Peritoneal Dialysis (PD)

By
JOSE BYRON DADULLA-
EVARDONE, RN

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Objectives
 To define Peritoneal Dialysis and to discuss its
principles.

 To list indications and contraindications of

Peritoneal Dialysis

 To enumerate general nursing care of patient

with Peritoneal Dialysis.

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PD
Principles of Peritoneal Dialysis
A. Usually temporary, can be used for clients in acute
reversible renal failure.

B. Basic goals of dialysis therapy.

1. Removal of end products of protein metabolism,
such as creatinine and urea.
2. Maintenance of safe concentration of serum
electrolytes.
3.Correction of acidosis and blood’s bicarbonate buffer
system.
4. Removal of excess fluid.

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PD
C. Renal perfusion is compromised when increased size of the
intravascular compartments and redistribution of blood volume result
from:
 Gram-negative sepsis
 Overdose of some drugs.
 Anaphylactic shock
 Electrolytes disturbances, such as acidosis.

D. Drugs are used to check for renal failure before client is placed on
dialysis.
1. In most cases, Mannitol is tried before dialysis.
1. Not reabsorb for kidney.
2. Has great osmotic effect and increases urinary flow.
3. Administration.
1. Given quickly in order to get higher blood level and then, in turn, filtered load.
2. If infusion is too slow, changes in the urinary flow depends on the amount of Mannitol
filtered.
3. Give 12.5g of a 25 percent solution in three minutes; if flow rate can be increased to
40 cc/hr, the client is in reversible renal failure.
4. Keep urine at 100 cc/hr with Mannitol.

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PD
1. Drugs such as Lasix (furusemide) and Edecrin
(ethacrynic acid) may be used if Mannitol is not
effective.
1. If the client does not respond to Lasix or edecrin,
diagnosis of acute tubular necrosis is stated.
2. If the client has increased urine output with drugs, be
sure to check electrolytes, as sodium and potassium
depletion occurs along with water loss.
3. In renal disease, make sure that drugs that depend on
kidney for secretion are not given.

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PD
 Dialysis is the process by which solutes and
fluid will pass through a semipermeable
membrane.
 Peritoneum is a large serous membrane
consists of a closed sac within the abdominal
cavity.
 Peritoneal Dialysis is the removal of solutes
and fluid across a semipermeable membrane
which is the peritoneum.

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PD

 PD is employed to remove waste and toxic

products from the blood ( peritoneal
capillaries ) to peritoneal cavity in cases of
renal insufficiency or failure.

 In order to achieve the above goal of

treatment , a solution which is called
Dialysate is infused into the abdomen
(peritoneal cavity) through an abdominal
catheter.
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PD
 The dialysate solution will stay in the
abdomen (peritoneal cavity) for specified
time, in order for difussion and osmosis
processes will occur.
 Diffusion is the movement of molecules from
an area of high concentration to an area of
low concentration.
Example: urea and creatinine in the blood will
shift to the peritoneal cavity with dialysate
which doesn’t have urea and creatinine
molecules.

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PD
 Osmosis is the movement of fluid from an
area of low concentration to areas of high
concentration.

 Dialysate solution inside the peritoneal cavity

with a high dextrose content causing a fluid
pull from intravascular (peritoneal capillaries)
to peritoneal cavity. Example: CAPD3

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 PD
Purpose
1. Aid in the removal of toxic substances and
metabolic wastes.
2. Establish electrolyte balance.
3. Remove excesses body fluid.
4. Assist in regulating the fluid balance of the
body.
5. Control blood pressure.
6. Control severe, intractable heart failure
when diuretics no longer promote
elimination of water and sodium.
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 PD
Indication for Peritoneal Dialysis
Acute renal failure.
Severe fluid overload in pediatric cardiac
patients.
To remove toxic and metabolic wastes.

