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‫‪peritonitis‬‬
‫‪ h h‬د ‪h‬جيهان دعبد لال‬
        ‫حكيمسيونس‬
  ‫مدرس التمريض الباطني والجراحي‬

        ‫والحالت الحرجة‬
Peritonitis
Definition:
    Peritonitis is an inflamation of the
 peritoneum, the serous memberan that
 lines part of the abdominal cavity.
 Peritonitis may be localized or
 generalized, and may result from
 infection and from a non-infectious
 process.
Types of peritonitis
              Or
        Classification

1-Infected peritonitis (localized or
  generalized infected peritonitis) or
  none infected peritonitis
2 Primary or secondary peritonitis
• Primary peritonitis is caused by the
  spread of an infection from the blood
  and lymph nodes to the peritoneum.
• Secondary peritonitis is the more
  common type of peritonitis, happens
  when the infection comes into the
  peritoneum from the gastrointestinal or
  biliary tract
Risk Factors
• Liver disease (cirrhosis)
• Fluid in the abdomen
• Weakened immune system
• Pelvic inflammatory disease
• Risk factors for secondary peritonitis include:
• Appendicitis (inflammation of the appendix)
• Stomach ulcers, Twisted intestine, Pancreatitis
• Inflammatory bowel disease, Injury caused by an
  operation.
• Peritoneal dialysis, Trauma.
Causative organisms


• pyogenic bacteria         - E-coli
• Aerobic and anaerobic     streptococci
  staphylococci
Causes


I- Infected peritonitis:
1) Generalized Infected peritonitis:
1.    Perforation    of    part   of  the
gastrointestinal tract       is the most
common cause of peritonitis. This
includes:
 Perforation of the distal esophagagus.
 perforation of the stomach as peptic
  ulcer, gastric carcenoma
 perforation of the duodenum (peptic
  ulcer)
 perforation of the remaining inttestine
  (e.g., appendicitis, inflamatory bowel
  disease, intestinal infarction, intestinal
  strangulation, colorectal carcinoma.
 Or perforation     of   the   gall   bladder
  (cholesystitis).
 Other possible reasons for perforation
  include abdominal trauma, ingestion of a
  sharp forgin body, perforation by an
  endoscope or catheter.
2. Disruption of the peritoneum, even in
 the absence of perforation of a hollow
 viscus, may also cause infection by
 letting    micro-organism   into    the
 peritoneal cavity. Examples include
 trauma, surgical wound, continuous
 ambulatory peritoneal dialysis, and
 intra-peritoneal chemotherapy.
3. Direct entry through an operative or
  traumatic wound.
4. Intra-peritoneal dialysis predisposes
 to peritoneal infection
5. Though blood spread in cases of
  septicemia and pyaemia but is rare.
2) Systemic or localized infections (such
  as tuberculosis) may rarely have a
  peritoneal localisation.
II-Non-infected peritonitis
1- Leakage of steril body fluids into the
  peritoneum, such as blood, gastric
  juice (e.g., peptic ulcer, gastric
  carcinoma), bile (e.g., liver), urine
  (pelvic   trauma),   pancreatic   juice
  (pancreatitis).
Note: While these body fluids are sterile at
 first, they frequently become infected once
 they leak out of their organ, leading to
 infectious peritonitis within 24 to 48 hours.
2- Sterile abdominal surgery under normal
  circumstances, causes localized or minimal
  generalized peritonitis through a foreign
  body reaction and/or fibrotic adhesions.
Pathophysiology

• In normal conditions, the peritoneum
  appears greyish and glistening. It becomes
  dull 2–4 hours after the onset of peritonitis,
  initially with serous or slightly turbid fluid.
• Peritonitis is caused by leakage of contents
  from abdominal organs into the abdominal
  cavity, usually as a result of inflammation,
  infection, ischemia, trauma, or tumor
  perforation.
• Bacterial proliferation occurs.
• Edema of the tissues results and exudation of fluid
  develops in a short time.
• Fluid in the peritoneal cavity becomes turbid with
  increasing amounts of protein, white blood cells,
  cellular debris, and blood. The immediate response
  of the intestinal tract is hypermotility, followed by
  paralytic ileuse with an accumulation of air and fluid
  in the bowel.
• Later on, the exudate becomes creamy and
  suppurative. It may be spread to the whole
  peritoneum
Nursing process:

