NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Genitourinary System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Dialysis

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Peritoneal Dialysis

Focus topic: Medical–Surgical Nursing

Definition: A method of separating substances by interposing a semipermeable membrane. The peritoneum is used as the dialyzing membrane and substitutes for kidney function during failure.

Principles of Peritoneal Dialysis
A. Usually temporary; can be used for clients in acute, reversible renal failure.

  • Treatment of choice for clients who are unable or unwilling to undergo hemodialysis or transplantation.
  • Used for clients with diabetes and cardiovascular disease who are at risk for fluid shifts, cannot use heparin, or are not responsive to other treatments.

B. Basic goals of dialysis therapy.

  • Removal of end products of protein metabolism, such as creatinine and urea.
  • Maintenance of safe concentration of serum electrolytes.
  • Correction of acidosis and blood’s bicarbonate buffer system.
  • Removal of excess fluid.

C. Renal perfusion is compromised when increased size of the intravascular compartment and redistribution of blood volume result from

  • Gram-negative sepsis.
  • Overdoses of some drugs.
  • Anaphylactic shock.
  • Electrolyte disturbances, such as acidosis.

D. Drugs may be used to check for renal failure before client is placed on dialysis.

  • In most cases, Mannitol is tried before dialysis.
    a. Not reabsorbed by kidney.
    b. Has great osmotic effect and increases urinary flow.
    c. Administration.
    (1) Given quickly to get higher blood level, which initiates diuresis and may prevent or minimize renal failure.
    (2) If infusion is too slow, changes in the urinary flow rate are delayed, as urine flow depends on the amount of Mannitol filtered.
    (3) Give 12.5 g of a 25% solution in 3 minutes; if flow rate can be increased to 40 mL/hr, the client is in reversible renal failure.
    (4) Keep urine at 100 mL/hr with Mannitol.
  • Drugs such as Lasix and Edecrin may be usedif Mannitol is not effective.
    a. If the client does not respond to Lasix or Edecrin, diagnosis of acute tubular necrosis is made.
    b. If the client has increased urine output with drugs, be sure to check electrolytes, as sodium and potassium depletion occurs along with water loss.
    c. In renal disease, make sure that drugs that depend on kidneys for excretion are not given.
Medical–Surgical Nursing

Peritoneal Dialysis Function
A. Works on principles of diffusion and osmosis, similar to hemodialysis; however, in this instance, the peritoneum is the semipermeable membrane.
B. Peritoneum is impermeable to large molecules (proteins).
C. Peritoneum is permeable to low-molecular-weight molecules (urea, glucose, electrolytes).
D. Cannot be used with clients who have the following conditions:

  • Peritonitis.
  • Recent abdominal surgery.
  • Abdominal adhesions.
  • Impending renal transplant.

E. Dialysate.

  • Contains electrolytes but no urea, creatinine.
    a. Common electrolytes in dialysate in mEq/L.
    Na+: 140–145
    Cl–: 101–110
    Ca++: 3.5–4.0
    Mg++: 1.5
    Lactate/acetate (base) : 43–45
  • b. Osmolarity.
    1.51% = 365 mOsm
    4.25% = 504 mOsm
    c. Amount: 1500–2000 mL infused over
    5–10 minutes.
  • Solutions vary in dextrose concentration.
    a. Solution of 1.5%: Used for drug intoxication and acute renal failure if large amounts of fluid are not required to be removed.
    b. Solutions of 2.5%: Used for clients requiring moderate amount of fluid removal.
    c. Solution of 4.25%: Used for removal of excessive fluid.
  • If hyperkalemia is not a problem, 4 mEq of potassium chloride is added to each solution.
  • Heparin is added to bottles to prevent clotting of the catheter.
  • Antibiotics may be added to prevent peritonitis.

F. Exchange process.

  • A series of exchanges or cycles that includes an infusion, dwell, and drainage of dialysate.
  • Cycles are repeated according to client need and MD orders.
  • Dialysate is infused by gravity through catheter into peritoneal cavity over 5–10 minutes; catheter is clamped.
  • Usual dialysate is 2 L per cycle and dwell time (time dialysate stays in peritoneal cavity) allows for process of diffusion and osmosis. Time varies from 30 minutes to 4 hours.
  • Catheter is unclamped and dialysate is drained by gravity for 10–30 minutes.

G. Observe dialysate solution during exchange.

  • Bloody drainage may be seen in first few exchanges after insertion of catheter.
  • Usual dialysate is straw-colored or colorless and clear.
  • Cloudy effluent indicates infection, and client must be treated immediately.

