Lakhasly

ALTOOSI UNIVERSITY / College of Nursing Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect.Keep accurate intake and output records related to the amount of dialysis fluid entering the peritoneal cavity and the amount in the drainage.Provide adequate hydration to patients at risk of dehydration: a. Surgical patients before, during, and after surgery b. Patients undergoing intensive diagnostic studies requiring fluid restriction and contrast agents (eg, barium enema, intravenous pyelograms), especially elderly patients who may have marginal renal reserve ALTOOSI UNIVERSITY / College of Nursing Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect.Nephrotoxic agents such as: a. Aminoglycoside antibiotics (gentamicin, tobramycin) b. Radiopaque contrast agents c. Heavy metals (lead, mercury) d. Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic) e. Nonsteroidal anti-inflammatory drugs (NSAIDs) f. Angiotensin-converting enzyme inhibitors (ACE inhibitors) 3.Prolonged renal ischemia resulting from: a. Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures) b. Myoglobinuria (trauma, crush injuries, burns) c. Hemoglobinuria (transfusion reaction, hemolytic anemia) 2.Nursing Diagnoses & Interventions for Clients with ESRD ND: Fluid volume excess & electrolyte imbalance related to decrease urine output & dietary & fluid restriction.Volume depletion resulting from: a. Hemorrhage b. Renal losses (diuretics, osmotic diuresis) c. Gastrointestinal losses (vomiting, diarrhea, nasogastric suction) 2.Acute Renal Failure Acute renal failure (ARF) is a reversible clinical syndrome where there is a sudden and almost complete loss of kidney function (decreased GFR) over a period of hours to days with failure to excrete nitrogenous waste products and to maintain fluid and electrolyte.Urinary tract obstruction, including: a. Calculi (stones) b. Tumors ALTOOSI UNIVERSITY / College of Nursing Critical Care Nursing (Practical) 4 Stage (2024- 2025) c. Benign prostatic hyperplasia d. Strictures e. Blood clots lect.Bone disease and metastatic and vascular calcifications due to retention of phosphorus, low serum calcium levels, abnormal vitamin D metabolism, and elevated aluminum levels.encourage high calorie, low protein, low potassium & low sodium snacks between mealsto reduce sources of restricted food & provides calories for energy while low protein for growth & tissue healing.It is involves the introduction of sterile dialyzing fluid through an implanted catheter into the abdominal cavity, the dialysate bathes the peritoneal membrane.Renal cells that cannot concentrate urine Increased GFR in this phase contributes to the passive loss of electrolytes which requires the administration of IV crystalloids to maintain hydration.During this phase, edema decreases, the renal tubules begin to function adequately and fluid and electrolyte balance are restored (if damage was significant, BUN and Creatinine may never return to normal levels).Anemia due to decreased erythropoietin production, decreased RBC life span, bleeding in the GI tract from irritating toxins and ulcer formation, and blood loss during hemodialysis.within dialysis machine, blood and dialysate compartment are separated by semi permeable membrane .blood is removed from the arterial end of the vascular access device, pumped through the machine at a rate of 100 to200 ml/min, and returned to the body through the venous access.Impaired cardiac efficiency resulting from: a. Myocardial infarction b. Heart failure c. Dysrhythmias d. Cardiogenic shock ALTOOSI UNIVERSITY / College of Nursing Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect.Neuromuscular/Behavioral signs: a. Headache b. Insomnia c. Confusion/ disorientation d.Asterixis e. Muscle weakness and cramping f. Peripheral Neuropathy h. Body image/ Self-Concept disturbances 6.Ali Hasan Alghazali ND: Altered nutrition less than body requirement RT dietary restriction Goal:maintain adequate nutritional status.Assess factors contributing to fatigue (anemia, fluid &electrolyte imbalance, depression) to provide indication of severity of fatigue.It is more likely to occur in acute renal failure or when blood urea nitrogen levels are very high( exceeding 150 mg/L).Manifestation includes: Head ache.Ali Hasan Alghazali Diuretic Phase : this phase occurs when the source of obstruction has been removed but the residual scarring and edema of the renal tubules remains.Monitor central venous and arterial pressures and hourly urine output of critically ill patients to detect the onset of renal failure as early as possible.Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism, and excessive intake (diet, medications, fluids).Types of dialysis Hemodialysis (HD) HDis the most commonly used method of dialysis and a highly efficient for removing waters and waste products from the body.During peritoneal dialysis, blood vessels in the abdominal lining (peritoneum) fill in for the kidneys, with the help of a fluid (dialysate) that flows into and out of the peritoneal space.By the processes of osmosis, diffusion, and active transport, excess fluid & solutes travel through peritoneal membrane and into the dialyzing fluid.The cycler automatically fills the abdomen with dialysis solution, allows it to dwell there and then drains it to a sterile drainage bag that empty in the morning.Contraindication of PD Peritoneal dialysis is not recommended if the patents have: extensive surgical scars in the abdomen.During this dwell time, waste, chemicals and extra fluid in the blood pass from tiny blood