RENAL SYSTEM FAILURE PYRAMID POINTS Causes of acute

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RENAL SYSTEM FAILURE

RENAL SYSTEM FAILURE

PYRAMID POINTS • • • Causes of acute and chronic renal failure Stages of

PYRAMID POINTS • • • Causes of acute and chronic renal failure Stages of renal failure Assessment findings in renal failure Therapeutic management of renal failure Principles of dialysis Preprocedure care for hemodialysis

PYRAMID POINTS • • • Disequilibrium syndrome Access for hemodialysis Monitoring patency of dialysis

PYRAMID POINTS • • • Disequilibrium syndrome Access for hemodialysis Monitoring patency of dialysis access devices Preprocedure care for peritoneal dialysis Complications of peritoneal dialysis Client education related to peritoneal dialysis techniques

RENAL FAILURE • DESCRIPTION – The loss of kidney function – Types include acute

RENAL FAILURE • DESCRIPTION – The loss of kidney function – Types include acute renal failure or chronic renal failure – The signs and symptoms of renal failure are caused by the retention of wastes and fluids, and the inability of the kidneys to regulate electrolytes

RENAL FAILURE • DESCRIPTION – Prerenal causes include intravascular volume depletion, decreased cardiac output,

RENAL FAILURE • DESCRIPTION – Prerenal causes include intravascular volume depletion, decreased cardiac output, or vascular failure secondary to vasodilation or obstruction – Renal causes include tubular necrosis, nephrotoxicity, and alterations in renal blood flow – Postrenal causes include obstruction of urine flow between the kidney and urethral meatus and bladder neck obstruction

TYPES OF RENAL FAILURE From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations

TYPES OF RENAL FAILURE From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W. B. Saunders

ACUTE RENAL FAILURE (ARF) • DESCRIPTION – The sudden loss of kidney function caused

ACUTE RENAL FAILURE (ARF) • DESCRIPTION – The sudden loss of kidney function caused by renal cell damage from ischemia or toxic substances – ARF occurs abruptly and can be reversible – It leads to hypoperfusion, cell death, and decompensation in renal function – The prognosis is dependent on the cause and the condition of the client – Near-normal or normal kidney function may resume gradually

ACUTE RENAL FAILURE (ARF) • CAUSES – Infection – Renal artery occlusion – Obstruction

ACUTE RENAL FAILURE (ARF) • CAUSES – Infection – Renal artery occlusion – Obstruction – Acute kidney disease – Dehydration – Diuretic therapy – Ischemia from hypovolemia, heart failure, septic shock, and blood loss – Toxic substances such as medications, particularly antibiotics

PHASE OF ACUTE RENAL FAILURE • Oliguric • Diuretic • Recovery (convalescent)

PHASE OF ACUTE RENAL FAILURE • Oliguric • Diuretic • Recovery (convalescent)

ACUTE RENAL FAILURE • OLIGURIC PHASE – Duration is 8 to 15 days, and

ACUTE RENAL FAILURE • OLIGURIC PHASE – Duration is 8 to 15 days, and the longer the duration, the less chance of recovery – Glomerular filtration rate decreases – Sudden drop in urine output; urine output less than 400 ml/day – Hypertension – Hyperkalemia – Sodium level normal or decreased – Fluid overload – Elevated BUN and creatinine

ACUTE RENAL FAILURE • DIURETIC PHASE – Glomerular filtration rate begins to increase –

ACUTE RENAL FAILURE • DIURETIC PHASE – Glomerular filtration rate begins to increase – Urine output rises slowly and then diuresis occurs (4 to 5 L/day) – Excessive urine output indicates recovery of damaged nephrons – Hypotension, tachycardia – Improvement in level of consciousness (LOC) – Hypokalemia, hyponatremia, hypovolemia – Gradual decline in BUN and creatinine

RENAL FAILURE • RECOVERY PHASE (CONVALESCENT) – A slow process; complete recovery may take

RENAL FAILURE • RECOVERY PHASE (CONVALESCENT) – A slow process; complete recovery may take 1 to 2 years – Urine volume is normal – Increase in strength – Increase in LOC – BUN is stable and normal – Client can develop chronic renal failure

CHRONIC RENAL FAILURE (CRF) • DESCRIPTION – The progressive loss and ongoing deterioration in

CHRONIC RENAL FAILURE (CRF) • DESCRIPTION – The progressive loss and ongoing deterioration in kidney function that occurs slowly over a period of time – It occurs in stages, is irreversible, and results in uremia or end-stage renal disease

CHRONIC RENAL FAILURE (CRF) • DESCRIPTION – CRF affects all of the major body

CHRONIC RENAL FAILURE (CRF) • DESCRIPTION – CRF affects all of the major body systems and requires dialysis or kidney transplant to maintain life – Hypervolemia can occur owing to the inability of the kidneys to excrete sodium and water, or hypovolemia can occur owing to the inability of the kidneys to conserve sodium and water

STAGES OF CHRONIC RENAL FAILURE • STAGE I: DIMINISHED RENAL RESERVE – Renal function

STAGES OF CHRONIC RENAL FAILURE • STAGE I: DIMINISHED RENAL RESERVE – Renal function is reduced – No accumulation of metabolic wastes – The healthier kidney compensates – Nocturia and polyuria occur as a result of decreased ability to concentrate urine

STAGES OF CHRONIC RENAL FAILURE • STAGE II: RENAL INSUFFICIENCY – Metabolic wastes begin

STAGES OF CHRONIC RENAL FAILURE • STAGE II: RENAL INSUFFICIENCY – Metabolic wastes begin to accumulate – Oliguria and edema occur as a result of decreased responsiveness to diuretics • STAGE III END-STAGE – Excessive accumulation of metabolic wastes – Kidneys are unable to maintain homeostasis – Dialysis or other renal replacement therapy is required

