PERITONEAL DIALYSIS

INTRODUCTION

PD was first used in 1923, it did not come in to widespread use for chronic
treatment until the 1970s with the development of soft , pliable peritoneal solution
bags and the introduction of the concept of continuous PD. In the united states ,
approximately 10% of patients receiving dialysis treatment are on PD.

The goals of PD are to remove toxic substances and metabolic wastes and to
reestablish normal fluid and electrolyte balance. PD may be the treatment of choice
for patients with renal failure who are unable or unwilling to undergo hemodialysis
or renal transplantation. Patients who are susceptible to the rapid fluid, electrolyte,
and metabolic changes that occur during hemodialysis experience fewer of these
problems with the slower rate of PD. Therefore, patients with diabetes or
cardiovascular disease, many older patients, and those who may be at risk for
adverse effects of systemic heparin are likely candidates for PD.
Additionally,severe hypertension, heart failure, and pulmonary edema not
responsive to usual treatment regimens have been success-fully treated with PD.

TERMINOLOGY

Dialysis: refers to the diffusion of solute molecules through a semipermeable

membrane, passing from the side of higher concentration to that of lower
concentration.

Diffusion: Movement of solutes from an area of greater concentration to an area

of lesser concentration. Urea, creatinine, uric acid, potassium, and phosphate
diffuse. RBCs, WBCs, and large plasma proteins are too large to diffuse.

Osmosis: Movement of fluid from an area of lesser concentration to an area of

greater concentration.

Ultrafiltration:(water and fluid removal) results when there is an osmotic

gradient or pressure gradient across the membrane. Increased pressure in the blood
and a decrease pressure in the dialysate causes fluid to move from the blood into
the dialysate.

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ANATOMY AND PHYSIOLOGY

The renal and urinary systems include the kidneys, ureters, bladder, and urethra.
Urine is formed by the kidney and flows through the other structures to be
eliminated from the body.

The kidneys are a pair of bean-shaped, brownish-red structures located

retroperitoneally (behind and outside the peritoneal cavity) on the posterior wall of
the abdomen from the 12th thoracic vertebra to the third lumbar vertebra in the
adult .The average adult kidney weighs approximately 113 to 170 g (about 4.5 oz)
and is 10 to 12 cm long, 6 cm wide, and 2.5 cm thick . The right kidney is slightly
lower than the left due to the location of the liver.

The renal parenchyma is divided into two parts: the cortex and the medulla . The
medulla, which is approximately 5 cm wide, is the inner portion of the kidney. It
contains the loops of Henle, the vasa recta, and the collecting ducts of the
juxtamedullary nephrons. The collecting ducts from both the juxtamedullary and
the cortical nephrons connect to the renal pyramids, which are triangular and are
situated with the base facing the concave surface of the kidney and the point
(papilla) facing the hilum, or pelvis. Each kidney contains approximately 8 to 18
pyramids. The pyramids drain into minor calices, which drain into major calices
that open directly into the renal pelvis. The renal pelvis is the beginning of the
collecting system and is composed of structures that are designed to collect and
transport urine. Once the urine leaves the renal pelvis, the composition or amount
of urine does not change.

URETERS, BLADDER, AND URETHRA

The urine formed in the nephrons flows into the renal pelvis and then into the
ureters, which are long fibromuscular tubes that connect each kidney to the
bladder. These narrow tubes, each 24 to 30 cm long, originate at the lower portion
of the renal pelvis and terminate in the trigone of the bladder wall.

Bladder stores urine temporarily. Bladder and ureters are lined by transitional
epithelium.a membraneous tube called urethra arises from the neck of the bladder .
urethra conveys urine to the exterior.in the female, the urethra is very short about
4cm long.

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FORMATION OF URINE

Urine formation occurs in the nephrons of kidney. It involves three steps. They are
glomerular filtration, selective reabsorption and tubular secreation.

 GLOMERULAR FILTERATION

It is the first step in the urine formation. It occurs in the renal corpuscle across the
wall of the glomerular capillaries and the inner wall of the bowman’s capsule.
When blood flows under high pressure through the glomerular capillaries, water
and dissolved substances of blood filter out into the lumen of the bowman’s
capsule. The protein free and cell free fluid in the bowman’s capsule which is
obtained by the process is called glomerular filtrate. The filtrate contain smaller
molecules like glucose, urea, creatinine, mineral salts etc. it does not contain larger
particles like blood cells, proteins and lipids,because the wall of the glomerular
capillary is impermeable to these macromolecules. The volume of fluid formed
from the glomerular capillaries into thebowman’s capsule per unit time is called
glomerular filteration rate. In man the GFR is 125ml/day.

The driving force for this filteration is provided by the difference between the
glomerular blood pressure and the sum of the osmotic pressure of plasma proteins
and the pressure of the filterate present in the bowman’s capsule.

Glomerular blood pressure=55 mm of hg

Pressure of filtrate in Bowman’s capsule=15mm of hg

Osmotic pressure of plasma protein=30 mm of hg

Net filtration pressure =55-(15+30)=55-45=10mm of hg

The outpushing glomerular blood pressure is always greater than the osmotic
pressure of plasma proteins and the pressure of filtrate in the bowman’s capsule.
The net filtration pressure is 10 mm of hg and this pressure is responsible for the
glomerular filtration.

