HEMODIALYSIS

OVERVIEW

Haemodialysis is a procedure done to artificially cleanse the blood of a person

when the kidney is already impaired and loses its function in a form known as end stage
renal failure to perform its vital functions mainly detoxifications of our blood and have it
excreted by our body as waste products. It is the most common form of dialysis done for
patients acutely ill and requires short term dialysis such as in cases of fluid retention,
drug overdose, and other physiologic problems and in long term or permanent therapy
for ESRD. Haemodialysis thought to prevent death for patient with ERSD but does not
cure renal disease and does not compensate for the loss of endocrine and metabolic
activities of the kidney. Every session of treatment has duration of 3 to fours. A dialyzer
serves as a synthetic semi permeable membrane, replacing the renal glomeruli and
tubules as the filter for the impaired kidneys.

PRINCIPLES OF HEMODIALYSIS

The main objectives of haemodialysis are to extract nitrogenous substances from

the blood and to remove excess water.

The principles behind hemodialysis are diffusion, osmosis, and ultrafiltration.

The toxins and waste in the body is removed by diffusion in manner of from an area of
higher concentration in the blood to an area of lower concentration in the dialysate.
Excess water removed from the body by osmosis in which water moves from an area of
higher solute concentration (the blood) to an area of lowere solute concentration (the
dialysate bath). Ultrafiltration is defined as water moving under high pressure to an area
of lower pressure.

The body’s buffer system is main tained using a dialysate bath made up of
bicarbonate or acetate, which is metabolized to form bcarbonate. Anticoagulant heparin
is administered to keep blood from clotting in the dialysis circuit. Cleanse blood is then
returned to the body.
VASCULAR ACCESS

SUBCLAVIAN, INTERNAL, JUGULAR, AND FEMORAL CATHETERS (central

venous catheter)

It is an access directly to the patients circulation for acute hemodialysis, it

is achieve by inserting a double lumen or multi lumen catheter. It can only be used for
only a short period of time when other types of vascular accsess is temporarily un
usable. Hematoma, pneumothorax, infection, thrombosis, and in adequate blood flow
are the common complications.

AV FISTULA

A more permanent access created surgically by joining an artery to a vein,

either side to side or end to side. The arterial segment of the fistula is used for arterial
flow and the venous segment for reinfusion of the dialyzed blood. The fistula takes 4 to
6 weeks to mature and can used for dialysis.

GRAFT

An arteriovenous graft that can be created subcutaneously interposing a

biologic, semibiologic, or synthetic graft material between an artery and vein. Graft is
created when when the patient vessel are not suitable for a fistula (patients w/
compromised vascular systems). Infection and thrombosis are the most common
complications.

COMPLICATIONS

 Hypotension may occur during the treatment as fluid is removed.

 Painful muscle cramping may occur, usually late in the dialysis as fluid and
electrolytes rapidly leave the extracellular space.
 Exsanguination may occur if blood lines separate or dialysis needles are
accidentally become dislodge.
 Dysrhytmias may result from electrolyte and pH changes or from removal of anti
arrhythmic medications during dialysis.
 Air embolism is rare but can occur if air enters the vascular syatem
  Chest pain may occur in patients with anemia atherosclerotic heart disease
 Dialysis disequilibrium results from cerebral fluid shifts. Signs and symptoms
include headache, nausea and vomiting, restlessness, decreased LOC and
seizures.

NURSING DIAGNOSES
Risk for infection related to presence of accsess to circulatory system.
Decreased cardiac output related to decreased circulatory volume.
Anxiety related to presence of chronic condition.
Altered nutrition less than body requirements related to intake restriction

NURSING MANAGEMENT
 Have the patient lie on bed after haemodialysis to prevent hypotension,
light-headedness and dizziness.
 Observe aseptic technique in caring for the vascular access to prevent
infection.
 Monitor body weight to assess for any fluid retention.
 Offer psychologically family support
 Dietary low in Sa, k, fat, protein, and high in calcium
 Fluid restriction since the kidney doesn’t secrete excess fluid
 Monitor vital signs
 Assess for fluid retention
 Assess for venous site for redness and swelling
 Check for audible sign and palpable thrill in the AV fistula and graft
PHARMACOLOGIC TREATMENT
Protamine sulphate – antidote for heparin
Epogen – a synthetic erythropoietin
Blood Pressure medications
Calcium supplements and multivitamins
Phosphorus binders – to lower phosphorus levels in the blood
Diuretics – to remove excess body fluids
 Stool softeners and laxatives – to prevent and treat constipation, which can be
caused by decreased fluid intake.
Iron supplements – to increase iron intake which is important for production of
red blood cell.
LABORATORY EXAMINATION
CBC – to evaluate RBC, hct, hgb count
BUN, creatinine, serum potassium, phosphorus – to evaluate level in the blood
and serve as basis for efficacy of hemodialysis.

