Module 3

Regarding multi-dose medication vials:

Labeling & Expiration: Must be labeled with the initials of the person opening the vial and the date it was opened (must be discarded within 28 days after opening except when the manufacturer specifies differently such as Epogen at 21 days)

Needle/syringe/vial: The vial may be entered more than once but requires a new sterile needle and syringe to puncture each medication vial to avoid pooling of medication from different vials

Regarding single-dose medication vials:

Must be used for only one patient

Each vial should only be entered once and then discarded

The same syringe may be used to enter up to two single use vials of the same medication and concentration to constitute the prescribed patient dose

At what time are medications containing a preservative discarded?

28 days (except when the manufacturer specifies differently such as Epogen multi-dose vial (MDV) at 21 days)

What size needle with the appropriately sized syringe should be used when drawing up heparin?

21g x 1 inch

Why would the nephrologist order a formulary exception of Citrasate or Citrapure dialysate concentrate?

To use as part of anticoagulation therapy during the dialysis treatment when heparin is contraindicated

How do you verify your needle is not in the access when administering Lidocaine?

Aspiration (pull back) of syringe plunger and you do not see blood in the syringe

How do you administer Topical Anesthetic Spray?

Wash access site, clean site per P&P, spray topical anesthetic to each cannulation site for 4-10 seconds from a distance of 3-7 inches. The skin will begin to turn white

Don’t frost the skin - numbing effect occurs with blanching

What is the time frame during which single use medications should be prepared and administered?

Within 4 hours (unless your state specifies another time limit)

What are the six items included in documenting and administered medications?

Time and date

Route of administration

Reason for giving

Medication dosage

Reason for administering

Patient response

What are the six rights of medication administration?

Time

Route

Amount

Medication

Patient

Documentation

What are the 4 medications PCTs can administer per DaVita P&P?

Saline (0.9% Sodium Chloride)

Heparin (1000u/mL) (if allowed per state regulations)

Lidocaine (1% Intradermal)

Topical Anesthetic Spray

What are two reasons for water treatment?

Prevent equipment damage

Patient safety

Aluminum in water used for dialysis causes:

Anemia

Bone disease

Nausea

Vomiting

Chlorine in water used for hemodialysis causes:

Hemolysis

Excess calcium and sodium in water used for dialysis causes:

Hypertension

Excess calcium and magnesium in water used for dialysis causes:

Muscle Weakness

What does the RO remove?

Organic and inorganic materials, bacteria and endotoxins

What are the two concerns with using DI Tanks?

Exhaust quickly

When exhausted they dump/release previously removed ions back into water

Response to Final Water Quality Alarm:

Bypass

Notify Charge nurse/FA/Biomed/Medical Director

If not restored must terminate treatments and complete REM

Water/Dialysate culture results:

Acceptable level: below 50 cfu/ml

Action level: 50-99 cfu/ml

Unacceptable level: 100 cfu/ml or >

Water endotoxin testing results:

Acceptable level: below 0.12 EU/ml

Action level: 0.12 to < 0.25 EU/ml

Unacceptable level: 0.25 EU or >

Dialysate endotoxin testing results:

Acceptable level: <0.25 EU/ml

Action level: 0.25 to < 0.50 EU/ml

Unacceptable level: 0.50 EU/ml or >

How often are water and dialysate cultures drawn and monitored for bacteria and endotoxins?

Monthly

What removes chlorine/chloramines?

Carbon Tanks

When does Chorine/Chloramine testing take place?

Always test while the RO is actively supplying water: After the RO has operated for at least 15 minutes first thing in the morning, before the first shift of patients, and every 4 hours

Where does Chlorine/Chloramine testing take place?

After Primary carbon tank sample port

What is an acceptable result for Chlorine/Chloramine testing?

Less than or equal to 0.1 mg/l

What actions do you need to take is the results are to high post primary tank for Chlorine/Chloramine testing?