 SELECTIVE REABSORPTION

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Reabsorption take place in the renal tubles. Reabsorption is a selective process .
these are two mechanisms for tubular reabsorption. They are active and passive
process. Substance which are of considerable importance to the body such as
glucose, aminoacids, vitamins, and some mineral ions are actively reabsorbed.
hence they are called high threshold substances.

Substances like urea, uric acid, ammonia, creatinine and ketone bodies are
reabsorbed in small quantities from the filtrate to the blood. So these substance are
called low threshold substance. Some other substances like creatinine, sulphates
etc. are not reabsorbed. Total amount of glucose ,most of the aminoacids and
vitamin c,about 70%of Na+,75%of K+ and a large amount of Ca+ are reabsorbed
by diffusion from the proximal convoluted tubule. Nearly about 75% of water is
also reabsorbed by osmosis from the PCT to the blood.

About 5% of H2O is reabsorbed from the descending limb of the loop of henle.
Ascending limb is impermeable to water. K+.Cl - and some Na+ are reabsorbed in
the ascending limb.DCT , collecting tubule and collecting duct actively reabsorb

Some Na+from the filtration and in exchange, excrete some K+ in the urine. Some
Cl- is also reabsorbed by DCT.

 TUBULAR SECREATION

It is the final step in urine formation and it involves the active secretion of some
substances from the blood into the filtrate in the renal tubule. It takes place in the
distal convoluted tubule. It is an active process that requires ATP,K+, H+, NH 3,
sulphur compounds, uric acid, creatinine, drugs like pencillin etc. tubular secretion
plays a major role in the regulation of the pHof blood.

PERITONEAL LAYER

Abdominal organs are almost completely covered by the peritoneum. The two
types of peritoneum are the parietal, which lines the abdominal cavity wall, and
visceral, which covers the abdominal organs. The peritoneal cavity is the potential
space between the parietal and visceral layers. The two folds of peritoneum are the
mesentery and omentum. The mesentery attaches the small intestine and the part of
large intestine to posterior abdominal and contains blood and lymph vessels. The
lesser omentum goes from the lesser curvature of the stomach and upper
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duodenum to the liver, and greater omentum hangs from the stomach over the
intestine like an apron. The omentum contains fat and lymph nodes.

DIALYSIS

Dialysis refers to the diffusion of solute molecules through a semipermeable

membrane, passing from the side of higher concentration to that of lower
concentration. The purpose of dialysis is to maintain the life and well-being of the
patient. It is a substitute for some kidney excretory functions but does not replace
the kidneys' endocrine and metabolic functions.

Types:

 1) Intermittent Peritoneal Dialysis (IPD): Automated cycler equipment is

used to deliver the dialysate. Client dialyses 3 to 5 times per week
usually overnight for about 8 hrs per treatment. Cycler times the
inflow and outflow and warns with alarms which will wake client.
 2) Continuous Ambulatory Peritoneal Dialysis (CAPD): Client controls
inflow and outflow 4 to 5 times daily with a dwell time of 4 to 8 hours.
Client instills 2 L from a collapsible bag then clamps and then removes
dialysate by gravity. After removal bag is discarded. Tubing is
changed every 1 to 2 months.

 3) Cyclic Continuous Peritoneal Dialysis (CCPD): Combination of

the other two. 3 to 4 transfers are made at night and 2 L are left in the
peritoneal cavity during the day. With CCPD the system is only opened
twice a day, once to connect at night and once to disconnect in the
morning.

DIALYSIS SOLUTIONS AND CYCLES

DIALYSIS SOLUTION are available commercially in 1-2 l,plastic bag with

glucose concentration of 1.5%,2.5% and 4.25%.the electrolyte composition is
similar to that of plasma.

Ultrafiltration during PD depends on osmotic gradient , with glucose being most

effective osmotic gradient.

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PHASES:The three phases of the pd cycle are inflow, dwell, outflow.the three
phases are called an exchange.

INFLOW: during inflow (fill) ,a prescribed amount of solution, usually 2L ,is

infused through an established catheter over about 10 minutes. The flow rate may
decreased when the patient feels pain. After the solution has been infused ,the
inflow clamp is closed before air enters the tubing.

DWELL: (EQUILIBRIUM) during which diffusion and osmosis occur between

patient’s blood and peritoneal cavity. the duration of dwell time can last 20 to 30
minutes 8 or more hours, depending on method of PD.

DRAIN: drain time takes 15to 30 minutes and may be facilitated by gently
massaging the abdomen or changing position.

APPROACHES
PD can be performed using several different approaches:
acute intermittent peritoneal dialysis, continuous ambulatory peritoneal dialysis
(CAPD), and continuous cyclic peritoneal dialysis (CCPD).
Acute Intermittent Peritoneal Dialysis
Indications for acute intermittent PD,
 uremic signs and symptoms (nausea, vomiting, fatigue, altered mental
status)
 fluid overload
 acidosis
 hyperkalemia.
 Although PD is not as efficient as hemodialysis in removing solute and
fluid, it permits a more gradual change in the patient’s fluid volume status
and in waste product removal. Therefore, it may be the treatment of choice
for the hemodynamically unstable patient. It can be carried out manually
(the nurse warms, spikes, and hangs each container of dialysate) or by a
cycler machine. Ex-change times range from 30 minutes to 2 hours. A
common routine is hourly exchanges consisting of a 10-minute infusion, a
30-minute dwell time, and a 20-minute drain time.
NURSING RESPONSIBILITY.
❖ Strict aseptic technique is maintained when changing solution containers
and emptying drainage containers.

