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

DIAGNOSIS 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.

INFERENCE 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 diffuse peritonitis.

PLANNING 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.

INTERVENTION 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.

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

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.

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

Reflects hydration
status and changes in renal function, which may warn of developing acute renal failure in response to hypovolemia and effect of toxins. Hypovolemia, fluid shifts, and

Observe skin and mucous membrane dryness and turgor.

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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.

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.

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Student Nurses Community

Student Nurses Community

Student Nurses Community