I. Basic Concepts Of Action
A. Definition
Dialysis is the process of diffusion of dissolved particles from one compartment to another compartment through a semipermeable membrane.
Hemodialysis is the path of blood through a tube outside the body to an artificial kidney, which made disposal of excess solutes and fluid. Frequency of hemodialysis varied from 2-3 x / week.
Blood containing waste products such as urea and creatinine flowing into an artificial kidney (dialiser), where it will meet with dialysate containing no urea and creatinine. Recurring flow of blood through the speed range dialiser at 200-400 ml / hour, more than 2-4 hours, is expected to reduce the levels of these waste products into a more normal state.
B. Destination
1. Waste products of protein metabolism such as urea, creatinine and uric acid.
2. Remove excess water by knowing the appeal between blood pressure and the liquid, usually consisting of positive and negative pressure (vacuum) in the dialysate compartment.
3. Maintain or restore the body's buffer system.
4. Maintain or restore the body's electrolyte levels.
C. Indication
1. Acute Renal Failure
2. Chronic renal failure, when gromelurus filtration rate of less than 5 ml / min
3. Serum potassium more than 6 mEq / l
4. Urea over 200 mg / dl
5. Blood pH of less than 7.1
6. Prolonged anuria, more than 5 days
7. Intoxication, drugs and chemicals
8. Hepatorenal Syndrome
D. Forms / Overview Equipment Used
1. Dialiser or Artificial Kidney
Consists of semi-permeable membrane that separates the blood and dialysate compartments.
2. Dialysate or fluid Dialysis
That fluid consisting of water and electrolytes from the main normal serum. Dialysate was created in the system clean with tap water and chemicals filter. Not a sterile system, because the bacteria are too large to pass through the membrane and the potential occurrence of infection in the patient at a minimum. Because bacteria from byproducts can cause pyrogenic reactions, especially in large permeable membrane, the water for the dialysate should be bacteriologically safe. Dialysate concentrates are usually supplied by the manufacturer komersildan commonly used by chronic unit.
3. System of dialysate
That is a tool that measures the proportion of the division and the automatic measurement and monitoring tools to ensure proper control of the ratio of concentrate and water.
4. Accessory Equipment
a. Hardware consists of:
1) blood pumps, infusion pumps for detecting heparin
2) The tool monitors the body temperature in case of insecurity dialysate concentration, changes in air pressure and leak blood.
b. The device is used in addition to disposable artificial kidney:
1) dialysis tube used to drain blood between dialiser and patients.
2) Transfer the pressure to protect the monitors of exposure to blood.
3) saline bags to clean up the system before use.
5. Human Component / Implementing
Hemodialysis executive power must have expertise in the use of high technology, achieved through training and practical teorits in clinical environments.
More important aspect is the understanding and knowledge that will be used nurses in providing care to patients during dialysis took place.
E. Preparation of Pre-Dialysis
The level and complexity of the problems that arise during hemodialysis will vary among patients and depends on several variables. For that before the hemodialysis process, need to be assessed in advance of:
- Diagnosis of disease
- Stage of disease
- Age
- Other medical problems
- Value labs
- The balance of fluid and electrolyte
- The state of emotion
F. Preparation Equipment
1. Arterial needle
2. Hose normal saline
3. Dialiser
4. Venous drip chamber
5. Detector
6. Port administration of drugs
7. Arterial pressure monitoring
8. Blood Pump
9. Diverter system dialiser
10. Venous pressure monitoring
11. Venous needle
12. Penginfus heparin
G. Actions Procedures
Access to the circulation system is achieved through one of several options: vistula or tandur arteriovenous (AV), or two-lumen hemodialysis catheter.
If vascular access has been established, the blood begins to flow, aided by a blood pump. Part of disposable circuit before dialiser designated as flow "arterial", both for differentiating blood entrance into the blood that has not reached dialiser and in reference to putting the needle: the needle "arterial" placed closest to the fistula or AV anastomosis tandur to maximize the flow Blood. Bags of normal saline fluid diklep always remain connected to the circuit before the blood pump. In the event of hypotension, blood from the patient can be clamped while normal saline fluids are clamped open and allows to quickly menginfus to improve blood pressure. Transfusion of blood and plasma expanders can also be connected to the circuit in this state and allowed to drip, assisted with the blood pump. Heparin infusion can be placed either before or after the blood pump, depending on the equipment used.