                  A-Assessment through:
•   Signs and symptoms   - Diagnostic parameters

Signs and symptoms of peritonitis:
• Symptoms depend on the location and extent
  of the inflammation.
• Abdominal pain and tenderness. At first, a
  diffuse type of pain is felt. The pain tends to
  become constant, localized, and more
  intense near the site of the inflammation.
• Diffuse     abdominal      rigidity,
  Swelling and tenderness in the
  abdomen with pain ranging from
  dull aches to severe, sharp pain is
  often   present,    especially    in
  generalized peritonitis
• Fever and chills, loss of appetite,
  thirst, nausea and vomiting.
• Reduced urine output
• Not being able to pass gas or stool
• Sinus tachycardia
• Development of paralytic ileus          (i.e.,
  intestinal paralysis), which also     causes
  nausea, vomiting and.
• Abdominal distension
• Auscultation reveals absent of bowel sound
  due to paralytic ileus
• In neglected cases the patient will present by
  sunken eyes
• Diagnostic parameters:
• A diagnosis of peritonitis is based on the
  clinical manifestations.
• Blood picture for leukocytosis.
• hypokalemia, hypernatremia, and acidosis
  may be present, but they are not specific
  findings.
•     Abdominal X-rays may      reveal   dilated,
    edematous intestines,
• Computed tomography (CT or CAT scanning)
  may be useful in differentiating causes of
  abdominal pain.
• In patients with ascites, a diagnosis of
  peritonitis is made via paracentesis.
• Culture of the peritoneal fluid can determine
  the    microorganism      responsible     and
  determine their sensibility to antimicrobial
  agents.
B-Nursing diagnosis:
• Abdominal pain.     2- Fluid volume
  deficit.
• Alteration in tissue perfusion
C- Nursing intervention:
1-Monitor and document          the severity,
  consistency,       location    and   other
  characteristics of pain.
3- The patient is placed on the side with knees
  flexed; this position decreases tension on
  the abdominal organs and maximize comfort.
4- Accurate recording of all intake and
  output and central venous pressure
  assists in calculating fluid replacement.
5- Monitor the quantity and quality of
  output from nasogastric tube
6- Maintain intravenous therapy.
7- Monitor the patient for signs and
  symptoms of shock.
8-Monitor the patient's bowel sounds by assessing for
  flatus or bowel movement.
9-Monitor the patient's mental, cardiac, and pulmonary
  status.
10-Monitor Signs that indicate that peritonitis is
  subsiding include a decrease in temperature and
  pulse rate, softening of the abdomen, return of
  peristaltic sounds, passing of flatus, and bowel
  movements.
11-Increases fluid and food intake gradually and
  reduces parenteral fluids as prescribed.
Medical Treatment of peritonitis:



General supportive measures such as
 intravenous rehydration and correction of
 electrolyte disturbances.
2.      Antibiotics are usually administered
     intravenously, but they may also be infused
     directly into the peritoneum.
Surgical treatment:



-laparotomy is needed to perform a
  full exploration and lavage of the
  peritoneum.
Preoperative preparation:
• A nasogastric tube is inserted to deflate the stomach
  and bowels and to prevent vomiting during induction
  of anesthesia.
• Intravenous fluids as saline or ringer solution are
  administered to correct the hypovolemia.
• Antibiotics: a combination of ampicillin, an
  aminoglycoside and metroniazol can cover all
  aerobic and anaerobic organisms.
• Analgesics are given for pain relieve.
• Foley catheter is inserted to check the urine output
  and the adequacy of fluid replacement.
Post operative care:
• Continuous antibiotic treatment.
• Drains are inserted during the surgical
  procedure, and the nurse must observe and
  record the character of the drainage
  postoperatively.
•     Care must be taken when moving and
    turning the patient to prevent the drains from
    being dislodged.
• Prepare the patient and family for discharge
  by teaching him to care for the incision and
  drains if he will be sent home with the drains.
[10]- Complications
Sequestration of fluid and electrolytes, as
revealed by decreased centeral venous pressure,
may cause electrolytes disturbances.
hypovolemia, leading to shock and acute renal
failure.
A peritoneal abscess.
sepsis may develop, so blood cultures should be
obtained.
The fluid may push on the diaphragm, causing
splinting and subsequent breathing difficulties.
Formation of fibrous tissue in the peritoneum
Adult respiratory distress syndrom.

