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Definition
Dialysis is a treatment that takes over the job of the kidneys when they
fail. Most patients begin dialysis when their kidneys have lost 85%-90% of their
ability. Dialysis will continue for the rest of their lives (or until they receive a
kidney transplant). This is called end-stage renal disease (ESRD).
ESRD is caused by conditions such as diabetes, kidney cancer, drug use,
high blood pressure, or other kidney problems. Dialysis is not a cure for ESRD. It
helps you feel better and live longer. It may also be used to treat patients with
edema that does not respond to treatment, hepatic coma, hyperkalemia,
hypercalcemia, hypertension, and uremia. The need for dialysis may be acute or
chronic.
Acute Dialysis is indicated when there is a high and rising level of serum
potassium, fluid overload, or impending pulmonary edema, increasing acidosis,
pericarditis and severe confusion. It may also be used to remove certain
medications or other toxins from the blood.
Prior to Procedure
Hemodialysis
• Weight, blood pressure, and temperature are taken
• Topical anesthetic (a pain numbing medicine) is applied to the arm for
needle insertion
• Heparin (a medication that prevents blood clotting) is given
Peritoneal Dialysis
Before the first treatment, the physician places a small, soft tube
(approximately 24 inches long) in the abdomen. This tube will remain there
permanently. A portion of the tube remains outside the body for use in the
process. It is important to keep this access clean and dry to prevent infection.
Anesthesia
For hemodialysis: topical anesthetic
After Procedure
Your blood pressure will be monitored.
Pain
In general, dialysis procedures do not cause pain. You will not feel the
blood exchange. There may be some temporary discomfort with the insertion of
the needle or tube.
Possible Complications
• Anemia
• Drop in blood pressure during dialysis
• Muscle cramps
• Nausea, vomiting
• Headaches
• Infection
• Feeling hot, sweaty, weak, and/or dizzy
• Peritonitis (infection of the peritoneum), which causes fever and stomach
pain (peritoneal dialysis only)
• Growth problems in children
• Inflammation of the heart sac (pericarditis)
• Neurologic problems
• Disruption of calcium and phosphorus balance, resulting in weakened
bones
Postoperative Care
Once the procedure is complete and blood pressure is stable, you are free
to continue daily activities. There are some special considerations:
Dietary Guidelines
Certain dietary guidelines should be followed. This will help to keep overall
health and optimize the treatment. Patients who have peritoneal dialysis may
have slightly fewer dietary restrictions than hemodialysis patients. This is due to
the more frequent filter schedule. Talk to your doctor about your specific dietary
needs.
Medications
Your doctor may give various types of medication. These include, but are not
limited to
• Blood pressure medications
• Calcium supplements or multivitamins
• Phosphorus binders—to lower phosphorus levels in the blood
• Diuretics—to remove excess fluid
• Stool softeners or laxatives—to prevent or treat constipation, which can be
caused by decreased fluid intake
• Iron supplements—to increase iron intake, which is important for
production of red blood cells
Outcome
Dialysis helps maintain blood pressure, cleaning of the blood, and
chemical and hormonal exchanges that are critical to survival.
You can remove some potassium from potatoes by soaking them in water.
Phosphorus. The mineral phosphorus can weaken your bones and make
your skin itch if you consume too much. Control of phosphorus may be even
more important than calcium itself in preventing bone disease and related
complications. Foods like milk and cheese, dried beans, peas, colas, nuts, and
peanut butter are high in phosphorus and should be avoided. You’ll probably
need to take a phosphate binder with your food to control the phosphorus in
your blood between dialysis sessions.
Salt (sodium chloride). Most canned foods and frozen dinners contain
high amounts of sodium. Too much of it makes you thirsty, and when you drink
more fluid, your heart has to work harder to pump the fluid through your body.
Over time, this can cause high blood pressure and congestive heart failure. Try
to eat fresh foods that are naturally low in sodium, and look for products labeled
“low sodium.”
