Patient Assessment Hemodialysis Technician Review Course

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Patient AssessmentHemodialysis Technician Review
Course

• Alice Hellebrand MSN, RN, CNN, CURN

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Assessing the Patient

• Performing the correct steps to ensure patient
  safety is the responsibility of the entire
  patient care team..Hemodialysis Technicians are
  an important part of this team which is why

Certification is Important
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Dialysis Treatment Orders

• Length and frequency of the treatment
• Dialyzer brand, model and size
• Dialysate composition
• Heparin dose
• Blood and dialysate rates
• Ultrafiltration parameter

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Pre Dialysis

• Prepare your equipment
• Extracorpeal Circuit
• Dialyzer
• Bloodlines
• Monitoring lines
• Heparin line
• Transducer protectors

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Pre-Dialysis

• Draw up your medication
• Read the drug name before, during and after
  drawing up the medication
• Check the expiration date
• Clean the vials rubber cap
• Use a single dose only once
• Write the date and your initials on the vial
• Draw air into the syringe and inject as much air
  into the vial as medication you are drawing up
• Expel any air bubbles before you give the
  medication

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Pre-Dialysis Patient Assessment

• Weight
• Edema
• Pulse
• Blood pressure
• Respiration
• Temperature
• General physical and emotional state
• Problems since last treatment
• Access status

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Weight

• Dialysis patients do not make urine therefore
  what they drink and eat stays in their body so
  they gain weight
• Edema
• Shortness of breath
• Rise in blood pressure
• Calculate the patients pre treatment weight gain
  in order to calculate how much fluid to remove

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Fluid Removal

• Your patient arrives complaining of shortness of
  breath and has periorbital edema. The estimated
  dry weight is 80kg. The pre-dialysis weight is
  85kg. Use .2kg for priming saline and .2kg for
  saline rinseback. Dietary intake will be .1kg and
  will receive 200ml of medication. The nurse
  states that the patient should leave at 81kg.
  What is your target loss during the entire
  treatment?
• A. 4100ml
• B. 4500ml
• C. 5400ml
• D.4700ml

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Fluid Removal

• What is your hourly target loss if the patient
  will be dialyzing 4 hours?
• A. 1175ml per hour
• B. 1125 ml per hour
• C. 1.175kg per hour
• D. both a and c

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Dry Weight Assessment

• After a treatment a patient at dry weight
• Normal blood pressure
• No edema
• No shortness of breath
• After a treatment a patient above dry weight
• High blood pressure
• Edema
• Shortness of breath

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Dry Weight Assessment

• After a treatment a patient below dry weight may
  have
• Low blood pressure
• Light headedness or dizziness
• Muscle cramping

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Pulse

• Radial-at wrist
• Brachial-at the crease of the elbow
• Apical-over the heart
• Pedal-on the foot
• Normal 60-100
• Tachycardia greater than 100
• Bradycardialess than 60

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Blood Pressure

• Optimal for adults 120/80
• Hypertensionhigh blood pressure
• Hypotension low blood pressure
• Orthostatic hypotension drop in blood pressure
  of more that 15mmHg or more upon rising from
  sitting position. Causes dizziness and
  possibility of fainting.

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Heparin

• Routine Continuous Infusion
• Inject a bolus (single amount) (e.g., 3050 U/kg)
  23 minutes before a treatment starts
• Use the heparin pump on the arterial bloodline
  to continuously pump heparin during the treatment
  (e.g., 7501,250 U/hour)
• Stop the heparin pump one hour before the end
  of the treatment, or per your centers policy

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Heparin

• Routine Repeated Bolus
• Inject a bolus dose of heparin 23 minutes before
  the start of the treatment.
• Give bolus doses of heparin throughout the
  treatment, per center policy.

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Heparin

• Tight Heparin
• Use for patients who have a slight to moderate
  risk of bleeding. The bolus dose and infusion
  rate is lower than with routine continuous
  infusion.
• Inject a bolus (single amount) (1020 U/kg) 23
  minutes before a treatment starts.
• Use the heparin pump on the arterial bloodline
  to continuously pump heparin during the treatment
  (500 U/hour).
• Stop the heparin pump one hour before the end of
  the treatment, or per your centers policy.

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Heparin

• Signs of too much heparin
• Nose bleeds
• Bleeding in the white part of the eyes
• Ecchymoses (bleeding into the skin)
• Prolonged bleeding from the access site after
  treatment
• Signs of not enough heparin
• Blood clots in the venous drip chamber or
  dialyzer
• Very dark-colored blood in the bloodlines
• Shadows or streaks in the dialyzer

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Monitoring During Dialysis

• Vital Signs
• Monitor as per your center
• Monitor the patients behavior, appearance,
  response and symptoms
• Give medications as prescribed
• Monitor the machine for alarms

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Documentation

• A way for staff taking care of the same patient
  to share information
• A basis to prescribe medical treatment
• A diagnostic aid for the team
• It is a legal document!!
• If its not charted IT WASNT DONE

