Dialysis
Overview of Dialysis
Dialysis is described as a machine version of the kidney used for clients with renal failure.
It functions analogously to a washing machine, cleaning the blood by filtering out waste and flushing out excess fluid and electrolytes.
Memory Aid for Dialysis
The term "diol" in dialysis can be associated with soap, indicating its role in cleansing the blood.
Types of Dialysis
Hemodialysis:
A shunt is surgically placed in the arm, allowing blood to be taken and cleaned in a dialysis machine.
Typically performed 3-4 times per week.
Missing a session can lead to high levels of electrolytes and waste in the blood, particularly potassium, which is critical to monitor.
Peritoneal Dialysis:
Not detailed in the provided information but is recognized as the second type of dialysis.
Priority Focus for Nursing in Hemodialysis
Assessments Before Dialysis
Fluid Assessment:
Weigh the patient before dialysis and compare current weight with the last post-dialysis weight from the medical record.
Monitor vital signs, look for edema, and listen to lung and heart sounds to assess fluid status.
Fistula Assessment:
Important to feel for a thrill (vibration) and hear a bruit (whooshing sound) over the fistula.
Absence of these signs indicates potential clot formation, risking decreased blood flow and possible loss of the arm.
Medication Management
Medications to Hold Before Dialysis:
Hold medications that cause hypotension, as fluid is removed during dialysis.
Categorized as follows:
A: ACE inhibitors and ARBs (e.g., lisinopril, losartan) - both may retain potassium.
B: Beta blockers (e.g., atenolol) - leads to low blood pressure and heart rate.
C: Calcium channel blockers (e.g., agents ending in -dipine, diltiazem) - lower blood pressure.
D: Diuretics (e.g., furosemide, hydrochlorothiazide) - dry the body, reducing blood pressure.
D: Vasodilators (e.g., nitroglycerin) - dilate blood vessels, resulting in lower blood pressure.
Medications Dialyzed Out of the Body:
Certain antibiotics like penicillin and cephalosporins, as well as digoxin, may be rendered ineffective during dialysis.
Water-soluble vitamins (B, C, folic acid) should also be held.
Calcium supplements can be given pre-dialysis to lower phosphorus levels safely.
Insulin can be administered as it is absorbed quickly.
Special Considerations During Dialysis
Heparin Administration:
IV heparin is added to blood during dialysis to prevent clotting; subcutaneous heparin is not necessary.
Examples on Exam Topics
Muscle Cramps & Tingling:
For clients reporting these symptoms, administer calcium carbonate, as it helps alleviate cramps.
Priority Assessment for Hemodialysis Clients:
Key term is restlessness, which could indicate Dialysis Disequilibrium Syndrome (DDS), a serious complication.
Dialysis Disequilibrium Syndrome (DDS)
Definition:
A condition occurring when solutes exit the bloodstream too quickly during hemodialysis, leading to fluid swelling in brain cells (increased intracranial pressure).
Key Signs of DDS:
Restlessness, disorientation, vomiting, headache.
Priority action is to stop or slow the infusion and report to the provider.
Avoid placing the patient in Trendelenburg position as it might worsen ICP.
Patient Education Regarding Fistula Care
Creation of Fistula:
A connection made between an artery and a vein, enabling arterial flow into a low-pressure vein.
It requires a healing period of several months.
Self-Care Instructions:
Patients should perform exercises like squeezing a rubber ball to improve blood flow and strengthen the new site.
Pitting Edema is common post-surgery and usually resolves in a week.
Signs to Report:
Five P’s of Perfusion:
Pale skin: pallor can indicate poor perfusion, must be reported.
Paresthesia: numbness or tingling is an early warning sign.
Other P’s include pain, pulse, and temperature, which also indicate perfusion but are less critical for early intervention.
Safety Precaution for Clients:
Clients should avoid putting pressure on the new shunt and monitor for any complications.
New Shunts
It is important to be cautious with new shunts as they heal.
Continuous monitoring is required for key issues:
Infection: Look for signs such as warmth, redness, or drainage at the shunt site.
Bleeding: Observe any unexpected blood loss.
Vibration/Tremors (Thrill): Feeling a thrill is essential as it indicates that blood flow is adequate.
Daily Monitoring: Clients are advised to check for thrill and vibration a few times each day.
This monitoring is crucial to avoid complications like stenosis (stiffening) or thrombosis (blood clotting) at the site.
No No's for Shunt Care
Key considerations to promote adequate blood flow and prevent clotting:
No Restrictive Clothing: Avoid tight clothing and jewelry such as watches or bracelets.
No Blood Pressure Measurement: Do not take blood pressure on the affected arm.
No Sleeping on the Affected Arm: Ensure to avoid resting on the shunted arm.
No Creams or Lotions: To minimize infection risk, refrain from using topical ointments at the site.
No Lifting Over Five Pounds: Heavy lifting is not allowed to prevent strain on the shunt.
No Purses: Students should memorize this as it commonly appears in NCLEX select-all-that-apply questions.
Peritoneal Dialysis vs. Hemodialysis
Peritoneal dialysis is distinctly different from hemodialysis.
No Shunt: There is no shunt involved in peritoneal dialysis; instead, the peritoneal cavity is used.
Technique: The peritoneal cavity is filled with a hypertonic solution to draw out solutes.
Dwell Phase: The solution is allowed to remain for approximately thirty minutes.
Drainage: After the dwell phase, the solution is drained via gravity.
Key Actions for Peritoneal Dialysis
Weight Measurement: Before any dialysis, it is essential to weigh the patient.
Warming Solutions: Always warm the dialysate solution before introducing it into the body.
Infection Risk in Peritoneal Dialysis
One of the most critical complications is the risk of infection.
Sterile Technique: Using a sterile technique when spiking and attaching the bag of dialysate is a priority.
Peritonitis: A small infection can lead to severe complications, such as peritonitis.
Key Signs of Infection: Report the following immediately:
Fever
Tachycardia
Cloudy Drainage: Remember the mnemonic: "no one likes cloudy days, and no one likes cloudy drainage".
Do Not Confuse Symptoms: The priority findings to watch for are not typically oliguria (very low urine output) or pruritus; these are common in renal failure.
Complications of Peritoneal Dialysis
Respiratory Distress: Can arise from rapid infusion or overfilling the abdomen.
Key Signs:
Crackles in Lung Bases
Rapid Respirations
Dyspnea: Difficulty breathing
Priority Intervention: Always raise the head of the bed first in case of respiratory distress.
Importance of ABC (Airway, Breathing, Circulation) principles: breathing takes priority over circulation (blood pressure).
Emergency Assessment Protocol for Insufficient Outflow
In the case of insufficient outflow during peritoneal dialysis, follow these steps:
Assess the Patient: Start by checking for abdominal distension and constipation.
Assess the Device: Look for any kinks or obstructions in the catheter and tubing.
Reposition: Change the patient's positioning to a side-lying position; do not flush the tubing initially as it can worsen outflow issues.
Contact Provider: Typically, there is no immediate need to call the healthcare provider, as repositioning will likely resolve the issue.
Dietary Considerations Post-Dialysis
After completing dialysis treatments, it is important to increase protein intake in the patient’s diet.
This is necessary because the blood has been cleansed of waste products, which often results in low protein levels in the body.
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