Chapter 47 Dialysis with lab values and catheter info.pdf

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Dialysis
Chapter 47

Important Lab Values – BUN and
Creatinine
 These Lab Values are used to monitor
adequacy of dialysis
 BUN = Blood urea nitrogen
 A waste product of protein metabolism.
Range of values for dialysis patients (prior to
treatment) = 60 – 100 mg%
 Before and after dialysis
 Creatinine
 Waste product of tissue metabolism

Important Lab Values – Sodium
(Na)
 Main electrolyte in extracellular
(outside the cell) serum (the fluid in
which the red blood cells are
suspended)
 Acceptable range (for all people,
including dialysis patients) = 133 –
145 mEq/L

Important lab values – Potassium (K)
 Main electrolyte inside cells
 Acceptable ranges for dialysis patients
(pre-treatment) = 3.0 – 6.0 mEq/L
 Hyperkalemia (high serum potassium)
 Cause is usually not following diet
 CAN LEAD TO LIFE-THREATENING
ARRYTHMIAS & DEATH!!!!

Important Lab Values – Calcium
(Ca)
 Along with phosphorus, imbalance in
values contribute to renal bone disease
 Body will respond to decrease Ca by
pulling what it needs from the bones
 Body will respond to increase Ca by
depositing calcium where it does not
belong
 Normal Range : 8.5 – 10.5 mEq/L

Important Lab Values – Phosphorus
(Ph) & Phosphates (PO4)
 Normal range = 2.6 – 4.5mg/dL
 Phosphorus is absorbed into tissues
 Once absorbed, difficult to remove by
dialysis
 With calcium, it forms deposits in soft
tissues
 High levels cause the patient to itch severely
 Calcium binders necessary to prevent
absorption into blood stream
 Present in most foods

Dialysis
 Movement of fluid/molecules across
a semipermeable membrane from
one compartment to another
 Used to correct fluid/electrolyte
imbalances and to remove waste
products in renal failure
 Treat drug overdoses

Dialysis
 Two methods of dialysis available
 Peritoneal dialysis (PD)
 Hemodialysis (HD)

Dialysis
 Begun when patient’s uremia can
no longer be adequately managed
conservatively
 Initiated when GFR (or creatinine
clearance) is less than 15 mL/min

Dialysis
 ESKD treated with dialysis because
 There is a lack of donated organs
 Some patients are physically or
mentally unsuitable for
transplantation
 Some patients do not want transplants

General Principles of Dialysis
Diffusion
 Movement of solutes from an
area of greater concentration to
an area of lesser concentration
 Osmosis
 Movement of fluid from an
area of lesser concentration
of solutes to area of greater
concentration
Osmosis and Diffusion across
Semipermeable Membrane

General Principles of Dialysis
 Ultrafiltration
 Water and fluid removal
 Results when there is an osmotic
gradient across the membrane

Peritoneal Dialysis
 Peritoneal access is
obtained by inserting
a catheter through
the anterior
abdominal wall
 Technique for
catheter placement
varies
 Usually done via
surgery

Peritoneal Dialysis
 After catheter inserted,
skin is cleaned with
antiseptic solution and
sterile dressing applied
 Connected to sterile
tubing system
 Secured to abdomen with
tape
 Catheter irrigated
immediately
Peritoneal Exit Site

Peritoneal Dialysis
 Waiting period of 7 to 14 days
preferable
 Two to 4 weeks after implantation,
exit site should be clean, dry, and
free of redness/tenderness
 Once site healed, patient may
shower and pat dry

Peritoneal Dialysis
Dialysis Solutions and Cycles
 Available in 1- or 2-L plastic bags
with glucose concentrations of 1.5%,
2.5%, and 4.25%
 Electrolyte composition similar to
that of plasma
 Solution warmed to body
temperature

Peritoneal Dialysis
 Three phases of PD cycle
 Inflow (fill)
 Dwell (equilibration)
 Drain
 Called an exchange

