Chapter 47 Dialysis with lab values and catheter info.pdf

Chapter 47 details on dialysis with important lab values

1. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Dialysis
Chapter 47

2. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Important Lab Values –BUN and
Creatinine
These Lab Values are used to monitor
adequacy of dialysis
BUN = Blood urea nitrogen
A waste product of protein metabolism.
Range of values for dialysis patients (prior to
treatment) = 60 – 100 mg%
Before and after dialysis
Creatinine
Waste product of tissue metabolism

3. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Important Lab Values –Sodium
(Na)
Main electrolyte in extracellular
(outside the cell) serum (the fluid in
which the red blood cells are
suspended)
Acceptable range (for all people,
including dialysis patients) = 133 –
145 mEq/L

4. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Important lab values –Potassium (K)
Main electrolyte inside cells
Acceptable ranges for dialysis patients
(pre-treatment) = 3.0 –6.0 mEq/L
Hyperkalemia (high serum potassium)
Cause is usually not following diet
CAN LEAD TO LIFE-THREATENING
ARRYTHMIAS & DEATH!!!!

5. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Important Lab Values –Calcium
(Ca)
Along with phosphorus, imbalance in
values contribute to renal bone disease
Body will respond to decrease Ca by
pulling what it needs from the bones
Body will respond to increase Ca by
depositing calcium where it does not
belong
Normal Range : 8.5 –10.5 mEq/L

6. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Important Lab Values –Phosphorus
(Ph) & Phosphates (PO4)
Normal range = 2.6 –4.5mg/dL
Phosphorus is absorbed into tissues
Once absorbed, difficult to remove by
dialysis
With calcium, it forms deposits in soft
tissues
High levels cause the patient to itch severely
Calcium binders necessary to prevent
absorption into blood stream
Present in most foods

7. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Dialysis
Movement of fluid/molecules across
a semipermeable membrane from
one compartment to another
Used to correct fluid/electrolyte
imbalances and to remove waste
products in renal failure
Treat drug overdoses

8. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Dialysis
Two methods of dialysis available
Peritoneal dialysis (PD)
Hemodialysis (HD)

9. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Dialysis
Begun when patient’s uremia can
no longer be adequately managed
conservatively
Initiated when GFR (or creatinine
clearance) is less than 15 mL/min

10. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Dialysis
ESKD treated with dialysis because
There is a lack of donated organs
Some patients are physically or
mentally unsuitable for
transplantation
Some patients do not want transplants

11. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
General Principles of Dialysis
Diffusion
Movement of solutes from an
area of greater concentration to
an area of lesser concentration
Osmosis
Movement of fluid from an
area of lesser concentration
of solutes to area of greater
concentration
Osmosis and Diffusion across
Semipermeable Membrane

12. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
General Principles of Dialysis
Ultrafiltration
Water and fluid removal
Results when there is an osmotic
gradient across the membrane

13. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Peritoneal Dialysis
Peritoneal access is
obtained by inserting
a catheter through
the anterior
abdominal wall
Technique for
catheter placement
varies
Usually done via
surgery

14. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Peritoneal Dialysis
After catheter inserted,
skin is cleaned with
antiseptic solution and
sterile dressing applied
Connected to sterile
tubing system
Secured to abdomen with
tape
Catheter irrigated
immediately
Peritoneal Exit Site

15. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Peritoneal Dialysis
Waiting period of 7 to 14 days
preferable
Two to 4 weeks after implantation,
exit site should be clean, dry, and
free of redness/tenderness
Once site healed, patient may
shower and pat dry

16. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Peritoneal Dialysis
Dialysis Solutions and Cycles
Available in 1-or 2-L plastic bags
with glucose concentrations of 1.5%,
2.5%, and 4.25%
Electrolyte composition similar to
that of plasma
Solution warmed to body
temperature

17. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Peritoneal Dialysis
Dialysis Solutions and Cycles
Three phases of PD cycle
Inflow (fill)
Dwell (equilibration)
Drain
Called an exchange

18. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Peritoneal Dialysis
Dialysis Solutions and Cycles
Inflow (Fill)
Prescribed amount of
solution infused
through established
catheter over about 10
minutes
After solution infused,
inflow clamp closed to
prevent air from
entering tubing
Dwell
Period of time when the
dialysate solution sits in the
peritoneum
Allows toxin, excess fluid to
pass into the dialysate solution
Also known as equilibration
Diffusion and osmosis occur
between patient
’s blood and
peritoneal cavity
Duration of time varies,
depending on method

19. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Peritoneal Dialysis
Dialysis Solutions and Cycles
Drain
Lasts 15 to 30 minutes
May be facilitated by
gently
massaging abdomen or
changing position
Turn the patient from side
to side and change
positions to allow pockets
of fluid to drain out if all
the dialysate fluid does
not return
Exchange
Word used to
describe the entire
fill-dwell-drain cycle

20. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Peritoneal Dialysis
Systems
Automated peritoneal
dialysis
(APD)
Cycler delivers the
dialysate
Times and controls fill,
dwell, and drain
Continuous ambulatory
peritoneal dialysis
(CAPD)
Manual exchange

21. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Peritoneal Dialysis
Complications
Exit site infection
Peritonitis
Hernias
Lower back problems
Bleeding
Pulmonary
complications
Protein loss

22. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Peritoneal Dialysis
Effectiveness and Adaptation
Pros
Short training program
Independence
Ease of traveling
Fewer dietary restrictions (More
liberal diet and fluids)
More stable lab values
Greater mobility than with HD
Patients administer own
treatment
No needles needed
Cons
Catheter in the abdomen
Self image issues
Route for infection
Need learning skills
Need storage space in home
(supplies for 1 month)
Treatment needs to be done
every day ( must be very
compliant)

23. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Hemodialysis
Vascular Access Sites
Obtaining
vascular access is
one of most
difficult problems
Types of access
Arteriovenous
fistulas and grafts
Temporary
vascular access

24. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Arteriovenous Fistula

25. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Assessment of the Internal Access
Other Assessments
Bleeding
Swelling
Bruising
Redness
Drainage
Pain
Change in thrill

26. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Patient Education
Lifeline–protect it
Teach patient how to protect it and check daily to see if it is
working properly
Feel over site and check “thrill”
Contact the HCP or hemodialysis nurse immediately if there is a
change in the quality of the thrill
Avoid any pressure or constriction on the access arm.
Don’t let anyone take a blood pressure or draw blood
Don’t wear tight clothing (elastic sleeves, wear a
watch, carry a purse, or sleep on the the access arm
Do not carry heavy objects with access arm
Do not allow venipuncture to the done by anyone
other the an trained dialysis personnel

27. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Patient Education (cont.)
Adhere to diet –between treatments waste products
won’t build up in blood to quickly
PD patient should have increase fiber in the diet to
offset constipation from decreased peristalsis. ( The
intestines are floating in the hypertonic dialysate
solution
PD patients must strictly adhere to handwashing and
asepsis, and follow guidelines to access abdominal
catheter
Epogen (erythropoietin) injections (subcutaneous or
IV) as prescribed increase energy and endurance
because increased RBCs means better oxygenation and
less fatigue

28. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Vascular Access Catheter

29. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Vascular Access Catheter

30. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Central Venous Catheters
Used as temporary and permanent access
Temporary access
Emergency dialysis
Acute renal failure
Waiting for permanent (internal) access to mature
Secured by suture
•NOTE: Check for suture prior to initiation of treatment
•If suture has become loose or dislodged on temporary
CVC
•Must be reported immediately
•Cannot be used until secured and proper
placement verified by x-ray/fluoroscopy

31. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Central Venous Catheters
Permanent access
Patients whose
vessels will not
support in internal
access
Dacron cuff at the
insertion (exit) site
Patient’s own tissue
grows into Dacron
•Secures catheter in
place
•Skin is good barrier
against infection

32. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Hemodialysis
Dialyzers
Long plastic
cartridges that
contain thousands of
parallel hollow tubes
or fibers
Fibers are
semipermeable
membranes

33. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Dialyzers (Artificial Kidney)

34. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Hemodialysis
Procedure
Two needles placed in fistula
or
graft
One needle is placed to pull
blood from the circulation to
the HD machine
The other needle is used to
return the dialyzed blood to
the patient
Use big needles –2 sticks 3
times/week –17g –14g

35. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Components of Hemodialysis

36. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Hemodialysis
Procedure
Dialyzer/blood lines primed with
saline solution to eliminate air
Terminated by flushing dialyzer with
saline to remove all blood
Needles removed and firm pressure
applied

37. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Hemodialysis
Procedure
Before treatment, nurse should
Complete assessment of fluid status,
condition of access, temperature, skin
condition. (weight, BP, peripheral
edema, lung and heart sounds)
During treatment, nurse should
Be alert to changes in condition
Measure vital signs every 30 to 60
minutes

38. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Hemodialysis
Complications
Hypotension
Muscle cramps
Loss of blood
Hepatitis

39. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Hemodialysis
Effectiveness and Adaptation
Cannot fully replace normal
functions of kidneys
Can ease many of the symptoms
Can prevent certain complications

40. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Continual Renal Replacement
Therapy (CRRT)
Alternative or adjunctive method for
treating AKI
Means by which uremic toxins and fluids
are removed
Acid-base status/electrolyte balance
adjusted slowly and continuously
Let the kidney rest
ICU –slow dialysis over days –weeks –
let kidney recover, heal or protect the
kidney

41. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Continual Renal Replacement
Therapy (CRRT)
Can be used in conjunction with HD
Contraindication
Presence of manifestations of uremia
(hyperkalemia, pericarditis) that necessitate
rapid resolution
Continued for 30 to 40 days
Hemofilter change every 24 to 48 hours
Ultrafiltrate should be clear yellow
Specimens may be obtained for
evaluation

42. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Continual Renal
Replacement Therapy (CRRT)
Two types of CRRT
Venous access
Arterial access

43. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Continual Renal
Replacement Therapy (CRRT)
Most common approaches:
venovenous
Continuous venovenous
hemofiltration (CVVH)
Continuous venovenous hemodialysis
(CVVHD)
Refer to pg. 1123 Table 47-13

44. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Continuous Venovenous
Therapies

45. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Continual Renal
Replacement Therapy (CRRT)
Large volumes fluid
removed hourly, then
replaced
Fluid replacement
dependent on
stability/individualized
needs of patient
Continuous venovenous
hemodialysis (CVVHD)
Uses dialysate
Dialysate bags attached to
distal end of hemofilter
Fluid pumped
countercurrent to blood
flow
Ideal treatment for
patient who needs
fluid/solute control but
cannot tolerate rapid fluid
shifts with HD
Continuous venovenous
hemofiltration (CVVH)

46. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Continual Renal
Replacement Therapy (CRRT)
Highly permeable, hollow fiber
hemofilter
Double-lumen catheter placed in
femoral, jugular, or subclavian vein
Removes plasma water and
nonprotein solutes

47. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Continual Renal
Replacement Therapy (CRRT)
CRRT versus HD
Continuous rather
than intermittent
Solute removal by
convection (no
dialysate required) in
addition to osmosis
and diffusion
Less hemodynamic
instability
Does not require
constant monitoring
by HD nurse
Does not require
complicated HD
equipment

48. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Interventions for CRRT
Anticoagulation needed -infuse heparin in low
doses as appropriate through the setup
To prevent infection , perform skin care at the
catheter insertion sites every 48 hours (or per
protocol), using sterile technique. Cover the
site with an occlusive dressing
Obtain serum electrolyte levels every 4 to 6
hours as ordered; anticipate adjustments in
replacement fluid or dialysate based on results

49. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Medications Given In the
Hemodialysis Setting
Kidney’sare major route
of excretion for drug
metabolites
Metabolic effects of
kidney failure changes
how drugs are broken
down and excreted
Use caution when
administering drugs to
patients on dialysis
Heparin
Epogen _ subq, IV
IV Iron Supplements
Calcium supplements
Antimicrobial
Parenteral nutrition
Antihypertensives
Albumin, mannitol,
IV fluids

50. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Antihypertensives
Points to remember:
Some are not removed by dialysis
May cause decrease in B/P during
dialysis
Most MD’s recommend delaying dose
until after dialysis
Instruct patient to take medication so
that peak action does not occur during
dialysis