The kidneys’ role…
Remove waste productsFluid controlBP controlRBC productionKeeping bones healthy
When our kidneys fail…
We may feel sick, sleepy, confused or nauseous. (waste products)
We will feel tired and pale. (RBC)We may have ankle swellings & start
to feel breathless. (extra fluid)We may have bad breath & loss of
appetite. (waste products)
PRESENTED BY
ANU ISSAC
RENAL DIALYSIS
• First form of dialysis practised by Romans.
• 1854- the term dialysis was used for the first time by Thomas Graham.
• 1913- first article on hemodialysis- ‘Artificial kidney’
• 1920’s- first dialysis performed by George Hass
• 1948- first successful dialysis in Mount Sinai hospital by Willem Kolff
Historical background
Dialysis is the movement of fluid and molecules across a semipermeable membrane from one compartment to another.
Clinically, dialysis is a technique in which substances move from the blood through a semipermeable membrane and into a dialysis solution (dialysate)
DEFINITION OF DIALYSIS
INDICATIONS
Dialysis: Methods
Hemodialysis Peritoneal Dialysis
OSMOSIS
Principles of dialysis
DIFFUSION
Ultrafiltration
Hemodialysis
Hemodialysis…
4-6 hours
Hemodialysis: Functions
Cleanses the blood of accumulated waste products
Removes the by-products of protein metabolism (urea, creatinine & uric acid)
Removes excessive fluidsMaintains or restores the buffer system
of the bodyMaintains or restores electrolyte levels
Removal of solutes and water from the blood across a semipermeable membrane
Definition
Selective filter for removing toxic or unwanted solutes from the blood
Dialyser
Basic flow path geometriesRectangular cross section, parallel plate
dialyser.
CIRCULAR CROSS SECTION; HOLLOW FIBER DIALYSER
Organic cellulose derivatives
Synthetic membranes
Membranes used in hemodialysis.
DIALYSATE
The fluid that is pumped through the dialyser on the opposite side of the semi permeable membrane to the patients blood.
Correct the chemical composition of uremic blood to normal physiological levels.
SOLUTE CONCENTRATION
SODIUM (mmol/L) 135- 143
POTASSIUM(mmol/L) 0-4
CHLORIDE 100- 111
CALCIUM 1.25 – 1.75
MAGNESIUM 0.75- 1.5
BICARBONATE 30- 35
GLUCOSE 0- 25 gm
Usual composition of hemodialysis dialysate
Sodium chloride ; Na+ 176 gm ; 82 mEq/L
Potassium chloride ; K+ 5.50 gm ; 2.0 mEq/L
Calcium chloride ; Ca + 8.00 gm ; 3.0 meq/L
Magnesium chloride ; Mg ++, Cl -
2.75 gm ; 0.75 mEq/L, 88.0 mEq/L
Acetic acid 9.0 gm ; 4.0 mEq/L
Purified water 1 liter
Concentrated acidic solution [ 'A' solution]
Sodium chloride 235 gms
Sodium bicarbonte 600 gms
Na + 55 mmoles
HCO3- 35 mmoles
Cl- 20 mmoles
Bicarbonate solution (B solution)
Na + - 137 mEq/LK + - 2 mEq/LCa ++ - 3.0 mEq/LMg ++ - 0.75 mEq/LCl ‾ - 108 mEq/LHCo3‾ 35 mEq/LCH3COO‾ 4 mEq/L
Final solution ( dialysate)
FiltrationActivated carbon filters (adsorption)Water softnersReverse osmosis (RO)De ionizationUltraviolet light exposure
Methods to treat water for dialysis
The removal of air
The removal of any chemicals
Preparation of the dialyser
PERMANENT VASCULAR ACCESSArterio venous fistula’s (AVF’s)
Arterio venous grafts (AVG’s)
Shunts
ACCESS FOR HEMODIALYSIS
Arterio venous fistula
Internal AV Fistula…
Advantages Disadvantages
less danger of clotting and bleeding can be used indefinitely decreased incidence of infection no external dressing required freedom of movement
cannot be used immediately after insertion venipuncture is required for dialysis infiltration of needles → hematoma aneurysm in the fistula Arterial steal syndrome Congestive heart failure
Arterio venous graft
Internal AV Graft…
Advantages Disadvantages
less danger of clotting and bleeding can be used indefinitely decreased incidence of infection no external dressing required freedom of movement
cannot be used immediately after insertion venipuncture is required for dialysis infiltration of needles → hematoma aneurysm in the fistula Arterial steal syndrome Congestive heart failure
External AV Shunt
Access is formed by the surgical insertion of 2 silastic cannulas into an artery or vein in the forearm or leg to form an external blood path.
