CARE OF THE HOSPITALIZED PERITONEAL DIALYSIS PATIENT

1
CARE OF THE HOSPITALIZED PERITONEAL DIALYSIS
PATIENT

• By Joni-Jill Tobrocke RN, CNN
• H.K. Freedman Renal Center
• C.V.P.H. Medical Center
• March 2007

2
Objectives

• The Learner will be able to
• Describe the basic principles of peritoneal
  dialysis (PD).
• Define steps required to complete a CAPD exchange
  using Baxters Ultrabag system.
• Describe methods for preventing infection when
  performing PD procedures.
• Describe the process for identifying treating
  peritonitis.
• Describe steps required to complete daily PD
  catheter exit site care.

3
Peritoneal Dialysis

• Is performed as an intracorporeal (inside the
  body) therapy making use of the peritoneal
  membrane.
• Is the process of cleaning the blood by using the
  lining of the peritoneal cavity (peritoneum) as a
  filter the peritoneum acts as a dialyzing
  membrane, permitting wastes from the body to
  cross it and empty into the instilled dialysate
  fluid .
• Is a type of dialysis usually done by the patient
  at home.

4
Types of Peritoneal Dialysis

• CAPD Continuous Ambulatory Peritoneal Dialysis
• Manual exchanges (approx. 30 Min. each) done
  approx. 4 times daily (1st thing in am, around
  lunchtime, around suppertime, and before bed).
• Utilizing Baxters ultrabag system.
• Aseptic technique mandatory in making all
  connections.

• APD Automated Peritoneal Dialysis
• Utilizes a machine to perform exchanges at night
  while the patient sleeps (8-10 Hrs on the
  machine).
• Provides greater daytime freedom.
• May or may not require 1 or 2 daytime exchanges
  also.
• Aseptic technique mandatory in making all
  connections.

5
Phases of Peritoneal Dialysis

• Fill
• Takes approx. 10 minutes.
• Usual volume is 2000 2500 mls.
• Dwell
• CAPD usually 4-6 Hrs during the day, and 8-10
  Hrs during the night.
• APD usually shorter dwells while sleeping and
  longer dwells during the day.
• Drain
• Takes approx. 20 minutes.
• Usual volume may be slightly less, the same as,
  or more than infused amt.
• Effluent (drained fluid) is normally clear
  (colorless or yellow).

6
Clearance Across the Peritoneal Membrane

• Waste products excess fluid move from the blood
  into the dialysate by diffusion osmosis.
• Fluid removal can be increased by increasing the
  amount of dextrose in the dialysate.
• Some medications will move across the membrane
  also.

Blood
Dialysate
Semipermeable Membrane
7
Access to The Peritoneum

• Considered the patients lifeline.
• Sterile technique required when connecting (or
  disconnecting) transfer set to catheter.
• Transfer set is clamped prior to opening to
  protect the PD catheter (strict aseptic technique
  is required when minicap is removed).

Twist Clamp
Transfer Set
Titanium Adaptor
Exit Site
Peritoneal Catheter
Minicap
All procedures requiring opening of the closed
system will be done by trained staff only
8
CAPD Exchange

• Aseptic technique mandatory in making all
  connections!
• Check dialysis orders for of dextrose, fill
  volume.
• Drained volume must be measured documented (a
  spring scale may be used).
• Dialysate should be warmed to body temperature
  using dry heat.

Baxters Ultrabag System Full Empty Bags
Connected by Tubing
9
Warming Dialysis Solution

• The PD solution will be heated to approximately
  body temperature using a dry-heat heating pad,
  which is used only for this purpose, set on low
• Any heating pad in use must have an inspection
  sticker attached before it is put into service

10
Intraperitoneal (IP) Medication

• If IP medications are prescribed, there is a
  strict sterile procedure to be followed. (At
  CVPH the pharmacists mix any IP meds)
• Some medications (i.e. Vancomycin, Tobramycin
  etc.) must be infused slowly (regulate by
  adjusting twist clamp on transfer set and/or
  lowering the IV pole).

11
Preparing for an Exchange

• Clean the work area.
• Gather supplies (Check expiration dates)
• Provide privacy, close doors / curtains, utilize
  Do Not Enter signs. (It is preferred that PD
  patients have private rooms. If they must share
  a room, the roommate must be free of infectious
  organisms).
• Fans / blowers must be turned off.
• Limit visitors (Anyone in room during an exchange
  must wear a mask).

12
Completing a Safe Exchange

• Follow the steps provided in the Baxter Ultrabag
  Aseptic Exchange Procedure step-by-step guide
  shown here and found in the Peritoneal Dialysis
  binder on R7.
• Proper hand washing using liquid antimicrobial
  soap is important prior to connecting and / or
  disconnecting the ultrabag.

13
Documentation

• Documentation
• All exchanges
• Exit Site care
• Daily weights CVPH utilizes a 24 Hour
  Peritoneal Dialysis Record to document.

14
PD Patients Are Knowledgeable

• Keep in mind that PD patients (or a caregiver),
  have been through extensive training and carry
  out their dialysis at home daily.
• They are protective of their lifelines, and
  will want to ensure that proper technique is
  used.
• If you get them the supplies they need, encourage
  them to carry out the exchange themselves if they
  are able.

