HEMODIALYSIS

INTRODUCTION

Hemodialysis is used for clients with acute or irreversible renal failure and fluid and electrolytes imbalances. It is usually the treatment of choice when toxic agents, barbiturates overdose need to be removedfrom the body quickly. Hemodialysis can be an outpatient or inpatient therapy. Routine hemodialysis is conducted in a dialysis outpatient facility, either a purpose built room in a hospital or a dedicated, stand alone clinic. Less frequently hemodialysis is done at home. Dialysis treatments in a clinic are initiated and managed by specialized staff made up of nurses and technicians; dialysis treatments at home can be self initiated and managed or done jointly with the assistance of a trained helper who is usually a family member.

HISTORICAL OVERVIEW

In 1943, William Kolff in the Netherland performed the first dialysis on a human being with the use of rotating drum dialyzer. He initiated dialysis treatment in the United States in 1948. Tremendous technology advances have been made in hemodialysis since the 1940s, allowing for safer, shorter treatments using sophisticated equipment.     

DEFINITION

Hemodialysis is a method for removing waste products such as potassium and urea, as well as free water from the blood when the kidneys are in renal failure. Hemodialysis is one of three renal replacement therapies (the other two being renal transplant; peritoneal dialysis).

INDICATION        

@ To correct fluid and electrolyte imbalance and to remove wastes in renal failure i.e. acute renal failure and chronic renal failure.

@ For clients with severe cardiovascular problems when clients are having severe fluid overload

@ To maintain the life and wellbeing of patient.

@ It can be the treatment of choice for patients with renal failure who unwilling to undergo peritoneal dialysis or renal transplant

@ To treat the overdoses or toxicity of the drugs or any toxins

@ To remove the overdoses of urea, glucose and fluid and electrolyte volume that hinders the normal mechanism of kidney.

THERAPEUTIC EFFECTS OF HEMODIALYSIS

@ To clear waste products from the body

@ Restore the fluid, electrolyte and acid base balance

@ Reverse some of the untoward manifestations of irreversible renal failure

@ Excessive urea, nitrogen and acid ions are removed

@ Reduce the effect of any medication toxicity

PRINCIPLE OF HEMODIALYSIS

     

             

The principle of hemodialysis is the same as other methods of dialysis; it involves diffusion of solutes across a semi permeable membrane. Sodium bicarbonate is added in a higher concentration than plasma to correct blood acidity. A small amount of glucose is also commonly used. The following principles are used in hemodialysis:-

1.      Diffusion is the movement of solutes from an area of greater concentration to an area of lesser concentration.

2.      Ultra filtration results when there is an osmotic gradient or pressure gradient across the membrane. In hemodialysis, the gradient is created by increasing pressure in blood compartment and decreasing the pressure in the dialysate compartment

3.      Osmosis is the movement of fluid from an area of lesser to an area of greater concentration of solutes. Glucose is added to the dialysate and creates an osmotic gradient across the membrane pulling the excessive fluid from the blood.

METHODS OF CIRCULATORY (VENOUS) ACCESS IN HEMODIALYSIS

In hemodialysis, three primary methods are used to gain access to the blood: an intravenous catheter, an arteriovenous (AV) fistula and a synthetic graft. The type of access is influenced by factors such as the expected time course of a patient's renal failure and the condition of his or her vasculature.

INTRAVENOUS CATHETER

Catheter access, sometimes called a CVC (Central Venous Catheter), consists of a plastic catheter with two lumens (or occasionally two separate catheters) which is inserted into a large vein (usually the vena cava, via the internal jugular vein or the femoral vein) to allow large flows of blood to be withdrawn from one lumen, to enter the dialysis circuit and to be returned via the other lumen. Catheters are usually found in two general varieties, tunneled and non-tunneled.

TUNNELED CATHETER/NON TUNNELED CATHETER

·         Non-tunneled catheter access is for short-term access (up to about 10 days, but often for one dialysis session only), and the catheter emerges from the skin at the site of entry into the vein.

·         Tunneled catheter access involves a longer catheter, which is tunneled under the skin from the point of insertion in the vein to an exit site some distance away. The tunnel acts as a barrier to invading microbes, and as such, tunneled catheters are designed for short- to medium-term access (weeks to months only), because infection is still a frequent problem.

