Dialysis

Definition
Dialysis is a treatment that takes over the job of the kidneys when they
fail. Most patients begin dialysis when their kidneys have lost 85%-90% of their
ability. Dialysis will continue for the rest of their lives (or until they receive a
kidney transplant). This is called end-stage renal disease (ESRD).
ESRD is caused by conditions such as diabetes, kidney cancer, drug use,
high blood pressure, or other kidney problems. Dialysis is not a cure for ESRD. It
helps you feel better and live longer. It may also be used to treat patients with
edema that does not respond to treatment, hepatic coma, hyperkalemia,
hypercalcemia, hypertension, and uremia. The need for dialysis may be acute or
chronic.

Acute Dialysis is indicated when there is a high and rising level of serum
potassium, fluid overload, or impending pulmonary edema, increasing acidosis,
pericarditis and severe confusion. It may also be used to remove certain
medications or other toxins from the blood.

Chronic or Maintenance dialysis is indicated in chronic failure, known as end-

stage renal disease, the presence of uremic signs and symptoms affecting all the
body system (nausea and vomiting, severe anorexia, increasing lethargy, mental
confusion), hyperkalemia, fluid overload not responsive to diuretics and fluid
restriction, and a general lack of well being. An urgent indication for dialysis in
patient with chronic renal failure is pericardial friction rub.

There are two types of dialysis:

1)Hemodialysis
2)Peritoneal dialysis

Parts of the Body Involved

• Hemodialysis—veins in the arm, leg, or neck
• Peritoneal dialysis—abdomen

Reasons for Procedure

The main functions of dialysis are to:
• Remove waste and excess fluid from the blood to prevent build-up
• Control blood pressure
• Keep a safe level of chemicals in the body, such as potassium, sodium,
and chloride
• It may also be done to quickly remove toxins from the bloodstream. This
can occur in cases of poisoning or drug overdose.

Risk Factors for Complications During the Procedure

Hemodialysis
 • Heart problems
Peritoneal dialysis
• Adhesions or significant abdominal scar tissue
• Infection of the peritoneum (lining of the abdominal cavity)
• Abdominal hernia
• Abdominal defects

Prior to Procedure
Hemodialysis
• Weight, blood pressure, and temperature are taken
• Topical anesthetic (a pain numbing medicine) is applied to the arm for
needle insertion
• Heparin (a medication that prevents blood clotting) is given
Peritoneal Dialysis
Before the first treatment, the physician places a small, soft tube
(approximately 24 inches long) in the abdomen. This tube will remain there
permanently. A portion of the tube remains outside the body for use in the
process. It is important to keep this access clean and dry to prevent infection.

Anesthesia
For hemodialysis: topical anesthetic

After Procedure
Your blood pressure will be monitored.

How Long Will It Take?

• The time needed for dialysis depends on a few factors:
• How much kidney function remains
• How much fluid weight gain has occurred since the last treatment
• Amount of waste in the body
• Body size
• Level of minerals in your body such as sodium, potassium, and chloride
• Dialysis method used

The approximate time and frequency of each method:

Type Length of Frequency of

procedure procedure
Hemodialy 2-4 hours 3 times/week
sis
CAPD 3-6 hours, plus 4 times/day
30 minutes to drain
CCPD 9-12 hours Every night
IPD 12 + hours 36-42 hours/week

Pain
In general, dialysis procedures do not cause pain. You will not feel the
blood exchange. There may be some temporary discomfort with the insertion of
the needle or tube.

Possible Complications
• Anemia
• Drop in blood pressure during dialysis
• Muscle cramps
• Nausea, vomiting
• Headaches
• Infection
• Feeling hot, sweaty, weak, and/or dizzy
• Peritonitis (infection of the peritoneum), which causes fever and stomach
pain (peritoneal dialysis only)
• Growth problems in children
• Inflammation of the heart sac (pericarditis)
• Neurologic problems
• Disruption of calcium and phosphorus balance, resulting in weakened
bones

Postoperative Care
Once the procedure is complete and blood pressure is stable, you are free
to continue daily activities. There are some special considerations:

Dietary Guidelines
Certain dietary guidelines should be followed. This will help to keep overall
health and optimize the treatment. Patients who have peritoneal dialysis may
have slightly fewer dietary restrictions than hemodialysis patients. This is due to
the more frequent filter schedule. Talk to your doctor about your specific dietary
needs.

