Troubleshooting non-infectious peritoneal dialysis issues.
Peritoneal dialysis (PD) has evolved from a procedure that used non-disconnect tubings and glass bottles (Gokal, 2000). In the past two decades, advances in technology have occurred, including disconnect continuous ambulatory peritoneal dialysis (CAPD) systems (1980s), new peritoneal catheter designs (1980s-1990s) (Keane et al., 2000), mad the exponential increase in the use of automated peritoneal dialysis (APD) (1990s-2000s) (Mehrotra & Nolph, 2000). The technical improvements that occurred in the early years of PD primarily impacted the reduction of infection (Keane et al., 2000).
In a recent study that examined greater than 30,000 patients initiating PD from 1999 to 2001, Guo and Mujais (2003) found that the majority of patients chose APD (59% 66%) over CAPD as their modality of choice. This trend demonstrates that in the United States, APD is becoming the mode of choice for PD. Guo and Mujais (2003) also observed that technique success was found to be higher in patients on APD than for patients on CAPD (see Figure 1). This was most apparent in the first year of dialysis. The authors further identified that the transfer rates to hemodialysis (HD) for patients on CAPD was highest in the first 6 months on the therapy. Guo and Mujais suggest that this "period of vunerability to technique failure may need to become a focus of interventional scrutiny" (Guo & Mujais (2003, p. S-6). Their observation is significant as the PD community strives to improve technique success and patient outcomes. If a patient leaves PD as a result of a transfer to HD or death, it is regarded as a technique failure (Guo & Mujais, 2003). Trans plantation is usually not included in data for technique failure (Mehrotra & Nolph, 2000). For the pro-pose of discussion in this article, PD technique failure will include transfer out of PD to HD only regardless of the reasons for transfer. PD technique survival is defined as the time that a patient will stay on PD vs. a transfer to HD. Some examples of reasons for transfer from PD to HD can be seen in Table 1.
[FIGURE OMITTED 1]
Guo and Mujais (2003) examined the effect of PD center size, mad found that as the dialysis center's percentage of patients starting dialysis on PD increased, technique failure rates decreased significantly. Centers that treated less than 20 patients had a higher rate of technique failure than programs with more than 20 patients. Shetty and Oreopoulos (2000) stated that PD programs that consistently manage 20 or more patients on PD have a better opportunity for the medical and nursing staff to gain experience in the therapy, be more familiar with the therapy innovations, and, therefore, be better able to support the patient on PD successfully. This illustrates how centers with less experience may have more challenges with providing optimat care for the patient on PD, thereby affecting patient outcomes.
Patient and/or caregiver training can have a critical impact on the clinical outcomes of a patient on PD. Keene et al. (2000) identified excellent patient education as a key component in improving peritonitis rates. When training patients on PD based on adult learning principles, Hall et al. (2004) were able to demonstrate improved patient outcomes. These positive outcomes included significant improvements ha peritonitis rates, normotensive blood pressure, maintaining target weight, higher KTV results, and fewer hospitalizations (Hall et al., 2004). In another study, Borg, Shetty, Williams, and Faber (2003) incorporated consistent patient retraining at 6 month intervals into their multifaceted improvement program to achieve a five-fold reduction in peritonitis.
Today, PD is a renal replacement therapy performed daily by thousands of patients or their caregivers in their places of residence. The United States Renal Data System (2003) identified that 26,510 patients were on PD in 2001. In a recent multi center study comparing patient satisfaction, 6.56 patients rated their dialysis care for PD and HD 7 weeks after starting dialysis. Eighty five percent (8.5%) of patients on PD reported their overall dialysis care to be excellent verses a 56% rating by patients receiving HD. The researchers concluded that clinicians should provide patients information about the option of PD (Rubin et al., 2004).
