Download Dialysis Therapy Management

HEPARINIZATION
During dialysis the patient’s blood comes into contact with man-made materials. This
contact may allow the blood to clot. The goal of hemodialysis is to move the blood out
of the body, clean it, and return it as quickly as possible. There is no time for clotting.
If the blood clots, the hemodialysis process is much more difficult and may need to be
halted.
Heparin is a ‘blood thinner,’ or anticoagulant which works inside the body to prevent
blood from clotting. The nurse practitioner and/or physician will order the amount of
heparin each patient is to be given during a hemodialysis treatment. Typically patients
are given a large dose of heparin, a loading dose, at the beginning of a treatment.
Then small amounts, continuous infusion, are given during the treatment. The initial
large dose helps to ‘jump-start’ the anticoagulation process. This way the hemodialysis
procedure will more than likely function more smoothly.
Care must be taken when administering heparin not to give the patient too much.
Accuracy is imperative here. Heparin is bottled in three ways or three concentrations,
1:1,000, 1:5,000, or 1:10,000. Before using heparin on a patient be certain you have
the correct concentration. (See drawing medications) After verifying the proper
concentration, check the doctor’s order to verify the correct dosage.
The machine allows for heparin to be slowly injected during the hemodialysis treatment.
The doctor often orders for the injection to stop approximately one hour before the end
of the dialysis treatment. Why would they do that? Heparin takes four to six hours to
stop working. Therefore, if you give the patient heparin up until the last minute, when
you remove the two large needles in his arm, it will take a VERY long time to clot.
Stopping the heparin 60 minutes prior to the termination of dialysis will allow most
patients’ blood to clot in ~15 minutes.
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COMPLICATIONS
When giving any medication is it vital to know the possible complications.
Too much heparin:
Prolonged bleeding after dialysis
Nosebleeds
Easy bruising
Stomach bleeding
Hematuria (blood in urine)
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Too little heparin:
Clotting of the dialyzer completely or a little
Poor rinseback
MONITORING AND TREATING A PATIENT DURING HEMODIALYSIS
Patients must be started on dialysis, monitored during dialysis, and then discontinued
from dialysis. Seems obvious, right? Let’s go through the steps. Before we touch, a
patient we must first greet them. Patient care is our priority and this includes the
patient’s physical as well as mental well being. Identify yourself if the patient doesn’t
know who you are. Be friendly and try to establish a positive relationship with your
patients.
COMMUNICATING
All people communicate by means of verbal and non-verbal communication. Verbal is
what is said and non-verbal is obviously what is not said but rather observed. I’m sure
you’ve seen someone who ‘appears’ to be anxious, or frightened. Or you’ve probably
heard the term, “actions speak louder than words,” this is what I’m referring to. What
we do is a means of communication, subject to interpretation by others. Did you ever
stop to think that even failure to act is a way of communicating? (5) Non-verbal
communication includes facial expressions, eye contact, tone of voice, body posture and
motions, and positioning within groups.
When watching a patient or greeting a patient, ask the patient how they are feeling,
then listen. I mean really listen. Listen carefully to be sure you truly hear what the say
and watch their non-verbal communication to see if the verbal matches the non-verbal.
Most dialysis patients return every other day. If you work with the same group week
after week, you will surely get to know these people. You’ll be able to ‘read them’ and
know if they are not feeling their best.
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If a patient is not feeling well, they may hold their head down, walk more slowly, talk in
a softer voice, and not have a happy look on their face. Regardless of what the patient
is communicating, be ready to provide emotional support and/or accommodate
emotional needs as necessary.
If the patient does not hear well, it will be important to speak more slowly, louder and
clear. If the patient speaks a language other than any language you know, special
accommodations must be made. Communicating with your patient is imperative.
Patients that are older may be addressed differently than patients that are younger.
Finally, before attempting any procedure on a patient, you must first explain what you
are doing. If the patient requires further explanation, beyond what you can do, you
must contact your nurse to assist. It is not proper or legal to perform any procedure on
a patient without their permission. If the patient doesn’t understand what is going to
take place, they will more than likely not give permission.
STARTING OR INITIATING DIALYSIS
The dialysis machine must be setup and ready for the patient. The machines are
disinfected during the night. This cleaner must be rinsed away before using on a
patient. Once this is rinsed, the machine must be tested to verify all poisons have been
removed. Now you can set up the machine.
Set up the machine according to the hands-on instruction given. Keep the cartridge
well seated before closing the pump. Prime the pre-dialyzer tubing by gravity before
connecting to the dialyzer to prevent air locks. Use 1,000 cc of saline to prime the
dialyzer. While priming the dialyzer, tap and roll the kidney to work as much air as
possible out.
