ARTIFICIAL KIDNEY UNIT

ANRTP 2
GROUP VI

Teena Marie P. Balbas Pia Jenina B. De La Cruz Mc Crister L. Silang Adrian M. Marcelo Alma A. Valiente

DIALYSIS

Overview The function of your kidneys is to purify your body by removing waste and excess fluid. Dialysis is a treatment used for people whose kidneys don't work properly. It's a common treatment that has been used for people with kidney problems since the 1940s. Dialysis (from Greek dialusis, meaning dissolution, dia, meaning through, and lysis, meaning loosening or splitting) is a process for removing waste and excess water from the blood, and is used primarily as an artificial replacement for lost kidney function in people with renal failure. The Purpose of Dialysis A properly functioning kidney helps prevent salt, extra water, and waste from accumulating in your body. It also helps control blood pressure and regulates important chemicals in the blood, such as sodium (salt) and potassium. When your kidneys don't perform these functions due to disease or injury, dialysis can help purify the blood and remove waste. How It Works There are two different types of dialysis:

Hemodialysis involves using an artificial kidney, known as a hemodialyzer, to remove waste and chemicals from the blood. It accesses the blood through a minor surgical procedure in the arm or leg, or through a plastic tube in the neck called a catheter. Peritoneal dialysis involves the surgical implantation of a catheter into your stomach area. During treatment, a special fluid called dialystate is pumped into the abdomen where it draws waste out of the bloodstream.

The length of treatment depends on the patient's size, the levels of waste in their body, and whether hemodialysis or peritoneal dialysis is used. Typical hemodialysis treatments last about four hours and are needed about three times a week. Peritoneal dialysis can be done at home, at work, or during sleep, depending on the style of treatment your doctor recommends.

The Intended Benefits Dialysis is intended to keep the body running as normal as possible while the kidneys are under repair or while a person waits for a kidney transplant. Without working kidneys or dialysis, salts and other waste products would accumulate in the blood and poison the person. Dialysis is NOT a cure for kidney disease or ailments affecting the kidneys. Other treatments are needed to address those concerns.

When do patients require dialysis? Patients usually require dialysis when the waste products in their body become so high that they start to become sick from them. The level of the waste products usually builds up slowly. Doctors measure several blood chemical levels to help decide when dialysis is necessary. The two major blood chemical levels that are measured are the "creatinine level" and the "blood urea nitrogen" (BUN) level. As these two levels rise, they are indicators of the decreasing ability of the kidneys to cleanse the body of waste products. The doctor uses other indicators of the patient's status to decide about the need for dialysis. If the patient is experiencing a major inability to rid the body of excess water, or is complaining of problems with the heart, lungs, or stomach, or difficulties with taste or sensation in their legs, dialysis may be indicated even though the creatinine clearance has not fallen to the 10-12 cc/minute level.

Hemodialysis General Procedure

(In-Patient)

PURPOSE To establish a documented quality procedure on the management of the in patient in the Hemodialysis Unit to a simpler, concise, yet sophisticated information about hemodialysis therapy to renal patients. Scope: This procedure applies to in-patient dialysis which covers the following: Receiving of patients for dialysis Administering hemodialysis treatment Discharge/ endorsement of patients after dialysis Process Map Start Inform dialysis unit of patients schedule/order for hemodialysis Details Responsible Person Reference

Gives AP/Nephrologist/ward -Carrying out of hemodialysis nurse Doctors order order. -Policy and Hemodialysis procedure in order is carried out informed consent and consent is -informed consent secured after explanation of the procedure. Prepares hemodialyis machine and materials needed Note: in case of machine/water system malfunction, hemodialysis staff will inform AP and/or the staff Receives special endorsement, Checks consent, result of Hep-B and hemodialysis parameter orders. Hemodialysis staff

Acknowledge and gives schedule of hemodialysis treatment

Receives patient/ endorsement from the ward and verifies doctors order

Ward nurse Hemodialysis staff

-Staff nurse endorsement

A Assess patient Physical examination of patient (subjective and objective) include TPR, CR, RR, BP, weigh and contraceptions if any. -prepare the machine -sets hemodialysis parameters as ordered. -Do skin preparation at the access site -cannulates AVF/Graft -Connects catheter to machine -secure blood specimen for lab purposes if any -starts hemodialysis treatment -administers heparinization -Assess patient condition every #0mins or as needed -administer medication treatment as standard management on emergencies and complications during dialysis. Hemodialysis Staff Patient assessment and monitoring -Taking the PR,RR, and BP

Preparation/sets parameters of Hemodialysis machine according to doctors order. Initiates cannulations and start/connect to hemodialysis machine

Hemodialysis Staff

-Installing the blooding system. Preparing of reused dialyzer

Hemodialysis Staff

Cannulating of AV fistula Open and connecting of catheter access heparinization

Attend/ anticipate needs and problems of the patient and administer standard medication during hemodialysis complications.

