Transcript Patient Assessment Hemodialysis Technician Review Course

Alice Hellebrand MSN, RN, CNN, CURN
PATIENT ASSESSMENT
HEMODIALYSIS TECHNICIAN
REVIEW COURSE
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
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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
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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?
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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
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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
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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:
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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 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
patient’s 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
patient’s blood
with saline, with
no air in the
bloodlines.
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.
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
>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
smaller
dialyzer and/or
slower blood
and dialysate
flows are
preferred.
Short, slow
dialyses may be
prescribed daily
for a few
Complication
Causes
Fever and/or chills • Infection
• Contaminated
dialyzer or
bloodlines
(endotoxin
exposure)
• Too-cold
dialysate
Signs & Symptoms
How to prevent it
• 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
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 15–
30 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
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.
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.
 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?????