Dialysis Nursing Care Plan & Management

Description

• Dialysis is primarily used to provide an artificial replacement for lost kidney function (renal replacement therapy) due to renal failure
• Dialysis works on the principles of diffusion of solute through a semipermeable membrane that separates  two solutions.
• Direction of diffusion depends on concentration of solute in each solution.
• Rate and efficiency depend  on concentration gradient, temperature of solution, pore size of membrane, and molecular size.

Two Mechanisms in Dialysis

1. Diffusion – movement of particles from an area of high concentration to one of low concentration across a semipermeable membrane.
2. Osmosis – movement of water through a semipermeable membrane from an area of lesser concentration of particles to one of greater concentration.

Indications

The decision to initiate dialysis or hemofiltration in patients with renal failure depends on several factors. These can be divided into acute or chronic indications.

• Indications for dialysis in the patient with acute kidney injury are:
  1. Metabolic acidosis in situations where correction with sodium bicarbonate is impractical or may result in fluid overload.
  2. Electrolyte abnormality, such as severe hyperkalemia, especially when combined with AKI.
  3. Intoxication, that is, acute poisoning with a dialysable drug, such as lithium, or aspirin.
  4. Fluid overload not expected to respond to treatment with diuretics.
  5. Complications of uremia, such as pericarditis or encephalopathy.
• Chronic indications for dialysis:
  1. Symptomatic renal failure
  2. Low glomerular filtration rate (GFR) (RRT often recommended to commence at a GFR of less than 10-15 mls/min/1.73m²). In diabetics dialysis is started earlier.
  3. Difficulty in medically controlling fluid overload, serum potassium, and/or serum phosphorus when the GFR is very low

Goals

• Reduce level of nitrogenous waste.
• Correct acidosis, reverse electrolyte imbalances, remove excess fluid.

Two main types of dialysis

I. Hemodialysis

• Hemodialysis removes wastes and water by circulating blood outside the body through an external filter, called a dialyzer, that contains a semipermeable membrane
• In hemodialysis, the patient’s blood is pumped through the blood compartment of a dialyzer, exposing it to a partially permeable membrane.
• The dialyzer is composed of thousands of tiny synthetic hollow fibers.
• The fiber wall acts as the semipermeable membrane. Blood flows through the fibers, dialysis solution flows around the outside the fibers, and water and wastes move between these two solutions.
• The cleansed blood is then returned via the circuit back to the body.
• Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer membrane.
• This usually is done by applying a negative pressure to the dialysate compartment of the dialyzer.
• This pressure gradient causes water and dissolved solutes to move from blood to dialysate, and allows the removal of several litres of excess fluid during a typical 3 to 5 hour treatment.
• Studies have demonstrated the clinical benefits of dialyzing 5 to 7 times a week, for 6 to 8 hours.
• These frequent long treatments are often done at home, while sleeping but home dialysis is a flexible modality and schedules can be changed day to day, week to week.

image credit to : www.niddk.nih.gov

Types of venous access for hemodialysis

1. External shunt
   • Cannula is placed in a large vein and a large artery that approximate each other.
   • External shunts, which provide easy and painless access to bloodstream, are prone to infection and clotting and causes erosion of the skin a round the insertion area.
2. Arteriovenous fistulas or graft
   • Large artery and vein are sewn together (anastomosed) below the surface of the skin (fistula) or subcutaneous graft using the salphenous vein, synthetic prosthesis, or bovine xenograft to connect artery and vein.
   • Purpose is to create one blood vessel for withdrawing and returning blood.
   • Advantage is greater activity range than AV shunt and no protective asepsis.
   • Disadvantage is necessity of two venipunctures with each dialysis.
3. Vein catheterization
   • Femoral or subclavian vein access is immediate
   • May be short or long term duration.

Nursing Considerations

Before the Hemodialysis

1. Allow the client to void.
2. Document the client’s weight.
3. Obtain vital signs as baseline.
4. Check the medications history of the patient before the procedure. Antihypertensives, sedatives and vasodilators are prevented in order to do away with hypotensive episode.

