dialysis

SHEILA A. ARAOBSN- IV; SET-2

DIALYSIS

Dialysis - from Greek "dialusis", meaning dissolution, "dia", meaning through, and "lysis", meaning loosening

-is a process for removing waste and excess water from the blood, and is primarily used to provide an artificial replacement for lost kidney function in people with renal failure.-may be used for those with an : -acute disturbance in kidney function- acute

kidney injury, previously acute renal failure)-chronic kidney disease stage 5- progressive but chronically worsening kidney function– (previously chronic renal failure or end-stage kidney disease)

- a procedure that is a substitute for many of the normal duties of the kidneys. - can allow individuals to live productive and useful lives, even though their kidneys no longer work adequately

Purpose Dialysis is most commonly prescribed for patients with temporary or permanent

kidney failure. People with end-stage renal disease (ESRD) have kidneys that are no longer capable

of adequately removing fluids and wastes from their body or of maintaining the proper level of certain kidney-regulated chemicals in the bloodstream.

For these individuals, dialysis is the only treatment option available outside of kidney transplantation . Dialysis may also be used to simulate kidney function in patients awaiting a transplant until a donor kidney becomes available.

Also, dialysis may be used in the treatment of patients suffering from poisoning or overdose in order to quickly remove drugs from the bloodstream.

When do patients require dialysis?

Patients usually require dialysis when the waste products in their body become so high that they start to become sick from them. The level of the waste products usually builds up slowly. Doctors measure several blood chemical levels to help decide when dialysis is necessary. The two major blood chemical levels that are measured are the "creatinine level" and the "blood urea nitrogen" (BUN) level. As these two levels rise, they are indicators of the decreasing ability of the kidneys to cleanse the body of waste products.

Doctors use a urine test, the "creatinine clearance," to measure the level of kidney function. The patient saves urine in a special container for one full day. The waste products in the urine and in the blood are estimated by measuring the creatinine. By comparing the blood and urine level of this substance, the doctor has an accurate idea of how well the kidneys are working. This result is called the creatinine clearance. Usually, when the creatinine clearance falls to 10-12 cc/minute, the patient needs dialysis.

The doctor uses other indicators of the patient's status to decide about the need for dialysis. If the patient is experiencing a major inability to rid the body of excess water, or is complaining of problems with the heart, lungs, or stomach, or difficulties with taste or sensation in their legs, dialysis may be indicated even though the creatinine clearance has not fallen to the 10-12 cc/minute level.

Starting indications

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Indications for dialysis in the patient with acute kidney injury are:o Metabolic acidosis in situations where correction with sodium bicarbonate is

impractical or may result in fluid overload.o Electrolyte abnormality, such as severe hyperkalemia, especially when

combined with AKI.o Fluid overload not expected to respond to treatment with diuretics.o Complications of uremia, such as pericarditis, encephalopathy, or

gastrointestinal bleeding.o Intoxication, that is, acute poisoning with a dialyzable substance. These

substances can be represented by the mnemonic SLIME: salicylic acid, lithium, isopropanol, Magnesium-containing laxatives, and ethylene glycol.

Chronic indications for dialysis:o Symptomatic renal failureo Low glomerular filtration rate (GFR) (RRT often recommended to commence at a GFR of less than 10-15 mls/min/1.73m2). In diabetics dialysis is started earlier.o Doo ifficulty in medically controlling fluid overload, serum potassium, and/or serum phosphorus when the GFR is very low

2 types of dialysis:

1. Hemodialysis-uses a special type of filter to remove excess waste products and water from the body.

-three primary methods are used to gain access to the blood: intravenous catheter- sometimes called a CVC (Central Venous Catheter)

-consists of a plastic catheter with two lumens (or occasionally two separate catheters) which is inserted into a large vein (usually the vena cava, via

the internal jugular vein or the femoral vein) to allow large flows of blood to be withdrawn from one lumen, to returned via the other lumen.

2 types ofcatheter:- Non-tunnelled catheter access is for short-term

access (up to about 10 days, but often for one dialysis session only), and the catheter emerges from the skin at the site of entry into the vein.

- Tunnelled catheter access involves a longer catheter, which is tunnelled under the skin from the point of insertion in the vein to an exit site some distance away. It is usually placed in the internal jugular vein in the neck and the exit site is usually on the chest wall. The tunnel acts as a barrier to invading microbes, and as such, tunnelled catheters are designed for short- to medium-term access (weeks to months only), because infection is still a frequent problem.- Complication: Infection

Stenosis

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arteriovenous (AV) fistula- recognized as the preferred access method.

