29 Care of the patient undergoing peritoneal dialysis

Overview/pathophysiology

Peritoneal dialysis uses the peritoneum as the dialysis membrane. Dialysate is instilled into the peritoneal cavity via a catheter surgically placed in the abdominal wall. Once the dialysate is within the abdominal cavity, movement of solutes and fluid occurs between the patient’s capillary blood and the dialysate. At set intervals, the peritoneal cavity is drained and new dialysate is instilled.

Indications for peritoneal dialysis:

Episodes of renal insufficiency that cannot be managed by diet, medications, and fluid restriction; end-stage renal disease (ESRD); drug overdose; hyperkalemia; fluid overload; and metabolic acidosis.

Components of dialysis

Catheter:

Silastic tube that is either implanted using general anesthesia as a surgical procedure for patients who will have long-term treatment or is inserted using local anesthetic at the bedside for short-term dialysis.

Dialysate:

Sterile electrolyte solution similar in composition to normal plasma. The electrolyte composition of the dialysate can be adjusted according to individual need. Glucose is added to the dialysate in varying concentrations to remove excess body fluid via osmosis. Note: Some glucose crosses the peritoneal membrane and enters the patient’s blood. Patients with diabetes mellitus may require additional insulin. Observe for and report indicators of hyperglycemia (e.g., complaints of thirst, changes in sensorium). Insulin and other medications may be added directly to the dialysate by dialysis nurses.

Types of dialysis

Continuous ambulatory peritoneal dialysis (CAPD):

Using sterile technique, the patient attaches a new bag of dialysate to the peritoneal catheter, allows the dialysate to drain out, and then allows new dialysate to drain in. The patient then clamps the catheter and places a new cap on the tubing using sterile technique. This process is repeated q4-6h (8 hr at night), 7 days/wk. CAPD is used primarily for ESRD.

Continuous cycling peritoneal dialysis (CCPD):

This is a combination of intermittent peritoneal dialysis (IPD) and CAPD. A cycler performs three dialysate exchanges at night. In the morning, a fourth exchange is instilled and left in the peritoneal cavity for the entire day. At the end of the day, the fourth exchange is allowed to drain out and the process is repeated. The patient is ambulatory by day and restricted to bed at night. CCPD is commonly done every night.

Health care setting

Home setting; acute care if patient has complications

Nursing diagnosis:

Risk for infection

related to invasive procedure (direct access of the catheter to the peritoneum)

Desired Outcomes: Patient is free of infection as evidenced by normothermia and absence of the following: abdominal pain, cloudy outflow, nausea, malaise, erythema, edema, increased local warmth, drainage, and tenderness at the exit site. Before hospital discharge, patient verbalizes signs and symptoms of infection and need for sterile technique for bag, tubing, and dressing changes.

ASSESSMENT/INTERVENTIONS	RATIONALES
Assess for and report indications of peritonitis (see “Peritonitis,” p. 442).	The most common complication of peritoneal dialysis is peritonitis. Indicators include fever, abdominal pain, distention, abdominal wall rigidity, rebound tenderness, cloudy outflow, nausea, and malaise.
Assess color and clarity of dialysate following outflow.	Bloody and cloudy outflow or the presence of fibrin in the outflow may be an initial sign of peritonitis. Note that bloody outflow may occur in female patients during menstruation.
Assess for and report redness, local warmth, edema, drainage, or tenderness at exit site. Culture any exudate, and report results to health care provider.	These are signs of infection at the exit site.
Maintain sterile technique when adding medications to dialysate.	To minimize risk of peritonitis and other infections, the dialysate must remain sterile because it is instilled directly into the body.
Follow agency policy for care of catheter exit site.	Exit site infections may lead to development of peritonitis.
Report to health care provider if dialysate leaks around catheter exit site.	This leakage can signal an obstruction or need for another purse-string suture around catheter site. Leakage around the exit site has been associated with increased risk of tunnel infections, exit site infections, and peritonitis. Organisms may track through subcutaneous tissue into the peritoneum, causing infection.
Instruct patient in the preceding interventions and observations if peritoneal dialysis will be performed after hospital discharge.	An informed patient likely will adhere to infection prevention interventions and know when to report untoward signs to health care provider.

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