[Adult] Peritoneal dialysis(PD)

1. Mimics the function of the kidneys by using the peritoneum as a semipermeable membrane to filer blood and remove excess fluid, electrolytes, and waste products (eg, urea)

-involves surgical placement of a catheter through which dialysate is infused and drained

-Can be continuous or intermittent

-Complications: infection ->perionitis ->sepsis

 

2. complication

(1) Peritonitis : a result of contamination during infusion connections or disconnections.

Typically, the earliest indication of peritonitis is the presence of cloudy peritoneal effluent, low-grade fever, abdominal pain, tarchycardia and rebound tenderness.

Later manifestations include low-grade fever, chills, generalized abdominal pain, and rebound tenderness.

To detect rebound tenderness, one hand is pressed firmly into the abdominal wall and quickly withdrawn.

There is pain on removal, indicating inflammation of the peritoneal cavity.

 

3. process of each phase:

(1) Fill phase: Instillation of dialysate

(2) Dwell phase: Dialysate remains in the peritoneal cavity, allowing exchange of fluid, electrolytes, and waste products

(3) Drain phase: After prescribed amount of time, the dialysate, electrolytes, and waste products are drained via gravity.

isotonic solution.

 

4. Nursing interventions

Ensure dialysate is warm prior to administration : Never use a microwave

When accessing the dialysis catheter: Wear a mask, Use aseptic technique, Cleanse around insertion site

Ensure that dressing around the catheter site is dry: Wet = infection risk

Decrease flow rate if client is uncomfortable

Keep drainage bag below the dialysis catheter site

Notify health care provider:

-Insufficient outflow (inflow > outflow)

-Troubleshoot before contacting the HCP

• Keep the drainage bag below the client's abdomen
• Check for kinks in the tubing
• Change the position by turning the client to a side-lying position or by asking the client to walk
• Assess for constipation and provide options for relief such as stool softner

-Abnormal outflow characteristic: Clear goes in, clear goes out!

• Cloudy: infection
• Bloody: expected during first few exchanges; later indicates vascular issue.
• Fecal/brown: interstinal perforation

-Peritonitis. Signs of peritonitis (Tachycardia, Fever, Abdominal pain/tenderness, Cloudy effluent)

• Send cloudy fluid to the laboratory for culture and sensitivity
• Prepare to administer antibiotics

-Care and maintenance

• Sterile dressing, sterile connection ( use sterile technique when spiking and attaching the bag of dialysate)
• Sitting at a 20-degree angle during self-administering PD exchange to reduce intraabdominal pressure and prevent complications
• Self assessment: weight daily, vital signs and document

NRS action

i) culture and sesitivity from the peritoneal effluent drainage bag ->antibiotics therapy

ii) 

 

Chills and rebound tenderness are signs of infection. Further assessment!

Dialysate is typically warmed to body temperature before instillation to prevent abdominal discomfort and increase urea clearance through vessel dilation.

Dry heating with a heating cabinet or incubator rather than a microwave is recommended to reduce the danger of burning the peritoneum. The dwell time is based on the prescribed dialysis method and should not be extended without a prescription.

1. Heat the remaining dialysate fluid:
   • 의미: 남아있는 투석액을 따뜻하게 하라는 지시입니다.
   • 이유: 투석액을 체온과 비슷한 온도로 데우면 복강 내에 주입할 때 환자가 느끼는 불편함을 줄일 수 있습니다. 또한, 따뜻한 투석액은 복막의 혈류를 증가시켜 투석 효율을 높일 수 있습니다.
2. Increase the dwell time:
   • 의미: 투석액을 복강 내에 더 오래 머무르게 하라는 지시입니다.
   • 이유: 투석액이 복강 내에 머무르는 시간이 길어질수록, 노폐물과 과잉 수분이 복막을 통해 투석액으로 이동할 시간이 증가합니다. 이는 투석의 효율성을 높이고 더 많은 노폐물과 수분을 제거하는 데 도움이 됩니다.

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Case 1
BP 168/88mmHg, PR: 72 bpm

 Clients receive peritoneal dialysis due to chronic kidney failure. The client's blood pressure is likely elevated secondary to the renal failure. This assessment is important to monitor, but crackles in the lungs are the priority.

 

Case 2
Client expriencing intermittent nausea

Clients with renal failure typically have electrolyte abnormalities (eg, acidosis) that lead to nausea. 

 

Case 3
Presence of 1+ pitting edema in ankles and feet bilaterally

Edema in the extremities can also indicate volume overload. But, this could be due to many other factors. (eb. BP medications such as amlodipine) or fluid overload from kidney disease. 

 

Case 4
Crackles present in the left and right lung bases

During the instillation and dwell portions of the cycle, clients are monitored closely for indications of respiratory distress (eg. difficulty breathing, rapid respirations, crackles) that can result from instilling the dialysate too rapidly, overfilling of the abdomen, or fluid entering the thoracic cavity. Crackles can also occur if over time there is more dialysate infused then is removed. (fluid gain)

 

해석:

주기 동안 투여 및 유지 단계에서, 투석액을 너무 빠르게 주입하거나 복부에 과도하게 채우거나 액체가 흉강으로 들어가는 등의 이유로 호흡 곤란(예: 호흡 곤란, 빠른 호흡, 천명음)의 징후가 있는지 고객을 면밀히 관찰합니다. 투석액이 주입된 양보다 제거된 양이 적을 경우(체액 증가)에도 천명음이 발생할 수 있습니다.

설명:

이 문장은 투석 치료 중 특히 투여(instillation)와 유지(dwell) 단계에서 환자의 상태를 모니터링해야 하는 이유를 설명하고 있습니다.

1. 투여(instillation) 및 유지(dwell) 단계:
   • 투여 단계에서는 투석액이 복부로 주입됩니다.
   • 유지 단계에서는 투석액이 일정 시간 동안 복부에 머무릅니다.
2. 모니터링의 중요성:
   • 투석액을 너무 빠르게 주입하거나 복부를 과도하게 채우면 호흡 곤란을 초래할 수 있습니다.
   • 호흡 곤란의 징후로는 호흡 곤란(difficulty breathing), 빠른 호흡(rapid respirations), 천명음(crackles) 등이 있습니다.
3. 체액 증가로 인한 문제:
   • 장기간 투석액이 주입된 양보다 제거된 양이 적을 경우 체액이 증가할 수 있습니다. 이는 천명음을 유발할 수 있습니다.

결론적으로, 투석 과정에서 적절한 투여 속도와 양을 유지하고, 환자를 면밀히 모니터링하는 것이 중요합니다. 이는 호흡 곤란과 같은 심각한 합병증을 예방하는 데 도움이 됩니다.

 

Case 5
PD is beginning to exhibit insufficient outflow. which action should the nurse perform initially?

Assess for abdominal distention and constipation

Examine the catheter for kinks and obstructions

Please the client in a side lying position

 

EXPLAINATION) Insufficient outflow results most often from constipation when distended intestines block the catheter's holes. If outflow becomes sluggish, the nurse should assess the client's bowel patterns and administer appropriate prescribed medications (eg. stool softeners)

The nurse should assess for fibrin clots and milk the tubing to dislodge or administer fibrinolytics (eg. alteplase) as prescribed.