WPC< L"ZփŊCd?o0h!'m V3hhZ-.*`a}`S0PףvaYOOUrlg S|1 t_#Ӥȸ.%]};"Cק]4`GxR:⮿w5-wYB)u"nHg%W4t[=A9%4۞P Z'cgH:#@ۿE Zt5]i5~IA.1 `w<ػ?B+m,%3)-ʩ5Bt(*%g0FS 9d,JrUDVQoGfBT%ߖKbJ 1%ʀ2l!%M ZJ@BG=K1#)ԜjuOka?nWdW#elYCuqk*#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<vU>^ w4# 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  64 '4heading 2  XXX     XXX<:Default Para\  `&Times New Roman1C) ;ng(+003|xU !USUS.,    #XXXX& L      #X#X     e  CHRONICPDCATHETEREXITSITECARE e  Ԍ  Ќ  #XX#   #XXX#X9##XXXX  SHOWERTECHNIQUE(fortheHealthyExitSite)'LY L   PURPOSE : $   2.  ToensurestandardizationoftechniquebetweenalloftheTorontoHomePeritoneal   Dialysis(PD)UnitsandHomeCareAgencies.   3.  Toreducetheriskofinfectionattheperitonealdialysiscatheterexitsite.Thismayalso t   reducetheriskofperitonitis. `    POLICY : $t    11.  Tobeperformedbyaregisterednurse(orregisteredpracticalnurse)trainedinPDfora P patientfollowingsuture/clip/steristripremovalusuallytwoweekspostPDcatheterimplantation. < Priortosuture/clipremoval,refertotheProcedureforPostOperativeDressingTechnique. ( 12.  Frequencyforexitsitecarebyshowertechniqueisbasedonthefollowing:     routinelydoneeverytwodays(minimum)     postshowering     dailyormorefrequentlyduringinfectionepisode t    dailyifcrustispresent ` 13.  InspectionoftheexitsiteanddocumentationoftheexitsiteconditiononthePatientCare 8 Recordisessential.Iftheexitsitebecomesinflamedorinfected,calltheHomePDUnit $t immediately.RefertotheProcedureforCareoftheInfectedPDCatheterExitSite.Alsonotify ` theunitifthereisanytrauma(eg.catheterhasbeenforciblypulled;therehasbeenaggressive L crustremovalresultinginrednessorbleeding)totheexitsite. 8 14.  Thestandardcleaningsolutionforcathetercareis2%chlorhexidinegluconateaqueous ! solutionwitha4%isopropylalcoholasastabilizer.Tradenameforthissolutionis "  Stanhexidine. #! Ifthepatientissensitivetochlorhexidinegluconate,checkhis/herrecordsorasktheHomePD p% # Unitforasubstituteantisepticsolutionorder. \&!$ 15.  Tubbathsarenotrecommendedforpatientswithperitonealcatheters. 4(#& 16.  Dressingshouldbeairpermeable.TapemaybesubstitutedbyBurnnetorFlexnetor  *\%( catheterimmobilizerbasedonpatientallergiesorpatientpreference. *H&) 17.  Ifmupirocinointmentisordered,ensurethatthePDcatheteristhesilastictype,andthe , (+ mupirocinisappliedsparingly.Mupirocincreammaybeusedwithpolyurethanecatheters. - ), Ї18.  Refillingliquidsoap/transferringliquidsoapbetweencontainersmustbeavoided.If  liquidsoapisunavailable,antibacterialliquidsoapmaybesubstituted(eg.Dial).  19.  Washclothsshouldbewhiteorlightcoloured.Withdarkcolours,thedyecancomeout. t Ifunabletoprovidecleanwashclothsandtowelsdaily,maysubstitutewithcleangauze. `   PROCEDURE : 8    17.  Assessthepatient'sabilitytoperformmodifiedshowertechniqueindependently.Ifnot,it  d shouldbedonebythenurse.(seeGuideline#1)  P  18.  Washhandsfortwominutes. (  19.  Gathertheequipment:(seeGuideline#2)      antibacterialliquidsoap(eg.Dial,Jergens)      cleanwashcloth      cleantowel t    chlorhexidinegluconate2%aqueoussolution `    3packagesof5x5cmgauze L    1dressing(i.e.meporeorgauze)(seeGuideline#8) 8    tape $t    mupirocinifordered+Qtipor3rdpackageofgauze ` 20.  Havepatientundressandremovetheolddressing.(seeGuideline#4) 8 21.  Examinetheolddressingandinspecttheexitsiteforsignsofinfection(redness,crusting,  swelling,sanguinousorpurulentdischarge).  22.  Washhands.  23.  LeavethePDcatheterandtransfersetorextensiontapedtotheabdomen. \  24.  