PERITONEAL DIALYSIS

INTRODUCTION

PD was first used in 1923, it did not come in to widespread use for chronic treatment until the 1970s with the development of soft , pliable peritoneal solution bags and the introduction of the concept of continuous PD. In the united states , approximately 10% of patients receiving dialysis treatment are on PD.

The goals of PD are to remove toxic substances and metabolic wastes and to reestablish normal uid and electrolyte balance. PD may be the treatment of choice for patients with renal failure who are unable or unwilling to undergo hemodialysis or renal transplantation. Patients who are susceptible to the rapid uid, electrolyte, and metabolic changes that occur during hemodialysis experience fewer of these problems with the slower rate of PD. Therefore, patients with diabetes or cardiovascular disease, many older patients, and those who may be at risk for adverse effects of systemic heparin are likely candidates for PD. Additionally,severe hypertension, heart failure, and pulmonary edema not responsive to usual treatment regimens have been success-fully treated with PD.

TERMINOLOGYDialysis: refers to the diffusion of solute molecules through a semipermeable membrane, passing from the side of higher concentration to that of lower concentration. Diffusion: Movement of solutes from an area ofgreater concentration to an area of lesser concentration. Urea, creatinine, uric acid, potassium, and phosphate diffuse. RBCs, WBCs, and large plasma proteins are too large to diffuse. Osmosis: Movement of fluid from an area of lesser concentration to an area of greater concentration.

Ultrafiltration:(water and fluid removal) results when there is an osmotic gradient or pressure gradient across the membrane. Increased pressure in the blood and a decreasepressure in the dialysate causes fluid to move from the blood into the dialysate.

ANATOMY AND PHYSIOLOGYThe renal and urinary systems include the kidneys, ureters, bladder, and urethra. Urine is formed by the kidney and ows through the other structures to be eliminated from the body. The kidneys are a pair of bean-shaped, brownish-red structures located retroperitoneally (behind and outside the peritoneal cavity) on the posterior wall of the abdomen from the 12th thoracic vertebra to the third lumbar vertebra in the adult .The average adult kidney weighs approximately 113 to 170 g (about 4.5 oz) and is 10 to 12 cm long, 6 cm wide, and 2.5 cm thick . The right kidney is slightly lower than the left due to the location of the liver.The renal parenchyma is divided into two parts: the cortex and the medulla . The medulla, which is approximately 5 cm wide, is the inner portion of the kidney. It contains the loops of Henle, the vasa recta, and the collecting ducts of the juxtamedullary nephrons. The collecting ducts from both the juxtamedullary and the cortical nephrons connect to the renal pyramids, which are triangular and are situated with the base facing the concave surface of the kidney and the point (papilla) facing the hilum, or pelvis. Each kidney contains approximately 8 to 18 pyramids. The pyramids drain into minor calices, which drain into major calices that open directly into the renal pelvis. The renal pelvis is the beginning of the collecting system and is composed of structures that are designed to collect and transport urine. Once the urine leaves the renal pelvis, the composition or amount of urine does not change.

URETERS, BLADDER, AND URETHRA

The urine formed in the nephrons flows into the renal pelvis and then into the ureters, which are long bromuscular tubes that connect each kidney to the bladder. These narrow tubes, each 24 to 30 cm long, originate at the lower portion of the renal pelvis and terminate in the trigone of the bladder wall. Bladder stores urine temporarily. Bladder and ureters are lined by transitional epithelium.a membraneous tube called urethra arises from the neck of the bladder . urethra conveys urine to the exterior.in the female, the urethra is very short about 4cm long. FORMATION OF URINEUrine formation occurs in the nephrons of kidney. It involves three steps. They are glomerular filtration, selective reabsorption and tubular secreation.

GLOMERULAR FILTERATION

It is the first step in the urine formation. It occurs in the renal corpuscle across the wall of the glomerular capillaries and the inner wall of the bowmans capsule. When blood flows under high pressure through the glomerular capillaries, water and dissolved substances of blood filter out into the lumen of the bowmans capsule. The protein free and cell free fluid in the bowmans capsule which is obtained by the process is called glomerular filtrate. The filtrate contain smaller molecules like glucose, urea, creatinine, mineral salts etc. it does not contain larger particles like blood cells, proteins and lipids,because the wall of the glomerular capillary is impermeable to these macromolecules. The volume of fluid formed from the glomerular capillaries into thebowmans capsule per unit time is called glomerular filteration rate. In man the GFR is 125ml/day.The driving force for this filteration is provided by the difference between the glomerular blood pressure and the sum of the osmotic pressure of plasma proteins and the pressure of the filterate present in the bowmans capsule.

