Chapter 57 Hemodialysis and Peritoneal Dialysis PDF

Chapter 57- Hemodialysis and Peritoneal Dialysis RNSG 2331-ADANCED CONCEPTS OF ADULT HEALTH 1. Discuss nursing priorities with hospitalized patients in the acute care setting to prevent kidney failure. Monitor lab values-BUN, Cr and electrolytes. Maintain MAP pressures above 65 mmHg...

Chapter 57- Hemodialysis and Peritoneal Dialysis RNSG 2331-ADANCED CONCEPTS OF ADULT HEALTH 1. Discuss nursing priorities with hospitalized patients in the acute care setting to prevent kidney failure. Monitor lab values-BUN, Cr and electrolytes. Maintain MAP pressures above 65 mmHg Close I and O recordings Careful diligence of IV fluid administrations Monitoring drug levels Fluid challenges Diuretic dosing and outputs management 2. Name at least 4 medications that can cause kidney nephrotoxicity. 1. Vancomycin 2. NSAIDS 3. Steroids 4. Gentamycin/Tobramycin 5. Chemotherapy-especially Cisplatin Others include-Cocaine and heroin, Tylenol OD, diuretics, fluroquinolones, some OTC medications 3. State the normal MAP pressure required to prevent kidney injury. If the MAP is too low the cardiac output is not efficient enough to pump blood to the vital organs. If MAP is too high over 100 mm HG-organ damage occurs due to thigh pressure gradient against the blood vessel that provide blood flow. Normal MAP (70-100 mm HG) Acute care settings MAP of 65 mmHg is acceptable. MAP is calculated using the following equation: MAP = Diastolic BP + 1/3 x (Systolic BP – Diastolic BP) 4. Describe the nutrition requirements for ESRD. Purpose of nutrition support is to provide nutrients to maintain nutrition status, preserve lean body mass and fluid balance and to preserve kidney function. Hemodialysis patients: Protein 1.2 gm/kg/day, Sodium 2-3 gm/day, Potassium 203 g/day 30-35 kcal/kg/day, phosphorus 0.6-1.2 g/day, Iron supplement if receiving erythropoietin injections, fluids depends on urine output (600-1000ml/day). Peritoneal patients: 1.2-1.3 g/kg/day, 25-30 kcal/kg/day, Sodium 2- 4 g/day, Potassium 2-3 g/day, Phosphorus 0.6-1.2 g/day, calcium individualized, Iron if taking erythropoietin injections. Fluids unrestricted if weight and BP controlled. Supplements… Kidney specific supplements include Supplena, Nepro or Nova source used because they are lower in phosphorus, sodium and potassium. Given orally or tube feedings. TPN is mixed by MD/pharmacy/dietician to meet the patient specific needs. 5. Explain methods used to treat kidney injury from nephrotoxicity. Restore fluid volume Adjust doses or discontinue medications May try steroids for interstitial nephritis Dialysis if necessary Identify the stages of GFR in relation to the ml/minute filtration values. Stage 1 GFR < 90 ml/min Stage 2 GFR 60-89 ml/min Stage 3 GFR 30-59 ml/min Stage 4 GFR 15-29 ml/min Stage 5 GFR < 15 ml/min 6. Identify the pre-intra-post procedural actions for dialysis catheter placement. PREPROCEDURE NURSING ACTIONS: Check for informed consent. Use a temporary hemodialysis dual‑lumen catheter or subcutaneous device until the provider inserts a long‑term device and it is available for access. Assess the patency of a long‑term device: arteriovenous (AV) fistula or AV graft (presence of bruit, palpable thrill, distal pulses, circulation) Pg. 379 Pre-Procedure (Continued) Avoid measuring blood pressure, administering injections, performing venipunctures, or inserting IV catheters on or into an arm with an access site. Elevate the extremity following surgical creation of an AV fistula to reduce swelling. Assess vital signs, laboratory values (BUN, blood creatinine, electrolytes, Hct), and weight. Discuss with the provider medications to withhold until after dialysis. Withhold any dialyzable medications and medications that lower blood pressure. Intra-Procedure Monitor for complications during dialysis. Dialysis circuit clotting, air bubbles in blood tubing, temperature of the dialysate (37.8° C [100° F]), regulation of the ultrafiltration. Hypotension, cramping, vomiting, bleeding at the access site, contamination