CHRONIC RENAL FAILURE (CRF) • CAUSES – May follow ARF – Renal artery occlusion

CHRONIC RENAL FAILURE (CRF) • CAUSES – May follow ARF – Renal artery occlusion – Chronic urinary obstruction – Recurrent infections – Hypertension – Metabolic disorders – Diabetes mellitus – Autoimmune disorders

CHRONIC RENAL FAILURE (CRF) • ASSESSMENT – Anorexia and nausea – Headache – Weakness

CHRONIC RENAL FAILURE (CRF) • ASSESSMENT – Anorexia and nausea – Headache – Weakness and fatigue – Hypertension – Confusion and lethargy, followed by convulsions and coma – Kussmaul’s respirations – Diarrhea or constipation – Muscle twitching and numbness of the extremities

CHRONIC RENAL FAILURE (CRF) • ASSESSMENT – Decreased urine output – Decreased urine specific

CHRONIC RENAL FAILURE (CRF) • ASSESSMENT – Decreased urine output – Decreased urine specific gravity – Proteinuria – Anemia – Azotemia – Fluid overload and signs of heart failure – Uremic frost: a layer of urea crystals from evaporated perspiration that appears on the face, eyebrows, axilla, and groin in clients with advanced uremic syndrome

RENAL FAILURE • IMPLEMENTATION – Monitor vital signs – Monitor urine and I&O (hourly

RENAL FAILURE • IMPLEMENTATION – Monitor vital signs – Monitor urine and I&O (hourly in ARF) – Monitor weight, noting that an increase of 0. 5 to 1 lb daily indicates fluid retention – Monitor BUN, creatinine, and electrolyte values – Monitor for acidosis and treat with sodium bicarbonate as prescribed – Assess urinalysis for protein, hematuria, casts, and specific gravity

RENAL FAILURE • IMPLEMENTATION – Monitor LOC – Assess for signs of infection, since

RENAL FAILURE • IMPLEMENTATION – Monitor LOC – Assess for signs of infection, since the client may not demonstrate a temperature or an increased white blood cell (WBC) count – Assess for dysrhythmias since a potassium level above 6 m. Eq/L will cause peaked T waves and a widened QRS complex – Monitor fluid overload; assess lungs for rales and rhonchi – Monitor for edema

RENAL FAILURE • IMPLEMENTATION – Administer prescribed diet; usually a moderate protein intake (to

RENAL FAILURE • IMPLEMENTATION – Administer prescribed diet; usually a moderate protein intake (to decrease the workload on the kidneys), high-carbohydrate, and lowpotassium and phosphorus diet is prescribed – Restrict sodium intake as prescribed based on the electrolyte level – Daily fluid allowances may be 400 to 1000 ml plus measured urinary output

RENAL FAILURE • IMPLEMENTATION – Administer sodium polystyrene sulfonate (Kayexalate) to lower the potassium

RENAL FAILURE • IMPLEMENTATION – Administer sodium polystyrene sulfonate (Kayexalate) to lower the potassium level as prescribed – Be alert to the mechanism for metabolism and excretion of all prescribed medication – Be alert to nephrotoxic medications, such as antibiotics, which may be prescribed – Prepare the client for dialysis if prescribed

SPECIAL PROBLEMS IN RENAL FAILURE • • Hypertension Hypervolemia Hypovolemia Potassium retention Phosphorus retention

SPECIAL PROBLEMS IN RENAL FAILURE • • Hypertension Hypervolemia Hypovolemia Potassium retention Phosphorus retention Low calcium Metabolic acidosis Anemia

SPECIAL PROBLEMS IN RENAL FAILURE • • Gastrointestinal (GI) bleeding Infection and injury Pruritus

SPECIAL PROBLEMS IN RENAL FAILURE • • Gastrointestinal (GI) bleeding Infection and injury Pruritus Muscle cramps Ocular irritation Insomnia and fatigue Neurological changes Psychosocial problems

HYPERTENSION • Failure of the kidneys to maintain homeostasis of the blood pressure •

HYPERTENSION • Failure of the kidneys to maintain homeostasis of the blood pressure • Monitor vital signs • Maintain fluid and sodium restrictions as prescribed • Administer diuretics and antihypertensives as prescribed • Administer propranolol (Inderal), a betaadrenergic antagonist, as prescribed, which decreases renin release (renin causes vasoconstriction)

HYPERVOLEMIA • • • Monitor vital signs Monitor I&O, weight, and for edema Monitor

HYPERVOLEMIA • • • Monitor vital signs Monitor I&O, weight, and for edema Monitor electrolytes Monitor for hypertension Monitor for congestive heart failure (CHF) and pulmonary edema • Enforce fluid restriction; avoid the administration of IV fluids • Administer diuretics as prescribed • Instruct the client to avoid foods with sodium and to avoid antacids or cold remedies containing sodium bicarbonate

HYPOVOLEMIA • • • Monitor vital signs Monitor I&O and weight Monitor electrolytes Monitor

HYPOVOLEMIA • • • Monitor vital signs Monitor I&O and weight Monitor electrolytes Monitor for hypotension Monitor for dehydration Provide replacement therapy based on the electrolyte results • Provide sodium supplements as prescribed depending on the electrolyte value

POTASSIUM RETENTION • Monitor vital signs and apical rate • Monitor potassium level •

POTASSIUM RETENTION • Monitor vital signs and apical rate • Monitor potassium level • Monitor for dysrhythmias (peaked T waves and widened QRS complex) indicating hyperkalemia • Provide a low-potassium diet • Administer medications as prescribed to lower the potassium level • Prepare the client for dialysis

PHOSPHORUS RETENTION • Phosphorus rises and calcium drops, which leads to stimulation of parathyroid

PHOSPHORUS RETENTION • Phosphorus rises and calcium drops, which leads to stimulation of parathyroid hormone, causing bone demineralization • Treatment is aimed at lowering serum phosphorus levels • Administer aluminum hydroxide preparations or other phosphate binders as prescribed that bind phosphorus in the intestine and allow the phosphorus to be eliminated

