Introduction
Dialysis is a life-sustaining treatment used when the kidneys can no longer effectively filter waste, excess fluids, and toxins from the blood. It’s most commonly needed in end-stage kidney disease (ESKD) or acute kidney injury when kidney function drops below 10–15% of normal capacity.
If kidneys fail to remove toxic substances and wastes from the body through the urine, it results in the development of edema, hyperkalemia, hypercalcemia, hypertension, uremia, and hepatic coma. Toxins or poisons must be removed immediately to prevent permanent or life-threatening damage. This can be achieved by dialysis and other management.
Definition
Dialysis is a therapeutic procedure in which metabolic waste products and fluids are removed from the body of a patient with poor renal function by artificial and mechanical techniques.
Purpose
- To maintain life and well-being of the patient until kidney function is restored.
- To remove unwanted substances from the blood if renal function does not return.
Indications
| Acute Dialysis | Chronic Dialysis |
| Acute renal failure with High/rising level of serum potassium.Increasing acidosis.Pericarditis and severe confusion.Poisoning/drug overdose.Accelerated hypertension.Encephalopathy.Neuropathy. | Chronic renal failure (end-stage renal disease) with Nausea and vomiting. Severe anorexia. Increasing lethargy. Mental confusion. Elevated serum potassium level. Fluid overload. General lack of well-being. Pericardial friction rub. |
Types
Peritoneal dialysis
- Intermittent peritoneal dialysis.
- Continuous ambulatory peritoneal dialysis.
- Continuous cycling peritoneal dialysis-using automated peritoneal dialysis machine overnight with prolonged dwell time during the day.
Hemodialysis
- Conventional hemodialysis: Usually done three times per week, for 3-4 hours for each treatment.
- Daily hemodialysis: Usually done 6 days/week by patients on their own, at home.
- Nocturnal hemodialysis: Usually done three to six nights per week, while the patient sleeps, with 6- to 10-hour duration per session.
Continuous renal replacement therapy
[This is a special procedure which includes continuous arteriovenous hemofiltration (CAVH), continuous venovenous hemodiafiltration (CVVHDF), and Continuous arteriovenous hemodiafiltration (CAVHD)].1) Peritoneal Dialysis
Definition
Peritoneal dialysis involves repeated cycles of instilling dialysate into the peritoneal cavity, allowing time for substance (metabolic waste) exchange through the peritoneal membrane and then removing the dialysate from the peritoneal cavity.
Purposes
- To assist in removal of toxic substances and metabolic wastes.
- To reestablish normal fluid balance by removing excess fluid.
- To restore electrolyte balance.
Indications
Patient;
- Unwilling for hemodialysis/renal transplantation.
- Susceptible to rapid fluid, electrolyte, and metabolic changes that occur during hemodialysis.
- At risk for side effects of the systemic use of heparin.
- With severe hypertension, congestive heart failure, and pulmonary edema not responsive to usual treatment regimen.
Contraindications
- History of multiple abdominal surgical procedures or chronic abdominal pathological conditions (e.g. pancreatitis, diverticulitis).
- Recurrent abdominal wall or inguinal hernias.
- Obesity with large abdominal wall and fat deposits.
- Preexisting vertebral disease.
- Severe obstructive pulmonary disease.
Types
There are different types of peritoneal dialysis, intermittent peritoneal dialysis, continuous ambulatory peritoneal dialysis, and continuous cycle peritoneal dialysis.
