Peritoneal dialysis: understanding, educating, and adhering to standards.

Chronic renal disease affects more than 26 million adults in the United States (Headley, 2014). Many more persons are at risk for this disease, especially older adults (Headley, 2014; Saxena, 2014). Renal replacement therapy options for patients with end-stage renal disease (ESRD) include renal transplant, hemodialysis, and peritoneal dialysis (Saxena, 2014).

In the early 20th century, peritoneal dialysis (PD) was used to treat patients with acute renal failure (Krediet, 2013). By the early 1970s, development of a special indwelling catheter and a method for continuous peritoneal dialysis prompted expanded use of PD to treat patients with ESRD (Ellsworth, 2016; Headley, 2014; Krediet, 2013). The highlights of this article include patient selection and preparation for PD; general physiology of PD; PD catheters and systems; and the importance of infection prevention, with emphasis on hand hygiene, catheter site care, and peritonitis. Nutritional and fluid management and patients' quality of life also are explored.

Patient Selection and Preparation

An interprofessional approach is needed to identify PD as an appropriate therapy for a patient. Nurses, dieticians, social workers, and physicians should partner in ongoing patient care (Saxena, 2014; Tregaskis, Sinclair, & Lee, 2015). A comprehensive pre-dialysis physical assessment ensures patient suitability for PD. In-depth assessment of the abdomen, cognitive and fine motor functioning, resources, and support options are specific foci. When PD begins, ongoing assessments and retraining sessions are required to respond to any changes and ensure knowledge and competency are maintained by the patient or caregiver (Tregaskis et al., 2015; Woodrow & Davies, 2011).

Nurses play a key role in educating patients and caregivers regarding PD, including administration guidelines and the need to adhere to appropriate techniques (Woodrow & Davies, 2011). The training and approach must be tailored to the education level and learning needs of the patient or caregiver (Segal & Messana, 2013). Infection prevention education is paramount.

The process must be performed in a clean environment and the use of sterile technique is imperative (Ellam & Wilkie, 2011). A surgical mask is recommended, and a hair cover should be worn by the nurse (or caregiver) and patient during all PD preparations, connections, and disconnections to reduce infection risks (Piraino et al., 2011; Segal & Messana, 2013). The patient or caregiver must demonstrate the ability to use appropriate technique and perform the PD exchange safely before treatment can be initiated (Segal & Messana, 2013).

General Physiology of Peritoneal Dialysis

PD involves a three-phase process for removing wastes from the blood without removing the blood from the body for waste filtration, as in hemodialysis (Ellam & Wilkie, 2011; Headley, 2014). Access to the peritoneal cavity is achieved by using a catheter inserted into and tunneled through the abdominal wall and then into the peritoneal space. Phase 1 (inflow or fill) involves instillation of a sterile dialysate solution through the catheter into the peritoneal cavity, filling the space around the kidneys, intestines, liver, stomach, and spleen (Headley, 2014; Saxena, 2014). Inflow takes approximately 10 minutes for infusion of 2 liters of solution (Cullis et al., 2014; Headley, 2014). The prescribed dialysate solution and the amount to be infused are individualized based on the patient's size and specific needs (Cullis et al., 2014; Headley, 2014).

During phase 2 (dwell), the tonicity of the solution pulls wastes and excess fluid from the capillary blood through the lining of the semi-permeable peritoneal membrane into the dialysate (Headley, 2014; Krediet, 2013; Saxena, 2014). Dwell time involves diffusion and osmosis (Ellam & Wilkie, 2011). The time for this process varies among patients, depending on the type of PD system in use (Headley, 2014). Diffusion occurs as the greater concentration of waste solutes in the blood (creatinine, electrolytes, urea, uric acid) moves across the peritoneal membrane into the lesser-concentrated dialysate. Glucose, included in the dialysate in varying amounts, causes osmosis to occur. The amount of glucose determines the strength of the resulting osmotic gradient, drawing excess fluid from the blood into the dialysate (Ellam & Wilkie, 2011; Headley, 2014; Krediet, 2013; Saxena, 2014).

The solution leaves the body in phase 3 (drain). The drain time can be approximately 20 minutes, depending on the volume of solution (Cullis et al., 2014). The complete three-phase process is termed an exchange (Headley, 2014).

