2RENAL REPLACEMENT THERAPIES PURPOSES OF DIALYSIS1. Removes excess fluids and waste products.2. Restores chemical and electrolyte balanceHEMODIALYSIS‑ one of several renal replacement therapies used for the treatment of renal failure. HD involves the extracorporeal (outside of the body) passage of the client’s blood through a semi permeable membrane that serves as an artificial kidney.
32. Absence of illnesses that would prevent or seriously complicate HD. CLIENT SELECTION GENERAL GUIDELINE REQUIREMENTS FOR APPROPRIATE CLIENT SELECTION1. Presence of fatal, irreversible renal failure when other therapies are unacceptable or ineffective.2. Absence of illnesses that would prevent or seriously complicate HD.3. Expectation of rehabilitation.4. The client’s acceptance of the regimen.
4Components of Hemodialysis Dialyzer or artificial kidneyDialyzer has 4 components: Blood compartment, Dialysate compartment, Semipermeable membrane, enclosed structure to support the membrane.Dialysate – made up of clear H2O & chemicals. Compositions may be altered accdg to pt’s needs for treatment of electrolyte imbalance. Warmed to 37.8 C = to 100 F to increase efficiency of diffusion. Prevent decrease in pt’s blood temperature.Vascular access routes – AV fistula, AV Graft, Dual Lumen Cathater, AV Shunt.Hemodialysis machine -
6PROCEDUREThe principles of HD are based on the passive transfer of toxins, which is accomplished by diffusion.When HD is initiated, blood and dialysate flow in opposite directions from their respective sides of an enclosed semi permeable membrane. The dialysate is a balanced mix of electrolytes and water that closely resembles human plasma. On the other side of the membrane is the client’s blood, which contains metabolic waste products, excess water, and excess electrolytes.During HD, the waste products move from the blood into the dialysate because of the difference in their concentrations (diffusion). Excess water is also removed from the blood into the dialysate (osmosis). Electrolytes can move in either direction, as needed, and take some fluid with them. Potassium and sodium typically move out of the plasma. This process continues as the blood and the dialysate are circulated past the membrane for a preset length of time.Duration and frequency of HD tx depend on the amt ofmetabolic waste to be cleared, and the amt of fluid to beremoved.
7COMPLICATIONS OF HEMODIALYSIS Dialysis disequilibrium syndrome- the cause isunknown but maybe due to rapid decrease inblood urea nitrogen levels during HD. These change can cause cerebral edema- leads to increase intracranial pressure.Infection- transmitted by blood transfusion are another serious complication associated with long term HD.Hepatitis Infection- in clients with chronic renal failure.
8Best Practice for Caring for the client Undergoing Hemodialysis Weigh the client before and after dialysis.Know the client’s dry weight.Discuss with physician whether any of the client’s medications should be withheld until after dialysis.Be aware of events that occurred during the dialysis treatment.Measure blood pressure, pulse rate, respirations, and temp.Assess for symptoms of orthostatic hypotension.Assess the vascular access site.Observe for bleedingAssess the client’s level of consciousness and assess for headache, nausea, and vomiting.
9COMPLICATIONS OF AV FISTULAE OR SYNTHETIC AV GRAFT Stenosis‑the most frequent cause of permanent peripheral hemodialysis access failure is vascular stenosis.Thrombosis‑ this complication is more common in synthetic AV grafts than native AV fistulae.Failure of maturation‑ a native AV fistula requires 1 to 4 months to mature; if blood flow is diminished by stenosis or multiple outflow veins, maturation will be impaired.Infection‑ a leading cause of complications and death in dialysis patient. Typical S/S of an infected dialysis access include local erythema, induration, tenderness, and purulent drainage from incision sites.Ischemic steal syndrome‑ diverting blood flow from the distal extremity through the hemodialysis access may cause pain and ischemia in some patients, esp.diabetic and elderly patient.Pseudoaneurysm‑ also called false aneurysm or pulsating hematoma
14PROCEDURE AND PROCESS The surgical insertion of a siliconized rubber (Sillastic) catheter into the abdominal cavity isrequired to allow the infusion of dialyzing fluid(dialysate) is infused according to the physicianorder, 1 to 2L of dialysate is infused by gravity (fill)into the peritoneal space over a 10 to 20 minutesperiod, according to the client’s tolerance. The fluiddwells in the cavity for a specified time ordered by thephysician. The fluid then flows out of the body (drain)by gravity into a drainage bag.
15Con’t of process and procedure the peritoneal outflow contains the dialysate in additionto to the excess water, electrolytes, and nitrogenouswaste products that have accumulated in the body.The Three Phases of the process:Infusion or fill.DwellOutflow or drain.PD occurs through diffusion and osmosis across theSemipermeable peritoneal membrane and adjacentcapillaries. The peritoneal membrane is large and porous.it allows solutes, which carry fluid with them to moveby an osmotic gradient fr an area of higher concentra-tion in the body (blood) to an area of lower concentrationin the dialyzing fluid.
16Complications of CAPDPERITONITIS‑the major complication of PD. The most common cause of peritonitis is contamination of the connection site during an exchange. The infection of peritoneum is manifested by cloudy dialysate outflow (effluent), fever, rebound abdominal tenderness, abdominal pain, general malaise, nausea, and vomiting.Cloudy or opaque effluent is the earliest sign of peritonitis. The best treatment of peritonitis is prevention.. The nurse must maintain meticulous sterile technique when caring for the PD catheter and when hooking up or clamping off dialysate bags.
17Con’t of Complication of CAPD Pain- pain during inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, it disappear after a week or two. Cold dialysate aggravates discomfort. Thus the dialysate bags should be warmed before instillation by use of a heating pad to wrap the bag or use of warming chamber.Microwave oven are not recommended for the warming of dialysate because of their unpredictable warming patterns and temperatures.Exit Site and Tunnel infections- the normal exit sitefrom a PD catheter should be clean, dry, and without pain or evidence of inflammation.
18Con’t of Complication of CAPD Insufficient flow of the Dialysate- Constipation is the primarycause of inflow or outflow problems. To prevent constipation,the physician orders a bowel preparation before placing the PDcatheter. The nurse ensures that the drainage bag is lower thanthe client abdomen. The nurse inspects the connection tubingand PD system for kinking or twisting and rechecks to makesure that clamps are open.Dialysate Leakage- when dialysis is initiated, small volumes ofdialysate are used. It may take clients 1 to 2 weeks to toleratea full 2-L exchange without leakage around the catheter site.Other Complication- The nurse notes any change in the color ofthe outflow.
19NURSING CARE DURING PERITONEAL DIALYSIS Evaluate baseline vital signsThe client is weigh, always on the same scale, before thebeginning of the procedure or at least every 24 hours whilereceiving the treatment.Baseline laboratory value determination, such as electrolyte andglucose levels,During PD, the nurse continually monitors the client. For the firstexchanges, record the vs every 15 minutes. Ongoing assessment for respiratory distress, pain or discomfort. Abdominal dressing around the catheter exit site is checked frequently for wetness. Monitor for dwell time.
20NURSING CARE CON’TFor hourly exchanges, dwell time usually ranges from 20 to 40Minutes. Blood glucose assessment is necessary, due toGlucose absorption occur in some patient.The outflow is recorded accurately after each exchange.Visual inspection of the outflow bag and daily weights may be sufficient to note the adequacy of the return.If drainage return is brown, a bowel perforation must be suspected.If drainage return is the same color as urine and has the same glucose concentration, a possible bladder perforation should be investigated.If drainage is cloudy or opaque, an infection is suspected.