Nursing Field Notes / Renal + Fluid · Med-Surg Course

Peritoneal Dialysis 🫙

Fill · Dwell · Drain — your own belly lining is the filter

NG-261 Renal ADHD-friendly visual edition

The peritoneal cavity is filled with a hypertonic solution to PULL solutes out. No machine filter, no blood outside the body — the peritoneal membrane is the dialyzer. Three test magnets live here: sterile technique 🧤, cloudy drainage ☁️, and sudden trouble breathing 🫁.

📄 Simple Nursing original — opens in Drive →

🧲 Hypertonic PULLSSugary dialysate drags water & waste across the peritoneum.

☁️ Cloudy = peritonitisFever + tachycardia + cloudy outflow ➜ report to HCP.

🫁 Can't breathe? HOB UPBreathing beats circulation. Raise the head of bed FIRST, then drain.

🌡️ Warm it firstFirst action before infusing = warm the dialysate. Never a microwave.

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HOW IT WORKS

STEP 1 · THE BELLY IS THE FILTER

One catheter, one membrane, one sugar gradient — that's the entire machine.

🩹 The set-up — catheter, cavity, two bags

The peritoneal cavity is filled up with hypertonic solution to PULL solutes out. A permanent peritoneal catheter tunnels through the abdominal wall into the peritoneal space. Fluid runs in by gravity from a bag hung ABOVE and drains out by gravity into a bag BELOW.

Fresh dialysate in Peritoneal membrane Effluent out Sterile exit site

🧠 “Bag up, belly full, bag down.” Picture a hot-water bottle in the belly ♨️ — it goes in warm, sits and soaks up the trash, then drains into a bag on the floor.

🧲 Why a SUGARY solution pulls fluid

Answer first: the dialysate is hypertonic (high dextrose). Hypertonic = more particles than the blood, so water is pulled OUT of the capillaries into the belly by osmosis. Waste follows by diffusion.

Stronger dextrose = more fluid removed. Concentrations commonly run from about 1.5% up to 4.25% — the provider picks it based on how much fluid must come off.

🧠 “Sugar is a sponge.” The sweeter the bag, the more water it sucks out.

⚖️ Peritoneal vs Hemodialysis

	Peritoneal 🫙	Hemo 🩸
Filter	The client's own peritoneum	A machine dialyzer
Where	At home, often nightly	Center, ~3×/week
Speed	Slow & gentle — steadier BP	Fast — hypotension & DDS risk
#1 danger	Peritonitis ☁️	Access clotting / bleeding
Diet	More liberal; protein loss is higher	Tighter K⁺ & fluid limits

🧠 PD is the slow cooker 🍲, HD is the pressure cooker ♨️. Slow & steady vs fast & risky.

🔁 The exchange: FILL ➜ DWELL ➜ DRAIN

Outflow should be equal to or MORE than inflow — that extra volume is the fluid you pulled off the client. Less out than in = a problem to solve (see DURING).

🧠 “Fill · Chill · Spill.” Three beats, always in that order. Chill = the dwell, where the actual dialysis happens.

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BEFORE THE EXCHANGE

STEP 2 · WEIGH · WARM · STERILE

"Proper preparation for peritoneal dialysis" — the exam wants two actions and one technique.

✅ Proper preparation — in order

⚖️ Take the weight. Empty bladder first, same scale, same clothes. This is the baseline for how much fluid you removed. 1 kg = 1 L.

🌡️ WARM the solution. The FIRST action before infusing is to warm the dialysate.

🧤 Sterile technique — PRIORITY. Mask, hand hygiene, sterile field, scrub the connection. The catheter is a straight road to the peritoneum.

📏 Baseline assessment. Vital signs, abdominal girth, lung sounds, exit-site inspection, last bowel movement.

🚽 Have the client empty the bladder before the fill for comfort and to reduce puncture risk with a new catheter.

🧠 “Weigh · Warm · Wash.” Three W's before a single drop goes in.

🌡️ Why warming is the FIRST action KAPLAN

🧠 “Cold cramps, warm welcomes.” If a question asks the first action before an exchange, the answer is warm the dialysate — not "check the drain," not "position the client."

🧤 Sterile technique is the PRIORITY — this is how peritonitis starts CAUTION

Every touch of that catheter is a possible direct inoculation of the peritoneum. Contamination almost always happens at the connection or the exit site.

😷 Mask on the nurse and the client for connect/disconnect.
🧼 Hand hygiene → sterile gloves → scrub the connection port.
🩹 Exit-site care daily with the ordered solution; keep it dry; report redness, warmth or drainage.
🚿 Teach: showers, not tub baths or swimming pools (varies by policy).
🔍 Inspect every bag: expiration, clarity, leaks, correct dextrose concentration.

