Discharge And Home Healthcare Guidelines

CRF and ESRD are disorders that affect the patient's total lifestyle and the whole family. Patient teaching is essential and should be understood by the patient and significant others. Note that you may need to work collaboratively with social services to arrange for the patient's dialysis treatments. Issues such as the location for outpatient dialysis and follow-up, home health referrals, and the purchasing of home equipment are important. All teaching should be reinforced at intervals during the patient's lifetime.

CARE OF PERITONEAL CATHETER FOR DIALYSIS. The access site is a sterile area that requires a sterile dressing except when the site is being accessed. Teach the patient or significant others the dressing technique recommended by your institution. In addition, the patient needs to learn the signs of an infected access site, such as swelling, redness, drainage, and odor. In addition, teach the patient to avoid restrictive clothing around the waist and to avoid external abdominal pressure.

CARE OF EXTERNAL ARTERIOVENOUS DIALYSIS ACCESS (SHUNT). A shunt can be surgically inserted on any limb, but the dominant arm is usually avoided. The access site is considered sterile and is covered with a sterile dressing at all times. Teach the patient to cover the access site between dialysis treatments with a dressing and further support, such as a nonelastic tensor bandage. Because one end of the shunt is inserted directly into an artery, care must be taken to ensure that the shunt does not accidentally come apart, which would lead to immediate hemorrhage. Teach the patient to carry a clamp to use if the shunt becomes disconnected. Teach the patient to feel for the "thrill" of blood moving through the shunt when it is touched (except during dialysis). The presence of darker blood within the shunt may indicate clotting; if this condition occurs, the patient needs to notify the dialysis staff or physician immediately. Any pressure on that limb—such as blood pressure readings, sleeping with the affected limb under the body, carrying boxes or groceries with that arm, or tight clothing—is contraindi-cated. Tell the patient not to use creams or lotions on the access site and to protect the site during bathing.

CARE OF THE ARTERIOVENOUS FISTULA. The increased pressure in the arterialized vein creates a large and sometimes unsightly vessel but also creates an access site with enough pressure to complete hemodialysis. Teach the patient to palpate a thrill over the anastomosis or graft site every day. Postoperatively, the patient may be asked to do strengthening exercises (grasping ball) to increase the size of the arterialized vein. After hemodialysis, the nursing staff applies pressure for a lengthy period of time to ensure clotting of the patient's blood. If the patient notices excessive bleeding after a dialysis treatment, she or he must notify the dialysis unit. Teach the patient that the site does not need to be protected during bathing. Tell the patient to remind all healthcare personnel that the involved arm should not be used for blood pressure measurements and phlebotomy.

POST-TRANSPLANTATION TEACHING. Discharge teaching for the patient with a renal transplant includes information about medications and the signs of rejection. The immunosup-pressive drugs place the patient at greater risk for infection and skin cancer. Teach the patient to avoid large groups of people in the first 3 to 4 months and strong sunlight for the duration of the transplant. Although most forms of daily activity are restricted only by how the patient is feeling, contact sports and heavy lifting are contraindicated because of the placement of the transplant. Teach the patient to report signs of infection, rejection, and skin changes immediately to the physician. Teach the patient or significant others about all medications, including dosage, potential side effects, and drug interactions.

Retinal Detachment

DRG Category: 046

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DRG Category: Mean LOS: Description:

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