Center for Studies and Support of Amyloidosis Hemodialysis Enf º Fábio Gonçalves INTRODUCTION Many people worldwide suffer

from a chronic kidney disease that causes loss of f unction of your kidneys. To survive all of them need some kind of renal replacem ent therapy. Currently there are only two methods of treatment for chronic renal failure, renal transplantation and dialysis. Dialysis is a physical process don e by ultrafiltration or diffusion through a semi-permeable membrane (selective b arrier that allows only the passage of some substances). There are two types of dialysis, peritoneal dialysis (peritoneal membrane) and hemodialysis (artificial membrane). In this paper, we discuss as a hemodialysis treatment and nursing ca re inherent to it. According to Phipps [et al.] (2003, p.1688), a hemodialysis " involves the diversion of blood from the patient's body into a dialyzer in which occurs the diffusion and ultrafiltration and then forward it to the circulation of the patient. "In addition to maintaining the life and well being of the dial ysis patient has four key objectives: Remove the blood end products of protein m etabolism such as urea and Creatine; Maintaining a safe concentration of serum e lectrolytes, correction of acidosis and refill the system blood bicarbonate buff er; Remove excess blood fluids. Hemodialysis is a process used in patients with acute illness and who require dialysis for a short period of time (days or weeks ), or in patients with chronic disease requiring prolonged treatment. Among the chronic renal failure approximately 95-98% undergo this treatment for this reaso n we will deepen this process. Hemodialysis allows for rapid and effective corre ction of uremia and acid-base imbalance of fluids and electrolytes. This process is extracorporeal circulation and blood, with the help of a pump, goes through a dialyzer - artificial membrane in contact with dialysate solution prepared in the machine promoted the blood filtration that after removal of toxic substances will return to the patient purified. The time required for dialysis is effectiv e depends on the patient's body and renal function still exists. The normal dura tion of hemodialysis is approximately 10-15 hours per week divided into three se ssions. The patient is always weighed before and after each treatment, so you ca n evaluate the weight gain between each dialysis and lost weight during it. Hemo dialysis as a treatment for irreversible renal failure should be continued inter mittently throughout the patient's life, except in case of successful renal tran splantation. 1 - DIALYSIS Dialysis is an alternative therapy used in patients with ESRD. This is nothing m ore than "a physical process by which the composition of a solute A is modified by exposure to a solute B, the solutions being separated by a semipermeable memb rane." (,) Despite the dialysis be performed with the aim of replacing kidney, t his is nevertheless an imperfect substitute, since it can not replace the hormon al function and metabolic activity of the same. Dialysis is divided into two typ es: peritoneal dialysis and hemodialysis. Peritoneal dialysis is a "process that is used in dialysis peritoneum as a semi-permeable membrane" 1.1 - HEMODIALYSIS Hemodialysis is the most widely used in developed countries and is a process whe re the patient's blood composition is altered by exposure to a dialysate solutio n which is separated by a semi-permeable membrane. Thus, there are two solutions on hemodialysis, the blood and dialysate, which are separated by a semipermeabl e membrane from dialysate. Between these two solutions are given for the exchang

e of blood and dialysate from dialysate into the blood, which allows blood to be free from substances in excess (urea, creatinine) and acquiring substances that are in deficit (calcium, bicarbonate) . The exchanges between blood and dialysa te are given by two mechanisms: diffusion and ultrafiltration. Diffusion is no m ore than the passage of solutes according to their concentration gradient. Thus, the solutes beyond the membrane, in order to strike a balance between their concentrations, that is beyond the membrane towar ds the more concentrated to less concentrated, so that both sides are equalized concentrations comas. It should be noted that the higher the molecular weight of solutes lower the rate of exchange and that the longer the two solutions are in contact the lower the spread, since the more time in contact€concentrations are more equalized, then trade will be lower. Ultrafiltration is a process where a solvent and solute u8m suffer a certain amount of pressure