Gunshot Wound Peritonitis

ST.
MARY’S COLLEGE
NURSING PROGRAM
Tagum City
A CASE STUDY
On
PERITONITIS
Presented to:
Zaida S. Jo, RN, MN
In Partial Fulfillment of the Requirements
In
Related Learning Experience
(RLE)
By
Mia Charisse F. Lamparero
BSN 4
July 30, 2010
TABLE OF CONTENTS
I. INTRODUCTION 3
A Objectives 5
II. ASSESSMENT 7
A. Biographical Data 7
B. Chief Complaint 7
C. History of Present Illness 8
D. Past Medical and Nursing History 8
E. Personal, Family and Socio-Economic History 8
F. Developmental History 8
G. Patient Need Assessment 9
Physical Assessment
 General survey 12
 Vital signs 12
 Nutritional status 13
 Integumentary System 13
 HEENT 13
 Pulmonary System 14
 Cardiovascular System 14
 Gastrointestinal System 14
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 Musculoskeletal System 14
 Genito-urinary System 14
 Course in the Ward 14
III. LABORATORY AND DIAGNOSTIC EXAMINATIONS 19
IV. REVIEW OF ANATOMY AND PHYSIOLOGY 26
V. SYMPTOMATOLOGY 32
VI. ETIOLOGY OF THE DISEASE 34
VII. PATHOPHYSIOLOGY
A Written 35
B. Diagram of Pathophysiology 36
VIII. PLANNING
A Nursing Care Plan 38
B. Discharge Plan 45
IX. PHARMACOLOGICAL MANAGEMENT 46
X. SYNTHESIS OF CLIENT’S CONDITION/
STATUS FROM ADMISSION TO PRESENT
A Conclusion 62
B. Patient’s Prognosis 62
C. Recommendations 64
XI. EVALUATION OF THE OBJECTIVES OF
THE STUDY 65
XI. BIBLIOGRAPHY 66
A. Textbooks
3
B. Internet Download
I. INTRODUCTION
Background of the Study
Peritonitis is a serious disorder caused by an inflammation of the peritoneum, most often due to a
bacterial infection. The peritoneum is a two-layered membrane that lines the abdominal cavity
and encloses the stomach, intestines, and other abdominal organs. The membrane supports the
abdominal organs and protects them from infection. However, occasionally the peritoneum itself
may become infected by bacteria or other organisms.
Infection usually spreads from organs within the abdomen. The inflammation may affect the
entire peritoneum, or be confined to a walled-off, pus-filled cavity (abscess).
A rupture anywhere along the gastrointestinal tract is the most common pathway for entry of an
infectious agent into the peritoneum. Peritonitis is a medical emergency: the muscles within the
walls of the intestine become paralyzed and the forward movement of intestinal contents stops
(ileus). It is most often caused by introduction of an infection into the otherwise sterile peritoneal
environment through organ perforation, but it may also result from other irritants, such as foreign
bodies, bile from a perforated gall bladder or a lacerated liver, or gastric acid from a perforated
ulcer. Women also experience localized peritonitis from an infected fallopian tube or a ruptured
ovarian cyst. Patients may present with an acute or insidious onset of symptoms, limited and
mild disease, or systemic and severe disease with septic shock.
4
Untreated, acute peritonitis may be fatal. The fundamental role of operative therapy in the
treatment of peritonitis was documented in 1926 when Kirschner reported that the mortality rate
from intra-abdominal infections decreased from more than 90% to less than 40% during the
period from 1890-1924 with the introduction of operative management. Other elements, such as
advances in the understanding of damage control surgery, novel antibiotics, and improvements in
intensive care unit (ICU) treatment have now reduced mortality to approximately 20%.
(http://emedicine.medscape.com/article/192329-overview)
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OBJECTIVES
The research for this case study, its data and substantial facts could not be attained
without the improvised objectives that are needed to be followed and observed that will guide us
in planning, preparing and arranging the information systematically. The objectives are devised
within the day of our clinical exposure. The objectives would serve us guiding principles for us
to arrive to our goals and aims.
A. General Objective:
Within the time-span of duty, the student nurse will complete the chosen case to be
studied with factual pertinent data gathered. As well as to know and familiarize other related
information connected to it and apply the nursing skills that had learned and practice not only or
the call of this study but also for the future reference.
B. Specific Objectives:
 To obtain sufficient and relevant information regarding patient’s condition.
 To present personal data of the patient.
 To trace the present history of the patient’s health and illness and define the diagnosis of
the patient having a Peritonitis.
 To conduct a thorough head-to-toe assessment serving as baseline data.
 To view and discuss the anatomy and physiology of the affected organs and system
basing from the patient’s diagnosis.
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 To present the pathophysiology of the patient’s diagnosis, both in diagram and narrative
form and list down the actual laboratory results of the patient.
 To identify the different drugs ordered and to know their action, indication, adverse
effects and nursing responsibilities.
 To make nursing care plan appropriate for the span of care to the patient and which also
correspond his condition at least 2 actual problems and 1 risk problem.
 To impart suitable and realistic health teachings to the watcher for the patient’s welfare.
 To evaluate the outcome of the condition of the patient.
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II. ASSESSMENT
A. BIOGRAPHICAL DATA
Name : Mr. Drain
Age : 25 years old
Sex : Male
Civil Status : Single
Birthdate : January 11, 1985
Birthplace : Bohol
Address: : Prk 5 Elizalde (Samil), Maco, Comval Province
Nationality : Filipino
Religion : Roman Catholic
Occupation : Miner
Attending Physician : Dr. Alvin C. Medina, M.D.
B. CHIEF COMPLAINT
The patient was admitted at Davao Regional Hospital last July 06, 2010 at 1:40 in the
dawn due to the complaint of Gunshot wound on the abdomen. He was attended at the
