1. Watch for Issues Before and During PD Training
When we teach safe home dialysis practice, our aim is to enable our patients to avoid complications and emergencies when possible—without inhibiting their learning by triggering fear and anxiety. We need to prepare—not scare, and help patients recognize and respond to issues before they cascade into bigger complications or emergencies. We must train our patients to observe themselves carefully so they can note subtle changes and take corrective action early.
We also must train patients to trust their intuition and act whenever something—anything—does not feel right. Ways that we can empower patients to trust themselves include:
Be Alert for Red Flags During a Home Visit Before a Patient Starts Training
In the Setting Patient Expectations for Home Dialysis course, you’ll find a detailed safety and logistical considerations checklist of what to look for in patients’ homes. This course will review major first home visit red flags.
To help avoid complications, be alert for signs of emotional instability or psychosocial dysfunction that you may need to address prior to training. Make sure these factors do not impact your patient’s motivation or willingness to learn.
Some clinics do not require a home visit prior to initiation of PD. Consider doing one anyway to help you better see how the set-up will work for your patient.
Remember the Showerhead!
IPatients on PD are susceptible to infections from unclean water. Biofilms develop within household pipes and microorganisms can be directly introduced to the exit site during routine care while showering. The CDC recommends cleaning showerheads with a white vinegar solution. Some PD patients are advised to use a bleach solution monthly to prevent infections (Figueiredo AE, 2023).
Remove hard water mineral scale.
Removable handheld shower heads can be soaked in a pot of white vinegar for 10-20 minutes to dissolve scale. If the shower head does not come off, the patient can fill a sturdy plastic bag with enough white vinegar to cover it and use a rubber band or tape to hold the bag in place. Tough scale may need longer soak time, a scrub brush, or couple of tablespoons of baking soda along with the vinegar.
Rinse with water.
Wash off all the vinegar so it does not end up on the patient. Rinse out the container if the shower head was removable.
Rinse with 1:100 diluted bleach.
Bleach kills most bacteria and fungi, but it is too strong to use on its own. One teaspoon of bleach to a gallon of water is correct. Use a rinsed-out pot for a removable shower head or a fresh bag for one that does not come off.
Rinse with water again.
Rinse off all bleach residue and run the shower for 5 minutes before using it.
If you see a red flag that makes you question whether a patient’s domestic situation is dangerous, exploitative, or abusive, as a nurse and a mandated reporter, you must call Adult Protective Services.
- Extreme filth that could create a fire hazard or infection risk
- Very poor personal hygiene
- Lack of food in the home
- No functioning toilets or running water to wash hands
- Signs of domestic abuse
Have diabetes and struggle with glucose control
Patients may not know at first that glucose is the most common osmotic agent in PD—and is absorbed into their blood. Patients with diabetes will have higher blood sugar readings and may need adjustments to oral meds or insulin after starting PD. Warn patients of this, suggest that they consult their diabetes doctor for updated parameter instructions. It is never too late to address diabetes.
Still make urine
Patients may not know at first that glucose is the most common osmotic agent in PD—and is absorbed into their blood. Patients with diabetes will have higher blood sugar readings and may need adjustments to oral meds or insulin after starting PD. Warn patients of this, suggest that they consult their diabetes doctor for updated parameter instructions. It is never too late to address diabetes.
Unsure why they take each of their meds
Some patients may not have discussed their meds with someone who looks across all of their scripts and OTC products. Patients need to know what medications they are taking—why—and how to take them properly. A medication review can be a good chance for you to:
- Verify their understanding
- Discuss side effects
- Look up drug interactions
- Find out if they are taking each drug as prescribed (and if not, why not).
A meta-analysis of ways to improve medication adherence in ESKD patients found 36 studies of 3,510 patients (Murali KMK et al., 2019). Most of these studies included patient education, counseling, or both—and had better outcomes as a result.
Taking meds prescribed by several doctors
Polypharmacy is use of five or more meds. As dialysis patients tend to have comorbidities, on average they take 6.8 meds (Beben, 2023), and 25% took 25 (or more) pills or capsules a day (Triantafylidis, 2018)! The risk of incorrect dosing, adverse drug interactions, and overall treatment burden increases with the number of meds per day. You will see polypharmacy more often than not. Do a full drug reconciliation with the patient and ask the nephrologist about deprescribing meds that may no longer be needed. (Hall, 2023; Beben, 2023; Triantafylidis, 2018).
Taking a drug that may be unnecessary, unsafe, or contraindicated in dialysis
“Potentially inappropriate” medications are prescribed to 40-60% of older adults with ESKD (Hall, 2023). Kidney failure reduces drug clearance, which can raise the risk of adverse effects and accumulations. Patients may also prefer to take fewer meds, especially if side effects hinder their independence or reduce their quality of life (Hall, 2023).
At risk for hypotension due to medication side-effects
Due to age and kidney function, dialysis patients may be more at risk for hypotensive effects of common meds such as diphenhydramine, gabapentin, and opiate pain killers (Triantafylidis, 2018). Hypotensive reactions can cause weakness, dizziness, falls, injuries, and long-term complications.
Have patients with partners each fill out a Partner Agreement on Tasks for Home Dialysis-PD (PATH-D-PD).
Discuss and compare completed forms while you watch for interpersonal red flags that might signal potential aggression, intimidation, discord, or domestic abuse concerns that could become safety issues. Watch for bullying, disrespect, or a burdensome division of labor.
A patient and partner who can’t get along and respect each other in front of you are unlikely unable to communicate and cooperate effectively at home. A patient and/or a care partner can be volatile. Most people can do PD by themselves. Some may need a helper for occasional tasks only, such as heavy-supply lifting.
Home dialysis may be a stressor that aggravates domestic discord and this can be a reason to train a patient solo, even if a partner is also in the home. If a partner is present and they do get along wonderfully—still encourage the patient to do as many of the treatment steps as possible.
PD may not be a good fit for a patient who refuses to learn or accept any responsibility for treatment because their partner will do it. A few thoughts:
Encourage patient participation. A patient who is capable of learning and doing PD but wants nothing to do with it may start to take control over the treatment if you separate them from the partner during training. Train the patient first and foremost. If a partner wants to know how to do PD too, let the patient teach the partner in front of you. This is a good way to ensure the patient understood what you taught them
Find ways for a partner to help. A partner who wishes to be helpful for PD can do so without having to actively perform medical tasks. They can break down boxes, organize supplies, or even manage ordering and receiving. Helpers do not have to do dialysis or dressing changes.
Teach the patient even if a partner is needed. Some patients do require a partner or caretaker for PD. When this is the case, teach the patient too and encourage as much patient involvement and participation as possible.
Model what to do about contamination. During training, help patients develop their own culture of infection control by modeling what a contamination is and what to do about it. Patients may not be aware of asepsis and the need for aseptic technique when they start training—but this knowledge is one of the most critical things they must leave with. Patients are the most invested in not getting an infection: they need to know how and why to use aseptic technique correctly.
Caution patients to avoid shortcuts. In an observational study, about half of patients on PD “took shortcuts, modified the standard exchange method, and/or ailed to follow appropriate hand hygiene protocols properly or follow aseptic technique” within 3 months of PD initiation (ISPD, 2022).