Nursing management of patient

undergoing peritoneal dialysis

MOHD.PARVEZ
MSC (N) 1ST YEAR
INTRODUCTION

Dialysis is used to remove fluid and uremic waste products from the
body when the kidneys cannot do so. It may also be used to treat
patients with edema that does not respond treatment ,hepatic coma,
hyperkalemia , hypercalcemia, hypertension, anduremia. Methods of
therapy include hemodialysis, continuous renal replacement therapy
(CRRT; ), and various forms of peritoneal dialysis. The need for dialysis
may be acute or chronic.
 
PERITONEAL DIALYSIS

peritoneal dialysis are to remove toxic substances

and metabolic wastes and to re-establish normal
fluid and electrolyte balance .peritoneal dialysis
involves repeated cycles of instilling dialysate into
the peritoneal cavity, allowing time for substance
exchange, and than removing the dialysate.
PURPOSES
1.To remove the end products of protein metabolism such as
urea and creatinine from the blood
2.To maintain the safe concentration of serum electrolytes
3.To correct acidosis and replenish the blood bicarbonate buffer
system.
4.To remove excess fluid from the blood.
 
INDICATION
1.Chronic renal failure.
2.Cardiovascular instability
3.Vascular access problems that prevent
hemodialysis,fluid overload or electrolyte
imbalance.
4.It has been used for overdose of drug and toxin.
 
ADVANTAGES

1.One of the primary advantage of peritoneal is its relative, which allow

it to be used in community health care facilities without all the
sophisticated equipment needed for dialysis.

2. It can be easily managed at home and often provided the client more
independent and mobility and hemodialysis.
PRINCIPLES
OSMOSIS
DIFFUSION
TYPES
1.Continuous ambulatory peritoneal dialysis
2. Continuous Cycle Peritoneal Dialysis

3. Intermittent Peritoneal Dialysis

1.Continuous ambulatory peritoneal dialysis
1. The dialysate is installed into the abdomen and left in the place for 4 to 8
hours.
2. The empty dialysate bog is folded up and carried in a pouch or packet, until it
is time to drain the dialysate.
3. The bag is later unfolded and placed lower than the
4. insertion site, so the fluid drains by gravity flow. When full bag is changed, the
new dialysate is instilled into the abdomen as the process continues.
 
5.Because there is no need for electricity, water. The client can go about almost
any desired activity during dialysis.
6. Because the continuous exchange process closely resembles normal renal
function, the body more easily maintains homeostasis
 
2. Continuous Cycle Peritoneal Dialysis
Continuous cycle peritoneal dialysis (CCPD) is similar to CAPD in which it
is a continuous dialysis, processes, but different in that it requires a peritoneal
cycling machine.
In this procedure there are usually three cycles done in the morning and at
night and one cycle within an 8 hours.
T
  he advantage of this procedure is that the peritoneal catheter is opened only
for the on and off procedures, which reduces the risk of infection.
 
Intermittent Peritoneal Dialysis
Intermittent peritoneal dialysis (IPD) is not a con- tinuous dialysis procedure
like CAPD and CCPD
Dialysis is preformed 10 to 14 hours for about 3 to 4 times a week with use of
same peritoneal cycling machine as in CCPD.
Hospitalized patients may be dialysate up to 24 to 48 hours at a time if they are
catabolic and require semi-permeable additional dialystic time.
 
 
PERITONEAL DIALYASIS PROCEDURE
1. The nurse explains the procedure to the patient and obtains signed consent for it.
2. Baseline vital signs, weight, and serum electrolyte levels are recorded.
3. patient is encouraged to empty the bladder and bowel to reduce the risk of puncturing
internal organs
 
4. The nurse also assesses the patient’s anxiety about the procedure and provides support and
instruction.
5. Broad-spectrum antibiotic agents may be administered to prevent infection. If the peritoneal
catheter is to be inserted in the operating room, this isexplained to the patient and family
 Access for PD
1. A siliconized rubber catheter such as a Tenckhoff catheter is surgically inserted into the
client’s peritoneal cavity to allow infusion of dialysis fluid; the catheter site is covered by a
sterile dressing that is changed daily and when soiled or wet.
2. The preferred insertion site is 3 to 5 cm below the umbilicus; this area is relatively avascular
and has less fascial resistance.
3. The catheter is tunneled under the skin, through the fat and muscle tissue to the peritoneum; it
is stabilized with inflatable Dacron cuffs in the muscle and under the skin
4. . Over a period of1 to 2 weeks following insertion,fibroblasts and blood vessels grow around
the cuffs, fixing the catheter in place and providing an extra barrier against dialysate leakage
and bacterial invasion.
If the client is scheduled for transplant surgery, the PD catheter may be either removed or left in
place if the need for dialysis is suspected post transplantation
Dialysate solution

