Introduction to dialysis, medical surgical nursing-1, for b. Sc nursing , self study material, prepared for online presentation.

1. Introduction to Dialysis
Prepared and presented by
Mr.Sarathchandran M.B
Nursing Tutor.
Swami Vivekananda College Of Nursing.
Udgir, Maharashtra.

2. Introduction to Dialysis
Subject: Medical Surgical Nursing -1
Unit: III
Topic: Introduction to Dialysis
Time duration: 60 Minutes x2=120 minutes
Group: B.Sc Nursing II Year

3. Introduction to Dialysis
General objective:After going through this content thoroughly the students will
have more confidence to deal people undergoing dialysis.
Specific Objective: After the lecture as per plan students will be able to
● Define Dialysis
● Indications for it.
● Types of Dialysis
● Hemodialysis
● Peritoneal Dialysis
● Nurses responsibility in caring clients undergoing dialysis.
Reference: https://www.healthline.com/health/dialysis#risks.
https://www.mayoclinic.org/tests-procedures/peritoneal-dialysis/about/pac-20384725

4. Content
● Introduction of dialysis
● Types Dialysis process
● Physiological principles of dialysis
● Hemodialysis dialysis
● Types of peritoneal dialysis
● Indications Complications
● Nursing care :
○ Before dialysis
○ During dialysis and
○ After dialysis
○ Patent Education

5. 10 mins
Introduction and
definitions, Types.
15 mins
Hemodialysis Process,
The Principles
10mins
Vascular Access for
Hemodialysis
15 mins
Pre-Intra-Post Dialysis
Care
10 mins
Nursing
Responsibility

6. 5 mins
Introduction and definitions,
Peritoneal Dialysis.
15 mins
Types of Peritoneal
Dialysis.
10mins
Indications and
contraindications
15 mins
Disadvantages and
complications of
Peritoneal Dialysis.
10 mins
Nursing Responsibility in
Peritoneal Dialysis.

7. INTRODUCTION AND DEFINITION
Introduction: The kidneys filter your blood by removing waste and excess fluid from your body. This
waste is sent to the bladder to be eliminated when you urinate.Dialysis performs the function of the
kidneys if they’ve failed temporarily or permanently. It has been practiced since the 1940s.
Definitions:
● In medicine, dialysis is the process of removing excess water, solutes, metabolic byproducts
and toxins from the blood in people whose kidneys can not perform these functions naturally.
● the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney.
What it is ? and What its not?
● Do: waste removal and fluid removal.
● Do Not Do not correct the endocrine functions of the kidney. Hence , dialysis is not a cure for
kidney failure.
Types: There are mainly two types: 1. Hemodialysis. 2. Peritoneal dialysis.
1. Hemodialysis: In this dialysis is accomplished using a machine and a dialyzer , also referred to as
an "artificial kidney." Hemodialysis is used to treat both acute (temporary) and chronic (permanent)
kidney failure. Nearly 90% of patients receives Hemodialysis.
2. Peritoneal dialysis: Peritoneal dialysis is a type of dialysis which uses the peritoneum in a person's
abdomen as the membrane through which fluid and dissolved substances are exchanged with the
blood. Approximately 10-15 patients are receiving peritoneal dialysis.

8. Hemodialysis:
● In hemodialysis blood is removed from the body and filtered through a man-made membrane called a dialyzer,
or artificial kidney, and then the filtered blood is returned to the body.
● Dialyzer
○ It is a hollow-fiber artificial kidneys that contain thousands of tiny tubules that act as semipermeable
membranes.The blood flows through the tubules, while a solution (the dialysate) circulates around the
tubules.The blood flows in one direction and the dialysate flows in the opposite.
○ The exchange of wastes from the blood to the dialysate occurs through the semipermeable membrane
of the tubules.
○ Hemodialysis usually is done three times a week. Each treatment lasts from 2 to 4 hours.
Principles of Hemodialysis are mainly three: Osmosis, Diffusion, and Ultrafiltration.
● Diffusion: The movement of solutes from an area of greater concentration to an area of lower concentration.
○ In renal failure urea, creatinine, uric acid, and electrolytes( Potassium, phosphate), move from the blood
to the dialysate with the net effect of lowering their concentration in the blood.
○ But WBC’s, RBC’s and other contents within the blood are too large to diffuse across the membrane
● Osmosis: The movement of fluid from an area of lesser to an area of greater concentration of solutes.
○ Glucose is added to the dialyzing solution and creates an osmotic gradient across the membrane to
remove excess fluid from the blood.
● Ultra filtration:Ultrafiltration is defined as water moving under high pressure to an area of lower pressure. This
process is much more efficient at water removal than osmosis.
○ It is accomplished by applying negative pressure or a suctioning force to the dialysis membrane.