exerted by the opposi te direction of movement, leading to solute and solvent beyond the semi-permeabl e membrane. A relevant aspect is the fact that the greater the pressure the grea ter the amount of solution that will overcome the semi-permeable membrane. In he modialysis the blood pressure side is positive and will be about 50 and 100 mmHg , reaching up to 250 mmHg, while the dialysate side is negative-450mmHg. After t he physical principles of hemodialysis, it is pertinent to study components invo lved in this process being: • • The diaslisador The dialysis machine (monitor) w ith their bombs, blood lines, detectors, hemoglobin, air, monotorização of tempe rature and conductivity, alarms and automatic clamping in abnormal situations • The dialysate solution (water, bicarbonate and acid solution). 1.1.1 - Basics DIALYSIS A dialyzer is composed of two compartments separated by a semipermeable membrane into a compartment which circulates blood flow, while another runs the dialysat e. The dialyzer in practice corresponds to the glomeruli and renal tubes, being an essential component in the process of hemodialysis. The dialyzer is divided into three types according to their construction, namely: coils, plates or capillari es (most used). They must have: A high capacity clearance for substances of low and medium molecular weight A negligible loss of essential substances to the bod y's capacity to remove liquids easily adjustable to current clinical situations A small internal volume and low volume of residual blood from a high security op erational and a low reproducibility of results of interaction with the body (bio compatible) A low-cost reusable A potential Regarding the type of membrane can b e the source cellulose (cuprofano, hemofrano) or synthetic (polysulfone, polyami de) more biocompatible but also the most expensive. This must have an area under the patient's body surface area, an average of 0.8 m2 and should be as thin as possible since it will be easier the solutes pass through it, then the greater i ts ability depurativa. The agent esterelisante dialyzers should be used in the l east possible allergic and is normally used ethylene oxide, autoclave or gamma r ays. MONITOR It is a device with a set of devices whose function is to circulate the snag and the dialysate solution from each side of a semipermeable membrane of a dialyzer and control the parameters of this process. Monitor hemodialysis should conside r the existence of two independent circuits, the blood and sterile external and dialysate mostly internal. The blood circuit is divided into two lines: arterial and venous line. The arter ial line consists of the following components: pump blood - which works by a per

istaltic mechanism. It is comprised of rotating rollers that push the tubing by compressing the blood. The more are the rotations and size of the segment of the pump the greater the blood flow. Gauge pressure - to control the "suction press ure" and that vascular access is subjected. Massive infusion line - extension of the arterial line, which is put in a negative pressure zone, allows the adminis tration of sera with debts equal to the pump. One should not administer medicati on, since it might be dialyzed. Line infusion of heparin - arteiral line extensi on that is connected to a programmable infusion pump. Venous line consists of th e following components: Ampoule vein - formed by a cup adapted to a sensor (dete ctor of air) that retains the air at a higher level and detects the presence whe n entered into the system. In the upper sector of the bulb is the line that conn ects to monitor venous pressure and controlling it. This area is also the line o f management solutions potentially dialyzable (iron, antibiotics and hypertonic solutions). Clamp automatic - automatic device that works in harmony with the ai r detector and clamp circuit prevents the passage of air to the patient. The cir cuit dialysate theme function to prepare and monitor the dialysate solution in t erms of concentration, temperature, flow and pressure. Proportional pump - respo nsible for the proportional dilution of dialysate components - water,€solution a cid and bicarbonate control conductivity - measures the dilution carried out by dosing pumps heater / thermometer - responsible for controlling the temperature of the dialysate, which must fall between 35 º C and 42 C degasser - responsible for removing the solution dialyzing the air it dissolved Controller dialysate f low - responsible for controlling the flow of dialysate desired Hemoglobin detector - photoelectric cell that detects the presence of the solute effluent