Peritoneal Dialysis (PD)

By
JOSE BYRON DADULLA-
EVARDONE, RN

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Objectives
 To define Peritoneal Dialysis and to
discuss its principles.

 To list indications and contraindications

of Peritoneal Dialysis

 To enumerate general nursing care of

patient with Peritoneal Dialysis.

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PD
Principles of Peritoneal Dialysis
A. Usually temporary, can be used for clients
in acute reversible renal failure.

B. Basic goals of dialysis therapy.

1. Removal of end products of protein
metabolism, such as creatinine and urea.
2. Maintenance of safe concentration of
serum electrolytes.
3.Correction of acidosis and blood’s
bicarbonate buffer system.
4. Removal of excess fluid.
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PD

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PD

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PD
 Dialysis is the process by which solutes
and fluid will pass through a
semipermeable membrane.
 Peritoneum is a large serous membrane
consists of a closed sac within the
abdominal cavity.
 Peritoneal Dialysis is the removal of
solutes and fluid across a
semipermeable membrane which is the
peritoneum.
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PD

 PD is employed to remove waste and

toxic products from the blood
( peritoneal capillaries ) to peritoneal
cavity in cases of renal insufficiency or
failure.

 In order to achieve the above goal of

treatment , a solution which is called
Dialysate is infused into the abdomen
(peritoneal cavity) through an
abdominal catheter.
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PD
 The dialysate solution will stay in the
abdomen (peritoneal cavity) for
specified time, in order for difussion and
osmosis processes will occur.
 Diffusion is the movement of molecules
from an area of high concentration to an
area of low concentration.
Example: urea and creatinine in the
blood will shift to the peritoneal cavity
with dialysate which doesn’t have urea
and creatinine molecules.

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PD
 Osmosis is the movement of fluid from
an area of low concentration to areas of
high concentration.

 Dialysate solution inside the peritoneal

cavity with a high dextrose content
causing a fluid pull from intravascular
(peritoneal capillaries) to peritoneal
cavity. Example: CAPD3
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 PD
Purpose
2. Aid in the removal of toxic substances
and metabolic wastes.
3. Establish electrolyte balance.
4. Remove excesses body fluid.
5. Assist in regulating the fluid balance of
the body.
6. Control blood pressure.
7. Control severe, intractable heart
failure when diuretics no longer
promote elimination of water and
sodium.
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 PD
Indication for Peritoneal Dialysis
Acute renal failure.
Severe fluid overload in pediatric cardiac
patients.
To remove toxic and metabolic wastes.

Contraindication for Peritoneal Dialysis

Abdominal wound or infection
Peritonitis
Abdominal disease
Fecal fistula or colostomy
Gastric or diaphragmatic hernia
Extensive adhesions from previous surgery.
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 PD
Nursing Ojectives

* To restore and maintain fluid and electrolyte

balance and
preserve renal function if possible.
* To prevent complication of therapy.

Equipment

Dialysis administration set Supplemental drugs as

requested
Local Anesthesia CVP monitoring equipment
Warmer Sterile gloves
Tube clamps Skin antiseptic
Teenckhoff peritoneal catheter (for Adult use) ECG
monitoring
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Trocath PD catheter (for Pediatric use) Suture
 Peritoneal Dialysis
Insertion of the Cannula
Check coagulation profile before insertion of the catheter.
The bladder should be empty before the procedures.

5. The abdomen is prepared surgically, and the skin and

subcutaneous tissues are infiltrated with local anesthetic.
6. A small mid line stab wound is made 3-5 cm below the
umbilicus.
7. The trocar is inserted through the incision with stylet in
place, or thin stylet cannula may be inserted
percutaneously.
8. The patient, if awake and cooperative, is requested, or
assisted, to raise his head from the pillow after the trocar is
introduces. This maneuver tightens the abdominal muscles
and permits easy penetration of the trocar without the
danger of injury to the intra-abdominal organs.
9. When the peritoneum is punctured, the trocar is directed
toward the left side of the pelvis. The stylet is removed, and
the catheter is tunnelled through the trocar and maneuver
into position.
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 Peritoneal Dialysis
Insertion of the Cannula
6. Dialysis fluid is allowed to run through the catheter while it
is positioned. This prevent the omentum from adhering to
the catheter, impeding its advancement or occluding It’s
opening.
3. After the trocar is removed, the skin maybe closed with a
purse- string suture ( this is not always done). A sterile
dressng is placed around the catheter.

5. For adult or permanent PD.

Whether you choose an ambulatory or automated form of
PD, you’ll need to have a soft catheter placed in your
abdomen. The catheter is the tube that carries the dialysis
solution into and out of your abdomen. If your doctor uses
open surgery to insert your catheter, you will be placed
under general anesthesia. Another technique requires only
local anesthetic.

