NURSING CARE MANAGEMENT 0112 RLE

Ist Semester, Academic Year 2021-2022

MODULE 17: NURSING CARE MANAGEMENT OF ADULT CLIENTS WITH

INFLAMMATORY CONDITIONS OF THE GASTROINTESTINAL SYSTEM

MODULE OVERVIEW:
This module is designed and prepared for BSN III students to gain adequate knowledge
on how to accurately assess early signs and symptoms of patients with Appendicitis
and Peritonitis and its medical, surgical and nursing management.

Video Viewing Activity (Asynchronous}

Video clips provides an additional resource for learners and the clinical instructors, as
well. For better You will watch the following videos Understanding on Appendicitis, surgical
interventions and assessment on 3 distinct signs of Appendicitis

Please click the link below:

https://www.youtube.com/watch?v=6LrL4ysi_AE&t=1s

https://www.youtube.com/watch?v=fey_pHnSyzA

https://www.youtube.com/watch?v=VrvOhM9euns&has_verified=1

Learning Guide Activity

You are to read the topic on Appendicitis. As part of your learning activity, you are given a task
to answer the learning guide on this topic. This will assess your understanding on the disease
process and its surgical, medical and nursing management.

After completing the Learning Guide Activity, you will meet with your professors to answer
any questions regarding Appendicitis and its management

You are now on- your second day duty on Medical Surgical (MS) Ward in a private tertiary
hospital in Pampanga. On your first day of duty, you are assigned to an American patient Mr.
Parker, a 69-year-old, stockbreeder and initially admitted due to low back pain and gradual
distention of abdomen of 6-8 weeks duration accompanied by abdominal pain. Had been taking
ibuprofen for pain and paracetamol prior to admission.

Medical records review revealed Mr. Parker has recurrent diverticulitis. As you read his chart
you recalled from your lecture that diverticulitis may cause complications that include
peritonitis.
PERITONITIS

Peritonitis is inflammation of the peritoneum — a serous membrane lining abdominal

cavity and viscera and covers the organs within your abdomen — that is usually due to
a bacterial or fungal infection.

There are two types of peritonitis:

● Spontaneous bacterial peritonitis. Sometimes, peritonitis develops as a

complication of liver disease, such as cirrhosis, or of kidney disease.

● Secondary peritonitis. Peritonitis can result from rupture (perforation) in your

abdomen, or as a complication of other medical conditions.

Etiology and Risk Factors:

Peritonitis may be spontaneous or secondary. Usually a result of bacterial infection; the

organisms come from diseases of the GI tract or, in women, from the internal reproductive
organs. Major sources of inflammation are from the GI tract, from the external
environment, and through the bloodstream. Normal flora of the intestine becomes a
source of infection when they enter the sterile peritoneal cavity. Most common is E. coli
and klebsiella, Proteus, Pseudomonas (streptococcus species. Can also be a result of
external sources such as injury or trauma or an association with abdominal surgery and
peritoneal dialysis.

There is no risk factor for peritonitis because the condition itself is a result of another
problem. Causes include:

● Bowel obstruction
● Bacterial invasion
● Ruptured or gangrenous appendix or gallbladder
● Perforated peptic ulcer
● Perforated stomach or intestine secondary to cancer or IBS
● Acute pancreatitis or mesenteric thrombosis
● Diverticulitis
● Penetrating wounds
Pathophysiology:

Inflammation, infection, ischemia, trauma, tumor perforation

Leakage of contents from abdominal organs

Accumulation into abdominal cavity

Bacterial proliferation occurs

Local inflammation, edema of tissues and exudation of fluid develops

Peritoneal cavity fluid becomes turbid with increase tamoun debris,

of protein, WBC, cellular
and blood

Severe systemic effects

shunting of extra blood to inflamed area of bowel to combat infection

Circulation Blood Volume PeristalticAactivity

Ceases-Pparalytic
Ileus

Fluids and Air Retention in Bowels

Intraabdominal Pressure

On admission to MS ward, your assessment findings on the patient are he was afebrile but
confused; physical examination revealed a rigid abdomen. Upon auscultation you noted absence
of bowel sounds. On the floor he vomited clear fluids, and you noted that to his I&O chart.
Intravenous fluids started and analgesics for pain. Blood collected and was sent to the laboratory
for further investigations.

To further enhance your knowledge on Peritonitis, you asked your clinical instructor about the
signs and symptoms of Peritonitis.

Mr. Parker is scheduled for CT scan and peritoneal aspiration in the later day.
Clinical Manifestations: Symptoms depend on the location and extent of the
inflammation
● Localized or generalized pain
● Rigidity of abdominal muscles (and pain that increases with any pressure or motion
of the abdomen
● Tender and distended abdomen
● Rebound tenderness
● Paralytic ileus
● Nausea and vomiting
● Low-grade fever
● Tachycardia
● Hypotension
● Absence of bowel sounds
● Shallow respirations
● Elevated WBC count

Diagnostics:
Blood tests.
CBC - high white blood cell count.
Blood Culture and Sensitivity test to determine if there are bacteria in the blood.
Serum electrolytes (Na, K, Cl)-altered levels of potassium, sodium and chloride

Imaging tests.
Abdominal X-ray-may show air and fluid levels and distended bowel hoop
Abdominal ultrasound may reveal abscesses and
CT scan may show abscess formation
MRI-may use as diagnosis of intra-abdominal abscess

Peritoneal fluid analysis. Using a thin needle, a sample of the fluid in the peritoneum
(paracentesis), especially for a patient on peritoneal dialysis or have fluid in your
abdomen from liver disease. If with peritonitis, examination of this fluid may show an
increased white blood cell count, which typically indicates an infection or inflammation. A
culture of the fluid may also reveal the presence of bacteria.

