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Renal Replacement Therapies Guide
DIALYSIS
Hemodialysis
Description:
In this type of dialysis, blood is taken from the patient via vascular access
and pumped into a dialyzer. Blood is separated from the dialysate (dialysis
solution) by a semipermeable membrane. Processes of diffusion and
ultrafiltration remove waste products, electrolytes, & excess water.
Smaller Molecules like glucose, electrolytes, & water can pass through
Larger Molecules like protein & RBCs are blocked. If you remove fluid too
quickly the patient will be dizzy. Give IV meds & most other meds after
dialysis (no point giving before because they won’t stay in the patient’s
blood, but if BP is very high, for example, it is ok to give BP meds-- orally)
-Before: Always get baseline VS, CHECK WEIGHT BEFORE AND AFTER,
look at previous labs
-After: must find out how much fluid was taken off
Temporary vascular access for hemodialysis = Quinton catheters (may be
in jugular, femoral, or subclavian, BUT used only for hemodialysis)
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a. External shunt (not common): temporary, created until AV fistula is
ready to use, connects an artery to a vein, puts the patient at risk for
infection & bleeding. Tesio catheter (permanent) only in subclavian
b. Internal AV fistula: Permanent vascular access for hemodialysis is
more common for permanent dialysis, surgically created in the non-
dominant arm, anastomosis of artery and vein, takes about a month to
mature so use graft in meantime, less likely to clot.
c. Internal AV graft: surgically implanted tube
AV fistula nursing care:
Auscultate for Bruit, Palpate for a thrill, Do not take BP on that arm, or
venous puncture, and Assess for infection. If post-op fistulas are repaired,
assess radial pulse, cap refill, & confirm no numbness
Dialysis process:
1. Blood is taken from the arm
2. Blood is pumped into the machine
3. A blood-thinning agent is added
4. Blood enters the dialyzer
5. Blood passes through a bubble trap
6. Blood is returned to the arm
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Important considerations of dialysis treatment:
-Hemodialysis for AKI – Short time.
-Hemodialysis for ESRD – No Cure.
-Treatments are scheduled for 3 times/week for a total of 9-12 hours,
hemodialysis or peritoneal dialysis is a constant factor of life, depending on
the individual patient situation and total health, the person may prefer death
to dialysis, and specific dialysis orders according to body size, residual
renal function (based on the current lab results), dietary intake, concurrent
illnesses
Complications of hemodialysis:
-Hypotension (fast fluid removal = dizzy), Bleeding (because heparin is
given to reduce the chance of blood clots), Infection (Local/Systemic) ex.
Staphylococcus Aureus = shows up in the blood, the patient will come back
from dialysis with a temp, Muscle cramps, Disequilibrium Syndrome, and
Cardiovascular disease
*Nursing responsibilities: Always assess I&O, lung sounds, weight before
and after, give meds after dialysis, monitor labs. You should probably hold
meds if they are not critical because dialysis because the meds will be
washed right out of their body.
Continuous Renal Replacement Therapy (CRRT):
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This technique allows more gradual fluid and solute removal than
hemodialysis, done over period of 12 to 24 hours, and does if patient can’t
tolerate hemodialysis
Peritoneal Dialysis
Description:
-Peritoneal membrane of patient is used as dialyzing surface
-Warmed sterile dialysate solution (BAT) is instilled into peritoneal cavity
through a catheter inserted into peritoneal cavity. Bat solution is based on
your labs. This is the solution needed to clean the blood. Metabolic waste
products and excessive electrolytes diffuse into dialysate while it remains in
abdomen
-The water diffusion is controlled by glucose in the dialysate, which acts as
an osmotic agent
-Fluid is drained off by gravity into sterile bag at set intervals, thus removing
waste products and excess fluid
-This can be done at the home AT EXTREMELY HIGH RISK FOR
INFECTION BECAUSE YOU INFUSE SEVERAL TIMES A DAY
Just managing fluid cannot be too cold or to hot
Types of peritoneal catheters:
A. Peritoneal catheters used for peritoneal dialysis
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B. Bent neck, curl catheters
C. Disc catheters
Types of Peritoneal Dialysis:
a. Continuous Ambulatory Peritoneal Dialysis (CAPD) =
-Dwell time is 4-6 hours & patient is not attached to the machine during that
time so they can move around as they wish, assure PT is in good body
alignment, confirm fluid draining into the bag is clear (if fluid is cloudy that
indicates peritonitis), 2L should go in over 4-8 hours, solution drains out 30
minutes later and not used for ARF, just CRF
b. Continuous Cyclic Peritoneal Dialysis (CCPD) =
-In cycles (only day, only night, etc.), assure patient is in good body
alignment; confirm fluid draining into the bag is clear (if fluid is cloudy that
indicates peritonitis)
-2L should go in over 4-8 hours; solution drains out 30 minutes later
-Not used for ARF, just CRF
Three phases:
-inflow (fill), dwell (equilibrium) and drain
Advantages (over hemodialysis):
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More dwelling time, less chance of volume shock, less diet
restriction (protein), more manageable, and less risk for bleeding &
infection because not via vascular access.
Disadvantage (over hemodialysis):
Chance for peritonitis and can’t use for abdominal surgery or trauma or
lung issue patient. Complications like peritonitis, leakage, bleeding
*Peritoneal access is obtained by inserting a catheter through the anterior
abdominal wall. The catheter has one or two Dacron cuffs on its
subcutaneous and peritoneal portions. The cuffs act as anchors and
prevent the migration of
microorganisms down the shaft from the skin. Catheter placement is done
through surgery.
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