During the Hemodialysis

1. Obtain vital signs periodically between 30 minutes.
2. Observe proper body alignment, allow frequent position changes.
3. Monitor for episodes of nausea and vomiting which may occur during the procedure.
4. Monitor for signs of bleeding by taking clotting time about 1 hour before the client comes off the machine. Observe clotting time at 30 to 90 minutes while on dialysis (Normal value: 6 – 10 minutes)

After Dialysis

1. Check the client’s weight, note any difference.
2. Assess for complications.
3. Check for signs of bleeding and status of the fistula.

Complications of Dialysis

1. Hypovolemic Shock – result of rapid removal or ultrafiltration of fluid from the intravascular compartment
2. Dialysis-disequilibrium syndrome – caused by rapid, efficient dialysis resulting in shifts in water, pH and osmolarity between fluid and blood.

Signs and Symptoms

1. Nausea & Vomiting
2. Headache
3. Hypertension
4. Agitation
5. Disorientation
6. Twitching
7. Peripheral paresthesias
8. Convulsions

II. Peritoneal dialysis

• Peritoneal dialysis is a treatment for patients with severe chronic kidney failure
• Wastes and water are removed from the blood inside the body using the peritoneal membrane as a natural semipermeable membrane.
• Wastes and excess water move from the blood, across the peritoneal membrane, and into a special dialysis solution, called dialysate, in theabdominal cavity which has a composition similar to the fluid portion of blood.
• In peritoneal dialysis, a sterile solution containing minerals and glucose is run through a tube into the peritoneal cavity, the abdominal body cavity around the intestine, where the peritoneal membrane acts as a semipermeable membrane.
• The peritoneal membrane or peritoneum is a layer of tissue containing blood vessels that lines and surrounds the peritoneal, or abdominal, cavity and the internal abdominal organs (stomach, spleen, liver, and intestines).
• The dialysate is left there for a period of time to absorb waste products, and then it is drained out through the tube and discarded. This cycle or “exchange” is normally repeated 4-5 times during the day, (sometimes more often overnight with an automated system).
• Ultrafiltration occurs via osmosis; the dialysis solution used contains a high concentration of glucose, and the resulting osmotic pressure causes fluid to move from the blood into the dialysate. As a result, more fluid is drained than was instilled.
• Peritoneal dialysis is less efficient than hemodialysis, but because it is carried out for a longer period of time the net effect in terms of removal of waste products and of salt and water are similar to hemodialysis.
• Peritoneal dialysis is carried out at home by the patient.

image credit to: http://kidneysdisease.com/

Three types of Peritoneal Dialysis

• 1. Intermittent peritoneal dialysis
• 2 Continuous ambulatory peritoneal dialysis
• 3. Continuous cycling peritoneal dialysis

Nursing Considerations

Patient Preparation

1. Allow the client to void before catheter insertion.
2. Institute abdominal skin preparation
3. Document the client’s weight before the dialysis
4. Take baseline vital signs

During the Procedure

1. Monitor the level of electrolytes.
2. Obtain samples of return dialysate for culture
3. Compare the client’s weight before and after the procedure
4. Monitor the vital signs every 30 minutes and report any deviations
5. Provide proper positioning for the dialysate to return from the peritoneal cavity. Place the patient in semi-Fowler’s position.

Complications of Peritoneal Dialysis

1. Excessive loss of fluid can result in hypovolemic shock or hypotension while excessive fluid retention can result in hypertension and edema.
   • The volume of dialysate removed and weight of the patient are normally monitored; if more than500ml of fluid are retained or a litre of fluid is lost across three consecutive treatments, the patient’s physician is generally notified.
2. Also monitored is the color of the fluid removed: normally it is pink-tinged for the initial four cycles and clear or pale yellow afterwards. The presence of pink or bloody effluent suggests bleeding inside the abdomen while feces indicates a .
3. The patient may also experience pain or discomfort if the dialysate is too acidic, too cold or introduced too quickly, while diffuse pain with cloudy discharge may indicate an infection. Severe pain in the rectum or perinium can be the result of an improperly placed catheter. The dwell can also increase pressure on the diaphragm causing impaired breathing, and constipation can interfere with the ability of fluid to flow through the catheter.

