HEMODIALYSIS

1
HEMODIALYSIS

• Physiological Impact
• Susan A. Bruck, RN
• November 10, 2008

2
Renal Function

• Regulation of fluid volume
• Electrolyte balance
• Acid base balance
• Removal of waste products

• Blood pressure control
• Anemia and red blood cell production
• Calcium /Phosphorous balance
• Vitamin D

3
RENAL FAILURE

• Acute Failure
• Hypo profusion
• Nephrotoxins
• Shock, Sepsis
• Decreased CO 2
• Heart Failure
• Aneurysms

• Chronic Failure
• Diabetic
• Nephropathy
• Hypertension
• Glomerulonephritis
• Cystic Kidney Disease
• Immunologic disorders
• Pyelonephritis
• Lupus Gout Scleroderma

4
WHAT IS DIALYSIS ?

• The process of removing wastes and excess fluid
  from the blood stream that damaged kidneys can no
  longer remove.
• Usually the treatment of choice when toxic
  agents, such as barbiturate overdose, need to be
  removed quickly.

5
When does a person need dialysis ?

• GFR falls below 10/ml/min
• When they exhibit signs and symptoms
• When there is less than 10 functioning kidneys
• We are born with 2 million nephrons, but can
  survive with 20,000

6
WHAT DO WE NEED ?

• Access to the blood stream
• Semipermeable membrane
• Dialysate

7
DIALYSIS PRINCIPLES

• Osmosis
• Diffusion
• Ultra filtration

8
OSMOSIS

• The movement of water across a semiperm-
• eable membrane from an area of lower
  concentration of solutes to an area of higher
  concentration of solutes.
• Osmosis ceases when concentration
• (osmolality) on the two sides of the semi
  permeable membrane equilibrates.

9
DIFFUSION

• Passive movement of particles from an area of
  higher to an area of lesser concentration of
  particles diffusion ceases when equilibrium is
  reached.

10
ULTRAFILTRATION

• The process by which plasma water is removed,
  (expressed in ml/min, or L per hour, )
• Because of a pressure gradient between the blood
  and the dialysate compartment. It is influenced
  by osmosis and by hydraulic pressure that forces
  water from one compartment to another.
• During dialysis it is the result of TMP which is
  moves the water from one compartment to another.

11
SEMIPERMEABLE MEMBRANE

• Used for dialysis/ located in the artificial
  kidney called a dialyzer.
• Two compartments/ blood and dialysate.
• Perforated with small pores for movement of small
  molecules.
• Many sizes.

12
THE PROCESS
13
THE DIALYZER

• Two separate compartments
• Hollow fibers or parallel plates
• Four ports
• 10,000 or more capillary like tubes
• Cellulose or synthetic materials

14
(No Transcript)
15
DIALYSIS ACCESSES

• TEMPORARY/ACUTE
• Subclavian
• Internal Jugular
• Femoral/ hard vs. soft

• PERMANENT
• AVF Arterial/Venous fistulas
• AVG Arterial /Venous grafts
• Tunneled Permacaths

16
CATHETER CARE

• Patients life line
• Venous access
• Clean dry occluded dressing
• Need a Nephrologists' order to use
• All are blocked with HIGH DOSE HEPARIN
• Permacaths are placed by Radiology
• Preventing infection

17
HOW TO ACCESS CATHETERS

• Only when all other options have been tried
• Must have Nephrologists order
• Sterile field
• Mask on nurse and patient
• Supplies-syringesSaline flushes Heparin
• REMOVE 3 Xs AMOUNT PRINTED ON CATH
• After use of catheter , relock with the exact
  amount of 5000 Units per ml of Heparin printed on
  the catheter

18
(No Transcript)
19
(No Transcript)
20
ACCESS ASSESSMENT CARE

• Patients life line
• Check for bruit and thrill every shift
• No BP or Needle sticks in arm (Post Sign)
• Patient education
• Aneurysm and Pseudoaneurysm
• Remove band aids/Tip Stops following day

21
THE PERSCRIPTION

• Kinetic model of Kt/V (Dialyzer clearance (
  K), time on dialysis (t), and the volume of urea
  distribution in the patient(V)
• Adequacy (effect of RRT to overcome uremic
  symptoms
• Hematocrit, albumin levels, fluid volume status,
  bone disease,and functional status
• Time, result desired, dial sate bath, BFR, and
  physical assessment help determine outcome

22
PRE-DIALYSIS ASSESSMENT

• Vital signs, TPR
• Weight (Compare to EDW)
• Blood pressure
• Heart, lungs, and presence of edema
• ACCESS
• Laboratory findings
• What else is going on with patient health status

23
PATIENT MONITORING

• Hypotension
• Muscle cramps
• Nausea and Vomiting
• Headache
• Itching
• Chest Pain
• Back Pain
• Fever chills
• Dialysis Disequilibrium

24
POST DIALYSIS ISSUES

• Hypotension
• Reduction of cardiac output-blood volume
  depletion
• Anemia
• Aggressive UF
• Hypoalbuminemia
• BP medications on board
• Eating on dialysis
• Treatments
• Trendelenburg, Normal Saline Bolus, Feed or
  small amount of boullion

25
POST ISSUES CONT

• Dialysis Disequalibrium Syndrome
• Systemic and Neurologic symptoms
• Usually severely uremic patients
• Often associated with rapid lowering of plasma
  solutes leaving urea and osmolarity higher in
  the brain then the plasma.
• Headache, restlessness, nausea and vomiting

26
CONT

• Fatigue/Lethargy
• Shift of fluid, electrolytes, and waste removal
  in 3- 4 hours that would have normally been done
  in 48 hours.
• Site Bleeding
• Monitor for oozing. Apply pressure and redress.
• Aneurysm rupture
• Watch site for shiny taught area. ER put finger
  in the dike. Dont put wads of towels or
  dressing. You must stop with direct pressure and
  call surgeon

27
NURSING ISSUES

• Other medical issues i.e. diabetes
• Skin care
• Inability to feed themselves (no Strength)
• Glucose intolerance, often need less, but should
  have some nourishment before dialysis
• Hypothyroidismcausing cold intolerance ,
  lethargy, goiter

28
NURSING

• Monitor trays, correct diet orders if necessary
• Giving phosphate binders at proper times
• Monitor fluid intake and ice intake
• Partner with Nursing Assistants to provide
  remarkable care i.e.. ACCURATE daily weights

29
PSYCOSOCIAL NEEDS

• THE ASSESSMENT
• Interview and behavior observation
• Psychological parameters
• Social parameters

30
CONCERNS TO DEAL WITH

• UNDERSTANDING THE DISEASE PROCESS
• COMPLIANCE WITH A STRICT REGIMEN
• RELATIONSHIPS WITH SPOUSE, CHILDREN, AND OTHER
  FAMILY MEMBERS
• FINANCIAL CONCERNS
• LOOSING CONTROL
• CHANGES IN LIFE STYLES