OBJECTIVES

At the end of the presentation students will be able to


Define different terms used in dialysis

Explain types of dialysis

Explain dialysis procedure

Point out equipment used in dialysis

Outline principle of dialysis
OBJECTIVES CONT.....


Discuss Complication of dialysis

Explain nursing management for dialysis patient.
INTRODUCTION
Definition of terms
Dialysis; The process of removing waste products and excess fluid
from the body.
Dialysis is necessary when the kidneys are not able to adequately filter
the blood.
Dialysis; is where a machine is used to replace a kidney after kidney
failure, The word dialysis come from the Greek word "dialusis", dia
meaning through and lusis meaning loosening
Dialyzer; an apparatus in which dialysis is carried out consisting
essentially of one or more containers for liquids separated into
compartments by membrane
TYPES OF DIALYSIS

Various types of dialysis give patients the opportunity to make

their treatment part of their everyday life.

There are 2 types of dialysis:


Hemodialysis

Peritoneal dialysis
HEMODIALYSIS.

Hemodialysis is the process of cleaning blood outside the
body, and involves taking blood from a blood vessel and
passing it through a synthetic filter, known as a dialyzer.

The blood is cleaned in the dialyzer before being returned to
the body, which is why the dialyzer is also referred to as an
“artificial kidney.
HEMODIALYSIS CONT....
The process is controlled by a dialysis machine, which pumps
the blood around the circuit, adds in an anticoagulant, and
regulates the cleaning process, among other things.
Hemodialysis usually takes around three to six hours and is
performed at least three times a week, usually in a dialysis center.
Instead of being treated in a dialysis center, patients may be
offered the option of receiving treatment in their own home
environment.
HEMODIALYSIS CONT.....
For this treatment, there needs to be a site where the blood is
taken out of the body and then returned to the blood stream.
This is called an access. After the access is made and healed, 2
needles are inserted into the access. One needle draws the blood
out and the other needle returns the blood to the body.
INDICATIONS FOR HEMODIALYSIS

Fluid overload (including refractory heart failure)

Hyperkalemia

Hypercalcemia

Metabolic acidosis

pericarditis
PICTURE OF HEMODIALYSIS MACHINE
PRINCIPLES OF HEMODIALYSIS

Diffusion

Osmosis

Ultrafiltration

These are the principles on which Hemodialysis is based.

PRINCIPLE CONT....
Diffusion.
The toxins and wastes in the blood are removed by diffusion.
That is they move from the an area of higher concentration in
the blood to an area of lower concentration in the dialysate.
Dialysate is a solution made up of all the important electrolyte in
their ideal extracellular concentrations.
PRINCIPLE CONT....
The electrolyte level in the patients blood can be brought
under controll by properly adjusting the dialysate bath.

The semipermiable membrane impedes the diffusion of large

molecules such as red blood cells and proteins
PRINCIPLES CONT...

Osmosis
excess water in the body is removed from the blood by
osmosis, in which water moves from the area of lower solute
concentrations, the blood to an area of higher solute
concentration which is the dialysate bath.

Ultrafiltration
is defined as water moving under high pressure to an area of
the lower pressure. This process is much more efficient at
water removal than osmosis.
PRINCIPLES CONT...
Ultrafiltration is accomplished by applying negative pressure or
a sunctioning force to the dialysis membrane. Because
patients with renal disease usually can not excrete water, this
force is necessary to remove fluid to achieve fluid balance.

The body buffer system is maintained using a dialysate bath
made up of bicarbonate which is the most common, or acetate
which is metabolized from bicarbonate.
PRINCIPLE CONT....
Anticoagulant

The anticoagulant heparin is administered to keep the blood
from clotting in the dialysis circuit.

