PRELIMINARY REPORT

CHRONIC KIDNEY DISEASE (CKD) ON HEMODIALYSIS

BY:

KARTINI ULFIANTI

020.02.1115

Nursing Profession Study Program

MATARAM HEALTH SCIENCES COLLEGE (STIKES)

2021
 CERTIFICATION SHEET

Has been reviewed and approved on:

Hari :
Date :

Student
KARINA CITRA MANDITHA
019.02.0943

Knowing

Academic Advisor Land Guide

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 INTRODUCTORY REPORT
CHRONIC KIDNEY DISEASE (CKD) ON HEMODIALYSIS

I. CHRONIC KIDNEY DISEASE (CKD)

A. Definition of CKD

Chronic Kidney Disease (CKD) or end-stage renal disease is a

chronic kidney dysfunction that is progressive and irreversible, where
the body's ability fails to maintain metabolism and fluid balance
and electrolyte, causing uremia (retention of urea and other nitrogenous waste in
blood. This occurs when the glomerular filtration rate is less than 50 mL/min.
(Smeltzer & Bare, 2000; Price, Wilson, 2002; Suyono, et al, 2001).
Chronic kidney failure is also known as Chronic Kidney Disease (CKD).
The difference between the word chronic here compared to acute is the chronology of time and

physiological level of filtration. According to Mc Clellan 2006, it is explained that kidney failure

Chronic is a condition of kidney disease that is persistent (duration ≥ 3

months with kidney damage, and damage to the glomerular filtration rate (GFR) with
GFR numbers ≤ 60 ml/min/1.73 m2 (Prabowo & Eka, 2014).
In this condition of chronic kidney failure, there is a gradual decline in kidney function.
with minimal signs and symptoms. Many patients are unaware of the onset.
the condition has reached a point where kidney function is only 25% (Agoes, 2010). Kidney failure

chronic is a disease that occurs over a long period of time until

for years and still not healed (Dharma, 2015).
Chronic kidney failure is kidney damage that occurs for more than 3
months, based on pathological abnormalities or signs of kidney damage such as proteinuria.
If there are no signs of kidney damage, the diagnosis of chronic kidney disease is established if
The glomerular filtration rate is less than 60 ml/min/1.73m², as follows:
1. Kidney damage > 3 months, which is a structural or functional abnormality of the kidneys, with or

without a decrease in glomerular filtration rate based on:

Pathological abnormality

Signs of kidney damage such as proteinuria or abnormalities in examination

imaging
 2. Glomerular filtration rate < 60 ml/min/1.73m² for more than 3 months with or without
kidney damage (Capernito, 2009).

B. Classification of CKD

There are 5 stages of chronic kidney disease determined through

calculation of the Glomerular Filtration Rate (GFR). To calculate GFR, the doctor
will send the patient's blood sample to the laboratory to check the levels
Creatinine in the blood. Creatinine is a waste product that comes from muscle activity.
that should be filtered from the blood by healthy kidneys. Below are 5
chronic kidney failure disease stadium as follows:

To assess GFR (Glomerular Filtration Rate) / CCT (Creatinine Clearance Test)

can be used with the following formula:

Creatinine clearance (ml/min) = (140 - age) x body weight (kg)

72 x creatine serum
In women, the result is multiplied by 0.85.

The stages of chronic kidney disease are as follows:

Stadium 1, with normal GFR (> 90 ml/min)
In stage 1 chronic kidney disease (CKD), symptoms are usually not yet felt.
which indicates damage to the kidneys. This is caused by the kidneys
 still functions normally even though it is no longer in 100% condition
so many patients are unaware of their kidney condition in the stage.
2. Stadium 2, with mild decrease in GFR (60 to 89 ml/min)
In stage 2, one may also not feel any unusual symptoms because of the kidneys.
still functioning well.
3. Stage 3, with moderate GFR decline (30 to 59 ml/min)
At this level, the accumulation of metabolic residues will accumulate in the blood.
what is called uremia. Symptoms may also begin to be felt such as:
a. Fatigue, a feeling of weakness/tiredness that is usually caused by anemia.

b. Fluid overload, this causes the patient to experience swelling.

