WPC  YݷR1Q 1q/V9g;ϩaσDriNE.GE9t "?mo_ұeoFȎp\l7߰/'bBW1vbw>M Jl@?}!b -΍ {y-%{Ci$#gݰ\72R%9|7zCd {s봅=X!b޷n{IX@ h>Xikh(`Է1JC`)jx#1VqVdXcBB2xJ6ù/3F@`4@i>|~y9`cڑz{.r7?0k`kJo'4;ECD6r6ofJo.~.۝F M=0[ ]N+*Vަ5k"QN=l䆧7(p)j{Vw f= a? ^ S w_ 4c w  m Lexmark Z51 Series Col (Copy 3)PX,,,,PX0(9 Z6Times New Roman RegularX($USUS.,2G+J 0_level1  X /%4 4 <DL/23  ..  2( 4 <DL2  2D+J 0_level2   ," <DL,23  ..  2( 4 <DL2  2A+J 0_level3   ) <DL)23  ..  2( 4 <DL2  2>+J 0_level4  ` &<<DL&23  ..  2( 4 <DL2  2;+J 0_level5   #DL#23  ..  2( 4 <DL2  28+J 0_level6    DL 23  ..  2( 4 <DL2  25+J 0_level7  h DDL23  ..  2( 4 <DL2  22+J 0_level8   L23  ..  2( 4 <DL2  2/+J 0_level9    L23  ..  2( 4 <DL2  2GJ 0_levsl1  X /%4 4 <DL/23  Ԁ  2( 4 <DL2  2DJ 0_levsl2   ," <DL,23  Ԁ  2( 4 <DL2  2AJ 0_levsl3   ) <DL)23  Ԁ  2( 4 <DL2  2>J 0_levsl4  ` &<<DL&23  Ԁ  2( 4 <DL2  2;J 0_levsl5   #DL#23  Ԁ  2( 4 <DL2  28J 0_levsl6    DL 23  Ԁ  2( 4 <DL2  25J 0_levsl7  h DDL23  Ԁ  2( 4 <DL2  22J 0_levsl8   L23  Ԁ  2( 4 <DL2  2/J 0_levsl9    L23  Ԁ  2( 4 <DL2  2GJ 0_levnl1  X /%4 4 <DL/23   2( 4 <DL2  2DJ 0_levnl2   ," <DL,23   2( 4 <DL2  2AJ 0_levnl3   ) <DL)23   2( 4 <DL2  2>J 0_levnl4  ` &<<DL&23   2( 4 <DL2  2;J 0_levnl5   #DL#23   2( 4 <DL2  28J 0_levnl6    DL 23   2( 4 <DL2  25J 0_levnl7  h DDL23   2( 4 <DL2  22J 0_levnl8   L23   2( 4 <DL2  2/J 0_levnl9    L23   2( 4 <DL2  6? 24heading 1         XXX  6? 24heading 2    XXX       XXX6: *4heading 3  XXX     XXX<:Default Para  d)Hairline d\  `&Times New RomanTable_AC) ;ng(3|xU !USUS.,  _  &XXXX& L      &X&X     u  CHRONIC_PD_ԀCATHETEREXITSITECARE u  Ԍ  Ќ  &XX&   #XXX&XI#&XXXX!    &XXX&X    !  POSTOPERATIVEDRESSINGTECHNIQUE'Li!b  JԌ L Ќ    &XXX&X  PURPOSE : $   1.  ToensurestandardizationoftechniquebetweenalloftheTorontoHomePeritoneal   Dialysis(_PD_)UnitsandHomeCareAgencies.   2.  Tominimizetheriskofinfectionandpromotehealingoftheperitonealcatheterexitsite. t     POLICY : 8    1.  Tobeperformedbyaregisterednurse(orregisteredpracticalnurse)trainedin_PD_Ԁforthe d  patientrecoveringfrom_PD_Ԁcatheterimplantation.Theearlypostoperativeorhealingperiodis P generallyconsideredtobetwothreeweeksfromthedateoftheimplantationprocedure.The < completehealingprocessgenerallytakessixweeks. ( Ѐ2.  Inordertominimizebacterialcolonizationoftheexitandtunnelduringtheearlyhealing  period,thedressingprocedureiscarriedoutasasterileprocedure(withadressingtray).  3.  Fortraumapreventiontotheexitsiteandtractiononthecuffs,anocclusivedressingis t usedtoensurecatheterimmobilization. ` 4.  Inordertopromote_epithelialization_Ԁoverthegranulationtissuebeneaththescab,asterile 8 andundisturbedconditionattheexitsiteduringtheinitialhealingperiodisimportant.The $t frequencyofthedressingprocedureislimitedintheearlypostoperativeperiod.Refertothe ` tableintheNursingGuidelines(#4).Oncehealinghasoccurred(generallyatthetimethe L clips/suturesareremoved),theprocedurereferredtoasShowerTechniqueisusually 8 recommended.  $ 5.  