Medications
Your doctor may give various types of medication. These include, but are not
limited to
• Blood pressure medications
• Calcium supplements or multivitamins
• Phosphorus binders—to lower phosphorus levels in the blood
• Diuretics—to remove excess fluid
• Stool softeners or laxatives—to prevent or treat constipation, which can be
caused by decreased fluid intake
 • Iron supplements—to increase iron intake, which is important for
production of red blood cells

Outcome
Dialysis helps maintain blood pressure, cleaning of the blood, and
chemical and hormonal exchanges that are critical to survival.

Call the Doctor If Any of the Following Occurs

• Signs of infection, including fever and chills
• Redness, swelling, warmth, increasing pain, excessive bleeding, or
discharge at the catheter or tube insertion
• site
• Blood or cloudiness in the peritoneal dialysis fluid
• Nausea or vomiting
• Abdominal pain
• Dizziness or weakness

How Diet Can Help

Eating the right foods can help improve your dialysis and your health. Your
clinic has a dietitian to help you plan meals. Follow the dietitian’s advice closely
to get the most from your hemodialysis treatments. Here are a few general
guidelines.
Fluids. Your dietitian will help you determine how much fluid to drink each
day. Extra fluid can raise your blood pressure, make your heart work harder, and
increase the stress of dialysis treatments. Remember that many foods—such as
soup, ice cream, and fruits—contain plenty of water. Ask your dietitian for tips on
controlling your thirst.
Potassium. The mineral potassium is found in many foods, especially
fruits and vegetables. Potassium affects how steadily your heart beats, so eating
foods with too much of it can be very dangerous to your heart. To control
potassium levels in your blood, avoid foods like oranges, bananas, tomatoes,
potatoes, and dried fruits. You can remove some of the potassium from potatoes
and other vegetables by peeling and soaking them in a large container of water
for several hours, then cooking them in fresh water.

You can remove some potassium from potatoes by soaking them in water.
Phosphorus. The mineral phosphorus can weaken your bones and make
your skin itch if you consume too much. Control of phosphorus may be even
more important than calcium itself in preventing bone disease and related
complications. Foods like milk and cheese, dried beans, peas, colas, nuts, and
peanut butter are high in phosphorus and should be avoided. You’ll probably
need to take a phosphate binder with your food to control the phosphorus in
your blood between dialysis sessions.
Salt (sodium chloride). Most canned foods and frozen dinners contain
high amounts of sodium. Too much of it makes you thirsty, and when you drink
more fluid, your heart has to work harder to pump the fluid through your body.
Over time, this can cause high blood pressure and congestive heart failure. Try
to eat fresh foods that are naturally low in sodium, and look for products labeled
“low sodium.”
Protein. Before you were on dialysis, your doctor may have told you to
follow a low-protein diet to preserve kidney function. But now you have different
nutritional priorities. Most people on dialysis are encouraged to eat as much
high-quality protein as they can. Protein helps you keep muscle and repair
tissue, but protein breaks down into urea (blood urea nitrogen, or BUN) in your
body. Some sources of protein, called high-quality proteins, produce less waste
than others. High-quality proteins come from meat, fish, poultry, and eggs.
Getting most of your protein from these sources can reduce the amount of urea
in your blood.
Calories. Calories provide your body with energy. Some people on dialysis
need to gain weight. You may need to find ways to add calories to your diet.
Vegetable oils—like olive, canola, and safflower oils—are good sources of
calories and do not contribute to problems controlling your cholesterol. Hard
candy, sugar, honey, jam, and jelly also provide calories and energy. If you have
diabetes, however, be very careful about eating sweets. A dietitian’s guidance is
especially important for people with diabetes.
Supplements. Vitamins and minerals may be missing from your diet
because you have to avoid so many foods. Dialysis also removes some vitamins
from your body. Your doctor may prescribe a vitamin and mineral supplement
designed specifically for people with kidney failure. Take your prescribed
supplement after treatment on the days you have hemodialysis. Never take
vitamins that you can buy off the store shelf, since they may contain
vitamins or minerals that are harmful to you.

Hemodialysis
Blood is filtered through an artificial kidney machine, called a dialyzer. The
blood travels from the body to the machine through tubes inserted into a vein in
your arm, leg, or neck. An access site called a fistula or shunt may be surgically
created in one of your veins.

