Question

Joni Winters, a 64-year-old female client, is admitted with a fractured hip. She has chronic renal failure and has continuous peritoneal dialysis (CAPD) exchanges every 6 hours. The Tenckhoft peritoneal catheter site has redness, which goes across the abdomen. The client states that her abdomen is tender to touch all over, and the nurse notes the abdomen is rigid. The bowel sounds are decreased, and the peritoneal dialysate is in the dwelling phase of the cycle. The vital signs are T, 101°F; BP, 140/90 mm Hg; HR, 110 beats/minute; RR, 28 breaths/minute. The client asks the LPN/LVN to provide the peritoneal dialysis because she has a broken hip and cannot manage it. What additional nursing assessment is needed before reporting the findings to the RN and the physician? (Provide detailed response, inclusive of what you as the nurse will DO)?

Answer 1

The additional nursing assessment which can be done are

• Redness ,tender,hematoma ,pedal pulse, cyanosis of toe at the site of fracture to rule out the circulatory pattern of the leg
• Assess for numbness or loss of sensation,alteration in the range of motion can occur due to any damage in centra central nervous system.
• Past and present medical and surgical history
• Allergic history (diet and drugs)
• Lifestyle (smoking, alcohol, drugs,tobacco, etc.,)
• Fatigue to rule out any malnutrition or deficiency of protein in the diet (to plan for the type of diet to be followed)
• Record the intake and output as it is the baseline to plan for care
• Hygienic status of the patient has to be assessed to prevent infection (meticulous hand washing, infection control practice)
• Blood glucose and oxygen saturation level has to be recorded
• Bowel habits has to be collected
• Usage of snt current medication to make a decision whether to be continued or not.
• Educate the patient about the basic care which will be provided by the LPN.