9. Schematic Diagram of Hemodialysis process and Structure of Dialyzer
Hemodialysis Process Dialyzer Structure

11. Vascular Access in Hemodialysis:
● A hemodialysis access, or vascular access, is a way to reach the blood for hemodialysis. Proper vascular
system must be established to allow adequate amount of blood to be removed, cleansed, and returned to
the patient’s vascular system frequently in most of the clients. An access is placed by a minor surgery.
● Types of access are available.
○ Temporary Catheter: Cuffed, Non cuffed.
- Non-cuffed tunneled catheters are used for emergencies and for short periods (up to 3 weeks).
- Tunneled cuffed catheters, a type recommended by the NKF for temporary access, can be used for
longer than 3 weeks or when AV fistula or graft has been placed but is not yet ready for use(4 to 6
weeks to mature fistula and dilate enough).
○ AV Fistula: An arteriovenous fistula is a surgically created abnormal connection or passageway
between an artery and a vein for hemodialysis treatments. Done usually in the forearm by joining an
artery to a vein either side to side or end to side . It's a preferred for permanent access.
○ AV Graft: An AV graft is the surgical created connection of a vein and an artery that utilizes a hollow,
biologic, semi biologic, or synthetic graft tube (the actual “graft”) for hemodialysis..The graft is usually
placed in the forearm or upper arm, but may be placed in the leg (upper thigh) if necessary.
● Taking care of fistula:
○ Check the access before and after each treatment, Keep the skin over access area clean.
○ Use the access site only for dialysis, assess blood pressure from non access arm.
○ Avoid sleeping on access arm under head or body. Wear loose clothing and jewelry over the access.
○ Protect arm from injury, Do not lift heavy objects or put pressure on access arm.

12. AV Fistula / AV Graft Temporary Catheter

13. PREDIALYSIS CARE
● Use standard precautions is very important in all the time with client.
● Informed Consent after proper Explanation and Assurance , Ask the patient to void.
● Withhold antihypertensive on the day of HD.
● Assess vital signs every 30 minutes, including orthostatic blood pressures (lying, sitting, and standing),
apical pulse, respirations, and lung sounds. (These data provide baseline information to help evaluate the
effects of hemodialysis. )
○ Hypertension may indicate excess fluid volume. The client who is hypotensive may not tolerate rapid
fluid volume changes during dialysis.
○ Abnormal heart sounds (e.g., a gallop or murmur) and changes in heart rate or rhythm may indicate
excess fluid volume or electrolyte imbalance.
○ Fluid overload may also cause dyspnea, tachypnea, and rales or crackles in the lungs.
● Record weight.Weight changes are an effective indicator of fluid volume.
● Assess vascular access site for a palpable pulsation or vibration and bruit(audible vascular sound) and for
inflammation. Infection and thrombus formation are the most common problems affecting the access site in
hemodialysis clients.
● Alert all personnel to avoid using the extremity with the vascular access site (or the nondominant arm, if
long-term access has not been established) for blood pressures or venipuncture. These procedures may
damage vessels and lead to failure of the AV fistula

