DIALYSIS

General Information: 1. Removal by artificial means of metabolic wastes, excess

electrolytes, and excess fluid from clients with renal failure.

2. Principles
A. diffusion movement of particles from an area of high

concentration to one of semipermeable membrane

B. osmosis - movement of water through a semipermeable membrane

from an area of lesser concentration of particles to one greater concentration.

Equiptments:
Blood line, NSS Hemodialysis catheter/needle Tourniquet Dialysate A solution composed of all the important electrolytes Dialyzer or artificial kidney Serves as synthetic, semipermeable membrane, replacing the renal glomeruli and tubules as the filters Contain thousand of tiny cellophane tubules that act as semipermeable membranes. Biocompatibility- hypersensitive, allergic or adverse reaction

Hemodialysis
1. Shunting of blood from the clients vascular system

through an artificial dialyzing system, and return of dialyzed blood to the clients circulation.
2. Dialysis coil acts as the semipermeable membrane;

the dialysate is a specially prepared solution.

1. Subclavian, internal jugular and femoral catheters

Immediate access for acute hemodialysis Risks: hematoma, infection, thrombosis

Be used for several weeks

2. Fistula
More permanent access Surgically inserted usually in the forearm by joining

(anastomosis) an artery to a vein (either side to side or end to end) It takes 4-6 weeks to mature before it is ready for use. Squeezing of rubber ball (increase size of the vessels)

3. Graft
Arteriovenous graft using a synthetic tube or graft,

implanted under the skin between an artery and vein. Indicated for small veins that wont develop properly into a fistula A graft doesnt need to develop as a fistula does, so it can be used sooner after placement, often within 2 or 3 weeks. Risks: infection, thrombosis

Nursing Care:
Auscultate for a bruit and palpate for a thrill to ensure

patency. Assess for clotting ( color change of blood, absence of pulsations in tubing>. Change sterile dressing over shunt daily. Avoid performing venipuncture, giving injections, or taking a blood pressure with a cuff on the shunt arm.

 Report bleeding, skin discoloration, drainage and pain.

Avoid restrictive clothing/ dressing over site. Position catheter properly to avoid dislodgement

during dialysis. ( subclavian cannulation)

Nursing care before and during 1. have client void dialysis: 2. chart clients weight
3. assess vital signs before and every 30 minutes during

procedure. 4. withhold antihypertensive, sedatives and vasodilators to prevent hypotensive episode ( unless ordered otherwise. 5. Ensure bed rest with frequent position changes for comfort. 6. inform client that headache and nausea may occur. 7. monitor closely for signs of bleeding since blood has been haparinized for procedures.

Nursing care : postdialysis

1. chart clients weight.
2. Assess for complications: Hypovolemic shock may occur as a result of rapid removal or ultrafiltration of fluid from the intravascular compartment.
Dialysis disequilibrium syndrome ( urea is removed

more rapidly from the blood than from the brain) assess for nausea , vomiting, disorientation, leg cramps and peripheral paresthesias,

Hemodialysis Complication:
1. 2. 3. 4. 5. 6. 7. 8.

Hypotension Bleeding Infection (local or systemic) Painful muscle cramping Dysrhythmias Air embolism Chest pain Dialysis disequilibrium Syndrome
Neurologic signs, attributed to cerebral edema, during or following

shortly after intermittent hemodialysis. A transient osmotic gradient that promotes water movement into the cells Gradual dialysis 150-250 mL/min

Peritoneal Dialysis
Introduction of a specially prepared dialysate solution into the

abdominal cavity, where the peritoneum acts as a semipermeable membrane between the dialysate and blood in the abdominal vessels. Treatment of choice who are unable or unwilling to hemodialysis and kidney transplantation Indicated for patients who are susceptible to rapid F/E and metabolic changes caused by hemodialysis Waste Products are cleared in 36-48 hours Preferred treatment for:
DM or cardiovascular disease (HPN, CHF and pulmonary edema) Older patients Side effects of heparin

Principles of PR
Peritoneum- a serous membrane that covers the

abdominal organs and lines the abdominal wall, serves as the semipermeable membrane. Diffusion and osmosis
Waste products move from an area of higher

concentration (peritoneal blood supply) to an area of lower concentration (peritoneal cavity) across the semipermeable membrane (peritoneum).

