Peritoneal Dialysis

Presented by:Advincula, JasminCailles, PatriciaCasco, GeraldCoson. Jan KarmelaEcleo, Jorhene

Francisco, BernadetteFloresta, NoellaReyes, KrishiaVillavicencio, JanellaYu, JanellePeritoneal DialysisDefinition:Removal of solutes and fluid across a semi-permeable membrane which is the peritonuem.Purpose:Aid in removal of toxins and metabolic wastesEstablish electrolyte balanceRemove excess body fluidAssist in regulating the fluid balance of the bodyControl BPControl severe intractable heart failure when diuretics no longer promote elimination of water and sodiumTypes of Peritoneal Dialysis:Continuous ambulatory peritoneal dialysisAutomated peritoneal dialysisContinuous cyclic peritoneal dialysisIntermittent peritoneal dialysisNightly intermittent peritoneal dialysisContinuous ambulatory peritoneal dialysisUsed with patients with ESRDPerformed at home by the patient or the trained caregiver who is usually the family member, the procedure allows the patient reasonable freedom and control of daily activitiesAutomated peritoneal dialysis

Necessitates use of a peritoneal cycling machineCan be performed as continuous cyclic, intermittent, or nightly intermittent peritoneal dialysis

Continuous cyclic peritoneal dialysis

Usually three cycles at night and one cycle with an 8-hour dwell in the morningAdvantage is that the peritoneal catheter is opened only for the on-and-off procedures, which reduces the risk of infectionDoes not require exchanges at work or schoolIntermittent peritoneal dialysisDialysis is performed for 10 to 14 hours, three to four times a week, by the same peritoneal cycling machine as in continuous cyclic peritoneal dialysisNightly intermittent peritoneal dialysisDialysis is performed for 8 to 12 hours each night with no daytime dwells Steps of intermittent peritoneal dialysisIntroduction of dialysate (1 to 8 L)Open infusion tubeClose drainageFor 10-15 minutesDwell timeRetained dialysateClosed infusion tube/regulatorAllows diffusionFor 20-30 minutesDrain dialysateOpen drainage regualtorChange 2 L of dialysateRepeat process30-32 exchange2-3 days

Steps of continuous ambulatory peritoneal dialysis1.5 to 3L of dialysate is instilled into the abdomen and left in place for a prescribed period of timeThe empty dialysate bag is folded up and carried in a pouch or pocket until it is time to drain the dialysateThe bag is then unfolded and placed lower than the insertion site so that the fluid drains by gravity flow.When full, the bag is changed and the new dialysate is instilledUsually uses four cycles every 24 hours including an 8 hour dwell overnight.

PREDIALYSIS CAREDocument VSWeigh daily or between dialysis runs as indicatedNote BUN, serum electrolytes, creatinine, pH and hct levels prior to peritoneal dialysis and periodically during the procedureMeasure and record abdominal girthMaintain fluid and dietary restrictions as orderedHave the client empty the bladder prior to catheter insertionWarm the prescribed dialysate solution to body temperature (37C) using a warm water bath or heating pad on low settingExplain all procedures and expected sensationsINTRADIALYSIS CAREUse strict aseptic technique during the dialysis procedure and when caring for the peritoneal catheterAdd prescribed medications to the dialysate; prime the tubing with solution and connect it to the peritoneal catheter, taping connections securely and avoiding kinksInstil dialysate into the abdominal cavity over a period of approximately 10 minutes. Clamp tubing and allow the dialysate to remain in the abdomen at all times during instillation and dwell time

During instillation and dwell time, observe closely for signs of respiratory distress, such as dyspnea, tachypnea, or crackles. Place in Fowlers or semi-Fowlers position and slow the rate of instillation slightly to relieve respiratory distress if it developsAfter prescribed dwell time, open drainage tubing clamps and allows dialysate to drain by gravity into a sterile container. Note the clarity, color, and odor of returned dialysate.

Accurately record the amount and type of dialysate instilled (including any added medications), dwell time, amount, and character of drainage.Monitor BUN, serum electrolyte and creatinine levelsTroubleshoot for possible problems during dialysisPOSTDIALYSIS CAREAssess vital signs, including temperature.Time meals to corresponds with dialysis outflow.Teach the client and family about the procedure.Complications of Peritoneal DialysisPulmonary EdemaCauses:High levels or nitrogen compounds and waste products - Azotemia High concentration of glucose dialysate.

Sample Nursing DiagnosisImpaired gas exchange related to altered oxygen supplementation secondary to peritoneal dialysis.