Hemodialysis Staff

Patient assessment and monitoring. Administration of oral medication, parenteral medication, Administration of drugs through intravenous. Administration of blood transfusion. Policy 7 procedure on drug administration.

B Changing the procedure and processing of Philhealth Procedure is charged using the SPCMC Bizbox system (self-pay, PHIC, PCSO, HMO) for settlement/ payment. -hemodialysis is terminated upon completion of treatment. However termination of hemodialysis may also varies depending on doctors order if any untoward signs and systems occurred. Assist patient during transport -endorsement procedure Hemodialysis staff Availing and monitoring of Philhealth outright deduction on hemodialysis sessions

Terminates HD and evaluates patient status

Hemodialysis staff

Termination of dialysis -disconnecting the patient -ternination of AV fistula -Termination of Catheter access

Transport/ endorses patient back to room

Hemodialysis staff

-Staff nurse endorsement -comfort and safety measures

Disinfect of dialyzer and hemodialysis

-disinfection and cleaning procedure of dialyzers before storage -disinfection/ cleaning of hemodialysis machine after each use

Hemodialysis staff

-Draining the dialyzer -Cleaning and disinfection of Dialyzer

END

Hemodialysis General Procedure

(Out-Patient)
Definition: Emergency dialysis is/are those patient/s who need/s to be dialyzed beyond dialysis units operating time. And/or those patient/s that are not scheduled for the day but needs to be dialyzed. PURPOSE To establish a documented quality procedure on the management of the in patient in the Hemodialysis Unit to a simpler, concise, yet sophisticated information about hemodialysis therapy to renal patients. Scope: This procedure applies to in-patient dialysis which covers the following: Receiving of patients for dialysis Administering hemodialysis treatment Discharge/ endorsement of patients after dialysis Process Map Start Preparation of dialysis machine and materials needed Details Staff prepares the machines and materials needed ahead of time before the arrival of the scheduled patients for the day Responsible Person Hemodialysis Staff Reference -installing the bloodline system -priming the dialyzer with saline solution -preparation of the new dialyzer -preaparation of reused dialyzer

Patient arrives directly at the unit on his/her scheduled dialysis

Patient arrieves directly at the unit. Note: patient informs hemodialysis staff in case of lates/or absences ahead of time. Annual consent for hemodialysis is secured asper DOH standard for regular patients.

Hemodialysis Staff

Assess patients condition

Physical examination Hemodialysis of patient (subjective Staff and objective) include TPR, CR, RR, BP, and weight Check patient access: palpate for bruit/thrill for AV fistula and graft.

- Taking the temperature, PR,RR, and BP

A Preparation/sets parameters of Hemodialysis machine according to doctors order. -Checks and sets Hemodialysis hemodialysis staff parameters according to doctors order on hemodialysis order form: target UF, blood flow rate, dialysis bath, heparinization etc. -Carrying out of Doctors order

Initiates cannulations and start/connect to hemodialysis machine

-Do skin preparation at the access site -cannulates AVF/Graft -Connects catheter to machine -secure blood specimen for lab purposes if any -starts hemodialysis treatment -administers heparinization

Hemodialysis staff

-Cannulating of AV fistula -Open and connecting of catheter access heparinization

Attend/ anticipate needs and problems of the patient and administer standard medication during hemodialysis complications.

-Assess patient condition every #0mins or as needed -administer medication treatment as standard management on emergencies and complications during dialysis.

Hemodialysis staff

Patient assessment and monitoring. Administration of oral medication, parenteral medication, Administration of drugs through intravenous. Administration of

blood transfusion. Policy 7 procedure on drug administration. B

Changes the procedure

Procedure is charged using the SPCMC Bizbox system (selfpay, PHIC, PCSO, HMO) for settlement/ payment.

Hemodialysis Staff

Availing and monitoring of Philhealth outright deduction on hemodialysis sessions

Terminates HD and -hemodialysis is Hemodialysis evaluates patient terminated upon Staff status completion of treatment. However termination of hemodialysis may also varies depending on doctors order if any untoward signs and systems occurred.