Cleansed blood is returned to the body. By the end of dialysis
treatment many waste products have been removed, the
electrolyte balance has been restored to normal, and the
buffer system has been replenished
EQUIPMENT FOR HEMODIALYSIS

Dialysers
most dialyser or artificial kidney, are either flat plate dialyser or
hollow fiber artificial kidney that contains thousands of tiny
cellophane tubules that act as semi permeable membranes.
The blood flows through the tubules, while the solution
(dialysate) circulates around the tubules.
The exchange of wastes from the blood to the dialysate occurs
through semi permeable membrane of the tubules.
 EQUIPMENTS CONT....`

dialyzer
VASCULAR ACCESS FOR HEMODIALYSIS
Before beginning hemodialysis treatment person needs to have
an access to their blood stream called vascular access .the
vascular access allow the blood to travel to and from the dialyisis
machine at large volume and high speed, then make treatment be
effectively.
TYPES OF VASCULAR ACCESS.
There are three types of vascular access:

Arteriovenous Fistula( AV Fistula)

Arteriovenous Graft(AV Graft)



Central venous catheter(cvc)


TYPES OF VASCULAR ACCESS CONT.......
Each access created on body surgically. there are limited body
places where access can be placed includes arms, legs, neck and
chest.
The fistula and grafting are considered to be the permanent
access because they placed under skin with the plan to use them
for long time.
VASCULAR ACCESS….
AV FISTULA
An AV fistula is created by creating directly the patient artery
and vein in arm.
This is simple procedure and may be performed as the
outpatient operation using local anasthetics.
FISTULAR AND GRAFT ACCESS
Fistula and graft
VASCULAR ACCESS CONT.....
Kidney and hemodialysis consider AV fistula as the Gold
Standard access because :

low risk of infections than other access types

it has low risk of forming the clots than other types


it allow for greater blood flow


it last longer than other types of access
PEOPLE MAY HAVE THE FOLLOWING ISSUES
WITH FISTULA

appearance of budging of veins at the access site


taking several months for new one to mature


fistula not maturing at all
VASCULAR ACCESS CONT....
AV GRAFT

The AV Graft is similar to fistula in that its also under the skin
connected of artery an d veins except that the Graft , Man made
tubing connecting to artery and vein .Graft are usually placed on
arm and sometimes on thigh. Graft has problem than fistula and
not last longer as fistula could.
VASCULAR ACCESS CONT......

CATHETER

Its a narrow tube that is placed into large central vein , usually in
the patient neck , chest or groins . Placement of Catheter usually
takes places less than half an hour . Usually two tubes extend out
of the body from the catheter :one allow the blood flow out of
the body and other allow blood flow back into the body
CATHETER
FACTORS TO CONSIDER IN TYPE OF DIALY-
SIS TREATMENT.

Availability of family to assist therapy

types of water supply at home

previous abdominal surgery

desire to travel

body size cardiac status, presence of vascular access

prevent deficiency and maintain good nutrional status
through adequate protein, energy, vitamins and minerals
FACTORS CONT..

control edema and electrolytes imbalance by controlling
sodium, potassium and fluid intake

prevent or retard development of renal osteodystrophy by
controlling calcium, potassium ,vitamin and PTH

Enable patient to eat palatable attractive diet that fit his or
her life style as much as possible
NUTRITIONAL THERAPY , FLUID AND
ELECTROLYTE BALANCE.

Dialysis drains body protein1.2g of protein for patient who
receive HD three times a week

albumin is limited factor of protein nutriture, but is routinely
used in evaluating ESRD

Patient with uremia have greater chance of lowered protein
intake

patient may tolerate other sources of protein i.e lean meat.
ENERGY NEEDS:


it should be adequate to spare protein

energy supply by carbohydrate and fat to prevent body
wasting 25kcal-40kcal/g of body weight
FLUIDS AND SODIUM BALANCE :


thirst may indicates Na intake, increased fluid gain and result
in hypertension

allowed weight gain HD patient 2-3 kg

Restriction on fluid 750-1000mls per day.
POTASSIUM:


restriction would be based on the frequency of HD

Be careful: low sodium food contains potassium chloride as
substitute i.e nuts and sea product
PHOSPHORUS:


as the GFR decreases ,phosphorus excretion also decreases

high protein diet be equated to phosphorus intake

phosphorus binder may causes :GI distress, diarrhea or gas
severe constipation
CALCIUM AND PARATHROMONE HORMONE
AS GFR decreased serum calcium level declines because

decreased ability to convert vitamin D

Increased need due to high Phosphorus intake

calciphylaxis (syndrome of calcification of blood vessel)

deposition in wound tissue with resultant vascular calcification
thrombosis, non healing wound and gangrene
LIPIDS:


high lipid increases risk of atherosclerotic diseases

elevate triglycerides without increase in cholesterol

low level cholesterol may lead to mortality of ESRD
VITAMINS:


Water soluble vitamin lost during dialysis
i.e vitamin B and C

Emphasis on folate

High phosphorus food contain high soluble vitamins i.e citrus
fruits ,vegetables

Niacin help to lower phosphate level in ESRD
NURSING MANAGEMENT FOR HEMODIALY-
SIS.

