The Nursing Process · 6 min read
The Nursing Process
Interviewing Techniques
Effective interviewing is foundational to peritoneal dialysis nursing practice. The interview establishes rapport, gathers essential health information, and identifies patient concerns that influence care planning.
Types of Interviews
The initial interview occurs at first patient contact and establishes baseline data. It covers chief complaint, history of present illness, past medical and surgical history, family history, social history, medications, allergies, and review of systems. Follow-up interviews occur at subsequent encounters and focus on interval changes, treatment response, and emerging concerns.
Communication Strategies
Open-ended questions encourage detailed responses and allow patients to express concerns in their own words. Examples include asking patients to describe their symptoms or explain what brings them to the clinic. Closed-ended questions elicit specific information such as yes/no answers or numerical data. These are useful for obtaining precise details about medication doses, symptom duration, or frequency of exchanges.
Active listening involves giving full attention to the speaker, maintaining appropriate eye contact, nodding, and providing verbal acknowledgments. Reflecting and paraphrasing demonstrate understanding and encourage elaboration. Summarizing at intervals confirms accuracy and allows correction of misunderstandings.
Barriers to Effective Communication
Language barriers require interpreter services or translated materials. Hearing impairment may necessitate written communication, hearing amplification devices, or sign language interpreters. Cognitive impairment requires simplified language, repetition, and caregiver involvement. Cultural differences influence communication styles, eye contact norms, personal space preferences, and health beliefs. Emotional distress such as anxiety, fear, or grief can impair information processing and recall.
Documentation of Interview Data
All interview findings require accurate, timely documentation in the medical record. Documentation should be objective, specific, and free of judgmental language. Direct patient quotes should be used when relevant. Information should be organized systematically using standardized formats.
Physical Assessment and Nursing Assessment
Comprehensive assessment identifies baseline status, detects changes, and guides interventions for peritoneal dialysis patients.
General Survey
Assessment begins with observation of overall appearance, level of consciousness, posture, mobility, hygiene, and apparent distress. Vital signs include blood pressure (sitting and standing to assess orthostatic changes), pulse rate and rhythm, respiratory rate and pattern, temperature, oxygen saturation, and pain level using standardized scales.
Integumentary Assessment
Skin assessment evaluates color, temperature, turgor, moisture, integrity, edema, and lesions. Peritoneal dialysis patients require specific attention to the catheter exit site for signs of infection including erythema, induration, drainage, crusting, and tenderness. Tunnel assessment involves palpation along the subcutaneous catheter path to detect tenderness, swelling, or fluctuance indicating tunnel infection.
Edema assessment includes evaluation of dependent areas (feet, ankles, sacrum) using the standard grading scale from trace to 4+. Periorbital edema may indicate fluid overload. Skin turgor assessment at the sternum or forehead helps evaluate hydration status.
Cardiovascular Assessment
Heart sounds are auscultated for rate, rhythm, and adventitious sounds. S3 gallop may indicate fluid overload. Pericardial friction rub suggests uremic pericarditis. Jugular venous distension is assessed at 45-degree elevation. Peripheral pulses are evaluated for presence, strength, and symmetry. Capillary refill is assessed for perfusion status.
Respiratory Assessment
Breath sounds are auscultated in all lung fields. Crackles may indicate pulmonary edema. Decreased breath sounds at bases may reflect pleural effusion. Respiratory rate, depth, pattern, and work of breathing are evaluated. Kussmaul respirations (deep, rapid breathing) may indicate metabolic acidosis.
Gastrointestinal Assessment
Abdominal assessment includes inspection, auscultation, percussion, and palpation. Inspection evaluates contour, symmetry, visible masses, and catheter exit site location. Auscultation assesses bowel sounds in all quadrants. Percussion identifies tympany, dullness, and organ borders. Palpation evaluates tenderness, masses, organomegaly, and fluid wave. Constipation assessment is crucial as it can impair peritoneal dialysis drainage.
Neurological Assessment
Level of consciousness, orientation, memory, and cognition are evaluated. Uremic encephalopathy may manifest as confusion, asterixis, myoclonus, or decreased consciousness. Peripheral neuropathy assessment includes evaluation of sensation, strength, and deep tendon reflexes in extremities.