Advantages

@ Ease of access

@ Can be used immediately

Disadvantages

@ It can restrict the patient’s activity especially if it is femoral catheter.

@ It is more prone to have infection if unsterile techniques are used during insertion.

ARTERIOVENOUS FISTULA

 AV (arteriovenous) fistulas are recognized as the preferred access method. To create a fistula, a vascular surgeon joins an artery and a vein together through anastomoses. One can feel this by placing one's finger over a mature fistula. This is called feeling for "thrill" and produces a distinct 'buzzing' feeling over the fistula. One can also listen through a stethoscope for the sound of the blood "whooshing" through the fistula, a sound called bruit.

    Fistulas are usually created in the nondominant arm and may be situated on the hand (the 'snuffbox' fistula'), the forearm (usually a radio cephalic fistula  in which the radial artery is anastomosed to the cephalic vein), or the elbow (usually a brachiocephalic fistula, where the brachial artery is anastomosed to the cephalic vein). A fistula will take a number of weeks to mature, on average perhaps 4–6 weeks. During treatment, two needles are inserted into the fistula, one to draw blood and one to return it.

Advantages

@ lower infection rates, because no foreign material is involved in their formation

@ higher blood flow rates (which translates to more effective dialysis), and

@ a lower incidence of thrombosis

@ Does not restrict patient’s activity.

Disadvantages

@ Bleeding can be there if pressure has been applied over the fistula

@ Infection can occur at the site of insertion of needles if site is not cleaned properly

@ Clotting can be there if constrictive clothing is used.

@ One has to wait until the fistula has been mature for the insertion of needles or arterial cannula.

@ Aneurysms can form in any internal fistula and are caused by repeated needle punctures at the same site.

@ Fistula causes a decrease in arterial blood flow to the areas distal to the fistula which may cause ischemic symptoms or steal syndrome vary from cold or numb fingers to gangrene.

@ Shunting of the blood can be there from arterial to venous side

ARTERIOVENOUS GRAFT

AV (arteriovenous) grafts are much like fistulas in most respects, except that an artificial vessel is used to join the artery and vein. The graft usually is made of a synthetic material sometimes chemically treated; sterilized veins from animals are used. Grafts are inserted when the patient's native vasculature does not permit a fistula.

Advantages

@ They mature faster than fistulas, and may be ready for use several weeks after formation (some newer grafts may be used even sooner).

@ It is a permanent method for vascular access in hemodialysis

@ Once it is maintained it provides easy access.

Disadvantages

@ Graft rejection can be the major disadvantage of arteriovenous graft.

METHODS OF VENOUS ACCESS IN PEDIATRIC PATIENTS

Ü  For short term external vascular access, percutaneous catheters are inserted in the femoral, subclavian, or internal jugular veins, even in very small children.

Ü  For long term access, dual lumen catheters can be placed similarly to other central venous access devices. They are ready to be used immediately and no needles are required.  

NURSING CARE OF CLIENTS WITH AV FISTULA, GRAFTS OR CATHETERS

@ Do not take the BP readings using the extremity in which the vascular access is placed.

@ Do not perform venipunctures or start iv’s in the extremity in which the vascular access is placed

@ Palpate thrills and Auscultate for bruits every 4 hourly

@ Assess the client’s distal pulses and circulation

@ Elevate the affected extremity postoperatively

@ Encourage the client for range of motion exercises

@ Check for bleeding at needle insertion sites or shunt tubing insertion sites

@ Assess for signs and symptoms of infection at needle site

@ Do not allow client to carry heavy objects or anything that compresses the extremity in which the vascular access is placed

@ Do not allow the client to sleep with his her body weight on top of the extremity in which the vascular access is placed.

COMPLICATION OF CIRCULATORY ACCESS

Nursing measures for prevention of complications in hemodialysis

ACCESS TYPE	BLEEDING	INFECTION	CLOTTING
AV fistula/ graft	apply pressure to the                     needle puncture sites	Ensure adequate site & cleaning before cannulation	Rotate the needle insertion with each hemodialysis treatment
AV shunt	keep clamps available	Perform exit site care three times a week	Assess for thrill and bruit signs
Hemodialysis Catheters	monitor the access site	Use aseptic techniques	Place a heparin after hemodialysis treatment.