Most dialysis machines use acid and bicarb to create the concentration differences
discussed in the beginning. These solutions or powders will need to be connect and
set-up during the initiation/set-up phase.
Connect the tubing to recirculate. A reuse kidney will need to recirculate for eight plus
minutes before testing to verify the Renalin has been removed. If using a dry-pack,
recirculate for two minutes as another way of verifying the kidney will give the patient
maximum performance. When the Renalin test is complete perform machine and
venous high-pressure tests.
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Connecting to the patient
There are several things to consider before connecting to the patient. The patient’s
access must be used.
ACCESS
Dialysis cannot occur without a proper access. Large amounts of blood are going in
and out of the patient at a very high speed. If the patient’s access is not working well,
this process is greatly impeded. This hemodialysis access is similar to an IV that may
be seen with many patients in a hospital. However, it is much much larger.
Vascular accesses are the lifeline of a hemodialysis patient. There are many types, but
four are seem most often: Fistula, Graft, Permacath, and ‘Shilley.’ These four are listed
in order of best to worse.
FISTULA
A fistula requires a surgical procedure where the patient’s own vein and an artery are
sewn together. Typically the veins and arteries in the arm are used. After the surgery,
these sutures must heal and mature. Once a ‘native’ fistula is matured, it can be
punctured repeatedly and remain in good condition. Native fistulas have fewer
complications than any other type of access. The surgeon can connect these two
vessels either side by side, end to end, or side to end.
However, some patients are not candidates for this type of surgery. If the patient has
had previous surgeries (6) to the vessels in the arms, damage to the blood vessels from
IV drug abuse and/or repeated bloodwork, atherosclerosis in the vessels, or few or poor
quality veins to choose from, graft will more than likely be placed.
GRAFT
A graft sews a patient’s vein and artery together using a Gore-Tex tubing that
resembles a natural vein. But this is NOT a vein and, therefore, cannot take the wear
and tear a natural vein can. As a result, patients have complications more frequently.
A Gore-Tex graft cannot be punctured in the same area repeatedly as well. The
materials will breakdown and soon resemble a tattered piece of cloth if allowed.
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PERMACATH
Permacath’s are large IV type catheters that are place in the patient’s neck or shoulder.
The large veins used lead a path that goes directly to the patient’s heart. Therefore,
sterility must be closely maintained. These central catheters, as they are sometimes
called, have two ports available, just as placing two needles into a fistula or graft.
What separates these catheters from a more temporary catheter is a cuff near the end
that exits the body. This cuff is similar to a piece of Velcro. The Velcro is attached to
the outside of the tubing. This cuff ‘grows into’ the fatty part just under the skin.
When this occurs, the catheter is more stable. Typically a patient can use this catheter
several months without any problems.
SHILLEY
Shilley catheters or temporary access catheters are similar to permacaths in that they
are placed in the same large vein. The major difference is there is no cuff. These
catheters are sewn onto the skin and the sutures hold it in place. Once the sutures are
removed, it can easily be taken out. These catheters are used for only a few weeks.
Once you know which type of access a patient has, you can proceed. Step one would
be to wash your hands and don gloves, as standard precautions. Next inspect the site.
Check the skin for any signs of infection, redness, heat, open sores, etc. Note where
the site has been previously punctured. Avoid sticking the patient in the same place.
An aneurysm can form if needles are inserted too often in the same area. The vessel
wall will become weak and balloon out. This weak area of the vessel may become so
thin that it leaks into the skin.
Avoid pseudoaneurysms as well. These are bulges in an access that appear similar to
an aneurysm with the ballooning out appearance, but these are not caused from weak
vessel walls, but rather a collection of blood and blood clots ‘stuck’ in one area.
Pseudoaneurysms often occur when improper techniques are used after needles are
removed.
NEVER insert a needle into an aneurysm or a pseudoaneurysm. If done, the vessel
could rupture and/or become infected.
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MONITORING THE PATIENT DURING DIALYSIS – INTRADIALYTIC
During the patient’s dialysis treatment, you will monitor the patient’s status very closely.
Every half-hour or more often ,you will check with the patient’s blood pressure, pulse,
arterial pressure and level of consciousness. If there are no changes, you will simply
continue to monitor. However, this is very unlikely. Patients may need help in
repositioning themselves in the chair or bed or stretcher for maximum comfort. Often
patients are given ice chips to eat during a treatment. These will need to be given to
the patient. These are the easiest concerns you will have during a treatment. Let’s
discuss some of the more involved issues. Patients are very limited in their movement
for the 3-4 or more hours when they are receiving a dialysis treatment.
