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 Baxter’s 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. 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 Baxter’s 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. Types of Peritoneal Dialysis

5. Phases of Peritoneal Dialysis • Fill • Takes approx. 10 minutes. • Usual volume is 2000 – 2500 ml’s. • 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. Baxter’s 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 weightsCVPH 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 S&S 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 S&S 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. doesn’t 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/Recommendations, 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.