Dialysis Prep Assignment
Student Name
Kelsey Gassett
Date
10/24/23
Grade
/50 points
I. Dialysis
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A
1.
2.
List 3 purposes of dialysis
Removes waste and extra fluids in your body to prevent them from building up in the body
Keeping safe levels of minerals in your blood, such as potassium, sodium, calcium, and bicarbonate
3.
B
Helps regulate blood pressure
Explain the difference between ultrafiltration and osmosis.
Ultrafiltration: water removal occurs through this process by (1) generating a transmembrane pressure,
which is greater than the plasma oncotic pressure. (2) by increasing the osmolarity of the dialysate [as in
peritoneal dialysis]
Osmosis: fluid moves from areas of high concentration to lower water concentration across a semipermeable
membrane until equilibrium. (In dialysis excess fluid moves from blood to the dialysate through a membrane
until the fluid level is the same between blood and dialysate)
II. Physiologic Principles
Hemodialysis
“Most common”
Advantages
• More effective clearance of waste
• Short time needed for treatment
Peritoneal dialysis
• Flexible schedule for exchanges
• Few hemodynamic changes during
and following exchanges
• Fewer dietary and fluid restrictions
Continuous
Renal
Replacement
Therapy
(CRRT)
• Applicability in hemodynamically
unstable patients, even in the presence
of shock
• Can be easily set up and ran by
regular ISU Staff (avoids the need for
specially trained dialysis nurses and
technicians
• Membranes in CRRT are typically
more permeable (allows for the
clearance of membranes as large as
20,000-40,000
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Disadvantages
• Disequilibrium syndrome
• Muscle cramps and back pain
• Headache
• Itching
• Hemodynamic and cardiac adverse events
(hypotension, cell lysis contributing to
anemia, cardiac dysrhythmias)
• Infection
• Increased risk for subdural and intracranial
hemorrhage from anticoagulation and
changes in blood pressure during dialysis
• Anemia
• Access site complications
• Protein loss
• Peritonitis
• Respiratory distress
• Inflammatory bowel disease
• Bowel perforation
• Infection
• Weight gain; Discomfort from “carrying_ 12 L in abdomen during dwell time; potential
for back pain or development of hernia
• requires more intensive anticoagulation
which can place pt. at risk for bleeding and
electrolyte disturbances
•must remain immobile for long periods of
time to ensure proper machine function
•not available at smaller hospitals, possibly
due to high equipment, training, staffing
cost, and relatively infrequent utilization.
• Has the ability to avoid rebound of
compounds removed from the blood
compartment which then re-equilibrate
from intracellular space to plasma
III. Hemodialysis Access
A.
AV Fistula
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Complete this table
Permanent or
Procedure to create
temporary?
Permanent
Surgeon creates an AV fistula by
connecting an artery and a vein in the
patient’s arm during a minor surgical
procedure.
Permanent
A surgeon places a graft under the skin
and connects an artery and a vein by
creating a stable access point for dialysis
Temporary
Inserted into large veins
How soon available for dialysis?
Requires some time to mature
before they can be used for
dialysis. Should be available a
few weeks-months post-op
AV Graft
Shorter time needed than
fistula, should be ready within a
couple weeks.
Subclavian or
Can be used immediately for
femoral catheter
dialysis.
B.
List four causes of decreased blood flow to a fistula or graft which can result in clotting and loss of patency
1.
Stenosis is the narrowing of the blood vessel at the site of the fistula or graft. It often occurs due to the
formation of scar tissue inside the blood vessel, which leads to reduced blood flow. Common cause of
clotting in hemodialysis access.
2.
Thrombosis refers to the formation of blood clots within the blood vessel of the fistula or graft. Clots can
obstruct blood clots within the blood vessel of a fistula or graft. The clots can obstruct blood flow and lead to
loss of patency. Can occur due to various factors, turbulent blood flow, injury to access site, problem with the
dialysis procedure.
3. Intimal hyperplasia is the thickening of the inner lining of a blood vessel. It’s a response to the placement of
the fistula or the graft leading to narrowing of the vessel and decreased blood flow.
4.
Infection and inflammation: infections near the fistula or graft sites can cause inflammation and damage to
the vessel walls. Inflammatory response can lead to the information of clots and decreased blood flow.
