Nursing Care of Patient

on Dialysis

“Don’t Worry I‘ll find a good site soon “ By: Ms. Shanta Peter

• Protocols – in each unit • In regard to machines – Procedure & patient care • Sanitizing machines• PD cath care/dressing /treatment• Flushing new PD catheter • PET • Peritonitis care • Investigation protocol • Vaccination• Records /Treatment flow sheets

Hemodialysis requires 5 things1. Access to patient’s circulation (usually via

fistula)2. Access to a dialysis machine and dialyzer with

a semipermeable membrane3. The appropriate solution (dialysate bath)

4. Time: 12 hours each week, divided in 3 equal segments5. Place: home (if feasible) or a dialysis center 

Access to Circulation Central Venous Catheter A-V Fistula A-V Graft

Hemodialysis – Procedure 1. Patient’s circulation is accessed2. Unless contraindicated, heparin is administered3. Dialysis solution surrounds the membranes and

flows in the opposite direction

4. Dialysis solution is: a. Highly purified water b. Na,K, Ca, Mg, Cl, & Dextrose c. Either bicarbonate or acetate, to maintain a proper pH

6. Via the process of diffusion, wastes are removed in the form of solutes (metabolic wastes, acid-base components and electrolytes)

7. Solute wastes can be discarded

8. Ultrafiltration removes excess water from the blood

9. After cleansing, the blood returns to the client via the access

Complications related to vascular Access in Hemodialysis

1. Infection

2. Catheter clotting

3. Central venous thrombosis

4. Stenosis or thrombosis

5. Ischemia of the affected limb

6. Development of an aneurysm

Hemodialysis: Nursing considerationsPre-dialysis careAssess• Weight: Determines amount of fluid to be

removed during dialysis• Vital signs: BP for hypo and hypertension;

temperature for sepsis; respiration for fluid overload

• Potassium level: Determines potassium level in dialysate (in the chronic setting, this is done monthly unless the patient is symptomatic

Review Medications

• Hold drugs that pass through the dialysis membrane, such as piperacillin, folic acid, and other water-soluble vitamins.

• Hold antihypertensive drugs, especially if systolic pressure is below 100, per physician order

• Review need for blood products

Check access site• Assess fistula or graft for infection• Assess circulation in distal portion of

extremity• Auscultate for bruit• Palpate for thrill• No IV or blood draws in that arm• No BP in arm

During dialysis

Watch for• Hypotension• Muscle cramps• Nausea and vomiting• Headache• Itching• Less commonly: disequilibrium syndrome,

hypersensitivity reaction, arrhythmia, cardiac tamponade, seizures, air embolism

Post-Dialysis care

• Monitor BP; report hypotension or hypertension• Watch for bleeding• Check weight and compare (weight loss should

be close to fluid removal goal set during treatment)

• Document unusual findings• Assess access site for bruit, thrill, exudate, signs

of infection, bleeding• Give missed meds, if indicated

Complications of dialysis

• Infection• Hernias• Nutritional Deficiencies• Low Blood Pressure• Muscle Cramps• Clotting Issues• Movement Issues• Dry and Itching Skin

Nursing interventions for H D

1. Explain procedure to client2. Cannulating & connecting to HD machine

3. Monitor hemodynamic status continuously4. Monitor acid-base balance5. Monitor electrolytes6. Insure sterility of system7. Maintain a closed system8. Discuss diet and restrictions on:

a. Protein intake    b. Sodium intake

                          c. Potassium intake                                    d. Fluid intake

9. Reinforce adjustment to prescribed medications that may be affected by the process of hemodialysis

10. Monitor for complications of dialysis related to: a. Arteriosclerotic cardiovascular disease b. Congestive heart failure c. Stroke d. Infection e. Gastric ulcers f. Hypertension g. Calcium deficiencies (bone problems such as aseptic necrosis of the hip joint) h. Anemia and fatigue i. Depression, sexual dysfunction, suicide risk 11 Dry Weight

Peritoneal Dialysis (PD )

Peritoneal dialysis (PD) is not always trouble-free Patients may experience both psychological and physical problems like ---------• Body image -- catheter outside , size and shape

of abdomen• Fluid overload•  Dehydration• Discomfort- uncomfortable when fluid in full

or blotted – backache , shoulder pain                                                                                   

• Poor drainage : a. Constipation b. Catheter displacement• Leaks • Hernia • Tunnel infection( exit site infection) • Peritonitis • Back pain