H. Monitor electrolyte balance throughout cycle.

  • Check muscle weakness, nausea, diarrhea as signs of hyperkalemia.
  • Monitor ECG for tall, peaked T waves and widening QRS as evidence of hyperkalemia.
  • Observe for hypokalemia—frequently decreased with dialysis: muscle weakness, hypotension, arrhythmias, anorexia, nausea, and vomiting.
  • Check for positive Chvostek’s and Trousseau’s signs as indications of low calcium levels.

Continuous Ambulatory Peritoneal Dialysis
A. A variation of peritoneal dialysis developed to allow the client to be dialyzed while ambulatory.
B. Procedure for continuous ambulatory peritoneal dialysis (CAPD).

  • Peritoneal catheter is inserted.
  • 500–2000 mL of dialysate infused through catheter by gravity (10–20 minutes).
  • The catheter is clamped, bag folded and placed in waistband of client’s clothes.
  • Every 4–6 hours, client drains fluid from peritoneal cavity.
    a. Unclamp catheter.
    b. Place pouch to allow drainage by gravity— below level of abdomen.
    c. Drain for approximately 20 minutes.
    d. Reclamp catheter and remove bag with drainage.
    e. Examine drainage—a change in color may indicate infection (glucose in dialysate predisposes client to infection).
  • Aseptically attach a new bag of dialysate and repeat procedure.
  • Repeat procedure 4–5 times daily.
  • Instruct client to change tubing every 24 hours using strict aseptic technique.

C. Be alert for possible complications: peritonitis, fluid and electrolyte imbalances, dehydration, catheter infection, abdominal pain and tenderness, and hemorrhage.
D. Body image is altered when fluid fills abdomen.
E. Altered sexuality and sexual dysfunction may occur.

Dialysis Procedure
A. Preparation for hospitalized clients.

  • Client voids before catheter insertion to prevent puncture of distended bladder.
  • Abdominal skin is prepped.
  • The area between the umbilicus and the pubic bone near the midline is most often used for catheter insertion.
  • Client is weighed before procedure and after voiding.
  • Baseline vital signs (including weight).

B. Dialysis process.

  • Dialysis fluid instilled in abdominal cavity.
  • Occurrence of osmosis, diffusion, and filtration via peritoneal membrane (called equilibration).
  • Fluid drained from abdominal cavity.
  • Process repeated with a time sequence allowed for each step. Period of time and number of cycles will vary according to client problem, tolerance, response, and type of solution.

C. Duration of dialysis depends on the following factors:

  • Client’s height and weight.
  • Severity of uremia.
  • Physical state of client.
  • Usual time period for dialysis is 24–72 exchanges or runs.

D. Monitoring the procedure.

  • Client’s electrolyte status is monitored during the process.
  • Periodic samples of the return dialysate are sent for culture.
  • Compare client’s weight before and after procedure to assess effectiveness of fluid removal.
  • Vital signs must be monitored closely.

E. Care of equipment during procedure.

  • Tubing should be changed every 8 hours using sterile technique when the procedure continues for days.
  • Warming the dialysate not only improves urea clearance but also maintains client’s body temperature and comfort.
  • Avoid getting air into tubing as this is uncomfortable for the client and impedes smooth and easy return of flow.

F. Quality and quantity of return.

  • Initial few outflows may be slightly bloody due to insertion process.
  • Cloudy fluid is usually an indication of peritonitis.
  • Bowel perforation should be suspected if flow is brown.
  • Record amount and type of solution for each inflow. This includes the medications added (e.g., potassium chloride, heparin, antibiotics).
  • Record outflow amount and characteristics.
  • Duration of each phase of the process should be recorded.
  • Keep a total net balance (difference between input and output for each exchange) and cumulative net balance.
  • Inform physician if client loses or retains large volumes of fluid.

G. Procedures to check when drainage slows.

  • Check proper position of clamps.
  • Look for kinking in tubes.
  • Milk the drainage tube.
  • Observe air vent in drainage bottle for patency.
  • Flush catheter.
  • Reposition direction of catheter within means.
  • Have client change positions.
  • Have physician change catheter.

Implementation
A. Each morning, observe for signs of infection.
B. Each day at the same time, weigh client with abdomen empty of solution.
C. Monitor vital signs to observe for complications.
D. Monitor dialysis exchange.

  • Keep exchange on time.
  • Maintain aseptic technique when changing bottles and tubing.
  • Record accurate intake and output on flow sheet.

E. Try the following interventions to assist in returning dialysate from peritoneal cavity.

  • Turn client on side and prop with pillows.
  • Place in Fowler’s position after solution is infused into abdomen.
  • Ambulate and/or have client sit in chair if client is able.
  • Palpate abdomen.
  • Place pillow or bath blanket under small of
    back (this also assists in relieving hiccoughs).

