p&p hemopatient guidelines

7/27/2019 P&P Hemopatient Guidelines

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Fluids

1. Daily uid allowance - 1.0 litre/day + urine output. I patient is anuric, intake may be > 500 mL/day as prescribed by physician.

2. IV uids are to be recorded in patient’s daily intake and output.3. DO NOT keep water at the bedside. Patient may have ice chips occasionally to help quench thirst.

4. NEVER give hemodialysis patients citrus juices - orange and graperuit, prune or tomato. Cranberry juice is OK. I unsure, check with theRenal Dietitian.

5. Post Fluid Restriction sign above the patient’s bed.

6. Weigh patients with acute renal ailure daily.

Food

1. The dietary intake or renal ailure patients is a medical prescription.

2. Notiy Department o Food Services when a patient is admitted. They should have access to the patient’s diet order.

3. Consult the Renal Dietitian regarding specifc diet and restrictions. Foods high in potassium are to be avoided. These include oranges,bananas, prunes, and extra milk. Mandarin oranges are fne.

4. To acilitate patient’s hemodialysis treatment times, please order early breakast and lunch trays. Patients should eat prior to dialysis aseating is generally prohibited on hemodialysis unless specifcally prescribed; thereore retain the tray on the ward or the patients when thereturn rom hemodialysis. For example: hemodialysis patients receiving treatment in the morning will return to the ward at 1400 hours anwill need lunch as they do not receive a tray while in hemodialysis.

5. Tube eeds can remain running during hemodialysis based on individual needs o the patient and nursing assessment. I the tube eeds areheld the dialysis sta will irrigate the tube.

Intravenous

1. I using a peripheral IV site, a saline lock should be used. All medications should be diluted or given with minimal amounts o uid (reer toPharmacology Guidelines).

2. For Central Venous Catheter (CVC) access ollow hospital procedure or dressing change. I dressing becomes soiled, wet or alls o theinpatient, Registered Nurses or Licenced Practical Nurses may change dressing according to the acility’s procedure; otherwise the dressingwill be changed in dialysis.

3. DO NOT insert IV into fstula arm.

Medications

1. A patient summary listing current medications will be sent to the ward on admission. Call the hemodialysis unit i one is not received. Reeto Medication Administration Record guidelines or in-hospital and long-term care patients.

2. Some medications such as anti-hypertensives require special considerations related to dialysis; thereore consult with a hemodialysis nurseor Nephrologist.

3. Any medications scheduled to be given at a time the patient is on hemodialysis will be given post hemodialysis unless specifcally ordered.

Drug Administration Specifc to a Renal Patient on hemodialysis: • CalciumCarbonateand/orsevelamermust be given with meals/snacks unless physician’s order specifes otherwise.• Replaviteisavitamintakenbyhemodialysispatientstoreplacevitaminslostduringhemodialysis.Becauseitiswater-soluble,itmustb

given ater treatment or at bedtime to avoid being dialyzed o.• Medicationstoincreasepatient’shemoglobinaregiveninthehemodialysisunit(e.g.EPO&IVIron).Ifunsure,contactthehemodialysi

unit to determine which medications will be given during hemodialysis.• Oralironsupplementsmustbegivenbetweenmealsoratbedtime.Nevergivethemwithphosphatebinders.• EmlaCreamisatopicalanestheticusedonehourpriortohemodialysistofreezetheneedlepuncturesites.Applyatoothpaste-sized

strip to areas along the fstula and cover with plastic wrap. Do not apply over skin irritation or open sores. Consult a hemodialysis nursto indicate location i unsure.

• Antacidcontainingmagnesiumshouldnotbegiven.• ApplicationofaNitropatchpre-dialysisispatient-specic.Ifremovedduringhemodialysisbecausethepatientexperiencesadecreasein

blood pressure, it should be replaced post hemodialysis. Clariy with nephrologist i the Nitro patch should be removed prior to hemodialys• IVantibioticswillbegiveninhemodialysisunitpostdialysisifordered3x/week.Ifordereddifferently,pleasecheckwiththenephrologis

or the administration schedule and dosage.

4. Please ensure all orders or newly prescribed medications or changes to current medications administered during hemodialysis are axed tothe hemodialysis unit as soon as possible.

5. Forward a copy o all discharge medications to the hemodialysis unit when the patient is discharged.

Procedure # 60.40.06

Guidelines for Managing Hospitalized Hemodialysis Patien

FORM # W-00346 01/11 Procedure # 60.40



Fistula/Access

1. When no other access is available, a hemodialysis catheter (i.e. CVC) may be used or blood sampling, IV uid administration, andmedication and blood product administration. Prior to accessing CVC, the hemodialysis unit should be notifed. At some sites a physician’sorder is required. For a newly inserted CVC, a chest x-ray must be done to veriy placement o the CVC and an order that confrms proper placement o thecatheter must be written by the doctor prior to use. When a CVC is in situ, but not in use, the dressing must be changed weekly and the lumens instilled with anticoagulant as ordered bynephrologist (usual requency is twice per week).