around the lower legs, around the face or hands. Patients may also
experiencing shortness of breath due to too much fluid in the body.
c. Changes in urine, the urine produced may be foamy indicating the presence of
protein content in urine. In addition, the color of urine also undergoes changes.
turning brown, dark orange, or red when mixed with blood.
Urine quantity can increase or decrease and sometimes patients often
wake up to urinate in the middle of the night.
d. Pain in the kidneys, pain around the waist where the kidneys are located can
experienced by some patients who have kidney problems such as
polycystic and infection.
e. Difficulty sleeping, some patients will experience difficulty sleeping due to
the appearance of itching, cramps or restless legs.
Stage 4, with severe decrease in GFR (15 to 29 ml/min)
When someone is at this stage, it is very likely within a time
it is required to undergo kidney replacement therapy / dialysis or to do
transplantation. A condition where there is a build-up of toxins in the blood or uremia
usually appears at this stage. Symptoms that may be felt at stage 4
is fatigue, fluid overload, changes in urine, pain in the kidneys, difficulty sleeping,
Nausea (vomiting or the urge to vomit), changes in food taste (can occur
that the food consumed does not taste like usual), and bad breath
uremic (urea that accumulates in the blood can be detected through breath odor)
that is unpleasant.
 Stage 5, end-stage renal disease/terminal (>15 ml/min)
At this level, the kidneys lose almost all of their ability to function.
optimally. For that, a kidney replacement therapy (dialysis) or
transplantation so that the patient can survive. Symptoms that may arise include
Stadium 5 includes loss of appetite, nausea, headache, feeling tired,
unable to concentrate, itching, urination not occurring or only a little
swelling (especially around the face, eyes and ankles), muscle cramps, and
change in skin color.

C. Etiology of CKD
The causes of GGK according to Price & Wilson (2006) are divided into eight classes.

among others:
1. Infections such as chronic pyelonephritis
2. Inflammatory diseases such as glomerulonephritis
3. Hypertensive vascular diseases such as benign nephrosclerosis, nephrosclerosis
malignant, renal artery stenosis
4. Connective tissue disorders such as systemic lupus erythematosus, polyarteritis
nodosa, progressive systemic sclerosis
5. Congenital and hereditary disorders such as polycystic kidney disease, acidosis.
kidney tubule
6. Metabolic diseases such as diabetes mellitus, gout, hyperparathyroidism, amyloidosis

7. Toxic nephropathy such as analgesic abuse, lead nephropathy

8. Obstructive nephropathy
Predisposing factors:
1. Diabetes
Aged over 60 years
3. Congenital kidney disease
4. Family history of kidney disease
5. Autoimmune (lupus erythematosus
6. Renal obstruction (BPH and prostatitis)
7. Ras
Precipitation factor:
1. Exposure to toxins and some excessive medications
2. Lifestyle (hypertension, atherosclerosis)
 3. Eating pattern (diet)

D. Clinical Manifestations of CKD

According to Smeltzer and Bare (2009), the clinical manifestations of chronic kidney failure are:

Cardiovascular
a. Hipertensi
b. Pitting edema
c. Periorbital edema
d. Enlargement of the neck vein

e. Pericardial friction rub

2. Pulmonary
a. Crickets
b. Shallow breath
c. Kusmaul
thick and viscous sputum
3. Gastrointestinal
a. Anorexia, nausea and vomiting
b. Gastrointestinal bleeding
c. Ulceration and bleeding in the mouth
d. Constipation / diarrhea
e. Breath smells of ammonia

Musculoskeletal
muscle cramps
Loss of muscle strength
c. Bone fracture
d. Foot drop
Integumen
shiny gray skin color
b. Dry, scaly skin
c. Itching
d. Ecchymosis
Thin and fragile chicken.
f. Thin and coarse hair
6. Reproduction
Amenorrhea
b. Testicular atrophy

Patients with CKD show different manifestations, depending on

at the stage of CKD experienced:
Stadium 1
A person with stage 1 CKD usually does not experience symptoms yet.
indicating kidney damage because the kidneys can still function normally.
Stadium 2
A person with stage 2 CKD usually does not yet experience symptoms.
indicates kidney damage even though there has been a slight decrease in GFR,
that is between 60-89.
3) Stadium 3
At this stage, symptoms may sometimes begin to be felt such as:
. Fatigue: a sense of weakness/tiredness that is usually caused by anemia.
. Fluid overload: Along with the decline in kidney function, the kidneys ...
unable to regulate the composition of fluids within the body. This
the patient will experience swelling around the feet area
under, around the face or hands. The patient may also experience shortness of breath
the result of too much fluid in the body.
. Changes in urine: the urine may be foamy, indicating the presence of
protein content in urine. In addition, the color of urine also undergoes changes.
to become brown, dark orange, or red when mixed with blood.
The quantity of urine can increase or decrease and sometimes the patient often
woke up to urinate in the middle of the night.
. Pain in the kidneys. Pain around the waist where the kidneys are located can
experienced by some patients with kidney problems such as
polycystic and infection.
. Difficulty sleeping: Some patients will experience difficulty sleeping.
due to the emergence of itching, cramps, or restless legs.
. Patients with stage 3 liver cirrhosis are advised to consult a specialist.
hypertension kidney (nephrologist). The doctor will provide the best recommendations

supportive therapy – therapy aimed at slowing the rate of functional decline

kidneys. In addition, it is also highly recommended to seek the help of a nutritionist to
 obtaining the right diet plan. Patients with CKD in this stage
it is usually requested to maintain adequate protein intake but still
be aware of the phosphorus levels in the food, because keeping
The phosphorus level in the blood remains low is important for the continuity of kidney function.