Dialiser is the next important component of the circuit. Blood flows into the blood compartment of dialiser, where the exchange of fluid and rest. Blood that leaves dialiser through the air and foam kondektor clamp and stop pumping blood when detected the presence of air. In this condition, any medications that will be administered through the port on dialysis medications. It is important to remember, however, that most drug administration was delayed until dialysis is complete unless it is ordered to be given.
Blood that has passed through dialysis back to the patient through "venosa" or hose Posdialiser. After the scheduled time of the action, ending with a clamp dialysis blood from patients, normal saline fluid nozzle opening, and rinse circuits to restore a patient's blood. Hose and dialiser discarded, although chronic dialysis program often buy equipment to clean and reuse dialiser.
General precautions should be followed carefully during dialysis because of exposure to blood. Face masks and gloves must be used by the executive power is hemodialysis.
H. Interpretation of Results
Results hemodialysis can be assessed by examining the amount of fluid removed and correction of electrolyte and acid-base disturbances.
I. Complication
1) Fluid Imbalance
a. Hypervolemia
These findings indicate the existence of excess fluids such as blood pressure rises, increased pulse and respiratory frequency, increased central venous pressure, dyspnea, cough, edema, excess addition of BB since last dialysis
b. Hypovolemia
Instructions to hypovolemia include decreased blood pressure, increased pulse rate, respiration, poor skin turgor, dry mouth, decreased central venous pressure, and decreased urine output. History lost a lot of fluid through the stomach that causes loss of BB that will lead to a shortage of nursing diagnoses fluid.
c. Ultra filtration
Symptoms are similar to ultrafiltarasi excessive shock to the symptoms of hypotension, nausea, vomiting, sweating, dizziness and fainting.
d. The series of ultrafiltration (Diafiltrasi)
Rapid ultrafiltration for the purpose of eliminating or preventing hypertension, congestive heart failure, pulmonary edema and other complications associated with excess fluid is often limited by the tolerance of the patient to manipulate the intravascular volume.
e. Hypotension
Hypotension during dialysis may be caused by hypovolemia, excessive ultrafiltration, blood loss into the dialiser, incompatibility pendialisa membrane, and antihypertensive drug therapy
f. Hypertension
The most frequent cause of hypertension is excess fluid, disequilibrium syndrome, renin response to ultrafiltration, and ansites.
g. Dialysis disequilibrium syndrome
Oleh group manifested symptoms suggesting disfungsiserebral range from nausea, vomiting, headache, hypertension until agitation, twitching, mental confusion, and seizures.
2) Electrolyte Imbalance
Electrolyte is a major concern in dialysis, which is normally corrected during the procedure are sodium, potassium, bicarbonate, kalisum, phosphorus, and magnesium.
3) Infection
Uremic patients decreased resistance to infection, which is expected due to decreased immunologic response. Pulmonary infection is the leading cause of death among adult uraemic.
4) Bleeding and Heparinisasi
Bleeding during dialysis may be due to an underlying medical konsidi such as ulcers or gastritis or perhaps due to excessive anticoagulation. Heparin is the drug of choice for simple administration, improve the freeze quickly, easily monitored and may be contrary to protamin.
J. Frequently Encountered Problems
1. Equipment problems
a) The concentration of the dialysate
Sudden or rapid changes in the concentration of dialysate mengakibatakan can damage blood cells and cerebral damage. Mild symptoms such as nausea, vomiting, and headache. In severe cases can lead to coma, mental derangement and death.
b) The flow of dialysate
Inadequate flow will not membahayakn patients but will disrupt the efficiency of dialysis.
c) The temperature
Temperature should be maintained at 36.7 to 38.3 C
d) blood flow
Factors affecting blood pressure is, fistula and catheter function and ektrakoporeal circuit.
