HEALTH EDUCATION in patients undergoing hemodialysis

1. Understanding Haemodialysis
Haemodialysis is derived from hemo meaning blood, and dialysis means separation or filtration. In principle hemodialysis blood placed side by side with dialysate fluid or washing separated by a semi-permeable membrane or membranes. These membranes can be traversed by the water and certain substances or waste substances. This process is called dialysis is the process of migration of water or a substance, material through a semi permeable membrane
Haemodialysis is a treatment for people who decreased kidney function. Haemodialysis takes over the function of the kidneys to cleanse the blood by flow through “artificial kidney”. Waste and excess water removed from the body during hemodialysis process takes place, this is usually done by the kidneys whose function is still good.
2. When to Undergoing Haemodialysis Treatment
Therapy is required if renal function has reached levels last one (stage V) of chronic renal failure. The doctor will determine a person’s level of renal function based on the calculation of GFR or Glomerular Filtration Rate, which at the level of GFR below 15, the kidneys a person is found in the category of terminal kidney failure (End Stage Renal Disease).
3. The purpose of Haemodialysis Therapy
Replacement therapy, hemodialysis activity has the objective:
a. Dispose of products of protein metabolism such as urea, creatinine and uric acid
b. Remove excess water.
c. Maintain or restore the body’s buffer system.
d. Maintain or restore the body’s electrolyte levels.
e. Improving the health status of patients.
4. How it Works Haemodialysis
An artificial kidney hemodialysis machine spliced ​​with. An IV will be tasked with the blood drain from your body to be cleaned in an artificial kidney, another IV line will drain the blood back into your body. This process which will dispose of waste and excess water from your body.
Haemodialysis requires a dialysis machine and a special filter called dializer (a semipermeable membrane) that is used to cleanse the blood, the blood removed from the patient’s body and circulating in a machine outside the body. Haemodialysis requires access to the bloodstream, then created an artificial connection between arteries and veins (arteriovenous fistula) through surgery (NKF, 2006).
In hemodialysis activity occurred 3 main processes as follows:
a) The process of diffusion of solute migration due to differences in levels in the blood and in dialysate. High Semakian differences in blood levels of the more material is transferred into the dialysate.
b) Process of Ultrafiltration is the process of migration of water and dissolved materials due to differences in hydrostatic pressure in the blood and dialysate.
c) Process of Osmosis is the process of displacement of water due to chemical energy, which is the difference of blood and dialysate osmolarity (Lumenta, 1996).
5. How To Care In Haemodialysis Patients
Needed a way so that your blood can get into the machine, this is called “access”. The most common access is a fistula in your arm. Your surgeon will make a small incision in your arm and connect two blood vessels, arteries and veins. This will make your veins become larger and easier to install two dialysis nurses needles, one for blood flow to the engine, the other drain blood into your body.
6. Vascular access for hemodialisi
Hemodialysis vascular access is the most sensitive aspect padahemodialisis because of the many complications and failures. To make a long-term intermittent dialysis, it is necessary to entrance into the vascular system of patients who can be relied upon. Vascular access can be classified as follows:
a. External vascular access (temporary), namely sub-clavicle and femoral catheter (HD-Cath)
 Immediate access to the blood circulation of patients in emergency hemodialysis achieved through subclavian catheterization for temporary use. Dual-lumen catheter or a multi-lumen inserted into the subclavian vein. Although the preferred method of vascular access is open it without risk, but these methods can usually be used for several weeks. Femoral catheter can be inserted into the femoral vein, and is used for several weeks, if the patient is not needed because the patient’s condition had improved or there are other means of access.
Indications:
- Acute renal failure
- Poisoning, drug overdose
- Renal failure phase of permanent vascular access information that has not been mature / experienced interference
- Kidney transplant patients who experienced rejection (rejection)
complications;
- Occurs thrombus
- Infection
- Stritura
- Dysfunction
care:
- Try to always dry
- After each dialysis lumen is always filled with NaCl + heparin 100IU/ml
- Try the lumen of the catheter tip is in contact with air
b. Internal vascular access (permanent)
 A more permanent fistula created surgically by connecting or connecting arteries with veins are side to side or end to side. The fistula may take 4 to 6 weeks to mature before it is ready for use. Time is required to give a chance to heal fistulas and dilated fistula vein segments properly so it can accept large berlumen needles with a size 14 to 16. Segment of artery fistula used to re-enter the blood that has been dialyzed, blood flow to accommodate this segment of the artery and vein fistula must be greater than normal blood vessels. The patient is recommended to perform exercises to increase the size of blood vessels, ie by squeezing a rubber ball to train fistula created under dilengan, thus the width of blood vessels that have been able to receive large needles used in the process of hemodialysis.
