Peritoneal dialysis

Peritoneal dialysis

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  PERITONEAL DIALYSIS Peritoneal dialysisis a way to remove waste products from your blood when your kidneys can no longer do the job adequately. A cleansing fluid flows through a tube (catheter) into part of your abdomen and filters waste products from your blood. After a prescribed period of time, the fluid with filtered waste products flows out of your abdomen and is discarded. Peritoneal dialysis differs from hemodialysis, a more commonly used blood-filtering procedure. With peritoneal dialysis, you can give yourself treatments at home, at work or while traveling. INDICATIONS  Diabetes  High blood pressure (hypertension)  Kidney inflammation (glomerulonephritis)  Multiple cysts in the kidneys (polycystic kidney disease) THE BENEFITS OF PERITONEAL DIALYSIS COMPARED WITH HEMODIALYSIS  Greater lifestyle flexibility and independence. These can be especially important if you work, travel or live far from a hemodialysis center.  More flexible dietary guidelines. Peritonealdialysis is done more continuously than hemodialysis, resulting in less accumulation of potassium, sodium and fluid.  More stable blood chemistry and body hydration. Peritoneal dialysis doesn't require intravenous (IV) access,which can disrupt your circulation and fluid levels.  Longer lasting residual kidney function. People who use peritoneal dialysis might retain kidney function slightly longer than people who use hemodialysis. COMPLICATIONS OF PERITONEAL DIALYSIS  Infections. An infection of the abdominal lining (peritonitis) is a common complication of peritoneal dialysis. An infection can also develop at the site where the catheter is inserted to carry the cleansing fluid (dialysate) into and out of your abdomen. The risk of infection is greater if the person doing the dialysis isn't adequately trained.  Weight gain. The dialysate contains sugar (dextrose). Absorbing some of the dialysate might cause you to take in severalhundred extra calories a day, leading to weight gain. The extra calories can also cause high blood sugar, especially if you have diabetes.  Hernia. Holding fluid in your abdomen for long periods may strain your muscles.  Inadequate dialysis. Peritonealdialysis can become ineffective after severalyears. You might need to switch to hemodialysis.
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  Peritoneal dialysis isa treatment used to clean the blood of extra fluid and waste that builds up in the body when the kidneys do not work. Catheter Placement and Care A tube or catheter is placed through the abdominal muscles. One end is put into the peritoneal space. The peritoneal space is the empty space that surrounds the organs of the abdomen. The other end of the tube comes out of the abdomen about 6 inches. A large dressing will be over the catheter site to protect the site, promote healing and prevent infection. The staff will change the dressing about 5 days after surgery. Keep the dressing dry. The catheter is not used for 2 weeks after placement so the area can heal. If you need dialysis during this time, hemodialysis will be done. Continuous Ambulatory Peritoneal Dialysis (CAPD) This 3-step process is called an exchange. 1. Fill A bag of solution called dialysate is put into the abdomen through the catheter. This bag holds about 2 quarts of fluid. It takes about 10 to 20 minutes to fill. When the bag is empty, it can be clamped off or the tubing can be capped off. 2. Dwell The solution stays in the abdomen 4 to 6 hours. While the solution is in the abdomen, extra fluid and wastes move from the blood and into the solution. 3. Drain Using gravity, the solution is then drained out of the body into a drain bag. The drained fluid is much like urine and will be clear yellow. It takes about 10 to 20 minutes to drain. When the solution is drained, a new bag of dialysate is connected to the catheter and the steps are repeated. These 3 steps are done about 4 times each day with meals and at bedtime. Each cycle takes 20 to 40 minutes. After you are trained, you can do peritoneal dialysis anywhere there is a clean, private area. To prevent infection, the exchange must be done under clean conditions and the patient may need to wear gloves and a mask. Continuous Cycling PeritonealDialysis (CCPD) With CCPD, there are fill, dwell and drain cycles, but the dwell time is shorter and a machine does the exchanges. The dwell time is about 1 ½ hours. The machine is set up and the person is connected to this machine for 8 to 10 hours during the night. The person is unhooked from the machine during the day.