TheconditionoftheexitsiteandincisionlinemustbedocumentedonthePatientCare "  Record. #! 6.  Reportingofseriouscomplicationsincludingleak,trauma,infectionandbleedingmust p% # bereportedtothehome_PD_ԀUnit. \&!$ 7.  Thestandardcleaningsolutionforcathetercareis_chlorhexidine_Ԁ_gluconate_Ԁ2%aqueous 4(#& solutionwitha4%isopropylalcoholasastabilizer.  )p$' ̀Ifthepatientissensitiveto_chlorhexidine_Ԁ_gluconate_Ԁ2%,checkhis/herrecordsoraskthe *H&) Home +4'* Ѐ_PD_ԀUnitforasubstituteantisepticsolutionorder. , (+ Ѐ - ), _ԀForremovalofgauzeattachedtoascab,alternatesolutionsmaybeprescribed(i.e.Shur  ЀClens,normalsaline).Cytotoxicagentsshouldbeavoidedinearlywoundmanagement.  8.  Tubbathsarenotrecommendedforpatientswithperitonealcatheters. t 9.  Dressingshouldbeairpermeable.Dependingoneachunit'spreference,materialsused L  includemepore,mefix,hypafixorgauzewithabdominalpadandpapertape.BurnnetorFlexnet 8  maybeusedinsteadoftapebasedonthepatient'sallergiesorpreference. $ t 10.  Ifmupirocinointmentisordered,ensurethatthePDcatheteristhesilastictypeandthe  L  mupirocinisappliedsparingly.Mupirocincreammaybeusedwithpolyurethanecatheters.  8    PROCEDURE :     1.  Assistthepatientasrequiredtoalyingorsittingposition.Assesstheconditionofthe   patient'scurrentdressing.Assessmentoftheexternalconditionofthedressingwillinfluencethe   suppliesassembledtocarryouttheprocedure.Instructthepatientregardingtheprocedure.(see t Guidelines#1,3,6,10) ` 2.  Gathertheequipment:(seePolicies#7,9,10andGuidelines#2,3,7,8) 8    steriledressingtray $t    masksfornurseandpatient `    sterilegloves+proceduralgloves L    EZEscrubbrush,chlorhexidinehandwash 8    34packagesofsterile10x10cmgauze $    abdominalpadsasrequired     chlorhexidinegluconate2%aqueoussolution     mepore,mefix,hypofixorpapertapeand/orBurnnet/Flexnet  3.  Closewindow/door/fantoroom.Ensureenvironmentandworkareaisclean.(see p Guideline#2) \  4.  Maskandhavepatientmask.(seePolicy#2andGuideline#3) 4"  5.  Complete2minutehandwashwithchlorhexidineskincleanserorEZEscrubbrush.  $\" 6.  Openthedressingtray.Addcleaningsolutionsandsuppliesrequired. %4!$ 7.  Removetheolddressing,takingcarenottoforciblyremoveanyscab.(seePolicy#7and ' #& Guideline#8) (#' AvoidpullingortwistingthePDcatheter.(seeGuideline#6) )$( 8.  Assessthesite. l+&* 9.  Wash_hands. D-(, Ї10.  Donsterilegloves.  11.  Drapethepatient.  12.  Cleansetheexitsiteinacircularfashionwithgauzesaturatedwith_chlorhexidine_ ` _gluconate_Ԁ2% L  Ѐstartingfromtheexitsiteandmovingoutwards.(seePolicy#7) 8  13.  Gentlypatdryorallowtoairdryfor3060seconds.(seeGuideline#6)  ` 14.  Cleansetheincisionline.  8  Ѐ15.  Apply_mupirocin_Ԁsparinglyaroundtheexitsiteasorderedbythephysician,usingagauze.   (seePolicy#10)   16.  Gentlylaythecleansed_PD_Ԁcatheterontoagauze.Completelycovertheexitsiteand   incisionwithseverallayersofgauze.(seeGuideline#6) p Coverwithanabdominalpad.Usealargepieceof_mefix_Ԁtapetosecurethedressing.Alternate \ dressingsmaybe_mepore_Ԁor_hypafix_Ԁ(withoutanabdominalpad)inthelater_postop_Ԁperiodwhen H thereislittleornodrainage.