vessels (capillaries) in the lining of the abdominal cavity (peritoneum) into the dialysis solution.Ali Hasan Alghazali c. Patients with neoplastic disorders or disorders of metabolism (eg, gout) and those receiving chemotherapy 2.To prevent toxic drug effects, closely monitor dosage, duration of use, and blood levels of all medications metabolized or excreted by the kidneys.Gastrointestinal Signs: a. Anorexia b. Nausea/Vomiting c. Diarrhea or Constipation d. Mucosal Ulcerations- GI Bleeding 4.Pericarditis, pericardial effusion, and pericardial tamponade due to retention of uremic waste products and inadequate dialysis.Instruct patient to avoid people with infections Knowledge deficit related to lack of information about diet, meds, dialysis, self-monitoring 1.Teach patient/family about dietary restrictions and rationale for these.Procedure of PD In peritoneal dialysis, a sterile cleansing solution (dialysate) flows through the catheter into the abdomen.Ali Hasan Alghazali Clinical Manifestations of ARF The following signs and symptoms are consistent with acute renal failure: 1.Take precautions to ensure that the appropriate blood is administered to the correct patient in order to avoid severe transfusion reactions, which can precipitate renal failure.Approximately 90-95% of nephrons are affected by CRF, damage is permanent and irreversible, and the disease is fatal without renal replacement therapy such as dialysis or transplant.Endocrine/ metabolic Signs a. Calcium/Phosphorus Imbalance- Renal osteodystrophy b. Metabolic Acidosis 7.Hemodialysis HD is a process of cleansing the blood of accumulated wasteproducts and restore fluid and electrolyte balance.Ali Hasan Alghazali PD works by using peritoneal membrane, which is inside the abdomen as a semi permeable membrane.Oliguric/Anuric Phase : this phase usually lasts between 8-14 days and is characterized by further damage to the renal tubular wall and membranes.Vasodilation resulting from: a. Sepsis b. Anaphylaxis c. Antihypertensive medications or other medications that cause vasodilation B: Intrarenal Failure 1.To prevent infections from ascending in the urinary tract, give meticulous care to patients with indwelling catheters.b. Pericarditis/ Pericardial Effusion c. Hypertension d. Congestive Heart Failure e. Hyperkalemia and edema 2.Hypertension due to sodium and water retention and malfunction of the renin-angiotensin-aldosterone system.Painful muscle cramping occurs late in dialysis as fluid and electrolytes rapidly leave the extracellular space.Dysrhythmias may result from electrolyte and PH changes or from removal of antiarrhythmic medications during dialysis.Peritoneal Dialysis (PD) Definition Peritoneal dialysis is a way to remove waste products from the blood when the kidneys can no longer do the function adequately.Continuous Ambulatory P.D. (CAPD) : Between 1.5 and 3 liters of fluid is run in four times a day, exchanging for the fluid from the previous exchange.Continuous Cycle P.D. (CCPD) : a machine called an automated cycler performs three to five exchanges at night while you sleep.An infection can develop at the site where the tube (catheter) is inserted to carry the cleansing fluid into and out of your abdomen.Infectious processes such as: a. Acute pyelonephritis b. Acute glomerulonephritis C: Postrenal failure 1.Continually assess renal function (urine output, laboratory values) when appropriate.Ali Hasan Alghazali Chronic Renal Failure Chronic renal failure is a progressive, irreversible kidney injury.Stage 3 (Moderate CRF)- GFR 30-59 ml/min- moderate decrease in GFR.buildup of waste- Not enough healthy nephrons to prevent it. There is an increase in BUN, creatinine, uric acid and phosphorous.Psychosocial Signs a. Denial b. Depression/ Grief c. Dependency ALTOOSI UNIVERSITY / College of Nursing Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect.Reproductive a. Amenorrhea b. Testicular atrophy c. Infertility Complications 1.Nursing intervention with Rational o Assess serum electrolyte level to provide base line data.Assist patient to cope with discomforts resulting from restriction to increase patient comfort with dietary restriction.Ali Hasan Alghazali Sensory and perceptual alterations related to uremia 1.The processes involved in hemodialysis are diffusion, osmosis, and ultra- filtration.Diffusion: is the movement of toxins and wastes from an area of greater concentration in the blood to an area to lower concentration in the dialysis.Osmosis: is the removal of excess water from an area of higher solute concentration (blood) to lower solute concentration ( the dialysis bath).Nausea and vomiting, diaphoresis, tachycardia, and dizziness are common signs of hypotension.Exsanguination may occur if blood lines separate or dialysis needles accidently dislodge.Peritoneal dialysis differs from hemodialysis as: a. a more commonly used blood-filtering procedure.Each exchange includes filling the abdomen with dialysate fluid, letting the fluid dwell in the abdomen, then draining the fluid.The solution contains a sugar that draws wastes and extra fluid through the capillaries in the peritoneum.When the dwell time is over, the solution, along with waste products drawn from the blood and any excess fluid, drains into a sterile collection bag.Ali Hasan Alghazali Peritoneal dialysis complications Peritonitis.The client should be urinate before insert the catheter into the peritoneum, to prevent the bladder puncture.3.4.5.6.7.8.9.10.3.4.5.6.7.2.3.4.5.1.2.3.4.5.1.2.3.4.5.2.5.6.2.3.2.3.4.2.1.2.3.2.3.4.5.2.3.4.5.6.2.2.2.3.4.5.

