MICHELLE WILKINSRN/CNERENAL UNIT SEPT 09

WORKING ALONGSIDE ESRD

HAEMODIALYSIS FOCUS

OVERVIEW

• Renal Function

• Haemodialysis – on paper

• Haemodialysis – the reality

• Conclusion

KIDNEYSTo excrete:Metabolic wastes

To regulate: Body water volume electrolyte balance/acid base balance

Metabolic: Activate Vit D. Renin production. Epoetin production.

Remember Renal function

=

Remove & Regulate

KIDNEY FAILURE

• Toxins - ↓ efficiency of blood clearance

• Assessed by measuring urea and creatinine• Urea- Is a waste product produced by the

liver (subjective symptoms)• Creatinine is a substance created by the

muscles

HAEMODIALYSIS (Blood = filtration)

•Removal of excess water - ultrafiltration •Reversal of Metabolic acidosis - buffer system

•Removal of waste products - diffusion

HAEMODIALYSISTo excrete:

Metabolic wastes √To regulate: Body water volume electrolyte balance/acid base

balance √

Metabolic: Activate Vit D. Renin production. Epoetin

production. X

HISTORY:•1924: George Haas (German) 1st successful human dialysisDialysis - 15 minutes – “no complications occurred”

•1943: WJ Kolff and H Berk (Netherlands) developed 1st practical human HD machineA rotating drum artificial kidney (30-40m cellophane tubing in a stationary 100-litre tank)

Kolff made clinicians interested in treatment of uraemia

1943 1990,s

HOW DOES HAEMODIALYSIS WORK?

•The process of dialysis occurs using a dialysis machine

•Blood from the client is pumped through an artificial kidney (filter) on the machine

•Dialysis fluid (dialysate) / ultrapure H20 / bicarbonate buffer

ACCESS

ARTERIOVENOUS FISTULA- (AVF)- Vein and artery joined together surgically

allowing arterial blood to flow through the vein causing venous engorgement and enlargement

- Matured for use at approx 6 weeks- Gauge of needles 17,16,15,14- Use of local anaesthetic

Brachial vein

Brachial artery

ACCESS SURGERY

A NEEDLED AV FISTULA

Aneurysed area

Venous site

Arterial Site

PTFE/GRAFT• Alternative option to AVF re poor forearm veins PTFE/Teflon material - inserted and joined at the side of the vein or artery, to minimize the interference with blood flow through the native vessels.• Useable at 2 weeks• 2ND choice to AVF ( lifespan)

CENTRAL VENOUS CATHETERS

• FEMORAL LINE – acute/urgent temporary access – no > 72hrs insitu

• INTERNAL JUGULAR (IJ) CATHETERS - temporary access – usually no > 2 weeks insitu

• TUNNELED CUFFED CATHETER- are used for longer term treatment ( new start without vascular access / issues with vascular access / vascular system unsuitable for creation of AVF or graft / waiting for AVF/ graft to mature)

•CXR post insertion• Extension sets / guidewires

Tunnelled Central Venous Catheters

IJ Placement

Finished Look

Dressing & Safety Label

LIVING WITH HAEMODIALYSIS

• Life style changes• Complications- Bp changes - Fluid overload - Hyperkalaemia - Access - Infection• Decisions for some to continue treatment?

THE LIFE OF A DIALYSIS PATIENT

Dialysis pts do not lead a normal life:

• HD minimum of 3x weekly tied (literally) to a machine• APD tied nightly to a machine• CAPD - repetitive ritual of exchanges• Choices removed• Dependent on a procedure/others

STRESSORS & SUPPORTS

• Medication intake routine• Diet, fluid restrictions• Dialysis & Illness• Losses- job, freedom, life term• Sexual dysfunction• MDT • Personality & Mental status• Family/friend supports

FOR EXAMPLE…

•ESRD DUE TO DIABETES

•FAMILY MAN

•LIVES RURAL/TRAVELS TO DIALYSIS

•NON-COMPLIANCE WITH MEDS

CONCLUSION POTENTIAL PERCEPTIONS:

• Clients will/should want to comply to dialyse 3x week – dialyse vs. die

• Clients / family may have to travel many kilometres for treatment but this is paid for – they are lucky

• Non-compliance means not interested in own wellbeing / not wanting to take part in their own care – true/false?

Vs. PT PERCEPTION

• “When I first got the letter telling me I needed dialysis. I tried to hide it. I felt like I was half a person, I was disabled. I wanted to just give up. I didn’t want to depend on a machine. I didn’t know what to do.”

• “When I found out I had a kidney problem and required dialysis; I was more shattered than anything else. I was frightened. I ran away for as long as I could.”

• “It was a shock finding out I had kidney failure. I was too sick at that point to try to run away from it. I didn’t want to go on dialysis. It’s terrible to have renal failure.”

“I felt we would never cope with the complicated machine, but the renal nurses teaching soon got us feeling more confident every session. When it was time for us to go it alone, panic struck at the beginning we were constantly (it seemed) phoning with queries, & they told us what to do and it always worked. Now dialysis is no longer something to dread, but has just become a way of life”

PROGRESSING TO…

REALITY

Outsiders potential perception vs. patient potential perception =

Can be so different - highlights the need to sit down with your clients / work with them and really understand what barriers they encounter and how they are feeling

REFLECTION

• Renal Function

• Haemodialysis – on paper

• Haemodialysis – the reality

LIVE TO DIALYSE vs. DIALYSE TO LIVE

REFERENCES• Dr Andy Stein & Janet Wild, RGN, 2007 Kidney Failure Explained- Third Edition

2007, chapters 1, What is Kidney Failure, pg’s 1-11, chapter 2, Toxin ‘Clearance’ pages 12-18, chapter 10 Haemodialysis, pg’s 66-84

• Website www.kidneypatientguide.org.uk• Shih, Li Chin 2009 Impact of Dialysis on Rurally Based Mäori Clients and Their

Whänau – Facing Fear Pg 40 • History of Dialysis -

http://www.discoveriesinmedicine.com/Apg-Ban/Artificial-Kidney.html• Photographs – dialysis machine/ AVF/ CVL – results of my newly acquired IT

skills• Acknowledgements to Lisa Harvey Jack (CNM) , Rey Tuando, Imelda Aying for

support and use of resources'