Peritoneal-Dialysis-exam-review.pptx

Peritoneal Dialysis
The Basics
Copy Right BCIT Specialty Nursing Nephrology

Review
 Review is an overview…students must still review all
course materials from NSNN 7400 to this point to
prepare for the exam…including article materials.

Definition
 Treatment for renal failure
 Uses clients peritoneal membrane as semipermeable
membrane
 Dialysis fluid instilled into peritoneal cavity
 Continuous modality
 Uremic toxins and solutes move across membrane by
process of Diffusion
 Fluid removal by Osmosis
 Regulates toxins, excess electrolytes and fluids

What’s the Difference?

Who Benefits from PD?
 Viable and effective dialysis treatment option for most ESRD clients
 Preserves residual renal function
 Reduces cardiovascular instability
 Decreases potential for systemic inflammation
 Improves blood pressure and volume control
 Allows client independence( travel) , promotes self-management and
self regulation
 Delay in use of blood access sites (AVF/CVC)
 Reduction in health care costs due do home and self management
focus

Contraindications for PD
 History of multiple abdominal surgeries( scarring and adhesions
may reduce surface area of peritoneal membrane)
 Presence of known peritoneal fissures( openings in between the
peritoneum and the pleura)
 Chronic and severe back pain
 Morbid obesity
 Acute or active diverticular disease ( may lead to ruptures into
peritoneum/ peritonitis.
 Advanced COPD ( increased pressure on diaphragm)
 Incapacitation- self-care not possible/ no caregiver.

The Terms!
 Dialysate: PD solution composed of water; an osmotic agent,
(dextrose); electrolytes such as sodium, chloride, magnesium,
calcium and buffer; lactate or bicarbonate
 Volume: the amount of dialysate used, typically ranging from two –
three litres
 Effluent: spent dialysate containing wastes and excess fluid from
the process of diffusion and osmosis.
 Fill (or infusion): a short period of time during which fresh dialysate
is instilled into the peritoneal cavity. Approximately 10 minutes.

The Terms!
 Dwell: the time during which dialysate sits in the peritoneal cavity,
permitting the dialysis to occur. This phase may take
approximately four to five hours to complete for clients on CAPD or
about an hour and a half to complete for clients on APD
 Drain: the short period during which dialysate is removed from the
peritoneal cavity. Takes approximately 20 minutes to complete.
 Exchange: the entire process of fill, dwell and drain. Several
exchanges within a 24 –hour period is typical
 Osmosis: movement of water through a semipermeable
membrane from solution of low concentration into a solution with a
higher concentration

PD Cannula (Catheter)
• Long pliable tube with many perforations to
assist with fluid instillation and drainage
• Catheter inserted at the bedside under
local anesthetic or in the OR under general
anesthetic
• Small incision made near the belly button
and then the tube is tunneled and the tip
placed in the abdomen
• The catheter is sutured initially
• Needs time to heal and tissue growth to
take place into the cuffs
Copy Right BCIT Specialty
Nursing Nephrology

PD
Cannula (Catheter)
 Flushes done post insertion
 After healing complete, ongoing flushing
done and training takes place
 Some of the catheter remains outside the
body at all times
 Catheter may be buried under skin if not
starting treatment for some time
 Exit site must be kept clean and covered

Types of peritoneal Dialysis
 Continuous Ambulatory Peritoneal Dialysis CAPD
 Performed manually through the day by client
 Generally 4-5 exchanges during waking hours
 Dialysate left in the peritoneal cavity overnight
 Requires little equipment, no power source
 Automated Peritoneal Dialysis APD
 Use of mechanical device called cycler
 Automatically controls exchange process
 Usually performed at night while client asleep

Removal of Fluid
 Ultrafiltration will be achieved through osmosis.
 Osmosis moves water through a semi-permeable membrane from
a solution of low solute concentration to a solution of high solute
concentration.
 A high solute concentration is required on one side of the
peritoneal membrane.
 Concentration of the PD solution, dwell time, membrane
permeability, oncotic pressure in the capillary beds play an
important role.

Length of time exposed to
membrane (dwell time)
Membrane Permeability
Concentration
Gradient (PD solution)
Factors affecting
rate of Osmosis
Ultrafiltration Achieved through Osmosis:
Oncotic
pressure in
capillary
beds

Osmosis

PD Focused Assessment
 Ideal weight assessment
 Appetite, nutritional status
 N+V, bowel routine/ constipation
 VS
 Exit site assessment
 Frequency and duration of exchanges
 Effluent ( if applicable)
 Adequacy , PET results
 Blood work
 Medications
 Comorbidities, diabetes etc.
 Psycho-social issues

Pre-dialysis Assessment:
Vital
signs
Fluid
intake
Edema
Appetite
Bowels
Respiratory
status
Medications
lab work
JVD
Previous data
Weight
Urine
output
1. Ideal Weight
Assessment

PD Complications

Purpose:
 To understand common complications that occur in PD, and expand
participant’s knowledge base of troubleshooting techniques.

Overview
 Membrane Assessment
 Draining Issues
 PD Fluid Gone Wrong
 Exit Site Infection
 Peritonitis
 Catheter Leaks

Physical Complications of PD
 Tunnel Infection
 Constipation
 Abdominal Discomfort
 Catheter Obstruction
 Hemoperitoneum
 Hypervolemia

Membrane Assessment
What does a healthy membrane look like?
*No scar tissue, large surface area, no hernias or prior surgeries to the area.
As well as minimizing peritonitis. This will achieve optimal PD.
*If you use larger fill volumes based on the body’s surface area, it will ensure
greater contact of the dialysis solution with the membrane which maximizes
diffusion.

