Download Dialysis Therapy Management

Dialysis Therapy
Management
◊
Dialysis Manual
Based on requirements of
Maryland Board of Nursing
Certified Nursing Assistant –
Dialysis Technician
-1-
Table of Contents
Background/History ............................................................................................... 3
What Is A Kidney ................................................................................................... 3
What Happens In The Kidney ................................................................................. 3
What Happens When The Kidneys Fail? ................................................................... 4
Dialysis ................................................................................................................. 4
Hemodialysis ......................................................................................................... 4
Transplantation ..................................................................................................... 6
No Option.............................................................................................................. 6
Acute Renal Failure Vs. Chronic Renal Failure .......................................................... 6
What Causes Renal Failure?.................................................................................... 7
How Do We Know That Dialysis Is Working On Our Patients? ................................... 8
Normal Values ....................................................................................................... 8
The Role Of The Dialysis Patient Care Technician ..................................................... 9
Team Members ...................................................................................................... 9
Professional Relationship Boundaries......................................................................10
Confidentiality ......................................................................................................11
Infection Control ...................................................................................................11
Handwashing........................................................................................................12
Equipment ............................................................................................................12
Safety And Environment ........................................................................................13
Mobility And Positioning ........................................................................................13
Assistive Device ....................................................................................................14
Data Collection .....................................................................................................15
How To Take These Measurements........................................................................17
Heparinization ........................................................ Error! Bookmark not defined.
Complications ......................................................... Error! Bookmark not defined.
Starting Or Initiating Dialysis ................................... Error! Bookmark not defined.
Monitoring The Patient During Dialysis ..................... Error! Bookmark not defined.
Complications ......................................................... Error! Bookmark not defined.
Medication.............................................................. Error! Bookmark not defined.
Reuse .................................................................... Error! Bookmark not defined.
References ............................................................. Error! Bookmark not defined.
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Background/History
What is a kidney?
Kidneys are incredible organs. Perhaps, more than any other organ, the kidney is the
most efficient and it does several important jobs. Two of the most common are
removing excess fluid and removing excess waste. They also control three hormones.
One helps to regulate blood pressure, another works to control your red blood cells, and
the third controls vitamin D affecting calcium absorption.
Most people have two kidneys. Each weighs about 5 ounces and is about the size of
your fist. They are located in the back of the body on either side of your spine, just
below your waist. That position keeps them very well protected in the body.
Each kidney is surrounded by a tough coating or capsule. Below the capsule is the
cortex. If you were to cut a kidney in half, you would find that it is divided into several
sections. The inner portion is called the medulla and is made up of several pie-shaped
wedges called pyramids. The points of the “pie” are called papillae. Each papilla
projects into a cup-shaped opening called a calyx. These calyces empty the urine into
the renal pelvis in the lower part of your body.
The renal pelvis is connected to a ureter. Both ureters empty into your bladder. The
bladder holds the urine until it is emptied through the urethra to the outside the body.
What happens in the kidney?
Each healthy kidney has an average of one million nephrons. The nephrons are the
working units for the kidney. Each nephron has a glomerulus and a tubule. A
glomerulus is a twisted ball of capillaries surround by a membrane called a Bowman’s