| Intermittent Peritoneal Dialysis (IPD) | Continuous Ambulatory Peritoneal Dialysis (CAPD) | Continuous Cycle Peritoneal Dialysis (CCPD) |
| It involves dialyzing for a total of 40 hours per week. The time period is divided into segments and is done three to seven times per week usually at night, the abdomen is left empty between dialysis sessions. | The dialysate is instilled into the abdomen and left in place for 4-8 hours. The empty dialysate bag is folded up and carried in the patient’s pocket until it is time to drain the dialysate. The bag is later unfolded and placed low than the insertion site, so that the fluid drains by gravity flow. When full, the bag is changed, and new dialysate is instilled into the abdomen as the process continues. | It is similar to CAPD. There are usually three cycles done at night. In the morning, fresh dialysate is instilled into the abdomen and the peritoneal catheter is clamped. The fluid is retained throughout the day and drained at night just before the night cycle begins. |
Articles
| Articles | Purpose |
| Sterile gloves and mask | To prevent cross-infection, maintain aseptic technique. |
| Sterile gauze | To apply dressing at the procedure site. |
| Sterile plastic bag with peritoneal dialysis solution 1 or 2 L | To help to remove the metabolic waste. |
| IV pole | To hold the dialysis solution bag. |
| Connecting tube with clamps | To allow the fluid to flow from the bag to the peritoneum and from the peritoneum to the collecting bag. |
| Local anesthesia | To anesthetize the area during the procedure. |
| Suture set | To secure the peritoneal tube. |
| Antiseptic solution as per hospital policy | To prepare the puncture site. |
Procedure
| Nursing Action | Rationale | |
| 1. | Explain regarding dialysis unit, procedure, what will be expected during the treatment, and duration of the procedure. | To win the cooperation and support. |
| 2. | Obtain informed consent from the patient. | Prevents litigation of staff. |
| 3. | Ensure that the patient emptied the bladder. | Reduces the risk of bladder perforation. |
| 4. | Flush the tubing with dialysis solution. | Prevents entering of air into the peritoneal cavity. Air causes abdominal discomfort and impairs the drainage function. |
| 5. | Assist the patient to maintain supine position. | Provides comfort to the patient. |
| 6. | Wash hands: wear the mask and gloves. | Minimizes cross-infection. |
| 7. | Prepare the abdomen by surgical asepsis. The skin and subcutaneous tissue are infiltrated with local anesthetic drug. | Minimizes the chance of infection. |
| 8. | Small midline incision made for 3-5 cm below the umbilicus and a trocar is inserted with the stylet through the abdominal tissue layers into the peritoneal cavity. | |
| 9. | After the trocar is inserted, instruct the patient to raise the head. | Helps to tighten the abdominal muscles and facilitates easy insertion of the trocar without any damage to the internal organs. |
| 10. | Once the trocar punctured the peritoneum, the trocar is directed toward the left side of the pelvis. Then the stylet is removed, and the catheter is inserted into the trocar. Once the trocar is removed, the skin is closed by suturing. | Prevents adherence of omentum with the catheter. |
| 11. | Apply sterile dressing around the catheter. | Prevents infection. |
| 12. | Add heparin, potassium, and antibiotic drugs with dialysis solution. | Heparin prevents formation of blood clot inside the catheter and antibiotics help to treat peritonitis. |
| 13. | The catheter is about 60 cm long and has two Dacron cuffs on its subcutaneous and peritoneal portions. Within a few weeks, fibrous tissue grows into the Dacron cuff, holding the cuff in place. | Acts as anchor and prevents the migration of microorganisms down the shaft from the skin. |
| 14. | Connect the catheter to the administration set which has been previously connected to the container of dialysis solution. Use the dialysis solution warmed to body temperature (98.6°F). | Warm fluids prevent the abdominal pain. Heating also leads to dilatation of peritoneal vessels and promotes urea clearance. |
| 15. | Allow the dialysis fluid to run into the peritoneal cavity till its completion (inflow phase). Usually it takes 10-15 minutes. If the patient feels abdominal pain, reduce the flow of infusion. | Steady flow of fluid indicates correction position of the catheter. If flow is too low, catheter position should be changed because sometimes it may be buried into the omentum. |
| 16. | Allow the fluid to remain in the peritoneal cavity for the prescribed period of time or for 20-30 minutes to 8 hours or more (dwell phase). | In this phase, diffusion and osmosis occur between the patient’s blood and the peritoneal cavity. |
| 17. | Unclamp the outflow tube. Allow the fluid to drain from the peritoneal cavity (drain phase) for 20-30 minutes or for prescribed period of time. | The abdomen draining occurs through siphon effect and gravity drainage. The drainage usually is straw in color. |
