University Nursing Case Study: Postoperative Peritonitis Care

This case study focuses on the postoperative care of Ms. Melody King, a 36-year-old patient who developed peritonitis after a ruptured appendix. The assignment utilizes Levett-Jones' Clinical Reasoning Cycle to assess the patient's condition, establish nursing goals, plan and evaluate patient-centered care. The student nurse identifies key issues such as pain management, risk of infection, fluid imbalance, and psychological distress. Interventions include monitoring vital signs, providing wound care, administering medications, positioning the patient for comfort, managing fluid intake and output, and promoting rest. The evaluation of care strategies includes monitoring for improvement in pain, fluid balance, and the absence of infection, as well as the reduction of anxiety and depression. The student reflects on the application of clinical reasoning skills, patient-centered care, and adherence to nursing standards, highlighting the importance of effective communication, pain assessment, and holistic care in improving patient outcomes. The student also mentions the importance of education and training for using different pain assessment tools.

Running Head: CLINICAL INTEGRATION SPECIALTY PRACTICE
Clinical integration specialty practice
Name of the Student
Name of the University
Author Note

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Introduction
The paper deals with case study of the Ms Melody King suffering from peritonitis
following the ruptured appendix. As a nurse, I have been assigned to Ms Melody for
postoperative care. The nursing goal is to utilise Levett-Jone’s Clinical Reasoning Cycle, to
examine, establish relevant nursing goals for the case study, plan and evaluate patient centred
care. The Clinical Reasoning Cycle developed by Levett Jone is the cycle of linked and ongoing
clinical situations. This cycle acts as a decision-making framework to consider the patient’s
condition, prioritise the key nursing issues and establish goals. It is difficult to improve the
patient’s health condition without effective clinical reasoning skills (Dalton, Gee & Levett-
Jones, 2015).
Patient’s situation, and process of related health information
Data collection
The case history of Ms Melody informs that she is 36 year old and was presented to the
emergency department for Left Lower Quadrant abdominal pain. The pain was severe and was
persistent for 2-3 days. The case reports of immediate laparoscopic surgery requirement for
removing the ruptured appendix. As per the admission history, the patient has history of asthma
and depression. Her current prescribed and complaint medications include seretide, ventolin, and
sertraline. Her clinical handover shows presents blood pressure to be 95/45mmHg, HR 120,
Temperature 38.3°Celcius, respiratory rate 22/minute and shallow and SpO2 95% on room air.
The case reports informs that currently the patient is facing increased nausea. Her centralised
abdominal pain assessment score showed 8 on 10. Physical assessment data showed a distended

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abdomen and generalised abdominal guarding. Further pathology tests were conducted to
investigate her condition and a raised white blood cell count and CRP was observed. The patient
is diagnosed with peritonitis following ruptured appendix Ms. Melody has been shifted to
surgical ward post operation.
Process of information
According to Brambillasca et al. (2017) peritonitis is the inflammation of the peritoneum
surrounding abdominal organs. It is known as grave complication of the surgical intervention,
appendectomy (surgical removal of ruptured appendix). It is due to the tactical or technical errors
rarely made during the operation. In majority of the cases, the condition occurs due to
perforation of the appendix. Spread of infection from the digestive organs is the principle
condition causing Peritinotis. When the bacterial invasion from the appendicitis into peritoneum
occurs, it results in inflammation.
White blood cells and CRPs are blood inflammatory makers and when applied to lower
quadrant abdominal pain is indicative of infections or inflammatory disease process. CRP is the
C-reactive protein secreted by liver when the bacterial infections occur. This is the underlying
reason for increased White blood cells and CRP level in the patient (Preto-Zamperlini et al.,
2014). Fever, nausea, abdominal distension, tenderness and continued abdominal pain are the
common signs and symptoms of this condition, also observed in the patient (fever- 38.3°Celcius
and pain score of 8 on 10). Further patient’s infective breathing pattern is evident from her low
blood pressure, rapid heart beating and shallow breathing (Chaudhary et al., 2015).
Ms Melody has increased risk of depression due to history of asthma and present
exacerbation of abdominal pain. If the pain is not treated she might have poor physical and

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mental health. Depression and anxiety due to pain is common during peritonitis and situational
crisis. It may decrease the functional and emotional status of the patient. Depression may also be
added by the financial constraints and the expensive treatment (Lutz et al., 2015).
Nursing problems/issues based on the health assessment data
Issues identified based on the health assessment data are-
 Increase in pain level
 Anxiety and depression due to untreated pain
 Exacerbation of peritonitis and complications due to reduced GI functions
 Risk of infection and risk of shock due to septicaemia or hypovolemia
Elevated pain levels are the prime concern in this case. This first priority area needs to be
addressed immediately. Patients with peritonitis have reduced GI functions and hence it must be
restored. Hence GI function restoration is the second priority area. If the infection is untreated, it
may further exacerbate the complications. Additional complications may include rebound
tenderness with guarding in abdomen, bowel sounds may decrease, rigid and distended abdomen.
In addition, next to shallow breathing, the breath sounds may decrease and diminished secondary
to shallow breathing. If the fever persist the pulse may be bounding. The patient also has the risk
of deficient fluid volume that may be caused due to shifting of fluids to intestinal lumen. It may
lead to fluid depletion in the vascular space. Thus, it is the third priority area that needs
intervention. The patient may also be at the risk for shock related to septicaemia or hypovolemia
(Sachs et al., 2017). Thus, intensive care is to be delivered to the patient to reduce infection. It is
the fourth priority area.

