17 gauge blood flow and pre-pump AP
Blood flow: 200-250 ml/min
Pre-pump AP: no more negative than - 150 mmHg
16 gauge blood flow and pre-pump
... [Show More] AP
Blood flow: 250-350 ml/min
Pre-pump AP: no more negative than - 200 mmHg
15 gauge needle blood flow and pre-pump AP
Blood flow: 350-450 ml/min
Pre-pump AP: no more negative than - 220 mmHg
14 gauge needle blood flow and pre-pump AP
Blood flow: greater than 450 ml/min
Pre-pump AP: no more negative than - 260 mmHg
Six basic pre-treatment data collection tasks
1. Pre-weight
2. Mobility
3. Vital signs (temperature, BP, heart rate, & respiration)
4. Peripheral edema
5. The patients general disposition
6. Vascular access
Digoxin
Can be used to treat CHF and can cause bradycardia
Hypovolemia
low blood volume
Abnormal BP findings
Systolic: greater than 140 mmHg or less than 90 mmHg
Diastolic: greater than 90 mmHg or less than 50 mmHg
*A 20 mmHg difference (increase or decrease) from patients typical post treatment systolic reading
General disposition
Patient's state of awareness and level of consciousness
pleural friction rub
low-pitched, grating or creaking lung sounds that occur when inflamed pleural surfaces rub together during respiration
edema
The condition of having too much fluid in the spaces between cells, in body cavities, and under skin tissue
Common causes for wheezes
Asthma
COPD
Pulmonary edema
Normal heart rate
60-100 bpm
How to calculate heart rate
Count the number of beats for 15 seconds, then multiply by 4
*if irregular, count for a full 60 seconds and evaluate if irregularity is normal for patient
Respiration rate
Normal rate: 12-16 breaths a minute
*respiratory rates of 24 or more breaths per minute require nurse assessment
Electrolyte that has a major role in muscle contraction and high or low levels can cause cardiac arrest
Potassium
Patient's whose renal failure is caused by diabetes are more likely to have
Neuropathy
Temperature increase by the end of treatment should be no more than ______ degrees
2 degrees
Patient presenting with a temp over their baseline may have
Infection
How to determine UF goal
Today's pre-treatment - target weight + the total amount of fluid (prime, rinseback, oral fluids, and IV fluids) = UF goal
Maximum hourly UF rate
No more than 13/ml/kg/hour
Target weight
The weight at which the patient has no edema or fluid in the lungs and the blood pressure is normal
Water treatment log entered when each day?
Prior to the start of dialysis treatments
Who reviews the daily water treatment logs?
The registered nurse
Total chlorine testing is done when?
Before the first patient, and every four hours until all activities requiring dialysis quality water are completed
Total chlorine samples are draw after the water system has been operating for ___ minutes
15 minutes
An acceptabletotal chlorine test result from the primary carbon tank is
<0.5 ppm
Hardness testing is done at the _______ of the day
End
Hardness testing results greater than ______ must be reported to the biomed team
>1 grain/gallon
How much of dialysate is water?
About 90%
Reason(s) for a high (more negative) pre-pump AP
Inadequate flow from vascular access
Reason(s) for a low (less negative) pre-pump AP
Vasospasm, inappropriate blood flow
If dialysate becomes too hot, it can
Hemolyze red blood cells
Dialysate that is too cold can
Cause hypothermic symptoms in the patient
Why is arterial pressure negative?
The blood pump pulls from the access, causing negative pressure
Dialysate is a mixture of:
Dialysis quality water, acid concentrates with electrolytes (sodium, calcium, magnesium, chloride, potassium, and glucose), and bicarbonate concentrate to buffer the acid
Low dialysate conductivity
Causes hemolysis
High dialysate conductivity
Causes crenation, the shriveling of red blood cells
If bleach and peracetic acid are mixed, _______ gas occurs
Chlorine
Two requirements that must be met prior to initiating system disinfection
1. There are no patients
2. There are no other processes using dialysis water
Acceptable test result for the absence of peracetic acid
<500 ppm (mg/L)
Machine daily internal cleaning
Heat disinfection, citric acid and vinegar rinse
Machine weekly internal cleaning
Bleach or peracetic acid disinfection
Maximum recirculation time after a machine has been set up prior to treatment
2 hours
Why do we limit recirculation time?
Bacterial proliferation could occur
What do you do if strikethrough of a transducer occurs?
Notify FA, find date of last strikethrough inspection, perform strikethrough recovery, document it in BART
Acceptable range for proportioned dialysate pH is
6.9-7.6
Manual conductivity must match delivery system displayed conductivity at
+/- 0.4
When are conductivity and pH testing performed?