Inadequate hygiene or improper care of the access site can increase the risk of infection and inflammation as
well.
Regular monitoring, proper care, and timely intervention are essential to prevent and address these issues,
ensuring the longevity and effectiveness of fistula and grafts used for hemodialysis.
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What is a thrill and what is its purpose?
Refers to a pulsatile or vibrating sensation that can be felt or sometimes heard over the vascular access site such as
an AV fistula or AV Graft. The purpose of checking for a thrill is to ensure the patency and functionality of the
vascular access.
Which access is most preferred for End Stage Renal Disease and why?
AV fistula
• long-term patency
• lower infection risk
• reduced thrombosis risk
• lower healthcare cost
• preservation of veins
• better blood flow
Describe client teaching points for care of a permanent access in the following areas:
1.
Daily Cleaning:
• hand hygiene
2.
3.
IV.
• access site cleaning: clean daily with mild soap and water. Gently pat dry with a clean, soft cloth. Do not use
alcohol-based products as they can dry out and irritate the skin.
• Avoid trauma: be careful to avoid trauma or injury to access site, no tight jewelry, or clothing that could put
pressure on the site.
When to call the Dr:
• when there is s/s of infection. Call the doctor if you notice any redness, swelling, warmth, or pus at the
access site.
• changes in blood flow: if you feel a sudden decrease of blood flow during dialysis or if you do not feel the
usual thrill or hear the bruit over access site. (possible clot or stenosis)
• bleeding or bruising: if you experience bleeding after needle removal or develop a large bruise call HCP
could indicate a bleeding issue or damage to the access.
IV stick in the access arm:
• avoidance of access arm: make sure to tell all HCP if you have a vascular access site in your arm and request
blood draws, injections and iv’s in your other arm. Protect access arm from any trauma or invasive
procedures.
• educate HCP: advocate for yourself, express the importance of preserving your access site and state the
risks associated with accessing the arm with vascular access.
• emergency situations: make sure experienced personnel handle the procedure. After any IV sticks, monitor
for s/s of infection or bleeding report anything ASAP
Generic care for Clients on Dialysis
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What medications are usually held during dialysis?
• potassium sparing diuretics
• NSAIDs
• potassium supplements
• insulin and oral hypoglycemic agents
What meds may be given before dialysis?
• anticoagulants
• anti-hypertensives
• erythropoiesis-stimulating agents
• calcium supplements
• Phosphate binders
Why is the client on hemodialysis at risk for bleeding?
• anticoagulation during hemodialysis
• platelet dysfunction
• uremic platelet dysfunction
• vascular access
• GI bleeding
• medications
• inadequate dialysis
Hypovolemic Shock
1.
What is the cause of hypovolemic shock that occurs during dialysis?
• Ultrafiltration
• hypotension
• bleeding
• GI bleed
• cardiac issues
• dehydration
• medications
2.
What should the nurse assess to detect hypovolemia during dialysis? Include vital signs and clinical signs?
.Vital Signs: b/p, hr, rr, temperature
• clinical signs
Skin condition: cool and pale skin can indicate poor perfusion
Diaphoresis (excessive sweating)
• LOC
Confusion, restlessness, or altered mental status can occur due to decreased cerebral perfusion
• urine output
Decreased urine output (oliguria) or absence of urine output (anuria) could indicate hypovolemia
• capillary refill
More than 2 seconds could suggest poor circulation
• peripheral edema
Sudden reduction in edema can indicate fluid loss but must be distinguished from dehydration
• mucous membranes
Dry or sticky can be a sign of dehydration
• jugular vein distention
Increased central venous pressure
• weight change
Significant decrease in weight during or after dialysis might indicate a rapid fluid removal
• assessment of access site
Assess for signs of bleeding, hematoma, signs of clotting
LABS
• Hgb + Hct
• electrolyte levels
• Patient hx and symptoms: dizziness, weakness, nausea, thirst
• Dietary and fluid intake: ask about diet habits and fluid intake to make sure they are consuming adequate
fluids between dialysis sessions.
3c. List dietary considerations below
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Amts allowed for average
hemodialysis pt
Protein: 0.6 to 0.8 grams per kg of
body weight/ day
Potassium: 2000-3000mg per day.
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Reasons for restriction
4 Foods to Avoid for Each
Reduced to lower the workload on the
kidneys where high potassium levels
cause dangerous heart rhythm
disturbances.