Repeat the test - if still to high - move onto secondary port and test, remember to notify biomed and FA

When should you follow up if secondary test results are within limits for Chlorine/Chloramine testing?

Every 30 minutes

When should you follow up if secondary test results are to high?

Stop dialysis by placing dialysis delivery system into bypass - do not rinse patients’ blood back

What is the purpose of the water softener?

To remove hard minerals such as calcium and magnesium

What is removed and why is this important?

For RO protection

When do we do hardness testing?

At the end of the day

Who must be notified when a patient fall has been witnessed?

The licensed nurse must be notified so the patient can be assessed

Definition of Hypotension:

Systolic BP <90 Diastolic BP < 50 or drop in systolic more than 20 mm/hg

Causes of Hypotensions:

Rapid or inappropriate fluid loss, antihypertensive drugs, low blood volume, food ingestion, unstable cardiovascular condition

A sudden decrease in blood pressure can be an indication that the patient is losing intravascular fluid too quickly, this change is equal to or greater than:

20mmHg

Symptoms of Hypotension:

Flushing, yawning, dizziness, ringing in the ears, tachycardia, anxious feeling, nausea/vomiting, cold clammy skin, seizures, cardiac arrest, visual complaints

Intervention for Hypotension:

Place patient in supine position, decrease UFR to minimum or turn off, water for less severe hypotension, 100-200 mL NS for severe hypotension (NOTE: dialysis patient care technicians (PCTs) may give up to 200 ml NS as allowed per state and local Board or Nursing regulations), inform the licensed nurse for further evaluation and intervention, monitor BP

Prevention for hypotension:

Frequent assessment of target weight, limit UFR to < 13 mL/kg/hr, UF profiling, extend treatment time, pure ultrafiltration

Consequences of organ stunning:

Heart: Acute stress on the cardiovascular system, development of left ventricular regional wall motion abnormalities (RWMAs), arrhythmias, can lead to cardiac failure

Gut: Releases endotoxin into circulation, inflammation

Kidneys: Causes fibrosis, loss of residual renal function

Brain: Causes multiple sites with white matter injury

Definition of Hypertension:

Pre-dialysis adult BP is >140/90

Post-dialysis adult BP is > 130/80

Causes of Hypertension:

Disease process, fluid overload, non-adherence with medication, renin-angiotensin cycle

Symptoms of Hypertension:

No symptoms, headache, dizziness, irritability, blurred vision, nervousness, edema - secondary to fluid retention

Intervention for Hypertension:

Take medications as prescribed, maintaining fluid balance (avoid excessive IDW gains)P

Prevention for Hypertension:

Promote fluid and medication adherence

Definition of muscle cramps:

Painful muscle contractions in extremities or abdomenca

Causes of muscle cramps:

Rapid or excessive fluid removal, hypo-osmolality, tissue hypoxemia/ischemia, electrolyte disorders or imbalances: low sodium, calcium, potassium, magnesium, any local irritating factor or metabolic abnormality of a muscle (e.g., severe cold, lack of blood flow, over exercise) S

Symptoms of muscle cramps:

Painful cramps usually occur late in dialysis

Intervention for muscle cramps:

Massage or apply opposing force, stretching of affected muscle, discontinue UFR, provide supplemental oxygen per nephrologist’s order, assess target weight, for severe cramping a normal saline bolus maybe indicated as prescribed

Prevention for muscle cramps:

Appropriate dietary control of fluid and electrolytes, UFR of <13 mL/kg/hr, decrease sodium loading, increase treatment time, UF profiling

Definition of seizuures:

Involuntary muscle spasms and loss of consciousness

Causes of seizures:

Some patients have seizures as a dialysis side effect ( severe hypotension, dialysis disequilibrium syndrome) or seizures may occur during dialysis as an adverse reaction to a problem such as the use of improperly prepared dialysate. Some patients may have a preexisting seizure disorder

Symptoms of seizures:

Change in level of consciousness, twitching and jerking movements of the extremities

