Fluid & Electrolytes pt. iii

what are the two types of Continuous Renal Replacement Therapies (CRRT)

-Continuous Venovenous Hemofiltration (CVVH) -Continuous Venovenous Hemodialysis (CVVHD)

How to Manage Discomfort and Pain in a Hospitalized Dialysis Patient

Antihistamines, analgesics; may need to adjust medication dosages

_____________________ meds must be withheld before dialysis to prevent hypotension. Blood pressure must constantly be monitored with a Hospitalized Dialysis Patient

Blood Pressure

_______________ in the Peritoneal Dialysis Procedure may contain heparin (prevent occlusion of catheter), potassium chloride (prevent hypokalemia), antibiotics (treat infection), regular insulin (patients w/DM due to high levels of dextrose)

Dialysate

Catheter Insertion for the Peritoneal Dialysis Procedure

Done in operating room or radiology suite; has 3 sections •(1) intraperitoneal: numerous openings and an open tip to allow dialysate to flow freely •(2) subcutaneous: passes from the peritoneal membrane & tunnels through muscle and subcutaneous fat to the skin •(3) external section for connection to the dialysate and tubing system

______________________________ is common in patients undergoing long-term Peritoneal Dialysis; cardiovascular disease is the leading cause of mortality and morbidity in patients w/kidney failure; many patients have suboptimal BP control; beta blockers and ACE inhibitors should be used to control BP and protect the heart; also consider use of aspirin and "statins"

Hypertriglyceridemia

Bloody drainage may be seen in the first few exchanges during ______________________ after insertion of a new catheter but should not occur long-term.

Peritoneal Dialysis

Continuous Renal Replacement Therapies (CRRT) is indicated for patients with:

acute or chronic kidney disease who are too unstable for hemodialysis; fluid overload secondary to oliguric kidney disease; kidneys wo cannot handle their high metabolic or nutritional needs

What are Chronic Kidney Disease complications:

anemia, gastric ulcers, uremia (metallic taste and nausea), renal osteodystrophy, calcification

Describe the Nursing management of Acute Intermittent Peritoneal Dialysis:

aseptic technique; assess VS, weight, I&O, lab values, skin turgor, edema, abdominal girth, patient status; documentation (exchange, dialysate concentration, pt status) •If peritoneal fluid does not drain properly, drainage can be facilitated by turning the patient from side to side or raising the HOB. Check patency of catheter; inspect for kinks, closed camps. •Monitor for complications (like peritonitis and bleeding)

Follow-up and referrals for Peritoneal Dialysis involve

changes in kidney disease, lab values, complications; health promotion activities and health screening

Movement of solute from the blood into the dialysate fluid in Peritoneal Dialysis is called _________________

clearance

Describe Bleeding as a complication of Peritoneal Dialysis:

common during menstruation for women & initial exchanges; frequent exchanges and addition of heparin to prevent blood clots

The removal of excess water during Peritoneal Dialysis occurs because...

dialysate has a high dextrose concentration, making it hypertonic. Selection of the appropriate solution is based on patient's fluid status.

Mechanical problems occasionally occur in Peritoneal Dialysis and affect instillation or drainage, what does this result in?

formation of clots in the catheter and constipation

S&S of Dialysis disequilibrium include:

headache, N/V, restlessness, decreased LOC, and seizures. possible complication of End-Stage Kidney Disease (ESKD)

Risks for Vascular Access Devices:

hematoma, pneumothorax, infection, thrombosis

Complications of Peritoneal Dialysis

peritonitis, leakage, and bleeding

It is important to avoid meds with ________________________ in a Hospitalized Dialysis Patient

potassium and magnesium

What are the Indications of Acute Intermittent Peritoneal Dialysis:

uremic S&S, fluid overload, acidosis, and hyperkalemia

Continuous Cyclic Peritoneal Dialysis:

uses a cycler for fluid exchanges; combines overnight intermittent PD with a prolonged dwell time during the day •CCPD is programmed to deliver an established amount of Peritoneal Dialysis solution that will dwell in the peritoneal cavity for a programmed period of time before it drains via gravity; set to deliver a specific number of fluid changes; peritoneal catheter is connected to a cycler machine every evening, before bed •CCPD has lower infection rates than other forms of PD because there are fewer opportunities for contamination; allows patient to be free from exchanges throughout the day, making it possible to engage in work and ADLs more freely

Continuous Ambulatory Peritoneal Dialysis

•2nd most common form of dialysis for patients w/ESKD •Performed at home by patient or caregiver; 4-5 times daily, 7 days a week •Y-shaped system is used: Dialysate solution is connected to one branch of the "Y" and a sterile open bag is connected to the second branch. The third part connects to the transfer set on the PD catheter. •Dialysate solution is infused for dwell; fluid is then drained •Reduce risk of peritonitis: avoid contamination, asepsis, meticulous care of catheter site