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Emergency department and had taken a clinical history and physical assessment. He was
immediately transferred at the operating room for STAT Ex-lap. He was attended by Dr. Medina,
a resident physician of the said hospital.
C. HISTORY OF PRESENT ILLNESS
Patient was on his way home when he passed a check point at Mawab and was signaled to stop
but didn’t stop. The military suspected him and he was immediately was shot at the back. They
hurriedly ran the patient to the hospital and was attended and given immediate interventions.
D. PAST MEDICAL AND NURSING HISTORY
The patient had upper respiratory tract infection when he was an 8 years old. Previously
he was not hospitalized. He does have complete immunizations and has no history of
hypertension, Diabetes mellitus and PTB. Whenever he had any flu or cough, His mother uses
herbal plants. He does not have any regular medical and dental check-ups. He does not have
allergies to what ever kind of foods and medications as far as he knows. Whenever he had fever
he takes Paracetamol and Bioflu. He does not experience any severe accidents except this one.
E. PERSONAL, FAMILY AND SOCIO-ECONOMIC HISTORY
Aka Mr. Drain is a 25 years miner. He was the youngest of a family of 3. The
family of Mr. Drain belongs to a marginalized socio-economic status. In order to provide and
sustain the daily needs of their family, his father works as a carpenter and his mother is a plain
housewife. His 2 sisters were already married and have their own family.
F. DEVELOPMENTAL TASK
 Robert J. Havighurst Developmental Task Theory
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According to Havighurst developmental theory, Mr. Drain, 25 years of age, belongs to a
period of adulthood which was achieving mainly located in family, work, and social life. Family-
related developmental tasks are described as finding a mate, learning to live with a marriage
partner, having and rearing children, and managing the family home. Mr Drain was working and
suffers to be away from his family just to have money to help for their everyday expenses. He
doesn’t have time to face his own life due to attending the needs of his parents.
G. PATIENT NEED ASSESSMENT
Date: June 2
Name of Patient: Mr. Drain Age: 25 years oldSex: _Male Status: Single
Admission Date/Time: July 06, 2010/ 1:40 am
Admitting Medical Diagnosis: GSW through and through POEX® Mandibular area POEX ®
Male, GCS to level
Arrived on Unit by: per stretcher From: CENSICU Room
Accompanied by: He is accompanied by his mother
AdmittingWeight /VS: 48kgs BP- 100/60 RR-25 PR-114 Temp- 36.7
Client’s Perception of reason for Admission:
“Napusilan man gud ko maam mao naa ko dinhi sa ospital,” verbalized by the patient
How has problem been managed by client at home: NONE
Allergies: No allergies was being experience according to the patient
Medication (at home): NONE, (at the hospital): Cefoxitin, Ranitidine, Ketorolac, Tramadol,
Metronidazole, Paracetamol
Physiological Needs:
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I. Oxygenation
 BP _100/60 PR 114 bpm RR 25 cycles/min CR_________
 Lungs (per auscultation: character: lung sound; symmetry of chest expansion; breathing
character and pattern.) fine, short, interrupted crackling sound was being heard upon
auscultation, symmetry chest expansion was being observe during breathing.
 Cardiac status (per auscultation sounds character; chest pain?
Dull, low pitched and longer followed by a silent then higher pitch: no chest pain noted
 Capillary Refill: Within 2 – 3 seconds using the blanched test
 Skin Character and Color: dry, pale, dark brown in color
 Life-supporting Apparatus: N-O-N-E
 Other Observations (related): with colostomy to colostomy bag, JP drain, Eschar noted on
both legs.
II. Temperature Maintenance:
 Temperature: 36.7º C
 Skin Character: dry, pale, dark brown in color; with good skin turgor
 Other Observations (related): N-O-N-E
III. Nutritional Fluid:
 Height: 5’ 4’’/ 48kg. Amount of food consumed: ¼ of meal served consumed
 Prescribed Diet: Diet as tolerated + 2 eggs/day
 Eating Pattern: 3x a day; can only consume ¼ of served meal
 Skin Character: dry, rough skin; with good skin turgor
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 Intake (IVF: Fluid/Water): Plain Nornal Saline Solution
 Other Observations (related):slim, eschar noted on both legs
IV. Elimination:
 Last Bowel Movement (frequency; amount, character): with colostomy to colostomy bag,
yellow to amber in color, few
 Normal Pattern: every meal
 Urination (frequency, amount, character, sensation): twice, with yellow ambered colored
urine, about 200 cc.
V. Rest-Sleep:
 Bed Time: 6: 00PM Waking Up Time: 6:00 AM
 Sleep (amount of sleep): 4-5 hours
 Problems (as verbalized): “Wala ko katulog kagabii kay sakit akoang tahi og igang pud
kaayo”
VIII. Stimulation-Activity:
 Work: Miner
 Reaction/Past time: Drinking while chatting with other co-worker
 Hobbies/Vices: Alcoholic Drinker/ Smoker
Safety-Security Need
 Neuro V/S: 15/15
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 Mental Status (coherent, responsive, conscious, unconscious): Coherent, Responsive and
consciuos
 Emotional Problem (diaphoretic, trembling, restless) Irritable, diaphoretic and fatigue.
Love-Belonging Need
 Children (living with?) NONE
 Husband (living with?) NONE
Self – Esteem Need
-Need to accept to be independent but still needs assistance to people around him. Appreciate the
care and love of family. Need to discuss feelings and concerns. Interact effectively to people.
Self- Actualization Need
- Control one’s emotions and discipline self particularly in taking care of health. Need to learn to
listen and follow what is advised for easy recovery.
PHYSICAL ASSESSMENT
 General Survey
Patient received lying on bed, awake, responsive, coherent to verbal communication, dry lips,
with normal capillary refill (less than 3 sec) with heplock ; fatigue and weakness noted
Vital Signs
Date/Shift Time Temp BP PR RR O2 SAT OUTPUT OUTPUT

