I. Overview
(1) Overview of Anatomy and Physiology
Peritoneum is a very thin serosa, which is divided into two parts: continuous wall and visceral peritoneum. The parietal peritoneum is attached to the abdominal wall, the diaphragm surface and the inner surface of the pelvic wall; Visceral peritoneum covers the surface of visceral organs and becomes its serosa layer. Peritoneal cavity is a potential cavity between parietal peritoneum and visceral peritoneum, and it is the largest body cavity in human body. There is 75- 100 ml yellow clear liquid in the normal peritoneal cavity, which plays a lubricating role; During the pathological process, the peritoneal cavity can hold several liters of liquid or gas. The peritoneal cavity is divided into two parts: abdominal cavity and omental sac, which communicate with each other through omental foramen. The parietal peritoneum is dominated by the main receptors, sensitive to various stimuli and accurate in pain location. Therefore, inflammation of the anterior abdominal wall peritoneum can cause local pain, tenderness and reflex abdominal muscle tension, which is the main clinical basis for the diagnosis of peritonitis. After the peritoneum in the central part of diaphragm is stimulated, it causes shoulder reflex pain or hiccup through phrenic nerve reflex. The innervation of visceral peritoneum belongs to autonomic nerve, which comes from sympathetic nerve and vagus nerve endings. It is sensitive to stimulation such as traction, increased pressure in gastrointestinal cavity, inflammation, oppression, etc., and its nature is often dull and painful, and its position is poor, mostly concentrated in the middle of the abdomen around the umbilicus. Severe stimulation can often cause heart rate slowdown, blood pressure drop and intestinal paralysis. Peritoneum has physiological functions such as lubrication, absorption and exudation, defense and repair, which can reduce gastrointestinal peristalsis or friction when it comes into contact with other internal organs, and can absorb a lot of effusion, blood, air and toxins. In severe peritonitis, the absorption of a large number of toxic substances can cause septic shock. Peritoneum can also ooze a lot of liquid, dilute toxins and reduce irritation. Macrophages in the exudate can devour bacteria, and fibrin in the exudate of foreign bodies can deposit around the focus, resulting in adhesion, limiting inflammation and repairing damaged tissues. But it can also form extensive fibrous adhesion in abdominal cavity, which affects the function of internal organs, such as intestinal obstruction.
Peritonitis is inflammation of peritoneal cavity wall and dirty peritoneum, which can be caused by bacteria, chemicals (such as gastric juice, bile, blood) or physical factors.
(2) Classification
Peritonitis can be divided into primary and secondary according to its pathogenesis. According to the etiology, it can be divided into bacterial and non-bacterial categories; According to the clinical process, it is divided into acute, subacute and chronic categories; According to the scope of involvement, it can be divided into two categories: diffuse and localized; Can be converted between different types.
Clinical acute peritonitis refers to secondary purulent peritonitis, which is a common surgical acute abdomen. It is acute peritonitis caused by purulent bacteria, including aerobic bacteria and anaerobic bacteria or a mixture of both. When the whole peritoneal cavity is involved, it is called acute diffuse peritonitis.
(III) Etiology
1. Secondary peritonitis is the most common type of acute suppurative peritonitis, accounting for 98%. The main pathogen of secondary peritonitis is the resident flora in gastrointestinal tract, among which Escherichia coli is the most common, followed by Bacteroides Anaerobic and Streptococcus.
(1) The most common causes of secondary peritonitis are perforation or rupture of internal organs in abdominal cavity, acute perforation of gastric ulcer and duodenal ulcer, and visceral rupture caused by abdominal injury, which often leads to chemical peritonitis first, and then to purulent peritonitis after secondary infection; Acute gangrenous gallbladder wall necrosis and perforation often cause extremely serious biliary peritonitis.
(2) Ischemia, exudation and inflammatory diffusion of abdominal organs; Can be seen in strangulated hernia, strangulated intestinal obstruction, acute suppurative appendicitis, acute pancreatitis and other pathological organ ischemia, bacterial exudates spread in the abdominal cavity to cause peritonitis.
