Dialysis Dialysis Dialysis Dialysis

ObjectivesObjectives

By the end of the lecture student will be able to

Explain dialysis types

Compare the dialysis types

Identify the indication for each type of dialysis

Identify the contraindication for each type of Identify the contraindication for each type of dialysis

Identify the complication for each type of dialysis

Discuss the nursing Preparation for patient with going dialysis

Discuss the nursing care post dialysis

DialysisDialysis

Dialysis-the movement of molecules and fluid across a semipermeable membrane from one compartment to another.

Clinically dialysis is a technique in which Clinically dialysis is a technique in which substances move from the blood through the membrane into a dialysis solution (dialysate).

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Dialysis is used to correct fluid and electrolyte imbalances and to remove waste products in renal failure.

Types of DialysisTypes of Dialysis

1) Hemodialysis (HD):

An artificial membrane is used as the semipermeable membrane that is in contact semipermeable membrane that is in contact with the patient’s blood.

2) Peritoneal dialysis (PD):

Peritoneal membrane Is used as the semipermeable membrane.

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Purpose of dialysis

Rapidly remove nephrotoxines in ARF pt’s caused by nephrotoxic damage to renal tube.

Remove excess fluid and metabolic waste Remove excess fluid and metabolic waste products in CRF pt’s.

Principle of dialysis

1) Diffusion:

The movement of solute from high concentration to low concentration .

2) Osmosis:

the movement of water through membrane from high to low concentration .

3) Ultrafiltration:

The movement of fluid through membrane by gradient pressure positive pressure [by push] or negative pressure [suck fluid through membrane

Clinical Indication Of Start Dialysis

Kidney failure GFR ≤ 15Fluid over load.Hyperkalaemia, nateramia can usullay be

managed medically .managed medically .Pericarditis Complication

HeamodialysisHeamodialysisHDHD

HemodialysisIt’s pumping the blood out of the body into

a dialyzer where impurities are removed, then returning the blood to the body.

Dialyzes consist of three parts:

1) Compartment for the blood.

2) Compartment for the dialysate.

3) Semi permeable membrane separating the two..

ESRD pts using HD treatments 3 times weekly for a duration of 3 - 5 hrs each time .

HD machine

Advantages of HDAdvantages of HD

Effective method to remove waste product.

Performed by trained professional .

Provide socialization for Pt. Provide socialization for Pt.

Only need dialysis 3 times per week.

No equipment at home.

Disadvantages Disadvantages of of HDHD

Dietary ristrictions

Bleeding from Vascular access

Travel to center Travel to center

Relative Contraindications of HD

Bleeding disorder or anemia.

Sever hypotension / shock. Sever hypotension / shock.

Serious heart or brain complication

(HF, arrhythmia urgent HTN)

Sever vascular disease

Diabetic retinopathy

Type of access for hemodialysis:

1. Venous catheter for temporary access :

It has two lumen to allow a two-way flow of blood.

Catheters are not ideal for permanent Catheters are not ideal for permanent access:

They can clog, infected, and cause narrowing of the veins.

Work for several weeks or months while permanent access develops

2. A fistula :

An artificially-formed link b/w artery An artificially-formed link b/w artery and vein. As a vein is exposed to the higher pressure from the artery.

fistula

3. Arteriovenous graft:

• Vascular access connects an artery to a vein using a synthetic tube, or graft, vein using a synthetic tube, or graft, implanted under the skin in arm.

Graft

Complications of fistulas and Complications of fistulas and graftsgrafts

Infection

Thrombosis

Haemorrhage

Distal ischemia(steal syndrome) due to Distal ischemia(steal syndrome) due to shunting of the arterial blood

aneurysm at the fistula site.

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Complications Complications Of HDOf HD

1) Hypotension:

primarily due to rapid removal of vascular volume which leads to decreased CO and SVR.

2) Muscle Cramps:

Too rapid removal of sodium and water or from neuromuscular hypersensitivity

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3) Loss of blood:

Residual blood not being rinsed properly, or dialyser membrane rupture.

◦ If client is heparinized Closely monitor heparanization and avoid over anticoagulation

◦ monitor connections to dialyzer and client very ◦ monitor connections to dialyzer and client very carefully during procedure

Complications cont..Complications cont..

