Ultrafiltration
Fluid pushed through the semipermeable membrane
Convection
Solutes dragged across semipermeable membrane along with
... [Show More] fluid
Diffusion
Particles move from area of high concentration to low
Osmosis
Fluid moves from area of low to high concentration
What are the kidneys' excretory functions?
To normalize electrolytes, remove wastes, provide fluid and nutrient balance
What are the kidneys' endocrine functions?
Renin secretion, erythropoietin secretion, vitamin D activation
What is the function of the acid concentrate?
Provides the concentration gradient for diffusion
What is the function of bicarbonate the dialysate solution?
Buffer the acid concentrate
What is the function of bicarbonate when it diffuses into the patient's blood?
Normalizes body pH
How do we replace normal excretory kidney functions?
Normalizes electrolytes, provide fluid balance through ultrafiltration
How do we replace normal endocrine kidney functions?
Provide medications
Outline the treatment goals for a patient with chronic kidney disease (CKD)
-slowing the progression of ckd
-managing comorbidities and complications
-controlling symptoms
-minimizing the effects of ckd on patients' lifestyles
-kidney replacement therapy modality education
-encouraging patients to actively participate in their healthcare
What are the most common causes for CKD in the USA?
Diabetes
Hypotension
Polycystic Kidney Disease
Why is it important to know what caused your patient's CKD?
So the nurse and PCT can inquire about possible problems during data collection and assessment
Signs and Symptoms of fluid imbalance
Hypertension
Edema
Shortness of breath
What does hypertension lead to?
Left Ventricular Hypertrophy
Why is sodium balance important?
Leads to volume expansion- increased CO- increased peripheral vascular resistance- increased BP
Signs and symptoms of Hyperkalemia
>6.5 mEq symptoms: extreme muscle weakness, abnormal heart rhythm, and possible cardiac arrest
Signs and symptoms of Hypokalemia
<3.5 mEq symptoms: fatigue, muscle weakness, paralysis, and respiratory failure, cardiac instability, arrhythmias, cardiac arrest
Why are dialysis patients anemic?
The lifespan of their RBC is 60 days or approx 1/2 of normal 120 days
Primary cause: lack of the hormone erythropoietin (epo)
Secondary cause: inadequate iron stores, inadequate dialysis, malnutrition, blood loss during treatment
How can you prevent contributing to lower hemoglobin levels and blood loss in dialysis patients?
Ensure Epogen dose is correct and administered, rinse back blood completely, avoid repeat lab draws
What is pericarditis?
Inflammation of the membrane (pericardial sac) around the heart
What is included in its treatment?
decrease or stop heparin
give more frequent dialysis
Systemic effects of CKD
Dry, itchy skin -> what do you do?
use hyper-fatty soaps and lotions caution patient re; safety at home, provide emotional support, control diabetes and phosphorus
Systemic effects of CKD
Peripheral Neuropathy (nerve pain in extremities)
-> what do you do?
monitor patient for changes in motor function, decreased strength in legs, C/O restless legs, burning feet.
advise patient not to walk barefoot, have good foot care practices
Systemic effects of CKD
GI problems -> what do you do?
inform rn and md of any bleeding problems/ constipation/ diarrhea/ er visits, take meds as ordered
ex: stool softness/ Imodium
Systemic effects of CKD
Psychological problems -> what do you do?
anxiety or depression
verbalize struggles to IDT
ex: the social worker
What are the 4 key elements affected in CKD-Mineral Bone Disorder (MBD)?
Calcium
Phosphorous
PTH
Vitamin D (Calcitrol)
All lead to CKD-MBD when they are abnormal
What are the symptoms of CKD-MBD in addition to bone disease?
Soft tissue calcification, itching, muscle weakness, pathological fractures, tendon ruptures, compression of vertebrae, atherosclerosis, heart disease
What is your role in CKD-MBD management?
report symptoms, urge patients to take meds at home and at treatment
report noncompliance problems related to non adherence
How much of normal kidney function is replaced by HD?