capsule. Blood is pumped from the heart and goes to the afferent arteriole of each
nephron. As it passes through the glomerulus, excess fluid and poisons are removed.
The cleaned blood is sent out through the efferent arteriole. These excess poisons and
fluid are stored in the bladder in the form of urine. When the bladder is full, it empties
outside the body and amazingly the blood is clean.
Cleaning blood is the function of the kidney and most people are aware of the hormone
production. This is the normal process.
-3-
What happens when the kidneys fail?
It stands to reason that as the kidneys fail, the job they are responsible for will fall
behind. Since the kidney is such an efficient organ, most patients are not aware of any
problems. When the kidneys fail, the patient’s blood work will show the changes before
the patient feels much of a change. Typically the creatinine and BUN value will start to
rise. When this occurs it is called “uremia.” Often times the nephrologist can give the
patient medications that will keep the values closer to a normal range. But these may
only help a patient for several years.
As the values rise and uremia becomes worse, the patient will typically lose much of his
energy. Tiredness, low blood count, itching of the skin, altered coloring of the skin, loss
of appetite, and generally not feeling ‘good’ are typical signs of uremia. When all of the
efforts to reduce the kidney failure have not been successful, the patient must be
started on some type of “Renal Replacement Therapy,” or the patient will die.
When the kidneys have lost about 90% of their function the patient is taught about his
four options:
1.
2.
3.
4.
Hemodialysis
Peritoneal Dialysis
Transplantation
No dialysis.
Let’s look at each one.
Dialysis
Both types of dialysis do the same thing. They both are able to replace two of the
functions of a natural kidney: removing excess fluid and removing excess poisons.
There are advantages to both therapies. However, neither does as well as the original
natural kidney, but they are adequate substitutes.
Hemodialysis
The hemodialysis type of dialysis is a process where dirty blood is taken outside the
body to be cleaned and then returned back once cleaned. Two needles are placed into
a patient. One is for removing the ‘dirty’ blood and the second is for returning the
‘cleaned’ blood. The ‘dirty’ blood in transported outside the body to flow through an
artificial kidney. The artificial kidney filters out excess fluid and poisons from the blood.
While the blood is being filtered, several technical processes are taking place. Two are
most important: they are diffusion and ultrafiltration or (convection).
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Diffusion is a process where particles go across a semipermeable membrane from an
area of high concentration to low concentration. Ultrafiltration is a process where fluid
is pushed across a membrane by a pressure.
To understand this better, let’s break each section apart. When the blood is outside the
body it filters through an artificial kidney. The artificial kidney is a plastic cylinder with
several hollow fibers
packed inside.
Blood enters here
Dialysate flows
Out here
Thousands of Hollow fibers
Dialysate flows
In here
Blood leaves here clean
Dialyzer
Blood enters the top of the kidney and travels through the numerous hollow fibers in
the dialyzer. As the blood is forced through the hollow fibers, poisons are drawn to the
dialysate side of the artificial kidney. The area surrounding the hollow fibers essentially
filters the blood.
If you remember, diffusion, by definition, is “particles going from an area of high
concentration to low concentration.” An everyday example of diffusion is when a tea
bag is placed into a cup of water. The tea inside the bag will work its way out. The
water will soon have lots of tea particles. This process is called diffusion.
Dialysate is a solution of very few particles and the blood is full, much like the tea bag
is full of tea. Therefore, poisons jump from the blood to the dialysate, like the tea
moves from the tea bag into the cup of water.
The dialysate that travels around outside the hollow fibers moves with pressure. This
pressure inside the dialyzer or artificial kidney is called transmembrane pressure or
TMP. This pressure on the hollow fibers “squeezes” the fluid from the patient, much
like taking the tea bag string and squeezing the water out. Excess fluid is removed by
‘squeezing’ the fibers. 7
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So let’s review: dirty blood goes into the top of the dialyzer and comes out of the
bottom of the dialyzer cleaned. While inside two major things occur, diffusion and
ultrafiltraton (UF). UF or excess fluid is removed because of the transmembrane
pressure or TMP, and excess poisons are removed because of the concentration
difference of the blood and the dialysate.
Transplantation
Transplantation is a surgical procedure where a ‘healthy’ kidney is placed inside a
patient whose kidneys no longer are able to do its normal work. Once inside, this ‘new’
healthy kidney takes over the place of the ‘old’ kidney. This is the best way to replace
the kidney function in a patient who has kidney failure. A healthy kidney can be
donated from a family member or friend or someone who has died and has agreed to