EQUIPMENTS USED IN HEMODIALYSIS

The hemodialysis machine pumps the patient's blood and the dialysate through the dialyzer. The newest dialysis machines on the market are highly computerized and continuously monitor an array of safety-critical parameters, including blood and dialysate flow rates; dialysis solution conductivity, temperature, and pH; and analysis of the dialysate for evidence of blood leakage or presence of air. Any reading that is out of normal range triggers an audible alarm to alert the patient-care technician who is monitoring the patient. Manufacturers of dialysis machines include companies such as Fresenius, Gambro, Baxter, B. Braun, NxStage and Bellco.

1.      WATER SYSTEM

An extensive water purification system is absolutely critical for hemodialysis. Since dialysis patients are exposed to vast quantities of water, which is mixed with dialysate concentrate to form the dialysate, even trace mineral contaminants or bacterial endotoxins can filter into the patient's blood. Water used in hemodialysis is carefully purified before use. Initially it is filtered and temperature-adjusted and its pH is corrected by adding an acid or base. Then it is softened. Next the water is run through a tank containing activated charcoal to adsorb organic contaminants. Primary purification is then done by forcing water through a membrane with very tiny pores, a so-called reverse osmosis membrane. This lets the water pass, but holds back even very small solutes such as electrolytes. Final removal of leftover electrolytes is done by passing the water through a tank with ion-exchange resins, which remove any leftover anions or cations and replace them with hydroxyl and hydrogen molecules, respectively, leaving ultrapure water.                     

2.      DIALYZER

The dialyzer is the piece of equipment that actually filters the blood. Almost all dialyzers in use today are of the hollow-fiber variety. A cylindrical bundle of hollow fibers, whose walls are composed of semi-permeable membrane, is anchored at each end into potting compound (a sort of glue). This assembly is then put into a clear plastic cylindrical shell with four openings. One opening or blood port at each end of the cylinder communicates with each end of the bundle of hollow fibers. This forms the "blood compartment" of the dialyzer. Two other ports are cut into the side of the cylinder. These communicate with the space around the hollow fibers, the "dialysate compartment." Blood is pumped via the blood ports through this bundle of very thin capillary-like tubes, and the dialysate is pumped through the space surrounding the fibers. Pressure gradients are applied when necessary to move fluid from the blood to the dialysate compartment.

3.      DIALYSATE BATH

The term "Dialysate bath" means the kind of dialysate prescribed by your Nephrologist. Because the electrolytes in the blood shouldn't be removed completely with the use of water so we use dialysate.  Too low level of sodium, potassium, calcium, phosphorus, magnesium, and other electrolytes, is as dangerous as high level. The dialysate contains these electrolytes in appropriate concentrations that prevent removing too much of them from the blood. Two of these electrolytes can be set as needed in the dialysate bath.

@ Calcium (Ca) can be 3.5, 2.5, 2 mEq /L, depending upon the patient's calcium.

@ Potassium (K) can be 4, 3, 2, 1 mmol/L, or zero (free-K). 4 is for patient that make a significant amount of urine and should not clear any potassium from their system. 3 is for patients that make some urine, 2 is for patients w/o any kidney function, 1 is used occasionally for patients with high potassium when needed. Free-K is rarely used and only in extreme cases of high potassium (like after surgery), and should be used only for an hour or so at the beginning of the treatment (to avoid removing too much potassium). Note that the low limit for potassium in the blood is 3.5.

4.      DIALYSATE FLOW

The dialysate pump, in addition to mixing the concentrate with water, moves the dialysate through the dialyzer. This pump has adjustable flow rate. For regular dialysis at blood flow up to 250 cc/ min the dialysate flow should be 500 cc/ min. For more efficient dialysis, called high flux, the blood flow is 400-500 cc/min and the dialysate flow is 800 cc/ min

5.      ULTRA FILTRATION ONLY

To be able to remove a lot of excess fluid without cramps the dialysate pump can be turned off for the last (or extra) 30 to 60 minutes while the UFR is set to 2000 cc/hour (or as much as needed). It is calledUF Only or Strictly UF. These terms signify that there is no diffusion, just UF. Waste and electrolytes are removed with the fluid by convection without changing the concentration in the body and hence without cramps.

