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PERITONEAL DIALYSIS CONTRAINDICATIONS TO PERITONEAL DIALYSIS:

PRINCIPLES: 1. Peritonitis
2. Recent abdominal surgery
- The peritoneum is the dialyzing membrane (SP 3. Abdominal adhesions, wound or infection
membrane) and substitutes for kidney function during 4. Impending renal transplant
kidney failure. 5. Fecal fistula or colostomy
6. Gastric or diaphragmatic hernia
- The peritoneal dialysis works on the principles of
diffusion and osmosis, the dialysis occurs via the
transfer of fluid and solute from the bloodstream
through the peritoneum. DIALYSATE SOLUTION

- The peritoneal membrane is large and porous, 1. Solution is sterile


allowing solutes and fluid to move via an osmotic 2. Solution contains electrolytes and minerals, a
gradient from an area of higher concentration in the specific osmolarity,a specific glucose
body to an area of lower concentration in the dialyzing concentration, and other medication additives
fluid. prescribed.
3. The higher glucose concentration, the greater
- The peritoneal cavity is rich in capillaries; therefore it
the amount of fluid removed during an
provides a ready access to blood supply.
exchange.
Basic Goals of Peritoneal Dialysis 4. Increasing the glucose concentration increases
the concentration of active particles that cause
1. Aid in the removal of toxic substances and osmosis and increases the rate of UF and the
metabolic wastes amount of fluid removed.
2. Establish electrolyte balance. 5. If hyperkalemia is not a problem, potassium
3. Removes excess body fluid. may be added to each bag of solution.
4. Assist in regulating the fluid balance of the 6. Heparin is added to the dialysate solution to
body prevent clotting of the catheter.
5. Control blood pressure. 7. Prophylactic antibiotics may be added to
6. Control severe, intractable heart failure dialysate to prevent peritonitis.
when diuretics no longer promote 8. Insulin may be added to the dialysate for the
elimination of water and sodium. client with diabetes mellitus.

NURSING OBJECTIVES:
ACCESS FOR PERITTONEAL DIALYSIS
a. To restore and maintain fluid and
electrolyte balance and preserve renal 1. A surgical insertion of a siliconzied rubber
function if possible. catheter into the abdominal cavity is
b. To prevent complication of therapy. required to allow infusion of dialysis fluid.
2. The preferred insertion site is to 3 to 5 cm
INDICATIONS OF PD: below the umbilicus because this area is
relatively avascular and has less fascial
a. Acute renal failure
resistance.
b. Sevre fluid overload in pediatric cardiac patients
3. The catheters are tunnelled under the skin
c. To remove toxic and metabolic wastes
to stabilize the catheter and reduce the risk
of infection.
4. Over a period of 1 to 2 weeks following i. When full, the bag is changed, new dialysate is
insertion, an ingrowth of fibroblasts and instilled into the abdomen, and the process
blood vessels occurs into the cuffs of the continues.
catheter, which fix the catheter in place and
provide an extra barrier against dialysate APD (Automated Peritoneal Dialysis)
leakage and bacterial invasion. a. It is similar to continuous ambulatory
EQUIPMENTS USED IN PD: peritoneal dialysis in that it is a continuous
dialysis process.
1. Dialysis administration set b. Requires a peritoneal cycling machine.
2. Local anesthesia
3. Warmer Types of Automated Peritoneal Dialysis
4. Tube clamps
5. Tenchkoff peritoneal catheter (adult - standard and curled) a. CCPD (Continuous Cycling Peritoneal Dialysis)
6. Trocath peritoneal catheter (pediatric)
- Dialysis usually consists of three cycles done
7. PD solution as prescribed
8. Supplemental drugs
at night and one cycle with an 8-hour dwell
9. CVP monitoring equipment done in the morning.
10. Sterile gloves - The sterile catheter system is opened only
11. Skin antiseptic for the ON and OFF procedures, which
12. ECG monitoring
reduces risk of infection.
13. Suture set
14. IV stand - The client does not need to do exchanges
during the day.
Types of PERITONEAL DIALYSIS b. IPD (Intermittent Peritoneal Dialysis)
- Dialysis is not a continuous procedure.
