hemodialysis and peritoneal dialysis for nursing students

1. DIALYSIS
JASMINESALAM
SECONDYEARMSCNURSING
UCON

2. DEFINITION
• Dialysis is procedure for cleaning and filtering the blood. It substitute for
kidney function when the kidneys cannot remove the nitrogenous waste
products and maintain adequate fluid, electrolyte and acid base balance.
[Barbara K Timby]

3. CONT..
• It’s defined as exchange of fluid across a semipermeable membrane.
Dialysis is not limited to filtration of kidneys and removal of nitrogenous
waste from the blood but implies addition or removal of excess water,
electrolytes and dialyzable poison from the blood.
[ S N Chung]

4. INDICATIONS
• Acute renal failure
• Chronic renal failure
• Poisoning
• Severe metabolic acidosis
• Hyperkalaemia irrespective of its causes
• Fluid overload or acute pulmonary oedema

5. TYPES
• Hemodialysis (through the artificial kidney)
• Peritoneal dialysis (through the peritoneal cavity)

6. HEMODIALYSIS

7. HEMODIALYSIS
• Hemodialysis is an efficient modality for correction of fluid and
electrolyte abnormalities due to acute kidney injury or chronic renal
failure.
• However, it is expensive to institute, requires expertise and skilled
nursing is not available at most centers.
• It is not suited for patients with hemodynamic instability, bleeding
tendency and in very young children where vascular access might be
difficult.

8. PRINCIPLES OF DIALYSIS
1. Diffusion
2. Osmosis
3. Ultra filtration & solvent drag

9. INDICATIONS
•A- acid base balance
•E- electrolyte problems
•I- intoxications
•O- overload of fluids
•U- uremic symptoms

10. Cont..
Indications of dialysis in acute renal failure (ARF)
• Severe fluid overload
• Refractory hypertension
• Uncontrollable hyperkalaemia
• Nausea, vomiting, poor appetite, gastritis with haemorrhage

11. Cont..
• Lethargy, malaise, somnolence, stupor, coma, delirium, asterixis,
tremor, seizures,
• Pericarditis (risk of haemorrhage or tamponade)
• Bleeding diathesis (epistaxis, gastrointestinal (GI) bleeding and etc.)
• Severe metabolic acidosis
• Blood urea nitrogen (BUN) > 70–100 mg/dl

12. cont..
Indications of dialysis in chronic renal failure (CRF)
• Pericarditis
• Fluid overload or pulmonary edema refractory to diuretics
• Accelerated hypertension poorly responsive to antihypertensive
• Progressive uremic encephalopathy or neuropathy such as confusion, asterixis,
myoclonus, wrist or foot drop, seizures
• Bleeding diathesis attributable to uremia

13. EQUIPMENTS & OTHER REQUIREMENTS
•Vascular access using central venous catheter
• Temporary access: It is established by percutaneous
insertion of catheter into a large vein such as the
internal jugular or femoral, subclavian vein is less
preferred.
• Permanent access: Construction of Arteriovenous
fistula permits repeated access for months to years.

14. Arteriovenous (AV) Fistula
An arteriovenous fistula is an abnormal connection or
passageway between an artery and a vein.
Usually radial artery and cephalic vein are
anastomosed in nondominant arm. Vessels in the
upper arm may also be used.
After the procedure the superficial venous system of
the arm dilates.

15. cont..
By means of two large bore needles inserted into the dialated venous
system, blood may be obtained and passess through the dialyzer.
The arterial end is used for the arterial flow and the distal end is used for
the reinfusion of dialysed blood.
Healing of AVF requires at least 6 to 8 weeks; a central vein catheter is
used.

16. AV Graft
If a patient is not a good candidate for an arteriovenous
fistula, an arteriovenous graft is considered.

17. CENTRAL VENOUS CATHETER
A third type of vascular access is a venous catheter.
A venous catheter is a plastic tube which is inserted into a
large vein, usually in the neck.

