The document discusses hemodialysis and peritoneal dialysis, both treatments for patients with kidney failure. Hemodialysis involves filtering blood through a machine, while peritoneal dialysis introduces a solution into the abdominal cavity to remove waste. Each method has specific procedures, benefits, and complications, as well as requirements for patient access and care.

3. HEMODIALYSIS

4. INDICATIONS

5. Dialysis therapy
 Dialysis is a process that artificially removes metabolic wastes
from the blood in order to compensate for kidney (renal) failure.
 Most common type is hemodialysis

6. DIALYSIS
 It is used to remove fluid and uremic waste products from the body
when the kidneys are unable to do so.
 Acute dialysis is indicated when there is a high and increasing level of
serum potassium, fluid overload, or impending pulmonary edema,
increasing acidosis, pericarditis and severe confusion. It may also be
used to certain medications or other toxins in the blood.

7. Dialysis
 A procedure for cleaning and filtering the blood.
 It remove the nitrogenous waste products and maintain adequate
fluid, electrolyte, and acid-base balance.
 During dialysis the client’s blood is filtered by diffusion and
osmosis.
 Substances such as urea, creatinine, and dangerously high levels
of potassium, and water move FROM the blood through the
semipermeable membrane TO the dialysate, the solution used
during dialysis that has a composition similar to normal human
plasma.

8.  OSMOSIS
 DIFFUSION
Principles of dialysis

10. Dialysis therapy
Allows abnormal substances to diffuse out of blood, cleaning it
The dialysis fluid creates a diffusion gradient
Patients blood is transported through a semipermeable tube into an
apparatus which contains dialysis fluid
Hemodialysis

11. Types
 Haemodialysis (HD)
 Peritoneal Dialysis (PD)

12. Hemodialysis…
 It is the process of cleansing the
blood.
 A dialysis process which requires a
machine to transport the blood
and dialysing fluid on either side
of a semi-permeable membrane to
effect the removal of toxic
metabolites and excess water

13. HEMODIALYSIS
 Dialysis process occurs outside the body in a machine
 The dialysis membrane is an artificial one: Dialyser
 The dialyser removes the excess fluid and wastes from the blood
and returns the filtered blood to the body
 Haemodialysis needs to be performed three times a week
 Each session lasts 3-6 hrs

14. HEMODIALYSIS
Patient
Access
Vascular catheter
A-V fistula
Synthetic vascular graft

15. Hemodialysis…
1. blood
2. access
3. tx w/
heparin
4.
dialyser
5. solute
exchange
6.
dialysate
7. body
4-6 hours

16. Hemodialysis Treatment with the new
dialysis machine

17.  Procedure
 The patient's access is prepared and cannulated.
 Heparin is administered (unless contraindicated).
 Heparinized blood flows through a semipermeable dialyzer in
one direction, and dialysis solution surrounds the membranes and
flows in the opposite direction.
 Dialysis solution consists of highly purified water to which
sodium, potassium, calcium, magnesium, chloride, and dextrose
have been added. Bicarbonate or acetate is also added to achieve
the proper pH balance.
 Through the process of diffusion, solute in the form of
electrolytes, metabolic waste products, and acid base components
can be removed or added to the blood.
 Excess water is removed from the blood (ultrafiltration).
 The blood is then returned to the body through the patient's
access

19. Performing HD
HD may be carried out:
 In a HD Unit
 At a Minimal Care / Self-Care Centre
 At Home

20. Requirements for Hemodialysis
 Access to the patient's circulation
 Dialysis machine and dialyzer with
semipermeable membrane
 Appropriate dialysate bath
 Time—approximately 4 hours, three times
weekly
 Place—dialysis center or home (if
feasible)

21. Hemodialysis : Functions
 Cleanses the blood of accumulated waste
products
 Removes the by-products of protein
metabolism (urea, creatinine & uric acid)
 Removes excessive fluids
 Maintains or restores the buffer system of the
body
 Maintains or restores electrolyte levels

22. Hemodialysis: Access
Subclavian and femoral catheter
External arteriovenous shunt
Internal arteriovenous fistual
Internal arteriovenous graft

23. SUBCLAVIAN & FEMORAL
CATHETER: INTERVENTIONS
 Assess insertion site for hematoma, bleeding, dislodging, and
infection.
 Do not use these catheters for any reason other than dialysis.

 Maintain an occlusive dressing.

