DIALYSIS

INTRODUCTION

 Dialysis ( dià, "through", lỳsis, "loosening or splitting") is the process of removing

excess water, solutes, and toxins from the blood in people whose kidneys can no longer
perform these functions naturally. This is also referred to as renal replacement therapy.
 Clinically dialysis is a technique in which substances move from the blood trough a
semipermeable membrane and into a dialysis solution

DEFINITON

 The movement of fluid and molecules across a semipermeable membrane from one
compartment to another

GOALS

 To remove the end products of protein metabolism such as urea and creatinine from the
blood
 To maintain a safe concentration of serum electrolytes
 To correct acidosis and replenish the bicarbonate level of the blood
 To remove excess fluid from the blood

PRINCIPLES

 DIFFUSION
 OSMOSIS
 ULTRAFILTRATION
DIFFUSION

 It is the movement of solutes from an area of greater concentration to an area of lesser

concentration
OSMOSIS
  Osmosis is the movement of fluid from an area of lesser concentration to an area of
greater concentration of solutes
 Glucose is added to the dialysate and create an osmotic gradient across the membrane,
pulling excess fluid from blood
ULTRAFILTRATION

 It refers to removal of fluid from the blood using either osmotic or hydrostatic pressure
to produce necessary gradient

TYPES

 PERITONEAL DIALYSIS
 HEMODIALYSIS

PERITONEAL DIALYSIS

 PD first used in the year 1923

DEFINITION

 It involves repeated cycles of instilling dialysate into peritoneal cavity allowing time for
substance exchange and then removing the dialysate
INDICATION

 Patients with kidney disease who are unable or unwilling to undergo hemodialysis or
kidney transplantation
 Patients with diabetes or cardiovascular disease, older patients those at risk for adverse
effect of systemic heparin
 Severe hypertension, HF, and pulmonary oedema not responsive to usual treatment
GOAL

 To remove toxic substance and metabolic waste and to reestablish normal fluid and
electrolyte balance
PROCEDURE

 Preparing the patient

 Preparing the equipment
 Inserting the catheter
 Performing the exchange
Preparing the patient

 Preparation depends on physical, psychological status ,level of alertness, previous

experience with dialysis and understanding familiarity with the procedure
 Explain procedure to the patient and getting consent
 Monitor baseline vital signs,weight,serum electrolytes
 Evaluate abdomen for the placement of catheter typically placed on the nondominant
side to allow patients easier access to catheter connection site

 Encourage patient to empty bladder and bowel to reduce risk of puncture of internal
organs

Preparing the equipment

 Before assembling the equipment nurse consult with physician to determine the
concentration of dialysate to be used and medication to be added
 Heparin added to prevent fibrin formation and resultant occlusion of peritoneal catheter
 Potassium chloride may be prescribed to prevent hypokalemia
 Antibiotics added to treat peritonitis caused by infection

 Regular insulin added for patients with diabetes due to high dextrose concentration of PD
solution

 Before adding medication the dialysate is warmed to body temperature to prevent patient
discomfort and abdominal pain and to dilate vessels of peritoneum to increase urea
clearance

 Dry heating is recommended , not recommended are soaking the bags of solution in
warm water and use of microwave oven
  Immediately before initiating dialysis nurse should assemble the administration set and
tubing by sterile technique

Inserting the catheter

 It is inserted in the operating room or radiology suite to maintaining surgical asepsis and
minimize risk of infection
 It is inserted through anterior abdominal wall
 Catheters are made of silicone with a radio opaque strip to permit visualization on X-ray
Peritoneal dialysis catheter

 It has 24 inches long 3 parts

 Intra peritoneal section
 Subcutaneous section
 External section
 These catheters have 2 cuff made of dacronpolyster
 This stabilize the catheter,limit movement, prevent leaks, and provide barrier against
micoorganisms
Performing the exchange

 PD is accomplished by putting dialysis solution into the peritoneal space

 Three phases of PD
 INFLOW(FILL)
 DWELL (EQUILIBRIUM)
 DRAIN
 THESE 3 PHASES ARE CALLED EXCHANGE

INFLOW
  Prescribed amount of solution usually 2L is infused through an established catheter over
about 10mts
 Flow rate may be decreased if patient has pain
 After solution has been infused the inflow clamp is closed before air enters the tubing
DWELL PHASE

