Peritoneal Dialysis: the nurse's role, start to finish

When it is done and why

Peritoneal dialysis uses the patient's own peritoneal membrane as the filter, exchanging warmed dialysate into the abdominal cavity to draw out excess fluid and metabolic waste by osmosis and diffusion, then draining it out. It is chosen for patients who want to dialyse at home, who have poor vascular access for haemodialysis, or who have cardiac instability that makes the rapid fluid shifts of haemodialysis risky.

It runs on one of two schedules. Continuous ambulatory peritoneal dialysis involves manual exchanges the patient performs several times a day, while automated peritoneal dialysis uses a cycler overnight so the patient is free during waking hours. Both achieve the same clearance goals through different rhythms, and the nurse's role is largely the same regardless of which schedule the patient follows.

Preparing the patient

Confirm catheter placement and healing before any exchange; a new peritoneal catheter typically needs two to three weeks to heal before use, and the exit site must be assessed for redness, drainage or tenderness at every session. Weigh the patient and check baseline vital signs, since these values are the comparison point for detecting fluid shifts during and after the exchange.

Set up in a clean, low-traffic area, close doors and windows to reduce airborne contamination, and have the patient perform hand hygiene along with a mask if institutional policy requires one during connection. Warm the dialysate bag to body temperature using a dedicated dialysate warmer or warming pad, never a microwave, since uneven microwave heating can scald the peritoneum on infusion and there is no way to verify the temperature is safe by touch alone.

The steps that matter for safety

Maintain strict aseptic technique at every connection point; the transfer set, the catheter and the dialysate bag are the three places contamination enters, and a break in technique at any one of them can seed peritonitis. Inspect the dialysate bag before use for cracks, cloudiness or discolouration, and check the expiry date and prescribed concentration against the order.

Confirm the correct dextrose concentration before instilling, since higher concentrations pull more fluid and the wrong strength can cause excessive fluid removal or inadequate clearance. Never force fluid in against resistance or pain, and never leave a bag warming unattended in a way that risks it exceeding body temperature.

During the procedure — the nurse's role

Instil the warmed dialysate over roughly ten minutes, watching for the patient reporting sharp pain, which can indicate rapid infusion or a temperature that is too high or too low. Monitor for shortness of breath during the fill, since a full abdomen can splint the diaphragm, particularly in patients with reduced lung reserve.

During the dwell, which typically lasts from thirty minutes to several hours depending on the prescription, monitor vital signs and ask about abdominal discomfort. At drain, observe the outflow closely: it should run clear to pale yellow. Cloudy or turbid return is the cardinal sign of peritonitis and should be treated as an urgent finding, not something to note and move past, because it usually means bacteria have entered the peritoneal cavity and antibiotic treatment cannot wait.

After: monitoring and complications

Record the exact volume in, volume out and net ultrafiltration for every exchange, since a consistently negative or unexpectedly low return signals a problem with drainage, catheter position or membrane function that needs investigation before the next cycle. Reweigh the patient and compare to baseline to confirm the fluid balance matches what the exchange record shows.

Watch for peritonitis beyond cloudy fluid alone: fever, abdominal pain and tenderness, and rebound tenderness together build the clinical picture, and any combination should prompt fluid culture and antibiotic review. Watch the exit site separately for infection, since exit-site infection and peritonitis are distinct complications that can occur together or independently. Other complications to track include hernia from raised intra-abdominal pressure, hyperglycaemia from dextrose absorption in diabetic patients, and constipation, which reduces drainage efficiency and is worth asking about at every visit.

Documentation and teaching

Document every exchange with the time, dwell duration, dialysate concentration, volume in, volume out, fluid clarity and any patient-reported symptoms. This record is what distinguishes an isolated bad drain from a developing pattern, and it is what a covering nurse or physician relies on if the patient deteriorates.

Teach the patient to recognise cloudy return themselves and to call the unit immediately rather than waiting for the next scheduled contact, since early treatment of peritonitis prevents membrane damage that can end peritoneal dialysis as an option altogether. Reinforce hand hygiene, mask use at connection if required, and exit-site care between exchanges.

Teach dialysate warming explicitly: a warmer or warming pad only, never a microwave, and never assume a bag feels the right temperature by touch. Cover the signs that warrant a call: fever, abdominal pain, cloudy fluid, reduced drainage volume or exit-site redness, and confirm the patient knows who to contact and when before they leave with home equipment for the first time.