Dialysis Study - Nursing PDF

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Type of Kidney Failure • Acute or AKI- a sudden episode or kidney failure or damage • Results from illness, injury, decreased perfusion • May or nay not require dialysis • Patient is often kept in the hospital and monitored closely for return of function • Ninety days is allotted for return of function before end-stage renal disease is diagnosed Causes of End-Stage Renal Disease (ESRD) • Diabetes • Hypertension • Glomerulonephritis • Other causes such as infection, stones, inherited disease autoimmune disease (lupus), birth defects, injury • AKI that does not recover function Dialysis • When kidney function goes below about 15%, kidney dialysis is necessary to clean the blood • Dialysis is a treatment to replace vital functions: removal of fluid and filtering of bodily toxins Types of Dialysis • Continuous Renal Replacement Therapy (CRRT) • Used for AKI as well as those not stable for hemodialysis • Done often in the ICU • Known as “Low and Slow” • Peritoneal Dialysis (PD) • Performed within the body • The peritoneal cavity in the abdomen helps dialysis solution called dialysate, and the peritoneum, the membrane around the cavity, acts as a filter • Great for children and needle phobia patients • Hemodialysis (3-4hrs, 4x/weeks) • A treatment that replaces kidney function • Hemodialysis is a therapy that filters waste, removes extra fluid and balances electrolytes (sodium, potassium, bicarbonate, chloride, calcium, magnesium, and phosphate) • Patient stops making urine Diffusion- Solvent moves by concentration gradient (higher to lower) Ultrafiltration- solution moves by pressure gradient (increased pressure to low)

Peritoneal Dialysis • Uses the highly vascular, semi permeable peritoneal membrane • Solution high in glucose is instilled, waste crosses through the membrane, left in until concentration on both sides is equal, and then drained

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Repeated over and over as directed by nephrologist • Can be done automatically in the night using a “cycler” Risk for infection (peritonitis) • Patient should wear a mask • Sterile procedure Benefits • This needle-free dialysis treatment uses the inner lining pf the abdomen to clean the blood • Flexible, easy treatment at home, work, or while on vacation • Peritoneal dialysis may help preserve remaining kidney function • More liberal diet/less fluid restrictions • Since this is perform everyday • Can eat more fruits and vegetables Disadvantages • Permanent abdominal catheter; appearance issues • No swimming in public pools/lakes • Done daily • Previous abdominal surgery can cause adhesions and PD is not an option • Not enough surface area of vascular membrane for waste diffusion to occur • High risk for infection

PD points to remember • Strict infection control • Effluent should always be clear; never cloudy nor fibrous (strands) • Should look like the color that went in or pale yellow • Contact physician if it ever doesn’t look right (signs of peritonitis) • If fluid will not drain properly, have the patient change positions • Remember most common reason of outflow problem is constipation! • Have to have regular bowl movements Hemodialysis • Blood is removed from the body and filtered through a man-made membrane called a dialyzer, or artificial kidney, and then the filtered blood is returned to the body • The average person has about 10 to 2 pints of blood; during dialysis only one pint (about two cups) is outside of the body at a time

The Dialyzer • The dialyzer is called the artificial kidney because it filters the blood- a job the kidneys used to do • A hollow plastic tube about a foot long and three inches in diameter contains many tiny filters • Two sections in the dialyzer, the section for dialysate and the section for the blood • A semipermeable membrane divides it. The membranes allows water and waste to pass through, but does not allow blood cells to pass through

Dialysate (bath) • Also called dialysis fluid, dialysis solution or bath • Pure water, electrolytes, and salts, such as bicarbonate and sodium • The dialysate has a low concentration of waste • The patient’s blood is high in waste • Can either remove or add electrolytes to the blood by diffusion Removing Blood • CVC- Central Venous Catheter (two weeks) • Usually placed emergently and temporarily into a large vessel in the neck or chest when a patient falls ill • High rate of infection • Tip of catheter sits in right atrium • #1 staph from skin travels to heart and gets endocarditis • Unable to get wet or shower • AVG (arteriovenous graft) • A piece of man-made tubing placed under skin that connects an artery to a vein • Can be transplanted animal (bovine) vessels or gortex • No not need time to mature • Higher rate of infection compare to AVF • Candidates • Diabetics, poor circulation, eldier that don’t have good native vessels • AVF (arteriovenous fistula) • A direct connection between an artery and a vein, essentially creating a “super vein” • Requires time to mature and grow to size • 6-8weeks before cannulation • Considered the “gold standard” and preferred access • Use a rope ladder technique for access • Nursing consideration: body image

