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University of Santo TomasCollege of Nursing

AY 2012-2013 1st SemesterNCM-106 Skills Laboratory

Hemodialysis and Peritoneal Dialysis

I. HEMODIALYSIS

Definition:- A kind of renal replacement therapy that is warranted when the kidneys can no longer remove wastes,

maintain electrolytes, and regulate fluid balance.

Purposes of Hemodialysis- Removes toxic nitrogenous substances from the blood- Remove excess water- Maintain or restore electrolyte levels- Cleanses the blood of accumulated waste products

Indications:- Acutely ill patients requiring short-term dialysis - Over dosage of medications or toxins from blood - Edema and fluid overload that does not respond to other treatment- Hepatic coma, hyperkalemia, hypercalcemia, uremic symptoms - Patients with advanced CKD and ESRD

Principles in Hemodialysis- Diffusion

o Toxins and wastes in the blood are removed by this principle from a higher concentration in the blood to an area of lower concentration in the dialysate

- Osmosiso Excess water is removed from the blood by this principle in which water moves from an area of low

concentration (blood) to an area of high concentration (dialysate bath)- Ultrafiltration

o Water moves under high pressure to an area of lower pressure. It is much more efficient than osmosis at water removal and is accomplished by applying negative pressure or a suctioning force to the dialysis membrane.

o This force is necessary to remove fluid to achieve fluid balance

The following are needed for hemodialysis:- Dialyzer

o Referred to as an artificial kidneyo Serves as a synthetic semipermeable membrane. It allows toxins, fluid, and electrolytes to pass

through. However, it impedes the diffusion of large molecules, such as RBCs and proteins.o Types:

Flat-plate or parallel flow-plate dialyzer Has two or more layers of semipermeable membrane, bound by a semigrid or rigid

structure. Hollow-fiber dialyzer

The most common type of dialyzer which contains fine capillaries, with a semipermeable membrane enclosed in a plastic cylinder.

- Dialysate o Solution made up of water and all important electrolytes in their ideal extracellular concentrations. o The electrolyte level in the patient’s blood can be brought under control by properly adjusting the

dialysate bath

- Vascular accessTYPE OF ACCESS DESCRIPTION WHEN IT CAN

BE USEDNURSING

CONSIDERATIONSArteriovenous fistula Created surgically by

joining or anastomosing an artery to a vein.

Needs 4-6 weeks to mature before it can be used

- Instruct client to perform hand exercises to increase the size of the vessels (ball squeezing)

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A section of vein is directly sutured to an artery. It is usually placed in the nondominant arm, using the cephalic vein and radial artery

Has the longest useful life

Best option for vascular access for chronic HD patients

- Arm precaution measures must be observed.

- Monitor for clotting.- Auscultate for bruit, palpate

for thrills.- Palpate pulses below the

fistula.- Monitor for hand swelling.- Monitor for signs of

infection.Atriovenous graft Created

subcutaneously interposing a biologic, semibiologic, or synthetic graft material between an artery and vein.

Artificial graft:- Client’s own

(autologous) saphenous vein

- Gore-tex - Bovine carotid

artery

2 – 3 weeks - Arm precaution measures must be observed.

- Assess for presence of a bruit and a thrill

- Monitor for common complications like: stenosis, infection, thrombosis and aneurysm

Venous catheters

1. Internal jugular catheters

- inserted into the jugular vein on the side of the neck

2. Subclavian catheters

- placed into the subclavian vein under the collarbone on the chest.

3. Femoral catheters

- placed in the large femoral vein in the leg near the groin.

- Venous catheters are flexible, hollow tubes which allow blood to flow in and out of the body.

- Most commonly used temporary access for HD up to 1 month.

Used immediately

- Dressings need to be changed and kept dry at all times.

- Watch out for signs of bleeding, hematoma, dislodging and infection

- Do not use the catheters for any other reasons

- Femoral vein catheter: Avoid sitting more than 45 degrees or lean forward to prevent occlusion of the catheter.

- Femoral vein catheter: Assess the extremity for circulation, temperature and pulses.

External arteriovenous shunt

- Formed by surgical insertion of two Silastic cannulas into an artery and a vein in the forearm or leg to form an external blood path.

Used immediately

- Avoid wetting the shunt- Dressings need to be

changed and kept dry at all times

- Arm precautions at all times.- Auscultate for bruit- Monitor for complications

like: infection, dislodgement, hemorrhage and skin erosions.

- Monitor for signs of clotting like: fibrin-white flecks in the tubing, absence of previously heard bruit, coolness of the tubing or extremity, and tingling sensation.

- Note that the shunt is patent

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if warm to touch.

Complications of Hemodialysis

1. Anemia 2. Hypotension

S/Sx: nausea and vomiting, diaphoresis, tachycardia, and dizziness3. Air embolus

S/Sx: chest pain, dyspnea, coughing and cyanosis4. Fever5. Infection 6. Hemorrhage 7. Painful muscle cramping 8. Dysrhythmias 9. Disequilibrium syndrome – results from rapid removal of waste products from the blood than from the

brain, which results to cerebral edema. a. Signs and symptoms

i. Headacheii. Nausea and vomiting

iii. Restlessnessiv. Decreased level of consciousnessv. Seizures

b. Interventionsi. Monitor for signs of disequilibrium syndrome

ii. Notify the physician if the signs occuriii. Reduce environmental stimuliiv. Prepare to dialyze the client for a shorter period at reduced blood flow rates to prevent

occurrence10. Hematoma, thrombosis, pseudoaneurysm formation, or even rupture of the graft and excessive bleeding

Nursing Responsibilities: Before Hemodialysis

1. Assess vital signs and lung sounds2. Record weight of the patient3. Assess vascular access site4. Assess medications to be withheld or modified on the day of dialysis session.