The goal of dialysis is to remove fluid. By doing so, the patient’s blood pressure will
naturally drop. Your job is to watch this blood pressure and if the values are
significantly less than the original, an intervention will be needed. Typically the first
step a dialysis staff member will do is to place the patient in a flat or Trendelenberg
position.
POST DIALYSIS
After a dialysis treatment, the patient must be observed. The patient more than likely
just had a large amount of fluid removed in a short period of time. When this occurs
patient’s often feel tired or worn out and drained.
As this fluid is being removed, a patient’s blood pressure will naturally fall. Therefore,
when a patient stands up after a hemodialysis treatment he/she could feel dizzy or
lightheaded. Listed below are the typical complications during hemodialysis:
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Complications
Problem
Causes
Signs/Symptoms
Air in Blood Lines
·In adequate blood flow rate, causing negative pressure, prepump (line collapses)
Microfoam/Micro-bubbles
Normal saline, if too cold when exposed to the warm dialysate,
forms a type of condensation that causes tiny air bubbles to
adhere to the dialyzer membrane and sides of the blood tubing.
· A latex injection port does not self-seal (needle gauge
greater than 20)
· Underfilling of drip chambers (causes turbulence)
· Underfilling of saline administration sets drip chamber
· Improper deaeration (air removal) of dialyzing fluid
· Residual air left in blood pathway after priming
· Introduction of air during dialysis (especially together with
absence of an arterial drip chamber)
Not priming the heparin injection line prior to opening
Inadequate connections pre-pump; i.e., fistula needle, saline,
monitor line connections.
“Foaming” in blood
· Arterial blood line separation due to untapped, improper luer
lock connection, or loose connections
· Blood noted on floor, chair, and/or clothing
· Hypotension
· Air entering the extracorporeal circuit
· Venous and/or arterial pressure may alarm (arterial and/or
venous pressure should decrease)
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Problem
Causes
Signs/Symptoms
Blood Loss (accidental)
· Venous blood line separation due to untapped, improper luer
lock connection, or loose connections
· Blood noted on floor, chair, and/or clothing
· Hypotension
· Venous pressure alarms (should be low venous pressure alarm)
· Dialyzer leak
· Dialyzer rupture
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· Arterial needle dislodgment
· Arterial needle slips out
· Venous needle dislodgment
· Venous needle slips out
Blood detector alarms
Blood detector alarms
Foamy pink to red-tinged dialysate
Blood on floor, chair, and/or clothing
Hypotension
Venous and/or arterial pressure alarms (low limit alarm)
Blood on floor, chair, and/or clothing
Hypotension
· Venous pressure monitor should alarm (low limit alarm)
· Clotted blood in venous blood line
· Venous pressure rises
· Unable to return blood via venous line
· Clots noticed in venous drip chamber
· Clotted blood in arterial blood line
· Arterial blood line with air in it (line “jumping”)
· Possible decrease in venous pressure
· Increase in arterial pressure
· Unable to pump blood into dialyzer
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Problem
Hemolysis
(Rupture of red cells)
Due to hypotonic dialysate –
diluted with too much water
Causes
Signs/Symptoms
Improperly diluted dialysis bath composition due to failure of
mixing system or human error:
· Failure to connect concentrate
· Huge rapid influx of water into circulation with the dilution of
plasma – water moves across the cell membrane and dilutes
intracellular constituents:
- Decreased sodium, calcium, magnesium, and chloride
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Obstruction of dialysate concentrate source
Malfunction of concentrate pump
Faulty concentrate
Failure of conductivity monitor
significant calibration error
fouling of probe
complete failure
failure to set correct limits in manual system
failure to test dialysate in batch system
Bypass mechanism failure
mechanical failure
- retrograde leak across bypass valve
Due to overheated dialysate
(temperature in excess of 470C)
· “Cranberry juice” or “cherry pop” (clear) blood in venous line
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Failure of thermostat; heater turned on inappropriately
Thermostat not set properly
Failure of dialysate high temperature sensor