PHOSPHORUS RETENTION • Administer aluminum hydroxide preparations at meals and not with other medications

PHOSPHORUS RETENTION • Administer aluminum hydroxide preparations at meals and not with other medications because they bind medications in the intestinal tract • Administer stool softeners and laxatives as prescribed to prevent constipation, because aluminum hydroxide preparations are constipating • Enforce phosphorus restriction in the diet

LOW CALCIUM • Occurs because of the high phosphorus level and because of the

LOW CALCIUM • Occurs because of the high phosphorus level and because of the inability of the diseased kidney to activate vitamin D • The absence of vitamin D causes a poor absorption of calcium from the intestinal tract • Monitor calcium level • Administer calcium supplements as prescribed • Administer activated vitamin D as prescribed

METABOLIC ACIDOSIS • The kidneys are unable to excrete hydrogen ions or manufacture bicarbonate,

METABOLIC ACIDOSIS • The kidneys are unable to excrete hydrogen ions or manufacture bicarbonate, resulting in acidosis • Administer alkalyzers such as sodium bicarbonate as prescribed • Note that clients with CRF adjust to low bicarbonate levels and do not become acutely ill

ANEMIA • A decreased rate of production of red blood cells (RBCs) occurs as

ANEMIA • A decreased rate of production of red blood cells (RBCs) occurs as a result of the diseased kidney and the decreased secretion of erythropoeitin • Monitor hemoglobin and hematocrit • Administer epoetin alfa (Epogen) as prescribed to stimulate the production of RBCs • Administer folic acid (vitamin B 9) as prescribed instead of oral iron, because oral iron is not wellabsorbed by the GI tract in CRF and causes nausea and vomiting

ANEMIA • Administer blood transfusions if prescribed, but blood transfusions are prescribed only when

ANEMIA • Administer blood transfusions if prescribed, but blood transfusions are prescribed only when necessary because they decrease the stimulus to produce RBCs • Monitor bleeding • Instruct the client to use a soft toothbrush • Administer stool softeners as prescribed • Avoid the administration of acetylsalicylic acid (aspirin) because the medication is excreted by the kidneys; and if administered, high toxic levels will occur and prolong bleeding time

GI BLEEDING • Urea is broken down to ammonia by the intestinal bacteria, and

GI BLEEDING • Urea is broken down to ammonia by the intestinal bacteria, and ammonia is a mucosal irritant that causes ulceration and bleeding • Monitor hemoglobin and hematocrit levels • Monitor stools for occult blood

INFECTION AND INJURY • Infection and injury need to be monitored and avoided because

INFECTION AND INJURY • Infection and injury need to be monitored and avoided because tissue breakdown causes increased potassium levels • Monitor for signs of infection • Avoid urinary catheters and provide strict asepsis during insertion and catheter care • Instruct the client to avoid fatigue, which decreases body resistance • Instruct the client to avoid people with infections • Administer antibiotics as prescribed, monitoring for nephrotoxic effects

PRURITUS • Urate crystals are excreted through the skin to rid of excess wastes

PRURITUS • Urate crystals are excreted through the skin to rid of excess wastes • This deposit of crystals is called uremic frost and it is seen in advanced stages of renal failure • Monitor for skin breakdown, rash, and uremic frost • Provide good skin care and oral hygiene • Avoid the use of soaps • Administer antipruritics as prescribed

MUSCLE CRAMPS • Occur in the extremities and hands and can be due to

MUSCLE CRAMPS • Occur in the extremities and hands and can be due to electrolyte imbalances • Monitor electrolytes • Administer electrolyte replacements as prescribed • Administer heat and massage as prescribed

OCULAR IRRITATION • Calcium deposits in the conjunctiva cause burning and watering of the

OCULAR IRRITATION • Calcium deposits in the conjunctiva cause burning and watering of the eyes • Administer medications to control the calcium and phosphate levels as prescribed • Administer lubricating eye drops

INSOMNIA AND FATIGUE • The diseased kidneys cause a build-up of wastes, causing fatigue

INSOMNIA AND FATIGUE • The diseased kidneys cause a build-up of wastes, causing fatigue in the client • Provide adequate rest periods • Administer mild central nervous system (CNS) depressants as prescribed

NEUROLOGICAL CHANGES • The build-up of active particles and fluids causes changes in the

NEUROLOGICAL CHANGES • The build-up of active particles and fluids causes changes in the brain cells and leads to confusion and impairment in decision-making ability • Monitor for confusion and monitor LOC • Protect the client from injury • Provide a safe and hazard-free environment • Use side rails as needed • Provide a calm and restful environment • Provide comfort measures and backrubs

PSYCHOSOCIAL PROBLEMS • Monitor the client for psychological problems such as depression, anxiety, suicidal

PSYCHOSOCIAL PROBLEMS • Monitor the client for psychological problems such as depression, anxiety, suicidal behavior, denial, dependency/independence conflict, and changes in body image

HEMODIALYSIS • DESCRIPTION – The diffusion of dissolved particles from one fluid compartment into

HEMODIALYSIS • DESCRIPTION – The diffusion of dissolved particles from one fluid compartment into another across a semipermeable membrane – The client’s blood flows through one fluid compartment and the dialysate is in another fluid compartment

FUNCTIONS OF HEMODIALYSIS • Cleanses the blood of accumulated waste products • Removes the

FUNCTIONS OF HEMODIALYSIS • Cleanses the blood of accumulated waste products • Removes the by-products of protein metabolism, such as urea, creatinine, and uric acid • Removes excessive fluids • Maintains or restores the body’s buffer system • Maintains or restores electrolyte levels

PRINCIPLES OF HEMODIALYSIS • The semipermeable membrane is made of a thin, porous cellophane

