RENAL REPLACEMENT THERAPIES

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RENAL REPLACEMENT THERAPIES

• Presented by
• Liz Ermitano
• Marlin Gomez
• Margarita Rodriquez
• Yumi Suzuki

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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 clients blood
  through a semi permeable membrane that serves as
  an artificial kidney.

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CLIENT SELECTIONGENERAL 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 clients acceptance of the regimen.

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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 pts needs
  for treatment of electrolyte imbalance. Warmed to
  37.8 C to 100 F to increase efficiency of
  diffusion. Prevent decrease in pts blood
  temperature.
• Vascular access routes AV fistula, AV Graft,
  Dual Lumen Cathater, AV Shunt.
• Hemodialysis machine -

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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 clients
  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.

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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.

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Best Practice for Caring for the client
Undergoing Hemodialysis

• Weigh the client before and after dialysis.
• Know the clients dry weight.
• Discuss with physician whether any of the
  clients 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 clients level of consciousness and
  assess for headache, nausea, and vomiting.

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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

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TYPES OF VASCULAR ACCESS FOR HEMODIALYSIS
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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.

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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
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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 clients 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.

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Cont 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
• Infusion or fill.
• Dwell
• 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
  concentra-
• tion in the body (blood) to an area of lower
  concentration
• in the dialyzing fluid.

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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.

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Cont 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.

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Cont 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.

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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.

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NURSING CARE CONT

• 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.