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 Peritoneal Dialysis
Insertion of the Cannula
Your doctor will make a small cut, often below and a little
to the side of your navel (belly button), and then guide the
catheter through the slit into the peritoneal cavity. As soon
as the catheter is in place, you can start to receive solution
through it, although you probably won’t begin a full
schedule of exchanges for 2 to 3 weeks. This break-in period
lets you build up scar tissue that will hold the catheter in
place.
The standard catheter for PD is made of soft tubing for
comfort. It has cuffs made of a polyester material, called
Dacron, that merge with your scar tissue to keep it in place.
The end of the tubing that is inside your abdomen has many
holes to allow the free flow of solution in and out.

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 Peritoneal Dialysis
Insertion of the Cannula

Two double-cuff Tenckhoff peritoneal catheters: standard (A), curled (B).

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Peritoneal Dialysis
Insertion of the Cannula
1. Commencing peritoneal dialysis on the patient
* The volume of PD fluid used is generally 20-30 ml/kg
* In unstable patient, 10-20 m/kg may be used

Attach the catheter connector to the administration

set, which has been previously connected to the
container of dialysis solution( warmed to bdy
temperature of 37°C). The solution is warmed to body
temperature for patient comfort and to prevent
abdominal pain. Heating also causes dilatation of the
peritoneal vessels and increase urea clearance.

* Hot PD fluid can damage the peritoneum.

* Cold PD fluid is painful, will contribute to
hypothermia and should not be used
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Peritoneal Dialysis
Insertion of the Cannula
 Drug (heparin, potassium, and antibiotics) are added
in advance. The addition f heparin, 100 unit per liter,
is routine added to the PD fluid to fibrin clot from
occluding the catheter. Potassium chloride may be
added on request unless patient has hyperkalemia.
Antibiotic are added for the treatment of peritonitis.
Permit the dialyzed solution to flow unrestricted into
the peritoneum cavity (usually takes 5- 10 mins.
completion).
if the patient experiences pain slow down the infusion.
Allow the fluid to remain in the peritoneal cavity for
the prescribed time period., 15 MINS. TO 4 HRS
(inflow time). Prepare the next exchange while the
fluid is in the peritoneal cavity. In order for potassium,
urea and other waste material to be removed, the
solution must remain in the peritoneal cavity for the
prescribe time( dwelling
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Peritoneal Dialysis
Insertion of the Cannula
1. The maximum concentration gradients takes place in
the first 5-10 mins. (outflow time) for small molecules,
such as creatinine and urea.
Unclamp the outflow tube. Drainage should be take
approximately 10-30 mins., although the time varies
with each patient.
 If the fluids is not draining properly: move the patient
from side to side facilitate the removal of peritoneal
drainage. The head of the bed may also elevated.
Ascertain if the catheter is patent. Check for closed
clamp, kinked tubing, or air lock. Never push the
catheter in as you will introduce bacteria. If the
drainage stop, or start to drip before the dialyzing
fluid has run out, manipulating the catheter tip may
be helpful ( or it may be necessary for the physician
to reposition the catheter).
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Peritoneal Dialysis
Insertion of the Cannula
1. When the outflow drainage ceases to run, clamp off the drainage
tube and infuse the next exchange.
take BP and pulse every 15 mins. During the first exchange and
every hour thereafter. Monitor the heart rate for sign of arrthymia. A
drop in blood pressure may indicate excessive fluid loss. Changes in
the vital sign may be indicate impending shock or over hydration.
3. Take the patient temperature every 4hrs. (especially after catheter
removal). An infection is more apt to become eviden after dialysis
has been discontinue.
4. The procedure is repeated until the blood chemistries level improve.
The usual duration for short- term dialysis is 36 to 48 hrs.
Depending on the patient condition, he will receive 24 to 48
exchanges .
5. Keep the exact record of the patient’s fluid balance during the
treatment. Know the status of the patient’s loss or gain of fluid at
the end of each exchange. Check dressing for leakage and weight
on gram scale if significant. The fluid balance should be about even
or should show slight fluid loss or gain , depending on the patient’s
fluid status and doctor’s order.

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Peritoneal Dialysis
Insertion of the Cannula
12. Promote patient comfort during dialysis.
Provide frequent back care and relieve pressure area
Have the patient turn from side to side.
Elevate head of bed at intervals.
Allow the patient to sit in chain for brief period if condition permits.
The patient may be mobilized during the outflow time if stable and
permission given by the doctor.

