Dialysis

exam 3

dialysis overview

• replacing work that kidneys used to be able to do

• uses a synthetic semi permiable membrane to clean and return blood to the patient

• different types

• when kidneys fail need treatment to replace the work of your kidneys

• = the movement of fluids and molecules across a semi permeanble membrane from one compartement to another

what dialysis does

• loosens and separetes (impurities) from the blood

• separates and removes:

  • toxins

  • excess electrolytes

  • fluids

• used for acute and chronic renal failure

morbidity and mortality with dialysis

• 10% of people who need dialysis die per year

• cause of death mainly related to cardiovascular problems

• younger patients do better than older

• non-diabetics do better than diabeteics

• most patients under 55 are encouraged to get transplant instead of life ling dialysis

management choices for renal failure

• diet and medication management

  • until renal function (GFR) 10-15% (stage 5)

• dialysis (types)

  • peritoneal dialysis

  • hemodialysis

  • continuous renal replacement therapy (CRRT)

• transplant

indications for dialysis

• severe azotemia

  • BUN > 90mg/dL

  • creatinine > 9 mg/dL

• drug toxicity

• fluid overload

• metabolic acidosis

• pericarditis

• encephalopathy

• about 10%-15% of kidney function

• severe fluid and elelctrolyte imbalances

• hyperK

vascular access

• used for hemodialysis

• site on body from which your blood is removed and returned

• usually prepared weeks or months before start dialysis

  • the site allows for easier and more efficient removal and replacement of blood with fewer complications

• 3 main types of venous access devides

  • central venous catheter

  • AV fistula

  • AV graft

central venous catheter (CVC)

• used for emergecy situations

• via IJ, femoral vein, or subcalvian

• immediate access to the pts circulation for acute hemodialysis is achieved by inserting a doubel lumen non coffee large bore cath into vein

pros and cons of CVC

• pros

  • can be used right away

  • no needles are needed to connect to the dialysis machine

• cons

  • temporary access

  • prone to thrombosis, hematoma, infection, pneumotorax

  • may not have the blood flow needed for enough dialysis

  • need protective cover over catheter to take a shower

  • can cause barrowing of major blood vessels

Arteriovenous fistula (AV-Fistula)

• fuses a artery and a vein of someones arm

• surgically created: rapid flow for optimal hemodialysis

• Repeated use of an AV fistula can cause bulging (pseudoaneurysms) that make the vessel larger and feel stronger, but actually damage the vessel structure, making it lower quality and more fragile over time.

• cannot be used immediately after surgery

  • TAKES 2-3 months to mature

  • lasts about 3 years (or 10+?)

• best option for hemodialysis “fistula first”

pros and cons of AV fistula

• pros

  • last longer

  • not prone to infection

  • provides excellent blood flow once it is realy to use

  • less likely to develop blood clots and become blocked

  • able to take showers once the access heals after surery

• cons

  • needs to mature 1-4 months before can be used

  • needles are inserted to connect to the dialysis machine

  • clotting may be a problem that may require surgery or other treatment to correct

  • needles are inserted

3 types of hemodialysis compared

nursing care for AV fistula/graft

• check patency QID (4 times a day)

  • listen for bruit and feel for thrill

  • no blood draws or BP on affected extremity

  • watch for bleeding post dialysis

AV graft

• usd for pts with inadequate blood vessels

• created subQ inserting graft ,aterial between artery and vein

• 2-5 weeks to mature

• lasts about 2 years

  • infection

  • thrombosis

  • stenonis

AV graft pros and cons

• pros

  • provide axcellent blodo flow once it is realy to use

  • you can take showers once the access heals after surgery

• cons

  • lasts less time than a fistila

  • more prone to infection that a fistula

  • needs at least two weeks before it can be used

  • clotting may be issue

  • needles inserted

teaching for fistulas and grafts

• DO’s

  • use lanolin lotion to prevent dry skin

  • check bruit freqiently

  • leave patches in place for 4-6 hours post dialysis (report porlonged bleeding or oozing)

  • use medic alert bracelet

  • report anything unusual

• DON’Ts

  • no blood draws, IVs or BP on affected extremity

  • no tight clothing, jewelry, or ID band over access site

  • do not lift heacy itens with teh access arm

  • do not allow pt to bump access extremity

  • do not scratch or pick at scabs

arterial venous needles

• two needed: 14fr or 16fr

  • one carries blood to the dialyzer (pull)

