peritonealdialysis and home care management.pptx

peritonealdialysis a

1. Ms.L . SUNEETHA, M.Sc. ( N ) 1 st year , SPGCON, Tirupathi PERITONEAL DIALYSIS

2. Objectives At the end of the class students will be able to : Define peritoneal dialysis Anatomy and physiology of peritoneal membrane The goals of peritoneal dialysis Indications and contra indications of PD Peritoneal dialysis access and insertion procedure The procedure of PD Different types of PD Complications of PD The advantages of PD over HD Nursing management of patients undergoing PD

3. Anatomy

4. Physiology The semipermeable peritoneal membrane allows solutes and water to be transported from the vascular system to the peritoneal cavity and vice versa.

5. Peritoneal dialysis: Introduction Peritoneal dialysis (PD) is a treatment for patients with severe chronic kidney disease. A dialysis technique that uses the patient's own body tissue- peritoneal membrane inside the abdominal cavity as a filter.

6. Goals of PD Remove toxic substances and metabolic wastes Reverse the symptoms of uremia Reestablish normal fluid and electrolyte balance Maintain a positive nitrogen balance Prolong life Have the maximum level of quality of life

7. Principles underlying peritoneal dialysis Three processes take place simultaneously Diffusion Osmosis Ultrafiltration

8. Treatment of choice for…. Patients with RF unable or unwilling to undergo HD or renal transplantation Diabetic patients Patients with cardiovascular diseases eg:heart failure Older patients Patients at risk of adverse effects of systemic heparin Patients with severe hypertension

9. Contra indications Absolute contra indications Peritoneal fibrosis and adhesions following intra abdominal operations Inflammatory gut diseases

10. Relative contra indications Hernias Significant loin pain Psychosis Diverticulosis Colostomy Obesity Significant decrease of lung functions

11. PD catheters Catheters for long- term use (Tenckhoff, Swan, Cruz) are usually made of silicone and are radioopaque to permit visualization on x- ray. These catheters have three sections: An intraperitoneal section with numerous openings and an open tip to let dialysate flow freely; A subcutaneous section that passes from the peritoneal membrane and tunnels through muscle and subcutaneous fat to the skin An external section for connection to the dialysate section

12. Catheters have two cuffs, which are made of Dacron polyester. The cuffs: stabilize the catheter limit movement prevent leak provide a barrier against microorganism Cuff placement : adjacent to the peritoneum subcutaneously. The subcutaneous tunnel (5 to 10 cm long) further protects against bacterial infection

13. Types of catheters The design of a peritoneal catheter need to be such that It should give maximum inflow and output Discourage infection Four main types Straight Tenckhoff Curled Tenckhoff Swan- neck T- fluted

14. PD catheters

15. PD catheters T fluted catheter Two –cuff tenckhoff catheter

16. Insertion techniques Blind placement using Tenckhoff trocar Blind placement using guide wire Surgical placement by dissection Mini trocar placement using peritoneoscopy

17. Preinsertion preparation of the patient Determine the catheter exit site Site : Midline 3 cm below umbilicus Lateral site At the lateral border of the rectus muscles On a line, half way between the umbilicus and anterior superior iliac spine Left lateral side is preferred as it avoids caecum

18. Pre operative care of the patient Take bath or have a shower in the morning Abdominal hair should be clipped Empty bowel and bladder before catheter insertion Enema can be given Staphylococcus aureus screening Administer antibiotics prophylactically

19. A trocar is used to puncture the peritoneum as the patient tightens the abdominal muscles by raising the head. The catheter is threaded through the trocar and positioned. Previously prepared dialysate is infused into the peritoneal cavity, pushing the omentum (peritoneal lining extending from the abdominal organs) away from the catheter. The physician may then secure the catheter with a purse- string suture and apply antibacterial ointment and a sterile dressing over the site

