Download Slide 1 - rivier.instructure.com.

Management of the Adult with
Renal Failure
Renal Failure
• The loss of kidney function
• The types of renal failure include acute renal
failure and chronic renal failure are caused by
the retention of wastes, the retention of fluids
and the inability of the kidneys to regulate
electrolytes
Risks associated with renal disorders
•
•
•
•
•
•
•
•
Associated medical conditions
Contact sports
Family history of renal disease
Frequent urinary tract infections
High-sodium diets
History of hypertension
Medication use
Trauma and injury
Terms
• Oliguria
– Urine output of less than 400ml a day
• Anuria
– Urine output less than 100ml per day
• Arterial steal syndrome
• Can develop following the insertion of an AV fistula
when too much blood is diverted to the vein and
arterial perfusion to the hand is compromised
• Azotemia
• The retention of nitrogenous waste products in the
blood
Chronic Renal Failure (CRF)
– The progressive loss
and
ongoing deterioration
of kidney
function that occurs
slowly over
a period of time.
– Irreversible
– Results in uremia or
end-stage renal disease
– CRF requires dialysis or kidney transplant to
maintain life
Acute Renal Failure
• The SUDDEN loss of kidney function
• Caused by renal cell damage from ischemia or
toxic substances
• Occurs abruptly
• Reversible
• Leads to hypoperfusion, cell death, and
decomposition in renal function
• The prognosis is dependent on the cause and
condition of the patient
• Near-normal or normal kidney function may
resume gradually
Renal Failure
• Prerenal causes include
– Intravascular volume depletion
– Decreased cardiac output
– Vascular failure secondary to vasodilation or obstruction
• Intrarenal causes
– Tubular necrosis
– Nephrotoxicity
– Alterations in renal blood flow
• Postrenal causes
– Instruction of urine flow between the kidney and urethral
meatus and bladder neck obstruction
Acute Renal Failure
• Causes
–
–
–
–
–
–
–
Phases of ARF
Oliguric
Diuretic
Recovery
Infection
Renal artery occlusion
Obstruction
Acute kidney disease
Dehydration
Diuretic therapy
Ischemia from hypovolemia, heart failure, septic
shock, or blood loss
– Toxic substances such as medications, particularly
antibiotics
Acute Renal Failure
• Oliguric Phase
– Duration is 8 to 15 days
– The longer the duration,
the less chance of
recovery
– Sudden drop in urine
output less than
400mL/day
– Anorexia, nausea,
vomiting
– Hypertension
– Decreased skin turgor
– Pruritus
– Tingling of the
extremities
– Drowsiness
progressing to
disorientation to coma
– Edema
– Dysrhythmias
– Signs of CHF and
pulmonary edema
– Signs of pericarditis
– Signs of acidosis
Acute Renal Failure
• Oliguric Phase
– Glomerular Filtration Rate (GFR) decreases
– Hyperkalemia
– Sodium level normal or decreased
– Fluid overload
– Elevated BUN and Creatinine
– Urine SpGr of 1.010 to 1.016
Acute Renal Failure
• Diuretic Phase
– Urine output rises slowly and then diuresis occurs
(4 to 5 L/day)
– Excessive urine output indicates recovery of
damaged nephrons
– Hypotension
– Tachycardia
– Improvement in LOC
Acute Renal Failure
• Diuretic Phase
– Glomerular Filtration Rate begins to increase
– Hypokalemia
– Hyponatremia
– Hypovolemia
– Gradual decline in BUN and Creatinine
Acute Renal Failure
• Recovery Phase
– A slow process
– Complete recovery may take 1 to 2 years
– Urine volume is normal increase in strength
– Increase in LOC
– BUN is stable and normal
– Patient can develop CHRONIC RENAL FAILURE
Acute Renal Failure
• Recovery Phase (Convalescent)
– BUN is stable and normal
– Complete recovery may take 1 to 2 years
Chronic Renal Failure (CRF)
• The progressive loss and ongoing deterioration in kidney
function that occurs slowly over a period of time
• It occurs in stages
• IRREVERSIBLE
• Results in uremia or end-stage renal disease
• Affects all major body systems
• Requires dialysis or kidney transplant to maintain life
• Hypervolemia can occur owing to the inability of the
kidneys to excrete sodium and water, or hypovolemia
can occur owing to the inability of the kidneys to
conserve sodium and water
Chronic Renal Failure (CRF)
• Causes
– May follow ARF
– Renal artery occlusion
– Chronic urinary
obstruction
– Recurrent infections
– Hypertension
– Metabolic disorders
– Diabetes mellitus
