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Today’s ScheduleWhat is peritoneal dialysis?

Access

Three stages to PD

Troubleshooting

Documentation

Sampling

Exit site care

Infection

Getting supplies

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Basics of peritoneal dialysisPeritoneal dialysis utilizes the peritoneal membrane to act as a dialysis membrane due to the rich blood supply and large surface area that it covers in the abdominal cavity

Dialysate solution containing glucose and solutes instilled through a catheter into the abdominal cavity

Excess fluid and waste products can be removed through the processes of diffusion and osmosis

Why is osmosis important?

The osmolarity of dextrose solution dictates how much fluid is removed during PDThe lower the glucose concentration, the less fluid removedSolutions available in 1.5%, 2.5%, 4.25% and Icodextrin (7.5%)

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What is removed from the peritoneum?From the internal circulation INTO the peritoneal cavity…

Water

Urea

Chloride

Sodium

Potassium

Creatinine

Five necessary componentsPatent catheter access to the peritoneum

Adequate peritoneal surface area

Adequate peritoneal capillary blood flow

Peritoneal dialysis solution

Adequate solution delivery system

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Peritoneal Dialysis CatheterPlaced in OR

May take up to 6 weeks for catheter tract to heal and catheter to be securely positioned in the pelvis

Catheter should not be used until 2 weeks post-op

BaxterShadyside uses the Baxter system

The system is easily identifiable because of the light blue cap on the catheter

Conversion kits are available to convert any other brand catheter to the Baxter system while the patient is in the hospital

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Getting readyAssess your patient

Vital signs

Estimated dry weight vs. today’s weight

Edema

I & Os

Lung sounds

Abdominal pain/distention

Three phases of peritoneal dialysis

DRAIN

FILL

DWELL

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Drain the patient

Average 20 minutes to drain, though may take up to one hourObserve the effluent for clarity

Cloudy? Possible infection- might need antibioticsFibrin? Protein sloughing- might just need heparinBloody? In women this may be normal during menses,

otherwise ABNORMAL

Normal is clear, yellow effluentIf it is not clear, CALL NEPHROLOGIST

Not draining as expected? This is where most troubleshooting occurs

Fill the patientTakes about 5-20 minutes to fill

Time of instillation depends on patient condition and volume of dialysate solution to be infused

Try to maximize fill volume , but be aware of patient size and comfort during the fill

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DwellMaximize dwell times to improve clearance

Factors affecting solute diffusion Surface area

Peritoneal permeability

Solute characteristics

Concentration gradient

Temperature of dialysis solution

Capillary blood flow

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TROUBLESHOOTING

PROBLEM CAUSE WHAT TO DORestlessness, numbness, 

tingling, itching Underdialyzed Check chemistries and notify nephrologist

Inadequate outflow Constipation, fribrin plug, partially closed clamps or kinks

May need enema or stoolsoftener, inspect for fibrin 

clots in bag, check for kinked/clamped tubing

Hypertension Too much sodium/fluid 

Check patient weights for significant loss or gain. 

Notify MD for need to restrict sodium and fluid intake

Shoulder pain Air in peritoneal cavity, inflow too fast, catheter positional

Prime the transfer set tubing before infusion, slow the rate 

of infusion, notify nephrologist of pain

Muscle cramps Excessive removal of sodium and fluid

Application of heat or massage may relieve pain, give saltines or broth, call renal MD for change in % or alternate with a lower 

dextrose %

Headache Hypertension, anxiety

Call Renal MD if hypertension persits after ultrafiltrationand/or administration of BP 

medication

Weak, shaky, sweaty, hypotension

Excessive removal of fluid and/or hypoglycemia

Check blood glucose, call Renal MD

Bleeding from exit site or bloody effluent

Catheter exit site infection, small capillary rupture from 

abdominal straining or menstrual cycle

Call Renal MD  

Nausea and vomiting Hypertension, hypotension, or peritonitis

Assess patient temperature, assess effluent for cloudiness, 

call renal MD

Rectal pain Catheter position Decrease inflow, positional change, notify Renal MD

Shortness of breath Fluid overloaded, anemiaCheck patient weights for 

significant loss or gain; check HCT; notify renal MD

TROUBLESHOOTING cont.

Fever PeritonitisAssess effluent for cloudiness, assess abdomen for pain or distension, call Renal MD

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DocumentationPrint PD Flow Sheet from Print on DemandDocument vital signs in eRecordDocument daily weight in eRecord and on flow sheet Start flow sheet with first AM exchange (usually 6 or 7am)ALWAYS start with a “drain”Document volume drained and appearance of effluentTHE VOLUME DRAINED SUBTRACTED FROM THE VOLUME INSTILLED WITH THE LAST EXCHANGE =

ACTUAL PATIENT FLUID REMOVALDocument this amount in I&O as Actual Patient Fluid Removal (found under ultrafiltrate)

Document dialysate concentration, volume instilledDocument output after EVERY exchange

Sending Effluent SamplesGather povidine iodine solution and 4 x 4s or betadine swabs, blood culture bottles, two lavender top tubes, 30cc syringe, 18 gauge needle, and pink vacutainer needleless transfer device

AFTER the fill stage, put a clamp on the short “Y” connector tubing next to the patient connector

Aseptically disconnect the system from the patient and cap off patient

Reverse the position of the bags by placing the full drain bag higher than the empty fill bag.