donate their organs. However, there is a chronic shortage of kidney donors.
No Option
Some of your patients may choose to do none of the above options. If a patient does
not get transplanted or go on one of the forms of dialysis, they will die. However, for
some patients, this may be a welcomed option.
ACUTE RENAL FAILURE VS. CHRONIC RENAL FAILURE
Renal failure is renal failure, right? Not exactly. Acute renal failure is a sudden loss of
renal function that may be reversible. Chronic renal failure is almost never reversible.
A patient who develops acute renal failure has a good chance of recovering his kidney
function. Often times it is caused by an illness or injury that stresses the kidney. When
the kidney is no longer under stress the normal function returns. If the stress does not
stop, the patient will develop a chronic renal failure.
Chronic renal failure takes much longer to develop. Typically, there is a slow steady
loss of nephrons, the working units of the kidney. Many of your patients will show NO
signs of being sick until 75% of their kidney is damaged. Some form of renal
replacement therapy will need to be started when 85% is lost.
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WHAT CAUSES RENAL FAILURE?
Many things can be responsible for a patient’s loss of renal function. Diabetes is the
number one cause. About 50% of patients are on dialysis because they have diabetes.
The high blood sugar levels wear on the tiny blood vessels in the kidney until they can
no longer carry blood efficiently. One of the first signs that a diabetic patient is
developing renal failure is microalbuminuria (small amounts of protein in the urine).
Diabetics should have their urine checked often to see if any protein is being “spilled
out” into the urine.
Hypertension, or high blood pressure, is the second most common cause of kidney
failure. A blood pressure that is too high can also hurt the small blood vessels that
supply the kidney. Continuous high pressure on the tiny vessels of the kidneys can
destroy the kidney. Years of varying blood pressures take its toll.
Glomerulonephritis is a condition that causes inflammation in the glomerulus of the
kidneys. Many patients who developed this condition had a streptococcal infection in
their past. Possibly they had a strept throat as a child that was never treated with
antibiotics. The body’s immune system worked very hard to fight the strept infection
and in doing so, this hurt some of the ‘good’ parts of the body as well. In the past
several years, pediatricians have increased their practice of culturing children’s ‘sore
throats.’ When strept throats are treated properly, glomerulonephritis is less likely.
Polycystic kidney disease is an inherited disease that causes large, fluid-filled cysts to
develop in the kidneys. These cysts eventually become so large and frequent that
normal kidney function is impaired. The advantage of this type of kidney disease is that
the outer shell of the kidney is not affected. This allows the other functions of the
kidney to perform more easily.
There are many other possible causes of renal failure. The most common causes are
drug toxicity, interstitial nephritis, obstruction, lupus, cancer, AIDS, or sickle cell
disease.
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HOW DO WE KNOW THAT DIALYSIS IS WORKING ON OUR PATIENTS?
There are a few tests that can be completed to measure how adequately someone is
being dialyzed. Measurement of BUN, Kt/V, URR, and Creatinine are most often used.
BUN (Blood Urea Nitrogen) is a measure of the amount of protein by-product in the
body. When we eat foods containing protein, the body breaks it down into several
useful parts and some non-useful parts or waste. Nitrogen is not a useful part, but
rather a waste product. Healthy kidneys excrete this poison and, therefore, BUN levels
are low. Patients with kidney failure are not able to clear the BUN. When we measure
a patient’s BUN value, we can see how many of the waste products have remained.
This will give us an idea of how much kidney function is working.
Normal Values – 5-25
Kt/V indicates the delivered dose of dialysis. In other words, how well the patient is
dialyzed. For hemodialysis a value of 1.2 or greater is ideal. For peritoneal dialysis 2.0
is the target for Kt/V. There is a long calculation to determine a Kt/V. In doing so we
include what residual renal function the patient has remaining, added to a long Kt/V
calculation.
K = dialyzer urea clearance
t = length of time on dialysis (minutes)
V = patient’s urea distribution volume in milliliters (complex calculation)
URR (Urea Reduction Rate) is much easier to calculate and lets us know how adequate
the dialysis treatment is alone, (doesn’t add in the residual renal function). URR
considers a patient’s BUN value prior to dialysis on a particular day, and then subtracts
the BUN value after a dialysis treatment. To calculate:
Predialysis
postdialysis
BUN
-BUN
X
----------------------------------predialysis BUN
100
65% or better is considered the best measure.
Creatinine is a waste-product of muscle. Similar to BUN waste products are removed
by a healthy kidney. When the kidney is sick, it is unable to remove waste products
efficiently. Patients with renal failure have elevated creatinine levels because the
kidney cannot remove all of the wastes.