7/6/10 1:20 am 36.5 100/60 114 25 96
11-7
7-3 8:15 am 36 80/50 128 20 98
8:45 am 36 90/60 100 20 100
13
7/8/10 9:30 am 38.4 150/90 108 26 94
7-3
7/9/10 1:18 pm 38.5 120/80 93 22
11-7
7-3 9:20 am 39.1 140/90 106 23
7/10/10 4:20pm 38 120/80 92 20
3-11
7/16/10 2:15 am 38.1 120/70 89 22
7-3
7/17/10 10:50 38 130/80 101 23
7-3 am
3-11 6:00pm 35.5 140/90 98 22
07/18/10 2:30 38.2 140/70 90 25
11-7
 Nutritional Status
Upon admission, patient was on NPO diet until he was transferred to CENSICU. He was then
on DAT when he already expel flatus and that was when he was already transferred at Surgery
Male Ward Normally takes meal 3 times a day. Depending on varied conditions, he consumes
moderate amount of food per meal. No known hypersensitivity to food allergens and other
problems related to food consumption.
 Integumentary System
Fine and thin yet dry hair was noted. His nails were in convex shape, smooth in texture,
capillary refill of less than 3 seconds with pale nail beds. With good skin turgor, dry, and brown
in color. Eschar was noted on both legs. Incision at the abdomen and at the lateral side of the
back noted with colostomy to colostomy bag attached with JP drain.
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 HEENT
The size of head was in proportion with the body. The eyes were symmetrical with the ears
(pinna); pupils react spontaneously to light, with pale conjunctiva. Eyebrows symmetrically
aligned, eyelashes equally distributed, lids closed symmetrically. With approximately 15 to 20
blinks per minute. No discharges noted on ears. Nasal septum was intact and in the midline, no
discharges or flaring, air moves freely through the nares. Non-pitting edema noted at both feet.
 Pulmonary System
With symmetrical chest expansion; crackles sound heard upon auscultation; RR: 25 cpm
 Cardiovascular System
Cardiac sound from dull, low pitched (“lub”) to higher pitch (“dub”) sound , with irregular
cardiac rhythm ; 114 beats per minute abnormal. Capillary refill time takes less than 3 seconds .
 Gastrointestinal System
With colostomy to colostomy bag, with fecal content brownish to yellowish in color.
 Musculoskeletal System
Weakness and fatigue noted as manifestation of the disease process, marked reluctant to
move. With limited range of motion.
 Genito-urinary System
Patient voided after meal in our shift. Urine appears amber in color, moderate in amount.
Client’s normal voiding pattern is 4 times a day. Palpation on kidneys reveals no evidence of
tenderness and distention.
H. COURSE IN THE WARD
Date/Shift Nurse’s Nurse Rationale Medical Rationale.
Assessment Intervention Management
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07/06/10 -awake, -labs forwarded - to diagnose -Labs: CBC - to diagnose
3-11 palor X-ray done pt condition X-RAY abd. pt condition
2PM -V/S: T:36.5 (STAT)
BP: 100/60 -on NPO - to prevent -NPO -to prevent
RR: 25 instructed aspiration aspiration
PR:114 -IVF started @ - When -IVF: PLR @ - When
-Gunshot left arm @160 infused into 160 cc/hr infused into
wound on cc/hr the body it PNSS @20 the body it
periumbilical -PNSS @ right acts cc/hr acts
area arm @ 20 cc/hr (temporarily) -Meds: (temporarily)
-consciuos, to increase Cefuxity 1g to increase
coherent and the blood IVTT the blood
body volume, and Metronidazole volume, and
weakness bring up the Ranitidine bring up the
noted blood blood
pressure. pressure.
-consent - protocol to -For STAT - People with
secured for ex- promote exlap peritonitis
lap safety to the -secure often need
-abdominal medical consent surgery to
perineal prep team on -secure 4 units remove
shaving done whatever of blood infected
will happen tissue and
16
repair
damaged
organs.
-FC To UB -to have an I&O every - to
inserted accurate hour determine
-NGT inserted monitoring decrease UO
with distal end of urine
keep opened
6:40 AM - with FC to -BT regulated -to replace -to PACU - Avoid
UB to 120cc/hr loss of blood -NPO aspiration
-output of during V/S q 15 precaution
yellow operation Meds: - to have
colored urine -keep -to prevent Ketorolac baseline
-Post –exlap thermoregulated chills, Tramadol data, for
-NGT open -hurled for 02 normal due close
to drain inhalation to anesthetic monitoring
-no output -v/s checked effect. -Keep warm - to prevent
upon and recorded -Transfuse 2 chills,
received units of blood normal due
-with BT -Repeat Hgh to anesthetic
-abdominal and Hct effect.
tape dressing -I & O q hr
intact with
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ileostomy
7/07/10 -with O2 @ -placed on bed - To promote - NPO - To promote
7-3 5 LPM via comfortably proper -MHBR proper
7 am face mask. distribution -Meds: distribution
of oxygen Furosemide of oxygen
throughout Salbutamol throughout
the body the body
-hooked to -to have
cardiac monitor baseline data
-due meds for close
given monitoring
7/08/10 -awake, -monitor I& O -for close -May sit on
coherent and monitoring bed
7-3 responsive to -remove FBC
verbal -Retain NGT
7:50 am command -encourage
-ileostomy ambulation
out put -monitor
yellowish in ileostomy
color output
7/11/10 -Encouraged to - to promote -Shift
observe good relaxation Cefoxitin to
hygiene, and comfort Co-amoxiclav
encouraged to - promote
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have a full body wound
bath, increase haeling
OFI and eat
nutritious foods
-Due meds
given
7/13/10 - febrile -Monitor V/S - to have -HOLD MGH to have
3-11 T:39.9 -Labs for baseline date -labs: CBC baseline date
7pm approval for close -STAT: for close
V/S referred to monitoring. createnine, monitoring
Dr Corpuz Na, K
-HOLD MGH -for STAT
as ordered IVP once with
-reinserted with normal crea
D5LR 1 Liter
@ 30 gtts/min.
7/20/10 -on HBR, -Encouraged - To promote -high protein to promote
7-3 asleep, dry full body bath proper diet early wound
10:15 am and cyanotic -Health distribution healing
lips with teachings on of oxygen
wound @ eating nutritious throughout
Right lower foods such as the body
extremities. fruits and -to promote
vegetables early wound
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healing
III. LABORATORY AND DIAGNOSTIC EXAMINATIONS
LAB EXAM NORMAL RESULTY INTERPRETATION/IMPLICATION
VALUE
Hematology 07/ 11/10
Hemoglobin 134-136g/L 105 DECREASE. The primary cause could be
the disorders of the bone marrow. However,
there are other common factors such as poor
nutrition that is associated with the vitamin
(B 12, folic acid) and mineral deficiency
like Iron should not be overlooked. Some
time any malabsorption syndrome of the
gastrointestinal tract could lead to poor
absorption of these vitamins and minerals
even though these are adequately supplied
via the food.( http://www.labtestsonline.org/
understanding/analytes/hematocrit/test.html)
Leukocyte 5.0-10.0 13.6 INCREASE. This increase in leukocytes
Concentration (primarily neutrophils) is usually
accompanied by a "left shift" in the ratio of
immature to mature neutrophils. The
increase in immature leukocytes increases
20
due to proliferation and release of
granulocyte and monocyte precursors in the
bone marrow which is stimulated by several
products of inflammation including C3a and
G-CSF.
( http://en.wikipedia.org/wiki/Leukocytosis)
Segmenters 0.40-0.60 0.81 INCREASE. indicates viral infection
Lymphocytes 0.25-0.40 0.19 DECREASE. Indicate diseases that affect
the immune system, such as lupus, and the
later stages of HIV infection.