Glomerular blood pressure=55 mm of hg

Pressure of filtrate in Bowmans capsule=15mm of hg

Osmotic pressure of plasma protein=30 mm of hg

Net filtration pressure =55-(15+30)=55-45=10mm of hg

The outpushing glomerular blood pressure is always greater than the osmotic pressure of plasma proteins and the pressure of filtrate in the bowmans capsule. The net filtration pressure is 10 mm of hg and this pressure is responsible for the glomerular filtration. SELECTIVE REABSORPTION

Reabsorption take place in the renal tubles. Reabsorption is a selective process . these are two mechanisms for tubular reabsorption. They are active and passive process. Substance which are of considerable importance to the body such as glucose, aminoacids, vitamins, and some mineral ions are actively reabsorbed. hence they are called high threshold substances. Substances like urea, uric acid, ammonia, creatinine and ketone bodies are reabsorbed in small quantities from the filtrate to the blood. So these substance are called low threshold substance. Some other substances like creatinine, sulphates etc. are not reabsorbed. Total amount of glucose ,most of the aminoacids and vitamin c,about 70%of Na+,75%of K+ and a large amount of Ca+ are reabsorbed by diffusion from the proximal convoluted tubule. Nearly about 75% of water is also reabsorbed by osmosis from the PCT to the blood.

About 5% of H2O is reabsorbed from the descending limb of the loop of henle. Ascending limb is impermeable to water. K+.Cl- and some Na+ are reabsorbed in the ascending limb.DCT , collecting tubule and collecting duct actively reabsorbSome Na+from the filtration and in exchange, excrete some K+ in the urine. Some Cl- is also reabsorbed by DCT. TUBULAR SECREATION

It is the final step in urine formation and it involves the active secretion of some substances from the blood into the filtrate in the renal tubule. It takes place in the distal convoluted tubule. It is an active process that requires ATP,K+, H+, NH3, sulphur compounds, uric acid, creatinine, drugs like pencillin etc. tubular secretion plays a major role in the regulation of the pHof blood. PERITONEAL LAYER

Abdominal organs are almost completely covered by the peritoneum. The two types of peritoneum are the parietal, which lines the abdominal cavity wall, and visceral, which covers the abdominal organs. The peritoneal cavity is the potential space between the parietal and visceral layers. The two folds of peritoneum are the mesentery and omentum. The mesentery attaches the small intestine and the part of large intestine to posterior abdominal and contains blood and lymph vessels. The lesser omentum goes from the lesser curvature of the stomach and upper duodenum to the liver, and greater omentum hangs from the stomach over the intestine like an apron. The omentum contains fat and lymph nodes. DIALYSISDialysis refers to the diffusion of solute molecules through a semipermeable membrane, passing from the side of higher concentration to that of lower concentration. The purpose of dialysis is to maintain the life and well-being of the patient. It is a substitute for some kidney excretory functions but does not replace the kidneys' endocrine and metabolic functions.Types:

1) Intermittent Peritoneal Dialysis (IPD): Automated cycler equipment is used to deliver the dialysate. Client dialyses 3 to 5 times per week usually overnight for about 8 hrs per treatment. Cycler times the inflow and outflow and warns with alarms which will wake client.

2) Continuous Ambulatory Peritoneal Dialysis (CAPD): Client controls inflow and outflow 4 to 5 times daily with a dwell time of 4 to 8 hours. Client instills 2 L from a collapsible bag then clamps and then removes dialysate by gravity. After removal bag is discarded. Tubing is changed every 1 to 2 months.

3) Cyclic Continuous Peritoneal Dialysis (CCPD): Combination of the other two. 3 to 4 transfers are made at night and 2 L are left in the peritoneal cavity during the day. With CCPD the system is only opened twice a day, once to connect at night and once to disconnect in the morning.

DIALYSIS SOLUTIONS AND CYCLES

DIALYSIS SOLUTION are available commercially in 1-2 l,plastic bag with glucose concentration of 1.5%,2.5% and 4.25%.the electrolyte composition is similar to that of plasma.Ultrafiltration during PD depends on osmotic gradient , with glucose being most effective osmotic gradient.

PHASES:The three phases of the pd cycle are inflow, dwell, outflow.the three phases are called an exchange.

INFLOW: during inflow (fill) ,a prescribed amount of solution, usually 2L ,is infused through an established catheter over about 10 minutes. The flow rate may decreased when the patient feels pain. After the solution has been infused ,the inflow clamp is closed before air enters the tubing.DWELL: (EQUILIBRIUM) during which diffusion and osmosis occur between patients blood and peritoneal cavity. the duration of dwell time can last 20 to 30 minutes 8 or more hours, depending on method of PD.

DRAIN: drain time takes 15to 30 minutes and may be facilitated by gently massaging the abdomen or changing position.APPROACHESPD can be performed using several different approaches:

acute intermittent peritoneal dialysis, continuous ambulatory peritoneal dialysis (CAPD), and continuous cyclic peritoneal dialysis (CCPD).