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Peritonitis

  • 1. .
  • 2. ‫‪peritonitis‬‬ ‫‪ h h‬د ‪h‬جيهان دعبد لال‬ ‫حكيمسيونس‬ ‫مدرس التمريض الباطني والجراحي‬ ‫والحالت الحرجة‬
  • 3. Peritonitis Definition: Peritonitis is an inflamation of the peritoneum, the serous memberan that lines part of the abdominal cavity. Peritonitis may be localized or generalized, and may result from infection and from a non-infectious process.
  • 4. Types of peritonitis Or Classification 1-Infected peritonitis (localized or generalized infected peritonitis) or none infected peritonitis 2 Primary or secondary peritonitis
  • 5. • Primary peritonitis is caused by the spread of an infection from the blood and lymph nodes to the peritoneum. • Secondary peritonitis is the more common type of peritonitis, happens when the infection comes into the peritoneum from the gastrointestinal or biliary tract
  • 6. Risk Factors • Liver disease (cirrhosis) • Fluid in the abdomen • Weakened immune system • Pelvic inflammatory disease • Risk factors for secondary peritonitis include: • Appendicitis (inflammation of the appendix) • Stomach ulcers, Twisted intestine, Pancreatitis • Inflammatory bowel disease, Injury caused by an operation. • Peritoneal dialysis, Trauma.
  • 7. Causative organisms • pyogenic bacteria - E-coli • Aerobic and anaerobic streptococci staphylococci
  • 8. Causes I- Infected peritonitis: 1) Generalized Infected peritonitis: 1. Perforation of part of the gastrointestinal tract is the most common cause of peritonitis. This includes:  Perforation of the distal esophagagus.
  • 9.  perforation of the stomach as peptic ulcer, gastric carcenoma  perforation of the duodenum (peptic ulcer)  perforation of the remaining inttestine (e.g., appendicitis, inflamatory bowel disease, intestinal infarction, intestinal strangulation, colorectal carcinoma.
  • 10.  Or perforation of the gall bladder (cholesystitis).  Other possible reasons for perforation include abdominal trauma, ingestion of a sharp forgin body, perforation by an endoscope or catheter.
  • 11. 2. Disruption of the peritoneum, even in the absence of perforation of a hollow viscus, may also cause infection by letting micro-organism into the peritoneal cavity. Examples include trauma, surgical wound, continuous ambulatory peritoneal dialysis, and intra-peritoneal chemotherapy.
  • 12. 3. Direct entry through an operative or traumatic wound. 4. Intra-peritoneal dialysis predisposes to peritoneal infection 5. Though blood spread in cases of septicemia and pyaemia but is rare. 2) Systemic or localized infections (such as tuberculosis) may rarely have a peritoneal localisation.
  • 13. II-Non-infected peritonitis 1- Leakage of steril body fluids into the peritoneum, such as blood, gastric juice (e.g., peptic ulcer, gastric carcinoma), bile (e.g., liver), urine (pelvic trauma), pancreatic juice (pancreatitis).
  • 14. Note: While these body fluids are sterile at first, they frequently become infected once they leak out of their organ, leading to infectious peritonitis within 24 to 48 hours. 2- Sterile abdominal surgery under normal circumstances, causes localized or minimal generalized peritonitis through a foreign body reaction and/or fibrotic adhesions.
  • 15. Pathophysiology • In normal conditions, the peritoneum appears greyish and glistening. It becomes dull 2–4 hours after the onset of peritonitis, initially with serous or slightly turbid fluid. • Peritonitis is caused by leakage of contents from abdominal organs into the abdominal cavity, usually as a result of inflammation, infection, ischemia, trauma, or tumor perforation.
  • 16. • Bacterial proliferation occurs. • Edema of the tissues results and exudation of fluid develops in a short time. • Fluid in the peritoneal cavity becomes turbid with increasing amounts of protein, white blood cells, cellular debris, and blood. The immediate response of the intestinal tract is hypermotility, followed by paralytic ileuse with an accumulation of air and fluid in the bowel. • Later on, the exudate becomes creamy and suppurative. It may be spread to the whole peritoneum