To prevent hyperkalemia, a condition
where high potassium levels cause
dangerous heart rhythm disturbances
1. Red meat
2. High protein dairy products
3. Organ meats
4. Processed meats
1. Bananas
2. Oranges
3. Potatoes/ Tomatoes
4. high-potassium salt
substitutes
1. Dairy Products
2. nuts, seeds
3. colas
4. Processed foods with
phosphorus additives
1. excessive consumption of
soups
2. excessive consumption of
sauces
3. high-water content fruits
and veggies like watermelon
and cucumbers
4. soda
1. Eggs
2. Fish
3. Poultry (chicken or turkey)
Phosphorus: 800-1,000 mg per day
To manage phosphorus levels in the
blood, which can affect bone health and
cardiovascular function.
Fluids: 1500-2,000 mL per day.
Limited to avoid fluid overload and
maintain electrolyte balance.
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Identify 3 food sources for high biological value proteins
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What discharge teaching would you do for YOUR client regarding his/her diet?
• Sodium Restriction—helps control b/p and fluid balance, reducing the risk of fluid overload and heart
problems
• Potassium Management—can cause dangerous heart rhythm disturbances. Managing k+ is VITAL FOR HEART
HEALTH
• phosphorus control—elevated phosphorus levels can lead to bone and heart problems. Phosphate binders
help control absorption.
• fluid restriction—prevents fluid overload.
• protein intake—high quality proteins like eggs, fish, and poultry, but avoid excessive `
• medication management
• monitoring and follow up
• lifestyle modifications
• Emergency Preparedness
• emotional support
• importance of compliance
Complete Lab & Diagnostic Test Information including the rationales
Client
Common textbook
Rationale for Abnormality
Result
manifestations for
(Pathophysiology- be specific)*
abnormalities* (must
Even if labs normal must
include possible
complete.
manifestations of high
and low results even if
lab below is normal
WBC 4.8 –
6.4
• High: fever, chills, body • Elevated wbc indicates
10.8 MM3
aches, increased heart
infection, inflammation or
rate, rapid breathing
stress, or leukemia.
• Low: increased risk of
infections, fatigue,
• Low wbc can result from bone
weakness, mouth sores
marrow disorders, autoimmune
diseases, or viral infections.
Hgb
HIGH: headaches,
• high rbc, hemoglobin, and
12 –16 (g/L)
10.8
dizziness, itching,
hematocrit can signify
Hct
redness in the face, high
polycythemia vera, chronic lung
37 – 47 (%)
32.4
blood pressure
disease, or dehydration, or bone
LOW: Fatigue, weakness, marrow disorders.
RBC
pale skin, shortness of
4.2 – 5.4
4.1
breath, cold hands and
• low values can indicate
mil/mm3
feet
anemia due to nutritional
deficiencies, chronic diseases, or
bone marrow disorders.
Na
HIGH: thirst,
• high sodium results from
135 – 145
145
restlessness, dry mouth,
dehydration, diabetes insipidus,
mEq/L
swollen tongue,
or excessive salt intake.
confusion
• Low sodium can occur due to
LOW: nausea, headache, heart failure, kidney disorders,
confusion, seizures,
or excessive fluid intake.
muscle cramps
K 3.5 – 5.3
HIGH: irregular
• high potassium can be due to
mEq/L
4.1
heartbeat, palpitations,
kidney failure, medications, or
muscle weakness,
uncontrolled diabetes
numbness, tingling
• low potassium may result
LOW: muscle weakness
from vomiting diarrhea or
fatigue, constipation,
certain medications
irregular heartbeat,
numbness
Ca (Serum) 8.5 8.2
HIGH: excessive thirst,
• high calcium can be caused by
– 10.5 mg/dL
frequent urination,
hyperparathyroidism, cancer, or
Ionized 4.5 –
abdominal pain, muscle
excessive vit D
5.1 mg/dL
weakness
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Test and
norms
4.
Treatment for the
abnormality or to
maintain normal value of
the client
Use Critical thinking with
this explanation.
Antibiotics, antiviral
medications
Proper hygiene and
infection control
Address underlying cause
hydration, specific
therapies for underlying
conditions.