Peritoneal Dialysis
Inflow (Fill)
 Prescribed amount of
solution infused
through established
catheter over about 10
minutes
 After solution infused,
inflow clamp closed to
prevent air from
entering tubing
Dwell
 Period of time when the
dialysate solution sits in the
peritoneum
 Allows toxin, excess fluid to
pass into the dialysate solution
 Also known as equilibration
 Diffusion and osmosis occur
between patient’s blood and
peritoneal cavity
 Duration of time varies,
depending on method

Peritoneal Dialysis
 Drain
 Lasts 15 to 30 minutes
 May be facilitated by
gently
massaging abdomen or
changing position
 Turn the patient from side
to side and change
positions to allow pockets
of fluid to drain out if all
the dialysate fluid does
not return
 Exchange
 Word used to
describe the entire
fill-dwell-drain cycle

Peritoneal Dialysis
Systems
 Automated peritoneal
dialysis
(APD)
 Cycler delivers the
dialysate
 Times and controls fill,
dwell, and drain
 Continuous ambulatory
peritoneal dialysis
(CAPD)
 Manual exchange

Peritoneal Dialysis
Complications
 Exit site infection
 Peritonitis
 Hernias
 Lower back problems
 Bleeding
 Pulmonary
complications
 Protein loss

Peritoneal Dialysis
Effectiveness and Adaptation
Pros
 Short training program
 Independence
 Ease of traveling
 Fewer dietary restrictions (More
liberal diet and fluids)
 More stable lab values
 Greater mobility than with HD
 Patients administer own
treatment
 No needles needed
Cons
 Catheter in the abdomen
 Self image issues
 Route for infection
 Need learning skills
 Need storage space in home
(supplies for 1 month)
 Treatment needs to be done
every day ( must be very
compliant)

Hemodialysis
Vascular Access Sites
 Obtaining
vascular access is
one of most
difficult problems
 Types of access
 Arteriovenous
fistulas and grafts
 Temporary
vascular access

Arteriovenous Fistula

Assessment of the Internal Access
 Other Assessments
 Bleeding
 Swelling
 Bruising
 Redness
 Drainage
 Pain
 Change in thrill

Patient Education
 Lifeline – protect it
 Teach patient how to protect it and check daily to see if it is
working properly
 Feel over site and check “thrill”
 Contact the HCP or hemodialysis nurse immediately if there is a
change in the quality of the thrill
 Avoid any pressure or constriction on the access arm.
Don’t let anyone take a blood pressure or draw blood
 Don’t wear tight clothing (elastic sleeves, wear a
watch, carry a purse, or sleep on the the access arm
 Do not carry heavy objects with access arm
 Do not allow venipuncture to the done by anyone
other the an trained dialysis personnel

Patient Education (cont.)
 Adhere to diet – between treatments waste products
won’t build up in blood to quickly
 PD patient should have increase fiber in the diet to
offset constipation from decreased peristalsis. ( The
intestines are floating in the hypertonic dialysate
solution
 PD patients must strictly adhere to handwashing and
asepsis, and follow guidelines to access abdominal
catheter
 Epogen (erythropoietin) injections (subcutaneous or
IV) as prescribed increase energy and endurance
because increased RBCs means better oxygenation and
less fatigue

Vascular Access Catheter

Central Venous Catheters
 Used as temporary and permanent access
 Temporary access
 Emergency dialysis
 Acute renal failure
 Waiting for permanent (internal) access to mature
 Secured by suture
• NOTE: Check for suture prior to initiation of treatment
• If suture has become loose or dislodged on temporary
CVC
• Must be reported immediately
• Cannot be used until secured and proper
placement verified by x-ray/fluoroscopy

Central Venous Catheters
 Permanent access
 Patients whose
vessels will not
support in internal
access
 Dacron cuff at the
insertion (exit) site
 Patient’s own tissue
grows into Dacron
• Secures catheter in
place
• Skin is good barrier
against infection

Hemodialysis
Dialyzers
 Long plastic
cartridges that
contain thousands of
parallel hollow tubes
or fibers
 Fibers are
semipermeable
membranes

Dialyzers (Artificial Kidney)

Hemodialysis
Procedure
 Two needles placed in fistula
or
graft
 One needle is placed to pull
blood from the circulation to
the HD machine
 The other needle is used to
return the dialyzed blood to
the patient
 Use big needles – 2 sticks 3
times/week – 17g – 14g

