Dialysis, PPT

Dialysis Overview

Objectives

• Discuss different forms of dialysis and nursing care for each.

• Compare and contrast different types of dialysis.

Definition and Introduction to Dialysis

• Dialysis: A medical procedure to remove waste products from the blood when kidneys fail to perform this function.

• Types of Dialysis Available:

  • Peritoneal Dialysis (PD)

  • Hemodialysis (HD)

• Initiation of dialysis occurs when a patient’s uremia can no longer be treated conservatively; specifically, when the Glomerular Filtration Rate (GFR) falls below $15{ mL/min/1.73 m}^2$ .

• A nephrologist determines the appropriate timing to start dialysis based on clinical evaluations.

• Dialysis is required to address uremic complications, which arise due to the accumulation of waste products in the bloodstream.

Peritoneal Dialysis (PD)

Overview

• Involves creating an artificial membrane through the peritoneum in the abdominal cavity.

PD Components

• Catheter: Inserted into the peritoneum.

• Dialysis Solution: A sterile solution that helps to remove waste products from the blood.

• Drain Bag: Collects waste fluid after dialysis.

PD Cycle

• Three Phases of a Manual PD Cycle:

  • Inflow (Fill): 2 to 3 liters of dialysis solution introduced over 10 minutes.

  • Dwell (Equilibration): The solution remains in the abdomen for 20 to 30 minutes or up to 8 hours, allowing for waste and toxins to diffuse into the solution.

  • Drain: The fluid is drained out of the abdomen over a period of 15 to 30 minutes.

• Each complete cycle is referred to as an exchange.

• Volume used depends on the size of the peritoneal cavity.

• Dextrose serves as an osmotic agent in the dialysis solution.

Complications of Peritoneal Dialysis

• Possible complications include:

  • Exit Site Infection

  • Peritonitis: Infection of the peritoneal cavity.

  • Hernias

  • Low Back Problems

  • Bleeding

  • Pulmonary Complications

  • Protein Loss: Nutritional concerns may arise due to protein loss during dialysis.

Effectiveness of Chronic PD

• Training: Short training program lasting 3 to 7 days for patients.

• Advantages of PD include:

  • Simplicity of the procedure.

  • Ability to perform the treatment at home, increasing patient participation.

  • No requirement for special water systems, which simplifies the setup of equipment.

Hemodialysis (HD)

Overview

• Requires rapid blood flow and access to a large blood vessel, making vascular access a challenging aspect of treatment.

Vascular Access Sites

• Types of Vascular Access:

  • Arteriovenous Fistulas: Preferred access method due to lower complications.

  • Arteriovenous Grafts: Used when fistulas are not viable.

  • Temporary Vascular Access: Catheter insertion into major veins when immediate access is required, typically the internal jugular or femoral vein.

Arteriovenous Fistulas and Grafts

• Fistulas: Created in the forearm or upper arm, allowing arterial blood to flow through a vein and become “arterialized.”

  • Requires a maturation period of about 3 months before use.

  • Physical signs of proper function include feeling a “thrill” or hearing a “bruit” due to high blood flow.

• Grafts: Comprises synthetic material bridging an artery to a vein, requiring healing time of 2 to 4 weeks and carry a higher risk of infection and clot formation.

HeRO Graft (Hemodialysis Reliable Outflow)

• This innovative access method is utilized when traditional access options have been exhausted.

• It consists of two pieces:

  • A reinforced tube that bypasses blockages.

  • A dialysis graft that anastomoses to an artery under the skin.

Risk Factors Associated with AV Fistulas and Grafts

• Risks include:

  • Distal Ischemia (Steal Syndrome)

  • Distal Pain: Pain experienced distal to the access site.

  • Neurological Symptoms: Such as numbness or tingling in fingers.

  • Poor Capillary Refill: Indication of compromised blood flow.

  • Aneurysms

• Safety Alerts:

  • Avoid BP, venipunctures, or IV lines on extremities with AV fistulas or grafts.

  • Visible signs (post signs or labeled armbands) should be in place to prevent complications and inform care providers.

Temporary Vascular Access

• Catheter Insertion: Utilizes internal jugular or femoral vein for immediate access; designed with two lumens for blood removal and return.

• Risks associated with temporary access include a high rate of:

  • Infection

  • Dislodgment

  • Malfunction

Hemodialysis Procedure

Pre-Treatment Assessment

• Prior to HD, assess:

  • Fluid status: Check weight, blood pressure, peripheral edema, heart and lung sounds.

  • Last post-dialysis weight and current predialysis weight to determine fluid to be removed.

  • Vascular access and vital signs (VS) every 30 to 60 minutes.

Needle Placement and Heparin Use

• Place 2 large bore needles in the fistula or graft:

  • One needle is used to withdraw blood from circulation to the HD machine.

  • The other needle returns the dialyzed blood to the patient.

• Heparin is administered to prevent clotting during dialysis.

Dialyzer and Blood Line Preparation

• The dialyzer and blood lines should be primed with saline to eliminate any air before use, and the process includes a termination step of flushing saline to ensure all blood returns to the patient once treatment is concluded.

Treatment Schedule

• Most patients undergo hemodialysis treatment in a community-based center for 3 to 4 hours, three days a week.

• Alternative schedules may include:

  • Short daily HD.

  • Long nocturnal HD.

  • Home HD.

Complications of Hemodialysis

• Common complications include:

  • Hypotension: Drop in blood pressure.

  • Muscle Cramps: May occur during treatment.

  • Blood Loss: Due to the need for vascular access.

Effectiveness of Hemodialysis

• Although HD cannot fully replicate normal kidney function, it can alleviate many symptoms and prevent certain complications.

• The cardiovascular disease carries a high mortality rate, and infectious complications are the second leading cause of death among dialysis patients.

• Individual Adaptation: Patients may experience positive, ambivalent, or depressed feelings regarding their health status.

• Nursing goals: Assist patients in achieving a healthy self-image and reclaiming their highest level of functioning, including potential return to work.

Continual Renal Replacement Therapy (CRRT)

Overview

• CRRT is a method employed for treating acute kidney injury (AKI), facilitating the removal of uremic toxins and fluids.

• It adjusts acid-base balance and electrolyte levels slowly and continuously, making it suitable for hemodynamically unstable patients.

• CRRT treatments occur over a 24-hour period and can be used in conjunction with traditional hemodialysis.

Nursing Interventions for CRRT

• Essential nursing interventions include:

  • Obtaining and monitoring patient weights.

  • Documenting daily laboratory values that reflect fluid and electrolyte balance.

  • Assessing intake/output, vital signs, and hemodynamic status on an hourly basis.

  • Ensuring appropriate care of access sites to reduce the risk of infection.

Wearable Artificial Kidney

Overview

• The wearable artificial kidney is a recently developed and approved therapy designed for patients with end-stage renal disease (ESRD).

• This innovative, miniaturized dialysis machine weighs approximately 10 pounds and connects to the patient via a catheter.

• Resembling a tool belt, it can filter blood continuously and runs on battery power, offering a new level of mobility and quality of life for patients undergoing dialysis therapy.

References

• Harding, M.M., Kwong, J., Hagler, D., & Reinisch, C. (2023). Lewis’s medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier: St. Louis, MO.

• Urden, Linda, D. et al. Priorities in Critical Care Nursing. Available from: Elsevier, (9th Edition), Elsevier Health Sciences (US).