High temperature sensor not set properly
Calibration error in dialysate temperature range
Major malfunction in heater cycle
Dialysate temperature monitor failure
Failure of machine to go into bypass
- mechanical failure
- retrograde leak across the valve
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Decreased protein
Pain in vein receiving hypotonic solution
Warmth in throat
Erratic blood pressure
Chest pain or tightness
Dyspnea
Anxiety
Restlessness
Throbbing headache
Nausea, vomiting, abdominal cramping, diarrhea
Seizures
· Arrhythmias – initially decreased pulse leading to rapid and
thready pulse
· Hyperkalemia
· Patient complains of feeling hot
· Skin is hot
· Skin may feel dry
· Headache and delirium
· Seizures
· Rapid, weak respiration
· Tachycardia (rapid pulse)
· Initial increase in systolic blood pressure, then a decrease with
CHF that follows an increased temperature
· Chest pain
· Dyspnea (difficulty breathing)
· Cardiac arrest
· Increased WBC's as a result of physiologic stress
Problem
Causes
Signs/Symptoms
· Lactic acidosis from anaerobic metabolism and hemolysis
· Hyperkalemia
· Derangement of normal clotting mechanisms
Crenation
(Shriveling of red cells)
Due to excess concentrate in
dialysis
· Water supply diminished or shut off
· Conductivity limits not set properly
· Proportioning unit not functioning properly
· Failure of conductivity monitor
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significant calibration error
fouling of probe
complete failure
failure to set correct limits in manual system
Bypass mechanism failure
· Very dark red blood
· Hypernatremia
· Water flux out of patient from intracellular to extracellular
(water movement is faster than sodium shift)
· Intracellular dehydration and hyperosmolality – contraction in
cell size
· Gradient for influx of calcium occurs
· Contracted or expanded extracellular volume
· Headache
· Nausea
Power Failure
· Overloading of electrical circuit
· Local blackout
· Machine accidentally unplugged
· Stoppage of equipment
· No lights until emergency generator kicks on
· Unarmed or defective air detector
· Careless IV administration
· Empty IV bag
· Large volume of air in venous line
· Chest pain
· Shortness of breath
· Air in blood lines or loose connections
· Air leak in the blood tubing or connections
· Separation of blood lines
· Very cold dialysate which contains large amounts of
dissolved air that is released when warmed
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Coughing
Cyanosis (blue-purple color of skin, lips, or nail beds)
Visual disturbances
double vision
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blindness
Confusion, restlessness, fear
Slight paralysis of one side of the body
Seizures
Coma
Possible cardiac arrest
Air Embolism
(air bubbles carried by the blood
stream into a vessel small enough
to be blocked by the bubble)
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Problem
Causes
Signs/Symptoms
Angina
(chest pain)
· Hypotension
· Anemia – low hematocrit/hemoglobin
· Anxiety
· Chest pain
· Rapid change in serum electrolytes, especially potassium
· Hypotension
· Volume excess
· Low potassium level or rapid drop in potassium in
conjunction with digitalis therapy
· Myocardial infarction (blockage of a heart artery)
· Slow or rapid and irregular pulse (heart rate)
· Skipped or extra beats
· Patient complains of “palpitations”
· Electrolyte imbalance, especially hyperkalemia (too much
potassium in the blood)
· Arrhythmias
· Myocardial infarction (hear attack)
· Cardiac tamponade (fluid buildup in the pericardial sac
surrounding the heart, preventing the heart from beating)
· Large air embolism
· Hemolysis (bursting of red cells)
· Exsanguination (loss of all blood)
· Hyperthermia (excessively high body temperature)
· Absence of apical or carotid pulse
· Rapid shifts in patient’s fluid volume
· Painful muscle spasms (usually in the extremities – hands and
feet)
Arrhythmia/Dysrhythmia
Cardiac Arrest
· Lack of spontaneous respiration
· Unresponsiveness
· Abnormal heartbeat on cardiac monitor
Muscle Cramps
· Shift in blood chemistries, especially sodium
· Fluid or electrolyte imbalance, especially depleted sodium
· Hypokalemia (low potassium)
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Problem
Causes
Signs/Symptoms
Dialysis Disequilibrium
Syndrome
In the brain, there is a slower
transfer of urea from the brain
tissue to the blood, so fluid is
drawn into the brain, causing
swelling.
