# Situation: A 62-year-old woman with chronic kidney disease (CKD) stage G5 performs continuous ambulatory peritoneal dialysis (CAPD) at home with four exchanges a day. Her husband helps her with the exchanges. She attends the hospital's peritoneal dialysis clinic for follow-up. During an evening exchange on the ward, where she has been admitted, the outflow is slow: after 30 minutes, only 900 mL of the 2,000 mL fill has drained. The clamps are open, the tubing has no kinks, and the bag hangs below her abdomen. She is comfortable, her vital signs are normal, and the fluid is clear, but she has not had a bowel movement for 4 days. A laxative is prescribed as needed. Which action should the nurse take?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 62-year-old woman with chronic kidney disease (CKD) stage G5 performs continuous ambulatory peritoneal dialysis (CAPD) at home with four exchanges a day. Her husband helps her with the exchanges. She attends the hospital's peritoneal dialysis clinic for follow-up.

During an evening exchange on the ward, where she has been admitted, the outflow is slow: after 30 minutes, only 900 mL of the 2,000 mL fill has drained. The clamps are open, the tubing has no kinks, and the bag hangs below her abdomen. She is comfortable, her vital signs are normal, and the fluid is clear, but she has not had a bowel movement for 4 days. A laxative is prescribed as needed. Which action should the nurse take?

## 보기

1. Raise the head of the bed and let it drain slowly overnight
2. Turn her from side to side and give the prescribed laxative **✔ 정답**
3. Irrigate the catheter with a syringe of 0.9% sodium chloride
4. Notify the physician that the catheter needs to be replaced

**정답: 2**

## 해설

When peritoneal dialysis outflow is slow, the nurse first checks clamps, kinks, and bag height, which are already correct here. The next measures are turning the client side to side and raising the head of the bed to free the catheter tip, and treating constipation, because a full bowel compresses the catheter and blocks outflow. Her 4 days without a bowel movement make constipation the likely cause.

## 심화 해설

Clinical context

A slow peritoneal dialysis outflow in a stable client with a patent system and clear effluent points first to a mechanical or functional cause rather than catheter failure. In this scenario, the clamps are open, the tubing is straight, and the drainage bag is positioned below the abdomen, so the usual external causes have already been ruled out. The client has not had a bowel movement for 4 days, which makes constipation the most probable contributor.

Why constipation slows PD outflow

The peritoneal catheter tip normally rests in the dependent portion of the peritoneal cavity, where fluid can drain by gravity. A distended, stool-filled colon can physically compress the catheter or displace its tip against the bowel wall. This creates a functional outflow obstruction even when the catheter itself is intact. Because the client’s vital signs are normal, the fluid is clear, and she has no pain, infection or peritonitis is unlikely; the clinical picture fits a mechanical obstruction from a full bowel. The 4-day absence of stool is a strong clue that the colon is distended enough to interfere with drainage.

Stepwise management of slow outflow

After confirming that the external system is open and correctly positioned, the next nursing actions are noninvasive maneuvers that reposition the catheter tip and relieve bowel pressure. Turning the client from side to side changes the relationship between the catheter and the bowel, often freeing the tip so that drainage resumes. Raising the head of the bed can also help by shifting intra-abdominal contents. At the same time, the prescribed laxative addresses the underlying cause. Treating constipation is a first-line intervention for slow outflow when the client is otherwise stable, because a full bowel is a common and reversible cause of catheter obstruction.

Watch out! Irrigation with 0.9% sodium chloride is not the first step here. Flushing the catheter may be needed for fibrin plugs or suspected intraluminal blockage, but this client’s clear fluid and constipation history make extraluminal compression far more likely. Key point! Catheter replacement is reserved for persistent mechanical failure, malposition, or obstruction that does not respond to conservative measures; it is not indicated before simple repositioning and bowel management have been attempted.