(3) Others: Peritonitis can also be caused by abdominal contamination during abdominal surgery, leakage of anastomoses between gastrointestinal tract and bile duct, and severe infection of front and rear abdominal walls.
2. Primary peritonitis has no primary focus in the peritoneal cavity, and bacteria spread to the peritoneal cavity through blood, urinary tract and female reproductive tract and cause inflammation, which is called primary peritonitis, accounting for 2%. Most pathogenic bacteria are hemolytic streptococcus,
Pneumococcus or (Escherichia coli) is more common in children, cirrhosis complicated with ascites or nephropathy, and patients are often accompanied by malnutrition or low resistance.
(4) Pathophysiology
After the peritoneum is stimulated by bacteria or gastrointestinal contents, it quickly reacts with congestion and edema and loses its original luster; Subsequently, a large amount of serous exudate is produced to dilute the toxins in the peritoneal cavity; A large number of phagocytes, neutrophils, necrotic tissues, bacteria and coagulated fibrin in the exudate make the exudate turbid and become pus. The pus mainly composed of Escherichia coli is mostly yellow-green, often mixed with other pathogenic bacteria, which thickens and stinks with feces.
The prognosis of peritonitis is not only related to the patient's general situation and local peritoneal defense ability, but also depends on the nature, quantity and duration of bacterial contamination. Bacteria and their endotoxin stimulate the body's defense mechanism and activate a variety of inflammatory mediators, which can lead to systemic inflammatory response. Severe congestion and edema of peritoneum during peritonitis can cause water and electrolyte disorder; Abdominal viscera soaked in pus can form paralytic intestinal obstruction. Intestinal dilatation makes diaphragm move up and affects cardiopulmonary function, and a large amount of liquid in intestinal cavity reduces blood volume obviously. Bacterial invasion and toxin absorption are easy to cause septic shock; Severe cases can lead to death. If the lesion is mild, the lesion is limited by wrapping or stuffing the omentum to form localized peritonitis; If pus accumulates in the abdominal cavity and is surrounded by adhesions such as intestinal loop omentum or mesentery, it will break away from the free peritoneal cavity to form abdominal abscess, such as subphrenic abscess, pelvic abscess and intestinal space abscess. After the peritonitis is cured, there are many fibrous adhesions in the abdominal cavity, and some intestinal tubes are adhered or angulated, which can lead to adhesive intestinal obstruction.
Second, nursing evaluation
(1) health history
Ask about the past medical history, especially pay attention to the history of gastric and duodenal ulcer, chronic appendicitis, other abdominal visceral diseases and surgical history; Do you have a recent history of abdominal trauma? Children should pay attention to whether they have a recent history of respiratory or urinary tract infection, malnutrition or other conditions that lead to decreased resistance.
(2) Physical condition
1, symptoms:
Abdominal pain (1) is the most important clinical manifestation. Pain is usually severe, persistent and unbearable. The pain is aggravated when breathing deeply, coughing and changing body position, and the patient is unwilling to change body position. The pain started from the primary focus and spread to the whole abdomen.
(2) Nausea and vomiting The peritoneum is stimulated, which can cause reflex nausea and vomiting. Vomiting is mostly divided into stomach contents, and bile or even fecal contents can be spit out when paralytic intestinal obstruction occurs.
(3) Changes of body temperature and pulse: These changes are related to the severity of inflammation. With the aggravation of inflammation, the body temperature gradually rises and the pulse gradually accelerates. If the primary lesion is inflammatory, the body temperature usually rises before peritonitis, and even higher after peritonitis. The pulse is much faster. If the pulse is faster, the body temperature will drop, which is one of the signs of the deterioration of the disease.
(4) General symptoms: poisoning symptoms such as high fever, rapid pulse, shallow breathing, excessive sweating, dry mouth, etc. And severe systemic failure such as severe dehydration, hypovolemia, metabolic acidosis and shock.