In addition, patients should also limit calcium intake if the content

in the blood is too high. There are no potassium restrictions unless found
The level in the blood is above normal. Usually limiting carbohydrates also
recommended for patients who also have diabetes. Controlling
Beverages are required in addition to sodium restriction for hypertension patients.

Stadium 4
The symptoms that may be felt in stage 4 are almost the same as in stage 3.
namely:
. Fatigue: a feeling of weakness/tiredness usually caused by anemia.
. Excess fluid: As kidney function declines, the kidneys
can no longer regulate the composition of fluids in the body. This is
the patient will experience swelling around the feet
below, around the face or hands. The patient may also experience shortness of breath.
the effect of too much fluid in the body.
. Changes in urine: the urine produced may be foamy indicating the presence of
protein content in urine. In addition, the color of urine also changes.
turns brown, dark orange, or red when mixed with blood.
The quantity of urine can increase or decrease and sometimes the patient often
wake up to urinate in the middle of the night.
. Pain in the kidneys. The pain around the lower back where the kidneys are located may
experienced by some patients who have kidney problems such as
polycystic and infection.
. Difficulty sleeping: Some sufferers will experience difficulty in sleeping.
due to the emergence of itching, cramps or restless legs.
. Nausea: vomiting or the feeling of wanting to vomit.
. Changes in food flavor: it can happen that the food consumed
it doesn't feel like usual.
. Uremic breath: urea that accumulates in the blood can be detected.
through bad breath.
. Difficult to concentrate
 Stage 5 (end-stage renal failure)
Symptoms that may arise in stage 5 include:
. Loss of appetite
. Nausea.
. Headache.
. Feeling tired.
. Unable to concentrate.
. Itching.
. Urine does not come out or only very little.
. Swelling, especially around the face, eyes, and ankles.
. Muscle cramp
. Skin color change

E. Pathophysiology of CKD

A decrease in GFR can be detected by obtaining a 24-hour urine sample for

creatinine clearance examination. As a result of the decrease in GFR, the creatinine clearance will

decrease, creatinine levels will increase, and blood urea nitrogen (BUN) will also
increasing.
Renal clearance disorders. Many problems arise in kidney failure as a result
from the decrease in the number of functioning glomeruli, which causes a decrease in clearance
(substance in the blood that should be filtered by the kidneys).
One of the kidney functions is to regulate blood sugar levels.
there are two hormones that play a role in the kidneys to control blood sugar levels
namely insulin and adrenaline hormones, insulin hormone functions as a reducer
the level of sugar in the blood while adrenaline hormone as an increase in sugar
blood. When the kidneys experience disorders, those two hormones cannot function
like their respective functions, kidney failure ethics occurs when someone is at risk of
hypoglycemia complications.
Symptoms of kidney failure experiencing hypoglycemia include nausea and vomiting, when
kidneys experience disorders causing impaired protein secretion resulting in
uremic syndrome, leading to acid-base balance disorders causing production
Increased acidity causes stomach acid to rise, leading to stomach irritation and nausea.

vomit.
 The lack of nutrient intake into the body is also one of the causes.
from hypoglycemia, because the intake of glucose in the blood is not met, for sufferers
Kidney failure will become more complicated when the nutrient intake contained in
inside it is glucose that cannot be utilized by the kidneys to be excreted
Adrenaline hormone to stimulate an increase in blood glucose levels.
Hypoglycemia must receive adequate management immediately.
food that contains carbohydrates or drinks that contain sugar
caloric or glucose 15-20 g intravenously. A re-examination is necessary.
blood glucose 15 minutes after glucose administration. Glucagon was given to the patient
severe hypoglycemia. To prevent the onset of hypoglycemia in patients, it is necessary to

