Transcript RENAL REPLACEMENT THERAPIES

RENAL REPLACEMENT
THERAPIES
Presented by:
Liz Ermitano
Marlin Gomez
Margarita Rodriquez
Yumi Suzuki
RENAL REPLACEMENT
THERAPIES
PURPOSES OF DIALYSIS
1. Removes excess fluids and waste
products.
2. Restores chemical and electrolyte
balance
HEMODIALYSIS- one of several renal replacement
therapies used for the treatment of renal failure.
HD involves the extracorporeal (outside of the
body) passage of the client’s blood through a semi
permeable membrane that serves as an artificial
kidney.
CLIENT SELECTION
GENERAL GUIDELINE REQUIREMENTS FOR
APPROPRIATE CLIENT SELECTION
1. Presence of fatal, irreversible renal
failure when other therapies are
unacceptable or ineffective.
2. Absence of illnesses that would
prevent or seriously complicate HD.
3. Expectation of rehabilitation.
4. The client’s acceptance of the
regimen.
Components of Hemodialysis
Dialyzer or artificial kidney
Dialyzer has 4 components: Blood compartment,
Dialysate compartment, Semipermeable membrane,
enclosed structure to support the membrane.
Dialysate – made up of clear H2O & chemicals.
Compositions may be altered accdg to pt’s needs for
treatment of electrolyte imbalance. Warmed to 37.8 C = to
100 F to increase efficiency of diffusion. Prevent decrease
in pt’s blood temperature.
Vascular access routes – AV fistula, AV Graft, Dual Lumen
Cathater, AV Shunt.
Hemodialysis machine -
PROCEDURE
The principles of HD are based on the passive transfer of
toxins, which is accomplished by diffusion.
When HD is initiated, blood and dialysate flow in opposite
directions from their respective sides of an enclosed semi
permeable membrane. The dialysate is a balanced mix of
electrolytes and water that closely resembles human plasma.
On the other side of the membrane is the client’s blood,
which contains metabolic waste products, excess water, and
excess electrolytes.
During HD, the waste products move from the blood into the
dialysate because of the difference in their concentrations
(diffusion). Excess water is also removed from the blood into
the dialysate (osmosis). Electrolytes can move in either
direction, as needed, and take some fluid with them.
Potassium and sodium typically move out of the plasma.
This process continues as the blood and the dialysate are
circulated past the membrane for a preset length of time.
Duration and frequency of HD tx depend on the amt of
metabolic waste to be cleared, and the amt of fluid to be
removed.
COMPLICATIONS OF HEMODIALYSIS
Dialysis disequilibrium syndrome- the cause is
unknown but maybe due to rapid decrease in
blood urea nitrogen levels during HD. These
change can cause cerebral edema- leads to
increase intracranial pressure.
Infection- transmitted by blood transfusion are
another serious complication associated with long
term HD.
Hepatitis Infection- in clients with chronic renal
failure.
Best Practice for Caring for the
client Undergoing Hemodialysis
Weigh the client before and after dialysis.
Know the client’s dry weight.
Discuss with physician whether any of the client’s
medications should be withheld until after dialysis.
Be aware of events that occurred during the dialysis
treatment.
Measure blood pressure, pulse rate, respirations, and
temp.
Assess for symptoms of orthostatic hypotension.
Assess the vascular access site.
Observe for bleeding
Assess the client’s level of consciousness and assess for
headache, nausea, and vomiting.
COMPLICATIONS OF AV FISTULAE OR
SYNTHETIC AV GRAFT
Stenosis-the most frequent cause of permanent peripheral
hemodialysis access failure is vascular stenosis.
Thrombosis- this complication is more common in synthetic
AV grafts than native AV fistulae.
Failure of maturation- a native AV fistula requires 1 to 4
months to mature; if blood flow is diminished by stenosis or
multiple outflow veins, maturation will be impaired.
Infection- a leading cause of complications and death in
dialysis patient. Typical S/S of an infected dialysis access
include local erythema, induration, tenderness, and purulent
drainage from incision sites.
Ischemic steal syndrome- diverting blood flow from the distal
extremity through the hemodialysis access may cause pain
and ischemia in some patients, esp.diabetic and elderly
patient.
Pseudoaneurysm- also called false aneurysm or pulsating
hematoma
TYPES OF VASCULAR ACCESS FOR
HEMODIALYSIS
ACCESS TYPE
DESCRIPTION
LOCATION
INITIAL USE
PERMANENT
AV Fistula
An internal
anastomosis of an
artery to a vein
Forearm
2-4 mo or longer
AV Graft
Synthetic vessel
tubing tunneled
beneath the skin,
connecting an artery
and a vein
Forearm
1-2 wk
Dual-lumen
hemodialysis
An extended-use
catheter, surgically
tunneled under the
skin with a barrier
cuff
Subclavian vein
Immediately
postoperatively and
after x-ray
confirmation of
placement.