| 18. | If the fluid is not drained properly, ask the patient to move from side to side. | Facilitates the removal of peritoneal drainage. |
| 19. | Check the drain for cloudy appearance, blood, or fibrin. | Indicates peritonitis. |
| 20. | Check the patency of the catheter, kinking, or air lock. Never push or pull the catheter. | Pushing the catheter may increase the risk of infection. |
| 21. | Assess the blood pressure every 15 minutes to 1 hour. Monitor the patient for any sign of dysrhythmia. | Hypotension indicates excessive fluid loss. |
| 22. | Monitor the temperature every 4 hours. | Elevated temperature indicates infection. |
| 23. | Assist the patient to change into a comfortable position such as lateral or Fowler’s position or sitting position. | The dialysis period is a lengthy one and leads to fatigue. |
| 24. | Strictly monitor and maintain the intake and output chart. | Positive balance shows effective function of peritoneal dialysis. |
| 25. | Watch for disturbances in fluid balance, edema, and dehydration. | |
| 26. | Check the vital signs every 15 minutes for 4 hours, every 0.5 hour for the next 4 hours, and then every hour. | Periodical monitoring helps to identify any early signs of complication. |
| 27. | Watch for signs of internal or external bleeding. | Prevents hypovolemic shock. |
| 28. | Assess for any complications such as the following: Peritonitis. Catheter-related complications. Displacement and plugging. Obstruction due to malposition. Fluid leakage (due to improper catheter function, incomplete healing of the insertion site, or excessive instillation). Bloody effluent (indicates bowel perforation). Massive diarrhea or fecal material returned in the dialysate (indicates perforation). Bladder perforation (if the bladder is not emptied prior to catheter insertion). Exit site infection. Pain due to rapid instillation. Low backache. Hernia. Systemic cardiovascular and neurological effects. Hypoalbuminemia leading to hypovolemia. Protein loss. Encapsulating sclerosing peritonitis and loss of ultrafiltration. Hyperglycemia due to absorption of glucose from dialysate and electrolyte changes. Respiratory difficulties-due to pressure on the diaphragm. | Helps to identify any early signs of complication. |
| 29. | Document the procedure: Exact time of beginning and each exchange, starting and finishing time of drainage. Amount of solution infused and recovered. Fluid balance. Number of exchanges. Medications added to dialyzing solution. Predialysis and post dialysis weight. Level of responsiveness at beginning, throughout, and at end of treatment. Assessment of vital signs and patient’s condition. | Serves as a legal evidence and prevents duplication of care. |
2) Hemodialysis
Definition
It refers to the therapeutic procedure of removal of unwanted toxic waste and fluids from the body by filtering the blood using a mechanical device called dialyzer or artificial kidney.
Principles
The three main principles involved in hemodialysis are as follows:
- Diffusion: The process of movement of toxins and wastes in the blood from an area of higher concentration in the blood to an area of lesser concentration in the dialysate.
- Osmosis: The process of movement of toxins and wastes from an area of lesser concentration in the blood to an area of higher concentration in the dialysate.
- Ultrafiltration: The pressure gradient that controls the removal of waste.
Common Vascular Access Sites for Hemodialysis
- Arteriovenous fistula: Creating communication by suturing veins to an artery.
- Arteriovenous graft: Arteriovenous connection using graft (polytetrafluoroethylene or autologous saphenous vein).
- Central vein catheters: Direct cannulation to the veins, for example, subclavian, internal jugular, or femoral veins.
Articles
| Articles | Purpose |
| A dialyzer with a semipermeable membrane (an artificial kidney) | To remove metabolic waste and excess water. |
| An appropriate dialysate bath | To achieve the proper pH and electrolyte balance. |
| Dialysis solution consisting of highly purified water to which sodium, potassium, calcium, magnesium, chloride, and dextrose have been added. Bicarbonate or acetate also added | |
| Crash cart | To resuscitate the patient in case of emergency. |
| BP apparatus | To monitor the level of BP every 15 minutes during the procedure. |
| Pulse oximetry | For continuous monitoring of oxygen saturation. |
| Sterile gauze | To apply pressure dressing. |
Procedure
| Nursing Action | Rationale | |
| Preprocedural care | ||
| 1. | Explain regarding dialysis unit, procedure, and what will be expected during the treatment, the type of pain experienced during treatment, and duration of the procedure. | Wins the cooperation and support. |
| 2. | Follow strict aseptic technique throughout the procedure. | Prevents the cross-infection. |
| 3. | Obtain the informed consent prior to the procedure. | Prevents litigation of the staff. |
| 4. | Inform that nausea and headache may be experienced during treatment and for a few hours afterwards. | Promotes coping ability of the patient during the procedure. |