PRINCIPLES OF HEMODIALYSIS • The semipermeable membrane is made of a thin, porous cellophane • The pore size of the membrane allows small particles to pass through, such as urea, creatinine, uric acid, and water molecules • Proteins, bacteria, and blood cells are too large to pass through the membrane • The client’s blood flows into the dialyzer; the movement of substances occurs from the blood to the dialysate

PRINCIPLES OF HEMODIALYSIS • DIFFUSION – The movements of particles from an area of

PRINCIPLES OF HEMODIALYSIS • DIFFUSION – The movements of particles from an area of greater concentration to lesser concentration • OSMOSIS – The movement of fluids across a semipermeable membrane from an area of lesser concentration of particles to an area of greater concentration of particles • ULTRAFILTRATION – The movement of fluid across a semipermeable membrane as a result of an artificially created pressure gradient

DIFFUSION From Thibodeau GA, Patton KT: Anatomy and Physiology, ed. 4, St. Louis, 1999,

DIFFUSION From Thibodeau GA, Patton KT: Anatomy and Physiology, ed. 4, St. Louis, 1999, Mosby.

OSMOSIS From Lewis SM, Heitkemper MM, Dirksen SR: Medical-Surgical Nursing: Assessment and Management of

OSMOSIS From Lewis SM, Heitkemper MM, Dirksen SR: Medical-Surgical Nursing: Assessment and Management of Clinical Problems ed. 5, St. Louis, 2000, Mosby.

ULTRAFILTRATION From Beare, P. & Myers, J. (1998). Adult health nursing, ed 3, St.

ULTRAFILTRATION From Beare, P. & Myers, J. (1998). Adult health nursing, ed 3, St. Louis: Mosby

DIALYSATE BATH • Composed of water and major electrolytes • The dialysate need not

DIALYSATE BATH • Composed of water and major electrolytes • The dialysate need not be sterile because bacteria are too large to pass through; however, the dialysate must meet specific standards and water treatment systems are used to ensure a safe water supply

DIALYZER USED IN HEMODIALYSIS From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations

DIALYZER USED IN HEMODIALYSIS From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W. B. Saunders

HEMODIALYSIS From Lewis SM, Heitkemper MM, Dirksen SR: Medical-Surgical Nursing: Assessment and Management of

HEMODIALYSIS From Lewis SM, Heitkemper MM, Dirksen SR: Medical-Surgical Nursing: Assessment and Management of Clinical Problems ed. 5, St. Louis, 2000, Mosby.

CONTINUOUS ARTERIOVENOUS HEMOFILTRATION From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3

CONTINUOUS ARTERIOVENOUS HEMOFILTRATION From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.

HEMODIALYSIS • IMPLEMENTATION – Monitor vital signs – Monitor laboratory values before, during, and

HEMODIALYSIS • IMPLEMENTATION – Monitor vital signs – Monitor laboratory values before, during, and after dialysis – Assess the client for fluid overload prior to the procedure – Assess patency of the blood access device – Weigh the client before and after the procedure to determine fluid loss

HEMODIALYSIS • IMPLEMENTATION – Hold antihypertensives and other medications that can affect the BP

HEMODIALYSIS • IMPLEMENTATION – Hold antihypertensives and other medications that can affect the BP prior to the procedure as prescribed – Hold medications that could be dialyzed off such as water-soluble vitamins and certain antibiotics – Monitor for shock and hypovolemia during the procedure – Provide adequate nutrition (client may eat prior to the procedure)

COMPLICATIONS OF HEMODIALYSIS • • Disequilibrium syndrome Dialysis encephalopathy Electrolyte changes Hepatitis Hypotension and

COMPLICATIONS OF HEMODIALYSIS • • Disequilibrium syndrome Dialysis encephalopathy Electrolyte changes Hepatitis Hypotension and shock Loss of blood Muscle cramping Sepsis

DISEQUILIBRIUM SYNDROME • DESCRIPTION – A rapid change in the composition of the extracellular

DISEQUILIBRIUM SYNDROME • DESCRIPTION – A rapid change in the composition of the extracellular fluid (ECF) occurs during hemodialysis – Solutes are removed from the blood faster than from the cerebrospinal fluid (CSF) and brain; fluid is pulled into the brain causing cerebral edema

DISEQUILIBRIUM SYNDROME • ASSESSMENT – Nausea – Vomiting – Headache – Hypertension – Restlessness

DISEQUILIBRIUM SYNDROME • ASSESSMENT – Nausea – Vomiting – Headache – Hypertension – Restlessness and agitation – Confusion – Seizures

DISEQUILIBRIUM SYNDROME • IMPLEMENTATION – Monitor for signs of disequilibrium syndrome – Notify the

DISEQUILIBRIUM SYNDROME • IMPLEMENTATION – Monitor for signs of disequilibrium syndrome – Notify the physician if signs of disequilibrium syndrome occur – Reduce environmental stimuli – Prepare to dialyze the client for a shorter period at reduced blood flow rates to prevent occurrence

DIALYSIS ENCEPHALOPATHY • DESCRIPTION – An aluminum toxicity that occurs as a result of

DIALYSIS ENCEPHALOPATHY • DESCRIPTION – An aluminum toxicity that occurs as a result of aluminum in the H 20 sources used in the dialysate, and the ingestion of aluminumcontaining antacids (phosphate-binders)

DIALYSIS ENCEPHALOPATHY • ASSESSMENT – Progressive neurological impairment – Mental cloudiness – Speech disturbances

DIALYSIS ENCEPHALOPATHY • ASSESSMENT – Progressive neurological impairment – Mental cloudiness – Speech disturbances – Dementia – Muscle incoordination – Bone pain – Seizures

DIALYSIS ENCEPHALOPATHY • IMPLEMENTATION – Monitor for signs of dialysis encephalopathy – Notify the

DIALYSIS ENCEPHALOPATHY • IMPLEMENTATION – Monitor for signs of dialysis encephalopathy – Notify the physician if signs of dialysis encephalopathy occurs – Administer aluminum-chelating agents as prescribed so that the aluminum is freed up and dialyzed from the body