Fistulas may need as long as 2 to 3 months to fully heal before they can be
used. They are never used if the treatment is temporary. They are typically
created many months before dialysis is begun.
 Hemodialysis is usually done at a dialysis center or hospital. It may be
done at home with assistance. It is usually done three times a week. Each
treatment lasts from two to four hours.

For this treatment, there needs to be a site where the blood is taken out of
the body and then returned to the blood stream. This is called an access. After
the access is made and healed, 2 needles are inserted into the access. One
needle draws the blood out and the other needle returns the blood to the body.

Access Sites
There are three main types of access sites.
• AV Fistula – With minor surgery, an artery is joined to a vein under the skin.
This is most often done in an arm.
• Graft – With minor surgery, a soft plastic tube is used to join the artery and
vein under the skin.
• A central catheter – For temporary dialysis, the doctor can put in a catheter in
a large vein, most often in the neck.

Indications
1. Chronic Renal Failure
2. Unstable overdose patient of Unknown Ingestion

Toxins and overdose substances cleared by hemodialysis

1. General
1. Low protein binding
2. Small volumes of distribution
3. Water solubility
4. Low Molecular weight
2. Specific (Mnemonic: I STUMBLED)
1. Isopropanol
2. Salicylates
3. Theophylline, Tenormin (Atenolol)
4. Uremia
5. Methanol
6. Barbiturates (e.g. Phenobarbital)
7. Lithium
8. Ethylene Glycol
9. Depakote (esp. if level >500)

Principles of Hemodialysis
The objectives of hemodialysis are to extract toxic nitrogenous substances
from blood and remove excess water. Diffusion, osmosis and ultrafiltration are
the principle on which hemodialysis is based.

 The dialysate is a solution made up of all the important electrolytes in their

ideal extracellular concentration.
 Excess water is removed from the blood by osmosis in which the water
moves from an area of higher solute concentration (blood) to a lower
solute concentration (dialysate).
 Ultrafiltration is defined as water moving under high pressure to an area of
lower pressure. This process is much more efficient at water removal than
osmosis. Ultrafiltration is accomplished by applying negative pressure or
as suctioning force to the dialysate membrane. Because patients with
renal disease usually cannot excrete water, this force is necessary to
remove fluid to achieve fluid balance.
 The body’s buffer system is maintained using a dialysate bath made up of
bicarbonate or acetate, which is metabolize to form bicarbonate.
 The anticoagulant heparin is administered to keep blood from clotting in
the dialysis circuit.
 Cleansed blood is returned to the body by the end of the dialysis
treatment, many waste products have been removed, the electrolyte
balance has been restored to normal, and buffer system has been
replenished.

Vascular Access
 Subclavian, internal, jugular and femoral catheters
 Fistula is created surgically usually in the forearm by joining anastomosing
an artery to a vein, either side to side or end to side.
 Graft in arteriovenous graft can be created by subcutaneously internally
positioning a biologic, semibiologic, or synthetic graft material between
artery and vein.

Equipment and Procedures

 When you first visit a hemodialysis center, it may seem like a complicated
mix of machines and people. But once you learn how the procedure works and
become familiar with the equipment, you’ll be more comfortable.

Dialysis Machine
The dialysis machine is about the size of a dishwasher. This machine has three
main jobs:
• pump blood and watch flow for safety
• clean wastes from blood
• watch your blood pressure and the rate of fluid removal from your body
Dialyzer

Structure of a typical hollow fiber dialyzer. The dialyzer is a large canister

containing thousands of small fibers through which your blood is passed. Dialysis
solution, the cleansing fluid, is pumped around these fibers. The fibers allow
wastes and extra fluids to pass from your blood into the solution, which carries
them away. The dialyzer is sometimes called an artificial kidney.
Reuse. Your dialysis center may use the same dialyzer more than once for
your treatments. Reuse is considered safe as long as the dialyzer is cleaned
before each use. The dialyzer is tested each time to make sure it’s still working,
and it should never be used for anyone but you. Before each session, you should
be sure that the dialyzer is labeled with your name and check to see that it has
been cleaned, disinfected, and tested.
Dialysis Solution
Dialysis solution, also known as dialysate, is the fluid in the dialyzer that
helps remove wastes and extra fluid from your blood. It contains chemicals that
make it act like a sponge. Your doctor will give you a specific dialysis solution for
your treatments. This formula can be adjusted based on how well you handle the
treatments and on your blood tests.
Needles
Many people find the needle sticks to be one of the hardest parts of
hemodialysis treatments. Most people, however, report getting used to them
after a few sessions. If you find the needle insertion painful, an anesthetic cream
or spray can be applied to the skin. The cream or spray will numb your skin
briefly so you won’t feel the needle.
Most dialysis centers use two needles—one to carry blood to the dialyzer
and one to return the cleaned blood to your body. Some specialized needles are
designed with two openings for two-way flow of blood, but these needles are less
efficient and require longer sessions. Needles for high-flux or high-efficiency
dialysis need to be a little larger than those used with regular dialyzers.