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Hemodialysis Nursing Care Plan

Nursing Diagnosis

• Injury, risk for [loss of vascular access]

Risk factors may include

• Clotting
• Hemorrhage related to accidental disconnection
• Infection

Possibly evidenced by

• Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

• Maintain patent vascular access.
• Be free of infection.

Nursing Interventions

Monitor internal AV shunt patency at frequent intervals:

• Palpate for distal thrill.
  • Rationale: Thrill is caused by turbulence of high-pressure arterial blood flow entering low-pressure venous system and should be palpable above venous exit site.
• Auscultate for a bruit.
  • Rationale: Bruit is the sound caused by the turbulence of arterial blood entering venous system and should be audible by stethoscope, although may be very faint.
• Note color of blood and/or obvious separation of cells and serum.
  • Rationale: Change of color from uniform medium red to dark purplish red suggests sluggish blood flow and/or early clotting. Separation in tubing is indicative of clotting. Very dark reddish-black blood next to clear yellow fluid indicates full clot formation.
• Palpate skin around shunt for warmth.
  • Rationale: Diminished blood flow results in “coolness” of shunt.
• Notify physician and/or initiate declotting procedure if there is evidence of loss of shunt patency.
  • Rationale: Rapid intervention may save access; however, declotting must be done by experienced personnel.
• Evaluate reports of pain, numbness or tingling; note extremity swelling distal to access.
  • Rationale: May indicate inadequate blood supply.
• Avoid trauma to shunt. Handle tubing gently, maintain cannula alignment. Limit activity of extremity. Avoid taking BP or drawing blood samples in shunt extremity. Instruct patient not to sleep on side with shunt or carry packages, books, purse on affected extremity.
  • Rationale: Decreases risk of clotting and disconnection.
• Attach two cannula clamps to shunt dressing. Have tourniquet available. If cannulas separate, clamp the arterial cannula first, then the venous. If tubing comes out of vessel, clamp cannula that is still in place and apply direct pressure to bleeding site. Place tourniquet above site or inflate BP cuff to pressure just above patient’s systolic BP.
  • Rationale: Prevents massive blood loss while awaiting medical assistance if cannula separates or shunt is dislodged.
• Assess skin around vascular access, noting redness, swelling, local warmth, exudate, tenderness.
  • Rationale: Signs of local infection, which can progress to sepsis if untreated.
• Avoid contamination of access site. Use aseptic technique and masks when giving shunt care, applying or changing dressings, and when starting or completing dialysis process.
  • Rationale: Prevents introduction of organisms that can cause infection.
• Monitor temperature. Note presence of fever, chills, hypotension.
  • Rationale: Signs of infection or sepsis requiring prompt medical intervention.
• Culture the site and obtain blood samples as indicated.
  • Rationale: Determines presence of pathogens.
• Monitor PT, activated partial thromboplastin time (aPTT) as appropriate.
  • Rationale: Provides information about coagulation status, identifies treatment needs, and evaluates effectiveness.

Administer medications as indicated:

• Heparin (low-dose);
  • Rationale: Infused on arterial side of filter to prevent clotting in the filter without systemic side effects.
• Antibiotics (systemic and/or topical).
  • Rationale: Prompt treatment of infection may save access, prevent sepsis.

Nursing Diagnosis

• Risk for deficient fluid volume

Risk factors may include

• Ultrafiltration
• Fluid restrictions
• Actual blood loss (systemic heparinization or disconnection of the shunt)

Possibly evidenced by

• Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

• Maintain fluid balance as evidenced by stable/appropriate weight and vital signs, good skin turgor, moist mucous membranes, absence of bleeding.