18. •Dialysate circuit in hemodialysis machine

19. • Pediatric dialyzer with tubings

20. • Dialysate fluid
COMPOSITION OF DIALYSATES FOR BICARBONATE DIALYSIS
COMPONENT CLASSIFICATION
RANGE TYPICAL
Electrolytes(mmol/l)
Sodium
Potassium
Calcium
Magnesium
Chloride
Buffers(mmol/l)
Acetate
Bicarbonate
pH
pco2
Glucose
135- 145
0-4.0
0-2.0
0.5-1.0
87-124
2-4
20-40
7.1-7.3
40-100
0-11
(0-200mg/dl)
140
2.0
1.25
0.75
105
3
35
7.2
5.5
(100mg/dl)

21. PROCEDURE OF HEMODIALYSIS
Patient access is prepared and cannulated
Heparin is administered
Heparin and red blood flows through semipermeable dialysis in
one direction and dialysis solution surrounds the membrane
and flows in the opposite direction.
Dialysis solution consist of highly purified water to which
sodium, potassium , calcium, magnesium chloride, and dextrose
have been added, bicarbonate is added to achieve the proper
pH

22. CONT..
Through the process of diffusion solute in the form of electrolytes, metabolic waste
products acid base balance 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 patient access.

24. COMPLICATIONS DURING DIALYSIS
Haemodialysis disequilibrium syndrome : In nephrology, dialysis
disequilibrium syndrome is the occurrence of neurologic signs and symptoms,
attributed to cerebral oedema, during or following shortly after intermittent
haemodialysis.
Hypotension
Muscle cramps
Nausea, Vomiting
Chest pain and Back pain
Fever and Chills

25. Dialyzer reaction
Arrhythmia
Cardiac tamponade
Intracranial bleeding
Seizures
Haemolyses
Neutropenia; compliment activation

26. OTHER COMPLICATIONS
Catheter lumen thrombosis
Infections
Pneumothorax
Haemothorax
Air embolism
Arrhythmia
Thrombosis
Nerve injury

27. NURSING MANAGEMENT OF
HEMODIALYSIS
1 . Before dialysis
2 . During dialysis
3 . After dialysis

28. 1 . BEFORE DIALYSIS
Initial Nursing Assessment
a. Weight
Present weight – dry weight = Target
weight
b. Vital signs
1. BP – standing, sitting
2. Cardiac rate and rhythm
3. Pulse rate
4. Respiratory rate
5. Temperature

29. 2 . DURING THE DIALYSIS:
Care of patient during the dialysis.
Nursing Action
1. Promote patient comfort during the procedure
A. Provide physical comfort measures.
a. Back care
b. Elevate head of the bed
c. Assist in turning
B. Keep patient informed of progress and results.
C. Provide any kind of activities as reading newspaper .
D. Provide care and attention to pt. considering physiological, psychological care,
remembering his needs, reactions and concerns.

30. 2. Maintain goodoutflow of blood.
A. Monitor alarms of the machine.
B Monitor vital signs. - a drop in blood pressure may indicate rapid fluid
loss that may lead to dehydration
3. Monitor changes in fluid and electrolyte status , weight changes.
A. Laboratory studies
B. Assess level of responsiveness at the beginning, throughout and at the
end of the dialysis .
C. Pre and post dialysis weight

31. 4. Monitor for complications
A. Infection - Bacteremia is an unwanted complication
1. Watch for chills/fever – ( Antibiotics may be given after the
treatment )
2. Redness around the access-- ( Request for blood culture )
Observe strict aseptic technique
B. Bleeding
1. Observe site for any blood leaks
2. Monitor vital signs.
3. Monitor for hypertension/ hypotension

32. 3- POST DIALYSIS
1 .Check for any blood works or medicines to be given before
terminating dialysis.
2 . Upon removal of fistula needle apply pressure dressing using
sterile gauze and wait until the puncture site has clotted.
3 . Tape on a new pressure dressing and instruct patient to
remove 4 to five hrs later when possible bleeding may occur.

