With uremia, as waste products build up in the blood, ammonia breath can result. Patients may also complain of the taste of metal in their mouths. Other indications include generalized swelling, especially of the hands, feet, and face; difficulty breathing (from fluid collecting in the lungs); increased nocturia (urination during the night); pruritis (itching); jaundice (yellow skin tone); trouble sleeping; pain in the kidney areas; and sexual problems (such as impotence or erectile dysfunction).
Infections in buttonhole tracts are almost always caused by improper scab removal. The scab should be removed with a special sterile scab remover that is supplied with the needle, sterile tweezers, or a sterile needle that is then discarded. The scab should never be picked off with a fingernail or other non-sterile device, such as a toothpick. If sterile technique is not used to remove the scab, bacteria can easily migrate up the tract and directly into the bloodstream.
As the blood is filtered, the water is filtered out into glomerular filtrate with about 180 liters produced each day. However, only about 1% of the water in glomerular filtrate is actually excreted as urine because most of the water is reabsorbed in the tubules back into the systemic blood system. If the kidneys are functioning properly, waste products are excreted in the urine and necessary electrolytes, such as sodium and potassium, are reabsorbed.
If a dialysis patient is very large in both stature and weight, the intervention that is most likely to improve the effectiveness of hemodialysis is an increase in the dialyzer size because this increases the clearance of waste products. The nephrologist prescribes the size of the dialyzer based on the patient's size and the prescribed duration of treatment. Another intervention that can increase the effectiveness of hemodialysis is to increase the duration of treatment.
When using a slide board to transfer a patient from the dialysis chair to a wheelchair, it should be placed at a 45-degree angle between the two sitting surfaces. The dialysis chair and the wheelchair must both be locked so they don't move during the transfer, and the arm should be removed from the wheelchair. A gait belt should be placed about the patient's waist prior to transfer for security purposes.
When creating a buttonhole tract, usually 8 to 10 consecutive cannulations are required before the tract is adequately formed. During this formation period, it is essential that the same person do the cannulations because this makes it more likely that the same angle will be used each time. The buttonhole technique cannot be used with grafts because they do not have muscle fibers that tighten around the tract after the needle is removed.
Patients receiving hemodialysis should be advised to avoid salt substitute because they often contain potassium in place of part of the sodium, and high potassium intake is dangerous. If a substitute is labeled "sodium free," it is often completely potassium. Patients can be encouraged to try using lemon juice in place of salt or to try using various herbs.
Substances that form ions (charged particles) are electrolytes. Electrolytes are found throughout bodily fluids and cells. Electrolyte balance is maintained by the kidneys, but with kidney failure, electrolyte imbalances are a constant concern. The electrolytes that are of special concern with hemodialysis are sodium (which keeps body fluids in balance), potassium (which helps to control nerves and muscles), calcium (which builds bones and teeth and plays a role in clotting, hormones, nerves, and muscles) and phosphorus (which builds bones and teeth and facilitates the use of energy).
Patients with uremia develop foamy or bubbly urine because when their urine contacts air after urination, the interaction between the air and the protein results in foaming. Although trace amounts of protein are a normal finding in urine, when kidneys begin to fail, the protein that normally is too large to filter into the urine begins to leak through in increasing amounts. Protein in the urine is one of the early signs of kidney failure.
When teaching a patient to self-cannulate using the tandem-hand technique, the patient places the thumb and index finger behind the technician's thumb and index finger, holding firmly but not so tightly as to impair the technician's movement. This technique allows the patient to feel the technician's hand movement when inserting the needle. The technician and patient should continue to use the tandem-hand technique until the patient feels confident enough to move to the next step where the two change hand positions.
If a pressure alarm sounds during hemodialysis of a patient with a right internal jugular central venous catheter indicating the blood flow rate is lower than prescribed, but the technician finds that the lines are clear and there are no signs of kinking, bleeding, or air entering the system, the next intervention should be to lower the patient's head and ask the patient to cough. This may help to move the tip of the catheter in order to increase blood flow.
