Clinical Procedure                                                      Page 1 of 12
Clinical Manual / Nursing Practice Ma...
Clinical Procedure                                                       Page 2 of 12
Clinical Manual / Nursing Practice M...
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Clinical Manual / Nursing Practice Ma...
Clinical Procedure                                                        Page 4 of 12
Clinical Manual / Nursing Practice ...
Clinical Procedure                                                       Page 5 of 12
Clinical Manual / Nursing Practice M...
Clinical Procedure                                                       Page 6 of 12
Clinical Manual / Nursing Practice M...
Clinical Procedure                                                      Page 7 of 12
Clinical Manual / Nursing Practice Ma...
Clinical Procedure                                                      Page 8 of 12
Clinical Manual / Nursing Practice Ma...
Clinical Procedure                                                       Page 9 of 12
Clinical Manual / Nursing Practice M...
Clinical Procedure                                                     Page 10 of 12
Clinical Manual / Nursing Practice Ma...
Clinical Procedure                                                     Page 11 of 12
Clinical Manual / Nursing Practice Ma...
Clinical Procedure                                                        Page 12 of 12
Clinical Manual / Nursing Practice...
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Microsoft Word - Peritoneal Dialysis - Acute, Stay Safe CAPD ...

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Microsoft Word - Peritoneal Dialysis - Acute, Stay Safe CAPD ...

  1. 1. Clinical Procedure Page 1 of 12 Clinical Manual / Nursing Practice Manual John Dempsey Hospital PROCEDURE FOR: Peritoneal Dialysis: Acute, Stay-Safe CAPD exchange procedure POLICY: 1. The initiation and maintenance of peritoneal dialysis will be performed by an RN or LPN who has been trained in continuous ambulatory peritoneal dialysis (CAPD). Patients may participate in their own peritoneal dialysis under the direct observation of the RN or LPN. 2. The system is maintained using aseptic technique and according to the written orders of the Licensed Independent Practitioner (LIP). 3. Exit site care is done daily. 4. Patients who are admitted with or develop peritonitis will have their transfer (extension) set changed according to the procedure listed below. Transfer sets will also be changed for non-peritonitis patients under the direction of the renal physician. 5. Masks must be worn by all personnel, including the patient, when examining the dialysis catheter exit site. EQUIPMENT: Dialysis solution - 2 liter bags (Stay-Safe solution with pre-attached tubing) Transfer set (if applicable) Stay-Safe Smart Cap (if applicable) Peritoneal Dialysis (PD) Flowsheet IV pole Stay-Safe Cap Stay-Safe organizer Peritoneal Dialysis Scale Mask Medication additive label (if applicable) CAPD warmer Betadine (if adding meds) Tubing to catheter adapter (if applicable; used if tubing brand differs from catheter brand. In emergency situations, adapters are also available in the Hemodialysis Unit.) PROCEDURE: ACTION POINTS OF EMPHASIS PREPARATION:
  2. 2. Clinical Procedure Page 2 of 12 Clinical Manual / Nursing Practice Manual John Dempsey Hospital PROCEDURE FOR: Peritoneal Dialysis: Acute, Stay-Safe CAPD exchange procedure ACTION POINTS OF EMPHASIS 1. Obtain LIP orders for solution, additives, dwell time, drainage time, frequency of exchanges. Gather all supplies needed for the exchange. 2. Have patient empty bladder. 2. If new onset of inability to void, notify LIP. 3. Place solution in CAPD warmer (37o 3. Place solution in the warmer C) to achieve body temperature. 30 to 90 minutes prior to commencing procedure to assure optimum temperature of fluid (37o C). Use only dry heat to warm. Do NOT warm solution in the microwave. 4. If initiating dialysis for the first 4. Weight recorded must be a dry time, weigh patient prior to weight. beginning CAPD exchange. For established dialysis patients, weigh patient after draining and before filling (dry weight) procedure. If daily weights are ordered, weigh at the same time each day after complete drainage. 5. Assess abdomen for bowel distention, 5. With bowel distention there is skin integrity and S/S of local an increased risk of bowel infection. Notify LIP for any perforation. Local infections changes. may be easily transmitted to the peritoneum via the catheter. 6. Obtain and record vital signs. INITIATION OF DIALYSIS: 1. Remove the appropriate dialysate bag 1. The CAPD warmer is not always from the CAPD warmer, and place it located in the patient’s room; on a clean towel on the patient’s some units have a designated bedside table. location for the warmer.