e) Leakage of blood
f) Air embolism
II. NURSING CARE BASIC CONCEPTS
(Taken from Doenges, Marillyn E. Nursing care plan. Issue 3. Jakarta; EGC, 1999)
Nursing Diagnosis:
INJURY,
HIGH RISK TO, LOSS vascular access
Risk Factors Include: Freezing; bleeding due to the release of the connection by accident
Possible evidenced by: (not applicable; signs and symptoms make the actual diagnosis)
Goals / Results Criteria: Maintain a patent vascular driveway
ACTIONS / INTERVENTIONS
Independent:
Freezing:
1. Keep an eye on potential internal AV stream at frequent intervals: Palpate distal vibrations;
RATIONAL: vibrations caused by turbulent blood flow pressure arterial system into the venous pressure is lower and should be palpated on the discharge side of the vein.
2. Auscultation to murmur;
RATIONAL: murmur is a sound caused by turbulent blood flow into the venous system and should be heard with a stethoscope, although it may be very dim.
3. Note the color of blood and / or cell separation and Serum before.
RATIONAL: color change from red medium to dark purplish red indicates blood flow inert / early freeze. The separation of the hose indicative freezing. Dark red blood then clear yellow fluid showed complete clot formation.
4. Palpation shunt skin for warmth.
RATIONAL: Decreased blood flow would result in "freezing" in the shunt.
5. Tell your doctor and / or perform the removal of clotting when there is evidence of loss of potential shunt.
RATIONAL: rapid intervention to secure the entrance; freezing but removal must be done by experienced personnel.
6. Evaluation of pain, numbness / tingling; noticed swelling of the extremities distal to the entrance.
RATIONAL: Indicates adekuatan lack of blood supply. Reduce the risk of freezing / termination.
7. Avoid trauma to the shunt; examples hose handle slowly, hold the position of cannula. Limit extremity activity. Avoid measuring TD or taking blood from the extremities of the existing shunt. Instruct patients not to sleep or carry loads, books, wallets at ektremitas sick.
RATIONAL: From some of the evidence found in the examination, may immediately action / intervention next response.
Bleeding:
8. Install two clamps on the dressing shunt cannula, provide tourniquets. When a separate cannula, first clamp the artery and then the vein cannula. When the hose off of the vein, the cannula clamp still in place doing the direct pressure on the bleeding. Attach tourniquets above or develop balloon at a pressure above the patient's systolic BP.
RATIONAL: Preventing massive blood loss when a separate cannula or shunt changing positions while waiting for medical help.
Infection:
9. Assess the skin surrounding the vascular access, notice redness, swelling, warm local, exudate, tender.
RATIONAL: Signs of local infection, sepsis can be if they are not addressed.
10. Avoid contamination on the access side. Use aseptic technique and a mask when providing care shunts, changing bandages, and when the process of dialysis.
RATIONAL: Signs of infection / sepsis requiring rapid medical intervention
11. Keep an eye on the temperature. Note the presence of fever, chills, hypotension.
RATIONAL: Determining the pathogen.
Collaboration:
12. Examples of the culture / blood samples as indicated.
RATIONAL: Infuse the arterial side of the filter to prevent freezing of the filter without systemic side effects.
13. Give medication as indicated, for example: Heparin (low dose); Antibiotics (systemic and / or topical)
RATIONAL: Treatment of the infection can quickly secure the entrance, preventing sepsis
Nursing Diagnosis: LACK OF LIQUID VOLUME, HIGH RISK OF
Risk Factors Include: Ultrafiltration, fluid restriction; actual blood loss (heparinisasi systemic or discharging)
Possible evidenced by: (not applicable; signs and symptoms make the actual diagnosis)
Goals / Results Criteria: Maintain fluid balance and body weight evidenced by stable vital signs, good skin turgor, mucous membranes moist, no bleeding
ACTIONS / INTERVENTIONS
Independent:
1. Measure each source of income and expenditure. Do this every day.
RATIONAL: Helps evaluate fluid status, especially when compared to body weight. Note: Urine output is inaccurate evaluation of renal function in dialysis patients. Some people show urine output with minimal kidney toxin clearance, others showed oliguria or anuria.
2. Weigh every day before / after dialysis done.
RATIONAL: Losing weight is a measurement of the precise measurement of ultrafiltration and fluid disposal.
