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Peritoneal Dialysis

Peritoneal Dialysis. Kidney A&P. I.  Kidneys A. Location - back of the abdominal cavity. The right kidney is lower than the left due to the liver . B. Size    approx. same size as your fist

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Peritoneal Dialysis

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  1. Peritoneal Dialysis Kidney A&P

  2. I.  Kidneys A. Location - back of the abdominal cavity. The right kidney is lower than the left due to the liver  • B. Size   approx. same size • as your fist • 4" long (12cm) 1-1/2" thick    (3cm) 2-1/2“ wide (6 cm) weighs:1/3 lb (150 gm) 

  3. C. Layers 1. Cortex- outermost layer (85% nephrons) shorter cortical nephrons (excretory/regulatory) 2. Medulla- middle layer (15% nephrons) longer juxtamedullary nephrons (concentration and dilution of urine) 3. Pelvis- inner layer (collecting system- urine)

  4. D. Blood flow through the Kidneys Heart pumps approx.1.2 liter blood/min to the kidneys via the renal artery. Blood then travels through a series of smaller arteries and then enters the glomeruli. Some of the fluid is filtered out of each glomerulus and then moves into Bowman's capsule. The filtrate then moves through the tubules where most of The sugar, water, and minerals are   reabsorbed back into the blood vessels. The filtrate then goes into the renal pelvis.

  5. E. Nephrons Functional units of the kidney. Approximately one million in the cortex and medulla of each kidney Cortical Nephron Juxtamedulary Nephron

  6. 1. Glomerulus  filters blood approx.1200 ml/min (1/4 cardiac output) efferent arteriole- blood out distal convoluted tubule afferent arteriole- blood in 2. Bowman's Capsule surrounds the glomerulus and collects the filtrate

  7. 3. Juxtaglomerular Apparatus • macula densa • and • juxtaglomerular cells • (1) systemic BP and • volume control via the • renin-angiotensin system • (2) local control of the • (GFR) by nitric oxide • production • (3) the production of erythropoietin in response to decrease in O2.

  8. 4. Tubules Proximal Convoluted-where 60%-70% filtrate containing water, glucose, nutrients, amino acids & ions from the glomerulus is re-absorbed into the capillaries.

  9. Loop of Henley- concentration of urine occurs (descending) water excreted (ascending) Na+, K+, Cl- excreted

  10. Distal Convoluted Tubules regulation electrolytes, H2O and pH (aldosterone- Na+) (ADH- water)

  11. Collecting ducts- water and urea are absorbed or excreted, then empty into the calyces. ADH-water Equilibrium-urea

  12. F. Major Functions  1. Remove water, urea, creatinine, and uric acid (components of urine)  2. Maintain electrolyte balance  3. Maintain acid/base balance by removing or retaining H+ / HCO3 ions  4. Regulate blood pressure by initiating renin / angiotensin response  5. Release erythropoietin to help maintain RBC production  6. Detoxification & elimination of toxins, drugs, and their metabolites

  13. Peritoneal Dialysis Renal Failure

  14. I I . Renal Failure   A. Acute vs. Chronic

  15. B. Types 1. Pre-Renal a) Definition  Any condition that impairs renal blood flow. Nephrons remain intact but decreased blood supply causes a drop in the glomerular filtration rate which results in decreased urine output b) Causes cardiac disorders- arrhythmias, chf, cardiac tamponade, MI vasodilatation- sepsis, anaphylaxis, medications, OD hypovolemia- hemorrhage, third spacing, shock, diuretics diabetes insipidus, burns, dehydration, vomiting, diarrhea, cirrhosis vascular- thrombus, stenosis, surgical clamping (AAA repair)

  16. 2. Renal (Intra-Renal)   a) Definition  direct damage to the kidneys b) Causes Pyelonephritis - infection of the kidneys from UTI (E.coli) Glomerulonephritis - antigen/antibody complexes (strep throat) Systemic lupus - connective tissue disorder Hereditary lesions - polycystic kidneys Acute Tubular Necrosis - anesthesia, radiographic dyes, lasix, vancomycin, corticosteroids, Amphotericin-B, ibuprophen, rhabdomyolysis, prolonged pre-renal causes

  17. 3. Post-Renal a) Definitionobstruction of the urinary system b) Causes prostatic hypertrophy, renal calculi, tumors, blood clots, pregnancy

  18. C. Stages of Chronic Renal Failure(normal GFR is 125 mL/min/1.73 m2) • STAGE 1 Kidney damage with normal GFR ( ≥90) • STAGE 2 Mild decrease in GFR (60-89) • STAGE 3 Moderate decrease in GFR (30-59) • STAGE 4 Severe decrease in GFR (15-29) • STAGE 5 Kidney failure (GFR <15)

  19. Glomerular Filtration Rate Serum Creatinine (mg/dl) Age Male/Female African American GFR(mL/min/1.73 m2) = 186 x (Scr)-1.154 x (Age)-0.203 x (0.742 if female) x (1.212 if African-American)

  20. D. Symptoms 1. weakness, fatigue 2. drowsiness, confusion 3. restless legs   4. itching 5. dry flaky skin   6. loss of appetite  7. metallic taste 8. nausea/vomiting

