Nursing Procedure 8.12
Assessment should focus on the following:
Nursing diagnoses may include the following:
Outcome Identification and Planning
Sample desired outcomes include the following:
Special Considerations in Planning and Implementation
Peritonitis is a frequent complication in clients with peritoneal dialysis; therefore, strict aseptic technique must be maintained.
The pediatric client may be anxious, apathetic, or withdrawn. Spend as much time with the pediatric client as possible, and arrange for family members to be present to provide support.
Many homebound clients dialyze intermittently at home by using a cycler. Observe return demonstrations until you are certain that the client and the family understand the importance of preventing infection.
If not contraindicated by agency's or manufacturer's policy, a blanket warmer may be used to warm dialysate solution, saving time in preparation.
Except in agencies where special training or certification is provided (see agency policy), this procedure cannot be delegated to unlicensed personnel. They may, however, assist with obtaining weights, emptying drainage receptacles/graduated containers, and recording output.
| Action | Rationale | |
|---|---|---|
| 1 | Perform hand hygiene. | Reduces microorganism transfer |
| 2 | Explain procedure to client. | Reduces anxiety; promotes cooperation |
| 3 | Determine if client is allergic to iodine-based antiseptics and use alternative, if indicated. | Avoids allergic reactions |
| 4 | Weigh client each morning and as ordered for each series of exchanges, and record weight. | Provides data needed to determine appropriate concentrations of fluids and additives |
| 5 | Place unopened dialysate fluid bag or bottle in warmer, if solution is not, at least at room temperature. | Enhances solute and fluid clearance; prevents abdominal cramping |
| 6 | Don mask. | Reduces spread of airborne microorganisms |
| 7 | Prepare dialysate with medication additives as ordered; prepare each bag according to the five rights of drug administration (client, drug, route, time, and dosage [concentration]; see Nursing Procedure 5.1); place completed medication label on bag. | Avoids errors that could affect end results of dialysis: Concentration affects osmolality, rate of fluid removal, electrolyte balance, solute removal, and cardiovascular stability |
| 8 | Insert dialysate infusion tubing spike into insertion port on dialysate fluid bag or bottle and prime tubing, then place fluid bag or bottle on IV pole. Some tubing spikes are designed like a screw cap with a spike in the center of the cap. Place an antiseptic solution in the cap before spiking the bag. | Eliminates air, which may contribute to client discomfort |
| 9 | Adjust position of bed so that fluid hangs higher than client’s abdomen and drainage bag is lower than abdomen (Fig. 8.14). | Enhances gravitational flow as fluid infuses and drains |
| 10 | Provide privacy. | Decreases embarrassment |
| 11 | Open and arrange cleaning supplies using inside of packages as sterile field (soak 4 × 4-in. gauze pads with saline or designated solution, leaving dry pads for covering or other dressing, if ordered). | Arranges field for efficiency |
| 12 | Don clean gown and sterile gloves; instruct each person in the room to put on appropriate protective wear (masks for all individuals in room, sterile gloves for nurse and assistant handling fluid bags). | Decreases nurse’s exposure to microorganisms and client’s exposure to airborne microorganisms; reduces risk of peritonitis |
| 13 | Remove old peritoneal catheter dressing and examine catheter site for catheter dislodgment or signs of infection; if leakage or abnormal drainage is noted, culture site. | Assesses catheter intactness; facilitates identification of infectious agent |
| 14 | Discard dressing and gloves; perform hand hygiene, and don sterile gloves. | Reduces microorganism transfer; prevents contamination of hands; prevents exposure to body secretions |
| 15 | Beginning at catheter insertion site, cleanse site with a circular motion outward, using peroxide or sterile saline on gauze or swab, and allow to dry; apply antiseptic agent recommended by agency or ordered by doctor (discard each gauze or swab after each wipe when cleansing site and applying antiseptic). | Decreases microorganisms at catheter insertion site; reduces risk of peritonitis |
| 16 | Using sterile technique, apply new dressing and secure with tape. | Protects site from microorganisms |
| 17 | Discard gloves and perform hand hygiene. | Reduces microorganism transfer |
| 18 | Label dressing with date and time of change and nurse’s initials. | Provides data needed to determine when next dressing change is due |
| 19 | Don sterile gloves. | Prevents contamination of hands; prevents exposure to body secretions |
| 20 | Connect end of dialysate tubing to abdominal catheter. | Connects tubing to begin dialysate infusion |
| 21 | Clamp tubing from abdominal catheter to drainage bag (outflow tubing). | Prevents dialysate from running through |
| 22 | Check client’s position (abdomen lower than height of fluid, which allows gravity to facilitate flow); check tubing for kinks or bends. | Removes obstructions that could affect infusion rate |
| 23 | Open dialysate infusion tubing clamp(s) and allow fluid to drain into peritoneal cavity for 10–15 min. Observe respiratory status and pain status while fluid infuses and while fluid remains in the abdomen (dwell time). Slow or stop infusion as needed to reduce discomfort. | Infuses dialysate for fluid and electrolyte exchange in peritoneal cavity using volume within client tolerance |
| 24 | Allow fluid to dwell in abdomen for 20 min (or amount of time specified by doctor). | Allows time for exchange of fluids and electrolytes |
| 25 | Open clamp leading to drain bag and allow fluid to drain for specified amount of time or until drainage has decreased to a slow drip (if all the fluid does not return, reposition client and recheck tubing leading to drainage bag). | Allows end products of dialysis to drain |
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| 26 | Record amount of fluid infused and amount drained after each exchange; add balance of fluids infused and drained on appropriate flow sheet (if net output is greater than amount infused by a large margin [200 mL or more] notify doctor). | Provides accurate record of fluid exchanges for determining fluid balance |
| 27 | Reassess the following client data every 30–60 min thereafter throughout exchanges: vital signs, output, respiratory status, mental status, abdominal status, appearance of dialysate return, abdominal dressing (should be kept dry), and signs of lethal electrolyte imbalances. | Alerts nurse to impending complications or need to change fluid and additive concentrations |
| 28 | Weigh client at end of ordered number of fluid exchanges. | Provides data regarding efficiency of exchanges in removing excess fluid |
| 29 | Obtain laboratory data as ordered and as needed (check doctor’s orders and agency policy regarding p.r.n. laboratory data). | Provides data about clearance of metabolic wastes as well as electrolyte status |
| 30 | When the total series of exchanges is completed, empty drainage bag into graduated container, discard bag and tubing, and cap peritoneal catheter. | Removes fluid waste so that other fluid may drain |
| 31 | Restore or discard all equipment appropriately. | Reduces transfer of microorganisms among clients; prepares equipment for future use |
| 32 | Remove and discard gloves and perform hand hygiene. | Reduces microorganism transfer |
Were desired outcomes achieved? Examples of evaluation include:
The following should be noted on the client's record:
Cost-Cutting Tip