Good day everyone, I am student nurse Christine Salimbagat, from MSU-IIT, and for today’s

simulation, I will be demonstrating a hemodialysis rotation and nursing management

particular to itching complication.

Without further ado, meet my patient, assuming that we have Mr. X here, 65 years old,
scheduled for hemodialysis today, received in a sitting position with an AV fistula access
placed on his upper right arm.

The first thing I’m going to do is explain the procedure to the patient
- Hello sir, kamusta man ka. Today, mag undergo ka ug dialysis, which is primarily
used to provide an artificial replacement for lost kidney function (renal replacement
therapy) due to renal failure
- dialysis works on the principles of diffusion of solute through a semipermeable
membrane that separates  two solutions, pamaagi saatong dialysis machine here
Before we start, I’m going to assess for:
- Weight to determine amount of fluid to be removed during dialysis
- Vital signs: BP for hypo and hypertension, Temperature for sepsis, respiration for
fluid overload
- We hold drugs that pass through the dialysis membrane even vitamins, and
antihypertensive drugs as ordered
Procedure proper
Set up the dialysis machine, according to protocol and manufacturer’s instruction
Do hand hygiene, don gloves, gown, masks and eye protection demonstrating appropriate use
of PPE

In accessing the fistula, assuming that the cannulation of the patient’s AV fistula, or insertion
is already done, where as we can see here, two needles are already inserted, site is cleaned
and secured, let’s proceed directly to the initiation of hemodialysis after assessing distal
portion extremity circulation, after we auscultate for bruit, and palpate for thrill

We started by having flush syringes, then attach to dialysis tubing.

Part of our assessment is to ensure the connection of tubing

We turn the dialyzer over and set the parameters on the heparin infusion pump as prescribed
We continue to assess the patient’s status and machine function throughout the treatment,
Remember that we already set the UF goal and treatment time, however: the patient now
complains of bilateral discontinuous itching 30 minutes after the initiation of hemodialysis

>>Here comes our complication Itching <<

Know that this itching, also called Pruritus is a distressing comorbidity found commonly in
patients with end-stage renal disease (ESRD), chronic kidney disease (CKD), and those on
dialysis
The pathogenesis has not been completely understood but here are the etiological factors that
are believed to contribute to uremic pruritus
- Immune Dysregulation, a systemic inflammatory disease
- Xerosis manifests as dry and scaly skin
- Hyperparathyroidism
- Uremic toxin accumulation
- Neural dysfunction
- Histamine mechanism
- Opioid mechanism
Assessment

- Generalized pruritus
- Duration of pruritus
- Character of pruritus (e.g. paroxysmal vs. continuous)
- Exacerbating and relieving factors
- Detailed drug history
- Treatments tried (prescription/over the counter, topical, oral etc.)
- Patient’s itching was persistent, recurrent and present over a wide area which was
discontinuous but bilaterally symmetric that may migrate over time. The itching was
persistent according to the pt, it was severe at night as compared to daytime, and was
aggravated by showering, dialysis, heat, stress, cold, and physical activity. He also has
a dry flaky skin. There are generally no primary skin lesions associated with pruritus,
but secondary lesions due to scratching are seen
Diagnosis
Impaired skin integrity
Planning
Our plan is of course to relieve the itching the patient experiences or at least ma manage for
us to conduct the hemodialysis appropriately. Patient will maintain intact skin integrity, and
will verbalize proper prevention of further injuries

Intervention

- 1. Adequate dialysis to regulate electrolyte levels

- 2. Lotions or medications for dry skin/allergies
- Ensure dialysis adequacy
- Consider heparin allergy (patient could be switched to Normal Saline flush)
- Considered changing dialyzer, tubing, dialysate (to ultra-pure dialysate fluid)
- Aggressive skin moisturization, since localized to a limited area of the skin, we
applied topical 10% urea plus dexpanthenol lotion which is effective in reducing
xerosis in dialyzed patients
- Neutral macroporous resin hemoperfusion (HP) was also used to treat maintenance
hemodialysis patients (MHD) with refractory uremic pruritus
- As per ordered, we administered 300 mg of gabapentin after the session to improve
ESRD pruritus
- Acupuncture, UVB phototherapy, and Opioid receptor modulator can also be
considered as indicated

-
- Educate because patient may be: (1) bothered by the appearance of skin, (2) frustrated
or annoyed by itching, (3) bothered by effects of itching on interactions or a desire to
interact with others, and (4) bothered by itching that it becomes hard to work
 - So: Bathing recommendations: Fragrance-free sensitive skin bar soap (i.e. Dove
sensitive skin® bar soap). Apply topical emollients such as fragrance-free emollient,
Baby oil, Menthol 0.25%/camphor 0.25% in emollient BID to TID and especially
after bathing; Limit use of soap to axillae and groin/perineum. Avoid excessive
bathing or bathing with hot water. Avoid wearing rough clothing, such as wool, over
itchy areas. Use mild detergent for clothes/sheets and rinse well. Keep fingernails
short and clean. Try not to rub or scratch the itchy areas. Keep your house cool and
humid. General idea:
- In addition to skin emollients, hydrating creams, and UV light therapy, proposed
medications have included antihistamines, gabapentin, pregabalin, and nalfurafine
- Particularly to this case, we educate the patient that “Sir, phosphorouse cause severe
itching and tissue calcifications, so take your phosphate binders as indicate by your
physician, and calcium should be more than 2,000 mg/day”

Evaluation

- We see to it that we are able to manage electrolytes especially phosphorous:  Often,

itching is caused by high blood levels of phosphorus. In your body, extra phosphorus
can bind with calcium and lead to feeling itchy.
- Patient state absence of itchiness na, or tolerable to continue the treatment
- Patient’s skin kay uniform in color sa the rest of the body, no redness, or even
swelling
- Patient verbalizes feeling of comfort, relaxed na siya, stable vital signs

Procedure proper – cont’n

- we set the arterial venous and dialysate pressure alarms to the maximum low and high
limits
- we turn off the TMP
- we turn the heparin infusion pump off
- we turn the blood pump off
- na work na nato iyang normal saline flush line
- We place a sterile barrier under the access and disconnect tubing
- We decannulate the AF fistula and importantly, sanitize the single patient machine
- Our post nursing dialysis care include
- Watching for bleeding
- Checking the pt’s weight and compare where the weight loss should be close to fluid
removal goal set during treatment
- Documenting unusual findings such as the pruritus or itchiness the patient has
experienced