24. Subclavian (vein) Catheter…
 may be inserted for short
term or temporary use in
acute renal failure
 usually filled w/ heparin &
capped to maintain
patency between dialysis
treatments
 may be left in place for up
to 6 wks if complications
do not occur

25. Femoral (vein) Catheter…
 may be inserted for
short term or temporary
use in acute renal
failure

 client should not sit up
more than 45° or lean
forward, or the catheter
may kink & occlude.

 an IV infusion pump w/
microdrip tubing should
be used if a heparin
infusion through the
catheter is prescribed

26. AV Fistula
 for chronic dialysis clients
 created surgically by
anastomosis of a large
artery & a large vein in the
arm
 Maturity: veins become
engorged due to the flow of
arterial blood into the
venous system; takes 1-2
wks.
 Maturity is required before
the fistula can be used

28. ARTERIO VENOUS
GRAFT
 for chronic dialysis clients who
do not have adequate blood
vessels for the creation of a
fistula
 Gore-Tex or a bovine (cow)
carotid artery as artificial vein
for blood flow
 Procedure involves the
anastomosis of the graft to the
artery, a tunneling under the
skin, and anastomosis to a
vein.
 can be used 2 wks after
insertion
 Complications: clotting,
aneurysms and infection

30. HEMODIALYSIS

32. HEMODIALYSIS
NURSING CONSIDERATIONS:
1. Blood can be heparinized unless it is contraindicated to prevent blood
clot.
2. Dialysis solution has some electrolytes and acetate and HCO3 added
to achieve proper pH balance.
3. Methods of circulatory access: AV fistula; AV graft or U-tube
4. Assess the access site for bruit, signs of infections and ischemia of
the hand.
5. Absence of thrill may indicate occlusion
6. No BP taking on the access site.
7. Cover the access site with adhesive bandage
8. Dietary adjustments Na and fluid intake.
9. Check blood chemistry
10. Constant monitoring of hemodynamic status, electrolytes and acid-
base balance.

34. Peritoneal Dialysis…
 A dialysis process which requires the
introduction of peritoneal dialysis
solution (dialysate) into the peritoneal
cavity via gravity or a cycler.
 A soft, elastic tube (catheter) inside the
abdomen is inserted through a minor
surgical operation.

35. PERITONEAL
DIALYSIS
 Indwelling catheter is implanted into the peritoneum.
 A connecting tube is attached to the external end of peritoneal
catheter T –tube.
 Plastic bag of dialysate solution is inserted to the end of T-tube; the
other end is recap.
 Dialysate bag is raised to shoulder level and infused by gravity in the
peritoneal cavity
 Infusion time = 10 minutes/2 liters; dwelling time is 4-6 hours
depending on doctor’s order.
 At the end of dwelling time, dialysis fluid is drained from the
peritoneal cavity by gravity
 Draining time is 10-20 minutes/2 liters
 Then repeat the procedure when necessary

36. ACCESS FOR DIALYSIS

37.  Procedure
 A permanent indwelling catheter is implanted into the peritoneum; the
internal cuff of the catheter becomes embedded by fibrous ingrowth,
which stabilizes it and minimizes leakage.
 A connecting tube is attached to the external end of the peritoneal
catheter, and the distal end of the tube is inserted into a sterile plastic
bag of dialysate solution.
 The dialysate bag is raised to shoulder level and infused by gravity into
the peritoneal cavity (approximately 10 minutes for a 2-L volume).
 The typical dwell time is 4 to 6 hours.
 At the end of the dwell time, the dialysate fluid is drained from the
peritoneal cavity by gravity. Drainage of 2 L plus ultrafiltration takes
about 10 to 20 minutes if the catheter is functioning optimally.
 After the dialysate is drained, a fresh bag of dialysate solution is
infused using aseptic technique, and the procedure is repeated.
 The patient performs four to five exchanges daily, 7 days per week,
with an overnight dwell time allowing uninterrupted sleep; most patients
become unaware of fluid in the peritoneal cavity.

38. Pre and post operative care for
Tenckhoff catheter insertion
 Pre operative care
 Fasting for 8 hours
 Allow essential medications
 Bowel preparation not necessary
 Removal of body hair limited to that necessary
to facilitate performance of procedure
 Empty bladder
 Single dose of prophylactic antibiotic
 Operating room or well equipped procedure
room

39. Pre and post operative care for
Tenckhoff catheter insertion
 Post operative care
 Catheter irrigation with 1 L of heparinized saline performed as an in-
and-out flush within 72 hours following surgery and weekly thereafter
until PD initiated
 Delay PD for a min of 2 weeks to allow wound healing
 Change dressings weekly for 2 weeks
 Then patient should begin a routine of daily exit-site cleansing with
antibacterial soap
 Showering only permitted after 1 month if wound healing
uncomplicated
 Avoid catheter movement at the exit site
 Use sterile gauze dressing over exit site
 No tub bathing and swimming

