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Running head: HEMODIALYSIS PATIENTS

Critical Analysis on the Care of
Hemodialysis Patients in the Acute Care Setting

Critical Analysis of the Care of
Hemodialysis Patients in the Acute Care Setting

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HEMODIALYSIS PATIENTS

2

Introduction
Chronic kidney disease (CKD) is a broad term that refers to a mixed group of diseases
that affects the structure and function of the kidneys (Levey & Coresh, 2012)
...
7 million Australians are known to have symptoms related to CKD e
...
albuminuria and
decreased kidney function
...
5 million people) of the
aforementioned individuals are aware that they are at risk of developing CKD (Australian Bureau
Statistics, 2013)
...
In fact, in 2013, the Australian Bureau of Statistics reported that the vast
majority or 80% of all CKD patients are on home or hospital/satellite hemodialysis
...
Then again, despite being the most established treatment for
chronic renal failure, nurses and nephrologists have been confronted with numerous challenges,
especially in the acute care setting i
...
beginning hemodialysis treatment
...
,
2014)
...

In majority of Australian hospitals, nursing care has focused therapeutic care on assisting
CKD patients in hemodialysis in the acute care setting
...
More importantly, however, the paper
highlights the importance of perceiving the patient as a bio-psycho-social-spiritual being rather
than focusing solely on the patient’s disease—that is CKD
...
She had just started her first
hemodialysis session the day prior, but is currently experiencing low urine output and brief
changes in sensorium
...

This case creates a picture of urgency, demanding prompt and competent attention from
the acute care nurses
...
As such, it is the primary objective of this paper to gain more knowledge and
awareness on the unique nursing needs of CKD patients undergoing hemodialysis in the acute
care setting
...

Definition of Chronic Kidney Disease
As has been mentioned, chronic kidney disease does not refer to a single illness but refers
to a group of diseases that disrupt both the anatomy and physiology of the kidneys
...
Under
these guidelines, chronic kidney disease as categorized based on the degree of kidney function,
using the glomerular filtration rate or GFR as the sorting parameter
...
However, it is most commonly computed using
the Cockcroft –Gault formula, which measures GFR in mL/min
...
85 (if female)
72 x Serum Creatinine (in mg/dL)

HEMODIALYSIS PATIENTS
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However, in order to homogenize creatinine clearance results and allow comparison with
other people, the corrected creatinine clearance is computed with reference to the patient’s body
surface area
...
73
BSA

Hence, CKD is defined as having kidney damage or having a creatinine clearance or GFR
of less than 60mL per minute for every 1
...
Additionally, in order to qualify as having a “chronic” renal failure in contrast
with “acute” renal failure, this GFR must have persisted for more than 3 months
...

However, apart from the creatinine clearance, CKD may also be diagnosed by
documenting the presence of kidney damage either through kidney biopsy or by detecting kidney
abnormalities through urine or blood samples, and again these pathologic abnormalities must have
persisted for more than 3 months to qualify as being “chronic
...
However, the abnormalities subsequently become severe enough to sufficiently reduce
creatinine clearance to less than 60mL/min/1
...

Patients diagnosed with CKD are subsequently classified according to the following
stages:
Table 1
...
73m2)
≥90
60-89
30 – 59
15 - 29

HEMODIALYSIS PATIENTS
5

5
Kidney Failure

<15 (or dialysis)

However, the decision on when to start hemodialysis remains challenging for most health
care practitioners because while dialysis resolves the signs and symptoms present in the patient,
treatment is usually lifelong, and dialysis is associated with significant risk for other
complications and the cost of receiving hemodialysis treatment can become overwhelming in the
long run
...
, 2014)
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According the U
...
National Kidney Foundation (2012), there
are over 1 million patients with ESRD worldwide
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S
...
The study of Stumpers and Thomson (2013) further found that the incidence rates of ESRD
are highest among indigenous Australians residing in very remote areas with rates that are close to
20 times the rates observed in non-indigenous populations
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7 million Australians with manifestations of early CKD
...
, 2010)
...
33% of the general
Australian population is at risk for developing CKD
...


HEMODIALYSIS PATIENTS
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Moreover, data from the registry for Australia and New Zealand Dialysis and Transplant
(ANZDATA) (2015) show that patients diagnosed with diabetes, hypertension and
glomerulonephritis are at high risk for acquiring kidney disease that necessitates dialysis
treatment
...
Data from ANZDATA registry also show that
in 2013, 2,544 Australians had started on kidney replacement therapy, either through kidney
transplant or via dialysis treatment
...

Regrettably, despite the large evidence base on the importance of hemodialysis treatment,
until now, majority of health care professionals still question the competency of modern
nephrology care teams
...
In this light, this paper critically reviews current trends on the therapeutic strategies provided
to hemodialysis patients in the acute care setting
...
As has been mentioned, hemodialysis
patients are at risk for infection, AVF or graft failure, and are exposed to various psychosocial
stressors
...


HEMODIALYSIS PATIENTS

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Preservation of the Arteriovenous Fistula (AVF) or Graft in the Acute Care Setting
...