of equipment Monitor vital signs and coagulation studies during dialysis. Monitor for bleeding, such as oozing from insertion site. Administer anticoagulants, such as heparin. Have protamine sulfate ready to reverse heparin. Provide emotional support and offer activities (books, magazines, music, cards, or television) Post-Procedure Monitor vital signs and laboratory values (BUN, blood creatinine, electrolytes, Hct). Decreases in blood pressure and changes in laboratory values are common following dialysis. Compare the client’s preprocedure weight with the postprocedure weight as a way to estimate the amount of fluid the procedure removed. 1 L fluid equals 1 kg (2.2 lb) Assess for the following. Complications (hypotension, clotting of vascular access, headache, muscle cramps, bleeding) Indications of bleeding or infection at the access site. Findings of disequilibrium syndrome. Findings of hypovolemia (hypotension, dizziness, tachycardia). Avoid invasive procedures for 4 to 6 hr after dialysis due to the risk of bleeding as a result of the anticoagulation. Reinforce AV fistula or AV graft precautions. 7. Summarize the function of dialysis procedures. Hemodialysis-filters the blood with a machine as the dialyzer to remove waste products. Peritoneal dialysis-filters the body wastes through the peritoneum in the abdomen with varying bags of fluids/hours and methods of treatment. 8. List the indications for dialysis and the presentations. Renal insufficiency Acute kidney injury Chronic kidney disease Drug toxicity Hyperkalemia chronic Hypervolemia 9. Discuss the peritoneal dialysis catheter procedure. 9. Describe the complications for graft/shunt placements. Clotting/Infection Disequilibrium syndrome Hypotension Anemia What occurs with each complication? Abdominal cramping Infectious diseases 10. Discuss the pre-procedures necessary for hemodialysis according to ATI. NURSING ACTIONS Check for informed consent. Use a temporary hemodialysis dual‑lumen catheter or subcutaneous device until the provider inserts a long‑term device and it is available for access. Assess the patency of a long‑term device: arteriovenous (AV) fistula or AV graft (presence of bruit, palpable thrill, distal pulses, circulation). More and more! Avoid measuring blood pressure, administering injections, performing venipunctures, or inserting IV catheters on or into an arm with an access site. Elevate the extremity following surgical creation of an AV fistula to reduce swelling. Assess vital signs, laboratory values (BUN, blood creatinine, electrolytes, Hct), and weight. Discuss with the provider medications to withhold until after dialysis. Withhold any dialyzable medications and medications that lower blood pressure. 11. Reason why weight is an important indicator of fluid status. 1 lb=2.2 kg Measure of fluid balance and weight status! Weight is the most sensitive indicator for fluid loss or gain as opposed to edema formation or lung secretions. Standing or sling weight. Never bed measurement for renal patients. 13. Name 3 complications from hemodialysis. Clotting/Infection Disequilibrium syndrome Hypotension 14. Describe disequilibrium syndrome and nursing action required for treatment. Disequilibrium syndrome results from too rapid a decrease of BUN and circulating fluid volume. It can result in cerebral edema and increased intracranial pressure. Early recognition of disequilibrium syndrome is essential. Manifestations include nausea, vomiting, changes in level of consciousness, seizures, and agitation. Advanced age is a risk factor for dialysis disequilibrium and hypotension due to rapid changes in fluid and electrolyte status. NURSING ACTIONS Use a slow dialysis exchange rate, especially for older adult clients and first‑time hemodialysis. Administer anticonvulsants or barbiturates if the client requires them. 15. Name several indications why peritoneal dialysis is used for dialysis. Peritoneal dialysis is the treatment of choice for the older adults who require dialysis. Peritoneal dialysis treats clients requiring dialysis who: 1. Are unable to tolerate anticoagulation. 