ACCESS FOR HEMODIALYSIS • • Subclavian and femoral catheter External arteriovenous shunt (AV shunt)

ACCESS FOR HEMODIALYSIS • • Subclavian and femoral catheter External arteriovenous shunt (AV shunt) Internal arteriovenous fistula (AV fistula) Internal arteriovenous graft (AV graft)

SUBCLAVIAN AND FEMORAL CATHETERS • DESCRIPTION – A subclavian (subclavian vein) or femoral (femoral

SUBCLAVIAN AND FEMORAL CATHETERS • DESCRIPTION – A subclavian (subclavian vein) or femoral (femoral vein) catheter may be inserted for short-term or temporary use in ARF – May be used until a fistula or graft matures or develops, or when the client has fistula or graft access failure due to infection or clotting

SUBCLAVIAN AND FEMORAL CATHETERS • SUBCLAVIAN VEIN CATHETER – Is usually filled with heparin

SUBCLAVIAN AND FEMORAL CATHETERS • SUBCLAVIAN VEIN CATHETER – Is usually filled with heparin and capped to maintain patency between dialysis treatments – The catheter should not be uncapped – The catheter may be left in place for up to 6 weeks if complications do not occur

SUBCLAVIAN AND FEMORAL CATHETERS • FEMORAL VEIN CATHETER – The client should not sit

SUBCLAVIAN AND FEMORAL CATHETERS • FEMORAL VEIN CATHETER – The client should not sit up more than 45 degrees or lean forward or the catheter may kink and occlude – Assess extremity for circulation, temperature, and pulses – Prevent pulling or disconnecting of the catheter when giving care – Use an IV control pump with microdrip tubing if a heparin infusion is prescribed

SUBCLAVIAN AND FEMORAL CATHETERS • IMPLEMENTATION – Assess insertion site for hematoma, bleeding, dislodging,

SUBCLAVIAN AND FEMORAL CATHETERS • IMPLEMENTATION – Assess insertion site for hematoma, bleeding, dislodging, and infection – Do not use these catheters for any reason other than dialysis – Maintain an occlusive dressing

EXTERNAL ARTERIOVENOUS SHUNT (AV SHUNT) • DESCRIPTION – Access is formed by the surgical

EXTERNAL ARTERIOVENOUS SHUNT (AV SHUNT) • DESCRIPTION – Access is formed by the surgical insertion of two Silastic cannulas into an artery and a vein in the forearm or leg to form an external blood path – The cannulas are connected to form a U-shape; blood flows from the client’s artery through the shunt into the vein – A tube leading to the membrane compartment of the dialyzer is connected to the arterial cannula

EXTERNAL ARTERIOVENOUS SHUNT (AV SHUNT) • DESCRIPTION – Blood fills the membrane compartment and

EXTERNAL ARTERIOVENOUS SHUNT (AV SHUNT) • DESCRIPTION – Blood fills the membrane compartment and flows back to the client by way of a tube connected to the venous cannula – When dialysis is complete, the cannulas are clamped and reattached to form their U-shape

ARTERIOVENOUS SHUNT From Sanders M et al (2000) Mosby’s paramedic textbook (2 nd ed.

ARTERIOVENOUS SHUNT From Sanders M et al (2000) Mosby’s paramedic textbook (2 nd ed. ) St. Louis: Mosby.

EXTERNAL ARTERIOVENOUS SHUNT (AV SHUNT) • ADVANTAGES – Can be used immediately following creation

EXTERNAL ARTERIOVENOUS SHUNT (AV SHUNT) • ADVANTAGES – Can be used immediately following creation – No venipuncture is necessary for dialysis • DISADVANTAGES – External danger of disconnecting or dislodging – Risk of hemorrhage, infection, or clotting – Skin erosion around the catheter site can occur

EXTERNAL ARTERIOVENOUS SHUNT (AV SHUNT) • IMPLEMENTATION – Avoid wetting the shunt – A

EXTERNAL ARTERIOVENOUS SHUNT (AV SHUNT) • IMPLEMENTATION – Avoid wetting the shunt – A dressing is completely wrapped around the shunt and kept dry and intact – Cannula clamps need to be available at the client’s bedside – Do not take a blood pressure, draw blood, place an IV, or administer injections in the shunt extremity – Monitor for hemorrhage, infection, and clotting

EXTERNAL ARTERIOVENOUS SHUNT (AV SHUNT) • IMPLEMENTATION – Monitor skin integrity around the insertion

EXTERNAL ARTERIOVENOUS SHUNT (AV SHUNT) • IMPLEMENTATION – Monitor skin integrity around the insertion site – Note that the shunt is patent if it is warm to touch – Auscultate and palpate for a bruit, although a bruit may not be heard and is not always felt with the shunt – Notify the physician immediately if signs of clotting, hemorrhage, or infection occur

EXTERNAL ARTERIOVENOUS SHUNT (AV SHUNT) • SIGNS OF CLOTTING – Fold back the dressing

EXTERNAL ARTERIOVENOUS SHUNT (AV SHUNT) • SIGNS OF CLOTTING – Fold back the dressing to expose the shunt tubing and assess for signs of clotting – Fibrin (white flecks) noted in the tubing – The separation of serum and cells – The absence of a previously heard bruit – Coolness of the tubing or extremity – Client complains of a tingling sensation

INTERNAL ARTERIOVENOUS FISTULA (AV FISTULA) • DESCRIPTION – Access of choice for chronic dialysis

INTERNAL ARTERIOVENOUS FISTULA (AV FISTULA) • DESCRIPTION – Access of choice for chronic dialysis clients – Created surgically by anastomosis of an artery in the arm to a vein; this creates an opening or fistula between a large artery and a large vein – The flow of arterial blood into the venous system causes the veins to become engorged (matured or developed)

INTERNAL ARTERIOVENOUS FISTULA (AV FISTULA) • DESCRIPTION – Maturity takes about 1 to 2

INTERNAL ARTERIOVENOUS FISTULA (AV FISTULA) • DESCRIPTION – Maturity takes about 1 to 2 weeks and is required before the fistula can be used, so that the engorged vein can be punctured with a large-bore needle for the dialysis procedure – Subclavian or femoral catheters, peritoneal dialysis, or an external AV shunt can be used for dialysis while the fistula is maturing or developing

ARTERIOVENOUS FISTULA From Lewis SM, Heitkemper MM, Dirksen SR: Medical-Surgical Nursing: Assessment and Management

ARTERIOVENOUS FISTULA From Lewis SM, Heitkemper MM, Dirksen SR: Medical-Surgical Nursing: Assessment and Management of Clinical Problems ed. 5, St. Louis, 2000, Mosby.