Contraindication for Peritoneal Dialysis

Abdominal wound or infection
Peritonitis
Abdominal disease
Fecal fistula or colostomy
Gastric or diaphragmatic hernia
Extensive adhesions from previous surgery.
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 PD
Nursing Ojectives

* To restore and maintain fluid and electrolyte balance and

preserve renal function if possible.
* To prevent complication of therapy.

Equipment

Dialysis administration set Supplemental drugs as requested

Local Anesthesia CVP monitoring equipment
WarmerSterile gloves
Tube clamps Skin antiseptic
Teenckhoff peritoneal catheter (for Adult use) ECG monitoring
Trocath PD catheter (for Pediatric use) Suture set
Peritoneal dialysis solution as requested IV stand

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 Peritoneal Dialysis
Insertion of the Cannula
Check coagulation profile before insertion of the catheter.
The bladder should be empty before the procedures.

1. The abdomen is prepared surgically, and the skin and subcutaneous

tissues are infiltrated with local anesthetic.
2. A small mid line stab wound is made 3-5 cm below the umbilicus.
3. The trocar is inserted through the incision with stylet in place, or thin
stylet cannula may be inserted percutaneously.
4. The patient, if awake and cooperative, is requested, or assisted, to
raise his head from the pillow after the trocar is introduces. This
maneuver tightens the abdominal muscles and permits easy
penetration of the trocar without the danger of injury to the intra-
abdominal organs.
5. When the peritoneum is punctured, the trocar is directed toward the
left side of the pelvis. The stylet is removed, and the catheter is
tunnelled through the trocar and maneuver into position.

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 Peritoneal Dialysis
Insertion of the Cannula
6. Dialysis fluid is allowed to run through the catheter while it is
positioned. This prevent the omentum from adhering to the
catheter, impeding its advancement or occluding It’s opening.
7. After the trocar is removed, the skin maybe closed with a purse-
string suture ( this is not always done). A sterile dressng is placed
around the catheter.

8. For adult or permanent PD.

Whether you choose an ambulatory or automated form of PD, you’ll
need to have a soft catheter placed in your abdomen. The catheter
is the tube that carries the dialysis solution into and out of your
abdomen. If your doctor uses open surgery to insert your catheter,
you will be placed under general anesthesia. Another technique
requires only local anesthetic.

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 Peritoneal Dialysis
Insertion of the Cannula
Your doctor will make a small cut, often below and a little to the
side of your navel (belly button), and then guide the catheter
through the slit into the peritoneal cavity. As soon as the catheter is
in place, you can start to receive solution through it, although you
probably won’t begin a full schedule of exchanges for 2 to 3 weeks.
This break-in period lets you build up scar tissue that will hold the
catheter in place.
The standard catheter for PD is made of soft tubing for comfort.
It has cuffs made of a polyester material, called Dacron, that merge
with your scar tissue to keep it in place. The end of the tubing that
is inside your abdomen has many holes to allow the free flow of
solution in and out.

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 Peritoneal Dialysis
Insertion of the Cannula

Two double-cuff Tenckhoff peritoneal catheters: standard (A), curled (B).

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Peritoneal Dialysis
Insertion of the Cannula
9. Commencing peritoneal dialysis on the patient
* The volume of PD fluid used is generally 20-30 ml/kg
* In unstable patient, 10-20 m/kg may be used

Attach the catheter connector to the administration set, which

has been previously connected to the container of dialysis
solution( warmed to bdy temperature of 37°C). The solution
is warmed to body temperature for patient comfort and to
prevent abdominal pain. Heating also causes dilatation of the
peritoneal vessels and increase urea clearance.

* Hot PD fluid can damage the peritoneum.