13. Observe the following:

A. Respiratory difficulty
- slow the inflow rate
- make sure the tubing is not kinked
- prevent air from entering peritoneum by keeping drip chamber
of tubing three quarters full of fluid.
- elevate head of bed: encourage breathing and coughing
exersices.
- turn patient from side to side.
- reduce the volume administered

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Peritoneal Dialysis
Insertion of the Cannula
13. B. Abdominal Pain
- encourage patient to move about if ambulant
c. Leakage
- change the dressings frequently, being careful not to dislodge the
catheter.
- used sterile plastic drapes to prevent contamination.
14. Keep accurate records:
- Exact time of beginning and end of each exchange: starting and
finishing time of drainage.
- amount of solution infused and recovered.
- fluid balance
- no. of exchanges
- medication added to dialysing solution.
- pre and post dialysis weigh plus daily weight.
- level of responsiveness at beginning, throughout, and at nd of
treatment.
- assessment of vital signs and patient’s condition.

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Peritoneal Dialysis
Insertion of the Cannula
Change peritoneal dialysis cannula monthly
usng sterile technique or as per unit protocol
(new tenckoff silicone catheter can be left in
for 3 month if required.)
Complication:
Peritonitis
Mechanical
Metabolic disturbances
Cardio- respiratory problem

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PD Solutions (Dialysate)
 CAPD 2 is a PD solution, potassium free
and with 1.5% Dextrose content.

 CAPD 3 is a PD solution, potassium free

and with 4.25% Dextrose content.

 The above dialysates can be

incorporated with additives such as
Heparin, Antibiotics, Na Bicarbonate,
etc.
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PD
 After a certain period of time, wherein
both processes difussion and osmosis
have occurred, the dialysate within the
peritoneal cavity together with the
metabolic wastes and extra fluid will be
drained into the collection bag through
peritoneal catheter exiting though the
outflow tubing.

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Type of PD
Continuous Ambulatory Peritoneal Dialysis
(CAPD)
 If you choose CAPD, you’ll drain a fresh bag of dialysis
solution into your abdomen. After 4 to 6 or more hours
of dwell time, you’ll drain the solution, which now
contains wastes, into the bag. You then repeat the cycle
with a fresh bag of solution. You don’t need a machine
for CAPD; all you need is gravity to fill and empty your
abdomen. Your doctor will prescribe the number of
exchanges you’ll need, typically three or four exchanges
during the day and one evening exchange with a long
overnight dwell time while you sleep.
 Continuous Cycler-Assisted Peritoneal Dialysis
(CCPD)
 CCPD uses an automated cycler to perform three to five
exchanges during the night while you sleep. In the
morning, you begin one exchange with a dwell time that
lasts the entire day.
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 PD
Preventing Problems
Infection is the most common problem for people on PD. Your
health care team will show you how to keep your catheter
bacteria-free to avoid peritonitis, which is an infection of the
peritoneum. Improved catheter designs protect against the
spread of bacteria, but peritonitis is still a common problem
that sometimes makes continuing PD impossible. You should
follow your health care team’s instructions carefully, but here
are some general rules:
Store supplies in a cool, clean, dry place.
Inspect each bag of solution for signs of contamination before
you use it.
Find a clean, dry, well-lit space to perform your exchanges.
Wash your hands every time you need to handle your catheter.
Clean the exit site with antiseptic every day.
Wear a surgical mask when performing exchanges.

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 PD
Keep a close watch for any signs of
infection and report them so they can
be treated promptly. Here are some
signs to watch for:
Fever
Nausea or vomiting
Redness or pain around the catheter
Unusual color or cloudiness in used
dialysis solution
A catheter cuff that has been pushed out
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 PD
Equipment and Supplies for PD
Transfer Set
A transfer set is tubing that connects
the bag of dialysis solution to the
catheter. When your catheter is first
placed, the exposed end of the tube
will be securely capped to prevent
infection. Under the cap is a
universal connector.
When you start dialysis training, your
dialysis nurse will provide a transfer
set. The type of transfer set you
receive depends on the company
that supplies your dialysis solution.
Different companies have different
systems for connecting to your
catheter.
Connecting the transfer set requires
sterile technique. You and your
nurse will wear surgical masks. Your
nurse will soak the transfer set and
the end of your catheter in an
antiseptic solution for 5 minutes
before making the connection. The
nurse will wear rubber gloves while
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PD
Depending on the company that supplies your
solution, your transfer set may require a
new cap each time you disconnect from
the bag after an exchange. With a
different system, the tubing that connects
to the transfer set includes a piece that
can be clamped at the end of an exchange
and then broken off from the tubing so
that it stays on the transfer set as a cap
until it is removed for the next exchange.
Your dialysis nurse will train you in the
aseptic (germ-free) technique for
connecting at the beginning of an
exchange and disconnecting at the end.
Follow instructions carefully to avoid
infection
Transfer set. Between exchanges, you can
keep your catheter and transfer set
hidden inside your clothing. At the
beginning of an exchange, you will
remove the disposable cap from the
transfer set and connect it to a Y-tube.
The branches of the Y-tube connect to the
drain bag and the bag of fresh dialysis
solution. Always wash your hands before
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handling your catheter and transfer set, dadulla evardone 30
and wear a surgical mask whenever you
PD

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