ALTOOSI UNIVERSITY / College of Nursing
Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali
Renal disorders
Acute and End stage of renal failure.
Acute Renal Failure
Acute renal failure (ARF) is a reversible clinical syndrome where there is a
sudden and almost complete loss of kidney function (decreased GFR) over a
period of hours to days with failure to excrete nitrogenous waste products
and to maintain fluid and electrolyte.
Phases of Acute Renal Failure
Onset Phase: this period represents the time from the onset of injury
through the cell death period. This phase can last from hours to days and is
characterized by:

1. Renal flow at 25% of normal


2. Oxygenation to the tissue at 25% of normal


3. Urine output at 30 ml (or less) per hour


4. Urine sodium excretion greater than 40 mEq/L.
   In this phase only 50% of the patients are noted to be oliguric. With
   prompt treatment, irreversible damage can be achieved during this pre renal
   failure onset phase.
   Oliguric/Anuric Phase : this phase usually lasts between 8-14 days and is
   characterized by further damage to the renal tubular wall and membranes.
   Other characteristics in the oliguric-anuric phase include:


5. Great reduction in the glomerular filtration rate (GFR)


6. Increased BUN/Creatinine


7. Electrolyte abnormalities (hyperkalemia, hyperphosphatemia and
   hypocalcemia)


8. Metabolic acidosis
   ALTOOSI UNIVERSITY / College of Nursing
   Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali
   Diuretic Phase : this phase occurs when the source of obstruction has been
   removed but the residual scarring and edema of the renal tubules remains.
   This phase usually lasts and additional 7-14 days and is characterized by:


9. Increase in glomerular filtration rate (GFR)


10. Urine output as high as 2-4 L/day


11. Urine that flows through renal tubules


12. Renal cells that cannot concentrate urine
    Increased GFR in this phase contributes to the passive loss of electrolytes
    which requires the administration of IV crystalloids to maintain hydration.
    Recovery Period Phase : The recovery phase can last from several months
    to over a year. During this phase, edema decreases, the renal tubules begin to
    function adequately and fluid and electrolyte balance are restored (if damage
    was significant, BUN and Creatinine may never return to normal levels). At
    this point the GFR has usually returned to 70% to 80% of normal.
    Causes of Acute Renal Failure
    A: Prerenal Failure


13. Volume depletion resulting from:
    a. Hemorrhage
    b. Renal losses (diuretics, osmotic diuresis)
    c. Gastrointestinal losses (vomiting, diarrhea, nasogastric suction)


14. Impaired cardiac efficiency resulting from:
    a. Myocardial infarction
    b. Heart failure
    c. Dysrhythmias
    d. Cardiogenic shock
    ALTOOSI UNIVERSITY / College of Nursing
    Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali


15. Vasodilation resulting from:
    a. Sepsis
    b. Anaphylaxis
    c. Antihypertensive medications or other medications that cause vasodilation
    B: Intrarenal Failure


16. Prolonged renal ischemia resulting from:
    a. Pigment nephropathy (associated with the breakdown of blood cells
    containing pigments that in turn occlude kidney structures)
    b. Myoglobinuria (trauma, crush injuries, burns)
    c. Hemoglobinuria (transfusion reaction, hemolytic anemia)


17. Nephrotoxic agents such as:
    a. Aminoglycoside antibiotics (gentamicin, tobramycin)
    b. Radiopaque contrast agents
    c. Heavy metals (lead, mercury)
    d. Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic)
    e. Nonsteroidal anti-inflammatory drugs (NSAIDs)
    f. Angiotensin-converting enzyme inhibitors (ACE inhibitors)


18. Infectious processes such as:
    a. Acute pyelonephritis
    b. Acute glomerulonephritis
    C: Postrenal failure


19. Urinary tract obstruction, including:
    a. Calculi (stones)
    b. Tumors
    ALTOOSI UNIVERSITY / College of Nursing
    Critical Care Nursing (Practical) 4 Stage (2024- 2025) c. Benign prostatic hyperplasia
    d. Strictures
    e. Blood clots
    lect. 1 Assistant Lect. Ali Hasan Alghazali
    Clinical Manifestations of ARF
    The following signs and symptoms are consistent with acute renal failure:


20. Decreased urine output (urine may be pink or reddish in color)


21. Edema (face, arms, legs, feet eyes)


22. Flank pain/Pelvic pain


23. Poor appetite (nausea, vomiting)


24. Bitter or metallic taste in mouth


25. Dry itchy skin


26. Easy bruising


27. Fatigue


28. Seizures/LOC


29. Shortness of breath


30. Arrhythmias


31. Sudden weight gain
    Preventing Acute Renal Failure


32. Provide adequate hydration to patients at risk of dehydration:
    a. Surgical patients before, during, and after surgery
    b. Patients undergoing intensive diagnostic studies requiring fluid restriction
    and contrast agents (eg, barium enema, intravenous pyelograms), especially
    elderly patients who may have marginal renal reserve
    ALTOOSI UNIVERSITY / College of Nursing
    Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali
    c. Patients with neoplastic disorders or disorders of metabolism (eg, gout)
    and those receiving chemotherapy


33. Prevent and treat shock promptly with blood and fluid replacement.


34. Monitor central venous and arterial pressures and hourly urine output of
    critically ill patients to detect the onset of renal failure as early as possible.


35. Treat hypotension promptly.


36. Continually assess renal function (urine output, laboratory values) when
    appropriate.


37. Take precautions to ensure that the appropriate blood is administered to
    the correct patient in order to avoid severe transfusion reactions, which can
    precipitate renal failure.