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 ❖ Vital signs,
❖ weight, I&O,
❖ laboratory values
❖ patient status are frequently monitored.
❖ The nurse uses a flow sheet to document each exchange and records vital
signs, dialysate concentration, medications added, exchange volume, dwell
time, dialysate fluid balance for each exchange (fluid lost orgained), and
cumulative fluid balance
❖ The nurse also carefully assesses skin turgor and mucous membranes to
evaluate fluid status and monitor the patient for edema.
❖ If the peritoneal fluid does not drain properly, the nurse can facilitate
drainage by turning the patient from side to side or raising the head of the
bed.
❖ The catheter should never be pushed further into the peritoneal cavity. Other
measures to promote drainage include checking the patency of the catheter
by inspecting for kinks, closed clamps, or an air lock.
❖ The nurse monitors for complications, including peritonitis, bleeding,
respiratory difficulty, and leakage of peritoneal fluid.
❖ Abdominal girth may be measured periodically to determine if the patient is
retaining large amounts of dialysis solution.
❖ The nurse must ensure that the PD catheter remains secure and that the
dressing remains dry.
❖ Physical comfort measures, frequent turning, and skin care are provided.
❖ The patient and family are educated about the procedure and are kept
informed about progress (fluid loss, weight loss, laboratory values).
❖ Emotional support and encouragement are given to the patient and family
during this stressful and uncertain time
CONTINUOUS AMBULATORY PERITONEAL DIALYSIS
CAPD is the second most common form of dialysis for patients with ESRD to be
started on (USRDS, 2007). CAPD is performed at home by the patient or a trained
caregiver who is usually a family member. The procedure allows the patient
reasonable freedom and control of daily activities but requires a serious
commitment to be successful.
CAPD works on the same principles as other forms of PD: diffusion and osmosis.
Less extreme fluctuations in the patient’s laboratory values occur with CAPD than
with intermittent PD or hemodialysis because the dialysis is constantly in progress.
The serum electrolyte levels usually remain in the normal range.

PROCEDURE

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  A permanent indwelling catheter is implanted into the peritoneum; the
internal cuff of the catheter becomes embedded by fibrous in growth, which
stabilizes it and minimizes leakage.
 A connecting tube is attached to the external end of the peritoneal catheter,
and the distal end of the tube is inserted into a sterile plastic bag of dialysate
solution.
 The dialysate bag is raised to shoulder level and infused by gravity into the
peritoneal cavity (approximately 10 minutes for a 2-L volume).
 The typical dwell time is 4 to 6 hours.
 At the end of the dwell time, the dialysate fluid is drained from the
peritoneal cavity by gravity. Drainage of 2 L plus ultrafiltration takes about
10 to 20 minutes if the catheter is functioning optimally.
 After the dialysate is drained, a fresh bag of dialysate solution is infused
using aseptic technique, and the procedure is repeated.
 The patient performs four to five exchanges daily, 7 days per week, with an
overnight dwell time allowing uninterrupted sleep; most patients become
unaware of fluid in the peritoneal cavity.

COMPLICATIONS
To reduce the risk of peritonitis, the patient (and all care-givers) must use
meticulous care to avoid contaminating the catheter, fluid, or tubing and to avoid
accidentally disconnecting the catheter from the tubing. Whenever a
connection/disconnection is made, hands must be washed and a mask worn by
anyone within 6 feet of the area to avoid contamination with airborne bacteria.
Excess manipulation should be avoided and meticulous care of the catheter entry
site is provided using a standardized protocol.

CONTINUOUS CYCLIC PERITONEAL DIALYSIS

CCPD uses a machine called a cycler to provide the exchanges. It is programmed
as to how much fluid to use and how long and how many exchanges need to be
done. Since it is programmed, it also keeps track of the total amounts removed and
will sound an alarm if limits are not met. It requires that a person set up and break
down the system for use, which typically takes about 15 minutes. CCPD combines
overnight intermittent PD with a prolonged dwell time during the day. The
peritoneal catheter is connected to a cycler machine every evening, usually just
before the patient goes to sleep for the night. Because the machine is very quiet,

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the patient can sleep, and the extralong tubing allows the patient to move and turn
normally during sleep.
In the morning, the patient disconnects from the cycler. Sometimes dialysate is left
in the abdominal cavity for a longer day dwell cycle. This day exchange is drained
during the day either by using a “Y” set or reattaching to the cycler. This process is
done every day to achieve the effects of dialysis required.
CCPD has a lower infection rate than other forms of PD because there are fewer
opportunities for contamination with bag changes and tubing disconnections. It
also allows the patient to be free from exchanges throughout the day, making it
possible to engage in work and activities of daily living more freely.