🧠 One dirty connection = one infected belly. There is no "clean enough" here — the peritoneum has no defense once bacteria are inside.

🧪 What the numbers should show STANDARD ADULT RANGES

Lab	Normal	PD watch-out
BUN	10–20 mg/dL	Should trend DOWN with good exchanges
Creatinine	0.6–1.2 mg/dL	Trend, not one value
Potassium	3.5–5.0 mEq/L	Can go LOW with frequent exchanges
Glucose	70–110 mg/dL fasting	📈 Rises — dextrose is absorbed. Watch diabetics.
Albumin	3.5–5.0 g/dL	📉 Falls — protein is lost in the effluent

🧠 Sugar UP, protein DOWN. The two labs peritoneal dialysis changes that hemodialysis doesn't.

🍗 Diet: protein goes UP

Answer first: peritoneal dialysis loses protein into the drained fluid every single exchange, so the client needs MORE dietary protein, not less.

🥚 High-quality protein — eggs, fish, poultry, lean meat
🍬 Watch carbohydrate/calories — the dextrose counts as sugar
🥦 Fiber & fluid — constipation blocks outflow (see DURING)

🧠 Protein leaks out the drain. Refill it with the plate.

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DURING THE EXCHANGE

STEP 3 · TROUBLE & FIRST ACTIONS

Three scenarios come up over and over: can't breathe, won't drain, and the belly turns hot.

🚨 Sudden respiratory distress ➜ FIRST ACTION: raise the HOB KAPLAN

Why it happens: too much fluid, infused too fast — the full abdomen pushes the diaphragm UP and the lungs can't expand.

🔎 KEY SIGNS

🫁 Crackles in the lung bases
💨 Rapid respirations
😮‍💨 Dyspnea — sudden onset during or after a fill

🚑 PRIORITY INTERVENTION

1️⃣ Raise the HOB — first action.
2️⃣ Slow or stop the inflow; drain the fluid per order.
3️⃣ Reassess lung sounds, SpO₂, respiratory rate; notify the HCP.

🧠 “Breathing beats circulation.” A client on peritoneal dialysis who suddenly starts breathing faster — the first action is always raise the head of the bed. Picture the belly as a balloon shoving the lungs upstairs 🎈 — sit them up and the balloon slides back down.

🚱 Insufficient outflow — assess in this order KAPLAN SCENARIO

Answer first: Patient ➜ Device ➜ Intervention. Assess the client before you touch the tubing, and touch the tubing before you reposition.

🧍 Assess the PATIENT — abdominal distention and CONSTIPATION. A full bowel is the most common reason fluid won't drain.

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🔌 Assess the DEVICE — catheter kinks, closed clamps, obstruction, fibrin clots, the bag not low enough, tubing trapped under the client.

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🔄 INTERVENE — reposition the client to a side-lying position; turn side to side; get them up and walking if allowed. Then notify the HCP if outflow is still poor.

Also do: keep the drain bag below the abdomen · check that inflow volume and outflow volume are recorded every exchange · less out than in = fluid retained, report it.

🧠 “P-D-I: Patient, Device, Intervene.” Same letters as Peritoneal Dialysis Issue. And remember the sneaky #1 cause: constipation — a loaded colon squeezes the catheter shut. 💩

🩸 Other things you may see in the drain

Finding	What it means
☁️ Cloudy	PERITONITIS — report 🚨
🩸 Blood-tinged	Can be expected in the first few exchanges after catheter placement, and in menstruating clients. New or bright bleeding = report.
🧵 Fibrin strands	Stringy white bits — can clog the catheter; report per protocol
💛 Clear, pale yellow	✅ Expected

🧠 Pale yellow = pass. Cloudy = call.

⚠️ Other complications to watch

🍬 Hyperglycemia — dextrose is absorbed; check glucose, especially in diabetics.
📉 Hypotension / hypovolemia — too much fluid pulled off with strong dextrose.
💧 Leakage at the exit site — report; increases infection risk.
🫃 Hernia & back pain — from the constant intra-abdominal volume.
🍽️ Anorexia / fullness — the belly is literally full; offer small frequent meals during a drain.

🧠 A belly full of sugar water explains all five: high sugar, low pressure, leaks, bulges, no appetite.

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AFTER + PERITONITIS

STEP 4 · THE ONE YOU MUST NOT MISS

Drain, measure, weigh — and stare at the color of that bag.

