Dialysis

Notes
MS vol. 2
Krizza Myrrh Gomera Balcita, RN
Dialysis
• Is used to remove fluid and uremic waste
products from the body when the kidneys are
unable to do so.
• Also used to treat patients with edema that does
not respond to other treatment, hepatic coma,
hyperkalemia, hypercalcemia, hypertension, and
uremia
• Methods: HD, CRRT, and PD
• May be acute or chronic
Dialysis
• Acute dialysis: high and increasing level of
serum potassium, fluid overload, or impending
pulmonary edema, increasing acidosis,
pericarditis and severe confusion. May also be
used to remove certain medications or toxins
from the blood.
• Chronic or maintenance dialysis: for ESRD,
presence of uremic signs and symptoms that
affects all body systems, hyperkalemia, fld
overload not responsive to diuretics, fld
restriction
Dialysis
• Urgent indication for dialysis in pts with CRF is
pericardial friction rub
• Successful kidney transplantation eliminates the
need for dialysis.
Hemodialysis
Notes

MS Vol. 2

KRIZZA MYRRH GOMERA BALCITA, RN

Hemodialysis
• Is the most common method of dialysis
• Used for patients who are acutely ill and require
short term with dialysis and for patients with ESRD
which require long term or permanent therapy.
• Dialyzer – artificial kidney; synthetic
semipermeable membrane, replacing the renal
glomeruli and tubules as the filter for impaired
kidneys.
• Does not cure renal disease and does not
compensate for the loss of endocrine and metabolic
activities of the kidneys.
Hemodialysis
• Treatments : 3-4 hours for three times a week
• Objectives:
▫ To extract toxic nitrogenous substances from the blood
▫ To remove excess water
• Diffusion, Osmosis, and filtration are the principles
on which hemodialysis is based.
• Diffusion – removal of toxins and wastes in the body
(movement from area of higher concentration in the
blood to an area of lower concentration in the
dialysate)
Hemodialysis
• Dialysate – a solution made up of all the important
electrolytes in their ideal extracellular concentrations
• Osmosis – removal of excess water from the blood;
water moves from area of higher solute concentration
to (blood) to an area of lower solute concentration
(the dialysate bath)
• Ultrafiltration – water moves under high pressure to
an area of lower pressure; much more efficient than
osmosis at water removal; utilizes applying negative
pressure or a suctioning force to the dialysis
membrane
Hemodialysis
• Buffer system: maintained using a dialysate made
of Bicarbonate (most common) or acetate which is
metabolized to form bicarbonate.
• Heparin – anticoagulant
• Dialyzer – hollow-fiber devices containing
thousands of tiny cellophane tubules that act as
semipermeable membranes. Blood flows through
the tubules while a solution (dialysate) circulates
around the tubules.
• Exchange of wastes from the blood to the dailysate
occurs through the semipermeable membrane of the
tubules
Hemodialysis
• Biocompatibility
• Middle weight molecule dialyzer
• High—flux dialysis: uses highly permeable
membranes that increase the clearance of low-
and mid- molecular weight molecules. Uses 500-
550 ml/min. Increases efficiency of treatment
while shortening their duration and reducing the
need of heparin.
Hemodialysis
VASCULAR ACCESS
• 300-550 ml/min.
• Vascular access devices:
• Short term access: double lumen large bore
catheter (subclavian, internal jugular vein, or
femoral vein); risks e.g hematoma,
pneumothorax, infection, thrombosis of the
subclavian vein, inadequate flow; can be used for
no longer than 3 weeks.
Hemodialysis
• Long term use: double lumen cuffed catheters may be
inserted to the jugular vein of patients required
central venous catheter.
• Arteriovenous Fistula - preferred method of
permanent access; created surgically usually in the
forearm by joining (anastomosing) an artery to a vein,
either side-to-side or end-to-side. Arterial segment is
for arterial flow and the venous segment is for the
venous flow. Fistula is matured for at least 14 days.
• Exercise to increase size of vessels: squeezing a rubber
ball for forearms fistulas
Hemodialysis
• Arteriovenous graft – subcutaneously
interposing a biologic, semibiologic, or synthetic
graft material between an artery and vein. Most
commonly used synthetic graft material is expanded
polytetrafluoroethylene. Example: Impra Vectra
graft made of thoralon and can be used for 24 hours.
Access can be achieved for 10 days with Artegraft (a
natural collagen vascular graft)
• Thrombosis and infection– are the most common
complications of arteriovenous grafts.
Hemodialysis
• Goal of treating patients with ESRD: maximize
their vocational potential, functional status, and
quality of life.
Hemodialysis
 Complications of Hemodialysis:
 Atherosclerotic cardiovascular disease (leading cause of
death)
 Hypertriglyceridemia
 Heart failure, coronary heart disease and anginal pain,
stroke, and peripheral vascular insuficiency