Baxter Healthcare Corporation's On Call Program is a data resource tool that tracks PD patient status over time, trends patient outcomes, and allows for program comparisons against the national Baxter average for quality improvement (Baxter Healthcare Corporation, 2003). In 2003, the On Call program data for the year identified that for those patients who transferred from PD to HD, non-infectious catheter complications accounted for 16% of the patient transfers, 9% resulted from peritoneal catheter infections and 21% from peritonitis (see Figure 2) (Baxter Healthcare Corporation, 2003). Non-infectious catheter complications include, for example, a nonfunctioning access (obstruction, migration, pulled out, removed), irreparable damage to the peritoneal catheter, or unresolved leaks (Baxter Healthcare Corporation, 2003). While peritonitis and exit site infections are frequently reported causes of technique failure, non-infectious issues are a common clinical focus in supporting the care of patients on PD. Patients on PD may experience a mechanical, system, access, or technical problem, often minor, frequently correctable, and possibly preventable. The minor technical issues are often resolved by the patient/caregiver, never reported, mad therefore not captured in facility data and tracking systems.
Non-infectious issues are frequently resolved when the knowledge of the PD system and procedures are understood. Troubleshooting the system includes evaluating the patient, the peritoneal catheter access, and the PD equipment that is being used to deliver the treatment. Occasionally, issues occur that cannot be resolved and require interruption of the therapy (Gokal et al., 1998).
Organanized Clinical Process Developed
The identification and resolution of non-infectious issues for PD require an organized clinical process to achieve the desired clinical outcomes. To assist in the troubleshooting of PD related non-infections issues, the following pathways (see Pathway Charts) consist of four components:
Key assessments: Identify major clinical findings.
Key activities: Identify key activities to obtain desired outcome.
Patient education: Provide patient/caregiver with the necessary education and/or tools to achieve the desired outcome.
Outcomes assessment: Use the continuous quality improvement process to track and trend to monitor and improve clinical outcomes.
By using these pathways as a guideline, PD nurses will have greatly increased their knowledge of the PD system and procedures. Thus, skills for identifying and resolving noninfectious issues related to PD therapy have improved while patient care has been greatly enhanced.
Troubleshooting Noninfectious PD Issues: Abdominal Discomfort Related to Peritoneal Dialysis (PD) During Fluid Inflow, Outflow or Dwell
Etiology: Noncatheter-Related: Intra-abdominal pressure increases in proportion to the volume of peritoneal dialysis (PD) fluid instilled into the peritoneal cavity (Bargman, 2000, p. 609). Abdominal discomfort due to distention is commonly seen when starting PD or increasing dialysis still volume. Rapid inflow of dialysis fluid, dialysis solution temperature, acidic PH of dialysis solutions, hypertonic solutions, and peritonitis are some of the causes seen in this patient population (Prowant, 2001).
Catheter-Related: Catheter-related pain may result when the catheter presses on the abdominal organs. Catheter-associated discomfort commonly occurs when PD catheter is first used (56%-75% of patients) (Twardowski & Nichols, 2000, p. 330). This often presents as pain or cramping at the end of drain when PD is initiated and usually resolves after a few months (Boeschoten, 2000). This effect is more common when the intraperitoneal portion of the catheter is straight than when a coiled tip catheter is used (Twardowski & Nichols, 2000, p. 319). Rectal pain can also occur with pressure from the PD catheter and when the intraperitoneal segment of catheter is too long (Prowant, 2001). Omental wrapping of the catheter may be indicated when catheter outflow pain is present (Twardowski & Nichols, 2000).
Indications: Patient complaint of epigastic distention, nausea, vomiting (Bargman, 2000, p. 621), pain, or cramping with infusion of new dialysis solution or during drain or continuous pain during dwell.
Troubleshooting Noninfectious PD Issues: Back Pain
Etiology: Altered spinal mechanics can result when dialysis fluid is instilled into the peritoneal cavity in the patient with weak abdominal muscle tone, poor posture, poor nutrition, or preexisting neuromuscular and skeletal diseases. Lumbar lordosis is amplified and the center of gravity is pushed forward (Prowant, 2001, p. 367).
Troubleshooting Noninfectious PD Issues: Pneumoperitoneum (Shoulder Pain)
Etiology: Pain related to free air under the diaphragm. This can occur in PD patients when air is infused into the peritoneum along with dialysis solution if tubing is not properly primed during the procedure. It can also result due to infusion pressure from a malpositioned PD catheter. When a PD patient presents with abdominal pain as well, a bowl perforation should be ruled out (Prowant, 2001).
