Angeles University Foundation

Angeles City, Philippines

A.Y. 2023-2024

FLIPPED CLASSROOM:
PERITONEAL DIALYSIS

SUBMITTED BY:
BENOZA, Christine Anne S.
CALLANTA, Joven T.
PINEDA, Arfienel M.
SAMSON, Jerika Ina S.
TUBIG, Alexa Jean S.
BSN 4-D / GROUP 16 / SUBGROUP A

SUBMITTED TO:
Diane Anne A. Lozano, RN

SEPTEMBER 2023
 ● BRIEF INTRO RE: CKD

The kidneys, each about the size of a fist, located on either side of the spine just
below the rib cage, are responsible for removing waste products and excess fluid from the
body. Each kidney contains about a million nephrons which is responsible for the filtering
function of the kidney. Blood enters the glomerulus where it is filtered while the remaining
fluid passes along the tubule. In the tubule, chemicals and water are either absorbed or
removed according to the body’s needs, the final product is urine which we excrete. However,
some people experience a decrease in this kidney function for a long period of time which is
defined to be chronic kidney disease. There are many possible causes for this disease
including diabetes which is the leading cause of kidney disease. This is because high levels of
blood sugar cause damage to the blood vessels and nephrons of the kidneys. This damage
causes the kidney not to function well. Another leading cause is hypertension wherein
narrowing, hardening, and weakening of arteries happen. The damaged arteries are not able to
supply enough blood to the kidneys. The nephrons are not able to receive adequate oxygen
and nutrients causing damage to them.

If the kidneys are too damaged, dialysis may be needed to help remove waste
products and excess fluid from the blood that the kidneys can no longer filter. Dialysis is
usually needed when the kidneys’ function is only around 10-15%. Additionally, a GFR
-which measures how well the kidneys are processing wastes- of below 15 ml/min indicates
the need for dialysis. Generally, this is stage 5 of chronic kidney disease and once dialysis or
transplantation is deemed necessary this is called End Stage Renal Disease (ESRD).
Furthermore, dialysis works by removing extra waste and fluids, keeping safe levels of
minerals in the body and it also helps regulate blood pressure. Two types of dialysis can be
done; hemodialysis and peritoneal dialysis. Hemodialysis makes use of a machine that filters
the waste and extra fluid from your body then the filtered blood goes back to the body. This
process requires a vascular access site and is usually done three times per week lasting for 4
hours per session. Another is peritoneal dialysis wherein the differences lie on where the
blood is filtered. In peritoneal dialysis, blood is filtered inside the body instead of a dialyzer
with a dialysate, and a catheter is placed on the belly.
● DEFINITION
○ What is Peritoneal Dialysis?

○ Peritoneal dialysis is a medical procedure employed to treat patients

experiencing kidney failure. It utilizes the peritoneum, the lining of the
abdomen, to internally cleanse the blood. This approach ensures a thorough
and streamlined process of blood filtration within the body, resulting in an
effective and efficient treatment method.
○ The peritoneum plays a vital role as the semipermeable membrane required for
dialysis. To gain access, a peritoneal dialysis catheter is inserted into the
abdomen. Peritoneal Dialysis operates based on the principles of osmosis,
diffusion, and ultrafiltration. Through this process, fluid and solute are
transferred from the bloodstream into the dialysate solution by crossing the
peritoneum.
○ The peritoneal membrane is known for its size and porosity, allowing solutes
and fluid to move through osmosis. This movement happens from areas of
lower concentration in the body to areas of higher concentration in the
dialyzing fluid. Additionally, the peritoneal cavity contains numerous
capillaries, providing easy access to the blood supply (Saunders, 2019).
● HOW DOES IT WORK?
○ This procedure starts with catheter insertion a few weeks before starting
peritoneal dialysis.
○ Moreover, at the beginning of the procedure, the dialysis solution (composed
of water with salt and other additives) flows from a bag through the catheter
into the abdomen. When the bag is empty, the patient can disconnect it and
cover the catheter with a cap, allowing them to resume their normal activities.
While the dialysate is inside the peritoneal cavity, it absorbs waste products
from blood vessels in the lining of the abdomen through the process of
osmosis.
○ After several hours, the dialysate and wastes absorbed are drained out of the
abdomen into an empty bag. The used solution can be discarded in the toilet.
The patient can then repeat the dialysis procedure with a new bag of dialysate.
○ Wastes are easily absorbed by the dialysate when it is fresh, however, the
filtering gets slower as time goes on. This necessitates the patient to drain the
used solution from the peritoneal cavity four to six times a day, then refill it
with fresh solution. This process is called an exchange. Exchanges can be
done during the day, or at night using a cycler that pumps the fluid in and out.
● TYPES OF PERITONEAL DIALYSIS
○ Continuous Ambulatory Peritoneal Dialysis (CAPD)
■ Continuous Ambulatory Peritoneal Dialysis (CAPD) does not require a
machine, thus, exchanges are done during the day by hand. Exchanges
can be done in any place that is clean and well-lit, and each exchange
takes about 30-40 minutes. That’s why it is called “ambulatory,” since
the patient is not attached to a machine of any kind and is able to
move—whenever, wherever. During the procedure, the patient can
perform basic ADLs such as reading, talking, watching, or even
sleeping. The dialysate stays in the abdomen for 4-6 hours or more
(dwell time). Normally, exchanges are done, at least, four times a day.
The patient sleeps with the solution in their abdomen and does not
have to wake up to perform another exchange.

