Peritoneal Dialysis. Sonia M. Astle PREREQUISITE NURSING KNOWLEDGE PROCEDURE

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1 PROCEDURE 121 Peritoneal Dialysis Sonia M. Astle PURPOSE: Peritoneal dialysis (PD) is used for the removal of fl uid and toxins, the regulation of electrolytes, and the management of azotemia. PREREQUISITE NURSING KNOWLEDGE PD works on the principles of diffusion and osmosis; thus, a basic knowledge of these concepts is necessary. Diffusion is the passive movement of solutes through a semipermeable membrane from an area of higher concentration to one of lower concentration. When this concept is applied to PD, diffusion occurs because the patient s blood contains waste products (solute), which gives it a higher osmolarity (concentration) than the dialysate. Therefore waste products in the blood diffuse across the semipermeable membrane into the dialysate solution. Osmosis is the passive movement of solvent through a semipermeable membrane from an area of lower concentration to one of higher concentration. The dextrose added to the dialysate gives it a higher osmotic gradient than that of the patient s blood. Therefore excess water in the blood is pulled into the dialysate via osmosis. PD uses the peritoneal membrane as the semipermeable membrane for both fluid and solutes. 7,19,23 Sterile dialysis fluid (dialysate) is infused into the peritoneal cavity of the abdomen through a flexible catheter (Fig ). A small-framed adult can usually tolerate 2 to 2.5 L of dialysate, whereas a large-framed adult may be able to tolerate up to 3 L in the abdominal cavity. The larger the volume of dialysate, the more effective the removal of blood urea nitrogen (BUN) and creatinine 5,6 ; however, peritoneal clearance may be improved with more frequent exchanges rather than an increase in the exchange volume. 1,5,6 The most limiting factor for the volume of dialysate is that it may cause direct pressure on the diaphragm and cause a compromise of respiratory excursion. 7,23,26 The PD dialysate contains higher concentrations of glucose than normal serum levels. These higher concentrations aid in the removal of water via osmosis and small-to-middle-weight molecules (urea, creatinine) via diffusion. Several concentrations of glucose are available in commercially prepared dialysate solutions (1.5%, 2.5%, and 4.25%). The higher the concentration of glucose in the dialysate, the greater the amount of fluid removal. Icodextrin, a relatively new alternative to glucose solutions, may be used as the osmotic agent. It has been shown to enhance ultrafiltration and clearance during the long dwell time in continuous ambulatory PD. This glucose polymer is metabolized to maltose and is not readily absorbed. 6,13,15,18,21 Metabolites may cause erroneously high glucose levels; check with the manufacture s guidelines to assure icodextrin metabolites will not interfere with the glucose analyzer being used for patient testing. PD involves repeated fluid exchanges or cycles. Each cycle has three phases: drain, instill, and dwell. If this is the patient s first dialysis cycle, the instillation phase will be first; however, if the patient has been on routine hemodialysis at home, for example, the drain phase will be done first, followed by instillation and dwell. During the drain phase, the dialysate and excess extracellular fluid, wastes, and electrolytes are drained via gravity from the peritoneal cavity via a peritoneal catheter. During the instillation phase, the dialysate is infused via gravity into the patient s peritoneal cavity through a peritoneal catheter. 3,4,21 During the dwell phase, the dialysate remains in the patient s peritoneal cavity, allowing osmosis and diffusion to occur. Dwell time varies based on the patient s clinical need and the delivery method of PD. 1,20 PD can be performed either manually with a dialysis administration set (continuous ambulatory PD) or with a cycler machine (continuous cycling PD [CCPD]) ( Fig ). With a cycler machine, multiple exchanges are programmed into the machine and run automatically. 6,24 Instillation of dialysate into the peritoneal cavity leads to increased peritoneal pressure. The amount of pressure depends on multiple factors, including the volume of dialysate instilled, patient position, age, body mass index, coughing, lifting, and straining. Patients requiring PD may experience complications directly related to increased peritoneal pressure. These may include inguinal and umbilical herniation with potential bowel incarceration, pericatheter and subcutaneous leaks causing abdominal and genital edema, and hydrothorax and hemoperitoneum. PD catheters can become clogged with the buildup of fibrin. Heparin or other anticoagulant medications are sometimes added to the dialysate or used as a separate flush to prevent occlusion. 3,5,7,23,26 PD dialysate should be warmed in a commercial warmer. Never warm the solution in a standard microwave oven, which heats unevenly and does not regulate the fluid temperature.23,