6.      HEPARIN PUMP

This pump delivers heparin to the blood tubing. The pump is a regular syringe that is pushed by a controlled motor. On all machines the rate can be adjusted. On newer machines the end time can be programmed too. Usually an initial dose of heparin is given when the treatment begins, then the pump delivers heparin until one hour before the end. To avoid clotting in the dialyzer it is rinsed with 100 cc saline every hour or so.

7.      ALARM

Exceptions in the machine operation trigger the alarm. There is a red alarm light and an audible beep. There is a mute button to stop the beeping but if the problem persists the beeping is resumed after a short period of time. There are many reasons for the machine to alarm: the reason is either indicated by a light or a message. If the pump stops there is a risk of clotting inside the dialyzer.

8.      PRESSURE CHAMBERS

The pressure chambers should be filled with blood up to about 0.5-0.6 inch (13-15 mm) below the top. There is usually a mark on the plastic at that level. If the level is too high blood may get into the filter and block it. If the level is too low air may get into the lines. During the treatment the level may go up with positive pressure and down with negative pressure because of slight air leak. In addition, air may be dissolved in or released from the blood.

9.      UF & UFR

The UFR should never be set to zero. Remember that the ultra filtration is the result of TMP - higher pressure in the blood pushes fluid through the membranes into the dialysate. Zero UFR means zero TMP. When the TMP is too low or zero, dialysate ingredients, as well as water, move from the dialysate into the blood. This is called back Filtration. If the water is not absolutely pure, bacteria may come in touch with the blood in the dialyzer and the patient may feel sick.

EQUIPMENTS USED IN PEDIATRIC PATIENT

                    Hollow fiber dialyzers are preferable for children because their blood compartment is relatively small and rigid. Pediatric dialysis can be safely carried out when the fluid volume required to fill both the dialyzer and blood tubing does not exceed 10% of the child’s calculated blood volume.

PROCESS OF DIALYSIS

The dialysis is performed inside the dialyzer, which is a plastic cylinder, in which the blood enters from the top (the red header), flows through thousands of extremely thin hollow fibers and leaves from the bottom. At the same time the dialysate enters from the bottom, flows around and in between the fibers, and leaves from the top. The fibers are semi permeable membranes, that is, smaller molecules in the blood stream can pass through them into the dialysate and bigger molecules as well as blood cells cannot. The dialysate is a water-based solution and its purpose is to absorb from the blood all that should be removed and nothing else.

Wastes and electrolytes move from the blood into the dialysate because their concentration in the blood is higher. This process is called diffusion. The dialysate flow ensures that fresh dialysate is present at all times so that the dialysate doesn't become saturated and the process never ends. Fluid is removed from the blood in the same way the kidneys do it - by blood pressure. This process is called Ultra Filtration (UF) and is similar to Reverse Osmosis (RO). With RO, the membrane pore size is very small and allows only water to pass through the membranes. In UF, the membrane pore size is larger, allowing some bigger molecules to pass through the pores with the water. The rate at which fluid is removed from the blood is called UFR (UF Rate). There is higher pressure in the blood passing through the dialyzer and lower pressure in the dialysate. This pressure difference is called TMP (Trans Membrane Pressure). The higher the TMP, the higher the UFR. As you can see, the dialyzer is doing the job of dialysis. The rest of the machine takes care of supplying the blood and the dialysate to the dialyzer, controls the flow and the pressures, and provides visual indication and alarm when something goes wrong.

HEMODIALYSIS PROCEDURE

A.    PREPARATORY PHASE OF HEMODIALYSIS

1)      Before or around the time the patient arrives for his/her scheduled session, a dialysis machine will be prepared. The technician or nurse will set up plumbing on the machine in a moderately complex pattern that has been worked out to move blood through the filter, allow for saline drip, and allow for various other medications/chemicals to be administered.

2)      The patient arrives and is carefully weighed. Standing and sitting blood pressures are taken. Temperature is taken.