21
G-CSF.

22
G-CSF.
Segmenters 0.40-0.60 0.92 INCREASE. indicates viral infection
ARTERIAL BLOOD GAS RESULTS 07/ 20/10

Lab Exam Normal Result Interpretation/ Implication
Ph 7.35-7.45 7.33 WITHIN NORMAL RANGE
PCO2 35-45 21.7 DECREASE.
PO2 80-100 131.1 INCREASE
HCO3 22-26 15.2 DECREASE
B.E + or -2 12.2 INCREASE
O2 SAT 95-100% 98.5 WITHIN NORMAL RANGE
IMPRESSION: Respiratory Alkalosis and Metabolic Acidosis, Hypovolemic shock.
SERUM ELECTROLYTES 07/ 07/10

Createnine 53.0-115.0 159.6 INCREASE. Increased creatinine levels in
the blood suggest diseases or conditions that
affect kidney function. These can include:
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Damage to or swelling of blood vessels in
the kidneys (glomerulonephritis) caused by,
for example, infection or autoimmune
diseases. Bacterial infection of the kidneys
(pyelonephritis) . Death of cells in the
kidneys’ small tubes (acute tubular necrosis)
caused, for example, by drugs or toxins
.Prostate disease, kidney stone, or other
causes of urinary tract obstruction. Reduced
blood flow to the kidney due to shock,
dehydration, congestive heart failure,
atherosclerosis, or complications of diabetes
(http://www.labtestsonline.org/understanding
/analytes/creatinine/test.html)
Calcium 1.13-1.32 1.14 WITHIN NORMAL RANGE

Sodium 135-148 146.7 WITHIN NORMAL RANGE
Potassium 3.50-5.00 3.91 WITHIN NORMAL RANGE
Createnine 53.0-115.0 159.6 INCREASE. Increased creatinine levels in
the blood suggest diseases or conditions that
affect kidney function. These can include:
Damage to or swelling of blood vessels in
the kidneys (glomerulonephritis) caused by,
for example, infection or autoimmune
24
diseases. Bacterial infection of the kidneys
(pyelonephritis) . Death of cells in the
kidneys’ small tubes (acute tubular necrosis)
caused, for example, by drugs or toxins
.Prostate disease, kidney stone, or other
causes of urinary tract obstruction. Reduced
blood flow to the kidney due to shock,
dehydration, congestive heart failure,
atherosclerosis, or complications of diabetes
(http://www.labtestsonline.org/understanding
/analytes/creatinine/test.html)
Calcium 1.13-1.32 1.24 WITHIN NORMAL RANGE

Sodium 135-148 134 WITHIN NORMAL RANGE
Createnine 53.0-115.0 108.7 WITHIN NORMAL RANGE
Calcium 1.13-1.32 1.24 WIHTIN NORMAL RANGE