CAPD (Continuous Ambulatory Peritoneal Dialysis)
- Dialysis is performed for 10 to 14 hours, 3 to
a. Continuous dialysis closely resembles renal 4 times a week.
function because it is a continuous process. c. Nightly Peritoneal Dialysis
b. Continuous dialysis does not require a machine -Dialysis is performed 8-12 hours each night
for the procedure. with no daytime exchanges or dwells.
c. Continuous dialysis promotes client
PERITONEAL DIALYSIS INFUSION
independence.
d. The client performs self-dialysis 24 hours a day a. One infusion (inflow), dwell, and outflow is
7 days a week. considered one exchange.
e. Usually four dialysis cycles are administered in b. Dialysis uses an open system that presents a
24 hours, including an 8-hour dwell time risk of infection.
overnight. c. Inflow: The infusion of 1 to 2 L of dialysate as
f. One and a half to 2L of dialysate are installed prescribed is infused by gravity into the
into the abdomen 4 times daily and allowed to peritoneal space, which usually takes 10 to 20
dwell as prescribed. minutes.
g. The dialysis bag, attached to the catheter, is d. Dwell Time: The amount of time that the
folded and carried under the client’s clothing dialysate solution remains in the peritoneal
until time for outflow. cavity is prescribed by the physician and can last
h. After dwell, the bag is placed lower than the to 20-30 minutes to 8 or more hours depending
insertion site so that fluid drains by gravity flow. on the type of the dialysis used.
e. Outflow: Fluid drains out of the body by gravity
into the drainage bag.
INTERVENTIONS BEFORE TREATMENT COMMENCING PERITONEAL DIALYSIS ON THE
PATIENT:
a. Monitor VS.
b. Obtain Weight. *The volume of PD fluid used is generally 20-230 ml/kg.
c. Have the client void, is possible.
*In unstable patient, 10-20 ml/kg may be used
INTERVENTIONS DURING TREATMENT a. Attach the catheter connector to the
administration set, which has been previously
a. Monitor VS. connected to the container of dialysis solution.
b. Monitor signs of infection. The solution is warmed to body temperature
c. Monitor for respiratory distress, abdominal pain (37°C) for patient comfort and to prevent
or discomfort. abdominal pain. Heating also causes dilatation
Respiratory Distress: of the peritoneal vessels and increase urea
- Slow inflow rate
clearance.
- Prevent air from entering peritoneum by keeping
drip chamber of tubing three quarters full of fluid.
*Hot PD fluid can damage the peritoneum.
- Elevate head of bed, encourage deep breathing
exercises
- Turn patient side to side
* Cold PD fluid is painful, and will contribute to hypothermia
- Reduce the volume administered and should not be used.
Abdominal Pain:
- Encourage patient to move about if ambulatory b. Drug (heparin, potassium, and antibiotics) are
d. Monitor signs of pulmonary edema. added in advance. 100 units per liter of heparin,
e. Monitor for hypotension and hypertension is routinely added to the PD fluid to fibrin clot
f. Monitor for malaise, nausea, vomiting. from occluding the catheter. Potassium chloride
g. Assess the catheter site dressing for wetness or may be added on request unless patient has
bleeding. hyperkalemia. Antibiotic are added for the
Leaks: treatment of peritonitis. Permit the dialyzed
- Change the dressings frequently, being careful not to solution to flow unrestricted into the
dislodge the catheter peritoneum cavity usually 10-20 minutes. If the
- Use sterile drapes to prevent contamination patient experiences pain slow down the
h. Monitor dwell time to extend beyond the
infusion.
physician’s order because this increases risk of
c. Allow the fluid to remain in the peritoneal
hyperglycemia.
cavity for the prescribed dwell time. Prepare
i. Turn the client from side to side if the outflow is
the next exchange while the fluid is in the
slow to start. Elevate head of bed at intervals.
peritoneal cavity. In order for potassium, urea
j. Monitor outflow, which should be continuous
and other waste material to be removed, the
stream after the clamp is opened.
solution must remain in the peritoneal cavity
k. Monitor outflow for color and clarity.
for the prescribed dwell time.
l. Monitor intake and output accurately.
d. The maximum concentration gradient takes
m. If outflow is less than the inflow, the difference
place in the first 5-10 mins outflow time for
is equal to the amount absorbed or retained by
small molecules, such as creatinine and urea.
the client during dialysis and should be counted
Unclamp the outflow tube. Drainage should
as intake.
take approximately 10-30 mins although the
Keep accurate records:
- Exact time of beginning and end of each exchange time varies with each patient.