Termination of dialysis -disconnecting the patient -ternination of AV fistula -Termination of Catheter access -comfort and safety measures

Patient for admission? YES: admission process -inform the resident doctor for patient admission either ER admission or Direct admission. -patient goes home after dialysis per wheelchair, ambulatory and/or stretcher -patient needs admission after dialysis as ordered by AP/Nephrologist.

Hemodialysis Staff

-Policies and procedure on direct admission

NO: Sent patient home

Disinfect of dialyzer -disinfection and and hemodialysis cleaning procedure of machine. dialyzers before storage -disinfection/ cleaning of hemodialysis machine after each use.

Hemodialysis Staff

-Cleaning and disinfection of Dialyzer. -parameters on reused dialyzer

END

Hemodialysis General Procedure

(Emergency Dialysis)
Definition: Emergency dialysis is/are those patient/s who need/s to be dialyzed beyond dialysis units operating time. And/or those patient/s that are not scheduled for the day but needs to be dialyzed. Purpose:

To establish a documented quality management of the unit, service to the client, care for the patient and quality procedure to a simpler, concise, yet sophisticated information about hemodialysis therapy to renal patients.

Scope: This procedure applies to emergency dialysis patients which covers the following: Procedure: Start Patient goes directly to Emergency Room Section Details ROD examines and gives emergency treatment to patient. Informs the AP/ Nephrologist regarding the physical and medical findings. Responsible Person ROD Reference Receiving of patients for dialysis Administering hemodialysis treatment Discharge/ endorsement of patients after dialyzer

Informs dialysis unit of patient for emergency dialysis (on-call)

Carries out doctors ER nurse order and secure consent for emergency dialysis.

-Carrying out of doctors order. -Policy on telephone/sms and verbal order. -Informed consent

A Acknowledge and confirms dialysis treatment -Prepares the dialysis machines and other materials needed. Hemodialysis Staff

Receives patient/ endorsement from the E.R. nurse and verify doctors order

-Receives special endorsement, checks consent for emergency dialysis and HD parameters.

Hemodialysis Staff

Endorsement of the patient

Assess patients condition

-Physical examination of Patient (subjective and objective) include TPR, CR, RR, BP, weigh and contraceptions if any.

Hemodialysis Staff

Taking the temperature, PR,RR, and BP

Initiates cannulation and start/connect to hemodialysis machine

-Sets hemodialysis Hemodialysis Staff parameter as ordered. Do skin preparation at the access site -cannulates AVF/Graft -Connects catheter to machine -secure blood specimen for lab purposes if any -starts hemodialysis treatment -administers heparinization

-Installing the bloodline system. - Preparing of new dialyzer -preparation of reused dialyzer -Open and connecting of catheter access heparinization -Patient assessment and monitoring. -Administration of oral medication, parenteral medication. -Administration of drugs through intravenous. -Administration of blood transfusion. -Policy 7 procedure on drug administration.

Attends/anticipate needs and problems of the patient and administer standard medication during hemodialysis complications

-Assess patient condition every 30mins or as needed -administer medication treatment as standard management on emergencies and complications during dialysis.

Hemodialysis Staff

B Charges the procedure and processing of Philhealth. - Procedure is charged using the SPCMC Bizbox system (self-pay, PHIC, PCSO, HMO) for settlement/ payment. Hemodialysis Staff Availing and monitoring of Philhealth outright deduction on hemodialysis sessions

Terminates HD and - Hemodialysis is evaluates patient terminated upon status completion of treatment. However termination of hemodialysis may also varies depending on doctors order if any untoward signs and systems occurred. Patient for admission ? YES: admission process NO: Sent patient home

Hemodialysis Staff

-Termination of dialysis -Disconnecting the patient -Termination of AV fistula -Termination of catheter access

Hemodialysis Staff -patient needs admission after dialysis as ordered by AP/Nephrologist.

-comfort and safety measures

-assist patient during transport -admission process

Disinfect of dialyzer -disinfection and and hemodialysis cleaning procedure machine. of dialyzers before storage -disinfection/ cleaning of hemodialysis machine after each use

-Draining the dialyzer -Cleaning and disinfection of Dialyzer

END

Cannulating of AV Fistula

Preparation: 1. Explain the procedure to the patient 2 Uses of the following words are indicative in explaining procedures. What should be done? Why should be done? How it will be done? 3. Duration of the procedure Possible complications that he/she will encounter The dos and donts during the procedure Post dialysis teachings and care 4. Wear the necessary gadgets before proceeding to such procedure. gloves mask goggles 5. Prepare the needed materials AV fistula needle with back-eye (2pcs) 2x2 OS pads (2pcs) Clamp Tourniquet Sterile cotton balls with alcohol and betadine Adhesive tape Sterile cherries for pressure dressing Syringe (tuberculine, 10cc, 30cc) -1 each 2% xylociane

