Module 14: Care of a Patient Requiring Dialysis

Question 1

renal system

Answer 1

• entire blood volume filtered through the kidneys every 4-5 minutes
• normal renal blood flow is 1200 ml/minute

Question 2

kidney failure

Answer 2

• acute kidney injury (AKI)
  
  • rapid onset (1-7 days)
  • may be reversible
  • high mortality rate (35-65%)

Question 3

Chronic Kidney disease (CKD)

Answer 3

• progressive loss of kidney function resulting in decline in glomerular filtration rate
• may be swagged according to glomerular filtration rate
• signs and symptoms minimal until more than 75% of glomerular filtration lost
• risk factors: diabetes. hypertension, smoking

Question 4

Monitoring Kidney Function

Answer 4

• glomerular Filtration Rate (GFR) *
• urine output and urinalysis
• Serum creatinine *
• creatinine clearance
• BUN *
• electrolyte
• arterial blood gases
• hemoglobin

Question 5

GFR (glomerular filtration rate)

Answer 5

• normal adult value: 90-120 ml
• used to detect and screen for early kidney damage and monitor kidney status
• determines how well blood is filtered by the kidneys
• calculated using a formula
• used as indicator for the need of hemodialysis or peritoneal dialysis

Question 6

Creatinine

Answer 6

• normal adult value: 45 - 110 umol/L
• is part of complete renal function panel which assists in the diagnosis of kidney function
• is excreted entirely by the kidneys, therefore is directly proportional to kidney excretory function
• elevated in renal disorders

Question 7

blood urea nitrogen

Answer 7

• normal adult value: 2-9 mmil/L
• rough estimate of kidney function and GFR in patient’s with normal liver function
• most kidney diseases cause an inadequate excretion of urea which causes rise in blood concentration

Question 8

Explain the reasons why a patient would require dialysis

Answer 8

• used to sustain life after kidneys fail
  
  • for acute renal failure - temporary
  • for chronic kidney failure - until the patient can obtain a kidney transplant

Question 9

Goals of dialysis

Answer 9

• remove the end products of protein metabolism from the blood
  
  • maintain safe concentrations of serum electrolytes
  • correct acidosis and replenish the body bicarbonate buffer system
  • remove excess fluid from the blood

Question 10

principles of dialysis

Answer 10

• movement of fluid and particles through a semipermeable membrane
  
  • patients blood, including metabolic waste, excess water and electrolytes are on one side of the membrane

Question 11

Peritoneal dialysis

Answer 11

membrane lining the abdomen acts as filter

• lining covering the abdominal organs
• parietal layer and visceral layer
• 1-2 square meters in size

Question 12

advantages of peritoneal dialysis

Answer 12

• continuous treatment
  
  • patient feels better
  • less restrictive diet
  • better blood glucose control
  • better bp control
• less interference with ADL
• no needle s
• no anticoagulation
• less anemia

Question 13

disadvantage of peritoneal dialysis

Answer 13

• change in body image
• risk of peritonitis
• no “days off”
• no tub baths
• no swimming
• backpain
• large amount of storage in the home
• increased loss of protein

Question 14

Catheter types

Answer 14

• percutaneous - through abdominal wall (tenckhoff)
• implanted
  Patient’s peritoneum is used as a semi permeable membrane
• 3 phases
  
  • inflow - about 2L of fluid infused
  • dwell - several hours, depends on order
  • drain -20-30 minutes

Question 15

Contraindications to Peritoneal Dialysis

Answer 15

• open abdominal wound
• recent abdominal surgery/ trauma
• patient opening between peritoneum and pleural cavity
• inadequate surface area due to scarring

Question 16

Complications of Peritoneal Dialysis

Answer 16

• Peritonitis: infection or inflammation of peritoneal cavity:
  
  • cloudy effluent
  • abdominal pain
  • fever/chills
  • nausea/vomiting

Question 17

Peritoneal Dialysis May be Preferred for:

Answer 17

• patients who lives in rural area
• severe heart disease
• patient preference - able to administer at home according to prescribed cycles
• poor vasculature
• for some diabetic patients

Question 18

Continuous Ambulatory Peritoneal Dialysis (CAPD)

Answer 18

• the dialysate solution stays in the abdomen for about 4-6 hours
• exchanges are done about 4 times a day
• the most commonly used form of peritoneal dialysis
• highest risk of peritonitis

Question 19

Continuous Cycling peritoneal Dialysis (CCPD)

Answer 19

• a machine automatically fills and drains the dialysate from the abdomen

Question 20

Hemodialysis

Answer 20

blood filter through dialysis machine “artificial kidney”

• filters out waste products, excess fluid, balances electrolytes
• intermittent (IHD)
• continuous (CRRT)
• Treatment takes 4-5 hours 3X week
  
  • clinic, home dialysis
  • nocturnal dialysis 6-8 hours, 6 nights per week

Question 21

hemodialysis advantages

Answer 21

• shorter time period per treatment
  
  • quickly resolves acute problems
  • patient not required to learn the procedure

