Peritonitis: Inflammation and Causes

Peritonitis

• Peritonitis is an inflammation of the peritoneum.

Pathophysiology and Etiology of Peritonitis

• Contents from outside the peritoneum irritate it.
• The introduced contents activate the complement system, causing irritation.
• As part of the response, WBC's move toward the irritation, fluid shifts to the irritant area taking intravascular spare fluid with it
• Adhesions develop.

Signs and Symptoms of Peritonitis

• Abdominal pain and distention
• Fever
• Altered bowel habits.
• Diminished bowel sounds.
• Paralytic ileus (a non-mechanical obstruction)
• Rebound tenderness over the affected area.
• Rigid, board-like abdomen.
• Hypotension and tachycardia.

Primary vs Secondary Peritonitis

• Primary peritonitis is caused by blood-borne organisms.
• Secondary peritonitis occurs when an organ perforates and spills its contents into the peritoneal cavity.
  • Ruptured appendix, ulcer perforation, or stab wounds can lead to secondary bacterial peritonitis

Complications of Peritonitis

• Sepsis
  • Hypovolemic shock
  • Metabolic alkalosis
  • Abdominal abscess
  • Bowel obstruction
  • Respiratory distress, potentially leading to ARDS due to fluid pushing on the lungs

Labs and Diagnostics for Peritonitis

• History and Physical (H&P) assessment.
• Complete Metabolic Panel (CMP)
• White blood cell count (WBCs).
• Lactic acid levels.
• Complete blood count (CBC), but fluid shifts may cause falsely elevated hematocrit.
• Activated clotting time (ACT).
• CT scan.
• Abdominal X-ray, and a Peritoneoscopy.
• Peritoneal aspiration.

Nursing Interventions for Peritonitis

• Regular abdominal assessments.
• Administer cold towels and remove blankets to manage fever.
• Continuous SpO2 monitoring
• Implement fall risk precautions, especially if patient experiences orthostatic hypotension.
  • Drainage needs and flexible positioning.
• Administer pain medications, antiemetics as prescribed NPO status with NG tube insertion.
• IV fluid administration, Paracentesis

Large Bowel Obstruction (LBO)

• Occurs when fluid, gas, and intestinal contents back up proximally to the point of the obstruction.

Pathophysiology and Etiology of Large Bowel Obstruction

• Proximal bowel distention from the blockage reduces fluid absorption and stimulates intestinal secretion.
• The bowel distal to the obstruction empties and collapses.
• Increased pressure in the bowel lumen leads to capillary permeability.
• Extravasation of fluids and electrolytes into the peritoneal cavity decreases circulating blood volume, causing hypotension and hypovolemic shock and tachycardia.
• Intestinal muscle fatigue and ceased peristalsis from increased distention reduces adequate blood flow and causes the bowel to become edematous and ischemic.
• Prolonged ischemia leads to necrosis and gangrene, referred to as intestinal strangulation or infarction.
• Gangrene leads to perforation; perforated bowel is an emergency and can lead to infection, sepsis, and potentially death.

Causes of Large Bowel Obstruction

• Colorectal cancer, diverticular disease, adhesions, ischemia, volvulus, and Crohn's disease.

Signs & Symptoms of Large Bowel Obstruction

• Abdominal pain and a feeling of impending doom.
• Nausea and vomiting, dependent on the location of the obstruction.
• Distention and constipation.
• High-pitched bowel sounds above the obstruction or absent paralytic ileus; hypoactive in LBO.
  • Gradual onset of symptoms, rare vomiting, no stool ("obstipation"), significant abdominal distention.
  • Crampy pain in the lower abdomen that comes and goes.

