ONLINE HEMODIALYSIS TRAINING SESSION 2

Transcription

1 ONLINE HEMODIALYSIS TRAINING SESSION 2 This document is a supplement to the Online Training. Do not reproduce. Copyright Dialysis4Career. All Rights Reserved.

2 The Renal Diet Why is the renal diet important? The majority of foods that a dialysis patient puts in their mouth becomes wastes and fluids. Because of renal failure the body can no longer remove these wastes and fluids and dialysis alone is not enough to help maintain homeostasis. In other words, the less waste and fluids consumed the less that needs to be removed during dialysis. Page 1

3 Food Pyramid for Healthy Eating with Kidney Disease Low Sodium Low Potassium Low Phosphorus Page 2

4 Food Groups Food Group Examples Importance Potassium Phosphorus Calcium Sodium Protein Banana, cantaloupe, avocado, chocolate, dried beans, mango, milk, nuts, orange juice, tomatoes, sweet potatoes, baked potatoes Cheese, cola, yogurts, seeds, whole grains, pizza, milk, nuts, chocolate, processed meats, ice cream, beer, brownies Dairy products, some green vegetables, medications, your own bones! Table salt, spices, seasonings, fast food, packaged foods, canned soups and vegetables, processed meats, cheeses, chips, crackers. Often used as a preservative for many items in our cupboard. Beef, chicken, turkey, fish, eggs Regulates heart muscle. Too much or too little can cause serious heart complications. Follow your prescribed intake Too much phosphorus causes itching, joint pain, weaker bones, calcium deposits in the organs and soft tissues. Make sure you take your phosphate binders with your meals! Needed for strong bones, teeth and muscle function. Low levels in the blood leads to bone loss, and weaker bones. This could make you at risk for injuries. Make sure you take your medications! Too much intake causes high blood pressure. Read your food labels; find alternatives when cooking, such as sodium free spices and seasonings. Important for muscles. Too much intake causes high BUN levels, which can cause you to feel nausea and sickness. Too little causes malnutrition and muscle weakness. Page 3

5 Protein Protein needs to be within normal range for growth and repair of body tissues. It helps fight infection and prevents loss of muscles. When protein is depleted the patient will be at risk for skin breakdown, infection and loss of muscle and tissues. An adequate amount of proper protein intake is recommended for the dialysis patient. Albumin is a blood protein. Low levels is usually an indicator of malnourishment which can be harmful for the dialysis patient. Page 4

6 Potassium A Mineral that is necessary to keep our muscles functioning properly. The heart is a big muscle, that is why our heart is affected when the potassium level is too high or too low. Potassium is intracellular and is removed during dialysis by diffusion. Normal Potassium level is meq/l When the potassium (K+) level is too high in the blood it may cause: NAUSEA DIFFICULTY BREATHING IRREGULAR HEARTBEAT CARDIAC ARREST When the potassium (K+) level is too low it causes: MUSCLE WEAKNESS DECREASED REFLEXES INCREASED HEARTBEAT Many dialysis patients have elevated potassium levels pre-dialysis. Treatment is a low potassium prescription. Low Potassium diet is recommended for the dialysis patient. Page 5

7 Sodium Sodium is one of the most important jobs of the kidneys is to rid the body of extra sodium. When the kidneys are not working properly, sodium builds up in the body. Too much sodium can cause: HIGH BLOOD PRESSURE INCREASED THRIST RAPID WEIGHT GAIN SWOLLEN HANDS & FEET (EDEMA) Fluids Fluid balance is important in dialysis patients to prevent excessive fluid retention in the body. Fluids is found in all foods. Some are hidden and some are visible. Those that are liquid at room temperature should be counted as part of your daily fluid portion. Recommended intake of fluid for the dialysis patient is 32 ounces daily. Increased fluids can cause: PULMONARY EDEMA SHORTNESS OF BREATH (SOB) Glucose Glucose is blood sugar. Diabetes is the most common cause of kidney failure. It is treated with diet, pills, and/or insulin. To assess how well diabetes is controlled, the doctor may order a routine glucose (blood sugar) test. This measures the level of glucose in the blood. Dialysate often contains glucose which helps keep the patient s glucose levels from becoming too low during the treatment. Page 6