INTERNAL ARTERIOVENOUS FISTULA (AV FISTULA) • ADVANTAGES – Since the fistula is internal, there

INTERNAL ARTERIOVENOUS FISTULA (AV FISTULA) • ADVANTAGES – Since the fistula is internal, there is less danger of clotting and bleeding – The fistula can be used indefinitely – Decreased incidence of infection – No external dressing is required – Allows freedom of movement

INTERNAL ARTERIOVENOUS FISTULA (AV FISTULA) • DISADVANTAGES – Cannot be used immediately after insertion

INTERNAL ARTERIOVENOUS FISTULA (AV FISTULA) • DISADVANTAGES – Cannot be used immediately after insertion – Needle insertions are required for dialysis – Infiltration of the needles during dialysis can occur and cause hematomas – An aneurysm can form in the fistula – Arterial steal syndrome can develop (too much blood is diverted to the vein and arterial perfusion to the hand is compromised) – CHF can occur from the increased blood flow in the venous system

INTERNAL ARTERIOVENOUS GRAFT (AV GRAFT) • DESCRIPTION – The internal graft is used primarily

INTERNAL ARTERIOVENOUS GRAFT (AV GRAFT) • DESCRIPTION – The internal graft is used primarily for chronic dialysis clients who do not have adequate blood vessels for the creation of a fistula – An artificial graft made of Gore-Tex or a bovine (cow) carotid artery is used create an artificial vein for blood flow

INTERNAL ARTERIOVENOUS GRAFT (AV GRAFT) • DESCRIPTION – The procedure involves the anastomosis of

INTERNAL ARTERIOVENOUS GRAFT (AV GRAFT) • DESCRIPTION – The procedure involves the anastomosis of the graft to the artery, a tunneling under the skin, and anastomosis to a vein – The graft can be used 2 weeks after insertion – Complications of the graft include clotting, aneurysms, and infection

ARTERIOVENOUS GRAFT From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for

ARTERIOVENOUS GRAFT From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W. B. Saunders

INTERNAL ARTERIOVENOUS GRAFT (AV GRAFT) • ADVANTAGES – Since the graft is internal, there

INTERNAL ARTERIOVENOUS GRAFT (AV GRAFT) • ADVANTAGES – Since the graft is internal, there is less danger of clotting and bleeding – The graft can be used indefinitely – Decreased incidence of infection – No external dressing is required – Allows freedom of movement

INTERNAL ARTERIOVENOUS GRAFT (AV GRAFT) • DISADVANTAGES – Cannot be used immediately after insertion

INTERNAL ARTERIOVENOUS GRAFT (AV GRAFT) • DISADVANTAGES – Cannot be used immediately after insertion – Needle insertions are required for dialysis – Infiltration of the needles during dialysis can occur and cause hematomas – An aneurysm can form in the graft – Arterial steal syndrome can develop (too much blood is diverted to the vein and arterial perfusion to the hand is compromised) – CHF can occur from the increased blood flow in the venous system

AV FISTULA AND AV GRAFT • IMPLEMENTATION – Do not measure a blood pressure,

AV FISTULA AND AV GRAFT • IMPLEMENTATION – Do not measure a blood pressure, draw blood, place an IV, or administer injections in the fistula or graft extremity – Monitor for clotting: complaints of tingling or discomfort in the extremity or the inability to palpate a thrill or auscultate a bruit over the fistula or graft – Monitor for arterial steal syndrome – Palpate or auscultate for bruit or thrill over the fistula or graft

AV FISTULA AND AV GRAFT • IMPLEMENTATION – Palpate pulses below the fistula or

AV FISTULA AND AV GRAFT • IMPLEMENTATION – Palpate pulses below the fistula or graft and monitor for hand swelling as an indication of ischemia – Note temperature and capillary refill of the extremity – Monitor for infection – Monitor lung and heart sounds for signs of CHF – Notify the physician immediately if signs of clotting, infection, or arterial steal syndrome occur

PERITONEAL DIALYSIS • DESCRIPTION – The peritoneum is the dialyzing membrane (semipermeable membrane) and

PERITONEAL DIALYSIS • DESCRIPTION – The peritoneum is the dialyzing membrane (semipermeable membrane) and substitutes for kidney function during kidney failure – Works on the principles of diffusion and osmosis, and the dialysis occurs via the transfer of fluid and solute from the bloodstream through the peritoneum

PERITONEAL DIALYSIS • DESCRIPTION – The peritoneal membrane is large and porous, allowing solutes

PERITONEAL DIALYSIS • DESCRIPTION – The peritoneal membrane is large and porous, allowing solutes and fluid to move via an osmotic gradient from an area of higher concentration in the body to an area of lower concentration in the dialyzing fluid – The peritoneal cavity is rich in capillaries; therefore, it provides a ready access to blood supply

PERITONEAL DIALYSIS From Thibodeau GA, Patton KT: Anatomy and Physiology, ed. 4, St. Louis,

PERITONEAL DIALYSIS From Thibodeau GA, Patton KT: Anatomy and Physiology, ed. 4, St. Louis, 1999, Mosby.

