Notebook dp

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REPUBLIC OF NAMIBIA
MINISTERY OF HEALTH & SOCIAL SERVICES
INTERMEDIATE HOSPITAL OSHAKATI
COURSES OF PERITONEAL DIALYSIS.
NOTEBOOK FOR NURSES’S COURSE OF PERITONEAL DIALYSIS
OSHAKATI HOSPITAL, IN ORDER TO STUDY AND TO LEARN
PERITONEAL DILAYSIS.
Author: Dr. Jose L. Rodriguez -Nephrologist
-2014-

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Index
1. Introduction
2. Chronic Kidney Failure. ESRD
3. History of Peritoneal Dialysis
4. What is the Peritoneal Dialysis
5. Dialysis physicochemical principles
6. Peritoneal access
7. Complication
8. Indications and Contraindications.
9. Types of Dialysis Peritoneal
10. Nursing Care and Management
11.Annexes

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1. Introduction
This Certificate Course will provide the student acquire the skills necessary
for comprehensive patient care in peritoneal dialysis, as well as the
necessary skills in the field of health education, communication strategies
and relationship to the renal patient.
The nursing professionals have the opportunity to handle the equipment
needed for renal replacement therapies in the later simulation rooms for
care, under the supervision of experts, the patient and be part of the
dialysis equipment for the duration of the internship clinics.
On completing the program, students will be able to enter the labor market
with a competitive and appropriate professional to the demands of this
group of the population.
Peritoneal dialysis is the most common form of renal replacement therapy
performed in the home. Peritoneal dialysis is the process of removing
excess fluid and metabolic by-products from the body by circulating
dialysis solution through the peritoneal cavity using a peritoneal catheter.
The group of Cuban doctors who worked on the creation of this book and
the completion of this course student wish you success in learning and the
beautiful task of saving lives with the use of this therapy.
Lovingly..
Dr. Jose L. Rodriguez.
Nephrologist.
I.H.O. Namibia.

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2. Chronic Kidney Failure. ESRD
Chronic kidney failure, also called chronic kidney disease, describes the
gradual loss of kidney function. Your kidneys filter wastes and excess fluids
from your blood, which are then excreted in your urine. When chronic
kidney failure reaches an advanced stage, dangerous levels of fluid,
electrolytes and wastes can accumulate in your body.
In the early stages of chronic kidney failure, you may have few signs or
symptoms. Chronic kidney failure may not become apparent until your
kidney function is significantly impaired.
Treatment for chronic kidney failure focuses on slowing the progression of
the kidney damage, usually by controlling the underlying cause. Chronic
kidney failure can progress to ESRD (end-stage kidney disease), which is
fatal without artificial filtering (dialysis) or a kidney transplant.
 GFR <15 ml/mint./1.72m². SC.
 Creatinine>900 mg/dl.,
 Urea> 40 mg/dl,
 K>7 mEq/L.
Symptoms
Signs and symptoms of kidney failure develop slowly over time if kidney
damage progresses slowly. Signs and symptoms of kidney failure may
include:
Nausea
Vomiting
Loss of appetite
Fatigue and weakness
Sleep problems
Changes in urine output
Decreased mental sharpness
Muscle twitches and cramps
Hiccups
Swelling of the feet and ankles
Persistent itching

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Chest pain, if fluid accumulates around the lining of the heart
Shortness of breath, if fluid accumulates in the lungs
High blood pressure (hypertension) that's difficult to control
Signs and symptoms of kidney failure are often nonspecific, meaning they
can also be caused by other illnesses. In addition, because your kidneys are
highly adaptable and able to compensate for lost function, signs and
symptoms of kidney failure may not appear until irreversible damage has
occurred.
Causes
Chronic kidney failure occurs when a disease or condition impairs kidney
function, causing kidney damage to worsen over several months or years.
Diseases and conditions that commonly cause chronic kidney failure
include:
Type 1 or type 2 diabetes
High blood pressure
Glomerulonephritis (gloe-mer-u-lo-nuh-FRY-tis), an inflammation of the
kidney's filtering units (glomeruli)
Polycystic kidney disease
Prolonged obstruction of the urinary tract, from conditions such as
enlarged prostate, kidney stones and some cancers
Vesicoureteral (ves-ih-koe-yoo-REE-ter-ul) reflux, a condition that causes
urine to back up into your kidneys
Recurrent kidney infection, also called pyelonephritis.
Complications
Chronic kidney failure can affect almost every part of your body. Potential
complications may include:
Fluid retention, which could lead to swelling in your arms and legs, high
blood pressure, or fluid in your lungs (pulmonary edema)
A sudden rise in potassium levels in your blood (hyperkalemia), which
could impair your heart's ability to function and may be life-threatening
Heart and blood vessel disease (cardiovascular disease)
Weak bones and an increased risk of bone fractures
Anemia
Decreased sex drive or impotence
Damage to your central nervous system, which can cause difficulty
concentrating, personality changes or seizures
Decreased immune response, which makes you more vulnerable to
infection
Pericarditis, an inflammation of the sac-like membrane that envelops your
heart (pericardium)

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Pregnancy complications that carry risks for the mother and the developing
fetus
Irreversible damage to your kidneys (end-stage kidney disease), eventually
requiring either dialysis or a kidney transplant for survival.
3 -History of Peritoneal Dialysis
Peritoneal dialysis – from the beginning to the present
When symptoms of uremia first appear in the body, it is a sign that the kidneys are not
functioning properly or have stopped filtering toxins from the blood. The Greek origin of the
word “uremia” shows that the awareness of this disease goes back much further than our
ability to effectively treat people this life-threatening illness. Only within the last hundred
years medical research has been able to lay the fundament for replacing the kidneys’
functions through dialysis.
The first progress with this treatment type was made during the 1920s, but it would take a
number of subsequent discoveries in the following decades to make peritoneal dialysis
accessible for a larger number of patients with kidney disease. These advances were
achieved by dedicated doctors and scientists whose efforts and discoveries led to ever-
improving treatment possibilities.
On the following pages, we offer an introduction to the fascinating history of peritoneal
dialysis and the discoveries which, to this day, help to ensure a longer and better life for
more than 250,000 peritoneal dialysis patients worldwide.
The fundamentals of peritoneal dialysis
As described in the introduction, peritoneal dialysis is one of the two established methods to
remove toxins and excess water from the human body. The lining of the abdomen
(peritoneum) is a thin, shiny membrane that has a surface of as much as two square meters
and covers the entire abdominal cavity. Since the peritoneum has good blood circulation, it is
an excellent natural filter membrane.

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Peritoneal Dialysis Catheter Care
GENERAL INFORMATION:
Peritoneal dialysis (PD) uses the lining of your abdomen (the peritoneal membrane) to filter
your blood. A small, soft tube called a catheter is used to fill your abdomen with minerals
and sugar dissolved in water. This cleansing liquid is called dialysis solution. Wastes,
chemicals, and extra water move into the dialysis solution while it is in your abdomen. After
a certain time, the solution is drained from your abdomen through the catheter, taking the
wastes with it. Your abdomen is then filled again with new dialysis solution. Each cycle of
filling and draining is called an exchange.
PD can be done in different ways.
Continuous cycler-assisted peritoneal dialysis (CCPD) uses a machine called a cycler to fill
and drain your abdomen. It is usually done a few times while you sleep. CCPD is also
sometimes called automated peritoneal dialysis (APD).

