Nursing care of patients on hemodialysis
To filter blood for patients with kidney failure, one must set up a system, one side is the body's blood, the other side is a filtrate similar to the extracellular fluid.
An artificial kidney is a treatment that uses a semi-permeable membrane to replace a failing kidney, in order to:
Filter out endogenous breakdown products accumulated in the blood that are toxic to the body in kidney failure. The most important are non-protein nitrogen: urea, creatinine, uric acid...
Adjust blood acidosis.
Correct electrolyte disturbances drain edema.
Remove toxins from the outside as in barbiturate poisoning.
Principles applied to hemodialysis
To filter blood for patients with kidney failure, one must establish a system: one side is body blood, the other side is a filtrate similar to extracellular fluid, in the middle, there is a semi-permeable membrane separating. The membrane does not allow substances with large molecules such as proteins to pass through. Substances of small size are filtered through the membrane to remove from the blood based on the following 4 principles.
Differential diffusion: substances such as urea, creatinine, potassium, sodium... are diffused across the membrane according to the concentration difference, substances with high blood concentration will diffuse across the membrane into the filtrate cavity and vice versa. For example, blood urea is high, the filtrate does not have urea. Urea diffuses from the blood into the filtrate and is eliminated from the body in the filtrate.
Osmosis: There is an equal concentration of water between the filtrate and blood, so there is no differential diffusion. To withdraw water for patients with edema, people mix more glucose into the dialysis solution to increase the osmolarity of the filtrate to a higher level in the blood. Water from the blood will penetrate through the membrane to the filtrate according to the principle of osmosis and is removed by the filtrate from the body.
Ultrafiltration: water and substances are pushed through the membrane by a device that increases the filtration pressure of the blood passing through the artificial filter.
Absorption: The substance to be filtered is absorbed as the blood passes through the filter containing the absorbent.
Blood purification techniques
Based on the application of the above 4 principles, so far there are 3 main techniques in hemodialysis
Blood absorption (hemoperfusion).
Solution for hemodialysis
Na: 138 mEq / l.
Cl: 107 mEq/l.
K: 0-1 mEq/l.
Acetate: 38 mEq / l.
Ca: 3 mEq/l.
Glucoza 1-2 g / l.
Mg: 1,5 mEq/l
Technique to bring blood out of the body
Arteriovenous shunt: now rarely used because of infection and coagulation blockage in the shunt tube.
Peripheral arteriovenous septal defect: arterial blood flows into the vein, making the vein easy to inject. This method is mostly used for cyclic hemodialysis.
Indications and contraindications in cyclic dialysis
Patients with end-stage chronic renal failure (stage 3.4). Dialysis 2 - 3 times a week, 5-6 hours each time.
Prepare for a kidney transplant.
The only relative, be cautious when the patient has:
Shock, low blood pressure.
Severe heart failure, pericardial effusion.
Coagulation disorders are not caused by high blood urea.
Over 70 years old, the patient's condition is too weak.
Complications and prognosis
Blood infection, viral hepatitis.
If the technique is good and specified correctly then:
10% die in the first year.
5% die in year 2.
Capable of prolonging life for 5 - 10 years.
For patients with indications for dialysis, the nurse needs to assess the patient's need for care before, during and after dialysis in order to have an appropriate care plan, minimizing complications. changes during dialysis.
Comments by asking patients
Since when has the patient been diagnosed with chronic renal failure?
How long does chronic kidney failure last?
Have you ever had dialysis?
Complications of previous dialysis sessions.
History of heart failure, cirrhosis of the liver.
Causes of chronic kidney failure.
General condition: too skinny?
Urine quantity: little or anuria?
Is there nausea and vomiting?
Respiratory status and breathing.
Signs of skin and mucous membranes.
The condition of bowel movements and the nature of stools.
Based on clinical and paraclinical symptoms to identify patients with end-stage renal failure, there are indications for cyclic hemodialysis.
Take vital signs.
Lung examination: rhythm, breathing pattern, abnormal sounds...
Cardiac examination: heart rate, pathological heart sounds.
Abdominal examination: ascites...
Check vital signs.
Measure urine output.
By exploiting the above symptoms, some diagnoses are possible in patients with chronic renal failure.
Pale skin and mucous membranes due to anemia.
