Dialysis is a process that removes waste and excess water from the blood when the kidneys fail. It uses diffusion and osmosis across a semi-permeable membrane as an artificial replacement for kidney function. There are two main types: hemodialysis which cleanses the blood directly by passing it through a dialyzer, and peritoneal dialysis which uses the peritoneal membrane in the abdomen as a filter. Both aim to maintain fluid, electrolyte and acid-base balance by removing toxins when the kidneys are unable to do so.

1. DIALYSIS
PRESENTED BY
MR.ROMAN BAJRANG
RELIANCE INSTITUTE OF NURSING

3.  Dialysis (from Greek dialusis,
meaning dissolution, dia, meaning through, and
lysis, meaning loosening or splitting) is a process for
removing waste and excess water from the blood,
and is used primarily as
an artificial replacement for lost kidney function in people
with renal failure.

4. CONT….
 Dialysis may be used for those with an acute disturbance
in kidney function (acute kidney injury, previously acute
renal failure), or progressive but chronically worsening
kidney function–a state known as chronic kidney disease
stage 5 (previously chronic renal failure or end-stage renal
disease).

5. Dialysis is an artificial process used to remove water
and waste substances from the blood when the
kidneys fail to function properly.
It generally works through osmosis and filtration of
fluid across a semipermeable membrane with the use
of a dialysate.
Dialysis is the procedure used to correct fluid and
electrolyte imbalances and to remove waste
products in renal failure.

6. PURPOSE
 The purpose of dialysis is to maintain fluid electrolyte and acid base balance and
to remove endogenous and exogenous toxins

7.  A semipermeable membrane
is a thin layer of material that
contains holes of various
sizes, or pores.
 This replicates the filtering
process that takes place in the
kidneys, when the blood
enters the
larger
kidneys and the
substances are
separated from the smaller
ones in the glomerulus.

8. is used to remove fluid and uremic waste
products from the body when the kidneys cannot
do so.
It may also be used to treat patients with edema
that does not respond to treatment, hepatic coma,
hyperkalemia, hypercalcemia, hypertension,
and uremia.

9. Indications for Dialysis
• The need for dialysis may be acute or chronic.
1. Acute dialysis is indicated
A.when there is a high and rising level of serum potassium, fluid
overload, or impending pulmonary edema, increasing acidosis,
pericarditis, and severe confusion.
B.to remove certain medications or other toxins (poisoning or
medication overdose) from the blood.
2. Chronic or maintenance dialysis is indicated inchronic
renal failure, known as end-stage renal disease (ESRD

10. ANATOMY AND PHYSIOLOGY

12. KIDNEYS
 The kidneys are a pair of organs, each about the
size of a fist, located on either side of your spine.

13. LOCATION
 Located at the Near of the abdominal cavity
in the retroperitoneal space.

14. * Urine formation
Excretion of waste products
Regulation of electrolytes
Regulation of acid base balance
Control of blood pressure
Secretion of prostaglandins
Synthesis of vitamin D to active form
KIDNEY FUNCTIONS

15. PRINCIPLE OFDIALYSIS
Dialysis works on the principles of the diffusion of solutes
and ultrafiltration of fluid across a semi-permeable
membrane.
Diffusion describes a property of substances in water.
. Substances in water tend to move
. From an area of high concentration
. Toan area of low concentration.
. Blood flows by one side of a semipermeable membrane
. A dialysate (or special dialysis fluid) flows by the opposite
side.
Diffusion
Osmosis
Ultra filtration & solvent drag

16. OSMOSIS
Movement of solvent molecules from
lower concentration to higher
concentration

17. . Water moves from an
area of high pressure
to an area of lower
pressure
OooOOO
. More efficient in fluid
removal than osmosis
Molecules which are
dissolved in the
solvent also get
removed- solvent drag
Ultra filtration & Solvent drag

18. METHODS OF DIALYSIS INCLUDE
Peritoneal dialysis
Hemodialysis

19. William Kolf invented the first "artificial kidney"
Father of hemodialysis

20. It is the removal of solutes and water
from body across a semipermeable
membrane (dialyzer .

21. HEMODIALYSIS
 It is the procedure of cleansing the blood of
accumulated waste products. It is used for patient
with end stage renal failure or for acutely ill
patient who require short term.