2. Abdominal signs:
Most patients present with acute symptoms, often taking supine position, flexion of both lower limbs and refusing to press the abdomen. Abdominal breathing is weakened or disappeared. The aggravation of abdominal distension indicates the deterioration of the condition. Abdominal tenderness, rebound pain and abdominal muscle tension are symbolic signs of peritonitis, which are called peritoneal irritation sign, especially where the primary lesion is located. Abdominal muscle tension caused by perforation of gastrointestinal tract and gallbladder can be "plank-like" rigidity, while abdominal muscle tension in children, the elderly, obesity and patients in the third trimester is not obvious and is easily ignored. In addition, the perforation of hollow organs can reduce or disappear the boundary of liver voiced sound; Mobile dullness can accompany ascites for a long time; Bowel sounds weaken or even disappear; Digital rectal examination showed that the anterior rectal fossa was full and tender, suggesting pelvic abscess. Visual diagnosis: abdominal distension is obvious, abdominal breathing movement is weakened or disappeared.
(3) Psychological and social status
To understand the psychological reaction of patients after illness, whether they have anxiety, fear and other manifestations. Ask patients about their cognitive level, psychological endurance and adaptation to hospital environment. Understand the attitude and financial endurance of family and relatives.
(4) Diagnostic examination
1. Blood test: white blood cell count and neutral ratio increased, but white blood cells did not increase in critically ill patients or those with decreased body response ability, only neutrophils increased.
2.X-ray: X-ray examination is selectively performed according to the suspected etiology in the medical history. For example, gastrointestinal perforation is suspected, and there is free gas under the diaphragm in high abdominal photos. In the late stage of peritonitis, the abdominal plain film is enlarged due to intestinal paralysis, the small intestine is flattened, the intestinal space is widened, and the extraperitoneal fat line is blurred or even disappeared.
3, rectal digital diagnosis: the front wall of the rectum is full and tender, suggesting pelvic infection or abscess formation.
4.b-ultrasound examination showed that there were different amounts of liquid in abdominal cavity.
5. Abdominal puncture
(1) Primary peritonitis: purulent, white, yellow or grass green, odorless.
(2) perforation of gastric and duodenal ulcer: yellow in color, containing bile, turbid, alkaline and tasteless (amylase content may be high)
(3) Intestinal strangulation and necrosis: bloody liquid, foul smell.
(4) Appendicitis perforation: purulent, white or yellowish, turbid, thin, slightly smelly or tasteless.
(5) Hemorrhagic necrotizing pancreatitis: bloody liquid, generally tasteless (high amylase content)
(6) Liver and spleen rupture: blood is not easy to coagulate after standing for several minutes.
Third, nursing diagnosis
(1) Deficiency of body fluid is related to vomiting, fasting, ascites in abdominal cavity and intestine.
(2) Pain is related to inflammatory stimulation of peritoneum.
(3) High fever is related to the absorption of infectious toxins.
Anxiety is related to pain, infection and poisoning.
Fourth, nursing goals
(a) The water and electrolyte balance of patients was maintained, and no acid-base imbalance occurred.
(two) patients with abdominal pain, abdominal distension and other discomfort to reduce or reduce.
(3) The patient's body temperature was controlled and gradually decreased to the normal range.
(4) The patients' anxiety is reduced.
Verb (abbreviation of verb) nursing measures
(A) the principle of treatment
1. Non-surgical treatment is feasible for patients with mild illness or a course of disease longer than 24 hours, and abdominal signs have been alleviated, or inflammation has been limited, or severe cardiopulmonary disease can not tolerate surgery, and primary peritonitis. It mainly includes semi-supine position, fasting, continuous gastrointestinal decompression to correct the disorder of water and electrolyte proficiency, anti-infection nutrition to support sedation, analgesia, oxygen inhalation and so on.
2. Surgical treatment Most patients with secondary peritonitis need timely surgical treatment, and non-surgical treatment can be used as preoperative preparation.
Surgical principles: including exploration and determination of the cause, treatment of primary lesions, thorough cleaning of abdominal cavity and adequate drainage.
(2) Specific nursing measures
1, preoperative care
Psychological care: do a good job of comforting and explaining patients and their families, stabilize patients' emotions and reduce anxiety and fear; Explain the disease knowledge about peritonitis, help them face the disease bravely, cooperate with medical treatment, and increase their confidence and courage to overcome the disease. ?