○ Automated Peritoneal Dialysis/Continuous Cycling Peritoneal Dialysis

(CCPD)
■ On the other hand, Automated Peritoneal Dialysis (APD), also known
as Continuous Cycling Peritoneal Dialysis (CCPD), is an automated
process that uses a machine called a “cycler” to perform your
exchanges 3-5 times during the night. A fresh solution will then be
used the next morning. The patient may leave this solution in their
abdomen all day or perform one exchange in the middle of the
afternoon without the machine.
■ While the instillation of APD dialysate is carried out while the patient
is in a supine position, whereas CAPD dialysate dwell is carried out
when the patient is in an upright position, the intraperitoneal pressure
is lowered by more than 50% in APD when compared to CAPD.
● INDICATIONS
○ End Stage Renal Disease (ESRD)
Peritoneal dialysis is indicated when kidney function is severely
impaired and can no longer maintain proper electrolyte balance, eliminate
waste products, and regulate fluid levels in the body.

○ Limited or Failed Vascular Access for Hemodialysis

Due to factors including prior vascular access failures, vascular
disease, or thrombosis, some individuals may have limited or compromised
vascular access for hemodialysis. Hence, peritoneal dialysis provides an
alternative option that doesn't require vascular access.

○ Poor Cardiovascular Status

Peritoneal dialysis is often considered for patients who have significant
cardiovascular issues that make hemodialysis less suitable. It has a gentler
impact on the cardiovascular system and can be better tolerated by some
patients.

○ Intolerance to Hemodialysis
Some people may experience intolerable side effects or complications
with hemodialysis, such as hypotension, muscle cramps, or nausea. Peritoneal
dialysis may be a more suitable option for them.

○ Pediatric Patients and Geriatric Patients

Peritoneal dialysis is often used in pediatric patients, especially those
who are aged 0-5 years old with ESRD, due to their smaller size and potential
difficulty in finding vascular access for hemodialysis. It can also be used for
geriatric patients who may have multiple comorbidities and reduced vascular
access options.

○ Desire for Home-Based Treatment/Preference

Peritoneal dialysis can be performed at home, allowing patients more
flexibility and independence in their treatment schedule compared to in-center
 hemodialysis, especially if they have work or family commitments. This can
be convenient for those who are distant from health centers as well.

○ Need for Continuous Renal Replacement Therapy (CRRT)

Peritoneal dialysis can be utilized as a form of CRRT in critically ill
patients with acute kidney injury when continuous treatment is necessary. It
provides a continuous method of waste and fluid removal.

● CONTRAINDICATIONS
○ Uncontrolled Infections or Peritonitis
Peritoneal dialysis involves placing a catheter into the peritoneal
cavity. If there are ongoing infections or peritonitis (inflammation of the
peritoneal membrane), the procedure can worsen the infection and lead to
further complications.

○ Abdominal Hernias
Abdominal hernias can be a contraindication because they can interfere
with the placement of the dialysis catheter and the stability of the peritoneal
membrane, potentially leading to complications.

○ Significant Abdominal Surgery or Scarring

Previous abdominal surgeries or extensive scarring can hinder the
proper functioning of the peritoneal membrane, which is necessary for
effective dialysis. Adhesions and scar tissue may impair the membrane's
ability to exchange fluids and solutes.

○ Severe Malnutrition
Peritoneal dialysis requires adequate muscle and nutritional status for
effective fluid and solute exchange. Patients with severe malnutrition or
wasting may not have the necessary abdominal muscle mass for successful
treatment.
 ● RISKS/COMPLICATIONS
Complications of peritoneal dialysis can include:
● Peritonitis - Peritonitis, which is an infection affecting the inner abdominal lining,
often emerges as a complication associated with peritoneal dialysis. Infections can
also stem from the catheter insertion point, responsible for transporting the cleansing
fluid (known as dialysate) into and out of the abdomen.
● Weight gain - Dialysate contains a sugar known as dextrose. If the body absorbs this
fluid, it could result in consuming hundreds of extra calories daily, potentially leading
to weight gain. Furthermore, these additional calories can elevate blood sugar levels,
particularly if the patient has diabetes.
● Hernia - Extended retention of bodily fluids can potentially exert strain on the
abdominal muscles and weaken them, hence increasing the risk of having a hernia.
● Inadequate dialysis - As time goes on, the effectiveness of treatment may diminish,
with peritoneal dialysis sometimes ceasing to work after several years, necessitating a
transition to hemodialysis.