Mechanical catheter dysfunction in PD

Mechanical complications are a recognized cause of reduced dialysis efficiency. Catheter dysfunction can result from fibrin, adhesions, omental wrapping, or entrapment of intraperitoneal structures, and these causes may require surgical revision if they persist [1][3]. However, the initial approach is always to correct reversible factors such as constipation, catheter tip position, and outflow posture before considering invasive intervention. In pediatric PD, non-infectious mechanical issues including catheter malposition and dysfunction remain significant challenges even as infection rates have declined, reinforcing the importance of systematic troubleshooting [4].

Why the other options are not appropriate

Raising the head of the bed and allowing slow drainage overnight may help reposition the catheter, but it does not address the most likely cause, which is constipation. Irrigation with saline is premature when the fluid is clear and the system is patent. Notifying the physician for catheter replacement is an over-escalation for a stable client with a reversible functional obstruction.

| Intervention | Rationale | Appropriateness here |
| --- | --- | --- |
| Turn side to side and give prescribed laxative | Repositions catheter tip and relieves bowel compression from 4 days of constipation | Correct first-line action |
| Raise head of bed and drain overnight | May help drainage but does not treat the underlying constipation | Incomplete |
| Irrigate catheter with saline | Used for fibrin or intraluminal blockage; fluid is clear here | Not indicated |
| Notify physician for catheter replacement | Reserved for persistent mechanical failure or malposition | Premature |

Clinical reasoning summary

The client’s stable presentation, clear effluent, and constipation point to extraluminal compression of the catheter by a distended bowel. The correct nursing action is to turn her from side to side to free the catheter tip and administer the prescribed laxative to relieve the constipation. This conservative approach addresses the most likely cause without exposing her to unnecessary catheter manipulation or surgical referral.References (research sources)

- [1]Catheter insertion techniques for improving catheter function and clinical outcomes in peritoneal dialysis patients.Research articleBriggs VR, Jacques RM, Fotheringham J, Maheswaran R, Campbell M, Wilkie ME. (2023) · DOI: 10.1002/14651858.cd012478.pub2

- [3]A Rare Case of Catheter Obstruction in Peritoneal Dialysis Due to Entrapment of Oviductal Fimbriae.Research articleGómez-Arciniega KD, Ángel-Montoya DA, Benítez-Jauregui HA, Mejía-Ramírez JL, Cortes-González CO. (2024) · DOI: 10.7759/cureus.69131

- [4]Non-infectious complications of peritoneal dialysis in children.Research articleParolin M, Ceschia G, Bertazza Partigiani N, La Porta E, Verrina E, Vidal E. (2025) · DOI: 10.1007/s00467-025-06713-5

## 임상 시나리오

Slow PD Outflow: Constipation FirstNoninvasive repositioning and bowel management before invasive steps
When outflow is slow, first verify clamps open, no kinks, and bag below abdomen. If these are correct, consider constipation as the most common mechanical cause.

A stool-filled colon can compress or displace the catheter tip. No bowel movement for 4 days strongly suggests this. Turn the client side to side and give the prescribed laxative.

CautionDo not irrigate or replace the catheter first. Clear fluid, normal vital signs, and no pain make peritonitis unlikely. Invasive steps are reserved for fibrin obstruction or confirmed catheter failure.

## 핵심 개념

- **Peritoneal dialysis outflow failure** — Slow or incomplete drainage of dialysate from the peritoneal cavity, often caused by mechanical obstruction, constipation, or catheter malposition.
- **Constipation in PD** — A full bowel can compress or displace the peritoneal catheter tip, causing functional outflow obstruction even when the catheter is intact.
- **Catheter repositioning** — Noninvasive maneuvers such as turning side to side or raising the head of the bed to free the catheter tip from bowel or omentum.
- **Laxative use in PD** — Treatment of constipation to relieve bowel pressure on the catheter and restore adequate drainage.
- **Peritonitis signs** — Cloudy effluent, abdominal pain, fever, or elevated white cell count; absent in this case, making infection unlikely.

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