Troubleshooting Noninfectious PD Issues: Leakage
Etiology. Dialysis fluid leaks from the peritoneal cavity into the abdominal wall, interstitial space with or without genital edema or infrequently into the pleural space
Early Leaks: Commonly presents as fluid drainage at the exit site or wound but can present as subcutaneous leak (Gokal et al.,1998), genital, scrotal, or penile edema (Baxter Healthcare Corporation, PD Catheter & Complications Management, 2001). Occurrence is less frequent when the PD catheter is placed through the rectus muscle (Twardowski & Nichols, 2000, p. 349). Patients at risk include patients with poor tissue healing, previous abdominal surgeries, and hernias as well as obese patients (Baxter Healthcare Corporation, 2001).
Late Leaks: Can occur months to years after the initiation of PD and present acutely subsequent to coughing, straining, or heavy lifting or chronically as a volume overload with decreased ultrafiltration and possibly a subcutaneous leak (Twardowski & Nichols, 2000, p. 349).
Troubleshooting Non-infectious PD Issues: Hydrothorax
Etiology: Dialysis fluid from the peritoneal cavity leaks into the pleural cavity due to a (congenital or traumatic) defect in diaphragm (Twardowski & Nichols, 2000) and increased peritoneal pressure (Bargman, 2000).
Indications: Dyspnea, chest pain, weight gain, decreased dialysis drain volumes, acute respiratory distress (Prowant, 2001). Unilateral pleural effusion in absence et volume overload and most common in women and on the right side (Bargman, 2000).
Troubleshooting Non-infectious PD Issues: Hernias
Etiology: Patients with congenital or acquired defect of or around the abdomen, increased abdominal pressure and abdominal wall tension due to the presence of dialysis fluid in the peritoneal cavity, leads to hernia formation in the PD population (Bargman, 2000, p. 609). The most common hernias are incisional, umbilical and inguinal. Incisional hernias occur more often when the PD catheter is placed through a midline approach rather than through the rectus muscle using a Para median approach (Gokal et al., 1998).
At Risk: Older female, multiparous patients and those who have had a leak after catheter placement or previous hernia repair (Bargman, 2000)
Troubleshooting Noninfectious PD Issues: Obstruction
Etiology: Most frequent in the first weeks following PD catheter placement (Gokal et al., 1998).
Inflow obstructions include: Mechanical blockage (clamps or kinks external or in subcutaneous tunnel) in transfer set; tubing or catheter; Post-implant clot/fibrin; Fibrin particularly with peritonitis; Catheter tip migration out of pelvis and catheter entrapment.
Outflow obstructions include: Mechanical blockage in transfer set or catheter, constipation, post- implantation blood clot or fibrin, fibrin, catheter tip migration out of the pelvis, catheter entrapment due to adhesions or omental wrap (Baxter Healthcare Corporation, 2001), and catheter hole occlusion due to pressure from adjacent organs (Gokal et al.,1998).
Troubleshooting Noninfectious PD Issues: Hemoperitoneum Blood in PD Fluid
Etiology: As little as 2 ml of blood in a liter of dialysis drain fluid can cause a blood-tinged appearance. Menstruation is a regular and benign cause of blood in the peritoneal cavity (Bargman, 2000, p. 626). Bleeding in PD is usually "minimal to moderate and resolves spontaneously" (Prowant, 2001, p. 367). Post-catheter insertion, blood-tinged drain fluid is common and usually resolves following several PD exchanges, severe bleeding post-insertion is rare (Twardowski & Nichols, 2000).
Causes include: PD catheter insertion without hemostasis, abdominal trauma, vessel perforation, catheter irritation, menstruation, ovulation, ovarian cysts, post-colonoscopy, colonoscopy or enema; peritonitis; abdominal or systemic diseases (Prowant, 2001).
Indications: Dialysis drain fluid is pink to red colored in appearance, bleeding may also occur at the exit site following PD catheter insertion. Bleeding that increases or does nor resolve is atypical (Prowant, 2001).
Troubleshooting Noninfectious PD Issues: Noninfectious Cloudy Effluent Peritoneal Eosinophilia
Etiology: Possible allergic response to PD catheter/plastic dialysis system, Intraperitoneal air introduced during laproscopic procedures or intraperintoneal air medications. Rarely due to fungal and parasitic infections. Peritonitis. PD fluid may appear cloudy due to fibrin presence or prolonged dwell (Leehey, Gandhi, & Daugirdas, 2001).