Complications:
- Stenosis
- Thrombosis
- Regional ischemia distal
- Edema of the distal region
- Pseudoaneurisma
- Infection
- Decompression cardiac
How to treat fistula:
Immediately after the operation:
• Keep the stitches and bandages remain dry.
• The doctor will determine when the stitches are opened, usually after 8-14 days.
• If there is swelling in the arm after fistula surgery, put your arm higher 1 pillow while sleeping.
• Inform the health worker if there is bleeding, pain or swelling continued.
• Check the fistula in your arm a few times a day by gently touching and feeling a bruit, that is subtle vibrations caused by blood flow.
Protect your fistula:
• Avoid sleeping with sleeves rolled to the side that had been installed fistula
• Avoid the use of a watch or bracelet on the arm that had been installed fistula
• Avoid lifting heavy objects (more than 12 kg) that had been installed on the arm fistulas
• Do not take blood, measuring blood pressure in the arm that had been installed fistula
Train your arms that have been installed fistula:
• The larger your fistula, the easier it is for nurses to access dialysis on your arm.
• Hold the sponge or tennis ball or soft rubber ball in the hand that performed the installation of fistula.
• Do a wringing motion 20 times, continue with the rest.
• Do this exercise several times a day.
• Exercises performed until the fistula is mature enough to be used.
• Your daily activities will not interfere with fistula.
• If there is a yellowish liquid / pus at the site of fistula placed, immediately contact your doctor.
• If you are still bleeding fistula after use, press and use a sterile gauze for 5 -10 minutes.
7. Complications Haemodialysis
According Tisher and Wilcox (1997) and Havens and Terra (2005) during the act of frequent hemodialysis complication that occurs once discovered, among other things:
a. Muscle cramps
Muscle cramps generally occur in half the time goes by hemodialysis until near the expiration of hemodialysis. Muscle cramps often occur in ultrafiltration (fluid withdrawal) is fast with high volume.
Management:
o lower the UF
o reduce the QB
o give hypertonic fluids in non-diabetic patients
o give calcium gluconate injection
prevention;
• use a dialysate with appropriate levels of Na
• do stretching exercises, especially in muscles that often experience cramps
• giving quinine sulfate 260mg or oxazepam 5-10mg orally 2 hours before dialysis
b. Hypotension
The occurrence of hypotension is possible because the use of acetate dialysate, low sodium dialysate, atherosclerotic heart disease, autonomic neuropathy, and an additional excess weight of the liquid.
Management:
• Trendelenburg position the patient made
• reduce / stop ultrafiltration
• give intravenous fluids 200ml 0.9% NaCl, monitor BP and pulse. If not improved again gave NaCl to 500ml, when it is set back ultrafiltration improved, if not improved given fluids such as hypertonic glucose 40% and provide oxygenation.
• If you need dialysis temporarily suspended, if it is improving, the HD can be restarted.
Prevention:
• try to increase inter-HD weight <1kg/hari
• Do not set the UF clients under dry BB
• keep the dialysate Na equal or above blood plasma
• try not to take medicine hypertension prior to dialysis
• use bicarbonate dialysate
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• Do not give food meat or oral glucose during dialysis to patients with normal intra-dialysis hypotension
c. Arrhythmia
Hypoxia, hypotension, cessation of antiarrhythmic drugs during dialysis, decreased calcium, magnesium, potassium, and serum bicarbonate are rapid effect on arrhythmias in hemodialysis patients.
d. Imbalance syndrome dialysis
Syndrome is believed to be the primary dialysis imbalance can result from other osmol-osmol clearance from the brain and that less rapidly than urea from the blood, resulting in an osmotic gradient between these compartments. This osmotic gradient causes water movement into the brain causing cerebral edema. This syndrome is not uncommon and usually occurs in patients undergoing hemodialysis with the first severe azotemia.
e. Hypoxemia
Hypoxemia during hemodialysis is an important thing that needs to be monitored in patients kardiopulmonar malfunctioning.
f. Bleeding
Uremia causes disturbances of platelet function. Platelet function can be assessed by measuring the bleeding time. The use of heparin during hemodialysis is also a risk factor for bleeding.
g. Indigestion
Gastrointestinal disorders that often occur are nausea and vomiting caused by hypoglycemia. Indigestion is often accompanied by headache.
Management: management of hypotension intuk addressed, if still vomiting nausea and antiemetic drug given for headache administered analgesic drugs
Prevention: avoid the incidence of hypotension during dialysis. Sometimes the QB drop for 1 hour beneficial for some patients.
h. Infection or inflammation can occur in vascular access.
i. Blood clots can be caused because the administered dose of heparin or inadequate blood rotation speed is slow.
j. Air embolism is a rare complication but it can only happen if the air entering the patient’s vascular system.