- Amount of solution infused and recovered e. If the fluid is not draining properly, turn the
- Fluid balance patient from side to side facilitate the removal
- No. of exchanges of peritoneal drainage. The head of the bed
- Medications added to dialyzing solution
- Pre and Post dialysis weight plus daily weight
may also be elevated. Ascertain if the catheter
- Level of responsiveness at beginning, throughout, and is patent. Check for closed clamp, kinked tubing,
at the end of the treatment or air lock. Never push the catheter in as you
- Assessment of VS and patient’s condition will introduce bacteria. If the drainage stops, or
start to drip before the dialyzing fluid has run
out, manipulating the catheter tip may be b. The cold temperature of the dialysate
helpful (or it may be necessary for the physician aggravates comfort, and the dialysate
to reposition the catheter). should be warmed before use, only with a
f. When the outflow drainage ceases to run, special dialysate warmer pad.
clamp off the drainage tube and infuse the next c. Place a heating pad on the abdomen during
exchange. the inflow to relieve discomfort; if a heating
g. Take BP and pulse every 15 mins. during the first pad is used, place it in low setting and
exchange and every hour thereafter. Monitor monitor client closely.
the heart rate for sign of arrhythmia. A drop in 3. Insufficient Outflow
blood pressure may indicate excessive fluid loss. a. Insufficient outflow may be caused by
Changes in the vital sign may indicate catheter migration out of the peritoneal
impending shock or over hydration. area; if this occurs, the physician must
h. Take the patient temperature every 4 hours reposition the catheter.
especially, after catheter removal. An infection b. Insufficient outflow also can be caused by a
is more apt to become evident after dialysis has full colon.
been discontinued. c. Maintain the drainage bag below the
i. The procedure is repeated until the blood client’s abdomen.
chemistry levels improve. The usual duration for d. Change the client’s outflow position by
short- term dialysis is 36 to 48 hrs. Depending turning the client on his or her side by
on patient’s condition, he will receive 24 to 48 ambulating the client.
exchanges . e. Check for kinks in the tubing
j. Keep the exact record of the patient’s fluid f. Encourage a high-fiber diet
balance during the treatment. Know the status g. Administer stool softeners as prescribed
of the patient’s loss or gain of fluid at the end of
each exchange. Check dressing for leakage and 4. Leakage around the catheter site
weight on gram scale if significant. The fluid a. Over a period of 1 to 2 weeks following
balance should be about even or should show insertion of the catheter, an ingrowth of
slight fluid loss or gain, depending on the fibroblasts and blood vessels into the cuffs
patient’s fluid status and doctor’s order. of the catheter occurse that fixes the
catheter into the cuffs of the catheter in
COMPLICATIONS OF PERITONEAL DIALYSIS place and provides an extra barrier agains
dialysate leakage and bacterial invasion.
1. Peritonitis
b. It may take up to 2 weeks for the client to
a. Maintain meticulous sterile technique when
tolerate a full 2-L exchange without leaking
hooking up of clamping off bags and when
around the catheter site.
caring for the catheter insertion site.
b. Follow instructional procedure for hooking
Characteristics of OUTFLOW
up or clamping off bags, which maybe
a. During the first or initial exchanges, the
include scrubbing the connection sites with
outflow may be bloody; outflow should
antiseptic solution.
be clear and colorless thereafter.
c. Monitor temperature closely.
b. A brown outflow indicates bowel
d. Monitor for fever, cloudy outflow, and
perforation.
rebound abdominal tenderness.
c. If the outflow is the same color as urine,
e. If peritonitis is suspected, obtain a culture
this indicates bladder perforation.
of the outflow to determine the infective
d. Cloudy outflow indicates peritonitis.
organism.
f. Administer antibiotics as prescribed.
2. Abdominal Pain Prepared by: Jojo Gepanayao,RN (2010)
a. Pain during inflow is common during the
first few exchanges, is caused by peritoneal
irritation, and disappears after 1 to 2 weeks
of dialysis treatments.