- To create a fistula, a vascular surgeon joins an artery and a vein together through anastomosis. Since this bypasses the capillaries, blood flows rapidly through the fistula. One can feel this by placing one's finger over a mature fistula. This is called feeling for "thrill" and produces a distinct 'buzzing' feeling over the fistula. One can also listen through a stethoscope for the sound of the blood "whooshing" through the fistula, a sound called bruit.

- In can be at : -hand- 'snuffbox' fistula' - forearm- usually a radiocephalic

fistula, or so-called Brescia-Cimino fistula

- elbow- brachiocephalic fistula - Complication: Steal syndrome

synthetic graft- The graft usually is made of a synthetic material, oftenPTFE, but sometimes chemically treated, sterilized veins from animals are used. Grafts are inserted when the patient's native vasculature does not permit a fistula.

- Complications: -thrombosis - blot clotting - infection

-Types of Hemodialysis: Conventional hemodialysis/ Chronic hemodialysis

-is usually done three times per week, for about 3–4 hours for each treatment, during which the patient's blood is drawn out through a tube at a rate of 200-400 mL/min. -The tube is connected to a 15, 16, or 17 gauge needle inserted in the dialysis fistula or graft, or connected to one port of a dialysis [[catheter] without needles]. -The blood is then pumped through the dialyzer, and then the processed blood is pumped back into the patient's bloodstream through another tube (connected to a second needle or port).- During the procedure, the patient's blood pressure is closely monitored, and if it becomes low, or the patient develops any other signs of low blood volume such as nausea, the dialysis attendant can administer extra fluid through the machine. -During the treatment, the patient's entire blood volume (about 5000 cc) circulates through the machine every 15 minutes. During this process, the dialysis patient is exposed to a weeks worth of water for the average person.

Daily hemodialysis - is typically used by those patients who do their own dialysis at home. It is less stressful (more gentle) but does require more frequent access. -This is simple with catheters, but more problematic with fistulas or grafts. -The "buttonhole technique" can be used for fistulas requiring frequent access. Daily hemodialysis is usually done for 2 hours six days a week.

Nocturnal hemodialysis

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- the procedure of nocturnal hemodialysis is similar to conventional hemodialysis except it is performed six nights a week and six-ten hours per session while the patient sleeps.

-Advantages of Hemmodialysis- Low mortality rate- Better control of blood pressure and abdominal cramps- Less diet restriction- Better solute clearance effect for the daily hemodialysis: better .tolerance and fewer complications with more frequent dialysis

- Disadvantages of Hemodialysis- Restricts independence, as people undergoing this procedure cannot travel around because of supplies’ availability- Requires more supplies such as high water quality and electricity- Requires reliable technology like dialysis machines- The procedure is complicated and requires that care givers have more knowledge- Requires time to set up and clean dialysis machines, and expense with machines and associated staff

- For this procedure, the patient has a specialized plastic tube placed between an artery and a vein in the arm or leg (called a "gortex graft"). Sometimes, a direct connection is made between an artery and a vein in the arm. This procedure is called a "Cimino fistula." Needles are then placed in the graft or fistula, and blood passes to the dialysis machine, through the filter, and back to the patient. In the dialysis machine, a solution on the other side of the filter receives the waste products from the patient.-The clinical benefits of dialyzing 5 to 7 times a week, for 6 to 8 hours. This type of hemodialysis is usually called "nocturnal daily hemodialysis", which a study has shown a significant improvement in both small and large molecular weight clearance and decrease the requirement of taking phosphate binders. These frequent long treatments are often done at home while sleeping, but home dialysis is a flexible modality and schedules can be changed day to day, week to week. In general, studies have shown that both increased treatment length and frequency are clinically beneficial

- Uses1. Short term therapy in acutely ill clients2. Long term use in clients with end-stage renal disease

- Hemodialysis requires five things:1. Access to patient’s circulation (usually via fistula)2. Access to a dialysis machine and dialyzer with a semipermeable membrane

3. The appropriate solution (dialysate bath)4. Time: 12 hours each week, divided in 3 equal segments5. Place: home (if feasible) or a dialysis center

- Contraindications: great caution in malignant tumors haemophilia hemiplegia prolonged internal bleeding.

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2. Peritoneal dialysis- uses a fluid that is placed into the patient's stomach cavity through a special plastic tube to remove excess waste products and fluid from the body.