taught how to adjust insulin injections with time and amount

food (carbohydrates).
Fluid and sodium retention. The kidneys lose the ability to
concentrating or diluting urine normally. There is fluid retention
and sodium; increases the risk of edema, congestive heart failure and
hypertension.
Anemia occurs as a result of inadequate production of erythropoietin.
the shortening of red blood cell lifespan, nutritional deficiencies, and the tendency to occur
bleeding due to the patient's uremic status, especially from the GI tract.
Calcium and phosphate imbalance. Serum levels of calcium and phosphate in the body
has a reciprocal relationship, if one increases, the other
will decrease. With the decrease in GFR, there is an increase in serum phosphate levels.
and conversely a decrease in calcium levels.
The decrease in calcium levels will trigger the secretion of parathyroid hormone, however in

in kidney failure, the body does not respond to increased secretion of parathyroid hormone.
as a result, calcium in the bones decreases causing changes in the bones and
bone disease.
Uremic bone disease (osteodystrophy). It occurs from complex changes in calcium.
phosphate, and parathyroid hormone balance.
(Smeltzer and Bare, 2009).
F. Supporting Examination
1. Laboratory examination
Laboratory tests that are generally considered supportive,
the possibility of Chronic Kidney Failure:
a. Blood Sedimentation Rate: Increased due to the presence of anemia, and
hypoalbuminemia.
b. Normocytic normochromic anemia, and a low reticulocyte count.
c. Urea and creatinine: Increased, usually the ratio between urea and
creatinine approximately 20 : 1. Remember, the ratio can increase because of
gastrointestinal bleeding, fever, extensive burns, steroid treatment, and
urinary tract obstruction.
d. This comparison decreases: Urea is smaller than Creatinine, on a low diet.
protein, and decreased Creatinine Clearance Test.
e. Hyponatremia: generally due to fluid excess.
f. Hyperkalemia: usually occurs in advanced kidney failure along with
decrease in diuresis.
g. Hypocalcemia and Hyperphosphatemia: occur due to reduced synthesis of 1,24
(OH)2 vit D3 on CKD.
Alkaline phosphatase increased due to bone metabolism disorders, especially isoenzymes.
bone alkaline phosphatase.
i. Hypoalbuminemia and Hypocholesterolemia; generally caused by disorders
metabolism and low protein diet.
j. Increased Blood Sugar, due to carbohydrate metabolism disorders in failure
kidney, (resistance to insulin effects in peripheral tissues)
k. Hypertriglyceridemia, due to disorders of fat metabolism, is caused by an increase
insulin hormone, somatotropic hormone, and decreased lipoprotein lipase.
1. Metabolic acidosis with respiratory compensation indicates a decrease in pH.
BE that is decreased, HCO3 that is decreased, PCO2 that is decreased, all of them

due to the retention of organic acids in renal failure.

2. Electrocardiogram (ECG) Examination

To check for the possibility of left ventricular hypertrophy, signs of pericarditis,
arrhythmia, electrolyte disturbances (hyperkalemia, hypocalcemia). Possible abnormal
indicates electrolyte and acid/base imbalance.
 3. Ultrasound (USG)
To search for reversible factors such as obstruction due to
stone or tumor mass, and to assess whether the process has advanced.
[Link] Photos of Abdomen

It is better without fasting, as dehydration will worsen kidney function.

Assess the shape and size of the kidneys and whether there are stones or other obstructions.

[Link]-Venous Pieolography (PIV)

This can be done through intravenous infusion pyelography, to assess
pelvicaliceal system and ureter.
6. Retrograde Pyelography Examination
Performed when there is suspicion of a reversible obstruction.
7. Chest X-ray Examination
Signs of pulmonary edema due to excess fluid should be visible.
overload), pleural effusion, cardiomegaly and pericardial effusion.
8. Radiological Examination of Bones
Searching for osteodystrophy and metastatic calcification.

G. Management of CKD
Conservative
TKRP Diet (High Calorie Low Protein)
Protein is limited because urea, uric acid, and organic acids are the results.
the breakdown of protein that will rapidly accumulate in the blood if there is
disruption in renal clearance. The protein consumed must have biological value.
(milk, eggs, meat) where these foods can supply amino acids
for cell repair and growth. Usually, fluids are allowed 300-600 ml/24
jam. Calories to prevent weakness from carbohydrates and fats. Provision
Vitamins are also important because dialysis patients may lose water-soluble vitamins.
through blood during dialysis.
2. Symptomatic
Hypertension
Ditangani dengan medikasi antihipertensi kontrol volume intravaskuler.
Congestive heart failure and pulmonary edema require fluid restriction, diet
low sodium, diuretics, digitalis or dobutamine and dialysis. Acidosis
Metabolic issues in CKD patients are usually asymptomatic and do not require treatment.
 however, sodium bicarbonate supplementation may be necessary during dialysis for
correcting acidosis.
b. Anemia
In CKD, it is treated with epogen (recombinant human erythropoietin).
Anemia in patients (Hmt < 30%) appears without specific symptoms such as malaise,
general fatigue and decreased activity tolerance. Neurological abnormalities may
occurs like twitching, headaches, delirium or seizure activity. Patients
protected from seizures.
3. Replacement Therapy with Hemodialysis
Dialysis is a process where solute and water undergo diffusion.
passive through a porous membrane from one liquid compartment to
Other liquid compartments. Hemodialysis and dialysis are the two main techniques.
used in dialysis, and the basic principle of both techniques is diffusion
solutes and water from plasma to the dialysis solution in response to the difference
certain concentration or pressure.
Continuous Ambulatory Peritoneal Dialysis (CAPD)
Peritoneal dialysis is a blood washing method using a membrane.
the peritoneal membrane, so that blood no longer needs to be expelled
from the body to be cleaned like what happens in dialysis machines. CAPD
is a chronic dialysis technique with low efficiency that requires
observe the patient's condition regarding susceptibility to fluid changes (such as patients

