By looking at certain blood values (e.g. Rationale: Prolonged dwell times, especially when 4.5% glucose solution is used, may cause excessive fluid loss. Encourage increased vegetables in the diet. The nurse teaches that this is the reason that the client is being prescribed which of the following phosphate binding agents? Imbalanced Nutrition; Less than Body Requirements. Diffusion – movement of particles from an area of high concentration to one of low concentration across a semipermeable membrane. A routine diabetic foot care program, including nursing assessment and patient education, may be associated with improved footwear adequacy and a reduction in neuropathy, ultimately leading to fewer foot ulcers and wounds. Hematest and/or guaiac stools, gastric drainage. Oxygen saturation on room air is 89%. Which of the following is the most appropriate nursing action? The client has a permanent peritoneal catheter in place. Stress importance of patient avoiding pulling or pushing on catheter. Measure and record intake and output, including all body fluids, such as wound drainage, nasogastric output, and diarrhea. Check the peritoneal dialysis system for kinks. Which of the following interventions is included in this client’s plan of care? In the acute care setting, you will undoubtedly know if you are taking care of a chronic dialysis patient. The shunt site should be assessed at least every four hours. Drain dialysate, and notify physician. 3. Haemodialysis can either take place in hospital with full nursing supervision, in hospital at night, in a “Satellite Dialysis Unit” or at home. Electrolytes: Dangerously high potassium levels are the typical cause for emergent dialysis. This creates a concentration gradient where the electrolytes will flow from the higher level of concentration (the patient’s blood) down to the lower level (the dialysate solution), thereby effectively removing it from the patient. Investigate reports of nausea and vomiting, increased and severe abdominal pain; rebound tenderness, fever, and leukocytosis. The nurse assesses the client who has chronic renal failure and notes the following: crackles in the lung bases, elevated blood pressure, and weight gain of 2 pounds in one day. Hospital Discharge of the Dialysis Patient: assessment, barriers and a bit of everything in between Kristin Woody CM, MSN Supervisor Care Management Department Regions Hospital . The nurse also encourages visiting and other diversional activities. I don’t wrap it up in a nice … The dwell can also increase pressure on the diaphragm causing impaired breathing, and constipation can interfere with the ability of fluid to flow through the catheter. Also, this page requires javascript. Rationale: In most cases, the amount drained should equal or exceed the amount instilled. If you give sodium polystyrene sulfonate rectally, make sure the patient doesn’t retain it and become constipated. Conducting a one-on-one session with the client. The nurse may also assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. Rationale: May indicate hypovolemia and hyperosmolar syndrome. Swollen legs may be indicative of congestive heart failure. Adhere to schedule for draining dialysate from abdomen. Rationale: Hypertension and tachycardia between hemodialysis runs may result from fluid overload and/or HF. The emphasis is on high-quality protein and your patient may also have to limit fluids, which can be tough! Limit activity of extremity. Polyuria occurs early in chronic renal failure and if untreated can cause severe dehydration. Presence of glucose-containing dialysate in the bladder will elevate glucose level of urine. Weigh when abdomen is empty, following initial 6–10 runs, then as indicated. CNS changes in renal failure rarely include headache. Vegetables are a natural source of potassium in the diet, and their use would not be increased. Measure all sources of I&O. Rationale: Decreased areas of ventilation suggest presence of atelectasis, whereas adventitious sounds may suggest fluid overload, retained secretions, or infection. - Binders will be given as scheduled and documented by the dialysis nurse while patient is in the kidney dialysis unit (KDU) - Floor nurse should not “reschedule” on the Electronic Medical Administration Record (eMAR) to allow dialysis nurse to document - Phosphate binders do not have to be sent to the dialysis unit with the patient (KDU has stock) Common Medications … Maternal and Child Health Nursing (NCLEX Exams), Medical and Surgical Nursing (NCLEX Exams), Pharmacology and Drug Calculation (NCLEX Exams), Dialysis is primarily used to provide an artificial replacement for lost kidney function (renal replacement