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Troubleshooting non-infectious peritoneal dialysis issues.

Peritoneal dialysis is commonly preformed by patients and their caregiers in the home, in nursing homes, and in both acute and rehabilitation hospitals. The success of the therapy requires that the nurse overseeing the care of the patient on peritoneal dialysis in the acute, sub-acute, and chronic settings has the skills and knowledge to identify specific non-infectious issues, choose an appropriate and effective intervention activity, document the findings and outcomes, and educate the patient to assist in the resolution of the non-infectious issues, and avoid future recurrence. This, article reviews the most common non-infectious complications that occur in patients on peritoneal dialysis and discusses an organized clinical process to troubleshoot the issues and achieve the desired clinical outcomes.

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.

Conclusion

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


References/Readings

Bargman, J. M. (2000). Non-infectious complications of peritoneal dialysis. In R. Gokal, R. Khanna, R. Th. Krediet, & K.D. Nolph (Eds.), Textbook (peritoneal dialysis (2nd ed., pp. 609-646). London: Kluwer Academic Publishers.

Baxter Healthcare Corporation. (2003). The On-Call Baxter Program Deerfield, IL: Baxter Healthcare Corporation.

Baxter Healthcare Corporation. (2001). Peritoneal dialysis catheter and complications Management. IL: Baxter Healthcare Corporation.

Boeschoten, E.W. (2000). Continuous ambulatory peritoneal dialysis. In R. Gokal, R. Khanna, R. Th. Krediet, 86 K.D. Nolph (Eds.), Textbook of peritoneal dialysis (2nd ed., pp. 387-417). London: Kluwer Academic Publishers.

Borg, D., Shelly, A, Williams, M., & Faber, D. (2003). Fivefold reduction in peritonitis using a multifaceted continuous quality initiative program. Advances in Peritoneal Dialysis, 19, 202-205.

Farina, J. (2004). Peritoneal dialysis and intraperitoneal insulin: How much? Nephrology Nursing Journal, 31(2), 225-226.

Fried, L, & Piraino, B. (2000). Peritonitis. In R. Gokal, R. Khanna, R. Th. Krediet, & K.D. Nolph (Eds.), Textbook of peritoneal dialysis (2nd ed., pp. 545-564). London: Kluwer Academic Publishers.

Gokal, R. (2000). History of peritoneal dialysis. In R. Gokal, R. Khanna, R. Th. Krediet, & K.D. Nolph (Eds.), Textbook of peritoneal dialysis (2nd ed., pp. 1-17). London: Kluwer Academic Publishers.

Gokal, R., Alexander, S., Ash, S., Chela, T.W., Danielson, A., Holmes, C., Jofee, P., Moncrief, J., Nichols, K., Piraino, B., Prowant, B., Slingeneyer, A., Stegmayr, B., Twardowski, Z., & Vas, S. (1998). Peritoneal catheters and exit-site practices toward optimum peritoneal access: 1998 update. Peritoneal Dialysis International, 18(1), 11-33.

Guo, A., & Mujais, S. (2003). Patient and technique survival on peritoneal dialysis in the United States: Evaluation in large incident cohorts. Kidney International, 64(Suppl. 88), S1-S10.

Leehey, D.J., Gandhi, V.C., & Daugirdas, J.T. (2001). Acute peritonitis and exit site infection. In J.T. Daugirdas, P.G. Blake & T.S. Ing (Eds), Handbook of dialysis (3rd ed., pp. 373-404). Philadelphia: Lippincott Williams & Wilkins.

Hall, G., Bogan, A., Dries, S., Duffy, A.M., Green, S., Kelley, K, Lizak, H., Nabut, J., Schinker, V., & Schwartz, N. (2004). New directions in peritoneal dialysis patient training. Nephrology Nursing Journal, 31(2), 149-163.

Keane, W.F., Bailie, G.R., Boeschoten, E., Gokal, R., Golpher, T.A., Holmes, C.J., Kawaguchi, Y., Piraino, B., Riella, M. ,& Vas, S. (2000). Adult peritoneal dialysis related peritonitis treatment recommendations: 2000 update. Peritoneal Dialysis International, 20(4), 396-411.

Mehrotra, R., & Nolph, K.D. (2000). Current status of peritoneal dialysis. In R. Gokal, R. Khanna, R. Th. Krediet, & K.D. Nolph (Eds.), Textbook of peritoneal dialysis (2nd ed., pp. 19- 36). London: Kluwer Academic Publishers.

Mujais, S., Nolph, K., Gokal, R., Blake, P., Burkart, J., Coles, G., Kawaguchi, Y., Kawanishi, H., Korbet, S., Krediet, R., Linholm, B., Oreopoulos, D., Rippe, B., & Selgas, R., (2000). Evaluation and management of ultrafiltration problems in peritoneal dialysis. Peritoneal Dialysis International 20, S5-S21.

Prowant, B.F. (2001). Peritoneal dialysis. In L. Lancaster (Ed.), ANNA core curriculum for nephrology nurses (4th ed., pp. 363-375). Pitman, NJ: American Nephrology Nurses' Association.

Rubin, H.R., Fink, N.E., Plantinga, PL.C., Sadler, J.H., Kliger, A.S. & Powe, N.R., (2004). Patient ratings of dialysis care with peritoneal dialysis vs hemodialysis. JAM& 29(6), 697-701

Sahani, M.M.,Boorgu, R., Ing, T.S., Mukhtar, K.N., & Popli, S. (2000). Tissue plasminogen activator coal effectively declot peritoneal dialysis catheters. American Journal of Kidney Diseases, 36(3), 675.

Shetty, A., & Oreopoulos, D.G. (2000). February). Peritoneal dialysis: It's indications and contraindications. Dialysis & Transplantation, pp. 71-76.

Twardowski, Z.J., & Nichols, W.K. (2000). Peritoneal dialysis access and exit-site care including surgical aspects. In R. Gokal, R. Khanna, R. Th. Krediet, & K.D. Nolph (Eds.), Textbook of peritoneal dialysis (2nd ed., pp. 307-361). London: Kluwer Academic Publishers.

United States Renal Department of Health and Human Services. (2003). Atlas of end-stage renal disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disease. USRDS 2003 Annual Data Report. Bethesda, MD: United States Renal Data System.

Uttley, L. & Prowant, B.F. (2000). Organization of a peritoneal dialysis programme The nurse's role. In R. Gokal, R. Khanna, IL Th. Krediet, & K.D. Nolph (Eds.), Textbook of peritoneal dialysis (2nd ed., pp. 363-386). London: Kluwer Academic Publishers.
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Title Annotation:Continuing Education
Author:Maaz, Donna E.
Publication:Nephrology Nursing Journal
Geographic Code:1USA
Date:Sep 1, 2004
Words:6051
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