14. INTRA AND POST DIALYSIS CARE
During Dialysis (Duration is generally 2 to 4 hours. )
● Continue to check and record vitals/15 min, Regular observation of Adverse reactions or complications.
○ Hypotension, Muscles cramps,Clot formation, Septicemia,Hepatitis, Disequilibrium syndrome are
commonly expected.
● Fluid removal during dialysis should be less than 13 cc/kg/hr to avoid risk, but that even at 10cc/kg/hr or
decreasing the mortality further. (700cc or ml /hr from one weighing 70kg x4 = 2.8 liter.
● Assess for bleeding at puncture site or elsewhere during dialysis and as well as after removal of needle.
● During treatment, serve foods as patient’s interest ( not for hypotensive prone patients). Pt. is allowed to
read, write, sleep, talk, or watch TV, back care and other diversional therapies also can be given.
After Dialysis:
● Continue to assess and document vital signs, weight, total RF and vascular access site condition. Rapid
fluid and solute removal during dialysis may lead to orthostatic hypotension, cardiopulmonary changes &
weight loss.
● Assess for other adverse responses to dialysis, such as dehydration, nausea and vomiting, muscle
cramps, or seizure activity. Treat as ordered. Excess fluid removal and rapid changes in electrolyte
balance can cause fluid deficit, nausea, vomiting, and seizure activity.
● Monitor BUN, serum creatinine, serum electrolyte, and hematocrit levels between dialysis treatments. These
values help determine the effectiveness of the treatment, the need for fluid and diet restrictions, and the
timing of future dialysis sessions.

15. POST DIALYSIS CARE
● Assess for dialysis disequilibrium syndrome, with headache, nausea and vomiting, altered level of
consciousness; and hypertension. It due to rapid changes in BUN, pH, and electrolyte levels during dialysis
may lead to cerebral edema and increased intracranial pressure.
● The anemia associated with renal failure does not improve with dialysis, and iron and folate supplements or
periodic blood transfusions may be needed.
● Renal failure and heparinization during dialysis increase the risk for bleeding. Take bleeding precautions.
● Frequent exposure to blood and blood products increase the risk for hepatitis B or C or other bloodborne
diseases, take precautions.
● Clients in renal failure may receive multiple transfusions, increasing the risk of transfusion reaction.
Close monitoring during to identify early signs of a reaction if a transfusion is given during dialysis.(e.g.,
chills and fever; dyspnea; chest, back, or arm pain; and urticaria or itching).
● Provide psychological support
○ Listen actively and address concerns and accept responses such as anger, depression, and
noncompliance. Grieving is treated as a normal response to loss of organ function.
○ Reinforce client and family strengths in coping with renal failure and hemodialysis.
○ The client may feel hopeless or helpless and resent dependence on a machine.
○ The nurse can help the client and family work through these responses and focus on positive
aspects of living. Refer to social services and counseling as indicated.

16. POST DIALYSIS CARE
● Clients with renal failure may need additional support services to help them adapt to and live with their
disease, do the needful.
● Fatigue, where you feel tired and exhausted all the time, is a common side effect in people who use either
form of dialysis on a long-term basis., Suggest activity intolerance management nursing interventions.
● Explain about the care necessary and about diet after HD(can be applied in peritoneal dialysis too).
○ Eat high-quality protein because it produces less waste for removal during dialysis. High-quality
protein comes from meat, poultry, fish, and eggs.
○ Avoid too much potassium diet: Milk-based recipes are high in mineral phosphorus and potassium.to
limit foods such as milk, cheese, and nuts, etc
○ Pineapple makes a sweet, low potassium alternative for those with kidneys problems. Plus, pineapple
is rich in fiber, manganese, vitamin C, and bromelain, an enzyme that helps reduce inflammation.
○ To limit fluid intake and also to avoid excess salt, Most dialysis patients need to limit their fluid intake
to 32 ounces per day. Techniques to manage your thirst/reduce thirst..
○ Dietitian can help you find ways to manage your thirst such as sugar-free hard candies, ice chips, or
frozen grapes. This will help you avoid drinking too much fluid between dialysis treatments.
● Record the condition of the patient, Medications as ordered and administered ( if any).
● Inform the family and patient of date for next dialysis. Send the patient home or ward.

17. Peritoneal Dialysis
● Peritoneal dialysis is a type of dialysis which uses the peritoneum in a person's abdomen as the
membrane through which fluid and dissolved substances are exchanged with the blood. It is used to
remove excess fluid, correct electrolyte problems, and remove toxins in those with kidney failure.
(Peritoneal dialysis was first carried out in the 1920s; however, long term use started from 1968s).Peritoneal
Dialysis Cheaper than Hemodialysis Worldwide.
● Process:
○ The dialysate flows into your abdomen(peritoneal cavity) and stays there for a prescribed period of
time (dwell time) — usually four to six hours
○ Dextrose in the dialysate helps filter waste, chemicals and extra fluid in your blood from tiny blood
vessels in the lining of your abdominal cavity.
○ When the dwell time is over, the solution — along with waste products drawn from your blood —
drains into a sterile collection bag the cycles are repeated.
○ The process of filling and then draining your abdomen is called an exchange. You may need three to
five exchanges during the day and one with a longer dwell time while you sleep.

