dialysis procedures

8/4/2019 Dialysis Procedures

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DialysisProcedures


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DialysisProcedures

Itissimple. Thereareonly3procedures: Initiation

Monitoring

Discontinuation

Well,maybenotsosimple


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InitiationofDialysis

PreDialysisSafetyChecks

InitiationProcedures

ImmediatePostInitiation

Procedures


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Predialysis SafetyChecks Watersystem

Temperature

Resistivity Residualdisinfectant

PrescribedDialyzer&Concentrate

Dialysis

Machine

Safety Alarmsactive

Dialysate conductivity&/orpH

IntegrityofExtracorporealCircuit

IfDialyzerReused Checkpatientsnameonlabel

Disinfectantresidualtest


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Predialysis PatientEvaluation PhysicalParameters

Weight BP (stand & sit) Temp

Pulse & Resp Complaints

EvaluateAccessStatus Signs of infection redness, tenderness,

unusual warmth, purulent drainage

Patency Graft & AVF: bruit, thrill

Catheter: easy aspiration (post disinfection)

Direction of flow (identify A & V)

FollowUniversalPrecautions Wash hands Glove Gown

Eye protection Mask


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InitiationofDialysis Graft/Fistula

Select sites Disinfect

Anesthetize Insert needles

Catheters

Disinfect catheter limbs

Aspirate heparin from limbs

Evaluate patency

DrawBloodWork

Prior to administering heparin

From arterial port Administer heparin post draw

InitiateBloodFlowtoDialyzer

Connect lines

Start at low BFR


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PostInitiation

Calculate/ApplyTMP

Fluid gain/ # Hours = UF vol (ml/hr)

UF Volume/ UF Coefficient = TMP

TMP = V resistance + Neg pressure

Setmachineparameters BFR DFR UFR Alarm limits

Dialysate temp Heparin Infusion rate

Patientcomfortmeasures


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Charting Overridingobjectives

Complete Legible

Treatmentdocumentation

Prescribedparameters

Pre&Postpatientassessment

Vitalsignsduringtreatment Medicationsgiven

Treatmentparameters

BFR,DFR,A&Vpressures,TMP/UFR

Patient/machinecomplications Yoursignature


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Monitoring

DuringTreatment

Detectionof

Complications BloodRelated

Dialysate Related

PatientRelated

ExtracorporealCircuit

Pressures

Anticoagulation

TreatmentFactors ImpactonClearance

Charting


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BloodSideComplications AirinBloodCircuit

Minor:usualcauseiscarelesssetup,drip

chamberlevelwilldrop,alarmwillsound

AirEmbolism Major:airdetectoralarmfailure

BloodLoss AccessRecirculation

Clotting

PoorBFR

NeedleInfiltration


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Dialysate SideComplications Dialysate Temperature

Hypothermia Hyperthermia

Hemolysis Dialysate temperature,

kinkedbloodlines,formaldehydeindialysatelines,inadequatewatertreatment(chloramines,copper,zinc,nitrates)

Crenation Hypertonicdialysate


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PatientRelatedComplications

Hypotension

Hypertension

MuscleCramps

Headache

Nausea&Vomiting

Headache Fever&/orChills

Fistula/GraftInfection,Thrombosis

FistulaAneurysm,Psuedoaneurysm

CentralVenousCatheterInfection CatheterThrombosis

CardiacDysrhythymia

Pericarditis,pericardialeffusion,cardiactamponade

DialysisDisequilibriumSyndrome

FirstUseSyndrome

Seizures Angina

Anaphylaxis

Pruritis

StealSyndrome

CardiacArrest

DialysisEncephalopathy(Al++)


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Extracorporeal

CircuitPressures

BloodSide

ElevatedPrePumpArterialPressure

RBCdamageifgreaterthan 250mmHg

Increaseindicatesobstructionofbloodflowintopump

ElevatedPostPumpArterialPressure

Increaseindicatesobstructionofbloodflowintodialyzer

ElevatedVenousPressure

Increaseindicatesobstructionofbloodflowintopatient

Dialysate Side FailureofNegativePressurepump

WatchBoth Transmembrane Pressureiskey


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Anticoagulation

Threemethods

Saline flush Flush blood circuit with saline q 30 min

No drugs

No bleeding risk during or post dialysis

Trisodium citrate

Difficult: requires 2 infusion pumps, 0 Ca++ dialysate

No bleeding risk during or post dialysis BUT maintaining

patients calcium balance is difficult & risky Citrate is metabolized into bicarbonate

