Case Study Analysis: Post-Operative Peritonitis Nursing Management

This case study presents the nursing care of a 20-year-old female patient admitted to the emergency department with severe abdominal pain, diagnosed with a perforated appendix and subsequently undergoing laparoscopic surgery. Post-operatively, the patient developed peritonitis, characterized by low blood pressure, rapid respiratory rate, abdominal pain, and a rigid, distended abdomen. The case study details the patient's medical history, including asthma and depression, and the nursing priorities identified: sepsis, high pain levels, and low blood pressure. The nursing interventions implemented focused on managing sepsis with antibiotics, controlling pain through pharmacological and non-pharmacological methods, and addressing low blood pressure through fluid management and monitoring. The evaluation of the patient's progress, including the use of relaxation techniques, medications, and monitoring vital signs, is also discussed, along with a reflection on the experience and the importance of correlating patient history with current symptoms.

Running Head: Assessment 3- Case Study
Assessment 3- Case Study
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Assessment 3- Case Study
Introduction
The patient, is a female aged 20 years, brought to ED for severe pain in right lower quadrant of
abdomen, lack of appetite, fever and nausea for the last 2-3 days. The clinical examination and
ultrasound of the abdomen diagnosed perforated appendix. 36 hours post emergency
laparoscopic surgery, her observations identified low blood pressure 94/45 mmHg, faster
respiratory rate of 24 per min, bloating and abdominal pain of 7/10 scale with rigid distended
abdomen. Her symptoms identified Peritonitis.
Person’s Situation
The patient had a medical history of asthma and depression. She takes medications like
Salbutamol, Sertraline and Seretide regularly. Post operative, the patient reported increased
centralized pain in abdomen that worsen movement and respiration, and is at the intensity of
7/10. She is identified with distended rigid abdomen with generalized abdominal guarding and
no bowel movement. The bowel sounds disappear with the progression of inflammation in
abdomen. The patient is still under a medical emergency due to swelling in peritoneum and
severe abdominal pain. The patient is acutely distressed and lies in his bed with shallow
breathings and minimal movement to relieve the abdominal pain.
Collection, Processing and presentation of Related Health Problem
Data related to patient’s medical history was collected from patient’s past medical records. The
patient has a history of asthma which had become severe after the surgery. The pain was self
reported by the patient. The physical examinations confirmed the distended rigid abdomen post
operative. The assessment of tenderness and tension in abdomen, blood tests, imaging techniques
like X Rays and Ultrasound are effective assessment tools to collect the data about the patient.
The patient identified with generalized tensing of abdominal wall muscles guarding the inflamed
organs. It occurs due to pressure of pain over the abdominal muscles. The primary peritonitis

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Assessment 3- Case Study
mostly occurs due to rupture and perforations in appendix. Peritonitis generally occurs due to
bacterial infection or sepsis. There is possibility that the disease can spread to the organs
underlying abdominal peritoneum and blood resulting into multiple organ failure, if left
untreated.
For further investigations, the patient was subjected to FBC, blood cultures, electrolytes and X-
Ray of abdomen. The results of pathology identified increased WBC count (leukocytosis) which
is in response to the sepsis. The X Ray also disgnosed gaseous and oedematous distention of
small and large bowels.
Three Nursing Issues
The three main priorities of the patient are: 1. Sepsis; 2. High Pain and 3.Low Blood Pressure
The patient is identified with increased WBC count and it shows inflammation and infection
which occurred after the laparoscopic surgery. The post operative high WBC count may also be
associated with extraperitoneal infection of exit site, catheter leakage and abdominal pain
(Tantiyavarong, Traitanon, Chuengsaman, Patumanond & Tasanarong, 2016).
The patient reported high level of centralized abdominal post operative pain due to peritonitis
and surgery. The pain gets worsen with movement and respiration. She is already a patient of
asthma. Her diaphragm movement during the respiration is likely to touch the rest of the internal
organs and peritoneal lining of the abdomen having inflammation. She requires immediate
nursing care to relieve her pain.
The patient reported low blood pressure (94/45 mmHg) post surgery. It may be due to dilated
systemic arteries and vaso-constricted renal arteries in the patient’s body (Kaowdley, 2015). It
causes retention of fluids in the abdomen and increased infection.
Goals

