Troubleshooting non-infectious peritoneal dialysis issues

Troubleshooting non-infectious peritoneal dialysis issues

Donna E. Maaz

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

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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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