Complications:
● Sepsis-major cause of death from peritonitis
● Shock-may result from septicemia and hypovolemia
● Intestinal obstructions-from adhesions

To better understand the Paracentesis procedure, your Clinical instructor provided a link for
your viewing activity after your clinical duty. https://www.youtube.com/watch?v=kdpP7H654Vw

Upon the confirmation of diagnosis, Mr. Parker’s diverticulitis has relapsed which caused him
peritonitis. The rationale of the medical and surgical management is being discussed to Mr.
Parker and his family. As a student nurse, you are there to support and reinforce information
to the patient and family.
Medical Management

● Maintain fluid and electrolyte balance – Replace losses with IV fluids especially if
peritonitis is advanced and surgery is contraindicated. Fluid, colloid and electrolyte
is the major focus of management. Administration of isotonic solutions is
prescribed for hypovolemia from fluid and electrolyte shifting from intestinal lumen
into the peritoneal cavity and depleted fluid in the vascular space.
● Control infection – IV antibiotic therapy with potent broad-spectrum agents;
surgical drainage and repair
● Analgesics for pain. Antiemetics for nausea and vomiting.
● Provide gastric decompression- Nasogastric tube insertion and suction assist in
relieving abdominal distention.
● Oxygen therapy to promote adequate oxygenation.
● Antibiotic therapy is initiated early with a large dose of broad-spectrum antibiotic
until a specific microorganism is identified and appropriate antibiotic can be used.

Surgical Management
Surgical objective: remove the infected material and correct the cause. Surgical treatment
is directed towards:
⮚ Excision (appendectomy)
⮚ Resection with or without anastomosis (intestine resection)
⮚ Repair (perforation)
⮚ Drainage (abscess)

Nursing Management:

● Obtain thorough history, including specific information about the client’s pain
● Assess the abdomen, noting the presence or absence of bowel sounds and
whether it is firm, distended or rigid. Note areas of rebound tenderness
● Report and document for nature of pain, its location on the abdomen and any
changes in location
● Administering of analgesics as ordered
● Positioning the patient for comfort are helpful in decreasing pain
● Accurate monitoring of intake and output ● Immediately report any manifestations
of sepsis
● Carefully monitor patients for complications.
______________________________________________________________________
After learning the medical and nursing management of patients with peritonitis, you learned
that to afford relief of patients who have abdominal distention nasogastric tube (NGT) is
inserted for decompression. To better understand how to do insertion and removal of NGT, the
link is provided by your Clinical instructor as part of your viewing activity.
https://www.youtube.com/watch?v=_bfyhbrdohU
___________________________________________________________________________

Before your duty ends you are now to make an individual Focus Charting based on
case scenario provided by your Clinical instructor. Submission due on 3rd RLE day not
later than 7AM.
___________________________________________________________________________

Video Conference (Synchronous)

Discussions will be made on Skill Checklist 12.4: Inserting Nasogastric Tube and Skill
Checklist 10.3: Assisting with Paracentesis. Feedback on your F-DAR will also be done
at this time.
Asynchronous Activity
To evaluate your learning for this week. We have prepared a Multiple-Choice Type quiz
for you. Please read the questions clearly and answer correctly.

REFERENCES
● Black, J.M. & Hawks, J.H. (2008) Medical-Surgical Nursing: Clinical Management for Positive
Outcomes. W.B. Saunders Company
● Smeltzer, S.C. et al. (2010) Brunner & Suddarth’s Textbook on Medical-Surgical Nursing.
Lippincott Williams & Wilkins
● https://www.mayoclinic.org/diseases-conditions/peritonitis/diagnosis-treatment/drc-20376250
● Brunner & Suddhart’s, Textbook of Medical-Surgical Nursing 13th edition.), Hinkle,J and
Cheever,K.
● https://www.youtube.com/watch?v=kdpP7H654Vw

Contributor:Ma. Teresa S. Cabanayan, RN, MN

NCM 0112 RLE Instructor

Peer Reviewed by: Gail Marie B. Gozun,RN,RM,NCII,MSN

NCM 0112 RLE Instructor

Prepared by:

Evangeline C. Bautista, RN,

Gail Marie B. Gozun,RN,RM,NCII,MSN

Reviewed and Evaluated by:

Anna Lyn M. Paano, RN, MAN
Level III Academic Coordinator

Sherwin M Quizon, RN, MN

Level III RLE Coordinator
Debbie Q. Ramirez, RN, PhD
Assistant Dean

Approved by:

Zenaida S. Fernandez, RN, PhD

Dean