NS3P1 RENAL Dialysis & Transplants

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  1. **Dialysis
    Movement of fluid/molecules across a semipermeable membrane from one compartment to another

    Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure; excessive levels of ca & potassium especially

    Treat drug overdoses

    • Clinically, dialysis is a technique in which substances move from the blood through a semipermeable membrane and into a dialysis solution (dialysate).
    • -can be at bedside or specific dialysis center
    • -keep in mind, it won't replace erythropoeitin production so epogen must still be given.

    • => Two methods of dialysis
    • Peritoneal dialysis (PD): In PD the peritoneal membrane acts as the semipermeable membrane

    Hemodialysis (HD): an artificial membrane (usually made of cellulose-based or synthetic materials) is used as the semipermeable membrane and is in contact with the patient’s blood.
  2. **Dialysis: Reasons to start it...
    Begun when patient’s uremia can no longer be adequately managed conservatively or by other measures

    • Initiated when GFR (or creatinine clearance) is less than 15 mL/min as seen in ESKD, ESKD treated with dialysis because
    • There is a lack of donated organs
    • Some patients are physically or mentally unsuitable for transplantation
    • Some patients do not want transplants

    • => This criterion can vary widely in different clinical situations, and the physician will determine when to start dialysis on the basis of the patient’s clinical status.
    • Certain uremic complications, including encephalopathy, neuropathies, uncontrolled hyperkalemia, pericarditis, and accelerated hypertension, indicate a need for immediate dialysis.

    • => An increasing number of individuals are receiving maintenance dialysis, including older adults and those with complex medical problems.
    • A patient’s chronologic age is not a factor in determining candidacy for dialysis. Factors that are important are the patient’s ability to cope and the existing support system.
  3. B. Functions of hemodialysis
    • 1. Cleanses the blood of accumulated waste products
    • 2. Removes the byproducts of protein metabolismsuch as urea, creatinine, and uric acid from the blood
    • 3. Removes excess body fluids
    • 4. Maintains or restores the buffer system of the body
    • 5. Corrects electrolyte levels in the body
  4. **General Principles of Dialysis
    => Diffusion: Movement of solutes from an area of greater concentration to an area of lesser concentration; Substances of low molecular weight can pass from the dialysate into a patient’s blood, and so the purity of the water used for dialysis is monitored and controlled.

    => Osmosis: Movement of fluid from an area of lesser concentration of solutes to area of greater concentration, Glucose is added to the dialysate and creates an osmotic gradient across the membrane, pulling excess fluid from the blood.

    • => Ultrafiltration
    • Water and fluid removal
    • done by use of glucose. Results when there is an osmotic gradient across the membrane

    -In PD, excess fluid is removed by increasing the osmolality of the dialysate (osmotic gradient) with the addition of glucose.

    -In HD, the gradient is created by increasing pressure in the blood compartment (positive pressure) or decreasing pressure in the dialysate compartment (negative pressure).

    Extracellular fluid moves into the dialysate because of the pressure gradient. The excess fluid is removed by creating a pressure differential between the blood and the dialysate solution with a combination of positive pressure in the blood compartment or negative pressure in the dialysate compartment.
  5. **Peritoneal Dialysis
    -type of cath:
    -Post op Care
    • In the United States, approximately 12% of patients receiving dialysis treatments are on PD.
    • Peritoneal access is obtained by inserting a catheter through the anterior abdominal wall
    • Technique for catheter placement varies
    • Usually done via surgery. During emergency situation: this isn't rapid. Hemodialysis is quicker to start.

    • => Prep: Preparation of the patient for catheter insertion includes emptying the bladder and bowel, weighing the patient, and obtaining a signed consent form.
    • -first time they dialysis: normal for output to be pink, bright red is bad.

