Gunshot Wound Peritonitis

ST. MARY’S COLLEGE

NURSING PROGRAM

Tagum City

A CASE STUDY

On

PERITONITIS

Presented to:

Zaida S. Jo, RN, MN

In Partial Fulfillment of the Requirements

In

Related Learning Experience

(RLE)

By

Mia Charisse F. Lamparero

BSN 4

July 30, 2010

TABLE OF CONTENTS

I. INTRODUCTION 3

A Objectives 5

II. ASSESSMENT 7

A. Biographical Data 7

B. Chief Complaint 7

C. History of Present Illness 8

D. Past Medical and Nursing History 8

E. Personal, Family and Socio-Economic History 8

F. Developmental History 8

G. Patient Need Assessment 9

Physical Assessment

General survey 12

Vital signs 12

Nutritional status 13

Integumentary System 13

HEENT 13

Pulmonary System 14

Cardiovascular System 14

Gastrointestinal System 14

Musculoskeletal System 14

1

Genito-urinary System 14

Course in the Ward 14

III. LABORATORY AND DIAGNOSTIC EXAMINATIONS 19

IV. REVIEW OF ANATOMY AND PHYSIOLOGY 26

V. SYMPTOMATOLOGY 32

VI. ETIOLOGY OF THE DISEASE 34

VII. PATHOPHYSIOLOGY

A Written 35

B. Diagram of Pathophysiology 36

VIII. PLANNING

A Nursing Care Plan 38

B. Discharge Plan 45

IX. PHARMACOLOGICAL MANAGEMENT 46

X. SYNTHESIS OF CLIENT’S CONDITION/

STATUS FROM ADMISSION TO PRESENT

A Conclusion 62

B. Patient’s Prognosis 62

C. Recommendations 64

XI. EVALUATION OF THE OBJECTIVES OF

THE STUDY 65

XI. BIBLIOGRAPHY 66

A. Textbooks

B. Internet Download

2

I. INTRODUCTION

Background of the Study

Peritonitis is a serious disorder caused by an inflammation of the peritoneum, most often due to a

bacterial infection. The peritoneum is a two-layered membrane that lines the abdominal cavity

and encloses the stomach, intestines, and other abdominal organs. The membrane supports the

abdominal organs and protects them from infection. However, occasionally the peritoneum itself

may become infected by bacteria or other organisms.

Infection usually spreads from organs within the abdomen. The inflammation may affect the

entire peritoneum, or be confined to a walled-off, pus-filled cavity (abscess).

A rupture anywhere along the gastrointestinal tract is the most common pathway for entry of an

infectious agent into the peritoneum. Peritonitis is a medical emergency: the muscles within the

walls of the intestine become paralyzed and the forward movement of intestinal contents stops

(ileus). It is most often caused by introduction of an infection into the otherwise sterile peritoneal

environment through organ perforation, but it may also result from other irritants, such as foreign

bodies, bile from a perforated gall bladder or a lacerated liver, or gastric acid from a perforated

ulcer. Women also experience localized peritonitis from an infected fallopian tube or a ruptured

ovarian cyst. Patients may present with an acute or insidious onset of symptoms, limited and

mild disease, or systemic and severe disease with septic shock.

Untreated, acute peritonitis may be fatal. The fundamental role of operative therapy in the

treatment of peritonitis was documented in 1926 when Kirschner reported that the mortality rate

3

http://www.healthscout.com/ency/68/473/main.html



from intra-abdominal infections decreased from more than 90% to less than 40% during the

period from 1890-1924 with the introduction of operative management. Other elements, such as

advances in the understanding of damage control surgery, novel antibiotics, and improvements in

intensive care unit (ICU) treatment have now reduced mortality to approximately 20%.

(http://emedicine.medscape.com/article/192329-overview)

4

http://emedicine.medscape.com/article/192329-overview

OBJECTIVES

The research for this case study, its data and substantial facts could not be attained

without the improvised objectives that are needed to be followed and observed that will guide us

in planning, preparing and arranging the information systematically. The objectives are devised

within the day of our clinical exposure. The objectives would serve us guiding principles for us

to arrive to our goals and aims.

A. General Objective:

Within the time-span of duty, the student nurse will complete the chosen case to be

studied with factual pertinent data gathered. As well as to know and familiarize other related

information connected to it and apply the nursing skills that had learned and practice not only or

the call of this study but also for the future reference.

B. Specific Objectives:

To obtain sufficient and relevant information regarding patient’s condition.

To present personal data of the patient.

To trace the present history of the patient’s health and illness and define the diagnosis of

the patient having a Peritonitis.

To conduct a thorough head-to-toe assessment serving as baseline data.

To view and discuss the anatomy and physiology of the affected organs and system

basing from the patient’s diagnosis.

To present the pathophysiology of the patient’s diagnosis, both in diagram and narrative

form and list down the actual laboratory results of the patient.

5

To identify the different drugs ordered and to know their action, indication, adverse

effects and nursing responsibilities.

To make nursing care plan appropriate for the span of care to the patient and which also

correspond his condition at least 2 actual problems and 1 risk problem.

To impart suitable and realistic health teachings to the watcher for the patient’s welfare.

To evaluate the outcome of the condition of the patient.

6

II. ASSESSMENT

A. BIOGRAPHICAL DATA

Name : Mr. Drain

Age : 25 years old

Sex : Male

Civil Status : Single

Birthdate : January 11, 1985

Birthplace : Bohol

Address: : Prk 5 Elizalde (Samil), Maco, Comval Province

Nationality : Filipino

Religion : Roman Catholic

Occupation : Miner

Attending Physician : Dr. Alvin C. Medina, M.D.

