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.

Risk for Trauma/Suffocation | Nursing Care Plan for Seizures Disorder

Risk factors may include

Weakness, balancing difficulties

Cognitive limitations, altered consciousness

Loss of large or small muscle coordination

Emotional difficulties

Possibly evidenced by

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

Desired Outcomes/Evaluation Criteria—Client Will

Risk Detection

Verbalize understanding of factors that contribute to possibility of trauma or suffocation and take steps to correct situation.

Risk Control

Demonstrate behaviors and lifestyle changes to reduce risk factors and protect self from future seizure events and injury.

Modify environment as indicated to enhance safety.

Maintain treatment regimen to control or eliminate seizure activity.

Significant Other [SO]/Caregiver Will

Knowledge: Personal Safety

Identify actions or measures to take when seizure activity occurs.

Nursing care plan with rationale:

1. Explore with client the various stimuli that may precipitate seizure activity.

Rationale: Alcohol, various drugs, and other stimuli, such as loss of sleep, flashing lights, and prolonged television viewing, may increase the potential for seizure activity. Client may or may not have control over many precipitating factors, but may benefit from becoming aware of risks.

2. Discuss seizure warning signs, if appropriate, and usual seizure pattern. Teach SO to recognize warning signs and how to care for client during and after seizure.

Rationale: Can enable client or SO to protect individual from injury and to recognize changes that require notification of physician and further intervention. Knowing what to do when seizure occurs can prevent injury or complications and decreases SO’s feelings of helplessness.

3. Keep padded side rails up with bed in lowest position, or place bed up against wall, and add floor pad if rails are not available or appropriate.

Rationale: Minimizes injury should frequent or generalized seizures occur while client is in bed.

4. Maintain strict bedrest if prodromal signs or aura is experienced. Explain necessity for these actions.

Rationale: Client may feel restless, need to ambulate or even defecate during aural phase, thereby inadvertently removing self from safe environment and easy observation. Understanding importance of providing for own safety needs may enhance client cooperation.

5. Stay with client during and after seizure.

Rationale: Promotes client safety and reduces sense of isolation during event.

6. Turn head to side and suction airway as indicated. Insert soft bite block per facility protocol, only if jaw relaxed.

Rationale: Helps maintain airway and reduces risk of oral trauma but should not be “forced” or inserted when teeth are clenched because dental and soft-tissue damage may result. Note: Current practice is mixed regarding the use of airways during seizure activity.

7. Cradle head, place on soft area, or assist to floor if out of bed. Do not attempt to restrain.

Rationale: Gentle guiding of extremities reduces risk of physical injury when client lacks voluntary muscle control. Note: If attempt is made to restrain client during seizure, erratic movements may increase, and client may injure self or others.

8. Perform neurological and vital sign checks after seizure: level of consciousness, orientation, ability to comply with simple commands, ability to speak, memory of incident, weakness or motor deficits, blood pressure (BP), pulse, and respiratory rate.

Rationale: Documents postictal state and time and completeness of recovery to normal state. May identify additional safety concerns to be addressed.

9. Reorient client following seizure activity.

Rationale: Client may be confused, disoriented, and possibly amnesic after the seizure and need help to regain control and alleviate anxiety.

10. Allow postictal “automatic” behavior without interfering while providing environmental protection.

Rationale: May display behavior of motor or psychic origin that seems inappropriate or irrelevant for time and place. Attempts to control or prevent activity may result in client becoming aggressive or combative.

Risk for Trauma/Suffocation | Nursing Care Plan for Pneumothorax

Nursing diagnosis: risk for trauma/suffocation

Risk factors may include

Concurrent disease or injury process

Dependence on external device—chest drainage system

Lack of safety education and precautions

Possibly evidenced by

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

Desired Outcomes/Evaluation Criteria—Client Will

Risk Control

Recognize need for and seek assistance to prevent complications.

Caregiver Will

Correct and avoid environmental and physical hazards.

Nursing intervention with rationale:

1. Review with client purpose and function of CDU, taking note of safety features.

Rationale: Information on how system works provides reassurance, reducing client anxiety.

2. Instruct client to refrain from lying or pulling on tubing.

Rationale: Reduces risk of obstructing drainage or inadvertently disconnecting tubing.

3. Identify changes and situations that should be reported to caregivers, such as change in sound of bubbling, sudden “air hunger” and chest pain, and disconnection of equipment.

Rationale: Timely intervention may prevent serious complications.

4. Anchor thoracic catheter to chest wall and provide extra length of tubing before turning or moving client.

Rationale: Prevents thoracic catheter dislodgment or tubing disconnection and reduces pain and discomfort associated with pulling or jarring of tubing.

5. Provide safe transportation if client is sent off unit for diagnostic purposes. Before transporting, check water-seal chamber for correct fluid level; presence or absence of bubbling;

and presence, degree, and timing of tidaling. Ascertain whether chest tube can be clamped or disconnected from suction source.

Rationale: Promotes continuation of optimal evacuation of fluid or air during transport. If client is draining large amounts of chest fluid or air, tube should not be clamped or suction interrupted

because of risk of accumulating fluid or air, compromising respiratory status.

6. Monitor thoracic insertion site, noting condition of skin and presence and characteristics of drainage from around the catheter. Change and reapply sterile occlusive dressing as needed.

Rationale: Provides for early recognition and treatment of developing skin or tissue erosion or infection.

7. Observe for signs of respiratory distress if thoracic catheter is disconnected or dislodged.

Rationale: Pneumothorax may recur or worsen, compromising respiratory function and requiring emergency intervention.