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What is Hemodialysis and its Nursing Care:Nursing Case Study

Wednesday, 5 March 2014

The procedure known as dialysis removes excess fluids and waste products and restores chemical and electrolyte balance. Hemodialysis involves passing the client’s blood through an artificial semipermeable membrane to perform the filtering and excretion functions of the kidney. In hemodialysis, blood goes through a tube from the body to a dialyzer. The dialyzer is the machine’s filter. Inside the dialyzer, wastes and extra fluids are cleaned from the blood. Then, the clean blood travels through another tube and back into the body.


This study focuses on data regarding hemodialysis; Indication/ Contraindication, Normal Findings/Normal Values, Assessment, Procedure, Nursing Care, and Complications. The goal of this study is to give nursing students and readers the awareness into this procedure, hemodialysis.

INDICATION
Any client may be considered for HD therapy. Starting this therapy depends on client symptoms, not on the creatinine clearance. Dialysis starts immediately for clients who have the following:

Uremia. Acute dialysis is initiated when a patient becomes symptomatically uremic, regardless of BUN or creatinine level. Dialysis may be started prophylactically when the BUN reaches 100 mg/dL even if the patient has few or no symptoms.

Pulmonary edema. Acute pulmonary edema is a life-threatening complication of ARF that necessitates immediate dialysis. Acute pulmonary edema can result from fluid overload directly attributable to ARF or as the result of an acute myocardial infarction or from overzealous administration of fluid.

Hyperkalemia. Hyperkalemia is a result of the damaged kidney’s inability to secrete potassium and the release of intracellular potassium (because of acidosis and tissue breakdown). Hemodialysis is effective in lowering potassium and is initiated when reaped recution of plasma potassium is indicated.

Acidosis. It is caused by inability of the kidneys to excrete hydrogen ion and to reabsorb bicaronate.

Neurologic changes. Toxic effects of uremia can result in central nervous system changes. Headache, insomnia, and drowsiness are early symptoms; confusion, convulsions, and coma may occur late. Dialysis is indicated when any of these symptoms symptoms are seen, and preferably before they occur.

Drug overdoses and poisonings. Dialysis is indicated for the treatment of some drug intoxications.

Many clients survive for years with HD therapy and others may only live a few months. How long the client survives using HD therapy depends on the client’s age, the cause of renal failure, and the presence of other diseases. The following are general client selection criteria:
  • Presence of irreversible renal failure when others therapies are unacceptable
  • Absence of illnesses that would seriously complicate HD
  • Expectation of rehabilitation
  • The client’s acceptance of the regimen

ASSESSMENT
Physical Assessment consists of the following:

Weight. Dialysis patients are weighed before, and after each dialysis treatment. Some patients follow their weights at home to guide the adjustment of their fluid intake between dialyses. Weight is a good indicator of how well the patient is controlling fluid balance between dialyses. Pre dialysis weight indicates how much ultra filtration is required during the treatment. Dry weight is the ideal post dialysis weight after the removal of all or most excess body fluid. Patients who are at dry weight are usually normotensive. If the post dialysis weight is too low, the patient may be hypovolemic and at risk for hypotension and clotting of the vascular access. Weight gained between dialysis procedures is due to fluid retention. Most dialysis units encourage patients to limit their weight gain to 0.5kg (or 1 lb) per day.

Blood pressure is often volume related. Hypertension may indicate volume overload. Hypotension may indicate dehydration. Blood pressure is measured while the patient is sitting and standing to evaluate orthostatic changes requiring intervention. Normal BP is an individual matter. In the ESRD patient, blood pressure is analyzed for trends, rather than absolute values. A systolic value greater than 170mmHg or less than 90mmHg or a diastolic value greater than 100mmHg should be reported to the physician.