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Assessment 3- Case Study
The post operative care of this patient was aimed to identify and manage the issues experienced
by the patient after surgery to improve the recovery. After the laparoscopic surgery, there are
always high likelihood of complications hence it is urgent and necessary perform patient
assessments.
The goals of nursing care for this patient involves identifying the post operative symptoms
immediately after the surgery, preventing the sepsis after surgery, pain management and
controlling the other underlying symptoms like low BP and respiratory problems.
The early control of the source of infection is essential to eliminate the bacteria form the
abdominal cavity (Lee, Kang, Noh & Park, 2016). The process involved following the post
operative instructions provided by the surgeons for recovery and antibiotics administration.
Nursing Care
SEPSIS
The first intervention focused on Sepsis. The combination of antibiotics Vancomycin 25 mg/L Ip
and Gentamicin 8 mg/L IP was administered for 5-7 days through IV route (NSW Government
Health services, 2019). The antibiotics were continued until the patient reduced her WBC count
and temperature. The persistent symptoms of leukocytosis were identified as a prompt for
searching drainable infection source in the abdomen. The nursing care involved controlling the
source of infection, a short course of antibiotics and lavage. The individual risk factors were
identified and frequent assessment of vital signs was done for monitoring hypotension and
respiratory rate. The urine output was monitored for oliguria symptoms due to antibiotics
administration and circulating toxins (ACT Government Health, 2014). Strict sterile technique
was maintained while catheterizing the patient, providing catheter care and performing perineal
cleansing regularly. It was aimed to prevent the growth of bacteria in urinary tract.
The patient was kept isolated by restricting the visitors for mitigating the potential risk of
secondary infection. The patient was assisted with peritoneal aspiration to remove fluids and
identify the causal microbe responsible for infection. Appropriate antibiotic therapy was selected

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Assessment 3- Case Study
on the basis of identified microbe. Lavage was used to eliminate the necrotic debris and control
poorly localized inflammation (Vera, 2014).
PAIN MANAGEMENT
The patient had high pain of the scale 7/10 which need to be controlled immediately. The patient
was kept at semi flowler’s position to minimize movement as much as possible. It facilitates
fluid drainage through gravity, lowers down the abdominal tension, irritation of diaphragm and
reduces pain. The pain was also due to post operative psychological symptoms. Moreover, the
patient has a history of depression, so appropriate interventions are required for addressing the
depression and post operative stress management. The recovery may be enhanced at a faster rate
to minimize the painful episodes. A combination of stress reduction and analgesic drugs is
effective to manage the high intensity pain (Daley, 2019). The patient was also provided regular
oral care to reduce the nausea which may elevate the intra abdominal pressure and pain. The
combination of opioids and Non steroidal anti-inflammatory drugs (NSAID) was given through
IV route. The patient was asked to splint the abdominal area with pillow while coughing or deep
breathing to lower down the movement. It reduces the guarding and muscle tension. The process
aimed to lowered own the pain from 7/10 to 1/10 measure which was the right level for normal
condition.
LOW BLOOD PRESSURE
The patient was advised to practice relaxation techniques to reduce BP and stress.
The nursing care focused on BP monitoring, Intake- Output monitoring, IV fluids and the
monitoring of drainage. The patient was monitored for dilation of arteries along with
vasoconstriction of veins. The measurement of electrolyte imbalance, protein and albumin
concentration was done to assess hypoxemia, circulating toxins and necrotic tissues.
Administration of plasma and blood is effective to replenish the circulating electrolyte balance
and the volume (Tantiyavarong et al., 2016). The colloids like blood and plasma takes the water
into the intravascular compartments by elevating the osmotic pressure gradient. Diuretics were
administered to facilitate excretion of toxins and improve the renal function. The nasogastric or
intestinal aspiration was given to improve the bowel movement.