  3. 3. Clinical Procedure Page 3 of 12 Clinical Manual / Nursing Practice Manual John Dempsey Hospital PROCEDURE FOR: Peritoneal Dialysis: Acute, Stay-Safe CAPD exchange procedure ACTION POINTS OF EMPHASIS 2. A simple check should be made of the following points: a. Proper Dextrose strength and amount of solution b. Proper labeling; expiration date c. CAPD warmer temperature d. Level of solution in each bag/appearance of solution (clarity) e. Maintenance of aseptic technique f. Inspect bag for leaks 3. Put on mask. Have patient put on mask. Scrub hands thoroughly with disinfectant soap. 4. Put on non sterile gloves. 4. Sterile gloves are not necessary unless you will actually be touching the catheter tip. 5. If medications/additives are 5. Some additives may be high ordered, cleanse additive port of alert medications and may require dialysate bag and medication port a double check. with betadine swab. Allow to dry for 5 minutes. Inject prescribed medication into dialysate bag and label properly. 6. Verify that a transfer set is on the 6. Patients who typically use catheter. If not, apply a transfer set Baxter supplies at home will using aseptic technique. CLOSE the need a transfer set. Attach extension set clamp. Smart-Cap per Smart-Cap transfer procedure and attach 7. Find the Stay-Safe disc (on the dialysate bag/tubing) with the colored plastic cover. Turn the blue dial on the disc counter-clockwise
  4. 4. Clinical Procedure Page 4 of 12 Clinical Manual / Nursing Practice Manual John Dempsey Hospital PROCEDURE FOR: Peritoneal Dialysis: Acute, Stay-Safe CAPD exchange procedure ACTION POINTS OF EMPHASIS until it fits into the cut-out portion of the plastic cover. 8. Remove the plastic cover after the dial is in the cut-out. The Blue dial will be at Position 1 (•). 9. Position the organizer at the edge of the work surface or on the IV pole. Place the disc into the organizer. 10. Hang the dialysate solution bag on 10. Breaking the frangibles will an IV pole and place the drain bag permit the fluid to flow. on a clean chux or towel on the floor. Break the frangible in the solution bag outlet port. 11. Remove the Stay-Safe cap from its package and place the cap in one of the two notches in the bottom-front of the organizer. 12. Place the end of the patient’s extension set in the other organizer notch. 13. Remove the protective cap from the 13. Use care not to contaminate Stay-Safe disc. Discard the cap. the end of the transfer set. 14. Unscrew the extension set from its 14. If the extension set is cap - the cap will remain in the contaminated, a tubing change organizer. must be done. 15. Immediately connect the extension 15. After making this connection set to the Stay-Safe disc. you may remove your mask. 16. OPEN the clamp on the extension 16. This will begin the drain set. Fluid will start to drain phase. Take note of the time from the patient as soon as the the drain phase started, and clamp is opened. record this on the peritoneal dialysis flowsheet.