Sodium 135-148 131.8 WITHIN NORMAL RANGE
Createnine 53.0-115.0 96.3 WITHIN NORMAL RANGE
IV. REVIEW OF ANATOMY AND PHYSIOLOGY
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A. Anatomy and Physiology
THE DIGESTIVE SYSTEM
The functions of the
digestive system are:
• Ingestion - eating
food
• Digestion -
breakdown of the
food
• Absorption -
extraction of
nutrients from the
food
• Defecation -
removal of waste
products
The digestive system also
builds and replaces cells
and tissues that are constantly dying.
Digestive Organs
The digestive system is a group of organs (Buccal cavity (mouth), pharynx, oesophagus,
stomach, liver, gall bladder, jejunum, ileum and colon) that breakdown the chemical components
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of food, with digestive juices, into tiny nutrients which can be absorbed to generate energy for
the body.
The Buccal Cavity
Food enters the mouth and is chewed by the teeth, turned over and mixed with saliva by the
tongue. The sensations of smell and taste from the food sets up reflexes which stimulate the
salivary glands.
The Salivary glands
These glands increase their output of secretions through three pairs of ducts into the oral cavity,
and begin the process of digestion.
Saliva lubricates the food enabling it to be swallowed and contains the enzyme ptyalin which
serves to begin to break down starch.
The Pharynx
Situated at the back of the nose and oral cavity receives the softened food mass or bolus by the
tongue pushing it against the palate which initiates the swallowing action.
At the same time a small flap called the epiglottis moves over the trachea to prevent any food
particles getting into the windpipe.
From the pharynx onwards the alimentary canal is a simple tube starting with the salivary glands.
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The Oesophagus
The oesophagus travels through the neck and thorax, behind the trachea and in front of the aorta.
The food is moved by rhythmical muscular contractions known as peristalsis (wave-like
motions) caused by contractions in longitudinal and circular bands of muscle. Antiperistalsis,
where the contractions travel upwards, is the reflex action of vomiting and is usually aided by the
contraction of the abdominal muscles and diaphragm.
The Stomach
The stomach lies below the diaphragm and to the left of the liver. It is the widest part of the
alimentary canal and acts as a reservoir for the food where it may remain for between 2 and 6
hours. Here the food is churned over and mixed with various hormones, enzymes including
pepsinogen which begins the digestion of protein, hydrochloric acid, and other chemicals; all of
which are also secreted further down the digestive tract.
The stomach has an average capacity of 1 litre, varies in shape, and is capable of considerable
distension. When expanding this sends stimuli to the hypothalamus which is the part of the brain
and nervous system controlling hunger and the desire to eat.
The wall of the stomach is impermeable to most substances, although does absorb some water,
electrolytes, certain drugs, and alcohol. At regular intervals a circular muscle at the lower end of
the stomach, the pylorus opens allowing small amounts of food, now known as chyme to enter
the small intestine.
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Small Intestine
The small intestine measures about 7m in an average adult and consists of the duodenum,
jejunum, and ileum. Both the bile and pancreatic ducts open into the duodenum together. The
small intestine, because of its structure, provides a vast lining through which further absorption
takes place. There is a large lymph and blood supply to this area, ready to transport nutrients to
the rest of the body. Digestion in the small intestine relies on its own secretions plus those from
the pancreas, liver, and gall bladder.
The Pancreas
The Pancreas is connected to the duodenum via two ducts and has two main functions:
1. To produce enzymes to aid the process of digestion
2. To release insulin directly into the blood stream for the purpose of controlling blood
sugar levels
Enzymes suspended in the very alkaline pancreatic juices include amylase for breaking down
starch into sugar, and lipase which, when activated by bile salts, helps to break down fat. The
hormone insulin is produced by specialised cells, the islets of Langerhans, and plays an
important role in controlling the level of sugar in the blood and how much is allowed to pass to
the cells.
The Liver
The liver, which acts as a large reservoir and filter for blood, occupies the upper right portion of
abdomen and has several important functions:
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1. Secretion of bile to the gall bladder
2. Carbohydrate, protein and fat metabolism
3. The storage of glycogen ready for conversion into glucose when energy is required.
4. Storage of vitamins
5. Phagocytosis - ingestion of worn out red and white blood cells, and some bacteria
The Gall Bladder
The gall bladder stores and concentrates bile which emulsifies fats making them easier to break
down by the pancreatic juices.
The Large Intestine
The large intestine averages about 1.5m long and comprises the caecum, appendix, colon, and
rectum. After food is passed into the caecum a reflex action in response to the pressure causes
the contraction of the ileo-colic valve preventing any food returning to the ileum. Here most of
the water is absorbed, much of which was not ingested, but secreted by digestive glands further
up the digestive tract. The colon is divided into the ascending, transverse and descending colons,
before reaching the anal canal where the indigestible foods are expelled from the body.
THE PERITONEUM
The peritoneal membrane is a semi-permeable membrane that lines the abdominal wall (parietal
peritoneum) and covers the abdominal organs (visceral peritoneum). The membrane is a closed
sac in males. The fallopian tubes and ovaries open into the peritoneal cavity in females. The size
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of the membrane approximates the body surface area (1-2 m2). There are about 100 cc of
transudate that is contained in the cavity in normal individuals.
A. Blood Supply
The parietal peritoneum derives its blood supply from the arteries in the abdominal wall. This
blood drains into the systemic circulation. The visceral peritoneum is supplied by blood from the
mesenteric and coeliac arteries which drain into the portal vein.
B. Lymphatics
Subdiaphragmatic lymphatics are responsible for 80% of the drainage from the peritoneal cavity.
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The drainage is then absorbed into the venous circulation through the right lymph duct and the
left thoracic lymph duct. A balance of solutes and fluid in the interstitial tissue is maintained by
absorption of fluid from the peritoneal cavity. The average lymphatic rate of absorption in the
PD patient is 0.5-1.0 ml/min. Factors that affect the rate of absorption are respiratory rate,
posture, and intra-abdominal pressure.
V. SYMPTOMATOLOGY
Symptoms Actual Rationale
symptoms
Swelling
√ Swelling is considered one of the five characteristics of
inflammation; along with pain, heat, redness, and loss of
function.( http://en.wikipedia.org/wiki/Swelling_%28medical
%29)
Redness
√ Redness and heat are due to increased blood flow at body core
temperature to the inflamed site; swelling is caused by
accumulation of fluid.
( http://en.wikipedia.org/wiki/Inflammation#Cardinal_signs)
Pain
√ Pain is due to release of chemicals that stimulate nerve endings.
Loss of function has multiple causes
(http://en.wikipedia.org/wiki/Inflammation#Cardinal_signs)
Fever
√ Redness and heat are due to increased blood flow at body core
temperature to the inflamed site; swelling is caused by
accumulation of fluid.
( http://en.wikipedia.org/wiki/Inflammation#Cardinal_signs)
Rigid
√ As soon as infection sets in, the whole peritoneum becomes
32
abdomen inflamed or pus-filled abscesses may form. When this happens,
the muscles of the intestine walls become rigid and the
digestive process is hampered as the contents of the intestines
cease their forward movement.( http://www.medical-
look.com/Digestive_system/Peritonitis.html)
Dehydration
√ fluids and electrolytes are lost into the lumen of the abdomen. .(
http://www.medical-
look.com/Digestive_system/Peritonitis.html)
Due to contraction of the muscles of the abdominal wall.
Difficulty
√
expelling (http://www.healthscout.com/ency/68/473/main.html#cont)
feces
Nausea and X Development of ileus paralyticus (i.e. intestinal paralysis),
vomiting which also causes nausea and vomiting.
(http://en.wikipedia.org/wiki/Peritonitis)
Increase
√ Sequestration of fluid and electrolytes, as revealed by decreased
heart rate central venous pressure, may cause electrolyte disturbances, as
well as significant hypovolemia, possibly leading to shock and
acute renal failure.( http://en.wikipedia.org/wiki/Peritonitis)

