HAWASSA UNIVERSITY

COLLEGE OF HEALTH AND MEDICAL SCIENCES

SCHOOL OF NURSING AND MIDWIFERY

POST GRADUATE PROGRAM

EMERGENCY MEDICINE AND CRITICAL CARE NURSING

Assignment on: Dialysis Procedure

Submitted By:

1. Beyene Feleke
2. Betelhem Demeke
3. Tadele Damena
4. Yunuka Marufa

Submitted To: Thomas (Assist. Prof. of EM & CCN)

Hawassa Ethiopia

Des, 2022

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Table of contents

Contents
Table of contents..............................................................................................................................1

INTRODUCTION...........................................................................................................................2

Types of dialysis..............................................................................................................................2

1. Hemodialysis............................................................................................................................2

2. CRRT........................................................................................................................................2

3. PD.............................................................................................................................................2

Principles of Hemodialysis..............................................................................................................3

PERIONEAL DIALYSIS................................................................................................................5

Approaches in PD............................................................................................................................6

Acute Intermittent Peritoneal Dialysis.............................................................................................6

Continuous Ambulatory Peritoneal Dialysis (CAPD).....................................................................7

Continuous Cyclic Peritoneal Dialysis (CCPD)..............................................................................7

Patient preparation for hemodialysis...............................................................................................8

Intra-procedural care........................................................................................................................8

Post procedural care.........................................................................................................................8

Hemodynamic monitoring & interpretation..................................................................................10

References......................................................................................................................................13

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INTRODUCTION

In kidney failure, kidneys do not perform their normal function. As a result toxic substances like
urea & creatinine accumulate in body and vital components like albumin leak out in the urine.

Therefore this condition can be managed by dialysis or kidney –transplantation. Dialysis is used
to remove fluid and uremic waste products from the body when the kidneys cannot do so. It may
also be used to treat patients with edema that does not respond to treatment, hepatic coma,
hyperkalemia, hypercalcemia, hypertension, and uremia.
Dialysis is a technique in which waste products move from blood through a semi-permeable
membrane into a dialysis solution (dialysate). It uses a membrane as a filter called dialyzer
and a solution called dialysate to accomplish this activity.

Types of dialysis

1. Hemodialysis

2. CRRT

3. PD.

Acute dialysis is indicated when there is a high and increasing level of serum potassium,
fluid overload, or impending pulmonary edema, increasing acidosis, pericarditis, and severe
confusion. It may also be used to remove medications or toxins from the blood or for edema
that does not respond to other treatment, hepatic coma, hyperkalemia, hypercalcemia,
hypertension, and uraemia

Hemodialysis is used for patients who are acutely ill and require short-term dialysis (days to
weeks) ,prevents death but does not cure renal disease. Also it does not compensate for the loss
of endocrine or metabolic activities of the kidneys. The objectives of hemodialysis is to extract
toxic nitrogenous substances from the blood and to remove excess water.

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 Principles of Hemodialysis

The objectives of hemodialysis are to extract toxic nitrogenous substances from the blood and to
remove excess water. In hemodialysis, the blood, laden with toxins and nitrogenous wastes, is
diverted from the patient to a machine, a dialyzer, in which the blood is cleansed and then
returned to the patient
.
i. Diffusion

ii. Osmosis

iii. Ultrafiltration

Dialyzer

Dialysis

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 Dialyzer

Dialyzers are hollow-fiber devices containing thousands of tiny straw like tubes that carry the
blood through it. The tubes are porous and act as a semi-permeable membrane allowing
toxins, fluid, and electrolytes to pass through.

 The constant flow of the solution maintains the concentration gradient to facilitate the
exchange of wastes from the blood through the semi-permeable membrane into the dialysate
solution, where they are removed and discarded.

Vascular Access for hemodialysis

Access to the patient’s vascular system must be established to allow blood to be removed,
cleansed, and returned to the patient’s vascular system at rates between 300 and 800 mL/min.

Types of vascular access

I. Subclavian, Internal Jugular, and Femoral Catheters

II. Arterio-venous Fistula

III. Arterio-venous Graft:

I. Subclavian, Internal Jugular, and Femoral Catheters

Immediate access to the patient’s circulation for acute hemodialysis is achieved by inserting
a double-lumen or multilumen catheter into the subclavian, internal jugular, or femoral vein
to achieve immediate access to the patient’s circulation for acute HD.
Is an external access and may be used for Hemodialysis immediately, placed in a large vein
through the neck or upper chest to access the catheter remain outside the body and does not
require cannulation, Connects directly to the blood tubing of the dialysis machine.
 It’s usually a temporary access for urgent dialysis

 The catheters are removed when no longer needed

 It involves some risk like hematoma, pneumothorax, infection, thrombosis of the

subclavian vein & inadequate flow.

