Dialysis

Dialysis

•(from Greek dialusis,"", meaning dissolution, dia, meaning through, and lysis, meaning loosening or splitting)

• is a process for removing waste and excess water from the blood and is used primarily as an artificial replacement for lost kidney function in people with kidney failure.

Purpose of Dialysis

•is used to remove fluid and uremic waste products from the body when the kidneys cannot do so.

• It may also be used to treat patients with edema that does not respond to treatment, hepatic coma, hyperkalemia, hypercalcemia, hypertension, and uremia.

Indications for Dialysis •The need for dialysis may be acute or chronic. 1. Acute dialysis is indicatedA.when there is a high and rising level of serum potassium, fluid overload, or impending pulmonary edema, increasing acidosis, pericarditis, and severe confusion.

B.to remove certain medications or other toxins (poisoning or medication overdose) from the blood.

2. Chronic or maintenance dialysis is indicated in chronic renal failure, known as end-stage renal disease (ESRD

Two main types of dialysis

1. Hemodialysis 2. Peritoneal Dialysis

Peritoneal Dialysis

•wastes and water are removed from the blood inside the body using the peritoneum as a natural semipermeable membrane.

•Wastes and excess water move from the blood, across the peritoneal membrane, and into a special dialysis solution, called dialysate, in the abdominal cavity

Types of peritoneal dialysis

•The first is manually through continuous ambulatory peritoneal dialysis (CAPD).

•The second is automatically through automated peritoneal dialysis (APD) which uses a cycler machine at night while the patient sleep.

1. CAPD is "continuous," machine-free and done while you go about your normal activities such as work or school. You do the treatment by placing about two quarts of cleansing fluid into your belly and later draining it. This is done by hooking up a plastic bag of cleansing fluid to the tube in your belly. Raising the plastic bag to shoulder level causes gravity to pull the fluid into your belly. When empty, the plastic bag is removed and thrown away.

When an exchange (putting in and taking out the fluid) is finished, the fluid (which now has wastes removed from your blood) is drained from your belly and thrown away.

This process usually is done three, four or five times in a 24-hour period while you are awake during normal activities. Each exchange takes about 30 to 40 minutes. Some patients like to do their exchanges at mealtimes and at bedtime.

2. APD differs from CAPD in that a machine (cycler) delivers and then drains the cleansing fluid for you. The treatment usually is done at night while you sleep.

Indications for Peritoneal Dialysis•Peritoneal dialysis may be the

treatment of choice for patients with renal failure who are unable or unwilling to undergo hemodialysis or renal transplantation.

•patients with diabetes or cardiovascular disease,

•many older patients, and those who may be at risk for adverse effects of systemic heparin

Procedure for Peritoneal dialysisPREPARING THE PATIENT . 1. The nurse explains the procedure to the

patient and obtains signed consent for it.

2. Baseline vital signs, weight, and serum electrolyte levels are recorded.

3. The patient is encouraged to empty the bladder and bowel to reduce the risk of puncturing internal organs.

4. Broad-spectrum antibiotic agents may be administered to prevent infection.

Procedure for Peritoneal dialysis

PREPARING THE EQUIPMENT (apply Strict Aseptic technique )

1. Consults the physician to determine the concentration of dialysate to be used and the medications to be added to it. (Heparin , Potassium chloride , Antibiotics’ Insulin) .

2. Before medications are added, the dialysate is warmed to body temperature to prevent patient discomfort and abdominal pain and to dilate the vessels of the peritoneum to increase urea clearance. Solutions that are too cold cause pain and vasoconstriction and reduce clearance. Solutions that are too hot burn the peritoneum.

3. Assemble the administration set and tubing. Fill the tubing with the prepared dialysate to reduce the amount of air entering the catheter and peritoneal cavity, which could increase abdominal discomfort and interfere with instillation and drainage of the fluid.

INSERTING THE CATHETER • Ideally, the peritoneal catheter is inserted

in the operating room to maintain surgical asepsis and minimize the risk of contamination. In some circumstances, however, the physician inserts the catheter at the bedside under strict asepsis.

PERFORMING THE EXCHANGE (1 to 4 hours, depending on the prescribed dwell time. )• Peritoneal dialysis involves a series of

exchanges or cycles which is repeated throughout the course of the dialysis which is based on the patient’s physical status and acuity of illness.

• An exchange is defined as the infusion, dwell, and drainage of the dialysate.

INFUSION : The dialysate is infused by gravity into the peritoneal cavity for a period of about 5 to 10 minutes to infuse 2 L of fluid. DWELL: (equilibration time) allows diffusion and osmosis to occur. (peaks in the first 5 to 10 minutes )

DRAINAGE • The tube is unclamped and the solution drains

from the peritoneal cavity by gravity through a closed system (10 to 30 minutes).