  5. 5. Clinical Procedure Page 5 of 12 Clinical Manual / Nursing Practice Manual John Dempsey Hospital PROCEDURE FOR: Peritoneal Dialysis: Acute, Stay-Safe CAPD exchange procedure ACTION POINTS OF EMPHASIS 17. Check the drain bag to make sure there is fluid in it. 18. When the drain is complete, turn 18. Record on the peritoneal the dial to Position 2 (••). Make diaylsis flowsheet the time sure the line/tubing from the the drain phase was solution bag to the disc fills completed. This is also the completely. time to obtain the patient’s “dry” weight” (after drain but before fill). 19. After about 5 seconds, turn the 19. Record on the peritoneal dial to Position 3 (•••). This dialysis flowsheet the time will start the fill into the the fill phase was initiated. abdomen. This will help ensure accurate time for dwelling in the peritoneal cavity. 20. When draining has stopped, and 20. This is “volume out”- on the filling has begun, weigh the peritoneal dialysis drainage bag on the peritoneal flowsheet. dialysis scale. 21. If the physician order is for any 21. Example: If the physician amount less than the full 2000 ml order is for 1500 ml of bag of dialysate: dialysate, but the dialysate in the bags is 2000 ml, then a. Close the white clamp on the 500 ml must be removed from transfer set. the fill bag prior to draining into the patient. b. Turn the dial to Position 3 (•••). If no sample is needed then run excess volume into the drain bag prior to beginning fill. When bag is weighed, subtract excess volume. If a sample is needed then the nurse will need to monitor the volume infused while standing at the bedside, ensuring that the patient only gets the volume
  6. 6. Clinical Procedure Page 6 of 12 Clinical Manual / Nursing Practice Manual John Dempsey Hospital PROCEDURE FOR: Peritoneal Dialysis: Acute, Stay-Safe CAPD exchange procedure ACTION POINTS OF EMPHASIS ordered. c. Allow the excess dialysate (the amount greater than what was ordered) to drain into the drain bag. d. Once excess fluid is removed from the fill bag, turn dial back to the 1st position (•) unlock white clamp on transfer set, then turn dial to the 3rd (•••) position to allow abdominal filling. 22. When the fill is complete, turn the 22. This will insert the closure dial to the very end of Position 4 pin from the disc into the (••••). end of the extension set. You will feel a “click” when you get to the last position. 23. CLOSE the extension set clamp. 24. Unscrew the protective cover from 24. See step 10 above. the new Stay-Safe Cap. 25. Unscrew the extension set from the disc- IMMEDIATELY attach the extension set to the new Stay-Safe cap. 26. Remove the capped extension set from the organizer and secure to the patient’s abdomen. 27. Place the protective cover from the new Stay-Safe cap on the used cap. Then remove the cap from the organizer and connect the other end of the protective cover to the disc to prevent drips.
  7. 7. Clinical Procedure Page 7 of 12 Clinical Manual / Nursing Practice Manual John Dempsey Hospital PROCEDURE FOR: Peritoneal Dialysis: Acute, Stay-Safe CAPD exchange procedure ACTION POINTS OF EMPHASIS 28. If not done earlier in the exchange (step #19), weigh and record the volume of solution drained using the peritoneal dialysis scale. 29. Empty the drain bag into the 29. Follow Universal Precautions. toilet. 30. Discard used supplies and record 30. Used supplies should be the exchange on the flowsheet: discarded in a biohazardous Volume In: (bags are 2,000 ml but container. LIP order may be for a smaller volume) Volume Out: This will be blank for the first exchange. Additives: Medications or electrolytes. Balance: Patient is in negative balance when outflow exceeds inflow for the complete exchange. Patient is in positive balance when outflow is less than inflow for that exchange. 31. Second exchange: repeat steps and 31. Record 24 hour cumulative continue per LIP order for balances on the peritoneal frequency. dialysis flowsheet. Draw a line separating each 24 hour balance. Begin a new 24 hour cumulative balance very day with the first exchange after midnight. TRANSFER SET CHANGE: Using Smart Cap EQUIPMENT: Sterile field Smart Cap Blue Clamp Cap Sterile gloves Mask New transfer/extension set
