Certified Clinical Hemodialysis Technician Review

Nephron

The functional unit of the kidney.

Nephron Components

A nephron consists of a glomerulus and a tubule.

Erythropoietin

A hormone produced by the kidneys.

Vitamin D

The active form is produced by the kidneys.

Leading Cause of ESRD

Diabetes is the leading cause of End-Stage Renal Disease (ESRD) in adults in the United States.

Itching

Patients with kidney failure often experience itching (pruritus) due to hyperphosphatemia.

Bone Disease

Kidney patients often develop bone disease because the kidneys stop producing calcitriol.

Symptoms Needing More Dialysis Time

Anorexia, fatigue, and swelling may indicate a patient needs more dialysis time.

Semipermeable Membrane

A porous barrier that allows only certain sized particles to cross.

Diffusion

The movement of particles from an area of higher concentration to an area of lower concentration.

Negative Pressure

Created when fluid is pulled through a restriction.

Ultrafiltration

Occurs when water is removed from blood because there is a pressure gradient between blood and dialysate.

Negative Pressure Location

The blood is usually under negative pressure in the arterial line section before the blood pump.

Factors Increasing Solute Diffusion

High concentration gradients increase the amount of solutes that will diffuse across the semipermeable membrane.

Dialysate Factors Affecting Clearance

Dialysate flow, time of treatment, dialyzer size, and blood flow rate affect clearance.

Dialyzer Waste Removal

Surface area and molecular weight cutoff affect the dialyzer's ability to remove wastes.

Dialysate Composition

Dialysate solution might be prescribed with bicarbonate, sodium, and potassium.

Most Important Safety Monitor

The dialysis technician is the most important safety monitor.

Dialysate Conductivity Measurement

Measures the total electrical charge of a solution.

Hypernatremia

Dialysate with too much sodium can cause headaches, high blood pressure, and shriveling of red blood cells (crenation).

Excess Calcium

Dialysate that has too much calcium can cause irregular heartbeat, severe muscle weakness.

Low Sodium

Dialysate that has too little sodium can cause low blood pressure, cramping, and bursting of red blood cells (hemolysis).

Factors Affecting Dialysis Adequacy

Time on treatment, blood and dialysate flow rates, and dialyzer clotting affect dialysis adequacy.

Normal Oral Temperature

Normal body temperature taken orally is 98.6°F.

Blood Pressure Measurement

A sphygmomanometer is used for measuring blood pressure.

Rapid Pulse

A rapid pulse of 104 beats/min indicates tachycardia.

Seizure Causes

Seizures during dialysis may be caused by electrolyte imbalance, hypotension, and dialysate composition errors.

Normal Resting Pulse Rate

The normal range for a resting pulse rate in an adult is 60 to 100 beats/min.

Increased Venous Pressure

Venous needle infiltration can cause an increase in venous pressure during dialysis.

Suspected Dialyzer Clotting

Check for venous needle placement if transmembrane pressure is gradually changing and you suspect clotting in the dialyzer.

Decreased URR or Kt/V

Look at increased access recirculation, diminished dialyzer performance due to reprocessing, and inadequate anticoagulation of the blood if there is a decrease in the patient's URR or Kt/V.

First Symptom of Dialysis Disequilibrium Syndrome

Headache is the first symptom a patient developing dialysis disequilibrium syndrome is most likely to exhibit.

Fluid Overload Symptoms

Tachycardia, hypertension, and dyspnea indicate fluid overload.

First Use Syndrome

First use syndrome is a hypersensitivity reaction to a dialyzer, characterized by back pain, anxiety, tachycardia, wheezing, circulatory collapse.

Dialyzer Reuse Problems

Blood leaks, first-use syndrome, and inconsistent ultrafiltration may be related to reuse.

Dialyzer Quality Control Checks

Two people must check the dialyzer to verify quality control information before a reprocessed dialyzer is used.

Incomplete Rinsing of Germicide

Burning in the access site, numbness in the access arm, and blurred vision can occur due to incomplete rinsing of germicide from a reprocessed dialyzer.