Low values may need iron
supplements and B12
injections
Dehydration + diabetes
insipidus: fluid
replacement
Hyponatremia: fluid
restriction or treat
underlying condition HF or
KD
Dietary modifications,
medications to enhance
potassium excretion, or
dialysis in severe cases.
Hypokalemia may require
potassium supplements,
diet changes, adjust
medications causing
excessive potassium loss
Hydration for
hyperparathyroidism (treat
underlying cause)
Hypocalcemia may require
calcium supplements and
Phos 2.5 – 4.5
mg/dL
6.7
Cholesterol
Less than 200
mg
189
Total Protein
6.0 – 8.5 g/dL
Albumin 3.4 –
5.0 g/dL
5.8
BUN 6 – 23
mg/dL
Creatinine 0.5
– 1.2 mg/dL
3.1
45
4.4
LOW: numbness and
tingling, muscle cramps,
seizures, brittle nails
HIGH: itching, joint pain,
bone fractures,
confusion
• low calcium can result from
hypothyroidism, kidney failure,
or vitamin D deficiency
• high phosphorus can occur in
kidney disease, hypothyroidism,
or excessive intake.
LOW: weakness, fatigue,
bone pain, loss of
appetite, respiratory
failure
HIGH: no specific
symptoms but a risk
factor for heart disease
and stroke
• Low phosphorus may result
from malnutrition, alcoholism,
or hyperthyroidism
HIGH: dehydration, low
urine output, dark urine,
dry mouth
• High cholesterol levels can
indicate a risk for a heart
disease and are influenced by
diet, genetics, and lifestyle
factors.
High protein levels can occur
due to dehydration or certain
diseases.
LOW: swelling (edema),
muscle wasting, fatigue,
weakened immune
system
HIGH: fatigue, loss of
appetite, nausea,
confusion, shortness of
breath
Low protein levels may result
from malnutrition, liver or
kidney disease, or chronic
inflammation
Elevated BUN + creatinine
suggest impaired kidney
function, dehydration, or
urinary tract obstruction.
LOW: liver disease,
malnutrition,
overhydration
Low values may occur due to
liver disease or low protein
intake
HIGH: fatigue, sob,
edema, n/v, muscle
cramps, hypertension,
pruritus, anemia,
neuropathy, confusion +
cognitive impairment
Elevated BUN + creatinine
suggest impaired kidney
function, dehydration, or
urinary tract obstruction.
LOW: muscle weakness,
fatigue, altered mental
status, loss of appetite,
muscle atrophy,
hypotension, nausea
and diarrhea, cramping,
cardiac arrythmias,
decreased GFR
Glucose
80 – 110
mg/dL
86
HIGH: excessive thirst,
frequent urination,
fatigue, blurred vision,
slow healing wounds
LOW: dizziness,
shakiness, confusion,
sweating, irritability
management of underlying
disorders like
hypothyroidism
Dietary restrictions
phosphate binders
Oral supplements
Iv fluids-severe cases
Diet and exercise
Medications (statins)
Adequate hydration
Nutritional support
Medication adjustments
Dietary changes
Dialysis –Severe cases
Medication adjustments
Dietary changes
Dialysis –Severe cases
Low values may occur due to
liver disease or low protein
intake
high glucose level are indicative
of diabetes or stress.
Low glucose levels can result
from insulinoma, liver disease,
or excessive alcohol
consumption
Insulin
PO hypoglycemics
Regular monitoring
Dietary adjustments
CO2 24 – 30.9
mEq/L
Mag 1.5 – 2
mEq/L
Parathyroid
Hormone
(PTH) 8 – 24
pg/ml
N – Terminal
26
1.7
674
The
clinics
goal is
between
100 and
300 mL
HIGH: sob, confusion,
drowsiness, increased
heart rate
High levels of CO2 indicate
respiratory acidosis, kidney
disease, or certain medications.
LOW: dizziness, tingling
in the extremities,
muscle cramps,
confusion
HIGH: nausea, vomiting,
weakness, hypotension,
respiratory distress
Low co2 levels suggest metabolic
acidosis, dehydration or kidney
disorders
LOW: muscle cramps,
tremors, seizures,
abnormal heart rhythms,
personality changes
HIGH: bone pain,
frequent urination,
abdominal pain, fatigue,
depression
Low magnesium can result from
malnutrition, alcoholism, or
kidney disorders.
