Nursing Care of Patient on Dialysis

Each patient is unique - so the dialysis patients.

1. Nursing Care of Patient on Dialysis “Don’t Worry I‘ll find a good site soon “ By: Ms. Shanta Peter

2. 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

3. Hemodialysis requires 5 things Access to patient’s circulation (usually via fistula ) Access to a dialysis machine and dialyzer with a semipermeable membrane 3. The appropriate solution (dialysate bath) 4. Time: 12 hours each week, divided in 3 equal segments 5. Place : home (if feasible) or a dialysis cente r  

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

5. Hemodialysis – Procedure 1 . Patient’s circulation is accessed 2. Unless contraindicated, heparin is administer ed 3 . 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. 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

7. 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

8. Hemodialysis: Nursing considerations Pre-dialysis care Assess 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

9. 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

10. 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

11. During dialysis Watch for Hypotension Muscle cramps Nausea and vomiting Headache Itching Less commonly: disequilibrium syndrome, hypersensitivity reaction, arrhythmia, cardiac tamponade , seizures, air emboli sm

12. 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

13. Complications of dialysis Infection Hernias Nutritional Deficiencies Low Blood Pressure Muscle Cramps Clotting Issues Movement Issues Dry and Itching Skin

14. Nursing interventions   for H D Explain procedure to client Cannulating & connecting to HD machine 3. Monitor hemodynamic status continuously 4 . Monitor acid-base balance 5. Monitor electrolytes 6 . Insure sterility of system 7. Maintain a closed system 8. Discuss diet and restrictions on : a . Protein intake b . Sodium intake c . Potassium intake d . Fluid intake

15.  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

16. 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 

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

18. 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

19. 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

20. 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 --- 

21.  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 

22. 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

23. 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.

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

25. MANAGEMENT Place in Trendelenberg position UF off Vital signs IV Saline bolus Do 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 .

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

27. 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 ) 

28.  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 C onsume 20-25 g fiber

29. • 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