2. Have difficulty with vascular access. 3. Have chronic infections or are unstable. 4. Have chronic diseases (diabetes mellitus, heart failure, severe hypertension). 16. Identify two major complications of peritoneal dialysis. Peritonitis Infection Protein loss Hyperglycemia or Hyperlipodemia 17. Discuss the nursing observations for dialysate flow from peritoneal dialysis. Poor dialysate inflow or outflow Causes include: Obstruction or twisting of the tubing Constipation Client positioning Fibrin clot formation Catheter displacement NURSING ACTIONS Reposition the client if inflow or outflow is inadequate. Milk the tubing to break up fibrin clots. Check the tubing for kinks or closed clamps. The three phases of the PD cycle (called an exchange) are inflow (fill), dwell (equilibration), and drain (outflow). Dialysate outflow should be pale yellow or amber colored. Cloudy outflow can signify infections, brownish outflow can indicate possible peritonitis an emergency. Monitor the color (should be clear, light yellow) and amount (should equal or exceed the amount of dialysate inflow) of outflow. Monitor for signs of infection (fever; bloody, cloudy, or frothy dialysate return; drainage at access site) and for complications (respiratory distress, abdominal pain, insufficient outflow, discolored outflow). Check the access site dressing for wetness (risk of dialysate leakage) and exit- site infections Warm the dialysate prior to instilling. Avoid the use of microwave ovens, which cause uneven heating Adhere to the times for infusion, dwell, and outflow. Maintain surgical asepsis of the catheter insertion site and when accessing the catheter. Keep the outflow bag lower than the client’s abdomen (drain by gravity, prevent reflux). Continued… Reposition the client if inflow or outflow is inadequate. Carefully milk the peritoneal dialysis catheter if a fibrin clot has formed. Provide emotional support to the client and family 18. Name the difference between the AV shunt and AV graft and how to make assessment. The AV fistula is considered as the the best choice The AV graft provides a solution for small or for vascular access. weak veins. – An AV fistula uses your own arteries and veins – The AV graft can be used as soon as 2-4 without the need for artificial material. – AV fistulas provide good blood flow for dialysis, weeks after placement. increasing the effectiveness and reducing – AV graft surgery is usually done on an treatment time. outpatient basis, under local anesthetic, – The risk of clotting or infection is significantly allowing for a rapid and easy recovery. lower than with other forms of vascular accesses. – AV fistulas are often a solution for people who are thought to have exhausted permanent access sites. 19. Identify specific medications to be avoided in person’s with ESRD. Statins doses should be adjusted because of liver and diabetes conditions, NSAIDS, pain medications due to kidney clearances problems-can build up in blood to higher levels, kidney function should be evaluated before antibiotics, antivirals given, certain diabetes medications because of kidney clearance and antacid use due to electrolyte and acid-base balances. Always check with HCP first before taking any OTC medications. 20. Describe two advantages of CAPD. Done by the patient with infusion of 4- 2 liters of dansylate exchanges into peritoneal cavity. Dwells 4 to 8 hours and occurs 7 days a week. During the dwell time the patient can use a continuous connect system or disconnect for a later time. No machine or partner is required. 21. Name 3 common problems that can occur after dialysis treatments. Peritonitis, pain and infections. Other complications associated with HD include hypotension, muscle cramps, and blood loss. References ATI: RN Adult Medical-Surgical Nursing (2019). Ed. 11. Assessment Technology Institute, Chapter 57, pgs. 379-382. ATI: Nutrition for Nursing (2019). Assessment Technology Institute, Chapter 14: Renal Disorders, pg. 85.