Posture: Semi-recumbent position can promote the accumulation of abdominal exudate in the pelvic cavity, thus reducing absorption, alleviating poisoning symptoms, facilitating drainage, and at the same time moving the diaphragm downward, relaxing the abdominal muscles, and reducing the influence of abdominal distension on breathing and circulation. In shock patients, supine position can prevent diaphragm and abdominal organs from moving up, thus affecting cardiopulmonary function, increasing blood flow back to the heart and improving cerebral blood flow. ?
Fasting and gastrointestinal decompression: patients with gastrointestinal perforation must fast and stay in gastrointestinal decompression. Gastrointestinal decompression can suck out the contents and gas in the gastrointestinal tract, reduce the gas accumulation in the gastrointestinal tract, improve the blood circulation of the gastrointestinal wall, help limit inflammation and promote the recovery of gastrointestinal function. ?
Correct the water-electrolyte disorder: according to the patient's access and physiological needs, calculate the total amount of fluid to be supplemented and correct the water-electrolyte disorder. Pay attention to monitoring blood pressure, pulse, urine volume, central venous pressure, electrocardiogram, serum electrolyte and blood gas analysis, adjust the composition and speed of infusion in time, and keep the urine volume of 30 ~ 50ml per hour. ?
Antibiotic treatment: Secondary peritonitis is mostly mixed infection, and the type of pathogenic bacteria should be considered in anti-infection treatment. It is more reasonable to choose antibiotics according to bacterial strains and drug sensitivity results. The solvent should be selected correctly, and penicillin drugs should be prepared on the spot to avoid allergens and reduce the curative effect.
Sedation and analgesia: Pethidine analgesics can be used for patients who have been diagnosed, treated and operated to relieve their pain. When the diagnosis is unknown or the condition is observed, analgesic drugs are not needed for the time being, so as not to cover up the condition. ?
Postoperative care?
Observation of illness: closely monitor the changes of vital signs, often patrol patients, listen to chief complaints, observe the changes of abdominal signs, whether there is subphrenic or pelvic abscess, etc. , and find anomalies and handle them in time. Pay special attention to the monitoring and maintenance of circulation, respiration and renal function in critically ill patients. ?
Posture: People who are not awake under general anesthesia should take the supine position with their heads tilted to one side to prevent suffocation or aspiration pneumonia caused by vomiting and keep the respiratory tract unobstructed. Patients who are awake after general anesthesia or epidural anesthesia can lie on their backs for 6 hours, and their blood pressure and pulse are stable, so they can be changed to semi-supine position, and patients are encouraged to turn over and exercise more to prevent intestinal adhesion. ?
Diet: After the operation, continue fasting and gastrointestinal decompression. After the recovery of intestinal peristalsis, remove the stomach tube and give it water and liquid diet, and gradually return to normal diet. During gastrointestinal decompression, give oral care regularly to prevent oral infection. ?
Fluid replacement and nutritional support: reasonably supplement water, electrolytes and vitamins, inject new blood and plasma when necessary, and give enteral and parenteral nutritional support to maintain the body's postoperative rehabilitation needs and improve the body's defense ability. Continue to use effective antibiotics to control intra-abdominal infection. ?
Health education?
Knowledge: Explain to patients the importance of fasting, gastrointestinal decompression and semi-recumbent position during non-operation, and teach patients to pay attention to the changes of abdominal symptoms and signs. ?
Diet: Instruct and explain postoperative dietary knowledge, encourage them to eat less and more meals step by step, and eat foods rich in protein, energy and vitamins to promote the repair of surgical wounds and the healing of incisions. ?
Activities: Explain the importance of early postoperative activities, encourage patients to do bed activities during bed rest, and get out of bed as soon as possible after physical recovery to promote the recovery of intestinal function and prevent postoperative intestinal adhesion. ?
Follow-up and follow-up: regular outpatient review after discharge. If the wound is red, swollen, hot and painful, body temperature rises and abdominal pain, stop exhausting and defecating, and see a doctor in time.
Abdominal abscess is divided into septal abscess, pelvic abscess and intestinal space abscess.
Secondary to acute peritonitis or intra-abdominal surgery, primary is rare.