18. Peritoneal Dialysis - Process and Catheter

19. Peritoneal Dialysis- Methods or types.
● Types/ Methods peritoneal dialysis: Different methods of peritoneal dialysis have different schedules of
exchange. The two main schedules are: continuous ambulatory peritoneal dialysis (CAPD) and automated
peritoneal dialysis (APD).
● Both types of PD have slightly different advantages, so it really comes down to clients personal preference
and schedule along with your nephrologist's recommendation.
○ CAPD - which stands for Continuous Ambulatory Peritoneal Dialysis - happens throughout the day, at
home or at work, while the person goes about his or her daily life. Between 1.5 and 3 litres of fluid is
run each time for four times a day, exchanging for the fluid from the previous exchange. Patient
doesn’t need a machine for CAPD; all he/she needs is gravity to fill and empty the abdomen. More
risk for peritonitis than APD due to more manual exchange in different set ups.
○ APD - Automated Peritoneal Dialysis(CCPD Continuous Cyclic Peritoneal Dialysis) - in which the
dialysate solution is changed by a machine, at night, while you are asleep. this method uses a
machine (automated cycler) that performs multiple exchanges at night while you sleep. The cycler
automatically fills your abdomen with dialysate, allows it to dwell there and then drains it to a sterile
bag that you empty in the morning. The machine will exchange 8-12 litres over 8-10 hours.You must
remain attached to the machine for about 10 to 12 hours at night only.In the morning you begin one
exchange with a dwell time that lasts the entire day.

20. Peritoneal Dialysis- Indications/ Contraindications.
● Indications: Peritoneal dialysis may be the better option if clients:
○ Can't tolerate the rapid changes of fluid balance associated with hemodialysis
○ Want to minimize the disruption of daily activities
○ Want to work or travel more easily
○ Have some residual kidney function
● Contraindications: Peritoneal dialysis might not work if clients have:
○ Extensive surgical scars in abdomen
○ A large area of weakened abdominal muscle (hernia)
○ Limited ability to care for oneself, or a lack of caregiving support
○ Inflammatory bowel disease or frequent bouts of diverticulitis
● The advantages of peritoneal dialysis (compared with hemodialysis include:)
○ Greater lifestyle flexibility and independence. These can be especially important if one works, travels
or lives far from a hemodialysis center.
○ A less restricted diet. Peritoneal dialysis is done more continuously than hemodialysis, resulting in less
accumulation of potassium, sodium and fluid. This allows clients to have a more flexible diet than they
could have on hemodialysis.
○ Longer lasting residual kidney function. People who use peritoneal dialysis might retain kidney
function slightly longer than people who use hemodialysis.

21. Disadvantages of Peritoneal Dialysis
● The disadvantages of PD include:
○ Must schedule dialysis into your daily routine, seven days a week.
○ Requires a permanent catheter, outside the body.
○ Runs the risk of infection/peritonitis.
○ May gain weight/have a larger waistline.
○ Very large people may need extra therapy.
○ Need ample storage space in your home for supplies
● If you have peritoneal dialysis, clients need to avoid:
○ Clients can do the exchanges at home, work or any clean place. You're free to go about your
normal activities while the dialysate dwells in your abdomen
○ Certain prescription and over-the-counter medications that can damage your kidneys,
including nonsteroidal anti-inflammatory drugs.
○ Soaking in a bath or hot tub, or swimming in a lake, pond, river or non chlorinated pool — which
increases the risk of infection. Showers and swimming in a chlorinated pool are generally
acceptable.

