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Dialysis & Renal transplant
Dialysis/Renal Transplant
82
Nursing
Undergraduate 3
12/01/2014

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Term
Dialysis
Definition
movement of fluid and molecules across a semipermeable membrane from one compartment to another
technique in which substances move from the blood through a semipermeable membrane and into a dialysis solution
Term
why is dialysis important?
Definition
It can correct fluid and electrolyte imbalances, remove waste, and treat drug overdoses
Term
what kind of membrane is used in hemodialysis?
Definition
artificial membrane
Term
what kind of membrane is used in periotoneal dialysis?
Definition
the peritoneal membrane
Term
When is dialysis used?
Definition
patients that can no longer be managed conservatively or when acute patients have complications (ex. hyperkalemia, etc)
Term
how does dialysis work?
Definition
diffusion, osmosis, and ultrafiltration
Term
diffusion
Definition
movement of solutes to an area of lesser concentration
Term
osmosis
Definition
movement of fluids to an area that is more concentrated with solutes
Term
ultrafiltration
Definition
pressure gradient is created to move fluids across the membrane
Term
Peritoneal dialysis
Definition
the peritoneum is used as a semipermeable membrane for dialysis.
catheter is inserted into the abd wall and into the peritoneal cavity
dacron cuffs @ subcut tissue & peritoneal anchors=anchors and prevent bacteria from migrating
Term
how is peritoneal dialysis inserted?
Definition
surgically or laparoscopically
Term
Who is a good candidate for peritoneal dialysis?
Definition
*hemodynamically unstable
*cant tolerate systemic anticoagulation
*lack vascular access (inadequate vessels for HD)
*use while waiting for Arterialvenous (av) fistulas to mature
*Diabetic pts do better with this bc better control of blood glucose with intraperiotneal insulin; avoids risk of hemorrhage from heparin used in HD
Term
Diabetics do better with PD or HD? Why?
Definition
PD offers better control of blood glucose with intraperitoneal insulin
Term
Peritoneal dialysis (PD) is contraindicated in pts with...
Definition
multiple abd surgerie or pathlogies (pancreatitis, diverticulitie, scarring)
recurrent abd wall or inguinal hernias=increased pressure from dialysate can complicate hernias
excessive obesity
vertebral disease/back problems=increased pressure
severe COPD=dialysate pushes on diaphragm
Term
Peritoneal dialysis cycle in detail
Definition
*1-2 L of dialysate is infused by gravity over 10-20 min aka FILL
*dialysate DWELLS in cavity for specified time by MD. osmosis and diffusion occurs. may be 10,20,30 min or hrs per MD
*fluid DRAINS out of body by gravity into bag. contains dialysate, excess water, electrolytes, and waste
Term
periotoneal dialysis cycle
Definition
FILL, DWELL, DRAIN=ONE CYCLE
**MD orders number and frequency of exchanges
Term
dialysate additive GLUCOSE
Definition
more hyperonic the glucose, the more fluid pulled off. MD orders concentration
Term
dialysate additive HEPARIN
Definition
prevents fibrin clot formation in tubing
Term
dialysate additive KCL
Definition
so dialysate does not pull off too much potassium
Term
dialysate additive ANTIBIOTICS
Definition
if suspected or confirmed peritonitis
**what color is dialysate?
Term
dialysate additive INSULIN
Definition
for diabetic patients
Term
CAPD continuous ambulatory peritoneal dialysis
Definition
patient manually performs exchanges 4 times a day, with dwell times of 4-8-10 hs. Usually ~2 L
Term
APD automated peritoneal dialysis
Definition
automated cycling machine (cycler) is programmed to provide for dialysate fill, dwell, and drain according to preset times and volumes. allows pt to cycle only at night or 3x/week instead of daily
Term
complications of periotoneal dialysis
Definition
peritonitis
protein loss
exit site infection
pulmonary complications
hernias
back problems
outflow problems
Term
how do you prevent peritonitis in periotneal dialysis?