3)      Access is set up. Insert two large gauge needles into the fistula. The two most common are lignocaine (lidocaine), a local anesthetic injected under the skin, and there is also a cream called EMLA which is applied to the skin 45 minutes before the needles are inserted. Fistulas are widely considered the desirable way to get access for hemodialysis, but they take time to set up and mature (anywhere between 5 weeks to 15 weeks).

4)      When access has been set up, the patient is then connected to the preconfigured plumbing, creating a complete loop through the pump and filter.

5)      Before the patient is connected, the machine should be setup and rinsed.

6)      Start the setup by connecting the dialysate lines to the dialyzer.

7)      Connect the blood lines to the dialyzer. Make sure that the red blood line and the red dialysate line are connected to the dialyzer on the same side.

8)      The rest of the setup should be performed according to the protocol in unit.

9)      When the setup is complete the arterial and venous blood lines are connected together.

10)  The blood tubing and the dialyzer are rinsed by re-circulating saline through them.

11)  At that time the UFR should be set to not less than 300 cc/ hour and should be on, and the saline line should be unclamped.

12)  To remove air from the blood lines and dialyzer, the machine should run for a few minutes with the dialyzer mounted upside down, that is, the red header is down and the blue one is up. In this position the saline flows up, air leaves the dialyzer and is trapped in the venous chamber.

13)  Remember that even if just a small amount of air is left in the blood lines, once they are filled with blood this air becomes foam and causes the air detector to shut the pump down. This may take a tech 5 to 15 minutes to fix; sometimes the patient should be disconnected and the blood must re-circulate for a few minutes.

14)  Time for the needles. While doing the needles let the machine continue with the rinse.

15)  Insert both needles and tape them according to protocol.

16)  Stop the pump, clamp both arterial and venous lines and clamp the saline line coming from the saline bag.

17)  Disconnect the arterial line from the venous line as they were connected for re-circulation. Hang the venous line on a bucket, or drain, make sure that it doesn't touch anything (use the inline clamp as a hanger).

18)  Check once more that all four clamps are clamped (needles and blood lines). Remove the syringe from the arterial needle and connect the red arterial line to the arterial needle. Unclamp the arterial needle and both blood lines.

19)  Turn the pump slowly 100-200 cc/min. Check your unit protocol. The blood flows out of the arterial needle and into the dialyzer. As the blood enters the dialyzer check that there is no visible blood leak at the top of the dialyzer.

20)  Connect the blue venous line to the blue venous needle line. Unclamp both clamps on the venous line and needle.

21)  Start the pump; increase the speed gradually to the ordered blood flow while watching the venous needle for signs of infiltration (swelling) and checking both arterial and venous pressures to be in range.

22)  Clear the UF display set the desired time and goal and starts the UF. If ordered start the heparin pump and sodium modeling.

23)  Once everything runs smoothly, double check the machine to ensure that nothing has been overlooked.

B.    PERFORMING HEMODIALYSIS

1)      The pump and a timer are started. Hemodialysis is underway.

2)      Periodically (every half hour, nominally) blood pressure is taken. As a practical matter, fluid is also removed during dialysis. Most dialysis patients are on moderate to severe fluid restrictive diets (in addition to other dietary restrictions), since kidney failure usually includes an inability to properly regulate fluid levels in the body. A session of hemodialysis may typically remove 2-5 kilograms (5-10 pounds) of fluid from the patient.

3)      The amount of fluid to be removed is set by the dialysis nurse according to the patient's "estimated dry weight." This is a weight that the care staff believes represents what the patient should weight without fluid built up because of kidney failure.

3)During dialysis, occasionally, patients have low blood pressure and lose consciousness. Often this is temporary and passes after the head is placed down (Trendelenburg position) for a short time.

4)      The smaller the needles the higher the pressure.

C.    POST-HEMODIALYSIS

1)      The patient is disconnected from the plumbing - blood lines (which is removed and discarded, except perhaps for the filter, which may be sterilized and reused with the same patient at a later date). Needle wounds (in case of fistula) are bandaged with gauze, held for up to 1 hour with direct pressure to stop bleeding, and then taped in place. The process is similar to getting blood drawn, only it is lengthier and more fluid or blood is lost.