- The intestines lie in the abdominal cavity, the space between the abdominal wall and the spine. A plastic tube called a "dialysis catheter" is placed through the abdominal wall into the abdominal cavity. A special fluid is then flushed into the abdominal cavity and washes around the intestines. The intestinal walls act as a filter between this fluid and the blood stream. By using different types of solutions, waste products and excess water can be removed from the body through this process.

- Purpose : o Aid in the removal of toxic substances and metabolic

wastes.o Establish electrolyte balance.o Remove excesses body fluid. o Assist in regulating the fluid balance of the body.o Control blood pressure.o Control severe, intractable heart

-types of Peritoneal Dialysis:A. Continuous Ambulatory Peritoneal Dialysis (CAPD).

o CAPD is the most common type of peritoneal dialysis. o It needs no machine. It can be done in any clean, well-lit

place. o With CAPD, your blood is always being cleaned. o The dialysate passes from a plastic bag through the

catheter and into your abdomen. o The dialysate stays in your abdomen with the catheter

sealed. After several hours, you drain the solution back into the bag.

o Then you refill your abdomen with fresh solution through the same catheter. Now the cleaning process begins again. While the solution is in your body, you may fold the empty plastic bag and hide it under your clothes, around your waist, or in a pocket.

B. Continuous Cyclic Peritoneal Dialysis (CCPD). o CCPD is like CAPD except that a machine, which

connects to your catheter, automatically fills and drains the dialysate from your abdomen. The machine does this at night while you sleep.

C. Intermittent Peritoneal Dialysis (IPD).o IPD uses the same type of machine as CCPD to add and

drain the dialysate. o IPD can be done at home, but it’s usually done in the

hospital. o IPD treatments take longer than CCPD.

- The Time It Takes:o With CAPD, the dialysate stays in your abdomen for about 4

to 6 hours. The process of draining the dialysate and replacing fresh solution takes 30 to 40 minutes. Most people change the solution four times a day.

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o With CCPD, treatments last from 10 to 12 hours every night.

o With IPD, treatments are done several times a week, for a total of 36 to 42 hours per week. Sessions may last up to 24 hours.

-Indications:o Acute renal failureo Chronic renal failureo Removal of dialyzable poisons and drugso Metabolic abnormalitieso Refractory congestive heart failure and pulmonary edemao Peritoneal lavageo Detection of intraperitoneal haemorrhageo Temperature regulation

-Contraindications:o Abdominal wound or infectiono Peritonitiso Abdominal diseaseo Fecal fistula or colostomyo Gastric or diaphragmatic herniao Extensive adhesions from previous surgery

-Advantages of peritoneal dialysiso Treatment at home, which means no need to go for

hemodialysis unit 3 times a week.o Self control of the therapyo No needles requiredo Better preservation of the remaining kidney function, which

is very important because Peritoneal dialysis helps removing the water and the waste products. This reduces the need for a high dose of dialysis, and also improves patients’ survival and their quality of life.

o Lower doses of medication needed to treat anemia developed because of kidney failure.

o Lower risk for hepatitis B and C (liver infections caused by virus)

o Better results after kidney transplantation, are the advantages of peritoneal dialysis.

-Complication of Peritoneal dialysiso Peritonitis-inflammation of the peritoneum may occur with

the recurrent procedureo Leakage of dialysate through catheter siteo Bleeding from the site of procedure,o Hyper triglyceridemia abdominal hernias may develop.

3. Hemofiltration- is a similar treatment to hemodialysis, but it makes use of a different principle. The blood is pumped through a dialyzer or "hemofilter" as in dialysis, but no dialysate is used. A pressure gradient is applied; as a result, water moves across the very permeable membrane rapidly, "dragging" along with it many dissolved substances, importantly ones with large molecular weights, which are cleared less well by hemodialysis. Salts and water lost from the blood during this process are replaced with a "substitution fluid" that is infused into the extracorporeal

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circuit during the treatment. Hemodiafiltration is a term used to describe several methods of combining hemodialysis and hemofiltration in one process.

4. Hemodialfiltration- is a combination of hemodialysis and hemofiltration. In theory, this technique offers the advantages of both hemodialysis and hemofiltration.

5. Intestinal dialysis- the diet is supplemented with soluble fibres such as acacia fibre, which is digested by bacteria in the colon. This bacterial growth increases the amount of nitrogen that is eliminated in fecal waste. An alternative approach utilizes the ingestion of 1 to 1.5 liters of non-absorbable solutions of polyethylene glycol or mannitol every fourth hour.