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Continuous ambulatory peritoneal dialysis (CAPD) uses gravity instead of a machine to fill
and empty your abdomen. With CAPD, you do manual exchanges of fluid a few times during
the day. You drain a fresh bag of dialysis solution into your belly by hanging the bag higher
than your belly. For a number of hours you let the fluid work inside your belly to remove the
waste fluids. Then you drain the fluid from your belly by hanging the bag at a level lower
than your belly catheter.
Before your first treatment, the catheter used for peritoneal dialysis is put into your belly
through a small cut near your belly button. Your healthcare provider will make the cut and
insert the catheter after you have been given an anesthetic. The catheter will be closed with
a clamp or valve when you are not having dialysis.
Your provider will give you a schedule for how often you will need to have dialysis. You will
have frequent weigh-ins and lab work to make sure the dialysis is helping you get rid of
wastes and keep a good balance of minerals.
What are the benefits of dialysis?
Dialysis does the work your failed kidneys would normally do. It keeps your blood clean and
healthy.
If you have kidney failure, dialysis can help you live longer. If you are otherwise healthy,
dialysis may allow you to keep working or enjoying the things you like to do.
If you are very sick and have other health problems, dialysis may seem like a burden that
only prolongs your suffering.
Having dialysis is a very personal decision to be discussed with your family and your
healthcare provider.
What are the risks of dialysis?
Possible problems with hemodialysis include:
problems with the access to your blood vessels, such as infection, blockage from clotting,
and poor blood flow
muscle cramps
a sudden drop in blood pressure, which can make you feel weak, dizzy, or sick to your
stomach.
The most common serious problem with peritoneal dialysis is an abdominal infection called
peritonitis. The infection can be treated with antibiotics.
How can I take care of myself?
Carefully follow the diet prescribed by your healthcare provider.
Do not drink more liquids than your provider recommends.
Follow the dialysis schedule as prescribed.
Take medicines exactly as prescribed by your provider.
If you are having hemodialysis, tell your provider if you have muscle cramps or feel weak,
dizzy, or sick to your stomach.

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If you are having peritoneal dialysis, tell your provider right away if you have these signs of
infection:
You have a fever.
You have belly pain.
The used dialysis solution has an unusual color or cloudiness.
The area around the catheter is red or painful.
What is continuous ambulatory peritoneal dialysis?
 Continuous ambulatory peritoneal dialysis (CAPD) is done to remove
wastes, chemicals, and extra fluid from your body. The peritoneum is a thin
lining on the inside of your abdomen. During CAPD, a liquid called dialysate is
put into your abdomen. It is put in through a CAPD catheter. The catheter is a
tube that goes from the outside, to the inside of your abdomen. The dialysate
pulls wastes and substances from your blood and lymph fluid through the
peritoneum. The wastes mix with the dialysate. The peritoneum works like a
filter as the wastes are pulled through it.
 The dialysate is left in your abdomen for 3 to 5 hours. This is called the
dwell time. After the dwell time, the dialysate is drained out through the
catheter. Filling and emptying your abdomen with dialysate is called an
exchange. CAPD exchanges can decrease or take away problems such as
swelling, itching, fatigue, and weakness. CAPD can help decrease high blood
pressure, and make you feel more like doing the things you enjoy.
When and how often should I do peritoneal dialysis? You and your caregiver will decide
how many exchanges you need to do each day. Your caregiver will also discuss which type of
PD may be best for you. During continuous ambulatory peritoneal dialysis (CAPD), you may
need to do 3 to 5 exchanges during the day, and one exchange during the night. Automated
peritoneal dialysis (APD) uses a cycler (special machine) to do your exchanges. One
exchange is done during the day, and 3 to 5 exchanges are done during the night while you
are asleep.

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How are CAPD exchanges done? Do your CAPD exchanges in a well-lit room that has no
pets, dander, strong breezes, or fans. Having pets or a breeze blowing in the room may
increase your risk of getting an infection.
 Supply list: Collect the following supplies and place them on a clean table
close to where you will be doing your CAPD exchange:
o Clean water and soap.
o Dialysate bag.
o Waste product bag.
o "Y"-shaped tubing.
o IV stand. This is needed so that you can hang your dialysate bag
on it. The stand should have a hook at the top to help hold the bag in place.
The dialysate fluid drains into your abdomen by gravity. Because of this, the
bag needs to be hung up higher than the level of your abdomen.
o Disposable (single use) medical gloves.
o Medical mask to wear over your face while doing CAPD.
o Tubing clamp, and a piece of soft cloth. Use the cloth as
padding between the clamp and catheter when you are clamping the catheter
tube. This will decrease the chance that the clamp will make a hole or crack in
the catheter. Ask your caregiver about other clamps that are less likely to
break the catheter or make holes in it.
o New plastic syringe without a needle (if needed).
 Wash your hands with soap and water: Rub your hands together with
soap for at least 15 seconds before rinsing them. Dry your hands with a clean
towel or paper towel. Do not touch the tubing or your catheter without washing
your hands and wearing gloves.
 Put on your gloves and mask: Put on your mask so that it covers your
mouth and nose. Keep your fingernails short and clean. Do not use fake nails.
Put on your gloves, being careful not to touch anything except your supplies
while they are on.
 Flush the tubing: Flushing the tubing with dialysate liquid before doing
CAPD may help prevent infections. Connect the lower end of the Y tubing to
your catheter. Connect the two other ends of the tubing to the dialysate bag,
and the waste bag. Clamp the tubing that is attached to the catheter that goes
into your abdomen. This will close off the tubing so that the dialysate does not
go into your abdomen yet. Allow 100 milliliters of fresh dialysate to flow out of
the bag, and down the tubing into the waste bag. After this amount of dialysate
has drained out, clamp the tubing that goes to the waste bag closed.
 Let the dialysate flow into your abdomen: Take the clamp off of the
tubing that is attached to the catheter that goes into your abdomen. Let the
rest of the dialysate flow into your abdomen. You may lie down, sit, or stand up
while the dialysate flows in. After all of the dialysate is in your abdomen, wash
your hands and put on new gloves. Disconnect your catheter from the tubing.
Clamp your catheter closed. Leave the dialysate in your abdomen for 3 to 5
hours of dwell time.
 Drain the dialysate out of your abdomen, and into the waste
bag: After the dwell time, follow the steps of washing your hands and putting
on your mask and gloves. Be sure the supplies that you need are easy to reach
and use. Connect the Y tubing to your catheter again. Do this in the same way
as you did to put the dialysate into your abdomen. Clamp the tubing that goes
to the dialysate bag so that it is closed. Remove the clamps from your catheter

