1. ★ body fluid I/O (Intake and Output)
1) body fluid intake
- Water enters the body through three sources; orally ingested liquids, water in foods, and water formed by oxidation of foods. Foods are liquid at room temperature, such as gelatin, custard, ice cream.
2) body fluid output
- Water lost through the skin is called insensible loss. The average amount of water lost by perspiration alone is 100㎖/day.
- Water lost from the lungs is called insensible loss and is lost through expired air that is saturated with water vapor.
- Large quantities of water are secreted into the gastrointestinal tract, but almost all this fluid is reabsorbed. A large volume of electrolyte-containing liquids moves into the gastrointestinal tract and then returns into the extracellular fluid. Ex) vomitus, drainage, diarrhea, feces
- The kidneys play a major role in regulating fluid and electrolyte balance and excrete the largest quantity of fluid. ex) urine
3) Weight is the best indicator of dehydration.
2. bedpan 대기
- ① 침대를 올림 ② 환자에게 무릎을 구부리고 엉덩이를 들라고 함 ③ 환자 밑에 bed pan을 댐 ④ 환자의 머리를 90°로 올림 ⑤ 침대를 낮춤
4. nelaton catheterization
5. foley catheterization
6. PD (Peritoneal Dialysis)
- PD works on the principles of osmosis, diffusion, and ultrafiltration; PD occurs via the transfer of fluid and solute from the bloodstream through the peritoneum into the dialysate solution. The peritoneum acts as the dialyzing membrane (semipermeable membrane) to achieve dialysis. The peritoneal membrane is large and porous, allowing solutes and fluid to move via osmosis from an area of higher concentration in the body to an area of lower concentration in the dialyzing fluid. One infusion (fill), dwell, and drain is considered one exchange.
- types of PD
(Continuous Ambulatory Peritoneal Dialysis)
|– Does not require a machine for the procedure.
– Four dialysis cycles are usually administered in a 24hr period, including an overnight 8 hr dwell time.
|automated PD||– Automated PD requires a peritoneal cycling machine.
– types of automated PD
- access for PD: A siliconized rubber catheter such as a Tenckhoff catheter is surgically inserted into the client’s peritoneal cavity to allow infusion of dialysis fluid.
- dialysate solution: All dialysis solutions are prescribed by the HCP. The solution contains electrolytes and minerals and has a specific osmolarity, specific glucose concentration, and other medication additives as prescribed. 투석 시 투석액은 체온 정도의 온도로.
- contraindications to PD: peritonitis, other GI problems such as diverticulosis, recent abdominal surgery, abdominal adhesions
- PD intervention: Monitor vital signs before, and after dialysis (투석 후 약간의 미열은 정상). Monitor for respiratory distress, pain, or discomfort (signs of pulmonary edema). Monitor laboratory values before, and after dialysis. Assess the client for fluid overload before dialysis and fluid volume deficit following dialysis. Weigh the client before and after dialysis to determine fluid loss. Do not allow dwell time to exten beyond the HCP’s prescription because this increases the risk for hyperglycemia. Monitor intake and output accurately; if the outflow is less than inflow, the difference is equal to the amount absorbed or retained by the client during dialysis and should be counted as intake. An outflow greater than inflow should be reported to the HCP as well as the appearance of frank blood or cloudiness in the outflow. Assess the catheter site dressing for wetness or bleeding.
- complications of PD: leakage around the catheter site (1 ∼2주 정도는 정상 소견임), insufficient outflow, abnormal outflow characteristics indicative of complications, abdominal pain, peritonitis, bladder or bowel perforation
7. HD (HemoDialysis)
- HD is the process of cleansing the client’s blood. It involves the diffusion of dissolved particles from one fluid compartment into another across a semipermeable membrane; the client’s blood flows through one fluid compartment of a dialysis filter, and the dialysate is in another fluid compartment. The client’s blood flows into the dialyzer; the movement of substances occurs from the blood to the dialysate by the principles of osmosis, diffusion, and ultrafiltration.
- The pore size of the membrane allows small particles to pass through the membrane. Proteins, bacteria, and some blood cells are too large to pass through the membrane.
- access for HD
|– a subclavian (subclavian vein) or femoral (femoral vein) catheter
– It may be inserted for short-term or temporary use in AKI. The catheter is used until a fistula or graft matures or develops, which is typically 6 weeks, or maybe required when the client’s fistula or graft access has failed because of infection or clotting.
– These catheters should only be sued for dialysis treatment.
– These catheters should only be used for dialysis treatment. Assess the insertion site for hematoma, bleeding, catheter dislodgement, and infection. Assess the extremity for circulation, temperature, and pulses. Maintain an occlusive dressing over the catheter insertion site. The client with a femoral vein catheter should not sit up more than 45 degrees or lean forward, because the catheter may kink and occlude.
|external ArterioVenous shunt
|– Two silastic cannulas are surgically inserted into an artery and vein in the forearm or leg to form an external blood path.
– Avoid getting the shunt wet. Assess for signs of hemorrhage, infection, or clotting.
|internal ArterioVenous fistula
|– A permanent access of choice for the client with CKD requiring dialysis. Maturity takes about 4 to 6 weeks. Subclavian or femoral catheters, peritoneal dialysis, or an external arteriovenous shunt can be used for dialysis while the fistula is maturing or developing.
– Teach the client that the shunt extremity should not be used for monitoring BP, drawing blood, placing IV lines, or administering injections. To ensure patency, palpate for a thrill or auscultate for a bruit over the fistula or graft. Notify the HCP immediately if signs of clotting (tingling or discomfort in the extremity, inability to palpate a thrill, inability to auscultate a bruit), infection, or arterial steal syndrome occur. Monitor lung and heart sounds for signs of heart failure.
|internal ArterioVenous graft||– The internal graft may be used for chronic dialysis clients who do not have adequate blood vessels for the creation of a fistula.
– Same as AV fistula intervention. An aneurysm can form in the graft; in addition, grafts clot more frequently than arteriovenous fistulas.
- HD intervention: Monitor vital signs before, during, and after dialysis. (The client’s temperature may elevate because of the slight warming of the blood from the dialysis machine. But notify the HCP about excessive temperature elevations (above 100.5℉) because this could indicate sepsis.) Monitor laboratory values before, during, and after dialysis. Assess the client for fluid overload before dialysis and fluid volume deficit following dialysis. Weigh the client before and after dialysis to determine fluid loss. Monitor for bleeding; heparin added to the dialysis bath to prevent clots from forming in the dialyzer or the blood tubing. Provide adequate nutrition; the client may eat before or during dialysis. Withhold antihypertensives and other medications that can affect the blood pressure or result in hypotension until after HD treatment. Also withhold medications that could be removed by dialyses, such as water-soluble vitamins, certain antibiotics, and digoxin. Assess the patency of the blood access device before, during, and after dialysis.
- complications of HD: air embolus, disequilibrium syndrome, encephalopathy, electrolyte alterations, hemorrhage, hepatitis, sepsis, shock, hypotension
8. CRRT (Continuous Renal Replacement Therapy)
- CRRT provides continuous ultrafiltration of extracellular fluid and clearance of urinary toxins over a period of 8 to 24 hours; used primarily for clients in AKI or critically ill clients with CKD who cannot tolerate HD. Water, electrolytes, and other solutes are removed as the client’s blood pass through a hemofilter. Because rapid shifts in fluids and electrolytes typically do not occur, hemofiltration is usually better tolerated by critically ill clients.