PERITONEAL DIALYSIS
Peritoneal dialysis is a substitute for kidney function during renal failure. The "peritoneum acts as a dialyzing membrane and dialysate is delivered into the peritoneal cavity
Preparation
1.Prepare Patient emotionally and physically.
2.Obtain consent, weight, vital signs before the dialysis.
3.Empty bladder and bowel.
4.Flesh tubing with dialysis Solution.
5.Make Patient comfortable in supine position.
Procedure
1. Prepare abdomen surgically.
2. Under Local Anaesthesia, a small midline stab wound is made 3-5cms. below the umbilicus.
3. Trocar is inserted with the stillet [Patient is requested to raise head from the pillow after the trocar is introduced. (This manoeuvre tightens the abdominal muscles and permits easier penetration of the trocar with danger of injury to the intra-abdominal organs)]
4. When peritoneum is punctured, the trocar is directed towards the left side of the pelvis. Stylet is removed and the catheter is inserted through the trocar. [Dialysis fluid is allowed to run thro the catheter while it is being positioned. This prevents the omentum from adhering to the catheter, impeding its advancement or occluding its opening].
5. After the trocar is removed, skin may be closed with a purse - string suture. A sterile dressing is placed around the catheter [the catheter is attached to the skin to prevent loss of the catheter in the abdomen].
6. Catheter is connected to the sterile tubing system and anchored to the abdomen. [The solution is warmed to body temperature for Patient comfort and to prevent abdominal pain. Hearing also causes dilatation of the peritoneal vessels and increases clearance]
7. Drugs (heparin, potassium, antibiotic) are added in advance. [Heparin prevents fibrin clots from occluding the catheter. Potassium chloride added on request unless Patient has hyperkalaemia. Antibiotics treatment of peritonitis.].
PHASES- Peritoneal Dialysis Cycles
1. INFLOW (FILL) Permit dialyzing solution to flow unrestricted into the peritoneal cavity 5-10 mins. Slow the infusion, if Patient experiences pain. After infusing, close clamp to prevent air entry.
[The inflow solution Should flow in a steady stream, if the fluid flows in too slowly the catheter may need be repositioned, because its tip may be buried in the omentum or it may be occluded by a blood clot. Flushing may help.]
2. DEWELL (EQUILIBRATION) Diffusion and osmosis occurs between the blood and peritoneal cavity. Fluid remains in the peritoneal cavity for the prescribed time period 20-30 mins. [For K, urea and other waste materials to be removed, the solution must remain in the peritoneal cavity for the prescribed time. The maximum concentration gradient takes place in the first 5-10 min for small molecules, such as urea and creatinine.]
3. DRAIN Unclamp outflow tube, to drain-20-30 mins. [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 - coloured. When outflow drainage ceases to run, clamp off the drainage tube and infuse the next exchange
The cycle begins again.
Nursing Management
1. Check outflow for cloudy appearance, blood / or fibrin. [May be early signs of peritonitis).
2. If the fluid is not draining properly, move the Patient from side to side to facilitate the removal of peritoneal drainage The head of the bed may also be elevated.
3. Ascertain if the catheter is patent. Check for closed clamp, kinked tubing or air lock. Never push the catheter in [introduces bacteria into the peritoneal cavity).
4 Monitor BP and pulse every 15 mins during the 1" exchange and every hour thereafter [HR for signs of dysrhythmia (A drop in BP may indicate excessive fluid less from glucose concentrations of the dialyzing solutions. Changes in vital signs may indicate impending shock er overhydration)].
5. The procedure is, repeated until the blood chemistry levels improve. The usual duration for short-term dialysis is 48-72 hrs.
6. Keep an exact record of patients fluid balance during the treatment. Know the status of the Patients loss or gain of fluid at the end of each exchange. Check dressing for leakage [ and weight on gram scale if significant (complications circulatory collapse, hypotension, shock and death; may occur if the Patient less tee much fluid through peritoneal drainage)]
7. Promote Patient comfort during dialysis.
a. Provide frequent back care and massage pressure areas.
b. Have the Patient turn from side to side.
c. Elevate the bed at intervals.
d. [Allow the Pt to sit in chair for brief periods if condition permits (only with surgically implanted catheter with trocar, Patient is usually on bed rest). The dialysis period is lengthy and the Patient becomes fatigued].
8. Observe for abdominal pain (pain may be caused by the dialyzing solutions not being at body temp, incomplete drainage of the solution, chemical irritation, pressure by the catheter, peritonitis, or air pressing on the diaphragm.] dialysate leakage.
9. Keep accurate records exact time of beginning, a end of each exchange: starting finishing time of drainage and amount of solution infused of recovered.
Complications - Peritonitis, Bleeding
Continuous Ambulatory Peritoneal Dialysis (CAPD) is a form of dialysis for Patients with end stage renal disease who want to take an active part in their home treatment. It is performed at bone by the Patient. A permanent indwelling catheter is implanted into the peritoneum; the internal cuff of the catheter becomes embedded by fibrous ingrowth, which stabilizes it and minimizes leakage. The dialysate (2L) is infused by gravity for 10 mins. Typical dwell time is 4-6 Hrs. Drainage of 2L plus ultrafiltration takes about 10-20 mins. The Patient performs 4-5 exchanges daily, 7 days a week with an overnight dwell time allowing uninterrupted sleep.
Continuous Cycler Peritoneal Dialysis (CCPD), is a combination of overnight intermittent peritoneal dialysis with a prolonged dwell during the day. The pt is connected to a cycler machine every evening at receives 3-5 2L exchanges during the night; in the morning the Patient caps off the catheter after infusing 1-2 L of fresh dialysate. This Des infection rate and permits the Patient to be free of exchanges.