B. CHIEF COMPLAINT

The patient was admitted at Davao Regional Hospital last July 06, 2010 at 1:40 in the

dawn due to the complaint of Gunshot wound on the abdomen. He was attended at the

Emergency department and had taken a clinical history and physical assessment. He was

immediately transferred at the operating room for STAT Ex-lap. He was attended by Dr. Medina,

a resident physician of the said hospital.

7

C. HISTORY OF PRESENT ILLNESS

Patient was on his way home when he passed a check point at Mawab and was signaled to stop

but didn’t stop. The military suspected him and he was immediately was shot at the back. They

hurriedly ran the patient to the hospital and was attended and given immediate interventions.

D. PAST MEDICAL AND NURSING HISTORY

The patient had upper respiratory tract infection when he was an 8 years old. Previously

he was not hospitalized. He does have complete immunizations and has no history of

hypertension, Diabetes mellitus and PTB. Whenever he had any flu or cough, His mother uses

herbal plants. He does not have any regular medical and dental check-ups. He does not have

allergies to what ever kind of foods and medications as far as he knows. Whenever he had fever

he takes Paracetamol and Bioflu. He does not experience any severe accidents except this one.

E. PERSONAL, FAMILY AND SOCIO-ECONOMIC HISTORY

Aka Mr. Drain is a 25 years miner. He was the youngest of a family of 3. The

family of Mr. Drain belongs to a marginalized socio-economic status. In order to provide and

sustain the daily needs of their family, his father works as a carpenter and his mother is a plain

housewife. His 2 sisters were already married and have their own family.

F. DEVELOPMENTAL TASK

Robert J. Havighurst Developmental Task Theory

According to Havighurst developmental theory, Mr. Drain, 25 years of age, belongs to a

period of adulthood which was achieving mainly located in family, work, and social life. Family-

related developmental tasks are described as finding a mate, learning to live with a marriage

partner, having and rearing children, and managing the family home. Mr Drain was working and

8

suffers to be away from his family just to have money to help for their everyday expenses. He

doesn’t have time to face his own life due to attending the needs of his parents.

G. PATIENT NEED ASSESSMENT

Date: June 2

Name of Patient: Mr. Drain Age: 25 years oldSex: _Male Status: Single

Admission Date/Time: July 06, 2010/ 1:40 am

Admitting Medical Diagnosis: GSW through and through POEX® Mandibular area POEX ®

Male, GCS to level

Arrived on Unit by: per stretcher From: CENSICU Room

Accompanied by: He is accompanied by his mother

AdmittingWeight /VS: 48kgs BP- 100/60 RR-25 PR-114 Temp- 36.7

Client’s Perception of reason for Admission:

“Napusilan man gud ko maam mao naa ko dinhi sa ospital,” verbalized by the patient

How has problem been managed by client at home: NONE

Allergies: No allergies was being experience according to the patient

Medication (at home): NONE, (at the hospital): Cefoxitin, Ranitidine, Ketorolac, Tramadol,

Metronidazole, Paracetamol

Physiological Needs:

I. Oxygenation

BP _100/60 PR 114 bpm RR 25 cycles/min CR_________

Lungs (per auscultation: character: lung sound; symmetry of chest expansion; breathing

character and pattern.) fine, short, interrupted crackling sound was being heard upon

auscultation, symmetry chest expansion was being observe during breathing.

9

Cardiac status (per auscultation sounds character; chest pain?

Dull, low pitched and longer followed by a silent then higher pitch: no chest pain noted

Capillary Refill: Within 2 – 3 seconds using the blanched test

Skin Character and Color: dry, pale, dark brown in color

Life-supporting Apparatus: N-O-N-E

Other Observations (related): with colostomy to colostomy bag, JP drain, Eschar noted on

both legs.

II. Temperature Maintenance:

Temperature: 36.7º C

Skin Character: dry, pale, dark brown in color; with good skin turgor

Other Observations (related): N-O-N-E

III. Nutritional Fluid:

Height: 5’ 4’’/ 48kg. Amount of food consumed: ¼ of meal served consumed

Prescribed Diet: Diet as tolerated + 2 eggs/day

Eating Pattern: 3x a day; can only consume ¼ of served meal

Skin Character: dry, rough skin; with good skin turgor

Intake (IVF: Fluid/Water): Plain Nornal Saline Solution

Other Observations (related):slim, eschar noted on both legs

IV. Elimination:

Last Bowel Movement (frequency; amount, character): with colostomy to colostomy bag,

yellow to amber in color, few

Normal Pattern: every meal

10

Urination (frequency, amount, character, sensation): twice, with yellow ambered colored

urine, about 200 cc.


V. Rest-Sleep:

Bed Time: 6: 00PM Waking Up Time: 6:00 AM

Sleep (amount of sleep): 4-5 hours

Problems (as verbalized): “Wala ko katulog kagabii kay sakit akoang tahi og igang pud

kaayo”


VIII. Stimulation-Activity:

Work: Miner

Reaction/Past time: Drinking while chatting with other co-worker

Hobbies/Vices: Alcoholic Drinker/ Smoker

Safety-Security Need

Neuro V/S: 15/15

Mental Status (coherent, responsive, conscious, unconscious): Coherent, Responsive and

consciuos

Emotional Problem (diaphoretic, trembling, restless) Irritable, diaphoretic and fatigue.