2 121 Peritoneal Dialysis 1081 PD administration set (most facilities are using closed delivery systems with attached drainage bag) Intravenous (IV) pole Warmed dialysate solution (use heating pad or commercial warmer) Sterile catheter caps (many facilities are using betadine impregnated caps) Labels for catheter Scale Additional equipment, to have available as needed, includes the following: Sterile container Three clamps (if not included in the PD administration set) Cycler with tubing Equipment for culture and/or cell count/hematocrit PATIENT AND FAMILY EDUCATION Figure Tenckhoff catheter used in peritoneal dialysis. (From Lewis SM, et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St. Louis, 2007, Mosby.) Figure Baxter HomeChoice Pro PD Cycler. (Courtesy Baxter International, Inc, Deerfi eld, IL.) The adequacy of dialysis and assessment of the patient s residual renal function should be evaluated on a periodic basis. Adequacy of dialysis can be measured with urea kinetic modeling (Kt/V) or urea clearance. 7,10,14 Residual renal functioning can be monitored with urine creatinine clearance. Collaboration with the nephrology team is necessary to monitor these parameters. EQUIPMENT Masks (for anyone in the room) Goggles or fluid shield face masks Sterile and nonsterile gloves 2 to 4 packs of sterile 4 4 gauze pads Antiseptic solution (follow institutional standards) Tape Sterile barriers Plastic hemostats (or clamps) Explain the purpose of PD. Rationale: PD is necessary to perform the physiological functions of the kidneys when renal failure is present. PD uses the lining inside the abdomen, called the peritoneal cavity, as a filter to clean the blood and remove excess fluid. Explain the procedure, and review any questions. Rationale: Explanation provides information and may decrease patient anxiety. Explain the need for careful sterile technique when the abdominal catheter is accessed. Rationale: Sterile technique is used to decrease the chance of peritoneal infection because pathogens can be introduced into the abdominal cavity via the catheter. 8 Explain the three phases of PD. Rationale: Because each phase is different, the patient must be informed of all three phases and the purposes, interventions, and possible complications of each. Explain the potential for feelings of fullness and possibly shortness of breath during the dwell phase. Rationale: The pressure of the dialysate fluid on the diaphragm may cause the patient to have these feelings, which are normal for the dwell phase. PATIENT ASSESSMENT AND PREPARATION Patient Assessment Obtain baseline vital signs, respiratory status, abdominal assessment, blood glucose level, and pertinent laboratory results (potassium, sodium, calcium, phosphorus, magnesium, renal function tests, complete blood count). Rationale: Patients in renal failure often have altered baseline assessments, according to both physical assessment and laboratory values. The availability of this information before treatments are started is helpful so that interventions, including the type and amount of dialysate fluid, can be individualized. Assess volume status, as indicated by the following: skin turgor, mucous membranes, edema, lung sounds, weight, intake, and output. Rationale: PD is often initiated for the

3 1082 Unit V Renal System control of hypervolemia. 17 Knowledge of a patient s pretreatment volume status is essential to allow for the individualization of treatment goals and interventions. Assess PD catheter and abdominal exit site for signs and symptoms of infection, leakage or drainage, or peritonitis. 5,10,11,13,16,17,25,26 Rationale: The catheter insertion site provides a portal of entry for pathogens that can result in septicemia or peritonitis. If the insertion site or effluent appears to be infected, further interventions (e.g., site change, culture, antibiotics) may be necessary. Cloudy or bloody dialysate solution Leakage at the catheter site Subcutaneous fluid in abdomen, groin, or upper thighs Abdominal pain Fever Chills Rebound tenderness Check the peritoneal catheter and tubing for kinks, puncture sites, and loose connections. Rationale: Adequate flow is essential for optimal treatment. A dysfunctional catheter can alter outcomes. Patient Preparation Verify that the patient is the correct patient using two identifiers. Rationale: Before performing a procedure, the nurse should ensure the correct identification of the patient for the intended intervention. Ensure the patient understands