3. Monitor TD, pulse, and hemodynamic stress when available during dialysis.
RATIONAL: hypotension, tachycardia, hemodynamic pressure drop indicates lack of fluids.
4. Ensure continuity of the shunt catheter / access.
RATIONAL: breakdown shunt / open access will allow eksanguinasi.
5. Perform an external bandage shunt. Do not allow injection of the shunt.
RATIONAL: Minimizing stress on revenue cannula to reduce changes in the position of a less careful and bleeding on the side.
6. Place the patient in the supine position / trandelenburg as needed.
RATIONAL: Maximizing venous return in the event of hypotension.
7. Kaji continuous bleeding or major bleeding at the access side, mucous membranes, incision / wound. Hematemesis / guaiak feces, gastric drainage.
RATIONAL: Heparinisasi systemic clotting during dialysis increases the time and place the patient at risk perdaahan, especially during the first 4 hours after the procedure.
Collaboration:
8. Supervise laboratory examination as indicated:
- Hb / Ht;
RATIONAL: Declining due to anemia, hemodilution, or actual blood loss.
- Serum electrolytes and pH;
RATIONAL: Imbalance may require changes in or additional dialysis fluid replacement to achieve balance.
- When freezing, sample ACT. PT / PTT, and platelet counts.
RATIONAL: The use of heparin to prevent clotting in the hemofilter blood flow and potentially alter coagulation and active bleeding.
9. Give IV fluids (eg physiological saline) / volume expanders (eg albumin) during dialysis as indicated:
RATIONAL: Liquid physiological saline / dextrose, electrolytes, and NaHCO3 may be infused in the vein hemofolter CAV when high-speed ultra filtration is used to remove extracellular fluid and toxic liquids. Volume expanders mugkin needed during / after hemodialysis in the event of sudden hypotension / real.
10. Blood / packaging HR when needed.
RATIONAL: HR destruction (hemolysis) by dialysis mechanics, loss of bleeding, lower RBC production can lead to severe anemia / progressive.
11. Decrease speed of ultrafiltration during dialysis as indicated.
RATIONAL: Reduce the amount of water for disposal and can improve hypotension / hypovolemia.
12. Give protamin sulfate when indicated.
RATIONAL: It may be done to restore the clotting time to normal or when the release of heparin (up to 16 hours after hemodialisasi).
Nursing Diagnosis: VOLUME LIQUID, EXCESS, HIGH RISK OF
Risk Factors Include: Revenue liquid fast / redundant; IV, blood, plasma ekspande, physiological saline is given to support the TD during dialysis.
Possible evidenced by: (Not applicable for signs and symptoms make the actual diagnosis).
Goals / Results Criteria: Maintain "dry weight" within normal limits edema patients, "breath sounds clear and sodium levels in the normal range.
ACTIONS / INTERVENTIONS
Independent:
1. Measure all sources of income and expenditure. Weigh routine.
RATIONAL: Helps evaluate fluid status, especially when compared to body weight. Weight gain between treatments should be not more than 0.5 kg / day.
2. Monitor BP, pulse.
RATIONAL: Hypertension and tachycardia among hemodialysis can be caused by excess fluid and / or heart failure.
3. Note the presence of peripheral edema / sacred. Gurgling breathing, dyspnea, orthopnea, neck vein distention, changes in ECG showed ventricular hypertrophy.
RATIONAL: Excess fluid for dialysis or hypervolemia efisennya not repeated among dialysis treatment apat cause / exacerbation of heart failure, as indicated by signs / symptoms of systemic venous congestion and / or breathing.
4. Note the mental changes.
RATIONAL: Excess fluid / hypervolemia, the potential for cerebral edema (disequilibrium syndrome).
Collaboration:
5. Monitor serum sodium levels. Limit your sodium intake as indicated.
RATIONAL: high sodium levels are associated with excess fluid, edema, hypertension, and cardiac complications,
6. Limit fluid intake orally indication, the long-time allows fluid during a 24 hour period.
RATIONAL: Intermittent Hemodialysis resulted in retention / excess fluid between the procedure and may require fluid restriction. Distance fluid helps reduce thirst
A. Definition
Dialysis is the process of diffusion of dissolved particles from one compartment to another compartment through a semipermeable membrane.