CONTRAINDICATIONS TO PERITONEAL DIALYSIS • • Peritonitis Recent abdominal surgery Abdominal adhesions Impending renal

CONTRAINDICATIONS TO PERITONEAL DIALYSIS • • Peritonitis Recent abdominal surgery Abdominal adhesions Impending renal transplant

PERITONEAL DIALYSIS DIALYSATE SOLUTION • Solution is sterile • Contains electrolytes and minerals, a

PERITONEAL DIALYSIS DIALYSATE SOLUTION • Solution is sterile • Contains electrolytes and minerals, a specific osmolarity, a specific glucose concentration, and other medication additives as prescribed • The higher the glucose concentration, the greater the amount of fluid removed during an exchange • Increasing the glucose concentration increases the concentration of active particles that cause osmosis, and increases the rate of ultrafiltration and the amount of fluid removed

PERITONEAL DIALYSIS DIALYSATE SOLUTION • Potassium: If hyperkalemia is not a problem, potassium may

PERITONEAL DIALYSIS DIALYSATE SOLUTION • Potassium: If hyperkalemia is not a problem, potassium may be added to each bag of solution • Heparin: Added to the dialysate solution to prevent clotting of the catheter • Antibiotics: Prophylactic antibiotics may be added to dialysate to prevent peritonitis • Insulin: May be added to the dialysate for the client with diabetes mellitus

ACCESS FOR PERITONEAL DIALYSIS • DESCRIPTION – A surgical insertion of a siliconized rubber

ACCESS FOR PERITONEAL DIALYSIS • DESCRIPTION – A surgical insertion of a siliconized rubber catheter into the abdominal cavity is required to allow infusion of dialysis fluid – The preferred insertion site is 3 to 5 cm below the umbilicus because this area is relatively avascular and has less fascial resistance

ACCESS FOR PERITONEAL DIALYSIS • DESCRIPTION – The catheters are tunneled under the skin

ACCESS FOR PERITONEAL DIALYSIS • DESCRIPTION – The catheters are tunneled under the skin to stabilize the catheter and reduce the risk of infection – Over a period of 1 to 2 weeks following insertion, there is an ingrowth of fibroblasts and blood vessels into the cuffs of the catheter, which fix the catheter in place and provide an extra barrier against dialysate leakage and bacterial invasion

TENCKHOFF, GORE-TEX, AND COLUMN-DISK CATHETER FOR PERITONEAL DIALYSIS From Beare, P. & Myers, J.

TENCKHOFF, GORE-TEX, AND COLUMN-DISK CATHETER FOR PERITONEAL DIALYSIS From Beare, P. & Myers, J. (1998). Adult health nursing (3 rd ed. ). St. Louis: Mosby

PERITONEAL DIALYSIS VIA A TENCKHOFF CATHETER From Ignatavicius, D. & Workman, M. (2002). Medical-surgical

PERITONEAL DIALYSIS VIA A TENCKHOFF CATHETER From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W. B. Saunders

CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) • Closely resembles renal function because it is a

CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) • Closely resembles renal function because it is a continuous process • Does not require a machine for the procedure • Promotes client independence • The client performs self-dialysis 24 hours a day, 7 days a week • Usually four dialysis cycles are administered in 24 hours, including an 8 -hour dwell time overnight

CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) • One and a half to two liters of

CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) • One and a half to two liters of dialysate are instilled into the abdomen four times daily and allowed to dwell as prescibed • The dialysis bag, attached to the catheter, is folded and carried in the client’s clothing until time for outflow • After dwell, the bag is placed lower than the insertion site so fluid drains by gravity flow • When full, the bag is changed, new dialysate is instilled into the abdomen, and the process continues

AUTOMATED PERITONEAL DIALYSIS (APD) • Similar to CAPD in that it is a continuous

AUTOMATED PERITONEAL DIALYSIS (APD) • Similar to CAPD in that it is a continuous dialysis process • Requires a peritoneal cycling machine • Can be done as intermittent peritoneal dialysis (IPD), continuous cycling peritoneal dialysis (CCPD), or nightly peritoneal dialysis (NPD)

INTERMITTENT PERITONEAL DIALYSIS (IPD) • Requires a peritoneal cycling machine • Not a continuous

INTERMITTENT PERITONEAL DIALYSIS (IPD) • Requires a peritoneal cycling machine • Not a continuous dialysis procedure • Performed for 10 to 14 hours, three to four times a week

CONTINUOUS CYCLING PERITONEAL DIALYSIS (CCPD) • Requires a peritoneal cycling machine • Usually consists

CONTINUOUS CYCLING PERITONEAL DIALYSIS (CCPD) • Requires a peritoneal cycling machine • Usually consists of three cycles done at night, and one cycle with an 8 -hour dwell done in the morning • The peritoneal cavity is opened only for the onand-off procedures, which reduces the risk of infection • The client does not need to do exchanges during the day

NIGHTLY PERITONEAL DIALYSIS (NPD) • Performed 8 to 12 hours each night with no

NIGHTLY PERITONEAL DIALYSIS (NPD) • Performed 8 to 12 hours each night with no daytime exchanges or dwells

PERITONEAL DIALYSIS INFUSION • DESCRIPTION – One infusion (inflow), dwell, and outflow is considered

PERITONEAL DIALYSIS INFUSION • DESCRIPTION – One infusion (inflow), dwell, and outflow is considered one exchange – Uses an open system that presents a risk of infection

PERITONEAL DIALYSIS INFUSION • INFLOW – The infusion of 1 to 2 liters of

PERITONEAL DIALYSIS INFUSION • INFLOW – The infusion of 1 to 2 liters of dialysate as prescribed is infused by gravity into the peritoneal space, which usually takes approximately 10 to 20 minutes • DWELL TIME – The amount of time that the dialysate solution remains in the peritoneal cavity; prescribed by the physician • OUTFLOW – Fluid drains out of body by gravity into the drainage bag

PERITONEAL DIALYSIS From Luckmann, J. (1997). Saunders manual of nursing care. Philadelphia: W. B.