Protein. Before you were on dialysis, your doctor may have told you to
follow a low-protein diet to preserve kidney function. But now you have different
nutritional priorities. Most people on dialysis are encouraged to eat as much
high-quality protein as they can. Protein helps you keep muscle and repair
tissue, but protein breaks down into urea (blood urea nitrogen, or BUN) in your
body. Some sources of protein, called high-quality proteins, produce less waste
than others. High-quality proteins come from meat, fish, poultry, and eggs.
Getting most of your protein from these sources can reduce the amount of urea
in your blood.
Calories. Calories provide your body with energy. Some people on dialysis
need to gain weight. You may need to find ways to add calories to your diet.
Vegetable oils—like olive, canola, and safflower oils—are good sources of
calories and do not contribute to problems controlling your cholesterol. Hard
candy, sugar, honey, jam, and jelly also provide calories and energy. If you have
diabetes, however, be very careful about eating sweets. A dietitian’s guidance is
especially important for people with diabetes.
Supplements. Vitamins and minerals may be missing from your diet
because you have to avoid so many foods. Dialysis also removes some vitamins
from your body. Your doctor may prescribe a vitamin and mineral supplement
designed specifically for people with kidney failure. Take your prescribed
supplement after treatment on the days you have hemodialysis. Never take
vitamins that you can buy off the store shelf, since they may contain
vitamins or minerals that are harmful to you.
Hemodialysis
Blood is filtered through an artificial kidney machine, called a dialyzer. The
blood travels from the body to the machine through tubes inserted into a vein in
your arm, leg, or neck. An access site called a fistula or shunt may be surgically
created in one of your veins.
Fistulas may need as long as 2 to 3 months to fully heal before they can be
used. They are never used if the treatment is temporary. They are typically
created many months before dialysis is begun.
Hemodialysis is usually done at a dialysis center or hospital. It may be
done at home with assistance. It is usually done three times a week. Each
treatment lasts from two to four hours.
For this treatment, there needs to be a site where the blood is taken out of
the body and then returned to the blood stream. This is called an access. After
the access is made and healed, 2 needles are inserted into the access. One
needle draws the blood out and the other needle returns the blood to the body.
Access Sites
There are three main types of access sites.
• AV Fistula – With minor surgery, an artery is joined to a vein under the skin.
This is most often done in an arm.
• Graft – With minor surgery, a soft plastic tube is used to join the artery and
vein under the skin.
• A central catheter – For temporary dialysis, the doctor can put in a catheter in
a large vein, most often in the neck.
Indications
1. Chronic Renal Failure
2. Unstable overdose patient of Unknown Ingestion
1. General
1. Low protein binding
2. Small volumes of distribution
3. Water solubility
4. Low Molecular weight
2. Specific (Mnemonic: I STUMBLED)
1. Isopropanol
2. Salicylates
3. Theophylline, Tenormin (Atenolol)
4. Uremia
5. Methanol
6. Barbiturates (e.g. Phenobarbital)
7. Lithium
8. Ethylene Glycol
9. Depakote (esp. if level >500)
Principles of Hemodialysis
The objectives of hemodialysis are to extract toxic nitrogenous substances
from blood and remove excess water. Diffusion, osmosis and ultrafiltration are
the principle on which hemodialysis is based.
Vascular Access
Subclavian, internal, jugular and femoral catheters
Fistula is created surgically usually in the forearm by joining anastomosing
an artery to a vein, either side to side or end to side.
Graft in arteriovenous graft can be created by subcutaneously internally
positioning a biologic, semibiologic, or synthetic graft material between
artery and vein.
Dialysis Machine
The dialysis machine is about the size of a dishwasher. This machine has three
main jobs:
• pump blood and watch flow for safety
• clean wastes from blood
• watch your blood pressure and the rate of fluid removal from your body
Dialyzer
Peritoneal Dialysis
The abdominal lining is called the peritoneal membrane. In this type of
treatment it is used to filter blood instead of a machine. A cleansing solution,
called a dialysate, is inserted into your abdomen. Fluid, wastes, and chemicals
pass from the tiny blood vessels in the peritoneal membrane into the dialysate.