– Autoimmune disorders
Chronic Renal Failure (CRF)
• Assessment
– Anorexia and nausea
– Headache
– Weakness and fatigue
– Hypertension
– Confusion and lethargy, followed by convulsions and
coma
– Kussmaul respirations
– Diarrhea or constipation
– Muscle twitching and numbness of the extremities
Chronic Renal Failure (CRF)
• Assessment
– Decreased urine output
– Decreased urine SpGr
– Proteinuria
– Anemia
– Azotemia
– Fluid overload and signs of heart failure
– Uremic frost: a layer of urea crystals from evaporated
perspiration that appears on the face, eyebrows, axilla,
and groin in patients with advanced uremic syndrome
Chronic Renal Failure (CRF)
• Nursing Implementation
– Monitor vital signs
– Monitor urine and I and O (hourly with ARF)
– Monitor weight, noting that an increase of 0.5 to 1 lb
daily indicates fluid retention
– Monitor BUN, creatinine, and electrolyte values
– Monitor for acidosis and treat with sodium bicarboonate
as prescribed
– Assess urinalysis for protein, hematuria, casts, and SpGr
Chronic Renal Failure (CRF)
• Nursing Implementation
– Monitor LOC
– Assess for signs of infection, since the patient may
not demonstrate a temperature or an increased
WBC
– Assess for dysrhythmias, since potassium level
above 6mEq/L will cause peaked T waves and a
widened QRS complex
Chronic Renal Failure (CRF)
• Nursing Implementation
– Monitor for fluid overload; assess lungs for rales
and rhonchi
– Monitor for edema
– Administer prescribed diet; usually a moderate
protein intake (to decrease the workload on the
kidneys) and a high- carbohydrate, low-potassium,
and low-phosphorus diet is prescribed
Chronic Renal Failure (CRF)
• Nursing Implementation
– Restrict sodium intake as prescribed, based on the
electrolyte level
– Daily fluid allowances may be 400mL to 1000mL
plus measured urinary output
Chronic Renal Failure (CRF)
• Nursing Implementation
– Administer sodium polystyrene sulfonate (Kayexalate) to
lower the potassium level as prescribed
– Be alert to the mechanism for metabolism and excretion
of all prescribed medications
– Be alert to nephrotoxic medications, such as antibiotics,
which may be prescribed
– Prepare the patient for dialysis as prescribed
Special Problems in Renal Failure
• Hypertension
– Failure of the kidneys to maintain homeostasis of
the blood pressure
– Monitor vital signs
– Maintain fluid and sodium restrictions as
prescribed
– Administer diuretics and Antihypertensives as
prescribed
– Administer propranolol (Inderal), a betaadrenergic antagonist, as prescribed, which
decreases renin release (renin eventually causes
vasoconstriction)
Special Problems in Renal Failure
• Hypervolemia
– Monitor vital signs
– Monitor I and O and weight
– Monitor for edema
– Monitor electrolytes
– Monitor for hypertension
– Monitor for CHF and pulmonary edema
– Enforce fluid restriction
– Avoid the administration of IV fluids
– Administer diuretics as prescribed
Special Problems in Renal Failure
• Hypervolemia (continued)
– Instruct the patient to avoid antacids or cold
remedies containing sodium bicarbonate
Special Problems in Renal Failure
• Hypovolemia
–
–
–
–
–
–
–
Monitor vital signs
Monitor I and O and weight
Monitor for edema
Monitor electrolytes
Monitor for hypotension
Monitor for dehydration
Provide replacement therapy based on the electrolyte
results
– Provide sodium supplements as prescribed depending
on the electrolyte value
Special Problems in Renal Failure
• Potassium Retention
– Monitor vital signs and apical rate
– Monitor potassium level
– Monitor for dysrhythmias (peaked T waves and
widened QRS complex) indicating hyperkalemia
– Provide a low-potassium diet
– Administer medications as prescribed to lower the
potassium level
– Prepare the patient for dialysis
Special Problems in Renal Failure
• Phosphorus retention
– Phosphorus rises and calcium drops, which leads
to stimulation of parathyroid hormone, causing
bone demineralization
– Treatment is aimed at lowering serum phosphorus
levels
– Administer aluminum hydroxide preparations or
other phosphate binders, as prescribed, that bind
phosphorus in the intestine and allow the
phosphorus to be eliminated
Special Problems in Renal Failure
• Phosphorus retention (continued)
– Administer aluminum hydroxide preparations at
