13.3 Peritoneal Dialysis Principles and Nursing Care

PD as an Alternative Modality

Peritoneal dialysis (PD) circulates dialysis solution through a catheter in the abdominal cavity. The peritoneal membrane separates capillary blood from the solution. Waste solutes move by diffusion, while glucose or another prescribed osmotic agent promotes water transfer. Unlike intermittent extracorporeal HD, the blood generally remains inside the patient's circulation and treatment involves repeated exchanges. PD is a substantive modality choice, not merely an emergency substitute for a failed fistula.

Explain advantages and burdens in relation to the patient's goals. Home flexibility and a different pattern of fluid removal may appeal to some patients; storage, daily tasks, infection risk, abdominal considerations and caregiver support may matter to others. Suitability is individualized. Previous abdominal surgery, body size or visual limitations do not automatically determine candidacy without specialist assessment and available assistance.

Fill, Dwell and Drain

Each exchange has a fill phase, a prescribed dwell and a drain. Continuous ambulatory peritoneal dialysis (CAPD) uses manual exchanges. Automated PD (APD) uses a cycler, often overnight, with prescription-specific daytime fluid or exchanges when needed. The number, volume and duration are individualized to membrane transport, residual kidney function, body size and goals. Do not copy another patient's schedule.

During a dwell, the osmotic gradient changes as glucose is absorbed. Higher-glucose solutions can increase water removal but also increase glucose exposure and may affect thirst, weight or glycemic control. Icodextrin may be used for selected long dwells; compatible glucose testing is essential because some meters can report misleadingly high glucose with its metabolites. Patients use only the solutions and devices prescribed by the PD team.

Fluid Accounting and Adequacy

PD ultrafiltration is the drained volume minus the instilled volume for the measured exchanges. If 2,000 mL is instilled and 2,350 mL drains, net removal for that exchange is 350 mL, excluding other intake and output. A drained volume of 2,350 mL is not 2,350 mL of patient fluid removed. Record complete exchanges and any leaks, incomplete drains or bypassed cycles.

Assess weight, BP, edema, breathing, residual urine and symptoms. Solute adequacy includes dialysis and residual kidney clearance, but laboratory targets do not replace appetite, function and clinical assessment. A decline in urine output can make a formerly sufficient prescription inadequate. Follow the PD team's collection instructions for effluent and urine; incomplete collections distort measured clearance.

Infection Prevention and Exit-Site Care

Hand hygiene, clean workspace, aseptic connection and protection from contamination are central. Train the patient to recognize a broken connection, touched sterile end or damaged bag and to follow the program's contamination response. Do not instruct the patient to reconnect a contaminated set casually. Exit-site care and any prophylactic product follow the PD protocol; a hemodialysis-catheter ointment routine is not automatically the PD routine.

Do not wait for all classic symptoms before reporting possible peritonitis. The clinician orders effluent cell count and culture and determines treatment. Clear fluid does not exclude every abdominal emergency. Keep track of antibiotic timing and specimen collection; treatment should not be delayed by an avoidable process problem.

Mechanical and Metabolic Problems

Constipation can impair catheter drainage, so bowel management may be part of the prescription. Catheter migration, fibrin, kinks, leaks and hernias need assessment. Do not force a flush or add unprescribed heparin or medication to a bag. New breathlessness during a fill may reflect intolerance or another illness and requires evaluation rather than simply increasing the dwell volume.

Glucose absorption can affect diabetes management, and protein loss through effluent affects nutrition. Monitor appetite, weight change, laboratory trends and the dietitian's plan. Fluid and potassium advice may differ from HD because residual function and daily removal differ. Avoid using a rigid HD food restriction sheet as the complete PD education plan.

Transitions and Follow-Up

Some patients move between PD and HD because of infection, inadequate clearance, mechanical problems, preference or changing support. Explain the reason, preserve future access options and communicate current medications and residual kidney function. A transition is not necessarily a failure of effort. Reassess what the patient needs to learn for the new modality rather than assuming prior dialysis experience covers the new equipment.

A PD patient calling about cloudy drain fluid should receive prompt instructions through the PD emergency plan, with effluent preserved when directed and timely clinical evaluation. The nurse's priority is possible infection and safe assessment, not reassuring the patient that every cloudy bag is harmless fibrin. Competent modality teaching includes this decision as well as the mechanics of an ordinary exchange.

Source: NIDDK peritoneal dialysis.