Nursing InterventionsMonitor respiratory rate/effort. Reduce infusion rate if dyspnea is present. (suggest diaphragmatic pressure from distended peritoneal cavity or may indicate developing complications.)Auscultate lungs, noting decreased, absent, or adventitious breath sounds, e.g., crackles/wheezes/rhonchi. (presence of atelectasis) Palpate for fremitus.(fluid collection on air tapping.)Note character, amount, and color of secretions.(susceptible to pulmonary infections as a result of depressed cough reflex and respiratory effort, increased viscosity of secretions, as well as altered immune response and chronic/debilitating disease.)Nursing InterventionsElevate head of bed or have patient sit up in chair. Promote deep-breathing exercises and coughing. (facilitation of chest expansion and mobilization of secretions)Review ABGs/pulse oximetry and serial chest x-rays. (appearance of infiltrates/congestion on chest x-ray suggest developing pulmonary problems)Administer supplemental O2 as indicated. (to lessen hypoxia)Administer analgesics as indicated. (alleviates pain, promotes cough expansion)Suction as needed. (expectorations of secretions.)Abdominal PainCAUSES:high hypertonicity dialysatehigh or low temperature of dialysateexcessive dialysateceliac infectioncatheter movement

Abdominal PainNURSING DIAGNOSIS:Acute pain r/t Infusion of cold or acidic dialysate, abdominal distension, rapid infusion of dialysate as manifested by pain scale of 7/10, guarding behavior, restlessness

Abdominal PainNURSING INTERVENTIONS:Assess PQRST of painExplain that initial discomfort usually subsides after the first few exchanges.Monitor for pain that begins during inflow and continues during equilibration phase. Slow infusion rate as indicated.

Abdominal PainNURSING INTERVENTIONS:Note reports of discomfort that is most pronounced near the end of inflow and instill no more than 2000 mL of solution at a single time.Prevent air from entering peritoneal cavity during infusion. Note report of pain in area of shoulder blade.Abdominal PainNURSING INTERVENTIONS:Elevate head of bed at intervals. Turn patient from side to side. Provide back care and tissue massageWarm dialysate to body temperature before infusingMonitor for severe/continuous abdominal pain and temperature elevation (especially after dialysis has been discontinued).Abdominal PainNURSING INTERVENTIONS:Encourage use of relaxation techniquesAdminister analgesics.Add sodium hydroxide to dialysate, if indicated.Peritonitis Causes: Catheter-related infectionTouch contamination Transvisceral migration due to intraabdominal pathology (eg, bowel leak)HematogenousVaginal leak, which is very rare

Risk Factors:Obese and diabetic patients

Can lead to:severe loss of protein, peritoneal adhesion, peritoneal thickening and peritoneal dialysis failure as well as blocking catheter, which can threaten life.Sample Nursing DiagnosisAltered Thermoregulation: Hyperthermia related to Inflammatory process as manifested by body temperature of 38.5C, flushed skin: warm to touch.

Nursing InterventionsMonitor VS especially core temperature every hour. Note presence or absence of sweating as body attempts to increase heat loss by evaporation. ((Evaporation is decreased bye environmental factors of high humidity and high as well as body factorsproducing loss of ability to sweat.))Increase oral fluid intake. (To support circulating volume and tissue perfusion.)Promote bed rest, encourage relaxation skills and diversional activities. (To reduce metabolic demands/oxygen consumption.)Promote surface cooling, loosen clothing and cool environment. (Heat is loss by evaporation and conduction)Nursing InterventionsProvide TSB as needed. Review specific risks factors/causes, signs and symptoms with the interventions required. (Heat loss is by convection radiation and conduction. )Discuss importance ofadequate fluid intake andprotein diet. (To prevent dehydration.)Administermedications as indicated to treat underlying cause, such as anti-pyretics. Administerreplacement fluids and electrolytes to support circulating volume and tissue perfusion. (To support circulating volume and tissue perfusion.)Obstructed drainage and blocking catheterCAUSES:Warping, movement, and blocking by fibrin, blood clottoo much gas in enteric cavity or abdominal cavity

Obstructed drainage and blocking catheterNURSING DIAGNOSIS:Risk for Excess Fluid Volume r/t Fluid retention (malpositioned or kinked/clotted catheter)

Obstructed drainage and blocking catheterINTERVENTIONS:Accurate recording of I & ORecord serial weights, compare with I&O balance. Weigh patient when abdomen is empty of dialysate (consistent reference point).Assess patency of catheter, noting difficulty in draining. Note presence of fibrin strings/plugs.

Obstructed drainage and blocking catheterINTERVENTIONS:Check tubing for kinks; note placement of bottles/bags. Anchor catheter so that adequate inflow/outflow is achieved.Turn from side to side, elevate the head of the bed, apply gentle pressure to the abdomen.Note abdominal distension associated with decreased bowel sounds, changes in stool consistency, reports of constipation.

Obstructed drainage and blocking catheterINTERVENTIONS:Monitor BP and pulse, noting hypertension, bounding pulses, neck vein distension, peripheral edema; measure CVP if available.Evaluate development of tachypnea, dyspnea, increased respiratory effort. Drain dialysate, and notify physician.Assess for headache, muscle cramps, mental confusion, disorientation.Obstructed drainage and blocking catheterINTERVENTIONS:Alter dialysate regimen as indicated.Monitor serum sodiumAdd heparin to initial dialysis runs; assist with irrigation of catheter with heparinized saline.Maintain fluid restriction as indicated.THANK YOU! hihi :>