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Peritoneal Dialysis (PD

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By JOSE BYRON DADULLAEVARDONE, RN
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Objectives

To define Peritoneal Dialysis and to discuss its principles. To list indications and contraindications of Peritoneal Dialysis To enumerate general nursing care of patient with Peritoneal Dialysis.
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Principles of Peritoneal Dialysis A. Usually temporary, can be used for clients in acute reversible renal failure. B. Basic goals of dialysis therapy. 1. Removal of end products of protein metabolism, such as creatinine and urea. 2. Maintenance of safe concentration of serum electrolytes. 3.Correction of acidosis and blood’s bicarbonate buffer system. 4. Removal of excess fluid.
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Dialysis is the process by which solutes and fluid will pass through a semipermeable membrane. Peritoneum is a large serous membrane consists of a closed sac within the abdominal cavity. Peritoneal Dialysis is the removal of solutes and fluid across a semipermeable membrane which is the peritoneum.
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PD is employed to remove waste and toxic products from the blood ( peritoneal capillaries ) to peritoneal cavity in cases of renal insufficiency or failure. In order to achieve the above goal of treatment , a solution which is called Dialysate is infused into the abdomen (peritoneal cavity) through an abdominal catheter.
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The dialysate solution will stay in the abdomen (peritoneal cavity) for specified time, in order for difussion and osmosis processes will occur. Diffusion is the movement of molecules from an area of high concentration to an area of low concentration. Example: urea and creatinine in the blood will shift to the peritoneal cavity with dialysate which doesn’t have urea and creatinine molecules.
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Osmosis is the movement of fluid from an area of low concentration to areas of high concentration. Dialysate solution inside the peritoneal cavity with a high dextrose content causing a fluid pull from intravascular (peritoneal capillaries) to peritoneal cavity. Example: CAPD3
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Purpose
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Aid in the removal of toxic substances and metabolic wastes. Establish electrolyte balance. Remove excesses body fluid. Assist in regulating the fluid balance of the body. Control blood pressure. Control severe, intractable heart failure when diuretics no longer promote elimination of water and sodium.
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Indication for Peritoneal Dialysis Acute renal failure. Severe fluid overload in pediatric cardiac patients. To remove toxic and metabolic wastes. Contraindication for Peritoneal Dialysis Abdominal wound or infection Peritonitis Abdominal disease Fecal fistula or colostomy Gastric or diaphragmatic hernia Extensive adhesions from previous surgery.
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Nursing Ojectives * To restore and maintain fluid and electrolyte balance and preserve renal function if possible. * To prevent complication of therapy. Equipment Dialysis administration set Supplemental drugs as requested Local Anesthesia CVP monitoring equipment Warmer Sterile gloves Tube clamps Skin antiseptic Teenckhoff peritoneal catheter (for Adult use) ECG monitoring 10/18/08 jose byron dadulla evardone Trocath PD catheter (for Pediatric use) Suture

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Peritoneal Dialysis
Insertion of the Cannula
Check coagulation profile before insertion of the catheter. The bladder should be empty before the procedures. The abdomen is prepared surgically, and the skin and subcutaneous tissues are infiltrated with local anesthetic. 6. A small mid line stab wound is made 3-5 cm below the umbilicus. 7. The trocar is inserted through the incision with stylet in place, or thin stylet cannula may be inserted percutaneously. 8. The patient, if awake and cooperative, is requested, or assisted, to raise his head from the pillow after the trocar is introduces. This maneuver tightens the abdominal muscles and permits easy penetration of the trocar without the danger of injury to the intra-abdominal organs. 9. When the peritoneum is punctured, the trocar is directed toward the left side of the pelvis. The stylet is removed, and the catheter is tunnelled through the trocar and maneuver into 10/18/08 position. jose byron dadulla evardone 13
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6. Dialysis fluid is allowed to run through the catheter while it is positioned. This prevent the omentum from adhering to the catheter, impeding its advancement or occluding It’s opening. After the trocar is removed, the skin maybe closed with a purse- string suture ( this is not always done). A sterile dressng is placed around the catheter. For adult or permanent PD. Whether you choose an ambulatory or automated form of PD, you’ll need to have a soft catheter placed in your abdomen. The catheter is the tube that carries the dialysis solution into and out of your abdomen. If your doctor uses open surgery to insert your catheter, you will be placed under general anesthesia. Another technique requires only local anesthetic.
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Your doctor will make a small cut, often below and a little to the side of your navel (belly button), and then guide the catheter through the slit into the peritoneal cavity. As soon as the catheter is in place, you can start to receive solution through it, although you probably won’t begin a full schedule of exchanges for 2 to 3 weeks. This break-in period lets you build up scar tissue that will hold the catheter in place. The standard catheter for PD is made of soft tubing for comfort. It has cuffs made of a polyester material, called Dacron, that merge with your scar tissue to keep it in place. The end of the tubing that is inside your abdomen has many holes to allow the free flow of solution in and out.

