SPECIAL CONSIDERATIONS: CARE OF THE HOSPITALIZED DIALYSIS PATIENT
Whether undergoing hemodialysis or peritoneal dialysis, the pa-tient may be hospitalized for treatment of complications related to the dialysis treatment, the underlying renal disorder, or health problems not related to renal dysfunction or its treatment.
When the hemodialysis patient is hospitalized for any reason, care must be taken to protect the vascular access from damage. The nurse assesses the vascular access for patency and takes precau-tions to ensure that the extremity with the vascular access is not used for measuring blood pressure or for obtaining blood speci-mens; tight dressings, restraints, or jewelry over the vascular access are to be avoided as well.
The bruit, or “thrill,” over the venous access site must be eval-uated at least every 8 hours. Absence of a palpable thrill or audi-ble bruit may indicate blockage or clotting in the access device. Clotting can occur if the patient has an infection anywhere in the body (serum viscosity is increased) or if the blood pressure has dropped. When blood flow is reduced through the access for any reason (hypotension, application of blood pressure cuff or tourni-quet), the access can clot or become infected. The nurse observes the patient for signs and symptoms of infection, such as redness, swelling, drainage from the site, and fever. Patients with renal dis-ease are more prone to infection; therefore, infection control measures must be used for all procedures.
When the patient needs intravenous therapy, the rate of admin-istration must be as slow as possible and should be strictly con-trolled by a volumetric infusion pump. Because dialysis patients cannot excrete water, rapid or excessive administration of intra-venous fluid can result in pulmonary edema. Accurate intake and output records are essential.
As metabolic end products accumulate, uremic symptoms worsen. Patients whose metabolic rate accelerates (those on corticosteroid medications or parenteral nutrition, those with infections or bleed-ing disorders, those undergoing surgery) accumulate waste prod-ucts more quickly and may require daily dialysis. These same patients are more likely to experience complications than other dialysis patients.
Cardiac and respiratory assessment must be conducted frequently. As fluid builds up, fluid overload, heart failure, and pulmonary edema develop. Crackles in the bases of the lungs may indicate pulmonary edema.
Pericarditis may result from the accumulation of uremic toxins. If not detected and treated promptly, this serious complication may progress to pericardial effusion and cardiac tamponade. Pericardi-tis is detected by the patient’s report of substernal chest pain (if the patient can communicate), low-grade fever (often overlooked), and pericardial friction rub. A pulsus paradoxus (a decrease in blood pressure of more than 10 mm Hg during inspiration) is often present. When pericarditis progresses to effusion, the friction rub disappears, heart sounds become distant and muffled, electro-cardiographic waves show very low voltage, and the pulsus paradoxus worsens.
The effusion may progress to life-threatening cardiac tam-ponade, noted by narrowing of the pulse pressure in addition to muffled or inaudible heart sounds, crushing chest pain, dyspnea, and hypotension. Although pericarditis, pericardial effusion, and cardiac tamponade can be detected by chest x-ray, they should also be detected through astute nursing assessment. Because of their clinical significance, assessment of the patient for cardiac complications is a priority.
Electrolyte alterations are common, and potassium changes can be life threatening. All intravenous solutions and medications to be administered are evaluated for their electrolyte content. Serum laboratory values are assessed daily. If blood transfusions are re-quired, they may be administered during hemodialysis, if possible, so that excess potassium can be removed. Dietary intake must also be monitored. The patient’s frustrations related to dietary restric-tions typically increase if the hospital food is unappetizing. The nurse needs to recognize that this may lead to dietary indiscretion and hyperkalemia.
Hypoalbuminemia is an indicator of malnutrition in patients undergoing long-term or maintenance dialysis. Although some pa-tients can be treated with adequate nutrition alone, some patients remain hypoalbuminemic for reasons that are poorly understood.
Complications such as pruritus and pain secondary to neurop-athy must be managed. Antihistamine agents, such as diphen-hydramine hydrochloride (Benadryl), are commonly used, and analgesic medications may be prescribed. Because elimination of the metabolites of medications occurs through dialysis rather than through renal excretion, however, medication dosages may need to be adjusted. Keeping the skin clean and well moisturized using bath oils, superfatted soap, and creams or lotions helps to promote comfort and reduce itching. Teaching the patient to keep the nails trimmed to avoid scratching and excoriation and to rub lotion into the skin instead of scratching also promotes comfort.
Hypertension in renal failure is common. It is usually the result of fluid overload and, in part, oversecretion of renin. Many dial-ysis patients receive some form of antihypertensive therapy and require intense teaching about its purpose and adverse effects. The trial-and-error approach that may be necessary to identify the most effective antihypertensive agent and dosage may confuse or alarm the patient if no explanation is provided. Antihyper-tensive agents must be withheld on dialysis days to avoid hy-potension due to the combined effect of the dialysis and the medication.
Typically these patients require single or multiple antihyper-tensive agents to achieve normal blood pressure, thus adding to the total number of medications needed on an ongoing basis. Re-search has demonstrated that by maintaining strict volume con-trol via absolute dietary salt restrictions, thorough explanation of the rationale behind the sodium restriction to the patient and family, and increased ultrafiltration by using more hypertonic peritoneal dialysis solution, most persons can maintain a normal blood pressure without the use of antihypertensive agents (Gunal, Duman, Ozkahya et al., 2001).
Patients with ESRD commonly have low white blood cell counts (and decreased phagocytic ability), low red blood cell counts (anemia), and impaired platelet function. Together, these pose a high risk for infection and potential for bleeding after even minor trauma. Preventing and controlling infection are essential because the incidence of infection is high. Infection of the vascular access site and pneumonia are common.
Patients receiving CAPD usually know how to care for the catheter site; however, the hospital stay should be an opportunity to assess compliance with recommended catheter care and to correct any misperceptions or deviations from correct technique. Recom-mended daily or three-or-four-times-weekly routine catheter site care is typically performed during showering or bathing. The exit site should not be submerged in bath water. The most common cleaning method is soap and water; liquid soap is recommended. During care, the nurse and patient need to make sure that the catheter remains secure to avoid tension and trauma. The patient may wear a gauze or semitransparent dressing over the exit site.
The medications prescribed for any dialysis patient must be closely monitored to avoid those that are toxic to the kidneys and may threaten remaining renal function. All medications must be monitored, and alterations in dosages may be necessary to pre-vent either toxic effects on the kidney or overdosage because of impaired renal excretion. Care must be taken to evaluate all prob-lems and symptoms that the patient reports without automati-cally attributing them to renal failure or to dialysis therapy.
Patients undergoing dialysis for a while may begin to re-evaluate their status, the treatment modality, their satisfaction with life, and the impact of these factors on their families and support sys-tems. Nurses must provide opportunities for these patients to express their feelings and reactions and to explore options.
The decision to begin dialysis does not require that dialysis be continued indefinitely, and it is not uncommon for patients to consider discontinuing treatment. These feelings and reactions must be taken seriously, and the patient should have the oppor-tunity to discuss them with the dialysis team as well as with a psychologist, psychiatrist, psychiatric nurse, trusted friend, or spir-itual advisor. The patient’s informed decision about discontinu-ing treatment, after thoughtful deliberation, should be respected.