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1. .
CLINICAL TEACHING
ON
PERITONEAL DIALYSIS.
PRESENTED BY
MS.JINUMOL
M.sc Nursing second year
NUINS.

2. INTRODUCTION
Peritoneal dialysis is the process during which the peritoneal cavity acts as reservoir for the
dialysate and peritoneum serves as semi-permeable membrane, across which excess body
fluids and solutes, including uremic toxins are removed .Peritoneal membrane is in contact
with rich blood supply to the abdominal organs and dialysate is infused into peritoneal cavity
via catheter.

3. .

4. DEFINITION
 Peritoneal Dialysis is a process or procedure which allows exchange of wastes, fluids and
electrolytes in the peritoneal cavity.
( Ignativicious)
 Peritoneal dialysis involves repeated cycling of instilling dialysate into peritoneal cavity,
allowing the time for substance exchange and then removing the dialysate.
(Joyce M Black)

5. INCIDENCE
The use of peritoneal dialysis has decreased and currently accounts for only 5 % to 6% of the
dialysis.

6. PRINCIPLES
• Diffusion
• Osmosis
• Ultrafiltration.

7. INDICATIONS
Patient’s with Chronic Kidney Disease.
Unstable patients who cannot tolerate anticoagulation.
Patients with chronic infections, vascular access problems
Peritoneal dialysis is often the treatment of choice for older adults,
because it offers more flexibility, if his or her status changes frequently.

8. CONTRAINDICATIONS
Peritoneal adhesions.
Extensive Intra-abdominal surgery.
Obesity
Recurrent episodes of peritonitis
Abdominal malignancies.
Respiratory diseases, ruptured diverticulum.

9. CONTINUE…..
• ADVANTAGES
• Easy to learn
• Can be done at home
• Ambulatory – no machines are
needed , when machines are used,
they are small
• Better BP Control
• Less dietary and fluid restriction
• Greater freedom in scheduling and
travelling.
• DISADVANTEGES
• Time consuming
• Sterile technique is required
• Presence of permentant catheter
• Risk for peritonitis and peritoneal
injury
• Contraindicated in abdominal
surgeries, chronic back pain or
development of hernias.

10. PROCEDURE
• Each peritoneal exchange
consists of 3 phases.
• Fill, dwell and drain.
• A siliconized rubber catheter is
surgically placed into the
abdominal cavity for infusion of
dialysate.
• Usually 1 to 2 l of dialysate is
infused by gravity (Fill phase)
• Fluid stays ( dwells) in the cavity
for a specified time, prescribed
by the nephrologist.

11. CONTINUE……..
• Fluid then flows out of the body (drains) by the gravity into drainage bag.
( peritoneal outflow generally called as “peritoneal effluent “ contains the dialysate and excess
waste , electrolytes and nitrogen –based waste products.)
• The 3 phases of the process ( infusion or fill, dwell and outflow or drain)makes up one
peritoneal dialysis exchange.

12. PROCESS
 Peritoneal dialysis occurs through diffusion and osmosis across the semi-
preamble peritoneal membrane and capillaries.
The peritoneal membrane is large and porous. It allows solutes and water to move
from an area of higher concentration in blood to an area of lower concentration
in dialysing fluid ( diffusion).
The fluid and waste products dialysed from patient move through blood vessels
wall, interstitial tissue and the peritoneal membrane and are removed when
dialyzing fluid drain from the body.

13. Factors affecting peritoneal dialysis
efficiency
• Decreased peritoneal membrane permeability caused by infection or
scarring.
• Reduced capillary blood flow resulting from blood vessel constriction.
• Vascular disease
• Decreased perfusion of peritoneum.

14. Dialysate Additives
• Heparin may be added to the dialysate to prevent clotting of the catheter or tubing.
• Other agents includes potassium and antibiotics.
• Antibiotics is given by intraperitoneal routes when peritonitis is present or suspected.

15. TYPES OF DIALYSIS.
• Continuous Ambulatory Peritoneal Dialysis.
• Automated Peritoneal dialysis.
• Intermittent Peritoneal Dialysis.
• Continuous cycling peritoneal Dialysis.