22. Complications of Peritoneal Dialysis
● Infections: Catheter-site infection and infection of the abdominal lining (peritonitis) are common
complication of peritoneal dialysis. An infection can also develop at the site where the catheter is
inserted to carry the cleansing fluid (dialysate) into and out of your abdomen. The risk of infection is
greater in CAPD or/ if the person doing the dialysis isn't adequately trained.
○ Peritonitis may lead to extensive adhesion formation, peritoneal fibrosis, loss of filtration.
● Weight gain:The dialysate contains sugar (dextrose). Absorbing some of the dialysate might cause
you to take in hundreds of extra calories daily, leading to weight gain. The extra calories can also
cause high blood sugar, especially if you have diabetes.
● Hernia: Holding fluid in your abdomen for long periods may strain your muscles.
● Inadequate/Ineffective dialysis: Peritoneal dialysis can become ineffective after several years as the
membrane loses its integrity. You might need to switch to hemodialysis.
● Abdominal pain, Low Back pain, Protein loss, Atelectasis and pneumonia also occurs less
commonly.

23. Nurses Responsibilities in Peritoneal Dialysis:
● Nursing interventions related to peritoneal catheter exit-site infection mainly include an emphasis on
prevention and early diagnosis as well as exit-site care.
● The key elements to prevention of exit-site infections are avoiding trauma to the exit site and tunnel,
avoiding cross contamination of the exit site, and cleaning a wet or dirty exit site as soon as possible.
● The insertion site is usually covered with a gauze dressing and tape to prevent the catheter from moving
and to keep the area clean.
● If a dressing change is needed before usual time (1 week), it should be done by a specially trained
peritoneal dialysis nurse using sterile techniques.
● The catheter should not be moved or handled excessively, because this can increase the risk of infection.
● The area should be kept dry until it is well healed, usually for 10 to 14 days.(This means that client should
not take a shower or bath or go swimming during this time.)
● Early diagnosis of exit-site infection is promoted by (1) teaching the patient or caregiver to assess the exit
site and tunnel routinely and to promptly recognize and report signs and symptoms of inflammation. (2)
routine exit-site evaluation by health care providers in the outpatient clinic.
● The skin around the catheter site should be washed daily or every other day with antibacterial soap or an
antiseptic (either povidone iodine or chlorhexidine).
● Other types of cleansers, such as hydrogen peroxide or alcohol, should NOT be used unless directed by a
healthcare provider.
● Avoid using tapes or dressings that prevent air from reaching the skin. The site should be covered with a
sterile gauze dressing, which should be changed every time the site is cleaned. The catheter should be
anchored to the skin with tape or a specially designed adhesive.

24. Nurses Responsibilities in Peritoneal Dialysis:
● After the first two weeks, the skin around the catheter should not be red or painful. The skin should feel soft.
There may be a small amount of thick, yellow mucus discharge around the catheter. A crust or scab may
form every few days.
● Call health care provider if you injure the catheter site to determine if further evaluation or treatment is
needed.
● Care of the infected exit site should focus on preventing cross contamination, keeping the exit site dry,
avoiding trauma and irritation, and in addition to routine care, may require removal of stubborn crusts and
cauterization of proud flesh.
● Topical soaks and therapy have been recommended, but improvement of infected exit sites has to be
documented add compared to know the effectiveness.
● Current treatment guidelines emphasize the use of intraperitoneal antibiotics and once-a-day administration
of aminoglycosides and provide indications for removal of the peritoneal catheter to reduce the risk of
peritonitis.
● It is important to avoid becoming constipated or straining after the catheter is inserted.To avoid constipation,
recommend a diet that is high in fiber, as well as a stool softener or laxative.
● Patient support groups and websites can provide reassurance and tips for general common issues like body
image disturbance from enlarged abdomen.
● Activities and peritoneal dialysis – In general, people using peritoneal dialysis should limit physical activities
when their peritoneal cavity is full (has a large-volume dwell). It is still possible to exercise and participate in
sports, although it should be discussed with doctor and included in patent education.