Decrease BP
√ Sequestration of fluid and electrolytes, as revealed by decreased
central venous pressure, may cause electrolyte disturbances, as
well as significant hypovolemia, possibly leading to shock and
acute renal failure.( http://en.wikipedia.org/wiki/Peritonitis)
VI. ETIOLOGY OF THE DISEASE
Etiology Actual Rationale
33
Etiology
PREDISPOSING FACTORS
Peritonitis is a medical emergency: the muscles
Delayed medical
√
intervention due to within the walls of the intestine become paralyzed
and the forward movement of intestinal contents

Place of incident
stops (ileus). Early treatment of GI inflammatory
conditions and preoperative and postoperative
antibiotic therapy help prevent peritonitis.
(http://www.healthscout.com/ency/68/473/main.
html#cont)
PRECIPITATING FACTORS
Gunshot wound
√ Peritonitis is an inflammation of the peritoneum, the
(Abdominal serous membrane which lines part of the abdominal
Trauma cavity and viscera. Peritonitis may be localised or
generalised, and may result from infection (often due
to rupture of a hollow organ as may occur in
abdominal trauma or appendicitis) or from a non-
infectious process.
( http://en.wikipedia.org/wiki/Peritonitis)
VII. PATHOPHYSIOLOGY
A. Written
Peritonitis, inflammation of the peritoneum, was precipitated by an abdominal trauma resulting
from gunshot wound and was predisposed by the delaye to seek medical intervention due to the
34
place of incident. With this, there is now the invasion of foreign material into the peritoneum
wherein there is now an out poring of fibrinous exudates and pockets of pus (absess) form
between the fibrinous adhesions. Signs of swelling, redness and pain will be experienced by the
patient. Pockets of pus glue together to the surrounding surface and a localized infection then
will took place. Patient will manifest elevated temperature, pain, stomach rigidity and a sudden
increase in leukocyte level. The infected material will be distributed widely over the surface of
the peritoneum and fluids and electrolytes are lost into the lumen of the abdomen where patient
will manifest signs of shock, dehydration and diminished peristaltic movement. This will then
lead to peritonitis that can be diagnosed through alteration of serum electrolyte levels: creatinine,
sodium and potassium. Laboratories in blood indicate increase in leukocytes, hemoglobin and
hematocrit. ABG results of Respiratory Alkalosis and Metabolic Acidosis, Hypovolemic shock.
If treated with medical and surgical management of Removal of infected material,
administration of fluids and electrolytes replacement, Oxygen therapy to improve ventilatory
fxn and drainage to the outside. (JP drain). Nursing Mgt of Monitoring vital signs and drainage,
Recording intake and output and central venous pressure, observing and record character of any
surgical drainage, increase foods and oral fluids gradually, Postoperatively, teach care of incision
and drains and observe proper hygiene and encourage early ambulation and given with:
Cefoxitin, Ketorolac, Ranitidine, Tramadol, Celebrex, Metronidazole, Co-amoxiclav,
Loperamide, Cipro floxacint, Salbutamol will lead to a fair prognosis.
If not treated with medical and surgical mgt, nursing mgt, and pharmacological mgt it will lead
to poor prognosis and complications of intestinal obstruction and sepsis that leads to death
35
B. Diagram of Pathophysiology
Predisposing Factors/s:
s/s: fever, pain,
Precipitating rigid
Factor shock,dehydration,
LOCALIZED Delayed medical intervention
abdomen,wound
Gunshot increase
INFECTION due to Place ofdiminished
incident
leukoctes trauma)
(Abdominal peristalsis
Infected material distributed