PROCEDURE GUIDELINES
Assisting the Patient Undergoing (Acute) Peritoneal Dialysis
EQUIPMENT
 Dialysis administration set (disposable, closed system)
 Peritoneal dialysis solution as requested

 Supplemental drugs as requested

 Local anesthesia
 Central venous pressure monitoring equipment
 Suture set
 Sterile gloves
 Skin antiseptic

PROCEDURE
Nursing Action
Preparatory phase
1. Prepare patient emotionally and
physically for the procedure.
2. Ensure that the consent form
has been signed.
3. Weigh patient before dialysis and
Rationale
1. Nursing support is offered by explaining
procedure mechanics, providing
opportunities for patient to ask questions,
allowing verbalization of feelings, and
giving expert physical care.
3.The weight at the beginning of the
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 every 24 hours thereafter,
preferably on an in-bed scale.
4. Take temperature, pulse,
respiration, and blood
pressure readings before
dialysis.
5. Have patient empty bladder.
6. Flush the tubing with dialysis
solution.
7. Make patient comfortable in a
supine position. Have patient and
health care personnel wear masks.
Performance phase
The following is a brief summary of
the method of insertion of a
temporary peritoneal catheter (done
under strict asepsis).
1.The abdomen is prepared
surgically, and the skin and
subcutaneous tissues are infiltrated and decreases the possibility of wound
with a local anesthetic.
2.A small midline incision is made
1¼ to 2 inches (3-5 cm) below the
umbilicus.
3. The trocar is inserted through the
incision with the stylet in place, or
a thin stylet cannula may be
inserted percutaneously.
4. Patient is requested to raise head 4. This maneuver tightens the abdominal
from the pillow after the trocar is
introduced.
5. When the peritoneum is
punctured, the trocar is directed
procedure serves as a baseline of
information. Daily weight confirms
ultrafiltration results and evaluates
volume status.
4. Measurement of vital signs at the
beginning of dialysis is necessary for
comparing subsequent changes in vital
signs.
5.If the bladder is empty, there is less risk
of perforating it when the trocar is
introduced into the peritoneum.
6. The tubing is flushed to prevent air from
entering the peritoneal cavity. Air causes
abdominal discomfort and drainage
difficulties.
7. This helps protect patient from airborne
contamination.
1.Surgical preparation of the skin
minimizes or eliminates surface bacteria
contamination and infection.
muscles and permits easier penetration of
the trocar without danger of injury to the
intra-abdominal organs.
5. This prevents the omentum from adhering
to the catheter, impeding its advancement
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 toward the left side of the pelvis.
The stylet is removed, and the
catheter is inserted through the
trocar and maneuvered into
position.
a.Dialysis fluid is allowed to run
through the catheter while it is
being positioned.
6. After the trocar is removed, the
skin may be closed with a purse-
string suture. (This is not always
done.) A sterile dressing is placed
around the catheter.
7. Attach the catheter connector to
the administration set, which has
been previously connected to the
container of dialysis solution
(warmed to body temperature,
98.6°F [37°C]).
8. Drugs (heparin, potassium,
antibiotic) are added in
advance.
9. Permit the dialyzing solution to
flow unrestricted into the
peritoneal cavity (usually takes 5-
10 minutes for completion). If
patient experiences pain, slow
down the infusion.
10Allow the fluid to remain in the
.peritoneal cavity for the
prescribed time period (20-30
minutes).
Prepare the next exchange while
the fluid is in the peritoneal cavity. first 5-10 minutes for small molecules,
11Unclamp the outflow tube.
or occluding its opening.
6. The catheter is attached to the skin to
prevent loss of the catheter in the
abdomen.
7. The solution is warmed to body
temperature for patient comfort and to
prevent abdominal pain. Heating also
causes dilatation of the peritoneal vessels
and increases urea clearance.
8. The addition of heparin prevents fibrin
clots from occluding the catheter.
Potassium chloride may be added on
request unless patient has hyperkalemia.
Antibiotics are added for the treatment of
peritonitis.
9. The inflow solution should flow in a
steady stream. If the fluid flows in too
slowly, the catheter may need to be
repositioned because its tip may be buried
in the omentum, or it may be occluded by
a blood clot. Flushing may help.
10For potassium, urea, and other waste
.materials to be removed, the solution
must remain in the peritoneal cavity for
the prescribed time (dwell or
equilibration time). The maximum
concentration gradient takes place in the
such as urea and creatinine.
11The abdomen is drained by a siphon
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 .Drainage should take .effect through the closed system. Gravity
approximately 20-30 minutes, drainage should occur fairly rapidly, and
although the time varies with each steady streams of fluid should be
patient. observed entering the drainage container.
The drainage is usually straw-colored.
12Check outflow for cloudy 12May be an early sign of peritonitis.
.appearance, blood, or fibrin. .
13If the fluid is not draining 13If the drainage stops, or starts to drip
.properly, move patient from side .before the dialyzing fluid has run out, the
to side to facilitate the removal of catheter tip may be buried in the
peritoneal drainage. The head of omentum. Rotating patient may be
the bed may also be elevated. helpful (or the physician may need to
reposition the catheter).
14Ascertain catheter patency. Check 14Pushing the catheter in introduces
.for closed clamp, kinked tubing, .bacteria into the peritoneal cavity.
or air lock. Never push the
catheter in.
15When the outflow drainage ceases
.to run, clamp off the drainage tube
and infuse the next exchange,
using strict aseptic technique.
16Take blood pressure and pulse 16A drop in blood pressure may indicate
.every 15 minutes during the first .excessive fluid loss from glucose
exchange and every hour concentrations of the dialyzing solutions.
thereafter. Monitor the heart rate Changes in the vital signs may indicate
for signs of dysrhythmia. impending shock or overhydration.
17Take patient's temperature every 4 17An infection is more apt to become
.hours (especially after catheter .evident after dialysis has been
removal). discontinued.
18The procedure is repeated until the 18The duration of dialysis depends on the
.blood chemistry levels improve. .severity of the condition and on the size
The usual duration for short-term and weight of patient.
dialysis is 48-72 hours. Depending
on patient's condition, 48-72
exchanges will be necessary.
19Keep an exact record of patient's 19Complications (circulatory collapse,
.fluid balance during the treatment. .hypotension, shock, and death) may occur
a.Know the status of patient's loss if patient loses too much fluid through
or gain of fluid at the end of peritoneal drainage. Large fluid losses
each exchange. Check dressing around the catheter may not be noted
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 for leakage and weight on gram
scale if significant. unless the dressings are
checked b.The fluid balance should be
about even or should show slight
fluid loss or gain, depending on
patient's fluid status.
20Promote patient comfort during 20The dialysis period is lengthy, and patient
.dialysis. .becomes fatigued.
a.Provide frequent back care and a.Pain may be caused by the dialyzing
massage pressure areas. solution not being at body temperature,
incomplete drainage of the solution,
chemical irritation, pressure by the
catheter, peritonitis, or air pressing on
the diaphragm, causing referred
shoulder pain.
b.Have patient turn from side to
side.
c.Elevate head of bed at intervals.
d.Allow patient to sit in chair for
brief periods if condition
permits (only with surgically
implanted catheter; with trocar,
patient is usually on bed rest).
21Observe for the following: 21Leakage around the catheter predisposes
. .patient to infection at the exit site and
a.Abdominal pain—note the time peritonitis. Dialysis may need to be
of discomfort during exchange terminated if leakage persists.
cycle and duration of symptoms.
b.Dialysate leakage—change the
dressings frequently, being
careful not to dislodge the
catheter; use sterile plastic
drapes to prevent contamination.
c.Place the patient in a more
upright position and use smaller
fluid volumes to try to relieve
pain and leakage.
22Keep accurate records. 22For proof of effectiveness of therapy and
. .for continuity of care.
a.Exact time of beginning and end
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 of each exchange: starting and
finishing time of drainage
b.Amount of solution infused and
recovered
c.Fluid balance
d.Number of exchanges
e.Medications added to dialyzing
solution
f. Predialysis and
postdialysis weight, plus
daily weight
g.Level of responsiveness at
beginning, throughout, and at
end of treatment
h.Assessment of vital signs and
patient's condition