Troubleshooting Noninfectious PD issues: Hypervolemia
Etiology: Insufficient removal of fluid (ultrafiltration) related to: incorrect use of dextrose concentration, insufficient sodium removal, incorrect fluid balance calculations, (Prowant, 2001), incorrect dialysis prescription, patient compliance, mechanical problems of PD catheter, or peritoneal membrane related causes (Mujais et al., 2000). Excessive fluid intake and/or salt intake.
In Diabetic Patients: "Hyperglycemia can adversely affect the maintenance of an osmotic gradient across the peritoneal membrane" (Mujais et al., 2000).
Indications: Dialysis treatment records verify decreased ultrafiltration, weight gain, edema, dyspnea, elevated blood pressure, neck vein distention, pulmonary edema, congestive heart failure, tachycardia followed by bradycardia (Prowant, 2001).
Troubleshooting Noninfectious PD Issues: Hypovolemia
Etiology: Excessive fluid removal related to inappropriate use of hypertonic solution, of too much sodium removal, or incorrect fluid balance calculations.
Diminished fluid and salt intake in chronic patients, strict restrictions of sodium and fluid in the acute population (Prowant, 2001).
Indications: Weight loss below baseline, weight below target weight, excessive fluid removal on dialysis treatment records, hypotension, postural hypotension, poor skin turgor, dry mucuous membranes, tachycardia, and negative fluid balance on acute patient intake and output documentation (Prowant, 2001).
Troubleshooting Noninfectious PD Issues: Organ Perforation during PD Catheter Insertion
Etiology: Perforation or laceration of internal organs during PD catheter insertion. Most common with acute rigid catheter placement (Twardowski & Nichols, 2000).
At Risk: Patients with bladder distention or abdominal distention secondary to paralytic ileus, bowel obstruction, or constipation and adhesions (Prowant, 2001).
Indications: Sudden, sharp or severe abdominal pain followed by watery diarrhea and poor dialysis drain. Dialysis drain solution may be cloudy, mixed with fecal matter and foul smelling (Twardowski & Nichols, 2000
Troubleshooting Noninfectious PD Issues: Catheter Adapter Disconnect or Fracture of Peritoneal Catheter
Etiology: Disconnect--Catheter adapter is loose or disconnects from the peritoneal catheter.
Damage to Peritoneal Catheter or Transfer Set--Inadvertent trauma to peritoneal catheter (cut, tear, or hole), unsuitable disinfectants and soaps are used on the catheter, peritoneal catheter is defective, use of an incorrect size catheter adapter, using a syringe or similar object to pierce the catheter to take a dialysis fluid sample results in permanent catheter perforation, an inappropriate clamp (such as a hemostat with teeth) is used to clamp the catheter (Prowant, 2001).
At Risk for: Patients who use soaps or cleaners on the catheter that are caustic to the catheter material, patients who routinely bend catheter in the same position, patients who use scissors on or near the catheter.
Indications: Patient notes wetness on clothing or catheter, Dialysis drain volume is decreased, catheter has a distinct wear line, a crack or hole is evident, catheter distal portion is stretched out (Prowant, 2001).
ANSWER/EVALUATION FORM Troubleshooting Non-Infectious Peritoneal Dialysis Issues Donna E. Maaz, BSN, RN, CNN
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Donna E. Maaz, BSN, RN, CNN, is Clinical Educator, Baxter Healthcare, Renal U.S. She is a member of ANNA's Mass Bay Chapter.