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  Inform Doctor whenany of these signs of PD problems:  Shortness of breath  Swelling in the arms, legs, face or abdomen  Extreme itching or bone pain, this can be a sign of too much phosphorus in the body  Dizziness, nausea or cramping in the toes, feet or stomach  Cloudy bags or drained dialysis solution is pink in color  Redness, pain or swelling  Leaking from the catheter site  Catheter adapter or catheter falls out, or comes apart  Hole in the catheter  Changes in blood pressure Peritoneal Dialysis Procedure There are three phases in one cycle of peritoneal dialysis (PD), they are: Fill, Dwell, Drain. During each exchange the first phase is draining from the previous cycle and then filling to begin the next cycle. Articles needed - Bedside table - 2 surgical masks - 2 sterile towels - 1 small sterile bowl - 1 sterile forceps - 2 sterile cotton swabs - 4 squares sterile gauze - 1 sterile 4x4 gauze - Lactated Ringer (LR) – ordered amount - D50W – ordered amount - 1 large syringe with needle may be reused for 24h if sterility is maintained - Infusion Set - Urinary catheter bag - Container with a lid containing 90% alcohol (change weekly) - 3 way stopcock (in open-all-ways position in 90% alcohol) use one NEW piece for each patient - 4-5cm section of suction tubing (in 90% alcohol) use NEW piece for each patient - 2 pairs of sterile gloves - Non-sterile kidney basin or bowl for discarded fluid - Bucket for drained dialysate
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  SL NO ActionRationale 1. Warm fluid and explain procedure to patient Part of compassionate patient- centered care is involving them in nursing actions. 2. Place surgical mask on patient and self, draw curtains, and ask any caregivers to leave until exchange is finished. Infection through the PD catheter is one of the greatest risks, so minimizing possible sources of infection is vital. 3. Wipe bedside table with alcohol. To prevent any contaminants from entering the sterile field. 4. Wash hands. 5. Place sterile towel under PD catheter, preventing contamination of other towels and center of drape. Prevents contaminants near connection site. Note: this towel is longer sterile after placed. 6. Place second sterile towel on bedside table (without contaminating sterile field) Provides sterile area to prepare supplies. 7. Place sterile bowl, sterile forceps, and two sterile cotton swabs, and gauze on sterile towel on bedside table. 8. Open container with 90% alcohol, stopcock, and suction tubing piece in it Allows you to retrieve necessary items without contamination 9. Use sterile forceps to remove stopcock and suction tubing from alcohol and place them in sterile bowl. Place forceps on edge of sterile field on table with tips inside sterile field. If placed directly on sterile field, the towel would become wet and therefore contaminated. Maintaining the sterility of tip for future use, though handle is not sterile. 10. Cut open the following items and use sterile forceps to remove them from the package and place them in the center of the sterile towel on the bedside table: - Fluid - Urinary bag - Infusion set - Syringe (if reusing syringe, use sterile forceps to obtain it form the Maintaining sterility of field and items and preparing for assembly. Tearing packages increases likelihood of contamination.
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  sterile package andplace on sterile towel on bedside table) being careful to maintain sterility of items and sterile field 11. 1 Close catheter clamp, or use Kelly Clamp to clamp catheter. Prepares for disconnection and preserves sterility of gloves later in procedure. 12. Don sterile gloves 13. Using syringe, remove from LR bag the same amount of fluid as the amount of D50 to be added. Discard into non-sterile kidney basin. Preparing to create a solution of the correct concentration. 14. Using syringe, draw up ordered amount of D50 and add to the bag of Lactated Ringer. Rotate to mix. This is the “dialysate” Creating the PD solution. Glucose provides the osmotic pressure for ultrafiltration. 15. Ensure roller clamp on infusion tubing is closed then spike dialysate bag. 16. Attach infusion set to appropriate port of stopcock This is where dialysate will infuse through. 17. Attach suction tubing to “urinary bag” port of stopcock as far as possible and attach urinary bag to suction tubing. Ensure drainage port on urinary bag is closed. Attach as far as possible to prevent leaks. This may become difficult after the suction tubing has been in the alcohol for some time and hardens. Consider replacing suction tubing if needed. 18. Turn stopcock “off” toward the Patient. To prevent fluid from draining prematurely. 19. With one hand, use a square of sterile gauze to hold PD catheter. With other hand, use one square sterile gauze to remove cap from PD catheter and place in alcohol. Continue bolding catheter with the same hand – do not let go until step 20 is complete. The catheter and cap are not sterile, so holding them with sterile gloves would contaminate the gloves. 20. With one hand, dip cotton swab into alcohol and cleanse port in a circular motion. Allow to dry. Decrease risk of infection at port, allow to dry to prevent fusing to connector. 21. Attach “patient” port of stopcock to PD catheter, ensuring that it is pushed all the The catheter is not sterile, so holding it with sterile gloves would contaminate the gloves. Must be