[FIGURE 1 OMITTED]

The Catheter

PD catheters are made of flexible silicone or polyurethane. They can be straight, swan-necked, or curled; can have an extraperitoneal single or double Dacron[R] cuff; and can vary in length (Ellsworth, 2016; Saxena, 2014). Tissue regrowth on the Dacron cuffs provides stability for the catheter. Double cuffs are preferred (Ellsworth, 2016), as the subcutaneous tunnel and the sinus tract of the catheter are shorter (Hain & Chan, 2013). The insertion site commonly is located to the left or right of the umbilicus and sometimes is placed through the superior abdominal wall or presternal area, for which extended-length catheters are necessary (Burkart, 2015; Ellsworth, 2016). Extended-length catheters may be needed for patients who are obese or have abdominal stomas (Ellsworth, 2016). The catheter most commonly used for PD access is the Tenckhoff catheter (Cullis et al., 2014; Hain & Chan, 2013). The side holes and enlarged diameter of the lumen enhance drainage and absorption of dialysate. The Tenckhoff catheter also has a low incidence of leakage (Cullis et al., 2014).

The catheter exit site usually heals in 10-14 days after placement. Ideally, the site should be allowed to heal prior to starting dialysis. When necessary, however, PD can be performed as soon as the catheter is placed and tested (Burkart, 2015; Ellam & Wilkie, 2011). Testing the catheter involves instilling approximately 100 mL of sterile saline into the peritoneal cavity and verifying any leakage at the catheter exit site. The drained fluid is examined for evidence of blood or feces (Ellsworth, 2016).

Types of Peritoneal Dialysis Systems

Two systems are available for performing PD: continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) (Ellam & Wilkie, 2011; Headley, 2014; Saxena, 2014). CAPD is performed manually. The catheter is connected to the dialysate solution and drain bag through use of a Y-connector or twin-bag system. This method has been linked to lower infection risk (Campbell, Johnson, Mudge, Gallagher, & Craig, 2015; Cullis et al., 2014). Dwell time for CAPD is 4 hours, with four exchanges expected during the day (Headley, 2014). After dialysate has infused and dwell time completed, effluent is drained into the waste bag. After the exchange, the catheter is disconnected from the tubing (Ellam & Wilkie, 2011; Headley, 2014). Figure 1 depicts common components of an exchange using CAPD.

APD processes are controlled by a machine called a cycler, which regulates the inflow, dwell, and drainage of the dialysate (Headley, 2014; Saxena, 2014). APD can be achieved continuously by leaving the dialysate in the abdominal cavity 24 hours daily (continuous cycler PD or CCPD), or by the nocturnal intermittent process (Ellam & Wilkie, 2011; Saxena, 2014). With the latter method, exchanges occur at night while the patient is asleep (Ellam & Wilke, 2011; Headley, 2014). The nocturnal cycler manages the process of four or more exchanges with shorter dwell times. Some patients may need an extra exchange during the day, depending on the amount of fluid and solute clearance achieved by the cycler (Headley, 2014).

Infection Prevention: Hand Hygiene

Infection is the most common problem associated with PD (Ellam & Wilkie, 2011; Segal & Messana, 2013). Poor hand hygiene is one cause of infection. Nurses must provide ongoing education to patients and caregivers, emphasizing hand washing as an integral part of the PD process, one that must never be omitted or shortened (Firanek & Guest, 2011). Recommendations from the Centers for Disease Control and Prevention (2016) indicate effective hand washing should last at least 15 seconds and involve vigorous rubbing of all hand surfaces with friction. Hands must be dried completely to reduce transmission of bacteria suspended in water droplets (Firanek & Guest, 2011). Artificial or untrimmed fingernails must be avoided to reduce bacteria (Segal & Messana, 2013). Wearing rings is associated with elevated bacterial counts, even after hand washing has been performed. Further recommendations include using approximately 3 mL of an alcohol-based gel for 15-30 seconds after the hand washing and drying process. Once the gel has been applied, the hands must be allowed to dry completely (Firanek & Guest, 2011; Segal & Messana, 2013).

Catheter Site Care

The catheter exit site must remain clean and dry, covered by a nonocclusive dressing until healing has occurred (Burkart, 2015). Exit site care must be performed daily and as needed using an antibacterial soap or specified cleanser (Segal & Messana, 2013). Crust or scabs at the site should be removed gently using soap and water or saline. Antibiotic ointments, creams, or drops applied directly to the site, as well as intranasal antibiotics, can be used to prevent bacterial colonization (Campbell et al., 2015; Hain & Chan, 2013; Piraino et al., 2011; Segal & Messana, 2013). The catheter type (e.g., polyurethane vs. silicone) should be considered when cleansing and applying anti-infective agents because products that degrade the catheter would be inappropriate for use (Hain & Chan, 2013). Care must be taken to prevent tension on the catheter, which could cause irritation or trauma to the site (Hain & Chan, 2013). The patient should be instructed to take sponge baths until the site has healed. Once the site has healed completely, showers are encouraged in lieu of tub baths (Hain & Chan, 2013).