2)      Temperature, standing and sitting blood pressure, and weight are all measured again. Temperature changes may indicate infection. BP discussed above. Weighing is to confirm the removal of the desired amount of fluid.

3)      Care staff verifies that the patient is in condition suitable for leaving. The patient must be able to stand (if previously able), maintain a reasonable blood pressure, and be coherent (if normally coherent). Different rules apply for in-patient treatment.

D.    POST-DIALYSIS WASHOUT

Following hemodialysis, patients may experience a syndrome called "washout". The patient feels weak, tremulous, extreme fatigue. Patients report they "are too tired, too weak to converse, hold a book or even a newspaper." It may also vary in intensity ranging from whole body aching, stiffness in joints and other flu-like symptoms including headaches, nausea and loss of appetite. The syndrome may begin toward the end of treatment or minutes following the treatment. It may last 30 minutes or 12-14 hours in a dissipating form. Patients though exhausted have difficulty falling to sleep. Eating a light meal, rest and quiet help the patient cope with washout until it has 'worn away.

SIDE EFFECTS AND COMPLICATIONS

Side effects caused by removing too much fluid and/or removing fluid too rapidly include

@ Cardiac arrhythmias from potassium imbalance

@ Hypotension and Hyponatremia- Low BP, Fatigue. Hyponatremia occur because sudden exchange of fluid during hemodialysis procedure.

@ Dialysis hangout- Chest pains, Leg-cramps, Nausea and headache. These symptoms are sometimes collectively referred to as the dialysis hangover or dialysis washout.

@ Hemodialysis requires access to the circulatory system, patients undergoing hemodialysis may expose their circulatory system to microbes, which can lead to sepsis, an infection affecting the heart valves (Endocarditis) or an infection affecting the bones (osteomyelitis).

@ Loss of blood- Bleeding may also occur. If a patient has received too much of heparin or has clotting problems, there can be significant post dialysis bleeding.

@ Hepatitis and HIV infection- cause of hepatitis B and C includes lack of adherence to universal precautions.

@ Sepsis- sepsis is most often related to infections of vascular access sites. Infections can be minimized by strictly adhering to infection control best practices. Nurses must monitor the patient for the sign and symptom of sepsis such as fever, elevated WBC and hypotension.

@ Heparin allergy is the most commonly used anticoagulant in hemodialysis, as it is generally well tolerated and can be quickly reversed with Protamine sulfate. Heparin allergy can infrequently be a problem and can cause a low platelet count.

@ First Use Syndrome is a rare but severe anaphylactic reaction to the artificial kidney. Its symptoms include sneezing, wheezing, shortness of breath, back pain, chest pain, or sudden death.

@ Disequilibrium syndrome- develops as a result of very rapid changes in the composition of extracellular fluid. Solutes are removed more rapidly from the blood which creates a high osmotic gradient in brain resulting in the shift of fluid into the brain, causing cerebral edema, muscle cramps. Early recognition of signs by the nurse and appropriate treatment with anticonvulsants and barbiturates may prevent a life threatening situation.

@ Aluminum intoxication- occurs because of aluminum accumulation from phosphate binders. It leads to mental cloudiness, dementia, and infiltration of the bone with aluminum leading to significant pain. Aluminum chelating agents may be administered so that aluminum is freed up and dialyzed from the body.

@ Long-term complications of hemodialysis include amyloidosis, neuropathy and various forms of heart disease. Increasing the frequency and length of treatments has been shown to improve fluid overload and enlargement of the heart that is commonly seen in such patients.

@ Pediatric patients- along with these complications, body changes related to the disease process such as growth retardation, skin color are stress provoking. Dietary restrictions are particularly burdensome for both children and parents. Hyponatremia causes seizures in most pediatric patients when large changes in serum osmolality may occur.

NURSING RESPONSIBILITIES IN HEMODIALYSIS

Nursing care of the patient during hemodialysis should center on monitoring the physical status of the patient before, during and after dialysis for evidence of physiologic imbalance and change, comfort and safety needs and helping the patient to understand and adjust to the care and changes in life style. The environment must provide protection from the conditions that would promote infection.

BEFORE HEMODIALYSIS NURSING CARE:

@ Before the procedure, patient should have opportunity to become familiar with the dialysis unit.