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Documentation

• Never erase
• Draw a single line through a mistake and write
  error and initial the mistake
• Never leave lines in the chart blank or partially
  filled in
• Record the time on all entries

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Complications of Dialysis
Complication Causes Signs Symptoms How to Prevent it
Air embolism (air bubbles block a blood vessel) Air detector is broken or not armed. A leak or loose connection in the extracorporeal circuit before the blood pump. Empty IV bags on the extracorporeal circuit before the blood pump. Depends on the patients body position when the air is infused. May include Chest pain Trouble breathing Coughing Blue lips, fingers, toes (cyanosis) Trouble seeing Confusion Arm the air detector throughout a treatment. Tighten all connections in the extracorporeal circuit. Check the normal saline level in the IV bag. Return the patients blood with saline, with no air in the bloodlines.
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Complication Causes Signs Symptoms How to Prevent it
Cardiac arrest (the heart stops) Extreme hypotension Electrolyte imbalance, especially high potassium Arrhythmias Heart attack Air embolism Severe blood loss No pulse No breathing Loss of consciousness Check vital signs during treatment. Tell the nurse right away about major vital sign changes and/or the patient complains of chest pain and sweating.
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Complication Causes Signs Symptoms How to Prevent it
Dialysis disequilibrium syndrome (brain swelling) If BUN is removed much faster from the blood than from the brain, disequilibrium is created and fluid moves into the brain cells. This is seen more often in patients who have acute kidney disease or a BUN level gt150 mg/dL. Headache Nausea Hypertension Restlessness Confusion Blurred vision Seizures Monitor the patient during treatment. Tell the nurse right away about major vital sign changes. In patients with high BUN (gt150 mg/ml) a smaller dialyzer and/or slower blood and dialysate flows are preferred. Short, slow dialyses may be prescribed daily for a few treatments.


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Complication Causes Signs Symptoms How to prevent it
Fever and/or chills Infection Contaminated dialyzer or bloodlines (endotoxin exposure) Too-cold dialysate Fever during dialysis Feeling cold Feeling cold without a fever (cold dialysate) Redness, swelling, tenderness, warmth, or drainage from access or other sites (e.g., feet, skin wounds Use aseptic technique to set up equipment. Use aseptic technique to inserting needles. Check vital signs. Tell the nurse right away about major vital sign changes. Check dialysate temperature before treatment. Use the right process to disinfect the dialysis machine and the water components. Test water and equipment for bacteria or pyrogens/endotoxins
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Complication Causes Signs Symptoms How to Prevent it
First-use syndrome Reaction to ethylene oxide (used to sterilize new dialyzers) Use of polyacrilonitrile (PAN) membranes in patients who take ACE inhibitors (a class of blood pressure pills) Symptoms usually occur in the first 1530 minutes of treatment Itching Chest and/or back pain Shortness of breath Hypotension Nausea General discomfort Rinse the dialyzer well before treatment, per center procedure. Use the right dialyzer
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Complication Causes Signs Symptoms How to Prevent it
Exsanguination (severe loss of blood) Bloodlines come apart Taking out dialysis needles with the blood pump on Crack in dialyzer casing or improperly fitted header cap Access rupture Blood on patient chair, clothes, and/or floor Hypotension Seizures Cardiac arrest Tighten all extracorporeal connections. Tape needles securely. Keep all accesses in view at all times (no blankets over access limbs). Monitor the extracorporeal circuit per procedure.
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Complication Causes Signs Symptoms How to Prevent it
Hemolysis (bursting of red blood cells) Kinked bloodlines Inadequate water treatment that allows chloramines, copper, zinc, or nitrates into the dialysate Too-warm dialysate Formaldehyde in a reused dialyzer Nausea Headache Stomach and back pain Hypertension or hypotension Cardiac arrest Bright red colored blood Check dialysate conductivity and temperature before treatment. Test dialysate for chloramines and disinfectants. Monitor bloodlines for kinks. Check that blood pump is calibrated for the bloodline header being used.
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• Your patient has completed the dialysis treatment
  and has reached the target loss prescribed, the
  standing blood pressure was 150/90 and apical was
  100. While at the scale you hear I cant
  breath. Your initial thought would be
• A. too much fluid was removed
• B. Why me?
• C. too little fluid was removed
• D. Orthostatic Hypotension

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• Your action would be?
• A. Give Saline
• B. Call a code
• C. Notify the nurse
• D. Call the physician

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• Your patient has been on 2 of the 4 hours
  prescribed for his dialysis treatment. The
  dialysate that is used is a 2.0K and 2.5Ca. Pre
  treatment vital signs were wt. 82kg (EDW 80kg),
  Pulse 90, BP 150/96 and Temp. 97.8. The patient
  tells you that the room is cold but has
  complaints of sweating. You
• A. Return all blood
• B. Assess blood pressure
• C. Give Saline bolus
• D. Assess patients temperature

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Questions?????