Intervention of seizures:

Protect patient and access arm from harm, protect airway, do not pry open clenched jaw once seizure has begun. Do not attempt to insert anything into the mouth, treat hypotension, dialysis disequilibrium syndrome, and hypoglycemia if indicated, administer oxygen, provide airway support, and discontinue dialysis if no response to interventions

Prevention for seizures:

Prevent hypotension, prevent large drops in BUN, monitor for therapeutic drug levels in patients with pre-existing condition

Definition of Dialysis Disequilibrium Syndrome:

A condition in which rapid or drastic changes in the patient’s extracellular fluid affect the brain

Causes of Dialysis Disequilibrium Syndrome:

Missed treatment, rapid drop in BUN

Symptoms of Dialysis Disequilibrium Syndrome:

Headache, hypertension, nausea, restlessness, seizures, confusion, blurred vision

Interventions for Dialysis Disequilibrium Syndrome:

Slower BFR and DFR than CKD patients, shorter initial treatments

Prevention for Dialysis Disequilibrium Syndrome:

Early recognition of mild symptoms

Decrease efficiency of dialysis by:

Use a less efficient dialyzer

Decrease treatment time

Decrease BFR and DFR during treatment

Shorter, more frequent dialysis sessions instead of longer ones.

Definition of fever and chills:

Any temperature greater than 100 degrees or increase over baseline of 2 degrees with symptoms

Causes of fever and chills:

Systemic infections, access infections, contamination of blood or dialysate compartments, pyrogenic reactionssuch as bacterial or viral infections, inflammatory processes, and reactions to medications.

Symptoms of fever and chills:

Nausea, vomiting, headache, hypotension, tachycardia, hot flushed skin, dry mucous membranes

Intervention for fever and chills:

Nurse must assess and evaluate patient for possible cause of fever

Notify the treating nephrologist and if ordered by the physician, obtain blood culture(s) per procedure and send to the lab

Provide for comfort measures, and administer antipyretics as ordered

Administer antibiotics as ordered

Schedule patient for permanent access evaluation

Prevention for fever and chills:

Avoid use of femoral catheters

Evaluate teammates’ technique

Definition of pyrogen reaction”

Elevated temperature- usually occurs 45-75 minutes into treatment

Causes of pyrogen reaction:

Pyrogens such as endotoxin

Symptoms of pyrogen reaction:

Chills, shaking, fever, hypotension, vomiting, muscle pain

Intervention for pyrogen reaction:

Provide support, report patient s/s to nurse, discontinue dialysis, notify physician, do not return blood, draw samples for culture and endotoxin per P&P and sequester all medical supplies (including disposables) used for the dialysis treatment per P&P

Prevention for pyrogen reaction:

Proper water treatment and disinfection of equipment

Proper preparation of dialysate

Proper machine set-up and priming

Definition of disinfectant infusion:

A breach in procedure can result in disinfectant being infused into the patient’s blood stream

Causes of disinfectant solution:

Not performing residual disinfectant testing, inaccurate residual testing, sterilant rebound

Symptoms of disinfectant infusion:

Pain at the venous needle, itching, restlessness, respiratory distress, flushing, chest pain, tingling around lips, back pain

Intervention for disinfectant infusion:

Turn off blood pump, clamp bloodlines, DO NOT RETURN BLOOD TO PATIENT

Prime and attach new saline bag and administration set to arterial access

Attach sterile syringe to venous access and aspirate 5 mL of blood. Discard syringe and attach normal saline filled syringe to venous access and flush with at least 5 mL

Notify nephrologist for orders

Start slow IV infusion of saline as ordered, monitor vital signs, give oxygen as ordered, treat symptoms of hypotension, as needed, collect blood samples as ordered

If patient is stable, set up new dialyzer and blood lines on a different dialysis delivery system if only single patient/dialysis machine are affected

