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Update in Home Peritoneal Dialysis Care. Presented by DeVonne Rice, RN,BSN,CNN. Objectives. Describe the peritoneal dialysis options available to the patient who chooses to do peritoneal dialysis Discuss the advantages and challenges of peritoneal dialysis - PowerPoint PPT Presentation
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Update in Home Peritoneal Dialysis Care
Presented by DeVonne Rice, RN,BSN,CNN
Objectives
• Describe the peritoneal dialysis options available to the patient who chooses to do peritoneal dialysis
•Discuss the advantages and challenges of peritoneal dialysis
• Outline the basics of the PD training program
CAPD
• Continuous ambulatory peritoneal dialysis (CAPD)
•All manual
• Patient performs 4-5 peritoneal infusion dwells/ drains (exchanges) daily
Advantages of CAPD
• No power source is required as no machine is involved
• Also, as no machine is involved patient can be more mobile and not confined to a chair/bed for long period
of time
• Takes about 30 minutes to do an exchange, so not much time involved per exchange
Disadvantages of CAPD
• Convenience as busy schedules require the time to perform the exchanges
• Requires a private/clean area to perform exchanges if working/school
Automated Peritoneal Dialysis (APD)
• Peritoneal dialysis exchanges are performed by a cycler machine while the patient sleeps
Advantages of APD
• Can free up patient during the day
• Portable machine, so easy to travel
Disadvantages of APD
• Confined to the cycler for the time that the doctor has ordered (maybe up to 8-10 hours)
Challenges of Peritoneal Dialysis
•Infectious
•Mechanical
•Non-infectious
Peritonitis• Remains a leading complication of peritoneal dialysis
• Around 18% of the infection-related mortality in PD patients is the result of peritonitis
• Remains a major cause of patients discontinuing PD and switching to hemodialysis
• 32% of PD patients with peritonitis transfer to HD
• PD community must focus attention on prevention and treatment of PD-related infections
• 25% of PD hospital admissions related to peritonitis
Causes of PeritonitisContamination
• At the time of connection• Hole in exchange tubing or catheter
• Loss of cap on end of tubing or failure to close clamp with leaking• Product defects
Exit Site• Improper anchorage of PD catheter
• Improper hygiene
Constipation• Bowel-source• Diverticulitis• Colitis
Causes of peritonitis cont.
Procedural•Colonoscopy
•From dental procedures•Gynecologic source
Diagnosis of Peritonitis•Cloudy peritoneal fluid•Abdominal pain
•Fever•Nausea•Diarrhea
•White cell count of >100mm3
Note: Symptoms can vary by organism
Management of Peritonitis
• Assess the need for hospitalization
• Management of the pain
• Limit oral fluids, use stronger glucose percentages due to possible ultra filtration problems
•Treat with identified antibiotics as ordered by protocol or doctor
• Keep a close watch on the exit site/tunnel
Peritonitis cont.
•Close attention must be paid to preventing exit site infections and peritonitis
•Every home program should work diligently to help prevent infections in their peritoneal patients
•The PD team, including the nephrologists, nurses, social workers, and dieticians should meet regularly to review all
peritoneal related infections
Exit Site Infection
Definition:Presence of purulent drainage, with or without
erythema of the skin at the peritoneal catheter-skin site
Management of Exit-Site Infections
•Empiric antibiotic therapy may be initiated immediately
•Culture with sensitivity testing is important in determining antibiotic therapy
•Antibiotic therapy must be continued until the exit site appears entirely normal
Note: Patient with an exit-site infection that progresses to peritonitis will often require catheter removal
Note: S. aureus and P. aeruginosa are responsible for the majority of infections
Exit Site Care to Prevent Infection• Anchoring and securing the PD catheter to prevent excessive
movement around the exit site area
• Routine exit-site care by the patient when the exit site is well healed
• Water and antibacterial soap are recommended by many centers
• Excellent hand hygiene before any exam of the patient’s exit site
•Patient should use topical antibiotic either at the catheter exit site, intranasally or both
Mechanical/Non-Infectious Challenges
PD catheter malfunction
•Migration of catheters
•Blockage due to omental trapping
Note: Can often be corrected through laparoscopic means
Catheter occlusion
•Severe Constipation
Note: May be corrected with use of laxatives
Challenges cont.
Membrane / Ultrafiltration failure/Volume status
•Glucose, the osmotic agent in standard PD solutions, causes changes in the membrane over time with eventually leads to
membrane failure
• Repeated cases of Peritonitis
Note: Newer biocompatible solutions without dextrose have shown less membrane damage and might better preserve the
peritoneal membrane
PD Training ProgramPD Training Nurse
•Must have good communication skills, be innovative and consistent, and believe in patient self-care
•Must develop proper training skills based on principles of adult learning
•Experience in medial/surgical nursing is beneficial, as PD patients often have other co-morbid conditions
Trainer Objectives•Provide an effective environment for learning
•Present an overview of the PD training plan to the patient
•Demonstrate the steps of the procedures consistently
•Encourage and support the learner through repetition
•Prevent the learner from practicing procedures until all steps have been learned in order
Trainer Objectives cont.•Provide immediate feedback during learner practice
•Help the learner problem solve by defining problems and talking about possible solutions
•Recognize that learners need repetition of new information in order for it to move from short-term memory to long-term
memory
Assessment
• You must assess for any special needs of the patient
• Pediatric patients
• Diabetic patients
• Mentally challenged patients
• Visually impaired
Equipment
•Patient preference for CAPD/APD
•If diabetic, must assure correct instrument to measure blood sugar
•Supply ordering/storage
Note: All of our patients are trained on CAPD in case of emergency.
In ClosingDisadvantages of peritoneal dialysis include:
•Risk of infections
•Patient may get tired of doing their treatment every day
•Logistical problems, supply delivery and storage space for the supplies
Closing cont.Advantages of peritoneal dialysis include:
• Portable equipment
• 2 x monthly clinic visits vs. 3 x weekly in-center hemodialysis treatments
• Fewer restrictions of diet and fluid
• Flexible life style
• NO needles
• Improves the preservation of residual renal function
Conclusion•The recent bundling of services for dialysis care into one payment offers PD as a cost-effective therapy and has generated a renewed interest the
dialysis community.
•The bundling may lead to improved provider expertise and greater PD utilization.
• We as providers have to be ready.
• Techniques to prevent and minimize episodes of peritonitis, use of more biocompatible solutions in preserving the peritoneal membrane, and careful manage of volume status can sustain the patient longer on
PD.