blood, evidence of rupture of the filter pressure and ultrafiltration Controller - responsible for the removal of liquids and dialyzable substance. An y of the blood lines have a "rubber" for administration of therapy - in the arte rial line if you want the product to work on the filter and patient (heparin), a nd venous line when pordutos are potentially dialyzable (hypertonic solutions, i ron and antibiotics). All circuit parameters of the blood, are presented and mon itored with alarms whose activation causes the stop of the pump, since the dialy sate circuit only occurs when the pump stops hemoglobin detector is activiated. All material used in the circuit of blood is unrecoverable because of circcuito of dialysate can be sterilized and used again. Dialysate The dialysate is an electrolyte solution with which the blood substance exchange during dialysis. This solution should have a composition that facilitates the t oxic chemicals in the blood are removed and that the solutes in the deficit even be reinstated. The dialysate should have a temperature identical to the human b ody, and each patient should be a specific dialysate, although the deficits in r enal failure are similar. Its composition should be highlighted the following: • • • Sodium: at concentrations of 138-140, aims and values of sodium in the bloo d of 130-140 (normalizes) Potassium in concentrations of 2-4, is intended to val ues potassium in the blood ranges of 4.5-6.5 (low) Calcium in concentrations of 2-3, 5; aims and values of calcium in the blood of 2, 4-4 (normalizes). The solutes produced either industrially or in central distributor of solutes ca n be modified by adding substances necessary to the patient (bathing corrected). As mentioned earlier, the "bath" is the solution resulting from mixing of treat ed water, acidic solution (acid), bicarbonate solid BiBag). 1.1.2 - Access to the vascular access blood flow in hemodialysis patients can be accomplished in five different ways, such as: • Arteriovenous fistula (Fig. 1) • arteriovenous graft (Fig. 2) • external arteriovenous shunt (Fig. 3) • Cathete rization of the femoral vein (Fig. 4) • Catheterization of the subclavian vein ( Fig. 5) arteriovenous fistula (see fig. 1) takes place through a surgery that al lows permanent access, creating a communication of an artery with a peripheral v

ein, leaving it with a greater flow, pressure and dilation. The location will be the non-dominant upper limb at the radial artery and vein, when this location i s not possible to decide by the ulnar artery, or a humeral vein near. The matura tion of the fistula takes on average 3-4 weeks, the patient should be encouraged to perform exercises for its development. The permanent access, such as arterio venous fistula and the graft may cause complications, Fig 1 arteriovenous fistulas particularly early (bleeding, infection and thrombosis) and late (thrombosis, in fection, reduction of debt, aneurisms and edema). The arteriovenous graft (see f ig.2) is used when lack of suitable vein. It is performed by anastomosis of an a rtery with a vein through a subcutaneous implant of the patient's own vein (graf t) or by synthetic graft. You can take the form straight or semicircular loop, l eaving to puncture a zone 10-15 cm. The external arteriovenous shunt is used as a long-term vascular access, and can be used immediately. When hemodialysis is p erformed, the connector between the tube and the venous blood is removed and the tube is connected to the dialysis machine (arterial line and venous line). used in emergency situations, while awaiting the completion or maturation of an arte riovenous fistula and when it is not possible to build the same catheterization is performed by two-way (outbound and return) identified by different colors red and blue respectively . Veins chosen for catheterization are usually the intern al jugular, the subclavian (see fig. 5) and less frequently used are the femur ( see fig. 6).