Peritoneal dialysis is a treatment for kidney failure that uses the peritoneal membrane in the abdomen as a filter. It involves infusing dialysate fluid into the abdomen through a catheter for diffusion and osmosis to occur. There are various types of peritoneal dialysis including continuous ambulatory peritoneal dialysis, automated peritoneal dialysis, and intermittent peritoneal dialysis. Nursing management focuses on preventing infections, monitoring for fluid overload, managing pain, and providing education on catheter care and lifestyle adjustments. Peritoneal dialysis offers patients greater independence compared to hemodialysis.
2. Objectives
At the end of the class students will be able to :
Define peritoneal dialysis
Anatomy and physiology of peritoneal membrane
The goals of peritoneal dialysis
Indications and contra indications of PD
Peritoneal dialysis access and insertion procedure
The procedure of PD
Different types of PD
Complications of PD
The advantages of PD over HD
Nursing management of patients undergoing PD
4. Physiology
The semipermeable peritoneal membrane allows
solutes and water to be transported from the vascular
system to the peritoneal cavity and vice versa.
5. Peritoneal dialysis:
Introduction
Peritoneal dialysis(PD) is a treatment for
patients with severe chronic kidney disease.
A dialysis technique that uses the patient's own body
tissue-peritoneal membrane inside the abdominal
cavity as a filter.
6. Goals of PD
• Remove toxic substances and metabolic wastes
• Reverse the symptoms of uremia
• Reestablish normal fluid and electrolyte balance
• Maintain a positive nitrogen balance
• Prolong life
• Have the maximum level of quality of life
8. Treatment of choice for….
Patients with RF unable or unwilling to undergo HD or renal
transplantation
• Diabetic patients
• Patients with cardiovascular diseases eg:heart failure
• Older patients
• Patients at risk of adverse effects of systemic heparin
• Patients with severe hypertension
9. Contra indications
Absolute contra indications
Peritoneal fibrosis and adhesions following
intra abdominal operations
Inflammatory gut diseases
11. PD catheters
Catheters for long-term use (Tenckhoff, Swan, Cruz) are usually
made of silicone and are radioopaque to permit visualization
on x-ray. These catheters have three sections:
(1) An intraperitoneal section with numerous openings and
an open tip to let dialysate flow freely;
(2) A subcutaneous section that passes from the peritoneal
membrane and tunnels through muscle and subcutaneous
fat to the skin
(3) An external section for connection to the dialysate section
12. Catheters have two cuffs, which are made of Dacron polyester.
The cuffs:
stabilize the catheter
limit movement
prevent leak
provide a barrier against microorganism
Cuff placement :
adjacent to the peritoneum
subcutaneously.
The subcutaneous tunnel (5 to 10 cm long) further protects
against bacterial infection
13. Types of catheters
The design of a peritoneal catheter need to be such
that
It should give maximum inflow and output
Discourage infection
Four main types
o Straight Tenckhoff
o Curled Tenckhoff
o Swan-neck
o T- fluted
16. Insertion techniques
Blind placement using Tenckhoff trocar
Blind placement using guide wire
Surgical placement by dissection
Mini trocar placement using peritoneoscopy
17. Preinsertion preparation
of the patient
Determine the catheter exit site
Site :
Midline
3 cm below umbilicus
Lateral site
At the lateral border of the rectus muscles
On a line, half way between the umbilicus and anterior
superior iliac spine
Left lateral side is preferred as it avoids caecum
18. Pre operative care of the
patient
Take bath or have a shower in the morning
Abdominal hair should be clipped
Empty bowel and bladder before catheter insertion
Enema can be given
Staphylococcus aureus screening
Administer antibiotics prophylactically
19. • A trocar is used to puncture the peritoneum as the patient
tightens the abdominal muscles by raising the head.
• The catheter is threaded through the trocar and
positioned.
• Previously prepared dialysate is infused into the peritoneal
cavity, pushing the omentum (peritoneal lining extending
from the abdominal organs) away from the catheter.
• The physician may then secure the catheter with a
purse-string suture and apply antibacterial ointment
and a sterile dressing over the site
21. Post operative care of the
patient
Goals:
Minimise bacterial colonisation of exit site
during early healing period
Prevent trauma to exit site and traction on
cuffs by immobilization of catheter
Minimise intra abdominal pressure to prevent
leakage
Do not disturb the exit site for 7-10 days
Flush the catheter with 500-1500 ml of PD fluid to check
patency
22. Composition of PD solution
Components
Na 132 mmol/l
Ca 1.25mmol/l
Mg 0.5mmol/l
Cl 100mmol/l
Lactate 35mmol/l
Glucose 1.36-4.25g/dl
Osmolarity 347-486
pH 5.2
23. PROCEDURE
Patient preparation
Explain the procedure & obtain informed consent.