preprocedural education. Answer questions as they arise and reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced. Assist the patient in applying a mask. Rationale: The risk for pathogen transmission is decreased. Reposition the patient to a comfortable position. Rationale: Proper positioning is important to ensure patient comfort, optimize respiratory status, and facilitate optimal flow through the abdominal catheter. Procedure for Peritoneal Dialysis Steps Rationale Special Considerations PD Initiation and Discontinuation 1. Verify PD orders, which should include: A. Manual or automated delivery system B. Dialysis solution type, volume, dextrose/icodextrin and calcium concentrations, and additional medications C. Fill volume/time, dwell time, drain volume/time D. Vital sign parameters E. Laboratory testing 2. HH 3. PE 4. Assemble equipment in a clean, draft-free area. 5. Remove the warmed dialysate bag from the protective pouch; check for expiration date, clarity, and leaks. 6. Hang the PD administration set on the IV pole, and clamp the tubing between the dialysate bag and the patient. 7. Assure the twist clamp on the catheter adaptor or extension set is in the locked position and the cap is secured. 8. Don a mask, and assist the patient in applying a mask. 9. Prepare a sterile field. Open a sterile container package or sterile 4 4 gauze packs. Familiarizes the nurse with the individualized patient treatment and reduces the possibility of error. Maintains aseptic technique. Assesses for contamination of dialysate. Fills tubing with dialysate; decreases chance of introducing air into the abdominal cavity. Prevents inadvertent disconnection. Reduces transmission of pathogens. Maintains aseptic technique. Ensure that patient weight and laboratory values are recorded before initiation of therapy and that the patient is wearing a mask and is properly positioned. A bathroom is not an appropriate place to prepare supplies or perform PD. The dialysate solution may have a frangible pin that needs to be broken to allow the solution to flow into the administration tubing.

4 121 Peritoneal Dialysis 1083 Procedure for Peritoneal Dialysis Continued Steps Rationale Special Considerations 10. Pour antiseptic solution into a Maintains aseptic technique. sterile container or onto sterile 4 4 gauze pads. 11. Scrub the area from the catheter cap to the twist/roller clamp. 12. Remove the cap and connect the catheter to the administration set or to the cycler line. 13. Remove PE and discard used supplies. 14. HH Drain Cycle 1. HH 2. PE 3. Place the drainage bag below the midabdominal area on a clean surface. 4. Assure the drainage tubing to the empty drainage bag is open. 5. Unclamp the twist clamp on the catheter adaptor or extension set of the catheter. 6. Monitor vital signs as prescribed during outflow. 7. Observe the outflow of the PD cycle. 8. Clamp the catheter when the effluent is completely drained. 9. Remove PE and discard used supplies. 10. HH Instillation Cycle 1. HH 2. PE 3. Assure the tubing to the catheter is clamped and unclamp the tubing between the dialysate and the drainage bag. 4. Flush the tubing between the dialysate bag and the drainage bag with approximately 100 ml of dialysate or for approximately 5 seconds. 5. Clamp the tubing to the drainage bag. The effectiveness of the antiseptic is dependent on the scrub time: Povidone-iodine, 2 3-minute scrub Hypochlorite, 1-minute scrub Chlorhexidine, 30-second scrub. Ensures a tight connection. Enhances flow by gravity. Allows flow into the drainage bag. Allows flow from the peritoneal cavity to the drainage bag. Assess for hypotension, tachycardia related to hypovolemia, and sudden release of intraperitoneal pressure. Turning the patient from side to side ensures that the patient s abdomen is empty of dialysate. Decreases leakage and contamination. Safely discards used supplies. Allows flow between the dialysate bag and the drainage bag. The flush before fill assures the effluent drainage left in the tubing to the drainage bag does not back flow into the peritoneal cavity. 18 Allows flow from the dialysate bag to the peritoneal cavity. Allow to air dry. Follow the manufacturer s recommendations because chlorhexidine cannot be used for some catheters. 3,11 If a cycler is used, follow the manufacturer s instructions for system setup. Allow minutes for outflow; observe and record characteristics (e.g., cloudy, bloody, clear, yellow) and amount of outflow. Reposition the patient if flow stops or is sluggish. Notify the physician or advanced practice nurse if drainage is cloudy or bloody. Notify the physician or the advanced practice nurse if the patient becomes hypotensive, has tachycardia, or has abdominal pain. This technique is a key factor in potentially lowering the risk of peritonitis from contamination. Procedure continues on following page

