Practice Question # 563.
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- Question 1 of 1
A client is admitted with complaints of severe pain in the right lower quadrant of the abdomen. To assist with pain relief, the nurse should take which of the following actions?Correct
Answer & Rationale:
The Answer is 4
Use comfort measures and pillows to position the client—CORRECT: non-pharmacological methods of pain relief.Incorrect
Answer & Rationale:
The Answer is 4
Use comfort measures and pillows to position the client—CORRECT: non-pharmacological methods of pain relief.
- Peritoneal irritation during inflow commonly causes pain during the first few exchanges; the pain usually disappears after 1 to 2 weeks of dialysis treatments.
- Warm the dialysate before administration using a special dialysate warmer pad, because the cold temperature of the dialysate can cause discomfort.
Abdominal Pain Cheat Sheet
Abnormal outflow characteristics indicative of complications
- Bloody outflow after the first few exchanges indicates vascular complications (the outflow should be clear after the initial exchanges).
- Brown outflow indicates bowel perforation.
- Urine-colored outflowindicates bladder perforation.
- Cloudy outflow indicates peritonitis.
- The main cause of insufficient outflow is a full colon; encourage a high-fiber diet, because constipation can cause inflow and outflow problems. Administer stool softeners as prescribed.
- Insufficient outflow may also be caused by catheter migration out of the peritoneal area; if this occurs, an x-ray will be prescribed to evaluate catheter position.
- Maintain the drainage bag below the client’s abdomen.
- Check for kinks in the tubing.
- Check for fibrin clots in the tubing and milk the tubing to dislodge the clot as prescribed.
- Change the client’s outflow position by turning the client to a side-lying position or ambulating the client.
Leakage around the catheter site
- Clear fluid that leaks from the catheter exit site will be noted.
- It takes 1 to 2 weeks following insertion of the catheter before fibroblasts and blood vessels grow into the catheter cuffs, which fix it in place and provide an extra barrier against dialysate
- leakage and bacterial invasion.
- Smaller amounts of dialysate need to be used; it may take up to 2 weeks for the client to tolerate a full 2-L exchange without leaking around the catheter site.
Changes in appetite or weight, difficulty swallowing, dietary intake, intolerance to certain foods, nausea or vomiting, pain, bowel habits, medications currently being taken, history of abdominal problems or abdominal surgery
- Ask the client to empty the bladder.
- Be sure to warm the hands and the end piece of the stethoscope.
Examine painful areas last.
When performing an abdominal assessment, the specific order for assessment techniques is inspection, auscultation, percussion, and palpation.
- Contour: Look down at the abdomen and then across the abdomen from the rib margin to the public bone; describe as flat, rounded, concave or protuberant.
- Symmetry: Note any bulging or masses.
- Umbilicus: Should be midline and inverted
- Skin surface: Should be smooth and even
- Pulsations from the aorta may be noted in the epigastric area, and peristaltic waves may be noted across the abdomen.
- Performed before percussion and palpation, which can increase peristalsis.
- Hold the stethoscope lightly against the skin and listen for bowel sounds in all four quadrants; begin in the right lower quadrant (bowel sounds are normally heard here).
- Note the character and frequency of normal bowel sounds: high-pitched gurgling sounds occurring irregularly from 5 to 30 times a minute.
- Identify as normal, hypoactive, or hyperactive (borborygmus).
- Absent sounds: Auscultate for 5 minutes before determining that sounds are absent.
- Auscultate over the aorta, renal arteries, iliac arteries, and femoral arteries for vascular sounds or bruits.