· Too rapid a change in serum electrolytes, pH, or osmolarity
· Hypertension
· Occurs more often in acute renal failure or when BUN values
are very high > 150 mg/dl)
· Nausea and vomiting
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Headache
Restlessness
Convulsions
Decreased level of consciousness
Coma
Death
Fever and/or Chills
· Infection
· Infected access
· Temperature over 990
· Redness, swelling or drainage from access
· Patient feels cold
· Shaking chills which lead to temperature elevation; chilling is
involuntary
· Temperature increase after dialysis is initiated, or temperature
increase after termination of dialysis
· Non-sterile technique
· Contaminated dialyzer
· Introduction of pyrogens (fever-producing substances) or
endotoxin (byproducts of bacterial cell walls) via dialysate or
inadequately reprocessed dialyzer
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· Patient feels cold
· Shaking chills which lead to a rise in temperature; chilling is
involuntary
· Hypotension
· Temperature rise midway into the patient’s treatment
Problem
Causes
Signs/Symptoms
Headache
· Fluid shifts
· Dialysis disequilibrium – a slower transfer of urea occurs
from the brain tissue to the blood, so fluid is drawn into the
brain, causing swelling
· Hypertension
· Change in sodium level
· Anxiety/nervous tension
· Pain in the head or facial area
· Error in initial heparin dose
· Error in heparin infusion pump setting
· Heparin pump malfunctioning
· Unusual bleeding around needle sites (during treatment)
· Prolonged bleeding from puncture sites post dialysis
· Purpura (bleeding under the skin) noted if patient injured
· Too many high K+ foods
· Frequent infections, or excessive tissue breakdown
· High serum glucose in diabetics
· Bleeding, particularly gastrointestinal; or surgery
· Sepsis (infection)
· Hemolysis (red blood cells swell and rupture) or crenation
(red cells shrink)
· Recent blood transfusions
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Weakness
Dizziness
Nausea
Vomiting
Chest pain
Arrhythmia
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Numbness
Tingling around mouth, tongue, hands, and feet
Cramps in thighs
Diarrhea
Cardiac arrest
Heparin Overdose
Hyperkalemia
(high potassium)
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Problem
Causes
Signs/Symptoms
Hypertension
(high blood pressure)
· Disequilibrium Syndrome
· Fluid overload
· Noncompliance with blood pressure medications
· Rennin response (damaged kidneys may overproduce rennin,
raising blood pressure)
· Volume overload due to excess sodium or water
· Increase in effective cardiac output during the course of
dialysis
· Increased peripheral vascular resistance (possible side effect
of EPO)
· Excessive ultrafiltraton – removal of too much fluid during
treatment
· Antihypertensive drugs
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Membrane
Biocompatibility Problems
Dizziness
Headache
Edema
Nausea
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Vomiting
No symptoms (must monitor)
Frequently asymptomatic (no symptoms)
High blood pressure reading
Gradual or sudden rise in blood pressure
· Headache, blurring vision
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· Anxiety
Hypotension
(low blood pressure)
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Low blood volume
Low weight gain
Dehydration (i.e., vomiting and diarrhea)
Unstable cardiovascular status
· Complement activation (immune reaction) caused by new
cellulose membranes (common reaction in some patients)
Nausea, vomiting, irritability
May have no symptoms
Rapid increase in hematocrit
High systolic blood pressure reading
Nervousness
· Gradual or sudden decrease in blood pressure, possibly
accompanied by dizziness, nausea and vomiting, perspiration or
cold, clammy skin, tachycardia; loss of consciousness
· An early symptom may be patients feeling quite wamr, fanning
themselves
· Yawning
· Low blood pressure at beginning of treatment
· Pallor, weakness
· Feeling faint
· Increase in apical pulse
· Feeling anxious
· Pruritis (itching)
· Back pain
· Hypotension
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Problem
First use syndrome
Anaphylaxis reactions
(immediate allergic reactions)
Causes
Signs/Symptoms
· Thought to be the result of hypersensitivity to the ethylene
oxide used to sterile some dialyzers
· May be sterilant that remains in the potting material of the
hollow fiber dialyzer
· Acute bronchoconstriction (narrowing of breathing passages)
· Vasodilatation (relaxation of blood vessels)
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Hypotension
Anaphylactic signs and symptoms
anxiety
cardiac output decreased
flushing
tightness in the chest
respiratory diseases
hives
Nausea
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Pruritis
(itching)
Hypotension
Disequilibrium Syndrome
Pyrogenic reaction
Influenza or intestinal virus
· Nausea
· Vomiting
· Headache
· Uremia
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Dry skin
Parathyroid dysfunction with calcium salt skin deposits
Allergy to medication (i.e., heparin) or to dialyzer
Calcium level in dialysate may be too high
Increased calcium in water due to reverse osmosis failure
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Severe generalized itching on and off dialysis
Reddened skin
Crusting
Increased phosphorus level
Increased itching only when on dialysis
Problem
Recirculation
(already dialyzed venous blood
mixing with arterial blood in the
patient’s access)
Causes
Signs/Symptoms
· Needles are too close together – less than 2 inches apart
· Darkening of blood – deoxygenation
· “Black Blood Syndrome”
· Increase of hematocrit
· Increase in viscosity (thickness) of blood during dialysis
· Reversed blood lines (arterial needle attached to venous
blood line and venous needle attached to arterial blood line)
· Inadequate flow from the access or poor positioning of the
arterial needle
· Poor arterial flow (arterial stricture, or narrowing); therefore,