TPR observations serve as a baseline at the start of dialysis. Temperature elevation suggests infection or complicating illness. An elevated temperature is often a sign of vascular access infection. Fever during dialysis may be cause by high dialysate temperature or a pyrogen reaction. A rapid pulse may result from anemia or fluid overload. Irregular heart rate may indicate cardiac complications, including those associated with serum potassium levels. An increase in pulse rate during dialysis may be associated with falling blood volume and may occur just before a drop in BP. Increased respiratory rate may indicate excessive fluid gain. Any unexped finding should be reported to the physician.

Edema is excessive accumulation of fluid within the tissue areas. Excessive weight gain between dialyses leads to bloating.Edema is seen in several areas of the body in several patients. it's going to gift at the ankle and sacrum, facial or periorbital areas or peripherally. The jugular veins are typically distended once the patient is fluid full. Fluid assessment determines the quantity of radical filtration needed throughout dialysis


Predialysis assessment includes:
A subjective analysis of the patient’s health since the previous dialysis treatment. Ask whether he or she has experienced symptoms such as headaches, hypotension, bleeding or diarrhea. Dialysis personnel can assess changes in mentation, speech or thought processes while patients describe their health and any problems between dialysis sessions.

Before infiltration of hemodialysis, the patient and machine are both evaluated. The patient’s physiologic status is assessed to ascertain the need to adjust dialysis orders or prescribed medications. The machine parameters are assessed to ensure that the prescribed procedure is implemented correctly. Preassessment includes the following:
  • Fluid status (respiratory rate, JVD, heart sounds, breath sounds, presence of edema)
  • Weight
  • Blood pressure, sitting and standing
  • TPR, including apical/peripheral pulse evaluation
  • Skin color, temperature, turgor and integrity
  • Vascular access patency and freedom from bleeding and infection
  • Interpretation of physical assessment and laboratory data for appropriate intervention and medication administration

Machine preassessment includes the following:
  • Dialyzer membrane check for patency and integrity
  • Blood tubing intact without leaks
  • Appropriate prescribed dialyzer
  • Dialysate fluid composition as ordered and within safe limits (12.8 to 14.8 mho) as read by a Myron-L meter.
  • Appropriate prescribed dialysate potassium and calcium
  • Temperature within limits (35 to 37C)
  • Correlation of machine conductivity with an external meter reading of dialysate
  • Dialysate delivery system free of sterilant or disinfectant agents
  • Extracorporeal blood circuit free of air
  • Blood pump properly oriented.
  • Dialyzer bloodline tubing free of kinks or crimps
  • Blood pump segment of tubing properly seated in the pump segment
  • Physician’s orders reviewed to ensure adherence to dialysis precription
  • All alarms programmed and set within limits
PROCEDURE

Hemodialysis is a process of purification and filtration of the blood enabling the body to get rid of waste products, excess salts and water from the blood. This is let pass through a tube to a semi-permeable membrane (dialyzer) that filters out waste products and helps the body keep the biogenic ions balance.

The procedure is monitored and controlled by a hemodialysis machine, which provides also the dialysis fluid, mixing it from a concentrate, solids and water. The machine pumps blood, adds anticoagulants, regulates the purification process and controls the mixing of dialysis solution and the rate of its flow through the system. It can also monitor and record the patient's vital characteristics. Dialysis solution carries away the waste products like urea, creatinine, phosphorus and excess water, and the cleansed blood is returned to the patient through a shunt.

Dialysis is conducted in a dedicated facility, either a special room in a hospital or clinic that specializes in hemodialysis. Nurses and technicians working in the facility have special training dedicated to dialysis. The patient typically receives 2-3 treatments per week, lasting ususally from 4 to 5 hours each. Patients can read, write, sleep, have small talks or follow TV.

Diffusion, osmosis, and ultrafiltration are the principles on which hemodialysis is based. The toxins and wastes in the blood are removed by diffusion – that is, they move from an area of higher concentration in the blood to an area of lower concentration in the dialysate. The dialysate is a solution made up of all the important electrolytes in their ideal extracelluar concentrations. The electrolyte level in the patient’s blood can be brought under control by properly adjusting the dialysate bath. The semipermeable membrane impedes the diffusion on large molecules, such as red blood cells and proteins.