FOR HEMODIALYSIS

Equipment and Procedures

1. 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

2. Dialyzer

- is a large canister containing thousands of small

fibers through which your blood is passed.

- Dialysis solution, the cleansing fluid, is pumped

around these fibers.

- The fibers allow wastes and extra fluids to pass

from your blood into the solution, which carries

them away.

- The dialyzer is sometimes called an artificial

kidney.

Reuse. Your dialysis center may use the same dialyzer more than once for your treatments. Reuse is considered safe as long as the dialyzer is cleaned before each use. The dialyzer is tested each time to make sure it's still working, and it should never be used for anyone but you. Before each session, you should be sure that the dialyzer is labeled with your name and check to see that it has been cleaned, disinfected, and tested.

3. Dialysis Solution

- Dialysis solution, also known as dialysate

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- Is the fluid in the dialyzer that helps remove wastes and extra fluid from your

blood.

- It contains chemicals that make it act like a sponge.

4. Needles

- Many people find the needle sticks to be one of the hardest parts of

hemodialysis treatments. Most people, however, report getting used to

them after a few sessions. If you find the needle insertion painful, an

anesthetic cream or spray can be applied to the skin. The cream or

spray will numb your skin briefly so you won't feel the needle.

- Most dialysis centers use two needles-one to carry blood to the dialyzer

and one to return the cleaned blood to your body.

- Some specialized needles are designed with two openings for two-way

flow of blood, but these needles are less efficient and require longer

sessions.

- Needles for high-flux or high-efficiency dialysis need to be a little larger

than those used with regular dialyzers.

Tests to See How Well Your Dialysis Is Working

The doctor will order for a:

- Blood Urea Nitrogen or BUN

- Creatine clearance test

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Both tests look at one specific waste productas an indicator for the overall level of

waste products in your system.

Procedure for hemodialysis

1. Patient’s circulation is accessed

2. Unless contraindicated, heparin is administered

3. Heparinized (heparin: natural clot preventer) blood flows through a semipermeable

membrane in one direction

4. Dialysis solution surrounds the membranes and flows in the opposite direction

5. Dialysis solution is:

a. Highly purified water

b. Sodium, potassium, calcium, magnesium, chloride and dextrose

c. Either bicarbonate or acetate, to maintain a proper pH

6. Via the process of diffusion, wastes are removed in the form of solutes (metabolic

wastes, acid-base components and electrolytes)

7. Solute wastes can then be discarded or added to the blood

8. Ultrafiltration removes excess water from the blood

9. After cleansing, the blood returns to the client via the access

Complications related to vascular access in Hemodialysis

1. Infection

2. Catheter clotting

3. Central venous thrombosis

4. Stenosis or thrombosis

5. Ischemia of the affected limb

6. Development of an aneurysm

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Nursing interventions for Hemodialysis

1. Explain procedure to client

2. Monitor hemodynamic status continuously

3. Monitor acid-base balance

4. Monitor electrolytes

5. Insure sterility of system

6. Maintain a closed system

7. Discuss diet and restrictions on:

a. Protein intake

b. Sodium intake

c. Potassium intake

d. Fluid intake

8. Reinforce adjustment to prescribed medications that may be affected by

the process of hemodialysis

9. Monitor for complications of dialysis related to:

a. Arteriosclerotic cardiovascular disease

b. Congestive heart failure

c. Stroke

d. Infection

e. Gastric ulcers

f. Hypertension

g. Calcium deficiencies (bone problems such as aseptic necrosis of the

hip joint)

h. Anemia and fatigue

i. Depression, sexual dysfunction, suicide risk

Complications during hemodialysis

1. Dysequilibrium syndrome

- Rapid removal of urea from blood.

- Reverse osmosis, with water moving into brain cells.

2. Cerebral edema

- Possible headache, nausea, vomiting, confusion, and convulsions; usually

occurs with initial dialysis treatments

- Shorter dialysis time and slower rate minimizes.

3. Hypotension

- Results from excessive ultrafiltration or excessive antihypertensive

medications.

4. Hypertension

- Results from fluid volume overload (water and/or sodium), causing

disequilibrium syndrome or anxiety.

5. Arrhythmias

- Due to hypotension and rapid removal of potassium.

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How Diet Can Help

1. Fluids.

- Your dietitian will help you determine how much fluid to drink each day.