Vomiting and nausea due to uremia.
Decreased urine output due to decreased glomerular filtration.
Increased fluid volume due to fluid and salt retention.
Risk of acute pulmonary edema due to blood stasis in the lungs.
The nurse analyzes, synthesizes and summarizes the data to determine the patient's needs, thereby creating a care plan. Care planning must take the patient's condition into account, recommending priorities first.
The patient must be rested quietly.
Eat enough energy, limit protein.
Executing the medical orders
Prepare the patient for hemodialysis.
Administer medication to the patient and administer medication as directed.
Do tests before, during, and after dialysis.
Monitor patients before, during, and after dialysis.
Coordinate with the doctor to perform the steps during the procedure.
Pulse, temperature, blood pressure, respiratory rate, weight, patient condition. If there is any abnormality, notify the doctor immediately.
Monitor urine quantity and color.
Follow up on some tests.
Patients and families need to know about the causes and detection of chronic kidney disease as well as possible complications during and after hemodialysis.
Implement a care plan
Perform basic care
Have the patient lie down with the head elevated and rest quietly.
Psychological preparation for patients and families for dialysis procedures.
Always keep the patient's body warm.
Observe and monitor vital signs.
Drinking water: it should be based on the patient's condition, blood pressure and urine output. Usually, the amount of water taken in, including eating and drinking, is about 300 ml plus the amount of urine during the day.
Eat easily digestible substances, ensure energy and vitamins. The amount of protein added should also be based on the patient's blood urea status.
To date, a reduced-protein diet supplemented with essential amino acids has been shown to be able to slow the progression of CKD.
Daily hygiene for patients
Daily cleaning of teeth and skin to avoid urgent infections, early detection of infections to guide treatment for patients. Clothes, pants, bed linen, and utensils must always be kept clean. If there is an ulcer on the skin, it must be washed with hydrogen peroxide or methylene blue.
Executing the medical orders
Blood tests such as: complete blood count, blood group, urea, creatinine, electrolytes and alkaline reserve, blood gas, pH, glucose, protein, Hb, hematocrit.
Urine tests: protein, urea, creatinine and cells, germs.
Prepare the patient:
The patient is in a sterile room.
Place a bladder catheter.
Wash and disinfect the skin of the vascular area to make a bridge as indicated, and cover it with a sterile, perforated bandage.
Drugs used: fully comply with medical orders when taking anticoagulants. At the end of hemodialysis, use sulfate protamine. If there are any abnormalities, notify your doctor.
Monitoring before hemodialysis:
Vital signs: pulse, temperature, blood pressure, breathing rate, the weight of the patient.
Anemia in patients with chronic renal failure.
Amount and color of urine.
Follow up tests:
Blood tests: urea, creatinine, electrolytes, blood gases, pH, glucose, protein, hematocrit, Hb.
Urinalysis: urea, creatinine.
Monitoring during hemodialysis:
The nurse must make a chart to monitor the hemodialysis process, taking notes every 15 - 30 minutes.
Vital signs: pulse, temperature, blood pressure, the breathing rate of the patient.
Patient condition: skin, mucous membranes, cold sensation, consciousness.
Monitor the patient's hemodynamic status.
Keep track of the drugs used in the filtration process.
Watch for possible adverse events:
Water and electrolyte disturbances.
Monitor filtration rate, total filtrate.
Monitor the rate of infusion, total infusion, type of fluid.
Monitor hemodialysis time.
Monitor the operation of the machine, ensure the safety of the transmission line, ensure the safety of the transmission line.
Follow-up after hemodialysis:
Vital signs and weight of the patient.
Amount of urine in 24 hours.
Watch for complications:
Blood infection, viral hepatitis.
Tests: urea, blood creatinine, blood electrolytes.
Patients and their families should be aware of the need for cyclic hemodialysis in patients with end-stage renal failure, as well as possible complications during and after hemodialysis.
Patient's condition after hemodialysis compared to before:
Can the patient urinate after running?
Will the signs of edema decrease?
The patient's neurological and gastrointestinal status.
Are the vital signs abnormal or better?
Did the electrolytes return to normal? especially potassium and alkaline reserves.
Is the primary nursing care assessment performed and responsive to the patient's request?
Errors or omissions need to be added to the care and treatment plan to be implemented.