Fluids and electrolytes are lost
widely over the surface of the
into the lumen of the abdomen
peritoneum
Invasion of foreign
material into the
Serum electrolytes: altered peritonium
Labs: Increase leukocytes,
potassium, sodium and hemoglobin, hematocrit
creatinine.
PERITONITIS
Out poring of fibrinous
exudates
If treated with: If not treated with:

Medical and Surgical Mgt: Pockets of pus (absess) form
between the fibrinous Medical and Surgical Mgt
- Removal of infected material
- administered fluids and electrolytes replacement. adhesions Nursing Mgt
s/s: swelling,
- Oxygen therapy to improve ventilatory fxn. Pharmacological Mgt
redness, pain
-drainage to the outside. (JP drain)
Nursing Mgt:
- Monitor vital signs and drainage.
-Record intake and output and central venous pressure POOR
-observe and record character of any surgical drainage
- increase foods and oral fluids gradually PROGNOSIS
-Postoperatively, teach care of incision and drains and observe
proper hygiene.
-encourage early ambulation
Pharmacological Mgt:
Cefoxitin
Ketorolac COMPLICATIONS:
Ranitidine
Tramadol Intestinal Obstruction
Celebrex Sepsis
Metronidazole
Co-amoxiclav
Loperamide
Cipro floxacint
Salbutamol
DEATH
36
FAIR
PROGNOSIS
VIII. PLANNING
A. Nursing Care Plan
FAIR
PROGNOSIS
37
38
39
40
41
42
43
B. Discharge Plan
To the patient who is diagnose of having peritonitis post ex-lap, it is deemed necessary that
after the hospital stay, compliance of the following action must be strictly observed for
rehabilitation.
Medications - Advise the client to take the medications on time to preserve the efficacy
of the drug. Instruct the client to take the medication with food to avoid GI irritation.
Exercise/Economic Factor - Encourage to do a routine ambulation as a light exercise.
Advise not to engage in strenuous activities. Encourage to take rest every after activity.
44
Treatment - Encourage to ask proper explanation before starting a procedure to
properly understand what is going to happen. Instruct client to ask and properly understand
before signing the consent.
Health Teaching - Encourage patient to take a bath and do ADL’s within limits if her
safety. Tell the patient to notify the physician immediately if there are unusualities. Follow all
instructions including medications, diet regimen and do’s and don’ts that was instructed to her by
the physician..
Out patient Follow-up - Advise to have a follow up check up any time after discharge.
Diet - Instruct patient to eat nutritious, high protein diet to promote healing and eat smaller,
more frequent meals to decrease feeling of fullness and bloating.
Spiritual/Sexual Activities - Encourage to reflect on her life situations and properly
understand these situations. To pray every day to help in coping up ones spirituality.
IX. PHARMACOLOGICAL MANAGEMENT
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
X. SYNTHESIS OF CLIENT’S CONDITION/ STATUS FROM ADMISSION TO
PRESENT
A Conclusion
As for the fact that his condition is reversible, the condition of Mr. Drain
aggravated due to poor compliance of the medical regimen. The medical team
gave the due care needed but still under observation. Thus prolong stay in the
hospital happens.
B. Patient’s Prognosis
61
Criteria Poor Fair Good Justification
Patient was still admitted and was
still under observation Conditions
still the same with complicatins.
Duration of Illness 
√ Rated it as fair because although
patient doesn’t willing to
Onset of Illness cooperate patient immediately
seek medical interventions and
was immediately cared for after
the pushed of the mother.

√ Rated it as good because patient
was still 25 years old and the said
Age condition doesn’t choose any age.