Important Facts
 PD different then HD in that peritoneal membrane is
permeable to plasma proteins which can be lost in
peritoneal fluid
 Clients protein intake may need to be increased
 During acute inflammation –peritonitis, membrane
permeability temporarily increases. Conversely +
overtime scarring from chronic inflammation can
decrease permeability
 IMPORTANT to keep peritonitis to a minimum.

Exit Site Infection

Draining Issues
What are draining issues ?
 Blood or fibrin clots
 Air lock
 Constipation
 Catheter migration
 Omental wrap
 Kinked or clamped faulty equipment
 Outflow failure:
The drainage volume is substantially less than the inflow volume and there is no evidence of pericatheter leakage. Usually occurs soon after catheter placement. Often preceded by irregular drainage, increased fibrin in
the dialysate or constipation.
 Inflow failure:
Solution will not flow from the dialysate bag into the peritoneal cavity.

Draining Issues
 What do we do about that?
Irrigate the peritoneal catheter per program policy.
Notify the Nephrologist when a blockage is suspected.
If using a thrombolytic agent, it requires a dwell period in the catheter in direct contact
with the clot to initiate local fibrinolysis.

BCPRA
BCPRA

Draining issues
Patient teaching:
 Assess drained effluent with each exchange for color, clarity and volume.
 Awareness of the importance of maintaining a bowel routine.
 Check for line kinks and or closed clamps as a first step if difficulty in
draining is noted.
 Change position and increase ambulation if difficulty in draining is noted.
 Report changes in drained volume or speed of drainage when noted.

Draining issues
Documentation:
 Assessed drainage problems
 Appearance and volume of drained effluent
 Treatment options provided
 Patient response to treatment options

PD fluid gone wrong
 Is this good or bad?

 What is the situation?
 White strands in effluent are fibrin.
 Fibrin formation increases in peritonitis.
 If untreated the fibrin can block the catheter and cause drain/filling problems.
 What do we do to fix Fibrin?
 Add heparin to solution for a dwell (PD clinic will give dosing).

 Causes
 Menstruating women, heavy lifting/trauma to abdomen
 Ruptured cyst if you have polycystic disease
 Recent enema, sigmoidoscopy, colonoscopy
 Recent PD catheter insertion
 It can also be an indication of abdominal trauma, disease and peritonitis.
 What do we do to fix it?
 Do two exchanges- by filling and immediately draining with no dwell time in between. Add heparin to each solution fill bag. Pt should call PD clinic if not clearing in one
day.

Exit Site infection
 What does it look like:
Red, swollen, painful, tender, draining
 Exit site infection can cause exit site tunnel infection and peritonitis. As a
complication of infection, a patient can have intestinal perforation. Early
surgical intervention and possible catheter removal should be performed
in addition to immediate initiation of therapy with antibiotics or antifungal.
 An exit-site infection that does not respond to treatment may lead to
persistent peritonitis which may require catheter removal or occasional
discontinuation of the peritoneal dialysis.

Would you remove crusts or scabs at the exit
site?

 It’s a barrier to exit site entrance. Removal may open it and
allow bacteria inside. It will come off on its own. Patience….

Peritonitis
 What is it?
Infections can thicken/ scar membrane overtime, PD may not be an option.
 Signs and Symptoms of peritonitis include:
 Abdominal pain
 Cloudy dialysis fluid
 An unusual odour of dialysis fluid
 Bloating or a feeling of fullness in abdomen
 Fever
 Nausea /Vomiting/Diarrhea
 Loss of appetite/ Fatigue
 Inability to pass stool or gas
 Area around PD catheter red or painful

Sign and symptoms of Peritonitis

Peritonitis

Peritonitis
 What do we do about it?
 Instruct patient to Drain PD fluid and keep bag to take to the hospital. Go to ER if PD unit is
closed.
 Peritonitis is one of the most feared complications of PD. As peritonitis is a life threatening
condition, it can be very disturbing for a person. Clients can live in constant fear of having it
– and can be paranoid with personal hygiene. They can isolate themselves from friends
and the outside world to minimize the risk of infection.

Catheter leaks
S&S:
•Genital, scrotal, or penile edema
•Volume overload with decreased UF
•External fluid at wound or exit site
•Edema of abdomen / increased girth
•Weight gain
•Decreased exchange of drain volume
Abdominal CT scan or fluoroscopy with contrast can reveal catheter leaks. When the catheter is
leaking, PD can be delayed for 2-3 weeks. Sometimes, a client has to be moved for hemodialysis
for 1-2 weeks. Catheter leaks may require surgical repair or catheter replacement. Catheter leakage
can increase the risk for exit site infection and peritonitis. The client may need to visit the PD clinic
more frequently. Body image can also be impacted by this problem.

References
• Counts, S.C. Core Curriculum for Nephrology Nursing 5th
edition 2008; 828 - 829.
• Ash S. Peritoneal Access Devices. Handbook of Dialysis,
4th Edition (2007) Lippincott Williams & Wilkins 356- 375
• Piarano, B., Bailie, G., Bernardini, J. et al. ISPD Guidelines
Recommendations. Peritoneal dialysis – related infections
recommendations: 2005 update. Peritoneal Dialysis
International 2005:25:107-31.
• NSNN 7400 NSNN 7400 MODULE 4 COURSE NOTES

Valuable Resource
 http://www.bcrenalagency.ca/health-
professionals/clinical-resources/pd-patient-training-
modules
 E-Learning Modules

Peritoneal-Dialysis-exam-review.pptx

Recommended

Recommended

More Related Content

Similar to Peritoneal-Dialysis-exam-review.pptx

Similar to Peritoneal-Dialysis-exam-review.pptx (20)

Recently uploaded

Recently uploaded (20)

Peritoneal-Dialysis-exam-review.pptx