Describe Caring for Catheter Site for a Hospitalized Dialysis Patient

•3-4 times-weekly routine catheter site care using liquid soap and water

Describe Protecting Vascular Access for a Hospitalized Dialysis Patient

•Access for patency; do not use extremity for BP or obtaining blood specimens •Evaluate for bruit or "thrill" at least every shift (absence may indicate blockage) •Observe for S&S of infection

What are the different variations of Peritoneal Dialysis

•Acute Intermittent Peritoneal Dialysis •Continuous Ambulatory Peritoneal Dialysis •Continuous Cyclic Peritoneal Dialysis

Describe IV Therapy Precautions for a Hospitalized Dialysis Patient

•Administer fluids at slow rate (rapid administration can lead to pulmonary edema); monitor & record I&O

Describe Performing the Exchange in the Peritoneal Dialysis Procedure

•An exchange is the entire cycle including the infusion (fill), dwell, and drainage of the dialysate •The dialysate is infused by gravity into the peritoneal cavity. (5-10 minutes is usually required to infuse 2-3 L of fluid) •The prescribed dwell time allows diffusion and osmosis to occur •At the end of dwell, the tube is unclamped and the solution drains from the peritoneal cavity by gravity through a closed system (10-20 min). Drainage fluid is normally colorless or straw colored, and should not be cloudy. •The number of cycles/exchanges are based on monthly lab values and the presence of uremic symptoms. •Exchanges can be performed manually (continuous ambulatory peritoneal dialysis [CAPD] or via PD machine that automatically performs exchanges usually during sleep (continuous cycling peritoneal dialysis [CCPD])

Describe how pericarditis occurs in a Hospitalized Dialysis Patient

•As fluid builds up, fluid overload, heart failure, and pulmonary edema develop; pericarditis may result from the accumulation of uremic toxins

How to provide Education on Self & Home Care in End-Stage Kidney Disease (ESKD)

•Assess learning needs, brief 10-15 min sessions (bc of potential brain issues from ESKD) •Home hemodialysis •Appropriate follow-up and monitoring

Complications of End-Stage Kidney Disease (ESKD)

•CKD complications will continue to worsen and require treatment •Sleep disturbances •Shortness of breath: fluid accumulation b/t dialysis •Hypotension: may occur during treatment as fluid is removed •Painful muscle cramping: fluid & electrolytes leaving extracellular space •Exsanguination: blood lines separate or dialysis needles become dislodged •Dysrhythmias: electrolyte or pH changes; removal of meds •Air embolism: air enters vascular system •Chest pain: in patients with anemia •Dialysis disequilibrium: cerebral fluid shifts

Equipment Preparation for the Peritoneal Dialysis Procedure

•Concentration of dialysate; aseptic technique; warm dialysate to body temp; assemble administration set and tubing

Describe Patient Preparation for the Peritoneal Dialysis Procedure

•Explanation of procedure; informed consent; baseline VS, weight, labs; abdominal assessment; empty bladder; antibiotics

What are Long-Term Complications of Peritoneal Dialysis

•Hypertriglyceridemia; abdominal hernias; Low back pain and anorexia from fluid in the abdomen; constant sweet taste *Abdominal hernias may result from increased intra-abdominal pressure

Vascular Access Devices

•Immediate access is achieved by inserting a double lumen, noncuffed, large-bore catheter into the subclavian, internal jugular, or femoral vein by the physician •Double-lumen cuffed catheters may also be inserted into the internal jugular vein by a surgeon or interventional radiologist •Access to the patient's blood system must be established to allow blood to be removed, cleansed, and returned to the patient's vascular system at the rapid rates of 300 and 800 mL/min.

Describe overall Nursing Interventions for End-Stage Kidney Disease (ESKD)

•Many medications are removed from the blood during hemodialysis; monitor levels of medication, many meds that are taken once daily can be held until after dialysis treatment •Protein intake is restricted to about 1.2 - 1.3 g/kg of ideal body weight per day; high biologic value •Sodium 2-3 g/day; fluids are restricted to an amount equal to the daily urine output plus 500 ml; goal is to keep weight gain under 1.5 kg •Potassium restriction depends on the amount of residual renal function and frequency of dialysis

Peritoneal Dialysis

•May be treatment of choice for individuals with kidney disease who are unable to or unwilling to undergo hemodialysis or kidney transplantation •Fewer than 8% of patients with ESKD receive PD

Continuous Renal Replacement Therapies (CRRT)

•May not require dialysis machines or dialysis personnel and can be initiated quickly •Requires access to the circulation and blood to pass through an artificial filter; hemofilter •Hemofilter is an extremely porous blood filter containing a semipermeable membrane

Describe Leakage as a complication of Peritoneal Dialysis

•May occur immediately after catheter insertion; avoid straining and increased activity; gradually increase volume of dialysate

