DIALYSIS

Definitions:- It is a process used to remove fluid and uremic waste products from the body when kidneys
cannot do so.

Or

It refers to the diffusion of solute molecules through a semi-permeable membrane, passing form higher
concentration to lower concentration.

BASIC GOALS:-

 To remove the end products of protein metabolism, such as urea and creatinine, from the blood.
 To maintain a safe concentration of serum electrolytes.
 To correct acidosis and replenish the bicarbonate levels of the blood.
 To remove access fluid from the body.
 To keep the client alive until a suitable donor is found.
 To maintain functions until the newly transplanted kidney starts functioning properly.

PRINCIPLES OF DIALYSIS:-

1. Ultrafiltration:- It refers to removal of fluid from blood using either osmotic or hydrostatic
pressure to produce the necessary gradient.
2. Diffusion:- It the process of passage of particles from an area of higher concentration to lower
concentration occurs through a semi-permeable membrane.
3. Osmosis:- It the process of passage of particles from an area of lower concentration to higher
concentration occurs through a semi-permeable membrane.

METHODS INCLUDE:-

1. Peritoneal Dialysis:-

 Intermittent peritoneal Dialysis.

 Intermittent peritoneal Dialysis.
 Continuous ambulatory peritoneal dialysis.
 Continuous cycling peritoneal dialysis.
 Automated peritoneal Dialysis.

2. Hemodialysis:-

3.Continuous Renal Replacement Therapies(CRRT).

HEMODIALYSIS

It is the process of cleansing the blood of accumulated wastes. It is the most commonly used method of
Dialysis. It is used for patients who are at ESRF or for acutely ill and require short term dialysis(days to
weeks).

PRINCIPLE:-

 Diffusion
 Osmosis

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  Ultrafilteration

PROCEDURE:-

The patient’s access is prepared and canulated.

Heparin is administered(unless contraindicated).

Heparinized blood flows through a semi-permeable dialyzer in one direction, and dialysis solution
surrounds the membranes and flow in the opposite direction.

Through the process of diffusion, solute in the form of electrolytes, metabolic waste products and acid-
base components can be removed or added to the blood.

Excess water is removed from the blood(ultrafiltration).

The blood is then returned to the body through the patient’s access.

REQUIREMENTS FOR HEMODIALYSIS:-

 Access to the patient’s circulation.

 Dialysis machine and dialyser with semipermeable membrane.
 Appropriate dialysate bath.
 Time- approximately 4 hours, 3 times weekly.
 Place- dialysis center or home (if feasible).

COMPONENTS TO DIALYSIS:-
There are three essential components to dialysis:

 The dialyzer
 The composition and delivery of the dialysate.
 The blood delivery system

1) THE DIALYZER :-The dialyzer consists of a plastic device with the facility to perfuse blood and
dialysate compartments at very high flow rates.
There are currently two geometric configurations for dialyzers: hollow fiber and flat plate.

These dialyzers are composed of bundles of capillary tubes through which blood circulates while
dialysate travels on the outside of the fiber bundle. In contrast, the less frequently utilized flat plate
dialyzers are composed of sandwiched sheets of membrane in a parallel plate configuration. The
advantage of the hollow fiber dialyser is easier reprocessing of the filter for reuse in future dialysis
treatments. Reprocessing and reuse of hemodialyzers are employed for patients on chronic hemodialysis
There are four categories of dialysis membranes:
 Cellulose
 Substituted cellulose

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 Cellulosynthetic and synthetic.

2) DIALYSATE:-
Dialysis in the Treatment of Renal Failure 1665
Composition of Commercial Dialysate for Hemodialysis is:-
Solute Bicarbonate Dialysate
Sodium (meq/L) 137–143
Potassium (meq/L) 0–4.0
Chloride (meq/L) 100–111
Calcium (meq/L) 0–3.5
Magnesium (meq/L) 0.75–1.5
Acetate (meq/L) 2.0–4.5
Bicarbonate (meq/L) 30–35
Glucose (g/L) 0–0.25

3)BLOOD DELIVERY SYSTEM The blood delivery system is composed of the extracorporeal circuit
in the dialysis machine and the dialysis access. The dialysis machine consists of a blood pump, dialysis
solution delivery system, and various safety monitors. The blood pump, using a
roller mechanism, moves blood from the access site, through the dialyzer, and back to the patient. The
blood flow rate may range from 250 to 500 mL/min.

DIALYSIS ACCESS The fistula, graft, or catheter through which blood is obtained for hemodialysis is
often referred to as a dialysis access. A native fistula created by the anastomosis of an artery to a vein.
This facilitates its subsequent use in the placement of large needles (typically 15 gauge) to access the
circulation.
METHODS OF CIRCULATORY ACCESS:-
1.Arteriovenous Fistula(AVF):- Creation of a vascular communication by suturing a vein directly to an
artery.
 Usually, radial artery and cephalic vein are anastmosed in non dominant arm
 After the procedure, the superficial venous system of the arm dilates.
 By means of two large-bore needle inserted into the dilated venous system, blood may be obtain
and passed through the dialyzer. The arterial end is used for arterial flow and the distal end for
reinfusion of dialyzed blood.
 Healing of AVF requires several weeks; a central vein catheter is used in the interim.
2. Arteriovenous graft –Arteriovenous connection consisting of a tube graft made from autologous
saphenous vein or from poly tetrafluoro ethylene . Ready to use in 2 to 3 weeks.