Showerandshampooasusual.Avoidscrubbingtheexitsite. 4"  25.  Applyantibacterialliquidsoaptoacleanwetwashclothandverygentlycleanaroundthe  $\" exitsite.Washtheexitsiteandsurroundingskininacircularmotionstartingfromtheexitsite $H # andworkingoutwards.(seeGuidelines#4+#5) %4!$ 26.  Rinsewell.(seeGuideline#6) ' #& 27.  Gentlypatdrytheexitsitefirstwithacleantowel.Thendrytherestofthebody. )$( 28.  Openthegauzepackages.Saturateonewithchlorhexidinegluconate2%. l+&* 29.  Paintasmallcircleofchlorhexidinegluconate2%aroundtheexitsiteinthe_same D-(, circularmotion.Ensurethat_chlorhexidine_Ԁ_gluconate_Ԁ2%isnot"probed"intothesinus.Allowto  airdryfor30seconds.  30.  Applythe_mupirocin_Ԁsparinglyaroundtheexitsiteasorderedbythephysician,usingaQ t tiporagauze.(seePolicy#7,Guideline#7) ` 31.  Placeone5x5cmgauzeunderthe_PD_Ԁcatheterattheexitsitesothatthecatheteris 8  restingonthegauze(optional).Applythefinaldressingsterilegauzewith_hypofix_Ԁor_mepore_. $ t (seeGuidelines#8+9)  ` 32.  Tapethetransfersettothepatient'sskininacomfortableposition,minimizingexcessive $  tensionontheexitsite.The_PD_Ԁcatheterandtransfersetmaybeloopedandanchoredatall   times.Somepatientsmayusean_immobilizer_.(seeGuideline#3)   33.  Documenttheconditionoftheexitsite.     NURSINGGUIDELINES : H   12.  Ensuretheprocedureisdoneinacleanenvironment(_eg_.nopetsintheroom). $t 13.  Glovesandmasksarenotnecessaryforchronicexitsitecare.Techniqueisclean. L However,masksmaybeusedatthenurse'sdiscretion(_eg_.ifhe/shehasacold;ifreferringunit 8 hasspecified).Gloves(procedural,notsterile)maybeusedintheeventofdischargeattheexit $ siteaspartofthe_BSP_Ԁpractices.Fordry,intactexitsites,glovesarenotrequired.  14.  Immobilizationofthe_PD_ԀcatheterATALLTIMESiscriticalinpreventingtraumaby  mechanicalactionduringhandlingandnormalbodymovements.  15.  Minimalandgentlemovementsofthecathetershouldbeusedwhenperformingexitsite \  care. H! 16.  Neverforciblyremovecrustfromthe_PD_Ԁcatheterexitsite.Hydrogenperoxideor_Shur_Ԅ  #p! _Clens_Ԁmayberecommendedaccordingtodoctor'sorder.  $\" 17.  Flowofthewatershouldbeinagentledownwardposition. %4!$ 18.  _Mupirocin_Ԁcreamismoreexpensivethan_mupirocin_Ԁointment. ' #& 19.  Thesizeofgauzeusedisoptionalaccordingtopatient/unitpreference.Someunitsmay )$( offerthepatienttheoptionofnotusingadressingsixmonthspost_PD_Ԁcatheterimplantationif *%) theexitsiteiswellhealed. l+&* 20.  Whensecuringthe_PD_Ԁcatheter,ensurethatthecatheterfollowsitsnaturaldirectionto D-(, avoidtraumatotheexitsite.Also,ensurethatthecatheterdoesnotbendatitsconnectiontothe  adapter,asthecathetercancrackovertime.Thisputsthepatientatriskforgettingperitonitis.    &  !  #XXX#X    !Y&  References!Y&&  &Ԍ t Ќ   #XXX#X  'tM&5.  _Gokal_ԀR,AlexanderS,AshS,ChenJ,_Danielson_ԀA,HolmesC,_Joffe_ԀP,_Moncrief_ԀJ, L  _Nichols_ԀK,PirainoB,_Prowant_ԀB,_Slingeneyer_ԀA,_Stegmayr_ԀB,TwardowskiZandVasS: 8  Peritonealcathetersandexitsitepracticestowardoptimumperitonealaccess.1998(official $ t reportfromtheInternationalSocietyforPeritonealDialysis).PeritonealDialysisInternational  ` vol.18,pp1133,1998.  L    6.  Lancaster,L:PeritonealDialysis;ExitSiteCarefromCoreCurriculumforNephrology $  Nursing,3rdedition,AmericanNephrologyNurses'Association,1995.   7.  _Thodis_ԀE,_Bhaskaran_ԀS,_Pasadakis_ԀP,_Bargman_ԀJ,VasSandOreopoulosD:Decreasein   thestaphylococcusaureusexitsiteinfectionsandperitonitisinCAPDpatientsbylocal   applicationof_mupirocin_Ԁointmentatthecatheterexitsite.PeritonealDialysisInternational,vol. p 18,pp261270,1998. \ #XXX#X#