Definition
Term
hemodialysis
Definition
patients blood is removed from the body and passes through a cartridge that has a synthetic semipermeable membrane that acts as an artificial kidney
Term
how often do you perform hemodialysis
Definition
3 days/wk for 3-4 hrs
Term
what is needed for hemodialysis?
Definition
large amount of blood flow--->surgical revision of blood vessels to provide access
Term
long term vascular access options in hemodialysis
Definition
external shunt
internal arteriovenous (AV) fistula
internal synthetic graft
Term
Internal AV fistula/shunt
Definition
anastamosis is created between an artery and a vein
*fistula provides arterial blood flow thru vein
Term
what happens to the AV shunt over time in HD? why is this significant?
Definition
the vein dilate and becomes tougher over time due to the increased pressure of the arterial blood in the vein; this now large vessel has enough blood flow to perform HD and is tough enough for multiple punctures
Term
how long does an internal AV shunt/fistule need to mature (dilate and toughen)?
Definition
4-6 weeks
Term
complication of internal AV shunt
Definition
aneurysm
Term
internal synthetic graft
Definition
synthetic graft forms a bridge between the arterial and venous blood supplies
Term
common occurrence with internal synthetic grafts (2)
Definition
clot formation and infections (need 2-4 weeks to heal)
Term
what can internal synthetic graft causee??? why???
Definition
GRANGRENE--->SURGERY; steal syndrome
Term
INTERNAL SYNTHETIC GRAFTS ARE...
Definition
SELF HEALING=CLOSE OVER PUNCTURE SITES ONCE NEEDLES ARE REMOVED
Term
steal syndrome: define and what does it occur in
Definition
internal synthetic grafts; ischemia distal to the graft bc the arterial blood is being shunted into the vein---->gangrene
Term
care of permanent vascular access sites!! KNOW!!!
Definition
DO NOT perform anything on affected extremity
*thrills palpable at arterial, middle, and venous segments
*auscultate for bruit normal=contiuous,soft,low pitched,
bad=high pitches harsh discontinuous
assess distal pulses/circulation
bleeding @insertion
Term
AV EXTERNAL shunt care...these always need...?
Definition
keep clamps handy on the dressing
Term
Pt. teaching for permanent acces sites
Definition
do not carry heavy objects or compress extremities
avoid constrictive clothing
report numbness, coldness, pain, any chngesin
report if access suddenly bulge
do not sleep on top of extremity
Term
when is temporary access used?
Definition
until permanent accesses have matured
in emergency situations when HD can not wait for permanent access
Term
temporary access sites for emergency HD
Definition
sublcavian, internal jugular, femoral veins
Term
differences in HD catheters
Definition
2 lumens with internal septum separating two segments
Term
DO NOT do this with HD catheters!!
Definition
infuse meds
Term
HEPARI and HD
Definition
heparin is injected into the lumen after dialysis and REMOVED prior to next use...NOT FLUSHED
Term
how much heparin for HD?
Definition
1000-5000 units/ mL
Term
Hemodialysis procedure
Definition
two needles are placed in the fistula or graft when HD is started. blood pump is used to send "arterial" blood to dialyzer, patients blood is returned thru a second needle creaeting a continuous cycleing of blood--->READ IN TEXTBOOK
Term
when is dialysate composition altered?
Definition
according to pt's needs
Term
herparin is added to patients blood to prevent clotting in the tubing and dialyzer membrane...give example
Definition
prevents clotting
Term
protamine sulfate
Definition
reverses anticoagulation effects of heparin
Term
what does duration and frequency of HD depend on?
Definition
amount of wastes, amount of fluid, clearance capacity of dialyzer
Term
things to know for HD
Definition
patient's weight, VS, have you received meds?
Term
Should meds be held in HD?