COMPLICATIONS
Nursing Action Rationale
1Peritonitis 1.Peritonitis is the most common complication.
. Antibiotics may be added to dialysate and also
a.Watch for nausea and given systemically.
vomiting, anorexia,
abdominal pain,
tenderness, rigidity,
and cloudy dialysate
drainage.
b Send specimen of
. dialysate for white
blood cell count and
full set of cultures.
2Bleeding 2.A small amount of bleeding around the
. Hemodialysis
a.Hematocrit of the
drainage fluid may be
taken to determine the
amount of bleeding.

Advantages Over
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catheter is not significant if it
does not persist. During the first
few exchanges, blood-tinged
fluid from subcutaneous
bleeding is not uncommon.
Small amounts of heparin may
be added to inflow solution to
prevent the catheter from
becoming clogged.

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  Physical and psychological freedom and independence
 More liberal diet and fluid intake
 Relatively simple and easy to use
 Satisfactory biochemical control of uremia

COMPLICATIONS
 Infectious peritonitis, exit-site and tunnel infections.
 Noninfectious catheter malfunction, obstruction, dialy-sate leak.

 Peritoneal “pleural communication, hernia formation.

 GI bloating, distention, nausea.
 Hypervolemia, hypovolemia.
 Bleeding at catheter site.
 Bloody effluent secondary to internal bleeding. In female patients, this may
occur during menstruation.
 Obstruction may occur if omentum becomes wrapped around the catheter or
the catheter becomes caught in a loop of bowel.

PATIENT EDUCATION
 The use of CAPD as a long-term treatment depends on prevention of
recurring peritonitis.
o Use strict aseptic technique when performing bag exchanges.

o Perform bag exchanges in clean, closed-off area without pets and

other activities.
o Wash hands before touching bag.
o Inspect bag, tubing for defects and leaks.
 Do not omit bag changes this will cause inadequate control of renal failure.
 Some weight gain may accompany CAPD the dialysate fluid contains a
significant amount of dextrose, which adds calories to daily intake.
 Report signs and symptoms of peritonitis cloudy peritoneal fluid, abdominal
pain or tenderness, malaise, fever

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NURSING MANAGEMENT

MEETING PSYCHOSOCIAL NEEDS

In addition to the complications of PD previously described, patients who

elect to do PD may experience altered body image because of the presence
of the abdominal catheter, bag, tubing, and cycler. Waist size increases from
1 to 2 inches (or more) with fluid in the abdomen. This affects clothing
selection and may make the patient feel “fat.” Body image may be so altered
that patients do not want to look at or care for the catheter for days or weeks.
The nurse may arrange for the patient to talk with other patients who have
adapted well to PD.

