Patient Assessment Hemodialysis Technician Review Course

1. Alice Hellebrand MSN, RN, CNN, CURN Patient AssessmentHemodialysis Technician Review Course

2. 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 Certification is Important

3. Dialysis Treatment Orders • Length and frequency of the treatment • Dialyzer brand, model and size • Dialysate composition • Heparin dose • Blood and dialysate rates • Ultrafiltration parameter

4. Pre Dialysis • Prepare your equipment • Extracorpeal Circuit • Dialyzer • Bloodlines • Monitoring lines • Heparin line • Transducer protectors

5. 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

6. Pre-Dialysis Patient Assessment • Weight • Edema • Pulse • Blood pressure • Respiration • Temperature • General physical and emotional state • Problems since last treatment • Access status

7. 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

8. 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

9. 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

10. 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

11. Dry Weight Assessment • After a treatment a patient below dry weight may have: • Low blood pressure • Light headedness or dizziness • Muscle cramping

12. 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

13. 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.

14. 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

15. 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.

16. 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.

17. 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

18. 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

19. 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

20. 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

21. Complications of Dialysis

28. 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

29. Your action would be? • A. Give Saline • B. Call a code • C. Notify the nurse • D. Call the physician

30. 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

31. Questions?????