🚨 PERITONITIS — key signs to REPORT to the HCP

What to do: notify the HCP · send the effluent for cell count, Gram stain & culture before antibiotics if ordered · expect antibiotics, often added to the dialysate (intraperitoneal) or IV per order · continue to monitor temp, HR, pain and the appearance of every bag.

🧠 “No one likes cloudy dayyyys — and nobody likes cloudy drainnnnage.” ☁️ Sing it. Cloudy fluid is white blood cells in the belly — that is infection, not sediment.

✅ After every exchange — the documentation habit

📏 Measure inflow and outflow and record both. Outflow should be ≥ inflow.

➖ Calculate the difference. Outflow − inflow = fluid removed. A negative number means the client kept fluid — report it.

👀 Describe the effluent — color and clarity, every single bag.

⚖️ Weigh the client after the drain, plus vital signs, lung sounds & edema check.

🩹 Exit-site check and dressing per policy.

🧠 “In, out, difference, describe, weigh.” If you can't say how much came back, you don't know what the treatment did.

🏠 Home teaching — what she tells the client

😷 Mask + handwashing every connection — no shortcuts, no exceptions.
☁️ Call for cloudy fluid, fever, or belly pain — do not wait for the next clinic visit.
⚖️ Weigh daily, log every exchange, log in/out volumes.
💩 Prevent constipation — it stops the drain. Fiber, fluids, ordered stool softener.
🩹 Keep the exit site clean, dry, and secured so the catheter isn't tugged.
🧊 Store bags clean & dry; check expiration and clarity before use.

🧠 Mask · Measure · Move the bowels. Three habits that prevent the three biggest PD problems.

⭐ Priority order when several things happen at once

🫁 Breathing problem — dyspnea/crackles ➜ raise HOB FIRST

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🚨 Signs of peritonitis — fever, cloudy drain ➜ report to HCP

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🚱 Poor outflow ➜ patient, then device, then reposition

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📋 Comfort & documentation

🧠 ABC still wins. Airway/Breathing outranks infection; infection outranks a slow drain.

⚡

QUICK RECALL

SAY IT OUT LOUD

🫙 Fill · Dwell · DrainHypertonic solution PULLS solutes & water across the peritoneum.

🌡️ Warm it FIRSTBefore: 1. weight · 2. warm the solution. Never a microwave.

☁️ Cloudy drainage+ fever + tachycardia = PERITONITIS ➜ report to HCP.

🫁 Sudden dyspneaFIRST: raise HOB. Breathing over circulation.

🧤 Sterile = PRIORITYEvery connection is a door straight into the peritoneum.

🚱 Won't drain?Patient (distention · constipation) ➜ Device (kinks) ➜ Intervene (side-lying).

🍗 Protein UPProtein is lost in the effluent every exchange. Glucose goes UP too.

📏 Out ≥ InRecord both. Less out than in = fluid retained = report.

🎯 Cover & check — 6 rapid-fire questions

Q1: What is the first action in proper preparation for peritoneal dialysis?

Warm the dialysate. (Take the weight, warm the solution — cold fluid causes cramping, chills and vasoconstriction, which means a poor exchange.) Never use a microwave.

Q2: A client on peritoneal dialysis suddenly begins to breathe more rapidly. First action?

Raise the head of the bed. The full abdomen is pushing the diaphragm up — breathing over circulation. Then slow/stop the inflow and drain per order, and notify the HCP. Key signs: crackles in the lung bases, rapid respirations, dyspnea.

Q3: The effluent is cloudy and the client has a fever of 101.4°F and a heart rate of 118. What is this and what do you do?

Peritonitis. Report to the HCP; send effluent for cell count, Gram stain and culture per order; expect antibiotics (often added to the dialysate or given IV). Sterile technique is the priority prevention.

Q4: The outflow is much less than the inflow. In what order do you assess?

1. Assess the PATIENT — abdominal distention and constipation. 2. Assess the DEVICE — catheter kinks, clamps, obstruction, bag position. 3. Intervene — reposition to side-lying. Then notify the HCP if it doesn't resolve.

Q5: Why does peritoneal dialysis raise blood glucose and lower albumin?

The dialysate is hypertonic dextrose — some sugar is absorbed across the peritoneum (glucose up). Protein crosses the other way into the effluent and is drained away (albumin down), so dietary protein is INCREASED.

Q6: What color should the drained fluid be?

Clear and pale yellow. Cloudy = peritonitis. Fibrin strands may clog the catheter. Blood-tinged fluid can be expected in the first few exchanges after catheter placement, but new or bright bleeding is reported.