Acute Intermittent Peritoneal Dialysis

Indications for acute intermittent PD, uremic signs and symptoms (nausea, vomiting, fatigue, altered mental status)

uid overload

acidosis

hyperkalemia. Although PD is not as efcient as hemodialysis in removing solute and uid, it permits a more gradual change in the patients fluid volume status and in waste product removal. Therefore, it may be the treatment of choice for the hemodynamically unstable patient. It can be carried out manually (the nurse warms, spikes, and hangs each container of dialysate) or by a cycler machine. Ex-change times range from 30 minutes to 2 hours. A common routine is hourly exchanges consisting of a 10-minute infusion, a 30-minute dwell time, and a 20-minute drain time.

NURSING RESPONSIBILITY. Strict aseptic technique is maintained when changing solution containers and emptying drainage containers. Vital signs, weight, I&O, laboratory values

patient status are frequently monitored. The nurse uses a ow sheet to document each exchange and records vital signs, dialysate concentration, medications added, exchange volume, dwell

time, dialysate uid balance for each exchange (uid lost orgained), and cumulative uid balance

The nurse also carefully assesses skin turgor and mucous membranes to evaluate uid status and monitor the patient for edema. If the peritoneal uid does not drain properly, the nurse can facilitate drainage by turning the patient from side to side or raising the head of the bed. The catheter should never be pushed further into the peritoneal cavity. Other measures to promote drainage include checking the patency of the catheter by inspecting for kinks, closed clamps, or an air lock. The nurse monitors for complications, including peritonitis, bleeding, respiratory difculty, and leakage of peritoneal uid. Abdominal girth may be measured periodically to determine if the patient is retaining large amounts of dialysis solution.

The nurse must ensure that the PD catheter remains secure and that the dressing remains dry. Physical comfort measures, frequent turning, and skin care are provided. The patient and family are educated about the procedure and are kept informed about progress (uid loss, weight loss, laboratory values). Emotional support and encouragement are given to the patient and family during this stressful and uncertain timeCONTINUOUS AMBULATORY PERITONEAL DIALYSISCAPD is the second most common form of dialysis for patients with ESRD to be started on (USRDS, 2007). CAPD is performed at home by the patient or a trained caregiver who is usually a family member. The procedure allows the patient reasonable freedom and control of daily activities but requires a serious commitment to be successful.

CAPD works on the same principles as other forms of PD: diffusion and osmosis. Less extreme uctuations in the patients laboratory values occur with CAPD than with intermittent PD or hemodialysis because the dialysis is constantly in progress. The serum electrolyte levels usually remain in the normal range.

PROCEDURE

A permanent indwelling catheter is implanted into the peritoneum; the internal cuff of the catheter becomes embedded by fibrous in growth, which stabilizes it and minimizes leakage.

A connecting tube is attached to the external end of the peritoneal catheter, and the distal end of the tube is inserted into a sterile plastic bag of dialysate solution.

The dialysate bag is raised to shoulder level and infused by gravity into the peritoneal cavity (approximately 10 minutes for a 2-L volume).

The typical dwell time is 4 to 6 hours.

At the end of the dwell time, the dialysate fluid is drained from the peritoneal cavity by gravity. Drainage of 2 L plus ultrafiltration takes about 10 to 20 minutes if the catheter is functioning optimally.

After the dialysate is drained, a fresh bag of dialysate solution is infused using aseptic technique, and the procedure is repeated.

The patient performs four to five exchanges daily, 7 days per week, with an overnight dwell time allowing uninterrupted sleep; most patients become unaware of fluid in the peritoneal cavity.

COMPLICATIONS

To reduce the risk of peritonitis, the patient (and all care-givers) must use meticulous care to avoid contaminating the catheter, uid, or tubing and to avoid accidentally disconnecting the catheter from the tubing. Whenever a connection/disconnection is made, hands must be washed and a mask worn by anyone within 6 feet of the area to avoid contamination with airborne bacteria. Excess manipulation should be avoided and meticulous care of the catheter entry

site is provided using a standardized protocol. CONTINUOUS CYCLIC PERITONEAL DIALYSISCCPD uses a machine called a cycler to provide the exchanges. It is programmed as to how much uid to use and how long and how many exchanges need to be done. Since it is programmed, it also keeps track of the total amounts removed and will sound an alarm if limits are not met. It requires that a person set up and break down the system for use, which typically takes about 15 minutes. CCPD combines overnight intermittent PD with a prolonged dwell time during the day. The peritoneal catheter is connected to a cycler machine every evening, usually just before the patient goes to sleep for the night. Because the machine is very quiet, the patient can sleep, and the extralong tubing allows the patient to move and turn normally during sleep.

In the morning, the patient disconnects from the cycler. Sometimes dialysate is left in the abdominal cavity for a longer day dwell cycle. This day exchange is drained during the day either by using a Y set or reattaching to the cycler. This process is done every day to achieve the effects of dialysis required.

CCPD has a lower infection rate than other forms of PD because there are fewer opportunities for contamination with bag changes and tubing disconnections. It also allows the patient to be free from exchanges throughout the day, making it possible to engage in work and activities of daily living more freely.