3. Central vein catheters- direct cannulation of vein (subclavin, internal jugular, femoral);
May be used as temporary or permanent dialysis access.

Complications of Vasular Access:-

1. Infection
2. Catheter clotting
3. Central vein thrombosis or stricture
4.Stenosis and thrombosis
5. Ischemia of the hand (steal syndrome)
6. Aneurysm or pseudo aneurysm.

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Hemolysis Schedule:- For ESRD patients continuous intermittent hemodialysis is used for life time
unless kidney transplantation is performed. A typical schedule is 3-4 hours of treatment 3 weeks apart.
This schedule varies with the size of client, the type of dialyser used, the rate of blood flow etc.

LIFE STYLE MANEGEMENT FOR CHRONIC HEMODIALYSIS:-

 Dietary management:- Restriction or adjustment of protein, sodium, potassium or fluid intake.

 Protein is restricted to 1g/kg of body weight.
 Sodium is restricted to 2-3g/kg.
 Fluids are restricted to an amount equal to daily urine output plus 500ml/day.
 Potassium is restricted to 1.5-2.5g/day.

PHARMACOLOGICAL THERAPY:- All medications( Antihypertensives, cardiac glycosides,

antibiotics, antiarrhythmic drugs)and their dosage must be carefully evaluated.

COMPLICATIONS :
 Hypotension
 Cramps
 Nausea and vomiting
 Back pain
 Itching
 Fever and chills.

PERITONEAL DIALYSIS

It is type of dialysis which involves repeated cycles of instilling dialysate into the peritoneal cavity,
allowing time for substance exchange an then removing the dialysate.

INDICATIONS:- The procedure is useful for

 ARF, ESRD and sever cardiovascular disease.
 To treat overdose of drugs and toxins

CONTRAINDICATIONS:-
 Hypercatabolism(uremic toxins are not cleared properly because of poor scarred condition of
peritoneal membrane)
 History of ruptured diverticula
 Abdominal disease
 Respiratory disease
 Peritonitis
 Abdominal malignancy
 Abdominal surgery

TYPES :-

1.Continuous ambulatory peritoneal dialysis(CAPD):- It is a form of intra corporeal dialysis that uses
the peritoneum for the semipermeable membrane.

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PROCEDURE:-

A permanent indwelling catheter is implanted into the peritoneum

A connecting tube is attached to the external end of the peritoneal catheter and the distal end of tube is
inserted into a sterile plastic bag of dialysate solution.

The dialysate bag is raised to shoulder level and infused by gravity into the peritoneal cavity

Typical dwell time is 4-6 hours

At the end of dwell time the drainage must be 2L plus ultrafiltration within 10-20 mins if the catheter is in
proper place.

After dialysate is drained, a fresh bag of dialysate solution is infused using aseptic techniques and the
procedure is repeated.

Patient performs 4-5 exchanges daily for a week.

COMPLICATIONS:-

 Infectious peritonitis
 Catheter malfunction, obstruction, dialysate leak.
 Hernia formation
 Distension
 Nausea
 Bleeding at catheter site

PATIENT EDUCATION:-

 Use strict technique when performing bag exchanges.

 Perform bag exchange in clean, closed-off area without pets etc.
 Inspect bag, tubing for defects and leaks
 Check weight because therapy cause weight gain.
 Report sign symptoms of peritonitis (cloudy peritoneal fluid, abdominal pain or tenderness,
malaise and fever).

2.CONTINUOUS CYCLIC PERITONEAL DIALYSIS:- In this type there are usually three cycles at
night and one cycle with an 8 hour dwell in the morning. The advantage of this procedure is that the
peritoneal catheter is opened only for the on-and-off procedures, which reduces the risk of infection.
Another advantage is that the client does not require exchanges at work or school.

3.INTERMITTENT PERITONEAL DIALYSIS:- Dialysis is performed for 10-14 hours, 3-4 times
/week.

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4.AUTOMATED PERITONEAL DIALYSIS:- It requires use of a peritoneal cycling machine. This
method can be performed as continuous cyclic, intermittent or nightly intermittent peritoneal dialysis.

5.NIGHT INTERMITTENT PERITONEAL DIALYSIS:- Dialysis is performed for 8-12 hours each
night with no daytime dwells.

PERITONEALCATHETER:- These are either acute catheters or chronic catheters:-

Acute catheter are used to perform acute continuous peritoneal dialysis, usually in an emergency setting
which have either one or two Dacron cuffs and are tunneled under the skin into the peritoneal cavity. An
acute catheter consists of a straight or slightly curved rigid tube with several holes at its distal end.
Catheters can be inserted at the bedside by making a small incision in the anterior abdominal wall; the
catheter is inserted with the assistance of a guide wire or stylet. Acute catheters are anchored externally
with adhesives or sutures and are usually reserved for temporary use because of the risk of infection,
which increases after 72 h of use.

