bab 5 renal replacement therapy
TRANSCRIPT
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
BAB 5
5. RENAL REPLACEMENT THERAPY
When patients have reached and stage renal disease are gibe option
to decide or decided by the nephrologists based on patient conditions
for a renal replacement theraphy. The option that are available are :-
5.1 Continuous Ambulatory Peritoneal Dialysis
- A tenckoff catheter is inserted into the peritoneum cavity and after
10 – 14 days, a training is given by a nurse.
- It’s a dialysis process that dose non stop. It’s continuously cleans
the blood 24 hours a day.
- Patient is free between 2 exchanges.
- Peritoneal membrane works like a semi-permeable filter.
5.2 Haemodialysis
- Haemodialysis is a procedure for removing dissolved waste or
contaminants ( eg urea, creatinine uric acid) from the blood
mainly by diffusion through a semipermeable membrane (dialyser
membrane) by using dialysate as a buffer when the kidney
filtration function fail. Diffusion, ultrafiltration and osmosis will be
happen during haemodialysis.
- A permanent access is created either ateriovenous fistula or
Brachiocephalic fistula or a temporary acces is inserted to the
patient haemodialysis procedure done.
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
Process A Semipermeable Membrane
(Sumber: http//www.shodor.org/master/biomed/physio/haemodialysis/fig2.jpg)
5.3 Kidney Transplant
Is the transfer of a healthy from the donor to patient with end stage
kidney failure. Only kidney transplant can replace all of the functions
of the kidney.
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
Schedule : Anemia for year 1999
Date HB Sr IRON Sr Ferritin Sr IPTH TIBC(g/dL) (umol/L) (µg/L) (pg/ml) (µmmol/L)
25.05.99 9.4 14 - - 54
06.07.99 8.1 29 - 45
12.08.99 8.1 20 - - 42
07.10.99 11.3 10 - - 45
22.11.99 13.2 10 - - 48
Schedule : Anemia for year 2000
Date HB Sr IRON Sr Ferritin Sr IPTH TIBC(g/dL) (umol/L) (µg/L) (pg/ml) (µmmol/L)
07.03.00 8.5 - - - -
13.04.00 8.9 18 - - 46
08.08.00 9.2 23 - - 49
07.09.00 10.8 10 - - 49
Schedule : Hemoglobin 1999 & 2000
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
MINISTRY OF HEALTH, MALAYSIA
DIALYSIS LABORATORY RESULTS CHARTHospital Raja Puteri Bainun, Ipoh, PerakName: Koh Kam Wah I/C No. : 590530-08-6095
LAB Test Date25.05.99 06.07.99 12.08.99 07.10.99 22.11.99
BiochemistryUrea pre
1.7 – 8.3 mmol/L21 20.2 18.7
Urea postSodium pre
135-145 mmol/L147 147 145
Sodium postPotassium pre
3.5-5.0 mmol/L4.5 4.6 4.6
Potassium postCreatinine pre
64-122 mmol/L911 856 994
Creatinine postChloride pre/Co2 96-108 mmol/L 107 105 98Uric Acid 142-416 mmol/L 302 443 401Total Protein 66-87 g/L 61 72 71Albumin 35-50 g/L 37 42 43Total Bilirubin Up to 21 mmol/L 5 1 1Alk phosphatase 53-128 U/L 101 91 90SGOT/SGPT Up to 42 U/L 12/13 20/19Calcium 2.0-2.6 mmol/L 1.96 2.40 2.43Inorganic Phosphate 0.8-1.6 mmol/L 2.06 2.12 2.05Ca x Po4 1.0 1.1 1.4Total cholesterol < 5.7 mmol/L 5.2 6.6 5.6Triglyceride < 1.7 mmol/L 1.9 1.5LDL – Cholesterol < 3.9 mmol/L 1.7HDL – Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/LFBSRBS
