Escolar Documentos
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DialysisProcedures
Itissimple.Thereareonly3procedures:
Initiation Monitoring Discontinuation
Well,maybenotsosimple
InitiationofDialysis
PreDialysisSafetyChecks InitiationProcedures ImmediatePostInitiation Procedures
Predialysis SafetyChecks
Watersystem
Temperature Resistivity Residualdisinfectant
PrescribedDialyzer&Concentrate DialysisMachineSafety
Alarmsactive Dialysate conductivity&/orpH
IntegrityofExtracorporealCircuit IfDialyzerReused
Checkpatientsnameonlabel Disinfectantresidualtest
Predialysis PatientEvaluation
PhysicalParameters
Weight BP (stand & sit) Temp Pulse & Resp Complaints
EvaluateAccessStatus
Signs of infection redness, tenderness,
unusual warmth, purulent drainage
Patency
Graft & AVF: bruit, thrill Catheter: easy aspiration (post disinfection)
FollowUniversalPrecautions
Wash hands Glove Gown Eye protection Mask
InitiationofDialysis
Graft/Fistula
Select sites Disinfect Anesthetize Insert needles
Catheters
Disinfect catheter limbs Aspirate heparin from limbs Evaluate patency
DrawBloodWork
Prior to administering heparin From arterial port Administer heparin post draw
InitiateBloodFlowtoDialyzer
Connect lines Start at low BFR
PostInitiation
Calculate/ApplyTMP
Fluid gain/ # Hours = UF vol (ml/hr) UF Volume/ UF Coefficient = TMP TMP = V resistance + Neg pressure
Setmachineparameters
BFR DFR UFR Alarm limits Dialysate temp Heparin Infusion rate
Patientcomfortmeasures
Charting
Overridingobjectives
Complete Legible
Treatmentdocumentation
Prescribedparameters Pre&Postpatientassessment Vitalsignsduringtreatment Medicationsgiven Treatmentparameters
BFR,DFR,A&Vpressures,TMP/UFR
Patient/machinecomplications Yoursignature
Monitoring DuringTreatment
Detectionof Complications
BloodRelated Dialysate Related PatientRelated
Charting
BloodSideComplications
AirinBloodCircuit
Minor:usualcauseiscarelesssetup,drip chamberlevelwilldrop,alarmwillsound
AirEmbolism
Major:airdetectoralarmfailure
Dialysate SideComplications
Dialysate Temperature
Hypothermia Hyperthermia
Hemolysis
Dialysate temperature, kinkedbloodlines, formaldehydeindialysate lines,inadequatewater treatment(chloramines, copper,zinc,nitrates)
Crenation
Hypertonicdialysate
PatientRelatedComplications
Hypotension Hypertension MuscleCramps Headache Nausea&Vomiting Headache Fever&/orChills Fistula/GraftInfection,Thrombosis FistulaAneurysm,Psuedoaneurysm CentralVenousCatheterInfection CatheterThrombosis CardiacDysrhythymia Pericarditis,pericardialeffusion, cardiactamponade DialysisDisequilibriumSyndrome FirstUseSyndrome Seizures Angina Anaphylaxis Pruritis StealSyndrome CardiacArrest DialysisEncephalopathy(Al++)
Extracorporeal CircuitPressures
BloodSide
ElevatedPrePumpArterialPressure
RBCdamageifgreaterthan250mmHg Increaseindicatesobstructionofbloodflowintopump
ElevatedPostPumpArterialPressure
Increaseindicatesobstructionofbloodflowintodialyzer
ElevatedVenousPressure
Increaseindicatesobstructionofbloodflowintopatient
Dialysate Side
FailureofNegativePressurepump
Anticoagulation
Threemethods
Saline flush
Flush blood circuit with saline q 30 min No drugs No bleeding risk during or post dialysis
Trisodium citrate