Question 22

hemodialysis disadvantages

Answer 22

• difficulty with hemodynamically unstable patient
  
  • problems with vascular access
  • specially trained operator required
  • anti-coagualtion required

Question 23

Vascular Access for Hemodialysis:

central venous catheter

Answer 23

• for temporary or long-term dialysis
  
  • for patient waiting for permanent fistula or graft
  • patient whose fistula or graft is not working
  • for peritoneal dialysis patient who requires hemodialysis
  • types
    
    • direct percutaneous
    • tunnelled
    • implanted port

Question 24

Vascular Access for Hemodialysis:
Arteriovenous Fistula (AVF)

Answer 24

• surgical anastomosis of an artery to vein
  
  • vein wall thickens and dilates
  • requires 2-6 months to mature
  • radial of brachial in non-dominant arm
  • can last up to 20 years ( average 7-9 years)

Question 25

arteriovenous Graft (AVG)

Answer 25

• graft tunnelled under subcutaneous tissue
  
  • diverts blood from artery to vein
  • usually in the arm
  • 1-4 weeks to mature
  • usually last 3 years

Question 26

Post-Op Care of a New Fistula/ Graft

Answer 26

• neuromuscular checks q1h
• elevate arm X 2-3 days
• assess for signs of infection
• tenderness
• blemishes
• bulging
• pulse distal to site
• palpate for a “thrill” and auscultate for a “bruit”
  
  • if these are absent - cannot be the access
  • notify physician

Question 27

Direct Percutaneous Hemodialysis Line

Answer 27

• double lumen - red port and blue port
• must not be used for anything except dialysis:
  
  • ports are flushed with high con heparin
  • dialysis line is their lifeline

Question 28

• Infection control

Answer 28

• infections major cause of death for patient with ERSD (end stage renal disease)
  
  • infection rate much higher with CVC than with fistula or graft

Question 29

• Risk of bleeding

Answer 29

• arterial bleeding is life threatening
  
  • ensure all connections are tight/secured
  • observe site at all times

Question 30

Dialysis Orders -Ordered by Nephrologist

Answer 30

• length of treatment
• blood flow rate
• target fluid loss
• monitoring patient

Question 31

Patient Teaching

Answer 31

• arm exercise start after 10-14 days
  
  • for fistula only
• no heavy lifting
• no tight clothing or jewellery
• avoid prolonged bending, or sleeping on the access arm
• keep site clean and avoid trauma

Question 32

Dialysate

Answer 32

• solution containing prescribed amount of fluid and electrolytes
• used to filter excess fluid and waste products from the body

Question 33

outline the assessments required in caring

for a patient requiring dialysis

Answer 33

• aseptic technique for catheter site
• initial dressing is left intact x 7 days
• assessment of catheter site for any signs of infection
• dressing changes per agency policy

Question 34

Describe the assessments and necessary precautions in caring for a patient with an arteriovenous shunt

Answer 34

• general health, fever, malaise
  
  • weight gain or loss
  • vascular access site
• need to assess each system thoroughly
• monitor urinary output
  
  • patient in complete renal failure may or may not void
  • foamy urine signifies protein loss
  • in and out catheterizations may be ordered q weekly
• on the arm with a fistula or graft
  
  • no BP cuff
  • no bloodwork
  • No IV’s
  • No wrist band
• Medication
  
  • all or part of a medication dose may be eliminated by dialysis
  • depends upon:
    
    • type of drug
    • flow rate of dialysis
    • medication may have to be given after dialysis or additional doses may be give
• Lab tests to monitor fluids, electrolytes and anemia

Question 35

Outline the common complications associated with renal failure and dialysis according to cause, clinical manifestations and nursing interventions

Answer 35

• Cardiovascular system
  
  • affecter by hypervolemia, hyperkalemia and hypocalcemia
• respiratory system
  
  • crackles to lungs
  • hyperventilation compensates for acidosis
  • ammonia odour to breath
• Integumentary System
  
  • affected by the accumulation of waste products
    
    • greyish-bronze pallor
    • thin, dry, fragile skin and nails
    • puritis
    • bruising
• Neurologic system
  
  • peripheral neuropathies - restless legs, burning feet, foot drop, decreased or loss of feeling in legs
  • mental status changes (lethargy, irritability, confusion)
    
    • altered attention span, memory and moods
• Gastrointestinal System
  
  • nausea/vomiting
  • metallic taste in mouth
  • blood glucose levels
  • fluid /food restrictions

Question 36

Describe fluid and dietary restrictions for a patient experiencing renal failure

Answer 36

• based on serum electrolytes and urea
• can include the following:
  
  • increased protein
  • limit potassium, phosphorous and sodium
  • limit fluid (1-1.5 L/day)
  • B complex, ViTamin X, folic acid
  • activated Vitamin D