HAEMATOLOGYHB g/dL 9.4 8.1 8.1 11.3 13.2TWDC 5300 5.5 4.6 4.5 4.8HCT 27.3 24.0 24.6 33.0 38.3Platelets THSD/mm³ 156,000 126,000 164,000 182,000 181,00MCV 91.7 93.3 98.3 96.0 90.5MCHC 34.4 33.8 33.0 34.2 34.5% Hypochromic RBCRetic/LymphoSr. IRON 10.6-28.3 µmol/L 14 29 20 10 10TIBC 44-75 µmmol/L 54 45 42 45 48Transferrin Ratio UIBC > 20 %Sr. Ferritin ug/LE.S.R mm/hrSerum intact PTH 13-54 pg/ml 522 665
Serum Aluminium
Pre DFOPost DFODelta
VIROLOGY / SEROLOGYHBs Ag -ve -veAnti HBsHBc AgAnti HCV -ve -veAnti HIV -ve -veCMVBlood group ‘o’
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
MINISTRY OF HEALTH, MALAYSIA DIALYSIS LABORATORY RESULTS CHART Hospital Raja Puteri Bainun, Ipoh, PerakName: Koh Kam Wah I/C No. : 590530-08-6095
LAB Test Date07.03.00 13.04.00 08.08.00 07.09.00
BiochemistryUrea pre
1.7 – 8.3 mmol/L20.2 22.2
Urea postSodium pre
135-145 mmol/L140 143
Sodium postPotassium pre
3.5-5.0 mmol/L4.5 4.6
Potassium postCreatinine pre
64-122 mmol/L1150
Creatinine postChloride pre/Co2 96-108 mmol/L 97 106Uric Acid 142-416 mmol/L 453 591Total Protein 66-87 g/L 70 71Albumin 35-50 g/L 41 39Total Bilirubin Up to 21 mmol/L 9 1Alk phosphatase 53-128 U/L 129 104SGOT/SGPT Up to 42 U/L 14/15Calcium 2.0-2.6 mmol/L 2,37 2.29Inorganic Phosphate 0.8-1.6 mmol/L 2.14 1.22Ca x Po4 0.9 1,1Total cholesterol < 5.7 mmol/L 6.0 5.9Triglyceride < 1.7 mmol/L 1.4 1.5LDL – Cholesterol < 3.9 mmol/LHDL – Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/LFBSRBS
HAEMATOLOGYHB g/dL 8.5 8.9 9.2 10.8TWDC 4.1 5.4 4.3 5.7HCT 24.2 23,7 26.0 30Platelets THSD/mm³ 148,000 168,000 162,000 225,000MCV 86.7 89.4 90.6 89.6MCHC 3.51 37.6 35.4 36% Hypochromic RBCRetic/Lympho 2.87 3.35Sr. IRON 10.6-28.3 µmol/L 18 23 10TIBC 44-75 µmmol/L 46 49 49Transferrin Ratio UIBC > 20 %Sr. Ferritin ug/LE.S.R mm/hrSerum intact PTH 13-54 pg/ml 456
Serum Aluminium
Pre DFOPost DFODelta
VIROLOGY / SEROLOGYHBs Ag -ve -veAnti HBsHBc AgAnti HCV -ve -veAnti HIV -ve -veCMV -ve -veVDRLBlood group
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
MINISTRY OF HEALTH, MALAYSIA
DIALYSIS LABORATORY RESULTS CHARTHospital Raja Puteri Bainun, Ipoh, PerakName: Koh Kam Wah I/C No. : 590530-08-6095
I LAB Test Date
03.01.08 03.04.08 10.08.08 16.10.08Biochemistry
Urea pre1.7 – 8.3 mmol/L
15.9 22.90 25.2 23.5Urea post 3.8 5.0 6.8 5.9Sodium pre
135-145 mmol/L3.8 5.0 6.8 5.9
Sodium postPotassium pre
3.5-5.0 mmol/L142 139 140 144
Potassium post 3.10 2.6 4.8 2.8Creatinine pre
64-122 mmol/L1014.0 1187.0 1227.0 1290
Creatinine postChloride pre/Co2 96-108 mmol/L 99 94 92 92Uric Acid 142-416 mmol/L 435 512 500 570Total Protein 66-87 g/L 75 73 79 79Albumin 35-50 g/L 46 46 40 47Total Bilirubin Up to 21 mmol/L 15.6 14.0 10.4 11.8Alk phosphatase 53-128 U/L 83 100 74 69Alanine Transminase Up to 42 U/L 21 16 20 28Calcium 2.0-2.6 mmol/L 2.32 2.28 2.45 2.82Inorganic Phosphate 0.8-1.6 mmol/L 1.60 1.53 2.37 1.75Magnesium 0.7-1.10mmol/L 1.09 1.04 1.12 .135Total cholesterol < 5.7 mmol/L 3.20 3.40 4.0 3.7Triglyceride < 1.7 mmol/L 1.40 1.60 4.4 2.7LDL – Cholesterol < 3.9 mmol/L 1.46 1.47 0.90 1.4HDL – Cholesterol > 1.4 mmol/L 1.10 1.20 1..10 1.10% of HDL > 25 mmol/L 2.91 2.83 3.64 3.36FBS 3.9 5.0 4.2 4.6SGOT 12.0 14.0 10 16