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Nursing goals
The main nursing goal in this case is to deliver postoperative therapy to prevent the
exacerbation of Peritonitis. The nursing goals appropriate for Ms Melody with peritonitis include
the following-
 Decrease the level of pain
 Reduce the risk of infection at the site of operation
 Reduce the risk of fluid volume deficit
 Prevent complications
 Restore the normal GI functions
 Reduce the level of anxiety and depression
These goals are developed as per the priority nursing area.
Nursing intervention
The first nursing interventions is to monitor the consciousness, intake and output, and
vital signs. Ms Melody will be frequently noted for decreased pulse pressure, increase in fever,
tachycardia and tachypnea. Patient’s blood pressure would be monitored by artereial line to
eliminate the risk of shock (Williams & Hopper, 2015). The second intervention is to provide
sterile surgical wound care to prevent infection and related complications. With the increase in
pain, the infection is indicated to be accelerated. Perineal Cleansing with appropriate solution is
necessary to prevent cross contamination and limit bacterial growth (Han et al., 2015).
The third intervention is to administer the medication that is analgesic and anti-emnetics
as prescribed. Anti-emetics are effective in reducing nausea and vomiting that exacerbates
abdominal pain. Analgesics reduce the intestinal irritation from circulating. It promotes pain

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relief (Litz et al., 2017). The fourth intervention is to set and move the patient’s position to
prevent drain uprooted. According to Doenges et al. (2014) analgesics together with proper body
positioning can help relieve pain. Ms Melody’s body position will be changed frequently, and
maintain wrinkle free bedding as edematous tissue with poor circulation is to prone breakdown.
Ms Melody can be maintained in semi-Fowler’s position as it will allow wound drainage by
gravity. It will reduce abdominal tension and also reduce pain. Other comfort measures such as
breathing, massage or diversional activities will be provided to promote relaxation and enhance
coping abilities.
The fifth intervention is to take the recording of all intake and output to ensure fluid
replacement. It will be followed by administering and close monitoring of the IV fluids. It
reflects the overall hydration status. Observation of the drain properties is essential and the color
number will be recorded. Drainage monitoring is the vital element of the postoperative care
(Kubota et al., 2015).
The sixth intervention is to schedule adequate rest and uninterrupted periods of sleep to
conserve energy and limit fatigue. In addition, the patient was provided oxygen via nasal prongs
to maintain normal oxygen saturation. It was required as the patient also has history of asthma
(Ignatavicius & Workman, 2015).
Evaluating nursing care strategies
The following outcomes can be observed that indicates response to nursing intervention
and care plan-
 The signs of peritonitis disappeared is the normal body temperature, pulse rate,
and breathing

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 The patient reports relive in pain and demonstrates relaxation skills
 The patient demonstrates improvement in the fluid balance indicated by stable
vital signs, adequate urinary output weight within acceptable reason. Normal
drinking and eating is restored
 The patient is free of drainage of erythema, wound site is clean without infection
 Reduction in anxiety and depression to manageable level. The patient
demonstrates the awareness of feelings
 Prevention of complications (postoperations)
Reflection on the person’s outcomes
While I was on my clinical placement on surgical ward of ___hospital , I was caring for
Ms Melody admitted for appendicitis and Peritonitis. I was assigned for postoperative care and
the case history showed for exacerbation of pain and vital signs indicated infective pattern.
Psychiatric anxiety and depression was prominent due to illness and situational crisis and history
of asthma. I was working under the supervision of RN and strictly followed the guidelines of
Nursing and Midwifery board standard 6.2 (Nursing and Midwifery Board of Australia -
Registered nurse standards for practice, 2017).
Firstly, I have administered the medication as prescribed by the physician an adjusting
the patient to semi-Fowler’s position. It will help her regain her comfort, reduce pain and level of
oxygen. Senior nurse leader appreciated me for my nursing decision and care plan. I have
applied the nursing critical thinking and reasoning skills. I have regularly observed the vital signs
and educated the patient about the pros and cons of not adhering to medication and instructions.

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Secondly, I have adhered to patient centered care. I have used active listening skills and
was sympathetic, when the patient described her pain and symptoms. I asked the patient to rate
her pain and used PQRST method of assessing pain (Wells, Pasero & McCaffery, 2017). To
make her feel comfortable, I have explained the cause of her infection and complications. The
more awareness she will have the better she can cope with the intervention.
After interventions, nursing assessment was ongoing and precise. Ms Melody was
continuously assessed for pain, fluid and electrolyte balance and monitoring of the GI functions
to assess response to the intervention. I was mindful of using safety strategies and holistic
approach to improve mental and physical wellbeing of Ms Melody. I have consulted physician
for analgesics and oxygen therapy to be provided (Tang et al., 2015).
Thus, I can conclude that the patient centred care and on time medication improved the
health outcomes of patients. I was successful in addressing the individual needs and goals of
patient. The patient’s right of autonomy, respect and dignity were maintained by involving her in
health related decisions. Her values, needs and preferences were respected (Krüger et al., 2016).
She hadaccess to health information, treatment options and have a freedom of choice regarding
physical and emotional comfort. During care, the patient’s privacy and confidentiality of
information were maintained. The standards and code of ethics of Nursing and Midwifery Board
of Australia were strictly followed (Gray Rowe & Barnes, 2016). Further, I think there should
be Education and training for using different pain assessment tools.
References

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