a. Antihypertensivesb. Insulin or oral hypoglycemic agentsc. Water- soluble vitaminsd. Some antibiotics

5. Monitor electrolytes and blood sugar levels6. Assure consent for dialysis, prescription, and schedule at dialysis unit are prepared and available.7. Provide adequate nutrition

During Hemodialysis1. Practice aseptic technique in introducing needles or initiating hemodialysis2. Verify HD prescription/order and throughout the HD session3. Monitor vital signs, cardiac rhythm, and blood sugar levels4. Monitor for signs of shock and hypovolemia5. Monitor for signs of disequilibrium syndrome

After Hemodialysis1. Assess and document VS, weight and vascular access condition.2. Monitor BUN, creatinine, serum electrolyte, and hematocrit levels between dialysis treatments.3. Assess other diverse response to HD such as dehydration, nausea and vomiting, muscle cramps or

seizures.4. Assess for bleeding at access sites or elsewhere.

Special Considerations1. Protect the vascular access

a. Assess site for patencyb. Arm precautionc. Always handle the arm with the fistula or graft and dressings carefully. Don’t use scissors or other sharp

instruments to remove the dressing because you may accidentally cut into the fistula.

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d. When cleaning the fistula exit sites, use each 4”X4” gauze pads only once and avoid wiping the area more than once to minimize the risk of contamination.

e. When re-dressing the site, make sure that the tape does not kink or occlude the fistula. f. If the exit sites are heavily encrusted, place a 2”X2” hydrogen peroxide-soaked gauze pad on the

area for about 1 hour to loosen the crust. Make sure that the patient is not allergic to iodine before using povidone-iodine.

g. Obtain blood samples from the patient, as ordered. Samples are usually drawn before the beginning hemodialysis.

h. Tight dressings, restraints, or jewelry over the vascular access must be avoidedi. Presence of bruit and thrill must be evaluated at least every 8 hrs. j. Assess for signs of clotting in vascular access. Patients are more prone to clotting in the access if

with infection or hypotension.k. Observe for signs and symptoms of infectionl. Assess the integrity of the dressing and change as needed

2. Take precautions during intravenous therapy due to higher risk of congestion3. Home Care

a. Before the patient leaves the hospital, teach him how to care for his vascular access site. Instruct him to keep the incision clean and dry to prevent infection.

b. To clean the incision daily until it heals completely and the sutures are removed (usually 10-14 days after the surgery).

c. Instruct patient to notify the physician if pain, swelling, redness or drainage in the accessed arm.d. Teach the patient how to use a stethoscope to auscultate for bruits and how to palpate a thrill.e. Explain that once the access site heals, he may use the arm freely. In fact, exercise is beneficial

because it helps stimulate vein enlargement f. Avoid putting excessive pressure on the arm. He should not sleep on it, wear constrictive

clothing on it, or lift heavy objects.g. He should also avoid getting wet for several hours after dialysis.

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II. PERITONEAL DIALYSIS

NOTE: For further discussion about Peritoneal dialysis kindly refer to your books Potter and Perry: Clinical Nursing Skills & Techniques 7 th Edition pages 893-895.

Complications of Peritoneal Dialysis:

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Complications Signs and Symptoms Nursing care and ManagementPeritonitis - abdominal tenderness

- distended abdomen- nausea/vomiting- fever/chills - rebound tenderness - malaise- cloudy dialysate output

- Send PD fluid to laboratory for WBC and culture

- Commence antibiotic therapy as ordered- Maintain good sterile technique in

handling

Infectiona. Transluminal

contamination-organism enter the peritoneum through the catheter due to touch or aerosol contamination of the PD fluid or equipment as a result of a breach in sterile technique

b. Endogenous contamination-organism arise from transmural migration across the bowel wall (e.g constipation,Diverticular disease)

c. Exogenous contamination- organism enter via an exit site infection

- Redness- Swelling- Fever - Pain - Presence of discharge

- Send PD fluid to laboratory for WBC and culture

- Commence antibiotic therapy as ordered- Maintain good sterile technique in

handling

Inadequate peritoneal dialysis

- Loss of residual renal function

- Non-compliance- Peritoneal membrane

failure- Constipation- Obstruction- Catheter migration

- Change positions (turning)- Treat constipation- Check catheter placement on plain

abdominal XRAY- Check biochemistry- Note fluid status

Fluid overload and Hypertension

- positive fluid balance- weight gain- dyspnea- edema- distended JV- pulmonary edema- cardiac failure- Inadequate fluid

removal (use of inappropriately low PD solutions, malfunctioning catheter, reduced insensible losses)

- Peritoneal membrane failure

- Hypoalbuminemia- Excess salt and water

intake- Cardiac failure

- Reduce salt and water intake- Monitor input and losses- Weigh daily- Treat underlying cause of fluid overload- Correct low serum albumin level-

Volume depletion - negative fluid balance- weight loss- reduced skin turgor- dry mucus membrane- postural hypotension- tachycardia

- Increase oral fluid intake by 1000ml per day

- Treat underlying cause of volume depletion

Metabolic abnormalities: Hypokalemia

- Weakness- Arrhythmia

- Increase dietary intake of potassium. Start on potassium supplements as ordered

Excessive glucose absorption

- Weight gain- Obesity

- Exercise- Reduce caloric intake

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Other complications:1. Abdominal pain - results from rapid instillation, incorrect dialysate pH or temperature, dialysate

accumulation under the diaphragm or excessive suction during outflow. Some are expected in the early stages but should disappear after 1 to 2 weeks.

2. Respiratory difficulties – occurs during dwelling time due o pressure on the diaphragm3. Hypoalbuminemia

Cdr/Mkg/Som/12