HAEMATOLOGYHB g/dL 12.1 11.7 12.2 11.7TWDC 5.1 8.1 7.6 6.5HCT 36.7 34.1 37.5 35.7Platelets THSD/mm³ 173 188 191 198MCV 99.6 95.9 101.0 102.6MCHC 33.0 34.4 32.6 32.8% Hypochromic RBCRetic/Lympho 13.4 12.7 3.71 3.47Sr. IRON 10.6-28.3 µmol/L 19.10 13.40 14 21TIBC 44-75 µmmol/L 39.40 44.40 44.0 50Transferrin Ratio UIBC > 20 %Sr. Ferritin ug/L 644.7 705.0 743.7 641.9E.S.R mm/hrSerum intact PTH 13-54 pg/ml 407 637.60 242.8 104.70
Serum Aluminium
Pre DFOPost DFODelta
VIROLOGY / SEROLOGYHBs Ag -ve -ve -ve -veAnti HBsHBc AgAnti HCV -ve -ve -ve -veAnti HIV -ve -ve -ve -veCMVVDRL -ve -ve -ve -veBlood group
MINISTRY OF HEALTH, MALAYSIA
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
DIALYSIS LABORATORY RESULTS CHARTHospital Raja Puteri Bainun, Ipoh, PerakName: Koh Kam Wah I/C No. : 590530-08-6095
LAB Test Date
05.02.09 07.05.09 13.08.09Biochemistry
Urea pre1.7 – 8.3 mmol/L
26.0 26.7 23.3Urea post 6.2 6.6 5.1Sodium pre
135-145 mmol/L139 138 139
Sodium post 143 141 143Potassium pre
3.5-5.0 mmol/L4.0 4.3 4.4
Potassium post 2.8 2.9 3.1Creatinine pre
64-122 mmol/L1250 1275 1266
Creatinine post 364 380 355Chloride pre/Co2 96-108 mmol/L 90/91 90/95 95/98Uric Acid 142-416 mmol/L 598 611 503Total Protein 66-87 g/L 75 74 70Albumin 35-50 g/L 45 44 47Total Bilirubin Up to 21 mmol/L - 13.9 14.5Alk phosphatase 53-128 U/L - 66 64Alanine Transminase Up to 42 U/L 31 39 20Calcium 2.0-2.6 mmol/L 2.12 2.45 2.55Inorganic Phosphate 0.8-1.6 mmol/L 2.18 1.49 1.37Magnesium 0.7-1.10mmol/L 1.17 1.27 1.49Total cholesterol < 5.7 mmol/L 4.5 4.5 3.4Triglyceride < 1.7 mmol/L 9.52 2.86 2.30LDL – Cholesterol < 3.9 mmol/L 0.5 2.4 1.5HDL – Cholesterol > 1.4 mmol/L 0.70 0.80 0.70% of HDL > 25 mmol/L 6.43 5.63 3.78FBS 4.8 4.1 4.4SGOT 16 15 11
HAEMATOLOGYHB g/dL 12.5 13.2 12.2TWDC 5.6HCT 36.9 40.0 35.7Platelets THSD/mm³ 193 169 183MCV 103.8 104.0 104.5MCHC 33.8 33.0 34.2% Hypochromic RBCRetic/Lympho 3.56 3.04 3.41Sr. IRON 10.6-28.3 µmol/L 13 26 14TIBC 44-75 µmmol/L 50 46 33Transferrin Ratio UIBC > 20 %Sr. Ferritin ug/L 2542.0 1504.0E.S.R mm/hrSerum intact PTH 13-54 pg/ml 440.80 453.90
Serum Aluminium
Pre DFOPost DFODelta
VIROLOGY / SEROLOGYHBs Ag -ve -ve -veAnti HBsHBc AgAnti HCV -ve -ve -veAnti HIV -ve -ve -veCMVVDRL -ve -ve -veBlood group
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
MINISTRY OF HEALTH, MALAYSIA
DIALYSIS LABORATORY RESULTS CHART
Hospital Umum Sarawak
Name: Jachin ak. Kirat I/C No. : 800107-13-5235 LAB Test Date
23.08.04 02.09.04 06.10.04Biochemistry
Urea pre1.7 – 8.3 mmol/L
Urea postSodium pre
135-145 mmol/LSodium postPotassium pre
3.5-5.0 mmol/LPotassium postCreatinine pre