* Cold PD fluid is painful, will contribute to hypothermia and
should not be used

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Peritoneal Dialysis
Insertion of the Cannula
9. Drug (heparin, potassium, and antibiotics) are added in
advance. The addition f heparin, 100 unit per liter, is routine
added to the PD fluid to fibrin clot from occluding the
catheter. Potassium chloride may be added on request unless
patient has hyperkalemia. Antibiotic are added for the
treatment of peritonitis.
Permit the dialyzed solution to flow unrestricted into the
peritoneum cavity (usually takes 5- 10 mins. completion).
if the patient experiences pain slow down the infusion.
Allow the fluid to remain in the peritoneal cavity for the
prescribed time period., 15 MINS. TO 4 HRS (inflow time).
Prepare the next exchange while the fluid is in the peritoneal
cavity. In order for potassium, urea and other waste material
to be removed, the solution must remain in the peritoneal
cavity for the prescribe time( dwelling time).

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Peritoneal Dialysis
Insertion of the Cannula
9. The maximum concentration gradients takes place in the first
5-10 mins. (outflow time) for small molecules, such as
creatinine and urea.
Unclamp the outflow tube. Drainage should be take
approximately 10-30 mins., although the time varies with
each patient.
9. If the fluids is not draining properly: move the patient from
side to side facilitate the removal of peritoneal drainage. The
head of the bed may also elevated. Ascertain if the catheter
is patent. Check for closed clamp, kinked tubing, or air lock.
Never push the catheter in as you will introduce
bacteria. If the drainage stop, or start to drip before the
dialyzing fluid has run out, manipulating the catheter tip may
be helpful ( or it may be necessary for the physician to
reposition the catheter).

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Peritoneal Dialysis
Insertion of the Cannula
9. When the outflow drainage ceases to run, clamp off the drainage tube and
infuse the next exchange.
take BP and pulse every 15 mins. During the first exchange and every hour
thereafter. Monitor the heart rate for sign of arrthymia. A drop in blood
pressure may indicate excessive fluid loss. Changes in the vital sign may be
indicate impending shock or over hydration.
10. Take the patient temperature every 4hrs. (especially after catheter removal).
An infection is more apt to become eviden after dialysis has been discontinue.
11. The procedure is repeated until the blood chemistries level improve. The
usual duration for short- term dialysis is 36 to 48 hrs. Depending on the
patient condition, he will receive 24 to 48 exchanges .
12. Keep the exact record of the patient’s fluid balance during the treatment.
Know the status of the patient’s loss or gain of fluid at the end of each
exchange. Check dressing for leakage and weight on gram scale if significant.
The fluid balance should be about even or should show slight fluid loss or
gain , depending on the patient’s fluid status and doctor’s order.

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Peritoneal Dialysis
Insertion of the Cannula
12. Promote patient comfort during dialysis.
Provide frequent back care and relieve pressure area
Have the patient turn from side to side.
Elevate head of bed at intervals.
Allow the patient to sit in chain for brief period if condition permits. The
patient may be mobilized during the outflow time if stable and permission
given by the doctor.

13. Observe the following:

A. Respiratory difficulty
- slow the inflow rate
- make sure the tubing is not kinked
- prevent air from entering peritoneum by keeping drip chamber of tubing
three quarters full of fluid.
- elevate head of bed: encourage breathing and coughing exersices.
- turn patient from side to side.
- reduce the volume administered

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Peritoneal Dialysis
Insertion of the Cannula
13. B. Abdominal Pain
- encourage patient to move about if ambulant
c. Leakage
- change the dressings frequently, being careful not to dislodge the catheter.
- used sterile plastic drapes to prevent contamination.
14. Keep accurate records:
- Exact time of beginning and end of each exchange: starting and finishing
time of drainage.
- amount of solution infused and recovered.
- fluid balance
- no. of exchanges
- medication added to dialysing solution.
- pre and post dialysis weigh plus daily weight.
- level of responsiveness at beginning, throughout, and at nd of treatment.
- assessment of vital signs and patient’s condition.

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Peritoneal Dialysis
Insertion of the Cannula
Change peritoneal dialysis cannula monthly usng
sterile technique or as per unit protocol (new
tenckoff silicone catheter can be left in for 3 month
if required.)
Complication:
Peritonitis
Mechanical
Metabolic disturbances
Cardio- respiratory problem

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PD Solutions (Dialysate)
 CAPD 2 is a PD solution, potassium free and
with 1.5% Dextrose content.