€In some cases try to use central venous catheterization of long dur ation, who have special physical characteristics, more flexible, with a life spa n greater and with less risk of infection. Fig 6 subclavian vein catheterization Fig. 5 femoral vein catheterization Fig. 3 external arteriovenous shunt Arteriovenous Graft Fig. 2 The temporary vascular access is via central venous catheterization is 1.1.3 - Advantages / Disadvantages Advantages: • The treatment is performed by a team of trained professionals • Th e procedure is relatively fast (lasts 2-4 hours), conducted in a safe and effect ive for the removal of toxic substances and excess water; • Contact social regul ar in the unit; • Treatment performed three times per week; • Access to permanen t internal Arteriovenous Fistula; • Dialysis controlled and monitored weekly by the medical staff and clinic; • Equipment safer and automated controls to provid e a dialysis efficiently and with less complications. Disadvantages: • Schedule fixed treatment; • Requires shift three times a week at dialysis center; • Diet limited intake of foods and liquids; • Dialysis more aggressive, and may present clinical complications; • Period between dialysis with limited displacement, tr ips and tours; • Requires use of needles for six weeks to make Hemodialysis; • R equires use of anticoagulant heparin during hemodialysis session was to prevent extracorporeal blood clotting; • Greater exposure to blood loss, due to retentio n the dialyzer, and punch lines; • Risk of viral infections such as hepatitis. 1.1.4 - Complications of hemodialysis Hemodialysis is now a sufficiently safe th erapeutic modality. However, despite its relative safety, hemodialysis may be ac companied by potentially serious complications and may even be fatal. In turn, t hese problems can be avoided or minimized if properly followed the guidelines on fluid intake, diet and medication. Then we will briefly address the complicatio ns that may occur during, after and at any time of hemodialysis. Complications d uring dialysis hypotension • It is one of the most frequent complications during dialysis. This is due to hyp ovolemia or excessive ultrafiltration, because if the liquid and the waste is re moved too quickly, the blood pressure may decrease. It can also occur due to the use of dialysate with acetate. • Muscle cramps

Rapid removal of fluid during dialysis may cause cramps in the legs. • Headache It appears occasionally at the end of dialysis session, due to changes in levels of removal of liquids and toxic substances. • Hyperthermia Can result from infection, endotoxemia, damage control system has a temperature of dialysate or anaphylactoid hypersensitivity reaction. • Syndrome imbalance Due to acute alteration of the nervous system, characterized by nausea, vomiting , headache, confusion, coma and convulsions. Prevents high balances to avoid during dialysis in patients with severe metaboli c acidosis, hypernatremia and azotemia. • • Chest pain Hemolysis It is a rare complication, usually attributed to breakdowns in the equipment (eg dialysis solutes heated excessively, use of high negative pressures in the extr acorporeal circuit) • gas embolism This occurred most often when the air was used to transfer blood from the dialyz er to the patient. • Hypercalcemia Arises due to the use of water containing large amounts of calcium, with or with out magnesium in the dialysis liquid. • Hemorrhage These are caused by excess heparin, rupture of blood vessels and rupture of memb rane dialysis. Complications after dialysis • hypertension In this case the hypertension may be due to inadequate ultrafiltration during di alysis, dialysis disequilibrium, removing excess liquid • Hypotension Arises due to excessive ultrafiltration. • Edema After dialysis, the swelling reflects an inadequate ultrafiltration. • Spontaneo us bleeding Hemodialysis patients are systematically heparinized and duration of anticoagula tion following dialysis is quite variable. Therefore, all these patients at risk of bleeding complications. Other complications that can occur at any time • Anemia May be caused by hematogenous accelerated loss (for hemolysis and bleeding) diso rder and erythropoietin production, resulting in sleeplessness, fatigue and pers istent malaise. • arteriosclerotic cardiovascular disease This complication is very common in dialysis patients for long periods of time a nd may lead to death. These diseases are due either to vascular risk factors pre viously existing, or the specific risk factors of chronic renal failure or its t reatment. • Neurological problems In this type of problem occurs Peripheral neuropathy, Seizures Myoclonic and dep ressions. Early diagnosis is very important, since patients can become suicidal