5 1084 Unit V Renal System Procedure for Peritoneal Dialysis Continued Steps Rationale Special Considerations 6. Open the clamp on the catheter. Allows flow from the dialysate bag to the peritoneal cavity. 7. Open the clamp from the dialysate bag to the catheter. Provides open access between the catheter and the PD tubing, allowing inflow of dialysate to the peritoneal cavity. 8. Set the flow rate as prescribed. Time for inflow depends on the height of the dialysate bag, the position of the patient, and the patency of the catheter. 9. Remove PE and discard used supplies. 10. HH Discontinuation of PD 1. HH 2. PE 3. When inflow is complete, clamp the dialysate tubing and the patient s catheter. Safely discards used supplies. Prepares catheter for disconnection. Monitor for signs of increased peritoneal volume. 4. Don a mask, and assist the Maintains aseptic technique. patient in applying a mask. 5. Open a sterile cap. Maintains aseptic technique. Follow institution standard regarding use of a betadine impregnated cap. 6. Disconnect the PD administration set from the patient s catheter. Preparing to end current dialysis cycle. 7. With the transfer/extension set tubing pointing in a downward position, apply the sterile cap. Maintains aseptic technique. 8. Securely tape the catheter to the patient s abdomen. 9. Obtain and record drainage bag weight. 10. Remove PE and discard used supplies. 11. HH Catheter Exit Site Care 1. HH 2. PE 3. Don a mask, and assist the patient in applying a mask. 4. Prepare a sterile field. Open sterile 4 4 gauze pads and sterile container. Prevents accidental dislodgment. Accurately assesses intake and output values. Safely discards used supplies. Maintains aseptic technique. 5. Pour antiseptic solution into a Reduces transmission of sterile container. microorganisms. 6. Remove the old dressing. Allows for visualization of the catheter site. 7. Inspect the catheter exit site and surrounding area for leakage, infection, or trauma. 8. Gently palpate the subcutaneous catheter segments and cuff. Provides assessment for complications. Assesses for pain, erythema, edema, or accumulated drainage. Be careful not to tug or dislodge the catheter. Note any odor or drainage on the old dressing. Note any pain, warmth, crusting, bleeding, tenderness, redness, or swelling that may indicate infection. Obtain a culture if drainage is present and notify the physician or advance practice nurse if the listed signs or symptoms are present.

6 121 Peritoneal Dialysis 1085 Procedure for Peritoneal Dialysis Continued Steps Rationale Special Considerations 9. Remove nonsterile gloves, and wash hands. 10. Apply sterile gloves. Maintains aseptic technique. 11. Use a sterile 4 4 gauze pad to hold the catheter off the skin. Helps prevent contamination of catheter by skin flora. 12. Cleanse the catheter and exit site with antiseptic solution. The effectiveness of the antiseptic is dependent on the scrub time: Allow to dry. A. Begin at the exit site, and move Povidone-iodine, 2 3-minute scrub outward in concentric circles. Hypochlorite, 1-minute scrub B. Keep cleansing solutions out of Chlorhexidine, 30-second scrub the catheter sinus track Apply a new catheter site dressing with sterile gauze or leave it open to the air. Follow institutional standards. 14. Remove PE and discard used supplies in appropriate receptacles. 15. HH Gauze wicks drainage away from the site. Safely discards used supplies. Some patients prefer to leave their well-healed catheter sites open to air. Expected Outcomes Catheter and exit site maintained without complications Instillation and drainage of dialysate without complications Respiratory status not compromised during treatment BUN and creatinine values restored to baseline levels Electrolyte values restored to baseline levels Glucose control maintained Accumulated fluid removed Peritoneum and abdomen intact Unexpected Outcomes Drainage/leakage from the exit site Poor dialysate flow during instillation or drainage Signs and symptoms of peritonitis Inability to drain the total amount of instilled dialysate Signs or symptoms of infection at the insertion or access site Dislodgment of the abdominal catheter Tubing disconnection Physiological complications during treatment Introduction of pathogens into the abdominal catheter Diaphragmatic impingement Viscous perforation by PD catheter Protein or blood loss from peritonitis Increased intraperitoneal volume Patient Monitoring and Care Steps Rationale Reportable Conditions 1. Perform and record predialysis and postdialysis weights. (Level D * ) Predialysis weight is an important factor in deciding how much PD is needed during treatment. It also helps to guide ongoing treatment and nutritional status. Postdialysis weight measures the effectiveness of the dialysis treatment. 3 5,7,12,23,26 These conditions should be reported if they persist despite nursing interventions. Abnormal increase or decrease in weight. * Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommen dations. Procedure continues on following page