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 II. Arterio-venous Fistula

A more permanent access, known as a fistula, is created surgically (usually in the forearm) by
joining (anastomosing) an artery to a vein, either side to side or end to side.
The arterial segment of the fistula is used for arterial flow and the venous segment for reinfusion
of the dialyzed blood. The fistula takes 4 to 6 weeks to mature before it is ready for use. This
gives time for healing and for the venous segment of the fistula to dilate to accommodate two
large-bore (14- or 16 gauge) needles. The patient is encouraged to perform exercises to increase
the size of these vessels (ie, squeezing a rubber ball for forearm fistulas) and thereby to
accommodate the large-bore needles used in hemodialysis.

III. Arterio-venous Graft

An arteriovenous graft can be created by subcutaneously interposing a biologic, semibiologic,

or synthetic graft material between an artery and vein. The most commonly used synthetic graft
material is expanded polytetrafluoroethylene (PTFE). Usually, a graft is created when the
patient’s vessels are not suitable for a fistula. Patients with compromised vascular systems (eg,
from diabetes) often need to have a graft to undergo hemodialysis. Grafts are usually placed in
the forearm, upper arm, or upper thigh. Infection and thrombosis are the most common
complications of arteriovenous grafts.

PERIONEAL DIALYSIS

It is a form of dialysis in which the patient’s peritoneal membrane is used as the

semipermeable membrane for exchange of fluid and solutes. Patients with diabetes or
cardiovascular disease, many older patients, and those who may be at risk for adverse
effects of systemic heparin are likely candidates for peritoneal dialysis.

Is removing toxic substances and metabolic wastes and to reestablish normal fluid and
electrolyte balance.PD may be the treatment of choice for patients with renal failure who
are unable or unwilling to undergo hemodialysis or renal transplantation.

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  Sterile dialysate fluid is introduced into the peritoneal cavity through an abdominal
catheter at intervals. Once the sterile solution is in the peritoneal cavity, uremic toxins
such as urea and creatinine begin to be cleared from the blood Diffusion and osmosis
occur as waste products move from higher concentration (the blood stream) to lesser
concentration (the dialysate fluid) through a semi permeable membrane (peritoneum). PD
usually takes 36 to 48 hours to achieve what hemodialysis accomplishes in 6 to 8 hours.

 This movement of solute from the blood into the dialysate fluid is called
clearance.

Approaches in PD

PD can be performed using several different approaches:

1. Acute intermittent peritoneal dialysis

2. Continuous ambulatory peritoneal dialysis (CAPD)

3. Continuous cyclic peritoneal dialysis (CCPD).

Acute Intermittent Peritoneal Dialysis

Indications for acute intermittent PD; uremic signs and symptoms (nausea, vomiting,
fatigue, altered mental status), fluid overload, acidosis, and hyperkalemia. Although PD
is not as efficient as hemodialysis in removing solute and fluid.

It permits a more gradual change in the patient’s fluid volume status and in waste product
removal. It may be the treatment of choice for the hemodynamically unstable patient.

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Continuous Ambulatory Peritoneal Dialysis (CAPD)

CAPD is second most common form of dialysis for patients with ESRD to be started on.
Performed at home by the patient or a trained caregiver who is usually a family member. Works
on the same principles as other forms of PD diffusion and osmosis.

Continuous Cyclic Peritoneal Dialysis (CCPD)

CCPD uses a machine called a cycler to provide the exchanges. It is programmed as how much
fluid to use, how long and how many exchanges need to be done. Has a lower infection rate than
other forms of PD because there are fewer opportunities for contamination with bag changes and
tubing disconnections.

Tenckhoff Catheter

• Is a catheter/device, placed in the abdomen between the parietal and visceral layer of the
peritoneal membrane.

• The Surgical Insertion of a Permanent Tenckhoff Catheter allows access to the

peritoneum for peritoneal dialysis.

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Patient preparation for hemodialysis

1. Explain the procedure to the patient.

2. Assist in obtaining signed consent.
3. Baseline vital signs, weight and serum electrolyte especially serum glucose, BUN, and
creatinine level.

4. Assess the patient’s anxiety about the procedure and provides support and instruction.

5. Assess vascular access site for a palpable pulsation or vibration and an audible bruit and
for inflammation.

6. Alert all personnel to avoid using the extremity with the vascular access site. These
procedures may damage vessels and lead to failure of the AV fistula.

