DIALYSIS

Dialysis
- Removal by artificial means of metabolic wastes, excess electrolytes, and
excess fluid from clients with renal failure using the principles of diffusion and
osmosis.
Purposes of Dialysis:

1. Remove the end products of protein metabolism from the blood.

2. Maintain safe levels of electrolytes
3. Correct acidosis and replenish blood bicarbonate system
4. Remove excess fluid from the blood.

HEMODIALYSIS
- Shunting of blood from the client’s vascular system through an artificial dialyzing
system, and return of dialyzed blood to the client’s circulation
ACCESS ROUTES:

a. External AV shunt
One cannula inserted into an artery and the other into a vein; both are
brought out to the skin surface and connected by a U-shaped shunt

Nursing Care:
1. Auscultate for a bruit and palpate for a thrill to ensure patency
2. Assess for clotting (color change of blood, absence f pulsation in the tubing)
3. Change sterile dressing over shunt daily.
4. AVOID performing venipuncture, administering IV infusions, giving injections,
or taking a BP with a cuff on the shunt arm.

b. AV Fistula

Internal anastomosis of an artery to an adjacent vein in sideways position;

fistula is accessed for hemodialysis by venipuncture; It takes 4-6 weeks to be ready
for use

Nursing Care for AV Fistula:

1. Auscultate for a bruit and palpate for a thrill to ensure patency.
2. Report bleeding, skin discoloration, drainage and pain.
3. AVOID restrictive clothing/ dressing over the site.
4. AVOID administration of IV infusions, giving injections, or taking BP with a
cuff on the fistula extremity
b. Femoral/ Subclavian Cannulation

Insertion of a catheter into one of these large veins for easy access to the
circulation; Procedure is similar to insertion of a CVP line
Nursing Care:
1. Palpate peripheral pulses in cannulized extremity
2. Observe for bleeding/ hematoma formation
3. Position catheter properly to avoid dislodgement during dialysis

Nursing Care: BEFORE & DURING DIALYSIS

1. Have the client void.
2. Chart client’s weight
3. Assess vital signs before and every 30 minutes during the procedure
4. Withhold antihypertensive, sedative and vasodilators unless ordered
otherwise.
5. Ensure bed rest with frequent position changes for comfort.
6. Inform client that headache and nausea may occur.
7. Monitor closely for signs of bleeding since blood has been heparinized for the
procedure
Nursing Care: POST DIALYSIS
1. Chart the client’s weight
2. Assess for complications
a. Hypovolemic Shock
b. Bleeding
c. Dialysis Disequilibrium Syndrome
- nausea, vomiting, elevated BP, disorientation, leg cramps, seizures, and
peripheral paresthesias
d. Air embolism
e. Infections
f. AIDS
g. LVH
h. Bone problems
Key Nursing Diagnosis
1. Risk for infection related to regular exposure of the client’s blood to the
external environment
2. Impaired gas exchange related to altered blood flow during dialysis
3. Risk for deficient fluid volume related to rapid fluid removal and electrolyte
changes during dialysis

PERITONEAL DIALYSIS
Nursing Care:
1. Chart the client’s weight.
2. Assess vital signs before, every 15 minutes during first exchange, and every
hour thereafter.
3. Assemble specially prepared dialysate solution
4. Have a client void
5. Inflow: allow dialysate to flow unrestricted (10-20 minutes)
6. DWELL: Allow the fluid to remain in the peritoneal cavity for prescribed period
(30-45 minutes)
7. DRAIN: Unclamp outflow tube and allow to flow by gravity
8. Observe characteristics of the solution:
CLEAR PALE YELLOW – normal
CLOUDY – infection, peritonitis
BROWNISH – bowel perforation
BLOODY – common initially but abnormal if continuous

9. Assess for complications

a. Peritonitis
b. Respiratory difficulty
c. Protein loss
d. Hypovolemia
Key Nursing Diagnoses
1. Risk for infection related to catheter insertion into the peritoneum
2. Deficient knowledge to unfamiliarity with peritoneal dialysis
3. Risk for deficient fluid volume related to excessive fluid removal during the
procedure.

