RRT Flashcards
1
Q
Is dialysis acute or chronic
A
Both
2
Q
Indications for acute dialysis
A
- Persistent hyperkalemia
- Fluid overload, hypertension
- Impending pulmonary edema (Fluid overload)
- Increasing metabolic acidosis
- Pericarditis
- Advanced uremia
- Remove toxic meds or overdose
- Edema unresponsive to other treatments
- Hepatic coma, uremic encephalopathy, hypercalcemia
3
Q
Indications for chronic or maintence dialysis
A
- Advanced CKD or ESKD
- Uremic signs and symptoms, N+V severe anorexia, increased lethargy, mental confusion
- Hyperkalemia
- Fluid overload not responsive to diuretics and fluid restrictions
4
Q
Hemodialysis
A
- Prevents death, not a cure
- Known as artificial kidney
- Can be done intermittently, outpatient, and at home
5
Q
Intermittent hemodialysis:
A
3x a week for 3-5 hours
6
Q
Outpatient dialysis
A
Dialysis center clinic/hospital
7
Q
Home dialysis
A
- Patient and caregiver, treatment time and frequency is flexible
8
Q
Principles of Hemodialysis
A
- Diffusion
- Osmosis with ultrafiltration
9
Q
How does hemodialysis work
A
- homeostasis/ body’s buffer system is maintained by dialysate bath (Bicarb or acetate)
- Heparin, anticoagulant used to keep blood clotting within the dialysis machine
10
Q
Goal of hemodialysis
A
- Cleansed blood returned to the body
- Fluid removal
- Electrolyte balance
- Acid base control, correcting acidosis
11
Q
Components of hemodialysis
A
- Dialyzer
- Dialysate/ dialysis bath
- Dialysis machine
- Water treatment
12
Q
Dialyzer
A
- Hollow fiber devices containing thousands of tiny capillary tubes that carry the blood through the artificial kidney
- Semi Permeable membranes allow toxins, fluids, electrolytes to pass across the membranes
- Constant flow of solution (Dialysate bath) maintains concentration gradient (Osmosis) to facilitate exchange of waste from blood across from the semipermeable membrane into the dialysate solution where they are removed and discarded
13
Q
Dialysis: Vascular access
A
- Known as the lifeline
- Central venous cath (CVC)
- Arteriovenous fistula (AVF)
- Arteriovenous graft (AVG)
14
Q
Vascular access device: CVC
A
- Double lumen, large bore (SC, IJ or femoral vein)
- Risks: hematoma, pneumothorax, infection, thrombosis , inadequate flow
- Cath removed when no longer needed, resolved Renal failure or perm access established
15
Q
Arteriovenous fistula (AVF)
A
- Created surgically
- Usually in the forearm by joining an artery to a vein
- Needles are inserted into the vessel to obtain blood flow adequate to pass through the dialyzer
- Venous segment dilates due to increased blood flow coming directly from the artery, once dilated it will accommodate 2 large bore needles (14-16 gauge)
- Arterial and venous segment
- Longest useful life and thus the best option for vascular access
Check the presence of a bruit and thrill
16
Q
AVF: Arterial segment
A
- Fistula for arterial flow to the dialyzer
17
Q
AVF: Venous segment
A
For reinfusion of dialyzed blood
Back to arm
18
Q
How long does it take for a AVF to establish
A
- 2-3 mo to establish
19
Q
Arteriovenous graft (AVG)
A
- Created by subcutaneously interposing a biologic, semi biologic or synthetic graft material between an artery and vein
- Graft is created when a patients vessels are not suitable for AVF
Check the presence of a bruit and thrill
20
Q
Complications of a AVG
A
Stenosis, infection, thrombosis
21
Q
Complications of hemodialysis
A
- Hypotension: From fluid removal (N+V, diaphoresis, tachycardia, dizziness)
- Malnutrition
- Bone pain and fractures from poor calcium metabolism and renal osteodystrophy
- Calcification of major blood vessels
- Phosphorus deposits in skin causing itching
- Seizures
- Major sleep issues
- Episodes of SOB often occur as fluid accumulates between dialysis treatments
- Painful muscle cramping , late into dialysis as fluid and electrolytes leave the extracellular space
- Exsanguination: Blood lines separate or dialysis needles become dislodged
- Dysrhythmias from electrolyte and PH changes from removal of antiarrhythmic meds during dialysis
- Air embolism
- Chest pain from anemia or arteriosclerotic heart disease
- Dialysis disequilibrium syndrome
22
Q
Dialysis disequilibrium syndrome (DES)
A
- Occurs from cerebral fluid shift
- S+S:
- HA, N+V restlessness, decreased LOC, seizures
- Mgmt
- Prevention
- Stop dialysis
- Supportive care: ABC, maintain airway, saline infusion (Hypertonic)
23
Q
Nursing mgmt of dialysis
A
- Monitoring, supporting, assessing ,educating the patients and caregiver. Being their advocate
- Constant monitoring during dialysis to avoid complications
-
Protecting vascular access
- No blood pressure venipuncture tight dressing, restraints
Assess for bruit and thrill
- No blood pressure venipuncture tight dressing, restraints
24
Q
Pharm therapy of dialysis
A
- Adjust dosage or timing of meds
- water soluble medications are readily removed (Vit B, C)
- Administered antibiotics post dialysis
- Fat soluble or protein binding meds: not easily dialyzed
- Hold BP meds prior to dialysis
- Anticoagulation
25
Nutritional and fluid therapy
* Goal of nutritional therapy: Minimize uremic symptoms and fluid and electrolyte imbalances
* Maintain good nutritional status through adequate protein calories and vitamin and mineral
* Enable the pt to eat a palatable and enjoyable diet
* **Restriction of dietary protein decreases the accumulation of nitrogenous waste, reducing uremic symptoms**
* **Fluid restrictions**
* **Potassium restriction**