    • => Tenckhoff Catheter: The catheter is about 60 cm long and has one or two polyester (Dacron) cuffs on its subcutaneous and peritoneal portions. The cuffs act as anchors and prevent the migration of microorganisms down the shaft from the skin.
    • Keep it sterile in the beginning

    • After catheter inserted, skin is cleaned with antiseptic solution and sterile dressing applied
    • Connected to sterile tubing system
    • Secured to abdomen with tape
    • Catheter irrigated immediately

    • => PD care post op:
    • Waiting period of 7 to 14 days preferable
    • Two to 4 weeks after implantation, exit site should be clean, dry, and free of redness/tenderness
    • Once site healed, patient may shower and pat dry-Some patients just wash with soap and water and go without a dressing; others require daily dressing changes.
    • However, teach all patients to examine their catheter site for signs of infection.
    • Showering is preferred because the exit site should not be submerged in bath water.
  6. **PD Dialysis Solutions and Cycles-
    different concentrations are used as ordered by the physcian

    Available in 1- or 2-L plastic bags with glucose concentrations of 1.5%, 2.5%, and 4.25%

    Electrolyte composition similar to that of plasma

    Solution warmed to body temperature

    • Dialysis solutions vary, and the choice of exchange volume is determined primarily by the size of the peritoneal cavity. A larger person may tolerate a 3-L exchange volume without any difficulty, whereas an average-size person usually tolerates a 2-L exchange.
    • -Ultrafiltration (fluid removal) during PD depends on osmotic forces; glucose is the most effective osmotic agent currently available. done because of high glucose concentratiion, complication: HYPERglycemia. So you must adjust the medication
  7. **Three phases of PD cycle

    Inflow (fill)
    Dwell (equilibration)
    • => Inflow
    • Prescribed amount of solution infused through established catheter over about 10 minutes
    • After solution infused, inflow clamp closed to prevent air from entering tubing
    • The amount of solution is usually 2 L.The flow rate may be decreased if the patient has pain.

    • => Dwell
    • Also known as equilibration
    • Diffusion and osmosis occur between patient’s blood and peritoneal cavity
    • Duration of time varies, depending on method
    • The duration of the dwell time can last 20 to 30 minutes to 8 or more hours, depending on the method of PD.

    • => Drain
    • Lasts 15 to 30 minutes; May be facilitated by gently massaging abdomen or changing position (teach pt to move around b/c over time, scar tissue may develop from cath, and change in position helps to remove all the fluid)
    • The cycle starts again with the infusion of another 2 L of solution. For manual PD, a period of about 30 to 50 minutes is necessary to complete an exchange.
    • Ultrafiltration (fluid removal) during PD depends on osmotic forces; glucose is the most effective osmotic agent currently available. Dextrose remains the most commonly used osmotic agent available in PD solutions.
  8. Types of peritoneal dialysis
    • 1. Continuous ambulatory peritoneal dialysis (CAPD)
    • a. Closely resembles renal function because it isa continuous process
    • b. Does not require a machine for the procedure
    • c. Promotes client independenced. The client performs self-dialysis 24 hours aday, 7 days a week.
    • e. Four dialysis cycles are usually administeredin a 24-hour period, including an overnight8-hour dwell time
    • .f. Dialysate, 1½ to 2 L, is instilled into theabdomen four times daily and allowed todwell as prescribed.
    • g. After dwell, the bag is placed lower than theinsertion site so that fluid drains by gravityflow.
    • h. After fluid is drained, the bag is changed,new dialysate is instilled into the abdomen,and the process continues.
    • i. Between exchanges, the catheter is clamped.

    • 2. Automated peritoneal dialysis (Box 62-8)
    • a. Automated dialysis requires a peritonealcycling machine
    • .b. Automated dialysis can be done as intermittentperitoneal dialysis, continuouscycling peritoneal dialysis, or nightly peritonealdialysis.
    • c. The exchanges are automated instead ofmanual

    • => Intermittent Peritoneal Dialysis
    • Dialysis requires a peritoneal cycling machine.Dialysis is not a continuous procedure.Dialysis is performed for 10 to 14 hours, three or fourtimes a week.

    • => Nightly Peritoneal Dialysis
    • Dialysis requires a cycling machine.Dialysis is performed 8 to 12 hr
  9. **Automated & Continous peritoneal dialysis
    • =>Automated peritoneal dialysis
    • (APD)Cycler delivers the dialysatez'
    • Times and controls fill, dwell, and drain
    • APD is the most popular form of PD because it allows patients to accomplish dialysis while they sleep. The machine cycles four or more exchanges per night with 1 to 2 hours per exchange. {See next slide for APD figure.}
    • It is difficult to achieve the required solute and fluid clearance solely with nighttime APD. Therefore, one or two daytime manual exchanges may also be prescribed to ensure adequate dialysis.