Nursing Care – P.D

• Imbalanced nutrition • Impaired physical Mobility• Self-Care Deficit • Risk for Constipation • Risk for disturbed Thought Processes • Anxiety [specify level] • Fear • Disturbed Body Image/situational /low Self-Esteem• Deficient Knowledge  regarding condition, prognosis, treatment, self-care, and discharge needs

Special considerations – Hospitalized patients (HD,PD)

• Protecting the vascular access• Precautions during I.V therapy • Monitoring symptoms of uremia• Detecting cardiac and respiratory Complications• Controlling electrolyte levels and Diet• Managing discomfort and pain• Monitoring BP• Preventing infection• Caring for the catheter site • Administering medications• Providing psychological support –pt and family

Special Nursing responsibilities – DIALYSIS

• Thrill /bruit every 8 hrs – Absence—blockage or clotting • Observe for clotting ( hypotension , application of tourniquet, BP cuff • IV therapy precautions – IV fluid – by pump high rate ---> pulm edema

------Maintain accurate I/O chart • Accumulation of uremic toxins ----> pericarditis, Pericardial effusion, tamponade (Pericaditis --> fever,, Chest pain, low BP during inspiration , rub , Low voltage ECG

Elect level – S K is more deadly Blood transfusions –give during HD --->extra K is excreted

• Monitor diet ---

• Discomfort /Pain – adjust the medication

dosage • skin clean and well moisture – bath oils, cream

lotions reduce itching (nail trimmed )• BP monitoring - High BP common • Antihypertensive medications – teach pts

purpose --- side effects • Withhold antihypertensive medications on

dialysis days --- to prevent hypotension • Medications : monitor all medications --- avoid

renal toxic drugs

• Preventing infection :- Low WBC , Low RBC , impaired platelets count ---> infection and bleeding ( Pneumonia is common)

• Catheter site care• Training CAPD --– compliance should be

checked • Cather care – showing/change dressing and

site care • Psychological support • Evaluate life and status – let pt and family

express feelings

Dialysis & Hypotension

• If syst B/P is 100mmHg or below then hypotensive or if hypertensive and become symptomatic with a drop in B/P.

• If pt is hypotensive but asymptomatic check B/P every 10 minutes do not give fluid replacement.

ETIOLOGY • It is a consequence of a decrease• in blood volume resulting in:• decreased cardiac filling• reduced cardiac output• hypotension if compensatory changes do not occur.

CAUSES • Excessive decrease in blood volume• Lack of vasoconstriction • Cardiac factorsSudden onset and may include:• Nausea & vomiting• Weak thready pulse, shallow respiration's• Light headednesss & fainting• Yawning, cold-clammy skin• Decreased mental state• Irritability, nervousness, stupor• Malaise, fatigue• Seizures

MANAGEMENT • Place in Trendelenberg position• UF off• Vital signs• IV Saline bolusDo not place in trendelenberg if have just had a transplant.• Reduce TMP to -10 but do not turn off• Switch UFR off if using a fluid control monitor• Give a 200 ml saline or gelofusine bolus-- repeated at 5

min intervals if pt remains hypotensive. Max 3 boluses over15 mins or a total of 600 mls.• If hypotensive but asymptomatic then check B/P every

10 mins.

PREVENTION • Patient education• Accurate patient assessment• Target weight assessment• Withhold anti-hypertensives• Dialysate sodium level

DIET –DIALYSIS • PD get calories from Dextrose in the fluid -PD patients

may eat fewer CHO than hemodialysis patients• Protein- HD loses 10-12 gms of Aminoacids and PD 5-

15gms of protein per treatment Also compensate infection inflammation anemia -->so consume HBV protein (1gm/Kg/day)• Na – Salt 2gm/day—salt induce thirst – High BP, and

HF• K- 2mg/day K is more efficiently removed in PD (daily

treatment)

• Phosphorous cause severe bone and heart

problems , itching and tissue calcifications (800-1000mg/Day)

• Take phosphate binders • Ca should be more than 2000mg/day. Ca is pulled

out by dialysis lead to serious health problems • Fluid- if they consume more fluid—use

concentrated dialysate if no urine out put – consume <than 4C (32)oz) /day include all food if urinate 4C + same amount of urine

• Consume 20-25 g fiber

•   1.2 g of protein/kg body weight/day for hemodialysis patients• 1.3 g of protein/kg body weight/day for peritoneal dialysis patients• 35 kcal/kg body weight for patient less than 60 years of age• 30 to 35 kcal/kg body weight For patients 60 years or older