PERITONEAL

DIALYSIS
BASIC PRINCIPLES, COMPLICATIONS
AND NURSING RESPONSIBILITIES
The most important members of that team are the
NURSES,
Who must be effective teachers,
Knowledgeable, flexible,
and committed to ensuring good outcomes.

Beth Piraino, MD
BASIC PRINCIPLES

PERITONEAL MEMBRANE
dialyzer
Parietal peritoneum most
important in peritoneal
dialysis

o Effectiveness depends on
the vascularity of the
peritoneum
PERITONEAL TRANSPORT MODEL

3-PORE MODEL solute and

water transport across the
capillary occurs via 3 pore
sizes
1. Transcellular pore
2. Small pores
3. Large pores
TRANSPORT PROCESSES

Diffusion higher to lower concentration (solutes)

Ultrafiltration water
Absorption gain of solutes and water

OSMOTIC AGENTS attracts fluid from the capillary space

to peritoneal space
Glucose concentrations 1.5%, 2.5%, 4.25%
 UF volume as a function of time after infusion of
dialysis solution
900
800
700
600
500
400 ultrafiltration (mL)
300
200
100
0
1 2 3 4 5 6
 If you want more fluid removed,
shorten the dwell time, since
glucose concentration in the PD
fluid is high at the initial dwell
period
Expect a high potassium removal

CLINICAL APPLICATION
APPARATUS AND MODALITIES OF PD

DIALYSIS CATHETER
APPARATUS AND MODALITIES OF PD

TRANSFER SET EXTENSION TUBINGS

BUFFER AGENTS

Lactate based
Acetate based
Bicarbonate based
MODALITIES

Continuous ambulatory peritoneal dialysis

CAPD
Automated Peritoneal dialysis APD
CCPD continuous cycling peritoneal dialysis
NTPD nocturnal tidal peritoneal dialysis
Provide health education to the patient and
relatives
CLINICAL APPLICATION
PD RELATED INFECTIONS

EXIT SITE INFECTION presence of purulent drainage

with or without erythema at the catheter-epidermal
interface

Organisms:
s. Aureus 78%
p. Aeruginosa - 11%
Others 8%
EXIT SITE CLASSIFICATION
PREVENTION OF EXIT SITE INFECTION

What is the primary goal of exit site care?

Routine exit site care by patient and nurse

Use antimicrobial soap once a day and rinse
Avoid hydrogen peroxide
There is evidence for aily antibiotic prophylaxis with mupirocin
or gentamycin cream*
Patients can be screened for nasal staph aureus carriage and
then given nasal prophylaxis*
* 2011 ISPD position statement on reducing the risk of PD related
infections
PRINCIPLES OF NURSING CARE FOR INFECTED
SKIN
Use sterile dressing
Provide exit site care 2x a day
Do not use cytotoxic agents in sinus
Do not forcible remove crusts and scabs
*application of soaks*
normal saline or hypertonic solution
wet gauze with solution and place over the exit site
Reassess exit site frequently
Immobilize catheter
PREVENTION OF TRAUMA

Instruct not to use belts/seatbelts

or tight clothing and avoid
sleeping on the abdomen
Avoid removing crust or scab
forcibly
Instruct to avoid scratching the
exit site
Do not provide vigorous exit site
care
 PREVENTION OF GROSS CONTAMINATION
Always keep the site clean and
dry
Proper hand hygiene
Instruct to avoid submersion in
lakes, rivers and public pools and
hot tubs as well
Use waterproof dressing or
barrier when swimming
Intruct the patient / relative to do
exit site care right after
submersion
PD RELATED INFECTIONS
TUNNEL INFECTION requires
ultrasound to diagnose
*signs and symptoms
Redness
Edema
Tenderness over the
subcutaneous tunnel
Intermittent or chronic
purulent, bloody discharge
PD RELATED INFECTIONS

PERITONITIS
*signs and symptoms*
1. Cloudy effluent- > 100wbc/mL
2. >50% neutrophils
3. With or without fever
4. With or without tenderness

