WPC[ mMG'-UPJ*1E/<><ϒ7V:ZH7\]H]}Y OXd8 NrZp})fd.)B۾fjqN >Ue!8}|mNZ5@ͷX +GeWm3Ibܬ/)X_x9 uEK6WzhjHbFs},X@fRw_(m"dP f>W@gt;ߖwq1I8Im.G66f֖GW U_nOb( 9`!z.ui3T6aV:hIm1d{.QEb3oc#6uoԥSf;@jO[KkdA3х._P)7 U;B\G"7@~!F.#D*#LUN  %[ 0:a 0 0 0t 0\ 0A 0# 0 0 0 0 0i 0B 0 0 0 0 0R 0 0 0 0 0e 07 0 0 0 0a 0$ 0 0<U>^ w43B mDLexmark 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  6E 54heading 1         XXX  6? 24heading 2         XXX  <:Default Para\  `&Times New RomanC) ;ng(:i+003|xU !USUS.,    #X@XXX& r      #X#X@     e  CHRONICPDCATHETEREXITSITECARE e  Ԍ  Ќ  #X@X#   #X@XX#X@9##X@XXX@!    #pX#X@    !  INFECTEDEXITSITE'rY!8  Ԍ L Ќ  #X@X#p   #X@XX#X@##X@XXX@ PURPOSE : J   1.  ToensurestandardizationoftechniquebetweenalloftheTorontoHomePeritoneal  & Dialysis(PD)UnitsandHomeCareAgencies.   2.  Tomonitorinfectionandthehealingprocessofaninfectedperitonealdialysiscatheter    exitsite.Thismayalsoreducetheriskofperitonitis.     POLICY : J    1.  Tobeperformedbyaregisterednurse(orregisteredpracticalnurse)trainedinPDfora &v patient b ЀdiagnosedwithaPDcatheterexitsiteinfection. N 2.  Increasefrequencyofexitsitecarebymodifiedshowertechniquetodailyortwicedaily & (orasorderedbyphysician).  3.  InspectionoftheexitsiteanddocumentationoftheexitsiteconditiononthePatientCare  Recordisessential.Iftheinfectedexitsiteworsens,i.e.progressiontoatunnelinfectionnoted  byindurationandcopiousdischarge,pleasenotifytheHomePDUnitimmediately. r 4.  Thestandardcleaningsolutionforcathetercareis2%chlorhexidinegluconateaqueous J solutionwitha4%isopropylalcoholasastabilizer.Tradenameforthissolutionis 6 Stanhexidine. "r Ifthepatientissensitivetochlorhexidinegluconate,checkhis/herrecordsorasktheHomePD  J Unitforasubstituteantisepticsolutionorder. !6 5.  Tubbathsarenotrecommendedforpatientswithperitonealcatheters. #! 6.  Dressingshouldbeairpermeable.TapemaybesubstitutedbyBurnnetorFlexnetor % # catheterimmobilizerbasedonpatientallergiesorpatientpreference. &!$ 7.  Ifmupirocinointmentisordered,ensurethatthePDcatheteristhesilastictype,andthe Z(#& mupirocinisappliedsparingly.Mupirocincreammaybeusedwithpolyurethanecatheters. F)$' 8.  Refillingliquidsoap/transferringliquidsoapbetweencontainersshouldbeavoided.If +n&) liquidsoapisunavailable,antibacterialbarsoapmaybesubstituted(eg.Dial).  ,Z'* 9.  Washclothsshouldbewhiteorlightcoloured.Withdarkcolours,thedyecancomeout. -2), Ifunabletoprovidecleanwashclothsandtowelsdaily,maysubstitutewithcleangauze.    PROCEDURE : t   1.  Assessthepatient'sabilitytoperformmodifiedshowertechniqueindependently.Ifnot,it P  shouldbedonebythenurse.(seeGuideline#1) <  2.  Washhandsfortwominutes.  d 3.  Gathertheequipment:(seeGuideline#2)  <     antibacterialliquidsoap/bodywashsoap(eg.Dial,Jergens) (     2cleanwashcloths      cleantowel      chlorhexidinegluconate2%aqueoussolution      3packagesof5x5cmgauze      1dressing(i.e.meporeorgauze)(seeGuideline#10) t    tape `    mupirociniforderedplusaQtiporanotherpackageofgauze L 4.  Ifhavingashower,havepatientundressandremovetheolddressing.Ifthedressingis $t notbeingchangedinconjunctionwithashower,simplyremovethedressing.(seeGuideline#4) ` 5.  Examinetheolddressingforamountandtypeofdrainage. 8 Examinetheexitsitenotingredness,crustinganddrainagetype.IffollowupswabforC+Sis $ ordered,obtainspecimen.  6.  Washhands.  7.  Leavethecatheterandtransfersetorextensiontapedtotheabdomen. p 8.  Ifshoweristaken,showerandshampooasusual.Avoidscrubbingtheexitsite. H! 9.  Applyantibacterialsoaptocleanwetwashclothandverygentlycleanaroundtheexitsite.  #p! Washtheexitsiteandsurroundingskininacircularmotionstartingfromtheexitsiteand  $\" workingoutwards.(seeGuideline#4) $H # 10.  