Continuous Arteriovenous Hemodialysis(CAVHD)

CAVHD offers the advantage of a concentration gradient for faster
clearance of urea. This is accomplished by the circulation of dialysate on one
side of a semipermeable membrane. The blood flow through the system
depends on the patient’s arterial pressure; a blood pump is not used as it is in
standard hemodialysis. CAVHD is usually set up and initiated by trained dialysis
staff and then maintained and monitored by critical care personnel.

Continuous Venovenous Hemodialysis(CVVHD)

CVVHD is a procedure in which blood is pumped from a double-lumen
venous catheter through a hemofilter and returned to the patient through the
same catheter. In addition to the benefits of ultrafiltration, CVVHD uses a
concentratration gradient to facilitate the removal of uremic toxins. Therefore,
no arterial access is required, hemodynamic effects are usually mild, and critical
care nurses can set up, initiate, maintain and terminate the system.

COMPLICATIONS DURING HEMODIALYSIS

Even though the safety of the hemodialytic procedure has improved greatly over the years, the
procedure is not without risks. Common problems are listed below.
Hypotension
A decrease in blood pressure is the most frequent complication reported during
hemodialysis. When fluid is removed during hemodialysis, the osmotic pressure is increased
and this prompts refilling from the interstitial space. The interstitial space is then refilled by
fluid from the intracellular space. Excessive ultrafiltration with inadequate vascular refilling
plays a major role in dialysis induced hypotension. The immediate treatment to hypotension is
to discontinue dialysis and place the patient in a trendelenburg position. This will increase
cardiac filling and may increase the blood pressure promptly.
Cramps
In the majority of hemodialysis patients, cramps occur toward the end of the dialysis
procedure after a significant volume of fluid has been removed by ultrafiltration. The
immediate treatment for cramps is directed at restoring intravascular volume through the use
of small boluses of isotonic saline. Prevention of cramps has been attempted with the
prophylactic use of quinine sulfate at least 2 hours prior to dialysis.
Febrile reactions
Febrile episodes should be aggressively evaluated with appropriate wound and blood
cultures. The suspicion of infection should be high. Treatment of endotoxin related fever is
generally supportive with antipyretics. Temperatures should be recorded at the initiation and
termination of dialysis treatment.
Arrhythmia
Patients on maintenance hemodialysis are at risk of cardiac arrhythmias. They occur
predominately in association with hemodialysis or may occur in the interdialytic period. Both
acute and chronic alterations in fluid, electrolyte, and acid-base homeostasis may be
arrhythmogenic in these patients.
Hemolysis
Hemolysis may result from a number of biochemical and toxic insults during the
dialysis procedure. The half-life of red blood cells in renal failure patients is approximately
one half to one third of normal and the cells are particularly susceptible to membrane injury.
Hypoxemia
A fall in arterial PO2 is a frequent complication of hemodialysis that occurs in nearly
90% of patients. The drop ranges from 5 to 35 mm Hg, and reaches its peak between 30 - 60
minutes after beginning dialysis. This is obviously undesirable for patients with underlying
cardiopulmonary disease. Also, patients on mechanical ventilators with constant minute
volume and inspired oxygen concentration can still develop hypoxemia during hemodialysis.

Peritoneal Dialysis
 The abdominal lining is called the peritoneal membrane. In this type of
treatment it is used to filter blood instead of a machine. A cleansing solution,
called a dialysate, is inserted into your abdomen. Fluid, wastes, and chemicals
pass from the tiny blood vessels in the peritoneal membrane into the dialysate.
It is then drained after several
hours. New dialysate can then be added to repeat the process. A port in the
abdomen may be needed for long-term treatment.