Love-Belonging Need

Children (living with?) NONE

Husband (living with?) NONE

11

Self – Esteem Need

-Need to accept to be independent but still needs assistance to people around him. Appreciate the

care and love of family. Need to discuss feelings and concerns. Interact effectively to people.

Self- Actualization Need

- Control one’s emotions and discipline self particularly in taking care of health. Need to learn to

listen and follow what is advised for easy recovery.

PHYSICAL ASSESSMENT

General Survey

Patient received lying on bed, awake, responsive, coherent to verbal communication, dry lips,

with normal capillary refill (less than 3 sec) with heplock ; fatigue and weakness noted

Vital Signs

Date/Shift Time Temp BP PR RR O2 SAT OUTPUT OUTPUT

7/6/10

11-7

1:20 am 36.5 100/60 114 25 96

7-3 8:15 am 36 80/50 128 20 98

8:45 am 36 90/60 100 20 100

7/8/10

7-3

9:30 am 38.4 150/90 108 26 94

7/9/10

11-7

1:18 pm 38.5 120/80 93 22

7-3 9:20 am 39.1 140/90 106 23

7/10/10 4:20pm 38 120/80 92 20

12

3-11

7/16/10

7-3

2:15 am 38.1 120/70 89 22

7/17/10

7-3

10:50

am

38 130/80 101 23

3-11 6:00pm 35.5 140/90 98 22

07/18/10

11-7

2:30 38.2 140/70 90 25

Nutritional Status

Upon admission, patient was on NPO diet until he was transferred to CENSICU. He was then

on DAT when he already expel flatus and that was when he was already transferred at Surgery

Male Ward Normally takes meal 3 times a day. Depending on varied conditions, he consumes

moderate amount of food per meal. No known hypersensitivity to food allergens and other

problems related to food consumption.

Integumentary System

Fine and thin yet dry hair was noted. His nails were in convex shape, smooth in texture,

capillary refill of less than 3 seconds with pale nail beds. With good skin turgor, dry, and brown

in color. Eschar was noted on both legs. Incision at the abdomen and at the lateral side of the

back noted with colostomy to colostomy bag attached with JP drain.

HEENT

The size of head was in proportion with the body. The eyes were symmetrical with the ears

(pinna); pupils react spontaneously to light, with pale conjunctiva. Eyebrows symmetrically

13

aligned, eyelashes equally distributed, lids closed symmetrically. With approximately 15 to 20

blinks per minute. No discharges noted on ears. Nasal septum was intact and in the midline, no

discharges or flaring, air moves freely through the nares. Non-pitting edema noted at both feet.

Pulmonary System

With symmetrical chest expansion; crackles sound heard upon auscultation; RR: 25 cpm

Cardiovascular System

Cardiac sound from dull, low pitched (“lub”) to higher pitch (“dub”) sound , with irregular

cardiac rhythm ; 114 beats per minute abnormal. Capillary refill time takes less than 3 seconds .

Gastrointestinal System

With colostomy to colostomy bag, with fecal content brownish to yellowish in color.

Musculoskeletal System

Weakness and fatigue noted as manifestation of the disease process, marked reluctant to

move. With limited range of motion.

Genito-urinary System

Patient voided after meal in our shift. Urine appears amber in color, moderate in amount.

Client’s normal voiding pattern is 4 times a day. Palpation on kidneys reveals no evidence of

tenderness and distention.

H. COURSE IN THE WARD

Date/Shift Nurse’s

Assessment

Nurse

Intervention

Rationale Medical

Management

Rationale.

07/06/10

3-11

2PM

-awake,

palor

-V/S: T:36.5

-labs forwarded

X-ray done

- to diagnose

pt condition

-Labs: CBC

X-RAY abd.

(STAT)

- to diagnose

pt condition

14

BP: 100/60

RR: 25

PR:114

-Gunshot

wound on

periumbilical

area

-consciuos,

coherent and

body

weakness

noted

-on NPO

instructed

-IVF started @

left arm @160

cc/hr

-PNSS @ right

arm @ 20 cc/hr

-consent

secured for ex-

lap

-abdominal

perineal prep

shaving done

- to prevent

aspiration

- When

infused into

the body it

acts

(temporarily)

to increase

the blood

volume, and

bring up the

blood

pressure.

- protocol to

promote

safety to the

medical

team on

whatever

will happen

-NPO

-IVF: PLR @

160 cc/hr

PNSS @20

cc/hr

-Meds:

Cefuxity 1g

IVTT

Metronidazole

Ranitidine

-For STAT

exlap

-secure

consent

-secure 4 units

of blood

-to prevent

aspiration

- When

infused into

the body it

acts

(temporarily)

to increase

the blood

volume, and

bring up the

blood

pressure.

- People with

peritonitis

often need

surgery to

remove

infected

tissue and

repair

damaged

organs.

15

-FC To UB

inserted

-NGT inserted

with distal end

keep opened

-to have an

accurate

monitoring

of urine

I&O every

hour

- to

determine

decrease UO

6:40 AM - with FC to

UB

-output of

yellow

colored urine

-Post –exlap

-NGT open

to drain

-no output

upon

received

-with BT

-abdominal

tape dressing

intact with

ileostomy

-BT regulated

to 120cc/hr

-keep

thermoregulated

-hurled for 02

inhalation

-v/s checked

and recorded

-to replace

loss of blood

during

operation

-to prevent

chills,

normal due

to anesthetic

effect.