PROCEDURE GUIDELINES

Assisting the Patient Undergoing (Acute) Peritoneal Dialysis

EQUIPMENT

Dialysis administration set (disposable, closed system)

Peritoneal dialysis solution as requested

Supplemental drugs as requested

Local anesthesia

Central venous pressure monitoring equipment

Suture set

Sterile gloves

Skin antiseptic

PROCEDURE

Nursing ActionRationale

Preparatory phase

1.Prepare patient emotionally and physically for the procedure.1.Nursing support is offered by explaining procedure mechanics, providing opportunities for patient to ask questions, allowing verbalization of feelings, and giving expert physical care.

2.Ensure that the consent form has been signed.

3.Weigh patient before dialysis and every 24 hours thereafter, preferably on an in-bed scale.3.The weight at the beginning of the procedure serves as a baseline of information. Daily weight confirms ultrafiltration results and evaluates volume status.

4.Take temperature, pulse, respiration, and blood pressure readings before dialysis.4.Measurement of vital signs at the beginning of dialysis is necessary for comparing subsequent changes in vital signs.

5.Have patient empty bladder.5.If the bladder is empty, there is less risk of perforating it when the trocar is introduced into the peritoneum.

6.Flush the tubing with dialysis solution.6.The tubing is flushed to prevent air from entering the peritoneal cavity. Air causes abdominal discomfort and drainage difficulties.

7.Make patient comfortable in a supine position. Have patient and health care personnel wear masks.7.This helps protect patient from airborne contamination.

Performance phase

The following is a brief summary of the method of insertion of a temporary peritoneal catheter (done under strict asepsis).

1.The abdomen is prepared surgically, and the skin and subcutaneous tissues are infiltrated with a local anesthetic.1.Surgical preparation of the skin minimizes or eliminates surface bacteria and decreases the possibility of wound contamination and infection.

2.A small midline incision is made 1 to 2 inches (3-5 cm) below the umbilicus.

3.The trocar is inserted through the incision with the stylet in place, or a thin stylet cannula may be inserted percutaneously.

4.Patient is requested to raise head from the pillow after the trocar is introduced.4.This maneuver tightens the abdominal muscles and permits easier penetration of the trocar without danger of injury to the intra-abdominal organs.

5.When the peritoneum is punctured, the trocar is directed toward the left side of the pelvis. The stylet is removed, and the catheter is inserted through the trocar and maneuvered into position.5.This prevents the omentum from adhering to the catheter, impeding its advancement or occluding its opening.

a.Dialysis fluid is allowed to run through the catheter while it is being positioned.

6.After the trocar is removed, the skin may be closed with a purse-string suture. (This is not always done.) A sterile dressing is placed around the catheter.6.The catheter is attached to the skin to prevent loss of the catheter in the abdomen.

7.Attach the catheter connector to the administration set, which has been previously connected to the container of dialysis solution (warmed to body temperature, 98.6F [37C]).7.The solution is warmed to body temperature for patient comfort and to prevent abdominal pain. Heating also causes dilatation of the peritoneal vessels and increases urea clearance.

8.Drugs (heparin, potassium, antibiotic) are added in advance.8.The addition of heparin prevents fibrin clots from occluding the catheter. Potassium chloride may be added on request unless patient has hyperkalemia. Antibiotics are added for the treatment of peritonitis.

9.Permit the dialyzing solution to flow unrestricted into the peritoneal cavity (usually takes 5-10 minutes for completion). If patient experiences pain, slow down the infusion.9.The inflow solution should flow in a steady stream. If the fluid flows in too slowly, the catheter may need to be repositioned because its tip may be buried in the omentum, or it may be occluded by a blood clot. Flushing may help.

10.Allow the fluid to remain in the peritoneal cavity for the prescribed time period (20-30 minutes). Prepare the next exchange while the fluid is in the peritoneal cavity.10.For potassium, urea, and other waste materials to be removed, the solution must remain in the peritoneal cavity for the prescribed time (dwell or equilibration time). The maximum concentration gradient takes place in the first 5-10 minutes for small molecules, such as urea and creatinine.

11.Unclamp the outflow tube. Drainage should take approximately 20-30 minutes, although the time varies with each patient.11.The abdomen is drained by a siphon effect through the closed system. Gravity drainage should occur fairly rapidly, and steady streams of fluid should be observed entering the drainage container. The drainage is usually straw-colored.

12.Check outflow for cloudy appearance, blood, or fibrin.12.May be an early sign of peritonitis.

13.If the fluid is not draining properly, move patient from side to side to facilitate the removal of peritoneal drainage. The head of the bed may also be elevated.13.If the drainage stops, or starts to drip before the dialyzing fluid has run out, the catheter tip may be buried in the omentum. Rotating patient may be helpful (or the physician may need to reposition the catheter).

14.Ascertain catheter patency. Check for closed clamp, kinked tubing, or air lock. Never push the catheter in.14.Pushing the catheter in introduces bacteria into the peritoneal cavity.

