- Risk for Infection Related to Traumatized skin or tissues and Rupture of appendix, ulcer, colon as evidenced by signs and symptoms of Infection
- Ineffective Breathing Pattern related to Abdominal pain or discomfort and increased physical exertion as evidenced by accessory muscle use and altered chest excursion
- Deficient fluid Volume related to Fluid shifting into the peritoneal space and retention of fluid in the abdomen as evidenced by hypotension and weakness
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Verbalized unable to follow hygiene measures to prevent infection Objective Data: -Swelling, -Redness, -Purulent drainage -Signs of Infection | Risk for Infection Related to Traumatized skin or tissues and Rupture of appendix, ulcer, colon as evidenced by signs and symptoms of Infection | Patient is free of infection as evidenced by vital signs within normal range and lack of evidence of infection such as swelling, redness, and purulent drainage from non-intact areas of skin. Patient verbalizes understanding of behavioral and hygiene measures to prevent infection. Patient verbalizes recognition of signs of infection that need to be reported to a healthcare provider for treatment. | 1. Keep the skin around the dialysis catheter clean. Patients who receive peritoneal dialysis should be instructed on keeping their PD catheter site clean and dry. 2. Maintain aseptic technique when accessing the PD catheter. When performing PD, do not allow the catheter tip to touch the skin or another surface, as this will cause contamination. The nurse and patient should both wear masks during the procedure. 3. Administer antibiotics. Broad-spectrum antibiotics should be administered until a specific pathogen is identified. 4. Prepare for surgery. Emergency surgery may be required in cases such as trauma or a burst appendix or colon to remove tissue, repair the rupture, and prevent the spread of infectious materials. | Patient is free from infection as evidenced by vital signs within normal range and lack of evidence of infection such as swelling, redness, and purulent drainage from non-intact areas of skin. Patient verbalized understanding of behavioral and hygiene measures to prevent infection. Patient verbalized recognition of signs of infection that need to be reported to a healthcare provider for treatment. |
Subjective Data: Difficulty breathing; shortness of breath or dyspnea Anxiety in relation to breathing Objective Data: -Dyspnoea -Abnormal respiratory rate; tachypnoea or bradypnea -Poor oxygen saturation -Abnormal ABG results -Shallow breathing -Pursed-lip breathing -Accessory muscle use when breathing -Nasal flaring -Cough | Ineffective Breathing Pattern related to Abdominal pain or discomfort and increased physical exertion as evidenced by accessory muscle use and altered chest excursion | Patient will maintain an effective breathing pattern with normal respiratory rate, depth, and oxygen saturation. Patient will have ABG results within normal limits. Patient will incorporate breathing techniques to improve breathing pattern. Patient demonstrates the ability to complete ADLs without dyspnea. | 1. Administer pain medications and antibiotic therapy. Peritonitis is often associated with severe abdominal pain affecting the patient’s breathing pattern, rate, and rhythm. Controlling the pain and resolving the infection can reduce swelling, help the patient breathe comfortably, and prevent respiratory distress. 2. Monitor the patient’s respiratory status. Oxygen saturation and the patient’s respiratory status must be monitored constantly to detect impending respiratory compromise, initiate prompt interventions, and prevent worsening of the patient’s condition. 3. Administer low-flow supplemental oxygen as ordered. Supplemental oxygenation ensures adequate oxygen is provided and prevents respiratory distress in patients with peritonitis. 4. Encourage a position of comfort. An upright position allows optimal lung expansion, enabling the patient to breathe more comfortably. The patient may also prefer a position with knees flexed to increase comfort and reduce episodes of shortness of breath. High Fowler’s positioning may be uncomfortable in some patients due to abdominal distension. 5. Prepare and assist in abdominal surgery as indicated. Surgical interventions enable the repair of the cause of peritonitis to prevent further infection and reduce inflammation. This will also resolve diaphragm irritation, reduce abdominal distension and pain, and correct respiratory distress. | Patient maintained an effective breathing pattern with normal respiratory rate, depth, and oxygen saturation. Patient has ABG results within normal limits. Patient incorporated breathing techniques to improve breathing pattern. Patient demonstrated the ability to complete ADLs without dyspnea. |
Subjective Data: verbalizes increased thirst and unable to drink more liquids Objective Data: -Dry mucous membranes -Hypotension -Tachycardia -Slow capillary refill -Weakness -Weak peripheral pulses -Altered skin turgor -Decreased urine output | Deficient fluid Volume related to Fluid shifting into the peritoneal space and retention of fluid in the abdomen as evidenced by Hypotension and weakness | Patient’s vital signs will remain stable and/or return to patient’s baseline. Patient’s intake and output will stabilize. Patient’s lab values will return to baseline. Patient will verbalize measures to take at home to maintain hydration/prevent dehydration. | 1. Evaluate the patient’s skin integrity. Fluid shifts in peritonitis, hypovolemia, and nutritional deficits can contribute to poor skin integrity and edematous tissues. 2. Administer fluid replacement as indicated. Fluid replacement through blood, plasma, or electrolyte replacement, can help correct electrolyte balances, and circulating volume lost to the peritoneal cavity. 3. Administer medications as indicated. Antiemetics may be prescribed to help reduce nausea and vomiting and prevent further loss of fluid and electrolytes. 4. Keep the patient on NPO and place a nasogastric tube as ordered. A nasogastric tube can help decrease gastric distention and prevent further leakage of bowel contents into the peritoneal cavity. | Patient’s vital signs remained stable and/or return to patient’s baseline. Patient’s intake and output stabilized. Patient’s lab values returned to baseline. Patient verbalized measures to take at home to maintain hydration/prevent dehydration. |