Hemodialysis is the path of blood through a tube outside the body to an artificial kidney, which made disposal of excess solutes and fluid. Frequency of hemodialysis varied from 2-3 x / week.
Blood containing waste products such as urea and creatinine flowing into an artificial kidney (dialiser), where it will meet with dialysate containing no urea and creatinine. Recurring flow of blood through the speed range dialiser at 200-400 ml / hour, more than 2-4 hours, is expected to reduce the levels of these waste products into a more normal state.
B. Destination
1. Waste products of protein metabolism such as urea, creatinine and uric acid.
2. Remove excess water by knowing the appeal between blood pressure and the liquid, usually consisting of positive and negative pressure (vacuum) in the dialysate compartment.
3. Maintain or restore the body's buffer system.
4. Maintain or restore the body's electrolyte levels.
C. Indication
1. Acute Renal Failure
2. Chronic renal failure, when gromelurus filtration rate of less than 5 ml / min
3. Serum potassium more than 6 mEq / l
4. Urea over 200 mg / dl
5. Blood pH of less than 7.1
6. Prolonged anuria, more than 5 days
7. Intoxication, drugs and chemicals
8. Hepatorenal Syndrome
D. Forms / Overview Equipment Used
1. Dialiser or Artificial Kidney
Consists of semi-permeable membrane that separates the blood and dialysate compartments.
2. Dialysate or fluid Dialysis
That fluid consisting of water and electrolytes from the main normal serum. Dialysate was created in the system clean with tap water and chemicals filter. Not a sterile system, because the bacteria are too large to pass through the membrane and the potential occurrence of infection in the patient at a minimum. Because bacteria from byproducts can cause pyrogenic reactions, especially in large permeable membrane, the water for the dialysate should be bacteriologically safe. Dialysate concentrates are usually supplied by the manufacturer komersildan commonly used by chronic unit.
3. System of dialysate
That is a tool that measures the proportion of the division and the automatic measurement and monitoring tools to ensure proper control of the ratio of concentrate and water.
4. Accessory Equipment
a. Hardware consists of:
1) blood pumps, infusion pumps for detecting heparin
2) The tool monitors the body temperature in case of insecurity dialysate concentration, changes in air pressure and leak blood.
b. The device is used in addition to disposable artificial kidney:
1) dialysis tube used to drain blood between dialiser and patients.
2) Transfer the pressure to protect the monitors of exposure to blood.
3) saline bags to clean up the system before use.
5. Human Component / Implementing
Hemodialysis executive power must have expertise in the use of high technology, achieved through training and practical teorits in clinical environments.
More important aspect is the understanding and knowledge that will be used nurses in providing care to patients during dialysis took place.
E. Preparation of Pre-Dialysis
The level and complexity of the problems that arise during hemodialysis will vary among patients and depends on several variables. For that before the hemodialysis process, need to be assessed in advance of:
- Diagnosis of disease
- Stage of disease
- Age
- Other medical problems
- Value labs
- The balance of fluid and electrolyte
- The state of emotion
F. Preparation Equipment
1. Arterial needle
2. Hose normal saline
3. Dialiser
4. Venous drip chamber
5. Detector
6. Port administration of drugs
7. Arterial pressure monitoring
8. Blood Pump
9. Diverter system dialiser
10. Venous pressure monitoring
11. Venous needle
12. Penginfus heparin
G. Actions Procedures
Access to the circulation system is achieved through one of several options: vistula or tandur arteriovenous (AV), or two-lumen hemodialysis catheter.
If vascular access has been established, the blood begins to flow, aided by a blood pump. Part of disposable circuit before dialiser designated as flow "arterial", both for differentiating blood entrance into the blood that has not reached dialiser and in reference to putting the needle: the needle "arterial" placed closest to the fistula or AV anastomosis tandur to maximize the flow Blood. Bags of normal saline fluid diklep always remain connected to the circuit before the blood pump. In the event of hypotension, blood from the patient can be clamped while normal saline fluids are clamped open and allows to quickly menginfus to improve blood pressure. Transfusion of blood and plasma expanders can also be connected to the circuit in this state and allowed to drip, assisted with the blood pump. Heparin infusion can be placed either before or after the blood pump, depending on the equipment used.
