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CARE OF THE
HOSPITALIZED
PERITONEAL DIALYSIS
PATIENT
By: Joni-Jill Tobrocke RN, CNN
H.K. Freedman Renal Center
C.V.P.H. Medical Center
March 2007
Objectives
The Learner will be able to:
Describe the basic principles of peritoneal dialysis
(PD).
Define steps required to complete a CAPD exchange
using Baxter’s Ultrabag system.
Describe methods for preventing infection when
performing PD procedures.
Describe the process for identifying & treating
peritonitis.
Describe steps required to complete daily PD
catheter exit site care.
Peritoneal Dialysis
 Is performed as an
intracorporeal (inside the
body) therapy making use of
the peritoneal membrane.
 Is the process of cleaning the
blood by using the lining of the
peritoneal cavity (peritoneum)
as a filter – the peritoneum acts
as a dialyzing membrane,
permitting wastes from the
body to cross it and empty into
the instilled dialysate fluid .
 Is a type of dialysis usually
done by the patient at home.
Types of Peritoneal Dialysis
 CAPD – Continuous
Ambulatory Peritoneal
Dialysis
 Manual exchanges
(approx. 30 Min. each)
done approx. 4 times daily
(1st thing in am, around
lunchtime, around
suppertime, and before
bed).
 Utilizing Baxter’s
ultrabag system.
 Aseptic technique
mandatory in making all
connections.
 APD – Automated
Peritoneal Dialysis
 Utilizes a machine to
perform exchanges at
night while the patient
sleeps (8-10 Hrs on the
machine).
 Provides greater daytime
freedom.
 May or may not require 1
or 2 daytime exchanges
also.
 Aseptic technique
mandatory in making all
connections.
Phases of Peritoneal Dialysis
 Fill
 Takes approx. 10 minutes.
 Usual volume is 2000 – 2500 ml’s.
 Dwell
 CAPD – usually 4-6 Hrs during the day, and 8-10 Hrs
during the night.
 APD – usually shorter dwells while sleeping and longer
dwells during the day.
 Drain
 Takes approx. 20 minutes.
 Usual volume may be slightly less, the same as, or more
than infused amt.
 Effluent (drained fluid) is normally clear (colorless or
yellow).
Clearance Across the
Peritoneal Membrane
Blood
Dialysate
Semipermeable
Membrane
 Waste products & excess
fluid move from the blood
into the dialysate by
diffusion & osmosis.
 Fluid removal can be
increased by increasing
the amount of dextrose in
the dialysate.
 Some medications will
move across the
membrane also.
Access to The Peritoneum
 Considered the
patients’ lifeline.
 Sterile technique
required when
connecting (or
disconnecting) transfer
set to catheter.
 Transfer set is clamped
prior to opening to
protect the PD
catheter (strict aseptic
technique is required
when minicap is
removed).
Twist
Clamp
Transfer Set
Titanium Adaptor
Exit Site
Minicap
Peritoneal Catheter
All procedures requiring opening of the closed
system will be done by trained staff only
CAPD Exchange
 Aseptic technique
mandatory in making all
connections!
 Check dialysis orders for
% of dextrose, & fill
volume.
 Drained volume must be
measured & documented
(a spring scale may be
used).
Baxter’s Ultrabag System  Dialysate should be
warmed to body
Full & Empty Bags Connected
temperature using dry
by Tubing
heat.
Warming Dialysis Solution
The PD solution will be
heated to approximately
body temperature using a
dry-heat heating pad,
which is used only for this
purpose, set on low
Any heating pad in use
must have an inspection
sticker attached before it
is put into service
Intraperitoneal (IP) Medication
If IP medications are prescribed, there
is a strict sterile procedure to be
followed. (At CVPH the pharmacists
mix any IP meds)
Some medications (i.e. Vancomycin,
Tobramycin etc.) must be infused
slowly (regulate by adjusting twist
clamp on transfer set and/or lowering
the IV pole).
Preparing for an Exchange
Clean the work area.
Gather supplies (Check expiration dates)
Provide privacy, close doors / curtains, utilize
“Do Not Enter” signs. (It is preferred that PD
patients have private rooms. If they must share
a room, the roommate must be free of infectious
organisms).
Fans / blowers must be turned off.
Limit visitors (Anyone in room during an
exchange must wear a mask).
Completing a Safe Exchange
 Follow the steps provided in
the “Baxter Ultrabag
Aseptic Exchange
Procedure” step-by-step
guide shown here and found
in the Peritoneal Dialysis
binder on R7.
 Proper hand washing using
liquid antimicrobial soap is
important prior to
connecting and / or
disconnecting the ultrabag.
Documentation
Documentation :
All exchanges
Exit Site care
Daily weights
CVPH utilizes a 24 Hour
Peritoneal Dialysis Record
to document.
PD Patients Are Knowledgeable
 Keep in mind that PD patients (or
a caregiver), have been through
extensive training and carry out
their dialysis at home daily.