Patients undergoing PD may also experience altered sexuality patterns and

sexual dysfunction. Although these problems may resolve with time, some
problems may warrant special counseling. Questions by the nurse about
concerns related to sexuality and sexual function often pro-vide the patient
with a welcome opportunity to discuss these issues and a first step toward
their resolution.

PROMOTING HOME AND COMMUNITY-BASED CARE

TEACHING PATIENTS SELF-CARE

Patients are taught as inpatients or outpatients to perform PD once their

condition is medically stable. Training usually takes 5 days to 2 weeks.
Patients are taught according to their own learning ability and knowledge
level. Because of protein loss with continuous PD, the patient is instructed to
eat a high-protein, well-balanced diet. The patient is also encouraged to
increase his or her daily fiber intake to help prevent constipation, which can
impede the flow of dialysate into or out of the peritoneal cavity. Many
patients gain 3 to 5 lb within a month of initiating PD, so they may be asked
to limit their carbohydrate intake to avoid excessive weight gain. Potassium,
sodium, and fluid restrictions are not usually needed. Patients commonly
lose about 2 to 3 L of fluid over and above the volume of dialysate infused
17
into the abdomen during a 24-hour period, permitting a normal fluid intake
even in an anephric patient (a patient without kidneys).

CONTINUING CARE

If a referral is made for home care, the home care nurse assesses the home
environment and suggests modifications to accommodate the equipment and
facilities needed to carry out PD. In addition, the nurse assesses the patient’s
and family’s understanding of PD and evaluates their technique in
performing PD. Assessments include checking for changes related to renal
disease, complications such as peritonitis, and treatment-related problems
such as heart failure, inadequate drainage, and weight gain or loss. The nurse
continues to reinforce and clarify teaching about PD and renal disease and
assesses the patient’s and family’s progress in coping with the procedure.

SPECIAL CONSIDERATIONS: NURSING MANAGEMENT OF THE

HOSPITALIZED PATIENT ON DIALYSIS

PROTECTING VASCULAR ACCESS

When the patient undergoing hemodialysis is hospitalized for any reason,

care must be taken to protect the vascular access. The nurse assesses the
vascular access for patency

TAKING PRECAUTIONS DURING INTRAVENOUS THERAPY

When the patient needs IV therapy, the rate of administration must be as

slow as possible and should be strictly controlled by a volumetric infusion
pump. Because patients on dialysis cannot excrete water, rapid or excessive
administration of IV fluid can result in pulmonary edema. Accurate intake
and output records are essential.

MONITORING SYMPTOMS OF UREMIA

As metabolic end products accumulate, symptoms of uremia worsen.

Patients whose metabolic rate accelerates (those receiving corticosteroid
medications or parenteral nutrition, those with infections or bleeding
disorders, those undergoing surgery) accumulate waste products more
quickly and may require daily dialysis. These same patients are more likely
than other patients receiving dialysis to experience complications.

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DETECTING CARDIAC AND RESPIRATORY COMPLICATIONS:
Cardiac and respiratory assessment must be conducted frequently. As fluid
builds up, fluid overload, heart failure, and pulmonary edema develop.
Crackles in the bases of the lungs may indicate pulmonary edema.
Pericarditis may result from the accumulation of uremic toxins. If not
detected and treated promptly, this serious complication may progress to
pericardial effusion and cardiac tamponade. Pericarditis is detected by the
patient’s report of substernal chest pain (if the patient can communicate),
low grade fever (often overlooked), and pericardial friction rub. A pulsus
paradoxus (a decrease in blood pressure of more than 10 mm Hg during
inspiration) is often present. When pericarditis progresses to effusion, the
friction rub disappears, heart sounds become distant and muffled, ECG
waves show very low voltage, and the pulsus paradoxus worsens. The
effusion may progress to life threatening cardiac tamponade, noted by
narrowing of the pulse pressure in addition to muffled or inaudible heart
sounds, crushing chestpain, dyspnea, and hypotension. Although
pericarditis, pericardial effusion, and cardiac tamponade can be detected by
chest x-ray, they should also be detected through astute nursing assessment.
Because of their clinical significance, assessment of the patient for these
complications is a priority.

CONTROLLING ELECTROLYTE LEVELS AND DIET

Electrolyte alterations are common, and potassium changes can be life-

threatening. All IV solutions and medications to be administered are
evaluated for their electrolyte content. Serum laboratory values are assessed
daily. If blood transfusions are required, they may be administered during
hemodialysis, if possible, so that excess potassium can be removed. Dietary
intake must also be monitored. The patient’s frustrations related to dietary
restrictions typically increase if the hospital food is unappetizing. The nurse
needs to recognize that this may lead to dietary indiscretion and
hyperkalemia. Hypoalbuminemia is an indicator of malnutrition in patients
undergoing long-term or maintenance dialysis. Although some patients can
be treated with adequate nutrition alone, some patients remain
hypoalbuminemic for reasons that are poorly understood.