Components of Hemodialysis

Hemodialysis
Procedure
 Dialyzer/blood lines primed with
saline solution to eliminate air
 Terminated by flushing dialyzer with
saline to remove all blood
 Needles removed and firm pressure
applied

Hemodialysis
Procedure
 Before treatment, nurse should
 Complete assessment of fluid status,
condition of access, temperature, skin
condition. (weight, BP, peripheral
edema, lung and heart sounds)
 During treatment, nurse should
 Be alert to changes in condition
 Measure vital signs every 30 to 60
minutes

Hemodialysis
Complications
 Hypotension
 Muscle cramps
 Loss of blood
 Hepatitis

Hemodialysis
Effectiveness and Adaptation
 Cannot fully replace normal
functions of kidneys
 Can ease many of the symptoms
 Can prevent certain complications

Continual Renal Replacement
Therapy (CRRT)
 Alternative or adjunctive method for
treating AKI
 Means by which uremic toxins and fluids
are removed
 Acid-base status/electrolyte balance
adjusted slowly and continuously
 Let the kidney rest
 ICU – slow dialysis over days – weeks –
let kidney recover, heal or protect the
kidney

Continual Renal Replacement
Therapy (CRRT)
 Can be used in conjunction with HD
 Contraindication
 Presence of manifestations of uremia
(hyperkalemia, pericarditis) that necessitate
rapid resolution
 Continued for 30 to 40 days
 Hemofilter change every 24 to 48 hours
 Ultrafiltrate should be clear yellow
 Specimens may be obtained for
evaluation

Continual Renal
Replacement Therapy (CRRT)
 Two types of CRRT
 Venous access
 Arterial access

Continual Renal
 Most common approaches:
venovenous
 Continuous venovenous
hemofiltration (CVVH)
 Continuous venovenous hemodialysis
(CVVHD)
 Refer to pg. 1123 Table 47-13

Continuous Venovenous
Therapies

Continual Renal
 Large volumes fluid
removed hourly, then
replaced
 Fluid replacement
dependent on
stability/individualized
needs of patient
Continuous venovenous
hemodialysis (CVVHD)
 Uses dialysate
 Dialysate bags attached to
distal end of hemofilter
 Fluid pumped
countercurrent to blood
flow
 Ideal treatment for
patient who needs
fluid/solute control but
cannot tolerate rapid fluid
shifts with HD
Continuous venovenous
hemofiltration (CVVH)

Continual Renal
 Highly permeable, hollow fiber
hemofilter
 Double-lumen catheter placed in
femoral, jugular, or subclavian vein
 Removes plasma water and
nonprotein solutes

Continual Renal
 CRRT versus HD
 Continuous rather
than intermittent
 Solute removal by
convection (no
dialysate required) in
addition to osmosis
and diffusion
 Less hemodynamic
instability
 Does not require
constant monitoring
by HD nurse
 Does not require
complicated HD
equipment

Nursing Interventions for CRRT
 Anticoagulation needed - infuse heparin in low
doses as appropriate through the setup
 To prevent infection , perform skin care at the
catheter insertion sites every 48 hours (or per
protocol), using sterile technique. Cover the
site with an occlusive dressing
 Obtain serum electrolyte levels every 4 to 6
hours as ordered; anticipate adjustments in
replacement fluid or dialysate based on results

Medications Given In the
Hemodialysis Setting
 Kidney’s are major route
of excretion for drug
metabolites
 Metabolic effects of
kidney failure changes
how drugs are broken
down and excreted
 Use caution when
administering drugs to
patients on dialysis
 Heparin
 Epogen _ subq, IV
 IV Iron Supplements
 Calcium supplements
 Antimicrobial
 Parenteral nutrition
 Antihypertensives
 Albumin, mannitol,
IV fluids

Antihypertensives
 Points to remember:
 Some are not removed by dialysis
 May cause decrease in B/P during
dialysis
 Most MD’s recommend delaying dose
until after dialysis
 Instruct patient to take medication so
that peak action does not occur during
dialysis

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