Dialysis Nursing Care Plan

Description

• Dialysis is primarily used to provide an artificial replacement for lost kidney function (renal replacement therapy) due to renal failure
• Dialysis works on the principles of diffusion of solute through a semipermeable membrane that separates  two solutions.
• Direction of diffusion depends on concentration of solute in each solution.
• Rate and efficiency depend  on concentration gradient, temperature of solution, pore size of membrane, and molecular size.

Two Mechanisms in Dialysis

1. Diffusion – movement of particles from an area of high concentration to one of low concentration across a semipermeable membrane.
2. Osmosis – movement of water through a semipermeable membrane from an area of lesser concentration of particles to one of greater concentration.

Indications

The decision to initiate dialysis or hemofiltration in patients with renal failure depends on several factors. These can be divided into acute or chronic indications.

• Indications for dialysis in the patient with acute kidney injury are:
  1. Metabolic acidosis in situations where correction with sodium bicarbonate is impractical or may result in fluid overload.
  2. Electrolyte abnormality, such as severe hyperkalemia, especially when combined with AKI.
  3. Intoxication, that is, acute poisoning with a dialysable drug, such as lithium, or aspirin.
  4. Fluid overload not expected to respond to treatment with diuretics.
  5. Complications of uremia, such as pericarditis or encephalopathy.
• Chronic indications for dialysis:
  1. Symptomatic renal failure
  2. Low glomerular filtration rate (GFR) (RRT often recommended to commence at a GFR of less than 10-15 mls/min/1.73m2). In diabetics dialysis is started earlier.
  3. Difficulty in medically controlling fluid overload, serum potassium, and/or serum phosphorus when the GFR is very low

Goals

• Reduce level of nitrogenous waste.
• Correct acidosis, reverse electrolyte imbalances, remove excess fluid.

Two main types of dialysis

I. Hemodialysis

• Hemodialysis removes wastes and water by circulating blood outside the body through an external filter, called a dialyzer, that contains a semipermeable membrane
• In hemodialysis, the patient’s blood is pumped through the blood compartment of a dialyzer, exposing it to a partially permeable membrane.
• The dialyzer is composed of thousands of tiny synthetic hollow fibers.
• The fiber wall acts as the semipermeable membrane. Blood flows through the fibers, dialysis solution flows around the outside the fibers, and water and wastes move between these two solutions.
• The cleansed blood is then returned via the circuit back to the body.
• Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer membrane.
• This usually is done by applying a negative pressure to the dialysate compartment of the dialyzer.
• This pressure gradient causes water and dissolved solutes to move from blood to dialysate, and allows the removal of several litres of excess fluid during a typical 3 to 5 hour treatment.
• Studies have demonstrated the clinical benefits of dialyzing 5 to 7 times a week, for 6 to 8 hours.
• These frequent long treatments are often done at home, while sleeping but home dialysis is a flexible modality and schedules can be changed day to day, week to week.

image credit to : www.niddk.nih.gov

Types of venous access for hemodialysis

1. External shunt
   • Cannula is placed in a large vein and a large artery that approximate each other.
   • External shunts, which provide easy and painless access to bloodstream, are prone to infection and clotting and causes erosion of the skin a round the insertion area.
2. Arteriovenous fistulas or graft
   • Large artery and vein are sewn together (anastomosed) below the surface of the skin (fistula) or subcutaneous graft using the salphenous vein, synthetic prosthesis, or bovine xenograft to connect artery and vein.
   • Purpose is to create one blood vessel for withdrawing and returning blood.
   • Advantage is greater activity range than AV shunt and no protective asepsis.
   • Disadvantage is necessity of two venipunctures with each dialysis.
3. Vein catheterization
   • Femoral or subclavian vein access is immediate
   • May be short or long term duration.

Nursing Considerations

Before the Hemodialysis

1. Allow the client to void.
2. Document the client’s weight.
3. Obtain vital signs as baseline.
4. Check the medications history of the patient before the procedure. Antihypertensives, sedatives and vasodilators are prevented in order to do away with hypotensive episode.

