PERITONEAL DIALYSIS

INTRODUCTION:

Peritoneal dialysis is the process during which the peritoneal cavity acts as
reservoir for the dialysate and peritoneum serves as semi-permeable membrane,
across which excess body fluids and solutes, including uremic toxins are
removed .Peritoneal membrane is in contact with rich blood supply to the abdominal
organs and dialysate is infused into peritoneal cavity via catheter.

DEFINITION:

Peritoneal Dialysis is a process or procedure which allows exchange of wastes,

fluids and electrolytes in the peritoneal cavity.

(Ignativicious)

Peritoneal dialysis involves repeated cycling of instilling dialysate into peritoneal

cavity, allowing the time for substance exchange and then removing the dialysate.
(Joyce M Black)

INCIDENCE

The use of peritoneal dialysis has decreased and currently accounts for only 5 % to 6%
of the dialysis.

PRINCIPLES:

 Diffusion
 Osmosis
 Ultrafiltration.

INDICATIONS:

Patient’s with Chronic Kidney Disease.

Unstable patients who cannot tolerate anticoagulation.
Patients with chronic infections, vascular access problems
 Peritoneal dialysis is often the treatment of choice for older adults, because it
offers more flexibility, if his or her status changes frequently.

CONTRAINDICATIONS:

Peritoneal adhesions.
Extensive Intra-abdominal surgery.
Obesity
Recurrent episodes of peritonitis
Abdominal malignancies.
Respiratory diseases, ruptured diverticulum.

ADVANTAGES:

 Easy to learn
 Can be done at home
 Ambulatory – no machines are needed , when machines are used, they are small
 Better BP Control
 Less dietary and fluid restriction
 Greater freedom in scheduling and travelling.

DISADVANTEGES:

 Time consuming
 Sterile technique is required
 Presence of permanent catheter
 Risk for peritonitis and peritoneal injury
 Contraindicated in abdominal surgeries, chronic back pain or development of
hernias.

PROCEDURE:

 Each peritoneal exchange consists of 3 phases.

 Fill, dwell and drain.
  A siliconized rubber catheter is surgically placed into the abdominal cavity for
infusion of dialysate.
 Usually 1 to 2 l of dialysate is infused by gravity (Fill phase)
 Fluid stays (dwells) in the cavity for a specified time, prescribed by the
nephrologist.
 Fluid then flows out of the body (drains) by the gravity into drainage bag.
(Peritoneal outflow generally called as “peritoneal effluent “contains the dialysate
and excess waste, electrolytes and nitrogen –based waste products.)

The 3 phases of the process (infusion or fill, dwell and outflow or drain) makes up one
peritoneal dialysis exchange.

PROCESS:

Peritoneal dialysis occurs through diffusion and osmosis across the semi- preamble
peritoneal membrane and capillaries.
The peritoneal membrane is large and porous. It allows solutes and water to move from
an area of higher concentration in blood to an area of lower concentration in dialyzing
fluid (diffusion).

The fluid and waste products dialyzed from patient move through blood vessels wall,
interstitial tissue and the peritoneal membrane and are removed when dialyzing fluid
drain from the body.

FACTORS AFFECTING PERITONEAL DIALYSIS EFFICIENCY:

 Decreased peritoneal membrane permeability caused by infection or scarring.

 Reduced capillary blood flow resulting from blood vessel constriction.
 Vascular disease
 Decreased perfusion of peritoneum.

DIALYSATE ADDITIVES:

 Heparin may be added to the dialysate to prevent clotting of the catheter or

tubing.
 Other agents include potassium and antibiotics.
 Antibiotics are given by intraperitoneal routes when peritonitis is present or
suspected.

TYPES OF DIALYSIS:

Continuous Ambulatory Peritoneal Dialysis.

Automated peritoneal dialysis.
Intermittent Peritoneal Dialysis.
Continuous cycling peritoneal Dialysis.

Continuous Ambulatory Peritoneal Dialysis:

 Most commonly used peritoneal dialysis.