Nursing Interventions

• Measure all sources of I&O. Have patient keep diary.
  • Rationale: Aids in evaluating fluid status, especially when compared with weight. Note: Urine output is an inaccurate evaluation of renal function in dialysis patients. Some individuals have water output with little renal clearance of toxins, whereas others have oliguria or anuria.
• Weigh daily before and after dialysis.
  • Rationale: Weight loss over precisely measured time is a measure of ultrafiltration and fluid removal.
• Monitor BP, pulse, and hemodynamic pressures if available during dialysis.
  • Rationale: Hypotension, tachycardia, falling hemodynamic pressures suggest volume depletion.
• Note whether diuretics and/or antihypertensives are to be withheld.
  • Rationale: Dialysis potentiates hypotensive effects if these drugs have been administered.
• Verify continuity of shunt and/or access catheter.
  • Rationale: Disconnected shunt or open access permits exsanguination.
• Apply external shunt dressing. Permit no puncture of shunt.
  • Rationale: Minimizes stress on cannula insertion site to reduce inadvertent dislodgement and bleeding from site.
• Place patient in a supine or Trendelenburg’s position as necessary.
  • Rationale: If hypotension occurs, these positions can maximize venous return.
• Assess for oozing or frank bleeding at access site or mucous membranes, incisions or wounds. Hematest and/or guaiac stools, gastric drainage.
  • Rationale: Systemic heparinization during dialysis increases clotting times and places patient at risk for bleeding, especially during the first 4 hr after procedure.

Monitor laboratory studies as indicated:

• Hb/Hct;
  • Rationale: May be reduced because of anemia, hemodilution, or actual blood loss.
• Serum electrolytes and pH;
  • Rationale: Imbalances may require changes in the dialysate solution or supplemental replacement to achieve balance.
• Clotting times: PT/aPTT, and platelet count.
  • Rationale: Use of heparin to prevent clotting in blood lines and hemofilter alters coagulation and potentiates active bleeding.
• Administer IV solutions (e.g., normal saline [NS])/volume expanders (e.g., albumin) during dialysis as indicated;
  • Rationale: Saline and/or dextrose solutions, electrolytes, and NaHCO₃ may be infused in the venous side of continuous arteriovenous (CAV) hemofilter when high ultrafiltration rates are used for removal of extracellular fluid and toxic solutes. Volume expanders may be required during or following hemodialysis if sudden or marked hypotension occurs.
• Blood/PRCs if needed.
  • Rationale: Destruction of RBCs (hemolysis) by mechanical dialysis, hemorrhagic losses, decreased RBC production may result in profound or progressive anemia requiring corrective action.
• Reduce rate of ultrafiltration during dialysis as indicated
  • Rationale: Reduces the amount of water being removed and may correct hypotension or hypovolemia.
• Administer protamine sulfate as appropriate.
  • Rationale: May be needed to return clotting times to normal or if heparin rebound occurs (up to 16 hr after hemodialysis).

Nursing Diagnosis

• Risk for excess fluid volume

Risk factors may include

• Rapid/excessive fluid intake: IV, blood, plasma expanders, saline given to support BP during dialysis

Possibly evidenced by

• Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes

• Maintain “dry weight” within patient’s normal range
• Be free of edema
• Have clear breath sounds and serum sodium levels within normal limits.