38. Prevent and treat infections promptly. Infections can produce progressive
    renal damage.


39. Pay special attention to wounds, burns, and other precursors of sepsis.


40. To prevent infections from ascending in the urinary tract, give meticulous
    care to patients with indwelling catheters. Remove catheters as soon as
    possible.


41. To prevent toxic drug effects, closely monitor dosage, duration of use,
    and blood levels of all medications metabolized or excreted by the kidneys.
    ALTOOSI UNIVERSITY / College of Nursing
    Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali
    Chronic Renal Failure
    Chronic renal failure is a progressive, irreversible kidney injury. Kidney
    function does not recover. When kidney function is too poor to sustain life, it
    is called end-stage-renal disease (ESRD).
    CRF has a gradual onset of months to years as opposed to ARF.
    Approximately 90-95% of nephrons are affected by CRF, damage is
    permanent and irreversible, and the disease is fatal without renal
    replacement therapy such as dialysis or transplant.
    Azotemia and uremia are terms used with chronic renal failure.
    Azotemia is collection of nitrogenous waste in the blood.
    Uremia is azotemia with clinical symptoms
    Stages in CRF


42. Stage 1- GFR > 90 ml/min-normal renal function


43. Stage 2 (Renal Insufficiency).
    GFR 60-89 ml/min- mild decrease in GFR.
    No buildup of waste but nephrons are still working overtime, may have an
    increase in BP which causes an increase in glomerular pressure on healthy
    nephrons.
    There is no S&S of renal failure in this phase.


44. Stage 3 (Moderate CRF)- GFR 30-59 ml/min-
    moderate decrease in GFR.
    buildup of waste- Not enough healthy nephrons to prevent it.
    There is an increase in BUN, creatinine, uric acid and phosphorous.
    An increase managing fluid volume and an increase in BP and edema.
    There are fluid and electrolytes changes.
    ALTOOSI UNIVERSITY / College of Nursing
    Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali
    If the pt. can manage their BP and diet, they can slow down the
    progression.


45. Stage 4 (Severe CRF).
    GFR 15-29 ml/min-there is a severe decrease in GFR.


46. Stage 5 (End-stage renal disease).
    GFR is less than 15 ml/min.
    S&S and kidney failure are seen.
    ESRF will result from severe fluid and electrolytes imbalances.
    Causes of Chronic Renal Failure


47. hypertension


48. Diabetes


49. Long history of analgesic abuse- Phenacetin


50. Chronic urinary tract infections


51. Glomerulonephritis.


52. long history of renal stones.


53. Polycystic kidney disease


54. Systemic Lupus erythematous (SLE ).
    Clinical Manifestations of Renal Failure:


55. Cardiovascular Signs:
    a. Anemia.
    b. Pericarditis/ Pericardial Effusion
    c. Hypertension
    d. Congestive Heart Failure
    e. Hyperkalemia and edema


56. Pulmonary Signs:
    a. Pulmonary Edema
    ALTOOSI UNIVERSITY / College of Nursing
    Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali
    b. Dyspnea
    c. Pleural Effusion


57. Gastrointestinal Signs:
    a. Anorexia
    b. Nausea/Vomiting
    c. Diarrhea or Constipation
    d. Mucosal Ulcerations- GI Bleeding


58. Integumentary Signs:
    a. Pruritus
    b. Bruising


59. Neuromuscular/Behavioral signs:
    a. Headache
    b. Insomnia
    c. Confusion/ disorientation
    d.Asterixis
    e. Muscle weakness and cramping
    f. Peripheral Neuropathy
    h. Body image/ Self-Concept disturbances


60. Endocrine/ metabolic Signs
    a. Calcium/Phosphorus Imbalance- Renal osteodystrophy
    b. Metabolic Acidosis


61. Psychosocial Signs
    a. Denial
    b. Depression/ Grief
    c. Dependency
    ALTOOSI UNIVERSITY / College of Nursing
    Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali


62. Reproductive
    a. Amenorrhea
    b. Testicular atrophy
    c. Infertility
    Complications


63. Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism,
    and excessive intake (diet, medications, fluids).


