Hemodialysis

INTRODUCTION TO HEMODIALYSIS

Dialysis
Healthy kidneys clean your blood and remove extra fluid in the form of urine. They
also make substances that keep your body healthy. Dialysis replaces some of these
functions when your kidneys no longer work. There are two different types of dialysis
- hemodialysis and peritoneal dialysis. The following is about hemodialysis.

Hemodialysis is a treatment to filter wastes and water from the patients' blood, as
the kidneys did when they were healthy. Hemodialysis helps control blood pressure
and balance important minerals, such as potassium, sodium, and calcium, in your
blood. During hemodialysis, the blood goes through a filter, called a dialyzer, outside
the body. A dialyzer is sometimes called an “artificial kidney.”

At the start of a hemodialysis treatment, a dialysis nurse or technician places two

needles into the patients arm. Each needle is attached to a soft tube connected to
the dialysis machine.

Indications for HD:

Acute Renal Failure
● Reversible
● is a sudden episode of kidney failure or kidney damage that happens
within a few hours or a few days.

Chronic Renal Failure

● Irreversible
● End-stage renal disease (ESRD)
● condition develops over a long period of time.
What happens to the blood while it’s in the filter?
Blood enters at one end of the filter and is forced into many, very thin, hollow fibers.
As the blood passes through the hollow fibers, dialysis solution passes in the
opposite direction on the outside of the fibers. Waste products from the patients'
blood move into the dialysis solution. Filtered blood remains in the hollow fibers and
returns to the patients body.
 In the filter, your blood flows inside hollow fibers that filter out wastes and extra salt
and water.

Vascular access surgery

One important step before starting hemodialysis treatment is having minor surgery to
create a vascular access. The vascular access will be the lifeline through which will
be connected to the dialyzer. Dialysis moves blood through the filter at a high rate.
Blood flow is very strong. The machine withdraws and returns almost a pint of blood
to the patients body every minute. The access will be the place on the patients body
where the nurse inserts needles to allow the blood to flow from and return to the
patients body at a high rate during dialysis.

Three types of vascular access exist.

● an arteriovenous (AV) fistula

● an AV graft
● a catheter

Work closely with the nephrologist and vascular surgeon—a surgeon who works with
blood vessels—to make sure the access is in place in plenty of time. Healing may
take several months. The goal is for the access to be ready for use when you are
ready for dialysis.

The surgeon connects an artery to a vein to create an AV fistula.

AV fistula
The best type of long-term access is an AV fistula. A surgeon connects an artery to a
vein, usually in your arm, to create an AV fistula. An artery is a blood vessel that
carries blood away from your heart. A vein is a blood vessel that carries blood back
toward your heart. When the surgeon connects an artery to a vein, the vein grows
wider and thicker, making it easier to place the needles for dialysis. The AV fistula
also has a large diameter that allows your blood to flow out and back into your body
quickly. The goal is to allow high blood flow so that the largest amount of blood can
pass through the dialyzer.
The AV fistula is a blood vessel made wider and stronger by a surgeon to handle the
needles that allow blood to flow out to and return from a dialysis machine.

The AV fistula is considered the best option because it:

● provides highest blood flow for dialysis

● is less likely to become infected or clot
● lasts longer

AV graft
If problems with the patients veins prevent from having an AV fistula, they may need
an AV graft instead. To create an AV graft, the surgeon uses a man-made tube to
connect an artery to a vein. The patient can use an AV graft for dialysis soon after
surgery. However,they’re more likely to have problems with infection and blood clots.
Repeated blood clots can block the flow of blood through the graft and make it hard
or impossible to have dialysis.

An AV graft uses a synthetic tube to connect an artery and a vein for hemodialysis.
Catheter

If the kidney disease has progressed quickly, or the patient have not had a vascular
access placed before they need dialysis, they may need a venous catheter—a small,
soft tube inserted into a vein in your neck, chest, or leg near the groin—as a
temporary access. A nephrologist or an interventional radiologist—a doctor who uses
medical imaging equipment to perform surgery—places the venous catheter while
you’re in a hospital or at an outpatient clinic. You’ll receive local anesthesia and
medicine to keep you calm and relaxed during the procedure.
The dialysis machine mixes and monitors the dialysate. Dialysate is the fluid that
helps remove the unwanted waste products from your blood. It also helps get the
electrolytes and minerals to their proper levels in the body. The machine also
monitors the flow of blood while it is outside of the patient's body. You may hear an
alarm go off from time to time. This is how the machine lets us know that something
needs to be checked.
Dialysate is a fluid that is made up of water, electrolytes and salts. During dialysis,
dialysate helps to clean the blood inside the dialyzer by removing waste products
and balancing electrolytes. The nephrologist will prescribe the dialysate that is right
for your patient.
The core of the dialyzer is made up of thousands of tiny mesh tubes. T e blood flows
inside each tube, and the dialysate stays on the outside of the tubes. Tiny pores in
the tubes let waste and excess fluids pass from the blood into the dialysate. The
clean blood then leaves the dialyzer and is returned to the body. "ARTIFICIAL
KIDNEY"

● Designed specifically to connect patient with an external system that

extracts blood of the patient to the dialyzer and reverts patient’s blood
from the dialyzer.
● Consists of 2 parts: Arterial and Venous line which are used during dialysis
with attached fistula and dialyzer.
● Unique chambers are there which reduce foaming, increase air removal
and do not trap EPO (Erythropoietin). This helps in ensuring and secure
machine fit and less incidence of wet out.
● Color coded ergonomic clamps and dialyzer connectors with tethered caps
that are seal tightly for disposal.
● Kink resistant tubing eases handling and ensures fast priming.
● Sterile, Non-Toxic and Pyrogen Free.