  • one returns cleaned blood to body (push)

bleeding from access site

• warning signs

  • bleeding from fistula or graft that lasts more than 20 mins after dialysis treatment is over

  • any bleeding from a catheter site or tube

• actions to take:

  • for bleeding from a fistla or graft, gently press teh access with a clean gauze pad to stop the blood; if bleeding lasts more than 20 mins call doctor

  • for bleeding from a catheter site or tube call doctor immedietly

hemodialysis overview

• done by a dialysis nurse

• about 3 times a week, 4-4.5 hour session (plus ½ hour pre and post)

• done either out patient or on dialysis floor

hemodialysis uses

• used both for short term acute illness and longterm for patients with CKD and end stage renal disease

• prevents death but does not cure renal disease

• does not compensate for the loss of endocrone or metabolic activities of the kidneys (example: creating RBCs)

contraindications of hemodialysis

• severe cardiac disease —> due to inability to tolderate fluid and electrolyte shifts

• bleeding disorders - inability to coagulate

• hemodynamic instability —> someone who has low bp or high HR

how demodialysis works

• removes wastes and water by circulating blood through external filyer

• blood flows in one direction and the dialysate soluation flow in the opposite direction of blood

• urea and creatinine are removed from the blood

• what happens: blood leaves through arterial needle a few oz at a time, heparin added to prevent clotting, then travels through dialyzer and back to pt

principles of dialysis

• osmosis

  • movement of fluids across selective permiable membrane from an area of low concentration to high

• diffusion

  • movement of dissolved particles across a semipermiable membrane fron an area higher concentration to an area of lower solute concentratoin

  • removes waste products from blood

• filtration

  • process of passing fluid through a filter or semipermiable membrane

• ultrafiltration

  • controlled fluid removal by manipulation of hydrostatic pressure

care of the dialysis pt *

• before starting

• weight

  • same scale, wearing same clothing, same time of day

• vitals

  • pulse may increase during dialysis due to decreased BV

  • BP may decrease

  • monitor for dysrhythmias

  • monitor temp - may indicate infection: check for cold ss, cough, pain, check access site

• listen for breath sounds

  • HF is frequent complications

• check for edema - face, feet, hands

• keep constant schedule for dialysis

  • dialysis is straining on glient - will be tired

• check emotional status - can be difficult and drianing

• check for medications

  • some are dialyzed out so might hold

  • use critical thinking to avalute anti hypertensives and dysrhythmic meds

Post dialysis care

• check weight

  • should be lower

  • typically use 1-2 L of fluid

• temp

  • may be slightly elevated

• BP

  • should be lower- if hypotensive may require bed rest

• pulse may increase due to fluid changes

• RR may slow

• assess for bleeding (heparin given)

  • if bleeding apply firm pressure

  • haparin remains in system for 4-6 hours

• check for muscle cramps

  • common problem du to remobal of large amts of fluid at rapid rate

• meds

  • admister meds that were held

hemodialysis complications

• infection

  • bacteremia

  • edocarditis

• exposure to blood born pathogens

  • hep B and C

• disequalibrium syndrome

disequalibrium syndrome

• typically new HD, results from shift between CSF and blood

  • develop cerebral edema

• ss: mild HA, mental confusion, seizures, NV, restlessness, fatigue, increased BP

• severe ss: agitation, twitching, confusion, convulsions

• nursing action: slow down dialysis rate

  • frquently assess pt

peritoneal dialysis

• wastes and fluids are removed from the blood inside the body, across peritoneal membrane

• a dialysate solution is intermittently introduced into and removed from the peritoneal cavity through a catheter

• uses: diffusion, filtration, osmosis

peritoneal dialysis catheter

• flexible tube inserted into the peritoneal cavity to facilitate dialysis.