15
Fluid Balance

• Fluid electrolyte balance must be maintained to
  prevent dehydration and/or fluid overload.
  Assess the patient for fluid volume status and
  obtain orders from the MD to adjust dextrose in
  dialysate if needed. Monitor
• Daily weights.
• Lung sounds.
• Presence of edema.
• Total I O (including and PD fluid
  balances).
• Blood pressure.
• Other SS of dehydration or fluid overload.

16
Catheter Care

• Exit site care will be done daily by the patient
  if able, or by trained staff.
• Scrub hands well.
• Examine exit site for SS of infection,
  irritation, or leakage if any, notify the
  nephrologist.
• Check the catheter connections They should be
  free from cracks, tears or leaks.
• Feel the catheter tunnel, report any swelling or
  pain.

17
Daily Exit Site Care

• Clean the skin around the catheter with a sterile
  gauze pad antibacterial soap (Start close to
  the catheter move out).
• Rinse well to remove all the soap.
• Dry the exit site area with a sterile gauze pad.
• Tape the tubing to the abdomen in a natural
  position to anchor/ immobilize it, protect it
  from trauma.
• If patient uses mupirocin ointment, obtain an
  order from MD, apply to exit site. If they use
  povidone-iodine prep pads, paint a 1 circle
  around the exit site allow to air dry.

18
Exit Site Care

• Apply a sterile gauze dressing ( if Pt. doesnt
  normally wear a dressing, they must wear one
  while in the hospital).
• Loop the catheter around tape again to secure
  it better.
• Repeat exit site care if exit becomes wet or
  soiled.
• Document any findings that site care was done.

19
Peritonitis in the PD Patient
CVPH has a protocol for peritonitis in the PD
patient which can be found in policy manager.

• Patients with peritonitis usually present with
  cloudy fluid and abdominal pain.
• Send the first cloudy drain bag to the lab for
  stat cell count w/ diff, gram stain culture.
• Prompt initiation of antibiotic therapy for
  peritonitis is critical to prevent complications
  limit damage to the peritoneal membrane. (If
  the patient has cloudy effluent Abd pain,
  antibiotic therapy should be initiated without
  waiting for confirmation of the cell count).
• The nephrologist on-call must be notified.

20
Abdominal Pain in Peritonitis

• Ranges from mild or even no pain to severe pain.
• The degree of pain is somewhat organism specific.
• If the patient is experiencing severe abdominal
  pain, rapid exchanges may be done up to two times
  to decrease pain (This delays initiation of
  antibiotics, should only be used in cases of
  extreme pain).
• In most cases, symptoms decrease rapidly after
  initiation of antibiotic therapy.
• Pain medications may be ordered PRN.

21
Peritonitis Continued

• Heparin 2000 units per bag is added (by the
  pharmacist) to dialysate when effluent is cloudy.
• Vancomycin should be infused over 45 minutes to
  prevent adverse reactions.
• Antibiotics must dwell in peritoneum for at least
  4 Hrs. (6-8 Hrs. preferred).
• Assess patient for possible source of infection
  (i.e. Catheter exit site, break in technique,
  recent contamination, constipation or diarrhea,
  cracks or leak in the catheter or transfer set).

22
Documentation

• Record assessment data in nurses notes.
• Record medications given.
• Notify Peritoneal Dialysis unit staff of
  peritonitis episode (so follow-up care can be
  arranged).

23
Emergencies

• Clamp tubing above disconnected area (nearer to
  the patient), immediately if system becomes
  disconnected, or if a leak is noted.
• Notify Nephrologist (prophylactic antibiotic
  orders may be needed).
• Stop any further instillation of fluid to the
  patient until a complete tubing change is made,
  and orders are received from the Nephrologist.

24
Miscellaneous

• Assess for alterations in blood glucose levels in
  diabetics from the use of dextrose-based
  dialysate.
• Check visually for changes in the appearance of
  the effluent with each exchange.
• If fibrin is present, an order can be obtained
  for the pharmacy to add heparin to the bags.
• If effluent is cloudy, Notify Nephrologist
  initiate peritonitis protocol.
• Document clarity of each exchange on PD flow
  sheet.
• Reinforce exit site dressing for newly inserted
  PD catheters. Do not remove original dressing
  unless trained to do so.
• Be alert to tubing getting kinked or caught under
  patient, which will prevent infusion or draining
  of dialysate.

25
Bibliography

• B. Piraino, et al., ISPD Guidelines/Recommendation
  s, Peritoneal Dialysis Related Infections,
  Recommendations 2005 Update.
• www.renalsource.com. Baxter Healthcare Corp.
  Introduction to Peritoneal Dialysis for Hospital
  Nursing Staff / 2004.
• CVPH Policy Manager
• Peritonitis Protocol in the Peritoneal Dialysis
  (PD) Patient.
• Protocol for PD Patient, Care of the Patient
  Receiving.
• Policy for CAPD exchanges.
• Procedure for PD Using the Manifold System.
• Catheter and Exit Site Care, Baxter Healthcare
  Corp. 2000.