Chapter 37
Nursing Care of Patients With Disorders of the Urinary System
717
Box 37.3 Care of Blood Access Fistula or Graft Fistulas or grafts that are created for dialysis access should not be used for any purpose other than dialysis. 1. Watch for signs of bleeding or infection at the access site. 2. Gently palpate the site for a thrill (vibration or pulsing feeling) that indicates adequate blood flow through the access site. 3. Listen for a bruit (swishing sound) at the access site by placing the diaphragm of a stethoscope gently on the site. 4. Do not take a blood pressure, use a tourniquet, draw blood, give an injection, or start any IV lines in an arm with an access site. 5. Many hospitals have indicators (such as a red arm bracelet) to signify that an arm should be protected. A sign above the bed may also be used. 6. Reinforce teaching to keep the access site clean and not to bump or cut it. 7. Reinforce teaching to follow weight restrictions for lifting with the access arm. 8. Reinforce teaching to avoid wearing constrictive clothing or jewelry over the access site. 9. Reinforce teaching to avoid prolonged bending of or sleeping on the arm with an access site. 10. Notify the HCP if signs of bleeding, reduced circulation, or infection occur in an access site extremity (e.g., coldness, numbness, weakness, redness, fever, drainage, or swelling). environment. A major complication is peritonitis (infection of the peritoneum), which can be life threatening, most com- monly related to poor technique when connecting the bag of dialyzing solution to the peritoneal catheter. The first sign of peritonitis is usually abdominal pain. (See Chapter 34 for signs and symptoms of peritonitis.) If symptoms occur, the patient must contact the HCP immediately so antibiotic treatment can begin. The patient should be taught to care
for the exit site (the site where the catheter comes out of the abdomen) and inspect both the site and the dialysate solution for signs of infection. Dietary education is also important. A dietitian can assist the patient in appropriate choices for adequate calories, pro- tein, and potassium intake. The patient using peritoneal dial- ysis typically has fewer dietary and fluid restrictions than the patient on hemodialysis because peritoneal dialysis is con- tinuous and maintains serum waste levels. Proteins are lost through the peritoneal membrane into the dialysate fluid, so increased dietary protein is needed.
LEARNING TIP Therapy
Hemodialysis Peritoneal dialysis
Continuous renal replace- ment therapy Temporary vascular access
Patient access Vascular access
Peritoneal catheter
Equipment
Specialized dialyzer
No dialyzer Hemofilter
Training
Dialysis nurse Patient
ICU nurse
Timing
Intermittent
Continuous Continuous
Solute removal Osmosis/ Diffusion
Osmosis/ Diffusion
Convection
Dialysate
Yes
Yes
No
Cardiovascular effects
Hypotension Rare
Rare
A B FIGURE 37.10 (A) Peritoneal dialysis works inside the body. Dialysis solution flows through a tube into the abdominal cavity, where it collects waste products from the blood. (B) Periodically, the used dialysis solution is drained from the abdominal cavity, carrying away waste products and excess water from the blood.
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