INTRODUCTION TO LIFE ilett) Preston. R.N.. ciriil John l i . 1:oic P I . 111.1).

I he aitihcial kidne\ , currentl? i n u i e I I I

arecis throughout the borld for people wilh rnd-stage kidney disease. is making life po+ silile for many who \+auld othern iw 11e tlratl. I.'oI most patients, utilization of thr 'trtihc ial organ should actually be consideird a R r - Introduction to Life. Many of them h a \ ? had chronic renal disease for years and h a t e lieen told tha they would live onl\ '1% long a i they could be managed conser\ati\ely ( i . r. Mith medications arid dietary cititl fluid i estrictions) . Therefoie. we find patients coming to us who have been psyc hologic*all\ prepaied to die. When such patienti die

c.rpted into an ai tihcial kidney pt ogrmi. they are faced suddenly uith the ivalizatiori that they are NOT going to die. Thr\ rn t r r the program with fears arid appr rhr r i s ion~ aliout this new life arid the stiarigv equip-

ment and strange people surrounding thetri. I t is an absolute nece ty that thr st,ifT of ci

kidney unit be serrsitiae to the patirtili' f ed- ings and give them support a i the\. po through their adjustnients to thi i tiru \ + < I v

of life.

Chronic t e n d disease ran present itself in inany foims, the most common being chronic plomei ulonephritis. chronic p, elonephr itis and polycystic kidney diiease. When the creatininr clearance deteriorates to less than 5 ml/inin., treatment with the artific<ial hid- tiey musl he considered.

HISTORJ The ar t i I i c ial kidne, removes waste 111 oclucts fiom the patient's hlood 11) a process called heniodialt iis. Although the idea as con- cei\ ed in 1913. the fi I st functioning artiiitial kidne) was not asseinliletl for significant clinical use until the ea t l j 19.50's. Even then, the ecjuipment \$as used almost exclusikely for acute renal failure, acute exaceihations of chtonic renal disease o t as pieparation o f the patient for suigery. Then, in 1955. Kolff a r i d b'atchinger de\ eloped the (\+in toil kidney, uhich is presently being used t t i m m v dialysis centers. This Kolff dialyze1 iequiies a latget Lolume of blood for prim- 111g ( nppioximatel) SO0 ( c ) , hut dialisis ran lie performed in six hours, iequi i ing a niininium of two six-hour treatments weekl) fot rnairitennnce of lii"e.

THE RRTERIO-VENOLrS SHUNT In order for chronic dialysis to he per- formed. one must obtain relativel\ per- manent access to the patierit's blood stream. This is achielerl 1)) insei ting a silastic-teflon cannula into an artery and vein of the a rm 01 leg. During the time the patient is not on hemotlialysis, the two cannulas a re connected to form an exteriorized arterio-venous shunt or fistula, and blood flous continuously from the artery outside the Iiody and hack into the cein. To preient infection of the shunt. mrticuloui care mu.t be exercised.

Mnrch 1969 67

Figure 1. Arterio-venous shunt connected to blood tubing o f the d idyzer .

The shunt is cleaned frequently with anti- bacterial agents and a sterile dressing is worn over it. Not until the development of this arterio-venous shunt in 1960 was pro- longed hemodialysis made possible. How- ever, the shunt still poses the most difficult problem in dialysis today. (See Figure 1

DIALYSIS PROCEDURE The dialyzer most commonly employed for maintenance dialysis today is the Kiil kid- ney, consisting of three, grooved plastic hoards and four sheets of cellophane. The two sheets of cellophane form each of the two envelopes which contain the blood film. (See Figure 2) The dialyzers are sterilized

F i g u r e 2. Kiil kidney nssembled on t i l t cart.

with lormaliri or related agents. After ster- ilizalion, disposable blood Iubing is attached to each end oI the kidney, then the blootl compartment is filled with heparinized sa- line. At the beginning of dialysis. the can- nulas are clamped, and the continuity of the shunt is disrupted. The arterial cannula is connected to the blood line leading to the dialyzer. The blood line coming from the dialyzer is connected to the venous cannula after the saline has been displaced by blood from the patient. When all clamps have been released, circulation of the blood through the artificial kidney is established. As the patient’s blood flows through the dialyzer inside the cellophane envelopes, an electro- lyte solution called dialysate flows above and below the sheets of cellophane. The Idood is physically separated from the dial- ysate at all times by the cellophane. As blood passes on one side of the membrane and dialysate passes on the other side, the non- volatile end products of metabolism are re- moved. Excess body fluid is removed and serum electrolyte abnormalities are corrected, all by the processes of osmosis, ultrafiltra- lion and dialysis. This is shown in a simpli- fied schematic diagram in Figure 3. As il- lustrated in the diagram, the red blood cells, white blood cells, and albumin will remain in the blood compartment, because they are much too large to pass through the tiny holes in the cellophane membrane. However, the smaller molecules (Ca, Na, K, C1, etc.) will pass through the holes in the cellophane membrane and will move from the area of greater concentration to the area of lesser concentration. Those substances which need to be removed from the patient’s blood are left out of the dialysate, or bath solution. The electrolytes, and other substances which are to remain unchanged, are put into the bath solution. When the concentration is ap- proximately the same on both sides of the membrane, there is no movement of mole- cules, hence no change in the serum concen-

68 AORN Journal

Blood Bath

THEORY OF DIALYSIS

FACTORS DETERMINING DIALYSANCE

1 . P a r t i c l e S i z e ( C e l l s , p l a t e l e t s , E p r o t e i n )

