Dialysate Dialysate is one of the two fluids used in dialysis. The other fluid being blood.

The term dialysate is borrowed from physical chemistry and refers to fluids and solutes which have crossed a membrane. The main function of the dialysate, is to remove waste material from the blood and to keep useful material from leaving the blood. Electrolytes and water are some materials included in the dialysate so that thier level in the blood can be controlled. As previously mentioned, the make up of dialysate or the dialysis 'bath', is: sodium chloride, sodim bicarbonate or sodium acetate, calcium chloride, potassium chloride, and magnesium chloride. This is the general composition of dialysate, but other compounds such as glucose may also be included. Glucose is sometimes included. Current treatment options for patients with severe chronic kidney failureare dialysis and kidney transplantation. Dialysis is a treatment that removes substances such as water, salts, and waste products (from the bodys normal metabolism), which build up in patients with failing kidneys. One is called hemodialysis (HD), where the blood is cleaned outside the body and then returned to the body. This treatment, done in a hospital, or a dialysis clinic, is normally done 3 times a week, where each session takes about 4 hours. In HD, a machine and a filter are required, as well as a system to get the blood out of the body, as well as returning the cleaned blood to the patient. In most patients, this so called access to the blood, is done by inserting two needles into blood vessels on the forearm. A few centers around the world can train patients for self- HD. In regard to transplantation, the new kidney can come from either a deceased person or a living donor.

Take care to avoid traumatizing the arm where the access is located; do not wear tight clothes, jewelry, carry heavy items, or sleep on the arm. Do not allow anyone to take blood or measure blood pressure on this arm. Rotate needle sites on the access. Use gentle pressure to stop bleeding when the needle is removed. If bleeding occurs later, apply gentle pressure; call a healthcare provider if bleeding does not stop within 30 minutes or if bleeding is excessive.

Hemoaccess Care. Your hemoaccess is your lifeline. Without a functional hemoaccess, HD cannot be performed effectively. For this reason, please note the following Dos and Donts in hemoaccess care. Dos: 1. Wash your arm and hands before each dialysis session (five step method). 2. Apply light pressure to stop bleeding after the dialysis needles are removed. Have the nurse check if the bleeding has stopped before you leave the KU. 3. Vary the needle puncture sites. Follow a puncture plan for advancing needle punctures along the length of the AVF or AVG before going back to the previous site. 4. For HD catheters, keep the site dry and clean using occlusive dressing. 5. Always keep the catheter tubes clamped and the ports covered with germ-free caps in order to prevent the entry of air. Entry of air into the bloodstream (air embolism) can be fatal. Donts: 1. After disinfection of the skin, avoid touching the area where the needle is about to enter. 2. Avoid compressing the AVG or AVF since this might cause it to clot. Do not wear tight sleeves, watches, belts, or bracelets over it, carry heavy loads across it, lie over it during sleep or have your blood pressure taken on the hemoaccess arm. 3. Never use your AVG or AVF for blood draws or IV insertions. The AVF or AVG is a high pressure system. An inexperienced health personnel may not be able to control the bleeding if this is punctured. If you are using catheters, do not allow inexperienced personnel to draw blood from the ports to minimize the risks of infections and clotting. Warning Signs Be familiar with the following warning signs involving your hemoaccess. If present, consult your Nephrologist as soon as possible. 1. Swelling, redness or drainage of pus on the hemoaccess site can be a sign of infection especially if fever is present. Hemoaccess infection can easily spread throughout the body once the germs enter the bloodstream. 2. A spreading bruise after a HD session may indicate bleeding under the skin. 3. A pulsating hard knot under the skin may indicate AVF or AVG damage because of repeated needle punctures in the same site. 4. Coldness, numbness, pain or weakness of the extremity where the AVG or AVF is located especially during HD sessions may indicate decrease of blood flow since some of the blood is diverted to the dialysis circuit. This is called Steal Syndrome. If present, inform your Nephrologist immediately. 5. The absence of vibrations over the AVF or AVG may mean that it has clotted. Inform your Nephrologist immediately since the hemoaccess will need to be repaired as soon as possible so as not to interrupt your HD treatments.

HEMODIALYSIS MONITORING Blood testing Patients who use hemodialysis, either at home and in-center, will be monitored with blood tests to ensure that the time and type of dialysis treatments (called dialysis prescription) are optimal. Studies have shown that the correct dialysis prescription improves health, prevents complications, and prolongs survival. Blood testing is done at least once per month, and adjustments to the dialysis prescription may be made based upon the results of testing. Body weight monitoring Because kidneys that are failing cannot remove enough fluid from the body, dialysis must perform this task. Accumulation of fluid between hemodialysis treatments can lead to complications. Most patients will be weighed before and after dialysis, and will be asked to monitor their weight on a daily basis at home. If your weight increases more than usual between treatments, contact your healthcare provider. Caring for the access It is important to take care of your access to prevent complications. Complications can occur even if you are careful, but are much less common if you take a few precautions:

Wash the access with soap and warm water each day, and always before dialysis. Do not scratch the area or try to remove scabs. Check the area daily for signs of infection, including warmth and redness. Check that there is blood flow in the access daily. There should be a vibration (called a thrill) over the access. If this is absent or changes, notify your healthcare provider. Sometimes, flow monitoring is done during the dialysis treatment using ultrasound (sound waves). The flow monitoring measures the speed of blood flow during dialysis treatment.

