Microsoft word - 2009 7.10 pd standing orders_final.doc

ADULT PERITONEAL DIALYSIS PATIENTS STANDING ORDERS 1. ALL PATIENTS TREATED WITH PERITONEAL DIALYSIS 1. PO water-soluble vitamin replacement daily. 2. Colace or equivalent, 100 mg., p.o. BID, unless diarrhea. 3. Gentamicin 0.1% cream to PD catheter exit site daily. Influenza vaccine should be administered to all patients except those with egg allergy, those for whom the patient’s physician has stated it is contraindicated, and those who refuse. Pneumococcal vaccine should be administered to all patients who have not received vaccination previously, except for those for whom the patient’s physician has stated it is contraindicated, have known allergy, and those who refuse. Date for subsequent five-year booster should be noted in cyberREN. i. For patients who have already received initial vaccination and ii. For patients who have received initial vaccination but date is uncertain, treat as initial vaccination. Dulcolax suppository, may repeat one time if no results, or; Sorbitol 70%, 30 cc, p.o., may repeat in 4 hours if no results. Wash daily with liquid antibacterial soap, cover with sterile dressing. Compazine, 10-mg. p.o., or 25-mg. suppositories may be given rectally one time during dialysis for moderate-to-severe nausea and vomiting, if patient is not hypotensive. Tylenol, 650 mg., may be given po 4 hours prn during dialysis (after checking patient's temperature) for mild pain of headache, joint and muscle ache. Northwest Kidney Centers Home Dialysis Program- Peritoneal Dialysis Unit Adult Peritoneal Dialysis Patients Standing Orders 5. TRANSFUSION REACTION (ICD9 999.89) OR DRUG REACTION a. Benadryl 25 mg., may be given I.V. over 2 minutes and repeated one time if necessary (if patient is not hypotensive) for chills, fever, rash, backache related to transfusion or drug reaction. b. Notify Pharmacy and physician of any drug reactions. 6. O2 FOR DYSPNEA OR CHEST PAIN (ICD9 799.02) At the nurse's discretion, O2 may be administered per nasal cannula at 2 L/min., or mask at 5 L/min. for dyspnea or chest pain. The nurse will observe usual precautions in patients with COPD. Low calcium dialysate (2.5 mEq/L) bath will be the choice for all patients starting peritoneal dialysis and for those already on peritoneal dialysis unless the attending nephrologist specifically orders the 3.5 mEq/L calcium dialysate for an individual patient. a. Catheter flush and dressing change predialysis at the nurse’s b. Flush catheter with 1,000 cc NS or dialysis fluid, leave 300 cc in c. Fill catheter with 3 cc heparin (1:1000 u/cc.) if fibrin present or Daily inspection, scrub with liquid antibacterial soap, cover with sterile dressing. C. ESTABLISHED PERITONEAL CATHETER OUTFLOW In the absence of signs and symptoms of peritonitis; i.e., abdominal pain, fever, cloudy outflow, absent bowel sounds, may: Administer prn medications for constipation, or Irrigate catheter to check patency and function prn when indicated. For slow drains or fibrin present, add heparin 1:1000 u/ml – 1/2 cc IP to overnight CAPD bag or 1 cc IP to each CCPD bag – until drain problem resolves or fibrin no longer present. Request standing upright Abdominal X-ray at nurse discretion to evaluate for evidence of constipation via attending physician's office. Northwest Kidney Centers Home Dialysis Program- Peritoneal Dialysis Unit Adult Peritoneal Dialysis Patients Standing Orders 1. Send peritoneal fluid samples for culture and sensitivity, gram stain, and cell count with differential. (ICD9 = 567.9) 2. Initiate peritonitis standing orders. 3. Notify physician. 4. Observe and review technique for dialysis procedure and schedule 1. If exit site drainage is present, send specimen for Culture and Sensitivity and gram stain. (ICD9 = 996.60) 2. For exit site infection, initiate catheter-related infection standing 3. Gentamicin Cream 0.1% to P.D. catheter exit site daily. 4. Notify physician. 1. NKC Special Profile. (ICD9 = 585.6) 2. CBC with platelets (ICD9 = 585.6) 3. PTH Intact. (ICD9 = 588.81) 4. Ferritin, Iron, TIBC, % Sat. (ICD9 = 275.0) 5. HIV, with patient consent. (ICD9 = 585.6) 6. HBsAg, Anti-HBs. (ICD9 = 585.6) 7. Hepatitis C Antibody (ICD9 585.6) 8. Aluminum (ICD9 = 268.2) 9. Hemoglobin A1c values will be obtained quarterly on patients who have a diagnosis of diabetes mellitus (ICD9 = 250.00). 