-to PACU

-NPO

V/S q 15

Meds:

Ketorolac

Tramadol

-Keep warm

-Transfuse 2

units of blood

-Repeat Hgh

and Hct

-I & O q hr

- Avoid

aspiration

precaution

- to have

baseline

data, for

close

monitoring

- to prevent

chills,

normal due

to anesthetic

effect.

7/07/10 -with O2 @ -placed on bed - To promote - NPO - To promote

16

7-3

7 am

5 LPM via

face mask.

comfortably

-hooked to

cardiac monitor

-due meds

given

proper

distribution

of oxygen

throughout

the body

-to have

baseline data

for close

monitoring

-MHBR

-Meds:

Furosemide

Salbutamol

proper

distribution

of oxygen

throughout

the body

7/08/10

7-3

7:50 am

-awake,

coherent and

responsive to

verbal

command

-ileostomy

out put

yellowish in

color

-monitor I& O -for close

monitoring

-May sit on

bed

-remove FBC

-Retain NGT

-encourage

ambulation

-monitor

ileostomy

output

7/11/10 -Encouraged to

observe good

hygiene,

encouraged to

- to promote

relaxation

and comfort

- promote

-Shift

Cefoxitin to

Co-amoxiclav

17

have a full body

bath, increase

OFI and eat

nutritious foods

-Due meds

given

wound

haeling

7/13/10

3-11

7pm

- febrile

T:39.9

-Monitor V/S

-Labs for

approval

V/S referred to

Dr Corpuz

-HOLD MGH

as ordered

-reinserted with

D5LR 1 Liter

@ 30 gtts/min.

- to have

baseline date

for close

monitoring.

-HOLD MGH

-labs: CBC

-STAT:

createnine,

Na, K

-for STAT

IVP once with

normal crea

to have

baseline date

for close

monitoring

7/20/10

7-3

10:15 am

-on HBR,

asleep, dry

and cyanotic

lips with

wound @

Right lower

extremities.

-Encouraged

full body bath

-Health

teachings on

eating nutritious

foods such as

fruits and

- To promote

proper

distribution

of oxygen

throughout

the body

-to promote

-high protein

diet

to promote

early wound

healing

18

vegetables early wound

healing

III. LABORATORY AND DIAGNOSTIC EXAMINATIONS

LAB EXAM NORMAL

VALUE

RESULTY INTERPRETATION/IMPLICATION

Hematology 07/ 11/10

Hemoglobin 134-136g/L 105 DECREASE. The primary cause could be

the disorders of the bone marrow. However,

there are other common factors such as poor

nutrition that is associated with the vitamin

(B 12, folic acid) and mineral deficiency

like Iron should not be overlooked. Some

time any malabsorption syndrome of the

gastrointestinal tract could lead to poor

absorption of these vitamins and minerals

even though these are adequately supplied

via the food.( http://www.labtestsonline.org/

understanding/analytes/hematocrit/test.html)

Leukocyte

Concentration

5.0-10.0 13.6 INCREASE. This increase in leukocytes

(primarily neutrophils) is usually

19

http://www.labtestsonline.org/

accompanied by a "left shift" in the ratio of

immature to mature neutrophils. The

increase in immature leukocytes increases

due to proliferation and release of

granulocyte and monocyte precursors in the

bone marrow which is stimulated by several

products of inflammation including C3a and

G-CSF.

( http://en.wikipedia.org/wiki/Leukocytosis)

Segmenters 0.40-0.60 0.81 INCREASE. indicates viral infection

Lymphocytes 0.25-0.40 0.19 DECREASE. Indicate diseases that affect

the immune system, such as lupus, and the

later stages of HIV infection.











20




Leukocyte

Concentration










G-CSF.











21









Leukocyte

Concentration










G-CSF.


Segmenters 0.40-0.60 0.92 INCREASE. indicates viral infection




22


ARTERIAL BLOOD GAS RESULTS 07/ 20/10

Lab Exam Normal Result Interpretation/ Implication

Ph 7.35-7.45 7.33 WITHIN NORMAL RANGE

PCO2 35-45 21.7 DECREASE.

PO2 80-100 131.1 INCREASE

HCO3 22-26 15.2 DECREASE

B.E + or -2 12.2 INCREASE

O2 SAT 95-100% 98.5 WITHIN NORMAL RANGE

IMPRESSION: Respiratory Alkalosis and Metabolic Acidosis, Hypovolemic shock.

SERUM ELECTROLYTES 07/ 07/10


Createnine 53.0-115.0 159.6 INCREASE. Increased creatinine levels in

the blood suggest diseases or conditions that

affect kidney function. These can include:

Damage to or swelling of blood vessels in

the kidneys (glomerulonephritis) caused by,

for example, infection or autoimmune

diseases. Bacterial infection of the kidneys

(pyelonephritis) . Death of cells in the

kidneys’ small tubes (acute tubular necrosis)

caused, for example, by drugs or

toxins .Prostate disease, kidney stone, or

23

http://www.labtestsonline.org/understanding/conditions/autoimmune.html


other causes of urinary tract obstruction.

