NURSING MANAGEMENT FOR PATIENT UNDERGOING HEMODIALYSIS

1. INTRODUCTION Nowadays people of Malaysia are threatened with a variety of illnesses caused by life style among the diseases that involve the kidneys of "renal failure". We know that the kidney is one of the most important organs in the human body functions. Renal is derived from the Latin word renes, meaning kidneys. Can be defined is a pair of kidneys are located behind the abdominal organs. Each kidney is about 4 or 5 inches long. It is about a fist size. Right kidney is located right below the diaphragm and behind the heart. While the left kidney is located below the diaphragm and spleen organ behind. Above each kidney is adrenal gland also known as

(suprarenal glands), and each kidney contains about one million units, which is referred to neurons. Irregular position in the abdominal area due to the liver causing the right kidney is slightly lower than the left kidney.

Retro peritoneum and kidneys is approximately 9 to 13 cm in diameter, which is slightly larger left than the right. It was around the level of T12 to L13 vertebral level. Some parts of the

kidney is protected by the bones of the eleventh rib and two twelve and each adrenal gland is fully protected by two layers of fat (per renal and Para renal fat) and renal fascia which helps cushion it..

1.1 KIDNEY FUNCTION

The bladder holds about 400 ml (1 / 4 pints) of urine when full. Normal urine normally produced is around 2 liters per day. The main function of the kidney is responsible for the generation of waste from the body, regulating electrolyte balance and blood pressure and stimulates production of red blood cells. It cleanses the blood and makes urine from waste and they produce them. Blood is pumped by the heart to the kidneys. Their kidneys have a drainage system that takes urine from the kidneys to the bladder. Drainage system as a channel with a tube (ureter) that

connects the kidney to the bladder. Urine down ureter (for each kidney) into the bladder. Urine is stored in the bladder prior to discharge from the body through another tube called the ureter

Another kidney function helps blood pressure. Fine blood pressure is controlled by a healthy kidney. When the kidneys fail one of their blood pressure usually rises. Although it is not really known why. Pressure high blood pressure will not cause symptoms except for very high pressure, but it increases the risk of stroke or heart attack.

The kidneys also help control the actual manufacture of blood cells. The kidneys help regulate blood cells, the actual manufacturing in the bone marrow. Floating in the liquid if the blood (plasma). Their job is to carry oxygen around the body. The kidneys also produce certain hormones that have important functions in the body, including the following: Active form of vitamin D (calcitriol or 1.25 dihydroxy-vitamin D), which controls the absorption of calcium and phosphorus from foods, promoting formation of strong bones. Erythropoietin (EPO), which stimulates bone marrow to produce red blood cells. Renin, which regulates blood volume and blood pressure

2. END STAGE RENAL FAILURE As we know, kidney failure is in various stages. Among them are the "acute renal failure", "chronic renal failure" and the final stage is the "end stage renal failure". Based on studies in the United State is created by the National Kidney Foundation in 2001, a total of 370,000 person end stage renal failure have a number of cases increased approximately 8% each year.

End-stage kidney failure (ESRF) defined by Abassi et all 2010 as a reduction in the irreversible in kidney function , which is severe enough to be fatal in the absence of dialysis or transplantation. .

"End stage renal failure" can also be defined as an irreversible decline in kidney function that is severe enough to be fatal in the absence of dialysis or transplantation. In general, end stage renal failure occurs when there is less than 10% of the remaining kidney function. In 2000 the final stage of kidney failure than 375,000 American affected aspects of MRE increased to 651,000 by 2010.

Stage 5 chronic kidney disease can be described as kidney failure, also known as end stage renal failure and chronic kidney disease has developed. Renal replacement therapy, dialysis or kidney transplant may be needed to sustain life.

2.2 CAUSES OF END STAGE RENAL FAILURE Although chronic kidney disease sometimes results from the major diseases of the kidney itself, the main reasons for diabetes and high blood pressure. 1. Type 1 and type 2 diabetes mellitus can cause a condition called diabetic nephropathy, which is the main cause of kidney disease in the United States. 2. High blood pressure (hypertension), if uncontrolled, can damage the kidneys, from time to time.