(seeGuideline#7) 4 17.  Asrequired,dateandinitialthedressing.  \ 18.  DocumenttheprocedureandconditionoftheexitsiteinthePatientCareRecord.Notify 4 the   unitifthereisanythingunusual(_eg_.leakage,discharge).(seePolicy#5+6)     NURSINGGUIDELINES :    1.  Informthepatientthatdressingchangesmaybeassociatedwithsomediscomfortdueto p localresponseattheincisionrelatedtotheuseofcleansingsolutionscontainingalcohol. \  2.  Ensuretheprocedureisdoneinacleanenvironment(nopets).Ifindicated,cleanthe 4"  counterorsurfaceareabeingusedtosetupthedressingtray.  #p! 3.  Thepostoperativedressingtechniqueisasterileprocedure.Ensurethepatient $H # understandswhyhe/sheneedstomaskduringthisprocedure. %4!$ 4.  Frequencyfor_PD_Ԁcatheterdressingwillbeorderedbythephysician,including: ' #&   &S1X&X#S1&S1#&S1S1  #&XX&S1$##XXX&X3%#&XXXX*'( 4ddd Xdd Xdd X(#(#,4ZN,ZZ+  8$$$'F)$(F)$  8  DressingOption ?$$$$,!R)$)"$$$ ?Comments U$$D,R)$*"  $$$$  UInitial_postop_Ԁdressing 6$$$#J*%+$$ 6Remainsinplacefirst1014days_postop_.Thendoshower J*%, technique. L$$;#6+&-  $$$  L23dressingsperweek 6$$$#.,~'.$$ 6Duringthe3rd6thweeks_postop_. L$$;#.,~'/  $$$  LPRNchange 6$$$#&-v(0$$ 6Dressingisnotintact+needstobechanged. &-v(1   Woundrequiresassessmentsecondarytopain,wetdressing.  Suspectedinfection.  Whenpatientisbeing_dialysed_.3)'   $$$ 3  5.  Ifthepatienthasmultipledressingsontheabdomen,cleananddresseachoneseparately, l beginningwiththe_PD_Ԁcatheter. X    6.  ImmobilizationofthecatheterATALLTIMESiscriticalinpreventingtraumaby 0  mechanicalactionduringhandlingandnormalbodymovements.Minimalandgentle  l movementsofthecathetershouldbeusedwhencarryingoutthedressingprocedure.Explainthe  X  importanceoftheseconceptstothepatient.  D  7.  Theamountofgauzeusedwillgraduallylessenasdrainagestops.   8.  Donotforciblyremovecrusts.Hydrogenperoxideor_Shur_Ԅ_Clens_Ԁmayberecommended   accordingtothephysician'sorder.   9.  _Mupirocin_Ԁcreamismoreexpensivethan_mupirocin_Ԁointment. h 10.  Teachthepatientthattubbathsshouldnotbetakenwithaperitonealcatheterinplace. @ Showersmustbeavoideduntiltheexitsiteiswellhealed(usually23weeks_postop_).Sponge ,| bathsshouldbeusedduringthisperiod. h 11.  Instructthepatientnottoliftanythingheavierthanasmallbagofgroceriesforthesix @ weekpostoperativeperiod. ,   &  "  &XXX&X    "1  References"11  1Ԍ  Ќ   &XXX&X  'w11.  _Gokal_ԀR,AlexanderS,AshS,ChenJ,_Danielson_ԀA,HolmesC,_Joffe_ԀP,_Moncrief_ԀJ, x _Nichols_ԀK,PirainoB,_Prowant_ԀB,_Slingeneyer_ԀA,_Stegmayr_ԀB,TwardowskiZandVasS: d  Peritonealcathetersandexitsitepracticestowardoptimumperitonealaccess.1998(official P! reportfromtheInternationalSocietyforPeritonealDialysis).PeritonealDialysisInternational <"  vol.18,pp1133,1998. (#x!   2.  Lancaster,L:PeritonealDialysis;ExitSiteCarefromCoreCurriculumforNephrology %P # Nursing,3rdedition,AmericanNephrologyNurses'Association,1995. %