Chapter 59: Hemodialysis and Peritoneal Dialysis

Chapter 59: Hemodialysis and Peritoneal Dialysis

Purpose of Dialysis

• Removes excess fluid and electrolytes

• Eliminates waste products

• Maintains acid–base balance

• Restores internal homeostasis via diffusion, osmosis, ultrafiltration

Types

• Hemodialysis

• Peritoneal dialysis

Hemodialysis

Blood is shunted through a dialyzer and returned to circulation

Requires vascular access

Initiated when uremic symptoms become severe

Typical schedule: 3 times per week, 3 to 4 hours per session

Two needles used: one arterial, one venous

Hemodialysis Indications

Potential Diagnoses

• Acute kidney injury

• Chronic kidney disease

• Renal insufficiency

• Persistent hyperkalemia

• Pulmonary edema

• Severe hypertension

• Hypervolemia unresponsive to diuretics

• Medication or illicit drug toxicity

Client Presentation

• Fluid volume overload

• Electrolyte and pH imbalances

• Elevated nitrogenous wastes

• Uremic manifestations

  • Cognitive impairment

  • Pruritus

  • Nausea and vomiting

• Bleeding tendencies

• Neurologic changes

Hemodialysis Considerations

Preprocedure Nursing Care

Access and Preparation

• Verify informed consent

• Use temporary dual-lumen catheter if long-term access not yet placed

• Assess AV fistula or graft

  • Palpable thrill

  • Audible bruit

  • Distal pulses

  • Circulation

Safety and Assessment

• No blood pressure, venipuncture, injections, or IVs in access arm

• Elevate extremity after AV fistula creation to reduce swelling

• Assess vital signs

• Review labs

  • BUN

  • Creatinine

  • Electrolytes

  • Hematocrit

• Obtain pre-dialysis weight

• Hold dialyzable medications and antihypertensives as prescribed

Intraprocedure Nursing Care

Monitoring

• Vital signs and coagulation studies

• Access site for bleeding or oozing

• Dialysis circuit

  • Clotting

  • Air bubbles

  • Dialysate temperature 37.8°C or 100°F

  • Ultrafiltration regulation

Common Complications

• Hypotension

• Muscle cramping

• Nausea and vomiting

• Bleeding at access site

• Equipment contamination

Medications and Support

• Administer anticoagulants such as heparin

• Keep protamine sulfate available to reverse heparin

• Provide emotional support and diversional activities

Client Teaching During Dialysis

• Report headache, nausea, dizziness immediately

Postprocedure Nursing Care

Assessment

• Monitor vital signs and labs

  • Decreased BP common

  • Lab value shifts expected

• Compare pre- and post-dialysis weights

  • 1 L fluid removed equals 1 kg or 2.2 lb

• Assess for

  • Hypotension

  • Headache

  • Muscle cramps

  • Bleeding

  • Access clotting

  • Disequilibrium syndrome

  • Hypovolemia signs (dizziness, tachycardia)

Precautions

• Avoid invasive procedures for 4 to 6 hours post dialysis

• Reinforce AV fistula or graft precautions

Post-Dialysis Client Education

• Report early signs of disequilibrium syndrome

• Check access site regularly

• Apply light pressure if bleeding occurs

• Contact provider if

  • Bleeding lasts longer than 30 minutes

  • No thrill or bruit present

  • Signs of infection occur

• Avoid heavy lifting with access arm

• Avoid constrictive clothing or objects on access extremity

• Do not sleep on access arm

• Perform hand exercises to promote fistula maturation

• Follow dietary guidance

  • Increased protein intake

  • Foods high in folate

• Take prescribed supplements and medications

A nurse is teaching a client who is scheduled for hemodialysis via an arteriovenous fistula. Which of the following instructions should the nurse include?

a

Avoid invasive procedures 4 hr after dialysis.

b

Wear a compression sleeve over the extremity with the vascular access.

c

Sleep on the side of the extremity with the vascular access.

d

Expect to experience nausea after dialysis.

a

Avoid invasive procedures 4 hr after dialysis.