* Lifestyle changes in social situations
26
Goal for interdialytic weight gain
* Weight gain under 1.5 kg
27
Home hemodialysis
* Flexibility: Allows travel, vacations, work and family activities
* Requires someone willing to take initiative for their health
* Requires commitment and cooperation of a caregiver to assist the patient
* Home environment is assessed and modified electrical outlets, plumbing facilities,storage
28
Home hemodialysis: Training
* Prepare, operate, disassemble, dialysis machine
* Maintain and clean equipment
* admin meds: Heparin
* Handle emergency problems : Electrical and mechanical problems, hypotension, shock , seizures : On call RN
* Home care nurse: evaluate compliance with techniques: assess pt for complications, reinforce instructions. provide reassurance
29
Continuous renal replacement therapy (CRRT)
* Main thing is that it replaces continuously, and its only for **Critically ill patients**
* Used for clinically unstable for traditional hemodialysis
* Methods are similar except its 24/7 for several days
30
Peritoneal dialysis (PD): Goal
* Removal of toxic substances and metabolic waste to reestablish normal fluid and electrolyte balance
31
Indications for PD
* Pt is unable or unwilling to undergo HD
* Pt is susceptible to rapid fluid, electrolyte and metabolic changes with HD
* DM or CVD (Bad Vasculature)
* Older Pts
* risk for adverse effects of systemic heparin
* Severe Hypertension, HF, Pulmonary edema not responsive to usual treatment regimens
32
PD is not indicated for who
* Pts with history of major abdominal surgery
* Altered LOC, dexterity issues, and other physical limitations (Arthritis), pt needs to be able to discontinue pump and stay on top of it
* Environment at home that is not suitable (Hoarders)
33
PD cath
* Soft and flexible with radiopaque strip, for x-ray visualization
* PD cath: nondominant side to allow easy access to cath connection site when exchanges are done
34
PD: Overview
* Peritoneal membrane: serves as semipermeable membrane
* Sterile dextrose dialysate fluid is put into peritoneal cavity through abdominal catheter at established intervals
* This solution is hypertonic (1.5, 2.5, 4.25) with the amount ranging from 1-3L
* Clearance via **diffusion and osmosis**
* Ultrafiltration: increased with higher glucose concentration
35
Ultrafiltration
Removal of fluid
36
PD: exchange
* Entire cycle including infusion (fill), dwell and drainage of dialysate
37
PD: Dialysate
* 2-3L
* Infused by gravity into the peritoneal cavity for about 5-10 min
* Prescribed dwell, equilibrium time allows for diffusion and osmosis
38
Peritoneal dialysis (PD): Drain
PD cath unclamped, solution drains from peritoneal cavity by gravity through a closed system for about 10-20 min
39
CAPD
* Continuous ambulatory peritoneal dialysis
* Manual
40
CCPD
* Continuous cycling peritoneal dialysis
* Machine automatically performs exchanges usually at night
41
PD: effluent
* Drainage color, colorless or straw colored, should be clear not cloudy
42
PD: Bloody drainage
* Would be normal for the first exchanges after insertion of a new cath
43
How is the number of echanges determined: PD
Based on lab values and uremic symptoms
44
Complications of PD: Peritonitis
* Most common and most serious complication
* Cloudy dialysate drainage fluid (Sent to lab for culture)
* Hypotension and shock (sepsis)
* Send effluent for cell count, gram stain and culture
* Antibiotics agents (Aminoglycosides or cephalosporins added to the exchanges)
* Intraperitoneal antibiotic agents
* Antibiotics for 10-14 days
45
Complications for PD
* Abdominal hernias: from increased intraabdominal pressure
* Hiatal hernia and hemorrhoids
* Low back pain and anorexia
* Mechanical problems
* Fibrin clots in PD cath
* Constipation
46
Main teaching for PD
* Aseptic technique: Need to maintain sterility
* Monitor vitals, weight, I+O, lab values
* Evaluate fluid status (edema)
47
PD troubleshooting
* Less drainage: turn patient side to side or raise HOB
* Check cath patency, kinks, closed clamps
* Secure intact, dry dressing
* Skin care
* Patient and family education: Fluid weight loss, lab values
* Emotional support, encouragement
48
Advantages of PD
* No hemodialysis machine: no venipuncture
* Control over daily activities: gain a sense of well being
* **More liberal diet**
49
Disadvantage of PD
Continuous dialysis 24 hours a day 7 days a week
50
Kidney transplantation
* Treatment of choice for most pts with ESKD: long waiting list tho
* Advantages
* No dialysis
* Improved sense of well being (More normal life)
* Cost is 1/3 of dialysis
* Elective procedure: need too be in best possible condition prior to transplant
51
Main contraindications for Kidney transplant
* Recent malignancy
* Active or chronic infection
* Severe irreversible, extrarenal disease (Inoperable CD, Chronic lung disease, severe PVD)
* Active infection (HIV, hep B/C)
* Obesity (BMI greater than 35)
* Current substance abuse
* Inability to give informed consent
* History of non adherence to treatment regimens
* Hypertension and diabetes
| **Donors can be rejected for the same reasons**
52
Nursing mgmt: kidney transplant
* Assess urinary function and overall wellbeing
* Assess transplant rejection
* Lifetime **immunosuppression**
* Interdisciplinary care
* Support groups and referrals
53
S+S transplant rejection
* Oliguria
* Edema
* Fever
* Increasing blood pressure
* Weight gain
* Swelling or tenderness over transplanted kidney site
## Footnote
Needs follow up care