    • => Continuous ambulatory peritoneal dialysis (CAPD)
    • Manual exchange
    • CAPD: Exchanges are carried out manually with 1.5 to 3 L of peritoneal dialysate at least four times daily, with dwell times averaging 4 hours. For example, one schedule exchanges at 7:00 AM, 12:00 noon, 5:00 PM, and 10:00 PM.
  10. PD Complications, Effectiveness & Adaptation
    • **PD Complications
    • Infection of the peritoneal catheter exit site is most commonly caused by Staphylococcus aureus or Staphylococcus epidermidis (from skin flora).

    • -#1: PERITONITIS!! FOllow asceptic technique. Signs, Color of fluid (cloudy is bad), infection of the site-abd pain.
    • -Most frequently, peritonitis occurs because of improper technique in making or breaking connections for exchanges.

    Because of increased intraabdominal pressure secondary to the dialysate infusion, hernias can develop in predisposed individuals such as multiparous women and older men. Increased intraabdominal pressure can cause or aggravate lower back pain.

    Bloody effluent over several days or the new appearance of blood in the effluent can indicate active intraperitoneal bleeding.

    Atelectasis, pneumonia, and bronchitis may occur from repeated upward displacement of the diaphragm, resulting in decreased lung expansion.

    The amount of protein loss is usually about 0.5 g/L of dialysate drainage, but it can be as high as 10 to 20 g/day. (so give protein in diet)

    • **Peritoneal Dialysis Effectiveness and Adaptation
    • Short training program
    • Independence
    • Ease of traveling
    • Fewer dietary restrictions because they don't have to be on a tight protein restriction as when they're on hemodialysis, BUT IN GENERAL, restrictions are lifted.
    • Greater mobility than with HD
    • Learning the self-management skills necessary for peritoneal dialysis is usually accomplished in a 3- to 7-day training program.

    Mortality rates are about equal between in-center hemodialysis patients and peritoneal dialysis patients for the first few years. However, after about 2 years, mortality rates for patients receiving PD are higher, especially for older patients with diabetes and patients with a history of prior cardiovascular disease.
  11. **Complications of peritoneal Dialysis-
    Peritonitis: rebound abd pain

    -abd pain: inflow causes pain during the firest few exchange, disappear after 1-2 week. But make sure to warm the dialysate

    • -Abd OUTFLOW characteristics indicative ofcomplications
    • 1. Bloody outflow after the first few exchangesindicates vascular complications (the outflowshould be clear after the initial exchanges).
    • 2. Brown outflow indicates bowel perforation.
    • 3. Urine-colored outflowindicates bladder perforation.
    • 4. Cloudy outflow indicates peritonitis.

    • => Insufficient outflow
    • 1. The main cause of insufficient outflow is a fullcolon; encourage a high-fiber diet, because constipationcan cause inflow and outflow problems.Administer stool softeners as prescribed.2. Insufficient outflow may also be caused by cathetermigration out of the peritoneal area; if thisoccurs, an x-ray will be prescribed to evaluatecatheter position.3. Maintain the drainage bag below the client’sabdomen.4. Check for kinks in the tubing.5. Check for fibrin clots in the tubing and milk thetubing to dislodge the clot as prescribed.6. Change the client’s outflow position by turningthe client to a side-lying position or ambulatingthe client.

    • => Leakage around the catheter site
    • 1. Clear fluid that leaks from the catheter exit sitewill be noted.2. It takes 1 to 2 weeks following insertion of thecatheter before fibroblasts and blood vesselsgrow into the catheter cuffs, which fix it in placeand provide an extra barrier against dialysateleakage and bacterial invasion.3. Smaller amounts of dialysate need to be used;it may take up to 2 weeks for the client to toleratea full 2-L exchange without leaking aroundthe catheter site.
  12. **Hemodialysis Vascular Access Sites
    • Obtaining vascular access is one of most difficult problems, Temp cath: is like central line (right at bedside) and procedure started shortly
    • Grafts or fistulas are more common

    • => Types of access
    • Arteriovenous fistulas and grafts
    • Temporary vascular access- similar to Central
    • note: Arteriovenous fistulas (AVFs) have the best overall patency rates and least number of complications (e.g., thrombosis, infections) of all vascular accesses.
    • In some situations when immediate vascular access is required, percutaneous cannulation of the internal jugular or femoral vein is performed.
    • FISTULA preferred: less chance of clotting, but this takes time to become functional, you need high flow of blood because you're shunting blood from artery to vein.Takes 3 months.