| 5. | Explain the typical schedule for haemodialysis that involves 5-6 hours of duration for haemodialysis, 3 days per week or depending on the physician’s order. Makes the patient understand the importance of dialysis treatment and promotes compliance with schedule. This schedule varies with; The size of the patient. The type of the dialyzer used. The rate of blood flow. The personal preference. | |
| Procedural care | ||
| 6. | The patient’s vascular access is prepared and cannulated. | Facilitates access to the patient’s circulation for effective hemodialysis. |
| 7. | Administer heparin as per the physician’s order. | Prevents blood clotting and enhances effective dialysis. |
| 8. | Connect the patient to the dialysis machine. | Removes the nitrogenous waste from the blood. |
| 9. | Heparinized blood flows through a semipermeable dialyzer in one direction and dialysis solution flows in the opposite direction. | Indicates effective dialysis process. |
| 10. | Metabolic wastes products and acid-base electrolytes can be removed from the blood through the process of diffusion. | Indicates effective dialysis process. |
| 11. | Excess water is removed from the blood by ultrafiltration. | Indicates effective dialysis process. |
| 12. | The purified blood from the machine is returned to the body through the patient’s vascular access site. | |
| 13. | Monitor vital signs, hemodynamic status, electrolytes, and acid-base balance. | Normal findings indicate hemodynamic stability and absence of complications. |
| Postprocedural care | ||
| 14. | Disconnect the patient from the dialysis machine. | |
| 15. | Apply pressure dressing to the puncture sites at the end of the treatment. | Prevents bleeding. |
| 16. | Continuously monitor vital signs, serum electrolyte level, acid-base balance, blood urea nitrogen, fluid status, and coagulation status. | Facilitates early identification and prevents from complications. |
| 17. | Assess for any complication such as the following: Hypotension/hypertension. Cardiac arrhythmias (due to potassium imbalance).Air embolism. Subdural, retroperitoneal, pericardial, and intraocular hemorrhage due to heparinization of blood. Restless leg syndrome. Pyrogenic reactions. Gastrointestinal ulcer disease (often complicated by hemorrhage). Muscle cramps (due to hyponatremia/hypo-osmolality).Infection (hepatitis B being most common. Infectious endocarditis. Dialysis equilibrium syndrome, characterized by mental confusion, deterioration in the level of consciousness, headache, and seizure lasting for several days. Aluminum intoxication which leads to mental cloudiness, dementia, and infiltration of the bone with aluminum leading to significant pain. | For early intervention. |
| Vascular access care | ||
| 18. | Keep the vascular access site clean. | Prevents infection. |
| 19. | Remove any restrictive clothing or jewelry from the arm. | Creates pressure and damages the vascular access site (fistula or graft). |
| 20. | Perform hand hygiene before you assess or touch the vascular access. | Prevents cross-infection. |
| 21. | Place an armband on the patient or a sign over the bed that says no BP measurements, venipunctures, or injections on the vascular access site. | When blood flow through the vascular access is reduced, it can clot and lead to failure of the fistula and graft. |
| 22. | Assess the vascular access for signs and symptoms of infection such as redness, warmth, tenderness, purulent drainage, open sores, or swelling. | For early identification of graft or shunt failure. |
| 23. | Avoid trauma or excessive pressure on the affected arm when moving or ambulating. | To prevent damage to the vascular access site. |
| 24. | Advise the patient not to use the arm with vascular access to carry heavy objects and not to sleep on the arm. | To prevent damage to the vascular access site. |
| 25. | Inform the patient not to use any creams and lotions on the vascular access site. | To prevent damage to the vascular access site. |
| Documentation | ||
| 26. | Document the procedure: Date, time, and condition of the patient before, during, and after the procedure.Serum electrolyte level, acid-base status, and vital signs in dialysis chart. The patient and family teaching regarding diet, vascular site care, follow-up, etc.Report to the physician if the patient had any complication. | Serves as a legal document and provides continuity of care. |
Special Considerations
- Monitor for cardiovascular disease, diabetes, and infections common in dialysis patients.
- Assess for fluid overload (e.g., edema, crackles) or dehydration.
- Tailor education and support based on the patient’s ability to understand and participate in care.
- Some medications (e.g., antibiotics, antihypertensives) may be removed during dialysis adjust timing accordingly.
- Often withheld before dialysis to prevent intradialytic hypotension.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
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