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and the waste bag. Let the dialysate drain from your abdomen and into the
waste bag. Throw away the waste bag as directed by your caregiver.
What problems might I have when I have a CAPD catheter? Tell your caregiver if you
have any of the following problems:
 Hernias (lumps) at your catheter exit site, belly button area, or
groin. A hernia is a fluid-filled sac. This sac may be caused by too much
dialysate going into your abdomen. Tell your caregiver if you see or feel a new
lump on your abdomen.
 Infection: Yellowish discharge (pus) may come out from the exit site or
out of your catheter. The exit site may look red and be painful to touch. You
may have a fever and chills, or feel very weak. You may feel sick, or start
throwing up. You may be constipated. Tell your caregiver if you get any of
these problems.
 Leaking dialysate from the exit site: You may see dialysate leaking
from the exit site for up to a month after you have your catheter put in. You
may notice that the dialysate drains out more slowly during exchanges, or
there is less of it.
 Pain: The skin around your exit site may be painful. You may feel pain in
your pelvis, low back, and shoulder while doing CAPD exchanges. Change your
body position when you are doing your exchanges. Try lying down, sitting, or
standing up. Ask your caregiver for exercises that you may be able to do to
help decrease back pain.
 Stomach swelling: You may feel full during and after CAPD exchanges.
This feeling may go away over time. If it does not go away, talk to your
caregiver.
What should I do when there is a flow problem with my peritoneal dialysis
catheter? When the dialysate is flowing into your abdomen during an exchange (inflow), the
flow may slow down or even stop. When the dialysis is draining out of your abdomen during
an exchange (outflow) this may also be a problem. The dialysate should take about ten
minutes to flow into your abdomen. The dialysate should take less than 45 minutes to drain
out of your abdomen. Inflow or outflow problems may mean that your catheter is blocked, or
that the tube has moved out of the right place.
 If the inflow or outflow of the dialysate is slow, you may try the
following:
o Put in 10 to 20 ml of dialysate or saline solution into the catheter
using a syringe. Hold the catheter and syringe in one hand. Use your other
hand to firmly push the dialysate out of the syringe, through the catheter, and
into your abdomen. This may push out the blood clot or move whatever is
blocking your catheter. After doing this process a few times, use the syringe
to try and pull fluid out gently. If fluid comes out, the catheter is no longer
blocked. If this does not help, your caregiver may need to put medicine
through the catheter that breaks down blood clots.
 If the inflow of the dialysate is fast but there is no outflow, you
may try the following:
o Change your position while doing your exchanges. You may sit up,
lie down, or lie on your side. You may even lie with your head down and your
feet up. Changing your position may make the dialysate flow out more easily.
If this does not help, disconnect the end of the tubing that is attached to your
catheter. Use a syringe to gently suck the dialysate out of your abdomen. Do
not pull on your catheter. It may move your catheter out of place even more.
You may also start bleeding if you pull on it. If the flow does not get faster,
call your caregiver.

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What diet changes may I need to make while I am doing peritoneal dialysis
exchanges?
 You may lose weight and become weak when you are doing CAPD
exchanges. You may not feel like eating. Your body may lose protein and other
nutrients that you need to be healthy. You may need to increase the fiber in
your diet by eating more vegetables and fruits. Fiber helps you have regular,
soft bowel movements (stools), and helps prevent constipation. Decreasing the
amount of salt in your diet may decrease your blood pressure. Ask your
caregiver what diet is best for you, and for more information about it.
 Your caregiver will ask you to limit the amount of liquids you drink. Your
caregiver will tell you how much to drink each day. Write down how much
liquid you drink each day. Measure the amount of urine you pass each time you
go to the bathroom. Show this information to your caregiver when you have
follow-up visits. He will tell you if you have too much or too little fluid in your
body, and what to do to correct it.
How and when are the bandages around my peritoneal dialysis catheter
changed? Your caregiver will change your bandages every week for the first two weeks. On
the third week, your bandages may need to be changed more often. When your exit site is
healed up, you may need to change your bandages every day. A healed exit site is pink in
color, and at least 13 millimeters in size (smaller than a dime). The area should not
be painful. Change your bandages as follows:
 Collect your supplies:
o Sterile (clean and new) medical gloves.
o Medical mask.
o New bandages.
o Soap and fresh water.
o Solution for removing old bandages and cleaning your skin. Ask
your caregiver what solution is best to use.
o Medical tape.
 Wash your hands: Use soap and water to wash your hands. Scrub them
for at least 15 seconds. Dry your hands well with a clean towel or new paper
towel.
 Put on your mask and gloves: Put on your mask, making sure that it
covers both your nose and your mouth. This will help prevent germs from your
nose or mouth going on your exit site. Put on your gloves. Do not touch
anything other than the bandage and your supplies when your gloves are on.
 Avoid moving your catheter: Do not pull or twist your catheter when
changing your bandages. Make sure that your catheter stays in its place.
 Remove old bandages: Use a sterile solution to carefully remove old
bandages from the exit site. Pour the solution over bandages that are stuck on
your exit site to loosen them. If there is a scab (dried up skin or blood), do not
pull on it. Take off the bandage very slowly. Look for pus, fluid, or blood
coming from the exit site. If you see these things, call your caregiver. If the
area is painful, call your caregiver.

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 Clean your wound, catheter, and skin: Wipe the exit wound, catheter,
and skin around the catheter with a sterile solution. Pat the area dry with a
clean bandage.
 Cover your catheter and the exit site with bandages: Covering your
catheter when you are not using it may help it stay in place. This may help stop
the catheter from bending and kinking, or being pulled out. Use several layers
of bandages to cover the exit site and the skin around your catheter. Hold the
bandages in place with tape.
Can I bath or shower while I have a peritoneal dialysis catheter? You cannot take a
bath or shower until two weeks after your catheter was placed. Getting your exit site wet
may delay healing. Use a washcloth, soap, and water to wash your skin. When the exit site
heals, your caregiver may let you take a shower. If you take baths, do not let the exit site go
under the water. Leave the bandages on until after your bath, and then put on new
bandages. After your exit site has fully healed, you may swim in the ocean or chlorinated
swimming pools. Dry the exit site right after swimming. Avoid using hot tubs, and swimming
in rivers or ponds.
What else can I do to help prevent infection at the catheter exit site?
 Keep your catheter held in the right place: Ask your caregiver how to
tape your catheter to your body. This may help prevent the catheter from
twisting and being moved or pulled out.
 Change your bandages as ordered by your caregiver: Germs may
grow on the exit site and on old bandages. Change your bandages every day,
or as often as your caregiver has told you to. You may need to keep your exit
site covered with bandages for six months to a year.
 Take antibiotic (germ-killing) medicine as ordered: This medicine
helps prevent or treat infection.
When will my peritoneal dialysis catheter be removed? Your catheter can be used for
up to two years if it is not blocked or damaged. Your caregiver may need to remove it if you
get an infection. He may replace it when it is cut, clogged, or damaged. It will be removed if
you need to have hemodialysis instead of PD. Your caregiver will remove it if you do not need
to have dialysis anymore.
When should I call my caregiver? Call your caregiver if:
 Pus or fluid is draining out of the exit site.
 The dialysate that drains out of your abdomen looks cloudy.
 The exit site is bigger than it used to be.
 There is no dialysate flowing out of your abdomen during an exchange,
even after changing positions and using a syringe.
 You have a fever (high body temperature) or chills.
 You have dull pain in your abdomen while doing a dialysis exchange.
 There is a new bump that has grown in your abdomen since you have
started doing CAPD exchanges.
 Your catheter exit site is red, tender or painful.
 You have questions about CAPD or your catheter.
When should I seek immediate help? Seek care immediately or call 911 if:
 You have hard, painful bowel movements and the stool is hard to pass.
 You have stomach pain, and you are vomiting (throwing up).
 You have trouble breathing while doing your exchanges.
 Your catheter has a crack or hole in it, or it has come part or all of the
way out of your abdomen.

