Dialysis and Renal transplantation

It is the process of removing waste from the blood. Ppt would help to learn especially for Nursing students.
Hemodialysis, Peritoneal dialysis, Renal transplantation

1. DIALYSIS

2. Meaning Is a process of removing waste and excess water from blood and is used primarily artificial replacement for lost kidney function in people with renal failure

3. GOAL To remove end products of protein metabolism Maintain concentration of electrolyte Correct acidosis Remove excess fluid

4. Principles Ultra filtration Refers to removal of fluid from blood using osmotic and hydrostatic pressure Osmosis Is the movement of fluids across a semipermeable membrane from an area of lower concentration of particle to higher concentration of particles

5. Diffusion Is the process of passage of articles from area of higher concentration to area of lower concentration

6. TYPES Hemodialysis Peritoneal dialysis

7. HEMODIALYSIS A process for removing metabolic waste products or toxic substance from blood stream.

8. Hemodialysis access Acute dialysis catheter Are non cuffed, non tunneled catheter Used for immediate vascular access Inserted in internal jugular vein or femoral vein Maintain occlusive dressing over the catheter i nsertion Assess the insertion site for Hematoma, bleeding, Catheter dislodgement

9. Subclavian vein catheter Femoral vein catheter The catheter usually filled with Heparin and copped to maintain patency between dialysis treatment The catheter should not uncapped The catheter may be left in place for up to 6 weeks if no complications occurs Assess the extremity for circulation, temperature, and pulse Prevent Pulling or disconnecting of the catheter when giving care Because the groin is not a clean site, meticulous perineal care is required Use an Iv infusion pump or controller which microdrip tubing if heparin infusion through the catheter to maintain patency

10. Internal Arterio venous fistula Is a connection of artery and vein Last longer Radio cephalic, brachiocephalic , brachio basilic

11. A permanent choice for client With CRF requiring dialysis The fistula is created surgically by anastomosis of a large artery and large vein in the arm The flow of arterial blood into venous system cause in the vein to become engorged ( Matured or developed)

12. Maturity is takes about 4-6 weeks, depending on the client ability to do hand flexing exercise such as ball squeezing, which help fistula mature Fistula is require to be mature before it can be used because the engorged vein is punctured with large bore needle for dialysis Subclavian or femoral catheters, peritoneal dialysis or external arterio venous shunt can be used for dialysis while fistula is maturing or developing.

13. Advantages Disadvantages Fistula is internal, the risk of cloting and bleeding low It can used indefinitely Decreased incidence of infection because of internal Once healing has occurred, no external dressing is required The fistula allows freedom of movement Can not used immediately after insertion so planning ahead for an alternate access for dialysis is important Needle insertion through the skin is required for dialysis Infiltration of the needles during dialysis can occur and cause hematomas An aneurysm can form in the fistula CHF can occur from the increased blood flow in the venous system

14. Arterial steal syndrome can develop in a client with an internal arteriovenous fistula. In this complication, too much blood is diverted to the vein and arterial perfusion to the hand is compromised

15. Arterio venous graft The internal graft may be used for chronic dialysis client who do not have adequate blood vessels for the creation of a fistula

16. An arterial graft made of Gore- Tex or a bovine (cow) carotid artery is used to create an artificial vein for blood flow. The procedure involves the anastomosis of an artery and vein using artificial graft The graft can be used 2 weeks after insertion Complication of graft including clotting, aneurysm and infection

17. Advantages Disadvantages Graft is internal, the risk of cloting and bleeding low It can used indefinitely Decreased incidence of infection because of internal Once healing has occurred, no external dressing is required The graft allows freedom of movement Can not used immediately after insertion Needle insertion through the skin is required for dialysis Infiltration of the needles during dialysis can occur and cause hematomas An aneurysm can form in the AV graft CHF can occur from the increased blood flow in the venous system Arterial steal syndrome can develop

18. Intervention for AV fistula and AV Graft Teach the client that the extremity should not be used for monitoring BP, Drawing blood, placing IV lines or administering injections Teach the client with an arteiovenous fistula hand fixing exercise such as ball squeezing to promote graft maturity Note the temperature and capillary refill of the extremity Palpate pulse below fistula or graft, and monitor for hand swelling as indication of ischemia Monitor for clotting Complains of tingling or discomfort in the extremity Inability to palpate a thrill or auscultate a bruit over the fistula or graft Monitor for infection

19. Monitor lung and heart sound for sign of CHF Notify the physician immediately if the sign of clotting, infection or arterial steal syndrome occure To ensure the Patency, palpate for a thrill or auscultate for a bruit over the fistula or graft. Notify the physician if a thrill or bruit is absent

20. External Arterio venous shunt Two Silastic cannulas are surgically inserted into an artery and vein in the forearm or leg to form an external blood path The cannulas are connected to From a U shape blood flows from the client’s artery through the shunt into the vein

21. ADVANTAGES DISADVANTAGES The external AV shunt use immediately No venipuncture is necessary Disconnection or dislodgment of the external shunt Risk for Hemorrhage, infection or clotting Potential for skin erosion around the catheter site

22. Interventions Avoid getting shunt wet Wrap a dressing completely around the shunt and keep it dry and intact Keep cannula clamps at the bed side or attached the arteriovenous disconnection Teach the client that shunt extremity should not use for monitoring BP, Drawing blood, Placing Iv line and drug admini . Monitor skin integrity Auscultate bruit and palpate thrill although a bruit not be heard with the shunt

23. Signs of clotting Fibrin – white flecks noted in the tubing Separation of Serum and cell Thrill Absent on palpation Coolness of the tubing or extremity Tingling sensation at site or in extremity