Rare, Severe Complications

• Acute anaphylaxis (allergic reaction to antigens)
• Acute hemolysis (red-blood-cell damage with hemoglobin loss)
• Air embolism (air bubble obstructing a blood vessel)
• Hypoxemia (low of oxygen in the blood)
Chronic Complications
• Access problems (e.g., clotting, infection, malfunction)
• Amyloidosis (causing carpal tunnel syndrome, shoulder pain)
• Anemia (reduction in red blood cell count)
• Arrhythmia (irregular heart beat)
• Calciphylaxis (calcification of tissue)
• Coronary artery disease
• Infection (causes death in 20% of people)
• Malnutrition (along with diet restriction)
• Renal osteodystrophy (bone degeneration with kidney disease)
• Vitamin and mineral deficiencies

Principles
- The peritoneum is the dialyzing membrane (SP membrane) and substitutes for
kidney function during kidney failure.
- The peritoneal dialysis works on the principles of diffusion and osmosis, the
dialysis occurs via the transfer of fluid and solute from the bloodstream through
the peritoneum.
- The peritoneal membrane is large and porous, allowing solutes and fluid to
move via an osmotic gradient from an area of higher concentration in the body
to an area of lower concentration in the dialyzing fluid.
- The peritoneal cavity is rich in capillaries; therefore it provides a ready access
to blood supply.

Basic Goals of Peritoneal Dialysis

1. Aid in the removal of toxic substances and metabolic wastes
2. Establish electrolyte balance.
3. Removes excess body fluid.
4. Assist in regulating the fluid balance of the body
5. Control blood pressure.
6. Control severe, intractable heart failure when diuretics no longer promote
elimination of water and sodium.

Nursing Objectives
a. To restore and maintain fluid and electrolyte balance and preserve renal
function if possible.
b. To prevent complication of therapy.

Indications
a. Acute renal failure
b. Severe fluid overload in pediatric cardiac patients
c. To remove toxic and metabolic wastes

Contraindications To Peritoneal Dialysis:

1. Peritonitis
2. Recent abdominal surgery
3. Abdominal adhesions, wound or infection
4. Impending renal transplant
5. Fecal fistula or colostomy
6. Gastric or diaphragmatic hernia

Dialysate Solution
1. Solution is sterile
2. Solution contains electrolytes and minerals, a specific osmolarity,a specific
glucose concentration, and other medication additives prescribed.
3. The higher glucose concentration, the greater the amount of fluid removed
during an exchange.
4. Increasing the glucose concentration increases the concentration of active
particles that cause osmosis and increases the rate of UF and the amount of fluid
removed.
5. If hyperkalemia is not a problem, potassium may be added to each bag of
solution.
6. Heparin is added to the dialysate solution to prevent clotting of the catheter.
7. Prophylactic antibiotics may be added to dialysate to prevent peritonitis.
8. Insulin may be added to the dialysate for the client with diabetes mellitus.

Access For Perittoneal Dialysis

1. A surgical insertion of a siliconzied rubber catheter into the abdominal cavity

is required to allow infusion of dialysis fluid.
2. The preferred insertion site is to 3 to 5 cm below the umbilicus because this
area is relatively avascular and has less fascial resistance.
3. The catheters are tunnelled under the skin to stabilize the catheter and
reduce the risk of infection.
4. Over a period of 1 to 2 weeks following insertion, an ingrowth of fibroblasts
and blood vessels occurs into the cuffs of the catheter, which fix the catheter in
place and provide an extra barrier against dialysate leakage and bacterial
invasion.

Equipments Used
1. Dialysis administration set
2. Local anesthesia
3. Warmer
4. Tube clamps
5. Tenchkoff peritoneal catheter (adult - standard and curled)
6. Trocath peritoneal catheter (pediatric)
7. PD solution as prescribed
8. Supplemental drugs
9. CVP monitoring equipment
10. Sterile gloves
11. Skin antiseptic
12. ECG monitoring
13. Suture set
14. IV stand

Peritoneal Dialysis Infusion

a. One infusion (inflow), dwell, and outflow is considered one exchange.
b. Dialysis uses an open system that presents a risk of infection.
c. Inflow: The infusion of 1 to 2 L of dialysate as prescribed is infused by gravity
into the peritoneal space, which usually takes 10 to 20 minutes.
d. Dwell Time: The amount of time that the dialysate solution remains in the
peritoneal cavity is prescribed by the physician and can last to 20-30 minutes to
8 or more hours depending on the type of the dialysis used.
e. Outflow: Fluid drains out of the body by gravity into the drainage bag.

Interventions Before Treatment

a. Monitor VS.
b. Obtain Weight.
c. Have the client void, is possible.