1. The solution is sterile.

2. All dialysis solutions are prescribed by the HCP; the solution contains electrolytes and
minerals and has a specific osmolarity, specific glucose concentration, and other medication
additives as prescribed
3. The higher the glucose concentration, the greater the hypertonicity and the amount of fluid
removed during a PD exchange.
4. Increasing the glucose concentration increase the concentration of active particles that cause
osmosis, increases the rate of ultrafiltration, and increases the amount of fluid removed
5. If hyperkalemia is not a problem, potassium may be added to each bag of dialysate solution.
6. Heparin is added to the dialysate solution to prevent clotting of the catheter.
7. . Prophylactic antibiotics may be added to the dialysate solution to prevent peritonitis.
8. Insulin may be added to the dialysate solution for the client with diabetes mellitus.
 
 
PD infusion
1. One infusion (fill), dwell, and drain is considered exchange
 
2. Fill: 1 to 2 L of dialysate as prescribed is infused by gravity into the peritoneal
space, which usually takes 10 to 20 minutes
3. Dwell time: The amount of time that the dialysate solution remains in the
peritoneal cavity is prescribed by the HCP and can last 20 to 30 minutes to 8 or
more hours, depending on the type of dialysis used
4. Drain (outflow): Fluid drains out of body by gravity into the drainage bag.
 
Nursing Management during peritoneal dialysis
 
. Monitor vital signs.
2. Monitor for respiratory distress, pain, or discomfort.
3. Monitor for signs of pulmonary edema.
4. Monitor for hypotension and hypertension.
5. Monitor for malaise, nausea, and vomiting.
6. Assess the catheter site dressing for wetness or bleeding.
7. Monitor dwell time as prescribed by the HCP.
8 . Do not allow dwell time to extend beyond the HCP’s prescription because this
increases the risk for hyperglycemia.
9. Initiate outflow; turn the client from side to side if the outflow is slow to start.
10. Monitor outflow, which should be a continuous stream after the clamp is
opened.
11. Monitor outflow for color and clarity.
12. Monitor intake and output accurately; if outflow is less than inflow, the
difference is equal to the amount absorbed or retained by the client during dialysis
and should be counted as intake.
13. An outflow greater than inflow as well as the appearance of frank blood or
cloudiness in the outflow should be reported to the HCP.
14. Patients receiving CAPD usually know how to care for the catheter site;
however, the hospital stay s hould be an opportunity to assess compliance with
recommended catheter care and to correct any misperceptions or deviations from
correct 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.
Complications of Peritoneal Dialysis
1.Peritonitis
 Monitor for signs and symptoms of peritonitis: Fever, cloudy outflow, rebound abdominal tenderness,
abdominal pain, general malaise, nausea, and vomiting.
 Cloudy or opaque outflow is an early sign of peritonitis.
 If peritonitis is suspected, obtain a sample for culture and sensitivity of the outflow to determine the infective
organism.
 Antibiotics may be added to the dialysate.
 Avoid infections by maintaining meticulous sterile technique when connecting and disconnecting
 PD solution bags and when caring for the catheter insertion site.
 Prevent the catheter insertion site dressing from becoming wet during care of the client or the dialysis
procedure; change the dressing if wet or soiled.
 Follow institutional procedure for connecting and disconnecting PD solution bags, which may include
scrubbing the connection sites with an antiseptic solution.
1.Abdominal pain
a. Peritoneal irritation during inflow commonly causes abdominal cramping and
discomfort during the first few exchanges; the pain usually disappears after 1 to
2 weeks of dialysis treatments.
b. of the dialysate can cause Warm the dialysate before administration, using a
special dialysate warmer pad, because the cold temperature discomfort.
1.Abnormal outflow characteristics indicative of complications
  main cause of insufficient outflow is a full colon; encourage a high-fiber
a. The
diet, because constipation can cause inflow and outflow problems. Administer
stool softeners as prescribed.
b. Insufficient outflow may also be caused by catheter migration out of the
peritoneal area; if this occurs, an x-ray will be prescribed to evaluate catheter
position.
c. Maintain the drainage bag below the client’s abdomen.
d. Check for kinks in the tubing.
e. Change the client’s outflow position by turning the client to a side-lying position
or ambulating the client.
f. Check for fibrin clots in the tubing and milk the tubing to dislodge the clot as
prescribed.
 