 They are protective of their
“lifelines”, and will want to
ensure that proper technique is
used.
 If you get them the supplies they
need, encourage them to carry out
the exchange themselves if they
are able.
Fluid Balance
Fluid & electrolyte balance must be maintained
to prevent dehydration and/or fluid overload.
Assess the patient for fluid volume status and
obtain orders from the MD to adjust dextrose in
dialysate if needed. Monitor:
Daily weights.
Lung sounds.
Presence of edema.
Total I & O (including + and – PD fluid balances).
Blood pressure.
Other S&S of dehydration or fluid overload.
Catheter Care
 Exit site care will be done
daily by the patient if able, or
by trained staff.
 Scrub hands well.
 Examine exit site for S&S of
infection, irritation, or
leakage – if any, notify the
nephrologist.
 Check the catheter &
connections – They should be
free from cracks, tears or
leaks.
 Feel the catheter tunnel,
report any swelling or pain.
Daily Exit Site Care
 Clean the skin around the catheter
with a sterile gauze pad &
antibacterial soap (Start close to the
catheter & move out).
 Rinse well to remove all the soap.
 Dry the exit site area with a sterile
gauze pad.
 Tape the tubing to the abdomen in a
natural position to anchor/ immobilize
it, & protect it from trauma.
 If patient uses mupirocin ointment,
obtain an order from MD, & apply to
exit site. If they use povidone-iodine
prep pads, paint a 1” circle around
the exit site & allow to air dry.
Exit Site Care
Apply a sterile gauze
dressing ( if Pt. doesn’t
normally wear a dressing,
they must wear one while
in the hospital).
Loop the catheter around
& tape again to secure it
better.
Repeat exit site care if exit
becomes wet or soiled.
Document any findings &
that site care was done.
Peritonitis in the PD Patient
CVPH has a protocol for peritonitis in the PD patient
which can be found in policy manager.
 Patients with peritonitis usually present with cloudy
fluid and abdominal pain.
 Send the first cloudy drain bag to the lab for stat cell
count w/ diff, gram stain & culture.
 Prompt initiation of antibiotic therapy for peritonitis is
critical to prevent complications & limit damage to the
peritoneal membrane. (If the patient has cloudy effluent
& Abd pain, antibiotic therapy should be initiated
without waiting for confirmation of the cell count).
 The nephrologist on-call must be notified.
Abdominal Pain in Peritonitis
Ranges from mild or even no pain to severe
pain.
The degree of pain is somewhat organism
specific.
If the patient is experiencing severe abdominal
pain, rapid exchanges may be done up to two
times to decrease pain (This delays initiation of
antibiotics, & should only be used in cases of
extreme pain).
In most cases, symptoms decrease rapidly after
initiation of antibiotic therapy.
Pain medications may be ordered PRN.
Peritonitis Continued
Heparin 2000 units per bag is added (by the
pharmacist) to dialysate when effluent is cloudy.
Vancomycin should be infused over 45 minutes
to prevent adverse reactions.
Antibiotics must dwell in peritoneum for at least
4 Hrs. (6-8 Hrs. preferred).
Assess patient for possible source of infection
(i.e. Catheter exit site, break in technique, recent
contamination, constipation or diarrhea, cracks
or leak in the catheter or transfer set).
Documentation
Record assessment data in nurses’
notes.
Record medications given.
Notify Peritoneal Dialysis unit staff
of peritonitis episode (so follow-up
care can be arranged).
Emergencies
Clamp tubing above disconnected area (nearer
to the patient), immediately if system becomes
disconnected, or if a leak is noted.
Notify Nephrologist (prophylactic antibiotic
orders may be needed).
Stop any further instillation of fluid to the
patient until a complete tubing change is made,
and orders are received from the Nephrologist.
Miscellaneous
 Assess for alterations in blood glucose levels in
diabetics from the use of dextrose-based dialysate.
 Check visually for changes in the appearance of the
effluent with each exchange.
 If fibrin is present, an order can be obtained for the
pharmacy to add heparin to the bags.
 If effluent is cloudy, Notify Nephrologist & initiate
peritonitis protocol.
 Document clarity of each exchange on PD flow sheet.
 Reinforce exit site dressing for newly inserted PD
catheters. Do not remove original dressing unless
trained to do so.
 Be alert to tubing getting kinked or caught under
patient, which will prevent infusion or draining of
dialysate.
Bibliography
 B. Piraino, et al., ISPD Guidelines/Recommendations,
Peritoneal Dialysis – Related Infections,
Recommendations: 2005 Update.
 www.renalsource.com. Baxter Healthcare Corp.
“Introduction to Peritoneal Dialysis for Hospital
Nursing Staff” / 2004.
 CVPH Policy Manager:
Peritonitis Protocol in the Peritoneal Dialysis (PD)
Patient.
Protocol for PD Patient, Care of the Patient
Receiving.
Policy for CAPD exchanges.
Procedure for PD Using the Manifold System.
 Catheter and Exit Site Care, Baxter Healthcare Corp.
2000.