CRRT

Hemodialysis

"separating from the blood" - Excess electrolytes, fluids, & toxins by hemodialyzer Intermittent treatment needed on regular basis - Several different options with specific schedule - Traditionally outpatient 3 x week (M-W-F or T-Th-Sat) - Short daily HD or nocturnal HD - Home HD Each treatment takes 3 to 4 hours Anticoagulation - heparin used - Heparin is no longer used b/c of significant allergies - heparin induced thrombocytopenia - they now use normal saline Vascular access

Hemodialysis vs. Peritoneal Dialysis

*HEMODIALYSIS* Temporary access can be placed at bedside Vascular access problems Extensive equipment Rapid removal of waste and fluid Needs specially trained personnel Dietary and fluid restrictions *PERITONEAL* Equipment quickly and easily assembled Simpler Less complications May be portable, home based Fewer dietary restrictions - PD - fluid restriction less severe, may need K supplements, limit high salt foods. A higher amount of protein diet is required compared to HD

3 Types of Dialysis

1. Hemodialysis 2. Peritoneal Dialysis 3. Continuous Renal Replacement Therapy (CRRT) - Very sick, very end stage

Permanent Vascular Access

2. Permanent Vascular Access Arteriovenous Fistula - surgical anastomosis of a peripheral artery and vein - preferred mode of access for HD - Should feel a thrill when you touch it - should document a positive bruit - the only time you WANT to hear this Arteriovenous Grafts - artificial synthetic device surgically implanted inside the limb NURSING CARE: - Protect the site - No BP, blood puncture, IV sites, IM injection on arm with fistula or graft (not even insulin), no jewelry - Alert other personnel to not use that arm - Avoid constrictive clothing or jewelry on arm - Check for thrill and bruit regularly - at least q shift - should vibrate under fingers - Monitor for complications - Check distal pulses, cap refill - Steal syndrome post surgery (homeostasis mechanism - body thinks there is decreased blood flow to the heart and the body will steal the blood from one of the limbs to shunt it back to the heart from the AF graft site - CLOSELY MONITOR BP)

Continuous Renal Replacement Therapy

Continuous therapy where waste and fluids are removed, electrolytes and acid-base status are adjusted gradually Allows patients to be dialyzed over 24 hours (more similar to normal kidney physiology) - Only done in ICU - Machine is mimicking kidney function Vascular access is double lumen catheter placed within jugular vein (or femoral vein) Monitored by critical care RN - 1 to 1 care - Patient is usually medically paralyzed Indications: - For hemodynamically UNSTABLE patient - Hypervolemic, edematous patient not responding to diuretics - Multiple organ dysfunction syndrome - Contraindication to HD or PD Contraindicatons: - Hematocrit > 45% (blood too thick) - Terminal Illness (should be on hospice - this could bring them closer to death than survival) - Uremic complications of Hyperkalemia or pericarditis

Nursing Management for CRRT

Critical care monitoring at least hourly - Hemodynamic status - I & O's - STRICT - ultrafiltration volume Assess hemofilter & blood tubing for clotting & kinks Monitor for complications - Decreased ultrafiltration rate, Clotting of filter, Hypotension, Fluid and electrolyte changes, Bleeding, Access dislodgement, or Infection - Can't put cold IV fluids in them b/c they can't compensate and it could cause the heart to shut down - Patients can have labs drawn up to four times a day

Dietary Restrictions for HD

Fluid restriction - Usually 600mls a day plus urine output from previous day - Not just about what they are drinking - fruit and vegetables also have a high water content "Renal Diet" - Low potassium - Low phosphorus - Low sodium - Avoid high protein foods (so protein restricted - moderate protein) - **Diet can sometimes be altered in severe malnutrition** Importance of educating patients ***Monitor daily weights - SHOULD NOT GAIN MORE THAN 3 LBS BETWEEN DIALYSIS TREATMENTS

Complications of HD

Hypotension - Must check VS before dialysis Muscle cramps - Due to shift of electrolytes Dysrhythmias - Shift in electrolytes Hepatitis B/C - Especially B b/c it can live for 5 days - if the dialysis are not cleaned properly a person could contract it Dialysis disequilibrium syndrome - ***Patients will complain of a headache - Cease everything and assess the pt's headache - have monitor heart rhythm Blood loss - Must properly disconnect a patient Hemolysis, air embolism (rare) - Poor technique

Nursing Management of HD

Monitor hemodynamic stability - What would you assess for? - BP is not always a good indicator in this case - monitor for changes in MS, dizziness, etc. Specialized monitoring before, during and after (Check labs, weight, vital signs BEFORE sending pt. to dialysis) - Dialysis nurse will routinely check VS during dialysis and sometimes pt. will have labs right after dialysis or the next day - Paying special attention to the sodium - Patient should weigh less after dialysis Vascular access care - Always want to make sure the access is patent and working properly Prevent complications Medication management - Find out from dialysis nurse what meds should be withheld on morning of HD for patients

Periotoneal Dialysis

Movement of solutes and fluid through the patient's peritoneal membrane - Patient who is cognitively aware can be taught to do it at home 3 Phases - Inflow (fill), Dwell, & Drain - What position for draining the dialysate? *Sitting or laying on their side May take 36 hours for therapeutic effect - HD is immediate Slow correction of biochemical imbalance Home-based, portable - Don't have to stay still during it - Automated peritoneal dialysis - while sleeping - Continuous ambulatory dialysis - during the day - In/Out - better to be equal than under

Complicatons

PD: - Peritonitis (rigid, boardlike abdomen) and Protein loss - Fluid that comes out should be clear - not purulent

Catheter Acess

Percutaneous catheters - short term/temporary (for use up to 3 weeks) - tunneled (long term access while awaiting placement of permanent access) Nurse Management of Catheters: - Strict Aseptic technique - Exit sites inspected for infection - Dressing changes using sterile technique - Minimal manipulation - no fluid or medication administration - no blood sampling (unless with a specific order & performed by dialysis RN only) - Important to keep the exit site and dressing clean to prevent infections. Assess the catheter site and dressing frequently. Change dressing if soiled, or bleeding at insertion site, must monitor and document it.

Complications of Peritoneal Dialysis

Peritonitis (most common) Exit site infection Hernias Low back problems - Extra weight in the abdomen Pulmonary complications - Diaphragm isn't able to be as flexible Protein Loss - Only dietary consideration for peritoneal dialysis patients - ***HIGH PROTEIN DIET IS ONLY FOR THESE PATIENTS

Dialysis

Treatment for Renal Failure Separation of solutes by moving through a semipermeable membrane What does dialysis do for the patient/body? Includes principles of: diffusion (involves solutes) osmosis with ultrafiltration (fluids)

When is it time for dialysis?

Worsening Labs - BUN, Creatinine, GFR Electrolyte imbalances - K, Phos Fluid overload - pulmonary edema, heart failure, hypertension Metabolic Acidosis Drug Overdose/Toxicity Uremic complications - mental status changes, uncontrolled hyperkalemia, pericarditis, etc.