Catheter-Associated Problems

Several potential problems are associated with PD (see Table 1). Prophylactic antibiotics typically are administered before PD catheter insertion to reduce infection risk (Segal & Messana, 2013; Woodrow & Davies, 2011). The effluent from a newly placed catheter may be slightly bloody during the first two exchanges. Ovulating or menstruating females also may note bloodtinged effluent. These circumstances are expected and require no intervention. Continuous bloody effluent after catheter insertion or effluent with sudden blood can indicate intraperitoneal bleeding. The nurse should assess the patient's blood pressure immediately, notify the healthcare provider, and obtain a serum specimen to verify the hematocrit (Headley, 2014).

The catheter exit site must be assessed consistently for signs and symptoms of infection: pain, redness, edema, crusting, and drainage. Omission of procedural steps and use of inappropriate technique can result in infection of the exit site or the segment within the abdominal wall along the catheter tunnel (Headley, 2014). Keen assessment and early recognition of abnormalities promote timely intervention and treatment, preventing major infections. Erythema alone may not be indicative of infection; purulent drainage is a definite problem. When purulent drainage is present, a specimen for culture and sensitivity should be collected (Hain & Chan, 2013).

Common catheter drainage problems can be related to occlusions (clots or fibrin), kinking, migration or malpositioning, and adhesions around the catheter (Ellsworth, 2016; Saxena, 2014). A flush-before-fill practice is recommended to decrease risk of infection (Campbell et al., 2015) and can be helpful to assess catheter patency. Close inspection of the catheter as well as the fill and drain processes can assist the nurse in identifying catheter-related problems.

Peritonitis

Exit site contamination or infection of the exit site or catheter tunnel promotes a high risk for infection within the peritoneum (peritonitis). Peritonitis can lead to substantial morbidity, as well as death (Campbell et al., 2015). A major cause of peritonitis is poor technique during the exchange process. See Table 2 for a list of common signs and symptoms associated with peritonitis.

Abnormalities in immunologic function also can contribute to peritonitis (Segal & Massana, 2013). Constipation and diarrhea are common in PD. Inflammation of the intestinal serosa allows intestinal bacteria to permeate and can heighten the risk for peritonitis (Segal & Messana, 2013; Tregaskis et al., 2015). Hypokalemia can cause decreased motility of the intestine, and bacterial overgrowth can occur to predispose the patient to peritonitis (Segal & Messana, 2013).

Antibiotic therapy (oral, intravenous, intraperitoneal) must be initiated to treat peritonitis. Empiric antibiotic therapy can be initiated until sensitivity results are available (Ellam & Wilkie, 2011; Hain & Chan, 2013; Headley, 2014; Woodrow & Davies, 2011). Upon completion of antibiotic treatment, the effluent should be tested again via culture and sensitivity because catheter infection commonly recurs. Patients with ongoing catheter-related problems and infection may have the catheter removed, creating a need for hemodialysis (Hain & Chan, 2013). Catheter-associated infection and peritonitis can be prevented through use of proper hand hygiene and adherence to practice guidelines and protocols. Every patient interaction allows nurses to educate the patient and caregiver, promote adherence to practice standards, and provide strategies for reducing risk and occurrence of peritonitis.

Nutritional and Fluid Management Considerations

Malnutrition is a critical risk factor for the patient with renal disease and can result from inadequate nutritional intake for a variety of reasons. The patient's appetite can be diminished by the filled peritoneal cavity. Consuming frequent small meals is recommended (Kourkouta, Monios, Frantzaza, & Iliadis, 2015). A dietician can educate the patient about appropriate dietary choices to meet bodily needs. See Table 3 for factors related to malnutrition in patients undergoing PD.

Dietary supplements often are needed for patients receiving PD because of disorders relating to water-soluble vitamins (B-complex and C) (Kourkouta et al., 2015). Patients are challenged with protein loss in the dialysate solution, requiring increased dietary protein. The peritoneal membrane becomes more permeable in patients with peritonitis, promoting an even greater loss of protein (Headley, 2014). High-quality protein of 1.21.3 g/kg/day is needed; sources include fish, meat, chicken, dairy products, and eggs. These foods also contain phosphorous, critical for patients undergoing PD. Serum phosphorous can be pulled from the skeletal system during PD, resulting in weakened bones and high fracture risk. Phosphate binders may be ordered to take with food to help the body rid excess phosphate (National Kidney Foundation [NKF], 2015).