and hypo-active. It is occasionally necessary to transfer the patient to a place where there are special and may require psychiatric intervention. • Itch It is a common complaint in dialysis patients. Many have skin surf, which exacer bates the problem and can be treated with creams or bath emollients. • Sexual dy sfunction The azospermia variables and sexual impotence in men are common components of ur emia. In women, despite regularize menstruation with adequate dialysis, pregnanc y is very rare. There may be return of fertility after transplantation. • Recurr ing The patient is more susceptible to infections, since there are exposition of blo ods products and foreign matter. It can also occur in the area of local infectio n in the shunt and fistula. • Chronic Ascites May be due to fluid overload associated with congestive heart failure, malnutrit ion (hypoalbuminemia) and inadequate dialysis. • Bone problems In this kind of complication can consider osteoarthritis, which produces pain an d bone fractures, aseptic necrosis of the hip and vascular calcification. 2 - NURSING CARE OF THE SICK undergoing dialysis According to Phipps [et al.] (2003, p. 1706), "one of the most important aspects of nursing care is to provide an opportunity for the patient and family talk ab out their feelings. Thoughts related to death and concern about the treatments c an produce considerable anxiety. "The nursing intervention in patients undergoin g hemodialysis goes far beyond the care provided at the meeting. Many people nee d help to maintain electrolyte balance, prevent injuries, among other things. 2.1 - Hemodialytic Treatment Upon treatment with hemodialysis, it is essential to fulfillment of certain proc edures in order to avoid complications such as contamination or cross-infection. Nursing care to be taken at the beginning of treatment are: • • • • • • • • Was h your hands, place the gloves; evaluate the patient according to the procedure, take samples of blood, if necessary; Draw and fill the extension of the needle "venous" blood. Inject slowly about half the initial bolus of serum heparinisado ; Proceed likewise with needle "blood" Proceed to connect the line "blood" Ensur e the security of the connection; • Connect to pump the blood, setting the speed at approximately 160 mL / min, to p revent hypotension and to allow physiological adaptation to hemodynamic changes; • Observe carefully monitor parameters and signs and symptoms of the patient durin g the procedure to avoid hypotension due to the inevitable exit of blood; • Stop the blood pump where there is the beginning of the blood in the distal part of the line "venous" in order to avoid unnecessary loss of blood;

• • • • Setting the monitor as dialysis prescription to ensure the quality of treatment; To ask about the presence of exaggerated amounts of interdialytic weight gain; Actuate ultrafiltration in order to avoid loss of time; Operate the pump of hepa rin, previously prepared with maintenance dose prescribed by programming it to c omplete the administration 30 minutes before the end of treatment. Thus it avoid s the hypocoagulation extemporaneous; • • Adapting the punch to the syringe holding it protected and ready to be used in f inishing treatment to avoid infection; Promote storage and perfect packing all t he stuff that should be on the top surface of minitor. The care of the end of treatment are: • • • • • Put new pair of gloves; Make sur e that there are at least 300 mL of saline; Fill the syringe with saline; Check the beginning of the return of blood ; clamping the beginning of the line "blood " and the extension of the needle "blood." Proceed with the disconnection and sc rew the end of "blood" to the punch inserted into the bottle of saline; • Set th e speed of return between 160-180 mL / min (depending on the patient's body volu me); • During reinfusion note: adverse symptoms underload water, hypotension, air emb olism, such as breathlessness, headache, sudurese, sudden cough, confusion, etc. Staining of the mixture blood / saline solution in the extracorporeal circuit , mainly in chamber vein. This requires avoiding excessive infusion of saline an d avoid minimal loss of blood; Quantity of saline infusion; venous pressure; • • • • Mild and intermittently clamp the arterial line, allowing for minimal loss of bl ood and an excessive infusion of saline; Prepare the blood pump and disconnect t he line "vein" of the extension of the needle "venous" Connect the ends of lines to extensions of translators of arterial and venous pressure circuit; If a pati ent is autonomous in the process of haemostasis: Remove the needles (the first "blood") without changing the angle or direction of them, putting two tampons i n their respective puncture sites; Put the needles in a visible place; Remov e the connectors bathroom by putting them in their respective receptacles of the monitor. Plug the holes in the dialyzer with initial caps; Start program indi cated chemical disinfection for the monitor to avoid cross-infection. • • If the patient is not autonomous for hemostasis should be done to promote or aid ; Complete haemostasis, put a towel or a compress Locle in each of the puncture. To assess blood pressure, pulse and provide the proper weighing of the patient making their records. 2.2 - PREVENTION OF INFECTIONS AND INJURIES Extensive lesions in the tissues can cause an elevation in serum potassium shoul d therefore be avoided, since this type of injury can release the systemic level , a lethal amount of cation, for a person with Chronic Kidney Disease. One of th e nursing interventions useful in these patients consists of helping patients to control blood loss. So it should be recommended to use a soft toothbrush, and t each the patient to comply with the curls and notify without delay a doctor. Asp

