Renal Replacement Therapy PDF

Adult Nursing Hinkle, J. L., & Cheever, K. H. (2022). Brunner and Suddarth’s textbook of medical-surgical nursing. Wolters kluwer india Pvt Ltd. Renal Replacement Therapy Lecturer: Dr. Mohammad Mahdi Saeed Learning Outcomes: What are renal replacement therapy Types of renal replacement therapy Indic...

Adult Nursing Hinkle, J. L., & Cheever, K. H. (2022). Brunner and Suddarth’s textbook of medical-surgical nursing. Wolters kluwer india Pvt Ltd. Renal Replacement Therapy Lecturer: Dr. Mohammad Mahdi Saeed Learning Outcomes: What are renal replacement therapy Types of renal replacement therapy Indications, contraindications of renal replacement therapy Advantages and disadvantages of renal replacement therapy Important points concerning HD, and PD Complications 1 Renal Replacement Therapy The use of RRT becomes necessary when the kidneys can no longer remove wastes, maintain electrolytes, and regulate fluid balance. Dialysis Types of dialysis include HD, CRRT, and PD. Acute or urgent dialysis is indicated when there is a high and increasing level of serum potassium, fluid overload, or impending pulmonary edema, increasing acidosis, pericarditis, and advanced uremia. It may also be used to remove medications or toxins (poisoning or medication overdose) from the blood or for edema or hypertension that does not respond to other treatment, and hyperkalemia. Chronic or maintenance dialysis is indicated in advanced CKD and ESKD in the following instances: the presence of uremic signs and symptoms affecting all body systems (nausea and vomiting, severe anorexia, increasing lethargy, mental confusion), hyperkalemia, fluid overload not responsive to diuretics and fluid restriction, and a general lack of well-being. An urgent indication for dialysis in patients with kidney disease is pericardial friction rub, which is indicative of uremic pericarditis. Hemodialysis (HD) HD is used for patients who are acutely ill and require short-term dialysis for days to weeks until kidney function resumes, as in patients with AKI, and for patients with advanced CKD and ESKD who require long-term or permanent RRT. HD prevents death but does not cure kidney disease and does not compensate for the loss of endocrine or metabolic activities of the kidneys. Approximately 62.7% of patients requiring long-term RRT are on chronic HD (USRDS, 2019). Most patients receive intermittent HD that involves treatments three times a week with an average treatment duration of 3 to 4 hours in an outpatient setting. HD can also be performed at home by the patient and a caregiver. See later discussion on home HD. Dialyzer 2 (Also referred to as an artificial kidney) is a synthetic semipermeable membrane through which blood is filtered to remove uremic toxins and a desired amount of fluid. Dialysate It is a solution that circulates through the dialyzer, made up of all the electrolytes in their ideal extracellular concentrations. Diffusion, Osmosis, and Ultrafiltration The toxins and wastes in the blood are removed by diffusion. Excess fluid is removed from the blood by osmosis, In ultrafiltration, fluid moves under high pressure to an area of lower pressure. This process is much more efficient than osmosis for fluid removal and is accomplished by applying negative pressure (a suctioning-type force) to the dialysis membrane. Because patients with ESKD requiring dialysis usually cannot excrete enough water. The anticoagulant heparin is given to keep blood from clotting in the extracorporeal dialysis circuit. Vascular Access 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 the rapid rates of 300 and 500 mL/min. Immediate access to the patient’s circulation for acute HD is achieved by inserting a double-lumen, noncuffed, large-bore catheter into the right or left internal jugular or femoral vein of either leg. The subclavian vein is rarely used as there is an increased risk for central stenosis. This method of vascular access involves some risk (e.g., hematoma, bleeding, pneumothorax, infection, thrombosis of the vein, inadequate flow). The preferred method of permanent vascular access for dialysis is an arteriovenous fistula (AVF) that is created surgically (usually in the forearm) by anastomosing (joining) an artery to a vein, either side to side or end to side. 3 Complications Cardiovascular diseases are the leading cause of death in patients on HD. Phosphorus deposits in the skin can occur and cause itching. Important Notes  Medications that are water soluble are readily removed during HD treatment, and those that are fat soluble or adhere to other substances (like albumin) are not dialyzed out very well. This is the reason some drug overdoses are treated with emergency HD and others are not. Many medications that are taken once daily should be administered after the dialysis treatment. Protein 1.2 g / kg/ day....... fluid 1000 – 1500 and according to output. 4 Peritoneal Dialysis In PD, the peritoneal membrane that covers the abdominal organs and lines the abdominal wall serves as the semipermeable membrane. Sterile dialysate fluid, containing dextrose and electrolytes, is introduced into the peritoneal cavity through an abdominal catheter at established 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 of these solutes occurs as waste products move from an area of higher concentration (the bloodstream) to an area of lesser concentration (the dialysate fluid) through a semipermeable membrane (the peritoneum). This movement of solute from the blood into the dialysate fluid is called clearance. 5 Important Notes  Aseptic technique is the best the nurse can do to prevent infection.  Most adult catheters have 2 cuffs made of Dacron polyester. The cuffs stabilize the catheter, limit movement, prevent leaks, and provide a barrier against microorganisms.  The number of cycles or exchanges and their frequency are prescribed based on monthly laboratory values and the presence of uremic symptoms. Advantages Freedom from a hemodialysis (HD) machine More control over daily activities Opportunities to eat a more liberal diet than allowed with HD; usually increased fluid allowance; improved serum hematocrit values; improved blood pressure control; avoidance of venipuncture; and improved sense of well-being. Disadvantages Need for dialysis 7 days a week Dietary alterations related to protein and potassium losses. Patients may be encouraged to increase the intake of protein and potassium in the diet due to these losses with PD fluid exchanges. Complications 1. Acute complications: Peritonitis, leakage, bleeding 2. Long term complications: Cardiovascular diseases, hernia, The Procedure Indications for acute intermittent PD, a variation of PD, include uremic signs and symptoms (nausea, vomiting, fatigue, altered mental status), fluid overload, acidosis, and 6 hyperkalemia. Although PD is not as efficient as HD in removing solute and fluid, it permits a more gradual change in the patient’s fluid volume status and in waste product removal. Therefore, it may be the treatment of choice for the patient who is hemodynamically unstable. It can be carried out manually (the nurse warms and hangs each container of dialysate) or by a cycler machine. Exchange times range from 30 minutes to 2 hours. One example of a routine is hourly exchanges consisting of a 10-minute infusion, a 30-minute dwell time, and a 20-minute drain time. Acute intermittent PD is not indicated for long-term patient management, but for specific situations such as patients who are referred late in the course of CKD (CKD stage 5) and require immediate dialysis. 7