therapy) due to renal failure. Contamination of the catheter during insertion, periodic changing of tubings/bags, Skin contaminants at catheter insertion site, Sterile peritonitis (response to the composition of dialysate). Cloudy drainage indicates bacterial activity in the peritoneum. Acute Dialysis Registered Nurse Job Description PURPOSE AND SCOPE: The Acute Dialysis Registered Nurse (RN) is responsible for providing acute hemodialysis therapy. The contrast used for heart catherization must be eliminated by the kidneys, which further stresses them and may produce acute renal failure. Place the patient in semi-Fowler’s position. Rapid/excessive fluid intake: IV, blood, plasma expanders, saline given to support BP during dialysis, Maintain “dry weight” within patient’s normal range. Add sodium hydroxide to dialysate, if indicated. Monitor serum sodium levels. Turn from side to side, elevate the head of the bed, apply gentle pressure to the abdomen. Rationale: Patients with end-stage renal disease (ESRD) may develop pericardial disease. Rationale: Aids in evaluating fluid status, especially when compared with weight. In a client in renal failure, which assessment finding may indicate hypocalcemia? MOM is not high in sodium. A client is undergoing peritoneal dialysis. Rationale: Redirects attention, promotes sense of control. Rationale: Thrill is caused by turbulence of high-pressure arterial blood flow entering low-pressure venous system and should be palpable above venous exit site. Actual blood loss (systemic heparinization or disconnection of the shunt). Rationale: Determines presence of pathogens. Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, and vomiting, twitching, and possible seizure activity. Note presence of peripheral or sacral edema, respiratory rales, dyspnea, orthopnea, distended neck veins, ECG changes indicative of ventricular hypertrophy. Make sure the attending MD on the case knows that you are taking care of a dialysis patient so they can get a renal consult. Capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand. The volume of dialysate removed and weight of the patient are normally monitored; if more than. No blood pressures or venipunctures should be taken in the arm with the AV fistula. Tums are prescribed to avoid the occurrence of dementia related to high intake of aluminum. Check the catheter for kinks or obstruction. Encourage the use of salt-free herbal/spice blends to enhance the taste of food and be sure to ask your patients what their favorite foods are so you can consult with the dietician about modifying them for the many renal diet restrictions. Peritoneal dialysis also removes toxins and excess fluid from the blood by utilizing the patient’s own peritoneal membrane as a semipermeable dialyzing membrane. Inspect mucous membranes, evaluate skin turgor, peripheral pulses, capillary refill. Some patients are so sick that require daily hemodialysis or, at least, daily evaluation for dialysis. When you have patients in chronic renal failure, you are essentially watching for a handful of KEY things: Of course, there’s more…like infection at the access site, peritonitis (if using peritoneal dialysis)…but those three things are the biggies. 4. Case-based scenarios are used to discuss how to apply infection prevention and control guidance for nursing homes and other long-term care facilities preparing for and responding to COVID-19. Please visit using a browser with javascript enabled. Reinforcing the dressing is not a safe practice to prevent infection in this circumstance. A client in renal failure develops hyperphosphatemia that causes a corresponding excretion of the body’s calcium stores, leading to renal osteodystrophy. Rationale: Identifies types of organism(s) present, choice of interventions. Reduce infusion rate if dyspnea is present. The nurse assures that the dressing is kept dry at all times. Wastes and excess water move from the blood, across the peritoneal membrane, and into a special dialysis solution, called dialysate, in the. The nurse has completed client teaching with the hemodialysis client about self-monitoring between hemodialysis treatments. A teenager who has an appendectomy and a pregnant woman with a fractured femur isn’t at increased risk for renal failure. To relieve the pain of gastric hyperacidity. Evaluate development of tachypnea, dyspnea, increased respiratory effort. Maintain fluid balance as evidenced by stable/appropriate weight and vital signs, good skin turgor, moist mucous membranes, absence of bleeding. The nurse should: Monitor vital signs every 15 minutes for the next hour, Discontinue dialysis and notify the physician, Continue the dialysis