irin should be avoided because it is normally excreted by the kidneys, which is now running poorly, can reach toxic levels and prolong bleeding time. The patien t should be alerted to the fact that the accumulation of liquids and hypertensio n, can cause disturbances in vision. These patients should avoid contact with ot her patients with infections and should avoid fatigue, which reduced the body's defenses. In the case of signs of infection appear should be addressed as soon a s possible to the doctor. 2.3 - MEDICATION The vast majority of people on dialysis, permanently taking dru gs, that help to ensure an overall well-being, concomitantly with dialysis. It i s the responsibility of nursing during the dialysis sessions, to prepare, admini ster and record the prescribed medication, taking the following precautions: 1. Check the expiration date and state of the medication, 2. Preparing the medicati on according to prescribed doses, 3. Administer medication according to the prot ocol of the Centre or clinical indications; 4. Monitor the patient's condition, prevent complications such as adverse reacti ons and to the emergence of these and alert the physician to act as shown in thi s 5. Register on the sheet of dialysis the drug, dose and time of administration . The following table lists the medications that are necessary to administer dur ing a hemodialysis session. It should be noted the important role of the nurse i n the preparation, administration of these drugs, and in patient management, and provide / anticipate possible complications. Heparin Drug Administration indica tions Maintenance - during treatment, diluted in SF. Via IV or SC at the end of treatment Home prevent blood clotting - to begin treatment in the extracorporeal circuit. Erythropoietin calcitriol Vancomycin Treatment of anemia Treatment of hyperthyroidism at the end of the syringe in hemodialysis secondary to CRF. appropriate. As a preventive measure in diluted in 100 cc of SF, in the last hour treatment of infections. hemodialysis, in slow infusion. Vaccine Hepatitis Preve ntion of Hepatitis B (if intramuscularly at the end of hemodialysis B Engerix "n ecessary). Table 1 - Drugs administered in the hemodialysis session For these drugs, there are others that should be administered by the patient in his home and is therefore the responsibility of meeting the same regimen. Howeve r, it is to do a school nurse and to take proper control of them. Accordingly,€h ow the drugs most commonly used are: Diuretics: may be used initially to stimula te the renal excretion of water. As renal failure progresses, it becomes necessa ry to restrict fluid intake. Aluminum hydroxide: the purpose of this product is to avoid deposits of calcium and phosphorus in soft tissues and thus avoid a series of complications, and Vit amins: some vitamins are lost during dialysis, so the level should be replaced b y the intake of this type medicines; Resónio (resin)-exchange potassium: this du st joins the intestine to potassium, thus preventing it moves into the blood. Th e resulting product is eliminated in feces, Iron: many patients on hemodialysis with anemia, to improve iron is often administered, this drug can be taken orall y or during dialysis then dissolved in serum; Blood-: patients with hypertension , not low after the hemodialysis session, will require medication to achieve thi s. Any of these medicines taken without medical supervision, can have disastrous effects, so it is imperative that medical surveillance of these patients. Much