First, subphrenic abscess
The abdominal cavity is divided into upper colon region and lower colon region by transverse colon and its mesentery. The upper colon region is also called the subphrenic region, and the liver divides it into the upper hepatic space and the lower hepatic space. The suprahepatic space is divided into left and right spaces by sickle ligament. The inferior hepatic space is divided into right inferior space and left inferior space by ligamentum teres hepatis. The left lower hepatic space is divided into left anterior space and left posterior space (omental sac) by stomach and hepatogastric ligament. The left anterior inferior hepatic space communicates with the left superior hepatic space, forming the left subphrenic space. The subphrenic part is the lowest when the patient lies flat, and abdominal abscess is easy to accumulate here during acute peritonitis. The location of abscess is related to the primary disease. Septal abscess can cause reactive pleural effusion, pleurisy, internal fistula and gastrointestinal bleeding.
1, clinically, the abscess site may have persistent dull pain, aggravated by deep breathing, and often located at the costal margin or near the midline under the xiphoid process. Abscess can cause hiccups by stimulating the diaphragm. When the infection affects the pleura and lungs, patients with pleural effusion and discoid atelectasis will have symptoms such as shortness of breath, cough and chest pain. There is knocking pain in the ribs, and in severe cases, the skin is locally sunken and edema, and the skin temperature is increased. X-ray examination showed that the affected side diaphragm was elevated, limited or disappeared with respiratory activity, blurred costal diaphragm angle, or pleural effusion. Diagnostic puncture can be carried out under the guidance of B-ultrasound, which can not only help diagnosis, but also suck pus, flush pus cavity and inject effective antibiotics for treatment.
2, the treatment principle:
Subdiaphragmatic abscess is mainly treated by surgery. In recent years, percutaneous catheter drainage has been widely used, with little trauma, generally no pollution to the free abdominal cavity and good drainage effect. Surgical incision and drainage can also be performed according to the abscess site. At the same time, we should strengthen nutritional support, infusion and the use of antibiotics.
Second, pelvic abscess
The pelvic cavity is the lowest in the abdominal cavity. Inflammatory exudate or pus in abdominal cavity is easy to accumulate here to form pelvic abscess. Pelvic peritoneum is small, and its ability to absorb toxins is limited. Therefore, the symptoms of systemic poisoning of pelvic abscess are often mild.
1, clinical manifestations
It often occurs during the treatment of acute peritonitis, after appendiceal perforation or colorectal surgery. It is characterized by elevated body temperature, rapid pulse, and typical rectal or bladder irritation symptoms, such as heavy feeling after urgency, frequent defecation, mucus-like stool, frequent urination, dysuria, etc. However, there is often no positive finding in abdominal examination, and a lump can be felt in rectal digital examination, which bulges into the rectal cavity, with tenderness and sometimes a sense of fluctuation. B-ultrasound can determine the location and size of abscess.
2. Principles of treatment
(1) Non-surgical treatment: when the abscess is small or not formed, antibiotics, physical therapy, etc.
(2) Surgical treatment: when the abscess is large. Anterior rectal wall puncture, married women can consider posterior fornix puncture and drainage.
Third, there is pus around the abscess between the intestine, mesentery and omentum. Can be single or multiple. Extensive adhesion around abscess can lead to adhesive intestinal obstruction.
1. Clinical manifestations: It can be a single abscess or multiple abscesses of different sizes. If there is extensive adhesion around the abscess, different degrees of adhesive intestinal obstruction may occur. The patient developed symptoms of suppurative infection, complaining of abdominal distension, abdominal pain, abdominal tenderness or touching a lump. The standing abdominal X-ray plain film shows the widening of intestinal wall spacing and local intestinal gas accumulation, and also shows the gas-liquid plane of small intestine.
2. Treatment principle: application of antibiotics, physical diathermy and systemic support. If B-ultrasound or CT examination shows that the abscess is mono-locular, localized and close to the abdominal wall, percutaneous drainage under the guidance of B-ultrasound can be used; If surgical treatment is ineffective or intestinal obstruction occurs, laparotomy should be considered to relieve obstruction and drain pus.