A specially
designed catheter
with two or three
lumens. Two
lumens are for blood
outflow and inflow
for hemodialysis: a
third lumen allows
venous access
without accessing
dialysis lumens
Subclavian, internal
jugular, or femoral
vein
Immediately after
insertion and x-ray
confirmation of
placement.
An external loop of
silastic tubing
connecting an artery
and a vein. Each
section of tubing is
sutured into a vessel
and brought through
a skin stab wound.
Forearm
Immediately after
insertion.
TEMPORARY
Hemodialysis
catheter (dual-or
triple
AV shunt (relatively
uncommon)
PERITONIAL DIALYSIS
Peritoneal dialysis (PD) takes place within the
peritoneal cavity. PD is slower than hemodialysis,
However , and more time is needed for the same
effect to be obtained.
TYPES OF PERITONEAL
DIALYSIS CAPD
Continuous Ambulatory Peritoneal Dialysis
MBCAPD- Multiple-Bag CAPD
APD- Automated Peritoneal Dialysis
IPD- Intermittent Peritoneal Dialysis
CCPD- Continuous Cycle peritoneal Dialysis
PROCEDURE AND PROCESS
The surgical insertion of a siliconized rubber
(Sillastic) catheter into the abdominal cavity is
required to allow the infusion of dialyzing fluid
(dialysate) is infused according to the physician
order, 1 to 2L of dialysate is infused by gravity (fill)
into the peritoneal space over a 10 to 20 minutes
period, according to the client’s tolerance. The fluid
dwells in the cavity for a specified time ordered by the
physician. The fluid then flows out of the body (drain)
by gravity into a drainage bag.
Con’t of process and procedure
the peritoneal outflow contains the dialysate in addition
to to the excess water, electrolytes, and nitrogenous
waste products that have accumulated in the body.
The Three Phases of the process:
1.
Infusion or fill.
2.
Dwell
3.
Outflow or drain.
PD occurs through diffusion and osmosis across the
Semipermeable peritoneal membrane and adjacent
capillaries. The peritoneal membrane is large and porous.
it allows solutes, which carry fluid with them to move
by an osmotic gradient fr an area of higher concentration in the body (blood) to an area of lower concentration
in the dialyzing fluid.
Complications of CAPD
PERITONITIS-the major complication of PD. The most
common cause of peritonitis is contamination of the
connection site during an exchange. The infection of
peritoneum is manifested by cloudy dialysate outflow
(effluent), fever, rebound abdominal tenderness, abdominal
pain, general malaise, nausea, and vomiting.
.
Cloudy or opaque effluent is the earliest sign of peritonitis.
The best treatment of peritonitis is prevention.
.
The nurse must maintain meticulous sterile technique when
caring for the PD catheter and when hooking up or clamping
off dialysate bags.
Con’t of Complication of CAPD
Pain- pain during inflow of dialysate is common
during the first few exchanges because of
peritoneal irritation; however, it disappear after a
week or two. Cold dialysate aggravates
discomfort. Thus the dialysate bags should be
warmed before instillation by use of a heating pad
to wrap the bag or use of warming chamber.
Microwave oven are not recommended for the
warming of dialysate because of their
unpredictable warming patterns and temperatures.
Exit Site and Tunnel infections- the normal exit site
from a PD catheter should be clean, dry, and with
out pain or evidence of inflammation.
Con’t of Complication of CAPD
Insufficient flow of the Dialysate- Constipation is the primary
cause of inflow or outflow problems. To prevent constipation,
the physician orders a bowel preparation before placing the PD
catheter. The nurse ensures that the drainage bag is lower than
the client abdomen. The nurse inspects the connection tubing
and PD system for kinking or twisting and rechecks to make
sure that clamps are open.
Dialysate Leakage- when dialysis is initiated, small volumes of
dialysate are used. It may take clients 1 to 2 weeks to tolerate
a full 2-L exchange without leakage around the catheter site.
Other Complication- The nurse notes any change in the color of
the outflow.
NURSING CARE DURING PERITONEAL DIALYSIS
Evaluate baseline vital signs
The client is weigh, always on the same scale, before the
beginning of the procedure or at least every 24 hours while
receiving the treatment.
Baseline laboratory value determination, such as electrolyte and
glucose levels,
During PD, the nurse continually monitors the client. For the first
exchanges, record the vs every 15 minutes. Ongoing
assessment for respiratory distress, pain or discomfort.
Abdominal dressing around the catheter exit site is checked
frequently for wetness. Monitor for dwell time.
NURSING CARE CON’T
For hourly exchanges, dwell time usually ranges from 20 to 40
Minutes. Blood glucose assessment is necessary, due to
Glucose absorption occur in some patient.
The outflow is recorded accurately after each exchange.
Visual inspection of the outflow bag and daily weights may be
sufficient to note the adequacy of the return.
If drainage return is brown, a bowel perforation must be
suspected.
If drainage return is the same color as urine and has the
same glucose concentration, a possible bladder perforation
should be investigated.
If drainage is cloudy or opaque, an infection is suspected.