 Anemia and fatigue (lack of energy and drive, apathy);
Epogen before treatment for the first 19 months
 Gastric ulcers and other GI problems
 Disturbed calcium metabolism leads to renal osteodystrophy
which produces bone pain and fractures
 Fluid overload, malnutrition, infection, neuropathy, and
pruritus
Hemodialysis
▫ Sleep problems
• Other complications:
▫ Hypotension (may occur during the treatment as fluid
is removed. Nausea, vomiting, diaphoresis,
tachycardia, and dizziness)
▫ Painful muscle cramping (may occur late in dialysis, as
f&e rapidly leave the extracellular space)
▫ Exsanguination (if blood lines separate or dialysis
needles become dislodged)
▫ Dysrrhythmias (electrolyte and ph changes)
▫ Chest pain (pts. With anemia or arteriosclerotic heart
dse)
Hemodialysis
▫ Dialysis disequilibrium
▫ results from cerebral fluid shifts. S&S: headache ,
nausea and vomiting, restlessness, decreased level of
consciousness, and seizures. More likely to occur in
acute renal failure or when blood urea nitrogen are
very high, e.g exceeding 150 mg/dl.
• Nursing management
▫ Constant monitoring of the dialysis, patient, dialyzer
and thee dialysate bath for clotting of the circuit, air
embolism, inadequate or excessive ultrafiltration,
blood leaks, contamination and access complications.
Hemodialysis
• Pharmacologic therapy
▫ Cardiac glycosides, antibiotic agents antiarrhythmic
medications, antihypertensive agents
▫ Antihypertensive taken before the treatment may
cause hypotension during dialysis.
▫ Metabolites of drugs bound to protein are not removed
during dialysis, removal depends on the weight and
suze of the molecule.
• Nutritional and fluid therapy
▫ Uremic symptoms or uremic syndrome
(accumulation of toxins in the serum)
Hemodialysis
▫ Goals : maintain good nutritional status through adequate
protein, calorie, vitamin and mineral intake, and to enable
patient to eat a palatable and enjoyable diet.
▫ Restricting dietary protein to reduce uremic symptoms and
decrease nitrogenous wastes
▫ Restriction of fluid
▫ Protein restriction : 1.2-1.3 g/kg/day ideal body weight per
day
▫ High biologic protein: eggs, meat, milk, poultry, and fish
▫ Sodium restriction: 2-3 g/kg/day
Urine output: 500 ml/day
▫ Goal weight gain: under 1.5 kg
▫ Potassium restriction: depends on the amount of residual
renal function and freq. of dialysis
Hemodialysis
Meeting Psychological Needs
 HD patients: Financial problems, diff. of holding a job,
waning sexual desire, depression from being chronically
ill, fear of dying, threatened family relationships, anger,
negative feelings, job insecurity, conflict and frustrations
 Counseling and psychotherapy
 Clinical nurse specialists, psychologists and social
workers can help
 Sense of loss
 Encourage to discuss end-of-life options
 Teaching must occur in brief as 10-15 minutes session
Hemodialysis
Continuous Renal Replacement Therapies
• Indicated for patients with acute or chronic renal
failure who are too critically unstable for traditional
hemodialysis; for pts. with fluid overload secondary
to oliguric ( low urine output ) renal failure and for
kidneys that cannot handle their acutely high
metabolic or nutritional needs.
• Hemofilter: extremely porous filter with
semipermeable membrane used in all methods.
• No rapid fluid shifts, does not require
dialysis machine personnel
Hemodialysis
Continuous Venovenous Hemofiltration (
CVVH)
• Used to manage acute renal failure
• Blood pumped at double lumen catheter through a
hemofilter and then returned to patient through
the same catheter
• Provides continuous slow fluid removal
(ultrafiltration)
• Mild hemodynamic effects and can be tolerated
• Does not require arterial access, critical care set up,
initiate, maintain and terminate system
Hemodialysis
Continuous Venovenous Hemodialysis
(CVVHD)
• Same with CVVH; uses double lumen catheter
• Uses concentration gradient to
facilitate the removal of uremic toxins
and fluid
• Effects: mild
Peritoneal Dialysis
• Goal: to remove toxic substances and metabolic
wastes and to re-establish normal F&E balance
• Treatment of choice for pts with renal failure who
are unable or unwilling to undergo HD or renal
transplantation
• For pts at risk for adverse effects of Heparin: with
DM, with heart dse
• Peritoneal membrane serves as the semipermeable
membrane
• Sterile dialysate fluid introduced at peritoneal cavity
at intervals
Peritoneal Dialysis
 Urea (cleared at 15-20 ml/min; creatinine is removed
at slower rate
 It takes 36-46 hours to achieve what HD
accomplishes in 6-8 hours
 Ultrafiltration (water removal) occurs at peritoneal
dialysis through osmotic gradient created by using
dialysis fluid with higher glucose concentration.
 Baseline vital signs, weight, and serum electrolyte
levels are recorded
 Encourage patient to empty the bladder and bowel to
reduce the risk of puncturing internal organs.
Peritoneal Dialysis
 Broad spectrum
prevent infection
antibiotic can be administered to