4) Hepatitis:

Due to lack of adherence to precautions used to prevent spread of the infection ( HBV- HCV)

5) Sepsis:

Most commonly related to infections of the vascular access Most commonly related to infections of the vascular access sites.

6) Disequilibrium syndrome:

Result of rapid changes in the composition of the extracellular fluid.

This creates high osmotic gradients in the brain resulting in the shift of the fluid into the brain (Cerebral edema).

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Nursing assessment pre HD:

1. Re-assuring and support pt.

2. Baseline vital signs

3. Weight.

4. Laboratory values [BUN] /creatinine4. Laboratory values [BUN] /creatinine/electrolytes /hemoglobin/hematocrit).

5. Neurologic status

6. Patency and the ability to easily aspirate blood from both ports.

7. Vascular access site for S/S of infection.

8. Check site for presence of bruit and quality of blood flow.quality of blood flow.

9. Adequate circulation to the distal parts of the access limb.

10. Preparation check machine

11. Maintenance of the circuit (arterial and venous pressures, clotting, blood leaks, or breaks in the closed system)..or breaks in the closed system)..

12. Prepare heparin dose.

Patient PreparationPatient Preparation

Ensure that patient understands pre-procedural teaching.

Position the patient in a comfortable position to facilitate optimal blood flow through the to facilitate optimal blood flow through the vascular access.

Nursing preparation during HD :

Set and connecting machine.

Using Aseptic technique.

Adequate priming dialyzer and set with saline.

Giving half dose of heparin. Giving half dose of heparin.

Observing the patient.

Check vital signs every 15 min in 1st hour then every hour .

Monitor electrolytes and glucose Must be during treatment as standard.

Administer medications to correct electrolyte abnormalities during treatment.

Monitor the circuit (occlusions; kinks, blood , vascular access lines, position of dialyzer).vascular access lines, position of dialyzer).

Treat if complication if occurs

Documentation.

Nursing care post HD:

1. Measuring the vital sign.

2. Measuring the weight.

3. Give some drugs( Erethropiotine, dextran)3. Give some drugs( Erethropiotine, dextran)

4. Putting machine in disinfecting.

5. Documenting all procedure.

Nursing Education for pt’s have of :vascular access

Checks access before each section.

Keep access clean all times.

Use access site only for dialysis.

Don’t put a blood pressure cuff on access arm.

Don’t wear jewelry or tight clothes over access site.

Don’t sleep with access arm under head or body.

Don’t lift heavy objects or put pressure on access arm.

Check the pulse in access every day.

((22))Peritoneal dialysis Peritoneal dialysis

PDPD

Peritoneal dialysis Peritoneal dialysis

PD uses the peritoneal membrane as the semipermeable membrane for both fluid solutes.fluid solutes.

Dialysate fluid infused into peritoneal cavity through a flexible abdominal catheter

Peritoneum

Peritoneal dialysisPeritoneal dialysis

❖Principles of PD are:

Diffusion

Osmosis

Process of PDProcess of PD

After placement of PD catheter-usually PD is not initiated until 7-14 days

To allow for proper sealing of the catheter.

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Three phases are present in peritoneal dialysis:

Inflow(fill):Dialysate solution is inserted ( 2 L) in an adult Dialysate solution is inserted ( 2 L) in an adult

over about 10-15 min(based on client comfort)

Dwell(equilibration):

Diffusion and osmosis occur b/w the pts blood and the peritoneal cavity.

The duration last 20-30 min to 8 hrs or more.

Drain:

Draining takes 20-30 min and may be facilitated by Draining takes 20-30 min and may be facilitated by gently massaging the abd.

The physician prescribes the actual dwell and drain times.

PD performed by:

1. Single tubing and bag setup.1. Single tubing and bag setup.

2. Cycler machine

Dialysissolution

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Abdcavity

Peritoneum

catheter

Both solute and fluid removal in PD is controlled by:

Glucose concentration in the dialysate.Glucose concentration in the dialysate.

Dwell time

Volume

Peritoneal membrane characteristic

Advantages

1) Simple

2) Cheep

3) Less complication

4) Few risk

Disadvantages of PD Dialysis every day.

Permanent catheter.