Meeting psychological needs
The nurse helps the patient to identify safe, effective coping
stratergies to cope with these ever present problems and
fears.

Promoting home and community based care. Good
communication between the dialysis staffs, unit staffs, and
home care nurses is essential for providing sound , continous
care.
NURSING MANAGEMENT CONT........

Teaching patient self care.
In many cases, the patient is home before learning needs and
readness to learn can be thoroughly evaluated.
Therefore, hospital based nurses dialysis staffs, and home care
nurses must work together to provide apropriate teaching that
meets the patients and family's changing needs and readness
to learn.
NURSING MANAGEMENT CONT...

Continuing care.
To facilitate renal rehabilitation, appropriate follow up and
monitoring by members of healthcare team including nurses
are essential to identify and resolve problems early on.
COMPLICATION OF HEMODIALYSIS

Atherosclerotic cardiovascular disease.
Disturbance of lipid metabolism hypertriglyceridemia appear to
be accentuated by hemodialysis

Heart failure, coronary heart disease and anginal pain ,stroke
and peripheral vascular insufficient may occur and may
incapacitate the patient
COMPLICATION CONT....

Anemia and fatigue contribute to diminished physical and
emotional wellbeing, lack of energy and drives, and loss of
interest.

Gastric ulcers and other gastrointestinal problems occurs from
the physiologic stress of chronic illness, medication and related
problems.
COMPLICATION CONT...

Disturbed calcium metabolism leads to renal osteodystrophy
that produce bone pain and fractures.

Other problems includes fluid overload associated with heart
failure, malnutrition , infections, neuropathy, and pruiritus.

85% of people undergoing dialysis experience sleep problems
that further complicate their overall health major status.
COMPLICATION CONT....

Hypotension may occur during the treatment as fluid is
removed. Nausea and vomitting, diaphoresis, tachycardia, and
dizziness are common signs of hypotension

Painful muscle cramps may occur, usually late in dialysis as
fluid and electrolyte rapidly leave the extracellular space.

Dysrhythmias may result from electrolyte and pH changes or
from removal of antiarrthimic medication during dialysis.
COMPLICATIONS CONT....

Air embolism is rare but can occur if air enters the vascular
system.

Chest pain may occur in patient with anemia or arteriosclerotic
heart disease.

Dialysis disequilibrium results from cerebral fluid shifts.
PERITONEAL DIALYSIS
With peritoneal dialysis, a catheter is put into the abdomen.
Special fluid, called dialysate, is put into the abdomen through
the catheter.
The fluid stays in the abdomen for several hours. During this
time, the body’s extra fluid and wastes move from the blood to
the fluid. This fluid is much like urine, and it is then drained from
the body through the catheter.
Clean fluid is then put into the abdomen, and the steps are
repeated
CONTRAINDICATIONS OF PERITONEAL
DIALYSIS

Extensive abdominal adhesion that limit dialysate flow.

Body wall defects

Peritoneal leaks

Intolerance to peritoneal dialysis volumes

Skin infections

Severe malnutrition

Frequent episode of diverticulitis
TYPES PF PERITONEAL DIALYSIS.

Continuous Ambulatory Peritoneal Dialysis (CAPD) is done 4
to 5 times each day and the fluid stays in the abdomen for 3
to 4 hours. This can be done anywhere there is a clean,
private area.