33. 4 . Ask your patient to rest at least 15 minutes and dangle
their legs to prevent postural hypotension after dialysis.
5 . Reinforce diet and fluid requirements of patient on
dialysis.
6 . Remind their about next schedule of their dialysis.
7 . Weigh patient before they leave the center

34. CARE OF VASCULAR ACCESS: CENTRAL
CATHETERS
Keeps the catheter dressing clean and dry.
Make sure the area of insertion site is clean and change the
dressing at each dialysis session.
Instruct patient on how to change dressings in an emergency
Instruct patient not shower or swim; but tell him/her that
he/she may take a bath.

35. Wear a mask over nose and mouth anytime the catheter is
opened to prevent bacteria from entering the catheter and the
bloodstream.
The caps and the clamps of the central catheter should be kept
tightly closed when not being used for dialysis.
Monitor exit site for soreness/redness.

36. CARE OF VASCULAR ACCESS: AV
FISTULAS/GRAFTS:
Keep the access site clean at all times.
Avoid injections, intravenous (IV) needles or fluids, or taking blood
samples in the access site arm.
Needle insertions for hemodialysis treatments should be rotated.
Do not take blood pressure or put pressure on the access arm.

37. Advise patients to avoid wearing jewelry or tight clothing, sleeping
on, or lifting heavy objects with the access arm.
Check the access arm for adequate circulation.
Check for signs of infection at the access site.

38. LIFE STYLE MANAGEMENT FOR CHRONIC
HEMODIALYSIS
Dietary management
 It involves restriction or adjustment of protein, sodium, potassium, phosphorus or
fluid intake.
 Ongoing health care monitoring includes careful adjustment of medication that
are normally excreted by the kidney or are dialyzable.
Haemodialysis treatment and complications
 Performs head to toe physical assessment before, during and after haemodialysis
regarding complications and access's security.
 Confirm and deliver dialysis prescription after review most update lab results.
Address any concerns of the patient and educate patient when recognizing the
learning gap.

39. Day-to-day care of arterial fistula
 Always wash hands with soap and warm water before and after
touching access. Clean the area around the access with antibacterial
soap or rubbing alcohol before dialysis treatments.
 Change where the needle goes into fistula or graft for each dialysis
treatment.
 Do not let anyone take blood pressure, start an I.V, or draw blood
from access arm.
 Do not let anyone draw blood from tunnelled central venous catheter.
 Do not sleep on access arm.
 Do not carry more than 10 lb with access arm.
 Do not wear watch, jewellery, or tight clothes over access site.
 Be careful not to bump or cut access.

40. PERITONEAL DIALYSIS

41. PERITONEAL DIALYSIS
Peritoneal dialysis (PD) is a treatment for kidney failure.
A special sterile fluid is introduced into the abdomen through a
permanent tube that is placed in the peritoneal cavity.
The fluid circulates through abdomen to draw impurities from
surrounding blood vessels in the peritoneum, which is then drained
from the body.

42. INDICATIONS
• Patient with acute kidney injury with severe or persistent
hyperkalaemia (>7meq/l)
• Fluid overload (Pulmonary oedema, Severe hypertension)
• Uremic encephalopathy
• Severe metabolic acidosis (total CO2 10-12mEq/L)
• Hyponatremia and Hypernatremia

43. MATERIALS REQUIRED

44. • Peritoneal dialysis solution
Other materials required
• Sterile set
• Surgical blade number 15
• Normal saline
• Suture
• Povidone iodine; Chlorhexidine

45. PROCEDURE

46. PREPARING THE PATIENT
• The nurse’s preparation of the patient and the family for PD depends
upon the patients physical and psychological status, level of alertness,
previous experience with dialysis, and understanding of and familiarity
with the procedure.
• The nurse explains the procedure to the patient/parents and assist in
obtaining the signed consent. Baseline vital signs, weight and serum
electrolyte levels are recorded.
• Evaluation of the abdomen for placement of the catheter is done to
facilitate self-care. Typically, the catheter is placed on the non-dominant
side to allow the patient easier access to the catheter connection site
when exchanges are done.

47. • The patient is encouraged to empty the bladder and bowel to
reduce the risk of puncture of the internal organs during the
insertion procedure.
• Broad spectrum antibiotics agent may be administered to
prevent infection.
• The peritoneal catheter can be inserted in interventional
radiology, in the operating room or at the bed side. Depending
upon the situation this will need to explained to the patient and
the family members.