23. Cleanses the blood of accumulated waste
products
Removes the by-products of protein
metabolism such as urea, creatinine, and
uric acid.
Removes excessive fluids
Maintains or restores the buffer system of
the body
Maintains or restores electrolyte levels
FUNCTIONS OF HEMODIALYSIS:

24. Acute poisoning
Acute renal failure
Severe edema
. Chronic renal failure
. Hepatic coma
. Metabolic acidosis
. hyperkalemia
INDICATIONS

25. Other chronic disease
. No vascular access
. Hemorrhage
. hypertension
. Very old people
. Inability to cope with treatment
regimen
. Coagulopathy
. Inability to survive procedure
CONTRAINDICATIONS

26. Haemodialysis Apparatus
a. Dialyzer
b. Dialysate
c. Blood delivery system

27. Dialyzer(Artificial Kidney)
" Plastic chamber - contains bundles
of capillary
tube through which blood circulates
while
dialysis solution travels outside the
bundle in
opposite counter current direction.
Diffusion & ultrafiltration happens
here.

28. Membranes using in dialyser
Cellulose
-Substituted Cellulose-
cellulose acetate
-Cellulosenthetic-Cellosyn/
Hemophan
-Synthetics-polyacrylonitrile,
polysulfone, polymethyl methacrylate

29. Blood Delivery system
Blood Pump - moves blood from access
site through the dialyzer &
back to the patient
Blood flow Rate - 250-500 ml/min

30. METHODS OF CIRCULATORYACCESS
 Arteriovenous fistula- An arteriovenous
fistula is an abnormal connection or
passageway between an artery and a vein.

31.  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.
 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 forthe
reinfusion of dialysed blood.
 Healing of AVF requires at least 6 to 8 weeks; a central vein catheter isused.

32. ARTERIOVENOUS GRAFT-
 If a patient is not a good candidate for an
arteriovenous fistula, an arteriovenous graft
is considered.

33. CENTRAL VEIN 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.

34. REQUIREMENT FOR HEMODIALYSIS….
 Access to patients circulation .
dialyzer with
 Dialysis machine and
semipermeable membrane.
 Appropriate dialysis bath.
 Time- approximately 4 hrs, three times
weekly.
 Place- dialysis centre or home (if feasible

35. DIALYZE
R

37. DIALYSATE

38. PROCEDURE
 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 the
proper pH balance.

39.  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.

40. COMPLICATIONS
 Infection
 Catheter clotting
 Central vein
thrombosis
 Stenosis or
thrombosis.
 Ischemia of the hand
 Aneurysm

41. PERITONEAL
DIALYSIS

42. ANATOMY

43. PERITONEUM-
forms the lining of
 The peritoneum is
the serous membrane that
the
abdominalcavity .
 It covers most of the intra-
abdominal (or coelomic)
organs, and is composed of a
layer
supported
of mesothelium
by a thin layer
of connective tissue.

44. CONTI
 T
…h
e peritoneum supports the
abdominal organs and serves
as a conduit for their blood
vessels, lymph vessels, and
nerves.

45. PHYSIOLOGY
 The semipermeable peritonealmembraneallows
solutesand watertobetransported from the
vascular system totheperitonealcavityand vice
versa.

46. Peritoneal dialysis:
Introduction
 Peritoneal dialysis(PD) is a treatment for
patients with severe chronic kidney disease.
 A dialysis technique that uses the patient's own body
tissue-peritoneal membrane inside the abdominal
cavity as a filter.

48. A.PERITONEAL DIALYSIS-
 Peritoneal dialysis is a way to remove waste
products from your blood when your kidneys can
no longer do the job adequately.

49. Goals of PD
• Remove toxic substances andmetabolicwastes
• Reversethe symptoms of uremia
• Reestablish normal fluid and electrolytebalance
• Maintain a positive nitrogenbalance
• Prolong life
• Havethe maximum level of qualityof life

50. Principles underlying peritoneal
dialysis
Three processes takeplacesimultaneously
 Diffusion
 Osmosis
 Ultrafiltration

51. Treatment of choice for….
Patientswith RF unableorunwilling toundergo HD orrenal
transplantation
• Diabeticpatients
• Patientswithcardiovasculardiseaseseg:heart failure
• Olderpatients
• Patientsatriskof adverseeffectsof systemic heparin
• Patients withseverehypertension

52. INDICATIONS
 VASCULARACCESSFAILURE
 INTOLEANCE TO HEMODIALYSIS
 CONGESTIVE HEARTFAILURE
 PROSTHETIC VALVULARDISEASE

53. Contra indications
Absolute contraindications
 Peritoneal fibrosis andadhesionsfollowing
intra abdominaloperations
 Inflammatory gutdiseases

54. Relative contra indications
Hernias
Significant loinpain
Psychosis
Diverticulosis
Colostomy
Obesity
Significantdecrease
of lung functions