 Cleanse the body ,helps to control the water and replaces the work of replaced
kidney.
 Portable type of Dialysis.
  Performed by the patients with the infusion of 2l -4l exchange of Dialysate into
the peritoneal cavity.
 Duration of dialysate is 4 to 8 hours in peritoneum in a day and exchange occurs
7 days in a week.
 During dwell period patient can use a continuous connect system or disconnect
system

Automated Peritoneal Dialysis:

 Often used in acute care setting settings, outpatient dialysis centers or in

patient’s home.
 APD uses a cycling machine for dialysate inflow, dwell and outflow according to
pre-set times and volumes.
 A warming chamber for dialysate is the part of machine
 Functions are monitored for patient’s specific needs
 Permits home dialysis while patient sleeps
 Reduces the incidence of peritonitis, because fewer connections and
disconnections are needed

Continuous- Cycling Peritoneal Dialysis (CCPD):

 Continuous – Cycling Peritoneal Dialysis is a form of automated dialysis that

uses an automated cycling machine.
 Exchange occurs at night while patient sleep.
 The final exchange of the night is left to dwell through the day and is drained in
the next evening as process is repeated.

Intermittent Peritoneal Dialysis:

IPD combines osmotic pressure with true dialysis. The patient usually requires
the exchange of 2l of dialysate at 30 to 60 minutes interval, allowing 15 to 20
minutes of drain time.
For most patients 30 to 40 exchanges of 2 L three times weekly are needed.
IPD can be automated or manual.
COMPLICATIONS:

 Hernia formation
 Leaks (including hydrothorax or pleuro peritoneal leaks)
 Local edema
 Back pain
 Gastrointestinal problems
 Gastroesophageal reflux
 Delayed gastric emptying
 Hemoperitoneum
 Pain on infusion or drainage of dialysate,
 Electrolyte imbalances, and
 Ultrafiltration failure.

NURSING MANAGEMENT:

Predialysis Care:

 Document vital signs including temperature, pulse and Blood pressure. These
baseline data help to assess fluid volume status and tolerance of the dialysis
procedure.
 Check the weight daily before the dialysis.
 Note BUN, Serum electrolytes and creatinine, PH, hematocrit level, prior to
peritoneal dialysis or periodically (helps to assess the efficiency of the treatment.)
 Measure and record abdominal girth (Increasing abdominal girth may indicate
retained dialysate, excess fluid volume or early peritonitis)
 Maintain fluid and dietary restriction as ordered (fluid and dietary restriction help
to reduce hypervolemia and control azotemia.)
 Have the client empty the bladder prior to catheter insertion. (Emptying bladder
reduces the risk of inadvertent puncture)
 Warm the prescribed dialysate solution to body temperature (98.60 F) using a
warm bath or heating pad. (Helps to prevent hypothermia)
 Explain all procedures and expected sensations.
Intra-dialysis care:

 Use strict aseptic technique during the procedure.

 Add prescribed medications to the dialysate solution prime the tubing with
solution and connect it to peritoneal catheter, taping connections securely and
avoiding kinks.
 Instill dialysate into the abdominal cavity over a period of approximately 10
minutes.
 Clamp tubing and allow the dialysate to remain in the abdomen for prescribed
dwell time.
 Keep the drainage tubing, clamped at all time, during installation and dwell time.
 During instillation and dwell time. Observe closely for the signs of respiratory
distress such as dyspnea, tachypnea or crackles.
 Place in fowler’s or semi fowler's and slow the rate of instillation slightly to relieve
the respiratory distress.
 After prescribed dwell time, open the drainage tubing clamps and allow the
dialysate to drain by gravity into a sterile container. Note the clarity, color and
odor of the returned dialysate. (Blood or feces in the dialysate may indicate organ
or bowel perforation.)
 Accurately record amount and type of dialysate instilled (including added
medications), dwell time and amount and character of drainage.
 Monitor BUN, serum electrolytes and creatinine level (helpful in assessing the
effectiveness of dialysis).
 Analyze for possible complications.

Post Dialysis Care:

o Assess vital signs (compare with pre-dialysis vital signs)

o Time meals to correspond with dialysis outflow.
o Teach the client and family about the procedure.
o Watch for complications.

CONCLUSION:
 Peritoneal dialysis is a way to remove waste products from blood when kidneys
can't adequately do the job any longer. During peritoneal dialysis, a cleansing fluid flows
through a tube (catheter) into part of abdomen. The lining of abdomen (peritoneum) acts
as a filter and removes waste products from blood. After a set period of time, the fluid
with the filtered waste products flows out of abdomen and is discarded. These
treatments can be done at home, at work or while traveling.

BIBLIOGRAPHY:

o Joyce M Black, “Textbook of Medical –Surgical Nursing”, Elsevier Publications,

8th Edition, 2010, pg no 823 -824.
o Lippincott Williams & Wikins Hand book of Dialysis ,Wolters Kluwers Publications
,Fifth Edition, 2015 ,Pg no:392 -400.
o Iganativicious “Text book of Medical Surgical Nursing”, Elsevier Publications,7th
Edition,2009, pg no 612 -614