F. Test urine for sugar.
G. Monitor for complications of peritoneal dialysis.

  • Peritonitis.
    a. Diffuse abdominal pain.
    b. Abdomen tender on palpation.
    c. Abdominal wall rigidity.
    d. Cloudy outflow.
  • Hypertension.
  • Pulmonary edema.
  • Hyperglycemia (insulin may be needed).
  • Hyperosmolar coma.
  • Protein loss (0.5–1.0 g/L of drainage).
  • Intestinal perforation.

Other Types of Peritoneal Dialysis
A. Continuous cycling peritoneal dialysis (CCPD).

  • Requires a peritoneal cycling machine.
  • Consists of having three cycles done at night and one cycle with an 8-hour dwell time in morning.
  • Peritoneal cavity opened only for the on and off procedures, thereby reducing risk of infection.
  • Client does not need to do exchanges during the day.

B. Intermittent peritoneal dialysis (IPD).

  • Requires peritoneal cycling machine.
  • Performed for 10–14 hours three to four times a week.

C. Nightly peritoneal dialysis (NPD).

  • Performed 8–12 hours each night.
  • No daytime dwells.

Medical–Surgical Nursing: Hemodialysis

Focus topic: Medical–Surgical Nursing

Definition: The diffusion of dissolved particles from one fluid compartment into another across a semipermeable membrane. In hemodialysis, the blood is one fluid compartment and the dialysate is the other.

Principles of Hemodialysis
A. The semipermeable membrane is a thin, porous, hollow, fiber (cellophane) system or flat-plate dialyzer.

B. The pore size of the membrane permits the passage of low-molecular-weight substances such as urea, creatinine, and uric acid to diffuse through the pores of the membrane.
C. Water molecules are also very small and move freely through the membrane.
D. Most plasma proteins, bacteria, and blood cells are too large to pass through the pores of the membrane.
E. The difference in the concentrations of the substances in the two compartments is called the concentration gradient.
F. The blood, which contains the waste products, flows into the dialyzer, where it comes in contact with the dialysate.
G. A maximum gradient is established so that movement of these substances occurs from the blood to the dialysate.
H. Dialysate (bath).

  • Composed of water and major electrolytes.
  • Tap water can be used (need not be sterile because bacteria are too large to pass through membrane).

Hemodialysis Function
A. Removes by-products of protein metabolism: urea, creatinine, and uric acid.
B. Removes excessive fluid by

  • Changing osmotic pressure (by adding more dextrose to dialysate).
  • Negative or positive hydrostatic pressure.

C. Maintains or restores body buffer system.
D. Maintains or restores level of electrolytes in the body.

Medical–Surgical Nursing: Dialysis Management

Focus topic: Medical–Surgical Nursing

Implementation
A. Take vital signs to observe for shock and hypovolemia.

  • Hypotension is caused by
    a. Fluid loss initially.
    b. Decreased blood volume, especially if hematocrit is low.
    c. Use of antihypertensive drugs between dialysis procedures.
  • Plasma or volume expanders can be used to increase blood pressure; sometimes blood is used while the client is on dialysis.

B. Check serum electrolytes frequently (pre-, mid-, and postdialysis).
C. Observe for painful cramping near end of dialysis as a result of rapid fluid and electrolyte loss.
D. Weigh client before and after dialysis to determine fluid loss.
E. Monitor for dysrhythmias resulting from electrolyte and pH changes.
F. Watch for leakage around shunt site.
G. Observe for dialysis disequilibrium syndrome.

  • Cerebral dysfunction symptoms.
    a. Nausea and vomiting.
    b. Headache.
    c. Hypertension leading to agitation.
    d. Twitching, mental confusion, and convulsions.
  • Syndrome is caused by rapid, efficient dialysis, resulting in shifts in water, pH, and osmolarity between fluid and blood.
  • In acutely uremic clients, avoid this syndrome by dialyzing slowly, for short periods of time over 2–3 days.
  • Use Dilantin (phenytoin) to prevent this syndrome in new clients.

H. If client is heparinized while on dialysis machine, do the following:

  • Take clotting time about 1 hour before client comes off the machine. If less than 30 minutes, do not give protamine sulfate (heparin antagonist)—not usually given, as there is usually
    no need to counteract effect of heparin.
  • Keep clotting time at 30–90 minutes while on dialysis (normal 6–10 minutes).

I. Shunt care.

  • Temporary vascular access.
    a. Percutaneous cannulation of subclavian, internal jugular, and femoral veins.
    b. Catheters are double or multilumen.
    c. Internal jugular and subclavian vein catheters in place 3–12 weeks, femoral catheter 2–3 days.
    d. Assess for signs of infection, thrombosis with pulmonary emboli, and hematoma.
    e. Maintain patency with intermittent heparin injection.
  • Arterial–venous fistula.
    a. Anastomosis of an artery and vein creates a fistula.
    b. Arterial blood flow into the venous system results in marked dilation of veins, which are then easily punctured with a 14-gauge needle.
    c. Two venipunctures are made at the time of dialysis.
    (1) One for blood source.
    (2) One for return.
    (3) Arterial needle is inserted to within 2.5–3.8 cm (1–1½ inches) from fistula, and venous needle is directed away from fistula.
    d. Observe for patency of graft site.
    (1) Check for bruit with stethoscope.
    (2) Observe for signs of infection.