Fluid Status Assessment
Accurate dry weight determination is essential. Clinical indicators of fluid status include blood pressure trends, weight changes, edema, jugular venous distension, and cardiopulmonary findings. Comparison of pre- and post-drain weights, along with ultrafiltration volumes, guides fluid management.
Human Anatomy and Physiology
Understanding normal anatomy and physiology provides the foundation for comprehending kidney disease and peritoneal dialysis principles.
Urinary System Anatomy
The kidneys are paired, bean-shaped organs located retroperitoneally at the T12-L3 vertebral levels. The right kidney sits slightly lower than the left due to liver position. Each kidney measures approximately 11 cm in length, 6 cm in width, and 3 cm in thickness. Adult kidneys weigh 120-170 grams each.
The kidney is surrounded by a fibrous capsule, perirenal fat, renal fascia, and pararenal fat. The renal hilum on the medial surface contains the renal artery, renal vein, lymphatics, nerves, and ureter.
Internal kidney structure consists of the outer cortex and inner medulla. The cortex contains glomeruli, proximal and distal convoluted tubules, and cortical collecting ducts. The medulla contains loops of Henle, medullary collecting ducts, and vasa recta arranged in pyramidal structures. Renal pyramids drain into minor calyces, which join to form major calyces that empty into the renal pelvis.
The Nephron
The nephron is the functional unit of the kidney. Each kidney contains approximately one million nephrons. The nephron consists of the renal corpuscle (glomerulus and Bowman's capsule), proximal convoluted tubule, loop of Henle (descending and ascending limbs), distal convoluted tubule, and collecting duct.
The glomerulus is a capillary tuft supplied by the afferent arteriole and drained by the efferent arteriole. Bowman's capsule surrounds the glomerulus and collects filtrate. The filtration barrier consists of fenestrated endothelium, glomerular basement membrane, and podocyte foot processes.
Kidney Functions
The kidneys perform filtration, reabsorption, secretion, and excretion. Glomerular filtration produces approximately 180 liters of filtrate daily. The glomerular filtration rate (GFR) averages 120-125 mL/min in healthy adults. Tubular reabsorption returns 99% of filtered water and most solutes to the blood. Tubular secretion adds substances to the filtrate for excretion.
Fluid and electrolyte regulation maintains sodium, potassium, calcium, phosphorus, magnesium, and water balance. Acid-base regulation occurs through bicarbonate reabsorption, hydrogen ion secretion, and ammonia production. Waste excretion eliminates urea, creatinine, uric acid, and drug metabolites.
Endocrine functions include erythropoietin production for red blood cell synthesis, renin secretion for blood pressure regulation, and calcitriol (active vitamin D) synthesis for calcium homeostasis.
Peritoneal Anatomy
The peritoneum is a serous membrane lining the abdominal cavity (parietal peritoneum) and covering abdominal organs (visceral peritoneum). The peritoneal cavity is a potential space between these layers normally containing only a small amount of serous fluid.
The peritoneal surface area approximates body surface area, ranging from 1.0-2.0 square meters in adults. The peritoneum receives blood supply from mesenteric, lumbar, and intercostal vessels. Peritoneal capillaries are the site of solute and fluid exchange during peritoneal dialysis.
The peritoneal membrane consists of a mesothelial cell layer, submesothelial connective tissue, and capillary endothelium. The effective exchange surface is the capillary network within the peritoneal tissue.
Pathophysiology of the Kidney and Urinary System
Acute Kidney Injury
Acute kidney injury (AKI) involves rapid decline in kidney function over hours to days. AKI is classified as prerenal, intrinsic, or postrenal based on etiology.
Prerenal AKI results from decreased renal perfusion due to hypovolemia, hypotension, cardiac failure, or renal artery obstruction. Kidney tissue remains intact, and function recovers with restored perfusion.
Intrinsic AKI involves direct kidney parenchymal damage. Acute tubular necrosis from ischemia or nephrotoxins is the most common cause. Glomerulonephritis, interstitial nephritis, and vascular disorders also cause intrinsic AKI.
Postrenal AKI results from urinary tract obstruction. Causes include prostatic enlargement, kidney stones, tumors, and strictures. Bilateral obstruction or obstruction of a solitary kidney causes AKI.
Finished reading?
Lock it in with a quick The Nursing Process quiz.