Acute Pain | Nursing Care Plan for Peritonitis

Nursing diagnosis: acute Pain related to Chemical irritation of the parietal peritoneum (toxins), Trauma to tissues, Accumulation of fluid in abdominal and peritoneal cavity (abdominal distention)

Possibly evidenced by
Verbalizations of pain
Muscle guarding, rebound tenderness
Facial mask of pain, self-focus
Distraction behavior, autonomic or emotional responses (anxiety)

Desired Outcomes/Evaluation Criteria—Client Will
Pain Control
Report pain is relieved or controlled.
Demonstrate use of relaxation skills or other methods to promote comfort.

Nursing intervention with rationale:
1. Investigate pain reports, noting location, duration, intensity (0 to 10 scale), and characteristics such as dull, sharp, or constant.
Rationale: Changes in location or intensity are not uncommon but may reflect developing complications. Pain tends to become constant, more intense, and diffuse over the entire abdomen as inflammatory process accelerates; pain may localize if an abscess develops.

2. Maintain semi-Fowler’s position as indicated.
Rationale: Facilitates fluid and wound drainage by gravity, reducing diaphragmatic irritation and abdominal tension, thereby reducing pain.

3. Move client slowly and deliberately, splinting painful area.
Rationale: Reduces muscle tension and guarding, which may help minimize pain of movement.

4. Provide comfort measures, such as massage, back rubs, and deep breathing. Instruct in relaxation and visualization exercises. Provide diversional activities.
Rationale: Promotes relaxation and may enhance client’s coping abilities by refocusing attention.

5. Provide frequent oral care. Remove noxious environmental stimuli.
Rationale: Reduces nausea and vomiting, which can increase intra-abdominal pressure and pain.

6. Administer medications, as indicated, for example: Analgesics and opioids
Rationale: Reduces metabolic rate and intestinal irritation from circulating and local toxins, which aid in pain relief and promote healing. Note: Pain is usually severe and may require opioid pain control.

7. Antiemetics, such as hydroxyzine (Vistaril)
Rationale: Reduces the nausea and vomiting that can increase abdominal pain.

8. Antipyretics, such as acetaminophen (Tylenol)
Rationale: Reduces discomfort associated with fever.