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Assessment 3- Case Study
Evaluation
The patient depicted abdominal distention due to delay in gastrointestinal mobility after surgery.
The sympathetic pathways to gastrointestinal tract gone disrupted and contributed to
inflammation in addition to sepsis.
Though the medical examinations after the surgery have provided details about the symptoms of
the patient, it is necessary to consider the patient medical history during the post operative care
(Abud, Kusumota, Santos, Rodrigues & Zanetti, 2015). While providing the antibiotic and pain
controlling medicines, it is necessary to consider their association and drug interaction with the
salbutamol and seretide medicines which are already taken by the patient on daily basis. BP can
be controlled by improving the cardiac output and reducing the inflammation in the abdominal
area (Holzheimer, 2011).
The pain was managed through pharmacological and non pharmacological interventions. A
combination of opioids and NSAID drugs was administered through IV. The interventions aimed
to improve the fluid balance which was evidenced by stable vital signs, good skin turgor and
adequate urinary output with bowel movements. The distention in the abdominal area had also
reduced. The pain was controlled through relaxation skills and medications.
Distended abdomen mainly occurs due to gas accumulation in the lower abdominal area. The
medications like Metoclopramide help in digestion and lower down the accumulation of bowels
in the intestine (Figueiredo, Moraes, Bernardini, Figueiredo, Barretti & Olandoski, 2015). After
the medications, the patient was instructed for how she can improve her health. The patient was
provided information regarding stress management, diet awareness and asthma controlling
techniques to prevent further deterioration in symptoms.
Reflection

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Assessment 3- Case Study
Initially, I found that the patient when reported the emergency department was having intense
pain. I was given responsibility of caring for the patient and assessing her symptoms to record
the data. I focused on her painful condition more than any other symptom and immediately
referred her for an ultrasound. Through my earlier work experience, I could understand the
patient’s symptoms and it helped me take prompt action without any delay. After the surgery, I
paid more attention to patient’s anesthesia recovery, sepsis control and pain management. I
ensured minimal body movement to reduce pain.
The overall procedure could successfully result in reducing the pain and infection in the patient.
However, during post operative phase her anxiety level had aggravated further. As the pain
subsided, I advised the patient after her recovery to adopt relaxation techniques like yoga,
meditation and exercise to improve her depression.
Conclusion
At the emergency ward, it is most necessary to identify the patient’s examination and assessment
records and correlate them with her medical history before and after the surgery. The pain at the
level of 7/10 is extreme for the patient and was taken as a priority. The abdominal distention and
rigidity was improved through pharmacological interventions. The patient showed controlled
pain, sepsis and BP in her 6th day of regular treatment and nursing care.

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Assessment 3- Case Study
Reference List
Abud, A, Kusumota, L., Santos, M., Rodrigues, F.,& Zanetti, M. (2015). Peritonitis and catheter
exit-site infection in patients on peritoneal dialysis at home. Revista Latino-
Americana de Enfermagem, 23(5), 902-909. https://dx.doi.org/10.1590/0104-
1169.0413.2630
ACT Government Health (2014). Peritonitis. Retrieved from
https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/peritonitis
Daley, B.J.(2019). Peritonitis and Abdominal Sepsis Treatment & Management. Retrieved from
https://emedicine.medscape.com/article/180234-treatment
Figueiredo,A., Moraes,T., Bernardini,J., Figueiredo,E., Barretti,P. & Olandoski,M. (2015).
Impact of patient training patterns on peritonitis rates in a large national cohort
study, Nephrology Dialysis Transplantation, 30(1), 137–
142, https://doi.org/10.1093/ndt/gfu286
Holzheimer RG. (2011). Management of secondary peritonitis. In: Holzheimer RG, Mannick JA,
editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich:
Zuckschwerdt; 2011. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK6950/
Kowdley K. (2015). Spontaneous Bacterial Peritonitis. Gastroenterology & hepatology, 11(1),
70–72. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4836582/
NSW Government Health services (2019). Assessment and management of peritoneal dialysis
associated peritonitis. Retrieved from

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https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/274082/
assessment-and-management-of-pd-associated-peritonitis.pdf
Lee, K. P., Kang, S., Noh, M. S., Park, S. J., Kim, J. M., Chung, H. Y., … Im, D. S. (2015).
Therapeutic effects of s-petasin on disease models of asthma and
peritonitis. Biomolecules & therapeutics, 23(1), 45–52.
doi:10.4062/biomolther.2014.069
Tantiyavarong, P., Traitanon, O., Chuengsaman, P., Patumanond, J., & Tasanarong, A. (2016).
Dialysate White Blood Cell Change after Initial Antibiotic Treatment Represented
the Patterns of Response in Peritoneal Dialysis-Related Peritonitis. International
journal of nephrology, 2016, 6217135. doi:10.1155/2016/6217135
Vera,M.(2014). 6 Peritonitis Nursing Care Plans. Retrieved from https://nurseslabs.com/6-
peritonitis-nursing-care-plans/3/