Nursing Interventions

• Measure all sources of I&O. Weigh routinely.
  • Rationale: Aids in evaluating fluid status, especially when compared with weight. Weight gain between treatments should not exceed 0.5 kg/day.
• Monitor BP, pulse.
  • Rationale: Hypertension and tachycardia between hemodialysis runs may result from fluid overload and/or HF.
• Note presence of peripheral or sacral edema, respiratory rales, dyspnea, orthopnea, distended neck veins, ECG changes indicative of ventricular hypertrophy.
  • Rationale: Fluid volume excess due to inefficient dialysis or repeated hypervolemia between dialysis treatments may cause or exacerbate HF, as indicated by signs and symptoms of respiratory and/or systemic venous congestion.
• Note changes in mentation.
  • Rationale: Fluid overload or hypervolemia may potentiate cerebral edema (disequilibrium syndrome).
• Monitor serum sodium levels. Restrict sodium intake as indicated.
  • Rationale: High sodium levels are associated with fluid overload, edema, hypertension, and cardiac complications.
• Restrict PO/IV fluid intake as indicated, spacing allowed fluids throughout a 24-hr period.
  • Rationale: The intermittent nature of hemodialysis results in fluid retention or overload between procedures and may require fluid restriction. Spacing fluids helps reduce thirst.

Peritoneal Dialysis Nursing Care Plans

Nursing Diagnosis

• Risk for Deficient Fluid Volume

Risk Factors

• Use of hypertonic dialysate with excessive removal of fluid from circulating volume

Desired Outcomes

• Will achieve desired alteration in fluid volume and weight with BP and electrolyte levels within acceptable range.
• Will experience no symptoms of dehydration.

Nursing Interventions

• Measure and record intake and output, including all body fluids, such as wound drainage, nasogastric output, and diarrhea.
  • Rationale: Provides information about the status of patient’s loss or gain at the end of each exchange.
• Maintain record of inflow and outflow volumes and individual and cumulative fluid balance.
  • Rationale: Provides information about the status of patient’s loss or gain at the end of each exchange.
• Assess hb and hct and replace blood components, as indicated.
  • Rationale: This is important in view of under dialysis in patients of normal or near normal hematocrit and suggests the need for modification of dialysis prescription in such situations.
• Adhere to schedule for draining dialysate from abdomen.
  • Rationale: Prolonged dwell times, especially when 4.5% glucose solution is used, may cause excessive fluid loss.
• Weigh when abdomen is empty, following initial 6–10 runs, then as indicated
  • Rationale: Detects rate of fluid removal by comparison with baseline body weight.
• Monitor vital signs. watch and report any signs of pericarditis (pleuritic chest pain, tachycardia, pericardial friction, rub), inadequate renal perfusion (hypotension), and acidosis.
  • Rationale: Patients with end-stage renal disease (ESRD) may develop pericardial disease.
• Monitor BP (lying and sitting) and pulse. Note level of jugular pulsation
  • Rationale: Decreased BP, postural hypotension, and tachycardia are early signs of hypovolemia
• Note reports of dizziness, nausea, increasing thirst.
  • Rationale: May indicate hypovolemia and hyperosmolar syndrome.
• Inspect mucous membranes, evaluate skin turgor, peripheral pulses, capillary refill
  • Rationale: Dry mucous membranes, poor skin turgor and diminished pulses and capillary refill are indicators of dehydration and need for increased intake and changes in strength of dialysate.
• Monitor laboratory studies as indicated: Serum sodium and glucose levels;
  • Rationale: Hypertonic solutions may cause hypernatremia by removing more water than sodium. In addition, dextrose may be absorbed from the dialysate, thereby elevating serum glucose.
• Maintain proper electrolyte balance. Serum potassium levels. Watch for symptoms of hyperkalemia (malaise, anorexia, paresthesia, or muscle weakness) and electrocardiogram changes (tall peaked T waves, widening QRS segment, and disappearing P waves), and report them immediately.
  • Rationale: Although a small percent of patients are chronically hypokalemic, hyperkalemia is by far the most common abnormality in dialysis patients.
• Assess patient frequently, especially during emergency treatment to lower potassium levels. If the patient receives hypertonic glucose and insulin infusions, monitor potassium levels. If you give sodium polystyrene sulfonate rectally, make sure the patient doesn’t retain it and become constipated.
  • Rationale: To prevent bowel perforation.
• Maintain nutritional status. Provide a high-calorie, low-protein, low-sodium, and low-potassium diet, with vitamin supplements.
  • Rationale: To balance nutritional intake.
• Aggressively restore fluid volume after major surgery or trauma.
  • Rationale: Dialysis dysequilibrium syndrome is a frequent complication of renal replacement therapy and seems to be related to changes in fluid balance.