more can still be dangerous to take other medications such as antibiotics or pai nkillers, even aspirin, without medical advice. A simple syrup can have bad effe cts, because it may contain too much potassium. 2.4 - NUTRITION OF THE DIALYSIS PATIENT In patients undergoing hemodialysis are no studies that confirm the high inciden ce of caloric and protein malnutrition. Barbas (,) gives that "one third of adul ts on hemodialysis show signs of severe protein-calorie malnutrition." The fact that dietary factors are directly related to morbidity and mortality of dialysis patients and their quality and rehabilitation, a careful evaluation nutrition b y qualified personnel is very important. According to the same author (,) a nutritional assessment is difficult to charac terize because "many of its manifestations are subtle and in many cases only som e nutritional parameters are altered at any given time." For this evaluation sho uld be used methods and parameters, which then, according beards, must be adapte d to the dialysis patient, such as: • History and clinical examination: the hist ory of nursing sensitive data such as alcoholism, diabetes, depression can be di scovered. The use of drugs prescribed to the patient undergoing hemodialysis may cause nausea, constipation, anorexia, etc.. The dietitian plays a central role in collecting data for the dietary history. • Kinetics of urea and PCR: lets you tailor the dose and dialysis. The PCR determines the daily intake of protein, t hrough a variety of blood samples and correct calculations. Normal values of CRP are between 1.2 and 1.3. • Anthropometric measurements: it is a quick and easy method in the evaluation of the deposits of protein and fat. Body fat is assesse d by measuring skin fold in the sub-scapular region with the circumference of th e area's media arm. • Serum proteins and amino acids: serum proteins have been s tudied as markers of nutritional status since these are reduced when the protein deposits are reduced. Serum albumin and transferrin are the most used. However, the first due to its long half-life (20 days) and due to the large capacity of the liver to synthesize only very late, appears diminished. As for the transferr in their interpretation is difficult since the iron status and administration of recombinant human erythropoietin leading independent changes in nutritional sta tus. • • Hormones and growth factors: when the growth hormone (GH) is reduced is indicative of malnutrition. Cholesterol: decreased levels of plasma cholesterol are a benchmark of malnutrition and is directly related to the mortality rate o f dialysis. 2.4.1 - Causes of malnutrition There are numerous causes that underlie magnet malnutrition by a dialysis patien t. According to Beard (,) the most common causes are "residual uremic symptoms, dietary restrictions and socio-economic problems," they are directly related to a lower-protein calorie intake needed. Intercurrent illness, the loss of vascula r access, gastrointestinal diseases, depression is aggravating factors of anorex ia. For the same author (,) insulin resistance "has long known effects on glucos e and lipid metabolism, while its effect on protein metabolism has only recently been identified and characterized.€Anemia facilitates malnutrition by decreasin g the apatite, the ability to exercise and wellness. Intradialytic losses which includes water-soluble vitamins that in combination with a low dietary intake co ntributes to a deficit if no prescription vitamin supplements suitable. Barbas g ives (,), in addition, the dialysis itself, has been proven as a cause of malnut rition by the "contact established between blood and dialysis membranes and bath , induces increased protein catabolism. This effect is greater the less they are biocompatible membranes for dialysis and bath ... " 2.4.2 - Correction of malnutrition For Barbas (, p.1869), in order to compensate for the loss of hypercatabolism protein and amino acids during the dialysis ses sions, patients should, "ingest 1.0 to 1.2 g protein / kg bw / day and 35Kcal/Kg weight / day. "All this must suffer through a vigilance of food surveys and est imations of PCR. Towards the maintenance of an adequate food supply may be neces

sary oral or parenteral dietary supplements. Anemia and other disturbances have to be treated, including depression is very common in these patients. In cases o f low levels of GH (growth hormone) that is available in recombinant human form. 2.4.3 - Proper nutrition diet There is no universal, specific to this patient po pulation, it is formulated by the dietitian or doctor, according to the same die tary habits and their socio-economic conditions. The main diet of the dialysis p atient is moderation in the water and restriction of potassium and sodium. • Wat er (liquid) A session between a patient and one should not increase more than tw o pounds. All that is greater than can be related to the presence of edema, are you going to lead to weight gain than expected which leads to increased blood pr essure. In order to counteract this, the patient should eat