Normal value – 0.7 – 1.5
-8-
THE ROLE OF THE DIALYSIS PATIENT CARE TECHNICIAN
TEAM MEMBERS
Dialysis can only be achieved by a multidisciplinary approach. There are several
members of a dialysis team. These include the primary care nurse, primary
nephrologists, nurse practitioner, social worker, dietician, and the dialysis patient care
technician.
The primary care nurse is responsible for supervising the patient’s care while on
dialysis. He or she is ultimately responsible for the practice of a CNA-DT. You function
directly under a nurse's license. Your tasks are considered ‘delegated tasks.’ This
means the nurse must know you are competent in doing the task he or she assigns to
you.
The social worker is the one who has special training in helping the patient cope with
the many changes that affect the patient’s life. They also assist patients with finding
resources for many different concerns, including transportation.
The dietician helps the dialysis patient decide which foods are best for their very
restricted diets. Patients on dialysis have numerous dietary restrictions that can be
complicated. If we remember the kidney is responsible for removing the waste
products from the food we have eaten. It makes sense that limiting certain foods may
be required.
The nephrologist (kidney doctor) and nurse practitioner work to monitor the patient’s
progress and dialysis prescription. Depending on lab results and how the patient feels,
they may alter the plan of care. They also write prescriptions for patients.
The technician or tech in a dialysis plays a vital role in the patient’s care. They function
very similarly to a primary nurse by setting up the machine and putting the patient on
dialysis. Observation skills are used when you put the patient on the machine, during
the dialysis treatment, and when the patient is taken off the machine.
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PROFESSIONAL RELATIONSHIP BOUNDARIES
As a healthcare provider, it is essential that a certain level of professionalism is kept.
That means acting in a professional manner. There are some expectations. To start
with, patients are different, not only in obvious preferences, but our patients come from
many different cultures and religions. It is your responsibility to respect their choices.
One patient may not be able to attend certain dates due to religious preferences or
another may not be willing to take blood transfusions. It is your responsibility to know
these differences when caring for your patients. The patient’s charts should contain
this information. If not, discuss with the nurse what you’ve discovered and be certain
these are added to the chart.
Once you know these preferences and follow them, they are to be used and discussed
ONLY during your care of that particular patient. All patients have a right to privacy.
Patient confidentiality is paramount. No information is to be discussed outside the
setting required for caring for the patient. The only exception to this is when you
discover that a patient is being abused. This needs to be reported to the nurse and
then to the social worker. We will discuss confidentiality further.
Organizing and prioritizing is a skill that everyone needs in his or her daily life. This is
true in your dialysis position as well. Patient care is always your priority.
Monitoring the patient and troubleshooting problems before they start is the best.
Acting on potential problems is essential. Always try to strive and apply the skills
learned during this training.
For the patient’s protection and your legal protection, recognize your limitations. Most
of the tasks you will be asked to do are delegated from a registered nurse. If you do
not know how to do a task, it is your responsibility to speak up and let that nurse and
your supervisor know.
Again our goal is for maximum patient care and benefits. In doing so we will need to
encourage our patients to do what is best for their health. This includes eating the
prescribed diet, staying on the machine the prescribed length of time, arriving to
dialysis treatments each ordered day and on-time, and promoting the patient’s
independence. All of these tasks need to be completed for the patient at their own
pace.
Many dialysis patients are preoccupied with their health and avoid recreational
activities. There are numerous benefits, for everyone, when outside interests are
fulfilled. Research supports an improved quality of life when people do.
I’d like to recommend that you consider something. Put yourself in the shoes of the
patient. How would you like to be treated?
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CONFIDENTIALITY
Patient’s privacy must always be protected. If made public, patients’ health records
could cause embarrassment and/or discrimination. Both the law and your job standards
require confidentiality. Failure to comply with this practice may lead to disciplinary
and/or legal action. Since most of our information is computerized keeping this
information private may be more difficult. But keep in mind this information is
PRIVATE.
INFECTION CONTROL
“Sterile” means free from germs. Asepsis means almost the same. When doing dialysis
procedures, it is very important that the tools used are kept sterile and your technique
is aseptically completed. Why? These germs or microorganisms can cause infection if