16. ContinuousAmbulatory Peritoneal
Dialysis
• Most commonly used peritoneal dialysis.
• Cleanse the body ,helps to control the water and replaces the work of replaced kidney.
• Portable type of Dialysis.
• Performed by the patients with the infusion of 2l -4l exchange of Dialysate into the peritoneal cavity.
• Duration of dialysate is 4 to 8 hours in peritoneum in a day and exchange occurs 7 days in a week.
• During dwell period patient can use a continuous connect system or disconnect system

17. Continuous Ambulatory Peritoneal
Dialysis

18. AUTOMATED PERITONEAL DIALYSIS
• Often used in acute care setting settings, outpatient dialysis centers or in patient’s home.
• APD uses a cycling machine for dialysate inflow ,dwell and outflow according to pre-set times and
volumes.A warming chamber for dialysate is the part of machine
• Functions are monitored for patient’s specific needs
• Permits home dialysis while patient sleeps
• Reduces the incidence of peritonitis, because fewer connections and disconnections are needed

19. AUTOMATED PERITONEAL DIALYSIS

20. Continuous- Cycling Peritoneal
Dialysis (CCPD)
Continuous – Cycling Peritoneal Dialysis is a form of automated dialysis that uses an
automated cycling machine.
Exchange occurs at night while patient sleep.
The final exchange of the night is left to dwell through the day and is drained in the next
evening as process is repeated.

21. INTERMITTENT PERITONEAL DIALYSIS
• IPD combines osmotic pressure with true dialysis.The patient usually requires the
exchange of 2l of dialysate at 30 to 60 minutes interval , allowing 15 to 20 minutes of drain
time.
• For most patients 30 to 40 exchanges of 2 L three times weekly are needed.
• IPD can be automated or manual.

22. COMPLICATIONS
• Peritonitis
• Bleeding
• Dialysate leakage
• Bladder perforation
• Pain
• Bowel Perforation.

23. NURSING MANAGEMENT

24. PREDIALYSIS CARE
• Document vital signs including temperature, pulse and Blood pressure.These baseline data help
to assess fluid volume status and tolerance of the dialysis procedure.
• Check the weight daily before the dialysis.
• Note BUN, Serum electrolytes and creatinine, PH, haematocrit level ,prior to peritoneal dialysis
or periodically ( helps to assess the efficiency of the treatment.)
• Measure and record abdominal girth(Increasing abdominal girth may indicate retained dialysate,
excess fluid volume or early peritonitis)

25. Continue……
• Maintain fluid and dietary restriction as ordered (fluid and dietary restriction help to reduce
hypervolemia and control azotaemia.)
• Have the client empty the bladder prior to catheter insertion.(emptying bladder reduces the risk of
inadvertent puncture)
• Warm the prescribed dialysate solution to body temperature (98.60 F) using a warm bath or heating
pad .( helps to prevent hypothermia)
• Explain all procedures and expected sensations.

26. Intra-dialysis care.
• Use Strict aseptic technique during the procedure.
• Add prescribed medications to the dialysate solution Prime the tubing with solution and
connect it to peritoneal catheter, taping connections securely and avoiding kinks.
• Instil dialysate into the abdominal cavity over a period of approximately 10 minutes.
• Clamp tubing and allow the dialysate to remain in the abdomen for prescribed dwell time.
• Keep the drainage tubing ,clamped at all time, during installation and dwell time.

27. Continue…
• During instillation and dwell time. Observe closely for the signs of respiratory distress such
as dyspnoea, tachyapnea or crackles.
• Place in fowler’s or semi fowler's and slow the rate of instillation slightly to relieve the
respiratory distress.
• After prescribed dwell time, open the drainage tubing clamps and allow the dialysate to
drain by gravity into a sterile container. Note the clarity, color and odor of the returned
dialysate. ( Blood or feces in the dialysate may indicates organ or bowel perforation.)

28. Continue….
• Accurately record amount and type of dialysate instilled ( including added
medications),dwell time and amount and character of drainage.
• Monitor BUN, serum electrolytes and creatinine level ( helpful in assessing the effectiveness
of dialysis).
• Analyse for possible complications.

29. POST DIALYSIS CARE
• Assess vital signs ( compare with pre-dialysis vital signs)
• Time meals to correspond with dialysis outflow.
• Teach the client and family about the procedure.
• Watch for complications.

30. CONCLUSION
• Peritoneal dialysis is a way to remove waste products from blood when kidneys
can't adequately do the job any longer. During peritoneal dialysis, a cleansing fluid
flows through a tube (catheter) into part of abdomen.The lining of abdomen
(peritoneum) acts as a filter and removes waste products from blood. After a set
period of time, the fluid with the filtered waste products flows out of y abdomen
and is discarded.These treatments can be done at home, at work or while
traveling.

31. SUMMARY
 DEFINITION
INCIDENCE
INDICATIONS
CONTRAINDICATIONS
PROCEDURE
NURSING MANAGEMENT
COMPLICATIONS

32. BIBLIOGRAPHY
Joyce M Black , “Textbook of Medical –Surgical Nursing”, Elsevier Publications,8th
Edition,2010, pg no 823 -824.
Lippincott Williams & Wikins Hand book of Dialysis ,Wolters Kluwers Publications
,Fifth Edition, 2015 ,Pg no:392 -400.
Iganativicious “Text book of Medical Surgical Nursing”, Elsevier Publications,7th
Edition,2009, pg no 612 -614.

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