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NEPHROLOGY GROUP :
MINANTON
SRIYATI
TINA MUZAENAH
MASTER OF NURSING
UNIVERSITY MUHAMMADIYAH OF YOGYAKARTA
2018
I. Patient Bibliography
1. Name : Mr. Z
2. Age : 64
3. Sex : Male
4. Religion : Islam
5. Marital Status : Maried
6. Occupation :
7. Source of Health care : Hospital
8. Date Of Admission : 9 October 2018
9. Provisional Diagnosis : CKD end stage
10. Date Of Surgery (if any) : 24 September 2018 for IJC
2. Pathophysiology
As renal function declines, the end products of protein metabolism
(normally excreted in urine) accumulate in the blood. Uremia develops and
adversely affects every system in the body. The greater the buildup of
waste products, the more pronounced the symptoms are.
The rate of decline in renal function and progression of ESRD is
related to the underlying disorder, the urinary excretion of protein, and the
presence of hypertension. The disease tends to progress more rapidly in
patients who excrete significant amounts of protein or have elevated blood
pressure than in those without these conditions.
b. Hemodialysis
Hemodialysis is used for patients who are acutely ill and require short-
term dialysis (days to weeks) and for patients with advanced CKD and
ESRD who require long-term or permanent renal replacement therapy.
Hemodialysis prevents death but does not cure renal disease and does
not compensate for the loss of endocrine or metabolic activities of the
kidneys. More than 90% of patients requiring long term renal
replacement therapy are on chronic hemodialysis (USRDS, 2007).
Most patients receive intermittent hemodialysis that involves
treatments three times a week with the average treatment duration of 3
to 4 hours in an outpatient setting. There are types of HD based on
vascular access, mainly:
1) Arteriovenous Fistulas and Grafts.
A subcutaneous arteriovenous fistula (AVF) is usually created in
the forearm or upper arm with an anastomosis between an artery
and a vein (usually cephalic or 4asilica). The fistula allows
arterial blood to flow through the vein. The vein becomes
“arterialized” with a larger caliber and thicker walls. The arterial
blood flow is essential to provide the rapid blood flow required
for HD. As the arterialized vein matures, it is more amenable to
repeated venipunctures. Maturation may take 6 weeks to months.
AVF should be placed at least 3 months before the need to initiate
HD. Normally, a thrill can be felt by palpating the area of
anastomosis, and a bruit (rushing sound) can be heard with a
stethoscope. The bruit and thrill are created by arterial blood
moving at a high velocity through the vein. AVFs are more
difficult to create in patients with a history of severe peripheral
vascular disease, those with prolonged IV drug use, and obese
women. For these individuals, a synthetic graft may be required.
2) Arteriovenous grafts (AVGs)
Arteriovenous grafts are made of synthetic materials
(polytetrafluoroethylene [PTFE, Teflon]) and form a “bridge”
between the arterial and venous blood supplies. Grafts are placed
under the skin and are surgically anastomosed between an artery
(usually brachial) and a vein (usually antecubital). An interval of
2 to 4 weeks is usually necessary to allow the graft to heal, but
some centers may use it earlier.
3) Temporary Vascular Access.
In some situations, when immediate vascular access is required,
catheterization of the internal jugular or femoral vein is
performed. A flexible Teflon, silicone rubber, or polyurethane
catheter is inserted at the bedside into one of these large veins and
provides access to the circulation without surgery. The catheters
usually have a double external lumen with an internal septum
separating the two internal segments. One lumen is used for blood
removal and the other for blood return. It is now recommended
that patients not be discharged from the hospital with a temporary
catheter. These catheters have high rates of infection,
dislodgment, and malfunction.
Long-term cuffed HD catheters are often used for temporary
vascular access. These catheters provide temporary access while
the patient is waiting for fistula placement or as long-term access
when other forms of access have failed. This type of catheter exits
on the upper chest wall and is tunneled subcutaneously to the
internal or external jugular vein
6. Complications of Hemodialysis
a. Hypotension.
Hypotension that occurs during HD primarily results from rapid
removal of vascular volume (hypovolemia), decreased cardiac output,
and decreased systemic vascular resistance. The drop in BP during
dialysis may precipitate light-headedness, nausea, vomiting, seizures,
vision changes, and chest pain from cardiac ischemia. The usual
treatment for hypotension includes decreasing the volume of fluid
being removed and infusion of 0.9% saline solution.
b. Muscle Cramps.
The pathogenesis of muscle cramps in HD is poorly understood.
Factors associated with the development of muscle cramps include
hypotension, hypovolemia, high ultrafiltration rate (large inter dialytic
weight gain), and low sodium dialysis solution. Cramps are more
frequently seen in the first month after initiation of dialysis than in the
subsequent period. Treatment includes reducing the ultrafiltration rate
and administering fluids (saline, glucose, mannitol). Hypertonic saline
is not recommended, since the sodium load can be problematic.
Hypertonic glucose administration is preferred.
c. Loss of Blood.
Blood loss may result from blood not being completely rinsed from
the dialyzer, accidental separation of blood tubing, dialysis membrane
rupture, or bleeding after the removal of needles at the end of dialysis.
If a patient has received too much heparin or has clotting problems,
post dialysis bleeding can be significant. It is essential to rinse back all
blood, to closely monitor heparinization to avoid excess
anticoagulation, and to hold firm but non occlusive pressure on access
sites until the risk of bleeding has passed.
b. Intra HD : Nausea
c. Post HD : None
b. Intra HD : Oriented
c. Post HD : Oriented
b. Intra HD : none
c. Post HD : none
b. Intra HD : -
c. Post HD : Ambulatory
6. Edema
a. Pre HD : none
b. Intra HD : none
c. Post HD : none
X. References