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PD in Emergency Dept Prezi

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by

Karen Forsberg

on 1 November 2013

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Transcript of PD in Emergency Dept Prezi

Peritoneal Dialysis Patients Presenting in ED with Peritontis
Discharge/Transfer/Admission
Following initial emperic antibiotics:

Patient can be discharged with anitibiotics
to cover until follow-up can be organized by Nephrologist and PD Clinic

or

Patient to be admitted to Renal Ward
An understanding of treating Peritoneal Dialysis Patient presenting to Emergency Dept
a) in a facility with Renal Services
b) in a facility without Renal Services
Discuss IHA Peritonitis – Peritoneal Dialysis PPO
Discuss Clinical Practice Standard Guidelines for Peritoneal Dialysis Patient presenting to ED (awaiting final approval)
What is Peritonitis
Infection / Inflammation of the peritoneum
Diagnosis based on 2 of 3 conditions
signs and symptoms of peritoneal inflammation
cloudy peritoneal fluid with an elevated
peritoneal fluid cell count
Nucleated cells >100x10 6/L with
>50% neutrophils
Positive culture or evidence of organism on Gram stain
Patient Presentation
Symptoms Range:
no abdominal pain to mild abdominal cramps to extreme abdominal cramps with rebound abdominal tenderness

Cloudy effluent

Nausea, vomiting, diarrhea, hypotension, and fever can occur
Fever and hypotension are not common and associated with more severe peritonitis
Triage - CTAS Level 2
If dialysis related complication: Triage Nurse assesses as CTAS level 2 and informs the ED physician

If peritonitis suspected print off Regional IH Peritonitis PPO and place on chart

If non-dialysis related complication: Patient will be assessed and triaged as per ED procedure
IH Peritonitis Pre-Printed Orders
Found on the Inside Net
Team Sites / Regional Pre-Printed Orders
Click on this link and scroll down to Peritonitis – Peritoneal Dialysis

http://inet.interiorhealth.ca/clinical/pharmacy/ Pages/formulary.aspx

For inpatient and outpatient use
First cloudy effluent is best
Take samples from home bag or
Drain abdomen after a minimum 2 hour dwell and obtain effluent sample
3 mls purple top vial – Fluid cell count
8-10 mls in anaerobic and 8-10 mls in aerobic blood culture bottles
10 mls in sterile container for culture and sensitivity

Lab Order Set: Category/ IH Peritonitis Peritoneal Dial
Obtaining Specimens
Initiating Empiric Therapy
International Society for Peritoneal Dialysis (ISPD)
recommends initiation of antibiotic therapy
as soon as cloudy effluent is seen
without waiting for fluid cell count

Empiric antibiotics must cover both
gram-positive and gram-negative organisms
Algorithm
PD Patient presents to ED

with Renal Services
ED Nurse to Assess Peritoneal Dialysis Patient
Dialysis Related Complications
y
e
s
n
o
Cloudy Effluent
Abdominal Pain
Fever
Nausea or vomiting
Break in technique
Contamination
Faulty PD Catheter
CTAS level 2
Notify ED Physician
ED physician to consult nephrologist on call or designate
Patient has brought in dialysis effluent
Collect & send effluent samplings to lab for Culture and Fluid cell count STAT
Report lab result and pt symptoms to ED physician
Antibiotics to be ordered as per Peritonitis PPO
ED Nurse to notify PD Clinic Nurse during clinic hours (week day)
or Call PD Nurse on Renal Ward or supervisor
PD Nurse to liase with ED staff for provision of Pt. care
Peritonitis PPO orders signed by ED physician
y
e
s
n
o
Patient has abdominal pain
PD Nurse to:
Assess pain
Follow PPO as ordered
Perform rapid exchanges if indicated
PD Nurse to administer I.P. antibiotics ASAP
Continue timely reassessment and collaborative care plan as per ED and PD standards
ED physician to notify Nephrologist of admission or discharge plans for antibiotics
Other Emergency Complications
Seen by ED physician according to level of acuity
Consult Nephrologist for all admitted PD pts
PD Nurse to be notified of all PD pt visits by voicemail
If ED RN not trained in PD, call PD clinic nurse
or PD Nurse on Renal ward after clinic hrs
for any PD treatment
PD Nurse/Pt/Family to perform dialysis exchange in
order to obtain samples
Allow 2 hrs dwell time before obtaining effluent samples,
then send for culture and fluid cell count STAT
Report lab results and Pt symptoms to ED physician
Antibiotics to be ordered as per Peritonitis PPO
Algorithm
PD Patient presents to ED
without Renal Services
ED Nurse to Assess Peritoneal Dialysis Patient
yes
no
CTAS level 2
Notify ED Physician
ED physician to consult nephrologist on call
Peritonitis PPO ordered
Patient has brought in dialysis effluent
Collect & send effluent samplings to lab for Culture and Fluid cell count STAT
Report lab result and pt symptoms to ED physician
Antibiotics ordered according to Peritonitis PPO
yes
no
Other Emergency Complications
Seen by ED physician according to level of acuity
Consult Nephrologist for all PD pts requiring admission
Nurse Pt/Family unable to perform exchange to obtain sample?
Notify ED physician
ED physician to notify Nephrologist for timely transfer
Develop plan of care treatment options
Nurse/Pt/Family is able to perform exchange and has supplies?
Allow 2 hrs dwell time before obtaining effluent samples, then send for culture and fluid cell count
Report lab result and pt symptoms to ED physician
Antibiotics ordered according to Peritonitis PPO
Patient/Family has brought in PD supplies and Nurse is able to administer IP antibiotic as soon as possible?
No
Inform ED physician
Notify Nephrologists and arrange transfer to Regional Hospital with Renal program.
Plan of care to be determined in consultation while waiting for transfer
Consider IV antibiotics
Yes
Follow PPO and administer

ED physician to notify Nephrolgist
on call if pt requires admission
or if discharged to plan for
antibiotics
Timely Transfer Probable
Arrange Transfer with receiving facility
Consider LLTO B.C. Bedline
Arrange Care planning meeting with ED RN/ED physician and Regional Nephrologist
no
Questions
Full transcript