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4. What is the Peritoneal Dialysis
Before dialysis was available, total kidney failure meant death. Today, people with kidney
failure can live because of treatments such as dialysis and kidney transplant.
What is dialysis?
Dialysis is a way of cleaning your blood when your kidneys can no longer do the job. It gets
rid of your body's wastes, extra salt and water, and helps to control your blood pressure.
Are there different types of dialysis?
There are two kinds of dialysis. In hemodialysis, blood is pumped out of your body to an
artificial kidney machine, and returned to your body by tubes that connect you to the
machine. In peritoneal dialysis, the inside lining of your own belly acts as a natural filter.
Wastes are taken out by means of a cleansing fluid called dialysate, which is washed in and
out of your belly in cycles.
How does peritoneal dialysis work?
A soft plastic tube (catheter) is placed in your belly by surgery. A sterile cleansing fluid is put
into your belly through this catheter. After the filtering process is finished, the fluid leaves
your body through the catheter.
There are two kinds of peritoneal dialysis:
Continuous Ambulatory Peritoneal Dialysis (CAPD)
Automated Peritoneal Dialysis (APD)
The basic treatment is the same for each. However, the number of treatments and the way
the treatments are done make each method different.
CAPD is "continuous," machine-free and done while you go about your normal activities
such as work or school. You do the treatment by placing about two quarts of cleansing fluid
into your belly and later draining it. This is done by hooking up a plastic bag of cleansing
fluid to the tube in your belly. Raising the plastic bag to shoulder level causes gravity to pull
the fluid into your belly. When empty, the plastic bag is removed and thrown away.
When an exchange (putting in and taking out the fluid) is finished, the fluid (which now has
wastes removed from your blood) is drained from your belly and thrown away. This process
usually is done three, four or five times in a 24-hour period while you are awake during
normal activities. Each exchange takes about 30 to 40 minutes. Some patients like to do
their exchanges at mealtimes and at bedtime.
APD differs from CAPD in that a machine (cycler) delivers and then drains the cleansing fluid
for you. The treatment usually is done at night while you sleep.
What kind of peritoneal dialysis is best?
The type of peritoneal dialysis that is best for you depends on your personal choice and your
medical condition. Your doctor will help you to choose the one that is best for you.
What are the pros and cons about being on peritoneal dialysis?
Some doctors feel that CAPD and APD have several benefits when compared to
hemodialysis. With continuous dialysis, you can control extra fluid more easily, and this may
reduce stress on the heart and blood vessels. You are able to eat more and use fewer
medications. You can do more of your daily activities and it is easier to work or travel.

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However, there are some people for whom peritoneal dialysis may not be appropriate. The
abdomen or belly of some people, particularly those who are morbidly obese or those with
multiple prior abdominal surgeries, may make peritoneal dialysis treatments difficult or
impossible. Peritonitis (infection of abdomen) is an occasional complication although should
be infrequent with appropriate precautions. When making a decision about the type of
treatment, you should take into consideration that peritoneal dialysis is usually a daily
process, similar to the working of the kidney and may be more gentle with fluid removal
from the body. Peritoneal dialysis is an effective form of dialysis, has been proven to be as
good as hemodialysis.
Peritoneal dialysis is not for everyone. People must receive training and be able to perform
correctly each of the steps of the treatment. A trained helper may also be used.
How are treatments paid for?
All types of dialysis are expensive, but, for most patients, the federal government now pays
80 percent of all dialysis charges, while private insurance or state medical assistance pays
the rest.
5. Dialysis physicochemical principles
Anatomy of the peritoneum
The peritoneal membrane is a semi-permeable membrane that lines the abdominal wall
(parietal peritoneum) and covers the abdominal organs (visceral peritoneum). The
membrane is a closed sac in males. The fallopian tubes and ovaries open into the peritoneal
cavity in females. The size of the membrane approximates the body surface area (1-2 m2).
There are about 100 cc of transudate that is contained in the cavity in normal individuals.
A. Blood Supply
The parietal peritoneum derives its blood supply from the arteries in the abdominal wall.
This blood drains into the systemic circulation. The visceral peritoneum is supplied by blood
from the mesenteric and coeliac arteries which drain into the portal vein.
B. Lymphatics
Subdiaphragmatic lymphatics are responsible for 80% of the drainage from the peritoneal
cavity. The drainage is then absorbed into the venous circulation through the right lymph
duct and the left thoracic lymph duct. A balance of solutes and fluid in the interstitial tissue
is maintained by absorption of fluid from the peritoneal cavity. The average lymphatic rate
of absorption in the PD patient is 0.5-1.0 ml/min. Factors that affect the rate of absorption
are respiratory rate, posture, and intra-abdominal pressure.
Physiology of the Peritoneum
The peritoneal membrane is a complex heterogenous, semi-permeable membrane with
multiple pores. The early models of peritoneal membrane transport included multiple sites
of resistance to the flow of solutes across the membrane. These included the capillary fluid
film overlying the capillary endothelium, the capillary endothelium per se, the endothelial
basement membrane, the interstitium, the mesothelial cells and the fluid overlying the
peritoneal membrane. Newer concepts such as the Three Pore Model suggest that the

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major resistance to peritoneal transport is in the capillary endothelium and its basement
membrane.
The Three Pore Model is a theoretical model validated by clinical observations1,2. It
suggests that the peritoneal capillary is the critical barrier to trans-peritoneal transport.
Solute and water transport across the peritoneal capillary is mediated by pores of three
different sizes.
Large pores (100-200 A) exist in small numbers and constitute < 0.1% of all pores. The
transport macromolecules and anatomically are identified as clefts between endothelial
cells. Small pores (40-60 A) are more numerous and believed to transport small solutes and
water. Ultra-small or transcellular pores (4-6 A) are water channels or aquaporin-1. They
are numerous and resemble the water channels present in red blood cells and renal

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proximal tubules. They transport water only (sieving) and are present in the endothelial
cells of the peritoneal capillaries.
During ultrafiltration in PD, and unlike HD, solutes do not move across the membrane in
direct proportion to their concentration in blood. Sodium is held back or sieved at the
aquaporin barrier while water moves through. Sieving makes ultrafiltration a less effective
form of convective solute transport.
Click image to enlarge
The semi-permeable peritoneal membrane allows solutes and water to be transported from
the vascular system to the peritoneal cavity and vice versa through diffusion. Diffusion is
the process of solutes moving from an area of higher concentration to an area of lower
concentration, which is the case when dialysate is instilled into the peritoneal cavity.
Actually, solutes move randomly in both directions, but there is simply more solute moving
from the high to low concentration side than in the opposite direction. Eventually, the
concentrations become equal on both sides of the membrane. This is termed equilibrium.
The movement of solute molecules is random and driven by thermal energy. This energy is
proportional to absolute temperature (degrees Centigrade above -273). This thermal
energy is transferred to kinetic energy which is the multiple of mass and velocity. Since this
energy is the same for different sized molecules at the same temperature, the larger
molecules must move more slowly in order to have the same energy as the smaller
molecules. Thus, the diffusive rate depends on molecular weight.

