Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,,,*,Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.,,Focus on Dialysis and Kidney Transplant,(Chapter 47, “Nursing Management: Dialysis and Kidney Transplant,” Lewis—Modified by L. Copenhaver),,,Focus on Dialysis and Kidney,1,Dialysis,Movement of fluid/molecules across a semipermeable membrane from one compartment to another,Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure,Treat drug overdoses,,,DialysisMovement of fluid/mole,2,Dialysis,Two methods of dialysis available,Peritoneal dialysis (PD),Hemodialysis (HD),,,Dialysis Two methods of dialys,3,Dialysis,Begun when patient’s uremia can no longer be adequately managed conservatively,Initiated when GFR (or creatinine clearance) <15 ml/min,,,Dialysis Begun when patient’s,4,General Principles of Dialysis,Diffusion,Movement of solutes from an area of greater concentration to an area of lesser,,,General Principles of Dialysis,5,General Principles of Dialysis,Osmosis,Movement of fluid from an area of lesser to area of greater concentration of solutes,Ultrafiltration,Water and fluid removal,Results when there is an osmotic gradient across the membrane,,,,,General Principles of Dialysis,6,Osmosis and Diffusion Across Semipermeable Membrane,Fig. 47-7,,,Osmosis and Diffusion Across S,7,Peritoneal Dialysis,Peritoneal access is obtained by inserting a catheter through the anterior wall,Technique for catheter placement varies,Usually done via surgery,,,Peritoneal DialysisPeritoneal,8,Peritoneal Dialysis,After catheter inserted, skin is cleaned with antiseptic solution and sterile dressing applied,Connected to sterile tubing system,Secured to abdomen with tape,Catheter irrigated immediately,,,Peritoneal DialysisAfter cathe,9,Peritoneal Dialysis,Waiting period of 7 to 14 days preferable,2 to 4 weeks after implantation, exit site should be clean, dry, and free of redness/tenderness,Once site healed patient may shower and pat dry,,,Peritoneal DialysisWaiting per,10,Tenckhoff Catheter,Fig. 47-8,,,Tenckhoff Catheter Fig. 47-8,11,Fig. 47-9 and Fig. 47-10,,,Fig. 47-9 and Fig. 47-10,12,Peritoneal Dialysis,Dialysis Solutions and Cycles,Available in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25%,Electrolyte composition similar to plasma,Solution warmed to body temperature,,,Peritoneal Dialysis Dialysis S,13,Peritoneal Dialysis,Dialysis Solutions and Cycles,Three phases of PD cycle,Called an exchange,Inflow (fill),Dwell (equilibration),Drain,,,Peritoneal Dialysis Dialysis S,14,Peritoneal Dialysis,Dialysis Solutions and Cycles,Inflow,Prescribed amount of solution infused through established catheter over about 10 minutes,After solution infused, inflow clamp closed to prevent air from entering tubing,,,Peritoneal Dialysis Dialysis S,15,Peritoneal Dialysis,Dialysis Solutions and Cycles,Dwell,Diffusion and osmosis occur between patient’s blood and peritoneal cavity,Duration of time varies depending on method,,,,Peritoneal Dialysis Dialysis S,16,Fig. 47-12,,,Fig. 47-12,17,Peritoneal Dialysis,Dialysis Solutions and Cycles,Drain,15 to 30 minutes,May be facilitated by gently massaging abdomen or changing position,,,,,Peritoneal Dialysis Dialysis S,18,Peritoneal Dialysis,Systems,Automated peritoneal dialysis (APD),Cycler delivers the dialysate,Times and controls fill, dwell, and drain,Continuous ambulatory peritoneal dialysis (CAPD),Manual exchange,,,Peritoneal Dialysis SystemsAut,19,Peritoneal Dialysis,Complications,,Exit site infection,Peritonitis,Abdominal pain,Outflow problems,Hernias,,,Peritoneal Dialysis Complicati,20,Peritoneal Dialysis,Complications,Lower back problems,Bleeding,Pulmonary complications,Protein loss,,,Peritoneal Dialysis Complicati,21,Peritoneal Dialysis,Complications,Carbohydrate and lipid abnormalities,Encapsulating sclerosing peritonitis,Loss of ultrafiltration,,,Peritoneal Dialysis Complicati,22,Peritoneal Dialysis,Effectiveness and Adaptation,,Short training program,Independence,Ease of traveling,Fewer dietary restrictions,Greater mobility than with HD,,,Peritoneal Dialysis Effectiven,23,Hemodialysis,Vascular Access Sites,Obtaining vascular access is one of most difficult problems,Types of access include,Shunts,Internal arteriovenous fistulas and grafts,Temporary vascular access,,,Hemodialysis Vascular Access S,24,Vascular