55. Preinsertion preparation
of the patient
 Determine the catheterexitsite
Site:
 Midline
 3 cm below umbilicus
 Lateral site
 At the lateral border of the rectusmuscles
 On a line, half way between the umbilicus and anterior
superior iliac spine
 Left lateral side is preferred as it avoids caecum

56. Pre operative care of the
patient
 Takebathorhaveashowerin the morning
 Abdominal hair shouldbeclipped
 Empty boweland bladderbeforecatheterinsertion
 Enema canbegiven
 Staphylococcusaureusscreening
 Administerantibioticsprophylactically

57. • A trocarisused topuncturetheperitoneum asthepatient tightens theabdominal
muscles by raisingthehead.
• The catheter is threaded through the trocarand positioned.
• Previously prepared dialysate is infused into the peritoneal cavity, pushing the
omentum (peritoneal lining extending from the abdominal organs) away from the
catheter.
• The physician may then secure the catheter with a purse-string sutureand
applyantibacterialointment and asteriledressingoverthesite

59. Composition of PD solution
Components
Na 132 mmol/l
Ca 1.25mmol/l
Mg 0.5mmol/l
Cl 100mmol/l
Lactate 35mmol/l
Glucose 1.36-4.25g/dl
Osmolarity 347-486
pH 5.2

60. PROCEDURE
Patientpreparation
Explain theprocedure & obtain informedconsent.
Baseline vital signs, weight,serumelectrolyte
levels arerecorded.
Assess patient’s anxiety abouttheprocedure.
Broad spectrum antibioticsprophylactically.

61. PROCEDURE
Equipment preparation
 Assemble the equipments needed
 Check physician’s order for the concentration of dialysate
and medications to be added
 Heparin : to prevent clotting
 KCl: to prevent hypokalemia
 Antibiotics : peritonitis
 Insulin : for diabetic patients

62. PROCEDURE
 Warm the dialysate solution to body
temperature:
 Toprevent patient discomfort and abdominal
pain
 Todilate the vessels of peritoneum
 Dry heating should be done
Too cold solution causes pain, cramping, and
reduce clearance

63. Not recommended....
 Soaking the bag of solution inwarmwater
 Useof microwaveto heat thefluid
 Avoid too coldsolution

64. Performing the exchange
Exchange:
Infusion
Dwell or
Equilibration time
Drainage

66. Performing the exchange
Infusion
 The dialysate is infused bygravity intothe
peritoneal cavity.
A period of about5 to 10 minutes isusually
required to infuse 2 L offluid.

67. • Dwell or equilibration and
drainage of dialysate
• Theprescribeddwell,orequilibration, timeallowsdiffusion and osmosis tooccur.
• Diffusionof small molecules,suchasureaand creatinine, peaks in thefirst 5 to
10 minutes of thedwelltime.
• Attheend of thedwell time, thedrainageportionof theexchangebegins.
• Thetubeisunclampedand thesolutiondrains fromthe peritonealcavity by
gravitythroughaclosedsystem.
• Drainageisusuallycompleted in 10 to30 minutes.

68. Performing the exchange
Drainage fluid
• Colorless or straw-colored
• Should not be cloudy
• Bloody drainage may be seen in the first few exchanges
Entire exchange time
 1 to 4 hours (depending on prescribed dwell time)

69. Types of peritoneal dialysis
Continuous ambulatoryperitonealdialysis
(CAPD)
Automated peritoneal dialysis(APD)
Continuous cycling peritoneal dialysis(
CCPD)
Intermittent peritonealdialysis
Nocturnal(nightly)intermittent peritoneal
dialysis

70. Continuous cycling peritoneal
dialysis
 Patientcarries PD solutionin theabdominalcavity
throughouttheday butperformsnoexchanges.
 At bedtime ,patient hooks upto the cycler ,which
drainsand refillstheabdomenwithsolutionthreeor
moretimes in thecourseof the night.

71. Automated peritoneal dialysis
 -is performed through acyclermachine.
 -during the nightwhenthepatientisasleep.

72. Continuous cycling peritoneal
dialysis
 Patientcarries PD solutionin theabdominalcavity
throughouttheday butperformsnoexchanges.
 At bedtime ,patient hooks upto the cycler ,which
drainsand refillstheabdomenwithsolutionthreeor
moretimes in thecourseof the night.

73. Intermittent peritoneal
dialysis(IPD)
• Intermittentperitonealdialysis isoffered topatientsona
temporary basis when their blood pressure is low or in
childrenwithacuterenal failuretotideoveracrisis.
• Itisperformed forashortperiodof 12-24 hours,2-3 times
weekly.
• Commonroutinehourlyexchangeconsistsof 10 min
infusion, 30mindwell timeand a 20 mindrain time.

74. Nocturnal intermittent
peritoneal dialysis
 Patientdrainsoutfullyattheend of thecycling
period,sotheabdomen isdryall day.
 Clearancesare loweronNIPD.

75. Assessing peritoneal dialysis
adequacy
 Creatinineclearance
 Asoluteremoval test based on the bodysurfacearea
 General well being

76. Infectious complications
Peritonitis
Mostcommonand mostseriouscomplication
 Diagnosis
 Cloudy PDeffluent
 Abdominal pain , tenderness ,pyrexia
 Identification of micro organisms inPDeffluent
incultureor positive gramstaining

77. Infectious complications
 Treatment
 Initial one to three rapid exchanges with 1.5%
dextrose solution – to wash out mediators of
inflammation
 Drainage fluid – examined for cell count ,
Gram’s stain, culture
 Intraperitoneal or intravenous antibiotics
 Unresolved peritonitis after 4 days of
appropriate therapy necessitates catheter
removal

78. Advantages of PD over HD
1. Easytousewithoutsophisticatedequipments
2. Easytomanage in homeand communityhealthcare
facilities
3. more independence andmobility
4. Dialysis treatment of choiceforchildren
5. Mayallowbetterblood pressureandvolumecontrol
with cardiovascularbenefits
6. Maygive betterqualityoflife
7. Lowerrisk of HepatitisC
8. Equalorbettersurvival inearlyyears

79. . Haemoglobin : 15 days
. Urea, creatinine, Na+, K+ : I
month
. Serology : 2 months
Investigation

80. MEDICALMANAGEMENT
Monitor patient
. Level of consciousness
. Vital Signs
Maintain airway
Administer Oxygen (per state/local protocols)
Support ventilations if or as necessary
Control any bleeding from the shunt or access site
Place patient in position of comfort
Transport to closest appropriate facility

81. PHARMACOLOGICALMANAGEMENT

82. Medications Common to Dialysis
Patients
Vitamins - water soluble
Phosphate binder ---- GIVE WITH MEALS
Phoslo (calcium acetate)
Renagel (sevelamere hydrochloride)
Caltrate (calcium cabonate)
Amphojel (aluminum hydroxide)
Iron Supplements -
don't give with phosphate binder or calcium
Antihypertensives - hold prior to dialysis

83. Erythropoietin
Calcium Supplements
Between meals, not with
iron
Activated Vitamin D.
aids in calcium absorption
Antibiotics
hold dose prior to dialysis
if it dialyzes out

84. SURGICAL MANAGEMENT
Kidney Awaiting Transplant

86. Transplanted Kidney

87. storation of "normal"
renal function
eedom from dialysis
turn to "normal" life
verses pathophysiological
changes rela
nal Failure
ss expensive than dialysis
after 1 st year
Advantages

88. Life long medications
Multiple side effects from
medication
Increased risk of tumor
Increased risk of infection
Major surgery
Disadvantages

90. Nursing management
 Potential for developing infectionrelated tothe
catheter

 Assess the site for any signs of infection; any
redness, rebound tenderness, swelling,drainagefrom
theexitsiteorchange invital signs
Maintain strictaseptictechniquewhilecarrying
out theprocedure

91. Nursing management
 Potential for developing cardiacandrespiratory
complications related to the uremic state and
presence of fluid intheperitoneum


 Frequent cardiac andrespiratoryassessment
 Watch for signs of fluidaccumulation;heart
failure, and pulmonaryedema
Auscultatethe baseof lungs forcrackles
Assess for signs of pericarditis;substernalpain,
low grade fever, and pericardialfrictionrub.

92. Nursing management
 Acute painand abdominal discomfortrelatedto
the dialysateinfusion
 Warm the dialysateto bodytemperature
 Altered nutrition less thanbodyrequirement
related tothe proteinloss
 High protein, fiber rich wellbalanceddiet
 Limit carbohydrateintake

93. Nursing management
 Knowledgedeficitrelated tocareof cathetersite
 Teachthepatientthepossiblesignsof infection
 Cathetercareshould bedonedaily
 Avoid tubbathand exitsiteshould not be
submerged inwater

94. Nursing management
 Altered body image related totheabdominal
catheter and bagandtubing
 Assess for any suchproblem
Allow the patient to express his feelings
and concerns about body image
disturbances.
 • Assist in selecting of properclothing
•
Provide an opportunity to the patient
to meet similar patients who are well
adjusted with the condition

95. Nursing management
 Altered sexual patterns andsexualdysfunction

 Provideprivacy tothe patientsothat he can
discuss hisproblem
Nursecan start thediscussion byasking aboutany
concerns related tosexuality