Chapter 37
Nursing Care of Patients With Disorders of the Urinary System
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patient’s blood. During the dialysis procedure, the patient’s blood and the dialyzing solution flow in opposite directions through the dialyzer. The dialysate contains electrolytes and fluid that resembles blood plasma. The patient’s blood with metabolic waste products, excess fluid, and electrolytes is on the other side of the enclosed semipermeable membrane. The waste products from the patient’s blood move into the dial- ysate by diffusion through the membrane because of the dif- ference in their concentrations. The dialysate solution carries the waste products away, and the cleansed blood is returned to the patient’s body intravenously (Fig. 37.7). A hemodial- ysis treatment is typically prescribed for 3 or 4 hours several times a week at a hemodialysis center (Fig. 37.8). Self-care hemodialysis is offered in some centers. Patients often do better when involved in treatments. Participation can range from doing some tasks to conducting the entire dialysis ses- sion after training. Hemodialysis can also be done at home with training. Hemodialysis is not without side effects, as fluid and electrolyte levels drop rapidly. After treatment, the patient may have muscle cramps, and feel lethargic, weak, and fatigued. Sudden drops in blood pressure may cause the patient to become dizzy and nauseated. Cardiac arrhythmias and angina may occur. Patients are given large amounts of
heparin, an anticoagulant, to keep the blood from clotting while it is in the dialyzer. Bleeding can occur from the punc- ture sites or other areas if injury occurs. Box 37.2 reviews nursing care for hemodialysis. Vascular Access. Long-term hemodialysis requires a perma- nent way to access the bloodstream for blood removal and return to the body during dialysis. Typical permanent vascular access options are an arteriovenous (AV) fistula (considered to be the gold standard) or a vascular access graft. Grafts are more prone to clotting and infection. Fistulas or grafts are placed in the arm when possible. NURSING CARE TIP It is important to save the veins of patients with chronic kidney disease for possible future fistula creation. The nondominant patient arm should not be used for IV lines, blood draws, or blood pressure to avoid damage to the veins because it will likely be the arm used for the fistula.
Early referral to a nephrologist can allow for the establish- ment of vascular access so that it is matured (strong) before the need for dialysis. If this does not occur, then a temporary
Box 37.2 Nursing Care for Hemodialysis
Dialyzer
1. Consult with the HCP about medications to hold before hemodialysis. Some medications, such as antihypertensives, can be harmful when they become effective during dialysis and can reduce blood pressure to dangerously low levels. Other medications can be dialyzed out of the body, losing their effect. 2. Ensure that the patient is weighed both before and after dialysis to document the weight loss from the fluid removal. 3. If the patient has laboratory tests ordered and blood needs to be drawn, coordinate this process with the dialysis nurse, who can obtain the blood samples and save the patient unnecessary needlesticks. To prevent painful needlesticks or other invasive procedures, a device that creates vibration to disrupt pain transmission can be held on the skin above the site of the procedure for 30 seconds. It is easy and fast to do, and patients are very appreciative. Some patients have their own devices and can teach you about it! An example of a pain-blocking vibration device can be seen at https:// paincarelabs.com/buzzy. 4. Provide morning care early. Provide breakfast before dialysis if the patient tolerates eating before dialysis. For some patients, eating can cause hypotension by diverting blood flow to the GI system for digestion during dialysis. 5. When the patient returns from dialysis, weigh the patient, monitor the access site for bleeding, and monitor vital signs to ensure they are stable. Administer medications that were held if not contraindicated and vital signs are stable. 6. Protect the patient’s dialysis access at all times, as outlined in Box 37.3.
Dialysate lines
Access
Blood lines
Hemodialysis machine
FIGURE 37.7 Hemodialysis.
FIGURE 37.8 Patient undergoing hemodialysis at dialysis center.
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