Primary Nursing Diagnosis

Pain (acute) related to inflammation of the peritoneal cavity

OUTCOMES. Comfort level; Pain control behavior; Pain level; Symptom severity

INTERVENTIONS. Analgesic administration; Anxiety reduction; Environmental management: Comfort; Pain management; Medication management; Patient-controlled analgesia assistance


Interventions are supportive and include fluid and electrolyte replacement. To rest the GI tract, a nasogastric (NG) or intestinal tube is inserted to reduce pressure within the bowel. Food and fluids are prohibited. Parenteral nutrition is often indicated for nutritional support. Monitor fluid volume by checking the patient's skin turgor, urine output, weight, vital signs, mucous membrane condition, and intake and output including NG tube drainage.

If the peritonitis has been caused by a perforation of the peritoneum, surgery is necessary as soon as the patient's condition has been stabilized to eliminate the source of the infection by removing the foreign contents from the peritoneal cavity and inserting drains. Paracentesis (abdominocentesis) to remove excess fluids may be necessary as well. After surgery, it is important to assess the patient frequently for peristaltic activity. Auscultate for bowel sounds, and check for flatus, bowel movements, and a soft abdomen. When peristalsis resumes, and the patient's temperature and pulse rate become normal, treatment generally calls for a decrease in parenteral fluids and an increase in oral fluids. If the patient has an NG tube in place, clamp it for short intervals. If the patient does not experience nausea or vomiting, begin oral fluids as ordered and tolerated.

Pharmacologic Highlights

Medication or

0 0

Post a comment