• usually used after waiting about 2 weeks (can be used within a couple days if needed)

use of peritoneal dialysis

• treatmemt choice for pts w renal failure who are unable or unwilling to do hemodialysis or renal transplant

• more independant

• can be managed at home or in hospital

• great for pts with:

  • cardiovascular disease

  • diabetes

  • advanced age or young age

• exchange process is slower and less stress on the cardiovacular system

automated peritoneal dialysis

• Continuous Cycler-assisted Peritoneal Dialysis (CCPD)

• Requires a machine called a cycler to fill and drain your abdomen, usually while you sleep

• Done in home setting

• Portable so patient can travel

manual - tontinuous ambulatory peritoneal dialysis

• portable system done by nurses or pt

  • 2L of warm dialysate infused through catheter by gravity then clamped

  • empty dialysate bag folded and placed in pocket or pouch and pt can move around

  • pt unfolds bag and drains dialysate into it using strict aseptic technique

  • new bag of dialysate is hung, and again drains into abdomen

  • cycle is repeated

3 phases of peritoneal dialysis

• infusion/fill

  • infused over about 10 mins

• dwell

  • 20-30 mins, up to 8 hours depending on method

• drain

  • 10-20 mins

note: PD usually takes 36-48 hours to acheive what hemodialysis accomplished in 6-8 hrs

disadvantages to peritoneal dialysis compared to hemodialysis

• contrainvicated with: severe obesity, severe COPD, abnormalties of peritoneal membrane

• need clean home with space for supplies

• family/pt must know sterile technique

• dialysis must be sterile

• glucose in dialysate

  • more concentrated to remove fluid

  • may need insulin

• les efficient

• takes more tome to achieve desired outcome

• high risk for infection —> peritonitis, catheter site infection

• hernias and pleural leak

• catheter can clog or become displaces

• cant be used after recent surgery

• hypertriglyceridemia

nursng care of peritoneal dialysis

• I&Os

• check /weigh output bag

• weights

• vitals

• ss of peritonitis: elevated temp, cloudy drainage, pain)

• aseptic technique

• assess for:

  • constipation

  • abdominal cramping

  • prevent catheter clogging

peritonitis - complication of peritoneal dialysis

• assess for ss: cluody effluent (liquid waste), and pain, rebound tenderness, N?V, fever

• obtain effluent sample for culture

• administer antibiots as ordered

• tach pt and family ss and prevention

exit site infection - complication of peritoneal dialysis

• monitor site daily for ss of infection: induration, erythema, purulence and hyperthermia

• increase daily cleaning of site

• apply topical antibiotics as ordered

• teach pt and family to avoid agents sich as creams and lotions around exit site

catheter tunnel infection - complication of peritoneal dialysis

• assess fro ss of infection: pain along tunnel, induration for several sm away from catheter, erythema leading away from exit site, and drainage at exit site or as tunnel is “milked” towards exit site

• teach pt and fam to avoud pulls ro tugs on the catheter or traima to exit cite

• emphasize the need to maintain cleansing regimen at exite site

fluid obstriction - complications of peritoneal dialysis

• change position of patient

• irrigate catheter

• enure that sufficient fluid is in abdomen (sometimes requires a residual reservoir)

complications of peritoneal dialysis (pain and more)

• rectal pain

  • ensure a sufficient reservoir of fluid

  • use slow infusion rate

• shoulder pain

  • ensure that all air is promed from infusion tubing

  • attempt draining the effluent with client in knee chest position

• hernia

  • monitor for increase in size of or pain in area of nernia

  • decrease volume of exchnages as ordered

  • dialyze with client isupine position

  • use abdominal binder or support for pt

  • avoid initiation of PD until exut sit healing has taken place

• fluid overload

  • peripheral edema, crackles in lungs, chnages in wt

  • dehydration

• dehydration

  • skin turgor, muscle cramps, hypoTN, tachycardia, dizziness

  • if dehydrated: discontinue hypertonic soluation and increase PO fluid inatke

CRRT dyalysis (continuous renal replacement therapy)

• indications:

  • used for hemodynamically unstable pts —> often multi system failure

• process

  • fluid, electrolytes, small to medium sized molecules are removed by slow continuous ultrafiltration

  • may be used in combination with dialysis

  • process can continue up to 30-40 days

• slow continual - momics kidney

• managed by critical care nurse

• types

  • contunuous venocenous hemodialysis diffuse

  • continuous venovenous hempfiltration concention

• methods are similar - require access to the circulation and blood to pass through an artificial filter

• hemo filter is used in all types

advantages of CRRT

• does not produce rapid fluids shifts

• does not require dialysis machines or personnel

• can be initiatided very quickly

• done by ICU nurses

• useful for pts who cannot tolerate HD, PD, or require large amounts of fluids

complications for CRRT dialysis

• fluid and electrolyte imbalances

  • acid/base imbalance

• hemorrhage from anticoagulation or distruption of filter or tubing

• infection

• rupture of filter

• clotting in filter

• loss of vacular access/clogged catheter is very common