  8. 8. Clinical Procedure Page 8 of 12 Clinical Manual / Nursing Practice Manual John Dempsey Hospital PROCEDURE FOR: Peritoneal Dialysis: Acute, Stay-Safe CAPD exchange procedure ACTION POINTS OF EMPHASIS Sterile 4x4 Gauze 1. Wrap gauze around proximal part of 1. Prevents contamination and catheter and clamp with blue clamp. outflow of fluid from patient peritoneum. Prevents catheter damage. 2. Prepare sterile equipment for procedure by placing on sterile field. 3. Put on sterile gloves and remove transfer set from patient. 4. Attach end of catheter to Smart-Cap 4. The Smart-Cap is manufactured and allow to soak for 5 minutes. with a betadine sponge inside. Remove gloves. 5. After 5 minutes open transfer set and mini cap packages onto sterile field. 6. Don sterile gloves. 7. Close transfer set clamp and screw mini cap on to end of transfer set. 8. Attach transfer set on to end of catheter using sterile 4x4’s to hold catheter. Ensure transfer set is tightly connected to the catheter. 9. Remove clamp. 10. If a CAPD exchange will be performed immediately after changing the transfer set, follow steps 1-30, “Initiation of Dialysis” as outlined above. If a CAPD exchange will not be done at this time, remove a Stay-Safe cap
  9. 9. Clinical Procedure Page 9 of 12 Clinical Manual / Nursing Practice Manual John Dempsey Hospital PROCEDURE FOR: Peritoneal Dialysis: Acute, Stay-Safe CAPD exchange procedure ACTION POINTS OF EMPHASIS from its package and place it on the end of the transfer set. 11. Document change of transfer set, serial number and patient response in the medical record. CATHETER/EXIT SITE DRESSING CHANGE: EQUIPMENT: Water Antibacterial Soap 1 drain sponge 2 packages sterile 4x4's Mask Tape Normal Saline 1. Don mask. Using aseptic technique, 1. Catheter/Exit site care should remove old dressing. be performed everyday and PRN. 2. Using soap and water, gently cleanse around catheter site in an outward circular motion. 3. Rinse area with normal saline soaked gauze. 4. Gently wipe around catheter site 4. Apply Bactroban ointment with dry gauze. around the catheter site. 5. Apply DSD, drain sponge. Tape in 5. Catheter must be secured at place. Do not occlude. all times. PROTOCOL: PERITONEAL DIALYSIS: CARE FOR A PATIENT RECEIVING DESIRED PATIENT OUTCOMES: 1. Patient will have appropriate infusion and outflow maintained during the procedure.
  10. 10. Clinical Procedure Page 10 of 12 Clinical Manual / Nursing Practice Manual John Dempsey Hospital PROCEDURE FOR: Peritoneal Dialysis: Acute, Stay-Safe CAPD exchange procedure 2. Any side effects/complications will be identified during and after the procedure and appropriately managed. 3. Patient and family will verbalize understanding of the need for peritoneal dialysis. 4. Patient who will be on chronic CAPD and family will verbalize understanding of all instruction given prior to discharge. Follow up teaching will be coordinated with renal team. ASSESSMENT: 1. Patients will receive overall assessment prior to initiation of peritoneal dialysis, and at least every eight hours thereafter. Special attention should be given to abdominal assessment, extent of edema, respiratory status and mental status. 2. Adult: Vital signs will be taken every 8 hours per unit protocol, or as per MD order. 3. Catheter site will be closely assessed for signs/symptoms of local infection, (For example: purulent drainage, pain at site, abdominal tenderness). Chills and a board-like abdomen may also be indicative of peritonitis. It may be necessary to add antibiotics to dialysate as ordered by physician. 4. If the patient complains of abdominal cramps or pain, inspect the tubing for the possibility of air getting into the abdomen or dislodged catheter. GENERAL NURSING CARE: 1. Accurate I & O including all forms of fluid intake (oral, IV, irrigation) and all output (urine, dialysis return, vomitus, diarrhea, wound drainage). The Peritoneal Dialysis Flowsheet is used to record peritoneal dialysis I & O only, but this is kept with other I & O data on the patient's Flowsheet/clipboard. All I & O records are for a 24 hour period only. I & O from the CAPD flowsheet should also be transferred to the main flowsheet. CAPD 24 hour cumulative balances will begin with the first exchange after midnight. Patient is weighed daily optimally at the same time, using the same scale, after outflow. 2. Indwelling Foley catheters are usually avoided since a bladder infection is dangerous in these patients. If an indwelling