20
Solute transport is influenced by the membrane permeability and size, characteristics of the
solute, the volume of dialysate instilled, and blood flow to the membrane. Solute transport
can be increased by maximizing the contact of dialysis solution with the membrane by
placing the patient in a supine position or increasing the exchange volume.
Osmosis is the movement of water across a semi-permeable membrane from an area of low
solute concentration to an area of high solute concentration. The hydrostatic pressure
gradient and the osmotic gradient between the blood and the dialysis solution influence
osmosis.
Increasing the dextrose concentration of dialysis solution enhances fluid removal by
increasing the osmotic gradient between the plasma and the peritoneal fluid. The higher the
dextrose concentration, the higher the fluid removal. The osmotic gradient is always
greatest at the beginning of the dialysis exchange. As osmotic equilibration is achieved, the
gradient decreases. Some reabsorption of fluid occurs when dialysate dwells beyond the
point of equilibration.
Alternatively, a glucose polymer can be used instead of glucose. The polymer is not
absorbed, so the fluid removal is sustained. This process is called colloid osmosis.
There is a significant amount of protein lost in dialysate. The amount lost varies from
patient to patient but averages between 5-8 gm/day. Protein loss stabilizes and remains
relatively constant unless the patient experiences peritonitis, then the protein loss increases
during the infection. It is very important that protein intake be adequate in the PD patient.
Daily protein requirements average 1.2-1.5 gm/kg of body weight. Other substances lost in
dialysate are amino acids, water-soluble vitamins, hormones and some medications.
Substances that are absorbed from dialysis solution into the systemic circulation include
dextrose and calcium. The increased concentration of dextrose in dialysis solution causes
dextrose to move into the systemic circulation.

21
The major factor influencing the systemic calcium absorption is the amount of ionized
calcium in the plasma and in the dialysis solution. A calcium concentration of 0.8 mmol/L in
dialysis solution provides an ionized calcium of 1.6 mmol/L. Half of a standard serum
calcium level of 2.20 - 2.58 mmol/L is ionized when the serum albumin is normal. Thus, with
an ionized calcium in dialysis solution of 1.6 mmol/L and an ionized serum calcium of 1.0
mmol/L, calcium can be absorbed into the systemic circulation.
6. Peritoneal Access
Successful peritoneal dialysis technique will depend largely peritoneal good access , since a
catheter operating properly and smoothly peritoneal access will ensure the survival of the
dialysis technique . Improvements in this dialysis therapy are associated with advances in
catheter design and implementation methods there of.
These advances are due to Palmer and Quinton , creators of the modern peritoneal
catheter. This tubular silicone catheter with multiple perforations distal was refined by
Tenckhoff and Schecter in 1968 , who improved the design . Thus, the distal part could be
straight or curled , the newest being the placement of two sleeves bioincompatible material
to cause severe fibrotic reaction . Thus getting hold the catheter to the abdominal wall ,
preventing the passage of microorganisms around the catheter.
Good access peritoneal must have the following characteristics
Easy deployment and removal
biocompatible material
Resistant to bacterial colonization
Provide high flows without pain
Not deteriorate with time
Let the normal function of the abdominal wall
Do not change too much aesthetics
Easy Care and Handling
minimum maintenance
No displacements
Minimize complications
Catheters
The catheter is a soft tube and consistent , peritoneal cavity communicating with the
outside , creating a unnatural entrance to this cavity. Portions of the catheter are three:
intraperitoneal, intramural (subcutaneous ) and externally.
Types of catheters
The types of catheters are divided according to three characteristics : design, material and
number of sleeves . According to the design include: straight , coiled intraperitoneal portion
and intramural part cauldron handle and gooseneck. For the material: silicone and
polyurethane. And they may have one or two sleeves .
The straight Tenckhoff catheter one or two sleeves has been widely used . Their placement
is easy. Today it tends to place catheters other design in order to improve the hydraulic
function , and also flows to perform the bore outlet , the inlet flow to the catheter into the
abdominal cavity . Another widely used type of catheter is the one with the coiled
intraperitoneal and intramural part swan neck , forcing an exit flow in the skin , thus
facilitating better hole cleaning . The polyurethane catheter Cruz has advantages and
disadvantages compared to silicon : design and faster flows , but is thermolabile and is
damaged most antiseptics. The intraperitoneal curl nuisance prevents high flows .

22
The catheter implantation
The peritoneal catheter to implant while an expert who knows the operation of the
peritoneal dialysis. Since the peritoneal catheters placed both surgeons and nephrologists ,
the classification of surgical implantation techniques and medical information may be
inaccurate , but for educational purposes we maintain this rating. Either maximum require
aseptic techniques .
Surgical Technique
This technique could call her open technique of catheter implantation , since it is made by
planes dissection with a 5 cm incision in skin, abdominal wall and peritoneum. Through this
opening the catheter is introduced and subsequently becomes layered closure . This
technique should be done in the operating room and is recommended in the situations
described below , to avoid complications during implantation.
Previous abdominal surgery
Widespread abdominal infection prior
Existence of abdominal adhesions
Recurrent peritonitis and torpid
Harnessing surgery for another reason
Need Omentectomy
On the patient's wishes
The medical technology
This technique of implementation is a blind , puncture , necessitating dissection of skin and
subcutaneous tissue . From the rectus fascia addresses the peritoneal cavity with the new
trocars , as the Y- TEC system , then the catheter with a guide . The approach to the
peritoneal cavity is blind , but prior to the introduction of the catheter if available you can
view laparoscope peritoneal cavity , enabling more security situations in recommending the
surgical technique . From here you try calling laparoscopic technique. This method of
introducing the catheter is increasingly widespread due to the advantages of the surgical
technique . The disadvantage of this mixed technique (percutaneous , subcutaneous
dissection , blind , laparoscopic ) is the probability of intestinal loop click on the other hand
act difficult if the intestinal loop is not attached to the parietal peritoneum puncture area .
Medical technical description
The patient must have previous training with the following steps:
Give laxatives and / or enemas for bowel
Shower or body wash
fasting
antibiotic
analgesia
sedation
Bladder Emptying
Wash with Betadine
mask
Lying with head slightly elevated
After general analgesia and sedation with midazolam , infiltrate skin and subcutaneous
tissue with local anesthetic and epinephrine in a 2 cm from the umbilicus , and lateral flow .
Dissect skin and subcutaneous tissue to the fascia of the rectus . From here to the Y- TEC
system addresses peritoneal cavity , making sure not to puncture the epigastric artery .
Trocar is removed and if we do laparoscopy cannula also retired , leaving the sheath . With