 CAPD 3 is a PD solution, potassium free and

with 4.25% Dextrose content.

 The above dialysates can be incorporated with

additives such as Heparin, Antibiotics, Na
Bicarbonate, etc.
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PD
 After a certain period of time, wherein both
processes difussion and osmosis have
occurred, the dialysate within the peritoneal
cavity together with the metabolic wastes and
extra fluid will be drained into the collection
bag through peritoneal catheter exiting
though the outflow tubing.

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Type of PD
Continuous Ambulatory Peritoneal Dialysis (CAPD)
 If you choose CAPD, you’ll drain a fresh bag of dialysis solution
into your abdomen. After 4 to 6 or more hours of dwell time,
you’ll drain the solution, which now contains wastes, into the
bag. You then repeat the cycle with a fresh bag of solution. You
don’t need a machine for CAPD; all you need is gravity to fill
and empty your abdomen. Your doctor will prescribe the
number of exchanges you’ll need, typically three or four
exchanges during the day and one evening exchange with a
long overnight dwell time while you sleep.
 Continuous Cycler-Assisted Peritoneal Dialysis (CCPD)
 CCPD uses an automated cycler to perform three to five
exchanges during the night while you sleep. In the morning,
you begin one exchange with a dwell time that lasts the entire
day.

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 PD
Preventing Problems
Infection is the most common problem for people on PD. Your health care
team will show you how to keep your catheter bacteria-free to avoid
peritonitis, which is an infection of the peritoneum. Improved catheter
designs protect against the spread of bacteria, but peritonitis is still a
common problem that sometimes makes continuing PD impossible. You
should follow your health care team’s instructions carefully, but here
are some general rules:
Store supplies in a cool, clean, dry place.
Inspect each bag of solution for signs of contamination before you use it.
Find a clean, dry, well-lit space to perform your exchanges.
Wash your hands every time you need to handle your catheter.
Clean the exit site with antiseptic every day.
Wear a surgical mask when performing exchanges.

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 PD
Keep a close watch for any signs of infection
and report them so they can be treated
promptly. Here are some signs to watch for:
Fever
Nausea or vomiting
Redness or pain around the catheter
Unusual color or cloudiness in used dialysis
solution
A catheter cuff that has been pushed out

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 PD
Equipment and Supplies for PD
Transfer Set
A transfer set is tubing that connects the bag
of dialysis solution to the catheter. When
your catheter is first placed, the exposed
end of the tube will be securely capped to
prevent infection. Under the cap is a
universal connector.
When you start dialysis training, your dialysis
nurse will provide a transfer set. The type
of transfer set you receive depends on
the company that supplies your dialysis
solution. Different companies have
different systems for connecting to your
catheter.
Connecting the transfer set requires sterile
technique. You and your nurse will wear
surgical masks. Your nurse will soak the
transfer set and the end of your catheter
in an antiseptic solution for 5 minutes
before making the connection. The nurse
will wear rubber gloves while making the
connection.

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PD
Depending on the company that supplies your
solution, your transfer set may require a new
cap each time you disconnect from the bag after
an exchange. With a different system, the tubing
that connects to the transfer set includes a piece
that can be clamped at the end of an exchange
and then broken off from the tubing so that it
stays on the transfer set as a cap until it is
removed for the next exchange. Your dialysis
nurse will train you in the aseptic (germ-free)
technique for connecting at the beginning of an
exchange and disconnecting at the end. Follow
instructions carefully to avoid infection
Transfer set. Between exchanges, you can keep your
catheter and transfer set hidden inside your
clothing. At the beginning of an exchange, you
will remove the disposable cap from the transfer
set and connect it to a Y-tube. The branches of
the Y-tube connect to the drain bag and the bag During an exchange, you can read,
of fresh dialysis solution. Always wash your
hands before handling your catheter and transfer talk, watch television, or sleep
set, and wear a surgical mask whenever you
connect or disconnect.

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PD

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