Risk for Trauma | Nursing Care Plan for Peritoneal Dialysis

Nursing diagnosis: risk for Trauma

Risk factors may include
Catheter inserted into peritoneal cavity
Site near the bowel and bladder with potential for perforation during insertion or manipulation of the catheter

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Experience no injury to bowel or bladder.

Nursing intervention with rationale:
1. Have client empty bladder before peritoneal catheter insertion if indwelling catheter not present.
Rationale: An empty bladder is more distant from insertion site and reduces likelihood of being punctured during catheter insertion.

2. Anchor catheter and tubing with tape. Stress importance of client avoiding pulling or pushing on catheter. Restrain hands if indicated.
Rationale: Reduces risk of trauma by manipulation of the catheter.

3. Note presence of fecal material in dialysate effluent or strong urge to defecate, accompanied by severe, watery diarrhea.
Rationale: Suggests bowel perforation with mixing of dialysate and bowel contents.

4. Note reports of intense urge to void or large urine output following initiation of dialysis run. Test urine for sugar, as indicated.
Rationale: Suggests bladder perforation with dialysate leaking into bladder. Presence of glucose-containing dialysate in the bladder will elevate glucose level of urine.

5. Stop dialysis if there is evidence of bowel or bladder perforation, leaving peritoneal catheter in place.
Rationale: Prompt action will prevent further injury. Immediate surgical repair may be required. Leaving catheter in place facilitates diagnosing and locating the perforation.