64-122 mmol/LCreatinine postChloride pre/Co2 96-108 mmol/LUric Acid 142-416 mmol/LTotal Protein 66-87 g/LAlbumin 35-50 g/LTotal Bilirubin Up to 21 mmol/LAlk phosphatase 53-128 U/LAlanine Transminase Up to 42 U/LCalcium 2.0-2.6 mmol/LInorganic Phosphate 0.8-1.6 mmol/LCa x Po4Total cholesterol < 5.7 mmol/LTriglyceride < 1.7 mmol/LLDL – Cholesterol < 3.9 mmol/LHDL – Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/LFBSRBS
HAEMATOLOGYHB g/dLTWDCHCTPlatelets THSD/mm³ MCVMCHC% Hypochromic RBCRetic/LymphoSr. IRON 10.6-28.3 µmol/LTIBC 44-75 µmmol/LTransferrin Ratio UIBC > 20 %Sr. Ferritin ug/LE.S.R mm/hrSerum intact PTH 13-54 pg/ml
Serum Aluminium
Pre DFOPost DFODelta
VIROLOGY / SEROLOGYHBs AgAnti HBsHBc AgAnti HCVAnti HIVCMV
Blood group
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
MINISTRY OF HEALTH, MALAYSIA
DIALYSIS LABORATORY RESULTS CHART
Hospital Umum Sarawak
Name: Jachin ak. Kirat I/C No. : 800107-13-5235 LAB Test Date
25.02.04 26.07.04 07.06.04 10.06.04 15.08.04Biochemistry
Urea pre1.7 – 8.3 mmol/L
Urea postSodium pre
135-145 mmol/LSodium postPotassium pre
3.5-5.0 mmol/LPotassium postCreatinine pre
64-122 mmol/LCreatinine postChloride pre/Co2 96-108 mmol/LUric Acid 142-416 mmol/LTotal Protein 66-87 g/LAlbumin 35-50 g/LTotal Bilirubin Up to 21 mmol/LAlk phosphatase 53-128 U/LAlanine Transminase Up to 42 U/LCalcium 2.0-2.6 mmol/LInorganic Phosphate 0.8-1.6 mmol/LCa x Po4Total cholesterol < 5.7 mmol/LTriglyceride < 1.7 mmol/LLDL – Cholesterol < 3.9 mmol/LHDL – Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/LFBSRBS
HAEMATOLOGYHB g/dLTWDCHCTPlatelets THSD/mm³ MCVMCHC% Hypochromic RBCRetic/LymphoSr. IRON 10.6-28.3 µmol/LTIBC 44-75 µmmol/LTransferrin Ratio UIBC > 20 %Sr. Ferritin ug/LE.S.R mm/hrSerum intact PTH 13-54 pg/ml
Serum Aluminium
Pre DFOPost DFODelta
VIROLOGY / SEROLOGYHBs AgAnti HBsHBc AgAnti HCVAnti HIVCMV
Blood group
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
Schedule : Anemia for year 1999
Date HB Sr IRON Sr Ferritin Sr IPTH TIBC(g/dL) (umol/L) (µg/L) (pg/ml) (µmmol/L)
25.05.99 9.4 14 - - 54
06.07.99 8.1 29 - 45
12.08.99 8.1 20 - - 42
07.10.99 11.3 10 - - 45
22.11.99 13.2 10 - - 48
Schedule : Anemia for year 2000
Date HB Sr IRON Sr Ferritin Sr IPTH TIBC(g/dL) (umol/L) (µg/L) (pg/ml) (µmmol/L)
07.03.00 8.5 - - - -
13.04.00 8.9 18 - - 46
08.08.00 9.2 23 - - 49
07.09.00 10.8 10 - - 49
Schedule : Hemoglobin 1999 & 2000
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
5.4 KT / V
Regular measurement of the delivered dose of haemodialysis. The
dialysis care team should routinely measure and monitor the delivered
dose of haemodialysis at last 3 monthly. The single pool Kt/V is a
dimensionless ratio representing fractional urea clearance.
a) “K” is the dialysis blood water urea clearance by using the
diayzer and speed the blood pump and dialysate flow for
clearance the urea from the patient blood to dialysate.by using
principle “diffusion”, “ultrafiltration”, “convection” and osmosis.
b) “T” is dialysis session length (hours).The longer hours (4
hours) patient diaysis, patient will better urea clearance.
