Clinical teaching on

Haemodialysis

Submitted to, Submitted by

MRs.Bindu pc Anusha M
Asst.Professor 1st year MSc NURSING
GCON,Kozhikode GCON,KOZHIKODE

Submitted on 24/01/23
 HEMODIALYSIS
Dialysis is used to remove fluid and uremic waste products from the body when the
kidneys cannot to do so. It is used for patients who are acutely ill and require short-term
dialysis and for patients with ESRD who require long-term or permanent therapy.
The need for dialysis may be acute or chronic. Dialysis used to physically prepare the
client to receive a transplanted kidney. Dialysis is usually necessary to keep the client alive
until a suitable donor kidney is found.

Goals
 To remove the end products of protein metabolism, such as urea and creatinine.
 To maintain a safe concentration of serum electrolytes
 To correct acidosis and replenish the bicarbonate levels of the blood
 To remove excess fluid from the blood
Types
 Haemodialysis
 Peritoneal Dialysis

HEMODIALYSIS
Hemodialysis is a process of cleaning the blood of accumulated waste products by
using an artificial kidney. In hemodialysis, the blood, laden with toxins and nitrogenous
wastes, is diverted from the patient to a machine, a dialyzer, in which the blood is cleansed
and then returned to the patient.

Principles
Dialysis works on the principles of the osmosis of solute and ultrafiltration of fluid
across a semi- permeable membrane. Diffusion is a property of substances in water;
substances in water tend to move from an area of high concentration to an area of low
concentration.
Blood flows by one side of a semi-permeable membrane, and a dialysate, or special
dialysis fluid, flows by the opposite side. A semipermeable membrane is a thin layer of
material that contains holes of various sizes, or pores. Smaller solutes and fluid pass through
the membrane, but the membrane blocks the passage of larger substances (for example, red
blood cells, large proteins).

Types of hemodialysis
 Conventional hemodialysis
 Daily hemodialysis
 Nocturnal hemodialysis
 CRRT
 SLED
 Conventional hemodialysis is usually done three times per week, for about 3–4 hours
for each treatment, during which the patient's blood is drawn out through a tube at a rate of
200–400 mL/min. The tube is connected to a 15-, 16-, or 17-gauge needle inserted in the
dialysis fistula or graft, or connected to one port of a dialysis catheter
Daily hemodialysis is typically used by those patients who do their own dialysis at
home. It is less stressful (more gentle) but does require more frequent access. This is simple
with catheters, but more problematic with fistulas or grafts. The "buttonhole technique" can
be used for fistulas requiring frequent access. Daily hemodialysis is usually done for 2 hours
six days a week.
Nocturnal hemodialysis is similar to conventional hemodialysis except it is
performed three to six nights a week and between six and ten hours per session while the
patient sleeps.
CRRTIs an extracorporeal blood purification therapy intended to substitute for
impaired renal function over an extended period of time and applied for or aimed at being
applied for 24 hours a day. The concept behind continuous renal replacement techniques is to
dialyse patients in a more physiologic way, slowly, over 24. hours, just like the kidney.
CRRT is performed mostly as convective therapy across a high-flux membrane, and using
industry-prepared substitution fluid in bags. CRRT is indicated in any patient who meets
criteria for hemodialysis therapy but cannot tolerate intermittent dialysis due to
hemodynamic instability. CRRT is better tolerated by hemodynamically unstable patients
because fluid volume, electrolytes and pH are adjusted slowly and steadily over a 24-hour
period rather than a 3– 4-hour period. This pattern more closely mimics the native kidney
and prevents abrupt shifts in fluid, electrolyte and acid-base balance.
SLED (Sustained Low‐Efficiency Dialysis) is a hybrid between CRRT and IHD,low
UF rates for HD stability, low efficient solute removal for less imbalance,uses conventional
HD machine and dialyzers, 8‐12 hrs per day, 5–7 days a week.