External AV Shunt…
Advantages Disadvantages
can be used immediately after insertion no venipuncture necessary for dialysis
external danger of disconnecting or dislodging the shunt risk of hemorrhage, infection or clotting skin erosion around the catheter site
Rope ladder puncture
Area puncture
Button hole puncture
Cannulation of AVF
Thrombosis
Stenosis of fistula
Aneurysm
Steal syndrome
Infection
Complications of AVF
Subclavian vein
Internal jugular vein
Femoral vein
Temporary access sites
for acute dialysisIn the patient who is imminently awaiting a
kidney transplant for maturation of AV accessLimited availability of vesselsPatients undergoing plasmapheresisFor continuos renal replacement therapiesPatients on peritoneal dialysis requiring
temporary hemodialysis because of peritonitis.
Temporary access is used insituations like…..
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
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
Weight
Blood volume monitoring
Blood pressure
Temperature and pulse
Serum biochemistry and hematology
Assessment of the patient
Kt / V – 1.2
URR – 65%Albumin - >35 g/LPotassium – 3.5 – 6.5 mmol/LPhosphate - < 1.8 mmol/LCalcium – b/w 2.2 and 2.6 mmol/LHb - > 10 g/L
Target pre-dialysis values
URR( urea reduction ratio) = 100 (1- Ct/Co)
Ct= post dialysis ureaCo= pre dialysis urea
ETO Gamma irradiation Steam sterilization Electron or e-beam sterilization
Sterilization of dialyser
HypotensionMuscle cramps Loss of blood Hepatitis Sepsis Disequilibrium syndrome Vascular steal Dialyser Reaction HemolysisAir embolism
Complications of hemodialysis
Control of HIV and HBsAg in dialysis unit
Home hemodialysis
PERITONEAL DIALYSIS
PERITONEAL DIALYSISAdequate Patient Care in the Most
Biocompatible Way
ACCESS FOR DIALYSIS
•
COMPOSITION OF DIALYSATE
Sodium 132- 142
Potassium 0- 4
Calcium 2.5- 3.5
Magnesium 0.5- 1.5
Lactate 35- 40
Chloride 101- 107
pH 5.0- 5.8
Dextrose 1.5- 4.25 gm/dL
Inflow (fill) – 10 minutes
Dwell ( equilibration) – 20 minutes to 8 or more hours
Drain - 15 to 30 minutes
Phases of peritoneal dialysis
Automated peritoneal dialysis (APD)
Continuous ambulatory peritoneal dialysis (CAPD)
Types of peritoneal dilaysis
Continuous cycling peritoneal dialysis ( CCPD)
Nocturnal intermittent peritoneal dialysis (NIPD)
Intermittent peritoneal dialysis (IPD)
Tidal peritoneal dialysis (TPD)
Forms of APD
Automated Peritoneal Dialysis
Requires a peritoneal cycling machine called a cycler
Can be done as intermittent peritoneal dialysis, continuous cycling peritoneal dialysis, or nightly peritoneal dialysis
CAPD: Equipments
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.
CAPD Cycle…
3. When it is time to drain off the effluent, 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.
o FREEDOM FROM DIALYSIS MACHINE
o CONTROL OVER DAILY ACTIVITIES
o OPPURTUNITIES TO AVOID DIETARY RESTRICTIONS
Advantages of CAPD
History of multiple abdominal surgeries.
Recurrent hernias
Obesity
Pre –existing vertebral disease
Severe obstructive pulmonary disease
CONTRAINDICATIONS
Exit site infectionPeritonitisAbdominal painOutflow problemsHernias Lower back problemsBleedingPulmonary complicationsProtein lossCarbohydrate and lipid abnormalitiesEncapsulating sclerosing peritonitis & loss of
ultrfiltration
Complications of peritoneal dialysis
Venous access therapies [venovenous]
Arterial access therapies [arteriovenous]
Continuous renal replacement therapy
Venous access therapies
o Continuous venovenous ultrafiltration (CVVU)
o Continuous venovenous hemofiltration (CVVH)
o Continuous venevenous hemodialysis (CVVHD)
ARTERIAL ACCESS THERAPIES
SLOW CONTINUOUS ULTRFILTRATION (SCUF)
CONTINUOUS ARTERIOVENOUS HEMOFILTRATION (CAVH)
CONTINUOUS ARTERIOVENOUS HEMODIALYSIS (CAVHD)
1) Fluid volume excess related to fluid accumulation/ inadequate dialysis
2) Risk for fluid volume deficit related to rapid removal of fluid during treatment
3) Risk for altered tissue perfusion related to risk of vascular access clotting/ disconnection
4) Risk for infection related to presence of access site and invasive procedure
5) Body image disturbance related to presence of access site.
NURSING MANAGEMENT
Pain/discomfort related to dialysis process.Altered thought process related to dialysis
diaequilibrium syndrome Ineffective individual/ family coping related to
diagnosis of chronic illnessNoncompliance to prescribed treatment
regimen
a)Imbalanced nutrition, less than body requirement related to protein loss in the dialysate
b)Risk for infection realted to presence of peritoneal dialysis catheter.
c) risk for imbalanced fluid volume related to hypertonicity of the dialysate or inadequate exchange.
d) activity intolerance to related to fatiguee) risk for complications related to the disease
condition and dialysis procedure
Preitoneal dialysis
1) TUCKER MARTIN SUSAN, CANOBBIO. M. MARY, PAQUETTE VARGO ELEANOR WELLS FYFE MARJORIE, PATIENT CARE STANDARDS, COLLOBORATIVE PRACTICE PLANNING GUIDES, 6TH EDITION, 1996, MOSBY PUBLICATIONS, USA, PAGE NO:- 690-696.
2) THOMAS NICOLA, RENAL NURSING, THIRD EDITION (2008). BALLIERE TINDALL, ELSEVIER PUBLICATIONS, CHINA, PAGE NO: 181-244.
3) KALLENBACH Z. JUDITH, GUTCH F.C, STONER H.MARTHA., COREA L. ANNA, REVIEW OF HEMODIALYSIS FOR NURSES AND DIALYSIS PERSONNEL, SEVENTH EDITION, 2005, ELSEVIER PUBLICATION ,MISSOURI, PAGE NO: 61- 136.
4) LEWIS. L SHARON,HEITKEMPER McLEAN, MARGARET, DIRKSEN RUFF SHANNON, O’BRIEN GRABER PATRICIA, BUCHER LINDA, LEWIS MEDICAL AND SURGICAL NURSING, ASSESSMENT AND MANAGEMENT OF CLINICAL PROBLEM, 7TH EDITION, 2011, ELSEVIER PUBLICATIONS, India, PAGE NO: 1216-1223.
5) NISSENSON R. ALLEN, FINE N. RICHARD, HANDBOOK OF DIALYSIS THERAPY, 4TH EDITION (2008), ELSEVIER PUBLICATIONS, PHILADELPHIA.
6) MASSRY G. SHAUL, GLASSOCK J. RICHARD, TEXTBOOK OF NEPHROLOGY, VOLUME 2 , 3RD EDITION, 1995, WILLIAM AND WILKINS PUBLICATIONS, USA, PAGE NO: 1510-1600.
Bibliography
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