c) “V” is the total volume of blood cleared during the dialysis
session. ( the urea distribution volume )
Schedule : Haemodialysis urea modeling
Date Dialyzer Blood flow Dialysate flow Urea Kt/v (ml/min) (ml/min) clearance
(ml/min)
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
21.11.03 F8 350 500 238 1.45
07.01.04 F8 350 500 241 1.65
05.04.04 F8 350 500 239 1.54
12.08.04 F8 350 500 237 1.44
Schedule : Haemodilysis urea modeling
Date BUN (mg/dl) Berat badan (kg)
Pre dialysis Post dialysis Pre dialysis Post dialysis
21.11.03 37 10 50.0 49.0
07.01.04 53 14 52.5 49.0
05.04.04 61 16 52.0 50.6
12.08.04 47 13 53.0 52.6
Graf : Kt/v Level
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
5.5 Nursing intervention for anaemia
a) Monitor blood status for maintain adequate iron store in blood.
Serum ferritin – Iron store in the body
Serum Iron - To maintain target hemoglobin and iron
levels in haemodialysis patients. Oral iron given (100mg
– 200mg ) or intravenous (IV Dextran 100 mg every week
for 10 doses)
Transferrin Saturation ( TSAT) - Reflects availability of
iron. Minimum target TSAT is >20%.
b) Give epoetin eg injection eprex after iron difficiency treated .
Maximum dose 1200ii/week or 4000ii/day for maintain
hemoglobin.
c) Adequate haemodialysis - Time dialysis should be 4 hours for
every treatment, 3 times per week, blood pump high (300 –
400cc/min), diaylsate flow 500 – 800 cc/min and using high flux
diayser for good clearance.
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
d) Prevent blood loss - Minimize the volume of blood samplings
taken. Return blood after complete haemodialysis as
completely and as soon as possible. Monitor heparin dose
during haemodialysis to prevent clotting during dialysis. Pre test
the diayser to prevent leakage.
e) Health Education - Take food contain high in iron eg internal
organ, egg ect. Iron tablet should not taken with phostphate
binder ( Calcium carbonate ) because calcium carbonate can
bind iron together. Iron tablet take with citrus fruit and avoid
drink with caffeine eg coffee and tea.
f) Monitor FBC and Serum Iron, TIBC and Serum Ferrittin every 3
monthly – To know status of hemoglobin patient.
5.6 Nursing Intervention For Reduce Phosphate In Patient Diet.
Limit intake of phosphate to less then 1000 mg/day. This will
also help phosphate binders to work more efficiently.
Avoid eating very large servings of meat, if possible, unless
advised otherwise by dietitian or doctor.
Eat your phosphate binders with meals which contain high
protein foods such as fish, chicken, meat or with complet meals
such as nasi lemak.
Avoid eating the cartilage and soft bones of fish, shellfish and
meat.
Reduce intake of cocoa, chocolate-based beverages and cola
drinks.
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
Limit dairy food products such as milk, curd/yogurt and cheese.
Use non-dairy creamer to replace milk in your beverages.
Always choose foods with low or moderate content of
phosphate.
If your blood phosphate level is high, avoid foods that have high
phosphate content.
Increasing the portion size of the food will increase the amount
of phosphate you are eating. While 1 piece of kuih may have
low phosphate content, taking many pieces will increase your
phosphate intake.
Controlling PTH levels prevents calcium from being withdrawn from the
bones. Usually, overactive parathyroid glands are controllable with a change
in diet, dialysis treatment or medication. If PTH levels cannot be controlled,
the parathyroid glands may need to be removed surgically. If your kidneys
are not making adequate amounts of active vitamin D, you can take synthetic
vitamin D (eg alfacalcidol) as a pill or in an injectable form. Renal
osteodystrophy can also be treated with changes in diet. Reducing dietary
intake of phosphorus is on of the most important steps in preventing bone
disease.
5.7 Health Education
How to care of his AVF..
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman
Kajian Kes ( Case Study )Post Basic Renal Nursing2/2009
Exercise
Advice patient to exercise his AVF hand regularly with a
rubber ball to stimulate the development of his AVF
Do Not Wear Tight long sleeves shirt with tight button.
Not to sleep with the AVF hand under the pillow.
No BP or blood taking on the AVF hand.
Avoid heavy lifting - Never use the AVF hand to carry
heavy things, it can spoilt the AVF.
Monitor for Thrill - Advice patient to feel for the thrill all
the time especially in the earlier part. If no more thrill
felt, ask the patient to come quickly to hospital and refer
him to the surgeon. The surgeon will remove any blood
clot and the AVF might works again after that.
Cleanliness - Advise patient to keep his AVF hand
clean at all times to prevent infection.
____________________________________________________________________________________________SN Ramlah Bt Hj. Saliman