Peritoneal dialysis

Peritoneal dialysis

In medicine, peritoneal dialysis is a method for removing waste such

as urea and potassium from the blood, as well as excess fluid, when the
kidneys are incapable of this (i.e. in renal failure). It is a form of renal
dialysis, and is thus a renal replacement therapy.

Peritoneal dialysis works on the principle that the peritoneal membrane

that surrounds the intestine, can act as a natural semipermeable
membrane (see dialysis), and that if a specially formulated dialysis fluid
is instilled around the membrane then dialysis can occur, by diffusion.
Excess fluid can also be removed by osmosis, by altering the
concentration of glucose in the fluid.
Dialysis fluid is instilled via a peritoneal dialysis catheter, (the most
common type is called a Tenckhoff Catheter) which is placed in the
patient's abdomen, running from the peritoneum out to the surface,
near the navel. Peritoneal dialysis catheters may also be tunnelled
under the skin and exit alternate locations such as near the rib margin
or sternum (called a presternal catheter), or even up near the clavicle.
This is done as a short surgery. The exit site is chosen based on
surgeon's or patient's preference and can be influenced by anatomy or
hygiene issues.

Peritoneal dialysis is typically done in the patient's home and

workplace, but can be done almost anywhere; a clean area to work, a
way to elevate the bag of dialysis fluid and a method of warming the
fluid are all that is needed. The main consideration is the potential for
infection. Peritonitis is the most common serious complication, but with
good technique can usually be avoided. Infections of the catheter's exit
site or "tunnel" (path from the peritoneum to the exit site) are less
serious. Because of this, patients are advised to take a number of
precautions against infection.

Types of peritoneal dialysis

There are three types of peritoneal dialysis.

• Continuous ambulatory peritoneal dialysis (CAPD), the

most common type, needs no machine and can be done at home.
Exchanges of fluid are done throughout the day, usually four
exchanges a day.
• Continuous cyclic peritoneal dialysis (CCPD) uses a machine
and is usually performed at night when the person is sleeping.
• Intermittent peritoneal dialysis (IPD) uses the same type of
machine as CCPD - if done overnight is called Nocturnal
intermittent peritoneal dialysis (NIPD).

Advantages and disadvantages of

peritoneal dialysis
]Advantages

• Can be done at home.

• Relatively easy to learn.
• Easy to travel with, bags of solution are easy to take on holiday.
• Fluid balance is usually easier than on hemodialysis
 • Theoretically better to start dialysis on, as native urine output is
maintained for longer than on hemodialysis.
• Excluding kidney transplant, PD is first choice method in treating
chronic kidney failure.

Disadvantages

• Requires a degree of motivation and attention to cleanliness

while performing exchanges.
• Possible complications (see below).

Side-effects and complications

Peritoneal dialysis requires access to the peritoneum. As this access
breaks normal skin barriers, and as people with renal failure generally
have a slightly suppressed immune system, infection is a relatively
common problem. With the development of prophylactic therapies,
infection rates have been dramatically decreased.

The infections can be localized, as in an exit-site or tunnel infection,

where the infection is limited to the skin or soft tissue around the
catheter. Infections that reach the peritoneum (peritonitis) are more
serious, and will likely require antibiotics and/or supportive care. If the
peritonitis is severe, removal of the catheter and a change of renal
replacement therapy modality to hemodialysis may be necessary.
Occasionally, severe peritonitis may be life-threatening.

Because external infections can travel into the peritoneum, it is crucial

that the any signs of infection at the exit site be called to the attention
of a health-care provider. Signs of infection include redness,
tenderness, and drainage. Quick treatment of exit site infections are
very important to avoid the more serious complications that may
jeopardize health, continued use of PD, or even life.

Long term peritoneal dialysis can cause changes in the peritoneal

membrane, making it less permeable and causing it to no longer act as
a dialysis membrane as well as it used to. This loss of function can
manifest as a loss of dialysis adequacy, or poorer fluid exchange (also
known as ultrafiltration failure). It may also cause diabetes because
of the glucose levels that are in the 'bags'

Other complications that can occur are fluid leaks into surrounding soft
tissue, often the scrotum in males. Hernias are another problem that
can occur due to the abdominal fluid load. These often require repair
before peritoneal dialysis is recommenced.