at a slower rate after checking the lines for air. Which teaching strategy would be most appropriate? Find out when they last went to dialysis and if they’ve missed any appointments. Ensure that small clamps are attached to the AV shunt dressing. The more hypertonic the solution, the greater the osmotic pressure for ultrafiltration and thus the greater amount of fluid removed from the client during an exchange. Use alcohol on the skin and clean it due to integumentary changes. Applying COVID-19 Infection Control Strategies in Nursing Homes Clinical Outreach and Communication Activity (COCA) Webinar, June 16, 2020. Record serial weights, compare with I&O balance. Many patients will perform peritoneal dialysis at home while continuing on with their daily activities as usual. Peritoneal dialysis (PD) offers the opportunity of a better quality of life for patients as long as they are able to perform dialysis according to the set procedures. Written materials that the client can review are superior to videotapes, because the clients may not be able to maintain alertness during the viewing of the videotape. The client is in pulmonary edema from fluid overload and will need to be dialyzed and have his fluids restricted, but the first interventions should be aimed at the immediate treatment of hypoxia. Provide care before and after therapy to patients both or either (depending on the assignment) at home and the hemodialysis unit. Rationale: Elevations indicate hypervolemia. The client with chronic renal failure tells the nurse he takes magnesium hydroxide (milk of magnesium) at home for constipation. Now here’s where I am going to keep it super simple. What is the purpose of giving this drug to a client with chronic renal failure? Rationale: Pain occurs at these times if acidic dialysate causes chemical irritation of peritoneal membrane. Monitor for signs of bleeding by taking clotting time about 1 hour before the client comes off the machine. Excessive loss of fluid can result in hypovolemic shock or hypotension while excessive fluid retention can result in hypertension and edema. Hypovolemic Shock – result of rapid removal or ultrafiltration of … Explain that initial discomfort usually subsides after the first few exchanges. Which of the following interventions should be done first? Rationale: Signs of local infection, which can progress to sepsis if untreated. To assess for fluid overload, you’ll monitor daily weights, edema and lung sounds. On assessment the nurse notes that the client’s temperature is 100.2. Providing all needed teaching in one extended session. Attach two cannula clamps to shunt dressing. Severe pain in the rectum or perinium can be the result of an improperly placed catheter. Check the medications history of the patient before the procedure. Observe clotting time at 30 to 90 minutes while on dialysis (Normal value: 6 – 10 minutes). Immediate surgical repair may be required. Watch for symptoms of hyperkalemia (malaise, anorexia, paresthesia, or muscle weakness) and electrocardiogram changes (tall peaked T waves, widening QRS segment, and disappearing P waves), and report them immediately. Observe meticulous aseptic techniques and wear masks during catheter insertion, dressing changes, and whenever the system is opened. What are you going to do about those? If you haven’t already noticed, your chronic renal failure patients take a lot of meds. Which of the following clients is at greatest risk for developing acute renal failure? After dialysis, assess the vascular access for any bleeding or hemorrhage. In addition, dextrose may be absorbed from the dialysate, thereby elevating serum glucose. Although the presence of a radial pulse in the left wrist and capillary refill time less than 3 seconds in the nail beds of the fingers on the left hand are normal findings, they do not assess fistula patency. For any patient with chronic renal failure, deciding whether or not to undergo dialysis is a daunting and life-changing decision - and as far as pre-dialysis nurse specialist Nerys Brick is concerned, pretending otherwise to prospective patients is not an option. Studies have demonstrated the clinical benefits of dialyzing 5 to 7 times a week, for 6 to 8 hours. The client spills water on the catheter dressing while bathing. The nurse assesses this client for which of the following clinical manifestations? 