Nursing Interventions for Large Bowel Obstruction

• Early recognition of deterioration in the patient's condition is key.
• Health and Physical assessment is a priority.
• Assess characteristics of abdominal pain, including the onset, frequency, color, odor, and amount of any vomitus.
• Assess bowel function by monitoring flatus, bowel sounds, and bowel movements.
• Examine the abdomen for scars, masses, distention, tenderness, rigidity, girth, muscle guarding, and rebound pain.
• Strict I&O monitoring.
• Address acid-base imbalances.
  • High metabolic alkalosis with high obstructions or metabolic acidosis in low obstructions.

Labs & Diagnostics for Large Bowel Obstruction

• Abdominal X-ray, CT scan, and contrast enema assist visualization.
• Sigmoidoscopy/colonoscopy is employed for LBO
• Blood tests: CBC, CMP with WBC for strangulation/perforation.
  • Increased Hct (hemoconcentration).
  • Hemoglobin/hematocrit to assess bleeding.
  • Electrolytes, BUN, and creatinine levels, and metabolic alkalosis levels.

Nursing Interventions for Large Bowel Obstruction

• Regain intestinal patency.
• Emergency surgery for strangulation or perforation that involves resection with anastomosis.
  • Partial or total colostomy or ileostomy.
• Colonoscopy- to remove polyps, dilate strictures, with laser destruction and removal of tumors.
• Conservative management for paralytic ileus or adhesion-related obstructions is often resolved without surgical intervention.
  • Long term PVN with obstruction.
• Monitor fluid, electrolytes, and acid-base abnormalities.
• Strict I&O and connect to suction.
• Bowel distention increases risk of edema, necrosis, and perforation.

Small Bowel Obstruction (SBO)

• Occurs when fluid, gas, and intestinal contents back up proximally to the point of the obstruction.

Pathophysiology and Etiology of Small Bowel Obstruction

• Proximal bowel distention from the blockage reduces fluid absorption and stimulates intestinal secretion.
• The bowel distal to the obstruction empties and collapses.
• Increased pressure in the bowel lumen leads to capillary permeability.
• Extravasation of fluids and electrolytes into the peritoneal cavity decreases circulating blood volume, causing hypotension and hypovolemic shock and tachycardia.
• Intestinal muscle fatigue and ceased peristalsis from increased distention reduces adequate blood flow and causes the bowel to become edematous and ischemic.
• Prolonged ischemia leads to necrosis and gangrene, referred to as intestinal strangulation or infarction.
• Gangrene leads to perforation; perforated bowel is an emergency and can lead to infection, sepsis, and potentially death.

Causes of Small Bowel Obstruction

• Surgical adhesions, hernias, cancer, strictures from Crohn's disease, intussusception

Signs & Symptoms of Small Bowel Obstruction

• Abdominal pain and a feeling of impending doom.
• Nausea and vomiting, dependent on the location of the obstruction.
• Distention and constipation.
• High-pitched bowel sounds above the obstruction or absent if paralytic ileus; absent or hypoactive distal to the obstruction.
  • Rapid onset if frequent, copious vomiting with bile or stool indicates a proximal obstruction.
  • Colicky, intermittent pain in the mid-upper abdomen, minimal abdominal distention if proximal or pronounced if distal.

Nursing Interventions for Small Bowel Obstruction

• Early recognition of deterioration in the patient's condition is key.
• Health and Physical assessment is a priority.
• Assess characteristics of abdominal pain, including the onset, frequency, color, odor, and amount of any vomitus.
• Assess bowel function by monitoring flatus, bowel sounds, and bowel movements.
• Examine the abdomen for scars, masses, distention, tenderness, rigidity, girth, muscle guarding, and rebound pain.
• Strict I&O monitoring.
• Address acid-base imbalances.
  • High metabolic alkalosis with high obstructions or metabolic acidosis in low obstructions.

Labs & Diagnostics for Small Bowel Obstruction

• Abdominal X-ray, CT scan, and contrast enema assist visualization.
• Sigmoidoscopy/colonoscopy is employed for SBO visualization.
• Blood tests: CBC, CMP with WBC for strangulation/perforation.
  • Increased Hct (hemoconcentration).
  • Hemoglobin/hematocrit to assess bleeding.
  • Electrolytes, BUN, and creatinine levels, and metabolic alkalosis levels.