Excess water is removed from the blood by osmosis, in which water moves from an area o higher solute concentration (the blood) to an area of lower solute concentration (the dialysate bath). Ultrafiltration is defined as water moving under high pressure to an area of lower pressure. This process is much more efficient at water removal than osmosis. Ultrafiltration is accomplished by applying negative pressure or a suctioning force to the dialysis membrane. Because patients with renal disease usually cannot excrete water, this force is necessary to remove fluid to achieve fluid balance.

The body’s buffer system is maintained using a dialysate bath made up of bicarbonate or acetate, which is metabolized to form bicarbonate. The anticoagulant heparin is administered to keep blood from clotting in the dialysis circuit. Cleansed blood is returned to the body by the end of the dialysis treatment, many waste products have been removed, the electrolyte balance has been restored to normal, and the buffer system has been replenished.

In hemodialysis system, blood from an artery is pumped into a dialyzer where it flows through the cellophane tubes, which act as the semipermeable membrane (inset). The dialysate, which has the same chemical composition as the blood except for urea dn waste products, flows in around the tubules. The waste products in the blood diffuse through the semipermeable membrane in the dialysate.

NURSING CARE

Before the procedure:

As discussed in the assessment, it is important to assess patient’s weight, before and after the dialysis Assess patient’s condition such as LOC, ambulatory per wheelchair/stretcher.

  • Get initial vital signs of patient before the dialysis in order to know the baseline data (further data are shown on the assessment). Before taking the BP, ask for the access site then take BP on the unaffected arm.
  • Know the client’s dryweight
  • After filling up dialysis form, calculate ultrafiltration goal.
  • Assist in preparing equipments for cannulation
  • Assess access site
  • Check machine’s setting
  • Start dialysis. Note the time the dialysis has started
  • Check blood flow rate, arterial/venous pressure, TMP, UFG, timer, etc.
  • Discuss to the physician whether any of the client’s medications should be withheld until after dialysis
  • Facilitate fluid and electrolyte balance
  • Prevent hypovolemia and shock and preventing disequilibrium phenomenon
  • Promote comfort
  • Maintaining activity and nutrition
  • Facilitate learning

During the procedure:

Assess patient’s general condition and response to the procedure. Watch out for signs and symptoms such as nausea, apprehension, shortness of breath, restlessness or agitation, irritability, itching, flushing, twitching, irrational behavior, sensation of faintness, and complaints of pain
  • Constant monitoring is required in dialyzer and the dialysate because of numerous complications including clotting of the circuit, air embolism, inadequate or excessive ultrafiltration (hypotension, cramping, vomiting), blood leaks, contamination, and access complication.
  • Constant vital signs monitoring. Any alteration may lead to life threatening situation.
  • Assess vascular access for patency and take precautions to ensure that the extremity with the vascular access in not used for measuring blood pressure or for obtaining blood specimens; tight dressings, restraints, or jewelry over the vascular access are to be avoided as well
  • The bruit or thrill, over the venous access site must be evaluated at least every 8 hours. Absence of a palpable thrill or audible bruit may indicate blockage or clotting in the access device. Clotting can occur if the patient has an infection anywhere in the body or if the blood pressure has droped.
  • Observe for signs and symptoms of infection, such as redness, swelling, drainage from the site and fever.
  • Cardiac and repiratory assessment must be conducted frequently. As fluid builds up, fluid overload, heart failure, and pulmonary edema develop. Crackels in the bases of the lungs may indicate pulmonary edema.
  • Be aware of the events that occurred during the dialysis treatment
  • Assess for symptoms of othostatic hypotension
  • Observe for hemorrhage
After the procedure:

  • Determine patient’s BP prior to termination
  • Close small and big clamps of arterial line. Wait until the blood is returned to the patient
  • Closely monitor client immediately after dialysis for any side effects from the treatment. Common complications include hypotension, headache, nausea, malaise, and vomiting, dizziness, and muscle cramps.
  • Obtain vital signs and weight for comparison with predialysis measurements. Blood pressure and weight are expected to be reduced as a result of fluid removal
  • Heparinization required for hemodialysis increases the clotting time and thus the risk for excessive bleeding.
  • Continue monitoring for hemorrhage until an hour.
  • All invasive procedures must therefore be avoided for four to six hours after dialysis.
  • Others. Care of sharps, universal precaution measures, spiritual care, SubQ injection of erythropoietin supplement, assist/observe IJ, CVC insertion, dressing change

COMPLICATIONS

Many fluid – related and infectious complications can occur from hemodialysis.

Hypotension at the beginning of dialysis occurs in some patients with a relatively small blood volume. This is the result of volume shifts as the dialyzer is filled with the patient’s blood. It is much less frequent with small – volume dialyzers than with larger ones.

Hypertension is a result of increased cardiac output as fluid overload is relieved. In other instances there may be an increased in peripheral vascular resistance on a reflex or hormonal basis. Antiotensin – converting enzyme inhibitor therapy or bilateral nephrectomy may be indicated in cases in which high rennin levels are present, whereas the hypertension in very young and elderly patients may respond to a lower blood flow rate and the use of a smaller surface area dialyzer.

Arrhythmias are common among older patients with disease ESRD. They are most often caused by underlying heart disease

Chest pain often happens to clients with heart history problem, the pain must be presumed to be angina. It may go away if blood flow is slowed or saline is infused.

Muscle cramp is probably because of fluid shifting or osmolar change, although pH change may play a role. Use of sodium modeling may be preventive, and infusion of hypertonic saline or a 50% dextrose solution usually brings relief once cramps occur

Hemolysis is the lysis (bread up) of the red blood cells resulting in the release of intracellular potassium. Hemolysis may be caused by chemical, thermal or mechanical events. Chemical causes of hemolysis include exposure of the blood to chemicals such as sodium hypoclorite, formaldehyde, copper or nitrates.

Air embolism occurs when air or a large amount of foam is introduced into a patient’s vascular system. It occurs when arterial or venous lines become disconnected or when blood or saline infusion bags run dry.

Disequilibrium syndrome may develop during hemodialysis or after it has been completed. The cause is thought to be due to the rapid decrease in fluid volume and blood urea nitrogen (BUN) levels during hemodialysis. The change in urea levels can cause cerebral edema and increased intracranial pressure.

Infectious diseases transmitted by blood transfusion are a serious complication of long-term hemodialysis such as Hepatitis B and C and Human Immunodeficiency Virus (HIV)

Formaldehyde reaction occurs when the patient’s blood is exposed to the sterilant. This may occur when a formaldehyde – filled dialyzer is incorrectly rinsed of the sterilant or from improper testing for the presence of residual formaldehyde.

Pyrogen reaction may occur from an improperly sterilized dialyzer, bacteria in the water system or dialysate, break in aseptic technique or improper access preparation.


REFERENCES
Altschuler (1998) Handbook of Sign&Symptoms. Springhouse Inc

Anderson (2000) Mosboy’s Pocket Dictionary of Medicine, Nursing, & Allied

Beers (2003) The Merck Manual of Medical Information. Merk&Co., Inc.

Brunner & Suddarth (2004) Medical – Surgical Nursing Vol. 2 10th Ed. Lippincott

Health. Mosby Company

Ignatavicuis (2006) Medical – Surgical. Elsevier

Smeltzer (2008) Medical- Surgical Nursing 11th Ed. Lippincott Williams & Wilkins

Stoner (2005) Review of Hemodialysis for Nurses & Dialysis Personnel 5th Ed. C.F. Gutch

Taber. (2000). Taber’s Cyclopedic Dictionary. F.A. Davis company

Ticson (2004) Herbs

Udan (2002) Medical – Surgical Nursing. Educational Publishing House

Williams & Wilkins

Image: wikipedia/commons


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