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Starting indications
2 types of dialysis: 1. Hemodialysis-uses a special type of filter to remove excess waste products and water from the body. -three primary methods are used to gain access to the blood: intravenous catheter- sometimes called a CVC (Central Venous Catheter) -consists of a plastic catheter with two lumens (or occasionally two separate catheters) which is inserted into a large vein (usually the vena cava, via the internal jugular vein or the femoral vein) to allow large flows of blood to be withdrawn from one lumen, to returned via the other lumen. 2 types ofcatheter: - Non-tunnelled catheter access is for short-term access (up to about 10 days, but often for one dialysis session only), and the catheter emerges from the skin at the site of entry into the vein. - Tunnelled catheter access involves a longer catheter, which is tunnelled under the skin from the point of insertion in the vein to an exit site some distance away. It is usually placed in the internal jugular vein in the neck and the exit site is usually on the chest wall. The tunnel acts as a barrier to invading microbes, and as such, tunnelled catheters are designed for short- to medium-term access (weeks to months only), because infection is still a frequent problem.
FOR HEMODIALYSIS
Equipment and Procedures 1. Dialysis Machine The dialysis machine is about the size of a dishwasher. This machine has three main jobs: pump blood and watch flow for safety clean wastes from blood watch your blood pressure and the rate of fluid removal from your body
2. Dialyzer is a large canister containing thousands of small fibers through which your blood is passed. Dialysis solution, the cleansing fluid, is pumped around these fibers. The fibers allow wastes and extra fluids to pass from your blood into the solution, which carries them away. The dialyzer is sometimes called an artificial kidney.
Reuse. Your dialysis center may use the same dialyzer more than once for your treatments. Reuse is considered safe as long as the dialyzer is cleaned before each use. The dialyzer is tested each time to make sure it's still working, and it should never be used for anyone but you. Before each session, you should be sure that the dialyzer is labeled with your name and check to see that it has been cleaned, disinfected, and tested.
4. Needles Many people find the needle sticks to be one of the hardest parts of hemodialysis treatments. Most people, however, report getting used to them after a few sessions. If you find the needle insertion painful, an anesthetic cream or spray can be applied to the skin. The cream or spray will numb your skin briefly so you won't feel the needle. Most dialysis centers use two needles-one to carry blood to the dialyzer and one to return the cleaned blood to your body. Some specialized needles are designed with two openings for two-way flow of blood, but these needles are less efficient and require longer sessions. Needles for high-flux or high-efficiency dialysis need to be a little larger than those used with regular dialyzers.
Tests to See How Well Your Dialysis Is Working The doctor will order for a: Blood Urea Nitrogen or BUN Creatine clearance test
Procedure for hemodialysis 1. Patients circulation is accessed 2. Unless contraindicated, heparin is administered 3. Heparinized (heparin: natural clot preventer) blood flows through a semipermeable membrane in one direction 4. Dialysis solution surrounds the membranes and flows in the opposite direction 5. Dialysis solution is: a. Highly purified water b. Sodium, potassium, calcium, magnesium, chloride and dextrose c. Either bicarbonate or acetate, to maintain a proper pH 6. Via the process of diffusion, wastes are removed in the form of solutes (metabolic wastes, acid-base components and electrolytes) 7. Solute wastes can then be discarded or added to the blood 8. Ultrafiltration removes excess water from the blood 9. After cleansing, the blood returns to the client via the access Complications related to vascular access in Hemodialysis 1. Infection 2. Catheter clotting 3. Central venous thrombosis 4. Stenosis or thrombosis 5. Ischemia of the affected limb 6. Development of an aneurysm
2. Cerebral edema
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2. Potassium. The mineral potassium is found in many foods, especially fruits and vegetables To control potassium levels in your blood, avoid foods like oranges, bananas, tomatoes, potatoes, and dried fruits. 3. Phosphorus. The mineral phosphorus can weaken your bones and make your skin itch if you consume too much. Foods like milk and cheese, dried beans, peas, colas, nuts, and peanut butter are high in phosphorus and should be avoided. 4. Protein. Before you were on dialysis, your doctor may have told you to follow a lowprotein diet to preserve kidney function. Most people on dialysis are encouraged to eat as much high-quality protein as they can. Protein helps you keep muscle and repair tissue, but protein breaks down into urea (blood urea nitrogen, or BUN) in your body. Some sources of protein, called high-quality proteins, produce less waste than others. High-quality proteins come from meat, fish, poultry, and eggs. Getting most of your protein from these sources can reduce the amount of urea in your blood. 5. Supplements. Vitamins and minerals may be missing from your diet because you have to avoid so many foods. Dialysis also removes some vitamins from your body. Take your prescribed supplement after treatment on the days you have hemodialysis. Never take vitamins that you can buy off the store shelf, since they may contain vitamins or minerals that are harmful to you.