Discard bicarbonate and rinse mixer according to policy. Do not initiate treatments until residual tests are negative - place the dialysate line connectors/uptake wands in the correct position and continue to rinse until the machines are clear, draw samples for culture and endotoxin per P&P and sequester all medical supplies (including disposables) used for the dialysis treatment per P&P

Prevention for disinfectant infusion:

Follow proper procedure when disinfecting the bicarb mixer, and dialysis delivery systems

Definition of dysrhythmias:

Irregular heartbeat

Causes of dysrhythmias:

Electrolyte imbalance, hereditary, disease process, medications

Symptoms of dysrhythmias:

Irregular heart rate, palpitations

Intervention for dysrhythmia:

Treat cause

Prevention for dsyrhythmia:

Review patient H&P, labs, speak with patient regarding history/experiences with irregular heartbeat, work with physician if patient has these signs & symptoms to manage care

Definition of chest pain/angina:

Chest pain or discomfort due to coronary heart disease. It occurs when the heart muscle doesn’t get as much blood as it needs. Characterized by an uncomfortable pressure, fullness, squeezing or pain in the center of the chest. May also feel discomfort in the neck, jaw, shoulder, back or armC

Causes of chest pain/angina:

Coronary artery disease (blocked arteries in the heart), anemia, hypotension, anxiety

Symptoms of chest pain/angina:

Chest pain, difficulty breathing, nausea I

Intervention for chest pain/angina:

Decrease BFR to 150 ml/min

If hypotensive, restore BP as ordered

Decrease UFR

Monitor vital signs

Document event, orders, treatment, patient response

Notify nephrologist

Administer oxygen/medications/adjust prescription as prescribed. Report to primary nurse

Prevention for chest pain/angina:

Prevent hypovolemia and hypotension, monitor hemoglobin, identify and treat with medication

Definition of cardiac arrest:

The cessation of heartbeat

Causes of cardiac arrest:

Lethal side effect of some dialysis problems - electrolyte imbalances, severe hypotension, underlying cardiac disease/myocardial infarction, cardiac tamponade, air embolism, hemolysis, large blood loss, anaphylactic reaction

Symptoms of cardiac arrest:

Absence of pulse, lack of respirations, patient unresponsive

Intervention for cardiac arrest:

Confirm is patient has a DNR order. If patient does not or unable to locate, begin resuscitation procedure

Establish unresponsiveness, call for help, initiate CPR, place patient on floor, if possible, connect AED

Discontinue dialysis and maintain patency of needles or CVC ports with NS

Administer oxygen and medications as ordered

Continue CPR until patient responds with sustained heart rate, spontaneous respiration or EMS responds

Preventions for cardiac arrest:

Close monitoring of patient on dialysis

Definition of first use syndrome:

A group of symptoms that occur shortly after starting a treatment with a new dialyzerc

Causes of first use syndrome:

Maybe ETO sterilized dialyzer or manufacturing residues in the dialyzer

Symptoms of first use syndrome:

Nervousness, chest pain, back pain, palpitations, itching, funny taste in mouth

Intervention for first use syndrome:

Notify nurse, manage symptoms and stop treatment, notify physicianP

Prevention for first use syndrome:

Rinse the dialyzer well before treatment, discuss an alternative dialyzer with physician

Definition of anaphylaxis:

Rapid, severe immune response to an allergen C

Causes of Anaphylaxis:

Ethylene Oxide (ETO) allergy, reaction to germicide left in blood lines, medication allergy

Symptoms of Anaphylaxis:

Initial: Uneasiness, warmth, a sense of impeding doom, agitations, restlessness, chest tightness, low back pain

Progresses to: Difficulty breathing, wheezing, tachycardia (high heart rate), hives, itching, periorbital edema, hypotension cardiac arrest, numbness and tingling around mouth

Intervention for Anaphylaxis:

Discontinue suspected therapy

Stop the blood pump, discontinue treatment and DO NOT RETURN THE BLOOD TO PATIENT