64. Pericarditis, pericardial effusion, and pericardial tamponade due to
    retention of uremic waste products and inadequate dialysis.


65. Hypertension due to sodium and water retention and malfunction of the
    renin–angiotensin–aldosterone system.


66. Anemia due to decreased erythropoietin production, decreased RBC life
    span, bleeding in the GI tract from irritating toxins and ulcer formation, and
    blood loss during hemodialysis.


67. Bone disease and metastatic and vascular calcifications due to retention of
    phosphorus, low serum calcium levels, abnormal vitamin D metabolism, and
    elevated aluminum levels.
    Nursing Diagnoses & Interventions for Clients with ESRD
    ND: Fluid volume excess & electrolyte imbalance related to decrease urine
    output & dietary & fluid restriction.
    Goal: maintain of fluid & electrolyte balance.
    Nursing intervention with Rational
    • Assess serum electrolyte level to provide base line data.
    • Daily weight the patient before & after doing dialysis to determine if the
    weight achieve & decreased to normal, which was recorded by the doctor.
    • Assess skin turgorto determine if there is presence of edema.
    • Assess V/S (BP, pulse, respiratory rat & rhythm ) to monitoring changes.
    • Provide foods & fluid with dietary restriction to promote dietary changes.
    ALTOOSI UNIVERSITY / College of Nursing
    Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali
    ND: Altered nutrition less than body requirement RT dietary restriction
    Goal:maintain adequate nutritional status.


68. Assess nutritional status by daily weight the patient & laboratory values to
    determine base line data for monitoring changes.


69. Provide patient’s food preference within dietary restriction to increase
    dietary intake.


70. encourage high calorie, low protein, low potassium & low sodium snacks
    between mealsto reduce sources of restricted food & provides calories for
    energy while low protein for growth & tissue healing.


71. Explain to patient & family rational for restrictions of certain foods &
    fluid.


72. Assist patient to cope with discomforts resulting from restriction to
    increase patient comfort with dietary restriction.
    ND: Activity intolerance related to fatigue & dialysis procedure.
    Goal:
    Participation in activity within tolerance.


73. Assess factors contributing to fatigue (anemia, fluid &electrolyte
    imbalance, depression) to provide indication of severity of fatigue.


74. Promote independence in self-care activities to promote & improve self-
    esteem.


75. Encourage the patient to alternate activity within rest to promote activity
    & exercise within limits & adequate rest.


76. Encourage the patient to rest after dialysis treatment because the dialysis
    treatment will exhaust the patient.


77. Place the patient in high fowler positionto facilitate diaphragmatic
    expansion.
    ALTOOSI UNIVERSITY / College of Nursing
    Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali
    Sensory and perceptual alterations related to uremia


78. assess mental status. Watch for confusion, irritability, behavioral changes,
    decreased attention.


79. Educate patient/family on relationship of uremia to mental status changes


80. Provide calm, non-stimulating environment


81. Provide short teaching sessions.


82. Safety measures as appropriate.


83. Reorient patient as necessary. Provide supportive environment.
    Risk for infection related to uremic effects on immune system


84. Maintain aseptic technique for procedures.


85. Assess for signs of infection (fever, chills, redness, edema, or drainage of
    site).


86. Instruct patient to avoid people with infections
    Knowledge deficit related to lack of information about diet, meds,
    dialysis, self-monitoring
    1.Teach patient/family about dietary restrictions and rationale for these. 2.
    Dietary consult helpful.