Heparin


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TwoHeparinMethods

Systemic

Method:bolus+constantinfusion

untillasthour

Objective:maintainACT1.52.0

baseline

TightSystemic Method:samebutlowerdoses

Objective:maintainACT1.21.4

baseline


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TreatmentFactors:

ImpactonClearance1

BloodFlowRate BFR smallmolecule(ex.urea)clearance

BFRhasmuchlesseffectonlargemolecules

Ultrafiltration Rate

UFRwillresultin clearance,viasolutedrag

Mainlyinvolveslargermolecules

Minimaleffectontotalclearance

Dialysate flowrate DFRwill clearance

Minimaleffectontotalclearance

IfBFR>350,hifluxdialyzer,500DFR 800DFR=Curea 510%


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TreatmentFactors:

ImpactonClearance2

Anticoagulation

Clottingreducesavailablemembranesurfacearea,thusclearance

TreatmentTime Longertime= clearance

Shortertime= clearance

5min perTx X156Tx/yr=780minor>3dialysis/yr

AccessRecirculation Causes:needlestooclose,accessstenosis,cardiopulmonary

recirculation Result:freshlydialyzedbloodmixeswithuremicbloodbeing

drawnintothearterialbloodline


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Discontinuation

TerminationofTreatment NeedleRemoval/CatheterCare

PostDialysisPatientAssessment

Documentation

PostDialysisMachineCare


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TerminationofTreatment DiscontinueHeparininfusion

Perunitprotocol(usually3060minpreD/C) Chartpatient&machineparameters

D/CTMP

Draw

post

dialysis

blood

samples ReduceBFRto100ml/min,wait 15seconds Alternative:drawseveralminutespostdialysis

Returnbloodtopatient

CheckpatientsBPbeforedisconnection Incasefurtherfluidinfusionisrequired


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NeedleRemoval Removeoneneedleatatime

Withdrawatsameangleasinsertion Applypressureovervessel(notskin)insertionsite

Amountofpressurematters Toolittle:prolongedbleeding,hematomaformation

Toomuch:clottedaccess

Clean&dresssiteafterbleedingstops

Note: Iffistulaclampsused,shouldfollowstrictprotocol

becauseapplicationofproperpressureisdifficult.


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CatheterCare Priortoremovingdialysislines,disinfectcatheter

portswith: Providone iodineor

Chlorhexadine gluconate

Flusheachcatheterlumenwithnormalsaline

Instillheparinintoeachlumen 5,00010,000unitsperlumenismostcommondosagerange

NOTE:volumeofheparinshouldjustbarelyexceedlumenvolume

Placefreshsteriledressingovercathetersite

Labelcathetersite DONOTFLUSH

#unitsheparinperlumen

Dateandinitialsofstaffmember


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PostDialysis

PatientAssessment

Vitalsigns BPsitting&standing

TPR

Physicalassessment Heart&lungsounds

Edema

Weight(fluidloss)

Vascularaccess

Patientsymptoms Patientcomments,complaints

Overallconditionobservations Generalcondition,behavior,mentalstatus


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Documentation Dialysisdata

Timestopped Volumeofrinseback saline

Bloodloss,ifany(includeclotsindialyzer,dripchambers)

Patientcondition Vitalsigns,physicalassessment

Overallcondition,includingvascularaccess

Specialinstructionstopatient,ifany

Time&methodofdeparture


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PostDialysis

MachineCare

Disconnectandrinseconcentratelines

Removedialyzer&bloodlines Disposeinhazardouswastecontainer

Iftobereused Ensurefilledwithsalineorheparinized saline,perunitprotocol

EnsureproperlylabeledwithpatientIDdata

Delivertoreuseareawithin1015minpostdialysis

Removeotherdisposables Disposeinhazardousornonhazardouswastecontainer,

asappropriate

Remove&disinfectnondisposables(ex.clamps)

Clean&disinfectoutsideofmachine


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DialysisProcedures

Summary

Initiation

Monitoring

Discontinuation

Itisnotsimple!

YOUarethekey.

dialysis procedures

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