Peritoneal Dialysis Notes

Peritoneal Dialysis

Learning Objectives

  • State purpose, indication, and contraindication.
  • Explain principles.
  • Explain nurse's responsibilities (pre, intra, post).
  • Document correctly.
  • Appreciate care and documentation importance.

Renal Replacement Therapy

  • Dialysis: Peritoneal, Hemodialysis.
  • Transplant: Living donor (LRRTx), Deceased donor (Non-LRRTx).

Peritoneal Dialysis Types

  • Continuous Ambulatory Peritoneal Dialysis (CAPD).
  • Automated Peritoneal Dialysis (APD).
  • Intermittent Peritoneal Dialysis (IPD).

Indications & Contraindications

  • Indications: End-stage kidney disease, vascular access problems, hemodialysis hazards, acute kidney injury, severe fluid overload.
  • Contraindications: Pleuroperitoneal fistula, infected abdominal wall, recent abdominal surgery, abdominal mass.

Anatomy of Peritoneum

  • Thin layer of loose connective tissue covered by simple squamous epithelium.
  • Semipermeable, bidirectional.

Peritoneal Dialysis - Definition

  • Solute and solvent exchange between blood (peritoneal capillaries) and dialysate using a permanent catheter.

Permanent Catheter (Tenckhoff)

  • Soft, flexible, biocompatible silicone tube with multiple pores.
  • Positioned in the pelvic area.
  • Catheter break-in: 10-14 days after insertion.

Preparation for Surgery

  • Pre-op assessment: Comorbidities (DM, obesity, hernia), laparotomy, diagnostic investigations, anesthetic evaluation.
  • Bowel preparation: Mild laxative.
  • NPO.
  • Infection prevention: Skin preparation (chlorhexidine or povidone-iodine), nasal spray (Mupirocin), prophylactic antibiotics.
  • Marking exit site: Avoid belt line, skin folds, scars; directed inferolaterally and downward.
  • Empty bladder fully.
  • Informed consent, education on catheter care, hygiene, and signs of complication.

Post-Op Care

  • Wound and exit site care: Sterile technique, avoid wetting for the first week, daily cleaning after healing.
  • Break-in period: 10-14 days post-insertion.
  • Pain management: Mild analgesics, avoid heavy lifting.
  • Prevention of infection: Monitor for inflammation, emphasize hand hygiene, antibiotics if indicated.
  • Catheter function test: Flushing 1-3 days post insertion (500-1000ml immediately after insertion).
  • Patient education: Hand hygiene, aseptic technique, bag exchange, complication recognition.

Principle of PD Treatment

  • IN (Dialysate in).
  • DWELL (Solution retained).
  • OUT (Dialysate out).

Dialysate Solution

  • Electrolyte solution similar to plasma (sodium, chloride, calcium, magnesium).
  • Lactate (bicarbonate buffer).
  • Glucose (osmotic agent): 1.5% (little/no UF), 2.5% (200-500mL UF), 4.25% (500-1000mL UF).

Intermittent Peritoneal Dialysis (IPD)

  • Solution installed into peritoneum cavity via catheter (10 minutes).
  • Dwell time: Standard 30 minutes to 2 hours (4 hours).
  • Drained out via tubing (20-30 minutes).

Nurse’s Responsibility Pre-Dialysis

  • Baseline assessment: Temperature, BP, weight.
  • Empty bladder/bowel.
  • Strict sterile technique for Tenckhoff catheter.
  • Blood investigation: BUN, FBC, RBS, HIV, HBV, Culture & sensitivity.
  • Dialysate & tubing: Expiry date, color, leakage, flush tubing.
  • Warm up dialysate to prevent abdominal discomfort.

Nurse’s Responsibility Intra-Dialysis

  • Prevent infection at exit site with aseptic technique; ensure clean and dry.
  • Tubing and dialysate: Check expiry, avoid touching spike part, spray with antiseptic; collection bag off the floor.
  • Infection: Turbid/cloudy effluent for C&S, FEME, rapid cycle, I/P fortum 250mgm, cloxa 250mgm, Ceftazidime, vancomycin.
  • Signs of peritonitis: fever, abdominal pain, turbid fluid, vomiting, diarrhea, anorexia
  • Flow Rate: Output ≥ input. If poor flow, check catheter position, kinking, fibrin clot; ask patient to move; inform doctor if continuous 3 cycles <2000cc per cycle with positive balance.
  • Excessive outflow: can cause drop in BP and dehydration
    Leakage: Infrom doctor for stitch/ change tubing, may cause peritonitis

Nurse’s Responsibility Post-Dialysis

  • Drain effluent completely.
  • Clean exit site.
  • Weight (dry weight).
  • TCA for next dialysis.

Continuous Ambulatory Peritoneal Dialysis (CAPD)

  • Managed by patient/caregiver.
  • 3-4 manual exchanges per day.
  • Duration: 4-6 hours.

Automated Peritoneal Dialysis (APD)

  • Home/center treatment using a cycler.
  • 3-6 changes over 8-9 hours during sleep.
  • 5L dialysate solution.
  • Some patients have a “last fill” to dwell during the day (CCPD).

Documentation

  • Exchange number, dialysate concentration, time in, dwell, drain, exchange volume, balance, cumulative balance, medication.

Peritoneal Dialysis - Advantages

  • Portability, independence, constant solute/solvent removal, less diet restriction.
    Carried out daily, prevent infection is paramount- proper technique
    Metabolic complications, structural changes.

Diet

  • Protein: 1.2-1.3g/kg/day (high biological value).
  • Sodium: Restrict 1-2g/day.
  • Potassium: Adjusted.
  • Calories: 30-35kcal/kg (including glucose from dialysate).
  • Vitamins: Water-soluble (B, C).
  • Fluids: Individualized, restrict intake 0.5-1 liter/day.

ADL

  • Resume normal activities, freedom to travel, breathing exercise.