Access to the blood

 An intravenous catheter
 An arteriovenous fistula (AV)
 A synthetic graft.
 Arteriovenous shunt
Catheter access, sometimes called a CVC (central venous catheter), consists of a
plastic catheter with two lumens (or occasionally two separate catheters) which is inserted
into a large vein (usually the vena cava, via the internal jugular vein or the femoral vein) to
allow large flows of blood to be withdrawn from one lumen, to enter the dialysis circuit, and
to be returned via the other lumen. Catheters are usually found in two general varieties,
tunnelled and non-tunnelled.
Non- tunnelled catheter is for short-term access (up to about 10 days, but often for one
dialysis session only), and the catheter emerges from the skin at the site of entry into the
vein.
 Tunnelled catheter access involves a longer catheter, which is tunnelled under the skin
from the point of insertion in the vein to an exit site some distance away. It is usually placed
in the internal jugular vein in the neck and the exit site is usually on the chest wall. The
tunnel acts as a barrier to invading microbes, and as such, tunnelled catheters are designed
for short- to medium- term access (weeks to months only), because infection is still a
frequent problem.
AV (arteriovenous) fistulas are recognized as the preferred access method. To create
a fistula, a vascular surgeon joins an artery and a vein together through anastomosis. Since
this bypass the capillaries, blood flows rapidly through the fistula. Usually, the anastomosis
is made at the wrist between the radial artery and the cephalic vein. A fistula will take a
number of weeks to mature, on average perhaps 6-8 weeks. One can feel this by placing
one's finger over a mature fistula. This is called feeling for "thrill" .One can also listen
through a stethoscope for the sound of the blood "whooshing" through the fistula, a sound
called bruit.
Advantages
 Lower risk of infection
 Lower tendency to clot
 Lower hospitalization rates
 Lower complication rates
 Lower morbidity and mortality
 Allows for greater blood flow
 Long-term patency
 Improved performance with time
 Less cost of implantation and maintenance
Disadvantages
 Slow maturation and failure of maturation
 More difficult to needle.
 Increase in size with age and aneurysm formation.
 Cosmetic appearance of dilated veins.
AV (arteriovenous) grafts are much like fistulas in most respects, except that an
artificial vessel is used to join the artery and vein. The graft usually is made of a synthetic
material, often PTFE (Polytetrafluoroethylene). They mature faster than fistulas, and may be
ready for use several weeks after formation (some newer grafts may be used even sooner)
Arteriovenous shunt is a U-shaped plastic tube inserted between an artery and a vein
(usually between the radial artery and cephalic vein), bypassing the capillary network, a for
merely common means of arterio-venous Access. It allows high blood flow so that large
amount of blood can pass through the dialyser.
Parts of hemodialysis machine
An extensive water purification system is absolutely critical for hemodialysis. Since
dialysis patients are exposed to vast quantities of water, which is mixed with dialysate
concentrate to form the dialysate, even trace mineral contaminants or bacterial endotoxins
can filter into the patient's blood. Because the damaged kidneys cannot perform their
intended function of removing impurities, ions introduced into the bloodstream via water can
build up to hazardous levels, causing numerous symptoms or death. Water is run through a
tank containing activated charcoal to adsorb organic contaminants.  Primary purification is
then done by forcing water through a membrane with very tiny pores, a so-called reverse
osmosis membrane. This lets the water pass, but holds back even very small solutes such as
electrolytes. Final removal of leftover electrolytes is done by passing the water through a
tank with ion-exchange resins, which remove any leftover anions or cations and replace them
with hydroxyl and hydrogen ions, respectively, leaving ultrapure water.

The dialyzer is the piece of equipment that actually filters the blood. Almost all
dialyzers in use today are of the hollow-fiber variety. A cylindrical bundle of hollow fibers,
whose walls are composed of semi-permeable membrane. Blood is pumped via the blood
ports through this bundle of very thin capillary-like tubes, and the dialysate is pumped
through the space surrounding the fibers. Pressure gradients are applied when necessary to
move fluid from the blood to the dialysate compartment. Dialyzer membranes come with
different pore sizes. Those with smaller pore size are called "low-flux" and those with larger
pore sizes are called high flux.
Procedure In hemodialysis, the client’s toxin-laden blood is diverted into a dialyzer,
cleaned and then returned to the client. While the blood is in the dialyzer, a mechanical
proportioning pumb cause dialysis fluid to flow on the other side of the membrane. Toxin
diffuse across the membrane from the blood to the dialysate.

Nursing Responsibilities in hemodialysis

 Prepare the patient emotionally and physically
 Check the consent properly
 Weight the patient
 Check the laboratory values like Complete blood count, serum electrolyte, Blood urea
nitrogen and coagulation profile, All Viral Marker
 Check vital signs of patient
 Instruct patient to empty bladder
 Check the catheter site or fistula properly
 Document all finding properly
 Aseptic technique must be practiced to connect dialyser to the patient
 Observation of the patient includes checking pulse and B.P every half hour and
respiration every hour
 Observe for hypothermia, cardiac irregularity, twitching, headache, pruritus, etc.
 Observation of the machine includes a sudden break in the circuit, high venous
pressure (due to kinking), low venous pressure, low arterial pressure, failure of the
blood pump etc.
 Watch for disequilibrium syndrome, hypersensitivity reaction, seizure and air
embolism
 Carefully terminate the dialysis
 Check the vital signs of patient carefully
 Document the procedure and vital signs properly
 Document all finding carefully (total UF and net UF)
 Look for complications e.g. hypotension, hypoglycaemia, and bleeding from site,
EKG changes etc
 Explain the dietary management of patient on hemodialysis includes restrictions such
as adjustment of protein
 Remove any restrictive clothing or jewellery from the arm.
 To prevent injuries, place an armband on the patient or a sign over the bed that says no
BP measurements, venepunctures, or injections on the affected side.
 Perform hand hygiene before you assess or touch the vascular access. Position the
patient's arm so the vascular access is easily visualized.
 After dialysis, assess the vascular access for any bleeding or hemorrhage.
 Palpate the vascular access at least every 8 hrly to feel for a thrill or vibration and bruit
with stethoscope that indicates arterial and venous blood flow and patency.
  Check the patient's circulation by palpating his pulses distal to the vascular access;
observing capillary refill in his fingers; and assessing him for numbness, tingling,
altered sensation, coldness, and pallor in the affected extremity.
 Assess the vascular access for signs and symptoms of infection such as redness,
warmth, tenderness, purulent drainage, open sores, or swelling.

Bibliography
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