diabetes and cardiovascular.

b. Clinical hemodialysis in the hospital
The common approach to handle kidney failure in Indonesia
is by using a dialysis machine (dialyzer) which functions as
artificial kidney.

Management of kidney failure includes:

1. Restriction of fluid, protein, and phosphate consumption.

2. Medications: diuretics to increase urination; aluminum hydroxide for

hyperphosphatemia therapy; antihypertensives for hypertension therapy and given medication that ...

should stimulate RBC production like epoetin alfa when anemia occurs.
3. Dialysis Dialysis can be performed to prevent complications of acute kidney failure.
serious, such as hyperkalemia, pericarditis, and seizures. Pericarditis improves
biochemical abnormalities; causing calcium, protein, and sodium to be consumed
 freely; eliminate bleeding tendencies; and assist
wound healing.
4. Management of hyperkalemia
Fluid and electrolyte balance is a major issue in failure.
acute kidney; hyperkalemia is the most life-threatening condition in
this disturbance. Therefore, patients are monitored for the presence of hyperkalemia through

a series of serum electrolyte level tests (potassium value > 5.5 mEq/L; SI: 5.5)
mmol/L), changes in ECG (low or very high T wave peaks),
and changes in clinical status. Increased potassium levels can be reduced by
the administration of ion-exchange resin (Sodium polystyrene sulfonate [kayexalate]), in a
orally or through retention enema.
5. Maintaining fluid balance
Fluid balance management is based on daily body weight.
measurement of central venous pressure, urine and serum concentration, lost fluids,
blood pressure and clinical status of the patient. Enter and output oral and parenteral
from urine, gastric drainage, feces, wound drainage, and perspiration are calculated and
used as a basis for fluid replacement therapy.
6. Kidney Transplantation (Smeltzer & Bare, 2005)

H. Complications of CKD

1. Hyperkalemia: due to decreased excretion, metabolic acidosis, catabolism and

excessive diet intake.
2. Pericarditis: Pleural effusion and cardiac tamponade due to uremic waste products and
inadequate dialysis.
3. Hypertension due to fluid and sodium retention and malfunction of the renin system.
angiotensin-aldosterone.
4. Anemia due to a decrease in erythropoietin, a decrease in the lifespan of red blood cells.

5. Bone diseases and calcification due to phosphate retention, low serum calcium levels,
metabolism of vitamin D and increased levels of aluminum.
6. Metabolic acidosis, renal osteodystrophy & sepsis, peripheral neuropathy, hyperuricemia
(Smeltzer & Bare, 2005)
II. HEMODIALYSIS
A. Definition of Hemodialysis

Dialysis is a process used to remove fluids and

waste products from within the body when the kidneys are unable to perform the process
The purpose of dialysis is to maintain life and well-being.
the patient until kidney function recovers. Therapeutic methods include hemodialysis,
hemofiltration and peritoneal dialysis. Hemodialysis is defined as the movement
the solution and water from the patient's blood pass through a semipermeable membrane (dialyzer) into

dialysate. Dialyzer can also be used to transfer most of the volume.

liquid.
Hemodialysis (HD) is a procedure to separate blood from
remaining substances or toxins that are carried out by flowing blood through a membrane
semipermeable where waste or toxins are diverted from the blood to the dialysate
which is then discarded, while the blood returns to the body according to the meaning
from hemo which means blood and dialysis which means to transfer.