allowed to get into certain areas of a patient’s body or even your body.
Therefore, every effort must be made to avoid germs from entering a patient’s catheter
or access it because they could cause an infection. How are organisms spread?
Organisms can enter the body three different ways: direct contact, indirect contact, or
by droplet.
Direct Contact occurs when you touch and infected area or person, then touch an
open area on your body such as your mouth, nose, cut, etc.
Indirect Contact occurs when you touch doorknobs, equipment, telephones, etc that
are contaminated with the germ, then touch an open area.
Droplet occurs from breathing, coughing, and sneezing. This allows tiny drops of body
fluids to touch or circulate to other people.
So, what can you do to prevent the spread of germs? There are several things that
must be done AT ALL TIMES!
1.
2.
3.
4.
HANDWASH between EVERY patient!
Make EVERY connection perfect.
Use standard precautions with all patient body fluid contacts. This means,
treat all body fluids as having the potential of being extremely dangerous.
Remove gloves properly
a.
Peel on glove off from the wrist area and hold it in the gloved
hand.
b.
With the ‘un-gloved’ hand, peel the second glove off by grabbing
the inside area near the wrist.
c.
Avoid ‘snapping’ the glove.
d.
Discard the used gloves immediately.
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HANDWASHING IS THE SINGLE MOST IMPORTANT THING YOU CAN DO TO
PREVENT THE SPREAD OF INFECTION!
Having said that, let’s review the proper way to wash your hands.
1.
2.
3.
4.
5.
6.
Water should flow down your hands.
Thoroughly cover you hands with soap and water.
Vigorously rub your hands together.
Scrub your hands for at least 30 seconds being certain not to forget the
area under your fingernails.
Dry your hands thoroughly.
Turn the water off with a dry towel.
Standard Precautions requires strict usage of personal protective equipment (PPE). This
includes gowns that cover you made of a fabric that resists fluid absorbing and a
helmet to protect parts of your face from a body fluid that could splash and gloves that
protect the hands.
EQUIPMENT
Equipment must be cleaned between patients to avoid possible contamination. Special
solutions containing different chemicals are used.
1.
Dialysis machines are cleaned with a solution that is wiped over all of the
front surfaces of the machine. This will remove any blood or body fluids
that may have been splashed onto the machine during the previous
patient’s treatment.
2.
Clamp soak in a beach type solution after being used on a patient.
3.
Dialysis chairs are cleaned between patients’ treatment and a new sheet is
used to cover.
4.
Reuse equipment is also cleaned to protect the reuse tech.
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SAFETY AND ENVIRONMENT
For your safety, PPE should be worn whenever there is a potential for body fluid
contamination or solution exposure. However if you are exposed, your supervisor must
be notified immediately. As for chemicals and cleaners, these must be handled properly
meaning the way the manufacturer intended their use. If any of these chemicals get on
your body, notify your supervisor. Get information from the Material Safety Data
Sheets (MSDS). These standards are created to be in compliance with Occupational
Safety Hazard Administration (OSHA). The MSDS contain information concerning what
should be done when there are different types of exposures. An MSDS book is located
on each unit.
Patients occasionally become sick enough that assistance from outside the unit is
necessary. When a patient’s heart stops or their blood pressure becomes so low that all
interventions are not helping, the CNA-DT must call for assistance. Every unit has
protocols and policies in place to manage a patient that is dieing. Always call for help in
these situations.
MOBILITY AND POSITIONING
Whether helping a patient to a chair, out of a stretcher, into the bathroom, or out of a
bed, proper body mechanics are required. If not used, you run the risk of hurting
yourself.
The basics of body mechanics use your own weight and muscles when moving a
patient. Keeping your body’s center of gravity always in the center allows the larger
muscles to do the work rather than smaller ones.
When pushing an object, it is best to lean toward it. When pulling an object try to allow
your body’s weight to counter balance. Hold heavy objects close to the body. Avoid
jerky movements on your muscles. When standing, keep your feet shoulder-width
apart and use your thigh muscles when lifting.
TRANSFERRING PATIENTS
Allow the patient to assist as much as possible and/or allowed. Do not transfer a
patient that requires more than one person alone. WAIT for assistance. DO NOT be
impatient.
Lock the wheels of a chair or bed or stretcher before moving the patient and check his
condition. If the patient states he or she cannot stand and needs a minute first, allow
the patient that time. It will save you time in the long run.
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For patients who can assist slightly, a pivot method is recommended. Have the chair
and the stretcher or other chair adjacent to each other. Stand in front of the patient
and help the patient stand holding under his arms. Slowly pivot the patient and