8 Calcium Calcium is a mineral needed for strong bones, teeth and muscle function. Calcium and phosphorus metabolism is altered in the dialysis patient, this lead to reduced levels of calcium in the blood causing bone deterioration and bone loss. The goal for the dialysis patient is to maintain or increase calcium levels. Normal Range : mg/dl Phosporus Phosphorus is a mineral that is necessary for strong bones. It is important to keep your blood level of phosphorus normal. When the phosphorus level gets too high, it can make your bones weak and brittle. It can also cause itching and fractures. It is important to pay careful attention to dialysis treatment diet and phosphorus binders. There are three ways to keep your phosphorus normal: FOLLOW YOUR DIET TAKE PHOSPHORUS BINDERS KEEP TRACK OF PHOSPHORUS LEVELS BINDERS: Renagel, Phoslo, Fosrenal, Tums, Calcium Carbonate PHOSPHATE BINDERS ARE TO BE TAKEN WITH ALL MEALS/FOOD. The binders absorbs the phosphorus from the food we eat. Nearly all foods have phosphorus. Normal Phosphorus level is mg/dl Page 7

9 How does chronic kidney disease affect your bones? With chronic kidney disease there is no homeostasis (no balance). When calcium is high, phosphorus is low. When calcium is low, phosphorus is high. This is a never ending vicious cycle. Damaged kidneys cannot dump extra phosphorus into the urine, which in turn causes high levels of phosphorus in your blood. They also cannot make vitamin D to help your intestines take in calcium from digesting food. This causes low calcium in your blood. Page 8

10 Vitamin D What does vitamin D do? Increase intestinal absorption of calcium & phosphorus thus increase them in the blood Decrease hormone production from the parathyroid glands What happens when vitamin D is not available, like in renal failure? Calcium is not absorbed from the G.I. (gastrointestinal) tract into the blood as easily thus causing a decrease in blood calcium. Parathyroid glands senses decrease in calcium in the blood, they release a hormone (parathyroid hormone = PTH) that causes calcium to come out of the bones and into the bloodstream. However, this overtime leads to brittle bones. What are the functions of the parathyroid gland? Release PTH when a decrease blood calcium levels are detected PTH causes calcium & phosphorous to be move from the bone into the blood What happens with the parathyroid function in renal failure? When the kidneys fail it usually causes: DECREASE calcium (due to loss of activated vitamin D) triggers a PTH release INCREASE phosphorous (due to decrease loss in urine) occurs with DECREASE calcium. Also a lack of phosphate binders leads to INCREASE phosphorous & DECREASE calcium Page 9

11 NOTE: This ongoing process is the main cause of bone disease (osteodystrophy or osteoporosis) in renal failure Signs and Symptoms of renal bone disease BONE PAIN FRACTURES MUSCLE WEAKNESS JOINT PAIN Due to this vicious cycle it is important for dialysis patients to have a diet low in phosphorus and high in calcium. The only problem is that the major foods that are high in calcium are also high in phosphorus. This is when it becomes very challenging for the dialysis patient. CONTINOUS PATIENT EDUCATION IS NEEDED TO HELP WITH CHANGE!!!!!!!!!!!!!!! Page 10

12 Lab Values and What They Mean CALCIUM mg/dl Level affect your bones PHOSPHORUS mg/dl High levels can affect your bones. High levels can cause itching, joint pain, weaken bones, calcium deposits. POTASSIUM meq/l Too high or too low can be dangerous as it affects your heart muscle. ALBUMIN > 40 g/l An indicator of how well nourished you are. BUN An indicator of protein in your diet. CREATININE Depends on muscle mass Waste product of muscle metabolism. URR > 65% Measures adequacy of a hemodialysis tx (how well your blood is being cleaned) or your dose of dialysis. KT/V > 1.2 Another measure of adequacy of a hemodialysis tx. SERUM FERRITIN mg/ml Ferritin is the amount of stored iron that is available. It is essential for the formation of red blood cells. TRANSFERRIN SATURATION At least 20% Iron stored in the body. HEMATOCRIT 33 36% Measures if you have enough red blood cells to carry oxygen to your tissues. HEMOGLOBIN 11 or greater An indicator of how well nourished you are. Page 11

13 Vascular Access For Hemodialysis A patient does not normally have veins large enough to allow the rapid and continuous blood flow needed for hemodialysis. All hemodialysis patients must undergo a surgical procedure to create an access. This access consists of two vascular entries into the blood systems. One entry allows for the pulling of blood outside the body. This is known as the arterial line, which is indicated by the color RED. The other entry allows for the return of clean blood back to the body. This is known as the venous line, which is indicated by the color BLUE. Three main types of access: Fistulas Grafts Catheters Page 12

14 Fistula A fistula is created surgically by joining an artery and a vein (Arteries are much larger than veins and carry more blood faster) This allows the higher volume of arterial blood to flow through the vein. This causes the vein to enlarge and over a short period of time develop thicker walls. A tourniquet should always be used ONLY on a fistula. Page 13