15.When the outflow drainage ceases to run, clamp off the drainage tube and infuse the next exchange, using strict aseptic technique.

16.Take blood pressure and pulse every 15 minutes during the first exchange and every hour thereafter. Monitor the heart rate for signs of dysrhythmia.16.A drop in blood pressure may indicate excessive fluid loss from glucose concentrations of the dialyzing solutions. Changes in the vital signs may indicate impending shock or overhydration.

17.Take patient's temperature every 4 hours (especially after catheter removal).17.An infection is more apt to become evident after dialysis has been discontinued.

18.The procedure is repeated until the blood chemistry levels improve. The usual duration for short-term dialysis is 48-72 hours. Depending on patient's condition, 48-72 exchanges will be necessary.18.The duration of dialysis depends on the severity of the condition and on the size and weight of patient.

19.Keep an exact record of patient's fluid balance during the treatment.19.Complications (circulatory collapse, hypotension, shock, and death) may occur if patient loses too much fluid through peritoneal drainage. Large fluid losses around the catheter may not be noted unless the dressings are checked carefully.

a.Know the status of patient's loss or gain of fluid at the end of each exchange. Check dressing for leakage and weight on gram scale if significant.

b.The fluid balance should be about even or should show slight fluid loss or gain, depending on patient's fluid status.

20.Promote patient comfort during dialysis.20.The dialysis period is lengthy, and patient becomes fatigued.

a.Provide frequent back care and massage pressure areas.a.Pain may be caused by the dialyzing solution not being at body temperature, incomplete drainage of the solution, chemical irritation, pressure by the catheter, peritonitis, or air pressing on the diaphragm, causing referred shoulder pain.

b.Have patient turn from side to side.

c.Elevate head of bed at intervals.

d.Allow patient to sit in chair for brief periods if condition permits (only with surgically implanted catheter; with trocar, patient is usually on bed rest).

21.Observe for the following:21.Leakage around the catheter predisposes patient to infection at the exit site and peritonitis. Dialysis may need to be terminated if leakage persists.

a.Abdominal painnote the time of discomfort during exchange cycle and duration of symptoms.

b.Dialysate leakagechange the dressings frequently, being careful not to dislodge the catheter; use sterile plastic drapes to prevent contamination.

c.Place the patient in a more upright position and use smaller fluid volumes to try to relieve pain and leakage.

22.Keep accurate records.22.For proof of effectiveness of therapy and for continuity of care.

a.Exact time of beginning and end of each exchange: starting and finishing time of drainage

b.Amount of solution infused and recovered

c.Fluid balance

d.Number of exchanges

e.Medications added to dialyzing solution

f.Predialysis and postdialysis weight, plus daily weight

g.Level of responsiveness at beginning, throughout, and at end of treatment

h.Assessment of vital signs and patient's condition

COMPLICATIONS

Nursing ActionRationale

1.Peritonitis1.Peritonitis is the most common complication. Antibiotics may be added to dialysate and also given systemically.

a.Watch for nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity, and cloudy dialysate drainage.

b.Send specimen of dialysate for white blood cell count and full set of cultures.

2.Bleeding2.A small amount of bleeding around the catheter is not significant if it does not persist. During the first few exchanges, blood-tinged fluid from subcutaneous bleeding is not uncommon. Small amounts of heparin may be added to inflow solution to prevent the catheter from becoming clogged.

a.Hematocrit of the drainage fluid may be taken to determine the amount of bleeding.

Advantages Over Hemodialysis Physical and psychological freedom and independence

More liberal diet and fluid intake

Relatively simple and easy to use

Satisfactory biochemical control of uremia

COMPLICATIONS Infectious peritonitis, exit-site and tunnel infections.

Noninfectious catheter malfunction, obstruction, dialy-sate leak.

Peritoneal pleural communication, hernia formation.

GI bloating, distention, nausea.

Hypervolemia, hypovolemia.

Bleeding at catheter site.

Bloody effluent secondary to internal bleeding. In female patients, this may occur during menstruation.

Obstruction may occur if omentum becomes wrapped around the catheter or the catheter becomes caught in a loop of bowel.

PATIENT EDUCATION The use of CAPD as a long-term treatment depends on prevention of recurring peritonitis.

Use strict aseptic technique when performing bag exchanges.

Perform bag exchanges in clean, closed-off area without pets and other activities.

Wash hands before touching bag.

Inspect bag, tubing for defects and leaks.

Do not omit bag changes this will cause inadequate control of renal failure.

Some weight gain may accompany CAPD the dialysate fluid contains a significant amount of dextrose, which adds calories to daily intake.