Management:
• supine sleeping position (feet higher than his head)
• lying to the left side of body
• QB and TMP lowered, if necessary, discontinued HD
• Give O2
• Maintain airway
Prevention;
• bubbletrap not too low
• air detector pairs
• the connections are tightened
k. Pruritus may occur during dialysis therapy when the end-products of metabolism leave the skin.
8. This – It Will Be Examined Before Haemodialysis
a) Access to dialysis
b) All lanes hemodialysis
c) Blood pressure and heart rate you
d) dialysis machine
e) Artificial Kidney
f) The fluid used for hemodialysis process
g) The complaint that you feel during the process of hemodialysis
Certain moments of your blood will be checked to see the state of your body and results of hemodialysis therapy
9. The duration of Haemodialysis Process Held
Hemodialysis process will last for about four or five hours depending on your physical condition. During that time only a small portion of your blood outside the body, because it will soon be returned to your body.
10. Preparation Before Haemodialysis
History:
In renal failure patients who will do these actions include:
a) Haemodialysis is for permanent or temporary.
b) The condition of the arteries and veins if there is a history of phlebitis, arteritis, etc..
o The use of the dominant arm, where the operations performed on the nondominan arm.
o Schedule of hemodialysis, because the surgery is performed at least 24 hours afterwards in the hope of the effects of heparin have been lost, also on other anticoagulant drug users be aware of the dangers of thrombosis and bleeding.
o Complaints tightness in the reclining position, with respect to the position of operating time.
o A history of comorbidities such as diabetes would complicate the action.
o The drugs routinely given to you previously.
o Reading materials for you during hemodialysis in progress, a snack.
- We recommend that you arrive 10 minutes prior to your schedule, please wait in the waiting room. When it’s time for your turn, the nurse would allow you to enter.
- Remove heavy clothing, handbags, wallets, shoes then weigh yourself.
- Tell the clerk how much you weigh.
- The nurse will measure your blood pressure
11. Suggested Diet For Dialysis Patients
Causes of decline in nutritional status in hemodialysis patients is:
• hemodialysis is a catabolic process (solving complex compounds into simpler compounds), on the hemodialysis process occurs through the dialysate amino acids spending and decreased synthesis (formation) proteins. during the process of muscle hd will release amino acids.
• uremia (presence of urea in the blood / high levels of urea in the blood), causing the patient became nauseated and decrease appetite.
• hormonal changes and comorbidities.
in addition to the dialysis process and the appropriate drug delivery, providing the right diet among dialysis time may help fix the problem gizi.pasien.
dietary goals:
1. prevent nutrient deficiencies as well as maintaining and improving the nutritional status, so that clients can perform normal activities.
2. maintain fluid and electrolyte balance.
3. keep the accumulation / buildup of metabolic waste products are not excessive.
Dietary advice:
A. enough energy, namely 35 kcal / kg ideal mm / day on the client hemodialysis (HD) or continuous ambulatory peritoneal (CAPD). on CAPD calculated the amount of energy derived from the dialysis fluid. weight loss if needed, should be done gradually (250-500 g / week to reduce the risk of catabolism of lean body mass (lean body mass).
B. high protein, to maintain nitrogen balance and replace amino acids lost during dialysis, which is 1 to 1.2 g / kg ideal mm / day on hd and 1.3 g / kg ideal mm / day in CAPD. 50% protein should be of high biological value.
C. carbohydrate, ie 55-75% of total energy needs.
D. normal fat, ie 15-30% of total energy needs.
E. sodium given in accordance with the amount of urine keluar/24 hours, namely:
O + 1 g of adjustment according to the amount of urine a day, ie 1 ½ grams for each liter of urine (hd).
O 1-4 + adjustments according to the amount of urine a day, ie 1 ½ grams per liter of urine (CAPD).
F. accordance with the urine potassium keluar/24 hours, namely:
G + O 2 adjustments according to the amount of urine a day, ie 1 g for every 1 liter of urine (hd).
G + O 3 adjustments according to the amount of urine a day, ie 1 g for every 1 liter of urine (CAPD).
G. high calcium, which is 1000 mg / day. if necessary, be given calcium supplements.
H. phosphorus limited, ie <17 mg / kg ideal mm / day.
I. fluid restricted, ie the number of urin/24 hours plus 500-750 ml.
J. vitamin supplements when necessary, especially water soluble vitamins such as B6, folic acid and vitamin c.
K. when appetite is less, provide enteral supplements containing high energy and protein.

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