- Extra fluid can raise your blood pressure, make your heart work harder, and

increase the stress of dialysis treatments.

- Remember that many foods-such as soup, ice cream, and fruits-contain plenty

of water.

2. Potassium. - The mineral potassium is found in many foods, especially fruits and

vegetables- To control potassium levels in your blood, avoid foods like oranges,

bananas, tomatoes, potatoes, and dried fruits.

3. Phosphorus. - The mineral phosphorus can weaken your bones and make your skin itch if

you consume too much. - Foods like milk and cheese, dried beans, peas, colas, nuts, and peanut

butter are high in phosphorus and should be avoided.

4. Protein. - Before you were on dialysis, your doctor may have told you to follow a low-

protein diet to preserve kidney function. - 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.

5. 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. - 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.

FOR PERITONEAL DIALYSIS

Peritoneal dialysis may be the better option if:- You can't tolerate the rapid changes of fluid balance associated with

hemodialysis. - During hemodialysis, your blood is pumped into a machine to be filtered

and then returned to your body.- You want to minimize the disruption of your daily activities and work or

travel more easily

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Peritoneal dialysis might not work for you if:- You have extensive surgical scars in your abdomen- You have a limited ability to care for yourself or lack caregiving support at

home- You have inflammatory bowel disease or frequent bouts of diverticulitis

Equipments of peritoneal dialysis :

Dialysis solution - 2 liter bags (Stay-Safe solution with pre-attached tubing) Transfer set (if applicable) Stay-Safe Smart Cap (if applicable) Peritoneal Dialysis (PD) Flowsheet IV pole Stay-Safe Cap Stay-Safe organizer Peritoneal Dialysis Scale Mask Medication additive label (if applicable) CAPD warmer Betadine (if adding meds) Tubing to catheter adapter (if applicable; used if tubing brand differs from catheter

brand. In emergency situations, adapters are also available in the Hemodialysis Unit.)

Procedure:1. Obtain doctor’s orders for solution, additives, dwell time, drainage time,

frequency of exchanges. Gather all supplies needed for the exchange. 2. Have patient empty bladder. If new onset of inability to void, notify doctor. 3. Place solution in CAPD warmer (37oC) to achieve body temperature. Place solution in the warmer 30 to 90 minutes prior to commencing procedure to assure optimum temperature of fluid (37o C). Use only dry heat to warm. Do NOT warm solution in the microwave. 4. If initiating dialysis for the first time, weigh patient prior to beginning CAPD exchange. For established dialysis patients, weigh patient after draining and before filling (dry weight) procedure. If daily weights are ordered, weigh at the same time each day after complete drainage. 5. Weight recorded must be a dry weight. 6. Assess abdomen for bowel distention, skin integrity and S/S of local infection. Notify doctor for any changes. With bowel distention there is an increased risk of bowel perforation. Local infections may be easily transmitted to the peritoneum via the catheter. 7. Obtain and record vital signs.

INITIATION OF DIALYSIS: 1. Remove the appropriate dialysate bag from the CAPD warmer, and place it on a

clean towel on the patient’s bedside table. The CAPD warmer is not always located in the patient’s room; some units have a designated location for the warmer.

2. A simple check should be made of the following points: a. Proper Dextrose strength and amount of solution b. Proper labelling; expiration date c. CAPD warmer temperature d. Level of solution in each bag/appearance of solution (clarity) e. Maintenance of aseptic technique f. Inspect bag for leaks

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3. Put on mask. Have patient put on mask. Scrub hands thoroughly with Disinfectant soap4. Put on non sterile gloves. Sterile gloves are not necessary unless you will actually be touching the catheter tip5. If medications/additives are ordered, cleanse additive port of dialysate bag and

medication port with betadine swab. Allow to dry for 5 minutes. Inject prescribed medication into dialysate bag and label properly. Some additives may be high alert medications and may require a double check.

6. Verify that a transfer set is on the catheter. If not, apply a transfer set using aseptic technique. CLOSE the extension set clamp. Patients who typically use Baxter supplies at home will need a transfer set. Attach Smart-Cap per Smart-Cap transfer procedure and attach

7. Find the Stay-Safe disc (on the dialysate bag/tubing) with the colored plastic cover. Turn the blue dial on the disc counter-clockwise until it fits into the cut-out portion of the plastic cover.