Reduced blood flow to the kidney due to

shock, dehydration, congestive heart failure,

atherosclerosis, or complications of diabetes

(http://www.labtestsonline.org/understanding

/analytes/creatinine/test.html)

Calcium 1.13-1.32 1.14 WITHIN NORMAL RANGE

Sodium 135-148 146.7 WITHIN NORMAL RANGE

Potassium 3.50-5.00 3.91 WITHIN NORMAL RANGE



Createnine 53.0-115.0 159.6 INCREASE. Increased creatinine levels in

the blood suggest diseases or conditions that

affect kidney function. These can include:

Damage to or swelling of blood vessels in

the kidneys (glomerulonephritis) caused by,

for example, infection or autoimmune

diseases. Bacterial infection of the kidneys

(pyelonephritis) . Death of cells in the

kidneys’ small tubes (acute tubular necrosis)

caused, for example, by drugs or

toxins .Prostate disease, kidney stone, or

24



http://www.labtestsonline.org/understanding

http://www.labtestsonline.org/understanding/conditions/diabetes.html

http://www.labtestsonline.org/understanding/conditions/chf.html

other causes of urinary tract obstruction.

Reduced blood flow to the kidney due to

shock, dehydration, congestive heart failure,

atherosclerosis, or complications of diabetes

(http://www.labtestsonline.org/understanding

/analytes/creatinine/test.html)

Calcium 1.13-1.32 1.24 WITHIN NORMAL RANGE

Sodium 135-148 134 WITHIN NORMAL RANGE




Createnine 53.0-115.0 108.7 WITHIN NORMAL RANGE

Calcium 1.13-1.32 1.24 WIHTIN NORMAL RANGE

Sodium 135-148 131.8 WITHIN NORMAL RANGE




Createnine 53.0-115.0 96.3 WITHIN NORMAL RANGE

25

http://www.labtestsonline.org/understanding

http://www.labtestsonline.org/understanding/conditions/diabetes.html

http://www.labtestsonline.org/understanding/conditions/chf.html

IV. REVIEW OF ANATOMY AND PHYSIOLOGY

A. Anatomy and Physiology

THE DIGESTIVE SYSTEM

The functions of the

digestive system are:

Ingestion - eating

food

Digestion -

breakdown of the

food

Absorption -

extraction of

nutrients from the

food

Defecation -

removal of waste

products

The digestive system also

builds and replaces cells

and tissues that are constantly dying.

26

Digestive Organs

The digestive system is a group of organs (Buccal cavity (mouth), pharynx, oesophagus,

stomach, liver, gall bladder, jejunum, ileum and colon) that breakdown the chemical components

of food, with digestive juices, into tiny nutrients which can be absorbed to generate energy for

the body.

The Buccal Cavity

Food enters the mouth and is chewed by the teeth, turned over and mixed with saliva by the

tongue. The sensations of smell and taste from the food sets up reflexes which stimulate the

salivary glands.

The Salivary glands

These glands increase their output of secretions through three pairs of ducts into the oral cavity,

and begin the process of digestion.

Saliva lubricates the food enabling it to be swallowed and contains the enzyme ptyalin which

serves to begin to break down starch.

The Pharynx

Situated at the back of the nose and oral cavity receives the softened food mass or bolus by the

tongue pushing it against the palate which initiates the swallowing action.

At the same time a small flap called the epiglottis moves over the trachea to prevent any food

particles getting into the windpipe.

27

From the pharynx onwards the alimentary canal is a simple tube starting with the salivary glands.

The Oesophagus

The oesophagus travels through the neck and thorax, behind the trachea and in front of the aorta.

The food is moved by rhythmical muscular contractions known as peristalsis (wave-like

motions) caused by contractions in longitudinal and circular bands of muscle. Antiperistalsis,

where the contractions travel upwards, is the reflex action of vomiting and is usually aided by the

contraction of the abdominal muscles and diaphragm.

The Stomach

The stomach lies below the diaphragm and to the left of the liver. It is the widest part of the

alimentary canal and acts as a reservoir for the food where it may remain for between 2 and 6

hours. Here the food is churned over and mixed with various hormones, enzymes including

pepsinogen which begins the digestion of protein, hydrochloric acid, and other chemicals; all of

which are also secreted further down the digestive tract.

The stomach has an average capacity of 1 litre, varies in shape, and is capable of considerable

distension. When expanding this sends stimuli to the hypothalamus which is the part of the brain

and nervous system controlling hunger and the desire to eat.

The wall of the stomach is impermeable to most substances, although does absorb some water,

electrolytes, certain drugs, and alcohol. At regular intervals a circular muscle at the lower end of

the stomach, the pylorus opens allowing small amounts of food, now known as chyme to enter

the small intestine.

28

Small Intestine

The small intestine measures about 7m in an average adult and consists of the duodenum,

jejunum, and ileum. Both the bile and pancreatic ducts open into the duodenum together. The

small intestine, because of its structure, provides a vast lining through which further absorption

takes place. There is a large lymph and blood supply to this area, ready to transport nutrients to

the rest of the body. Digestion in the small intestine relies on its own secretions plus those from

the pancreas, liver, and gall bladder.

The Pancreas

The Pancreas is connected to the duodenum via two ducts and has two main functions:

1. To produce enzymes to aid the process of digestion

2. To release insulin directly into the blood stream for the purpose of controlling blood

sugar levels

Enzymes suspended in the very alkaline pancreatic juices include amylase for breaking down

starch into sugar, and lipase which, when activated by bile salts, helps to break down fat. The

hormone insulin is produced by specialised cells, the islets of Langerhans, and plays an

important role in controlling the level of sugar in the blood and how much is allowed to pass to

the cells.