    Graft: shorter time, surgery site to heal: 2-3 weeks so it could be in use. Tube there, so higher risk for occlusion

    -Subclavian vein cath
    -Femoral Vein
    • A. Subclavian and femoral catheter
    •  A subclavian (subclavian vein) or femoral(femoral vein) catheter may be inserted forshort-term or temporary use in ARF.b. The catheter is used until a fistula or graftmatures or develops, which is typically 6weeks, or may be required when the client’sfistula or graft access has failed because ofinfection or clotting.
    • 2. Interventions
    • a. Assess insertion site for hematoma, bleeding,catheter dislodgement, and infection.b. These catheters should only be used fordialysis treatments.c. Maintain an occlusive dressing over thecatheter insertion site.

    • 3. Subclavian vein catheter
    • a. The catheter is usually filled with heparin andcapped to maintain patency between dialysistreatments.
    • b. The catheter should not be uncapped exceptfor dialysis treatments.
    • c. The catheter may be left in place for up to6 weeks if no complications occur.

    • 4. Femoral vein catheter
    • a. Assess the extremity for circulation, temperature,and pulses.b. Prevent pulling or disconnecting of the catheterwhen giving care.c. Because the groin is not a clean site, meticulousperineal care is required.d. Use an IV infusion pump or controller withmicrodrip tubing if a heparin infusionthrough the catheter to maintain patency isprescribed.The client with a femoral vein catheter shouldnot sit up more than 45 degrees or lean forward,because the catheter may kink and occlude.
  14. **Arteriovenous Fistula
    Arteriovenous fistula created by anastomosing an artery and vein.

    A subcutaneous AVF is most commonly created in the forearm with an anastomosis between an artery and a vein (usually cephalic).

    Maturation time may take 6 weeks to months. AVFs should be placed at least 3 months before the need to initiate HD.

    • Normally, a thrill can be felt by palpating the area of anastomosis, and a bruit (rushing sound) can be heard with a stethoscope. The bruit and thrill are created by arterial blood moving at a high velocity through the vein
    • Usually start with lower arm, complications of clotting causes need to switch sites.
  15. Internal arteriovenous fistula (Saunders: see Fig. 62-2)
    Advantages and Disadvantages
    •  Description
    • a. A permanent access of choice for the clientwith CRF requiring dialysisb. The fistula is created surgically by anastomosisof a large artery and large vein in the arm.c. The flow of arterial blood into the venoussystem causes the vein to become engorged(matured or developed).d. Maturity takes about 4 to 6 weeks, dependingon the client’s ability to do hand-flexingexercises such as ball squeezing, which helpthe fistula mature.e. The fistula is required to be mature before itcan be used because the engorged vein ispunctured with a large-bore needle for thedialysis procedure.f. Subclavian or femoral catheters, peritonealdialysis, or an external arteriovenous shuntcan be used for dialysis while the fistula ismaturing or developing.

    • 2. Advantages
    • a. Because the fistula is internal, the risk of clottingand bleeding is low.b. The fistula can be used indefinitely.c. Fistulas have a decreased incidence of infectionbecause it is internal and is not exposed.d. Once healing has occurred, no external dressingis required.e. The fistula allows freedom of movement.

    • 3. Disadvantages
    • a. The fistula cannot be used immediately afterinsertion so planning ahead for an alternateaccess for dialysis is important.b. Needle insertions through the skin and tissuesto the fistula are required for dialysis.c. Infiltration of the needles during dialysis canoccur and cause hematomas.d. An aneurysm can form in the fistula.e. Congestive heart failure can occur from theincreased blood flow in the venous system.Arterial steal syndrome can develop in a client withan internal arteriovenous fistula. In this complication,too much blood is diverted to the vein, and arterialperfusion to the hand is compromised
  16. Saunders Internal arteriovenous graft (see Fig. 62-2)
    • 1. Description
    • a. The internal graft may be used for chronicdialysis clients who do not have adequateblood vessels for the creation of a fistula.
    • b. An artificial graft made of Gore-Tex or abovine (cow) carotid artery is used to createan artificial vein for blood flow.
    • c. The procedure involves the anastomosis of anartery to a vein using an artificial graft.
    • d. The graft can be used 2 weeks after insertion.
    • e. Complications of the graft include clotting,aneurysms, and infection.

    • 2. Advantages
    • a. Because the graft is internal, the risk ofclotting and bleeding is low.
    • b. The graft can be used indefinitely.
    • c. The graft has a decreased incidence of infection.
    • d. Once healing has occurred, no external dressingis required.
    • e. The graft allows freedom of movement.