meals and not with other medications, because they
bind medications in the intestinal tract
– Administer stool softeners and laxatives as prescribed
to prevent constipation, because aluminum
hydroxide preparations are constipating
– Enforce phosphorus restriction in the diet
Special Problems in Renal Failure
• Low calcium
– Occurs because of the high phosphorus level and
because of the inability of the diseased kidney to
activate vitamin D
– The absence of vitamin D causes a poor
absorption of calcium from the intestinal tract
– Monitor calcium level
– Administer calcium supplements as prescribed
– Administer activated vitamin D as prescribed
Special Problems in Renal Failure
• Metabolic Acidosis
– The kidneys are unable to excrete hydrogen ions
or manufacture bicarbonate, resulting in acidosis
– Administer alkalyzers such as sodium bicarbonate
as prescribed
– Note that patients with CHF adjust to low
bicarbonate levels and do not become acutely ill
Special Problems in Renal Failure
• Anemia
– a decreased rate of production of RBCs occurs as a
result of the diseased kidney and the decreased
secretion of erythropoetin
– Monitor hemoglobin and hematocrit
– Administer epoetin alfa (Epogen) as prescribed to
stimulate the production of RBCs
– Administer folic acid (vitamin B9) as prescribed,
instead of oral iron, because oral iron is not well
absorbed by the GI tract in CRF and causes nausea and
vomiting
Special Problems in Renal Failure
• Anemia
– Administer blood transfusions as prescribed, but
blood transfusions are prescribed only when
necessary because they decrease the stimulus to
produce RBCs
– Monitor bleeding
– Instruct patient to use a soft toothbrush
– Administer stool softeners as prescribed
– Avoid the administration of acetylsalicylic acid
(ASA) because the medication is excreted by the
kidneys; and if administered, high toxic levels will
occur and prolong bleeding time
Special Problems in Renal Failure
• GI Bleeding
– Urea is broken down to ammonia by the intestinal
bacteria, and ammonia is a mucosal irritant that
causes ulceration and bleeding
– Monitor hemoglobin and hematocrit levels
– Monitor stools for occult blood
Special Problems in Renal Failure
• Infection and Injury
– Infection and injury need to be monitored and avoided
because tissue breakdown causes increased potassium
levels
– Monitor for signs of infection
– Avoid urinary catheters and provide strict asepsis during
insertion and catheter care
– Instruct patient to avoid fatigue, which decreases body
resistance
– Instruct patient to avoid persons with infections
– Administer antibiotics as prescribed, monitoring for
nephrotoxic effects
Special Problems in Renal Failure
• Pruitis
– Urate crystals are excreted through the skin to rid
of excess wastes
– This deposit of crystals is called uremic frost, and
it is seen in advanced stages of renal failure
– Monitor for skin breakdown, rash, and uremic
frost
– Provide good skin care and oral hygiene
– Avoid the use of soaps
– Administer antipruritics as prescribed
Special Problems in Renal Failure
• Muscle Cramps
– Occur in the extremities and hands and can be
due to electrolyte imbalances
– Monitor electrolytes
– Administer electrolyte replacements as prescribed
– Administer heat and massage as prescribed
Special Problems in Renal Failure
• Occular irritation
– Calcium deposits in the conjuctiva cause burning
and watering of the eyes
– Administer medications to control the calcium and
phosphorus levels as prescribed
– Administer lubricating eye drops
Special Problems in Renal Failure
• Insomnia and fatigue
– The diseased kidneys cause a buildup of wastes,
causing fatigue in the patient
– Provide adequate rest periods
– Administer mild CNS depressants as prescribed
Special Problems in Renal Failure
• Neurological changes
– The buildup of active particles and fluids causes changes
in the brain cells and leads to confusion and impairment
in decision-making ability
– Monitor for confusion and monitor LOC
– Protect the patient from injury
– Provide a safe and hazard-free environment
Special Problems in Renal Failure
• Neurological changes (continued)
– Use side rails as needed
– Provide a calm and restful environment
– Provide comfort measures and backrubs
– Psychosocial problems: monitor patient for