venous blood pulled through the arterial line
· Arterial needle facing away from anastomosis (with an
increased venous pressure)
· Poor venous blood return
- venous stricture
- low flow through fistula
- tourniquet above venous needle
· Inadequate blood flow in the vascular access
Restlessness and Insomnia
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Inadequate dialysis
Missed treatment
Depression
Anxiety
Hypercalcemia (too much calcium in the blood)
Hyperkalemia (too much potassium in the blood)
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Fatigue, weakness and difficulty sleeping
Anxious, depressed
Loss of appetite
High BUN
Seizures
· Dialysis Disequilibrium
· Change in level of consciousness
· Jerking movements of the arms and legs
· Electrolyte
· Change in level of consciousness
· Delivery of improperly prepared dialysate
· Change in level of consciousness
· Jerking movements of the arms and legs
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Problem
Causes
Signs/Symptoms
Aneurysms
True aneurysm
A ballooning out of a weakened
portion of the fistula vessel
(active blood flows through the
true aneurysm on puncture,
aspirated blood is fresh. Occurs
most commonly at the
anastomosis in an AV fistula
False Aneurysm
(pseudoaneurysm)
blood with false aneurysm is a
collection of blood with no
“communication” with blood in
the active vessel; if punctured,
dark, old, and possibly clotted
blood would be aspirated
· Infiltration (needle punctures through opposite vessel wall)
of interior of vessel
· Repeated puncture of vessel at same site; “one-site-it is”
especially when proximal veins mature slowly or do not
mature
· Shearing between the walls of the vessel during
venipuncture
· Dilation (enlargement) of vessel wall a predominant sign
· Bounding pulse in area of dilation
· Area possibly more sensitive to venipuncture than remaining
fistula
Grafts:
· Unsealed needle puncture site and hematoma formation
· Unusual dilation of graft anywhere along its course
· Repeated cannulation of same sites
· Difficulty with venipuncture
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Problem
Clotting
(Thrombosis)
Causes
Signs/Symptoms
Any of the following can cause decreased blood flow through
the anastomosis (surgical connection between artery and vein)
and access. Any time there is decreased rate of flow, clotting
can occur.
1. Hypotension
- Recurrent orthostatic hypotension (a fall in blood pressure
upon standing)
- Severe chronic hypotension
· Absence of bruit/thrill
· Occasional patient complaints of pain at the arterial anastomosis
prior to complete thrombosis
· In a fistula, poor to no definition (dilation) of venous branches
of fistula when tourniquet is applied to upper arm
· Able to aspirate (withdraw) only black blood during venipuncture
- Volume depletion in the vascular system
2. Prolonged pressure
(compression of blood flow) on the vessel by:
- Holding the extremity in one position for extended periods of
time
- Prolonged direct pressure on the vessel following needle
removal
- Use of constrictive clothing, bandages, or clamps
Inadequate arterial blood flow
4. Stenosis (narrowing) of the Arterial anastomosis or any
area of vein near the arterial anastomosis or venous end
Poor venous return may be caused by narrowing of the
vessel
Development of a “pseudodiaphragm” (plaque formation
that reduces blood flow) in a graft at the venous anastomosis;
this membranous diaphragm can continue to narrow further
until blood flow through the vessel is diminished to the point
that clotting occurs.
7. Infection
8. Repeated venipuncture of the same sites particularly in a
graft
9. Repeated infiltration compresses vessel
Compression from hemorrhage into the tunnel of a graft
Compression from a “pseudoaneurysm”
Increase in venous pressure
· Increased percent of recirculation
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-Syndrome” Sudden decrease in
· Arterial blood flow and pressure or increase in venous pressure
when graft if compressed between two needles
· Gradual increase in BUN and creatinine with no change in diet or
muscle mass
Problem
Excessive Bleeding
Infection
(More serious in an AV graft than
in an AV fistula; due to risk of
disintegration of some synthetic
materials and subsequent
hemorrhage)
Causes
Signs/Symptoms
Change in color of blood in art erial needle line when
normal saline or dilute blood is introduced into circulation
through the venous needle
· Technical problems especially when inserting needles too
close to, or into the anastomosis itself:
- penetration of vessel walls at venipuncture
- abrupt movement of the accessed limb
- overloading of heparin
- repeated venipunctures in the same sites will cause vessel
weakness
- Vessel weakness creating an aneurysm, which may
precipitate excessive bleeding
· Unusual bleeding during dialysis around puncture sites
· Prolonged bleeding of access after dialysis
· Break in a septic technique during cannulation or surgical
procedure
· Redness
· Bacterial spreading from another infected site in the body
· Poor hygiene and care of access arm
· Swelling
· Tenderness
· Pain
· Drainage
· Any fluid collection around the graft
· Fever with or without other signs if the infection is in the interior
of the graft
· Positive blood cultures
· Early post-operative infection possibly extending the entire
length of the graft because of the invasion of the tunnel
· Fever and/or chills as hemodialysis treatment progresses
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Problem
Ischemia
Steal syndrome (local and
temporary loss of circulating
blood due to obstruction of
circulation to a limb)
Causes
Signs/Symptoms
Fistula:
· Affected limb colder distally (further from the body) than nonaffected limb and often paler
If the anastomosis is too big, it can deprive the rest of the
limb of an adequate amount of blood flow. Sometimes the
blood flow will travel up an arm instead of down, for example.