Interventions During Treatment

a. Monitor VS.
b. Monitor signs of infection.
c. Monitor for respiratory distress, abdominal pain or discomfort.
Respiratory Distress:
- Slow inflow rate
- Prevent air from entering peritoneum by keeping drip chamber of tubing
three quarters full of fluid.
- Elevate head of bed, encourage deep breathing exercises
- Turn patient side to side
- Reduce the volume administered
Abdominal Pain
- Encourage patient to move about if ambulatory
d. Monitor signs of pulmonary edema.
e. Monitor for hypotension and hypertension
f. Monitor for malaise, nausea, vomiting.
g. Assess the catheter site dressing for wetness or bleeding.
Leaks:
- Change the dressings frequently, being careful not to dislodge the
catheter
- Use sterile drapes to prevent contamination
h. Monitor dwell time to extend beyond the physician’s order because this
increases risk of hyperglycemia.
i. Turn the client from side to side if the outflow is slow to start. Elevate head of
bed at intervals.
j. Monitor outflow, which should be continuous stream after the clamp is
opened.
k. Monitor outflow for color and clarity.
l. Monitor intake and output accurately.
m. If outflow is less than the inflow, the difference is equal to the amount
absorbed or retained by the client during dialysis and should be counted as
intake.

Keep accurate records:

- Exact time of beginning and end of each exchange
- Amount of solution infused and recovered
- Fluid balance
- No. of exchanges
- Medications added to dialyzing solution
- Pre and Post dialysis weight plus daily weight
- Level of responsiveness at beginning, throughout, and at the end of the
treatment
- Assessment of VS and patient’s condition

Complications Of Peritoneal Dialysis

1. Peritonitis
a. Maintain meticulous sterile technique when hooking up of clamping off
bags and when caring for the catheter insertion site.
b. Follow instructional procedure for hooking up or clamping off bags,
which maybe include scrubbing the connection sites with antiseptic
solution.
c. Monitor temperature closely.
d. Monitor for fever, cloudy outflow, and rebound abdominal tenderness.
e. If peritonitis is suspected, obtain a culture of the outflow to determine
the infective organism.
f. Administer antibiotics as prescribed.
2. Abdominal Pain
a. Pain during inflow is common during the first few exchanges, is caused
by peritoneal irritation, and disappears after 1 to 2 weeks of dialysis
treatments.
b. The cold temperature of the dialysate aggravates comfort, and the
dialysate should be warmed before use, only with a special dialysate
warmer pad.
c. Place a heating pad on the abdomen during the inflow to relieve
discomfort; if a heating pad is used, place it in low setting and monitor
client closely.
3. Insufficient Outflow
a. Insufficient outflow may be caused by catheter migration out of the
peritoneal area; if this occurs, the physician must reposition the catheter.
b. Insufficient outflow also can be caused by a full colon.
c. Maintain the drainage bag below the client’s abdomen.
d. Change the client’s outflow position by turning the client on his or her
side by ambulating the client.
e. Check for kinks in the tubing
f. Encourage a high-fiber diet
g. Administer stool softeners as prescribed
4. Leakage around the catheter site
a. Over a period of 1 to 2 weeks following insertion of the catheter, an
ingrowth of fibroblasts and blood vessels into the cuffs of the catheter
occurse that fixes the catheter into the cuffs of the catheter in place and
provides an extra barrier agains dialysate leakage and bacterial invasion.
b. It may take up to 2 weeks for the client to tolerate a full 2-L exchange
without leaking around the catheter site.

Characteristics Of Outflow
a. During the first or initial exchanges, the outflow may be bloody; outflow
should be clear and colorless thereafter.
b. A brown outflow indicates bowel perforation.
c. If the outflow is the same color as urine, this indicates bladder perforation.
d. Cloudy outflow indicates peritonitis.