MANAGING DISCOMFORT AND PAIN

Complications such as pruritus and pain secondary to neuropathy must be

managed. Antihistamine agents, such as diphenhydramine hydrochloride
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(Benadryl), are commonly used, and analgesic medications may be
prescribed. How ever, because elimination of the metabolites of medications
occurs through dialysis rather than through renal excretion, medication
dosages may need to be adjusted. Keeping the clean and well moisturized
using bath oils, super fatted soap, and creams or lotions helps promote
comfort and reduce itching. Teaching the patient to keep the nails trimmed
to avoid scratching and excoriation also promotes comfort.

MONITORING BLOOD PRESSURE

Hypertension in renal failure is common. It is usually the result of fluid

overload and, in part, over secretion of renin. Many patients undergoing
dialysis receive some form of antihypertensive therapy and require ongoing
teaching about its purpose and adverse effects. The trial and error approach
that may be necessary to identify the most effective antihypertensive agent
and dosage may confuse the patient if no explanation is provided.
Antihypertensive agents must be withheld before dialysis to avoid
hypotension due to the combined effect of the dialysis and the medication.
Typically these patients require single or multiple antihypertensive agents to
achieve normal blood pressure, thus adding to the total number of
medications needed on an ongoing basis.

PREVENTING INFECTION

Patients with ESRD commonly have low WBC counts (and decreased
phagocytic ability), low RBC counts (anemia), and impaired platelet
function. Together, these pose a high risk for infection and potential for
bleeding after even minor trauma. Preventing and controlling infection are
essential because the incidence of infection is high. Infection of the vascular
access site and pneumonia are common. Preventing Infection Patients with
ESRD commonly have low WBC counts (and decreased phagocytic ability),
low RBC counts (anemia), and impaired platelet function. Together, these
pose a high risk for infection and potential for bleeding after even minor
trauma. Preventing and controlling infection are essential because the
incidence of infection is high. Infection of the vascular access site and
pneumonia are common.

CARING FOR THE CATHETER SITE

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Patients receiving CAPD usually know how to care for the catheter site;
however, the hospital stay is an opportunity to assess catheter care technique
and correct misperceptions or deviations from recommended technique.
Recommended daily or three or four times weekly routine catheter site care
is typically performed during showering or bathing .The exit site should not
be submerged in bath water. The most common cleaning method is soap and
water; liquid soap is recommended. During care, the nurse and patient need
to make sure that the catheter remains secure to avoid tension and trauma.
The patient may wear a gauze or semi transparent dressing over the exit site.

ADMINISTERING MEDICATIONS

All medications and the dosage prescribed for any patient on dialysis must
be closely monitored to avoid those that are toxic to the kidneys and may
threaten remaining renal function. Medications are also scrutinized for
potassium and magnesium content, because medications containing
potassium or magnesium must be avoided..

PROVIDING PSYCHOLOGICAL SUPPORT

Patients undergoing dialysis for a while may begin to re evaluate their status,
the treatment modality, their satisfaction with life, and the impact of these
factors on their families and support systems. Nurses must provide
opportunities for these patients to express their feelings and reactions and to
explore options. These feelings and reactions must be taken seriously, and
the patient should have the opportunity to discuss them with the dialysis
team as well as with a psychologist, psychiatrist, psychiatric nurse, trusted
friend, or spiritual advisor. The patient’s informed decision about
discontinuing treatment, after thoughtful deliberation, should be respected.

NURSING DIAGNOSIS

1) Ineffective airway clearance related to pain of abdominal incision,

abdominal discomfort, and immobility; risk for ineffective breathing pattern
related to high abdominal incision

GOAL: Improved airway clearance

Nursing Interventions
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1. Administer analgesic agent as prescribed.

RATIONALE: Enables patient to take deep breaths and cough

2. Splint incision with hands or pillow to assist patient in coughing.

Rationale:Splints incision and promotes adequate cough and prevention of

atelectasis

3. Assist patient to change positions frequently.

Rationale:Promotes drainage and inflation of all lobes of the

lungs 4Encourages adequate deep breaths.

Rationale: Encourage use of incentive spirometer if indicated or prescribed.

5. Assist with and encourage early ambulation.

Rationale: Mobilizes pulmonary secretions

2)Acute pain and discomfort related to positioning, and stretching of

muscles during procedure

GOAL: Relief of pain and discomfort

Nursing Interventions

1. Assess level of pain.

Rationale: Provides baseline for later evaluation of pain relief strategies

2. Administer analgesic agents as

prescribed. Rationale: Promotes pain relief

3. Splint incision with hands or pillow during movement or deep breathing

and coughing exercises.

Rationale: Minimizes sensation of pulling or tension on incision and

provides sense of support to the patient

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4. Assist and encourage early ambulation.