Skin Preparation of AV Fistula Site 1. With the use of sterile cotton balls soaked in betadine, disinfect the site by swabbing 2. In a circular motion, start disinfecting the site; inner to outer area 3. Repeat work instruction number 2.2 using alcohol instead of betadine 4. Allow 3-5 minutes before cannulating

Cannulating And Hooking To Dialysis Machine I. Cannulating the AV fistula of the patient 1. Check for the bruit sounds on the fistula site 2. Locate the arterial and venous sites by palpation (the arterial being nearest to the fistula site). If it is hard to locate, apply a tourniquet proximal to the arteriovenous site. 3. Anesthesize the arterial and venous puncture site by injecting 0.1cc of 2% xylocaine intradermally (optional). 4. Clamp the AV fistula needles. Cannulate the arterial and venous sites by using AVF needle is inserted towards the heart. Puncture sites should be at least 1cm away from the previous puncture site. Puncture should be directed tangential to the blood adhesive wall 5. Secure the needle using adhesive tape. 6. Backflow (good backflow indicates that the needle is inside blood vessel).

II. Hooking To Dialysis Machine 1. Slowly release the cap of the arterial fistula needle to release air from the fistula needle tubing then clamp. 2. Clamp the arterial bloodlines and disinfect the end before connecting to arterial fistula needle. (use betadine in disinfect the end side of bloodline). 3. Open arterial clamps (bloodlines, AVF needle). 4. Switch ON the blood pump of the dialysis machine and allow blood to fill the arterial tubing, dialyzer and up to about of the venous line. 5. Stop the blood pump of dialysis machine 6. Release slowly the cap of venous fistula needle to expel air, then clamp. 7. Clamp the venous bloodline and disinfect the end before connecting to venous fistula needle. 8. Open venous clamps (bloodline, AVF needle) 9. Switch ON the blood pump of the dialysis machine and regulate blood pump to a minimum rate of 150 or as ordered.

Termination Of A.V. Fistula

Materials needed Procedure a. b. c. d. e. f. g. Put on gloves Turn off blood pump Turn off machine alarm guards (arterial, venous, TMP) Clamp arterial fistula and bloodlines Disconnect the arterial fistula and bloodlines Connect the arterial line to NSS line and open NSS line Turn on blood pump to 100ml/min. and allow 50-100 ml of NSS to push blood back to the patient. Place the NSS container in the upright position to allow air to further push back the patients blood. h. With a 10cc syringe, push remaining blood in the AVF with 3-5ml of air. WARNING: DO NOT ALLOW AIR TO ENTER THE PATIENT i. Once blood has reached the venous chamber, lower blood pump speed to 50 ml/min until blood is completely returned to the patient. WARNING: DO NOT ALLOW AIR TO ENTER THE PATIENT sterile cherries (2packs) clamp 10cc syringe Adhesive tape Gloves A.V. fistula needle covers

j. Turn off the blood pump. Clamp the venous fistula and venous tubings. k. Disconnect the venous fistula from the venous line using a 10cc syringe, push remaining blood in the venous fistula 3-5ml of air. WARNING: DO NOT ALLOW AIR TO ENTER THE PATIENT l. Carefully remove adhesive tapes from the inserted areterial fistula needle. Remove the arterial cherries. Repeat the same for the venous fistula needle. m. Once oozing has stopped, replace with clean cherry and secure with adhesive tape wrapped around the arm.

Installing the blood line system

I. II. III.

IV. V.

VI. VII.

VIII.

IX.

X. XI. XII. XIII.

XIV.