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  way in. note: handsare no longer sterile. pushed all the way in to prevent leakage. 22. Place urinary bag on the floor. Wrap dialysis fluid next to hot water bottle. Facilitates drainage and keeps fluid warm while maintaining a closed system. 23. Turn stopcock “off” towards infusion set and open catheter clamp. Allows dialysate to flow from abdomen into urinary bag. 24. Ensure dialysate is flowing into urinary bag without leaks. Allows accurate measuring of drainage and prevents contamination of sterile towel. 25. Remove gloves and cleanse hands. Gloves are no longer sterile. Monitor the bag often to ensure the urinary bag is emptied when it is full. 26. a) If reusing syringe, use forceps to remove other items from sterile towel on bedside table and place syringe in the center. b) Place sterile bowl with 2 remaining gauze squares, and 1 sterile swab on bedside table. Cover with sterile gauze and place forceps in bowl. c) Then cover the syringe by folding the sterile towel, keeping the center sterile. 27. Reposition patient from one side to the other and palpate abdomen as needed. This promotes and ensures complete draining. 28. When draining is finished, clean hands, put on clean gloves, hand fluid on IV pole, and turn stopcock off toward patient. This will stop draining and allow flushing of stopcock. 29. Open infusion Set clamp, allowing fluid to flush tubing until it enters the stopcock. Close infusion Set clamp. Air will drain into urinary bag instead of peritoneal cavity. 30. Turn stopcock off to urinary bag and open roller clamp again to begin “Fill” phase, ensuring that fulling happens in ordered time. This allows new dialysate solution to enter peritoneal cavity in a closed system, decreasing risk of infection. Filling too quickly can cause complications and discomfort.
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  31. If usingtwo bags, when first bas is empty: clean hands, put on clean gloves, close roller clamp, remove spike from bag and spike second bag being extremely cautious not to contaminate or touch spike, then resume infusing. Remove gloves and clean hands. This action is one of the biggest risks as the system is then open to contamination. 32. Just before Fill phase is finished (all ordered fluid has been infused), remove sterile gauze from sterile bowl. 33. Use sterile forceps to remove catheter cap from alcohol and place in sterile bowl. Be careful not touch the end of the cap that attaches to the PD catheter as this will introduce contaminants to peritoneum increasing risk for infection. 34. Close roller clamp on infusion set and clamp PD catheter. Prevents dialysate from flowing out when removing exchange set-up and re- capping PD catheter. 35. Clean hands and don sterile gloves. Prevents infection when handling the catheter and opening the system in following steps. 36. Using remaining 2 pieces of sterile gauze. With one hand: hold PD catheter. With other hand: remove stopcock assembly from PD catheter. Continue holding PD catheter with gauze in one hand until re-capping is completed. Using gauze preserves sterility of gloves and decreases risk of contamination of the PD catheter. 37. Dip sterile cotton swab in alcohol and swab catheter port in a circular motion. Allow to dry Cleans port of entry, preventing risk of infection. 38. Place catheter cap on port being extremely careful not to contaminate the end of the cap that attaches to the port, or the port itself. Prevents infection from entering the peritoneum. 39. Disassemble system: - Place suction tubing in 90% alcohol - Place stopcock in “open all ways” position into 90% alcohol Do not leave suction tubing piece attached to stopcock - Discard urinary bag after measuring output If suction tubing piece remains attached or stopcock is not placed in “open all ways” position, alcohol is not able to access and disinfect all parts of the system.
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  - Discard infusionset and fluid bags. 40. Remove surgical mask and allow caregivers to return. PD system is now closed so risk for contamination is low. 41. Complete documentation including: - Amount of fluid - Color and quality of fluid - Times of in and out - Any concerns noted, such as discomfort - What time the syringe is replaced Allows monitoring of efficacy of PD, fluid balance, and changes in patient’s condition.