Hemodialysis and peritoneal dialysis have been around since the mid 1940's. It began to be regularly used in 1960 and is now a standard treatment all around the world. Thousands of patients have been helped by these treatments. It is a life saving procedure, but it is not without cost. If you are not a nurse specializing in dialysis, it can be very intimidating to see one of these special patients on your unit.  What can you do to meet this patient’s needs and ensure that they receive quality care under your hands?

The very basic thoughts to keep in mind are what you already know about the kidneys and their function, and what can be inferred from simplistically thinking about dialysis as a filtering mechanism.  These two things form the basis of a dialysis patient’s universe: they have to be constantly vigilant about what goes into their bodies and what is taken out to maintain a very delicate balance.

Then, break this knowledge down to apply it your nursing care.

General Care
Be mindful of energy expenditures.  Dialysis is exhausting, recovery is exhausting, and the build up of toxins prior to dialysis is exhausting.  In short, your dialysis patient needs to be judicious about how they will spend their available energy.

Diet
The general diet for the dialysis patient is often referred to as the “Low-Everything Diet” (low potassium, low phosphorus, low sodium, low fluid and, controlled protein).  However, it is important to remember that the renal diet is highly individualized.  The patient is taught portion control, moderation and how to make food choices based on their most recent lab values.  Special attention is given to maintaining appropriate potassium, phosphorus, sodium and protein levels.  Patients who are maintaining proper nutrition and being well-dialyzed should not be losing weight or suffering from a poor appetite. A dietician referral can be very helpful in managing this aspect of their care in the hospital.

Medications
Dialysis patients often have complicated medicine regimes that need to be followed very closely.  For example: phosphorus binders are given to soak up unused phosphorus and should always be given along with a meal or snack, not alone.

You may see large amounts of specific vitamin and mineral supplements, such as: B-vitamins, Biotin, Calcium, and Lecithin. Medications for high blood pressure (the leading cause of kidney disease), and tachycardia resulting from dialysis are also frequently present.

Fistula and Graft Care
Fistula and graft sites need to be cleaned and assessed daily. Watch for changes in the skin’s appearance including: redness, bruising, localized swelling, bulging, or pustules.  The area around the site should be assessed for swelling, temperature, numbness, weakness, or pain.  Become familiar with the feel of the pulse within the fistula or graft.  Changes, either weakening or becoming bounding, may indicate complications.

Blood draws and blood pressure monitoring should not be performed on the extremity housing a fistula or graft.

Special Concerns and Risks
Dialysis is devastatingly difficult for the heart and the body and carries a significantly high risk for sudden death. Most dialysis patients die at night in their sleep, or even on their way to dialysis, in the dialysis unit, or soon after dialysis. Almost two-thirds of these patients will die from cardiovascular causes, but very few of these patients will have a previous cardiac history. In the dialysis patient, any cardiac warning sign should be treated seriously.

It is also important to note that, even though the dialysis patient is fighting to live, death is frequently on their mind. The 20-year-old dialysis patient can only expect an average of 14 more years. For the 50-year-old beginning dialysis patient it’s only six years.  Nursing assessments for well-being and quality-of-life should not be overlooked for the dialysis patient.

 

References:

 

Altman, S.D., and Plummer, R. Caring for Your Vascular Access: A Little Effort Can Make a Big Difference! aakpRENALIFE, Vol. 21, No. 4,  2006. 

American Association of Kidney Patients.  AAKP.org

Bleyer, A.J., Finkelstein, F.O., and Kliger, A.S. American Society of Nephrology 2007: Improving Care for Dialysis Patients. Medscape.com

McCallister, A. Good Food Choices: How the Renal Dietitian Can Help.  aakpRENALIFE, Vol. 17, No. 5 2002.

National Kidney Foundation. Kidney.org.

Robinson, K. Improving Quality: Patients Shaping the Future. aakpRENALIFE, Vol. 20, No. 3, 2004.

 

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