B. Purpose of Hemodialysis

According to Havens and Terra (2005), the purposes of hemodialysis treatment include:
1. Replacing the kidney function in excretion, which is to dispose of waste.
metabolism in the body, such as urea, creatinine, and other metabolic waste.
2. Replacing the kidney's function in excreting bodily fluids that should be released.
excreted as urine when the kidneys are healthy.
3. Improving the quality of life for patients with declining kidney function.
 4. Replacing kidney function while waiting for other treatment programs.
According to PERNEFRI (2003), the duration of hemodialysis is adjusted.
according to individual needs. Each hemodialysis session lasts 4 - 5 hours with a frequency of

2 times a week. Hemodialysis ideally should be done 10 – 15 hours/week with Blood

flow (QB) 200–300 mL/minute. Meanwhile, according to Corwin (2000). Hemodialysis
takes 3 - 5 hours and is done 3 times a week. At the end of the interval 2 -
3 days between hemodialysis, the balance of salt, water, and pH is no longer normal.
Again. Hemodialysis also contributes to anemia because some blood cells
Red blood cells are damaged during the dialysis process.

C. Hemodialysis Process
The process mechanism in the hemodialysis machine, blood is pumped from the body into

into the dialysis machine and then cleaned in the dialyzer (artificial kidney), then the patient's blood
which has been cleaned is pumped back into the patient's body. The dialysis machine that is the most

has just been equipped with a computerized system and continuously monitors
array of safety-critical parameters, including blood and dialysate flow rates, blood pressure,
heart rate, conductivity, pH, and others. If there is anything abnormal,
The alarm will sound. Hemodialysis requires vascular access (vessel
blood) hemodialysis (AVH) that is sufficient to obtain good blood flow
quite large, specifically requires a blood flow rate of 200 - 300 ml/minute.
continue for 4 – 5 hours of hemodialysis.
AVH can be in the form of a catheter placed in the vein in the neck or
that is temporary. For the permanent one, a connection is made between the artery and
Vein, typically in the forearm referred to as an arteriovenous fistula, is more commonly known as
(Brescia) Cimino fistula. Then the blood from the patient's body enters the circulation.
blood machine hemodialysis that consists of inlet/arterial hose (to the machine) and hose
outlet/venous (from the machine to the body), both ends are connected to a needle and cannula
that is inserted into the patient's blood vessel. Blood after passing through the inlet tube enters

dialyze. The amount of blood that occupies the blood circulation in the machine is around 200 ml. In

The blood dialyzer is cleaned, waste continuously penetrates the membrane and
crossing to the dialysate compartment, on the other side the dialysate fluid flows in
the hemodialysis machine with a speed of 500 ml/min enters the dialyzer at
Dialysate compartment. Dialysate is a concentrated fluid containing materials.
The main electrolytes and glucose, this fluid is pumped into the machine while being mixed.
with clean water that has undergone a complex purification process
treatment). During the hemodialysis process, the patient's blood is given heparin to prevent it from clumping.

it freezes when outside the body, namely in the machine's blood circulation.
The principle of hemodialysis is the same as the method of dialysis. It involves the diffusion of solutes.

the separation of any semipermeable membrane. The principle of separation using a membrane

this occurs in the dialyzer. Blood that contains metabolic waste residues with
high concentration is passed through a semipermeable membrane found in
dialyzer, where in the dialyzer the dialysate is flowed in the direction that
counter current
The driving force used is the difference in concentration of the dissolved substance.
in the form of toxins such as small particles, such as urea, potassium, uric acid, phosphate and
The advantage of chloride in blood and dialysate. The higher the concentration of the toxin.
in the blood and dialysate, the diffusion process becomes faster. In contrast to
peritoneal dialysis, where transport occurs between static fluid compartments,
hemodialysis relies on convective transport and uses a counter
flowing, where the dialysate flows in the opposite direction to the flow
extracorporeal circuit. This method can improve the effectiveness of dialysis.
The dialysate used is a sterilized mineral ion solution, urea.
and other metabolic waste, such as potassium and phosphate, diffuse into the dialysate.
In addition, ultrafiltration is used to separate what is dissolved in the blood.
The driving force used in this ultrafiltration is the pressure difference.
hydrostatic between blood and dialyzer. Blood pressure higher than the dialyzer
forcing water through the membrane. If the pressure from the dialyzer is lowered then

the ultrafiltration speed of water and blood will increase.

If these two processes are combined, clean blood will be obtained.
after being passed through the dialyzer. This principle is used in machines
modern hemodialysis, thus its effectiveness in replacing the role of the kidneys
very high. (Rizal, 2011)
Three (3) principles of HD work:
1. Diffusion process: The movement of substances due to differences in concentration in the blood.

more and more are moving to dialysis.

2. Ultrafiltration Process: The movement of substances and water due to hydrostatic differences within

blood and dialysate.

