1. Alice Hellebrand MSN, RN, CNN, CURN

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

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 ComplicationCausesSigns & Symptoms How to Prevent it Air embolism (air bubbles block a blood vessel) Air detector is broken or not armed. A leak or loose connection in the extracorporeal circuit before the blood pump. Empty IV bags on the extracorporeal circuit before the blood pump. Depends on the patient’s body position when the air is infused. May include: Chest pain Trouble breathing Coughing Blue lips, fingers, toes (cyanosis) Trouble seeing Confusion Arm the air detector throughout a treatment. Tighten all connections in the extracorporeal circuit. Check the normal saline level in the IV bag. Return the patient’s blood with saline, with no air in the bloodlines.

22. ComplicationCausesSigns & Symptoms How to Prevent it Cardiac arrest (the heart stops) Extreme hypotension Electrolyte imbalance, especially high potassium Arrhythmias Heart attack Air embolism Severe blood loss No pulse No breathing Loss of consciousness Check vital signs during treatment. Tell the nurse right away about major vital sign changes and/or the patient complains of chest pain and sweating.

23. ComplicationCausesSigns & Symptoms How to Prevent it Dialysis disequilibrium syndrome (brain swelling) If BUN is removed much faster from the blood than from the brain, disequilibrium is created and fluid moves into the brain cells. This is seen more often in patients who have acute kidney disease or a BUN level >150 mg/dL. Headache Nausea Hypertension Restlessness Confusion Blurred vision Seizures Monitor the patient during treatment. Tell the nurse right away about major vital sign changes. In patients with high BUN (>150 mg/ml) a smaller dialyzer and/or slower blood and dialysate flows are preferred. Short, slow dialyses may be prescribed daily for a few treatments.

24. ComplicationCausesSigns & SymptomsHow to prevent it Fever and/or chills Infection Contaminated dialyzer 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 other sites (e.g., feet, skin wounds Use aseptic technique to set up equipment. Use aseptic technique to inserting needles. Check vital signs. Tell the nurse right away about major vital sign changes. Check dialysate temperature before treatment. Use the right process to disinfect the dialysis machine and the water components. Test water and equipment for bacteria or pyrogens/endotoxins

25. ComplicationCausesSigns & SymptomsHow to Prevent it First-use syndrome Reaction to ethylene oxide (used to sterilize new dialyzers) Use of polyacrilonitrile (PAN) membranes in patients who take ACE inhibitors (a class of blood pressure pills) Symptoms usually occur in the first 15– 30 minutes of treatment: Itching Chest and/or back pain Shortness of breath Hypotension Nausea General discomfort Rinse the dialyzer well before treatment, per center procedure. Use the right dialyzer

26. ComplicationCausesSigns & SymptomsHow to Prevent it Exsanguination (severe loss of blood) Bloodlines come apart Taking out dialysis needles with the blood pump on Crack in dialyzer casing or improperly fitted header cap Access rupture Blood on patient chair, clothes, and/or floor Hypotension Seizures Cardiac arrest Tighten all extracorporeal connections. Tape needles securely. Keep all accesses in view at all times (no blankets over access limbs). Monitor the extracorporeal circuit per procedure.

27. ComplicationCausesSigns & SymptomsHow to Prevent it Hemolysis (bursting of red blood cells) Kinked bloodlines Inadequate water treatment that allows chloramines, copper, zinc, or nitrates into the dialysate Too-warm dialysate Formaldehyde in a reused dialyzer Nausea Headache Stomach and back pain Hypertension or hypotension Cardiac arrest Bright red colored blood Check dialysate conductivity and temperature before treatment. Test dialysate for chloramines and disinfectants. Monitor bloodlines for kinks. Check that blood pump is calibrated for the bloodline header being used.

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?????