Nursing Diagnosis

• Risk for Ineffective Breathing Pattern

Risk factors may include

• Abdominal pressure/restricted diaphragmatic excursion; rapid infusion of dialysate; pain
• Inflammatory process (e.g., atelectasis/pneumonia)

Desired Outcomes

• Display an effective respiratory pattern with clear breath sounds, ABGs within patient’s normal range.
• Experience no signs of dyspnea/cyanosis

Nursing Interventions

• Monitor respiratory rate and effort. Reduce infusion rate if dyspnea is present.
  • Rationale: Tachypnea, dyspnea, shortness of breath, and shallow breathing during dialysis suggest diaphragmatic pressure from distended peritoneal cavity or may indicate developing complications.
• Auscultate lungs, noting decreased, absent, or adventitious breath sounds: crackles, wheezes, rhonchi.
  • Rationale: Decreased areas of ventilation suggest presence of atelectasis, whereas adventitious sounds may suggest fluid overload, retained secretions, or infection.
• Note character, amount, and color of secretions.
  • Rationale: Patient is susceptible to pulmonary infections as a result of depressed cough reflex and respiratory effort, increased viscosity of secretions, as well as altered immune response and chronic and debilitating disease.
• Elevate head of bed or have patient sit up in chair. Promote deep-breathing exercises and coughing
  • Rationale: Facilitates chest expansion and ventilation and mobilization of secretions.
• Review ABGs and pulse oximetry and serial chest x-rays.
  • Rationale: Changes in Pao2 and Paco2 and appearance of infiltrates and congestion on chest x-ray suggest developing pulmonary problems.
• Administer supplemental O2 as indicated.
  • Rationale: Maximizes oxygen for vascular uptake, preventing or lessening hypoxia.
• Administer analgesics as indicated.
  • Rationale: Alleviates pain, promotes comfortable breathing, maximal cough effort.
• Maintain nutritional status. Provide a high-calorie, low-protein, low-sodium, and low-potassium diet, with vitamin supplements.
  • Rationale: To balance nutritional intake.

Nursing Diagnosis

• Risk for Infection

Risk factors may include

• Contamination of the catheter during insertion, periodic changing of tubings/bags
• Skin contaminants at catheter insertion site
• Sterile peritonitis (response to the composition of dialysate)

Possibly evidenced by

• Not applicable. Existence of signs and symptoms establishes an actual nursing diagnosis.

Desired outcome

• Identify interventions to prevent/reduce risk of infection.
• Experience no signs/symptoms of infection.

Nursing Interventions

• During peritoneal dialysis,position the patient carefully. Elevate the head of bed.
  • Rationale: To reduce pressure on the diaphragm and aid respiration.
• Be alert for signs of infection (cloudy drainage, elevated temperature) and, rarely, bleeding.
  • Rationale: Cloudy effluent is suggestive of peritoneal infection.
• Observe meticulous aseptic techniques and wear masks during catheter insertion, dressing changes, and whenever the system is opened. Change tubings per protocol.
  • Rationale: Prevents the introduction of organisms and airborne contamination that may cause infection.
• Change dressings as indicated, being careful not to dislodge the catheter. Note character, color, odor, or drainage from around insertion site.
  • Rationale: Moist environment promotes bacterial growth. Purulent drainage at insertion site suggests presence of local infection. Note: Polyurethane adhesive film (blister film) dressings have been found to decrease amount of pressure on catheter and exit site as well as incidence of site infections.
• Observe color and clarity of effluent.
  • Rationale: Cloudy effluent is suggestive of peritoneal infection.
• Apply povidone-iodine (Betadine) barrier in distal, clamped portion of catheter when intermittent dialysis therapy used.
  • Rationale: Reduces risk of bacterial entry through catheter between dialysis treatments when catheter is disconnected from closed system
• Investigate reports of nausea and vomiting, increased and severe abdominal pain; rebound tenderness, fever, and leukocytosis.
  • Rationale: Signs and symptoms suggesting peritonitis, requiring prompt intervention.
• Monitor WBC count of effluent
  • Rationale: Presence of WBCs initially may reflect normal response to a foreign substance; however, continued and new elevation suggests developing infection.
• Obtain specimens of blood, effluent, and drainage from insertion site as indicated for culture and sensitivity.
  • Rationale: Identifies types of organism(s) present, choice of interventions
• Monitor renal clearance: BUN, Cr
  • Rationale: Choice and dosage of antibiotics are influenced by level of renal function.
• Administer antibiotics systemically or in dialysate as indicated.
  • Rationale: Treats infection, prevents sepsis