 During this phase diffusion and osmosis occurs between the patient’s blood and the
peritoneal cavity
 Duration can last from 20-30 mts to 8 or more hours depending on the method of PD
DRAIN

 It takes 15-30mts and may be facilitated by gently massaging abdomen or changing

position
 The cycle starts again with the infusion of another 2L of solution
 For manual PD a period of about 30-50mts is required to complete an exchange
 Ultrafiltration depends on osmotic forces with glucose being the most effective osmotic
agent
 Dextrose is the most commonly used osmotic agent in PD solution
 Alternative to dextrose PD solution include icodextrin and amino acid solution
PD APPROACHES

 ACUTE INTERMITTENT PD
 CONTINUOUS AMBULATORY PD
 CONTINUOUS CYCLIC PD/AUTOMATED PD
ACUTE INTERMITTENT PD

 INDICATED IN
 Uremic signs and symptoms
 Fluid overload
 Acidosis
 Hyperkalemia
 Haemodynamically unstable patients
 It can be carried out manually or by a cycler machine
  Exchange time ranges from 30mts-2hrs

 One routine is hourly exchange consisting of 10mts infusion, 30mts dwell time and 20mts
drain time

CONTINUOUS AMBULATORY PERITONEAL DIALYSIS

 It is the second most common form of dialysis for patients with ESKD
 It is performed at home by the patient or a trained care giver who is usually a family
member
 It allows reasonable freedom and control of daily activities
PROCEDURE

 A ‘Y ‘ Shaped system is most commonly used

 Bag containing dialysate solution connected to one branch of Y and sterile empty bag is
connected to second branch
 Third part of Y open and available for connection to transfer set on PD catheter
 For doing procedure initially patient performs hand washing and don a mask and remove
the cap from the transfer set

 Open end of Y set is connected to the end of transfer set and dialysate infused where it
will dwell

 After that patient clamp off the transfer set,tubing set and applies a new cap ,make it as a
closed system

 Patient drains fluid from peritoneal cavity through the catheter into an empty bag

 Longer the dwell time better the clearance of uremic toxins

Indication –CAPD

 Patient willingness, motivation, and ability to perform dialysis at home

 Strong family or community support system
 Interim therapy while awaiting kidney transplantation
  ESKD secondary to DM, HTN, uremia
 Special problems with longterm HD

 Failing vascular access devices

 Excessive thirst

 Severe hypertension

 Postdialysis headache

 Severe anemia

Contraindications

 Adhesions from previous surgery or systemic inflammatory disease

 Chronic back ache and pre existing disc disease
 Severe arthritis
Advantage

 Freedom from hemodialysis machine

 Control over daily activities
 Opportunities to eat a more liberal diet

Disadvantage

 Continuous dialysis 24hrs a day ,7 days a week

 Dietary alteration related to potassium and protein loses

CONTINUOUS CYCLIC PD/AUTOMATED PD

 Most popular form of PD because it allows patients to do dialysis while they sleep
 An automated device called cycler is used to deliver dialysate for APD
 Cycler is similar to a DVD player
 Automated cycler times and control the fill, dwell, and drain phases
  Machine cycles four or more exchange per night with 1-2 hrs per exchange

Complications

 Exit site infection

 Peritonitis
 Hernias
 Lower back ache problems
 Bleeding
 Pulmonary complication
 Protein loss
Exit site infections

 Caused by Staph aureus or Staph epidermidis

 Clinical features includes redness tenderness, and drainage
 Treated by antibiotic therapy
 If not treated immediately subcutaneous tunnel infection may progress and cause
peritonitis necessitates catheter removal
Peritonitis

 Result from contact contamination or exit site or tunnel infection

 Caused by staph aureus or epidermidis
 Clinical features are
 Abdominal pain
 Rebound tenderness
 Cloudy peritoneal effluent with WBC >100 cell/µL
 Fever may or may not be present
 GI features

 Diarrhoea

 Vomiting
  Abdominal distension

 Hyperactive bowel sounds

 IV, oral, or intraperitoneal antibiotics

 Repeated infection may require removal of peritoneal catheter and a temporary or

permanent change of modality to HD

Hernias

 Because of increased intra abdominal pressure secondary to dialysate volume hernias can
develop in multiparous woman and older men
 PD can resume after hernia repair
Lower back ache problems