2. Fistula Care:• Postasignabovethepatient’sbed(inaccordancewithfacilitypolicy),whichindicatesthepatient’sstulaarm.

• DO NOT puncture fstula arm.

• Thehandofthenon-stulaarmisthepreferredsiteforIVs.

• DO NOT take blood pressures on the fstula arm.

• Checkpatencyofstuladailybyfeelingthethrillovertheanastamosisandalongthestulaandbylisteningforbruitwithastethoscope. Notiy a hemodialysis nurse or nephrologist i fstula is not unctioning.

• TipStops/Suresealsorotherbrandnamedressingsmustberemoved4–6hoursposthemodialysis.

• Ifthepatient’shemodialysispuncturesitesbleed,applypressurefor10minutesandreapplygauzedressingwhenbleedingstops.

• No constrictive clothing, armbands, or watches should be worn on the fstula arm.

Bloodwork

1.DO NOT

draw blood rom the fstula arm.

2. Non-urgent bloodwork should be drawn in hemodialysis. Notiy hemodialysis sta i bloodwork is required and provide a requisition. Monthlybloodwork(e.g.CBC,Chemistry,INR,PTH)isroutinelydrawnonchronichemodialysispatients.Thisshouldpreventunnecessaryorextrablooddraws.

3. The patient is required to ast or triglycerides and cholesterol testing.

Appointments

1. All appointments or hemodialysis patients should be scheduled on non-hemodialysis days. I unable to do so, please consult thehemodialysis unit to coordinate the appointments with the hemodialysis times.

Admission/Discharge

1. Call the hemodialysis unit when a hemodialysis patient is admitted or discharged and determine the hemodialysis schedule or the patient.

Communication

1. A verbal report is the preferred mode of communication. For units that have standing agreements with the hemodialysis unit, a faxedreport may be used if unable to reach the nurse assigned to the patient if the patient had a stable hemodialysis treatment.

2. The report should include the most recent vital signs, any medications received, recent treatments, recent test results, the patient’s condition,and any other pertinent inormation.

3. The inpatient unit will do all dressing changes except CVC dressings unless the CVC dressing is wet or soiled.

4. a) The patient chart, including the Medication Administration Record , should accompany the patient to hemodialysis. All medicationsgiven in hemodialysis, including prn and routine meds, must be signed or in the inpatient chart. I the patient receives a medication in thehemodialysis unit that is not related to the dialysis process (e.g. analgesic, anti-nausea, etc.) and it is not ordered in the inpatient chart,this inormation shall be documented in the Integrated Progress Notes and verbally communicated.

b) ForPatientswithElectronicPatientRecords:Onarrivaltothehemodialysisunitthepatient’svisitistemporarilylocatedtothehemodialysisunitintheelectronicpatientrecord(EPR).Thepatient’spaperchartwillaccompanythepatienttothehemodialysisunit.All renal paper orders are suspended until the hemodialysis RN has reconciled the medications with the nephrologist and the ordersaresubsequentlyenteredintotheEPR.Allmedications,therefore,musthaveanorderintheEPRandonceadministeredmustbe

documentedonthemedicationworklistintheEPR.IfamedicationisrequiredandthereisnoorderthehemodialysisRNwillcontactthenephrologisttoentertheorderintotheEPR.

5. The hemodialysis unit should provide as much warning as possible to the inpatient unit when changes are made to the dialysis schedule.Preerably, at least eight hours notice should be given to ensure the patient is adequately prepared and patient care is minimally disrupted.

6. I the patient’s condition has changed since the last hemodialysis treatment or i the patient has become or is unstable, please notiy thehemodialysis unit.

7. I the patient is able, the preerred mode o transportation to the hemodialysis unit is a wheelchair.

Note

Inused MRIs - check with nephrologist on call as hemodialysis may be required within 2 hours o receiving this test.

When a patient has any other diagnostic imaging with contrast, they do not necessarily need hemodialysis within 24 hours. Theirkidney unction is already diminished. This does not apply to patients in Acute Renal Failure. The nephrologist will make this decision.

Procedure # 60.40.04 01/11



Please contact the patient’s hemodialysis unit i any clarifcation is needed on whether a medication is to be administered on the ward or in the hemodialysis unit.

Medication Preerred Administration Time(UNLESSSPECIFIEDOTHERWISE)

Rationale

Antibiotics, IV

Antibiotics removed by hemodialysis:

Amoxicillin LinezolidAmpicillin MeropenemCeazolin MetronidazoleCeotaxime MoxioxacinCeoxitin PenicillinCetazidime Piperacillin ± tazobactamCeuroxime Ticarcillin ± clavulanateCephalexin TobramycinGentamicin Trimethoprim/sulamethoxazoleImipenem Vancomycin

I ordered 3 times per week, IV antibiotics are usually given in the hemodialysis unit.Please contact patient’s hemodialysis unit to confrm.

