Renal Replacement Therapies in the blood to an area of lesser concentration in the

PERITONEAL DIALYSIS dialysate.

2. Osmosis
LEARNING OBJECTIVES: a. Excess water is removed
At the end of the discussion, the learners will be able to: b. Water moves from an area of higher solute
concentration (blood) to lower solute concentration
1. describe key concepts related to dialysis. (dialysate).
2. differentiate peritoneal dialysis from hemodialysis. 3. Ultrafiltration
3. enumerate the different types of peritoneal dialysis. a. movement of fluid across a semipermeable
4. describe the complications associated with peritoneal membrane as a result of an artificially created
dialysis. pressure gradient. Water moving under high pressure to
5. apply the nursing process in identifying nursing an area of lower pressure.
management in the care of a client undergoing renal b. Much more efficient water removal than osmosis.
replacement therapy. Accomplished by applying negative pressure or
suctioning force to the dialysis membrane.
I. DIALYSIS 4. Buffer system
A. Definition a. the body’s buffer system is maintained using a
1. Also called renal replacement therapy (RRT), is the dialysate bath made up of bicarbonate (most
passage of particles from an area of high concentration to common) or acetate.
an area of low concentration across a semi-permeable b. The dialysate need not be sterile because bacteria and
membrane. viruses are too large to pass through the pores of the
2. It is the process used to remove fluid and uremic semipermeable membrane; however, the dialysate must
waste products when the kidney is unable to do so. meet specific standards, and water is treated to ensure a
safe water supply.
B. Goals c. Heparin is given to keep blood from clotting in the
1. To remove the end products of protein metabolism. extracorporeal dialysis circuit (Dialyzer).
(urea and creatinine) 5. Dialyzer
2. To maintain a safe concentration of serum a. Dialyzers are hollow-fiber devices containing
electrolytes. thousands of tiny capillary tubes that carry the
3. To correct acidosis blood through the artificial kidney.
4. To remove excess fluid b. The tubes are porous and act as a semipermeable
membrane, allowing toxins, fluid, and electrolytes
C. Classifications to pass across the membrane.
1. Acute or Urgent Dialysis 6. Vascular Access
a. high and increasing level of serum potassium a. Access to the patient’s vascular system must be
b. fluid overload (impending pulmonary edema) established to allow blood to be removed, cleansed,
c. to remove medications or toxins (poisoning or and returned to the patient’s vascular system.
medication overdose) from the blood
2. Chronic or Maintenance Dialysis III. TYPES OF DIALYSIS
a. For chronic renal failure / maintenance [Advanced A. Peritoneal Dialysis
Chronic Kidney Disease (CKD) and End-Stage Renal 1. The utilization of the peritoneal cavity and the
Disease (ESRD)] peritoneum as the semipermeable membrane that
b. Occurrence of uremic signs and symptoms removes excess fluids.
affecting body system. (nausea and vomiting, severe 2. The membrane is accessed by insertion of a PD
anorexia, increasing lethargy, mental confusion) catheter through the abdomen.
“The decision to initiate dialysis should be reached 3. Cycle is initiated with the inflow of the dialysate
only after thoughtful discussion among the patient, family, by gravity into the peritoneum (Fill time). Initial
primary provider, and other health care team members. infusion is usually 1 to 2 L over 10-20 minutes.
Successful kidney transplantation eliminates the need 4. The dialysate remains in the abdomen (Dwell
for dialysis.” time). Allowed to drain by gravity (Drain time).
5. The dwell time and drain time are specified in the
II. PRINCIPLES OF DIALYSIS doctor’s orders. Seriously ill clients may receive up to 24
1. Diffusion exchanges in a day.
a. Toxins and wastes are removed B. Hemodialysis
b. Solutes moving from an area of greater concentration 1. Hemodialysis is a renal replacement therapy
involving the process of cleansing the client’s blood. dialysis, or nightly peritoneal dialysis.
2. Vascular access site must be established; access c. The exchanges are automated instead of
may be temporary or permanent. manual.
d. Most clients prefer to have the dialysis
IV. PERITONEAL DIALYSIS done while sleeping.
A. Access D. Contraindications for PD
1. Peritoneum. 1. Peritonitis
a. Serous membrane that covers the abdominal 2. Recent Abdominal Surgery
organs and lines the abdominal wall. 3. Abdominal Adhesions
b. Serves as the semi-permeable membrane. 4. Other GI problems such as Diverticulitis
B. Indications
1. PD is the treatment of choice for the older adult E. Complications
2. Indicated or clients requiring dialysis who are: 1. Peritonitis
a. Unable to tolerate anticoagulation a. Most common and serious complication
b. Have difficulty with vascular access b. cloudy or opaque outflow
c. Have chronic infections or are unstable 2. Leakage
C. Types of Peritoneal Dialysis a. Occur usually after the catheter is inserted
1. Continuous Ambulatory Peritoneal Dialysis b. stops for several days allowing the site to heal
(CAPD) 3. Bleeding
a. Closely resembles renal function because it is a a.common during the first few exchanges
continuous process b. common in young menstruating women.
a. Does not require a machine for the procedure. Hypertonic fluid pulls blood from the uterus, through
b. The client performs self-dialysis 24 hours a the opening of the fallopian tubes, and into peritoneal
day, 7 days a week. cavity.
c. Four dialysis cycles are usually administered 4. Hyperglycemia
in a 24-hour period, including an overnight 8-hour a. Can result due to the hyperosmolarity of the
dwell time. dialysate.
d. Dialysate, 1.5 to 2 L, is instilled into the b. Glucose may be reabsorbed from the
abdomen 4 times daily and allowed to dwell as dialysiate into the blood especially in patients with
prescribed (bags are weighed to determine output); the diabetes mellitus.
catheter is clamped and the bag is rolled up during 5. Hyperlipedemia
dwell time. a. May occur from long term therapy and lead to
e. The dialysate is infused into the abdomen and hypertension.
remains there for a specified time (2-6 hours). 6. Long term complications
f. The dialysate is remove by gravity drainage a. Abdominal Hernias. And hemorrhoids.
after the prescribed time. (incisional, inguinal, diaphragmatic, and umbilical),
2. Automated Peritoneal Dialysis probably resulting from continuously increased
a. Automated dialysis requires a peritoneal intra-abdominal pressure. The persistently elevated
dialysis cycling machine. intra-abdominal pressure also aggravates symptoms
b. Automated dialysis can be done as continuous of hiatal hernia and hemorrhoids.
cycling peritoneal dialysis, intermittent peritoneal b. Low back pain and anorexia from fluid in
the abdomen.