Dialiser is the next important component of the circuit. Blood flows into the blood compartment of dialiser, where the exchange of fluid and rest. Blood that leaves dialiser through the air and foam kondektor clamp and stop pumping blood when detected the presence of air. In this condition, any medications that will be administered through the port on dialysis medications. It is important to remember, however, that most drug administration was delayed until dialysis is complete unless it is ordered to be given.
Blood that has passed through dialysis back to the patient through "venosa" or hose Posdialiser. After the scheduled time of the action, ending with a clamp dialysis blood from patients, normal saline fluid nozzle opening, and rinse circuits to restore a patient's blood. Hose and dialiser discarded, although chronic dialysis program often buy equipment to clean and reuse dialiser.
General precautions should be followed carefully during dialysis because of exposure to blood. Face masks and gloves must be used by the executive power is hemodialysis.
H. Interpretation of Results
Results hemodialysis can be assessed by examining the amount of fluid removed and correction of electrolyte and acid-base disturbances.
I. Complication
1) Fluid Imbalance
a. Hypervolemia
These findings indicate the existence of excess fluids such as blood pressure rises, increased pulse and respiratory frequency, increased central venous pressure, dyspnea, cough, edema, excess addition of BB since last dialysis
b. Hypovolemia
Instructions to hypovolemia include decreased blood pressure, increased pulse rate, respiration, poor skin turgor, dry mouth, decreased central venous pressure, and decreased urine output. History lost a lot of fluid through the stomach that causes loss of BB that will lead to a shortage of nursing diagnoses fluid.
c. Ultra filtration
Symptoms are similar to ultrafiltarasi excessive shock to the symptoms of hypotension, nausea, vomiting, sweating, dizziness and fainting.
d. The series of ultrafiltration (Diafiltrasi)
Rapid ultrafiltration for the purpose of eliminating or preventing hypertension, congestive heart failure, pulmonary edema and other complications associated with excess fluid is often limited by the tolerance of the patient to manipulate the intravascular volume.
e. Hypotension
Hypotension during dialysis may be caused by hypovolemia, excessive ultrafiltration, blood loss into the dialiser, incompatibility pendialisa membrane, and antihypertensive drug therapy
f. Hypertension
The most frequent cause of hypertension is excess fluid, disequilibrium syndrome, renin response to ultrafiltration, and ansites.
g. Dialysis disequilibrium syndrome
Oleh group manifested symptoms suggesting disfungsiserebral range from nausea, vomiting, headache, hypertension until agitation, twitching, mental confusion, and seizures.
2) Electrolyte Imbalance
Electrolyte is a major concern in dialysis, which is normally corrected during the procedure are sodium, potassium, bicarbonate, kalisum, phosphorus, and magnesium.
3) Infection
Uremic patients decreased resistance to infection, which is expected due to decreased immunologic response. Pulmonary infection is the leading cause of death among adult uraemic.
4) Bleeding and Heparinisasi
Bleeding during dialysis may be due to an underlying medical konsidi such as ulcers or gastritis or perhaps due to excessive anticoagulation. Heparin is the drug of choice for simple administration, improve the freeze quickly, easily monitored and may be contrary to protamin.
J. Frequently Encountered Problems
1. Equipment problems
a) The concentration of the dialysate
Sudden or rapid changes in the concentration of dialysate mengakibatakan can damage blood cells and cerebral damage. Mild symptoms such as nausea, vomiting, and headache. In severe cases can lead to coma, mental derangement and death.
b) The flow of dialysate
Inadequate flow will not membahayakn patients but will disrupt the efficiency of dialysis.
c) The temperature
Temperature should be maintained at 36.7 to 38.3 C
d) blood flow
Factors affecting blood pressure is, fistula and catheter function and ektrakoporeal circuit.