● PREPARATIONS NEEDED
○ Catheter insertion
1. A siliconized rubber catheter, specifically a Tenckhoff catheter, is surgically
implanted into the peritoneal cavity of the patient for the purpose of
facilitating the infusion of dialysis fluid. To maintain a sterile environment, a
dressing is applied to cover the site where the catheter is inserted. This
dressing must be changed on a daily basis or whenever it becomes soiled or
wet.
2. The recommended placement location is approximately 3 to 5 centimeters
below the umbilicus. This specific area has minimal blood flow and offers less
resistance from the fascia.
3. The catheter is inserted subcutaneously, passing through adipose and muscular
tissue to reach the peritoneum. It is secured using inflatable Dacron cuffs
within the muscle and beneath the skin.
4. During a span of 1 to 2 weeks after insertion, fibroblasts and blood vessels
will develop around the cuffs, securing the catheter in position. This process
 not only reinforces the catheter but also acts as an additional safeguard against
dialysate leakage and bacterial infiltration.
5. In the event that the client is scheduled for transplant surgery, it will be
determined whether to remove or retain the PD catheter based on the
possibility of requiring dialysis after transplantation.

○ Dialysis Training
○ Following training, individuals are typically capable of independently
conducting both forms of peritoneal dialysis. To ensure proficiency in
exchanges and infection prevention, guidance from a dialysis nurse is
provided for a duration of 1 to 2 weeks. It is advisable for participants to have
a trusted companion present during this training period. With the aid of a
trained friend or family member, one can be equipped to handle situations
when assistance with exchanges is required due to illness or other
circumstances.
○ When opting for automated peritoneal dialysis, it is essential that you acquire
the necessary skills to effectively manage the process. This includes
familiarizing yourself with tasks such as preparing the cycler, connecting the
bags of dialysis solution, and placing the drain tube. Additionally, in order to
be well-prepared for any unforeseen circumstances such as power failures or
additional exchanges during the day, it is crucial to also learn how to perform
manual exchanges alongside nighttime automated peritoneal dialysis.
■ Performing an exchange
a. By hand

● Continuous ambulatory peritoneal dialysis (CAPD) is a manual

method that does not require the use of a machine. This allows for
more flexibility and convenience as you can perform the exchanges by
hand in any clean and well-lit space. Each exchange typically takes
around 30 to 40 minutes, during which time you can engage in
activities such as reading, talking, watching television, or even
sleeping. With CAPD, the dialysis solution is kept in your abdomen for
a period of 4 to 6 hours or longer, known as the dwell time. Typically,
you would change the solution at least four times a day and have it in
your abdomen while you sleep at night. The advantage of CAPD is that
there is no need to interrupt your sleep to perform an exchange.
● Step-by-Step Process:
1. Following proper hand hygiene and wearing a surgical mask,
you will proceed to drain the used dialysis solution from your
abdominal cavity into the designated drain bag. As you reach
the end of this process, it is common to experience a gentle
pulling sensation indicating that most of the fluid has been
extracted. Lastly, securely close the transfer set to complete this
procedure.
 2. It is essential to warm each bag of solution to body temperature
prior to use. This can be achieved by utilizing an electric
blanket or allowing the bag to rest in a tub of warm water.
Many solution bags are packaged in a protective outer wrapper,
which allows for safe warming in a microwave. However, it is
important to note that once you have removed the bag from its
wrapper, microwaving should not be attempted.
3. To effectively administer the solution, hang the new bag on a
pole and establish a connection with the tubing.
4. Before initiating the flow, it is essential to remove any trapped
air within the tubes. This can be done by allowing a small
amount of warm solution from the new bag to directly enter the
drain bag.
5. Ensure that the tube connected to the drainage bag is securely
fastened.
6. Next, proceed to open or reattach the transfer set and replenish
your abdominal cavity with a fresh solution of dialysis from the
hanging bag.