Chronic catheters are flexible and made of silicon rubber with numerous side holes at the distal end.
These chronic catheters usually have two Dacron cuffs to promote fibroblast proliferation, granulation,
and invasion of the cuff. The scarring that occurs around the cuffs anchors the catheter and seals it from
bacteria tracking from the skin surface into the peritoneal cavity; it also prevents the external leakage of
fluid from the peritoneal cavity. The cuffs are placed in the preperitoneal plane and approximately 2 cm
from the skin surface. The most common chronic peritoneal dialysis catheter in use is the Tenckhoff
catheter.

Composition of Peritoneal Dialysate

Solute Dianeal (PD-2)
Sodium (meq/L) 132
Potassium (meq/L) 0
Chloride (meq/L) 96
Calcium (meq/L) 3.5
Magnesium (meq/L) 0.5
D,L-Lactate (meq/L) 40
Glucose (g%)
pH 5.2

CONTINUOUS RENAL REPLACEMENT THERAPY(CRRT)

These are various therapies that may be indicated for the patients who have acute or chronic renal failure.
These use extracorporeal blood circulation through a small-volume, low-resistance filter to provide
continuous removal of solutes and fluid in intensive care settings.

INDICATIONS:-
 Those who are too clinically unstable for traditional hemodialysis.
 Renal failure
 Pulmonary edema
 Cerebral edema
 Acute electrolyte disorders-metabolic crisis
 Septic shock

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TYPES:-
1.Continuous Arteriovenous Hemofiltration(CAVH):- Blood is circulated through a small-volume,
Low-resistance filter using the patient’s arterial pressure rather than that of the blood pump as is used in
hemodialysis. Blood flows from an artery to a hemofilter. After filtration the blood return to body through
vein.

2.Continuous Arteriovenous Hemodialysis(CAVHD):- It has many of the characteristics of CAVH but

offers the advantage of a concentration gradient for faster clearance of urea. This is accomplished by the
circulation of the dialysate on one side of a semi-permeable membrane.

3.Continuous Venovenous Hemofiltration(CVVH):- Here blood from a double-lumen venous catheter

is pumped through a hemofilter and returned to the patient through the same catheter. Here the filteration
occurs slowly so the hemodynamic effects are mild and better tolerated by patients with unstable
conditions.

4.Continuous Arteriovenous Hemodialysis(CVVHD):- It is similar to CVVH. Blood is pumped from a

double-lumen venous catheter through a hemofilter and returned to the patient through the same catheter.
Here concentration gradients are required to remove the uremic toxins. So no arterial access is required.

NURSING MANAGEMENT:-

Assessment:

 Assess the client for multiple effects of chronic renal disease on all body systems.
 Assess the clients understanding of his/her disease condition, diagnostic tests, treatment.
 Assess the client and family’s understanding about dialysis and diet management.
 Assess for any sign and symptom of complications.

NURSING DIAGNOSIS:-

1.Altered fluid volume(can be deficient or excess) related to impaired renal functions, fluid shift
between dialysate and blood.

Expected outcome:- Fluid balance will be achieved.

Interventions:-
 Monitor fluid volume status by daily weighting
 Monitor BP regularly
 Maintain input/output chart
 Follow the strict diet plan focusing on fluid restrictions

2. Imbalanced nutrition less than body requirement related to anorexia and nausea.

Expected outcome:- Adequate nutrition level will be maintained.

Interventions:-

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 Assess the clients status for persistant nausea and vomiting
 Help to stimulate client’s appetite
 Give dietary counseling to the client.
 Involve the client in planning his diet
 Give written diet plan to client
 Serve the diet attractively

3. Risk for impaired skin integrity related to edema, dry skin and pruritus.

Expected outcome:- Skin integrity will be maintained.

Interventions:-
 Assess the skin condition of the client.
 Assess the pressure site frequently.
 Avoid use of soap.
 Apply moisturizers to prevent dryness
 Teach the client about foot care etc

4. Risk for infections related to presence on indwelling catheter.

Expected outcome:- patient will be free from infections.

Interventions:-
 Check the vital signs of patient
 Check the insertion sight of catheter for presence of any redness etc
 Follow strict aseptic techniques
 Soak the catheter in disinfectant solution if it is needed next time.
 Change the dressings on time

BIBLIOGRAPHY

 Black JM, Howks JH. Medical Surgical Nursing. South Asia.ed.8 th.Pp.822-34.
 Brunner, Sidharth.Textbook of Medical Surgical Nursing. Lippincott William and
Wilkins.ed.10th.Pp.1285-1300.
 Lippincott. Manual of Nursing Practice. Jaypee Brothers Medical Publishers(p)Ltd.ed.8 th.Pp.752-
64.
 Burkart JM. Peritoneal dialysis in Brenner and Rector’s The Kidney. Saunders, 2004. ed.7th