2. ‘It is important that patients are aware of all the options and what their choices are. Either they are in the hospital for a complication of their renal failure or it will be pretty obvious they receive dialysis when you see/feel/hear their HD access site (most often this will be an arteriovenous fistula or an arteriovenous graft). Objectives 1. Rationale: Infused on arterial side of filter to prevent clotting in the filter without systemic side effects. Large artery and vein are sewn together (anastomosed) below the surface of the skin (fistula) or subcutaneous graft using the salphenous vein, synthetic prosthesis, or bovine xenograft to connect artery and vein. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. Patient will verbalize decrease of pain/discomfort. Good luck! Administer antibiotics systemically or in dialysate as indicated. Leaving catheter in place facilitates diagnosing and locating the perforation, Fluid retention (malpositioned or kinked/clotted catheter, bowel distension; peritonitis, scarring of peritoneum). 2011; Chou & Kalantar‐Zadeh 2017). Periodontal disease, premature tooth loss, and xerostomia are more common among dialysis patients and can lead to systemic inflammation … You want to watch their blood pressure and watch their hearing output. Instruct patient not to sleep on side with shunt or carry packages, books, purse on affected extremity. Correction of acidosis (by absorption and metabolism of lactate) 3. High mortality rates along with a substantial burden of physical, psychosocial, and spiritual symptoms and an increasing prevalence of decisions to withhold and stop dialysis … Cannula is placed in a large vein and a large artery that approximate each other. Monitor PT, activated partial thromboplastin time (aPTT) as appropriate. Redness at the insertion site indicates local infection, not peritonitis. Assess the AV fistula for a bruit and thrill. A client with chronic renal failure has completed a hemodialysis treatment. Patients undergoing hemodialysis can have a whole host of acute complications, including: Chronic complications include bone loss (due to altered calcium metabolism), cardiovascular disease, stroke and even gastric ulcers. Increased cardiac output related to fluid overload. So the glucose and sodium bicarb will diffuse INTO the patient’s blood, thereby correcting acidosis while preventing hypoglycemia. He complains of shortness of breath, and +2 pedal edema is noted. See? However, it is not always straightforward. The patient may also experience pain or discomfort if the dialysate is too acidic, too cold or introduced too quickly, while diffuse pain with cloudy discharge may indicate an infection. The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. He’d get dialyzed and the BP would come down…even being on a cardene gtt didn’t really help his BP. Rationale: Systemic heparinization during dialysis increases clotting times and places patient at risk for bleeding, especially during the first 4 hr after procedure. This cycle or “exchange” is normally repeated 4-5 times during the day, (sometimes more often overnight with an automated system). Rationale: To balance nutritional intake. Experience no injury to bowel or bladder. Warmth, redness, and pain in the left hand. On-going assessment and evaluation of the client, reviewing the data collected by the LPN and UAP in order to make any judgments or decisions relative to patient care. Through the process of diffusion, waste products and excess electrolytes in the blood move across the peritoneal membrane and into the solution. The solution typically needs to dwell for 2-6 hours (depending on various factors and the patient’s needs), and some people utilize a machine so they can perform their dialysis at night while they sleep. Add heparin to initial dialysis runs; assist with irrigation of catheter with heparinized saline. There are two main types of dialysis: hemodialysis and peritoneal dialysis. The client is complaining of a headache and nausea and is extremely restless. Assess hb and hct and replace blood components, as indicated. These products are made from aluminum hydroxide. Rationale: Rapid intervention may save access; however, declotting must be done by experienced personnel. Fluid overload may potentiate HF and pulmonary edema. The nurse is assisting a client on a low-potassium diet to select food items from the menu. Bleeding is caused by too-rapid infusion of the dialysate. Dialysis-disequilibrium syndrome – caused by rapid, efficient dialysis resulting in shifts in water, pH and osmolarity between fluid and blood. When you think of dialysis, you probably think of patients who have chronic renal failure who go to the dialysis center three days a week, sit there for a few hours, then go home. Dialysis to the rescue! Assess hb and hct and replace blood components, as indicated. In this post we’ll cover the main types of dialysis, indications for urgent dialysis and the nursing care of these often-complex