Student Nurses Community

NURSING CARE PLAN Peritonitis

ASSESSMENT
SUBJECTIVE:
Sumasakit ang
tiyan ko at
nasusuko ako
(I've been
experiencing
abdominal pain and
I feel nauseous)

as verbalized by
the patient.

OBJECTIVE:

Dry mucous
membranes
Poor skin
turgor
Weak
peripheral
pulses
V/S taken as
follows
T: 36.5C
P: 49
R: 14
BP: 110/ 80

DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

Deficient
(mixed) fluid
volume may be
related to fluid
shifts from
extracellular,
intravascular,
and interstitial
compartments
into intestines
and/or
peritoneal
space;
vomiting;
medically
restricted
intake;
nasogastric or
intestinal
aspiration;
fever;
hypermetabolic
state.

Peritonitis is an
acute
inflammation of
the
visceral/parietal
peritoneum and
endothelial lining
of the abdominal
cavity, or
peritoneum.
Peritonitis can be
classified as
primary or
secondary,
localized or
generalized.
When the
peritoneal cavity
is contaminated
by bacteria, the
body initially
produces an
inflammatory
reaction that
walls off a
localized area to
fight the
infection. If this
walling off
process fails, the
inflammation
spreads and
contamination
becomes
massive,
resulting in

After 8 hours of
nursing
interventions, the
Patient will
demonstrate
improved fluid
balance as
evidenced by
adequate urinary
output with
normal specific
gravity, stable
vital signs, moist
mucous
membranes,
good skin turgor,
prompt capillary
refill, and weight
within acceptable
range.

Independent
Monitor vital signs,
noting presence of
hypotension
(including postural
changes),
tachycardia, and
fever. Measure
central venous
pressure (CVP) if
available.
Maintain accurate
intake and output
and correlate with
daily weights.
Include measured
and estimated
losses, such as
with gastric suction,
drains, dressing,
hemovacs,
diaphoresis, and
abdominal girth for
third spacing fluid.
Measure urine
specific gravity.

Observe skin and

RATIONALE
Aids in
evaluating
degree of fluid
deficit,
effectiveness of
fluid
replacement
therapy, and
response to
medications.
Reflects over all
hydration status.

Reflects
hydration status
and changes in
renal function,
which may warn
of developing
acute renal
failure in
response to

EVALUATION
After 8 hours of
nursing
interventions, the
Patient was able
to demonstrate
improved fluid
balance as
evidenced by
adequate urinary
output with
normal specific
gravity, stable
vital signs, moist
mucous
membranes,
good skin turgor,
prompt capillary
refill, and weight
within acceptable
range.

Student Nurses Community

diffuse peritonitis.

mucous membrane
dryness and turgor.

Eliminate noxious
sights or smells
from environment.

Change position
frequently, provide
frequent skin care,
and maintain, dry
wrinkle-free
bedding.

Collaborative
Monitor laboratory
studies.

Maintain NPO
status with NG or
intestinal aspiration.

hypovolemia
and effect of
toxins.
Hypovolemia,
fluid shifts, and
nutritional
deficits
contribute to
skin turgor and
taut edematous
tissues.
Reduces gastric
stimulation and
vomiting
response.
Edematous
tissue with
compromised
circulation is
prone to
breakdown.
Provides
information
about hydration
and organ
function.
Reduces
vomiting caused
by hyperactivity
of bowel;
manages
stomach and
intestinal fluids.