8. Remove the plastic cover after the dial is in the cut-out. The Blue dial will be at Position 1 (•).

9. Position the organizer at the edge of the work surface or on the IV pole. Place the disc into the organizer.

10. Hang the dialysate solution bag on an IV pole and place the drain bag on a clean chux or towel on the floor. Break the frangible in the solution bag outlet port. Breaking the frangibles will permit the fluid to flow.

11. Remove the Stay-Safe cap from its package and place the cap in one of the two notches in the bottom-front of the organizer.

12. Place the end of the patient’s extension set in the other organizer notch. 13. Remove the protective cap from the Stay-Safe disc. Discard the cap. Use care

not to contaminate the end of the transfer set. 14. Unscrew the extension set from its cap - the cap will remain in the organizer. If

the extension set is contaminated, a tubing change must be done. 15. Immediately connect the extension set to the Stay-Safe disc. After making this

connection you may remove your mask. 16. OPEN the clamp on the extension set. Fluid will start to drain from the patient as

soon as the clamp is opened. This will begin the drain phase. Take note of the time the drain phase started, and record this on the peritoneal dialysis flowsheet.

17. Check the drain bag to make sure there is fluid in it. 18. When the drain is complete, turn the dial to Position 2 (••). Make sure the

line/tubing from the solution bag to the disc fills completely. 18. Record on the peritoneal diaylsis flowsheet the time the drain phase was completed. This is also the time to obtain the patient’s “dry” weight” (after drain but before fill).

19. After about 5 seconds, turn the dial to Position 3 (•••). This will start the fill into the abdomen. Record on the peritoneal dialysis flowsheet the time The fill phase was initiated. This will help ensure accurate time for dwelling in the peritoneal cavity.

20. When draining has stopped, and filling has begun, weigh the drainage bag on the peritoneal dialysis scale. This is “volume out”- on the peritoneal dialysis flowsheet.

21. If the physician order is for any amount less than the full 2000 ml bag of dialysate: a. Close the white clamp on the transfer set. b. Turn the dial to Position 3 (•••). If no sample is needed then run excess volume into the drain bag prior to beginning fill. When bag is weighed, subtract excess volume. If a sample is needed then the nurse will need to monitor the volume infused while standing at the bedside, ensuring that the patient only gets the volume ordered.

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c. Allow the excess dialysate (the amount greater than what was ordered) to drain into the drain bag. d. Once excess fluid is removed from the fill bag, turn dial back to the 1st position (•) unlock white clamp on transfer set, then turn dial to the 3rd (•••) position to allow abdominal filling.

22. When the fill is complete, turn the dial to the very end of Position 4 (••••). This will insert the closure pin from the disc into the end of the extension set. You will feel a “click” when you get to the last position. 23. CLOSE the extension set clamp. 24. Unscrew the protective cover from the new Stay-Safe Cap. See step 10 above. 25. Unscrew the extension set from the disc- IMMEDIATELY attach the extension set to the new Stay-Safe cap. 26. Remove the capped extension set from the organizer and secure to the patient’s

abdomen. 27. Place the protective cover from the new Stay-Safe cap on the used cap. Then remove the cap from the organizer and connect the other end of the protective cover to the disc to prevent drips. 28. If not done earlier in the exchange (step #19), weigh and record the volume of solution drained using the peritoneal dialysis scale. 29. Empty the drain bag into the toilet. Follow Universal Precautions. 30. Discard used supplies and record the exchange on the flowsheet: Volume In: (bags are 2,000 ml but doctor order may be for a smaller volume) Volume Out: This will be blank for the first exchange. Additives: Medications or electrolytes. Balance: Patient is in negativebalance when outflow exceeds inflow for the complete exchange. Patient is in positive balance when outflowis less than inflow for that exchange. Used supplies should be discarded in a biohazardous container. 31. Second exchange: repeat steps and continue per LIP order for frequency.Record 24 hour cumulative balances on the peritoneal dialysis flowsheet. Draw a line separating each 24 hour balance. Begin a new 24 hour cumulative balance very day with the first exchange after midnight.

Nursing Considerations:

Patient Preparation:

Allow the client to void before catheter insertion.

Institute abdominal skin preparation

Document the client’s weight before the dialysis

Take baseline vital signs

During the Procedure:

Monitor the level of electrolytes.

Obtain samples of return dialysate for culture

Compare the client’s weight before and after the procedure

Monitor the vital signs every 30 minutes and report any deviations

Provide proper positioning for the dialysate to return from the peritoneal

cavity. Place the patient in semi-Fowler’s position.