Dialyzer Processing Purpose

Dialyzers are processed before use to rinse out manufacturing residues and to establish the original fiber bundle volume of the dialyzer and check for leaks.

Rejecting a Reprocessed Dialyzer

Reject a reprocessed dialyzer if it has less than 80% of original fiber bundle volume.

AAMI

AAMI recommends voluntary standards for dialysis water treatment.

Water and Dialysate Bacteriologic Testing

According to AAMI standards, bacteriologic testing for water and dialysate should take place monthly.

Total Microbial Count Limit

According to the AAMI standards, the total microbial count of water used to prepare dialysate shall not exceed 200 CFU/mL.

Stenosis Signs

Changes in the thrill and bruit are signs of stenosis.

Anastomosis Types

Artery-side to vein-side, artery-end to vein-end, artery-end to vein-side, and artery-side to vein-end are anastomosis types.

Anastomosis

Surgical connection between two blood vessels.

Bruit

Buzzing, swooshing sound heard in a fistula or graft.

Thrill

Vibration from pulse of blood in a dialysis vascular access.

Stenosis

Narrowing of a blood vessel.

Thrombosis

Blood clotting.

Aneurysm

Ballooning of a weak spot in a blood vessel wall.

Infiltration

A needle tip that punctures a vessel and goes out the other side, allowing blood to seep into the surrounding tissue.

Catheter Statements

Internal jugular vein is the preferred insertion site for both temporary and long term catheters.

Arteriovenous Fistula Preference

Fistulae have the lowest rates of primary failure of all known accesses.

Break in Extracorporeal Circuit

The appearance of air or foam in any bloodline indicates a break in the integrity of the extracorporeal circuit.

Complications During Dialysis Monitoring

Separation of bloodlines or rupture of an access, the presence of air or foam in the line, bleeding around needle or catheter exit sites, and sudden change in blood flow or venous pressure, or line collapse.

Poor Catheter Blood Flow

A blood clot, poor placement of the catheter within the blood vessel, and a fibrin sheath that has formed around the catheter can cause poor blood flow during dialysis in patients with catheters.

Ultrafiltration Calculation

A dialyzer with an ultrafiltration coefficient of 12 (K\(_\text{uf}\) of 12) and a TMP of 120 will remove: \[ 12 \frac{\text{mL}}{\text{hr} \cdot \text{mmHg}} \cdot 120 \text{ mmHg} = 1440 \text{ mL/hr} \]

Infiltrated Venous Needle

Insert a second needle above the venous infiltration.

Needle Gauge

With a 17 gauge needle, you will only be able to attain a 250 mL/min -300 mL/min QB.

Bleeding after Needle Removal

Suspect venous stenosis if the patient's access site has bled for thirty minutes after needle removal for the last three treatments with no change in the heparin prescription, and there has also been a steady increase in venous pressure during treatment.

Buttonhole Technique

Remove the scab, cannulate the same site at the same angle, by the same caregiver with sharp needles for 3-4 weeks to create a tunnel.

Rising Venous Pressure

Clotting of the venous line or venospasm can cause the venous pressure on a dialysis machine to start to rise but the venous needle is not infiltrated.

Factors Affecting Peritoneal Membrane Permeability

Peritonitis infection and amount of residual renal function affect peritoneal membrane permeability.

Water System Reference Guide

This guide is intended to serve as a resource for staff, and does not include every step from FKC policies, procedures, or Manufacturer's Instructions For Use (IFUs).

Chlorine and Chloramines

Chlorine and chloramines are added to city water to reduce or eliminate bacteria.

Water Contaminants

Substances such as aluminum, fluoride, copper, and zinc. Chlorine or Chloramine, which is a combination of chlorine and ammonia. Bacteria and Endotoxins.

Hemolysis Patient Symptoms

Low blood pressure, chest pain, shortness of breath, cherry soda red/cranberry/translucent blood.

Pyrogenic Reaction Patient Symptoms

Fever and chills, nausea and vomiting, hypotension.