LOW: numbness,
tingling, muscle cramps,
seizures, dry skin
High magnesium can occur in
kidney failure or excessive
intake.
High PTH levels indicate
hyperparathyroidism, kidney
disease, or vitamin d deficiency
Low PTH suggest
hypothyroidism or improper
feedback regulation
Oxygen therapy
Ventilation
Managing metabolic
disorders
Diet changes
Supplements
Address underlying causes
such as kidney disorders
Calcium
Vitamin D supplements
Address malnutrition
Manage autoimmune
disorders
Resources: Med surg book, and diagnostic test book and websites
* complete for all labs, regardless of if the client had one drawn or no
6.
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List two complications that can occur during the client’s dialysis.
1. Hypotension
Causes: Rapid removal of fluid during dialysis can lead to a sudden drop in blood pressure.
Symptoms: dizziness, lightheadedness, nausea, blurred vision, or fainting
Management: slow down fluid removal, adjusting the dialysis prescription, changing the patients position,
administer iv fluids if necessary
2. Muscle Cramps
Causes: electrolyte imbalance (low potassium, low calcium) and rapid fluid removal
Symptoms: painful muscle contractions (legs)
Management: adjusting dialysis. Proper hydration, supplement with medications, change diet to
accommodate electrolyte imbalances
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a. List assessments that should be performed immediately before dialysis
Vital signs
Blood pressure, heart rate, respiratory rate
Weight
Measure current weight compared to target weight
Rational weight. Gain between dialysis sessions can indicate fluid retention, which needs to be
removed during dialysis
Fluid Status
Edema (esp. legs and ankles)
Lung sounds (crackles or wheezes might indicate fluid overload)
Jugular venous distention
Rationale—monitoring fluid status helps determine the appropriate amount of fluid to remove during
dialysis.
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Access site assessment
Thrill (vibrations) and bruit (swishing)
Site inspection
Rationale
Lab values
Pre-dialysis blood test
Rationale
Medication review
Current medications
Rationale
Patient assessment
Symptoms
Overall condition
Rationale
Dialysis machine and settings
Machine checks
Dialysis prescriptions
Rationale
b.
Fluid imbalances
1. What is the protocol for treatment of hypovolemia during dialysis?
• reducing ultrafiltration rate
• iv fluids
• monitoring: vs, bp, hr, oxygen saturation
What is meant by dry weight?
- refers to the ideal weight at which a hemodialysis patient’s fluid balance is optimized, and excess fluid (volume
overload) is removed.
- Achieving and maintaining dry weight is essential for managing fluid imbalances and preventing complications
such as hypertension, edema, and heart failure.
How would the nurse explain to the client the need for fluid restriction between dialysis?
- Educate on kidney function
- Emphasize importance
- Individualized plan
- Practical tips
- Discuss consequences
- Encourage communication
- Involve family
b. List 5 comfort measures the nurse should provide during dialysis
1)
Positioning and Support: Proper seating, Cushions and blankets, Frequent position changes
2)
Pain management: assessment, pain relief, heat therapy
3)
Emotional Support and distraction: emotional support, distraction
4)
Hygiene and personal care: oral care, skin care, bathroom assistance
5)
Adequate monitoring and communication: regular monitoring, communication
Disequilibrium Syndrome
c. Discuss in depth the etiology of disequilibrium syndrome?
• Osmotic Shift Theory
• Urea Re-Entry Theory
• Cerebral Blood Flow Theory
• Vasogenic Edema Theory
• Cytotoxic edema theory
More common to patients new to dialysis or have not undergone dialysis for an extended period of time.
d. List Signs and symptoms of disequilibrium syndrome:
• headache, n/v, agitation + restlessness, altered consciousness, muscle twitching, increased intracranial
pressure (ICP), hypertension
Renal Transplant
1)
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Explain the protocol for renal transplant.
• evaluation
• matching
• surgery
• recovery
• post-transplant care
2) List the pros and cons for choosing to have a renal transplant?
• PROS:
Improved quality of life:
Long-term solution
Dietary freedom
Potential cost savings
Better survival rates
• CONS:
Risk of rejection
Surgery Risks
Limited donor supply
Side effects of medications
Lifestyle adjustments
Total:
VI. Care during Dialysis