nursing care of patient undergoing dialysis

1. DIALYSIS

2. Introduction
Dialysis refers to diffusion of solid molecules through
semipermeable membrane passing from higher concentration
to lower concentration.
The main purpose is to :
 Maintain fluid , electrolyte and acid base balance.
 To remove endogenous and exogenous toxins.
It is substitute for some kidney excretory function but does not
replace the kidneys endocrine function.

3. Types
Haemodialysis
Peritonial dialysis

4. Haemodialysis
 Hemo = blood , dialysis = seprate
 It is the process of cleaning the blood of accumulated
waste product.
 It is used for the patient who is acutely ill and and require
short term dialysis (days to week ) and for the patients with
advanced CKD and ESRD who required longterm or
permanent treatment.
It prevent death but don’t cure disease.
 3 times a week with an average 3-4 hours in outpatient
settings.

5. Indication
 Clinical
Fluid overloads not responding to diuretics .
Uremic convulsion.
Persistent dyspnea , vomiting and restlessness.
Signs of pericarditis , pericardial effusion and
 pericardial frictional rub.

6. Cont…
 Biochemical
Chemical ARF CRF
Urea 35 mmol/l >40 mmol/l
Creatinine >700 mmol/l >1000 mmol /l
Potassium >6.5 meq /l 6.5 meq/l
Ph <7.1 <7.1
Bicarbonate <12 <12

7. Requirements of hemodialysis
 Access to patient circulation .
 Dialysis machine .
 Dialyzer .
 Appropriate dialysate bath .

8.  Methods of circulatory access
1. Arteriovenous fistula ( AVF ) : It is preferred
method of vascular access. It is created by
joining an artery to a vein , either side to
side or end to side.
Usually , radial artery and cephalic vein are
anastomosed in non dominant arm ;
vessels in the upper arm may also be used.
After the procedure the superficial venous
system of arm dilates.

9. Circulatory access cont…
By the means of 2 large bore needles inserted into the
dilated venous system, blood may be obtained and
passed thrugh the dialyzer.
The arterial end is used for arterial flow and the distal
end is used for reinfusion of dialysed blood.
Healing of AVF requires at least 6 to 8 weeks ; the centre vain
is used for interim.

10. Cont…
2. Arteriovenous Graft : Arteriovenous
connection consisting of a tube graft made
from autologous saphenous vein or from
polytetrafluoroethylene . Usually graft is
created when the patient’s vessels are not
suitable for creation of an AV fistula. Patient
with compromised vascular system ( e.g.
diabetes ) will graft because their native
vessels are not suitable for creation of fistula.
Ready to use in 3 to 4 weeks.

11. Circulatory access cont…

12. Circulatory access cont…
 Centeral vein catheter : Direct
cannulation of vein (subclavian vein ,
internal jugular or femoral ); may be
used as temporary or permanent dialysis
access.

13. Dialysis meachine

14. Dialyser
 It is hollow fiber devices containing thousand of tiny straw like
tubes that carry the blood through the dialyzer.
 The tube are porous and act as semipermeable membrane
allowing toxins fluid and electrolytes to pass through.
 The constant flow of solution maintain the concentration
gradient to to facilate the exchange of wastes from the blood
through semi permeable membrane into the dialysate solution
where they are removed and discard.

15.  Dialysate
 It is a solution made up of all
the important electrolyte in
their extracellular
concentration.
 Dialysis solution is:
Highly purified water
Na,K, Ca, Mg, Cl, &
dextrose
Either bicarbonate or
acetate, to maintain a
proper pH

16. Physiological principles
1. Diffusion : The toxins and wastes in blood are removed by
diffusion i.e they move from an area of higher concentration
in blood to an area of lower concentration in the dialysate.
2. Osmosis : Excess water I removed from blood by osmosis ,
in which water move from an area of lower concentration
potential to an area of high concentration potential.
3. Ultrafiltration : Created by increased pressure in the blood
compartment or a decreased pressure in the dialysate
compartment. In this water moves under high pressure to
an area of low pressure.

17. Direction of blood and dialysate flow in
artificial kidney
 Blood flow by one side of
semipermeable membrane
and a dialysate or fluid
flows by the opposite side
or the blood flow in one
direction and the dialysate
in opposite direction.

18. Complications
 Acute Complications
1. Hypotension
2. Muscle cramp
3. Disequilibrium
syndrome
4. Pruritus
5. Hypoglycemia
6. Hypokalemia
7. Dysrhythmia
8. Air embolus
9. Hemolysis

19. Cont…
1. Arterial disease
2. Hypertension
3. Anaemis
4. Osteodystrophy
5. Acquired renal cysts.
6. Malnutrition
8. Dialysis dementia
9. Respiratory problems
10.Endocraniopathies
 Chronic Complications

20. Care of blood access fistula or graft
1. Proper exercise by squeezing of hand .
2. Avoid heavy lifting .
3. Avoid pressure while sleeping .
4. Avoid any pricks .
5. Avoid taking BP on access hand.
6. Keep access clean all time, do not use any cream or lotions
on the vascular site .
7. Avoid wearing jewellery and tight clothes .

21. Cont…
8. Listen for bruit at the site by placing the diaphragm of
stethoscope gently on the site .
9. Check the functioning of vascular access several times a
day by palpating the site for a thrill , which is buzzing or
pulsing feeling that indicates good blood flow through the
access site .
10.Assess the vascular site for any signs of infection such as
redness , warmth , tenderness ,open sores and swelling .

22. NURSING MANAGEMENT

23. Before dialysis
1. Explanation about the procedure /duration ,expected
outcomes and possible complications .
2. Informed consent .
3. Collect all the investigations report .
4. Check vital signs :BP for hypo and hypertension;
temperature for sepsis; respiration for fluid overload.
5. Weight: Determines amount of fluid to be removed during
dialysis and patient’s clinical conditioning before starting .
6. Check efficiency of AV fistula .

24. Cont…
7. Review Medications : Hold drugs that pass through the
dialysis membrane, such as piperacillin, folic acid, and
other water-soluble vitamins. Hold antihypertensive drugs,
especially if systolic pressure is below 100, per physician
order .
8. Preparation of dialyzer –arterial venous tubing
9. Preparation of dialysis sets/area .
10.Setting of emergency cart .
11.Preparation of procedure area .
12.Start dialysis .

25. During dialysis
1. Monitor vital signs in every 15 minutes .
2. Provide comfortable position , diversional activities to
promote comfort and help to pass time .
3. Assess for dialysis disequilibrium syndrome , with
headache , nausea and vomiting , altered LOC , and
hypertension .Rapid change in the BUN and electrolytes
level lead to cerebral edema and increased ICP .

26. Cont…
4. Assess for the other responses to dialysis such as
dehydration , nausea , vomiting , muscle cramps or seizure
activity .
5. If a transfusion is given during dialysis , monitor for the
possible transfusion reaction .
6. Assess for bleeding at the access site or elsewhere.
Heparinization during dialysis increases the risk for
bleeding.

27. After dialysis
1. Positioning of patient as comfortable .
2. Monitor vital signs and status of patient .
3. Carefully removing of arterial and venous tubing and apply
effective pressure on that area to prevent bleeding .
4. Record the outcome .
5. Inform patient and visitors for next date of dialysis .
6. Explain about the home care including fistula care .