Antibiotics removed by hemodialysis:

• Iforderedoncedaily,administeratbedtime.

• IfBID,give1stdoseatstandardmorningtimeand2nddoseatbedtime(asinpatients may be dialyzed during the evening dialysis shit).

• IfTIDorQID,giveatregularlyscheduledtimeswithatleast1-2dosespost-hemodialysis

Antihypertensives (all)

Antihypertensives removed by hemodialysis:AtenololCaptoprilEnalaprilLisinoprilMetoprololMethyldopaRamipril

Inpatientswithlowbloodpressure(i.e.systolicbloodpressure<100mmHg),consult with a physician regarding whether to hold or administer antihypertensivesprior to hemodialysis.

Antihypertensives removed by hemodialysis:• Iforderedoncedaily,administeratbedtime.

• IfBID,give1stdoseatstandardmorningtimeand2nddoseatbedtime(asinpatients may be dialyzed during the evening dialysis shit).

• IfTIDorQID,giveatregularlyscheduledtimeswithatleast1-2dosespost-hemodialysis.

Note: Some patients may have antihypertensivesspecicallyorderedtobegivenBEFOREhemodialysisifthey have increased blood pressures during hemodialys

Calcitriol, IV

Calcitriol, oral (Rocaltrol®)

IV calcitriol always given in the hemodialysis unit.

Administeratbedtimeifbeingusedtolowerparathyroidhormone(PTH).

Administer at standard dosing times i being used to treat or prevent hypocalcemia(e.g. pre or post parathyroidectomy).

Less hypercalcemia and hyperphosphatemia with oralcalcitriol when given at bedtime.

Calcium carbonate (Apo-Cal®, Tums®) Administer with meals unless otherwise specifed.

Calcium Drug Interactions:

OralFluroquinoloneantibiotics–e.g.ciprooxacin,levooxacin,ormoxioxaxcin.Administer oral uroquinolone antibiotics 2 hours beore or 4 hours ater calciumcarbonate. Calcium decreases absorption o oral uroquinolones. Does not apply i uroquinolone antibiotic is given I.V.

Iron(oral)–ferroussulfate,ferrousgluconate,ferrousfumarate.Administer1-2hours beore or ater calcium carbonate. Calcium decreases absorption o oral irontablets by 30-40%.

Calcium is used to binds phosphorus in ood and toincrease calcium levels in hypocalcemic patients.

Calcium absorption rom calcium carbonate is increased 1

to30%byadministeringwithameal.However,patientsonvery large doses o calcium to treat/prevent hypocalcemia(e.g. post-parathyroidectomy) may be prescribed calciumcarbonate both with AND in between meals.

Darbepoetin ala (Aranesp®) Always given in the hemodialysis unit. Note: This only applies to hemodialysis patients. RenaHealthClinicandPeritonealDialysispatientswillreceivsubcutaneous doses o darbepoetin ala on the ward.

Emla®Cream Apply1hourpriortohemodialysis. ApplyEmla®alongthestulawheretheneedleswill be inserted. Sites should be 6-8 cm apart and at least 2 cm rom previous sites.Generously apply and do not rub in (the cream should remain a white blob). Coverwith plastic wrap (Saran Wrap®) so it will not rub o.

Emla®isatopicalanestheticusedtofreezehemodialyneedle sites.

Do not apply over open sores or skin irritation.

Epoetinalfa(Eprex®) Always given in the hemodialysis unit. Note: This only applies to hemodialysis patients. RenaHealthClinicandPeritonealDialysispatientswillreceivsubcutaneous doses o epoetin ala on the ward.

Fluoroquinolone antibiotics, oral(e.g. Ciprooxacin, Levooxacin)

Once daily oral doses: administer at bedtime

IV uroquinolones: no issues

Oral calcium, iron, and aluminum containing medicatiocause greatly decreased absorption o these antibioticsGive 2 hours beore or 4 hours ater these drugs. Dosinat bedtime will usually allow the correct interval.

Gabapentin, oral Give dose(s) ater hemodialysis; usually given at bedtime i used or restless legsyndrome.

Signifcantly removed by hemodialysis.

Iron, IV:IV Iron dextranIV Iron sucrose (Venoer®)IV Sodium erric gluconate (Ferrlecit®)

Always given in the hemodialysis unit.

Nitroglycerin patches I applied in AM, leave on or hemodialysis unless otherwise specifed by patient orphysician.

Rarely causes signifcant hypotension, however, the usenitroglycerin patch during hemodialysis is patient-spec

Sevelamer (Renagel®) Always with meals. Bindsphosphorusinfood.

VitaminBandC(Replavite®) Administer at bedtime. Signifcantly removed by hemodialysis.

Prepared by Lori Wazny 2008; Reviewed August 2010

Medication Administration TimesGuidelines for Hospitalized or Long-Term Care Patients receiving (Chronic) Hemodialys

01/11 Procedure # 60.40

p&p hemopatient guidelines

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