7 1086 Unit V Renal System Patient Monitoring and Care Steps Rationale Reportable Conditions 2. Perform baseline and ongoing assessments, including the following: A. Vital signs B. Jugular vein distention C. Presence or absence of edema D. Skin turgor E. Mucus membranes F. Intake and output G. Pulmonary assessment, including expiratory tidal volume and peak inspiratory pressures on the mechanically ventilated patient H. Abdominal assessment 3. Monitor BUN, creatinine, and electrolyte levels during treatment at a frequency determined by institutional standards. 4. Administer medications to correct metabolic abnormalities as prescribed. 5. Monitor serum glucose at the beginning of the treatment and throughout the treatment according to institutional standards. Administer insulin as prescribed to maintain glucose control. 6. Monitor the integrity of the PD setup. 7. Monitor for signs and symptoms of infection at the catheter exit site. Continued Important to establish a baseline before initiation of treatment. 7,12,23,26 Monitors for complications. Hypotension Hypertension Fever Hypothermia Jugular vein distention Dry mucous membranes Shortness of breath Crackles Edema Abdominal distention or tenderness Rebound tenderness Decreased tidal volume Increased peak inspiratory pressures Fluids and electrolyte levels shift Hyperglycemia during treatment. 7 BUN or creatinine levels abnormal for the patient Hyperkalemia or hypokalemia Hypernatremia or hyponatremia Hypercalcemia or hypocalcemia Patients with renal failure are predisposed to many metabolic abnormalities. Common medications administered to patients with renal failure include the following 7,23,26 : Vitamin D and calcium carbonate to increase the serum calcium level and prevent or treat bone disease Erythropoietin and iron to treat anemia Deferoxamine mesylate to remove excessive iron Stool softeners because constipation can impair drainage of PD fluid Phosphate binders to treat hyperphosphatemia The glucose in the dialysate solution predisposes patients to hyperglycemia, especially patients with diabetes. 1,9 Disconnections in the setup provide a portal of entry for pathogens that can lead to peritonitis. 3,7,11,17,22 Hypercalcemia or hypocalcemia Abnormal hemoglobin or hematocrit values Hyperphosphatemia or hypophosphatemia Decreased albumin or prealbumin levels Hyperglycemia or hypoglycemia Fever Tachycardia Cloudy or bloody dialysate Identifies the need for intervention. Site redness or edema Warmth Bleeding Purulent drainage Pain or tenderness Fever

8 121 Peritoneal Dialysis 1087 Patient Monitoring and Care Steps Rationale Reportable Conditions 8. Monitor the ease with which the dialysate is both instilled and drained through the abdominal catheter. 9. Follow institutional standards for assessing pain. Administer analgesia as prescribed. 10. Monitor for signs and symptoms related to quality of life. 2 Continued Patients may need repositioning to facilitate flow through the abdominal catheter. Catheters may also become kinked or occluded. Fibrin clots can obstruct outflow; heparin may be added to the dialysate solution if prescribed. Rapid infusion can cause abdominal pain. Inability to instill or drain fluid through the abdominal catheter Identifies need for pain interventions. Continued pain despite pain interventions. Patient may require further treatment management. Renal diet may also be prescribed, with adjusted protein, phosphorus, carbohydrate, and fluid intake that takes into account the patient s current catabolic state, residual renal function, adequacy of dialysis, and removal of amino acids by dialysis. 7,12,23,26 Fatigue 2 Depression2 Headache2 Poor appetite2 Pruritis 2 Constipation. 2 Documentation Documentation should include the following: Patient and family education Date and time of treatment initiation Treatment/exchange number Condition of the abdominal catheter and exit site at time of treatment Date and time of dressing application Patient weight before and after treatment Pain assessment, interventions, and effectiveness Intake and output Length and parameters of treatment Dialysate solution used Total ultrafiltration output Vital signs/hemodynamic parameters throughout the treatment Unexpected outcomes Nursing interventions Laboratory assessment data References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit