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MED SURG: Dialysis

Terms in this set (33)

dialysis
-technique in which substances move from the blood across the semi-permeable membrane into a dialysis solution
-corrects fluid and electrolyte imbalances
-removes case products from the blood
-2 types: peritoneal (PD) and hemodialysis (HD)
treatments for stage 4 and 5 kidney failure
1. conservative
2. transplant
3. peritoneal dialysis
4. hemodialysis
osmosis
movement of water through a semipermeable membrane from a less concentrated solution into a more concentrated one
diffusion
movement of particles from an area of higher concentration to lower concentration
ultrafiltration
water, fluid and particle removal across a membrane by an osmotic or pressure gradient
Peritoneal Dialysis (PD)
-peritoneal lining is the semi-permeable membrane
-requires a peritoneal dialysis catheter placement through the abdominal wall into the peritoneal cavity (Tenkoff)
-a daily treatment that the patient is trained to perform at home; supplies delivered to patient's home
-can also be performed in a hospital
Tenkoff Catheter
-placed in OR or at bedside if needed
-do not use catheter for 7-14 days (needs to mature)
-do not remove the initial dressing over the catheter unless instructed by physician or dialysis nurse
PD catheter care
-site of Cath insertion is called exit site
-patients will clean this site at home in the shower or may use an antiseptic solution
-patient may choose to place a dry piece of gauze over the site or leave open to air
-site should be clean, pink and dry
continuous ambulatory peritoneal dialysis (CAPD)
-patient does manual exchanges during the day every 4-6 hours but may or may not during the night
automated peritoneal dialysis (APD)
patient connects to machine at night WHEN SLEEPING for 8-10 hours; exchanges of fluid are done by the machine
complications of PD
-peritonitis
-exit site infection
-abdominal pain (lots of fluid in stomach)
-hernias
-protein and potassium losses
-increased blood sugars
peritonitis
abdominal pain, fever, cloudy peritoneal fluid, diarrhea, vomiting, elevated WBCs of peritoneal fluid
treating PD complications
-exit site infections or peritonitis: meticulous skin care and antibiotics
-abdominal pain: warm solution, change patient's position, correct constipation, decrease rate of dialysis solution infusion
-losses: increase potassium and protein intake
-blood sugars: insulin administered for hyperglycemia
hemodialysis (HD)
-requires access to large blood vessel
-treatment 3x a week for 3-5 hours
-done in a dialysis unit, hospital or patients home that is specially equipped and family is trained
-blood is pumped through a dialyzer the contains semi-permeable membranes to remove the fluid and toxins
Hemodialysis accesses
1. artery-venous (AV) fistula
2. artery-venous (AV) graft: if veins are not viable
3. Cath in the internal jugular, subclavian or femoral vein: not ideal d/t increase of infection and should only be temporary or for emergency use
fistula
abnormal passageway between two organs or between an internal organ and the body surface
*listen for bruits when checking if fistula is intact*
Steel syndrome
impaired circulation
CHECK FOR DISTAL PULSES
hemodialysis procedure
1. needles are placed into patient's fistula or graft (no needles required if patient has a Cath)
2. blood is pumped from the patient's cues through a semi-permeable membrane (dialyzer)
3. Dialysate solution increases toxin removal
4. heparin is administered to decrease clotting of blood during the procedure (check exit site)
5. 0-7kg of fluid can be removed during HD
nursing considerations for HD
-access for bruit and thrill at least once a shift
-monitor fistula or graft for bleeding and s/s infection
-do not use arm w/ fistula/graft for BP or venipunctures
-patient should not wear tight clothing or sleep on arm with the fistula or graft
drug therapy
-dialysis clears "some" meds from body
-check with the dialysis nurse regarding medications to hold before dialysis (often anti-hypertensives, vitamins, supplements and antibiotics are held before dialysis)
hypoalbuminemia and dialysis
-many pts on dialysis have low Alb levels
-d/t dialysis loss, inflammation and decreased nutritional intake
-low Alb levels leads to increased morbidity/mortality
-even small increases in Alb levels can lead to improved patient outcomes (clients on dialysis will need to eat higher levels of protein)
-Kidney Disease Outcomes Quality Initiative
Kidney Disease Outcomes Quality Initiative
recommends maintaining a serum albumin level of 4g/dL
Nocturnal Hemodialysis (NH)
1. center: takes place 3-6 nights a week for 8 hours, patient sleep at the center while they dialyze and are monitored by staff
2. home: patients dialyze 3-6 times a week and may be connected Bia a phone modem or internet to a center for monitoring, a partner needs to be trained in addition to the patient
benefits of nocturnal hemodialysis
-pts take less meds to better control BP and P levels
-increase energy, an improvement in quality of life and HD is less intrusive in their lives
-diet can be a bit more liveralized
-increase rapport with the dialysis staff and receive more individuals care
-compliance is better
-increased length of life
HD aftercare
-monitor VS (disequilibrium syndrome)
-monitor access site for bleeding (increased risk of bleeding with patients receiving heparin)
-monitor bruit and thrill
-avoid drawing labs for 4-6 hrs d/t imbalances
-fluid and dietary restrictions
-administer meds that may have been held
disequilibrium syndrome
n/v
agitation
increased ICP
PT and OT
-deconditioning is a significant problem in this population and starts in the pre-dialysis stage
-assists in building muscle, improving VO2 peak values, cardiac functioning and HR variability
-exercise is often not part of the patient's care plan
-low Alb can also lead to protein-energy malnutrition
palliative care
-mortality rates for people with CKD are increased
-advancing age, comorbidities and high symptoms burden are common among people receiving renal care
-some patients may choose not to start dialysis
-other patients may choose to start and willingly decide to stop tx at some point after starting
continuous renal replacement therapy (CRRT)
-continuous therapy that filters blood to remove fluid and toxins: much slower process than HD and removes 25-50cc/hr
-benefits the hemodynamically unstable patient who requires dialysis: sepsis/ COVID 19
-performed in the critical care unit
-managed by critical care and/or dialysis nurse
wearable artificial kidney (WAK)
-recently developed and approved for use
-miniaturized dialysis machine (10 lbs on a belt)
-connects to patient via catheter
-designed to filter blood in ESRD
-can run continuously on batteries
-FDA approved for trial use
kidney transplant
-best choice for ESRD
-reverses may f the pathophysiologic conditions associated with renal failure
-extremely successful
transplant issues
-sources of donor organs
-medications (lifelong)
-longterm patient responsibilities after the transplant
-meds: tacrolimus, Prednisone, cyclosporine
transplant complications
*lack of available organs
*rejection
*infection (biggest sign=fever)
-CAD and malignancies related to immunosuppressant therapy
-recurrence of orginal renal dx
-guilt or emotional considerations related to cadaveric or living donor
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