8 Peritoneal Dialysis Nursing Care Plans

Peritoneal dialysis uses the patient's own peritoneal membrane as the filter. When the kidneys fail, this is one of the ways you pull fluid and waste out of the body.

What is Peritoneal Dialysis

Dialysis removes fluid and waste the failing kidneys can no longer clear. There are two types: hemodialysis and peritoneal dialysis. Peritoneal dialysis uses the abdominal lining, the peritoneal membrane, as a semipermeable filter across which fluid and dissolved substances (electrolytes, urea, glucose, albumin, and other small molecules) move between the blood and a dialysate solution.

The principle is the same as hemodialysis: passive movement of water and solutes across a semipermeable membrane by diffusion, with solute moving from the side of greater concentration to lesser. The peritoneum lets nitrogenous wastes, toxins, and fluid pass from the blood into the dialysate. It is sometimes preferred because the technique is simpler and the physiologic changes more gradual than hemodialysis.

The manual single-bag method is usually inpatient, with short dwell times of 30 to 60 minutes repeated until you get the effect you want. The most common type is continuous ambulatory peritoneal dialysis (CAPD): the patient manages it at home with bag and gravity flow, using a long overnight dwell and 3 to 5 cycles daily, 7 days a week, no machinery. Continuous cycling peritoneal dialysis (CCPD) uses a machine to run shorter overnight dwells (3 to 6 cycles) plus one 8-hour daytime dwell, which gives the patient more independence.

Nursing Care Plans and Management

Goals are fluid and electrolyte balance, monitoring vitals and weight, watching for infection, keeping the catheter placed and working, teaching self-care, and supporting the patient through treatment.

Nursing Problem Priorities

1. Care of the peritoneal catheter and access site
2. Monitoring dialysis fluid parameters and fluid balance
3. Infection prevention and control
4. Monitoring vital signs and dialysis adequacy
5. Patient and caregiver education on technique, self-care, and compliance
6. Management of complications (peritonitis, catheter infections, hernias)
7. Collaboration on dialysis prescription and medication adjustments
8. Nutritional support specific to peritoneal dialysis

Nursing Assessment

Assess for the following subjective and objective data:

• Discomfort or pain during the procedure
• Changes in appetite, energy, or sleep
• Abdominal pain, bloating, or fullness
• Blood pressure, heart rate, and temperature
• Catheter site for redness, swelling, or drainage
• Weight, to track fluid balance
• Dialysate color, clarity, and presence of fibrin or debris
• Dialysis adequacy and ultrafiltration volumes
• Signs of peritonitis, hernia, or catheter malfunction

Assess for factors related to the problems patients encounter:

• Hypertonic dialysate removing too much circulating volume
• Abdominal pressure or restricted diaphragmatic excursion; rapid infusion; pain
• Inflammatory process (atelectasis, pneumonia)
• Catheter contamination during insertion or bag/tubing changes
• Skin contaminants at the insertion site
• Sterile peritonitis (response to dialysate composition)
• Catheter insertion through the abdominal wall, irritation, or malposition
• Irritation or infection within the peritoneal cavity
• Cold or acidic dialysate, abdominal distension, rapid infusion
• Inadequate osmotic gradient of dialysate
• Fluid retention (kinked or clotted catheter, bowel distension, peritonitis, peritoneal scarring)
• Excessive PO or IV intake

Nursing Diagnosis

Build the nursing diagnoses from your assessment and the patient's priorities. The labels matter less than the clinical judgment behind them.

Nursing Goals

Goals and expected outcomes may include:

• The patient will reach the desired fluid volume and weight with BP and electrolytes in acceptable range.
• The patient will have no symptoms of dehydration.
• The patient will show an effective respiratory pattern with clear breath sounds and ABGs within their normal range.
• The patient will have no dyspnea or cyanosis.
• The patient will identify interventions to reduce infection risk and have no signs of infection.
• The patient will report decreased pain and show a relaxed posture and ability to rest.
• The patient will have no bowel or bladder injury.
• The patient will show dialysate outflow that meets or exceeds infusion, with no rapid weight gain, edema, or pulmonary congestion.

Nursing Interventions and Actions

1. Promoting Fluid Balance

Pull off too much fluid and the patient goes dry. Deficient fluid volume and electrolyte imbalance are the risks here.

Measure and record intake and output, including wound drainage, nasogastric output, and diarrhea, and keep a running record of inflow, outflow, and cumulative fluid balance. Tells you the patient's net loss or gain at the end of each exchange.

Assess Hgb and Hct; replace blood components as indicated. Under-dialysis in a patient with normal or near-normal hematocrit signals the need to adjust the prescription.

Follow the schedule for draining dialysate. Prolonged dwell times, especially with 4.5% glucose solution, can cause excessive fluid loss.

Weigh when the abdomen is empty, after the initial 6 to 10 runs, then as indicated. Compared against baseline, this shows the rate of fluid removal.

Monitor vitals; report signs of pericarditis (pleuritic chest pain, tachycardia, pericardial friction rub), inadequate renal perfusion (hypotension), and acidosis. ESRD patients can develop pericardial disease.

