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Chapter 30:
Patient Management: Renal
System
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
What Is Dialysis?
• Dialysis is an artificial method of performing the kidneys’
function.
• Removes byproducts of metabolism that can build up and
cause life-stopping events
• Indications: can be used short or long term
– Short term for drug overdoses or to reverse acute renal
failure
– Long term when kidney function ceases to provide
homeostasis
• Uses the principles of osmosis and diffusion
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Types of Dialysis
• Hemodialysis (HD)
• Continuous renal replacement therapy (CRRT)
• Peritoneal dialysis (PD)
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Access Sites
• Depends on type of dialysis
– Peritoneal (PD) uses a Tenckhoff catheter inserted by a
surgeon in the abdominal cavity
• Extracorporeal circulation is done for hemodialysis and CRRT
• CRRT and HD can use a venous access site, usually in a central
line access like a dual-lumen catheter
• Hemodialysis uses either a graft or AV fistula
– Both involve surgical anastomosis of an artery to a vein
(AV fistula)
– Surgically implanted Teflon graft
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Hemodialysis
• Differences
• Indications
• Assessment
• Management
• Complications
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Hemodialysis: Differences and Indications
• Differences
– Extracorporeal
– Machine (dialyser) is artificial kidney
– Intermittent
– Filters out water (ultrafiltration)
– Filters out waste metabolic products (urea, nitrogen,
and excessive electrolytes)
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Indications for Hemodialysis
• Acute situations
– Uremic, electrolyte and fluid overload due to acute or
chronic renal failure or other diseases
– Some drug overdoses
• Chronic situations
– CRF
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Hemodialysis Assessments
• Contraindications
– Hemodynamic instability: Blood will be taken out of
the body, which will lower the BP and put stress on
the cardiac system.
– Coagulopathy: The patient will be given heparin.
Excessive bleeding leading to hemorrhage could
result.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assessments Before Hemodialysis
• Predialysis assessments include:
– History and reasons for HD
– Vital signs with current lab results
– Predialysis weight (often called “wet weight”)
– Intake and output
– Functioning of the site for patency; bruit/thrill
– Outcomes of the therapy (in collaboration with the
renal physician)
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Equipment and Management
• Check all equipment, medications like heparin and fluids
–
Don PPE (gown, gloves, mask)
• Access vascular site and secure the lines
• Observe flow from “venous” line through dialyser
• Monitor VS and troubleshoot site problems
–
Remove samples and check lab values
• Disconnect lines once expected outcome is met (correct labs, time on
dialysis) and place in biohazard bag for removal
• Flush access site
• Check “dry weight” (weight at the end of procedure, when most fluid
is removed)
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Potential Complications
• Dialysis dysequilibrium
• Hypovolemia
• Hypotension
• Hypertension
• Muscle cramps
• Angina
• Dysrhythmias
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Pre- and post-dialysis weights are critical in determining
expected outcomes in patients on all forms of dialysis.
A. True
B. False
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Answer
A. True
Rationale: Predialysis weights reflect the patient’s “wet
weight,” the fluid retained since the last dialysis
treatment. Post-dialysis weight is important in
determining whether expected outcomes were met, as
well as the effectiveness of therapy. An excessive weight
loss is also indicative of complications like dialysis
dysequilibrium.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Continuous Renal Replacement Therapy
(CRRT)
• Similarities to HD
– Blood is extracorporeal
– Requires an access site
– Uses principles of osmosis and diffusion
• Differences
– Can be done over a longer period of time
– Can be done if the patient is hemodynamically unstable
because it’s slower
– Fluid must be replaced and calculated frequently
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Major Types of CRRT
• CVVH
– This is indicated primarily for fluid removal, as in the
case of heart failure intractable to medications.
• CVVH-D
– This is done when the patient needs both fluid and
waste product removal.
– It is a combination of CRRT and dialysis.