2 . Trans-membrane C o n c e n t r a t i o n

Gradient

( E l e c t r o l y t e s , water, 8 n o n - e l e c t r o l y t e s )

g A l h

Ca*+ + Cat+

l 1COj + f K O j

I Na+ t-t3 N a t

I c1+ Gi-+ c1+

SKI 2 h

I

I I

I

I

I

I

I

POj ---H 0

4 -?" so

200 Urea + 0

20 C r e a t . tJ 0

100 Dext . H- 200 Dext.

H 2 0 c--lj H20

T " r e s s

tration. During a twelce-hour dialysis O I I the Ki i l dialyzer. the hlood ured nitrogen ( 'III Ire hiought do\in to approximately one-ihit d its original Ielel. A standard dialysate (oniposi-

tion can he used for almost all patirril\. At thr rnd of the piocedure, all but 5 10 10 (

of Iilood in the kidney is returned 10 the patient. The continuity of the A-V s h i m 1 is

r estoied. a dressing applied, and the Iiatient ( a n go home. T h e Kiil kidney holds 250 t n 300 cr's of blood and does not hair l o he piirned. Ho\,ever. tF$o twelce-hour. 01 Iliiee

right-houi treatments are required pet neeh.

HOME DIALYSIS Be( ause of the prohibi t i le cost of tlialysi. ( approximately $10,000 pel patient pt'i \ear i r i a dialysis cen ter ) , more emphasis is no\\ h i n g placed on home dialysis. Here tht. cost can he clecieased to ihe iange of $.:,OOO t o

S LOO0 pel )ear after the initial ecluii)tnrrit in \ eitment. At home, the patient can t l i a l y L r

himself lhlee time5 meeklv. for eiphi I I O L I I ~

- C e l l s and P l a t e l e t s -

P r o t e i n -

E l e c t r o l y t e s

-

?ion E l e c t r o l y t e s

-

Water

eacti time. thereby preventing the drastic rhanges that inevitahly occur on twice-week- 1) tliallsis.

PATI EN'T S ELECT1 ON Since the need For dialysis is so great and ihe availability of facilities and finances is so limitrd. centers must, of necessity, select those for treatment who are the best candi- dates. Our. criteria for selection a re as fol- lows: 1 . Young uremic adults 2. Cooperative with:

A. Treatmenk I<. Re h a bili ta t ion e fIor ts

3. Absence of se\-ere complications of 11 rxbmia 1.. Ahsenve of major Ilehavioral disorders Although the main purpose of our program is the maintenance and rehabilitation of those people hiith chronic renal diseases, other uses of the artificial kidney fall under these rategories: a I managernent of acute

renal failure, b ) removal of exogenous and endogenous toxins and c ) support of trans- plantation studies.

STAFFlNG The nursing situation found in a unit such as this is quite unlike that found in any other area of nursing. The traditional nurses’ uni- forms have been cast aside in favor of street clothes. Every attempt is made to provide the patients with pleasant surroundings, not un- like their homes. We attempt to maintain open lines of communication between staff members themselves and between the staff and the patients through weekly staff meet- ings where every problem from medical com- plications to interpersonal relationships is discussed. In addition to our director ancl the nurses and technicians on the staff, we have working with us a psychiatrist, a social worker, a dietitian and research fellows. The

impoitance of furnishing psychological sup- port to the patients cannot be ovei-empha- sized. By giving them an opportunity to ex- press their fears and anxieties, we can help them to develop a comfortable and realistic at- titude toward their disease and its treatment.

It has now been well-documented that the artificial kidney is capable of replacing the vital functions of the human kidney. Several patients throughout the country are currently being maintained on hemodialysis following bilateral nephrectomy. It is quite apparent, then, that kidneys are no longer an es- sential criterion for life. However, once this slatement has been made, the problem of making the artificial method of treatment available to the masses requiring it becomes obvious. Until treatment can be made avail- able on the large scale warranted at this time, theie will be many patients who will not have this Re-Introduction to Life.

REFERENCES

Albers, Jo Ann, “Dialysis Teaching Manila1 for Clinical il.‘r/rs/ng, C. 1’. hlosby Company, St. Louic, Nurses,” Seattle Artificial Kidnry Center. Seattle, ‘lissouri> 1967.

Hampms, Constantine L., and Schupak, Eugene, Long-Term Hemodinlysis, Grune and Stratton, New Washington, 1967.

Bergerson, Betty S., et al. Current concept^ ZR ’koih, 1967

PHOENIX R E G I O N A L INSTITl!TE

M A Y 2-3, 1969

A O R N Phoenix and the Valley, Arizona, will host its first NCE-Regional Insti- tute at Del Webb’s Townrhouse in Phoenix. Founded in 1966, the chapter has grozLn to a membership of 92 and has bcen planning the institute for the past year and one-half. Making use o f questionnaires and letters o f inquiry, a n extensive survey was conducted to obtain in formation on areas of interest, possible institute sites, and l ike ly participants. T h e tentatizw program f o r the two-day conference on OR nursing includes topics reflecting a broad scope of interest to professional nurses. Staff Nurse Development, Ensuring a n Unbroken Care Circuit, A Team Approach t o Therapy, Infection Probe, An Experimental Minicourse in Electricity, T h e Nature of Pain and Suffering, and Operation Space are sonre of the subjects to be discussed by individual speakers and panel participants. Bette Clenions is General Chairman for the Institute, and Joyce Summers is the Chapter President.

70 A O R N .lourncrl