Need help NCP for peritonits

[ryze21]

my clinical instructor wants me create a hypothetical NCP for peritonitis that is diagnosed by ineffective tissue perfusion. the signs and symptoms of peritonitis are abdominal pain and distention,fever 38.0C,weakness,Nausea and vomiting,the skin turns pale and cold,increased heart rates and breathing,hypotension,shock,inability to pass urinate and stools.I wish you can help me. many thanks.:bowingpur

[Daytonite, BSN, RN]

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - you also need to create a cause of this patient's peritonitis.

• http://www.merck.com/mmpe/sec02/ch011/ch011b.html#sec02-ch011-ch011b-402 - "peritonitis is inflammation of the peritoneal cavity. the most serious cause is perforation of the gi tract (see acute abdomen and surgical gastroenterology: acute perforation), which produces immediate chemical inflammation followed shortly by infection from intestinal organisms. peritonitis can also result from any abdominal condition that produces marked inflammation (eg, appendicitis, diverticulitis, strangulating intestinal obstruction, pancreatitis, pelvic inflammatory disease, mesenteric ischemia). intraperitoneal blood from any source (eg, ruptured aneurysm, trauma, surgery, ectopic pregnancy) is irritating and results in peritonitis. barium causes severe peritonitis and should never be given to a patient with suspected gi tract perforation. peritoneo-systemic shunts, drains, and dialysis catheters in the peritoneal cavity predispose a patient to infectious peritonitis, as does ascitic fluid. rarely, spontaneous bacterial peritonitis occurs, in which the peritoneal cavity is infected by blood-borne bacteria. peritonitis causes fluid shift into the peritoneal cavity and bowel, leading to severe dehydration and electrolyte disturbances. adult respiratory distress syndrome can develop rapidly. kidney failure, liver failure, and disseminated intravascular coagulation follow. the patient's face becomes drawn into the masklike appearance typical of hippocratic facies. death occurs within days."
  

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

• early signs
  
  • abdominal pain - the patient will lie with legs flexed and not move
    
  • nausea and vomiting
    
  • anorexia
    
  • inability to pass stools and flatus
    
  • hiccups
    
  • fever 38.0c
    
  • tachycardia
    
  • tachypnea, but shallow breathing
    

  [*]later signs

  • signs of dehydration
    
    • skin turns pale and cold
      
    • decreased urine output and concentration
      
    • weakness
      
    • thirst
      
    • dry skin and mucus membranes
      
    • confusion
      
    • decreased b/p and skin turgor
      

    [*]no bowel sounds

    [*]abdominal rigidity, distension and tenderness

  [*]severe signs

  • multisystem organ failure (kidneys, liver)
    
  • dic (disseminated intravascular coagulation)
    
  • death
    

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

• ineffective breathing pattern r/t increasing abdominal pressure aeb tachypnea and shallow breathing
  
• ineffective tissue perfusion, gastrointestinal and renal r/t inflammation of the peritoneal cavity aeb abdominal pain and tenderness, abdominal distension, absent bowel sounds, nausea and vomiting, hypotension and anuria
  
• deficient fluid volume r/t retention of fluid in the bowel aeb pale and cold skin, decreased and concentrated urine output and concentration, dry skin and mucus membranes, decreased b/p and skin turgor, weakness, thirst and confusion
  
• hyperthermia r/t inflammation of the peritoneal cavity and dehydration aeb fever 38.0c, tachycardia and tachypnea
  
• acute pain r/t inflammation of the peritoneal cavity aeb abdominal pain and the patient lying with legs flexed and not moving
  
• risk for injury r/t abnormal clotting factors
  

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals are what you predict will happen when your interventions are performed. your nursing interventions target the signs that were listed in step #2 and that are the basis of each of the nursing diagnosis. for example, with hyperthermia r/t inflammation of the peritoneal cavity and dehydration aeb fever 38.0c, tachycardia and tachypnea your nursing treatments will be focused on the fever of 38.0c and doing things for it and the rapid heart and breathing rates.

good luck with your care plan! you can find more information about peritonitis on the emedicine site: http://www.emedicine.com/