depression, anxiety, suicidal behavior, denial,
dependence/independence conflict, and changes
in body image
Hemodialysis
• The process of cleaning a patient’s blood
• The diffusion of dissolved particles from one
fluid compartment into another across a semi
permeable membrane
• The patient’s blood flows through one fluid
compartment, and the dialysate is in another
fluid compartment
Hemodialysis
• Functions
– Cleanses the blood of accumulated waste
products
– Removes the by-products of protein metabolism,
such as urea, creatinine, and uric acid
– Removes excessive fluids
– Maintains or restores the body’s buffer system
– Maintain or restores electrolyte levels
Hemodialysis
• Principles
– The semi permeable membrane is made of a thin,
porous cellophane
– The pore size of the membrane allows small particles
to pass through, such as urea, creatinine, uric acid,
and water molecules
– Proteins, bacteria, and blood cells are too large to
pass through the membrane
– The patient’s blood flows into the dialyzer; the
movement of substances occurs from the blood to the
dialysate
Hemodialysis
• Diffusion
– The movement of particles from an area of greater
concentration to one of lesser concentration
• Osmosis
– The movement of fluids across a semi permeable
membrane from an area of lesser concentration of
particles to an area of greater concentration of
particles
• Ultrafiltration
– The movement of fluid across a semi permeable
membrane as a result of an artifically created pressure
gradient
Hemodialysis
• Dialysate Bath
– Composed of water and major electrolytes
– Needs not to be sterile because bacteria are
too large to pass through; however, the
dialysate must meet specific standards, and
water treatment systems are used to ensure a
safe water supply
Hemodialysis
• Nursing Implementation
– Monitor vital signs
– Monitor laboratory values before,
during, and after dialysis
– Assess the patient for fluid overload prior to the
procedure
– Assess patency of the blood access device
– Weigh the client before and after the procedure to
determine fluid loss
Hemodialysis
• Nursing Implementation (continued)
– Hold antihypertensives and other medications
that can affect the BP prior to the procedure as
prescribed
– Hold medications that could be dialyzed off, such
as water-soluble vitamins and certain antibiotics
– Monitor for shock and hypovolemia during the
procedure
– Provide adequate nutrition (client may eat prior to
procedure
Complications of Hemodialysis
• Disequilibrium Syndrome
– A rapid change in the composition of the
extracellular fluid (ECF) occurs during
hemodialysis
– Solutes are removed from the blood faster than
from the Cerebrospinal fluid (CSF) and brain
– Fluid is pulled into the brain, causing cerebral
edema
Disequilibrium Syndrome
• Assessment
• Nursing Implementation
– Nausea and vomiting – Monitor for signs
– Notify physician
– Headache
– Reduce environmental stimuli
– Hypertension
– Prepare to dialyze patient for
– Restlessness and
shorter period at reduced
agitation
blood flow rates to prevent
– Confusion
occurrence
– Seizures
Dialysis Encephalopathy
• An aluminum toxicity that occurs as a result of
aluminum in the water sources used in
dialysate, and the ingestion of aluminumcontaining antacids (phosphorous binders)
Dialysis Encephalopathy
• Assessment
– Progressive neurological impairment
– Mental cloudiness
– Speech disturbances
– Dementia
– Muscle incoordination
– Bone pain
– Seizures
Dialysis Encephalopathy
• Nursing Implementation
– Monitor for signs of dialysis encephalopathy
– Notify the physician if signs of dialysis
encephalopathy occur
– Administer aluminum-chelating agents as
prescribed so that the aluminum is freed up and
dialyzed from the body
Access for Hemodialysis
• Subclavian and femoral catheter
– May be inserted for short-term or temporary use in
ARF
– May be used until a fistula or graft matures or
develops, or when the client has fistula or graft
access failure because of infection or clotting
– Assess insertion site for hematoma, bleeding,
dislodging, and infection
– Do NOT use these catheters for any reason other
than dialysis
– Maintain an occlusive dressing
Subclavian Vein Catheter
• Is usually filled with heparin and capped to
maintain patency between dialysis treatments