24. Hemodialysis Apparatus Dialyzer Referred to as artificial kidney Remove excess waste and fluid from blood Made up of thin fibrous material fibers from a semipermeble membrane which allows small particles and liquid to pass through

25. Dialysate The fluid and solute in a dialysis process that flow through dialyzer do not pass through the membrane and discarding along with removal toxic substance Composition : sodium chloride Sodium bicarbonate Sodium acetate calcium chloride Potassium chloride

26. Tubing machine

27. COMPLICATION Low blood pressure Muscle cramps Itching Anemia Access site complication Febrile reaction Hemolysis

28. AIR EMBOLUS Introduction of air into circulatory system Dyspnea, tachypnea, Chest Pain Hypotension Reduce oxygen saturation Cyanosis Anxiety Changes of sensorium

29. Interventions Stop the hemodialysis Turn the client on the left side, with head down Notify physician Administer oxygen Vital signs

30. DISEQUILIBRIUM SYNDROME A rapid changes in the composition of the extracellular fluid occurs during hemodialysis Solute are removed from the blood the faster than from CSF and brain; fluid is pulled into the brain causing cerebral edema Nausea, vomiting, Headache, Hypertension, Restlessness and agitation , Muscle cramps, confusion, Seizure

31. Slow or stop the dialysis Notify the physician Prepare the administre IV hypertonic saline solution, albumin, or manitol if prescribed

32. Dialysis Encephalopathy An aluminium Toxicity from dialysate water sources containing aluminum; also can occur from ingestion of aluminum containing antacid (phosphorus binders) Progressive neurological Impairment Mental Cloudiness Speech disturbance Muscle incoordination, bone pain, Seizure

33. Monitor for the sign of encephalopathy Notify physician Administering aluminum Chelating agents as prescribed so that the aluminum is released and dialyzed from the body

34. NURSING CARE Weight and volume status : assess BP, weight Remove restrictive clothing or jewelry from arm Avoid pressure on vascular site Hand hygiene Review laboratory records Hold the medication

35. PERITONEAL DIALYSIS The process uses the patient peritoneum in abdomen as a membrane across which fluid and dissolved substance are exchanged from blood

36. Peritoneal membrane is large and porous, allowing solutes and fluid to move via osmosis from an area of higher concentration to lower concentration in the dialyzing fluid. The peritoneal cavity reach in capillaries therefore it provides a ready access to the blood supply.

37. Indication Patient who are not willing and unable to undergo to hemodialysis ARF CRF

38. Contraindication Peritonitis Recent abdominal surgery Abdominal Adhesion Other GI problems Such as Diverticulities

39. Procedure preparation of patient Explain the procedure Baseline data's are recorded Patient is encourage to empty bowel and bladder Broad spectrum antibiotic

40. Access for Peritoneal Dialysis A siliconized rubber catheter such as Tenckhoff Catheter is surgically inserted into the client’s Peritoneal cavity to allow infusion of dialysis fluid The preferred Insertion site is 3 to 5 cm below Umbilicus this area is relatively avascular and has less fascial resistance The catheter is tunneled under the skin, through the fat and muscle tissue to the peritoneum; it is stablize with inflatable D arcon cuffs in the muscle and under skin

41. Over a period of 1 to 2 weeks following insertion, fibroblast and blood vessels grow around the cuffs, fixing the catheter in place and providing an extra barrier against dialysate leakage and bacterial invasion If the client is scheduled fro transplant surgery the peritoneal catheter may either be removed of left in place if the need for dialysis is suspected post transplantation.

42. Preparing equipment (Dialysate solution) The Solution is sterile All Dialysis solution are prescribed by the physician; the solution contain electrolytes and minerals and has a specific osmolarity , specific glucose concentration and other medication additives as prescribed The higher the glucose concentration, the greater the hypertonicity and the amount of fluid removed during a peritoneal dialysis exchange

43. The higher glucose concentration, the grater the hyper tonicity and the amount of fluid removed during peritoneal dialysis exchange Increasing the glucose concentration increases the concentration of active particles that cause osmosis, increase the rate of ultra filtration and increases the amount of fluid removed Heparin is added to prevent clotting Insulin may added – if client is DM

44. Performing exchange Infusion (fill)- dialysate infused by gravity in to peritoneum 5-10 min is usually required to infuse Dwell - time allow to diffusion and osmosis Drainage- drain from peritoneal cavity by gravity

45. TYPES Continuous ambulatory peritoneal dialysis (CAPD) 1.5 – 3 liter of diaysate fluid instilled in the abdomen and left place for a prescribed period of time Solution drain by gravity flow Use four dialysis cycle every 24 hours

46. Automated peritoneal dialysis Use of peritoneal cycling machine This method can be performed as continuous and cyclic

47. COMPLICATION

48. Kidney transplantation

49. Kidney transplantation involves transplanting a kidney from living donor or deceased donor to recipient who have no longer has renal function

50. A living donor is a person who is alive at the time of donation and may or may be related to recipient A deceased or cadaveric transplant comes from someone who has died and donated his or her organ

51. Native kidney not usually removed Transplant kidney is placed in the patient iliac fossa anterior to iliac crest because it allow for easier access to the blood supply needed to perfuse kidney

52. Preoperative MGT Complete physical examination of the donor and recipient Assess the bladder neck function Patient must free from infection Psychosocial evaluation Hemodiaysis perform before prior to transplantation Consent Dietary restriction

53. Postoperative management Assessing patient for transplant rejection: oliguria, edema, fever, increase BP, Weight Preventing infection: Monitoring urinary function Monitoring complication

54. Contraindication Malignancy Active or chronic infection Sever irreversible disease HIV Hepatitis B and c Diabetes and HTN