    • 3. Disadvantages
    • a. The graft cannot be used immediately afterinsertion.
    • b. Needle insertions through the skin and tissuesto the graft are required for dialysis.
    • c. Infiltration of the needles during dialysis canoccur and cause hematomas.
    • d. An aneurysm can form in the graft; additionally,grafts clot more frequently than arteriovenousfistulas.
    • e. Arterial steal syndrome can develop (toomuch blood is diverted to the vein, and arterialperfusion to the hand is compromised).
    • f. Congestive heart failure can occur from theincreased blood flow in the venous system.
  17. Vascular Access Catheter:
    A, Right internal jugular placement for a tunneled, cuffed semipermanent catheter.

    B, Temporary hemodialysis catheter in place. To do dialysis right away, Central lines are more prone to infections.

    C, Long-term cuffed hemodialysis catheter.

    Perm cath: develops while the fistula heals (so pts end up having all three sometimes.)

    Priorities: make sure cath is working, watching for bruit and thrill. Monitor circulation of arm. Assess for infection. Elevate to reduce swelling and pain but assessing for good circulation.
  18. Interventions for an arteriovenous fistula and arteriovenous graft
    1. Teach the client that the extremity should not beused for monitoring blood pressure, drawingblood, placing IV lines, or administering injections.

    2. Teach the client with an arteriovenous fistulahand-flexing exercises such as ball squeezing (ifprescribed) to promote graft maturity.

    3. Note the temperature and capillary refill of theextremity.

    4. Palpate pulses below the fistula or graft, and monitorfor hand swelling as an indication of ischemia.

    5. Monitor for clotting.a. Complaints of tingling or discomfort in theextremity.b. Inability to palpate a thrill or auscultate abruit over the fistula or graft.

    6. Monitor for arterial steal syndrome.

    7. Monitor for infection.

    • 8. Monitor lung and heart sounds for signs of CHF.
    • 9. Notify the physician immediately if signs ofclotting, infection, or arterial steal syndrome occur.
  19. **Hemodialysis Dialyzers
    Long plastic cartridges that contain thousands of parallel hollow tubes or fibers

    • Fibers are semipermeable membranes
    • -The blood is pumped into the top of the cartridge and is dispersed into all of the fibers.

    Dialysis fluid (dialysate) is pumped into the bottom of the cartridge and bathes the outside of the fibers with dialysis fluid.
  20. **Hemodialysis Procedure
    Two needles placed in fistula or graft

    • One needle is placed to pull blood from the circulation to the HD machine
    • The other needle is used to return the dialyzed blood to the patient

    The needles used for HD are large bore, usually 14- to 16-gauge, and are inserted into the fistula or graft to obtain vascular access.

    AnticoagulantHeparin is added to the blood as it flows into the dialyzer because any time blood contacts a foreign substance, it has a tendency to clot. So pt risk for bleeding.

    Dry weight: consider weight AFTER dialysis, look at other symptoms: Vitals,

    • => Components of Hemodialysis:
    • Blood is removed via a needle inserted in a fistula or via catheter lumen. It is propelled to the dialyzer by a blood pump. Heparin is infused either as a bolus before dialysis or through a heparin pump continuously to prevent clotting.
    • Dialysate is pumped in and flows in the opposite direction of the blood. The dialyzed blood is returned to the patient through a second needle or catheter lumen. Old dialysate and ultrafiltrate are drained and discarded.
    • Dialyzer/blood lines primed with saline solution to eliminate air
    • Terminated by flushing dialyzer with saline to remove all blood
    • Needles removed and firm pressure applied
    • Dialysis is terminated by flushing the dialyzer with saline solution to return the blood in the extracorporeal circuit back to the patient through the vascular access.
  21. **Hemodialysis Nursing Assessment:
    • =>Before treatment, nurse should
    • Complete assessment of fluid status, condition of access, temperature, skin condition
    • The difference between the last postdialysis weight and the current predialysis weight determines the ultrafiltration or the amount of weight to be removed.
    • pt should be able to cooperate: Dementia? They must be able to have to sit down.

    Order early breakfast. Give insulin because they're gooing to have food. Give phosphate binders.