48. PREPARING THE EQUIPMENT
• In addition to assembling the equipments for PD
• Nurse consult the physician to determine the concentration of the
dialysate to be used and the medication to be added to it
• Heparin
• Potassium chloride.
• Antibiotics
• Regular insulin

49. • Aseptic technique.
• Before medication are added the dialysate is warmed to body
temparature.
• Solution that are too cold cause pain cramping and vasoconstriction and
reduce clearance.
• Dry heating is recommended.
• Methods not recommended
1. Soaking the bags of the solution in warm water
2. Use of microwave to heat the fluid

50. •Immediately before initiating dialysis using aseptic
technique, the nurse assembles the administration set
and tubing.
•The tubing is filled with the prepared dialysate to reduce
the amount of air entering the catheter and peritoneal
cavity which could increase abdominal discomfort and
interfere with instillation and drainage of the fluid

51. INSERTING THE CATHETER
Ideally , the peritoneal catheter is inserted in the operating
room or radiology suite to maintain surgical asepsis and
minimize the risk of contamination.
However in some circumstances the physician may insert the
rigid stylet catheter at the bedside using strict asepsis.
Whenever a rigid catheter is used, carefully securing and close
observation for bowel perforation is essential to minimize the
complications

52. Catheter for long term use ( e.g tenckhoff, swan)are usually
soft and flexible and made of silicon with a radiopaque strip to
permit visualization on X- ray.
These catheter have three section
An interaperitoneal section with numerous openings and an
open tip to let dialysate to flow freely.
A subcutaneous section that passess from the peritoneal
membrane and tunnels through muscle and subcutaneous fat
to the skin.
An external section for connection to the dialysate system.

53. • Most of these catheter have two cuffs which are made of
Dacron polyester. The cuffs stabilizes the catheter, limit
movements, prevent leaks, and provide a barrier against the
organism.
• One cuff is placed just distal to the peritoneum and other cuff is
placed subcutaneously.
• The subcutaneous tunnel 5 to 10 cm long further protects
against bacterial infections

54. PERFORMING THE EXCHANGE
• PD involves a series of exchange or cycles. An exchange is defined as the infusion ,
dwell , and drainage of the dialysate. This cycle is repeated through out the course of
the dialysis.
• The dialysate is infused by gravity into the peritoneal cavity a period of about 5 to
ten minutes is usually required to infuse 2 to 3 L of fluids.
• The prescribed dwell or equiliberation time allows diffusion and osmosis to occur.
• At the end of the dwell time the drainage portion of the exchange begins.

55. • The tube is unclamped and the solution drains from the peritoneal cavity by
gravity through a closed system.
• Drainage is usually completed in 10 to 20 min.
• The drainage fluid is normally colourless or straw colour and should not be
cloudy.
• Bloody drainage may be seen in the first few exchanges after insertion of a
new catheter but should not occur after that time.
• The number of cycles or exchanges and their frequency are prescribed
based on the monthly laboratory values and presence of uremic symptoms.

56. • The removal of excess water during PD occur because dialysate
has a high dextrose concentration making it hypertonic. An
osmotic gradient is created between the blood and the dialysate
solution.
• Dextrose solution of 1.5 %, 2.5% and 4.25% are available in
several volumes from 1000 ml to 3000 ml .
• The higher the dextrose concentration the greater the osmotic
gradient and the more water will be removed. Selection of the
appropriate solution is based on the patient fluid status

57. TYPES
1.Continuous ambulatory PD
2. Automated peritoneal dialysis
•Intermittent peritoneal dialysis
•Continuous cycling peritoneal dialysis
•Nightly peritoneal dialysis

58. 1. CONTINUOUS AMBULATORY PERITONEAL
DIALYSIS
• It is the form of intracorporeal dialysis that uses the peritoneal as the semipermeable membrane.
• Procedure-
• A permanent indwelling catheter is implanted into the peritoneum, the internal cuff of the catheter
becomes embedded by fibrous in growth which stabilizer it and minimize leakage.
• The tube for connecting the catheter to an administration set attached via a locking mechanism to the
distal end of the peritoneal catheter called the transfer set.
• It remains with the patient and must change at regular intervals.
• There are many types of administration sets, the most common being the double bag system. The
double bag system has a pre attached bag of dialysate solution and drainage which has been shown to
reduce peritonitis rates.
• In CAPD a patient is prescribed a set of number of exchanges

59. • During the fill, the dialysate bag is raised to shoulder level and
infused by gravity into the peritoneal cavity,
• During 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 if functionally optimal.
• After the dialysate is drained, a fresh bag of dialysate solution is
infused using aseptic technique and procedure is repeated.
• Patient perform 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.

60. Patient education:
• The use of CAPD as along term treatment depends on
prevention recurring peritonitis.
• Use a strict aseptic technique when performing bag use.
• Perform bag exchange in clean, closed off area without pets
and other activities.

61. 2. AUTOMATED PERITONEAL DIALYSIS
•- it is performed through acycler machine.
•-during the night when the patient is asleep.

62. Continuous cycling peritoneal dialysis
•Patient carries PD solution in the abdominal cavity
throughout the day but performs no exchanges.
•At bedtime, patient hooks up to the cycler ,which drains
and refills the abdomen with solution three or more
times in the course of the night.

63. • Intermittent peritoneal dialysis
• It is an option for treating acute kidney injury when access to the
bloodstream is not possible or hemodialysis /CRRT is not available.
• It is similar to CAPD in that it involves access to the peritoneal cavity
either with a newly inserted rigid stylet catheter or in chronic peritoneal
patient the existing chronic catheter can be used.
• In IPD exchange ranges from 30 min to 2 hours. Exchanges are repeated
continuously for a prescribed period of time which varies from 12 to 36
hours.
• Due to the rapid exchange patients are on bed rest. As with all peritoneal
dialysis procedure aseptic technique is essential during catheter insertion
exchanges and dressing changes to prevent peritonitis.

64. ADVANTAGES OF PD
•Painless and no bleeding
•Home based therapy
•Gentler and works more like the natural kidney

65. DISADVANTAGES
•Infections
•Weight gain
•Hernia
•Inadequate dialysis

66. SIGNS AND SYMPTOMS
Fluid overload Fluid underload Peritonitis
 Hypertension
 Pitting edema of feet,
ankles and hands
 Crackles in lung field
 Shortness of breath
 Jugular vein distention
 Pulmonary edema
 Fatigue
 Ascites
 Periorbital edema
 Hypotension
 Tachycardia
 Muscle cramps(legs)
 Abdominal pain during
exchange
 Nausea
 Vomiting
 Cloudy out flow fluid( effluent)
 Systemic infection sympoms

67. COMPLICATIONS
• Bleeding after catheter insertion
• Perforation of gut
• Abdominal pain
• Leakage around catheter
• Difficult drainage
• Pulmonary complications
• Peritonitis
• Metabolic problems

68. NURSING MANAGEMENT
Potential for developing infection related to the catheter
Assess the site for any signs of infection; any redness,
rebound tenderness, swelling, drainage from the exit site
or change in vital signs Maintain strict aseptic technique
while carrying out the procedure

69. Potential for developing cardiac and respiratory complications
related to the uremic state and presence of fluid in the
peritoneum
Frequent cardiac and respiratory assessment
Watch for signs of fluid accumulation; heart failure, and
pulmonary edema Auscultate the base of lungs for crackles
Assess for signs of pericarditis; substernal pain, low grade
fever, and peri cardial friction rub.

70. Acute pain and abdominal discomfort related to the dialysate
infusion
Warm the dialysate to body temperature
Altered nutrition less than body requirement related to the
protein loss
 High protein, fibre rich well-balanced diet
Limit carbohydrate intake

71. Knowledge deficit related to care of catheter site
Teach the patient the possible signs of infection
Catheter care should be done daily
Avoid tub bath and exit site should not be
submerged in water