Dialysis Nursing Care Plan

 

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.