3. Glomerulonephritis inflammation and damage to the kidney filtration system, which can lead to kidney failure. Post infectious conditions and lupus which is one source of many Glomerulonephritis. 4. Polycystic kidney disease is an example for the children of chronic kidney disease in which both kidneys have multiple cysts. 5. The use of painkillers such as acetaminophen (Tylenol) and ibuprofen (Motrin, Advil) fixed on a long period of time can lead to analgesic nephropathy, another cause of kidney disease. Some other drugs can also damage the kidneys. 6. clogging and hardening of the arteries (atherosclerosis) that lead to the kidneys causes a condition called ischemic nephropathy, which is another cause of progressive kidney damage. 7. Obstruction of urine flow by the rocks, the restrictions (narrowing), or cancer can also cause kidney disease. 8. Other causes of chronic kidney disease, including HIV infection, the cells sickle disease, heroin abuse, amyloidosis, kidney stones, chronic kidney infections and certain cancers.

3.0 CLINICAL FINDINGS AND EFFECTS ON PATIENTS

Patient with end stage renal failure have a variety of signs or symptoms that can be seen and different. It can be explicit or hidden. Based on the laboratory results obtained from Madam Wong her serum creatinine is higher than normal readings, the normal creatinine are in range less than 97. Creatinine blood test is to find proper kidney function and is used to hemodialysis

determine glomerular filtration rate, by the result found her had to undergo immediately.

Based on the symptoms shown, she suffered "Shortness of breath '. It is caused by fluid accumulation in the lungs. Other signs that patient also experience fatigue and

confusion in which the patient is in a state of uremia syndrome. In this situation can be seen where the level of creatinine in the blood are increase. This syndrome can affect body systems such as the intestines, nerves and heart. Another cause of fatigue maybe patient have a mild anemia due to hemoglobin are 10.1 g/ dl. For the patient who need to go to hemodialysis ,hemoglobin should be maintain at 11 g/dl.

"Pitting edema" is one of the symptoms listed for renal patients

which it occur when kidney

function has deteriorated it could no longer filter the liquid and keep the balance of salt. When this happens, fluid and salt from the body fluid build up in body tissues and cause edema.

Other symptoms that may be identified as the patient's skin will become dark or bright, unusual skin than the original and will be a change in the nails. Others laboratory examination done such as taking blood for "blood urea nitrogen," in which to look at kidney function. Urea is the main product of protein metabolism. Its formed in liver and excreted mainly by kidney in urine. If the kidneys are unable to remove the urea in the blood it will rise.

Besides taking full blood count is one of examination must do in patient with renal failure, its for detect renal anemia which full blood count is a component, such as hemoglobin, hematocrit .

Urine output are also one of symptom that can be seen in end stage renal failure was caused when 90% of nephrons almost fails it can cause "blood urea nitrogen" and "creatinine"

increases so that it causes "polyuria" changed to "oliguria . "

Chronic

disease

have

characteristic

that

lead to patient fatigue and symptoms of

depression. End

stage renal failure

in terms of influencing an individual's physical,

psychological, and emotional health. The impacts can be seen is that according to Morsch, Concalus & Banis, 2006 end stage renal failure is Associated with poor quality of life,

depression (Kimmel & Peterson, 2006), reduced physical functioning Ability (Cleary & Diennan 2005; O'Sullivan 2007 ), poor sleep quality (Elder et all, 2007) and fatigue (Mc Cann & Boore, 2008; O'Sullivan & Mc Carthy, 2007).

Having chronic condition such end stage renal disease is likely to have a impact on patient everyday life. The concerns commonly identified among of end stage renal failure patient are disruption of lifestyle (Devins et all.2001).Whereas Blaschek 2003 said that suffering from continuing symptom , stress and uncertainly of life. Intervention aimed at modifying know mortality risk factors are expected to have considerable impact in this patient population in survival and hopefully, Qol (Lindquist& Syoden 1998, Golper 2001, Loss- Ayau et all- 2008 ).