The Liver

The liver, which acts as a large reservoir and filter for blood, occupies the upper right portion of

abdomen and has several important functions:

29

1. Secretion of bile to the gall bladder

2. Carbohydrate, protein and fat metabolism

3. The storage of glycogen ready for conversion into glucose when energy is required.

4. Storage of vitamins

5. Phagocytosis - ingestion of worn out red and white blood cells, and some bacteria

The Gall Bladder

The gall bladder stores and concentrates bile which emulsifies fats making them easier to break

down by the pancreatic juices.

The Large Intestine

The large intestine averages about 1.5m long and comprises the caecum, appendix, colon, and

rectum. After food is passed into the caecum a reflex action in response to the pressure causes

the contraction of the ileo-colic valve preventing any food returning to the ileum. Here most of

the water is absorbed, much of which was not ingested, but secreted by digestive glands further

up the digestive tract. The colon is divided into the ascending, transverse and descending colons,

before reaching the anal canal where the indigestible foods are expelled from the body.

THE PERITONEUM

The peritoneal membrane is a semi-permeable membrane that lines the abdominal wall (parietal

peritoneum) and covers the abdominal organs (visceral peritoneum). The membrane is a closed

sac in males. The fallopian tubes and ovaries open into the peritoneal cavity in females. The size

30

of the membrane approximates the body surface area (1-2 m2). There are about 100 cc of

transudate that is contained in the cavity in normal individuals.

A. Blood Supply

The parietal peritoneum derives its blood supply from the arteries in the abdominal wall. This

blood drains into the systemic circulation. The visceral peritoneum is supplied by blood from the

mesenteric and coeliac arteries which drain into the portal vein.

B. Lymphatics

Subdiaphragmatic lymphatics are responsible for 80% of the drainage from the peritoneal cavity.

31

The drainage is then absorbed into the venous circulation through the right lymph duct and the

left thoracic lymph duct. A balance of solutes and fluid in the interstitial tissue is maintained by

absorption of fluid from the peritoneal cavity. The average lymphatic rate of absorption in the

PD patient is 0.5-1.0 ml/min. Factors that affect the rate of absorption are respiratory rate,

posture, and intra-abdominal pressure.

V. SYMPTOMATOLOGY

Symptoms Actual

symptoms

Rationale

Swelling Swelling is considered one of the five characteristics of

inflammation; along with pain, heat, redness, and loss of

function.( http://en.wikipedia.org/wiki/Swelling_%28medical

%29)

Redness Redness and heat are due to increased blood flow at body core

temperature to the inflamed site; swelling is caused by

accumulation of fluid.(

http://en.wikipedia.org/wiki/Inflammation#Cardinal_signs)

Pain Pain is due to release of chemicals that stimulate nerve endings.

Loss of function has multiple causes

(http://en.wikipedia.org/wiki/Inflammation#Cardinal_signs)

Fever Redness and heat are due to increased blood flow at body core

temperature to the inflamed site; swelling is caused by

accumulation of fluid.(

32

http://en.wikipedia.org/wiki/Inflammation

http://en.wikipedia.org/wiki/Inflammation#Cardinal_signs)

Rigid

abdomen

As soon as infection sets in, the whole peritoneum becomes

inflamed or pus-filled abscesses may form. When this happens,

the muscles of the intestine walls become rigid and the

digestive process is hampered as the contents of the intestines

cease their forward movement.( http://www.medical-

look.com/Digestive_system/Peritonitis.html)

Dehydration fluids and electrolytes are lost into the lumen of the abdomen. .(

http://www.medical-look.com/Digestive_system/Peritonitis.htm

l)

Difficulty

expelling

feces

Due to contraction of the muscles of the abdominal wall.

(http://www.healthscout.com/ency/68/473/main.html#cont)

Nausea and

vomiting

X Development of ileus paralyticus (i.e. intestinal paralysis),

which also causes nausea and vomiting.

(http://en.wikipedia.org/wiki/Peritonitis)

Increase

heart rate

Sequestration of fluid and electrolytes, as revealed by decreased

central venous pressure, may cause electrolyte disturbances, as

well as significant hypovolemia, possibly leading to shock and

acute renal failure.( http://en.wikipedia.org/wiki/Peritonitis)

Decrease BP Sequestration of fluid and electrolytes, as revealed by decreased

central venous pressure, may cause electrolyte disturbances, as

well as significant hypovolemia, possibly leading to shock and

33

http://en.wikipedia.org/wiki/Shock_(circulatory)

http://en.wikipedia.org/wiki/Hypovolemia

http://en.wikipedia.org/wiki/Electrolyte_disturbance

http://en.wikipedia.org/wiki/Central_venous_pressure

http://en.wikipedia.org/wiki/Electrolyte

http://en.wikipedia.org/wiki/Fluid

http://en.wikipedia.org/wiki/Acute_renal_failure

http://en.wikipedia.org/wiki/Shock_(circulatory)

http://en.wikipedia.org/wiki/Hypovolemia

http://en.wikipedia.org/wiki/Electrolyte_disturbance

http://en.wikipedia.org/wiki/Central_venous_pressure

http://en.wikipedia.org/wiki/Electrolyte

http://en.wikipedia.org/wiki/Fluid

acute renal failure.( http://en.wikipedia.org/wiki/Peritonitis)

VI. ETIOLOGY OF THE DISEASE

Etiology Actual

Etiology

Rationale

PREDISPOSING FACTORS

Delayed medical

intervention due to

Place of incident

Peritonitis is a medical emergency: the muscles

within the walls of the intestine become paralyzed

and the forward movement of intestinal contents

stops (ileus). Early treatment of GI inflammatory

conditions and preoperative and postoperative

antibiotic therapy help prevent peritonitis.