Bruit & Thrill • “Hear” the bruit • The “whooshing” sound heard with a stethoscope over the fistula/graft • Changes in pitch could represent narrowing/stenosis • “Feel” the thrill • The “buzzing” vibration felt with the fingers over the fistula/graft • Absence means the access is “clotted” Prior to Treatment • Labs are review to determine what electrolytes needs removal or replacement (K+, Ca+, CO2, BNP: indicator of congestive heart failure, are the primary monitored lab values) • BNP: good indicator of how quickly pt needs dialysis • The patient is weighed are assessed for signs and symptoms of fluid overload

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• Edema, crackles at bases, SOB The access is assess for signs and symptoms of infections and or dysfunction

Cannulation • Two needles are used each treatment • One (the red arterial) removes the “dirty” blood and takes it to the machine • The other (blue venous) returns the “clean” blood back to the patient • Average gauge needle is 15 but start out with a 17g • Need to keep arm completely still over infiltration can occur During Treatment • Vitals are monitored every 15-30mins as well as pressure reading inside the access • Average treatment is between 3-4 hours (3/week) • Fluid and waste are emptied into a drain behind the machine • Access remain visible at all times to be access for bleeding or needle dislodgment • Blood is monitored for air to prevent embolism • Heart is monitored for changes and or abnormal cardiac rhythms Common Meds • Heparin- given to prevent clotting in the extra corporeal circuit (aka the lines/tubing) • Venofer- Iron sucrose • Without adequate iron, Epogen will not work • Epogen- erythropoietin hormone, stimulate the bone marrow to produce red blood cells • Hecterel or Zemplar- synthetic vitamin D that helps to control high levels or parathyroid hormone (PTH) • Albumin- given IV to help “shift or pull” fluid back into the blood from swollen tissues • For low hypotensive patients • Blood transfusions- noncompliant patient or just had surgery • Various IV antibiotics- Vanco, Ancef, Gent • Immunocompromised when in ESRD • Given last hour of dialysis so they are not washed not After Treatment • Needles are removed and most patients hold sited for 10-15 minutes • CVCs are dwelled with heparin or saline • Bandages are applies and removed within hours or by the next day • Post vitals are obtained and an assessment is done. Weight is taken determine if the “dry weight” was achieved • Dry weight that doctor determines by the lungs being cleared, no peripheral edema, BP being in a normal range Potential Complications • Hypotension • Pulling fluid out too fast • Eating on the dialysis machine • In order to digest food blood is rushing to the stomach • To connect this give saline

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Syncope Vomiting- Eating Headaches- Fluid shift and electrolyte changes Muscle Cramping- Removing Fluid Cardiac arrest/death Air embolism • Patient grabs chest and panicked look • Intervention: left side Trendelenburg DDS (Dialysis Disequilibrium Syndrome) • Rare problem that occur in new patient and children that consists or irritability, confusion, blurred vision, seizures, and even death • Often happens with a BUN >100 (uremic state) • From correcting electrolytes abnormalities too rapidly, too fast

Additional therapy for ESRD • Transplant • Younger and healthier patients • You keep the defective kidney and the new one is transplanted in the middle • Transplant is not a cure or a kidney disease; only a treatment • You will have ESRD you entire life • Can get you off dialysis • Same meds you take to prevent rejection and nephrotoxic

Limb Alert • Place upon admission • No BP or IV • Do not position the patient on that arm Phosphorus Binders • Phosphorus is too big to cross the dialysis membrane • Calcium Acetate • Given with meals Foods • Encourage whole grains • Plain Stroman white bread is best • Be careful with dairy, nuts, beans Fluid Restriction • If patient drinks too much will lead to left ventricular hypotrophy and CHF • Encourage only 1500cc of fluid per day • Of all liquid sources...