Body image change.

Risk of infection. Risk of infection.

Possible weight gain.

Storage space needed for supplies

ContraindicationsContraindications

Colostomy, IleostomyHx of multiple abd surgical

procedures.Severe obstructive pulmonary Severe obstructive pulmonary

diseaseIntra abdominal adhesion Hernia Morbid obesity.

Types of PD

1) Intermittent PD (IPD)1) Intermittent PD (IPD)2) Continuous ambulatory PD

(CAPD )3) Automated PD (APD) 4) Optimized continuous PD

(OCPD )

(1) Intermittent PD : 1) In elderly pt’s with no vascular access.2) Unstable on HD

25 L of dialysate 24hrs with 2Lexchange of 2 hr.

10 min running in.90 min dwell time. 20 min for drainage.

(2) Continuous ambulatory PD :

1) 3-5 exchange over 24hrs it move large 1) 3-5 exchange over 24hrs it move large molecular weight .

2) Instill dialysate and go to his activities .3) After 6-8 hr dwell time drain the solution in

to the bag and discard it .4) Instill new bag continuously 24hr a day 7

days a week.

(3) Automated PD :

Used to perform rapid exchange over night .Used to perform rapid exchange over night .

A) Night time :

Rapid exchange over night and dry during day

A) Continuous cycling PD :

Perform at night and CAPD in the day time .

Solutionsupply

Fluid meterPump

Heater bag

Drain lineDrain line

Drain line

(4) Optimized continuous PD :

Used when maximal solute transfer Used when maximal solute transfer is needed.

In case of anuric pt’s .Exchange over night along day dwell

and extra exchange done .

Complications of PDComplications of PD

1) Exit site infections.

2) Peritonitis: (dialysate ,tubing or from progression of exit site or tunnel infections).infections).

3) Abdominal pain: ( low pH of the dialysate solution)

4) Outflow problems- when is less than 80% of the inflow, may be catheter kinking.

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Complications cont..Complications cont..

5) Hernia.

6) Bleeding

8) Pulmonary- atelectasis and pneumonia

9) Protein loss.9) Protein loss.

10) Carbohydrate and lipid abnormalities.

11) Encapsulating sclerosing peritonitis.

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Nursing care of Nursing care of PD patientsPD patients

PrePre-- PD Nursing carePD Nursing carePatient preparationPatient preparation

Ensure that patient understands pre-procedural teaching.

Assist the patient in applying the mask.

Re-position patient to a comfortableposition.

Patient assessment

1) Assess baseline vital signs.2) Weight pt.3) Check blood investigations (RFT , BUN) .4) Measure abd. girth , fluid and diet restriction .5) PD catheter and exit site for S/S of infection or leakage5) PD catheter and exit site for S/S of infection or leakageor S/S of peritonitis:

❖ Cloudy dialysate solution❖Abdominal pain❖ Fever❖ Chills❖ Rebound tenderness

IntraIntra-- PD PD Nursing careNursing care

1) Use aseptic technique .

2) Instill dialysate over 10 min and clamp tube.

3) During dwell time observe S/S of 3) During dwell time observe S/S of respiratory distress.

4) After dwell time open clamp and observe solution for clarity, odder, blood .

5) Record the amount .

6) Monitor laboratory investigation

8) Documentation: Pt and family education I&O Date and time of treatment initiation Condition of abdominal catheter

Vital signsCondition of abdominal catheter

Vital signs Laboratory assessment data Exit site at time of treatment. Date and time of dressing application Nursing interventions Pt wt before and after

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Post Post --PD PD Nursing careNursing care

1. Assess and record V/S.

2. Maintain fluid and dietary restriction and give stool softener .

3. Teach pt and family about procedure 3. Teach pt and family about procedure

Patient And Family Education

Explain the purpose of PD.

Explain the procedure and review any questions to decreases pt anxiety.

Explain the need for careful sterile technique when accessing the abdtechnique when accessing the abdcatheter.

Explain the three phases of PD.

Explain the potential for feelings of fullness and possibly S.O.B during the dwell phase

Complications :

1. Bladder perforation

2. Bowel perforation

3. Intra peritoneal bleeding

4. Fluid leak 4. Fluid leak

5. Exit site infection

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