• The catheter should not be uncapped
• The catheter may be left in place for up to 6
weeks if complications do not occur
Femoral Vein Catheter
• The client should not sit up more than 45
degrees or lean forward, or the catheter may
kink and occlude
• Assess extremity for circulation, temperature,
and pulses
• Prevent pulling or disconnecting of the
catheter when giving care
• Use an IV control pump with microdrip tubing
if a heparin infusion is prescribed
External Arteriovenous shunt
(AV Shunt)
• Access is formed by the surgical insertion of 2
silastic cannulas into an artery and a vein in
the forearm or leg, to form an external blood
path
• The cannulas are connected to form a U
shape; blood flows from the client’s artery
through the shunt into the vein
• A tube leading to the membrane
compartment of the dialyzer is connected to
the arterial cannula
External Arteriovenous shunt
(AV Shunt)
• Blood fills the membrane compartment
and flows back to the client by way of a
tube connected to the venous cannula
• When dialysis is complete, the cannulas
are clamped and reattached to form their
U shape
External Arteriovenous shunt
(AV Shunt)
• Advantages
– Can be used immediately following creation
– No venipuncture is necessary for dialysis
• Disadvantage
– External danger of disconnecting or dislodging
– Risk of hemorrhage, infection, clotting
– Skin erosion around the catheter site can occur
External Arteriovenous shunt
(AV Shunt)
• Nursing Implementation
– Avoid wetting the shunt
– A dressing is completely wrapped around the shunt and kept dry
and intact
– Cannula clamps need to be available at the bedside
– Do NOT take a blood pressure, draw blood, place an IV, or
administer injections in the shunt extremity
– Monitor for hemorrhage, infection, clotting
– Monitor skin integrity around the insertion site
– Note that the shunt is patent if it is warm to touch
– Auscultate and palpate for a bruit, although a bruit may not be
heard and is not always felt with the shunt
– Notify the MD immediately if signs of clotting, hemorrhage, or
infection occur
External Arteriovenous shunt
(AV Shunt)
• Signs of clotting
– Fold back the dressing to expose the shunt tubing
and assess for signs of clotting
– Fibrin-white flecks noted in the tubing
– The separation of serum and cells
– The absence of a previously heard bruit
– Coolness of the tubing or extremity
– Patient C/O of a tingling sensation
Internal Arteriovenous shunt
(AV Fistula)
• Access of choice for CRF – dialysis
• Created surgically by anastomosis of an artery in the
arm to a vein; creating an opening or fistula between a
large artery and a large vein
• The flow of arterial blood into the venous system causes
the veins to become engorged (mature or developed)
• Maturity takes about 1 to 2 weeks and is required
before the fistula can be used, so that the engorged vein
can be punctured with a large-bore needle for the
dialysis procedure
• Subclavian or femoral catheters, peritoneal dialysis, or
an external AV shunt can be used for dialysis while the
fistula is maturing or developing
Internal Arteriovenous shunt
(AV Fistula)
• Advantages
– Since the fistula is internal, there is less danger of
clotting and bleeding
– The fistula can be used indefinitely
– Decreased incidence of infection
– No external dressing is required
– Allows freedom of movement
Internal Arteriovenous shunt
(AV Fistula)
• Disadvantages
– Cannot be used immediately after insertion
– Needle insertions are required for dialysis
– Infiltration of the needles during dialysis can occur
and cause hematomas
– Arterial steal syndrome can develop (too much
blood is diverted to the vein, and arterial
perfusion to the hand is compromised)
– CHF can occur from the increased blood flow in
the venous system
Internal Arteriovenous graft
(AV Graft)
• The internal graft is used primarily for chronic dialysis
clients who do not have adequate blood vessels for
the creation of a fistula
• An artificial graft made of Gore-Tex or bovine (cow)
carotid artery is used to create an artificial vein for
blood flow
• The procedure involves the anastomosis of the graft
to the artery, a tunneling under the skin, and
anastomosis to a vein
• The graft can be used 2 weeks after insertion
• Complications of the graft include clotting,