87. Instruct patient/family about meds and administration times.


88. Provide information about dialysis treatment options, procedures, etc


89. Assess patient/family’s understanding of above and reinforce as
    necessary.
    Evaluation


90. The patient is able to maintain dietary & fluid intake with restriction.


91. The patient explained in his own word the rational for dietary restriction
    & his appetite is increased at meal time.
    ALTOOSI UNIVERSITY / College of Nursing
    Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali


92. Patient reports an increase in sense of well-being & he is more able to
    participate in activity & exercise.
    Hemodialysis
    HD is a process of cleansing the blood of accumulated wasteproducts and
    restore fluid and electrolyte balance. It is used for patients with end stage of
    renal failure( ESRF), or for acutely ill patients who require short-term ( day
    to week) dialysis.
    The processes involved in hemodialysis are diffusion, osmosis, and ultra-
    filtration.


93. Diffusion: is the movement of toxins and wastes from an area of greater
    concentration in the blood to an area to lower concentration in the dialysis.


94. Osmosis: is the removal of excess water from an area of higher solute
    concentration (blood) to lower solute concentration ( the dialysis bath).


95. Ultra –filtration: is the removing of water under high pressure to an area
    of lower pressure.
    Types of dialysis
    Hemodialysis (HD)
    HDis the most commonly used method of dialysis and a highly efficient
    for removing waters and waste products from the body.
    It used for patients who are acutely ill and require short- term dialysis
    (days to week) and for patients with End Stage renal disease (ESRD) who
    require long- term or permanent therapy.
    HD patients require treatment three times a week for an average three to
    four hours per dialysis.
    within dialysis machine, blood and dialysate compartment are separated
    by semi permeable membrane .blood is removed from the arterial end of the
    vascular access device, pumped through the machine at a rate of 100 to200
    ml/min, and returned to the body through the venous access.
    ALTOOSI UNIVERSITY / College of Nursing
    Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali
    Heparin may be added to the blood at the arterial end to prevent blood
    clotting while in the machine.
    Vascular Access for Hemodialysis
    A vascular access should be prepared weeks or months before starting
    dialysis.
    Type of vascular access


96. Arteriovenous fistula.


97. Arteriovenous graft.


98. Eternal arteriovenous shunt.


99. Femoral vein catheterization.


100. Sub clavian vein catheterization.
     Complications of HD
     A: short-term complications


101. Hypotension may occur during treatment as fluid removed. Nausea and
     vomiting, diaphoresis, tachycardia, and dizziness are common signs of
     hypotension.


102. Painful muscle cramping occurs late in dialysis as fluid and electrolytes
     rapidly leave the extracellular space.


103. Exsanguination may occur if blood lines separate or dialysis needles
     accidently dislodge.


104. Dysrhythmias may result from electrolyte and PH changes or from
     removal of antiarrhythmic medications during dialysis.


105. Air embolism is rare but can occur if air enters the patient's vascular
     system.


106. Chest pain may occurs because of anemia or in patients with ischemic
     heart diseases.
     ALTOOSI UNIVERSITY / College of Nursing
     Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali


107. Dialysis disequilibrium result from cerebral fluid shifts. It is more likely
     to occur in acute renal failure or when blood urea nitrogen levels are very
     high( exceeding 150 mg/L).Manifestation includes:
     Head ache.
     N &V.
     Restlessness.
     Decrease level consciousness., or seizure.
     Long –term complications of HD


108. Anemia: is one of the majorclinical problemof CRF patient
     Causes:
     Less production of erythropoietin .
     Loss of renal parenchyma.
     Toxic effect uremia on CBC membrane.
     Secondary causes include infection, malnutrition, iron deficiency and folic
     acid).


109. Bone disease.
     Peritoneal Dialysis (PD)
     Definition
     Peritoneal dialysis is a way to remove waste products from the blood
     when the kidneys can no longer do the function adequately.
     During peritoneal dialysis, blood vessels in the abdominal lining
     (peritoneum) fill in for the kidneys, with the help of a fluid (dialysate) that
     flows into and out of the peritoneal space.
     It is involves the introduction of sterile dialyzing fluid through an
     implanted catheter into the abdominal cavity, the dialysate bathes the
     peritoneal membrane.
     ALTOOSI UNIVERSITY / College of Nursing
     Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali
     PD works by using peritoneal membrane, which is inside the abdomen as
     a semi permeable membrane. By the processes of osmosis, diffusion, and
     active transport, excess fluid & solutes travel through peritoneal membrane
     and into the dialyzing fluid.
     After a selected period about(20- 30) minute, then the fluid is drained out
     of the abdomen by gravity.
     Peritoneal dialysis differs from hemodialysis as:
     a. a more commonly used blood-filtering procedure.
     b. use fewer medications and,
     c. eat a less restrictive diet than you can with hemodialysis.
     Types of Peritoneal Dialysis (PD)