Rationale: Promotes resumption of muscle activity exercise

3)Fear and anxiety related to diagnosis, outcome of surgery, and alteration in

urinary function

GOAL: Reduction of fear and anxiety

1. Assess patient’s anxiety and fear before surgery if

possible. Rationale: Provides a baseline for postoperative

assessment

2. Assess patient’s knowledge about procedure .

Rationale: Provides a basis for further teaching

3. Evaluate the meaning of alterations resulting from procedure for the

patient and family or partner.

Rationale: Enables understanding of patient’s reactions and responses to

expected and unexpected results of procedure.

4. Encourage patient to verbalize reactions, feelings, and fears.

Rationale: Affirms patient’s understanding of and ultimate resolution of

feelings and fears

5. Encourage patient to share feelings with spouse or partner.

Rationale: Enables patient and partner to receive mutual support and reduces
sense of isolation from each other.

6) Offer and arrange for visit from member of support group (eg, os-tomy
group, if indicated).

Rationale: Provides support from another person who has encountered the
same or a similar procedure and an example of how others have coped with
the alteration.

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REVIEW OF LITERATURE

24
 Continuous Ambulatory Peritoneal Dialysis
1. ROBERT P. POPOVICH, Ph.D.;
2. JACK W. MONCRIEF, M.D.;
3. KARL D. NOLPH, M.D., F.A.C.P.;
4. AHAD J. GHODS, M.D.;
5. ZBYLUT J. TWARDOWSKI, M.D.; and
6. W. K. PYLE

Abstract
The technique of continuous ambulatory peritoneal dialysis was evaluated in
nine patients during 136 patient weeks. The major objectives were to see if
continuous ambulatory peritoneal dialysis would provide [1] acceptable
control of serum chemistries by usual criteria, [2] adequate removal of
sodium and water, [3] tolerable protein losses, and [4] a low prevalence of
peritonitis with episodes responsive to therapy with continuing continuous
ambulatory peritoneal dialysis. Preliminary findings suggest continuous
ambulatory peritoneal dialysis represents an effective ambulatory, portable,
internal dialysis technique. Larger solute clearances per week may approach
values six times greater than with most hemodialysis techniques. Small-
solute clearances approach dialysate flow rate (8.3 ml/min) and are
comparable to other dialysis techniques on a weekly basis. Edema is readily
controlled and protein losses should be tolerable with adequate protein
intake. Peritonitis occurs on the average every 10 weeks but responds to
therapy promptly with continuing continuous ambulatory peritoneal dialysis.
If the prevalence of peritonitis can be reduced, continuous ambulatory
peritoneal dialysis appears to represent a very attractive dialysis technique.

PROTEIN LOSSES DURING PERITONEAL DIALYSIS

Michael J Blumenkrantz, Gerhard M Gahl, Joel D Kopple, Anjana V Kamdar,

Michael R Jones, Michael Kessel and Jack W Coburn

ABSTRACT

Protein losses during peritoneal dialysis. The losses of protein into dialysate
have been considered a major limitation of maintenance peritoneal dialysis.
We, therefore, undertook a comprehensive evaluation of protein losses in 30
patients undergoing maintenance intermittent peritoneal dialysis (IPD), 12
patients undergoing acute IPD, and 8 patients undergoing continuous
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ambulatory peritoneal dialysis (CAPD). The weekly loss of protein based
upon the usual treatments per week was relatively similar with the three
modes of dialysis. Protein losses during repeated dialyses were similar for a
given patient, but there was marked interpatient variation. During
maintenance IPD, protein loss was 12.9 (SD) 4.4 g per 10 hours of
dialysis; albumin loss was 8.5 g, and IgG loss was 1.3 g. Approximately
50% of the protein loss was from the ascitic fluid accumulated during the
interdialytic interval, and concentrations of most proteins in the ascitic fluid
correlated with their serum levels. Serum protein concentrations were in the
low, normal range and did not change during dialysis. The development of
peritonitis markedly increased protein losses. During acute IPD, 23.3
16.5 g of protein were lost per 36 hours of dialysis, lower losses than those
previously reported. With CAPD, 8.8 1.7 g of protein were removed per 24
hours; also immunoglobulin losses correlated with their serum
concentrations. The results of these studies suggest that, in the absence of
peritonitis, dialysate protein losses do not appear to limit the usefulness of
peritoneal dialysis.

CONCLUSION

PD is especially indicated for the individual who has vascular access

problems or responds poorly to the hemodynamic stresses of HD(e.g the
older adult patient with diabetes and cardiovascular disease)the diabetic
patient with ESRD does better with PD than with HD. The advantage of
PD for the diabetic patient include better BP control , less hemodynamic
instability

BIBLIOGRAPHY
➢ Black m Joyce ,Jane hokanson,Medical surgical nursing. 7th
edition.Missouri: Elsevier publications.2005. pageno:
➢ Lewis Sharon manic,Heitkemper,Medical surgical nursing. 6th
edition. Missouri:Elsevier publication.2004.page no:
➢ Lippincott. Manual of nursing practice .7th edition. International
student edition:Philadelphia:page no:.

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➢ NET REFERENCE
➢ When your patient needs peritoneal dialysis by EDEN
ZABT .Nursing 2003,volume 33.
➢ An introduction to peritoneal dialysis :renal resource centere
2010/www. Renal.resource.com.
➢ AVAILABLE FROM:www.angelfire .com.
➢ www.autherstream.com

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