Peritoneal Dialysis Nursing
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Direct answer
Hold the drain bag up to the light before discarding it: cloudy effluent is peritoneal dialysis peritonitis until culture says otherwise, and the nurse who spots it at the first exchange has shortened the illness by a day. Peritoneal dialysis (PD) uses the peritoneum as a semipermeable membrane, with a Tenckhoff catheter carrying dialysate in and out — continuous ambulatory PD (CAPD) runs about four exchanges of 2 to 2.5 litres daily (drain 10 to 20 minutes, dwell 4 to 6 hours, fill 5 to 10 minutes), while automated PD cycles overnight. Nursing owns the technique chain — hand hygiene, mask, sterile connections, warm dialysate, aseptic exchange — plus exit-site care, patient and family training (most PD in India is self-performed at home), and vigilance for peritonitis, exit-site and tunnel infection, catheter malfunction, fluid overload, hyperglycaemia, hernias and protein loss.
What you must remember
- Exchange mechanics: drain (10 to 20 minutes), dwell (4 to 6 hours), fill (5 to 10 minutes); roughly 4 exchanges of 2 to 2.5 litres daily; dialysate dextrose 1.5, 2.5 or 4.25 per cent sets the osmotic pull.
- Peritonitis — diagnose early: cloudy effluent plus abdominal pain or fever; diagnostic standard is an effluent white cell count above 100 per microlitre with over 50 per cent neutrophils; commonest organisms Staphylococcus epidermidis and aureus, gram-negatives and fungi in recurrent cases; treatment is intraperitoneal antibiotics, and fungal peritonitis usually means catheter removal.
- Exit-site care: daily or alternate-day washing with antiseptic per protocol, drying, and fixation of the catheter without tension; score exit sites for infection — redness, swelling, pain, purulent discharge; Staphylococcus aureus nasal carriage is a recognised risk.
- Technique discipline: handwash for 60 seconds, mask on patient and nurse, clean surface, check solution clarity and expiry, warm dialysate to about 37 degrees, sterile connection, never touch the transfer set tip — touch contamination is the commonest peritonitis route.
- Malfunction patterns: slow or no drainage (catheter migration, omental wrapping, fibrin clot — repositioning, flushes, heparin into dialysate), inflow pain (dialysate temperature), and early exit-site leaks.
- Metabolic and nutritional care: glucose absorption (weight gain and hyperglycaemia risk), daily protein loss of roughly 5 to 15 g into effluent — so PD patients need about 1.2 to 1.3 g per kg per day of protein plus fibre for constipation, which itself impairs drainage.
- Ultrafiltration failure: weight gain, hypertension and oedema signal failing fluid removal — daily weight, blood pressure, fluid restriction; hernias need surgical review.
Training a patient for home CAPD
A 46-year-old teacher with end-stage renal disease chooses PD over centre haemodialysis. Training begins with the why — the peritoneum as membrane, the exchange as diffusion and osmosis — then the how, drilled until asepsis is muscle memory: handwashing timed with a clock, mask, bag checked against light, connection without the transfer set tip touching anything. The nurse teaches drain-inspect-fill, makes him narrate each step aloud, and simulates failures — a cloudy bag, a contaminated clamp — because home complications happen without a nurse present. Exit-site care is demonstrated on him and then by him: wash, dry, secure, no tension. He learns sick-day rules (abdominal pain, cloudy fluid, fever — come in with the bag), keeps a daily weight and blood pressure diary, and plans exchanges around school hours; his wife is backup. At the exit-site review four weeks later, a small redness is caught, cultured, and treated before it becomes tunnel infection — the quiet payoff of a trained patient and a scoring system.
Where PD questions focus in exams
The banker answer across INC and critical-care papers is the earliest sign of peritonitis — cloudy effluent — with the cell-count criterion (more than 100 white cells per microlitre, over half neutrophils) as the mark-winning addition; "abdominal pain and fever" alone is a partial answer. Viva traps include the protein-loss figure (5 to 15 g daily — hence the high-protein diet), why constipation wrecks drainage (bowel pressure displacing the catheter tip), and differentiating exit-site infection (local redness and discharge) from tunnel infection (induration along the tract) from peritonitis (intraperitoneal signs). PD remains underused relative to haemodialysis in India for cost and logistics, but home CAPD is expanding — and training quality, not the catheter, determines peritonitis rates.
Frequently asked questions
What is the earliest and most reliable sign of CAPD peritonitis?
Cloudy peritoneal effluent, usually with pain or fever; supported by an effluent white cell count above 100 per microlitre, neutrophil-predominant.
How is a CAPD exchange performed aseptically?
Handwash for at least a minute, mask on, clean area, inspect and warm the dialysate, connect with no-touch technique, drain, dwell, fill — the transfer set tip never touches anything.
What daily exit-site care does a Tenckhoff catheter need?
Washing with soap and water or antiseptic per protocol, thorough drying, securing the catheter without tension, and scoring for redness, swelling, pain or discharge that suggests infection.
Why do PD patients need a high-protein diet?
Because 5 to 15 grams of protein are lost into the effluent daily and glucose absorption adds calories — requiring about 1.2 to 1.3 g per kg per day of protein.
What causes slow or absent drainage during an exchange, and what is done?
Constipation, catheter migration, omental wrapping or fibrin clots; management includes treating constipation, repositioning, flushes, intraperitoneal heparin, and surgical review if unresolved.