Allow enough effluent necessary for samples ordered to drain back into dialysate bag and then clamp tubing

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Sending Effluent SamplesScrub the medication injection port with betadine and allow at least 5 minutes to dry

Use sterile gauze to absorb and remove excess povidineiodine that may be on the sampling port

Insert needle attached to syringe into the sampling port and withdraw effluent amount needed for test

Inject 10 cc into each blood culture bottle using the pink needless vacutainer

Inject remainder of effluent into the two lavender top tubes

Label and send specimens to the lab

Medication AdditivesMedications usually added: Heparin, antibiotics, potassium and/or insulin

Pharmacy will mix additives when ordered

INSULIN

ANTIBIOITICS

HEPARIN

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Exit site careInspect catheter exit site and tunnel at least every shift and before and after each exchange

Cleanse the site Every Day

Cleanse prn if site appears dirty or wet

Use antibacterial cleansing agent such as soapy water to clean and wash off residue

Do not forcibly remove rust, scab, or cuticle

Apply antibacterial ointment as ordered

Cover with non-occlusive sterile 4X4 gauze

Immobilize catheter

Infection#1 concern with peritoneal dialysis

Reason why gloves, masks, and controlled environment are essential for exchange

Pus exudate- INFECTION

Red/pink = NORMAL

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Where do I get supplies?Pharmacy will fill and dispense all PD solutions to the nursing unit with a patient medication label attached

Take the 4 West PD cart to the patient room (leave cart outside room is patient is in isolation)

If the 4 West cart is in use, obtain a cart from 6 Main

A heater should be kept with each cart

Get replacement supplies from the PD stock room on 6 Main

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ReferencesBlake P & Daugirdas J, Physiology of peritoneal dialysis. In: Daugirdas J, Blake P, Ing T, 

eds. Handbook of Dialysis, 3rd ed. New York, NY: Lippincott Williams & Williams: 2001, 281‐296. 

Chow KM, Szeto CC, Law MC, Fun Fung JS, Kama‐Tao Li P. Influence of peritoneal dialysis training nurses' experience on peritonitis rates. Clin J Am Soc Nephrol. 2007;2(4):647‐52.

Chow SK, Wong FK. Health‐related quality of life in patients undergoing peritoneal dialysis: effects of a Farina J. Peritoneal dialysis: strategies to maintain competency for acute and extended care nurses. Nephrol Nurs J. 2008;35(3):271‐5.

Farina J. When PD is the only choice... A trusting relationship between nurse and patient fosters positive outcomes! Nephrol Nurs J. 2004 Sep‐Oct;31(5):590‐1.

Finkelstein FO, Ezekiel OO, Raducu R. Development of a peritoneal dialysis program. Blood Purif. 2011;31(1‐3):121‐4. 

Grapsa EI, Klimopoulos S, Tseke P, Papaioannou N, Tzanatos H. Peritoneal dialysis without a physical peritoneal dialysis unit. Clin Nephrol. 2010 Jun;73(6):449‐53.

Korbet SM. Acute peritoneal dialysis prescription. In: Daugirdas J, Black P, Ing T, eds. Handbook of Dialysis, 4th ed New York, NY. Lippincott Williams & Williams; 2007, 376‐386.

Leung DK. Psychosocial aspects in renal patients. Perit Dial Int. 2003;23 Suppl 2:S90‐4.

Luongo M, Knotek B, Biel L. Peritoneal Dialysis Nurse Resource Guide. Nephrol Nurs J. 2003 Oct;30(5):535‐64.

Maaz DE. Troubleshooting non‐infectious peritoneal dialysis issues. Nephrol Nurs J. 2004 Sep‐Oct;31(5):521‐32, 545.

McCarthy A, Cook PS, Fairweather C, Shaban R, Martin‐McDonald K. Compliance in peritoneal dialysis: a qualitative study of renal nurses. Int J Nurs Pract. 2009 15(3):219‐26.

McCarthy A, Shaban R, Boys J, Winch S. Compliance, normality, and the patient on peritoneal dialysis. Nephrol Nurs J. 2010 May‐Jun;37(3):243‐50.

Nasso L. Our peritonitis continuous quality improvement project: where there is a will there is a way. CANNT J. 2006;16(1):20‐3.

Prowant B. Peritoneal dialysis. In Lancaster L ed. Core Cirriculum for Nephrology Nursing. 4th ed. Pitman, NJ. American Nephrology Nurses’ Association. 2001:331‐378

Tan PC, Morad Z. Training of peritoneal dialysis nurses. Perit Dial Int. 2003;23 Sup 2:S206‐9.Taskapan H, Tam P, Leblanc D, Ting RH, Nagai GR, Chow SS, Fung J, Ng PS, Sikaneta T, 

Roscoe J, Oreopoulos DG. Peritoneal dialysis in the nursing home. Int Urol Nephrol.2010;42(2):545‐51. 

USRDS 2009 ADR reference tables. Available at www.usrds.org. Accessed 3 December 2011.Yang Z, Xu R, Zhuo M, Dong J. Advanced nursing experience is beneficial for lowering the 

peritonitis rate on peritoneal dialysis. Perit Dial Int. 2011 Jun 30. Zyga S, Sarafis P, Stathoulis J, Kolovos P, Theophilopoulos D. Acute renal failure: methods of 

treatment in the intensive care unit. J Ren Care. 2009;35(2):60‐6.

References