Hemodialysis Complications

Access Site Clotting or Infection

• Anticoagulation increases bleeding risk

• Cannulation increases infection risk

• Risk factors

  • Immunosuppression

  • Advanced age

  • Fragile veins

• Nursing Actions

  • Use surgical aseptic technique

  • Avoid compression of access

  • No BP or venipuncture on access arm

  • Assess for thrill and bruit

  • Monitor for redness, swelling, drainage, fever

Disequilibrium Syndrome

• Caused by rapid reduction of BUN and fluid shifts

• Leads to cerebral edema and increased intracranial pressure

• Manifestations

  • Nausea

  • Vomiting

  • Headache

  • Altered level of consciousness

  • Seizures

  • Agitation

• Risk factors

  • Older adults

  • First-time dialysis

• Nursing Actions

  • Slow dialysis rate

  • Administer anticonvulsants or barbiturates if prescribed

Hypotension

• Caused by rapid fluid removal or antihypertensive use

• Nursing Actions

  • Infuse IV fluids or colloids

  • Lower head of bed

  • Slow or discontinue dialysis if unresponsive

Anemia

• Caused by blood loss and decreased erythropoietin

• Nursing Actions

  • Administer erythropoietin

  • Monitor hemoglobin and RBC count

  • Monitor for hypotension and tachycardia

  • Transfuse blood products as prescribed

Infectious Disease Risk

• Due to repeated blood exposure and transfusions

• Risks include hepatitis B, hepatitis C, HIV

• Nursing Actions

  • Use sterile equipment

  • Maintain skin antisepsis

  • Follow standard precautions

Peritoneal Dialysis

Dialysate is instilled into the peritoneal cavity with a prescribed dwell time

Peritoneum acts as a semipermeable membrane

Waste products (urea, creatinine), excess electrolytes, and fluid move from blood to dialysate by diffusion and osmosis

Effluent drains by gravity into a drainage bag after dwell time

Requires intact peritoneal membrane without adhesions from infection or multiple surgeries

Peritoneal Dialysis Indications

Preferred for many older adults requiring dialysis

Appropriate for clients who

• Cannot tolerate anticoagulation

• Have poor vascular access

• Have chronic infections or are medically unstable

• Have chronic conditions such as diabetes mellitus, heart failure, severe hypertension

A nurse is caring for a client who is experiencing disequilibrium syndrome during hemodialysis. Which of the following actions should the nurse take?

a

Administer an opioid medication to the client.

b

Prepare to administer an antihypertensive medication to the client. 

c

Check the client’s level of consciousness.

d

Increase the client’s dialysis exchange rate.

c

Check the client’s level of consciousness.

Peritoneal Dialysis Considerations

Assessment

• Obtain dry weight (without dialysate instilled)

• Assess vital signs

• Review labs

  • Electrolytes

  • BUN

  • Creatinine

  • Blood glucose

• Assess ability to self-perform dialysis and maintain sterile technique

  • Level of alertness

  • Prior dialysis experience

  • Understanding of procedure

Client Education

• Expect abdominal fullness during dwell time

• Mild discomfort may occur initially with infusion

Types of Peritoneal Dialysis

• Continuous ambulatory peritoneal dialysis (CAPD)

  • Manual exchanges

  • Performed daily, typically 4 to 8 hr dwell times

  • Allows normal daily activity

• Continuous-cycle peritoneal dialysis (CCPD)

  • Automated exchanges at night during sleep

  • Final exchange dwells during the day

• Automated peritoneal dialysis (APD)

  • Short exchanges every 30 min

  • Runs 8 to 10 hr overnight

Intraprocedure Nursing Care

Monitoring

• Monitor vital signs frequently, especially during initial treatments

• Monitor blood glucose (dialysate contains glucose)

