condition improves
Semi-Fowler's position
Avoidance of lifting for at least 6 weeks postoperatively
Broad-spectrum I.V. antibiotics based on the infecting organism, such as cefotaxime sodium, amoxicillin-clavulanate potassium, cefoxitin sodium, cefotetan, ticarcillin disodium-clavanulate potassium, piperacillin sodium -tazobactam sodium, ampicillin-sulbactam, imipenem, vancomycin hydrochloride and gentamicin (peritoneal instillation), and ofloxacin
Metronidazole for fungal infection
Diuretics, such as furosemide, to reduce ascitic fluid
Fluid and electrolyte replacements
Analgesics for pain; antiemetics for nausea and vomiting
Treatment of choice; procedure varies with the cause of peritonitis
Percutaneous abscess drainage
Nursing Considerations-Nursing Diagnoses
Acute pain
Deficient fluid volume
Imbalanced nutrition: Less than body requirements
Risk for ineffective gastrointestinal tissue perfusion
Risk for injury
Nursing Considerations-Expected Outcomes
express feelings of increased comfort
identify strategies to reduce anxiety
maintain normal fluid volume
discuss fears and concerns
maintain adequate caloric intake
exhibit signs of adequate GI perfusion and regain normal bowel function
remain free from signs and symptoms of complications.
Nursing Considerations-Nursing Interventions
Initiate I.V. access if one is not already in place, maintain I.V. site and ensure patency, and administer I.V. fluids and electrolytes as ordered. Provide I.V. site care according to facility policy.
Give prescribed drugs; administer I.V. antibiotics as ordered.
Encourage the patient to express his feelings and concerns; provide emotional support and comfort measures.
Institute cardiac monitoring as indicated. If hemodynamically unstable, anticipate the need for hemodynamic monitoring.
Provide NG tube care, ensure patency of NG tube, and note the color and characteristics of the drainage.
Maintain NPO status, auscultate bowel sounds, evaluate abdomen for tenderness and rigidity, and begin oral intake as indicated by return of bowel sounds and passage of flatus and stool.
Assist the patient in assuming a position of comfort; elevate the head of the bed to assist with pain relief and promote maximum chest expansion.
Prepare the patient and the family for possible surgery, including what to expect after surgery, such as equipment, monitoring, drainage devices, and wound care.
Nursing Considerations-Monitoring
Vital signs
Cardiopulmonary status
Hemodynamic status
Pain level and relief
Fluid balance
Nutritional status
NG tube function and drainage
Bowel function
Postoperative status
Incision site and dressing
Signs and symptoms of dehiscence
Nursing Considerations-Associated Nursing Procedures
Blood culture sample collection
Health history interview and physical assessment
IV bag preparation
IV catheter insertion
IV pump use
Intake and output assessment
Oral drug administration
Pain management
Postoperative care
Preoperative care
Preparing a patient for abdominal surgery, OR
Temperature assessment
Patient Teaching-General
disorder, possible underlying cause, diagnosis, and treatment, including the possibility of surgery if necessary
prescribed medication therapy, including the drug name, dosage, frequency of administration, and duration of therapy
need to continue oral antibiotics for a specified number of days even if the patient is feeling better to ensure complete resolution of infection
possible adverse effects of medication, such as nausea, vomiting, gastric distress, and rash
preoperative and postoperative measures, such as coughing and deep-breathing techniques, leg exercises, position changes, incentive spirometry, and monitoring
signs and symptoms of infection
incisional/drainage site care, including signs and symptoms of infection and dressing changes as appropriate
dietary and activity limitations (depending on type of surgery)
importance of follow-up care as indicated.