Rated as good because he
√ complied in all medication and
treatment. Even if he stayed in the
Willingness to Take hospital for almost a month
Medication/Complian already.
ce to Medical
Procedure
62
√ Rated it as fair because although
the condition arise from
complications of gunshot trauma
still the patient doesn’t comply
Lifestyle with health teachings regarding
importance of ambulating and
hygiene.
We rated it good since that the
emotional and physical support
Family Support  from the family is good and also
he is well cared for.
COMPUTATION:
POOR 1X1=1
FAIR 2X3=6
GOOD 3X2=6
1 + 6 + 6 = 13/18 FAIR Prognosis
C. Recommendations
With this study, the student nurses were able to gain more knowledge and wider view and
perspective of the complication of peritonitis. Thus, the student nurses would like recommend
and share some pointers on how to deal with different diseases with gastrointestinal tract such as
peritonitis..
63
To the government, primarily they should allocate sufficient budget to sustain and provide
better facilities. They must be responsible enough to create awareness program for care and
management for all the Filipino people.
To the health care team, they should righteously implementing basic and ideal procedures
regardless of the health care facilities where they belong. They must observe and always
remember to keep in line with their duties.
To the community and the family, that they must be insufficient coordination with the
government and the health care team regarding promotion of health and wellness.
Through the course of interaction with Mr. Drain, some limitations were noticed that made
us to recommend some interactions to aid in recovering those limitations such as:
 Emphasize the importance of compliance of medical regimen and interventions
related to the process of care.
XI. EVALUATION OF THE OBJECTIVES OF THE STUDY
The student nurse was able to meet the objectives of this case on peritonitis. Based on the
gathered data regarding the client’s chief complaint, history of present illness, personal, family
and socio-economic history and actual interview to the client, and able to determine the factors
that affect the patient’s condition.
Upon performing the cephalocaudal assessment, able to identify the systems affected that
showed the signs and symptoms, and its manifestations of the said condition. Nursing
interventions were provided to the patient like health teaching regarding the importance on the
compliance of the medical regimen and the infection control procedures such as proper draining
64
of colostomy bag, changing of dressing regularly, ambulating and hand hygiene. Series of
laboratory test such as CBC and U/A were being made and interpreted which lead to the
diagnosis of peritonitis.
During the period of his hospitalization, problems were identified and prioritized,
then, nursing care plan were formulated.
XII. BIBLIOGRAPHY
A. Textbooks
Douges, M.E. et.al., (2002). Nurse’s pocket guide: diagnosis, interventions & rationales.
(8th Edition). Philadelphia: F.A. Davis Company.
Douges, M.E. et.al., (2002). Nursing care plan: guidelines for individualizing patient
care (6th Edition) Philadelphia: F.A. Davis Company.
Gulandick, M. et.al., Nursing care plan. (3rd Edition)
65
Ignatavicius, D.D. & Workman, M.L. (2006). Medical-surgical nursing: critical thinking
for collaborative care. (5th Edition). St. Louis, Missouri: Elsevier Saunders.
Kozier, B. et.al., (2004). Fundamentals of nursing: concepts, process & practice. (7th
Edition). Philippines: Pearson Education South Asia PTE Ltd.
Smeltzer, S.C. & Bare, B.G. (2004).Textbook of medical-surgical nursing(10th Edition,
Volume 2). Philadelphia: Lippincott Williams and Wilkins. pp 553-538.
Spratto, G.R. & Woods, A.L. (1994). Nurse’s drug reference. USA: Delmar Publishers
Incorporated.
Ulrich & Canale. (2005). Nursing care planning guides. (6th Edition).
B. Internet Downloads
http://www.labtestsonline.org/understanding/analytes/hematocrit/test.html
http://en.wikipedia.org/wiki/Leukocytosis
http://www.healthline.com/adamcontent/fatigue#hl2
http://www.emedicinehealth.com/chest_pain/page3_em.htm
66

Gunshot Wound Peritonitis

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Gunshot Wound Peritonitis

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ST.

Zaida S. Jo, RN, MN

In Partial Fulfillment of the Requirements

Related Learning Experience

Mia Charisse F. Lamparero

C. History of Present Illness 8

D. Past Medical and Nursing History 8

E. Personal, Family and Socio-Economic History 8

G. Patient Need Assessment 9

 Course in the Ward 14

III. LABORATORY AND DIAGNOSTIC EXAMINATIONS 19

IV. REVIEW OF ANATOMY AND PHYSIOLOGY 26

VI. ETIOLOGY OF THE DISEASE 34

A Nursing Care Plan 38

IX. PHARMACOLOGICAL MANAGEMENT 46

X. SYNTHESIS OF CLIENT’S CONDITION/

STATUS FROM ADMISSION TO PRESENT

XI. EVALUATION OF THE OBJECTIVES OF

Background of the Study

may become infected by bacteria or other organisms.

entire peritoneum, or be confined to a walled-off, pus-filled cavity (abscess).

mild disease, or systemic and severe disease with septic shock.

to arrive to our goals and aims.

 To obtain sufficient and relevant information regarding patient’s condition.

 To present personal data of the patient.

the patient having a Peritonitis.

 To conduct a thorough head-to-toe assessment serving as baseline data.

basing from the patient’s diagnosis.

effects and nursing responsibilities.

correspond his condition at least 2 actual problems and 1 risk problem.

 To evaluate the outcome of the condition of the patient.

Name : Mr. Drain

Age : 25 years old

Civil Status : Single

Birthdate : January 11, 1985

Address: : Prk 5 Elizalde (Samil), Maco, Comval Province

Religion : Roman Catholic

Attending Physician : Dr. Alvin C. Medina, M.D.

a resident physician of the said hospital.

C. HISTORY OF PRESENT ILLNESS

D. PAST MEDICAL AND NURSING HISTORY

E. PERSONAL, FAMILY AND SOCIO-ECONOMIC HISTORY

 Robert J. Havighurst Developmental Task Theory

G. PATIENT NEED ASSESSMENT

Admission Date/Time: July 06, 2010/ 1:40 am

Male, GCS to level

Arrived on Unit by: per stretcher From: CENSICU Room

Accompanied by: He is accompanied by his mother

AdmittingWeight /VS: 48kgs BP- 100/60 RR-25 PR-114 Temp- 36.7

Client’s Perception of reason for Admission:

How has problem been managed by client at home: NONE

Allergies: No allergies was being experience according to the patient

 BP _100/60 PR 114 bpm RR 25 cycles/min CR_________

auscultation, symmetry chest expansion was being observe during breathing.

 Cardiac status (per auscultation sounds character; chest pain?

 Capillary Refill: Within 2 – 3 seconds using the blanched test

 Skin Character and Color: dry, pale, dark brown in color

 Life-supporting Apparatus: N-O-N-E

II. Temperature Maintenance:

 Other Observations (related): N-O-N-E

III. Nutritional Fluid:

 Height: 5’ 4’’/ 48kg. Amount of food consumed: ¼ of meal served consumed

 Prescribed Diet: Diet as tolerated + 2 eggs/day