Other symptoms, if untreated, can cause life-threatening condition and can be formed. 1. metabolic acidosis, or increased acidity of the body due to the inability to manufacture bicarbonate, will alter enzyme and oxygen metabolism, causing organ failure. 2. Unable to remove potassium and increases in serum potassium levels (hyperkalemia) is Associated with a fatal heart rhythm disturbances (arrhythmias), including ventricular tachycardia and ventricular fibrillation. 3. Increased level of urea in the blood (uremia) can affect the function of various organs of the brain (encephalopathy) with alteration of thinking, inflammation of the lining of the heart (pericarditis), decreased muscle function because of low calcium levels (hypocalcemia). 4. The weakness may be caused by anemia in which red blood cell count decreased, because of lower levels of erythropoietin produced by the kidneys failed be able to stimulate the bone marrow. The decrease in red cells with a decrease in the ability to carry oxygen in the blood, resulting in decreased oxygen delivery to the cells for them to do the work, therefore, the body tires quickly. And, with less oxygen, the cells are easier to use anaerobic metabolism (= without aerobic = oxygen). This can lead to the total increase in acid production which can not be handled by the kidneys that have failed

5.

As waste products build in the blood, loss of appetite, lethargy and fatigue was very strong. This can lead to decreased mental function, and coma may occur.

4. .MANAGEMENT OF THE PATIENT UNDERGOING HEMODIALYSIS

Dialysis is a treatment

that takes over the task performed by the kidneys. Once for the

last stage kidney failure (end stage renal failure), most patient requiring dialysis treatment. This treatment is likely for life except for kidney transplants.

According to Wong et all 2007 there are approximately

3000 patient on dialysis of

whom 80% are on continuous ambulatory peritoneal dialysis and remaining 20% are receive hemodialysis.. Hemodialysis is done where an artificial kidney (haemodialyzer)

connected to a machine that filters work to remove waste impurities and excess fluid from the body. This procedure is carried out in a special unit (hemodialysis unit) in the hospital and takes around four hours per session to three sessions a week. The patient will require fistula of blood from the body to flow into the artificial kidney. The surgeon will make this fistula by connecting an artery to the venous blood vessels to become larger blood vessels. During dialysis, waste products in the bloodstream are carried out of the body. At the same time, electrolytes and other chemicals are added to the blood. The purified, chemically-balanced blood is then returned to the body.

In the hemodialysis treatment of several aspects of care should be taken into consideration, including the vascular access. Patients who undergo dialysis vascular access and so requires access sites must be protected from damage or infection. Malovrh 2005 suggests a long-term survival and quality of life of patients on hemodialysis depend on dialysis adequacy through the appropriate vascular access. Ateriovenous fistula and graft require subcutaneous access and, to protect their access sites from unnecessary pressure or injury, venepuncture, cannulation,

arterial-line insertion Engebretson 2010).

and the use of blood-pressure cuffs must be avoided (Richard and

In addition of

vascular access, care diet is also important for end stage renal failure patients.

Among are fluid intake and other food. The volume of urine passed by patients undergoing dialysis is too small to remove all the fluid from their food and drink. Fluid retention leads to increased blood volume, distended blood vessels and high blood pressure, which can in turn

lead to pulmonary edema (Agar 2010).

According to Kalanter-Zadeh (2009)in a study of fluid gain in patients undergoing dialysis found that the average patient gained between 1.5 and 2.0kg of fluid between dialysis sessions, and that a weight gain of at least 4kg over two consecutive dialysis sessions was associated with a 28 per cent increased risk of death. Optimal fluid management is a determinant of survival in patients undergoing renal replacement therapy (Collins and Mujais 2002) and,Blair 2009 states that patients with chronic kidney disease, morbidity and mortality are increased by excessive fluid intake. Most patients undergoing dialysis are restricting to 1 liter fluid a day and if they are given extra fluids intravenously, they must be monitored constantly.