25. Health Education
● Educate about catheter placement.
○ Catheter placement can be done under general anesthesia and usually takes less than one hour.
○ The skin around the catheter should be kept dry until it is well healed -- about 10 to 14 days.
○ Clent should not take a shower or bath or go swimming during this time.
● Training on aseptic techniques should be done.
● Training on how to use the peritoneal dialysis equipment.
● About Diet and nutrition :
○ Same as in hemodialysis mentioned above
○ Eat high-quality protein because it produces less waste for removal during dialysis. High-quality
protein comes from meat, poultry, fish, and eggs.
○ Avoid too much potassium diet: Milk-based recipes are high in mineral phosphorus and potassium.to
limit foods such as milk, cheese, nuts, etc
○ Pineapple makes a sweet, low potassium alternative for those with kidneys problems. Plus, pineapple
is rich in fiber, manganese, vitamin C, and bromelain, an enzyme that helps reduce inflammation.
○ To limit fluid intake and also to avoid excess salt, Most dialysis patients need to limit their fluid intake
to 32 ounces per day. Techniques to manage your thirst/reduce thirst..
○ Dietitian can help you find ways to manage your thirst such as sugar-free hard candies, ice chips, or
frozen grapes. This will help you avoid drinking too much fluid between dialysis treatments.

26. Hemofiltration and Continuous Renal Replacement
● Hemofiltration is a technique in which water and solutes are driven mainly by positive hydrostatic pressure
across(the pressure gradient, unlike diffusion and osmosis in hemodialysis.) a semipermeable membrane
from the blood compartment into the filtrate compartment, from where it is drained.
● Hemodialysis is a diffusive therapy removes small solutes mainly, whereas hemofiltration is a convective
therapies (hemofiltration and hemodiafiltration) may also eliminate larger molecules such as myoglobin or
cytokines.
● During the hemofiltration, an ultrapure replacement fluid is reinfused to the patient to keep volume
homeostasis.
● Hemofiltration/haemofiltration, is a renal replacement therapy which is used in the intensive care setting.
● It is usually used to treat acute kidney injury (AKI), but may be of benefit in multiple organ dysfunction
syndrome , poisoning or sepsis.
● The main advantages of this treatment are characterized by its better control of hypertension,
hyperhydration, and possibly of uremic bone disease.
● Continuous Renal Replacement Therapies/CRRT: It is a slow and continuous(unlike intermittently in typical
hemodialysis) extracorporeal (outside the body) blood purification therapy.
● Indications: acute kidney injury, oliguria, anuria, abnormal blood tests, metabolic acidosis, increased or
decreased temperature, pulmonary edema, overdose of a toxin, hormone and metabolic abnormalities,
cardiac failure, and increased fluid needs of a patient.

27. Dialysis Patients FAQs
● When/Who needs dialysis?
The need dialysis is when one develops end stage kidney failure, usually by the time you lose about 85 to
90 percent of your kidney function and have a GFR of <15. Or a poisoned state also may demand dialysis.
● How long can you live on dialysis 3 times a week?
Depends on kidneys residual functioning and the metabolic load and waste products. Renal dietitians
encourage most people on hemodialysis to minimise the activity and eat high-quality protein because it
produces less waste for removal during dialysis, so it may reduce the frequency demands for dialysis. 75- to
79-year-olds on dialysis live 3.1 years on average; 80- to 85-year-olds on dialysis live 2.5 years on average;
and. Patients on dialysis ages 85 and up live two years on average. With Peritoneal dialysis average life
expectancy is 5-10 years, however, many patients have lived well on dialysis for 20 or even 30 years.Is it
painful to have dialysis?
Dialysis itself does not hurt. In hemodialysis the needles may hurt going in, but they should stop hurting after
that. You can ask for numbing medicine before you get the needle sticks if they bother you.
● Do dialysis patients still urinate?
It only reduces the total urine output, most patients still make some urine on dialysis but the longer you
are on dialysis the less urine that you make, especially with hemodialysis.
● What is the best form of dialysis?
Peritoneal dialysis is an effective form of dialysis, has been proven to be as good as hemodialysis.
Peritoneal dialysis is not for everyone.

28. Learning /
answering hints.
Question that frequently asked in
exams are
● Indications for peritoneal dialysis,
● Principles of hemodialysis

29. Thankyou
● to the one who made it easy.
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● to the one from whom i understood it.
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● to the one who attempt to understand it.
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● to the one taxed for my time and effort.
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● to the one who corrected it further.
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● to the one who executes this idea.
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● to the one who share it further.
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● to the one who is missed out.