Nursing Care Plan for Patients undergoing Peritoneal Dialysis

PERITONEAL DIALYSIS

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• replaces the jobs your kidneys can no longer do

• works inside the body and uses own peritoneum

• involves introduction of dialysis fluid into the peritoneal cavity using the PERITONEUM to filter and clean the blood

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PERITONEAL FLUID

• the dialysis solution has sugar called glucose

• 1.5% – weak solution

• 2.5% – medium solution

• 4.25% – strong solution

THE EXCHANGE PROCEDURE

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TYPES OF PERITONEAL DIALYSIS

• Intermittent Peritoneal Dialysis

– Acute

– Chronic

• Continuous Ambulatory Peritoneal Dialysis

• Automated Peritoneal Dialysis

INTERMITTENT PERITONEAL DIALYSIS

• PD that last within 48 – 72 hours

• could be done manually or with the use of cycler machines

• requires hospitalization

• interrupted sequence of PD

• greater risk of infection

• makes use of either a permanent catheter or a temporary catheter

CONTINUOUS AMBULATORY PERITONEAL DIALYSIS ( CAPD )

• done regularly 3 or 4 or 6 times daily

• no need for hospitalization (home dialysis)

• makes use of a permanent catheter

• feeling of well being

• allows freedom of movement

• lesser incidence of infection

AUTOMATED PERITONEAL DIALYSIS

• APD is a new treatment method that is performed at home, at night while you sleep, using a cycler machine

• primary method of APD is CCPD (Continuous Cycling Peritoneal Dialysis)

• patient can go about his daily activities

WHICH PATIENT ARE SUITABLE FOR PD?

• suitable for all ESRD patients

• strongly indicated in patients

1. medical

– unstable CV disease

– increased intracranial pressure

– difficult to establish vascular access

CONTRAINDICATIONS FOR Peritoneal Dialysis

Medical

– severe inflammatory bowel disease(acute active diverticulitis, active ischemic bowel disease, abdominal abscess)

Psychosocial

– severe active psychotic disorder or manic depressive

– marked intellectual disability with no helper

Important Reminders:

• Clean work surface

• Put on face mask and wash hands thoroughly

• Check the S C A L E of the solution bag

• Strength

• Clarity of solution

• Amount

• Leak in solution bag

• Expiration date

The areas where germs are most likely to enter the peritoneum

  1. The connection between PD catheter and titanium adaptor
  2. The connection side between transfer set and TwinBagTM
  3. Exit site/ Tunnel
  4. When doing exchange/ ES care
  5. Defective product

INFECTIOUS COMPLICATIONS

1. Peritonitis

– inflammatory condition of the peritoneum caused by a microbial insult that gain access to the cavity

INDICATORS

• Sign & symptoms of peritoneal inflammation ( abdominal tenderness and rigidity )

• cloudy peritoneal fluid (wbc >100/ul,N>50%)

•  demonstration of bacteria (by GS or culture)

•  (2 out of the 3 criteria)

Causes:

• break in PD technique causing touch or airborne infection

• Tunnel infection

• infection migrated from catheter exit site

• infection from the lumen of the catheter

Nursing actions and Plan

• allow at least 4-hour dwell before submitting specimen (cell count and CS)

• check exit site for the presence of infection (send specimen for Effluent Specimen for Culture Sensitivity if discharge is present)

• if patient on CAPD, assess if the patient needs to be admitted

• while waiting for the results of dialysate culture cover patient with the ff antibiotics

– 1st gen. cephalosporin PO (gram +)

– aminogly IP or quinolones PO (gram –)

• once dialysate fluid cultures result are available adjust the antibiotics as necessary

• HEPARIN may be added only if there is fibrin and the dialysate fluid remains cloudy (300 – 1000 u/exc)

2. Exit Site Infection

– infection of the skin surrounding the peritoneal dialysis catheter

S/S

• Erythema >10mm around catheter site

• Exudate from the exit site

• Positive culture from the exudate

• ( 2 out of the 3 criteria )

Nursing actions

• once Exit Site Infection is already diagnosed, send a specimen for CS

• do frequent exit site care and use non-occlusive dressing

• apply mupirocin or fucidin ointment to exit site every change of dressing

PD Exchange

The place for dialysis exchange should be:

• Clean

• Free from drafts/dust

• Well lit

• No distraction

• No pet

Preparation:

1. Wear mask。

2. Close door and windows, and clean the table

3. Remove dialysis bag from overpouch

4. Remove transfer set from clothing

5. Wash hands

6. Check solution bag

Expiration date, Concentration, Volume, Connection cap,Tubing, Frangible, Leakage,

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Keep free from contaminants

(1) Patient connection end of Twin Bag

(2) Inside of disconnect cap.

(3) Patient connection of transfer set

Dispose the drained effluent and the used equipment properly

  • Drain out the effluent  into the toilet.
  • Roll up the line and bag
  • Put bundled TwinBag to trash bag.
  • Wash hands after completingthis procedure
  • Dispose as regulargarbage

Long term Exit Site Care
Why it’s important? Prevent infection
It includes care of the site and checking the area every day.

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1. Remove and throw away old dressing

2. Wash hands

3. Examine ES and tunnel

4. Clean around the catheter with antibacterial liquid soap using sterile cotton swab/ 4X4 gauze. Clean from the catheter outward in circular motion, then rinse with tape water / sterilized NS

5. Pat the skin dry with sterilized cotton swab/ 4×4 pad.

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6. Apply Povidone-Iodine

7. Wait one minute for dry

8. Remove Povidone-Iodine with sterile N.S. to avoid skin stain

9. Dry the ES and skin around the catheter

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10. Cover ES with sterilized 4X4 gauze and tape it securely.

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Peritoneal Dialysis Nurse

• Plays a central role in organizing and administering the PD program

• Coordinates the administrative and clinical aspects of the program

Administrative Responsibilities

• Training and re-training of PD patients

• Coordinating the refinement of treatment protocols

• Record keeping and documentation

• Coordinating with other members of the team regarding patient care and management

Clinical Responsibilities

Pre-Dialysis Patients:

1. Assess pt. for modality selection and inform nephrologist of recommendation

2. Inform eligible patients of PD options,benefits and limitations

3. Pre-operative care for catheter insertion

For the Hospitalized Patient:

1. Pre-Operative teaching

2. Documenting and overseeing post-op care for the catheter

3. Arrangement for back-up dialysis

4. Discharge instructions

Prior to and During Training:

1. Consultation with physician and appropriate PD system and products

2. Patient training and modification of training tools to ensure effective training

For the patient at Home:

1. Patient follow-up(phone Calls)

2. Patient clinic visits

3. Home visits

4. Continuing assessment and education of the patient

5. Coordination of patient care

Key Responsibilities

• Patient training and re-training

• Patient clinic visits

• Starting a patient ( includes home visit)

• Development of training procedure

• Patient care coordination

• Care of hospitalized patient

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Posted in Nephrology, Nursing Care Plans, Nursing Intervention, Urology

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