Nursing 4 Lecture 5 Hemodialysis

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Nursing 4 Lecture 5 Hemodialysis
2012-02-06 16:55:53

Nursing 4 Lecture 5 Hemodialysis
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  1. Hemodialysis:
    That start of dialysis is based on symptoms, NOT GFR.

    Can survive for years w/ hemodialysis

    • Started immediatley for:
    • -Fluid overload that is not relieved by diuretics
    • -Uremic symptoms (n/v, decreased attention span, decreased cognition, worsening anemia, and pruritis)
    • -Pericarditis
    • -Uncontrolled HTN
    • -Neurologic problems
    • -Development of bleeding
  2. Procedure:
    • Works by diffusion
    • -Movement of molecules from a higher concentration to a lower concentration

    -The dialysate is warmed to 100 degrees F to prevent hypothermia
  3. Anticoagulation:
    • -Needed to prevent clot formation in the dialyzer or tubing
    • -Heparin is most commonly used
    • -Heparin remains active in the blood for 4 to 6 hours after treatment putting the patient at rx for hemorrhage
    • -Pts receiving erythropoietin may require additional heparin
  4. Access: Catheters
    • -Form of temporary access
    • -Large bore catheters are placed in large veins that can support acceptable blood flows
    • -Most are used in emergency situations, for a SHORT period of time

    ALTHOUGH, a tunneled catheter can be used for prolonged periods of time, often weeks to months
  5. Arteriovenous Fistula:
    • -Requires advanced planning because a fistula takes a while after surgery to develop (in rare cases, as long as 24 months)
    • -A properly formed fistula is less likely than other kinds of vascular access to form clots or become infected
    • -Tend to last many years (longer than any other kind of vascular access)
    • -Desirable because rates of infection are very low and it is durable

    A surgeon creates an AV fistula by connecting an artery directly to a vein, frequently in the forearm. Connecting the artery to the vein grows larger and stronger, making repeated needle insertions for hemodialysis treatments easier. For the surgery, you'll be given a local anesthetic. In most cases the procedure can be performed on an outpatient basis.

  6. Arteriovenous Graft:
    If you have small veins that won't develop into a fistula, you can get a vascular access that connects an artery to a vein using a synthetic tube, or graft, implanted under the skin in your arm.

    • -The graft becomes an artificial vein that can be used repeatedly for needle placement and blood access during hemodialysis
    • -A grafy does not need to develop as a fistula does, so it can be used sooner after placement, often within 2 to 3 weeks

    • -Have more problems with clotting and infection and need replacement sooner
    • -BUT a week cared for graft can last several years

  7. How access is made:
    • -Permanent access is created by surgically joining an artery to a vein
    • -Allows the vein to receive blood at high pressure, leading to thickening of the veins wall
    • -The "arterialized vein" can sustain repeated puncture and provides excellent blood flow rates
    • -The connection between an artery and a vein can be made using blood vessels (fistula) or a synthetic bridge (graft)
  8. Venous Catheter for Temporary Access:
    • -If kidney disease progressed quickly, you may not have time to get a permanent vascular access before you start hemodialysis treatments
    • -You may need to use a venous catheter as a temporary access

    • -A catheter is a tube inserted into a vein in your neck, chest, or leg near the groin
    • -It has two chambers to allow a two way flow of blood
    • -once the catheter is placed, needle insertion is not necessary

    • -Catheters are not ideal for permanent access
    • -They can clog, become infected, and cause narrowing of the veins in which they are placed
    • -BUT if you need to start hemodialysis immediatley, a catheter will work for several weeks or months while your permanent access develops
  9. Vascular Access:
    • -Ateriovenous fistula or arteriovenous graft for long term permanent access
    • -Hemodialysis catheter, dual or triple lumen, or arteriovenous shunt for temporary access
  10. Vascular Access Precautions:
    • 1. Do not take blood pressure readings using the extremity in which the vascular access is placed
    • 2. Do not perform venipunctures or start an IV line in the extremity in which the vascular access is placed
    • 3. Palpate for thrills and auscultate for bruits every 4 hours while the patient is awake
    • 4. Assess the distal pulses and circulation
    • 5. Elevate the affected extremity postoperatively
    • 6. Encourage range of motion exercises
    • 7. Check for bleeding at needle insertion sites or shunt tubing insertion sites (keep small clamps handy on the dressing of the AV shunt)
    • 8. Assess for manifestations of infection at needle sites and shunt tubing inserion sites
    • 9. Instruct the patient not to carry heavy objects or anything that compresses the extremity in which the vascular access is placed
    • 10. Instruct the patient not ot sleep with his or her body weight on top of the extremity in which the vascular assess is placed
  11. Complications:
    • Thrombosis:
    • -Most frequent complication
    • -Some pts are at a greater risk for clotting than others and my be given anticoagulant drugs
    • -Intervention radiology can treat failing grafts
    • -Grafts fail because of high pressure arterial flow entering the venous system
    • -Muscle layers of the veins react to this increased pressure by thickening
    • -The venous thickening reduces or occludes blood flow
    • -Radiologists inject a thrombolytic drug (tPA) to dissolve the clot
    • -The clot usually dissolves within minutes and often a stricture is revealed at the point where the graft and the vein connect
    • -The stricture can be treated b balloon angioplasty

    • Infection:
    • -Most are caused by staphylococcus aureus introduced during cannulation
    • -Caused by staff, BE STERILE

    • Aneurysm:
    • -Can form in the fistula and are caused by reapeated needle punctures at the same site
    • -Large aneruysms may cause loss of the fistulas function and may require surgical repair

    • Ischemia:
    • -When the fistula decreases arterial blood flow to areas below the fistula
    • -"steal syndrome": vary from cold or numb fingers to gangrene
    • -If the collateral circulation is inadequate, the fistula may need to be tied off and a new one created in another area to preserve extremity circulation

    Heart failure
  12. Interventions for Complications of an AV fistula or AV graft:
    • Bleeding:
    • - Apply pressure to the needle puncture sites

    • Infection:
    • -Ensure adequate site cleaning before cannulation

    • Clotting:
    • -Avoid restrictive devices
    • -Rotate needle insertion sites with each hemodialysis treatment
  13. Interventions for Complications of an AV shunt:
    • Bleeding:
    • -Keep clamps available

    • Infection:
    • -Perform exit site care 3 times/wk

    • Clotting:
    • -Avoid constrictive devices
    • -Assess for thrill and bruit
  14. Interventions for Complications of Hemodialysis Catheters:
    • Bleeding:
    • -Monitor the access site

    • Infection:
    • -Use aseptic technique

    • Clotting:
    • -Place a heparin or heparin/saline dwell solution after hemodialysis treatment
    • -Not used between treatments
  15. Hemodialysis Nursing Care: