patient assessment hemodialysis technician review course
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Alice Hellebrand MSN, RN, CNN, CURN. Patient Assessment Hemodialysis Technician Review Course. Assessing the Patient. - PowerPoint PPT PresentationTRANSCRIPT
Alice Hellebrand MSN, RN, CNN, CURN
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
Dialysis Treatment Orders Length and frequency of the
treatment Dialyzer brand, model and size Dialysate composition Heparin dose Blood and dialysate rates Ultrafiltration parameter
Pre Dialysis
Prepare your equipment Extracorpeal Circuit
Dialyzer Bloodlines Monitoring lines Heparin line Transducer protectors
Pre-Dialysis
Draw up your medication Read the drug name before, during and after
drawing up the medication Check the expiration date Clean the vial’s 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
Pre-Dialysis Patient Assessment Weight Edema Pulse Blood pressure Respiration Temperature General physical and emotional state Problems since last treatment Access status
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
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
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
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
Dry Weight Assessment
After a treatment a patient below dry weight may have:
Low blood pressure Light headedness or dizziness Muscle cramping
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 Bradycardia=less than 60
Blood Pressure
Optimal for adults 120/80 Hypertension=high 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.
Heparin Routine Continuous Infusion
Inject a bolus (single amount) (e.g., 30–50 U/kg) 2–3 minutes before a treatment starts
• Use the heparin pump on the arterial bloodline to continuously pump heparin during the treatment (e.g., 750–1,250 U/hour)
• Stop the heparin pump one hour before the end of the treatment, or per your center’s policy
Heparin
Routine Repeated Bolus Inject a bolus dose of heparin 2–3
minutes before the start of the treatment.
• Give bolus doses of heparin throughout the treatment, per center policy.
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) (10–20 U/kg) 2–3 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 center’s policy.
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
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
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 it’s not charted IT WASN”T DONE
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
Complications of DialysisComplication Causes Signs &
SymptomsHow to Prevent it
Air embolism(air bubbles blocka blood vessel)
• Air detector is broken or not armed.• A leak or looseconnection in theextracorporeal circuit before the blood pump.• Empty IV bags on the extracorporealcircuit before theblood pump.
Depends on the patient’s bodyposition when the air is infused.May include:• Chest pain • Trouble breathing• Coughing• Blue lips, fingers, toes (cyanosis)• Trouble seeing• Confusion
Arm the air detectorthroughout a treatment.• Tighten all connections in the extracorporealcircuit.• Check the normal salinelevel in the IV bag.• Return the patient’s bloodwith saline, with no air in the bloodlines.
Complication Causes Signs & Symptoms
How to Prevent it
Cardiac arrest(the heart stops)
Extreme hypotension• Electrolyteimbalance,especially highpotassium• Arrhythmias• Heart attack• Air embolism• Severe blood loss
No pulse• No breathing• Loss of consciousness
Check vital signsduring treatment.• Tell the nurse right awayabout major vital signchanges and/or thepatient complains ofchest pain and sweating.
Complication Causes Signs & Symptoms
How to Prevent it
Dialysisdisequilibriumsyndrome(brain swelling)
If BUN is removedmuch faster from the blood than from the brain, disequilibrium iscreated and fluid moves into the brain cells.• This is seen moreoften in patients who have acute kidney disease or a BUN level >150 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 (>150 mg/ml) a smallerdialyzer and/or slower blood and dialysate flows are preferred. Short, slow dialyses may be prescribed daily for a few treatments.
Complication Causes Signs & Symptoms
How to prevent it
Fever and/or chills
• Infection• Contaminateddialyzer 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 othersites (e.g., feet, skin wounds
Use aseptic techniqueto set up equipment.• Use aseptic techniqueto inserting needles.• Check vital signs.• Tell the nurse rightaway about major vitalsign changes.• Check dialysatetemperature beforetreatment.• Use the right processto disinfect the dialysismachine and the watercomponents.• Test water andequipment for bacteriaor pyrogens/endotoxins
Complication Causes Signs & Symptoms
How to Prevent it
First-use syndrome
• Reaction to ethyleneoxide (used to sterilize new dialyzers)• Use of polyacrilonitrile(PAN) membranes inpatients who take ACE inhibitors (a class of blood pressure pills)
Symptoms usually occur in the first 15–30 minutes of treatment:• Itching• Chest and/or back pain• Shortness of breath• Hypotension• Nausea• General discomfort
• Rinse the dialyzer well before treatment, percenter procedure.• Use the right dialyzer
Complication Causes Signs & Symptoms
How to Prevent it
Exsanguination(severe loss of blood)
• Bloodlines come apart• Taking out dialysisneedles with theblood pump on• Crack in dialyzercasing or improperlyfitted header cap• Access rupture
• Blood on patient chair, clothes, and/or floor• Hypotension• Seizures• Cardiac arrest
• Tighten all extracorporealconnections.• Tape needles securely.• Keep all accesses in view at all times (no blankets over access limbs).• Monitor the extracorporealcircuit per procedure.
Complication Causes Signs & Symptoms
How to Prevent it
Hemolysis (burstingof red blood cells)
• Kinked bloodlines• Inadequate watertreatment that allowschloramines, copper,zinc, or nitrates intothe dialysate• Too-warm dialysate• Formaldehyde in areused dialyzer
• Nausea• Headache• Stomach and back pain• Hypertension or hypotension• Cardiac arrest• Bright red colored blood
Check dialysateconductivity andtemperature beforetreatment.• Test dialysate forchloramines anddisinfectants.• Monitor bloodlines for kinks.• Check that bloodpump is calibrated for the bloodline header being used.
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 can’t breath”. Your initial thought would be A. too much fluid was removed B. Why me? C. too little fluid was removed D. Orthostatic Hypotension
Your action would be? A. Give Saline B. Call a code C. Notify the nurse D. Call the physician
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
Questions?????