• Record inflow and outflow volumes

• Assess effluent

  • Color should be clear to light yellow

  • Amount should equal or exceed inflow

• Monitor for infection

  • Fever

  • Cloudy, bloody, or frothy effluent

  • Drainage at access site

• Monitor for complications

  • Abdominal pain

  • Respiratory distress

  • Inadequate inflow or outflow

  • Discolored effluent

Procedure Safety

• Warm dialysate before instillation

  • Do not microwave (uneven heating)

• Maintain strict surgical asepsis during catheter access

• Adhere to prescribed infusion, dwell, and outflow times

• Keep outflow bag below abdomen to promote gravity drainage and prevent reflux

• Reposition client if flow is inadequate

• Gently milk catheter if fibrin clot present

• Provide emotional support to client and family

Postprocedure Nursing Care

Assessment

• Monitor weight

• Monitor labs

  • Electrolytes

  • Creatinine

  • BUN

  • Glucose

Client Education

• Perform meticulous home care of access site

• Perform exchanges at home as instructed

• Follow medication regimen carefully

• Seek support resources such as the National Kidney Foundation

• Take prescribed vitamin and mineral supplements

• Report inability to manage access care (cognitive or physical limitations)

• Be aware that body image changes from abdominal distention may occur

A nurse caring for a client who is scheduled for peritoneal dialysis (PD). Which of the following actions should the nurse take?

Select all that apply.

a

Monitor the client’s blood glucose levels.

b

Report cloudy dialysate outflow.

c

Warm the dialysate in a microwave oven.

d

Assess the client for bleeding.

e

Check the access site dressing for wetness.

f

Maintain medical asepsis when accessing the catheter insertion site.

a

Monitor the client’s blood glucose levels.

b

Report cloudy dialysate outflow.

d

Assess the client for bleeding.

e

Check the access site dressing for wetness.

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When taking actions, the nurse should monitor the client’s blood glucose, because the client is at risk for hyperglycemia due to glucose in the dialysate. The nurse should monitor the client for manifestations of an infection, such as cloudy effluent, fever, abdominal pain, and monitor the client for bleeding. The client who has a new PD catheter might have blood in effluent for the first week due to trauma during the catheter insertion. Check the access site dressing for wetness and look for kinking, pulling, clamping, or twisting of the tubing, which can increase the risk for exit-site infections.

Peritoneal Dialysis Complications

Peritonitis

• Caused by microorganisms entering the peritoneal cavity

• Earliest sign is cloudy or opaque effluent

• Additional findings

  • Fever

  • Abdominal pain

• Nursing Actions

  • Maintain strict aseptic technique

  • Monitor effluent appearance

• Client Education

  • Use sterile technique during all exchanges

  • Report signs of infection immediately

Access-Site Infection

• Can result from dialysate leakage

• May progress to peritonitis

• Risk increased in older adults with chronic illness

• Nursing Actions

  • Maintain asepsis at access site

  • Assess for wetness from leaks

  • Monitor for redness, swelling, purulent drainage, fever

• Client Education

  • Inspect site daily

  • Prevent pulling, twisting, or tension on tubing

  • Report infection signs promptly

Protein Loss

• Dialysate removes protein along with wastes

• Nursing Actions

  • Encourage increased dietary protein

  • Monitor serum albumin

• Client Education

  • Follow renal diet with increased protein intake

Hyperglycemia and Hyperlipidemia

• Caused by glucose absorption from dialysate

• Long-term therapy may increase triglycerides and blood pressure

• Nursing Actions

  • Monitor blood glucose

  • Administer insulin as prescribed

  • Administer antilipemic medications as ordered

• Client Education

  • Monitor blood glucose regularly

  • Follow dietary recommendations

  • Take antihypertensive medications as prescribed

Poor Dialysate Inflow or Outflow

Causes

• Kinked or twisted tubing

• Constipation

• Improper positioning

• Fibrin clot formation

• Catheter displacement

Nursing Actions

• Reposition client

• Check tubing for kinks or closed clamps

• Gently milk tubing to clear fibrin clots

Client Education

• Inspect tubing during exchanges

• Adjust position or bag height to improve flow

• Prevent constipation with diet and stool softeners

• Lie supine with head slightly elevated during CCPD or APD treatments