 3. Osmosis Process: The movement of water due to chemical energy that is the difference
osmolality and dialysate.
4. The body's buffer system is maintained by the addition of acetate that will diffuse.
with dialysate fluid into the patient's blood and undergoes metabolism for
forming bicarbonate. The cleaned blood is returned to the body.
through the patient's vein

D. Hemodialysis Complications
Hypotension can occur during dialysis therapy when fluid is removed.
Air embolism is a rare complication but can occur if air
entering the patient's vascular system.

3. Swelling can occur due to a decrease in pCO2 along with the occurrence of
blood circulation outside the body.
4. Pruritus can occur during dialysis therapy when the metabolic end products
leaving the skin.
5. Dialysis imbalance disturbances occur due to the transfer of cerebral fluid and
appears as a seizure attack.
Muscle cramps occur when fluids and electrolytes quickly leave.
extracellular space.

Nausea and vomiting are events that often occur.

III. NURSING CARE CONCEPT

A. Assessment
1. Biodata
Including name, age, gender, race, religion, address, occupation, education
Chronic Kidney Failure primarily occurs in the elderly (ages 50-70), and in the younger age group.

It can occur in all genders but 70% in men.

2. Main complaint
Clients with hemodialysis usually complain of: Weakness, dizziness, itching, numbness.

baal, bengkak-bengkak, sesak, kram, BAK tidak lancar, mual, muntah, tidak nafsu
 ["eating","difficulty sleeping","palpitations","diarrhea","difficulty defecating","blurry vision","pain"]

kepala, nyeri dada, nyeri punggung, susah berkonsentrasi, kulit kering, pandangan
darkness, muscle pain, pain at needle puncture, leakage at blood access, sweating
cold, cough with phlegm/no phlegm.
Medical history:
a. Current medical history
b. History of past illness
c. Family medical history
3. Vital signs: increased body temperature, rapid and weak pulse, hypertension, rapid breathing
and in (Kussmaul), dyspnea.
4. Physical examination:
a. Rest/sleep activities
1) Fatigue, weakness or malaise
2) Insomnia
3) Muscle tone decreases
4) ROM decreases
b. Circulation
1) Palpitations, angina, chest pain
2) Hypertension, jugular vein distension
3) Dysrhythmia
Pallor
5) Hypotension/hypertension, weak/fine pulse
Periorbital-pretibial edema
7) Anemia
8) Hyperlipidemia
9) Hyperparathyroid
10) Thrombocytopenia
11) Pericarditis
Atherosclerosis
CHF
14) LVH
c. Elimination
1) Polyuria at the initial stage of kidney disorder, oliguria, and anuria in the advanced phase

2) Dysuria, urine color analysis

 3) History of stones in the urinary tract
4) Ascites, bloating, diarrhea, constipation
d. Nutrition/Fluid
1) Edema, weight gain
2) Dehydration, weight loss
Nausea, vomiting, anorexia, upper abdominal pain
4) Effects of diuretic administration

Skin turgor
Stomatitis, gum bleeding
Subcutaneous fat decreases
Abdominal distension
9) Thirst
10) Ulcerative gastritis
Neurosensor
1) Headache, blurred vision
Tired, insomnia
Cramps, spasms, soreness
4) Iritasikulit
5) Tingling, numbness

f. Comfort
1) Headache, dizziness
2) Shoulder pain, back pain
3) Itching, pruritus,
4) Cramps, spasms, tingling, numbness
g. Oxygenation
Kussmaul breathing
Short-quick breaths
3) Ronchi
h. Security
1) Transfusion reaction
2) Fever (sepsis-dehydration)
3) Recurrent infections
4) Decrease in endurance
 Uremia
Metabolic acidosis
Convulsions
8) Bone fracture
i. Sexual
Decrease in libido
2) Hair (-), amenorrhea
3) Erectile dysfunction
4) Testosterone and sperm production decrease
Infertile
5. PemeriksaanPenunjang
Laboratory
Complete urine
Complete blood count includes: Hb, Hct, WBC, Platelets, ESR, Pre and post Urea,
{"kreatinin pre dan post":"creatinine pre and post","protein total":"total protein","albumin":"albumin","globulin":"globulin","SGOT-SGPT":"SGOT-SGPT"}

bilirubin, gamagt, alkali fosfatase, kalsium, fosfor, kalium, natrium, klorida,

gula darah, SI, TIBC, saturasi transferin, feritin serum, pth, vit D, kolesterol
total, HDL, LDL, trigliserida, asamurat, Hbs Ag, antiHCV, anti HIV, CRP,
astrup:pH/P02/pC02/HCO3
Typically, the following can be found: anemia, hyperkalemia, hyperphosphatemia,
hypocalcemia, uremic, increased creatinine, low blood pH, client GD
DM decreased
2) Radiology
a) Ronsen, Usg, Echo: the possibility of finding evidence of enlargement
heart, presence of urinary tract/kidney stones, cortex size, image
kidney condition, presence of enlargement of kidney size, kidney vascularization.