Difficult: requires 2 infusion pumps, 0 Ca++ dialysate No bleeding risk during or post dialysis BUT maintaining patients calcium balance is difficult & risky Citrate is metabolized into bicarbonate
Heparin
TwoHeparinMethods
Systemic
Method:bolus+constantinfusion untillasthour Objective:maintainACT1.52.0 baseline
TightSystemic
Method:samebutlowerdoses Objective:maintainACT1.21.4 baseline
TreatmentFactors: ImpactonClearance1
BloodFlowRate
BFR smallmolecule(ex.urea)clearance BFRhasmuchlesseffectonlargemolecules
Ultrafiltration Rate
UFRwillresultin clearance,viasolutedrag Mainlyinvolveslargermolecules Minimaleffectontotalclearance
Dialysate flowrate
DFRwill clearance Minimaleffectontotalclearance
IfBFR>350,hifluxdialyzer,500DFR 800DFR=Curea 510%
TreatmentFactors: ImpactonClearance2
Anticoagulation
Clottingreducesavailablemembranesurfacearea,thusclearance
TreatmentTime
Longertime= clearance Shortertime= clearance
5min perTx X156Tx/yr=780minor>3dialysis/yr
AccessRecirculation
Causes:needlestooclose,accessstenosis,cardiopulmonary recirculation Result:freshlydialyzedbloodmixeswithuremicbloodbeing drawnintothearterialbloodline
Discontinuation
TerminationofTreatment NeedleRemoval/CatheterCare PostDialysisPatientAssessment Documentation PostDialysisMachineCare
TerminationofTreatment
DiscontinueHeparininfusion
Perunitprotocol(usually3060minpreD/C)
Returnbloodtopatient CheckpatientsBPbeforedisconnection
Incasefurtherfluidinfusionisrequired
NeedleRemoval
Removeoneneedleatatime Withdrawatsameangleasinsertion Applypressureovervessel(notskin)insertionsite Amountofpressurematters
Toolittle:prolongedbleeding,hematomaformation Toomuch:clottedaccess
Clean&dresssiteafterbleedingstops
Note:Iffistulaclampsused,shouldfollowstrictprotocol becauseapplicationofproperpressureisdifficult.
CatheterCare
Priortoremovingdialysislines,disinfectcatheter portswith:
Providone iodineor Chlorhexadine gluconate
Flusheachcatheterlumenwithnormalsaline Instillheparinintoeachlumen
5,00010,000unitsperlumenismostcommondosagerange NOTE:volumeofheparinshouldjustbarelyexceedlumenvolume
Placefreshsteriledressingovercathetersite Labelcathetersite
DONOTFLUSH #unitsheparinperlumen Dateandinitialsofstaffmember
PostDialysis PatientAssessment
Vitalsigns
BPsitting&standing TPR
Physicalassessment
Heart&lungsounds Edema Weight(fluidloss)
Vascularaccess Patientsymptoms
Patientcomments,complaints
Overallconditionobservations
Generalcondition,behavior,mentalstatus
Documentation
Dialysisdata
Timestopped Volumeofrinseback saline Bloodloss,ifany(includeclotsindialyzer,dripchambers)
Patientcondition
Vitalsigns,physicalassessment Overallcondition,includingvascularaccess
Specialinstructionstopatient,ifany Time&methodofdeparture
PostDialysis MachineCare
Disconnectandrinseconcentratelines Removedialyzer&bloodlines
Disposeinhazardouswastecontainer Iftobereused
Ensurefilledwithsalineorheparinized saline,perunitprotocol EnsureproperlylabeledwithpatientIDdata Delivertoreuseareawithin1015minpostdialysis
Removeotherdisposables
Disposeinhazardousornonhazardouswastecontainer, asappropriate
Remove&disinfectnondisposables(ex.clamps) Clean&disinfectoutsideofmachine
DialysisProcedures
Summary
Initiation Monitoring Discontinuation
Itisnotsimple!
YOUarethekey.