20. Post operative care of the patient Goals: Minimise bacterial colonisation of exit site during early healing period Prevent trauma to exit site and traction on cuffs by immobilization of catheter Minimise intra abdominal pressure to prevent leakage Do not disturb the exit site for 7- 10 days Flush the catheter with 500- 1500 ml of PD fluid to check patency

21. Composition of PD solution Components Na 132 mmol/l Ca 1.25mmol/l Mg 0.5mmol/l Cl 100mmol/l Lactate 35mmol/l Glucose 1.36-4.25g/dl Osmolarity 347- 486 pH 5.2

22. PROCEDURE Patient preparation Explain the procedure & obtain informed consent. Baseline vital signs, weight, serum electrolyte levels are recorded. Assess patient’s anxiety about the procedure. Broad spectrum antibiotics prophylactically .

23. PROCEDURE Equipment preparation Assemble the equipments needed Check physician’s order for the concentration of dialysate and medications to be added Heparin : to prevent clotting KCl: to prevent hypokalemia Antibiotics : peritonitis Insulin : for diabetic patients

24. PROCEDURE Warm the dialysate solution to body temperature : To prevent patient discomfort and abdominal pain To dilate the vessels of peritoneum Dry heating should be done Too cold solution causes pain, cramping, and reduce clearance

25. Not recommended .... Soaking the bag of solution in warm water Use of microwave to heat the fluid Avoid too cold solution

26. Performing the exchange Exchange : Infusion Dwell or Equilibration time Drainage

27. PERITONEAL DIALYSIS

28. Performing the exchange Infusion The dialysate is infused by gravity into the peritoneal cavity. A period of about 5 to 10 minutes is usually required to infuse 2 L of fluid.

29. Dwell or equilibration and drainage of dialysate The prescribed dwell, or equilibration, time allows diffusion and osmosis to occur. Diffusion of small molecules, such as urea and creatinine, peaks in the first 5 to 10 minutes of the dwell time. At the end of the dwell time, the drainage portion of the exchange begins. The tube is unclamped and the solution drains from the peritoneal cavity by gravity through a closed system. Drainage is usually completed in 10 to 30 minutes .

30. Performing the exchange Drainage fluid Colorless or straw-colored Should not be cloudy Bloody drainage may be seen in the first few exchanges Entire exchange time 1 to 4 hours (depending on prescribed dwell time)

31. Performing the exchange No.of exchanges According to patient’s physical status and acuity of illness Dextrose solutions Dextrose solutions of 1.5%, 2.5%, and 4.25% are available in several volumes, from 500 mL to 3,000 mL, allowing the dialysate selection to fit the patient’s tolerance, size, and physiologic need

32. Types of peritoneal dialysis Continuous ambulatory peritoneal dialysis (CAPD) Automated peritoneal dialysis (APD) Continuous cycling peritoneal dialysis ( CCPD) Intermittent peritoneal dialysis Nocturnal(nightly)intermittent peritoneal dialysis

33. Continuous ambulatory peritoneal dialysis (CAPD) Carried out during day time , manually by patients or by caregivers Dialysis fluid is infused to the peritoneal cavity Dwell time for between 3 - 10 hrs Most suitable for patients whose membrane transport solutes at a slow to average rate

34. Automated peritoneal dialysis - is performed through a cycler machine. - during the night when the patient is asleep.

35. Continuous cycling peritoneal dialysis Patient carries PD solution in the abdominal cavity through out the day but performs no exchanges. At bedtime ,patient hooks upto the cycler ,which drains and refills the abdomen with solution three or more times in the course of the night.

36. Intermittent peritoneal dialysis(IPD ) Intermittent peritoneal dialysis is offered to patients on a temporary basis when their blood pressure is low or in children with acute renal failure to tide over a crisis. It is performed for a short period of 12-24 hours,2- 3 times weekly. Common routine hourly exchange consists of 10 min infusion, 30min dwell time and a 20 min drain time.

37. Nocturnal intermittent peritoneal dialysis Patient drains out fully at the end of the cycling period, so the abdomen is dry all day. Clearances are lower on NIPD.