Monitor BP lying and sitting, pulse, and jugular pulsation. Decreased BP, postural hypotension, and tachycardia are early signs of hypovolemia.

Note dizziness, nausea, and increased thirst. May signal hypovolemia and hyperosmolar syndrome.

Inspect mucous membranes, skin turgor, peripheral pulses, and capillary refill. Dry membranes, poor turgor, and diminished pulses point to dehydration and the need for more intake or a change in dialysate strength.

Monitor serum sodium and glucose. See Laboratory and Diagnostic Procedure

Maintain electrolyte balance. Watch potassium for hyperkalemia (malaise, anorexia, paresthesia, muscle weakness) and ECG changes (tall peaked T waves, widening QRS, disappearing P waves); report immediately. Hyperkalemia is by far the most common electrolyte abnormality in dialysis patients.

Assess frequently during emergency potassium-lowering treatment. With hypertonic glucose and insulin infusions, monitor potassium. If giving sodium polystyrene sulfonate rectally, make sure the patient does not retain it and become constipated. Retention risks bowel perforation.

Provide a high-calorie, low-protein, low-sodium, low-potassium diet with vitamin supplements. Balances nutritional intake.

Aggressively restore fluid volume after major surgery or trauma. Dialysis disequilibrium syndrome is tied to abrupt fluid shifts.

2. Managing Effective Breathing Pattern

A belly full of dialysate pushes on the diaphragm and limits lung expansion. Fluid overload and electrolyte shifts add to the respiratory load.

Monitor respiratory rate and effort; reduce infusion rate if dyspnea appears. Tachypnea, dyspnea, and shallow breathing during dialysis suggest diaphragmatic pressure or a developing complication.

Auscultate lungs for decreased, absent, or adventitious sounds (crackles, wheezes, rhonchi). Decreased ventilation suggests atelectasis; adventitious sounds suggest fluid overload, retained secretions, or infection.

Note character, amount, and color of secretions. Depressed cough reflex, thick secretions, and altered immunity make these patients prone to pulmonary infection.

Elevate the head of bed or sit the patient up; promote deep breathing and coughing. Aids chest expansion and clears secretions.

Review ABGs, pulse oximetry, and serial chest X-rays. See Laboratory and Diagnostic Procedure

Administer supplemental O2 as indicated. Maximizes oxygen uptake and prevents hypoxia.

3. Managing Pain

Acute pain during PD comes from the catheter, peritonitis, the dialysate itself, or abdominal cramps. Track it and find the source.

Investigate reports of pain; note intensity (0 to 10), location, and triggers. Points you to the source and the right intervention.

Watch for pain that starts during inflow and continues through equilibration; slow the infusion rate. Acidic dialysate chemically irritates the peritoneal membrane.

Explain that initial discomfort usually eases after the first few exchanges. Reduces anxiety and promotes relaxation.

Note discomfort most pronounced near the end of inflow; instill no more than 2000 mL at a time. Likely abdominal distension from the dialysate. Reduce the infused volume.

Keep air out of the peritoneal cavity during infusion; note shoulder blade pain. Air irritates the diaphragm and refers pain to the shoulder. Smaller exchange volumes may be needed until the patient adjusts.

Elevate the head of bed at intervals, turn side to side, and give back care and tissue massage. Relieves abdominal and muscle discomfort.

Warm dialysate to body temperature before infusing. Warm solution dilates peritoneal vessels and speeds urea removal. Cold dialysate causes vasoconstriction, discomfort, and dangerous core cooling that can precipitate cardiac arrest.

Monitor for severe or continuous abdominal pain and temperature elevation, especially after dialysis stops. May signal developing peritonitis.

Encourage relaxation techniques. Redirects attention and restores a sense of control.

Administer analgesics as indicated. See Pharmacologic Management

Add sodium hydroxide to dialysate if indicated. Occasionally used to adjust pH when the patient cannot tolerate acidic dialysate.

4. Promoting Infection Control and Minimizing Risk for Infection

The catheter is a direct line into the peritoneal cavity. Let bacteria in and you get peritonitis: pain, fever, inflammation, and failing dialysis.

Position the patient with the head of bed elevated during dialysis. Reduces diaphragmatic pressure and aids respiration.

Watch for signs of infection (cloudy drainage, fever) and, rarely, bleeding. Cloudy effluent suggests peritoneal infection.

Use meticulous aseptic technique and wear masks during catheter insertion, dressing changes, and any time the system is open; change tubing per protocol. Prevents introduction of organisms and airborne contamination.

Change dressings carefully without dislodging the catheter; note drainage character, color, and odor at the site. Moisture breeds bacteria, and purulent drainage signals local infection. Polyurethane adhesive film dressings reduce pressure on the catheter and lower site infection rates.

Observe color and clarity of effluent. Cloudy effluent suggests peritoneal infection.

Apply a povidone-iodine (Betadine) barrier on the clamped distal catheter during intermittent therapy. Reduces bacterial entry between treatments when the catheter is disconnected.