Nursing Diagnosis

• Acute Pain

May be related to

• Insertion of catheter through abdominal wall/catheter irritation, improper catheter placement
• Irritation/infection within the peritoneal cavity
• Infusion of cold or acidic dialysate, abdominal distension, rapid infusion of dialysate

Possibly evidenced by

• Reports of pain
• Self-focusing
• Guarding/distraction behaviors, restlessness

Desired Outcomes

• Patient will verbalize decrease of pain/discomfort.
• Patient will demonstrate relaxed posture/facial expression, be able to sleep/rest appropriately.

Nursing Interventions

• Investigate patient’s reports of pain; note intensity (0–10), location, and precipitating factors
  • Rationale: Assists in identification of source of pain and appropriate interventions.
• Explain that initial discomfort usually subsides after the first few exchanges.
  • Rationale: Information may reduce anxiety and promote relaxation during procedure.
• Monitor for pain that begins during inflow and continues during equilibration phase. Slow infusion rate as indicated.
  • Rationale: Pain occurs at these times if acidic dialysate causes chemical irritation of peritoneal membrane.
• Note reports of discomfort that is most pronounced near the end of inflow and instill no more than 2000 mL of solution at a single time.
  • Rationale: Likely the result of abdominal distension from dialysate. Amount of infusion may have to be decreased initially.
• Prevent air from entering peritoneal cavity during infusion. Note report of pain in area of shoulder blade.
  • Rationale: Inadvertent introduction of air into the abdomen irritates the diaphragm and results in referred pain to shoulder blade. This type of discomfort may also be reported during initiation of therapy or during infusions and usually is related to stretching and irritation of the diaphragm with abdominal distension. Smaller exchange volumes may be required until patient adjusts.
• Elevate head of bed at intervals. Turn patient from side to side. Provide back care and tissue massage
  • Rationale: Position changes and gentle massage may relieve abdominal and general muscle discomfort.
• Warm dialysate to body temperature before infusing
  • Rationale: Warming the solution increases the rate of urea removal by dilating peritoneal vessels. Cold dialysate causes vasoconstriction, which can cause discomfort and excessively lower the core body temperature, precipitating cardiac arrest.
• Monitor for severe or continuous abdominal pain and temperature elevation (especially after dialysis has been
  discontinued).
  • Rationale: May indicate developing peritonitis.
• Encourage use of relaxation techniques
  • Rationale: Redirects attention, promotes sense of control.
• Administer analgesics.
  • Rationale: Relieves pain and discomfort.
• Add sodium hydroxide to dialysate, if indicated.
  • Rationale: Occasionally used to alter pH if patient is not tolerating
    acidic dialysate

Nursing Diagnosis

• Risk for Trauma

Risk factors may include

• Catheter inserted into peritoneal cavity
• Site near the bowel/bladder with potential for perforation during insertion or by manipulation of the catheter

Possibly evidenced by

• Not applicable. Existence of signs and symptoms establishes an actual nursing diagnosis.

Desired Outcomes

• Experience no injury to bowel or bladder.