Cluster of Patient Symptoms

Patients experiencing similar symptoms. Always suspect a water emergency and take appropriate action.

Backflow Preventer

First piece of equipment that the water goes through in the dialysis facility, prevents water from flowing back into the city water supply.

Water Booster Pump

Increases incoming city water pressure.

Air (Expansion/Bladder) Tank

Assists in maintaining minimum water pressure.

Multimedia filter

Removes large particles from the incoming water (10 microns or larger).

Carbon Tank

Removes chlorine and chloramines through a chemical reaction with carbon. Also removes organic substances through the process of adsorption.

AAMI Carbon Tank EBCT

AAMI requires a minimum of 10 minutes of EBCT.

FKC Carbon Tank EBCT

FKC requires a minimum of 12 minutes of EBCT for new water treatment systems.

Water Softener

Removes calcium and magnesium through the process of ion exchange.

RO

Product water exits the RO and meets the AAMI standards for water to be used for dialysis.

RO Membranes

RO membranes must be replaced at 80% rejection.

Ultrafilters

Remove bacteria and endotoxin and are located after the RO machine.

Product Water Divert Valve

Sends water to the drain when it exceeds the TDS or conductivity alarm limits.

Deionization Tanks

Method of water treatment used during RO failure and is part of the 'Alternate Water Supply Plan'.

Total Chlorine Testing

Total chlorine testing for a central water system must be performed and documented by 2 qualified staff members (one being nurse in charge).

Total Chlorine Test Strip Immersion

RPC Ultra-Low Total Chlorine Test Strips are immersed in the sample for 60 seconds.

Total Chlorine Test Strip Wait Time

Once removed from the sample, you must wait 20 seconds to allow the strip to develop the proper color before comparing it to the color chart.

Total Chlorine Testing Frequency

Total chlorine is tested prior to the initiation of treatment in the morning and at least every 4 hours while patients are dialyzing.

Safe Range for Total Chlorine

Safe range for the total chlorine is less than 0.10 ppm (0.00-0.09 ppm).

Chlorine Breakthrough Procedure

If total chlorine is 0.1 ppm or greater, do not initiate any patient treatments.

Chlorine Breakthrough Action Plan Documentation

Implement the Chlorine Breakthrough Action Plan Documentation per facility policy and procedure.

Dialysate Conductivity Safe Range

The safe conductivity range and machine alarm limits is + or - 0.5 mEq/L from Theoretical Conductivity (TCD).

Dialysate Check

Four ways dialysate is checked to ensure it is safe are: pH, conductivity, monitoring machine temperature, a negative residual chlorine test after routine (weekly) machine bleach disinfection and before the first treatment after disinfection.

Residual Bleach Purpose

The purpose of Residual Chlorine Strips is to test for residual bleach.

Bacteria and Endotoxin Testing Frequency

Routine testing for bacteria and endotoxin should take place monthly.

CFU

CFU is an abbreviation for Colony Forming Unit.

FKC Bacteria Action Level

The FKC action level for bacteria in product water exiting the RO is 20 cfu/ml. The FKC action level for bacteria for water in the tank, piping and distribution loop is 20 cfu/ml.

FKC Endotoxin Action Level

The FKC action level for endotoxin in product water exiting the RO is 0.125 EU/ml. The FKC action level for endotoxin for water in the tank, piping and distribution loop is 0.125 EU/ml.

Clinical and Technical Management Action

Clinical and Technical Management must take action for any lab report with Bacteria and Endotoxin exceeding FKC action levels.

Total Chlorine Levels

Total chlorine levels that are within the safe range for our patients is 0.00 ppm -0.09 ppm.

TCL-1 (Total Chlorine Log)

This log is used for routine daily Total Chlorine documentation of safe ranges between 0.00ppm-0.09 ppm.

TCL-2 (Total Chlorine Log)

This log is used for breakthrough documentation when Total Chlorine levels are 0.10 ppm or greater after the first Carbon tank.