Investigate nausea, vomiting, severe abdominal pain, rebound tenderness, fever, and leukocytosis. These point to peritonitis and need prompt intervention.

Monitor the WBC count of effluent and obtain blood, effluent, and site cultures as indicated. See Laboratory and Diagnostic Procedure

Administer antibiotics systemically or in dialysate as indicated. See Pharmacologic Management

5. Promoting Safety and Minimizing Injury Risk

Infusing and draining dialysate can traumatize the peritoneal membrane if technique is sloppy. Catheter movement, repeated site use, and membrane damage all raise the risk.

Review history for prior surgeries and abdominal or pelvic infections. Gauges catheter-related trauma risk.

Assess the catheter site for redness, swelling, or tenderness, and for displacement or twisting. These signal infection, trauma, or mechanical stress.

Assess the abdominal wall for weakness or herniation. Puts the catheter at risk of trauma or displacement.

Observe the amount and consistency of drained fluid; note cloudy or bloody output. Points to peritoneal infection or trauma.

Ask about discomfort or pain. May indicate trauma or a catheter issue.

Have the patient empty the bladder before catheter insertion if no indwelling catheter is present. An empty bladder sits farther from the insertion site and is less likely to be punctured.

Anchor catheter and tubing with tape; tell the patient not to pull or push on the catheter; restrain hands if indicated. Reduces trauma from manipulation.

Note fecal material in effluent or a strong urge to defecate with severe watery diarrhea. Suggests bowel perforation with dialysate mixing into bowel contents.

Note an intense urge to void or large urine output after starting a run; test urine for sugar as indicated. Suggests bladder perforation; glucose-containing dialysate in the bladder raises urine glucose.

Stop dialysis if there is evidence of bowel or bladder perforation, leaving the catheter in place. Prevents further injury; immediate surgical repair may be needed, and the catheter helps locate the perforation.

6. Preventing Fluid Overload

When the body absorbs more dialysate than it drains, fluid builds up: edema, dyspnea, rising blood pressure.

Assess catheter patency, noting drainage difficulty, fibrin strings, and plugs. Slow flow and fibrin suggest partial occlusion needing intervention.

Check tubing for kinks; position bottles and bags and anchor the catheter for adequate inflow and outflow. Poor equipment function retains fluid and leaves toxins uncleared.

Monitor BP and pulse for hypertension, bounding pulses, neck vein distension, and peripheral edema; measure CVP if available. Assess heart and breath sounds for S3, crackles, and rhonchi. Elevations indicate hypervolemia, which can drive HF and pulmonary edema.

Assess for headache, muscle cramps, confusion, and disorientation. Suggest hyponatremia or water intoxication.

Record serial weights against I&O, weighing when the abdomen is empty. A positive balance with weight gain means fluid retention.

Note abdominal distension with decreased bowel sounds, stool changes, and constipation. These impede effluent outflow.

Monitor serum sodium, BUN, and creatinine. See Laboratory and Diagnostic Procedure

Turn side to side, elevate the head of bed, and apply gentle abdominal pressure. Improves outflow when the catheter is obstructed by the omentum.

Watch for tachypnea, dyspnea, and increased respiratory effort; drain dialysate and notify the physician. Abdominal distension and diaphragmatic compression cause respiratory distress.

Alter the dialysate regimen as indicated. Glucose or sodium concentration may need changing for efficient dialysis.

Add heparin to initial runs; assist with heparinized saline irrigation. Prevents fibrin clots that obstruct the catheter.

Administer diuretics as prescribed and maintain fluid restriction as indicated. See Pharmacologic Management

7. Administering Medications and Pharmacologic Support

Antibiotics prevent and treat peritonitis, analgesics manage discomfort, diuretics address fluid imbalance, and phosphate binders control phosphate in chronic kidney disease.

Analgesics (NSAIDs or opioids) Manage pain from abdominal distension, the catheter, or surgical site discomfort.

Antibiotics Prevent and treat peritonitis by eradicating the causative organism and stopping its spread.

Heparin Keeps dialysate flowing by preventing catheter clots and malfunction.

Diuretics Increase urine output to remove excess fluid and relieve edema and hypertension.

8. Monitoring Laboratory and Diagnostic Procedures

Blood chemistry (electrolytes, BUN, creatinine) tracks dialysis adequacy and metabolic status. Peritoneal fluid analysis (cell count, culture, sensitivity) detects peritonitis and guides antibiotics. Ultrasound or X-ray checks catheter placement and function.

Serum sodium and glucose Hypertonic solutions can cause hypernatremia by removing more water than sodium, and absorbed dextrose can raise serum glucose.

BUN and creatinine Track dialysis adequacy and kidney function; both are cleared during dialysis.

ABGs, pulse oximetry, and serial chest X-rays Changes in Pao2 and Paco2 and new infiltrates or congestion suggest developing pulmonary problems.

WBC count Initial WBCs may be a normal response to a foreign substance; continued or new elevation suggests infection.

Culture and sensitivity Identifies organisms in peritoneal fluid and their antibiotic susceptibility to guide therapy for peritonitis.