  11. 11. Clinical Procedure Page 11 of 12 Clinical Manual / Nursing Practice Manual John Dempsey Hospital PROCEDURE FOR: Peritoneal Dialysis: Acute, Stay-Safe CAPD exchange procedure catheter must be left in place, a closed drainage system must be used, Foley care must be given every shift and PRN. 3. General observations should be made at least every 8 hours, including tolerance of procedure, status of the exchange, presence of any leakage and condition of catheter site. 4. Good skin care and oral hygiene are provided every 8 hours and PRN. 5. Obtain blood-work, dialysate cultures and cell counts on dialysate as ordered by physician. 6. In general these patients should have a high protein diet (especially so with peritonitis). POTENTIAL COMPLICATIONS: 1. Peritonitis is a major complication. The dressings must be changed at least every day using sterile technique. Refer to procedure. 2. Difficulties with either infusion or drainage of dialysate can occur. Corrective action includes checking the tubing for kinks, checking the clamps, the use of a tongue depressor to splint kinked tubing, turning the patient from side to side, and gentle inward/upward pressure to the lower abdomen by palpation. If these methods fail to restore smooth instillation and drainage, notify the physician. 3. Uremic psychosis may be encountered in some patients. This may be manifested by lassitude, poor memory, stupor, coma, delirium, psychomotor activity, depression, over-activity, combativeness, or paranoia. Treatment should be both preventative and symptomatic. Side rails should be up, and supportive reassurance given. The need for restraints will be assessed on an individualized basis. The fall risk protocol should be implemented. PATIENT TEACHING: 1. If the patient has been doing peritoneal dialysis at home, encourage him/her to participate in the exchanges. Incorporate patient's usual routine as much as possible. 2. Reinforce reason/goal for treatments, risks and benefits.
  12. 12. Clinical Procedure Page 12 of 12 Clinical Manual / Nursing Practice Manual John Dempsey Hospital PROCEDURE FOR: Peritoneal Dialysis: Acute, Stay-Safe CAPD exchange procedure 3. Encourage patient to resume usual activity level between exchanges. 4. If patient will be going home with permanent peritoneal dialysis catheter, instruct patient and family in complete exchange technique, with special emphasis on aseptic technique. Document teaching on the Patient and Family Teaching Record. Follow-up teaching and ongoing care will be coordinated by the renal fellow or attending. REPORTABLE CONDITIONS: 1. Adult: Report any consistent returns that are 300 to 400 ml more or less than that infused with each exchange. 2. Report abnormal color/appearance of drainage. Fluid should be clear yellow, and you should be able to read writing on the bag through the fluid. 3. Report abnormal vital signs, increased temperature, and any signs/symptoms of infection at catheter site or peritonitis. 4. Report changes in behavior, paranoia, confusion and lassitude. 5. Report patient color changes, petechiae and other signs and symptoms of anemia. 6. Report if peritoneal drainage is not flowing well 7. Report any diarrhea or constipation. DOCUMENTATION: 1. Complete Peritoneal Dialysis flowsheet for each exchange. (24 hour period begins with the first exchange after midnight). 2. Document patient assessment per protocol. APPROVAL: Nursing Standards Committee EFFECTIVE DATE: 10/89 REVISION DATES: 1/93, 3/96, 10/97, 3/00, 12/02, 5/03, 11/03, 1/04, 4/05, 8/08

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