V. NURSING MANAGEMENT
A. Peritonitis
1. Monitor for signs and symptoms of peritonitis:
Fever, cloudy outflow, rebound abdominal tenderness,
abdominal pain, general malaise, nausea, and vomiting.
2. If peritonitis is suspected, obtain a sample for C/S
of the outflow
3. Antibiotics may be added to the dialysate.
4. Avoid infections by maintaining meticulous
sterile technique when connecting and disconnecting PD
solution bags and when caring for the catheter insertion
site.
B. Abdominal pain
1. Peritoneal irritation during inflow commonly causes
abdominal cramping and discomfort during the first few
exchanges; the pain usually disappears after 1 to 2 weeks of
dialysis treatments.
2. Warm the dialysate before administration, using
a special dialysate warmer pad.
C. Abnormal outflow
1. Bloody outflow after the first few exchanges
indicates vascular complications (the outflow should be
clear after the initial exchanges).
2. Brown outflow indicates bowel perforation.
3. Urine-colored outflow indicates bladder
perforation.
4. Cloudy outflow indicates peritonitis.
D. Insufficient outflow
1. The main cause of insufficient outflow is a full
colon; Constipation can cause inflow and outflow
problems.
2. Insufficient outflow may also be caused by catheter
migration out of the peritoneal area; if this occurs, an
x-ray will be prescribed to evaluate catheter position.
3. Maintain the drainage bag below the client’s
abdomen.
4. Check for kinks in the tubing.
5. Change the client’s outflow position by turning the
client to a side-lying position or ambulating the client.
6. Check for fibrin clots in the tubing and milk the
tubing to dislodge the clot as prescribed.

VI. REFERENCES
Cheever, K., Hinkle, J. & Overbaugh, K. Brunner and Suddarth's
Textbook of Medical-Surgical Nursing. 15th ed. 2022
Zerwekh, J. Illustraded Study Guide for the NCLEX RN Exam.
10th ed. 2019
Sharma, M.P. Comprehensive Textbook of Medical Surgical
Nursing. 1st ed. 2016
Silvestri, A., et.al. Saunders Comprehensive Review for the
NCLEX RN Examination. 8th ed. 2020.
Prepared by: JOHN EMMANUEL C. MAGTIBAY, RN / NCM 118n
LEC / 1st Sem 2023-2024