 Peritoneal catheter is to be inserted in the operation

room.
 Heparin may be added to the dialysate to prevent
fibrin formation and resultant occlusion of the
peritoneal catheter.
 Potassium chloride may be prescribed to prevent
hypokalemia.
 Antibiotics may be added to treat peritonitis
 Regular insulin may be added for patients with
diabetes, however, a larger than normal dose is
needed because about 10% of insulin binds to the wall
if the dialysate
 Aseptic technique is imperative
Peritoneal Dialysis
• Complications with long term PD:
▫ Abdominal hernias (incisional, abdominal,
inguinal, diaphragmatic and umbilical);
hiatal hernia and hemorrhoids
▫ Low back pain and anorexia from water in
the abdomen and a constant sweet taste
related to glucose absorption may also
occur.
▫ Formation of clots in the peritoneal
catheter and constipation
Peritoneal Dialysis
• Approaches:
▫ Acute intermittent peritoneal dialysis
▫ Continuous ambulatory peritoneal
dialysis (CAPD) and
▫ Continuous cyclic peritoneal dialysis
(CCPD)
Acute Intermittent PD
• Indications: a variation of PD include uremic
S&Sx (nausea, vomiting, fatigue, altered mental
stat)
• Fluid overload, acidosis, hyperkalemia
• Permits more gradual change in the patient’s fld.
Volume status and in waste product removal.
• Treatment of choice for hemodynamically
unstable pts
• Exchange time range: 30 minutes to 2 hours
Acute Intermittent PD
• Common routine: 10 mins – infusion ; 30
minutes dwell time; 20 minutes drain time
• Strict aseptic technique
• Warm, spike, hang each container of dialysate
• Monitor: v/s, weight, I&O, lab values, and
patient status
• Document at flow sheet: exchange, v/s, dialysate
concentration, medications, added exchange
vol., dwell time, dialysate fld. balance,
cumulative fld. balance
Acute Intermittent PD
• Assess skin turgor and mucous membranes to
evaluate fluid stat and monitor patient for
edema
• If unable to drain, turn patient from side to side
or elevate HOB
• Never push catheter further on peritoneal cavity
• Other measures to promote drainage: checking
patency of catheter for kinks, closed clamps or
air locks
Acute Intermittent PD
• Monitor complications:
▫ Peritonitis
▫ Bleeding
▫ Respiratory difficulty
▫ Leakage of peritoneal fluid
• Measure abdominal girth periodically to
determine if patient is retaining large amount of
dialysis solution
• Physical comfort measures:
▫ Turning and Skin care
Continuous Ambulatory PD
• CAPD
• Performed at home by the patient or by a trained
caregiver (can be a family member)
• Allows patient reasonable freedom and control
of daily activities
• Principle of peritoneal dialysis:
▫ Diffusion
▫ Osmosis
Continuous Ambulatory PD
• Procedure:
▫ Patient performs exchanges 4-5 times a day, 24
hours a day, 7 days a week @ intervals scheduled
throughout the day
▫ Fluid (effluent) drainage 20-30 minutes
▫ The longer the dwell time, the better the clearance
of middle-side molecules
▫ If dwell time is excessive, the patient absorbs
some of the effluent back into the body
Continuous Ambulatory PD
• Complications
• Nursing Management:
▫ Altered body image: waist size may increase from
1-2 inches or more in the abd.; group therapy
▫ Altered sexuality d/t presence of drain bag and
dialysate bag which contains 2 liters of dialysate
▫ Instruct patient to eat high protein, well-balanced
diet
▫ Increase fiber intake to prevent constipation
▫ Limit carbohydrate to avoid excessive weight gain
(usual wt. gain 3-5 lbs)
Continuous Ambulatory PD
• Potassium, Sodium and fluid restrictions are not
usually needed
• 2-3 Liters of fluid drainage in a 24 hour period,
permitting a normal fluid intake even in
anephric patients
• Assess for weight gain, peritonitis, treatment
related problems like heart failure, inadequate
drainage, weight gain or loss
Continuous Cyclic PD
• Combines overnight intermittent peritoneal
dialysis with prolonged dwell time during the
day
• Peritoneal catheter is connected to a cycler
machine every evening and the patient receives
three to five 2 to 3 L exchanges during the night
• In he morning patient caps off the catheter after
infusing 2-3L of fresh dialysate and remains
until the it is reattached to a recycler machine at
night time
Continuous Cyclic PD
• Has a lower infection rate than other forms of
peritoneal dialysis
• Allows patient to be free from exchanges
throughout the day, making it possible to engage
in work and ADLs freely
Protecting vascular access
• Assess for patency
• Avoid using area of vascular access for taking BP
or obtaining blood specimens, tight dressings,
restraints, or jewelry over the vascular access
must be avoided as well
• Evaluate bruit or thrill sound at least every 8
hours
• Absence may indicate blockage or clotting in
vascular access.
• Clotting can occur if patient has an infection
anywhere in the body (serum viscosity increases)
Protecting vascular access
• Clotting also occur if BP has dropped
• Clotting contributing factor: hypotension,
application of BP cuff or tourniquet
• Assess for signs and symptoms of infection
(redness, swelling, drainage from the exit site,
fever and chills)
• For IV therapy, rate of administration must be as
slow as possible and should be controlled by a
volumetric infusion pump
Detecting complications
• Cardiac and respiratory assessment must be
conducted frequently. As fluid builds up, fluid
overload, heart failure, and pulmonary edema
develop
• Crackles in the bases of the lungs indicate
pulmonary edema
• Pericarditis may result from accumulation of
uremic toxins (may progress to pericardial effusion
and cardiac tamponade)
• Pericarditis is detected by reports of substernal
chest pain, low grade fever, and pericardial friction
rub
Detecting complications
• Pulsus paradoxus ( a decrease in BP of more
than 10 mmhg during inspiration) is often
present in pericarditis.
• Heart sounds become distant and muffled, low
voltage of ECG, pulsus paradoxus worsens.
• Effusion may progress to life threatening cardiac
tamponade, noted by narrowing of the pulse
pressure in addition to muffle or inaudible heart
sounds, crushing chest pain, dyspnea and
hypotension
Managing Discomfort and Pain
• Pruritus and pain secondary to neuropathy:
antihistamine agents such as diphehydramine
hydrochloride (Benadryll) are commonly used
and analgesic medications may be prescribed
• Keep skin clean and well moisturized using bath
oils, superfatted soap and creams or lotions
helps promote comfort and reduce itching
• Keep nails trimmed
• Apply lotion to skin instead of scratching
Monitoring BP
• Hypertension is common in renal failure
• Result of fluid overload and in part of over
secretion of renin
• Antihypertensive therapy – must be withheld
before dialysis to avoid hypotension ue to the
combined effect of the dialysis and the
medication.
Preventing infection
• Low WBC count and decreased phagocytic
ability, low RBC counts (anemia) and impaired
platelet function
• Infection of the vascular site and pneumonia is
common.
Providing Psychological support
• Help them express their feelings and reacations,
explore options
• Patient’s informed decision about discontinuing
treatment, after thoughtful deliberation should be
respected
Caring for Catheter site
• Recommended 3-4 times weekly routine
catheter site care performed during showering
or bathing
• Most common cleaning method: soap and water,
liquid soap is recommended
Administering medications
• Scrutinized for potassium and magnesium
content (must be avoided)
Pharmacologic agents
Antihypertensive and Cardiovascular
agents