Access for Hemodialysis,,Fig. 47-13,,,Vascular Access for Hemodialys,25,Fig. 47-13-D,,,Fig. 47-13-D,26,Hemodialysis,Dialyzers,Long plastic cartridge that contains thousands of parallel hollow tubes or fibers,Fibers are the semipermeable membrane,,,,,Hemodialysis DialyzersLong pla,27,Hemodialysis System,Fig. 47-16,,,Hemodialysis System Fig. 47-16,28,Hemodialysis,Procedure,Two needles placed in fistula or graft,Needle closer to fistula or red catheter lumen pulls blood from patient and sends to dialyzer,Blood returned from dialyzer to patient through second needle or blue catheter,,,,Hemodialysis ProcedureTwo need,29,Hemodialysis,Procedure,Dialyzer/blood lines primed with saline solution to eliminate air,Heparin added to blood as it flows to dialyzer,Terminated by flushing dialyzer with saline to remove all blood,Needles removed and firm pressure applied,,,,Hemodialysis ProcedureDialyzer,30,Hemodialysis,Procedure,Before treatment nurse should,Complete assessment of fluid status, condition of access, temperature, skin condition,During treatment nurse should,Be alert to changes in condition,Perform vital signs every 30 to 60 minutes,,,,Hemodialysis ProcedureBefore t,31,Fig. 47-17,,,Fig. 47-17,32,Hemodialysis,Complications,Hypotension,Muscle cramps,Loss of blood,Hepatitis,Sepsis,Disequilibrium syndrome,,,Hemodialysis ComplicationsHypo,33,Hemodialysis,Effectiveness and Adaptation,Cannot fully replace metabolic and hormonal functions of kidneys,Can ease many of the symptoms,Can prevent certain complications,,,Hemodialysis Effectiveness and,34,Continual Renal Replacement Therapy (CRRT),Alternative or adjunctive method for treating ARF,Means by which uremic toxins and fluids are removed,Acid–base status/electrolytes adjusted slowly and continuously,,,Continual Renal Replacement Th,35,Continual Renal Replacement Therapy (CRRT),Can be used in conjunction with HD,Contraindication,Presence of manifestations of uremia requiring rapid resolution,Continued for 30 to 40 days,Hemofilter change every 24 to 48 hours,Ultrafiltrate should be clear yellow,Specimens may be obtained for evaluation,,,Continual Renal Replacement Th,36,Continual Renal Replacement Therapy (CRRT),Two types of CRRT,Continuous arteriovenous therapies (CAVTs),Continuous venovenous therapies (CVVTs),Most commonly used,Continuous venovenous hemofiltration (CVVH),Continuous venovenous hemodialysis (CVVHD,),,,Continual Renal Replacement T,37,Continual Renal Replacement Therapy (CRRT),Continuous venovenous hemofiltration (CVVH),Large volumes fluid removed hourly, then replaced,Fluid replacement dependent on stability/individualized needs of patient,,,,Continual Renal Replacement T,38,Continual Renal Replacement Therapy (CRRT),Continuous venovenous hemodialysis (CVVHD),Uses dialysate,Dialysate bags attached to distal end of hemofilter,Fluid pumped countercurrent to blood flow,Ideal treatment for patient who needs fluid/solute control but cannot tolerate rapid fluid shifts with HD,,,,Continual Renal Replacement T,39,Continual Renal Replacement Therapy (CRRT),Highly permeable, hollow fiber hemofilter,Uses double-lumen catheter placed in femoral, jugular, or subclavian vein,Removes plasma water and nonprotein solutes,,,Continual Renal Replacement T,40,Continual Renal Replacement Therapy (CRRT),CRRT versus HD,Continuous rather than intermittent,Solute removal by convection (no dialysate required) in addition to osmosis and diffusion,Less hemodynamic instability,Does not require constant monitoring by HD nurse,Does not require complicated HD equipment,,,,,Continual Renal Replacement T,41,Kidney Transplantation,More than 66,000 patients currently awaiting deceased (cadaveric) kidney transplants,19,549 kidneys were transplanted in 2004,More than 6990 living donor transplants in 2004,,,Kidney TransplantationMore tha,42,Kidney Transplantation,Advantages of kidney transplant compared with dialysis,Reverses many of the pathophysiologic changes associated with renal failure,Eliminates the dependence on dialysis,Less expensive than dialysis after the first year,,,,,Kidney TransplantationAdvantag,43,Kidney Transplantation,Recipient Selection,Contraindications to transplantation,Disseminated malignancies,Cardiac disease,Chronic respiratory failure,Extensive vascular disease,Chronic infection,Unresolved