yourself so that the patient’s leg back is touching the surface being used. If the patient
starts to fall and you can clearly not stop the fall, try to EASE the patient to the floor or
bed. This easing should help reduce injury.
If the patients can do nothing for themselves, lifting the patient may be necessary.
Two staff members on either side of the patient can lift under the patient’s arm and
move the patient or a sheet placed under the patient may be used as a sling and two or
more staff members grab the sheet and hammock the patient to the other position.
Keep this in mind when transferring patients. Having a sheet or blanket underneath
may help in repositioning the patient. It is much easier to grab and pull a sheet than to
position yourself comfortably under a patient.
After placing the patient in the position, always verify that the patient is comfortable.
Placing a blanket on the patient’s lap is desired. Be certain all limbs are supported. A
pillow or blanket can be used to help prop certain body areas. If the patient will remain
in a bed or stretcher for an extended period of time, skin integrity must be considered.
The patient is not to stay in one position for great lengths of time. This could be
compared to ‘sitting on your foot.’
Allow me to explain. If you sit on your foot while on a sofa or chair, how long is that
comfortable? Not long, right? After about an hour your leg hurts, your foot is falling
asleep, and you’re stiff. When a patient is not able to move on their own, this occurs as
well. Yet they are not able to move around when their foot falls asleep. This must be
considered for patient comfort and skin integrity.
ASSISTIVE DEVICES
If you patient is mobile with a walker or cane, monitor their steps. Watch to see if the
patients can balance himself. Allow the patient as much independence as possible, but
intervene if you see that the patient could get hurt.
If you patient needs to use a bedpan while on dialysis, use the same body mechanics
listed above when moving the patient. When assisting the patient with the use of toilet
tissue, standard precautions are to be used. The patient’s skin must be treated with
care. All soiled materials should be removed. If soap and water are used, be certain it
is rinsed away and dried thoroughly to prevent skin breakdown. If any open areas or
reddened areas are seen, bring these to the attention of the nurse immediately.
- 14 -
DATA COLLECTION
Several measurements must be taken to monitor your patient while on dialysis.
Monitoring pulse, respiration, blood pressure, temperature, and arterial pressures help
follow the patient’s progress during dialysis. The primary purpose is to secure a safe
and effective treatment. Any readings that are not within the normal limits (WNL)
corrected by using the methods taught during orientation. If there is no improvement,
the nurse covering your group of patients must be told. There are several measures
that are watched during a hemodialysis treatment.
1.
Temperatures are taken prior to the initiation of dialysis and after the
termination. An elevated temperature may indication inflammation and/or
infection. It is expected that a patient’s temperature will increase during
the hemodialysis treatment, but a temperature greater than 100o F is
cause for concern and should be reported.
2.
Blood pressure readings are usually monitored every 30 minutes. While
fluid is being removed from a patient’s body, the blood pressure will
typically decrease. This is expected. However, if the patient’s blood
pressure gets too low, the heart cannot disperse the blood to all of the
places it needs to be and the patient may lose consciousness or have
irregular heartbeats.
3.
Pulse rate is also monitored. When a patient’s blood pressure drops
secondary to decreasing the fluid in the body, typically the patient’s pulse
will increase.
4.
Respiratory rate is monitored. Breathing 12-24 times a minute falls within
a normal range. However, if you patient is breathing much faster or
slower, there is often cause for concern. Breathing too slowly could be
that the patient might arrest. Breathing too quickly may indicate a stress
response from the patient.
5.
Arterial pressure readings are checked at the same time blood pressure
readings are done. An arterial pressure should be no lower than –260. If
the pressure is allowed to become greater ,there is a high chance of
hemolyzing or crushing and destroying the Red Blood Cells. While your
patient is on the machine, monitor the arterial pressure closely to prevent
this from happening.
- 15 -
6.
Venous pressure readings are checked throughout the treatment.
Increases of venous pressure over time may suggest problems with the
access.
7.
Access site observation is very important during hemodialysis. Monitoring
for infiltration (will appear like swelling) or bleeding is important. If the
site is infiltrated, the patient’s blood is not being routed properly. If not
corrected, this will only get worse. If there is blood at the site, then the
needle needs attention as this can cause many problems. One would be
infection. This is typically a nursing responsibility.
8.
Weight is also monitored before and after hemodialysis. Before the
dialysis treatment the patient’s weight is usually elevated above their
estimated dry weight (EDW). After a hemodialysis treatment and the fluid