1. NKC Special Profile: Monthly. (ICD9 = 585.6) 2. CBC monthly (ICD9 = 585.6) 3. Ferritin, TSAT, Fe, TIBC: quarterly, (Jan, April, July, Oct) for all 4. PTH Intact: quarterly (Jan., April, July, Oct.) for all patients 5. Aluminum: Annually (Jan.) if not on aluminum hydroxide; quarterly if on aluminum hydroxide. (ICD9 = 268.2) 6. HBsAg, Anti-HBs: Annually. (ICD9 – 585.6) 7. Hepatitis C Antibody: Semiannually (Jan., July) (ICD9 585.6) To monitor adequacy, initiate Adequacy Protocol. (ICD9 = 585.6) Northwest Kidney Centers Home Dialysis Program- Peritoneal Dialysis Unit Adult Peritoneal Dialysis Patients Standing Orders 5. DARBEPOETIN (ARANESPTM) (ICD9 285.21) B. To start patients on AranespTM, hematocrit must be less than 36%. The target hematocrit range is 33% - 36%. For total maintenance doses of AranespTM, doses of greater than 200 mcg/wk require CMO approval. F. No monthly dose of > 1200 mcg is permissible. Maintain current dose. Monthly dose decrease per table (O) depending on dosage frequency HOLD AranespTM and notify MD. Redraw Hct on routine. schedule. When Hct <36% resume at one dose titration lower than dose at the time it was placed on HOLD. 1. Positive stool for occult blood. 2. Hct > 42%. I. Dose of AranespTM shall be either: 25 mcg, 40 mcg, 60 mcg, 100 mcg, 150 mcg, and 200 mcg except for naïve patients (see item L below). Splitting of fixed doses is not allowed. J. AranespTM shall be given q 1 week, q 2 week or q 4 week. Patients will start at q 1 week or q 2 week dosing. L. DOSE INITIATION FOR UNTREATED PATIENTS: ESA naive patients will be dosed as follows: M. DOSE CONVERSION FOR EPOGENTM TREATED PATIENTS: See: PD Addendum: AranespTM Conversion Tables. Northwest Kidney Centers Home Dialysis Program- Peritoneal Dialysis Unit Adult Peritoneal Dialysis Patients Standing Orders N. DOSE TITRATION FOR TARGET RANGE ACHIEVEMENT: UPWARDS: If Hct below goal of 33%, increase dose per table below: O. DOSE TITRATION FOR TARGET RANGE ACHIEVEMENT: DOWNWARDS: If Hct >36% but < 42%, decrease dose per table below once monthly. If Hct >42 %, HOLD. Northwest Kidney Centers Home Dialysis Program- Peritoneal Dialysis Unit Adult Peritoneal Dialysis Patients Standing Orders Note: Iron Sucrose (Venofer) or Sodium Ferric Gluconate (FerrlecitTM) are used in the home dialysis programs. (ICD9 258.21) A. All patients on Peritoneal Dialysis should receive FerrlecitTM or Venofer Continuing oral iron supplementation is at the attending physician's discretion if patient is receiving IV iron. C. Goals: Ferritin 100 – 500mg/mL and TSAT 25% - 50%. 1. Lab monitoring of TSAT and ferritin quarterly in January, April, July, 2. Iron labs must be drawn at least 1 week after last IV iron dose. E. Test Dosing: (To be given during PD training.) 1. FerrlecitTM: For patients new to FerrlecitTM Administer FerrlecitTM test dose of 25mg (2cc of a 62.5 mg vial) over 3 minutes for the first dose only to assure no allergic reaction. 2. Venofer ®: For patients new to Venofer.) Give test dose of 25mg Venofer® IV for the first dose only to assure no allergic reaction. 3. Have available intravenous medications to treat possible anaphylactic reaction (ICD9 995.29) to IV iron when it is administered: (benadryl, 25-50 mg IV; epinephrine 1:1000, 1 mg/mL, 0.2-1 mL SQ or IM; solumedrol, 125 mg IV), regardless of whether a patient had a prior dose or not. Northwest Kidney Centers Home Dialysis Program- Peritoneal Dialysis Unit Adult Peritoneal Dialysis Patients Standing Orders F. Repletion: For patients who are iron deficient (TSAT <20% and Ferritin a. Infuse 125mg of Ferrlecit IV monthly for three months. b. Wait no less than one week following the final repletion dose to draw iron laboratory values. c. Adjust Ferrlecit dose based on laboratory values (see IV Iron Dose Adjustments chart below). OR a. Infuse Venofer® 200mg IV monthly for three months. b. Wait no less than one week following the final repletion dose of Venofer to draw iron laboratory values. c. Adjust dose of Venofer® based on laboratory values. (see IV Iron Dose Adjustments chart below). G. IV Iron Dose Adjustments base on laboratory values per chart: 7. HEPATITIS B PATIENT SURVEILLANCE AND VACCINATION Protein intake: 1.2 to 1.5 gm./kg. Body weight. Phosphorus: .8 to 1.2 gm./day. Other guidelines individualized. Northwest Kidney Centers Home Dialysis Program- Peritoneal Dialysis Unit Adult Peritoneal Dialysis Patients Standing Orders Dry Weight Evaluations to be performed before patient completes peritoneal home dialysis training and three times yearly with Peritoneal Adequacy Testing. B. DIABETES CARE May refer to certified diabetic educator as needed. 1. DOSE CONVERSION FOR EPOGENTM TREATED PATIENTS: Patients on EpogenTM will be converted to AranespTM per conversion table. (See item A.) 2. Patients previously on AranespTM q 1 week, q 2 week, or q 4 week will continue 3. Patients previously on AranespTM q 3 week will be converted to q 2 week. A. DOSE CONVERSION OF EPOGEN TREATED PATIENTS to AranespTM Initiate dose conversion of EpogenTM-treated patients to AranespTM with q 1 week administration to assure stability of hematocrit prior to expanding interval of administration. B. DOSE CONVERSION FOR CHANGING Q 3 WEEK TO Q 2 WEEK ARANESPTM C. DOSE CONVERSION FOR CHANGING Q 1 WEEK TO Q 2 WEEK ARANESPTM

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