A vascular access that is able to serve its functions is one that has good vascular flow and
patency, and permits the repeated access on the site with the use of two needs
...
However, complications related to the AVF access
accounts for a large number of patient hospitalizations and have become a significant cause for
mortality and morbidity among patients undergoing dialysis
...

The three most common complications related to vascular access in the acute care setting
include stenosis, thrombosis, and, of course, infection, and such has increased therapeutic reliance
on the more risky central access line e
...
subclavian access (Pantelias, 2012)
...
In order
to prevent stenosis and thrombosis, and subsequently improve patency, experts have placed high
regard on effective and continuous clinical monitoring of the AVF
...
, 2010)
...
However, the high predictive values are dependent on the proficiency of the health care staff
as well as the consistency of graft monitoring
...
As cited by Vale et al
...
Subsequent

HEMODIALYSIS PATIENTS
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studies also show that in equal concentrations, N-propanol is the most effective type of alcohol in
removing resident organisms on the hand
...

Richard (2011) further cited that apart from maintaining patency and preventing infection,
the use of proper cannulation technique effectively preserves AVF sites
...
This method uses the entire
vessel length, and with each needle cannulation, vascular access is spaced backwards before the
last insertion site, and then directed back along the entire vessel length again
...

Effective and regular vascular access site monitoring, frequent alcohol-disinfection, and
the use of proper needle cannulation technique helps preserve the AVF site and prevent
thrombosis, stenosis, and infection
...
These have
ultimately improved patient outcomes, helping patients survive and live more fulfilling lives
...
Current studies have not been able
to effectively compare the different methods used to prevent stenosis, thrombosis, and infection in
AVF sites
...

Blood Pressure Control
...
Poorly controlled blood pressure is
among the major risk factors for developing cardiovascular disease among ESRD patients
...
Furthermore, it was also found that after dialysis treatment, an
increase in systolic BP was observed even for patients who have pre-dialysis BPs of less than 110
mmHg
...
, 2011)
...
It was further cited that these variations are attributed to:
(1) location (where the BP is taken), (2) time in relation to the dialysis (before or after dialysis),
and (3) the method of measuring BP (auscultatory, intravascular or oscillometric)
...

Because ABP is taken over a 24-hour timeframe, it is able to provide blood pressures upon
awakening and during sleep, when BP and cardiovascular risk are noted to be at their peaks
...
g
...
,
2013)
...
(2011) evaluated the prognostic value of ABP in a sample of
436 patients and was able to obtain conclusive evidence that ABP is extremely valuable in
predicting both renal and cardiovascular risk
...
Several studies have highlighted the benefits offered by ABP in
addressing the highly variable blood pressures observed in ESRD patients
...
Unfortunately, albeit promising, existing studies have
been unable to compare its accuracy and predictive value to other blood pressure methods i
...

intravascular, oscillometric and auscultatory
...


HEMODIALYSIS PATIENTS
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Nonetheless, the role of ABP in predicting patient care outcomes for hemodialysis treatment
remains a very fertile ground for future research
...
This research endeavor has successfully identified
potential challenges that the acute care team may encounter in the care of hemodialysis patients,
particularly in preserving the AVF site and in maintaining blood pressure control
...
This arms them with the proper tools to address the various and complex needs of posthemodialysis patients
...
As such, it is recommended that future studies be dedicated to exploring the advantages
and disadvantages of various patient care practices-launching more sophisticated and relevant
research ventures that will be able to generate meaningful insights on how to provide better care
for patients with acute hemodialysis
...
& Robbin, M
...
(2010)
...

Hemodialysis International
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Levey, A
...
(2012)
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The Lancet, 379(9811), 165-180
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, Ayala, D
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, Otero, A
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, & Moyá, A
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(2013)
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Chronobiology International, 30(1-2), 145-158
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3109/07420528
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703083
Nesrallah, G
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, Mustafa, R
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, Clark, W
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, Bass, A
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, Hemmelgarn, B
...
&
Klarenbach, S
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Clinical practice guideline for timing the initiation of chronic
dialysis
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Oluyombo, R
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, Soje, M
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, Olanrewaju, T
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(2014)
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International Journal of Nephrology and Renovascular Disease, 347
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2147/ijnrd
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, Dong, J
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, & Zuo, L
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The effectiveness of intensive nursing care on
seasonal variation of blood pressure in patients on peritoneal dialysis
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doi:10
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1365-2648
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05833
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(2012)
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World Journal Of Nephrology, 1(3), 69
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5527/wjn
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i3
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(2011)
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Critical Care Nursing Quarterly, 34(1), 76-83
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1097/cnq
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(2013)
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Australian Indigenous Health Bulletin, 13(2)
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(2010)
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Annals of Internal Medicine,
113(5), 392
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7326/0003-4819-113-5-392
Vale, E
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& Polkinghorne, K
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Nursing care of arteriovenous fistula /
arteriovenous graft
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Viitattu, 20
Van Loon, M
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, Kessels, A
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H
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M
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Cannulation practice patterns in
haemodialysis vascular access: predictors for unsuccessful cannulation
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35, 82-89

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