HEMODIALYSIS (HD) AND PERITONEAL DIALYSIS (PD)

OVERVIEW

The module provides an overview of the kidney functions as well as the

physiology of urine formation. It focuses on concepts related to dialysis treatment of
patients with chronic kidney disease to support the learning needs of the nursing
students on how to care for patients undergoing hemodialysis, peritoneal dialysis or
CRRT.

LEARNING OUTCOMES

After the successful completion of the module, you should be able to:

1. Describe the process of Hemodialysis and Peritoneal dialysis and how it works to
filter blood.
2. List three types of vascular access for Hemodialysis.
3. Describe the complications of dialysis, how to prevent them & how to detect
them.
4. Differentiate between Peritoneal and Hemodialysis
5. Identify the roles and duties of a nurse in this area.
6. Discuss nursing care and health teachings to be provided to dialysis patients and
their families.

LEARNING CONTENT

DIALYSIS

 A dialysis is a process which separates the solutes in the blood by differential

diffusion through a semi-permeable membrane to affect the removal of toxic
metabolites and excess water.

Indications for patients with:

1. Fluid overload
2. Increasing levels of serum K+
3. Impending pulmonary edema
 4. Increasing acidosis
5. Poisoning or medication overdose
6. Uremia

Types:

1. Intermittent Hemodialysis
2. Peritoneal Dialysis
3. CRRT - (Continuous Renal Replacement Therapy)

Functions of hemodialysis

1. Cleanses the blood of accumulated waste products

2. Removes the by-products of protein metabolism (urea, creatinine & uric acid)
3. Removes excessive fluids
4. Maintains or restores the buffer system of the body
5. Maintains or restores electrolyte levels

Hemodialysis: Access

 Subclavian and Femoral catheter

 External Arteriovenous shunt
 Internal Arteriovenous fistula
 Internal Arteriovenous graft

HD Complications

 Chest pain
 Dysrhythmias
 Air embolism
 Anemia
 Gastric ulcers
 Patients with uremia report a metallic taste
 Nausea and vomiting
 Bone pain and fractures
  Itchiness
 Sleep disturbances
 Shortness of breath
 Hypotension
 Painful muscle cramps
 Disturbances of lipid metabolism (hypertriglyceridemia)
 Heart failure, coronary heart disease, angina, stroke, and peripheral vascular
insufficiency

Nursing Management - HD

1. Promote Pharmacologic therapy

2. Promote Nutritional and Fluid therapy
3. Meeting Psychosocial needs
4. Teach patient self-care
5. Continuing of care

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 is
introduced into the peritoneal cavity through an abdominal catheter at intervals.

Continuous Ambulatory Peritoneal Dialysis (CAPD)

 Can be performed in any clean and convenient place.

 Requires No machinery
 The dialysate is left in the abdomen for up to 8 hours
 The manual exchanges use gravity to drain the used fluid out of the peritoneal
cavity and replace it with fresh fluid.
 Dialysis takes place while patient continues normal activities.
 Most CAPD patients need to do 4 bag exchanges per day.
 5 to 2.5 liters of fluid per exchange
  Each exchange takes 30-40 minutes

Automated Peritoneal Dialysis (APD)

 aka Continues Cyclic PD (CCPD)/APD

 Uses a machine to exchange the fluids
 Each session lasts from 10-12 hours
 Usually done at night while patient sleeps
 Machine has 3 main functions:
- Heats PD fluid to body temperature
- Controls time of exchange & amount of fluid used
- Monitors treatment (safety alarms)

Procedure for Peritoneal Dialysis

1. PREPARING THE PATIENT:

a. Explain the procedure & obtain a signed consent
b. Record baseline vital signs, weight & serum electrolytes
c. Encouraged to empty bladder &bowel
d. Administer broad-spectrum antibiotic agents as ordered to prevent infection.
2. PREPARING THE EQUIPMENT:
a. Consult physician re-concentration of dialysate & medications to be added to
it. (Heparin, KCl, antibiotics etc..)
b. Warm the dialysate to body temperature
c. Assemble the administration set & tubing. Fill the tubing with the prepared
dialysate to reduce the amount of air entering the catheter & peritoneal cavity.
3. INSERTING THE CATHETER
- Ideally, the peritoneal catheter is inserted in the operating room to maintain
the surgical asepsis & minimize the risk of contamination.
4. PERFORMING THE EXCHANGE
- (1-4 hours, depending on the prescribed dwell time)
- Infusion à dialysate is infused by gravity into the peritoneal cavity for a period
of 5-10 mins to infuse 2L of fluid.
 - Dwell à allows diffusion & osmosis to occur (peaks in the first5-10 minutes)
- DRAINAGE
 The tube is unclamped and the solution drains from the peritoneal
cavity through a closed system (10 to 30 minutes).
 The drainage fluid is normally colorless or straw colored and should
not be cloudy. Bloody drainage may be seen in the first few exchanges
after insertion of a new catheter but should not occur after that time.
 The removal of excess water during peritoneal dialysis is achieved by
using a hypertonic dialysate with a high dextrose concentration that
creates an osmotic gradient (Dextrose solution of 1.5%, 2.5% and
4.25%)

PD Complications

1. Acute Complications
a. Peritonitis
b. Leakage
c. Bleeding
2. Long Term Complications
a. Hypertriglyceridemia
b. Anorexia
c. Low Back pain

Nursing Management - PD

1. Meeting Psychosocial Needs

2. Teaching Patient Self-Care
3. Continuing Care

Continuous Renal Replacement Therapies (CRRT)

 methods used to replace normal kidney function by circulating the patient’s blood
through a filter and returning it to the patient
Types of CRRT:

1. Continuous arteriovenous hemodialysis (CAVHD)

2. Continuous venovenous hemodialysis (CVVHD)
3. Slow continuous ultrafiltration (SCUF)
4. Continuous arteriovenous hemodiafiltration (CAVHDF)
5. Continuous venovenous hemodialfiltration (CVVHDF)

SPECIAL CONSIDERATIONS:

NURSING MANAGEMENT OF THE HOSPITALIZED PATIENT ON DIALYSIS/ RRT

1. Protecting vascular access

2. Taking precautions during Intravenous therapy
3. Monitoring symptoms of Uremia
4. Detecting cardiac and respiratory complications
5. Controlling electrolyte levels and diet
6. Managing discomforts & pain
7. Monitoring blood pressure
8. Preventing infection
9. Caring for the catheter site
10. Administering medications
11. Providing psychological support

LEARNING RESOURCES:

https://www.youtube.com/watch?v=EU2skU3bgS8

REFERENCES:

Smeltzer, S. Bare, B., Hinkle, J. & Cheever, K (2010). Brunner & Suddarth’s Textbook
of Medical-Surgical Nursing, 12th ed. Wolters Kluwer/ Lippincott Williams& Wilkins,
Philadelphia, USA
Sole, M., Klein, D. & Moseley, M. (2013). Introduction to Critical Care Nursing (6th ed.).
Elsevier Inc. St. Louis, Missouri, USA