AVF AND AVG KIT

● GAUGE 17 OR 16 NEEDLE
● TOURNIQUET
 ● CLEAN GLOVES
● COTTON BALLS
● GAUZE
● SCISSOR
● MICROPORE
● DRAPE
● ALCOHOL PADS

CATHETER DRESSING KIT

● 2 pairs Sterile gloves
● 2 pairs of clean gloves
● Heplock
 ● Drape
● Betadine/ Chlorhexidine
● Mask
● Micropore
● Tegaderm
● 2 10cc syringe

TEGADERM AND CHLORHEXEDINE

PRE HD ASSESSMENT:
● Pre HD Weight
● Blood Pressure
● Cardiac Rate
● Respiratory Rate
● Temperature
 ● Oxygen Saturation
● Auscultate for Lung sound
● Check for edema
● Assess Vascular Access
○ AVF and AVG
■ A bruit (a rumbling sound that you can hear)
■ A thrill (a rumbling sensation that you can feel)
○ CVC- assess for any signs of infection and patency using sterile
technique

HD Calculations:

DEFINITION OF TERMS:

DRY WEIGHT - normal weight without any extra fluid in your body

PRE HD WEIGHT - weight before hemodialysis treatment

POST HD WEIGHT - weight after hemodialysis treatment

ULTRAFILTRATION GOAL - total fluid excess to be remove from the patient's body
including the additional components such as flushing, blood transfusion, amino acid
supplement and IV iron.

ULTRAFILTRATION NET - the amount of excess water to be removed in the

patient's body without any additional components.

1kg=1L

Additional components: it will be added to UF net

400cc - Total blood return taken from both arterial and venous bloodlines.

this is a constant additional component to your UF goal.

To Prevent Clotting: Heparin or Flushing

Heparin - if patient is on Heparin as an anticoagulant, no need to add to UF Goal.

Flushing - if the patient has bruises, wounds, upcoming surgeries such as dental,
AVF Creation, or any surgeries, flushing is indicated, and you will add 800cc to your
goal.

Blood Components - 250cc, 400cc, 450cc

Nephrosteril - 500cc
Iv Iron - 100cc

SAMPLE SOLVING:
PROBLEM #1
Pre HD weight: 52kgs

Dry weight: 50kgs

For AVF creation tomorrow

Solve for UF net and UF goal

Your answer should be in liters

PRE-HD WT - DRY WT = WT GAIN

WT GAIN + CONSTANT RETURN + FLUSHING = TOTAL UF GOAL

52KGS- 50KGS= 2KGS or 2L

2L+400CC+800CC= 3200CC OR 3.2L

UF NET: 2L

UF GOAL: 3.2L

PROBLEM #2
DRY WEIGHT: 49.5KGS

PRE HD WEIGHT: 52.5 KGS

PATIENT HAS NO BRUISES, WOUNDS, OR UPCOMING SURGERIES

WITH ADDITIONAL PRBC: 450ML

SOLVE FOR UF NET AND UF GOAL

Use cc or liters

PRE HD WT - DRY WT= WEIGHT GAIN

52.5 -49.5 = 3KGS OR 3L

WEIGHT GAIN + CONSTANT RETURN + ADDITIONAL PRBC= UF GOAL

3L + 400CC+ 450CC= 3850CC

UF NET: 3L

UF GOAL: 3850CC

During Dialysis:
● Monitor patients every 30 minutes
● Documentation
● Inform AP about patients Pre HD assessment and refer accordingly

Post HD assessment:
● Check post HD vital signs and record.
● Weigh patient and record
● Going home instructions and health teaching
● Injection of Erythropoietin
● Evaluate and document patients’ response to HD treatment.
● Document any complications during the treatment

HD Nurse Responsibilities:
● Oversees the preparation of the delivery system, dialysate bath, and
dialyzer and confirms that all mandatory alarm tests on the dialyzer and
equipment are performed.
● Reviews physician orders for dialysis patients, collects pre-treatment
dialysis data, and reviews patient records prior to dialysis.
● Conducts pre-dialysis patient assessment including obtaining patient vital
signs and assessing the patient' s vascular access, laboratory findings,
and the patient' s general health.
● Verifies that patients are taking all prescribed medications and performs
medication reconciliation.
● Documents findings of patient assessments and interventions and advises
providers of any significant change in the patient's condition and other
pertinent information.
● Discusses patient concerns and answers questions relevant to care.
● Oversees dialysis technicians in the performance of dialysis from start to
finish, monitors patient reaction to treatment and performance of the
dialysis machines and demonstrates an in-depth understanding of the
mechanics of dialysis.
● Assesses, prepares, and cannulates a patient' s vascular access
(including needle insertion in arteriovenous fistula or grafts for aseptic
connection with dialysis equipment).
● Utilizes sterile techniques to assess the dialysis catheter exit site and to
apply dressing on the patient' s vascular access (dialysis catheter,
arteriovenous access) per protocols.