How to Promote Pharmacologic Therapy in End-Stage Kidney Disease (ESKD)

•Medication dosages or timing may require adjustment

Nursing Management of Hospitalized Dialysis Patient

•Monitor Symptoms of Uremia- As metabolic end products accumulate, symptoms of uremia worsen •Detecting Cardiac and Respiratory Complications- Assess for crackles, substernal chest pain, low-grade fever, pericardial friction rub •Control Electrolyte Levels and Diet •Manage Discomfort and Pain •Monitor lab values and dietary intake; hypoalbuminemia is an indicator of malnutrition is patients undergoing long-term or maintenance dialysis •Monitoring Blood Pressure •Preventing Infection •Caring for Catheter Site

Describe Peritonitis as a complication of Peritoneal Dialysis

•Most common and serious complication •1st sign is cloudy drainage fluid; diffuse abdominal pain and rebound tenderness later •Diagnostics: gram stain and culture of drainage fluid •Treatment: antibiotics

Continuous Venovenous Hemofiltration (CVVH): Type of Continuous Renal Replacement Therapy (CRRT)

•Often used to manage Acute Kidney Injury •Blood from a double lumen venous catheter is pumped through a hemofilter and then returned to the patient •Provides continuous slow fluid removal. Hemodynamic effects are mild and better tolerated •Requires trained critical care nurses

Describe how Osmosis plays a role in the Process of Dialysis

•Osmosis is when water moves from an area of low concentration potential (blood) to an area of high concentration potential (dialysate). •Because patients with disease requiring dialysis usually cannot excrete water, this force is necessary to remove fluid to achieve fluid balance. •Body's buffer system is maintained using a dialysate bath made up of bicarbonate or acetate, which is metabolized to form bicarbonate. •Heparin is given to keep blood from clotting.

Nursing Management of Peritoneal Dialysis

•Provide opportunities for patient to discuss issues/concerns related to body image, sexuality •Education about PD at home (understanding of procedure, evaluate technique, things to report) •Diet: high-protein, increase fiber, limit carbohydrates -Potassium, sodium and fluid restrictions are usually not needed

How to Promote Nutritional and Fluid Therapy in End-Stage Kidney Disease (ESKD)

•Restriction of protein, sodium, potassium, phosphorus and fluid intake

Continuous Venovenous Hemodialysis (CVVHD): Type of Continuous Renal Replacement Therapy (CRRT)

•Same process as CVVH •Uses a concentration gradient to facilitate removal of uremic toxins and fluid by adding a dialysate solution into the circuit •Hemodynamic effects are usually mild •Done by critical care nurses w/support of nephrology staff

Describe the Process of Peritoneal Dialysis

•The peritoneal membrane (covers the abdominal organs and lines abdominal wall) serves as the semipermeable membrane •Sterile dextrose dialysate fluid is infused into the peritoneal cavity; uremic toxins begin to be cleared from the blood •Diffusion and osmosis occur as waste products move from the bloodstream (higher concentration) to the dialysate fluid (lower concentration) through the peritoneum (semipermeable membrane) •Because substances cross the peritoneum at different rates, adjustments in dwell time and amount of fluid are made •Ultrafiltration (water removal) occurs in PD through an osmotic gradient created by using a dialysate fluid with a higher glucose concentration than the blood

Describe the Process of Dialysis

•The toxins and wastes in the blood are removed by diffusion - move from an area of higher concentration in the blood to an area of lower concentration in the dialysate. •The dialysate is a solution that circulates through the dialyzer; contains all the electrolytes in their ideal extracellular concentrations. •The semipermeable membrane impedes the diffusion of large molecules (RBCs and proteins). •Excess fluid is removed from the blood by osmosis. •In ultrafiltration, fluid moves under high pressure to an area of lower pressure. More efficient than osmosis; negative pressure or suctioning force is applied to dialysis membrane •Cleansed blood is returned to the body with the goal of removing fluid, balancing electrolytes, and managing acidosis.

Describe Acute Intermittent Peritoneal Dialysis (variation of PD)

•Treatment of choice for the hemodynamically unstable pt; gradual change in the patient's fluid status and waste product removal •Exchange times range from 30 min - 2hours (manual or machine)

Arteriovenous Fistula

•arterial segment is used for arterial flow to the dialyzer and the venous segment for reinfusion of the dialyzed blood; access will need 2-3 months to mature before used •Preferred method of permanent vascular access •Created surgically by joining an artery to a vein

what are the goals of Peritoneal Dialysis

•to remove toxic substances and metabolic wastes to re-establish normal fluid and electrolyte balance

Arteriovenous Graft

•usually created when the patient's vessels are not suitable for creation of an AVF; usually placed in the arm, but may be placed in thigh or chest wall; stenosis, infection, and thrombosis are most common complications •Created by subcutaneously interposing graft material between an artery and vein