Definition
some MDs hold all, some give all, some hold BP meds
Term
complications of HD
Definition
*disequilibrium syndrome
*hypotension
*muscle cramps d/t K loss
*Loss of blood
Hepatitis B & C
Sepsis
Term
disequilibrium syndromE
Definition
unsteady, keep in bed
READ IN BOOK
Term
hypotension in HD
Definition
UNDERSTAND, READ IN BOOK
Term
CRRT Continuous Renal Replacement Therapy
Definition
used in ARF as an adjuvant or alternative therapy
*performed at bedside with few IV poles,filter, and replacement fluids
*in ICU
Term
kidney translplant
Definition
give pt normal renal function and eliminates dialysis need
*trade dialysis for meds
Term
not a good candidate for transplant if...
Definition
*psych disorders
*malignancies
*cardiac failure
*respiratory failure
*chronic infection
*extensive vascular disease
sever DM, hyperparaythyroid disease
Term
where can organs come from?
Definition
living related donors
living unrelated donors
cadaver donors->brain dead
paired organ donation
Term
Why are live donors better?
Definition
pt and graft survival rates better
kidney is immediately available
recipient is in best possible condition bc it is elective
kidney usually functions immediately bc minimal cold time
Term
Histocompatibility studies include
Definition
ABO blood group
HLA antigens
crossmatch=serum from recipient with donor cells
Term
what is removed from donor prior for kidney transplant?
Definition
nephrectomy on donor removing kidney, renal artery, renal vein, and ureter
Term
where is kidney placed in recipient?
Definition
extraperitoneally in right anterior ileac fossa
Term
what about the vines and ureter?
Definition
renal artery and vein are attached to the iternal iliac artery and vein; ureter is tunneled trhough the bladder into the bladder cavity and sutured in place
Term
What do you do after new kidney is in place?
Definition
CHECK FOR URINE!
Term
What to expect from new kidney
Definition
urine production
*may need dialysis until kidney starts to work
*some cadaveric kidneys develop ATN during cold time
RNs must label and protect dialysis sites
*pts need to know the kidney needs time to work
Term
Recipient care post op
Definition
HOURLY I&O
ML/ML hourly fluid replacement
diuresis slows down as BUN & Creatinine normalize
electrolyte replacement
avoid dehydration bc it can injure new kidney
Term
Bad sign for new kidney and what it may mean
Definition
UOP drops suddenly->dehydration, rejection, obstruction
Term
special considerations for new kidney
Definition
cath present for 3-5 days to allow anastamosis to heal
Term
what is one possible cause of obstruction in new kidney
Definition
blood clot
Term
DO NOT perform this on a pt with post renal transplant without an order
Definition
catheter irrigation
Term
immunosuppressive therapy
Definition
adequately suppress immune response but also prevent infections
*pt on maintenance meds
Term
immunosuppressive meds (5)
Definition
corticosteroids
*cyclosporine
*ATG
*ALG
*monoclonal antibodies
Term
how do monoclonal antibodies work?
Definition
prevent & treat acute rejections. interferes with t lymph function a few min after infusion
Term
most common and most threatening complication of renal transplantation
Definition
transplant rejection
Term
hyperacute rejection
Definition
antibody mediated
*minutes to hours
pt has already formed antibodies that immediately attack kidney
*MUST TAKE OUT
*exposed to foreign antigens from previous pregnancie, blood transfusions, etc..
Term
acute rejection
Definition
*4 days to 4 months after transplant
*cytotixic T cells are created that attack new kidney
*usually REVERSIBLE with immunosuppressive meds
Term
signs of rejection
Definition
looks like renal failure
*increasing BUN and creatinine
*fever
*weigh gain
*decreased UOP
*increased BP
*tenderness over new kidney
Term
chronic rejection
Definition
*MO to YEARS AFTER TRANSPLANT
*NO THERAPY MUST RETRANSPLANT/DIALYSIS
*T & B cells invade kidney and damage it
*silent->proteinuria, HTN, increasing creatinine
Term
complications of renal transplant
Definition
*infection
*HTN
*malignancies
*vascular disease
*renal artery stenosis
*aseptic bone necrosis
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