Figure 2 The On-Call Baxter Program Data for 2004 Losses to Hemodialysis Other Medical 15% Psych 20% Catheter Infection 9% Catheter Problems 16% Inadequacy 14% Peritonitis 21% Other 5% Note: table made from pie chart. Table 1 The On-Call Baxter Program Data for 2003 Patient Loss: Reason Codes for Losses to Hemodialysis Peritonitis Catheter Infection Catheter Problems (non-Infectious) * Leaks * Obstruction * Migration * Pulled/Lost * Removed/Malfunction * Inadequate Dialysis Ultrafiltration Failure/Fluid Management Issues Other Medical * Physical Handicap * Transfer to Hemodialysis Until Transplant * Inadequate Dietary Intake * Low Serum Albumin * Albumin Loss * Respiratory Problems * Cardiac Problems * Diabetic Complications * Cancer * Stroke * Coma * Hernia * Digestive Tract Problems * Abdominal Surgeries * Gained or Lost Too Much Weight (not fluid related) Key Assessments Key Activities Observe dialysis exchange, For abdominal distention: inflow and outflow: * Treat constipation * Monitor dialysis outflow * Decrease dialysis fluid fill drainage (effluent) for volume when patient is color and clarity upright * Evaluate patient for the * Use larger dialysis fluid frequency and degree of fill volumes in supine or distention or discomfort partially reclining position * Check dialysis solution (Gokal et al., 1998) temperature * Consider automated * Rule out peritonitis peritoneal dialysis (APD) * Monitor and document the * Use weaker dextrose dextrose % and the amount concentration when of drain volume when the increasing dialysis fill patient complains of volume, In acute dialysis distention alternate dextrose if necessary (Prowant, 2001, p. 367) * Pro-motility drugs may be helpful (cisapride, erythromycin) (Bargman, 2000, p.621) Catheter related and non-related: * Change position during infusion or drain * Reduce dialysis infusion rate (lower IV pole, close transfer set clamp partially) * Ensure proper dialysis temperature-warm dialysis fluid to body temperature * Leave small amount of dialysis fluid in the patient, Tidal PD * Investigate PD catheter position- Flat plate of abdomen * Reposition PD catheter if unresolved * For extreme conditions: Intraperitoneal (IP) xylocaine 1% or bicarbonate may be considered (Boeschoten, 2000, p. 395) Patient Education Outcomes Evaluation For Abdominal Distention: Data collection to include: Instruct patient to: * Duration and degree of discomfort * Avoid upright positions * Interventions during exchanges when * Adjustments to dialysis initiating dialysis, supine prescription when possible * Patient tolerance * Avoid activities that * Medications prescribed and increase intra-abdominal patient tolerance pressure--including * Diagnostic tests and results constipation and straining (Uttley & Prowant, 2000, p. 376) * Eat during drain phase of exchange * Wear loose clothing with waistbands or suspenders * Eat frequent, smaller meals * Avoid foods that decrease esophageal sphincter control (chocolate, alcohol) (Bargman, 2000, p. 621) Catheter related and non-related: Teach patient causes and interventions: * Rapid inflow-reduce infusion rate - Too rapid a transition to larger dialysis fill volumes-slowly increase fill volumes - Dialysis solution too warm or too cold-warm to body temperature - Potential cause and interventions for PD catheter malposition - Peritonitis-prevention Key Assessments Key Activities * Document pain or discomfort Identify high-risk patients with altering patient dialysis solution fill * Exercise, no straining volumes * Good body mechanics * APD with reduced volume during the day as needed * Avoid constipation * Evaluation of musculoskeletal system if issue persists * Refer to rheumatologist or physiotherapist prn Patient Education Outcomes Evaluation Instruct the patient: Data collection to include: * To report pain or muscular * Duration and degree of discomfort discomfort * To increase dialysis * Adjustments to dialysis solution volume when supine prescription or schedule (especially new patient) * Interventions * Consider APD * Patient tolerance * Teach patient abdominal * Medications prescribed and strengthening exercises. patient tolerance Pelvic tilt exercises are * Diagnostic tests and appropriate in patients results on PD * Correct posture to minimize back strain (Bargman, 2000) Key Assessments Key Activities * Observe patient/caregiver's * Prime PD system according to exchange procedure to manufacturer's instructions verify adequate tubing * Rule out pain of cardiac priming is included origin * Patient complaint of * Assess for bowel perforation shoulder pain * To remove air: * Patient reports recent - Drain patient with infusion of air during elevated hips, knee- chest exchange procedure or Trendelenberg position following a full volume