Video Transcript Notes

Hub and Catchment Area

Hubs have similar community patterns.
Catchment areas branching out from hubs often have affluence.
- Rate of Peritoneal Dialysis (PD) in affluent areas is around 40%, indicating bias.

Social Determinants and Maslow's Hierarchy

Social determinants, as per Maslow's hierarchy, affect patient choices.
Patients preoccupied with basic needs (safe food, housing) struggle to focus on health control.
Education and financial stability are crucial for improving life quality and healthcare decisions because it allows a person to move up the Maslow's hierarchy.
Affluent, educated, and insured patients demand options and seek second opinions if unsatisfied.
They assert control over their healthcare.

Financial Aspects of Dialysis

Each dialysis treatment costs over $1000$ , done three times a week on many patients generates significant revenue.
Acute care involves upfront costs that are later reduced, while chronic care is often a financial loss for healthcare, leading to more admissions, unless patients have good insurance or Medicare.
Example: A 98-year-old patient had $7000$ X-rays and MRIs, costing $12,000$ , despite being stable.

Peritoneal Dialysis (PD) Process

PD relies on gravity.
Dialysate solution infuses via tubing in about 10 minutes (usually two liters).
Solution dwells in the cavity for about six hours, during which osmosis and diffusion occur.
Fluid drains out by gravity and is discarded; a new solution is instilled.
Process: Instill, dwell, drain, repeat.

CAPD (Continuous Ambulatory Peritoneal Dialysis)

Patient drains overnight, then instills new solution in the morning.
bag is taken along during the day, allowing mobility.
After dwelling, the bag is weighed to measure volume, then discarded, and a new bag is instilled.
Each phase (fill, dwell, drain) is one PD exchange.
Number of exchanges varies by patient.

Sterility and Aseptic Technique

Sterility is crucial in PD to avoid peritonitis.
Patients often prefer self-administration to avoid hospital-acquired infections because the risk of peritonitis is very high is you don't respect sterile procedures.
Aseptic technique involves wearing a mask during dressing changes or tubing setup.
Avoid contamination; bacteria in a glucose-rich solution in a warm, dark environment causes rapid infection.
Access points are cleaned with iodine or chlorhexidine.
The speaker claims that they can teach a 9-year-old how to do it.
Patients must adhere to the schedule and monitor output to ensure adequacy.

Calculating PD Output

PD output is calculated by measuring the drained fluid volume using a scale.
Example 12-hour shift:
- 6 AM: 2 liters in.
- 9 AM: 2.3 liters out. Exchange balance: $-300$ ml. Net: $-300$ ml.
- 9 AM: 2 liters in.
- 12 PM: 2.1 liters out. Exchange balance: $-100$ ml. Net: $-400$ ml.
- 12 PM: 2 liters in.
- 3 PM: 2.2 liters out. Exchange balance: $-200$ ml. Net: $-600$ ml.
- 3 PM: 2 liters in.
- 6 PM: 2.3 liters out. Exchange balance: $-300$ ml. Net: $-900$ ml.
- Total net balance: $-900$ ml (considerable output).
- If a patient voids 900 ml in 12 hours, that's adequate.
PD patients have more fluid intake freedom due to constant fluid removal.
Example: negative 500ml exchange. The next exchange shows positive. You need to look at the intake for the day. If the pt. didn't drink they are going toward the wrong direction.

Fluid Balance and Intervention

Example with varying output:
- Exchange 1: $-500$ ml net balance.
- Exchange 2: $-400$ ml, cumulative $-900$ ml net balance.
- Exchange 3: Positive 200 ml (1.8 liters out of 2 liters instilled).
  - 200 ml absorbed due to inadequate fluid intake.
A single positive balance isn't a crisis, but repeated positive balances require nephrologist collaboration.
Nephrologist will assess patient's intake.

Adjusting Dialysate Concentration

Dialysate solution concentration can be adjusted to alter fluid removal.
Higher concentration (e.g., 4.25%) pulls more fluid.
Patients are stabilized and connected to a dialysis center for support.

Addressing Positive Balance

Assess patient's intake if a zero or positive balance occurs.
Ensure adequate fluid intake to prevent the body from retaining fluid.
Monitor intake to avoid fluid deficit, whether on PD or not.

Complications of Peritoneal Dialysis

The earliest sign of complication is cloudy dialysate output (effluent).
Normal effluent is clear with a slight yellow tinge; cloudiness indicates dead bacteria.
Other signs include fever and elevated white blood cell count.
Advanced peritonitis signs: rigid abdomen (potentially indicating perforation) and rebound abdominal tenderness.
Repeated peritonitis can cause scarring, reducing peritoneal lining effectiveness, potentially leading to hemodialysis or treatment cessation. They don't want us to touch them. They are right to not trust the sterile conscience.