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Assessment/Equipment Before Instituting
CCRT
• Assessment is essentially the same as for HD
• Contraindicated with coagulopathies too
• Additional equipment needed includes venous access,
line for anticoagulation, blood pump, NSS replacement
line, dialysate bag, graduated drainage bag (looks similar
to a urinary catheter bag), and replacement fluid (filter is
much more porous with CVVH, so calculation of
replacement fluid is needed)
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Complications
• Similar to HD
• Access site problems
• Clotting
• Air in circuit
• Blood leaks
• Hypotension
• Hypothermia
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Peritoneal Dialysis
• Access site is abdominal catheter (no extracorporeal blood
flow)
• Uses peritoneum as semipermeable membrane for exchange of
water and waste products
• Uses principle of diffusion
• Slower
• Can be done intermittently or constantly
• Short term or long term, but not for emergency situations
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Peritoneal Dialysis Indications
• Temporary site for dialysis until graft or AV shunt
matures
• Patient’s choice
• Intact abdominal cavity without adhesions or surgery
• Repeated peritonitis
• Easy to teach
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Procedure for Peritoneal Dialysis
• Warmed dialyzing solutions (tonicity determines
fluid/electrolyte loss
• Can be done by hand
• Automated systems available
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Procedure and Assessments
• VS and labs
• Wet weight
• Tubing flushed with dialysate
• Hooked up sterilely to abdominal catheter
• Solutions are instilled into abdominal cavity
• Left to dwell (time specified) and then drained (time
specified)
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Question
A patient is visiting your clinic for a peritoneal dialysis
treatment. He says, “I don’t feel well. I feel feverish and
my abdomen is red and sore.” This patient probably
has:
A. Dialysis dysequilibrium
B. Peritonitis
C. Hypokalemia
D. Catheter clotting
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
B. Peritonitis
Rationale: Peritonitis is the most significant complication of
peritoneal dialysis. The catheter can be infected at any
place along the equipment hookup. Signs and symptoms
of peritonitis include what this patient is describing.
Dialysis dysequilibrium is characterized by changes in
mentation. Hypokalemia is vague but usually presents
with weakness and fatigue. An inability to instill
dialysate would indicate catheter clotting.
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Complications of Peritoneal Dialysis
• Peritonitis
• Respiratory distress when fluid is indwelling
• Fluid retention
• Catheter clotting
• Hypotension/hypertension
• Electrolyte issues
• Pain or intolerance to procedure
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Psychosocial Needs for Patients and
Families Undergoing Dialysis
• Short term
–
Generally “hope”
–
“Light at the end of the tunnel”
–
Decrease pain from access site and procedures
• Long term
–
Denial initially
–
Support through grieving process
–
Less traumatic if longer term in CRF
–
Financial and social support systems and community resources
needed
–
Decision to terminate therapy
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Fluid Therapies: Fluid Volume Deficit
• Fluid volume deficit (FVD)
– Lose of volume
– Causes: dehydration, GI losses, renal losses, third
spacing
– High-risk groups: very young, very ill, very old,
stroke, dysphasia
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FVD Replacements
• Crystalloids
– Fluid challenge is given with isotonic solutions like 0.9%
NSS
– If intracellularly dehydrated, can give hypotonic solutions
like 0.45 NSS cautiously
– Fluid maintenance is around 2-3 L/day
• Colloids
– Usually albumin but can include hetastarch and dextran
– High molecular weights; can pull fluid into vascular space
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Fluid Therapies: Fluid Volume Excess
• Fluid volume excess (FVE)
– Too much fluid
– Causes: heart, renal, liver failure; medications like
steroids
– Interventions are aimed at finding/treating
underlying causes
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Question
A patient is receiving a diuretic but the only thing he
remembers is that the nurse told him it was a
“potassium-sparing one.” Of the list below, which one
could this patient be describing?