b. Using a cycler

● Automated peritoneal dialysis, also known as CCPD or continuous

cycler-assisted peritoneal dialysis, is a highly efficient and
convenient treatment option. During the night, a machine called a
cycler performs the necessary exchanges while you sleep. This allows
for multiple fillings and drainings of your belly with fresh solution,
 ensuring optimal cleansing and waste removal. In the morning, you
wake up with a fresh solution in your belly, ready to start your day.
Throughout the day, you have the flexibility to either keep the solution
in your belly or do a single exchange in the afternoon without relying
on the machine. Automated peritoneal dialysis provides patients with
an effective and hassle-free way to manage their condition.
● Step-by-Step Process:
1. Automated peritoneal dialysis involves the use of a cycler
machine to administer the dialysis solution in your abdomen.
With this method, you have the ability to customize the amount
and timing of the solution through programming options on the
cycler.
2. The cycler is programmed to execute three to five exchanges on
a nightly basis. To initiate the process, you attach tubing to the
cycler and connect it to three to five bags of dialysis solution,
allocating one bag for each exchange. In certain instances, the
machine may feature a separate tube exclusively for the final
exchange before concluding the session.
3. The cycler operates according to the schedule you establish. It
has several functions, including 1) releasing a clamp to
facilitate the drainage of used solution from your belly into
the drain line, 2) warming fresh dialysis solution prior to its
introduction into your body, and 3) releasing a clamp to
permit body-temperature solution to flow into your belly.
4. The cycler is equipped with a fluid meter that accurately
measures and records the volume of solution it removes. By
comparing the input and output amounts, the cycler allows both
you and your doctor to assess whether an adequate volume of
fluid is being eliminated during treatment. This valuable
information helps determine the effectiveness of the therapy in
removing excess fluid from your body.
5. Certain cycling machines offer the option to connect a lengthy
drainage hose that empties directly into your toilet or bathtub.
 Alternatively, there are models equipped with a disposal
container.
■ Catheter site care

Your healthcare providers will provide you with precise instructions on how to
care for your catheter in order to reduce the risk of infections. It is important to keep
the following guidelines in mind:
1. Safely store your supplies in a cool, clean, and dry location.
2. Before using any bag of solution, carefully examine it for any signs of
contamination, such as cloudiness.
3. Ensure you have a well-lit and sanitary area to conduct your exchanges.
4. Thoroughly wash your hands every time you handle your catheter.
5. Follow the instructions provided by your healthcare team and clean the area
where your catheter enters your body daily.
6. For added protection, wear a surgical mask during exchanges.

● PERITONEAL DIALYSIS VS HEMODIALYSIS

○ Hemodialysis is an ongoing procedure, usually conducted at a dialysis center
with sessions occurring 3 to 5 times per week. It necessitates the utilization of
an access point in the arm (AV Fistula) for blood filtration. Conversely,
peritoneal dialysis is also continuous, conducted daily, and involves filtering
the blood through rinsing the peritoneal cavity, the abdominal empty space.
The advantage of peritoneal dialysis is that it can be managed from the
convenience of one's home.
● NURSING RESPONSIBILITIES
■ Position the patient properly, elevate the head of the bed.
■ Warm the dialysate at body temperature.
■ Observe strict aseptic technique
■ Be alert for signs of infection (cloudy drainage and elevated
temperature).
■ Measure and record intake and output, including all body fluids
■ Weigh the patient when the abdomen is empty of dialysate.
■ Monitor vital signs, especially blood pressure and pulse. Also, note
bounding pulse and neck vein distention.
■ Anchor the catheter and tubing with tape and educate the patient to
avoid pulling or pushing the catheter.
■ Inform the patient that the first few bottles of drainage will normally be
pink-tinged.
■ Strictly adhere to the schedule for draining dialysate from the
abdomen.
■ Note reports of nausea and vomiting, increased and severe abdominal
pain, and fever, especially after dialysis.
■ Note reports of intense urge to void or large amount of urine after
dialysis has been initiated.
■ Note the presence of fecal material in the dialysate or a strong urge to
defecate with diarrhea.
■ Immediately stop dialysis if bowel and bladder perforation is noted.
 References

● Ellsworth, P. (2021). Peritoneal Dialysis Catheter Insertion: Overview, Indications,

Contraindications. Medscape.
https://emedicine.medscape.com/article/1829737-indications
● Dialysis, P., & Health, N. (2023). Peritoneal Dialysis - NIDDK. Retrieved 27 August
2023, from
https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/peritone
al-dialysis
● Mayo Foundation for Medical Education and Research. (2023, May 2). Peritoneal
dialysis. Mayo Clinic.
https://www.mayoclinic.org/tests-procedures/peritoneal-dialysis/about/pac-20384725
● National Kidney Foundation. (n.d.). How Your Kidneys Work.
https://www.kidney.org/kidneydisease/howkidneyswrk
● Sachdeva, B., Zulfiqar, H., & Aeddula, N. R. (2022). Peritoneal Dialysis. PubMed;
StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532979/
● University of Maryland Medical Center. (n.d.). Types of dialysis: Hemodialysis and
peritoneal dialysis: Kidney disease. Hemodialysis and Peritoneal Dialysis | Kidney
Disease | https://www.umms.org/ummc/health-services/kidney/dialysis/types