15%
Define Acute Kidney Injury (AKI)
term incorporates a wide spectrum of kidney issues
includes acute kidney failure as well as less catastrophic kidney function changes
may dialyze in an out-patient facility until kidney function recovers
Pre-renal causes of AKI
obstruction, volume depletion, impaired cardiac function
Intra-renal causes of AKI
ischemic ATN, sepsis, SIRS, septic shock, anaphylaxis drugs, good pasture syndrome, acute glomerulonephritis, trauma, open heart surgery
Post-renal causes of AKI
obstruction, oliguric, bladder rupture, pregnancy
Treatment goals for a patient with AKI:
How do you help in restoring kidney function?
find the cause of AKI
Treatment goals for a patient with AKI:
How do you protect kidneys from further injury?
avoid substances to the kidney which may be toxic (radiographic contrast, amphotericin B, low dose aspirin, NSAIDS)
Treatment goals for a patient with AKI:
What is important when monitoring weight and BP?
keep a little extra fluid on them so it is available to the kidneys when they start filtering/ ultra-filtrating on their own
Treatment goals for a patient with AKI:
AKI patients are at increased risk for which complications?
hypovolemia and hypotension
Treatment goals for a patient with AKI:
What do you need to consider in regards to their vascular access?
patients will typically have a dialysis catheter, be careful to avoid catheter related infections
Explain the difference between AKI and CKD
eliminating the cause of the AKI can often lead to the return of kidney function
you cannot eliminate the cause of CKD which is HTN, diabetes, genetic disorders (PKD)
What makes dialysis patients more susceptible to HAIS?
immunosuppressed and more vulnerable to infection which leads to the 2nd most common cause of death in this population
Why are dialysis patients at increased risk for acquiring a HAI at the facility?
dialysis procedure itself requires prolonged access to the patient's blood and bacterial infections especially those involving vascular accesses (CVC)
What is the most common transmission route for HAIs?
contact
What is the most important intervention you can do to prevent HAIs?
hand hygiene
What is the most common infectious complication in hemodialysis patients?
vascular access infection
What germ causes the most common infections in hemodialysis patients?
MRSA- must pay attention to infection control
proper hand hygiene, cleaning an disinfecting procedures to prevent spread of infection
Why is wearing gloves so important?
reduce the risk of hand contamination and prevent the transfer of organisms already on hands
Why do you need to perform hand hygiene before and after wearing gloves?
gloves are not impervious and have microscopic pores
What is the difference between OSHA and CMS infection control requirements?
OSHA: requires employers to provide workers with a safe workplace
CMS: concerned with patient care and patient safety
What are V-tags and why are they important?
they state specific regulations to be met within a condition such as infection control, providing interpretive guidance for each regulation and citing deficiencies by tag #
Is a cleaned dialysis machine considered a 'clean area'?
no
When should sharps containers be removed from the treatment floor?
when they are 3/4 full
State the 3 strategies recommended by KDOQI to decrease the risk of infection when working with a CVC?
- using facemarks when lumens or exit site is exposed
- wearing clean gloves and avoid touching exposed surfaces
- minimizing catheter lumen or exit sites from being exposed
Who can use sinks dedicated for hand washing?
teammates and patients
What is the correct procedure in regards to your hands when you have casual contact with a patient?
no gloves- but hand hygiene required
How can you tell when a sink is clean or dirty in your facility?
it is labeled
Explain the HBV classification and state which test is performed monthly on HBV susceptible patients?
HBsAg: Hepatitis B surface antigen - tested monthly for susceptible its and non-responders
Anti-HBs: Hepatitis B surface antibody
Anti-HBclgM: Hepatitis B Core AB-IGM
How often are machine alarm tests performed?
As part of the priming procedure and before the initiation of each patient treatment
How long can a dialyzer be set up for once recirculation is complete?
2 hours and no longer because bacteria can grow then
The manual conductivity value must match +/- _______ on the Fresenius (FMC) dialysis delivery system displayed conductivity.