Also, a common issue that arises in PD patients is the accumulation of

fibrin in the PD effluent. This can cause draining and/or filling issues if
too much collects in or around the catheter inside the peritoneum. To
break up the fibrin, Heparin must be injected into the bags of dialysate
(generally 1mL Heparin per liter of dialysate) until the fibrin clears up.
One sign of peritonitis is the accumulation of very large amounts of
fibrin in the PD effluent.

Step-by-step description of peritoneal

dialysis (a CAPD exchange)
1. The supplies and materials needed for an exchange are.. Notable
amongst these is a bag of dialysis fluid (also called dialysis
solution), a solution comprised of a known amount of a glucose
dissolved in water. The strength of this solution determines the
osmotic gradient, and therefore the amount of water that diffuses
out of the bloodstream. Common strengths of glucose are 0.5%,
1.5%, 2.5% and 4.25%. 1.5% is approximately fluid-neutral; it
neither adds nor removes fluid and is used for patients who are
primarily concerned with waste removal rather than fluid
regulation. Higher concentrations lead to greater water removal.
A higher dextrose concentration moves fluid and more wastes
into the abdominal cavity, increasing both early and long-dwell
exchange efficiency. Eventually, however, the body absorbs
dextrose from the solution. As the concentration of dextrose in
the body comes closer to that in the solution, dialysis becomes
less effective, and fluid is slowly absorbed from the abdominal
cavity. Electrolytes are also present in the fluid to maintain
proper body levels. Patients weigh themselves, and measure
temperature and blood pressure daily to determine whether the
body is retaining fluid and, thus, what strength of fluid to use.
Dialysis fluid typically comes premixed in a disposable bag-and-
tube apparatus; no additional equipment is needed. The
apparatus consists of two bags, one empty and one with the fluid,
connected via flexible tubing to a Y-shaped fitting. The bag is
heated to body temperature, to avoid causing cramping. Dry heat
is used; common methods include microwaves (NOT
recommended), heating pads and solar radiation (often using the
dashboard of a car, for instance while travelling).
2. The patient, who performs the entire procedure themselves, dons
a disposable surgical mask, scrubs their hands using antibacterial
soap, and tucks a clean towel into the waistband of their pants to
 protect their clothing. The bag of dialysis fluid is removed from
the protective packaging, and is hung from an IV stand or other
elevated location, such as a coat hook. The tubing attached to
the bag of fluid is uncoiled, and the second (empty) bag is placed
on the floor. The Y-shaped connector is attached to the catheter
tip; a protective cap must be removed from both of these before
the connection is made, and the two portions of the connector
are not permitted to touch anything, to avoid possible
contamination.
3. Once connected to the system, the patient clamps the tubing
connected to the full bag of dialysis fluid and then releases the
twist valve located in the tip of their catheter; this permits fluid to
flow into or out of the peritoneal cavity. Because the full bag of
fluid is clamped off but the empty bag is not, the effluent (used
dialysis fluid) from within the peritoneum can drain out of the
catheter and into the lower, waste bag. Emptying the abdomen of
fluid takes approximately fifteen minutes, and the patient is free
to perform tasks such as reading, watching television and
browsing the internet.
4. When the abdomen has drained, the lower drain-bag is clamped
off. The twist valve in the catheter is also closed. The clamp is
then removed from the upper tubing, permitting dialysis fluid to
drain out into the abdomen. The clamp to the drain bag is briefly
opened and some fluid is drained directly from the upper bag into
the lower bag. This clears the line of air and other impurities. The
drain line is then clamped off and the twist valve on the catheter
end is opened. This permits fluid to enter the peritoneum. Filling
the abdomen with fresh fluid takes about fifteen minutes, and the
patient enjoys the same freedoms as while draining.
5. Once the entire bag of fluid (an amount varying primarily based
on body size, ranging from 1500 to 3000 mL) has been
introduced to the abdomen, the patient then cleans their hands
again (typically using an antiseptic alcohol-based cleanser) and
puts the surgical mask on. The Y-connector is detached from the
catheter tip and a protective cap is placed on the end of the
catheter.

The effluent is inspected after a dialysis exchange is complete; a

cloudy effluent indicates probable peritoneal infection. The effluent is
drained into a toilet, and the various dialysis supplies are di