  21. Symptoms (continued) 9. edema, puffiness around eyes 10. shortness of breath 11. high blood pressure 12. muscle cramping 13. decreased sexual interest 14. decreased urinary frequency 15. amenorrhea 16. testicular atrophy

  22. E. Complications As renal function declines, the end products of protein metabolism accumulate in the blood and adversely affect every system in the body. 1. Hyperkalemia 2. Metabolic Acidosis 3. Pericarditis (effusion / tamponade) 4. Pulmonary Edema 5. Hypertension 6. Anemia 7. Bone disease 8. Vascular calcifications

  23. F. Treatment Options 1. Transplantation 2. Dialysis a) hemodialysis b) CRRT (ICU) c) Peritoneal 3. No Treatment

  24. Complications

  25. Complications Peritoneal Dialysis

  26. Peritoneal Dialysis C A P D

  27. III . Peritoneal Dialysis A. Definition removal of fluid and waste products via a dialysis catheter located in the peritoneal cavity; space between the stomach, liver, spleen, intestines and kidneys by: 1) diffusion 2) osmosis 3) ultrafiltration 4) convection

  28. Ultrafiltration Occurs because of a pressure gradient Convection Occurs as solvent drag. Solvent brings the solute with it.

  29. B. Process 1. Infusion- 1 to 3 liters of sterile dialysate solution is infused through the dialysis catheter into the abdominal cavity which comes into contact with the peritoneal membrane. 2. Dwell - The membrane is semi-permeable and acts as a filter which allows waste products and excess fluid to pass from the blood stream, across the membrane and into the dialysis solution. 3. Drain - After a specified dwell time the fluid containing the waste and excess fluid is drained out. (however!!!)

  30. 1- Drain -  2- Infusion- 3- Dwell -

  31. C. Types    1. CCPD -  Continuous Cycler Peritoneal Dialysis (or APD - Automated PD). Cycler is used during the night to perform up to 8 exchanges. Long dwell during the day    2. CAPD -  Continuous Ambulatory Peritoneal Dialysis 4 or 5 exchanges per day

  32. D. Dialysate   1. Definition: Fluid containing dextrose and electrolytes    2. Concentrations: Higher concentrations of glucose pull more fluid    a) 1.5%   b) 2.5%   c) 4.25%

  33. EXTRANEAL is a glucose-free polymer that is indicated for a single daily exchange for the long 8-16 hour dwell during CAPD or APD. ƒ Recent findings have shown that it improves the long-dwell ultrafiltration and clearance of creatinine and urea compared to 4.25% dextrose.

  34. Some glucose monitoring systems have given falsely elevated glucose readings due to the presence of maltose. Patients and health care providers have withheld treatment of hypoglycemia or administered insulin inappropriately which has resulted in loss of consciousness, coma, permanent neurological damage and death. Plasma levels of Extraneal and its metabolites return to baseline within approximately 14 days following cessation of administration.

  35. 3. Possible Additives   a) heparin   b) insulin (added by pharmacy)   c) antibiotics (added by pharmacy)   d) potassium (added by pharmacy)

  36. Advantages 1. flexible schedule 2. less expensive than Hemodialysis 3. fairly easy to learn 4. fewer dietary restrictions  5. no needles required 6. dialysis can be done at home, on vacation or wherever you are 7. no blood loss 8. continue daily activities Disadvantages 1. burn out, no days off 2. procedure must be followed exactly to prevent peritonitis 3. altered body image 4. risk of infection 5. permanent catheter access 6. larger clothing size because of fluid in the peritoneal cavity 7. some protein loss 8. storage space (supplies)

  37. Peritoneal Dialysis Nursing Responsibilities

  38. IV   Nursing responsibilities A. room environment - during bag connection, tubing change, adding meds, exit-site care for recent post ops     1. prefer a private room (roommate approved by  MD)     2. air vent covered     3. door closed (sign on door) Procedure in Progress Do Not Enter     4. curtain pulled     5. mask on patient, roommate, staff

  39. B. accurate I&O C. daily weights abdomen must be empty, weigh after first AM drain D. exit site care (daily) immediately post-op - do not disturb recent post-op - ExSept long standing - soap & water

  40. E. phosphate binders must be given immediately before or after meals, otherwise  they are calcium supplements Examples:. PhosLo, Renagel, Ca+ carbonate (Tums) F. sorbitol standing order. No fleets enema or MOM. (Mg+ not removed by dialysis) G. tubing clamps soak in hibiclens / betasept (in open position) rinse off prior to use change solution every 24hrs.

  41. H. IV rates watch, especially pre-op and post-op patients. Use IV Pump! I. insulin is stable 2 hrs. in the warmer 24 hrs. out of the warmer J. potassium is stable 1 hr after added (adheres to bag)

  42. K. heparin should be added to the bag prior to the infusion during the current exchange. Does not cross the peritoneal membrane so does not cause systemic anticoagulation L. Specimens C & S – aerobic & anaerobic culture bottles, 30ml extra in sterile specimen cup Cell Count – lavender top tube (must hand deliver specimens to the lab!)

  43. M. Documentation Meditech: CAPD Assess & Care (150344)

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