Baseline vital signs, weight, serum electrolyte
levels are recorded.
Assess patient’s anxiety about the procedure.
Broad spectrum antibiotics prophylactically.
24. PROCEDURE
Equipment preparation
Assemble the equipments needed
Check physician’s order for the concentration of dialysate
and medications to be added
Heparin : to prevent clotting
KCl: to prevent hypokalemia
Antibiotics : peritonitis
Insulin : for diabetic patients
25. PROCEDURE
Warm the dialysate solution to body
temperature:
To prevent patient discomfort and abdominal
pain
To dilate the vessels of peritoneum
Dry heating should be done
Too cold solution causes pain, cramping, and
reduce clearance
26. Not recommended....
Soaking the bag of solution in warm water
Use of microwave to heat the fluid
Avoid too cold solution
29. Performing the exchange
Infusion
The dialysate is infused by gravity into the
peritoneal cavity.
A period of about 5 to 10 minutes is usually
required to infuse 2 L of fluid.
30. •Dwell or equilibration and
drainage of dialysate
• The prescribed dwell, or equilibration, time allows diffusion
and osmosis to occur.
• Diffusion of small molecules, such as urea and creatinine,
peaks in the first 5 to 10 minutes of the dwell time.
• At the end of the dwell time, the drainage portion of
the exchange begins.
• The tube is unclamped and the solution drains from the
peritoneal cavity by gravity through a closed system.
• Drainage is usually completed in 10 to 30 minutes.
31. Performing the exchange
Drainage fluid
• Colorless or straw-colored
• Should not be cloudy
• Bloody drainage may be seen in the first few exchanges
Entire exchange time
1 to 4 hours (depending on prescribed dwell time)
32. Performing the exchange
• No.of exchanges
According to patient’s physical status and acuity of
illness
• Dextrose solutions
Dextrose solutions of 1.5%, 2.5%, and 4.25% are
available in several volumes, from 500 mL to 3,000
mL, allowing the dialysate selection to fit the patient’s
tolerance, size, and physiologic need
34. Continuous ambulatory peritoneal
dialysis (CAPD)
Carried out during day time , manually by patients or
by caregivers
Dialysis fluid is infused to the peritoneal cavity
Dwell time for between 3 - 10 hrs
Most suitable for patients whose membrane transport
solutes at a slow to average rate
36. Continuous cycling peritoneal
dialysis
Patient carries PD solution in the abdominal cavity
through out the day but performs no exchanges.
At bedtime ,patient hooks upto the cycler ,which
drains and refills the abdomen with solution three or
more times in the course of the night.
37. Intermittent peritoneal
dialysis(IPD)
• Intermittent peritoneal dialysis is offered to patients on a
temporary basis when their blood pressure is low or in
children with acute renal failure to tide over a crisis.
• It is performed for a short period of 12-24 hours,2-3 times
weekly.
• Common routine hourly exchange consists of 10 min
infusion, 30min dwell time and a 20 min drain time.
40. Dialysis related problems
Protein loss
Protein loss through the peritoneal membrane @ 6-
12g/day in a PD patient
To compensate for this PD patients need to eat between
1 – 1.2 g/ kg body weight/ day
The loss is increased during peritonitis
Other substances lost in dialysate are amino acids,
water-soluble vitamins, hormones and some
medications
41. Dialysis related problems …
Cardio vascular and lipid problems
Increased glucose absorption from the PD fluid
Raised intra abdominal pressure
Can cause hernias & dialysate leakage around the
insertion site
If leakage occurs , PD must be ceased for a short period
42. Dialysis related problems
Drainage problems
Reasons can be
Kinks in the tubing
Constipation
Fibrin formation
Milking can be done
Heparin administration
Streptokinase or urokinase in 0.9% NaCl
Malpositioned catheter
43. Dialysis related problems
Blood stained effluent
In menstruating females; due to endometriosis or
retrograde bleeding through fallopian tube
Severe intraperitoneal bleeding ; due to straining while
lifting a heavy object or suffering trauma to abdomen
Shoulder pain
Following infusion of fresh dialysate
Referred pain caused by intra abdominal pressure or air
under the diaphragm
Resolve within 20 min; analgesics can be given
44. Infectious complications
Peritonitis
Most common and most serious complication
Diagnosis
Cloudy PD effluent
Abdominal pain , tenderness , pyrexia
Identification of micro organisms in PD effluent
in culture or positive gram staining
45. Infectious complications
Treatment
Initial one to three rapid exchanges with 1.5%
dextrose solution – to wash out mediators of
inflammation
Drainage fluid – examined for cell count ,
Gram’s stain, culture
Intraperitoneal or intravenous antibiotics
Unresolved peritonitis after 4 days of
appropriate therapy necessitates catheter
removal
46. Infectious complications
Exit site infection
The presence of purulent drainage with or without
erythema of the skin at catheter epidermal interface.