Interventions for Small Bowel Obstruction

• Regain intestinal patency, emergency surgery for strangulation or perforation.
• Intestinal resection of obstructed section with anastomosis or may involve partial or total colostomy or ileostomy Endoscopic assessment is employed to remove polyps, dilate strictures, with laser destruction and removal of tumors. Conservative management for paralytic ileus or adhesion-related obstructions is often resolved without surgical intervention.
  • Strict I&O
• If long term PVN with obstruction needs intestinal decompression and can increase risks of edema, necrosis and perforation
• Monitor fluid, electrolyte, and acid-base abnormalities.

Lab/Ox Clinical Manifestations Patho Medication Interventions for Small Bowel Obstruction

• Labs/OX

  • Abd X-ray
  • H+P
  • CMP
  • Small Bowel FT/OR CT Scan
  • CBC (OBC'S)
  • ⅄lactic

• Clinical Manifestations

  • Abd Pain
  • Distended Abdomen
  • Vomiting/Nausea
  • Hypoactive BS
  • Bm ± Constipation

• Patho: Small Bowel Obstruction

  • Adhesion develops + blocks
  • Peristalsis in ileum
  • Gas & Fluid content builds + build up proximal
  • Collapsed distal bowel

• Medication Interventions

  • Pain medication
  • Ngtube placement
  • antiemetic
  • NPO

GallStone Obstruction (Cholelithiasis and Cholecystitis)

• Cholecystitis is the inflammation of the gallbladder.
• Cholelithiasis is a gallstone obstruction of the common bile duct in the gall bladder.

Cholangitis

• Total Obstruction occurs
• Bile begins to build up in liver, also know as Hyperbilirubinemia (jaundice), liver becomes congested
• Elevated Bilirubin levels due to no release of bile

Causes

• The exact cause is unknown factors like bile salt, bilirubin, calcium and for protein out of bile
• Contributing factors include stasis may be related to immobility, pregnancy, inflammartory or obstructive lesions

Risks

• Female, multiparity estrogen treament
• Native American Ancestry
• Sedentary life style, obesity
• Age over 40
• Familial tendancy

Tests

• WBC count
• Serum Bilirubin Level (Hyperbilirubinemia - jaundice)
• Urinary Bilirubin Level
• Liver enzyme levels
• ⅄ serum amylase levels OR lipase level (pancreatitis)
• ERCP- visualization of the gallbladder, cystic duct, common hepatic duct, and common bile duct

Interventions

• ERCP:direct visualization -manage Pain -Maintain fluids electrolyte

Cholecystitis

• ACALCULOUS- older adults critically ill Prolonged immobility, prolonged parendil nutrition, adhesions, cancer, etc
• Causes scarring- decreases function Choledochoolithiasis -Encrw W/ sphincterotomy -direct visual - dilation of bile duct placed
• May lodge ducts obstruction - may need operation ensure patiency T- tube bile exploration common drains excess - site care

Post Operation care

Vs Monitor vitals Careful assessement - lung exercises COMFORT Sim's Positioning

Diet

• LOW fat frequent meals long Rapid weightloss may causes stones therapy
• fat-soluble Vitamin AD IEK after
  • cholecysetcomy liquid meals first few days for -Incisional chole .com 4-6 weaks - anticholinergics - antiemetics

acute pancreatitis

• Liver makes. bile, gall bladder -Stores enzymescauses
• Spillage of pancreatic autondigestion Severe pain from mild edemaSevere haemorrhages due to liver causes -Women gall bladder disease -men- alcoholUse -Infection

Labs

Serum amylaselevel Livers Us Er cp.

Complications

• fluid pseudocysts
• abscess high fever, surgical draining
• systeminvolve -Hypertension -shock

interventions

1V H Aggressive E.i

other notes

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