This problem may be worse in-patients with vascular, such as
diabetes.
· Cyanotic (blue) nail beds may be present
Grafts:
Normal arterial blood supply to distal extremity is shunted
through the access, thus depriving the distal extremity of
needed oxygenation; occurs most commonly in patients with
poor distal circulation before surgery.
· Pain in distal extremity (finger or toe) ranging from mild to
severe and made worse or precipitated by dialysis is the classic
symptom
· Cold
· Pale
· Cyanotic finger or toe
· Pain in distal extremity made worse by hemodialysis
Needle
Infiltration/Hematoma
(The seepage of blood from a
vessel into the surrounding soft
tissue)
· Improper venipuncture
· Burning and tenderness at insertion site
· Movement of the extremity after needle placement, which
pushes the needle through the vessel
· Needle slips out, or through the vessel, and into the
surrounding tissue
· Immediate swelling of the area
· Hardness of the area
· Pain
· Discoloration
· Discomfort for several days
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Problem
Poor blood flow
(Inadequate blood flow and/or
continuous collapsing when the
blood pump is on)
Causes
Signs/Symptoms
· Using an incorrect needle gauge
· The blood in the tubing will appear foaming
· Clotted needle or cannula
· Since there is little or no blood flow through the dialyzer, the
venous drip chamber may partially or totally collapse
· Air will appear in the blood level in the venous drip chamber will
be lower then normal (i.e. below the chamber filter)
· Arterial line “jumping”
· Clamp on line
· Incorrect needle placement of the needle or cannula within
the vessel. The needle bevel may be pushed up against the
vessel wall.
· Needle not in vessel
· Vessel spasms
· Improper blood pump speed
· Clotted access
· Kinking of the tubing
· Failed access
Hematoma formation
(Swelling caused by blood leaking
from vessel)
· Penetration of both walls of the vessel by a cannula (most
often is the underlying reason for a hematoma upon cannula
insertion procedure)
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· Pump segment collapse
· High pre-pump negative pressure
· Painful, hard, discolored swelling (caused by blood escaping
from a vessel into surrounding tissue)
Problem
Causes
Signs/Symptoms
Kinking
· Kink in blood lines
· The catheter bending when the patient moves or lies on the
same side as the catheter site
· Sutures at the exit site may be kinking the catheter at the
point of entry
· Arterial line
· Collapse of the arterial blood line (line will be “jumping”
· The venous resistance will be low
· Venous line
· Increased venous resistance/pressure
One-way obstruction
· Should be suspected when a portion of the catheter can be
flushed, but fluid cannot be withdrawn
· Usually by tip malposition
· Air bubbles in the tubing set – the blood is foamy
· Incorrect placement of the catheter within the host vessel
with side holes sucked up against vessel wall
· Collapsed arterial blood line (i.e., pillow)
· Venous drip chamber has collapsed or is set at a lower level
than normal
Poor blood flow
· Drop in arterial pressure
· Blood in arterial line will appear in foamy
· Since there is little or no flow through the dialyzer the venous
chamber may also partially or totally collapse
· Air bubbles will appear in the blood tubing, and the blood level
in the drip chamber may be lower than it normally should be, i.e.