 Increased intrabdominal pressure can aggravate lower back pain

 Lumbosacral curvature is increased by intraperitoneal infusion of dialysate
 Orthopedic binders and exercise programs are beneficial
Bleeding

 PD effluent after the first few exchanges to be pink or slightly bloody secondary to the
trauma associated with catheter insertion
 Bloody effluent over several days or new appearance of blood in effluent can indicate
active intra peritoneal bleeding
 Check BP and hematocrit
Pulmonary complication

 Atlectasis ,pneumonia, and bronchitis result from upward displacement of diaphragm

resulting in decreased lung expansion
 Longer dwell time increase pulmonary problems
 Treatment focus on frequent repositioning and deep breathing exercise

 When patient lying in bed elevate the head of the bed

Protein loss
  Peritoneal membrane is permeable to plasma proteins,amino acids and
polypeptides ,these may lost in dialysate fluid
 Amount of loss is about 0.5g/l of dialysate drainage it can be as high as 10-20 g/day
 Loss may increase as much as 40 g/day during episodes of peritonitis
 Excessive protein loss leads to malnutrition and may indicate need to stop PD
temporarily sometimes permanently

Nursing management

 1)Promote patient comfort during procedure

 Provide physical comfort
 Keep patient informed of progress and result
 Provide care of the whole patient
 2)Maintain peritoneal dialysis fluid infusion and drainage

 a)If fluid is not draining properly

 Move patient from side to side to facilitate removal of

peritoneal drainage

 Head of the bed may be elevated

 Never push in the catheter

 Check for closed clamp,kinked tubing, or air lock

 b)Use strict aseptic technique when adding exchanges or emptying drainage containers

 c)Take BP and pulse every 15mts during first exchange and every hour thereafter

 d) take temperature every 4 hours

 3) Monitor changes in fluid and electrolyte status,weight changes, vital signs, i/o

 4) Monitor for complications

  5)Meeting psychosocial needs

 Patient’s with PD may experience altered body image because of the presence of
abdominal catheter ,bag, tubing and cycler
 Nurse should make arrangements for the patient to talk with other patients who
have adapted well to PD
 Patient’s with PD may also experience altered sexuality pattern and sexual
dysfunction
 Nurse must enquire related to sexuality and sexual function often provide the
patient with a welcome opportunity to discuss these issues and a first step toward
their resolution
 6) Promoting home and community based care
 Educate patients about self care
 Discuss about normal kidney function, disease process, catheter and exit site
care,V/S and weight measurement, management of fluid balance, maintenance of
aseptic technique, and demonstrating how to do exchange
 Discuss about PD prevention, complication ,dietary restriction and medications

HAEMODIALYSIS

 It is used for patients who are acutely ill and require short term dialysis for days to weeks
until kidney function resumes
 It is used for patients with advanced CKD and ESKD who require long term or
permanent renal replacement therapy
DEFINITION
  Hemodialysis: A medical procedure to remove fluid and waste products from the blood
and to correct electrolyte imbalances.
 This is accomplished using a machine and a dialyzer, also referred to as an "artificial
kidney."
 It is a procedure in which the blood laden with toxins and nitrogenous wastes is diverted
from the patient to a machine via the use of a blood pump to the dialyzer ,where toxins
are filtered from the blood and blood is returned to the patient

OBJECTIVES

 To extract toxic nitrogenous substances from the blood and to remove excess fluid
INDICATIONS

 Acute indication
 Acidaemia from metabolic acidosis in situations in which corrections
with sodium bicarbonate is impractical or may result in fluid overload
 Electrolyte abnormality such as severe heperkalemia especially when
combined with AKI
 Intoxication ie acute poisoning with a dialyzable substance (salicylic
acid, lithium)
 Overload of fluid not expected to respond to treatment with diuretics
 Uremia complications such as pericarditis,encephalopathyor GI
bleeding

 Chronic indications

 Patient with symptomatic kidney failure and low GFR

DIALYZER

 Dialyzers are hollow fiber devices containing thousands of tiny capillary tubes that carry
blood through the artificial kidney
  The tubes are porous and act as semipermeable membrane allowing toxins fluid and
electrolyte to pass across the membrane