During the Hemodialysis

1. Obtain vital signs periodically between 30 minutes.
2. Observe proper body alignment, allow frequent position changes.
3. Monitor for episodes of nausea and vomiting which may occur during the procedure.
4. Monitor for signs of bleeding by taking clotting time about 1 hour before the client comes off the machine. Observe clotting time at 30 to 90 minutes while on dialysis (Normal value: 6 – 10 minutes)

After Dialysis

1. Check the client’s weight, note any difference.
2. Assess for complications.
3. Check for signs of bleeding and status of the fistula.

Complications of Dialysis

1. Hypovolemic Shock – result of rapid removal or ultrafiltration of fluid from the intravascular compartment
2. Dialysis-disequilibrium syndrome – caused by rapid, efficient dialysis resulting in shifts in water, pH and osmolarity between fluid and blood.

Signs and Symptoms

1. Nausea & Vomiting
2. Headache
3. Hypertension
4. Agitation
5. Disorientation
6. Twitching
7. Peripheral paresthesias
8. Convulsions

II. Peritoneal dialysis

• Peritoneal dialysis is a treatment for patients with severe chronic kidney failure
• Wastes and water are removed from the blood inside the body using the peritoneal membrane as a natural semipermeable membrane.
• Wastes and excess water move from the blood, across the peritoneal membrane, and into a special dialysis solution, called dialysate, in theabdominal cavity which has a composition similar to the fluid portion of blood.
• In peritoneal dialysis, a sterile solution containing minerals and glucose is run through a tube into the peritoneal cavity, the abdominal body cavity around the intestine, where the peritoneal membrane acts as a semipermeable membrane.
• The peritoneal membrane or peritoneum is a layer of tissue containing blood vessels that lines and surrounds the peritoneal, or abdominal, cavity and the internal abdominal organs (stomach, spleen, liver, and intestines).
• The dialysate is left there for a period of time to absorb waste products, and then it is drained out through the tube and discarded. This cycle or “exchange” is normally repeated 4-5 times during the day, (sometimes more often overnight with an automated system).
• Ultrafiltration occurs via osmosis; the dialysis solution used contains a high concentration of glucose, and the resulting osmotic pressure causes fluid to move from the blood into the dialysate. As a result, more fluid is drained than was instilled.
• Peritoneal dialysis is less efficient than hemodialysis, but because it is carried out for a longer period of time the net effect in terms of removal of waste products and of salt and water are similar to hemodialysis.
• Peritoneal dialysis is carried out at home by the patient.

image credit to: http://kidneysdisease.com/

Three types of Peritoneal Dialysis

• 1. Intermittent peritoneal dialysis
• 2 Continuous ambulatory peritoneal dialysis
• 3. Continuous cycling peritoneal dialysis

Nursing Considerations

Patient Preparation

1. Allow the client to void before catheter insertion.
2. Institute abdominal skin preparation
3. Document the client’s weight before the dialysis
4. Take baseline vital signs

During the Procedure

1. Monitor the level of electrolytes.
2. Obtain samples of return dialysate for culture
3. Compare the client’s weight before and after the procedure
4. Monitor the vital signs every 30 minutes and report any deviations
5. Provide proper positioning for the dialysate to return from the peritoneal cavity. Place the patient in semi-Fowler’s position.

Complications of Peritoneal Dialysis

1. Excessive loss of fluid can result in hypovolemic shock or hypotension while excessive fluid retention can result in hypertension and edema.
   • The volume of dialysate removed and weight of the patient are normally monitored; if more than500ml of fluid are retained or a litre of fluid is lost across three consecutive treatments, the patient’s physician is generally notified.
2. Also monitored is the color of the fluid removed: normally it is pink-tinged for the initial four cycles and clear or pale yellow afterwards. The presence of pink or bloody effluent suggests bleeding inside the abdomen while feces indicates a .
3. The patient may also experience pain or discomfort if the dialysate is too acidic, too cold or introduced too quickly, while diffuse pain with cloudy discharge may indicate an infection. Severe pain in the rectum or perinium can be the result of an improperly placed catheter. The dwell can also increase pressure on the diaphragm causing impaired breathing, and constipation can interfere with the ability of fluid to flow through the catheter.