A. Furosemide (Lasix)
B. Hydrochlorothiazide (HCTZ)
C. Spironolactone (Aldactone)
D. Mannitol (Osmotrol)
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
C. Spironolactone (Aldactone)
Rationale: Spironolactone (Aldactone) is the only
potassium-sparing diuretic on this list. It would be good
to use for a patient in renal failure with hypertension.
Furosemide (Lasix) is a loop diuretic,
hydrochlorothiazide (HCTZ) is a thiazide diuretic, and
mannitol (Osmotrol) is an osmotic diuretic.
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Treatment of Fluid Volume Excess
• Water and sodium restriction
• Diuretics
– Loop (furosemide [Lasix])
– Thiazide (hydrochlorothiazide [HCTZ])
– Potassium-sparing (spironolactone [Aldactone])
– Carbonic anhydrase inhibitors (acetazolamide
[Diamox])
– Osmotic (mannitol [Osmotrol])
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Disorders of Electrolyte Metabolism from
Dialysis
• Sodium imbalances
• Potassium imbalances
• Calcium imbalances
• Magnesium imbalances
• Phosphorus imbalances
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Sodium Imbalances
• Hyponatremia
– Causes: Heart, liver, and renal failure cause excessive
water retention. SIADH creates normal volume but low
sodium.
– Treatment: Identify and correct underlying cause;
diuretics, 3% NSS (to correct low sodium), and fluid
restrictions if hypervolemic.
• Hypernatremia
– Causes: Dehydration, excessive sweating, decreased
intake, diabetes insipidus, hyperaldosteronism (Cushing’s
disease)
– Treatment: Correct underlying condition; diabetes
insipidus (DDAVP), IV hypotonic solutions.
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Potassium Imbalances
• Hypokalemia
–
Causes: Administration of diuretics like furosemide (Lasix),
diarrhea, metabolic acidosis (H+ out of cell, K+ goes into cell),
inadequate dietary intake (ETOH) and too much insulin
–
Treatment: Find and treat the underlying cause. K+
supplementation in dietary, PO, or IV.
–
Use caution when giving K+ IV. Always dilute in 50–100 mL &
give over 1-2 hr. Always use infusion pump. Monitor site for
infiltration.
• Hyperkalemia
–
Causes: ARF, CRF, too much oral/IV supplementation, improper
phlebotomy technique (sudden, unanticipated change), acidosis,
massive cellular damage (burns, trauma)
–
Treatment: Dialysis with ARF/CRF. Gut binding drugs. Harder to
treat than hypokalemia, so always check K+ levels before
administration.
–
Emergency treatment: Calcium IV, sodium bicarbonate IV (shifts
K+ into cell), IV insulin and glucose
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Calcium Imbalances
• Hypocalcemia
–
Causes: Removal of parathyroids, pancreatitis, ETOH, use of
trisodium citrate (CRRT), decreased albumin
–
Treatment: Increase dietary ingestion. Give calcium
supplements.
–
Calcium gluconate administration: Lengthen time given IV if
digoxin is present in drug regimen. Check IV site for phlebitis.
• Hypercalcemia
–
Causes: Associated with tumors producing a PTH-like substance
–
Treatment: Diuretics and IV fluids
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Magnesium Imbalances
• Hypomagnesmia
– Cause: Dietary from ETOH, loss through GI tract, loop
diuretics and other drugs
– Treatment: Determine cause; nutritional, oral, or IV
supplementation
– Magnesium sulfate: Given IV; check BP and DTRs
• Hypermagnesmia
– Cause: ARF/CRF, excessive oral intake (antacids,
supplements)
– Treatment: Dialysis, avoid administration, diuretics
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Phosphate Imbalances
• Hypophosphatemia
– Causes: ETOH, refeeding syndrome (driven into cell with
insulin after prolonged starvation), phosphate-binding
antacids
– Treatment: Give oral or IV supplementation
• Hyperphosphatemia
– Causes: Renal failure when calcium is low, phosphate is
high
– Treatment: Give phosphate binders and calcium
supplements
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