• The drainage fluid is normally colorless or straw-colored and should not be cloudy. Bloody drainage may be seen in the first few exchanges after insertion of a new catheter but should not occur after that time.

• The removal of excess water during peritoneal dialysis is achieved by using a hypertonic dialysate with a high dextrose concentration that creates an osmotic gradient ( Dextrose solutions of 1.5%, 2.5%, and 4.25%).

NURSING RESPONSIBILITY Predialysis Care• Document vital signs including temperature, orthostatic blood pressures (lying, sitting, and standing), apical pulse, respirations, and lung sounds. These baseline data help assess fluid volume status and tolerance of the dialysis procedure. Hypertension, abnormal heart or lung sounds, or dyspnea may indicate excess fluid volume. Poor respiratory function may affect the ability to tolerate peritoneal

dialysis. Temperature measurement is vital, because infection is the most common complication of peritoneal dialysis.

• Weigh daily or between dialysis runs as indicated. Weight is an accurate indicator of fluid volume status.

• Note BUN, serum electrolyte, creatinine, pH, and hematocrit levels prior to peritoneal dialysis and periodically during the procedure. These values are used to assess the efficacy of treatment.• Measure and record abdominal girth. Increasing abdominal girth may indicate retained dialysate, excess fluid volume, or early peritonitis.• Maintain fluid and dietary restrictions as ordered. Fluid and diet

restrictions help reduce hypervolemia and control azotemia.• Have the client empty the bladder prior to catheter insertion. Emptying

the bladder reduces the risk of inadvertent puncture.• Warm the prescribed dialysate solution to body temperature (98.6° F or

37° C) using a warm water bath or heating pad on low setting. Dialysate is warmed to prevent hypothermia.

• Explain all procedures and expected sensations. Knowledge helps reduce anxiety and elicit cooperation.

Intradialysis Care•Use strict aseptic technique during the dialysis procedure and when caring for the peritoneal catheter. Peritonitis is a

common complication of peritoneal dialysis; sterile technique reduces the risk.

•Add prescribed medications to the dialysate; prime the tubing with solution and connect it to the peritoneal catheter, taping connections securely and avoiding kinks. This allows dialysate to flow freely into the abdominal cavity and prevents leaking or

contamination.

•Instill dialysate into the abdominal cavity over a period of approximately 10 minutes. Clamp tubing and allow the dialysate to remain in the abdomen for the prescribed dwell time. Keep drainage tubing clamped at all times during instillation and dwell time.

Dialysate should flow freely into the abdomen if the peritoneal catheter is patent. Dialysis, the exchange of solutes and water between the blood and dialysate, occurs across the peritoneal membrane during the dwell time.

values are used to assess the effectiveness of dialysis• Troubleshoot for possible problems during dialysis. a. Slow dialysate instillation. Increase the height of the container and reposition the client. Check tubing and catheter for kinks.

Check abdominal dressing for wetness, indicating leakage around the catheter. Slow dialysate flow may be related to a partially obstructed tube or catheter.

b. Excess dwell time. Prolonged dwell time may lead to water depletion or hyperglycemia.c. Poor dialysate drainage. Lower the drainage container,

reposition, check for tubing kinks. Check abdominal dressing. Tubing or catheter obstruction can also interfere with dialysate drainage.

Postdialysis Care•Assess vital signs, including temperature. Comparison of

preand postdialysis vital signs helps identify beneficial and adverse effects of the procedure.

•Time meals to correspond with dialysis outflow. Scheduling

meals while the abdomen is empty of dialysate enhances intake and reduces nausea.

•Teach the client and family about the procedure. The client

may elect to use peritoneal dialysis at home to manage endstage renal disease and prevent uremia.

Complications of Peritoneal Dialysis• PERITONITIS (inflammation of the peritoneum) is the

most common and most serious complication; characterized by cloudy dialysate drainage, diffuse abdominal pain, and rebound tenderness.

• LEAKAGE of dialysate through the catheter site may occur immediately after the catheter is inserted

• BLEEDING - common during the first few exchanges after a new catheter insertion because some blood exists in the abdominal cavity from the procedure.

LONG-TERM COMPLICATIONS • Hypertriglyceridemia ; abdominal hernias (incisional,

inguinal, diaphragmatic, and umbilical), hemorrhoids.

Reference: Brunner and Suddarth’s Medical surgical Nursing 10th Edition

Thank You

BY: LIBBY HARRY