roughly the same amo unt of fluid removed. • Potassium Due to the fact that a toxic substance that ca n dwarf the kidneys eliminate potassium intake should be restricted. Fruit and v egetables are the foods richest in potassium, soon to be avoided. The patient sh ould not eat more than two pieces of fruit daily and avoid melons, bananas, grap es, figs, peach and passion fruit. Should never eat yogurt and pieces because th ey are a rich source of calcium. The patient should not consume meat Young (veal and chicken) and beef fat because they are rich in potassium. Should avoid cook ies and similar for which you have doubts as to its composition. In foods that b elong to the group of carbohydrates and high in potassium, the waters are baking more diverse, less the amount of potassium they have. • Sodium There must be a severe restriction not only by direct action in hypertension, but the sensation of thirst because forcing the patient to drink more fluids. In the preparation of food should be avoided salt use, and should avoid foods hi gh as the same. Olives, sausage, smoked sausage, etc.. • Protein is not recommen ded a restriction of total protein, nannies alert to excessive consumption, resu lting in products that are eliminated in hemodialysis: urea, creatimina, phospho rus. Should always prefer the proteins of plant origin. Canned, cured meats, org ans, offal and shellfish are rich in protein soon be consumed in moderation. The re are some advice that nurses can provide the patient and which are very import ant with these: • • • • • Read food labels properly, Avoid pre-prepared food, du e to high sodium content; not eat in places where there may purchase food withou t salt; Try replacing the salt with herbs, garlic, olive oil and lemon juice; Ea t fruits or vegetables within the orders of the dietitian. 2.5 - maintain the fluid balance For the water balance, it is the role of the nurse to perform the following nurs ing actions: • • • • Identify signs of imbalance, Drinking in the amounts prescr ibed; Eat within limits; control weight; 2.6 - PROMOTING COMFORT, REST AND SLEEP How many steps to control the itching is required: • • • • Keep the skin hydrate d, avoid excessive heat; Bath emollients; Keep nails trimmed and arranged. As for the cramps, they are very widespread in both legs or hands and are relate d to sodium depletion. To this end, effective measures are temporary application of heat. With regard to insomnia and chronic fatigue is key: • • • • Rest perio ds during the day;€Baths of warm water before going to sleep; Perform relaxing a ctivities one or two hours before bedtime; Perform relaxation techniques. 2.7 - TEACHING THE PATIENT AND FAMILY It is the responsibility of the nurse to clarify any doubts either the patient o r to his family, performing teachings about • • • • • • • • Relationship between symptoms and causes; relationship between diet, fluid restriction, medication a nd blood biochemical values ; preventive health care, diet, including fluid rest

riction; Assessment of excess fluid; Medication; Planning for the gradual increa se in physical exercise; Measures to control itching; • Planning health care continuum. 3 - CONCLUSION In this work we conclude that patients undergoing hemodialysis, patients are ext remely fragile. To hold a session of hemodialysis vascular access has to be foun d in good condition and works because it is through him that the blood circulate s between the body-machine. Accesses can be catheters, arteriovenous fistulas, a rteriovenous graft, shunt externaarteriovenosa, femoral vein catheterization and subclavian. Upon treatment with hemodialysis, it is essential to fulfillment of certain procedures in order to avoid complications such as contamination or cro ss-infection. Nursing care procedures are intended not only to have the beginnin g and end of treatment, as well as teaching the patient to allow a good continui ty of care. Thus, as regards the education sessions, the nurse should alert the patient to the care they should have with the vascular access, with its power (r estricted to liquids and without sodium and potassium), and be alert for possibl e complications that might occur in long, medium and short term. Finally we conc lude that chronic renal failure patients suffer from psychological problems due to the impact of the disease lead to the destruction of the ego and the patient put under intense mental and emotional stress. We as nurses must be vigilant and help the patient to prevent the onset of depression, conflict, dependence - ind ependence, anxiety, suicidal behaviors, denial and stress by dietary restriction s.