PERITONEAL DIALYSIS From Luckmann, J. (1997). Saunders manual of nursing care. Philadelphia: W. B. Saunders

PERITONEAL DIALYSIS INFUSION • IMPLEMENTATION BEFORE TREATMENT – Monitor vital signs – Obtain weight

PERITONEAL DIALYSIS INFUSION • IMPLEMENTATION BEFORE TREATMENT – Monitor vital signs – Obtain weight – Have the client void, if possible – Assess electrolyte and glucose levels

PERITONEAL DIALYSIS INFUSION • IMPLEMENTATION DURING TREATMENT – Monitor vital signs – Monitor for

PERITONEAL DIALYSIS INFUSION • IMPLEMENTATION DURING TREATMENT – Monitor vital signs – Monitor for signs of infection – Monitor for respiratory distress, pain, or discomfort – Monitor for signs of pulmonary edema – Monitor for hypotension and hypertension – Monitor for malaise, nausea, vomiting

PERITONEAL DIALYSIS INFUSION • IMPLEMENTATION DURING TREATMENT – Assess the catheter site dressing for

PERITONEAL DIALYSIS INFUSION • IMPLEMENTATION DURING TREATMENT – Assess the catheter site dressing for wetness or bleeding – Monitor dwell time as prescribed by the physician and initiate outflow – Do not allow dwell time to extend beyond the physician’s order because this increases the risk for hyperglycemia – Turn the client from side to side or have client sit upright if the flow is slow to start

PERITONEAL DIALYSIS INFUSION • IMPLEMENTATION DURING TREATMENT – Monitor outflow, which should be a

PERITONEAL DIALYSIS INFUSION • IMPLEMENTATION DURING TREATMENT – Monitor outflow, which should be a continuous stream after the clamp is opened – Monitor outflow for color and clarity – Monitor I&O accurately – If outflow is less than inflow, the difference is equal to the amount absorbed or retained by the client during dialysis and should be counted as intake

COMPLICATIONS OF PERITONEAL DIALYSIS • • • Peritonitis Abdominal pain Insufficient outflow Leakage around

COMPLICATIONS OF PERITONEAL DIALYSIS • • • Peritonitis Abdominal pain Insufficient outflow Leakage around the catheter site Abnormal characteristics of outflow

PERITONITIS • Maintain meticulous sterile technique when hooking up or clamping off bags, and

PERITONITIS • Maintain meticulous sterile technique when hooking up or clamping off bags, and when caring for the catheter insertion site • Follow institutional procedure for hooking up or clamping off bags, which may include scrubbing the connection sites with an antiseptic solution • Monitor fever, cloudy outflow, and rebound abdominal tenderness • If peritonitis is suspected, obtain a culture of the outflow to determine the infective organism • Administer antibiotics as prescribed

ABDOMINAL PAIN • Pain during inflow is common during the first few exchanges, is

ABDOMINAL PAIN • Pain during inflow is common during the first few exchanges, is caused by peritoneal irritation, and usually disappears after a week or two of dialysis treatments • The cold temperature of the dialysate aggravates the discomfort and the dialysate should be warmed before use only with a special dialysate warmer pad • Place a heating pad on the abdomen during the inflow to relieve discomfort

INSUFFICIENT OUTFLOW • May be caused by catheter migration out of the peritoneal area;

INSUFFICIENT OUTFLOW • May be caused by catheter migration out of the peritoneal area; if this occurs, the catheter must be repositioned by the physician • Can also be caused by a full colon • Maintain the drainage bag below the client’s abdomen • Change the client’s outflow position by turning or ambulating • Check for kinks in the tubing • Encourage a high-fiber diet • Administer stool softeners as prescribed

LEAKAGE AROUND THE CATHETER SITE • Over a period of 1 to 2 weeks

LEAKAGE AROUND THE CATHETER SITE • Over a period of 1 to 2 weeks following insertion of the catheter, an ingrowth of fibroblasts and blood vessels into the cuffs of the catheter occurs, which fix the catheter in place and provide an extra barrier against dialysate leakage and bacterial invasion • It may take up to 2 weeks for the client to tolerate a full 2 -liter exchange without leaking around the catheter site

CHARACTERISTICS OF OUTFLOW • During the first or initial exchanges, the outflow may be

CHARACTERISTICS OF OUTFLOW • During the first or initial exchanges, the outflow may be bloody; outflow should be clear and colorless thereafter • A brown outflow indicates bowel perforation • If the outflow is same color as urine, this indicates bladder perforation • Cloudy outflow indicates peritonitis

UREMIC SYNDROME • DESCRIPTION – The accumulation of nitrogenous waste products in the blood

UREMIC SYNDROME • DESCRIPTION – The accumulation of nitrogenous waste products in the blood due to the inability of the kidneys to filter out these waste products – It may occur as a result of acute or chronic renal failure

UREMIC SYNDROME • ASSESSMENT – Oliguria – The presence of protein, red blood cells,

UREMIC SYNDROME • ASSESSMENT – Oliguria – The presence of protein, red blood cells, and casts in the urine – A urine specific gravity of 1. 010 – Elevated levels of urea, uric acid, potassium, and magnesium in the urine – Hypotension or hypertension

UREMIC SYNDROME • ASSESSMENT – Alterations in LOC – Electrolyte imbalances – Stomatitis –

UREMIC SYNDROME • ASSESSMENT – Alterations in LOC – Electrolyte imbalances – Stomatitis – Nausea or vomiting – Diarrhea or constipation

UREMIC SYNDROME • IMPLEMENTATION – Monitor vital signs – Monitor electrolyte values – Monitor

UREMIC SYNDROME • IMPLEMENTATION – Monitor vital signs – Monitor electrolyte values – Monitor I&O – Provide a diet low in protein unless the client is on peritoneal dialysis – Limit sodium, nitrogen, potassium, and phosphate intake as prescribed