15 Grafts A graft is a hollow tube made from artificial material. It is surgically positioned under the skin to join an artery and a vein. When the procedure is completed, the patient s blood flows from the artery through the artificial graft into the vein. When assessing (prior to placing the needles in for dialysis) a vascular access (fistula and graft) you need to feel for the thrill and listen for the bruit. THRILL- The thrill is the vibration of blood flowing through the patient s fistula or graft. It can be felt by touching a patient s access. BRUIT A bruit is a buzzing or swooshing sound caused by the high pressure flow of blood through a patient s fistula or graft. The bruit can be heard through a stethoscope at the anastomosis and for some distance along the access. NOTE: When placing needles into the vascular access (graft or fistula), the venous needle is always placed toward the heart or in the direction of flow of blood. The arterial needle can be placed in either direction, toward the heart with the flow of blood or away from the heart against the flow of blood. Page 14

16 Catheters Central Venous Catheter (CVC) is placed most commonly in the jugular or subclavian veins. It is constructed in varying lengths and may be placed for a short or long term use. Catheters are used immediately until the patient s access (fistula or graft) is matured. Page 15

17 Aneurysm An aneurysm is a ballooning or bulging of a weak spot in a blood vessel. Because severe bleeding can occur if an aneurysm ruptures, great care must be taken with a patient who has one. Anuerysms can occur if needles are inserted too often in to the same area of a fistula. Pseudoaneurysm A pseudoaneurysm is a false aneurysm, a bulging pocket of blood around a fistula or, more commonly, a graft. Pseudoaneurysm can occur if a graft has been damaged by repeated punctures in the same are. They can rupture, which is a medical emergency. A graft with a pseudoanuerysm may need to be repaired or replaced. Thrombosis A formation of a thrombus, or blood clot is the most common cause of access failure. Early thrombosis in a graft or fistula is most often caused by surgical problems with the anatamosis, or by twisting of the vessel or graft. Stenosis Stenosis is narrowing of a blood vessel. Stenosis slows the flow of blood and causes turbulence inside the vessel, setting the stage for more serious complications such as thrombosis. Anastomosis A anastomosis is a surgical connection. In a vascular access, the anastomosis is the spot where a vein and artery are joined to form a fistula, or where the artificial vein is joined to the patient s artery and vein for a graft. Dialysis needles should not be inserted into the area of the anastomosis. Page 16

18 Infiltration Collection of blood that has escaped the blood vessel into the surrounding tissue. This is caused by the passing through of the vessel wall during cannulation. Cannulation (inserting a dialysis needle) is done at a 45 degree angle but can vary according to how deep or shallow the access was surgically placed. Steal Syndrome A few patients develop ischemic (poor circulation) changes to the fingers on the arm in which the access was placed. Signs and Symptoms Coldness Poor function Gangrene Necrosis of tips of the fingers Page 17

19 Access Infection Signs and Symptoms Pain Redness Fever greater than 99 Chills Drainage Intervention Notify charge nurse Wait for instructions/orders to initiate Treatment Blood cultures is ordered by the physician if temperature is higher than 100 Antibiotics as ordered by the physician Access replacement/revision as needed Page 18

20 Access Recirculation Venous blood mixing with the arterial blood in the access. Signs and Symptoms Dark blood or black blood syndrome Increased hematocrit Increased thickness of the blood Inappropriately high URR Causes Reversed blood lines Inadequate blood flow Needles to close together Venous stenosis- poor venous return Intervention Place tip of needles two inches apart Arterial needle towards the anastamosis Correct connection of blood lines to needles Access evaluation and intervention by surgeon or radiology as needed Page 19

21 Complications of Hemodialysis Hypotension Low blood pressure is the most common complication of hemodialysis. Signs and Symptons Decreased blood pressure Nausea and vomiting Dizziness Loss of consciousness Increased heart rate - Yawning - Confusion - Changes in vision - Muscle cramps - Sweating Causes of Hypotension Excessive ultrafiltration High blood pressure medication Incorrect weight loss calculation Gain of true body weight Unstable cardiac status Malnutrition Anemia Interventions for Hypotension Call for assistance Trendelenburg position Stop ultrafiltration Administer normal saline Lower the fluid removal goal Assess patient by talking to them to verify they are alert and responding to treatment Recheck blood pressure every 2-3 minutes until stable Document all interventions and responses NOTE: Interventions are chosen specific to each patients needs. Page 20

22 Hypertension High blood pressure Hypertensive crisis is sudden or severe Hypertension, exceeding 200/120, this can when patients stop taking their blood pressure medications. Hypertension can also be caused by excess fluid gains or excessive sodium intake Management of hypertension Fluid and sodium restriction Evaluation of dry weight (true weight) Septicemia/Bacteria Infection in the blood caused by microorganisms causing systemic disease. Signs and Symptoms General feeling of malaise Fever greater than 99 Chills Page 21