RELAPSING PERITONITIS
PD RELATED INFECTIONS

COMPLICATIONS OF
PERITONITIS
Temporary reduction of UF
Increased protein loss
Catheter removal
Adhesions
Transfer to HD
Death
KEYS TO LOW EXIT SITE AND PERITONITIS
RATES
Experienced personnel
Adequate patient and relative
training
Proper hand washing techniques
Continuous monitoring of rates
and organisms
TROUBLESHOOTING COMMON CLINICAL
PERITONEAL DIALYSIS PROBLEMS
WHAT SHOULD YOU DO IF THE FLUID IN THE
DRAIN BAG IS NOT CLEAR?

CLOUDY FLUID FIBRIN IN DRAINED FLUID

TROUBLESHOOTING COMMON CLINICAL
PERITONEAL DIALYSIS PROBLEMS
BLOOD-STAINED DRAIN NURSES RESPONSIBILITIES
FLUID BAG ASSESS!!
If occasional little bit of Refer to doctor
blood normal
Women may see pink drain
fluid one or two days before
TREATMENT
the start of their period Flushing out fresh
If after active exercise or dialysate until blood
heavy lifting --> pink drain ceases
fluid
TROUBLESHOOTING COMMON CLINICAL
PERITONEAL DIALYSIS PROBLEMS
ABDOMINAL PAIN NURSES RESPONSIBILITIES
*characterized by ASSESS!!
Deep pelvic pain or
Warm the dialysate
cramping while draining Inquire for revision of
or filling which feels like order
rectal or bladder pain
TROUBLESHOOTING COMMON CLINICAL
PERITONEAL DIALYSIS PROBLEMS
SHOULDER PAIN is not NURSES RESPONSIBILITIES
normal with PD ASSESS immediately
Shoulder pain may Check if with pain meds
sometimes occur when Inform and refer if
draining and goes away persistent.
after filling. dry pain
TROUBLESHOOTING COMMON CLINICAL
PERITONEAL DIALYSIS PROBLEMS
SHORTNESS OF BREATH

NURSES RESPONSIBILITIES
ASSESS!!
Hook to oxygen support
Obtain saturation
If with signs and symptoms of congestion
REFER
TROUBLESHOOTING COMMON CLINICAL
PERITONEAL DIALYSIS PROBLEMS
HIGHLY ELEVATED BLOOD PRESSURE

NURSES RESPONSIBILITIES
Instruct to restrict amount of fluids and salt in diet
If persists ASSESS and REFER
TROUBLESHOOTING COMMON CLINICAL
PERITONEAL DIALYSIS PROBLEMS
DECREASED BLOOD NURSES RESPONSIBILITIES
PRESSURE Instruct to stand and sit
*signs and symptoms gradually
Weak
Hold PD if too low
Prevent fall episode
Dizzy and light-headed
Leg cramps
sweating
OTHER COMMON CLINICAL PERITONEAL
DIALYSIS PROBLEMS
ANEMIA NURSES RESPONSIBILITIES
*caused by low iron Assess for fatigue and body
level and uremia weakness

TREATMENT
erythropoeitin
COMMON MECHANICAL PERITONEAL DIALYSIS
PROBLEMS
LEAKING DIALYSATE BAG
- Moisture is normally seen but if
with mL of fluid is noted
DISCARD
SLOW DRAINING OR FILLING
*inflow obstruction blockage such
as clamps or kinks
*outflow obstruction constipation
or catheter entrapment
NURSES RESPONSIBILITIES
Remove clamps or transfer
set
Position the patient
Fill bag should be higher
than the abdomen
The drainage bag should be
lower
COMMON MECHANICAL PERITONEAL DIALYSIS
PROBLEMS
FLUID LEAKING OUT AROUND THE EXIT SITE

NURSES CARE MANAGEMENT

Cover the site with gauze
Document!!
Notify the physician