When changing the acid container or changing the acid concentrate
External transducer protectors must be replaced
Prior to each patient use or whenever blood or saline is observed in contact with the patient side of the transducer protector
The only solution we use to prime blood lines and dialyzer
Sodium chloride 0.9% (normal saline)
Convection or solute drag
Solutes move with the water across the semipermeable membrane
Osmosis
The movement of water across a semipermeable membrane from the side with the lower solute concentration to the side with higher solute concentration
Ultrafiltration
removes water from the blood during dialysis by pushing it across a semipermeable membrane
The most frequent causes for renal failure in the US
Diabetes mellitus and hypertension
Environmental surfaces are cleaned with
1:100 bleach solution
Visible or gross blood spills are cleaned with
1:10 bleach solution
Alcohol based hand rubs must contain
60-70% alcohol
Wash your hands for a minimum of
15 seconds
Most common vascular access types
Arteriovenous fistula (AVF), Arteriovenous graft (AVG), and Central venous catheter (CVC)
How is an AVF made?
A vascular surgeon connects an artery to a vein (anastomosis)
Preferred type of dialysis access?
Arteriovenous fistula (AVF)
How is an AVG created?
A vascular surgeon placed a synthetic tube underneath the skin with one end connected to an artery, and the other end connected to a vein
HeRO graft
A Hemodialysis reliable outflow graft is an access option for patients who have central venous stenosis or venous outflow obstruction and have issues maintaining optimal blood flow with an AVF/AVG
How is a HeRO graft created?
It is half graft and half catheter. A 6mm PTFE graft is connected to the brachial artery and tunneled under patient skin and a large CVC-like device is place via the internal jugular vein into the right atrium of the patients heart. A titanium adapter connects the PTFE graft to the CVC.
Inflow stenosis sound
Water hammer pulse
Outflow stenosis sound
Whistling sound
Steal syndrome
Too much blood going to the access, leaving the distal portion of the limb without enough oxygen.
KDOQI rule of 6's
1. The fistula should be no deeper than 0.6cm
2. The diameter of the fistula should not exceed 0.6cm
3. The fistula should have a minimum blood flow of 600 ml/min
If infection is suspected, cannulation can only occur
In areas that are not in close proximity to the site of suspected infection
A quiet access where there is no thrill or bruit
Is stenosed, and should not be cannulated
A localized, blood filled dilation of a blood vessel
Aneurysm
Blood trapped under the skin surrounding an area of the AVG, it indicates graft damage due to repeated needle insertions without allowing sufficient time to heal
Psuedoaneurysm
What does NFACT stand for?
New Fistula Assessment and Cannulation Team
Beginner Cannulator
A teammate with less than six months experience and less than ten successful cannulations
Intermediate cannulator
A teammate with at least six months experience and at least ten successful cannulations of established fistulae
Advanced cannulator
A teammate who have completed all other cannulator requirements on the NFACT checklist and has expert assessment and cannulation skills
Newly mature fistula
A new fistula that has received it's post op exam by the surgeon/nephrologist and meets the criteria listed in the KDOQI rule of 6's. Should only be cannulated through physician order by an advanced cannulator
Mature Fistula
A fistula that has successfully tolerated it's prescribed needle gauge and blood flow rate for at least six treatments. This fistula may be cannulated by an intermediate cannulator
Established fistula
A fistula that has been cannulated by arterial and venous needles for at least two months without signs or symptoms of dysfunction. A beginner cannulator may insert this patient's needles.
How do you determine the flow of blood through the access?
Place your finger at the midpoint, press on the midpoint and feel for the thrill above and below. The side with the stronger thrill is the arterial side, and the side with the weaker thrill is the venous side.
Considerations for needle placement:
1. Choosing areas without dips or curves
2. Do not insert needle closer than 1.5 inches from the anastomosis (incision)
3. Keep the needle tips at least 1.5 inches apart to prevent recirculation
4. Ask your patient about any areas that may be painful to them
5. Never cannulate an aneurysm or psuedoaneurysm
6. Allow previous sites to heal for two weeks before cannulating them again
Recirculation
When dialyzed blood returning through the venous needle re-enters the extracorporeal circuit through the arterial needle rather than returning to systemic circulation
One-site-itis
Placing the access needles into the same confined area time after time, weakening the AVF/AVG walls and causing subsequent aneurysms/psuedoaneurysms
Needle insertion angle for AVF
25 degrees. Always use a tourniquet
Needle insertion angle for AVG
45 degrees. If AVG is not stable underneath the skin, a tourniquet may be used but is not intended for routine practice.
Signs of needle infiltration/hematoma
1. Localized pain and/or swelling of access
2. Generalized pain in access extremity
3. Discoloration or bruising of vascular access or extremity
4. Tight, shiny skin over vascular access
5. Changes in arterial or venous pressure during treatment without a change in blood flow
What should you do if you suspect needle infiltration/hematoma?
Tell the registered nurse.
To prevent skin tears when removing tape from frail skin
Hold skin taut
How long should you wait before checking to see if the cannulation site has stopped bleeding?
5-10 minutes
After cannulation sites have stopped bleeding and are dressed, you should check for the presence of
Bruit and thrill
What is required for utilization of vascular access clamps?
A physician order
After placement of a vascular access clamp, you must verify the presence of thrill and bruit ________ and ________ the clamp to prevent clotting of the access
Above and below [Show Less]