Report signs and symptoms of peritonitis cloudy peritoneal fluid, abdominal pain or tenderness, malaise, feverNURSING MANAGEMENT

MEETING PSYCHOSOCIAL NEEDS

In addition to the complications of PD previously described, patients who elect to do PD may experience altered body image because of the presence of the abdominal catheter, bag, tubing, and cycler. Waist size increases from 1 to 2 inches (or more) with uid in the abdomen. This affects clothing selection and may make the patient feel fat. Body image may be so altered that patients do not want to look at or care for the catheter for days or weeks. The nurse may arrange for the patient to talk with other patients who have adapted well to PD.

Patients undergoing PD may also experience altered sexuality patterns and sexual dysfunction. Although these problems may resolve with time, some problems may warrant special counseling. Questions by the nurse about concerns related to sexuality and sexual function often pro-vide the patient with a welcome opportunity to discuss these issues and a rst step toward their resolution.PROMOTING HOME AND COMMUNITY-BASED CARE

TEACHING PATIENTS SELF-CARE

Patients are taught as inpatients or outpatients to perform PD once their condition is medically stable. Training usually takes 5 days to 2 weeks. Patients are taught according to their own learning ability and knowledge level. Because of protein loss with continuous PD, the patient is instructed to eat a high-protein, well-balanced diet. The patient is also encouraged to increase his or her daily ber intake to help prevent constipation, which can impede the ow of dialysate into or out of the peritoneal cavity. Many patients gain 3 to 5 lb within a month of initiating PD, so they may be asked to limit their carbohydrate intake to avoid excessive weight gain. Potassium, sodium, and uid restrictions are not usually needed. Patients commonly lose about 2 to 3 L of fluid over and above the volume of dialysate infused into the abdomen during a 24-hour period, permitting a normal uid intake even in an anephric patient (a patient without kidneys).CONTINUING CARE

If a referral is made for home care, the home care nurse assesses the home environment and suggests modications to accommodate the equipment and facilities needed to carry out PD. In addition, the nurse assesses the patients and familys understanding of PD and evaluates their technique in performing PD. Assessments include checking for changes related to renal disease, complications such as peritonitis, and treatment-related problems such as heart failure, inadequate drainage, and weight gain or loss. The nurse continues to reinforce and clarify teaching about PD and renal disease and assesses the patients and familys progress in coping with the procedure.

SPECIAL CONSIDERATIONS: NURSING MANAGEMENT OF THE HOSPITALIZED PATIENT ON DIALYSIS

PROTECTING VASCULAR ACCESSWhen the patient undergoing hemodialysis is hospitalized for any reason, care must be taken to protect the vascular access. The nurse assesses the vascular access for patency

TAKING PRECAUTIONS DURING INTRAVENOUS THERAPY

When the patient needs IV therapy, the rate of administration must be as slow as possible and should be strictly controlled by a volumetric infusion pump. Because patients on dialysis cannot excrete water, rapid or excessive administration of IV uid can result in pulmonary edema. Accurate intake and output records are essential.

MONITORING SYMPTOMS OF UREMIA

As metabolic end products accumulate, symptoms of uremia worsen. Patients whose metabolic rate accelerates (those receiving corticosteroid medications or parenteral nutrition, those with infections or bleeding disorders, those undergoing surgery) accumulate waste products more quickly and may require daily dialysis. These same patients are more likely than other patients receiving dialysis to experience complications.

DETECTING CARDIAC AND RESPIRATORY COMPLICATIONS: Cardiac and respiratory assessment must be conducted frequently. As uid builds up, uid overload, heart failure, and pulmonary edema develop. Crackles in the bases of the lungs may indicate pulmonary edema. Pericarditis may result from the accumulation of uremic toxins. If not detected and treated promptly, this serious complication may progress to pericardial effusion and cardiac tamponade. Pericarditis is detected by the patients report of substernal chest pain (if the patient can communicate), low grade fever (often overlooked), and pericardial friction rub. A pulsus paradoxus (a decrease in blood pressure of more than 10 mm Hg during inspiration) is often present. When pericarditis progresses to effusion, the friction rub disappears, heart sounds become distant and muffled, ECG waves show very low voltage, and the pulsus paradoxus worsens. The effusion may progress to life threatening cardiac tamponade, noted by narrowing of the pulse pressure in addition to mufed or inaudible heart sounds, crushing chestpain, dyspnea, and hypotension. Although pericarditis, pericardial effusion, and cardiac tamponade can be detected by chest x-ray, they should also be detected through astute nursing assessment. Because of their clinical signicance, assessment of the patient for these complications is a priority.

CONTROLLING ELECTROLYTE LEVELS AND DIET

Electrolyte alterations are common, and potassium changes can be life-threatening. All IV solutions and medications to be administered are evaluated for their electrolyte content. Serum laboratory values are assessed daily. If blood transfusions are required, they may be administered during hemodialysis, if possible, so that excess potassium can be removed. Dietary intake must also be monitored. The patients frustrations related to dietary restrictions typically increase if the hospital food is unappetizing. The nurse needs to recognize that this may lead to dietary indiscretion and hyperkalemia. Hypoalbuminemia is an indicator of malnutrition in patients undergoing long-term or maintenance dialysis. Although some patients can be treated with adequate nutrition alone, some patients remain hypoalbuminemic for reasons that are poorly understood.