exchange - A flat plate of the abdomen to identify PD catheter position and identify free air in the peritoneal cavity - A chest x-ray will identify the presence of free air under the diaphragm Patient Education Outcomes Evaluation Proper priming procedure for Data collection to include: PD system * Diagnostic testing and * For manual systems, always results close clamps after infusion * Interventions of solution * Results of interventions * About positioning to remove air during exchanges * Avoid use of PD vented systems (Prowant, 2001) Key Assessments Key Activities Indicators: Increase clinic visit frequency * External fluid at wound or External leaks: exit site * Edema of abdomen/increased * Verify clear fluid at girth incision or exit site * Scrotal, penile or labial contains glucose, using edema glucose test strip * Decreased exchange drain * Document condition of exit volume site, subcutaneous cuff, * Decreased ultrafiltration tunnel and/or wound * Weight gain * Alter dressing change procedure to accommodate increased fluid drainage Subcutaneous leaks: * Monitor girth * Examine flank and back for subcutaneous fluid * Examine for scrotal, penile or labial swelling * Order/review abdominal (CT) Diagnostic work-up: * Peritoneography * Abdominal fluoroscopy with contrast * Abdominal scintigraphy Therapeutics: Dialysis therapy: * Initiate PD supine position, using low volume exchanges (500 to 1500 ml) prn * If required, use hemodialysis (HD) back up for 1-2 weeks In new patients who do not require dialysis immediately: * Delay PD for 2-3 weeks * For External Leak, restart PD with trained staff Invasive steps: * Persistent leaks may require surgical repair * Recurrent leaks may require catheter replacement Patient Education Outcomes Evaluation Alter dressing change Data Collection to Include: procedure and frequency * Type of catheter and * Report physical changes insertion technique indicating potential leak * Condition of exit/wound * Alter dialysis regimen if * Condition of subcutaneous required to lower cuff and tunnel intra-abdominal pressure * Type of leak following surgical * Diagnostic testing and correction results * Monitor for signs and * Interventions symptoms of exit site * Results of Interventions infection and peritonitis * Alteration in dialysis * More frequent clinic visits prescription are required for observation Note: Reprinted with permission from Baxter Healthcare Corportation (2001). Key Assessments Key Activities Signs and symptoms of Assess lung sounds pleural effusion * Observe for shortness of * Cough or shortness of breath breath or cough especially * Chest Pain supine * Weight gain * Stopping PD may lead to * Decreased dialysis drain resolution volumes * Temporary HD for 2-4 weeks * Small pleural effusion may may allow communication be symptom free to seal * Acute respiratory failure * Thoracentesis may be * Unilateral pleural effusion indicated with tetracycline, present on x-ray without talc, autologous blood or volume overload fibrin glue for correction * Glucose positive, low of the defect protein, pleural fluid on * Surgical repair (Prowant, thoracentesis 2001 * Isotope scanning to identify pleural-peritoneal communication Patient Education Outcomes Evaluation * Report physical changes Data collection to include: indicating potential leak * Alter dialysis regimen if * Type of leak required * Diagnostic testing and * More frequent clinic visits results are required for observation * Interventions * Response to interventions Key Assessments Key Activities Assess for swelling at Inspect and examine suspect umbilicus, groin, scrotum, locations labia or incision * Surgical referral * Evaluate for tenderness and * Schedule more frequent inflammation follow-up * Determine reducibility/ pain/size Therapeutics: * If incisional, review catheter placement procedure * All hernias ultimately requires repair * Following surgical repair consider APD with no daytime dialysis exchange * Initiate supine, intermittent low volume peritoneal dialysis 2-4 weeks post-repair Patient Education Outcomes Evaluation * Minimize intra-abdominal Data collection to include: pressure (straining, heavy lifting, stair climbing, * Type of hernia coughing, constipation) * Interventions * Report increase in size of * Response to intervention hernia or pain * Alterations in dialysis * Following repair instruct prescription or schedule patient to avoid cross contamination of exit site and wound dressings * Observe for recurrence Note: Reprinted with permission from Baxter Healthcare Corportation (2001). Key Assessments Key Activities Observe dialysis exchange * Examine PD catheter --fluid inflow and outflow (including the portion beneath patient's garments), Determine type of obstruction: transfer set and