Other Potential Issues

Abdominal distension due to two liters of fluid.
Difficulty breathing (more common initially) due to fluid pushing on the diaphragm; elevate the patient.
Slight cramping early on should subside.
Dialysate should be warmed because the body temperature is $98.6$ , and the dialysate bag is at room temp which is $72$ .
Warming methods include warmers, heating pads, or body contact. You can't microwave the bag.
Consider kinks or obstructions and leakage around the catheter during instillation since nothing should leak.
Leakage compromises accurate output measurement and irritates the skin, potentially requiring a new catheter or temporary dialysis catheter.
Bloody effluent is abnormal, especially if the patient is anticoagulated.

Color Changes and Trauma

Bloody effluent is problematic even in anticoagulated patients.
Blunt Abdominal Trauma:
- Significant injury due to tightly packed organs.
- Risk of ruptured spleen or lacerated liver, leading to rapid internal bleeding.
- Diagnosis relies on tachycardia and other signs.

Peritoneal Lavage

Peritoneal Lavage: Rapid diagnostic method in blunt abdominal trauma using a PD catheter. Is now replaced.
Surgeons insert a catheter and infuse saline solution.
Blood in the effluent indicates the need for immediate surgery (ex-lap) to identify and address the bleeding.
Microscopic blood may allow for a CAT scan for better assessment.
Portable ultrasound in ERs has reduced the reliance on lavage.

Continuous Renal Replacement Therapy (CRRT)

CRRT has replaced PD in critical care and trauma hospitals because it is effective in stabilizing the patient.
In trauma, PD was limited due to common abdominal injuries.
CRRT involves continuous blood filtration at slower rates, typically in high-level trauma ICUs.
It requires one-to-one care due to the risk of bleeding and filter clotting.
Clotted blood cannot be returned, leading to hemoglobin drops.

CRRT Setup and Process

Historical PD Setup: Prepping multiple bags at once.
CRRT: Blood is pumped from one access through a filter, dialysate solution washes through the filter, and output is measured continuously.
CRRT is labor-intensive, requiring constant monitoring.

Continuous vs. Hemodialysis

CRRT is similar to hemodialysis in that it used blood.
Hemodialysis involves high pressure and rapid flow rates which are not appropriate for trauma pt so CRRT uses blood at low pressures.
CRRT is performed continuously by the ICU team and requires knowlage in trauma pt so is more appropriate.
Trauma units prioritize neurosurgery and other surgeons, with orthopedics in the background.
Fluid, oxygen, and blood management are critical in trauma.

Importance of Compliance

Compliance is crucial for dialysis patients' health as it affects fluid intake, diet, medication management, dialysis treatments, lifestyle, and infection control.
The term "non-compliant" can be judgmental, as most people don't adhere perfectly to health guidelines.
Dialysis pt falls into the sick role because they are not taking care of themselves. Need to be cautions and understanding.

Addressing Compliance Issues

Healthcare providers should understand the reasons behind non-compliance to provide effective support and have an understanding.
Avoid blaming patients or thinking they deserve negative outcomes.

Examples of Compliance Challenges

Diabetics: Dietary restrictions and medication adherence.
Hemoglobin A1c: Useful marker but shouldn't be used to dismiss patient efforts.

Effective Communication and Goal Setting

Avoid superiority; focus on understanding the patient's perspective. Must be aware and have a plan
Collaborate with patients to identify manageable changes and realistic goals.
Acknowledge the challenges patients face, like the constant need to eat while managing a restrictive diet.

Personal Examples and Strategies

The speaker eats a consistent salad for lunch due to it being an easy decision.
The speaker balances healthy choices with occasional indulgences, limiting late-night eating.

Physician Collaboration

The speaker works with a proactive physician focusing on minimal effective doses and individualized treatment plans.
The physician uses multiple drugs at lower doses for combined benefits.

Addressing Medication Side Effects

Discuss potential side effects, like sexual dysfunction, with patients.
Consider alternative medications or strategies to improve adherence.

Patient Empowerment and Planning

Encourage patients to plan medication "vacations" or breaks, especially for medications affecting sexual function.
Work with patients to find solutions that align with their values and lifestyle.

Clinical Scenario: Dialysis Patient Assessment

In a dialysis center, prioritize assessing the client with no thrill/bruit due to access issues impacting treatment.
Access is the lifeline for dialysis, and compromised function affects the procedure.
Hemoglobin is lower in dialysis patients, and the use of erythropoietin and iron is closely managed.
If EPO value is high can cause people to stroke out. If to low they would be in 6-7. Which requires blood infussion.