110. Continuous Ambulatory P.D. (CAPD) :
     Between 1.5 and 3 liters of fluid is run in four times a day, exchanging for
     the fluid from the previous exchange. This takes about 30-40 minutes.
     Gravity moves the fluid through the tube and into and out of the belly.
     Each exchange includes filling the abdomen with dialysate fluid, letting
     the fluid dwell in the abdomen, then draining the fluid.
     Patient may need three to four exchanges during the day and one with a
     longer dwell time while sleeping .
     Patient is free to go about the normal activities while the dialysis solution
     dwells in the abdomen between exchanges.


111. Continuous Cycle P.D. (CCPD) :
     a machine called an automated cycler performs three to five exchanges at
     night while you sleep.
     The cycler automatically fills the abdomen with dialysis solution, allows
     it to dwell there and then drains it to a sterile drainage bag that empty in the
     morning.
     The machine will exchange 8-12 liters over 8-10 hours and then leave 1-2
     liters to dwell during the day.
     ALTOOSI UNIVERSITY / College of Nursing
     Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali
     This gives thepatient more flexibility during the day, but he must remain
     attached to the machine for 10 to 12 hours at night.
     In the morning, patient begins one exchange with a dwell time that lasts
     the entire day.
     Contraindication of PD
     Peritoneal dialysis is not recommended if the patents have:
     extensive surgical scars in the abdomen.
     a large abdominal hernia.
     inflammatory bowel disease or frequent bouts of diverticulitis.
     Procedure of PD
     In peritoneal dialysis, a sterile cleansing solution (dialysate) flows through
     the catheter into the abdomen.
     The solution stays in the abdomen for a prescribed period of time, known
     as dwell time.
     During this dwell time, waste, chemicals and extra fluid in the blood pass
     from tiny blood vessels (capillaries) in the lining of the abdominal cavity
     (peritoneum) into the dialysis solution.
     The solution contains a sugar that draws wastes and extra fluid through
     the capillaries in the peritoneum.
     the belly may feel fuller than usual while the dialysis solution is there, but
     it's generally not uncomfortable.
     When the dwell time is over, the solution, along with waste products
     drawn from the blood and any excess fluid, drains into a sterile collection
     bag.
     The process of filling and then draining the abdomen is called an
     exchange.
     ALTOOSI UNIVERSITY / College of Nursing
     Critical Care Nursing (Practical) 4 Stage (2024- 2025) lect. 1 Assistant Lect. Ali Hasan Alghazali
     Peritoneal dialysis complications
     Peritonitis. An infection can develop at the site where the tube (catheter)
     is inserted to carry the cleansing fluid into and out of your abdomen.
     Weight gain. The fluid used to clean the blood in peritoneal dialysis
     contains sugar (dextrose). Patient may take in several hundred calories each
     day by absorbing some of this fluid, known as dialysate. Weight gain may
     follow. The extra calories can also lead to high blood sugar especially in
     diabetic patients.
     Weakening of the abdominal muscles (hernia). Holding fluid in the
     abdomen for long periods may strain the belly muscles.
     Fluid obstruction.
     Dehydration, and shoulder pain.
     Nursing managements for peritoneal dialysis patients


112. The client should be urinate before insert the catheter into the peritoneum,
     to prevent the bladder puncture.


113. Place the bottles of dialysate in warm water.


114. Keep accurate intake and output records related to the amount of dialysis
     fluid entering the peritoneal cavity and the amount in the drainage.


115. Monitor the client's vital signs every 15 minutes.


116. Monitor the client's weight daily