VASCULAR ACCESS

 VASCULAR ACCESS DEVICES

 ARTERIOVENOUS FISTULA
 ARTERIOVENOUS GRAFT

VASCULAR ACCESS DEVICES

 Immediate access is achieved by double lumen noncuffed large bore catheter into
subclavian, internal jugular or femoral vein
 Double lumen cuffed catheters may also be inserted by surgeon or interventional
radiologist into internal jugular vein
 Advantage of this catheter is that it has cuffs under the skin, Insertion site heals, sealing
the wound and reducing the risk for ascending infection
ARTERIOVENOUS FISTULA

 AV fistula is created surgically by anastomosing an artery to vein either side to side or

end to end
 It will need 2-3 months to mature before it can be used
 Arterial segment of fistula used for arterial flow to dialyzer and venous segment used for
reinfusion of dialyzed blood
 As AVF matures venous segment dilate due to increased blood flow coming directly
from the artery

 Once sufficiently dilated it will accommodate two large bore needles for dialysis
treatment

 Patient encouraged to perform hand exercise to increase the size of these vessels
  Once established this has the longest life and thus is the best option for vascular access
for patient requiring ongoing hemodialysis

ARTERIOVENOUS GRAFT

 These are made up of synthetic material (PTFE, Teflon) and form a bridge between an
artery and vein it is created when patients vessels are not suitable for creation of AVF
 Graft are placed under the skin and are surgically anastomosed between artery and vein

 2-4 weeks is necessary to allow the graft to heal

 COMPLICATION

 Stenosis ,infection,thrombosis

 Steal syndrome ( distal ischemia and pain because too much arterial blood is being
shunted or stolen from the distal extremity, classic features are pain distal to access
site ,numbness or tingling of fingers worsen during dialysis ad poor capillary refill)

PROCEDURE

 Assess fluid status

 Assess weight,BP, periphealoedema,lung and heart sounds
 Assess condition of vascular access and temperature
 Calculate the weight difference between last post dialysis and present
predialysis to determine the ultrafiltraon amount
 Arrange the articles needed
 Two large bore needles are used usually 14-16G
 One used to pull blood from the circulation (red catheter lumen)to HD
machine other used to return dialyzed blood to patient(blue catheter
lumen)
 When blood comes in contact with the dialyzer it has a tendency to clot so
heparin is added to prevent clotting
  Dialysate delivery system pumps dialysate through the dialyzer
countercurrent to the blood flow
 To terminate the treatment saline is used to return the blood in the extra
corporeal circuit back to patient through vascular access
 Needles are removed from the patient and a firm pressure is applied
 Vital signs should be checked atleast every 30-60mts

COMPLICATIONS

 HYPOTENSION

 It result from rapid removal of vascular volume decreased cardiac output and decreases
SVR
 Patient may have lightheadedness, nausea, vomiting seizures,vision changes and chest
pain
 Treatment includes decreasing volume of fluid removed and infusion of 0.9% saline
solution

 MUSCLE CRAMPS
 High prevalence in the first month of HD
 Hypotension,hyovolemia,high UF and low sodium dialysate induced
vasoconstriction followed by hypoperfusion, abnormal muscle relaxation
may occur
 Other causes are hypocalcemia,hypomagnesaemia,hypokalemia,low cardiac
indx,low potassium and calcium dialysate
 Management : saline ,glucose, manitol, nifedepine, muscle stretching
 Prevention :stretching exercise, dialysate sodium,dialysate magnesium,
biotin
 LOSS OF BLOOD
 It result from blood not being completely rinsed from the dialyzer,accidental separation
of blood tubing, dialysis membrane rupture or bleeding after the removal of needles
 Treatment include rinse back all blood,closely monitor heparinization ,hold firm non
occlusive pressure on access sites
 HEPATITIS
 Hepatitis B
 Hepatitis C
 DISEUILIBRIUM SYNDROME
 It develops as a result of very rapid changes in the composition of extra cellular fluid
 Urea,sodium and other solutes are removed more rapidly from the blood than from the
CSF and brain. It creates high osmotic gradient in the brain resulting in shift of fluid into
brain causing cerebral oedema
 Features are nausea,vomiting, confusion, restlessness,headache,twitching and jerking
seizures
 Treatment includes slowing or stopping dialysis ,infusing hypotonic saline solution,
albumin or manitol to draw fluid from the brain cells