below the filter
· Increased resistance to blood flow returning to the patient,
which in turn may produce involuntary ultrafiltraton
· Improper blood pump speed
· Vessel spasm
· Collapse in the arterial blood line
· The resistance on the venous return will be low
Thrombus - clot Formation may
occur at the tip or in the tubing of
either side of the catheter
· Blood that was left to stagnate (sit) in the catheter between
treatments
· Inadequate heparinization of the catheter
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· Unable to aspirate (withdraw) blood from either side of the
catheter
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MEDICATION
We’ve discussed heparin as a medication given and used by both dialysis nurse and dialysis
technicians. There are three other medications that are allowed to be given. Before giving
any medication, you must first verify the doctor’s order. Check to see what the allowable
dosage is and what time frames the medications can be given. Always look at the
medication and verify it is the correct color and size. If it is not, call the pharmacy and/or
check with the RN covering for you. Verify the medications are not expired. Checking the
expiration date must occur three times:
1. When you initially pick up the medication.
2. Prior to putting the medication in the proper container.
3. Prior to discarding the package of medication.
The three medications that you are allowed to give p.o. (by mouth) are acetaminophen,
diphenhydramine, and quinine sulfate. Let’s take each one separately:
Acetaminophen
Most people know this drug as Tylenol. Few people are known to be allergic, but whenever
you give a drug you must ask the patient if they are allergic to any medications. The dosage
allowed to be given can be 375 mg to 1000 mg, only once during their treatment and ONLY
if the patient had not taken any Tylenol up to four hours prior. If the patient states they
took some Tylenol six hours before coming to dialysis, it would be okay to give the patient a
dose during dialysis.
It’s important to know adverse effects that medications can give. These can be found in the
Facts and Comparisons Book located on each unit. The largest concern for Tylenol is for
patients who have liver problems. Tylenol is cleared out of the body in the liver. Too much
Tylenol can hurt a person’s liver and if the Tylenol is given to someone with a bad liver, it
can make him or her worse.
Diphenhydramine
Most people know this drug as Benadryl. As discussed earlier, patients on dialysis often itch.
Benadryl has been very helpful for many patients on dialysis. Benadryl does have a side
effect of drowsiness. For some patients this is helpful in that they sleep during the HD
treatment. Benadryl may only be given q4h (every four hours) like Tylenol. Therefore, it will
be important to check with your patient when their last dose of this medication was taken.
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Quinine Sulfate
Quinine, although not used as often today, has been used very successfully for leg cramping.
While the fluid is being removed during the dialysis process, many patients feel a drawling
and/or pulling in their legs, much like a leg cramp. These leg cramps can be very painful for
the patient. If someone not connected to a machine acquired a leg cramp, they would most
likely stand up. Unfortunately, dialysis patients should not stand while receiving an HD
treatment. Applying heat, pushing on the heel of the foot while the toes are pointing up can
help. However, if these measures are not successful, quinine may be an option. Always
check to verify the patient does have an order for quinine.
Once a medication is given, it must be documented in the chart. Date and exact time given
must be written down. Avoid touching the medication with your bare hand. Open the
container into a medication cup or the patient’s hand. Do not use any p.o. medication that
has fallen onto a dirty surface. And ALWAYS, ALWAYS, verify the medication dose AND if
the patient is allergic.
Drawing Medications into a syringe
Follow specific unit procedures
MSDS – Material Safety Data Sheets
Fine each of tese sheets and comply with each units’ standards.
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REUSE
What is reuse?
The term “reuse” in a dialysis unit refers to the artificial kidney, or dialyzer, being used more
than one time or “reused.” The kidney is used on the patient, and then sent through a
process that cleans then sterilizes it. Once sterilized, it can be used over and over until it is
no longer effective.
How does one know if a dialyzer is no longer effective?
Each time a kidney is used, the volume inside is measured. Let’s say we fill the kidney with
a fluid, and it can hold 100 cc. Once it is used small blood clots may fill some of the hollow
fibers and restrict fluid from flowing into those places. Therefore, when you fill the kidney
again, it may hold only 99cc of fluid. With each use, the volume will more than likely drop.
Our standard is to reuse the kidney over and over until its fill volume has dropped 20% of
the original volume, or in this case when the kidney can hold only 80 cc of fluid.
Most units have a limit besides the fill volume of the kidney that will stop a kidney from
being reused. Some dialysis units will not reuse a kidney more than 50 times, even though it
can hold >80% of the original fill volume. The belief is the kidney will greatly lose its
effectiveness after 50 uses.
The role of the CNA-DT would include cleaning these dialyzers, processing the old blood out,
then sterilizing and storing for future use.
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REFERENCES
1- http://www.bloodpressure.com/article.cfm
2-http://www.onhealth.com/conditions/resource/conditions/item, 367.asp
3-http://www.uaa.alaska.edu/health/page8.html
4-http://www.aomc.org/HOD2/fitness/PointersOnPulse.html
5-http://www.bizmove.com/skills/m8g.htm
6-Amgen Manual
7http://rds.yahoo.com/_ylt=A9hnMifUz5pGHk4AlDajzbkF/SIG=125056tmu/EXP=1184637268
/**http%3A/222.flickr.com/photos/kdemetras/450972592
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