aneurysms, and infection
Internal Arteriovenous graft
(AV Graft)
• Advantages
– Since the graft is internal, there is less danger of
clotting and bleeding
– The graft can be used indefinitely
– Decreased incidence of infection
– No external dressing is required
– Allows freedom of movement
Internal Arteriovenous graft
(AV Graft)
• Disadvantages
– Cannot be used immediately after insertion
– Needle insertions are required for dialysis
– Infiltration of the needles during dialysis can occur
and cause hematomas
– An aneurysm can form in the graft
– Arterial steal syndrome can develop
– CHF can occur with the AV graft also
Nursing Implementation of AV fistula and
AV graft
• Do NOT measure a BP, draw blood, place an IV, or administer
injections in the fistula or graft extremity
• Monitor for clotting
– C/O tingling or discomfort in the extremity
– Inability to palpate a thrill or auscultate a bruit over the fistula or graft
• Monitor for arterial steal syndrome
• Palpate or auscultate for bruit or thrill over the fistula or graft
• Palpate pulses below the fistula or graft, and monitor for hand
swelling as an indication of ischemia
• Note temperature and capillary refill of the extremity
• Monitor for infection
• Monitor lung and heart sounds for signs of CHF
• Notify the physician immediately of signs of clotting, infection, or
arterial steal syndrome occur
Peritoneal Dialysis
• The peritoneum is the dialyzing membrane (semi
permeable membrane) and substitutes for kidney function
during kidney failure
• Works on the principles of diffusion and osmosis, and the
dialysis occurs via the transfer of fluid and solute from the
bloodstream through the peritoneum
• The peritoneal membrane is large and porous, allowing
solutes and fluid to move via an osmotic gradient from an
area of higher concentration in the body to an area of
lower concentration in the dialyzing fluid
• The peritoneal cavity is rich in capillaries; therefore, it
provides a ready access to blood supply
Peritoneal Dialysis
• Contraindications to peritoneal dialysis
– Peritonitis
– Recent abdominal surgery
– Abdominal adhesions
– Impending renal transplant
Peritoneal Dialysis
• Dialysate Solution
– Solution is sterile
– Contains electrolytes and minerals, a specific osmolality, a specific
glucose concentration, and other medication additives as
prescribed
– The higher the glucose concentration, the greater the amount of
fluid removed during the exchange
– Increasing the glucose concentration increases the concentration
of active particles that cause osmosis, and increases the rate of
ultrafiltration and the amount of fluid removed
– Potassium: if hyperkalemia is not a problem, potassium may be
added to each bag of solution
– Heparin: added to the dialysate solution to prevent clotting of the
catheter
– Antibiotics: may be added to prevent peritonitis
– Insulin: may be added for clients with DM
Peritoneal Dialysis
• Access
– a surgical insertion of a siliconized rubber catheter
into the abdominal cavity is required to allow infusion
of dialysis fluid
– The preferred insertion site is 3 to 5 cm below the
umbilicus because this area is relatively avascular and
has less fascial resistance
– The catheters are tunneled under the skin to stabilize
the catheter and reduce the risk of infection
Peritoneal Dialysis
– Over a period of 1 to 2 weeks following
insertion, there is an ingrowth of fibroblasts
and blood vessels into the cuffs of the catheter,
which fix the catheter in place and provide an
extra barrier against dialysate leakage and
bacterial invasion
Types of Peritoneal Dialysis
• Continuous ambulatory peritoneal dialysis
(CAPD)
• Closely resembles renal function because it is a continuous
process
• Does not require a machine for the procedure
• Promotes client independence
• The client performs self-dialysis 24 hours a day, 7 days per
week
• Usually for dialysis cycles are administered in 24 hours,
including 8-hour dwell time overnight
• One and a half to two liters of dialysate is instilled into the
abdomen four times daily and allowed to dwell as prescribed
Types of Peritoneal Dialysis
• Continuous ambulatory peritoneal
dialysis (CAPD)
• The dialysis bag, attached to the catheter, is folded
and carried in the client’s clothing until time for
outflow.