Ultrafiltration Water removal occurs through an osmotic gradient created by adding dextrose to the dialysate.

Equiptments/ preparation
Rigid stylet catheter is inserted 3-5 cm below the

umbilicus Dialysate- 500 mL to 3000 mL Dextrose solutions of 1.5%, 2.5%, and 4.25% Heating cabinet, incubator, heating pad Dialysate is warmed to prevent discomfort and dilate vessels to increase urea clearance Flow Sheet Heparin to prevent blood clot to the catheter Antibiotics, insulin and KCL may be added

Performing the exchange

1.

Infusion

5-10 minutes 2 liters of dialysate solution

2. Dwell Time allows for diffusion and osmosis to occur 5-10 minutes (diffusion creatinine and urea) 3. Drainage 10-30 minutes Drainage should be colorless or straw-colored and should not be cloudy Bloody drainage is normal during the first few exchange

Approaches of PD

 Continuous ambulatory Peritoneal Dialysis A continuous type of peritoneal dialysis performed at home by the client or significant others. Dialysate is delivered from flexible plastic containers through a permanent peritoneal catheter. Following infusion of the dialysate into the peritoneal cavity, the bag is folded and tucked away during the dwell period.

PD Complications
1. Peritonitis Most common and serious complication Caused by: staphylococcus epidermidis, staphylococcus aureus Cloudy dialysate drainage, diffuse abdominal pain, and tenderness 2. Leakage Occur usually after the catheter is inserted It stops for several days allowing the site to heal

3. Bleeding Common during the first few exchanges Common in young menstruating women Hypertonic fluid pulls blood from the uterus, through the opening of the fallopian tubes, and into the peritoneal cavity 4. Long term complications Abdominal hernias Hemorrhoids

Nursing Care :
chart clients weight. Assess vital signs before, every 15 minutes during first exchange,

and every hour thereafter. Assemble specially prepared dialysate solution with added medications. Have client void. Warm dialysate solution to body temperature. Assist physician with trocar insertion. Inflow: allow dialysate to flow unrestricted into peritoneal cavity ( 10 -20 minutes) Dwell : allow fluid to remain I nperitoneal cavity for prescribed period ( 30 -45 minutes) Drain: unclamped outflow tube and allow to flow by gravity.

 Observe characteristics of dialysate outflow:

A. clear pale yellow: normal B. cloudy : infection, peritonitis

C. brownish : bowel perforation

D. bloody : common during first few exchanges,

abnormal if continues. Monitor total I & O and maintain records

 Assess for complications: A. Peritonitis resulting from contamination of solution or tubings during exchange. B. respiratory difficulty: may occur from upward displacement of diaphram due to increased pressure in the peritoneal cavity; assess for signs and symptoms of atelectasis, pneumonia and bronchitis. Protein loss : most serum proteins pass through the peritoneal membrane and are lost in the dialysate fluid; monitor serum protein levels closely.

Evaluation :
1. adequate urinary output with specific gravity/ laboratory

studies within clients normal range; stable weight; absence of edema; pulmonary congestion. Client verbalizes increased tolerance for activities. Skin and mucous membranes free from ecchymoses/ bleeding: improved laboratory values ( CBC, Platelet, clotting factors) no signs of bleeding. Client identifies ways to compensate for cognitive impairment; demontrates improved problem solving skills. Stable weight gain. Vital signs within normal range, client identify measures to prevent/ reduce the risk of infections.

Nursing Diagnosis
1. Altered tissue perfusion: renal
2. Risk for infection 3. Altered nutrition: less than body requirements

4. Risk for injury

5. Altered urinary elimination 6. Fluid volume excess 7. Impaired skin integrity