38. Assessing peritoneal dialysis adequacy Creatinine clearance A solute removal test based on the body surface area General well being

39. Dialysis related problems Protein loss Protein loss through the peritoneal membrane @ 6- 12g/day in a PD patient To compensate for this PD patients need to eat between 1 – 1.2 g/ kg body weight/ day The loss is increased during peritonitis Other substances lost in dialysate are amino acids, water- soluble vitamins, hormones and some medications

40. Dialysis related problems … Cardio vascular and lipid problems Increased glucose absorption from the PD fluid Raised intra abdominal pressure Can cause hernias & dialysate leakage around the insertion site If leakage occurs , PD must be ceased for a short period

41. Dialysis related problems Drainage problems Reasons can be Kinks in the tubing Constipation Fibrin formation Milking can be done Heparin administration Streptokinase or urokinase in 0.9% NaCl Malpositioned catheter

42. Dialysis related problems Blood stained effluent In menstruating females; due to endometriosis or retrograde bleeding through fallopian tube Severe intraperitoneal bleeding ; due to straining while lifting a heavy object or suffering trauma to abdomen Shoulder pain Following infusion of fresh dialysate Referred pain caused by intra abdominal pressure or air under the diaphragm Resolve within 20 min; analgesics can be given

43. Infectious complications Peritonitis Most common and most serious complication Diagnosis Cloudy PD effluent Abdominal pain , tenderness , pyrexia Identification of micro organisms in PD effluent in culture or positive gram staining

44. Infectious complications Treatment Initial one to three rapid exchanges with 1.5% dextrose solution – to wash out mediators of inflammation Drainage fluid – examined for cell count , Gram’s stain, culture Intraperitoneal or intravenous antibiotics Unresolved peritonitis after 4 days of appropriate therapy necessitates catheter removal

45. Infectious complications Exit site infection The presence of purulent drainage with or without erythema of the skin at catheter epidermal interface. Tunnel infection Can present as an extension of the exit site infection into the catheter tunnel. Swelling, pain and redness over the subcutaneous tunnel may be observed . Management Culture of drainage Antibiotic therapy

46. Advantages of PD over HD Easy to use without sophisticated equipments Easy to manage in home and community health care facilities more independence and mobility Dialysis treatment of choice for children May allow better blood pressure and volume control with cardiovascular benefits May give better quality of life Lower risk of Hepatitis C Equal or better survival in early years

47. Nursing management Potential for developing infection related to the catheter  Assess the site for any signs of infection; any redness, rebound tenderness, swelling, drainage from the exit site or change in vital signs Maintain strict aseptic technique while carrying out the procedure

48. Nursing management Potential for developing cardiac and respiratory complications related to the uremic state and presence of fluid in the peritoneum   Frequent cardiac and respiratory assessment Watch for signs of fluid accumulation; heart failure, and pulmonary edema Auscultate the base of lungs for crackles Assess for signs of pericarditis; substernal pain, low grade fever, and pericardial friction rub.

49. Nursing management Acute pain and abdominal discomfort related to the dialysate infusion Warm the dialysate to body temperature Altered nutrition less than body requirement related to the protein loss High protein, fiber rich well balanced diet Limit carbohydrate intake

50. Nursing management Knowledge deficit related to care of catheter site Teach the patient the possible signs of infection Catheter care should be done daily Avoid tub bath and exit site should not be submerged in water

51. Nursing management Altered body image related to the abdominal catheter and bag and tubing   Assess for any such problem Allow the patient to express his feelings and concerns about body image disturbances. Assist in selecting of proper clothing Provide an opportunity to the patient to meet similar patients who are well adjusted with the condition

52. Nursing management Altered sexual patterns and sexual dysfunction Provide privacy to the patient so that he can discuss his problem Nurse can start the discussion by asking about any concerns related to sexuality

53. Conclusion Long term outcomes associated with peritoneal dialyses are good. The treatment is usually effective for years. However scarring of the peritoneum and repeated infections may require a change to hemodialysis.