patients. T he client who is … Note: Urine output is an inaccurate evaluation of renal function in dialysis patients. This chapter explores nursing a patient on haemodialysis, including nursing care of vascular access, pre- and post-operative care of access, cannulation of fistulae, complications of fistulae and their management, grafts, percutaneous tunnelled and temporary vascular catheters, complications of vascular catheters and their management, strategy for improving vascular … The nurse should explain that the major advantage of this approach is that it: Has fewer potential complications than standard peritoneal dialysis, Is faster and more efficient than standard peritoneal dialysis. Observe proper body alignment, allow frequent position changes. If family members are present at the sessions, they can reinforce the material. Our aim in this study was to assess the change in PD patients' knowledge about their treatment and … Obtain specimens of blood, effluent, and drainage from insertion site as indicated for culture and sensitivity. 3 months after the completion of the initial assessment and within 3 months for an established dialysis patient transferring from one dialysis facility to another. The client asks whether her diet would change on CAPD. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. Note whether diuretics and/or antihypertensives are to be withheld. A client has a history of chronic renal failure and received hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Low glomerular filtration rate (GFR) (RRT often recommended to commence at a GFR of less than 10-15 mls/min/1.73m, Difficulty in medically controlling fluid overload, serum potassium, and/or serum phosphorus when the GFR is very low. Any items you have not completed will be marked incorrect. Rationale: May be reduced because of anemia, hemodilution, or actual blood loss. Rationale: Facilitates chest expansion and ventilation and mobilization of secretions. You have not finished your quiz. Rationale: Maximizes oxygen for vascular uptake, preventing or lessening hypoxia. Strictly follow the hemodialysis schedule. Restrain hands if indicated. Rationale: Minimizes stress on cannula insertion site to reduce inadvertent dislodgement and bleeding from site. Allow an extra 500 ml of fluid intake to dilute the electrolyte concentration. A nurse is assessing the patency of an arteriovenous fistula in the left arm of a client who is receiving hemodialysis for the treatment of chronic renal failure. His last hemodialysis treatment was yesterday. During the client’s dialysis, the nurse observes that the solution draining from the abdomen is consistently blood tinged. Rationale: Reduces risk of bacterial entry through catheter between dialysis treatments when catheter is disconnected from closed system. Assessment of the AV fistula for bruit and thrill is important because, if not present, it indicates a non-functioning fistula. Patients who are fluid volume overloaded with renal disease are often VERY hypertensive. These frequent long treatments are often done at home, while sleeping but home dialysis is a flexible modality and schedules can be changed day to day, week to week. Will experience no symptoms of dehydration. Provide back care and tissue massage. Correct acidosis, reverse electrolyte imbalances, remove excess fluid. The nurse would use which of the following standard indicators to evaluate the client’s status after dialysis? Intoxicants: If your patient has overdosed on something and you need to get it out NOW, then dialysis could be the way to go. Assess for headache, muscle cramps, mental confusion, disorientation. Rationale: Aids in evaluating fluid status, especially when compared with weight. Many nurses are playing now! Rationale: Symptoms suggest hyponatremia or water intoxication, Rationale: Changes may be needed in the glucose or sodium concentration to facilitate efficient dialysis. After Dialysis. Elevate head of bed or have patient sit up in chair. An AV shunt is a less common form of access site but carries a risk for bleeding when it is used because two ends of an external cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. Reposition the client to his or her side. Ineffective therapeutic Regimen Management related to lack of knowledge about therapy. Check the client’s weight, note any difference. Check for signs of bleeding and status of the fistula. Change dressings as indicated, being careful not to dislodge the catheter. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. Compare your findings with the predialysis results and report anything not within the defined limits as predetermined by the healthcare provider. Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnecting of peritoneal dialysis. Rationale: Patient is susceptible to pulmonary infections as a result of depressed cough reflex and respiratory effort, increased viscosity of secretions, as well as altered immune response and chronic and debilitating disease. During peritoneal dialysis,position the patient carefully. Dialysis allows for the exchange of particles across a semipermeable membrane by which of the following actions? Clients with diabetes are prone to renal insufficiency and renal failure. • Patients need to be assessed to see if the dialysis prescription is appropriate, including blood pressure and management of fluid status. Which of the following interventions would be done first? In hemodialysis, blood is removed from the patient and passed through a machine called a dialyzer. Have clear breath sounds and serum sodium levels within normal limits. Assess for blebs (ballooning or bulging) of the vascular access that may indicate an aneurysm that can rupture and cause hemorrhage. ), the doctor and the nurse will be able to determine if the therapy is effective. Abstract. The nurse is caring for a hospitalized client who has chronic renal failure. Rationale: Information may reduce anxiety and promote relaxation during procedure. Warm dialysate to body temperature before infusing. Provides information about the status of patient’s loss or gain at the end of each exchange. Assess skin around vascular access, noting redness, swelling, local warmth, exudate, tenderness. The nurse should immediately: Clients with peritoneal dialysis catheters are at high risk for infection. Anchor catheter so that adequate inflow/outflow is achieved. A client with diabetes who has a heart catherization, A pregnant woman who has a fractured femur. “I’ll take it with meals and bedtime snacks.”, “I’ll take it every 4 hours around the clock.”, “I’ll take it when I have a sour stomach.”, “I’ll take it between meals and at bedtime.”. If loading fails, click here to try again. Infection is a complication that shou… Handle tubing gently, maintain cannula alignment. Announcement!! Rationale: Decreases risk of clotting and disconnection. In hemodialysis, the patient’s blood is pumped through the blood compartment of a dialyzer, exposing it to a partially permeable membrane. Also monitored is the color of the fluid removed: normally it is pink-tinged for the initial four cycles and clear or pale yellow afterwards. These data provide baseline information to help evaluate the effects of hemodialysis. Note presence of fibrin strings and plugs. A dialysis nurse will either come to the room to perform HD (if the patient is in ICU), or the patient might go down to a dialysis center in the hospital to receive their treatment. Very dark reddish-black blood next to clear yellow fluid indicates full clot formation. Permit no puncture of shunt. Provide proper positioning for the dialysate to return from the peritoneal cavity. Passage of fluid toward a solution with a lower solute concentration. The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. CAPD does not work more quickly, but more consistently. Rationale: Alleviates pain, promotes comfortable breathing, maximal cough effort. Aluminum hydroxide gel is administered to bind the phosphates in ingested foods and must be given with or immediately after meals and snacks. Patients with ESRD have extensive and unique palliative care needs, often for years before death. CAPD is costly and must be done daily. When not being dialyzed, the AV fistula site may get wet. Which of the following factors causes the nausea associated with renal failure? Elevate head of bed at intervals. Assess patient frequently, especially during emergency treatment to lower potassium levels. Maintain nutritional status. Maintain record of inflow and outflow volumes and individual and cumulative fluid balance. The connecting tubing and the peritoneal dialysis system is also checked for kinks or twisting and the clamps on the system are checked to ensure that they are open. Disequilibrium syndrome may be due to the rapid decrease in BUN levels during dialysis. Although clients with renal failure can develop stress ulcers, the nausea is usually related to the poisons of metabolic wastes that accumulate when the kidneys are unable to eliminate them. Your nursing interventions when your patient returns from a hemodialysis treatment are almost identical to your predialysis interventions. The physician must be notified. If unable to get more output despite checking for kinks and changing the client’s position, the nurse should then call the physician to determine the proper intervention.