1. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Focus on Dialysis Mosby, chapter 47 S. Buckley, RN, MS Fall, N246

2. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Kidneys Function: principal organs of the urinary system. Primary functions are: 1. regulate the volume and composition of extracellular fluid (ECF) 2. excrete waste products from the body

3. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Additional functions of kidneys Control BP Produce erythropoietin (stimulates production of RBC’s) Activate vitamin D Regulate acid base balance (renin, angiotensen)

4. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Why the need for dialysis? Renal failure-complete or partial impairment of kidney function resulting in an inability to excrete metabolic waste products and fluid, as well as causing functional disturbances of all body systems.

5. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Renal failure Acute (ARF)-syndrome characerized by a rapid loss of renal function with progressive azotemia. Mortality rate for intrarenal ARF is ~50% Chronic (CKD)-usually develops slowly over months to years and necessitates the initiation of dialysis or transplantation.

6. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. terms related to the phases of renal failure Oliguria-diminished urine output related to inadequate perfusion of kidney. U/O <400ml/day. Uremia-condition in which renal function declines and symptoms develop. Accumulation of metabolic byproducts that are normally excreted by the kidneys

7. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. terms Anuria-absence of urine formation. Polyuria-large volumes of urine Hematuria-blood in urine Anemia- hemoglobin (Hgb) <13 g/dl, (Occurs in most patients with CKD) Pruritis-itching or burning skin.

8. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Urine formation Outcome of multistep process of filtration, reabsorption, secretion, and excretion of water, electrolytes, and metabolic waste products. Urine is result of process, but primary function is to filter the blood and maintain the body’s internal homeostasis.

9. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

10. Glomerular filtration Urine formation begins at the glomerulus, where blood is filtered. Glomerulus is semipermeable membrane the allows filtration. The hydrostatic pressure of the blood within the glomerular capillaries causes a portion of the blood to be filtered across the membrane.

11. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Glomerular filtration rate The amount of blood filtered by the glomeruli in a given time is termed the glomerular filtration rate (GFR). Normal GFR=125ml/min.

12. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Creatinine clearance Most common indicator used to analyze urinary system disorders (creatinine clearance). Creatinine is a waste product produced by muscle breakdown. Urinary excretion is a measure of the amount of active muscle tissue in the body. Value range-85-135ml/min.

13. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. BUN and creatinine BUN-blood urea nitrogen-commonly used test. Concentration of urea in blood, breakdown of amino acids (regulated by rate of kidney excretion) Normal finding-10-30mg/dl

14. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic and acute kidney disease Occurs when kidneys are no longer able to clean toxins and waste from blood. Symptoms of failure: changes in urination, edema, weakness, fatigue, ammonia breath, flank pain, itching, n & V.

15. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Prevalence of CKD 16.8% of U.S. population (CDC, 2004) Greater among people with diabetes (40.2%) Non-Hispanic African Americans (19.9%) Mexican Americans (18.7%.) Native Americans (3x white pop, ~45%!!!).

16. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. The average annual incidence rate of dialysis was 12 times greater in persons with diabetes (130 per 100 000) vs without diabetes (11 per 100 000). By 1999–2000, diabetic patients comprised 51% of the incident dialysis population. The average annual prevalence rate was 10 times greater in the diabetic cohort. Patients with diabetes had more co- morbidities at the start of dialysis and poorer 3 year survival (55 vs 68%; P<0.0001).

17. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Dialysis Movement of fluid/molecules across a semipermeable membrane from one compartment to another Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure Treat drug overdoses

18. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Dialysis (Cont’d) Two methods of dialysis available  Peritoneal dialysis (PD)  Hemodialysis (HD)

19. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Dialysis (Cont’d) Begun when patient’s uremia can no longer be adequately managed conservatively Initiated when GFR (or creatinine clearance) <15 ml/min

20. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Dialysis (Cont’d) Certain uremic complications also indicate a need  Encephalopathy, pericarditis

21. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. General Principles of Dialysis Diffusion  Movement of solutes from an area of greater concentration to an area of lesser concentration

22. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. General Principles of Dialysis (Cont’d) Osmosis  Movement of fluid from an area of lesser concentration to an area of greater concentration of solutes

23. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. General Principles of Dialysis (Cont’d) Ultrafiltration  Water and fluid removal  Results when there is an osmotic gradient across the membrane

24. Osmosis and Diffusion Across Semipermeable Membrane Fig. 47-7 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

25. Peritoneal Dialysis Peritoneal access is obtained by inserting a catheter through the anterior wall Technique for catheter placement varies Usually done via surgery

26. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis (Cont’d) After catheter inserted, skin is cleaned with antiseptic solution and sterile dressing applied Connected to sterile tubing system Secured to abdomen with tape Catheter irrigated immediately

27. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis (Cont’d) Waiting period of 7 to 14 days preferable 2 to 4 weeks after implantation, exit site should be clean, dry, and free of redness/tenderness Once site is healed, patient may shower and pat dry

28. Tenckhoff Catheter Fig. 47-8 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

29. Fig. 47-9 A-C and Fig. 47-10 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

30. Peritoneal Dialysis Dialysis Solutions and Cycles Available in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25% Electrolyte composition similar to plasma Solution warmed to body temperature

31. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Dialysis Solutions and Cycles (Cont’d) Three phases of PD cycle  Called an exchange Inflow (fill) Dwell (equilibration) Drain

32. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Dialysis Solutions and Cycles (Cont’d) Inflow  Prescribed amount of solution infused through established catheter over about 10 minutes  After solution infused, inflow clamp closed to prevent air from entering tubing

33. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Dialysis Solutions and Cycles (Cont’d) Dwell  Diffusion and osmosis occur between patient’s blood and peritoneal cavity  Duration of time varies depending on method

34. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 47-12

35. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Dialysis Solutions and Cycles (Cont’d) Drain  15 to 30 minutes  May be facilitated by gently massaging abdomen or changing position

36. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Systems Automated peritoneal dialysis (APD)  Cycler delivers the dialysate  Times and controls fill, dwell, and drain Continuous ambulatory peritoneal dialysis (CAPD)  Manual exchange

37. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Complications Exit site infection Peritonitis Abdominal pain Outflow problems Hernias

38. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Complications (Cont’d) Lower back problems Bleeding Pulmonary complications Protein loss

39. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Complications (Cont’d) Carbohydrate and lipid abnormalities Encapsulating sclerosing peritonitis Loss of ultrafiltration

40. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Peritoneal Dialysis Effectiveness and Adaptation Short training program Independence Ease of traveling Fewer dietary restrictions Greater mobility than with HD

41. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hemodialysis Vascular Access Sites Obtaining vascular access is one of most difficult problems  Types of access include Shunts Internal arteriovenous fistulas and grafts Temporary vascular access

42. Vascular Access for Hemodialysis Fig. 47-13 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

43. Hemodialysis Dialyzers Long plastic cartridge that contains thousands of parallel hollow tubes or fibers Fibers are the semipermeable membrane

44. Hemodialysis System Fig. 47-16 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

45. Hemodialysis Procedure Two needles placed in fistula or graft Needle closer to fistula or red catheter lumen pulls blood from patient and sends to dialyzer Blood returned from dialyzer to patient through second needle or blue catheter

46. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hemodialysis Procedure (Cont’d) Dialyzer/blood lines primed with saline solution to eliminate air Heparin added to blood as it flows to dialyzer Terminated by flushing dialyzer with saline to remove all blood Needles removed and firm pressure applied

47. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hemodialysis Procedure (Cont’d) Before treatment, nurse should  Complete assessment of fluid status, condition of access, temperature, skin condition During treatment, nurse should  Be alert to changes in condition  Perform vital signs every 30 to 60 minutes

48. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 47-17

49. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hemodialysis Complications Hypotension Muscle cramps Loss of blood Hepatitis Sepsis Disequilibrium syndrome

50. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Hemodialysis Effectiveness and Adaptation Cannot fully replace metabolic and hormonal functions of kidneys Can ease many of the symptoms Can prevent certain complications

51. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) Alternative or adjunctive method for treating ARF Means by which uremic toxins and fluids are removed Acid-base status/electrolytes adjusted slowly and continuously

52. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Can be used in conjunction with HD Contraindication  Presence of manifestations of uremia requiring rapid resolution Continued for 30 to 40 days

53. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Hemofilter change every 24 to 48 hours Ultrafiltrate should be clear yellow Specimens may be obtained for evaluation

54. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Two types of CRRT  Continuous arteriovenous therapies (CAVTs)  Continuous venovenous therapies (CVVTs) Most commonly used  Continuous venovenous hemofiltration (CVVH)  Continuous venovenous hemodialysis (CVVHD)

55. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Continuous venovenous hemofiltration (CVVH)  Large volume of fluid removed hourly, then replaced  Fluid replacement dependent on stability/individualized needs of patient

56. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Continuous venovenous hemodialysis (CVVHD)  Uses dialysate  Dialysate bags attached to distal end of hemofilter

57. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Continuous venovenous hemodialysis (CVVHD) (cont’d)  Fluid pumped countercurrent to blood flow  Ideal treatment for patient who needs fluid/solute control but cannot tolerate rapid fluid shifts with HD

58. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) Highly permeable, hollow fiber hemofilter Uses double-lumen catheter placed in femoral, jugular, or subclavian vein Removes plasma water and nonprotein solutes

59. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) CRRT versus HD  Continuous rather than intermittent  Solute removal by convection (no dialysate required) in addition to osmosis and diffusion  Less hemodynamic instability

60. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Continual Renal Replacement Therapy (CRRT) (Cont’d) CRRT versus HD (cont’d)  Does not require constant monitoring by HD nurse  Does not require complicated HD equipment

61. Fig. 47-19 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

62. Chronic Kidney Disease Gerontologic Considerations About 35% of ESRD patients are 65 years of age or older Most common diseases leading to renal failure in the older adult  Hypertension  Diabetes

63. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Evaluation Maintenance of ideal body weight Acceptance of chronic disease No infections No edema Hematocrit, hemoglobin, and serum albumin levels in acceptable range

64. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study

65. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study 65-year-old female with history of progressive renal failure for 5 years Diagnosed with type 1 diabetes mellitus when 15 years of age

66. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) She has diabetic retinopathy with macular degeneration Gives herself insulin using an insulin pen

67. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Case Study (Cont’d) Lab values  BUN 72 mg/dl  Serum creatinine 7.5 mg/dl  GFR 12 ml/min

68. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Discussion Questions 1.What are her options for renal replacement therapy? 2.Which one would be the best choice for her?