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Equipments of peritoneal dialysis : Dialysis solution - 2 liter bags (Stay-Safe solution with pre-attached tubing) Transfer set (if applicable) Stay-Safe Smart Cap (if applicable) Peritoneal Dialysis (PD) Flowsheet IV pole Stay-Safe Cap Stay-Safe organizer Peritoneal Dialysis Scale Mask Medication additive label (if applicable) CAPD warmer Betadine (if adding meds) Tubing to catheter adapter (if applicable; used if tubing brand differs from catheter brand. In emergency situations, adapters are also available in the Hemodialysis Unit.)
Procedure: 1. Obtain doctors orders for solution, additives, dwell time, drainage time, frequency of exchanges. Gather all supplies needed for the exchange. 2. Have patient empty bladder. If new onset of inability to void, notify doctor. 3. Place solution in CAPD warmer (37oC) to achieve body temperature. Place solution in the warmer 30 to 90 minutes prior to commencing procedure to assure optimum temperature of fluid (37o C). Use only dry heat to warm. Do NOT warm solution in the microwave. 4. If initiating dialysis for the first time, weigh patient prior to beginning CAPD exchange. For established dialysis patients, weigh patient after draining and before filling (dry weight) procedure. If daily weights are ordered, weigh at the same time each day after complete drainage. 5. Weight recorded must be a dry weight. 6. Assess abdomen for bowel distention, skin integrity and S/S of local infection. Notify doctor for any changes. With bowel distention there is an increased risk of bowel perforation. Local infections may be easily transmitted to the peritoneum via the catheter. 7. Obtain and record vital signs. INITIATION OF DIALYSIS: 1. Remove the appropriate dialysate bag from the CAPD warmer, and place it on a clean towel on the patients bedside table. The CAPD warmer is not always located in the patients room; some units have a designated location for the warmer. 2. A simple check should be made of the following points: a. Proper Dextrose strength and amount of solution b. Proper labelling; expiration date c. CAPD warmer temperature d. Level of solution in each bag/appearance of solution (clarity) e. Maintenance of aseptic technique
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Risks Many of the risks and side effects associated with dialysis are a combined result of both the treatment and the poor physical condition of the ESRD patient. Dialysis patients should always report side effects to their healthcare provider. Anemia -Hematocrit (Hct) levels, a measure of red blood cells, are typically low in ESRD patients. This deficiency is caused by a lack of the hormone erythropoietin, which is normally produced by the kidneys. The problem is elevated in hemodialysis patients, who may incur blood loss during hemodialysis treatments. Epoetin alfa, or EPO (sold under the trade name Epogen), a hormone therapy, and intravenous or oral iron supplements are used to manage anemia in dialysis patients. Cramps, nausea, vomiting, and headaches -Some hemodialysis patients experience cramps and flu-like symptoms during treatment. These can be caused by a number of factors, including the type of dialysate used, composition of the dialyzer membrane, water quality in the dialysis unit, and the ultrafiltration rate of the treatment. Adjustment of the dialysis prescription often helps alleviate many symptoms. Hypotension -Because of the stress placed on the cardiovascular system with regular hemodialysis treatments, patients are at risk for hypotension, a sudden drop in blood pressure. This can often be controlled by medication and adjustment of the patient's dialysis prescription. Infection Both hemodialysis and peritoneal dialysis patients are at risk for infection. Hemodialysis patients should keep their access sites clean and watch for signs of redness and warmth that could indicate infection. Peritoneal dialysis patients must follow the same precautions with their catheter. Peritonitis, an infection of the peritoneum, causes flu-like symptoms and can disrupt dialysis treatments if not caught early. Infectious diseases
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Test
What it Means
Normal Levels The normal serum creatinine range for men is 0.5-1.5 mg/dL. The normal range for women is 0.6-1.2 mg/dL.