Takesecondwashclothandwetitwithcleanwater.Rinseexitsitewellensuringthatno & "% waterentersthesinus.CrustsmaybesoftenedbysoakingwithShurClensorhydrogen ' #& peroxide.Neverforciblyremoveacrust.Itshouldgraduallyfalloffastheexitsiteheals.(see (#' Guidelines#5,#6and#7) )$( 11.  Gentlypatdrytheexitsitewithacleantowel,thendrytherestofthebody. l+&* 12.  Openthegauzepackages.Saturateonewithchlorhexidinegluconate2%. D-(, Ї13.  Paintasmallcircleofchlorhexidinegluconate2%aroundtheexitsiteinthesame  circularmotion.Ensurethatchlorhexidinegluconate2%isnot"probed"intothesinus.Allowto  airdryfor30seconds.  14.  Applythemupirocinsparinglyaroundtheexitsiteiforderedbythephysician,usingaQ ` tiporagauze.(seePolicy#7,Guidelines#8and#9) L  15.  Placeone5x5cmgauzeunderthecatheterattheexitsitesothatthecatheterisrestingon $ t thegauze(optional).Applythefinaldressingsterilegauzewithhypofixormepore.  ` 16.  Tapethetransfersettothepatient'sskininacomfortableposition,minimizingexcessive  8  tensionontheexitsite.ThePDcatheterandtransfersetmaybeloopedandanchoredatall $  times.Somepatientsmayuseanimmobilizer.(seeGuidelines#3and#11)   17.  Documenttheconditionoftheexitsite.     NURSINGGUIDELINES : p   1.  Ensuretheprocedureisdoneinacleanenvironment(eg.nopetsintheroom). L 2.  Glovesandmasksarenotnecessaryforchronicexitsitecare.Techniqueisclean. $t However,masksmaybeusedatthenurse'sdiscretion(eg.ifhe/shehasacold;ifreferringunit ` hasspecified).Gloves(procedural,notsterile)maybeusedintheeventofdischargeattheexit L siteaspartoftheBSPpractices.Fordry,intactexitsites,glovesarenotrequired. 8 3.  ImmobilizationofthecatheterATALLTIMESiscriticalinpreventingtraumaby  mechanicalactionduringhandlingandnormalbodymovements.  4.  Minimalandgentlemovementsofthecathetershouldbeusedwhenperformingexitsite  care. p 5.  NeverforciblyremovecrustfromthePDcatheterexitsite.HydrogenperoxideorShur H! Clensmayberecommendedaccordingtodoctor'sorder. 4"  6.  Somepatientsmaybeorderedtohavehydrogenperoxidesoaks.Hydrogenperoxide  $\" shouldbea1:10dilutionor510%concentration.Aftersoapandwaterwash,pourhydrogen $H # peroxideonto2x2gauze.Wrapgauzearoundcatheterandleavefor5minutes.Drywithgauze %4!$ andapplyantisepticsolutionfollowedbymupirocinifordered.Mesalt(saltimpregnatedgauze) & "% mayalsobeorderedifthereiscopiousdrainagefromthesite. ' #& 7.  Flowofthewatershouldbeinagentledownwardposition. )$( 8.  Mupirocinisonlyusedforgrampositivebacteria. l+&* 9.  Mupirocincreamismoreexpensivethanmupirocin_ointment. D-(, Ї10.  Thesizeofgauzeusedisoptionalaccordingtopatient/unitpreference.Someunitsmay  offerthepatienttheoptionofnotusingadressingsixmonthspost_PD_Ԁcatheterimplantationif  theexitsiteiswellhealed.  11.  Whensecuringthe_PD_Ԁcatheter,ensurethatthecatheterfollowsitsnaturaldirectionto ` avoidtraumatotheexitsite.Also,ensurethatthecatheterdoesnotbendatitsconnectiontothe L  adapter,asthecathetercancrackovertime.Thisputsthepatientatriskforgettingperitonitis. 8    REFERENCES :  `   8.  _Khanna_,RandTwardowski,Z.RecommendationsforTreatmentofExitSitePathology.  <  PeritonealDialysisInternationalvol.16,supplement3,1996,ppS100S164. (  9.  _Nolph_ԀK,TwardowskiZ,_Prowant_ԀBand_Khanna_,R.HowtoMonitorandReport   Exit/TunnelInfections.PeritonealDialysisInternationalvol.16,supplement3,1996,pp.S115   S117.   10.  _Prowant_ԀB,_Khanna_ԀRandTwardowski,Z.CaseReportsforIndependentStudy. ` PeritonealDialysisInternationalvol.16,supplement3,1996,pp.S105S114. L 11.  _Prowant_,BandTwardowski,Z.RecommendationsforExitSiteCare.Peritoneal $t DialysisInternationalvol.16,supplement3,1996,pp.S94S99. ` 12.  Twardowski,Zand_Prowant_,B.ExitSiteStudyMethodsandResults.Peritoneal 8 DialysisInternationalvol.16,supplement3,1996,pp.S6S31. $ 13.  Twardowski,Zand_Prowant_,B.ClassificationofNormalandDiseasedExitSites.  PeritonealDialysisInternationalvol.16,supplement3,1996,pp.S32S50.  #X@XX#X@%#