psychosocial disorders,,,,Kidney Transplantation Recipie,44,Kidney Transplantation,Histocompatibility Studies,Purpose of testing is to identify the HLA antigens for both donors and potential recipients,,,Kidney Transplantation Histoco,45,Kidney Transplantation,Donor Sources,Compatible blood type deceased donors,Blood relatives,Emotionally related living donors,Altruistic living donors,,,Kidney Transplantation Donor S,46,Kidney Transplantation,Surgical Procedure,Live donor,Nephrectomy performed by a urologist or transplant surgeon,Begins an hour or two before the recipient’s surgery is started,Rib may need to be removed for adequate view,Takes about 3 hours,,,Kidney Transplantation Surgica,47,Kidney Transplantation,Surgical Procedure,Live donor,Laparoscopic donor nephrectomy,Alternative to conventional nephrectomy,Primary method of live kidney procurement,,,,Kidney Transplantation Surgica,48,Kidney Transplantation,Surgical Procedure,Kidney transplant recipient,Usually placed extraperitoneally in the iliac fossa,Right iliac fossa is preferred,,,Kidney Transplantation Surgic,49,Fig. 47-19,,,Fig. 47-19,50,Kidney Transplantation,Surgical Procedure,Kidney transplant recipient,Rapid revascularization critical,,Donor artery anastomosed to recipient internal/external iliac artery,,Donor vein anastomosed to recipient external iliac vein,,,,Kidney Transplantation Surgic,51,Kidney Transplantation,Surgical Procedure,Kidney transplant recipient,When anastomoses complete, clamps released and blood flow reestablished,Urine may begin to flow or diuretic may be given,Surgery takes 3 to 4 hours,,,Kidney Transplantation Surgic,52,Kidney Transplantation,Nursing Management,Preoperative care,Emotional and physical preparation,Immunosuppressive drugs,ECG,Chest x-ray,Laboratory studies,,,Kidney Transplantation Nursing,53,Kidney Transplantation,Nursing Management,Postoperative care,Live donor,Care is similar to laparoscopic nephrectomy,Close monitoring of renal function,Close monitoring of hematocrit,,,Kidney Transplantation Nursing,54,Kidney Transplantation,Nursing Management,Postoperative care (cont’d),Recipient,Maintenance of fluid and electrolyte balance is first priority,Large volumes of urine soon after transplanted kidney placed due to,New kidney’s ability to filter BUN,Abundance of fluids during operation,Initial renal tubular dysfunction,,,Kidney Transplantation Nursing,55,Kidney Transplantation,Complications,Rejection,Hyperacute (antibody-mediated, humoral) rejection,Occurs minutes to hours after transplantation,,,Kidney Transplantation Complic,56,Kidney Transplantation,Complications,Rejection (cont’d),Acute rejection,Occurs days to months after transplantation,,,Kidney Transplantation Complic,57,Kidney Transplantation,Complications,Rejection (cont’d),Chronic rejection,Process that occurs over months or years and is irreversible,,,Kidney Transplantation Complic,58,Kidney Transplantation,Complications,Infection,Most common infections observed in the first month,Pneumonia,Wound infections,IV line and drain infections,,,Kidney Transplantation Complic,59,Kidney Transplantation,Complications,Infection (cont’d),Fungal infections,Candida,Cryptococcus,,Aspergillus,Pneumocystis jiroveci,,,Kidney Transplantation Complic,60,Kidney Transplantation,Complications,Infection (cont’d),Viral infections,CMV,One of the most common,Epstein-Barr virus,Herpes simplex virus,,,Kidney Transplantation Complic,61,Kidney Transplantation,Complications,Cardiovascular disease,Transplant recipients have,increased incidence of atherosclerotic vascular disease,Immunosuppressant can worsen hypertension and hyperlipidemia,Adhere to antihypertensive regimen,,,Kidney Transplantation Complic,62,Kidney Transplantation,Complications,Malignancies,Primary cause is immunosuppressive therapy,Regular screening important preventive care,,,Kidney Transplantation Complic,63,Kidney Transplantation,Complications,,Corticosteroid-related complications,Aseptic necrosis of the hips, knees, and other joints,Peptic ulcer disease,Glucose intolerance and diabetes,,,,Kidney Transplantation Complic,64,Nursing Management,Evaluation,Maintenance of ideal body weight,Acceptance of chronic disease,No infections,No edema,Hematocrit, hemoglobin and serum albumin levels in acceptable range,,,,Nursing Management EvaluationM,65,。