@ The nurse has to obtain a written consent from the client.

@ The nurse should provide adequate explanation of what will happen and what will be expected of them during the treatment.

@ Record the current weight and compare to patient’s dry weight (estimated weight with no excess fluid and near normal blood pressure).

@ Obtain the baseline vital signs.

@ Assess the patient for fluid overload (pedal edema, peri-orbital edema, neck vein distension, adventitious breath sounds).

@ A blood sample is drawn to determine the level of serum electrolytes and waste products, and the patient’s physical status is assessed.

@ Patient should be told that they may experience some headache and nausea during and after the treatment for few hours.

@ The patient is assured that all these symptoms such as headache, nausea, vomiting, muscle cramps will abate and that frequent monitoring during the procedure will help to control the degree of change that occurs during hemodialysis.

@ Maintain the aseptic technique throughout the procedure.

@ Pediatric patients need reassurance about the nature of the preparation for hemodialysis and the conduct of the treatment

DURING HEMODIALYSIS NURSING CARE:

@ Know the client’s dry weight.

@ Discuss the physician whether any of the client’s medication has to be withheld until after hemodialysis.

@ Be aware of the events that occurred during the hemodialysis treatment

@ Measure the client’s blood pressure, pulse rate, respirations and temperature.

@ Assess for symptoms of orthostatic hypotension.

@ Assess the vascular access site for any complication, bleeding, dislodgement.

@ Assess the client’s level of consciousness and assess for headache, nausea and vomiting.

@ Nursing care includes measures to increase the patient’s physical comfort.

@ Changing the position increases the tolerance of the painful procedure.

@ Activity during hemodialysis is largely a matter of individual preference. Some client’s sleep during the whole procedure where as some client’s prefers to read the newspaper, magazines.

@ Some individuals feel hungry during the procedure where as others feel nauseated even with the smell of food. Practice indicates that either allowing or discouraging eating freely during procedure is matter of choice for the individual.

@ During the procedure if hypovolemia occurs, nursing measures include placing the head end side flat in position and raising the foot end side of the bed.

@ Administration of normal saline solution may be necessary to restore the blood pressure. Vital signs have to be monitored closely.

@ Keep the patient quiet, reducing environmental discomfort such as temperature extremes and bright lights.

@ Mild analgesics may help to relieve headache.

@ If there is any alteration in the client’s physiology the therapy has to be discontinued as soon as possible.

@ The patient who has recently undergone any surgery has to be monitored closely during the hemodialysis to prevent hemorrhage. Check the signs of bleeding.

@ Record each and every moment and procedure the nurse has performed.

@ Accurate recording of BP, Pulse rate, UFR set and any medication that is administered during the procedure.

POST DIALYSIS NURSING CARE:

@ Following the dialysis, the person’s weight has to be recorded again to determine the amount of fluid loss during treatment and for comparison with predialysis measurements and postural vital signs is assessed.

@ Nurse facilitates the patient learning process. Major teaching points specific to hemodialysis include the following:-

@ The process of hemodialysis and relationship to the person’s own need of body.

@ Care of the vascular access, including monitoring for complications such as absent thrill or built over artery indicating no blood flow, constriction of fistula, infection, hemorrhage.

@ Advise the client that where to obtain care if complications occur.

@ Common complications of hemodialysis, ways to schedule hemodialysis treatments for minimal interference with lifestyle.

@ The nurse closely monitors the patient immediately after hemodialysis and for several hours afterwards for any side effects from the treatment. The more common clinical manifestations of complications include: hypotension, headache, nausea, vomiting, malaise, dizziness.

@ Excessive hypotension may require rehydration with intravenous fluids.

@ The client’s temperature has to be checked. It can also be elevated because the dialysis machine warms the blood slightly. If the temperature is elevated excessively, sepsis is suspected and a blood sample is obtained, as ordered, for culture and sensitivity determinations.

@ The client is at risk for bleeding so close monitoring of the client is required.

@ All invasive procedure must be delayed for 4-6 hours after hemodialysis and the nurse closely monitors for the signs of hemorrhage during hemodialysis and for 1 hour after hemodialysis. 