    Drugs to hold: mulitvitamin for after, antibiotics, anti-seizures so it's not dialyzed, HOLD BOTH BP because you already know it's going to drop, so check after VS and then take BP meds, diuretics (effect on BP)

    • => During treatment, nurse should
    • Be alert to changes in condition
    • Measure vital signs every 30 to 60 minutes
    • DON"T FEED: causes drop of BP
  22. Hemodialysis Complications, Effectiveness & Adaptaition
    • **Hemodialysis Complications
    • Hypotension that occurs during HD results primarily from rapid removal of vascular volume (hypovolemia), decreased cardiac output, and decreased systemic intravascular resistance.

    Factors associated with the development of muscle cramps include hypotension, hypovolemia, high ultrafiltration rate (large interdialytic weight gain), and use of low-sodium dialysis solution.

    Blood loss may result from incomplete rinsing of blood from the dialyzer, accidental separation of blood tubing, dialysis membrane rupture, or bleeding after the removal of needles at the end of dialysis.

    At one time, hepatitis B had an unusually high prevalence in dialysis recipients, but the incidence today is quite low. Currently, hepatitis C is responsible for the majority of cases of hepatitis in dialysis recipients. First session: dysequilibrium

    • **Hemodialysis Effectiveness and Adaptation
    • Cannot fully replace normal functions of kidneys
    • Can ease many of the symptoms Can prevent certain complications
    • HD does not alter the accelerated rate of development of cardiovascular disease and the related high mortality rate.
    • The yearly death rate among patients receiving maintenance dialysis remains high and is estimated to be between 19% and 24%.
    • Individual adaptation to maintenance HD varies considerably. Initially, many patients feel positive about the dialysis because it makes them feel better and keeps them alive, but there is often great ambivalence about whether it is worthwhile.
  23. A patient undergoes peritoneal dialysis exchanges several times each day. What should the nurse plan to increase in the patient’s diet?
  24. Dialysis encephalopathy
    1. Description: An aluminum toxicity from dialysatewater sources containing aluminum; also canoccur from ingestion of aluminum-containingantacids (phosphate binders). This is not a commonoccurrence.

    • 2. Assessment
    • a. Progressive neurological impairmentb. Mental cloudinessc. Speech disturbancesd. Dementiae. Muscle incoordinationf. Bone paing. Seizures

    • 3. Interventions
    • a. Monitor for the signs of dialysis encephalopathy.b. Notify the physician if signs of dialysisencephalopathy occur.c. Administer aluminum-chelating agents asprescribed so that the aluminum is releasedand dialyzed from the body.

    A. Description

    1. A human kidney from a compatible donor isimplanted into a recipient.

    2. Kidney transplantation is performed for irreversiblekidney failure; specific criteria is establishedfor eligibility for a transplant.

    3. The recipient must take immunosuppressivemedications for life.

    • D. Cold ischemic time
    • 1. Cold ischemic time is the time elapsed betweenthe cessation of blood flow to the kidney andthe time required for anastomosis of the kidneyin the recipient
    • 2. The maximum transplantation time is up to72 hours.
  26. Live vs Cadaver Donors
    • B. Living related donors
    • 1. The most desirable source of kidneys for transplantationis living related donors who closelymatch the client.
    • 2. Donors are screened for ABO blood group, tissue-specific antigen, human leukocyte antigensuitability, mixed lymphocyte culture index(histocompatibility); donors are also screenedfor the presence of any communicable diseasesand undergo a complete medical evaluation aswell as a nephrology consultation.
    • 3. The donor must be in excellent health, with twoproperly functioning kidneys.
    • 4. The emotional well-being of the donor isdetermined.
    • 5. Complete understanding of the donation processand outcome by the donor is necessary.

    • C. Cadaver donors
    • 1. Cadaver donors must meet the institution’s criteriaof brain death.
    • 2. Cadaver donors usually need to be younger than70 years.
    • 3. Cadaver donors must have normal renal function,although “marginal” donor organs havebeen used with the consent of the recipient.
    • 4. No malignant disease outside the central nervoussystem can be present.
    • 5. No generalized infection or communicable diseasecan be present.
    • 6. No renal trauma can be present.
    • 7. The potential donor must be negative for communicablediseases at the time of donation.
    • 8. Once cerebral death has been established fora potential donor, restoration of intravascular volume,weaning from vasopressors, and establishingdiuresis are crucial; management of the donor isdetermined by organ bank personnel.
    • 9. Continuous ventilation, and normal bloodpressure and heart rate are maintained until thekidneys and other organs are surgically removed.
  27. Preop Transplant
    Preoperative interventions