Intra-procedural care

1. Dialysis is started, all the machine parameters & safety alarm limits are set.

2. BP, pulse are checked again after starting treatment, monitored & recorded every hourly.

3. Patient is monitored for 4 hours during the dialysis for any discomforts.

4. During the dialysis patient can read books, watch TV, eat food.

5. Appropriate follow-up and refer to physician as needed.

6. Adjust as warranted based on patient's response.

7. Order diagnostic studies or laboratories (i.e. exit site cultures, blood cultures) as
warranted and treat as appropriate in collaboration with physician.

Post procedural care

• Assess and document vital signs, weight, and vascular access site condition.

• Monitor BUN, serum- creatinine, serum electrolyte, and hematocrit levels.

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 -changes in BUN, pH and electrolyte levels during dialysis lead to cerebral edema
and increased intracranial pressure.

• Provide iron and folate supplements or periodic blood transfusion for anemia due to
renal failure.

• Assess for dialysis disequilibrium syndrome, with headache, nausea and vomiting,
altered level of consciousness; and hypertension.

• Assess for other adverse responses to dialysis, such as dehydration, nausea and
vomiting, muscle cramps, or seizure activity.

• Assess for bleeding at the access site or elsewhere (Heparinization during dialysis
increase the risk for bleeding).

• Use standard precautions at all times.

- Frequent exposure to blood and blood products increase the risk for hepatitis B or C
or other blood borne diseases.

• If a transfusion is given during dialysis, monitor for possible transfusion reaction

(e.g., chills and fever; dyspnea; chest, back,or arm pain; and urticaria or itching).

• Close monitoring during and after the transfusion is important to identify early signs
of a reaction.

• Provide psychologic support and listen actively.

• Address concerns and accept responses such as anger, depression, and

noncompliance.

• Reinforce client and family strengths in coping with renal failure and hemodialysis.

• The client may feel hopeless and resent dependence on a machine.

• The nurse can help the client and family work through these responses and focus on
positive aspects of living.

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Hemodynamic monitoring & interpretation

1. Calibrate and level the system at least once a shift using the right atrium as a
constant reference level.

2. Calibration and leveling ensure that accurate pressures are recorded.

3. Measure all pressures between breaths. This ensures that intra-thoracic pressure
does not influence pressure readings.

4. Maintain 300 mmHg of pressure on the flush solution at all times. This ensures a
continuous flow of flush solution through the pressure tubing and catheter to
prevent clot formation and catheter occlusion.

5. Monitor pressure trends rather than individual readings. Individual readings may
not reflect the client’s true status.

6. Obtain a chest X-ray before infusing intravenous fluid into any newly placed
central line. Chest X-ray verifies the location of the catheter and helps to prevent
pneumothorax.

7. Set alarm limits for monitored hemodynamic variables. Turn alarms on. Alarms
warn of hemodynamic instability.

8. Use aseptic technique during catheter insertion and site care. Aseptic technique is
important to prevent infection.

9. Assess and document appearance of the insertion site at least every shift; observe
for signs of inflammation, infection, or phlebitis.

10. Change intravenous solutions every 24 hours, site dressing every 48 hours, and
tubing to the insertion site every 72 hours.

11. Label solution, tubing, and dressing with date and time of change. These
measures help to prevent infection.

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12. Thoroughly flush stopcock ports after drawing blood samples from the pressure
line. Flushing prevents colonization of bacteria and occlusion of the catheter.
13. Assess pulse and perfusion distal to the monitoring site. Frequent assessment is
vital to ensure perfusion of the distal extremity.

14. When discontinuing the pressure line, apply manual pressure to the insertion site
as soon as the catheter tip is out.

15. Hold pressure for 5 to 15 minutes or until the bleeding stops. This is particularly
important for arterial lines to prevent bleeding and hematoma formation.

16. Secure all connections and stopcocks. This is done to prevent disconnection of the
invasive line and potential hemorrhage.

17. Keep tubing free of kinks and tension. This prevents the catheter from becoming
clotted or inadvertently dislodged.

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References

1. LeMone P, Burke K &Bauldoff G. 2011. Medical-surgical nursing : critical thinking in

client care.5th Edi. Pearson Education, Inc., publishing as Pearson.
2. Brunner & Suddarth’s textbook of medical-surgical nursing. — 10th ed. / Suzanne C.
Smeltzer ... [et al.] p 1285.

3. Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh School of

Medicine, USA 2016.

4. Brunner medical-surgical nursing 12th edition,page1334

5. Williams medical-surgical nursing 3rd edition, page 800.
6. Gomez, N.J. (Ed.). (2011). Nephrology nursing scope and standards of practice, 7th Edition.
Pitman, NJ: American Nephrology Nurses' Association.

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