dialysis equipment tubing for clamps * One way (Outflow) or kinks. obstruction: Fluid will infuse but not drain Noninvasive steps: * Two way obstruction: Fluid does not infuse or drain * Eliminate kinks in transfer * Inflow obstruction: Pain on set and catheter inflow once compartment * Change body position volume is exceeded * Correct constipation (Mujais et al., 2000) * Obtain frontal and lateral x-ray of abdomen to visualize catheter and rule out constipation In case of fibrin-related obstruction: * Add heparin 500 to 2000 U/L to dialysis each exchange If unsuccessful: * Instill fibrinolytic agent into catheter * Dislodge blockage (to be performed only by experienced PD personnel) * Use a 50 ml syringe to infuse heparinized dialysis fluid or saline. Using moderate pressure, instill fluid into PD catheter then withdraw slowly. ("push and pull" maneuver) Discontinue procedure if patient notes pain or cramping. * Consider use of recombinant tissue plasminogen activator (tRA) (Sahini et al., 2000) Invasive steps: * Laparoscopy * Fluoroscopy with stylet manipulation or guided stiff wire * Open surgical repositioning of catheter, partial omentectomy or catheter replacement (Baxter Healthcare Corporation, 2001 Patient Education Outcomes Evaluation * Tape and anchor catheter Data collection to include: * Prevent constipation with diet exercise, stool * Type of Obstruction softeners * Diagnostic testing * Position tubing to prevent * Etiology kinking while sleeping on * Interventions APD * Response to Interventions * Provide patient/caregiver with written troubleshooting directions Key Assessments Key Activities * Observe dialysis exchange * For post-insertion blood drain fluid for color and tinged dialysis outflow: clarity * 200-1500 ml volume flush * Rule out peritonitis with heparinized dialysis * Obtain patient history, fluid or saline until drain investigate potential causes is clear (Gokal et al., to include menstruation, 1998 recent enema, sigmoidoscopy, *Add heparin 500-1,000 colonoscopy, episode of U/L to maintain patency abdominal trauma or (Gokal et al., 1998) abdominal disease * Observe drain fluid color with dialysis exchanges * Document number of days bleeding is noted and color changes * Check hematocrit (serum and dialysis) as needed * Consider investigating for peritonitis or other acute abdominal issue (Prowant, 2001) Patient Education Outcomes Evaluation * Instruct women of Data collection to include: reproductive age about the potential for hemoperitoneum * Interventions * Observe dialysis exchanges * Response to intervention drain fluid for decreasing * Alterations in dialysis color prescription or schedule Teach patient to: * Avoid heavy lifting/trauma * Document frequency, duration and treatment of bloody effluent * Heparin is not absorbed through the peritoneum so there is not an increased risk for bleeding (Kobert & Kronfol, 2001, p. 338) * Bleeding, typically minimal to moderate may resolve spontaneously (Prowant, 2001) Key Assessments Key Activities * Cloudy effluent * Culture PD drain fluid * Dialysis fluid cell count * Closely monitor patient is low status * WBC differential: * D/C intraperitoneal (IP) Neutrophils <50% antibiotics (antibiotics are Eosinophils >10% or not required) (Prowant, 2001 * Absence of abdominal pain, * Heparin when indicated fever or other signs and * Persistent cases may require symptoms of acute infection * Steroids/Antihistamines * Occurs within first 3 months of PD * Usually resolves spontaneously in 2-6 weeks Patient Education Outcomes Evaluation * Educate patient on the signs Data collection to include: and symptoms of infectious peritonitis * Interventions * Instruct patient to document * Response to interventions drain fluid clarity each exchange and report any change in status Key Assessments Evaluate: Key Activities * Weight (above target weight) * Use 2.5% or 4.25 % dextrose * Vital signs exchanges -- * Serum glucose * Shorten dwell time. * Lung sounds * Screen for reversible causes * Edema status of fluid overload * Cardiac status * If diabetic: control * Decreased urinary output hyperglycemia with * Dialysis treatment flow intraperitoneal and/or sheets for ultra-filtration subcutaneous insulin and dextrose concentration * Evaluate intake and output used * Restrict sodium/fluid intake * Accurate intake and output * Treat constipation (I & O) * Verify catheter position * Current antihypertensive and function regimen * Reevaluate target weight * Monitor weight closely * Monitor vital signs * Monitor cardiac and respiratory status * Reevaluate dialysis prescription suitability for peritoneal membrane category * Use alternative osmotic agent/ Icodextrin for long dwell * Consider routine use of loop diuretics (Mujais et al., 2000) * Reevaluate peritoneal