    • 1. Verify histocompatibility tests of donor, whichwill be done by organ bank personnel.
    • 2. Administer immunosuppressive medications tothe recipient for 2 days before the transplantation,as prescribed.
    • 3. Maintain strict aseptic technique for therecipient.
    • 4. Verify that hemodialysis of the recipient wascompleted 24 hours before transplantation.
    • 5. Ensure that the recipient is free of anyinfections.
    • 6. Assess renal function studies.
    • 7. Encourage discussion of feelings of the donorand the recipient.
    • 8. Provide psychological support to the live donoror cadaver donor family and the recipient.
  28. POST OP Transplant
    1. Urine output usually begins immediately if thedonor was a living donor; it may be delayedfor a few days or more with a cadaver kidney.2. Hemodialysis may be performed until adequatekidney function is established.3. Monitor vital signs, central venous pressure (CVP),and pulse oximetry for signs of complications.4. Monitor urine output hourly; immediatelyreport a urine output less than 100 mL/hr.5. Monitor IV fluids closely; for the first 12 to 24hours, IV fluid replacement is based on hourlyurine output.6. Administer prescribed diuretics and osmotic agents.7. Monitor daily weight to evaluate fluid status.8. Monitor daily laboratory results to evaluaterenal function, including hematocrit, BUN,and serum creatinine levels, and monitor urinefor blood and specific gravity.9. Position the client in a semi-Fowler’s positionto promote gas exchange, turning from theback to the nonoperative side.10. Monitor Foley catheter patency; the Foley catheterremains in the bladder for 3 to 5 days toallow for anastomosis healing.11. Note that urine is pink and bloody initially butgradually returns to normal within several daysto weeks.12. Notify the physician if gross hematuria andclots are noted in the urine.13. Monitor the three-way bladder irrigation, ifpresent, for clots; irrigate only if a physician’sprescription is present.14. Remove the Foley catheter as soon as possibleto prevent infection.15. Maintain aseptic technique and monitor forinfection; infection is the primary cause ofdeath in the first year post-transplant.16. Maintain strict aseptic technique with woundcare.17. Monitor for bowel sounds and for the passage offlatus; initiate a specific diet and oral fluids as prescribedwhen flatus and bowel sounds return(usually, fluids, sodium, and potassium arerestricted if the client is oliguric).18. Maintain good oral hygiene, monitoring forstomatitis and bacterial and fungal infections.19. Encourage coughing and deep-breathingexercises.20. Administer medications as prescribed, whichmay include antifungal medications, antibiotics,immunosuppressive agents, andcorticosteroids.21. The client is usually ambulated after 24 hours.22. Assess for organ rejection by monitoring of laboratoryvalues closely.23. Promote live donor and recipient relationship.24. Monitor both the donor and recipient fordepression.25. Provide the recipient with instructions followingthe kidney transplantation (Box 62-11).26. Assist the recipient to cope with the bodyimage disturbances that occur from long-termuse of immunosuppressants.27. Advise the recipient of available support groups.
  29. **Client Instructions Following Kidney Transplantation
    Avoid prolonged periods of sitting.

    • Monitor intake and output.
    • Recognize the signs and symptoms of infection andrejection.

    Use medications as prescribed, and maintain immunosuppressivetherapy for life.

    Avoid contact sports.

    Avoid exposure to persons with infections.
  30. G. Graft rejection
    • 1. Assessment :
    • Temperature higher than 100 F (37.7 C)
    • Pain or tenderness over the grafted kidney2- to 3-lb weight gain in 24 hours
    • EdemaHypertensionMalaise
    • Elevated blood urea nitrogen and serum creatinine levels
    • Decreased creatinine clearance
    • Elevated white blood cell count
    • Rejection indicated by ultrasound or biopsy

    • 2. Hyperacute rejection
    • a. Hyperacute rejection occurs at the time ofanastomosis of the organ.b. Interventions: Removal of rejected kidney

    • 3. Acute rejection
    • a. Most common type; occurs most frequentlywithin 6 weeks postoperatively, but canoccur any time post-transplant.b. Interventions: Potentially reversible withincreased immunosuppression and if treatedearly; administer high doses of corticosteroids,or monoclonal antibodies if corticosteroidsare ineffective.
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NS3P1 RENAL Dialysis & Transplants
Dialysis & Transplant
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