Medication Management

Avoid administering antihypertensive medications before dialysis because we get into problems if we just say no.

Ethical Considerations in Nursing Practice

A renal unit pt. just received insuline. this is the pt you should assess. Must recognize that the RX is for hyperkelemia is a abc priority.

Clinical Quiz: Priority Decision-Making

It's critical to recognize the order for insulin and D50 IV push is a treatment for hyperkalemia and an ABC priority because can develop V-fib.
Tunnel catheter, a new order of 10 unites is not as important as D50.

Understanding Mental Status

Multivatamin use pt: Know what are their orientation and where their cognitions are.
It can be from manythings: lack of O2 or perfusion. Fluid imbalances. Electrolytes, and what is contributing to the infection.
It not just neuro: It can be something physiological.

Altered Mental Status

Altered mental status is a broad term.
Encompasses changes in consciousness, orientation, and cognitive function.
Requires specific identification of symptoms.
Immediate causes must be ruled out quickly.

Physiological Factors

Not just neurological; can be hemodynamic, oxygenation, or electrolyte-related.
Acute changes often have physiological causes.
Example: Patient found outside, stuporous.

Rapid Assessment: First Five Steps

Blood sugar check (hypoglycemia).
Blood pressure assessment (hypotension).
Oxygen saturation (hypoxia).
Pupil examination (drug overdose or head trauma).
Signs of head trauma (falls).

Confusion: Definition and Types

Confusion is an alteration in clear thinking, information processing, cognitive function, judgment, and reality perception.
Acute Confusion: Known as delirium; rapid onset.
Chronic Confusion: Known as dementia; gradual decline.

Acute Confusion (Delirium)

Interference with the ability to process information and impairs judgment.
May resemble acute psychosis, especially in hyperactive delirium.
*Yelling out is never consider normal.
Requires prompt diagnosis and intervention.

Delirium: Example in Clinical Practice

Patient screaming when touched or moved during care indicates a perceived threat.
Such non-normal delirium behaviours need to trigger the nurse.
Needs to understand that is part of the condition

Delirium and Dementia: Contrasting Behaviors

Dementia: Chronic state with consistent, though impaired, behaviors. I need to walk the dog.
Delirium superimposed on Dementia: Abrupt, acute change in baseline behavior that requires an intervention.
Example (Ms. Christine): Walking around but does know what to do that triggered to loose her shit.

Poor Assessment

Nobody want to assist the pt in acute delirium.
Everything is just about the confussion and nothing more.
Lack of 02 and high fuid. The reason there confussed is the only fact that they are confussed and no body touch them.
Restraining Them: You want to use them and they don't work and you are not able to treat this kind of pt in the proper way.

Outcomes of Poor Patient Management

Poor medication response.
If we have a good treatment but we don't use or the meds don't match then nothing.
Poor research: You need to use your medications appropriately to perform a test and not make a restrained pt.
You need to assess, and give medications and see if any differences are triggered.

Touch them, get vitals. This is the basics. No more new words.

Hypoxia and Environmental Factors:

Continuous noise and lights.
Never is totally dark, and every room is dark.
Putting them in a box with lights.
Full of Drugs:
Loss of reality.
Always paranoia in your thinkinking.

Example Conversation With A Patient With The Disease

Mister: Mr Williams:

Nurses: What can I help you with that name: And what can do her name and show that you do are the nurse.
What did the nirse did what was so good? She got to the level.
Calling the name and make it soft and clear with any questions.
Clear state and what she did it.
Try reorient them: Is one thing to say but is very difficult to make them do it.
Never get too close or what is going to happen.

What is the first you neeed to check.

Full 02: How is the pt 02? What about the white cell.
The Oider: You need to treat and reorient them with what they need.

An easy and nice way to have it. I get them wrong or right.

Minds: Alchool and Drugs + Electrolytes and Endrocrine + Injury 02 and Infection Pychtric.

The quick easy way to have it and remined all you want.

Know The List:

Alcohol intoxication

They smell terrible. They can have labor or they can say they like or love you. They are ataxic ..

Withdroal

Opposite side and with not the correct care it can be lethal.

What is it?

We judge our pts and that it and that is it what they deserve.
Do not assist them and for that 20 % die form what they get and that is wrong.

What do you think?

It only last 3 days, but you get to be in the situation for a long time. Make sure the right meds and doses are in place so no troubles trigger to trigger.
Head Trauma, Psychiatric Pts Seizure and Stroke.
If those meds are not administered then something can and we need to perform what to do.
Don't assume always test it to know because as nurses and caregivers. What we perform for the pts.