Possible complications of peritoneal dialysis:

Peritonitis

Respiratory difficulty

Hypertension

Pulmonary edema

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Hyperglycemia

Hyperosmolar coma

Intestinal perforation

Aftercare

Both hemodialysis and peritoneal dialysis patients need to be vigilant about keeping their access sites and catheters clean and infection-free during and between dialysis runs.

Dialysis is just one facet of a comprehensive treatment approach for ESRD. Although dialysis treatment is very effective in removing toxins and fluids from the body, there are several functions of the kidney it cannot mimic, such as regulating high blood pressure and red blood cell production. Patients with ESRD need to watch their dietary and fluid intake carefully and take medications as prescribed to manage their disease.

Risks

Many of the risks and side effects associated with dialysis are a combined result of both the treatment and the poor physical condition of the ESRD patient. Dialysis patients should always report side effects to their healthcare provider.

Anemia-Hematocrit (Hct) levels, a measure of red blood cells, are typically low in ESRD patients. This deficiency is caused by a lack of the hormone erythropoietin, which is normally produced by the kidneys. The problem is elevated in hemodialysis patients, who may incur blood loss during hemodialysis treatments. Epoetin alfa, or EPO (sold under the trade name Epogen), a hormone therapy, and intravenous or oral iron supplements are used to manage anemia in dialysis patients.

Cramps, nausea, vomiting, and headaches-Some hemodialysis patients experience cramps and flu-like symptoms during treatment. These can be caused by a number of factors, including the type of dialysate used, composition of the dialyzer membrane, water quality in the dialysis unit, and the ultrafiltration rate of the treatment. Adjustment of the dialysis prescription often helps alleviate many symptoms.

Hypotension-Because of the stress placed on the cardiovascular system with regular hemodialysis treatments, patients are at risk for hypotension, a sudden drop in blood pressure. This can often be controlled by medication and adjustment of the patient's dialysis prescription.

InfectionBoth hemodialysis and peritoneal dialysis patients are at risk for infection. Hemodialysis patients should keep their access sites clean and watch for signs of redness and warmth that could indicate infection. Peritoneal dialysis patients must follow the same precautions with their catheter. Peritonitis, an infection of the peritoneum, causes flu-like symptoms and can disrupt dialysis treatments if not caught early.

Infectious diseases

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Because there is a great deal of blood exposure involved in dialysis treatment, a slight risk of contracting hepatitis B and hepatitis C exists. The hepatitis B vaccination is recommended for most hemodialysis patients. As of 2001, there has only been one documented case of HIV being transmitted in a United States dialysis unit to a staff member, and no documented cases of HIV ever being transmitted between dialysis patients in the United States. The strict standards of infection control practiced in modern hemodialysis units minimizes the chance of contracting one of these diseases.

Test What it Means Normal Levels

Serum Creatinine

Creatinine is a waste product that is made when your body breaks down protein you eat and when muscles are injured. A high serum (blood) creatinine level means kidney damage. Creatinine levels may vary somewhat, even when the kidneys work normally. So, your doctor should check your level more than once before diagnosing CKD. Creatinine levels tend to be higher in men and people with large muscles. Measuring creatinine is only the first step to finding your level of kidney function.

The normal serum creatinine range for men is 0.5-1.5 mg/dL. The normal range for women is 0.6-1.2 mg/dL.

Creatinine Clearance

Creatinine clearance is a test sometimes used to estimate filtering capacity of the kidneys. The amount of creatinine in your urine is compared to the amount of creatinine in your blood. Your doctor may test your urine by asking you to collect your urine for 24 hours in a special container.

Normal creatinine clearance for healthy men is 97-137 mL/min. Normal creatinine clearance for healthy women is 88-128 mL/min.

Glomerular Filtration Rate (GFR)

GFR is a more accurate way to measure how well your kidneys filter wastes from your blood. Your GFR gives your doctor an idea of the speed at which your kidneys are failing, and whether you are at risk for complications of kidney disease. GFR can be estimated from serum creatinine, using a formula.

Healthy adults have a GFR of about 140*; normal is greater than 90. Children and the elderly usually have lower GFR levels. A GFR less than 15 is kidney failure.

*GFR is reported in mL/min/1.73 m2.

Urine Albumin Inside healthy kidneys, tiny filtering units called nephrons filter out wastes but keep in large molecules, like red blood cells and albumin (protein). Some kidney

In a 24-hour urine sample, a normal level is less than 30 mg/day.