is removed the patient’s weight should be lower. The CNA-DT should
know how to calculate the difference between their original weight and
their goal weight and their pre- or post-weights.
9.
Patient’s overall appearance. This would include his skin. Is it pale or
purple, cold or warm? Are his nails purple, do they have any cuts or
sores? Is there a rash? All of these need to be included in your
observations and documentation.
- 16 -
How to take these measurements
1.
Temperature
To take a patient’s temperature, place the dotted or pointed end of the
thermometer under the tongue. Close the mouth and hold the thermometer in place for
1 minute or till the device signals it is complete. Do not take a temperature immediately
after drinking liquids or smoking a cigarette. At least 10 minutes should pass.
Normal oral temperature is 98.6 degrees F (37 degrees C). The patient’s doctor
or nurse practitioner should be notified if/when a patient’s temperature rises above
1000 (3).
2.
Blood Pressure
Your blood pressure is the force of blood pushing against artery walls as it flows
through your body. Like air in a tire, blood fills arteries to a certain capacity. Just as
too much air pressure can damage a tire, so can too much blood pressure damage
healthy arteries.
A blood pressure reading appears as two numbers. The first and higher of the
two is a measure of systolic pressure, or the peak force of blood as it is actually being
pumped by the heart. The second number measures diastolic pressure, or the force of
blood when the heart is filling for the next beat. Normal blood pressure rises steadily
from about 90/60 at birth to about 120/80 in a healthy adult. Anyone with a blood
pressure of 140/90 on at least two occasions is said to have high blood pressure. If this
continues the person may be placed on antihypertensives (2).
The following standards for assessing high blood pressure (without regard to age) have
been established by the National Institutes of Health JNCVI.
Category
Optimal
Normal
High Normal
Hypertension
Stage 1
Stage 2
Stage 3
Systolic
(mmHg)
<120
<130
130 - 139
Diastolic
(mmHg)
<80
<85
85 - 89
140 - 159
160 - 179
> 180
90 - 99
100 - 109
> 110
- 17 -
Have the patient’s arm relaxed and supported so that the cuff is at the same
level as the heart. The patient’s legs should not be crossed, and the patient should
avoid talking while the pressure is being measured.
The first measurement is a palpation at the wrist to estimate the systolic
pressure. Since the average heart rate is 60 to 70 beats per minute, the mercury needs
to fall about at least 70 points. That should take about 20 seconds to deflate the cuff
until all sounds are gone. If this is done faster, it is not accurate.
Consider the cuff size
The usual size cuff is accurate for arms up to about 11 inches in circumference.
If the cuff is too small, the pressure will be overestimated.
Blood pressure changes significantly in response to several different things. It
varies in a fairly regular manner during the daily cycle, lowest during sleep, and rising
an hour or so before waking to its highest in mid-morning. Activities of daily living,
work, exercise, and emotion further influence blood pressure, as do the seasons of the
year. Consequently, an individual’s pressure may move from well below to far above
140 in the same day.
Some patients only have an elevated pressure in the doctor’s office, so-called
“white coat hypertension”. Most studies indicate that they do not require drug
treatment (1).
3.
Pulse Rate
A pulse can be taken on any part of the body that a pulse can be felt. However,
most pulse rates are obtained on the wrist or arm. To obtain a pulse, a gentle touch or
pressure is applied over the area. Use the pads of your index and middle fingers to find
the pulse on the patient’s wrist. Feel for the base of the thumb with your fingers. Move
your fingers to just about an inch below the thumb base and press down lightly until
you feel an intermittent "throbbing" sensation - that's the pulse.
You can also take a pulse by placing a stethoscope over the patient’s heart and
listening for the beat (left side of the upper portion of the chest). Once you've found
your pulse, look at a clock or watch with a second hand and count the number of beats
for a period of 15 seconds. Multiply the number of beats by 4 to find out your
"heartbeats per minute (4)."
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4.
Respiratory Rate
To obtain a respiratory rate, you need to watch and count as the patient
breathes. Simply count the number of times the patient’s chest rises and falls and
multiply the number by 4. This is the respiratory rate for one minute. Keep in mind that
most people will breathe differently when they know someone is watching. Try to not
allow the patient to know you are counting their breaths. Many health-care
professionals will hold a patient’s wrist when counting breaths as if they were taking a
pulse. This may help to defocus the patient.
5.
Arterial Pressure
This is the pressure used to pull the blood from the patient’s access. Ideally
you’ll want to use as little pressure as possible to pull the blood. Too much pressure
can damage the red blood cells and ultimately destroy them, hemolyzed them.
Therefore, the arterial pressure during a hemodialysis treatment should be kept –260 or
less. How is that done?
Causes of Lower Arterial Pressure