23
the stents increase the inlet to the peritoneal cavity , thereby facilitating introduction of the
guide catheter and leave the internal dacron below the fascia . It checks the operation of the
catheter with 500-1000 ml of dialysis solution . After verification of the proper functioning
of the catheter are given points crown around the entrance hole in the abdominal wall .
Depending on the type of catheter is made with the subcutaneous tunnel and the hole
tunneling out of the catheter with a 4 mm punch , leaving the outer sleeve diameter of 2 cm
from it.
The variety introduced by Moncrief catheter burial for 20 days and then dig part of it, there
is no data that provide the benefits of this technique. Catheter care in the postoperative
period should be: the immobilization of the catheter, wound cures every 2-3 days , cleaning
the hole , prophylactic antibiotic therapy for 1 week and periodic washing .
Dialysis is the process of removing fluid and waste products from the body, a function
usually performed by the kidneys, through artificial means. Two types of dialysis:
hemodialysis and peritoneal dialysis. Peritoneal dialysis accomplishes the removal of waste
and excess fluid by using the abdominal lining, called the peritoneal membrane, as a filter a
membrane across which fluids and dissolved substances (electrolytes, urea, glucose,
albumin and other small molecules) are exchanged from the blood.
Peritoneal dialysis is similar in principle to hemodialysis. Both of these forms of renal
replacement therapy depend upon the passive movement of water and dissolved
substances (solutes) across a semipermeable membrane. This process is called diffusion.
The direction of movement of solute is determined by the relative concentration on each
side of the membrane, so that a substance goes from the side of greater to lesser
concentration.
Contraindication
Peritoneal dialysis is contraindicated in patients withhypercatabolism because adequate
clearance of uremic toxins cannot be achieved with this method of dialysis. Peritoneal
adhesions and scarring are also contraindications. Caution should be used when prescribing
peritoneal dialysis for patients with a history of ruptured diverticuli, respiratory disease,
recurrent peritonitis (infection of the peritoneum), abdominal malignancies, severe vascular
disease, back problems, and those who are obese.
7-Complication of the Peritoneal Dialysis
Peritoneal dialysis (PD) is not always trouble-free. Patients may experience both
psychological and physical problems, discussed below.
Responsibility
Some kidney patients get tired of the responsibility of doing their peritoneal dialysis every
day. If this is a problem, talk to your peritoneal dialysis nurse who may be able to help you
incorporate more flexibility into your routine.
 Body image
Some peritoneal dialysis patients find it difficult to accept a permanent PD catheter. They
worry that the catheter may affect their sexual activity and their relationship with their
partner.
Peritoneal dialysis nurses can help with tips on how to disguise the PD catheter.
Peritoneal dialysis tends to stretch the abdomen, giving it a rounded appearance.
Keeping fit and doing exercises to strengthen the abdominal muscles will help counteract
this. PD nurses can give advice on suitable exercises.
 Fluid overload

24
Fluid overload occurs when there is too much fluid in the body. It is characterised by a
sudden increase in body weight, swollen ankles, and/or shortness of breath. Generally
dialysis patients need to restrict their fluid intake to prevent fluid overload. Peritoneal
dialysis patients, however, have more flexible fluid allowances than haemodialysis patients.
 Dehydration
Dehydration occurs when there is too little fluid in the body. It can be caused by excess fluid
loss due to diarrhoea or sweating. It is characterised by dizziness, feeling sick, or a sudden
decrease in weight. Dehydration is far less common than fluid overload in dialysis patients.
 Discomfort
Some PD patients find that having the dialysis fluid in their abdomen is uncomfortable. They
feel full or bloated. Others suffer from backache or experience shoulder pain, especially
when draining in or out. Very rarely, some patients experience discomfort when fresh fluid
is drained in.
Renal units can give advice on how to minimize or avoid discomfort.
 Poor drainage
One of the most common problems with peritoneal dialysis, especially among new patients,
is poor drainage of the dialysis fluid. The most common causes are:
1. Constipation - The pressure of the peritoneal dialysis fluid in the abdomen can cause
movement of the bowel to slow down, increasing the likelihood of constipation.
Constipation can cause the bowels to press against the catheter and interrupt drainage. It
can also displace the catheter inside the peritoneal cavity. To avoid constipation, peritoneal
dialysis patients may need to change their diet. In some cases, the patient's doctor may
prescribe a laxative.
2. Catheter displacement - Sometimes the PD catheter moves into the wrong position. It
may "float" back into the right place naturally. If not, a minor operation or manipulation
under X-ray may be required to correct its position.
 Leaks
In some patients, the peritoneal dialysis fluid leaks out around the catheter exit site. If this
occurs, it may be necessary to decrease the volume of fluid in each exchange or stop
peritoneal dialysis temporarily and have haemodialysis for a short period of time until the
leak has resolved. Occasionally, it may be necessary to place a new catheter at a different
site. In some people, fluid leaks into the genitals and causes swelling. In men, this is called
scrotal leak. If this occurs, peritoneal dialysis must be temporarily stopped until the leak has
healed and a period of temporary haemodialysis may be required.
 Exit-site infections
An infected exit site is inflamed, red, sore, and discharges pus. It can be treated with
antibiotics. Occasionally, the infection spreads inward, following the catheter tube along the
"tunnel" through the abdominal wall. This type of infection is called a tunnel infection. If this
occurs, it may be necessary to remove the catheter and put a new one in. A temporary
period of haemodialysis may be required.
Prevention of infections is extremely important. Patients need to follow the procedures
covered during the initial PD training in order to care for their exit site. Good hygiene, and
keeping the catheter taped down on the skin to protect the catheter, can significantly
reduce the chances of getting an infection.
 Hernia
A hernia is the protrusion of an organ (most commonly the bowel) through muscle wall,
causing swelling. Sometimes a hernia may be undetected at the time a peritoneal catheter is

25
put in. This may become a problem later as the constant pressure of dialysis fluid on the
hernia may cause it to become bigger and painful. Surgery may be required to correct the
problem. In some cases haemodialysis may be needed for a short time to allow healing after
the operation. Alternatively, small volume PD exchanges may be recommended. Until
patients have healed completely, they should not lift heavy objects.
 Peritonitis
Peritonitis is an infection of the peritoneum, usually caused by bacteria entering through the
catheter. This can happen when patients touch the open ends of the connections between
the bag of dialysis fluid and the catheter. Sometimes, even though everything is kept clean,
an infection can get into the abdomen from the outside.
The chances of getting peritonitis are greatly reduced by following correct dialysis exchange
procedures. Peritonitis infections are not that common. On average, patients can expect to
get less than one attack of peritonitis every year. Some patients never get one.
Peritonitis is easy to recognise. Dialysis fluid is normally clear. Peritonitis makes it cloudy.
Some patients also experience abdominal pain and fever.
Adding antibiotics to fresh dialysis fluid is the method of treatment. Some patients are
shown how to do this at home.
Occasionally, a patient may get several attacks of peritonitis in a row. When this happens,
the PD catheter may need to be replaced and the abdomen 'rested' by not using peritoneal
dialysis for 4 to 6 weeks. During this time, the patient usually needs to have haemodialysis
until PD is resumed.
Repeated attacks of peritonitis may damage the peritoneum and reduce the efficiency of
the dialysis. If this happens, the patient will have to change to haemodialysis for long-term
treatment.
8- Indication and Contraindications
INDICATIONS
Pediatric peritoneal dialysis can be used mainly in situations of renal failure, primary or secondary
source (eg cardiac surgery ) and in other situations. Oligoanuria acute renal failure ( urine output less
than 0.5 cc / kg / h ), which does not respond to diuretics and may be accompanied by positive
balance :
Hypervolemia
hypertension
HF
pleural effusion
anasarca
Electrolyte disturbances and blood pH produced or not by acute renal failure :
severe metabolic acidosis
hyperkalemia , hypernatremia , hypercalcemia
elevated BUN
uremic encephalopathy ( accompanied by stupor, coma or convulsions)
Hemolytic- uremic syndrome
severe hypothermia
Acute intoxication by toxic dialyzable through the peritoneum . (Table 1 : Types of toxic dialyzable
through the peritoneum ) It is considered that when it is dialyzable toxic water soluble and has little
affinity for plasma proteins . Soluble toxic or they bind tightly to plasma proteins are not adequately
dialyzed by this method
TOXIC non-dialysable
TOXIC dialyzable