It is then drained after several
hours. New dialysate can then be added to repeat the process. A port in the
abdomen may be needed for long-term treatment.
Principles
- The peritoneum is the dialyzing membrane (SP membrane) and substitutes for
kidney function during kidney failure.
- The peritoneal dialysis works on the principles of diffusion and osmosis, the
dialysis occurs via the transfer of fluid and solute from the bloodstream through
the peritoneum.
- The peritoneal membrane is large and porous, allowing solutes and fluid to
move via an osmotic gradient from an area of higher concentration in the body
to an area of lower concentration in the dialyzing fluid.
- The peritoneal cavity is rich in capillaries; therefore it provides a ready access
to blood supply.
Nursing Objectives
a. To restore and maintain fluid and electrolyte balance and preserve renal
function if possible.
b. To prevent complication of therapy.
Indications
a. Acute renal failure
b. Severe fluid overload in pediatric cardiac patients
c. To remove toxic and metabolic wastes
Dialysate Solution
1. Solution is sterile
2. Solution contains electrolytes and minerals, a specific osmolarity,a specific
glucose concentration, and other medication additives prescribed.
3. The higher glucose concentration, the greater the amount of fluid removed
during an exchange.
4. Increasing the glucose concentration increases the concentration of active
particles that cause osmosis and increases the rate of UF and the amount of fluid
removed.
5. If hyperkalemia is not a problem, potassium may be added to each bag of
solution.
6. Heparin is added to the dialysate solution to prevent clotting of the catheter.
7. Prophylactic antibiotics may be added to dialysate to prevent peritonitis.
8. Insulin may be added to the dialysate for the client with diabetes mellitus.
Equipments Used
1. Dialysis administration set
2. Local anesthesia
3. Warmer
4. Tube clamps
5. Tenchkoff peritoneal catheter (adult - standard and curled)
6. Trocath peritoneal catheter (pediatric)
7. PD solution as prescribed
8. Supplemental drugs
9. CVP monitoring equipment
10. Sterile gloves
11. Skin antiseptic
12. ECG monitoring
13. Suture set
14. IV stand
Characteristics Of Outflow
a. During the first or initial exchanges, the outflow may be bloody; outflow
should be clear and colorless thereafter.
b. A brown outflow indicates bowel perforation.
c. If the outflow is the same color as urine, this indicates bladder perforation.
d. Cloudy outflow indicates peritonitis.
CAPD
How CAPD Works
Continuous ambulatory peritoneal dialysis (CAPD) involves instilling
2 to 3 liters (quarts) of fluid at a time into the person's abdominal (or
"peritoneal") cavity through a flexible plastic catheter that is implanted in the
abdominal wall [Figure 3]. The fluid is allowed to remain in the abdominal
cavity for a period of hours, gradually absorbing waste products and toxins
from the body; it is then drained out and replaced with fresh fluid.
This procedure of fluid exchange is performed by the patient, and is
done 4-5 times a day, 7 days a week. The procedure involves careful use of
sterile technique and constant monitoring of blood pressure, fluid volumes,
and weights, so many patients are not able to perform this type of dialysis. A
variation on this procedure is dialysis with a cycler, in which the patient
performs one or two fluid exchanges daily, as described above, and then
hooks up to an automatic cycler, which performs several more exchanges
during the night as the patient sleeps.
Advantages of CAPD
Flexibility in Schedule - Although CAPD requires a great deal of work on
the part of the patient, patients who have the manual dexterity and ability to
learn the procedure and the ability to be compulsive about record keeping
and sterile technique find that this type of dialysis gives them more flexibility
of schedule and greater freedom to work, go to school, and be active in
general.
Flexibility in Diet - CAPD also allows a more liberal diet than hemodialysis,
because fluid and potentially harmful substances (such as potassium, salt,
and protein) are continuously removed by dialysis as they are eaten, and thus
do not accumulate in harmful or dangerous amounts.
Dialysis
Submitted by:
Jessa A. Urriza
BSN IV- A
Submitted to:
Mrs. Elenita Carandang