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Insertion of the Cannula

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

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Insertion of the Cannula
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Commencing peritoneal dialysis on the patient * The volume of PD fluid used is generally 20-30 ml/kg * In unstable patient, 10-20 m/kg may be used Attach the catheter connector to the administration set, which has been previously connected to the container of dialysis solution( warmed to bdy temperature of 37°C). The solution is warmed to body temperature for patient comfort and to prevent abdominal pain. Heating also causes dilatation of the peritoneal vessels and increase urea clearance. * Hot PD fluid can damage the peritoneum. * Cold PD fluid is painful, will contribute to hypothermia and should not be used
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Insertion of the Cannula

Drug (heparin, potassium, and antibiotics) are added in advance. The addition f heparin, 100 unit per liter, is routine added to the PD fluid to fibrin clot from occluding the catheter. Potassium chloride may be added on request unless patient has hyperkalemia. Antibiotic are added for the treatment of peritonitis. Permit the dialyzed solution to flow unrestricted into the peritoneum cavity (usually takes 5- 10 mins. completion). if the patient experiences pain slow down the infusion. Allow the fluid to remain in the peritoneal cavity for the prescribed time period., 15 MINS. TO 4 HRS (inflow time). Prepare the next exchange while the fluid is in the peritoneal cavity. In order for potassium, urea and other waste material to be removed, the solution must remain in the peritoneal cavity for the 10/18/08 jose byron time). 18 prescribe time( dwelling dadulla evardone

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Insertion of the Cannula
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The maximum concentration gradients takes place in the first 5-10 mins. (outflow time) for small molecules, such as creatinine and urea. Unclamp the outflow tube. Drainage should be take approximately 10-30 mins., although the time varies with each patient. If the fluids is not draining properly: move the patient from side to side facilitate the removal of peritoneal drainage. The head of the bed may also elevated. Ascertain if the catheter is patent. Check for closed clamp, kinked tubing, or air lock. Never push the catheter in as you will introduce bacteria. If the drainage stop, or start to drip before the dialyzing fluid has run out, manipulating the catheter tip may be helpful ( or it may be necessary for the physician to reposition the catheter).
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Insertion of the Cannula
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When the outflow drainage ceases to run, clamp off the drainage tube and infuse the next exchange. take BP and pulse every 15 mins. During the first exchange and every hour thereafter. Monitor the heart rate for sign of arrthymia. A drop in blood pressure may indicate excessive fluid loss. Changes in the vital sign may be indicate impending shock or over hydration. Take the patient temperature every 4hrs. (especially after catheter removal). An infection is more apt to become eviden after dialysis has been discontinue. The procedure is repeated until the blood chemistries level improve. The usual duration for short- term dialysis is 36 to 48 hrs. Depending on the patient condition, he will receive 24 to 48 exchanges . Keep the exact record of the patient’s fluid balance during the treatment. Know the status of the patient’s loss or gain of fluid at the end of each exchange. Check dressing for leakage and weight on gram scale if significant. The fluid balance should be about even or should show slight fluid loss or gain , depending on the patient’s fluid status and doctor’s order.
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Insertion of the Cannula
12. Promote patient comfort during dialysis. Provide frequent back care and relieve pressure area Have the patient turn from side to side. Elevate head of bed at intervals. Allow the patient to sit in chain for brief period if condition permits. The patient may be mobilized during the outflow time if stable and permission given by the doctor. 13. Observe the following: A. Respiratory difficulty - slow the inflow rate - make sure the tubing is not kinked - prevent air from entering peritoneum by keeping drip chamber of tubing three quarters full of fluid. - elevate head of bed: encourage breathing and coughing exersices. - turn patient from side to side. - reduce the volume administered
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Peritoneal Dialysis
Insertion of the Cannula
13. B. Abdominal Pain - encourage patient to move about if ambulant c. Leakage - change the dressings frequently, being careful not to dislodge the catheter. - used sterile plastic drapes to prevent contamination. 14. Keep accurate records: - Exact time of beginning and end of each exchange: starting and finishing time of drainage. - amount of solution infused and recovered. - fluid balance - no. of exchanges - medication added to dialysing solution. - pre and post dialysis weigh plus daily weight. - level of responsiveness at beginning, throughout, and at nd of treatment. - assessment of vital signs and patient’s condition.
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Insertion of the Cannula
Change peritoneal dialysis cannula monthly usng sterile technique or as per unit protocol (new tenckoff silicone catheter can be left in for 3 month if required.) Complication: Peritonitis Mechanical Metabolic disturbances Cardio- respiratory problem