6.

If your hemoaccess continues to bleed after HD, inform the staff immediately. Off operating hours, proceed to the ER.

respiratory parameters,

rate

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quality

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temperature outside of established parameters, MIKEE and MIK's PART: equipments, parts sa dialyzer, and how to do what not to be done during hemo any new complaint reported by patient, change in mental status, hemodialysis access. vi. Assess patients response hemodialysis prescription to the delivery of the

vii. Assess patients psychosocial adjustment to hemodialysis CARE OF THE TREATMENT OBJECTIVE: To provide patient with a safe and appropriate dialysis treatment PROCESS STANDARDS: Assessment 1. The nurse will assess the following parameters pre-dialysis, during treatment (as patients condition warrants), and postdialysis: A. Patient i. Weight (pre and post only), blood pressure, heart rate and rhythm, respiratory rate and quality, temperature (pre/post and during as patients condition warrants), and dialysis vascular access. ii. Assess patients general condition including: edema, skin, mental status, ability to ambulate, level of functioning, general sense of well-being, and any change from baseline. iii. Solicit complaints from patient and evaluate before initiation of dialysis, during dialysis, and prior to discharge from the Renal Unit the following: headache, dizziness, blurred vision, nausea, vomiting, diarrhea, constipation, or tarry stools, fever, chills, shortness of breath, dyspnea, chest pain, palpations, pain, bleeding, insomnia, weakness, fatigue, or change in level of activity, and changes in appetite. iv. Review laboratory test results prior to initiation of treatment. v. In addition to the above, assess patient during dialysis for any of the following: blood pressure and pulse outside of established parameters, PATIENT RECEIVING A HEMODIALYSIS viii. Assess patients understanding of: hemodialysis principles, hemodialysis procedure, current treatment prescription, signs and symptoms of hemodialysis complications, anticoagulation regimen, vascular access, routine laboratory test, monitoring of hemodialysis adequacy, medications, prescribed diet,

CARE OF THE TREATMENT

PATIENT

RECEIVING

HEMODIALYSIS

Assessment continued: Patient sodium restriction and thirst management, reporting of occurrences, illnesses, or injuries since last treatment and emergency procedures while on hemodialysis. B. Delivery system i. Integrity of extracorporeal circuit. ii. Pressure monitor readings iii. Anticoagulant delivery iv. Blood flow rate v. Alarm limits and/or conditions INTERVENTION: 1. Notify physician of any assessment findings that might require modification of the Hemodialysis prescription. 2. Adjust and administer prescribed hemodialysis treatment based on predialysis assessment

findings. 3. Based on patient assessment modify treatment plan to minimize complications, using sodium modeling, ultrafiltration profiling. 4. Administer medications as prescribed. 5. Provide or encourage diversional activity, as appropriate. 6. Monitor patients response to the treatment plan and collaborate with the health care team and the patient to modify the treatment plan. 7. Encourage adherence to treatment regimen and provide ongoing skill development and support. 8. Identify resources to assist patient to achieve psychosocial adjustment and rehabilitation goals. 9. Initiate consultations or referrals, as appropriate. PATIENT TEACHING: 1. Instruct patient regarding hemodialysis hemodialysis procedure, current treatment prescription, signs and symptoms of anticoagulation, vascular access, laboratory principles,

Quality Pulse Rate Character Rhythm Blood pressure (sitting and standing) Weight Temperature Level of consciousness *Access site Redness Pain Swelling Drainage Catheter dressing Bruit/Thrill *Patients response to treatment Anxiety Disturbed self concept Fear of death Adaptive *Patient Education Hemodialysis principles an appropriate and safe Hemodialysis procedure Current treatment prescription Signs and symptoms of complications Anticoagulation Vascular access Laboratory tests Monitoring of hemodialysis adequacy Medications Diet and fluid prescription including sodium restriction and thirst management

complications,

tests, monitoring of hemodialysis adequacy, medications, diet and fluid prescription including sodium restriction and thirst management, and reporting of symptoms, illnesses, injuries, or hospitalizations since last treatment. Instruct patient in emergency procedures while on hemodialysis. 2. Teach or reinforce the benefits of following the prescription for treatment, medication, exercise, and nutrition therapy. OUTCOME STANDARDS: 1. The patient will receive hemodialysis treatment.

2. The patient will be free of treatment-induced complications, including hemolysis, pyrogen reaction, dialyzer reaction, air embolism, and exsanguination. 3. The patient will be free of complications of anticoagulation. 4. The patient will demonstrate knowledge of the dialysis equipment and procedures, and of potential treatment or equipment-related complications.

CARE OF THE TREATMENT

PATIENT

RECEIVING

HEMODIALYSIS

Reporting of symptoms, illnesses, injuries, or hospitalizations since last treatment Emergency procedures while on hemodialysis Reference: 1. Burrows-Hudson, S., Prowant, B. American Nephrology Nurses Association Nephrology Nursing

HAVE I DOCUMENTED: *Vital signs Respiratory Rate

Standards of Practice and Guidelines for Care. (2005). Pp.7172. Pitman NJ: Anthony J. Jannetti, Inc