@ The nurse advises the client about the dietary limitations which are necessary in chronic dialysis to avoid biochemical complications and to facilitate adequate hemodialysis.

@ Fluid and sodium are restricted to prevent fluid overload, with its associated symptoms of hypertension, cerebral manifestations and congestive heart failure.

@ Client is advised (in case of pediatrics, parents are advised) about potassium, phosphorous and protein restricted diet to prevent complications. The nurse can provide dietary chart to the patient.

@ Methods to reduce the risk of infection should be reviewed, including the provision of daily care to the catheter site. Activities like swimming may be discouraged to prevent infection.

HEMODIALYSIS SITE CARE

@ Assess venous site for redness or swelling and dressing for bleeding or other drainage to detect infection or bleeding complication at an early stage.

@ Assess vital signs for signs of infection

@ Check for the presence of pain or numbness in the extremity where the access is located to determine if the change in the blood flow is taking blood supply from the tissues distal to fistula. Clients may develop a problem known as steal syndrome as the fistula changes blood patterns and steals oxygen from parts of the extremities

@ Check for the presence of audible bruit and palpable thrill in the fistula/ graft to determine patency and monitor flow through the access.

@ Wash hands. It prevents spread of microorganisms.

@ Put on sterile gloves. To maintains sterile technique.

@ Position the extremity to palpate the fistula. It prevents trauma to the fistula.

@ Palpate gently over the area with finger tips or palm of hand to feel for thrill. Tests for adequate blood flow through the fistula

@ Auscultate over the area with a stethoscope to detect a bruit (swishing noise). 

@ Palpate pulses distal to the fistula and observe capillary refill in the extremity. Tests for adequate blood flow through the fistula. Notify the physician or qualified practitioner if bruit and thrill are absent. Surgical interventions may be necessary to restore flow.

@ Assess for symptoms of infection, bleeding or sensation impairment in the area around the fistula and the entire extremity.

@ Inform the client to avoid any activities that will restrict flow or cause injury to the affected extremity

@ Cleanse the catheter surrounding site with Povidine Iodine swabs beginning at insertion site and going out in a circular motion. Removes pathogens from the skin and prepares for a new dressing.

@ Cleanse ends of the catheter with alcohol swabs and then attach new primed male adapters. Removes any old blood or drainage.

@ Discard all the waste thoroughly according to hospital policy and protocols. Biomedical waste management will prevent the spread of infection.

BIBLIOGRAPHY

1)         Lippincott. Manual of nursing practice. 8th edition: Indian; Lippincott Williams and Wilkins. P-759-763.

2)         Lewis, Dirksen, Heitkemper. Medical surgical nursing. 6th edition: Mosby. P- 1229-1234

3)         Doenges Marilyn E. Nursing care plan. 6th edition: Philadelphia. P- 560-63

4)         Bobbee Terill. Renal Nursing. A practical approach. Ausmed publications. P- 89-165

5)         Gaylene Bonska, Altman. Fundamental & Advanced nursing skills. P- 1056-1061 

6)         Long, Phipps, Cassmeyer. Medical Surgical Nursing. A nursing process approach. 3rd edition. P- 1085-1090.

7)         Donna D., M. Linda, Mary A. Medical Surgical Nursing. A nursing process approach. Volume II; 2nd edition, Saunders; 1991. P- 2127-2138.

8)         Norton, Spiezio, La Manna. Varying heparin requirements in hemodialysis patients receiving erythropoietin. American Nephrology Nurses’ Associations Journal, 19(4). P- 367-372.

9)         Ball Jane, Bindler Ruth. Pediatric nursing caring for children. 2nd edition. P- 691-95.

10)     Donna L. Wong. Nursing care of infants and children. 5th edition, Mosby. P-1323-25.

11)     http://www.journals.elsevierhealth.com/periodicals/yjarr/article/PIIS1073444901700118/abstract

12)     http://en.wikipedia.org/wiki/File:Plugged_into_dialysis.jpg

13)     http://www.uptodate.com/patients/content/topic.do?topicKey=~cKFQO5IpxApIu7#18

14)     http://www3.interscience.wiley.com/journal/122648826/abstract?CRETRY=1&SRETRY