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PD Solutions (Dialysate)

CAPD 2 is a PD solution, potassium free and with 1.5% Dextrose content. CAPD 3 is a PD solution, potassium free and with 4.25% Dextrose content.

The above dialysates can be incorporated with additives such as Heparin, Antibiotics, Na Bicarbonate, etc. 10/18/08 jose byron dadulla evardone

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After a certain period of time, wherein both processes difussion and osmosis have occurred, the dialysate within the peritoneal cavity together with the metabolic wastes and extra fluid will be drained into the collection bag through peritoneal catheter exiting though the outflow tubing.

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Type of PD
Continuous Ambulatory Peritoneal Dialysis (CAPD)  If you choose CAPD, you’ll drain a fresh bag of dialysis solution into your abdomen. After 4 to 6 or more hours of dwell time, you’ll drain the solution, which now contains wastes, into the bag. You then repeat the cycle with a fresh bag of solution. You don’t need a machine for CAPD; all you need is gravity to fill and empty your abdomen. Your doctor will prescribe the number of exchanges you’ll need, typically three or four exchanges during the day and one evening exchange with a long overnight dwell time while you sleep.  Continuous Cycler-Assisted Peritoneal Dialysis (CCPD)  CCPD uses an automated cycler to perform three to five exchanges during the night while you sleep. In the morning, you begin one exchange with a dwell time that lasts 10/18/08 the entire day. byron dadulla evardone jose 26

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Preventing Problems
Infection is the most common problem for people on PD. Your health care team will show you how to keep your catheter bacteria-free to avoid peritonitis, which is an infection of the peritoneum. Improved catheter designs protect against the spread of bacteria, but peritonitis is still a common problem that sometimes makes continuing PD impossible. You should follow your health care team’s instructions carefully, but here are some general rules: Store supplies in a cool, clean, dry place. Inspect each bag of solution for signs of contamination before you use it. Find a clean, dry, well-lit space to perform your exchanges. Wash your hands every time you need to handle your catheter. Clean the exit site with antiseptic every day. Wear a surgical mask when performing exchanges.
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Keep a close watch for any signs of infection and report them so they can be treated promptly. Here are some signs to watch for: Fever Nausea or vomiting Redness or pain around the catheter Unusual color or cloudiness in used dialysis solution A catheter cuff that has been pushed out
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Equipment and Supplies for PD
Transfer Set A transfer set is tubing that connects the bag of dialysis solution to the catheter. When your catheter is first placed, the exposed end of the tube will be securely capped to prevent infection. Under the cap is a universal connector. When you start dialysis training, your dialysis nurse will provide a transfer set. The type of transfer set you receive depends on the company that supplies your dialysis solution. Different companies have different systems for connecting to your catheter. Connecting the transfer set requires sterile technique. You and your nurse will wear surgical masks. Your nurse will soak the transfer set and the end of your catheter in an antiseptic solution for 5 minutes before making the connection. The nurse will wear rubber gloves while 10/18/08 making the connection. jose byron dadulla evardone

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Depending on the company that supplies your solution, your transfer set may require a new cap each time you disconnect from the bag after an exchange. With a different system, the tubing that connects to the transfer set includes a piece that can be clamped at the end of an exchange and then broken off from the tubing so that it stays on the transfer set as a cap until it is removed for the next exchange. Your dialysis nurse will train you in the aseptic (germ-free) technique for connecting at the beginning of an exchange and disconnecting at the end. Follow instructions carefully to avoid infection Transfer set. Between exchanges, you can keep your catheter and transfer set hidden inside your clothing. At the beginning of an exchange, you will remove the disposable cap from the transfer set and connect it to a Y-tube. The branches of the Y-tube connect to the drain bag and the bag of fresh dialysis solution. Always wash your hands before 10/18/08 jose byron handling your catheter and transfer set, dadulla evardone and wear a surgical mask whenever you

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