Renal Replacement Therapies

• What are the three types of vascular access in renal replacement therapy?

  IV, AV Fistula, AV graft
• What is the vascular access IV for RRT indicate?

   ​

  • Short Term: < 3 weeks; inserted subclavian, internal jugular, or femoral vein​
  • Long Term: have silicone cuff to decrease infection & prevent displacement 
• How does the AV fistula function?

  preferred method​

  • Anastomosis (joining) of artery to vein usually brachial/radial to cephalic vein​
  • May take 2 wks – 4 mo to mature; plan in advance​
  • Appears large, bulging, tortuous under skin​
  • Venous: dilates d/t inc arterial pressure ~ helps w/ rapid blood return [reinfusion]​
  • Arterial: used for flow to dialyzer
• How does an AV graft function in RRT?

  • AV graft: prosthetic graft btwn an artery & vein​
  • More quickly than a fistula but don't last as long ​
  • Prone to infection​
  • Can feel thrill (palpable pulsation) or hear bruit
• What care is considered when using the IV catheter as a vascular access in dialysis?

  • Do not use for IVs or blood draws​
  • Monitor for signs of infection​
  • Flushing and dressing change by HD nurse ​
• What care is considered when using an AV graft or fistula during dialysis treatment?

  • No procedures on that arm!! ​
  • Ex. BP, draws, constricting arm band/garments, sleep on arm, any weight ​
  • Check bruit and thril q shift​
  • Monitor neuro circulation distal to site q shift​
  • Monitor for signs of infection ​
• How does hemodialysis work?

  • Pt blood passes through artificial kidney (dialyzer), which performs filtering and excretion functions of kidneys​
  • Toxins removed by diffusion [waste conc higher in blood to diasylate (lower conc)]​
  • Bicarb & Ca will move from diasylate to blood ​
  • Excess Fluid removed by osmosis/ultrafiltration ​
  • Ultrafiltration done to dec fluid vol excess​
  • Excess water into diasylate by osmosis ​
  • Performed in permanent or temporary vascular access​
• What drug is typically given with hemodialysis treatment?

  Heparin given during procedure to prevent blood clotting in machine
• What are some nursing actions to consider during pre-dialysis treatment?

  • Check wt & VS [if hypotensive = might not do HD]​
  • Wt best indicator for how much fluid came off​
  • AM: hold ALL meds until post dialysis​
  • PM: hold BP and diuretic meds 
• What are some priority nursing problems to consider in post-dialysis care?

  • Risk for hypotension
  • Disequilibrium Syndrome
  • Other complications
  • muscle cramps
  • arrhythmias
  • Malaise
  • Infection [hepatitis, HIV, cytomegalovirus]
  • immunosuppression
  • Dialysis access
• How does the nurse manage the risk for hypotension post-dialysis?

  • VS, site check for bleeding ​
  • Dysfunctional platelets combined w/ needles & heparin = @ risk for bleeding 
• How does the nurse assess for disequilibrium syndrome is post-dialysis care?

  D/t rapid F&E shift --> cerebral edema --> seizures --> death​

  • Sx: dizziness, change in mental status, seizures, headache
• What other nursing care should be considered for the patient undergoing hemodialysis?

  • Screen and address psychosocial needs
  • Client Education
• What type of client education should be given for the care in hemodialysis?

  • Care of access site: Sx of infection [fever, redness, drainage, swelling]​
  • Teach to check graft patency [thrill or bruit]​
  • Diet: high in folate [beans, green vegetables]​
  • Meds & Supplements as prescribed ​
  • Prevent restriction on extremity w/ vascular site
• What is continuous renal replacement therapy?

  "gentler" dialysis for those unable to tolerate acute hemodialysis or critically ill patients

  • slower process that does NOT cause dramatic fluid & electrolyte shifts
• What is the main purpose of CRRT?

  pull off fluid; diasylate can be added in to remove toxins
• What is required in the nursing care of CRRT?

  Hourly assessment of VS, equipment, and I & O

  • 1:1 nursing
  • seen in ICU setting
• How long does CRRT typically go for?

  runs continuously for several days
• How does peritoneal dialysis work?

  • Diasylate (2L) is infused into the peritoneal cavity​
  • Toxins & water move across peritoneal membrane (filtering) into diasylate by osmosis & diffusion​
  • Diasylate w/ Toxins and excess fluid drained out by gravity ​
  • Can be continuous or intermittent 
• Will the patient continue to use peritoneal dialysis life long?

  Eventually pt will experience dec in kidney fx and will need Hemodialysis or a transplant 
• Who are considered to be good candidates for peritoneal dialysis?

  • Intolerance to rapid fluid shift (DM, cardaic diease)​
  • Those at risk to side effects of heparin​
  • Ambulatory patients ~ offers inc pt control & flexibility​
  • Fewer dietary restrictions & greater mobility ​
  • Other Indications: pt did not tolerate HD well or vascular access probs ​
  • Avoids rapid shift & Sx that come
• Who is contraindicated to receive PD?

  • Multiple abdominal surgeries [scar tissue]​
  • Recent hernias [weakened abd tissue]
• What is continuous ambulatory peritoneal dialysis?

  • Infused 4-5x/day - dwell time 4 – 6 hrs​
  • No Dialysis at night – dwell overnight​
  • No Machine needed​
  • Pt ambulatory during the day​
  • Less extreme fluctuations in lab values since it is constant ​
  • Reasonable freedom and control ~ programmed to meet individual needs 
• What diet is recommended for the patient undergoing continuous ambulatory peritoneal dialysis?

  moderate protein, increased fiber ​
• Why should the client undergoing CAPD be in a moderate protein diet with increased fiber?

  Fiber = prevent constipation

  moderate protein because the client is losing more protein since peritoneal membrane is more permeable to proteins
• What is continuous cyclic peritoneal dialysis?

  • Overnight Intermittent PD with prolonged dwell time during the day​
  • Cycler machine does the work overnight​
  • Dwells during the day​
  • Lower rate of infection – fewer disconnection​
  • No exchanges during the day – more freedom
• When does the dwell time occur during CAPD?

  dwells overnight
• When does the dwell time occur during CCPD?

  dwelling during the day
• What are some potential complications to consider during the care of a patient undergoing peritoneal dialysis?

  Infection (peritonitis), pain, respiratory compromise
• How does the nurse manage infection for the client undergoing peritoneal dialysis?

  • Peritonitis or catheter site infection [Sx: redness, tenderness, drainage]​
  • Cloudy effluent & Inc WBCs​
  • Tx: Antibiotics
  • For recurrent infections = removal of PD and switch to Hemodialysis
• How does the nurse manage pain for the patient undergoing peritoneal dialysis?

  Slow down infusion

  • infusing diasylate too fast or too cold
  • Monitor the position of catheter - could be resting bladder/bowel/peritoneum
• How does the nurse manage respiratory compromise in the client undergoing peritoneal dialysis?

  • Repeated upward displacement of diaphragm --> dec lung expansion​
  • Inc risk w/ longer dwell times 
• What is some additional information to considerr with the perio=toneal catheter?

  • Tenckhoff catheter made of elastic Teflon with Dacron felt cuffs ​
  • 10 – 14 days after placement, in-growth occurs and fixates the catheter ​
  • Anti-microbial cap on end ~ sterile exchange ​
  • Usually dressing on the insertion site ​
  • Exit site usually on lower abd, near the umbilicus