Tunnel infection
Can present as an extension of the exit site infection
into the catheter tunnel. Swelling, pain and redness
over the subcutaneous tunnel may be observed.
Management
Culture of drainage
Antibiotic therapy
47. Advantages of PD over HD
1. Easy to use without sophisticated equipments
2. Easy to manage in home and community health care
facilities
3. more independence and mobility
4. Dialysis treatment of choice for children
5. May allow better blood pressure and volume control
with cardiovascular benefits
6. May give better quality of life
7. Lower risk of Hepatitis C
8. Equal or better survival in early years
48. Nursing management
Potential for developing infection related to the
catheter
Assess the site for any signs of infection; any
redness, rebound tenderness, swelling, drainage from
the exit site or change in vital signs
Maintain strict aseptic technique while carrying
out the procedure
49. Nursing management
Potential for developing cardiac and respiratory
complications related to the uremic state and
presence of fluid in the peritoneum
Frequent cardiac and respiratory assessment
Watch for signs of fluid accumulation; heart
failure, and pulmonary edema
Auscultate the base of lungs for crackles
Assess for signs of pericarditis; substernal pain,
low grade fever, and pericardial friction rub.
50. Nursing management
Acute pain and abdominal discomfort related to
the dialysate infusion
Warm the dialysate to body temperature
Altered nutrition less than body requirement
related to the protein loss
High protein, fiber rich well balanced diet
Limit carbohydrate intake
51. Nursing management
Knowledge deficit related to care of catheter site
Teach the patient the possible signs of infection
Catheter care should be done daily
Avoid tub bath and exit site should not be
submerged in water
52. Nursing management
Altered body image related to the abdominal
catheter and bag and tubing
Assess for any such problem
Allow the patient to express his feelings and
concerns about body image disturbances.
Assist in selecting of proper clothing
Provide an opportunity to the patient to meet
similar patients who are well adjusted with the
condition
53. Nursing management
Altered sexual patterns and sexual dysfunction
Provide privacy to the patient so that he can
discuss his problem
Nurse can start the discussion by asking about any
concerns related to sexuality
54. Conclusion
Long term outcomes associated with peritoneal
dialyses are good.
The treatment is usually effective for years.
However scarring of the peritoneum and repeated
infections may require a change to hemodialysis.
Notas del editor
Peritoneum covers abdominal cavity,,semi permeable membrane.,,.highly vascular,,,BSA1.5-2 m2.two layers parietal &visceral...pariet-attached to abdo wall,,,viscer is wrapped arund internal organs,,,space b/w these layers –peritoneal cavity,,large no. Of arteries &veins in cavity
Very simple and effective technique...HD uses an artificial membrane...here natural membrane is used
Uremia-urea in the blood,,,disorientation,confusion,drowsiness,,slurred speech,,coma//seizure,,hypertension,,hypocalcemia,hyponatremia,hyperphosphatemia,hyperkalemia
During HD rapid fluid & electrolyte changes occur,,pts. Who r susceptible to these prob..experience fewer prob. With PD..bcz it occurs in a slower rate...
1)Fibrotic encasement of the small intestine,,some toxins stimulate fibro blastic proliferation&reactive fibrosis 2)fibrous bands dt form b/w tissues &organs3)grp.of inflammatory condi.. Of small intes &colon 4)excess breakdown of specific substance or body tissue leads to wt.loss&wasting
To ensure hyper osmolarity.
To increase urea clearance.. Dry heat-heating cabinet,incubator,heating pad
Introduce bacteria to the exterior of bag and increase chance of peritonitis....increase the danger of burning peritoneum...to reduce amnt of air entering the catheter and peritoneal cavity
defined as the infusion, dwell and drainage of the dialysate....clearance-proces of removal of substances from blood
Creat clara >70/L/wk/1.73 m2....urea clear >2.1/wk creat molecular wt.113Da urea mole wt, 60 Da