MANAGING DISCOMFORT AND PAIN

Complications such as pruritus and pain secondary to neuropathy must be managed. Antihistamine agents, such as diphenhydramine hydrochloride (Benadryl), are commonly used, and analgesic medications may be prescribed. How ever, because elimination of the metabolites of medications occurs through dialysis rather than through renal excretion, medication dosages may need to be adjusted. Keeping the clean and well moisturized using bath oils, super fatted soap, and creams or lotions helps promote comfort and reduce itching. Teaching the patient to keep the nails trimmed to avoid scratching and excoriation also promotes comfort.

MONITORING BLOOD PRESSURE

Hypertension in renal failure is common. It is usually the result of uid overload and, in part, over secretion of renin. Many patients undergoing dialysis receive some form of antihypertensive therapy and require ongoing teaching about its purpose and adverse effects. The trial and error approach that may be necessary to identify the most effective antihypertensive agent and dosage may confuse the patient if no explanation is provided. Antihypertensive agents must be withheld before dialysis to avoid hypotension due to the combined effect of the dialysis and the medication. Typically these patients require single or multiple antihypertensive agents to achieve normal blood pressure, thus adding to the total number of medications needed on an ongoing basis.

PREVENTING INFECTION

Patients with ESRD commonly have low WBC counts (and decreased phagocytic ability), low RBC counts (anemia), and impaired platelet function. Together, these pose a high risk for infection and potential for bleeding after even minor trauma. Preventing and controlling infection are essential because the incidence of infection is high. Infection of the vascular access site and pneumonia are common. Preventing Infection Patients with ESRD commonly have low WBC counts (and decreased phagocytic ability), low RBC counts (anemia), and impaired platelet function. Together, these pose a high risk for infection and potential for bleeding after even minor trauma. Preventing and controlling infection are essential because the incidence of infection is high. Infection of the vascular access site and pneumonia are common.

CARING FOR THE CATHETER SITE

Patients receiving CAPD usually know how to care for the catheter site; however, the hospital stay is an opportunity to assess catheter care technique and correct misperceptions or deviations from recommended technique. Recommended daily or three or four times weekly routine catheter site care is typically performed during showering or bathing .The exit site should not be submerged in bath water. The most common cleaning method is soap and water; liquid soap is recommended. During care, the nurse and patient need to make sure that the catheter remains secure to avoid tension and trauma. The patient may wear a gauze or semi transparent dressing over the exit site.

ADMINISTERING MEDICATIONS

All medications and the dosage prescribed for any patient on dialysis must be closely monitored to avoid those that are toxic to the kidneys and may threaten remaining renal function. Medications are also scrutinized for potassium and magnesium content, because medications containing potassium or magnesium must be avoided..

PROVIDING PSYCHOLOGICAL SUPPORT Patients undergoing dialysis for a while may begin to re evaluate their status, the treatment modality, their satisfaction with life, and the impact of these factors on their families and support systems. Nurses must provide opportunities for these patients to express their feelings and reactions and to explore options. These feelings and reactions must be taken seriously, and the patient should have the opportunity to discuss them with the dialysis team as well as with a psychologist, psychiatrist, psychiatric nurse, trusted friend, or spiritual advisor. The patients informed decision about discontinuing treatment, after thoughtful deliberation, should be respected.

NURSING DIAGNOSIS1) Ineffective airway clearance related to pain of abdominal incision, abdominal discomfort, and immobility; risk for ineffective breathing pattern related to high abdominal incision

GOAL: Improved airway clearance

Nursing Interventions

1. Administer analgesic agent as prescribed.

RATIONALE: Enables patient to take deep breaths and cough

2. Splint incision with hands or pillow to assist patient in coughing.

Rationale:Splints incision and promotes adequate cough and prevention of atelectasis

3. Assist patient to change positions frequently.

Rationale:Promotes drainage and ination of all lobes of the lungs4Encourages adequate deep breaths.Rationale: Encourage use of incentive spirometer if indicated or prescribed.5. Assist with and encourage early ambulation.Rationale: Mobilizes pulmonary secretions

2)Acute pain and discomfort related to positioning, and stretching of muscles during procedure

GOAL: Relief of pain and discomfort

Nursing Interventions

1. Assess level of pain.

Rationale: Provides baseline for later evaluation of pain relief strategies

2. Administer analgesic agents as prescribed.

Rationale: Promotes pain relief

3. Splint incision with hands or pillow during movement or deep breathing and coughing exercises.

Rationale: Minimizes sensation of pulling or tension on incision and provides sense of support to the patient4. Assist and encourage early ambulation.