e) Leakage of blood
f) Air embolism
II. NURSING CARE BASIC CONCEPTS
(Taken from Doenges, Marillyn E. Nursing care plan. Issue 3. Jakarta; EGC, 1999)
Nursing Diagnosis:
INJURY,
HIGH RISK TO, LOSS vascular access
Risk Factors Include: Freezing; bleeding due to the release of the connection by accident
Possible evidenced by: (not applicable; signs and symptoms make the actual diagnosis)
Goals / Results Criteria: Maintain a patent vascular driveway
ACTIONS / INTERVENTIONS
Independent:
Freezing:
1. Keep an eye on potential internal AV stream at frequent intervals: Palpate distal vibrations;
RATIONAL: vibrations caused by turbulent blood flow pressure arterial system into the venous pressure is lower and should be palpated on the discharge side of the vein.
2. Auscultation to murmur;
RATIONAL: murmur is a sound caused by turbulent blood flow into the venous system and should be heard with a stethoscope, although it may be very dim.
3. Note the color of blood and / or cell separation and Serum before.
RATIONAL: color change from red medium to dark purplish red indicates blood flow inert / early freeze. The separation of the hose indicative freezing. Dark red blood then clear yellow fluid showed complete clot formation.
4. Palpation shunt skin for warmth.
RATIONAL: Decreased blood flow would result in "freezing" in the shunt.
5. Tell your doctor and / or perform the removal of clotting when there is evidence of loss of potential shunt.
RATIONAL: rapid intervention to secure the entrance; freezing but removal must be done by experienced personnel.
6. Evaluation of pain, numbness / tingling; noticed swelling of the extremities distal to the entrance.
RATIONAL: Indicates adekuatan lack of blood supply. Reduce the risk of freezing / termination.
7. Avoid trauma to the shunt; examples hose handle slowly, hold the position of cannula. Limit extremity activity. Avoid measuring TD or taking blood from the extremities of the existing shunt. Instruct patients not to sleep or carry loads, books, wallets at ektremitas sick.
RATIONAL: From some of the evidence found in the examination, may immediately action / intervention next response.
Bleeding:
8. Install two clamps on the dressing shunt cannula, provide tourniquets. When a separate cannula, first clamp the artery and then the vein cannula. When the hose off of the vein, the cannula clamp still in place doing the direct pressure on the bleeding. Attach tourniquets above or develop balloon at a pressure above the patient's systolic BP.
RATIONAL: Preventing massive blood loss when a separate cannula or shunt changing positions while waiting for medical help.
Infection:
9. Assess the skin surrounding the vascular access, notice redness, swelling, warm local, exudate, tender.
RATIONAL: Signs of local infection, sepsis can be if they are not addressed.
10. Avoid contamination on the access side. Use aseptic technique and a mask when providing care shunts, changing bandages, and when the process of dialysis.
RATIONAL: Signs of infection / sepsis requiring rapid medical intervention
11. Keep an eye on the temperature. Note the presence of fever, chills, hypotension.
RATIONAL: Determining the pathogen.
Collaboration:
12. Examples of the culture / blood samples as indicated.
RATIONAL: Infuse the arterial side of the filter to prevent freezing of the filter without systemic side effects.
13. Give medication as indicated, for example: Heparin (low dose); Antibiotics (systemic and / or topical)
RATIONAL: Treatment of the infection can quickly secure the entrance, preventing sepsis
Nursing Diagnosis: LACK OF LIQUID VOLUME, HIGH RISK OF
Risk Factors Include: Ultrafiltration, fluid restriction; actual blood loss (heparinisasi systemic or discharging)
Possible evidenced by: (not applicable; signs and symptoms make the actual diagnosis)
Goals / Results Criteria: Maintain fluid balance and body weight evidenced by stable vital signs, good skin turgor, mucous membranes moist, no bleeding
ACTIONS / INTERVENTIONS
Independent:
1. Measure each source of income and expenditure. Do this every day.
RATIONAL: Helps evaluate fluid status, especially when compared to body weight. Note: Urine output is inaccurate evaluation of renal function in dialysis patients. Some people show urine output with minimal kidney toxin clearance, others showed oliguria or anuria.
2. Weigh every day before / after dialysis done.
RATIONAL: Losing weight is a measurement of the precise measurement of ultrafiltration and fluid disposal.
