NURSING CARE IN DIALYSIS

R.Raja Rajeswari, Dialysis Nurse, L.Sivamani, Dialysis Technician Government General Hospital, Chennai-3

Dialysis is a process that substitutes for renal function by removing excess fluid and/or accumulated endogenous or exogenous toxins. Dialysis is most often

used for patients with ARF and chronic (end-stage) renal disease. The two most common types are hemodialysis and peritoneal dialysis. Dialysis therapies include intermittent hemodialysis (IHD), continuous arteriovenous hemodialysis. (CAVHD), continuous venouvenous hemodialysis (CVVHD) and peritoneal dialysis. Currently the majority of patients receiving hemodialysis for chronic renal failure are treated as outpatients in hemodialysis units of large hospitals. In most of these units it is the nurses that handle the entire dialysis procedure with little if any direct supervision from physicians. The nurses are also the ones on the health team that have the most contact with the patients. Thus the nurse must have a thorough knowledge of the pathophysiology of renal failure, of the mechanics and technical aspects of the dialyzer, of the expected outcomes and complications of hemodialysis and, particularly, the needs of the hemodialysis patient. The nurses that choose to work with chronic hemodialysis patients can enjoy much satisfaction in assisting in maintaining both a productive life and a long term relationship with chronic renal failure patients. The nurse makes the differences.

The provision of comprehensive care to patients requiring maintenance hemodialysis has developed in to a complex multidisciplinary effort involving nurses at all levels. Nephrology nursing has evolved over 15 years into a model of so called expanded practice, i.e., one in which technical expertise and broad scientific and professional education are necessary as well as significant commitment to quality of care. The dialysis nurse is responsible for all forms or renal replacement therapy, including hemodialysis, peritoneal dialysis, and continuous renal replacement therapies across the age continuum. Nursing care focuses on close assessment and monitoring of the patient during their dialysis treatment, patient, family and staff education, and dismissal planning in collaboration with the multidisciplinary team. NURSING PRIORITIES 1. Promote homeostasis 2. Maintain comfort 3. Prevent complications 4. Support patient independence / self-care 5. Provide information about disease process/prognosis and treatment needs PROVIDING THE BEST CARE To offer your patient top care, implement the following: 1. If your patient is scheduled for morning dialysis treatments, arrange an early breakfast for him. If a meal arrives while hes in dialysis, save it for later he cant eat during dialysis. (if hes diabetic, make sure he gets his insulin and breakfast before dialysis).

2. Give him his water soluble medications after dialysis; otherwise, theyll be dialyzed out of his system. Check with the physician about holding

antihypertensive medications. Dialysis lowers blood pressure (BP), so your patient may be at risk for compounding hypotension during the treatment. Also check with the physician about removing a nitroglycerin patch. 3. If the physician orders blood work, coordinate with the dialysis nurse about wholl draw the blood. This way, youll prevent your patient from additional needle sticks and from losing more blood than necessary. 4. Send intravenous (I.V.) medications (such as antibiotics, calcitriol and iron compounds) with the patient when he goes to the dialysis unit. The

dialysis nurse will administer them, adjusting fluid overload. This also prevents extra needle sticks for the patient. 5. When the patient returns from dialysis, assess his access site for bleeding and make sure his BP is table before letting him resume activity. 6. Regularly evaluate your patients serum potassium level for hyperkalemia. 7. Remind all staff avoid using the patients dialysis access arm for administering I.V. medications, taking BP, or drawing blood. 8. Access the thrill and bruit of the access site each shift. If theyre absent, notify the physician or the dialysis nurse and document this information in the patients chart. Also watch for signs of infection, such as warmth, redness, swelling, or pain in the access arm.

9. If post dialysis bleeding occurs at the access site, apply direct pressure to the site for 15 minutes (or longer, if necessary) to stop the bleeding. If the bleeding continues, notify the physician. After controlling the bleeding, apply a dressing. Make sure you remove the dressing after 24 hours. 10. Teach your patient about diet restrictions and tell him to avoid foods high in potassium and sodium. 11. If your patient has both diabetes and ESRD and becomes hypoglycemic, give him apple juice instead of orange juice. Remember, citrus fruits and juices are high in potassium. 12. Restrict your patients fluids to 1,000 ml/day (or as directed). Avoid administering continuous infusions of I.V. fluids. monitor and document his fluid intake and output. 13. If he has an external dialysis access, the dialysis nurse or central line team should perform the dressing change. The catheter should be used for dialysis only, because it contains high concentrations of heparin to keep the catheter patent between dialysis treatments. 14. Address the psychosocial aspects of ESRD. The disease and its treatments cause many concerns about employment, finances, health and sexual functioning, leading to anger or depression. Teach him how to