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diseases damage these filters so albumin and other proteins can leak into the urine. Protein—albumin—in the urine can be a sign of kidney disease. Albumin can be measured with a urine dipstick or a 24-hour urine collection to find out how much protein is "spilling" into the urine. Albumin levels can increase with heavy exercise, poor blood sugar control, urinary tract infections, and other illnesses.

Microalbuminuria

Microscopic amounts of protein too small to be measured with a standard dipstick test can be an early sign of kidney disease—especially in people with diabetes. Special dipsticks or laboratory tests can find microalbuminuria. The American Diabetes Association guidelines recommend that anyone with type 1 or type 2 diabetes have a test for microalbuminuria at least yearly.

Urine in healthy people contains less than 150 mg/L of albumin.

Blood Urea Nitrogen (BUN)

Blood Urea Nitrogen (BUN) is another measure of wastes (urea) in the blood. Urea is produced from the breakdown of protein already in the body and protein in your diet. A high BUN usually means that kidney function is less than normal, but other factors may affect the BUN level. Bleeding in the intestines, congestive heart failure, and certain medications may make the BUN higher than normal. As BUN rises, symptoms of kidney disease may appear, such as a bad taste in the mouth, poor appetite, nausea, and vomiting. In dialysis, BUN is used to measure whether a person is receiving the correct amount of dialysis. Sometimes a low BUN may also mean that you are not eating enough protein.

The normal BUN level for healthy individuals is 7-20 mg/dL in adults, and 5-18 mg/dL in children.

Patients on dialysis have higher BUNlevels, usually 40-60 mg/dL. The nephrologist (kidney doctor) and dietitian will help determine whether the BUN is in the correct range.

Measures of Anemia


Hematocrit (Hct)

Hematocrit is the percentage of red blood cells in the blood, used to check for anemia. Anemia—a shortage of oxygen-carrying red blood cells—often begins at the early

The normal Hct level for healthy individuals is 40-50% for men and 36-44%

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stages of kidney disease. It causes severe fatigue, heart damage, and other health problems. Anemia can be treated.

for women.

Hemoglobin (Hgb)

Hemoglobin is the part of red blood cells that actually carries oxygen. Both hematocrit and hemoglobin levels are measured to check for anemia.

The normal Hgb level for healthy individuals is 14 to 18 g/dL for men and 12 to 16 g/dL for women.

Measures of Diabetes Control


Hemoglobin A1c (HbA1c)

The HbA1c measures your blood sugar control over the last 3 months. According to the National Diabetes Education Program, people with diabetes should have their HbA1c tested at least once every 6 months.

The goal is to keep your HbA1c less than 6.5%.

Glucose Glucose is blood sugar. It is measured to determine if your body is able to digest and use sugar and carbohydrates correctly. Although high blood glucose levels are mainly found in diabetics, some medications can raise your blood glucose level. Diabetes is diagnosed if the non-fasting blood glucose is higher than 200 mg/dL.

Normal (fasting) glucose levels are 65-110 mg/dL. In people with diabetes, the blood glucose goal before eating is 80-120 mg/dL. After eating, the blood glucose goal is 100-140 mg/dL.

Measures of Nutrition


Serum Albumin

The level of albumin (protein) in the blood is a measure of good nutrition. Research shows that people with kidney disease who become malnourished and do not get enough protein may suffer from many complications. It is especially important for people on low protein diets to have their serum protein levels measured.

Normal serum albumin levels in healthy people are 3.6-5.0 g/dL. The goal for people on dialysis is an albumin level greater than 4.0 g/dL

http://www.lifeoptions.org/kidneyinfo/labvalues.phphttp://nursing.uchc.edu/nursing_standards/docs/Peritoneal%20Dialysis.pdfhttp://en.wikipedia.org/wiki/Dialysishttp://www.surgeryencyclopedia.com/Fi-La/Kidney-Dialysis.htmlhttp://www.esrdnet17.org/Patients/chooseperitoneal.pdfhttp://www.mayoclinic.com/health/peritoneal-dialysis/MY00282

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http://www.mayoclinic.com/health/peritoneal-dialysis/MY00282

http://www.esrdnet17.org/Patients/chooseperitoneal.pdf

http://www.surgeryencyclopedia.com/Fi-La/Kidney-Dialysis.html

http://en.wikipedia.org/wiki/Dialysis

http://nursing.uchc.edu/nursing_standards/docs/Peritoneal%20Dialysis.pdf

http://www.lifeoptions.org/kidneyinfo/labvalues.php