NURSING MANAGEMENT
 Protecting vascular access
 Assess the vascular access for patency
 Takes precautions to ensure that extremity with vascular access is not used for
measuring BP or for obtaining blood specimens
 Tight dressings, jewellery, or restraints over the vascular access must be avoided
 Bruit, or thrill over the venous access site must be evaluated .absence of thrill may
indicate blockage or clotting in vascular access
  If patient is having HD catheter or implanted HD access device must observe for
signs and symptoms of infection
 Taking precautions during IV therapy
 If patient needs IV therapy, the rate of administration must be slow as possible
 Accurate I/O record should be maintained
 Monitoring symptoms of uremia
 When metabolic end products accumulates symptoms of uremia worsen
 Patients receiving corticosteroid medication or parenteral nutrition ,those with
infection or bleeding disorders and undergoing surgery ay accumulate waste
products quickly and may require daily dialysis
 Detecting cardiac and respiratory complication
 Frequently monitor the cardiac and respiratory status
 When fluid builds up, fluid overload ,HF and pulmonary edema may develop.
Pericarditis may result from the accumulation of ureic toxins if not detected early
serious complications may develop
 It can be detected by substernal pain , low grade fever, pericardial friction rub and
paradoxical pulse
 Controlling electrolyte levels and diet
 All IV solutions and medications to be administered are evaluated for their
electrolyte content
 Serum laboratory values are assessed daily
 Dietary intake must be monitored
 Hypoalbuminemia is an indicator of malnutrition patients can be treated with
adequate nutrition
 Managing discomfort and pain
 Complications such as pruritus and pain secondary to neuropathy must be managed
 Antihistamine (diphenhydramine hydrochloride) and analgesic medication may be
prescribed
 Keep the skin clean, superfatted soap, and creams promote comfort and reduce
itching
 Monitoring BP
  Hypertension in renal failure is common
 It is the result of fluid overload, and over secretion of renin
 Monitor BP regularly
 Antihypertensive agents must be withheld before dialysis to avoid hypotension
due to combined effect of fluid removal with dialysis treatment and medication
 Preventing infection
 Patients with ESKD have low WBC,RBC, and impaired platelet function so more
risk for infection
 Maintain asepsis during procedures
 Promoting pharmacologic therapy
 Many medications are removed from the blood during haemodialysis therefore
dosage and timing of medication administration require adjustment
 Medications that are water soluble are readily removed during haemodialysis
treatment and those are fat soluble are not dialyzed [Link] is because drug
overdose are treated with emergency hemodialysis
 Patients who are taking cardiac glycosides. Antibiotic agents, antiarrhythmic
medications ,anti hypertensive agents are monitored closely
 Promoting nutritional and fluid therapy
 Goals of nutritional therapy are to minimize uremic symptoms, and fluid
electrolyte imbalances , to maintain good nutritional status
 Restricting dietary proteins decreases the accumulation nitrogenous wastes,
reduce uremic symptoms
 Meeting the psychosocial needs
 Patients requiring long term haemodialysis are often concerned about the
unpredictability of the illness and the disruption of their lives, patients may have
financial problems difficulty holing job, and fear of dying .Dialysis often alter the
lifestyle of the patient and family
 Nurse need to give the patient and family an opportunity to express feelings of
anger and concern about the limitation that the disease and treatment impose

 Educating about self care

  Preparing the patient for hemodialysis is essential
 Education must occur in brief 10-15mts sessions with time added for clarification,
repetition, reinforcement and questions from the patient and family
 Home care education may include discussions regarding renal failure its effects,
causes,indication for haemodialysis , common problems occur during the
procedure ,fluid restriction, dietary restriction ,vascular access care etc

 Continuing and transitional care

 To facilitate renal rehabilitation appropriate follow up and monitoring by
members of health care team are essential to identify and resolve problem

REFERENCES

1) Hinkle J L, Cheever K H. Brunner &Suddarth’s Textbook Of Medical –

Surgical Nursing .[Link] Kluwer:2014.1548-1561

2) Dirksen, Lewis et al. Lewis’s Medical Surgical Nursing.2nd

[Link].1042-1048

3) Phipps,Sands, [Link] Surgical Nursing .[Link]: 1480- 1488

4) Ignatavicius,Workman. Medical Surgical Nursing .6th ed.1620-1630

5)BlackJM,[Link]’s Medical Surgical Nursing.1st south asia ed.800-830