26
CONTRAINDICATION
No absolute contraindications , but will particularly value your choice in case of:
Alterations in the integrity of the wall ( omphalocele , gastroschisis ... )
Diaphragmatic hernia or diaphragm or fistula surgery pleuro -peritoneal or intraperitoneal
Recent abdominal surgery
Infection or abdominal wall cellulitis
peritonitis
Severe intraperitoneal hemorrhage
Massive or rapid catabolism poisoning (not recommended because dialysis acts more slowly )
Patients in shock
9.The Type Of Dialysis
There are two types of peritoneal dialysis:
 Continuous ambulatory peritoneal dialysis (CAPD) .With CAPD, dialysate is instilled into
and drawn out of the abdominal cavity by gravity alone. No machine is needed. The dwell
time for CAPD ranges from four to 10 hours. The CAPD patient usually performs four
exchanges per day, including an eight-hour overnight dwell. This continuous exchange most
closely resembles normal renal function, and it is also convenient because the exchanges
can be performed anywhere since no equipment is required
 Automated peritoneal dialysis (APD). with APD there are three different scheduling
methods, including :
1. continuous cyclic peritoneal dialysis (CCPD),
2. intermittent peritoneal dialysis (IPD), and
3. nightly peritoneal dialysis (NPD).
Description
Before peritoneal dialysis begins, patients have a catheter surgically inserted into
their peritoneal cavity.
The catheter is usually placed 1.2–2 in (3–5 cm) below the umbilicus.
 When dialysis is ready to begin, a bag of fluid (dialysate) containing sterile water, normal
plasma, electrolytes, and glucose is infused into the abdominal cavity. The volume of
dialysate used can range from1.5–3 qt (1.5–3 l), and the concentration of electrolytes and
glucose is altered according to what the physician prescribes.
 The dialysate is left in the abdominal cavity for anywhere from one hour to 10 hours,
depending on the type of dialysis.
 The period of time that the dialysate is left in the abdominal cavity is called the dwell
time. At the end of the prescribed dwell time, the dialysate is drained out of the abdominal
cavity through the catheter.
 The drained dialysate takes waste products with it. This process of instilling a bag of
dialysate, dwell time, and emptying the dialysate is called an exchange.
 The amount and timing of exchanges performed by patients depends on the type of
dialysis, the recommendation of the physician, and the lifestyle of the patient.
 Peritoneal dialysis works based on the principles of osmotic pressure and
diffusion. Osmotic pressure is the moving of fluid toward the solution with a higher solute
concentration. Diffusion is the passing of particles from an area of high concentration to an
area of lower concentration.
 The dialysate infused into the abdominal cavity is prepared with specific concentrations
of electrolytes and glucose that will draw the waste products and excess fluid across the
peritoneal membrane using diffusion and osmotic pressure. The pores in the peritoneal

27
membrane are large enough to allow the waste to pass through into the abdominal cavity,
but small enough that blood cells and other protein molecules are unable to pass through
 The Type Of Dialysis
There are two types of peritoneal dialysis:
 Continuous ambulatory peritoneal dialysis (CAPD) .With CAPD, dialysate is instilled into
and drawn out of the abdominal cavity by gravity alone. No machine is needed. The dwell
time for CAPD ranges from four to 10 hours. The CAPD patient usually performs four
exchanges per day, including an eight-hour overnight dwell. This continuous exchange most
closely resembles normal renal function, and it is also convenient because the exchanges
can be performed anywhere since no equipment is required
 Automated peritoneal dialysis (APD). with APD there are three different scheduling
methods, including :
4. continuous cyclic peritoneal dialysis (CCPD),
5. intermittent peritoneal dialysis (IPD), and
6. nightly peritoneal dialysis (NPD).
10.Nursing Care and Management
General Peritoneal Information
Hand Hygiene
In order to help stop the spread of bacteria in the unit please carefully wash your hands or
use hand sanitizer before entering the unit and after leaving.This
will help keep you and keep all of our patients healthy.
Food & Drinks
Eating on dialysis is not recommended because it can cause a drop in blood pressure and
seriously affect your treatment. Some people may wish to bring a healthy snack to eat when
treatment is over. Your renal dietician can provide more information about suitable snacks.
Bathroom Breaks
It is best to train your body to have bowel movements before your treatment.
The need to go for a bowel movement while on dialysis can have serious, harmful effects
during your treatment by affecting blood pressure. Washrooms are available to use before
and after treatment. If you really need to go while receiving dialysis a bedpan will be
provided. If you are having constant issues with constipation or diarrhea, make sure to talk
to your doctor or nurse.
Predialysis:
Give physical and psychological preparation to the patient
Check you have signed the consent form
Although Patient
Take SV
Urination
Helping PVC catheter insertion: ECG monitoring can also be used
Rinse the tubing with dialysis solution
Leave the patient comfortable in a supine position
TRANS DIALYSIS:
Optimizing patient comfort during dialysis (implement physical comfort measures, keep the
patient in regard to their development and results)
Provide care as whole person

28
Keep management and dialysis fluid drainage
Using strict aseptic techniques when you add the solution or drain emptied containers
Measure SV.
NOTAS
Catéter Permanente: Tenckhoff ,Swan ,Cruz
Duración:
DP = 36 – 48 hrs
HD = 6 – 8 hrs
Farmacología:
Heparina: Prevención de coágulos de fibrina el catéter y oclusión
KCL tratamiento Hipocaliemia
LABORATORIO
TP ( tiempo de protrombina) = 11 – 13 seg ( factor de la goagulación)
TPT = Tiempo parcial tromboplastina = 25 – 35 seg
The nursing care in Dialysis Pediatric
Us record every child's vital signs before starting the first infusion
Check the heater maintains the liquid (37 ° C) (Figure 10: Heater dialysis).
Peritoneal dialysis cycles tend to have a generally lasts 60 minutes, during which the dialysis
fluid is infused under gravity for the first 20 minutes, the peritoneal cavity remains in
another 20 minutes and allowed to leave for the remaining 20 minutes.
These times of entry, stay and departure can be adjusted by the physician according to the
needs of each child.
We note that increasing the residence time increases the risk of hyperglycemia by
absorption of dialysate glucose.
A liquid inlet too suddenly may cause effects on hemodynamic and ventilatory child, plus it
can cause pain.
The volume of liquid in each pass infuse is prescribed by the doctor, and usually between
30-50 cc / kg (maximum 2 liters). It is advisable to start early and 10cc/kg cycles within 24-48
hours not exceeding 20 cc / kg, to reduce the risk of hemodynamic compromise. (Photo 11:
dispensing burette)
It is advisable that the first exchange not remain in the peritoneal cavity set 20-30 minutes,
but the drenaremos immediately. This will check if a blood vessel is injured.
To facilitate entry of the liquid and the drained, keep the child lightly built.
The liquid should be clear and colorless. It is relatively common for the principle is slightly
bloody. In this case, will have to monitor the patient's analytical (hematocrit and
coagulation) and fibrin formation which could clog the orifices Tenckhoff catheter.
If the fluid is brown or brown, sospecharemos a possible perforation of the colon
If urine is similar to and has the same glucose concentration than this, bladder perforation
sospecharemos possible.
If the liquid is cloudy, sospecharemos possible infection.
We will schedule valuation and all vital signs, or whenever necessary if respiratory and
hemodynamic status is unstable.
Will value, and record on the sheet of dialysis the following:
dialysate composition (will note any changes in the composition which is required along the
process)
cycle start time
amount of fluid infused