Attach the dialyzer to the appropriate holder. the dialyzer should be attached to the machine about the height of the rinse bridge. Arterial side of the blood line system should then be connected to the saline solution bag. Attach the arterial pressure monitoring line to the pressure sensor on the blood module. The line cannot be bent or kinked and the filter should be screwed firmly on the sensor coupling. Open the cover on the blood pump and pull out hand crank Place the blood pump tubing in the left tubing guide. By turning the rotor with the hand crank, the blood pump tube will guide itself into place automatically. Care must be taken that the pump tubing is fitted properly. Put hand crank back into position and close pump cover Remove the protection cap on the arterial blood line connection and attach it to the arterial blood intake connection of the dialyzer. The connector must ne firmly attached to the blood intake connector of the dialyzer. Fill the syringe with heparin solution and connect it to the heparin line. Fill the line up to the T-coupling. Gesture that there is no air in the line. Place the syringe in the holder. Put the handle of the heparin pump cover downward and open. Place the red claw in the moulding of the upper edge of the pump. Place or clip the heparin line inside the pump and close the cover. Install the pump tubing carefully so there is no tension in the line. Note direction of discharge. Remove the protective cap on the venous blood line connector and attach security to the venous blood port on the dialyzer. Using the rotary knob open the safety air detector (SAD). Install the venous bubble catcher so that it snaps into position. Reclose the parts and place the patient connecting line in the tubing clamp. Attach the venous pressure monitoring line to the venous pressure monitoring connection on the blood module. The pressure monitoring line must not be squeezed or kinked and the filter must be tightly connected. Patients venous blood line connector should be placed in a clean flask or attached to an empty fluid bag.

NOTES: Observe sterile procedure! Place the blood during tubing system in the intended function element or holder. Beware of the danger of hemolysis resulting from kinks in the tubing!

Complications of Dialysis
1. Hypotension

Common Causes: Excessive or inaccurate volume depletion Consumption of large meals on dialysis Anemia Antihypertensive meds Unstable cardiac status

Signs & Symptoms: Anxious feelings N/V Dizziness or faint feeling Pallor Yawning Hot feeling Weakness Sweating Tachycardia Loss of consciousness

Interventions: Discontinue UF Place patient in Trendelenburg position Infuse 100-200cc NSS, D50-50 or Hypertonic Saline (as ordered by Nephrologist on duty) Close monitoring

Preventions: Accurate pre-dialysis weight Accurate assessment of patient Hold antihypertensive meds Maintain adequate hematocrit Treat cardiovascular problems Encourage fluid restriction

2. Muscle Cramps Common Causes: Excessive fluid removal Associated with hypocalcemia or hyponatremia

Interventions: Stop UF Infuse 100-200cc NSS Bolus of osmotic agent such as D50-50 Extend cramped muscle by pressing against the muscle

Preventions: Proper dietary control of fluid and electrolytes Correct Target & Dialysis Body Weight (DBW)

3. Chest Pain Common Causes: Anemia Cardiac disease Severe vascular volume depletion

Interventions: Discontinue dialysis (If Severe) Administer oxygen & drugs as ordered Decrease UF Goal Assess & treat volume depletion

Preventions: Blood transfusion if necessary Maintain higher hematocrit

4. Air Emolism Common Causes: Defective Air Detector (machine) Open IV Line & Port

Signs & Symptoms: Visualization of air in the system Chest pain Dyspnea Coughing Cyanosis Visual problems Confusion

Interventions: 5. Headache Common Causes: Disequilibrium Hypertension Anxiety Disconnect the patient to the system Turn patient to left side in T-position (to trap the air in the apex of Right Ventricle) Administer oxygen 4-6L/min Check V/S

Interventions: Pain reliever May stop UF for 5 minutes

6. Nausea & Vomiting Common Causes: Hypotension Disequilibrium Too rapid UF Flu

Interventions: Stop UF Infuse 100cc NSS

Check BP

7. Disinfectant Reaction Common Causes: Inadequate rinsing of dialyzer Disinfectant present in the water system

Signs & Symptoms: Pain at Fistula site Chest pain Back pain Shortness of breath Irregular pulse Dry mouth & thick tongue

Interventions: Disconnect the patient to the system Recirculate blood 10-15 minutes Check the blood lines for brownish color (If present, discard the blood)

8. First Use or Dialyzer Allergic Reaction Signs & Symptoms: Back pain Acute bronchorestriction Initial feeling of uneasiness Urticaria Facial edema Hypotension or hypertension

Interventions: Disconnect patient to the system Oxygen administration Infuse NSS if BP is low

9. Fever / Pyrogen Reaction Common Causes:

Infection Introduction of pyrogens via dialysate Contaminated water supply

Signs & Symptoms: Feeling of coldness after initiating dialysis Involuntary shaking Chills that leads to temperature elevation Hypotension

Interventions: 10. Itching Common Cause: Minor allergic symptoms manifested by low grade hypersensitivity to dialyzer or blood circuit component Assess signs of infection Administer antipyretic as ordered

Interventions: Use of antihistamine Topical capsaicin cream Moisturizing & lubrication of the skin Using emollients is recommended UV light therapy especially UVB light