Nursing Interventions

• Have patient empty bladder before peritoneal catheter insertion if indwelling catheter not present.
  • Rationale: An empty bladder is more distant from insertion site and reduces likelihood of being punctured during catheter insertion.
• Anchor catheter and tubing with tape. Stress importance of patient avoiding pulling or pushing on catheter. Restrain hands if indicated.
  • Rationale: Reduces risk of trauma by manipulation of the catheter.
• Note presence of fecal material in dialysate effluent or strong urge to defecate, accompanied by severe, watery diarrhea.
  • Rationale: Suggests bowel perforation with mixing of dialysate and bowel contents.
• Note reports of intense urge to void, or large urine output following initiation of dialysis run. Test urine for sugar as indicated.
  • Rationale: Suggests bladder perforation with dialysate leaking into bladder. Presence of glucose-containing dialysate in the bladder will elevate glucose level of urine.
• Stop dialysis if there is evidence of bowel and bladder perforation, leaving peritoneal catheter in place.
  • Rationale: Prompt action will prevent further injury. Immediate surgical repair may be required. Leaving catheter in place facilitates diagnosing and locating the perforation

Nursing Diagnosis

• Risk for Excessive Fluid Volume

Risk Factors

• Inadequate osmotic gradient of dialysate
• Fluid retention (malpositioned or kinked/clotted catheter, bowel distension; peritonitis, scarring of peritoneum)
• Excessive PO/IV intake

Desired Outcomes

• Demonstrate dialysate outflow exceeding/approximating infusion.
• Experience no rapid weight gain, edema, or pulmonary congestion.

Nursing Interventions

• Maintain a record of inflow and outflow volumes and cumulative fluid balance
  • Rationale: In most cases, the amount drained should equal or exceed the amount instilled. A positive balance indicates need of further evaluation.
• Record serial weights, compare with I&O balance. Weigh patient when abdomen is empty of dialysate (consistent reference point).
  • Rationale: Serial body weights are an accurate indicator of fluid volume status. A positive fluid balance with an increase in weight indicates fluid retention.
• Assess patency of catheter, noting difficulty in draining. Note presence of fibrin strings and plugs.
  • Rationale: Slowing of flow rate and presence of fibrin suggests partial catheter occlusion requiring further evaluation and intervention
• Check tubing for kinks; note placement of bottles and bags. Anchor catheter so that adequate inflow/outflow is achieved.
  • Rationale: Improper functioning of equipment may result in retained fluid in abdomen and insufficient clearance of toxins.
• Turn from side to side, elevate the head of the bed, apply gentle pressure to the abdomen.
  • Rationale: May enhance outflow of fluid when catheter is malpositioned and obstructed by the omentum.
• Note abdominal distension associated with decreased bowel sounds, changes in stool consistency, reports of constipation.
  • Rationale: Bowel distension and constipation may impede outflow of effluent.
• Monitor BP and pulse, noting hypertension, bounding pulses, neck vein distension, peripheral edema; measure CVP if available.
  • Rationale: Elevations indicate hypervolemia. Assess heart and breath sounds, noting S3 and crackles, rhonchi. Fluid overload may potentiate HF and pulmonary edema.
• Evaluate development of tachypnea, dyspnea, increased respiratory effort. Drain dialysate, and notify physician.
  • Rationale: Abdominal distension and diaphragmatic compression may cause respiratory distress.
• Assess for headache, muscle cramps, mental confusion, disorientation.
  • Rationale: Symptoms suggest hyponatremia or water intoxication
• Alter dialysate regimen as indicated.
  • Rationale: Changes may be needed in the glucose or sodium concentration to facilitate efficient dialysis
• Monitor serum sodium
  • Rationale: Hypernatremia may be present, although serum levels may reflect dilutional effect of fluid volume overload.
• Add heparin to initial dialysis runs; assist with irrigation of catheter with heparinized saline.
  • Rationale: May be useful in preventing fibrin clot formation, which can obstruct peritoneal catheter.
• Maintain fluid restriction as indicated.
  • Rationale: Fluid restrictions may have to be continued to decrease fluid volume overload.