Continuous Cycling Peritoneal Dialysis (CCPD) is done using a
special machine. The fluid stays in the abdomen for a shorter
time, about 1½ hours. The machine is set up and the person is
connected to this machine for 8 to 10 hours during the night.
PICTURE OF PERITONEAL DIALYSIS
peritoneal
UNDERLYING PRINCIPLES O PERITONEAL
DIALYSIS

Diffusion

Osmosis

Ultra filtration
EQUIPMENT FOR PERITONEAL DIALYSIS

Administration set and tubing.
The tubing is filled with the prepared dialysate to reduce the
amount of air entering the catheter and peritoneal cavity.
NURSING MANAGEMENT FOR PATIENT OF
PERITONEAL DIALYSIS
PRE DIALYSIS CARE
• Document vital signs including temperature, orthostatic blood
pressures (lying, sitting, and standing), apical pulse, respirations,
and lung sounds.
•These baseline data help assess fluid volume status and tolerance
of the dialysis procedure.
• Poor respiratory function may affect the ability to tolerate
peritoneal dialysis.
•Temperature measurement is vital, because infection is the most
common complication of peritoneal dialysis
PREDIALYSIS CONT

Maintain fluid and dietary restrictions as ordered. Fluid and diet
restrictions help reduce hypervolemia and control azotemia.

Have the client empty the bladder prior to catheter insertion. Emptying
the bladder reduces the risk of inadvertent puncture.

Warm the prescribed dialysate solution to body temperature (98.6° F or
37° C) using a warm water bath or heating pad on low setting.

Dialysate is warmed to prevent hypothermia.

Explain all procedures and expected sensations.

Knowledge helps reduce anxiety and elicit cooperation
 INTRADIALYSIS NURSING MANAGEMENT
Use strict aseptic technique during the dialysis procedure and when caring
for the peritoneal catheter. Peritonitis is a common complication of peritoneal
dialysis; sterile technique reduces the risk.

Add prescribed medications to the dialysate; prime the tubing with

solution and connect it to the peritoneal catheter, taping connections
securely and avoiding kinks.
•This allows dialysate to flow freely into the abdominal cavity and
prevents leaking or contamination.
INTRADIALYSIS CONT......

• During instillation and dwell time, observe closely for signs of

respiratory distress, such as dyspnea, tachypnea, or crackles.
• Place in Fowler’s or semi-Fowler’s position and slow the rate of
instillation slightly to relieve respiratory distress if it develops.
• Respiratory compromise may result from overly rapid filling or
overfilling of the abdomen or from a diaphragmatic defect that
allows fluid to enter the thoracic cavity.
INTRADIALYSIS CONT...

• Accurately record amount and type of dialysate instilled (including

any added medications), dwell time, and amount and character of the
drainage.
• When more dialysate drains than has been instilled, excess fluid has
been lost (output). If less dialysate is returned than has been
instilled, a fluid gain has occurred (intake).
• Monitor BUN, serum electrolyte, and creatinine levels. These values
are used to assess the effectiveness of dialysis.
POST DIALYSIS MANAGEMENT

• Assess vital signs, including temperature. Comparison of pre and

post dialysis vital signs helps identify beneficial and adverse effects of
the procedure.
• Time meals to correspond with dialysis outflow. Scheduling meals
while the abdomen is empty of dialysate enhances intake and reduces
nausea.
COMPLICATIONS OF PERITONEAL DIALYSIS

Peritonitis

Leakage

Bleeding

Weight gain

Hernia
SUMMARY

Dialysis treatment is done when no longer kidney function as
usual. It is needed when kidney can no longer take care of the
body needs.

Types of dialysis are hemodialysis and peritoneal dialysis.

There are three types of vascular access.

Av fistula,av graft,central catheter.

Principles of dialysis are osmosis, diffusion, and ultrafiltration.
SUMMARY CONT…
• Factors to consider in type of dialysis treatment.
• Availability of family to assist therapy especialy for home
dialysis, also consideration of previous abdominal
surgery.
• Also dialysis can result to following complication such as
Anemia, hypotension, air embolism, dysrhythmias and
fatigue
CONCLUSION
•
Dialysis helps to increase the survival rate of those suffering
from end stage renal disease although those with poor
economic status may fail to perform this procedure.

The type of dialysis to be carried out depends on patient
preference and accuracy of the procedure itself.

Hemodialysis is mostly preferred than peritoneal dialysis due
to its effectiveness and duration of time it takes.
REFERRENCES

Carey, H.B.,Chorney, W.,pherson, k., et al (2001) continous
peritoneal dialysis and extended care facility. American journal
of kidney disease 37(3), 580-587.

Hinkle, J and Cheever, k.(2008). Brunner and suddarlths.
Textbook medical surgical nursing.(14 th edition)