+/- 0.4 mS
What is the safe dialysate pH range?
between 6.9 and 7.6
What is "strikethrough" of an external pressure transducer and why is it of concern?
when fluid could have entered the machine and contaminated the internal pressure transducer protector providing a reservoir for microorganisms and causing subsequent patient blood infections
Why is it important for patient care teammates to know when the water treatment system disinfection was performed?
because the end-to-end disinfection process will also introduce the disinfectant solution to the dialysis delivery systems through their water inlet lines
The "reasonable and prudent" standard of care for nephrology nursing key concepts are:
- the standard of care is that care which a reasonable and prudent nephrology nurse would give under the same or similar circumstances
- the standard of care includes actions a reasonable and prudent nephrology nurse would do, as well as actions the nurse would avoid doing
- in general, the standard of care for nephrology nursing is keyed to this specialty and the skills and knowledge expected of a nephrology nurse
- following the standard of care makes the care given defensible and avoids negligence
when supervising non-licensed, assistive personnel, it is the responsibility of the licensed nurse to ensure these teammates also meet the standard of care
What role does DaVita's P&P play?
standard of care
best demonstrated practice
prima facie evidence
What are the risks of doing it your way?
negligence
proximate cause
damages
What are the four reasons why we document in the medical record?
proof care was rendered
provides data for continuity and planning of patient care
communication tool
permanent legal record
List six occurrences when to chart:
1. baseline assessment
2. change from baseline assessment
3. change in patient's condition
4. procedure or treatment
5. medication given and patient response
6. patient teaching
What are the appropriate times for documentation?
pretreatment vitals and data collection
observations during treatment
post treatment vitals and data collection
What are the possible consequences of poor or incomplete documentation?
entries may be discarded it unable to read, can be left open to interpretation or attack on your care
What are the 6 items included in charting administered medications?
time and date
route of administration
reason for giving
medication dosage
reason for administering
patient response
What does SMART communication stand for?
S- simple: keep message clear
M- meaningful: think about what and why you are sending the message
A- actual: just report the facts
R- read: make sure you are sending the message you intend
T- teach: others about SMART
What are the 5 W's to be used when completing a REM?
what
when
where
why
witness
What are the 3 things you should not include in REM?
personal opinions
speculation
vendettas
What is the difference between data collection and assessment? Who does what?
Assessment- Nurse
- determining depth of edema
- rate, rhythm, quality of heart sounds
- respiration rate, difficulty, identifying unusual sounds
Data Collection- PCT
- nothing presence of edema
- heart rate and rhythm
- respiration rate, recognizing unusual sounds
- machine parameters, safety checks
What is the role of the PCT prior to treatment initiation?
complete data collection and PCT must notify the RN if there are any abnormal findings prior to initiation of treatment
What is the role of the RN prior to treatment initiation?
access abnormal findings from data collection, determine appropriate interventions (based on physician orders) and contact physician if needed
When is pre-treatment assessment by the RN required?
based on state law (may be before or in first hour of treatment) or if data collection has abnormal findings
for patients with AKI- a pretreatment assessment is always required
What BP reading error can be caused by an incorrect cuff size?
cuff too small- reading may be higher than actual BP
cuff too large- reading may be lower than actual BP
When is post-treatment assessment by the RN required?
required by some states
if there were unusual findings
Target weight:
- determined by physician order
- TW is the physician-prescribed weight post-dialysis that the patient can safely and reasonably achieve
-TW should be modified by the physician based on the patient's tolerance, ongoing signs of fluid overload, and changes in fluid status
-must be adjusted in a timely manner so that the physician's most recent order is taken into account for each treatment. you may not adjust the TW retroactively
Interdialytic Weight Gain (IDWG) Calculation:
Pre weight - last post weight
UF Goal Calculation:
Pre weight - target weight + rinse back
UFR Calculation:
UF goal / tx hours
What are the 4 consequences of sodium loading during dialysis?
increased thirst
large fluid gains
more hypotension and ischemic events during treatment
State 3 ways we can contribute to sodium loading during dialysis
broth
normal saline, hypotonic saline
increased sodium in dialysate (high setting in machine or sodium modeling)
What are the consequences if a patient is consistently fluid overload (hypervolemia)?
LVH, increased CVP, hypertension, increased mortality, pulmonary edema, increased hospitalization rate [Show Less]