PERITONEAL DIALYSIS
OVERVIEW
 The goal of peritoneal dialysis are to remove toxic substance and metabolic
waste and to re-establish normal fluid and electrolyte balance. Peritoneal dialysis
maybe the treatment of choice for patients with renal failure who are unable to unwilling
to undergo hemodialysis and kidney transplantation. Patients who are susceptible to the
rapid F/E and metabolic changes that occur during hemodialysis experiences fewere of
these condition with the slower rate of peritoneal dialysis. The more likely to be the
candidate for peritoneal dialysis are those diadetic and have cardiovascular disease
patients, at risk for the adverse effects of systemic heparin.

Type of Peritoneal Dialysis

 Continuous Ambulatory Peritoneal Dialysis (CAPD)

If you choose CAPD, you’ll drain a fresh bag of dialysis solution into your abdomen.
After 4 to 6 or more hours of dwell time, you’ll drain the solution, which now contains
wastes, into the bag. You then repeat the cycle with a fresh bag of solution. You don’t
need a machine for CAPD; all you need is gravity to fill and empty your abdomen. Your
doctor will prescribe the number of exchanges you’ll need, typically three or four
exchanges during the day and one evening exchange with a long overnight dwell time
while you sleep.

 Continuous Cycler-Assisted Peritoneal Dialysis (CCPD)

CCPD uses an automated cycler to perform three to five exchanges during the night
while you sleep. In the morning, you begin one exchange with a dwell time that lasts the
entire day.

 Nocturnal Intermittent- uses the same type of machine as CCPD. This requires
assistance and is usually done at a hospital or center. It often takes longer than
CCPD.

Preventing Problems

Infection is the most common problem for people on PD. Your health care team will
show you how to keep your catheter bacteria-free to avoid peritonitis, which is an
infection of the peritoneum. Improved catheter designs protect against the spread of
bacteria, but peritonitis is still a common problem that sometimes makes continuing PD
impossible. You should follow your health care team’s instructions carefully, but here
are some general rules:Store supplies in a cool, clean, dry place. Inspect each bag of
solution for signs of contamination before you use it. Find a clean, dry, well-lit space to
perform your exchanges. Wash your hands every time you need to handle your
catheter. Clean the exit site with antiseptic every day. Wear a surgical mask when
performing exchanges.

Keep a close watch for any signs of infection and report them so they can be
treated promptly. Here are some signs to watch for:Fever Nausea or vomiting Redness
or pain around the catheter unusual color or cloudiness in used dialysis solution a
catheter cuff that has been pushed out.

Purposes of Peritoneal dialysis

 Aid in the removal of toxic substances and metabolic wastes.

 Establish electrolyte balance.
 Remove excesses body fluid.
 Assist in regulating the fluid balance of the body.
 Control blood pressure.
 Control severe, intractable heart failure when diuretics no longer promote
elimination of water and sodium.

Indication for Peritoneal Dialysis

 Acute renal failure.
 Severe fluid overload in pediatric cardiac patients
 To remove toxic and metabolic wastes.

Contraindication for Peritoneal Dialysis

 Abdominal wound or infection
 Peritonitis
 Abdominal disease
 Fecal fistula or colostomy
  Gastric or diaphragmatic hernia
 Extensive adhesions from previous surgery.
Complication:
 Peritonitis
 Bleeding
 Leakage
 Metabolic disturbances
 Cardio- respiratory problem
INTERVENTIONS BEFORE TREATMENT
 a. Monitor VS.
 b. Obtain Weight.
 c. Have the client void, is possible.
INTERVENTIONS DURING TREATMENT
 a. Monitor VS.
 b. Monitor signs of infection.
 c. Monitor for respiratory distress, abdominal pain
 or discomfort.
 Respiratory Distress:
 - Slow inflow rate
 - Prevent air from entering peritoneum by keeping
 drip chamber of tubing three quarters full of fluid.
 - Elevate head of bed, encourage deep breathing
 exercises
 - Turn patient side to side
 - Reduce the volume administered
 Abdominal Pain:
 - Encourage patient to move about if ambulatory
 d. Monitor signs of pulmonary edema.
 e. Monitor for hypotension and hypertension
 f. Monitor for malaise, nausea, vomiting.
 g. Assess the catheter site dressing for wetness or
 bleeding.
 Leaks:
 - Change the dressings frequently, being careful not to
 dislodge the catheter
 - Use sterile drapes to prevent contamination
 h. Monitor dwell time to extend beyond the
 physician’s order because this increases risk of
 hyperglycemia.
 i. Turn the client from side to side if the outflow is
 slow to start. Elevate head of bed at intervals.
 j. Monitor outflow, which should be continuous
 stream after the clamp is opened.
 k. Monitor outflow for color and clarity.
 l. Monitor intake and output accurately.
 m. If outflow is less than the inflow, the difference
 is equal to the amount absorbed or retained by
 the client during dialysis and should be counted
 as intake.
 Keep accurate records:
 - Exact time of beginning and end of each exchange
 - Amount of solution infused and recovered
 - Fluid balance
 - No. of exchanges
 - Medications added to dialyzing solution
 - Pre and Post dialysis weight plus daily weight
 - Level of responsiveness at beginning, throughout, and
 at the end of the treatment
 - Assessment of VS and patient’s condition