Nuclear imaging can determine GFR

3) Ekg
There is an enlargement of the heart, arrhythmia, hyperkalemia,
myocardial hypoxia.

B. Nursing Diagnosis
The decrease in cardiac output is associated with an increased cardiac load.
 2. Fluid and electrolyte balance disorders are related to secondary edema.
Fluid volume imbalance due to retention of Na and H2O.
3. Nutritional needs lower than the body's requirements are related to anorexia,
nausea and vomiting.
4. Breathing pattern disturbances related to secondary hyperventilation, compensation
through respiratory alkalosis.
5. Skin integrity disorders are associated with pruritus.
6. Intolerance of activities is related to inadequate tissue oxygenation and
fatigue.

C. Nursing Plan
A decrease in cardiac output is related to an increased cardiac load.
Purpose:
Decreased cardiac output did not occur with the outcome criteria:
Maintaining heart rate with evidence of blood pressure and heart rate
Within normal limits, the peripheral pulse is strong and equal to the capillary refill time.

Intervention:
a. Auscultation of heart and lung sounds
b. Examine the presence of hypertension

c. Investigate chest pain complaints (PQRST)

d. Kaji tingkat aktivitas dan respon terhadap aktivitas.
2. Fluid and electrolyte balance disturbances are related to secondary edema.
fluid volume imbalance due to Na and H retention2O.
Objective:
Maintaining an ideal body weight without excess fluid with the result criteria:
There is no edema, balance between input and output.
Intervention:
a. Assess fluid status by weighing daily weight, input and output balance
output, skin turgor and vital signs
b. Limit fluid intake
c. Explain to the patient and family about fluid restrictions
d. Encourage/ teach the patient to record fluid intake, especially intake.
and the output
3. Nutritional needs less than the body's needs are related to anorexia.
nausea and vomiting.

Goal :
Maintaining adequate nutritional input with outcome criteria:
Showing stable body weight

Intervention:
a. Awasi konsumsi makanan/ cairan
b. Note the presence of nausea and vomiting

c. Give small amounts of food but often

d. Serve the food while it is warm
e. Provide oral hygiene care
4. Breathing pattern disturbances related to secondary hyperventilation, compensation
through respiratory alkalosis.
Objective:
Breathing pattern returns to normal/stable

Intervention:
a. Auscultation of breath sounds, note any additional sounds
b. Teach the patient effective coughing and deep breathing
c. Arrange your position as comfortably as possible

d. Limit activities

5. Skin integrity disorders are associated with pruritus.

Goal:
The integrity of the skin can be maintained with the outcome criteria:

Maintaining intact skin

Demonstrating behaviors/techniques to prevent skin damage
Intervention:
a. Skin inspection for changes in color, turgor, vascular, watch for the presence of
redness
b. Monitor fluid intake and hydration of the skin and mucous membranes
c. Inspection of the area depends on the edema
d. Change position as often as possible

e. Provide skin care

 f. Keep the linen dry
g. Advise the patient to use a cool, damp compress for
maintaining pressure on the pruritic area
h. Recommend wearing loose cotton clothing
i. Recommend using lotion or powder
6. Intolerance to activity is related to inadequate tissue oxygenation and
fatigue.
Purpose:
Patients can increase tolerable activities.
Intervention:
a. Monitor the patient to carry out activities
b. Examine the factors that cause fatigue
c. Encourage alternative activities while resting
d. Maintain adequate nutritional status
 REFERENCES

Carpenito, L.J. [Link] Asuhan & Dokumentasi Keperawatan. Ed. 2Jakarta : EGC

Corwin, E.J. 2001. Translation: Pendit, B.U. Handbook of pathophysiology. Jakarta:

Medical Book Publisher EGC.
Price, S.A. & Wilson, L.M. Translation by: Anugerah, P. 2006. Pathophysiology: Clinical
concept of disease processes. 4th Edition. Jakarta: Medical Book Publisher EGC.
Smeltzer, Suzanne C., Bare, Brenda G. 2005. Brunner & Suddarth Textbook of Medical
Surgical Nursing 10thEdition. Lippincott Williams & Wilkins.
Suyono, S, et al. 2001. Textbook of Internal Medicine. Third edition. Jakarta: Publisher Office
FKUI.