Types of peritoneal dialysis

• Continuous ambulatory peritoneal dialysis (CAPD)—is the most
common type of peritoneal dialysis. A bag of dialysate is infused into the
abdomen through a catheter. It remains there for 3-6 hours and is drained.
The abdomen is refilled with fresh solution. This way your blood is always
being cleaned. No machine is needed.
a. Continuous dialysis closely resembles renal function because it is a
continuous process.
b. Continuous dialysis does not require a machine for the procedure.
c. Continuous dialysis promotes client independence.
d. The client performs self-dialysis 24 hours a day 7 days a week.
e. Usually four dialysis cycles are administered in 24 hours, including
an 8-hour dwell time overnight.
f. One and a half to 2L of dialysate are installed into the abdomen 4 times
daily and allowed to dwell as prescribed.
g. The dialysis bag, attached to the catheter, is folded and carried under
the client’s clothing until time for outflow.
h. After dwell, the bag is placed lower than the insertion site so that fluid
drains by gravity flow.
i.When full, the bag is changed, new dialysate is instilled into the
abdomen, and the process continues.
• Automated Peritoneal Dialysis
a. It is similar to continuous ambulatory peritoneal dialysis in that it is a
continuous
dialysis process.
b. Requires a peritoneal cycling machine.
Types of Automated Peritoneal Dialysis
a. CCPD (Continuous Cycling Peritoneal Dialysis) — is done using a
special machine. The fluid stays in the abdomen for a shorter time, about
1½ hours. The machine is set up and the person is connected to this
machine for 8 to 10 hours during the night. The person is unhooked from
the machine during the day.
- Dialysis usually consists of three cycles done at night and one cycle with
an 8-hour dwell done in the morning.
- The sterile catheter system is opened only for the ON and OFF
procedures, which
reduces risk of infection.
- The client does not need to do exchanges during the day.
 b. IPD (Intermittent Peritoneal Dialysis) —uses the same type of
machine as CCPD. This requires assistance and is usually done at a
hospital or center. It often takes longer than CCPD.
- Dialysis is not a continuous procedure.
- Dialysis is performed for 10 to 14 hours, 3 to 4 times a week.
c. Nightly Peritoneal Dialysis
-Dialysis is performed 8-12 hours each night with no daytime exchanges or
dwells.

CAPD
How CAPD Works
Continuous ambulatory peritoneal dialysis (CAPD) involves instilling
2 to 3 liters (quarts) of fluid at a time into the person's abdominal (or
"peritoneal") cavity through a flexible plastic catheter that is implanted in the
abdominal wall [Figure 3]. The fluid is allowed to remain in the abdominal
cavity for a period of hours, gradually absorbing waste products and toxins
from the body; it is then drained out and replaced with fresh fluid.
This procedure of fluid exchange is performed by the patient, and is
done 4-5 times a day, 7 days a week. The procedure involves careful use of
sterile technique and constant monitoring of blood pressure, fluid volumes,
and weights, so many patients are not able to perform this type of dialysis. A
variation on this procedure is dialysis with a cycler, in which the patient
performs one or two fluid exchanges daily, as described above, and then
hooks up to an automatic cycler, which performs several more exchanges
during the night as the patient sleeps.

Preparing for CAPD

Like hemodialysis, CAPD requires preparatory surgery. A flexible
catheter must be surgically implanted in the abdominal wall and then
requires several weeks to scar firmly in place.

Advantages of CAPD
Flexibility in Schedule - Although CAPD requires a great deal of work on
the part of the patient, patients who have the manual dexterity and ability to
learn the procedure and the ability to be compulsive about record keeping
and sterile technique find that this type of dialysis gives them more flexibility
of schedule and greater freedom to work, go to school, and be active in
general.
Flexibility in Diet - CAPD also allows a more liberal diet than hemodialysis,
because fluid and potentially harmful substances (such as potassium, salt,
and protein) are continuously removed by dialysis as they are eaten, and thus
do not accumulate in harmful or dangerous amounts.

Infection and CAPD

The main complication of this type of dialysis is infection, of which there is
a risk every time an exchange is performed and every time the abdominal
catheter is uncapped in order to add fluid to the abdominal cavity or to drain
fluid from it. The symptoms of abdominal cavity infection, or “peritonitis,” are
abdominal pain, fever, and cloudy fluid draining from the abdomen.
This type of infection, which can be quite serious, is treated with
antibiotics given either IV or in the dialysis fluid that is instilled into the
abdomen. In order to avoid peritonitis, it is extremely important for the
patient to carefully follow sterile technique every time they do a fluid
exchange, which requires wearing sterile gloves and a mask, as well as using
sterile disposable equipment, tubing, and dialysis fluid. Repeated episodes of
peritonitis can cause scarring in the abdominal cavity, sometimes so severe
that peritoneal dialysis will no longer work.

Laguna State Polytechnic University

Main Campus
Sta Cruz,Laguna

Dialysis
Submitted by:
Jessa A. Urriza
BSN IV- A

Submitted to:
Mrs. Elenita Carandang