Fluid management is an important nursing focus. Semm sodium and fluid intake must be monitored. Fluid restrictions may be necessary. The 24-hour urine output plus 500-700 ml provides an approximate total daily intake for the patient. Additional fluid can cause elevated blood pressure and weight gain (Kourkouta et al., 2015). The type of dialysate must be considered carefully to aid in controlling blood pressure and fluid balance. Dialysate solutions can be acidic and hyperosmolar, and have high glucose concentrations. Over time, the solution can cause structural and functional changes within the peritoneal membrane that can affect the ultrafiltration process (Krediet, 2013; Saxena, 2014). Glucose can enter the semm through the peritoneum, causing hyperglycemia. Although PD maintains waste levels in the blood, semm glucose still must be measured to help regulate fluid status, prevent hyperglycemia, and monitor weight gain (Burkart, 2015; NKF, 2015).

Patients can develop hernias and may have complaints of low back pain related to increased intraabdominal pressure from the PD dwell (Ellsworth, 2016; Headley, 2014). Hernias can be repaired, and a lumbar binder or approved exercises to strengthen the back muscles may provide some comfort. Lung expansion can be restricted when the dwell upwardly displaces the diaphragm (Headley, 2014). Pulmonary complications, such as atelectasis, bronchitis, and pneumonia, have been associated with PD. Elevating the head of the bed, repositioning, and encouraging deep breathing exercises may provide some relief (Headley, 2014).

Quality of Life

PD allows patients and caregivers to be more independent. The opportunity for home therapy or treatment with considerably fewer life interruptions lends a normalcy that is not possible for many persons during management of ESRD. Employment remains possible, with limitations dependent on the role. Exercise is important and should be included in the interprofessional plan of care. Types of exercise are individualized, with the greatest restrictions during the PD dwell time (Burkart, 2015). Some patients may be sensitive to body image related to the catheter and the associated increase in abdomen girth (Burkart, 2015; Saxena, 2014). Social support can be an important factor for development of self-confidence to be successful with PD (Saxena, 2014). See Table 4 for organizations offering resources and support for patients and caregivers.

Conclusion

The need to understand the distinct processes involved in PD and adhere to all infection prevention techniques cannot be overstated (Cullis et al., 2014; Ellam & Wilkie, 2011). Education of nursing staff, caregivers, and patients is vital. Nurses, patients, and caregivers must use strict aseptic technique when performing PD to prevent complications and achieve quality of life with this home-based therapy. E5H3

Mary L. Schreiber, MSN, RN, CMSRN, is Nursing Faculty Member, Orangeburg-Calhoun Technical College, Orangeburg, SC, and a national speaker for PESI Healthcare.

REFERENCES

Burkart, J.M. (2015). Patient information: Peritoneal dialysis (beyond the basics). Retrieved from http://www.uptodate.com/contents/peritoneal-dialysis-beyond-the-basics

Campbell, D.J., Johnson, D.W., Mudge, D.W., Gallagher, M.P., & Craig, J.C. (2015). Prevention of peritoneal dialysis-related infections. Nephrology Dialysis Transplantation, 30(9), 1461-1472. doi:10. 1093/ndt/gfu313

Centers for Disease Control and Prevention. (2016). Hand hygiene in healthcare settings. Retrieved from http://www.cdc.gov/hand hygiene/providers/index.html

Cullis, B. Abdelraheem, M., Abrahams, G., Balbi, G., Cruz, D. N., Frishberg, Y., ... Finkelstein, F.O. (2014). ISPD guidelines/ recommendations: Peritoneal dialysis for acute kidney injury. Peritoneal Dialysis International, 34(5), 494-517. doi:10.3747/pdi.2013.00222

Ellam, T., & Wilkie, M. (2011). Peritoneal dialysis. Medicine, 39(7), 434-437.

Ellsworth, P.l. (2016). Peritoneal dialysis catheter insertion. Retrieved from http://emedicine.medscape.eom/article/1829737-overview#showall

Firanek, C., & Guest, S. (2011). Eland hygiene in peritoneal dialysis. Peritoneal Dialysis International, 31(4), 399-408. doi:10. 3747/pdi.2010.00239

Plain, D.J., & Chan, J. (2013). Best available evidence for peritoneal dialysis catheter exit-site care. Nephrology Nursing Journal, 40(1), 63-69.