3. Monitor TD, pulse, and hemodynamic stress when available during dialysis.
RATIONAL: hypotension, tachycardia, hemodynamic pressure drop indicates lack of fluids.
4. Ensure continuity of the shunt catheter / access.
RATIONAL: breakdown shunt / open access will allow eksanguinasi.
5. Perform an external bandage shunt. Do not allow injection of the shunt.
RATIONAL: Minimizing stress on revenue cannula to reduce changes in the position of a less careful and bleeding on the side.
6. Place the patient in the supine position / trandelenburg as needed.
RATIONAL: Maximizing venous return in the event of hypotension.
7. Kaji continuous bleeding or major bleeding at the access side, mucous membranes, incision / wound. Hematemesis / guaiak feces, gastric drainage.
RATIONAL: Heparinisasi systemic clotting during dialysis increases the time and place the patient at risk perdaahan, especially during the first 4 hours after the procedure.
Collaboration:
8. Supervise laboratory examination as indicated:
- Hb / Ht;
RATIONAL: Declining due to anemia, hemodilution, or actual blood loss.
- Serum electrolytes and pH;
RATIONAL: Imbalance may require changes in or additional dialysis fluid replacement to achieve balance.
- When freezing, sample ACT. PT / PTT, and platelet counts.
RATIONAL: The use of heparin to prevent clotting in the hemofilter blood flow and potentially alter coagulation and active bleeding.
9. Give IV fluids (eg physiological saline) / volume expanders (eg albumin) during dialysis as indicated:
RATIONAL: Liquid physiological saline / dextrose, electrolytes, and NaHCO3 may be infused in the vein hemofolter CAV when high-speed ultra filtration is used to remove extracellular fluid and toxic liquids. Volume expanders mugkin needed during / after hemodialysis in the event of sudden hypotension / real.
10. Blood / packaging HR when needed.
RATIONAL: HR destruction (hemolysis) by dialysis mechanics, loss of bleeding, lower RBC production can lead to severe anemia / progressive.
11. Decrease speed of ultrafiltration during dialysis as indicated.
RATIONAL: Reduce the amount of water for disposal and can improve hypotension / hypovolemia.
12. Give protamin sulfate when indicated.
RATIONAL: It may be done to restore the clotting time to normal or when the release of heparin (up to 16 hours after hemodialisasi).
Nursing Diagnosis: VOLUME LIQUID, EXCESS, HIGH RISK OF
Risk Factors Include: Revenue liquid fast / redundant; IV, blood, plasma ekspande, physiological saline is given to support the TD during dialysis.
Possible evidenced by: (Not applicable for signs and symptoms make the actual diagnosis).
Goals / Results Criteria: Maintain "dry weight" within normal limits edema patients, "breath sounds clear and sodium levels in the normal range.
ACTIONS / INTERVENTIONS
Independent:
1. Measure all sources of income and expenditure. Weigh routine.
RATIONAL: Helps evaluate fluid status, especially when compared to body weight. Weight gain between treatments should be not more than 0.5 kg / day.
2. Monitor BP, pulse.
RATIONAL: Hypertension and tachycardia among hemodialysis can be caused by excess fluid and / or heart failure.
3. Note the presence of peripheral edema / sacred. Gurgling breathing, dyspnea, orthopnea, neck vein distention, changes in ECG showed ventricular hypertrophy.
RATIONAL: Excess fluid for dialysis or hypervolemia efisennya not repeated among dialysis treatment apat cause / exacerbation of heart failure, as indicated by signs / symptoms of systemic venous congestion and / or breathing.
4. Note the mental changes.
RATIONAL: Excess fluid / hypervolemia, the potential for cerebral edema (disequilibrium syndrome).
Collaboration:
5. Monitor serum sodium levels. Limit your sodium intake as indicated.
RATIONAL: high sodium levels are associated with excess fluid, edema, hypertension, and cardiac complications,
6. Limit fluid intake orally indication, the long-time allows fluid during a 24 hour period.
RATIONAL: Intermittent Hemodialysis resulted in retention / excess fluid between the procedure and may require fluid restriction. Distance fluid helps reduce thirst