(http://www.healthscout.com/ency/68/473/main.ht

ml#cont)

PRECIPITATING FACTORS

Gunshot wound

(Abdominal

Trauma

Peritonitis is an inflammation of the peritoneum, the

serous membrane which lines part of the abdominal

cavity and viscera. Peritonitis may be localised or

generalised, and may result from infection (often due

to rupture of a hollow organ as may occur in

abdominal trauma or appendicitis) or from a non-

infectious process.(

34


http://en.wikipedia.org/wiki/Acute_renal_failure

http://en.wikipedia.org/wiki/Peritonitis)

VII. PATHOPHYSIOLOGY

A. Written

Peritonitis, inflammation of the peritoneum, was precipitated by an abdominal trauma resulting

from gunshot wound and was predisposed by the delaye to seek medical intervention due to the

place of incident. With this, there is now the invasion of foreign material into the peritoneum

wherein there is now an out poring of fibrinous exudates and pockets of pus (absess) form

between the fibrinous adhesions. Signs of swelling, redness and pain will be experienced by the

patient. Pockets of pus glue together to the surrounding surface and a localized infection then

will took place. Patient will manifest elevated temperature, pain, stomach rigidity and a sudden

increase in leukocyte level. The infected material will be distributed widely over the surface of

the peritoneum and fluids and electrolytes are lost into the lumen of the abdomen where patient

will manifest signs of shock, dehydration and diminished peristaltic movement. This will then

lead to peritonitis that can be diagnosed through alteration of serum electrolyte levels: creatinine,

sodium and potassium. Laboratories in blood indicate increase in leukocytes, hemoglobin and

hematocrit. ABG results of Respiratory Alkalosis and Metabolic Acidosis, Hypovolemic shock.

If treated with medical and surgical management of Removal of infected material,

administration of fluids and electrolytes replacement, Oxygen therapy to improve ventilatory

fxn and drainage to the outside. (JP drain). Nursing Mgt of Monitoring vital signs and drainage,

Recording intake and output and central venous pressure, observing and record character of any

35

surgical drainage, increase foods and oral fluids gradually, Postoperatively, teach care of incision

and drains and observe proper hygiene and encourage early ambulation and given with:

Cefoxitin, Ketorolac, Ranitidine, Tramadol, Celebrex, Metronidazole, Co-amoxiclav,

Loperamide, Cipro floxacint, Salbutamol will lead to a fair prognosis.

If not treated with medical and surgical mgt, nursing mgt, and pharmacological mgt it will lead

to poor prognosis and complications of intestinal obstruction and sepsis that leads to death

B. Diagram of Pathophysiology

36

Precipitating FactorGunshot wound

(Abdominal trauma)

Predisposing FactorDelayed medical intervention due to Place of incident

Invasion of foreign material into the

peritonium

Out poring of fibrinous exudates

Pockets of pus (absess) form between the fibrinous

adhesions s/s: swelling, redness, pain

LOCALIZED INFECTION

Infected material distributed widely over the surface of the peritoneum

Fluids and electrolytes are lost into the lumen of the abdomen

s/s: fever, pain, rigid abdomen, increase

leukoctes

s/s: shock,dehydration,

diminished peristalsis

PERITONITIS

If treated with:

Medical and Surgical Mgt:- Removal of infected material- administered fluids and electrolytes replacement.- Oxygen therapy to improve ventilatory fxn.-drainage to the outside. (JP drain)

Nursing Mgt:- Monitor vital signs and drainage.-Record intake and output and central venous pressure-observe and record character of any surgical drainage- increase foods and oral fluids gradually-Postoperatively, teach care of incision and drains and observe proper hygiene.-encourage early ambulation

Pharmacological Mgt:CefoxitinKetorolacRanitidineTramadolCelebrexMetronidazoleCo-amoxiclavLoperamideCipro floxacintSalbutamol

If not treated with:

Medical and Surgical MgtNursing MgtPharmacological Mgt

COMPLICATIONS:

Intestinal ObstructionSepsis

POOR PROGNOSIS

DEATH

Serum electrolytes: altered potassium, sodium and creatinine.

Labs: Increase leukocytes, hemoglobin, hematocrit

FAIR PROGNOSIS

VIII. PLANNING

A. Nursing Care Plan

37FAIR PROGNOSIS

38

39

40

41

42

43

B. Discharge Plan

44

To the patient who is diagnose of having peritonitis post ex-lap, it is deemed necessary that

after the hospital stay, compliance of the following action must be strictly observed for

rehabilitation.

Medications - Advise the client to take the medications on time to preserve the efficacy

of the drug. Instruct the client to take the medication with food to avoid GI irritation.

Exercise/Economic Factor - Encourage to do a routine ambulation as a light exercise.

Advise not to engage in strenuous activities. Encourage to take rest every after activity.

Treatment - Encourage to ask proper explanation before starting a procedure to

properly understand what is going to happen. Instruct client to ask and properly understand

before signing the consent.

Health Teaching - Encourage patient to take a bath and do ADL’s within limits if her

safety. Tell the patient to notify the physician immediately if there are unusualities. Follow all

instructions including medications, diet regimen and do’s and don’ts that was instructed to her by

the physician..