• After dwell, the bag is placed lower than the
insertion site so that fluid drains by gravity flow
• When full, the bag is changed, new dialysate is
instilled into the abdomen, and the process
continues
Types of Peritoneal Dialysis
• Automated Peritoneal Dialysis (APD)
– Similar to CAPD in that it is a continuous dialysis
process
– Requires a peritoneal cycling machine
– Can be done as intermittent (IPD)
– Can be done as continuous cycling (CCPD)
– Or nightly (NPD)
Types of Automated Peritoneal Dialysis
• CCPD
– Requires a peritoneal cycling machine
– 3 cycles @night
– 1 cycle w/8HR dwell in morning
– No exchanges during day
– Peritoneal cavity is opened only for the ON and OFF
procedures, reducing risk of infection
Types of Automated Peritoneal Dialysis
• IPD
– Requires a peritoneal cycling machine
– Not a continuous dialysis procedure
– Performed for 10 to 14 hours, 3 to 4 times a week
• NPD
– Performed 8 to 12 hours each night with no daytime
exchanges or dwells
Peritoneal Dialysis Infusion
• One infusion (inflow), dwell, and outflow is considered
one exchange
• Uses an open system that presents a risk of infection
• Inflow: the infusion of 1 to 2 liters of dialysate as
prescribed is infused by gravity into the peritoneal
space, which usually takes about 10 minutes
• Dwell time: the amount of time the dialysate solution
remains in the peritoneal cavity; prescribed by the
physician
• Outflow: fluid drains out of body by gravity into the
drainage bag
Peritoneal Dialysis Infusion
• Nursing Implementation before treatment
– Monitor vital signs
– Obtain weight
– Have client void, if possible
– Assess electrolytes and glucose levels
• Nursing Implementation during treatment
– Monitor vital signs
– Monitor for signs of
•
•
•
•
•
infection
respiratory distress, pain, discomfort
pulmonary edema
Hypotension, hypertension
Malaise, nausea, vomiting
Peritoneal Dialysis Infusion
• Nursing Implementation during treatment
(continued)
– Assess the catheter site dressing for wetness or bleeding
– Monitor dwell time as prescribed by physician and initiate outflow
– Do not allow dwell time to extend beyond the physician’s order –
it increases the risk for hyperglycemia
– Turn the client side to side or have the client sit upright if the flow
is slow to start
– Monitor outflow, which should be a continuous stream after the
clamp is opened
– Monitor outflow for color and clarity
– Monitor I and O accurately
– If outflow is <inflow, the difference is equal to the amount
absorbed or retained by the client during dialysis and should be
counted as intake
Complications of
Peritoneal Dialysis
• Peritonitis
– Maintain meticulous sterile technique when hooking up or
clamping off bags, and when caring for the catheter insertion site
– Follow institutional procedure for hooking up and clamping off
bags, which may include scrubbing the connection sites with an
antiseptic solution
– Monitor temperature closely
– Monitor for fever, cloudy outflow, and rebound tenderness
– If peritonitis is suspected, obtain a culture of the outflow to
determine the infective organism
– Administer antibiotics as prescribed
Complications of
Peritoneal Dialysis
• Abdominal pain
– Pain during inflow is common during the first few
exchanges, is caused by peritoneal irritation, and usually
disappears after a week or two of dialysis treatments
– The cold temperature of the dialysate aggravates the
discomfort, and the dialysate should be warmed before
use, only with a special dialysate warmer pad
– Place a heating pad on the abdomen during the inflow
to relieve discomfort
Complications of
Peritoneal Dialysis
• Insufficient outflow
– May be caused by catheter migration out of the
peritoneal area; if this occurs, the catheter must be
repositioned by the physician
– Insufficient outflow can also be caused by a full colon
– Maintain the drainage bag below the client’s abdomen
Complications of
Peritoneal Dialysis
• Insufficient outflow
– Change the client’s outflow position by turning or
ambulating
– Check for kinks in the tubing
– Encourage a high-fiber diet
– Administer stool softeners as prescribed
Complications of
Peritoneal Dialysis
• Leakage around the catheter site
– Over a period of 1 to 2 weeks following insertion
of the catheter, an ingrowth of fibroblasts and
blood vessels into the cuffs of the catheter occurs,
which fix the catheter in place and provide an
extra barrier against dialysate leakage and
bacterial invasion
– It may take up to 2 weeks for the client to tolerate
a full 2-liter exchange without leaking around the
catheter site
Complications of
Peritoneal Dialysis
• Characteristics of outflow
– During the first or initial exchanges, the outflow
may be bloody; outflow should be clear and
colorless thereafter
– Brown outflow indicates bowel perforation
– If the outflow is same color as urine, this indicates
bladder perforation
– Cloudy outflow indicates peritonitis
Uremic Syndrome
• The accumulation of nitrogenous waste
products in the blood because of the inability
of the kidneys to filter out these waste
products
• May occur as a result of Acute or Chronic
Renal Failure
Uremic Syndrome
• Assessment
– Oliguria
– Presence of protein, RBCs, casts in the urine
– SpGr of 1.010
– Elevated levels of urea, uric acid, potassium and
magnesium in urine
– Hypotension or hypertension
– Alterations of LOC
– Electrolyte imbalances
– Stomatitis
– Nausea and vomiting
– Diarrhea or constipation
Uremic Syndrome
• Nursing Implementation
– Monitor vital signs
– Monitor electrolyte values
– Monitor I and O
– Provide a diet low in protein
unless client is on PD
– Limit sodium, nitrogen, potassium, and
phosphate intake as prescribed