membrane transport type if not responding to interventions * Preserve residual renal function (avoid nephrotoxic agents like aminoglycosides, nonsteroidal anti-inflammatory drugs and radio contrast dye (Mujais et al., 2000) * Preserve peritoneal membrane function, prevent peritonitis (Mujais et al., 2000) Patient Education Outcomes Evaluation Instruct patienVcaregiver Data Collection to include: about causes of fluid overload: * Interventions * Response to interventions Inadequate ultrafiltration * Alterations in dialysis related to: prescription * Decreased output * Increased fluid intake * Increased sodium intake * Inappropriate dextrose regimen for several exchanges * Decreased insensitive losses secondary to seasonal temperature changes (Prowant, 2001) Provide patient/caregiver with written instructions for: * Appropriate dextrose concentration use according to weight, blood pressure and volume status * Dietary counseling for salt and fluid intake * Signs and symptoms of volume overload and dehydration * Instruct patient to document dextrose use, weight changes and symptoms on flow sheet. * If diabetic: educate patient on need to avoid hyperglycemia Key Assessments Key Activities Evaluate: * Use 1.5 % dextrose exchanges * Lengthen dwell times * Weight (Below target weight) * Increase salt and fluid * Vital signs intake (temporarily) * Blood pressure sitting and * Measure I & O standing * IV fluid and sodium replace * Cardiac status for if necessary tachycardia * Re-evaluate target weight * Skin turgor * Document prescription * Dialysis flow sheets for changes ultra-filtration and * Monitor weight closely dextrose usage * Monitor vital signs closely * Accurate I&O * Reevaluate target weight * Current anti hypertensive regimen Patient Education Outcomes Evaluation Instruct patient/caregiver Data collection to include: about causes of dehydration * Interventions * Increased output * Response to interventions (residual and dialysis * Alterations in dialysis ultrafiltration) prescription * Decreased fluid intake * Decreased sodium intake * Inappropriate dextrose regimen for several exchanges * Increased insensitive losses secondary to seasonal temperature changes (Prowant, 2001) Provide patient/caregiver with written instructions for: * Appropriate dextrose concentration use according to weight, blood pressure and volume status * Dietary counseling for salt and fluid intake * Signs and symptoms of dehydration * Instruct patient to document dextrose use, weight changes and symptoms on flow sheet. Key Assessments Key Activities * Verify the presence of * Monitor vital signs glucose in urine or feces * Discontinue peritoneal with dipstick dialysis * Diagnosis based on signs * Arrange surgical consult and symptoms * Drain bladder if bladder * Document condition perforation prn (Prowant, 2001) * Antibiotic therapy * Observe for peritonitis Patient Education Outcomes Evaluation * Provide patient with written Data collection to include: preoperative and postoperative instructions * Type of peritoneal catheter * Arrange for preoperative * Intervention bowel preparation * Type of perforation * Provide emergency medical * Response to intervention contact information * Patient outcome Key Assessments Key Activities * Observe for dialysis fluid For adapter disconnect or leak from peritoneal catheter fracture: catheter or transfer set * Observe for peritonitis * Stop dialysis * Initiate prophylactic * Clamp catheter proximal to antibiotics damage * If catheter length is adequate, Use sterile technique to: * Disinfect catheter above the damaged area * Trim catheter above expanded area on catheter or fracture * Using sterile scissors trim the catheter above the area that is damaged or stretched * Fit a sterile, new adapter into the catheter (Prowant, 2001 * Attach transfer set to adapter If catheter portion is marginal length: * Repair with appropriate manufacturer's repair kit or catheter extension Patient Education Outcomes Evaluation Instruct patient to: Data collection to include: * Stop dialysis * Type of peritoneal catheter * Clamp catheter proximal to * Intervention damaged spot * Type of perforation * Cover area with sterile * Response to intervention dressing * Patient outcome * Go to clinic or emergency room as soon as possible Teach patients to: * Secure catheter and transfer set under clothing avoiding sharp bends in catheter * Keep sharp objects and tools away from catheter * Avoid using unsuitable disinfectants and soaps on catheter * Use only clamps provided on catheter
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|Title Annotation:||Continuing Education|
|Author:||Maaz, Donna E.|
|Publication:||Nephrology Nursing Journal|
|Date:||Sep 1, 2004|
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