Out patient Follow-up - Advise to have a follow up check up any time after discharge.

Diet - Instruct patient to eat nutritious, high protein diet to promote healing and eat smaller, more frequent meals to decrease feeling of fullness and bloating.

Spiritual/Sexual Activities - Encourage to reflect on her life situations and properly

understand these situations. To pray every day to help in coping up ones spirituality.

IX. PHARMACOLOGICAL MANAGEMENT

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

X. SYNTHESIS OF CLIENT’S CONDITION/ STATUS FROM ADMISSION TO

PRESENT

A Conclusion

As for the fact that his condition is reversible, the condition of Mr. Drain

aggravated due to poor compliance of the medical regimen. The medical team

gave the due care needed but still under observation. Thus prolong stay in the

hospital happens.

B. Patient’s Prognosis

Criteria Poor Fair Good Justification

Duration of Illness

Patient was still admitted and was

still under observation Conditions

still the same with complicatins.

Onset of Illness

Rated it as fair because although

patient doesn’t willing to

cooperate patient immediately

seek medical interventions and

was immediately cared for after

the pushed of the mother.

Rated it as good because patient

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Age

was still 25 years old and the said

condition doesn’t choose any age.

Willingness to Take

Medication/Complian

ce to Medical

Procedure

Rated as good because he

complied in all medication and

treatment. Even if he stayed in the

hospital for almost a month

already.

Lifestyle

Rated it as fair because although

the condition arise from

complications of gunshot trauma

still the patient doesn’t comply

with health teachings regarding

importance of ambulating and

hygiene.

Family Support

We rated it good since that the

emotional and physical support

from the family is good and also

he is well cared for.

COMPUTATION:

63

POOR 1 X 1 = 1

FAIR 2 X 3 = 6

GOOD 3 X 2 = 6

1 + 6 + 6 = 13/18 FAIR Prognosis

C. Recommendations

With this study, the student nurses were able to gain more knowledge and wider view and

perspective of the complication of peritonitis. Thus, the student nurses would like recommend

and share some pointers on how to deal with different diseases with gastrointestinal tract such as

peritonitis..

To the government, primarily they should allocate sufficient budget to sustain and provide

better facilities. They must be responsible enough to create awareness program for care and

management for all the Filipino people.

To the health care team, they should righteously implementing basic and ideal procedures

regardless of the health care facilities where they belong. They must observe and always

remember to keep in line with their duties.

To the community and the family, that they must be insufficient coordination with the

government and the health care team regarding promotion of health and wellness.

Through the course of interaction with Mr. Drain, some limitations were noticed that made

us to recommend some interactions to aid in recovering those limitations such as:

Emphasize the importance of compliance of medical regimen and interventions

related to the process of care.

XI. EVALUATION OF THE OBJECTIVES OF THE STUDY

64

The student nurse was able to meet the objectives of this case on peritonitis. Based on the

gathered data regarding the client’s chief complaint, history of present illness, personal, family

and socio-economic history and actual interview to the client, and able to determine the factors

that affect the patient’s condition.

Upon performing the cephalocaudal assessment, able to identify the systems affected that

showed the signs and symptoms, and its manifestations of the said condition. Nursing

interventions were provided to the patient like health teaching regarding the importance on the

compliance of the medical regimen and the infection control procedures such as proper draining

of colostomy bag, changing of dressing regularly, ambulating and hand hygiene. Series of

laboratory test such as CBC and U/A were being made and interpreted which lead to the

diagnosis of peritonitis.

During the period of his hospitalization, problems were identified and prioritized,

then, nursing care plan were formulated.

65

XII. BIBLIOGRAPHY

A. Textbooks

Douges, M.E. et.al., (2002). Nurse’s pocket guide: diagnosis, interventions & rationales.

(8th Edition). Philadelphia: F.A. Davis Company.

Douges, M.E. et.al., (2002). Nursing care plan: guidelines for individualizing patient

care (6th Edition) Philadelphia: F.A. Davis Company.

Gulandick, M. et.al., Nursing care plan. (3rd Edition)

Ignatavicius, D.D. & Workman, M.L. (2006). Medical-surgical nursing: critical thinking

for collaborative care. (5th Edition). St. Louis, Missouri: Elsevier Saunders.

Kozier, B. et.al., (2004). Fundamentals of nursing: concepts, process & practice. (7th

Edition). Philippines: Pearson Education South Asia PTE Ltd.

Smeltzer, S.C. & Bare, B.G. (2004).Textbook of medical-surgical nursing(10th Edition,

Volume 2). Philadelphia: Lippincott Williams and Wilkins. pp 553-538.

Spratto, G.R. & Woods, A.L. (1994). Nurse’s drug reference. USA: Delmar Publishers

Incorporated.

Ulrich & Canale. (2005). Nursing care planning guides. (6th Edition).

B. Internet Downloads

http://www.labtestsonline.org/understanding/analytes/hematocrit/test.html

http://en.wikipedia.org/wiki/Leukocytosis

http://www.healthline.com/adamcontent/fatigue#hl2

http://www.emedicinehealth.com/chest_pain/page3_em.htm

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http://www.emedicinehealth.com/chest_pain/page3_em.htm

http://www.healthline.com/adamcontent/fatigue#hl2

http://en.wikipedia.org/wiki/Leukocytosis

http://www.labtestsonline.org/understanding/analytes/hematocrit/test.html

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Documents

Gunshot Wound Peritonitis