Pleadley, C. (2014). Acute kidney injury and chronic kidney disease. In S.L. Lewis, S.R. Dirksen, M.M. Heitkemper, & L. Bucher (Eds.), Medical surgical nursing: Assessment and management of clinical problems (9th ed.) (pp. 1101-1132). St. Louis, MO: Elsevier.

Kourkouta, L., Monios, A., Frantzaza, E., & lliadis, C. (2015). Nutrition and peritoneal dialysis patients - A review. Progressive Health Science, 5(2), 205-210.

Krediet, R.T. (2013). Peritoneal dialysis: From bench to bedside. Clinical Kidney Journal, 6(6), 568-577. doi:10.1093/ckj/sft122

National Kidney Foundation (NKF). (2015). Nutrition and peritoneal dialysis. Retrieved from https://www.kidney.org/atoz/content/nutripd

Piraino, B., Bernardini, J., Brown, E., Figueiredo, A., Johnson, D. W., Lye, W., ... Szeto, C. (2011). ISPD position statement on reducing the risks of peritoneal dialysis-related infections. Peritoneal Dialysis International, 31(6), 614-630. doi:10.3747/pdi.2011.00057

Saxena, R. (2014). Peritoneal dialysis: misperceptions and reality. The American Journal of the Medical Sciences, 348(3), 250-261.

Segal, J.H., & Messana, J.M. (2013). Prevention of peritonitis in peritoneal dialysis. Seminars in Dialysis, 26(4), 494-502. doi:10. 1111/sdi.12114

Tregaskis, R, Sinclair, P.M., & Lee, A. (2015). Assessing patient suitability for peritoneal dialysis. Renal Society of Australasia Journal, 11(3), 112-117.

Woodrow, G., & Davies, S. (2011). Renal association clinical practice guideline on peritoneal dialysis. Nephron Clinical Practice, 118(1), 287-310. doi: 10.1159/000328073

TABLE 1.
Problems Associated
with Peritoneal Dialysis

*   Catheter-related

    --Exit site/tunnel infection
    --Drainage
    --Migration/malposition
    --Peritonitis

*   Nutritional challenges

*   Constipation

*   Hernias

*   Peritoneal membrane changes

*   Bleeding

*   Low back pain

*   Pulmonary problems

Sources: Ellam & Wilkie, 2011;
Ellsworth, 2016; Firanek & Guest, 2011;
Headley, 2014; Kourkouta et al., 2015

TABLE 2.
Signs and Symptoms
of Peritonitis

*   Cloudy effluent

*   Exit site

   --Edema
   --Erythema
   --Tenderness
   --Purulent drainage

*   WBC > 100 cells/[micro]L

*   > 50% neutrophils

*   Abdominal pain

*   Abdominal distention

*   Diarrhea

*   Hyperactive bowel sounds

*   Fever (in some cases)

Sources: Ellam & Wilkie, 2011; Hain &
Chan, 2013; Headley, 2014

TABLE 3.
Factors Related to Malnutrition

*   Emotional instability (depression)

*   Medication side effects

*   Inadequate uremia treatment (waste product of protein
    breakdown)

*   Abnormalities in taste sensation

*   Inflammatory changes in peritoneum

*   Endocrine disorders

*   Metabolic changes

*   Financial hardship

*   Infection

*   Protein inadequacy

*   Acid-base changes during dialysis

Sources: Kourkouta et al., 2015; NKF, 2015

TABLE 4.
Organizations for PD Information and Support

American Nephrology Nurses Association (ANNA)
www.annanurse.org

Centers for Disease Control and Prevention (CDC)
www.cdc.gov

DaVita[R]
https://www.davita.com/

International Society for Peritoneal Dialysis (ISPD)
http://ispd.org/

National Institute for Diabetes and
Digestive and Kidney Diseases (NIDDK)
www.niddk.nih.gov/Pages/default.aspx

National Kidney Foundation[R]
www.kidney.org

National Library of Medicine
 www.nlm.nih.gov/medlineplus/healthtopics.html

Article Details

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Title Annotation:	Evidence-Based Practice
Author:	Schreiber, Mary L.
Publication:	MedSurg Nursing
Article Type:	Report
Geographic Code:	1USA
Date:	Jul 1, 2016
Words:	3324
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Topics:	Chronic kidney failure Care and treatment Patient outcomes Continuous ambulatory peritoneal dialysis Usage Peritoneal dialysis Usage