29
infusion time
residence time and / or Check Out
volume and characteristics of fluid drained
balance schedule
balance accumulated in 24 hours
Water will do a strict control of the patient, recording all income (intravenous, oral or
enteral ...) and losses (diuresis, gastric drainage, surgical drains ...), to take stock
accumulated as accurate as possible.
Daily weights if the situation permits
Value the presence of pain and discomfort
Analytical control:
during the first 24 hours blood tests will be performed every 4-8 hours, to evaluate mainly
glucose and serum potassium and other electrolytes and osmolality.
day is necessary to know the state of coagulation, hematology and renal function
Daily will collect a sample of peritoneal fluid for cell count (to assess the presence of
erythrocytes), biochemistry (especially protein) and perform bacteriological culture (in order
to make possible early detection of infection).
The dialysis system was completely replaced every 72 hours. The change is made sterile
technique, the same way as the initial connection.
We apply the appropriate care system and Tenckhoff catheter:
find the existence of kinks or obstructions in the circuit, which hinder the infusion or
drainage
cure the catheter insertion site every 72 hours or whenever necessary (if soiled or wet)
secure the catheter to the skin safely to prevent accidental extraction (apply approximation
points or similar)
Pericatheter protect the skin, keeping the dry zone and using protective patches (Comfeel R
type), and thus avoid the formation of pressure sores in the area which supports the
Tenckhoff catheter.
When the catheter is removed, we will send the tip to microbiology, together with a sample
of peritoneal fluid dialyzed
How to manage supplies
In peritoneal dialysis, have a lot of supplies, including dialysis bags, connectors and
masks. You need a wardrobe of 3 x 5 feet or wall space of 10 feet. The person who will bring
supplies boxes, stack them where you want and rotate so you use the old before the
new. You should keep track of their supplies and order new ones once a month.
The dialysis bags can not be frozen nor should they be exposed to very hot and must be
always dry. If kept in the basement or garage, it's best to stack them on a table to support
them in the ground. Remember to use these bags every day, so keep them far away from
the room where the treatment is carried out not convenient.
How to control your care
As you are the person in charge of their daily care, there are some things you learn to do to
check how you are progressing. Among them:
 Pay attention to how you feel: You are the best judge of your energy level, the pace
of your breathing, any pain or swelling.
 Record the amount of fluid in each exchange: Keep precise records of how much
fluid treatment placed in each exchange in and going out. If you are removing all liquids
(plus excess water) you should contact your nurse.

30
 Take your blood pressure: Measure and record your blood pressure to see if you are
in the healthy range using a bracelet to take blood pressure.
 Keep track of your weight: You should weigh yourself every day, using the same
thing to see if you are taking enough fluids.
 Get monthly blood tests: Your doctor will order blood tests to measure things like
potassium and phosphorus in your blood and to determine if you are getting adequate
peritoneal dialysis.
 Collect urine for analysis: You can collect all of your urine for 24 hours in a
refrigerated jar and bring it to the center. The Residual Renal Function test measures how
well your kidneys yet. In the first year with PD, this test should be performed every 2
months.
 Raise dialysate for testing: A few times a year your doctor will ask you to bring some
or all of dialysate used to perform a peritoneal equilibrium test (PET, for its acronym in
English). You must enter the center and make a series of exchanges, then do you draw a
blood sample. The PET help to know how long to leave the fluid in your abdomen for best
results.
Addressing the unexpected
Unexpected events that may have to deal with quite possibly should be an infection or a
problem with the catheter or cycler. In their training, learn how to act when signs of
infection in your catheter at the exit of the catheter or peritoneum. Call your doctor or
nurse immediately if you experience:
 Pus, redness or swelling or if you have pain around your catheter exit or in your
abdomen.
 Signs of an infection of the peritoneum is a murky drainage bag, abdominal cramps,
pain or fever.
 A lump in the abdomen or pelvic area can mean a possible separation in the muscle
wall (hernia).
Some events that are not emergency in PD can be quite alarming though probably not
harmful:
 A crack or break in the catheter or transfer set can leave you vulnerable to
infections. If this happens, close the catheter over the crack with the clamp in the training
given. Then, call your nurse or doctor.
 There may be blood if a small blood vessel ruptures within your peritoneum. In
women, there may be blood in the drainage bag every month or so during ovulation or
during a menstrual period. Very occasionally this may be a sign of aortic aneurysm. If you
are concerned, call your nurse or doctor.
 If you enter an air bubble in the peritoneum with dialysate fluid can have a severe
shoulder pain. Do not worry! Your body will absorb the air. Ask your nurse about ways
that exist to make sure all the air is out before making connections.
 If you feel pain during drainage, changing positions can help. You can also place the
machine in an area higher or lower. Talk to your nurse about your options.

31
ANNEXES:
Table I: Composition of glucose-containing dialysis solutions.
Dianeal® PD1 CAPD 2-4 Gambrosol trio 10®
(Baxter) (Fresenius) (Gambro)
Sodium 132 134 132 mmol/l
Calcium 1.75 1.75 1.75 mmol/l
Magnesium 0.75 0.5 0.25 mmol/l
Chloride 102 103.5 96 mmol/l
Lactate 35 35 40 mmol/l
Glucose 13.6-38.6 15-42.5 15.2-38.8 g/l
Osmolality 340-483 358-512 353-492 mOsm/l
PH 5.5 5.5 6.5

32
Table 2 Practice Exercise DP
HOJA DE DIÁLISIS PERITONEAL
Name of:
Nº HISTORIA:
FECHA:
Composición
líquido
Hora
entrada
Volumen
Entrada
Tiempo
Permanencia
Volumen
Salida
Balance Balance
Acumulado
Dialisan 15,00 80 cc 20 ´ 90cc 0cc
“ “ 16,00 80 cc 20 ´ 100 cc -20 cc -20cc
“ “ 17,00 80 cc 20 ´ 110 cc -30 cc -50 cc
Dialisan+
20mEq ClK
18,00 80 cc 20 ´ 70 cc +10 cc -40 cc
“ “ 19,00 80 cc 20 ´ 95 cc -15 cc -55 cc

33
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recommendations. BMJ 2004; 328:1490
2. Guyatt G, Gutterman D, Baumann MH et al. Grading strength of
recommendations and quality of evidence in clinical guidelines. Chest 2006; 129:
174-181
3. Guyatt GH, Oxman AD, Vist GE et al. GRADE: an emerging consensus on rating
quality of evidence and strength of recommendations. BMJ 2008; 336:924-926
4. Guyatt GH, Oxman AD, Kunz R et al. GRADE: going from evidence to
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for the prevention, diagnosis, evaluation and treatment of Hepatitis C in chronic

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