Hyperkalaemia in most people, about 90 per cent of potassium is excreted by the kidneys and patients undergoing dialysis who fail to adhere to dietary advice may be at risk of

hyperkalaemia due to decreased potassium excretion (Challinor 2008). Hyperkalaemia affects the ability of cardiac muscle tissue to conduct electrical impulses, potentially resulting in ventricular fibrillation and a systolic arrest (Ahee and Alexander 2000),

NURSING PROCESS PROBLEM High risk GOAL of To INTERVENTION EVALUATION

Arterivenous thrombosis Aneurysm

reduce 1.Educate her on the Her arteriovenous Fistula is still in good Fistula Arteriovenous Fistula care of Arteriovenous condition and and Complication Fistula fuctioning well to 2.Avoid cannulation same site 3.Treat infection if repeated at the

due

knowledge deficit.

present 4.Cannulate carefully try not to puncture the fistula 5.Refer to Doctor if there is bad aneurysm 6.Keep fistula clean and dry

NURSING PROBLEM

OBJECTIVE

NURSING INTERVENTION

EVALUATION

Fluid volume excess Patient will not show 1. Assist in dialysis Patient not show sign related to failure or signs and symptoms and monitor patient and comprised renal of excess fluid. progress. symptoms of

excess fluid.

regulatory mechanism 2 .Administer or oral

intravenous

fluids as prescribed.

3. Monitor intake and output chart .Strict

fluid intake to patient.

4. Use small cup to drink ,so that patient cannot take a lot of water.

5. Do daily weight and chart.

6. Monitor vital sign .Sign and symptom Short of breath(SOB) Early sign of fluid overload

7. Offer ice chips or flavored ice pops.

Record intake. Helps minimizes thirst. Provide mouth care. frequent Helps

minimize thirst.

NURSING PROBLEM Pedal edema

OBJECTIVE

NURSING INTERVENTION

EVALUATION

To reduce pedal edema

.Evaluate

the Pedal edema reduce intervention

extended

of edema after

and its location ,so given. that action could be taken to relief condition. 2.Advice patient to elevate his leg during lying down to reduce the

swelling 3. Restricted fluid 500 ml POD (Previous

Day Output) and take low salt diet to avoid fluid retention. 4.Medication strictly follow ordered 5. Monitor the Doctors

condition of patient during treatment and inform doctor the changes about

NURSING PROBLEM Impaired integrity related

OBJECTIVE

NURSING INTERVENTION

EVALUATION

skin Patient's skin remains 1. Encourage use of to intact and free of prescribed phosphate and binders when serum phosphorus level is elevated. Excess phosphorus binds with free calcium in the serum. The resulting calcium-phosphate

pruritus and dry skin erythema secondary to uremia abrasions. and edema

complex is deposited in soft tissues and can cause necrotic patches in the skin. In addition, elevation in calcium-phosphate product is associated with increased risk of death, aortic calcification, mitral valve calcification, and coronary artery calcification. Phosphate binders help prevent elevation in calcium-phosphate product. 2. Administer as

antihistamines

prescribed if needed. Because accumulating nitrogenous wastes

are excreted through the skin, pruritus is common in patients with uremia and

causes frequent and intense Pruritus decreases scratching. often with a

reduction in BUN and

improved phosphorus control. itching Decreases and

subsequent scratching that can result in

abrasions infection. 3.

and/or

Keep patient's

fingernails cut short. Prevents abrasions scratching. 4. Teach patient skin when

to monitor scratches for evidence of

infection and to seek medical attention

early if signs and symptoms of infection appear. Uremia

retards wound healing and thus increases the risk for infection. 5. Encourage use

of skin emollients and soaps with high fat content. Uremic skin is often dry and scaly because of reduction in oil gland activity. Skin emollients and

soaps with high fat content replace oils and help reduce

itching from dryness. 6. Advise patient to

bathe every other day and lotion upon to apply skin immediately exiting

bath/shower. Patients should avoid harsh

soaps, soaps or skin products containing

alcohol, and excessive bathing, skin itching. 7. Advise patient and significant others to prevent and

dryness

about increased risk for bruising. Clotting abnormalities capillary place and fragility with

patient

uremia at increased risk for bruising. 8. Provide

scheduled skin care and position changes for patients with Helps

edema.

prevents breakdown pressure.

skin from

PROBLEM

OBJECTIVE

INTERVENTION

EVALUATION