1.Leakage around the catheter site
 
a. Clear fluid that leaks from the catheter exit site will be noted.
b.It takes 1 to 2 weeks following insertion of the catheter before
fibroblasts and blood vessels grow into the catheter cuffs, which fix it
in place and provide an extra barrier against dialysate leakage and
bacterial invasion.
c. Smaller amounts of dialysate need to be used; it may take up to 2
weeks for the client to tolerate a full 2-L exchange without leaking
around the catheter site.
 
Related research article
Continuous flow peritoneal dialysis: assessment of fluid and solute removal in
a high-flow model of "fresh dialysate single pass

Abstract
Background: Growing concern over the limited capacity of the peritoneal dialysis (PD) system has revived interest in
continuous flow peritoneal dialysis (CFPD), a modality in which continuous circulation of PD fluid is maintained at a high flow
rate using two separate catheters or one dual-lumen catheter. The CFPD regimen contrasts the "inflow/outflow" regimen, which
requires specific times devoted to filling and draining the peritoneum via a single-lumen catheter. Historical data established
CFPD capabilities in providing higher solute clearance and ultrafiltration rate (UFR) using either an open loop system with a
single pass of fresh PD fluid, or various external purifications of the spent dialysate.

Objective: To compare, in patients with various peritoneal transport patterns, fluid and solute removal achieved during a
standardized program of CFPD versus two control schedules: nightly intermittent peritoneal dialysis (NIPD) and nightly tidal
peritoneal dialysis (NTPD). This study focused on small solute clearances and UFR using only isotonic PD solution (Dianeal
PD1 1.36%; Baxter Healthcare, Castlebar, Ireland). The model of fresh dialysate, single pass, was used to optimize solute
gradients and to characterize the impact of a continuous flow regimen on peritoneal transport characteristics.
Methods: In a crossover trial, 4-hour CFPD sessions were performed at a fixed dialysate flow
rate (100 mL/ minute) in 5 patients being treated with automated PD. A hemofiltration monitor
(BM25; Baxter Healthcare, Brussels, Belgium) was adapted to the CFPD technique. The
peritoneal cavity was filled through a temporary second catheter and simultaneously drained
using the permanent peritoneal access. Fluid and solute removal were compared to data obtained
from a control period based on 8-hour sessions of NIPD or NTPD using 13 L of isotonic
dialysate.
Results: High-flow CFPD enhanced the diffusive transport coefficient compared with the
alternative flow regimen in patients ranging from low to high transporters. Weekly creatinine
clearance increased from 36.9 L (22.3 - 49.6 L) and 37.3 L (27.5 - 45.0 L) with NIPD and NTPD
respectively, to 74.9 L (42.3 - 107.5 L) with CFPD. Mean UFR was 2.44 mL/min with CFPD
versus 0.92 and 0.89 mL/min with NIPD and NTPD respectively. The mass transfer area
coefficient (MTAC) of creatinine with CFPD was 2.5-fold that obtained from the peritoneal
equilibration test data.
Conclusion: Our results confirm that CFPD is highly effective in increasing fluid and solute
removal. Furthermore, consistent with historical data, our findings indicate that the enhanced
solute transfer is not due only to steeper solute gradients, but also depends on increased MTAC in
a wide range of peritoneum transport characteristics
Summary
in this seminar we have discussed about the peritoneum dialysis and its
introduction along with type of peritoneal dialysis, its undergoing nursing
management about peritoneal dialysis.
 
Conclusion
Peritoneal dialysis involve introduction, type of peritoneal dialysis,
undergoing nursing management. this helps and aids a health care
provider to do manage early complication related peritoneal dialysis
and to take prompt intervention alter the course of peritoneal dialysis.
 Bibliography
1) Brunner and Suddarth; Textbook of Medical Surgical Nursing 13th Edition Volume II. New Delhi; Wolters Kluwer Publication,
2010, page no.1293-1295

2) 1 clement basic concept of nursing procedures: Textbook nursing fundamental 2 edition jaypee page no.343-346.

3) Harding, Kwong, Roberts, Hagler, Reinisch; Lewis’s Medical Surgical Nursing 11 th Edition Volume II. Philadelphia; Elsevier
Publications 2015, Pg. no. 876-890.

4) Freida P, Issad B. Continuous flow peritoneal dialysis: assessment of fluid and solute removal in a high-flow model of "fresh
dialysate single pass". Perit Dial Int. 2003 Jul-Aug;23(4):348-55. PMID: 12968842