23 Muscle Cramps Muscle cramps are caused by rapid removal of fluid and sodium from the blood TOO MUCH TOO FAST Intervention Normal saline Hypertonic solution/sodium modeling Massage the affected leg Patient applies pressure to heel of foot Disequilibrium Syndrome Rapid change in serum electrolytes, PH, and osmolality. Usually occurs when BUN is greater than 150 (increase urea) and first hemodialysis treatment. When a patient is very uremic during dialysis, fluid is shifted to the brain cells causing swelling. Signs and Symptoms Hypertension Nausea and vomiting Headache - Restlessness - Convulsion - Coma Intervention: Patient s First Treatment Decrease Blood Flow Rate (BFR) Decrease Dialysate Flow Rate (DFR) Decrease Treatment Time Page 22

24 First Use Syndrome First use syndrome results from an allergic-type reaction to new dialyzers. Signs and Symptoms Itching - Chest pain - Nausea Back pain - Dizziness - SOB Hypotension (low blood pressure) Symptoms usually begin between 5 to 30 minutes into treatment. Intervention Return blood and discard dialyzer Give oxygen Treat patient s Symptoms Dialysis can be re-started with new dialyzer Page 23

25 Reuse Dialyzer Reuse or Reprocessed Dialyzers decrease the risk of First Use Syndrome. Reuse dialyzers are reprocessed with chemicals so the patient can use the same dialyzer over and over again (up to uses per dialyzer) Reprocessing chemicals must be rinsed from the dialyzer prior to treatment. The reprocessed dialyzer must be labeled with the patient s name and identifying number. Two teammates must verify the absence of the reprocessing chemical in the dialyzer and verify the patient, patient ID and correct dialyzer. Page 24

26 Emergencies in Hemodialysis Air Embolism An air embolism occurs when air bubbles enter the bloodstream and are carried into a vessel small enough to be blocked by the air. The air embolism in the vessel acts like a clot, blocking the flow of blood. Dialysis machines have an air detector on the venous bloodline to help prevent this problem which can be fatal. Signs and Symptoms Air in venous line - Chest pain SOB - Coughing Seizures - Headache Restlessness and confusion Causes Unarmed/defective air detector Empty saline bag Loose or seperated blood line connection Intervention Immediately clamp both blood lines (venous and arterial) stop the blood pump! Turn the patient on their left side in trendelenburg position, administer oxygen! This position prevents air movement to the brain by trapping the air in the right atrium of the heart, where it can be absorbed over a period of hours. Page 25

27 Hemolysis The destruction of red blood cells by bursting, causing the release of free hemoglobin and potassium into the blood stream, which can cause the heart muscle to beat irregularly. Signs and Symptoms Cherry Pop appearance of the blood in the venous line Chest pain SOB Headache Rapid pulse Causes Improperly prepared dialysate Exposure of blood to chemical disinfectant Exposure of blood to chlorine in the water Over occlusion of the blood pump Dialysate temperature to high Intervention Stop blood pump, clamp both lines and Do Not Return the Blood!!!!!!!!! Administer oxygen Call for 911 Treat patient symptoms Prepare for cardiac arrest Page 26

28 Medications Heparin Heparin is a blood thinner (anticoagulant) used during dialysis so blood will flow freely through the blood lines of the dialysis machine. It can be given intermittently or continuously. Continuous infusion uses a pump to slowly inject heparin into the blood lines at a prescribed rate during a treatment. Heparin is not used in the following situations: GI bleeding Menses Pericarditis Epogen Epogen is used to treat anemia. Used to replace the hormone erythropoietin. Which helps stimulate the bone marrow to produce red blood cells. Zemplar and Hectorol Zemplar and Hectorol activates vitamin D to enhance absorption of calcium Venofer An iron replacement therapy Phosphate Binders Phosphate binders should be taken with meals and/or foods. The binders helps absorbs phosphorus from the food you eat. Renal failure patient have high levels of phosphorus which can be controlled by diet and medication. Examples - Renagel, Phoslo, Tums Hypertonic Solution A concentrated sodium chloride salt solution. (quick fix for cramping and hypotension, IV push, prn order) Sodium Modeling is a program within the dialysis machine in which it releases, in intervals, small amounts of sodium while the patient is being dialyzed and is usually prescribed by the doctor for complications associated with hemodialysis (long term treatment for cramping and hypotension) Antibiotics Vancomycin and Gentamycin are the two most commonly used antibiotics in hemodialysis. Page 27