Rationale: Promotes resumption of muscle activity exercise

3)Fear and anxiety related to diagnosis, outcome of surgery, and alteration in urinary function

GOAL: Reduction of fear and anxiety

1. Assess patients anxiety and fear before surgery if possible.

Rationale: Provides a baseline for postoperative assessment

2. Assess patients knowledge about procedure .

Rationale: Provides a basis for further teaching3. Evaluate the meaning of alterations resulting from procedure for the patient and family or partner.

Rationale: Enables understanding of patients reactions and responses to expected and unexpected results of procedure.

4. Encourage patient to verbalize reactions, feelings, and fears.

Rationale: Afrms patients understanding of and ultimate resolution of feelings and fears

5. Encourage patient to share feelings with spouse or partner.

Rationale: Enables patient and partner to receive mutual support and reduces sense of isolation from each other.

6) Offer and arrange for visit from member of support group (eg, os-tomy group, if indicated).

Rationale: Provides support from another person who has encountered the same or a similar procedure and an example of how others have coped with the alteration.REVIEW OF LITERATUREContinuous Ambulatory Peritoneal Dialysis

1. ROBERT P. POPOVICH, Ph.D.;

2. JACK W. MONCRIEF, M.D.;

3. KARL D. NOLPH, M.D., F.A.C.P.;

4. AHAD J. GHODS, M.D.;

5. ZBYLUT J. TWARDOWSKI, M.D.; and

6. W. K. PYLEAbstract

The technique of continuous ambulatory peritoneal dialysis was evaluated in nine patients during 136 patient weeks. The major objectives were to see if continuous ambulatory peritoneal dialysis would provide [1] acceptable control of serum chemistries by usual criteria, [2] adequate removal of sodium and water, [3] tolerable protein losses, and [4] a low prevalence of peritonitis with episodes responsive to therapy with continuing continuous ambulatory peritoneal dialysis. Preliminary findings suggest continuous ambulatory peritoneal dialysis represents an effective ambulatory, portable, internal dialysis technique. Larger solute clearances per week may approach values six times greater than with most hemodialysis techniques. Small-solute clearances approach dialysate flow rate (8.3 ml/min) and are comparable to other dialysis techniques on a weekly basis. Edema is readily controlled and protein losses should be tolerable with adequate protein intake. Peritonitis occurs on the average every 10 weeks but responds to therapy promptly with continuing continuous ambulatory peritoneal dialysis. If the prevalence of peritonitis can be reduced, continuous ambulatory peritoneal dialysis appears to represent a very attractive dialysis technique.

PROTEIN LOSSES DURING PERITONEAL DIALYSIS

Michael JBlumenkrantz, Gerhard MGahl, Joel DKopple, Anjana VKamdar, Michael RJones, MichaelKessel and Jack WCoburn

ABSTRACT

Protein losses during peritoneal dialysis. The losses of protein into dialysate have been considered a major limitation of maintenance peritoneal dialysis. We, therefore, undertook a comprehensive evaluation of protein losses in 30 patients undergoing maintenance intermittent peritoneal dialysis (IPD), 12 patients undergoing acute IPD, and 8 patients undergoing continuous ambulatory peritoneal dialysis (CAPD). The weekly loss of protein based upon the usual treatments per week was relatively similar with the three modes of dialysis. Protein losses during repeated dialyses were similar for a given patient, but there was marked interpatient variation. During maintenance IPD, protein loss was 12.9(sd) 4.4 g per 10 hours of dialysis; albumin loss was 8.5 g, and IgG loss was 1.3 g. Approximately 50% of the protein loss was from the ascitic fluid accumulated during the interdialytic interval, and concentrations of most proteins in the ascitic fluid correlated with their serum levels. Serum protein concentrations were in the low, normal range and did not change during dialysis. The development of peritonitis markedly increased protein losses. During acute IPD, 23.316.5 g of protein were lost per 36 hours of dialysis, lower losses than those previously reported. With CAPD, 8.81.7 g of protein were removed per 24 hours; also immunoglobulin losses correlated with their serum concentrations. The results of these studies suggest that, in the absence of peritonitis, dialysate protein losses do not appear to limit the usefulness of peritoneal dialysis.CONCLUSIONPD is especially indicated for the individual who has vascular access problems or responds poorly to the hemodynamic stresses of HD(e.g the older adult patient with diabetes and cardiovascular disease)the diabetic patient with ESRD does better with PD than with HD. The advantage of PD for the diabetic patient include better BP control , less hemodynamic instabilityBIBLIOGRAPHY

Black m Joyce ,Jane hokanson,Medical surgical nursing. 7th edition.Missouri: Elsevier publications.2005. pageno:

Lewis Sharon manic,Heitkemper,Medical surgical nursing. 6th edition. Missouri:Elsevier publication.2004.page no:

Lippincott. Manual of nursing practice .7th edition. International student edition:Philadelphia:page no:.

NET REFERENCE

When your patient needs peritoneal dialysis by EDEN ZABT .Nursing 2003,volume 33.

An introduction to peritoneal dialysis :renal resource centere 2010/www. Renal.resource.com.

AVAILABLE FROM:www.angelfire .com.

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