(3) Palpate pulses distal to shunt for circulation.
e. No blood pressure monitoring (BPs), tourniquet, or blood drawing on shunt arm.

  • Arteriovenous graft.
    a. Graft is implanted subcutaneously between an artery and a vein.
    b. Performed when client’s own vessels are not adequate for shunt.
    c. Venipuncture same as for arteriovenous (AV) fistula.

Guidelines for Dialysis Management
A. Limit fluid intake (500 mL over previous day’s output); provide accurate intake and output. (Goal is to keep client’s weight gain under 1.5 kg between dialyses.)
B. Provide diet low in sodium (2–3 g), 1 g/kg protein, high carbohydrate, high fat, and foods low in potassium.

  • Dietary protein should be of animal source.
  • Include meat, eggs, milk, poultry, fish in diet.

C. Check vital signs for indication of hypovolemia; check temperature elevation for indication of possible infection.
D. Auscultate lungs for signs of pulmonary edema.
E. Provide shunt care for clients on hemodialysis.
F. Observe level of consciousness—indicative of electrolyte imbalance or thrombus.
G. Administer antihypertensive drugs between dialysis if ordered.
H. Administer diuretics if ordered.
I. Administer blood if ordered (cellular portion only is needed because of low hematocrit).
J. Weigh daily to assess fluid accumulation.
K. Prevent use of soap (urea causes dryness and itching, and soap adds to this problem).
L. Provide continued emotional support.

  • Allow for expression of feelings about change in body image.
  • Encourage expression of fears of death, especially during dialysis.
  • Encourage family cooperation.
  • Support required change in lifestyle.

Medical–Surgical Nursing: Renal Transplant

Focus topic: Medical–Surgical Nursing

Definition: Implantation of a human kidney from a compatible donor to the recipient.

Characteristics
A. Irreversible kidney failure.
B. Recipient must take immunosuppressive medications for life.

Donors
A. Living related.

  • Most desirable source.
  • Screened for ABO blood type, human leukocyte antigen (HLA) suitability, tissue-specific antigen, and histocompatibility.
  • Must be in excellent health.
  • Must have two fully functioning kidneys.
  • Emotional well-being determined early in screening process.
  • Must be able to comprehend the donation process and outcomes.

B. Cadaver.

  • Must be < 60 years of age.
  • Must meet criteria for “brain death,” cannot have cardiac death.
  • Renal function must be normal.
  • Cannot have metastatic disease, HIV-positive status, or hepatitis B–positive status.
  • Donor cannot have the following:
    a. Abdominal or renal trauma.
    b. Hypotension.
    c. Generalized infection.
  • Must have cardiopulmonary support maintained until the kidneys are surgically removed.
  • Once brain death has occurred, restore intravascular volume, wean from vasopressors, and maintain diuresis.

C. Warm ischemic time—time elapsed between cessation of perfusion and cooling of the kidney and the time required to anastomose the kidney.

  • Maximum time: 30–60 minutes.
  • Kidney can be cooled; this increases transplant time to between 24 and 48 hours.

Implementation
A. Preoperative.

  • Verify histocompatibility tests (per hospital policy).
  • Administer medications.
  • Keep client free from infection (follow protective isolation as indicated).
  • Follow hospital policy for dialysis prior to transplant.
  • Provide emotional support to donor and recipient.

B. Postoperative.

  • Assess kidney function—may occur immediately or be delayed a few days; monitor every hour.
  • Maintain hemodialysis until adequate kidney function is maintained.
  • Monitor VS, I&O, daily blood work, urine tests.
  • Keep client in semi-Fowler’s position.
  • Maintain patency of Foley—urine will be pink to bloody initially, returns to clear yellow within days to weeks. If clots occur, notify physician immediately.
  • Remove Foley as soon as indicated to prevent infection. CAUTI (catheter associated urinary tract infection) common when Foley left in place for prolonged periods of time. CAUTI increases length of stay.
  • Maintain protective isolation with strict aseptic technique.
  • Monitor for possible complications.
    a. Hemorrhage from anastomosis.
    b. Failure of ureteral anastomosis—causing leakage of urine into peritoneal cavity.
    c. Renal artery thrombosis.
    d. Infection.
    e. Resection.
  • Provide teaching to client and family.
    a. Use and side effects of prescribed medications.
    b. Vital signs and weight.
    c. Signs and symptoms of organ rejection.
    d. Dietary changes.
  • Provide psychological support to client and family.

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