  • 17. Nursing process: A-Assessment through: • Signs and symptoms - Diagnostic parameters Signs and symptoms of peritonitis: • Symptoms depend on the location and extent of the inflammation. • Abdominal pain and tenderness. At first, a diffuse type of pain is felt. The pain tends to become constant, localized, and more intense near the site of the inflammation.
  • 18. • Diffuse abdominal rigidity, Swelling and tenderness in the abdomen with pain ranging from dull aches to severe, sharp pain is often present, especially in generalized peritonitis • Fever and chills, loss of appetite, thirst, nausea and vomiting.
  • 19. • Reduced urine output • Not being able to pass gas or stool • Sinus tachycardia • Development of paralytic ileus (i.e., intestinal paralysis), which also causes nausea, vomiting and. • Abdominal distension • Auscultation reveals absent of bowel sound due to paralytic ileus • In neglected cases the patient will present by sunken eyes
  • 20. • Diagnostic parameters: • A diagnosis of peritonitis is based on the clinical manifestations. • Blood picture for leukocytosis. • hypokalemia, hypernatremia, and acidosis may be present, but they are not specific findings. • Abdominal X-rays may reveal dilated, edematous intestines,
  • 21. • Computed tomography (CT or CAT scanning) may be useful in differentiating causes of abdominal pain. • In patients with ascites, a diagnosis of peritonitis is made via paracentesis. • Culture of the peritoneal fluid can determine the microorganism responsible and determine their sensibility to antimicrobial agents.
  • 22. B-Nursing diagnosis: • Abdominal pain. 2- Fluid volume deficit. • Alteration in tissue perfusion
  • 23. C- Nursing intervention: 1-Monitor and document the severity, consistency, location and other characteristics of pain. 3- The patient is placed on the side with knees flexed; this position decreases tension on the abdominal organs and maximize comfort.
  • 24. 4- Accurate recording of all intake and output and central venous pressure assists in calculating fluid replacement. 5- Monitor the quantity and quality of output from nasogastric tube 6- Maintain intravenous therapy. 7- Monitor the patient for signs and symptoms of shock.
  • 25. 8-Monitor the patient's bowel sounds by assessing for flatus or bowel movement. 9-Monitor the patient's mental, cardiac, and pulmonary status. 10-Monitor Signs that indicate that peritonitis is subsiding include a decrease in temperature and pulse rate, softening of the abdomen, return of peristaltic sounds, passing of flatus, and bowel movements. 11-Increases fluid and food intake gradually and reduces parenteral fluids as prescribed.
  • 26. Medical Treatment of peritonitis: General supportive measures such as intravenous rehydration and correction of electrolyte disturbances. 2. Antibiotics are usually administered intravenously, but they may also be infused directly into the peritoneum.
  • 27. Surgical treatment: -laparotomy is needed to perform a full exploration and lavage of the peritoneum.
  • 28. Preoperative preparation: • A nasogastric tube is inserted to deflate the stomach and bowels and to prevent vomiting during induction of anesthesia. • Intravenous fluids as saline or ringer solution are administered to correct the hypovolemia. • Antibiotics: a combination of ampicillin, an aminoglycoside and metroniazol can cover all aerobic and anaerobic organisms. • Analgesics are given for pain relieve. • Foley catheter is inserted to check the urine output and the adequacy of fluid replacement.
  • 29. Post operative care: • Continuous antibiotic treatment. • Drains are inserted during the surgical procedure, and the nurse must observe and record the character of the drainage postoperatively. • Care must be taken when moving and turning the patient to prevent the drains from being dislodged. • Prepare the patient and family for discharge by teaching him to care for the incision and drains if he will be sent home with the drains.
  • 30. [10]- Complications Sequestration of fluid and electrolytes, as revealed by decreased centeral venous pressure, may cause electrolytes disturbances. hypovolemia, leading to shock and acute renal failure. A peritoneal abscess. sepsis may develop, so blood cultures should be obtained. The fluid may push on the diaphragm, causing splinting and subsequent breathing difficulties. Formation of fibrous tissue in the peritoneum Adult respiratory distress syndrom.