• Hypertension – manage by intravascular volume

control and a variety of antihypertensive agents
heart failure and pulmonary edema may also
require treatment with fluid restriction, low
sodium diets, diuretic agents, inotropic agents
(digoxin [Lanoxin] or dobutamine [Dobutrex])
Antiseizure agents
• Observe pt for abnormalities like slight
twitching, headache, delirium, or seizure activity
• Record onset of seizure with the type, duration
and general effect on the patient
• IV diazepam (Valium) or phenytoin (Dilantin)
• Side rails are usually raised and padded to
protect patient.
Erythropoietin
• Anemia asso. With chronic renal failure is
treated with recombinant human erythropoietin
(Epogen)
• Anemia (hct less than 30%) non specific
symptoms: malaise, general fatigability,
decreased activity tolerance.
• Administered Intravenously or subcutaneously
3x a week in ESRD. Takes 2-3 weeks for hct to
increase
Erythropoietin
• Adverse effects: hypertension, increased clotting
of vascular access sites, seizures and depletion of
body iron stores
• Influenza like symptoms with initiation of
therapy, tend to subside with repeated doses.
• Management involves adjustment of heparin to
prevent clotting lines during HD treatments
• Iron supplements: sucrose (Venofer), ferric
gluconate (Ferrlecit)
Erythropoietin
• Patient’s BP and serum K level are monitored to
detect hypertension and increasing serum
potassium levels.
• This therapy has decreased the need for
transfusion and its associated risks, including
blood borne infectious dse, antibody formation
and iron overload