Serum Creatinine Creatinine is a waste product that is made when your body breaks down protein you eat and when muscles are injured. A high serum (blood) creatinine level means kidney damage. Creatinine levels may vary somewhat, even when the kidneys work normally. So, your doctor should check your level more than once before diagnosing CKD. Creatinine levels tend to be higher in men and people with large muscles. Measuring creatinine is only the first step to finding your level of kidney function. Creatinine Clearance
Creatinine clearance is a test sometimes Normal creatinine clearance used to estimate filtering capacity of the for healthy men is 97-137 kidneys. The amount of creatinine in your mL/min. Normal creatinine urine is compared to the amount of clearance for healthy creatinine in your blood. Your doctor may women is 88-128 mL/min. test your urine by asking you to collect your urine for 24 hours in a special container. GFR is a more accurate way to measure how well your kidneys filter wastes from your blood. Your GFR gives your doctor an idea of the speed at which your kidneys are failing, and whether you are at risk for complications of kidney disease. GFR can be estimated from serum creatinine, using a formula. Healthy adults have a GFR of about 140*; normal is greater than 90. Children and the elderly usually have lower GFR levels. A GFR less than 15 is kidney failure. *GFR is reported in mL/min/1.73 m2.
Urine Albumin
Inside healthy kidneys, tiny filtering units In a 24-hour urine sample, a called nephrons filter out wastes but keep normal level is less than 30 in large molecules, like red blood cells and mg/day. albumin (protein). Some kidney diseases
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Measures of Anemia
Test Hematocrit
What it Means
Normal Levels
Hematocrit is the percentage of red blood cells in the The normal Hct level for blood, used to check for anemia. Anemiaa shortage of healthy individuals is 4017
SHEILA A. ARAO BSN- IV; SET-2 (Hct) oxygen-carrying red blood cellsoften begins at the early 50% for men and 36-44% stages of kidney disease. It causes severe fatigue, heart for women. damage, and other health problems. Anemia can be treated. Hemoglobin is the part of red blood cells that actually carries oxygen. Both hematocrit and hemoglobin levels are measured to check for anemia. The normal Hgb level for healthy individuals is 14 to 18 g/dL for men and 12 to 16 g/dL for women.
Hemoglobin (Hgb)
Test
What it Means
Normal Levels
Hemoglobin The HbA1c measures your blood sugar control over The goal is to keep your HbA1c A1c (HbA1c) the last 3 months. According to the National less than 6.5%. Diabetes Education Program, people with diabetes should have their HbA1c tested at least once every 6 months. Glucose Glucose is blood sugar. It is measured to determine if Normal (fasting) glucose levels your body is able to digest and use sugar and are 65-110 mg/dL. In people carbohydrates correctly. Although high blood glucose with diabetes, the blood levels are mainly found in diabetics, some glucose goal before eating is medications can raise your blood glucose level. 80-120 mg/dL. After eating, Diabetes is diagnosed if the non-fasting blood the blood glucose goal is 100glucose is higher than 200 mg/dL. 140 mg/dL.
Measures of Nutrition
What it Means The level of albumin (protein) in the blood is a measure of good nutrition. Research shows that people with kidney disease who become malnourished and do not get enough protein may suffer from many complications. It is especially important for people on low protein diets to have their serum protein levels measured.
Normal Levels Normal serum albumin levels in healthy people are 3.6-5.0 g/dL. The goal for people on dialysis is an albumin level greater than 4.0 g/dL