Dialysis

Complications of PD

-Abdominal distention -Exit site infection -Infection (Peritonitis) -Dialysate leakage at site -Hernias -Lower back problems -Bleeding -Pulmonary complications -Protein loss 1.3g/kg (0.5g/L usually but can be as high as 10 to 20g/day. Furthermore during episodes of peritonitis pt's can lose up to 40g/day as a result of the peritoneal membrane becoming more permeable as a result of the infection.

What are the three arteriovenous (AV) access for HD

-ArterioVenous Fistulas (AVF) -ArterioVenous Grafts (AVG) -HeRO Graft

Nursing Management of PD

-Assess fluid volume status: weight, VS, edema, heart/lung sounds -Monitor electrolytes, BG, WBC, protein -Use aspetic technique when connecting tubing, monitor temperature, catheter site for s/s of infection -Avoid using cold dialysate -Reposition/sit-up for drain time -Assess outflow for amount, clarity

Surgical creation of AV access for HD has several risks.

-Distal ischemia (steal syndrome) and pain because too much arterial blood is being shunted or "stolen" from the distal extremity. -Aneurysms: can develop in the AV access and can rupture if left untreated.

What are the indications for renal replacement therapy?

-GFR less than 15 -Elevated BUN & Creatinine levels *high levels of urea nitrogen are toxic to the brain and CNS. -uncontrolled hyperkalemia -severe fluid overload

AVF's are harder to create in what type of patients?

-History of severe peripheral vascular disease (PVD) (e.g., people w/DM) -Those with prolonged IV drug use (e.g, heroin users) -Obese women.

After treatment for HD the nurse will assess the patient for?

-Monitor for hypotension -Obtain weight -Watch for bleeding (heparinization)

SAFETY LIMB ALERT!!! AVF's and AVG's

-Never perform BP measurements, IV line insertion, blood draws or venipuncture in an extremity with AV access. -These special precautions are taken to prevent infection and clotting of the vascular access. -When a patient is hospitalized, place signs in patients room and label the arm with a pink limb alert band that says, "NO BP, blood draws, or IV in this arm".

Manifestations of steal syndrome are:

-Pain distal to the access site -Numbness/tingling of fingers that may worsen during dialysis -Poor capillary refill.

Patient preparation for PD includes:

-emptying the bladder and bowel -weighing the patient -obtaining a signed consent form (because there is going to be a catheter inserted surgically into the abdomen).

Thrill

A palpable vibration that can be felt by palpating the fistula. This is created by arterial blood moving at a high velocity through the vein.

Bruit

A rushing sound that can be heard with a stethoscope. The sound is created by arterial blood moving at a high velocity through the vein.

Before beginning treatment for HD the nurse will assess the patient for?

Access fluid status -Weight (current & previous) -Vital signs Assess Fistula (shunt) -Feel the thrill -hear a bruit Hold meds Antihypertensives -ACE & ARB's (pril & sartan) -BETA blockers (lol's) -CA Channel blocker (dipine, amil, zem) -Diuretics (Furosemide, hydrochlorothiazide) -Dilators (Nitroglycerine) Antibiotics, Digoxin and water soluble vitamins (B, C and folic acid) should be held because they will be washed out with dialysis and therefore shouldn't be given before treatment. *While the pt is on dialysis, take vital signs at least every 30-60 minutes because rapid BP change may occur.

Diagnosis and treatment of peritonitis

Cultures, Gram stain, and a WBC differential of the peritoneal effluent are used to confirm the diagnosis of peritonitis Antibiotics cab be given orally, IV, or intra-peritoneal to treat infection.

What are the important nursing care needs of patients receiving HD via a fistula?

Frequently monitor the pulses and neurovascular status distal to the fistula (CMS, and cap refill) Check for patency by: palpating the thrill & auscultating for bruit Limb Alert

HeRO Graft

Graft is a special bridge access used in patients when other access options are exhausted. It consists of 2 pieces: a reinforced tube to bypass blockages in veins and a dialysis graft anastomosed to an artery to be accessed for HD

Complications of HD

Hypotension (Most frequent problem) -results from rapid removal of vascular volume (hypovolemia), decreased CO, and decreased systemic vascular resistance. S/S: light-headedness, N/V, seizures, vision changes, and chest pain from cardiac ischemia. Treatment: decrease the volume of fluid removed and infuse 0.9% NS. Muscle cramps Treatment: reduce the ultrafiltration rate and give fluids. Loss of blood -results from blood not being completely rinsed from the dialyzer, accidental separation of blood tubing, dialysis membrane rupture, or bleeding after removing the needles at the ned of HD. Treatment: rinse back all blood, avoid excess anticoagulation, and hold firm pressure on access sties until the risk for bleeding has passed. Infection (local or systemic) Immune system suppression due to high levels of Urea nitrogen and creatinine, damage WBC, access site contaminated. Hepatitis -outbreaks of hep B occur likely from breaks in infection control practice.

The 3 phases of the PD cycle are:

Inflow (fill); a prescribed amount of solution, usually 2 L, is infused through an established catheter over about 10 minutes. decrease the flow rate if pt experiences pain. once solution is fully infused, the inflow clamp is closed. Dwell (equilibration); during this phase diffusion and osmosis occur between the pt's blood and peritoneal cavity. duration is between 4-6 hours. Drain; solution is drained in 15-30 minutes and may be facilitated by gently massaging the abdomen or changing positions. Together, the 3 phases are an exchange. a period of about 30-60 minutes is needed to complete an exchange.

Patient teaching for PD

Once the catheter incision site is healed , the patient may shower and then pat the catheter and exit site dry. wash with water and a mild soap once incision site is healed. It is critical to maintain aseptic technique to avoid peritonitis. all patient need to daily examine their catheter site for s/s of skin breakdown & infection

Comparison of PD vs HD

PD: Pros: Can start it right away, Portable system, Fewer dietary restrictions, preferable method for pt's w/DM Cons: Peritonitis, protein loss into dialysate, contraindicated in pt's w/multiple abd surgeries HD: Pros: rapid fluid removal, rapid removal of urea and creatinine, effective K+ removal, less protein loss. Cons: Surgery for permanent access placement, specially trained personnel necessary, added blood loss that contributes to anemia, hypotension during dialysis, heparinization may be necessary, diet and fluid restrictions.

Physcosocial & emotional aspects in patients receiving dialysis treatment.

Poor body image Depression Livestyle changes Neurological changes (because high levels of urea nitrogen are toxic to the CNS)

Dialysis cannulas

Red: takes blood from patient send it to the dialysis machine. Blue: returns blood from dialysis machine to the patient.

ArterioVenous Fistulas (AVF)

The process of connecting an artery to a vein. This process of creating a fistula allows arterial blood to flow through the vein. The vein becomes "arterialized," increasing in size and developing thicker walls. Maturation may take 4-6 weeks. AVF should be placed at least 3 months before starting HD.

peritoneal dialysis (PD)

The removal of wastes, electrolytes and fluids from the body using peritoneum as dialysis membrane

Manifestations of peritonitis

diffuse abdominal pain, rebound tenderness, diarrhea, vomiting, abdominal distention, hyperactive bowel sounds Fever may or may not be present (#1 sign) *Cloudy peritoneal effluent; To determine if the peritoneal effluent is cloudy drain the effluent and place the drained bag on reading material. If you cannot read the print through the effluent, it is cloudy.

temporary vascular access

internal jugular tunneled catheter- is a thin tube that is placed under the skin in a vein, allowing long-term access to the vein. It is commonly placed in the neck. It is most commonly placed in the neck (internal jugular) but may also be placed in the groin (femoral), liver (transhepatic), chest (subclavian) or back (translumbar). can be used 3-4 weeks

Dialysis

is the movement of fluid and molecules across a semipermeable membrane from one compartment to another using the principles of osmosis and diffusion. Clinically, it's a technique in which substance move from the blood through a semipermeable membrane and into a dialysis solution (Dialysate). This process corrects fluid and electrolyte imbalances and remove waste products in kidney failure. It also may be used to treat drug overdoses.

ArterioVenous Grafts (AVG)

made of synthetic materials (polytetrafluoroethylene [PTFE, Teflon]) and form a "bridge" between the arterial and venous blood supplies. 2-4 weeks is usually needed to heal. they are more likely than AVF's to become infected and tend to form clots.

Automated peritoneal dialysis (APD)

most popular form of PD because it allows patients to do dialysis while they sleep over 8-10 hours. Cycler times and controls the fill, dwell and drain phases. 4 more exchanges per night, 1-2 hours per exchange. Fluid left in abdomen during day Alarms and monitors built into system.

hemodialysis (HD)

treatment for renal failure using artificial kidney machine to filter waste from blood -uses a dialyzer as the artificial kidney.

When is dialysis indicated?

when the patients uremia can no longer be adequately treated with conservative medical management. Generally, this is when the GFR is less than 15 mL/min