Inpatient acute medical or surgical unit
- Appendectomy, see Nursing Care Plan CD-ROM
- Inflammatory bowel disease: ulcerative colitis, regional enteritis (Crohn’s disease, ileocolitis)
- Psychosocial aspects of care
- Renal dialysis: peritoneal
- Surgical intervention
- Total nutritional support: parenteral/enteral feeding
- Upper gastrointestinal/esophageal bleeding
- Patient Assessment Database
- Tachycardia, diaphoresis, pallor, hypotension (signs of shock)
- Tissue edema
- Inability to pass stool or flatus
- Diarrhea (occasionally)
- Hiccups; abdominal distension; quiet abdomen
- Decreased urinary output, dark color
- Decreased/absent bowel sounds (ileus); intermittent loud, rushing bowel sounds (obstruction); abdominal rigidity, distension, rebound tenderness; hyperresonance/tympany (ileus); loss of dullness over liver (free air in abdomen)
Anorexia, nausea/vomiting, thirst
- Projectile vomiting
- Dry mucous membranes, swollen tongue, poor skin turgor
Sudden, severe abdominal pain, generalized or localized, referred to shoulder, intensified by movement
- Distention, rigidity, rebound tenderness; distraction behaviors; restlessness; self-focus
- Muscle guarding (abdomen); flexion of knees
Shallow respirations, tachypnea
History of pelvic organ inflammation (salpingitis), puerperal infection, septic abortion, retroperitoneal abscess
- History of recent trauma with abdominal penetration, e.g., gunshot/stab wound or blunt trauma to the abdomen; bladder perforation/ruptured gallbladder, perforated carcinoma of the stomach, perforated gastric/duodenal ulcer, gangrenous obstruction of the bowel, perforation of diverticulum, UC, regional ileitis; strangulated hernia
- Discharge plan
- DRG projected length of inpatient stay: 4.9 days
- Assistance with homemaker/maintenance tasks
- Refer to section at end of plan for postdischarge considerations.
- CBC: WBCs elevated, sometimes more than 20,000. RBC count may be increased, indicating hemoconcentration.
- Serum protein/albumin: May be decreased because of fluid shifts.
- Serum amylase: Usually elevated.
- Serum electrolytes: Hypokalemia may be present.
- ABGs: Respiratory alkalosis and metabolic acidosis may be noted.
- Cultures: Causative organism (often Escherichia coli, streptococci, staphylococcus, or rarely, pneumococcus) may be identified from blood, exudate/secretions or ascitic fluid, cloudy peritoneal dialysate.
- Abdominal x-ray: May reveal gas distension of bowel/ileus. If a perforated viscera is the cause, free air will be found in the abdomen.
- Chest x-ray: May reveal elevation of diaphragm.
- Pelvic ultrasound: Can diagnose peritonitis caused by ruptured appendix or diverticulitis.
- Paracentesis: Peritoneal fluid samples may contain blood, pus/exudate, amylase, bile, and creatine.
- Control infection.
- Restore/maintain circulating volume.
- Promote comfort.
- Maintain nutrition.
- Provide information about disease process, possible complications, and treatment needs.
- Infection resolved.
- Complications presented/minimized.
- Pain relieved.
- Disease process, potential complications, and therapeutic regimen understood.
- Plan in place to meet needs after discharge.