40. How Peritoneal Dialysis works…
 Peritoneum – semi-permeable; rich blood
supply
 When a dialysate is put into the peritoneal
cavity, the dialysate gently pulls the small
pieces of waste products & water from the
blood into the dialysate via the semi-
permeable membrane. (diffusion &
osmosis)

41. Diffusion & Osmosis…
 Electrolytes & minerals: tiny chemical
substances normally found in the blood
 Diffusion – the movement of electrolytes &
minerals through the peritoneum from greater
to lesser concentration; stops when 2 sides of
the membrane are equally crowded
 Osmosis – the movement of water into the
dialysate using sugar/glucose (glucose attracts
water)

43. Types of Peritoneal Dialysis…
 Continuous Ambulatory Peritoneal Dialysis (CAPD)
 Automated Peritoneal Dialysis (APD)

44.  Continuous cycling peritoneal dialysis ( CCPD)
 Nocturnal intermittent peritoneal dialysis (NIPD)
 Intermittent peritoneal dialysis (IPD)
 Tidal peritoneal dialysis (TPD)
Forms of APD

45.  Inflow (fill) – 10 minutes
 Dwell ( equilibration) – 20 minutes to 8 or more
hours
 Drain - 15 to 30 minutes
Phases of peritoneal
dialysis

46. CAPD Cycle…
1. The dialysate is instilled into
the peritoneal cavity through an
implant catheter attached to a
transferline, which is attached to
a bag of dialysate.
2. Once the fluid has been
instilled completely into the
peritoneal cavity, the empty
bag and transferline are
folded up and worn in a cloth
pouch beneath the clothing.
Thus, the patient is free to
ambulate and resume his
normal daily activities.

47. CAPD Cycle…
3. When it is time to drain off the , the bag is unfolded, placed on the floor and
drainage is achieved by gravity. A new bag of dialysate is then attached to the
transferline and the process is repeated. Usually the solution exchange
procedure takes about 15 minutes.

48. CAPD
 Dialysis takes place 24hrs a day, 7 days a week
 Patient is not attached to a machine for treatment
 Exchanges are usually carried out by patient after
training by a CAPD nurse
 Most patients need 3-5 exchanges a day i.e.
 4-6 hour intervals (Dwell time) 30 mins per exchange
 May use 2-3 litres of fluid in abdomen
 No needles are used
 Less dietary and fluid restriction

49. CAPD Exchange

50. Automated Peritoneal
Dialysis
 Similar to CAPD
 Requires a peritoneal
cycling machine
called a cycler
 Can be done as
intermittent peritoneal
dialysis, continuous
cycling peritoneal
dialysis, or nightly
peritoneal dialysis

52. APD
 Uses a home based machine to perform
exchanges
 Overnight treatment whilst patient sleeps
 The APD machine controls the timing of
exchanges, drains the used solution and fills
the peritoneal cavity with new solution
 Simple procedure for the patient to perform
 Requires about 8-10 hrs
 Machines are portable, with in-built safety
features and requires electricity to operate

53. Peritoneal Dialysis: Complications
 Peritonitis
 Signs: cloudy bag, stomach pain, fever
 If suspected, obtain a culture of the outflow to
determine the infective organism
 Abdominal Pain
 Pain during inflow is common during the 1st few
exchanges & usually disappears 1 to 2 wks of dialysis
treatments
 Place heating pad
 Insufficient Outflow
 Check for placement; refer to physician
 Encourage high-fiber diet
 Leakage around the catheter site
 May take up to 2 wks for client to tolerate a full 2L
exchange w/o leaking around the catheter site
 Bladder or Bowel Perforation

54. Nursing Interventions
 Monitor vital signs.
 Monitor for signs of infection.
 Monitor for respiratory distress, pain, or discomfort.
 Monitor signs of pulmonary edema.
 Monitor for hypotension & hypertension.
 Monitor for malaise, nausea, vomiting.
 Assess the catheter sit dressing for wetness or bleeding.

Monitor dwell time as prescribed by the physician & initiate flow.
 Do not allow dwell time to extend beyond the physician’s order because this increases
the risk for hyperglycemia.
 Turn the client from side to side if the outflow is slow to start.
 Monitor outflow, which should be a continuous stream after the clamp is opened.
Monitor outflow for color & clarity.
 Monitor intake & output accurately.