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?????