Separation of blood tubing from
the arterial access





Stop the blood pump
Clamp bloodline and access line
Alert the nurse
Evaluate patient blood loss
Restart dialysis if ordered

Inadvertently opened saline
administration line



Clamp saline administration line
Alert the nurse
Adjust UFR to remove the additional
fluid

Opening in the arterial blood
tubing that allows air to enter

Locate and eliminate source of air
entrance
Remove air from the system by
withdrawing using a syringe


Decrease in blood pump speed

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Restore blood pump rate to prescribed
setting
Causes of Increased Negative Arterial Pressure



 Blood flow problems
 Arterial needle infiltrated
 Arterial needle is clotted
Arterial needle is poorly positioned
Kinking of the arterial blood tubing
Hypotension







6.
Stop the blood pump.
Re-establish arterial blood flo
Resume Rx blood flow rate
Alert nurse to problem
Straighten blood tubing
Verify hypotension by obtaining a
blood pressure
Treat hypotension per protocols
Venous pressure is also monitored.
Potential concerns are:
Causes of Lowering Venous Pressure

Separation of blood tubing from the
arterial access






The venous blood tubing is kinked.

Straighten blood tubing

Clotting of the dialyzer



Evaluate extent of clotting
Replace dialyzer
Resume dialysis

Decrease in blood pump speed

Verify that the blood pump rate is at
the Rx rate
Stop the blood pump
Clamp bloodline
Alert the nurse
Evaluate patient blood loss
Restart dialysis if ordered
Causes of Increased Venous Pressure






Kinking of the venous blood
tubing between the monitor and
the patient
Blood flow problems
Arterial needle infiltrated
Arterial needle is clotted
Arterial needle is poorly
positioned
Increase in blood pump speed

Straighten the blood tubing



Stop the blood pump
Restore venous blood flow
Resume Rx blood flow rate

Verify that the blood pump rate is at
the prescribed setting
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